Are Antidepressants Any Better Than A Sugar Pill?
Depression, or Major Depressive Disorder, affects about 7 percent of adults in the United States annually. It is the leading cause of disability in the 15-44 age group, according to statistics from the National Institute for Mental Health. Recent data from the Centers for Disease Control and Prevention (CDC) show that drugs to treat depression, or antidepressants, are the most commonly prescribed drugs in the US. That means that antidepressants are prescribed more than drugs to treat heart disease, diabetes, asthma and other diseases. In 2005, there were 118 million prescriptions written for antidepressants in the US. This reflected a tripling of these prescriptions bewteen1988-1994 and 1999-2000. According to data cited in the Washington Post, these prescriptions came at a cost of almost 10 billion dollars in 2008.
But are these drugs actually doing any good?
An analysis published in this week’s Journal of the American Medical Association (JAMA) questions the efficacy of antidepressants for many patients.
The study is a meta-analysis, essentially a grouped analysis of data from several studies. It looked at studies published from January 1980 through March 2009 and included only the most scientifically rigorous studies, randomized, placebo controlled trials using an FDA approved antidepressants in the treatment of depression in adults. The studies included used a standardized questionnaire to rate the severity of the patients’ depression, the Hamilton Depression Rating Scale. In essence, these studies compared antidepressants to placebo, or sugar pill, in patients with varying severity of depressive symptoms. There are thousands of controlled clinical trials of antidepressant use over the last 50 years that have shown that antidepressants are helpful in treating depression, but this new analysis is unique in rigorously breaking down the data by degree of depression.
What did the authors find? Their analysis suggests that many commonly prescribed antidepressants may be no more helpful than a placebo, except in cases of severe depression.
The authors of the study reviewed trials of two antidepressants, paroxetine (Paxil) and imipramine (Tofranil). Paroxetine belongs to the class of medications called SSRIs (Selective Serotonin Reuptake Inhibitor). Other commonly prescribed SSRIs include fluoxetine (Prozac), citalopram (Celexa), escitalopram (Lexapro), and sertraline (Zoloft). Imipramine is from one of the oldest classes of antidepressants, the tricyclic antidepressants (TCAs).
The researchers found that, compared with placebos, these drugs caused a much steeper reduction in symptoms of severe depression only (cases scoring in the top quarter of the sample). Patients with less than severe depression got little or no added benefit from the medications, and the degree of benefit increased proportionately to the severity of their patients’ depressive symptoms. The most depressed patients did get substantial improvement with treatment with these medications.
Limitations: because of the stringency of the criteria used for selecting these studies, the number of studies and of patients included in this analysis was relatively small. In total, data from 6 studies (718 patients) were included. Furthermore, the depression symptom questionnaire used, while the one most commonly used in clinical practice, may not be a perfect measure of depression severity. The study only looked at two drugs. However, the SSRIs are the most commonly prescribed antidepressants and are similar enough to one another that the studies of paroxetine can likely be applied to all SSRIs. Finally, the study looked at the effect of treating depression initially or acutely, and not long-term or maintenance treatment.
These possible limitations aside, though, this analysis raises a critical eye at how depression is most commonly treated, with antidepressants. The authors concluded, “Prescribers, policy makers, and consumers may not be aware that the efficacy of medications largely has been established on the basis of studies that have included only those individuals with more severe forms of depression” and that this fact is “not reflected in the implicit messages present in the marketing of these medications to clinicians and the public.”
It is clear that antidepressants are necessary and can be lifesaving in cases of severe depression. For people with more moderate symptoms of depression, this analysis suggests that treatments other than antidepressants may be equally helpful. The alternatives include psychotherapy and supportive care such as nutrition, exercise, sunshine, and rest.
* * *
The abstract of the original article can be found at:
http://jama.ama-assn.org/cgi/content/short/303/1/47?home
Fournier, JC, DeRubeis, RJ, et al. Antidepressant Drug Effects and Depression Severity: A Patient-Level Meta-analysis. JAMA 2010; 303(1):47-53
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Comments
There seems to be little doubt that antidepressants work for people with serious long-term depressions (full disclosure: I'm one). Seems to me that the problem is that depression is a very wide term, used both for those who suffer chronic depressions throughout their lives and those who experience quite natural depressions after a traumatic event. These two categories seem very different to me, so I'm not surprised that they must be treated differently.
We just have to make sure we don't throw the baby out with the bathwater. The key is to get better at discerning which patients will actually be helped by such drugs. For that, studies like this one is invaluable.
Norwonk: I certainly do not mean to imply that antidepressants are not useful. They are invaluable and absolutely lifesaving for some people. I thought this study was important because it may lead us to reconsider if too many, or the wrong people, are being treated with medication when another kind of therapy may be equally or more helpful. Research like this is crucial, because a lot of medicine is practiced without scientific evidence to it up. Thanks for your insights.
Oh, you mean work FOR THE PATIENT??? Irrelevant.
A few years ago I went on Zoloft during a crisis, and it saved my life. I took it for three years, went off because I didn't want to spend my life on medication. And it was hard to cope. But then menopause came along and alleviated my depression. I still have a blue day now and then, but nothing--NOTHING--compared to the past.
Be very careful about giving advice, too. An anti-depressant may not be a cure, but if you shop around and find one that works for you, it might save your life while you look for a better, long-term solution.
It's impossible for people who don't live with severe depression to understand how bad it feels, and why it seems that suicide would bring the only relief. And unless you really know that, have experienced it or studied it close-up for many years, you can't advise people who suffer from depression.
What I have observed is once a psychiatric drugs go generic (as have all the bipolar mood-stalizer drugs), their inadequacy is suddenly "discovered" when patients have been complaining about the drugs the whole time.
By the way, light and exercise do have benefits in helping depression, but require the depressed individual to be motivated enough to pursue them. Given that one of the cardinal symptoms of depression is lack of motivation, this is easier said than done.
Wired explains the phenomena here:
Placebos Are Getting More Effective. Drugmakers Are Desperate to Know Why.
"the degree of benefit increased proportionately to the severity of their patients’ depressive symptoms."
Its not a matter of black and white, working or not working. Everyone will respond to pharmaceutical intervention a bit differently.
Great post. Rated.
R
There are chemical imbalances in some. I wish I could be a person that is shiny, happy and needs no help in the depression department. But, alas, that is not me.
As for sunshine, exercise blah blah blah. Glad it works for some.
But for those who cannot tolerate the sun or are able to 'exercise' and may have an issue others have no clue about, keep popping the pills. They may save your life! They did mine!
They did a study of suicide's brains and all had way too low Serontonin. That study I believe.
For many of the patients I care for, antidepressants are a lifesaver. For others, however, they are not helpful. The lifestyle interventions /nonmedical treatments I describe are helpful no matter the degree of depression, and in very mild cases, may be enough.
Rob Stone and Just Juli make good points about the lack of coverage for mental health care/psychotherapy, and that often taking medication is the only option.
Leonde Delmare makes a good point about side effects. Any medication or even supplement can have side effects, sometimes mild, sometimes serious, and this is something doctors and patients need to keep in mind whenever considering prescribing or taking medication.
HellsBells: thanks! I am glad you found this to be a balanced post.
This is what we want. Happiness found. No more pursuing it. And we're willing to depend on anything to get it.
Pathetic.
Real clinical depression doesn't respond to placebos, but happiness hunters do.
I take Oemga 3 supplements ever since my estrogen has gone south. It definitely works for me. The proof: I sometime forget my daily vitamin regime, organized in weekly trays. I can forget to take them for days. What reminds me to take them is always one thing: I descend into a hole mentally. When that happens I go, "Why am I feeling this way?" And then I go to my tray and see its been two days since.
I'm my own test group.
Our feelings evolved for a reason. If you're feeling depressd, that almost always means that there is something in your life that needs changing.
This study, along with the meta-analysis by Irving Kirsch pubilished in PLoS, confirmed what everyone with any experience of life as it is lived could have figured out -- there may be a few people who really have something out of whack with their brain chemistry, but for the rest of us it's just a matter of taking responsibility for one's life, finding the courage to change what can be changed andto accept what cannot. Just like the rest of us.
http://open.salon.com/blog/xylocopa/2009/06/01/a_depressing_proposal
I have major depression- had it all my life except as a child. I was imipramine back in the day. It made me feel worse. The antdepressant I am taking now has been a life saver, literally.
More research must be done. It's a debilitating illness that can strike anyone. Many have it and consider themselves "normal". Drugs can provide an effective role in treating depression. I have seen the evidence in others as well.
I resisted sending her to therapy and giving her medication for two years, but finally succumbed when it was clear that all the books on anxiety and all of my parenting skills and all of the well meaning but eventually totally useless advice from friends, family, teachers, school counselors, and neighbors--when all of it failed to make a dent. So I took her to therapists and discovered that it didn't help much at all. Then I took the real plunge--medication. She's currently on Zoloft.
Does it help? I don't honestly know. The dosage is very very low as I'm afraid of long term side affects. But still I am afraid to wean her off it completely. As it is, she mostly makes it to school, mostly makes it to other activities, mostly can get on planes, mostly can start and stop vacations without major panic attacks.
She's told me that on a scale of one to ten (and believe me, she's been at a ten), "normal" for her is a two. Is Zoloft keeping her at a two? Would it be higher without the medication? I'm not ready to watch her find out.
She's beautiful, bright, incredibly talented in art...but yeah, this medication thing? No easy answer. If it was my body, no worries. But she's my child.
As I state in my post, this study and I personally do NOT question that antidepressants are effective, and indeed lifesaving, medications for people with severe depression. This study's findings appear different from previous studies in part because those studies grouped all people with depression together, not analyzing how severe their symptoms were, and on closer analysis many of those patients had severe depression. So, in fact, rather than refuting the previous research, this study confirms previous findings that antidepressants are effective. The key point is the degree of depression.
Thanks for a great discussion. I am glad that antidepressants have helped many of you, and wish you continued health and happiness.
It bothers me very much when I see people dismissing medication for people who are depressed, because the criticism might be the reason that someone doesn't seek help.
Think about it.
The authors findings were also presented before their methods were discussed. The information regarding the number of subjects involved and the number of studies reviewed was not disclosed until after the conclusions were presented. I think knowing how the conclusions were reached as they are presented is important for a reader to assess the relevance and context of the information. People's emotions are moved by those conclusions before their minds have the chance to evaluate the quality of the information.
Thank you for sharing this information and most of all for including how to find the actual paper! It always bothers me when papers are summarized or reviewed without giving the me a chance to see the paper for myself.
Most antipsychotics are not effective for bipolar depression but there is one that did very well in studies for bipolar 1 depression and that is Seroquel. The problem with Seroquel is the side effects, most importantly, weight gain. No other agent has proved to be as effective for bipolar depression and that includes lithium and especially Lamictal.
I have just read an NPR report on this research that says the following:
"But there's some resistance from mental health practitioners to the Hamilton labels [that were used in this research to categorize each individual's depression as being either mild, moderate, severe, or very severe]. They say the "severe" and "very severe" categories are misleading and don't corresponded well with how real-life doctors see their patients.
'The Hamilton "concept of 'severe,' I think many psychiatrists would think of as 'moderate,' " said Dr. Mark Olfson, a professor of clinical psychiatry at Columbia University. Dr. Greg Simon from the Group Health Research in Seattle, agreed, telling me, 'The Hamilton scale was made up by Max Hamilton, bless his soul, in the 1960s and everyone has used it since because it's just a tradition, but there are actually much better measures.'"
--"Drug Studies Lean On Flawed Measure Of Depression"
http://www.npr.org/blogs/health/2010/01/antidepressant_studies_lean_on_1.html
So my doc tried a few different drugs and I had various side effects and figured out that I should just deal with life and not hide behind drugs. Heck, one drug and I can't remember which one, made me like an automaton, a robot. Moving through life like a cloud, passing around things but not absorbing anything.
I look at my experiences with anti-depressants and have had a largely negative experience with many of them. The side effects were worse than the depression.
Some people hide from life in alcohol or 'recreational' drugs and yet so many others hide behind those 'official' drugs and sometimes they aren't worth the trouble. EVERY drug has side effects and some of them can kill you, or make you want to do yourself. Life isn't supposed to be all wine and roses. It's time to stop victimizing ourselves and wasting so damn much money and start FEELING life and DEALING with it...
My 2 cents...
I had to quit the medication because I developed an addiction and couldn't sleep without it. After some decent therapy and learning some healthy coping skills, I've found that I can manage my depression.
This WILL NOT work for everyone and i sincerely hope people get the help they need, with or without drugs. Whatever works for them.
@PatA: She isn't "dismissing" the value of anti-depressants, simply pointing out that they are NOT a cure-all. There ARE other means of treating psychological conditions besides drugs.
I'm pooped out on Prozac and could use some optimism.
~R
The important recommendation is this: if you are sufficiently depressed to be considering medication, you need to spend some time talking to someone about your condition/situation. If your physician is recommending medications, he/she should also be recommending psychological health care (e.g., psychotherapy).
More on this topic (and a depression screening inventory):
"Anti-Depressant medication may not be an effective treatment for mild or moderate symptoms"
at http://everydaypsychology.com
The modern lifestyle factors of stress, poor nutrition and the lack of deep, restful sleep have all contributed to depleting key, chemical messengers in the brain like Serotonin, Dopamine and Norepinephrine that effect our moods.
And, due to the over-consumption of sodas and depleted nutrients in the soils, 80% of the U.S. public is deficient in Magnesium, a key mineral essential for the production of Serotonin.
Also, the fluoride in the water supply corrupts Serotonin and Melatonin(Fluorinated Melatonin)and this explains why so many Americans wake up foggy headed in the morning. In Western Europe, 97% of the countries there have outlawed the addition of this poison to the public water supply under "The Poisoning without consent act."
The most notable side effect of depleted brain chemistry is overpowering cravings for junk food/drink...the very culprit in the epidemic rise of excess weight gain /obesity.
So..we hold the dubious title of being the fattest and most depressed
nation in the world.
None of the prescription mind drugs do anything to restore healthy levels of Serotonin...they simply attempt to minimize the rate at which it is depleted and all of them disrupt hormonal balance long term.