Today’s media has been full of headlines screaming "antidepressants don’t work!" and I’ve spent the day grumbling about sensationalism. Let’s get this clear. The study actually says that it found published trials (as opposed to all trials conducted) tended to be more positive – unpublished trials tended to be more negative. No shit sherlock. This study was looking at ‘publication bias’ – what happens when mainly favourable results get published, which ends up in your product looking better than it is.

When publication bias is taken into account the difference between certain SSRIs and placebo is not statistically significant enough to be accepted by NICE‘s guidelines. Not that they "don’t work" but that they "don’t work well enough" in ‘mild’ to ‘moderate’ depression (and NICE guidelines don’t actually advocate prescribing SSRIs for ‘mild’ depression). (Have a read of this Bad Science thread for a more informed debate, and also see where I lifted that last line from.)

But there are other places where you can get the science. I’m here for more of a bit of experiential reasoning. I thought I’d already blogged in passing about the possible placebo effect of anti-depressants (hereon referred to as ADs because it’s late and I can’t be arsed) but I can’t find it so maybe I didn’t. My second stint on ADs was of absolutely no bloody use at all but I had always credited the first stint as being my saviour. However, the second stint made me re-evaluate… there is a thing called ‘regression to the mean’, often used as an argument against homeopathy, which says that over time, most illnesses will get better by themselves. Could be a cold, could be inflammation – the body has a remarkable ability to heal itself. But for illnesses of a reasonably long duration people tend to get fed up and by the time they get round to trying whatever the guy in Holland and Barrett recommends / get desperate enough to beg their GP for drugs, it’s highly likely the illness is on the mend anyway – the body is returning back to the ‘mean’ (ie, standard) state.

Periods of depression are usually reckoned to last about six months. By the time I hit the doctor’s office the first time, in the midst of a huge breakdown, I was around the six month mark. It’s entirely likely that I was hitting the bottom of the curve anyway and would have regressed to the mean without the help of ADs. It’s impossible to know for sure. Or it could easily have been a placebo response – let’s face it, what would be more natural than a psychosomatic response to a psychological illness?

The other, somewhat ironically depressing, aspect of ADs is Big Pharma’s attempts to repackage the same old drugs as treatments for something else. I’ve been pondering blogging about this for a while (inspired by a podcast of Ben Goldacre’s where he has a go at Big Pharma for doing this very thing) but never quite got round to it. In some cases they’re pretty much inventing new illnesses that can be miraculously treated with the repackaged drugs (damnit, there was a female sexuality ‘disorder’ that could supposedly be treated with SSRIs – anyone? Anyone?). And it does make me wonder… if these drugs can apparently treat everything, do they in fact treat nothing?

So am I now anti-ADs? Not really. With certain caveats. People with depression need something and in the current health treatment environment, there aren’t enough talking therapies to go around. Maybe if the NHS stopped spending so much money on ADs there’d be enough. I don’t know. Are ADs better than placebo? Well, this study shows that actually, they are, just not by a huge amount. There could be an argument to be made for using placebos over ADs on the grounds that the efficacy difference isn’t huge, and that perhaps the lack of side effects in placebos would make up for the lesser efficacy… I can’t comment, my personal experience of side effects is nil. But ethically I doubt the entire medical establishment could secretly switch to placebos over ADs, and once you know you’re getting a placebo the benefit is wiped out so it’s impractical. Are Big Pharma a bunch of corporate fuckwits? Yes, but probably no more than any other industry; it’s just that pharma has the health of the population in its hands rather than sofa fabrics.

It’s not cut and dried. Nothing’s ever cut and dried. And always remember to research behind the newspaper article when you see anything important. Which is the most damning indictment I can come up with from all this – your news outlet of choice cannot be trusted to give you the full, balanced, story.

If you want to know about some drugs that do work, read on. After yesterday’s "ow-fuck-ow" I managed to accidentally overdose in a very small way on painkillers… I realised as I got into work that I’d mixed codeine and too large a dose of ibuprofen. Which wasn’t clever. How people who are addicted to painkillers get anything done I’ll never know; I spent all morning sitting at my desk feeling somewhat woozy and heavy. I know, I’m a moron.


9 responses to “Pills

  1. Nick February 27, 2008 at 10:19 am

    I found AD’s useful for stabilisation but not much else beyond that which is why I am trying to come off them. They were a good quick fix though whilst my head was unravelling to put the brakes on things getting worse. However as a long term thing I am finding them next to useless. I can’t tell anymore whether I am tired due to depression or because of the pills or both or what is going on in my head.
    On the subject of painkiller’s I had a fun day in uni when I over the course of the day took a weeks Dihydracoedine. Never felt so warm and fuzzy!

  2. Nickmed February 27, 2008 at 10:29 am

    I also think the problem comes with the fact that still people confuse “feeling depressed” with “having depression” which really doesn’t help things.

  3. Rachel February 27, 2008 at 11:42 am

    Two articles today that I found very interesting: one about the positive side of depression which I found myself nodding in recognition at, and another article expanding on my small point about drugs companies making maladies up to have new markets for their drugs.
    Totally agree that ADs are best used as a quick stabiliser until longer term therapies are available but I would urge people to read the last couple of paragraphs in the main section of the second article – oh, fukkit, I’ll paste them here:
    “But will this really address the problem? If antidepressant drugs are losing out, the therapies that the government favours – mostly cognitive-behavioural – are based on the very same principles as the drugs. They target surface symptoms, they must deliver set outcomes and they must do this in a set period of time. In fact, these are exactly the same criteria as the drugs but without the drugs.
    Isn’t this in essence a resurgence of the mental hygiene movement that many thought a relic of the early 20th-century? Cognitive therapies are being tailored to replace drugs, and treatment will become more and more mechanised, ignoring the real dynamics of human interaction. Symptoms will be seen as mistakes to be corrected rather then legitimate expressions of unconscious conflicts or desires. Shouldn’t the new results encourage us to treat quick-fix solutions with scepticism? And to listen carefully to what lies beneath the surface depressions of each individual sufferer?”

  4. Nick February 27, 2008 at 12:49 pm

    Totally agree with those two paragraphs. It almost as though people fear mental illness (even that term is loaded with prejudice). It is something that needs to swept under the carpet.
    And to me that is exactly what these new treatments seem to do. Despite a new approach and more openness we keep falling into the same old traps. If someone is screaming, yes you can give them something to stop them screaming but isn’t it best to find out exactly why they are screaming? Exactly what is going on deep beneath the surface. Beyond just the cold chemical analysis.
    I am about to start CBT. I am dubious about it, but they say they would like to use it as a stabiliser before they put me forward for psychotherapy. I am however getting the impression from what they have told me that seeing as I have had clinical depression for nearly fifteen years in varying severity, this is not something that is likely to ever go away and that ultimately it is just part of who I am and that I need to just accept into my being. At one point this fact would have depressed (harhar) me, but actually now it almost seems liberating.
    That 1st article looks interesting. Be interesting to read it (once I am out of this lecture!!!)

  5. Rachel February 27, 2008 at 1:02 pm

    Yes… I feel a post coming on about why it’s “necessary” to “cure” depression “completely” at all…

  6. Nick February 27, 2008 at 2:17 pm

    I like that article, the one I said I was gonna comment on.
    “It is possible that depression defends us against the tendency to deny our true needs by chasing unobtainable goals and helps to bring these needs into sharper focus”
    “There is some evidence from scientific studies to show that depressed people are rather more realistic in their thinking than “healthy” individuals – the phenomenon of “depressive realism”
    And this made me laugh:
    “Ed Hagan has suggested that getting depressed is like going on strike for better pay and conditions”

  7. Liz February 27, 2008 at 4:50 pm

    When meta-analyses get press attention I’m gonna have something to say about it! (mainly I’m cross that none of ours are getting picked up, though that’s not surprising as it’s not a revelation that there’s not much good evidence about Chinese herbal medicine for angina).
    I sat down to write a whole load of stuff about this and the ‘sceptical psychiatrist’ David Healy said everything far better than I could: http://www.guardian.co.uk/society/2008/feb/27/mentalhealth.health1
    (he said very sensible things in the mental health journal I worked on and always met his deadlines, so maybe I’m biased in favouring his opinion!)
    The fundamental methodological issue here is about the difference between results that are statistically significant and clinically significant. These are not the same thing in the slightest. Clearly, we should be interested in what makes a clinical difference, but pharma companies need only prove statistical significance (which is VERY open to manipulation, one way is through publication bias) to get their drugs approved for sale. This is demonstrated very well by the fact that most studies don’t actually look at clinical outcomes, for example asking people whether they felt better, but at biological markers that can be more easily measured. This is leading to a whole other argument about quantitive and qualitative data but it really is shocking that the majority of medical research is permitted by the “culture of the scientific establishment” to have remarkably limited clinical relevance.
    I appreciate that a “statistically significant greater benefit than placebo” (or not) is a tricky concept to report to the public (along with other healthcare-related concepts like risk and numbers needed to treat/harm). Hell, even the doctors don’t understand it. That’s part of the scientist’s problem. So maybe I shouldn’t get mad at Sian what’s-her-name on BBC Breakfast when she’s trying to get in the face of the guy who’d probably spent over a year writing this review. But I still did.

  8. Rachel February 27, 2008 at 5:04 pm

    See, the differences between statistically and clinically significant are what I decided not to even attempt to go into the details of at nearly midnight last night, and wussed out in favour of the Bad Science forum instead 🙂
    And the whole point that it’s a difficult subject to get across to the public is why we should get mad at the media when they fail. It’s their job to present (in the case of the BBC, anyway. In theory) accurate, unbiased, reporting that educates and informs. And if their current journalists can’t do that they should find some who can…
    (The article Liz references is the second one I linked to in my comment, and that Nick liked. I’m glad we all liked that article!)

  9. Nick February 27, 2008 at 11:03 pm

    Been thinking about this today and it is funny that of all days that this discussion should crop up it should be today because today has been the day I have felt the AD’s losing there grip most since stopping taking them. Stability for me has meant everything being grey. Unrelenting, numb, boring grey.
    Now I have all the colours back. Music sounds so much better off meds (maybe that is placebo!?). All I know is that days like this everything feels tingly and swirly and whilst it can bad it can also be good, with my brain being able to go off a wondering where it likes. AD’s keep my mind on a lead. Yet though a lead may keep something coming to harm it can all stop it discovering something good.

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