A while back I did some research on the genetics of mental illness, and was appalled to discover some disturbing things about medical psychiatry (by “medical psychiatry” I mean psychiatry centered on drug therapy rather than talk therapy). First of all, for the vast majority of drugs used to combat mental illness—and especially depression—the doctors had no idea how they worked, yet they pretended they did. Patients were regularly told, when prescribed antidepressants like SSRIs (selective serotonin reuptake inhibitors; Prozac is the classic specimen) that their depression was due to a chemical imbalance in the brain. SSRIs, for example, increase the amount of the neurotransmitter serotonin in the synapses (gaps) between neurons by preventing its reabsorption by the neurons. Because these drugs seemed to work (more on that below), doctors and pharmaceutical companies blithely concluded that depression resulted from a deficit of serotonin. But that’s ludicrous, for just because a drug alleviates a symptom doesn’t allow you to conclude that the symptom was due to the deficit of that drug. It’s like saying that headaches are caused by a deficit of aspirin! As Marcia Angell notes in her reviews below, “. . . instead of developing a drug to treat an abnormality, an abnormality was postulated to fit a drug.”
An acquaintance of mine, visiting a psychiatrist for depression, was told that her “brain was wired up wrong”! That verges on medical malpractice.
I also learned that the genetics of mental illness is a subject rife with uncertainty and unreproduceable results. For every study localizing a “gene” or gene region responsible for a condition like depression, there was a counter-study showing no effect at all. Nevertheless, medical students in psychiatry are taught that the major mental illnesses have a genetic basis (I’ve seen the textbooks).
Despite all this, psychiatry continues to be increasingly “medicalized,” that is, talk therapy is replaced by drug therapy (doctors can make a lot more money prescribing drugs than talking, for during the hour occupied by a talk therapy session, a psychiatrist could see and prescribe meds to three or four patients). And pharmaceutical companies make millions of dollars prescribing drugs for mental illnesses, so they continually try to expand the range of conditions that count as drug-requiring “illnesses,” including obsessive-compulsive disorder, various attention-deficit syndromes, and so on.
The whole mess is encapsulated in the book used by doctors to “diagnose” mental illnesses, the Diagnostic and Statistical Manual of Mental Disorders (DSM), which is now undergoing its fifth revision. If you ever get a chance to look at it, do. You’ll find that “diagnosis” is based on conforming to a certain number of symptoms in a numbered list. To be diagnosed with a “major depressive episode,” for example, you need to have five out of the nine symptoms described by the DSM. But what if you have only three or four? Then you don’t get your meds. It’s all quite bizarre, and I concluded that the whole drug/genetics/diagnosis nexus is driven by three things: the desire of psychiatrists to be like “regular” doctors who treat well defined illnesses with well defined medications, the nebulous and ill-defined character of mental illnesses, and the desire of pharmaceutical companies to milk the public out of as many dollars as possible. This does not deny, of course, that mental disorders are often serious and life-threatening conditions that require some type of treatment or intervention.
And these conclusions—and other ones just as dire—are shared by Marcia Angell, author of two new articles in The New York Review of Books “The Epidemic of mental illness: Why?” and “The illusions of psychiatry” (they’re free, so have a look). Angell is a pathologist with an M.D., studied microbiology, and was the first woman editor of The New England Journal of Medicine. Her piece is basically an essay centered on four books, The Emperor’s New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker, Unhinged: The Trouble with Psychiatry—A Doctor’s Revelation about a Profession in Crisis, by Daniel Carlat, and the latest DSM, Fourth Edition, Text Revision (DSM-IV-TR), published by the American Psychiatric Association.
Antidepressants and anti-anxiety drugs are so widely prescribed in America that if you’re not taking them yourself, you certainly know someone who is, so you owe it to yourself to have a look at these articles. Among Angell’s eye-opening statements and conclusions are these:
- Mental disorders are increasing at a furious rate in America, especially for children. While 1 in 184 Americans qualified for government disability aid for mental illness in 1987, the number more than doubled (1 in 76) by 2007. In children, the rise was an astonishing 35-fold! This almost certainly reflects not a genuine jump in disorders, but an increase in the frequency of diagnosis.
- As we all know, psychiatric talk therapy has been largely supplanted by the use of drugs. Medical students are now given minimal training in talk therapy and maximal training in how to prescribe drugs.
- There is no substantive evidence that mental illness is caused by chemical imbalances in the brain.
- Antidepressants are far less effective than people think: in fact, they may not be effective at all. Trials are typically only a month or two long, and I am not aware of any long-term tests of these drugs. More disturbing is that the drugs are barely better than placebos. Pharmaceutical companies doing blind testing of antidepressants are required to submit only two blind clinical studies with positive results, and these could be out of a much larger number of studies showing no positive results. That, in fact, seems to be the case. When Irving Kirsch investigated the studies, he found that while antidepressants were three times as effective as no treatment at all, they were only marginally better than placebo drugs, which “cured” depression at a rate 82% that of real antidepressants. Moreover, when you look at the degree of improvement of antidepressants over placebos, the difference, though statistically significant, is miniscule. Few people taking antidepressants know these depressing statistics.
- Doctors observed that other drugs with no effect on serotonin, like synthetic thyroid hormone, also appeared to relieve depression. What these drugs had in common was that they all had side effects. Was it the side effects, then, that helped depression? Sure enough, when doctors used placebos that had side effects (“active placebos”; one of these is atropine) rather than inactive placebos, they found no difference between antidepressant and placebo. A reasonable conclusion from this study is that patients, when they experience side effects, think that they’ve “broken the blind test,” and are taking the real drug. They then improve simply as a result of realizing that they’re taking something that’s supposed to help them.
- Whitaker’s book reaches an even more depressing conclusion. He realized that the “natural history of mental illness” has changed over the decades: while schizophrenia and depression, for instance, used to recur episodically, separated by periods of normality, now they are “chronic and lifelong”. Whitaker concludes that psychoactive drugs actually change the brain in a way that prolongs and intensifies mental disorders, for the brain tries to compensate, ineffectually, for the chemical imbalances induced by drugs. Here is a really disturbing passage from Whitaker’s book:
“Imagine that a virus suddenly appears in our society that makes people sleep twelve, fourteen hours a day. Those infected with it move about somewhat slowly and seem emotionally disengaged. Many gain huge amounts of weight—twenty, forty, sixty, and even one hundred pounds. Often their blood sugar levels soar, and so do their cholesterol levels. A number of those struck by the mysterious illness—including young children and teenagers—become diabetic in fairly short order…. The federal government gives hundreds of millions of dollars to scientists at the best universities to decipher the inner workings of this virus, and they report that the reason it causes such global dysfunction is that it blocks a multitude of neurotransmitter receptors in the brain—dopaminergic, serotonergic, muscarinic, adrenergic, and histaminergic. All of those neuronal pathways in the brain are compromised. Meanwhile, MRI studies find that over a period of several years, the virus shrinks the cerebral cortex, and this shrinkage is tied to cognitive decline. A terrified public clamors for a cure.
Now such an illness has in fact hit millions of American children and adults. We have just described the effects of Eli Lilly’s best-selling antipsychotic, Zyprexa.”
- The DSM book resulted from a deliberate decision by the American Psychiatric Association (APA) to “remedicalize psychiatry” in the late 1970s. Each time it is revised, the number of disorders included increases drastically: the latest has 365, more than doubling the 182 in the DSM-II. Angell notes a serious lack of scientific underpinning:
“Not only did the DSM become the bible of psychiatry, but like the real Bible, it depended a lot on something akin to revelation. There are no citations of scientific studies to support its decisions. That is an astonishing omission, because in all medical publications, whether journal articles or textbooks, statements of fact are supposed to be supported by citations of published scientific studies. (There are four separate “sourcebooks” for the current edition of the DSM that present the rationale for some decisions, along with references, but that is not the same thing as specific references.) It may be of much interest for a group of experts to get together and offer their opinions, but unless these opinions can be buttressed by evidence, they do not warrant the extraordinary deference shown to the DSM.”
- The connection between drug companies and psychiatrists has always been congenial—I would call it corrupt. The companies pay for the doctors to go to conferences, often in vacation-y places, they sponsor their research, and give them huge fees as consultants and speakers. Angell notes that in states that must reveal financial connections between drug companies and doctors, psychiatrists get more largesse than any other group of physicians. And 20% of the funding of the American Psychiatric Association (which, of course, publishes the DSM) comes from drug companies.
- More than half of the contributors to the new version of the DSM (95/170) have financial ties to drug companies, “including all of the contributors to the sections on mood disorders and schizophrenia.”
- Drug companies also give a ton of money to patient advocacy groups, like the National Alliance on Mental Illnesses—groups whose agendas include a strong push for drug therapy for mental disorders.
- Perhaps the most disturbing thing in Angell’s articles is the huge increase in drug therapy for mental disorders in children, who are often treated with drugs not approved by the FDA for their diagnosed disorder. “Juvenile bipolar disorder” increased 40-fold between 1993 and 2004, and autism more than fivefold. As Angell notes, “Ten percent of ten-year-old boys now take daily stimulants for ADHD—’attention deficit/hyperactivity disorder’—and 500,000 children take antipsychotic drugs.”
Angell and the authors she reviews describe further disturbing things, like the drug industry’s illegal push to get doctors to prescribe drugs for conditions for which those drugs haven’t been approved by the FDA (American Food and Drug Administration). If you are a patient, or know someone who is, you must have a look. These articles, and the data presented by Angell, have convinced me more than ever that medical psychiatry is largely a scam, a rotten-to-the-core coalition between psychiatrists and pharmaceutical companies. Now I know that many psychiatrists are deeply motivated to help their patients, for mental disorders are among the most frustrating and recalcitrant conditions faced by doctors, and many patients indeed need urgent medical or therapeutic attention. But the way it’s being done now is not only ineffective, but positively harmful—although lucrative for doctors and drug companies. The few researchers and psychiatrists crying out against the madness, as in the three books under review, are largely shouting in the wilderness.
UPDATE: To the readers who are taking medications for mental disorders, do not take this post as an incitement to quit your medications. I hope nobody interpreted my piece this way, but I wanted to make that crystal clear. I am not a physician and am merely recounting my own experience, conclusions, and the article of Dr. Angell. But I do urge you to read that article, whether or not you’re a patient.
I would add, though, that personal testimony that a drug has “helped” a person is not the same thing as positive results in a double-blind study. Many people claim that they have been helped by homeopathic medicine or other “cures” that can’t be documented scientifically. The placebo effect (which must be operative in homeopathy) is well documented.
Finally, for similar views on the self-serving behavior of the pharmaceutical industry with respect to treating mental illness, see Frederick Crews’s (open-access) 2007 NYRB piece, “Talking back to Prozac,” a review of three books on psychiatry and “Big Pharma.”
Pulling the mote out your web page while ignoring the beam in mine:
“Is medical psych[i]atry a scam?”
It’s appears obvious from Peter’s reply that the reality or the fallacy of psychiatry “is in the eye of the beholder.” Literally! I couldn’t get rid of the “beam” in my eye, until I got rid of my psychiatrist who was blinded by the “beams” in his eye. Like any pseudo-scientific school of thought psychiatry is nothing more, nor less, than a secular belief system. Just like Physiognomy, Phrenology, Electrodiagnoscopy, etc. All the facts in the world are not going to dissuade a believer. As a “born-again heretic” I’ve learned to alter my beliefs to conform to the facts.
Yep, it is a huge scam. I suffer from depression, and my insurance will only cover the sort of “walking prescription pad” you’re talking about. It was hugely offensive when I realized that the doctor was getting paid something along the lines of $700 AN HOUR to say hi and write a prescription for drugs with terrible side effects that turned out to be no more effective than a couple of beers three times a week. No talking, although one of the multiple doctors I saw suggested I do talk therapy by myself with a notebook.
Now I’m off the drugs, off the doctors and I feel… no different, really. Well, except that I’m not gaining 2 pounds a month and sweating like a pig constantly.
I don’t know. What is psychatry?
More on the topic here: http://www.uic.edu/htbin/cgiwrap/bin/ojs/index.php/bsi/issue/view/241
in the journal Behavior and Social Issues. Oddly, when I brought it up on a medical blog, I was accused of being a Scientologist.
Oh, that looks like an unbiased source.
Gotta love a “science” journal with a section titled ‘Notes from a Roving Radical Behaviorist’.
Whitaker thinks Scientology has been such a boon to the pharmaceutical industry that they couldn’t have invented anything better themselves. They can simply dismiss, and encourage others to dismiss, any criticism as being motivated or manipulated by Scientology.
This all seems fairly exaggerated to me and can be summed up as “the brain is too complex to completely understand at this time”. I mean, these books seriously claim that there is no evidence that chemicals cause mental illness? It’s like they’ve purposefully ignored neuroscience (hint: it’s chemicals all the way down). At least I have no wonder anymore where Tom Cruise gets this stuff from.
Maybe better to ignore it than to oversimplifiy so jejunely.
Bones are chemicals all the way down too, so I guess it’s a useful approach to say that chemicals cause osteoporosis?
No, that is exactly the problem with it. What chemicals are they talking about? Why make such brash claims?
I think you’re a little confused. It’s the drug companies and psychiatrists prescribing the drugs who argue that they have this extensive knowledge of the brain. The books are arguing that the monoamine hypothesis that supplies the alleged mechanism for the effectiveness of these drugs has not been supported and there’s a good deal of evidence against it. This is discussed at length in the books by Whitaker and Kirsch.
I was just linking to this elsewhere, but here it is again:
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020392
The strangest response I’ve heard is like, “Duh, we know that’s garbage,” but with no appreciation of what that means in terms of the drugs.
That response doesn’t actually come off as all that strange to me because it is widely known to laypeople that the the seratonin hypothesis that SSRIs are correcting a “sertonergic dysfunction in the pathophysiology” is a guess that may be wrong. I’m not sure how the mechanism being different would have much significance as long as the problem is being treated. Does it really matter if something else is actually going on in the end? The only way I can think of right now that it would matter would be for all the chasing of shadows by people pursuing a dead end mechanism.
I don’t think that’s widely known at all. I think it’s widely believed among laypeople (and many doctors) that “antidepressants work by fixing a chemical imbalance in the brain.”
But no other mechanism is being proposed. They guessed at a pathology on the basis of the drugs’ action, but that has turned out to be wrong.
Except that the evidence in these books is quite strong that the problem is not being treated. Furthermore, Whitaker argues that the drugs are creating a neuropathology.
I hear what you are saying, and as far as SSRIs are concerned I agree it would be quite a scam to be selling expensive pills to people that screw up their libido and many other unrelated things but not actually treat the effing depression. In other words, if the pills only seem to work because they put people into their own personal twilight zones where their perception feels fresh and new because of all the weirdness, then that is deplorable.
This is just so much worse if true because it would mean that SSRIs are causing harm and not treating the problem. SSRIs would effectively be leaving people worse off after they finish SSRI treatment. The thought that people taking SSRIs could have been duped is seriously making me feel ill.
It doesn’t really matter whether they know the mechanism, although it’s bad that they pretend they do. What matters is whether, under properly controlled conditions, the drugs work compared to a placebo that has side effects. And the evidence is that they don’t work.
They don’t work? So the FDA is in on this conspiracy, eh? And a pretty unholy cabal it would be – doctors, pharma companies, insurance companies, and the FDA – who all hate one another.
Jerry, you have jumped the shark on this one. You sound way too much like a homeopathy defender, or an antivaxxer for comfort.
Concerning SSRIs, I feel that this is truly too big of a problem for me to understand well enough to come to a conclusion on at this time, so I think I will remain on the fence about it for now although it is worrying that real harm could be occurring as you say whether that be only financial or actual physical damage to patients.
Yes – it is useful to think that chemicals cause osteoporosis
Does that mean that the pharamceuticals will someday be able to create drugs that can cure osteoporosis or what do you mean by “it is useful to think that chemicals cause osteoporosis”? How does that help people diagnosed with osteoporosis?
This makes me sick. My wife and I have done some similar research, but didn’t go as deeply, but what we found was similar. It reminded me of the fact that a non-trivial number of “anti”-depressants can actually cause a person to feel just good enough to commit suicide.
Your last point is not really surprising. If you can’t function because you are depressed you don’t likely have the energy to commit suicide. Feel a bit better and now you have the energy.
But plenty of medications have the side effect of causing the problem they are trying to suppress. That’s hardly a reason to single out a certain class of medications.
Psych drugs don’t cause a person to feel “just better enough” to commit suicide. They can create a condition called “akathisia” that causes a horrific condition where the person wants to jump out of his skin.
As for the drugs doing any good, maybe you should re-read Kirsch. These drugs are clinically no more useful than a sugar pill, and come with a myriad of health-destroying side effects, both short- and long-term.
There ARE solutions for mental problems (yes, even schizophrenia), but psychiatrists and pharmaceutical companies are opposed to them. Wonder why…
I discovered this 20 years ago when I had a bit of depression due to a life problem (death in family). I saw a therapist (talk) and was sent to a pharmapsycotherapist to obtain a drug to ‘solve’ the problem. I realized that this buffoon had no clue as to what drug or what dosage to use. They wanted to just try things out. The first drug they tried made me angry and violent, so I stopped taking it and told both therapists to go to hell and the depression lifted when I realized the life problem was not of my making and not under my control, so I ignored it.
Whitaker discusses the long-term studies, and the outcomes of many are catastophically bad.
That’s at least some improvement over this: In the early 70’s, during college summers I worked as a floor orderly in a relatively inner-city community hospital, sometimes on the small psych unit. I was never given a clue as to patients diagnoses there (vs. the medical floors), I think in part because the staff was partly clueless, but I remember once the husband of my HS English teacher was admitted, probably in retrospect for a manic/depressive episode. He told me that he had been told that every summer his blood got too thick.
Wait a sec —
How on Earth do these drugs get FDA approval without proper testing? Shirley drugs that target other organs wouldn’t be approved on such bad evidence…would they?
And the FDA isn’t the only governmental body that oversees the efficacy and safety of drugs. What about its counterparts on the rest of the planet? Are they similarly incompetent?
Cheers,
b&
Fortunately, not all appear to be quite as incompetent (or whatever you want to call it), at least when it comes to children:
http://www.guardian.co.uk/science/2003/dec/10/drugs.sciencenews
Whitaker has links to the scathing reports about SSRIs for children in the BJM and Lancet and discusses the FDA at some length. Kirsch talks about the regulatory bodies in other countries, too.
They are obviously incompetent, if not criminally culpable. Who thinks it’s reasonable to base approval decisions on 8 week trials for drugs with serious side-effects that are routinely given to patients for years at a time? (And don’t call me Shirley!)
Considering the massive expense of drug approval, I doubt there is another way. Phase 3 testing is expensive. And you hardly know which drug is going to kill people. Imagine trying to get approval of Tylenol today. I would rate that far more dangerous than any antidepressant. Or anticonvulsants with SUDEP (sudden unexplained death epilepsy that may be medication related).
The best that could be hoped for is stricter after approval tracking. But there is always an outcry if a drug is removed from the market for side effects because not everybody is harmed. See Avastin.
Many, many insurance companies will not pay for talk therapy, certainly not for a sufficient time period. Because it lasts longer than the one visit for meds, it’s not as cost-effective for the companies.
Drugs are (seemingly) effective for some major mental illnesses such as (well-diagnosed) schizophrenia and bipolar disorder, but, as the articles show, very iffy for the more nebulous conditions they’re most often used for.
Psychiatrists also, well, stink. A friend had to see no fewer than ten before she found one who could treat her bipolar even within established guidelines, such as they are. Through her own reading she became more knowledgeable than nine of these “doctors” about the guidelines. She was also much more logical in the decision of when to try a drug.
For example, for excessive anxiety, one psychiatrist told her that there were no anoxylytics other than the new-generation antipsychotics. Luckily she knew very well that the minor tranquilizers existed and had many fewer side effects.
That said, the major mental illnesses are so dreadful, and have such high suicide rates (bipolar and “major” depression) that even a placebo with long-term damaging effects is preferable. It beats suicide.
I wish to see any substantive evidence that viciously expensive talk “therapy” is effective beyond placebo.
I’m pretty sure I’ve read about studies showing talk therapy to be ineffective for most, with the possible exception of cognitive behavioral therapy.
Here’s a meta-analysis:
http://www.sciencedirect.com/science/article/pii/S0272735805001005
Good for mood, anxiety, personality, and eating disorders, substance abuse. Nor for bipolar or schizophrenia.
I thank thee.
I should have narrowed my request in accordance with my intent.
In my classification system, CBT does not fall within the “talk therapy” class.
(By definition; as it requires active and chronic behavioural modification by the client, with requisite confirmation by the practitioner.)
Pure “talk therapy” is that mostly engaged in by psychoanalysts, Fraudian or otherwise.
I agree. I think there’s no data on other kinds of talk therapy, and CBT involves much more than talk.
Diane, you’re welcome!
Garnetstar, thank you!
Is medical psychiatry a scam? … The DSM book resulted from a deliberate decision by the American Psychiatric Association (APA) to “remedicalize psychiatry” in the late 1970s.
I have direct, very negative personal experience that arose in part from deep skepticism about this profession.
I had a long-term relationship with a woman that appeared healthy to nearly all family and friends, but was was seriously troubled in private. She had intense, unforgiving rages against me and others for trivial, often imagined offenses, she alternated between villainizing and idealizing people, had a bizarre aversion to ever being alone, and other dysfunctional behaviors that could only be seen in private.
The negative behaviors were very unpleasant and I had my concerns about how normal they were, but couldn’t put my finger on any of it—I looked up manic depressive, but that didn’t fit. I’ll admit that my own hard-science background biased me toward regarding nearly everything from clinical psychiatry as bullshit. And a lot of it is bullshit, but as I learned, not all of it, and not the stuff that was affecting my partner and our relationship.
As this relationship was finally ending publicly, a good friend of ours that had observed some of these behaviors first-hand told me, “stvs, you really should look up BPD in the DSM.” So I did, and I’ll never forget the feeling of electric shock reading an internet description of my deeply personal and secret problems, problems I had no idea affected anyone else.
One conclusion I drew is that clinicians who deal with these problems sure know what they’re talking about, and a lot more that I gave them credit. Whether they can treat these disorders is another question.
I don’t know enough about pharmaceutical industry to comment about the ethical issues you’ve raised, but I’d caution against a blanket condemnation. People with psychological problems and disorders are in deep shit, and so are the other people in their families. I’m very lucky in that I got to walk away from these problems, but not everyone is so fortunate. Finding provably effective treatments — chemical or behavioral — is laudable, even if the doctors don’t completely know what they’re doing at the time.
Gotta tell you, Jerry, after 9 months of fruitless talk therapy, I reluctantly tried SSRIs. I’m not happy with them, but they saved my life.
I, too have had good luck with them. I’ve been on and off SSRIs for many years. I’ve felt the difference after about 2 weeks of starting them. I always start and stop slowly too, tapering the dose.
I was part of a clinical trial 10 years ago, but became so depressed I got out. I was afraid I was on placebo or a dose that was too low. They gave me the drug. Again, a noticable difference in just a couple of weeks. I do wish I could find out what I was taking in the trial.
I was under the impression that SSRI mechanisms were well understood. a “Reuptake Inhibitor” sure sounds like it’s understood. I won’t go off my meds anytime soon, but it’s something to think about. I do hope they will be studied more.
The things that SSRIs do to your brain are well understood, yes.
However, Jerry’s point is more subtle than that: although we understand what SSRIs do to the brain, we don’t know if the thing they do actually affects depression. As Jerry says, it might just be that SSRIs are acting as a placebo.
It’s logical implication; we know that the effect of SSRIs reduces depression, but we don’t know that depression is caused by not-effect of SSRIs.
I do consider myself quite skeptical, so would be surprised if I was experiencing a placebo effect. The difference between my depression before the meds and after is marked.
Of course, I cannot say that my depression would have gone away without the SSRIs, I’m not sure I want to test it on myself. But I have gone quite a while without going back on the meds. The difference is amazing.
I do think that many people do not have chronic depression and probably don’t need meds because they will get better.
That’s an excellent point.
You also have to remember that the drugs were never tested on significantly depressed people. At best they were used on moderate depression which might be different from severe depression. The reason for this is safety. You don’t want to harm patients. That this makes the study less useful is not really a concern because it likely makes the study more likely to succeed. That’s the unintended combination of regulatory agencies concerned with safety and companies concerned with profit.
I’m currently using Zoloft and have been since about 1995 or so.
I fractured my skull when about six years old, fell from a moving vehicle.
Years later, in my forties, I became angry all the time and was plagued by thoughts of suicide. Things came to a head when I blew up at one of our children. Can’t blow up at the boss, right? :(.
My wife insisted that I seek help. They prescribed Zoloft and told me that it would probably take a week or more before I felt better. I felt better almost immediately, which makes me suspect a placebo affect.
I continued the prescribed dosage for some years, but at a cost of losing my favorite activity, which is running. I went from 1500 miles per year to less than 300. I simply lost the desire to run.
Whenever I would try to wean myself off of the medicine, the anger and suicidal thoughts would return.
I’m now sixty years old,still on the meds, though at a dosage that seems to allow mental stability and some running.
By the way, the whole issue of serotonin and re-uptake agents seems to me to be another nail in the ID coffin. Why would a designer have serotonin dumped into the brain and then design a mechanism to clean up the excess?
I too sustained a brain injury, but it was a “mild” (anything but in some ways) closed head injury thirty years ago. Because I was a young adult at the time I have the memorable experiences of what my thought processes were prior to my injury and after.
Let me say right off that if meds are helping you I think that is fantastic. I am not here to argue your own success. It may be exactly what helps you because no two brain injuries are exactly alike. Nor any two people.
But I am very concerned about antidepressants being used because of my own experiences which are different than yours.
When I read that science doesn’t know exactly how antidepressants work, but that they do seem to do something positive it scares me. I think how much more clear this would be if everyone knew what it is like to have a fully functional brain and then have one that has been compromised through injury.
I can tell you to a certainty that the uninjured brain is a cohesive unit with a type of strength to stand up to the demands of the day. It is a strength people take for granted.
The injured brain, however, is not so strong and you are much more sensitive to how food, sleep, stress, etc have an immediate and compromising effect on how you think. You may get very mentally worn out by things that did not wear you our previously.
Having said that, there is a heightened sensitivity to medications. I did take antidepressants for a few years and they were absolute hell. They caused my brain to be less functional, less sharp, more fatigued and my moods had a life of their own. It was hideous.
I am not a fan of antidepressants. We do not know how SSRI’s work. But just the fact they do something good happens at times isn’t enough. I reapeat. We do not know how they work.
Having had the experience of a hyper sensitive brain from my injury I am very concerned for what we don’t know about these chemicals effects on the brain.
It is not wise, it is not even scientifically or medically sound to say, “Meh, whatevah” when dealing with an unknown effect of chemicals on the brain.
What area of the brain is being harmed? We do not know to a certainty. We do know there are problems with suicidal ideations that are reported with the use of these drugs. However, like the article says, the test results are basically “sold to the highest bidder”.
I have a loved one who has been on these drugs for years and I have watched a change that is extremely concerning. But I can’t say anything because that person is totally convinced these are happy drugs that make their life worth living. And they believe the gospel of SSRI’s magical properties. Trouble is they do not see how they have changed for the worse over time. They just know they are having terrible problems with temper and emotional stability.
I, having experienced a brain injury and being aware of how moods can be affected by just about anything when your brain is weakened do believe it is the medication.
This is a facinating post,hard science vs psychiatry and its alliance with the pharmaceutical industry.
My mom was severely physically and mentally abused as a toddler/child. Her mom killed herself when she was 13. She has suffered severe depression, ptsd (constant startle response), and a hard-to-describe form of schizophrenia – she hears a voice but it’s only one voice and she is aware when it is happening…the voice berates her and mocks her and at times suggests that she do harmful things to herself. Last week she burned her hand badly and couldn’t remember what happened. She has been on a variety of drugs that either made her very sick or so zombied-out that she would rather die than live like that. I feel there is nothing left to do. The psychiatrists don’t listen to shit so she doesn’t tell them what is going on (for instance when the voice is more active). She sits there in shame as they prescribe one unhelpful/harmful drug after another. She is now suffering inflammatory lupus. She has had several serious suicide attempts (NO..NOT a “cry for help”…she should have died in every instance…for example drinking a gallon of gasoline), and at this point, even though I love her with all my heart…who am I to say she should continue to put herself through this…anyway…I’m crying now…I think I will share this article with her.
I’m so sorry. I sincerely hope that things somehow improve for both of you.
Many good points in the OP. However — is there any actual evidence that old-fashioned talk therapy is better? I’m sure there are some studies, but I bet they are very tough to do well — how do you do a control, how do you avoid placebo effect, what does long-term benefit/harm mean, etc.? And certainly there’s a long history of pseudoscience silliness in talk therapy, from recovered memories all the way back to Freud.
The above, plus:
“Many, many insurance companies will not pay for talk therapy, certainly not for a sufficient time period. Because it lasts longer than the one visit for meds, it’s not as cost-effective for the companies.”
…probably explain the current situation.
I will say that I know a number of people — all women, whatever that small sample means — that see psychiatrists regularly, and they all seem to be in control what they are doing, and they actively try out different psychiatrists and regimes until they find something that works. “Trial and error” might not be such a bad strategy, given the complexity of the brain and society.
There does seem to be a “therapy culture”, and I do wonder if throwing around all this medication is a good idea. On the other hand, it is at least possible that back “in the olden days” either (a) psychiatric issues were less common because everyone had children they were trying to keep from starving and similar life-and-death issues to deal with (ending, often, in infant mortality and adult death before 50), and/or (b) society just tolerated a lot more misery and crazy, attributing it to demons and suffering-is-good-for-you and whatnot.
Some societies are far more accepting of what used to be called eccentricity than others. I often think our US consumer culture with its messages of exactly how every one should look/behave/interact creates “pathologies” out of what could be regarded as normal variation within a population…
Exactly!
If all of the “boffins”** in Britain during WW2 had been on Ritalin:- Radar, universal computing machines, sonar, magnetrons, jet engines, etc, etc. would not have graced this planet at the time that they did so.
______________________
** Those tolerated and valuable eccentrics who would (rightly) have been assessed as having (not “suffering from”) Asperger’s Syndrome.
Who knows, they might have been taking amphetamine since Benzedrine (“bennies”) were very popular at the time and used by many soldiers. The classic British spy James Bond used them frequently 🙂
Ritalin is not a treatment for Asperger’s. In fact, there are no medications for treating Asperger’s, but there are medications that can help relieve some of the more personally distressing symptoms of the illness (i.e., people do suffer from the illness). It actually makes them more functional, not less.
Examples, please?
For what it is worth, I have Asperger’s, but cannot identify any ‘distressing’ symptoms.
As for your initial point: I have a close friend who was diagnosed with Asperger’s, and immediately prescribed a never-ending course of Ritalin.
It was kind of this latter pseudo-medical episode to which Prof. Coyne presumably, and correctly, refers.
Prior to meeting someone with Asperger’s at an AAI conference a couple of years ago (the one Jerry spoke at actually!) I had never heard of any medications for the syndrome. However, she takes, or at least took at he time, the SSRI Celexa for anxiety (if I recall correctly), the benzodiazepine Klonopin for more acute anxiety, and the stimulant Adderall, which she said helped her to focus on the outside world and be more social (I’d be more social if I were on amphetamines, too!).
You mean like Alan Turing was treated?? Imprisoned and medicated for homosexuality?
No I don’t think eccentricity was generally more accepted in the past. Indeed it was easier to ‘manage’ those people because they generally had no rights.
Won’t argue with the majority of your post, but this section is somewhat dodgy. You really shouldn’t be mixing the mapping of disease genes (which hasn’t been very successful in depression) with assessing heritability via things like twin studies.
Agreed. I thought there was fairly good evidence that some disorders, such as schizophrenia, “ran in” families.
Yes, especially depression and bipolar too.
Indeed!
Unsurprisingly, it’s complicated. A study on adopted children in Finland found that there is a heritable component to schizophrenia but if children are raised in a stable environment, the chance of developing schizophrenia can be reduced by 86%. They also noted that children with a low genetic risk can still develop it.
This could mean that schizophrenia has a genetic component, it could also mean that these children are just more sensitive to environmental stresses and this expresses itself as schizophrenia.
http://www.schizophrenia.com/familyenv1.htm
Interesting, thank you!
I have a positive experience of medical psychiatry. I have been trying to deal with various life-long problems such as recurrent depression, anxiety and OCD. My periods of depression have been treated with SSRIs, specifically Celexa. It has been very effective, although there is the usual few-weeks waiting until the effects start.
Now I’m on continuous low-dose Celexa to deal with anxiety and OCD. It’s great, and really effective again, whereas talking therapies were useless.
I wonder if the problem with effectiveness is because a wide range of illnesses are called ‘depression’.
Sadly, the low dose wasn’t enough for me. I take 80 mgs a day. The regular dose of 40 didn’t seem to do enough.
I don’t think I have side effects, but I have wondered what long term effects my body might be likely to endure.
I don’t want to come across as being glib about your medical troubles or the possible help you’ve gotten from SSRIs, but what you’ve just described is exactly what the placebo effect would do.
To someone who has suffered from depression and been helped by SSRI’s the whole article is glib. It’s insulting to suggest that we don’t know the difference between our illness and a placebo. It’s the reason that we know that talk therapy to treat a real organic disease is just nonsense. Our experience is that it’s as effective as homeopathy. This whole thing reeks of scientology.
Hear hear!
Like the other comments, some things you say raise question marks. For instance, you say that it takes several weeks for you to notice an effect. Presumably then you start to feel better. Could this be merely the normal course of the disorder which results in an improvement, rather than an effect of the drugs? People who take ecinacea to cure their colds say the same thing as you’re saying which always makes me reluctant to trust anecdotes.
And have you tried talk therapy? I have a couple people in my family who have issues with depression and there has been a much bigger change using CBT than drugs. Again an anecdote but this is backed up by many studies which show that CBT is more effective than any medication for mild to moderate depression.
Hope you continue to find ways to manage.
I have tried talk therapy. However, it does get quite costly and my insurance doesn’t cover it anymore.
I tried to do my part in a clinical study years ago, but when my depression worsened I was afraid I was not on the meds I needed. There was therapy involved in that study. I had to leave the study and the Celexa they gave me made a difference. I really feel bad about having to leave the study–I really wanted to help.
I hate anecdotes too, but the difference is so noticeable.
By the way, I had a friend that was put on statins (I think) she became depressed, her whole mood changed. She got them to stop her meds and her mood was OK. If meds can cause depression, surely it’s not hard to see that they can also stop them. But they definitely need do more studies.
By the way, I’d like to add that I don’t have side effects (that I notice) with the Celexa (generic) I’m on.
I see where the studies have shown the side effects are the “key” for study subjects to know if they are on placebo or not. The only SSRI I’ve taken that gave me side effects was Effexor. I got off of that one right away. I’ve taken Zoloft and now Celexa and I think one other with no real side effects (other than relief from deprssion). So not everyone who takes SSRIs feels side effects.
Interesting! Effexor actually affects serotonin and norepinephrine, it’s not selective for serotonin.
Maybe the side effects came from Effexor’s norepinephrine activity? So you don’t get those when you take a serotonin-selective medicine.
Glad you found something that works!
I think that’s what my doc thought. By the way, he’s suggested it at the time because it was new. I think he had samples. You know how they can be affected by those sales reps!!
What do you think about the people who try an antidepressant for a month or so, experience no improvement, try another, no improvement, etc., but then find a drug that does improve the depression significantly? That happens quite a bit.
At first glance, one might think that, if a placebo effect was the main reason for the response, that it would show up when the patient starts taking the first drug.
I’m not advocating that hypothesis, just wondering what a possible reason for such a response could be?
I suppose that would rule out the placebo effect.
But I am wondering if statistics really show that this happens “quite a bit.”
It’s, um, in Kirsch’s book.
Two members of my family take the drugs which you mention above, and I have often wondered about their effectiveness.
I thank you for adding your voice to this debate, and although as you may or may not be aware, I don’t share your views on religion, I’ve come to have great respect for your scientific expertise.
Yeah, I’ve been skeptical of medical psychiatry for a while. I was diagnosed with Bipolar II (after being diagnosed with ADHD by one psychiatrist and depression by another), and I’ve been on pretty much everything you can name. Seroquel played a pretty big part in totally screwing up my early college experience; it made it almost impossible to wake up in time for classes, and I ended up dropping morning class after morning class. None of the other stuff I was taking ever noticeably improved my depression (I’m still pretty skeptical of these “hypomanic” episodes), and many semesters I ended up just not caring and taking horrible grades.
I stopped taking all of my medication a year and a half ago, got a job that required me to wake up at 6 every morning, and went back to school, and what do you know? I’m getting one of the top grades in practically every class I’m taking, and I think my sleep schedule has a LOT to do with it. I’m still not too terribly social and have occasional bouts of light-to-moderate depression, but I’ve learned that they are temporary and I deal with them accordingly.
And to think that I wanted to go into psychiatry a few years ago. Now I’m not saying that drug therapy is a bad thing, but the way we tend to go about doesn’t strike me as horribly scientific.
This sleep-cycle business, (sleep in late when young, yet swap when older), is a normal element of maturation.
It need not be correlated with anything more.
It is all about the money.
A method of treatment is “effective” if it can be documented well enough that the insurance will pay for it. Whether the patient is actually helped seems to have very little importance.
#10 an #11 address many issues I was going to address. stvs’s story is a very familiar one. I think we need to remember that we are talking about illnesses. Illnesses effect people differently and using blanket condemnation of a spectrum of treatments for an illness is unwise.
Many of these people suffer and suffer horribly, as do their families and friends (if they have any left). Talk therapy is notoriously hard to get, especially if a someone relies on public health care.
One person close to me who has a history of suicide attempts and depression repeatedly went in for help to avoid such an episode and was led by questioning to say something the therapist or psychiatrist found suspect. What happened? He ended up locked in a psych ward because the doctor feared for his safety even though the person said he was not suicidal at the time.
This is 100% legal and a person can be held against their will for days for “observation” in a hostile, alien environment then released without support until a depressive episode reoccurs. This has happened to him several times.
BTW, psych meds and anti-anxiety drugs did seem to help him to an extent. It’s not a scam, but due to his treatment at the hands of the system he refuses to see a psychiatrist, psychologist or even his M.D. (he has HIV) because he fears losing his freedom. His mental and physical health continue to worsen, but he is hopeless and scared of the system.
These illnesses are (for the most part) real and I see nothing wrong with medical treatment, but we need more access to talk therapy and social support. The system itself needs to be reformed to respect people’s wishes and humanity. Stopping the budget cuts would help too.
“the desire of psychiatrists to be like ‘regular’ doctors”
Psychiatrists do have a “regular” medical degree, don’t they?
At first I thought this entry was a joke, but looks like Coyne has completely gone of the deep end:
– postulating the same Big Pharma conspiracy theories as anti-vaccine cranks. Coyne even uncritically mentions the supposed increase in autism, which we know from people like Paul Offit is bogus.
– selective use of data on SSRI efficacy, ignoring the increased effects of SSRIs compared with placebo for individuals with severe depression (e. g. Fournier et. al. (2010), Kirsch et. al. (2008))
– falsely characterizes the mainstream view of causes of depression as “chemical imbalance” and treatment as “SSRIs”. In fact, many different causes (e. g. genetic predisposition, negative thought patterns, increased stress etc.) and treatments (e. g. psychotherapy, lifestyle changes etc.) available.
– Suggests that the original reason scientists thought SSRIs worked is no longer believed (true), means that it does not work at all (false).
At best, Coyne is passing on attacks on a popular strawman, at worst he is shamelessly inciting pharmaceutical nihilism. It is entirely possible that some people can read this blog entry, go off their medication because they felt it was convincing and, say, commit suicide. Come to think of it, this line of argumentation mirrors HIV/AIDS denialism: big pharma conspiracies, claims that the major treatment doesn’t work, claims that the cause of the disease doesn’t even exist etc.
I guess this is more evidence for the thesis that a rational expertise in one area (evolutionary biology) does not prevent you from becoming a crank in another field.
Deep end, my butt. Read the articles and take it up with Angell; I am merely reporting what she said, and she’s former editor of the NEJM. I haven’t personally read the studies of SSRIs for severe depression, but the drugs would have to be compared with active placebos that have side effects. This is what Kirsch says about severe depression, according to Angell:
As for what the mainstream view is, I have seen several pamphlets for SSRIs from drug companies that clearly say that it’s due to a chemical imbalance. That’s also what several friends of mine have been told. As for whether SSRIs work, Angell gives the data–they don’t work better than active placebos.
And give me a break, you think the pharma companies are innocent here? They’ve clearly encouraged misuse of drugs for illnesses for which they haven’t been FDA-approved, and have paid doctors handsome sums for their consultations and approval. They also are constantly trying to expand usages of drugs for other conditions. They’re in it for the money, pure and simple.
Actually, SSRI’s have been compared in longitudinal studies with placebos.
Guess what…
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045
Absolutely shocking.
Regards,
John
That’s the sort of thing in your original post I find most disturbing.
A student caught making these kinds of protocol errors would be flunked, along with (at the least) a stern lecture on academic dishonesty.
What you describe is a situation I’d expect to read in an Upton Sinclair novel or Ralph Nader essay. I thought we were past that sort of thing, at least at this scale and in this industry.
b&
Just because you forward claims does not make you innocent, especially since you admit that, in your own words, “haven’t personally read the studies of SSRIs for severe depression”. Your actions are borderline intellectually irresponsible.
Angell may be a former editor of NEJM, but Duesberg is a member of the NAS. This does not lend him any credence on his claims about HIV whatsoever, and so cannot logically lend Angell any on SSRIs.
In your defense, you did not decide to read the studies, but went on to quote someone who described the position of another person who stated something that was not even relevant or coherent? Do you honestly believe that large scale studies on SSRI efficacy published in respected journals (e. g. JAMA, PLoS Med.) “forgot” to control for dosage? Also, if they experience more side effects, would that not make them, ceritis paribus, worse, and not better? In fact, Angell did not discuss the qualifiers the studies themselves used, namely that placebo effects are weaker in individuals with severe depression. Why would one forget to mention something that greatly benefits ones one position? I can think of one: Angell/Kirsch most likely simply didn’t read it. So the criticism doesn’t make sense on any level.
No one is denying that pharmaceutical companies sometimes act unethically, but if you (I assume) reject the exact same line of reasoning made by the anti-vaccine crowd in their attempts to tarnish vaccines, why accept it with respect to SSRIs? Seems plainly contradictory. Besides how do you plan on getting large-scale companies inventing new drugs and vaccines without financial incentives?
There’s strong evidence of the effectiveness of vaccines and a solid understanding of the pathologies involved and the vaccines’ mechanism of action. The opposite is the case with SSRIs.
What on earth are you talking about?
It’s complicated, but worth explaining (if not to Emil, then possibly to others). Kirsch illustrates how the responsiveness to the drugs by severity of depression remains steady, while the responsiveness to placebo decreases with severity. This divergence creates a larger gap (which is still quite small in clinical terms) between placebo and drug responsiveness at the severe end, but this obviously doesn’t look like the result of greater effectiveness of the drug but lesser effectiveness of the placebo. He hypothesizes that, due to their being more likely to have been on antidepressants before and likely receiving a higher dosage (which causes more side effects), “more extremely depressed patients are particularly likely to recognize whether they have been put on placebo or on the real drug” (pp. 33-4), thus reducing the responsiveness to placebo amongst this group.
For the record, he also cites a European review that didn’t even find this difference.
“He hypothesizes that, due to their being more likely to have been on antidepressants before and likely receiving a higher dosage (which causes more side effects), “more extremely depressed patients are particularly likely to recognize whether they have been put on placebo or on the real drug””
If by hypothesize you mean wildly speculate, then yes he’s hypothesizing. Notice, however, that he offers up no actual evidence for his “hypothesis.” He’s guessing that patients noticing side effects results in a placebo effect. Why then wouldn’t patients improve immediately? One notices the side effects immediately, but the antidepressant effects are not apparent for 2 to 6 weeks.
Exactly what studies of severe depression?
Part of the problem is that there really isn’t good data. People with severe depression never get in clinical trials. It’s pretty much an exclusion factor.
So you are left with other studies that probably lump feeling blue, with moderate depression and severe depression. What those have to do with one another, who knows.
Well, of course they are. They’re friggin’ corporations. Corporations make products and then market them. (Actually, the shareholder bit is even more important, but that’s another discussion.)
I know; my husband’s a senior scientist at Pfizer. BigPharma employs thousands of PhD’s, many of whom actually want to discover and develop truly efficacious drugs to help real people. They are not exactly delighted when the best sellers turn out to be the serendipitously discovered erectile dysfunction & hair growth remedies. (Except, of course, for the fact that when the company does well, their jobs are more secure.)
Remember, it’s not corporations’ job to police themselves with some imagined corporate ethics. (Much as we wish they all would.) Capitalism just doesn’t work that way. When society considers matters of life & death (health care) important enough to prioritize and regulate, so that every company is under the same restrictions, we can begin to rein in Big Pharma.
Meanwhile,it’s ludicrous to expect them to be “in it” for anything but the money.
(That said, you’ve probably got a pharma scientist to thank for the drugs that have saved the life of someone you know.)
Dr. Coyne,
Please, with respect, What are the alternatives to depression being due to chemical changes (so called “imbalance), in the brain? I don’t understand why you have such a reaction to this seemingly obvious claim.
It seems to me that the claim is to say to those who suffer from depression that their calamity is not a real disease, that it’s all “in their head”, i.e. immaterial, therefore it cannot be treated by material, “chemical” means. The depressed might as well take sugar pills. It seems that you don’t take depression seriously.
When did anyone here ever say that depression (or any other emotion) is as a result of anything other than chemical changes in our brain? That’s either a strawman or a huge misreading of the argument. Maybe you should go back and re-read the OP.
That’s doubly idiotic. One can say that SSRIs or SSREs are not more effective than a placebo and still think that depression is serious.
I thought you were putting your foot in your mouth when talking with MKG but you’ve really kicked it up a notch here.
Whatever. MKG obviously has his own problems. Do you really think that alcohol is a recommended treatment for anxiety or depression?
I’m just asking questions. I don’t understand why Dr. Coyne reacts so strongly to the idea that patients are told that their depression is due to a “chemical imbalance”. What should they be told? What is the alternative explanation? Here is the quote below.
“As for what the mainstream view is, I have seen several pamphlets for SSRIs from drug companies that clearly say that it’s due to a chemical imbalance. That’s also what several friends of mine have been told.”
Just because depression (and all other emotions) arise from biochemistry doesn’t mean that it arises from the entire brain having too little (or too much) serotonin, nor does it mean that SSRIs or SSREs are a good treatment.
Depression could be caused by other chemicals, it could be isolated to small number of neurons or specific areas of the brain or it could be the result of a select group of neurons. Bathing the entire brain in increased serotonin is a blunt instrument, to say the least. Even if some parts of the brain have lowered levels, boosting serotonin for the entire brain could make things far worse. SSRIs can easily have a neutral effect, a mildly positive one which masks symptoms but exacerbates the underlying cause, or it can be very beneficial.
That’s why we seek data, evidence, studies. That’s why we’re asking whether these studies show results greater than a placebo. That’s why it’s totally idiotic to say that people who question the efficacy of SSRIs must believe depression has some other cause or that they aren’t taking it seriously. I can’t imagine what short circuited for you to make this leap.
Well duh to all that. You’re not even responding to my question.
Dr. Coyne, (who I have immense respect for), seemed to be implying that pharmaceutical companies were falsely advertising the idea that depression was due to “chemical imbalances”. I just don’t see what’s so false about that assertion. It’s a distortion to say that they are claiming that depression result from a lack of their drug.
It’s only meant to allay patient’s concerns over their condition being anything other than an organic disease over which they have little control.
If you understand what I said, then why are you having such a hard time with this?
There’s almost no evidence for a chemical imbalance and since both SSRIs and SSREs work, this is evidence against a broad chemical imbalance. The only evidence that depression stems from a broad imbalance is that SSREs seem to help which, as has been said, is like saying headaches are caused by a lack of aspirin.
You are jumping waaaay past the evidence, erecting bizarre strawmen and then putting this false dichotomoy that either we care about depression and accept that it comes from a lack of serotonin or we’re magical thinkers who don’t care about the depressed. Even when pressed, you don’t flesh out your argument. Bah.
I just wanted to know what was meant by “chemical imbalance” and why you’re so reluctant to attribute depression to such a thing. I didn’t say anything about anything specific regarding SSRI etc. nor was they mentioned in the OP. Just this vague idea of
chemical imbalance is being rejected, but in favor of what, I don’t know. It’s very common for patients to be told that their problem is “mental”, not physical. Scientologists take it a couple steps further. I don’t see why you want to join their witchhunt.
Bah yourself. You appear to have a low tolerance for the thoughts and experiences of others.
Are you seriously trying to cite Kirsch 2008 as evidence against himself? Did you fail to notice that Angell’s review is partially of a book by…Kirsch? Anyway, Kirsch’s 2008 conclusion:
This is of course elaborated on in the book.
I’m using Kirsch as evidence against Angell, just like you can use Darwin as evidence against a creationist misinterpreting Darwin.
Since the two groups being compared are both severely depressed (one get SSRIs, the other placebo), their placebo effect is, if everything else is constant, equal. So, contrary to your interpretation, it does show a higher effect (SSRI group minus control) in patients with severe depression, even though the placebo effect is weaker in individuals with severe depression.
Are you dense? Angell’s article – which it doesn’t appear you’ve read – is based on Kirsch’s book – which it also doesn’t appear you’ve read.
Kirsch explicitly argues against the notion of “increased effects of SSRIs compared with placebo for individuals with severe depression.” He explicitly argues, based on a thorough review of the data, that apparent small effects are due to a decreased placebo responsiveness in that group. I just quoted it, for heaven’s sake, and noted that he expands on this quite a bit in the book.
The problem with your argument is that the placebo response in antidepressant trials is very very high. Being in a clinical trial gives a lot of benefit to people on placebo – they have to get out of the house, interact with people a lot more, get a lot of positive feedback.
It is this high placebo effect – 45-65% – which confounds the clinical trials. With longer trials, one generally sees placebo efficacy going down, with drug efficacy staying level.
On the other hand, highly seratonergic antidepressants do show what’s called a “poop out” effect long term. They can stop working, and doctors (typically GP’s) respond by simply increasing the dose which makes things worse. Psychiatrists are a lot more likely to use combination therapy which recruits other transmitters.
Look, I hate the “Pharma Shill Gambit” as much as the next person, but when it comes to psychiatric drugs it really is something that has to be considered.
Unlike vaccines, there is a lot of money in psychiatric drugs, and a significant proportion of that money is aimed directly at doctors in the field.
A big part of the problem is that GP’s have been encouraged by the insurance companies to treat patients depressive without referring them at the get-go. To save the insurance companies the cost of having of a very serious disease treated by competent experts.
I am not sure what your suggestions would be to a primary care doctor. Should they refer every single depressed patient to a psychiatrist?
An excellent post.
For folk interested in related stuff – I’d recommend this site:
http://neuroskeptic.blogspot.com/
Couple of good articles pertaining to this issue this month such as this one:
http://neuroskeptic.blogspot.com/2011/06/bipolar-kids-you-read-it-here-first.html
Another site I RSS is this one – here’s an article on bipolar disorder:
http://neurocritic.blogspot.com/2011/06/akiskal-and-bipolar-spectrum.html
Personally, I have manic-depression. In fact, clinical depression and manic-depression (I hate bipolar – means nothing as it does not describe the condition as accurately as manic depression!) runs in my maternal line.
Mother, her brother (not deceased via suicide), their father and his sister (former committed suicide), their father (my great grandfather) – again, took his own life. There are other members of my family on the maternal line too who have had severe breakdowns requiring lengthy psychiatric care in hospital, etc.
Fortunately I have no kin nor cousins, and being gay I have no chance of passing on this horrid condition.
Because of my family history I took part in a very large study comparing the brains of manic-depressives, schizophrenics and people with no underlying severe mental health problem. Very interesting results, btw.
On a final note, I no longer take medication daily. I get psychotherapy when I need it; have access to strong benzo-drugs when I start to go “hyper” and the support of good people in my life.
Being on anti-psychotics was the equivalent of having a lobotomy. They’re so toxic too. The risks far outweigh the benefits. I’ve seen this first hand. Anti-convulsants are just as bad.
An excellent book – which I have got my G.P. (doctor) and my psychiatrist to read is “The Myth of the Chemical Cure” by a psychiatrist, Dr. Moncrieff. My doctor thought it was brilliant, my psychiatrist is embarrassed. there’s a short article by Dr. Moncrieff here –
http://www.guardian.co.uk/commentisfree/2008/feb/26/pharmingtoday
Well worth a read.
Regards,
John
Thank you for that well-referenced point of view!
What a load. I’ve suffered from severe depression my whole life. Shock treatments in the 70’s left me with permanent memory loss. Talk therapy left me with nothing and cost me money. Might as well have gone to church. Went for 35 years without treatment or meds of any kind. 35 years of suffering I can’t even think about without crying. Finally asked a doctor for one of the sri’s. It was like being set free. A true “religious” experience. Every time someone goes on a mission to prove that mental illness and the drugs that treat it are all a scam, hoax, lie of the drug companies, I want to smack them. No, there is no way to measure brain chemistry or come up with an exact dosage or correct drug except by trial and error. Unfortunate but better than the suffering of mental illness. And yes a lot of whiny people want medicine every time they feel a little bummed out, or stressed. Which leads to problems for the whiners and an assumption that that means the meds are no good. Over prescribing of anti-depressives is as much the fault of the patients as the doctors. These medicines are serious business, for serious problems. They should be treated as such and not dispensed to everyone with a sad.
You’ve made some important points, IMO.
We use a psychiatric nurse practitioner who is predominantly talk-therapy. Because of him, I’ve know about the placebo effect for SSRI’s for a long time. That doesn’t surprise me in the least.
OTOH, there are some conditions where there are legitimate medicines that do legitimate work. Even SSRI’s, such as for OCD.
I think there’s definitely a use/abuse issue here. And part of the problem is market demand (of which, admittedly, pharma marketing can be partly responsible). There is some danger, I think, of throwing out the baby with the bathwater, tho.
The British Psychological Society’s “Response to the American Psychiatric Association: DSM-5 Development” makes for interesting reading. Not everyone is as enamored of psychopharmacology as the APA appears to be. Google “Response to American Psychiatric Association: DSM-5” for the PDF.
Over here in Australia, newer approaches such as ACT (Acceptance and Commitment Therapy) are gaining in popularity, both as mainstream therapy and as a self-help strategy.
Not a good analogy. Regular users of aspirin, and other NSAIDs (acetaminophen (Tylenol, paracetamol), ibuprofen (Advil, Motrin), naproxen sodium (Aleve)) often suffer withdrawal headaches for 1 to 3 days if they stop taking, or reduce their intake of the drug. Thus, in some cases, a deficit of aspirin can be a (partial) cause of a headache.
I had difficulty with depression for a number of years and was prescribed various antidepressants, by psychiatrist confident that they knew what was wrong and absolutely insistent that the antidepressants would help. In fact, they never helped at all. This puzzled the psychiatrists, who then insisted that the lack of effect was due to my negative attitude towards the treatment.
Psychiatrists repeatedly insisted to me that I had a biochemical imbalance in my brain and that I could not change that by my own efforts alone. Yet, at the same time, they insisted that, by my efforts alone, I could prevent the drugs from having an effect.
Did you report this quack to the Medical Council?
Well shit, this is disturbing!
I currently take an SSRI for premature ejaculation, and now I’m concerned I’m gonna be fucking up my brain chemistry if I stay on it! :-/
Don’t be. There is much nonsense to be found in this particular post.
What is “talk therapy?” Most so-called “talk therapies” are a placebo. Enlightened therapsists have turned to empirically based methods using specific techniques for specific problems. Most are drawn from Cognitive Behavior Therapy or Multimodal Therapy. The emphasis is one data-based evidence not speculative assumptions.
Cognitive Behavioural therapy has helped me a lot. More so than drugs did (for me – I would not speak for others in this thread who have found drugs ameliorating) – and fortunately living in a country where you pay taxes and get medical care without having to look for cash I can see speak with my therapist by making a ‘phone call. If my mental state is unfit, I’ll be seen immediately – whatever time of day – by a psych.
such a shame other folk don’t have these options, or for their families and loved ones such as phere, whose post touched me deeply.
Regards,
John
“Talk therapy” is an umbrella term encompassing CBT and others. Kirsch talks about how in the case of depression, which so fundamentally involves expectations, all therapies are in a significant sense placebos, but in the case of CBT and others – as opposed to drugs – this is a feature not a bug. The sections of the book about placebos are fascinating.
This would represent a fundamental misunderstanding of placebo.
Just because talk therapy involves something ‘non-tangible’, doesn’t mean it is a placebo. CBT in particular requires changing how you think, becoming more aware of how your thinking affects your moods, and changing your behaviour to challenge unhealthy thinking and to establish new experiences to support healthy thinking.
A placebo would be something more along the lines of talking about chit chat or listening to relaxing or motivational (but non-therapeutic) speech. A placebo would not have long-term therapeutic effects (CBT does, on the other hand). If it *did* have long-term therapeutic effects, then it would not *be* a placebo, it would be a therapy.
So, if Kirsch’s POV is that any form of talk therapy is a form of placebo, then he simply has too broad a definition of placebo, such that it includes legitimate therapies!
Kirsch is one of the foremost placebo experts in the world.
Is that a fallacy I smell? Why yes, I think it is. Hmmmm, Argument From Authority, I believe. Lovely aroma. A bit like a cross between bovine and equine excrement.
Aww shucks, my got eaten. Probably (sniff, sniff) would have worked fine. Oops.
Wow, that’s some sensitive anti-html filter there. Can’t even use angle-brackets separated by several spaces.
You are remarkably dishonest. I’ve been telling people to read the books for the evidence. That sentence was solely in response to:
It’s highly doubtful that someone on a blog understands placebos better than a recognized expert who’s published a couple hundred journal articles, books, and book chapters on the subject.
http://en.wikipedia.org/wiki/Irving_Kirsch
You’re adding nothing here other than these snide and incorrect fallacy accusations.
Interesting. You think I’m arguing with Kirsch, when in fact I’m arguing with you.
You are presenting *your own* interpretation of placebo, and then trying to use Kirsch’s accomplishments as somehow defending your claims. Fallacy 101.
Snide? Yes. Incorrect? No.
Posting a URL to Kirsch’s Wikipedia page as if it were evidence supporting your claims is classic Argument From Authority.
Kirsch, Irving(2010). The Emperor’s New Drugs: Exploding the Antidepressant Myth (p. 165).
READ THE DAMN BOOK.
Okay fine, I just ordered it from Amazon. Even if Orac trashes it, I’m sure it’ll be an interesting exercise.
😀
You know what the sad thing is? I was just saying to someone…When I first posted about this I had the stupid idea that other people would be interested and read and we on science/skeptical blogs would have this great fruitful critical discussion of the evidence. After a few of these threads, this seems highly unlikely if not impossible. I never thought the books were flawless (and socially I’m more radical than them), but now I feel like I’m pushed to defend every minor point they make and to correct every misapprehension rather than free to discuss them critically in light of the obvious problems they, amongst others, provide substantial evidence of.
I really hope Orac approaches this fairly, as I think a hit piece from him at this moment would have a negative effect on future discussion. People would read it as license to not engage with the books, even skeptically, and that would be a shame.
“I don’t want to come across as being glib about your medical troubles or the possible help you’ve gotten from SSRIs, but what you’ve just described is exactly what the placebo effect would do.”
Of course it is what the placebo effect would do if placebos were effective for my condition.
I don’t have classic depression. I don’t get medication because I’m feeling sad. I suffer from forms of anxiety and OCD.
Perhaps SSRIs are more effective for those conditions.
What I am a bit concerned about is use of words like ‘scam’, which might lead to people for whom the medication works stopping.
No, I’m really not happy with the word ‘scam’, I am afraid!
Of course it is what the placebo effect would do if placebos were effective for my condition.
Have you seen the research showing they’re not?
Perhaps SSRIs are more effective for those conditions.
Given what we’ve just read, do you think there’s actually evidence to support that?
“Have you seen the research showing they’re not?”
“Given what we’ve just read, do you think there’s actually evidence to support that?”
Just so I can be clear – are you actually trying to make a diagnosis of me and suggest I change my medication because of Jerry’s post? How responsible do you think that is?
Where exactly is the medical and psychiatric expertise here?
I don’t find this discussion a particularly healthy[sic] one. So, I’ll leave you all to it.
Just so I can be clear – are you actually trying to make a diagnosis of me and suggest I change my medication because of Jerry’s post?
Nope.
I’m trying to see if you have any valid evidence for your claims. It’s kind of what we do here.
I’m a doctor (but not a psychiatrist) so I just wanted to add my two cents worth:
1. The published data have consistently shown that antidepressants generate a significant but small improvement over and above the placebo. This is what doctors are taught and this is why they are prescribed. I take your fascinating point about the effects perhaps being due to the side-effects. I wasn’t aware of this hypothesis (I’m not a psychiatrist!) but I’ll certainly be reading up on it tonight!
BUT, and here I can only speak from anecdotes, the full range of therapies are always taught and promoted. It was never the case that we were taught only to prescribe. Indeed, most consensus recommendations (e.g. the U.K.’s influential National Institute for Clinical Excellence – NICE) urge psychotherapy (not pharmacotherapy) for the initial treatment of mild depression, due to concerns over medicinal side-effects.
Furthermore, it has also consistently been shown that pharmacotherapy and psychotherapy are EQUIVALENT in efficacy, although there seems to be some additive effect if they are combined. So if pharmacotherapy doesn’t work other than through placebo – deeply troubling but possibly true! – then perhaps NOTHING does? Perhaps if depression lifts it is simply the natural course of the disease? I’m not sure.
2. Your points about the “big pharma” are well taken. A huge number of doctors are ENORMOUSLY concerned over the fact that the vast majority of trials are industry-sponsored, rather than conducted by an independent body. In fact, a meta-analysis of the most commonly used (“second generation”) antidepressants showed that 69% of the trials were sponsored by pharmaceutical companies, 9 percent by governmental or independent sponsors, and the funding source was not identifiable for 22 percent. Needless to say, this makes one extremely skeptical about whether they can be trusted, especially when the putative effects are so small. This problem isn’t limited to psychiatry by any means, and is one of the biggest problems facing medicine’s evidence base.
3. Lastly, please don’t lump all of psychiatry together (not that you have). The evidence for anti-depressants might be shaky, but for things like schizophrenia they are unequivocally helpful and often the ONLY option initially.
All in all a wonderful article. Let us hope the psychiatric community catches a wake-up…
You missed the part in the blog post where Jerry points out that these drugs have side effects, and placebos do not – which leads to some people realizing that they are in the test group and not the control group. When you use a placebo with side effects, the “significant but small improvement” goes away.
Uh, no, the last two sentences of mine that you quote refer to exactly this. Sorry if that wasn’t clear. Of course, the explanation given (that people on the trials who had a side-effect thought they had got the real drug and this “ramped up” the placebo effect) is fascinating, but by no means the only one. For instance, using either eltroxin or atropine as placebo was a poor choice, since both are well known to have neurological effects of their own. Perhaps the dummy placebo did really help…? You’d need to do more tests obviously, so as it stands it is perfectly defensible to argue that the drugs DO have a small but significant additional effect over placebo. (I’m not necessarily defending this view, however.)
I really hope people will read the book, because the argument is made quite clearly.
Will do! Thanks.
Firstly, I agree with the good physician. I’m in medical school now and we’re taught not just to prescribe. We are taught that it is an option, and that many others exist and most are complementary to each other. A major point is that the best outcomes are seen with both pharmacological and counseling treatments combined. I’d consult what the NIH publishes about depression and treatment. http://www.nimh.nih.gov/health/publications/depression/index.shtml
Secondly, I was sad to see such generalities in the original post, and the use of the word scam. It sounds a bit like Bill Maher to me.
Believe me, pharma would love to have someone else run the (expensive and fraught) tests. As is US custom (and maybe other countries?), we’d rather the fox mind the henhouse than use tax dollars to create a disinterested testing authority.
For what it’s worth, I’ve seen a lot of psychiatrists, and each one has, without fail, encouraged me in the strongest terms to seek out talk therapy in conjunction with their prescriptions.
Interesting that he expected you to seek it yourself. The New York Times recently ran an article about the difficulty traditional talk therapists are having just staying in business, what with the lack of insurance coverage for it and the emphasis on psychotropics.
…And with Woody Allen no longer being depressed about the angst of living in New York.
I think it is pretty clear that a lot of the commentators here are too deep into the conspiracy thinking to be open to the idea that they are mistaken, but the blog “Science-Based Medicine” has two good entries on this matter called “Psychiatry-Bashing” and “Study shows antidepressants useless for mild to moderate depression? Not exactly.” where they deconstruct the myth that SSRIs are not effective.
They conclude
“In summary, then, by using questionable exclusion criteria, the authors accessed only 3 clinically relevant studies (the Paxil studies), involving only one SSRI. It is not clear that these studies are representative of existing studies on SSRIs, or even if they can be generalized to other SSRIs. Dr. Rubeis’ assertion that for patients with mild to moderate depression there is little evidence that “medications” add to efforts to treat the depression cannot be justified by the findings in his study. I find his claims to be irresponsible. The paper adds to the literature on antidepressants but is so limited that it cannot tell us whether antidepressants are effective for mild to moderate depression.”
So the conclusions this particular anti-SSRI meta-analysis draws for mild to moderate depression is not even valid and similar criticisms can probably be leveled against K. To go from these studies to “SSRIs are useless [compared with placebo]” is not just irresponsible, it is bad science.
I re-read that SBM post and it is coming at the question from the angle that SSRIs are proven science and that one or two mavericks are trying to disprove them, and to that extend, Dr Tuter says the one study she reviewed was inadequate. That’s not the same as reviewing the studies on SSRIs and concluding that they are effective and beyond reproach.
There could be many explanations for the apparent success of SSRIs – they could be genuinely effective or, as the linked article in the OP writes (and JAC mentioned):
You’re right, I would be very interested to see SBM wrote something specifically devoted to this. Is this another “maverick” scientist going against a mountain of evidence, or is this a real problem?
No. Kirsch used all of the studies submitted to the FDA for the major antidepressants, which he could only obtain through a FOIA request. Whitaker talks about a large number of studies, including longterm studies conducted by NIMH.
Again, it’s obvious that you haven’t read the works in question. But given that you yourself cited Kirsch 2008 (against Kirsch 2010!) it doesn’t exactly help your credibility to now be making ignorant assumptions about his research. You should go read the books and then come back when you have something knowledgeable to say.
Salty –
While I understand your distress about people responding to a book they haven’t read, that’s not what’s happening here. They are responding to a particularly ill-informed and alarmist post by Jerry, who is commenting on two articles written by someone commenting on several different books and coming to the conclusion that all of medical psychiatry is a scam based on mostly third hand information. And if you’re going to berate commenters for not reading this book, berate Jerry as well.
You ignore SC’s rebuttals to your comments above, and then come down to the bottom of the thread to post some more.
Doesn’t look like honest engagement in a discussion to me.
I think it is pretty clear that a lot of the commentators here are too deep into the conspiracy thinking to be open to the idea that they are mistaken…
We’re commenters, actually. And yes, stressing the need to make logical conclusions based on sound evidence is just what a conspiracy theorist would do.
Given that SC’s rebuttals are mostly some variation of “You haven’t read the book,” I see no need for Emil to respond to every one of SC’s rebuttals.
My initial reaction on seeing the title and first few paragraphs was “Oh dear, I hope this isn’t another scientists wading in on a subject he doesn’t understand and mangling the evidence.” But I think JAC treaded a good line and what he says more or less agrees with many other expert sources that I’ve seen elsewhere.
Just a few comments:
– “talk therapy” is incredibly broad and probably encompasses a wide range of treatments, some may be very poor and others very good. There are a few narrow areas like Cognitive-Behavioral Therapy which have proved to be extraordinarily effective. Far more effective for mild to moderate depression than medication (I’m not aware of how it works on severe cases).
– it can be very difficult to see psychologists and people trained in talk therapy but it’s very easy to get meds. I’ve seen this myself where there can be 4-6 month waiting lists only to have someone pass you along to another person who has, yes, another 4-6 month wait. It can be very frustrating! Medical plans may not cover many visits for talk therapy or restrict your options. All of this means that, for many people, the “best” solution may be very difficult to get.
– The major drugs for treating depression are SSRIs, Selective serotonin reuptake inhibitors, which increase the level of seratonin. JAC got it right when he compared treating depression with SSRIs to treating headaches with aspirin, though the situation is actually far worse. There is another class of drugs which do the exact opposite and decrease the serotonin, and guess what, they also are used to treat depression (called SSRE, selective serotonin reuptake enhancers)! Things could be even worse still. The body adapts to taking SSRIs and over time their result gets flipped and instead of increasing serotonin, they decrease it.
All of this strongly implies that serotonin levels are not the cause of depression and these drugs are at best masking the real disorder, possibly doing nothing beneficial at all, and because of their very real side effects and because they discourage people from seeking talk treatment, probably doing more harm than good.
I’m reading the excellent linked articles and keep finding more and more troubling statements.
– there’s no dose-response curve, something that the SBM blog mentions constantly. That is extremely troubling.
– the effect of SSRIs matches that of active placebos, so it looks like it’s the side-effects which determine the “effectiveness” and nothing to do with the serotonin
– the brain-altering effects of these drugs can cause/mimic mania or Parkinson’s which result in more drugs, leading some patients to take six or more drugs to deal with side effects of the drugs to reduce side effects of the initial drugs. If that’s not bad enough, this leads to brain atrophy.
– because the drugs are potent and mess with the brain (and because the brain compensates), getting off the drugs is dangerous and difficult. “The symptoms produced by withdrawing psychoactive drugs are often confused with relapses of the original disorder, which can lead psychiatrists to resume drug treatment, perhaps at higher doses.”
And a lot more. Sobering stuff.
Yes, a swift cessation of SSRI dosing is very dangerous and the results to one’s state of mind during the ensuing recovery period are then completely involuntary and uncontrollable.
“…the brain-altering effects of these drugs can cause/mimic mania or Parkinson’s…”
You are conflating two different drug categories: antipsychotics can cause Parkinsonian symptoms, not antidepressants.
A big problem with Jerry’s post and the articles he links to is that they are both trying to cover way too much territory. Antidepressants do not equal antipsychotics do not equal meds for ADHD. And treating adults with meds does not equal treating children with the same meds. The articles Jerry cites are a mess in that they try to cover way too much territory and lead to mistaken conclusions like yours.
I sold medical books in Greece for 3 years. Pharmaceutical companies were our best customers (books were purchased as “educational aides” for doctors). In addition, based on my discussions with publishers in the US and the UK, pharmaceutical companies spend even bigger bucks on books and even outright kickbacks in these markets. In my experience and what I’ve heard from others in the publishing and pharmaceutical field, pretty much all medical specialties get these “gifts” from the pharmaceutical industry.
I’m not sure if this intended or not, but this blog post makes it seem like individual psychiatrists somehow are recipients of more pharmaceutical largesse than other medical specialties. I simply don’t know that is the case.
Well, Angell reports that:
From Whitaker:
citation: J. Olson, “Drug makers step up giving to Minnesota psychiatrists,” Pioneer Press, August 27, 2007.
It’s my understanding that there are now national “sunshine laws,” which will likely show the same thing as the states did.
I believe that. I used to work as a pharma rep selling an antidepressant to psychiatrists. There are relatively few psychiatrists, and they write a lot of prescriptions, so they are highly targeted by sales reps. I worked in Vermont – I bet I helped pump up those Vermont numbers. My company paid huge amounts to a certain dopamine expert to speak all around the country for years. He has the biggest house in the county, let’s put it that way.
So, in other words, only 32.7% of psychiatrists received money during the 4-5 years of 2002-2006. Strange. For a big pharma conspiracy to work, you’d need much closer to 100%.
And Whitaker’s reporting is somewhat deceptive, making it seem like a guy made $570,000 in one year, when actually that covers the years from 2002-2006, or only $142,500. Still a nice chunk of change, but hardly conspiracy worthy, especially if that’s the top earner!
I found a more complete source from here (note the bias of the website; PsychWatch is a well-known Scientology front): http://psychwatch.blogspot.com/2007_08_01_archive.html
So, a) the $7.4 million refers to a 4-year sum, b) that sum includes money for scientific grants(!), i.e. research, not just lifestyle perks, c) only 28 of 187 (15%) received more than $50,000 during 4 years(!), d) the actual median amount was only $2,700 over 4 years, or approx. $675 per year, and e) this median amount only applies to 32.7% of psychiatrists.
Clearly, the ‘psychiatrists are just stooges in the pockets of big pharma’ is a hugely exaggerated viewpoint, which blows things way out of proportion. A psychiatrist might enjoy a bonus of $675 per year, but they’d hardly use that as an excuse to swindle all of their clients to become financial slaves of big pharma.
I’m not defending the kickbacks. I think it’s unethical in many cases (lifestyle perks) and questionable in others (possibility of influencing research), but it is not anywhere close to what it would have to be to support the idea that medical psychiatry is a ‘scam’.
And please, please, note that there is an active and determined pseudo-skeptical, pseudo-scientific movement (not all anti-psych are Scientologists, but all Scientologists are anti-psych) which is deliberately pushing questionable and over-hyped information around the public sphere. Please pull out your baloney detection kits and put on your skeptic caps when you hear this kind of thing.
I don’t think this is an accurate representation of what’s being argued about the influence of these companies. But you are minimizing the problem (which is likely underestimated from the disclosures), and you fail to note that the ones receiving large sums are often the most influential, like this guy (not in Minnesota):
http://www.nytimes.com/2008/06/08/us/08conflict.html
Further, payments to individuals are not the only form of influence the companies exert, as Angell, Whitaker, and others document extensively. When you’re amongst skeptics, the “conspiracy theorist” ad hom is only going to take you so far. OK, I’m out.
I am not minimizing the problem. I’m countering the hugely exaggerated claims from the conspiracists.
When you’re defending a conspiracist viewpoint, ‘conspiracist’ usually sounds like an ad hom. But it’s not. I notice you completely ignored my substantive points about the implausibility of the ‘scam’ hypothesis.
(sniff, sniff) That smells like another fallacy. Hmmm. A bit harder to discern the scent, since there are several fallacies closely related. Could be Red Herring (trying to change the subject to me ‘minimizing’ the problem of kickbacks, which I actually explicitly acknowledged as a problem), could be Moving Goal Posts (trying to get me to prove that there’s *no* influence at all, when I only have to show that there is *not enough* influence to support the ‘scam’ hypothesis), could be Shifting the Burden of Proof (it is actually up to the ‘scam’ conspiracists to provide better evidence to substantiate their claim).
Hmm, come to think of it, I detect all three! Good one, almost had my sniffer fooled there. The Red Herring. Always throws me off a bit. (As Red Herrings tend to do.)
I don’t think one needs to characterize even a part of these payments as “kickbacks”. I was in the industry at during the period in question. By that point one would have to have been out of one’s mind to offer money for prescriptions simply because one would have a very good likelihood of going to jail – let alone the ethical implications. It is possible that those moneys went to physicians who enrolled a few patients in their practices in clinical studies and were compensated for their time, but did not receive an actual grant.
They were stupid; you’re misunderstanding the meaning of “scam” here and presenting it as a fully conscious conspiracy by pretty much every psychiatrist. That isn’t the argument made in these books.
Look, I was responding to a specific suggestion that psychiatrists don’t receive more funding from pharmaceuticals companies than other specialties. The evidence suggests they do, and that they – especially the most influential – receive a lot. This is of course only one part of the influence picture, but it was the question specifically raised in the post I was responding to. Then you jumped in with your nonsense. You’re not responding to the actual content of the books in question, so there’s little point in this exchange.
No, it doesn’t have to be fully conscious, just like homeopathy doesn’t. You’re misrepresenting *my* position.
The ‘scam’ hypothesis I’m referring to is the one put forth in Jerry’s post. Whether or not that’s what the books argue is beside the point. The point is, Jerry’s defending an implausible conspiracy theory that discounts the actual science and efficacy behind psychiatric medicinal treatments:
You responded to the question of whether psychiatrists receive more money from pharma than other doctors. While it is actually true, the source you quoted was exceptionally deceptive (intentionally or not, it does not matter), making the problem appear to be much bigger than it is. I responded to that with quotes from the original source, showing that the median amount of money amounts to around $675 per year, to only 32.7% of psychiatrists, which is a pittance.
You responded to that with *additional* claims about the ‘extensive’ influence companies have over psychiatrists.
It was *this* which prompted me to refer to the implausibility of the ‘scam’ hypothesis, not your first comment about whether psychiatrists receive more money or not.
You have moved beyond “responding to a specific suggestion that psychiatrists don’t receive more funding” to defending the idea that there is large-scale influence which undermines the science behind psychiatric medicine. Your other comments in this post are of the same vein, so it’s disingenuous to try to avoid the burden of substantiating your position with evidence beyond just saying, “Read the book!”
Michael Behe wrote a book lots of people found convincing too. Big f’ing deal.
I don’t even know what you’re talking about at this point. The evidence is there in the books, and it isn’t misleading. I’ll leave it to others to read and draw their own conclusions, which I’m confident they can do despite your sad attempts at spin.
Likewise!
Thanks, good info. My anecdotal perception is that psychiatric drug prescriptions are higher in the US than in Europe so I guess I’m not that surprised.
Another difference between the US and Europe is that government supported long term care is not really available thanks to Reagan.
My understanding is also that the prison system in the US also ends up being where a lot of people with serious mental illness end up so it would be interesting to see how that factors in to all this. Source: http://www.nami.org/Template.cfm?Section=Top_Story&Template=/ContentManagement/ContentDisplay.cfm&ContentID=38174
Jerry,
I agree with Emil Karsson. I’m very surprised to find you re-posting and apparently embracing this kind of pseudo-skeptical denialism. I think you owe it to your readers (and to yourself, to be honest) to look deeper into this matter and realize that you are supporting a biased, anti-scientific viewpoint here.
Don’t just uncritically parrot what one or a few people report. We must compare those reports with the positive arguments from the other side and see which side the evidence most favours. Your description of the pro-medicine viewpoint (largely copied from the viewpoints of anti-psych sources, and largely a straw man), is simply not an accurate portrayal of current psychiatric best-practices and research.
I have previously had a discussion over this topic here: http://www.rationalresponders.com/forum/29497#comment-345892
To highlight, I’ll draw your attention to a review of this ‘controversy’, from “The Scientific Review of Mental Health Practice”, which is a website affiliated with: Commission for Scientific Medicine and Mental Health (CSMMH), Scientific Review of Alternative Medicine (SRAM), Center for Inquiry International (CFI), Committee for the Scientific Investigation of Claims of the Paranormal (CSICOP), Skeptical Inquirer Magazine (SI)
The review is posted at: http://www.srmhp.org/0201/media-watch.html
It is well worth a read for a balanced take on this issue, which addresses the question of effectiveness vs. placebo. Also see additional links to more relevant research in the discussion forum post (first link above).
Long and short of it: Placebo effect is particularly large in studies of depression. However, modern SSRIs, especially Sertraline and Escitalopram, *do* show greater efficacy than placebo alone, even with placebos which cause side-effects. The more severe the depression, the more effective the SSRIs are. They are also effective for chronic, low-level depression (dysthymia), which is what I have. For a thorough list of studies in this area, see http://www.pswi.org/professional/pharmaco/depression.pdf and http://en.wikipedia.org/wiki/Selective_serotonin_reuptake_inhibitor
Here are some confounding *facts* which undermine the hypothesis that ‘it’s all a big pharma conspiracy’:
1) Several medications have gone off-patent and are now available in cheap generic form, and yet they are still prescribed regularly. E.g. Prozac, Zoloft, et al. If it was all a conspiracy of psychiatrists and pharma, then you would expect the psychiatrists to avoid prescribing generics.
2) When a pharmaceutical company performs a study of their own drug, they don’t simply compare it to placebo alone. They compare it to all the major competing drugs in the market. Now imagine that Company A’s Drug X is no better than placebo(!). And Company B develops a Drug Y, which is at least better than placebo. When they test drug Y, they don’t just test it against placebo, but ALSO against drug X. But if Company B found out that Company A’s product is no better than a placebo (!), you would expect profit-mad company B to shout this news at the top of their lungs, “Hey, our competitors are selling you snake oil! Buy Drug Y instead! At least it actually works a bit.”
But, this does not happen. Instead, you find that Company B reports that while Drug Y is better than Drug X, they are BOTH better than placebo.
Pharma companies are simply too competitive to allow big conspiracies to work. They are not all sweetness and light, but they are not all entirely evil, either.
Oh, by the way. The only talk therapy with significant empirical evidence to support it (that I know of) is Cognitive Behavioural Therapy: http://en.wikipedia.org/wiki/Cognitive_behavioral_therapy
I don’t have a link handy, but I recall reading about research which showed that CBT was complementary to SSRIs in treatment of depression, meaning that individually they each had a positive effect, but that combining CBT with SSRIs increased the overall effectiveness of both. This seems to suggest that they operate on two somewhat independent (or inter-dependent) mechanisms of depression.
“I’m trying to see if you have any valid evidence for your claims. It’s kind of what we do here.”
The burden of proof is surely on those who claim that a branch of medicine is a scam. That’s quite a big claim.
I think the burden is on the makers and prescribers of drugs to show that they’re effective and safe.
They’ve met that burden. That’s what FDA trials *do*. The burden is now on pseudo-skeptic conspiracists to show that the studies supporting SSRIs are *all* bunk.
If I can jump in between you two — that’s why I keep going back to this bit from Jerry’s original essay:
If Jerry’s claim is true — and I’m in no position to evaluate said claim — then those FDA trials are worse than useless. They would, indeed, create a loophole for sanctioned fraud that a corporate executive with the morals of those at Phillip Morris or BP would be all over like lipstick on a Palin.
Is “Big Pharma” more considerate of public health than “Big Oil” is considerate of the environment or “Big Tobacco” the health of its customers? Is it in any less of a position to influence the governments that would regulate it? Is Smith’s Invisible Hand somehow more effective at controlling the pharmaceutical industry?
Cheers,
b&
I am not referring to the invisible hand. I have no respect for market fundamentalism. The competition I refer to is more like evolutionary competition than market woo woo.
The big difference between SSRIs and oil/tobacco is that SSRIs are *different* drugs with different efficacies, sold under *different* patents. If Company A can show that Company B’s patent is fraudulent, then that would be a direct blow against Company B which does *not* hurt Company A, whose patent remains intact.
Even *if* Jerry’s claim were true, and companies selectively published studies in favour of their own drugs, that would *not* stop competing companies from selectively publishing studies which both a) support their own drugs, and b) prove that their competitor’s product is worthless.
As far as I’m aware, this has not happened. You simply don’t hear of companies finding that their competitor’s product is useless. However, nearly all published studies compare competing drugs. How do you explain that, if the FDA studies are all basically fraudulent?
This is one of Ben Goldacre’s bugbears. He’s written extensively about how this undermines the results of published data and has campaigned to force companies to release all their data if they wish their drugs to be patented and approved for sale.
I don’t know that it makes them worse than useless but you’re right, it means that there’s a much bigger chance that the data achieves statistical significance through random chance.
There’s actually a lot of overlap between Angell and Goldacre. His book Bad Science works well with the others in its focus on research manipulation. It’s amazing that someone at Orac’s blog was just dismissing Angell as a conspiracy theorist because her book title contained “Big Pharma,”* when Goldacre’s contains “Big Pharma Flacks” and I don’t see those accusations hurled at him. She was also an outspoken critic of CAM long before Goldacre or Orac. It’s very strange to read some of the remarks about her.
*And me because my blog contained the phrase, even though it was because it was in the title of an article by Harriet Washington I was posting about and not in my actual text. It’s all so pathetic.
Big Pharma, Big Tobacco, Big Oil, etc., are monsters we create ourselves. These industries are in competition with each other* and the one that pauses to be ‘more ethical’ than the others dies. If there were ever a true case of social Darwinism, this would be it.
In capitalism/free enterprise systems, it is totally up to the society to come up with the needed regulation. That the “Bigs” get away with being so rapacious reflects only the short-term greed and stupidity of the populace and the “leaders” they elect.
(Or are supposed to be. I like to say that my husband has worked for the “same” company for over a quarter of a century–good ol’ Upjohn/Monsanto/Pharmacia/Warner & Lambert/Parke-Davis/Wyeth/Pfizer…to name just the takeovers that come to mind. Where the fuck have the monopoly laws gone?)
Indeed, we have created a social structure that all but guarantees that corporations will be short-sighted sociopaths.
Just as such behavior is not sustainable at an individual level, it’s even less sustainable at a global level. Corporations of the hand-wavingly distant future won’t be nearly so irresponsible; they’ll either have grown up or they’ll have gone extinct (and most likely take out humanity with them).
I still don’t fully understand the emergent nature of corporations…but, then again, I don’t understand how consciousness emerges from a collection of cells.
Many many years ago I had a short temp assignment doing graphic design for Motorola where I was editing promotional materials for the “land warrior of the future” or some such — wearable networked computers that would make it even easier for one set of kids to kill another set of kids. I was literally (for a few weeks) in the business of selling weapons to hit squads, and it wasn’t until long afterwards that I realized that that’s what I was doing.
I’m sure the majority of people doing the “dirty work” for these corporations either haven’t had this kind of an epiphany…or, if they have, it’s come so late in life that doing anything about it would mean causing immediate and direct harm to themselves and their families. At that point, what on Earth do you do?
To muddy matters even worse…in an entirely different context, I taught a number of computer classes for Motorola University. Amongst my students were a couple of the engineers that designed and built the radios on the Mars rovers. How could you not support such an endeavor with all your heart?
(Attendance was mandatory…the only thing I had over those guys was that I had had some supervised play-time with the software before they did, and it was my job to reduce the time they would have to waste doing the same. A number of the other students, though…well, I’m sure they were competent assemblers, but some really had a hard time with what I thought was rather basic stuff.)
Heinlein was right: man is not a rational animal, he is a rationalizing animal.
Cheers,
b&
Ah, so you’ve been tainted by association, too! 😀
An awful lot of what must be done to perpetuate society as we know and more or less like it has to be done by something like corportions. Expecting corporations to have ethics is like expecting dogs to have calculus; one hopes, of course, that the individual people that make up the corporation have some kind of reasonable ethics, but there are huge temptations toward corruption the way things stand.
Government regulation is woefully lacking, but is not going to be the only answer anyway, as the big corporations are perfectly capable of staying beyond the reach of any one government. Something like a UN for international business/commerce would seem to be necessary; not that the current UN is all that effective at its mission.
I’ve long felt the next best tactic will be international unions, which are pretty embryonic ATM. Checks and balances, checks and balances…
Doesn’t seem to me that even progressives are making much of a fuss about snowballing conglomerations. Pretty soon the one media corp will merge with the one pharma corp will merge with the one ag corp…
Where’re those SSRI’s when you need ’em?
Canines DO experience kidney stones. It *is* to be expected!
[www.springerlink.com/content/t0l3k38218022454]
…is like expecting dogs to have matrix algebra.
Diane G–“Government regulation is woefully lacking, but is not going to be the only answer anyway, …”
Have you not noticed, it’s not corporations that generally start wars, it’s GOVERNMENTS. It’s not corporations who routinely use violence to bend people to their will, it’s governments Turning to governments for ethical leadership is laughable.
An anecdote about psychiatry, if you don’t mind.
I’ve been dealing with anxiety and depression for pretty much all of my life, and I’ve been on and off more antidepressants than I could count. I also have had severe sexual dysfunction, which is to say almost complete genital anesthesia. A few years ago, I put two and two together and figured out that the anesthesia was the result of the SSRIs. My doctor refused to believe me, or even discuss why I was wrong (I have a rudimentary understanding of brain biology and the function of the drugs) and tried to pawn me off on sex therapists, but I was absolutely convinced that the drugs were the cause.
Through a bit of internet sleuthing, I discovered that, yes, many other people have the same sort of problem, and it’s even been made note of in medical journals. Since then, I’ve stopped taking psychiatric drugs of any stripe and after six months my anesthesia has almost completely disappeared. But I’ll still remember how monumentally unhelpful my doctor was, and for that matter, psychologists, urologists, no one seemed to be aware of the issue.
I’m willing to admit that it’s possibly a very rare problem, and there wasn’t necessarily any malicious cover-up going on, but shouldn’t a psychiatrist have the understanding of brain biology to comprehend how such a thing could happen? Wouldn’t he at the very least have the scientific curiosity to work with me to figure out what was going on.
Incidentally, the drugs never helped me with the depression or anxiety.
That finding is exactly why I’m on an SSRI for premature ejaculation (PE)!
I only started on the drug 6 mo or so ago, prescribed by my urologist. He told me that people taking SSRIs for depression found that it took them longer to achieve orgasm, and so scientists eventually thought “maybe this will help people with PE.” He told me – and I don’t know what research is actually out there – that this had been studied, and that taking an SSRI for PE won’t affect your affect if you don’t have depression (not surprising after reading Jerry’s post!)
I’m concerned though, after reading all this. I wonder what the research really shows. I’m doubtful that there’s any good research on long-term effects.
Well, loathe as I am to jump in on anecdotes, I’d simply add that “sexual dysfunction” is a relatively common (2-5%) side-effect of SSRIs. It is amazing that your doctor didn’t know about it – even when you pointed out the connection. I’d change doctor…
My thoughts exactly!
“I think the burden is on the makers and prescribers of drugs to show that they’re effective and safe.”
Yes, of course. I was simply posting here that I seemed to find certain specific SSRIs effective for anxiety/depression and OCD. As for my condition possibly going away with time anyway, I doubt that is the case, as some time ago it took some time to find the right medication and dose.
It’s a bit strange, given that context, to be treated just a little bit as if I was a shill for Big Pharma.
I’m just a harmless little Gnu, honest!
Now I really must trot away.
No one is treating you that way, Steve. You’re being overly defensive.
Now I’ll be the first to admit that sometimes, when you’ve got a problem that’s bothering you and you find something that works, that’s the most important thing. Nevermind what works for other people – you’re feeling better and that is a huge relief.
But I’m not making prescriptions for Steve Zara here. I’m having a discussion on a science blog about evidence, and you made a comment saying that SSRIs made you feel better, *after we just read an article about placebos doing the exact same thing.* I asked you, in effect, how do you know this isn’t the placebo effect? At which point you went on the defensive and made excuses for the fact that you don’t know.
Unless you can find a placebo with the same effects that don’t affect serotonin, good luck. Because if altering that chemical corrects the problem, medicine pretty much calls it good. Medicine isn’t science and I think this issue is pretty common throughout.
Is my gout medication an active placebo? After all, uric acid levels don’t correspond to gout attacks.
Are statins placebos? The LDL/HDL hypothesis is full of holes.
How about that anticonvulsant I take for migraine prevention? They don’t understand the mechanism of action for that either, nor for its primary purpose (and it was actually developed for an entirely different clinical problem).
It’s actually fascinating to read what we don’t know about how medications work. The data sheets are full of “we don’t know the mechanism of action or why it works but it acts on x, y, z”
Pseudoscience practitioners are also full of statements like “we don’t know how reiki works, but it does.”
Except, it doesn’t work any better than a placebo. That’s the point.
LOL. Sadly that is too often the case.
Despite assertions here otherwise, medicine has a long history of settling for “mere” symptom relief, whether or not a scientific etiology can be determined for the reasons why such relief works.
When it comes down to tin tacks, “we” are merely meat taxis for the genes in our gonads, with a heapin’-helpin’ of parasite stow-aways, and also for, (in ~50% of the human population), the DNA in your mitochondria.
I wish I could distil that into a bumper-sticker.
How about:
“WE ARE ALL JUST MOBILE SACKS FOR CO-OPERTIVES OF GENES”
?
Nope. Doesn’t have that “ring” to it.
Any advertising execs out there in real-land who might be able to ‘spin’ it for me?
Steve, I don’t know if you’ll see this, but I really didn’t think anything of the sort and didn’t intend for you to feel that way. I never thought you were being anything but honest. It’s just that anecdotal evidence is, well, anecdotal evidence.
As for the rest of the thread, there’ve been several comments – especially those from wonderist and yesmyliege – that really just elicit the same response from me, which is to recommend that they read and engage with the books. I don’t have time to address every response with long summaries or quotations from the books or the literature they cite, but I can say that while the books aren’t perfect several of these issues are covered in depth there.
No duh. Really, you ought to be a lot more careful with the disclaimers, which should be up front. As for the content, well, maybe I’ll do a response after I finish my R01 this week. There are a lot of problems. Suffice it to say, I would recommend that you stick with evolution and atheism.
LOL! Well, that was my fear as well. I confess that I am sympathetic to JAC’s argument but this is often an indication that I may be discounting conflicting evidence and inflating what supports my views. And of course outsiders are in a bad position to spot the flaws in their reasoning.
I hope that you’ll dish out some respectful insolence or deal the dish on some SBM. When you have time of course.
Seconded – I would love to see Orac’s take on this. Please do write a response!
Well, I hope you’re planning – unlike others – to read the books before you respond to the arguments.
I assume Orac will be responding to Jerry’s post and the irresponsible articles that referenced bits of several books in order to make the argument that medical psychiatry is a scam. I don’t know why you would expect him to read all of the books mentioned before responding. Jerry not only didn’t read these books or bother to educate himself beyond a couple of articles, he came to an exceptionally hasty conclusion that psychiatry is a scam.
You know, disclaimers are good, but he’s not a medical doctor and this isn’t a medical blog. It would be a bit odd for someone to suddenly stop taking their medication because they read a post by an evolutionary biologist. Not unthinkable, so they’re good, but odd.
Indeed. I was shocked at how bad Coyne’s post was. It’s really a shame, particularly after his excellent post on evolution in medicine. Ah, well…
I look forward to reading your take on this, Orac–we’ve been hashing this issue out over and over again at Pharyngula and different perspectives would be informative.
—-
I am not a medical doctor, so I will not offer an opinion on the scientific underpinnings of the use of medication in psychiatry.
However, I am a licensed social worker with over a decade of experience with individuals, families and children, in the areas of substance abuse, mental illness, suicide, child sexual abuse, child physical abuse and neglect, domestic violence, rape/sexual assault and emotionally disturbed adolescents & children.
My ‘anecdata’ from those hundreds of clients is that while science has not yet developed a foolproof cure for mental illness, and while the broken & gluttonous US health system sometimes hurts those with mental illness as much as it helps–psychiatric medication is still a necessary and useful tool for those with mental illness.
Several commenters above noted success by trial and error, and I would state that this is essential, because every person has their own individual responses to psychiatric medications, and no drug works the same (or at all) for everyone.
“like the National Alliance on Mental Illnesses—groups whose agendas include a strong push for drug therapy for mental disorders.”
Um…citation please? http://www.nami.org/template.cfm?section=About_NAMI
Look, NAMI’s primary focus has always been to decrease the stigma of mental illness and advocate for individuals with mental illness. And that advocacy means fighting for what the CLIENT wants. NAMI is constantly promoting therapeutic alliances with family and community to bring the focus of treatment on providing a supportive atmosphere for individuals with mental illness. They’re far more likely to try to promote a reunion between an estranged mother and daughter (and find community supports so the mentally ill daughter could return home) than they are to pass out newsletters saying “Come and get it! Two for one special–Prozac and Xanax in limited edition pill containers designed by Charlie Sheen!” 🙂
“As we all know, psychiatric talk therapy has been largely supplanted by the use of drugs.”
*sigh* Really?
YES–big pharmaceutical companies are greedy. (Newsflash! Sarah Palin is an idiot! PZ likes tentacles!) YES–medical schools need a primer on bedside manner. YES–we down in the trenches armed with nothing but our notepads need some respect from the stethoscope-wearing crowd. 😉 YES–insurance companies are as trust-worthy as Wall Street.
BUT–I’ve been doing this for over a decade, and I’ve worked in hospitals, government agencies, residential treatment centers, group homes, private mental health offices, non-profits and consumer advocacy groups. I’ve met a hell of a lot of psychiatrists that George Bush Jr could beat in Scrabble–and a lot more that were asses. But I’ve met less than a handful that thought psychiatric drugs supplanted other therapeutic interventions. Every office or institution I’ve ever worked in would not prescribe psychiatric medication unless it was also accompanied by some other form of therapeutic support–in fact, the provider (Value Options) that approves Medical Assistance claims in MD will not approve certain psych prescriptions without an accompanying therapy referral.
And speaking of–one point for all of the folks pushing CBT. I like CBT too, and it’s pretty damn effective–but it’s not a magic wand and there are other treatment modalities that are equally effective.
Additionally, CBT and most other insight-oriented or behavior-oriented therapies rely on at least some measure of intellectual functioning. CBT used by a therapist without sufficient training can cause more harm than good. And CBT will not work on individuals incapable of basic levels of self-insight or limited intellectual functioning without significant modification–and, again, therapists correctly trained on said modification.
Finally, the blanket condemnation of psychiatrists as money grubbing incompetents is both inaccurate and insulting. There are a lot of good people out there doing their best to help others. And most of them aren’t rich either.
…though they’re probably richer than us social workers. 😉
You should really read the books. They cover every point you make, including NAMI. I’m sure there’s more about it in the books though I can’t be bothered to find it right now, but according to a recent article in the NY Times:
http://www.nytimes.com/2011/03/06/health/policy/06doctors.html
*It’s possible that this is wrong; they don’t cite a source.
So, SC, are these books peer-reviewed scientific literature themselves? No? I thought not. So why are you constantly copping to them?
Here are some alternative hypotheses for you to consider:
1) The books don’t actually say what you think they say, i.e. you are misinterpreting or unconsciously exaggerating their points.
2) The books are saying what you think they’re saying, but the authors are simply incorrect in *their* interpretations of the evidence, for unconscious reasons.
3) The books are saying what you think they’re saying, but they are more seriously biased by ideology, or simply ‘pet theory’ bias. I.e. the authors are guilty of cherry picking studies to reference, confirmation bias, exaggerating ‘problems’ with psychiatry and pharmacology (much like IDiots exaggerate the problems with the evidence for evolution), etc.
All three of these hypotheses are far more plausible to me than the hypothesis that SSRIs have no real science to back them, are no better than active placebos, and for some reason nearly all psychiatrists, researchers, and — crucially — competing pharma companies, have not bothered to point this out.
IMHO, you have the burden of proof to support your own hypothesis over and above these prima facie more-plausible hypotheses, and that will require a lot more than repeated calls to “Read the books!”
9/11 conspiracy theorists, ID proponentsists, UFO conspiracists, and all sorts of other conspiracists have their books too. Books alone are not enough. Neither are NYT articles. That’s why we have science in the first place, to sort the wheat from the chaff.
The current science points towards the efficacy of SSRIs over and above even active placebos (I provided links to such research in one of my first comments on this thread). If you want to dispute that, bring on the evidence.
You have no way of knowing how plausible your “hypotheses” are or what the evidence is unless you READ THE BOOKS.
What a bizarre article, and on a scientific blog as well. It is as if science is not valid, and should be substituted with non-evidenced conspiracy theories.
– Drug therapies, combined with verifiable diagnosis criteria, works. That this is so is revealed right after the unreferenced claim that “studies showing no positive result”.
Also there may or may not be an attempt to push for using placebo, but I think that is illegal. You can’t harm patients, ergo you can’t lie to them.
– Talk therapies are mentioned, maybe as an alternative. Again not clear. And no data on efficiency.
– Invalid connection of psychiatry with drug therapy. The latter is used in medicine (at least where I live: Sweden).
– Claiming that expansion of putatively working methods are somehow a problem to levy against the methods.
– Claiming that “few” contrary voices somehow substantiates instead of making problematic the idea of drugs not working.
Really, what differs between this article and the usual anti-vaxx claims? I can’t see it.
Where is this, more importantly, where is it shown that drug therapies work better than placebo? There’s a lot of discussion in the articles about how active placebos yield the same results as the drugs which means it’s fair to say that the drugs to not work.
AFAIR, there have been studies on Cognitive Behavioral Therapy (a form of talk therapy) and there is clear data demonstrating that it is superior to drugs for depression. I’m not sure about for other issues like bipolar.
Except the contrary voices back up their claims with science and there are many reasons to believe that the drug consensus is weak. When we see these factors coming together, it is NOT comparable to the anti-vaxx group and it is good reason to question or even doubt the majority.
To be exact, the study determined that CBT was as effective as imipramine (an older, tricyclic antidepressant). They did not report on its efficacy compared to other antidepressant.
I think it’s important to separate the kinds of illness we’re talking about, and the kinds of medication. Manic depression and schizophrenia certainly respond to drug treatment, and not to talk therapy alone.
Lithium was shown be be effective back in the fifties, and has always been off-patent. The older antipsychotic drugs and antidepressants were also very effective (the tricyclics and MAO inhibitors are supposedly more effective than SSRIs), and the use of them started again in the fifties.
The reason they’ve been supplanted by SSRIs and anticonvulsants is that the older drugs’ side effects are truly ferocious. SSRIs could be said to have “fewer” side effects (or at least not as many life-threatening ones) than the older drugs.
I’d be interested in seeing studies of the broad-spectrum antidepressants, that affect more than one neurotransmitter. Especially with the major mental illnesses.
“I think the burden is on the makers and prescribers of drugs to show that they’re effective and safe.”
Great idea! We could even have a governmental agency which oversees this process, and we could put it in a huge complex in Silver Springs, Maryland. ;>)
Oh, good grief. Read the books.
And please note:
Lancet editorial, 2004:
*A review a bit later in the BMJ recommended against the use of this as well.
You do realize that the FDA requires that antidepressants MUST prove to the FDA’s satisfaction that they are both safe and effective in a minimum of two well-controlled clinical trials based on FDA guidelines?
You do realize what a joke this is / you are?
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC437172/
Salty – your use of personal attacks and your repeated mantra of “READ THE BOOKS” isn’t helping your case at all (and smacks of desperation). Have you done any reading that addresses the claims of these books or any reading about the psychopharmacology of antidepressants which address how they REALLY work. Psychopharmacologists and the FDA have known for years that these drugs don’t work simply by increasing the activity of serotonin or norepinephrine or dopamine.
So please, until you read books that tell the other side of the story, enough with the “read the books.”
I have to go with orac here. This is his field.
No, it isn’t. He’s a surgical oncologist specializing in breast cancer.
He is however, unlike Jerry, a medical doctor. Would you give Orac’s comments more credence if he were a psychiatrist. I’m guessing “no.” It would appear that you do not trust the profession.
Jerry is a scientist.
Marcia Angell is a pathologist, former EIC of the New England Journal of Medicine, expert on pharmaceutical-industry involvement in medicine, and public CAM critic since before Orac. I don’t know if she blogs, though, so feel free to discount her completely.
Kirsch is a clinical psychologist and recognized placebo expert who’s published on the subject for decades. Does not blog, as far as I know.
Daniel Carlat – author of the other book (aside from the DSM) that Angell reviews – is a practicing psychiatrist. He also blogs, about psychiatry.
Regrettably, this post is an example of what happens when an expert in one field comments on another when they largely rely on the work of others.
What are your qualifications to make that comment?
Reading the article is all that is needed to come to this conclusion.
The various comments belie that simplistic response.
I have read the article, and did not arrive at that conclusion.
It seems that I am not alone.
What was the point of your trivial & incorrect above remark, in response to a question personally posed to another poster’s intent?
What interests me is the the idea that we all must ideally sit in the centre of the bell curve to be ‘normal’ and should take medication to achieve that if necessary. We are evolved and evolving animals so what is normal in a biological sense as opposed to cultural norms? The idea of medicating ourselves to an approximation of an acceptable norm is predicated on there being some sort of Platonic ideal ‘human’ to aspire to, whereas we are a snapshot in the evolution of homo sapiens.
I think most individuals who work in mental illness share the same positive belief that things like autism, bipolar, and probably all personality disorders, are part of the expected variance of the human condition.
The point you’re missing is that when someone begins to receive treatment for a disorder or syndrome, it’s because the impairment to their life is *clinically significant.* It’s not to force people into some sense of normative functioning; it’s rather to help treat problems that the patient identifies as interfering with what they want out of their life. No one puts a gun to your head and makes you take mood stabilizers if you are diagnosed with bipolar: it’s your choice. I’ve my share of anecdotal stories of friends who don’t take medication and who occasionally become manic but function for the most part, fine. Some people aren’t that lucky.
Agree with you re ‘clinically significant’ cases. I guess I was thinking more of how there sometimes seems to be a desire to medicalise everything, rather than accept there will be naturally times in our lives when we will not be functioning at our best (bereavement, divorce, work stress etc.) and reaching first for a pill is not to my mind the answer. We need to be able to ride the waves (unless of course a jagged rock is approaching). Here in Ireland the pharma companies can’t advertise directly so they’ve started throwing out sponsored ‘fishing net’ ads with enough vague sympthoms to catch people. The vitamin and homeopathy industries don’t help as they seek to alt-med everything into a pill-popping cure.
The homeopathy industries not only “don’t help”, they actively hinder, and kill innocent folk, including infants.
This is not how mental illnesses are identified. It is not enough to simply deviate from the ‘norm’. It also requires demonstrating a significant negative impact on the person’s life (e.g. suffering, relationships, hygiene, physical health, ability to maintain income, etc.).
If psychiatry considered any deviation from the ‘norm’ as a disease, then having a high IQ, or extraordinary artistic talent, would be called a ‘disease’.
My reply above to srsScience hopefully clarifies where I was coming from. However, you mention high IQ – there has been a trend for quite a while to assign people typically called ‘geniuses’ eg. Einstein, Beethoven, etc to autism spectrum disorders. So yes, it could be argued that pyschiatry does try to medicalise high IQ.
Maybe it is because Eglish is not my first tongue, but the term “medical psychicatry” sounds ambigous to me. Isn’t psychiatry a subfield of medical sciences?
I would rather use the term “psychiatric pharmacology” when referring to the treatment of mental ailments with chemicals.
I agree.
Thank you kindly for this post, Professor Coyne. My admiration for you, boundless though it seemed, has just increased one-hundred-fold. You may have also just saved my life, not to mention saving me (and my family) thousands of dollars in medical “care”.
In early April of this year, after getting abruptly fired on February 5th (from yet another corporate engineering job in the Silicon Valley, after simply voicing technical differences of opinion to my ultra-religious boss, and to certain other insecure colleagues, and after working every single day in the month of January, including weekends, for at least 12 hours per day), I agreed to go seek medical help at the desperate request of my naive (and devoutly Catholic) parents. This was the beginning of an incredible and terrifying experience, from which I am only now recovering.
We drove to my doctor’s office (a young, smart Asian woman), and with my parents in the room I told her I was having “suicidal thoughts” due to the fact that my patchwork-quilt career was now looking bleaker and bleaker. I had no actual plans for suicide; I was merely expressing a deep, frustrated sadness (and perhaps religiously-indoctrinated shame?) that all my goals and aspirations since graduating Stanford were seemingly unfulfilled. My mother, sensing an opportunity to voice her own fears, then told Dr. Lee that I owned a handgun — a gun I had purchased ten years earlier at a show in Reno at the urging of my NRA-loving brother. Dr. Lee’s eyes widened at this revelation.
For myself I began asking Dr. Lee questions about SSRI medicines, and told her I had reviewed double-blind studies that had indicated they were no better than placebos. Dr. Lee scoffed at this, and briefly explained her understanding of serotonin re-uptake “mechanics,” and told me these medicines had “come a long way since Prozac“, meaning they had been vetted thoroughly — and that they indeed “worked” for many patients. I also asked her about the libido-reducing side effects of these drugs — and she countered by asking me if that would be “such a bad thing”, at least in my case. (Yes, my use of marijuana and prostitutes had been aired previously in the discussion).
Suddenly, Dr. Lee then shocked all of us to the core by saying she was ordering me immediately to the Eden Hospital Emergency room in nearby San Leandro, and that if I didn’t agree to go, she would enlist the help of a police escort. I was quite amazed and somewhat angry at her demand, and as I walked dazedly to the car with my parents (who seemed robotic and foreign to me at this juncture), I asked my mother if she would “turn me in” if I refused to go to the emergency room. She said quietly “yes.” Seeing the tears in her eyes softened me considerably, and I suppressed the impulse to open my passenger-side door and merely get out, at a stoplight.
We parked the car at Eden, and I was admitted to an observation room after a two-hour wait (in the waiting room with people who REALLY needed medical help), and then I was obligated to twiddle my thumbs for SIX ADDITIONAL HOURS, by myself, in a hallway observation room, with the occasional nurse popping in, while another room in the PSYCH WARD upstairs was ostensibly being prepared. (When I actually got to the Psych Ward near midnight, there were mostly empty rooms, so I’m not sure what the delay was all about).
I then spent a mentally agonizing night on an uncomfortable, rickety bed, and in the morning I was brought in to see the staff psychiatrist, a large Russian man (with considerable Sigmund-Freud resemblance) named Dr. Boris Zalkovsky. Dr. Zalkovsky harshly suppressed every single one of my scientific questions — he wasn’t going to address the subject of SSRI medicines with me in this venue, he said. His main concern was how he (and Eden) were going to be paid, because after all I had just lost my medical benefits by losing my job. He then scared the utter piss out of me when he mentioned that the price for staying one single day in the Eden Hospital Psych Ward was somewhere in the vicinity of $5000.00 PER. Satisfied with my trembling answer concerning Cobra-extensions on my previous health benefits (which I was reluctantly granted, thank Jebus), Dr. Z then proceeded to write and administer four scripts: a drug called Abilify (Aripiprazole), one called Celexa (citalopram), Ativan (Lorazepam), and Ambien. I signed papers agreeing to swallow these pills, and that was it for Dr. Zalkovsky, until FIVE INTERMINABLY BORING DAYS LATER, when I was finally released from the hospital, whereupon Dr. Z simply signed my release papers, scolded me for being “argumentative,” and then repeated to my stunned parents the exorbitant price for the services that had already been rendered.
There is a lot more to this story, but it’s getting a bit long and tedious for WEIT. I’ll summarize by saying that I felt not one bit different after 6 weeks of ingesting these “depression medicines”. If anything, I felt a little worse. And I was completely open-minded about trying these drugs, believe me. I was COMPLETELY unable to masturbate the entire time — it just felt like there was nothing down there. I was still attracted visually to women walking by or on television, but to act sexually on that impulse would have been utterly futile.
Three weeks ago, I stopped taking all the drugs. And if you’ve never felt depression before, take SSRI medicines and then quit cold-turkey. I soon realized I myself had never really experienced true depression, because during the first week after stopping I was like a complete zombie — I didn’t want to eat, sleep, blog, read, or exercise. I wanted simply to vanish from the face of the Earth. It was the lowest point of my entire life, and horribly stressful thoughts of suicide played upon my mind hourly.
The good news is I’m quite relieved to be feeling somewhat “normal” again presently, and I don’t plan on revisiting “depression” medicines any time soon. Sorry to monopolize the WEIT podium — it just seemed apropos given this excellent post by Professor Coyne’s on the subject.
I know what you mean. I took citalopram for a while, but all it did was preventing me from having an orgasm. I was still horny and could get it up, but nothing came out. And then I stopped using it. I had shivers for a month, the withdrawl was extremely unpleasant, but I had orgasms again
I think the moral to this, and other tales in the comments is never tell a US doctor that you have had suicidal thoughts! You don’t need to worry in Australia, we have no facilities for psychiatric patients any more, we wait for them to commit crimes and put them in prison.
Or into parliament.
ROTFLOL!
This is horrible advice for anyone dealing with depression or suicidal thoughts.
You know how you get out of the locked ward? You say, ‘I don’t feel comfortable here. I would prefer to recieve my treatment in an outpatient setting.’ Don’t yell. Don’t argue. Don’t justify yourself. Don’t deny that you have problems. Just stay calm and politely ask them to let you out.
I’ve tried it. It works.
And definitely watch out for those sneaky little “mood survey” forms the nurses hand you twice a day in the hospital. Don’t check any of the boxes. Just write in that you’re feeling fine, and that you’re eager to go home and get on with your happy life.
Otherwise Jebus knows what they might do.
It may not be my place to say this, saintstephen…but never under any circumstances allow your parents to be involved with your psychiatric issues. I to learned the hard way over this. It gives them unprecedented powers over you, that they’ll always use againt used…and making uninformed decisons “in your best interests.” My life was almost ruined….as yours almost was. If you need professional help, then try to network with those you can trust and confine in. I finally found what I was looking for. I hope you can too.
*confide with…not confine.
Oh. My. Gawd.
I’m so sorry, saintstephen. And glad that your posts here indicate you managed to land on your feet in spite of all that horrific bullshit.
I’m sorry too, StStephen. I can’t believe how many meds they gave you.
Your post does reiterate how important it is to go slowly on and off SSRIs.
I always taper mine up and down–probably more slowly than needed. But I have avoided headaches and other symptoms. For those considering stopping or starting, get a pill cutter if you can’t cut them well. It beats withdrawal symptoms.
By the way, I don’t suggest starting or stopping without medical advice, but since so many people mention withdrawal symptoms, I think prescribers are neglecting to make sure patients hear this info.
Dear Dr. Coyne:
Thank you for the article. As you point out, an especially disturbing aspect is the prescription of anti-depressants for children.
You might find the following documentary on the topic aired on PBS interesting: http://www.pbs.org/wgbh/pages/frontline/medicatedchild/
Sunny
While the fine-tuning argument of theology is complete bullshit, modern psychiatry should employ this technique when it comes to matters of pharmacological profusion.
A little garlic goes a long way.
This takes me back to the 1980s and a psychiatrist named Thomas Szasz, whose most famous book proclaimed that there was no such thing as mental illness.
I interviewed him once. Interesting man.
I have also read much of the literature involving the “registration” trials for the major anti-depression and anti-anxiety drugs. And it is quite true: the response to the active drug is paralleled by an almost-equally robust response to the placebo. I, for one, am not convinced anything clinically important is being derived from the use of most of the antidepressant medications.
With an important exception of side effects. There, the active drugs win hands down. I know that I won’t be taking any of the voluntarily.
I will say that the mood stabilizing drugs for bipolar disorder have been shown to be quite useful. And antipsychotics can be literal life-savers to those who truly need them. So, I don’t think it’s as black-and-white as Dr. Coyne suggests.
But for the past 25 years or so, I’ve become quite appalled at the explosion of the use of stimulants for children with “ADHD”. I’m sure that there might be a small minority of kids who truly need and benefit, but I’m afraid the VAST majority of children are nothing but victims of one of the largest scams ever perpetrated on worried parents.
BTW: The trials for antidepressants are almost all available free online through PubMed or other resources. In fact, the package inserts of the drugs are ALL available for free online, and they have the data on the pivotal trials embedded in them.
I invite anyone whose physician is suggesting an antidepressant to find the relevant article on the drug in question, print out the graphic that shows the “relief” of depressive symptoms of the active drug versus placebo, and hand it to the physician with placebo circled. Say, “I’d rather have that one, please. It works almost as well with virtually no side effects.”
Gee, that’s a great idea. How about these:
– http://www.ukmi.nhs.uk/NewMaterial/html/docs/escitalopram.pdf
– http://www.neuroassist.com/93a%20escitalopram%20in%20primary%20care%20articlex.pdf
– http://www.cipralex.com/about_cipralex/superior_efficacy/efficacy_in_depression/cipralex_vs_citalopram.aspx (includes a nice shiny graph!)
I’ll take the bottom curve (Escitalopram), doc.
Also Sertraline: http://en.wikipedia.org/wiki/Sertraline
A hint: If your scientific reference begins with a drug name followed by a .com, it’s probably not going to be taken seriously as a disinterested source, and neither are you.
Hilarious.
A hint: Only one of them did (the one with the shiny graph). I could easily list a dozen more: http://scholar.google.com/scholar?q=escitalopram+major+depression+placebo&hl=en&as_sdt=0&as_vis=1&oi=scholart
You know, it’s interesting. You resort to ad hom, trying to distract from the argument by attacking the source, instead of making a counter argument. That’s another fallacy. Which side tends to be using all the fallacies? Hmmmmm…..
BTW: The source of the data for the shiny graph is an actual published scientific paper, so are you now claiming that it’s a fraudulent paper? Interesting. You seem to be willing to dig yourself deeper into your hole. I would recommend taking a step back and re-evaluating your position. Which side of history do you want to be on? The side with the evidence, or the side with the conspiracy theory?
And that’s the one I was referring to. Particularly amusing in a post/thread containing extensive evidence of the manipulation and selective release of research by drug companies. About the dumbest thing you could’ve linked to. Congratulations.
I don’t think I’ve ever encountered anyone so fond of naming logical fallacies but without the slightest grasp of what these names mean. I don’t think you’ve correctly applied one on this thread. That has to be some sort of record. Congratulations again.
Oh! You just have to listen to the homophobic rap atheist who calls in to “The Atheist Experience” for someone who has less grasp of the implications of logical fallacies!
“Homophobic rap atheist?”
Probably the fewer people that listen to him, the better!
Beware of the “file-drawer” effect.
Poor studies can remain unpublicized.
Hear, hear.
Except that there are competing interests publishing comparative studies of competing drugs. If a company found their competitor’s product to be worthless, wouldn’t you expect them to publish that finding?
You keep beating this favorite Randite / Smith drum with your invisible hands.
When was the last time you saw Ford marketing its cars by widely publishing safety design flaws in a GM car?
When was the last time you saw Exxon expose safety problems with a BP oil rig?
When was the last time you saw DuPont and Monsanto digging through each other’s dirty linen?
Jerry’s suggestion is that the entire class of SSRI drugs, regardless of manufacturer, is either of much more limited utility than advertised (only works on a small yet-to-be-identified subset of patients) or not significantly better than a placebo (keeping in mind that placebos have been shown to be significantly better than nothing).
If Jerry’s suggestion is true, then, no. I wouldn’t at all expect one manufacturer to point out flaws in another manufacturer’s wares. They’d have to be blithering fucking idiots to do so, for there’s no way they could do that without bringing down the house on their own heads as well.
Cheers,
b&
It is my understanding that all manufacturers of antidepressants must now provide on-line ALL of their studies – negative as well as positive – for anyone who wants to review them. I know that GSK, at the very least, does this.
You “understand” incorrectly.
Chinese manufacturers, (for example), are not obliged to publish all trials.
Are you able to support your understanding with data?
I am not aware of any Chinese pharmaceutical companies who develop new drugs applications for application to the FDA. Do you? Or are you just jumping on the word “manufacturers” for the hell of it?
Who said anything about the FDA in the context of your globally sweeping remark?
Or does the world of pharmacology stop at the borders of the USA?
There ya go, Jerry. Now you’ve brought the ADHD denialists out of the wood-work. This is getting ridiculous.
Oooh, ALL CAPS! That looks like fun!
Antidepressant-Placebo Debate in the Media
Balanced Coverage or Placebo Hype? http://www.srmhp.org/0201/media-watch.html READ THE DAMN SENSIBLE ARTICLE.
Placebo Versus Antidepressant
Review: The Emperor’s New Drugs: Exploding the Antidepressant Myth
By Floyd E. Bloom
June 08, 2010
http://www.dana.org/news/cerebrum/detail.aspx?id=28024
READ THE DAMN NEGATIVE REVIEW BY AN ACTUAL NEUROPHARMACOLOGY RESEARCHER (KIRSCH IS NOT).
“A quick fix would stop drug firms bending the truth” Ben Goldacre
http://www.badscience.net/2008/02/619/
READ THE DAMN ‘BAD SCIENCE’ BLOG POST.
*headdesk*
first paragraph from the author:
From the author:“SSRIs, for example, increase the amount of the neurotransmitter serotonin in the synapses (gaps) between neurons by preventing its reabsorption by the neurons. Because these drugs seemed to work (more on that below), doctors and pharmaceutical companies blithely concluded that depression resulted from a deficit of serotonin. But that’s ludicrous, for just because a drug alleviates a symptom doesn’t allow you to conclude that the symptom was due to the deficit of that drug”.
Just a few thoughts: there are 100 billion neurons in the human brain and at least 10 times as many other cells (whose functions are far from being fully understood), so that’s roughly one trillion cells all crammed together in the brain, with a single neuron containing as many as 10,000 connections with other neurons. Do neuroscientists understand how SSRIs work? No, not exactly, but here’s the deal. SSRIs were rationally-designed drugs to target systems in the brain that several serendipitous findings on human mood states led them to. Science works based on observations, like the very observation above (the SSRI alleviates the symptoms). The hypothesis that SSRIs block serotonin reuptake in a test tube and in mammalian brains would naturally lead one to believe that there is a link between serotonin and depression/mood states. To come up with ANY OTHER hypothesis in the wake of findings from other antidepressants with similar effects on serotonin systems (monamine oxidase inhibitors and tricyclic antidepressants) would be irrational and foolish. Again, does anyone fully understand how SSRIs work? No, the impact of these drugs on the biology of the brain is likely to be staggering (remember the one trillion cells), but so is the impact of CBT. Other pharmacological approaches that might be more successful at alleviating depression are being tested in neuroscience labs around the world. SSRIs are not the be-all, end-all antidepressant, but can be lifesavers for some. Stop oversimplifying, stop sensationalizing, and get with the science.
What is interesting is that IF SSRI’s actually worked by increasing the intraneuronal concentrations of seratonin by reuptake blockade, they would be expected to work within minutes to improve mood. But they don’t.
What has been shown is that used over time, they upregulate the number of seratonin receptors, and do it at just about the same timescale that clinical studies demonstrate that they elevate mood.
If the FDA allowed us vivisection rights (damn them!), we might have figured it all all out sooner. As it is, it’s a difficult business as brain biochemistry is a dynamic system that responds to perturbations.
I’m not clear as to why the inhibition of the reuptake of seratonin would have to work to improve mood within minutes. 1) The blockade process may take much more time than mere minutes before it reaches the critical point where mood begins to be alleviated. 2) Mood may have a certain momentum to it that takes time to reverse.
Also, how can you tell they “upregulate the number of seratonin receptors” after X amount of time without running into the same problem of not being able to do vivisections of people’s brains.
Thanks for a rational, informed approach to the subject.
I have always known that my brain was wired up wrong.
I have not found the right drug yet to wire it properly, or the right shrink with the right pharmaceutical endorsement.
Perhaps, shrinks should have their endorsements emblazoned on their white coats, so you know what kind of a cocktail you will get before laying on the couch.
As a person who sufers from chronic and social anxiety, (though I am managing fine currently threw talk therapy and CBT), I am glad to hear my discision not to take any medication all this time for it was founded in science and reason. And my suspicions confirmed about SSRI’s…which I’ve had more one shrink trying push this on me like drug peddlers pushing crack onto kids. I am glad I dodged those bullets. Thanks for sharing that, Jerry.
Remember the rule, if the answer to the title question is ‘NO’ then you shouldn’t write the article, or at least you should change the title.
In theory, it should work. The brain’s chemistry makes it all happen, so changing the balance of some stuff should improve things.
In theory. In practice, we don’t know what the heck we’re doing. Machine gunning at mosquitos. Using a sledgehammer where a small mallet is better. Blinding Spock with the whole light spectrum when ultraviolet is enough.
Look up icepick lobotomy and prepare to be stunned. Medical psychiatry has a much better theory, but in practice it’s more similar than it oughta be.
Dr. Coyne, I am extremely disappointed by your post. It shows a lack of understanding and respect for those of us who have mental illnesses. From the age of 8, I had been trapped and repressed by a web of anxiety and depression that affected every aspect of my daily life. One year ago (at the age of 23), I finally overcame my biases against psychiatric medicine (which came from the media and popular culture) and began taking an antidepressant (an SSRI). In all my YEARS of talk therapy, I never had experienced anything that allowed me to finally break completely free from my chains – my fear of other people’s judgments, my deep and unsubstantiated pessimism about my future, my deep dissatisfaction with every aspect of myself, etc. Your post furthers the notion that those of us who rely on psychiatric medication are actually fine and that we are inventing our problems. That we would be perfectly okay without medication, if we would only let ourselves. To that I say, why don’t you try dealing with chronic depression and anxiety before passing judgment? Why don’t you try living your life afraid of other people and afraid of your own self-criticism, and then have other people tell you how you don’t need medication, how medication doesn’t work, how you should just deal with it by talking to a therapist? Well, I tried that for 15 years. I have NEVER felt okay until I started taking this medicine. And that is not due to any placebo effect. I don’t CARE that they don’t know exactly how it works. What I care about is that it allows me to live my life and feel okay about myself. And I don’t need anyone else telling me why I should feel bad about myself for needing this medication. If you have never had depression, it is COMPLETELY unfair of you to judge those of us who live with it every day and who have been helped by psychiatric medicine.
I really think you need to re-read the article, because Jerry didn’t say anything of the sort. He is not in the least disparaging of depression, nor of the terrible effect it has on its sufferers. What he was questioning was whether people who needed intervention were getting treatment that was as effective as it was touted to be.
He is on your side here. You have misread this.
You are right – I got overly upset about this. It’s just that it is so frustrating to me when people talk about how our society is overly reliant on psychiatric medication and that everyone would be better off without it. It’s a judgment on those of us who need medication to function in our daily lives. So when Dr. Coyne suggests that psychiatric medicine itself is a “scam,” it feels like the same sort of judgment. I should not have overreacted like this. I have just come to expect better from this blog.
Your response is completely understandable given your circumstances and Jerry’s overreaction to reading a couple of articles. I too expect better from this website and was stunned when I read this particular article.
As an addendum, while it’s true that antidepressants do not work for everyone (and that some people find that certain brands of SSRIs work better for them than others), it is RIDICULOUS to compare the effects of SSRIs to the effects of homeopathy! First, homeopathy has no plausible mechanism; SSRIs do. Secondly, the brain is a complex and mysterious organ. Just because some people respond much better to SSRIs than others does not mean that the effect of SSRIs is merely a placebo. There are many, many people just like me who have been helped immensely by an antidepressant medication after years of talk therapy did no good. To chalk up our experiences to a placebo effect is demeaning and insulting. I know what I have been through, and I know where I am now. I also know what happens when I forget to take my medication. There is no way that this is a placebo. Especially considering how badly I have wanted to feel better for the past 10 years or more. One CANNOT will oneself to recover from depression. No placebo can be effective in dissipating the cloud of negativity and hopelessness that surround those of us who suffer from this condition.
“The brain’s a mysterious and complex organ”.
Did you read the links I gave above?
FACT: Pharmaceuticals pay folk to write/re-wrrite/issue statements about the efficacy of drugs ’cause wi’ the brain being a mysterious and complex organ, only folk being PAID MONEY can say “Hey! These drugs work! SSRI’s work!”
Look at the evidence: it’s awfully (in both meanings of the word) what the tobacco industry did.
Yep – drugs – certain drugs can help when one is insane. But we’re talking about folk being prescribed powerful drugs for years – or life.
I’ve given links – check them out. I know all too well – perhaps (in mania or depression, one tends to have fugues) – what medication for life means.
Sorry if I’m a bit shouty, but question. Read. Don’t jump to conclusions. Reach them.
Regards,
john
“Pharmaceuticals” pay no one.
Shouting doesn’t make your arguments sound more rooted in evidence, it actually does the reverse. Saying that people who dispute the effectiveness of your drugs or your beliefs doesn’t mean they don’t care about your struggles – that really is the same ridiculous claim that religious people make all the time. And when even the people defending SSRIs agree that they offer no benefits for mild to moderate depression (but have many negative side effects) then yes, a comparison with homeopathy isn’t out of the question – homeopathy is an inactive placebo, SSRIs could be an active placebo. If you wish to dispute that (and many here are), complaining that no one understands you and SHOUTING about your poor life doesn’t make you more compelling, it makes it sound like you don’t have any evidence.
On the off chance that you’re still listening…
If you read the literature, this is exactly wrong. CBT, a form of talk therapy, has been demonstrated to be effective at dealing with many forms of mental illness. Of course you aren’t just willing yourself like in The Secret, but directed, focused work can yield results without drugs (or with reduced quantities).
And as for whether placebos can or cannot help, I think this is the most ridiculous claim yet. There are many studies which show that placebos do help, active placebos help even more. The studies on both sides of this issue reinforced this countless times.
I’m sorry that you have dealt with depression personally but this doesn’t give you a free pass to make scientific claims without support or evidence any more than a Mommy Instinct does, nor do I think you should be using this problem to silence critics out of sympathy for you. I am glad that you are willing to share your personal experience but try to remember that it is just one anecdote.
First, I never said that talk therapy is not effective. I said it didn’t help ME. Yes, I know the studies on CBT, and I know it has helped many people. I don’t think drugs are the only answer, but I do think they are part of the answer. Secondly, I was sharing my personal experience not because I think one anecdote proves anything, but because many people like me have had the same experience of being frustrated by years of talk therapy and have found that medication is far more effective for them. Finally, I was not trying to “silence my critics” or to “complain about my poor life”; I was merely offering my personal experience of being helped by antidepressant medication. It has made a big difference in my life. Obviously you don’t think this is a valid point, but you certainly don’t need to be nasty about it.
I agree with Hannah. These others literally don’t know what they’re talking about. They’ve never walked the walk, they’re just wildly speculating about “meta-analyses”. Those of us whose “analyses” might be a little more immediate may beg to differ.
Talking to depression is like talking to a broken leg. That’s where the witchcraft is. Maybe it would help if you shake some rattles and burn some incense and draw a pentagram on the floor.
One poster on this thread thinks that drinking more alcohol would be a good treatment for depression. The Scientologists think that depressed people have souls infected with ancient intergalactic thetans! Good grief!
Is this the same crew that went after vaccines?
That assertion is hovering over an actionable libel.
We all know that you, (employing a pseudonym), refer to me, (using my full name), and you should know by now that I claim no such thing, and have been corrected on multiple occasions.
I have never claimed that ethanol is a treatment for the disease, merely self-elected temporary symptomatic relief.
I respectfully request that you retract this libel against me.
“the disease” excludes depression, by the way.
I was clearly referring to anxiety.
Which is temporarily ameliorated via ingestion of ethanol.
The poster persists in incorrectly conflating “depression” with “anxiety” in some bizarre and seemingly obsessive manner that I can only guess as to its source.
Depression and anxiety are related illnesses that both respond to some antidepressants. Depression and anxiety also often go hand-in-hand. I know this from personal experience, 18 years as a mental health professional dealing directly with the severely mentally ill(social worker, so I was poorly paid and certainly received no incentives from the pharmaceutical industry), and copious reading on the subjects (depression, anxiety, medications) over the course of the 24 years that I’ve been receiving treatment (both medication and psychotherapy which as has long been known by most good psychiatrists, psychologists and anyone who reads even a little bit on the subject, work better than either alone).
“That assertion is hovering over an actionable libel.”
WTF?!! A response to a response to a web post is “hovering over an actionable libel”? Please tell me you’re joking.
“Hovering over actionable libel”? I think maybe you take yourself far more seriously than I do.
enjoy the thread.
OT: Long before the internet it was common to use caps for individual words to indicate emphasis, and I see no reason not to continue to do so; it’s much quicker and still seen frequently in comics, etc., and is widely understood. I only see “shouting” when an entire post (or at least, sentence) is in all-caps. Just my $0.02…
Excellent point, especially on a website where there is no indication how to italicize or bold.
Yes it is…
I rather think a lot of ‘mental illness’ is an indulgence for better off people who do not have the real problems that the poor have. When life is a struggle there is no time for such things (though that does not mean they do not exist I admit). Is it just existential doubt?
I have had two girlfriends who suffered from what I would call bouts of severe depression, & it was no fun – neither took ‘medication’ but they lived with it. One used to hit herself in the face. A friend killed herself three months after giving birth. Another friend has missed more than a year of work in a two year period with ‘panic attacks’. She was on drugs which her doctor prescribed for too long according the the British National Formulary, & they seemed to have no effect. I realize that these things are concrete problems for those people, YET I cannot understand them at all. I always wanted to say “pull yourself together; where’s that stiff upper lip?; there are millions MUCH worse off” etc, but of course I did not. Is there something wrong with me? Do I lack empathy? Am I the deficient member of society because I think of them as weak?
Possibly…
“Is there something wrong with me? Do I lack empathy? Am I the deficient member of society because I think of them as weak?”
I think you’ve answered your own existential query there.
Regards,
John
You dissapoint me, Dom.
Not to mention, “disappoint.” (Cussword!)
Me too.
Severe mental illness is agony, not to mention life-threatening. You seem ignorant of the vast literature describing these conditions and their basis.
Please read something and educate yourself–I think your thinking will change.
I understand that on the technical level. I am trying to be honest! If you do not suffer from depression but live with someone who does, it can be incredibly -frustrating, and wears you down. I am not unsympathetic – I am posing the question as to whether I am odd because I find this impossible to comprehend. John above thinks I am right to think that I am deficient in this. Is this the reason that I cannot understand why people need religion? Sorry to disappoint…
Dominic;
Living with a depressed person can be very trying.
One often feels like saying: just put your shoulder to the wheel.
However, as others have said, you should read up about depression and try to help those depressed people who are around you.
It’s not their “fault” or responsibility that they are depressed.
And it could happen to you too.
Well, yes, I think you are currently deficient. Your ignorance leads to your quite unjustified feelings.
Not understanding these disorders at all would be remedied by learning about them.
There are many, many books written specifically for the friends and families of people with specific disorders. They all increase the relatives’ understanding and thereby their empathy.
Just seek out the knowledge, and your understanding and opinions will drastically change (I promise). Better to do this before someone else you love needs your support, as it currently seems that you’d be incapcable of giving any. Not because you wouldn’t want to—you just don’t know how.
I, too suggest you do some reading. One good book is by tracy Thompson, The Beast: A Journey Through Depression.
You might understand a little better. I’d hate to think you are friends with anyone suffering from mental illness and that you haven’t learned a thing. Not much of friend, I’d say.
Is there not a difference between depression and mental illness? If no one knows why these things happen how do we know anything at all about ‘treating’ them?
I am loath to defend myself much but would say I was not unsupportive in those cases – I lived with the situation in one case for three years and the person would not seek any ‘professional’ help – perhaps rightly judging by what has been said about drug treatments. I am chastened by everyone’s disapproval of me but I would have expected nothing else. Thanks for the suggestions.
To answer your question…
I’d say there’s something wrong with your understanding of mental illness, and that misunderstanding allows you to think that, say, depressed people are just being needy.
Do some research on mental illness, if you want to understand.
Dom, historically one of the biggest problems faced by the mentally ill has been pretty much what you said–that people don’t understand it, and react as if problem is simply a behavioral one that sufferers could ‘cure’ if they’d just try.
Seems to me this should be easier for biological determinists (where have I heard that recently? 😀 ) to understand than anyone else. Remember–our consciousness is just the result of those anatomical/electro-chemical interactions in the brain. Think how complex that system is, and how many ways there could be for it to screw up!
IMO, though, a problem does arise due to the imprecision of diagnoses and lack of definitive tests for most of the syndromes we feel are true mental illnesses. For some conditions, such as ADHD in children and depression, I think it’s possible that there is some overdiagnosis, for various reasons. This in turn leads to skepticism, which is appropriate; but not at the expense of the truly functionally challenged.
I suspect most of the posters here with some history of depression were greatly put off with your comparing not understanding depression with not understanding religion.
Yes you are right of course… Regarding your last sentence – I am sorry if that is the case. I totally understand on an ‘intellectual’ level if you like. At an emotional level though it is different. what I know and what I feel are not always in agreement. I suppose my mistake is to have this conversation with muyself in public – I just believed in being honest about this.
Well, at the emotional level I suspect we’ve all been guilty of the same response at one time or another. You can put away your hair shirt. 😀
Thank you…
I think we can all probably agree that antidepressants have been over-hyped and oversubscribed, but there are two sides to this story. Jerry writes:
“Trials are typically only a month or two long, and I am not aware of any long-term tests of these drugs.”
The first part of that sentence is erroneous – that only applies to initial drug trials required for licensing. There have been many far more extensive studies on the efficacy of anti-depressants. See:
F. M. Quitkin, J. G . Rabkin, J. Gerald, J. M. Davis, and D. F. Klein.
Validity of Clinical Trials of Antidepressants
Am J. Psychiatry 157: 3, March 2000, pp. 327-337
“Recent reports have criticized the design of antidepressant studies and have questioned their validity. These critics have concluded that antidepressants are no better than placebo treatment and that their illusory superiority depends on methodologically flawed studies and biased clinical evaluations… Conclusions: The issue of bias or allegiance effects for both antidepressant and psychotherapy research is real. Investigators of all orientations must guard against potential bias. However, studies cited as supporting the questionable validity of antidepressant trials fail upon closer examination to support assertions that these trials are invalid.”
http://ajp.psychiatryonline.org/cgi/content/abstract/157/3/327
One of the books reviewed in the NYRB article cited by Jerry is by Irving Kirsch, and the studies of which he has been lead author have been widely publicized. Far less publicized are several highly critical analyses of these studies:
“Listening to Meta-Analysis but Hearing Bias.” Donald F. Klein, Prevention & Treatment, Volume 1, Article 0006c, 1998
“The article [Kirsch el 1998] is criticized because it derives from a miniscule group of unrepresentative, inconsistently and erroneously selected articles arbitrarily analyzed by an obscure, misleading effect size. Further, numerous problems with the meta-analytic approach, in general, and Kirsch and Sapirstein’s use of it, in particular, go undiscussed.”
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=1999-11094-005
The statistical analysis in Kirsch et al’s widely reported 2008 meta-analysis of antidepressant drug trials has been criticized by several people with expertise in statistics. e.g,:
“So my conclusion is that I don’t trust this study, and I certainly don’t trust their conclusions. I’m not sure exactly why my analyses are so different from the authors’ but I’m fairly sure it has something to do with their over reliance on the standardised mean difference as a measure of effect size.”
http://pyjamasinbananas.blogspot.com/2008/02/antidepressants-redux-2.html
Again:
“Most worryingly, the very basis of what is “statistically significant” in [Kirsch’s] research is under question. A similar study of antidepressants’ efficacy, led by Prof Erick Turner and published this year in the New England Journal of Medicine, found similar statistical results to Prof Kirsch, but its interpretations were different: each drug they studied was clinically superior to the placebo. This didn’t make it into the press. Instead, Prof Kirsch’s study did, because it provokes fear…
I am no fan of the pharmaceutical industry or the way it tries to manipulate data to promote its drugs. I think antidepressants are too readily prescribed and access to psychotherapy too limited. But provocative studies such as Prof Kirsch’s do more harm than good. As an academic, he doesn’t have to witness its impact. While he sits in his ivory tower, those on the ground pick up the pieces.”
http://www.telegraph.co.uk/health/main.jhtml?xml=/health/2008/03/31/hmax131.xml
Another study not reported in the press:
“The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.”
http://jama.ama-assn.org/cgi/content/short/303/1/47
Ben Goldacre was critical of the media reporting of Kirsch et al’s 2008 study:
“It was a restricted analysis (see below) but, more importantly, on the question of antidepressants, it added very little… It did not look at all the trials ever done on these drugs: it looked only at the trials done before the drugs were licensed (none of them more than six weeks long), and specifically excluded all the trials done after they were licensed…”
http://www.badscience.net/?p=619
At the time of publication of Kirsch et al (2008) I looked into the credentials of the co-authors. My conclusion was that they are rather an odd bunch for such a paper, two being Assistant Professors of Psychology (one whose academic interest is in the field of memory), and another two were at the Center for Health Intervention and Prevention (University of Connecticut), where the main area of work is HIV/AIDS, though there is an “Obesity Interest Group”. The only co-author with any explicit statistical credentials is Thomas J. Moore, Institute for Safe Medication Practices, Pennsylvania. Biography: A.B. from Cornell University, Ithaca, N.Y; Graduate courses in statistics and statistical computing.
That’s a very strange post, there. The only criticisms of the 2008 study* are from a blog and the Telegraph. As you note, Goldacre’s criticisms are of the media reporting. To the extent that they can be read as criticisms of the research itself – and people should read Goldacre’s article -they’re addressed in the book. Your remarks about the supposed credentials of the researchers aren’t really worthy of a response. It seems quite like you just went searching for negative press on the study, and this was the best you could find. This manner of proceeding – as opposed to beginning by reading the book and engaging with it – I find odd.
*The criticism of the 1998 study are rather ironic in light of the later FOIA request and research.
This is quite simply bizarre.
As I’ve explained above, this severity-response finding is not inconsistent with Kirsch’s placebo hypothesis, and he deals with it in the book. People who cite Fournier contra Kirsch should be aware that Fournier doesn’t see it that way.
I checked most of the references. Ben Goldacre seems silent on the issue beyond offering a tacit approval and then discussing the issue of how drug companies can bury their bad data while fishing for positive results, just what Kirsh was saying.
The other references were more of a mixed bag. They agreed that drugs for mild to moderate depression were not called for and should be discontinued, but said that for sever depression the drugs can help. They said that Kirsh’s meta-analysis only reviewed the trials before the drugs went into wide use and later studies have strengthened the case for drugs to treat severe cases.
I think this does go some of the way towards contesting Kirsh’s claims. There are some things which he’s argued that still disturb me but I can see already that there are a lot of games being played on both sides and without a more reliable source, it’s best for me to remain on the fence.
This is covered in the books.
The trials on the basis of which the drugs went into use.
Does this really sound that plausible? The trials submitted to the FDA to get the drugs approved were significantly weaker than later ones? The full gamut of research – and not the manipulated, selected studies they get published – showed the drugs were better than the studies submitted to the FDA? Not from what I’ve seen.
Barbui, Corrado, Toshiaki A. Furukawa and Andrea Cipriani, ‘Effectiveness of Paroxetine in the Treatment of Acute Major Depression in Adults: A Systematic Re-Examination of Published and Unpublished Data from Randomized Trials’, Canadian Medical Association Journal 178, no. 3 (2008): 296-305.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2211353/
(These data are only available because GSK had to set up a trials register as part of a legal settlement; they’re probably still finding ways to get around it, though.)
No, it doesn’t, and both books discuss more recent research.
You haven’t seen any “games” being played on Kirsch’s “side,” and this is a silly claim. Instead of remaining on the fence without further knowledge, you could always go to Amazon and download the book for like $9.99. Takes a few hours to read.
SC – I ordered it for my kindle and when I’m finished my current book, I’ll read it.
From what other reputable people are saying, yes it does sound like Kirsh is playing some games. For a start, it sounds like he omitted the better, independent evidence from longer term studies of severely depressed patients. You imply that there’s no better studies than what was submitted to the FDA but doctors have strongly disagreed. When you add the “lone maverick” problem and there are a lot of reasons to be sceptical of Kirsh.
But I’ve also said that it sounds like there are a lot of reasons to doubt the current practices. I believe that strongly enough that I’ve put my own money down to buy his book and am committing to do more reading.
At the moment though, I don’t see any noble shining lights here.
WTF?
No, it doesn’t.
No, you’re extremely confused and I think being misled. Back in the ’90s, Kirsch, interested in placebo effects, performed a metaanalysis of 38 published studies of antidepressants covering over 3000 patients. Some people – about whom we know little – said that study selected the more negative research (odd given that they weren’t primarily interested in antidepressants), and others criticized the metaanalysis as such – it was a relatively new technique at the time.
But the drug companies had withheld 40% of the clinical trials (in addition to other techniques), making the published literature insufficient for a metaanalysis: the published literature was and is heavily skewed in favor of the drugs. This is what Goldacre points to in the discussion of Kirsch’s and the NEJM paper, and why he, Kirsch, Angell, Washington, etc., have been pushing for a required registered trials database that’s publicly available.
One way to address this somewhat was to get the full clinical trials submitted to the FDA for drug approval, which Kirsch did via FOIA. It’s not everything, and it too is going to be biased towards the drugs, since this is the research sponsored by the drug companies. This is one reason it’s so strange for people to suggest that this would lead to a negative bias.
The long-term “criticism” is equally bizarre. Kirsch and Whitaker cite long term research:
Most of the trials are short because people drop out of them. The very long term research cited by Whitaker, though it has problems, shows horrendous outcomes for the drugs. Just awful.
Probably the best sample available for a metaanalysis in the years following Kirsch’s data is the kind I cited above. It’s all of the clinical trials from GSK, obtained due to a legal settlement. Kirsch has been trying to get more of the studies, but the companies fight it every step of the way. In this context, it’s silly to point to one study and say it shows effectiveness, because it’s one study and we know the published literature is skewed and spun and that negative studies don’t appear. That’s what Kirsch and others have been trying to address. And he didn’t omit anything about severely depressed patients or any other group. He’s not “playing games.”
What “lone maverick problem”? He’s not a lone maverick, and that wouldn’t be a problem.
I really hate this kind of reasoning. Someone makes an argument, then others smear him, and before you even investigate you’re willing to assume the worst.
OK, I have to get to other things, and if you’re going to read the book anyway I shouldn’t have to do this. Bye.
Correction (spaced out): The 1998 study looked at 19 trials covering about 2000 people and the 2008 study looked at 35 trials covering about 5000 people.
Sorry about that. Bye again.
Yeah, sure. Because of the byzantine way in which drug patents in the US operate. Pharma may put several years of research into developing a drug; it is patented as soon as it is produced, before clinical trials, and the patent is good for only 20 years. Thus there is a race to get FDA approval so that the company can sell the drug under patent for as long as possible; but the testing and approval process can take many years. All of this time the company is paying researchers, buying components, building manufacturing facilities, and running expensive clinical trials with not only no return yet on the investment but not even any certainty of ever having a return.
FDA testing regs are quite strict, but testing can’t possibly go on forever or cover every possible combination of patient, drug, & other drugs; thus, much research continues after approval to gather data on long-term effects, to test drugs on different age groups, to compile data from the much wider population that is now taking the approved drug, to qualify drugs for uses other than those they were approved for, etc.
The fence is looking comfortable to me, too.
And me.
There’s been a lot of “Is not! Is too!” flying around on this post. For me, it’ll come down to the validity of Jerry’s claims of the flawed nature of the clinical trials — namely, whether or not there has been pattern and practice of suppressing certain results and overemphasizing the significance of others.
Everything else both sides have been arguing is plausible. All that is commentary.
Does the total body of research into SSRIs rise to the level of standards currently accepted by the scientific (not just medical) community? That’s the only question that needs to be answered.
Cheers,
b&
I can’t imagine how anyone could have any question about this.
Correction:
In reply to “Trials are typically only a month or two long, and I am not aware of any long-term tests of these drugs”, I wrote:
“The first part of that sentence is erroneous – that only applies to initial drug trials required for licensing. There have been many far more extensive studies on the efficacy of anti-depressants.”
Jerry is right that pre-licensing drug trials are only about six weeks long. I misread it as alluding to studies of efficacy in general.
Although we’ve come a long way from cigars and cocaine (never underestimate Freud), human psychology will always be a soft science because so much is based on biofeedback and informed speculation. As a “modest” monist, I think the important distinction should be between long-term disorders of the brain versus more ephemeral emotional/behavioral manifestations. Whereas pharmacology can address symptoms arising from neuronal activity, other forms of therapy explore how those neurons have developed in the brain to process information over time. With such complex interactive circuitry, it becomes necessary to differentiate the steam from the steam engine. Neurology, psychotherapy, and pharmacology must synchronize approaches to customize treatment for the client rather than allowing one field to dominate.
“It seems quite like you just went searching for negative press on the study, and this was the best you could find.”
SC: You shouldn’t make assumptions about someone of whom you know nothing. I have been interested in this field for a considerable time, and make it a practice (as with all other topics in which I have an interest) to meticulously seek out studies and articles on both sides of the argument – hence my starting by pointing out there are two sides to the issue.
You write:
“The only criticisms of the 2008 study* are from a blog and the Telegraph.”
The reason I cited the Telegraph article is because it cited a study that came to different conclusions from Kirsch et al (2008) on the same issue, a point you overlook in your comment.
There were several other people knowledgeable in statistics who challenged the Kirsch et al (2008) statistics online. That these are blogs does not make necessarily make them questionable, as should be clear from these analyses of Kirsch et al (2008) by the blogger in question:
http://pyjamasinbananas.blogspot.com/2008/03/statistics-and-depression.html
http://pyjamasinbananas.blogspot.com/2008/03/regression-in-depression.html
http://pyjamasinbananas.blogspot.com/2008/03/final-analysis.html
You write:
“This manner of proceeding – as opposed to beginning by reading the book and engaging with it – I find odd.”
I presume you mean the Kirsch book, one of several reviewed in the NYRB. I find it odd that you should make such a remark when my comment was addressed to Jerry’s general discussion of the issue, not a specific book. I’d say you missed the main point of my comment, which was to cite studies that were not in accord with the general tone of Jerry’s article, or most of the previous comments – in other words, as I wrote, there are two sides to the this issue, one of which was not getting much of a hearing. And since you’re implicitly criticizing me for not having read Kirsch’s book, I’d be interested to know if you have read the two scholarly studies I cited that are highly critical of Kirsch et al’s critiques:
F. M. Quitkin, J. G . Rabkin, J. Gerald, J. M. Davis, and D. F. Klein
Validity of Clinical Trials of Antidepressants
Am J. Psychiatry 157: 3, March 2000, pp. 327-337
http://ajp.psychiatryonline.org/cgi/content/abstract/157/3/327
“Listening to Meta-Analysis but Hearing Bias.” Donald F. Klein, Prevention & Treatment, Volume 1, Article 0006c, 1998
http://psycnet.apa.org/index.cfm?fa=buy.optionToBuy&id=1999-11094-005
I wouldn’t want to make to much of the credentials of the co-authors of the Kirsch et al 2008 paper, but I don’t think it entirely irrelevant that for a paper specifically on a psychiatric topic none of them have any cited expertise in psychiatry.
Please explain this (to me) cryptic comment:
“The criticism of the 1998 study are rather ironic in light of the later FOIA request and research.”
It’s funny that you quote Goldacre saying that the study “added very little” when what followed was “We already knew that SSRIs give only a modest benefit in mild and moderate depression…,” and the article linked to at “already knew” was…the 1998 study by Kirsch.
It was discussed in the press (google it), and it’s not inconsistent with Kirsch, which you’d know if you read the book.
Yes, that’s what this post and the Angell articles are about.
I find that odd, especially since your entire comment was about Kirsch.
The two studies you’ve cited are about Kirsch’s 1998 metaanalysis. As he discusses in the book (and was shown in the note added by the editors of the journal at the time), metaanalysis was relatively new at the time. Further, the studies available were limited by the drug companies themselves. I don’t know about those responses (though they have a certain tone…), but this discussion was about the more comprehensive metaanalysis 10 years later.
Well, I’m criticizing you for jumping in to post criticisms of Kirsch without having read Kirsch’s book. This is strange to me in light of:
Here you don’t have to seek out anything! The Angell articles are about these books. I don’t understand how someone doesn’t find it strange to read about the arguments made and evidence provided in books and, rather than reading the books and the criticisms, jump to reading criticisms (especially when the criticisms came before the book and could be answered in the book!). This isn’t meticulously seeking out both sides by any stretch of the imagination.
Sure. The studies available for metaanalysis in 1998 were limited by the drug companies. Kirsch had to file a FOIA request to get the full contingent of studies submitted to the FDA (which is outrageous, as Goldacre argues). As Kirsch suggests (p. 25), “these were the data upon which the antidepressants that are on the market today were approved for doctors to prescribe. If there was anything wrong with those data, then arguably the drugs should not have been approved in the first place.” He responds to critiques about the alleged limitations of the study set. Some of the challenges are downright weird, e.g., that the FDA-submitted studies are short – there’s a reason for this, and it doesn’t help the case for drugs.
SC: The “already knew” link you cite in Goldacre’s article is *not* to “the 1998 study by Kirsch”, but to a blog item on a 2005 report in the BMJ by Kirsch and Moncrieff. The blog includes the following caveat: “In response, Darrel Reiger from the American Psychiatric Association is quoted as saying the researchers have ‘written an article that selectively pulls out negative studies and conveniently ignores or mischaracterizes positive studies’,” so perhaps Goldacre’s “already knew” should have been a bit less definite.
On Fournier et al (2010) you write: “It was discussed in the press (google it), and it’s not inconsistent with Kirsch, which you’d know if you read the book.”
I acknowledge I should have rechecked the article itself (in my files), but nevertheless I didn’t say it was predominantly inconsistent with Kirsch et al (2008) (as the first above quoted sentence makes clear), I was only indicating that the second quoted sentence has a rather different emphasis from the Kirsch paper:
“The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.”
When I wrote that Fournier et al was not discussed in the press I was referring to daily newspapers, which (certainly in the UK) made the Kirsch claims a big story. I can’t recall a single equivalent article on the Fournier paper, and a limited Google search doesn’t bring up any. More generally, scholarly articles that have drawn different conclusions to Kirsch on antidepressants never get the (newspaper) press coverage he has got.
“I find that odd, especially since your entire comment was about Kirsch.”
My entire comment was about the efficacy of antidepressants, with Kirsch’s claims (cited in Jerry’s article) and its critiques used as a platform.
“The two studies you’ve cited are about Kirsch’s 1998 metaanalysis. As he discusses in the book (and was shown in the note added by the editors of the journal at the time), metaanalysis was relatively new at the time. Further, the studies available were limited by the drug companies themselves.”
That some of the limited licensing trials were not available in 1998 is not relevant to the Kirsch et al (1998) paper, as there were numerous much more comprehensive studies available.
“I don’t know about those responses [critiques of Kirsch et al] (though they have a certain tone…), but this discussion was about the more comprehensive metaanalysis 10 years later.”
Please give an example of the “certain tone” of the critiques of Kirsch et al (1998) (which you acknowledge you don’t know). Here’s an example of the spirit of Quitkin et al (2000) cited above:
“Investigators of all allegiances should not be complacent about the possibility of bias affecting their studies… Rather than repeatedly examining old studies for their flaws and strengths, it would be constructive to move on to the next stage of research, including the formation of research consortia… with investigators of varying theoretical orientations….”
The supposedly “more comprehensive meta-analysis 10 years later” was not more comprehensive – on the contrary it was limited to licensing trials of limited time length of which the subjects experienced predominantly low to moderate depression and very few severe depressives.
“Well, I’m criticizing you for jumping in to post criticisms of Kirsch without having read Kirsch’s book.”
Since in relation to the efficacy of antidepressants (the main subject of this thread) Kirsch’s own research plays a significant role, it is entirely relevant to point out that there have been severe academic criticisms of his papers (which I have read) on this specific point, regardless of the contents of his recent book.
“I don’t understand how someone doesn’t find it strange to read about the arguments made and evidence provided in books and, rather than reading the books and the criticisms, jump to reading criticisms (especially when the criticisms came before the book and could be answered in the book!). This isn’t meticulously seeking out both sides by any stretch of the imagination.”
I have not “jumped” to reading criticisms. My many years of interest in this topic (I have numerous articles going back years both in a filing cabinet and in PC folders) has involved reading the conclusions and contentions (on either side) before reading the critiques. On the topic of efficacy studies (which is what I am concerned with here), Kirsch has written about these in more general articles. When I say I seek out both sides, it doesn’t (and can’t) mean I seek out articles and books on topics I’m interested in *continuously*. When Kirsch et al came out and was widely publicized in 2008, at that time I sought out all the major responses I could find. For instance the direct responses to the article, many by well-informed commenters: http://tinyurl.com/6bzouua
That was just a brief interlude in my investigating and researching other topics in which I have been more deeply involved and which have taken precedence over following up recent books such as those reviewed in NYRB. That doesn’t mean I’m in no position to cite critiques of the kind of studies on which Kirsch bases many of his arguments about antidepressants.
On my query about your “ironic” comment re Kirsch et al (1998), your response does not address several methodological criticisms of the paper (see Quitkin et al [2000] and Klein [1998]).
So some guy from the APA says something and that’s enough for you.
Perhaps you shouldn’t have used his “adds little” in your critique of Kirsch without understanding him!
Well, you certainly implied it.
It isn’t inconsistent with the book, though, which you’d understand if you read it.
It was discussed on CNN.com. But Kirsch is a senior professor and Fournier was a doctoral student, and who cares, since Fournier doesn’t contradict Kirsch, as Fournier himself makes clear.
You’ve presented no evidence of that, or of the quality or importance of any of these papers. And it would an irrelevancy in any case.
You are tedious. It referred almost exclusively to Kirsch. Jerry’s post was about the articles by Angell, which were a review of Kirsch’s and two other books.
Baloney. And of course it’s relevant – it’s the reason he filed the FOIA request to get the data. These alleged comprehensive studies couldn’t have been so because they didn’t have the full data.
*This withholding is only one small part of the manipulation of published research.
He did for the 2008 study, which is what the book/review are about.
From Klein: “The article is criticized because it derives a minuscule group of unrepresentative, inconsistently and erroneously selected articles arbitrarily analyzed by an obscure, misleading effect size.” I don’t know anything about Klein (or his relationships with the pharma industry, for that matter), but if you can’t read the hostility in this abstract you haven’t read many academic papers. The 1998 study, according to Kirsch, analyzed 38 studies of over 3000 patients. It should be noted that they weren’t primarily interested in antidepressants at this point but in the placebo effect, so the suggestion that they skewed their selection of studies is kind of strange.
Oh, read the friggin’ books.
It’s relevant, but an entirely improper way to go about things, and you know it.
Yes, you have. You’re presenting (some alleged and not altogether worthwhile) criticisms not even of the book without reading the book. The post is about a review of the book – it’s the most recent and thorough treatment of the subject by Kirsch, and you jump in with random criticisms of his work from 1998 that make little sense in this context.
It hasn’t here. You haven’t even read the book in question.
Then I would think that when Kirsch comes out with an actual book discussing the matter in great detail and responding to criticisms, and someone posts about that, you would read it before returning to the criticisms. And if all you could find re the 2008 paper was an article in the Telegraph and some blog posts, that’s hardly damning.
blah blah blah You could’ve read half the book in the time it’s taken you to comment here.
FFS. I’m going to respond to Tyro above. Please read it. This is my last response to you.
In response to my writing “That some of the limited licensing trials were not available in 1998 is not relevant to the Kirsch et al (1998) paper, as there were numerous much more comprehensive studies available”, SC writes:
“Baloney. And of course it’s relevant – it’s the reason he filed the FOIA request to get the data. These alleged comprehensive studies couldn’t have been so because they didn’t have the full data.”
You don’t seem to recognise the difference between the restricted licensing trials and the very many new and more comprehensive studies on fresh patients that took place in the years following licensing. Those conducting the later studies didn’t need the shelved licensing trials because they were doing fresh studies on *new* groups of patients.
SC: “So some guy from the APA says something and that’s enough for you.”
All I wrote was that the linked page had a caveat about the claims of Hirsch and Macrieff, and that Goldacre should have recognized that the views of these co-authors are not definitive. Compare that to your comments about studies coming to different conclusions, including by several reputable and knowledgeable authors critically examining Kirsch et al’s 1998 paper in close detail such as the two I cited that you have clearly never read: “You’ve presented no evidence… of the quality or importance of any of these papers.”
Yes, you’re right. It’s time to call a halt.
“It referred almost exclusively to Kirsch.”
No. No, it didn’t. This is simply your interpretation of the article. You seem to have taken a rather myopic view of the articles Jerry linked to – to you it’s all about Kirsch’s book and anyone presenting an opposing opinion to Jerry’s article and the articles he linked to simply need read Kirsch’s book and they’ll be put straight. It’s almost as though you’ve adopted Kirsch’s book as your bible. ; p
The articles were about 4 different books and did not refer “almost exclusively to Kirsch.”
I have not read Kirsch’s book either (yet), but how would you respond to someone who had and yet still disagreed with his conclusions based on information outside of Kirsch’s book? Your apparent allegiance to his book leads me to conclude that you would say they have not understood the book, or misread it, or that the information they’re basing their conclusions on are baseless and/or irrelevant, or something to that effect.
That sentence referred to Allen’s comment. Really, I’m not sure I should even bother suggesting that people read the books, since there are several people who’ve demonstrated a profound inability to read for comprehension.
Thomas Szatz provides an interesting insight into mental health in ‘the manufacture of madness’ tracking the increase in institutions to a decrease in the demonic possession.
I wrote a detailed comment of Coyne’s post here: http://debunkingdenialism.wordpress.com/2011/06/26/why-jerry-coyne-is-wrong-about-medical-psychiatry/
Excellent response.
hahahahahaha
ha
I love the smell of sock-puppet in the morning.
Sock puppet. I do not think you know what this means.
Excellent overview, Jerry. Thanks!
I cross-posted this on my Evolutionary Christianity blog, here:
Jerry Coyne: “Is Medical Psychiatry a Scam?”
http://evolutionarychristianity.com/blog/?p=3591
Keep up the great writing.
Co-evolutionarily,
~ Michael
I cross-posted PZ’s letter to Emma yesterday:
PZ Myers: “How Do You Know That?”
http://evolutionarychristianity.com/blog/?p=3563
My apologies if this has already been mentioned, but even if it was a minor point in the post, it rubbed me the wrong way…
JC says “it’s like saying headaches are caused by a deficiency in aspirin”. Yup. It’s called “analgesic rebound”, and it’s a living hell. Even if it’s an induced state and not a ‘natural’ one, it’s still real.
And I am also one of those who benefits from a low dose SSRI. I was reluctant to take it, but it made sense to me that over a decade of acute chronic pain had messed up my brain. I also use CBT. Could the SSRI be placebo? I don’t deny it, any more than I can deny that all on my shelf of meds may have placebo effects. I hope to stop taking it someday, but not yet.
I think Something Happens in a society where all our basic needs are met, we have a significant amount of leisure time to occupy ourselves, and our daily concerns are not about survival. In the fifties, after the Great Depression, and World War 2, babies stopped dying like flies, antibiotics fixed people, surgery and anesthesia were possible, and food and jobs were plentiful. Then…mother’s little helper became a phenomenon…one was SUPPOSED to be happy with life in the suburbs, 2 cars, healthy children, food on the table….but the brain didn’t “know” this….does brain chemistry change when the stress of working long hours, trying to not starve, find shelter, care for your family, etc.?? Because leisure time, without worrying about survival, instead worrying about how big your ass is, must be filled with actions and thoughts. What happens chemically in the brain?
Half jokingly, I say SSRIs should be in the water–I know so many people who have depression who get better…but these people also get therapy. I have had very positive experiences with psychiatry, but my psychiatrist provides therapy as well as prescribes meds if indicated. And it is expensive..and insurance variably covers it. Cognitive behavioral therapy is effective, but expensive.
I am a physician myself. Psychiatrists have a very difficult job, and they treat seriously ill people. Practicing evidence-based medicine is very difficult when the evidence is, well, not good. But in the real world, a physician has to make decisions about real patients with the best evidence at hand. May I suggest that JC that you have not walked in those shoes, nor has “a pathologist” (they don’t take care of people who are alive, in general).
That being said, there are charlatans and bad doctors. Psychiatrists are also hard to find, there are not enough of them which adds to the problem. And medical students learn very little about “talk therapy”. They do a 6 week rotation, typically at an inpatient psychiatry unit with sick inpatients. Most do not get any significant outpatient exposure, and we only learn the neuropsychiatry interviewing basics. That has not changed in the last 25 years. Think about how much a medical student has to learn in 4 years. But I digress.
Thought-provoking post. Thank you for you blog, I enjoy it immensely.
I offer my own personal testimony as someone who was not at all helped by drugs. Mental disorders certainly exist; being opposed to psychiatric drugs is not saying the problems don’t exist. And I respect people who insist that drugs made them feel normal again. Maybe that’s true. I, however, wasted twelve miserable years, then went off the drugs cold turkey (a bad idea, but it worked for me mostly due to my grim determination) and now I find that lack of contact with the “depression-is-doom” crowd has improved my life greatly.
I heard the imbalanced brain chemistry line throughout my childhood. My other favorites are “These drugs are toxic in large quantities” (to scare me off from ODing) oh… “but not toxic enough to be fatal.” Ha! “You need to take them or else you’ll try to commit suicide.” Oh really? I also got “We don’t know how these work, but you need to take them.” That went along with “Psychiatry is a new field and we don’t know very much yet, but if you don’t follow every direction unquestioningly, we’ll treat you like a juvenile delinquent.” And “these drugs can give you permanent neuromuscular damage. We need to check for that every now and then.” I get the impression they don’t talk to kids like that anymore. It’s too bad, really. Sure, the shrinks scared me shitless, but at least they were honest.
““You need to take them or else you’ll try to commit suicide.” Oh really?”
The statistics on patients with major depression who respond to drug therapy, go off the drug, suffer another relapse, get treated, then go off the drug is very scary indeed and is why you were told it is a serious business. No one could predict that->you<- personally would commit suicide, I think they meant the generic "you" if they used the word.
A significant number of major depression patients who have a second relapse and then go untreated will commit suicide. By the time one gets to the population of patients who have 5 untreated relapses, 80% of them will be lost to suicide.
Hm, all this talk about psychiatrists and little about their underappreciated kin, clinical psychologists. The CP I know says that she feels that the psychiatists, like many MDs, do not receive enough basic science education. She is also scathing concerning GPs and other non-psychiatrists prescribing psychiatric medication: after all, how many hours of basic psych do *they* have? In many places I’ve heard it wouldn’t even make up an undergraduate minor.
My own, unscientific, maybe-this-is-all-a-placebo account: After years (decades?) of anxiety, which became debilitating in my 30s and grew to include agoraphobia so intense it affected my thoughts and behavior every single day, I started (talk) therapy. It was useful, I guess. Nothing really changed, but I got better at seeing my anxiety for what it was—a kind of smudgy filter over reality. After years of therapy, I reluctantly went on meds (Celexa). Within a couple months, things changed. My “default setting” was no longer hyper-vigilant. I could do things that had seemed impossible or painful years before. I had my life back.
Does this mean Celexa does what it’s presumed to do? No, I guess not.
I’m not sure I care.
I know of more than a few folks who very successfully self-medicate for this condition with ethanol.
Can’t beat those old folk remedies.
That’s stupid. They may think that they are self medicating but in reality they are just alcoholics.
Do you have anything beyond personal opinion to support that assertion?
Ethanol is possibly the oldest psychoactive drug known to humans.
Your dismissal of those who employ it for symptomatic relief as “stupid”, and “just alcoholics” is offensive, bizarrely insulting and paternalistic.
You actually got me thinking.
Both SSRIs and ethanol are known to alter the mood of the individual ingesting the substance.
Both are known to have different effects on mood depending on the individual taking them. Some people find the effects positive; some negative; some don’t notice much either way.
With both, dosage can have qualitative as well as quantitative changes in the effects.
Both are known to have serious side-effects, possibly worse than the condition they’re being used to counter. And, in both cases, long-term usage can exacerbate the condition rather than ameliorate it — again, dependent to some degree on dosage and certainly upon the individual.
Neither is anything close to a clear-cut guaranteed fix, the way that (say) an intravenous application of saline (lactated ringer’s, whatever) is an effective treatment of acute dehydration. Or as safe.
Aside from the degrees and proportions of everything above, I’m at an utter loss to think of a significant pharmacological difference between the two. Granted, those degrees and proportions are themselves quite significant…but, if you’re considering (or trying) the one, I can’t think of any reason in principle why the other should be off the table. It’s a different set of tradeoffs, and that set may work better for you or cause you less harm.
No, I don’t think ethanol is a good way to treat psychological disorders. But plenty of drugs in use aren’t good ways to treat the disorders, either; even the doctors will admit as much. It’s just that the treatments are (theoretically) better than nothing at all. I’m sure there must be cases where ethanol, as bad as it has the potential to be, is better than both nothing and the other drugs used to treat these disorders; the only question would be how many cases and how best to identify them.
Of course, what we all want is a treatment as safe, effective, and clear-cut as IV saline for the dehydrated. But I’m sure we also all want (invisible) (pink) (unicorn) ponies as well.
Cheers,
b&
If your friends think they suffer from depression and are successfully treating it ethanol then they are seriously deluded as to their actual medical condition as well as to the curative properties of alcohol.
They’re just alcoholics seeking to justify their addiction.
I’m sure that you’ve been drunk. Have you ever taken SSRI’s? Have you ever been clinically diagnosed with depression? Why do you think that you know anything about this? In what way do you think the SSRI experience is anything like the drunk experience, especially with respect to real organic illnesses like depression.
I specifically said, in plain English, that they were employing ethanol for SYMPTOMATIC relief, not for cure.
Your impertinence, coupled with irrelevant insulting assumptions lead me to consider that your opinions on this matter are not worthy of further consideration.
Thanks for the compliments MKG
Alcohol is a sedative hypnotic, like barbituates, well known as depressants of the CNS.
Depression is an organic disease. In no way does alcohol treat the symptoms of depression in any positive way. It’s likely to make them worse. If you are depressed and you drink, you are just a depressed drunk. Your comment is incredibly ill informed.
One final (vain?) attempt to correct your mischaracterisations of my PLAIN message:
The OP was referring specifically and clearly to anxiety and agoraphobia.
Somehow you strangely morph these into an unrletaion condition: “depression”.
Anxiety is often successfully self-medicated with ethanol, like it or not.
You seem to be on a simplistic (and seemingly puerile) crusade against ethanol consumption.
I do not know why, and I do not care why.
Simply cease confusing your pious jihad with my rational observations and I shall then be happy to read your comments.
“Anxiety is often successfully self-medicated with ethanol, like it or not.”
Successfully self medicated? Are you serious? What do you consider success?
Alcohol is a horrible option for anxiety relief. It’s not reliable, it’s effects are very transient, it causes rebound anxiety in a matter of hours, it’s the nutritional equivalent of eating straight sugar, if you use it for long-term relief you end up addicted to a drug which is more harmful to the body than many illegal drugs.
If you’re referring to alcohol as self-medication for everyday, normal, transient anxiety then yeah, it can relieve anxiety. This thread, though, is talking about treatments for serious mental illness.
Help. I am a neurologist who has been in practice for about 35 years. I use these drugs every day to try and help my patients. Sometimes they help and sometimes they don’t. Depression, schizophrenia, bipolar disorder are very real. The tools we have to treat them are imperfect but for now they are all we have but in my personal experience, most of the time they work both alone and when combined with compassionate care and some form of “insight” therapy such as Cognitive Behavioral Therapy.
Some people forget the history of psychiatry and need to visit museum to see the torture tools that were in use just 60 years ago. I was partially trained in one of the last warehouses for the mentally ill that passed for a state mental hospital. It was not a pretty or inspiring site.
Criticism is justified as long as it comes with some statement of constructive suggestions and working hypotheses as to how we can do better and build upon the progress that we have made. Meanwhile out in the trenches we try to help people. Some people heal and others have a lifelong struggle with their inner demons be they bad chemistry, wiring or programming. All I and my colleagues can do is struggle along with them and use the best tools that medical science can provide us for now.
BTW – Psychiatry is not a scam or a conspiracy but a struggle to help people.
I find it didactic to replace certain key-terms with others, such that a comment my be seen in the new light of one “from the other side”, as it were.
Take it as you may.
It is not intended as an insult, but as a mere prism in which one may choose to see a reflection of one’s assertions.
“Help! I am a homeopathist who has been in practice for about 35 years. I use these nostrums every day to try and help my patients. Sometimes they help and sometimes they don’t. Depression, schizophrenia, bipolar disorder are very real. The tools we have to treat them are imperfect but for now they are all we have but in my personal experience, most of the time they work both alone and when combined with compassionate care and some form of “insight” therapy such as Reiki Therapy.
Some people forget the history of hoemeopathy and need to visit museum to see the torture tools that were in use just 60 years ago. I was partially trained in one of the last warehouses for the mentally ill that passed for a state mental hospital. It was not a pretty or inspiring site.
Criticism is justified as long as it comes with some statement of constructive suggestions and working hypotheses as to how we can do better and build upon the progress that we have made. Meanwhile out in the trenches we try to help people. Some people heal and others have a lifelong struggle with their inner demons be they bad subluxations, spinal wiring or programming. All I and my colleagues can do is struggle along with them and use the best tools that medical science can provide us for now.
BTW – Homeopathy is not a scam or a conspiracy but a struggle to help people.”
Can you see it from my point of view?
I think this underestimates the agony, desperation, and life-disruption of these mental illnesses.
When you’re desperate, in vicious long-term pain, and possibly facing losing everything to repeated or long-term hospitalizations, even a slight, temporary improvement is enormous. Even the disease lifting just a little can be everything, keeping you from suicide and out of the hospital at least a while longer. Even if it’s a placebo effect.
And, the big difference is, as noted, that there is no better way to treat these illnesses. It’s not like woo, in which there are often medical means to a cure.
Until something better comes along (and I hope that’s soon), doctors and sufferers have to try what’s out there, and hope for benefit. And stop it and try again, and try again, and try again.
As I say, you’re ignoring the dreadful reality of these illnesses, the suffering can be beyond imagination.
“As I say, you’re ignoring the dreadful reality of these illnesses, the suffering can be beyond imagination.”
Indeed, depression at it’s worst is absolutely terrifying. It is torture: emotional, mental, and physical.
The functionality of SSRI in the brain is understood and can be measured in animal testing.
Homeopathy has no measurable effect at all.
Stop comparing apples with oranges.
What a fascinating discussion/argument/bashing I’ve seen here.
As someone who takes SSRIs, I am very interested to see more about this. I have a lot of reading to do, given all the links posted here.
I look forward to seeing other website writers (read: bloggers) write about this subject as I can see Jerry has started a long discussion.
It is amazing how quickly arguments like this can become just like those that anti-science people use. This thread has led me to question some things I believe–in a good way.
Thanks Jerry, for a thought provoking, informative article.
This thread has led me to question some things I believe–in a good way.
Hear, hear! There’s no way I won’t come out of this knowing more than I did before. I really hope Orac does a blog post on this, as he is my go-to person for science-based medical information.
Thanks, Lynn (from someone who supports his argument). Yours is the sort of response I’d been hoping for when I first raised this subject and didn’t find, but it’s great to see. I recommend the Kirsch book.
As a psychiatrist in Canada, I would say that most mental illnesses are very difficult to treat, whether with talk therapy, medications, or any other modality. And those that are more effective than placebo, are usually only modestly so, and carry risks and side effects, which must be considered. The treatments that we have do not work as well as we wish, and certainly have been sold as miraculous and powerful treatments in the past, which has not been born out by the facts.
I’ve had a lot of experience along these lines & I have to come out on Jerry’s side that this is all very fishy. I cured myself of severe depression, agoraphobia & panic attacks. I simply had a hunch that these were extreme responses to present stimuli and I worked my way out. It was Hell and it took 4.5 years, during which time I was legally classified as “disabled”. But I did it, sans drugs, sans therapy, and a day came when I went back to work (2004) and it was all behind me. Even if you need a drug you have to deal with the reality of your life, you need to explore your psyche, you need to make attitude adjustments. Otherwise, you will remain vulnerable to extreme mental states.
I’m not speaking of clinically insane people, those beyond self control, but of most people I meet who take drugs for anxiety. Survival is stressful. We need to deal with it. Biologist Robert Sopalsky is great on this.
So, what sort of evidence are you looking for?
The notion that depression and anxiety are caused, in part, by chemical imbalance is a hypothesis. Talk therapy is also based on a hypothesis, and there are competing hypotheses. We can’t prove any of it.
Does the notion that neurotransmitter activity contributes to depression make some sense? Sure. It seems to me that the way to test that notion is to try drugs that change neurotransmitter behavior. If studies show that the drug helps, then why not administer the drug? The hypothesis isn’t proven, but it is stronger than it would be otherwise.
I don’t think the problem of applying a solution before understanding a problem is confined to psychiatry. It is my understanding that the, the cause/effect relationship between cholesterol is hardly conclusive, yet Lipitor is constantly prescribed as a preventative.
If you’re going to object to a lack of scientific rigor in psychology, then the entire discipline needs to be chucked.
My best friend is a psychologist, and he is pretty emphatic that the classic freudian therapy is gone for good. Not so much because it’s ineffective, but because insurance companies don’t think the proles deserve it. Drug therapy is ineffective, but hefty profits are made by all, so it isn’t going anywhere. BTW, I’m no fan of Scientology, but guess who was right on this one…
Classic Freudian therapy (Freudian psychoanalysis) should be gone for good. It was never anything more than pseudoscience based on some severely erroneous guesses Freud made about the psychology of fewer than ten patients. It’s worse than ineffective, it can be harmful (I mean really! Penis envy?!).
If, however, you’re talking about other forms of psychotherapy, most insurance companies not only pay for it, under the new health care laws they will have to pay for it and will not be able to limit the number of visits per year as they have in the past. Of course this doesn’t apply to all insurance companies and hasn’t gone into effect everywhere yet, but some insurance companies have already adopted this.
As many others here have noted, drug therapy has been shown to work equally well as psychotherapy in the treatment of depression and they work ever better in combination. This is old information and I’m surprised your your psychologist friend doesn’t know this. Psychotherapy is useless for schizophrenia. It’s also useless for someone so depressed that they are mentally unable to participate in psychotherapy. Many depressed people can, however, participate in therapy after their mood has been improved with medication.
I don’t think that anyone has yet mentioned that the majority of people taking antidepressants get them from their general practitioners. Most people don’t see psychiatrists; they can be difficult to find, especially in non-urban areas. How does this figure into the whole “psychiatrists are in cahoots with Big Pharma.” GP’s are not psychiatrists.
Why bother to comment at all Salty? I assume you didn’t read Emil’s post. Are you concerned that you might encounter some disconfirming evidence for your seemingly dogmatically held belief that antidepressants don’t work because the great prophet Kirsch hath spoken thusly?
Because while you’re transparently a fool, knowing the general intelligence of the readership here I’m confident that at least some people will question previous beliefs and critically examine the evidence for themselves, and that in the future some of us (intelligent people, so not you, obviously) can have an informed, reasonable discussion of the matter.
Salty,
You claim to know more about this subject than you actually do, based, it appears, solely on reading a couple of books. You’ve also assumed – based on nothing – that I am unwilling to change my mind about this particular subject. If you honestly believe that I should change my mind based on Jerry’s post, the articles he’s linked to, and the discussion on this page, then it is you that is truly the fool. Your reliance on personal attacks (on several people in this discussion) displays your lack of intelligence. You’ve repeatedly shown that if someone continues to disagree with you no matter what you write, you retaliate with personal attacks. That’s truly indicative of someone who either doesn’t have a valid point to begin with or, in the very least, someone who cannot tolerate disagreement.
For a clearer point of view, I suggest watching Robert Sapolsky’s “Sapolsky on Depression” on YouTube(http://www.youtube.com/watch?v=NOAgplgTxfc) and reading Stephen M. Stahl’s “Depression and Bipolar Disorder: Stahl’s Essential Psychopharmacology” and Lewis Wolpert’s “Malignant Sadness” for starters.
BTW, my previous post was meant to be a response to your “hahahaha” comment to Emil’s post where he linked to his rebuttal to Jerry’s post. It was not meant to be a stand alone comment. I mention this to provide some context. I’m sure you still think I’m an unintelligent fool, but this is just your method of dismissing the comments of those you disagree with. That, and you’re obviously just a rude, pompous individual. Enjoy your superiority complex. It’s nothing if not charming.
Redundantly correct.
I am eminently qualified to speak from personal experience.When I was 8-9,I suffered a concussion from a bicycle accident>i fractured my skull,and was unconscious for several minutes.I have taken several of these drugs including one(zypreza),that was characterized to me as both expensive,new,and powerful.I am quite certain I gained weight,and suffered extreme suicidal ideation.I didn’t realize this until reading “anatomy of an epidemic”.Anybody who claims,without SUBSTANTIAL corroborating evidence that talk therapy doesn’t work,is a danger,and a threat to people in need of help.They should shut their mouths,and stay our of it,for safety sake.They are ill informed,and irresponsible in the highest degree.I know from personal experience.
You have it exactly the wrong way around.
It is incumbent upon those who claim efficacy to show: “SUBSTANTIAL corroborating evidence that talk therapy does work”.
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To be diagnosed with a “major depressive episode,” for example, you need to have five out of the nine symptoms described by the DSM. But what if you have only three or four? Then you don’t get your meds.
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That statement is inaccurate. If you have fewer symptoms, but are in distress, you get a different diagnosis, but you still get meds. I didn’t read the rest of the article, and you may have some valid points, but I am a social worker, and most of my patients have been helped tremendously by medications. Notice I didn’t say ALL. Some had no response, and a few had bad side effects, but not many. Research shows that combination therapy (psychotherapy and medication) is more effective than either one alone. Furthermore, there is evidence that taking medication has a healing effect over time on a brain that’s predisposed to depression.
I’m also a bit suspicious of drug companies and studies funded by them, but I don’t think we need to throw out the baby with the bath water either.
Psychology tries to adjust people to what is considered as normal. Who knows what is normal? There are psychologists who trying to prove that Jesus, Einstein, Buddha etc as neurotic. According to them every one is ill. Do you know Freud never allowed anyone to analyze him?
http://www.vaticanbankclaims.com/quebec.pdf
The above is a link to the petition submitted to the Vatican by the poor little kids of Quebec who were the guinea pigs of psychiatrists such as Heinz Lehmann to develop the chemical lobotomy, CPZ (chlorpromazine, also called thorazine or largactil).
We are right now in the throes of Phase 3 of MK ULTRA – psychotropic drugs used by normal humans. In 1971, the leaders of MK ULTRA compiled a book – “Psychotropic Drugs in the Year 2000 – Use by Normal Humans” that laid out their plans for us to be on drugs.
In 1972, Heinz Lehmann headed the “Canadian Commission of Inquiry into the use of Non-Medical Drugs” (cost – $4 million) to make our addictions to psychotropic drugs part of Canada’s Economic Action Plan. Watch out. We are in for it if we don’t fight back.
A good friend of mine has a Ph.D in psychology. She’s a graduate of Pepperdine University, and she her own private practice until she “retired” and pursued her lifelong dream of photography of which she’s an ace at.
She has battled depression and has suffered with the condition since she was a preteen. She has been medicated for her “disorder” for nearly two decades, and she is now suffering from kidney and liver disfunction at the age of 48!
She wanted to major in psychology to better understand her own problems. She told me that many students who major in psychology do indeed have problems of their own that they think they can identify with by intensive study of psychology.
She never regretted her studies and she feels that she’s helped many of her patients over the years, but she believes that most psychiatric meds are dangerous in the long term. She also believes that talk therapy is going the way of the dinosaur. So many doctors are free and easy to just dispense drugs and tell their patients that the meds are perfectly safe. Their is great ignorance in the medical community regarding prescription medications and their long term effects.
My friend, of course, was not licensed to prescribe meds being a psychologist, she believed that talk therapy was the most effective treatment there was. Talk therapy is very, very time intensive but it has everlasting benefits. She wishes that would’ve been the option when she was younger and that her psychiatrist would’ve recommended talk therapy over the numerous drug combinations she was on for so long.
Is psychiatry a scam? Yes and no. I do believe that doctors are so heavily indebted in the BIG PHARMA, believing all of the promotional literature and supplemented literature on the world’s “wonder drugs” that doctors have become blinded about the truth regarding the dangers of these drugs. Telling their patients that these drugs are “scientifically proven to be safe,” “they will cure you,” “alternative (natural) treatments won’t work,” “you’ll be on these meds for life.” These are some of the very familiar comments that patients are told be their doctors.
Some people may get relief from their mental “disorders” via medications, but what are the long term effects of these drugs? Doctors and researchers still don’t know exactly how some of these drugs function! Are these drugs safe in the long run? I doubt it. No, let me rephrase that, NO they’re not safe!
I’ve learned to cast of very skeptical eye on the medical community. By and large it’s a money machine. I don’t believe there are too many doctors who really give a rat’s back side about their patients. Keep them medicated and they’ll keep coming back with more problems. That’s why there’ll NEVER be cures for heart disease, cancer, depression, Alzheimer’s disease, AIDS, etc. Just expensive treatments complete with plenty of side effects and more drugs needed to combat the side effects. The hundreds of billions of dollars made by BIG PHARMA annually is what it’s all about.
Psychiatry is medical in name only. Heinz Lehmann came to Canada in 1937 from the University of Berlin where the Nazis were developing the T4 programme (extermination processes). He developed the chemical lobotomy on the poor little children of Quebec – the “Duplessis Orphans”. These little kids were told they were going on a bus ride to the country and ended up being incarcerated for most of their childhood in psychiatric hospitals, designated “MENTALLY RETARDED”, as subjects of his and his fellow psychiatrists’ experiments. In 1967, he held a meeting in Puerto Rico and the book “Psychotropic Drugs in the Year 2000 – Use by Normal Humans” came about, published in 1971. In 1972, he chaired the “Canadian Commission on the Use of Non-Medical Drugs” to give free reign to the medical profession to experiment on the public without impunity and to earmark billions of dollars for “research”. Hence, our current culture. The poor public is oblivious.
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