Expert reaction to study on the clinical effectiveness of sertraline
sciencemediacentre.org
sciencemediacentre.org
My wife has been taking it for quite sometime and it's sometimes a struggle to see how she moves past it. And while it is ancedotal I feel sometimes there are things that should bother her but don't and I wonder if normal mental anxiety is suppose to play some part in that. Hard to have any definitive answer but I find it and interesting thought.
I’ve found that if I spend enough time with anyone this sorts of disparities become apparent, with or without mind altering drugs.
It's for some reason rarely mentioned as a side effect.
Because the SSRI stops them from being bothered?
Additionally, we make up stories to justify why we feel bad. If you stop feeling bad, the story goes away. Fear about the meaning of self or soul sounds to me like a story justifying the feelings that an SSRI could save someone from.
Depression and anxiety, even when mild, can be pernicious in their self-preservation. Self-identifying with a symptom, and avoiding a potential cure because "it could turn you into an entirely different person" by removing that symptom, is often the disease talking.
SSRIs don't turn you into a different person. When working properly (i.e., right dose, right med), they simply give you more mental space to deal with and work through problems. Who you become after working through your issues is entirely up to you.
Or is your response the drugs talking? I know at least with my addiction to cigarettes in my teens the dependency had some very persuasive mental arguments that kept me at it.
YMMV of course.
I still have anxiety, it just doesn't take complete control. I'm not a slave to my anxiety anymore, I can push past it if I really want to do something, something that in the past would have had me utterly paralyzed and broken.
It's not even a high dose.
This is a remarkably clever way to dismiss those with whom you disagree - "If you don't, that must be the disease talking." As pointed out by jcoffland, the counterpart could be the drugs talking. There is not necessarily a known psychiatric ground state for a given person, so it's difficult to evaluate what's talking, and you'll probably never get a person free of all possible confounding variables. I'm not saying it's not true in some cases, but there are legitimate concerns and it's not reasonable to toss them out.
> When working properly (i.e., right dose, right med)
This is the no-true-scotsman problem. Theoretically, if you have the _exact_ right dose and the _exact right med_, you'll do better. Problem is that these are very fine-grained meds and it can take years to work through them all and get it exactly right. By that point, you might have changed. Sure, it's possible, but saying, "Oh, if you just had the right dose, it would work better!" isn't a solution. You can't just "get the right dose", even if you move shrinks.
As for dose and med, I was fortunate in that I responded to the first SSRI prescribed (citalopram). Fiddling with the dose is trivial, though. Once you're on top of your condition the doctor will probably take your lead if you suggest going up or down, and in any case your own customised dose is merely a pill cutter away even without your doctor's permission.
[Standard disclaimer that SSRIs are unlikely to solve the underlying problem, but can buy mental scope to address it, etc. etc. They can also be difficult to withdraw from (I'm now on my third go) so it's not like they're a panacea, or in way "happy pills"]
Sertraline made me feel a bit "numb" overall. Negative things didn't hit me as bad, but positive things also didn't move me as much either. Lithium and aripiprazole given similar effects, but at a much greater magnitude, and much greater side effects (extreme nausea for me). Combined with Cognitive Behavioral Therapy, I think the idea is to have sertraline reduce your latent stress response and to have your doctor / CBT help you establish rational control. Then take out the drugs like you'd take off the training wheels. Though some people stay on sertraline for a long time (perhaps too long?).
Sertraline definitely changes your personality on a global level, but the total magnitude of the change appears slight (at least to me). Overall it made me just more blithe in the steady state, for better and for worse. Except during the 2-4 weeks following a dosage ramp-up. Then I actually got increase stress-- dangers felt larger-than-life, and I lost confidence in being able to overcome some physical dangers. It was like the signal-to-noise of the stress response was off. After the 4 weeks, though, that surreality went away.
The most objective change for me was in terms of exercise-- all metrics of performance went down at least 10-20%. Dosage increases made me feel like I was recovering from an injury-- my whole cardio felt off.
Where sertraline made me feel less productive, bupropion made me feel better, even "good" or "winning" at times. Bupropion gave me little 'micro seizures' at times, though, and my sleep got worse, as if I was taking a ton of caffeine.
I think the common notion that anti-depressants magically make you feel better is wrong. Bupropion is close to that notion-- it's technically a bit of an upper. But sertraline is just kind of a nullifier.
After the experience, it's clear to me why some of my colleagues in Silicon Valley (even my roommate, now at FANG) take cocaine or adderall. If all you want is the "win" feeling and don't care about the consequences (or think you're bigger than them), uppers make a lot of sense. Sertraline is more for dealing with extreme sadness or threats, like the fear of failure or of violent colleagues.
Absolutely bonkers that an engineer (I assume?) would think they need to do this to push themselves through the day while working at one of those companies (or really, any company besides his/her own). I always chocked this up to leftover substance addiction from college. I'm a bit interested in this - how would you convinced a coked-up colleague that they're literally killing themself for some faceless company and a load papers with symbols on them? Must they crash and burn first prior to getting off their dopamine-riddled high horse? There are just so many options available now, conventional and not.
I strongly feel that anyone who has run though a gamut of SSRIs or otherwise has a substance problem need to give psychedelics like iboga a serious look. (I know, quite a tough sell. One can really only get help if they want it and are willing to make serious changes.)
On the other hand, I think this kind of autonomic response doesn't really define me as a person. For a long time, my main response to anything was 'I hate it and it terrifies me'. That's something I never particularly saw as 'me' either, but it did obviously have its effect on the sort of person I am, the kind of thinking and talking I got used to. These things get threaded into your personality, but I think personality really plays out over a longer timescale. The things that have been constant in the way I do stuff has been constant over a couple of decades of mental illness and different meds, even though the outward appearance, and the internal sensorium, the mindscape, have been radically different at each point. I'm certainly more relaxed than I was, but I don't really see this as different in kind from the differences to the psyche wrought by depression or anxiety. It's a change to who I am, and how I act, but a much smaller, less painful, and ultimately less deep-carving one than living with mental illness.
At the same time, there's been acknowledgment that the forms of illness encountered in reality don't really map on well to diagnostic categories. So rather than major depression and generalized anxiety disorder, it's more like there are levels of general distress, and specific problems with low positive emotion, or high negative emotion, or arousal. This has contributed to things like the NIH RDoC initiative.
These two things have sort of combined to lead to a lot of questions about what antidepressants are actually doing, in terms of how it's affecting dimensions of mood and other areas of functioning, thought of in a more detailed way. So in this study rather than targeting a specific diagnostic population, they did a randomized controlled trial of a heterogeneous group of patients, and then assessed antidepressant effects on distress and well-being in a more detailed, comprehensive way than the typical diagnostic assessment.
The results aren't really surprising but are interesting to think about in the context of these issues. For instance, it's not surprising that antidepressant effects might manifest in well-being or anxiety measures, because general anxiety and depression measures can be correlated as high as .8 or .9, and well-being, while less correlated, still tends to tag along. From a replicability standpoint it raises some interesting issues because there's sort of a "fishing expedition" given all the measures, even though things were preregistered, which is worth some discussion, but the effects are all in the anticipated direction even if not significant, raising the question of whether or not p-values really are the most important thing in general.
Overall the study is one piece, but it fits together with a more general body of evidence suggesting that antidepressants are really fuzzy in their effects, and might better be thought of as "antidistress" agents, or as having a general calming effect. Not mind-blowing, but does contradict the way the meds are typically portrayed in public discussion.