Pop a million happy pills? Antidepressants, nuance, and the mediaBMJ 2018; 360 doi: https://doi.org/10.1136/bmj.k1069 (Published 09 March 2018) Cite this as: BMJ 2018;360:k1069
- Kate Adlington, clinical editor, The BMJ
“Pop more happy pills,” screamed the Sun’s front page on 22 February. It referred to the first major network meta-analysis comparing 21 antidepressants for acute depression in adults, published in the Lancet.1 All were found to be more effective than placebo for short term treatment.2
“Antidepressants: major study finds they work,” said the BBC. “The drugs do work: antidepressants are effective, study shows,” announced Sarah Boseley in the Guardian,3 in contrast to her coverage of a previous meta-analysis almost a decade ago: “Prozac, used by 40m people, does not work say scientists.”45
Many news outlets called for more prescribing: “Antidepressants should be given to a million more Britons,” instructed the Telegraph.6 But what about overtreatment, let alone the practical and financial implications?
More importantly, what about the evidence? The study did not consider prescribing practice; neither did it mention a million untreated people. In fact, the paper’s coauthor John Geddes had mentioned this figure in an interview with the Guardian: “It is likely that at least one million more people per year [in the UK] should have access to effective treatment for depression, either drugs or psychotherapy.”3 The headlines missed his nuance, and the legitimacy of his numbers has been questioned.7
Press coverage was rich in generalisation, despite the limitations given in the Lancet’s press release. The Sun said that “pills were up to 113 per cent more likely to tackle depression than no treatment at all”8—but only amitriptyline had the highest odds ratio of 2.13. And few news reports differentiated mild depression from the more severe symptoms of most study participants.
Largely they also omitted to mention the small effect sizes, side effects, the predominance of pharma sponsored trials, or other treatment options such as psychotherapy or cognitive behavioural therapy.
The Daily Mail later devoted two pages to caution.9 James Davies, a member of the Council for Evidence-based Psychiatry which publicises the risks of psychiatric drugs, emphasised that the average length of prescription for people taking antidepressants is much longer than the two month courses studied.9
The study finding morphed into a media message that all antidepressants are effective in all depression. Nonetheless, the psychiatric and research communities seemed cautiously to confirm that the positive media coverage was justified.
Carmine Pariante, for the Royal College of Psychiatrists, decreed, “This meta-analysis finally puts to bed the controversy on antidepressants.”10 Results from many previous antidepressant studies have been scattered and inconsistent (an “evidence myth constructed from a thousand randomized trials”11).
The network meta-analysis made the largest amount of published and unpublished data to date available for scrutiny. Allan Young, psychiatry professor at King’s College London, is on balance confident about the findings. “Network meta-analyses are now widely accepted but depend on the data put in,” he told The BMJ. “This study used a large amount of high quality data so it can be trusted.”
Practical advice came from Helen Stokes-Lampard, chair of the Royal College of General Practitioners: “Although antidepressants are of proven benefit—as this study shows—no doctor wants their patients to become reliant on medication; so, where possible, GPs will explore alternative treatments, such as talking therapies or CBT.”2 But given long waiting times for NHS psychological and mental health services, antidepressants could help in the short term.
The ideological debate about the use of antidepressants has long been fervent and polarised. Many people, including some psychiatrists, dispute that depression can be treated with drugs rather than by resolving underlying social determinants. Few declare their financial or ideological interests when commenting on research. It is unlikely that any study will settle the matter for these opponents; the London consultant psychiatrist Derek Summerfield suggested recently that doctors prescribe antidepressants “by reflex” when they can’t help a patient’s “social predicament.”12
The study may well move the debate forward for patients. The hashtags #medsworkedforme and #medsdidntworkforme were trending soon after publication. Geddes and Andrea Cipriani, another of the authors, told The BMJ, “Perhaps the most striking media outcome for all of us was the Twitter conversation. This seemed to reflect the true lived experience of people with depression and we find the tweets both humbling and moving. A step forward to fight stigma in mental health.”
Competing interests: I have read and understood BMJ policy on declaration of interests and declare that I’m a psychiatry trainee and sit on the professional practice and ethics committee at the Royal College of Psychiatry.
Provenance and peer review: Commissioned; not externally peer reviewed.