It's common knowledge now that antidepressants are no better than placebo for the majority of patients. It's true that antidepressants successfully treat depression. The problem is that sugar pills ("placebos") also successfully treat depression, and the sugar pills are about as effective as antidepressants, without any of the drugs' side effects.
Irving Kirsch, a researcher who pioneered the use of meta-analysis in studying antidepressants, writes about the chimera of antidepressant effectiveness in his book. Kirsch's main argument is that placebos are effective treatments for depression, and that antidepressants add very little except side effects.
After analyzing 38 clinical trials involving more than 3000 depressed patients, Kirsch found that only 25% of the benefit of antidepressant treatment was due to the drug effect. The placebo effect, the patient's hope that he will improve from treatment, was twice as powerful as the drug effect.
When analyzing the data, Kirsch also found that the newer antidepressants (e.g. SSRI's) were no better than the older antidepressants. Even more surprisingly, he found that sedatives, barbiturates, antipsychotic drugs, stimulants, opiates, and thyroid medications were as effective as antidepressants in treating depression. The only thing that these drugs have in common is that they produce easily noticeable side effects. Kirsch explains that in a clinical trial, patients are randomly assigned to either a treatment (drug) group or a placebo group. If the patient knows that he's been assigned the drug, he'll feel more hopeful and optimistic--i.e. he'll feel less depressed. Since the studies are supposed to be double-blind, the only way the patient can know this is if he gets side effects. If he tells his doctor about the side effects, then the doctor will also know that he's been assigned the treatment. The doctor may have a different attitude toward the patient if he knows that he's been assigned the treatment. So the supposedly double-blind study isn't really double-blind. That's the reason why the other drugs also were effective for depression. Any drug that causes side effects will make both the patient and doctor more confident and hopeful, since the side effects make them know that the patient is receiving the actual treatment. The placebo effect, not the chemical action of the drug, treats the depression.
As part of his research project, Kirsch used the Freedom of Information Act to obtain unpublished clinical trial studies from the FDA. Combining this data with the published studies, Kirsch found that the drug effect was less than 20%. By contrast, the drug effect for pain medication is about 50%. Kirsch also found that the therapeutic effect of antidepressants, unlike most other medications, is not dose dependent. Higher doses of antidepressants produce more side effects, but don't reduce the symptoms of depression more than lower doses.
These above-mentioned results were well known by researchers, regulatory agencies, and drug companies, but not by most doctors and patients. Pharmaceutical companies have used some tricks to keep this "dirty little secret" from the general public, including:
1) Withholding negative studies from publication
2) Publishing positive studies multiple times
3) Publishing only some of the results from multi-site studies
4) Publishing data that was different from what they submitted to the FDA
Why were the drugs approved, when they show so little benefit over placebo? Regulators only require two clinical trials having positive results. Negative trials don't count. Drug companies can conduct as many trials as they want until they find two with positive results. Kirsch calls this "voodoo science." It makes things too easy for drug companies.
In the last three chapters, Kirsch discusses at length the placebo effect. Placebo effects are examples of how suggestion can change how people feel and behave. Expectancies are important in placebo effects. If people expect to get better, depending on how strong they believe this, and what kind of disorder they have, there's a chance that they will get better. Depression and pain are two disorders that respond well to placebos.
Since placebos work so well for depression, why not prescribe placebo pills to depressed patients instead of medications? Placebo pills are cheaper and don't have any side effects. Kirsch argues that this is wrong because it involves deception. A better alternative is psychotherapy, especially cognitive-behavioral therapy. Therapy is the "quintessential placebo," a treatment that utilizes the placebo effect (i.e. the relationship between therapist and client, and the client's expectancies of getting better), but does so without deception. Psychotherapy has a number of advantages over medication, including no side effects, reduced likelihood of relapse, and less long-term cost.
One problem with this book is that Kirsch seems to think that placebos will effectively treat all kinds of depression, including the more severe kinds. He acknowledges that the placebo response is reduced for the most severe types of depression. In other words, medications are more effective relative to placebos for the most severely depressed. He explains this by saying that because the severely depressed patients are more likely to have been on antidepressant medication before, and have higher dosages prescribed, they can more easily recognize whether they are on the actual drug or placebo. This will reduce the placebo effect for those assigned the sugar pill, which means that the drug effect is really a placebo effect in disguise. I don't agree with this explanation. I think that some of the severe types of depression are biologically based, not responsive to placebos, but responsive to antidepressant medication.
In conclusion, "The Emperor's New Drugs" is an excellent account of the ineffectiveness of antidepressants, written by a pioneering researcher. It makes one wonder how so many people were fooled for so long into thinking that antidepressants treated patients by correcting chemical imbalances. Its weakness is that the author doesn't distinguish between the majority of cases of mild to moderate depression in which drugs are no more effective than placebo, and the small number of biologically-based more severe cases in which placebos aren't effective, but drugs are.
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