[biohacker85]

Sometimes I wish I wasn't so cynical, but I've suspected that SSRIs are a preferred treatment because it is almost impossible to get off of them. They say "It can take up to a month for it to work" is just a way to make sure dependency is strong enough by that point to make withdrawal unbearable. Many people don't fully understand the concept of withdrawal or chemical dependency, and will think the "medicine" works because they feel awful without it.

[yosame]

Well no, SSRIs (essentially) work by becoming tolerant to their effects, which takes 3 weeks to 3 months. It's not a conspiracy, it's just how they work.

They're a preferred treatment because they're usually effective and they're far safer than other medication classes for depression.

[arcticbull]

Interestingly enough, SSRIs are only slightly but statistically significantly better than active placebos. While early trials showed a big difference between antidepressants and placebos, more recent studies have significantly narrowed that gap. FDA data shows a reduction of symptoms of about 30% in placebo vs 40% in antidepressants. [1]

[edit] Doctors note that the difference between antidepressants and placebo isn't clinically significant. They do something, but not much which is why the revival and breakthrough drug designation of psychedelics in the treatment of - especially major - depression is so exciting.

[1] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4592645/

[Aurornis]

Contrarians and cynics have been trying the "barely better than placebo" angle for decades, but antidepressants are indeed superior to placebo.

You can find articles and reviews that play games with statistics, cherry pick studies, and use various thresholds for effect size to try to downplay it, but they do work for a lot of people.

> While early trials showed a big difference between antidepressants and placebos, more recent studies have significantly narrowed that gap.

The part you're leaving out is that the placebo effect is quite strong in studies for depression and even pain. It's misleading to say "barely better than placebo" without explaining that placebo works quite well in those studies.

Placebo effect is also getting stronger over time: https://bigthink.com/health/placebo-effect-worse/

[arcticbull]

> Contrarians and cynics...

I don't think they're contrarians and cynics although some undoubtedly are. They seem to be study authors. The fact is treatments, even broadly used ones, aren't always super effective. Sometimes they're just the only ones we have, and we as humans have a bias towards action being over inaction in medical care.

I may be contrarian and cynical in a lot of things, but modern medicine isn't one of them. I just like to be data driven.

> ... but they do work for a lot of people.

They work for most of those people just about as well as a sugar pill would, yes. Slighly better. There's a real mismatch in terms of public perception of how much better they actually work.

> Contrarians and cynics have been trying the "barely better than placebo" angle for decades, but antidepressants are indeed superior to placebo.

The study that I linked showing the 30%-40% numbers are from FDA data. There's no games played, the study authors got the FDA data by FIOA.

The fact that placebo effect is strong doesn't really mean much other than depression is something that you can treat through things like therapy, which the data shows is exactly as effective as antidepressants. A psychosomatic angle, even if that's not the right word. The desire to heal is sufficient to change the way you think about your situation, and that exists no matter what you're taking.

If taking your conclusion to an extreme, the placebo effect was exactly as strong as an antidepressant - or stronger - why wouldn't we just prescribe sugar pills instead? In fact since the delta between SSRIs and sugar pills is clinically insignificant - while SSRIs have tons of side-effects - why wouldn't we just prescribe sugar pills now? Does that mean sugar pills are effective against depression, or are SSRIs treating depression largely through placebo?

Putting it another way, the placebo effect doesn't treat punch biopsy wounds. [1]

[1] https://pubmed.ncbi.nlm.nih.gov/30212845/

[mrguyorama]

>The study that I linked showing the 30%-40% numbers are from FDA data. There's no games played, the study authors got the FDA data by FIOA.

Most people who take SSRIs and swear by them have had to try multiple of them to find one that works (usually very well) for them. A study that only looks at one drug will have a much lower rate of success than a study that looked at SSRIs as an entire class of medicine.

[Aurornis]

> Sometimes I wish I wasn't so cynical, but I've suspected that SSRIs are a preferred treatment because it is almost impossible to get off of them.

That is indeed very cynical! However, it's not correct. SSRIs are actually much easier to quit than our previous generation antidepressants. The first "S" in SSRI stands for "Selective", meaning they more or less selectively work on the serotonin transporter. Older medications were less selective and worked on a lot of different systems, which often meant withdrawal was even more difficult as multiple different systems were in rebound all at once.

The older medications can be more effective for resistant cases, but due to the higher side effect profile and more difficult withdrawal they are second line treatment.

> They say "It can take up to a month for it to work" is just a way to make sure dependency is strong enough by that point to make withdrawal unbearable.

Quite the conspiracy theory.

But again, it's unfounded. SSRIs are known to take up to a month to work because the antidepressant effect is the result of a sequence of changes that happens over time. The brain has to arrive at a new equilibrium with medication, and the various systems and feedback loops don't immediately recalibrate.

The biggest flaw in the theory that “they” prescribe SSRIs to get people addicted is that most SSRIs are cheap. $4/month at Walmart cheap, or $10 every 3 months. The common ones are long off patent.

I hope nobody takes the parent comment too seriously. If you're suffering from major depression, don't let HN conspiracy theory comments scare you away from trying treatments that work well for many people (though not everyone, but you don't know if you don't try)

[VHRanger]

I mean, obviously removing a serotoninergic med will change your homeostasis.

The real reason SSRIs are so popular is that they work (not always, but often to some extent) and for depression it's much cheaper to make a pill than book a therapists time

[jdietrich]

SSRIs replaced older-generation antidepressants because they're similarly effective and much safer - that's not to say that they don't have side-effects, but they probably won't kill you. TCAs are extremely toxic in overdose (an obvious and serious shortcoming in patients with elevated suicide risk) and MAOIs come with a really difficult set of drug-drug interactions and dietary restrictions.

We know from the data that SSRIs work about as well as psychotherapy. We also know that SSRIs and psychotherapy work considerably better than either treatment alone. SSRIs don't work nearly as well as we'd like, they can cause significant side-effects, but they do deliver very important benefits for many patients and they're an important tool in the psychiatric arsenal with no adequate substitute yet. We need more and better treatment options, but we shouldn't unfairly denigrate the treatment options we have right now.

I don't mean to diminish anyone's lived experience, but I've always been slightly sceptical of claims about withdrawal effects of antidepressants. I suffer from TRD and have withdrawn cold turkey from maximum doses of several antidepressants with no ill-effects, but I didn't get any significant benefits when I was taking those drugs. If you stop taking a drug that was effectively reducing your depressive symptoms and you feel terrible, there's a fairly obvious explanation.

[DanBC]

I strongly agree with everything you say, but...

> but I've always been slightly sceptical of claims about withdrawal effects of antidepressants.

Even the manufacturers warn against discontinuation effects. See the "If you stop taking venlafaxine" paragraph here: https://www.medicines.org.uk/emc/product/764/pil#gref

The UK NICE has advice about stopping antidepressant meds: https://www.nice.org.uk/guidance/ng215 and the UK BNF will mention withdrawal for some meds: https://bnf.nice.org.uk/drugs/venlafaxine/#treatment-cessati...

The Royal College of Psychiatrists has advice about stopping anti-depressants: https://www.rcpsych.ac.uk/mental-health/treatments-and-wellb...

Clearly, it's not a problem that affects everybody, and it's more common with some meds than others, but that doesn't mean these effects are not real.

[jdietrich]

Sorry, in hindsight my comment was unreasonably broad and unclear.

I think it's obviously true that someone might feel anywhere from "a bit weird" to "really quite unwell" for a couple of weeks after discontinuing an antidepressant. I don't know how effective GPs are in communicating that, but you're right that it's there in the patient information leaflet.

What I don't see as particularly plausible are the extremely long withdrawal syndromes reportedly lasting many months or years, or the extremely prolonged tapering regimes that involve tiny fractional doses. I cannot conceive of any plausible biological mechanism for these symptoms, or a plausible mechanism by which a tiny fraction of a clinically relevant dose might alleviate them. Prolonged post-withdrawal effects are reasonably common with GABAergic drugs, but the mechanism and mode of action of these drugs is radically different.

If someone has been taking 20mg of escitalopram, it's perfectly sensible to step down to 10mg and perhaps 5mg over a few weeks to allow their serotonin system to upregulate without too much drama. If they're a year down the line, they're taking 0.2mg and they feel suicidal if they miss a dose, I don't think there's a biochemical explanation for their symptoms.

[piuantiderp]

You just discovered most prescriptions in the US. Big example, insulin, once you take it, ooof, never going back...