Our recent paper evaluating whether antidepressants do more harm than good was recently reviewed by the Finnish journalists Jussi Valtonen and Aku Kopakkala in the Finnish magazine, Psykologi, and it drew critical response from a Finnish psychiatrist—Dr. Matti O. Huttunen. Dr. Huttunen’s response is written in Finnish and he holds the copyright to it. However, with my colleague, Andy Thomson, I wrote a rebuttal to Dr. Huttunen, which was published in the October, 2012 issue of Psykologi. We publish the English version of it here.
Dr. Huttunen defends antidepressant medications and other psychotropic drugs against several criticisms that have recently been levied against them, which were reviewed in the original article by Jussi Valtonen and Aku Kopakkala. At the end of his letter, Dr. Huttunen states: “Improving psychiatric care requires continuous research and criticism founded on research.” However, much of his letter displays a startling disregard for scientific evidence and argument.
For instance, he repeatedly appeals to his own clinical experience, and the clinical experience of other psychiatrists, as evidence that antidepressants are effective in reducing symptoms. “Every psychiatrist who has worked in the field for a while has come across patients for whom antidepressant drugs are clearly beneficial, and this is even more so for antipsychotics.” Of course, clinical observation plays an important role in the scientific process, primarily by generating hypotheses. But it does not constitute evidence in any rigorous sense. Formal scientific studies are needed to correct misperceptions and erroneous beliefs, and to control for the powerful placebo effect prevalent in the treatment of emotional disorders.
Also troubling is how he treats evidence about the harmful effects of antidepressants. Dr. Huttunen cites a paper we recently published reviewing the beneficial and harmful effects of antidepressants (Andrews et al., 2012), and he acknowledges that these drugs “cause various, often uncomfortable and sometimes even dangerous adverse effects”. Nevertheless, he states that antidepressant treatment is “not fundamentally unjustified or harmful according to current understanding.” His explanation? “In reality, if a drug shows clear adverse effects, it should be discontinued or the patient switched to another one utilizing a different mechanism of action.” Elsewhere, he acknowledges that many physicians prescribe drugs when they shouldn’t and continue them longer than they should, so this explanation hardly seems compelling.
Dr. Huttunen also ignores the primary scientific evidence that we relied on to argue that antidepressants do more harm than good. Depression is associated with many life-threatening illnesses and conditions, such as an increased risk of heart disease, stroke, diabetes, and suicide. For this reason, many physicians believe that antidepressant medications are effective in reducing the symptoms of depression and save lives.
But antidepressant medications also have many negative side effects—digestive problems, sexual dysfunction, abnormal bleeding, stroke, certain forms of cancer, developmental problems in infants, and dementia in the elderly. While some of these problems also occur in depression, antidepressant use increases the chance they will occur. Moreover, some of the side effects can be fatal.
The crucial issue, then, is whether antidepressants save more lives than they take. The most direct way of addressing it is to look at how antidepressant use affects the chance of dying from any cause. In examining this issue, it is important to take into account that depression itself is associated with an increased risk of death. So if antidepressants do more good than harm, as Dr. Huttunen presumes, the prediction is that among people with depression, antidepressant users will have a lower risk of death than non-antidepressant users.
We are aware of five studies, each from a different research group, that attempted to estimate the effect of antidepressant treatment on the risk of death. All five studies found that the risk of death was higher among older people (>50 years old) receiving antidepressant treatment, especially if they were also depressed. We reviewed three of these studies in our paper, and the estimated risk of death was nontrivial. In a study published in the British Medical Journal, antidepressants were estimated to cause 10 to 44 deaths out of a 1000 people over a year, depending on the type of antidepressant (Coupland et al., 2010). In comparison, the painkiller Vioxx was taken off the market in the face of evidence that it caused 7 cardiac events out of 1000 people over a year (Bresalier et al., 2005). Since cardiac events are not necessarily fatal, the number of deaths estimated to be caused by antidepressants is arguably of much greater concern.
An important caveat is that these studies were not placebo-controlled experiments in which depressed participants were randomly assigned to placebo or antidepressant treatment. For this reason, one potential problem is that perhaps the people who were taking antidepressants were more likely to die because they had more severe depression. However, the paper published in the British Medical Journal was able to rule out that possibility because they controlled for the pre-medication level of depressive symptoms. In other words, even among people who had similar levels of depression without medication, the subsequent use of antidepressant medications was associated with a higher risk of death.
The best evidence that we currently have suggests that antidepressants take more lives than they save. It is this evidence that led us to argue that antidepressants do more harm than good. Dr. Huttunen, and other psychiatrists who defend antidepressant drugs, claim to be concerned about the welfare of their patients. Yet the research showing an increased risk of death with antidepressant use is largely ignored by mainstream psychiatry. Why? It cannot be because these papers were published in obscure places. Four of the studies were published in reputable medical journals—The British Journal of Psychiatry, Archives of Internal Medicine, Plos One, and the British Medical Journal. The fifth study was presented this year at the American Thoracic Society conference in San Francisco and received a good deal of media attention. Moreover, the Women’s Health Initiative study (Smoller et al., 2009) is the same study that previously identified the dangers of hormonal replacement therapy for postmenopausal women.
Dr. Huttunen makes other scientifically and medically irresponsible statements. For instance, he refers to debates about the safety and efficacy of antidepressants and antipsychotics as “doctrinal disputes among psychiatrists, psychologists, and psychotherapists” and that patients suffer the most from these disputes because they will often refuse the treatment that they need. But debates about the safety and efficacy of antidepressants and antipsychotics are not doctrinal disputes of the sort that plagued psychoanalysis. We are not arguing over whether castration anxiety and penis envy are normal parts of psychological development in men and women.
An accusation of scaremongering distracts from the legitimacy of the questions that are being raised. In all of clinical medicine, two fundamental questions about any treatment are: Is it effective? Is it safe? There is now a rigorous debate on antidepressants’ effectiveness. Our focus in this response to Dr. Huttunen is that we should all be troubled by the fact that research questioning the safety of antidepressants has been presented and ignored.
Paul W. Andrews, PhD, JD
Department of Psychology, Neuroscience & Behaviour
J. Anderson Thomson, Jr., MD
University of Virginia
Counseling and Psychological Services, Student Health
Conflicts of interest: The authors report no conflicts of interest.
© Copyright to the English version is retained by the authors.
Almeida, O. P., Alfonso, H., Hankey, G. J., & Flicker, L. (2010). Depression, antidepressant use and mortality in later life: The Health in Men Study. Plos One, 5(6): e11266.
Andrews, P. W., Thomson, J. A., Jr., Amstadter, A., & Neale, M. C. (2012). Primum non nocere: An evolutionary analysis of whether antidepressants do more harm than good. Frontiers in Psychology, 3, 117.
Bresalier, R. S., Sandler, R. S., Quan, H., Bolognese, J. A., Oxenius, B., Horgan, K. et al. (2005). Cardiovascular events associated with rofecoxib in a colorectal adenoma chemoprevention trial. New England Journal of Medicine, 352, 1092-1102.
Coupland, C., Dhiman, D., Morriss, R., Arthur, A., Barton, G., & Hippisley-Cox, J. (2011). Antidepressant use and risk of adverse outcomes in older people: Population based cohort study. British Medical Journal, 343, d4551.
Ryan, J., Carriere, I., Ritchie, K., Stewart, R., Toulemonde, G., Dartigues, J. F. et al. (2008). Late-life depression and mortality: Influence of gender and antidepressant use. British Journal of Psychiatry, 192, 12-18.
Smoller, J. W., Allison, M., Cochrane, B. B., Curb, J. D., Perlis, R. H., Robinson, J. G. et al. (2009). Antidepressant use and risk of incident cardiovascular morbidity and mortality among postmenopausal women in the Women's Health Initiative Study. Archives of Internal Medicine, 169, 2128-2139.
For a description of the study presented at the American Thoracic Society conference in San Francisco, see http://www.eurekalert.org/pub_releases/2012-05/ats-aua051412.php.