The Rise and Fall of PaxMedica - Page 4

Reconsidering SSRIs

The pharmaceutical companies have promoted the idea that "chemical imbalance" is the cause of depression and massive marketing has convinced millions that they can cure it by manipulating their neurotransmitters. But if psychotherapy research has eroded the conviction that there's only "one method" for conducting successful psychotherapy, a new, harder review of drug research over the past decade has likewise undermined the simplistic, "one-factor" theory of antidepressant action. Even the "empirical proof" for the effectiveness of medications is now considered suspect. In 2008, Erick Turner and other researchers at the Oregon Health and Science University subpoenaed the FDA to release all the studies on antidepressant effectiveness in its archives. Because science journals prefer positive findings over negative ones, Turner and his colleagues were unsurprised to find unpublished studies concluding that SSRIs are no more effective than placebo.

But they were astonished by the number of such negative studies. Research reporting positive effects for antidepressants was 12 times more likely to be published than studies reporting negative results. Turner et al. concluded that publication bias had inflated the common impression of the effectiveness of SSRIs by about a third overall, and for some medications, the figure was twice as high.

Indeed it now appears that the early widely touted success of SSRIs was based on an overly simplified methodology and cherry-picking of results. Recent large-scale reanalysis in 2006 of the studies of efficacy of SSRIs indicates that these agents are effective between 56 to 60 percent of the time. Since one recent metanalysis in 2005 by Bruce Arroll and others shows that between 42 and 47 percent of subjects respond to a placebo, an effect 10-15 percent greater than placebo hardly justifies psychiatric and popular confidence in SSRIs as the first-line treatment for one of the most common mental disorders. In a 2006 Scientific American study aptly entitled "Antidepressants: Good Drugs or Good Marketing?" David Dobbs reported that, partly because of the simplistic "one-factor/chemical imbalance" model of depression causation, only 50 percent of all drug trials over the past century were published or reported—basically, only the ones with positive outcomes.

In 2006, three enterprising psychologists, Kevin McKay, Imel Zac, and Bruce Wampold found striking evidence for the importance of the therapeutic relationship by obtaining and reanalyzing data, paradoxically enough, about the effectiveness of medications. A major study by the National Institute of Mental Health's Treatment of Depression Collaborative Research Program, which focused on different approaches to depression—but did not even include the therapeutic relationship as a variable—compared the effects of the antidepressant imipramine with a placebo. The published results heralded the power of the pill. In the reanalysis of the study by McKay, Zac, and Wampold, however, it became apparent that the most effective psychiatrist actually got better results with placebos than the worst-performing psychiatrist got with antidepressants.

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