Antidepressants Don't Work. Sorry.

Are antidepressants effective? The definitive answer from a recent review seems to be "no". Antidepressants are typically no better than placebo and when they are better, the effect is tiny. And antidepressants often have unpleasant side-effects.

Why did we think otherwise? Why did we think Prozac, say, was a wonder drug, when in fact it has very little antidepressant effect? Why did people think it changed them?

The simple answer is bias. Biased studies, produced by biased researchers, published in biased journals, reviewed by biased editors and reviewers. Bias is very difficult to eliminate. In this case the drugs were very expensive to develop and test. So the temptation to exaggerate the effect was enormous. This was mainly done by not reporting studies that showed no or negative effects. But some of the studies were poorly designed and also allowed bias to creep in. Whether this was deliberate or unconscious is another matter. The fact is that bias was an important factor in the science of these drugs.

And this was backed up by the usual media hysteria about wonder-drugs. The media are a particularly pernicious element in this situation. Even more than the big pharmaceutical companies they are invested in bias. News media bias is towards any story that will provoke strong emotions, especially anger, disgust, fear, or lust. And if a promising story doesn't quite make the grade it can easily be sensationalised so that it does the job. Prozac became a sensation for precisely this reason. A lot of false information about "happy pills" circulated and the general public became thoroughly misinformed on the subject of antidepressants.

And because of the bad science and the media hype the people prescribing these drugs were already biased when they started dishing them out and this meant they were more likely to focus on apparent successes and less likely to even see apparent failures. Many people prescribed the drug were not really depressed. So a bit of placebo was all they needed to feel better.

All this adds up to a massive misunderstanding. We had to wait for a whole new generation of scientists to be hatched and start questioning the orthodoxy. Which is what is happening now.

I used to be a firm believer. I bought the chemical imbalance narrative of depression and the drug treatment option. I took various drugs for decades. But they didn't really work. I still got depressed. I still got suicidal (despite being on two antidepressants). It's facetious, but there is some truth to the quip:

"Before you diagnose yourself with depression, check you are not surrounded by arseholes."  

Although I have some underlying pathology, the usual trigger for my depression is situational, and especially to do with conflicts in my living situation. Depression is an adaptive response to our environment. For example if it is triggered by hyper-stimulation, we may become aversive to sensory stimulation or find ourselves responding with anger to everything. Because of the distorting effect that psychoanalysis has had on our intellectual landscape we don't look for situation causes, we only look for individual psychological causes. But this is almost always a mistake. Environment, and especially social environment, is always a factor in mental illness. It is not always the immediate or necessary cause, but it is always a factor. In my case it has frequently been causal and it accounts for the underlying pathology.

So the whole long experiment with these drugs has been a misunderstanding based on bias and misinformation.

This raises the question that if ADs don't work, is there an moral argument for, say, homoeopathy? The homoeopath gives a null-treatment, delivered with conviction in a semi-ritualised context to cultivate belief. That belief in the treatment generates the placebo effect which results in a real increase in well-being!

BTW if you are taking antidepressants and this news tempts you to stop taking them, please do so gradually. Suddenly stopping them can have very unpleasant withdrawal effects. Taper off doses gradually. And let people know, because it will most likely be disturbing.

UK Government Mental Health Policy

My comment on the story in The Conversation: Many wealthy countries face a mental health crisis – here’s what governments can do. 4 August 2016.

Your policy approach is entirely focussed on after the horse has bolted. Palliative approaches are always more expensive in the long run than preventative approaches. It is better vaccinate against the disease than to wait for the epidemic and treat everyone in hospital. This is axiomatic in health care, and yet one that is almost never applied to mental health.

You say the most worrying trend is the rise of mental ill-health is in young people. But you want to wait until they are unemployed to help them. You miss the most obvious government intervention which is to introduce resilience training to schools to help young people stay mentally healthy and not succumb to mental illness. A variety of approaches are available, though most of them threaten to undermine the education system churning out obedient workers and insatiable consumers. Which may be why think-tanks and governments are unconsciously reluctant to consider them.

Secondly we need to look at underlying causes for mental illness. The most serious problem we have is social dislocation and alienation. Not only is this implicated in problems like depression, but it is also the main underlying cause of addiction problems also.

Free market capitalism is predicated on ignoring human needs in favour of profit (this was what Marc and Engels complained about 150 years ago and is just as true under the modern version). Families and communities are torn apart because investment does not go where the workers are, but workers are forced to go where the investment is. With no extended family and no community, workers are reliant on nuclear families and these cannot sustain the load - they are increasingly breaking down. Capitalism as we currently practice it is driving the atomisation of society. And the atomisation of society is driving the rise in mental health and addiction problems. At which point a welfare safety-net becomes stretched to breaking point. And at this point we watch in horror as the government begin to dismantle the safety-net, making it considerably less safe, and to demonise and punish people who use it, with the negative emphasis most on those who need the safety-net the most.

So government policy needs to invest in and strengthen local communities. And lately it has massively cut local government spending. Two 30% cuts in funding since 2010 in my county. Though in out county we are fortunate to have high employment we also have a very acute housing shortage, with attendant high housing costs and high homelessness. Local communities need to be able to provide work, housing, and social services. At present many cannot.

More and more people are struggling to afford shelter and food. The government pays out nearly £20 billion a year in subsidising rents through Housing Benefit. Meanwhile there is a chronic lack of housing, and an acute shortage of affordable housing. If basic needs are not met comfortably, then people are stressed. If they are stressed and there is no community support, then they may become mentally ill. This is not rocket science. The government needs to build 250,000 mainly lost-cost houses. But it knows that if it does this the housing bubble will collapse, the middle classes will be left with negative equity, and they will be voted out next election. So they promise to build 25,000 houses at some point in the future, at a cost of £1 billion, and proclaim themselves the party of the workers. The irony is so acute that one would impale a rhino on it.

In order to formulate effective policies any government needs to clarify whose needs they prioritise. Clearly there are many constituents, many communities, many powerful lobby groups, divided loyalties with political parties, and pressures from international trading partners. All we can hope is that the cost of mental illness becomes unsustainable and forces the government to formulate effective policies. As it is the crisis has not yet peaked and government are still betting on pandering to powerful business lobbies and the 1%. I predict it will have to get a lot worse before government take any action in the right direction, and we may continue to see effective cuts to mental health funding as in recent years.

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Note. George Monbiot has written on the same subject: Neoliberalism is creating loneliness. That’s what’s wrenching society apart. The Guardian. 12 Oct 2016.