Do Antidepressants Really Work?

When it comes to judging mental health interventions, I rely on the usefulness criterion: if a thing is useful, keep doing it. If it isn’t, stop.

Lots of things are useful, and I am not a one-size-fits-all kind of guy. The problem with antidepressants is that they tend to be a one-size-fits-all answer. More often than not, I see them used improperly.

Recently, I came across a thoughtful and accurate application of antidepressants. Curiously (or maybe not), it did not involve humans.

According to specialists at the UK’s Royal College of Veterinary Surgeons, about two thirds of parrots treated with Prozac stop pulling their feathers and mutilating themselves while receiving the antidepressant (News.com.au, 2008). The self-destructive behavior can develop when the birds become bored and isolated. According to the article, Prozac was administered “in the most extreme of cases.” Before administering the drug, they tried other interventions.

“Firstly, we will change the environment of the animal and make sure it has more stimulation and toys.... When we have ruled out underlying medical problems, we try to break the cycle by using Prozac.”

That article appeared the same day as a Financial Times piece casting serious doubt on the efficacy of antidepressants:

“Prescribing anti-depressants to the vast majority of patients is futile, as the drugs have little or no impact at all, according to researchers.

“Almost 50 clinical trials were reviewed by psychologists from the University of Hull who found that new-generation anti-depressants worked no better than a placebo – a dummy pill – for mildly depressed patients.

“Even the trials that suggested some clinical benefit for the most severely depressed patients did not produce convincing evidence” (Davoudi, 2008; original research here).

What gives? Why are the birds responding to a pill that is no better than a placebo? Are the birds acting as corporate shills, peddling snake oil on behalf of Big Pharmaceutical? Nah. Everybody knows that only wascally wabbits and scrappy road runners are capable of that level of organization.

First, let’s not forget that only two thirds of the birds responded to the Prozac treatment. That’s barely enough for a veto override, if we’re talking about Congress. That’s good, but not impressively so. Still, there is a stark distinction between the reported success rates of birds and humans. One possible explanation is proper use.

An ass-backward approach

The veterinarians took a different approach to prescribing Prozac than do most physicians: they isolated the worst cases and used antidepressant medication as a last resort rather than a first intervention. Before prescribing anything, the vets ruled out other problems and tried to increase the birds’ level of activity. This is as it should be.

Physicians and psychiatrists working with depressed people tend to take the opposite approach. They tend to prescribe first and ask questions later (though I have known many excellent MDs who behave differently).

Examining data from various Western cultures, Jureidini & Tonkin (2006) noted that antidepressant prescriptions increased dramatically with the advent of a new, safer class of drugs (SSRIs, like Prozac) in the mid-1980s. They argue that general practitioners and psychiatrists have become complacent and are prescribing antidepressants far too often and in the wrong cases. For example:

• Prescribing for mild depression: SSRIs have not been shown to be effective for mild depression. Yet, “67 % of antidepressants prescribed by general practitioners in the UK go to patients with mild depression.... Another study, from the US, found that in 44% of cases, antidepressants were used for mild depression or other disorders, situations in which it is known that antidepressants are no more effective than placebo” (p. 626).

• Prescribing outside of medical indications: There is little evidence that SSRIs are useful for conditions other than major depression, and there is controversy as to whether the drugs should be prescribed to children at all due to concerns of increased suicide risk. Yet physicians offer the drugs to children for the treatment of ADHD, OCD, aggression, eating disorders, and bed-wetting (p. 627). In adults, the drugs are used incorrectly to treat anxiety disorders, where existing evidence suggests that SSRIs have, at best, only a minor effect on a small number of patients (p. 627).

• Prescribing to less suitable populations: In addition to prescribing to children, physicians have increased prescriptions among the elderly. In nursing homes, the problem “is not overuse of antidepressants, but under-treatment of depression,” which has been estimated to have a prevalence of up to 30% (p. 629). Birds, you’ll recall, are offered antidepressants only after other interventions failed. If only our elders received such respect.

• Excessive doses and durations: There is no evidence that an increased dose of an SSRI will be effective after a standard dose has failed, yet many physicians and psychiatrists routinely increase dosages when their patients report no improvement (p. 628). Moreover, many patients (and I’ve met a lot of them) continue to receive SSRI prescriptions well beyond the six-month guideline. There is a good case to be made for ongoing prescriptions with people who suffer repeated, debilitating depressive episodes. However, there is no data suggesting that most cases actually meet that criterion (p. 629).

Get a bigger hammer

Speaking of excessive dosages, I’ve seen several examples of ever-increasing medications applied to relatively straightforward cases of depression or anxiety that should have been treated behaviorally. When one medication fails, some physicians will increase the dosage and/or add progressively stronger medications to the mix. I call it the “get a bigger hammer approach to mental health,” and the literature backs me up.

In a study of prescribing patterns, Cascade et al. (2007) noted that a majority of patients who report depression to their physicians receive a prescription for one SSRI. (Bear in mind that most people should receive no medication at all.) However, as the physician’s perception of severity increases (and “perception” is an awfully squishy notion here), some add one or two additional antidepressants to the first. Some will throw in an anti-anxiety drug, and some will even add an antipsychotic to the mix. That is a total of three to five psychotropic medications at one time. That’s one helluva response to your average mood or anxiety problem.

I’ve seen this more times than I care to recount, often in response to mild or moderate depression or anxiety. The result can be a patient who is so medicated and confused that it’s a wonder they can feel anything at all.

Sometimes, drugs are the answer

Lest I give you the impression that I stand against antidepressants, let me clarify. I’ve seen them help. I’ve even suggested them for some of my patients. On rare occasions, they are Heaven-sent.

But I have never seen antidepressants fix anything permanently. This is probably not news to you: permanent fixes usually involve work and change. Bottom line: if you are suicidal or immobilized by depression then, by all means, get that prescription. However, if you are troubled, anxious, or unhappy, there is a better approach. Start by seeing someone like me who can help you identify and respond to the real problem. Tinkering with your God-given synapses should be a last resort.

-IS

References
Cascade, E.F., Kalali, A.H., & Blier, P. (2007). Treatment of depression: antidepressant monotherapy and combination therapy. Psychiatry, 4(11), 25-27.

Davoudi, S. (2008). Study casts doubt on antidepressants. Financial Times Online. Downloaded on February 28, 2008 from: http://www.ft.com/cms/s/0/ 6fce3400-e3d5-11dc-8799- 0000779fd2ac.html?nclick_check=1

Jureidini, J. & Tonkin, A. (2006). Overuse of antidepressant drugs for the treatment of depression. CNS Drugs, 20(8), 623-632.

Kirsch, I., Deacon, D.J., Huedo-Medina, T.B., et al. (2008). Initial severity and antidepressant benefits: A meta-analysis of data submitted to the food and drug administration. Public Library of Science: Medicine. Downloaded on February 28, 2008 from: http://medicine.plosjournals.org/perlserv/ ?request=get-document&doi=10.1371/ journal.pmed.0050045&ct=1

Comment on this article