Editor's Choice

Finding meanings

BMJ 2008; 336 doi: http://dx.doi.org/10.1136/bmj.39511.393287.43 (Published 06 March 2008) Cite this as: BMJ 2008;336:0
  1. Jane Smith, deputy editor, BMJ
  1. jsmith{at}bmj.com

    Antidepressants continue to dominate this week. Last week a study in PLoS Medicine which claimed that newer antidepressants were mostly no better than placebo (BMJ 2008;336:466, doi: 10.1136/bmj.39503.656852.DB) attracted wide attention in the media and some criticism in both PLoS Medicine’s rapid responses and our own (www.bmj.com/cgi/eletters/336/7642/466#191157).

    This week Jeanne Lenzer and Shannon Brownlee pursue one aspect of that study—its use of a “freedom of information” request to get data from unpublished studies—to examine the issue of publication bias (doi: 10.1136/bmj.39504.662685.0F).They quote a study showing that among trials of antidepressants only 8% of those with negative findings were published compared with 97% of those with positive findings.

    Two of the authors of that study, Erick Turner and Robert Rosenthal, write in the BMJ this week about their interpretation of the PLoS Medicine study (doi: 10.1136/bmj.39510.531597.80). They agree that antidepressants are less efficacious than is apparent from journal articles (because of publication bias), but their interpretation is different: they conclude that each drug is better than placebo—maybe not by much, but still better. Their advice to clinicians and patients is “be circumspect but not dismissive.”

    Another controversy about newer antidepressants prompted by reanalysis of trial data—their effect, positive or negative, on the incidence of suicide—seems to be resolved this week. In their observational study Benedict Wheeler and colleagues (doi: 10.1136/bmj.39462.375613.BE) show that in the UK suicide rates declined when antidepressant use steadily increased but continued to decline when their use fell sharply (following regulatory restrictions). In an editorial Gregory Simon concludes that clinical trials cannot determine whether antidepressants increase or decrease the risk of suicide because these events are simply too rare (doi: 10.1136/bmj.39482.666366.80).

    This year sees the 30th anniversary of the declaration of Alma Ata, which made primary care the foundation of delivering “health for all by the year 2000.” Stephen Gillam reflects in his Analysis article on what has happened to that ambition and to primary care in those 30 years (doi: 10.1136/bmj.39469.432118.AD). His assessment is sobering: too many developing countries have failed to provide even a limited package of primary care and have been hampered by the proliferation of “vertical” projects to tackle specific diseases. But he also points out that many developed countries have strengthened their primary care, influenced by Alma Ata, and it “helped enshrine the idea of health care as a human right.”

    Yet even that may be under threat in Britain. Iona Heath devotes her Observations column this week to the British government’s “policy of enforced destitution of asylum seekers” (doi: 10.1136/bmj.39506.606215.94) and its proposal that people seeking asylum who have been refused it should also be refused access to primary care services. She argues that the policy compromises doctors’ ethical codes. She asks doctors to resist, quoting Albert Camus: her plea is for “a modest thoughtfulness which … will constantly be prepared to give some human meaning to everyday life.”

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