Do antidepressants have any role in treating mild depression?

In recent years there has been a lot of attention given to the question: “Do antidepressants really work”? There is general agreement that in cases of severe depression, the evidence supports their efficacy. However, there is ongoing debate about the usefulness and role of pharmacotherapy for milder depressions.

There have been at least two meta-analyses of antidepressant trials that found no benefit from taking an antidepressant when an individual has mild to moderate depression. I am not an expert on statistical methods, and am not qualified to judge the merits of these meta-analyses (in fact, about all I can say about a meta-analysis is that it involves lumping the results of a number of studies together, giving some more weight than others depending on the size and quality of the study, and then running statistical tests on the combined results). There are many critiques of these two studies by other experts in psychiatry and statistics, pointing out the various ways in which the studies chosen to be included in the meta-analyses, and the statistical methods used to analyze them, lead to erroneous conclusions. Also, there are other analyses, using a larger database, that find that antidepressants are effective in treating mild depression.

There are points on which I am in complete agreement with the medication skeptics. Psychotherapy is underused, is often undervalued, and sometimes has more lasting benefits. Insurance coverage for psychotherapy should be equal to that of coverage for treatment with an antidepressant. Medication has been over-utilized and relied on to do things which it is unable to accomplish. Pharmaceutical companies have had much too great an influence on training and education of physicians, and have proven to be unethical on so many occasions that almost anything that comes from them is suspect. Even diagnostic categories have been influenced by them. Their impact has been so great that I wonder if much of the research done over the past couple of decades is reliable, even some not directly supported by drug company funding.

As an example, during the late 1990’s and into the 2000’s, there was an enormous push to get clinicians to suspect bipolar disorder under every rock or bush on the clinical landscape, with warnings of the dire consequences that comes from using an antidepressant rather than a mood stabilizer, preferably a second-generation antipsychotic. Much, probably most, of the research done, studies published, conferences held and speakers paid to talk about this were funded by pharmaceutical companies with a financial incentive for clinicians to prescribe a newer antipsychotic (such as Zyprexa, Seroquel, Risperdal, Abilify, Geodon). The list of soft signs of bipolar disorder, and clues from the history, that supposedly supported a diagnosis of bipolar disorder became quite extensive. One of the consequences of Big Pharma money was an explosion in the rates of diagnosis of bipolar disorder, which continues today.There are good reasons to screen for bipolar disorder when a patient presents with depression, in particular the facts that antidepressants don’t work very well for bipolar depression and that some patients can be harmed by them. The exact role of antidepressants in bipolar depression continues to be debated, in part because we still don’t have enough information from good studies.

Getting back to the main issue I wanted to address: are antidepressants ever helpful for chronic mild depression, or recurring forms of mild-moderate depression? Putting aside the research, which can be interpreted either way depending on what you want to believe, my experience leads me to say yes, most definitely. But not always, and not for everyone. Both professionally and in my private life, I have observed them help some individuals, and do nothing for others. Most convincing to me is the antidepressant effect they have produced, of many years duration, for people I know well. Without an antidepressant, they would have been forced to endure years of depression. And psychotherapy had been engaged in, sometimes for long periods of time. If clinicians were to follow the current trend in some circles and not prescribe for mild or moderate depression, it would consign some people to experience unnecessary suffering, impaired functioning and a lower quality of life. And of course, the impact on family can be severe.

I am not arguing that every depression should be treated with medication. I believe that medication should be one of a number of treatment options, and that clinicians should not be the ones to decide what is the right treatment. Rather, they should educate their patients and be guided by their patients’ preferences. Psychotherapy can be effective for depression, but it does not work for everyone, and some people don’t want psychotherapy. Also, most psychotherapy studies used well-trained therapists following a manualized treatment approach, such as Interpersonal Psychotherapy or Cognitive Behavior Therapy. In the real world, therapists tend not to follow evidence-based therapy guidelines, opting for an “eclectic” approach, which has little or no evidence to support its effectiveness. Having personal experience with both traditional psycho-analysis and a humanistic/eclectic approach, I know that psychotherapy can work and be very helpful. However, I also know from professional and personal experience that psychotherapy can be a waste of time and money; it can turn people off to getting help of any kind if they have the misfortune of seeing an incompetent therapist, and it occasionally makes some people more ill or worse off than before they engaged in therapy. Harm from psychotherapy may not be common, but it is incorrect to assume that only medication has the potential to have adverse effects.

Antidepressants are one of a number of treatment options that should be offered to someone with depression, even if it is mild. Exercise, behavioral activation, cognitive therapy, dynamic therapies and medication are some of the evidence-based treatments to be discussed with patients, so that they can make an informed decision.