Do a million more patients need to be taking antidepressants? The evidence they work is questionable at best. Brooke Follow Mar 3, 2018 · 6 min read

BBC just published the headline, “Anti-depressants: Major study finds they work,” based on a study recently released in the Lancet, but the true effect is smaller than this headline would lead you to believe. Dr Steve Ilardi, a prominent academic at Duke, looked into the fine print. What wasn’t mentioned was that, “The average outcome difference between those on medicines vs placebo was about 2.4 points on 55-point HRSD depression rating scale. Britain’s National Institute for Clinical Excellence has called such effects “clinically insignificant.”

Further, Illardi explains that “trials used initial ‘placebo washout’ to exclude all rapid placebo responders, stacking the deck in favor of meds.” Many patients in the control group were already on antidepressants and then given sugar pills. This put them into withdrawal and further biased the results. The media did not take note of this. One article wrote only, “antidepressants work” and another claimed a million more patients need to be taking them. Never mind that the effect was clinically insignificant, the benefits less than the side effects, and that the study was not even blinded.

Failing to blind the placebo is common practice in privately funded depression studies. As the drugs have side effects, patients can tell if they are taking the drug or a sugar pill. Dr. Moncrieff at University College London notes, “This may explain why antidepressants that cause the most noticeable alterations, such as amitriptyline, appeared to be the most effective in the recent analysis.”

A Cochrane review analyzed depression trials where something was put into the placebo to blind them better. In these trials the placebo caused symptoms similar to what depression drugs would, such as dry mouth. When this was done, the difference shrunk to 1 on a scale up to 52. The minimum perceptible change on this scale is a 6 meaning that patients could no longer tell the difference. Danish physician and leader of the Nordic Cochrane Center, Peter Gøtzsche, hypothesizes that this is due to the profit motive of pharmaceutical companies. He says, “They do not want to put something into the placebo because then we could all see the emperor has no clothes.”

Even including these sources of bias, the new Lancet study found a smaller effect than the famous “antidepressants don’t work” study by Kirsch et al. in 2008. Using data reported by the companies themselves, the effect is smaller now than ten years ago, but the papers are reporting success.

Stepping back a bit, even if the effect is the same as placebo, the placebo effect is real. Certainly some patients could benefit from that? This is true, but unlike a sugar pill, these medicines are not harmless. In data released by the pharmaceutical companies, again, likely to be an underestimate, patients are predisposed to agitation and violence including suicide, and homicide. (Patients who attempted suicide or killed themselves while taking the medicines were also added to the control group introducing another source of bias.) For the patients who do not experience these extreme effects, they are likely to experience sexual and relationship problems as well as stunted emotions. At a conference on the harms of psychiatric medicines, Gøtzsche explains bravely:

“These drugs cause sexual dysfunction in 50% of patients who did not previously have sexual problems. This is not likely to save intimate relationships. It’s common in psychiatry that if anything happens you always put the blame on the patient and not the pill, this happened here where female anorgasmia was coded as female genital disorder. ‘It’s your fault, it’s not our pills fault.’ In a Spanish study you can see that people get decreased libido where up to 70% of men could not get orgasm or even an ejaculation. These drugs do something, prevent a male from ejaculating, that’s strong stuff, really, really strong stuff, but they don’t work for depression. Some patients, they yawn during orgasm. It’s ok you know in the old films to take a cigarette and yawn afterwards, but it’s not ok to yawn during your climax. It doesn’t help a new relationship. ‘Why are you yawning?’ ‘I don’t know.’ ‘Did you also yawn with other women?’ ‘No.’ ‘So you don’t like me?’ ‘Yes.’ ‘So why are you yawning?’ ‘I don’t know.’ Very bizarre side effect. I know a psychiatrist who knew three boys who could not get an erection because they were on antidepressant drugs the first time they tried to have sex. They tried to kill themselves. They thought, ‘something is wrong with me.’ It has a consequence to use useless drugs that have harms.” If patients complain, “The typical reaction of doctors in these cases is arrogance. The psychiatrists think, ‘You don’t like my drugs? So maybe you don’t like me?’ It’s human, but it’s wrong. Patients are left to find their own way through this hell that doctors have created for them.”

What about using the drugs with other approaches, like therapy? There is evidence that when you combine these drugs with psychotherapy, the therapy is less likely to be effective. Gøtzsche continues, “There is good reason for this. If you take away people’s feelings, how can you work with them in psychotherapy? If you take away their thoughts, how can you work with what they think?” Worryingly, there is limited evidence that when coming off antidepressants that patients regain their ability to feel. That is, if they are able to come off them at all. Due to dependence, this transition can take months or years.

A common argument is that, even if these drugs are ineffective, patients do not have any other options. Still, a lack of treatments options would not justify promoting treatments that are ineffective at best or harmful at worst. Furthermore, Dr. Illardi and Dr. Moncrief have written extensively on strategies for reducing depression that effectively reduce symptoms, “effectively” here meaning above and beyond placebo. Moncrief explains, “several studies have found that the outcomes of people treated with antidepressants are worse than the outcomes of people with depression who are not treated with antidepressants.”

To people with chronic illnesses, like ME, Lyme Disease, or MS, the costs are even higher. This is where the discussion becomes personal to me. So often patients with serious health conditions are encouraged to try antidepressants when doctors cannot find the source of their symptoms. “Just try,” doctors will say. Medical providers can become so hyper-focused on a patient’s emotional reaction to being ill they ignore all other physical symptoms. Rather than helping, this medicine is more likely to only add side effects and interactions to the medicine these patients need to be taking.

Why would medical professionals insist on prescribing medicine that does not work? This is another place where the debate becomes muddy. Often people presume, kickbacks from drug companies are the source of the problem. However, if this is the case, why is it so easy to get psych medications but hard to get doctors to prescribe medicine that would help? If this theory were true, presumably doctors would push all medicines, not just psychiatric ones. To me, it seems more likely to me that doctors have been led astray by this same reporting that has misled the rest of us.

This is an issue that is close to my heart. These medicines are prescribed aggressively (9% of U.K. population is taking them) and I have many close friends taking them. Even if I could convince people who are taking them what the data shows, usually by the time I find out it’s too late, because they have already been on the drugs for some time and by then it’s too late to avoid the effects. I wish more writing was done on this so that people knew in advance the true costs and benefits.

It is true that if, on average the drugs have no effect that means half of people got better. This debate occurs in the chronic illness community all the time. I’ve benefitted from drugs that we know, on average, have no effect for patients. The same drugs that allow me to walk are ones that have caused other patients to become bedridden. Should we still prescribe those drugs? Maybe, but I think we should be honest about their effects and how likely they are to work. Due to the amount of bias in these trials, I would want to see the results of independent studies before saying I support their use.

Discussing all the poor research I have seen in other areas of medicine this year, such as the recently discredited PACE trial, a fellow patient said, “I’m starting to understand how these papers have not been retracted yet and why those docs felt that what they were doing was ok. Everyone else is doing it.”

You can read more in this brilliant editorial here: https://www.madinamerica.com/2018/02/challenging-new-hype-antidepressants/

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