Recently the controversy over long-term outcomes of those who use psychotropic medication has flared up again. Some people argue depression/bipolar/mental illness patients do the same, or better, when they don’t take psychiatric medications long-term. However, the statistics they use to assert this claim are often faulty.
A study from Calgary, Alberta, Canada (yes, we do research up here too, select Science Direct to see the study) has attempted to fix some of the bias seen in other long-term depression treatment outcome statistics. I’ll cut to the chase for you:
Over the course of eight years people with depression who took antidepressants had better outcomes.
Depressed People Do Not Do Better by Taking Antidepressants
The reason people say those with depression who take antidepressants do not do better, or do worse, goes something like this:
We looked at 100 people with depression and over five years those who didn’t take antidepressants were less depressed.
Put that in the middle of some persuasive text and the villagers gather with pitchforks at the doors of psychiatrists everywhere.
Why are they Wrong? What’s the Problem with This Data?
Um, OK. Anyone see the problem here? Anyone?
It should be obvious. Those who don’t take antidepressants (or who go off antidepressants) are typically less sick than those who do take antidepressants. If you’re sicker, you’re more likely to get treatment. It’s not rocket science.
For some reason everyone wants to gloss over that bit.
This is what you call sampling bias.
Measuring Depression Treatment Outcomes Long-Term
Trouble is, you can’t randomly assign people people with a mental illness to treatment/no treatment over the course of a year or more. Sure, the depression treatment outcome data would be better, but the people might not fair so well.
We have to think smarter. If you can’t assign people at random, can you account for variables like duration of mental illness and severity of depression symptoms?
The association between antidepressant use and depression eight years later: A national cohort study by Colman et al. tried to take these variables into account.
Confounding Depression Variables
As I’ve mentioned in the past, depression is not one thing, depression is a spectrum disorder. You may have a variety of symptoms with a variety of severities and still be “depressed” (bipolar is the same). Somehow, we have to quantify that.
We do know some variables that correlate to depression treatment outcomes. Colman et al. measured:
- Severity of depression
- History of depression
- Duration of past depression
- Suicidal behavior
- Physical health
- Demographics (gender, education, etc.)
Depression variables were measured based on scientific scales derived from various methods including personal interviews. You can read all about it here.
Population of People with Depression
For this study, patient population data used was collected by a Canadian agency in the National Population Health Survey in 1998/99 through 2006/2007 every two years. 486 people (of 17,276) were identified as having depression in 98/99 and were followed, 66% of which provided complete data in 06/07 (321 people). Population was all ages, treatments and representative of general population.
Colman et al. analyzed the above variables for all 486 so they could ascertain who was most likely to drop out of the study (or give incomplete information) based on their variables; however, obviously only 321 were used to determine treatment outcome measures.
Depression Treatment Outcomes and Adjusting for Variables
As I said above, if you do not adjust for variables that lead to treatment likelihood, you get statistics that aren’t valid (they’re too biased). Sicker people get treatment.
So, the numbers when you do not account for bias look like this in the depressed population over eight years:
- Those who took antidepressants were as likely to be depressed as those who didn’t take antidepressants.
But when you adjust for the mentioned variables, that changes to:
- Those who took antidepressants in 98/99 were less likely to be depressed eight years later (OR = 0.36, 95% CI: 0.15–0.88)
(There are other findings and statistics (not overly significant and in scientist-eze) here.)
Long-Term Depression Outcomes Better with Antidepressants
All that is a fancy way of proving the people who took antidepressants were less likely to be depressed eight years later.
In part two, discussion about the strength and limitations of this study and other interesting findings and citations.
Desperation is a good reason not to take meds for depression. Desperation is also a good reason to stop taking anti depressants. Depression has so many facets, isn’t it difficult to properly diagnose what your attempting to cure?
Thank you again for another well informed blog post. So many people have told me how antidepressants have helped their lives, I don’t need to hash over studies. However, I will say that in bipolar depression, it has been discussed that the most important factor in preventing bipolar depression is preventing bipolar mania and hypomania. The toll that mania takes on the body induces a state of depression and low mood. The body is reacting to the hypermetabolic states of mania and hypermania with exhaustion and subsequently depression. Utilizing an SNRI was always helpful to me when I was using a mood stabilizer as well. So it’s important that people know this about bipolar disease. SSRI’s and SNRI’s are helpful when in a depressed state – they should be used with a mood stabilizer in bipolar disorder to prevent swinging too far the other way and inducing mania.
I have been very anti-meds and have refused to take meds (for severe anxiety and depression, etc). I have experienced varying degrees of wellness over this 10 year period. Sometimes I am a little bit functionable and can force myself to be productive. Other times, like now, I struggle to cope with anything. I am completely shutdown.
I have got to the point where I see medication as possibly providing the only solution. I would have liked to have seen change come about through psychotherapy but I have been either unable to access it or have been unable to engage with it. I think that a sustained personal effort is just way beyond me at this point.
I have seen a psychiatrist (yet another one) and he has asked that I trial medication for six weeks. If that is successful then I would be asked to stay on it for two years.
It will be interesting to see how this pans out.
Hi Jackie,
I was very anti-meds when I was diagnosed as well. I had been anti-meds my whole life. Pretty much anti-doctor, actually. (I just wrote about it but the piece isn’t available online yet.) I only started taking meds due to my absolute desperation and the pain. Which I think is the same for many people.
If you haven’t tried cognitive behavioral therapy, I highly recommend you do. It’s very different than psychotherapy. This article is about cognitive behavioral therapy (CBT) and bipolar, but CBT is applied in the same ways to various illnesses: http://www.healthline.com/health-blogs/bipolar-bites/cognitive-behavioral-therapy-effective-bipolar-disorder
Just make sure to get a practitioner that specializes.
If you decide to try medication try to be patient. It can take a long time to see if a medication works and not all medications work for all people. You probably know that, but it can take several medication trials to find one that is right for you.
And keep in mind that while you might be “asked” to stay on it for 2 years, that is not iron-clad. It’s always within your control to withdraw in the future if that’s a choice you want to make.
Thanks.
– Natasha Tracy
Unfortunately, I couldn’t read the study as I do not have a subscription to that particular magazine. If you could post a link to the actual study or even an abstract I’d appreciate that.
“It should be obvious. Those who don’t take antidepressants (or who go off antidepressants) are typically less sick than those who do take antidepressants. If you’re sicker, you’re more likely to get treatment. It’s not rocket science.
For some reason everyone wants to gloss over that bit.”
I agree this factor needs to be controlled for. The best way to do this is a random assignment of medication vs non-medication.
“Trouble is, you can’t randomly assign people people with a mental illness to treatment/no treatment over the course of a year or more. Sure, the depression treatment outcome data would be better, but the people might not fair so well.”
Whatever you think of the ethical matters, it has been done. I also question the practice of presupposing that anti-depressants are needed to fair well, and not doing better science based on this belief. In fact it is clear that such a ‘knowledge’ of the results of a study before a study is conducted is a perfect example of bias.
By your admission, the treatment outcome data of a randomized study would be better.
So let’s look at this randomized long-term study comparing 16 weeks of various types of treatment and then following the long-term outcomes of those involved. Those who did not relapse for 8 weeks after treatment were “30% (14/46) for those in the cognitive behavior therapy group, 26% (14/53) for those in the interpersonal therapy group, 19% (9/48) for those in the imipramine plus CM group, and 20% (10/51) for those in the placebo plus CM group.”
More so, once 6/12/18 month follow-ups were done on this group: “Among patients who had recovered, rates of Major Depressive Disorder relapse were 36% (8/22) for those in the cognitive behavior therapy group, 33% (7/21) for those in the interpersonal therapy group, 50% (9/18) for those in the imipramine plus CM group, and 33% (5/15) for those in the placebo plus CM group.” (CM= Clinical Management)
In this study the anti-depressant performed the worst out of any therapy, including placebo.
This relapse percentage of patients who’ve discontinued anti-depressants is similar to the findings of an analysis on 27 papers comparing relapse rates of 1800 remaining on anti-depressants and 1100 discontinuing anti-depressants. (http://www.ncbi.nlm.nih.gov/pubmed/9559348). It found that it takes 14.2 months on average for 50% of patients who have discontinued SSRI’s to relapse. Moreover longer prior treatment did not yield lower postdiscontinuation relapse risk, and differences in relapses off versus on antidepressants fell markedly with longer follow-up. Contrary to prediction, gradual discontinuation (dose-tapering or use of long-acting agents) did not yield lower relapse rates.
Hi Danielle,
Sorry for the confusion. All you have to do is select “Science Direct” and the study comes up. You don’t need to subscribe to anything.
Well, I’m not trying to suggest that antidepressants are a necessary condition for getting better but I am suggesting that not letting people choose whether they get them (due to random assignment) seems unethical and would lead to lots of drop-outs.
I see your numbers and I do have issues with that study. For example, they used one antidepressant, but it’s likely that that antidepressant would only work for a percentage of people and some of those people would need another drug, which wasn’t done there. Also, that was only 16 weeks, which isn’t really long enough to show what I’m talking about which is why I remarked on the study in this article as due to its length, I think has something specific to say about antidepressant treatment “in the wild” as they say.
– Natasha
Long-term outcomes destracts from the more pertinent question; do SSRIs even work?
UK and US researchers led by Irving Kirsch of Hull University, UK, studied all clinical trials submitted to the FDA for the licensing of the four SSRIs: fluoxetine (Prozac), venlafaxine, nefazodone, and paroxetine (Seroxat or Paxil), for which full datasets were available.
They conclude that, “compared with placebo, the new-generation antidepressants do not produce clinically significant improvements in depression in patients who initially have moderate or even very severe depression”.
So if people never responded in the first instance, then their long-term outcome does not relate to an SSRI, but rather other factors.
ps I find it interesting that i never meet placebo responders. Everyone seems to swear these drugs are life savers. Inevitably alot of people saying this are placebo responders, like my self; a ten year SSRI veteran who stopped 124 days ago for good.
Hi Ben,
I am aware of that study and this article doesn’t address that shorter-term viewpoint. You could argue this longer-term study has people doing better on account of other factors but I have yet to see what those other factors may be and over the course of a decade, this study is far more robust than any clinical trial data.
And of course you never meet a placebo responder. No one would know if they were having a placebo response.
– Natasha Tracy
P.S.
In regards to the comment below me about “antidepressants being BS”…It’s true that not ALL people need antidepressants. Each individual person and their body chemistry and brain chemistry is totally unique. But, in so many cases, medication has completely saved people’s lives and helped them tremendously. As far as people not being resilient enough and relapsing, well, I’d rather take a medication that would help me, than continuously live, let me correct that. EXIST, day to day in a state of misery, like I do right now. Antidepressants aren’t necessarily the magic bullet, or cure-all obviously, but just like any other means of treatment, they’re a tool to help the person get better again. I can say in my own experience from trying a myriad of things to get better, that nothing so far has helped me much, and I cannot continue dealing with this and being this way. My only other option is a medication, because I’ve been down all the other roads, and they haven’t led to recovery for me.
I enjoy your blogs, and I really like your hair!
I myself suffer from depression, anxiety, agoraphobia, and panic disorder. It can be a very confusing, frustrating, and disheartening trying to deal with these illnesses, let alone trying to find the right treatment that works for the individual, not to mention the scores of conflicting information out there. I’ve tried studying and learning to the best of my ability about things that would help my condition. Some people say medication works, some say it’s no more effective than a placebo; which may be true for some people, but maybe in more moderate to severe cases, I really don’t see how that would be possible. In my case, I have taken two antidepressants, zoloft and lexapro, both of which were the only ones I’ve tried that had the least side effects, and the ones that worked the best for me personally. Now, if a placebo could make me feel much better on a continual basis, like I did when I was taking an antidepressant, as compared to now, when I haven’t taken one for years, and I feel miserable, then the placebo would have completely helped all of my disorders. But, it hasn’t. In my own comparison, being on the antidepressant that worked for me, compared to me trying all these other forms of therapy and not being on an antidepressant, I can say that there is a major difference. Comparing the “natural” methods with taking an antidepressant, almost none of them have improved or helped me in the way that I was feeling when I had been on an antidepressant. Some people say that exercising and therapy will take care of it. Well, I can say that I’ve tried many things. I’ve gone through self help programs and books, I’ve had hypnotherapy, I’ve been to numerous counselors over the years, I’ve tried a handful of medications (antidepressants, and one benzodiazepine, but with a few of them once they started working, I stopped taking them, which wasn’t smart). I’ve done yoga, meditation, breathing exercises, I exercise daily, I eat very healthily, a mostly all organic diet, currently I’m seeing a chiropractic Dr. who does nutritional response testing. I’ve been dealing with these disorders for over half of my life, and for a while now I’ve been trying all of these things, and I haven’t seen any real improvement. It gets frustrating because while I know firsthand the side effects of antidepressants, I do know that a few of them did work for me, and I did feel a lot better than I did before, or even how I feel now. These studies that tell people that antidepressants don’t work, that they’re harmful, and basically just bash them outright, can make it difficult especially for people like us who have mental disorders whether or not we want to get help in the form of a medication. I already have enough information that goes back and forth on why it’s good or why it’s bad, let alone my anxiety about my health and what it could do to me, and also the flat out hopelessness I feel, because I’ve tried everything and I honestly can’t seem to get better on my own. I don’t know where these studies are getting their information, or from what people, but when I was on an antidepressant, I felt so much better. I can say from looking at my life, that while exercising, eating healthy, going to therapy and many other methods I’ve tried, are definitely helpful and things that people should continually do, I know that in my case, it has not helped me whatsoever with my anxiety, my fatigue, my depression, my irritability, my negativity. At this point I have no other options for help. I have to consider an antidepressant. I try to research as much as I can, but as you’ve mentioned, there’s so much that we don’t know about. It makes it very difficult for me to make an informed and educated decision whether or not to take an antidepressant due to the overload of conflicting and extreme information i.e. either people and or studies that are either totally pro-medication, or anti-medication. I think when it comes down to it, of course people who have these problems, like anyone else out there, just want to be happy and healthy. People who don’t have these problems have no clue what we struggle with day to day. So now, it really makes it even more depressing and discouraging for a person like me who has tried so many avenues, spent so much money and time on trying to recover, cope, and become healthy and improve my life, but I just haven’t had that happen. I’m not saying that I think medication is the only answer, or the only means of help, but personally in my case, it’s something that I seriously have to consider taking again, because I have not gotten any better after everything I’ve done. I appreciate your insight and information on these topics. It’s good to be able to read something by a person who not only wants to share this information, but from someone who also deals with it firsthand as well. People seem to go to the extremes with what side they’re on concerning the medication debate, but for the people who have exhausted every other avenue, and have no other options, it’s nice to have information, and to not have to feel awful or scared about taking a medication.
We’re already scared to death, all we want to do is live. Isn’t that the point of recovering?
Actually, I’ve heard studies where they corrected for this factor, and it appeared that those who take anti-depressants fare much worse in the longterm. The author’s conclusion wasn’t so much that it was the drugs that were the problem, but rather the idea that one can’t recover on their own- lack of resiliency.
I think anti-depressants are totally BS. If they were any good, they’d have a street value.
Kimbriel,
Certainly you are welcome to point to conflicting material. As I mentioned, a host of variables were taken into account and I know of no similar study.
“I think anti-depressants are totally BS. If they were any good, they’d have a street value.”
Ah, because on my street corner there is a massive call for anti-malarials, HIV cocktails and chemotherapy drugs. Those drugs must not be any good either.
– Natasha Tracy
And if you wish to be pedantic, both antipsychotics and antidepressants have a street value.
However, that’s not a measure of anything.
– Natasha
Dear Natasha,
I am truly sorry to read that you’re not as well as you’d want to be although I noted you’re still in there trying. At some point you will find what works for you and achieve a reasonable degree of wellness.
I enjoy your words and analogies such as “The internet is to spear-laden”. You’re being exceedingly kind. There are cruel, disgusting, demented and exceedingly sick individuals trolling forums and hiding behind supposed anonymity lacking civility and the ability to thoughtfully and knowledgably discuss the topics and issues at hand. Lacking those abilities their needs to demean these forums as you’ve noted and to which I too have long been a target.
I can only implore you to ignore the garbage, perverse behaviors and continue first and foremost your goal of achieving your own wellbeing and secondly through your skillful research and writings continue to share your thoughts with those who better perceive and care for your unbiased presentations.
There is an old accounting adage that, “Figures don’t lie but liars figure.” This is not to imply that the researchers are lying only that in many of these studies, as you also noted, “depression is a spectrum disorder” and patients (study subjects) bring a plethora of contributing variables to the table. It is then up to those more schooled and knowledgeable to attempt a reasonable explanation for the results and why I’ve seen through these many years constant opposing interpretations of the same data i.e. the VNS study results.
Until such time one has to be cognizant when reading such reports that many of these studies utilize interview evaluations and reference the DSM manual which is anything but scientific in my opinion and lacks the use of definitive diagnostic tools such as blood testing, X-rays, scans etc. Although I am not qualified scientifically to fully understand the data collection, statistical administration of the data I do note in many of these documents the use of keywords such as, in our opinion, may, further studies are suggested, we believe, etc., etc. which leads me to opine we still have a long, long way to go.
As a very long, long time support person and health care advocate to my spouse I acknowledge the studies, discuss it with her attending physicians and evaluate those results based upon our own personal experiences and curiously enough contrary to these current findings Joyce has been depression free without the use of anti-depressants for some time. This is not to endorse not using anti-depressants but to illustrate our own individual and unique experiences. In my opinion these studies should only be a guiding tool for the patient and physician to consider amongst the varied treatment options currently available.
Warmly,
Herb
vnsdepression@gmail.com
http://www.vnstherapy-herb.blogspot.com/
You have to understand, studies are about a population, and not an individual, so they can only be used to inform the problem at large, not for any one person. A person is not a statistic.
So this isn’t the kind of research you take to your doctor, this is just the kind of research that validates current practices and informs future practices and study. It matters because people have questions about long-term data, and here we have some.
(In part two I talk about a couple of other interesting things. But 1. This doesn’t mean that the people in that study were on antidepressants the whole time. They weren’t. 2. The important part of depression treatment is a complete remission of symptoms. The problem frequently seen is that without proper treatment people live with many depression symptoms during “remission” and this is a huge risk factor for future depressions.)
– Natasha Tracy
Hi Natasha,
Joyce and I have been away in high country and we recently returned so I just started to catch up on some readings. As always keep up your good work. It’s nice to read your more balanced position as opposed to the numerous anti-everything sites out there.
As for the study you’re now presenting I’m sure in several months something will be published with a differing position only adding to the confusion. The challenge with psychiatry is we’re still a long way from declaring this an exact science. In any event, while I too peruse these studies it still brings me back to my declaration of “The Trial and Error Approach to Wellness”.
What I do miss in your more recent writings is about you and how are you doing? The appearance of your being busy and engrossed in this website and other writing endeavors might lead one to believe that you’re stabilized and in remission; I certainly hope so but I would like to hear it from you. Is your VNS currently activated and would you care to elaborate and share on this as well as your current treatment regimen and mood state?
Please forgive me if I’m out of line by asking you but your previous writings were descriptive, graphic and your self-expressions we’re captivating and understandably not necessarily appropriate for this forum.
As always, I wish you and those challenged by these horrific disorders wellness and all the good you would wish for yourselves.
Warmly,
Herb
vnsdepression@gmail.com
http://www.vnstherapy-herb.blogspot.com/
Hi Herb,
“…in several months something will be published with a differing position only adding to the confusion..”
Well, you might be right about that, but I haven’t seen anything to date that takes variables into account this effectively. We will learn more and eventually we will ascertain, specifically, the group of people who really will do better long-term on medication and those who are better served in other ways. The best we can do is identify that _overall_ people get better and just try to improve things from there.
You’re not out-of-line asking about me. No problem.
You may have noticed that I’ve been attracting quite a bit of negative feedback in the last little while. People take the time to comment negatively on how I look, what I wear, the room I do videos from, my mental state, my diagnosis, my treatment, my treatment history and most everything else you can think of. Nasty people get personal.
And so I feel compelled to not give them additional ammunition at this point. The trouble with my personal writing is that it _is_ so personal and so raw that it opens me up to a lot of attack.
Additionally, I have to be extremely careful about mentioning other people now as I’m no longer anonymous. It doesn’t matter that I don’t mention people by name, no one wants to read 700 words on how depressed someone got due to your actions, even if it is a product of the disease and not the person themselves. It upsets people and makes life difficult for me.
So now I have a professional face. I need that. I need that to be taken seriously and present arguments and build my platform and career as a writer. What I’m hoping to do is take my personal experiences and weave them through my writings so people get a sense of both. But I write what takes me at the moment, and sometimes that’s just research areas more than personal areas.
I appreciate your comment and I appreciate your missing that content. You’re not the only one. I miss it too, and others have contacted me to say the same. But I’m in a different place in my work and my writing has changed to reflect that. I think those writings will still exist but probably in a different format. The internet is to spear-laden.
As for me? No. I’m not really stable. I’m working on it but I’m in muck up to my eyeballs treatment-wise and there are pointy things at every angle. Likely I’m going to have to pick one of these things on which to impale myself and see how it goes. I’m trying not to think about it. I have too much writing to do :)
– Natasha Tracy