Ronald Pies, MD, is Editor-in-Chief Emeritus of Psychiatric Times, and a professor in the psychiatry departments of SUNY Upstate Medical University and Tufts University School of Medicine. His article, Antidepressants and the Sound of One Hand Clapping, is about faith. He explains:

From my perspective, we are witnessing what might be called a crisis of faith in the realm of antidepressant treatment. Now, “faith” is a curious term. It may imply something like “confidence”—or something more akin to “deep religious conviction.” My experience with a few recent blog postings has convinced me that both interpretations apply to the state of antidepressant research and treatment.

First, there is the issue of confidence, with respect to the efficacy of antidepressants (ADs) in both acute treatment studies and studies of long-term prophylaxis. (“Efficacy” usually refers to benefit under controlled, clinical conditions; “effectiveness,” to naturalistic settings). It turns out that the reported efficacy of ADs in acute treatment studies is, to a large degree, in the eye of the beholder—or of the statistical analyst. A great deal depends, for example, on how much stock we put in a 2- or 3-point change on the Hamilton Depression Rating Scale (HDRS, commonly known as the HAM-D) and how we understand the nature of the “placebo response.” http://www.searchmedica.com/resource...ue&ds=0&srid=3

After years of treatment, I finally figured out being a passive participant in my treatment was not working. I believed it when I was told after a little work here and a little work there, I was going to be all better. I did not get better, just more cynical.

Being more active in my treatment I think was something I needed to do. I still did not fully appreciate that being active meant more than deciding the topic of discussion at a session or asking about increasing the dosage of a medication. I just became more frustrated at the lack of progress.

When I was told I may not get better, I at last got past thinking a better therapist or a different medication was the answer. Being active came to mean taking full responsibility for my well-being. It was only then that I started to get better. I had been clapping with one hand.

Dr. Pies does an excellent job of encapsulating the debate over the efficacy of antidepressants. He does not state the public has been preyed upon by flimflam men, as I believe. He does say:

And so, overall, what is my verdict on antidepressants? In my estimation, our present medications for depression are only mediocre. For moderate to severe, and especially melancholic, cases of major depression, ADs are effective and sometimes lifesaving, particularly when part of a comprehensive treatment plan that includes psychotherapy. And, there is convincing evidence that ADs prevent relapse at least during the 6 months or so after a bout of major depression. For mild, non-melancholic cases of depression, I generally favor beginning with psychotherapy, given the “costs” of antidepressant side effects. In this regard, we urgently need to find antidepressants that are more effective and better tolerated. Recent research suggests that agents that modulate the N-methyl-D-aspartate (NMDA) system (eg, ketamine(Drug information on ketamine)) are worth further exploration.24 In sum: I do not hear loud applause for our current antidepressant armamentarium. I believe I hear the sound of one hand clapping.

So what is next? We need to improve access to psychiatric care, so that patients who need antidepressants are seen by those best trained and most knowledgeable in their use. We need to work more closely with our colleagues in primary care, so that they become more proficient in the diagnosis and treatment of depression. We need to investigate carefully even the very rare side effects of antidepressants, so that we do not lose the confidence of the general public. We need to avoid even the appearance of conflicts of interest, related to “Big Pharma.” And perhaps most important, we need to listen attentively and respectfully when our patients tell us they are not happy with their treatment.

Dr. Pies' article leaves me with a lot of ambivalence. On the one hand, I am outraged by the endless hype about the benefits of treatment that many see little of. On the other, I appreciate more the work of dedicated professionals who make a difference in the lives of so many despite the handicaps.