24. What depression is, and how to treat it.
Part 1 on depression and cancer.
I worry that in my last blog post I might have slipped, and accidentally twisted the knife. I did not mean to, especially because cancer is so cruel to begin with. One day, you are living your life, trying to pay the bills, loving your family most of the time and occasionally getting annoyed with them. Then the next day, the path bends down. You feel fatigued, cough more often, and a weird lump appears. You hope it is nothing, but the path keeps dipping, the fatigue drains your energy more. After putting it off for too long, you make an appointment with your doctor, who looks concerned and sends you for tests. Within weeks, you hear the dreaded word ‘cancer’ and your heart groans with pain and fear.
If that was not bad enough, in the last post I mentioned that depression is associated with higher rates of cancer recurrence and mortality. That is a double whammy. Not only are you dealing with the physical impact of the disease, you also need to take action on the psychological dimension as well. It is a nasty spiral. You are dealing with the pain and exhaustion of surgery, chemo or radiation, and feeling wretched about it. If you sink into depression, then your risk of recurrence and mortality notch upward. This can lead to hopelessness, which then intensifies your depression.
Thankfully, you are not alone in dealing with this issue. There are multiple steps that you can take to reduce your risk of becoming depressed, or to treat your depression if you are experiencing it currently. The first step is to understand what depression is. One of the most important studies in psychiatry followed nearly 5000 people for 12 years. They found that 88% of the time, depression is the result of really stressful life events.[i] These include loss of a romantic relationship, getting demoted at work, or the death of a loved one. It also includes serious health concerns, such as being diagnosed with cancer. This may come as a bit of a surprise to you, because of the very wide-spread belief that depression is due to a chemical imbalance in the brain. TV commercials, psychiatrists, magazine articles and websites have told the public that depression is due to being low in serotonin. The truth is that there has never been any solid evidence that low serotonin is linked to depression.[ii] If that were the case, then depression would occur randomly. But we already saw that 88% of the time it follows right after stressful life events.
This raises the question, how did the chemical imbalance idea get spread so far if it has no foundation? Think about who profits from the idea. If people believe that their depression is due to a chemical imbalance, then they believe they have to swallow a chemical, a pill, to correct this imbalance. Every time someone is depressed because their boyfriend dumps them, or they have a bully of a boss, they are prescribed pills. That means the drug companies profit enormously. You will not be surprised to learn that the drug companies spent billions of dollars advertising these pills directly to the public[iii] and to doctors.[iv] It paid off enormously. For example, a few years ago, there were 35 million people living in my country, Canada. There were 50 million prescriptions filled for antidepressant pills.[v] That is enough for every man, woman, and child in the country. As well as every dog, cat, and horse. There are so many of these pills, that even the wild fish in the streams are affected by them.[vi]
So yeah, the whole ‘chemical imbalance’ myth made dozens of billions of dollars for the drug companies, while ignoring the single largest cause, which was stressful life events. Such as getting a cancer diagnosis. Would that be so bad if the drugs worked? Many people find the drugs slightly helpful. Others find them very helpful at stabilizing their mood, which definitely is good. However, others say that the pills ruined their lives with negative side effects. What does the research say? To simplify this complex topic[vii] it is enough to know that depression is measured on a 54 point scale, when researchers compare the pill to a placebo. When the active pill is compared to placebo, the difference is 1.8 points.[viii] On a 54 point scale. Yup, the average person cannot tell the difference. It is only by running such large studies that researchers pick up on these small gaps between placebo and pill. Half of the studies show there is no difference between the two, and half show there is a distinction. You will not be surprised that the drug companies did not publish the group of studies that concluded the pills are useless.[ix]
The difference of 1.8 points on a 54 point scale is actually an overestimate. The reason is because the placebos are inert. Frequently, people in the research study can tell if they are on the active pill because of side effects like dry mouth, dizziness, weird dreams, etc.[x] Once people believe that they are on the active pill, they experience hope, because they believe the chemical can help them. Conversely, the people who have no side effects, and deduce they are on the placebo, become disappointed. They signed up for this research study, somewhat hoping they would get the real pill, and get better. As a result, they show less improvement.[xi]
Now that you have learned that there is no proof of a chemical imbalance, and that the pills to treat depression are just a bit better than placebo, does this mean that you should stop taking your pills? No. As I said, some people find the pills quite helpful. We know very little about the human brain, and why a small group responds well to them. And stopping abruptly, especially if you have been on them for years, can lead to nasty withdrawal effects.
Furthermore, this does not mean that you should never take psychiatric pills. That is a complex decision, where you weigh the pros and cons of the pills carefully. For example, the SSRI’s frequently cause loss of sexual functioning.[xii] They are so powerful at reducing sex drive that a senior psychiatrist recommends giving them to sex offenders in order to reduce their risk of re-offending.[xiii] And lest you think he is a fringe voice, Dr. Bradford has received every available award in forensic psychiatry in the United States and Canada save one. [xiv] You need to balance if the probable loss of sexual functioning is worth it, if you believe the pills will reduce your depression. If you are severely depressed, that may be a small loss to you. No one can make that decision for you, you just need the full scope of information to give real consent.
That is what I have tried to do, to let you know that stressful life events are the major cause of depression. You also need to know there is no intellectual foundation to the most common way of treating it, which is pills. Yes, the pills help some, but there are several other ways of treating the emotional pain and sorrow that comes from hearing that you have cancer. These interventions are just as, if not more effective than pills in the short run, and are substantially more effective in the long run. They also have no negative side effects. We will look at them in the next blog post, so make sure you are subscribed. Leave any comments or questions below, especially if you want me to unpack a point in detail.
[i] Keller MC, Neale MC, Kendler KS. (2007) Association of different adverse life events with distinct patterns of depressive symptoms. Am J Psychiatry. Oct;164(10):1521-9.
[ii] Moncrieff J, Cooper RE, Stockmann T, Amendola S, Hengartner MP, Horowitz MA. (2022). The serotonin theory of depression: A systematic umbrella review of the evidence. Mol Psychiatry. 1–14.
[iii] Lacasse, J. R., & Leo, J. (2005). Serotonin and depression: a disconnect between the advertisements and the scientific literature. PLoS Med. Dec, 2(12), e392. PMID: 16268734
[iv] Schwartz LM, Woloshin S. (2019) JAMA. Medical marketing in the United States, 1997-2016. Jan 1;321(1):80-96. doi: 10.1001/jama.2018.19320. PMID: 30620375
[v] https://nationalpost.com/news/new-research-found-antidepressants-may-increase-risk-of-early-death
[vi] https://www.upi.com/Science_News/2017/08/31/Large-concentrations-of-antidepressants-found-in-the-brains-of-Great-Lakes-fish/5331504193020/
[vii] Interested readers are referred to Michael P. Hengartner, MP. (2022). Evidence-biased antidepressant prescription: Overmedicalisation, flawed research, and conflicts of interest. Palgrave, MacMillan. https://doi.org/10.1007/978-3-030-82587-4
[viii] Stone MB, Yaseen ZS, Miller BJ, Richardville K, Kalaria SN, Kirsch I. (2022) Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: Individual participant data analysis. BMJ. Aug 2;378:e067606. doi: 10.1136/bmj-2021-067606. PMID: 35918097
[ix] Turner EH, Matthews AM, Linardatos E, Tell RA, Rosenthal R. (2008). Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. Jan 17;358(3):252-60.
[x] Wolfaardt UB, Reddon JR, Joyce AS. (2005) Assessing the efficacy of antidepressants: the transactional paradigm. Med Hypotheses. 64(6): 1229-36.
[xi] Jureidini J, Moncrieff J, Klau J, Aboustate N, Raven M. (2024). Treatment guesses in the Treatment for Adolescents with Depression Study: Accuracy, unblinding and influence on outcomes. Aust N Z J Psychiatry. Apr;58(4):355-364. doi: 10.1177/00048674231218623. PMID: 38126083
[xii] Serretti A, Chiesa A. (2009). Treatment-emergent sexual dysfunction related to antidepressants: A meta-analysis. J Clin Psychopharmacol. Jun;29(3):259-66. doi: 10.1097/JCP.0b013e3181a5233f. PMID: 19440080
[xiii] Bradford JM. (2001). The neurobiology, neuropharmacology, and pharmacological treatment of the paraphilias and compulsive sexual behaviour. Can J Psychiatry. Feb;46(1):26-34. doi: 10.1177/070674370104600104.
[xiv] https://jbradfordforensicinc.com/about/ Accessed August 23, 2021.