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study actually says that it found published trials (as opposed to all trials conducted) tended to be more positive – unpublished trials tended to be more negative.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.