Attacks on antidepressants: signs of deep-seated stigma?

Psychiatry is used to being attacked by external parties with antidiagnosis and antitreatment agendas. However, the recent disclosure that a doctor (Professor Peter Gøtzsche) had joined a new group, the Council for Evidence-based Psychiatry, whose launch was accompanied by newspaper headlines such as “Antidepressants do more harm than good, research says” and “Psychiatric drugs are doing us more harm than good” in The Times and The Guardian plumbs a new nadir in irrational polemic. What is especially worrying is that this doctor is a co-founder of the Nordic Cochrane collaboration, an initiative set up to provide the best evidence for clinical practitioners. What is the truth about antidepressant effi cacy and adverse eff ects, and why would Professor Gøtzsche apparently suspend his training in evidence analysis for popular polemic? Depression is a serious and recurrent disorder that is currently the largest cause of disability in Europe and is projected to be the leading cause of morbidity in high-income countries by 2030. Antidepressants have an impressive eff ect size in the treatment of acute cases of depression, with a number needed to treat of around six. For example, the recently updated Cochrane review of amitriptyline, which involved 18 randomised controlled trials and 1987 participants, shows that it is signifi cantly more eff ective than placebo in achieving acute response (odds ratio 2·67, 95% CI 2·21–3·23), and that signifi cantly fewer participants allocated to amitriptyline than to placebo withdrew from trials because of treatment ineffi cacy. How can this fi nding represent more harm than good? A smaller proportion of treated patients withdrew because of side-eff ects and the pattern of results was the same in industrysponsored and independently funded trials. Indeed, in general, eff ect sizes for psychiatric indications do not diff er from those of drugs used in physical medicine. Moreover, antidepressants have an impressive ability to prevent recurrence of depression, with a number needed to treat of around three, which makes them one of the most eff ective of all drugs. Suicide kills about 6000 people every year in the UK. Most of these people are depressed and more than 70% are not taking an antidepressant at the time of death. Blanket condemnation of antidepressants by lobby groups and colleagues risks increasing that proportion. In countries where antidepressants are used properly, suicide rates have fallen substantially. Of course, all active drugs have adverse eff ects, but for the new antidepressants these are rarely severe or lifethreatening, even in overdose situations. Indeed, the new antidepressants, especially the selective serotonin reuptake inhibitors, are some of the safest drugs ever made. In our experience, the vast majority of patients who choose to stay on them do so because they improve their mood and wellbeing rather than because they cannot cope with withdrawal symptoms when they stop. Many of the extreme examples of adverse eff ects given by the opponents of antidepressants are both rare and sometimes suffi ciently bizarre as to warrant the description of an unexplained medical symptom. To attribute extremely unusual or severe experiences to drugs that appear largely innocuous in doubleblind clinical trials is to prefer anecdote to evidence. The incentive of litigation might also distort the presentation of some of the claims. Antipsychiatry groups usually claim that depressed patients should be treated with exercise and psychotherapy instead of drugs. However, little controlled evidence exists to support the use of psychotherapy as an alternative to antidepressants in major depression. Indeed, if psychotherapy had to be tested according to the same rules as drugs, then whether or not it could be licensed for this indication is questionable. Moreover, the implication that, unlike antidepressants, psychotherapy is free of adverse eff ects is highly misleading. Suicidal ideation and even completed suicide are recognised adverse eff ects with psychotherapy, and sexual interference with patients by therapists is a matter of concern. Finally, exercise treatment, as the recent Cochrane review concludes, ”is moderately more eff ective than a control intervention for reducing symptoms of depression, but analysis of methodologically robust trials only shows a smaller eff ect” and exercise is no more acceptable to patients than are psychological or pharmacological treatments. What motivates doctors with a commitment to evidence-based practice to make such a series of fl awed statements about antidepressants? We can only speculate. First, general practitioners (GPs) clearly see a lot of patients with minor somatic and Lancet Psychiatry 2014