Antidepressants are not antidepressants

Just a few years back the editor of an issue of the monthly British Journal of Psychiatry (BJP) Bulletin wrote, as usual, a comment piece on the issues of that month’s content. I can’t recall the reference date simply because it was an introductory comment. I think you will understand when I explain. The editor related a then recent consultation with a patient attending him for longterm treatment of   depression. But on this occasion it seemed without preamble the patient declared, ‘I am now better’. The consultant   clearly pleased to hear this good news, went into considerable detail of the biochemical complexity underpinning antidepressants such as serotonin and noradrenaline underpinning the posited antidepressant activity in the classic catecholamine hypothesis associated with mood disorders and their treatment.

The patient, having listened attentively to his consultant elaborating on the neurochemistry explanation of how antidepressants work then responded with a short declaration, “I have fallen in love”. Let there be no doubt I have a huge respect for our colleague and his penning that vignette. Far too many of us doctors in the past have actually accepted that antidepressants have a cast iron scientific basis of antidepressant chemical medication effectiveness. I have to confess I can’t recall anything else of that editorial. But on reflection I can’t remember ever reading or hearing that major tranquillisers were not major tranquillisers, or that antipsychotics were not antipsychotics, that anxiolytics were not anxiolytics, that hypnotics were not hypnotics. I am open to contradiction.

It is heartening to fast forward to an encouraging content development announced in the BJPych Bulletin February 2018 issue: a paper boldly titled “Antidepressants are not antidepressants”. There is an editorial announcement of a new and challenging regular feature titled, “Against the Stream Series”. Its declared aim is to encourage publication each month of “controversial issues of relevance to psychiatrists and mental health professionals”. Philip Graham and Peter Tyrer are the drivers and Invigilators. They deserve our congratulations and best wishes in that endeavour.

That first issue does not disappoint. The chosen paper’s full title is “”Against the stream: Antidepressants are not antidepressants – an alternative approach to drug action and implications for the use of antidepressants”. The author, Joanna Moncrieff, is impressively forensic in demonstrating a weakness of the evidence base in support of the chemical case for antidepressants lies. She has but a modest bibliography (22 references). It tackles antidepressant effects and severity; antidepressants effects and the medication – centred model of drug action. What’s more the whole presentation of the case and comparison with the placebo effect is a model of clarity and substance. It is worth emphasising here that whereas antidepressants are not antidepressants they most certainly are psychoactive.

In recent years the number of authors appended to individual papers has increased substantially (as indeed have associated bibliographies) . The other day I stopped counting at 15 authors on one paper. That number was, I grant you, at the heavy end in sampling. If there is some serious, perhaps legally significant, flaw in any such paper, who can be held responsible, how is accountability established?   I now consider most such articles as way above my pay grade and leave them respectfully aside having dutifully read the summary.

As I read this first “Against the stream” piece and its content I became curious wondering was there any other literature along similar lines because of the fundamental questioning of the mainly received acceptance   of antidepressant   function claim from the 1950s up to the present . One would expect that a study or studies along the same lines might have produced similar questioning articles not a million miles from Moncrieff’s paper. This prompted my doing a very simple “Antidepressants are not Antidepressants” single Google search (all I feel capable of in todays super sophisticated tech world).Much to my surprise up shot just one PubMed 2008 reference “Why antidepressants are not antidepressants:STEP-BD,STAR*D, and the return of neurotic depression”. I made a hard copy of the PubMed reference.

It remains puzzling that a finding such as the 10yrs-old PubMed publication was not followed by a veritable tsunami of comment in the 10 year hiatus since 2008: has not already had the sort of research attention it would seem to deserve.

Moncrieff considers that….. “patients should be informed that there is no evidence that antidepressants work by correcting a chemical imbalance, that antidepressants have mind-altering effects, and that evidence suggests they produce no noticeable benefit compared with placebo.

Dr Dermot J Ward