In a sane society, the absurdity of “screening” for depression would immediately be apparent. You mean, you don’t know how you feel? And if you really don’t know, doesn’t that mean you need to spend some time in open and honest consultation with yourself?
Nevertheless, the US Preventive Services Task Force, a part of the Agency for Healthcare Research and Quality of the US Department of Health and Human Services, has recommended screening adolescents between the ages of 12 and 18 for depression. The Task Force based its recommendation on a systematic evidence review published in Pediatrics by Dr. Selvi B. Williams and his colleagues. A press release by the Task Force notes that “Depressed children and adolescents are at an increased risk of suicide, which is the third-leading cause of death among people aged 15 to 24 and the sixth-leading cause of death among those age 5 to 14.”
That’s an odd point to bring up, since the article by Williams et al. acknowledge that the treatment of choice for depression, Selective Serotonin Reuptake Inhibitors, or SSRI’s, more than double the occurrence of “suicide-related adverse events” (i.e., suicidal ideation and suicide attempts). No actual suicides were observed in the studies cited by Williams et al., but a review Dr. David Healy and Chris Whitaker found that SSRI’s more than doubled not just the occurrence of suicide-related events but of actual suicides.
Odder still, the article by Williams et al. found no evidence that screening adolescents for depression resulted in more adolescents being treated for depression, let alone any evidence of improved clinical outcomes. Has the maxim First Do No Harm been replaced with Why The Hell Not?
The press release does contain some cautionary words, that screening should be performed “only when appropriate systems are in place to ensure accurate diagnosis, treatment and follow-up care.” Reminds me of those advertisements for cholesterol-lowering drugs, which contain just enough lip service to diet and exercise to deflect criticism. You really think the drug companies give a crap if you exercise and eat sensibly?
It’s hard to imagine this as anything more than a ploy to drum up some more business for the drug companies. Not that they don’t have plenty already. According to the Agency for Healthcare Research and Quality, 11% of all women and 5.4% of all men in the non-institutionalized population in the United States take antidepressant drugs. So it’s a pretty good guess that some of the people reading this are taking antidepressant medication. I have found that many people taking antidepressants take it as a terrible insult if anyone suggests that most depression might not properly be regarded as a medical problem.
If you are one of those people, I offer for your consideration another point of view: the drug companies may not necessarily have your best interest at heart.
If you say you took antidepressant drugs and felt better, I have no reason to doubt your word. But that, in and of itself, proves nothing. The placebo effect is well-known to science. How do you know you wouldn’t have done just as well taking a sugar pill? For that matter, depression can be (often is) a self-limiting condition. People get depressed, and then find within themselves the inner strength to carry on. How do you know that’s not what happened in your case?
The only way to resolve these questions is through placebo-controlled, clinical trials. But herein lies another problem. In a paper published in BMJ, Dr. Hans Melander and his colleagues reviewed all 42 placebo-controlled clinical trials of five SSRI’s submitted to the Swedish Drug Authority as a basis for marketing approval. 21 of these studies showed the drugs performed significantly better than a placebo and 21 did not. 19 of the 21 studies which found statistically significant benefits were published, while only six of the 21 which did not were published. In plain English, the drug industry routinely buries negative results. Even the most conscientious doctor cannot give you unbiased information if the journals he relies on are biased.
To help rectify this situation, Dr. Irving Kirsch and his colleagues used a Freedom of Information Act Request to obtain data on all clinical trials submitted to the US Food and Drug Administration for the licensing of four commonly prescribes SSRI’s: fluoxetine (trade name Prozac), venlafaxine (brand name Effexor), nefazodone (trade name Serzone), and paroxetine (trade name Paxil). Tens of millions of prescriptions are written for these drugs every year.
Kirsch et al. analyzed the data for all the clinical trials, both published and unpublished, and found that overall these drugs were NO BETTER THAN A PLACEBO when it came to treating major depression. Only for the small minority of patients, at the upper end of the most severely depressed range, were these drugs found to produce clinically significant benefits (and rather meager ones, at that). The full text of the study, published by the Public Library of Science, is available here.
These results are about what anybody with any experience with life as it is lived could have predicted. Mental illness is real. There is a tiny subset of patients who really do have something out of whack with their brain chemistry, and who can derive a benefit (albeit often a small one) from psychotropic medication. But for most of us, it’s just a matter of taking responsibility for our lives, of finding the strength to change what we can and to accept what we cannot change.
Even modest lifestyle changes can have profound effects on major depression. In a study published in Psychosomatic Medicine, Dr. Michael Bayak and his colleagues compared the effects of sertraline (trade name Zoloft) and exercise on a group of patients over 50 years of age, all diagnosed with major depression. None of these patients had any medical condition that would prevent regular exercise. Patients were randomly assigned to three groups. One group was treated with sertraline; one group took 30 minutes of aerobic exercise, three times a week; and the third group got both sertraline and regular exercise. Patients in the exercise group fared better than either those who received medication or, perhaps surprisingly, those who received medication and exercise.
Treatment with mind-altering drugs ought to be considered a last resort, reserved only for the tiny subset of the most severely depressed patients and/or those whose depression has not responded to lifestyle changes. Otherwise, we will never get around to addressing the personal, familial, and societal problems that cause people to feel depressed and alienated.
Unfortunately, the drug companies cannot make obscenely huge profits by selling to a tiny number of patients. Once they have a drug on the market, there is relentless pressure to expand the boundaries of illness, to pathologize more and more of normal human variation. For more information about how this process works, see the book Selling Sickness by Ray Moynihan and Alan Cassels.
If you think about it, clinical depression couldn’t possibly be as common as the drug companies want us to believe. Our Paleolithic ancestors trekked hundreds of miles in search of game, ran down woolly mammoths, and battled giant cave bears – not to mention each other. They didn’t lie down and say, “I’m too depressed to go on,” – and if any of them did, they got weeded out of the gene pool. We were meant to thrive.
Are there any fellow geezers out there who remember when adults told young people, Get High On Life, Not Drugs? Now granted, that advice usually came from people whose drugs of choice were tobacco and hard liquor, just about the two worst drugs there are. On the other hand, hypocrisy is the homage that vice pays to virtue. The advice was perfectly sound.
Since time immemorial, it was taken for granted that it was an individual’s responsibility to cultivate the internal and external resources to deal with adversity. Within the space of a lifetime, that idea has come to be regarded as utterly ludicrous, on a par with a belief in unicorns. What has happened to us?
Photo via Wikimedia Commons