Antidepressants work. Why can’t we ask something more useful?

Earlier this week, The Guardian published the results of their survey, “Do antidepressants work?” Overall, responses from all five countries were remarkably similar – about 75% of people thought they did work, based on their own experiences.

This may sound exciting but actually, it’s largely a waste of time. Not only are the responses biased beyond the point of usefulness – but we already know the answer to the question.

Get some perspective

When you run a survey like this, only people who’ve had memorable experiences of antidepressants will respond – the ones who’ve had their lives transformed for better or worse. People who’ve had forgettable experiences will simply decline to fill in the form, making the results an unrealistic sample of two polarised camps.

Also, there is no guarantee that the improvements and deteriorations that people reported were due to their antidepressant. No matter how miraculous the recovery or horrific the side effect, it could’ve happened on a placebo or without a tablet at all, as part of life itself. There’s no way of telling by simply asking someone.

As a sensible scientist once said, “the world looks flat from where I’m standing”. Our own points of view are hopelessly biased, so it’s only when we look at the bigger picture that we can accurately see what’s really going on. This is why we have clinical trials – and when you look at those, the answer is clear – antidepressants work.

Even the staunchest of detractors agree. Joanna Moncrieff, who usually states that antidepressants only work via a generalised “numbing” effect, published a meta-analysis with Simon Wessely reporting that they do actually seem to work better than a “numbing” placebo. And the much debated meta-analysis of Irving Kirsch, who has written a whole book vehemently attacking the whole concept of antidepressants, suggests that they do still work in severe depression.

Of course they don’t work for everyone, no drug does. But in comparison to many other drugs in medicine, they work damn well. You’d need to give 50 people a statin to stop one of them having a non-fatal heart attack or stroke. The same number applies to aspirin. But the relapse rate in depression drops from 41% to 18% if you take tablets – the “number needed to treat” is less than 5.

In fact, an elegant paper by Leucht (2012) notes that overall, most psychiatric drugs are at least as effective as other medical drugs – but perhaps that’s a discussion for another day.

Always read the label

Sure, antidepressants have side effects, but again, so do all drugs. Here’s the side effect list for Ibuprofen, which I assume no one is debating the effectiveness of:

  • increased risk of heart attack
  • increased risk of stroke
  • nausea
  • vomiting
  • diarrhoea
  • indigestion
  • abdominal pain
  • headache
  • dizziness
  • fluid retention
  • raised blood pressure
  • gastritis
  • duodenal or gastric ulcers
  • allergic reactions
  • bronchospasm

Just because a drug has side effects doesn’t make it ineffective and certainly doesn’t justify sensationalism – just a level of caution when we prescribe it and high quality research to learn more.

Ask something more helpful

Persisting in asking if antidepressants work, when we know that they do, is an insult to those who clearly benefit from them and need them to live their lives. To tell people that they are being duped into sedation for “problems of living” by drug companies minimises their distress and devalues their right to an effective treatment. This “pillshaming” is a form of stigma which only mental health patients suffer.

We are wasting valuable time and column inches which could be spent discussing far more fruitful questions, albeit ones which wouldn’t sell papers:

  • Are we prescribing antidepressants too readily for problems that could be fixed without them – often in primary care?
  • Why is accessing talking therapy as an alternative option so difficult? Is this affecting antidepressant prescribing rates?
  • Do we discuss the indications, effects and side effects of tablets well enough with patients?
  • How close are we to tests and scans that can tell us if someone will benefit from a certain antidepressant?

We need to move on from asking if antidepressants work – and starting asking how they work best.

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About Alex Langford
I am a psychiatrist (now an SpR) based in Oxford after 3 years working in South East London. Before I went into psychiatry, I used to be a general medical doctor, and I also have a BSc in psychology. I'm particularly interested in improving the public face of psychiatry, evidence based medicine, teaching and patient rights. Don't mention cricket unless you've got the next fortnight free to discuss it.

12 Responses to Antidepressants work. Why can’t we ask something more useful?

  1. PC says:

    Having taken antidepressants, my view is that yes, they do “work”, but it depends on what your definition of “work” is. They…”antidepress”…they calm you down, reduce the cortisol in the body that causes depression, and so on. But do they increase happiness levels? Do they help you feel vital, alive, and engaged with life? That’s the real question. For me, they didn’t do any of those things. I’ve had much better results by giving up junk food, taking care of my health, taking probiotics and the correcet vitamins, regular exercise, dealing with my emotions and stresses, and generally engaging with life again. The weird thing is that when I was on meds…I felt too tired to do any of these things. Everything seemed much harder, because I felt shut down emotionally.

    I’m not judging those who take meds here…just relaying my own experience. Everyone has to make their own choice. But the problem with meds is that they often seem like an easy route out of doing the things in life which will give you truly lasting happiness…such as the things I mentioned. What people really need to be prescribed are ways of coping with their emotions and compassion. Unfortunately we don’t live in a society that promotes this.

    Hope this helps. Again, I must point out that I am not belittling or looking down on anyone who takes meds – not at all! I just wish there were more visible options to make us happier.

    • Good point – even if antidepressants were complete “magic” and simply switched off the “depressed” part of your brain (which they certainly don’t), you’d still have a lot of bad memories and social issues to work through – they can only form part of a bigger package of care – but that doesn’t mean people should slate them because the other parts of the care aren’t provided.

  2. Pingback: Anonymous

  3. I think it’s really important to address the articles like the Guardian one in a balanced manner, I’ve heard only too often the old ‘happy pills handed out like sweets…’ without regarding their efficacy. Although I do think care should be given when prescribing, anti-depressants sent me cycling into mania…

  4. Pete W. Wargo says:

    these drugs were an okay phase. but its time to get back to the orgins of the whole creation of these drugs. ..anti-depressants are extremely dangerous. there is no question about it. ..we need to get to a more natural rooted mechanism. ..not a synthetic developed off of a synthetic with natural roots. ..hows about a Uey? remember the 60s? …i see the clinical MDMA sessions being a huge buffer to get back to the LSD. ..honestly, we need to lower the amount of MDMA being consumed today. ..MDMA serves phenominal clinical use. ..hows about we get back on track, eh? and don’t forget, puffpuffpass .

  5. Interesting you should mention drug labels. Clinical trials are pretty good at identifying side effects, but don’t capture all of them. Perhaps the guardian should have encouraged people to report their side effects to the MHRA so a better picture of their prevalence can be identified and put in the label if needed.

  6. You seem fearful, Alex, that antidepressants may be merely placebo.

    • I’m not really sure how you’ve reached that conclusion Duncan. The angle of the piece is fairly clear, there is no hidden message.

      In any case, this is science. One should not be fearful that a theory isn’t true, just willing to accept evidence that it isn’t and adjust it accordingly. If such evidence were presented I would do so, because I’m only in this job to help people.

      But as the article states, such evidence is persistently not forthcoming.

      • The facts are that even in clinical trials a third to a half of people are not helped and the difference between placebo nd active drug is small. Your patients should know. I hope you tell them.

  7. In fact in many cases it’s less than half. For example, the STAR-D trial which recruited refractory cases only reported around a 35% remission rate for citalapram. And yes, the average effect size is small. But this is a far cry from ‘don’t work’. As the post states, they still work far better than many other medical drugs, which we’re prone to overestimating.

    Yes, facilitating patient choice with sufficient information is key, so I do tell my patients.

    • NICE says they the effect size is not clinically significant. And I agree medicine in general does not pay enough attention to small effect sizes (see http://criticalpsychiatry.blogspot.co.uk/2012/02/psychiatric-drugs-just-as-ineffective.html). By the way, science is a sceptical position. You haven’t disproved the null hypothesis. The small effect size could be due to unblinding in clinical trials, if it is, this means antidepressants don’t work, although I suppose it depends what you mean by “work”., because I suppose a placebo works.

  8. I’m not a great fan of anti-depressants, especially for people with families. I feel its a quick fix for GPs over counselling. I don’t feel anti-depressants address the psychological imbalance of trauma or depression, it may initially suppress the pain the memories but how do you then deal with the issue? How do anti-depressants address the emotional effects on children. For example depression doesn’t just affect the parent, its has mental health ramifications on the partners and children. What about the psychological affects of addiction, when the person doesn’t think they can cope without them ? I could go on, I just feel its a quick cost effective fix.Question is is it really cost effective when the impact on a family can create lasting cycles of mental health within children!!!!

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