The efficacy of anti-depressants
As most people will have heard by now (it’s been pretty widely reported), a recent study by a British University (Hull) suggests that…
… compared with placebo, the new-generation antidepressants do not produce clinically significant improvements in depression in patients who initially have moderate or even very severe depression, but show significant effects only in the most severely depressed patients. The findings also show that the effect for these patients seems to be due to decreased responsiveness to placebo, rather than increased responsiveness to medication. Given these results, the researchers conclude that there is little reason to prescribe new-generation antidepressant medications to any but the most severely depressed patients unless alternative treatments have been ineffective.
Kirsch, Deacon, Huedo-Medina, Scoboria, Moore and Johnson
Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration
I’ve just finished reading the actual study (link above). It’s a statistical analysis of the available data, not a psychiatric / medical study in itself, so it was tough going and rather dull stuff for someone like me with no formal training in statistics. All the same, if this study is confirmed (and it’s important to note that it has only just been opened up to the peer-review process, so we shouldn’t leap to any conclusions until this has been done) then it’s a damning indictment not only of the pharmaceutical companies (who, after all, we kind of expect this kind of behaviour from anyway) but more importantly of the regulatory bodies all over the world who have approved this medication.
In the interests of full disclosure, I should point out that the findings come as something of a surprise to me. Some years ago I was diagnosed with clinical depression (on the severe side, but not within the “most severe” category… I did not require hospitalisation, though it was considered at one stage) and prescribed extremely high doses of one of the SSRIs investigated by the Hull analysis. I’m no longer taking them — I’m very glad to say, as I wasn’t a fan of the side-effects — but I do attribute my recovery in part to the medication. Needless to say, I’m rather intrigued by the possibility that I’d have gotten roughly the same benefit from a placebo.
Indeed, if anything, this seems to be another justification for my current belief that psychoanalytic psychotherapy (incorporating, though not restricted to, some of the techniques of Cognitive Behavioural Therapy) is the best treatment for depression. It probably goes without saying, that particular belief is one of the primary reasons I’m studying what I’m studying (mind you, that’s a far longer article).
Because of the enthusiastic approval of anti-depressants by official regulators, doctors see it as a simple and efficient way of treating an increasingly common illness. Unfortunately, if — as it appears — the bloody things don’t actually work, then it means we’re flushing an awful lot of public money down the drain (or rather, we’re meekly handing it over to large corporations) which has an actively damaging effect on public health, as we’re underfunding other therapies which do have a clinically significant effect above and beyond that produced by a placebo.
As I say, we half-expect large corporations to fudge the figures in search of profit, but the regulatory bodies are supposed to be on our side. We employ them to root-out these kinds of false claims, but if this study is confirmed, it would appear that the FDA (and the others who followed suit) are guilty either of dangerous incompetence, or of deliberately putting corporate profits before the mental health of the public.
UPDATE 16:35 I was chatting with a friend today. His girlfriend was on the same antidepressants as I was prescribed (Venlafaxine) and like me, she found them helpful but is glad to be off them. He said, mischievously but rather perceptively, “aren’t you lucky you were taking them while they still worked?”
I wonder how many incidences like this it will take to shift the popular image of therapy as routinely ineffectual, whereas—side-effects and philosophical objections aside—at least these targetted no-nonsense drugs work. Therapy’s generally more expensive, but—at least it is, or can be, interesting.
February 28th, 2008 | 10:52am
by Gyrus
The placebo effect is really, really interesting. You can even test it, to some extent – a saline injection is a better anaesthetic than a sugar pill, and blue sugar pills are better anti-depressants than red ones. We’re really suggestible creatures.
It’s a bit hard to do a double-blind controlled study of therapy, unfortunately. I’ll swear on a stack of copies of the Interpretation of Dreams that therapy works – I’ve seen it. But I don’t know that it works better than nothing – because, of course, I haven’t seen those same people live through those same years without therapy.
February 28th, 2008 | 11:50am
by Phil
I am old enough to remember the old style antidepressants. They were not very effective, took weeks to produce what little benefits they did and inflicted truly awful side-effects. The new style medication was, for people like me, a absolute revelation. Placebo? Why, I wonder, didn’t the old style antidepressants have as powerful a ‘placebo’ effect as the new ones? Strange, no? Then of course we have the widely documented effectiveness of SSRIs in the treatment of animals, where the argument for a placebo effect is rather problematic.
But even if we fully accept the findings of the recent study (which I do not) we must realise that the placebo effect does not mean that had these drugs never been developed, widely praised and thought effective by patients and doctors we could have got the same antidepressant effect by simply giving the patient a sugar pill (see my previous point above). The placebo effect doesn’t work on quite such a simplistic level as that.
Anyway, jump on the couch and talk amongst yourselves by all means, I’ll keep taking the pills when I need them 🙂
February 29th, 2008 | 9:21am
by Mike Power
When I was an editor on ‘The Lancet’ there was another editor who put to me that placebo is one of the most successful drugs ever invented. It has significant results in a wide-range of conditions and costs hardly anything to produce. You can in fact regard all double-blind trials as actually trials of placebo.
March 2nd, 2008 | 6:38pm
by Joel
Incidentally, those tempted by medication for depression might want to try a daily dose of 200 micrograms of selenium. Selenium is not a “cure” for depression, but lack of it could be a cause. Selenium is very low in UK soil and most people don’t get enough of it.
March 2nd, 2008 | 6:50pm
by Joel
Then of course we have the widely documented effectiveness of SSRIs in the treatment of animals, where the argument for a placebo effect is rather problematic.
Homeopaths can and do say the same.
But I’m not saying that taking a tablet can’t directly affect your mental state – this blog would (ahem) not be the best place to make that claim. I do think the placebo effect is real, and that in some situations it’s probably more consistent and reliable than the pharmacological effect.
March 6th, 2008 | 11:05pm
by Phil
I too was on anti-depressants for about two years, and stopped taking them just a month or two before this story came out. So it was quite strange for me to see all these headlines about them “not working” when it’s obvious to me that my life has been turned around. I would never have been able to get to my final year of university where I am now, and probably hardly have ever left the house. Clearly though doctors prescribe way too many of them, you simply have to walk into a GPs office and say “I’m depressed” and they’ll throw a prescription at you straight away. Maybe there should be some kind of “test” although I’m not sure how that would work. I am also interested in CBD although unfortunately was never offered it. I can’t remember the exact statistics but I read recently that a majority of doctors would rather prescribe CBT (or other “talking therapies”) rather than or alongside pills, but they simply dont have the resources and waiting lists are often 6 months to a year. So it’s pretty clear where the government should be spending their money…
March 11th, 2008 | 10:48am
by Andy