Monday, March 21, 2011

Challenging the psychopharmaceutical revolution: two books

*This is not a recommendation for anyone to stop taking antidepressants or other drugs. Don’t do this. If you read this or the books and are concerned, talk to your doctor.*

I’ve been mentioning a couple of books I read recently: Robert Whitaker’s Anatomy of an Epidemic

(which had been on my radar since I saw him on BookTV several months ago) and Irving Kirsch’s The Emperor’s New Drugs

Both challenge widely held notions about mental illness and the psychopharmaceutical revolution. They approach the subject from different angles and cover different ground – Whitaker is a science journalist interested in the social and political history of mental illness, while Kirsch is a placebo expert who performed some of the earliest meta-analyses of antidepressants - yet they discuss much of the same scientific literature and converge on a number of central points.

Both conclude that the “chemical imbalance” model for depression and other conditions that these drugs are alleged (particularly by the multi-billion dollar neuropharmaceutical industry) to correct is simply false. Not only is it not supported by the evidence, but there is a great deal of evidence against it. This notion is deeply entrenched in our thinking about mental illness, with profound consequences. It’s interesting to me that people seem so resistant to questioning it – as I see it, this paints people prescribed these drugs as fundamentally broken, and presents recovery as largely if not entirely passive. It’s disempowering in addition to being just wrong.

Neither believes these drugs are effective treatments, and both bring numerous arguments and evidence to bear on this point. Kirsch offers a fascinating discussion of placebos and expectations, particularly in mental illness, that moves beyond the dichotomy of physical disease vs. imaginary problem. He contends that all effective therapies for depression are essentially placebos, but argues that in the case of non-drug therapies this is a feature, not a bug. The brain is constantly changing in response to experience and action, and the physiological changes are real. Opposing the chemical imbalance model (like questioning claims about gendered neuro-“hardwiring”) does not mean denying the physicality of the brain; it means approaching the brain’s complexity and plasticity in all of its magnificence. Again, this is, as far as I’m concerned, positive information that reflects reality.

Kirsch, a therapist, discusses questions of ethics with regard to placebos, with all of this complexity in mind. He asks, if antidepressants are really functioning placebos, what’s the harm in recommending or prescribing them to depressed people? In addition to problems involving the therapeutic trust relationship, expense, and a preference for more participatory therapies, he notes the often serious side effects of these drugs. Whitaker also discusses these in depth, and goes further to examine what the drugs actually do in the brain. He contends that rather than fixing a chemical imbalance they introduce a pathology, and explains how.

This is, Whitaker argues, what’s behind the bad long-term outcomes for people on the drugs – in addition to the serious side effects, he says, the drugs put people at greater risk for chronicity and more severe forms of the condition - e.g., they lead to depression becoming bipolar disorder, and to rapid cycling, which he claims was virtually unheard of prior to their introduction.

This argument forms part of the larger historical case Whitaker attempts to make: that not only have these drugs not proven to be the miracle that did away with mental “diseases,” but that their use has contributed to a staggering epidemic of mental illness. This is a complicated story involving changing diagnostic criteria and social policy, and none of the variables is truly independent, but he argues that much of what we’re seeing in terms of mental illness and related disability is iatrogenic. It’s a more difficult argument to make, and I’d like to read his book Mad in America to see if he provides more information from the pre-drug era, but it’s compelling. What isn’t discussed enough, if he’s correct, is how lasting this is – what the prospects are for long-term recovery - if the drugs are stopped; I don’t think good data exist to answer that question.

The most disturbing part of Whitaker’s book is the section on children. Frighteningly, this is also one of the most thoroughly documented. What surprised me when I first brought this up in a comment thread was the resistance to the arguments even in the context of discussing children, and even after I linked to a small selection of the evidence from Whitaker’s site. I mean, if it’s correct that these drugs are ineffective and extremely dangerous for children, prescribing them is a terrible thing to do and making children take them is a violation of their rights and a form of abuse, with potentially far more damaging long-term effects than other forms. The evidence he provides (including, incidentally, noting things like this) certainly makes a case for stepping back and examining this very critically.

The good news, according to both authors, is that some non-drug treatments are effective, and have few or no long-term side effects and dramatically better long-term outcomes. Neither proposes a magic bullet or suggests that everyone can be cured, but of course even if there were no alternatives beyond active placebo, that wouldn’t make the drugs any safer or more effective. It would strengthen the case for more research on and evidence-based evaluation of treatment programs. As someone who finds the drug story weak and disempowering, I see understanding this history as therapeutic in itself. Later in his book, Kirsch talks about the sorts of events and social conditions that lead to depression and need to be addressed as a public health matter, but this idea is only sketched out. Next up on this theme:

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