Antidepressants - Going Backwards: INTRO

Welcome to Renegade psych. A nuanced podcast dedicated to informing the American public about the flagrant shortcomings of our healthcare system. I'm a board certified psychiatrist. And, along with my guests, break down interesting and important topics into several segments to appeal to both the general public, as well as medical and psychiatric students, residents and practitioners. My primary motivations are to appreciate nuance in major medical and psychiatric discussions, Educate listeners on the undue and widespread influence of big business in healthcare, and Provide accurate and reliable information on relevant mental and medical health topics. While I'm still young and have a lot to learn in my career, I cannot continue to stand idly by while so many in my field repeatedly fall victim to pharmaceutical interests, misinformation, and manipulation of existing data at the expense of Americans’ health. Whether you struggle with your mental health, work in behavioral health or the health care system, or want to better understand our healthcare systems over-promise-and-under-deliver status quo, my guests and I hope to provide public education on some of the most pertinent, under-reported, and controversial issues in psychiatry, mental health, and healthcare in general.

Disclaimer: this podcast is for informational purposes only. The information provided in this podcast and related materials are meant only to educate. This information is not intended as a substitute for professional medical advice. While I am a medical doctor and many of my guests have extensive medical training and experience, nothing stated in this podcast nor materials related to this podcast, including recommended websites, techs, graphics, images, or any other materials, should be treated as a substitute for professional medical or psychological advice, diagnosis or treatment. All listeners should consult with a medical professional, licensed mental health provider or other healthcare provider if seeking medical advice, diagnosis, or treatment

The concepts of depression and its worse outcome, suicide, go back millennia. This is a unique human phenomenon. Our large and complex frontal lobes allow us to constantly peer into the past and insistently try to predict our futures. When those futures seem overly bleak, or we become persistently overwhelmed, we can be thrust into a depressive episode and shut down. Our minds may become hyperactive and ruminate, while our bodies and motivations are lethargic.

Major depressive disorder and bipolar disorder, previously grouped into one spectrum of mental disorders called Manic-Depressive Illness, are the mental health diagnoses most associated with suicide. According to CDC data. Suicide took more than 48,000 lives in the United States alone in 2021, with 1.7 million suicide attempts and 12.3 million adults seriously considering it. According to the World Health Organization, in 2019, 700,000 people worldwide committed suicide, representing approximately 1.3% of all world deaths. In 2019, 58% of those deaths occurred in individuals before the age of 50 years old, giving an average years-of-life-lost of 34 years per suicide. That means in the U.S., more than 1.6 million years-of-life are lost each year to suicide. Extrapolated worldwide, around 24 million years-of-life are lost yearly. The risk of suicide in depression, including unipolar and bipolar depression, is 4-5%, compared to a fraction of a percent in the general population. Depressed people account for 30 to 40,000 suicides per year in the U.S., the vast majority of overall suicides. This is a serious problem when discussing mortality. But losses of vitality, productivity, and meaningful living far outpaced the numbers of people who die or the numbers of years lost.

Unfortunately, our medical and psychiatric understandings of depression and the criteria outlined in the DSM or Diagnostic Statistical Manual, the manual used for psychiatrists diagnosing mental illnesses, has been progressively watered down over the last several decades, and cookie cutter treatment regimens for all subtypes of depression has more Americans taking anti-depressants than ever before. The umbrella of the depression diagnosis, previously understood as a post-pubescent condition with a strong biological, or genetic, predisposition to depression and suicide, has now been widened to include kids, adolescents, and adults undergoing adverse life circumstances, what was previously described as situational, or neurotic, depression. Those with biologic or melancholic depression are believed to have a genetic and heritable predisposition to becoming depressed, are far more likely to die by suicide and are more likely to benefit from medications that raise the total amount of monoamines, including dopamine, norepinephrine, and serotonin. Those with situational, or nephrotic, depression are less likely to commit suicide, more likely to respond to therapy and nonpharmacologic treatments, and less likely to respond to medications, especially in the long-term.

However, if we treat all depressive subtypes the same, that means the 70-90% of situationally-depressed persons can also take medications, oftentimes for years or even lifetimes. More people on anti-depressant medication means more revenue is generated for industry involved in this market. Again, we are witnessing the influence of marketing, advertising, and big business economic interests superseding what the leaders in the medical field generally consider good medical practice.

In addition to casting a wider diagnostic net, our current quote unquote gold-standard treatments are much less effective than in the mid-to-late 1900s. The major class of antidepressants introduced in the 1950s were the MAOIs, or MonoAmine (Oxidase) re-uptake Inhibitors. They act to increase the neuro-availability of all the major monoamines, including dopamine, norepinephrine and serotonin. Due to concerns about their side effect profiles, including significant dietary restrictions and interactions with wine and cheese, MAOIs were replaced by the TCA's, or TriCyclic Antidepressants, which act mostly on serotonin and norepinephrine, but also have serious cardio-toxicity in overdose. The TCAs were replaced by the well-known and modern SSRIs, or Selective Serotonin Re-uptake Inhibitors, in the latter decade of the 20th century. They are now some of the most commonly prescribed medications in the United States. They have questionable efficacy. While they're arguably safer and more risk averse, they do not take into account the serious consequences of not treating biologic depression effectively, potentially death. They also reduce the concept of depression to the professionally debunked and reductionistic notion of a serotonin deficiency.

These transitions are almost assuredly in part driven by profit motives, to the detriment of the American public and our scientific understanding of depression. We don't know a whole lot more about depression now compared to the middle of the 20th century as pharmaceutical companies do not have vested interest in conducting research that could limit the number of persons likely to respond to antidepressant medications and thereby eat into their profit margins.

Today, we're going to talk about what depression is, discuss the historical transition from MAOIs to TCAs to SSRIs, and reveal how the Train Wreck of Medical Publishing and the current medical-industrial complex hinders our ability to conduct and utilize accurate and effective research to move the train of psychiatric knowledge and understanding forward.