Whether or not antidepressants work has been hotly debated by mental health professionals over the last three years. In this article I want to put forward a balanced opinion about how effective antidepressants may or may not be. Before I begin, I can’t emphasise strongly enough that you always consult your physician before making any changes to your medication regimen.
What are antidepressants?
The most commonly prescribed antidepressants at the moment are a class of medications called Selective Serotonin Reuptake Inhibitors (SSRIs). As you almost certainly already know the brain is made of nerve cells that transmit messages to each other. These messages are transmitted along nerve cells by electrical impulses. When one nerve cell needs to transmit a message to another nerve cell chemicals are sent across the gap between the two nerve cells. The different chemicals released send different kinds of messages from one nerve cell to another. The SSRI medications function by causing an accumulation of a chemical called serotonin in the gaps between nerves and therefore increasing the strength of the message.
Serotonin is involved in regulating mood, sleep, muscle contraction and learning. So far so good, but this theory has some serious holes in it. Research so far has been unable to find convincing evidence that people experiencing depression have decreased serotonin (or any of the other molecules that send messages across the gaps in nerve cells). You also cannot make people depressed by reducing their amount of serotonin.
Who says they work?
Drug companies tell us they work. Now I’m certainly not against drug companies; they’ve developed thousands of effective medicines that help reduce suffering and prevent deaths. It costs millions of dollars to do the research needed for drug development and millions more to demonstrate the drugs are effective and get them approved by government bodies. With that said there is a big financial incentive for the pharmaceutical companies to produce drugs that recover their costs and make a profit for their shareholders. They call these ‘blockbuster’ drugs and SSRIs have certainly been blockbusters for the drug companies. They are now the most commonly prescribed type of medication in the USA with 11% of americans age 12 and over taking antidepressants. Antidepressant sales are estimated at 20 billion dollars a year.
Since the introduction of SSRI antidepressants the diagnosis of depression has increased 500-1000 fold. Sound fishy that since these drugs came out a hell of a lot more people have depression.
How effective are antidepressants claimed to be? According to the president of the American Psychiatric Association, Dr. Jeffery Liberman:
“As a class, antidepressant medications are highly effective. They alleviate substantial amounts, if not complete symptoms, in 50 to as high as 80% of patients treated who suffer from major depression”.
Who says antidepressants don’t work?
Many researchers and clinicians are skeptical that antidepressants are as effective as the studies conducted by the drug companies would have us believe. Their skepticism is based on several factors. Firstly, there are the results of what researchers call meta-analyses. Meta-analysis is a process where the results from many clinical trials are combined to provide a more accurate measure of how effective a treatment is. A landmark meta-analysis of antidepressant clinical trials was published in the Journal of the American Medical Association in 2010 the results of which shocked professionals the world over.
In these studies, people are included in clinical trials who are not given medication but unbeknownst to them are given a sugar pill (placebo) instead. The meta-analysis showed that 82% of the effect of the medication was attributed to the placebo effect, which is largely caused by the expectation that the medicine will make you better. The mind is powerful, isn’t it? This conclusion of the study was as follows:
“The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.”
Another reason researchers are skeptical is that drug companies have been withholding clinical trials that produce results that their drugs aren’t effective. Of 74 registered clinical trials only 37 with positive results were published. The remainder were either not published or presented in a way that made it seem the drugs were effective.
Some researchers and practitioners are also asking the question “What is depression anyway?” The diagnosis for depression is based on a checklist that people came up with; it’s not like diabetes where you can measure blood sugar levels. It may be that not all the people being diagnosed with depression are suffering from the same thing. Hence, we’re probably comparing apples with oranges, which makes trying to figure out whether a medication is effective considerably difficult.
My personal opinion based on the drug company trials, the researchers’ meta-analysis and my clinical experience is as follows:
- Depression is over-diagnosed and consequently many patients are inappropriately treated with antidepressants
- Antidepressants are likely to be ineffective for the majority of people diagnosed with depression (being mild to moderate depression)
- A fraction of people, especially those with severe depression, may benefit tremendously from treatment with antidepressants
I want to emphasise that the response to antidepressants is highly variable depending on the person. This is best illustrated by the words of one of my clients, “I may as well have been swallowing Tic Tacs for all the good they did me”, whilst there are other clients I see who are generally doing well, but find that their depression returns each time they try to go off antidepressants.
What to do?
I recently had a couple contact my practice who wanted to know if there was a pill I could prescribe them that would fix their marriage. This is how far we’ve come that we believe we can take a pill to fix about any problem. Many of the people that come to see me have depressing life situations and if I transposed myself into their situation I would feel depressed or anxious too. It is worth evaluating what you might need to change in your life before trying to fix the way you feel with a pill. In my opinion anyone who is taking any kind of psychiatric medication should have a course of psychotherapy and check in with his or her therapist at regular intervals. Psychotherapy has been shown to be highly effective for the treatment of depression without medication or in combination with medication. A meta-analysis of the effectiveness of psychotherapy was published in 2008 in the Journal of The American Medical Association showing that after psychotherapy treatment 96% of patients were better off than the comparison groups.
I’d be interested to hear your personal experiences with antidepressants in the comments section below. Were they helpful, ineffective, or harmful?
The team at Paul the Counsellor provides confidential, supportive, non-judgemental counselling and psychotherapy to individuals and couples in the Melbourne CBD.
0458 090 687
253 Lonsdale St, Melbourne VIC 3000