Let us be very clear as to what this signifies: When researchers were evaluating the antidepressant in a context where they were no longer interested in proving its therapeutic power, there was a dramatic decrease in that apparent power, as compared to an earlier context when they were enthusiastically interested in demonstrating the drug's potency. A change in researcher motivation was enough to change outcome. Obviously this means too that the present double-blind design for testing drug efficacy is exquisitely vulnerable to bias.
Another matter of pertinence to the presumed biological rationale for the efficacy of antidepressants is that no consistent links have been demonstrated between the concentration of drug in blood and its efficacy. Studies have found significant correlations for some drugs, but of low magnitude. Efforts to link plasma levels to therapeutic outcome have been disappointing.
Similarly, few data show a relationship between antidepressant dosage levels and their therapeutic efficacy. That is, large doses of the drug do not necessarily have greater effects than low doses. These inconsistencies are a bit jarring against the context of a biological explanatory framework.
We have led you through a detailed critique of the difficulties and problems that prevail in the body of research testing the power of the antidepressants. We conclude that it would be wise to be relatively modest in claims about their efficacy. Uncertainty and doubt are inescapable.
While we have chosen the research on the antidepressants to illustrate the uncertainties attached to biological treatments of psychological distress, reviews of other classes of psychotropic drugs yield similar findings. After a survey of anti-anxiety drugs, psychologist Ronald Lipman concluded there is little consistent evidence that they help patients with anxiety disorders: "Although it seems natural to assume that the anxiolytic medications would be the most effective psychotropic medications for the treatment of anxiety disorders, the evidence does not support this assumption."
Biological Versus Psychological?
The faith in the biological approach has been fueled by a great burst of research. Thousands of papers have appeared probing the efficacy of psychotropic drugs. A good deal of basic research has attacked fundamental issues related to the nature of brain functioning in those who display psychopathology. Researchers in these areas are dedicated and often do excellent work. However, in their zeal, in their commitment to the so-called biological, they are at times overcome by their expectations. Their hopes become rigidifying boundaries. Their vocabulary too easily becomes a jargon that camouflages over-simplified assumptions.
A good example of such oversimplification is the way in which the term "biological" is conceptualized. It is too often viewed as a realm distinctly different from the psychological. Those invested in the biological approach all too often practice the ancient Cartesian distinction between somatic-stuff and soul-stuff. In so doing they depreciate the scientific significance of the phenomena they exile to the soul-stuff category.
But paradoxically, they put a lot of interesting phenomena out of bounds to their prime methodology and restrict themselves to a narrowed domain. For example, if talk therapy is labeled as a "psychological" thing—not biological—this implies that biological research can only hover at the periphery of what psychotherapists do. A sizable block of behavior becomes off limits to the biologically dedicated.
In fact, if we adopt the view that the biological and psychological are equivalent (biological monism), there is no convincing real-versus-unreal differentiation between the so-called psychological and biological. It all occurs in tissue and one is not more "real" than the other. A patient's attitude toward the therapist is just as biological in nature as a patient's response to an antidepressant. A response to a placebo is just as biological as a response to an anti-psychotic drug. This may be an obvious point, but it has not yet been incorporated into the world views of either the biologically or psychologically oriented.
Take a look at a few examples in the research literature that highlight the overlap or identity of what is so often split apart. In 1992, psychiatrist Lewis Baxter and colleagues showed that successful psychotherapy of obsessive-compulsive patients results in brain imagery changes equivalent to those produced by successful drug treatment. The brain apparently responds in equivalent ways to both the talk and drug approaches. Even more dramatic is a finding that instilling in the elderly the illusion of being in control of one's surroundings (by putting them in charge of some plants) significantly increased their life span compared to a control group. What could be a clearer demonstration of the biological nature of what is labeled as a psychological expectation than the postponement of death?
Why are we focusing on this historic Cartesian confusion? Because so many who pursue the so-called biological approach are by virtue of their tunnel vision motivated to overlook the psychosocial variables that mediate the administration of such agents as psychotropic drugs and electroconvulsive therapy. They do not permit themselves to seriously grasp that psychosocial variables are just as biological as a capsule containing an antidepressant. It is the failure to understand this that results in treating placebo effects as if they were extraneous or less of a biological reality than a chemical agent.
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