“A dangerous idea!” That was the response after a presentation I gave to a small group of academic leaders with an interest in psychopharmacology [over 15 years ago].
What evoked such a response? The acknowledgment that most currently available antidepressants specifically treat only one out of four patients with major depression based on the bulk of clinical trials data.
There was no argument about the accuracy of this statement, but…some claim it is “dangerous” to admit that the specific response rate to most antidepressants is 20%–30% because such an acknowledgment might undermine the value of antidepressant treatment.
By the “specific” response rate Preskorn means the number of depressed people who’ll get better on antidepressants and who wouldn’t have done so well on placebo. This rate is fairly low because, while most people get better on antidepressants, most of those improve on placebo as well.
Preskorn rejects the view that it’s dangerous to acknowledge this:
…there are several problems with this reaction. First, it is hard to deny reality. The “placebo” response rate in antidepressant trials is arguably the most reproducible finding in psychiatry. Moreover, if available antidepressants were magic bullets, then polypharmacy would not be so common. Second, this reaction ignores the fact that antidepressants are tremendously valuable to the patients who specifically benefit from them…
Every treatment in every area of medicine has limitations. Acknowledging that fact should galvanize us to action. Denial on the other hand perpetuates the status quo.
Unfortunately, we’re not told who these academic leaders were. I wonder if they included amongst their ranks some of the “key opinion leaders” in the field whose leadership proved rather less than ideal. The column is actually adapted from a 1996 article by Preskorn.
Preskorn is right, of course, that denying the fact that antidepressants are only substantially better than placebo in a fraction of people who get diagnosed with “depression” is wrong, and also misses the point: because hundreds of millions of Americans have diagnosable depression (due to the loose definition of “depression”), even if they only helped 1% of them, they’d still help over a million people.
But he doesn’t mention that this approach was ultimately self-defeating. As a result of the failure to acknowledge that antidepressants are only helpful in some cases of depression (namely “severe” depression), these drugs became very widely used and – oh dear – people started saying that the drugs are being overused, and don’t work in most people who take them.
Whoever could have seen that coming.
This has “devalued” antidepressants – and psychiatry itself – more than anything else has.
Preskorn SH (2011). What Do the Terms “Drug-Specific Response/Remission Rate” and “Placebo” Really Mean? Journal of psychiatric practice, 17 (6), 420-424 PMID: 22108399