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Is it time to abandon the ‘don’t ask, don’t tell’ policy for antidepressants?

It’s been more than a decade since scientists first published the startling (and, let’s face it, rather depressing) finding that antidepressant medications are no more effective than a placebo at lifting depression in most people.

In the meantime, sales of antidepressants in the United States have doubled, from 13.3 million in 1996 to 27 million in 2005. In 2008, American spent $9.6 billion on these drugs.

Are antidepressants “a triumph of marketing over science”? Maybe, suggests science writer Sharon Begley in the cover article of the Feb. 8 issue of Newsweek. In the article, she details why, despite the strong scientific evidence that “the lion’s share of the drugs’ effect comes from the fact that patients expect to be helped by them, and not from any direct chemical action on the brain,” consumers and physicians alike continue to resist the idea that antidepressants are “basically expensive Tic Tacs” for everybody except those with very severe depression.

I’ve emphasized that last phrase because I, like Begley, worry that people for whom these drugs are working will suddenly stop taking them. As Begley points out, tossing out the medications “can cause serious withdrawal symptoms, including twitches, tremors, blurred vision, and nausea — as well as depression and anxiety.”

Still, it’s clear from the growing pile of research, including a study published in January in the Journal of the American Medical Association, that for people with mild to moderate depression (that’s 87 percent of people being treated for the illness), the placebo effect explains most of the drugs’ benefits.

As one of the co-authors of the latest study, a meta-analysis of six previously published placebo-controlled studies, told Begley: “Most people don’t need an active drug. For a lot of folks, you’re going to do as well on a sugar pill or on conversations with your physicians as you will on medication. It doesn’t matter what you do; it’s just the fact that you’re doing something.”

Indeed, psychotherapy has been shown to be more effective — and to have significantly lower relapse rates — than either pills or placebos for treating mild to moderate depression, Begley points out. “But there’s the little matter of reality,” she adds. “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.”

For these reasons, many experts believe that the current “don’t ask, don’t tell” policy about antidepressants should continue. Even a placebo effect is better than no effect for people in emotional pain, they argue.

But a growing number of scientists believe it’s time to end this charade. One of those is Irving Kirsch, the University of Connecticut professor of psychology who co-authored the 1998 landmark study that first raised serious questions about the effectiveness of antidepressants, and who, despite some nasty attempts by antidepressant advocates to marginalize him professionally, has continued his research on this topic. (His book, “The Emperor’s New Drugs,” was published late last year.) Writes Begley:

Maybe it is time to pull back the curtain and see the wizard for what he is.… 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, [says Kirsch], 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.”

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Comments (7)

  1. Submitted by Paul Scott on 02/02/2010 - 01:42 pm.

    Thanks for this great post. I saw Kirsch talk about his work back in 2003 or 2004, before an (unfortunately) skeptical audience at Mayo. As a health writer I was really blown away. Like most people, I had no reason to doubt the entire premise of antidepressants — the serotonin deficiency, chemical imbalance, etc etc — and I had taken them myself for several years for mild depression/anxiety. But his work was completely sound science, and I set about pitching a story on it and I am here to tell you that NO ONE wanted to touch it. Harper’s assigned it, but then killed it in later drafts. In the process I interviewed Kirsch and found him to be credible, bemused and sort of dumbfounded that so few wanted to contemplate the implications of the fact that 58 million people were taking expensive, pharmacologically active substances that had no measurable unique drug effect on the disease they were purported to treat.

    After Harper’s handed the story back to me I took it to the NYT mag, were I had worked before, then the Atlantic, then Esquire, then Mother Jones, and nobody, but nobody was interested. IN here, I also produced a length book proposal that my agent showed to over 30 major publishers, all of whom had no interest. After a while you started to worry they thought you were a Scientologist or some sort of anti psychiatry zealot, which I am not. More likely, the resistance is due to the fact, as you said, that no one wants to be the bearer of bad news, and even more likely, that everyone or at least everyone in publishing, is on the drugs. Men’s Health to its great credit finally assigned the story two years ago, but I had to go to France to report it. American psychiatry will not even debate this issue.

    An unmentioned implication of the inefficacy of SSRI’s is that they cause a small percentage of users to want to hang themselves or commit suicide in some other grim fashion, even though the regulators have grudgingly only accepted that this happens to users under 25. (Like the body has some sort of magical transfer of drug metabolizing properties in your mid-20s.) When you take that small percentage over the massive number of users worldwide, you are talking about a drug that does not have any unique benefit but which does cause potentially tens of thousands of people to kill themselves.

    My one quibble with the Newsweek article: she implied that the choice is between drugs from GPs or therapy from psychiatry, when in fact the vast amount of talk therapy offered in this country is from licensed clinical psychologists and MSWs — CBT primarily, but also DBT and interpersonal therapy. It’s my impression that psychiatry has taken up the pharmacological cure to such an extent that they have no time and little training in empirically supported talk therapies. I hope that changes.

  2. Submitted by Susan Perry on 02/02/2010 - 06:11 pm.

    Thanks, Paul, for such an informed comment.

    I agree with you on Begley’s vagueness about therapists. I should have expounded on that in my post.

  3. Submitted by Monica Drewelow on 02/02/2010 - 07:53 pm.

    Thank you Susan Perry for the always interesting articles. As a nurse in long term care I see so many patients started on antidepressants for mild depression, usually,(in my opinion), with little to no effect. But the medications are rarely tapered and discontinued because this is the standard practice now. Interventions such as ongoing talk therapy, therapeutic activities, etc, are not done, or not done for any length of time to be effective because they are labor intensive and not reimbursed. It’s easier to give a pill.
    These medications are overused as treatment for mild depression, but to say that, without being considered, as in the previous comment, a Scientologist or a nutcase (not a therapeutic term), is to go up against a massive institutional and societal belief system, supported by the drug industry and reinforced every time a commercial for celexa is on tv.

  4. Submitted by Jeff Perry on 02/03/2010 - 03:07 pm.

    Ms. Perry:

    Do you know if the “placebo” research also applies for children and adolescents who take antidepressants? Also, I’ve read that the most effective intervention for treating depression is therapy combined with medication, rather than one or the other. Perhaps this can be explained by an effective strategy (therapy) implemented in concert with a placebo effect (perception that medication works).

  5. Submitted by Paul Brandon on 02/04/2010 - 10:06 am.

    The drug placebo effect becomes part of the therapy — psychotherapy is itself a form of suggestion.

  6. Submitted by Pat Thompson on 02/04/2010 - 10:09 pm.

    Susan, have you seen the recent Science-Based Medicine post on this topic?

  7. Submitted by Amy Nelson on 02/17/2010 - 06:30 pm.

    It is of course, very shocking to hear that after 30 years of research, it is only finally coming to our attention now. The media has been ignoring the data because these drug companies have so much investment, and people don’t really care about the data, as long as they’re feeling happy. Yes, it is easier to take a pill than go talk to someone. I’m sure that the drug companies can invest in psychological treatment, and then go buy out a candy company.

    But in all honesty, if a drug works just as well as a placebo, it means that there are other ways to fix the problem. It means that the drug is not altering the brain chemistry in a significant way for most people. Yet we can’t forget the people that it does work for — the people with severe depression. This poses a separation of a biological and psychological kind of depression. We’re not yet able to differentiate between the different entities that most likely make up what exactly constitutes Major Depressive Disorder. It seems likely that the more biological causes would respond better to pharmacological treatments than would a more psychologically-based problem. Think of how sometimes even electroshock therapy is effectively (though controversially) used in very severe forms of depression. Severity might be acting as a proxy for the degree of biological dysfunction, and therefore the severely ill are the ones responding better to antidepressants. For the rest of the 87% who are only mildly depressed, I think it is important that they are aware of what they’re being prescribed.

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