Psychiatric medications as super-placebos

This isn’t directly related to my interest in the psychological aspects of language as behavior, but it does bear on the question of why humans suffer psychologically in the first place, and on how such suffering should best be treated: a review in The New York Review of Books of three books on what seems to be the con game of psychiatric medication.

The review is titled The Epidemic of Mental Illness: Why? and the books involved are The Emperor’s New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch, Basic Books, 226 pp., $15.99 (paper); Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, by Robert Whitaker, Crown, 404 pp., $26.00; and Unhinged: The Trouble With Psychiatry—A Doctor’s Revelations About a Profession in Crisis, by Daniel Carlat, Free Press, 256 pp., $25.00.

The reviewer herself, Marcia Angell, is bylined as former editor in chief of The New England Journal of Medicine, so it would be hard to argue that she is a naive audience for the topic. Although the review is already online, it is forward-dated to the June 23 issue of the magazine; it is billed as the first of two parts, so we must wait till the second installment arrives to find out exactly where Angell stands. From what she has written so far, though, she seems extremely sympathetic to the anti-medication arguments in all three books. If you are at all interested, you should read the review yourself; but here are a few snippets that I find particularly arresting.

When it was found that psychoactive drugs affect neurotransmitter levels in the brain, as evidenced mainly by the levels of their breakdown products in the spinal fluid, the theory arose that the cause of mental illness is an abnormality in the brain’s concentration of these chemicals that is specifically countered by the appropriate drug. For example, because Thorazine was found to lower dopamine levels in the brain, it was postulated that psychoses like schizophrenia are caused by too much dopamine. Or later, because certain antidepressants increase levels of the neurotransmitter serotonin in the brain, it was postulated that depression is caused by too little serotonin . . .

. . . the main problem with the theory is that after decades of trying to prove it, researchers have still come up empty-handed. All three authors document the failure of scientists to find good evidence in its favor. Neurotransmitter function seems to be normal in people with mental illness before treatment.

And what about the anecdotal trump card we can all pull out, of our friend or relative who says that in their dark hours, it was an antidepressant that helped them more than anything else? According to the review, one of the authors, Irving Kirsch, is a psychologist at the University of Hull in the UK; he has been studying antidepressants for 15 years, and has come to the conclusion that they are essentially a kind of super-placebo: because they exhibit detectable side-effects, they convince the persons taking them of their benefits. In other words, if the side-effects did not occur, it seems very possible that the persons taking the drugs would not know to feel better. Angell summarizes Kirsch’s argument on this point this way:

[He] was also struck by another unexpected finding. In his earlier study and in work by others, he observed that even treatments that were not considered to be antidepressants—such as synthetic thyroid hormone, opiates, sedatives, stimulants, and some herbal remedies—were as effective as antidepressants in alleviating the symptoms of depression. Kirsch writes, “When administered as antidepressants, drugs that increase, decrease or have no effect on serotonin all relieve depression to about the same degree.” What all these “effective” drugs had in common was that they produced side effects, which participating patients had been told they might experience . . .

He suggests that the reason antidepressants appear to work better in relieving severe depression than in less severe cases is that patients with severe symptoms are likely to be on higher doses and therefore experience more side effects.

I wonder if this also might explain the widespread phenomenon of “poop-out,” in which a medication that had seemed helpful suddenly stops working. A placebo effect only lasts for so long before life intrudes again.


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