Exercise as a Treatment for Depression

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Are Sugar Pills Better than Antidepressant Drugs?

We’ve learned that exercise compares favorably to antidepressant medications as a first-line treatment for mild to moderate depression (in my video Exercise vs. Drugs for Depression). But how much is that really saying? How effective are antidepressant drugs in the first place?

A recent meta-analysis sparked huge scientific and public controversy by stating that the placebo effect can explain the apparent clinical benefits of antidepressants. But aren’t there thousands of clinical trials providing compelling evidence for antidepressant effectiveness? If a meta-analysis compiles together all the best published research, how could it say they don’t work much better than sugar pills?

The key word is “published.”

What if a drug company decided only to publish studies that showed a positive effect, but quietly shelved and concealed any studies showing the drug didn’t work? If you didn’t know any better, you’d look at the published medical literature and think “Wow, this drug is great.” And what if all the drug companies did that? To find out if this was the case, researchers applied to the FDA under the Freedom of Information Act to get access to the published and unpublished studies submitted by pharmaceutical companies, and what they found was shocking.

According to the published literature, the results of nearly all the trials of antidepressants were positive, meaning they worked. In contrast, FDA analysis of the trial data showed only roughly half of the trials had positive results. In other words, about half the studies showed the drugs didn’t work. Thus, when published and unpublished data are combined, they fail to show a clinically significant advantage for antidepressant medication over a sugar pill. Not publishing negative results undermines evidence-based medicine and puts millions of patients at risk for using ineffective or unsafe drugs, and this was the case with these antidepressant drugs.

These revelations hit first in 2008. Prozac, Serzone, Paxil, and Effexor worked, but so did sugar pills, and the difference between the drug and placebo was small. That was 2008. Where were we by 2014? Analyses of the published data and the unpublished data that were hidden by drug companies reveals that most (if not all) of the benefits of antidepressants are due to the placebo effect. And what’s even worse, Freedom of Information Act documents show the FDA knew about it but made an explicit decision to keep this information from the public and from prescribing physicians. 

How could drug companies get away with this?

The pharmaceutical industry is considered the most profitable and politically influential industry in the United States, and mental illness can be thought of as the drug industry’s golden goose: incurable, common, long term, and involving multiple medications. Antidepressant medications are prescribed to 8.7 percent of the U.S. population. It’s a multi-billion dollar market.

To summarize, there is a strong therapeutic response to antidepressant medication; it’s just that the response to placebo is almost as strong. Indeed, antidepressants offer substantial benefits to millions of people suffering from depression, and to cast them as ineffective is inaccurate. Just because they may not work better than fake pills doesn’t mean they don’t work. It’s like homeopathy—just because it doesn’t work better than the sugar pills, doesn’t mean that homeopathy doesn’t work. The placebo effect is real and powerful.

In one psychopharmacology journal, a psychiatrist funded by the Prozac company defends the drugs stating, “A key issue is disregarded by the naysaying critics. If the patient is benefiting from antidepressant treatment does it matter whether this is being achieved via drug or placebo effects?”

Of course it matters!

Among the side effects of antidepressants are: sexual dysfunction in up to three quarters of people, long-term weight gain, insomnia, nausea, and diarrhea. About one in five show withdrawal symptoms when they try to quit. And, perhaps more tragically, the drugs may make people more likely to become depressed in the future. Let me say that again: People are more likely to become depressed after treatment by antidepressants than after treatment by other means – including placebo.

So, if doctors are willing to give patients placebo-equivalent treatments, maybe it’d be better for them to just lie to patients and give them actual sugar pills. Yes, that involves deception, but isn’t that preferable than deception with a side of side effects? See more on this in my video Do Antidepressant Drugs Really Work?

If different treatments are equally effective, then choice should be based on risk and harm, and of all of the available treatments, antidepressant drugs may be among the riskiest and most harmful. If they are to be used at all, it should be as a last resort, when depression is extremely severe and all other treatment alternatives have been tried and failed.

Antidepressants may not work better than placebo for mild and moderate depression, but for very severe depression, the drugs do beat out sugar pills. But that’s just a small fraction of the people taking these drugs. That means that the vast majority of depressed patients—as many as nine out of ten—are being prescribed medications that have negligible benefits to them.

Too many doctors quickly decide upon a depression diagnosis without necessarily listening to what the patients have to say and end up putting them on antidepressants without considering alternatives. And fortunately, there are effective alternatives. Physical exercise, for example, can have lasting effects, and if that turns out to also be a placebo effect, it is at least a placebo with an enviable list of side effects. Whereas side effects of antidepressants include things like sexual dysfunction and insomnia, side effects of exercise include enhanced libido, better sleep, decreased body fat, improved muscle tone, and a longer life.


There are other ways meta-analyses can be misleading. See The Saturated Fat Studies: Buttering Up the Public and The Saturated Fat Studies: Set Up to Fail.

More on the ethical challenges facing doctors and whether or not to prescribe sugar pills in The Lie That Heals: Should Doctors Give Placebos?

I’ve used the Freedom of Information Act myself to get access to behind the scenes industry shenanigans. See, for example, what I found out about the egg industry in Who Says Eggs Aren’t Healthy or Safe? and Eggs and Cholesterol: Patently False and Misleading Claims.

This isn’t the only case of the medical profession overselling the benefits of drugs. See How Smoking in 1956 is Like Eating in 2016The Actual Benefit of Diet vs. Drugs and Why Prevention is Worth a Ton of Cure (though if you’re worried about your mood they might make you even more depressed!)

In health,

Michael Greger, M.D.

PS: If you haven’t yet, you can subscribe to my free videos here and watch my live, year-in-review presentations:

Discuss

Michael Greger M.D., FACLM

Michael Greger, M.D. FACLM, is a physician, New York Times bestselling author, and internationally recognized professional speaker on a number of important public health issues. Dr. Greger has lectured at the Conference on World Affairs, the National Institutes of Health, and the International Bird Flu Summit, testified before Congress, appeared on The Dr. Oz Show and The Colbert Report, and was invited as an expert witness in defense of Oprah Winfrey at the infamous "meat defamation" trial.


54 responses to “Are Sugar Pills Better than Antidepressant Drugs?

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  1. If they are used at all, like you said, used as a last resort when all else fails, not given out like candy, and only for a short period of time! I was prescribed one after a long battle with severe depression, and very reluctant to add yet another drug to the growing pharmacopoeia, but three weeks later, one morning I arose and it was like walking out of a cave, and the sun came out again. I was astounded and sucked in. It should have only been used to get over the hump, not for an extended period, and getting off of them many years later when I went WFPB was harder and more miserable than you can imagine. Quitting smoking and narcotics was easier! Had the info about diet been accessible from any of the doctors I could have been spared so much misery and damage from RA and other issues, so I am thrilled to see the movement picking up some speed! It can’t happen fast enough!

  2. “Cynicism, depression and boredom are mistakes of the intellect.” said Maharishi Mahesh Yogi.

    Only in America would we develop a money making machine based on an intellectualizing population. 

  3. I was prescribed all the drugs mentioned by name in this article and more. They came with various side effects that often made me feel lousy and some were indeed addictive. Yet only one of them, Prozac, helped, but at a cost. It caused me to loose my empathy for others along with my libido. This contributed to the destruction of my marriage along with interpersonal losses and a loss of the ability to work. It did temporarily relieve my depression, but after two years, lost it’s effectiveness. I’ve since found that re-engaging in life, rather than morning my losses is a much more effective remedy for depression.

  4. Coincidentally I referred to my meds as sugar pills earlier today. It’s ironic ’cause sometimes I feel sugar pills would have a stronger effect.

  5. This is the one area from your book I strongly disagree Dr. Gregor. Your book is outstanding and I have recommended it consistently to my patients since reading it, however I think you tread on very dangerous ground here. My views are based upon 20+ years of clinical experience as an MD, and someone that has been touched personally by both suicide of loved ones and familial depression. There is absolutely no doubt that these medications (i.e. SSRI’s) are not only superior to otc Rx such as SAM-e or St. John’s Wort, but that their clear efficacy has had profoundly beneficial impacts on the individuals taking them. Yes, nutrition, sleep and exercise are critical pieces to mental health, but to discount the validity of Rx options available to assist people in times of critical need is to enhance the risks for acts of self-destruction that can be devastating to all involved. Your stance is baffling to me; somewhat like a throwing the baby out with the bathwater approach.

    1. You are a compassionate MD. Having one’s mental/emotional state acknowledged and nurtured by a compassionate professional, could that be a major component of the ‘drug’ benefit?
      Many folks experience a lessening of depressive symptoms before drugs can take effect: hope is powerful.

      1. That I am, but I can assure based on years of trial and experience that to discount the efficacy of these medications is not only in error, but is reflective of egregious arrogance as well.

        1. To report and reflect upon the research is “egregious arrogance” whereas claiming that your own personal opinions are The Truth is not?

        2. Mmmm, I thought he did support treatment for very severe -suicide risk- patients. Even my mother had SSRI’s thrown at her when she complained of fluttery feelings/edginess and energy slumps: she had low blood sugar. I’m betting 9 out of 10 would be better off with other treatment (I’m no scientist) however, ‘other’ treatment is often nonexistant on health insurance

        3. This website promotes a science-based view of diet and medicine. Personal testimony is not considered valid science. Have you not considered that the prescription drugs you gave your patients worked better than the OTC drugs because your patient were expecting them to work better, hence a stronger placebo effect?

          Please stop spreading your unscientific and potentially harmful views. SSRI’s have a black box warning for a reason and their use is not justified based on the evidence.

          1. I will not stop spreading the truth of years of professional practice and experience. Of countless lives aided and at times outright saved. Whereas you may place your faith on “research”, I stand by the validity of my scope of experience. And yes, it is clearly more than a placebo effect. Most patient’s when they take these medications do not “believe” it will provide the benefit it ultimately does. The surprise to them is the actual, and commonly profound, efficacy seen. It is always a bit of a shock to discover how much chemistry drives their mood and energies. We would like to believe we can correct neurotransmitter imbalances by pulling ourselves up by our bootstraps but it simply doesn’t work like that. No more so than a patient suffering from Hashimoto’s disease, Diabetes mellitus, or Hypogonadism can correct these hormonal imbalances with attention on diet and exercise alone.

            1. I also have personal experience with anti-depressants. I was told as a teenager that the reason I was skipping high school was not the poor quality of education it provided but rather a “chemical imbalance” in my brain that would never go away without taking SSRIs. When I refused, I was taken to court by psychiatrists who lied to the judge saying I was a “danger to myself and others”, and was then forced to take these drugs on court order. They provided me with no benefits and I believe they gave me suicidal thoughts (a known side effect). As much as your experience tells you SSRIs are beneficial, I also have a good deal of experience telling me they are harmful.

              But in the end, neither of our personal experiences will actually tell us whether these drugs are effective, only science will. As far as I know, there is no actual medical test that can show there is a chemical imbalance in a persons brain, and the whole theory was based off of questionable studies done on rats. If we went back a few decades, we would see doctors telling us how the lobotomies they performed have helped thousands of patients, and like you would have no interest in looking at the actual research that said otherwise.

              1. Well your experiences have clearly impacted your present perspectives. Regardless, we are all unique chemically driven beings and your personal experience doesn’t discount the potential value of these medications for others. 20+ years of trial and experience is all of the “research” or “science” I need. It’s safe to say I have an extremely larger sample basis to draw these conclusions then your own Sir. There are thousands of people who can echo these sentiments I’ve shared.

                1. There are also thousands of people that can echo the sentiments I’ve shared, so what’s your point? For a disease that usually resolves on it’s own without any intervention, personal anecdotes are not a good way of determining what the effectiveness of a drug is.

                  I’m really curious why you keep using the words ‘science’ and ‘research’ in quotations? Are you saying that the decades of suppressed studies showing anti-depressants to ineffective are wrong, or are you trying to say that you dismiss the scientific method altogether? If it’s the former, then prove it, if it’s the later, than I would like to know what makes you any different than a witch doctor or snake oil salesman?

    2. As a depression patient who is treated by a wonderful gp who is definitely not “give out meds like candy” I would like to confirm that you are right. I now know that meds are more than just helpful. I love my life now, (I did not before). You are right about everything you wrote. I know you are right, I am on the other side, the patient side. I know first hand that meds work.

      Let people talk, as they will always do. Know that you are doing the right thing with your patients. You are truly helping them and I know you are not an evil person making money out of prescribing drugs that don’t work and only have side effects. Thank you for writing on this post. As a physician you have a lot more credibility than me who is just a patient. :-)

    3. As much as I treasure Dr. G’s commitment to his cause, I also have to say as a patient, he’s way off on this one. Like many of the illnesses the good doctor opines on, it’s difficult to ascertain a sense of where he stands on the role of genetics in the equation. I am turning 55 and have seen the members of my previous generation on both sides wrestle with various anxiety disorders my entire life. These people ranged from very health conscious to not so much. I don’t know how many of you have experienced a moderate form of depression or panic disorder. But let me tell you something. You want to talk about side effects?? Sexual dysfunction??? LMAO. I was so happy to be done with my psych issues that you could slice my entire duct work right off and I wouldn’t have gives a rats butt! Again, I love the way Dr. G. stacks this site with the best ways to maintain good health. He is awesome. Unfortunately however, there are plenty of people who eat nothing but broccoli and blueberries every day after their 1-hour jog, and get cancer or drop dead of a heart attack at age 50 anyway. The drug companies are a necessary evil my friends. No way around it.

          1. “Obviously flawed”? Obvious to whom? He is first referring to a meta-analysis. This is a review of of published and unpublished studies, many of which were hidden by big pharma and only revealed through FOIA inquiries.
            You believe the studies are flawed because in your experience, you found drugs beneficial, but this does not say the drugs have NO effect. They seem to work in some cases, but only as well as placebos. I have taken fluoxetine off and on for 25 years. I find it beneficial at times. Is it placebo? Could be, but when I am exercising and eating WFPB and no junk and still find myself sliding into what may be SAD and circumstantial depression, I take the pills. It works. I can’t argue with the studies, because I have done enough research to know that the placebo effect can work even when we KNOW it is placebo. You, on the other hand, want to say that your experience disproves the clinical evidence and that is, indeed, disordered.

            1. “Clinical evidence” is working with these issues (anxiety/depression/mental illness) as a physician for years and seeing the results and benefits firsthand for hundreds of people. Most, but not all. To attribute all of this to a “placebo” effect, stems simply from a lack of similar experience and knowledge, or what one may call ignorance.

                1. I don’t believe in studies PERIOD. The entire World is full of BS. I’ve worked at Johns Hopkins for 20 years, and I trust what my top-notch Hopkins docs tell me. So far it’s been a blessing to be here for both me and my family. Take all the sugar pills you want. I’m sticking with my Cymbalta because I believe neurotransmitters actually exist, actually play a major role in depression and anxiety, and can actually be manipulated into functioning well. I also believe we landed men on the moon, and have little time for conspiracy theories.

                  1. I’m seriously curious what you’re doing on this website if you “don’t believe in studies PERIOD.” This site ONLY looks at studies. Period. That’s all that happens here day after day. Maybe you just mean this study?

                    1. Right. Good question. The answer is ….Occasionally I’m curious to find out if there are any studies that confirm what I see in my own work. Sort of an icing on the cake if you will. But I would rarely take any research displayed here as carved in stone.

                  2. That’s fine, I am sticking with fluoxetine until Spring. It seems to work for me. This is not a conspiracy theory, it is a fact that corporations often hide studies that go against the fiscal interests of the industry.

              1. No that is not Clinical evidence, that is your personal, anecdotal experience DOCTOR Andrew. Your arrogance is a big part of the problem. I want to see you back here with an analysis of all the relevant Clinical evidence that supports your personal experience. Now scoot.

                1. In fairness, I doubt if patients lie much about feeling relief from depression. From my experience with depressives episodes, I would do anything to get relief, and I would be incapable of hiding the fact that a med wasn’t working. Depression is like a grotesque pain, and I would be desperate to continue trying to find something that works.

                  1. I agree.
                    It is just that I understand that many patients are said to lie about taking their medications. Also, in an unstructured one-on-one environment, especially involving an authority figure like a doctor, there is a desire to please the other person. This can be compounded by asking questions like “have the medications helped?” Such questions invite a “yes” answer. This is an issue that cognitive psychologists, trained interrogators and professional survey designers are aware and take steps to avoid. I am not so sure that many physicians are as aware of the pitfalls of asking questions in the wrong way..
                    It is a particular problem, I imagine, with depression where symptoms and responses are largely assessed by patient reports rather than eg lab tests or descriptions of physical changes. It is why I am wary of accepting reports like Dr Dale’s at their face value.

                    1. Yes, I am reluctant to accept such reports as well. And, you are right about the lying to docs, something I have never understood. I don’t recall being intimidated by doctors or afraid to ask questions and I don’t recall ever intentionally lying to a doctor. I go to them for medical care, not approval.

    4. I have to agree with Dr. Dale. I absolutely love this website and its views on nutrition, etc. And no amount of name calling (“witch doctor”, “snake oil salesman”) can convince me that anti-depressants are only high-priced placebos. Like Dr. Dale, I’ve been in practice for 30 years. 20% of the US population suffers from depression at some point in their lives. That’s a lot of people, which means that I’ve seen an awful lot of depressed people over the years. And I’ve seen it over and over again……people respond to anti-depressants. It is a placebo effect? Maybe. But if it is, why are some effective for a given individual and others aren’t? Is it because I have to give them the right placebo? There’s probably truth in both arguments. But like Dr. Dale, I think it’s dangerous to just write off antidepressants as totally useless.

  6. Hi there!

    I was searching for information about ‘Lectins’ in your website and in your book “How not to Die” and there’s none. It seems that it’s pretty bad for the health and a lot of food that here appears as a healthy, ‘allegedly’ is not, because its amount of Lectins, as All grains. Nightshades including tomato, peppers, potato, and eggplant. Gluten from wheat, rye, barley, malt, and maybe oat. Legumes – All beans including soy and peanut. Dairy including milk, and milk products as cheese, cottage cheese, yogurt, and kefir. Yeast (except brewer’s and nutritional). All lot of fruits and vegetables… Would you please explain the ‘Lectin’ ‘thing’ in the aliments and if it’s toxic or not? Thank you!

    1. Sometimes it is hard to see the forest for the trees. Especially when there is so much misplaced hysteria about lectins. First let’s look at the forest, that is, health and longevity of large groups of people eating plants containing lectins.

      If lectins in food are bad for humans why are beans the most important dietary predictor of survival in older people studied in four different countries?
      “Increased Lifespan from Beans”
      http://nutritionfacts.org/video/increased-lifespan-from-beans/
      If lectins in beans, grains and other plants are so bad why are the Seventh-day Adventist vegetarians of Loma Linda, CA, USA the longest living Blue Zone population?
      http://nutritionfacts.org/video/the-okinawa-diet-living-to-100/
      Have you ever read of a Blue Zone consisting of people eating a Paleo type diet?

      Now let’s look at the trees, that is, lectins specifically and “antinutrients” in general (although that term is unfortunate for biochemicals that have such beneficial effects on plant consumers).

      According to the nutritionist Jack Norris who has a reputation for thoroughly reviewing the scientific literature, there are few studies on humans in vivo regarding lectins specifically. Most studies are on animals and/or were performed in vitro. Perhaps that is why Dr Greger doesn’t directly talk about lectins, although it is obvious from the foods he recommends that he isn’t concerned about the potential negative effects of lectins in foods properly prepared. That said, Jack Norris’ conclusion from the available data is that short of eating raw beans, which few rational people do, it is doubtful that you should worry about lectins.

      Here is a blog (with some links to references) written by a registered dietitian that summarizes “antinutrients” including lectins. Her conclusion is also not to worry about lectins.
      http://www.thinkybites.com/content/2015/8/14/wlur78iyulmfvk47mywyhtnclojoaz

    2. Sprouting and then cooking beans and grains greatly diminishes the amount of lectins in these foods. There are substantial nutritional and health benefits to these foods, so avoiding them because of the lectins severely limits the healthy foods you can eat.
      John S

  7. “What if a drug company decided only to publish studies that showed a positive effect, but quietly shelved and concealed any studies showing the drug didn’t work?”

    Then surely the company would be held to the rule of law and suffer the penalties afforded to scoundrels.

    1. You would hope but the government doesn’t care because they’re making money off of the situation themselves. If you look again at the post you’ll see that the FDA KNEW about the studies and to this day has done nothing but tacitly approve of the situation.

  8. As Dr. Greger stated, severe depression really does demand stronger medications vs. “sugar pills.” I have moderate depression, which has been improved greatly by St. John’s Wort, “placebo effect” notwithstanding. I think Dr. Greger’s “1 in 5” people experiencing serious side-effects when trying to d/c Rx antidepressants is way too conservative. I’ve worked in psych facilities as a counselor for some 30 years and I can tell you it’s AT LEAST 2 out 5, probably more. Patients are routinely admitted on the unit just to begin the taper-off. And why? Because of the “brain zaps,” the confusion and mental anguish, the physical debility (etc.) that come with these med withdrawals!
    On top of that, the side effects from almost all psych meds (anxiolytics, antidepressives, antipsychotics, etc.) can be summed up thusly: A RUSH TO OLD AGE. Since they are CNS inhibitors, general fatigue, poor thinking and concentration, memory problems, etc., are the tradeoffs. If someone really needs Rx antidepressants (and many do), then fine. But in my opinion, far, far too many of these prescriptions are written when counseling and lifestyle changes would accomplish the same and provide many extra benefits. But then, Rx meds are much faster and easier than having to hire creative, competent staff who can reach out, communicate, motivate and follow up over time with the patient. NOPE, you admit ’em, snow ’em, Rx the hell out of ’em and then throw ’em back out when they’ve, ah, “stabilized.” They return again and again, of course, in similar dire straits, because the meds didn’t work, or they hate the side effects, and/or nobody ever helped them gain real insight, motivation and understanding re their mental health situation.
    Didn’t mean to get carried away, but I do find this situation so very frustrating.

  9. Dr. Greger has shown such critical thinking when it comes to nutrition, it’s a little surprising to see his bias creep into the world of psychiatry. The first antidepressants, MAO inhibitors, were discovered totally by accident. It turns out that some of the antibiotics used to treat tuberculosis in the 1950’s were MAO inhibitors, and it was observed that some of the patients with TB who were taking these drugs experienced an elevation of their moods. It’s a big stretch to attribute this result to a placebo response. It seems very unlikely that people in the unhappy situation of being treated for tuberculosis would have the expectation that what they were taking would lead to a mood improvement. Remember, this was at a time when no medication had ever produced such a response. Another early compound, imipramine, was being studied as a possible medication to increase the effectiveness of chlorpromazine,an antipsychotic, when it was noted to have a beneficial effect in relieving depression with both motor and mental retardation, something totally unexpected.

    Rather than assume all antidepressant medications (more than 40 such medications have been marketed in the United States) are no better than placebo, the question I would expect him to ask is, “Are there reasons other than ‘the placebo response’ which could explain the results of large meta-analyses?” I would like to suggest one reason would be the change in the patient selection for such research. The first patients taking medication in which an antidepressant effect was noted were selected for some other reason. The mood elevating effects in some patients were more than could be explained by the fact that their medical problems improved. Some became almost euphoric. Explaining away a mood elevating effect in a medication used to augment chlorpromazine is evan a little more difficult.

    In the last 65 years, the characteristics of people who think they have a depressive disorder have changed. In the 50’s and 60’s, depression wasn’t talked much about. People coming in for treatment may have had a different problem than those presenting today. Not only is the stigma less, but the medicalization of a bad mood has lead to people claiming to have a psychiatric disorder as a reason for their ongoing misery. The number of people presenting to physicians’ offices complaining of “racing thoughts” and “mood swings” has grown exponentially. Has the incidence of bipolar disorder really exploded, or is something else going on?

    There is no objective test for depression. People selected for research studies are chosen mostly on the basis of self reported symptom severity, measured by questionnaires. Could it be that the people receiving high scores today are not the same as people in studies 50 or 60 years ago?

    I am suggesting that there is so much noise in the system now that it makes a quality meta-analysis impossible. At this point, in answering the question regarding the effectiveness of antidepressant medication, we are still waiting for one of Dr. Greger’s “until now” moments.

    1. Dennis,

      Interesting insights. Well, how about an “until now” moment ? …….

      The use of urinary neurochemistry and fMR’s along with SPECT scans has brought lots of new insights.

      The simplicity and cost effectiveness of the urinary testing should be among the required labs, prior to treatments.

      Without getting into the placebo issues lets consider my and other physicians experiences of profound patient changes, with the elimination of allergens in their diet to lowering levels of endocrine disruptors, to name just two aspects.

      To approach the issues of depression, a whole person chemical evaluation should be a starting point, not just the typical Hamilton scores or other self-reported observations and then RX’s.

      As to noise….nah… we are seeing a significant level of depression clinically which I believe is directly related to a host of issues from lifestyles to chemical toxins.

      Do some anti-depressants seem to really work……I’ll admit I rarely prescribe them however, they have a place in treatment very occasionally for the correct patient, as Dr. Greger suggested, it’s the rare patient.

      Dr. Alan Kadish moderator for Dr. Greger

      1. I suspect that in the next few years, we will have a true “until now” moment. I agree that new insights into brain chemistry and neurophysiology may help us better identify people with depressive symptoms in a more homogeneous fashion, so we can see if there are groups for whom such medication is most likely to be beneficial. I hope so. I can’t count the number of people who have explained away their unfortunate life circumstances and inability to have successful interpersonal relationships “because I’m bipolar.” An explantaion like that, clung to so tenaciously, makes it impossible to suggest another approach which might be more effective, if somewhat more difficult than swallowing a pill.

        But the reality is today that there are no biological markers identified as yet which have any utility in diagnosis in the office setting.

        I’m in total agreement that diet contributes to a lot of emotional misery these days, probably more than most people realize and certainly more than many patients are willing to accept.

        “As to noise….nah… we are seeing a significant level of depression clinically which I believe is directly related to a host of issues from lifestyles to chemical toxins. ” I was talking about noise in the selection of patients in research studies. We just cannot be sure that the patients in Study A with elevated HAM-D’s are the same as those in Study B. And if their not, it makes it more difficult for a meta-analysis to show anything significant.

        In some ways, you make my point. Patients who presented to doctors in the 50’s and 60’s saying they were depressed may not be the same as those today, due to a myriad of changes in lifestyle and the chemical environment in which we exist. All “depression” may not be the same. And if that’s the case, it would be reasonable to consider the possibility that anti-depressant medication may be very effective on some sub-groups of folks with the complaint of “depression,” but not others.

  10. Dr. Gregor, I’m a physician and typically I love your content but I’m concerned with your message on this particular issue. I agree with another physician below, that it can be potentially dangerous for someone with your influence to undermine psychiatric treatment. My eyes are open: pharm industry is profit-driven, data is manipulated, providers over-diagnosis and over-prescribe, people are lazy and want a pill instead of changing their lifestyle. The system sucks and there’s metadata to challenge the other metadata that says it works. So what? Metadata is great if you want to opine academically, politically, or conceptually but what does it have to do with the crying, apathetic mother in my office who already doesn’t want to take any medication? Or the psychotic young man who just needs an excuse to trash his pills? Or the traumatized soldier from deployment whose family is disintegrating? I have seen drastic improvements in quality of life with these treatments and just as many patients have attested here, their lives were changed, or even saved. There is already overwhelming obstacles and stigma to obtaining mental health care and a growing anti-mental health movement which is fear and pain based (not data based), I don’t want to add nutritionfacts.org to the list of things that can get prevent me from helping my patients. Sir, be careful with your words.

  11. Dr. Greger, I’m a physician and typically love your content however I agree with concerns from another physician below, that your perspective may undermine psychiatric treatment and that’s potentially dangerous for patients. My eyes are open: biopharm industry is profit-driven, data is manipulated, providers over-diagnose and over-prescribe, people are lazy and want a pill instead of changing their lifestyle. Now you’re pointing to metadata which challenges established metadata that says psychiatric medication works. Since then several studies have emerged challenging the original 2008 study and so it goes. So what? What does metadata have to do with the apathetic, crying mother who can barely take care of herself let alone her children and is hesitant in treatment? Or the dangerously psychotic young man who already wants to throw his pills in the trash? Or the traumatized soldier back from deployment who can’t stop thinking of hanging himself with his kids in the next room? All real cases, not hyperbole. Metadata is population level, great for academic, political, or conceptual opining but for those of us on the front lines of a growing, potentially deadly, mental health epidemic in this country, with sick patients in front of us, you’re language isn’t as objective as you might think and invalidates a lot of blood, sweat and tears, both patient and providers alike. There is already an overwhelming amount of resistance, obstacles, and stigma to obtaining mental health, in addition to a growing anti-mental health movement which is pain and fear based (not science/data based). I don’t want to add nutritionfacts.org to the list of things that can prevent me from helping my patients. I have seen drastic improvements in quality of life with these treatments and as many patients have attested here, they have changed or even saved their lives. Readers, read the link from the actual article, it reads differently than Dr. Greger’s interpretation: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3736946/. Sir, I commend your pursuit of the truth but please be careful with your words.

    1. I agree with the above. I am also a physician.. I think he danger is that the average reader is going to take away the idea that “all psychiatric meds don’t work better than placebo” – that is a catastrophic misunderstanding and needs to be clearly articulated as mood stabilizers, antidepressants, antipsychotics etc. save lives daily when it comes to patients with serious mental illness. I think consultation with other psychiatrists can help bring more balance to this article. – Doc T

  12. Sorry for the typo, “their” instead of “they’re,” but the tiny window for replies makes proofreading difficult. ;)

  13. This is a big issue in the world of mental health, and of course in this article you are only able to scratch the surface of the debate.
    I work as a psychological therapist. Whilst I find it concerning that SSRIs work for only slightly more people than placebo, there are a number of things to consider:
    1. This finding takes place in the setting of randomised-controlled trials, which may be quite different from normal prescribing settings;
    2. Cognitive-behavioural therapy (which has the best evidence for the treatment of depression) also works only slightly better than placebo and SSRIs (although has longer-lasting effects).
    3. Cochrane reviews do appear to find some antidepressants are beneficial in certain circumstances http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006117.pub4/full
    4. Please be aware that you may also have a bias in which research you report – would you have posted this if it said that medication was more helpful? You are reporting a finding 9 years later, and much more research must have taken place since then.
    5. I’m sorry to say it, but many antidepressants are cheap, both in financial costs and in time for the physician. This may be partly why they are doled out when there are clearly other issues causing people to be depressed.
    6. You fail to mention the nocebo effect, in which people can experience side-effects from a placebo.

    Speaking from my experience at work (as someone who is cynical about medications), I have to admit that I have seen the positive impact of antidepressants. I would say from my experience that antidepressants ‘take the edge off’ symptoms, which enables patients to benefit more fully from lifestyle and thinking changes as a result of therapy. Whether there is some kind of interaction which leads people to start noticing every time their mood picks up slightly, and this leads them to feel more hopeful, I don’t know (this may account for the placebo effect). If placebos would have the same impact that would be great.
    Many people who are depressed are so desperate, they are willing to take anything that will help – even if it is just the placebo effect. In much the same way, smokers often pay a lot of money for hypnotherapy, which also harnesses the same processes.

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