The Atlantic web site has just published a strange piece on the efficacy of the antidepressants. When getting into a discussion with about antidepressants with a supporter of the drugs the first thing to figure out is: Are they going to talk about science or anecdotes? Ten-years ago the proponents usually talked all about science and evidence based medicine. If you brought up an anecdote you were considered non-scientific. But the tables are now turned. Now that the science is showing that the once presumed efficacy of the SSRIs is questionable, the proponents are relying more on anecdotes. Given the fact that the likes of Kirsch, Whitaker, and Angell have been focusing on the science it would seem that someone who disagrees with their arguments should really focus on the science and not just throw out another anecdote. Don’t look for a discussion about the science in the latest Atlantic article written by Maura Kelly.
Right after the title, before even getting to the article, there is a header that shows that the author doesn’t even really understand what the debate is about. Kelly says, “But just because some people are taking SSRIs that don’t need them doesn’t mean that the drugs don’t work.” No one – not Kirsch, Whitaker, or Angell, has ever equated the idea that lack of efficacy in an individual person means that the person is not depressed. They all acknowledge that depression is real and that treatment is appropriate. The problem is that the SSRIs don’t appear to work very well. To question the utility of SSRIs in no way automatically equates to the idea that depression is not real. How could such an obvious error in logic make it into the Atlantic.
The article is interesting if one looks at it as one person’s experience with depression and recovery, but it adds very little to the discussion about the efficacy of the SSRIs. It is simply a personal testimonial to one SSRI success story. Of course, the SSRIs have worked for some people, even in the Kirsch meta-analysis they worked for some people. Scientists argue about the number needed to treat for the SSRIs, or the percentages, but very few people say it is zero. So the fact that out of the millions who take SSRIs there are some success stories is not surprising. No one is arguing this. But, the reality is that they haven’t worked for everyone.
The subtitle of the Atlantic Piece is: Antidepressants really help people. But if you really want to prove this then the way to do it is to talk about the science and not another anecdote. Rather than try and stack up anecdotes on each side and see which side is higher – which is what is going on in the comments section of the Atlantic article – a scientist designs an experiment to move the discussion forward. This is exactly what the companies did with their controlled clinical trials which they submitted to the FDA to get their drugs approved. And at first glance the studies seemed to say that the drugs worked, so everyone trumpeted the studies, and the drugs got approved, and the marketing departments did their job, and all in the name of science the drugs became a financial success. Then along comes Kirsch who simply looked at the studies in a more detailed approach and showed that the initial conclusions were a little premature. Keep in mind all he did was look at the same studies which were submitted to the FDA. He did exactly what a scientist is supposed to do. His studies highlight the fact that the drugs don’t work for a whole lot of people. Kelly, is now saying to forget the science, they worked for me.
No doubt, that for every legal and illegal drug being sold on the market or on the street, one can find users who will highly recommend the drug. But is this a reason to take it? In fact, most of those addicted to an illegal drug probably first took the drug because they heard from a friend how great it was. But wouldn’t these people have been better off if instead of listening to anecdotes they listened to science? Should people pondering the use of an antidepressant not be told about the science?
Consider her proof that the drugs work. She doesn’t cite studies, or data, but mentions some experts: “Luckily, I’m not the only one convinced of the good they’re doing.” She goes on to cite several psychiatrists who wrote into The New Review of Books to criticize Angell. Dr. John Oldman wrote in and said, “The bottom line is that these medications often relieve the patient’s suffering,” and Dr. Daniel Carlat wrote, “on the whole, they work.” But missing from the Atlantic Piece is Angell’s reply, which starts off with: “… these letters simply assume that psychoactive drugs are highly beneficial, but none provides references that would substantiate that belief. Our differences stem from the fact that I make no such assumption.” From there, Angell basically destroys the letter writers’ arguments.
Kelly also cites Peter Kramer who attempted to salvage the reputation of the SSRIs in the New York Times. According to Kramer, the main problem with the Kirsch study is that he based his work on the FDA database, which is nothing more than a collection of faulty trials. So because the trials were faulty we can forget the science and go back to anecdote. However, in the past, when the trials were in vogue, Kramer had a different stance. In his 2005 book Against Depression, he said “Antidepressants have proved effective in large scale multi-site trials whose results have been published in either way, pro or con.” In other words, when people thought the clinical trials supported the use of the SSRIs they were good trials. But now that a more in-depth analysis of the trials has revealed that there is little difference between drug and placebo, the trials should be considered irrelevant?
On the surface, instead of moving the discussion along in a scientific manner, the Atlantic piece simply harkens back to the days of anecdotes. At a deeper level it is highlighting the fact that the scientific justification for the SSRIs is on shaky ground.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.