Relighting the inner flame

Townsend Letter for Doctors and Patients, Jan, 2007 by Jule Klotter

Since Townsend Letter's original publication of "Relighting the Inner Flame" in August/September 1996, selective serotonin reuptake inhibitors (SSRIs) have redefined depression. An estimated 67.5 million people have started a SSRI since Prozac arrived on the market in 1988, Zoloft appeared in 1992, and Paxil in 1993. (1) Thanks to heavy direct-to-consumer advertising, depression is widely viewed as "a chemical imbalance ... a lack of serotonin." Alliance for Human Research Protection has found that, although most quit taking the drugs within the first year, millions of US patients remain on SSRIs for several years. About 25% of SSRI users find that they have difficulty withdrawing from these drugs. (2) Some patients misinterpret withdrawal effects, believing those effects to be the return of their original symptoms. When they return to taking the SSRI and withdrawal symptoms disappear, patients (and practitioners) believe that the drugs are necessary for their health.

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Jeffrey R. Lacasse and Jonathan Leo question the efficacy of SSRIs and the serotonin imbalance hypothesis that has been so widely disseminated. In their essay for PLoS Medicine, the authors refer to a 2002 analysis, submitted to the US FDA by Irving Kirsch and colleagues. This analysis examined all published and unpublished clinical trials that antidepressant manufacturers submitted to the FDA for medication approval, obtained through the Freedom of Information Act. Kirsch's team found that "the placebo duplicated about 80% of the antidepressant response, [and] 57 % of these pharmaceutical company-funded trials failed to show a statistically significant difference between an antidepressant and inert placebo." (3)

The high placebo response and "modest efficacy" of SSRIs in these studies cause Lacasse and Leo to question the serotonin hypothesis. They point out that treatment of known biochemical imbalances, such as insulin deficiency, shows more reliable and concrete results. Also, several treatments that do not affect serotonin levels relieve depression. Tricyclic antidepressants, for example, have about the same efficacy as SSRIs, according to a Cochrane systematic review. St. John's wort performed better than Paxil in a 2005 study (BMJ. 330:503), and exercise was as effective as Zoloft in a 1999 study of older patient with major depression (Arch Intern Med. 159:2349-2356). "To our knowledge," Lacasse and Leo write, "there is not a single peer-reviewed article that can be accurately cited to directly support claims of serotonin deficiency in any mental disorder, while there are many articles that present counterevidence." (4) Unfortunately, advertising has more influence than science among anxious and depressed patients and many practitioners.

People who believe SSRIs are the solution for a chemical imbalance are more likely to stay on the drugs long-term. Unfortunately, very little data exists about the long-term efficacy of SSRIs or their potential for permanent health damage. By issuing a public health advisory in March 2004, (5) the FDA has acknowledged that SSRIs increase the risk of suicide in children and adults. Antidepressants have helped many people, but they are not the only solution. "Relighting the Inner Flame" offers other ways to deal with depression.

Many of us, at one time or another, experience depression. Physical ailments, circumstances that seem beyond our control, and underlying beliefs of worthlessness, hopelessness, and guilt batter the inner flame. Without that flame, life seems a pointless burden. We withdraw from life. Depression, says psychiatrist Stephen Nezezon, is like "a pilot light getting blown out on a stove." Some people identify the problem and relight the pilot in a very short time. Others exist for years in isolating darkness. They do not know what it feels like to be happy and to live fully with energy and joy. How does one relight the pilot and guide it from a weak, sputtering light to a steady, bright flame?

Many doctors and patients believe that Prozac (fluoxetine) is the answer. Its world sales totaled $2 billion dollars in 1995, and forecasters predict that sales will continue to rise as more people seek help for depression. Prozac, the first of a new family of antidepressants called serotonin-selective reuptake inhibitors (SSRI), has metamorphosed psychiatric medicine. As Peter Kramer explains in his book Listening to Prozac, these drugs reinforce a biochemical view of psychological states and are redefining psychological health. Researchers are now saying that a low serotonin level in the body is low self-esteem, that low serotonin levels cause feelings of submissiveness and unworthiness. Prozac raises serotonin levels. Because it increases serotonin, Prozac can increase assertiveness and tolerance, which raises low self-esteem, a major contributor to depression.

Antidepressants can quickly break cycles of emotional pain, depression, and fear, empowering patients to see that their mood can change. Many alternatively-inclined doctors find antidepressants, Prozac among them, useful for patients who are too distraught for counseling and/or suicidal. Antidepressants can, indeed, be a first step towards healing. In a letter to Townsend Letter, Philip R. Kavanaugh, MD, wrote: