The antidepressant debate

Moncrieff, Joanna

doi:10.1192/bjp.180.3.193

Cited by 48 publications

(29 citation statements)

References 26 publications

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“…Such assumptions contradict the basic premises underlying the depression guidelines. Yet, as growing evidence suggests that the benefits of pharmacological treatment are largely derived from suggestion effects, [42][43][44] the hypothesis that the patient's model of depression predicts response to treatment is highly plausible. It is also possible that physicians who respond to patient cues by not offering antidepressants reduce the potential for recovery.…”

Section: Comparison With Existing Literaturementioning

confidence: 99%

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

et al. 2012

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Section: Comparison With Existing Literaturementioning

confidence: 99%

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

et al. 2012

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“…The large placebo effects in antidepressant treatments have recently been debated as they throw into question the use of antidepressant medication. 10 The placebo effect is notoriously fickle and not, as sometimes believed, associated with neuroticism. 11 A good example of the unpredictability of the placebo response is found in research on the effects of suggestion in asthma.…”

Section: How Large Is the Placebo Response?mentioning

confidence: 96%

Using the placebo response in clinical practice

Hyland

2003

Clinical Medicine

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-This paper reviews the psychological mechanisms that lead to placebo responses and the physiological basis for reduction in symptoms. Some psychologica l mechanisms (expectancy, conditioning) lead to symptom reduction but are unlikely to reduce underlying pathology. Other mechanisms (therapeutic relationship, empowerment) may additionally reduce later pathology. The nature, size and duration of the placebo response depends on the placebo inducing context. In clinical practice, the placebo response creates an adjunctive response to that of active treatment. It is a useful, but fickle, boon as it is difficult to predict when it will occur. KEY WORDS: empowerment, expectancy, placebo, psychology, therapeutic relationshipThe term placebo response has been defined recently as 'the reduction in a symptom as a result of factors related to a subject's/patient's perception of the therapeutic intervention' . 1 Research on placebos often involves psychological symptoms such as depression or pain, so there is a tendency to treat placebo responses as 'not real' or only psychological. However, placebo responses can create a variety of physiological changes. Not only is placebo pain reduction mediated in part by endorphin release, 2 but placebos create endogenous dopamine release in Parkinson's disease 3 and changes in bronchial muscle tone (peak expiratory flow rate) in asthmatics. 4 Placebo responses are just as real as any other therapeutic response -what distinguishes them is their cause.When evaluating pharmacological and other treatments, placebo responses are an inconvenience that must be controlled by using randomised controlled trials (RCTs). However, in clinical practice, placebo responses have an impact on patient outcome. It is increasingly recognised that, when properly handled, the placebo effect is a 'boon to busy clinicians and their patients' . 5 The aim of this paper is to examine how this boon can be exploited in clinical practice. How large is the placebo response?One way of evaluating the overall impact of placebo responses is to compare the outcome in the placebo arm of an RCT with that of the treatment or verum arm. Table 1 reproduces the results of a meta-analysis of improvement rates in the placebo and verum (active) arms of several RCTs. 6 The authors conclude that: placebo responses vary considerably between different diseases, and clinically significant numbers of patients improve without active treatment. It was also concluded from RCT data that, contrary to common belief, placebo responses can be long term, at least 12 weeks in duration.One difficulty in evaluating the long-term impact of the placebo response is that some chronic diseases remit spontaneously. The true effect of the impact of placebos requires comparison with the natural history of the disease rather than with a baseline of no change. With this comparison, the extent of placebo response is reduced. 7 A review 1 comparing placebo with natural history in RCTs of analgesia which included a natural history arm suggests a mean...

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“…The evidence that antidepressants are more effective than placebo in the treatment of major depressive disorder needs little rehearsal (although for a critical view, see Moncrieff, 2002). It is worth a moment's reflection on what this means with issues centred on the size of effect and clinical relevance.…”

Section: When Are Antidepressants An Effective Choice?mentioning

confidence: 99%

Drug treatment of depression: reflections on the evidence

Anderson

2003

Adv. psychiatr. treat

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Guidelines are readily available for the treatment of depression, and more recent ones are explicitly evidencebased. Their core messages vary little but they tend to minimise uncertainties and gloss over difficult areas. This article examines three areas of uncertainty: the thresholds of severity and, for milder depression, the duration of illness for which antidepressants are more effective than placebo; the next step in drug treatment when a patient has failed to respond adequately to a first antidepressant; and how long continuing on antidepressants should be recommended in relation to individual patients' needs. It is concluded that the uncertainties in relation to treating individual patients are a combination of lack of evidence and individual patient factors but there is also an intrinsic uncertainty that will continue to require good clinical judgement. Abstract Box 1 General principles for assessing quality of intervention studiesHigh quality: systematic reviews of good-quality randomised controlled trials (RCTs) or a large definitive RCT Intermediate quality: small RCTs, non-randomised or open studies Low quality: case reports, opinion

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The antidepressant debate

Cited by 48 publications

References 26 publications

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

What we talk about when we talk about depression: doctor-patient conversations and treatment decision outcomes

Using the placebo response in clinical practice

Drug treatment of depression: reflections on the evidence

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