Expert Sets Record Straight on Antidepressant Myths

Antidepressants do “really work” and do not “cause suicide,” said Anthony Rothschild, M.D., at APA’s 2013 annual meeting during a discussion of his second book in the Evidence-Based Guides series, the evidence-based guide to antidepressant medications (American Psychiatric Publishing, 2012). Rothschild is the Irving S. and Betty Brudnick Endowed Chair and Professor of Psychiatry at the University of Massachusetts Medical School.

Rothschild said that although clinicians have successfully used antidepressants to treat millions of patients suffering from depression for 50 years, Kirsch and colleagues published in 2008 a paper claiming that although antidepressants are statistically superior to placebo, the magnitude of the drug-placebo difference is small and that these differences were clinically relevant only in patients with severe depression. Surprisingly, he said, the paper received considerable attention in the media, including radio, front-page newspaper coverage, and on “60 Minutes.” Rothschild said that the focus on questions about whether antidepressants really worked needlessly upset patients and their families. He pointed out that many experts in the field have argued that the analysis by Kirsch and colleagues was seriously flawed because it relied upon unusual statistical techniques biased against antidepressants.

Rothschild also discussed the fact that some have questioned whether treatment with the SSRIs and other antidepressants can induce suicidal ideation and whether they worsen existing suicidal ideation. Although the totality of the reliable scientific evidence indicates that SSRIs and other antidepressants do not cause suicide, the FDA has required that all antidepressants contain a black-box warning that they are associated with “suicidality” in children, adolescents, and young adults up to age 24. Rothschild said that clinicians should be aware of two important points: (1) the FDA’s black-box warning does not indicate that antidepressants increase the risk of suicide in anyone or that they increase the risk of suicidal thinking or behavior in patients ages 25 and older; and (2) although the FDA used the concept of “suicidality” as a proxy for completed suicide, they are not the same thing. The term “suicidality” has been criticized as grossly overestimating the risk of suicide and as not being as clinically useful as more specific terminology such as ideation, behavior, attempts, and suicide.

The workshop included discussions regarding the fact that antidepressants are prescribed for many patients in addition to those who have major depressive disorder, including patients with bipolar disorder, posttraumatic stress disorder, schizophrenia, and personality disorders, as well as those with other medical illnesses. The workshop reviewed the use of antidepressants for so-called off-label use—to treat illnesses for which the medications do not have FDA approval—and emphasized that practicing clinicians need to understand the use of antidepressants among several special populations, including children and adolescents, geriatric patients, and pregnant and lactating women.