On the 21st February, 2018, a study addressing the effectiveness of antidepressant drugs was published in The Lancet. It has caused quite a stir. Accepting the subsequent media headlines at face value, one would be forgiven for believing that a cure for all human misery had been confirmed and that emotional distress and suffering could now be eradicated from our planet. Across TV screens, newspapers and the social media, representatives of the psychiatric establishment, together with its followers wedded to the illness-like-any-other approach to human suffering, typically displayed a mix of glee and self-righteousness. The central message was that all those pesky critical people who had dared to suggest that antidepressants are overprescribed, minimally effective and doing more harm than good had been proved wrong and should now be silenced.
Further reflection on the Lancet study, and the reaction to it, leads to a very different conclusion: it represents a stark example of how to spin a mundane, predictable finding into something that sounds ground breaking.
Outline of the study
The explicit overarching aim of the research in question was to compare the relative efficacy and acceptability of 21 antidepressant drugs currently prescribed across the Western world. Pooling the results from 522 trials involving over 116,000 people, the researchers found that all 21 of the antidepressants reduced symptoms in ‘adults with major depressive disorder’ to a significantly greater extent than a dummy pill (placebo). In addition, the relative effectiveness of each drug was considered with some (amitriptyline, for example) ranking higher than others (fluoxetine, for example). A huge study leading to an emphatic conclusion: all antidepressants work. The psychiatric establishment wasted no time in spreading the joyous news.
Psychiatry’s media machine goes into overdrive
The psychiatric establishment, clearly well prepared for this moment and using their enduring ties with the media to their advantage, swiftly spread the good news. Glyn Lewis (professor of psychiatric epidemiology at University College London) told the BBC that the study provided ‘compelling evidence’ for the effectiveness of antidepressants.
The lead author of the study, Dr Andrea Cipriani, suggested the implications were even more emphatic. In an interview for the BBC he proclaimed, ‘The study is the final answer to a long-standing controversy about whether antidepressants work for depression’. Using similar words from a – presumably – pre-prepared script, Professor Carmine Pariente, representing the Royal College of Psychiatry, stated that the study’s findings ‘finally put to bed the controversy on antidepressants’.
Nourished by the enthusiasm of these psychiatric experts, the newspapers – even the quality ones – repeated the enduring mantras of psychiatry’s propaganda machine. The Guardian conveyed the doctors’ hope that the study will ‘help to address the global under-treatment of depression’, and then followed it up with a classic piece of psychiatric spin: ‘If cancer or heart patients suffered this level of under-treatment there would be a public outcry’.
The Independent was even more outspoken, its headline screaming: ‘DOCTORS SHOULD PRESCRIBE MORE ANTDEPRESSANTS FOR PEOPLE WITH MENTAL HEALTH PROBLEMS’. Reading this definitive conclusion, I could almost feel the friction-generated heat as biological psychiatrists and pharmaceutical-company representatives across the Western world rubbed their hands together in anticipation of further financial rewards.
The 64-million prescriptions of antidepressants each year (in England alone) is apparently not enough. Curiously, while espousing the we-desperately-need-more-medical-treatment message, a pivotal fact is overlooked: as antidepressant consumption has exponentially increased, so has the apparent number of ‘depressed’ people within our communities. In contrast to the physical health arena, where more investment in oncology and cardiology consistently leads to greater recovery rates for cancer and heart problems, psychiatry’s prescribed chemicals appear to achieve the opposite effect.
Weaknesses of the study
The study under scrutiny is not without merit. In accessing data from 116,000 consumers of antidepressants it constitutes the largest ever investigation into the impact of antidepressant drugs on symptoms commonly associated with ‘depression’. Usefully, the central finding suggests that all antidepressant drugs achieve a statistically significant reduction in these symptoms (as measured by commonly-used ‘depression’ rating scales) over and above that achieved by an inert pill or placebo.
Nonetheless, this research investigation harbours a number of important weaknesses and flaws that render the grand conclusions (of the authors, psychiatric establishment and media) premature and irresponsible. These deficiencies – broadly in decreasing order of concern – are as follows:
- Short-term follow up
On average, patients were assessed only eight weeks after commencing on the antidepressant. Such a short follow up is totally at odds with the real world where recipients remain on the drugs for a minimum of several months and often for years. Valid conclusions about the pros and cons of antidepressants cannot be drawn from such a brief timeframe.
- Exclusion of ‘treatment-resistant’ patients
Those people who, based on their histories, were deemed to be ‘treatment resistant’ were not included in the study. Given the widespread prescribing of antidepressants, those adjudged to be ‘treatment resistant’ would have previously taken antidepressant drugs without realising any benefits. Omission of these non-responders from the systematic review will likely have inflated the recorded level of antidepressant effectiveness.
- High risk of bias
Based on the authors’ own judgements, only 18% of the 522 trials included in the study were deemed to be at ‘low risk’ of bias.
- Withdrawal effects as a confounding variable
Given the ubiquitous presence of antidepressants within mental health populations, it seems highly likely that many of the people included in the study would already have been taking these drugs at the onset of the investigation. As such, a significant proportion of those patients allocated to the placebo group may have experienced withdrawal effects, thereby skewing the results in favour of those receiving antidepressants. (Information about this potential confounding factor is difficult to extract from the published study. However, in light of psychiatry’s enduring disregard for the serious discontinuation effects suffered by many patients undergoing antidepressant withdrawal, it is reasonable to assume that the studies included in the Lancet article failed to consider this as a confounding variable).
- Difficulty accessing the original studies
There have been reports that independent researchers are being denied access to the data from the original studies. Dr David Healy – a highly-respected critical psychiatrist – expressed the view on social media that the articles underpinning the Lancet study are ‘junk’, often based on ghost-written papers.
- Conflicting interests
Three of the prominent authors in the study have disclosed that they have received remunerations for consultancy and/or lecture work from a number of pharmaceutical companies. It is therefore possible that their impartiality may have been compromised.
- Funding sources
With regards to the 522 trials included in the systematic review, 78% of them were funded by pharmaceutical companies. Considering the drug industry’s track record of data manipulation and hiding studies with unfavourable outcomes, this raises questions as to whether the investigations included in the research truly represent the current status of antidepressant-evaluation trials.
Ignoring the bigger picture
The serious weaknesses of the Lancet study (listed above) would indicate that caution is required when considering its implications for antidepressant prescribing in the real world – a warning apparently ignored by the authors and psychiatry representatives in their post-publication hyperbole. Furthermore, the study fails to address three other important issues of relevance when considering the desirability or otherwise of widespread antidepressant use.
Firstly, the frequent side effects associated with antidepressant consumption have not been adequately factored into the deliberations about the pros and cons of further prescribing. Nausea, headaches and sleep disturbances are commonplace. The most commonly used type of drug – the SSRIs – also routinely impair sexual interest and sexual arousal in both men and women (a further burden for people already suffering misery and self-loathing). Less frequently, more serious side effects may be experienced such as foetal abnormalities, disorientation, muscle cramps, seizures, bleeding in the gut and bone fractures in older people.
Secondly, the Lancet study, and subsequent comments from psychiatry representatives, totally ignored the fact that antidepressants are habit forming and that withdrawal often evokes a discontinuation effect. This omission is consistent with clinical psychiatry’s reluctance to recognise the impact of stopping the drug, particularly after a lengthy period of consumption. People striving to withdraw from antidepressants often endure psychological consequences, such as irritability, anxiety and weepiness, as well as a range of physical reactions that may include nausea, vomiting, dizziness, insomnia, vivid dreams and electric-shock sensations in the limbs. Anyone who doubts the level of distress endured by many people when trying to get off these drugs should read the many personal testimonies (such as those described on the ‘Let’s Talk Withdrawal’ Facebook site.
Thirdly, it is of great concern that the increasingly frequent expressions about potential links between antidepressants and both suicide and homicide have not been addressed. It is irresponsible to be energetically promoting the mass administration of a substance that, for some recipients, might trigger catastrophic acts of violence or self-destruction.
A predictable and mundane finding
Even if we ignore the serious flaws in the Lancet study, and uncritically accept its central conclusion that all antidepressants produce a statistically significant reduction in the level of symptoms associated with ‘depression’, what value is this finding with regards to improving the lives of all those people suffering misery and overwhelm? Very little.
While some people express very positive outcomes after taking antidepressants, the Lancet study confirms that the average response is a modest reduction in scores on commonly used rating scales measuring the severity of ‘depression’. For most recipients, this small shift is unlikely to be associated with any meaningful improvement in their wellbeing and quality of life; to use the language of mental health research, the outcome will be of no clinical significance.
It is important to remember that, unlike cancer and heart problems, there is no identified biological pathology that underlies ‘depression’, no physiological imbalance to be rectified. Instead, when we talk about ‘depression’ we are referring to a cluster of human experiences associated with distress and overwhelm. The rating scales used in research include a measure of symptoms such as agitation, sleeplessness, and anxiety so any chemical that reduces arousal is likely to achieve statistically significant shifts in overall scores in the short term – who is to say that a daily dose of alcohol would not realise similar changes to those reported in the Lancet study?
How can we reduce human misery?
In England alone, the number of antidepressant prescriptions each year has more than doubled from 31 million in 2006 to almost 65 million in 2016. During this time frame, the number of people suffering ‘depression’ has also markedly increased. The appeals for even more antidepressant dispensing is clearly not going to reduce the amount of human misery within our society. Would it not be much more reasonable to focus on societal changes that would lessen the likelihood of people descending into misery and hopelessness?
There is a robust evidence base to support the premise that a range of adversities and pressures, rife within the Western world, play a prominent role in the creation of ‘depressed’ people. It would make far more sense to develop a multilevel, whole-system approach to counter the current levels of human misery by more effectively addressing issues such as childhood abuse, poverty, homelessness, inequality, discrimination, loneliness and domestic violence.
A primary focus on doling out more antidepressants as a cure for human misery is misguided and unhelpful. Medicalising distress and suffering in this way will only benefit those privileged groups who currently gain advantage from this ‘illness like any other’ approach: the pharmaceutical industry and the psychiatry profession. The findings of the Lancet study do not change this assertion.
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