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Are antidepressants the answer for depression?

Wednesday, 16 April 2008

Dr Jon Jureidini, Adelaide psychiatrist, writes:

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Some psychiatrists have been slow to acknowledge research evidence raising questions about the effectiveness of antidepressants in treating depression.

In the face of such research, some have been arguing that increased treatment of depression in Australia has resulted in decreased suicides.

One prominent advocate of this argument is Professor Ian Hickie. But the conclusions that be drawn from the studies he uses in support of this argument are weak.

Ecological studies look for an association between measure suicide rates and antidepressant usage at a population level. Cohort studies compare suicide levels in patients with and without various treatments. Ecological and cohort studies cannot show cause and effect, and there is no ecological or cohort study suggesting a protective effect for antidepressants that cannot be balanced with a study of similar methodology that shows the opposite.

There is no convincing evidence that antidepressants reduce suicide. There is convincing evidence that they increase suicidal behaviour in younger patients.

We can not be confident about which patients, if any, should receive antidepressants, but we can be confident that many people who are prescribed antidepressants should not be.

So why are some psychiatrists continuing to promote antidepressants so enthusiastically? And why don’t we have better quality evidence to guide our treatment of depression?

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Ian Hickie, Brain & Mind Research Institute Wednesday, 16 April 2008 3:40:29 PM: It's always a pleasure to have Dr Jureidini comment on my advocacy for increased treatments for depression. Hopefully, it will enourage those with a serious interest to go to the primary sources. Additionally, those same people may not fall for the simplistic argument that if it was not shown in an RCT involving small numbers of individual subjects (ie that increased treatments for depression affect national suicide rates), then it did not happen. As in much public health (eg does smoking reduction reduce lung cancer incidence?) one relies heavily on population-based studies - not just individual clinical trials. For those interested in these issues, I'd recommend W. Hall et al BMJ 2003 for the review of the Australian data. As a co-author of the paper, I'd point out to Dr Jureidini and colleagues the conclusion that we drew with regards to the overall positive effect of providing all treatments (not just medicines) on suicide rates.
Embi Wednesday, 16 April 2008 3:42:07 PM: The problem in many cases is trying to identify whether the depression is "mild", "moderate" or "severe". Neither I nor my doctor, family or friends appreciated how severely depressed I was until I attempted suicide. I was getting up each day and going to work and talking to people - so everyone, including me, assumed my depression couldn't be too severe. I had been off my antidepressants for about six months and gradually sunk into a pit of despair that all the talking therapy couldn't get me out of. Antidepressants have been a literal life-saver for me and I worry that this study means they may be denied to someone who like me presents "too well" in the future. I agree that antidepressants alone aren't the answer but let's not throw the baby out with the bathwater. Perhaps the answer is to prescribe properly funded counselling and medication at the same time. I suspect, however, that society would bulk at the cost of this.
Sally Goldner Wednesday, 16 April 2008 3:59:25 PM: Embi, I'm with you. From a personal perspective: I'll save space and refer to my blog http://seeresssally.blogspot.com/2008/03/drugs-legal-ones.html rather than reprint here. Another perspective (by far NOT the only one) is elimination of social stigma against marginalised groups. Research by the Australian Research Centre in Sex, Health and Society (Writing Themselves in Again, Tranznation) found a direct correlation between discrimination and risk factors ranging from suicide, through depression to substance abuse and general anxiety. Vichealth I believe has similar research on racial and cultrual discrimination. And I'd guess it's another of the factors facing indigenous communities too.
Stephen Thursday, 17 April 2008 1:11:00 PM: Bio-psychiatry has for years oversold the potential benefits of anti-depressants, invoking the fear of suicide as a powerful means to stifle debate. The evidence now tells us that the suicide rate is not affected for or against by the prescription of anti-depressants, since suicide is both a complex phenomenon built on multiple causative pathways and its incidence in terms of statistical significance is (thankfully) rare. That is, generalisations don't fit. Governments should adopt an evidence-based approach to mental health treatment, accepting that the status quo reliance on psychotropic medications has been an abject failure. What we need is a whole-of-life mental health promotion strategy, one that encourages resilience and ameliorates those social factors that contribute to mental ill health.
Jon Jureidini Thursday, 17 April 2008 2:57:02 PM: Perhaps Ian Hickie could clarify where in the Hall BMJ paper we can find "clear cut evidence" (his words) that increased treatments for depression in Australia has resulted in decreased suicides in Australia (rather than evidence of an association).
ian Hickie Thursday, 17 April 2008 10:30:43 PM: It seems we are now going to have an argument about association versus causation. Does smoking 'cause' lung cancer or heart attack? is there clear evidence that the reduction in smoking rates has led to reduced deaths from lung cancer or heart attack - or are these major public health successes merely associations? If one accepts that we have clear cut evidence of the benefit of reducing smoking, then i would argue that we have clear evidence of the benefits of treating depression (and as we stated in Hall et al BMJ 2003, not merely using medicines to treat depression).
peter Thursday, 17 April 2008 11:55:12 PM: Another study Mr Hickie, this time at Florida State University also just stated that there is little scientific evidence that depression is caused by a chemical imbalance as you have no idea how the mind works. And why do you continue to push anti -depresants even on 2-3 year olds when it is stated that that you don't know what causes deppresion.?A drug didn't cause the problem so a drug won't fix it. Drugs that are proven more and more to cause suicide... fact. If psychiatrists really knew how the mind worked and how to really counsel people ,they wouldn't have to get medicated, in some cases for life ,with their problem still existing would they?They would get better quickly rather than be stuck in the mental health systemand on a life genrally of anti-depressantsStop pushing drugs Mr Hickie can you quickly explain the difference between the mind and brain?
kurt Friday, 18 April 2008 6:51:51 AM: I would say that Anti-d's have a place in treatment of depression but are not THE treatment for depression. Psychiatry and Psychology for that matter haven't come up with treatment for disappointment, rejection etc so they lump it into one amorphous tag of "depression", then the very experinces of life become medicalised. Not many people are depressed they are more disappointed and all those associated feelings. The alternatives though are labour intensive talk therapies and in this economic world it's not economic to do so. Anti-d's are more the "Codral for the mind", soldier on. Ian Hickie can mention the suicide rate if he likes and has an very, very strong incentive to do so but he speaks of it in isolation from other social trends like alcohol and drug use, family breakdown, the increased acceptance of gay and lesbian people ( a huge implicator in suicide that the medical profession doesn't speak of). Maybe we should change the definition of depression, then less people would be
Jon Jureidini Friday, 18 April 2008 2:11:54 PM: Ian Hickie claims that doubting the evidence of the benefits of treating depression is tantamount to denying that we have clear cut evidence of the benefit of reducing smoking. Careful, consistent epidemiological evidence leads us to conclude that reduction in smoking rates has led to reduced deaths from lung cancer. 1. Could Dr Hickie please specify what exactly is the equivalent evidence (ie, the data from Hall's study or elsewhwere) about the benefits of treating depression? 2. And what contrary findings would be considered sufficient to change his conclusions? (Prediction: Dr Hickie will not answer my specific questions.)
ian hickie Friday, 18 April 2008 5:05:03 PM: in reply to Dr Jureidini: 1. consistent epidemiological evidence (i understand that this website has my 700 word response for later posting) 2. consistent epidemiological evidence of no effect or of an opposite effect (Prediction: no evidence of the effect will ever change Dr Jureidini's interpretation of that data)
kurt Friday, 18 April 2008 6:10:14 PM: Come on boys play nice.
Melissa Raven Saturday, 19 April 2008 11:11:25 AM: A question for Ian Hickie: Is there a causal relationship between antidepressant prescribing rates specifically (not depression treatments generally) and suicide rates at the population level?
Neil Cole Saturday, 19 April 2008 3:40:52 PM: Jon Jureidini discussion of evidence of suicide omits any discussion of Lithium.. It is not strictly an anti-depressent, the principles of causation are similar. Lithium, which I have been on for fifteen years, in "Manic Depressive Illness" Jamieson and Goodwin, is proven categorically that it reduces aggression in people who have bi-polar disorder therefore reduces the risk of suicide. The increase in diagnosis, reduction in stigma, and increase in prescription of lithium must have had an effect on suicide rates over the last ten years. Certainly on aggression. The causal relationship between suicide rates and anti-depressents seem to me a logical rather than an evidentiary question. They take away suicidal ideation in most people... they certainly do in me and take me out of deep state of melancholia. They tend to reduce suicidail ideation, in my case they help and in many others I know. The evidence with Lithium on agression and suicide is unequivocal.
Melissa Raven Monday, 21 April 2008 6:01:45 PM: Ian Hickie claims increased depression treatments reduce suicide rates, based on consistent epi evidence. But consistency of association is only 1 of Hill's 9 criteria for causal inference – and the evidence is NOT consistent. Safer & Zito 2007: 'ecological data linking reduced suicide trends to increased antidepressant use support, at best, a weak hypothesis. There is no consistent ecological pattern of completed suicide in relation to SSRI usage. Conclusions based on such incomplete data appear to be more polemical than a balanced and cautious scientific statement'. Wheeler 2008: data don't support claims reduced use increased suicidal behaviour. Simon 2008: 'Treatment is probably too sporadic to affect overall suicide rates And in many countries declining suicide rates PRECEDED SSRI use (Safer & Zito), failing the temporality criterion Whereas concluding that an association isn't causal doesn't need consistent evidence of no/opposite effect, just a significant amount, which there
ian hickie Tuesday, 22 April 2008 9:38:37 PM: Melissa Raven suggests that treatment of depression (which is not limited to use of antidepressants) meets only one of nine of Bradford Hill's criteria for causal inference in epidemiology. In my view, a considerable argument can be put for several others - notably the key features of temporality and gradient - an issue we addressed in detail in Hall et al 2003 (all nine include: strength, consistency, specificity; temporality, biological gradient, plausibility' coherence, experiment and analogy). The increase in suicide in youth groups where treatments have now gone down adds further weight to the temporal argument. However, perhaps we should leave the key statement to A.B. Hill "all scientific work is incomplete...that does not confer upon us a freedom to ignore the knowledge we have, or to postpone the action that it appears to demand at a given time". Although some don't like it, continued treatment of depression in Australia saves lives everyday.
james rose Wednesday, 23 April 2008 8:41:21 PM: a good reference on SAMe in depression is by Teodoro Bottiglieri in American journal of Clinical Nutrition, 76 (2002 supplement ) pp. 1151-7S title S-Adenosyl-L-methionine etc. . See http://www.ajcn.org/cgi/content/full/76/5/1151S See also later blog listing.
james rose Wednesday, 23 April 2008 9:29:29 PM: A good reference about use of SAMe in depression, is an a review article by Teodoro Bottiglieri, at http://www.ajcn.org/cgi/content/full/76/5/1151S this is just one of the nutrient substances, normal parts of our body's metabolism, which have proven useful in treating depression. A good general overview of the use of nutrients in the treatment of depression from the Pfeiffer treatment Center can be read at http://www.hriptc.org/BioTreatment.html
neil cole Wednesday, 7 May 2008 10:55:59 AM: I beleive that anti-depressents are a big part of the answer. All the evidence done beyond the drug companies suggest they are the front line treatment. What is happening here is that our deisre to show how much we hate multinationals, like drug companies, we are throwing the baby out with the bath water. I think we have to look more closely at the causes of depression, and why it has proliferated so much, rather than saying anti-depressents are not the answer! Is it not possible that people are very depressed and they need the medication, so let's ask why and not simply say it's all the drug companies pushing their drugs which is usually the underlying assumption.

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Are antidepressants the answer for depression?

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