“The drugs do work!” cry the headlines. But read the full report and the picture is rather different…

 

“Major depressive disorder is one of the most common, burdensome, and costly psychiatric disorders worldwide in adults.”

If you read the news recently following the publication of the report on Anti Depressants (Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis), you would be forgiven for thinking this was the final word on the issue. The message was clear: the drugs work and millions more should be taking them. But delve into this thoughtful, measured report and the picture is far less clear.

The writers recommend caution in drawing conclusions due to the “paucity of information reported in the original studies” and “a [possible] bias in conduct, analysis, or reporting of head-to-head trials, driven by commercial interests”. They note that whilst “depressive symptoms tend to spontaneously improve over time” for more persistent depression antidepressants have become the norm: “because of inadequate resources, antidepressants are used more frequently than psychological interventions.” They point out "there is a long-lasting debate and concern about their efficacy and effectiveness, because short-term benefits are, on average, modest; and because long-term balance of benefits and harms is often understudied”

“Because of inadequate resources, antidepressants are used more frequently than psychological interventions.” 

What then are we to make of the report’s finding that “all antidepressants included in the meta-analysis were more efficacious than placebo”?

The report’s remit was in essence to compare the benefits of taking one kind of antidepressant over another, and then compare that to taking nothing at all. And they concluded broadly that yes, the antidepressants they compared were better than taking nothing.

Asking the right questions

The problem lies in the question. What if the question had been "how can we best help people with depression?"
Consider this. “You’re hungry. I am going to give you camomile tea, coffee or nothing. Let me know which makes you feel better.” Coffee comes out best for fending off the hunger pains. Camomile tea calms the digestive system - that is best for some people. But not everyone likes coffee or camomile tea, so nothing is better for those people. Result: coffee is the best treatment for hungry people. An accurate reflection of the question as it was posed. If the question had been “what is the best thing to give hungry people?” I am sure we would all have come up with the answer “food!”
In essence this report began by saying the equivalent of food is too expensive  - you have to make the best of the drinks on offer to satisfy your hunger pangs.

If the question being posed had been “what is the best way to help people with depression?” then I suspect the answer would have been much broader. Indeed the report hints at the value of these other factors, such as being cared for (“the expectation of receiving an active treatment”), listened to (“the therapeutic setting”) and the personal connection (“the frequency of study visits”).

                             

NHS: a mix of exercise, support groups and talking therapies are most effective to combat depression.

In the UK, the NHS website page on depression recommends that for mild to moderate depression, a mix of exercise, support groups and talking therapies are the preferred treatment protocols. Even in severe cases of depression, the advice is a combination of talking therapies and antidepressants is most effective.

Finally a word from someone who has struggled with anxiety and depression for years. In her 2016 piece in The Telegraph “Antidepressant nation: is stress making pill poppers of us all?” Sarah Thompson speaks of her love/hate relationship with antidepressants, and her decision to quit. “Medication restored my cheery disposition, but it also made me feel weirdly numb. I missed emotional contrast, the light and shade of life, which had been eclipsed by the dazzle of artificial sunshine. So I’m doing all the boring things, being more mindful and going gently through life.”

References:

http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(17)32802-7/fulltext

https://www.nhs.uk/conditions/clinical-depression/treatment/

http://www.telegraph.co.uk/women/womens-health/10889310/Antidepressant-nation-is-stress-making-pill-poppers-of-us-all.html

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