Overprescribed and dangerous - but these drugs can help

Are anti-depressants depressingly ineffective? Malehealth editor Jim Pollard with a personal take on the latest research.

A review of 47 clinical trials of Prozac and three other anti-depressants - February 2008 - has produced headlines claiming that these drugs are not helping most of the patients for whom they are prescribed. But what does the review really tell us?

First, there is nothing new in this research - it is a review of studies that have already taken place. What is important about it is that it includes unpublished trials.

The published trials are not exactly a ringing endorsement of anti-depressants. They suggest that these drugs have, at best, 'only modest benefits over placebo treatment'. But the unpublished trials are worse. It is their inclusion in the review that leads the researchers to conclude that 'the benefit (of anti-depressants) falls below the accepted criteria for clinical significance'.

Malehealth has drawn attention in the past to the reluctance of drug companies, researchers and journal editors alike to publish negative research. This is not acceptable and the University of Hull team who put together this review deserve to be congratulated for digging out this buried bad news.

However, let's not exaggerate the findings of the review. In my opinion they suggest faults in prescribing rather than in the drugs themselves.

To put it bluntly, a lot of people are on these drugs. All told, some 31 million prescriptions for anti-depressants were written in 2006 - a record. This review covered four of them: two SSRIs - Fluoxetine (Prozac) and Paroxetine (Seroxat); an SNRI - Venlafaxine (Effexor); and Nefazodone (Serzone).

Whatever the reasons - the desire for profit, the need to recoup substantial research costs - the drug companies have been quite happy for anti-depressants to be prescribed in this 'me too' way. But the truth is this is not really what they are intended for. As the UK's health guidance body NICE make clear: mild depression should not normally be treated with drugs.

After all, much mild depression is actually, for want of a better word, 'normal'. After a bereavement, relationship break-up, job-loss or any number of other 'depressing' events, it's not unusual to feel down. Often very down. What you really need is someone to talk to.

On the face of it, this is what should happen - NICE recommend talking therapies for milder depression - but, as the government's own happiness consultant pointed out a couple of years ago, there aren't enough NHS-funded counsellors and therapists to go round.

Result: it's cheaper and easier is to dole out the anti-depressants.

One of the points that the Hull review makes is that response to placebo (that is, sugar pills that do nothing) in anti-depressant trials is 'exceptionally large' - larger than in the trials of pain-killers, for example. For me, this shows the value in depression of talking to another human being - in this case, the doctor - and their taking an interest in you. In other words, it is evidence that talking is the best treatment for mild depression rather than evidence that anti-depressants don't work when properly prescribed.

There is a clear difference between the sort of depression we are talking about here which is based on circumstances and for which time is often the best healer and what you might call systemic depression - depression that's there regardless.

I've been fighting a war of attrition with depression on and off since I was thirteen and it usually has nothing to do with whether good or bad things are happening in my life. It's for this sort of depression that anti-depressants can really make a difference. And this is why I'm not going to join in the chorus of disapproval for anti-depressants following this review.

Most of my depressive bouts have been manageable - nasty but not enough to stop me working or getting on with my life to some extent. But a couple of times they've cut deeper leaving me stranded in a black hole pretty much unable to function.

On those occasions, if it wasn't for these drugs, I don't know what I would have done.

There really was no alternative to anti-depressants. That's why I believe that for more serious depression, the sort that time and changing circumstance don't seem to affect, anti-depressants can help.

Of course, for this sort of depression talking helps too. I've written about my experiences of therapy before on malehealth. But it's tough talking - therapy rather than counselling, digging around in the dirt, opening the various cans of worms. And, for me, taking the anti-depressants lifted my mood enough that I could actually do the talking and get something out of it.

Anti-depressants aren't a miracle cure despite what some might have tried to suggest in the past. We don't even really know how they work and no drug for which that is true should be doled out like sweets.

Anti-depressants do, however, have something in common with your favourite sweets - once you've started on them it can be very difficult to stop.

Coming off anti-depressants is tough and, frankly, neither the medical profession nor the pharmaceutical industry pay anything like enough attention to this. Certainly, they don't know how best to manage it. There are many other side-effects of anti-depressants too - not least, the risk of suicide in some.

Awareness of these problems ought to deter doctors from willy-nilly prescribing and ought to stop the drug companies from promoting anti-depressants for widespread use. If this review helps encourage them to do that and create a more balanced attitude to the place of anti-depressants in the treatment of depression, it is to be welcomed.

As far as I'm concerned, the headaches and the loss of interest in sex ought to be enough to deter all but the most depressed from popping these pills.

• More on depression and mental health problems
• Depression FAQs
• University of Hull review in PLoS Medicine