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Overprescribing antidepressants: where’s the evidence?

BMJ 2014; 348 doi: https://doi.org/10.1136/bmj.g4218 (Published 30 June 2014) Cite this as: BMJ 2014;348:g4218

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Margaret McCartney questions whether there is overprescribing of antidepressants and doubts that the information provided by the Council for Evidence Based Psychiatry that antidepressant use had increased by 92% in England since 2003 is correct (1).

I can assure McCartney that the use of antidepressants has increased dramatically. An OECD report found an increase in defined daily doses of 88% between 2000 and 2011 in the United Kingdom, similar to the average of 89% in 19 OECD countries (2). In Denmark, sales of SSRIs are so high that every one of us can be in treatment for 6 years of our lives. Marketing and widespread corruption have played a major role for this disaster (3). The increase in sales of SSRIs was closely correlated to the number of products on the market (r = 0.97), and 100% of the DSM-IV panel members who defined what ‘mood disorders’ are had financial ties to the drug makers (4).

It is very likely that antidepressants cause more harm than good (5). There are many problems with the trials (3), one of which being that they have not been effectively blinded. Many years ago, adequately blinded trials of tricyclic antidepressants were done, in which the placebo contained atropine, which causes dryness in the mouth like the active drugs do. These trials reported very small effects of antidepressants (standardised mean difference 0•17, 95% confidence interval 0•00–0•34) (6). This corresponds to about 0.7 on the Hamilton scale, i.e. no effect. Thus, antidepressants might very well be ineffective (3,5), and they have never been shown to work for outcomes that really matter like saving relationships and getting people back to work. In contrast, they cause a lot of harm, e.g. half the patients develop sexual problems and even when tapering off them slowly, half the patients have difficulty stopping the drugs because of withdrawal effects, which can be severe and long-lasting and are very much the same as those seen on benzodiazepines (3,7).

Antidepressants increase the risk of suicide, at least in young people, and I doubt they are safe at any age (3). A carefully controlled cohort study of depressed people over 65 years of age showed that SSRIs more often lead to falls than older antidepressants or if the depression was left untreated (8). For every 28 elderly people treated for 1 year with an SSRI, there was one additional death, compared to no treatment. McCartney doubts that this could be true and argues that a cohort study is “capable of finding association but not causation.” I find the study pretty convincing, particularly because the authors also did a self controlled case series analysis - a within patients comparison, which implicitly removes the effects of all characteristics that vary between patients. If we want to learn about the harms of drugs, we cannot afford to dismiss carefully controlled cohort studies. In fact, randomized short-term drug trials are notoriously unreliable for this purpose.

McCartney says that she has “no illusions about the effectiveness of antidepressants in mild to moderate depression.” Since most of those treated have mild or moderate depression, she contradicts what she said in her headline, “Overprescribing antidepressants: where’s the evidence?” She is a general practitioner from Glasgow and should pay a visit to another GP from Glasgow, Des Spence, who recently concluded about antidepressants: “We are doing harm” (9).

1. McCartney. Overprescribing antidepressants: where’s the evidence? BMJ 2014;348:g4218.

2. Health at a Glance 2013: OECD indicators. http://www.oecd.org/els/health-systems/Health-at-a-Glance-2013.pdf (last checked 1 July 2014).

3. Gøtzsche PC. Deadly medicines and organised crime: how big pharma has corrupted health care. London: Radcliffe Publishing, 2013.

4. Nielsen M, Gøtzsche P. An analysis of psychotropic drug sales. Increasing sales of selective serotonin reuptake inhibitors are closely related to number of products. Int J Risk Saf Med 2011;23:125–32.

5. Gøtzsche PC. Why I think antidepressants cause more harm than good. Lancet Psychiatry 2014 (in press).

6. Moncrieff J, Wessely S, Hardy R. Active placebos versus antidepressants for depression. Cochrane Database Syst Rev 2004;1:CD003012.

7. Nielsen M, Hansen EH, Gøtzsche PC. What is the difference between dependence and withdrawal reactions? A comparison of benzodiazepines and selective serotonin re- uptake inhibitors. Addiction 2012;107:900–8.

8. Coupland C, Dhiman P, Morriss R, et al. Antidepressant use and risk of adverse outcomes in older people: population based cohort study. BMJ 2011;343:d4551.

9. Spence D. Are antidepressants overprescribed? Yes. BMJ 2013;346:f191.

Competing interests: No competing interests

01 July 2014
Peter C Gøtzsche
Professor
Nordic Cochrane Centre, Rigshospitalet, Copenhagen