Transcription
Today we're going to talk about how anti-depressants actually work. And no, not the lie that you've been told that they fix some kind of chemical imbalance, but the real truth about what these drugs really do to the brain. And so, if you're someone taking one of these medications, you need to understand this because knowing exactly what they do and how they work is essential to using them safely. And that's what we're going to talk about today.
For those of you who don't know me, I'm Dr. Yseph. I'm a psychiatrist and I used to be a drug researcher who worked in the pharmaceutical industry and at the FDA and now I help people safely come off psychiatric medications.
To start this off, I just want to level set. Let's talk about what anti-depressants actually are. Anti-depressant is essentially an umbrella term for a whole class of medications used for depression. And all of these drugs work by affecting neurotransmitters in the brain. These are the chemical messages, things like dopamine, serotonin, norepinephrine.
But let's focus in on one class of anti-depressant, the SSRI. These are the selective serotonin reuptake inhibitors. And they are the most popular class. These are usually what people are thinking of when they're taking anti-depressants. And examples of these include things like Prozac, Lexapro, and even Zoloft.
So, let's talk about how SSRIs work. Essentially, they block the re-uptake of serotonin in the brain, increasing the overall amount of it. So, that's all good, but why would we use a drug like this to treat a condition like depression?
Well, all of this comes down to something called the chemical imbalance myth. Now, the chemical imbalance myth claims that low neurotransmitter levels like serotonin are the cause of depression. And I want to highlight that, you know, with my voice. So, this means it's not life, it's not relationship problems, it's not a lack of meaning. They believed that depression is actually due to low neurotransmitters.
And we have to think about where this idea comes from. And from my research, I have to tell you, it's kind of scary because part of it comes just from history, but the other part of it was born in drug company marketing departments. And so, let's take a brief segue to talk about how this dark myth emerged.
And so, it starts in the 1950s and researchers were giving a drug called to tuberculosis patients. This drug had antibiotic properties and they thought it was going to help with the infection. But what they noticed was that when they gave it to the tuberculosis patients, they started to look more energized. They started to look happier. They started to move around a lot more. And the researchers thought, "Huh, that's interesting. I wonder if this drug could help patients with depression." And so they gave it to their researcher friends who went and used it. And lo and behold, it actually worked. The depressed patients became more upbeat and energized.
Now, the researchers knew a little bit about they knew that it inhibited an enzyme called monoamine oxidase. Now, this is a mouthful, but essentially what that is, it's an enzyme in the brain that breaks down neurotransmitters like serotonin. And so, some researchers who saw that it helped their depressed patients said, "Huh, I wonder if depression might be caused by low levels of chemicals like serotonins, and maybe that's why these drugs help."
Well, if you're like me, you would think at best this was just an interesting line of thinking at the time, because sure, why not? But if you really think about it and slow down for a second, a more compelling narrative was really that these drugs simply worked like other drugs like alcohol or caffeine or cocaine that they they had a chemical effect that changed or boosted your mood in some way because I mean after all, hadn't they just seen it work in tuberculosis patients who weren't depressed at all? They were just like really fatigued because they were sick. And so it clearly wasn't specifically just helping with depression.
And so this is where this story really takes a dark turn because the chemical imbalance idea, it really took off not because the evidence supported it or because it was the most logical thing, but because it made for a much better commercial narrative. And and let me explain that because there's a bit of nuance here. You see, most people have always been very wary of taking drugs that simply mask symptoms for things. People intuitively know that if you have a problem, it's important to address the root cause. Because if you just mask the symptoms, the original problem isn't going to resolve and it can actually just worsen over time. Think about it like this. If you had all of a sudden severe stomach pain and it kept on occurring, you wouldn't want to just take some opiates to mask the pain. You'd want to know like, hey, what is going on in my stomach? Is there something in there that's serious? Could it be getting worse? Does it need to be treated?
Drug companies knew this. They knew it would be easy to sell these drugs if people thought they were cures for real medical conditions rather than temporary symptom masking drugs. And so they started to push this message out to the public. They would say things like, "Well, you know, some doctors think depression is a medical problem and that it should be treated like other medical conditions." And their favorite analogy became this. You've probably heard it. Depression is just like diabetes. And a diabetic needs insulin. And it would be unscientific to deprive someone of that.
But there's a clear problem with this analogy. You see, in type 1 diabetes, we know the islet cells in the pancreas are destroyed by an autoimmune process. And so, your body simply cannot make insulin. And so, it makes perfect sense that you would need to inject it to replace it. But with depression, was there ever any proof that it was caused by problems in neurotransmitters? And now, that's a fair question, and researchers have been looking at this for decades. And I have to tell you this as someone that has scoured this research. Not once have they ever found consistent evidence that there is a difference in brain chemistry between people who have depression and those without.
And there was this excellent 2022 paper done by Joanna Monreef at University King's College London where they reviewed all of this evidence and I mean everything. I mean the research that she covered in her paper was comprehensive. They looked at studies where they had analyzed spinal fluid samples. This is the fluid that kind of floats around the brain. And they had looked in there for the metabolites of things like serotonin to see, you know, is the metabolites of serotonin different in depressed brains and non-depressed brains. And there was no difference. They also did autopsies of people who were very depressed and they died of suicide. And they looked at receptor densities, you know, are there different serotonin receptor densities in these brains. And so they they they did their pathology slide and they looked under the microscope and then they compared it to healthy non-depressed brains and there was no difference. And they've done many other studies like this and they never found a difference.
And to just hammer this point home because there are no biological objective measurable differences in the neurotransmitters between depressed and non-depressed individuals. This is why when you go and see a family medicine doctor or a psychiatrist, they're not measuring your serotonin levels or anything like that. And so you have to kind of ask yourself, if there's no actual difference in the serotonin between a depressed and a non-depressed brain, what exactly are these drugs doing that boost things like serotonin?
Now, this is the time where I give you the hard truth about the matter, and this has been hidden for a long time. And I'm going to sound a little cynical saying this, but I've been a psychiatrist for 10 years now. I worked at the FDA. I've been in academic medical centers and in the pharmaceutical industry. And I can tell you that establishment psychiatrists are allergic to the topic about how these drugs actually work and they avoid it like the plague because once you acknowledge actually what these drugs are doing, the entire enterprise of psychiatry starts to look like a complete scam. And I've seen academic researchers go blue in the face and do mental gymnastics to argue that the way these drugs work is by reversing some kind of genetic problem in the brain or some chemical thing or something to do with brain brain derived neurotrphic factor or glutamate or whatever the trending neurochemical is in the news because they want to avoid the truth.
And what is the truth? The truth is that these drugs are not specific treatments for any brain illness. They are drug-like substances. They're just like alcohol, cocaine, caffeine, opiates. They induce a chemical effect that masks symptoms. And so you might be thinking to yourself, okay, I get that. You know, maybe morally I object to masking symptoms with a drug, but I could see that, you know, in some instances that's okay. So is this really that bad if that's how they work? And that's what we're going to talk about in the next section because you're going to see that these drugs are neither good nor bad, but it really depends how you use them for them to be good and not bad.
Let's talk about SSRIs, the most common type of drug. Let's talk about really what they do. So, as I mentioned before, they alter serotonin and that produces a characteristic drug effect. And so, for most people, that effect is going to be one of like numbing or calming. And I know they're called anti-depressants, but these really aren't energizing or uplifting drugs. They act much more like drugs that kind of mellow people out. And so, if you're someone who has severe anxiety, this effect can feel very therapeutic because it can turn down the volume on your symptoms. And if that anxiety is so intense that you get to the point where you're suicidal, where you're so anxious, you start to feel hopeless and like life is just overwhelming, that numbing effect can make you feel more functional. And it can even feel lifesaving for some people.
And so all of this sounds pretty good, but what is the catch? Well, there are three major drawbacks to this, and they all apply to people who take these drugs long term. And these risks are so important that everybody needs to know about them before they even get on the drugs. Now, remember, I'm talking about long-term use here. And of the 15% of Americans who take anti-depressants, most of them are long-term users. 70% of people in the US on these drugs have been on them for over 2 years. And so, let's go into this. Let's talk about the three things that you need to know.
Well, the first thing is that they don't fix the underlying cause. You know, most people are depressed for totally understandable reasons. Like, I've been doing this for a long time, and when you talk to people, it's very hard for me to remember someone who came in who did not have very logical reasons for being upset. These are usually things like social isolation, relationship problems, work stress, lack of meaning. It can also be medical issues due to poor diet and lifestyle. And if you're depressed or anxious because of those reasons, if you just start popping pills to manage that anxiety, you're not going to address the causes of your symptoms and they're just going to continue to grow in the background and fester.
Now, I know there may be a few people out there who are just like, "Well, my life is still pretty good, but I'm anxious and I've always been anxious. That's just how I am. Isn't it okay for me to take the drug then because after all, I I don't think there's underlying issues." Well, it's still kind of risky to be honest. And it is because of the next point.
Now, the next major issue people need to be aware of is that the brain develops tolerance to these medications. Many people think that when you take a drug like an SSRI, it's like a heat-seeking missile and it only targets that part in your brain that controls your mood. But that's not true at all. You see, these drugs affect all of the physiology in our bodies that are dependent on that neurotransmitter system. And so, with the serotonin, we know it affects our cardiovascular system like our heart. It affects our digestive tract. It even affects our immune system. And because the body functions within a very narrow physiological range, it doesn't like it when all of a sudden we're on drugs that sort of disrupts our systems. And so the body will start to send signals back up to the brain to tell it to produce less serotonin and to make the serotonin receptors less sensitive. This is the body's way of saying, "Hey, we need to get back into balance." And this is how tolerance happens and why after 6 months of being on Lexapro or a new drug the effect kind of fades and and you talk to people then they say I don't really know what this drug is doing or you know it's only working like 10% and I feel like I need a higher dose and so they get a higher dose and then they need a higher dose and they need a higher dose and within a couple of years they're maxed out on the drug and they kind of don't have any other options either to stay on a drug that's really not working for them anymore or to start stacking more and more drugs on top of it and then you go through that same cycle of tolerance and this is how you end up with people who are on like five or six different medications and I saw them all the time when I was working in the county system and seeing a lot of general psychiatry patients.
Now the last issue I want to talk about is probably the most important and that is that these drugs can cause a long-term toxicity. Because when you recognize that these drugs aren't replacing something that the brain is missing and it's just kind of subjecting the brain to a drug effect, you may start to remember the rule that daily drug use can actually be harmful to the brain. Now, this happens with all kinds of chemicals, recreational and non-recreational. So, like if we take alcohol or methamphetamine, we know it causes structural damage to the brain in daily users. And we actually see that same pattern with all psychiatric medications. I mean we know antiscychotics cause a permanent movement disorder called [ __ ] disynesia. We know lithium can cause something called silent syndrome which damages the cerebellum and leads to a lot of tremors. We know benzoazipines cause bzzoazipene induced neurological dysfunction where you get earring and light sensitivity and agorophobia and brain fog. And yes anti-depressants can cause these problems too. And the most common long-term toxicity I see with anti-depressants is called tardive dysphoria, which is a complicated Greek sounding name, but essentially it's a toxicity that develops from long-term use, which is characterized by feeling chronically fatigued, having brain fog, and feeling emotionally flat.
Now the really unfortunate aspect about this drug induced worsening on anti-depressants is that in psychiatry it can be so easy to blame that worsening on the underlying illness rather than the medications themselves. And so often times many doctors rather than admitting that they've actually harmed the patient by putting them on those drugs, they'll tell the patient, "Hey, you've got treatment resistant depression. You your underlying condition has just morphed in some way and now it's worse." And you know where that leads? Well, unfortunately, it leads to more drugs and sometimes even more dangerous interventions like ketamine, TMS, ECT, when really the problem is the drug was making them worse.
So, let's shift gears and go back to why I think psychiatry avoids having these conversations. The truth is is that when you acknowledge that there's all of these long-term problems with the drugs, it actually starts to shine a light on a lot of very dysfunctional ways that we do things in psychiatry. And I want to go through some of them. The first thing is that 15% of our US population are on these drugs. I mean, what does that say about our country and the way we're living? That 15% of people need to be in this numbed state on a daily basis. That's concerning. The second thing that you realize is that we're essentially giving out drugs to alter people's personality and moods. And these are being handled by family medicine doctors like who see patients for 7 minutes of facetime. These guys are dispensing 80% of our psychiatric medications. That is very limited oversight for someone who's being given a drug that changes their personality and mood. Next up, we have to worry about how even psychiatrists use these drugs. I mean, it should be clear to you that you should only ever use these medications now if you have a deep understanding of the person's life and you've tried multiple non-drug approaches to fix it at the cause. Now, it's going to be no surprise to a lot of people listening to this that many psychiatrists just see patients in like these 20-minute med checks and really aren't invested in helping people in non-drug ways. That's really concerning. And I believe these facts would make many people really question how we're using these medications and the whole like economics and rationale about mental health care in the US. And because of that, that's why I don't think we talk about it.
And so, let's end this on a high note now. Let's talk about how these drugs should actually be used. And so here's what I believe now. If anti-depressants are used, they should be prescribed only after all non-drug approaches have been tried. And I mean psychotherapy, diet, sleep, exercise, addressing relationship problems, and work and life stresses. And ideally, if they are used, they should only be used in the short term to help someone through an acute crisis, help them be less suicidal, help them have more motivation. But you want to give them the drug along with a clear plan to transition off. And so while they're on the medication, you're actually helping them with all of the skills that they need to come off of it so that in a year's time they can do a taper off and live drug-free and not worry about the tolerance issues or the long-term toxicity problems.
That's it for me today. I hope you enjoyed this deep dive on how anti-depressants actually work. And if you appreciate honest evidence-based discussions about medicines and psychiatry, please consider liking this video, subscribing to the channel, and sharing the content. Thank you.