In the week that has followed the publication and media reports of this Lancet paper, I have noticed how Psychiatry (my profession) has seemed to be struggling with any threat to its authority.
I am not part of the social media community, though some years ago I was. I left social media because it seemed to me to struggle to deal with complex matters. Too often debates centred around the poles to the detriment of the middle ground. I have observed this effect with the current debate on antidepressants following the publication of the above Lancet meta-analysis.
I have previously outlined my interpretation of what this publication can or cannot say. I was disappointed that the authors and the experts giving opinions made little effort to clarify that this study is based on short-term, 8 weeks studies for severe depression (not mild or moderate) and that it does not provide evidence for longer term prescribing. It should have also been made clear that this study was based on whether antidepressants, taken over 10 weeks were “tolerated” or not, and had nothing to say about the experience of side-effects.
Dr Margaret McCartney and Dr Mark Porter expressed similar concerns in “Inside Health” on BBC Radio 4.
Dr Mark Porter: “And talking of the real-world, the other thing that struck me about this was the average duration of antidepressants when they looked at antidepressants in the study was just 8 weeks, and you and I know that the average course, in fact the minimum course is something like 9 months”.
Dr Margaret McCartney: “Oh at least, and one of the big problems that we have, as yet unanswered, is what is the effect of taking these drugs perhaps on and off, mainly on, for years at a time and that is where we have real deficits in our information, it is really tragic that so many trials have been done looking at the short term when the real life use is of months and even of years. It is really appalling that decades have passed without us asking the fundamental question of how we are using them today and whether that is safe and effective, good practice or not.”
I believe that it is important for us to consider perspectives from generalists such as Dr Porter and Dr McCartney who are also regular commentators on a very wide-range of health issues.
In what follows I wish to present the views of the specialists in their own words:
The common theme expressed in these expert opinions demonstrates an unwillingness to consider beyond the short term. They also appear to maintain a polar position which is not helpful in encouraging reasoned debate. It would seem to me that this reflects a wish to maintain a position of authority and credibility. I find it disappointing that the language used to describe those who offer experience of antidepressants can add to the stigma which my profession is so keen to address.
I was recently involved in a Radio Scotland discussion on this subject. One of the points that I made was that we should listen to all voices, including the experts and also to those who have had experience of taking antidepressants.
The Chief Medical Officer for Scotland has launched an initiative called “Realistic Medicine“. The issue of antidepressant prescribing should be examined as part of this initiative.
Some people undoubtedly experience dependence and/or withdrawal reactions to antidepressants, which can be severe. We do not know the scale of this because of the lamentable lack of long term studies. It occurs to me that my profession may also have a problem with dependence, in this case on its authority, and faces similar challenges when this authority may be withdrawn.
Update: At the time of writing this post, 1 in 7 Scots were taking antidepressants. In the few years that have since passed, that number has risen to nearly 1 in 5.