Beyond Blue

Beyond Blue

In Defense of Antidepressants

Peter Brown, clinical professor of psychiatry at Brown University and a prominent mental health hero of mine, published an excellent piece in Sunday’s issue of The New York Times. As he has done in the past, he successfully debunks the debunkers. I think he’s improving at his game as the assaults against antidepressants grow more fierce and numerous.

Now, mind you, I consider myself very conservative when it comes to psychoactive (or psychopharmaceutical) drugs. Having been overmedicated by more than one psychiatrist in the past, I am of the opinion that a person should throw everything she has at her mental health (intense cardiovascular exercise, Omega-3 capsules, meditation and/or prayer, regular psychotherapy, a healthy diet, good sleep hygiene, light therapy, service work, and community involvement—yes, all of those) before considering antidepressants. A better diet and exercise alone may be able to repair neural circuits and brain chemistry for someone with situational or mild depression.


However, when you are dealing with the “I want to be dead” thoughts a few times every hour for months on end—and are working like hell at achieving some kind of balance in your life with the help of all the other alternative therapies—I am of the opinion that the risks of toughing it without meds outweigh the risks of taking meds when you stop to consider the increased chances a depressed person has of developing cardiovascular disease and heart attacks, the compromise to her immune system making her three times more likely to catch a cold or something worse, like shingles. And let’s not forget the devastation and disruption depression produces in a marriage and on the emotional well-being of children.

With so much literature out these days on the weak effect of antidepressants—that these medicines are no more effective than placebos–and endless reports about Big Pharma’s manipulation of drug trials, it’s difficult for the average person to feel good about taking antidepressants—even if the death thoughts occur so frequently that she has difficulty functioning at her job and making dinner for her kids.


This is where my hero, Peter Kramer, comes in … to fill in all the details that the prominent stories about antidepressants conveniently leave out. Kramer writes:

Could this be true? Could drugs that are ingested by one in 10 Americans each year, drugs that have changed the way that mental illness is treated, really be a hoax, a mistake or a concept gone wrong?

This supposition is worrisome. Antidepressants work—ordinarily well, on a par with other medications doctors prescribe. Yes, certain researchers have questioned their efficacy in particular areas—sometimes, I believe, on the basis of shaky data. And yet, the notion that they aren’t effective in general is influencing treatment.


Kramer goes on to dissect one such popular piece of research—the study that was covered in the Newsweek article awhile back (which argued psychopharmaceutical drugs were no more effective than a placebo) and the recent New York Reviews articles by former Editor in Chief of The New England Journal of Medicine Marcia Angell. The examination uses data submitted to the Food and Drug Administration in the late 1980s and the 1900s that was ill suited to answer questions about mild depression. Why? Often in FDA studies, subjects are included who do not suffer from depression. Moreover, companies that are in a hurry to get medications to market have motivation to run quick, sloppy trials. So it’s no wonder, then, that a few weeks down the road these subjects are free of depressive symptoms. Also, to get free care or incentive payments offered as part of the study, some people may exaggerate their symptoms.


Kramer probes another study by psychologist Robert DeRubeis, which graced the headlines of a USA Today piece, titled “Antidepressant lift may be all in your head.” Kramer explains:

Dr. DeRubeis, an authority on cognitive behavioral psychotherapy, has argued that the washout method plays down the placebo effect. Last year, Dr. DeRubeis and his colleagues published a highly specific statistical analysis. From a large body of research, they discarded trials that used washouts, as well as those that focused on dysthymia or subtypes of depression. The team deemed only six studies, from over 2,000, suitable for review. An odd collection they were. Only studies using Paxil and imipramine, a medicine introduced in the 1950s, made the cut — and other research had found Paxil to be among the least effective of the new antidepressants. One of the imipramine studies used a very low dose of the drug. The largest study Dr. DeRubeis identified was his own. In 2005, he conducted a trial in which Paxil did slightly better than psychotherapy and significantly better than a placebo — but apparently much of the drug response occurred in sicker patients.


Building an overview around your own research is problematic. Generally, you use your study to build a hypothesis; you then test the theory on fresh data. Critics questioned other aspects of Dr. DeRubeis’s math. In a re-analysis using fewer assumptions, Dr. DeRubeis found that his core result (less effect for healthier patients) now fell just shy of statistical significance. Overall, the medications looked best for very severe depression and had only slight benefits for mild depression — but this study, looking at weak treatments and intentionally maximized placebo effects, could not quite meet the scientific standard for a firm conclusion. And yet, the publication of the no-washout paper produced a new round of news reports that antidepressants were placebos.


In the end, the much heralded overview analyses look to be editorials with numbers attached. The intent, presumably to right the balance between psychotherapy and medication in the treatment of mild depression, may be admirable, but the data bearing on the question is messy.

Much like I, Dr. Kramer is by no means a pill-pusher. In his 1993 bestseller, “Listening to Prozac,” he wrote, “To my mind, psychotherapy remains the single most helpful technology for the treatment of minor depression and anxiety.” He believes that drugs are “permissive,” in that they remove the roadblocks to self-healing. I absolutely concur. The role of medication in my own recovery is to stabilize me enough that I can use all my other tools with more effectiveness. Psychotherapy is no good if you don’t have the concentration to have a dialogue with your therapist.


Kramer doesn’t argue that antidepressant treat all ranges of mood disorders alike—from mild, situational depression to severe major depression. He believes that drugs work best to combat the “stuckness” in a person’s brain that is preventing resiliency. His hope for future research is to identify this “stuckness” with more accuracy so that doctors know when antidepressants should be included in treatment. Says Kramer:

Better-designed research may tell us whether there is a point on the continuum of mood disorder where antidepressants cease to work. If I had to put down my marker now — and effectively, as a practitioner, I do — I’d bet that “stuckness” applies all along the line, that when mildly depressed patients respond to medication, more often than not we’re seeing true drug effects. Still, my approach with mild depression is to begin treatments with psychotherapy. I aim to use drugs sparingly. They have side effects, some of them serious. Antidepressants help with strokes, but surveys also show them to predispose to stroke. But if psychotherapy leads to only slow progress, I will recommend adding medicines. With a higher frequency and stronger potency than what we see in the literature, they seem to help.


My own beliefs aside, it is dangerous for the press to hammer away at the theme that antidepressants are placebos. They’re not. To give the impression that they are is to cause needless suffering.

As always, Dr. Kramer, thank you.

Image courtesy of Wikimedia Commons.

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  • http://AddaURLtothiscomment Mary Anne Thompson


    Ok here I go again, on my soap box. I have been a guinea pig for anti depressants, sleep aids, anxiety meds for over 20 yrs now! I have taken so many the list of which ones I have not tried would be shorter. I have been on Paxil in the past for over a yr, then it quit wking. I currently take CYMBALTA! I highly recommend it to anyone as it not only helps with chemical imbalances (SSRI) but also helps with physical pain. It is being prescribed for fibro now. I also take Klonopin (breaking the scored pills in half and taking only a 1/2) twice a day for anxiety.
    ALOT of the pills our are very dangerous, do have horrible side effects not to mention the interactions with other meds even over the counter pills or natural/herbal remedies.
    I wish the media, magazine articles would cease. Us depressants, those with bipolar disorder or worse have enough problems without being told that we are imagining them helping us. There is already such a stigma put on us who have problems which are probably caused by the water we drink (which had been proven to have Mercury and Chloride in it) the foods we eat (especially processed foods with all the chemicals and preservatives in them) the air we breathe…the aluminum and other things falling through the air from the chemtrails and being absorbed into our skin and lungs. We are lucky to still be here.
    It IS something to be depressed about if you have nothing else going on in your life that is bad. Which from what I have read here in everyone’s posts is NOT the case.
    Let’s all just keep our appts, take our Dr prescribed med’s, keep going to therapy, be here for each other…
    Put one foot in front of the other, breathe in and breathe out. That is all we can do….some days are Diamonds and some days are STONES.
    Let me close with something I heard someone say in a 12 step retreat I attended that I really liked:
    Coincidence is GOD’s wish to remain anonymous!


  • Elizabeth

    Antidepressants work. I will testify to that truth in my life against any nay sayer. I have been on Lexapro for over a year and I continue to get better and better. Therapy alone was not enough for me but Lexapro (plus some other meds that are not classed as antidepressants) help me get over being STUCK so much of the time. God bless modern medicine!

  • http://AddaURLtothiscomment Jean

    I have not found the right meds or combination of meds, for myself yet. I’m sure it’s out there somewhere, though. Today has really been one of my ‘stuck’ days – I regret not doing more with my life, not having a real career, having an unsupportive unencouraging family. You know, the usual!!
    Having read Mary Anne’s post, I might talk to my dr. about giving Cymbalta a try. Sadly, Lexapro (taken for the last year or so) has only made me very, very sleepy. Truth is, there’s no ‘one-size-fits-all’ medication for anyone….we’re all different.

  • http://AddaURLtothiscomment Kevin Keough

    This is a timely and very balanced review of the controversy surrounding antidepressants and specifically the politically correct position that they are no better than sugar pills. Actually, Kramer was extremely reserved in his critique of the literature that putatively shows antidepressants are essentially useless and comments about the prevailing politically correct public opinion that antidepressants don’t work.

    Granted Big Pharma is interested in maximizing profits with no genuine concern for people helped by pharmaceuticals that make it to market. Yes, there is corruption at every level of psychotropics from clinical trials to advertizing and more. As a medical historian Dr. Edward Shorter claimed the only real advancement in psychopharmacology since the early 1970’s are Wellbutrin and Effexor—both marginal advancements. Big Pharma has no interest in curing depression—be very clear about this reality.

    Such considerations are irrelevant to human beings whose quality of life is significantly diminished and levels of agony seem to become more severe over time till suicide seems the only “intelligent” step out of a life turned shipwreck. Antidepressants do work for lots of people. A competent and empathic psychiatrist can prescribe medications that not only keep people alive but allow them to participate a bit more fully in human experience.

    Intellectual bullies claiming expertise in psychopharmacologic research especially psychologists that place guild interests before the needs of patients ought be subject to criminal prosecution for knowingly distorting research that intends to prove antidepressants don’t work and cognitive-behavior therapy is the real messiah. People do kill themselves, marriages are ruined, relationships with children and peers become strained at best.

    No, we are not allowed to spread lies that threaten the lives of innocent people. Yes, people who do will be identified and publicly shamed for starters.

  • http://AddaURLtothiscomment MK

    I just stumbled across this post while doing some of my own research. I have been dealing with a mild but very persistent form of depression since my late teens. While therapy has probably been the most effective tool in my arsenal, medication has definately helped with the “stuckness” Dr. Kramer mentioned. I have been incredibly lucky in that I have responded very well to Pristiq and have recently added Deplin which has also been very effective. I am still trying to get over certain other aspects of my depression such as executive function issues and insomnia but I am optimistic. I still see a therapist regularly but I have finally accepted that medication is probably the smartest option for me right now, especially since I became a parent. I have been looking for something like this since I finally came to the realization that the form of depression I have needs to be treated as an illness and not simply a state of mind. It’s great to see that there are people out there who really seem to understand this concept.

    And for Jean I am still struggling with thoughts dealing with I should have done/do more with my life. Although I described my depression as mild it has caused me to walk away from a job I worked very hard to get. I still struggle with that. But I know that if I had stayed it would have done more harm than good. I hope you don’t have so much regret that it causes you even more problems. I know that feeling so well.

  • http://AddaURLtothiscomment Mayview

    Wow…thanks for this article.
    As I telling a good friend today…I happily take my antidepressant every evening…actually, I almost feel excited about it!! I was so depressed and full of anxiety for so long, that now that I am feeling better, I am so thankful for Cipralex (Lexapro)!! I have been taking the AD for about 4 months now and it has been such a blessing…
    My only regret is not seeking medical help sooner.

  • http://AddaURLtothiscomment Ann

    I’ve had severe depression and anxiety on and off since I was 15; now I’m 42, and I can definitely say that antidepressants have saved my life over and over again. I know there’s a stigma about taking medication, of any kind really, but especially medications for mental illness. It is so sad to know that so many people could have their suffering relieved by taking antidepressants, but they think they’d be seen as weak. And so they tough it out and just end up in more pain, (and sometimes inflict pain on others), and in the worse cases commit suicide. I’m so thankful that antidepressants, and other drugs for mental illness, are so much better and have less side effects than they did when I was a teenager. Therapy and antidepressants are the best answer when it comes to clinical depression. I, along with so many others, are living testaments of this!

  • http://AddaURLtothiscomment Peg

    Therese, you do mean Peter Kramer and not Peter Brown, in your intro sentence, right? Thanks. Peg

  • http://AddaURLtothiscomment Kay

    This is my new soapbox! I’ve recently been diagnosed with cyclothymia, basically mild BP mood swings that cycle very rapidly, which ends up being more chaotic than I could ever express. I showed symptoms of depression all my life, but didn’t realize it til toward the end of high school when I started having daily panic attacks. My family doctor prescribed an SSRI(the only type of meds I consider to be antidepressant). It destroyed me. Basically, it made me borderline manic, and triggered the cyclothymia. Then the DRs put me on a large dose of Abilify and another SSRI. It was the worst combo possible. The Abilify caused symptoms that mimicked or actually were depression, and the SSRI made my thoughts race and my anxiety level increase.

    I think SSRIs can be very dangerous, and should be carefully prescribed and monitored. All this said, I BELIEVE IN MEDS. I just think that there are so many conflicting messages going to some doctors, they end up giving the wrong meds.

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