near 10 percent of all Americans Symptoms of depression appear every year. One of the most common types of treatment involves a combination of medication and antidepressants. According to the CDC, around 13 percent of Americans over the age of 18 They were taking antidepressants between 2015 and 2018. The most commonly prescribed of these are called selective serotonin reuptake inhibitors (SSRIs), which are designed to alter the flow of serotonin in the brain.

I am one of the millions who take an SSRI—called sertraline—to manage symptoms of anxiety, depression, and obsessive-compulsive disorder. Before talking to a psychiatrist about taking this drug, I noticed the impending doom and dread, as well as dozens of thoughts and feelings every minute. Basically, it’s like saying your own shit all day long. Taking the medication helped me tremendously, as it did for many others.

And that makes it all the more strange that, like many other complex illnesses, researchers aren’t exactly sure what causes depression, and that serotonin is one of the main culprits. In the 1960s, scientists calmly confirmed that certain drugs used as sedatives helped relieve depression. Because these drugs act on the serotonin system, Gerard Sanacora, a psychiatrist at Yale University and director of the Yale Depression Research Program, “leads to a very simple idea,” he told The Daily Beast.

Most scientists now follow the idea that there are many Genetic, social and biological contributions to depression; And yet the idea of ​​a chemical or serotonin imbalance is stuck in the popular zeitgeist. It has been widely used because of its prominence in drug advertisements Prozac At the end of the 1980s – even when psychiatric research was already changing its perspective.

That brings us to the debate surrounding SSRIs. Most neuroscientists, psychiatrists, and clinicians who study and treat depression agree: Antidepressants such as SSRIs work Also cognitive therapy. With the right treatment, depression remission rates can vary. 5 and 50 percent. Thanks to these drugs, there is no question that people like me are getting real relief.

But if depression isn’t linked to serotonin levels as we once thought, it raises the issue that we don’t know how SSRIs work and why they might help some depressed people. There are several promising theories that suggest they play a role in creating larger and more complex physiological changes beyond increasing serotonin levels by mediating gut bacteria, helping the brain grow new cells and look after itself. But none of these theories have been proven yet.

The ensuing discussion turned into a full-blown debate, pitting psychiatry against the minority of researchers who don’t believe antidepressants actually work.

Every few years, a new study has emerged from the shadows that claims to “debunk” the serotonin hypothesis. These studies show that depression is caused by social situations or traumatic experiences, and that antidepressants do not work, reduce feelings, or actively cause harm. They believe that depression is better with therapy than medication.

The ensuing discussion turned into a full-blown debate, pitting psychiatry against the minority of researchers who don’t believe antidepressants actually work.

Disputes between competing academics and researchers are as intense and vicious as any other fight on the Internet—see Twitter conflicts, op-eds for think-tanksAnd The news media themselves. The pharmaceutical industry’s shady history further feeds doubts about the effectiveness of antidepressants. When Antidepressant clinical trials have not yielded the hoped-for results; Drug companies have biased the record in favor of antidepressants by essentially burying the evidence—which has fueled mistrust of these drugs and their makers.

Adding fuel to the fire, one A recent review study Published in the magazine Molecular psychiatry He reviewed decades of data on serotonin levels in depression, found no evidence of a link between the two, and presented this as evidence that SSRIs either don’t work or simply dull emotions. This conclusion It was criticized by many psychiatrists and clinicians– The study didn’t even analyze whether antidepressants worked – but by Support of the authors of the study, Right wing media Anyway, push this message.

Dr. Joanna Moncrieff, a psychiatrist at the University of London, said: “If there is a benefit, I would say it is a result of numbing the emotions, and if it is not, the evidence shows that the difference between the drug and the placebo is very small.” Research told The Daily Beast. “Anti-anxiety drugs are drugs that change your mental state, so generally, it’s not a good idea to do that. [that] on a long-term basis.”

Moncrief herself is “an influential figure in what she calls it.Critical psychiatry” describes the activity of the Critical Psychiatry Network, which Moncrief co-chairs. on the websiteMaking claims about the nature and causes of mental disorders and the effects of psychiatric interventions poses a scientific challenge. Researchers associated with this activity They advocate against the use of drugs for mental health conditions and even have It has introduced covid-19 conspiracies.

If depression is caused by an interaction of stressful events and biology, as some in the Critical Psychiatry Network argue, it doesn’t follow why that means antidepressants don’t work. “I just don’t follow the logic,” he said.

Four other experts The Daily Beast spoke to specifically pushed back against Moncrieff’s findings, emphasizing that her and her team’s paper disproves two hypotheses underlying the serotonin theory. There is a well-known chemical imbalance hypothesis, in which a deficiency of the neurotransmitter serotonin in the body leads to depression. But Roger McIntyre, a professor of psychiatry and pharmacology at the University of Toronto, says, “The concept of chemical imbalances in your brain has never been presented as a coherent, comprehensive, evidence-based idea.

Instead, the serotonin hypothesis that psychiatry takes seriously and McIntrye and others argue is supported by evidence is that dysfunction of the whole body’s serotonin system contributes to clinical depression. This includes problems with the amount of receptors that bind to serotonin, how the cells fire, and many other disruptions at the biomolecular level. They argue that Moncrief is wrong when he makes the grand claim that there is no evidence that serotonin is involved in depression.

The concept of chemical imbalance in your brain has never been presented as a coherent, comprehensive, evidence-based proposition.

Roger McIntyre, University of Toronto

Furthermore, ignorance of a drug’s mechanism of action is not sufficient reason to prevent its use if it is helping people. “We are very confident that SSRIs work for depression,” Tyler Randall Black, a child and adolescent psychiatrist at the University of British Columbia, told The Daily Beast. “There’s rime and evidence that they’re working, but not why they’re working.” McIntrey pointed out the fact We don’t fully know how Tylenol works.Although it is one of the most widely used pain relievers in the world. Tylenol affects the brain in unexpected ways – even if it numbs it. Social or psychological illnessIt is not a reason to remove it from the market.

Discontinuing these medications can have unwanted side effects because therapy is often unavailable, making SSRIs the only available option. “The need for mental health care far outstrips access,” Sanacora said, noting that many Americans have to wait months to find a good cognitive behavioral therapist. Also, suddenly deciding to stop taking SSRIs can be dangerous: One in five patients Those who do this experience flu-like symptoms, insomnia, imbalance, and other symptoms that can last up to a year.

Psychiatrists who spoke to The Daily Beast emphasized that the serotonin hypothesis is a simplistic way to explain complex disorders like depression, but they also pointed out that it has developed negative side effects over time. Awais Aftab, a psychiatrist at Case Western Reserve University in Cleveland, Ohio, told The Daily Beast that the “chemical imbalance” narrative has negatively impacted patients’ decision-making and patience.

Access to mental health care far exceeds demand.

Gerard Sanacora, Yale University

Phil Cowen, a psychiatric pharmacologist at the University of Oxford in the United Kingdom, told The Daily Beast that socioeconomic status contributes to depression, leading people in the critical psychiatry space to believe that it “empowers doctors and industry” for patients. Ironically, it ignores the millions of “experienced people” who have been helped by antidepressants.

Still, the million dollar question remains: How do SSRIs work? Aftab explained that they are promoting the hypothesis of a new leader. Formation of new neurons And new Connections between neurons in the brain. The hippocampus, a seahorse-shaped region of the brain important for memory and learning, shrinks and loses neurons when depressed. It looks like SSRIs Stimulates the formation of nerve cellswhich integrates into the hippocampus to restore its function and structure. Other studies suggest SSRIs help the brain rewire its connections causing clinical symptoms associated with depression.

He also adds that SSRIs may work in different ways in different individuals, so treatments can be more tailored to each case.

And more precisely, individualized treatments may require psychiatrists to be more honest with their patients about what we know and don’t know about these drugs and oversimplified (and inaccurate) explanations.

Black tries to do this with his patients: “I’d say we know for sure that it affects serotonin, but we don’t know how that changes your brain, and we don’t know if you’re deficient in serotonin to begin with.” He finds that these open discussions about what we know about medicine and drugs can pay off in the long run, and many of his patients still choose to take supportive medicine as part of their search for what works best.

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