Most patients with depression seen in primary care have mild to moderate depression. In trials these patients respond equally well to placebo as to pharmacologically active treatment. We discuss the role of placebo treatment in this situation.
An estimated 3 million people in the UK are currently depressed, with winter and the economic situation likely to increase this number. Even without screening for depression in primary care it is likely that more patients with sub-threshold to moderate depressive symptoms will require care.
A recent paper by Fournier and colleagues showed that the pharmacological management of mild and moderate depression is based on poor evidence. They, and others, found that for mild to moderate depression placebo is as effective as antidepressant treatment. Fournier and colleagues concluded that ‘there is little evidence to suggest that they produce specific pharmacological benefit for the majority of patients with fewer severe acute depressions.’1
Furthermore, in clinical care, patients with mild to moderate depression can be expected to have a better placebo than in clinical trials2 and the placebo response has been shown to persist over time.3
Current NICE guidance4 recommends sleep hygiene, active monitoring, and low-intensity psychosocial interventions but advises against antidepressants routinely to treat persistent subthreshold depressive symptoms or mild depression because of a poor risk–benefit ratio.
Where to from here: sleep hygiene, active monitoring, and low-intensity psychosocial interventions are first-line treatment but access to psychological therapies remains a problem.
We believe that it should be possible to augment (not replace) these options with a drug that does not carry the risks of antidepressants, is significantly cheaper, and is equally effective for mild to moderate depression – a placebo.
Folic acid is essential for the synthesis of monoamines and may well be the most suitable placebo. It may even have intrinsic activity and is currently the subject of a randomised controlled trial as an augmenting treatment in moderate to severe depression.5
We recently recommended an approach to the safe use of placebo treatment6 and believe that for patients with mild to moderate depression who cannot access psychological therapies immediately, such an approach would be more honest, ethical, evidence-based, safer, and cheaper than the use of selective-serotonin reuptake inhibitors. The period when a patient is receiving sleep hygiene, active monitoring, and low-intensity psychosocial interventions should also be used for placebo treatment.
- © British Journal of General Practice, January 2011
