I recently ran across this interesting article (found here) which is the latest in a long series over the years comparing antidepressant efficacy to placebos. I know that this is a controversial subject with some believing that all (or most) of antidepressant effect is placebo effect and others believing that antidepressants do indeed work better than placebos, especially among the most severely depressed patients. The researchers in this article did a review of several trials and concluded that antidepressants work better than placebo in those with mild and moderate depression. The most interesting statistic from this paper in my mind is this: in this, the most positive analysis that I have read on the effect of antidepressants, the “Number Needed to Treat” (NNT) to have one patient do better than by placebo alone was five (5). In other words, 4 out of 5 patients in this study got no benefit from the antidepressant over placebo.
What does this mean? This statistic does NOT mean to me that we should stop prescribing antidepressants because that they are worthless. Many depressed patients probably would respond to a true placebo–but we can’t prescribe placebos! It is unethical in the real, clinical world to give someone a pill with no active ingredients and not tell them that you are doing so–which kind of defeats the purpose of a placebo. When antidepressants are given to truly depressed patients, something like two-thirds benefit. To me, how much of this benefit is due to placebo effect is irrelevant, since I cannot prescribe a placebo. What I DO take away from this discussion is that a lot of antidepressant effect is placebo effect. I think most psychiatrists would agree with this. And this is important. How you initially present the antidepressant to the patient is critical to how well it eventually is going to work.
With that in mind, I want to present my “antidepressant speech.” This is the speech I use for patients with mild-moderate depression. I have honed this speech over many years and I find it works well for me. I am sure that others have better speeches. I would love to hear about them so I can make my own speech even better. Please critique! That is the point.
The idea of the antidepressant speech is to enhance the placebo effect of the antidepressant I am going to prescribe. The main barrier to this are the false expectations of my patients as to what the antidepressant is going to do. If a patient thinks that the antidepressant is going to have some effect, and it does not have that effect, then the patient instantly loses faith in the antidepressant. Then the antidepressant will not work because the patient doesn’t believe anymore that it will work. Here are the most common false beliefs about antidepressants:
1. The antidepressant will work right away. Before I wised up to this, I don’t know how many times I prescribed an antidepressant and then, within a week, had the patient complain that it was not working. Sometimes they would complain the next day! One reason for this is that street drugs give immediate effects. When inmates smoke meth or inject heroin, they feel the drug effect right now. So they come to believe that this is how drugs work. Antidepressants, of course, are not like this. You do not get the full effect of a typical antidepressant for up to 12 weeks. I need to explain this in my speech.
2. The antidepressant will take away all of my bad and negative emotions. This, of course, is not true. No antidepressant will make inmates like being in jail or enjoy being away from their loved ones or look forward to a jury trial where they likely will be sent to prison. That is why “Rah-Rah” speeches don’t work. If you say to a patient “This is going to make you feel great,” and it doesn’t make him feel great, you have lost the battle. In my speech, I need to convey the idea that the antidepressant is going to help, but in a subtle way. (As an aside, this principle is why it is important to make an accurate diagnosis of true depression by DSM-IV criteria in the first place before prescribing the antidepressant. All people are going to be unhappy about being in jail. That is normal. Don’t treat normal as if it is a disease).
3. If a little is good, more will be better. This is not true of most antidepressants, especially the SSRIs. The dose is the dose. We know that antidepressants will not take away all bad and negative emotions, but if the inmate thinks that they are supposed to, they will constantly be asking for more. If we prescribers play into this, we can get onto a treadmill where we prescribe higher doses and then other medications and then even more medications in a fruitless attempt to achieve something we can never achieve. Instead, we will end up dealing with a myriad of negative side effects. This kind of high dose poly pharmacy often hurts patients more than it helps them.
Also because most of antidepressant effect is placebo effect, patient will likely get no benefit from increasing doses. They are unlikely to “believe” in the bigger dose more than the smaller dose, especially if I include this in my speech. Once again, I am more likely to cause noxious side effects with increasing doses than I am to get a better outcome.
So here is the typical speech for antidepressant prescriptions to patients with mild-moderate depression. I am going to use citalopram as an example:“The mental health worker and I have been talking about you and we think that you probably will benefit from an antidepressant. I’m going to prescribe a medicine to help your depression and I need to tell you a little bit about it. The first thing is, and you probably know this already, is that no antidepressant is a magic pill. You won’t take this and wake up tomorrow thinking “I’m so happy! I love being in jail!” (aside: most inmates laugh at this point). In fact, in order to work, these medications have to build up in your blood for several weeks. You may feel improvement right away, but if you take this medicine for a couple of weeks and you don’t think it is doing enough–you’re still going to get more. At 4 weeks, you’re still going to get more, at 6 weeks, you’re still going to get more–all the way until around 12 weeks. At 12 weeks, you will have gotten everything you’re going to get. But most people at that point say ‘You know what? I’m feeling better, at least a little.’ You still won’t like being in jail, no drug will make you happy about that or get rid of the stress of your legal situation and the courts and all that. But most people say that an antidepressant helps. I’m going to use a medication called citalopram. It is also called Celexa. A variation of this is called Lexapro. You may have seen these advertised on television. They are maybe the most prescribed antidepressants in the world. Citalopram is cool because usually, you don’t have to increase the dose. The dose I prescribe is the dose–there is no need to increase the dose later. Like all drugs, citalopram sometimes has some side effects I am going to tell you about. Some people just don’t like the way it makes them feel–but most people do fine and even say it helps. If it makes you feel worse in any way, will you please let us know? Citalopram can sometimes can cause problems with your sex life (aside: many inmates laugh here too. ‘I don’t have a sex life. I’m in jail’) but most people get along OK. Some people say it helps them to sleep,, others say they need less sleep when they take it. Those are the big ones. Besides taking citalopram, you need to work on helping yourself. The mental health workers have discussed this with you. If you stay active by exercising and reading and playing games and talking to others, you will do better than if you don’t. Do you have any questions?”
So that is my basic speech. The delivery varies, depending on the patient, of course. But even with questions, it usually takes less than 5 minutes. Hopefully, after hearing this, patients will not expect immediate results, will not expect the antidepressant to make them perfectly happy and will not expect an ever bigger dose to work better. Since I began using this speech, my success rate with antidepressants has improved dramatically, meaning that I get fewer complaints that the medication is not working, fewer requests for dosage increases and, well, fewer complaints of any kind.
What do you say in your antidepressant speech? How could I improve mine? Please comment!