Antidepressants: A Sociological Explanation for the Success

of Pharmaceuticals

Graham Wall
Introduction
In this paper, I will be exploring some of the implications of the relationship between allopathic
and alternative medicine, mostly pertaining to Western society. In particular, I will be focusing
on both pharmaceutical and alternative treatments for depression/anxiety. First, I will be
mentioning some of the popular pharmaceuticals and herbal medications, explaining how they
are intended to work, and offering some theoretical insights in relation to the linguistic and
epistemological details of the pharmaceutical treatments. Second, I will be discussing the history
behind the chemical imbalance theory, the evolution of pharmaceutical antidepressants, and how
the chemical imbalance theory influences the DSM-5. A discussion of the viability of animal
studies will also ensue in this section. Third, I will be providing statistics on the sales and
marketing of pharmaceuticals and the globalized use of antidepressants. Fourth, I will be
discussing the following three objects of conflict: the reliability of the chemical imbalance theory
and the efficacy of pharmaceuticals, the disdain some consumers have for pharmaceuticals, and
the DEA trying to control kratom use in the United States. Finally, I will be utilizing actor-
network theory to discuss the relationship between the pharmaceutical industry and alternative
medicine. The purpose of this paper is to show that social processes like the construction of the
chemical imbalance theory, scientific research, and marketing have all been pivotal to the
success of pharmaceuticals, wholly apart from whether or not they are ontologically more
effective than alternatives.

Pharmaceutical and Alternative Treatments: What They Are and How They Work
Pharmaceutical antidepressants have evolved over time, and I will be expounding upon this
historical process in the following section. Here I would like to provide some basic details on the
pharmaceutical and alternative treatments for depression and anxiety that pertain to our
contemporary context. Pharmaceutical antidepressants include monoamine oxidase inhibitors
(MAO inhibitors), tricyclic antidepressants (TCAs), and selective serotonin reuptake inhibitors
(SSRIs). It is important to note that there are some discrepancies between how these medications
are intended to operate. In order to understand how MAO inhibitors work, I must first explain
what monoamine oxidase refers to. Monoamine oxidase is an enzyme that decreases serotonin
levels within the axon terminal in the brain (Kolb and Whishaw 174). The three key terms in this
definition are ‘enzyme,’ ‘serotonin,’ and ‘axon terminal.’ These will also be important when
defining TCAs and SSRIs. An enzyme is a protein that originates from a living cell and is able to
produce chemical changes in organic substances by means of chemical action (Dictionary.com).
Serotonin is an important neurotransmitter within many neurological processes, such as sleep,
memory, and even depression itself (Dictionary.com). An axon terminal is a part of the axon that
allows it to make contact with other nerve cells or effector cells (Farlex Partner). Since the MAO
enzyme decreases serotonin levels, MAO inhibitors work as an opposing response; that is to say,
their purpose is to increase serotonin and have it released rather than decreased. TCAs and
SSRIs, on the other hand, inhibit the transporter that delivers serotonin to the axon terminal
(Kolb and Whishaw 174).
What can be gathered from the terminology and definitions just mentioned is that although
pharmaceutical antidepressants operate differently, they all share the purpose of promoting
proper brain chemistry. From these terms and definitions, it is recognized that proper serotonin
levels are of utmost importance. General understanding aside, critical thinking on the knowledge
I have brought into focus is also important. While some might find themselves convinced by
such esoteric language, an immediate sociological concern begins to surface: Why do
neuropsychologists resort to using technical language to explain brain functions and components,
when mental health is a concern among the general population? Terms such as ‘enzyme,’
‘serotonin’ and ‘axon terminal’ are not used in routine conversations. It is ironic how there is
this, albeit non-monetary, privatization of knowledge in the written theories, considering health-
systems that operate from this paradigm are meant to serve the public. It seems intuitive that a
great number of persons would not understand what these terms meant.

Our understanding of the brain’s different sections and functions is probably elementary at best.
First of all, science is defined as “systematic knowledge of the physical or material world gained
through observation and experimentation” (Dictionary.com; emphasis mine). The plain truth of
the matter is that nobody has actually seen a functioning brain in itself. The closest humans have
come to observing the brain is through technology such as magnetic resource imaging (MRI).
But the results these scanners render are not true access to the brains themselves; they are mere
images. This is not some abstract philosophic notion that has no practical utility, as some
scientists themselves have affirmed this attitude. In the words of neuroradiologist Mario
Mastroianis, “The images pretend a precision and objectivity which is not really there” (Burri
375; emphasis mine).

Moreover, whose observation counts in obtaining scientific knowledge? It seems to me that there
are two main types of actants who can make observations: laypersons and scientists. Considering
techniques to understand the brain, whether that is through MRI scans or otherwise, it is the
scientists who have access to these methods, not laypersons. Considering this, we arrive at the
question of whose narrative is more trustworthy. Is it that of the scientist, who has personal
experience and accumulated the information for themselves, or is that of the layperson, who only
has to interpret secondary information? If personal experience is more trustworthy, this is
problematic for laypersons because most do not have the time or resources to practise science in
such a way that adheres to the standards of the scientific community. For scientists, however, this
is not a problem because they are the ones publishing the accounts of their practices and
observations. They are also the ones who the laypersons are told to trust. Laypersons receive
secondary information and must interpret that information as laypersons. This means that
laypersons are not using empiricist methods to understand phenomena that are meant to be
understood empirically. In the case of what a patient is told about their brain, they do not get to
see it for themselves, and based on Mastroianis’ quotation, neither do scientists. The other
problem is that scientists have paradigms by which their thought collectives interpret and explain
their findings. Unless a layperson has a penchant for autonomous study, chances are high that
their interpretations of scientific information do not meet the standards of the scientific
community.
Turning to alternative methods, I would like to first note some of the main features. The first
important detail about alternative medicine is that the term not only denotes medicines, but
therapies and treatments as well, and particularly those that are separated from mainstream
medicine or health care practices (Castree et al.). It is also important to mention that when
alternative medicine is used in tandem with mainstream medicine, the term becomes
complementary medicine rather than alternative. In addition, research on alternative medicine
has generally been quite limited, and so, the effectiveness and physiologic properties are not well
understood (Lewith). For this reason, my elaborations on these will be more limited compared to
what I wrote about pharmaceuticals. From these descriptions, it can be inferred that alternative
medicine is more varied in its forms compared to pharmaceuticals. While pharmaceuticals are
strictly ingested, alternative medicines are not. Some of these treatments include light therapy,
acupuncture, yoga, meditation, and medications like St. John’s wort or 5-HTP (Mercola). Since
pharmaceutical antidepressants are my point of comparison, I will be focusing on ingested
alternative treatments, otherwise known as herbal medications.

There are numerous herbal medications available, some of which are socially acceptable, some
of which are not. The aforementioned St. John’s wort and 5-HTP are both herbal medications,
and some other kinds include American ginseng, kava, and rhodiola (WebMD; NOW Foods). It
has been suggested that 5-HTP and kava work similarly to pharmaceuticals. 5-HTP is said to
specifically increase serotonin levels in the brain, while kava is said to have an effect on the
brain and other parts of the CNS, though it is not specified which parts (WebMD; WebMD). As
mentioned earlier, research is lacking on how these drugs work, so what can be said about them
is often imprecise.

One herbal medication that is less socially acceptable is kratom. Unlike kava, St. John’s wort,
and 5-HTP, which a company like NOW Foods widely distributes, kratom is not so easily
accessible (NOW Foods). To accentuate this point, I would like to draw some observations from
Madam Kratom, a website that prides itself as being “Canada’s most trusted Kratom store.”
Under the terms and conditions heading of the policies listed on the site, it is stated in upper-case
letters that their products are not intended for human consumption and that customers have to be
18 or older (Madam Kratom). This is interesting because there were no such warnings on the
NOW Foods site, and as I will write about later, kratom certainly is subject to human
consumption. Like the previous herbal medications mentioned, research on kratom is also
limited, though it has been stated that there are “more than 20 biologically active chemicals in
the drug, including several that bind opioid receptors in the human brain and have the potential
to lead towards physical dependence and addiction” (MacLaren). Now that I have discussed
these preliminary details, I would like to elaborate on the chemical imbalance theory.
The Chemical Imbalance Theory: A Brief History
The chemical imbalance theory was introduced in the mid-20th century. Various scientific
findings brought this about, including: the potential of chlorpromazine to treat psychosis;
monoamines acting as neurotransmitters in the CNS; and an understanding of how monoamines
operate in the brain, such as their synthesis, storage, release, and activation. These discoveries
also brought about the emergence of the discipline of psychopharmacology and the practice of
treating mental disorders with prescribed medication (France et al. 411).

The first antidepressant drugs of the modern era, iproniazid and imipramine, were introduced in
the 1950s. Originally, these drugs were used to treat tuberculosis, but when it was discovered
that some tubercular patients had elevated moods upon using this medication, iproniazid and
imipramine were tested on psychiatric patients both in and outside the United States. It remained
a popular treatment for depression for many years until concerning potential side effects had
surfaced (France et al. 411-412). This scenario shows science as a rather messy practice. It was
clearly not the original intention of the doctors to use these drugs to treat depression, but rather,
it was an opportunity they stumbled upon through a more calculated treatment of a different
illness.

Also of significance in the 1950s was reserpine, which is an alkaloid contained in the root of
Rauwolfia serpentina. Prior to being introduced in the United States, this herbal medicine was
used in India as a treatment for both psychosis and hypertension. This drug was found to have
neuroleptic effects, meaning it operates as a depressant (France et al. 412). What is fascinating
about this is that nearly 70 years ago, herbal medicine was intersecting with the pharmaceutical
industry. Through animal studies, it was first found that serotonin was present in the CNS and
affected behavior. Reserpine was found to decrease serotonin levels, and so, a hypothesis was
developed that low serotonin levels caused depression (France et al. 412).

Notice here though that this study was performed on non-human animals. As Michael B.
Bracken, an epidemiologist at Yale University, mentions in an article from 2009, this has been a
controversial issue for a long time. For instance, the Persian polymath Ibn Sina was writing
about this topic a thousand years ago, not to mention that one of Alexander Pope’s most quoted
statements is “The proper study of mankind is a man” (Bracken 120). For my purposes here, the
most important implication is the similarity between the CNS of human and non-human animals,
particularly the brain, since the CNS simply refers to the brain and spinal cord (Colman). The
spinal cord is only of peripheral importance (if any at all) since antidepressants are used to treat
the brain. Of course, it is common sense that human brains are more complex than non-human
animal brains.

Robert O. Duncan, a behavioral scientist from York College, offers some interesting insights on
the topic. Focusing on the sub-topic of self-awareness (sometimes called metacognition), Duncan
writes that this is what distinguishes humans from a majority of other animal species. He notes
that the prefrontal cortex is generally regarded as the source of self-awareness, though there is no
certainty in the matter. There are other factors that could have a part in this ability, such as the
size of the brain, a more robust cognitive ability, as well as a greater degree of connection
between brain areas (Duncan). Now, I should like to note here that self-awareness has massive
implications for antidepressant usage and their effect on the body. Depression and anxiety are
difficult mental states to manage precisely because of self-awareness. This is not to say that a
lack of self-awareness would cause the burdensome effects of anxiety and depression to simply
vanish into thin air. What I am saying is that self-awareness multiplies the mental pain. For
instance, suppose that someone struggles with pessimism and worry, two symptoms of
depression and anxiety. In particular, this person is concerned about going to a certain location
and seeing people they know. This person does not want to go there because they have bad past
experiences and are sure those experiences will happen again if they go. The person in this
example could not have any of those concerns without self-reflection because it is, in part,
themselves they are worried about. In addition to this, people who are concerned about their
mental health, at least some of them, will go to see someone who might be able to help them,
such as a doctor or a therapist. To say to oneself “I need help” is contingent upon self-reflection.

The next monumental moment in the process happened in the early 1980s, when the first SSRI,
zimelidine, appeared on the market. The efficacy zimelidine had at the time not only caused
other pharmaceutical companies to follow suit and add SSRIs to their repertoire of products, but
also caused a re-evaluation of the serotonin hypothesis of the 1950s. The new hypothesis added
that in addition to insufficient serotonin levels in the brain, depression was caused by other
chemical insufficiencies, particularly, in monoamines norepinephrine and dopamine (Owens 6).

An important document that these different stages of science led to was the fifth edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), which is the most current
edition of this document. Its descriptions for depression and anxiety reveal that this document
reinforces the idea that these illnesses are problems that pertain to the brain. Citing Hasler and
Northoff and Ravindran et al., it is stated that many brain regions, including the prefrontal
cortex, anterior cingulate, amygdala, and hippocampus have been involved in persistent
depressive disorder. Citing Jorge et al. 2004 and Levin et al. 2005, it is also mentioned that
depression is associated with traumatic brain injury. Still yet, it has been suggested, though there
is no certainty on the matter, that depression might be episodic (that is, recurring), in certain
persons with static brain injuries and other CNS diseases (American Psychiatric Association).

Within the description for anxiety, there is much less detail as to the brain’s relation, considering
it is only mentioned once. The brain is mentioned within the context of panic attacks, and
somewhat surprisingly, no part of the brain is mentioned to cause them. Instead, it is mentioned
that people with panic disorder have a tendency to overreact to non-threatening sensations, such
as a mild physical symptom or a side effect from a medication. The example listed in the DSM-5
involves a person believing that their headache indicates they have a brain tumor (American
Psychiatric Association). What I found most interesting whilst referring to the DSM-5 was how
the chemical imbalance theory was not mentioned. I merely have guesses as to why this is the
case. As will be explained in greater detail later in this paper, the viability of this explanation has
been questioned, so that could be a factor. Nevertheless, I think that mentioning this information
from the DSM-5, which again, is a relevant document, has affirmed my point that the chemical
imbalance theory has had a major effect on how depression and anxiety are understood and
treated. Since I have reached the point of talking about these medications in the contemporary
context, I think it is appropriate to look at another implication of modernity: the sales and
marketing of pharmaceuticals.

Sales and Marketing

The chemical imbalance explanation still remains to be a popular theory about the cause of
depression and anxiety, as Lacasse and Leo mention in Critical Thinking in Clinical Diagnosis
and Assessment, which was published in 2015 (275). They include pharmaceutical marketing as
a major reason for the popularity of the chemical imbalance explanation. In 2014, BBC news
published an article that referred to GlobalData’s statistics on the profits of major pharmaceutical
companies. American company Johnson & Johnson had spent the most on sales and marketing in
2013, spending $17.5 billion. AbbVie, another American firm, had spent the least, at a rate of
4.3%. Between these were eight other companies, which I will be listing in order by region.
American firms dominated the list, making up half of those mentioned (five out of ten). The
three I have not mentioned include Pfizer ($14.6 billion), Merck ($9.5 billion), and Eli Lilly
($5.7 billion). Two Swiss companies made it onto the list: Novartis ($14.6 billion) and
Hoffmann-La Roche ($9 billion). A couple of firms from the UK also made it onto the list: GSK
($9.9 billion) and AstraZeneca ($7.3 billion). Finally, Sanofi, a company based in France, had
spent $9.9 billion (Anderson).

The previously mentioned numbers are exorbitant in their own right; however, their mountainous
nature is accentuated when compared to what is spent on research and development. Virtually all
of the companies spent more on sales and marketing than research and development, with the
exception of Hoffman-La Roche. Johnson & Johnson only spent $8.2 billion on research and
development, which is less than half of what was spent on sales and marketing ($17.5 billion).
Also notable were Novartis and Pfizer, as the former spent $4.7 billion more on sales and
marketing, while the latter spent $4.6 billion more. The differences in spending for the remaining
companies were significantly less drastic (Anderson).

To give some perspective on how widespread pharmaceutical antidepressants are used, I would
like to mention a study from Business Insider that was published in 2016. Referring to data from
2013 courtesy of the OECD, the authors note that antidepressant use was rising in every country
the study considered. In a matter of four years, antidepressant use in Germany increased by 46%,
reaching a rate of 50 per 1,000 people. During the same period, it increased by approximately
20% in Spain and Portugal, the former being 50 per 1,000 and the latter being 78 per 1,000. Use
in Iceland was very high, as it was estimated that 106 per 1,000 used antidepressants. The United
States was added to the analysis by the authors, and the results indicated that use in this country
was even higher than Iceland, meaning that antidepressant usage in the United States was the
highest out of the 26 countries included. Eleven percent of Americans over 12 years of age use
antidepressants, and 110 per 1,000 use them overall. Also high on the list was Australia, coming
in at third place, which had 89 per 1,000 antidepressant users. Canada was fourth on the list, with
a rate of 86 per 1,000. In fifth place was Denmark, which had 85 per 1,000 (Gould and
Friedman). While it would be most convenient to also include a similar study to recognize herbal
medication use, based on my research, it appears that such a study is lacking. Despite this lack of
information, it reinforces the important point that alternative medicine does not have the social
status that pharmaceuticals have; if it did, it seems most apparent to me that such medications
would receive the attention of researchers.

Chemical Conflict and Kratom Chaos

There has been much conflict among academics and health care workers about the validity of the
chemical imbalance theory and the efficacy of pharmaceutical antidepressants. Based on my
research, many academics do not find the theory compelling and have reserves about the efficacy
of pharmaceutical antidepressants. Lacasse and Leo, whose article I mentioned earlier, wager
that the chemical imbalance theory is untenable. One reason they mention is that a lot of the
literature revolving around this topic is tainted by bad methodology, including small sample sizes
and uncontrolled confounding variables. Citing Roggenbach et al., 2002, the German Medical
Board and colleagues stated: “Reported associations of subgroups of suicidal behavior (e.g.
violent suicide attempts) with low CSF–5HIAA [serotonin] concentrations are likely to represent
somewhat premature translations of findings from studies that have flaws in methodology”
(Lacasse and Leo 277). As well, in 2008 a meta-analysis was published that looked at the
efficacy of antidepressants. Obtaining data from all clinical trials submitted to the U.S. Food and
Drug Administration (FDA), their findings indicated that severity of depression is a factor for
how well the antidepressants work. They note that there was nearly no difference between the
placebo effect and the effect of the drug itself for those with moderate depression. However, it
was slightly more effective for those with severe depression (Kirsch et al. 260). These are
surprising responses given what the attitude of the pharmaceutical industry at large is, and such
research appears to be opposed to some of the beliefs that this industry propagates.

Beyond academic research, there are informal methods that people have used to speak out
against pharmaceutical antidepressants. The public-centred Drugwatch.com has a number of
pages devoted to this topic (Drugwatch.com). Concern is expressed over some of the side effects
of SSRIs, including: insomnia, fatigue, headaches, and even suicidal thoughts (Drugwatch.com).
However, those in favor of pharmaceuticals have voiced their opposition to alternative methods,
too. Tension ensued between the Drug Enforcement Administration (DEA) and kratom users
earlier this year. “Kratom (or Ketum) is a psychoactive plant preparation used in Southeast Asia.
It is derived from the plant Mitragyna speciosa Korth” (Hassan et al. 138). On August 30, the
DEA announced their plan to “place the active materials in the kratom plant into Schedule I of
the Controlled Substances Act in order to avoid an imminent hazard to public safety” (DEA).
The reasons as to why the DEA intends to add kratom to this list include its high potential for
being abused, its lack of accepted medical use in the United States, and it not being considered
safe under medical supervision, all of which are characteristics of a Schedule I controlled
substance (DEA).
Though the DEA is a separate organization from the pharmaceutical industry, the use of the term
‘accepted medical use,’ despite its ambiguity, certainly does include the pharmaceutical industry
because the FDA regulate what drugs pharmacies can sell, and the DEA requested the expertise
of the FDA to evaluate kratom and recommendations regarding scheduling (Kosegarten and
Pisano; Noble). Many kratom users ingest this substance as an alternative antidepressant, among
other medicinal purposes, which is why this social control interest on behalf of the DEA has
upset a great number of people. DEA spokesman Russ Baer told US News on September 30 that
"We can't rely upon public opinion and anecdotal evidence. We have to rely upon science"
(Nelson).

Actor-Network Theory
So far, I have briefly mentioned one example of herbal medicine, reserpine in particular, and its
interaction with the pharmaceutical industry. By looking at the relationship between alternative
treatments for mental health and pharmaceutical treatments for mental health through the lens of
actor-network theory, I would like to demonstrate that, despite the discrepancies between the
two, they still exist in the same network. Since actants can be human or otherwise, the network
goes beyond doctors, consumers, and alternative health spokespersons. It also includes the
chemical imbalance theory and the treatments themselves because all of these, in some way, can
restrain or enable one another. For instance, the acceptance of the chemical imbalance theory
enables psychiatrists and the like to advance their research on this topic. Antidepressants can
enable or restrain health benefits for individual consumers, based on how their body reacts to the
medication.

Despite the conflict-theory scenario I mentioned, the divide between alternative medicine and
pharmaceuticals should not be understood as being a total divide. The truth of the matter is that
the pharmaceutical industry and its affiliates are not totally opposed to alternative medicine, as
some pharmacies sell herbal medications. In 1998, Chang et al distributed surveys to pharmacists
in Virginia and North Carolina. Of the 164 pharmacists who were surveyed, 73.6% sold herbal
medication in their work settings (710). What is also fascinating, is that the survey tested the
knowledge that the pharmacists had of herbal medication. Table 2 shows these statements, where
both St. John’s wort and kava are mentioned, which are used to treat depression and anxiety
(713). At the very least, this suggests that certain pharmacies sell alternative antidepressants.

Indeed, a quick search through the stock of popular drug stores indicates that they sell alternative
antidepressants. For instance, on London Drugs’ website, in their supplements section they
include both St. John’s wort and a 5-HTP product (London Drugs). As well, on the Shoppers
Drug Mart website, they have an entire section devoted to herbal medications. They sell both St.
John’s wort and rhodiola, in addition to a plethora of others (Shoppers Drug Mart).
Conclusion
By considering some of the pharmaceutical and alternative treatments available and how they
operate, I showed that pharmaceuticals are intended to treat the brain and that alternatives have
that same intention, at least to some degree, though research is lacking as to how alternatives
exactly work. In mentioning how the chemical imbalance theory was constructed through
scientific findings, in addition to discussing the evolution of pharmaceutical antidepressants, I
revealed that the chemical imbalance theory influenced an authoritative document (i.e., the
DSM-5). By looking at the statistics on the sales and marketing of pharmaceuticals and the
globalized use of antidepressants, it was demonstrated that an exorbitant amount is spent on sales
and marketing and that pharmaceutical antidepressants are widely used, even beyond Western
borders. The conflict-theory framework was useful in evaluating the reliability of the chemical
imbalance theory, the efficacy of pharmaceuticals, the quasi-anti-pharmaceutical attitude of
Drugwatch.com, and the DEA’s attempt to control kratom use in the United States. By looking at
these examples, I showed how conflict can arise from both authoritative and non-authoritative
sources alike. Finally, by using actor-network theory to evaluate the relationship between the
pharmaceutical industry and alternative medicine, I showed that the two can co-exist, as made
evident by stores like London Drugs and Shoppers Drug Mart who sell herbal medications for
depression/anxiety.

Regarding research, there is a lack of information on how herbal medications work, how well
they work, and how much is spent on marketing. The focus here has not been which drug is
better per se, but rather, to document the social processes that pharmaceuticals have undergone to
be understood by society at large as being superior to alternative treatments. This could very well
be the case, but since research is limited on making proper comparisons, epistemic humility
ought to be embraced.
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