Will we ever settle the debate around antidepressants?
Matilda Singer discusses recent developments into the effectiveness of antidepressants, and the debate from which they stem.
With one of the largest scale investigations into the effectiveness of antidepressants having been published inThe Lancet just last month, now seemed like the perfect time to discuss the extremely contentious and personal topic that is psychiatric medication. From sertraline to citalopram, numerous people in the UK take medication daily to manage their mental health conditions. But despite being in such widespread use there is ongoing debate as to whether they are truly a viable treatment. Numerous patients believe they have saved their life, while others report horrendous side effects, and some feel they have no effect at all.
These discrepancies were at the basis of The Lancet’s study, a six-year-long systematic review and network meta analysis, looking at the efficacy (response rate) and the acceptability (treatment continuity) of 21 antidepressants in treating adults with major depressive disorder. Across 552 trials involving 116,477 participants, the overwhelming conclusion was that these drugs are indeed more effective than placebo.
This new report comes following a powerful wave of anti-pharmaceutical backlash that has been gaining momentum in the last few years. One of most vocal writers in this camp is Ben Goldacre, doctor-turned-scientific journalist and author of the bestselling books Bad Science and Bad Pharma. In both his books, and on his blogs, he aims to end the misrepresentation of scientific research in popular media and curtail powerful pharmaceutical companies that many fear have increasing influence on both the direction of scientific research, and on consumer habits. Goldacre is well respected in his crusade and has successfully debunked many of the medical myths spread by ill-qualified journalists. MMR vaccine doubts, initially fuelled by another study from The Lancet published in 1998, and Gillian McKeith’s credibility, seem to be long-settled arguments.
However, psychotherapist James Davies (author of Cracked) and journalist Johann Hari (author of Lost Connections) have recently joined the ranks, and I find their arguments to be more problematic. In their works, Davies and Hari take the anti-pharmaceutical movement to a new level, claiming that antidepressants have absolutely no effect and are no better than placebo, that depression (and several other mental illnesses) are entirely socially constructed conditions, and, most controversially, that pharmaceutical companies may be covering up this truth in order to push pills and make fortunes. Both present personal anecdotes alongside their points; Davies has a long list of patients unsuccessfully treated with antidepressants and Hari has been facing his own battle with depression since his teens. Yet, the irony is that an argument supposedly designed to move us away from scientific dogmatism has ended up driving us to the other end of the spectrum: exchanging one banal, binary opinion for another.
Many of their arguments have an element of truth behind them. Antidepressants are often overprescribed and wrongly offered as the first (and sometimes only) treatment option for sufferers. Similarly, we know that individual wellbeing can be strongly influenced by both the immediate environment and our surrounding society. Good quality sleep, regular exercise, meaningful work and strong interpersonal relationships are known factors that can positively affect our mental health. I’m not sure which doctors Hari has been seeing, but I would be surprised to find any GP not recommending lifestyle changes as part of their treatment, whether you were being prescribed medication or not.
And anyone with a basic knowledge of psychology will know that these are not new ideas. As Hari does acknowledge in his book, the biopsychosocial model emerged in the 1970s as an extension of the biomedical model (the latter looking only at biological factors such as genetics and biochemistry), additionally taking into account psychological factors such as personality and social factors in determining an individual’s health. What is unfortunate is that Hari seems to be misrepresenting the argument as some kind of revolution he is leading, with Lost Connections being described as “a radical new way of thinking about depression and anxiety”.
Even more worryingly, the language found between the covers is sensationalist. Whilst simultaneously claiming previous pharmaceutical research is inconclusive, Hari finds alternative academics with evidence to support his own views, explaining they have ‘proved that depression is’ caused by other factors. I would like to remind him that “proved” is a dangerous word to use in the context of psychological research. One could argue that, as a notoriously subjective research area, is anything ever proven? I would also like to point out that this is exactly what Ben Goldacre is fighting against. There is nothing more powerful than a punchy headline like ‘Is everything you think you know about depression wrong?’ to get books flying off the shelves. But perhaps these authors are more interested in selling books than helping readers make informed decisions.
I believe the underlying judgement of those who do feel a benefit from medication, as opposed to those who do not, is cruel and unhelpful. Depression is a painful and isolating condition that many would do anything to escape from, however uncertain the treatment. Antidepressants may not work every single time, and they might even cause side effects. But this could also be said of chemotherapy – would we dare say that people should not be trying this to treat their cancer? I think the fact that we wouldn’t clarifies the stigma and shame that still surrounds our discussion of mental disorders compared to physical illnesses.
For me, this troubling movement has reached a worrying peak. And in that sense, The Lancet’s study could not be coming at a better time to ground us. While far from conclusive, the evidence suggests that depression may not only be exacerbated by something biological, but that it could also stem from social or psychological factors. The meta-analysis demonstrates that medication works for some (but not all) patients significantly more than placebo, but we know that therapy and lifestyle changes are also important aspects of treatment.
Taken as a whole, this evidence might lead us to fall back on the famous quote “Genes load the gun, environment pulls the trigger”. The truth is that we don’t know exactly what causes depression. What we can say is that we are all doing our best with the resources available to us. In this vein, it is important to recognise the privilege of people who are able to afford long-term therapy and alternative treatments. Medication is sometimes the cheapest and quickest option available, especially in the context of overworked GPs and increasingly stretched NHS services. This isn’t something to celebrate, but it is something to acknowledge.
In their books, Davies and Hari tell the stories of people who have undergone horrific experiences as a result of taking medication. As a counter to this, the Twitter hashtag #MedsWorkedForMe was recently set up for people to fight back against the demonising of antidepressants, and to help share positive experiences that were otherwise being drowned out. Given that shame exacerbates mental health problems, it does seem counter-intuitive for us to be telling others that they are wrong for taking medication. However, this discourse does make sense. We like certainty. We want black and white conclusions. We long to hear “you have x condition, therefore you need y to get better”. But unfortunately, our understanding of mental health problems is still a nebulous area. Perhaps an embrace of ambiguity and a tolerance of others’ treatment preferences is the only sure conclusion to be reached in this debate.