This is not a small detail. It means that a tremendous amount of money and effort has been spent on answering a simple question: does it work?

Here at PsychosisNet we are not against medication, it’s important to point that out. Every day we see people benefiting from antidepressants, antipsychotics, or mood stabilisers. Sometimes, medication can pull people out of a severe crisis. It happens, and there is no point denying it.

But there’s another side of the coin, and that side doesn’t get nearly enough attention.

Different people have different experiences

Psychological suffering is not a simple concept. It’s about mental phenomenons. They are emergent. That means that something new, something important can just suddenly pop up without warning. They are created by a unique mix of biology, life history, relationships, stress, coincidence, and purpose. That makes them personal by definition, and difficult to predict. Their course differs very strongly from one person to the next, and that is what makes research so complicated.

Still, for decades we have been pretending this problem has been solved. As if you can simply determine whether antidepressants work using RCT’s (Randomised Controlled Trials). During these RCT’s, two groups are formed: one is given the drug and the other one isn’t, then we examine which one does better. And we call that ‘evidence based’ proof in psychiatry.

Evidence-based psychiatry: What the trials don’t show us:

Recent large-scale research using national data from Sweden and Finland (over 200,000 people) highlights a major issue.

When selecting participants for antidepressant trials:

Over one-third of real-world patients would be excluded
With broader criteria, more than half would not qualify

Excluded groups include people with:

Comorbid medical conditions
Substance use
Previous suicide attempts
Complex psychiatric profiles

In other words: the very people most often seen in clinical practice.

This reveals a fundamental problem in evidence-based psychiatry:
the evidence is based on a selective populati

Should this be the norm?

This makes it very clear that so called ‘evidence-based proof’ is strongly determined by selection. You mainly measure people with a relatively favourable path, so you get relatively positive results. Those results look stable, but they only are within that selected group.

And then another thing. Even within that selected group, the effect of the antidepressants is not the same for everyone. The average difference between medication and placebo is being carried by a small group of people with a positive response. For most of them, the effect is small, or non-existent. We just don’t know who those people are. We can’t point them uot beforehand.

So what looks like an average difference within the group, is really an accumulation of individual stories that can go in any which way.

So the question is inevitable: do we want to keep using these RCT’s as the norm for everything? Do we want to continue building guidelines on group averages, that may say nothing about the individual in front of you.

Uncertainty, customisation and co-creation

Psychical suffering isn’t easy to define in standard protocols. It’s isn’t a defect that you have to repair, but a process that develops itself quickly. Medication can help sometimes, and sometimes not, sometimes temporarily, and sometimes it comes at a price. You can only explore this, step by step, with your eyes open.

This requires something completely different from the mental healthcare sector; to stop pretending they know everything, and not use so many strict guidelines. There needs to be more room for uncertainty, customisation, and co-creation between healthcare professional and patient. To not use medication as a standard solution, but as a possible option in a personal process.

We need to appreciate complexity, and not pretend like everyone is the same. Then you can honestly say: we don’t always know someone’s situation beforehand. And that would be a better basis for adequate care.