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Not so sure when there's a pill, there's a way

Over the past quarter of a century, Americans have been gobbling up antidepressants like M&Ms. Now there are scientists claiming that these same antidepressants are about as effective as M&Ms. Oddly enough, the argument has all the zeal of a religious debate.

A few weeks ago Dr. Peter Kramer's essay "In Defense of Antidepressants" was framed in red and given the lead page of the New York Times Sunday Review section. As always with essays on depression, the piece hit the jackpot on hits and comments.

Back in the early '90s, Kramer was the John the Baptist of the new antidepressants, selective serotonin uptake inhibitors (SSRIs). In his blockbuster bestseller, Listening to Prozac, the Brown University clinical professor of psychiatry argued that Prozac provided a near miraculous elixir for depression. Debate over the book exploded in part because Kramer suggested that the recently developed antidepressants were so pure and potent that even people who were not clinically depressed ought to consider going to the medicine cabinet. Like some other substances, both legal and illegal, ingesting Prozac made some feel as though they were born again and becoming their true selves. Other Prozac panegyrics followed, such as Lauren Slater's Prozac Diary.

By 2008, a jaw-dropping 8.9 percent of Americans were on antidepressants. But like most wonder drugs, Prozac and its spinoffs have hit the wall. While they provide dramatic assistance for some, they are not nearly as effective for depression as was originally believed. A number of recent studies indicate that the vulnerary powers of Prozac-type drugs are essentially due to nothing more than a placebo effect. As an article in Newsweek hinted, the effects of SSRIs are all in your head.

With a career-long vested interest in promoting these medications, Kramer is understandably somewhat defensive about this topic. While I do not believe that he is persuasive, Kramer contends that research casting doubt upon antidepressants is flawed, largely on the grounds of problems with recruiting good subjects for clinical drug trials involving people suffering from mild depression.

As Marcia Angell points out in her review of Irving Kirsch's book, The Emperor's New Drugs: Exploding the Antidepressant Myth, in 42 trials involving six different SSRIs (that is, Prozac, Paxil, Zoloft, Celexa, Serzone and Effexor) that were submitted to the FDA, "overall, placebos were 82 percent as effective as the drugs." Should we believe that recruitment was the problem in all 42 of these drug trials? While there are many individuals who literally swear by SSRIs, according to this analysis and others, at a population level there is scant reason to believe that they are much more effective than a placebo in treating mild depression.

Unlike in decades past when Kramer and others promoted Prozac as a panacea, there is today a great deal of debate about the powers of these potions. Moreover, almost every pharmacologist will tell you, "there are no free rides with drugs." Where it was once believed that SSRIs were relatively free of side effects, it is now acknowledged that these drugs can have serious adverse consequences.

Still, Kramer insists that Prozac and other such drugs do in fact help in alleviating profound melancholy and are therefore worth the risks. However, he goes further and cautions, "it is dangerous for the press to hammer away at the theme that antidepressants are placebos. They're not. To give the impression that they are is to cause needless suffering."

The warning that one or another idea is "dangerous" is almost always a dangerous idea. In the squabble over the place of pills in adjusting psychic life, it has often been suggested that the doubting Thomases of pharmacopeia are, as Kramer puts it, "the cause of needless suffering" because when expressed, our doubts inhibit the afflicted from seeking out medical assistance.

For many, belief in the power of drugs has become an article of faith. Indeed, it used to be that when you taught a class in philosophy, students would begin fidgeting when questions about God's existence loomed up. These days, most students can yawn at those problems. But just float the question of the efficacy of psychotropic drugs and you'll have young people squirming in their seats and sometimes even storming out of the room.

A few years back, I taught a class in which nearly two-thirds of the students volunteered that at one point or another they had been on psychotropic medications. Asked to reflect, the overwhelming response was that their mood problems or difficulties in concentrating were a product of that now passe piety about a "chemical imbalance." Playing the devil's advocate, I argued that just because aspirin helps your headache, it does not follow that your brain is aspirin deficient. Emotional investment in their pills and the narrative about a chemical imbalance was so robust that I actually had to walk the discussion back and calm students down.

For many, belief in the possibility of divine assistance has been replaced by a blind faith in the idea that where there is a pill there's a way. That this kind of trust in pharmaceuticals has become an important article of secular faith is echoed in the fact that seriously questioning their usefulness and value can, a la Kramer, trigger a response that is not far from the charge of heresy.

Kramer and his apostles see no difficulty with prompting people to seek out medical assistance for psychiatric problems. And yet, they knit their brows and wag their fingers about causing "needless suffering" at anyone daring to suggest that given the now widely acknowledged possibility of serious side effects and questions about their effectiveness, you may want to think thrice about starting a regime of one of the Prozac family.

But the warning about "needless suffering" is a sword that cuts two ways. There are many walking under the black sun of depression who would do better to find someone to talk with about their inexplicable sadness than to scurry from doctor to doctor adjusting their meds. There are throngs who would prefer spiders on their backs to having to open up to a stranger about their inner life. And for many of these people, inflated claims about drugs has unfortunately encouraged them to distance themselves from the need to think about their lives.

Gordon Marino is professor of philosophy and director of the Hong Kierkegaard Library at St. Olaf College. He is also an ethics fellow at the Center for Clinical and Cognitive Neuropharmacology, University of Minnesota. His Ethics: The Essential Writings was recently published by Modern Library.

Not so sure when there's a pill, there's a way 08/06/11 [Last modified: Saturday, August 6, 2011 4:31am]
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