I just wanted to elaborate on what the consequences are if antidepressants are really no better than placebo. Of course the nature of placebo in this sense is that it is given inadvertently (see eg. my BMJ letter). Doctors do not knowingly prescribe antidepressants as placebos. In fact, as advocates of antidepressants they can react vehemently against suggestions that antidepressants do not work (see eg. previous post). Nor do patients assume that antidepressants are placebo, even if the medication has a positive effect. They are more likely to ascribe any improvement to a true antidepressant effect of the medication. Faith in antidepressants is commonly reinforced by the belief that medication improves a brain problem causing depression such as a chemical imbalance (see eg. another previous post).
I’m not wanting to undermine people’s faith in medication. It’s important we have a balanced view of the advantages and disadvantages of antidepressants (see eg. previous post). We have to live with the uncertainty of the ongoing debate about the efficacy of antidepressants (see eg. another previous post), however much some people may want to close that debate down and conclude that antidepressants are definitely effective.
If we have to accept the uncertainty about the advantages of antidepressants, perhaps looking at the potential disadvantages will help us better assess their value. Doctors have always underestimated the difficulties in withdrawing from antidepressants (see eg. previous post) and the extent to which they are making people dependent on them (see eg. another previous post). Patients are not always warned about the risks of stopping antidepressants when they first start them, which they should be. Even if doctors routinely provided this warning, people can still naturally become fearful that discontinuing medication may upset the mental equilibrium they have managed to achieve with antidepressants after being depressed (see yet another previous post). Patients may believe the antidepressant is maintaining that equilibrium, whether it has been the cause of the improvement or whether changes have happened for other reasons. In other words, people can form attachments to their medication more because of what they mean to them than what they actually do (see my article). Any change threatens an apparent stability related to the meanings that the medications have acquired over time. It may, therefore, be easier to stay on medication than stop it. Considering also the difficulties people can have when they do try to stop, it is not surprising that people can stay on medication for long periods of time. They can be left in a vicious cycle of wanting to discontinue medication but feeling compelled to continue.
Furthermore, people can often be left with the sense that antidepressants have masked the real problem or altered their experience of themselves and relationships with others (see previous post). This is to be expected if antidepressants act as placebos. The experience is commonly expressed by patients as a flattening of emotional responses or emotional numbing (see eg. another previous post).
Withdrawal problems and not feeling one has made a proper recovery are high prices to pay for taking antidepressants. It’s understandable people are attracted to the offer of antidepressant relief from what may well have been a desperate situation when depressed. However, if we can’t necessarily say that antidepressants are any better than placebo, and the medication can leave people with these drawbacks, which are caused because antidepressants are placebos, then have they really helped? More people seem to be deciding the harms caused are not worth starting antidepressants.
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