Tag Archives: chemical imbalance

02/7/23

Paradigm Shift Needed with Depression

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There has been a study published in Molecular Psychiatry, “The serotonin theory of depression: a systematic umbrella review of the evidence,” that debunked the chemical imbalance theory of depression. Wonder of wonders, it led to conversations in the general public about depression and the use of antidepressants. Was the theory just an urban legend, or is it just a shorthand explanation of how antidepressants work, “even if it’s not entirely accurate.” It also resulted in what seemed to be as much a personal attack to the lead author of the study, Joanna Moncrieff, by Rolling Stone: “Who Is the Psychiatrist Behind the Antidepressant Study Taking Over Right-Wing Media?”

She and the other researchers were ridiculed for doing an umbrella review of “outdated” studies. One professor of psychiatry was quoted as saying: “Wow, next she’ll tackle the discrediting of the black bile theory of depression.” The term originated in the humoral theory of Hippocratic medicine, where an excess of black bile was thought to result in a melancholic temperament and lead to symptoms of depression. This was the dominant theory for depression, or melancholia, from antiquity through the 19th century.

Responding to the Rolling Stone article on her blog, Moncrieff said ignoring her critique was no longer working. So, “champions of big Pharma and mainstream psychiatry have gone into attack mode.” In what she referred to a “a time-honoured tactic,” she described how Rolling Stone attempted to discredit her by associating her with the right-wing media coverage of their research.

The article accuses me of ‘promoting widely disputed beliefs about the dangers of various mental health interventions such as antidepressants or alternative forms of treatment’. This is not accurate. Most of the adverse effects I have highlighted in my research are widely recognised, and those that are less well-recognised (such as post SSRI sexual dysfunction- which is now recognised officially by the European Medicines Agency) have not been ‘widely disputed,’ or indeed disputed at all.

Psychiatric Times also used the black bile slur asking its physician readers what they would think if they saw the headline: “Depression Probably Not Caused by Excessive Black Bile.” The authors condescendingly said they believed that Moncrieff et al thought they were publishing something “extraordinarily newsworthy or controversial.” They concluded that “depression is a complex, heterogenous disorder with biological, psychological and sociological determinants and risk factors.” Placebo-controlled studies offered “ample evidence that serotonergic agents are safe and effective in the treatment of acute major depressive disorders.” They hoped that patients and clinicians were not deterred from using antidepressants by the review.

These ad hominem attacks were not the only coverage. On Point, a pod cast on NPR radio, featured Daniel Carlat, the chair of psychiatry at Melrose Wakefield Hospital, part of the TuftsMedicine network, Joanna Moncrieff and Anne Harrington, a professor of the history of science at Harvard University. The host for “Behind the new study changing how doctors view depression” noted while antidepressants work for some people, Pfizer and other pharmaceutical companies don’t know how they work to relieve depression symptoms, “especially SSRIs.” Meghna Chakrabarti said some studies show that as many as 85% of the public believe the chemical imbalance theory of depression. “People have been told for three decades now, that depression is due to a chemical imbalance, and that they need to take antidepressant treatment to put that imbalance right.”

The program explored the gap between what the medical community knows about antidepressants, what the public knows, and why that gap exists. Dr. Carlat said many of the studies reviewed by Moncrieff et al were ones he had read before he wrote his 2010 book, Unhinged: The Trouble with Psychiatry – a Doctor’s Revelations about a Profession in Crisis. He thought their study pulled the data together “in a nice way” that made it very clear: “People have been led to believe that there is a chemical imbalance theory of depression.” Listen to the 40-minute program to hear more from Dr. Carlat.

The overall message seems to be yes, the public believed there was a chemical imbalance theory of serotonin deficiency for depression, but that’s old news. Researchers and academic psychiatrists have never believed this urban legend. Nevertheless, antidepressants still work and are safe and effective, so don’t be deterred from using them. However, that effectiveness rate is only slightly better than a placebo in the clinical trials approved by the FDA. And that difference—around two points on the 52-point Hamilton D depression scale—is “clinically imperceptible.”

Marc Stone was the lead author of a new study published in the BMJ, the British Medical Journal, in August of 2022. He is the Deputy Director for Safety with the FDA. Irving Kirsch, the principal investigator, is the Associate Director of the Program in Placebo Studies at Harvard Medical School, noted for his work on placebo effects with antidepressants. See “Dirty Little Secret” and “Do No Harm with Antidepressants” for more on Kirsch’s work on antidepressants and placebos.

Stone et al again replicated the less-than-two-point difference between drug and placebo across all 73,388 participants. “We found a drug effect among adults equivalent to 1.82 points, with a standardized mean difference of .24.” The response distributions did not appear to be unimodal to the researchers. Further analysis of the data found the optimal model for drug and placebo responses was “a combination of three overlapping normal distributions,” which they referred to as Large responses, Minimal responses and Non-specific. About two thirds of participants had a Non-specific response; and about 15% had a substantial antidepressant effect.

Reviewing the BMJ study for Mad in America, Peter Simon said:

The drug and placebo groups both had extremely high rates of symptom improvement: 84.4% of the placebo group found their depression symptoms improved, while 88.5% of the drug group improved. However, in many cases, this “improvement” was small.

More important is the number of people who experienced a large improvement. This improvement is more likely to be clinically relevant. The researchers found that those taking the drug were more likely to experience this level of improvement—24.5% of the antidepressant group experienced large improvement, versus 9.6% of the placebo group.

Based on these numbers, there seems to be a small group—about 15% of people—who experience a large response to the drug who would not otherwise improve to this level.

Unfortunately, the researchers found no way to predict who, exactly, is in this 15%. They write that if everyone with a depression diagnosis is given an antidepressant, about seven people need to be given the drug (and thus be exposed to the harmful effects with no benefit) before one person benefits.

Only one in seven people who use antidepressants will notice a clear improvement and researchers can’t predict who those individuals will be. That means 85% of individuals using antidepressants will not have a clinically noticeable improvement. Stone et al said the effectiveness of all placebo-controlled antidepressant efficacy trials submitted to the FDA between 1979 and 2016 was 1.82 points on the HAMD17, ranging from 1.62 to 2.56. It is generally agreed that drug-placebo differences greater than 3 points are necessary for a clinician to detect a minimal improvement with a patient. See “Fighting or Fueling Suicide with Antidepressants?”

It doesn’t seem that placebo-controlled studies of antidepressants offer ample evidence that they are “safe and effective” in treating acute major depression. The findings and conclusions of “The serotonin theory of depression: a systematic umbrella review of the evidence” cannot be easily ignored or dismissed.

One final research article to consider is by Peter Sterling, a professor of Neuroscience at the Perelman School of Medicine, University of Pennsylvania. He is a self-described “hard core” neuroscientist. His article, “A Neuroscientist Evaluates the Standard Biological Model of Depression,” concluded that current evidence does not support the hypothesis that depression is “a localized, disordered neural circuit.” Neuroimaging cannot identify “the mental disturbance” we call depression; nor can it be predicted in individuals by analyzing their genetic makeup.

“Chemical imbalance” theories of depression have not been supported, thereby removing any scientific rationale for “antidepressant” drugs. The drugs are not specific but rather affect myriad neurotransmitter systems, offering little advantage for most individuals, but commonly causing long-term harm. The brain adapts to antidepressant drugs, just as it adapts to drugs of abuse, and so for both withdrawal can be extremely difficult.

Depression is far better predicted by levels of childhood trauma, life stress, and lack of social supports. Depression in individuals is significantly reduced by physical repairs to their depressed communities and by psychological repairs through shared experience of childhood trauma and chronic domestic abuse.

If researchers and academic psychiatrists never believed the chemical imbalance theory of depression, why weren’t they as assertive challenging this urban legend as they have been at minimizing the significance of “The serotonin theory of depression: a systematic umbrella review of the evidence?” Does an effectiveness rate of 15% with antidepressants justify 85%—6 of 7 who use them—receiving ineffective, marginally better treatment effectiveness than placebo? Supporters of the current paradigm of depression and its treatment dismiss or minimize evidence that challenges it. There needs to be a paradigm shift in how we think about depression and its treatment.

12/20/22

Business as Usual with Antidepressants

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In “Serotonin or Not, Antidepressants Work” for Psychiatric Times, Drs. Ronald Pies and George Dawson wrote a critique of an article in Molecular Psychiatry by Moncrieff et al, “The serotonin theory of depression: a systematic umbrella review of the evidence.” They were puzzled with the article’s claim, that there was “no support for the hypothesis that depression is caused by lowered serotonin activity or concentrations.” They said it was like seeing an article in 2022, that said depression was probably not caused by excessive black bile.

Pies and Dawson dismissed the review as nothing more than “old wine in new bottles.” Then they listed 7 ways they thought the review and its conclusions were amiss. The role of serotonin in mood disorders was not settled science and there may be a role for it “in some types of depression, which is almost certainly a heterogeneous group of disorders.” They quoted Dr. Michael Bloomfield who said: “The problem with the review [by Moncrieff et al] is that…it has lumped together depression as if it is a single disorder, which from a biological perspective does not make any sense.”

Yet it does make sense when you do an umbrella review of studies where depression was assessed as the singular disorder of Major Sepressive Disorder, according to the DSM—which is published by the American Psychiatric Association.

Depression is a complex, heterogeneous disorder with biological, psychological, and sociocultural determinants and risk factors. Very few—if any—US psychopharmacologists and academic psychiatrists have ever endorsed a sweeping chemical imbalance theory of mood disorders. Historically, psychiatrists have never explained clinical depression solely in terms of reduced serotonin or any specific neurotransmitter. Many drugs in clinical medicine work through unknown or multiple mechanisms, as SSRIs do, and this does not affect their safety, efficacy, or approval for medical use. Results of placebo-controlled studies offer ample evidence that serotonergic antidepressants are safe and effective in the treatment of acute major depressive episodes. If serotonergic agents are not helpful, antidepressants from other classes (eg, noradrenergic/dopaminergic agents) may be considered.

Their final word was they hoped patients and clinicians would not be deterred from using antidepressants by the review, “or by the fact that SSRIs’ mechanism of action is complex and not completely understood.” So, the bottom line of their critique was whether or not we understand how serotonin influences depression, SSRIs work. In other words, the serotonin theory of depression may be wrong, but there must be a biochemical connection because antidepressants work. The effectiveness of SSRIs and other antidepressants is evidence of such a relationship. We just haven’t discovered what it is yet.

The Moncrieff et al article has received a significant amount of support as well as critique since it was published. The Rolling Stone wrote how the article “went viral,” but then essentially attempted to marginalize Moncrieff and dismiss her research.

In an email to Rolling Stone, Moncrieff said, “I see our research as linked with the way we understand and evaluate antidepressants, and it logically follows from my other work on the nature of drug action.” I think this statement by Moncrieff is the center of the dispute, but that was not where Rolling Stone went. It went off on a tangent, noting how the Church of Scientology organization, CCHR, frequently promoted her work. Also, that ‘far-right’ commentators like Matt Walsh and Tucker Carlson were promoting its findings. They suggested she was dabbling in conspiratorial thinking. If you conclude that antidepressants don’t work after reading her paper, then you got the wrong message.

Joseph Comaty, a Medical Psychologist, thought the paper didn’t undermine the efficacy of antidepressants. “But we just don’t know the biochemical theory of depression.” As we learn more about mental illness, things will change. According to Comaty: “if what we once believed is no longer tenable, then yeah, we’ll move along and come up with a new one.” That is just the process of scientific inquiry.

However, the mythical nature of the serotonin hypothesis of depression doesn’t seem to have been translated into the marketing and public discussion of antidepressants just yet. And why is it psychiatrists are referring to the Moncrieff et al study as old wine in new wine skins, saying it is akin to declaring depression is not caused by an excess of black bile? If they’ve known the chemical imbalance theory of depression was an error for several years, why did they not correct that false impression in the public media that is now discussing the Moncrieff et al review?

In a blog article, Moncrieff responded to some of the inaccuracies and distortions in the Rolling Stone article. She said apparently their finding was so obvious that it was met with yawns by the psychiatric community. “Yet the public were kept in the dark about the lack of evidence for a chemical imbalance for three decades in what an Australian psychiatrist recently called a ‘scourge on our profession’. And the public is very interested.” Their original paper is in the top 500 most shared scientific papers—of the 21 million that have ever been tracked—and their article in The Conversation (the one Pies and Dawson referred to) had over a million hits by August 3rd.

She noted the attempt to discredit her by association to the Scientologists and the ‘right-wing media.’ The article said she promoted the belief that SSRIs were linked to aggressive behavior, which was said to be a fringe view used by right wing media to argue against gun control in the US. She did comment on research published in the British Medical Journal (BMJ) that found a link between antidepressants and aggressive behavior, as well as suicide, in young people. Her comments were published in an invited editorial in the BMJ.

The journalist does present my response to these issues, but bringing them up seems to suggest that because of this we should never have publicised or maybe even done our research. This amounts to the suggestion that millions of people should be denied information about the drugs they put in their body every day because the message might be taken up by the ‘wrong’ people.

The ’right’ people seem to be the ones who have known for thirty years that the chemical imbalance theory was disproved. They’ve known it was an urban myth, yet did not speak up and correct the wrong impression given to the public. Now that the public is paying attention, they say the news about serotonin is old hat. It seems they want you to ignore the conclusions of the Moncrieff et al study and just return to business as usual with antidepressants.

For more information on the Moncrieff et al study its implications, see “The Death of the Chemical Imbalance Theory?” and “The Myth of the Serotonin Theory of Depression.”

06/22/21

Drugs Do Not Fix Chemical Imbalances

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Researchers at Harvard’s McLean Hospital observed that the public perception of mental illness was increasingly understood in neurobiological and genetic terms. There is some evidence that these explanations had an unintended consequence of reducing optimism for recovery among individuals with depression. Despite this, very little is known about how these beliefs interact with the treatment process and outcomes in a psychiatric treatment setting. They wanted to know if the language used affected treatment protocols and patient expectations. They found that believing depression was caused by a chemical imbalance was related to poorer treatment expectations.

In fact, they found that more depressed individuals showed a stronger relationship between chemical imbalance beliefs and lower treatment expectations. In “The dangers of the chemical imbalance theory of depression,” Derek Beres noted while the chemical marker serotonin is correlated with depression, it does not cause depression. “Decade after decade, however, we’ve been marketed the idea that chemical imbalance is the culprit behind depression.”

Instead of doctors diagnosing patients, they increasingly confirm what the patient suspected all along. The patients self-diagnose because they saw an advertisement or listened to a friend. Doctors too often comply without further investigating of the reasons for their reported distress. Medicalizing mental health softens the stigma of depression, but it also disempowers the patient. In “Stressors and chemical imbalances: Beliefs about the causes of depression in an acute psychiatric treatment sample,” the McLean researchers wrote:

More recent studies indicate that participants who are told that their depression is caused by a chemical imbalance or genetic abnormality expect to have depression for a longer period, report more depressive symptoms, and feel they have less control over their negative emotions.

Doctors, media, and advertising come together with a similar message. Everyday blues is a real medical condition, everyone is susceptible to clinical depression, and drugs correct the underlying physical conditions. Counseling aimed at self-insight seems to serve little purpose. The McLean team of researchers found patients expected little from psychotherapy and a great deal from pills. “When depression is treated as the result of an internal and immutable essence instead of environmental conditions, behavioral changes are not expected to make much difference.”

Doctor Ronald Pies referred to and cited “Stressors and chemical imbalances” in his January article in Psychiatric Times, “What We Tell Patients about Depression, and What They Say They Have Been Told.” Pies said the study found that the most commonly endorsed explanations for depression were psychosocial explanations, not “the chemical imbalance notion.” He said popular beliefs about the cause of depression could be adopted from a variety of sources, including television advertisements and anti-stigma campaigns promoting biogenetic explanations. These beliefs could also come from individual treatment experience. “All of this is simply to note that popularization of the chemical imbalance canard is almost certainly an over-determined effect, in which the role of psychiatrists (or other clinicians) is but 1 possible causal factor.”

But he seems to have glossed over the primary finding of “Stressors and chemical imbalances.” Patients who believe a chemical imbalance or genetic abnormality caused their depression do worse. The results of the study’s abstract said:

We found that although psychosocial explanations of depression were most popular, biogenetic beliefs, particularly the belief that depression is caused by a chemical imbalance, were prevalent in this sample. Further, the chemical imbalance belief related to poorer treatment expectations. This relationship was moderated by symptoms of depression, with more depressed individuals showing a stronger relationship between chemical imbalance beliefs and lower treatment expectations. Finally, the chemical imbalance belief predicted more depressive symptoms after the treatment program ended for a 2-week measure of depression (but not for a 24-hour measure of depression), controlling for psychiatric symptoms at admission, inpatient hospitalizations, and treatment expectations.

“Stressors and chemical imbalances” was not critiquing psychiatry for spreading the chemical imbalance theory, which Pies has called a kind of urban legend. The researchers examined etiological beliefs about depression and studied how they were related to treatment expectations and outcomes. If you believed in the chemical imbalance theory of depression, you tended to have poorer treatment outcomes. But that isn’t the only problem with believing in this “urban legend.”

Consequences of Believing in a Chemical Imbalance

 

Dutch researchers interviewed people who were given medical advice to discontinue antidepressants. The participants’ use of antidepressants was determined to be “not indicated” based upon clinical practice guidelines. This meant that participants had no current mental health diagnoses, no history of recurring mental health problems, and they had been taking antidepressants longer than nine months. Reporting on the study for Mad in America, Peter Simons said that despite receiving advice to discontinue, more than half refused to stop taking their antidepressant. The researchers identified two significant barriers to discontinuation.

The first was fear that if they ever stopped taking antidepressants, they would not be able to cope with the rebound depression. One of the participants said: “That’s my biggest fear. The misery I was in, before I got these medicines. I never want to relive that. I never want to go back to how I felt then. And because of this fear, I just can’t attempt to stop them.” Another person said if she would remain well, she would quit tomorrow. “But . . . to go through the hell I went through again? No.”

The second barrier was a belief in the serotonin deficiency theory, the chemical imbalance theory. The participants described their antidepressant use as supplying a deficient substance they needed to function normally. This resulted in their acceptance of a lifelong dependency. “I just need it. For me, this isn’t a psychological illness, it’s physical. And my body isn’t able to make enough serotonin, so I take the pill to supply it.”

There was a comparison to diabetes by her doctor reported by one participant.

She (the GP) told me, you should see it like you have a deficiency in your brain, you miss a certain substance and the medicine supplies it. She told me it’s just like someone with diabetes who needs insulin for the rest of their life. Well, I kind of believe that, so never questioned my use since.

The Dutch researchers said the biological model for depression seemed to backfire:

Another important barrier was the notion that antidepressants are necessary to supply the deficient serotonin. This serotonin deficiency resulted in patients expecting continued use of their medication. Presumably this is the result of the explanation the GPs gave to their patients at first prescription, or at least what patients (choose to) remember. The biological model for depression seems to backfire, making it difficult to persuade the patient to discontinue the drug. This is an important and new finding. GPs must keep this in mind while explaining the course of treatment for depressive and anxiety disorders. On the other hand, uneasiness with the perception of a biological cause could enhance attempts to stop antidepressants.

The chemical imbalance theory of depression is a false, unfounded report. For decades, the idea has been falsely marketed to consumers that a chemical imbalance is the culprit behind depression. Even psychiatrists, as seen with Dr. Pies, want to distance themselves from this “canard.” This urban legend is associated with poorer treatment outcomes and leads individuals with no apparent clinical need to remain on antidepressants instead of tapering off of them. We need to ask, how did we get here?

In his interview for Scientific American, “Has the Drug-Based Approach to Mental Illness Failed?”, Robert Whitaker described his journey away from the conventional understanding that depression and schizophrenia were caused by chemical imbalances in the brain, to founding the webzine, Mad in America.

Whitaker said he is convinced that psychiatric medications cause net harm when used over the long term. “I wish that weren’t the case, but the evidence just keeps mounting that these drugs, on the whole, worsen long-term outcomes.” Increasingly, he is not sure the medications provide real a short-term benefit either. “When you look at the short-term studies of antidepressants and antipsychotics, the evidence of efficacy in reducing symptoms compared to placebo is really pretty marginal, and fails to rise to the level of a ‘clinically meaningful’ benefit.” His concern and the concern of Mad in America has grown beyond studies with psychiatric medications:

Mad in America’s mission is to serve as a catalyst for rethinking psychiatric care in the United States (and abroad). We believe that the current drug-based paradigm of care has failed our society, and that scientific research, as well as the lived experience of those who have been diagnosed with a psychiatric disorder, calls for profound change.

He thinks our society organized itself with regard to mental illness around a false narrative presented as a narrative of science. In the early 1980s, we began to hear that psychiatric disorders were cause by chemical imbalances in the brain; and that like insulin did for diabetes, there was a new generation of psychiatric medications that could fix those imbalances. “We came to believe that there was a sharp line between the ‘normal’ brain and the ‘abnormal’ brain, and that it was medically helpful to screen for these illnesses, and that psychiatric drugs were very safe and effective, and often needed to be taken for life.”

But what can be seen clearly today is that this narrative was a marketing story, not a scientific one. It was a story that psychiatry, as an institution, promoted for guild purposes, and it was a story that pharmaceutical companies promoted for commercial reasons. Science actually tells a very different story: the biology of psychiatric disorders remains unknown; the disorders in the DSM have not been validated as discrete illnesses; the drugs do not fix chemical imbalances but rather perturb normal neurotransmitter functions; and even their short-term efficacy is marginal at best.

The above quotes from participants in the Dutch study and the quote on how the biological model for depression backfired, are found in the research article published in Therapeutic Advances in Psychopharmacology, “Patients’ attitudes to discontinuing not-indicated long-term antidepressant use.”

10/29/14

Creating Chemical Imbalances

“Rather than fix chemical imbalances in the brain, the drugs create them.” (Robert Whitaker, Anatomy of an Epidemic)

One of the most enlightening books I’ve read recently was Anatomy of an Epidemic, by Robert Whitaker. In the foreword, Whitaker said he originally believed that psychiatric drugs were like “insulin for diabetes.” He believed that psychiatric researchers were discovering the biological causes of mental illnesses and that this led to the development of a new generation of psychiatric drugs that helped “balance” brain chemistry. Then he stumbled upon some research findings that challenged that belief, “and that set me off on an intellectual quest that ultimately grew into this book.”

What follows is a collection of quotes from Anatomy of an Epidemic and a chart containing data on psychiatric medications.  There is little additional commentary by me. The power of the quotes is underscored by the sales and prescription data in the chart.

Some of the quotes were handily gathered together for me on Goodreads. My chart is a combination of a listing of the top 25 prescribed psychiatric medications in 2013 found on PsychCentral and data for 2013 pharmaceutical sales on Drugs.com. It follows the rank order given by John Grohol on PsychCentral for the top 25 most prescribed psychiatric medications in 2013.  I then included the sales data found on Drugs.com from its list of the top 100 pharmaceutical drugs by gross retail sales for the listed drugs.

Drug

Prescriptions-2013

Use

Sales-2013

Xanax (alprazolam)

48,465,000

Anxiety

Zoloft (sertraline)

41,416,000

Depression, anxiety, OCD, PTSD, PMDD

Celexa (citalopram)

39,445,000

Depression, anxiety

Prozac (fluoxetine)

28,258,000

Depression, anxiety

Ativan (lorazepam)

27,948,000

Anxiety, panic disorder

Desyrel (trazodone)

26,242,000

Depression, anxiety

Lexapro (escitalopram)

24,920,000

Depression, anxiety

Cymbalta (duloxetine)

18,573,000

Depression, anxiety, fibromyalgia, diabetic neuropathy

5,083,111,000

Wellbutrin XL (bupropion)

16,053,000

Depression

Effexor (venafaxine)

15,796,000

Depression, anxiety, panic disorder

Valium (diazepam)

14,754,000

Anxiety, panic disorder

Paxil (paroxetine)

14,335,000

Depression, anxiety, panic disorder

Seroquel (quetiapine)

14,326,000

Bipolar disorder, depression

1,183,989,000

Amphetamine salts (Adderall)

12,785,000

ADHD

727,892,000

Risperdal (pisperidone)

12,320,000

Bipolar disorder, schizophrenia, iirritability in autism

Vyvanse (lixdexamfetamine)

9,842,000

ADHD

1,689,091,000

Concerta ER (methylphenidate)

8,803,000

ADHD

Abilify (aripiprazole)

8,747,000

Bipolar disorder, schizophrenia, depression

6,293,801,000

Wellbutrin SR-W (bupropion)

8,238,000

Depression

Buspar (buspirone)

8,065,000

Sleep, anxiety

Vistaril (hydroxyzine)

8,052,000

Anxiety

Amphetamine salts ER (Adderall)

7,925,000

ADHD

Zyprexa (olanzapine)

5,101,000

Bipolar disorder, schizophrenia

Concerta/Ritalin (methylphenidate)

5,335,000

ADHD

1,383,814,000

Pristiq (desvenlafaxine)

3,217,000

Depression

Of the top 25 prescribed psychiatric drugs in 2013, 13 were to “treat” anxiety; 13 were to “treat” depression; 4 were to “treat” panic disorder; 4 were to “treat” bipolar disorder; and five were to “treat” ADHD. As the chart indicates, some of the medications are used for two or more disorders. In fact, 11 of the top 13 prescribed medications in 2013 could be used for anxiety; 10 of the top 13 could be used for depression.  Three of those were benzodiazepines (Xanax, Ativan and Valium); nine were antidepressants of some type (Zoloft, Celexa, Prozac, Desvrel, Lexapro, Cymbalta, Wellbutrin, Effexor and Paxil); and one, Seroquel, was an antipsychotic.

In addition to causing emotional distress, long-term benzodiazepines usage also leads to cognitive impairment (137). Although it was thirty years ago that governmental review panels in the United States and the United Kingdom concluded that the benzodiazepines shouldn’t be prescribed long-term … the prescribing of benzodiazepines for continual use goes on (147). Antidepressant drugs in depression might be beneficial in the short term, but worsen the progression of the disease in the long term, by increasing the biochemical vulnerability to depression. . . . Use of antidepressant drugs may propel the illness to a more malignant and treatment unresponsive course (160). In a recent survey of members of the Depressive and Manic-Depressive Association, 60 percent of those with a bipolar diagnosis said they had initially fallen ill with major depression and had turned bipolar after exposure to an antidepressant (181). Given that the biology of ADHD remains unknown, it is fair to say that Ritalin and other ADHD drugs ‘work’ by perturbing neurotransmitter systems. . . . Cocaine acts on the brain in the same way (227).

Disturbing, huh?

Only six of the most widely prescribed medications were among the 100 best sellers. The six best selling psychiatric medications in the order of their sales were: 1) Abilify ($6.294 billion); 2) Cymbalta ($5.083 billion); 3) Vyvanse ($1.689 billion); 4) Concerta/Ritalin ($ 1.384 billion); 5) Seroquel ($1.184 billion); 6) Amphetamine salts (found in Adderall, $727.9 million). Part of the explanation for the difference is that the majority of the prescribed psychiatric medications are now off patent and available as generic drugs. So they typically don’t make as much money for pharmaceutical companies. An example would be how Abilify was the top grossing prescription for all medications in 2013, but only the 18th most prescribed medication.

With the exception of VyVanse, I’d expect most of the six to also drop out of the top 100 selling drugs of the next few years. Abilify’s patent expires in October of 2014. Cymbalta’s patent expired in December of 2013. Vyvanse’s patent will expire in 2023. Concerta’s patent expired in 2011. Seroquel’s patent expired in 2012.

If you expand the boundaries of mental illness, which is clearly what has happened in this country during the past twenty-five years, and you treat the people so diagnosed with psychiatric medications, do you run the risk of turning an anger-ridden teenager into a lifelong mental patient? (p. 30) We have been focusing on the role that psychiatry and its medications may be playing in this epidemic, and the evidence is quite clear. First, by greatly expanding diagnostic boundaries, psychiatry is inviting and ever-greater number of children and adults into the mental illness camp. Second, those so diagnosed are then treated with psychiatric medications that increase the likelihood they will become chronically ill. Many treated with psychotropics end up with new and more severe psychiatric symptoms, physically unwell, and cognitively impaired. This is the tragic story writ large in five decades of scientific literature (209). Twenty years ago, our society began regularly prescribing psychiatric drugs to children and adolescents, and now one out of every fifteen Americans enters adulthood with a “serious mental illness.” That is proof of the most tragic sort that our drug-based paradigm of care is doing a great deal more harm than good. The medicating of children and youth became commonplace only a short time ago, and already it has put millions onto a path of lifelong illness (246). For the past twenty-five years, the psychiatric establishment has told us false story. It told us that schizophrenia, depression, and bipolar illness are known to be brain diseases, even though … it can’t direct us to any scientific studies that document this claim. . . . Most important of all, the psychiatric establishment failed to tell us that the drugs worsen long-term outcomes (358).