Here's the scoop...
I'm starting with the New York Times article "Do Antidepressants Work," dated 12 March 2018.1 According to that article, "the effectiveness of antidepressants was limited for those with moderate depression, and small for those with severe depression."
The New York Times seems to have been careful in understanding what the concerns were. One of the issues brought up in this first analysis2 is as follows:
Research trials (74 of them) submitted to the Food and Drug Administration (FDA) indicated that
About half of the trials had “positive” results - i.e. the antidepressant performed better than a placebo, and
The other half of the trials had “negative” results - the antidepressant performed no better than or worse than a placebo.
Research papers that are part of the published literature (in journals, etc.) indicated that
Most of the "positive" results trials were published in journals.
Only three of the 'negative" results were published in journals. Twenty two other trials with "negative" results were not published.
Some (11) of the trials with "negative" results were published in journals but adjusted to sound as if they were positive results.
The public doesn't generally read research trials submitted to the FDA. The public does however read or reference articles published in journals. From the public's point of view, the overwhelming information in published literature is that antidepressants work, but that's misleading because we only see those "positive" results in articles published in journals that we the public see the most.
We are being fed incorrect / incomplete information, because that's the information that's most easily accessible.
The second analysis3 looked at was about whether antidepressants worked better than placebos. According to that analysis
"The new-generation antidepressants do not produce clinically significant improvements in depression in patients who initially have moderate or even very severe depression." In short, the antidepressants don't work much better than a placebo.
"[The antidepressants] show significant effects only in the most severely depressed patients. The findings also show that the effect for these patients seems to be due to decreased responsiveness to placebo, rather than increased responsiveness to medication." Or, when the antidepressants do work better than the placebo, it's because the placebo effect isn't working very well, not because the antidepressant is a good one.
I suppose that this is somewhat good news for severely depressed people, but it's hardly a ringing endorsement for antidepressants.
One useful finding in this study is that extremely depressed patients are less responsive to a placebo than less severely depressed patients, but have similar responses to antidepressants. It is not clear what value this knowledge is though.
What about further research ?
The New York Times article continues to discuss the matter and includes other studies. Discussed also are concerns about who does the studies, which ones are released to the public, the size of the trial group, and how long the study goes on for.
We can decide to be paranoid about drug companies et al, but that's a non-productive stance, and the New York Times suggests that any bias is minor. I'm willing to assume that most of the persons involved in research on mood swings are doing their work in good faith and looking out for the interest of us bipolar and depressed people.
Severely Depressed get the most bang from antidepressants. That's good. It's not clear how much help though. That's not so good.
The New York Times article summarises the issues as follows:
"The bad news is that even though there were statistically significant differences [between antidepressant and placebo], the effect sizes were still mostly modest [basically, the antidepressant works only a little bit].
The benefits also applied only to people who were suffering from major depression, specifically in the short term. In other words, this study provides evidence that when people are found to have acute major depression, treatment with antidepressants works to improve outcomes in the first two months of therapy." [but there isn't much information past two months].
Because we lack good data, we still do not know how well antidepressants work for those with milder symptoms...especially if patients have been on the drugs for months or even years...
Bold text is mine. [Text in square brackets are my comments]
1 The referenced online article Aaron E. Carroll, 'Do Antidepressants Work?' New York Times, https://www.nytimes.com/2018/03/12/upshot/do-antidepressants-work.html (accessed 22 January 2019) also appears in print: Aaron E. Carroll, 'New Study Tilts the Debate Over Antidepressants', New York Times, New York Edition. 13 March 2018. Page A15.
2 Turner, E. et al. 'Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy', New England Journal of Medicine, Vol. 358. no. 3, 2008, pp. 252-260. https://www.nejm.org/doi/full/10.1056/NEJMsa065779 (accessed 22 January 2019)
3 Kirsch, I. et al. 'Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration', PLoS Med 2008 Feb. 5(2): e45. Published online 26 Feb 2008. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2253608/ (accessed 22 January 2019)
Caution: Antidepressants here means antidepressants, and NOT all of the various drugs that we take. Meds such as mood stabilisers, anti-epileptics, anti-anxiety, muscle relaxants, etc. do NOT fall under this discussion. We are looking only at those that mostly affect serotonin and dopamine.
What Should you Do Now?
Follow your Psychiatrist...
The New York article indicates that taking antidepressants gives ambiguous results. You may not like that conclusion, but there aren't many alternatives. As spotty as their capability are, antidepressants still work better than most alternatives. They are worth taking just in case you are in the fraction of people that are helped by the medications.
One thing you should definitely do is to work closely with your psychiatrist. If you have concerns about whether your meds are working well or not, your psychiatrist is likely to be a good resource - they can suggest alternative medications and they should have information about possible problems that taking new medications may cause.
You will probably be annoyed and frustrated with the lack of progress of the existing medications in stabilising your mood swings. But regardless of what you do, stay in touch with your psych. You can't fix a problem if you cut yourself off from one of your resources.
Don't always expect your meds will work well.
Keep a Mood Chart!
Pay attention to what is happening to you!
You will NOT be able to take the meds and just chill. Because your antidepressants may not work as well as you will like (or at all), you will need to actively monitor what the meds do to you. This means you are going to have to set up and keep a Mood Chart to see what effect they have over time.
In this way, you will get to check what is happening, and you will have documentary evidence to show to your psychiatrist and your family and friends when you tell them that you need to make adjustments to your meds.
And yes, this process of trial and error is time consuming and NOT AT ALL FUN. I know. Nevertheless, persevere.
I personally think the current
medical model for Depression is wrong.
Although this has nothing to do with the earlier discussion, I am reminded that I have a (minority) opinion that believes that the current medical model for dealing with mood swings is wrong. I think that's why the existing meds don't work very well.
I'd love to find persons who are doing alternate research on the biological models for depression and mania, particularly those who are looking at the spectrum of disorders that include epilepsy and near equivalents. My theory is that depression and mania are a brain's reaction to an epileptic type cascade of electrical impulses in the brain.
If anybody is doing any information on this, could you please let me know. Much appreciated.
END
first published 22 Jan 19
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