Antidepressant Medication No Better Than a Placebo?

According to this article, a new meta-analysis of recent research studying the effects of SSRI antidepressants (such as Prozac) on depression has concluded that unless a person is suffering from severe depression, there is no clinically significant difference between the medication and a placebo.  Even when the depression was severe, the difference was not all that much.  Let's sort through all of this...

First, a meta-analysis is a powerful research tool that allows researchers to analyze areas of interest by combining similar research studies in one large "super study."  An important facet of research is that, the larger your sample size (i.e. number of participants), the more faith one can have in the results.  What a meta-analysis does is combine smaller studies that are ostensibly measuring the same thing, and combining them in order to increase the sample size, and therefore the strength of the conclusions.

Next, what this study highlights is the power of the brain (though that was not its primary intent).  Even being in this field as long as I have, I am still amazed, at times, at the concept of the placebo effect, and just how strong it can be.  Really interesting stuff.  In this case, simply believing one was taking a pill that should make them feel better leads to some improvement.  To my mind, this also makes the case for cognitive-behavioral therapy (CBT): If you change your perception, you change your feelings and behaviors.

What's also important to take away from this is that the pharmaceuticals are selling something their products can't deliver.  No, I am not trashing antidepressants; I think they can be an important part of one's overall treatment for depression.  However, this idea that if somebody takes a pill, they can treat such a complex issue, an issue with biological, psychological, and social/interpersonal aspects is absurd.  Now, more than ever, it should be apparent that individuals with depression ought to be participating in therapy to address the areas of their mood disorder that their medication does not impact.  Again, treating depression, anxiety, etc. is a multifaceted effort - period.

A couple of other good summaries of this research can be found here and here.  Bottom line - if you're on an antidepressant, don't discontinue it without working with your doctor on getting off of it.  In the meantime, if you are experiencing mild or moderate depression, some sort of therapy or skill-building ought to be part of your treatment.  Ditto for severe depression, though the type and scale of the therapy will likely differ at that level.  If you suffer from any level of depression, or work with clients who suffer from depression, do not expect that they will be fine because of a prescription. 

Comments

[Swivelchair]

Hi JD -
This is a whole different paradigm for the biopharma business. I think we're moving from blockbuster drugs to personalized medicine.

The missing link is the genetic (or other) testing to see who will be most responsive to the drug.

The other thing about Prozac is that it took the shame out of getting your mental health treated. People complain, but I think the Prozac (and their ilk) direct to consumer adverts were a boon for patients -- many MD's just didn't take mental health seriously.

One more thing -- depression untreated changes the shape of your brain. And the wiring. Just like PTSD. I don't think people realize this, so studies of psycho-therapy effectiveness show people improve over time -- but how much of that is due to the therapy and how much of that is due to removing the stress on the brain and the brain tissue/cells healing? Seems like an ambiguous result to me.

[Jeremiah Dwyer]

Hey Swivel,

Good points. But I think the effectiveness of psychotherapy can be quanitifed by several observations (no links or citings, but I'm sure I'm on solid ground here):

1) The improvement of groups receiving therapy vs. control groups on a wait list or no treatment (if it is simply brain recovery, should show same results).

2) Effectiveness of therapy in preventing relapse (including against individuals on SSRIs)

3) The fact that at least 50% of depression is the result of cognitive and interpersonal, rather than biological, factors - manipulate the psychological (i.e. cognitive) and interpersonal factors, manipulate the outcome (for example, improved social connectiveness, better choices, increased comfort with healthy risk-taking, etc). Improvement in those areas will lead to better mood, since depression is made up of that stuff (well, at least 50% anyway)

4) This one I'm less sure about, but I believe I've read documentation that participation in therapy will show altered brain structure versus controls - therapy is impacting the wiring positively as well.

Good stuff, I'll definitely want to keep an eye out for more research on these topics!