It has been hard to escape anti-depressants in the news recently. There has been much made in the media of the publication of an analysis of previously unpublished research, which seems to show that drugs like Prozac, Seroxat and Efexor were no better than placebos – tablets with no active ingredients. But what do these revelations mean to people who are depressed and need help to alleviate the suffering Depression can bring? What implications do they have for GPs, who have less than ten minutes to help the depressed patient in distress in their consulting room and nothing but anti-depressants to offer them? 

The research team led by Irving Kirsch, from the Department of Psychology at the University of Hull, analysed thirty-five clinical trials of fluoxetine (Prozac), paroxetine (Seroxat), venlafaxine (Efexor) and nefazadone (no longer available in the UK involving 5,133 patients, 3,292 of whom had been randomized to medication and 1,841 of whom had been randomized to placebo. Some of this data had not been previously made available by the drug companies.

They found that the placebo effect was 80%, compared to an estimated 50% in pain medication trials, and that the difference between the effect of the anti-depressants and the effect of the placebo was below the UK National Institute for Health and Clinical Excellence (NICE) recommendations for clinical significance, except for patients with severe Depression. The difference for those with severe Depression was due to the fact that that group did not respond as well to the placebo. The study concluded: “there seems little reason to prescribe anti-depressant medication to any but the most severely depressed patients, unless alternative treatments have failed to provide a benefit”. However, the researchers also noted that more data was needed, because in all of the trials analysed – except one – the patients’ average scores in the Hamilton Depression Rating Scale at the beginning of the trial showed they were very severely depressed ( 23 or over).¹

While these results are important and cannot be ignored, they are not necessarily the death blow to anti-depressants like Prozac that has been reported in much of the media. Another study by Turner et al, which has not received so much media attention, also looked at unpublished evidence, and while their results were similar, the conclusions they drew were not. Turner et al did not use the NICE recommendation for clinical significance. They said that the research proved that anti-depressants were more effective than placebo and when considering the possible benefits of anti-depressant treatment: “be circumspect, but not dismissive”.²

NICE itself does not recommend anti-depressants as a first line treatment for mild to moderate Depression, suggesting that people should have access to Cognitive Behaviour Therapy and self-help options. NICE is now reported to be re-examining the evidence around this class of anti-depressants. It cannot legally get unpublished data from drug companies, but is to ask them publicly to hand it over, which will leave them facing criticism if they do not comply.

The truth is that no one remedy will work for everyone with Depression. While Depression is treatable, the best form of treatment is a holistic approach, which does not rely on one form of treatment. It is important to remember that anti-depressants do have a place in treatment, particularly in severe Depression, as part of an overall package of support. While in an ideal world everyone would have access to non-pharmaceutical interventions, the reality is that in many areas of Scotland, there are long waiting lists for talking therapies, and so GPs are left with nothing but anti-depressants for their patients with Depression. And, so they became over-prescribed.

Throughout Scotland, new innovative approaches to the treatment of Depression are being pioneered. These include hypnotherapy CDs available at your GP surgery; self-help books on prescription; Computerised Cognitive Behavioural Therapy (CCBT); self-help courses based on Cognitive Behaviour Therapy, such as Living Life to the Full and Stresspac; and exercise on prescription. The Scottish Intercollegiate Guideline Network (SIGN),  is currently working on a guideline for the non-pharmacological treatment of Depression. This was instigated by Depression Alliance Scotland, and we have been part of the group, which has been working together on alternatives to medication, since June. The group is now considering relevant research papers and will make recommendations based on the research A draft Guideline will be sent out to reviewers – including people affected by Depression. There will then be a national meeting, where representatives can give their views and comments and you can be involved.

Draft copies of the Guideline will be available in August 2008, and the National Meeting will take place on Wednesday 10^th September this year. We very much hope that some interested readers will be able to come along to the meeting and share their views on the draft. If you have any queries on this or would like to be on the list to review the draft and attend the National Meeting, please contact Ruth at Depression Alliance Scotland on 0131 467 3050 or ruthl@dascot.org  We would be glad to hear from you if you would like to be involved in this.

The controversy around anti-depressants will probably continue raging for a while yet. It is important that the fact that some people are helped by anti-depressants is not overlooked. The fact that the drug companies have only selectively published their research is scandalous, and we urge the pharmaceutical industry to be transparent with its research findings, so that people with Depression and clinicians can make informed choices about the best treatment. We also strongly urge the Scottish Government to fund non-pharmacological treatments for Depression and to ensure that a variety of treatment options for Depression are made available in all areas of the country. We hope that publication of the SIGN guideline will be useful in providing guidance to the Government and to practitioners. Finally, if you are on anti-depressants and have concerns, speak to your GP or prescribing doctor.

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