Having depression or another mental illness like anxiety or PTSD is a very difficult time for many people and often they turn to their family doctor for help. Seemingly, more often than not, the very first step of treatment involves being given a prescription for antidepressants (AD’s) as a way to medicate and treat the symptoms. Unfortunately using antidepressants before looking at other alternatives may come with some risks and may not be the best first choice for treatment.

 

Side Effects and the Long Term

A new critical review of the scientific research on the effects of the newer classes of antidepressants builds on earlier concerns and brings up a number of significant concerns about using antidepressants as a “first line treatment” for depression.

Researcher André F. Carvalho and his colleagues  published their review of the current research in the August 2016 edition of the journal Psychotherapy and Psychosomatics.    This review looked at the research regarding the long-term use of antidepressant drugs and their side effects.   The review was based on examining research studies on people diagnosed with Major Depressive Disorder (MDD), and found that there were a number of  important safety issues and even some potentially serious adverse events, which may occur as a consequence of using antidepressants.    (The newer classes of antidepressants fall into the category of SSRI’s and SNRI’s which include drugs under brand names like Prozac, Effexor, Pristiq, Paxil, Celexa, Lexapro, Zoloft and a long list of many others).

Here is a full list of  the problematic and possibly dangerous side effects according to this study:

Several side effects are transient and may disappear after a few weeks following treatment initiation, but potentially serious adverse events may persist or ensue later. They encompass:

gastrointestinal symptoms    (nausea, diarrhea, gastric bleeding, dyspepsia),

hepatotoxicity,

weight gain and metabolic abnormalities,

cardiovascular disturbances (heart rate, QT interval prolongation, hypertension, orthostatic hypotension),

genitourinary symptoms (urinary retention, incontinence),

sexual dysfunction,

hyponatremia,

osteoporosis and risk of fractures, bleeding,

central nervous system disturbances (lowering of seizure threshold,    extrapyramidal side effects, cognitive disturbances),

sweating,

sleep  disturbances,

affective (mood) disturbances (apathy, switches, paradoxical effects),

ophthalmic manifestations (glaucoma, cataracts)

and hyperprolactinemia.

The authors of the study concluded that when it comes to side effects:

ADs, particularly following long-term use, may increase the risk of experiencing additional psychopathological (e.g. treatment emergent affective switches and paradoxical symptoms), or medical (e.g. obesity and bleeding) problems that do not necessarily subside after discontinuation of the drug, and that may modify responsiveness to subsequent treatments.

AD’s used over the long term may cause psychological problems to worsen in some patients, may even cause new symptoms  to appear and may also cause medical problems that may continue long after the drugs use is stopped.

They also make note that we should be aware that:

the history of toxicology reminds us vividly of the lag that often occurs between the first approval of a drug for use in humans and the recognition of certain adverse events from that drug.

Carvalho and his colleagues came to the  overall conclusion that when it comes to antidepressant use for depression:

the use of ADs should be limited to those patients with the more severe and chronic forms of MDD, (Major Depressive Disorder) for the shortest possible  period of time.

and  that consumers should err on the side of caution:

the findings of this review suggest that long-term treatment with new generation ADs should be avoided if alternative treatments are available.

Suicidality, Antidepressants and Young People

Carvalho and his colleague’s paper also draws attention to and makes note that suicidality may also be a possible side effect of antidepressants, most especially when it come to children and adolescents.

There has been much concern of late that antidepressants used by young people may come with a risk of suicidality —  this certainly raises a red flag.   In fact, both the US Food and Drug Administration and Health Canada caution their use in young people.

Health Canada and the U.S. Food and Drug Administration (FDA) have issued advisories to patients, families, and health professionals to closely  monitor for warning signs of suicidal behaviour in children and adults younger than 25 who take antidepressants. This is especially important at the beginning of treatment or when doses are changed.

Health Canada and the FDA also advise patients to watch for an increase   in anxiety, panic attacks, agitation, irritability, insomnia, impulsivity, hostility, and mania. It is most important to watch for these behaviours in children, who are less able to control their impulses and may be at greater risk for suicidal behaviours.  (myhealth.alberta.ca 2015)

Do antidepressants even work in young people?

In addition to the suicide risk,  other new research questions the very effectiveness of antidepressant use with young people.

In a recent paper, lead author Dr. Andrea Cipriani from Oxford University and her colleagues reviewed the scientific evidence for 14 different antidepressant studies in children and young adults and found that the majority of antidepressants are no better than sugar pills (placebos) at relieving the symptoms of major depression in young people.    The study did find that one AD, Prozac, (Fluoxetine) was found to be effective but only just barely so.

The authors of this study come to a pretty clear conclusion that for children and adolescents antidepressants may not be a good first choice and state:

When considering the risk–benefit profile of antidepressants in the acute  treatment of major depressive disorder, these drugs do not seem to offer a clear advantage for children and adolescents.

What about antidepressant and adults?

German Psychologists Jürgen Margraf and Silvia Schneider in an editorial for the  issue of the journal EMBO Molecular Medicine put forward that psychotropic drugs are not proving to be an adequate solution to mental health issues.   They argue that the effects of psychiatric drugs for disorders like depression, anxiety, and ‘ADHD’ are very short-lived, are not a long term solution and may even have negative long-term consequences.

In a scathing critique of the use of psychotropic drugs Margraf and Schneider argue that mental health issues have continued to grow exponentially in the populations of the Western World over the last fifty years.  They argue that psychotropic drugs have been portrayed as a miracle cure and therefore our mental health issues should be reduced and not increasing.

…the percentage of disabled mentally ill patients in the USA has risen by more than 600% since the 1950s (Whitaker, 2010) and similar rates are seen in European countries. Most epidemiologists agree that this “epidemic” is not caused by increased incidence. Moreover, the once rapid succession of new therapeutic developments seems to have halted, at least in pharmacology, as big companies are withdrawing from research on mental disorders. How can this apparent contradiction be explained? Could it be that therapeutic progress is much less than we think or are being told? Could it be that the course of depression, anxiety, schizophrenia, or ADHD has been altered for the worse? Could it be that we cannot make therapeutic progress because the concept of mental illness and its treatment is deeply flawed? There are strong reasons to assume that all three suspicions are in fact true (2016).

So given that the side effects and possible risks of antidepressants caution against their widespread use as a first-line treatment and that many warning bells are sounding that AD’s may not be the effective panacea they have been made out to be…   what are other options?

 

The Case for Psychotherapy

One safe and proven alternative to antidepressants is psychotherapywith an educated and qualified professional like a Psychologist or a Clinical Social Worker.

Hundreds upon hundred of studies since the 1960’s have found that psychotherapy helps people deal with mental health issues in an effective way.   According to Lambert (2006) about 75 percent of people who enter psychotherapy show some benefit.   In another earlier study, Smith, Glass, & Miller (1980) found that people who entered psychotherapy were better off than 80% of those who didn’t receive treatment.

Margraf and Schneider suggest that  psychotherapy is a  better choice than psychotropic drugs, most especially over  the long term:

What really counts therefore is lasting improvement. Here, the picture looks radically different: Lasting success after the end of treatment has only been shown for psychotherapy (typically CBT), whereas the effects of drug treatments vanish rapidly once the drugs are withdrawn. This is obvious for anxiety disorders, depression, and ADHD and may also apply to schizophrenia. There are now plenty of data and evidence that, in the long term, the drugs do not work (2016).

In August 2012, the American Psychological Association released their Recognition of Psychotherapy Effectiveness document in which they laid out their case for using psychotherapy based on hundreds of research studies over decades of time and came to a number of  conclusions.  Here are some very important ones that make the case for psychotherapy as an effective treatment for mental health issues:

• The general or average effects of psychotherapy are widely accepted to be significant and large.
• The results of psychotherapy tend to last longer and be less likely to require additional treatment courses than psychopharmacological treatments.
• There is a growing body of evidence that psychotherapy is cost-effective, reduces disability, morbidity, and mortality, improves work functioning, decreases use of psychiatric hospitalization, and at times also leads to reduction in the unnecessary use of medical and surgical services including for those with serious mental illness.
• For most psychological disorders, the evidence from rigorous clinical research studies has shown that a variety of psychotherapies are effective with children, adults, and older adults.
• In studies measuring psychotherapy effectiveness, clients often report the benefits of treatment not only endure, but continue to improve following therapy completion as seen in larger effect sizes found at follow-up.
• The research evidence shows that psychotherapy is an effective treatment, with most clients/patients who are experiencing such conditions as depression and anxiety disorders attaining or returning to a level of functioning, after a relatively short course of treatment, that is typical of well-functioning individuals in the general population.

Looking at the APA’s conclusions, which are based on many years of solid research, it seems that psychotherapy may be an effective and safe first line alternative to using antidepressants for many people without the risks of side effects or long term problems.

 

This blog is not intended to be medical advice or diagnosis and should in no way replace consultation with a medical professional about your own particular circumstances — especially when it comes to using or ending the use of psychiatric drugs which may have dire consequences.   Please consult with a medical professional about your own unique situation. 

 

 

References:

American Psychological Association.  (2013)  Recognition of Psychotherapy Effectiveness  2013 American Psychological Association 2013, Vol. 50, No. 1, 102–109 http://www.eagt.org/research/APA-Resolution-Recognition-of-Psychotherapy-Effectiveness.pdf

Carvalho A, F, Sharma M, S, Brunoni A, R, Vieta E, Fava G, A, The Safety, Tolerability and Risks Associated with the Use of Newer Generation Antidepressant Drugs: A Critical Review of the Literature. Psychother Psychosom 2016;85:270-288

Cipriani, Andrea et al. Comparative efficacy and tolerability of antidepressants for major depressive disorder in children and adolescents: a network meta-analysis The Lancet , Volume 388 , Issue 10047 , 881 – 890

Lambert, Michael J.; Archer, Andrea Goodheart, Carol D. (Ed); Kazdin, Alan E. (Ed); Sternberg, Robert J. (Ed), (2006). Research Findings on the Effects of Psychotherapy and their Implications for Practice. Evidence-based psychotherapy: Where practice and research meet. , (pp. 111-130). Washington, DC, US: American Psychological Association, xi, 295 pp. doi:10.1037/11423-005

Margraf, J., & Schneider, S. (2016). From neuroleptics to neuroscience and from Pavlov to psychotherapy: more than just the “emperor’s new treatments” for mental illnesses?. EMBO Molecular Medicine, e201606650.

Smith M., Glass, G. & Miller, T. (1980). The Benefits of Psychotherapy. Baltimore, MD: John Hopkins University Press.

myhealth.alberta.ca (2015)  Health Canada and FDA Advisories for Antidepressants. https://myhealth.alberta.ca/Health/Pages/conditions.aspx?hwid=zu1129