SSRIs


I read Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America as a counterpoint assignment in one of the diagnosis classes in my Couples & Family Therapy program. It was an excellent book about the history and science of several psychological problems, both as phenomena and diagnoses, including depression, depression, bipolar disorder, ADHD, and schizophrenia. As a university student, I had the opportunity to check out for free any of the many academic citations in the book that piqued my interest, and each one that I looked at seemed indeed to provide the evidence he claimed. I haven’t read anything like all of them (there are nearly 700), but enough to satisfy myself that Whitaker has done some good journalism here, and that his hypotheses are credible.

Two of these hypotheses is about childhood bipolar disorder, the first of which he calls the “ADHD to bipolar pathway.” The side effects of stimulants such as those used to treat ADHD are substantially similar to bipolar symptoms, as shown in the table below, from p. 238. (The formatting is slightly different than Whitaker’s, thanks to an Open Office/Wordpress interaction.) Multiplying the estimated rate of stimulant-induced bipolar-like symptoms by the 3,500,000 children and teens taking those medications, Whitaker estimates we should see approximately 400,000 “bipolar youth” as a result.

The ADHD to Bipolar Pathway

Stimulant-Induced Symptoms

Bipolar Symptoms

Arousal

Dysphoric

Arousal

Dysphoric

Increased lethargy

Intensified focus

Hyperalertness

Euphoria

Agitation, anxiety

Insomnia

Irritability

Hostility

Hypomania

Mania

Psychosis

Somnolence

Fatigue, lethargy

Social withdrawal, isolation

Decreased spontaneity

Reduced curiosity

Constriction of affect

Depression

Emotional lability

Increased energy

Intensified goal-directed activity

Decreased need for sleep

Severe mood change

Irritability

Agitation

Destructive outbursts

Increased talking

Hypomania

Mania

Sad mood

Loss of energy

Loss of interest in activities

Social isolation

Poor communication

Feelings of worthlessness

Unexplained crying

The second part of Whitaker’s thinking on childhood bipolar disorder is an SSRI to bipolar pathway. Estimates of the rate of the well-know SSRI side effect of mania, multiplied by 2,000,000 children and adolescents on the medications, give us the possibility of producing at least 500,000 SSRI-induced bipolar disorders in young people.

If true, these hypotheses could go a long way to explain the skyrocketing rates of childhood bipolar disorder diagnoses, as most diagnoses of childhood bipolar disorder are made on children who are already taking stimulants and/or SSRIs. The primary alternative, and more mainstream, hypothesis is not that stimulants and SSRIs are iatrogenic, but that since those medications solve the problems of ADHD and depression, the symptoms of bipolar disorder that emerge show that the diagnostician had initially guessed wrong, and that bipolar disorder was the previously-existing and underlying cause of the ADHD and/or depression. This, of course, may be true, but it seems very important to discover for certain whether it is!

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I know people who happily smoke pot, drink beer, and use other recreational drugs with no apparent concern, but who would not take an Ibuprofen because it’s bad for your liver. This confuses me. Yes, non-steroidal anti-inflammatory drugs are bad for your liver. So are many, many other mainstream drugs, like antidepressants and birth-control pills. (Here’s a list.)

But what is the reasoning that lets hippy-friendly drugs off the hepatotoxicity hook? It seems to be that these drugs are “natural” and so they are trustworthy, as if God wouldn’t make such righteous substances poisonous. This is not rational.

It’s true that there isn’t as much research on the hippy-friendly drugs as there is on medical drugs. The FDA makes pharmaceutical companies do a bunch of expensive research on the drugs trying to go the legitimate route, but they don’t get involved in the illegal stuff. There is some research, though, and we do know that even hippy drugs are made out of chemical compounds that the liver has to metabolize before we can pee them out. It is safe to assume that pot, acid, mushrooms, ecstasy, cocaine, and the rest of your recreational drug list are bad for your liver. (And alcohol, duh.)

I will happily support you in not taking over-the-counter pain meds, but if an Ibuprofin is a drop in the hepatotoxic-lifestyle bucket, your priorities confuse me. If you are willing to ingest any number of chemicals in order to feel good, why not ingest one or two more to feel a little less pain?

According to the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders, Text Revision (DSM-IV-TR), there is a mental disorder that is usually diagnosed in childhood or adolescence called Oppositional Defiant Disorder. It afflicts somewhere between 2-16% of people, more boys than girls before puberty, but equal numbers of boys and girls after puberty. Family therapists are not into giving medical-model diagnoses in general, but in many cases, a DSM diagnosis is the only way for a family to get their insurance companies to pay for them to get help. In one of my internship sites, for example, I will need to provide a DSM diagnosis after the first session with a family in order to get the clinic paid for our work. As I understand it, this is a common diagnosis for kids who are giving their parents and teachers a hard time.

Note that the word “often” is used to mean something like “more than usual,” so whichever kids who are most like this will qualify for this Disorder, as long as someone important believes that their behavior is significantly impairing their social or academic functioning. Note also that these symptoms could be occurring in just one setting (say, just at school) and the kid will still qualify for ODD, unlike the symptoms for ADHD, which have to occur in at least two settings to qualify for the diagnosis.

Outside of family therapy, ODD is very commonly treated with Ritalin for “comorbid” ADHD. Kids diagnosed with ODD are also fairly commonly given antidepressant and/or antipsychotic medication, on the guess that they have an underlying Mood Disorder or Bipolar Disorder, though there is little to no research on these medications for children, especially in combination.

The following is word-for-word from the DSM-IV-TR, page 102:

Diagnosis criteria for 313.81 Oppositional Defiant Disorder

A. A pattern of negativistic, hostile, and defiant behavior lasting at least 6 months, during which four (or more) of the following are present:

(1) often loses temper

(2) often argues with adults

(3) often actively defies or refuses to comply with adults’ requests or rules

(4) often deliberately annoys people

(5) often blames others for his or her mistakes or misbehavior

(6) is often touchy or easily annoyed by others

(7) is often angry or resentful

(8) is often spiteful or vindictive

Note: Consider a criterion met only if the behavior occurs more frequently than is typically observed in individuals of comparable age and developmental level.

B. The disturbance in behavior causes clinically significant impairment in social, academic, or occupational functioning.

C. The behaviors do not occur exclusively during the course of a Psychotic or Mood Disorder.

D. Criteria are not met for Conduct Disorder, and, if the individual is age 18 or older, criteria are not met for Antisocial Personality Disorder.

Psychology hit the actual headlines last week, with Sharon Begley’s “The Depressing News About Antidepressants” in Newsweek. The story is that, if you look at all the evidence, not just the “successful” trials, SSRIs like Prozac and Paxil do not work better than a placebo for mild and moderate depression. Begley also tells the story as if she’s sorry to break the news and spoil the placebo effect. Here’s my version of the headlines from this story:

Pharmaceutical Companies Have Known For At Least Ten Years That SSRIs Work No Better Than Placebos: At least, anyone there who understood statistics and paid any attention to their research.

The Idea That SSRIs Are Better Than Placebos Was Propagated By Publishing Only the “Successful” Trials: This, obviously, was quite unethical.

The FDA Almost Certainly Knew That SSRIs Were No Better Than Placebos, Too: They had all of the research. Perhaps they did not read it.

People Who Read Psych Journals Knew SSRIs Were No Better Than Placebos Two Years Ago: The news caused a stir in my undergrad psych lab in 2008.

We Do Not Know What Causes Depression: The idea that depression has to do with the neurotransmitter serotonin was based largely on the (incomplete) evidence that SSRIs (selective serotonin re-uptake inhibitors) cured depression. In fact, we have pretty limited knowledge of what goes on inside a living brain. In fact, we have no ethical way to measure how much serotonin or any other neurotransmitter is where inside anyone’s living brain, so when a doctor tells you something like, “You are depressed because you have overactive serotonin re-uptake mechanisms,” they are passing on speculation, not science.

If You Recovered From Mild to Moderate Depression While On An SSRI, It Was Probably Your Own Hope That Lifted You Out: The thing about placebos is that they work pretty well. If you benefited from the placebo effect, it was your own strength, your own hope, that made the difference. You overcame that challenge. I think that’s pretty cool.

While SSRIs Do Not Treat Depression Better Than Placebos, They Do Have Side Effects: Here’s a list from wikipedia: Decreased or absent libido, Impotence or reduced vaginal lubrication, Difficulty initiating or maintaining an erection or becoming aroused, Persistent genital arousal disorder despite absence of desire, Muted, delayed or absent orgasm (anorgasmia), Reduced or no experience of pleasure during orgasm (ejaculatory anhedonia), Premature ejaculation, Weakened penile, vaginal or clitoral sensitivity, Genital anesthesia, Loss or decreased response to sexual stimuli, Reduced semen volume, Priapism (persistent erectile state of the penis or clitoris)anhedonia, apathy, nausea/vomiting, drowsiness or somnolence, headache, bruxism (involuntarily clenching or grinding the teeth), extremely vivid and strange dreams, dizziness, fatigue, mydriasis (pupil dilation), urinary retention, changes in appetite, changes in sleep, weight loss/gain (measured by a change in bodyweight of 7 pounds), may result in a double risk of bone fractures and injuries, changes in sexual behaviour,increased feelings of depression and anxiety (which may sometimes provoke panic attacks), tremors (and other symptoms of Parkinsonism in vulnerable elderly patients), autonomic dysfunction including orthostatic hypotension, increased or reduced sweating, akathisia, liver or renal impairment, suicidal ideation (thoughts of suicide), photosensitivity (increased risk of sunburn), Paresthesia, Mania, hypomania, sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished libido, a severe and even debilitating withdrawal syndrome, a slight increase in the risk of self-harm, suicidal ideation, and suicidality in children, neonatal complications such as neonatal abstinence syndrome (NAS) and persistent pulmonary hypertension, and platelet dysfunction.

Until Your Medicated Kids Are Old, We Will Not Know What All of the Side Effects of Treatment by SSRIs Are: This is true for any new drug, and it’s worth considering. If your child is on Prozac or other new drug, they are essentially part of a massive experimental trial.

Pharmaceutical Companies Pay for Psychiatric Educations: Why would it surprise anyone that treatment equals drugs in this case?

Most Antidepressant Prescriptions Written by Health Care Providers With No Significant Psychiatric Training: GPs, OBGYNs, pediatricians, etc account for 80% of SSRI prescriptions.