What does it mean to say that antidepressants don't work?

Like Carmine Pariante, I have treated thousands of patients since I started as a trainee psychiatrist in 1985 and became a consultant over 25 years ago (see post on my personal blog). He is convinced that antidepressants work (see article), whereas I am more sceptical. He's correct that I'm in a minority. The trouble with relying on personal experience is that we can delude ourselves.

Pariante does recognise that "about one in three patients with serious clinical depression who takes them doesn't get better". Actually what he means is that about a third of patients do not seem to be helped in clinical trials. These trials are only short-term and people on antidepressants are compared with those taking placebo. About a half of patients in the clinical trials taking placebo also seem to improve. It's, therefore, misleading to imply that two-thirds of patients are getting better because of antidepressants (see post summarising evidence of outcomes with antidepressants). The difference between active and placebo treatment in clinical trials is much smaller than most people realise. In fact it's so small it could be an artefact (see previous post). 

Buying into idea of chemical imbalance causes psychotropic medication discontinuation problems

As mentioned in my previous post, I have been reading The sedated society: The causes and harms of our psychiatric drug epidemic edited by James Davies (2017). The chapter by Luke Montagu, entitled "Desperate for a fix: My story of pharmacetical misadventure", describes the problems he had discontinuing psychotropic medication after "having bought into the idea of a chemical imbalance" when he was taking medication. Luke's father is the Earl of Sandwich, and one of the co-chairs of the All Party Parliamentary Group for Prescribed Drug Dependence (see previous post). As Luke says:-

[P]sychiatry, in league with the pharmaceutical industry, chooses to perpetuate two fundamental hoaxes. The first ... is that the suffering we call mental illness has a biological basis, like cancer or diabetes, caused by an imbalance of chemicals in the brain ... The second hoax follows on from the first, namely, that today’s drug treatments target and correct this chemical imbalance, just like antibiotics fight infection or insulin treats diabetes.

He goes on:-

One day these beliefs and treatments will seem as misguided as the theory of the four humours, when bloodletting, blistering and purging were believed to restore the correct balance of blood, phlegm and bile

As I said in my previous post, historically it helps to see the chemical imbalance theory as a myth, as it's wrong like humoral theory. I hope Luke's right that it will be found to be misguided, but there are powerful reasons why people do believe it (see eg. previous post). Maybe one of the major reasons for getting rid of it is to prevent people developing discontinuation problems.

Social construction of childhood depression

Sami Timimi, in his chapter "Starting young: Children cultured into becoming psycho-pharmaceutical consumers - The example of childood depression" in The sedated society (2017), describes how SSRI antidepressant prescribing for young people has increased, apart from a hiatus around 2004 because of concerns at the time about lack of efficacy and increased suicidality. Despite these concerns, prescribing has continued to increase by arguing in a biased way that the benefits of antidepressants outweigh the risks.

As Sami says:-

It was only relatively recently (in the late 1980s) that our understanding of childhood depression began a far-reaching transformation. Prior to this childhood depression was viewed as a very rare disorder, different to adult depression and not amenable to treatment with antidepressants ...  A shift in theory and consequently practice then took place as influential academics claimed that childhood depression was more common than previously thought (quoting figures such as 8–20% of children and adolescents), resembled adult depression, and was amenable to treatment with antidepressants.

Sami tries to relate this construction of childhood depression to child-rearing practices. I tend to prefer the simpler explanation that it reflects our belief in the chemical cure. I suppose the view in which I was schooled that childhood depression is uncommon and different to adult depression was also socially constructed (see previous post). However, as I said in my BMJ letter, I don't want to get too hung up about whether childhood depression exists. The problem is when it is seen as a biological entity for which antidepressants are indicated.