A 2022 study review in Molecular Psychology revealed the link between a serotonin imbalance in the brain and depression is more tenuous than many researchers previously thought. When this link was considered fact by so many until now, how it is handled going forward could show how trust can be salvaged in science and medical care.

Depression has existed throughout history, although the scientific and cultural understanding of the condition has shifted and changed.

One of the earliest terms for depression was “melancholia,” which can be traced back to Mesopotamia, where mental health conditions were considered to be related to demonic possession and were usually treated by religious leaders.

While the name, understanding and treatment for depression have shifted and grown through the ages, not all of the theories and treatments have been winners. Lobotomies, for instance, are not looked upon in history with kind eyes.

While lobotomies were recorded to have helped patients appear calm, they had severe and unethical side effects like personality changes and cognitive damage, and they could lead to death.

Now, treatment strategies for depression have shifted toward seeking the best treatment of symptoms with the fewest severe side effects possible – a shift made possible, tragically, through the deaths or maltreatment of past patients.

Depression treatment strategies used today include psychotherapy, medication or some combination of both. The Mayo Clinic states there are many options for depression treatment available that can be discussed with a doctor or therapist.

Some medications to treat depression target serotonin systems in the brain to improve mood and energy. These medications were developed because the best medical knowledge at the time suggested serotonin contributes to maintaining mood, cognition and reward systems in the brain. This understanding led to the idea that boosting the function of serotonin in the brain could help people with depression symptoms.

According to surveys, 80% of the general public was under the impression that depression is caused by a “chemical imbalance” in the brain.

But, given this new revelation from Molecular Psychology, is it ethical to use serotonin boosting medication if the source of the problem does not lie there?

Side effects matter, and unfortunately, the unpredicted side effects of having either too much serotonin or having it artificially boosted are starting to reveal themselves.

The authors of the study review wrote that serotonin-modulating antidepressants actually can lead to reduced serotonin levels over time, which means these medications could actually cause the very problem they were meant to alleviate.

This, paired with the fact that reduced serotonin levels are not strongly associated with depression, could mean the medications can cause a problem that did not exist in the first place.

Prescribing a medication that could cause a serious brain chemistry problem that a patient did not have to begin with could be an unethical choice. These medications can also come with a whole host of other side effects, including nausea, sleep changes, appetite changes or issues with sexual desire and function.

Additionally, antidepressants do not have a particularly high success rate of reducing depression symptoms. Studies have shown that antidepressants improved depression in only about 20% more people compared to a placebo treatment and prevented recurrence in only about 27% more people than the placebo.

While antidepressants can be helpful for some, they are far from being a solution for everyone suffering from a disease. If the drugs are not treating the root of the problem, their effectiveness is likely limited.

Instead of targeted treatment of a chemical imbalance, it is like sticking a bandaid on a bullet wound. Worse, it is like closing up the wound without removing the bullet. Yes, it can stop the bleeding, but the source of the problem is still there under the surface, hiding itself as it can fester into a much larger problem.

This non-specific approach can lead to frustration and ultimately mistrust between care providers and patients and potentially be dangerous to some.

So, how do we move forward with this revelation to ensure trust in our providers following the science as it grows and shifts?

First off, providers need to be honest about these drugs, what they can and cannot do and what the risks are, especially with long term use. Many providers already do this, but as complicating scientific results arise, it is all the more important to avoid mistrust. A positive benefit may be worth the risk, but physicians need to be cautious about misinformation and risks.

If serotonin boosting antidepressants are being considered, it is time to implement serotonin testing in patients before, during and after treatment. This would help providers and patients know how the drug is affecting their levels. This strategy would also help reduce the chances of serotonin levels dropping.

This monitoring is a common practice in many medical conditions that can last years or an entire lifetime, such as diabetes or thyroid conditions. It is time that depression is monitored in this way as well.

Second, it is time to move these drugs down on the priority list. Serotonin should not be a reflexive target when selecting treatment options for patients.

Additional research is being conducted to develop more effective targets for drugs to treat depression, and as the understanding of the underlying biology of depression grows, then so will the available treatment options that actually treat the source. It is okay, and often very good, to let go of an old treatment to make room for a new, more accurate and effective choice.

Third, therapy needs to be moved up the priority list.

Depression is a condition that is likely as individualized as the person experiencing it, and therefore, the key appears to be to develop as individualized a treatment strategy as is needed. Drugs can help slow the bleeding, but ultimately therapy is the most individualized treatment a person can find at the moment that can reach beyond the abilities of current drug options.

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