Does long term use of psychiatric drugs cause more harm than good?

We are a group of Cochrane editors who are responsible for the Cochrane Reviews that relate to mental health. Like Peter Gøtzsche we are writing in our personal capacity. Cochrane does not, and should not, have an agreed policy on the prescribing of psychotropic medicines.

We recognise that Peter has an important record as a renowned methodologist studying questions of bias, and as a researcher conducting systematic reviews. Therefore his interpretation of the evidence commands respect. However, we are concerned that in this article he steps beyond the accepted role of an independent researcher by appearing to recommend a course of action, and that this could, if acted upon, lead to patient harm.

We agree with Peter that the benefits of psychotropic drugs have long been exaggerated, or that harms (including suicide) have been underestimated. Peter is one of the many researchers that deserve credit for uncovering how the effects of bias, most notably selective outcome reporting, have created this distorted picture. We also agree that such overly optimistic interpretations lead to patient harm.

Despite this we make the following observations:

• The motion of the debate refers to “long term” use of psychiatric drugs, however Peter’s article appears to consider all use. This should have been clarified in the article, and failing to distinguish between short-, medium and long-term use for different types of patients does not facilitate the reader’s understanding.
• Psychotropic drugs and the patients for whom they are prescribed differ widely. Treating them as a homogenous whole is not helpful within such a concise article, given that there will be very different benefits and harms in different populations and with different drugs.
• The central argument Peter makes – that 98% of psychotropic drugs could be stopped without causing harm – is potentially damaging to patient well being, and is not justified within the article. In many cases the citations provided lead either to his own unpublished book or those of others, rather than scientific study reports. Thus it is hard or impossible for the reader to check their veracity.
• The data on suicide related to the use of antidepressants are central to Peter’s argument, and yet the only citation is to his own unpublished book. It is unclear in this section whether the figures presented relate to total suicides in the studies, total suicides in those taking antidepressants, or additional suicides in people taking antidepressants compared with those not taking them. This is an important distinction, and gets to the heart of how many of these suicides can be attributed to the antidepressants. The same is true for the estimates of total deaths: the data as presented are simply insufficient to justify the confident conclusions and precise estimates reported.
• In the Cochrane Review cited (tricyclic antidepressants versus active placebo), Peter merely states that the “review did not find any meaningful effect”. This over simplifies the findings of the review, which is now substantially out of date, identified scarce and heterogeneous data from old studies and led the authors to describe their findings as uncertain or “tentative”.

In summary, we are concerned that the picture painted by Professor Gøtzsche may be a partial one, and that the extreme recommendations he makes based on his interpretation of the published research are inappropriate, and insufficiently justified by the scientific literature presented, to guide decision making in practice or health policy.

Dr David Tovey, FRCGP
Editor in Chief, Cochrane
London, UK

Dr Rachel Churchill
Co-ordinating Editor, Cochrane Depression, Anxiety and Neurosis Group
University of Bristol

Professor Clive E. Adams
Co-ordinating Editor, Cochrane Schizophrenia Group, Institute of Mental Health, University of Nottingham

Dr Geraldine Macdonald
Co-ordinating Editor, Cochrane Developmental, Psychosocial and Learning Problems Group
Queen’s University, Belfast