Healing from depression is a long, slow process. My depression was the result of trauma (a subject I’m saving for another post as I am not yet ready to share it), so when I sought help in December I knew I needed a therapist to help me work through what happened to me. We agreed in our first session to see what we could do with therapy alone, and leave antidepressants as a discussion down the road if things did not improve.
Confident that depression was not going to become my new normal, that I could overcome, heal, and move on from it, I set out to do everything my therapist recommended to get better. I created structure and routine for myself that wasn’t entirely dependent on work. I went to the gym every other day, went for walks with my mom when I could, joined a weekend hiking group on Meetup, and started taking classes at a yoga studio, all because exercise has an enormous effect on my mood, and so do the outdoors and socializing. I tried to dress in ways that made me feel confident, and would take the time to put on makeup in the mornings and take it off at night. I changed my eating habits to avoid sugar, and made sure I wasn’t eating absentmindedly while working or watching Netflix. I started learning Chinese and got back into my coding classes. I joined a book club and started reading more, and I created this blog to write more. I even tried meditation and daily affirmations. And I continued to attend therapy once a week.
Yet, in spite of all this, there were still days and weeks where I couldn’t even bring myself to get out of bed in the mornings. It didn’t matter if I had ten hours of sleep, I would stay in bed, sleep in, and tell myself I could go to the gym tomorrow. I spent hours in the car on my commute ruminating on the same worn-out subjects until I couldn’t focus on anything at work, or would explode at my family upon returning home. After one particularly bad week, I decided to go out with some people I hardly knew. I drank way too much and ended up spending the night on the couch of a complete stranger’s apartment. Luckily, I was with very good people. They looked after me and made sure I was safe. But I’m well aware the night could have gone very differently. My mom was enraged that I had acted so recklessly, and that I had missed the yoga class we had planned the next morning. Knowing that I had hurt and disappointed her caused so much guilt and self-hatred that I quickly spiraled downward until I wanted to cut myself again. I texted a crisis helpline and they helped me manage the urge. But the next few days were hard.
I was already frustrated that after months of therapy I was still having circular, intrusive thoughts, but when this incident happened, it scared me. I thought I had moved past thoughts of self-harm. I felt like I was back at square one, like I hadn’t made any progress at all. I began to think maybe my problem was deeper than I realized. Maybe I couldn’t get better on my own. Maybe my brain was messed up and I needed medication to make it right. After months of being depressed, the idea that I could take a pill and magically feel happy and like my old self again sounded too good to be true, so I decided to start looking into antidepressants.
At that time, I was in-between therapists. I had a three week gap where my old therapist was changing locations and no longer able to see me, and my new therapist did not yet have any openings. So instead of talking to one of them about antidepressants, I was left to do my own research. Luckily, the research I did for my last post on loneliness led me to Johann Hari’s book Lost Connections, which dives into this subject in detail.
One thing I appreciate about Hari’s writing is that he clearly comes from a background of investigative journalism. Unlike a self-help writer pretending to have all the answers and looking to share their own opinion, he is looking for the truth, or at least pointing to where it might be found. He traveled all over the world interviewing experts for this book, and draws on both statistical and anecdotal evidence, while still allowing the reader to come to their own conclusions. I highly recommend reading Lost Connections to anyone who has ever been depressed, or knows someone who has.
Hari writes about his own experience with depression, and how as a teenager he was prescribed antidepressants. He describes the immense, initial improvement these drugs had on his mood, as well as the slow, inevitable decline in their effectiveness that led him to continually up the dose again and again, year after year. He, like many of us, believed the popular medical explanation for depression: Depressed people have a chemical imbalance in their brains, they don’t have enough serotonin, and the only way to fix it is with chemical antidepressants like selective serotonin reuptake inhibitors (SSRIs).
However, as he did more research, Hari came to understand that this explanation is far from the full picture. As it turns out, almost all the studies done on antidepressants are funded by pharmaceutical companies, the same people making and selling drugs such as Prozac, Paxil, and Zoloft. They have complete control over how these studies get published. They can edit and cherry-pick the data, so that the public is only aware of findings that support the use of these drugs. If a study doesn’t result in any positive findings for the company, they may choose not to publish it at all. As a result, the information we have about the effectiveness of antidepressants is incredibly biased. But luckily, in order for a drug to be sold to the public, pharmaceutical companies must submit their full unedited findings to the Food and Drug Administration. This means that copies of the real results of these studies do exist, and one of Hari’s interviewees, Irving Kirsch (Associate Director of the Program in Placebo Studies and a lecturer in medicine at the Harvard Medical School), was able to get his hands on them.
When looking at the complete data, it becomes clear that the majority of antidepressants’ effectiveness is caused by the placebo effect. In most of the studies, sugar pills were equally as effective at treating depression as SSRIs. To be clear, I’m not saying antidepressants don’t work, I’m saying the reason they do has very little to do with the levels of serotonin in our brains, and everything to do with our expectations. Any extra improvement the drugs provided that was not accounted for by the placebo effect was so minimal as to be almost meaningless (less than the effects of getting a good night’s sleep). Millions of people each year are paying their hard-earned money and dealing with a variety of side effects like weight gain, intestinal problems, and loss of sexual desire, in order to obtain the same results for their mental health they might have had with a sugar pill.
Not only does this show that antidepressants aren’t as effective at treating depression as we thought, we are also looking in the wrong place for the cause of depression. What if the chemical imbalance in a depressed brain is not the cause of depression, but another symptom of it? Hari’s book explores this premise and identifies what may be the real causes of depression, which include biological, psychological, and social factors. There are obvious causes like unresolved trauma and grief, but there are also more subtle factors, like a pervasive sense of loneliness; an oppressive, unfulfilling work environment; insecurity and a lack of hope for the future; and looking for happiness in the wrong places due to our consumerist culture. These causes need to be discovered and remedied in order for depression to be cured.
We like the theory that depression is simply a chemical imbalance, because it gives credence to the disease as a physical ailment, no different than diabetes or pneumonia. For people who are depressed but feel that they should be happy, who believe they have no reason not to be, understanding depression as a random chemical imbalance allows them to acknowledge their suffering. It validates their sense that something is wrong, even if they can’t point to grief or trauma as a reason why. It also seems to provide an easy fix. Take a few pills and you’ll feel better. But more often than not, the causes of depression are external. It turns out prescribing antidepressants to a depressed person without any other treatment is a bit like prescribing painkillers to a patient with foot pain without ever bothering to look and see the nail in their foot. When you treat the symptoms and not the cause you will never be able to heal, and it may just prolong the suffering.
So where does that leave me? Unsurprisingly, I am no longer interested in trying antidepressants. If most of their effectiveness is just placebo, I doubt they would work on me now that I’ve read this book. That’s not to say other people should go off them. If you believe they work for you then the probably do, specifically for that reason. But I would still encourage you to closely examine your life and see if their is a cause for your depression you hadn’t considered before. Hari’s book is a good place to start.
For my part, I know now that I have to stop minimizing what happened to me, face my trauma head-on, and realize it’s going to be a long time before I’m fully okay again. I can’t just snap my fingers (or take a pill) and get there. It’s going to take a lot of hard work and a lot of therapy. I’m going to continue to have days where I can’t quite bring myself to get out of bed. But rather than seeing those days as failures, I can change my mindset and see all the other days where I get up and get out of the house as major accomplishments. Twice now I have reached out for help instead of giving in when I felt the temptation to self-harm, and I can choose to see that as proof of my bravery and strength.
Speaking of therapy, I absolutely love my new therapist. She seems to get me in a way the old therapist never did. I feel that in just a couple weeks of meeting with her (over Skype) I have already made more progress than I did over several months with my old therapist. It turns out picking a therapist is a bit like dating. Don’t just settle for the first one you meet. Find one who connects with you on a personal level. It might just seem like any professional will do, but the relationship you have with your therapist is unique and can have a huge effect on your healing process.
Therapy, with the right therapist, can be incredibly helpful no matter who you are or what you are going through. I truly believe everyone should have a therapist, even if they only meet with them once a year like an annual check-up. But although a therapist can help us discover the causes of our depression and give suggestions that can help us, due to the nature of some of the causes of depression, healing may mean not only making changes in our individual daily lives, but also shifting our values, priorities, and organizational structures as a society. This isn’t easy to do, especially right now when everyone is quarantined, meeting people face-to-face isn’t an option, and the future seems more unstable than ever. I debated with myself whether the timing for publishing this post was right given the current circumstances. After all, with the constant barrage of bad news and everyone’s mental health at an all-time low, stepping in and saying antidepressants aren’t effective as anything other than placebos seems incredibly unhelpful.
But on the other hand, what better time to discuss the real causes of depression and the real solutions than when everyone is hyper-aware of their health (mental and otherwise)? The coronavirus is making us aware of the problems with our consumerist, individualist culture, and showing us what actually matters. Social-isolation has shown us the importance of community. Staying inside shows us how much we need the outdoors. Fighting over toilet paper and hoarding face masks and hand sanitizer shows how we have been valuing things more than people. Dividing the work force into those who are essential and those who aren’t makes us question our obsession with celebrity, and wonder why the essential workers are often the ones getting paid the least. Even job losses give us an opportunity to reconsider whether we were ever really valued at our jobs, whether we found them meaningful, and whether there isn’t something we’d rather be doing with our lives. We are being forced to reevaluate our individual lives, as well as the social, cultural, political, and economic context we live in. There is a lot more pain and suffering we are going to have to go through before this pandemic is over, and our society will not be the same when we come out the other side, but hopefully at least some of those changes will be for the better.
MJM Writes 
I really enjoyed this post …. you, my dear, are brilliant!
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I’m a nurse. I’m also someone who has struggled with depression for much of my life. I don’t think there is a one size fits all answer when one tries to dig themselves out of depression.
I have seen others benefit from antidepressants. They have also helped me with my struggle.
Who is to say what the “real causes” of depression is? The causes are multifactorial.
Antidepressants aren’t for you…great. Don’t be so quick to write them off for others.
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Hi Kate, I appreciate your perspective as a nurse and as someone who has been struggling with depression longer than I have. As someone who has never tried them personally, I tried not to make any definitive claims on the effectiveness of antidepressants for myself or anyone else. I think you’ll find that I do make an effort in this post to differentiate between the claim that antidepressants do not work, and the claim that they do work but not for the reasons we assumed. I believe that antidepressants have helped many people, and I believe that they can continue to do so. But exactly how they help isn’t entirely clear. It’s not easy to measure decreases in depressive symptoms when the symptoms are so varied and subjective, and they can be affected by any number of factors we can’t always account for or control. Moreover, it’s a fact that pharmaceutical companies have been biasing public opinion about antidepressants by withholding information. At no point do I claim antidepressants don’t work, I simply claim that the full studies do not provide any solid evidence that they do, at least not beyond the effects of a placebo. That doesn’t mean another study can’t come along and provide this evidence, it just hasn’t happened yet. If anything, this goes to show how powerful placebos are.
I base my claims on the evidence provided in Johann Hari’s book. I highly recommend you read Hari’s book yourself. Like you, he was on antidepressants for many years and believed in their effectiveness, and like you he was highly skeptical and uncomfortable with the idea that they don’t work for the reasons we think they do. Even after writing Lost Connections he still believes that chemical antidepressants do have a place in treatment for depression, and they can help certain patients. I would suggest reading his book to gain a fuller understanding of my perspective in this post. You can look at the evidence he provides and combine that with your own experiences to form your own opinion.
My goal in this post was not to tell anyone to go off antidepressants, that’s a highly personal decision and I am not a doctor; nor was it my goal to deny anyone’s experiences with antidepressants. If you tell me they work for you, I believe you, I’m not writing that off. Instead, I simply wanted to share the reasons for my personal decision not to try them. I agree with you that there is no “one size fits all” answer for depression and that the “causes are multifactorial.” In fact, those are exactly the points I was trying to make. Anyone who seeks help for their depression and is simply told their serotonin levels are off and that a pill will fix it is being done a disservice because they are being given a one size fits all answer. I am encouraging people to look beyond the chemical imbalance explanation and see if there are any other factors that may be causing their depression. Some possibilities Hari covers in his book are “disconnection from meaningful work, disconnection from other people, disconnection from meaningful values, disconnection from childhood trauma, disconnection from status and respect, disconnection from the natural world, and disconnection from a hopeful or secure future, in addition to genetics and brain chemistry,” but this is not an exhaustive list. Most people will probably have a combination of these as factors, and for most people drugs aren’t enough.
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