The Dirty Little Secret

The article that follows is a controversial one. It reaches a controversial conclusion - that much of the therapeutic benefit of antidepressant medications actually derives from placebo responding. The article reaches this conclusion by utilizing a controversial statistical approach - meta-analysis. And it employs meta-analysis controversially - by meta-analysing studies that are very heterogeneous in subject selection criteria, treatments employed, and statistical methods used. Nonetheless, we have chosen to publish the article. We have done so because a number of the colleagues who originally reviewed the manuscript believed it had considerable merit, even while they recognized the clearly contentious conclusions it 

In the decade that has passed since our article was published, the dust has settled around the issue of meta-analysis. It is no longer considered a controversial procedure. Meta-analyses of clinical trials are now routinely published in all of the top medical journals, and the National Institute for Health and Clinical Excellence (NICE), which publishes the treatment guidelines that are used by the NHS, crafts recommendations on the basis of meta-analyses that it conducts. Nevertheless, the editors were right about our article being controversial. Although some scholars in the field were persuaded by our analyses, others were sceptical, to put it mildly.2 The sceptics knew that antidepressants worked - if we had found otherwise, we must have done something wrong. Certainly there were other clinical trials of antidepressants beyond those that we had included in our analyses. Surely an analysis of those studies would point to a different conclusion. 

There were indeed clinical trials of antidepressants that we had not included in our meta-analysis, and there was also a meta-analysis of those other trials that had used some of the same methods we had used. It showed the same results that we had reported. The difference between drug and placebo in published trials of antidepressants was modest at best.3 Still, the controversy continued. 

A second advantage of using the FDA reports is that the agency carefully scrutinized the data that the drug companies had sent them. They examined the design of each of the studies and appraised the statistical procedures that were used to analyse the results. They asked the companies to provide more information and conduct additional data analyses where they deemed these to be needed. Most importantly, they excluded from consideration inadequate and poorly controlled trials. This enabled us 

Finally, all of the trials in the FDA data set included the same measure of depression, a physician-rated scale called the Hamilton Rating Scale for Depression (HRSD). The Hamilton scale is completed by doctors based on interviews and observations of patients. The doctor rates the patient s mood, thoughts about suicide, sleep disturbances and other symptoms of depression. For example, one point is given if the patient feels that life is not worth living, and four points are scored if the person has made a serious suicide attempt. The result is a numerical score that can range from o to 51. 

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THE DIRTY LITTLE SECRET OF THE MARTINI CRAZE, Said... 

Not even the food industry would dare claim that synthetic colors, flavors, preservatives, and other food additives are healthy. But their dirty little secret is that many of these ingredients can actually damage your health. More and... 

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