Treatment of depression with antidepressants is primarily a placebo treatment

I’ve mentioned before that NICE may be laying itself open to judicial review about its depression guideline (see previous post). I’ve also emphasised the lack of clear evidence from clinical trials that antidepressants are effective, because placebo amplification may be an explanation of any statistically significant results (see eg. another previous post). This means we should have more of a psychological rather than pharmaceutical model of antidepressant action (Ankarberg & Falkenström, 2008).

Although it should not be surprising, empirical findings confirm that one of the most influential factors in the treatment of depression is the quality of the early therapeutic relationship, not necessarily medication (Blatt & Zuroff, 2005). Pretreatment characteristics of patients may also be factors in outcome. Training in the treatment of depression, therefore, needs to focus on teaching competence in establishing effective therapeutic relationships. Randomised controlled trials, which NICE tends to concentrate on, may be considered the gold standard of experimental design, but naturalistic studies may well have more external validity. The long-term outcome of treatment for depression may not necessarily be that good (see previous post). I’m not encouraging exploitation of the placebo effect, but merely acknowledgement of the importance of the doctor-patient dynamic, even when medication is used (see my BMJ letter). Perhaps NICE should start from a position of therapeutic nihilism before it makes any recommendations about treatment (see last post), but at least it should be clear that the therapeutic relationship is significant and almost certainly affects outcome.