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Russell Collins: The Controversy Over Antidepressants

What does the debate about antidepressants mean for people suffering seriously with mental disorders?

We go through this periodically about antidepressants. Within the past few months, we’ve had a heavily hyped book appear with “Exploding the Antidepressant Myth” in its title; a USA Today headline proclaiming “Antidepressant Use May Be All in Your Head”; an article in a serious cultural publication wondering whether “psychoactive drugs are useless”; and a Newsweek cover story dispensing “The Depressing News about Antidepressants.”

Usually, these waves of antidepressant anxiety are triggered by some new piece of research or the suicide of a celebrity taking these medications. This time, it’s a new raft of books focused on the way drug companies have slanted their reporting of research to sell more products.

These books and the articles reporting on them make fascinating reading. They tell the story of drug companies driven by greed to skew their research in order to sell more Prozac and Celexa and other brand-name antidepressants.

In one book, The Emperor’s New Drugs, Irving Kirsch, a British psychologist, reviews the complete file of FDA-approved research on four of the most popular antidepressants, and finds that they work not much better than a placebo. Other books and articles focus more broadly on psychiatric medicines and the way Big Pharma has managed to “medicalize” the entire discussion about mental illness, and dictate the terms of psychiatric treatment in this country.

But there is a problem with all this public condemnation of the drug companies and their products. Despite what you might take away from the headlines, antidepressants and other psychotropic drugs work well for some patients — particularly for those who suffer most! If the big drug companies were suddenly shut down, the mental health profession would be ill-equipped to deal with the fallout: a deluge of relapsing patients, people whose lives had been seriously improved, even normalized, by the products these companies make.

You wouldn’t necessarily know that by reading the news, and I’m concerned that all the dust being kicked up might be confusing and discouraging to someone considering using antidepressants for the first time. Will antidepressants help me feel better and be more effective and satisfied in my life? This is what that patient wants to know.

Deceptive Research, Big Pharma and the Placebo Effect

The basic accusation being made is this: In their pursuit of profitability, the drug companies have chosen to selectively publicize the research that says these drugs work well, while keeping secret the studies that say they don’t. When you factor in the missing research, the evidence for these drugs is weak: They may not work much better than a sugar pill or placebo.

Moreover, the argument goes, through aggressive marketing and PR, and because American consumers are suckers for simplistic scientific explanations, we have been sold the bill of goods that our human brains are a chemical stew and that the tens of millions of people with depression are merely suffering from a “chemical imbalance.” One that can be corrected with a pinch of extra serotonin or a dash of dopamine delivered courtesy of Pfizer’s Zoloft or Eli Lilly’s Prozac. In other words, we’re being snowed by an incredibly Big Lie.

This may all be true. I don’t know any drug company executives, but I’ve known a lot of entrepreneurs and businessmen in the course of my life, and they are pretty intent on making money. I do know that the chemical imbalance story — at least the one that describes serotonin deficiency as the target imbalance for antidepressants — has remained stubbornly unprovable for 30 or so years, despite being a powerful story for the selling of these drugs. But here’s the flip side: The motives and marketing tactics of the pharmaceuticals industry are in one way a sideshow to the main event. Many, many people are helped by these drugs.

Conspiracy Theories, Unsupported Claims and Selling Books

By far the most visible defender of antidepressant effectiveness is Peter Kramer, a psychiatrist and Harvard University professor whose 1987 bestseller Listening to Prozac contributed hugely to both the public understanding and the popularity of “second generation” antidepressants such as Prozac, Zoloft, Paxil and Lexapro.

Kramer’s thesis in that book, in contrast to the chemical imbalance theory, was that we actually don’t know yet how these medications relieve unhappiness, but by “listening” carefully to their patients’ reports of improving moods, psychiatrists and researchers are getting a better and better understanding of the workings of the mind and brain.

In subsequent books, Kramer has attacked what he considers the fuzzy-minded romanticizing of depression as an emotion related to creativity, one uniquely and importantly human. No, Kramer says. It’s just a sickness, and a particularly devastating one that we are beginning to get a handle on through research into psychotropic drugs.

Now, in an article last week in The New York Times, Kramer hits back hard at those claiming Prozac and the other antidepressant medications are a scam. Instead, he says, the recent books and articles purporting to expose the scam are based on flimsy research and faulty assumptions themselves.

“Could this be true?” Kramer asks rhetorically. “Could drugs that are ingested by one in 10 Americans each year, drugs that have changed the way that mental illness is treated, really be a hoax, a mistake or a concept gone wrong?”

This is a dangerous question to ask, of course, since the answer from the generally skeptical American consumer could easily be, “Uh, yeah?” But Kramer supports his argument with a statistical critique of the anti-antidepressant camp’s argument. Kramer’s analysis is complicated and, to be honest, hard to follow. But his is a respected voice in the psychiatric community, and he does not seem to be getting any financial benefit from defending Big Pharma. I think he is representing the facts as he sees them.

Then why is there so much piling on among book writers and journalists around this claim that Big Pharma is covering up and lying about the effectiveness of antidepressants? The pharmaceutical firms are a fat target, Kramer says, and people just love to hear them taken down every once in awhile. Antidepressants make good gossip, too, he notes, with “something like celebrity status; exposing them makes headlines.”

Who Do You Trust?

Cynicism about the pharmaceuticals industry versus cynicism about journalists and book writers; if you’re thinking of asking your doctor about an antidepressant for you, how do you even begin?

Here are some pretty well-accepted facts.

» 1. Antidepressants sometimes produce positive, even life-changing benefits for people suffering with depression. This is an incredibly important piece of news to someone who is struggling with chronic sadness or pessimism, someone who is alone or isolated in life, or someone whose low energy or lack of self-worth gets in the way of living up to his potential. Or someone who’s just tired of wasting life being unhappy.

If it were not for item No. 2 on this list, I would say to pretty much anyone diagnosed with major depression — especially if they have tried and failed at other ways to lift their mood — to try antidepressants under the guidance of their physician (ideally, a psychiatrist) to see if they work. Why not?

» 2. And this is the big Why Not. Antidepressants frequently have side effects. These can be quite mild and transitory, like a headache that goes away after a week, or they can be serious enough to cause a patient to discontinue their use. In rare cases, antidepressants have been shown to worsen depression or cause suicidal thinking. Because you won’t know about side effects in advance, you’re best off taking antidepressants under the care of a qualified physician — someone who is experienced in managing the common side effects, and who can steer you toward a different antidepressant if necessary. Your safest bet is a psychiatrist, if that’s a possibility for you.

Would it be worth the risk of experiencing side effects for a chance to break out of a devastating cycle of serious depression and loss?

People with serious depression usually have difficult lives. They have few good relationships or they dramatically underperform in their work lives. They make bad decisions based on fear or lack of self-esteem. They lack energy for major changes. And so, they cycle down.

Antidepressants can sometimes break the cycle where other forms of treatment fail. I have a cousin who recently got into therapy after a course of antidepressants gave her the energy to re-engage in life. For her, and for others in similar situations, these medications can be literally a lifesaver.

» 3. For people with more mild forms of depression, the picture isn’t so clear. For one thing, the side effects, even mild ones, might weigh more heavily in your decision. Also, the charges being made about questionable effectiveness apply mainly to this type of patient — one who is mildly or even moderately, but not seriously, depressed. Practically speaking, this means the likelihood of antidepressants working for you is significantly lower than for seriously suffering patients. That certainly doesn’t mean you shouldn’t try them, just factor in the lower likelihood of success into your decision.

There’s another reason to put off taking medications when you are only mildly depressed. Working with depression in therapy can be an opportunity for personal growth, development and exploration. All the great pioneers of psychology, starting with Sigmund Freud, viewed psychotherapy as a way of unblocking the natural developmental pathways toward a state of mature mental and emotional balance.

While antidepressants can alleviate the deep suffering of depression, they don’t in themselves promote growth or discovery, and that may be a reason to try psychotherapy first. Individual therapy, couple counseling and family therapy have all been demonstrated effective in treating depression.

Bottom Line

Let’s face it. The big pharmaceutical companies may well be snowing us with their expensive marketing campaigns. Not only that, but their published research is incomplete, and therefore suspect. And it’s a pretty sure thing that at least some of the effectiveness of these pills comes from our belief in them — otherwise known as the placebo effect. But for patients with serious major depression, medication often does the job. Even for less severe forms of depression, we all know people who have benefited from these drugs. And as a powerful treatment method in the struggle against depression, even the dire message of this week’s headlines shouldn’t deter us from medications that work.

— Russell Collins, Psy.D., is a Santa Barbara psychotherapist and divorce mediator. Click here for more information.

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