Depression: We have been duped

What do we really know about anti-depressants?

Posted Feb 23, 2009

I predict, that when all of us look back 10 years from now, we will see that today we have reached the tipping point, a paradigm change, in the treatment of mood disorders. Having been a practicing, teaching, and writing in the field of mood disorders since my days at the National Institute of Mental Health in 1982, I am certain that that these days are the tipping point.

In 1988, the western world was taken by storm by Prozac. Patient's were seemingly freed from difficult side effects which plagued them. They had not yet learned that there were other side effects waiting for them around the bend.

Psychiatrists were inflated with a sense of efficacy with their newfound tool. This stuff is so good, maybe we should put Prozac in the drinking water, we quipped. We didn't know that within ten years we would be layering medication upon medication in an effort to help only 30- 50% of our patients fully recover from mood disorders.

And the financial markets and pharmaceutical companies were enthralled with the promise of a pill for every illness. They didn't know that lawsuits and ‘me-too-drug' rivalries would threaten them.

Now, 21 years later, in 2009 we can see more clearly. We don't have to listen to Prozac, we can listen to our patients, and what we are too often hearing is "these new drugs just don't cut it". They help at the rate of placebo. And, they create other problems, such as weight gain, metabolic syndrome, diabetes, and sexual dysfunction. It's time to face the facts. We have been oversold.

Am I saying that medications don't work? Absolutely not. Certainly every psychiatrist has seen miracles with medication. Yet, somehow, the miracles have become less and less frequent. What used to be a slam-dunk, now often doesn't work, and so psychopharmacologists have become experts at tweaking the serotonin, the dopamine, the norepinephrine, and now the newest sexy molecule-glutamate. And there are other sexy molecules in the wings: CRF antagonists, cannabinoid receptor modulators, interleukin modulators and more. There are so many molecules involved in the pathophysiology of mood disorders that the parade will never end. And this is not to say that these new medicines will not help some people. But they will not be the answer, they cannot be the answer.

Why? Because of one simple fact: The head is connected to the body by a thing called the neck. And you simply can't just ignore the body when treating mood disorders. And guess what-the person is embedded in this soup called environment. And try as insurers, physicians and patients might, we will not be able to ignore the fact that we cannot be separated from the cultural and chemical soup we are swimming in.

How you might wonder can I say that we have been oversold?

On January 17th, 2008 the prestigious New England Journal of Medicine, published a landmark paper by Eric Turner and others:

"Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy".

This paper showed that among 74 FDA registered studies of antidepressants, 31% were not published. 37 studies showing positive results were published, while studies showing negative or questionable results were, with three exceptions, either not published (22 studies) or published in a way that (the authors conclude) erroneously conveyed a positive outcome. This means that if one were to read the literature, one would believe that 94% of the trials conducted were positive. In contrast to the published literature, the study authors, who reviewed all the FDA studies, found a 51% rate of positive trials. And finally, the ‘effect size' (useful for making clinical decisions, effect size is a measure of the strength of the relationship between two variables such as mood improvement and the use of a medication) reported from journal reports were often larger than the data on file with the FDA justified. The numbers were inflated.

We are facing the fact: culture, psychology, lifestyle, attachments, diet, hormones, toxicities, immune function, infection, gastrointestinal function are players in the depression story, just as they are in most other chronic disorders