Peter Kramer’s Defense of Antidepressants

Cover of Listening to Prozac

“Could drugs that are ingested by one in 10 Americans each year, drugs that have changed the way that mental illness is treated, really be a hoax, a mistake or a concept gone wrong?”  asks Brown University psychiatrist Peter Kramer in this article. Kramer lambasts the current meme that antidepressants are no better than placebo, especially for mild depression. His major point is that the research on which that conclusion is based was contaminated by a recruitment process that selected many subjects who were not truly depressed. Thus, when followed over time, they got better regardless of whether they were on antidepressants or placebos, obscuring the value of the drugs for truly depressed patients.(For a more sophisticated discussion, in my opinion, of the reasons why there has been a lessening gap between medications and placebos, see this article in Wired by Steve Silberman.)

Kramer is best known for his popular 1993 book, Listening to Prozac, in which he argued that some people feel “better than well” when treated with such medications. In particular, energy, assertiveness and self-confidence can be enhanced even if they were not pathologically diminished before the patient was treated. Kramer discusses the prospect of “cosmetic psychopharmacology” — when a medication can improve socially desirable traits even in people without pathology, should it be used in such a fashion? Raising the issue should inform, narrowly, psychiatrists’ prescribing practices, and, more broadly, both values-based and fiscally-based societal considerations of antidepressant use.


Indeed, antidepressant use has continued to grow wildly in the almost two decades since, and with it the windfall for the drugs’ manufacturers. But you will find very few prescribers, consumers or insurance payors who believe this is the “cosmetic” treatment of those who are not truly ill merely to give them an edge in a competitive society. Instead, the trend has been justified by the redrawing of the boundaries of illness so that a far broader set of conditions are said to be medication-responsive. This is a concern whether you are a naive materialist, who believes in the strictly biological explanation for medication efficacy, or if you attribute the benefits to placebo effect and self-fulfilling prophecy. (Despite the fact that I am a psychopharmacologist, I tend to believe we understand so little about the ‘black box’ of the brain that we are a long way away from being able to tell the difference.)

Kramer worries that newly-skeptical physicians affected by the emperor-has-no-clothes backlash against antidepressant use will fail to treat deserving patients appropriately:

“…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…”

He centers his article around a vignette in which a friend of his with post-stroke depression had not been placed on an antidepressant despite the research supporting improved outcome. (Notably, I think, unlike what he did in Listening to Prozac, he is not reflecting on his own prescribing practices, merely those of his colleagues.) But if the meme about antidepressant efficacy changes profoundly enough, some patients will not get better even when they are prescribed these medications, because of the undercutting of the self-fulfilling prophecy. And is that a good thing or a bad thing?

Given that my bias in my work is toward treating sicker patients (I work in a hospital with only a limited outpatient practice with the “worried well”), I am among those who decry the creeping medicalization of everyday life. I don’t know if antidepressants are less “effective” in healthier patients because of the diffuseness and ambiguity about the meaning of “effective”. (Throughout psychiatric research, I see profound confusion and lack of consensus about how to measure outcome.) Severely depressed patients, because core aspects of severe depression include pessimism and despondency, are probably far less susceptible to suggestibility. I don’t know if the research has been done but I would suspect that severe depression sabotages the placebo effect. Thus the observed benefit of antidepressants in this class of patients is more likely to be biological. A nervous system out of whack for some reason can probably be rebalanced better with some pharmacological influence that counteracts the imbalance.

BERLIN - NOVEMBER 22:  Singer and guitarist Br...
Placebo (Brian Molko)

In less ill patients, the balance may indeed shift in favor of placebo effects as the basis for observed benefits. But I have another concern, which has fueled my reluctance to prescribe them too readily, about the expansion of antidepressant use in our society. Although the medications are not, in the formal sense of the term, addictive (i.e. they do not hijack the brain’s craving and pleasure circuitry and there is no tolerance and no acute withdrawal syndrome from abrupt discontinuation of use), I have long worried that too readily prescribing antidepressants for those who do not necessarily start out ‘needing’ them may make them ‘need’ them down the line. Think of it this way. The CNS is a homeostatic mechanism. If it is in balance, it resists and counters changes. (Disease is a perturbation in function outside of the range in which it can by intrinsic mechanisms restore itself to homeostasis.) Give antidepressants to a brain in balance, to amp up certain functions, and counteractive mechanisms may be put into play to restore balance. A new set-point may be established that may persist even after the removal of the medication which was the original influence. Someone who did not need the medication in the first place may be converted into someone who does, perhaps for the rest of their life.

Frauenfelder Interview with Maryn McKenna, author of Superbug

Magnified 20,000X, this colorized scanning ele...

The Fatal Menace of MRSA: “MRSA (Methicillin Resistant Staphyoloccus Aureus) kills more people every year than AIDS. In the US alone 19,000 die from it each year, and another 369,000 are hospitalized because of it. The World Health Organization calls MRSA the most important health issue of the 21st century.

I interviewed McKenna about her book and MRSA. You can read it below. You can also listen to the audio recording of my interview.” (via Boing Boing)


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Many Food Allergies May Be ‘All in the Mind’

Rubber Ducky #00

‘Why do more people seem to suffer more allergic reactions than in the past?

A new report, commissioned by the federal government, finds the field is rife with poorly done studies, misdiagnoses and tests that can give misleading results.

While there is no doubt that people can be allergic to certain foods, with reproducible responses ranging from a rash to a severe life-threatening reaction, the true incidence of food allergies is only about 8 percent for children and less than 5 percent for adults, said Dr. Marc Riedl, an author of the new paper and an allergist and immunologist at the University of California, Los Angeles.

Yet about 30 percent of the population believe they have food allergies. And, Dr. Riedl said, about half the patients coming to his clinic because they had been told they had a food allergy did not really have one.

Dr. Riedl does not dismiss the seriousness of some people’s responses to foods. But, he says, “That accounts for a small percentage of what people term ‘food allergies.’ “‘ (New York Times )

Annals of Emerging Diseases

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Ebola vaccine closer after monkey trials: ‘Ebola, a viral disease that kills as many as 90% of infected humans, may be one step closer to a cure.

Researchers at government institutions in the U.S. have created a vaccine that successfully immunises monkeys against the two most lethal strains of the disease, and have found that it also protects against a newer strain not represented in the vaccine.’ (Cosmos)

Blue dye in M&Ms linked to reducing spine injury

“The same blue food dye found in M&Ms and Gatorade could be used to reduce damage caused by spine injuries, offering a better chance of recovery, according to new research.

Rats injected with BBG not only regained their mobility but temporarily turned blue.

Researchers at the University of Rochester Medical Center found that when they injected the compound Brilliant Blue G (BBG) into rats suffering spinal cord injuries, the rodents were able to walk again, albeit with a limp.” (CNN)

The decline and fall of high-fructose corn syrup

US sweetener consumption, 1966-2004. It is app...

“High-fructose corn syrup first started trickling into our food supply about 40 years ago; by 1984, it was flowing from just about every soda fountain in the country. These days HFCS accounts for almost half of all the added sugars in the U.S. diet, but the corn Niagara may soon be over. Last week, PepsiCo became the latest manufacturer to turn its back on America’s sweetener, introducing three new soft drinks—Pepsi Natural, Pepsi Throwback, and Mountain Dew Throwback—sweetened with a “natural” blend of cane and beet sugars. Next week, Snapple will roll out its most expensive advertising campaign ever to promote a “natural” line of tea drinks brewed with “real” cane sugar. Pizza Hut, Kraft Foods, and ConAgra have also made the switch in recent months. Not even a $30 million multimedia campaign from the Corn Refiners Association has done much to reverse the trend.” — Daniel Engber(Slate)

Capitalism and the flu

“Mike Davis, whose 2006 book The Monster at Our Door warned of the threat of a global bird flu pandemic, explains how globalized agribusiness set the stage for a frightening outbreak of the swine flu in Mexico:

‘The Spring Break hordes returned from Cancún this year with an invisible but sinister souvenir.

The Mexican swine flu, a genetic chimera probably conceived in the fecal mire of an industrial pigsty, suddenly threatens to give the whole world a fever. Initial outbreaks across North America reveal an infection rate already traveling at higher velocity than the last official pandemic strain, the 1968 Hong Kong flu.’ ” (

Industrial livestock production and swine flu

Taken from EPA website (

“…[I]ndustrial livestock production is a powerful driver of viral (and bacterial) evolution. […In an article published yesterday at Socialist, Mike Davis] emphasizes that the transition “from old-fashioned pig pens to vast excremental hell, unprecedented in nature, containing tens, even hundreds of thousands of animals with weakened immune systems, suffocating in heat and manure, while exchanging pathogens at blinding velocity with their fellow inmates and pathetic progenies” creates a perfect storm for evolving pathogens likely to establish resistance to antivirals and antibiotics. This is not just the case in China (everyone’s favorite target for allocating bird flu blame) or Mexico (everyone’s new favorite target for allocating swine flu blame). To quote Davis, anyone “who has ever driven through Tar Heel, N.C. or Milford, Utah–where Smithfield Foods subsidiaries each annually produce more than 1 million pigs as well as hundreds of lagoons full of toxic shit–will intuitively understand how profoundly agribusiness has meddled with the laws of nature.” In short, in addition to animals raised for slaughter in cruel conditions, chemically enhanced and/or genetically altered meat products, environmental degradation, and unjust toxic factory work conditions, the global industrial food complex is producing some really scary microbes as well.” (Somatosphere).

Predicting Flu With the Aid of (George) Washington

The best way to track the spread of swine flu across the United States in the coming weeks may be to imagine it riding a dollar bill. The routes taken by millions of them are at the core of a computer model at Northwestern University that is predicting the epidemic’s future. Reassuringly, it foresees only about 2,000 cases by the end of this month, mostly in New York, Los Angeles, Miami and Houston.” (New York Times )


In a Mexican Village With Swine Flu, Complaints About a Hog Farm Persist

“While public health officials are still trying to determine where the outbreak of the swine flu started, there has been a lot of speculation online this week about a possible, though as yet unsubstantiated, link to an industrial hog farm in Veracruz, Mexico.

As my colleague in Mexico, Marc Lacey, reported on Wednesday, “state health authorities looking for the initial source of the outbreak,” toured the “million-pig hog farm in Perote, in Veracruz State.” Mr. Lacey explained:

The plant is half-owned by Smithfield Foods, an American company and the world’s largest pork producer. Mexico’s first known swine flu case, which was later confirmed, was from Perote, according to Health Minister José Ángel Córdova. The case involved a 5-year-old boy who recovered.

via The Lede Blog – NYTimes.

When It Comes To Shampoo, Less Is More

Private collection.

“Americans love to shampoo. We lather up an average of 4.59 times a week, twice as much as Italians and Spaniards, according to shampoo-maker Procter & Gamble.

But that’s way too often, say hair stylists and dermatologists. Daily washing, they say, strips the hair of beneficial oil (called sebum) and can damage our locks.” via NPR.

Another Reason Not to Fight with Your Adolescent Child

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Teen Conflicts Linked To Potential Risk For Adult Cardiovascular Disease:

‘…[I]n a study of otherwise healthy, normal teens who self-reported various negative interpersonal interactions, researchers found that a greater frequency of such stress was associated with higher levels of an inflammatory marker called C-reactive protein, or CRP. CRP has been identified as an indicator for the later development of cardiovascular disease (CVD).

“Although most research on stress and inflammation has focused upon adulthood, these results show that such links can occur as early as the teenage years, even among a healthy sample of young men and women,” [an investigator] said. “That suggests that alterations in the biological substrates that initiate CVD begin before adulthood.” ‘ via Science Daily.

The Maggots in Your Mushrooms

Making the Peanut Butter and Jelly Sandwich

“The Georgia peanut company at the center of one of our nation’s worst food-contamination scares has officially reached a revolting new low: a recent inspection by the Food and Drug Administration discovered that the salmonella-tainted plant was also home to mold and roaches.

You may be grossed out, but insects and mold in our food are not new. The F.D.A. actually condones a certain percentage of “natural contaminants” in our food supply — meaning, among other things, bugs, mold, rodent hairs and maggots.

In its (falsely) reassuringly subtitled booklet “The Food Defect Action Levels: Levels of Natural or Unavoidable Defects in Foods That Present No Health Hazards for Humans,” the F.D.A.’s Center for Food Safety and Applied Nutrition establishes acceptable levels of such “defects” for a range of foods products, from allspice to peanut butter.” — EJ Levy via NYTimes op ed.

The fear about peanut allergies is nuts

Nothing Takes the Taste Out Of Peanut Butter
“Peanut-allergy panic has spread across the nation. In a recent essay, Harvard physician and sociologist Nicholas Christakis relates an incident in which a peanut was spotted on the floor of a school bus, “whereupon the bus was evacuated and cleaned (I am tempted to say decontaminated), even though it was full of 10 year olds who, unlike 2 year olds, could actually be told not to eat off the floor.”

Actions like that are no doubt overdue in the minds of organizations like the 30,000-member Food Allergy and Anaphylaxis Network (FAAN), a Virginia-based advocacy organization that has led the fight to raise awareness about peanut and other food allergies in both children and adults. Go to its Web site and you’ll see some eyebrow-raising points.

• The incidence of food allergies has doubled over the past 10 years.

• Food allergy is believed to be the leading cause of anaphylaxis outside hospitals, causing an estimated 50,000 emergency department visits each year in the U.S.

• Each year in the U.S., it is estimated that anaphylaxis caused by food results in 150 deaths.

Those FAAN numbers get cited in nearly every news report about food allergies. The organization’s founder, Anne Munoz-Furlong, mother of a food-allergic child, is well known in the media as a food allergy expert. She has done her own research and her studies have been published in medical literature. Now major medical groups, like the American Academy of Pediatrics, have recommended that children avoid eating peanuts until age 3. As for consuming other potentially allergic foods (such as strawberries or dairy), the AAP has, until recently, suggested that kids wait until age 2.

But on closer examination, food allergies are not the epidemic we’ve been led to believe. FAAN’s advocacy may have helped to create rules and laws that are based less on sound science than on a significant misrepresentation of facts. Ironically, by accepting these facts, we may be increasing our risk of developing food allergies.” — Rahul Parikh MD via Salon.


A Mysterious Link Between Sleeplessness and Heart Disease


‘Although a number of studies have suggested that people who sleep less are at greater risk of heart disease and death, this is the first investigation to measure how much its subjects actually are sleeping, said Dr. Sanjay Patel, assistant professor of medicine at Case Western Reserve University and expert in sleep medicine. Patients’ own self-assessments can be very inaccurate, he added.

What isn’t clear is whether reduced sleep triggers physiological changes that increase heart disease risk, or whether a third, unrelated factor causes both changes, he said.

“It’s possible, for example, that people who are under more stress may be both sleeping less and at higher risk of heart disease,” Dr. Patel said.

If so, he added, “If we got those people to sleep more but they still were under a lot of stress, it wouldn’t change their risk of heart disease.” ‘

via New York Times.

U.S. Doctors Regularly Prescribe Real Drugs As Placebo Treatments, Study Claims

Prescription placebos used in research and pra...

“Many rheumatologists and general internal medicine physicians in the US say they regularly prescribe ‘placebo treatments’ including active drugs such as sedatives and antibiotics, but rarely admit they are doing so to their patients, according to a study on

The use of placebo treatments in clinical practice has been widely criticised because it is claimed that the practice by its very nature is deceptive and therefore violates patients’ autonomy. But advocates of placebo treatments argue that they could offer effective treatment for many chronic conditions without necessarily deceiving patients. Despite the controversy, to date there has been little data on doctors’ attitudes towards and the use of placebo treatments in the US.” (Science Daily)

The only people bent out of shape by this are those unsophisticated physicians who can believe only in the concrete and materialistic explanations for how they ‘heal’. Most of medicine mobilizes patients’ healing resources through symbolism, ritual and enlistment into a belief system. That’s why I have such a hard time with the (equally concrete) critics of Western allopathic medicine. It is not that they offend me by not believing in what I do, but rather that they undermine the power of belief which is the basis of how physicians heal. In short, most treatment is probably mediated by the placebo response. Patients inherently give up their autonomy by consulting a health professional, and treatment will not work without an element of faith on their part.


Mythbusting Dept.

sleep-deprivation is awesome

“…The apparent desire for more shut-eye, together with oft-repeated assertions that our grandparents slept longer, all too easily leads to the conclusion that we in the west are chronically sleep-deprived. Adding to these concerns are recent claims that inadequate sleep causes obesity and related disorders, such as diabetes.

Plus ca change. Claims of widespread sleep deprivation in western society are nothing new – in 1894, the British Medical Journal ran an editorial warning that the ‘hurry and excitement’ of modern life was leading to an epidemic of insomnia.

Even then it probably wasn’t true. The fact is that most adults get enough sleep, and our collective sleep debt, if it exists at all, has not worsened in recent times. Moreover, claims that sleep deprivation is contributing to obesity and diabetes have been overblown. My assertion is that the vast majority of people sleep perfectly adequately. That’s not to say that sleep deprivation doesn’t exist. But in general we’ve never had it so good.” (New Scientist)

Obesity, Abnormal ‘Reward Circuitry’ In Brain Linked

Structure of dop...dopamine

“Although recent findings suggested that obese individuals may experience less pleasure when eating, and therefore eat more to compensate, this is the first prospective evidence for this relationship… Using brain imaging and chocolate milkshakes, scientists have found that women with weakened ‘reward circuitry’ in their brains are at increased risk of weight gain over time and potential obesity. The risk increases even more for women who also have a gene associated with compromised dopamine signaling in the brain.” (Science Daily)

Tea ‘healthier’ drink than water

Mineral water (original German description ind...

“Public health nutritionist Dr Carrie Ruxton, and colleagues at Kings College London, looked at published studies on the health effects of tea consumption.They found clear evidence that drinking three to four cups of tea a day can cut the chances of having a heart attack.Some studies suggested tea consumption protected against cancer, although this effect was less clear-cut.Other health benefits seen included protection against tooth plaque and potentially tooth decay, plus bone strengthening.Dr Ruxton said: ‘Drinking tea is actually better for you than drinking water. Water is essentially replacing fluid. Tea replaces fluids and contains antioxidants so it’s got two things going for it.'” (BBC)