Turning to the drugs, what can they really do for us?
What about the other arguments against the drugs? Irving Kirsh points to the placebo effect; in a placebo control trial, drugs are not much more effective than a placebo. But do these placebo control trials work? When really struggling, who would sign themselves up to such a trial? If a friend of yours was struggling would you suggest they sought help in a system where they might only receive a placebo? It is unlikely. We see the outcome of this bias quite conclusively; patients in placebo control trials tend not to look like normal patients in the clinic. In general the patients in a trail are not very depressed. The placebo effect is strong. In the placebo control trial, the placebo is effective at reducing depression. This makes it very hard for the antidepressants to perform better than the placebo. Should we be surprised by this? Perhaps not; with a short term, mild illness, doing anything is likely to be good. If we take a cohort of severely depressed patients, the drugs do work substantially better then the placebo. Go one step further and take a group of dsythmia patients, i.e. patients with chronic, long term, mild depression and the placebo does very little for them, while the antidepressants continue to have a significant effect. So Professor Cowen summaries, we should only be giving antidepressants to those who have chronic or severe depression. Doctors should think carefully before prescribing antidepressants. This is not, however, an easy decision to make. In primary care it is not easy to decide what severe or chronic is.
Before closing Professor Cowen turned his attention to another side of the placebo effect story. The press and the public loved Kirsh’s work. They jumped on the idea that Antidepressants were ineffective. The media headline ran “buck up you Prozac people.” Why were we all so excited to hear that antidepressants didn’t work? For one we no longer trust drug companies, but there is more to this. Professor Cowen pointed towards the strong stigma towards Antidepressants. There is stigma surrounding depression and the suggestion that this can be cured by a sugar pill, well it pours fuel on the fire. None of this helps the severely depressed individual and we must remember amongst all of this that many patients hate taking drugs – it is deeply unpleasant to feel reliant upon medication. You wonder each day, ‘what exactly would I be like if I didn’t take these pills? Would I still be me? Would I be a different me?’
SRSH would like to thank Professor Cowen for his insightful and empathetic talk.