When Antidepressants Harm

We’ve all heard the idea that depression involves a chemical imbalance in the brain. Perhaps it comes from a deficiency in the neurotransmitter serotonin. We’ve also been told that antidepressants work by reversing this deficiency.

For example, Medline, an informational website hosted by the National Institutes of Mental Health, tells us that the drug imipramine works by “increasing the amounts of certain natural substances in the brain that are needed to maintain mental balance.”

If that’s true, depressed people ought to take antidepressants in the same way that diabetics ought to take insulin. What could be more natural than to take a drug that reverses a disorder?

Yet recent research has shown that there’s almost no evidence that depression stems from a serotonin deficiency. Some studies even suggest that, except in the most severe cases, antidepressants scarcely outperform placebos. Perhaps it’s time for a different approach.

A healing signal

On a newer view associated with the school of thought known as evolutionary psychiatry, depression isn’t usually a “disorder” or “disease” at all. It’s a healing mechanism in its own right.

Consider fever. Before the 1700s, doctors thought fever – the heat associated with infection – was a terrible disease. They tried to fight it with drugs, bleeding, and vomiting.

Around 1700, they came to understand that fever, far from being a disease, was actually a designed mechanism of the human body. We now know that fever exists to help us fight infections.

For that matter, consider physical pain – say, the pain of a stubbed toe. Nobody likes being in pain. From evolution’s point of view, however, pain serves an important function. It’s there to alert us that something’s gone wrong with our body tissues or inner organs.

Evolutionary psychiatrists think that depression, too, is often a healing mechanism rather than a disorder. They have different theories about what, precisely, its purpose is. But at the most general level, they think the purpose of depression is to show us that something in our lives is not going well and needs to be changed.

It could be a job path, a life goal, or a relationship. Depression is there to tell us that our lives have taken a wrong turn and we should reevaluate our choices.

I’ve written quite extensively about this theory in this blog, for example, here, here, and here. Now, I want to explore a slightly different issue: What does this mean for antidepressants?

Should we take antidepressants?

Even if depression isn’t a “disease” or “disorder,” you might think they’re still useful to take. For example, they can help us manage our emotions to the point where we’re able to go to a therapist and get the help that we need, just like painkillers help manage pain until we get to a doctor.

But I want to consider a more radical proposal. What if antidepressants, by blunting our negative emotions, sometimes prevent us from getting better? What if they prolong our suffering by preventing us from listening to what depression is trying to say?

The evolutionary psychologist Paul Andrews and colleagues proposed this idea about 10 years ago in an important paper entitled “Primum non nocere: An evolutionary analysis of whether antidepressants do more harm than good.”

Andrews holds that the purpose of depression is to mobilize our cognitive resources to help solve serious life problems. That means sometimes, antidepressants might prolong depression by preventing it from reaching its natural end. (Primum non nocere refers to the central tenet of the Hippocratic Oath, “First, do no harm.”)

The Vanderbilt psychologist Steven Hollon has also advanced this point of view. In a recent paper, he and his co-authors give the following assessment: “[Antidepressant medications] may be palliative at best: they suppress symptoms for only as long as they are taken but do nothing to shorten the course of the underlying (biologic) episode. It is also possible that they…may [prolong] the underlying episode by interfering with the normal homeostatic mechanisms that would otherwise cause the underlying episode to spontaneously remit.”

Next steps

This doesn’t mean that nobody should ever take antidepressants. It doesn’t mean that people who take them should stop taking them. (Given reports of withdrawal problems, people should avoid stopping antidepressants abruptly without medical guidance.) But it does mean that as a society, we need to seriously rethink our approach to mental health.

Currently, nearly one in five American college students are on antidepressants. About one-seventh of the adult population of the UK are on them, too. Clearly, we have a serious problem with overprescription. Doctors are far too prone to prescribe these drugs without even considering whether the depression might have healing value in its own right.

The evolutionary view also suggests a more central role for a certain kind of therapy – one that takes seriously the idea that depression is nature’s signal that’s meant to guide us. Perhaps before immediately seeking a prescription, it can be more useful to talk with a therapist who can help us discover what our depression is trying to say.