social psych 1 ssri vs placebo

1Running Head: SSRI ANTIDEPRESSANTS VS. PLACEBO TREATMENTS

Are SSRI Antidepressant Drugs Really Just a Placebo Treatment?

Christopher Daemen

Bishop’s University

Term paper

PSY 245A: Social Psychology I

Professor Leo Standing

Oct 28th, 2013


Abstract

In his 2008 study, Kirsch and his colleagues found that placebo’s are nearly as effective

in treating depression as Selective Serotonin Reuptake Inhibitors. This paper will shed some

light in the debate on whether SSRI antidepressant drugs are really just as effective as placebo

treatment by looking into some of the variables that deserve consideration when interpreting

Kirsch’s et al. 2008 results. Findings show a case can be made both ways. Psychiatrists, who

make their living prescribing antidepressants, defend the drug’s efficacy, whereas Psychologists,

who do not prescribe drugs, are more skeptical. Professionals must evaluate the patient’s

circumstances and offer hope, a sympathetic ear, practical advice, and, insight. In many cases,

after weighing the options, they may decide that an antidepressant may help.


Are SSRI Antidepressant Drugs Really Just a Placebo Treatment?

Introduction

In light of published articles suggesting that placebos offer a reasonably good treatment

for depression, we may wonder if SSRIs are more effective than placebo treatment, the inactive

substance believed to have no physical or chemical effect on the condition being studied, that

serves to keep studies double-blind. Given antidepressants are more costly than placebos and

have more undesirable side-effects, is the benefit worth the costs?

Background In 2008, Irving Kirsch and his colleagues published a meta-analysis of

placebo-controlled clinical trials of antidepressants reported to the FDA. The widely-reported

results were controversial.


As much as 80% of the positive response to these medications may have been a placebo

effect. The authors concluded that the popular drugs may have no pharmacological effect at all.

The Kirsch study showed an average drug-placebo difference of less than 2 points on the

Hamilton Rating Scale for Depression (HRSD), which is a 17 or 21 item scale administered by

the physician, that covers mood, thoughts and other symptoms of depressive illness, such as

sleep and appetite.

Purpose This paper will shed some light in the debate on whether SSRI antidepressant

drugs are really just as effective as placebo treatment by looking into some of the variables that

deserve consideration when interpreting Kirsch’s 2008 results.

Argument

What is called the placebo effect is the tendency for nearly any treatment to make people

feel better. In practice the placebo effect also stands for several non-specific factors associated

with treatment. At the turn of the century, these non-specific responses were becoming stronger

in trials of anti-depressant drugs; problematic, to say the least, for researchers. B. T. Walsh and

his colleagues looked at 75 randomized controlled trials published between 1981 and 2000 and

found that on average, the later the study, the stronger the response to placebo. The proportion

of the people responding to antidepressants in

these trials was also rising, though not as

rapidly. When placebo responses become

stronger, there is less room at the margins,

where the antidepressant’s effect can be seen

as found by Kirsch et al. in 2008.


One might argue that the trend is due to changes in the kinds of patients who participated

in these clinical trials. Twenty years ago, more of these patients were suffering from more

severe forms of depression. Those were the types of patients more likely to respond to

antidepressants and less likely to respond to a placebo. By 2008, many depressed patients were

already taking antidepressants. Because treatment was initiated earlier, fewer patients were

referred to studies. To cope with this shrinking pool of subjects, researchers turned to

advertising, which meant they were recruiting people with less severe symptoms. Researchers

may have felt pressure to inflate HAM-D scores in order to boost participation in these studies.

One may argue that study subjects up to 2008 may have had milder forms of depression, that

were more responsive to non-specific influences, such as the hope or anticipation of

improvement, the chance to talk about their problems with enthusiastic professionals trying to

find better treatments.

It is important to take into consideration that randomized controlled trials have their

limitations. Depression comes in many forms. It is not a single, simple condition. This

enormous variety makes it almost impossible to control for all the variables, even in a single

trial, and still more difficult to compare one trial with another. Also, because the Hamilton scale

contains only one direct question about depression, all the other items are less specific, so that

people with other problems, like anxiety, may score high. Hamilton developed the scale for the

most severely mentally ill. People with middling scores are a diverse group and may improve

for numerous reasons.

Furthermore, any scale, such as the HAM-D or CANMAT guidelines for depression is

only a rough approximation of a person’s experience. No researcher would begin to argue that


one number could describe what is happening biologically, physiologically and socially, when a

person becomes depressed.

Meta-analysis has its limits as well. Combining many results into a single number can be

misleading because studies vary so much in their design. They have different types of subjects,

with different types of depression. Some forms may respond to anti-depressants, some to

psychotherapy, some to both and some to a placebo. Thus, even treatments that seem equally

effective may help different patients.

What’s more is that there are more recent, competing analyses to defend the vast

literature demonstrating the effectiveness of antidepressants. In 2009, Cipriani and her

colleagues published work titled Comparative Efficacy and Acceptability of 12 New-Generation

Antidepressants: A Multiple-Treatments Meta-Analysis that found certain new-generation

antidepressants to be more effective than others in treating depression.

Conclusion

Kirsch’s 2008 meta-analysis then, need to be viewed through the proper lenses. Given

the limitations of meta-analyses and other factors such as baseline severity, the types and nuance

of depression, mixed in with variance in the types of people recruited for clinical trial one can

conclude that larger, more statistically powerful clinical trials will be more useful than meta-

analyses for answering questions about antidepressant efficacy. Psychiatrists, who make their

living prescribing antidepressants, defend the SSRI’s efficacy, whereas Psychologists, who do

not prescribe drugs, are more skeptical. Professionals must evaluate the patient’s circumstances

and offer hope, a sympathetic ear, practical advice, and, insight. In many cases, after weighing

the options, they may decide that an antidepressant may help.


References

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Efficacy and Acceptability of 12 New-Generation Antidepressants: A Multiple-

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social psych 1 ssri vs placebo

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