The two papers by Middleton and Moncrieff,1 and Anderson and Haddad2 published in the January edition of the Journal highlight a fundamental fault line that runs under the concept of depression: the current conventional rationale for treatment of depression with antidepressant medication is increasingly untenable. It has been recognised for some time that the serotonin hypothesis that provides the explanatory model for the supposed action of selective-serotonin reuptake inhibitors is not supported by current evidence.3 Despite this the model remains dominant, largely through the efforts of the pharmaceutical industry to cultivate a profitable sector of the market. As a result we have a pseudoscientific myth that pervades our approach to human distress.4
There is now substantial evidence to suggest that antidepressant drugs exert their effects through mechanisms such as an active placebo response5 and by inducing non-specific abnormal mental states rather than by any specific ‘antidepressant’ action.6 Although many clinicians and patients report improvements in depressive symptoms associated with the use of antidepressants, it is ethically questionable to justify treatment based on a naïve and misleading hypothesis.
A critique of the use of antidepressants would necessarily involve a reappraisal of our understanding of the concept of depression itself. There is growing concern that the term is increasingly used inappropriately to medicalise normal human experience.7,8 Such a strategy, if pursued to its logical conclusion – as currently seems to be the case with the development of DSM-V – would effectively convert much of human experience into overly simplistic technical problems, to be addressed by biomedical solutions that are likely to be ineffective and possibly harmful.9
The widespread use of these agents needs to be reconsidered particularly within primary care where they are least likely to be of benefit. It is time for us to rise to Middleton and Moncrieff's challenge and to recognise that antidepressants are ‘unlikely to do any good and may do some harm.’
REFERENCES
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