Headlines From Psychology, Part 4

Psychology hit the actual headlines last week, with Sharon Begley’s “The Depressing News About Antidepressants” in Newsweek. The story is that, if you look at all the evidence, not just the “successful” trials, SSRIs like Prozac and Paxil do not work better than a placebo for mild and moderate depression. Begley also tells the story as if she’s sorry to break the news and spoil the placebo effect. Here’s my version of the headlines from this story:

Pharmaceutical Companies Have Known For At Least Ten Years That SSRIs Work No Better Than Placebos: At least, anyone there who understood statistics and paid any attention to their research.

The Idea That SSRIs Are Better Than Placebos Was Propagated By Publishing Only the “Successful” Trials: This, obviously, was quite unethical.

The FDA Almost Certainly Knew That SSRIs Were No Better Than Placebos, Too: They had all of the research. Perhaps they did not read it.

People Who Read Psych Journals Knew SSRIs Were No Better Than Placebos Two Years Ago: The news caused a stir in my undergrad psych lab in 2008.

We Do Not Know What Causes Depression: The idea that depression has to do with the neurotransmitter serotonin was based largely on the (incomplete) evidence that SSRIs (selective serotonin re-uptake inhibitors) cured depression. In fact, we have pretty limited knowledge of what goes on inside a living brain. In fact, we have no ethical way to measure how much serotonin or any other neurotransmitter is where inside anyone’s living brain, so when a doctor tells you something like, “You are depressed because you have overactive serotonin re-uptake mechanisms,” they are passing on speculation, not science.

If You Recovered From Mild to Moderate Depression While On An SSRI, It Was Probably Your Own Hope That Lifted You Out: The thing about placebos is that they work pretty well. If you benefited from the placebo effect, it was your own strength, your own hope, that made the difference. You overcame that challenge. I think that’s pretty cool.

While SSRIs Do Not Treat Depression Better Than Placebos, They Do Have Side Effects: Here’s a list from wikipedia: Decreased or absent libido, Impotence or reduced vaginal lubrication, Difficulty initiating or maintaining an erection or becoming aroused, Persistent genital arousal disorder despite absence of desire, Muted, delayed or absent orgasm (anorgasmia), Reduced or no experience of pleasure during orgasm (ejaculatory anhedonia), Premature ejaculation, Weakened penile, vaginal or clitoral sensitivity, Genital anesthesia, Loss or decreased response to sexual stimuli, Reduced semen volume, Priapism (persistent erectile state of the penis or clitoris)anhedonia , apathy, nausea/vomiting, drowsiness or somnolence, headache, bruxism (involuntarily clenching or grinding the teeth), extremely vivid and strange dreams, dizziness, fatigue, mydriasis (pupil dilation), urinary retention, changes in appetite, changes in sleep, weight loss/gain (measured by a change in bodyweight of 7 pounds), may result in a double risk of bone fractures and injuries, changes in sexual behaviour,increased feelings of depression and anxiety (which may sometimes provoke panic attacks), tremors (and other symptoms of Parkinsonism in vulnerable elderly patients), autonomic dysfunction including orthostatic hypotension, increased or reduced sweating, akathisia, liver or renal impairment, suicidal ideation (thoughts of suicide), photosensitivity (increased risk of sunburn), Paresthesia, Mania, hypomania, sexual dysfunction such as anorgasmia, erectile dysfunction, and diminished libido, a severe and even debilitating withdrawal syndrome, a slight increase in the risk of self-harm, suicidal ideation, and suicidality in children, neonatal complications such as neonatal abstinence syndrome (NAS) and persistent pulmonary hypertension, and platelet dysfunction.

Until Your Medicated Kids Are Old, We Will Not Know What All of the Side Effects of Treatment by SSRIs Are: This is true for any new drug, and it’s worth considering. If your child is on Prozac or other new drug, they are essentially part of a massive experimental trial.

Pharmaceutical Companies Pay for Psychiatric Educations: Why would it surprise anyone that treatment equals drugs in this case?

Most Antidepressant Prescriptions Written by Health Care Providers With No Significant Psychiatric Training: GPs, OBGYNs, pediatricians, etc account for 80% of SSRI prescriptions.

darlene Says:

February 20, 2010 at 9:07 am

I knew it!

thefifthone Says:

February 20, 2010 at 11:30 am

First of all, I totally agree with your overall point–antidepressants are more ‘experimental’ and less effective than anyone has been letting on. AND medicating developing minds with psych meds that cannot currently be proven to be non-harmful is ludicrous! Also, I think that it is ridiculous (I really was shocked to hear it) for anyone besides a psychiatrist, or properly trained psychotherapist to be prescribing anti-depressants–or any psych drug for that matter.
However, let’s be realistic here: medications all have side effects. Until they perfect molecular encapsulation (coming soon I’m told) there is no way to avoid medication side effects. That having been said, pharmaceutical companies are required to report ANY instance of side effects no matter how small the margin, at least that is what I have been told. With that in mind, it seems to me that many, if not all, of those side effects that you listed are symptoms of depression–so it would stand to reason that people who are being ‘treated’ for depression would commonly experience those problems since, as you pointed out, the medication is no more effective than a placebo.
I don’t mean to be a pain in the neck or anything, but it seems that the way you presented the information is no less biased than the lady who is “sorry to break the news” to the ignorant public. I imagine that the tone of your statement is intentional as a hard-shot at the arrogant, frivolous, malpractice-worthy behavior of the practitioners and pharmaceutical companies that have propagated the anti-depressant myth. It just seems a little bit self-congratulatory. Then again, maybe I’m just feeling defensive again.

obnocto Says:

February 20, 2010 at 12:11 pm
Well said, Ben. I can certainly get ranty about this subject!

My point in listing the side effects was to point out that just because they don’t work better than placebos for mild and moderate depression, they are not inert, so any physician who prescribes them to someone who is not severely depressed may not be using appropriate risk/benefit analysis.

Also, it’s interesting to me that physicians who understand this are in a bind, because it is illegal to prescribe placebos (without ruining the effect by announcing that this is a placebo) but their patients would be much better off, because placebos tend to be side-effect free.

Another point is that pretty much everyone “knows” that depression is a biological serotonin imbalance, and will continue to “know” that for many years because of the unscrupulous withholding of evidence by pharma companies, their aggressive “education” (read “advertising/indoctrinating”) of health care providers and the public, and the lack of skepticism and science savvy of those providers and the public. It’s shameful. And people have gotten very, very rich from it.

Last, as a mental-health provider in training, I need to be on the lookout for what we will be ashamed of having done, much as many surgeons still alive feel about the 40,000 lobotomies performed in the US. I suspect it will be the mass drugging of kids that is currently going on.

Nathen