Antidepressant efficacy may be overblown

“Antidepressants, for the most part, do not provide meaningful benefit, two investigators in the UK argue in a report in the British Medical Journal this week, having reviewed published medical evidence on antidepressant efficacy.

Most people with depression are often initially prescribed an antidepressant by their doctor. Prescriptions for these medications have risen dramatically in the last decade.

In an interview with Reuters Health, Dr. Joanna Moncrieff, an author of the report, said, ‘I do not think there is such a thing as a drug that will specifically relieve depression. I think so-called antidepressants are just drugs that do other things, such as sedating or stimulating people.’ In fact, she continued, “I am skeptical as to whether there is a biochemical syndrome of depression despite the portrayal by the drug companies and some psychiatric literature.”

Moncrieff, a lecturer at the University College London and co-chair of the Critical Psychiatry Network, describes depression as a condition that “should be dealt with without drugs, because it’s something people need to learn to deal with themselves.” (Reuters Health)

Antidepressants may be, partly, the victims of their own popularity. Antidepressant prescribing practices have expanded far beyond the most severely ill patients who have a biochemically determined and biochemically treatable condition, and aggregate data on their efficacy, of course, depends on the denominator as well as the numerator. There are several major, interrelated, reasons for the explosive expansion of antidepressant ‘customers’ in recent decades. First, the development of the ‘second-generation’ antidepressants (SSRIs and their successors) suggested greater tolerability and less troublesome management of the patient on an antidepressant. Second, rapacious pharmaceutical companies hit upon the strategy of marketing these medications to primary care doctors rather than psychiatrists only. A related, although probably minor, influence has been the relaxation of rules against advertising drugs directly to the lay public as well. And changes in the mental health care system have progressively edged high-priced psychiatrists out of service delivery roles in favor of less costly ancillary professionals such as social workers and other masters-level clinicians, especially in the area of talking therapy. In an effort to hold onto shrinking market share, there has been market pressure for psychiatrists to create added demand for their indispensable service niche — prescribing. They have done this by progressively enlarging the scope of conditions that are asserted to be susceptible to biological manipulation. The overall impact of these trends has been most evident in the drastic explosion of numbers of antidepressant prescriptions written over the past 10-15 years.

Moncrieff is onto something, I think, in the claim that antidepressants may not so much treat depression itself as “do other things, such as sedating or stimulating people.” In particular, these newer, SSRI and post-SSRI antidepressants may be, as I and others have often observed, more partial antidepressants than some of the older, “outmoded” agents; that may go along with their increased tolerability (since there is probably no free lunch in psychopharmacology any more than there is anywhere else). May of us feel they treat the ancillary symptoms better than the core depression. The article mentions sedation, and I would add agitation and anxiety; the antidepressants are probably better anti-anxiety medications than the anxiolytics in the Valium-like benzodiazepine family.

But I am not as troubled by this as she is. There is a misconception about what clinical depression is; this is partly bred of the unfortunate coalescence of the medical term we use to refer to a distinct clinical state and the lay use of the word. A major depression, biochemically treatable (and, in fact, it is so much the proven standard of care that a malpractice suit can be brought against a medical or nonmedical mental health practitioner who does not counsel her patient with major depression to seek an antidepressant) is not just the sadness of mood, the ‘down’ day, the ‘blahs’ or the ‘blues’, or even merely hopeless and helpless thinking, which most people mean when they say they are going through something depressing. This is often the assumption behind someone’s statement that depression is something “people need to learn to deal with themselves”. This is a misguided and destructive attitude the depressed patients I treat often receive from their uncomprehending families and friends, which compounds the difficulties they are having in their functioning and correction of which is an important contributor to their recovery. A patient with a major depression is struggling with a whole-body illness with changes in most organ systems and physiological functions including their energy metabolism, their hormonal rhythms, their basic sleep architecture, their digestive functions, immunological competence, modulation of pain, and numerous aspects of their autonomic nervous system, as well as the tissue integrity of various regions of their brains. Like a snake eating its own tail, the mental changes precipitate and worsen the bodily changes, and the somatic symptoms worsen the cognitive and emotional. The mind-body connection is, of course, a two-way street. The point is, there are indeedmany ancillary symptoms to treat in a depressive episode, and doing so has a potentially important impact on the patient’s ability to function! I have often said that medication is like a bicycle — the most efficient way to get some place, but you still have to (a) know where you want to go; and (b) do the pedaling yourself. Properly used, antidepressants are a vehicle for restitution in people otherwise too debilitated to “deal with it themselves,” precisely so they can begin to “deal with it themselves” by more effective functioning in their relationships, their activities of sustenance, their participation in their community, and their psychotherapies.

The Reuters headline said that it was an “expert” telling us that antidepressants are less effective than we had been led to believe, but I find critiques like Moncrieff’s to be vestiges of a scientifically naive and outmoded mind-body dualism. Nonetheless, the value of this study and, indeed, of the sociological critique of modern biological psychiatry as a whole, may be to raise the hue and cry about the extent to which psychiatrists have forgotten that they are not the be-all and end-all in the treatments of their patients’ depressive and other conditions, and that medication is not a cure. Antidepressants are more like the insulin diabetics take to keep their glucose metabolism regulated in the face of their disease than like an antibiotic that eradicates a patient’s pneumonia.

I would welcome your comments, particularly if (a) you have personal experience with depression or antidepressants; (b) you disagree with me on this; or even if (c) you got to the end of this argument without your attention flagging.

Planet with three suns challenges astronomers

//' cannot be displayed] “A NASA-funded astronomer has discovered a world where the sun sets over the horizon, followed by a second sun and then a third, as pictured in this artist’s conception released by NASA July 13, 2005. The new planet, called HD 188753 Ab, is the first known to reside in a classic triple-star system.” (Yahoo! News)

Looking for the Candy, Finding a Back Story

Even Charlie and the Chocolate Factory gets its ‘family values’:

“Inexplicably, and at great risk to the integrity of the movie, the filmmakers have burdened him with a psychological back story pulled out of a folder in some studio filing cabinet. Why does Wonka spend his days confecting sweets? Why, in the movies these days, does anyone – artist, serial killer, superhero – do anything? An unhappy childhood, of course. I’ll grant that it was clever to make Wonka’s dad a mad, sugar-hating dentist (and to cast the unmatchably sinister Christopher Lee in the role), but to force a redemptive story of father-son reconciliation onto this story is worse than lazy; it is a betrayal of a book that the filmmakers seem otherwise to have not only understood, but also honored. Sentimentality about family relationships does not feature heavily in Dahl’s world. Matilda, for example, the title character of another Dahl book, was more than happy to give herself up for adoption.” (New York Times )