Recently, the news magazine 60 Minutes offered a piece on the role of placebos in the treatment of depression. If held to the usual standards of broadcast journalism, the piece would not be particularly disturbing. The 60 Minutes news magazine, however, has a strong track record of breaking news stories in an accurate and reliable fashion. Historically, 60 Minutes held a higher standard for the subject matter examined, and the depth of its reportage. Lesley Stahl’s piece on placebos was a break in this chain. It tended to confuse the issue, rather than draw a conclusion from the evidence. The confusion was not limited to the role of placebos, but the role of antidepressants in general.
Lesley Stahl’s piece made the assertion that antidepressant effectiveness is largely due to the placebo effect. This is not news. The fact that drug companies only select those studies that are favorable to their drug, suppressing the unfavorable studies, is also not news. A number of detailed and accurate books have been published on this exact topic-even a critique by a former director of the American Medical Association. It may have been news if Mrs. Stahl focused on the consequences of suppressing unfavorable studies. Instead, Mrs. Stahl attempted to appear impartial by berating the Harvard professor whose research has reinforced the role of the placebo. It may have been news if Mrs. Stahl found that the professor’s research was flawed. She cast doubt on his conclusions without ever achieving some conclusion of her own. She appealed to psychiatrists, paid by drug companies, as experts to evaluate the research of an unbiased academic. At no time in the piece did Mrs. Stahl refer to the professor by his correct title, though she unfailingly referred to drug company psychiatrists by their professional titles. The end result was to cast doubt on both placebos and antidepressants.
The first fact to consider is that most competent psychiatrists are just as concerned with side-effects as the intended effect. A patient who cannot sleep is given a sedating antidepressant over one that is activating. A patient who sleeps too much and can’t wake in the morning is prescribed an activating antidepressant. Patients who are overweight are prescribed antidepressants that cause minimal weight gain, while those who have lost their appetite and are losing weight are given antidepressants that increase appetite. The side-effect of medication is often as important in the treatment of depression as the main intended effect. The only difference between a medication’s side-effect and main effect is the intention of the humans that formulate the drug. The human body does not know the difference between side and main effects of medications. This very important feature of antidepressant medication treatment was never mentioned in Mrs. Stahl’s report.
The second fact to consider is the one scientifically proven effect of SSRI antidepressants. This class of antidepressants is able to increase neurogenesis in the brain. Depression causes a slowing of neurogenesis in the hippocampus and the caudate. The SSRIs may prepare the brain to act upon change; to categorize and retain novel stimuli. This is likely the reason that medication in combination with psychotherapy is two to four times more effective than either treatment in isolation. While the SSRI effect on neurogenesis has been proven scientifically, the intended effect of antidepressant medication has weak or inconsistent proof. If Mrs. Stahl questioned why drug companies decline to market antidepressants in combination with psychotherapy, that may have been newsworthy.
The third and last fact to consider is that placebos have been researched for over fifty years. This is far from being newsworthy. It is like breaking news on the value of soap and water. The brain’s response to placebos and antidepressant drugs is nearly identical. Using brain scans that take snapshots of brain metabolism and activation (PET), researchers have discovered that placebos cause a similar increase in brain activation (glucose uptake) as antidepressant medication. Placebo treatment is not known to cause an increase in brain neurogensis, but this appears to be an artifact of scant research, rather than from actually being disproved. Well-controlled studies may yet reveal that placebos cause neurogensis, but there is little economic motivation to perform this study. If Mrs. Stahl questioned why drug companies decline to research placebos, that may have been newsworthy as well.
In summary, Lesley Stahl danced around the relevant issues regarding antidepressant medications. Perhaps she was unaware that the side-effects of drugs may be therapeutic, that SSRIs potentiate neurogenesis, and that both placebos and drugs affect glucose metabolism in a similar fashion. Mrs. Stahl fell short of asking relevant questions; for example, should antidepressant medication be used primarily for its side effect(s), should physicians continue to recommend drug treatment over psychotherapy, and should drug companies market psychotherapy in combination with placebos or antidepressants? Any one of these questions may have received an answer that could have changed the future of depression treatment. Important aspects of depression treatment were ignored, while well-proven old information was touted as breaking news. Lesley Stahl’s piece failed to arrive at a conclusion, let alone a call to action. It is unfortunate that the net effect of Mrs. Stahl’s piece will be to further confuse the issues surrounding the current treatment of clinical depression. It was not 60 Minutes‘ finest hour; certainly not their finest fifteen minutes.