Effectiveness of antidepressantsBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1073 (Published 09 March 2018) Cite this as: BMJ 2018;360:k1073
All rapid responses
One of the problems with "Evidence Based Medicine" (EBM) is that it can be misinterpreted as "Medicine Supported by the Most Evidence" (MSME). Innovation is stifled by this error, since MSME simply looks at whether what we are doing works compared with not doing it or doing something else.
Basing the medicine we practise on available evidence can permit innovation but the protagonists of MSME may not trust new interpretations and applications of old evidence.
I declare interest having used anatomical evidence (the juxtaposition of the 3rd & 4th Cranial nerve nuclei with the Edingher-Westphal nucleus) and observational evidence (noticing the typical gaze of neonates) as a basis to describe and use a simple technique, 'BabyGaze' for treating anxiety (not depression) in adults (1).
Though many colleagues welcome a simple non-pharmacological approach in anxiety, others have accused me of putting patients in danger by using a treatment based on evidence rather than that which is supported by the sort of complex and expensive studies that attract pharmaceutical funding to give validation to drugs through MSME.
While there is MSME evidence that Antidepressants are effective for some people in certain circumstances, there are other treatments such as psychological therapies that are also of benefit and that are based on evidence, even if the investment in randomised controlled trials to prove their MSME worth (rather than as a basis for understanding their effectiveness) is more sparse.
Basing Medicine, including innovation, on evidence is a good thing but we should beware of the "never mind the quality feel the width' argument of MSME when it is passed off as EBM.
1. Ashworth AJ, Dutton PV BabyGaze: A rapid neurobiological Intervention for Anxiety, Panic and Anger. Int J Psychiatry Vol 2 Issue 2 2017
Competing interests: I have published on alternatives to psychotropic medication
McCormack and Korownyk provide a very helpful analysis . They point out that the average odds ratio for remission within 8 weeks was 1.56 so that if the probability of remission within 8 weeks was 0.4 on placebo, then on treatment it would be 1/(1+1/(0.4/0.6*1.56)) = 0.51, the NNT being 1/(0.51 – 0.4) = 9.
If the probability of remission in a patient with mild depression were 0.95, then by applying the same assumptions and calculation, the probability of remission on treatment would increase only to 1/(1+1/(0.95/0.05*1.56))= 0.967, the NNT being 1/(0.967-0.95) = 58. Similarly if the probability of a patient with severe depression going into remission were 0.05, the probability of doing so on treatment would be 1/(1+1/(0.05/0.95*1.56))= 0.076, the NNT being 1/(0.076-0.05) = 38. Further advice therefore is to estimate the probability of a patient going into remission without treatment and to estimate the probability of remission with treatment using the odds ratio as shown above.
This illustrates the ‘triage principle’ of treatment where patients with mild and severe conditions may benefit little from treatments. It is failure to understand this when interpreting the average results of RCTs that is the cause of over-diagnosis and over-treatment. It should be understood that it is the odds ratio that is constant for all absolute risk reductions. The relative risk reduction is NOT constant as widely asserted but only provides reasonable approximations for low baseline probabilities.
1. BMJ 2018;360:k1073
Competing interests: No competing interests
Recent evidence reveals that administered antidepressants increase suicide risks by 2-5 times. 
Cognitive behavioural therapy halves the risk of repeated suicide attempts. 
A recent meta-analysis, level I evidence, clearly demonstrated that SSRIs double the risk of suicide and violence in adults. 
Furthermore, antidepressants increase all cause mortality by 33%! 
Another meta-analysis published in the British Journal of Psychiatry has found that even patients with the most severe depression can expect to get as much benefit from cognitive behavioural therapy (CBT) as those with less severe symptoms. 
Even Behavioural Activation effectively decreases depressive symptoms. 
Competing interests: No competing interests