Against my better judgement, I've been reading about Tom Cruise and his connubial breakdown. I was interested to find out that a major contributing factor was supposedly Scientology. I generally avoid any celebrity news, and so was a bit disappointed in myself when I started digging deeper. I was quite shocked by his trenchant anti-psychiatry stance, and especially by this video.
I'm not going to speak out against Scientology. I've seen the Panorama documentary - I'm not crazy.
However, I thought I might use my experience to depict a balanced portrayal of antidepressants and relevant issues around them. I have been a doctor for nine years and specialised in psychiatry for six of them. In this time I have prescribed hundreds of tablets, including antidepressants.
"There is no such thing as a chemical imbalance... antidepressants - all it does is mask the problems. There's ways, there's vitamins, there's exercise" - Tom Cruise
"Rigorous, published, peer-reviewed research clearly demonstrates that treatment works. Medications can be an important and even life-saving part of a comprehensive and individualized treatment plan." - Brooke Shields
In essence there are three main groups of antidepressant. The oldest type, called monoamine oxidase inhibitors are very rarely used any more, because they have serious side-effects such as extremely high blood pressure after eating certain foods.
Nowadays it is much more common for doctors to prescribe SSRIs (serotonin specific reuptake inhibitors). Fluoxetine, which is known as Prozac is the Tom Cruise of antidepressants. Citalopram is less well known, but popular nonetheless. There are another four licenced for use in the UK.
In addition there are also tricyclic antidepressants, which were more popular in the past, but nowadays tend to be used when SSRIs haven't worked.
How do antidepressants work?
To paraphrase a shampoo advert... here comes the science.
It's quite complicated, and we don't fully understand all of their actions.
There are chemicals in the brain, called monoamine neurotransmitters - monoamine describes their structure, and neurotransmitter is the name given to any substance within the brain and within nerves that affects their function. These are distributed between cells in the brain, which are called neurones.
There are three main chemicals that travel between these cells that are thought to have an effect on mood. These are noradrenaline, serotonin and dopamine. After they are transported from one cell to another, they are broken down in the gaps between cells (called synapses) and recycled. SSRIs and tricyclic antidepressants affect the way these chemicals are absorbed back into cells. This results in a higher concentration of the chemicals in the gaps between cells, and as a result, this can reverse some of the symptoms of depression. Monoamine oxidase inhibitors also increase the amount of these chemicals available in the brain, but they actually work inside the brain cells, rather than in the gaps between them.
When these chemicals are passed from one cell to another, they travel via receptors on the outside of the cells. Receptors are basically gates. In addition to altering chemical levels, antidepressants also affects the number of receptors that grow on the outside of brain cells. They do this in ways we do not fully understand, though this may be an explanation as to why antidepressants take several weeks to work.
Are antidepressants exclusively used in the treatment of depression?
Nope. They are used to treat a number of mental disorders, including obsessive-compulsive disorder (OCD), and anxiety disorders. They're even occasionally used in other less common disorders such as anorexia.
In addition, it's important to bear in mind that antidepressants are not appropriate for all cases of depression, especially milder forms.
So if somebody feels depressed, that doesn't automatically mean they should start taking antidepressants?
That's right. First of all, it's vital to make sure the diagnosis is correct. Depression isn't just a feeling of low mood. I think it's important not to pathologise normal feelings. I'm sure Mr Cruise would indict all psychiatrists of this practice. Everybody has periods of low mood. Depression is something more. It's accompanied by other symptoms such as a lack of energy and interest or pleasure in activities. Sometimes it's associated with weight loss, poor sleep and poor appetite.
In some situations low mood is normal, such as bereavement or adjusting to a major life event. Sometimes, physical causes such as hormonal problems can cause low mood. In these cases antidepressants might not be appropriate. This is why people who think they might be depressed should see their GP's first.
You mentioned that antidepressants shouldn't be used in milder forms of depression.
That's right, I did. Guidance suggests that for mild depression a better option is to watch and wait, as the depression might resolve by itself. People can also use cognitive behaviour therapy (CBT). In this form of therapy, people look at their negative thoughts, feelings and behaviour, recognise the triggers that cause them, and try to change them. There are other tactics for dealing with mild depression, such as exercise and also St John's wort.
However, in stronger forms of depression, like moderate or severe depression, these other treatments are not likely to be enough. In these cases, antidepressants can be helpful.
Do they work quickly?
No. One of the salient problems, is that people have unrealistic expectations of this timeframe. Perhaps doctors need to explain this more thoroughly. Some people might take antidepressants for a few days and feel no improvement. They then prematurely stop taking them, which is a shame, because they could be missing out on the benefits. It usually takes around 4 to 6 weeks for antidepressants to work. They need to be taken on a daily basis within this time. Each individual tablet won't lift somebody's mood.
Do all antidepressants work after if taken for this period of time?
Unfortunately not. Trials have shown that they work for around half to two-thirds of people. Around a third of people are treatment resistant, which means it might take them several trials to find an antidepressant that works, and even then they may not be successful.
I remember once treating an elderly gentleman with depression, who was previously a very cheerful, sociable man. He had to try out seven different types of antidepressants before he found one that restored his quality of life to a level he found acceptable.
And they all have side-effects?
Unfortunately they do. However the extent to which people are bothered by them can vary significantly. Some people barely notice any, and benefit from treatment. Other people find side-effects intolerable, and feel that they prefer not to be on medication. In this case, it is best to work with a doctor and try a different type of antidepressants, or a different dose to see if that's any better.
What are the common side effects that someone should expect?
Common general side effects include insomnia, nausea, dry mouth, sweating, and problems getting an erection. There are more specific side effects for specific medications as well.
Sounds like a lot.
Yeah, fair enough. Though you should bear in mind that these are all possible side effects. That's not to say that people get them all - or any in fact. Some people are lucky enough not to get any. It's impossible to predict, so people need to try medications out.
Like most things in life, taking antidepressants has its advantages as well as downfalls. I think it's unethical and harmful to pretend that they can help everybody. It's also naive to think that they cannot help anybody. People should be given information and options, so they can make their own decisions.
I have plenty more to say on this topic, including addiction, withdrawal symptoms, safety in overdose, and the disparate experiences of patients I have treated. However, I will express this in a separate blog. My unofficial editor (my official wife) tells me that my blogs are too long.
I very much doubt Tom Cruise will be reading this. If you are, Tom, I just like to say that I accept that trying to pacify the war of the worlds between Scientology and psychiatry is mission impossible. I know psychiatry has its shortcomings. Antidepressants are not perfect by any means. But by focusing only on a minority report of poor outcomes, you're keeping your eyes wide shut. In the same way, skewing data by promulgating only the work of a few good men is risky business.
What about you, dear Huffington Post UK readers ?
What are your experiences with antidepressants?
Terrible? Lifesaving? Neither?
Are there any questions you would like me to address in the second part of my blog?