Arguing over antidepressents

Antidepressants are long established, widely used, extensively researched, and poorly understood. We have had one of our largest postbags in response to an editorial that argued “watchful waiting for minor depression, full dose treatment for major depression” (5 October, p 829). Poppycock, say some of our correspondents.

Correspondents disagree over whether non-drug treatments are helpful for mild depression. “Options desired by patients such as counselling seem to be ineffective,” says David Gill (p 826). But Robert Tan says that “An attentive ear is often more effective than drugs” (p 827). Next, there is the suggestion that patients with mild depression may be responding not to any antidepressant action but to a “placebo with side effects” (p 827) Alternatively, it may be the hypnotic, anxiolytic, and analgesic effects of the drugs that make patients appreciate them (p 827). This may be part of the explanation of why most of the general practitioners among our correspondents are convinced that antidepressants do work in lower doses than are usually recommended. They resent authorities lecturing them for prescribing in doses that are supposedly too low to be effective.

An editorial points out that antidepressants are widely used to treat neuropathic pain, irritable bowel syndrome, temperomandibular joint dysfunction, atypical pain, and fibromyalgia (p 763). Yet in Britain no antidepressant is licensed for these indications. But, argue the editorialists convincingly, they work in these conditions. Indeed, in patients with postherpetic neuralgia the number needed to treat to achieve 50% reduction in pain after three to six weeks is 2.3. This is comparable to the benefit achieved by the most effective analgesics in acute pain.

Sometimes it can be hard to get people to pay attention to things that matter, but two short reports may help. The first may help encourage people to donate blood. Those unmoved by arguments of public good might be impressed by Finnish data suggesting that those who give blood have a reduced chance of a heart attack (p 793). The second report may be useful in getting through to the media, who tend to be obsessed with meningitis but uninterested in the effects of poverty on health: the study finds a strong link between deprivation and rates of meningitis (p 794).

Finally, Patrick J Morrison responds enthusiastically (p 832) to the description in our Christmas issue of software called Selfcite 2.0 that will increase your citation rate by helping you to cite your own papers. Morrison's Egocite 6.0 has extra features including the possibility of updating your curriculum vitae every week and spreading a one page paper over two pages. The 1997 upgrade of the software will also include Salami-cite.