I have recently written an academic piece on the putative debate on whether depression is a medical disorder or a psychosocial condition, and whether people with depression should be helped by prescribing antidepressants or through societal change. I call this a “putative debate” because people who are critical of antidepressants often force such a dichotomous choice where none should be: all health problems are both medical and psychosocial; all people with a health problem can be helped by both medications and societal changes.
Gemma Harris’ blog, which was published yesterday, touches on some of these themes from the point of view of her lived experience. Inspired by her sincere account of how antidepressant medications have helped her, and of the stigma that still surrounds people who take medications for mental health problems, I have suggested to her that I could republish a shorter version of my academic piece as a complement to her blog.
Depression is physical, as physical is the mind, and physical are emotions and behaviours
I often get accused of having a ‘reductionist’ point of view, because, as a neuroscientist, I firmly believe that all our mental processes, all our emotions and behaviours — friendship, love, sadness, happiness — have a physical substrate, as they reside in the brain, even if we do not yet fully understand this biological substrate. If all mental processes are in the brain, then so is depression.
What else can depression be, if not “physical”? The only alternative to this view is that the mind is an independent, non-physical entity: that it is, basically, a “spirit”, a “soul”. But this is the domain of faith and religion, not science and medicine.
Yes, the brain regulates emotions and behaviours, in the same way that the heart pumps blood, the stomach absorbs nutrients, and the spleen hosts immune cells.
Hippocrates said it:
Men ought to know that from the brain and from the brain only arise our pleasures, joys, laughter and jests as well as our sorrows, pains, grieves and tears.
Antidepressants do not “cure” the causes of depression — and most of the other medications that we use in medicine also do not “cure” the causes of the disorder
Painkillers take the pain away, not the cause of the pain; anti-hypertensives lower blood pressure, they do not cure hypertension; statins lower cholesterol, they do not cure the genetic problem that generates the high levels. Dexamethasone and heparin save people infected by COVID, even if these drugs do not even remotely affect the virus infection. And so on, and so forth.
Arguably, only antibiotics or antivirals tackle the cause of a disorder. Or surgery (and not every time).
Instead, people who are critical of antidepressants argue that medications for depression should have a different value threshold: that antidepressants should not be prescribed because they do not act on the cause of the disorder.
Antidepressants improve depressed mood
One of the problems of research on antidepressants is that some of the measurable therapeutic effects are influenced by the way depression is assessed, and in particular the type of symptoms scales used. Some of the most used scales are chosen not because they are the best, but because they have always been historically requested by the regulatory agencies that approve new medications. Some were developed before I was born, when we used antidepressants that we are no longer using today.
Notwithstanding these limitations, there is clear evidence that, when people with depression are asked the simple question of whether antidepressants improve their mood, there is a clear, positive effect compared with dummy-pills. The ‘number needed to treat’ for antidepressants, a clinically-relevant measure of the effectiveness of medications, is around 7–10, which is similar to medications for other disorders.
This is perhaps the most straightforward scientific validation of Gemma’s personal lived experience, and shows that research in big numbers and personal stories lead to the same conclusion: antidepressants are helpful. Not for all people with depression, but certainly, for many.
Are antidepressants perfect drugs? The best we can ask for? Of course not.
Even with multiple medication exposures, one third of individuals do not achieve full disappearance of depressive symptoms. Side effects, including withdrawal effects at suspension, can be challenging for some patients, as recent guidelines from the Royal College of Psychiatrists emphasise.
We need to conduct more research and get better medications. While maximising the benefits that people can obtain from the medications that are available today.
Antidepressants are one of the tools to help people cope with the adverse circumstances and the societal problems that have led to their depression, while we are fighting for societal changes
Imagine that you are a patient with cancer, and that you are told that the reasons why you have cancer is a combination of genetic predisposition and of societal factors that are worsened by adverse life circumstances, such as lack of healthy food and high pollution levels in the area where you live now or grew up as a child. This is an accurate statement.
Now imagine saying to this patient with cancer that, since the causes of cancer are societal, they should not be receiving any pharmacological treatment, but instead all the efforts should be focussed on improving society.
What would people with cancer say? What would people say?
Yet, this is what people who are critical of antidepressants seem to advocate: that, because people’s depression is precipitated by societal problems — and of course, it is: by poverty, discrimination, abuse, wars — , then we should not treat these societal problems with antidepressants.
Yet we are not treating the societal problems with antidepressants. We are treating people who are depressed. While we are fighting for societal changes.
I firmly believe that we, mental health scientists and clinicians, have a duty to participate in the societal debate on behalf of the people who suffer most. In fact, Inspire the Mind was born not only to talk to the public about mental disorders but also to advocate on behalf of the people who are struggling: children with no food, pregnant women in prisons, migrants and refugees, ethnic minorities, victims of war; those living in poverty, polluted areas, countries with limited access to medical care.
We can all fight for societal change: write to your parliament representative, sign a petition — and yes, write a blog, for Inspire The Mind or for another platform fighting for health and social justice.
In the meantime, as clinicians, we will also continue to support individual people with the psychological and pharmacological support we can provide.