Since the 1960s, mental health research, especially research on depression, has been based on the serotonin theory of depression, which suggests that depression is caused by low levels of serotonin. Consequently, the use of Serotonin Reuptake Inhibitors (SSRIs) in the treatment of depression has been steadily rising; 1 in 8 American adults were taking antidepressants before Covid and that number rose by 18.6% during 2020. That number is continuously increasing, however, there seems to be a lack of evidence of efficacy. A 2022 umbrella review finds there to be no evidence that suggests low serotonin levels cause depression. What does that mean for those on SSRIs? What will be the future direction of mental health research? How will this affect those that are suffering from depression?
Main Findings of the Research on Serotonin Theory of Depression
Chemical Imbalance and SSRIs
The main justification for the use of antidepressants was the idea that depression was the result of abnormalities in brain chemicals, particularly serotonin. Around 80% or more of the general public believe that it is empirically established that depression is caused by a chemical imbalance. This erroneous claim has plagued popular media and many general practitioners still use it to justify their prescriptions. Most of the studies within the review found no evidence of reduced serotonin activity in people with depression compared to people without. Therefore, the review suggests that the huge research and effort based on the serotonin hypothesis has not produced convincing evidence of a biochemical basis for depression.
SSRIs Have No Unique Short-Term Effects
A short-term analysis indicates that there are no specific antidepressant drugs. Most of the short-term effects of antidepressants are shared by many other drugs, and that long-term drug treatment with antidepressants or any other drugs has not been shown to lead to long-term elevation of mood. The pharmaceutical and mental health industry should abandon the term “antidepressant” and adopt a drug-centered model consistent with a demedicalized approach to depression. The drug-centered model suggests that drugs cause biochemical abnormality rather than relieving it. One may drink alcohol to relieve social anxiety. However, that does not imply that alcohol corrects a chemical imbalance underlying social anxiety.
Alternative Explanations of SSRI Efficacy
Amplified Placebo
Self-fulfilling prophecy
In psychology, a self-fulfilling prophecy is a belief or expectation about the future that an individual holds that manifests or comes true because the individual holds it. Spiritual individuals tend to intertwine the idea of manifestation with the psychological concept of self-fulfilling prophecy. If I am to believe the world is a horrible place, I will only see the horrible things of the world. This will further my belief in a horrible world. My subconscious belief about the world presents opportunities for me to confirmation bias my belief and thus fulfill the prophecy
SSRI
If one is to extrapolate this idea to SSRIs, then we can understand a possible alternative explanation as to why they work. This is not a new discovery. Researchers use placebos all the time in clinical trials with medication to test for alternative effects. Depressed individuals have been told by the popular media and their healthcare providers that SSRIs will make them feel better. They take the medication expecting to feel better, which in turn causes the individual to focus on the positives.
SSRIs Create an Abnormal Brain State
Takes the Edge Off
Another explanation for SSRI efficacy is that it takes the edge off. The drug creates an abnormal brain state that relieves the individual of depression symptoms. This is synonymous with the idea that antidepressants emotionally castrate the patient. It is hard to be depressed if you don’t feel anything. From personal experience, when I was taking Zoloft, I felt as if it took my soul. I became an emotionless robot. If I am to feel nothing, then I no longer can feel the detrimental effects of depression. Thus, my suicidal ideation decreases immensely or ceases to exist. I understand this is not the case for everyone. These are just possible alternative explanations as to why SSRIs seem to work.
Benefits and Drawbacks of SSRIs
Benefits
I remember that my good friend came to me explaining that she realized that she had an eating disorder. At that moment, I told her that she needed to reveal the truth to her family and seek professional help. If she had waited too long, the window of opportunity would have closed. Her mind would have rejustified her eating patterns. Who knows how long it would take for another window of opportunity to arise.
The main benefits I see to SSRIs are the strong acute effects. These effects can, in the short-term, mitigate the effects of depression. Within the short term, I believe the individual is in the same place my friend was at. They are at a window of opportunity where, they are treading, and their head is slightly above the water. They only have so much time to scream for help before they fatigue sets in and they begin to sink again. During that time, I think that it is paramount to be in therapy. Mental health practitioners need to pair drug treatment with therapy. If not, individuals may be stuck in an everlasting cycle of increasing the dosage or drowning in despair.
Drawbacks
Long-term Dependency on SSRIs to Function Normally
SSRIs are a bandage to the gaping hole created by trauma, grief, loss, and other cries from the soul. One can attempt to fill it with a higher and higher dosage of antidepressants, but the truth is, without proper treatment, one will be bound to a life leaning on the crutches of a drug that has proven to have no empirical substantiation.
The Oppositional Model of Tolerance
The oppositional model of tolerance states that continued drug treatment may stimulate processes that run counter to the initial acute effects of a drug.
Early Treatment
Long-Term Treatment
Loss of Clinical Effects and Increased Side Effects
With long-term therapy, loss of treatment efficacy and some side effects, which do not occur initially, may appear. The patient will build a tolerance to the medication over time, which will progressively reduce the desired response. During this time, the patient may experience apathy or fatigue. Furthermore, the patients may relapse in the sense that they will be hit by another depressive episode.
Refractoriness
A refractory phase is characterized by higher rates of relapse while on treatment, lower remission to subsequent treatments, as well as higher intolerance to further treatment. This is caused by pharmacological manipulations. Either by switching the antidepressant or increasing the dosage. These pharmacological manipulations have a high chance of propelling the client into a more depressive illness.
Post-Treatment
New Withdrawal Symptoms
Like any other drug, weaning off or going cold turkey from SSRIs, will induce a broad range of somatic and psychological symptoms: headache, dizziness, flu-like symptoms, nausea, anxiety, panic attacks, dysphoria, irritability, confusion, and worsening of mood. Symptoms typically begin within 3 days of stopping antidepressant medication or initiating medication taper. Untreated symptoms may be mild and resolve spontaneously in 1–3 weeks.
Persistent Post-Withdrawal Disorder
This disorder is characterized by experiencing withdrawal symptoms for months or years after being off of the medication. Withdrawal symptoms are likely to be misunderstood as indications of relapse and may lead to starting treatment with antidepressants again, perpetuating the problem.
Resistance if the Same Treatment is Reinstituted
If a patient comes off of the medication and a year later has a depressive disorder, they may not respond to the same antidepressant that improved the depressive symptoms before. The lack of differentiation between an illness episode that is unresponsive to a certain treatment and the lack of response to previously effective therapy is likely to generate confusion. Such confusion is increased by the assumption that treatment was right in the first place and failure to respond is blamed on patients’ characteristics. “Treatment resistance” thus prompts switching and increasing the dosage of the antidepressant. . Yet, these therapeutic strategies may trigger a cascade of negative effects.
Future Directions of SSRI and Mental Health Research
Decrease in the Stigmatization and Pathologization of Mental Illness.
In a sense, I find it relieving that our mental illness cannot be simply cured via medication. For decades, they have minimized our experiences and suffering to a digestible diagnosis that they can cure through pharmacotherapy. However, depression is a huge part of us and not something curable. I believe the more we deviate from the idea that there is a cure for mental illnesses such as depression and anxiety, the more we will promote healthy change. They have given us a false promise and given the false hope that there is a cure for our existence, but in truth, we are who we are, and we must learn how to live side by side with it. They have promised an external answer to an internal problem.
Depression is not the enemy; the enemy is those who told us that it was. Those who have pathologized the masses of neurodivergent individuals for the purpose of exploiting a vulnerable population for billions of dollars in pharmaceutical profits. They have led us to believe that there is something wrong with us. However, as my eyes begin to open, I see that our brains just work differently than others. They have forced us into a box that simply does not fit in and that could also be a significant factor in our depression. As a child, you would put shapes into holes and learn that the triangle doesn’t fit into the square. The pharmaceutical industry and many health providers have been attempting to put the triangle into the square. We fit into the triangle piece. The question is, where do we find sanctuary and peace?
Self-Efficacy and Love
I believe this to be a blessing in disguise. The vale has been lifted and now we can start the actual work of helping those that are suffering from mental illness. Instead of persuading those suffering into believing that there is an out and a cure, how about we help them affirm the life that they are currently living. Instead of telling them to seek outwardly for the answer to their problems, maybe they can search for the answer internally. We have been told that we are mentally ill and we are condemned to a life of suffering. However, the truth is that everything is a self-fulfilling prophecy. If we no longer internalize and self-label as the diagnosis that has been given to us, we can control our destiny again. If we believe that there is hope, then we can escape the chains of pathologization.
Through individualized and personalized therapy treatment plans, I think that we can help everyone understand the unique intricacies of their brain. They shouldn’t have to walk up a mountain with a boulder on their back. Expressing to them that there is nothing wrong with their brain, there is no chemical imbalance, and the only thing needed is nurture and love towards themselves. Through profound vulnerability, self-compassion, self-love, self-empathy, and having therapists who are willing to mold themselves into each individual case, I believe that any person could climb out of the metaphorical well. Love is always the answer, but it can be the hardest choice. To choose love when everything is telling you not to is exactly when you need to choose it. Love can singlehandedly solve the mental health crisis.