Addiction to Antidepressants

Sadness is not depression. It should be differentiated from involutional melancholia (known as endogenous, rather than reactive, depression), which has no obvious social cause. Sadness is the natural response to painful circumstances and should be allowed to run its course rather than be suppressed with drugs. We learn from experience and become more understanding and encouraging of other people as a result of working through our various difficulties. Involutional melancholia, the unexpected deep sense of inner emptiness that affects some people, can be treated with drugs or electro-convulsive therapy but surely these should be the last resort rather than the first, especially when non-invasive treatments such as a Twelve Step programme (first formulated by Alcoholics Anonymous) are available.

Involutional melancholia occurs in post-puerperal depression, post traumatic depression, addictive disease and in true clinical depression (if that condition exists distinct from an addictive tendency). There is a risk in using the word "depression" in any diagnosis: it may trigger an almost automatic prescription for an antidepressant, particularly in the private healthcare sector when medical insurance companies may restrict cover to patients "requiring" medication. I believe the results are that clinical depression is vastly over-diagnosed and antidepressants vastly over-prescribed. Our knowledge of brain biochemistry is still in its absolute infancy and it must therefore be preferable, even for these patients, for pharmaceutical as well as recreational drugs to be avoided. The best option must surely be total abstinence from all mood-altering substances and processes so as to allow the brain the uncluttered opportunity to heal itself. The natural healthy instinct for doctors should be to take people off drugs of any kind rather than put them on anything at all other than a Twelve Step programme or other constructive "talking therapies" that enhance self-efficacy.

Many people suffering from involutional melancholia discover for themselves the mood-altering properties of some substances and processes, including the mood-altering properties of some prescription medications, such as painkillers, tranquillisers, antidepressants and sleeping tablets. These people, probably at least ten percent of the population, are caught between a rock and a hard place: they can’t live without mood-altering substances and processes (because they perceive that without them they would remain feeling strangely different from other people or inexplicably lonely or even desperately depressed) but also can’t live with them (because these substances often have cumulative damaging effects). These depressed people who become dependent upon drugs of one kind or another are called addicts. (The tendency towards addiction can be diagnosed in young children – see the booklet "Preventing Addiction" by Dr Robert Lefever on this web site - and overt addiction can be diagnosed in adults long before damage occurs - see the Shorter PROMIS Questionnaire also on this web site.) Because the tendency towards addiction exists before the use of any drug, depression and addiction are often really the same thing: people who are addicts are depressed and people who are depressed may be addicts who have not yet used mood-altering substances and processes addictively.

The concept of dual diagnosis with both addiction and depression, is therefore tautologous. Addicts who are depressed despite working a Twelve Step programme are, in our experience, usually still undermining its effectiveness by continuing to use mood-altering substances (most commonly nicotine) or processes (most commonly addictive relationships, using other people as if they were drugs). The relief that these mood-altering substances and processes provide is merely temporary and the depression returns when the effects wear off; hence the "need" for continued use.

Treating addicts with antidepressants is therefore contraindicated in all circumstances. If addicts are depressed they need to examine their entire range of addictive behaviour in order to become fully abstinent from all mood-altering substances and processes. Then they need to work the Twelve Step programme on a continuing basis and not assume that merely reciting the Twelve Steps in a meeting of an anonymous fellowship would be sufficient to achieve recovery. Emotions Anonymous exists for those who have not yet "treated" their depression with mood-altering substances or processes.

Taking antidepressants reduces the range of feeling that can be experienced. Counselling addicts should primarily be a process that encourages them to experience all their feelings, the unpleasant as well as the pleasant, so that they learn to use their feelings as indicators of whether their behaviour is consistent with their true values. Thus attempting to counsel addicts who are on antidepressants is relatively ineffective other than simply in terms of education on basic facts (such as the effects and risks of using various substances and processes) that are probably known already anyway. Addicts act on their feelings rather than on their intellectual understanding and a compulsion would not be so if it were merely a deficit of knowledge. Therefore this form of educational counselling does not help addicts towards modifying the grip of their addictive disease, even though it may help to change some specific behaviours.

The most significant problem caused by prescribing antidepressants is that they are themselves addictive. Obviously they are: they are mood-altering drugs. They don’t cause addiction any more than alcohol, nicotine, cannabis or cocaine causes addiction. These substances are often used non-addictively by people who are not addicts. This can easily be seen to be true for alcohol: many people drink, even regularly and sometimes heavily, without being alcoholic. They need to be aware that they have impaired judgement when they use alcohol, and that this can lead to damage to self and others, but that doesn’t make them alcoholic. Alcoholism is diagnosed on why the sufferers drink (primarily to change their mood) rather than on what or how much they drink. Correspondingly, many people use other mood-altering substances and processes without being addicted to them. They may damage themselves or others through this use but it doesn’t make them addicts.

Addicts in my view are likely to be born, not made. The addictive tendency is probably in their genes, not a product of social circumstances or upbringing nor a habit that has got out of control. There may be an in-born defect in the neurotransmission systems in the mood centres of the brain. The concept that addicts are people who experimented with mood-altering substances or processes unwisely and then lost control is only true for these people. Lots of other people experiment unwisely and do not lose control. Again consider alcohol, a dangerous drug, that in the UK kills one hundred people a day yet it is used without damaging effects by millions. The addictive population is distinct from the general population, as can be determined by the Shorter PROMIS Questionnaire. Damage from addictive substances and processes is mostly dose related but it is fallacious to assume that addicts necessarily use the greatest quantities. They may do so but, alternatively, they may use mood-altering substances and processes only in sporadic binges separated by periods of abstinence characterised by the "Dry Drunk Syndrome" in which the underlying depressed mood is seen in the absence of its customary "treatments".

Giving antidepressants to addicts therefore makes their problem worse rather than better. It disguises one problem but creates another. Antidepressants are blunderbuss therapy, blasting the neurotransmission systems so that there is no residual capacity for the delicate fluctuations in feelings that give life its colour in response to the varying effects of daily experiences. People feel better when prescribed antidepressants, of course they do – because that is precisely what these drugs are designed to do. They would also feel "better" on alcohol, nicotine, cannabis, heroin or cocaine or any other mood-altering substance or process. The particular important feature of the chemistry of antidepressants, however, is the time scale of their action: they take a long time to have their effect (this is measured in weeks rather than in minutes for alcohol and seconds for cocaine) and they also take a long time to wear off before withdrawal symptoms set in - but when withdrawal symptoms do set in they do so very severely.

This peculiarity of time scale for the initial mood-altering effects and subsequent withdrawal symptoms of antidepressants causes two significant areas of confusion. Firstly, recreational drug addicts tend not to use antidepressants primarily (as they would use cannabis, Ecstasy, LSD, amphetamines, solvents, cocaine or heroin) because, by comparison, antidepressants take too long to act. This does not mean that antidepressants are not addictive. The addictive nature of antidepressants would be seen in a high relapse rate of recovering addicts who are prescribed them, particularly when these drugs are withdrawn. This is what needs to be studied.

As with Methadone, alcohol, nicotine, cannabis and other mood-altering substances, antidepressants perpetuate an active addictive state rather than alleviate it. Many recovering (abstinent and attending an anonymous fellowship) addicts have tried using one or more of these other substances (on the grounds that they never previously had significant problems with them) only to find in time that they were dragged back into full-scale addiction. For example, some cigarette smokers are able to stay abstinent from other drugs (nicotine may have been their primary addiction all along) for a long time and to have a recovery of sorts (why would they ever smoke if not to suppress their feelings and what true recovery, rather than mere abstinence, can exist in that state?) but cigarette smokers nonetheless have twice the relapse rate of non-smokers.

Correspondingly, there is severely questionable recovery when being prescribed regular Methadone while working a Twelve Step programme. Methadone Anonymous exists for people who want to stay on it rather than come off it and this is as counter-productive to recovery as maintaining resentment towards one’s family of origin while attending meetings of CoDA (Co-dependents Anonymous) or ACOA (Adult Children of Alcoholics). By the same token, recovering addicts who take an antidepressant are using a mood-altering drug. The fact that it is prescribed, rather than recreational, is a legal rather than biochemical concept.

The second area of confusion that results from the long time scale of action of antidepressants is that withdrawal symptoms do not occur immediately upon cessation of taking them but commonly occur two or more weeks afterwards. At that time the symptoms may be interpreted as demonstrating a need for further prescription of an antidepressant rather than be seen as the withdrawal symptoms that they actually are. This is the same mistake that is commonly made by alcoholics with hangovers, "needing" treatment with the hair of the dog that bit them (i.e. another drink) or by cigarette smokers saying that they "need" another cigarette to cover withdrawal symptoms.

Thus the major clinical problem seen with antidepressants is when patients try to come off them for good and without succumbing to another form of addiction. The same is true in particular for Methadone but withdrawal symptoms and the risk of finding alternative outlets for the addictive tendency are a part of any addiction. The absence of immediate physical withdrawal symptoms for cocaine was what caused that drug initially to be thought by some doctors to be non-addictive. The psychological effects of cocaine withdrawal, however, can be very severe in people who have addictive disease by nature rather than in those people who use cocaine "recreationally" on occasions.

Doctors do not advise patients to stay permanently on cocaine, nor high quantities of alcohol, nor nicotine but, bizarrely, some doctors do advise patients to remain permanently, or at any rate for many years, on Methadone or antidepressants. This shows a complete misunderstanding of the nature of addiction and recovery and a shocking disregard for the sanctity of the human brain and spirit. "Harm minimisation" and "medicinal treatment" are bizarre concepts when the gains are at a price of a chemical dependency that takes away the colour of emotional life. In any case, one study performed in Manchester by "The Big Issue" in 1998 showed that fifty per cent of patients being prescribed regular Methadone augmented their supply with daily heroin, with all the same risks as before. Other studies (see www. socialaudit. org.uk). have shown that antidepressants, despite their significant negative effects, frequently have little more positive effect than a placebo.

Treating addiction to antidepressants is therefore among the most difficult of all addictions to treat, precisely because its true nature is so poorly understood and because doctors may inadvertently work against the best clinical interests of their patients. Faced with the prospect of a suicide, doctors often reach for a prescription pad so that they can be seen to be "doing" something. However, when a successful suicide has used antidepressants the doctor is not blamed but thought to have done his or her best to "help" the patient. Nothing could be further from the truth. Prescribing a mood-altering drug makes it less likely that the patient will find a solution to internal as well as external problems because the sense of equanimity is artificially induced. The best treatment is understanding and time, in conjunction with total abstinence and working a Twelve Step programme, allowing the homeostatic powers of the brain to work their own magic unencumbered by mood-altering substances or processes of any kind. Then patients can experience the whole range of human feeling and live their lives to the full.

© Dr Robert Lefever January 2001