Antidepressants like placebo

Antidepressants little better than placebo

Ask any honest psychiatrist (if one can be found alone, not overheard by peers) and you will hear that his least satisfying prescription is that of an anti-depressant. Whether used for symptoms of depression or anxiety, robust, reliable relief is simply not at all common. Thus it has become expected for psychiatrists to prescribe successive trials of or multiple concurrent antidepressants, “adjunctive” agents like anti-psychotics, or to add additional agents targeted to specific symptoms like a sedative for insomnia or a stimulant for daytime sleepiness. This has become state of the art.

After decades of use during which the psychiatric literature was replete with articles testifying to their proved efficacy, it is now common to read that anti-depressants cannot reliably be shown to be more effective than placebo. Recent “meta-analyses” of older positive reports demonstrate that when those smaller studies are combined the re-calculated efficacy data shows results not better than placebo.

Such data lead to the landmark articles by Angell in the New York Review of Books of July 14 and 23 which have occasioned much spirited comment in the media, both general (see Kramer in the July 9 New York Times “in defense of antidepressants) and psychiatric (see Kaplan in Psychiatric Times October 2011 “Antidepressants: Lifesavers-or Active Placebos). The response of psychiatry to this controversy has not at all been to listen to head the message, but rather to shoot the messenger.

The first line of defense has been the personal testimony, both of psychiatrists and more so of patients testifying to their successful use of antidepressants and the dreadful outcomes that would be certain if such drugs were not readily available. Kramer’s op/ed letter had hundreds of responses in support of antidepressant use.

A second line of defensive has been primarily in the psychiatric literature. This has been the attempt to undermine confidence in the use of placebos in double blind or other controlled studies of psychiatric drugs, especially antidepressants. Kaplan’s article is just a recent example of many such efforts to ascribe to placebos “active” treatment effects that somehow mysteriously skew the results toward the negative and away from proving the efficacy of such “obviously” helpful drugs. Such efforts receive lavish support from pharmaceutical manufacturers wary of losing their largest source of profitability.

It should come as no surprise then that the most recent efforts to establish placebos as “active” agents would join forces with parallel efforts to legitimize other treatment modalities that are thought by devotees to be efficacious but have as yet failed every effort to empirically prove such efficacy. “The Power of Nothing” by Michael Specter in the 12 December New Yorker reports favorably on the rise of “an anti-technology, anti-science feeling in the west”, the “merging of conventional and alternative therapies” and the expansion of “science” from the material into the supernatural domain. These trends are heavily supported by the National Institutes of Health. The goal of such support is “nothing less than a transformation of American medicine” by understanding and applying “the complex biology of the placebo response” in order to “make people feel better”.

Toward this goal we supposedly need to “broaden the definition of healing” and believe that “objective data should not be the only criterion for doctors to consider”, so that placebos and other alternative therapies can be used as “active” treatment modalities without concern for proved efficacy even if used in a “pious fraud”.

With this in mind, the physician of the NIH-idealized future will be justified, even commended, in prescribing any modality – conventional, placebo or “alternative”, proved or not – that makes the patient “feel better”. Such an enlightened physician would have a fuller understanding of “the relationship between rationality and feeling and between science, critical thinking, and the art of medicine”. He would understand how he himself is an active placebo-like treatment agent, a Shaman-like figure who treats not just “disease” but “illness” using the “rituals” of enlightened care firmly convinced “I am a damn good healer”. “Because, in the end, it isn’t really about the needles. It’s about the man.”


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