I finally got around to reading Louis Menand’s article on psychiatry in the March 1, 2010, The New Yorker. The article covers the same ground, though much more comprehensibly, that many of my recent posts (also Jan. 13, Jan. 6 ) have–kicking off with a review of Gary Greenberg’s Manufacturing Depression (2010).  It is a worthwhile read.  Menand asks all the questions we’ve been asking, and if he leaves us with any point of view it is that “science will never answer them.”

Do not read the psychiatric literature. Everything in it, from the science (do the meds really work?) to the metaphysics (is depression really a disease?), will confuse you. There is little agreement about what causes depression and no consensus about what cures it. Virtually no scientist subscribes to the man-in-the-waiting-room theory, which is that depression is caused by a lack of serotonin, but many people report that they feel better when they take drugs that affect serotonin and other brain chemicals.

Other books covered in the article:

• Irving Kirsch’s The Emperor’s New Drugs (2010)
• Christopher Lane’s Shyness (2007)
• David Healy’s The Antidepressant Era (1997)
• Andrea Tone’s The Age of Anxiety (2009)
• David Herzberg’s Happy Pills in America (2008)
• Jerome Wakefiled and Allan Horwitz’s The Loss of Sadness (2007)
• Peter Kramer’s Against Depression (2005) and Listening to Prozac (1994)
• and older books from the 50s and 60s.

As I read my way through the article, I found myself often agreeing with the skeptical point of view, but I had to kick myself back awake.  Mental illness is real.  Bad things can happen.  People’s lives get destroyed.  The fact that there is energetic debate within and outside the industry shouldn’t lead people to the conclusion that these diseases are not real and shouldn’t be treated with the best tools available.

As a branch of medicine, depression seems to be a mess. Business, however, is extremely good. Between 1988, the year after Prozac was approved by the F.D.A., and 2000, adult use of antidepressants almost tripled. By 2005, one out of every ten Americans had a prescription for an antidepressant. IMS Health, a company that gathers data on health care, reports that in the United States in 2008 a hundred and sixty-four million prescriptions were written for antidepressants, and sales totalled $9.6 billion.

What a successful [drug trial] typically shows is a small but statistically significant superiority (that is, greater than could be due to chance) of the drug to the placebo.  So how can Kirsch [in The Emperor's New Drugs] that the drugs have zero medicinal value?

His answer is that the statistical edge, when it turns up, is a placebo effect.  Drug trials are double-blind: neither the patients (paid volunteers) nor the doctors (also paid) are told which group is getting the drug and which is getting the placebo.  But antidepressants have side effects, and sugar pills don’t.  Commonly, side effects of antidepressants are tolerable things like nausea, restlessness, dry mouth, and so on.  (Uncommonly, there is, for example, hepatitis; but patients who develop hepatitis don’t complete the trial.)  This means that a patient who experiences minor side effects can conclude that he is taking the drug, and start to feel better, and a patient who doesn’t experience side effects can conclude that she’s taking the placebo, and feel worse.  On Kirsch’s calculation, the placebo effect—you believe that you are taking a pill that will make you feel better; therefore, you feel better—wipes out the statistical difference.

One objection to Kirsch’s argument is that response to antidepressants is extremely variable. It can take several different prescriptions to find a medication that works. Measuring a single antidepressant against a placebo is not a test of the effectiveness of antidepressants as a category. And there is a well-known study, called the Sequenced Treatment Alternatives to Relieve Depression, or STAR*D trial, in which patients were given a series of different antidepressants. Though only thirty-seven per cent recovered on the first drug, another nineteen per cent recovered on the second drug, six per cent on the third, and five per cent after the fourth—a sixty-seven-per-cent effectiveness rate for antidepressant medication, far better than the rate achieved by a placebo.

Kirsch suggests that the result in STAR*D may be one big placebo effect. He cites a 1957 study at the University of Oklahoma in which subjects were given a drug that induced nausea and vomiting, and then another drug, which they were told prevents nausea and vomiting. After the first anti-nausea drug, the subjects were switched to a different anti-nausea drug, then a third, and so on. By the sixth switch, a hundred per cent of the subjects reported that they no longer felt nauseous—even though every one of the anti-nausea drugs was a placebo.

Later studies have shown that patients suffering from depression and anxiety do equally well when treated by psychoanalysts and by behavioral therapists; that there is no difference in effectiveness between C.B.T., which focusses on the way patients reason, and interpersonal therapy, which focusses on their relations with other people; and that patients who are treated by psychotherapists do no better than patients who meet with sympathetic professors with no psychiatric training. Depressed patients in psychotherapy do no better or worse than depressed patients on medication. There is little evidence to support the assumption that supplementing antidepressant medication with talk therapy improves outcomes. What a load of evidence does seem to suggest is that care works for some of the people some of the time, and it doesn’t much matter what sort of care it is. Patients believe that they are being cared for by someone who will make them feel better; therefore, they feel better.

In 1980, the F.D.A. required that anxiety medications carry a warning stating that “anxiety or tension associated with the stress of everyday life usually does not require treatment with an anxiolytic.” The anxiety era was over. This is one of the reasons that when the SSRIs, such as Prozac, came on the market they were promoted as antidepressants—even though they are commonly prescribed for anxiety. Anxiety drugs had acquired a bad name.

The position behind much of the skepticism about the state of psychiatry is that it’s not really science. “Cultural, political, and economic factors, not scientific progress, underlie the triumph of diagnostic psychiatry and the current ‘scientific’ classification of mental illness entities,” Horwitz complained in an earlier book, Creating Mental Illness (2002), and many people echo his charge. But is this in fact the problem? The critics who say that psychiatry is not really science are not anti-science themselves. On the contrary: they hold an exaggerated view of what science, certainly medical science, and especially the science of mental health, can be.

Progress in medical science is made by lurching around. The best that can be hoped is that we are lurching in an over-all good direction.

The DSM lists only disorders—clusters of symptoms, drawn from clinical experience—not diseases. Since people manifest symptoms in an enormous variety of combinations, we get a large number of disorders for what may be a single disease.

Depression is a good example of the problem this makes.  A fever is not a disease; it’s a symptom of disease, and the disease, not the symptom, is what medicine seeks to cure.  Is depression—insomnia, irritability, lack of energy, loss of libido, and so on—like a fever or like a disease?  Do patients complain of these symptoms because they have contracted the neurological equivalent of an infection?  Or do the accompanying mental states (thoughts that my existence is pointless, nobody loves me, etc.) have real meaning?  If people feel depressed because they have a disease in their brains, then there is no reason to pay much attention to their tales of woe, and medication is the most sensible way to cure them.  Peter Kramer, in Against Depression (2005), describes a patient who, after she recovered from depression, accused him of taking what she had said in therapy too seriously.  It was the depression talking, she told him, not her.

Depression often remits spontaneously, perhaps in as many as fifty per cent of cases; but that doesn’t mean that there isn’t something wrong in the brain of depressed people.

Depression is episodic. It starts and stops. Then starts again. Kramer argues that is progressive, and episodes worsen (deepen) over time.

In the case of mood disorders, it is difficult to find a test to distinguish mental illness from normal mood changes. The brains of people who are suffering from mild depression look the same on a scan as the brains of people whose football team has just lost the Super Bowl.

Given the current scanning technology, and where and how we choose to look.

Science, particularly medical science, is not a skyscraper made of Lucite. It is a field strewn with black boxes. There have been many medical treatments that worked even though, for a long time, we didn’t know why they worked—aspirin, for example. And drugs have often been used to carve out diseases. Malaria was “discovered” when it was learned that it responded to quinine. Someone was listening to quinine. As Nicholas Christakis, a medical sociologist, has pointed out, many commonly used remedies, such as Viagra, work less than half the time, and there are conditions, such as cardiovascular disease, that respond to placebos for which we would never contemplate not using medication, even though it proves only marginally more effective in trials. Some patients with Parkinson’s respond to sham surgery. The ostensibly shaky track record of antidepressants does not place them outside the pharmacological pale.

At the bottom of column 15, in a 18 column article, we have arrived at the most important part of the article for me. I hope everyone reads this far.

Many people today are infatuated with the biological determinants of things. They find compelling the idea that moods, tastes, preferences, and behaviors can be explained by genes, or by natural selection, or by brain amines (even though these explanations are almost always circular: if we do x, it must be because we have been selected to do x). People like to be able to say, I’m just an organism, and my depression is just a chemical thing, so, of the three ways of considering my condition, I choose the biological. People do say this. The question to ask them is, Who is the “I” that is making this choice? Is that your biology talking, too?

Yes, your biology, and your psychology, and your philosophy talking.

The decision to handle mental conditions biologically is as moral a decision as any other.

The recommendation from people who have written about their own depression is, overwhelmingly, Take the meds! It’s the position of Andrew Solomon, in The Noonday Demon (2001), a wise and humane book. It’s the position of many of the contributors to Unholy Ghost (2001) and Poets on Prozac (2008), anthologies of essays by writers about depression. The ones who took medication say that they write much better than they did when they were depressed. William Styron, in his widely read memoir Darkness Visible (1990), says that his experience in talk therapy was a damaging waste of time, and that he wishes he had gone straight to the hospital when his depression became severe.

Don’t hesitate to ask someone for help.