What's The Real Deal: Antidepressants or Placebo?
Ongoing media debate in recent years has brought attention to the over-prescription of antidepressant medications in Australia.
Being one of the most frequently prescribed drugs, the rate has more than doubled since 2000, with an average 10% of Australia's adult population taking them - not to mention children and adolescents.
Now however, due to a recent article by Dr Christopher Davey and Professor Andrew Chanen, from Orygen, the National Centre of Excellence in Youth Mental Health and The University of Melbourne, published by The Medical Journal of Australia (MJA), there is a call to de-emphasise the use of antidepressant medications. Reason being; they are no better than placebo.
Australia's Rapid Rise in Antidepressant Use
The Australian New Zealand Journal of Psychiatry published a study in 2013, showing a 58.2% increase in the prescribed use of psychotropic drugs between 2000-2011. This was mainly driven by a 93.5% increase in antidepressant usage.
In the past two decades, Australia has also seen a major increase in antidepressant prescriptions to children and adolescents. Another study published by the Australian New Zealand Journal of Psychiatry, in 2014, showing antidepressant usage had increased by 16.1% in this subpopulation between 2009-2012, the most rapid increase seen in children between the ages of 10-14 years.
How Does Australia Compare to Other Countries?
According to an OECD report from 2013, Australia ranked second for antidepressants consumption among 23 countries. However, across England rates saw a sharp 6.5% increase in 2015. Though, in children under 18 years of age in Norway, there was only a 1% increase, over an 11-year period from 2004-2014.
Featured Image Credit: Health Indicators at a Glance 2013 by OECD
Who is to Blame for Overprescribing?
Experts can’t help putting a large part of the onus on GPs in the clinical setting.
Professor Philip Mitchell, the Head of the University of New South Wales School of Psychiatry, quoted for ABC News, saying:
"My impression is that they [GPs] really feel they need to be doing something but there is that pressure. We know that for many GPs they can only spend 8 to 12 minutes with a patient and it's simpler to write a script for that time."
The blame could also be placed on scientific literature. It has been reported that published research has been manipulated, suggesting significant benefits for antidepressants, when in actual fact; the conclusions were put under great scrutiny and considered inaccurate and misleading.
Pharmaceutical companies have also come under fire. For example, the US government brought two companies to their knees with liability for misleading claims regarding the efficacy and safety of antidepressants for children and adolescents.
What’s The Real Deal: Antidepressants or Placebo?
The effect sizes for antidepressant use have now come under the spotlight as being far less effective than once believed. While the overall effect is higher for severe depression, according to the recent MJA article, "meta-analyses show a modest overall effect size of about 0.3." Effect size for children and adolescents is even less.
Of major concern are the wide range of common side effects that come alongside antidepressant usage, particularly in adolescents where antidepressant use frequently produces increased suicidal thoughts and behaviours; along with an increase in aggressive behaviour in both children and adolescents.
Researchers have been surprised by the response at which people are responding to placebo, the gap between medication and placebo sharply narrowing, even for those with severe depression.
What is becoming apparent is that patients are recovering from depressive symptoms over time, irrespective of treatment, which is why there is now a call to de-emphasise the use of antidepressant medications for alternative options.
Will There Be a New Framework for Health and Medical Professionals?
It may seem that the logical conclusion is to stop prescribing antidepressant medications. However, there is a modest effect, which is still considered clinically significant, particularly in some patients.
However, it is suggested that medical professionals consider establishing a framework, which may include:
- Offer psychotherapy - cognitive behavioural therapy and interpersonal psychotherapy – though considered effective, unfortunately in Australia we currently have no data for usage or access to these services.
- Recommend frequent exposure to green space - which has been shown to reduce depression, anxiety and stress in several studies.
- Suggest exercise and diet changes as an adjunct to other treatments.
- Explore complementary or alternative medicines and holistic lifestyle choices - such as natural therapeutic agents, mindfulness and meditation, herbal medicines, or yoga.
- Consider medication for depression that is at least moderate to severe, or when the above strategies are refused or not effective.
- Patients should be closely monitored and medication adjusted or ceased if little to no effect.
- Combination treatments are viewed as the most effective and appropriate treatment for depression. For example, psychotherapy combined with placebo has a better outcome than medication versus placebo alone.
Overall, to address this highly complex issue, there likely needs to be a combined effort between researchers, medical professionals, and health organisations to establish more comprehensive definitions of depression and mental health issues; along with a framework that guides processes for those treating patients in clinical settings.
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