Bernards Voices

Continuing the topic of Judith Miller’s, We’ve Got Issues, Alison Gopnick writes in Slate:

Sometimes, at least, Warner seems to think that her epiphany licenses the conclusion that we should indeed be giving children drugs for this range of psychological problems (though she’s fuzzy about this). But nowhere in the book does she explain or evaluate the scientific evidence that could actually help answer this question. In fact, there are far more references to newspapers than to scientific journals, and she consistently treats an anecdote or an interview as if it has the same weight as a meta-analysis or a randomized clinical trial.

But everything about human beings, cultural or individual, innate or learned, is in our brains. Loss and humiliation change our serotonin levels, education transforms our brain connections, social support affects our cortisol. Neurological and psychological and social processes are inextricable. The work of psychological science is to identify causes at many levels of description—social, cultural, individual, and neurological.

Syndromes like autism, ADHD, or dyslexia are like “fever” or “dropsy,” rather than like malaria or polio. They are names for somewhat incoherent collections of symptoms rather than clearly identified causes.

The trouble is that these therapies take time and attention and funding, and they are actually discouraged by the American health care system: It is almost always easier to get reimbursed for drug treatments than for behavioral ones.

Some comments from readers:

Robyn: Did the reviewer read the same book I did? It sure doesn’t seem so. In any event, at least Ms. Warner supplied references (pages upon pages of them) of her extensive research (including the MTA study to which the reviewer refers, though more thoroughly and in much greater detail). Where are the reviewer’s references?

Gopnick replies: The MTA study had extremely careful and rigorous diagnostic criteria for ADHD and a carefully designed 14-month long drug intervention including placebo-controlled initial trials, as well as carefully designed behavioral interventions. The results are complicated but the bottom line is that 1) all groups improved over time 2) in the short term medication and combined medication and behavior therapy were better at dealing with direct ADHD symptoms such as teacher reported inattentiveness than therapy alone. However, therapy and medication were about equally effective in improving social adjustment and school achievement. 3) The effects were different in different subgroups of children. 4) In the long term, 3 to 8 years, there [were no differences in?] effect of different treatments. 5) This was true even when the degree of continued drug use was taken into account. 6) The best predictor of long term outcomes was the social support and income of parents and the severity of the initial symptoms. 7) Many of the study authors, though certainly not all, had received funding or otherwise worked with the pharmaceutical companies.

So my take as a scientist is that the very best study of the clearest case with the most rigorous diagnoses at this stage has equivocal results at best for long term efficacy of drugs, as compared to other non-chemical intervention or policies.

On February 12, 2010 WNYC’s Leonard Lopate interviews psychotherapist and author Gary Greenberg.  Greenberg is covered by Harpers, The New Yorker, NPR, so he has established himself as a voice people listen to.

More and more people have begun to ask themselves if they are happy, and if their unhappiness is a disease that can—and should—be treated by medication. Gary Greenberg discusses depression, drawing on medical scholarship, his 25 years as a psychotherapist, and his own experience with depression to show how it has been marketed as a widespread chronic disease, packaged by scientists, doctors, and marketing experts. In Manufacturing Depression: The Secret History of a Modern Disease Greenberg asks what we gain and lose with this approach.

I had to grit my teeth for the first 20 minutes of this interview, until Lopate and Greenberg got past their soundbite Q&A to the more nuanced discussion. By the end, I thought this was a useful podcast, but if I had stopped too soon I would been left stewing in my own reinforced biases and opinions. Here are my cryptic notes from their conversation as it unfolded:

• Depression is a manufactured medical condition, a manufactured disease, not a real one.
• This has been motivated by big-pharma greed for profits.  About 20 years ago, the FDA changed their rules and drug companies had to not only show their drugs were safe, but they also had to say which disease they were fixing.  so big pharma needed a disease in order to sell their anti-depressants.
• Often times people are just unhappy, experiencing sorrow, and it is caused by their environment (death, loss of job, divorce…).  As a talk therapist, Greenberg wants to make sure that these external causes are not masked by drugs but dealt with in therapy, so the person then adjusts their environment and feels better.
• The bio-chemical, molecular causes of depression have not been scientifically identified or proven (so it is not a disease).  This point really irritated me, because we are constantly treating (and saving or at least improving lives) medical conditions which are not completely understood at the molecular level.
• Greenberg then acknowledges that in some cases there may be real bio-chemical causes to depression (not just an external event making us feel sad).
• And then the discussion goes to: some people get stuck feeling sad, and don’t get better, and that “getting stuck” also might have bio-chemical causes that we don’t yet understand.
• Greenberg says his own research methodology in defense of the book is historical, and not scientific.  He traces the development over the last 100 years of the drugs, the treatments, the governmental and industrial policies, and draws conclusions.  He, as the author, is a historian not a scientist.
• Greenberg himself suffers from depression.  He participated in a trial for omega-3 fatty acid.  He was on the placebo, but the doctors concluded he was on the drug, because he got better.
• Greenberg does refer his patients, who are depressed, and who he thinks warrant medication, to psychiatrists.

Greenberg is not totally against anti-depressants.  His main point is that he wants people to realize why they are taking them.  These drugs which effect emotions, consciousness, personalities … their effectiveness is often influenced by the point of view of the patient.  So that if the patient thinks they have a disease called depression, that belief itself changes the way the drugs work and the way the patient feels.  Greenberg would rather the patient think they are not sick, but are taking the anti-depressant to “lift and stabilize their mood.”  Greenberg also implies (or says directly) that if the patient takes this latter position, that they will be in a better position to tackle the other external, environmental issues that cause depression … exercise, eat well, find gainful employment, repair or get into a new relationship.  He also mentioned that he couldn’t believe (or he was amazed, astonished, or amused) that depressed people would trade diminished sex drive for feeling better taking a drug–I guess implying that sex is the better drug.

If you do listen to the podcast, and draw different conclusions, please comment and correct my notes.

I agree with Greenberg that it is important for the patient to not view the anti-depressant as a silver bullet which will “cure” everything.  Talk therapy is helpful (necessary) in identifying adjustments to your environment (and the way you approach your environment) that reduce depression.

The March 1 New Yorker has a book review of Manufacturing Depression, which I will read shortly.

While Greenberg was writing his book, he published an article in Harpers, which I read at the time.  He was interviewed then by NPR’s Jane Clayson on On Point.

The broadcast motivated 68 comments by listeners, so that’s a good sign that the content was controversial and provocative.

I like this comment the best.  Mike said, better than I:

What difference does it make if depression is environmental in cause? A gunshot wound is environmental in cause. Does this mean it should not be treated?

Another useful comment from k:

i take issue with the statement that “anti depressants don’t work’ – the study showed that anti depressants do not work for those who are not truly depressed and do not need them . Anti depressants DO WORK for those who are truly in need of them.

From a short piece in today’s The New York Times, Acupuncture May Ease Depression in Pregnancy:

Up to a quarter of all women suffer from depression during pregnancy, and many are reluctant to take antidepressants. Now a new study suggests that acupuncture may provide some relief during pregnancy, even though it has not been found to be effective against depression in general.

The lead author, Rachel Manber, a professor of psychiatry and behavioral sciences at Stanford, said the results suggested that some symptoms of depression during pregnancy might be related to physical discomfort that is alleviated by acupuncture. Still, the results were striking, she said.