15 January 2018 Depression

Depression and antidepressants - have psychiatrists got it all wrong?

A recent book about depression, "Lost Connections: Uncovering The Real Causes of Depression – and the Unexpected Solutions" by Johann Hari has created quite a stir.  The book has been reproduced in part in the Guardian newspaper.  Johann Hari repeats a number of views about antidepressant, for example that they only work by a 'placebo effect' and that they are based on an erroneous view of depression being due to a 'chemical imbalance' in the brain namely low levels of serotonin.  Hari points out that there are many social situations that can lead to depression (e.g. death of a loved one, work related stress).  He argues that we should be focusing on addressing these situations rather than giving antidepressants to people. 

Professor Carmine Pariantefrom King's College London has written a piece for the Independent newspaperchallenging some of Hari's views and he has kindly agreed for this to beattached to this site. I think it makesfor interesting reading.

I strongly disagree with Hari's reading of the literature around antidepressants.  The evidence does NOT support the notion that they only work via a 'placebo effect'.  There is clear evidence that they can work and have a very significant positive effect on the lives of people who are depressed.  I agree that depression is NOT simply due to a chemical imbalance in the brain.  However there is strong evidence of biological changes in the brain of people who are depressed.  I think it is also important to consider that "depression" is probably not just one thing.  At one end of a severity spectrum there is simply human misery which is part and parcel of everyday life.  At the other end there is a disorder in which people can experience hallucinations and delusions, stop eating and drinking and have intense suicidal ideas and planning.  Part of the reason why there seem to be endless debates about what depression is and how it should be treated is that these very different situations are conflated.  Those arguing most vociferously for the use of antidepressants would never suggest that they should be used for anybody suffering any degree of sadness in any situation.  In addition, the problems underlying these difficulties, at both ends of the spectrum, are not likely to be the same for all individuals.  Problems need to be considered at a social (e.g. work stress), psychological (e.g. loss of a loved one) and biological (e.g. altered serotonergic neurotransmission) level to be best understood and managed.  I agree with an argument that suggests that it is wrong to just consider depression as a result of a brain dysfunction ignoring all other factors in a person's life.  However, this is not what good doctors, psychiatrists and mental health workers are trained to do.  They take into account all aspects of the individual in a holistic way.  This should allow for the appropriate use of medication alongside psychological therapies and social interventions.  In my view, a narrow focus just on the social or psychological factors underlying a person's depression, but ignoring the biology, is just as bad as an approach that focuses just on the biology and ignores the circumstances of a person's life.  This is because it potentially leads to the preclusion of treatments known to be effective.

Hamish McAllister-Williams

Professor of Affective Disorders,

Newcastle University