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Abstract
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The World Health Organization has declared depression to be one of the world's leading causes of human ill health and disability worldwide.1 The rate of depression continues to rise, posing a challenge to the health care system to better manage this mental health crisis.
Long-practising physicians bear a chain made of those who have died during their service, perhaps the heaviest links being those who have died by suicide.
Family physicians pride themselves on practising in an evidence-based manner. In February 2020, Iltis et al2 showed quite clearly that there was no evidence for the use of antidepressants in suicidal patients, as none of the 28 publications examined from 2000 through 2013 included persons with suicidality.
A commentary published in November 2019 captured the entire controversy around antidepressant use in its title: "Does the emperor have any clothes? Depends on who you ask."3 The author, Dr Alexander Tsai, insightfully reviewed the conflicting studies about the merits and liabilities of antidepressants. Key findings were that antidepressants, compared with placebo, improve mood in the short term by 2 to 3 points on the Hamilton Depression Rating Scale, which is too small a difference to appear as an improvement to either patients or clinicians. Studies disconfirmed even what Dr Tsai termed the treatment-by-severity interaction, wherein antidepressants are thought to act more powerfully in those more severely afflicted with depression. Dr Tsai also emphasized that there are simply no good data on the long-term use of antidepressants.3
Another recent review of antidepressant use revealed no valid evidence of beneficial effects in major depression, no clear evidence for their use in severe depressive states, and no evidence at all for long-term use.4
Physicians are taught a biological paradigm. Our very daily routine is to assess, measure, diagnose, and treat--often with a drug. We are taught to not hesitate to prescribe for severe presentations of depression. Further, we are taught to increase the dose of medication or add a booster drug if there is no movement on severity scores on reassessment visits. There is a clear pathway for drug treatment. Physicians know the medications well, and know the steps of drug therapy and their sequence...
Language: en |