SEVERAL perennial controversies are being given fresh impetus by news that antidepressant drugs may help only a small number of those who are prescribed them.
Irving Kirsch鈥檚 team at the University of Hull, UK, reviewed nearly 50 studies of the efficacy of four widely prescribed antidepressants. In a paper published in PLoS Medicine last week, the researchers conclude that the drugs work only in the most severe cases, with little difference otherwise from a placebo. The drugs are Eli Lilly鈥檚 Prozac, GlaxoSmithKline鈥檚 Seroxat, Bristol-Myers Squibb鈥檚 Serzone and Wyeth鈥檚 Effexor.
Drug companies have challenged the finding, with one spokesman saying that the study was based on a small subset of early pre-approval data. But this is not the only study of its kind. In January, US researchers reported that the effectiveness of 12 antidepressants has been exaggerated, because trials with negative or questionable results were not published ().
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One of the controversies concerns the best way to treat depression. For Kirsch the implication is clear. As he puts it, 鈥渄epressed people can improve without chemical treatments鈥�. The British government shares that view: it recently announced that over the coming three years as a preferred alternative to drug treatment.
Oceans of ink are quite rightly spilled on the related questions of what depression is and how it is best treated, a subject that encompasses equally great oceans of human suffering. There is a simple-seeming question at the heart of this controversy which, surprisingly, has not yet been satisfactorily resolved. It concerns the supposed difference between depression as unhappiness prompted by the social, economic and personal problems that an individual might face, and psychological pain and dysfunction arising from clinically detectable pathology or trauma. Is there a real difference between the two, or is there a continuum? Is it tenable to continue with the assumption that a neat dividing line exists between psychology and physiology?
鈥淥ceans of ink are spilled discussing what depression is and how to treat it鈥�
This is not just the old mind-body debate. Even if mind is nothing other than the output of the brain鈥檚 activities 鈥� as surely it is 鈥� there is still room for people to take sides on whether medication or talk is the answer to life鈥檚 painful discontents. With cognitive therapies proving their worth, and doubts being raised about antidepressants, it is easy to forget that drugs are also a powerful tool for psychiatrists tackling problems other than depression.
Another controversy surrounds the suggestion made by critics of pharmaceutical companies, sometimes with justification, that they manipulate data in order to protect profits. in the last decade, and one of the main areas of increase relates to children. Very serious questions would need to be asked if it is true that antidepressants are ineffective for all but the worst cases, and if the drug companies know this.
But alongside this important point let鈥檚 not forget the fact that pharmaceutical innovation is hugely expensive and time-consuming, and that modern drugs have saved and extended lives mightily. This is not an excuse for malpractice, but a contextualising remark intended to restrain any reflex hostility to 鈥渂ig pharma鈥� on the alleged grounds that it puts profit irresponsibly before truth or life. Without profits it could not do research, and without research it could not contribute, as it clearly has done, to human welfare. In the debate to come about Prozac and the rest, let us get the facts right.
Read all of A. C. Grayling鈥檚 articles here
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