E130 - What Should You Know about Anti-depressants? (feat. the Lively Minds podcast)

This week Alex goes on the the Lively Minds Podcast to chat to hosts Will and Ellie. They take a deep dive into anti-depressants and SSRIs (Selective Serotonin Reuptake Inhibitors), which is the most commonly prescribed form of antidepressant in the UK.

They discuss what we know about the effectiveness of SSRIs, what we don't, and why there is so much debate about their use.

You can check out Lively Minds on Apple, Spotify and every major podcast platform:

https://podcasts.apple.com/gb/podcast/lively-minds-the-uk-mental-health-podcast/id1670147948

Dr. Alex Curmi is a consultant psychiatrist and a UKCP registered psychotherapist in-training.

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

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Transcript

Welcome back. One of the nice things about having a podcast is every so often you get to be a guest on a podcast. A couple of weeks ago, I was on the Lively Minds Podcast, another podcast dedicated to mental health in the uk. Lively Minds is hosted by Ellie, a freelance artist, producer, editor, and access consultant, and will a filmmaker radio and podcast producer.

With over 20 years experience working in the public sector today, I'm able to share the conversation I had with Will and Ellie. The topic of discussion was primarily the debate about antidepressants, what we know about their effectiveness and how they work, what we don't know, and the different camps people seem to fall into.

In discussing this topic, we also discussed depression more broadly and different ways it can be approached. I also venture some of my opinions as to why modern psychiatry is so focused on drug-based approaches. I really enjoyed speaking to Will and Ellie. It's obvious they care a lot about approaching mental health in a [00:01:00] careful, nuanced way, and they both bring some lived experience, which is extremely valuable.

If you're interested in these kinds of topics, definitely check out Lively Minds. They have recent episodes on rethinking happiness, understanding self-harm, and the relationship between art and mental health. The Lively Minds Podcast is available on Apple, Spotify, and every major podcast platform. As for today, here's my conversation all about the antidepressant debate with Will and Ellie on lively minds.

As always, thank you for listening. We're joined by Dr. Alex Kmy from The Thinking Mind Podcast. Alex is a consultant psychiatrist, as well as a trainee psychotherapist. Through his podcast, he has been having some fascinating conversations with people on all sides of the SSRI debate. So it is properly a debate, isn't it, with attitudes from different mental health professionals in different roles as well within mental health.

Um, [00:02:00] ranging, like quite significantly in terms of how helpful they believe the medication to be. Yeah. It's a debate that I have to admit. I've often found quite unhelpful. Um, sometimes I think it can be difficult to see through the fog, especially when experts start using lots of biomedical jargon to make their points so before.

We start, I just wondered if you, for any listeners who haven't heard the term SSRI before, if you could just very briefly, Alex, explain what they are, how they're prescribed. Yeah, sure. And firstly, thank you so much for inviting me. It's an absolute pleasure to be with you. SSRI. Of course, the most. One of the most commonly prescribed antidepressants, uh, SSRI stands for selective serotonin re-uptake inhibitor.

Uh, so what we know is, uh, we have nerve cells in our brain that connect to each other between the nerve cells. You have these things called synapses. Synapses are the gaps where we have, uh, neurotransmitters, chemicals that are [00:03:00] released that signal between one nerve cell and another nerve cell. There are loads of different kinds of neurotransmitters.

Everyone knows about dopamine, of course, serotonin, uh, and, and GABA and other ones. SSRIs work on serotonin. So what you have is one nerve cell might secrete some serotonin to signal something to another nerve cell, and then over time that serotonin is, uh, taken up by the cells. And what SSRIs do is they delay that, that re-uptake, so they inhibit the re-uptake, hence selective serotonin reuptake inhibitor.

And of course, the fact that SSRIs do this has led to some discussion about how and why they may influence people with depression and mood, uh, mood problems, which I'm sure we'll talk about. But that's, that's just a general overview of what SSRIs are and, and what they do. I. Thank you. It would be really good.

I think just so that the audience is clear on what our general positions are, on the question of SSRIs, [00:04:00] um, just for us each, just to very briefly give the headlines of our position when it comes to our perspective, our attitude towards SSRIs. Um, Ellie, do you wanna go first? Yeah, sure. So, um, I think Will, thinks that I'm like completely.

Antip Pharmaceuticals and Antip pharmacology. Um, and has, has wanted us to have a, a big argument on the podcast about this, like ages. That's what I, I came prepared for a big argument. I was hoping that's what we'll have. Oh, no. Well, maybe, who knows? But the, the, the B in my bonnet I actually have is specifically about anti-psychotic medication, which is different to SSRIs.

However, I am super skeptical of any kind of purely biomedical understanding of mental health because. I think it leads to an over-prescription of pharmaceuticals. Um, and that ends up being a substitute for putting the funds and [00:05:00] resources into treatments that can actually change people's quality of life, um, and other treatments.

So like talking therapy, social and economic policies that actually make people's lives a bit more bearable. And I, I do disagree with the idea that depression is. Like a biological thing that you have. Um, I, I do agree with Joanna Re's sort of distinction of that, where being in a depressive state is the thing that's happening rather than you have this biological sort of like thing that you need to like, treat and manipulate and then it goes away or something.

Um, and I have been on SSRIs for. Nearly 20 years, which is actually a really long time. Um, and I don't have any plans to come off them particularly soon though, when I was adding up how many years I've been on them, it did freak me out a bit and I was, I would like to be in a sort of like safer and more stable life place where I would start to [00:06:00] hopefully experiment with lowering the dosage and coming off them.

So that's my, that's my position probably. And my take is that, uh, I have also been on SSRIs for not as long as Ellie, but for for several years. Um, and have found them very helpful in tackling my mental health condition, which is more in the sort of anxiety in OCD space than depression. Um, but that said, I do share concerns that SSRIs are, um, prescribed perhaps, um, without enough thought about these sort of.

More sociopolitical circumstances around somebody's, uh, life and the things that might be impacting that, that, that their life and also maybe not necessarily being prescribed with patients, knowing fully about the potential risks as, as well as the rewards of taking them. So, yeah. I would say that I'm broadly quite positive about SSRIs because it just because of my own personal [00:07:00] experience and seeing the change that actually happened, particularly with my OCD after I started taking them.

Um, Alex what's your headlines? So my, my headline or my elevator pitch for SSRIs is probably similar to all antidepressants and probably similar to psychiatric medications in general, which is I think they can be useful tools. Taking a very cautious, targeted time-limited approach and making sure to be very transparent about what we know and don't know about these medications, what we know and don't know about the biological underpinnings of the mental health conditions that we commonly have.

And I would say that I largely agree with both of your concerns. I do worry about the problem of over-prescription. I do worry about the neglect, uh, of discussion around things like psychological reasons for having mental health difficulties, socioeconomic [00:08:00] difficulties, political difficulties. I worry about all of that.

I would say I don't know any psychiatrist that really rely on a purely biomedical model. Maybe, maybe a small minority, uh, but largely I find that most of the psychiatrists I've met and trained with are really kind of aware of this problem. And increasingly so. You know, one of the things that I think is a little bit disappointing about how the specialty of psychiatry really evolved is, you know, if you go back to the fifties, sixties, most psychiatrists were also trained.

In psychotherapy of some kind and therefore they got the benefit of inheriting a lot of the wisdom of psychoanalysis and other forms of, of, of psychological knowledge. And I think that was really amazing. I think when psycho-pharmacology really came around in a big way, I. I think psychiatry kind of saw that as a opportunity to, opportunity to be like, okay, let's, let's be real doctors and we'll just concentrate on chemicals and biology and medicine.

And that's will make us [00:09:00] feel like we're kind of more neurologists. And, uh, I think that really fits in with the, uh, biological bias that medically trained professionals tend to have. And we really went hard in that direction. As late as the nineties and the two thousands and the 2010s, there was a real optimism that biology was gonna revolutionize mental health.

We, we discovered the genome and we mapped it and we were gonna find all the genes for all the mental health conditions and we, we were really gonna figure it out biologically. Uh, and, and, and drug drug therapy was gonna be a part of that that hasn't really panned out. And, and so I think starting with roughly where I started training and maybe the generations of psychiatrists and mental health professionals training below me, there's this increasing concern that we've become divorced from a lot of really good psychological wisdom.

Uh, that is limiting our ability to treat our patients effectively. So, but all of [00:10:00] that being said, coming back to my original point, I think these can be useful tools with a ton of precautions and a ton of transparency. Could you then tell us, um, I. A little bit about what the debate around the effectiveness of SSRIs actually is and how significant it is.

That's a good question. I don't, I don't know if I can say what the debate is exactly, or how significant it is. I'll tell you what I've seen. The debate about antidepressants is largely reflected by the debate about depression itself. So there's a, there's, there's I think people who are more within the mainstream or of academic psychiatry particularly who are really concerned about the biological underpinnings of depression.

I. And therefore that depression should have a biologically based medical treatment. And they feel that antidepressants have been useful tools for some decades to help people with depression, and there is some [00:11:00] evidence for that. Uh, there's another subset who probably would say, actually, we're not sure about these biological underpinnings for depression, but.

The medications do seem to work and therefore, uh, their, their use is justified on that grounds. Uh, and then there's another side to this debate, which is something like depression has no biological underpinnings, and I. There isn't any convincing treat there, there isn't any convincing evidence that antidepressants are useful treatments and therefore depression as a medical or biological entity, and antidepressants as, as, as viable medical tools should just be disregarded.

That's more Joanna Re's point of view, who I interviewed, uh, on my podcast, and I would say that's not exactly where I am. So. What? What I would say is I would agree with her that there, we haven't really delineated depression biologically, you know, and that's the problem with all mental health conditions, mental health conditions, [00:12:00] the diagnoses themselves, they're not based on causes, they're based on outcomes.

Like depression is an outcome. Mania as an outcome. Suicide is an outcome, and they're complicated behavioral and experiential outcomes like any. Psychiatric symptom is one of two things. It's either someone's behavior or someone's experience. That's it. All the psychiatric symptoms fall into one of those two categories, whether it's a hallucination or an impulsive act or difficulty concentrating.

Um. Look at medical conditions. Often you're the, the, the conditions themselves are pointing to a cause. So like, type one diabetes is a failure of the pancreas to produce insulin. Or COVID-19 is a specific virus causing a specific, uh, collection of symptoms, whereas. With psychiatry, we have the outcome.

It's a bit like if we diagnose people as having a cough, right? But one person might have a cough because of COVID and another person might have a [00:13:00] cough because of tuberculosis. Two very different causes, but they have an outcome that kind of resembles, uh, each other, the cough. That's kind of where we're at in psychiatry.

I think a lot of psychiatrists suspect that. Depression is probably a group of conditions if it is a condition at all. Similarly, there may be subtypes of things like a DHD. There may be subtypes of psychotic illnesses or the way they overlap with a mood problem like bipolar. So all of this. Is the, the, the bedrock underneath the debate of then what does that mean about the drugs that we use?

And I said, are these different camps? There's the camps that feel actually, we kind of know how we work, how they work, therefore we should prescribe them. There's the camp, which I subscribe to, which is we don't really understand how they work, but they seem to be safe with the right precautions and effective in enough cases that they're worth trying.

Albeit with the precautions, that's my camp. And then there's the camp that's [00:14:00] like, there's no biological underpinning and there's no convincing evidence that they work at all. Or the, the risks, the harms outweigh the benefits, therefore we shouldn't prescribe them. So I think that's kind of an overview of the landscape.

That's really helpful. Thank you. You mentioned it briefly before about the growing prescription rates of SSRIs in the uk. And we have seen a massive increase in the last 10 years of, I guess, primary care prescriptions for SSRIs. I was gonna ask, what's your view on it, which I'm still asking, but also wanted to ask.

Is it, do you distinguish in that between over-prescription as a frontline treatment or, and overdosing. Over Dosaging almost. Do you see what I mean? Yeah. Uh, I'll talk about over prescription first. Uh, often something I've kind of come to believe in philosophically is that strengths and weaknesses often aren't as separate as we think [00:15:00] they are.

I think. Strength something. Strengths and something's weaknesses are often joint at the hip, two sides of the same coin. So if you take antidepressants and really David Taylor, who is, uh, the lead pharmacist at the, at the multi hospital and he authored the multi guidelines, which is one of the leading psychiatric medication prescription guidelines globally.

The reason people understandably gravitate towards antidepressants is because they're fast, they're quick, and when they work, they can provide that quick relief of what are really quite debilitating symptoms like if you've ever been depressed, you know, it's a really debilitating thing to experience, and when antidepressants work, they can provide some decent relief of those.

Problems in a few days to a couple of weeks, and that's a big deal because even though there's tons and tons of options on the menu when it comes to treating depression, they're generally not as fast. I. That's the strength of antidepressants. But as [00:16:00] I said earlier, I think the strengths are often tied to the weaknesses.

The weakness of antidepressants is you can just prescribe them quickly, and that can give you the opportunity to ignore all of the other things that's going on in that person's life. Now, as I said before, depression, like every psychiatric condition is just an outcome, and because it's a complicated experiential and behavioral outcome, it's gonna be influenced by all sorts of factors.

Ranging from that person's genetics to yes, maybe some of the underpinning biological realities. Still pretty mysterious though. Uh, their social life, their nutrition, the, how much they exercise their psychological problems, whether or not they're in a good relationship, how many friends they have, how much time they spend outside, whether or not they feel they have meaningful work, whether or not they're in an existential quandary.

You get my point. There's all sorts of inputs going into this, and those inputs take a long time to examine. [00:17:00] Prescribing an antidepressant does not take a long time. That's a really good thing. But the underlying problem, the underlying weaknesses, we can become overly reliant on that. We can decide to not, you know, go through all of those different factors that I mentioned, and it's worth mentioning.

That most of this antidepressant prescription is happening at the, the gp, the family practice level, and I'm not in any way knocking GPS or how they practice. Gps are on the incredible amounts of pressure. They, they're, they're basically forced to see people in tiny, tiny appointment times of 10 minutes, which as a psychiatrist, I can't relate to at all.

I have the luxury, the luxury of spending at least half an hour. 45 minutes, sometimes an hour and a half with a patient and get to dive into every aspect of their history. And gps don't have that luxury. And I think, so I don't think it's really any individual GPS fault. I think it's kind of a systemic problem that needs a systemic, [00:18:00] um, solution.

But I think this reliance on the speed of antidepressants and this hope, as I said, that started really in the nineties and two thousands around antidepressants that they were gonna. Fix everyone's depression. It, it's led to this problem of over-prescription. You asked the question about dosage as well.

Yeah. What I have seen unfortunately in my practice is, you know, often patients with depression will start on an antidepressant. It'll have a bit of an effect, then the effect will wear off. That happens with drugs. It's called tolerance, and then the doses are increased, and then if the effect wears off.

At the point where the dose is maxed out, then either, either another antidepressant is added or the antidepressant has changed and that can happen, so on and so forth. For years. Yeah. Without ever talking about all of those other factors I mentioned. And that's, in my opinion, is a tragedy is the biggest problem we have.

Yeah. Around depression. I, in my view, yeah. That's what kind of concerns me most about the over-prescription thing. It's not so much [00:19:00] the fact that more people are. As a first. I mean, this is also a concern that under the first line of treatment being started on like the lowest dose of citalopram instead of kind of other things being investigated for all the reasons you just said, but also the things all I can see in my head as a pattern of if that keeps happening, what you just described, what kind of drugs and strength of drugs is that person going to end up on in.

Six years time. Yeah. Once they've mapped out the frontline SSRI, is it then adding in this, at which point is the side effects producing other things that then get treated and it can end up being Yes. Really quite a serious situation from kind of what was initially intended as a plaster Yes. To try and cover a short period of time.

Yeah. And, and David Taylor says, you know, we should be thinking about antidepressants at the same frame of mind, we think about anti antibiotics short. Targeted very carefully looking at benefits and risks and side effects, uh, [00:20:00] and being very quick to stop. I I, if the risks outweigh the side effect, if the risks outweigh the benefits, and that's something I've seen over and over again in my practice.

I really can't emphasize how much I've seen. This is patients just remaining on antidepressants for 2, 5, 10 years. The doctors aren't checking in with the patient. About how this antidepressant is working and whether or not it's worth continue to take. And most tragically, the patient isn't checking in with themselves.

I. And I think I'm, I'm not obviously putting all the responsibility on the patient, but I do think we should be able to create a culture where, where this kind of check-in happens very frequently and patients are really encouraged to, to take care of and think about their medicine in a proactive sense.

And I also think sort of on this point, because we're talking about antidepressants and depression really in the mild to moderate. Population. Yeah, so if you think of like the huge circle of people in, in the UK with depression, we're talking [00:21:00] about the two huge outer rings. The vast majority of people who have mi mild or moderate depression.

It is my belief that for most of those people. Although depression is yes, debilitating and unpleasant, it's also a useful signal that something is not quite right in that person's life. And that is not like a fault thing or a blame thing. It's not a moralistic judgment. I think that ev, the evolutionary process gave us this thing called a mood and in a system of emotions for a reason, and that's as a signal light to tell us something might be not quite right now, what it is.

Hard to say, you know? 'cause you need to do an individual analysis of that person's life. And I would also want to mention that modern life has gotten more and more complicated and more and more mismatched to the environment in which our brains evolved. That's that's an evolutionary perspective, and I think that's a huge problem.

And I think in the modern West, people are being called upon to look after their mental health. [00:22:00] Implicitly in a way that we've never had to in human history because, you know, the, the, our brains were more matched closely to our environments. And now in modern life, I think people find themselves on their own.

Surrounded by quite alienated, alienating technology in very strange foreign circumstances as far as our brain is concerned. And this poses all, all, all sorts of challenges. Um, but, but I think it's really worth understanding that. Mood problems can be a very useful signal. Just like having a check engine light on your car can tell you something's wrong.

I think for many people it's a useful signal that we, that yes, we want to relieve the suffering, but also we want to pay, try and pay attention to what that signal means. And maybe that's the biggest, one of the biggest things I see missing in our culture, and that's something that's more addressed, for example, in the world of psychotherapy.

So could you tell us then what we know about the effectiveness of SSRIs? Um, I guess there's sort of almost two parts to this question as well, which is [00:23:00] in, on the one level, one of the debates appears to be whether or not they work. And then another debate appears to be how effectively they work as well.

Could you just sort of take us through that? Yeah, so I got this information from David Taylor, who I mentioned earlier, um, head pharmacist at the Motzi Hospital. And he, you know, no one really knows the research better than David. He's seen the published studies, he's seen the unpublished studies. He knows why some studies are published and why, or not.

Uh, you're not gonna get better data than him. He would say all antidepressants, and this includes SSRIs and other antidepressants overall have an effect size of 0.3. If you take into account the published, just the published studies, if you take into account the unpublished studies, uh, they have an effect size of 0.2.

So what does this mean? This idea of effect size? So effect size is kind of a standard way of. Measuring how effective a medication is for treating a [00:24:00] condition in all of medicine, physical health and mental health. And generally speaking, if, if a medicine has an effect size of 0.2, 0.3, it's considered small to moderate, 0.5 is considered like significantly more moderate.

And then 0.91, 1.2, that's like a big, really convincing effect size. Just because 0.2, 0.3 is small to moderate doesn't mean it's not useful. And then you also have to take, so for example, if a randomized control trial shows a particular antidepressant, uh, to have an effect size of 0.3, what that means is the average person in the treatment arm who got the antidepressant as opposed to placebo is probably better off.

In terms of their depression than around 60, 62% of people, uh, in the controlled placebo arm. So it's actually quite a big deal. And also what that effect size maybe doesn't capture is some people are gonna do really well. [00:25:00] Like some people, when they get an antidepressant, it really works quite effectively.

Some people, uh, are gonna have no effect and some people are gonna be worse off 'cause of side effects. So the best way to summarize the treatment of. The effectiveness of antidepressants is kind of around 0.2 to 0.3, which is a small to moderate effect similar to something like cognitive behavior therapy for anxiety, for instance.

So reasonable, uh, but, but small. Just wonder if there are many other medical conditions and drugs that are prescribed with such readiness. When the, the research to back it up is kind of the level that we have of the SSRIs and only having a n 0.2 or three. Effectiveness. Yeah, so I actually, uh, looked a couple of, uh, did a bit of research on this, and it's quite common actually.

Okay. So if you look at something like aspirin for heart attack prevention, and it's worth saying like aspirin is a. It's a standard part of [00:26:00] heart attack prevention, but it's a pretty small piece of the puzzle as I think antidepressants should be. Incidentally. Yeah. And that would have an effect size of about 0.22.

Um, and I also found the study saying like, statins for heart attack prevention, again, a small piece of the puzzle that's about 0.30, so it's pretty common. Um, but. What you want to know, you know, what you want to let the patient know with antidepressant prescriptions is the potential for side effects, uh, the potential for withdrawal symptoms, and again, targeted time limited.

And you also want to get, you want to do that thorough assessment for the depression, taking into account all those factors I mentioned so they realize they have options and that especially for the mild to moderate cases. I think whether or not to take antidepressants is a personal choice. Yeah. That should be contextualized within all the other things, within all the other options that the person could choose to treat their depression.

And that could include exercise. [00:27:00] Again, looking after their nutrition, trying something like psychotherapy, trying something like couples therapy if they're in a marriage. And that might be a source of the relation of the, of the problems with mood, looking at their job and how they spend their time. All of those things.

So I, I think. You have to mention the effect size, but you also have to mention the potential negative, uh, effects of antidepressants. And you have to mention all the other options and do that really thorough assessment so they can say, okay, this is a overall small piece of the puzzle here. And again, no shame if you, if if given all that information a patient wants to proceed with an antidepressant, you know, and I think with the right precautions it is safe.

Um, but. Yeah. What I, I would share your echo, your worries that I don't think this is happening most of the time that an antidepressant is prescribed, and perhaps this is what we're all starting to slowly wake up to as a society. One thing that, um, it seems to be from, from my perspective, which obviously is a [00:28:00] very much a layman's perspective, so I've got no idea how true this is, but it, it seems like the research into the effectiveness of SSRIs is very heavily focused on depression.

On the treatment of depression, whereas in fact, of course, SSRIs are used for a whole range of mental health conditions. I mean, they're used for, uh, from listening to your podcast, I realize that they're used for other things as well. Um, but you know, they're, they're used for, uh, treating anxiety.

P-T-S-D-O-C-D-I mentioned earlier that, for me personally, it seems, from what I can tell, that the SSOI that I take has had quite a. Good impact on my personal situation when it comes to OCD. So how much evidence is out there, would you say about the effectiveness of SSRIs on these other, uh, conditions? Uh, I think I, I'm not an expert on.

All of how antidepressants have been researched for all of those conditions. They've all been studied, uh, and they've all been shown, shown to be effective, probably with a similar effect [00:29:00] size. But you don't quote me on that look from, you know, if I actually remember professor, uh, Taylor, David Taylor, um, saying words that effect on, on, on the interview that you had with him.

Yeah. Which is, it's kind of roughly speaking, uh, a similar story really. Uh, in terms of the effectiveness, but, but what I would add is with all of those conditions, again, you need to look at, uh, root causes and psychological intervention. So especially with trauma, I. You're gonna want to see if you can help the patient process that underlying trauma that would be ideal.

And now there's, you know, trauma specific therapies like EMDR for, for instance, for PTSD, uh, anxiety. What I, I, I don't think enough people under understand is anxiety is really amenable to psychological. Approaches, uh, like especially if you're anxious about the specific thing, like a phobia or, or a particular situation like being in a crowd.

Exposure therapy is one of the most reliable [00:30:00] things that we know in psychology, really treats anxiety well. Exposure therapy is obviously way more uncomfortable than taking your medication, but it's really effective and more than treating your anxiety, it helps you become, you know, a more resilient person.

And that's kind of one of the reflections I end up having in my journey kind of training and doing my podcast is, you know, personal development, uh, and, and growing your capacities as a person is really the other side of the coin of treating your mental health. They're again, joined at the hip. I think the, the, the, the more the, the less you take the time to develop yourself.

In my view, and maybe this sounds a bit harsh, I don't know, but the less to take your time, the, the less you take the time to develop yourself, the more vulnerability you are likely to be to developing a mental health condition and vice versa. So yeah, I think drugs can be useful for those conditions too.

But you're gonna also, we want to see, wanting to see what can he do in parallel to [00:31:00] treat things a bit more definitively. Yeah, I agree with that so much. If you just take a very kind of absolutist like, oh, I can't. Um, do that because I've got this depression thing, right. That's totally separate To me, it's a, it's a weird avoidant comfort to Right.

Some people who have it and they take comfort in the fact that it's this separate thing that I have and therefore I can't do this, this, and this, but that's what it is and I have medication for it. When actually you like how we grow and develop and mature emotionally and Yeah. Build resilience is through.

But you know, working on ourselves all the time, and that's another. Reason I feel so uneasy about it. 'cause I've had conversations lots of times with people who feel are very much like that. And I'm like, but this means you're not doing any self-reflection on why you're not happy. And, and what you've just said is one of the re one of the things I spend the most time I.

Thinking about which is to what extent is [00:32:00] diagnosis useful versus to what extent can diagnosis become a kind of crutch or, or a limiting belief or, or the beginning of a set of limiting beliefs. And it keeps me up at night, honestly, because I think you can make such a strong case for both in some. Cases.

In some situations, it's so useful to have a professional, say you have a set of problems that we recognize that there is treatment existing, that it's not super, you know, there is some mystery, but it's not entirely mysterious. There is this thing called depression. When people get really low mood and they lose their appetite and they wake up really early in the morning and they feel like a lack of pleasure from their day-to-day lives, that's a thing we understand, and there's this whole menu of options to treat it.

That's super useful in so many cases. Equally, you can have situations where people just, like you said, might say, oh, I can't because of fill in the blank, and that problem keeps me up at night. So thank you for raising it. Yeah, yeah, I, I agree [00:33:00] with you both with. Maybe with a slight caveat, which is that I think, um, I think there's something, one, one thing that I, I realize about my, my sort of journey with taking SSRIs is that I spent about 15 years not taking SSRIs.

So I was quite, I think probably unusually, perhaps late, I wasn't subject to that kind of liberal prescribing. Challenge that, um, we've been talking about. Uh, and so it was a good 15 years after trying a whole range of different sort of psychological, uh, treatments, um, and having a whole range of different types of therapy, um, all through the NHS that I eventually just sort of went, I'm gonna try SRIs now.

I'm gonna try medica, I'm gonna try medication now. And now. Yeah. It's, it's, it's. As it's, it's now seven years and I that I've been taking them and I am sort of thinking to myself now and I have had a con conversation with the doctor about at what point it might be time to start, you know, thinking about, [00:34:00] um, coming off them In a sense, it's almost like trying to turn it around so that the first line I.

Treatments are actually those more psychological interventions. And, and also of course, um, looking at sort of that broader sociopolitical picture and trying to just improve people's lives and sort of support that. It's almost like those should be the first line interventions. And then if that doesn't work or of, you know, if there's still ongoing challenges that then SSRIs could become a part of the solution.

Although I do take what you said earlier, Alex, about how one of the. Attractions of SSRIs is their relative. When they do work, they're relatively fast acting. Mm-hmm. Nature, which I guess is one of the reasons why they have so often use as first line. Another thing to add in favor of that last bit that you said actually is also that sometimes the, even, even when the things are very obvious of what is making someone's, you know.

War, bereavement. Yeah. Yeah, yeah, yeah. Um, when something's really obvious, it's not always something that either the medical profession or that [00:35:00] individual can actually do anything about. And that, that is also I, I like, yeah, I do acknowledge that as well. And the. Other point I would mention as well is that there is still a lot of stigma and shame about taking medication.

Absolutely. And I think as, as though, even though I have my reservations about psychiatric medication, I think the shame and stigma is unwarranted and not helpful. Yeah. You know, we're having this conversation now about drugs like, uh, Ozempic and Manjaro. Incidentally, those have huge effect sizes of like one or 1.2 or something like that.

Yeah, those are the big guns. So we know they're effective and we know how they work, but there's shame about, you know, should you use a, a tool like a drug to help with. Your mood or should you use it to help with a weight problem? And I think this is just to be honest, a bug in, in our, in the humanities software in that we tend to, I think we can make an evolutionary argument that we make moralistic judgments [00:36:00] about people's behaviors and their outlooks, which then causes us to make more holistic judgements about.

Using medications as a easy way out or a shortcut. Yeah. And I think that's totally inappropriate. I don't, I don't really subscribe to that. Yeah. That's like the bane of my existence. 'cause I think, 'cause I've got lots of, um, physical health problems and chronic health problems. I probably get sort of like advertised or bombarded more often than others with this kind of content.

But like, it's gone in hand in hand with the kind of. You know, taking medication goes against the kind of current trend of both, like, you know, hack your way into being your ultimate self. And also it's viewed almost like as an opposite to kind of nature and diets and nutrition and, and people on the.

Extreme side of both of those, there are moral [00:37:00] judgments on someone taking medication and it's, and it's horrendous. And, and people judge themselves. Yeah. Like, I'm taking a medication and therefore, you know, I'm weak or there's something, you know, uh, inadequate about me. And it's like, if you're lucky enough to live in a society that can avail you with certain tools Yeah.

That can prescribe you medication. Yeah. Absolutely. Use them if they work. Yeah. You know, they're just tools. Life's really hard and a, a. I always, no matter what it is, even if it's kind of an unhealthy habit, I always just think people should sort of. Remember that life's really hard and lots things, life physic hard people do.

They're just trying. They're just trying to use what tools they can access to make it more bearable. Yeah, and expanding on the point I made earlier, like modern life is really strange. We ju, it's changed so much. I'm sure. If you guys reflect on what your lives are like when you were children to now, the change is enormous.

I certainly feel that way and it seems to be only getting faster. It's totally bewildering. Yeah. I've never [00:38:00] really been in a position like this and. Again, if you think about what it was like to be a human throughout most of human history, you probably had very little authorship over your life. You're kind of just thrown into a tribe or a civilization.

You're probably locked into place. You had a very specific set family. You probably only knew a small amount of people. There's only a tiny amount of people you really could know probably as when we were hunter gatherers, Dunbar's number, like 150 people, maybe 200. But even if you go into. Medieval times.

What's the maximum amount of people you could know in a lifetime? Probably way less than now. Where Yeah. You can use something like a dating app to send a digital brochure of our service to millions of people in a large size city. It's totally insane. And, and, and so come with that. Yeah. We have more choices than ever and we in the West, we love choice.

We worship choice and freedom. But choice and freedom past a certain point, it's kind of like [00:39:00] money where if you get, if you go from like no choices to a bit of choices, that really increases our happiness. And really gives us a sense of autonomy and authorship, and that's great. As soon as we go past a few choices, there's like a famous TED Talk about this.

It's totally bewildering and anxiety provoking. If you go from like three choices to like 10 or 50 or a hundred choices, it's bewildering because it's way too much to process. And then you're burden burdened with the anxiety constantly of, am I gonna make the wrong choice or not the best possible choice, or am I gonna have a worse outcome than my neighbor?

And so on and so forth. And all of that, I think is manifesting in the myriad of mental health challenges. We see now even the rise of safety. Like we live in safe. Yeah, we live in really safe societies, safer than ever before. But safety isn't good for anxiety. Like having safety makes anxiety worse because we're not exposed really to challenges and we're, we don't often give ourselves the opportunity.

To face challenges, which is the thing that's [00:40:00] exposure therapy. That's what decreases anxiety. Again, I'm not arguing necessarily for a dangerous society here, but we have to understand the second and third order effects of the, of the civilizations and cultures we build. I. Often we, we, we become victims of our own success.

We build a really safe society, and we become more anxious. We build a really comfortable society. We become less resilient. These are all problems I think we really need to start thinking about and taking seriously. What do you make of the debate around how SSRIs actually work, and to what extent do you think the question matters?

I think the question does matter. I don't think the question is. 100% necessary to prescribe them. There are many treatments in medicine where we don't know precisely how something works, as long as it's reasonably safe with the right precautions, and we can see that it's having a benefit for the. Person involved.

I don't think it's mandatory, but of course it's a very useful question and [00:41:00] it's a question we need to try and answer to the best of our ability. What I can tell with antidepressants is there's nothing convincing, there's not enough convincing research, and Joanna Moncrief makes this argument really well.

Uh, there's nothing definitive to say, okay, this is how they work. Perhaps it's interact, it's, it's affecting the serotonin system in different ways. And I think you can make a case that the serotonin system can affect mood and, and all the things that go along with mood, but it just hasn't been demonstrated scientifically what's happening in the brain with depression.

And therefore, I. Uh, and also rather, uh, what's happening in the brain under the effect of an SSRI that's helping that person. So I think it's still pretty mysterious. Some psychiatrists may disagree with me on that, but I personally believe even though we don't, we haven't really answered that question, they can, they can still be useful tools in some cases.

And your practice, I presume you've, um, experienced like both prescribing people SSRIs, but also supporting [00:42:00] people to come off them. I just wondered if you could tell us a bit. Kind of what that's like when you're working with people to come off an SSRI and how you kind of work with someone to sort of distinguish between withdrawal symptoms and kind of.

A return of significant symptoms. Yeah. What I would say is I tried, I don't end up prescribing a ton of antidepressants in my practice, and neither do I end up weaning people off a lot. That's more because of the idiosyncrasies of my career and the different things I do, uh, than for any other reason. But what I can tell you about.

Helping people come off antidepressants is like, for many people it's fine as long as they do a reasonably slow taper. Uh, obviously whatever antidepressants you're on, whatever dosage you're on, you should speak to your doctor about this. If your doctor doesn't think you need to taper at all, then probably seek a second opinion.

But you generally [00:43:00] speaking, want to reduce an antidepressant slowly and you want to kind of find out are you in the category of someone who has withdrawal symptoms, which is, I think still kind of a minority overall, although it's common Or are you in the majority who probably you'll be fine and just a reasonable taper would would be, would be sufficient if you start to lower your antidepressant and you find actually I'm starting to get withdrawal effects.

And those could be anything from like. Headaches to, uh, brains, apps to appetite disruption, sleep disruption, sometimes anxiety, sometimes moods can come back. Um, then you want to go back up to where you were before and just hold it there for much longer. You basically, if you're starting to get withdrawal effects from antidepressant reduction.

You just want to go extremely slowly and, and hold, do a holding pattern at each dose reduction way longer than you think is reasonable. And I might be like a month as a particular dose or two months, and it might come down to really cutting down, cutting the [00:44:00] tablets. Finally, um, the best person to re, to look up about this is Mark Horowitz, who I had on my podcast.

Maybe you guys can put a link in the description and he has a website where it goes through all of this and how the protocols for coming off antidepressants. Cool. I think. Something very important for people to know is, especially if you're in that group. Who have withdrawal symptoms is, it's not linear because basically drugs occupy receptors in our brain, and you would think, okay, if I reduce the drug by 50%, I'm gonna reduce how much the drug takes up the receptor by 50%.

But it's not like that. It's not linear. So what you might find is you might go from 100 100 milligrams of a drug to 50 milligrams and reduce biotin percentage, but the 50 to 25 milligram reduction reduces the receptor occupancy by a much bigger percent percentage. 'cause it's a non-linear process. And that's why people might be coming to the end of their antidepressant taper.

And actually the, the withdrawal effects come hard and [00:45:00] fast. And if that's the case, then you want to hold, go back up. Hold there for ages and then go down really, really slowly and and cautiously to try to minimize those withdrawal effects. But if you want to look up more about that, mark Horowitz is the guy I'd also like to just briefly mention.

Um, there are other sort of biologically based tools. We can use for depression, particularly TMS, uh, transcranial magnetic stimulation and newer forms of TMS that are being pioneered in places like Stanford University in the US with different kinds of protocols of how you apply it. Uh, and those are, are potentially really promising as well.

And there are other kinds of drugs being researched like psychedelics, like psilocybin and ketamine. And I think, as David Taylor told me on when I interviewed him, there tends to be a lot of optimism in the beginning, uh, where they think, oh, we we're seeing these huge effect sizes and no side effects.

And then generally what happens as science [00:46:00] progresses, you'll find the effect size. Uh, generally wears down and, and maybe new, new risks and side effects will crop up and you realize it's not great for everyone. But that's fine because it's still just another menu in the menu of options. I. The more options a patient has, the better, in my view, especially the more sort of different types of options a person has.

So I think good to acknowledge. There are other kinds of treatments as well, besides sort of conventional antidepressants and SSRIs. I really like that way of thinking of it as like just sort of more options to add to the menu that you can choose from. Yes, I think that's a really nice way to, yes, I, and maybe the very last thing I'd say is I am optimistic.

Possibly about AI and the combination of AI and psychiatric genetics, maybe to help us understand and, and predict who is gonna respond to what better. Uh, just because of the sheer computational power that AI might give us access to. Perhaps it's a tool that will help us understand, oh, okay, this [00:47:00] person needs Celine at a hundred milligrams.

Versus this person needs psilocybin. And I am aware that I'm probably sounding really close to that nineties, two thousands optimism that we're gonna biologically unravel us all. Maybe, maybe I wouldn't go that far, but I would say, yeah, maybe. No, you think we're gonna technologically unravel us all? Maybe AI powered research will help us, uh, pre target our drug treatments a bit better.

That's gonna be my cautious. Prediction, your course prediction. Interesting. Yeah. Thank you so much, Alex, for coming on. It's been really great to meet you, and that was really, really, really interesting. Um, so thank you a lot. Um, and thank you everyone for listening. As always, you can find us on social media at Lively Minds Pod.

Make sure that you subscribe to Lively Minds wherever you get your podcasts. And tune in again next month for another episode. Please note that this show does not constitute medical advice and is not a replacement for seeking professional help. You can find signpost and support on our website, lively minds pod.com.

Please check out The Thinking Mind Podcast that is presented by Dr. [00:48:00] Alex Kmy. And you can also hear on there the two interviews that we've frequently referred to in this conversation with Professor Moncrief and Professor David Taylor. Take care and bye for now. Bye.