Do antidepressants work? Three treatment guidelines, totaling more than a thousand pages, should give us something to go on, right?
In 2010, the American Psychiatric Association (APA) issued its third edition to its Practice Guideline for the Treatment of Patients with Major Depressive Disorder. That same year, in the UK, the National Institute for Health and Clinical Practice (NICE) issued its latest version of The NICE Guideline on the Treatment and Management of Depression in Adults. The year before, the Canadian Network for Mood and Anxiety Treatments (CANMAT) issued its update to its Clinical Guidelines for the Management of Major Depressive Disorder in Adults.
All three guidelines are based on “evidence-based practice.” The ideal is that each treatment recommendation is backed by a substantial body of scientific data, preferably rigorously conducted clinical trials and meta-analyses of these trials. The APA Guideline lists more than a thousand footnotes, most with more than one citation. A lot of evidence, but is it telling us what we need to know?
The guidelines cover a lot of ground, including non-meds treatments, and on all the main points they are in general accord. But let’s narrow our focus (for now) to antidepressants. In brief:
- In general, over the short term, for moderate-to-severe depressions, there is strong evidence that antidepressants will improve your condition, even if only somewhat. For milder depressions, the evidence suggests giving antidepressants a miss.
- The various classes of antidepressants are comparable in efficacy but not in side effects. Thus, side effects becomes the main clinical consideration in matching antidepressant to patient. This translates to new-generation antidepressants (such as SSRIs and SNRIs) being regarded as first-line treatments.
- If your first antidepressant doesn’t work, there is strong evidence that it is worth trying a second antidepressant. The odds go way down when trying a third.
- The evidence also indicates that if your antidepressant is working, it is a good idea to stay on it for a year.
But what the lack of evidence tells us may be far more revealing, namely:
Which Med Should You Try First?
We have no advance knowledge of which particular class or brand of antidepressant will work best to improve a patient’s individual condition. An “energizing” depressant for a “vegetative” depression, for instance, sounds like a good idea. Too bad there are no studies involving modern meds to test that proposition.
The APA Guideline, to its credit, did grapple with this very issue. But the only studies it had to go on were small ones that compared two ancient types of antidepressants, MAOIs to TCAs. Not very helpful.
NICE had different motives. Being a part of the UK’s public health system, they were looking for value for money. Accordingly, their Guideline recommended a generic SSRI as a first option for any patient presenting with severe depression. That may be good for the taxpayer, but is it good for the patient?