Monday, July 20, 2015

Irving Kirsch: The Emperor's New Drugs

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Irving Kirsch believes that antidepressants don't work and that we are doing society a giant disservice by selling the public a line (and a lot of drugs) that depression is a chemical imbalance and that medicine is the way to fix it. His argument is well thought out and backed up by a lot of science, but it's a hard one to swallow (yes, I did that on purpose). He knows that, and he has taken his lumps (of sugar pills) from the scientific community. The lay reader (like me) has a hard, if not impossible, time though, knowing what to believe since it's kind of a crazy argument- or, at least one that goes counter to everything we've been told for decades- and, as he said, no one in the scientific community agrees with him, either. So is "The Emperor's New Drugs" the well-written screed of a lunatic/agitator/fringe guy or is it the beginning of a new and accurate trend in how we think about mental health/illness?

I have no idea what the answer is to that question. What I do know is that Kirsch has laid out his case very clearly and knows what he is up against. He gets off to a good start as the first piece of his analysis was done in the mid-90s when he and a colleague did a meta-analysis of the placebo effect in the treatment of depression. He was roundly criticized, pretty much from every side. Not only did people not believe him, they also didn't believe that meta-analysis was a thing. Now meta-analysis is very much a thing and the main argument left is that there's no way that the placebo effect could be what's causing people to get better in these clinical trials of anti-depressants. Only, according to Kirsch's analysis of the data (and his analyses of the analyses), the placebo effect is almost as strong as that of the anti-depressants, and so close that you can't disregard it. And, importantly, he did a Freedom of Information act for the many, many unpublished studies, as only the published studies were the ones that most doctors were basing their opinions on. The published studies still didn't show much difference between the real pills and the sugar pills- the unpublished studies showed even less. But the practitioners, scientists and academics aren't having it.

Placebos work because on depression because we want them to work, he says. And so do anti-depressants. We join clinical trials on treating depression because we're depressed, but also because we kind of want to get better. When we're in a clinical trial, there is a hope- an expectation- that we CAN get better through the treatment. And when we're in a blind trial (neither the patient or the clinician know what the patient is getting), anti-depressants have more likelihood of success for one main reason: they have side effects. We may try not to guess whether we are getting the placebo or not, but when we start to have headaches, nausea and sexual dysfunction, we're going to be pretty sure that we're getting the Real Thing, at which point we are going to get pretty excited- maybe this is it- the treatment is right for us! And this, to Kirsch, is the only thing that accounts for the difference in effectiveness between medically active pills and sugar pills. I am not going to go through all of the reasons and studies, but it's pretty convincing stuff. And pretty scary stuff that makes your mind want to go "nope, no sir," like all of his critics have.

I will say that the one thing that made me think, "oh, maybe they're right" is his emphasis on cognitive behavioral therapy (CBT). Kirsch has a string of ideas on thinking past the chemical imbalance theory and using anti-depressants for the treatment of depression, but they rest heavily on the wide availability of CBT. I don't know much about this treatment, but what I have heard about it isn't particularly positive. I don't think I've ever done this before, but I'll send you right to the wikipedia section on criticisms of CBT. There are lots of them, and they are varied. Say what you will about talk therapy, but this isn't what Kirsch is about. He's not really about getting at the root of the problem, but about fixing things. Again, his idea is radical and would involve rethinking our current understandings of how depression works, so I'm not sure that he's wrong, but I got a little wary at this point in his conclusion.

This is a fascinating book by a man who has been ripped to shreds by his scholarly community and lived to tell the tale. He's not apologetic and wants us to understand where he's coming from. The book is certainly mind-opening, if not mind-changing, at least for me.