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SSRI's Effects

Q. I'm a Clinical Psychologist practicing in primary mental healthcare in the UK. Although also qualified as a Neuropsychologist, my orientation is primarily psychodynamic. I meet many patients who take Prozac as well as other SSRIs, usually prescribed by their GPs (family doctors). Frequently, this is in response to what seems like understandable emotional responses to adverse life events such as relationship break-ups, bereavements and other life-cycle transitions. As a mood-altering drug, one can see why Prozac is often prescribed under these circumstances, often helping to alleviate the emotional pain associated with such experiences. However, as pharmacological psychiatry colonizes ever greater areas of our lives, one might fear that everything will soon become something to be treated.

Leaving the issue of treatment of "depression" aside, I hope it's not too polemic in the current climate, to state that emotional distress can be a way of alerting us to the fact that something is going awry in our immediate environment. I think it's interesting to speculate on how SSRIs affect our ability to negotiate the losses which are an intrinsic part of living. Logically, use of an artificial mood-enhancer might impair one's ability to pass through the usual processes of emotional growth and practical adaptation.

This is an area I'm trying to research for my post-qualification doctorate. I've come across several useful, non-academic resources on the web which deal with this issue. Unfortunately, I'm drawing something of a blank when it comes to empirical research.

Are there any resources or contacts you could recommend?

A. You are raising some important and controversial (not to say, polemical!) issues. But as to what might seem to follow logically, let's remember that Aristotle thought it quite logical that an arrow's flight depended on the air's rushing around behind the arrow and pushing it forward. As you imply, empirical research--not logic--is what is needed!

Actually, to my knowledge, there is very little empirical research, if any, showing that the use of fluoxetine (Prozac), other SSRIs, or related agents interfere in any way with the usual processes of emotional growth and practical adaptation. Nor would I regard an SSRI as an artificial mood-enhancer. It is no more (or less) artificial, in my view, than using talk therapy. Both are simply methods of altering neurochemical processes in a beneficial way.

Indeed, the most recent empirical evidence suggests that psychotherapy and antidepressant medication do very much the same thing in the brain, when treating several psychiatric disorders. Furthermore, they appear to be synergistic, rather than antagonistic--at least in their effects on clinical depression. I will concede, though, that these medications are sometimes unnecessarily prescribed for transient situational stressors, which would yield readily to brief, supportive therapy-and with fewer side effects.

I also will acknowledge that the SSRIs can provoke gastrointestinal and sexual side effects, and a small percentage of patients may develop a sort of apathy or emotional flattening that may somewhat compromise their ability to work through their problems, in my view (see, e.g., Hoehn-Saric et al, J Clin Psychiatry 1991;52:131-33). Also, there is some modest support for the idea that benzodiazepines may interfere with new learning, during the early stages of cognitive-behavioral therapy.

I also agree with you that--up to a point-emotional distress can be a way of alerting us to the fact that something is going awry in our immediate environment. Beyond a certain point, however, emotional distress ceases to serve an alerting function, and begins to erode our physical and emotional well-being in quite destructive ways.

The analogy may be made with fever. To be sure, a mild fever is a kind of evolutionary adaptation. It both signals us that something is wrong--e.g., we have been exposed to a pathogen--and signifies that our immune defense systems have swung into action. But if that fever rises, say, to 106 degrees F., we can suffer permanent brain damage, unless emergency measures are taken. The analogy, of course, is with understandable emotional responses to adverse life events versus severe, major depression. So much for philosophizing!

What empirical studies bear upon these questions? In general, you may want to see some of the studies comparing brain changes with SSRIs to those seen with various types of psychotherapy; e.g., the work of Dr. Lewis Baxter on PET scan changes with SSRIs versus cognitive therapy in patients with OCD. With respect to clinical outcome, a seminal study is that of Keller et al (N Engl J Med 2000 May 18;342(20):1462-70), in which 681 adults with a chronic nonpsychotic major depressive disorder were assigned to 12 weeks of outpatient treatment with nefazodone (maximal dose, 600 mg per day), the cognitive behavioral-analysis system of psychotherapy (16 to 20 sessions), or both.

In brief, the combination of the two was significantly more efficacious than either treatment alone. Although nefazodone is not precisely an SSRI, if antidepressants impaired one's ability to pass through the usual processes of emotional growth and practical adaptation, I would have expected some evidence of interference with CBT in the group that received nefazodone.

Of course, your question sought to leave the issue of treatment of depression aside. But it is hard to imagine why antidepressants would show no adverse effect on acquisition of CBT skills in depressed individuals, and yet somehow impair less severely ill individuals from achieving emotional growth and adaptation. In any case, I know of no empirical studies demonstrating this to be the case. There is, as you may know, a good deal of anecdotal discussion of these issues in Dr. Peter Kramer's famous book, "Listening to Prozac", and you might consider contacting him on this matter.

You may also want to read Dr. D.L Cabaniss's essay, "Beyond dualism: psychoanalysis and medication in the 21st century" (Bull Menninger Clin 2001 Spring;65(2):160-70) and a somewhat opposing viewpoint from Dr. MH Swoiskin (Bull Menninger Clin 2001 Spring;65(2):143-59). Good luck with your research!

December 2002

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