MDD Treatment Guidelines Fall Short
Fourth, the difficult differential diagnosis between bipolar and unipolar depression is hardly mentioned. No reference is made to the repeated evidence that 30%-40% of patients with bipolar disorder are initially misdiagnosed with MDD (BMJ 2010;340:c854) nor to some data indicating that the single most common cause of treatment-refractory depression is misdiagnosed bipolar depression (J. Affect. Disord. 2005;84:251-7).
Recent meta-analyses of antidepressant randomized controlled trials that incorporate previously unpublished data made available through the FDA archives provide a context that appears to be missing from these guidelines. About 95% of the published scientific literature indicates that antidepressants are more effective than placebo in the acute treatment of MDD. An equal number of studies, showing that antidepressants were no better than placebo, have not been published. When all the actual studies, published and unpublished, are compiled, about 51% of studies are positive and 49% are negative (N. Eng. J. Med. 2008;358:252-60).
In providing this context, I am not suggesting that antidepressants do not work at all. However, it seems reasonable to conclude that the scientific literature has led the profession to believe that antidepressants are far more effective than they really are. This context is not reflected in the new guidelines.
Any treatment guidelines for MDD face a major problem. In debates about DSM revisions, it has become clear that diagnoses such as DSM-IV MDD are invented "pragmatically," based primarily on the opinions of DSM leaders about what is "good" for clinical practice, rather than on scientific research (Association for the Advancement of Philosophy and Psychiatry Bulletin 2010;17). Given the way the DSM is created, it might not be surprising to find variable benefits with our treatments. The fault may lie not in our drugs, but in us, and the ways in which we diagnose and treat.
Dr. Ghaemi is professor of psychiatry and director of the mood disorders program at Tufts Medical Center, Boston. He currently receives a research grant from Pfizer. He is the author several books, including "A Clinician’s Guide to Statistics and Epidemiology" (Cambridge: Cambridge University Press, 2009); "The Rise and Fall of the Biopsychosocial Model: Reconciling Art & Science in Psychiatry" (Baltimore: Johns Hopkins University Press, 2009); and "The Concepts of Psychiatry: A Pluralistic Approach to the Mind and Illness" (Baltimore: Johns Hopkins University Press, 2007).
