Mad in America: Rethinking Mental Health

This week, we interview Dr Joanna Moncrieff. Dr Moncrieff is a psychiatrist, academic and author. She has an interest in the history, philosophy and politics of psychiatry, and particularly in the use, misuse and misrepresentation of psychiatric drugs. As an author, Dr Moncrieff has written extensively on psychiatric drugs and her books include The Myth of the Chemical Cure, A Straight Talking Introduction to Psychiatric Drugs and The Bitterest Pills: the troubling story of antipsychotic drugs.

She is one of the founding members of the Critical Psychiatry Network which consists of psychiatrists from around the world who are sceptical of the idea that mental disorders are simply brain diseases and of the dominance of the pharmaceutical industry.

We talk about the recent meta-analysis of the efficacy and tolerability of 21 antidepressant drugs, widely reported in the UK news media on February 22nd.

In the episode we discuss:

• The approach taken in the largest ever meta-analysis of efficacy and tolerability of 21 common antidepressant drugs.
• The problems inherent in comparing antidepressants with each other, as opposed to trials that compare the active drug to a placebo.
• That the main conclusion reached was that all the antidepressants studied were better than placebo at reducing depressive symptoms.
• The limitations of the study, particularly how response rate was selected as the primary outcome measure.
• That ‘response’  is mostly defined as a reduction in the Hamilton Depression Rating Scale (or other scale) rating of 50% or more during the study.
• That the response rate can artificially inflate the difference between drug and placebo.
• The problems with blinding in the supporting trials and the effects of including people who are already receiving antidepressant treatment.
• That the study did not include adverse effects or withdrawal difficulties, only dropout rates which are not representative of the whole picture of taking the drugs.
• The short-term nature of the supporting trials, mainly 8 weeks, with a range of 4 to 12 weeks, which cannot be easily compared with the real world experience of people taking the drugs for much longer periods.
• That, when the primary data is analysed (the depression rating scale scores)  the differences between placebo and antidepressants are very small and probably clinically insignificant.
• The uncritical and sensational nature of the media reporting of the study and the link to the Science Media Centre.
• The concerns about the reporting that depression is under-treated in the UK which is not supported by the results of the study.
• That people should carefully consider the balance of benefit versus risk, taking into account the potential for adverse effects or difficulties stopping the drugs.

Relevant links:

Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network meta-analysis

Challenging the New Hype About Antidepressants

The Hamilton Depression Scale

Empirically derived criteria cast doubt on the clinical significance of antidepressant-placebo differences

Efficacy of antidepressants in adults

The Science Media Centre