Ever since I can remember I’ve had an interest in things mechanical. As a boy I’d spend hours under the hood of a neighbor’s car trying to understand how all the parts worked. It was a good grounding. Overlooking the smallest detail could mean the whole engine grinding to a halt. Equally, not having the correct tool for the job meant making do and this inevitably resulted in hit-and-miss outcomes. You see where I’m going with this?
If we have a complex job but we understand what we’re doing, why we’re doing it, and we have all the correct tools and requisite skills, there’s no reason why we shouldn’t fix the problem. If any of these elements are missing then it becomes a whole different issue. Take depression. What exactly is it and how is it caused? We_ think_ we know some of the answers but there are a lot of unknown’s. Well what about antidepressants? Good question.
In the world of the blind the one-eyed man is king. We use antidepressants because it’s what the medical profession prescribes for depression. It’s what’s available. But antidepressants only seem to have positive effects for some people. Why? Is it that only certain types of depression respond to antidepressants? Is it placebo? It could be either and more besides. The fact is we don’t really understand depression but what we can do is track the history of antidepressants.
All licensed medication has to be approved via clinical trials. These trials have a number of inclusion and exclusion criteria such as age, gender, body weight, and so on. The stricter the criteria, the more things are narrowed down and the better people are matched, the higher the likelihood of effects being seen. There’s a problem with this approach and it was recently highlighted in the Journal of Psychiatric Practice. According to the published study this ruling in and out of people from antidepressant clinical trials means more than 82 percent of people with depression wouldn’t be eligible because they fall outside of the criteria.
It gives some insight into why depression in the real world can seem so very different to the tight controls of the laboratory. But lets not be too harsh. We have to make progress somehow and if we’re working on a job we don’t fully understand and with only a few tools to do it, there’s a limit to what can be achieved. But, just because you’ve spent a fortune on your hammer and glue and you're having to work in the dark, doesn’t give you the right to pretend it’s anything more than it is.
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Sheldon H. Preskorn, Matthew Macaluso, Madhukar Trivedi. How Commonly Used Inclusion and Exclusion Criteria in Antidepressant Registration Trials Affect Study Enrollment. Journal of Psychiatric Practice, 2015; 21 (4): 267