Academia

Shouting "Screw You" At Prozac

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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 "Using complete data sets (including unpublished data) and a substantially larger data set of this type than has been previously reported, we find the overall effect of new-generation antidepressant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.

NEXT: Second Thoughts on WFB

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  1. psychiatric medical science

    Can you type that string of words with a straight face?

  2. or for mixing subjects who really are depressed with a bevy of people to whom the drugs were misprescribed and thus don’t work.

    Since there is no way to scientifically tell if someone is “really depressed” (if that term has any real meaning at all), yeah, I guess these drugs are misprescribed a lot.

  3. As I said on another forum when this study came up:

    With Zoloft I am a functional human being. Without it, I am not.

    As far as I’m concerned, that means ‘case closed’. I wouldn’t use my anectdotal evidence to evaluate whether or not Zoloft will work on anyone else… but frankly, I don’t care if it works on anyone else or not.

  4. Theres no doubt in my mind that anti-depressants have a real benefit for some people. Theres also no doubt in my mind that for some people anti-depressants are a waste of money. The problem is that no one has figured out a way to distinguish which case will be true.

    The real problem here is that there is no one disease called depression. What health practitioners call depression is really just a constellation of symptoms in the feel bad rainbow.
    Some people may feel crappy because they are chemically imbalanced, while others feel crappy because they have bad attitudes or make terrible life choices. Some therapies help some people, while others don’t.

    So if your sample size is broad enough to contain everybody that feels bad about their lives for whatever reason, then yeah, its not surprising to me that you don’t see a statistically significant effect to treatment. But this is not unique to anti-depressants.

  5. The reporting on this study has been terrifically bad; the new study actually only confirms a guideline for treatment of mild depression put in place in 2004. See:

    http://www.badscience.net/?p=619

    for more.

  6. My experience was a little different than isildur’s (apart from not taking the one ring, I mean). I took Paxil and it seemed to help at first. Later, I noticed that I was physically addicted to it. (I missed a dose and got weird withdrawal symptoms – I felt like my eyes were coming loose, my head rattled when I tried to get out of bed, and so on.) Shortly afterward, I decided I had to give it up. Before I used Paxil, I had tried Zoloft. When they put me on a reasonable dose (after having a half-normal dose at first) it immediately sent me into a pretty bad panic attack.

    Suffice to say, I’m trying to deal with things without drugs now.

  7. 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;

    Is being able to adopt a pose of intellectual sophistication the main criterion for being a Reason writer? Like a lot of people, I have pretty strong anecdotal evidence that antidepressants work. No, anecdotal evidence doesn’t prove anything. But when it comes down to “Who are you going to believe, your own lying eyes, or a smug Reason blogger who read a study somewhere,” I’ll reserve judgment a little while longer.

  8. Bill Mill – I am not surprised in the slightest.

  9. ….that casts doubt on the effectiveness of such SSRIs and SSNIs commonly prescribed for depression as Prozac and Effexor.

    Red wine is clearly much more effective. Without those nasty side effects. Unless, of course, you count calories……….

  10. In completely unrelated news, Boyd Coddington (Boyds Wheels & American Hot Rod) has died of complications of Diabetes.

    I once watched him take a chunk of aluminum and machine it into a gorgeous custom valve cover. It was awesome.

    I don’t worship him, in part, because he didn’t like me much (it was a long time ago and that is not to say he would remember me from Adam anyway). The feeling was a bit mutual, but he was an incredible talent, with a penchant for perfection.

  11. Warning: Anecdotal Evidence Forthcoming

    I take Effexor to keep from going through everyday thinking that something is terribly wrong with me and my life despite no evidence to support such thinking.

    Thus far it has worked for me.

    I sincerely believe that far too many people are prescribed drugs they don’t need for problems that could be solved by eating a little better and getting a little exercise. I have discovered I’m not one of those many.

  12. from a libertarian point of view, the problem with stories like those in the Guardian is that the revelations will be used to increase state psychiatric power, rather than the other way round. there has been a trend towards a story of this kind for a while now, and it seems to be part of the plan to legitimise the massive increase in state spending on psychotherapy services. the leader of the Liberal Democrats has in effect admitted as much. also, such articles always hold on to the claim that forced drugging is a medical cure for real a disease, though only a proportion (but an important one) of those who now take these drugs have the disease. the issue is not whether the drugs work, and libertarians should understand this better than anyone.

  13. Travis, can you offer any evidence that some people are chemically imbalanced?

  14. Obviously everyone has an opinion. I have worked in a psychiatric hospital for ten years and have experienced a bout of depression in my time. There is no doubt that antidepressants work the majority of the time. That has been what I have observed. They worked for me many years ago and I went on to achieve my personal goals thereafter. I am now a professional.

  15. I just wrote a long-winded comment that I believe was lost. (Unless this will appear right below it and I am double posting).

    But, while I used some examples about research and clinical treatment, I will try to boil it down to it’s simplest form,

    Depression is likely to have numerous underlying problems. Depression treatment often requires the patient trying a few different drugs until they find one that works for them. Given that it is a collection of problems with similar symptoms, and the drugs are closer to treating the underlying problems than the symptoms, the results of the study are unsurprising. Many depressed individuals will not respond to one drug, or will respond only weakly. The samples of the individual studies may have been skewed so that when a difference was found between drug and placebo, it is because the sample had people with a similar underlying problem – and when no difference was found, the sample may have had more diverse problems or fewer people with the problem the drug treats. You would expect low significance and low effect sizes from these experimental models, and likely none from a metaanalysis.

    I will respond with more examples if my previous comment does not appear or if anyone disagrees for a reason I can address.

  16. I am just going to include my favorite example that was lost in my first comment. It is certainly not exactly analogous, but I think helps illustrate some of the underlying problem.

    Consider a group of patients being studied that all complain of a fever. If you give them an antipyretic (fever lowering drug), it will probably help most of them with that one symptom. Depression is identified as a cluster of symptoms. However, a fever is more a sideeffect of the real problem that can be treated somewhat independently of the cause. The same does not hold true for depression.

    Consider the same group of patients. If given an antibiotic, some of them with bacterial infections would show improvement of symptoms. However, those with the fever caused by a viral infect, a drug, cancer, or one of the other possible causes would not be effected. This might look similar to the individual studies that were analyzed in the meta study. There may be some improvement statistically, or none statistically. The effect size would be low. Now, if you treated them with other courses of treatment, you might get similar results. If you then analyzed it altogether, you might find this family of fever reduction treatments (all the treatments that treat the specific ailment) are ineffective. You would be missing the fact that they are effective if targeted correctly though.

    As I stated before, this is not a true analogy. The differences are subtle, but I hope it helps illustrate why this study is not surprising, and also does not necessarily mean that these drugs are ineffective at treating cases of depression. It just means they are not likely to be effective at treating all cases of depression.

  17. Also, open access journals are are absolutely wonderful.

  18. I take Effexor to keep from going through everyday thinking that something is terribly wrong with me and my life despite no evidence to support such thinking.

    I hear that, man. I know several people, some who surprised me at the confession, who take these kinds of drugs and who are happy with the results. One chick I know describes it exactly as you do.

    Me? I’m the glass empty guy just waiting in anticipation for the inevitable descent of my day from that fabulous cup of morning Columbian into crap. Then, in the evening, I pour a little red wine and miraculously Life Makes A U-Turn.

  19. Jared, i disagree entirely with everything you wrote. Depression is not a real disease, but a metaphorical disease, like spring fever. hence, there can be no cure for it. whether ingesting a drug makes people report being less depressed has nothing to do with medicine.

  20. With Zoloft cannabis I am a functional human being. Without it, I am not.

    As far as I’m concerned, that means ‘case closed’. I wouldn’t use my anectdotal evidence to evaluate whether or not Zoloft cannabis will work on anyone else… but frankly, I don’t care if it works on anyone else or not.”

    There, fixed that for myself.

  21. Since there is no way to scientifically tell if someone is “really depressed” (if that term has any real meaning at all)

    Well there is the common scientific practice of operationalizing a definition–

    Diagnosis of Major Depressive Disorder, Single Episode

    Summarized from the Diagnostic and Statistical Manual of Mental Disorders- Fourth Edition

    A. The person experiences a single major depressive episode:

    1. For a major depressive episode a person must have experienced at least five of the nine symptoms below for the same two weeks or more, for most of the time almost every day, and this is a change from his/her prior level of functioning. One of the symptoms must be either (a) depressed mood, or (b) loss of interest.
    1. Depressed mood. For children and adolescents, this may be irritable mood.
    2. A significantly reduced level of interest or pleasure in most or all activities.
    3. A considerable loss or gain of weight (e.g., 5% or more change of weight in a month when not dieting). This may also be an increase or decrease in appetite. For children, they may not gain an expected amount of weight.
    4. Difficulty falling or staying asleep (insomnia), or sleeping more than usual (hypersomnia).
    5. Behavior that is agitated or slowed down. Others should be able to observe this.
    6. Feeling fatigued, or diminished energy.
    7. Thoughts of worthlessness or extreme guilt (not about being ill).
    8. Ability to think, concentrate, or make decisions is reduced.
    9. Frequent thoughts of death or suicide (with or without a specific plan), or attempt of suicide.
    2. The persons’ symptoms do not indicate a mixed episode.
    3. The person’s symptoms are a cause of great distress or difficulty in functioning at home, work, or other important areas.
    4. The person’s symptoms are not caused by substance use (e.g., alcohol, drugs, medication), or a medical disorder.
    5. The person’s symptoms are not due to normal grief or bereavement over the death of a loved one, they continue for more than two months, or they include great difficulty in functioning, frequent thoughts of worthlessness, thoughts of suicide, symptoms that are psychotic, or behavior that is slowed down (psychomotor retardation).

    B. Another disorder does not better explain the major depressive episode.

    C. The person has never had a manic, mixed, or a hypomanic Episode (unless an episode was due to a medical disorder or use of a substance).

    Thia,

    You seem to be suffering from disordered Szaszian thinking. You may want to see someone about that.

  22. The problem is that no one has figured out a way to distinguish which case will be true.

    Well, to be fair, there is the best-practice recommendation of trying the medication out, and seeing if it works by closely monitoring the symptoms of those on the medication.

  23. Neu Mejican,
    are you kidding? quoting the DSM is probably worse than making no argument at all. and so how precisely is Szasz mistaken?

  24. There are so many ways to address the possible meanings of your response, Thia.

    However, I want to address a few quickly. If you are objecting to the use of labels because there are different underlying causes, I couldn’t agree with you more. The labels only describe symptoms which may have different underlying causes, which may even be (as in this study, in my view) damaging to research into treatment. 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. If you think noone has the symptoms associated with depression, then there is no point talking to you, because that is silly (barring the aforementioned mind-body debate I do not think is important here). However, I am going to guess that is not the case.

    If, however, you are arguing that people with depression fall on a normal continuum of human emotion – I cannot disagree, there is not enough evidence either way, and I certainly think many people diagnosed with depression would fall into this category even if all do not. In terms of whether or not to seek treatment (it should not be forced unless someone has done something to justify depriving their liberty of choice) I think the DSM has the useful criterion of functional impairment. If people feel bad enough they want to feel better, trying to find a useful drug or treatment is very helpful. Of course, many people at the low end of this spectrum may have real differences that are easily detectable in terms of brain structure or function. Even if the differences are only in terms of place on a scale – the same is true of other medical problems such as heart disease.

  25. Thia,

    Jared covers the basics.

    Szasz: “To be a true disease, the entity must somehow be capable of being approached, measured, or tested in scientific fashion.”

    In science it is quite routine to measure behaviors. Approaching the entity of major depression is not a scientifically intractable problem.

    e.g.,

    Biological Psychiatry
    Volume 48, Issue 8, 15 October 2000, Pages 791-800

    Dysfunction in neural circuits involved in the pathophysiology of mood disorders

    3D MRI studies of neuroanatomic changes in unipolar major depression: the role of stress and medical comorbidity

    Yvette I. Sheline

    Abstract

    Increasing evidence has accumulated for structural brain changes associated with unipolar recurrent major depression. Studies of neuroanatomic structure in early-onset recurrent depression have only recently found evidence for depression-associated structural change. Studies using high-resolution three-dimensional magnetic resonance imaging (MRI) are now available to examine smaller brain structures with precision. Brain changes associated with early-onset major depression have been reported in the hippocampus, amygdala, caudate nucleus, putamen, and frontal cortex, structures that are extensively interconnected. They comprise a neuroanatomic circuit that has been termed the limbic-cortical-striatal-pallidal-thalamic tract. Of these structures, volume loss in the hippocampus is the only consistently observed change to persist past the resolution of the depression. Possible mechanisms for tissue loss include neuronal loss through exposure to repeated episodes of hypercortisolemia; glial cell loss, resulting in increased vulnerability to glutamate neurotoxicity; stress-induced reduction in neurotrophic factors; and stress-induced reduction in neurogenesis. Many depressed patients, particularly those with late-onset depression, have comorbid physical illnesses producing a high rate of hyperintensities in deep white matter and subcortical gray matter and brain damage to key structures involved in the modulation of emotion. Combining MRI studies with functional studies has the potential to localize abnormalities in blood flow, metabolism, and neurotransmitter receptors and provide a better integrated model of depression.

  26. Why exactly is hostility to psychiatry a libertarian issue? Is there a Libertarian-Scientology merger in the works?

  27. Hostility to it in and of itself isn’t – but that doesn’t mean some libertarians might not also feel that way.

    There are related issues though.
    – Involuntary committal
    – Involuntary medication
    – Being declared unfit to make medical or economic decisions

    Whether or not these should be allowed, are important issues of psychiatry that relate to libertarian viewpoints.

    I must admit I do not see how this article relates to them though, even if the study was newsworthy (which I don’t really think it is). The coverage of it is pretty unscientific, though. So the usefulness of showing that prozac or another antidepressant does not work for most people with depression (the opposite of what I think is a common lay view) is lost by the misinterpretation of the data.

  28. Neu Mejican,

    In the study you cited, can a person examining such neuroanatomic structure diagnose specific “disorders” using those results in a blind manner?

    Until that happens, there is no disease to be diagnosed.

  29. 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.

  30. Thia,

    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.

    By that definition most physical symptoms are metaphorical symptoms.

    I assume you are not familiar with the history of psychiatry, because if your were,

    Be honest…is this Tom Cruise?

    Nebby,

    Not yet, but they are making progress. See the recent Nature article on identifying Alzheimer’s using MRI.

  31. Nebby,

    Until that happens, there is no disease to be diagnosed.

    You are making a fundamental error in thinking here. A diagnosis and a disease are not the same thing. A disease can be present without a way to diagnosis it, clearly.

    As for depression, it can be diagnosed using other tools…the MRI is not needed.

  32. *makes popcorn*

    wheeee!

    engrams go bye-bology
    when it’s time for scientology!

  33. I think it was quite clear that I meant causes of symptoms associated with depression, such as high levels of negative affect. Also, if you read what I wrote, you would know that I think forcing drugs on people is bad. However, one gets the idea that you do not really care to read responses for content, but to just react. Barring actual thought out critiques or opinions, I am not going to continue posting responses.

    However, the idea that feelings cannot be a symptom is ridiculous. I understand you wish to discredit psychiatry and psychiatric illness, so I will not bother discussing them further, as there seems little chance you would read and think about it, instead of just read and respond. However, *feelings* that you might consider psychiatric can be caused by many things and are known symptoms of diseases or health concerns that would be even more interesting for you to deny. There are many examples, this is just the two that come to mind first: vitamin deficiency (such as B) – depression, paranoia – and cardiac problems (feeling of impending doom can be the only felt symptom)

  34. Neu Mejican,
    i am talking about metaphorical *diseases*.
    why would you smear anyone who disbelieves the state-sponsored history of psychiatry (as a progressive humanitarian science) as a Scientologist? having said that, at least that religion has the decency to oppose psychiatric coercion.

    “the MRI is not needed”
    ouch!!!

  35. Thia (Tom, whatever),

    Metaphorical diseases…

    Metaphorical symptoms…

    You are presenting metaphorical arguments…lacking substance, without merit, worthy of mocking…

    I agree that Szasz has legit points regarding coercion, the confluence of state power and medicine…

    This does not make his misguided position on the existence of mental illness worth taking seriously.

  36. Jared,

    but that is a different argument. if you can offer nothing against the proposition that mental illness is never a justification for coercion, then discussing whether depression is x,y,or z in your opinion is, to my mind, completely pointless. you continue to use the word “symptom,” but if we are not talking about medicine, then why bother with the medical metaphor? i suggest that if you are against psychiatric coercion, you ought to drop the use of psychiatric terminology. not doing so implies a) that you do not reject psychiatric coercion, and b) think that psychiatric terminology is helpful is having honest conversations about human life.

  37. “This does not make his misguided position on the existence of mental illness worth taking seriously.”
    why not? or am i not allowed to ask?

  38. If mental illness isn’t real, then how do some of the posters here explain what they see when they look in the mirror?

    Do the voices just assure you that it’s an illusion put there by THE MAN?

  39. I was working in a psych hospital while fluoxetine was being tested back in ’88. I don’t know about depressed patients, but for Obsessive Compulsive Disorder patients it was like a miracle cure. People who hadn’t worked for years because of handwashing or counting obsessions just gave them up and became functioning adults again. It was really amazing in a field where cures are usually incremental.

  40. @ Isildur

    I am also on Zoloft. I can function fine without it, but I have noticed a marked improvement in my relationships and stress levels since i’ve gone on it. It could possibly be placebo effect.

    The problem i have with this study is that depression coexists with a number of other disorders, such as OCD, ad(h)d, etc…so even if the drug doesn’t “work” on depression, it can alleviate it by fixing other issues, like mild ocd for example.

  41. actually, scratch that. Before i was on zoloft i had substance abuse issues which went away almost immediately upon starting Zoloft.

  42. Well, to be fair, there is the best-practice recommendation of trying the medication out, and seeing if it works by closely monitoring the symptoms of those on the medication.

    Like this…….

    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.

    They should have more control groups.I’ll suggest wearing a lucky rabbit’s foot,burying some personal items in a Prince Albert can, putting a piece of camphor in your shoe and sacrificing a chicken.Then seeing if it works by closely monitoring the symptoms of those on the hoodoo

  43. Thia,

    You are, of course, allowed to ask.

    The main reason Szasz’s arguments are not worth taking seriously is that they are based on idiosyncratic definitions of almost all the key terms…disease, symptom, science, entity, mind, mental illness. For instance, the whole “metaphoric disease” tact misuses both the term “metaphoric” and the term “disease.”

    Psychiatric illnesses, just like other illnesses, are based on assessment of the functioning of body systems serving body functions. Like most assessment of body functioning, indirect measures are used when less direct means are unavailable. This is true in diagnosis of disease inside or outside of the realm of mental illness. Impairment or disease of mental systems serving mental functions are as real as disease or impairment of other body systems.

    You do not need to deny the existence of impaired functioning in mental systems to raise the issues of coercion and consent for treatment.

  44. “Mental illness” has no known pathologies.

    Sci-Tech Encyclopedia: Pathology

    The study of the etiologies, mechanisms, and manifestations of disease. Techniques and knowledge gained from other disciplines, including anatomy, physiology, microbiology, biochemistry, and histology, are utilized. The information obtained from the study of pathology is necessary prior to developing methods with which to control and prevent disease.

    Notice how they left out “behaviors”

    Bring on your “scientology” ad hominems, it is all you’ve got……….

  45. I’ve taken Prozac since 1994 and it has helped me. Two things I’ve noticed:

    1) It lowers my sex drive to near zero

    2) If I miss a day or so I start to have weird dreams, about havng violent arguments with my deceased mother (no joke here)…

    Take it for what it’s worth…

  46. standard libertarian disclaimer:

    I think people ought to be able to shoot speedballs or sit in Orgone accumulators if they feel it “helps them”.

  47. SIV,

    That wins the non-sequitor of the day award.

    The most widely used classification system of disease world-wide

    http://www.who.int/classifications/apps/icd/icd10online/

    Please note the section at this link
    http://www.who.int/classifications/apps/icd/icd10online/navi.htm#f00

  48. non sequitur?

    that is one of the facts central to Szasz’ assertions on “mental illness”. If and when a pathology is discovered it becomes a “real” physical illness and leaves the sphere of psychiatry for neurology or whatever other branch of “real medicine” that is appropriate.

  49. or were you referring to the speedball disclaimer?

  50. I dunno about what’s a disease and what’s not, I just know that the SSRI pills did me some serious damage (on the order of five years of my life down the toilet) and being off them is not really helping either.

    Disclaimer: And also, I’m drunk.

  51. With Zoloft cannabis I am a functional human being. Without it, I am not.

    You’re my brother-in-law, aren’t you?

  52. WTF?

    Dam HTML Gremlin Squirrels! Gimme some of that Zoloft before I take the 12 Gage to the computer.

  53. SWDWtLHJ,

    (on the order of five years of my life down the toilet)

    Why did you keep taking them for 5 years then?

    Feelings of depression would seem to be wholly subjective. Maybe happy people actually feel worse than you but they just don’t know it!

    I kind of feel a constant low grade mania and can’t really focus on any one thing for any length of time.I could probably parlay that into a dexedrine ‘script but I don’t think the legal speed is worth the stigma.

  54. SIV,
    Actually it was going off them once I discovered I was addicted that took me roughly 5 years to get through. I still may have some lingering physical side-effects, but I can sort of deal with most of them.

    I don’t know from “feeling worse”. I only know that it’s often a struggle to try to convince myself not to commit suicide. So if happy people feel worse, I pity them.

  55. Dondero: More reasons why I don’t use my real name or credit card number or allergy to Kryptonite or whatever else your identity-thieving ass wants me to post.

    Everyone else: Apologies for the honesty.

    My only excuse: drugs – this time alcohol, not Paxil.

  56. If and when a pathology is discovered it becomes a “real” physical illness and leaves the sphere of psychiatry for neurology or whatever other branch of “real medicine” that is appropriate.

    So you are saying that if recent evidence that schizophrenia is associated with caudate nucleus abnormalities pans out it will become a neurological disorder and not a mental illness.

    That seems inappropriate for many reasons.
    A nice article on the ins and outs of this kind of thinking…
    http://schizophreniabulletin.oxfordjournals.org/cgi/content/abstract/30/4/1043

    The difficulty in defining disease is not restricted to impairments of mental function…


  57. So you are saying that if recent evidence that schizophrenia is associated with caudate nucleus abnormalities pans out it will become a neurological disorder and not a mental illness.

    Where did you get the idea that I said that?

    I just worked 20 days straight 10 hours per so I’m too tired to copy and paste your link tonight but “recent evidence schizophrenia is associated with…..” sounds like the usual neuroscience imaging phrenology that never pans out.

  58. Green, the dreams don’t frighten me anymore. Not sure why, they’re just as intense but, somehow, it’s like, oh, one of those again.

    Wrestled a rattle snake wrapped around my neck and strangled him with my bare hands last night.

  59. Job Guy, I think you gotta do whatever gets you through the day.

    You know, I don’t know how to get around to saying it, but anyone who has actually pulled somebody from the abyss knows that it’s real. The abyss, I mean. Sometimes it’s just a lapse, sometimes it’s a lifestyle, and sometimes the neurons just ain’t firing on all eight cylinders. Nonetheless, if you’ve ever dragged anyone in or out of the green ward at county lock down, the one with the frosted glass and the wire mesh inlay, it sort of puts things in a bit of a different perspective.

    I seen some really odd things in my day and let me assure you, normal is vastly underrated. I’ll take it.

  60. Scientology is proof that mental illness exists.

  61. Neu Mejican,

    “The main reason Szasz’s arguments are not worth taking seriously is that they are based on idiosyncratic definitions of almost all the key terms”
    Don’t you see? The definition of disease has been stretched (by the state) so that it can encompass anything at all. As Szasz quite correctly points out, without agreement on what constitutes disease, any talk of mental illness is difficult, to say the least.

    “Psychiatric illnesses, just like other illnesses, are based on assessment of the functioning of body systems serving body functions.”
    But psychiatric illnesses are not “just like” real illnesses, in so many ways. If you want to use the metaphor, then go ahead, but without the power to coerce, mental illness is useless as a strategy to render people not responsible for their behavior.

    “You do not need to deny the existence of impaired functioning in mental systems to raise the issues of coercion and consent for treatment.”
    I am aware of this, but simply think you are grossly mistaken. Who defines what constitutes mental impairment? If you agree that all coercive psychiatry is illegitimate, then why are you trying to legitimize all of the instrumentation the state psychiatric industry use?

  62. TWC, thanks.

  63. Thia,

    The definition of disease has been stretched (by the state)

    No. It was never as strict as you would like to believe.

    without agreement on what constitutes disease, any talk of mental illness is difficult, to say the least.

    Again, it is incorrect to assume that illness is a concept with clear boundaries. It is a very difficult concept to pin down generally…

    but without the power to coerce, mental illness is useless as a strategy to render people not responsible for their behavior.

    You assume that is the purpose of nosology in psychiatry, but it isn’t. The primary purpose is to find ways to help people. There may be abuse in particular cases, and the state may use the system for its purposes, but the system was not set up to control people, but to help them. This is where you go off the rails.

    Who defines what constitutes mental impairment? If you agree that all coercive psychiatry is illegitimate, then why are you trying to legitimize all of the instrumentation the state psychiatric industry use?

    The tight relationship you imagine between state interests and medical interests is a phantom. Most state involvement in the industry has been to restrain doctors in an effort to reduce harm to their patients, as the state recognizes the power they can have in over a patient (licensing is more about assurance of treatment quality than anything else…[no need to bring up the standard libertarian boiler plate about how it distorts the market]).

  64. Close italics…close italics… Damn

  65. Close italics…close italics… Damn

    Yeah, it started looking like you were having a dialogue with yourself. A sure sign that some psychiatric “help” is needed

  66. Yeah, it started looking like you were having a dialogue with yourself. A sure sign that some psychiatric “help” is needed

    No it isn’t!

  67. JMR,

    The inner dialogue is not indicative of mental illness…but thinking I will convince anyone of anything on this thread might be.

  68. 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.

  69. Thia,

    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?

    You are assuming that the point of diagnosing mental illness is to lock someone up and drug them. That is untrue on its face. A majority of treatment for mental illness is provided to people who are seeking help, not being institutionalized. The system is set up, actually, in such a way that many people seeking help can’t get it. The hurdle for coercive treatment is pretty steep in this country. It may not be steep enough. It may even be abused in particular cases. Recognizing that is not the same as asserting that all diagnosis of mental illness serves the purpose of confinement and coercive treatment.

    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.

    Strange assertions continue. 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. (I feel safe with an estimate with 10- 20% on the high end for those with serious mental illness that would result in the option even being considered…and they are a minority of patients seeking psychiatric treatment).

    Virchow’s definition of disease is still what pathologists look for.

    Pathologists are not the only ones interested in disease. Here is a standard medical definition of disease (emphasis added).

    disease /dis?ease/ (di-zez?) any deviation from or interruption of the normal structure or function of any body part, organ, or system that is manifested by a characteristic set of symptoms and signs and whose etiology, pathology, and prognosis may be known or unknown.

  70. I will point out that I did not search for that definition…it was the first one to pop up in a google search for “disease definition”

  71. 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

  72. Thia,

    I’ll grant that depression is not a disease, under a traditional definition thereof. So what?

    Why is it wrong for psychiatrists to prescribe medicines which both they and the patient believe increase functioning?


    All psychiatric treatment is coercive, actually or potentially.

    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.

  73. Thia,

    I have personal experience of working in these places

    Are you working under the assumption that most psychiatric treatment is inpatient?

    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.

    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.

    Guns don’t kill people, people do…
    Mental Illness doesn’t coerce people, people do…

    Or something like that.

  74. In other words, to note that a diagnosis of mental illness can be used as a weapon against a political enemy is not an argument against the reality of the underlying disease that diagnosis attempts to describe.

  75. A gun is an inanimate object.

    A gun can be used to kill people.

    A gun, however, is not death.

    A gun does not stop existing because it can be used to deny people their basic rights.

  76. Mental illness is a real thing.

    Mental illness can be used (illegitimately) as an excuse to take away people’s rights.

    Even worse (?), a diagnosis of mental illness can be used against someone who does not, in fact, have a mental illness as a strategy to take away their legitimate rights.

    Mental illness does not stop existing because of this potential.

  77. It is however true that psychiatrists today have no interest in the subject.

    If that is true, it seems odd that the put so much effort into the effort to improve diagnosis so that it is more fruitful in elucidating underlying etiology and effective treatments.

    http://www.dsm5.org/planning.cfm
    and
    http://appi.org/book.cfm?id=2292

  78. 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?

  79. pathology…etiology….who needs ’em!

    Disease can be thought of as the presence of pathology, which can occur with or without subjective feelings of being unwell or social recognition of that state. Illness as the subjective state of “unwellness” can occur independently of, or in conjunction with, disease or sickness (with sickness the social classification of someone deemed diseased, which can also occur independently of the presence or absence of disease or illness (c.f. subjective medical conditions). Thus, someone with undetected high blood pressure who feels to be of good health would be diseased, but not ill or sick. Someone with a diagnosis of late-stage cancer would be diseased, probably feeling quite ill, and recognized by others as sick. A person incarcerated in a totalitarian psychiatric hospital for political purposes could arguably be then said to not be diseased, nor ill, but only classified as sick by the rulers of a society with which the person did not agree. Having had a bad day after a night of excess drinking, one might feel ill, but one would not be diseased, nor is it likely that a boss could be convinced of the sickness.

  80. Where is the disease to be found in someone washing his hands fifty times a day?

    Depends.
    Is the hand-washing a) compulsive and something the patient wishes they didn’t do…or b) do they work in a restaurant?

    In case “a” above, the disease is in the patients brain. Their body system for control of behavioral impulse control is malfunctioning.

    Etiology is unclear, but quite likely involves the fronto-striatal system involved in impulse control. Active research is making progress. The condition appears to be responsive to medication, which improves outcomes for many who seek treatment.

  81. here is a joke, of sorts.

    Person A: Mental illness is a real thing

    Person B: Where is it?

    Person A: In your mind.

    Person B: No, it really isn’t. And it isn’t in the cadaver either. But from what you’ve been saying, it is quite definitely in your mind, for you believe in it so resolutely.

    I don’t remember the last time I heard someone say “medical illness is a real thing.” If mental illness is so real, then why do the public need to be told again and again (via state funding) that this is so?

  82. And, again, to be clear.
    Since this is an internet thread, I have diagnosed the above illness without including all the important contextual information that would be needed to do it properly. Assume, in my assertion, that the proper procedures were employed.

    Is is possible that even then, my diagnosis would be incorrect…yes, it is. But that is a whole nuther issue.

  83. my attempt at a joke surely takes second place to your answering of the hand-washing question! i hadn’t even thought of people working in a restaurant!!

  84. The real joke is that Thia thinks a cadaver has a mind.

    Mind = the functioning of the brain.

    Cadaver’s do not have functioning brains, so the do not have minds.

  85. Cadavers do not have minds, and I, apparently, can’t type.

  86. An tangent.

    Why is there no love for the (state enforced?) rule that the first letter in a sentence be capitalized?

    The rule helps segregate individual thoughts into units for ease of comprehension.

  87. What if I don’t work in a restaurant, but choose to wash my hands 50 times in one day anyway? Or, would my brain disease disappear as soon as I stopped washing my hands so regularly? Anyway, I thought we were talking about *mental* illness? Why then would my *brain* be the location of the disease? If so, it would be a real disease, and we both be happy.

    *I was so amused at your answer that I didn’t think to capitalize.

  88. Thia,

    That last comment is general.
    Your last post just reminded me of the tendency on H&R…related to the LatinoInvasion lack of spaces thing.

  89. It sounds like you work in the mental health profession. Is it rude to ask if this is the case?

  90. I thought we were talking about *mental* illness? Why then would my *brain* be the location of the disease?

    Are you under the impression that your mind is some magical spirit that inhabits your earthly body?

    The mind is nothing more, nor less, than the activity of the brain.

    As for your question…washing your hands is not the issue. Compulsive behaviors are not determined to be compulsive solely on frequency of occurrence. There needs to be the whole “I can’t stop myself” thing going on.

    But you know that and are just being disingenuous now, right?

  91. Thia,

    It is not rude to ask.

    And no, strictly, strictly speaking, I do not work in the mental health profession…although I work alongside many who do.

    I do research in diagnosis and treatment of developmental disabilities.

    An area which shares many of the challenges of psychiatry.

  92. I don’t remember the last time I heard someone say “medical illness is a real thing.” If mental illness is so real, then why do the public need to be told again and again (via state funding) that this is so?

    The public suffers from the disease of psychiatry denialism. The etiology of which is trusting their intuition and experience more than the command of authority.

  93. “The mind is nothing more, nor less, than the activity of the brain.”
    Well, that is quite a philosophical position to take, especially with regard to human freedom and responsibility. No time for that here though.

    So you actually believe in addiction too? Sometimes I feel like I can’t stop myself from going to work, and wished to God that I could just go back to sleep. As Thomas Szasz likes to say, mutatis mutandis…

  94. The public doesn’t believe in mental illness…what, are you all crazy? ;^)

    The main source of the confusion about “depression” versus “Major Depression” is that the public believes the first to be an example of the second. Mental Health is not a state sponsored myth being foisted on the public against their better judgment (unless you think Dr. Phil is a covert state agent, I guess).

  95. You know, I got the feeling we could have an interesting chat, and then you go and spoil it all by saying something like “Mental Health is not a state sponsored myth being foisted on the public against their better judgment”

  96. “The mind is nothing more, nor less, than the activity of the brain.”
    Well, that is quite a philosophical position to take, especially with regard to human freedom and responsibility. No time for that here though.

    Not really.
    It is pretty much axiomatic.
    Cartesian dualism hasn’t been taken seriously in the mainstream of science for quite a time now.

    Of course, Szaszian thinking may require dualism to make sense.

  97. I am curious, btw, why you think that an embodied mind is somehow a threat to human freedom and responsibility.

    The premise that you are free do act and are responsible for your actions does not require dualistic views on mind/brain.

    And the existence of mental disorder does not, automatically, exempt one from responsibility for one’s actions.

    It’s not like the embodied mind support assertions like “I didn’t do it my brain did…”

    Quite the opposite, in fact.

  98. Szasz, and anyone who takes him seriously, is a crank.

  99. JT,

    if by “crank” you mean “zealously eccentric”, that would describe most libertarians.
    It doesn’t mean Szasz is wrong.

  100. crank

    Look, if you intend by that utilization of an obscure colloquialism to imply that my sanity is not up to scratch….

  101. 100 comments and no one pointed out that “SSNI”s don’t exist?

  102. Jamie,

    Because they do…
    e.g., Strattera

    http://www.addcoach4u.com/adhdmedicationco.html

  103. Of course, SNRI is a more common acronym…

  104. 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.

  105. It is the fact that if your symptom is severe, the placebo stops working with the symptom. So the pill has the effect to the disease or symptom of the patient much .. don’t forget to take the pill.

  106. It is the fact that if your symptom is severe, the placebo stops working with the symptom. So the pill has the effect to the disease or symptom of the patient much .. don’t forget to take the pill.

  107. It is the fact that if your symptom is severe, the placebo stops working with the symptom. So the pill has the effect to the disease or symptom of the patient much .. don’t forget to take the pill.

  108. It is the fact that if your symptom is severe, the placebo stops working with the symptom. So the pill has the effect to the disease or symptom of the patient much .. don’t forget to take the pill.

  109. 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.

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