How antidepressants can help

The first sentence of Martin Thomas’s article, "How capitalism makes distress" (Solidarity 659), could be a case study in how socialists shouldn’t write about medications:

“Around 10% of people in richer capitalist countries are on antidepressants, though they usually do no better than placebo” (emphasis added).

Martin’s ham-fisted side comment — the second clause — in an otherwise good article, is both false and — despite intentions — dismissive.

The article Martin cites itself states that they are “slightly more effective than a placebo” for “most people”, and cites a study that “for 15% of people antidepressants provided large benefits independent of the placebo effect”. For people struggling with depression, any “slight” help — on top of an already considerable placebo effect — cannot be simply dismissed as nothing.

The British Medical Journal (BMJ) paper that the more sensationalist Economist article Martin read cites finds that “mean difference between drug and placebo favoured drug... Differences between drug and placebo increased significantly (P &#60 0.001) with greater baseline severity [i.e. worse initial depression].” The BMJ’s paper states clearly that “meta-analyses have [already] confirmed that antidepressants have greater efficacy than placebo, but the mean difference is small”.

A more adequate coverage of the BMJ paper than Martin’s sentence would recognise several important things.

Assuming — not uncontroversially — that the “trimodal model” of response distributions that this particular BMJ metastudy uses is valid, it shows that 24.5% of people got a very large improvement in depression on drugs (15% more than placebo), only 12% saw “minimal” improvement (9% less than placebo) — with most having an improvement somewhere in the middle. Furthermore, without this assumption, or with a different one, the distribution of the significant benefits of antidepressants above and beyond placebos may well be more uniform. The paper’s authors themselves recognise its limitations. Another limitation in generalising from its findings is that “about 78% of patients with major depressive disorder are excluded from typical clinical trials”. Such limitations should caution against sweeping simplistic generalisations.

The BMJ article considers only studies (submitted to the USA’s FDA) of antidepressants on their own, against depression. But antidepressants can be used to treat other conditions, including OCD, anxiety, PTSD, and some chronic pain. Martin’s misreading of the facts could not be automatically extended to other conditions.

The NHS states that “[i]t’s not known exactly how antidepressants work.

“While antidepressants can treat the symptoms of depression, they do not always address its causes. This is why they're usually used in combination with therapy to treat more severe depression or other mental health conditions.

“Research suggests that antidepressants can be helpful for people with moderate or severe depression. They're not usually recommended for mild depression, unless other treatments like talking therapy have not helped.

“If you take an antidepressant for 4 weeks without feeling any benefit, speak to your GP or mental health specialist. They may recommend increasing your dose or trying a different medicine.”

That is, they should be used to complement other treatments, not on their own; they should generally only be used with those for whom their benefit beyond placebo is, on average, greater — and for whom the need is greater; and a different drug should sometimes be tried where they have a limited impact. The BMJ study recognises that different antidepressants have different levels of efficacy above and beyond the placebo. Some people may respond better to some and worse to others; switching may allow an even greater net benefit beyond placebo.

A major study in The Lancet found that “[a]ll antidepressants were more efficacious than placebo in adults with major depressive disorder”. It recognises that many stop taking antidepressants, and for different reasons: such as getting side effects, and without sufficient benefit to deem it worth continuing. It emphasises that there are complex trade-offs to be made by clinicians prescribing — and patients taking — each, or any, antidepressant.

It recognises at the top that “because of inadequate resources, antidepressants are used more frequently than psychological interventions.”

Both the BMJ and Lancet articles are serious metastudies. The Economist’s back-of-an-envelope tallying up of a number of published and unpublished trials, each counting as one result, is not.

We seek to build a society that ends many of the driving forces of misery. Short of, and as part of fighting for that, we seek an expansion of health and social care. Therapy and other non-pharmacological interventions which are currently underfunded, hard to access, and insufficient, would be much more readily available. These social changes would reduce the burdens of depression, anxiety, PTSD; would reduce the need for antidepressants; meanwhile increasing their efficacy when used. There would be increased support for helping people to come off them, safely, and in a timely manner.

There are many drawbacks of antidepressants, from side-effects to dependency. Medical practitioners should not prescribe them lightly, and — I believe — for the most part, don’t. None of my friends who I’ve talked to about their taking antidepressants found the decision an easy one. If misplaced prescription of antidepressants is a significant problem in the UK, it is almost certainly due primarily to lack of wider support to make them redundant. More evidence — which the BMJ article may help contribute to — may allow more targeted, and so more effective, treatment. Under-treatment of serious depression certainly is a serious problem.

A dismissive attitude towards antidepressants — common on much of the left — is not only false and simplistic, but harmful. We can critique the social causes of depression, and the insufficient non-pharmacological support, without dismissing pharmacological support. Antidepressants are by no stretch of the imagination a sufficient answer to depression, but that does not mean that they aren’t — for some people in some situations — part of the answer. We can critique for-profit pharmaceutical R&D without binning their findings.

How will the perhaps 10% of those reading Martin’s false sentence who take antidepressants to feel? For most of them these evidence-based medications will have been a significant and real help, for a debilitating condition. We should not say: “you were foolish to take them”, “your GP was foolish to prescribe them”, or even “you should stop taking them”. Nor should we seek to deflate the very real placebo component of their benefit. We should recognise the complexity of the situation, and what we don’t know as well as what we do.