(text by Jacob Stegenga)
Impossible to think clearly, exhausted, your joy of living lost in invisible suffering. The pain is even physical with headaches, cramps, backache. You feel suffocated, you feel guilty and say that you are worthless and that it would be better to die… These are the symptoms of depression, which some people are affected to a greater or lesser degree. This disease affects about 10% of the population, and many millions of people take antidepressants to control it. Today we have good reasons to doubt the effectiveness of these.
Several empirical clinical studies on antidepressants have been done in the last 10 years and we have a lot of data to rely on. However, there is a problem: experts disagree about the merits of the studies and the problems that arise from them. Philosophy can help, as it is a discipline that studies the concepts and methods of science and offers us a better view and analysis of the results obtained. After witnessing the hecatomb of depression and seeing many people around me resort to medication, I began to use my courses as a philosopher to understand the effects of antidepressants. A thorough analysis of the results shows that antidepressants are of little or no value.
Depression affects many of us. If you find the arguments convincing, the message here could be disappointing. If you are already taking antidepressants, you may be tempted to stop, but please be careful. We have several cases where people have suffered withdrawal effects. In addition, we have little data on alternative methods of intervention, such as psychotherapy or lifestyle changes. Therefore, patients must be extremely cautious when planning to change their medication or approach to treatment. If you are depressed, your doctor or psychiatrist has the necessary knowledge and data about your health – despite the fact that most doctors overestimate the benefits or underestimate the problems associated with antidepressants, you may want to show them this essay.
The best evidence on the effectiveness of antidepressants comes from clinical trials and meta-analyses of these trials. The majority of these studies are directed and funded by the companies that create antidepressants, so this obviously creates a huge conflict of interest. The studies only last a few weeks, which is far less than the time patients take their antidepressants. The subjects chosen for the studies are carefully selected, usually excluding the elderly, those with other illnesses, or those taking other forms of medication – in other words, the typical subject of people who usually take antidepressants – which means that the results of the clinical studies cannot be relied upon. Studies that tend to show the efficacy of antidepressants are published, while studies that tend to show the ineffectiveness of antidepressants are not published. For example, in 2012 the pharmaceutical company GlaxoSmithKline pleaded guilty to criminal charges for promoting the antidepressant Paxil to children in the United Kingdom.
The scale of Hamilton
Every study of antidepressants uses a scale to measure the severity of depression before and after the study. These scales are misleading and are designed to overestimate the effectiveness of antidepressants. One of the reference scales for this type of study is the Hamilton Rating Scale for Depression. This study has 17 questions with several possible answers. Each answer is given a specific score, and at the end of the test the results of each question are added together to give an overall measure of the patient’s level of depression, for a maximum of 52 possible points. The goal when trying a new antidepressant is that the score of the test group that tried the new antidepressant should be higher than the score of the test group that received a placebo. This scale was created in 1960 by psychiatrist Max Hamilton in the United Kingdom.
The problem with this scale is that large changes in a subject’s score can occur as a result of trivial changes in a subject’s real depression. For example, there are three questions about the quality of a subject’s sleep, with a total of six possible points, and there is a question about how much a subject is fidgeting, with up to four points. So a drug that simply made people sleep better and fidget less could lower one’s depression score by 10 points. To put this in context, recent clinical guidelines in the UK have required drugs to lower depression scores on this scale by an average of only three points. When a measurement scale measures what we want it to measure, we say the scale has ‘construct validity’. The general problem with depression-severity scales is that they lack construct validity, and this contributes to overestimating the effectiveness of antidepressants.
The placebo effect
The placebo effect is when patients improve merely as a result of the medical care they have received rather than as a result of the biochemical properties of their drug. The idea is that the mere expectation that you will get better after receiving medical care can itself contribute to you getting better. Some diseases are more responsive to placebo than others, and depression is one of the most placebo-responsive of all diseases. Since much clinical research aims at discovering the true biochemical effects of drugs, trials include a control group that receives a placebo (sometimes control groups receive competitor drugs), and the allocation of subjects to the drug group or the placebo group is concealed from subjects (this is sometimes called ‘blinding’). To estimate the active biochemical effects of the drug, the measured outcomes in the drug group are compared with the measured outcomes in the placebo group.
Blind-breaking is when subjects accurately guess which group of a trial they are in. This can occur because of the presence or absence of side-effects – for example, two common side-effects of antidepressants are weight gain and problems with sexual functioning, and so if a subject in a trial on a new antidepressant gained weight and developed difficulty achieving orgasms, she might accurately guess that she was in the drug group. This accurate guess could then lead to an expectation that her symptoms of depression will improve, and then her symptoms could in fact improve, by the placebo effect alone.
There is not much empirical evidence on the frequency of blind-breaking in trials of antidepressants, though some experts believe that it is very high. (A simple improvement to trials would be to ask subjects to guess their group at the end of the trial, which would give researchers some indication of the extent of the placebo effect in the trial – this is sometimes but not often done, yet could easily be done in all trials.)
Analyzing the results
When you take the time to analyze the results, it becomes clear that antidepressants are not medically beneficial. Meta-analyses must consider the results of all clinical studies, even those that have not been published. It is not possible to know if all studies have been taken into account, since the majority of studies paid for by the pharmaceutical industry are biased, but it is nevertheless an attempt to have as much information as possible. What do they show then?
In the meta-analysis that included as many diverse studies as possible, the level of severity between patients who received an antidepressant and those who received a placebo changed by only 2 points, which is virtually indifferent. This study has been repeated every year for 10 years and the results are always the same: antidepressants do not have the desired effect. In the rules imposed for clinical studies, to declare the antidepressant as effective it must decrease the anxiety level by at least 3 points, and many psychiatrists and doctors say that the difference should be 7 points to conclude that there is a real effect. No medication does that.
Simply put, we have many reasons to believe that there is no benefit to taking antidepressants for those who suffer from them. In addition, we know that these products cause many side effects such as weight gain, sexual problems (lack of libido) and sleep problems. Studies have also shown links between antidepressants and the risk of violence, suicide and psychotic episodes in women. A long-standing theory about depression is that it is caused by a lack of serotonin. A class of antidepressants (SSRIs: Selective Serotonin Reuptake Inhibitors) that help raise serotonin levels in an effective artificial way has long been considered the best way to treat depression. However, new studies conclude that this is a simplistic and misleading way to treat depression.
The other major problem
Another major problem, depression is very reactive to placebos! For a large proportion of subjects in the placebo test group, the level of depression dropped by as much as 10 to 15 points. The placebo effect is incredible – for example, having a larger pill causes the patient to have a greater reaction than when taking a smaller pill. If someone reports seeing beneficial effects from antidepressants, it is likely because the illness fluctuates in intensity.
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