The presence of hope can be just as powerful as its absence. Just ask anyone with depression. Depression is a devastating illness that thrives on hopelessness. This sense of hopelessness can be worsened when medication, often taken as a last resort, fails to deliver any relief. New research finds clues as to why antidepressants don’t work for everyone.
There are a number of treatments for depression, and amongst the most common are SSRI’s (Selective Serotonin Reuptake Inhibitors). About 50% of people who take SSRI’s find that their depressive symptoms are halved within 8 weeks of taking the medication. Then there are the other 50%. For those people, antidepressants just don’t work.
Out of the people who do find relief, half of them will see a return of the symptoms, taking the actual recovery rate to 25%.
The way we think about depression is changing.
Though SSRIs are a lifeline for many people, their sketchy levels of effectiveness have put pressure on the idea that depression is caused by a lack of serotonin. The way we think about depression is changing. More recently, there has been a dramatic shift away from the serotonin theory of depression. There are a number of reasons for this:
- If depression was caused by low serotonin, it would be expected that medication which increases serotonin would be more effective than the 50% strike rate of SSRIs.
- A number of studies (including here and here) have found that in some depressed people, serotonin is elevated.
- There are other treatments for depression, including therapy, a combination of meditation and exercise, and medication that has little effect on levels of SSRI, that can reduce depression as much as SSRI’s do.
- The key argument in the serotonin theory of depression was the observation that increasing serotonin relieved depression. However, in the same way that a headache is not caused by low levels of paracetamol, the effectiveness of SSRI’s does not necessarily mean that depression is caused by low serotonin.
- Recent research points to the possible role of oxidative stress in depression.
SSRI’s seem to have some capacity to heal, but not reliably, and only in around half of the people who take them. Clearly something is missing. New research seems to have found some pieces that can start to fill out the picture.
Why Antidepressants Don’t Always Work – Let’s talk about the research.
In a study published in the journal, ‘Brain, Behavior and Immunity,’ researchers found important clues about how SSRI’s work, and more importantly, what can be done to increase their effectiveness.
‘There is no doubt that antidepressants work for many people, but for between 30 and 50% of depressed people, antidepressants don’t work. No-one knows why. This work may explain part of the reason.’ – Silvia Poggini, researcher, Intituto Superiore di Sanita, Rome.
From the research, it seems that the effectiveness of SSRIs doesn’t happen directly by increasing serotonin. What seems more likely, it that SSRIs facilitate recovery by increasing the plasticity of the brain so it can be changed, healed and strengthened by environmental and lifestyle factors. (Plasticity refers to the brain’s capacity to change.)
‘In a certain way it seems that the SSRIs open the brain to being moved from a fixed state of unhappiness, to a condition where other circumstances can determine whether or not you recover’ – Silvia Poggini.
The research was conducted in mice. (Mice are often used in research in place of humans because of their biological and genetic similarity to humans.) After the mice had been stressed for two weeks, they were all given SSRIs. They were then split into two groups. Half the mice continued to be exposed to stress while the other half were put in a calmer, less stressful environment.
The mice that were treated with SSRIs and put into the more comfortable environment showed an improvement in their depression symptoms. In contrast, the ones who were treated with the SSRIs and put into the stressful environment showed a distinct worsening of their symptoms.
What makes a difference?
When someone takes SSRIs, the environment and the things that person does, play a critical role in whether he or she will get better, stay the same, or get worse.
The research suggests that the effects of the SSRIs aren’t necessarily on serotonin, but on the brain’s capacity for change. The medication conditions the brain for recovery, and the environment drives the recovery – for better or worse. The environment has a heavy influence on how the person will respond to the antidepressants.
‘This work indicates that simply taking an SSRI is probably not enough. To use an analogy, the SSRIs put you in the boat, but a rough sea can determine whether you will enjoy the trip. For an SSRI to work well, you may need to be in a favourable environment. This may mean that we have to consider how we can adapt our circumstances, and that antidepressant treatment would only be one tool to use against depression.’ –Silvia Poggini.
What can help?
Environment seems to be key. Environments that are nurturing and supportive of healing are more likely to change and strengthen the brain in a positive way. This might be enhanced if SSRIs have prepared the brain for this. On the other hand, environments that are stressful and unsupportive, and a lifestyle that doesn’t nurture the body and the brain, will potentially fail to make the most of any benefits of SSRIs.
The research is in its early days, and more will be needed before we have a clearer picture.
In the meantime, an abundance of research has found strong evidence for the effectiveness of various lifestyle and behavioral factors in easing the symptoms of depression. These include meditation, exercise, reduced stress, diet, sleep, and the company we keep. These have been found to change the structure and function of the brain in ways that promote a healthy brain.
The idea that healing is more likely through a combination of environment and medication is nothing new, but this research gives us evidence of the importance of environment and lifestyle in healing from depression.
And finally …
The hopelessness that is so characteristic of depression can be worsened when medication fails to bring any sort of relief. For at least 50% of people, medication makes no dent at all in their symptoms. From the research, it seems that the effect of antidepressants may be more indirect than once thought. More importantly, it seems that they might not be as effective on their own, as they can be when lifestyle and environmental factors are able to support the healing.
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