This week it was claimed that there is more compelling ‘evidence’ that antidepressants are more efficacious and safer for the treatment of depression. A global study led by researchers from Oxford University hit the front pages on Thursday. There were headlines in newspapers saying things like “The drugs do work” and “millions more of us should be taking antidepressants”. Is there a load of hype over nothing or has there been a real breakthrough?
The results have produced lots of excited statements from office holders at royal colleges to big pharma companies about the efficacy of these drugs, and indeed, which drugs are better than others. Professor Helen Stokes-Lampard, Chair of the Royal College of GPs, for instance, said “Taking antidepressants is frequently portrayed as a negative thing or something done only when other therapies are not available or have failed, but this in itself can add to the unfortunate stigma that sometimes exists around people with mental health conditions”. Andrea Cipriani, who led the latest study, said: “Undertreated depression is a huge problem and we need to be aware of that. We tend to focus on overtreatment but we need to focus on this.” He said that doctors should switch from the least effective antidepressants, including Prozac and citalopram, two of the most commonly prescribed in Britain, towards the best performing ones, which are up to twice as good as a placebo.
Amongst all the excited stories a lot of the detail of the study was lost. The study analysed data from 522 trials, although half are unpublished, involving 116,000 patients with moderate to severe levels of depression, a level at which people struggle to work or socialise. Those numbers made it a big study, for sure, but as I understand it, they were only monitoring people for 8 weeks. Some people are taking antidepressants for years. What about them? The study also found that these drugs do very little for a significant number of individuals suffering with depression (about a third) and, indeed, the study actually found clinically insignificant differences to placebo (and, by the way, you won’t get side effects with placebo treatment). Side effects such as loss of libido might be enough to actually cause depression. The study did seem to set the bar very low by comparing antidepressants with placebos. What about a study comparing antidepressants to talking therapy intervention?
This study would appear to add weight for those who believe in the serotonin deficiency theory for the treatment of depression. This theory holds that taking of medication essentially corrects an imbalance in the brain and facilitates greater functioning. Proponents of this view see “ideological” resistance to antidepressants fuelled by a misguided belief that illness linked to social problems should not be treated with pills. However, others dispute the serotonin deficiency theory and not just on ideological grounds. Instead the relief of depression comes about from increased levels of neurogenesis (this is the process of the brain continuing to create new neurons from neural stem cells). So, selective serotonin reuptake inhibitors (SSRIs) boost levels of neurogenesis and it is this increase in the rate of neurogenesis that brings about the change in depression, not an increase in serotonin.
The serotonin deficiency theory for the treatment of depression could be potentially stigmatising in of itself for some who might feel disempowered. The message is along the lines … You need to take the pills. If you don’t, the risk is that you could become chronic and dependent. People taking the pills might welcome the spirit of the serotonin deficiency theory as once diagnosed they now feel that they have a ‘condition’ and can now apply a pharmacological fix. But other studies show that SSRIs can have serious side effects and some control studies show that they only work in any case in 50% of cases for the relief of depression.
According to NHS Digital there were 64.7m prescriptions for antidepressants in 2016. In 2006 that number was 31m. This is a huge increase and perhaps reflects greater awareness of the problem and less reluctance by GPs to prescribe. Or, is it that the world is becoming increasingly neuro toxic? Depression comes and goes and fluctuates so it’s difficult to know what works and what doesn’t in treatment. That’s why we need placebo controlled trials like this one. The trouble with this study is that it doesn’t address criticisms that these type of studies conflate differences between antidepressants and placebo. The essential truth is that no one knows for sure that even if people get better taking a course of antidepressants treatment whether they are better as a result of placebo, or due to other positive things which they are doing elsewhere in their life, the natural course of mood changes or least likely a positive effect of the drug itself.
See also
what works for treating depression
Worried about your mental health and wondering whether you should take antidepressants? It would be advisable to discuss your situation with a medically qualified doctor such as your GP or a psychiatrist. They can undertake some diagnostics and can discuss with you appropriate options for the management of your depression, whether that is medication or combination therapy with psychological support.