Mad in America

My confidence in the NYT just fell off the table. GREAT job in this piece. I'd love to see a drug that did the trick with depression. It's a scourge. Sadly, that drug is not yet on the market. Thanks for bringing some truth to this discussion. Can you shorten your piece and send a letter to the editor of the NYT?

You didn't even get into Kramer's citing the withdrawal studies as proof of efficacy. He said there was a study dropped 4410 people from antidepressants immediately onto placebo. Amazingly, the people who weren't dropped like a rock had a 70% lower relapse rate. No discussion at all about withdrawal effects.

The question is, Are people like Peter Kramer so invested in their ego and their world view that they can't see the truth and change their minds? Or does he actually know he is lying? I bet most people out there are caught up in what they learned and not willing to ask questions and challenge authority. However, some people truly know they are lying and are willing to hurt and deceive people in order to make money or protect their status.

Excellent analysis. My jaw dropped twice - once when reading the article itself, with its confused thinking and unabashed 'it's all good' theme, and the second when I read the comments. If people truly responded like that IRL, I would be an advocate of antidepressants. They don't, is the problem. The overwhelming 'it saved my life' doesn't of course address the placebo question, but I simply don't see people like that. Where did they all come from? Strange.

Great article Robert, as seems to always be the case for you.

I wanted to add two points I think your readers might be interested in that I have come across when reading and reviewing similar literature and arguments.

1) About clinical significance: I have seen several people who are themselves struggling with several depression, or who have a loved one who is, take a stance that "any difference is clinically significant when you are talking about suffering this severe." I can emphasize with there desire to receive help, or to help a loved one, even if only a little, and with how powerless people can feel over depression. That said, I have deep concerns about the side effects of the drugs not outweighing the small benefits (which I personally believe to be a statistical and experimental artifact, and not actual additional help).

To get a sense of how small the difference actually is, I would invite readers to look at the actual Halmion Depression Inventory discussed in the article. The difference is only two shades on two questions across the entire test, and there are serious side effects.

http://www.real-depression-help.com/hamilton-depression-scale.html
http://en.wikipedia.org/wiki/Selective_serotonin_reuptake_inhibitor#Adve...

2) Placebo response: As I read the evidence, the actual clinical debate is where the drugs lie on the spectrum of 80% to 100% placebo (in the evidence robert cites the placebo effect is 7.8, purported drug effect is 1.8). This is noteworthy, in that it shows us that as far as we can tell, most of what people struggling with depression need are rituals of empathic, compassionate attention and remorilization. That is where at least 80% of the effect across hundreds or thousands of studies of all types of depression treatment, and I would argue that at least 80% of our attention should be. I recommend Robert's review of the Soteria projects in his Mad in America as an example of how programs conceptualized in this frame can be helpful for even the most severely distressed.

There are 2 stories here. One is- What is the truth about the efficacy of anti-depressants? Two is- Why does Kramer and Psychiatry so blatantly distort the objective truth?

I'll just briefly say something about the second theme- Kramer and Psychiatry distort the truth because the cognitive dissonance produced by their behavior requires them to shift their beliefs about what is moral and ethical in order to not feel that inner confictual dissonance.

For Kramer to ignore all the damage done by anti-depressants and still promote them even though the neglible positive effects don't justify the harm done, means he needs to concoct such a transparently obvious distortion of the facts. He isn't lying in the usual meaning of the word. He absolutely believes the story he is telling himself - and the NY Times audience.

That is the definition of cognitive dissonance. It is more than justification, denial, or rationalization. Cognitive dissonance and it's relief is at work behind all the abusive Psychiatric practices.

From lobotomy, ECT, mass hysterectomies done to stop imagined hysteria, mass chemical straight jackets for millions, diagnosing and medicating children for non-existent bi-polar, giving prophylactic meds to children with no psychotic symptoms, and now finally, for board certified child Psychiatrists strapping down 3 year old children and shocking their developing brains with ECT- all of these abuses are done by Medical Doctors like Kramer who sleep fine at night because they have expanded their beliefs to allow them to continue their immoral behavior.

The open-ended, self perpetuating medical model paradigm of human emotional suffering is their haven. The tighter they cling as true believers to the dogmatic belief system that proclaims that the diseased brain is their territory and their's alone to cure, they can ease any and all cognitive dissonace produced by behaviors that would hopefully make you and I turn away and vomit before we could switch on the electrical current into a toddler's brain.

It's anosognosia!!! When you don't know what you don't know.

the comment by DOCTOR cornwall is intriguing. im always glad when anybody cites psychiatrys capital crimes but im not sure thats what kramer is doing here. i havent read listening to prozac in @20 years-- or the times piece--, but he seemed to be of the compassionate/poetic subset of the putting words to feelings talk therapy types who bought the serotonin hypothesis as opposed to a mengelish bioshrink. so is he blinded or ignorant or evil.

inquiring minds need to know!

this is esp. important to me because as a longterm sometimes agitated depressive i went looking for prozac in the early nineties and was very fortunate to consult a weirdo homeopathic md psychiatrist who wouldnt give it to me because he was smart enough to have already learned that it could cause impulsive homo/suicidality. may have saved my (or someone elses) life

L-tryptophan or 5-HTP will increase your Serotonin (and subsequently Melatonin) levels, but big-pharma can't patent what's essentially food.

Dr. Cornwall wonders, "Why does Kramer and Psychiatry so blatantly distort the objective truth?"

The answer to this question seems obvious enough. Psychiatrists like Kramer are simply agents and tools of Big Pharma. Their objective is to maximize pharmaceutical profits, that's all.

One thing that has surprised me over the years is how many healthcare practitioners seem to lack scientific literacy. I'd like to think that, as an MD, Kramer is capable of reading and understanding these studies, but I can all too easily imagine that he is simply confused when presented with something that conflicts with What Everybody Knows Is True.

As a long time NYT subscriber and one who has struggled with depression to the point of disability, I was disappointed that the NYT saw merit in publishing Peter Kramer's op-ed. It is telling that his piece ended with anecdotal evidence rather then empirical, i.e. the story of a friend. So often this is "evidence" of last resort when one represents broadly what one can't evidence narrowly, i.e. that antidepressants work more then nominally.

Until there is an honest discussion of depression, the effectiveness of various treatments, and the outcomes they foster in the community our mental health system will be continue to afford the majority of individuals marginal or sub-marginal depression care rather then that care which makes a difference.

Can the psychiatrists and our mental health system handle the truth whatever that may be? If not, can it continue represent itself as fostering in the majority of cases "Recovery", and of late, "Wellness & Recovery"?

now that ive read kramer anecdotal panegyric twice im still not sure what his problem is altho i may be attached to not hating him since i was sufficiently impressed with his narrative 20 yrs ago that i wanted to join the 'shiny happy people' (title of a critical piece by david rothman)

anyway joe i would suggest that mds and their subalterns have never been and can never be the best place to go for emotional healing. (the evidnece suggests they are a good place to go to get iatrogenic illness!!)i fear that the biopsychiatric argument -- and the drugging response which is its obvious and usually sole solution-- holds much sway even among its angriest critics like myself.

'care that makes a difference'
can it come from a profession that wins nobels for inventing lobotomy. thats leading light of the 19th century -- benjamin rush still on the APA seal--thought that african americans suffered from a disease of too much melanin?

These kind of articles need to published again and again; the dominant biomedical paradigm is so powerful that it will (unfortunately) take years to demolish (and let us not forget what we want to create to replace it).

There is currently a petition to the New York Times to allow Robert Whitaker to submit a reply to Peter Kramer's article. We feel it's only fair and good journalistic practice to allow Whitaker to voice his opinion and research on the issue of antidepressant prescription and use.

Link to the petition: http://www.change.org/petitions/a-petition-to-nyt-requesting-an-opportun...

So much B.S. from all sides,I'm getting sick of this. In my book, I strongly attack the sleeze that is often produced by big Pharma, and have never worked for them, but for some reason I end up having to the one to defend antidepressants from the nonsense of the anti-psychiatry folks.

These folks tend to think that snake oil such as homeopathy is better than anything in mainstream medicine, but they never seem to question the "science" behind THOSE claims. Homeopathy: the only system of medicine that does not work - by its own definition!

The idea that is completely neglected by the generic question, "Do antidepressants work?" is that the question should instead be, "for what symptoms of what disorders and under what circumstances?" The general "do they work" question is almost as stupid as the question, "What is better for depression, medication or psychotherapy?" The two treatment modalities target completely different aspects of sometimes completely different disorders!

If the question is, "do antidpressants work for the so-called vegative symptoms in ADULTS with MAJOR DEPRESSION (loss of appetite, early AM awakening, anhedonia, psychomotor slowing, lack of energy, lack of initiative, and poor concentration among others)," the drugs work brilliantly.

I have thirty years of prescribing them, as well as personal experience, that says they do. So do hundreds of other non-pharma connected, and diligent psychiatrists (as opposed to the worthless ones doing 20 minute evals using symptom checklists).

"Widespread clinical experience" and "clinical anecdote" are not synonyms. If it weren't for the former, we would never learn about the toxic effects of some medications that lead to all of those black box warnings.

If the question is, "Do antidepressants make depressed people feel less sad?" then the answer is "it depends." It depends on a bunch of factors, but the two biggest ones are, 1) does the patient have dysthymia or major depression? If they have dysthymia, the meds may not do a whole lot. If they have a melancholic major depression, the vegetative signs go away but some patients may remain very unhappy.

Why? Because of the second factor, which is, "What is the patient's baseline?" If they are unhappy people because of bad relationships, crappy childhood syndrome, or whatever, the antidepressants are NOT going to fix that.

The outcome measures used in drug studies also tend to be used, totally inappropriately, as inclusion/exclusion for the study. Both the Beck and the Ham-D DO NOT DISTINGUISH BETWEEN DYSTHYMIA AND MAJOR DEPRESSION, because they do not ask about the time course of the symptoms or their pervasiveness.

Those two qualities are what distinguish major depression from chronic unhappiness. Pharma wants doctors to believe that unless a formerly depressed patient has no mood symptoms at all, then they are not having a complete response to an antidepressant, and should be put on an additional med like Abilfy, which most people believe is an antidepressant when it isn't. Isn't it strange that all this bull about antidepressants not working is coming out just as most of them have gone generic?

Instead, doctors should be asking if the patient has RETURNED TO THEIR OWN PERSONAL BASELINE. Even though dysthymia and major depression sometimes have a lot of overlap and we don't have any blood tests to distinguish the two disorders, their phenomenology, time course, pervasiveness, and response to medication are completely different, which is pretty good evidence that the two syndromes are different beasts. And you can most definitely have both at the same time!!

The CRO's that do drug studies are paid by the number of patients they recruit, so their is an incentive for them to recruit people whe don't meet criteria for MDD. Just because someone rates a depression as severe (and very often subjects either exaggerate or understate their symptoms) on a Ham-D, that does not mean they have a severe major depression. They can still be dysthymic.

I'd like to give Whitaker the benefit of the doubt and think that he does not really understand much about the different depressive syndromes, but whether he does or not, he does not seem to make this rather crucial distinction.

The related question of whether SSRI antidepressants reduce emotionally instability in patients with such psychological problems as borderline personality disorders is something I won't talk about much, but there are studies and a crapload of clinical experience that says that they do. But to really answer the question, you have to know exactly what kind of stresses the individual patient is actually under, and environmental and interpersonal factors are not even asked about in the majority of drug studies, which makes many of them completely worthless.