This paper examines the benefit or lack of it of antidepressants. Are they more effective than placebos, though bearing in mind that placebos can be effective.
The Age, Opinion page, Monday March 3, 2008, p 15
You can’t treat depression without getting to the heart of the problem.
When I trained in the 1960’s in London my teachers told me how lucky I was to start my career in the new era of psychotropic drugs. And indeed, 10-21 days after I prescribed antidepressants, I saw severely depressed patients improve before my eyes.
Thirty years later, in emergency departments and in my clinical practice, I had opposite experiences. Patients on long-term antidepressants came out of even severe depressions before my eyes again, but this time, during our first meeting, as we touched for the first time on core problems. Such patients stopped their medications, as they no longer needed them.
Now a study by Kirsch and colleagues in the Public Library of Science (Medicine) that accessed unpublished research by drug companies suggests that antidepressants are no better than placebos except in the severest cases. Does that mean that my initial experiences with drugs were due to placebo effects?
Actually, I had puzzled over many years about the placebo effects of antidepressants. Usually the drugs had only 5-25% advantage over placebos. But in a large enough study even the lower range was statistically significant, and the drug was deemed to be effective. I wondered why the efforts devoted to find better drugs were not spent on research and improvement of placebo effects, which were clearly very potent.
To understand my different experiences over 30 years, the differences between drug, placebo, and specific therapies need to be addressed.
Drug therapy works on the assumption that depression is a disease, and that like an infection can clear with antibiotics, depression can clear with antidepressants. Various drugs with various biochemical effects have been claimed over the years to specifically elevate pathologically depressed moods.
Placebo, an inactive medication, is nevertheless often associated with powerful suggestion by an authority figure such as a doctor that the medication will fix the ailment, as well as with removal to a safe problem-free environment like a hospital, and provision of kindness and concern for how patients feel. Specific treatment for depression involves identifying a major loss and suppressed grief in relation to the loss. It involves identifying hope beyond hopelessness and despair for such a loss, and allowing the grieving process to take place with support from the therapist. It was when patients I saw in the emergency department were given their first opportunity to express their grief that their depressions turned to healthy tears.
‘It is easier then to immerse oneself in keeping busy, rather than open a can of worms.’
It must be noted that depression refers to a variety of emotions that psychiatry and psychology have not separated clinically for treatment. Among other emotions, they include defeat, demoralization, anguish, abandonment, frustration and betrayal. As with depression, specific treatment requires, through hope and support, recognition of the nature of the symptoms and their origins, and then dealing with them in the present context.
The reason why drug and placebo therapies are so popular is not only because of a desire for a simple solution by both patient and doctor, but also because of fear on the part of the patient that to uncover their real problems will expose their belief that their lives are meaninglessness; a fear that may be conveyed to doctors, and even resonate within them. It is easier then to immerse oneself in keeping busy, rather than open a can of worms.
In reality, doctors and patients negotiate an amalgam of drug, placebo and specific treatments according to their capacities, and available knowledge of the times. For instance, we are much more attuned to stresses and traumas than we were in the ‘60s.
Benefits can be obtained in many combinations of treatments. But not addressing specific issues has costs. Patients are left in an uneasy equilibrium of being and not being themselves, while doctors chase their own tails as patients keep returning with unresolved problems.
The 12 million antidepressant prescriptions written in Australia in 2005-06 might have cured some, helped many from being overwhelmed at the time, and produced side-effects in others.
But there is no easy drug fix for psychological wounds. Kindness and suggestion can be useful stop-gap measures. But proper diagnosis and healing of root causes is still the best medicine.
Dr Paul Valent worked as liaison psychiatrist in emergency departments for 25 years. He founded and is ex-president of the Australasian Society for Traumatic Stress Studies.Categories: Biopsychosocial