Placebo Effect

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