[minds high] The Depressing News About Antidepressants

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The Depressing News About Antidepressants

By Sharon Begley | NEWSWEEK | http://www.newsweek.com/id/232781

Although the year is young, it has already brought my first moral
dilemma. In early January a friend mentioned that his New Year's
resolution was to beat his chronic depression once and for all. Over
the years he had tried a medicine chest's worth of antidepressants,
but none had really helped in any enduring way, and when the side
effects became so unpleasant that he stopped taking them, the
withdrawal symptoms (cramps, dizziness, headaches) were torture. Did I
know of any research that might help him decide whether a new
antidepressant his doctor recommended might finally lift his chronic
darkness at noon?

The moral dilemma was this: oh, yes, I knew of 20-plus years of
research on antidepressants, from the old tricyclics to the newer
selective serotonin reuptake inhibitors (SSRIs) that target serotonin
(Zoloft, Paxil, and the granddaddy of them all, Prozac, as well as
their generic descendants) to even newer ones that also target
norepinephrine (Effexor, Wellbutrin). The research had shown that
antidepressants help about three quarters of people with depression
who take them, a consistent finding that serves as the basis for the
oft-repeated mantra "There is no question that the safety and efficacy
of antidepressants rest on solid scientific evidence," as psychiatry
professor Richard Friedman of Weill Cornell Medical College recently
wrote in The New York Times. But ever since a seminal study in 1998,
whose findings were reinforced by landmark research in The Journal of
the American Medical Association last month, that evidence has come
with a big asterisk. Yes, the drugs are effective, in that they lift
depression in most patients. But that benefit is hardly more than what
patients get when they, unknowingly and as part of a study, take a
dummy pill—a placebo. As more and more scientists who study depression
and the drugs that treat it are concluding, that suggests that
antidepressants are basically expensive Tic Tacs.

Hence the moral dilemma. The placebo effect—that is, a medical benefit
you get from an inert pill or other sham treatment—rests on the holy
trinity of belief, expectation, and hope. But telling someone with
depression who is being helped by antidepressants, or who (like my
friend) hopes to be helped, threatens to topple the whole house of
cards. Explain that it's all in their heads, that the reason they're
benefiting is the same reason why Disney's Dumbo could initially fly
only with a feather clutched in his trunk—believing makes it so—and
the magic dissipates like fairy dust in a windstorm. So rather than
tell my friend all this, I chickened out. Sure, I said, there's lots
of research showing that a new kind of antidepressant might help you.
Come, let me show you the studies on PubMed.

It seems I am not alone in having moral qualms about blowing the
whistle on antidepressants. That first analysis, in 1998, examined 38
manufacturer-sponsored studies involving just over 3,000 depressed
patients. The authors, psychology researchers Irving Kirsch and Guy
Sapirstein of the University of Connecticut, saw—as everyone else had—
that patients did improve, often substantially, on SSRIs, tricyclics,
and even MAO inhibitors, a class of antidepressants that dates from
the 1950s. This improvement, demonstrated in scores of clinical
trials, is the basis for the ubiquitous claim that antidepressants
work. But when Kirsch compared the improvement in patients taking the
drugs with the improvement in those taking dummy pills—clinical trials
typically compare an experimental drug with a placebo—he saw that the
difference was minuscule. Patients on a placebo improved about 75
percent as much as those on drugs. Put another way, three quarters of
the benefit from antidepressants seems to be a placebo effect. "We
wondered, what's going on?" recalls Kirsch, who is now at the
University of Hull in England. "These are supposed to be wonder drugs
and have huge effects."

The study's impact? The number of Americans taking antidepressants
doubled in a decade, from 13.3 million in 1996 to 27 million in 2005.

To be sure, the drugs have helped tens of millions of people, and
Kirsch certainly does not advocate that patients suffering from
depression stop taking the drugs. On the contrary. But they are not
necessarily the best first choice. Psychotherapy, for instance, works
for moderate, severe, and even very severe depression. And although
for some patients, psychotherapy in combination with an initial course
of prescription antidepressants works even better, the question is,
how do the drugs work? Kirsch's study and, now, others conclude that
the lion's share of the drugs' effect comes from the fact that
patients expect to be helped by them, and not from any direct chemical
action on the brain, especially for anything short of very severe
depression.

continue reading on:
http://www.newsweek.com/id/232781



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