What do Big Pharma, Patrick Holford, and Homeopaths all have in common? Well, apart from any other similarities, they all claim to be able to “boost your serotonin”, “remedy your neurotransmitter imbalance”, or help you to “overcome depression.”
Patrick Holford recommends, in his book Optimum Nutrition For The Mind, “keeping your crucial neurotransmitters in balance.” He goes on to write something which I found rather interesting:
Most prescription drugs aim to correct these imbalances, but have undesirable side-effects. Instead, I recommend supplementing the amino acid 5-hydroxy tryptophan (5-HTP) 100mg up to 300mg, twice a day, to boost your serotonin levels.
The section of the book is headed “Overcoming Depression.” Patrick Holford seems to believe that “boosting your serotonin levels” will help you overcome depression, that prescription drugs for depression work (and, notably, that they work by “boosting” your serotonin), that 5-HTP has the same effect, and that 5-HTP is not associated with side-effects in the same way that SSRI drugs are.
The idea that both 5-HTP and SSRI drugs increase serotonin levels and help with depression, but only one has side-effects is one that I find odd. Holford does not support his comment with any references, so I can only assume that this comment is based on opinion rather than anything factual.
[Note: Holford also calls St John’s Wort “the happiness herb” in the same chapter, and claims that it is “one of the most thoroughly researched of all natural remedies.” It’s worth pointing out that this thorough research has revealed that St John’s Wort has some undesirable side-effects: St John’s wort and depression: slight efficacy at best, many drug interactions]
While SSRI drugs do seem to have some effect on depression, it is far from clear that this effect is due to a simple “more serotonin = better mood” equation. As Ben Goldacre writes here, the serotonin hypothesis:
was always shaky, and the evidence now is hugely contradictory. I’m not giving that lecture here, but as a brief illustration, there is a drug called tianeptine – a selective serotonin reuptake enhancer, not an inhibitor – and yet research shows this drug is a pretty effective treatment for depression too.
The excellent Mind Hacks blog has a fascinating post on ‘depression as a brain disease’:
If depression is nothing more than low serotonin, drugs that specifically lower serotonin levels in the brain should lead to depression or at least low mood. Studies which have tried this in both healthy participants and depressed patients show remarkably little effect on mood, with a mild dysphoria being the only occasional effect.
The post concludes:
It is clear from the scientific literature that a purely biological theory of mental illness is not sufficient to explain and treat the experience of mental distress. Furthermore, simplified theories, that argue, for example, that depression is ’caused by low serotonin’ are lacking in support and best avoided.
Both Vaughan Bell of Mind Hacks and Ben Goldacre of Bad Science link to a paper in Nature titled Is mood chemistry?
recent evidence indicates that problems in information processing within neural networks, rather than changes in chemical balance, might underlie depression, and that antidepressant drugs induce plastic changes in neuronal connectivity, which gradually lead to improvements in neuronal information processing and recovery of mood.
It would suit pharmaceutical companies, and supplement manufacturers, if there were a simple narrative that would help to sell their pills.
It seems the reality is that it’s a bit more complicated than “low serotonin causes depression”, or “boost your serotonin levels and overcome depression.” I suspect, however, that it is now the case that, whether true or not, “everyone ‘knows’ now that boosting serotonin ‘cures’ depression.”
For nutritionists and supplement manufacturers pushing 5-HTP as a serotonin booster, or something that will help overcome depression, this Cochrane review might make for uncomfortable reading:
A large number of studies appear to address the research questions, but few are of sufficient quality to be reliable. Available evidence does suggest these substances are better than placebo at alleviating depression. Further studies are needed to evaluate the efficacy and safety of 5-HTP and tryptophan before their widespread use can be recommended. The possible association between these substances and the potentially fatal Eosinophilia-Myalgia Syndrome has not been elucidated. Because alternative antidepressants exist which have been proven to be effective and safe the clinical usefulness of 5-HTP and tryptophan is limited at present.
In the case of Big Pharma, Ben Goldacre has described the “dodgy behaviour”, the “$600 billion pharma industry”, and the publication bias made clear by a paper in the New England Journal of Medicine. He’s also written that “in popular culture the depression/serotonin theory is proven and absolute.”
This meta analysis of ‘Efficacy and Tolerability of Tricyclic Antidepressants and SSRIs Compared With Placebo for Treatment of Depression in Primary Care‘ notes that all the SSRI vs placebo studies included in their review had some commercial involvement – but, more importantly, it tells us that: “Many studies reviewed were of low methodological quality, and nearly all studies were of short duration.”
It is unfortunate that so many published studies in this are are apparently of low methodological quality – and this is a situation that needs to be addressed. “More research” is a line almost invariably included in academic papers. Perhaps it should come with a qualifier along these lines: “…unless it’s as badly-designed as the crap we’ve just trawled through.”
And now, if you will follow me, we shall move from bad behaviour, marketing pills, and the poor quality of some research to homeopathy. Don’t worry – it’s not far.
ABC Homeopathy offer “suggestions of homeopathic remedies for Seratonin Imbalance” and have helpfully grouped the symptoms experienced by a previous vistor to their homeopathic remedy finder.*
I ticked the little box next to the symptoms “mind; emotions, feelings, attitude, disposition; indifference, apathy, etc.” I clicked the “find remedies” button and the next page came up:
The homeopathic remedy which best matches your symptoms is Sepia […] For potency information, please see our potency guide. […] If you need to buy this remedy, please support the remedy finder by buying through our online shop.
I checked the potency guide, which told me:
Not all homeopaths agree on dosage and potency, but as a general rule, Chronic illnesses (i.e. those that you’ve had for a long time) should be treated with high potencies (i.e. 30x – 200c.) and Acute conditions (i.e. those that are relatively new) with low potencies (i.e. 6x or 6C)
I clicked on the “add to shopping basket” option and found that, if I wished to purchase their suggested remedy for chronic depression, they could sell me “Tablets- off the shelf; 30C; 125 tablets; £6.50” I know – it’s not very holistic, is it? More ‘simplistic’ than ‘holistic’, I would say.
You might think I’ve been unfair to homeopaths by using an online remedy finder rather than the words of a homeopath. Well, the Society of Homeopaths themselves say, on a page titled “Stress, anxiety and depression”, that:
It is not only counselling that has a role to play in preventing serious mental illness. In a national survey conducted by The Society of Homeopaths, 87% of patients who complained of mental and emotional problems reported positive change.
30C of Sepia – or 30C of any other homeopathic remedy – would in all likelihood contain not a single molecule of the active ingredient. I would be relying on vibrational energies left by the ingredient that they had diluted out of existence, or the memory of water. Well, to be more precise I suppose I would be relying on the memory of sugar (remembering something that the water had been remembering when it was dripped onto the sugar pills).
SSRIs might help with depression. St John’s Wort* or 5-HTP might help, but are is not recommended. The only way that homeopathy might help with depression is either through the placebo effect, or perhaps by providing someone with a bloody good laugh when you describe to them the process of manufacturing magic water and dripping it onto sugar pills.
*For further comment on St John’s Wort, please see the comment by Silphion in the thread below.
This Cochrane review concludes:
The available evidence suggests that the hypericum extracts tested in the included trials a) are superior to placebo in patients with major depression; b) are similarly effective as standard antidepressants; c) and have fewer side effects than standard antidepressants. The association of country of origin and precision with effects sizes complicates the interpretation.
The note of caution in this conclusion seems to relate to the research carried out in Germany being more favourable to hypericum. This remedy is popular in Germany and Neuroskeptic discusses the possible effect that its popularity may have on the research conducted into it. There are also some interesting comments from pj in the thread that follows Neuroskeptic’s post.
* I’ve noticed this odd spelling of serotonin before. Today I spotted a couple of other oddities – serotonine and seratonine.