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A Recent Article in the NY Times Discusses the Problems with Antidepressants
Dr Peter Kramer at Brown University wrote an article in the past Sunday NY Times Opinion Review: In Defense of Antidepressants – It's a worthy read on several levels, not the least of which is the fact that it puts into perspective much of the outright gossip and diatribe about psych meds – specifically antidepressants. Bottom line: antidepressants do work predictably and exceedingly well – unless there are other comorbid issues, as we have so frequently documented here at CorePsych Blog.
Do take a moment to review Kramer's antidepressant comments and my response comment in the NYT here below.
Said Kramer:
Last month brought an especially high-profile debunking [of antidepressants]. In an essay in The New York Review of Books, Marcia Angell, former editor in chief of The New England Journal of Medicine, favorably entertained the premise that “psychoactive drugs are useless.” Earlier, a USA Today piece about a study done by the psychologist Robert DeRubeis had the headline, “Antidepressant lift may be all in your head,” and shortly after, a Newsweek cover piece discussed research by the psychologist Irving Kirsch arguing that the drugs were no more effective than a placebo.
The Study Efficacy Numbers Just Don't Match Office Experience
– Yet the unwritten, unhappy circumstance that distorts the efficacy numbers: Depression, like ADHD, often presents as far more than simply “depression,” with many comorbid and contributory problems that are often completely overlooked, as many myopically treat only the depressive symptoms that appear on the obvious surface. Untreated comorbid conditions do perpetuate the depressive symptoms – and frequently skew efficacy stats as well as clinical outcomes.
My Comment, #276, on Kramer's Excellent NYT Article:
[If you think this comment makes sense please do weigh in and recommend it over at the NY Times.]
Thanks Dr Kramer for your courageous comments on depression and antidepressants, a conundrum of circumstances which, at this level of our neuroscientific development, should be taken for granted as positive intervention strategies, rather than so obviously controversial.
In 2011 we find ourselves still awash in wondering what-to-do because many aren't yet listening to the available brain and body technology – the massive evidence available on brain and body neurophysiological imbalances. What we see is what we're getting.
The unfortunate reality: depression itself, as most of the DSM4, is predominantly a descriptive term with little appreciation for, or measurement of, the underlying biology that can encourage depressive regression. For years we have considered these unhappy matters as only “conflictual” and “psychological,” rather than *also* originating as downstream effects of so many biomedical challenges. Nowhere is this more evident than in the fact that many professionals regularly miss cognitive depression because they only consider depressive ‘affect' as the interloper. [Cognitive depression: Clint Eastwood as the Stranger in “High Plains Drifter” – he needs medication.]
The reason for the controversy is quite simple: we regularly miss the causal biology because we are not yet accepting biomedical evidence as replicable and useful. We overlook important medical questions, food allergy questions, immune dysregulation questions [and more], as we tilt with the tips of icebergs rather than study those ominous underwater structures.
An interesting clinical example in this regard is the high controversy attending biomedical measures such as SPECT imaging, measurement of urinary neurotransmitters, and testing for IgG imbalances – all of which yield measurable targets. Many accept cholesterol as a biomarker – but cholesterol is not “diagnostic,” as even high levels can be associated with clean arteries. Available science provides more answers.
Or you can drop a comment here as well! Thanks,
Postscript
FYI: An additional Sunday Antidepressant review in Letters was pub at NYT [http://nyti.ms/nAsNWc]: Remember this perspective: Angell is a pathologist [bio says lecturer in ‘social medicine at Harvard'], the other “experts” are psychologists, and yet it seems that they continue to quote numbers, with no earthly psychopharmacologic experience. Personally, I have no clinical experience to comment on pathology or the vagaries of psychological testing. So often we see trauma surgeons commenting on psychiatry… it's like baseball players who become experts on child care. The big problem with psych: everyone thinks they're an expert – from ADHD to antidepressants.
Looking at numbers cut from research based upon appearances with no biologic understanding and a clinical bias against medications in the first place only encourages the more informed to dig deeper and explore the variables that actually create that measurable unpredictability.
We Must Improve The How, Not The What
Psychiatry is common sense, – isn't it – or is it? Let's just take a moment to get all of the variables straight – is the problem the meds or the way we use the meds?
The plain truth: Yes, meds are indeed often used ineffectively and capriciously, but ineffective outcomes are most often not the fault of the meds, rather the misinformation and limited knowledge of how to use psych meds by practitioners in general. Used carefully, with understanding CYP 450 and metabolic vagaries that arise more often than not, antidepressant meds work quite predictably.
Let's not throw the baby out with the bathwater. Irresponsibly biased anti-medication reports can actually kill people.
cp
Related articles
- In Defense of Antidepressants (tricitypsychology.com)
- Peter Kramer defends antidepressants (whyevolutionistrue.wordpress.com)
- Are Antidepressants Just Placebos With Side Effects? (3quarksdaily.com)
- Peter Kramer Responds to Recent Criticisms of Antidepressants (historypsychiatry.wordpress.com)
- Anti-inflammatory drugs oppose antidepressant drug action (mindblog.dericbownds.net)
- Opinion: In Defense of Antidepressants (nytimes.com)
- Do antidepressants work? (psychologytoday.com)
13 Comments
Dr. Parker
15yr old boy takes pristiq, Wellbutrin / depressio , ADD and lamictal for absence seizures, also aderrall for attention. He lays in bed all weekend and after school. Still depressed, raised his lamictal 75mg and it seemed to help som. he also has adipose fat stomach since tiddler and is hypothyroid , Lyme too, I will start treating Lyme
when schoool is out. I did a spect scan in 2007, is info still good? Different antidepressant. How can I help him?
I take pristiq and Wellbutrin and am increasing to 450 mg. I’ve done this in past and it has helped don’t feel like pristiq does much
Thanks, susan
@Esusanlarsen SPECT Results still as good as one can get from the macro view. They remain consistent until the underlying issues are adequately addressed. With just these few remarks I know he needs specific testing that will address more cellular systems. Absolutely needs a more complete workup and we can certainly do it. – Please email Sarah today sarah.corepsych[at]gmail.com
Take a look here for a few more remarks, then set up with Sarah a Brief Phone Chat with me for clarification, – no charge.
http://www.corepsychblog.com/244-2/neuroscience/
Talk soon,
cp
[…] Antidepressants will work – just get the diagnosis right […]
Neal,
Thanks for weighing in, many are far to simplistic with the labeling and treatment process, good to hear from someone on the street with an opportunity for more evolved understanding and improved clinical response.
cp
Erich,
That “all psychotropics” can’t be my assertion. I don’t think they do… but the “experts, the psychologists and the pathologist who don’t use these meds assert that they do. I differ with them. Please show me where Parker said that – and will correct! Looks like you were differing with them?
Thanks,
cp
Not to spark a ‘flame war’ [dislike flaming intensely], but must challenge blanket assertion that _all_ psychotropics (inarguably!) cause permanent brain alteration- presumably refers to structural damage. Query: what is the source of your information? I believe Dr. Parker can confirm that decades of clinical experience and research shows that, for most people, stimulants in particular (MPD/AMP) are safe and effective even for extended periods of time **when properly dosed for the individual patient.**
Dr. Parker,
I’m very interested in what you have to say, but you have to iron out some seriously annoying tech issues on your site. On numerous occassions, I’ve tried clicking on links within your site, and they lead me to error pages. This is incredibly frustrating. Your link above (http://nyti.ms/qDu3F) goes nowhere. The email you sent had a link to your blog post, but the link didn’t work (https://corebrain.infusionsoft.com/link/16e15f4e0/d1240a0). It sent me to an error page that merely said, “You 404’d it. Gnarly, dude.” Such a stupid, condescending error message doesn’t exactly reflect well on you or your site.
You have great things to impart to your readers, so please tell your tech person to get their act together. Much obliged, Arsen Markarian
Arsen,
Excellent points, links cleaned up – the shortening of the nyt site didn’t come over, thanks for pointing that out, and the newsletter, big oops on that one, can assure you didn’t mean to, just got into a rush, – appreciate your interest and feedback, got rid of the narly dude too that was a WP problem, needed a specific plugin fix… Done!
cp
I completely agree with your concerns and observations… the problem with both sides of the polemic, even the ortho guys… is that they often become defensively reductionistic in their claims [everyone needs this] and thereby invite attack from the opposite side who is categorically against the initial assertion;-)
cp
Thanks so much, preparing an op-ed piece for the Times on this subject, they may not pub it, but I am writing about it in more detail, – has to be said.
cp
Dr. Parker,
I have been interested in your work because I view your conviction that so-called “mental illnesses” are rooted very real extra-brain physical dysfunctions that are detectable and treatable, as a great leap for patient care.
However – and without raising questions about WHY it is thought that measuring urinary markers of neurotransmitter metabolism tells us anything at all about levels of neurotransmitters in the brain itself – I have to say that I think it is incredibly sad that the work of the pioneers of orthomolecular therapies (Abram Hoffer, M.D., PhD, et al) continues to be ignored and/or “discredited,” by even open-minded, conscientious physicians, such as yourself.
The use of nutrients – notably niacin, often in megadoses, to address and correct underlying metabolic glitches has been used successfully by thousands of grateful patients world wide for over 60 years, not only for schizophrenia, but for ADHD, depression, bipolar, etc, allowing victims to live normal, healthy lives, free of side effects and the permanent brain alteration that comes, unarguably, with all psychiatric drugs.
The use of orthomolecular strategies to correct the downstream brain dysfunction of nutritional deficiencies and/or metabolic dysfunction would make the debate about the benefit of psychiatric drugs moot.
In 1982, after eight years of treatment with psychiatric drugs for “chronic mental illness”, I was fortunate to learn about and obtain for myself orthomolecular therapy based on tissue mineral analysis of hair samples. I had an immediate remission of all symptoms which has lasted to this day. By 1982, orthomolecular therapy was greatly refined over Hoffer’s original methods and diet and supplement programs were custom designed for an individual’s needs. This is why state of the art orthomolecular therapy and now the new neurotransmitter balancing programs can never be evaluated in double-blind studies, too many variables.
Abram Hoffer wrote an excellent analysis of contemporary diagnosis near the end of his life in 2009.
http://findarticles.com/p/articles/mi_7396/is_317/ai_n42850579/ Hoffer’s (and his associates’) great contribution was the discovery of adrenochrome, not one substance, but several metabolites of epinephrine.
Countless thousands have been caught in the whirlpool he describes, which matches my own history exactly. Schizophrenia, then bipolar disorder, then finally schizo-affective disorder. Had I not found orthomolecular therapy, death would have followed shortly after, I am sure.
THANK YOU FOR THIS, DR. P! I WAS WAITING FOR SOMEONE TO SAY THIS. OF COURSE IT WOULD BE YOU!
Yet the unwritten, unhappy circumstance that distorts the efficacy numbers: Depression, like ADHD, often presents as far more than simply “depression,” with many comorbid and contributory problems that are often completely overlooked, as many myopically treat only the depressive symptoms that appear on the obvious surface. Untreated comorbid conditions do perpetuate the depressive symptoms – and frequently skew efficacy stats as well as clinical outcomes.