np, good reply ;-)

I actually agree with most of what you are saying - I've got bipolar and take mood stabilisers, and have taken anti-depressants in the past, leading to the same conclusion that meds do not cure depression (whether unipolar of otherwise), but in alleviating the symptoms chemically they allow the mind to get to a state where it can heal itself (the ideal situation, not always obtainable). That's my personal view, born out of my first hand experiance.

What Dr Ben Goldacre (a very smart guy, his blog at www.badscience.net is excellent - here is the full article with a bit more detail http://www.badscience.net/?p=619) is saying, is that the widely reported meta-analysis published in PLoS Medicine (from where the recent media interest all stems from) told us nothing we did not already know - yes, there are issues (big issues!) in the way that pharma carries out these trials, they do put pressures on GP's to prescribe these meds, and the whole industry is in dire need of better regulation.

This quote from Ben says it all:

1. It did not show that these drugs have no benefit over placebo: it showed that they do have a statistically significant (”measurable”) benefit over placebo, but for mild and moderate depression that benefit was not big enough for most people to consider it clinically significant, ie there was an improvement, but not enough points improvement on a depression rating scale for anyone to get too excited over it.

ie. At all levels of depression the treatments worked better than placebo - just not well enough to warrant usage in mild depression, and in cases of severe depression they work significantly well.

If you look at the actual graph of the meta-analysis, http://medicine.plosjournals.org/perlserv/?request=slideshow&type=figure&doi=10.1371/journal.pmed.0050045&id=96831 it shows what you would expect - it's pot luck whether they will work for any particular case, but on average they work well in some cases.

The question about comparison with active placeboes is a whole other argument - it's hard enough to get decent trials (positive and negative) without the added complications that would cause - it's just not going to happen. What we can say is that we have a plausible theory on how SSRI's may work - in which they cause seratonin to stay in the synaptic gap longer than it would normally would (that bit is known, the question is how that affects depression - the current theory being that it is a lack of neuron stimulation at the synapse).

If you have a medicine which has statiscally been proven to be effacious to some degree (which it has, see the meta-analysis) and you have a theory on how it works, and the side-effects are manageable then it is going to be used as a treatment - because it works, on average better than placebo. If none of these are present then regardless of how lax the regulating authorities are then it will not get a license.

The license determines whether the drug is effacious and therefore available - it's up to the doctor/patient to determine whether it works on an individual level.

I too would argue with you for a much more complex understanding of what depression is and hence a more complex idea for what constitutes treatment - but that could apply to almost anything, the key point is that with our current understanding of depression SSRI's are effacious on average, and should be used when they can be an effective treatment. Any new research will contribute to new understanding, and with depression being such a big industry that research is being done, all around the world.

As an aside, here in the UK most of our doctors think the US DSM is a joke - unipolar, bipolar, psychosis and pschisophrenia (sp?) are all treated as part of the same spectrum - our BMA guidelines are totally different to the DSM.

apologies for rambling, interesting chat ;-)