The widely held clinical view of ‘antidepressants’ as highly effective and specific for the treatment of all types of depressive disorders is exaggerated. Nassir Ghaemi, MD, MPH1

This statement begins Dr. Ghaemi's review of “Why antidepressants are not antidepressants: STEP-BD, STAR*D, and the return of neurotic depression“ published in Bipolar Disorders in 2008. The article addresses a segment of the controversial evidence to be presented as part of Annual Meeting recertification programming surrounding the use of antidepressants in clinical practice. Key points delineated by Dr. Ghaemi during this Sunday, April 30th presentation are certain to stimulate conversation and debate about the evidence including:

  • Antidepressants have limited short-term efficacy in unipolar depression, and less in acute bipolar depression

  • Long-term prophylactic effectiveness in recurrent unipolar major depression remains uncertain and doubtful in recurrent bipolar depression

  • The concept of depression may be excessively broad

  • There may be unrealistic expectations of universal efficacy of drugs considered ‘antidepressants’

  • Treatment-refractory depression may actually reflect failure to distinguish depressive conditions that are less responsive to antidepressant therapy

  • Expectations of antidepressants for specific types of patients with symptoms of depression or anxiety require critical re-evaluation

  • A revival of the concept of neurotic depression would make it possible to identify patients with mild-to-moderate, chronic or episodic dysthymia and anxiety who are unlikely to benefit from antidepressant therapy

You may be asking yourself, what is neurotic depression? If you have been in practice since the early 1980's you may remember this diagnosis being removed from DSM-III. The symptoms of neurotic depression are frequently seen in clinical practice today and include patients with mild-to-moderate, chronic depressive and anxiety symptoms that impair their lives, but which do not usually meet major depressive criteria. In current practice, the diagnoses of major depression, generalized anxiety disorder, and dysthymia are often melded together or anxiety is considered comorbid to the depression or dysthymia. Dr. Ghaemi argues that the DSM-IV-TR diagnostic category of major depression is too broad and this may be the reason behind the disappointing long-term results of antidepressants in the STAR*D trial. He states that nosology precedes pharmacology and if the diagnosis is wrong, the treatment will be ineffective.

Moreover, Dr. Ghaemi uses a contrast of metaphors to help evaluate the evidence surrounding the chronic use of antidepressant therapy. Major depressive disorder is often considered analogous to a chronic illness such as diabetes. Antidepressants, like insulin, are needed for long-term management. Dr. Ghaemi suggests that we should perhaps shift the analogy to that of infectious diseases. “Antidepressants for depressive disorders might be analogous to antibiotics: effective, sometimes essential and even life-saving in acute illness, but ineffective or dangerous in excessive or overly prolonged use.”

Dr. Ghaemi concludes the paper by emphasizing the point that evaluating the evidence does not dismiss the use of antidepressants in psychiatry. Rather, clinical research should proceed with a critique of current knowledge, followed by experimentation in order to establish new knowledge and resolve controversy.

As Chair of the 2012 College of Psychiatric and Neurologic Pharmacists Recertification Committee, I invite you to join us for Dr. Ghaemi's presentation as he “makes sense of antidepressants” through an evidence-based review of the literature. Dr. Ghaemi will be signing copies of his book A First-Rate Madness: Uncovering the Links Between Leadership and Mental Illness before the presentation. For more information about Dr. Ghaemi and his publications, visit his website at http://www.nassirghaemi.com.

Additional information regarding the study can also be found at:

Ghaemi SN. Why antidepressants are not antidepressants: STEP-BD, STAR*D, and the return of neurotic depression. Bipolar Disord 2008;10:957–968.