Drugs don’t help to break the cycle of depression

Justin Thomas examines the treatment options and suggests the UAE establish a mental-health strategy.

‘Now the drugs don’t work, they just make you worse,”crooned Richard Ashcroft, frontman for English rock group The Verve. The song, The Drugs Don’t Work, went straight to number one in the UK charts, ultimately becoming the group’s most successful single ever.

One journalist for the New Musical Express described it as “a thing of devastatingly downbeat beauty”. The song’s UK release date, September 1, 1997, coincided with the death of Princess Diana, the so-called “people’s princess”, and this melancholic anthem captured perfectly the mournful mood of the nation.

For me, however, the song always brings to mind the world’s most well known antidepressant medication, Prozac.

In 1987 the global pharmaceutical giant, Eli Lilly, was granted permission to market a drug called Fluoxetine. The brand name dreamed up for this new wonder drug was Prozac. Within a decade Prozac sales would account for around a quarter of Eli Lilly’s $10 billion (Dh36.7bn) annual revenue.

The drug’s curative claims were founded on the contentious idea that depression was, in some way, caused by a deficiency in a brain chemical, or neurotransmitter, called serotonin. Fluoxetine – now Prozac – caused an increase in serotonin and could therefore bring relief to the serotonergically challenged unhappy masses.

This idea was seductive in its simplicity – it still is – and the promise of a magic bullet against depression proved irresistible. This was happiness in a blister pack for a choose-your-mood generation; a proposition much easier to sell than the “definitely addictive” and “probably dangerous” medications of previous decades.

Furthermore, in 2001 Eli Lilly’s patent for Fluoxitine expired, Prozac’s monopoly on the misery industry was over, and the door opened for other drug manufacturers to get in on the act. Overnight, hundreds of copycat brands were born, including T-Zac, Felixina and Seromex.

However, the effectiveness of Prozac, and the legions of Fluoxetine-based pretenders it spawned, has come to be widely challenged. It isn’t so much that the drug doesn’t work, because it does. The real issue is: how does it work? And more importantly: how well does it work compared to alternatives?

In several large-scale studies of the drug’s effectiveness, Prozac has been found to be little more effective than an inert sugar pill. The once great panacea is now viewed in some quarters of the scientific community as little more than a placebo. Some contend its effectiveness is largely based on the patient’s own mood-altering belief that pharmacological help is on the way.

A related issue is what some people have come to call “discontinuation syndrome”. Put simply, this is the idea that when people feel better and stop taking their medication, they are highly likely to relapse. Some researchers even suspect that the use of medications such as Prozac may actually be contributing to the high rates of relapse. One proposed answer to this issue is to maintain patients on the drugs indefinitely. To me, this sounds like a very murky proposition; the place where good business meets bad medicine.

One highly effective alternative to Prozac and its numerous antidepressant relatives is cognitive therapy. Cognitive therapy is talk-based, and clients explore different ways of looking at situations and try out some new, more adaptive responses to negative moods. Trials comparing cognitive therapy with Prozac tend to show that both treatments are equally effective over the short term. However, over the longer term, cognitive therapy is clearly superior and it boasts far lower relapse rates. Even when patients are kept on a maintenance dose of Prozac or a similar drug, the rates of relapse tend to be lower among those patients receiving cognitive therapy only.

The happy compromise to this situation has been to suggest that we offer both antidepressants and cognitive therapy simultaneously. However, there is emerging evidence that individuals given both treatments simultaneously have higher relapse rates than those who have cognitive therapy only. One explanation for this is that, antidepressants may interfere with the ability to learn and retain the gains and changes made during cognitive therapy.

It is the chronic rate of relapse – the revolving door – in depression that makes it so problematic. In recent years, this realisation has shifted much-needed research attention towards prevention: how can we prevent depression in the first place and how can we prevent subsequent relapse?

These are hugely relevant questions for the Gulf region, too. According to the Supreme Council of Health in Qatar, the nation’s number one health burden is depression. How can we reduce the rate of this debilitating psychological complaint here in the UAE? A national strategy for mental health might be a useful place to start.

Justin Thomas is an associate professor of psychology at Zayed University and author of Psychological Well-Being in the Gulf States