A Prozac Nation?
We are, if you believe the headlines, living in the midst of an unprecedented mental health crisis, exacerbated by the stress and isolation of the pandemic. According to the US Centers for Disease Control and Prevention, at the end of May, nearly 40% of American adults had experienced symptoms of depression and anxiety during the past month, with nearly a quarter filling a prescription for an antidepressant or other psychiatric drug. The rise in mental health problems has been particularly dramatic among the young: the New York Times reported in July that between 2017 and 2021, antidepressant use rose by 41% among American teenagers.
Often, such grim descriptions are paired with an upbeat solution: better access to mental health care, including psychiatric drugs. Given the understanding of mental health that has been promoted to the public for the past 40 years, this advice makes sense. We have come to understand that depression and other mental problems are disorders of the brain. Psychiatric treatments fix this brain disorder, or at least induce changes in the brain that are helpful to the suffering person.
However, if the past is prologue to the future, this understanding will continue to make the problem worse. For the past 35 years, we have sought to spread “awareness” of depression and other mental health issues. This has led to a dramatic increase in the prescribing of antidepressants: in 1990, the CDC reported that fewer than 3% of adults had taken an antidepressant during the previous month — a number that rose to 13.2% in 2018 and 23.1% earlier this year. Yet the burden of depression in the United States and other Western countries has only risen during this time.
There is a fundamental reason why. We have organised our thinking, and care, around a narrative of medical progress — of effective drugs that fix chemical imbalances in the brain — that isn’t to be found in the scientific literature. And the chasm between what is told to the public and what is found in the scientific literature has led our societies astray.
Writers, philosophers, and doctors have long observed that melancholy — a time of sadness or grief — visits nearly everyone now and then. As the 17th-century physician Robert Burton advised in The Anatomy of Melancholy, “it is most absurd and ridiculous for any mortal man to look for a perpetual tenure of happiness in this life”. It was only when melancholy became a “habit” that it could be considered a “disease”.
This was the understanding that prevailed until the Eighties. People often suffered bouts of depression, particularly in response to setbacks in life, but such feelings were seen as normal. Depression was only a “disease” in cases where people stayed depressed for no apparent reason, and these were rare. Community surveys conducted in the Thirties and Forties in the United States found that fewer than one in a thousand adults suffered an episode of “clinical depression” each year. Among this group, most did not need to be hospitalised, and only a small minority became chronically ill.
These findings led experts at the National Institute of Mental Health (NIMH) in the Seventies to advise the public that depression was an episodic disorder, which would generally clear up on its own. Most depressive episodes, wrote Dean Schuyler, head of the depression section at the NIMH, “will run their course and terminate with virtually complete recovery without specific intervention”.
However, this understanding of depression was soon to disappear.
During the Seventies, leaders of the American Psychiatric Association (APA) worried that their field was in crisis. Critics argued that psychiatry functioned more as an agency of social control than as a medical discipline, that its diagnoses lacked validity, and that its brand of talk therapy, psychoanalysis, was no more effective than other therapies offered by psychologists and counsellors.
In response, American psychiatry decided to rebrand itself. The public needed to understand that psychiatrists were medical doctors who cared for patients with real diseases. Not only would this rebranding improve psychiatry’s public image, but it would also give psychiatrists a privileged place in the therapeutic marketplace. They had the power to prescribe drugs, while psychologists and counsellors did not.
The APA, when it published the third edition of its Diagnostic and Statistical Manual in 1980, reconceptualised psychiatric disorders as diseases of the brain. The age-old distinction between ordinary depressive episodes and “clinical depression” was dropped, and both were lumped together as a single “disease”. Nancy Andreasen, future editor of the American Journal of Psychiatry, set forth tenets of this new psychiatry in her 1984 book, The Broken Brain. “The major psychiatric illnesses are diseases,” she wrote. “They should be considered medical illnesses just as diabetes, heart disease and cancer are.” With this understanding in mind, the APA quickly set out to market its new model of depression to the public.
It found an ally in pharmaceutical companies, who were also eager to change the narrative. Erasing the distinction between ordinary depression and clinical depression promised to create a huge market for antidepressants. Pharmaceutical companies gave money to the APA to develop its PR machinery in the early Eighties, and then, in 1988, they provided funds to support a NIMH campaign, called the Depression Awareness, Recognition and Treatment (DART) program, that was designed to sell the disease model to the public.
In anticipation of this campaign, the NIMH had conducted a survey of public attitudes about depression. Only 12% of Americans said they would take a pill — an antidepressant — to treat a depressive episode. And 78% said they “would live with it until it passed, confident that they could handle it with their own”. The purpose of DART was to relieve the public of this “misconception”. According to the NIMH, Americans needed to understand that depression was a “disorder” that regularly went “underdiagnosed and undertreated”. Absent treatment, it could become a “fatal disease”.
The public was also presented with a new — apparently scientific — theory of depression: that it was caused by a lack of serotonin in the brain. Thankfully, scientists had discovered a medicine, selective-serotonin reuptake inhibitors (SSRIs), that fixed this chemical imbalance. Prozac and other SSRIs were heralded in the media as “breakthrough medications” that could not only fix depressed patients but make them feel “better than well”.
Untreated depression was now presented as a pressing public health concern. Most important, people were being trained to monitor their own emotions, and to treat sadness or emotional discomfort as symptoms of a disease requiring medical intervention.
The PR blitz worked. In a 2005 press release, the APA shared the “good news”: 75% of consumers now understood that “mental illnesses are usually caused by a chemical imbalance in the brain”.
The low-serotonin theory of depression arose in the Sixties from the discovery of how the first generation of antidepressants, tricyclics and monoamine oxidase inhibitors, altered normal brain function. Both hindered the normal removal of serotonin (a monoamine) from the synaptic cleft between neurons.
Once this “mechanism of action” was discovered, researchers hypothesised that perhaps depression was due to too little serotonin. However, when researchers ran experiments to test whether people diagnosed with depression, prior to being medicated, suffered from low serotonin, the results were disappointing. As early as 1984, NIMH investigators concluded that “elevations or decrements in the functioning of serotonergic systems per se are not likely to be associated with depression”.
Investigations into the low-serotonin theory continued, but none provided convincing evidence to support it, and in 1999, the APA, in the third edition of its Textbook of Psychiatry, declared the theory dead, writing that decades of research “has not confirmed the monoamine depletion hypothesis”.
These conclusions were never promoted to the public, and so, this past June, when British investigators published a review of the history of this research and found there was no evidence to support the low-serotonin theory of depression, their conclusions were reported as shocking. In fact, we have known as much for two decades.
The real story, however, is even worse. Antidepressants block the normal reuptake of serotonin from the synaptic cleft. In response, the brain adapts to try to maintain its normal functioning. Since antidepressants raise serotonin, the brain responds by dialing down its own serotonergic machinery. In other words, antidepressants induce the very abnormality — a deficit in serotonergic function — hypothesised to cause depression in the first place.
Antidepressants, then, do not fix any known disorder. But, their defenders might counter, could they nonetheless help depressed people?
Here, too, the evidence is thin. In the world of “evidence-based” medicine, placebo-controlled, double-blind randomised trials (RCTs) are the gold standard for assessing a drug’s effectiveness. A recent meta-analysis of such studies determined that 15% of depressed patients treated with an antidepressant experience a short-term benefit; the remaining 85% are exposed to the adverse effects of the drugs without any benefit beyond placebo.
Even those short-term results suggest a major problem with widespread use of antidepressants: six of seven patients experience the drugs’ side-effects without any corresponding benefit. The most common side-effect may be sexual dysfunction, which in some cases can last long after patients stop taking the drugs. But some patients can also suffer from a drug-induced worsening of their original symptoms.
There are two notable elements of this drug-induced worsening. First, antidepressants triple the risk that a depressed patient, within 10 months of initial treatment, will turn manic and be diagnosed as bipolar, which is a much more severe disorder than depression. Second, over the long-term, antidepressants increase the risk that a person will remain symptomatic and functionally impaired.
The latter worry showed up in the Seventies, not long after antidepressants were introduced. At that time, clinicians still had a memory of depressive episodes that regularly cleared up without the use of drugs, and several reported that patients treated with antidepressants were now relapsing more frequently than before. Epidemiological studies agreed. The third edition of the APA’s Textbook of Psychiatry, published in 1999, summed up the disappointing findings: Only about 15% of patients treated with antidepressants recover and are still well at the end of one year.
Studies conducted since then suggest that even that 15% recovery rate may be too high. In the largest antidepressant trial ever conducted, the STAR*D study, only 108 of the 4041 patients who entered the trial remitted and remained well at the end of one year, a stay-well rate of 3%. The vast majority never remitted, remitted and then relapsed, or dropped out of the study. Meanwhile, a 2006 NIMH study of depressed patients who didn’t take antidepressants found that 85% recovered after one year, just like in the pre-antidepressant era.
Naturalistic studies in depressed patients regularly find that, over the long term, medicated patients are more likely to remain symptomatic and to become functionally impaired. These findings led Italian psychiatrist Giovanni Fava to propose, in a series of papers dating back to the Nineties, that antidepressants induce a biological change in the brain that makes patients more vulnerable to depression. As Rif El-Mallakh, an expert in mood disorders at the University of Louisville School of Medicine, put it in a 2011 paper: “A chronic and treatment-resistant depressive state is proposed to occur in individuals who are exposed to potent antagonist of serotonin reuptake pumps (i.e., SSRIs) for prolonged time periods.”
In other words, there is reason to believe that the mass prescription of antidepressants is making us, on the whole, more depressed. Indeed, the “economic burden” of depression — composed of workplace-related costs (absence from work), suicide-related costs, and direct-care costs — has steadily risen since the SSRIs came on the market. In 1990, it was calculated at $116 billion in inflation-adjusted terms. By 2020, it had nearly tripled to $326 billion.
Disability due to mood disorders has also risen. In community surveys conducted in 1991 and again in 2002, 30% of the adult population was found to suffer from an anxiety, mood, or substance disorder, based on DSM diagnostic criteria. However, while the prevalence of these disorders didn’t change, the percentage of people who got treated did, rising from 20% in 1991 to 33% in 2002. Over the same period, the number of American adults receiving a government disability payment due to a mood disorder rose from 292,000 to 940,000.
Following the publication of DSM III in 1980, the public was told a story of a great advance in medicine. Research had found that depression was due to a chemical imbalance, which antidepressants fixed. We organised our thinking around that narrative: depression was a biological “disease” that required medical treatment. This false narrative is the root cause of our mental health crisis today.
The tragedy is that there is another, more optimistic narrative about depression that exists in the scientific literature. This narrative informs us that human beings are responsive to their environments, and that depressive episodes often arise in response to setbacks in life. Time, and finding ways to change one’s environment, regularly lead to a spontaneous remission of depressive feelings.
A society that wants to promote good “mental health” should strive first to create more nurturing environments — improving access to housing and childcare, and working toward a more equal distribution of financial resources. It should also favour, as a first response, holistic treatments for depression — diet, exercise, walks in nature, social engagements, and so forth — as these complement our natural capacity to recover.
Antidepressants could still serve as a useful tool. Their use would simply need to be informed by research that tells of their limited short-term efficacy and of their potential negative long-term effects. Doctors would also need to inform patients that these drugs do not fix a “chemical imbalance”. True informed consent would dramatically reduce the use of these drugs, and surely diminish prescribing habits that treat them as a go-to response.
Paradigm shifts do happen, and today’s mental health crisis is telling us that one is desperately needed. Forty years of the disease model of depression has left us sicker and unhappier than ever before. There is little reason to believe that more of the same will fix our problems, and plenty of reason to think it will continue to make them worse.
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SubscribeAs a young adult I had what one might term a major depressive episode. I couldn’t focus at work, sleep, or find much joy in anything. Close to losing my job, I finally turned to my incredibly sensitive and supportive manager for help. He saved me by listening to me and giving me increasingly harder assignments that I could succeed in. No meds. And I began to thrive once again at work.
Several years later I found myself in a loveless marriage (he had his own problems, chiefly addiction to alcohol and gambling) with a job I disliked and was failing in. This time I used the medical profession for help and with the aid of a competent psychologist finally found some relief from the depression that had taken over my life. But I was on Zoloft and hated it. I slowly began to realize that my depressive episodes were situational and that I just might be able to overcome them. With the help of a psychiatrist I weaned off the medication despite being warned I would need it for the rest of my life. Now, some 35 years later I have remained depression and medication free.
Lesson? I believe many cases of depression are situational. And many people today are falling to feelings of victim hood and searching for easy answers. Life has never been easy but it seems harder today than ever. But walloping doses of frequently unnecessary meds are not the answer. But Big Pharma thinks so.
the lesson is that people need to take responsibility for their own wellbeing vs ‘lazy’ dependency attitudes – sure it is hard work educating yourself, but all the info is out there. Figure out what you need/want for a measure of contentedness and make that happen – dont overestimate your abilities, assess all the propaganda being constantly fired at you – in short WAKE UP !!!!
How depressing, maybe I’ll go and eat a bar of chocolate to cheer me up !
‘Time, and finding ways to change one’s environment, regularly lead to a spontaneous remission of depressive feelings.’
That’s a good takeaway from that article. I’ve no doubt that the pharma industry is not shy in promoting its interests and one hopes that there is oversight. I’m also pretty sure that anti-depressants may not be a perfect solution but they are a help in many cases.
Absolutely. I suffered from ‘depression’ for decades after my mother destroyed my education as a musician. Eventually, I recognised that what I was actually suffering from was grief. Rather than trying to make it go away, I prioritised spending on singing lessons and, after a number of years, obtained a diploma and a place in the region’s top amateur choir. Lockdowns were a major setback, of course, but allowing myself to do the thing that I had been grieving for was the answer, not mind and voice-numbing drugs.
A most uplifting story
This article is worth my subscription to Unherd alone. Whittaker lays bare the neurochemical shift that is debilitating and creating dependency, debilitation and death. The story of how professional self-interest and drug company opportunism fused to create this situation is one of the scandals of our time. Sadly though in a world where marginal gains are worshipped as major advances, the 15% will probably be held up as “crisis averting treatment outcomes” .that’s why I empathise with Krishna below when he feels helped. I also get his well made point about social isolation and obsessiveness. The real story though that this cynical fix was the wrong approach, needs to be more widely known. I dispute the narrative that the left and progressives are not in favour of these neurochemical approaches. They used to be critics of big Pharma but with some exceptions such as Johan Hari have become supporters and enablers, especially by their uncritical acceptance of vaccine narratives and alignment with the chemical castration inherent in transgenderism. I’ll buy Whitaker’s book so I can review his sources properly but this is a very important piece.
I began psychiatric training in 1979 and continue to practise on a part-time, semi-retired basis. I agree with much of what is said in this article. I do think however that it is based on a concept of depression that does not reflect the complexity of clinical or human reality. This is not to criticise the author as this inadequate thinking pervades much of clinical research and practice.
Depression is a capacious term that embraces a wide range of negative states of mind. In patients with severe clinical depression (formerly known as melancholia), depression denotes a condition that is a clear break from normal feeling and thinking, and which has a distinctive clinical picture. People with this condition have a pervasive depression of mood that does not respond to changes in circumstances. Sleep and appetite are impaired. Thinking may be disturbed and, in severe cases, frankly delusional. There is a loss of motivation and concentration. The risk of suicide is high.
The level of suffering and disability is out of proportion to any adverse events in the person’s life. The course of the condition is one of relapses and remissions. Family studies show clear evidence of genetic vulnerability. These conditions do not respond to psychotherapy. For these and other reasons, I think the medical or illness model is the appropriate one to apply.
The other big group of depressed patients that come the way of psychiatrists are those who have experienced early traumatisation, neglect or other adversity, such as childhood sexual abuse. People in this group are often depressed but the quality of this is quite different from the first group. Suicidal thinking is common but completed suicide is rare.
They are often treated with antidepressants but these are not usually effective. They generally do much better with various forms of psychotherapy. The medical model has a role in patients whose nervous systems have been dysregulated by severe traumatisation, and medications such as alpha adrenergic blocking drugs can often be of great help.
Finally, there is depression as part of the normal repertoire of emotional responses to all that life throws at us. As the author states, this nearly always gets better in time and recovery can be helped along by self-efficacy, and informal care and support.
It was DSM-III in 1980 that began the process of placing depression on a single spectrum, sub-divided on the basis of severity. This is one factor that allowed the medical model to expand its application from conditions where it is clearly appropriate to those in which it has little to offer, or where it may cause harm. If we are to make progress we have to recognise that depression not a single entity, that it embraces a range of emotional states, and that there is no model or approach to treatment that will be applicable to all of these.
This is very clear, thank you.
I’m a little skeptical of the benefits of the medical profession. Undoubtedly, medicine can help us; can save us sometimes. The trouble is, it seems to me, that people are complicated and medics get enthused by science and are tempted to fix things that they cannot fix.
have issues with the piece here. Such narratives actually add to the misery and agony of those battling personal crisis – family, relationships, professional, financial, health that unendingly inflict and pile agony & misery on helpless souls who then lose their capacity to navigate a life that is stressful, complex and unrelentingly assaulting by default.
Something has to give. If not circumstances that repeatedly badger you, incapacitate you, then at least to make sure your brain is wired enough to keep you functional. In such a respect psychiatric medications do help. I’m telling my experience and divulging this fact to some of you here in trust and faith. Most battling depression, grief, trauma don’t get support of friends & kins. To express your failures, inadequacies & vulnerabilities is seen to be shameful and embarrassing in times when success, status and proclaiming your state of bliss, joy & happiness in social media is de jure. For this reason many battling such problems don’t even reveal matters to the world and even if they do, the onus for the misery is put on them, which only compounds matters for the already broken and shamed. One can certainly agree that social support , emotional support, empathy are useful and can be the most effective therapy needed, but in the kind of narcissistic world that worships mamon and colonised by anxieties of work & family, such support is unlikely to come from even trusted friends and kins. When completely isolated, in despair and agony, what does one do? For often when the objective conditions are so extrinsic to such folks and are unrelenting, you want them to kill themselves ? To that extent psychiatric medications do help. It is what has kept me alive (so far)
I’m from India. The bogey of pharma industry orchestrating a mental health crisis is again a narrative of the wokes left-liberals. What do they know of mental/emotional suffering that only the disease and the diseased know? The same indeed is often the template for many diseases including pandemics particularly respiratory, gastrointestinal. No intervention, medicines, vaccines, are required. All such is ‘manufactured’, ‘invented’ by antibiotic, analgesic & antipyretic lobby! Disease itself is an construction ! Of course ensuring better societal hygiene, environmental safeguards that improve the quality of air, water and habitation conditions are certainly the long term solution. But till that happens and till folks can truly learn to be empathetic and have capacities to extend emotional support to the distressed, leave the psychiatrists, the allegedly venal pharma companies, the medical profession itself and more importantly the depressed, grieving lot alone!
There is nothing alleged about the venality of pharmaceutical companies or, for that matter, the psychiatric “profession”, and the author lays it out quite clearly.
I am sorry for your troubles and wish you the very best. I can say from long and bitter experience that my husband’s family offered all the love, emotional, and financial support to his now institutionalized younger brother, who was “diagnosed” as depressed when he was a young college student and immediately put on antidepressants. He has spent 40+ years going through every psych and drug fad, tried to kill himself countless times (usually just dramatic enough to get him re-admitted to his favorite hospital ward), and had his life ruined because “doctors” told him there was only a pharmaceutical and psychiatric answer to his perfectly normal freshman year anxiety.
I would think, after just the last two years, we’d all have learned by now what pharmaceutical companies priorities are. And it sure as h*ll isn’t our wellness.
James Tutton M.D.
I am a retired emergency medicine physician who graduated from med school in 1973. I was privy to most of the grotesque carnival that has been the entanglement of big pharma with psychiatry. Whitaker is spot on in his article! I have seen so many patients in my line of work who decades ago would have just considered themselves simply unhappy now find themselves medicated and worse off all to fill the coffers of predatory pharmaceutical companies. Sadly many us in the medical profession join the dance because it is easier to write a prescription than to take the time to help someone realize as Schopenhauer put it “fate is cruel and men wretched”.
Please don’t throw the baby out with the bathwater. I don’t doubt big pharma promoted depression drugs way beyond actual need, but pay attention to the cases where antidepressants were essential, as for krishna sampath, and myself. Regardless of the reason for the onset of severe depression (cruel fate and wretchedness included), they helped me stay alive long enough to be able to address contributing factors. (And let me add, I was opposed to taking psychoactive drugs initially.) They are not effective for everyone. But they are very effective for some and can be the difference between life and death.
It is undeniable — some people like their psychiatric drugs. (If you don’t like them, perhaps you should take a good look at what benefit you actually do get from them.)
Jeez, after spending the first 20 years of my adult life thinking in old fashioned terms that most depression can be cured pretty quickly by action by the individual – change job; divorce; exercise; etc; and then the latter 20 years accepting that depression is a much more serious and long term health condition that can require drugs and years of treatment; and now I’m being told my original view was correct.
Why do humans have to make life so much more complicated than it already is?
I’ve often wondered how many of the stories we hear of people doing weird, stupid things are the result of medications they’re on. Not just SRIs.
Getting too close to dangerous wildlife, leaving the trail and falling into super hot thermal springs in Yellowstone NP, bone-headed boating accidents, etc. Internet trolling. Maybe even mass shootings.
I’m pretty sure that no one is even trying to keep track.
If they really believe in ESG, first on the banned list has to be Big Pharma. They’re truly vile.
That’s that then (thankfully) what is the next idiocy we all need to rush into like lemmings (yes! I know! Lemmings aren’t as stupid as us.).
We all in the developed and developing nations need to take a long hard look at ourselves and wonder why we have bought so deeply into the narrative of endless progress, and the belief that there will always be a tech solution to every problem. Big Pharma is giving us what we apparently want.
‘Trauma’ is the new kid on the block in this area, now being promoted heavily in the training and practice of psych professionals. If your parents divorced or your pet died or you lost your job, you can now join the ranks of the officially unwell and wait for help to arrive. And on it goes.
“A society that wants to promote good “mental health” should strive first to create more nurturing environments — improving access to housing and childcare, and working toward a more equal distribution of financial resources.”
This statement is just nonsense. If you grind your political axes in your writing you deserve to lose all credibility
I propose you read this: BMJ 2022;379:o2529
and this: https://www.bmj.com/company/newsroom/study-reveals-extensive-network-of-industry-ties-with-healthcare/
You think something published in the BMJ is credible?
I was thinking the same thing. “More equal distribution of financial resources” sounds like socialism as a cure for depression. As for “childcare”, what on earth does that have to do with depression?
I think that the first part of the quoted statement (up to ‘environments’) actually makes some sense, but the rest is simply inadequate, and ignores a huge factor in the current upsurge in mental health ‘issues’ especially amongst the young, namely family breakdown. That is something for which there is no quick state-engineered fix.
Interesting article. Based on my own personal expierence, I believe that “depression” (however one chooses to define it) can be a result of difficult circumstances (being unhappy at work and loneliness, to name but two factors) but also because of a person’s personality. Some people are naturally more melancholic than others. Having said that, the medications can still work! Anytime I go off my antidepressant medication, I feel like rubbish. It’s not that I always feel great when I’m on them, but when I’m off them I feel so angry and irritable I could explode. As for behavioural therapy: the less said about that, the better. A depressed person could possibly get more out of talking to their dog or cat that talking to those money grabbers who oftentimes don’t have a clue and who rigidly apply their dubious theory (that thoughts influence mood and that said thoughts can be controlled) to every depressed patient.
I can’t take anything screaming about the imaginary ‘Big Pharma’ bogeyman seriously.
As for depression – I agree, the best treatment for most cases of so-called depression is exercise, fulfilling hobbies and a good diet. The fact that it’s not recommended by doctors is not due to some great conspiracy by drug manufacturers, as the psychotically minded imagine – it’s because people seek a diagnosis of depression primarily to avoid being held accountable for their behavior. So called ‘Big Pharma’ is simply responding to a market need.