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23 February 2018

Stop vilifying antidepressants – mental health is more complex than the “insteaders” think

The largest ever meta analysis in psychiatry found that, based on the evidence we have, antidepressants are effective.

By Mark Brown

“Antidepressants work,” blared headlines about a new study published in medical journal The Lancet this week. Hundreds of millions of people live with depression. In a world where vaccines are viewed with suspicion and the internet overflows with dubious health advice “they don’t want you to know”, The Lancet paper didn’t end debate, it inflamed it.

What the study tells us is simple. It took data from 522 double blind randomised control trials (RCTs) of 21 commonly used antidepressants carried out between 1979 and 2016. This meta analysis included 116,477 individual participants across the 522 double blind studies, 87,052 who were randomly assigned to receive a drug and 29,425 who were not. This is the largest ever meta analysis in psychiatry. It found that, based on the evidence we have, antidepressants are more effective than a placebo and, apart from in the case of one antidepressant, more tolerable than doing nothing. It also found some antidepressants seem to be more effective than others for some people.

More than half of the studies the authors included contained unpublished data. This was because they had chased up drug companies and regulatory bodies for data not published in original reports or from studies that never made it to publication. This significant amount of “new” data means the study could consider factors like remission, drop-outs due to side effects, changes in symptoms, sponsorship, study precision, and dosing schedules. Such factors were left out of their previous paper on the same subject published in 2009.

The finding of this report will not be sufficient to silence critics and sceptics. The authors found that 78 per cent of the trials included in their meta analysis were funded by pharmaceutical companies and that 73 per cent of the studies had a moderate risk of bias. The trials that were included only observed people for eight weeks, so can’t tell us anything about long term effects.

Science often feels complicated, and runs contrary to our sense of how meaningful stories are made. Where are the goodies and baddies in the antidepressants story? When are the dashing heroes and nefarious schemes? People who have not experienced depression often find something distasteful in the idea that people might face problems that are beyond their own resources to solve. For some the objection is moral: how can you be expected to be a fully competent actor in you own fate, if your feelings and judgement are altered at source? For others, antidepressants allow people to settle for less than they should demand and to acquiesce to events that they should oppose. Conspiracy brings together moral and political objections to create a story that “they” want everyone to take antidepressants for financial or political or other even more devious reasons..

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Discussions about antidepressants often become discussion about everything but antidepressants. The central hypothesis of Johann Hari’s recent book on depression holds that our inability to focus on what is important in life leads us to turn to antidepressants instead of seeking solutions to our ennui and sadness. Discussion of antidepressants always attracts “insteaders”. “Why,” the insteader will ask, “Are we prescribing antidepressants when we could be doing this thing which I am particularly keen on instead?” Insteads range from having a healthier diet to doing more exercise to reconfiguring society, most being either amusingly cosmetic or hubristically over-reaching. Changing the world is hard when you can’t bear the feeling of your own skin and when every world feels like a stone dropped in a stagnant pond.

Depression is a here-and-now experience. It happens in your life, in your relationships, in the bathroom mirror, on the bus, in your bed. All depressions are different and all depressions are the same. The devil of depression is in the details: the heavy, terrible weight of idiosyncratic horrors and malfunctions and sadnesses, the heart that feels like a fist in your chest. What is statistically true is often personally less so.

Depression makes events wind down to grey nothingness. Broader debate wants to make a drama out of antidepressant use, to find the story within the story. No amount of evidence will settle concerns that are based in a moral rather than scientific judgement. Rarely, when antidepressants are debated, is the question on the table “why can’t we have better meds?”

Antidepressants have always suffered at the hands of those who wish to present them as the answer singular, rather than a contributor to a story of feeling better that takes many actors to get right. The decision to take antidepressants is never easy, but it is often a mundane and ordinary one. The evidence of this study tells us that whether antidepressants are the main hero or simply a bit part player, there’s no evidence just yet for leaving them out of the story of being able to live with depression

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