Iconic Films

2 for 1 tickets to Casablanca, this coming Monday

Navigation - link to other main sections from here

From The Times

February 28, 2008

If it's all in the mind, fine

There's a lot about depression we don't know. So if placebos work, we should be happy

Camilla Cavendish

My first reaction to this week's front-page headline, “Depression drugs don't work”, was surprise. I took Prozac only once, but it was transforming. I know several people who have found the same. One believes that it saved her from suicide. Her depression has been, at times, a crippling illness.

My second reaction was alarm. No sooner had the new study come out than it was being presented as a morality tale of corrupt pharmaceutical companies marketing ineffective drugs to a population of the worried well who should bloody well be pulling their socks up. The “no pain, no gain” lobby were out in force, claiming that depression serves a useful purpose, because it tells us what we need to hear if we are to fix our lives. I wonder if they've ever had to live with a sufferer. Real depression is a state you can't just drag yourself out of. Clearly, drugs work only for some people. But should we deny anyone the chance to see if they are among the lucky ones?

I read the University of Hull study. It analyses the clinical trials of six new generation anti-depressants called SSRIs (selective serotonin reuptake inhibitors), carried out before those drugs were licensed. Using unpublished data that the manufacturers had sat on, the researchers concluded that these drugs worked no better than a placebo for the majority of patients with moderate depression, and only marginally better for those who were severely depressed. It is damning stuff.

It doesn't mean that no one got better. Many did. But the control group did almost as well on placebos, which duplicated “more than 80 per cent of the improvement seen in the drug groups”. Even among the most severely depressed, who were less responsive to placebos, the improvement in the control group was still “significant”. This compares, the authors say, with the placebo effect on pain which “is estimated to be about 50 per cent of the response to pain medication”. Wow. If placebos are so good at relieving pain, and even better at relieving depression, why aren't we studying placebos?

There is clearly a great deal we still don't know about the brain. So while it is disgraceful that the authors had to fight pharmaceutical companies to get unpublished and unfavourable data, I am still not sure that the industry is defrauding the public by pushing happy pills. As the Harvard psychiatrist David Healy pointed out in Let Them Eat Prozac, different personalities react to different pills in vastly different ways. Some people spring back to life and others slump. The problem with Hull's meta-analysis is that it obscures individual variations by lumping all the data together. It doesn't tell us that no drugs work for anyone, but nor does it shed much light on what works for who.

I found a US study called Star*D, funded by the respected National Institute of Mental Health, which has followed 4,000 patients for seven years. Thirty per cent of these recovered on the first drug and another 21 per cent after changing drug. A 50 per cent cure rate looked good to me. But that research has been attacked for not including placebos, which some psychiatrists say would have had a similar effect. According to a Canadian task force, “spontaneous remission can occur over six to twelve months in up to 50 per cent of affected people”.

So what are we to believe? On the one hand we have people clearly crippled by depression. On the other we have people bouncing back to health with no help. There is clearly a confusion between depression and sadness, a normal human response to difficulties that doesn't need to be medicalised. Every doctor I have talked to thinks that medics have become slap-happy about happy pills. They turned from Valium to SSRIs because they were less addictive. But should we go as far as Irving Kirsch, from Hull, when he asserts that “there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients”, when we still seem to know so little about how these pills work and on who?

Sixteen million prescriptions for antidepressants were written in the UK last year, for 3.5 million people. That's a lot. But 38 million prescriptions were written for antibiotics, of which a higher proportion were probably unnecessary. And antibiotics have terrible side-effects. They have bred resistant bacteria that are killing people in hospitals. Yet I haven't heard anyone argue that a good dose of flu makes you a better person, or that we should restrict antibiotics only to people with pneumonia.

It is the eagerness to stigmatise antidepressants that makes me wary. It is easy to forget how revolutionary these drugs have been. In the 1960s the first generation of antidepressants released hundreds of thousands of people from the hell of mental hospitals. The idea that depression was a chemical imbalance in the brain that could be treated was a liberation. Prozac becoming a household name has been an enormously powerful way to reduce the stigma of mental illness.

Having read the research, I suppose my own boost from Prozac was a placebo effect. If so, I guess it'll never work for me again. But bravo the placebo, while it lasted. I didn't need to wait two years for therapy on the NHS: I needed a quick fix to regain equilibrium. I dislike our tendency to moralise about people who occasionally want a short cut to deal with reality. Britain's traditional approach to self-medication is alcohol: I have seen the effects of that, and I would take the happy pills over that any day. Even if their benefits are all in the mind.

"Real depression is a state you can't just drag yourself out of."

Oh no? That's not actually true. I suffered a period of depression as an adolescent, but it did eventually pass, with a great deal of effort and work. But there were no drugs involved, and when I have, since then, felt it creeping up again I developed the mental tools myself to be able to deal with it.

Incidentally, I did try councelling whilst at university. It was utter nonsense, didn't tell me anything I didn't already know and was no help at all.

I am not suggesting that those who are severly and chemically depressed should not have drugs or receive counselling. However it is important to have mental control techniques, and plenty of awareness of how the patterns of your mind can lead you to good or bad places, whether one is depressed or even just miserable.

GB, London,

Good article.

Strange though, how there's a lot of 'slagging-off' of depressives, anti-depressants and the doctors who minister this stuff just at a time when, HEY! the government wants to get millions of depressed 'shirkers' back to work . . . I wonder if there is any connection between the 'slag-off' merchants and trendy, cognitive therapists that are going to line they're pockets out of all this misery?

It's enough to make you depressed, to be frank.

G.Morgan, Oxford

Mr G.P. Morgan, Oxford, UK

Eat more and hotter curry. That cures everything, but you may have to go to the loo more often.

m wilson, bidache, france

A very well-balanced article. I have been using anti-depressants as a supplement to counselling, and I have no doubt that they are helping me to function well.

Rod, Kelso,

Of course homeopathy is no more than a placebo. But if its use significantly reduces the time spent by GPs and consultants on difficult to treat non-life-threatening conditions (e.g. moderate depression), and the patient feels she has improved, where is the problem?

Calum Jones, London, UK

I was diagnosed with clinical depression a few years ago and found it was the combination of antidepressants and therapy which helped. Later I came across Neuro Linguistic Programming which has helped me immeasurably, not only by giving me tools and techniques to improve my life, but helped me to realise that while I may not be able to control all that happens in my life I AM in control of how I choose to respond.
"There are no resistant clients, only incompetent therapists" - Richard bandler, co-originator of NLP.

Peter, Birmingham, UK

I'm saddened by this research. I can only say that my partner has been prescribed two sets of anti depressants. The first set of tablets worked for two months then he started to slide back into depression. When he changed to the second ones they worked perfectly, helping him to deal with the depression whilst he waited for counselling and for 9 months afterwards. After 2 years he is now strong enough to come off them and now he is weaning from them he is beginning again to suffer (much reduced) symptoms. In the light of this, I cannot see how it can be placebo after one false start and the reaction even now the "root causes" have been addressed. I hope, as many others have said, that those who do find benefit from these pills continue to take them for as long as they as individuals need.

Alison, salford, UK

I agree that depression is a chemical imbalance in the brain. However, drugs are foreign chemicals to the brain and break up the natural chemical reactions forming around our brain. No-one person is going to react to certain drugs as their genetics and diets play a part which is probably why only a certain amount of people become better. The best way to heal yourself is through healthy food.

Marie-Claire Oliver, Bath, United Kingdom

RR, sack your psychiatrist and replace him/her with somebody who is has the skills to help you with a broader range of meds and has a knowledge of CBT, art/music/drama therapy, meditation, exercise, sleep and diet. Your psychiatrist is blaming you for his/her inability to help. Physiotherapists do not blame their patients for being "non-compliant" when their manipulations do not alleviate their patients' pain. I experienced clinical depression and was "sacked" by my psychiatrist for being "non-compliant" when I refused SSRIs that had not prevented reduced previous suicide attempts. Thankfully, I found a highly skilled psychiatrist who provided CBT, offered SNRIs when I decided I needed meds, and I met a brilliant art therapist. Other meds and/or therapy and lifestyle changes may help you. Please persist in finding what works for you. You can feel better again. Good luck.

Monica, London, UK

I believe some research has been done which suggested that the placebo effect works even if patients know that they are taking a placebo. Not a finding which the pharmaceutical industry is keen to publicize, I imagine.

Alan, Cambridge,

I'm with Camilla on this one. 'Whatever get's you through the night' - Frank Sinatra.

I was moderately to severely depressed for three years earlier this decade. Discussed it with my GP & he pointed out the risks of using the medication, so we decided I would try to work my way out of it without medication. Which eventually worked. But it took years really. And I wasn't completely nonfunctional - just close enough to perhaps understand how bad it can be for others.

Now I wonder about that decision? WHat if the doctor had lied to me and put me on a placebo? Might it have helped with no risk? Or would I have looked it up on the internet and tumbled to the deception? Probably the latter.

Don , Ipswich,

Before the new antidepressants were introduced to clinical practice they should have been approved by the Medicine Control Agency. This regulatary body will have received all the studies, negative and positive, in order to make their judgement. Since they issued a licence they must have considered the SSRIs to be more effective and/or safer than existing medications.

anthony byrne, camberley,

The trouble is that you can only kid yourself if you imagine that the pill you're taking is the real stuff. Once you know it's a placebo, the placebo effect simply won't work. Of course, some psychiatrists may have a bit of a vested interest in all this. Or will you accuse me of being revoltingly cynical?

Maggie, Crouch End , England

Better than Placebo, no better than Placebo ...? These comparisons are meaningless without an understanding that Placebo is a complex multi faceted variable ranging from positive to negative ('Nocebo'). What matters to a patient is whether he or she feels better or worse after treatment and that is what our health system has always been about, whether we are talking about homeopathic treatment or the likes of Prozac. Meta analyses like the Hull study may be useful in helping scientists better understand the mechanism of action of a particicular treatment perhaps leading to improved treatments emerging in the future but they can be both misleading and dangerous if used to vilify or outlaw established treatments given by responsible health practitioners and which help patients now.

John K.H. Cook, Wirral, England

I think somewhere in the maelstorm of this write up with all its pros and cons, we seem to have detoured or gone haywire with the topic....Do anti-depressent drugs work or not, or they simply act like some palcebo.Well..if it's all in the mind,we don't need a team of clinical psychologists and medical researchers working hard and high to understand the intricacies of our human mind and various mental disorders. I don't want to advocate any such drug be it "Prozac" the wonderdrug of our times, valium or some anti-depressants. The moot point is, when a person is afflicted by depression or some psychotic disorder, his brain chemistry goes haywire and shows clinical anomalies. The flow of neuro-transmittors and various other blood secretions like endophrines get inhibited, causing changes in mood, thought formation and a state of melancholy and depression.Scientific results show that such drugs augments free flow of such natural anti-depressant secretions in our body,Pills do work!!

sandy, New Delhi, India

has anyone taken time to consider the damage the public denouncement of these drugs will have on those who were reaping some benefit from them? if they were helping keep a loved one calmer and more controlled one must ask what will happen to them now? will the people who publicised these findings give an alternative that will be as affordable? or will the media who so doggedly report all news with scant regard for public safety or care? if suicide rates soar in the next 6 months will these people feel guilt or will they puff out their chests and arrogantly state they were revealing the truth? i think not but then i don't count do i....i'm just a member of the public.

mike c, banbury, uk

Camilla is hot!. She could take me out of any depression.

Raza, Karachi,

For the love of Pete! It's no wonder that GPs cannot convince their patients that they don't need antibiotics for flu when the population are still fed such misinformation by the press. I have lost count of the amount of times doctors have tried to explain, slowly now: antibiotics only work on bacterial infections. Flu is caused by infection with a virus. Antibiotics do not work on viral infections.

Patients are overprescribed anitbiotics by doctors who are frankly exhausted trying to make this distinction and have given up. Do we really want this to be the case with pharmaceuticals that can dramatically alter someone's mind??

Neil, NY, US

Rubbish! Homeopathy IS placebo - the dilution is such that there is NOY ONE active molecule left in the liquid given to the patient.
Whereas SSRIs DO have an effect - users almost always report sensations indicating a change in brain chemistry - feelings like jet lag, muzziness, detachment etc. until after they stabilise and usually feel calmer and "lighter". Speak to GPs who are delighted to be able to give something safe that benefits most patients.
Meta-studies are OK but the individual tests and their differing methods are lumped together smearing the results together into a middling blandness.
Scientific and rational scrutiny of hypothesis and data is good but don't throw out the baby with the bathwater - these pills do work and I speak from personal experience as a patient and as someone who's seen the effects on others and their doctors.
PS Doctors don't get expenses paid trips to the Caribbean and are lucky these days to get a dinner where they listen to a boring presentation!

Richard, Herts, UK

This article makes interesting reading. As a survivor of significant depression I think there are two important points.

Depression can be enhanced (?) by an imbalance of chemicals in the brain brought on by outside circumstances such as continued fear or stress. Drugs can rectify the imbalance and make the patient safer, either through direct chemical action or, as is suggested here, by a placebo effect, whereby merely taking the drugs calms the patients.

What is important to recognise is that drugs will not solve the depression. The only way that can happen is for the patient to decide to deal with it. This is perhaps the hardest part, because many of us deny the issues which are causing the depression and then fail to see how to deal with them.

Further confusion arises with people trying to help us. No one method to solve the problems we are confronted with works for every person. You must keep trying till you find the one that does. If the drugs keep you safe whilst you do, good

Neil Marshall, Doha, Qatar

I suffer from Major Depressive Order and have done for 3 years as a result of workplace bullying. I have tried antidepressants of all the major classes, but unfortunately none made any difference. The SSRIs gave me the worst side effects of all. What the drug companies also don't tell you are the debilitating withdrawal symptoms one can suffer coming off these drugs. I have been on the try this one, try that one rollercoaster ride for so long that I have at last told my psychiatrist that enough is enough. His response was that I was becoming non-compliant and not trying to help myself - like I deliberately want to my life to be living hell!!!!! The use of anti-depressants in the treatment of depression is a very inexact science. For some they are life-saving, but for many totally useless. But those drug companies continue to make billions as doctors are educated that depression is a chemical imbalance which can be fixed using their drugs. I wish they did work for me though...

RR, Adelaide, Australia

When a meta-analysis appears claiming to show that homoeopathy (for example) is all placebo, many readers pile in with ridicule and vitriol saying what a waste it is of NHS money.

The same people should now write in and say the same thing about SSRIs. As should doctors who normally get together and write in that complementary medicine shouldn't be funded.

But they won't, because ineffective pills from pharmaceutical companies don't challenge their belief systems, and if the doctors shut up they will still get all their expenses paid to conferences in the Caribbean to be informed about the latest drugs being peddled.

I'll tell you one thing: homoeopathy is a damn sight cheaper and has very few side-effects. Yes, homoeopathy does have some side-effects, because it isn't just placebo. So I'll say it for the people I mentioned above: stop funding horrendously expensive drugs and spend NHS money on cheap complementary medicine, which is much better value and slightly more effective.

Jack, London, England

Also in Camilla Cavendish

Also in Columnists

Times Recommends

OUR COLUMNISTS

Camilla Cavendish

Camilla Cavendish has been a McKinsey management consultant, an aid worker, and CEO of a not-for-profit company. She is now a leader writer and columnist on The Times