Do Antidepressants Work?
Answer: Yes! Answer: Yes! Answer: Yes! Antidepressants do not work. This is not to be Clintonian, but the definition of "work" will determine whether or not antidepressants actually work.
The controversial Journal of the American Medical Association published a study that concluded antidepressants were no better than placebos in treating most patients with depression . Jay Fournier, a University of Pennsylvania researcher, analyzed individual data from six clinical trials. They found that antidepressants are superior to placebo only in the treatment of very severe depression. Placebos are nearly as effective for patients suffering from mild to moderate depression and severe depression.
There have been at least four other review articles published in the last eight years that have come to similar conclusions about the limited clinical efficacy of antidepressants, and one of the study authors, psychologist Irving Kirsch, has recently published a book on the topic, provocatively entitled The Emperor's New Drugs: Exploding the Antidepressant Myth. Recent reviews questioning antidepressants' clinical effectiveness go against what is commonly believed in the psychiatric world. In fact, Prozac was an instant hit. In 1990, Newsweek Magazine published a cover photo featuring the Prozac capsule.
It is not difficult to agree on the essential facts of antidepressant effectiveness. Antidepressants are statistically superior to placebos in double-blind controlled studies that use randomised control trials. This debate centers around how to interpret these results. It revolves around the difference between statistical and clinical significance.
A statistical significance is a sign that an effect cannot be explained by chance, and therefore is likely to have reliable statistics. Statistics significance doesn't indicate how large the effect is or what its practical implications are. A patient's experience with an antidepressant is clinically significant. It indicates how much the effect has a positive impact on their symptoms. Although antidepressants have been statistically proven to outperform placebos, clinically speaking the differences between the two are not significant. On a scale of depression that runs from 0 to 52, there is an average difference between placebo and drug at two points. The difference is not more than the 3 points that are considered minimally important clinical improvements in depression.
What about the testimony from patients who claim that antidepressants have helped to relieve their symptoms? However, these reports don't contradict the results of randomized controlled studies. Antidepressants have shown significant improvements in patients who were treated. The clinical trials data indicate that placebos can improve patients by about 75% compared to patients receiving antidepressants. However, only 25% of the improvements seen in antidepressants-treated patients are due to antidepressants. Rest of the improvement can be attributed to a placebo effect. There is no placebo in clinical practice. Patients and doctors will likely attribute any improvement in symptoms to medication.
Double-blind, randomised controlled trials have shown that antidepressants perform only marginally better than placebos. It is possible to ask if there are patients who antidepressants work well for. Although this is likely, no one knows with any certainty what subset of patients will respond.
Aside from the fact that antidepressants can have a small average effectiveness and are not clinically meaningful, there should also be subsets of patients where antidepressants don't work, or worse, are harmful. Pharmaceutical companies, which are the main sponsors of drug trial funding, have a strong interest in increasing the availability of their medication to as many people as possible. They have no interest in conducting any studies that would identify these subsets. This would reduce their profit margins.
Many have suggested that antidepressant critics should remain silent and refrain from publicizing their findings. This is because if antidepressants' effectiveness depends on patients trusting their doctors and treating them with respect, publicizing that they appear to be less effective than placebos could have the effect of hurting patients. This is not a good idea. History is full of treatments once thought to be effective, that have turned out to be harmful or ineffective. It is dangerous to ignore all the evidence and return to prescientific medicine. This will be detrimental to the patients in the end.
Let's see, what is the final word? Antidepressants have been shown to improve depression symptoms in clinical trials. However, evidence suggests that a lot of this improvement may be due to a placebo effect. Many patients who are treated with antidepressants show significant improvements. If the measure of efficacy is compared with placebo, then the best evidence shows that antidepressants are not very effective. The cost of antidepressant medications and their side effects should not make it easy for the public or the psychiatrists to accept a small benefit over placebo.
In fact, Walter Brown, a Brown University School of Medicine psychiatrist, suggested that mild-to-moderately depressed patients be treated with placebos for 4-6 weeks. Patients could then switch to active medication if they did not get better. Brown suggested that patients be informed that placebos can be prescribed openly. He explained to patients that placebos have been shown in clinical trials that depression symptoms improved. Then, he asked them if they'd like to test a placebo. Brown made his revolutionary prescription to harness the placebo effect in depression treatment sixteen years ago. Do you think it's time to fulfill the prescription? .