When I was diagnosed with depression - amongst other things - my doctor prescribed SSRIs with a caveat that they might or might not work.

After a few weeks I was tapered off them.

I felt no different before, during or after them.

What helped was 3 daily walks around the park, around 9km per day after each meal.

Anecdotal but it is what it is. Right now I have bigger problems than just depression.

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Aurornis 10 hours ago | parent | next [-]

> After a few weeks I was tapered off them.

> I felt no different before, during or after them.

SSRI onset is slow, which is one of the common problems with treatment.

In studies where they survey both the patient and their family members, the family members actually start noticing improvements before the patient. Onset is slow and it takes a long time for patients to realize the positive effects.

Ideally they’re prescribed along with other lifestyle changes like your walks. It doesn’t have to be an either-or. A lot of patients get offended when doctors suggest things like walking because they think it indicates the doctor is telling them to “just walk it off” which doesn’t go well.

It’s not surprising you didn’t feel anything noticeable after a few weeks. It’s also unfortunate, but not too surprising, that your doctor wasn’t informed enough to communicate these things. Some doctors are great about setting expectations and following up. Others write a prescription and send patients off to fill it without the necessary context.

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jaggederest 10 hours ago | parent [-]

The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT, effect size or remission rate (individually! STAR-D treatment algorithm works for the vast majority of people)

Especially in acute cases, I think they should be replaced or augmented by something stylistically in the direction of esketamine. 6-8 weeks per medication trial is an absolute eternity, especially since some minority of major depressive episodes resolve spontaneously after a few months to a year.

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Aurornis 9 hours ago | parent | next [-]

> The other problem with SSRI treatment is that individually they are only barely better than placebo. They're among the worst classes of drugs as far as NNT,

These numbers are really misunderstood when taken out of context.

SSRIs have an NNT around 7, depending on the study you look at (random Google result https://pubmed.ncbi.nlm.nih.gov/19588448/ as an example )

Which sounds terrible if you know nothing about NNT. But when you learn that Tylenol has an NNT of almost 5 and even a powerful drug like Xanax has an NNT of 4, you realize that NNT is a difficult measure of drug efficacy.

> Especially in acute cases, I think they should be replaced or augmented by something stylistically in the direction of esketamine. 6-8 weeks per medication trial is an absolute eternity

Ketamine and esketamine are used a lot to begin therapy. They’re not good long-term options though, so they’re best used to start treatment as a bridge to SSRI efficacy.

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D-Machine 3 hours ago | parent | next [-]

> SSRIs have an NNT around 7, depending on the study you look at [...] Which sounds terrible if you know nothing about NNT. But when you learn that Tylenol has an NNT of almost 5 and even a powerful drug like Xanax has an NNT of 4, you realize that NNT is a difficult measure of drug efficacy

This kind of comparison is utterly meaningless (like saying a Cohen's d of 0.3 is large for phenomena X, so if we see 0.4 in phenomena Y, it is large in Y), and is just one part of why NNT as usually reported is basically deceptive for antidepressants.

What qualifies as an effective "treatment" has to be anchored to a minimal important difference, and this is what antidepressants really don't clearly have, on average. I.e. saying the NNT of SSRIs is around 7 is not really practically interpretable, because they tend not to base NNTs here on the amount of patients that actually experienced a clinically meaningful change, they just count the number that exceed some arbitrary (usually purely statistical) threshold.

If you reformulate NNT competently to count number of people needed to be treated to ensure one has (on expectation) a minimally important difference in the depression scales, then the NNT gets even larger than is typically reported.

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jaggederest 9 hours ago | parent | prev [-]

Okay, so we set aside NNT, even though their NNH is also quite low, and that's highly relevant, what about effect size and remission rate? This feels a bit like cherrypicking. And you'll note I said "augmented", as well, if somebody is going through the treatment algorithm with SSRIs, by all means, that's the bridge to stability for somebody on a longer term course.

But many people don't need anything more than acute treatment, so what about them?

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Aurornis 9 hours ago | parent [-]

> what about effect size and remission rate? This feels a bit like cherrypicking

Trying to pull out NNT feels like cherry picking because it sounds really bad to people who don’t know how other drugs look on this measure.

If your point is that it would be better if we had better drugs then I agree.

I think trying to imply that SSRIs are barely a step above useless is not helpful, though. Statistics like NNT and remission rates do not capture incremental improvements that these medications can make for people who need all the help they can get. Even if it doesn’t cause complete remission by itself it can be very helpful.

	▲	jaggederest 3 hours ago \| parent [-]
		> If your point is that it would be better if we had better drugs then I agree. My point is that there are other interventions which do have an effect size over the perceptual threshold. Exercise is a big one, but there are lots - sleep deprivation, intensive therapy, the esketamine class, TMS, ECT in extremis, (nature exposure and other seeming woo like that need study but are promising) are all significantly better than handing someone an SSRI. And many of those don't have the withdrawal symptom and side effects under treatment that SSRIs do. People are, in aggregate, being harmed by SSRIs displacing things that work right now, and also displacing the urgency of new drug development in the space. The gap is that, in an acute treatment setting, people are being handed a drug that cannot be effective for at least a week or two, up to 6-8 weeks, instead of drugs that work in hours or days.

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MrDrMcCoy 10 hours ago | parent | prev [-]

+1 on therapeutic ketamine. Got me out of a bad spot, and felt better long after it was over. You can get it by mail in the US from Mindbloom, who offered excellent care despite being remote in my case.

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121789 10 hours ago | parent | prev | next [-]

I think exercise, sunlight, good sleep and diet, and good social relationships are all more effective than SSRIs. But anyone who's had bad depression knows how hard those things are to maintain if you're depressed. SSRIs make some portion of people functional enough where they can at least build a healthy life. But definitely not everyone, and they are definitely not "the cure"

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garciasn 10 hours ago | parent | prev | next [-]

Lexapro, noted in the article, was literally life changing for me. I felt better within 3d and I notice severe issues if I miss ~3d of doses in a row, even though the half-life should support ~7d without according to my physician.

That said, yes; walking is the best medicine for me.

	▲	zdragnar 10 hours ago \| parent [-]
		I start getting effects the same day if I miss my morning dose, but like you, it was life changing (in a good way) for me. I've got two friends who didn't benefit from it, so it isn't a miracle cure for everyone, sadly.

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10 hours ago | parent | prev [-]

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