Antidepressants, Hoax or Opportunity?

It’s been Fifteen years after Dr Irving Kirsch published his landmark study that showed that, in cases of mild to moderate depression, antidepressants are no more effective that a sugar pills. Yet, as of 2013, these drugs are still prescribed at a rate of 270 million prescriptions per year, costing $9.4 billion. Over the years Dr Kirsch has had to fend off numerous challenges to his results, but he has continued his research, and continues to publish with his book “The Emperor's New Drugs: Exploding the Antidepressant Myth,” reviewed here. Other studies have supported his results. In this article, Antidepressants a Complicated Picture, published on the National Institute of Mental Health web site, Dr Thomas Insel says “Mild depression tends to improve on placebo so that the difference between antidepressant use and placebo effect is very small, or at times, absent.” The entire controversy is summarized in this 60 Minutes segment: Treating Depression is There a Placebo Effect?  (These finding relate to people with mild to moderate depression, antidepressants are shown to have greater efficacy in cases of severe depression)

The main resistance to these results seems to come from the medical community (Once you get away from the drug companies with their vested interests), and it is two fold: On one hand, the doctors see their patients get better on the drug, and on the other, doctors worry that “If that doesn’t work, what do we give them?” The answers to both concerns is actually the same, and revolve around the placebo effect, what it is and how it works.

It is a common misconception that placebos do nothing, and that is simply not true. While it is true that placebo drugs have no active ingredients, and placebo operations are only pretend, the effects they have are very real. The 60 Minutes segment above described an study where patients were given real and placebo knee operations, and the results, two years down the road, were exactly the same for real and placebo treatments. This is not say there was no significant improvements, but that the improvement were same whether the patient had the operation, or only believed they had the operation. The point is that most people given antidepressants get better, but people given placebos also improve, at exactly the same rate. But since antidepressants cost many times more than the sugar pills and can have serious side effects, are we really doing no harm by pretending they work?

Now we come to the other objection, that we have to give them something to make them feel better. Therein lies the conundrum. You see, giving a patient a placebo and calling it a drug, is unethical, by today’s standards, because you a lying to the patent. But it is apparently perfectly ethical to prescribe a placebo, if the doctor doesn’t know it’s a placebo. Which is, in effect, the situation we have now, where we spend billions of dollars a year on drugs with no more potency than sugar, and nasty side effects, but that's ok because we believe they work.

What, exactly, is the placebo effect and how does it work, and why aren't we throwing the full power of our medical system behind using it to improve patient health? You can find lots of definitions of placebo on the web, but the fact is that nobody knows how it works. But the stone cold fact is, it does, being demonstrated by the examples above.

So, why isn’t the medical establishment standing up and taking notice? I think there are a couple of reasons, the first one is that we still hang onto ideas of the nineteenth century that say that mental problems are a moral failing, that things like depression are symptoms of a “weak mind.” While we say we are more enlightened today, the perception persists is that a disease isn’t “real” unless there is a measurable, objective, biochemical basis for it. There is still a real stigma attached to mental health issues and treatment.

The other reason that we don’t exploit the placebo effect is the materialist mindset of our scientific community. Our Western mindset insists that all phenomena relating to consciousness arise from the physical brain, and, therefor, all emotional and mental issues must be curable by manipulation of that physical brain. In this model, the mind is completely separate from the body, and, despite the huge body of evidence, we still find the idea of involving the mind in treating mental and physical problems distasteful. We are so much more comfortable taking a pill, or having an operation, because that is a “real” treatment.

I really hope to see this change in my lifetime. I expect spiraling health care costs will force a shift in attitudes, if only to save money. Think about it: We are spending over $9 billion a year on the myth that depression can be treated chemically. And that is just one treatment. How many other pills, treatments, operations out there are equally expensive and also no better than a placebo. Can we really afford to keep going down this path? The biggest obstacle here, is that all the large players in the medical system have strong interests in keeping things just as they are, since introducing any new alternative treatment methods will, inevitably, take money and business from the current players.

I am seeing these attitudes shifting, slowly, and I hope we see some significant progress on this before the our health system implodes.