Antidepressants

This chapter amplifies the work of Roland Kuhn on the first tricyclic antidepressant and then reviews the advent of controlled trials, concerns over the placebo response, the shift to active placebos, and an increase of the placebo response over time. The results of meta-analytic studies on antidepressants are reviewed, noting the similarity to meta-analytic studies of antipsychotics, with both classes of drugs showing little improvement in efficacy. The problems with methodology and publication bias will be examined, as well as the ongoing debate over the influence of severity and gender on efficacy. The impact of antidepressants on suicidality and aggression will be reviewed. For all the justifiable concerns over antidepressants, this chapter will also acknowledge studies indicating that antidepressants have lowered mortality rates and are effective in preventing relapse. Finally, the chapter will stress the marked heterogeneity of depression, with as many as one thousand clinical presentations and at least four differing clinical pathways over time. I note as well the poor predictive power of the DSM diagnosis, which has remained fairly consistent since 1980, despite the criticism.