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 NYTimes.com 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.

Prozac
Placebo?

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)

Caveats

Intentionally blank pages at the end of a book.

Do not use if you have ever had an allergic reaction to this product or any of its ingredients.
Failure to follow all instructions and warnings can result in serious injury.
Please leave as clean on leaving as you would like to find on entering.
Any resemblance to actual persons living or dead is purely coincidental.
Place all seat backs and tray tables in fully upright position.
Post office will not deliver without proper postage affixed.
Do not operate heavy machinery while reading this weblog.
Caution: Dates on calendar are closer than they appear.
Please note locations of emergency exits upon arrival.
No animals were harmed in the production of this page.
May be used as flotation device in case of emergency.
No ideas were harmed in the making of this weblog.
Anything you say can and will be used against you.
Satisfaction guaranteed; return for full refund.
Names have been changed to protect the innocent.
All questions answered, all answers questioned.
Objects on screen are closer than they appear.
If condition persists, consult your physician.
Detach and include upper portion with payment.
Nutritional need is not established in humans.
Caution: do not swallow. May cause irritation.
Do not use if safety seal is torn or missing.
Please inform author if you cannot read this.
Product is sold by weight and not by volume.
In emergency, break glass, pull down handle.
Caution! The edge is closer than you think.
Contents may have settled during shipment.
Do not fold, staple, spindle or mutilate.
Prices subject to change without notice.
Freshest if used before date specified.
Valid only at participating locations.
If swallowed, do not induce vomiting.
You have the right to remain silent.
Do not remove under penalty of law.
This page intentionally left blank.
Use only in well-ventilated areas.
Do not exceed recommended dosage.
No user-serviceable parts inside.
Warning, contents are flammable.
No shirt, no shoes, no service.
Void where prohibited by law.
You break it, you’ve bought it.
You need not be present to win.
Keep out of reach of children.
Part of a daily balanced diet.
First pull up, then pull down.
Apply only to affected areas.
Other restrictions may apply.
Close cover before striking.
Do not think of an elephant.
Viewer discretion advised.
You must be present to win.
Caution, low-flying ideas.
Honk if you can read this.
No purchase is necessary.
More taste, less filling.
Internet access required.
Not a low-calorie food.
Don’t try this at home.
Wash hands after using.
Consume in moderation.
Store in a cool place.
For external use only.
Mix well before using.
Your mileage may vary.
Money-back guarantee.
Shake well before use.
Lather, rinse, repeat.
Use only as directed.
Consume responsibly.
Ignore this notice.
Slippery when wet.
Unplug after use.
Same-day service.
No preservatives.
No trespassing.
No exit.

Other thoughts?

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 )