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Berger D: Psychiatric Times (Letter), 16:8, August, p.7; 1999.

In his article that seriously questions whether chemical imbalances exist for Axis I disorders, Dr. Simon Sobo (PT April 1999) opines that the "well, whatever" feeling of apathy that may be caused by SSRI's is the non-specific effect of these meds that gives them their efficacy across a spectrum of psychiatric disorders. I think that there are a few points that were not considered in the article that question the logic of this argument.

First, as described in the same issue on p. 15 by Dr. Pies, this apathy can be treated with addition of buproprion without diminishing the antidepressant effect- thus suggesting that apathy is not the cause of the antidepressant effect. Second, not every patient that responds to an SSRI for a variety of disorders develops apathy; and apathy is not decribed as a problem in responders with a variety of disorders who are treated with non-SSRI antidepressants (ie. TCAs). It seems then that the apathy of SSRIs is likely to be a seperate effect from their antidepressant/antipanic etc. effects. This "well, whatever" (side)effect may be very useful for agitated and irritable persons across many diagnoses, however, SSRIs are not considered treatment for manic or schizophrenic psychosis while mood stabilizers/antipsychotics are, again suggesting seperate biological underpinnings for these problems ("well, whatever" would otherwise be optimal for paranoid persons).

Regarding why there is biological efficacy across a spectrum of psychiatric disorders for SSRIs, there are a number of possibilities: 1.) SSRIs (more correctly SRIs- serotonin reuptake inhibitors) do more than just reuptake serotonin and so may have a number of mechanisms of action; 2.) SSRI action may be in the final common pathway, or common modulating pathway, for a number of differing chemical abberations; 3.) The same chemical abberation occuring in a different location of the brain may result in a different diagnosis. True, the mechanism of action of SSRIs is not known. If you look at the mechanism of action for a number of medical medications in the PDR it will say "unknown". This does not mean these are not biological conditions.

Finally, I think Dr. Sobo brings up the issue of "cause" vs. "meaning" for the "thousands of scenarios that culminate in depression". For some patients maybe the meaning of the precipitating stress was the cause, however, I think there are many whose distress has "meaning" but is not the "cause" as the issues fade in tandem with successful antidepressant medication. Psychotherapy is clearly warranted in either case, adding medication if improvement is not seen with some psychotherapy and/or if symptoms are severe.

Doug Berger, M.D., Tokyo, Japan

Dr. Berger is in private practice in Tokyo, and is Visiting Assistant Professor of Psychiatry at the Albert Einstein College of Medicine, Bronx, New York.