Do Antidepressants Help or Not?

In the United States, 9.5% of the adult population experiences some form of mood disorder. Of these, almost half are classified as severe. The rates in Canada are similar, although the authors stress that there is more unmet need in the US among those without health insurance. (my plug for socialized medicine).

The most common treatment for depression is pharmacological, and in the minds of some, that means a conspiracy by “Big Pharma”. Of course, in the minds of the CAM crowd everything about modern medicine is a conspiracy of some sort. If the studies don’t support their beliefs, then the studies must be wrong.

CAM seems to be the most effective in pain management, mood disorders, and other conditions where variability of symptoms is normal. Some groups, such as Scientologists, argue against the existence of a physiological basis for depression.  For most of us however, a diagnosis of a mood disorder leads to a prescription for an anti-depressant.

Harriet Hall, in a recent post at Science Based Medicine discusses the efficacy of anti-depressants in the presence of conflicting studies. She compares the interpretation of results found in different studies by Erik Turner and Irving Kirsch. Kirsch views anti-depressants as being not effective, while Turner sees them as definitely better than treatment with a placebo.

Erick Turner, M.D., Department of Psychiatry, Oregon Health and Science University; Staff Psychiatrist, Portland Veterans Affairs Medical Center; Former reviewer, FDA.

In Turner’s analysis,

none of the confidence intervals overlapped zero. This means that, while there is some probability that the true effect size is zero, meaning that antidepressants and placebo are equal in efficacy, that probability is negligibly small.

The question becomes, if anti-depressants are not used, what is the appropriate treatment for mood disorders.

Psychotherapy avoids the side effects of drugs, but it has its own drawbacks: it is expensive, time-consuming, and variable in quality. How effective is psychotherapy? Psychotherapy trials also suffer from publication bias, just like antidepressant drugs. And when one weeds out low quality studies, psychotherapy has an effect size of only 0.22, lower than the value for antidepressants reported by Kirsch himself, So if we reject any treatment below the (arbitrary) 0.5 cutoff, when a mental health care provider is faced with a patient in need of help, is he or she to do nothing at all?

Major depression  is a debilitating disease. In Canada, the suicide rate is 15 per 100,000 people, with specific groups being much higher. Non-treatment is not an option.

In Canada, suicide accounts for 24 percent of all deaths among 15-24 year olds and 16 percent among 16-44 year olds. Suicide is the second leading cause of death for Canadians between the ages of 10 and 24.8 Seventy-three percent of hospital admissions for attempted suicide are for people between the ages of 15 and 44.

Dr. Hall goes on to state that a  recent study showed that antidepressants reduced the risk of suicide by 20% in the long term.

She concludes her article with a reminder of the challenge of practising medicine based upon science and the difficulty that media has in reporting complex research.

Once more, science fails to give us the black-and-white answers we crave. And once again we are reminded that we can’t rely on the media for accurate, nuanced information about medical science.

In the end, we are faced with the fact that anti-depressants do not work for everyone, but currently they are  the best tools we have for fighting major depression. The argument is not whether or not to use anti-depressants, but how to make the use more effective.

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