Do Antidepressant Medications Prolong Depressive Episodes?

An evolutionary psychologist suggests that antidepressants thwart depression’s function to help us resolve complex social problems.

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Advances in evolutionary understandings of depression as an adaptation – like pain or anxiety – suggests that depression plays an adaptive role in resolving complex social issues. This view, called the analytical rumination hypothesis (ARH), posits that depression may have evolved precisely to facilitate prolonged dwelling on the issues that bring us down. In a new article in the flagship journal American Psychologist, Vanderbilt Psychology Professor Steven Hollon applies this evolutionary perspective to explain the lackluster results of antidepressants for depressed individuals.

Hollon argues that interventions like antidepressant medications (ADMs) disrupt the rumination process by masking symptoms and prolonging the underlying depressive episode, leaving it unresolved. Cognitive therapy and interpersonal psychotherapy, on the other hand, can do a better job at addressing the neurobiology of the underlying episode to the extent that they facilitate the resolution of complex social problems.

“To the extent that [the ARH] is true, then any intervention that facilitates the functions that depression evolved to serve is likely to work better in the long run than one that simply anesthetizes the pain,” Hollon writes.  
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The use, efficacy, and marketing of ADMs have been criticized for a variety of reasons, including increasing the risk of suicidality, especially for youth, misreporting clinical trial results, and causing withdrawal problems and risks in pregnancy. Others have raised concerns about the rationality behind the classification of depression as an illness requiring neurochemical modifications. Others have noted the worrying correlation between ADM use and long-term disability. Thus, critics from a wide range of perspectives have argued that ADMs may do more harm than good as a treatment for depression.

Hollon’s work might offer a unique explanation as to why this is so. Humans have two distinct information processing styles: one fast (Type I) and the other slow and demanding (Type II). Depression engages Type II information processing, which is “more likely to be employed when there are complex problems to be solved that Type I thinking cannot resolve.”

The ARH suggests that depression evolved to facilitate thinking and dwelling on complex social problems. In this view, depression is an evolved adaptation, and pathologization of depressive symptoms is simply a misguided artifact of clinical culture. Hollon writes:

“It is clinicians who have given rumination a bad reputation, largely because it is seen as a potential cause of distress.”

If this is correct, it could explain why therapy appears to have an enduring positive effect. For example, a 2013 study found that cognitive therapy cut the risk for relapse after treatment termination by more than half, relative to prior treatment with ADMs.

The ARH could also explain why patients treated with ADMs have a 30% greater risk of death: by simply masking symptoms, ADMs may have an iatrogenic effect. As Hollon notes, it is dangerous to assume that suppressing the symptoms of an evolved adaptation does not affect underlying homeostatic mechanisms: “the brain alters its synaptic parameters in response to taking ADMs,” and there is no reason to believe these long-term alterations will be benign.

The takeaway from this evolutionary perspective is that while ADMs may suppress symptoms, they may also disrupt the evolutionary purpose of depression and thus end up prolonging the underlying episode. At the same time, they may produce long-term maladaptive changes in the brain, cognition, behavior, and society.

While the analytical rumination hypothesis is by no means certain, the issue is of clear importance to public health and can be resolved empirically. The author proposes a research plan designed to determine whether ADMs are indeed iatrogenic in terms of prolonging the life of the underlying depressive episode or if the “apparent enduring effect” of therapy is simply an artifact of differential mortality. The results of this research could privilege psychosocial interventions that facilitate the functions depression evolved to serve, rather than medications that “merely anesthetize the distress.”

 

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Hollon, S. (2020). “Is Cognitive Therapy Enduring or Antidepressant Medications Iatrogenic? Depression as an Evolved Adaptation.” American Psychologist, Vol. 75 No. 9, pp. 1207-1218. (Link)

13 COMMENTS

  1. Given how well the symptom constellations psychiatry identifies as mental illness correlate with historic trauma I’ve long wondered if they’re sort of flu-like symptoms of the mind; i.e. not specific to any ‘disease’ but signs of the mind trying to protect and heal itself.

    According to a 2015 study led by Andrew Holmes traumatic memories are reprocessed and integrated via the coordinated actions of the amygdala and prefrontal cortex; so a good connection between them is needed to enable the resolution of trauma. That connection is the dopamine D2 pathway through the ventral tegmental area. So if you have a lot of particularly traumatic memories to process you might expect that link to become quite active.

    The neurobabble that justifies neuroleptics as treatment for psychotic illness would have it that psychosis is caused by over-activity in precisely that pathway, so the drugs try to block it.

    Now, if rather than being an illness psychosis is a side effect of the mind’s attempts to self heal – in the same way flu like symptoms are signs of the body’s attempts to heal – then we’d expect blocking that response to prolong the ‘psychotic illness’ by preventing resolution of the underlying trauma. And whaddya know? Giving psychosis patients long term neuroleptic therapy increases the duration of the ‘disease’ the drugs purport to treat.

    On the face of it, it’s hard to see how depression, schizophrenia, etc, would increase an individual’s evolutionary fitness. Yet the conditions remain common in the human race; they haven’t been eliminated by selection pressure. Likewise it’s hard to see how flu-like symptoms help anyone survive and produce offspring, but we know that by and large they’re signs of the immune system doing just that.

    So if ‘mental illness’ symptom clusters are manifestations of the mind’s ‘immune’ responses and self-healing functions, suppressing them may entrench the underlying problems that give rise to them. Which is what we see when we look at long term psychiatric drug use.

    • Good comment.
      And why is there often a resolution when there is complete acceptance by others? There is no “resolution” in drug treatments or labels, or giving people bogus prognosis. We still have to answer why pure acceptance and ongoing acceptance are actual resolutions. Why do they “work”? And there is no “better” within psych. It is just different.

      Only by tolerating another’s distress seems to teach them to also be able to cope with uncomfortable stuff.
      I am certain that fear and feeling powerless are behind much of it but psych finds it more time efficient and monetarily more rewarding than cheering people on.

      And to prove their point they will ALWAYS use a person who they’ve ruined for years of drugging plus none resolved traumas, and those victims are their examples of “mental illness”.

    • What you state is interesting? So, the question is: why do we have shots for the flu? But, then that question is why do we have drugs for these alleged psychiatric illnesses? In my plain, home-made intelligence, I suggest we are not supposed to feel fantastic 100% of the time. The paradox of being human may be that we need to feel bad to feel good and vice versa. That is our birthright. And it may be criminal how the disciplines of traditional medicine and the false psychiatry try to steal it from us. Only a small part of this is a life or death matter, but in actuality a life and death matter. Thank you.

      • We have flu shots to protect us against the underlying problem; influenza virus. Flu-like symptoms aren’t caused by the virus, they’re caused by the body’s response to it. And because those symptoms are triggered in response to lots of things – viruses, bacteria, some toxins – looking only at the symptoms and saying you’ve got ‘Flu like symptom syndrome’ then applying the same treatments to all the cases would be medically irresponsible. It would be like psychiatry.

        That said, sometimes the symptoms themselves can be dangerous. Normally a fever would help fight off the pathogens but if it gets too high it can kill, so sometimes it is appropriate to treat the symptoms.

  2. I have a friend who practices Cognitive Behavioural Therapy and what he told me was that it was impossible for a person to be depressed unless they think depressing thoughts.

    This friend of mine started therapy late in life and had suffered from depression and anxiety – but he appears consistently happy to me.

  3. People do not “get better” with psych treatments. Period.
    If there are any, they would have gotten better anyway. People
    need to work through their stuff, whatever that is and feeling shitty
    is part of it. Like physio after surgery.

    The problem with being “treated” at all is that people are getting “treated” by a BS paradigm.
    Kids go to “learn” about “mental illness” from Professors who tell them what it is and looks like.
    There is no science.

  4. Serotonin drugs cause cognitive impairment(1), double dementia (2)
    and cause emotional impairment(3). Of course to those selling the drugs and whose social status depends on view that the drug users are biologically defective and “lack insight (also known as lack intelligence)” these negative drug effects appear as a feature and not a bug. The drugs causing withdrawal that can last a year plus is another feature because as all sober former drug addicts know, withdrawal is experienced as the drug being a good thing.

    (1) https://www.amjmed.com/article/S0002-9343(15)00077-7/pdf
    (2) https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6079596/
    (3) https://www.nature.com/articles/s41398-019-0496-4

  5. Makes a lot of sense, I had two episodes of depressed mood in my 20s and came out of them after about 6 months without any treatment (both triggered by affairs of the heart). Yes, my experience is that depressive states required me to deeply reflect on what needed to be changed in my life – either my attitude or external things to myself as well.
    Later in life several times I have felt myself starting to go “down” again but was able to pull myself out quickly by changing things.
    Fundamentally I see “depression” in most cases as causally a “spiritual” crisis of meaning and purpose – though the evolutionary biologists may not agree!

  6. If you eat a poisonous sandwich and spend a whole week throwing up you dont spend ages imagining that you must be throwing up because your girlfriend or boyfriend hurt your feelings, or that you are bending over a lavatory puking up because your mom said something about your aquiline nose in your youth. You dont board a long distance bus, as you cup handfuls of vomit, en route to a weary therapist. You dont book an appointment with a psychologist to get to the bottom of what is really causing you to feel so godforsakenly ill. Instead you deduce that your beautifully orderly digestive organ, the noble stomach, has been fed something indigestible. It is THAT SIMPLE. You have been poisoned. Full stop. But when your brain has been poisoned by medication, toxins that it does not fare well on, the tendency is to regard the brain as mystifying in a way that the stomach is not regarded as mystifying. The brain is indeed a glorious alchemist of mindblowing complexity, but to only regard it this way DELAYS putting down the metaphorical questionable poisonous sandwich. It is as if you get blinded by a vanity that the brain is so magnificent it is impervious to the chemical equivallent of a cricket bat…or a stinking sandwich.

    On the one hand there is alot for a person to overcome in terms of decades of propaganda about how dauntingly delicate the brain is and how it needs science laboritories and experts with DIY drills to set it straight or it will never recover naturally. But on the other hand there is a need to trust the brain’s very simple metaphorical and natural gag reflex as if it, like the stomach, is trying to tell an ill person to throw up the latest capsule that may be making them miserable. That trust, in the brain’s natural simplicity has been eroded by centuries of control freaks who say their expertise is necessary. And we buy into the egotism of having a special delicate brain because we dont want a nice workaday ordinary simple one, like the stomach is superbly simple. Human egotism wants to gaze in the therapists mirror and find a brain that never throws up the bleeding obvious.

    • I am glad I read your post after I had my sandwich for my lunch. But, those drugs we speak of — at the very end of my being forced to take them— I threw them up! I could no longer swallow those little pills. It was if my brain, my stomach, my gag reflux were screaming—no more of those evil little pills– They’re killing us and you—stop now–which I did! Sometimes, the brain does throw up in revolt to your actions and the brain being so smart and persuasive gets the other organs–like the stomach, etc. to help. And, actually, two years before I got to that point, the drugs had put me into a nearly comatose state for days…And what pills were left they had prescribed me to take— well my brain and body worked together to say –no more! Why wouldn’t I listen earlier? I was still in the evil propaganda snares, etc. of the psych goons, etc. Thank you.

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