Antidepressants and Placebos

I’ve been diagnosed with depression close to 15 years.  Like anything my mind becomes focused on, I’ve studied to a fair extent the subject of depression and the issues related to it.

Depression is a rather odd phenomena.  In some ways, it’s a socially acceptable mental disease.  Severely depressed people often look and act completely normal.  Unless someone is bi-polar, they won’t have any extremely noticable shifts in mood or behavior.  I know that I’m extremely capable of hiding my depression and no one would know if I didn’t tell them.  And yet it can be severely debilitating.  Because a depressed person may appear completely normal it makes it all the more challenging.  The depressed person can hide their illness which will just make them feel more isolated.  It’s extremely common for people to kill themselves, and afterwards their friends and family didn’t even know the person was unhappy.

It’s in ways just like life in general except magnified.  Depression has become a very popular disease considering how many people are on antidepressants.  In the past, people suffered and that was the way it was.  But I suppose such things as school shootings have made many people realize that private problems easily turn into public problems.  Depression is probably over-diagnosed and it makes sense.  Everyone wants to be happy.

Unfortunately, there is no effective happy pill.  Here are some links about research, analysis, and commentary on the effectiveness of antidepressants:

http://en.wikipedia.org/wiki/Placebo#Depression

http://en.wikipedia.org/wiki/Antidepressant#Review_studies

http://ajp.psychiatryonline.org/cgi/reprint/159/1/122

http://ajp.psychiatryonline.org/cgi/reprint/159/5/728

http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045

http://content.nejm.org/cgi/content/abstract/358/3/252

http://www.chelationtherapyonline.com/technical/p58.htm

http://www.time.com/time/health/article/0,8599,1717306,00.html

http://psychcentral.com/blog/archives/2008/02/26/antidepressant-data-showed-not-as-effective-as-thought/

Basically, antidepressants are only significantly effective for the severely depressed and even then it’s questionable.  They help some people, but not most.  Most people taking antidepressants probably might as well be taking sugar pills.

Research, however, is complex.  It’s hard for even research scientists to determine effectiveness.  Simply being involved in research causes a placebo effect.  The doctor is a placebo effect.  The hospital is a placebo effect.  The drug companies themselves are a placebo effect.  Generally speaking, new drugs are the most effective not because of better research but simply because they’re new and their effectiveness lessens the longer they’re on the market.  I’m not saying drugs are useless, but all of this is particularly true for antidepressants.  The drug companies have had a hard time finding antidepressants that work much better than a placebo.  Even considering the best antidepressants, most of the effectiveness comes from the simple placebo effect of being given a pill by a doctor.

This leads to a moral conundrum.  A placebo is probably most effective when someone doesn’t know it’s a placebo (although there is research that shows that even when a doctor tells a patient they gave them a placebo they can still sometimes gain benefit from it, but research also shows that the effect of a placebo goes down after the patient is informed).

Anyways, antidepressants are big business.  If I remember correctly, they are the most widely prescribed of the mental health drugs.  But I doubt doctors tell their patients about the questionable effectiveness of antidepressants before prescribing them.  They do work at least as placebos and so what is the harm?  It’s a moral question and depends on what are your moral values.  Does a doctor have the moral responsibility to always tell the truth?  There are plenty of cases, for example, where someone health quickly diminishes after getting a negative prognosis.  The relationship between doctor and patient isn’t an objective reality.  Most of the help a doctor can offer is simply himself, his presence and authority.

Nonetheless, one of my biggest moral values is truth.  To me, this has more to do with authenticity than honesty per se, but it’s hard to be authentic if you’re not telling the truth.  Can a doctor be authentic in caring about a patient while lying to them?  Is deception appropriate as long as it’s done with paternalistic good intentions?  Basically, should a doctor treat a patient like an equal human being or like a child?

Many people would say it doesn’t matter.  A doctor should do whatever helps.  The problem is that it isn’t always clear.  Deception can have negative effects if, for instance, a patient discovers the deception.  If the patient loses faith in the doctor or in doctors in general, then the whole placebo effect goes out the window.

Even this post brings up a moral issue.  Any person who reads this, will likely have an increase in doubts towards the effectiveness of drugs.  Placebos are given to patients all of the time without the patients knowing.  How do you actually know anything your doctor prescribes for you is actually an active drug?  You don’t.  And even if you’re taking a real anti-depressant, it might be no different from a sugar pill.  A depressed person who learns of these facts will probably experience less effective treatment by being prescribed antidepressants.  This post itself is a nocebo.