Antidepressants for mild depression. Placebo or not?

It was front page news in the Netherlands yesterday: the official new medical guideline for the treatment of mild depression will discourage prescribing antidepressants.

About one million people in the Netherlands (that’s one in seventeen) is currently on antidepressants.

GP’s are urged to limit prescribing antidepressants to people suffering from very heavy depressive symptoms. And only if those symptoms are interfering with their every day life.
I’m interpreting this as limintng antidepressant to patients suffering the classical symptoms of a major depressive disorder.

All other depressive complaints will be labeled as “mild depressed complaints” and will be treated with the following protocol:

  1. Doc gives advice what a mild depressive disorder is and that it will pass
  2. Doc gives advice to sleep and eat right, keep working, keep being social. If taht doesn’t work, come back in six weeks.
  3. If that doesn’t help, short CTB psychotherapy aimed at dealing with depressive thoughts. The therapy can be administered by the GP himself, by a therapist or, most preferred, by internet therapy.
  4. If that doesn’t help after six weeks the doc prescribes generic antidepressant no 1 and tells patient to return after six weeks.
  5. If that doesn’t help, prescribe another generic antidepressant. Rinse, repeat.

All of this came about by the news in the medical community that most antidepressants work little better then placebo. Cost reductions will be a factor too, as well as the commonly held belief that treating depression with meds is somehow "weak"or “unnatural”.

I always thought that research results indicating antidepressants as ot very effective, had a major flaw.
I firmly believe that there are many kinds of depression, and that it is a matter of tweaking the med, the dosage and addition therapy to the specific person. And that doctors curently don’t have more then trial and error to go on.

Based on that, a blind study on antidepressants will of course give a low measure of effectiveness. Yet, on this board there are many, many anecdotes of people who can’t function without their antidepressant. People who noticed a true difference between one drug/dosage and another. How would the placebo effect explain that?

I agree there seem to be multiple types of depression, read a recent article proposing a model for that. Hopefully in time more targetted recommendations will result.

But there are risks for antidepressants, the side effects themselves have a good risk for making someone more depressed, eg sexual dysfunction and weight gain. So theres something to be said for needing a very clear effect to prescribe them as the norm, trying other options first, and reserving them for more treatment resistant types. I think side effects alone are one reason why clearer treatment effects arent found for them with milder forms of depression.

Recent article on risks:

Edit: OK read that article in more detail, probably needs a grain of salt.

The milder the level of depression, the more these kinds of risks become important.

I also see many people who simply dont want to try them, so exhausting other options first may reduce resistance to trying them in a more comprehensive way. They’re talking a 12 week delay till trying them, I think thats a pretty reasonable delay for mild depression, given whats suggested will work for many people.

I guess one concern would be that they do get to the stage of them being tried, I could imagine some people losing faith in that process and giving up on medical help before they got to that point of antidepressants being tried. But Im also aware of the reverse happening.

Otara

Otara, I’d be interested in that article you mentioned about progress in distinguishing different types of depression. Can you find a link?

I hadn’t thougth about the effect you mention of this protocol maybe making it more natural for the GP to proscribe antidepressant drugs at a logical point. I have seen time and time again how people who could benefit from at least trying antidepressants, don’t do it. I’va com tho think it is actually a symptom of depression to be against taking ad, because “I have to be able to do it on my own” (guilt and unreal expectations) to “it won’t work anyway, the side effects will be more then I can handle, and it might destroy what makes me, me” (which is the classical depressed symptom of pessimism and hopelessness).
Doctors, to me, seem far to willign to leave it up to the depressed patient to say if he wants to try ad or not. Even when it is clear that a refusal is the depression speaking, not the patient.

Read it in in one of my local journals in Oz, Ill try and track the issue down.

I would agree that I often see people because they think antidepressants are the ‘wrong’ way to go, and also because they take more notice of the negative effects first, including nocebo effects. Much of the time they gave up on them inside a month or even a week, because they havent experienced an obvious positive effect to balance any negative experiences out. Often my initial work involves discussing these issues with clients, but by definition Im generally only seeing clients where they dont feel they’ve worked, ie your pretty classic biassed sample.

So I agree that beliefs about them can be part of the problem in really trying them, but that might be addressed in the more detailed protocol that no doubt exists. I would have expected trials to have identified fairly quickly if this was a major factor in reducing overall effectiveness though, as it would be very much in drug companies interests to do so.

Otara

Where does it say that, a news story? Placebos often do provide positive results, but the reason that antidepressants, and indeed most drugs, work is because they perform significantly better than placebo, not “little better.” In the US at least, I believe it is not legal to prescribe a placebo when not in the context of a study.

I believe that drugs are overprescribed, but I am very uncomfortable with some people’s beliefs, as you suggest, that drugs = crazy person, crutch, etc. I recently had someone tell me that all depression can be cured by going outside and being social. It wouldn’t have been appropriate to tell him that while that works, it is extremely unhelpful for others. It also suggests that depression arises from behavior and not from usually genetic or physiological factors, where drugs do help.

That is true of the most popular antidepressants, the SSRIs, and likely the class that is implied when Maastricht reports prescribing a “generic antidepressant.” Many other types do not have the same side effects, namely the sexual stuff. One I was on was kind of the opposite. Trazodone has almost no side effects, except one extremely rare sexual one, priapism.

Theres little debate that antidepressants can help for major depression, its mild depression where things are more controversial.

The side effects I gave were common ones, many others exist. Eg for the one you cited:

http://en.wikipedia.org/wiki/Trazodone#Side_effects

The beliefs discussed are the ones people taking them can have that can get in the way of using them. I dont think anyone in this thread so far is suggesting that they shouldnt be taken because only crazy people take them.

Otara

What exactly constitutes “mild depression”? I was going to chime in by saying that when I took antidepressants for what I thought was perhaps mild-to-moderate depression, the effect was noticeable and extreme, but on following Maastricht’s link, I see that I had 7 out of 9 of the symptoms of a major depressive disorder. (Yikes.)

So what exactly is mild depression? Feeling kind of bummed out sometimes, or what?

Yeah, I know that. Many of those side effects are ones that will not keep someone from taking a drug, especially since many are common across all psychiatric drugs. Losing all interest in sex or weight gain are ones that usually gives people pause.

And the OP mentioned why there is a resistance to medication, and I was riffing off of that. Not that she was suggesting that, as it is clear in the OP that she is not.

Depression is a chemical imbalance in the brain, I’m skeptical of this type of problem being able to be defined as “mild”.

I’d think it’d be best to define “mild,” too. I am not up to snuff on what the medical community’s definition is, besides major depressive disorder and dysthymia. And non-US, non-DSM diagnoses may be different. I am assuming that the general perception (layman) is getting sad occasionally, but not having thoughts of suicide, or not impacting one’s life in a major way so that they don’t ever have problems holding down a job too. Then there are disorders like dysthymia, which can also be considered mild, but in a different direction. Here, the depression is still low in intensity, but it lasts long periods of time. And then there are people who get horrible depression, but it only a couple times a year, so it doesn’t interfere with life much. Who here is mild? Some? All? It could be a mistake to assume and treat all these similarly.

OK, I’ll bite. Why are you skeptical? You can have mild everything else. Why not depression?

Sure, a person might meet all the symptoms of major depression. But how disabling are they? Are you unable to get out of bed, or does it just take you a little longer? Have you completely lost your appetite or are you just not as ravenous as you normally would be? Are you suffering from crying jags or do you just feel “meh”? Are your family members frightened for you, or are they totally unaware of what’s going on because you can “pass” as normal?

It is frustrating arguing with doctors that while it is true you have been diagnosed as clinically depressed and yeah, you do have depressive symptoms, you are not ready to jump off a building right this instant, and no you don’t need heavy-duty drugging. A person can actually be depressed and not be suicidal. I remember the moment I crossed over from dysthymic to sho-nuff major. I remember when “meh” turned into “kill me now”. There is a big difference.

There are shades of gray to everything. Mental illness is no different.

http://depressionet.org.au/what-is-depression/types/#severity

Quick google.

Consider the concept of a 10% shortfall in a vital chemical vs a 90% for instance, eg diabetes - can be managed by lifestyle vs absolutely need to have injections for instance.

And we havent really identified a single ‘chemical’ for depression yet anyhow, which is a huge topic in itself.

Antidepressants ‘work’ for major depression but they dont seem to work in the way insulin does and one theory is that depression may be a cluster of symptoms with multple causation in the brain rather than one simply chemical shortfall.

The wiki article for SSRI’s mentions that mild depression may sometimes be caused by excess serotonin for instance, which would mean the worst thing you could do is take SSRI’s for people with that issue.

Otara

If my depression was caused by a chemical imbalance in my brain then why did I get well from talk therapy? And have stayed well for over 25 years? I just do not believe this is “the cause”.

I don’t think a cure from talk therapy is sufficient reason to think you didn’t have a chemical imbalance. Talking can make you more emotionally aware–and emotions are ultimately regulated by chemicals. Your thought processes can influence your emotional state just as your emotional state influences your behavior. We can impact our chemicals just as our chemicals impact us.

You were cured for the same reason that someone who has a knee injury is cured through physical therapy.

Because therapy can adjust your nervous system, e.g. biofeedback and CBT can potentially lower activity in ways like the sympathetic nervous system. This controls your “fight or flight” responses, and can say lower a person’s anxiety. Lowered sympathetic activity can mean fewer neurotransmitters or hormones released back to the brain, and cause neurochemical changes in the brain without taking any drugs.