The more researchers delve into the research behind antidepressants — the class of drugs commonly prescribed to treat depression — the more they find that perhaps the majority of antidepressants’ treatment effect is based upon the simple belief that the drug will help.
Newsweek’s Sharon Begley has a lengthy article discussing the growing body of evidence that calls into question decades’ worth of prescriptions. It’s a story that we’ve covered previously, that TIME covered nearly a year ago, and that Therese Borchard had a response to. It seems to be journalists’ favorite “go to” story now in mental health, because there’s a black-and-white controversy — do antidepressants work or don’t they?
People mistakenly believe that one type of research is somehow superior to another form of research. However, data is data and research is research. All things being equal, if it’s done in as objective a manner a human being can do it, then it’s all good and informative. A study conducted 20 years ago is just as valid today, as long as the design of the study was solid and unbiased. And a single-case experimental design, while not very generalizable, can still lead — and has led — to valuable insights into human behavior.
So I get a little concerned when we do give more weight to the most recent study, or the most recent meta-analysis. They have their place, but their place is in context — understanding the body of research as a whole. (Because meta-analyses never take into account the entire body of research on a drug or topic — they always have inclusion and exclusion criteria, criteria that can directly impact the results they find.)
To see another article about this issue go ’round and ’round the bend with both sides, but not really bringing anything new to the discussion, is a little frustrating. I think it’s pretty obvious that if a drug was supposed to help people, but didn’t, people would stop taking it and doctors would eventually stop prescribing it. Since it’s unethical to prescribe placebos to patients outside of a research study, what choice do doctors and patients have — the drug works. (Well, not always, of course, but in many people who take it, and who keep trying a different antidepressant if the first one doesn’t work, according to the results of the STAR*D study.)
Why antidepressants work is an important academic question. If it’s mostly the “placebo effect,” then that’s a sign that a lot of research is wrong. A lot. Drug studies that found significant clinical differences (not just statistical differences) have to be better explained. And those that found virtually no clinical differences need to better see the light of day. We certainly need to understand why we’ve been prescribing an entire class of medications for decades if we honestly believe they are no better than a sugar pill.
But back to the article… As I said, it’s basically a rehash of this question — Are antidepressants effective or not? — which I suspect we’ll see appear in a mainstream media outlet from now on at least once or twice a year. The answer is simple — yes, they can be effective. But perhaps not always for the reasons we thought.
Begley also seems a little confused, telling readers that only psychiatrists conduct psychotherapy (when, of course, there are psychologists, clinical social workers, marriage and family therapists, and a host of other professions that provide psychotherapy):
It’s all well and good to point out that psychotherapy is more effective than either pills or placebos, with dramatically lower relapse rates. But there’s the little matter of reality. In the U.S., most patients with depression are treated by primary-care doctors, not psychiatrists. The latter are in short supply, especially outside cities and especially for children and adolescents. Some insurance plans discourage such care, and some psychiatrists do not accept insurance. Maybe keeping patients in the dark about the ineffectiveness of antidepressants, which for many are their only hope, is a kindness.
This would have also been a great time to mention the mental health parity act that just went into effect, guaranteeing that most insurance plans can no longer “discourage” psychotherapy treatment. But this wouldn’t be the first time Begley doesn’t quite understand what she’s talking about when it comes to mental health. She’s the journalist who took the Association for Psychological Science’s press release about a new training model they were advancing (in the form of a journal article in one of their own journals) and turned it into an uncritical look at Why do psychologists reject science?. We had a far more critical take on this pseudo-science.
But it’s that last line of that paragraph that is especially troubling and paternalistic. People should know whether the treatment they are receiving has research data to back up its effectiveness. But then they should also know and be able to put that into some kind of context. Like the fact that a lot of common medical procedures are only now starting to gain an evidence base, yet they continue to be done (and have been done for decades) with little scientific evidence that they work. Why hold mental health to the fire, when health care in general has been lacking a scientific evidence base for nearly all of the last century?
As for Kirsch, he insists that it is important to know that much of the benefit of antidepressants is a placebo effect. If placebos can make people better, then depression can be treated without drugs that come with serious side effects, not to mention costs. Wider recognition that antidepressants are a pharmaceutical version of the emperor’s new clothes, he says, might spur patients to try other treatments. “Isn’t it more important to know the truth?” he asks. Based on the impact of his work so far, it’s hard to avoid answering, “Not to many people.”
Let’s get real. People choose antidepressants over psychotherapy because antidepressants — placebo or not — take 2 seconds to take and require virtually no thought as a treatment. Psychotherapy, on the other hand, takes an hour every week out of your schedule, and requires not only thought, but active, often difficult changes to be made in the way you think and feel. It’s hard work. That’s why most people will continue to opt for the pill, no matter it’s effectiveness — it’s easier and for those who benefit from its effects, it works.
I am, of course, all in favor of more people giving psychotherapy a try. But I’m also a pragmatist and know that many people have already given psychotherapy a try, and unfortunately it didn’t work out for them. Whether it was due to a bad therapist, a misunderstanding of the expectations of therapy, or whatever. People don’t only want options — they need them.
So yes, let’s figure out the important question of why antidepressants work. But let’s also continue to give people the treatment options they need, and not pretend there’s a single answer to someone overcoming depression. There isn’t.
Read the full article: The Depressing News About Antidepressants
Placebo effect is one explanation; DNA is another likely one (not often considered). See February 1 & 8 issue of Business Week; article entitled “This Drug’s For You”. Fascinating stuff…
Well, the Newsweek article calls for many commentaries. I will limit to two.
The charge that “many clinicians fail to “use the interventions for which there is the strongest evidence of efficacy” and “give more weight to their personal experiences than to science” seems convincing on first look. It is a fact, well, from my own experience!, that clinicians rely greatly on their personal experiences to guide them on their practice. Surely, basing on science would be less biased and more reliable. Unfortunately, this simplicity conceals great difficulties.
First, published results can hardly be extended to the specific populations you are dealing with in real-life. The introduction of the DSM-III was hailed as a great improvement for science because it would lay out the specific criteria that had to be met before posing a diagnosis. By using these criteria, it was argued, we would insure that all researchers would be discussing about the same population across the studies. This promise has not always be fulfilled. In fact, each mental health institution has its own subject characteristics, because of the way subjects are recruited and referred within the district. One institution might be recruiting more treatment resistant patients because it acts as a third-line service center. Another institution might be heavily recruiting from low-income populations. Yet, another institution, based in a city of a middle size, might be recruiting patients from all horizons. All three would publish studies about “depressed patients” or “schizophrenic patients”, but the underlying characteristics of the population would be quite different. Moreover, some centers might have more schizophrenia with a paranoid subtype, while another institution might recruit more of the disorganized type, because of the bias of the first-line providers (some deal better with paranoia or with disorganization than others, altering the rate of reference to the second-line institutions).
And this is not to mention the differences in the way treatment is applied. Every clinician applies CBT differently. Published studies rarely describe the details of the therapy the therapist offers, or the specific steps he and his patients underwent, and in any case, no published study ever describes the warmth and confidence that linked the therapist to its patients (one could measure it by self-rating tests, but one never does). Thus, a specific clinician has little confidence that he will be able to reproduce the experimental condition of any specific research.
My second comment refers to the way the recent meta-analyses on antidepressants. Most of these meta-analyses reveal that the beneficial effect of antidepressants were smaller than previously thought, with some studies denying that the effect is statistically or clinically significant. Of course, absence of statistical significance does not mean absence of difference. What people often don’t know is that there are ways to test that a difference is null, ways that differ form testing that a difference is statistically significant. The recent meta-analyses did not test that the difference was null, but looking at their results, my presumption is that this null test would fail (suggesting that there is a likely difference). The trend towards a beneficial effect for antidepressants seems too important, even though it does reach statistical significance.
I think that studies are good for generalized methodologies but each case must be debated on its own merits. If it works for them and they are happy regardless of whether it really works then who cares? If they are willing to risk the side effects then let them. Give over the reigns of treatment to the one being treated and not so much the doctor. A doctor can provide advice and warnings but ultimately it is my body and my mind. The of course must with the understanding that the side effects are not causing a danger to those around them.
I have much the same thoughts on religion, if it makes you feel and helps you to do the right thing then go for it just so long as you don’t allow it to interfere with my life and my happiness.
I love it!!! “Let’s get real. People choose antidepressants over psychotherapy, because antidepressants…take 2 seconds to take and require virtually no thought as a treatment.”
And with that statement, when patients put no thought into the treatment process, how do they really know if the medication works? And, when 70% of antidepressant prescriptions in this country are written by non-psychiatrists, what is that message?! It is a dumbed down public who wants to further the effort by just hearing the quick fix mentality of pharma, overwhelmed doctors, and, you had to know this was coming Dr Grohol, the internet!
You didn’t get a psychiatric illness overnight, people, so why do you think it will get better overnight? Depression isn’t a sore throat. Well, unless you are screaming from the psychic pain of the problem. Sorry for the poor metaphor, but, maybe it gets the attention.
Meds do work. So does therapy, problem solving, maturity and coping, and, having supports.
Take that above multifaceted RX and use it for 6 weeks and call me with an update. I hope it will be a call you and I will enjoy!
I was being a little facetious in the way I worded that part, but the truth is that when someone walks into their doctor’s office complaining of lack of energy, a sudden sense of hopelessness about the future, little interest in past activities and hobbies, and a general depressed mood, the simple explanations offered by most docs (“oh, that sounds like it might be depression, caused by a neurochemical imbalance. This antidepressant should help”) sound pretty reasonable.
That’s why I believe the Carter Center’s work in trying to get primary care physicians to better understand the impact they have on mental health issues is of great importance. Primary care docs need not only to be a part of the conversation — they need to be hit over the head with the importance of not just prescribing meds and shuffling their patients with mental health concerns out the door.
But it’s all so inter-related. Many can’t refer, because they know all of the psychiatrists they refer to are booked up for 3 months in advance. And a physician’s inclination is always to refer to another physician, not necessarily just any mental health professional (despite other mental health professionals’ abilities to diagnose and treat).
It’s complicated in terms of how do you encourage less prescriptions and more psychotherapy. It’s not simply a matter of education.
If an alternative health practitioner claimed that in their practice x supplement worked in spite of the studies showing that it didn’t, they would be accused of providing anecdotal evidence and not following evidenced based medicine. Why is it ok when psychiatrists do this regarding this study? It seems like a double standard to me.
By the way, I am not defending alternative folks as I have not had great experiences with them either.
Also, if antidepressants are as effective as people claim they are, can anyone point me to a link to at least a 5 year study showing this? I would like one that is full access.
I asked this twice on Dr. Carlat’s blog but I never received a response.
I don’t doubt that ADs can be effective in the short term. But I greatly question whether they are effective long term. And even if they are, I am thinking the side effects would take away some of that effectiveness.
All very interesting – I would add that Psycotherapy costs a lot as well, which is another reason why patients won’t go. They simply can not afford it.
You can get the medications very inexpensively these days (at least the ones that have generics) but the same can not be said for therapy.
I applaud The Carter Center’s effort as well, and look to to therapy community to find less expensive, yet effective ways to help patients.
I also can’t believe, from a macro level, that we just passed mental health parity legistlation. Why are we treating our brain as a seperate entity from the rest of our body? It all works together, and I wonder what we were thinking when we developed science by seperating them out, it simply does not make sense to me.
Keep up the good work all!
Well… define “work” 🙂
Sure they numbed me emotionally. Does that mean they “worked”?
When I decided to come off them and see what I was like, just me unaltered, I had some adjusting to do. Suddenly faced with having to feel much more than I was used to seemed overwhelming. I would imagine this would cause some to thinkg that they did “work” and that I’d better hurry up and get back on them.
But I didn’t. I’m free. Some psychotherapy is cheap. Good psychotherapy isn’t cheap, but it’s a part of my life, at last.
anti depressants don’t solve the problem they just assist in suppressing the emotions, that’s why they never work
Where this web article leaves me lacking is that it makes little mention of the research upon which the Newsweek article was based. To me this article is nothing but redirection — don’t like the Kirsch research so attack the journalist (not the researcher)…Sour grapes without substance.
I’m dismayed at the implication that taking medication is somehow “easy” or some sort of cop-out and that those who choose to take medication are somehow avoiding the”real” issues. That is insulting to those of us who take medication and who have worked hard to get our depression in remission and reclaim our lives.
What about those of us who have gone through therapy with excellent psychotherapists and not gotten relief? Have we somehow done therapy wrong? I don’t think so. Sometimes talk therapy is simply not enough (sometimes it is). Sometimes one cannot even benefit from talk therapy until there has been some improvement through medication. And sometimes it is necessary to continue medication long after talk therapy has been done. Everyone is different.
It is understood and established that there is a biological underpinning to mood disorders. Working with a good psychopharmacologist to find the correct medication is anything but easy and requires diligence and patience. I cannot think of one person I know who takes medication who would rather not. But we know all too well the consequences of not taking it.
If the efficacy of medication were due solely to placebo effect, then every trial of a medication should result in a positive effect. I have taken antidepressants that had no benefit whatsoever despite my hopefulness and desire for relief. I have tried discontinuing medications (under medical supervision), hopeful that I was well enough to do without them, only to find that after several weeks I needed to go back on them. The placebo effect may be a real phenomenon, but we can’t chalk up all successes on antidepressants to placebo effect.
With respect to the comments that medication works by numbing emotions, I would say that a medication that numbs emotions is the wrong drug for that person. With appropriate medication, I (and others I know) am not numbed. My emotions are brought back into the realm of reasonable.
tablarosa — I did address that, in the paragraph about how research is research. And while this new research sheds some interesting light on previous research, it doesn’t negate that prior research. Since the Newsweek article didn’t even touch upon the decades’ worth of prior studies — other than in context Kirsch’s research — I saw it for what it was: a biased piece of journalism that gave lip service to alternative explanations. Or putting the new research into any kind of context within the entire body of research on antidepressants. As opponents of antidepressants often note, “Just because it’s new, doesn’t make it better.” The same is true of research.
Martina — I apologize, as I know that’s always a danger in pointing out the differences between taking an antidepressant and going to psychotherapy. I know psychotherapy doesn’t work for everyone (for a myriad of complex reasons), and noted as much in the article. Antidepressants are a necessary treatment option, which is the crux of this piece.
There is a huge frustration component to any of these treatments — finding the right medication combination, waiting on it to work, etc. — and I sympathize that taking an antidepressant may not always be as simple as I suggested. And I agree that antidepressants aren’t meant to numb emotions — if they’re doing that for a person, it may very well they’re not on the right medication.
Several points and questions come to mind:
A psychiatrist (the medical director of a rehab I worked at) told me that he was about to leave the field of psychoanalysis because his clients weren’t getting better. Just then, Prozac hit the scene and suddenly his clients WERE getting better (in combination with his therapy).
I have seen clients who had no interest in therapy (and perhaps weren’t the best candidates for therapy either) yet they were required to see me if they wanted their medication.
If it’s a case of all or nothing, perhaps giving medication without therapy is better than giving nothing at all?
Perhaps, as Dr. Daniel Amen suggests, rather than starting out with medication, we should start with therapy and alternative forms of nutritional, herbal, and dietary healing and when that fails only then should we proceed to SSRIs and other forms of medication.
Anyway, I don’t portend to have answers–just questions and points to ponder.
Here is a link to the Business Week article I quoted in my last comment: http://www.businessweek.com/magazine/content/10_05/b4165058407403.htm?chan=magazine+channel_what%27s+next
Let’s not lose sight of the point of the Newsweek article:
It’s not that SSRI anti-depressants, or other anti-depressants don’t work. It’s that on whole, they don’t work in a statistically significant way more effectively than placebos.
Placebos and SSRI drugs seem to work almost equally effectively in large segments of the depressed population.
That’s the conundrum the Newsweek writer poses.
But it’s not a new observation and it doesn’t bring anything new to the conversation. And it’s an observation based upon flawed reasoning — that newer research or a single type of research has more weight than older research. This reasoning is not widely accepted amongst researchers, but it’s one that the media always seems to emphasize. So many words in that article, but so few of them used to place anything into a broader context.
Thanks for posting this. I worked throughout my life with major depression that was never diagnosed, and found some very useful non-medication supports, including therapy.
However, I developed a thyroid condition that wasn’t caught, and my depression got so intense that it was like being on a haunted carnival ride that I could not control. All of my previous fixes were useless, and therapy did not work.
But I was afraid of antidepressants, and clung to the idea that they were only placebo. Thankfully, after many years of suffering, and a poor start with a med that didn’t work, I found an antidepressant that made me feel better than well with minimal side effects.
I hadn’t realized how amazing the antidepressant was until my endocrinologist (who found my thyroid disorder) asked me to titrate off of it. He thought (and I think he’s incorrect) that the med was interfering with my thyroid treatment.
Brutal does not even begin to describe what it was like to return to my original dysthymic state, and to enter into a suicidal depression again.
I honestly don’t know how I survived so many years of major depression. I think I was a superhero or something. It is a miserable state, and has nothing whatever to do with immaturity, willpower, lack of talk therapy, or nutritional deficiencies.
So let’s make sure that we aren’t scaring truly depressed people away from antidepressants. They were a literal lifesaver for me, and both my GP and psychiatrist are just astonished that my endocrinologist so cavalierly took me off of them.
I stopped titrating when I experienced what a drop from 60mg to 40mg did to me, and I’m still waiting to see if I will ever downregulate to this lower dose. I’ll see my endocrinologist next week, and give him the chance to defend his protocol, but it is likely that I’ll titrate back up to my original, successful dose.
Antidepressant therapy absolutely worked for my major depression, once I got the right one. And it didn’t numb my feelings; rather, it simply and effectively stopped me from falling into the depths of despair.
These can be lifesaving drugs, so let’s make sure we don’t throw them out or demonize them simply because many GPs overprescribe. GPs also overprescribed antibiotics, and led us into the MRSA epidemic.
I think the issue is more global, in that our health care system is so broken that many physicians are reaching for the magic pills so they can see their 35 patients per day, thereby keeping their board of directors happy with the census numbers.
If this information about antidepressants is distributed to these overworked and overbooked physicians, my concern is that it will be as misunderstood and hamhandedly applied as so many things are in our current health care morass.
Which means that struggling superheroes such as I once was will have even more reasons to avoid antidepressants, and will suffer for no good reason.
I was a critic against antidepressants. I never wanted to take them and I figured I would never need them. When my therapist suggested antidepressants-I said No, Iâ€™m not doing it, I donâ€™t want to be “One of those folkâ€™s pills.” When I first started seeing her, I was a little depressed. But overtime, my depression became apart of my life. I was crying every weekend; I did not want to be alone. But on Monday morning, I would get up for work as if nothing was wrong. Well overtime, I could not fake it, and I ended up on antidepressants. The first time I want to my gyno and she prescribed my medication. It didnâ€™t work, I was still crying, what was wrong with me. So I continued with my therapy and got worse, my therapist suggested I should take some time off of work. WHAT?? Not me, I have to work, I have to keep going. Well, I ended up taking 8 weeks off of work for depression. I did go to a Hospital and had group therapy. I was fine after the eight weeks, on cloud nine. I was ready to change the world. With my new found happiness, I had to return to work. I work in customer service. NOOOOO I donâ€™t want to go back. I had anxiety attacks. Then I went to a pchytraist and he gave me Ativan. By the way, after reading online information itâ€™s highly addictive. So I took my relaxing pills and went to work. But after a week or two, I had a relapse. I didnâ€™t want to go on, I felt like I was alone. So on the night of 09-21-09, I attempted to take some pills. Well at least I tell myself that I was just holding the pills in my hand. I ended back in the hospital, this time on Suicide watch. I was in the hospital again, this time I could not get out without my doctors approval. I felt my freedom was gone. I was BETTER than this; I was not like â€œthem.â€ Guess What?? I was a person with a mental illness; I needed help just as much as they did. Long story short, It wasnâ€™t until I got the right mix of medication than I began feeling better. Iâ€™ve had relapses. But this time, I get help immediately. I now realize that I have a mental illness. I havenâ€™t made many changes, but Iâ€™m trying. Iâ€™m asking my job to relocate me closer to my family. Iâ€™m leaving a verbally abusive relationship. I realize that I can not change people. I am still alone; I have many friends but no support. I will use my EA meetings as my support. I have good days and bad days, but the medication helps me deal with life better. I can actually remember better and my focus is improving. So medication did help, for me. Once I put my pride aside, I was able to ask for help. I havenâ€™t told my whole battle with depression. Some folks think that you can just pray it away, or sleep it away. Itâ€™s not that easy… But everyday gets a little better.
Thanks for your balanced and nuanced perspective, John! I will be posting a blog soon on the Psychiatric Times website that addresses the Begley article in detail. I also left a comment under Therese Borchard’s blog. –Best regards, Ron Pies MD
Thank you for this article. I seriously feel I’m suffering from Double Depression and have been suffering from since puberty, though I’m only able to have a therapist (which is a blessing) instead of trying therapy with medication (supposedly therapy along with anti-depressants together is the best way to treat depression successfully, but of course, everybody’s different) because my parents are so dead-set against them.
While I’m not depressed to the point of being stuck in bed all the time, I do have severe depression (it manifests itself in different ways for people, yes including thinking but not acting on suicide).
God Bless you and the people who commented on this article, it reinforces my belief that people have to seriously look into what’s best for them (despite not personally being able to do such at this point in time).
The articles on the “ineffectiveness” of antidepressants have been written not by people who have any direct experience of them, but by doctors or pharmacologists. Sure, antidepressants are not perfect but I can tell you from my own experience that I suffer dangerous major depressions when off of meds but have only dysthymia when on meds. When on my meds, I am better able to make healthy changes in life-style and behavior. I think it is highly irresponsible to try to stop people from taking meds, just because those meds aren’t perfect. Listen to people who have actually used antidepressants.
The data fro the JAMA article. Let’s let the statistical facts (as opposed to the anecdotal evidence — with 100 million plus scrips written for anti-depressants every year there are bound to be a lot of anecdotes!) speak….
* Mild to moderate depression: Effect size of d = .11, which is tiny (and was not statistically significant)
* Severe depression: Effect size of d = .17, which is pretty darn small (and not statistically significant)
* Very severe depression: Effect size of d = .47, which is moderate.
I guess you missed the part where I said that while ONE study’s results are indeed interesting, it doesn’t negate all of the other research done on antidepressants. The JAMA study only looked at 6 studies. There have been a lot more than 6 studies done on antidepressants in 30 years!