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Sunday
Sep142014

Are Anti-Depressants Really Effective? Pros and Cons

Depression can be an extremely painful ailment; typical symptoms are a complete lack of energy, a desire to isolate, avoidance of all previously pleasurable activities, hopelessness, and suicidal thoughts. Who wouldn’t want to treat such a debilitating condition? Well, surprisingly, a large number of people, for a variety of reasons:

 1. “I don’t like taking medicines”

This concern may relate to the perceived complexity of remembering to take one or two pills a day, to religious reasons, or to a concern about medicine being "unnatural."

 2. "I might become addicted"

We've all heard stories about pill poppers, addicted to "uppers," "downers," or whatever. And there are anecdotal (and factual) stories about withdrawal difficulties with anti-depressants; they should never be abruptly terminated.

 3. "I can beat this myself"

Men who can wrongly view taking medication as indicative of weakness often cite this reason.

 4. Side Effects

Concern about side effects is warranted. For many of the SSRIs (selective serotonin reuptake inhibitor), particularly the earliest ones (Prozac, Paxil, Zoloft), side effects range from nausea and diarrhea to difficulty achieving orgasm and a generalized sense of "being drugged." If side effects surface, the medication can be stopped (although not abruptly).

 5. Anti-depressants are only a cover-up for my real problem(s)

It is true that anti-depressants are focused on symptom relief. Psychotherapy has been shown to be an essential element in the cure of depression, however symptoms such as hopelessness and lack of energy can prevent patients from seeking or continuing psychotherapy. The anti-depressants can relieve these symptoms so that therapy has a chance to work.

 6."I want to feel emotions; anti-depressants will numb me out and I'll be like a zombie."

There are people who react this way to anti-depressants, however they are a very small percentage of cases, and again the medication can be stopped.

 On to the question of the efficacy of anti-depressants. Two meta-analyses published in 2008 (Kirsch) and 2010 (Fournier) found that in mild and moderate depression, the effect of SSRIs is small or none compared to placebo*.  Furthermore, it has been shown that pharmaceutical companies have buried studies that don't demonstrate efficacy (the FDA only requires evidence of effectiveness, so only studies that show positive results are submitted). Balancing these findings, however, are the following facts:

 A) In the real world, an M.D./psychiatrist would either switch or supplement an anti-depressant that was not working. The way clinical studies are structured for FDA approval they cannot take this dynamic into account.

 B) The studies are very expensive to conduct, so they are almost all very short-term. As soon as statistically significant results are achieved (which could be as little as a 5 or 10% improvement, depending on the studies' sample size) the studies are generally stopped. It is certainly possible that longer studies would generate a more positive impact.

 C) Many patients in clinical studies do not comply with the recommended procedures. They fail to take medication for any number of reasons: forgetfulness, difficulty swallowing the pill, misunderstanding instructions, failure to perceive a benefit, or temporary remission of symptoms.

 It is fair to say that anti-depressants seem to be of very limited value in cases of mild depression, or depression that is situational (e.g. reacting to the loss of a loved one, provided that the depression is not too extensive in length). They may be quite useful in more serious cases, although that will vary by individual and needs to be monitored by a medical doctor. Meta studies show that combining anti-depressants with psychotherapy is far more effective than medicine alone, for the reason cited above (#5).

 

 *The studies also reported that in very severe depression the effect of SSRIs is between "relatively small " and "substantial," a pretty confusing finding.

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