Shouting "Screw You" At Prozac
Brian Doherty | February 29, 2008, 8:35pm
Found via Kevin Drum at the Washington Monthly, an interesting new metastudy written up in the UK Guardian that casts doubt on the effectiveness of such SSRIs and SSNIs commonly prescribed for depression as Prozac and Effexor.
An excerpt from the Guardian account:
The study examined all available data on the drugs, including results from clinical trials that the manufacturers chose not to publish at the time. The trials compared the effect on patients taking the drugs with those given a placebo or sugar pill.
When all the data was pulled together, it appeared that patients had improved - but those on placebo improved just as much as those on the drugs.
The only exception is in the most severely depressed patients, according to the authors - Prof Irving Kirsch from the department of psychology at Hull University and colleagues in the US and Canada. But that is probably because the placebo stopped working so well, they say, rather than the drugs having worked better.
"Given these results, there seems little reason to prescribe antidepressant medication to any but the most severely depressed patients, unless alternative treatments have failed," says Kirsch.
The paper, published today in the journal PLoS (Public Library of Science) Medicine, is likely to have a significant impact on the prescribing of the drugs.
.........
The pattern they saw from the trial results of fluoxetine (Prozac), paroxetine (Seroxat), venlafaxine (Effexor) and nefazodone (Serzone) was consistent. "Using complete data sets (including unpublished data) and a substantially larger data set of this type than has been previously reported, we find the overall effect of new-generation antidepressant medication is below recommended criteria for clinical significance," they write.
From my own perspective on the rolling juggernaut of psychatric medicine, I somehow doubt the optimistic "likely to have a significant impact" bit. Especially given Kevin Drum's observation on how little play this has gotten in American media, which still seems to be the case.
Drum's comment thread is very interesting and worth at least skimming for those who care about this topic. Lots of people jousting with the results, some of them of the level of intellectual sophistication of those who note that, damn, that horoscope that day really described exactly what I was going through; others raise the notion that the study might be misleading for either conflating some drugs that work with others and dragging down the working drugs average, or for mixing subjects who really are depressed with a bevy of people to whom the drugs were misprescribed and thus don't work.
The full study, from the open-access Public Library of Science.
Ronald Bailey wrote back in July 2007 for reason on the fascinating world of public access open source scientific journals such as Public Library of Science.
This July 2007 reason feature by me touches on some of the things that psychiatric medical science can't quite tell us.
And see this July 2000 reason interview with psychiatric critic Thomas Szasz, conducted by Jacob Sullum.
Thia | March 1, 2008, 4:00pm | #
Jared,
"If you are objecting to the use of labels because there are different underlying causes, I couldn't agree with you more"
If by labeling, you mean detention and drugging, then that's a good start. But causes of *what*?
"If you think that human behavior is separate from underlying feelings, I disagree completely, but I don't feel like getting into a mind-body debate."
It is separate in the sense that feelings are not political, but behaviours (towards others) definitely are). There is no need to debate mind-body.
"If you think noone has the symptoms associated with depression."
If people say they feel x,y,z, then how could I possibly know otherwise? But they are not symptoms, unless they are metaphorical symptoms.
"it should not be forced unless someone has done something to justify depriving their liberty of choice"
what does this mean?
i don't see that you addressed my initial response to you in any way. Feelings, nor behaviour, can be a disease, except metaphorically. And whether taking drugs makes one feel better is a moral, and not a medical, matter.
Neu Mejican,
What are you trying to say? I assume you are not familiar with the history of psychiatry, because if your were, you would do better to not quote contemporary establishment "research" on the science of locking people up and drugging them. If any present mental illness were to be shown to be a real disease (much like epilepsy was), then it would be treated only with consent from the person with the disease. If this were so, psychiatry as we know it today would disappear completely. I have no problem with your opinions on what "major depression" is or is not, but stripped of power to coerce persons said nor have the disease, your argument is merely academic.
Thia | March 2, 2008, 12:40pm | #
Neu Mejican,
"No. It was never as strict as you would like to believe"
Sure it was. Virchow's definition of disease is still what pathologists look for. When you find mental illness in the cadaver, then you might have a case. Most sensible people today know that people can be sick literally, but the economy, or a joke, can be sick only metaphorically.
"it is incorrect to assume that illness is a concept with clear boundaries. It is a very difficult concept to pin down generally..."
But i already told you that the stricter definition constitutes what the word meant, and hence what it means. If you want to broaden the definition to include any unwanted behaviors, then the definition will obviously be difficult to pin down. But this is a problem for you, not me!
"You assume that is the purpose of nosology in psychiatry, but it isn't. The primary purpose is to find ways to help people."
Are you serious? Earlier you said that "I agree that Szasz has legit points regarding coercion, the confluence of state power and medicine...", but now you are pulling a 180 and saying that locking people up and drugging them is how to help a person. Which is it?
"Most state involvement in the industry has been to restrain doctors in an effort to reduce harm to their patients"
I can only think that you are joking. Who gave psychiatrists the power they today enjoy? Who gets to define mental illness? The State, of course. Moreover, your definition of "help" is a strange one indeed, because if I decide that my friendly psychiatrist is not helping me, there is nothing I can do, because *you* know that he is helping me. And once coercion is decided upon, how better to justify it than showing that the "patient" has a disease, which is no different to heart disease or cancer. Etc, etc.
Your point about the literal/metaphoric nature of illness is an interesting topic, and you correctly point out that one does not need disbelieve in mental illness to reject psychiatric coercion. But, in my opinion, you are dead wrong on both counts, and your blind re-assertions of the standard psychiatric industry propaganda makes me think I was right to question your motives re: definition of disease. If you want to convince anyone of anything, try using better arguments.
Thia | March 2, 2008, 2:05pm | #
Neu Mejican,
"You are assuming that the point of diagnosing mental illness is to lock someone up and drug them. That is untrue on its face"
No, that is not my assumption. I said that mental illness is the *justification* for detention and drugging. Without it, the political aspect of the whole thing is made explicit. Mental illness is strategy, not disease.
"The hurdle for coercive treatment is pretty steep in this country. It may not be steep enough."
no comment required.
"If you are unhappy with the treatment you are getting from your psychiatrist...stop consenting to treatment, seek treatment with someone else. You are acting like most psychiatric services are involuntary. They are not."
All psychiatric treatment is coercive, actually or potentially. If you disagree, you might try walking out of a psychiatric institution when you feel that it is not the place for you. If the powers that be do happen to agree that you can leave, then you have been lucky, but it must be said that they will do more than "keep you on file," so to speak. Anyway, the point you keep avoiding is that they have no justification in having the power to decide whether you go free or stay in a prison and ingest poison. I am not disagreeing that a small percentage are officially "voluntary," but personally I think it mendacious to assert that voluntary psychiatric services are anything of the sort. While entirely unnecessary for my argument, I have personal experience of working in these places, and know it to be true. I am sure most psychiatrists would readily admit that if a "patient" refused to stay, they could and would detain them if they felt it necessary. And it is much less paperwork if the person remains "voluntary" (ask any junior doctor).
"Pathologists are not the only ones interested in disease"
I never implied that to be the case. It is however true that psychiatrists today have no interest in the subject.
"It is true that, in the strictest terms, we cannot speak of the mind as becoming diseased." - Emil Kraepelin
Thia | March 2, 2008, 2:51pm | #
Pendulum,
"Why is it wrong for psychiatrists to prescribe medicines which both they and the patient believe increase functioning?"
It is wrong because state licenses for prescribing drugs is coercive. People should be free to ingest any substance they wish, and should not have to get the approval of an agent of the state to do so.
"Well, yeah, and going to the mall is a life-threatening activity, actually or potentially. But the theoretical possibility that a psychiatrist will lock up you when you complain that you've been feeling down lately is not a good reason to criticize the effectiveness of SSRIs."
I wasn't using the existence of state psychiatric powers to criticize the effectiveness of SSRIs. Perhaps my words were not clear - where did you think that I made such a claim?
Neu Mejican,
"Are you working under the assumption that most psychiatric treatment is inpatient?"
That is the paradigm, but it is becoming less so. This is important in that the coercion becomes less direct, and I could ask you if you are working under the assumption that psychiatrists lack the power to detain and drug outpatients?
"You are conflating two distinct concepts.
Yes, mental illness may be used as a justification for detention and drugging...it may be used as a strategy, and it is a strategy that may be abused...this does not mean that mental illness is unreal or metaphorical."
Mentall illness is used to justify psychiatric coercion. If I were to write a list of behaviors I felt were "mental illnesses," then nothing would happen. When the state does it, on the other hand, it has the power to use the alleged existence of mental illness to deprive people of responsibility and liberty. Bad behavior is something you do, not something you have. Where is the disease to be found in someone washing his hands fifty times a day?
Jared | March 4, 2008, 12:03pm | #
Thia,
I stayed away as long as I could. Neu has made alot of the same points I would, in regards to coercion. The parts you are missing, or just plain disbelieving where evidence lies - again, the mind body problem I referenced originally may explain this - are as follows.
1. Psychiatry is coercive "care."
This certainly is possible the way things are set up, and may often be the case. Whether or not this is justified is a much broader subject. However, a large amount of psychiatric care is outpatient work with little likelihood (although some possibility of) coercion.
"If it is possible that p, then p" is a false statement, and that seems to be your guiding belief in relation to coercion in psychiatry. Even if in your (as I see it) extremely twisted worldview, the majority of psychiatry was for evil, coercive controlling purposes, that does not mean there is not a valid treatment for the disorders psychiatry claims to treat.
Whether or not it is a social issue that needs more attention to limit possible coercion is different from whether or not all care is coercive. I think there are many everyday examples of uncoercive care, but that there are also abuses in the system. I think the good generally outweighs the bad, but that does not mean improvement is not necessary.
2. Psychiatric disorders are only behavior and feelings, there is no underlying physical cause.
Currently, there are many disorders where behavior is the main form of diagnosis. It is the most obvious one, a complaint of depression is the best way to know if someone is depressed. That is, again, not the same thing as saying that there is not an underlying physical problem. Assuming there isn't requires a dualistic view of the mind-brain relation. (Unless, as I stated before, you just mean it isn't enough to make it a disease, which I addressed earlier).
You may deride MRI evidence at times, and cadaver brain analysis, but that is just a way to avoid physical evidence of problems. But you cannot deny them and then say that there is no evidence of disease similar to that found in other illnesses. You may say, hey, that cadaver doesn't have a mental illness, just some abnormality. The same can be true of a heart problem. You can see the cause of the problem (clot, or whatnot) that impairs functioning, but not the impaired functioning itself, as it is no longer functioning. The same is true in the brain, with certain mental illness. In people with certain disorders, their are differences in the amount of matter, and in the structure of neurons (such as a decrease in amount of dendritic projections in one brain area) that change the functioning. How and why is not understood (by me at least, but I am not an expert), but it will be. Just because it is more complex and harder to understand does not deny it's reality. These signs are much like plaques in the brain or other problems that would be found in brain of someone being treated by a neurologist (the field you mentioned as where the "real" psychiatric diseases would migrate to).
In both cases, the logic you use to disassemble the system seems either faulty on it's face, or to use different assumptions at one point than at another, or just nonexistent. I have the distinct feeling that if anyone agreed with you at the beginning of your comments, you have since convinced them otherwise.
