Do the drugs work?

I was struck the other day by the reporting in the press of an academic paper on antidepressants and their impact [1]. According to these reports antidepressants were now officially verified as very effective and should be taken by more people. But was this really what the study was saying? This is the story.

In the paper Cipriani et al (2018) argued, on the basis of a systematic review of the evidence, that: ‘All antidepressants were more efficacious, though some more efficacious than others, than placebo in treating adults with major depressive disorders’.  There were important qualifications. The review was looking at short-term effects; it was not being claimed that anti-depressants worked better than other treatments; gains came with side effects; the gains were at times modest. But nonetheless there was an impact. There was less about implications for practice in the paper so I went to the press release from the University in which the lead author was based to see if I had missed something. In the release the implications were summed up as:

‘Antidepressants can be an effective tool to treat major depression, but this does not necessarily mean that antidepressants should always be the first line of treatment. Medication should always be considered alongside other options, such as psychological therapies, where these are available. Patients should be aware of the potential benefits from antidepressants and always speak to the doctors about the most suitable treatment for them individually.’ [2]

The reporting in the press was however quite different from this press release and can best be described as victory narrative about the power of science to solve whatever ails us, in this case major depression. This narrative was carried across the UK press and, I think, was taken up internationally as well. To turn to the UK, the left leaning Guardian proclaimed in an opinion piece: ‘It’s official: antidepressants are not snake oil or a conspiracy – they work’. The author of the piece summed up the research by saying ‘we should get on with taking and prescribing them’ [3]. The Times led with ‘More people should get pills to beat depression. Millions of sufferers would benefit, doctors told’ [4]. The Independent went further ‘Doctors should prescribe more antidepressants for people with mental health problems, study finds’. And the same article went as far as to claim ‘Research from Oxford University, which was published in The Lancet, found that more than one million extra people would benefit from being prescribed drugs and criticised “ideological” reasons doctors use to avoid doing so.’[5]. This left the Mail, which can usually be relied upon to offer the most far-fetched take on evidence based practice, looking quite mainstream. It suggested that ‘Millions MORE of us should be taking antidepressants: Largest-ever study claims the pills DO work and GPs should be dishing them out. [6]

I have nothing of value to say about the treatment of depression [7] but I am familiar with systematic studies, particularly in education. Their obvious value is that they tell you something really useful about the sweep of evidence (here that antidepressants tend to work better than placebos) and their scope makes their findings intuitively convincing (Cipriani et al aggregated over 500 studies and included over 100,000 patients). Systemic reviews are not however reliable guides as to what to do in individual cases as they are focused on the general picture. Further, systematic review might establish a measure of correlation but doesn’t tend to engage deeply in saying why doing X might work better than doing Y. Systematic reviews are only as good as the studies they aggregate. Here some argue that the whole field of medical research is distorted by pharmaceutical funding which makes any reported research unreliable. However this was not the stance of Cipriani et al and their research was independently funded. Instead a more widespread criticism of systematic review is that the case studies they access are often stilted to showing impact quite simply as the ones that show no impact are a lot less interesting to write, let alone publish. At least this is how it often looks in education.

Whatever we think about systematic review, the press went way beyond what was presented in the Cipriani et al paper and, in doing so, exaggerated the strengths of systematic review. We can put forward different reasons why this happened. Some [8] would see this as the influence of vested commercial interests but more likely in this case is that a big and wild claim was more likely to catch readers’ attention than a small and balanced one. I also think that reporting of anything that comes out of academic research is distorted by a desire to believe that there are simple solutions to complex problems when clearly there are not. So in one sense over-inflation of academic findings should be expected but what most disappointed me was the uniformity of the response. A head of steam was built up around the unqualified efficacy of antidepressants which was not the story in the original research.

Before moving on from this story, I became interested in the way that the press reports had been discussed in the online comments sections. The comments turned out to be civil and insightful, at least more so than I had predicted. There were blanket statements condemning pharmaceutical companies and accusations that the authors were part of a conspiracy to have us take drugs for private profit. However there was no shortage of people giving balanced and insightful accounts of their own experiences of antidepressants. In fact these experiences tended to be positive though writers were at pains to say this was their personal experience and they could not generalise for others. It was a case of the comments doing a better job than the reporting and I wonder whether this was because the politics of the issue did not follow predictable lines and this allowed a greater degree of openness.

References

[1] Cipriani A, Furukawa TA, Salanti G, et al. Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis The Lancet. Published online February 21 2018

[2] University of Oxford Antidepressants more effective in treating depression than placebo,

http://www.ox.ac.uk/news/2018-02-22-antidepressants-more-effective-treating-depression-placebo

[3] Rice-Oxley, M. (2018) It’s official: antidepressants are not snake oil or a conspiracy – they work. Guardian [online] https://www.theguardian.com/society/2018/feb/21/its-official-antidepressants-are-not-snake-oil-or-a-conspiracy-they-work

The paper’s regular health correspondent (Sarah Bosely) concluded along the same lines that ‘The drugs do work: antidepressants are effective’. Guardian [online] https://www.theguardian.com/science/2018/feb/21/the-drugs-do-work-antidepressants-are-effective-study-shows

What I found misleading here, and in other press reporting, was that commentary about the Cipriani et al paper was mixed up with a comments by other experts on the widely acknowledged lack of support for people with depression. The implication was that to be critical of the study was to condemn people to untreated depression.

[4] Smyth, C. (2018) More people should get pills to beat depression, Millions of sufferers would benefit, doctors told. Sunday Times [online]

https://www.thetimes.co.uk/article/more-people-should-get-pills-to-beat-depression-sv5vhczss

[5] Khan, S. (2018) Doctors should prescribe more antidepressants for people with mental health problems, study finds. Independent [online] http://www.independent.co.uk/news/health/antidepressants-prescribe-mental-health-problems-oxford-university-lancet-a8222371.html

[6] Pickles, K. (2018) Millions MORE of us should be taking antidepressants: Largest-ever study claims the pills DO work and GPs should be dishing them out. Mail [online]
http://www.dailymail.co.uk/health/article-5419967/Millions-taking-antidepressants.html#ixzz58mtfeilm

[[7] If you have a special interest then go to the NHS Choices Review of Evidence aimed at practitioners and the general public. They conclude from reading Cipriani et al that:

People are more likely to see their symptoms improve if they take an antidepressant than if they take a placebo. The researchers said the effects of the drugs were “mostly modest” and noted that antidepressants are just one of several evidence-based treatments for depression.

They also comment that Cognitive behavioural therapy, rather than antidepressants, remained the first-choice treatment for people with mild symptoms. This however was  not a concern of the study itself.

NHS Choices (2018) Big new study confirms antidepressants work better than placebo [online] https://www.nhs.uk/news/medication/big-new-study-confirms-antidepressants-work-better-placebo/

[8] A full on critique of the research and its reporting was offered in particular by Dr Joanna Moncrieff who appeared on television and wrote to the papers offering her objections. To get a flavour go to the blog Mad in America below where she is interviewed by James Moore. [online]

https://www.madinamerica.com/2018/03/dr-joanna-moncrieff-challenging-new-hype-antidepressants/