Monday, January 28, 2008

Waging War on Antidepressants

Bad Science recently posted a detailed critique of the hypothesis that depression is caused by low serotonin levels and therefore treatable by increasing serotonin levels in the brain. Here is a bit of the argument.

The second paper is more interesting. Over the past few decades, we have been subjected to a relentless medicalisation of everyday life by people who want to sell us sciencey solutions. Chancers from the $56 billion international food supplement industry want you to believe that intelligence needs fish oil, and that obesity is just your body’s way of crying out for chromium pills (”to help balance sugar metabolism” etc).

Similarly, quacks from the $600 billion pharma industry sell the idea that depression is caused by low serotonin levels in the brain and so – therefore - you need drugs which raise the serotonin levels in your brain: you need SSRI antidepressants, which are “selective serotonin reuptake inhibitors”.

That’s the serotonin hypothesis. It was always shaky, and the evidence now is hugely contradictory. I’m not giving that lecture here, but as a brief illustration, there is a drug called tianeptine – a selective serotonin reuptake enhancer, not an inhibitor – and yet research shows this drug is a pretty effective treatment for depression too.

Meanwhile in popular culture the depression/serotonin theory is proven and absolute, because it was never about research, or theory, it was about marketing, and journalists who pride themselves on never pushing pills or the hegemony will still blindly push the model until the cows come home. Which brings us on to our second new study on antidepressants. Two academics, a lecturer and an associate professor of neuroanatomy, decided to chase journalists, in the style of this column - or rather, in the style of this column on crack - and fired off multiple emails, demanding unrealistic levels of referencing from doubtless irritated and baffled hacks. They proudly document their work with an excessive number of examples, and I will pick just a few.

“In the New York Times (12/31/06), Michael Kimmelman wrote about the life and work of Joseph Schildkraut, one of the founders of the chemical theory of depression. The Times reporter stated, ‘A groundbreaking paper that he published in 1965 suggested that naturally-occurring chemical imbalances in the brain must account for mood swings, which pharmaceuticals could correct, a hypothesis that proved to be right [italics added].’” The prof’s gave chase. “E-mails to the author requesting a citation to support his statement went unanswered.” A victory for the noble pedantry.

“In another New York Times article (6/19/07), ‘On the Horizon, Personalized Depression Drugs,’ Richard Friedman, the chairman of Psychopharmacology at the Weill Cornell Medical College, stated: ‘For example, some depressed patients who have abnormally low levels of serotonin respond to SSRIs, which relieve depression, in part, by flooding the brain with serotonin.’” They chased, and they give no quarter. “For his evidence he supplied a 2000 paper by Nestler titled, “Neurobiology of Depression,” which focuses on the hypothalamic pituitary system, but not on serotonin.”

The serotonin hypothesis will always be a winner in popular culture, even when it has flailed in academia, because it speaks to us of a simple, abrogating explanation, and plays into our notions of a crudely dualistic world where there can only be weak people, or uncontrollable, external, molecular pressures. As they said in the Pittsburgh Tribune Review (4/2/07) “It’s not a personal deficit, but something that needs to be looked at as a chemical imbalance.”

Not long on the heels of this article, Wired has posted a brief review of Yale lecturer Charles Barber's new book, Comfortably Numb: How Psychiatry Is Medicating a Nation.

Sometime in the 1990s, the concept of better living through chemistry turned a corner, thanks to drug companies' efforts to synthesize antidotes for every possible mood swing. So writes Yale lecturer Charles Barber in his new book, Comfortably Numb: How Psychiatry Is Medicating a Nation. An OCD sufferer himself, Barber spent a decade working in places like New York City's Bellevue Hospital. He knew something was wrong when he discovered that his colleagues' perfectly functional, $300-an-hour Upper West Side clients were taking the same potent pills as his own schizoid, homeless, crackhead patients. "I would spend part of the day in shelters dealing with seriously ill people," Barber says. "Then I'd go to cocktail parties and find out that the people there were on the same medications." He proposes that we just say no to multinational drug peddlers and heal ourselves with cognitive and dialectical behavioral therapies — "talk therapy" techniques that minimize pill pushing, dispense with Freudian dream analysis, and engage patients in actively reprogramming their own brains. It's like "a highly selective carpentry of the soul," Barber writes — therapy as self-engineering.

He does acknowledge the need for medication in the hardest cases. Just like cancer, severe mood disorders can be life-threatening and should be treated as such, Barber says. But we need to distinguish between real depression and just being bummed out.

The vast majority of the 227 million prescriptions for antidepressants in 2006, he notes, were for people in the second category. Barber lambastes the drug industry for its attempt to turn "the worried well" into customers; he also takes aim at the Diagnostic and Statistical Manual of Mental Disorders for according disorder status to conditions like social anxiety and adjusting to a cross-country move. "Nonsense," Barber writes, "anger, greed, laziness, impulsivity, as well as jealousy, lust, anguish, and so on, are simply part of the human predicament. They are not medical conditions."

It hasn't been a good week for antidepressants. However, I do think that these drugs are useful, even if they are being over-prescribed. Certainly, not as many people need them as are taking them. And I would much rather see people get good therapy that can actually address the causes of depression and not merely act as band-aids.

But people want a magic pill. Few are willing to do the real work of therapy, and even what Barber is proposing is more a quick-fix therapy than a beneficial effort to heal the underlying wounds.

Psychology seems to be at a cross-roads -- traditional talk therapy is being replaced by CBT and its relatives in the cases where therapy is used at all, and the preference seems to be medication.

My guess is that this is a response to the insurance industry and their limits on therapy session coverage. Good therapy takes time, but insurance companies want to get people in and out as cheaply as possible.

For a lot of people, it's simply not the best option.

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