Sunday, September 18, 2011

Psychiatrists and NIMH: Set the record straight

The other day, the Today show featured a health segment with Dr. Nancy Snyderman talking to Natalie Morales about the importance of early detection of various conditions, including depression.

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From the transcript:
Snyderman: But the hallmark for depression versus just having a lousy day is hopelessness. People say it's like being in a steel can where you just can't claw yourself up the sides. If you're irritable, you no longer like to do the things you like to do, and I mean reduced sex drive, like nothing brings you satisfaction anymore, sometimes fatigue, you'll hear women say I just don't want to get out of bed in the morning. Or difficulty concentrating. Any of those alone may not be enough, but put them together and it's important. And for you and I who have children, you have to really look at transitional times in a child's life. Pre-adolescents can really become depressed and when you see it as a parent you may not notice it. But changing grades, friends at school.

Morales: Hormones.

Snyderman: All of that stuff. We even know that in utero we can start to pick up on depressed babies based on how they respond to music and what their overall environment is like. This is not something to be worried about; it's not something to be chastised. It is really something to understand, because there are phenomenal treatments, including therapy.

Morales: And it's usually lower levels of serotonin that triggers depression?

Snyderman: The whole neurotransmitters. And a lot of times it's medicine. Increasingly we believe it's medicine and some kind of therapy.
Now, there’s so much wrong here I wouldn’t know where to begin (how exciting for pharmaceutical companies to have that vast in-utero market still to exploit!), but this last response struck me. In the past couple of months, I’ve noted Abraham Nussbaum asserting that he “know[s] of no serious psychiatrist who believes that psychotropic drugs ‘fix chemical imbalances in the brains’ of their patients” and NIMH head Thomas Insel conceding that notions of neurotransmitter imbalances as the cause of depression are “beginning to look antiquated.” The subject also arose in the recent exchange about Marcia Angell’s article, in which her interlocutors Friedman and Nierenberg refer to serotonin deficiency as “an outdated and disproven chemical imbalance theory of depression.”*

I just read Bruce Levine’s Surviving America's Depression Epidemic: How to Find Morale, Energy, and Community in a World Gone Crazy,** which is a few years old, and was surprised [?] to discover that Insel’s been saying this since at least 2007 (making his recent “beginning to believe” sound rather odd). Despite the fact that the monoamine hypothesis has long been discredited,
…the general public continues to hear (through antidepressant commercials and from many mental health authorities) about the neurotransmitter deficiency theory of depression, and so it was news to many Americans when Newsweek, in a February 26, 2007, cover story about depression, reported: "For decades, scientists believed the main cause of depression was low levels of the neurotransmitters serotonin and norepinephrine.... [However, a] depressed brain is not necessarily underproducing something, says Dr. Thomas Insel, head of the National Institute of Mental Health - it's doing too much.... Instead of focusing on boosting neurotransmitters (the function of the antidepressants in the popular SSRI category such as Prozac and Zoloft), scientists are developing medications that block the production of excess stress chemicals."

Pharmaceutical companies, however, have been so effective at marketing the neurotransmitter deficiency theory of depression that even though the NIMH has now retreated from this view, the general public and many doctors continue to believe it. The mental health establishment has not yet zealously publicized its newer depression theory - that excess stress chemicals (such as cortisol) can cause nerve cell damage - perhaps because it would confuse millions of patients who continue taking neurotransmitter-enhancing drugs (it would certainly upset the pharmaceutical companies that manufacture them) (p. 23).
Amusingly (OK, darkly amusingly), the newest depression “theory” from Insel is completely different from the 2007 “theory,” but that this absurd situation continues year after year – the repeated acknowledgements that the alleged mechanism for the alleged efficacy of antidepressants is wrong with at the same time no real effort made to correct widespread public misperceptions stemming from doctors and from advertising - is amazing and unacceptable. The public has a right to know what the science has shown about this important question, and it’s well past time for people who obviously know the facts to set them out plainly and honestly.

* As Nussbaum does with Whitaker, Friedman and Nierenberg suggest that Angell is ignorantly or disingenuously setting up a straw man by pointing out the scientific discrediting of the chemical imbalance idea: “Angell uses an outdated and disproven chemical imbalance theory of depression (i.e., serotonin deficiency) as a straw man to deny that depression has any biological basis at all.”

Angell replies: “Contrary to Friedman and Nierenberg, I do not 'deny that depression has any biological basis at all'. I know very well that all thoughts, emotions, and behaviors have their origin in the brain. But it is a great leap from recognizing the obvious fact that mental states arise in the brain to knowing why and how they arise. …As for the chemical imbalance theory of depression being a straw man, I still hear it invoked frequently. Even Oldham seems to entertain it in his letter, saying ‘…there is no consensus on whether these imbalances are causes of mental disorders or symptoms of them’.”

** A mixed bag, ranging from the science-based and truly insightful to the borderline wooish and irritating. I recommend…the good parts. I can’t be too harsh as it was through him that I read about Ignacio Martín-Baró.

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