The efficacy of antidepressants has been called into question in recent years, and yet their use in the West continues to increase. Doctors prescribe antidepressants with ease and regularity, knowing that alternatives (such as psychotherapy and cognitive behaviour therapy or CBT) are thin on the ground.

We talk about medicalising distress: making an illness out of negative social and personal life experiences, and yet we still do not have good ways of dealing with these experiences that obviate the use of medication.

Medicalizing individual difference & eccentricity reduces rich palette of human nature. @PaulGlasziou @Mental_Elf pic.twitter.com/LwHAfYIH5a

— Allen Frances (@AllenFrancesMD) July 6, 2016

Methods

Quite simply, this new open access paper (Gibson et al, 2016) is based on the qualitative (content and thematic) analysis of responses to a single open question in an anonymous online survey. The question asked participants to complete the phrase:

In my life antidepressants have been…

There must have been additional questions regarding demographic characteristics as the paper reports on the profile of the participants as well. The survey was live for nearly a year and was answered by 1,829 people aged over 18 across New Zealand.

Results

The profile of the respondents showed them to have above average education, to be younger than average and predominantly female (77%). It is not clear how well this profile fits that of people in New Zealand who are prescribed antidepressants.

In summary:

• 54% of the participants reported positive experiences of antidepressants
• 28% reported mixed experiences
• 16% reported negative experiences.

Within these broad headings, several themes emerged.

Positive experiences

Within this group, participants described antidepressants in four main ways:

• Some described them as a necessary treatment for an underlying illness, with a clear belief in the biomedical model for understanding depression
• For others, antidepressants acted to enable them to function or to carry out their normal duties
• Some regarded the drug as a temporary means of dealing with stressful events, including interpersonal or social problems
• Finally, some invested significantly more emotion in antidepressants describing them, for example, as a ‘life-saver’.

Negative experiences

Interestingly, the negative (and the mixed) experiences appear more nuanced:

• Some people in this group simply found antidepressants to be ineffective
• Others found the side effects to be too unpleasant to continue with the drug
• For some people, the numbing of emotions impacted on their lives in problematic ways (e.g. feeling ‘like a zombie’)
• Another group of people described antidepressants as a kind of ‘fake fix’, covering up or leading them to tolerate circumstances that they subsequently felt should have been addressed directly
• Finally, some people experienced the drug as a sign that they were not coping; it was as if it undermined the control they had over their lives.

Mixed experiences

• In the mixed group there were many people who described weighing up the benefits of taking antidepressants with the unpleasant side-effects, as a ‘necessary evil’
• Central among the side-effects discussed were sexual dysfunction and weight gain. Some had stopped taking the drug as a result, whilst others resigned themselves to living with the side-effects
• Some people similarly described antidepressants as having benefits but making them feel unlike themselves
• Another theme was dependency, and the difficulty that some people were having in coming off the drug, with little follow-up advice or information about this
• Finally, some people talked of the struggle to find an antidepressant that worked, or that did not cause significant side-effects.

Conclusions

The authors conclude that their findings demonstrate the inadequacy of the question ‘Do antidepressants work?’, providing us with greater understanding of the meanings people ascribe to taking them.

They highlight the need for professionals to enter into a dialogue with patients to explore the meaning that antidepressants hold in their lives, and to not mislead them into thinking there is a ‘known chemical aetiology’ in depression. This in itself is an interesting conclusion, since it seems that it is those people who believe in this chemical aetiology who have the most positive experiences of antidepressants.

Strengths and limitations

This study has two significant limitations; one is that it is based on the completion of a single open question and the second that it was available online only. The latter results in a potentially skewed population (predominantly female, younger and higher educated), and the former is too superficial and leaves a great many questions unanswered.

The authors’ conclusion about the importance of the meanings people ascribe to their medication, leads one to wonder more about those underlying beliefs and the values of the participants. Although it seems logical to assume that those who describe the drug as a necessary treatment for an underlying illness might believe in a biomedical understanding of depression, it would be so much more illuminating to have been able to ask those additional questions.

A follow-up qualitative study involving interviews with sub-samples of people giving positive, negative and mixed responses would have been a valuable addition.

Summary

Overall, I feel that this paper promises more than it delivers. Perhaps this is partly because I have insider knowledge; I was keen to review this paper because I have been taking antidepressants for nearly 18 years. I can identify with a great many of the views and experiences of the participants in the study. I have moved through and back and forth between the positive, negative and mixed experiences described. Although initially trying about four different types of antidepressant, I eventually settled on Venlafaxine. Looking back on this now, I can see that it was the one that I tolerated best; whether it actually impacted on my depression at that stage, I had long since lost sight of. And, some 17 years later, I am still taking a small dose; I have been unable to stop taking it due to the withdrawal effects and no GP has shown any interest in this difficulty.

At the heart of this study is the complex and powerful relationship between the efficacy of medication and the placebo effect, something eloquently described by both Joanna Moncrieff (2013; 2001) and Ben Goldacre (2013). There is no reliable scientific evidence for the antidepressant action of antidepressant drugs, but the psychology of our beliefs is powerful and fascinating. However, I am left with an ethical question. If people benefit more from antidepressants when they believe in an underlying chemical imbalance, who are we to deny them this belief? Ultimately, this study leaves many questions unanswered, questions that cry out for follow-up studies.

Links

Primary paper

Gibson K, Cartwright C, Read J. (2016) ‘In my life antidepressants have been…’: a qualitative analysis of users’ diverse experiences with antidepressants. BMC Psychiatry 2016 16:135 DOI: 10.1186/s12888-016-0844-3

Other references

Goldacre, B. (2013) Bad Pharma. Fourth Estate.

Moncrieff, J. Why there’s no such thing as an antidepressant. Blog 27 November 2013

Moncrieff J. Are antidepressants overrated? A review of methodological problems in antidepressant trials. J Nerv Ment Dis 2001 May;189(5):288-95.

Rice-Oxley, M. and Fishwick, C. ‘Medicalisation of misery to blame for soaring use of antidepressants, say GPs‘. The Guardian 21 November 2013.

Photo credits

• Eugene Kim CC BY 2.0
• Vinoth Chandar CC BY 2.0
• Beatnik Photos CC BY 2.0
• e-Magine Art CC BY 2.0