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Monday, July 25, 2011

How Antidepressants Work, Part One

On a recent Google search I found a reference to Dr. Marcia Angell’s article “The Epidemic of Mental Illness: Why?” in The New York Review of Books.  Dr. Angell gained popularity by becoming an editor-in-chief of the New England Journal of Medicine and has since written many articles about the negatives of the pharmaceutical industry.  She agrees with other authors in her review as follows:

1. Our understanding of categories of mental illness and their treatments has been influenced by drug companies, in that drug companies create mental illness categories or diagnoses so that their drugs will have places to be used when marketed.

2. Mental illness is not caused by chemical imbalances in the brain.

This view is actually too simplistic.

For example, we now have diagnoses such as post traumatic stress disorder (PTSD), social anxiety disorder (SAD), and premenstrual dysphoric disorder (PMDD) which did not exist formally 10-15 years ago.  She might posit that these were created just for marketing purposes.  However, we must admit that some people suffer immensely from collections of symptoms that may sort themselves out into those artificial categories of PTSD, PMDD, and SAD. Clearly, patients have these symptoms and a disorder is defined as a collection of symptoms that causes problems in daily functioning.

These categories of new diagnoses might have been partially created by the pharmaceutical companies, but these symptoms clearly exist in people who are suffering.  If we dialed back the clock would we feel comfortable stating that PTSD, PMDD, SAD, etc. just plain old do not exist? That these patients do not deserve symptomatic treatment as their illnesses are hoaxes or a ploy from pharmaceutical companies?  Where does that leave us?  Perhaps we should allow patients with bona fide disabling symptoms to suffer as their illnesses were made up by companies?  It feels like throwing out the baby with the bath water instead of accepting the good and bad of the situation.  Even if these are not ‘real diagnoses’, they are ‘real symptoms’.

Are mental illnesses caused by brain chemical imbalances?  Sometimes, but often not.  We have known this for years.  This is not new news.  We tell patients about these imbalances as it is easy to understand. Just like adding insulin for diabetics who have no insulin, it is a replacement.  Frankly, we add psychiatric medications into a patient’s system and they do change brain chemical levels or block certain brain receptors instantly, but patients do not get instantly better.  Most patients get better 2-6 weeks later after their chemicals or receptors have been manipulated and changed for weeks.

So what happens?  Basically, when we add psychiatric medications into a patient’s system, the patient now has altered brain chemicals, causing the brain to react to these new imbalances by increasing or decreasing its nerve firing in certain brain areas. This then causes DNA in neurons to turn on or off certain genes.  Genes encode and allow new proteins to be made and these proteins likely increase nerve health, functioning, and firing so that certain brain areas can communicate better.  This takes several weeks, as we need those genes to turn on/off and give nerve cells time to build a lot of proteins. So, psychiatric drugs are needed to start a series of events — a chain reaction — in the brain, starting with manipulating chemicals so that symptoms can eventually get better.

So to say that all antidepressants, for example, really don’t work or can’t work because they fix imbalances that aren’t the real cause of depression is flawed.  Antidepressants may fix imbalances or may even cause them, but that ultimately gets the brain to change its functioning to improve symptoms associated with depression, PTSD, SAD, PMDD, etc.

Posted by: Thomas L. Schwartz, MD at 10:44 am