Blog Post No. 163

By Dr Jim Byrne

27th February 2018

Dr Jim’s Counselling Blog:

Regarding some announcements about depression and medication

Some research results that should be known by all counsellors and psychotherapists, as well as their clients

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Copyright (c) Jim Byrne, 2018

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Context

We wanted to post a blog about the new hype about antidepressants, which has been generated by a new report, which will be mentioned below; and which has been wildly hyped in the British newspapers over the past few days.

Then the magazine, What Doctors Don’t Tell You, produced an article which we liked, and we posted a link to that article, on Facebook, as follows:

Antidepressants: The baddest of the bad is revealed

Antidepressants are a family of drugs that are bad and dangerous to know – and now researchers have named Effexor (venlafaxine) as the baddest of the bad…

WDDTY.COM

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Some time later, there was a response.

A statement in defence of antidepressants!

A contact on a major social media platform posted this piece:

Unnamed Person: “…”  (The statement made by Unnamed Person has been removed, at their request, and is now replaced by a simple statement of the objections they made to my post above.) This was the substance of their objection:

1. It is ridiculous to post my post, because it is based on just ONE study!.

2. It seemed to Unnamed Person that there is a rigorous 6-year study of antidepressants and talking therapy which I should have posted alongside my post, for the sake of balance. And for the sake of acting responsibly.

I (Jim Byrne) responded like this:

Jim Byrne Hi Unnamed Person,
Thanks for your message. So I looked up the study to which you refer, and this is what I found:

“The international study – an analysis pooling results of 522 trials covering 21 commonly-used antidepressants and almost 120,000 patients – found that all such drugs were more effective than placebos.” (Source, SBS News, Australia: https://www.sbs.com.au/…/antidepressants-really-do-work…).

What could possibly be wrong with the design of that study?

Well, look! They “…pooled the results of 522 studies…”.

What could be wrong with that?

Well, *how many* studies were *conducted* by drug companies, where they *refused* to release the results? It could be that they hide the almost half of studies which show *no benefit*, and publish the just over 50% that show *modest benefits*. (And they try very hard to *hide* the very widespread and *very serious* negative side effects of all of these ‘medicines’. (See this report in The Sydney Morning Herald – an equally well known Australian news outlet: https://www.smh.com.au/…/2008/03/02/1204402265828.html)

Here are some extracts from that Sydney Morning Herald source:

“The key issue is simple. In any situation, to make any kind of sensible decision about which treatment is best, a doctor must be able to take into account all of the available information. But drug companies have repeatedly been shown to bury unflattering data.”

“Sometimes they bury data that shows drugs to be actively harmful. This happened in the case of Vioxx and heart attacks, and SSRIs and suicidal thoughts. Such stories feel, intuitively, like cover-ups. But there are also more subtle issues at stake in the burying of results showing minimal efficacy, and these have only been revealed through the investigations of medical academics.”

“In January a paper in the New England Journal Of Medicine dug out a list of all trials on SSRIs that had ever been registered with the US Food and Drug Administration and then went to look for those same trials in the academic literature. There were 37 studies which were assessed by the regulator as positive and, with a single exception, every one of those positive trials was written up, proudly, and published in full.”

“But there were also 33 studies which had negative or iffy results and, of those, 22 were simply not published at all – they were buried – while 11 were written up and published in a way that portrayed them as having a positive outcome.”

I (Jim) then commented:

So, Unnamed Person, let me sum up. You cannot evaluate the effectiveness of drugs when the companies producing those drugs are allowed to selectively publish the results they want you to hear; and to hide the results they do not want you to hear.

And if some idiot, or charlatan, does a meta-analysis of the studies published by the drug companies, and their patsies, and says this proves those drugs are safe and effective, I have just one thing to say to them: This is not science! This is not good academic work! This is propaganda for the drug companies!

So, Unnamed Person. Who is being ridiculous? Think again about the flag you were flying under: “There is a *rigorous* 6-year study of antidepressants”. That flag is a pirate rag! There is no possibility of rigorous studies of all of the data on antidepressants so long as drug companies are allowed to hide bad data, and to publish what they choose to show us! 

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Unnamed Person‘s response

Later, Unnamed Person, got back to me:

Jim Byrne Hi Unnamed Person, I did not mean to batter your about. You came out batting for Big Pharma – without realizing that that was what you were doing. You thought you were citing irrefutable evidence of a high quality against my paltry single study. The point about my single study is that it adds a little to the body of knowledge we are building up about the effects of food on mood. People who eat junk foods, or a diet high in carbohydrate are likely to get inadequate amounts of the amino acid studied – argenine. As such, they may be vulnerable to major depression. They should be informed of that risk, and not told that they can eat any kind of diet they like – including high carbs, high sugar, and junk – and then Big Pharma will fix them up with ‘Medicine’. But most of the antidepressants being prescribed for depression should not be in use at all, because the *proportion* of patients who take them, who will develop serious side effects – like sexual dysfunction or suicidal ideation – is well above the 10% safety line – often as high as 40%, or 50% or more than 60%. It is *unethical* for physicians to cause so much predictable *harm*! But they continue to do it, and studies of the kind you cited earlier do help to keep their consciences quiet! PS: I did not mean to beat you up. But if you call my attempts to educate the public – about self-care – ‘ridiculous’, I guess I will normally come out fighting! 🙂

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Some thoughts from Mad in America

PS: Since Unnamed Person was interested in how well or how badly my position on antidepressants might be supported by scientific studies and expert support, I was pleased to see that Dr Joanna Moncrieff has published a piece on the latest hype in the Mad in America online blog – here: https://www.madinamerica.com/2018/02/challenging-new-hype-antidepressants/

Here is an extract from the opening of Dr Moncrieff’s piece:

Challenging the New Hype About Antidepressants

By

Joanna Moncrieff, MD

February 24, 2018

The extraordinary media hype over the latest meta-analysis of antidepressants puts the discussion of these drugs back years. Despite the fact that 9% of the UK population are taking antidepressants,¹ and rates of prescribing have doubled over the last decade,² the authors of the analysis are calling for yet more prescribing. John Geddes suggested in The Sun newspaper that only 1 in 6 people are receiving adequate treatment for depression in high income countries. In The Guardian he estimates that 1 million more people require treatment with antidepressants in the UK, but by my maths, if 9% are already taking them and they only represent 1 in 6 of those who need them, then 54% of the population should be taking them. I make that another 27 million people!

The coverage was almost universally uncritical, and said little about the terrible adverse effects that some people can suffer while taking antidepressants, or while trying to get off them. The Guardian even claimed that the new “groundbreaking” study will “put to rest doubts” about antidepressants.

But there is nothing ground-breaking about this latest meta-analysis. It simply repeats the errors of previous analyses. Although I have written about these many times before, I will quickly summarise relevant points.

The analysis consists of comparing ‘response’ rates between people on antidepressants and those on placebo. But ‘response’ is an artificial category that has been arbitrarily constructed out of the data actually collected, which consists of scores on depression rating scales, like the commonly used Hamilton rating Scale for Depression (HRSD). Analysing categories inflates differences.³ When the actual scores are compared, differences are trivial, amounting to around 2 points on the HRSD which has a maximum score of 54. These differences are unlikely to be clinically relevant, as I have explained before. Research comparing HRSD scores with scores on a global rating of improvement suggest that such a difference would not even be noticed, and you would need a difference of at least 8 points to register ‘mild improvement’.

Moreover, even these small differences are easily accounted for by the fact that antidepressants produce more or less subtle mental and physical alterations (e.g. nausea, dry mouth, drowsiness and emotional blunting) irrespective of whether or not they treat depression. These alterations enable participants to guess whether they have been allocated to antidepressant or placebo better than would be expected by chance.⁴ Participants receiving the active drugs may therefore experience amplified placebo effects by virtue of knowing they are taking an active drug rather than an inactive placebo. This may explain why antidepressants that cause the most noticeable alterations, such as amitriptyline, appeared to be the most effective in the recent analysis.

Antidepressant trials often include people who are already on antidepressants. Such people may experience withdrawal symptoms if they are randomised to placebo, which, given that almost no antidepressant trial pays the slightest attention to the problems of dependence on antidepressants, are highly likely to be classified as relapse.

The analysis only looks at data for eight weeks of treatment, whereas in real life people often take antidepressants for months or even years. Few randomised, placebo-controlled trials have investigated long-term effects, but ‘real world’ studies of people treated with antidepressants show that the proportion of people who stick to recommended treatment, recover and don’t relapse within a year is staggeringly low (108 out of the 3110 people who enrolled in the STAR-D study and satisfied inclusion criteria).⁵ Moreover, several studies have found that the outcomes of people treated with antidepressants are worse than the outcomes of people with depression who are not treated with antidepressants,⁶⁷ even in one case after controlling for the severity of the depression (as far as possible).⁸ The huge increase in prescribing of antidepressants over the last three decades has been accompanied by a substantial rise in the numbers of people who are in receipt of long-term disability benefits due to depression and related disorders in the UK, and this is at a time when benefits for other disorders, like back pain, have been reducing.⁹

Calling for antidepressants to be more widely prescribed will do nothing to address the problem of depression and will only increase the harms these drugs produce. …

…For more, please click the link that follows: https://www.madinamerica.com/2018/02/challenging-new-hype-antidepressants/

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1. Lewer D, O’Reilly C, Mojtabai R, Evans-Lacko S. Antidepressant use in 27 European countries: associations with sociodemographic, cultural and economic factors. Br J Psychiatry 2015 Sep;207(3):221-6.
2. NHS Digital. Antidepressants were the area with largest increase in prescription items in 2016. Cited 2018 Feb 23; Available from: URL: http://content.digital.nhs.uk/article/7756/Antidepressants-were-the-area-with-largest-increase-in-prescription-items-in-2016
3. Kirsch I, Moncrieff J. Clinical trials and the response rate illusion. Contemp Clin Trials2007;28:348-51.
4. Fisher S, Greenberg RP. How sound is the double-blind design for evaluating psychotropic drugs? J Nerv Ment Dis1993 Jun;181(6):345-50.
5. Pigott HE, Leventhal AM, Alter GS, Boren JJ. Efficacy and effectiveness of antidepressants: current status of research. Psychother Psychosom 2010;79(5):267-79.
6. Ronalds C, Creed F, Stone K, Webb S, Tomenson B. Outcome of anxiety and depressive disorders in primary care. Br J Psychiatry1997 Nov;171:427-33.
7. Dewa CS, Hoch JS, Lin E, Paterson M, Goering P. Pattern of antidepressant use and duration of depression-related absence from work. Br J Psychiatry2003 Dec;183:507-13.
8. Brugha TS, Bebbington PE, MacCarthy B, Sturt E, Wykes T. Antidepressants may not assist recovery in practice: a naturalistic prospective survey. Acta Psychiatr Scand1992 Jul;86(1):5-11.
9. Viola S, Moncrieff J. Claims for sickness and disability benefits owing to mental disorders in the UK: trends from 1995 to 2014. BJPsych Open 2016;2:18-24.
10. Farnsworth KD, Dinsmore WW. Persistent sexual dysfunction in genitourinary medicine clinic attendees induced by selective serotonin reuptake inhibitors. Int J STD AIDS2009 Jan;20(1):68-9.
11. Sharma T, Guski LS, Freund N, Gotzsche PC. Suicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reports. BMJ2016 Jan 27;352:i65.
12. Fava GA, Gatti A, Belaise C, Guidi J, Offidani E. Withdrawal Symptoms after Selective Serotonin Reuptake Inhibitor Discontinuation: A Systematic Review. Psychother Psychosom2015 Feb 21;84(2):72-81.
13. Reefhuis J, Devine O, Friedman JM, Louik C, Honein MA. Specific SSRIs and birth defects: Bayesian analysis to interpret new data in the context of previous reports. BMJ2015;351:h3190.

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Postscript

In November 2017, we (Renata Taylor-Byrne and Jim Byrne) published a book on How to Control Your Anger, Anxiety and Depression, Using nutrition and physical exercise.  There is a lot of evidence, and a growing evidence base, that the major mood disorders (which Big Pharma wants to treat with hard drugs with nasty side effects) can better be managed by healthy diet and regular physical exercise (and a good night’s sleep!)

Here is a brief extract from one of the main sections that deal with diet and depression:

(ii) Treating depression

There are many different views about how to treat depression, and here is a summary of some of the most recent explanations of what is happening to us when we are depressed.

Firstly, the views of Dr Kelly Brogan will be summarised, as she has a unique explanation, which she has described in her recent book, titled ‘A Mind of Your Own’ (2016)^[i]. She is a practising psychiatrist in America, with training as a medical doctor, and a degree in cognitive neuroscience, including clinical training from the NYU School of Medicine. She uses holistic methods of treating her patients and describes her work as ‘lifestyle medicine’.  In this approach, she uses the techniques of meditation, nutrition and physical activity as crucial daily habits with which to treat her depressed patients (and this approach overlaps, but is not co-extensive with, the E-CENT approach [Byrne, 2016]).

Dr Brogan’s view is that depression is a symptom or sign:  “…that something is off-balance or ill in the body that needs to be remedied”.

She considers that mental illness symptoms aren’t entirely psychological or solely neurochemical. And she points out in her book that there is no single study which has produced evidence that depression is caused by a lack of chemical equilibrium in the brain.

She considers depression to be a grossly misidentified state and in particular for women who, in the US, are being medicated at the rate of one in seven. Also, one in four women in their 40’s and fifties use psychiatric drugs.

She states: “We owe most of our mental illnesses – including their kissing cousins such as chronic worry, fogginess and crankiness – to lifestyle factors and undiagnosed physiological conditions that develop in places far away from the brain, such as the gut and the thyroid”, and she goes on to state that:

“You might owe your gloominess and unremitting unease to an imbalance that is only indirectly related to your brain’s internal chemistry. Indeed, what you eat for breakfast … and how you deal with that high cholesterol and afternoon headache (think Lipitor^[ii] and Advil^[iii]) could have everything to do with the causes and symptoms of depression.”

Her opinion of the foolishness of applying chemical solutions to people’s problems is very clear. In her view: “… if you think a chemical pill can save, cure or ‘correct’ you, you’re dead wrong. That is about as misguided as taking aspirin for a nail stuck in your foot.”

Her approach is to get a medical and personal history of her clients, their manner of birth (natural or section), whether breast fed or not; and she orders lab tests to ascertain the whole picture of their biological make-up.

She focusses on the information from their cellular analysis and the workings of the immune system, and points out to the reader of her book that, over the last twenty years, medical research has identified the significant part that inflammation plays in the creation of mental illness.

She also focuses on the client’s lifestyle, dietary habits e.g. sugar consumption, the condition of their guts, and microbe balance (in their guts), hormone levels – e.g. thyroid and cortisol – and genetic variations in their DNA, which could affect their susceptibility to depression. And finally, their beliefs about their own health can also play a role, she says.

So Dr Kelly Brogan shares the same conviction as Dr Perlmutter (2015): that the state of our guts is a very important determinant of our emotional well-being.

Dr Perlmutter (2015) states: “Depression can no longer be viewed as a disorder rooted solely in the brain. Some of the studies have been downright eye-opening. For example when scientists give people with no signs of depression an infusion of a substance to trigger inflammation (in the body), classic depression symptoms develop almost instantly”. (Page 76)

Perlmutter is a board-certified neurologist and Fellow of the American College of Nutrition. He is also president of the Perlmutter Health Centre in Naples, Florida. Dr Perlmutter considers that our mental health and physical wellness are totally affected by the internal systems of bacteria that operate in the gut.

But what exactly is going on in our guts? Apparently, we’ve all got millions of microbes in our body and most of them live in our digestive tract (10,000 species!). And each of the microbes have their own DNA, and that means that for every human gene in our body, there are at least 360 microbial genes. These organisms include fungi, bacteria and viruses.  In a healthy gut, most of these microorganisms are ‘friendly’, with a few ‘bad’ bacteria which are controlled by the ‘good’ stuff.

These tiny microbes: (1) strongly influence our immune system; (2) affect absorption of nutrients; (3) signal to us whether our stomach is empty or full; (4) and determine our level of inflammation and/or detoxification (which are directly related to disease and health).   They also affect our moods.

Apparently our guts contain 70-80% of our immune system, and so our gut bacteria participate in maintaining our immunity.

They can also keep cortisol and adrenaline in check. These are the two major hormones of the stress response, which can cause havoc in the body when they are continually triggered and flowing.

And our gut microbes influence whether we get any or all of the following conditions: Allergies, ADHD, asthma, dementia, cancer and diabetes, a good night’s sleep; or whether we quickly fall prey to disease-causing germs. And there is increasing evidence of a link to anxiety and depression.

Dr Perlmutter makes recommendations for changes in people’s diet which he says will:

(1) treat and prevent brain disorders;

(2) alleviate moodiness, anxiety and depression;

(3) bolster the immune system and reduce autoimmunity problems; and

(4) improve metabolic disorders, including diabetes and obesity, which are all linked to overall brain and body health.

He makes recommendations which are very practical, including…

…end of extract…

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Endnotes

[i] Brogan, K. (2016) A mind of your own: The truth about depression and how women can heal their bodies to reclaim their lives. London: Thorsons.

[ii] Lipitor is a drug commonly prescribed for reducing high cholesterol.

[iii] Advil (ibuprofen) is a nonsteroidal anti-inflammatory drug (NSAID). Ibuprofen works by reducing hormones that cause inflammation and pain in the body.

For more about this book, please go to: How to Control Your Anger, Anxiety and Depression, Using nutrition and physical exercise.

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