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Why we are sceptical of antidepressant analysis

Fluoxetine antidepressant pills
‘My GP prescribed fluoxetine and it was this medication which enabled me to return to work full-time.’ Photograph: Joe Raedle/Getty Images

It was disappointing to read such an uncritical description of the latest analysis of antidepressant trials that does not address doubts about the widespread use of these drugs (The drugs do work, says study of antidepressants, 22 February).

The analysis consists of comparing “response” rates between people on antidepressants and those on placebo. But “response” is an artificial category that has been arbitrarily constructed out of the data actually collected, which consists of scores on depression rating scales. Analysing categories inflates differences. When scores are compared, differences are trivial, and unlikely to be clinically relevant.

Moreover, even these small differences are easily accounted for by the fact that antidepressants produce more or less subtle mental and physical alterations (eg nausea, dry mouth, drowsiness and emotional blunting) irrespective of whether or not they treat depression. These enable participants to guess whether they have been allocated to antidepressant or placebo, thus enhancing the placebo effect of the active drugs. This may explain why antidepressants that cause the most noticeable alterations, such as amitriptyline, appeared to be the most effective.

“Real world” studies show that people treated with antidepressants have poor outcomes and fare worse than depressed people who do not receive antidepressants. Increased prescribing will do more harm than good. Adverse effects include sexual dysfunction, which may occasionally persist after the drugs are stopped, agitation, suicidal and aggressive behaviour among younger users, prolonged and severe withdrawal effects and foetal abnormalities. The costs of encouraging more people to consider themselves as flawed and diseased are hard to quantify.
Dr Joanna Moncrieff Reader in critical and social psychiatry, University College London
Dr Hugh Middleton FRCPsych, University of Nottingham
Co-chairs, Critical Psychiatry Network

• Your article was disappointingly uncritical. There are already 65 million prescriptions a year in the UK, double the rate of 10 years ago. One in 13 men, and one in seven women, are already receiving these drugs. Yet your article suggested more people should be on them.

It is easy to artificially and temporarily lift mood with chemicals, but chemicals cannot address the many social causes of human distress. The idea that antidepressants are treating a chemical imbalance that somehow causes depression has recently been debunked as a drug-industry-created myth.

Neither the paper nor your article report any of the long list of serious adverse effects which lead most people to throw these drugs away within the first few weeks. For example, my own 2014 study, the largest direct-to-consumer survey to date, found that more than half reported emotional numbing, sexual difficulties, and withdrawal effects. Suicidality as a result of taking these drugs was reported by 39% and a reduction in positive feelings by 42%. More balance please.
Professor John Read
University of East London

• Your article on depression was of great interest. I was a consultant clinical psychologist in the NHS for 37 years, and took early retirement 10 years ago, because I could. In 1999 I suffered my first episode of severe clinical depression and was off work for three months. At that time I read Lewis Wolpert’s very full account of his own clinical depression, Malignant Sadness, which I found immensely useful and enlightening. Indeed to describe clinical depression as a malignant form of sadness is entirely appropriate. My GP prescribed fluoxetine and it was this medication which enabled me to return to work full-time. During the rest of my career in the NHS I had repeated episodes of clinical depression which were successfully treated with fluoxetine, and during those 10 years I only took a further three months off work.

I retired in 2007 and since then I have been taking fluoxetine daily. However, just under three years ago this medication was becoming less and less effective, and I saw a psychiatrist privately. I was prescribed reboxetine to take in addition to fluoxetine, which not only had extremely unpleasant side effects but actually made the depression worse. I came off reboxetine after only three months and within 48 hours was feeling back to normal.

Since then I have continued to take fluoxetine daily, and again it has ceased to be completely effective. My excellent GP, who has supported me throughout the past 20 years, has prescribed mirtazapine, 15mg taken at bedtime, and this has been very successful.

I know I can only speak from my own personal experience, but I see no difference between taking antidepressant medication and taking, for instance, calcium channel blockers to control hypertension.
Name and address supplied

• Depression may be one of the world’s biggest “under-treated” illnesses, but we also need to dig a little deeper and ask what are the underlying driving forces behind the epidemic. It is due, in large part, to winner-takes-all capitalism and the poverty, inequality and dissatisfaction it cultivates. On top of colonialism and buccaneering capitalism, the last thing the world needs is for us to export our broken mental health treatment model. Drugs have their place, but the evidence from thousands of clinical trials is clear: mindfulness meditation is at least as good as drugs and counselling for the worst forms of depression. And spending just 10-20 minutes a day practising a simple breathing meditation will help reduce the anxiety, stress and unhappiness that so often precedes depression.
Dr Danny Penman
Co-author of Mindfulness: A Practical Guide to Finding Peace in a Frantic World and The Art of Breathing

• Big pharma must be rubbing their hands with glee at the report about the effectiveness of antidepressants. George Monbiot’s article on Frome in Somerset (Journal, 21 February) highlighted the physical health benefits of a vibrant caring community, which must surely be extended to mental wellbeing.

I wonder what the beneficial effect on depression levels would be if we lived in a more equal society, where community resources are not ravaged by the policies of austerity. Meanwhile drug companies pump out the soma and make their billions, numbing the senses of many.
Howard Yardy
Llangeitho, Ceredigion

In the UK, Samaritans can be contacted on 116 123. In the US, the National Suicide Prevention Lifeline is 1-800-273-8255. In Australia, the crisis support service Lifeline is on 13 11 14. Other international suicide helplines can be found at www.befrienders.org.