Most people get their medical information from the Internet. And that unnerving fact makes it especially important that medical websites are evidence-based, with information that's accurate, balanced, and up-to-date.
How medicines are presented has a significant influence on prescribing patterns and perceptions of their safety. But informed consent isn't possible if known harms are minimized or presented in ways that are faulty and misleading.
Hence the significance of a just-published study in the International Journal of Risk and Safety in Medicine. Leading researchers Maryanne Demasi (Nordic Cochrane Centre, Copenhagen) and Peter C. Gøtzsche (Institute for Scientific Freedom, Copenhagen) applied a checklist of 14 predefined criteria to prominent websites from 10 different countries in which antidepressants are widely prescribed. They developed a cross-sectional study of the presented benefits and harms on websites based in Australia, Canada, Denmark, Ireland, New Zealand, Norway, South Africa, Sweden, the UK, and the US.
They found a pattern both consistent and global, especially concerning antidepressant withdrawal, suicidality, and sexual and other side effects. Due in part to drug company sponsorship and related commercial pressures, the websites' listing of the benefits and harms of antidepressants was found repeatedly to "conflict with the scientific evidence."
Applying international guidelines, such as the Canadian Medical Protective Association's Good Practices Guide and Australia's National Health and Medical Research Council, Demasi and Gøtzsche determined that none of the websites met acceptable standards for informed consent or scientific evidence. The widespread misinformation they detailed was instead "likely to lead to inappropriate use and overuse of antidepressants" and to "reduce the likelihood that people will seek better options like psychotherapy."
Demasi and Gøtzsche put the websites into three groups, tied to whether they were governmental institutions, advocacy groups, or consumer organizations. When information about the funding was unclear, they emailed or called the organizations for clarification.
They found all of the websites to list both uses and benefits to antidepressants. One Australian website claimed without evidence, "Most people (60-70 percent) will recover in 6 to 8 weeks of taking antidepressants." Another: "Around 70 percent of people with major depression start to feel better with the first type of antidepressant they are prescribed."
Twenty-nine (74 percent) of the websites attributed depression to a "chemical imbalance," a notion debunked more than a decade ago, but one that websites continue to suggest can be fixed and corrected. Statements on prominent U.S. health care providers argue: "It's a chemical imbalance in your brain that needs to be treated." "Chemicals in your brain called neurotransmitters may be out of balance." "If you are depressed, these are out of balance and do not work properly."
With formal European recognition of Post-SSRI Sexual Dysfunction, 23 (59 percent) of the websites mentioned that antidepressants were associated with sexual dysfunction. An Irish website stated that SSRIs are known to cause "low sex drive, lack of orgasm, and, in men, abnormal erection or ejaculation."
However, 22 websites (56 percent) also claimed that antidepressants could prevent relapse, advising medications be taken typically for six to nine months, with some websites even suggesting for a lifetime. The website for the UK Royal College of Psychiatrists is quoted as asserting, contrary to revised consensus, that if people are having trouble stopping their medications: "Most doctors would say that it is more likely that the original condition has returned."
Demasi and Gøtzsche determined that 25 (64 percent) of the websites indicated that antidepressants "may cause increased suicidal ideation." But "23 (92 percent) of them contained incorrect information, and only two (5 percent) websites noted that the suicide risk is increased in people of all ages." Moreover, "Twenty-eight websites (72 percent) warned patients about withdrawal effects but only one stated that antidepressants" use can result in dependency.
Regarding suicidality, Demasi and Gøtzsche note that although the FDA in 2007 expanded its black-box warning on SSRIs to include everyone under 25 years, one website trivialized the warning by stating that suicidality was rare and only observed in those "under the age of 18 years." Despite a large number of studies buttressing the FDA warning, the UK Royal College of Psychiatrists is quoted as asserting: "There is no clear evidence of an increased risk of self-harm and suicidal thoughts in adults of 18 years or over." Of the available evidence-base, Demasi and Gøtzsche are emphatic: "Antidepressants for children are all unsafe."
Their timely study appears in the wake of similar hard-hitting analysis by Gøtzsche in the journal's previous issue—a study concluded: "Long-term use of antipsychotics and antidepressants is not evidence-based." Regarding the widespread problem of inflated effect sizes, clinical trials that aren't adequately blinded, and outcomes either switched or interpreted subjectively, Gøtzsche concludes: "The widespread use of psychiatric drugs does not appear to be evidence-based but seems to be driven mainly by commercial pressures."
Amid these and similar warnings about the overprescribing of SSRI antidepressants, due in part to coronavirus-related stress and anxiety, on a scale felt worldwide, it is especially important to hear reminders that COVID-19, though a pandemic, is not a mental health crisis. That, as Dr. Lucy Johnstone explains, "It's healthy to be afraid in a crisis" and "wrong to view our natural fears as mental health disorders."
"It is neither true nor helpful to frame these reactions as a 'mental health crisis,'" adds Public Health England. And from the UK's Council for Evidence-Based Psychiatry: "Anxiety, low mood, panic, fear, and confusion are understandable responses to a very real threat."
Demasi, M. and P. Gøtzsche. 2020. “Presentation of benefits and harms of antidepressants on websites: A cross sectional study.” Int J Risk Saf Med. 2020. doi: 10.3233/JRS-191023. [Epub ahead of print]
Gøtzsche, P. “Long-term use of antipsychotics and antidepressants is not evidence-based.” Int J Risk Saf Med. 2020;31(1):37-42. doi: 10.3233/JRS-195060. [Link]