Now in the current issue of Skeptic, I have an article called “Depression Treatment: What Works and How We Know” (article rights owned by Skeptic but which I am allowed to republish on my web site). I thought that some of you would be interested in what happened to this article at the Huffington Post.
I am a Huffington Post blogger, and after I first submitted this article as a blog to the Huffington Post in December 2010, an editor emailed me that she wanted to run it not just as a blog but as a “feature,” saying “It’s a very hot topic and should get a lot of exposure.” She told me that their medical review board wanted information on antidepressant efficacy for the “seriously depressed,” and so I added it (including the Irving Kirsch quote about this). She also wanted me to change myths in the original title (“5 Depression Treatment Myths: Good News for Critically Thinking Depression Sufferers”) to controversies, which I agreed to. However, then prior to publication, I noticed that they had made some other changes, including a shocking “Editors’s Note” about electroshock (ECT), and so I emailed them
If HuffPo wants to call them “controversial beliefs” rather than “myths” in this context, I’ll accept that.
The other addition that HuffPo made about ECT that I noticed, I simply cannot accept — even as an editor’s note — because it is not true. [The Huffington Post Editor’s Note was: “ECT is now a safe, life-saving treatment for people with psychotic depression or severe, suicidal depression that does not respond to a systematic approach that combines medication and therapy.”]
Let me explain, in the January 2007 the journal Neuropsychopharamacology published an article (see reference below) about a large-scale study on the cognitive effects (immediately and six months later) of currently used ECT techniques. The researchers found that modern ECT techniques produce “pronounced slowing of reaction time” and “persisting retrograde amnesia” (the inability to recall events before the onset of amnesia) that continues six-months after treatment. I should add that the leading researcher here, Harold Sackheim, had previously been known as a strong ECT advocate. So, I certainly would not call ECT “safe” and the research tells us, as I pointed out, that ECT, scientifically speaking, is not all that effective.
Harold A. Sackeim, et al., “The Cognitive Effects of Electroconvulsive Therapy in Community Settings, Neuropsychopharamacology (2007) 32: 244-254.
Following my email about ECT, my article was never published, neither as a blog or as feature, and I received an email from the boss of the editor who had initially been so enthusiastic about the article. The higher-up’s email said:
I don’t want to take up any more of your time — I know you’re busy. I’d like to apologize for the back and forth. [My subordinate] should have waited until she heard from our medical reviewer before having you do any additional work/sourcing. As it is, I am going to pass on the piece for Health. I look forward to your next submission and promise a smoother process going forward.
I republished parts of this article in other zines, and the good news is that this article is now, in its entirety with full references, on the newsstands (in the same section as Scientific American) in the current issue of Skeptic, which has titled the article “Depression Treatment: What Works and How We Know.”
Bruce E. Levine, a practicing clinical psychologist, writes and speaks about how society, culture, politics and psychology intersect. His latest book is Get Up, Stand Up: Uniting Populists, Energizing the Defeated, and Battling the Corporate Elite. His Web site is www.brucelevine.net
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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Huffington Post has a longstanding love affair with biological psychiatry.
Even forced drugging lobbyist DJ Jaffe “writes” for Huffington Post.
Huff does have a regular blog by Breggin. Maybe they try to have both sides heard.
I loved the article. Thanks for making me discovery Williams James: “Faith in a fact can help create the fact.”.
I have been a fan of Skeptic magazine for years, and the only thing that has occasionally bothered me about that literature is that self-fulfilling prophecies, placebos, beliefs and faith have always been dismissed as anomalies that should be indiscriminately removed from the face of the earth, rather than identified for what they are.
What is dangerous is the inability to distinguish between faith and science, between beliefs and knowledge, between assumptions and the laws of nature (and thanks for Skeptic for helping making those distinctions). But faith that is acknowledged as faith can be a force for good (for optimism, mental health, and motivation, and to change the world for the better in any area related to the human mind).
I am glad you got to publish in Skeptic an article debunking the fact that faith is all bad or incompatible with critical thinking.
“From several classic studies, we know that moderately depressed people are, in a sense, more critically thinking than are non-depressed people.”. Isn’t your article showing that this is likely just a self-fulfilling prophecy, resulting from the irrational belief that “critical thinking is not compatible with faith”. Once debunked, critical thinking becomes compatible with reasonable optimism, and reasonable happiness.
Your article is an excellent summary, Dr. Levine.
About STAR*D — About 4,000 people were switched on and off drugs in the STAR*D study, yet the data contain not a single case of antidepressant withdrawal syndrome.
Given the prevalence of withdrawal syndrome (30%-80%), this is not a credible result. A washout period of a couple of weeks between antidepressant trials is simply not enough time for withdrawal symptoms to vanish completely.
The multicenter STAR*D study (inconsistent criteria, study supervision, and scoring) only used an instrument to capture symptoms of depression as a scoring device; it contained no questions pertaining to withdrawal symptoms. Withdrawal syndrome was most likely counted as “relapse,” sending the subject on to the next leg of the study.
If data about withdrawal symptoms had been captured, STAR*D’s questionable statistics showing antidepressant efficacy would be even more questionable. Efficacy probably would be firmly in the negative column — more harm than good.
Of course withdrawal wasn’t looked at, because the Star*D project was funded by a pharmaceutical company and ran by a psychiatrists heavily funded his whole career by Pharma.
According to the article, STAR*D was a U.S. taxpayer funded study:
“…to the exasperation of many scientists, there was no placebo control in this $35 million U.S. taxpayer funded STAR*D study. And to make matters worse, STAR*D researchers disclosed receiving consulting and speaker fees from the pharmaceutical companies that manufacture the antidepressants studied in STAR*D.”
I have no trouble believing that chemical imbalances and brain malfunctions occurred during my mental illness but psychoneuroimunological studies that prove how the emotional system is an interdependent partner with all other body systems and provide evidence that thought can and does become chemistry, validate my belief that in my case, at least, the chemical imbalances resulted from my diseased emotions rather than the other way around. Though I cannot speak for other cases of mental illness, I am grateful that I was spared a diagnosis that implied that my illness was due to a genetic or chemical imbalance and beyond my control.
Any story that reduces my experience to the part of me that can be placed in a test tube or seen under a microscope would negate an immense part of me that was fully engaged in the psychosis. The part that I have been taught to define as my soul or my psyche was moved during and by my experience to the point of allowing me to change the direction of my life and the value I place on my existence.
“I have no trouble believing that chemical imbalances and brain malfunctions occurred during my mental illness but psychoneuroimunological studies that prove how the emotional system is an interdependent partner with all other body systems and provide evidence that thought can and does become chemistry, validate my belief that in my case, at least, the chemical imbalances resulted from my diseased emotions rather than the other way around.”
I live on a planet where no other human beings can offer the brain chemical measurement service, nor do any of these human beings know what a properly ‘measured’ brain chemical deal would look like, so I don’t make any claims about my brain chemistry.
Nor do claim an experience or crisis is an ‘illness’, there is nothing ‘medical’ here, apart from the ‘stories’ we are told, and the roles the fake doctors play in the pseudomedical theater that is psychiatry.
Excellent comment, excellent writing, Anonymous.
I worked in Texas right before STAR*D started and interviewed with the research head of the project. It was only taxpaper supported in the sense that the routine patient care under the protocol was covered as usual by the state. All the important research hypotheses and decisions were under Pharma influence and funding.
I’m not a bit surprised!
We can agree the STAR*D results, no matter how they’re sliced, are suspect.
And, of course, no alternative servies like psychotherapy and recovery-services were included or compared.
According to the article, STAR*D included some cognitive behavioral therapy for comparison with the pharmaceuticals:
“…three groups in Step Two switched from Celexa to one of three antidepressants, and their remission rates ranged from 25 to 26.6%; but one group in Step Two switched from Celexa to cognitive therapy, and its remission rate was 41.9%. STAR*D researchers did not assess whether any differences in treatment effectiveness were statistically significant.”
I recommend article.
To view it, click on link, above, that reads:
“Depression Treatment: What Works and How We Know.”
I have a universal theory of shame as the basis of all so-called mental illness–shame as the internalization of oppression of one kind or another. Therapy that works is therapy in which the therapist does not shame the patient (for instance, by invalidating their life experience by saying their distress is meaningless and organic; or by denying shame caused by the family and the social system by ocating the problem within the patient) and that creates an environment of trust in which unacknowledged shame (from family and social sources) can come to consciousness and be examined and externalized.
If the problem of unacknowledged shame is not dealt with, therapy will go nowhere. It is hard for therapists to deal with shame, because of their own shame avoidance. Thus a good therapist has is one who has come to terms with their own shame.
I think that CBT therapy can function, like drugs, to deny and suppress shame, because it attempts to work on shame-generated thought patterns (low self-worth, etc.) without going into the underlying shame itself.
I think the reason that one therapy works as well as another, is because what actually makes therapy work is the nature of the bond between the patient and the therapist — whether is is honest and respectful and treats the patient’s experience as meaningful. Obviously treating the patients thoughts, feelings and emotions as “moods” or “affect” or “symptoms” or “like diabetes” is highly disrespectful and silencing. With respect, therapy is a collaboration.
I say this as someone who spent years in ineffective therapy, with a number of different therapists, as well as being prescribed antidepressants, anti-convulsants, anti-psychotics and benzos. My last therapist was willing to work with me without drugs, and I am off all psych drugs for 3 years now, and making real progress through therapy…
Shame is the lynchpin!
Congratulations on your progress, lydiaeccles. I agree with you that shame and oppression are so huge in this.
Two thoughts…1st, great job Bruce. Below is the research conducted on ECT. I have placed the citations in order below of appearance. I highlighted this work in another blog response, and will start blogging for Mindfreedom soon…
In 1979, the FDA categorized the ECT device as a Class III, high risk device, meaning that it’s benefits have not been shown to outweigh its risks, and that it presents a “potential unreasonable risk of injury or illness.” It ruled that brain damage and memory loss were risks of the procedure. Thirty plus years later and most recently within the past two years, the FDA upheld it’s decision to keep the Class III listing, as no evidence has accumulated to disprove these findings. Rather, rather there has been a stream of continued evidence in the research demonstrating significant harmful effects.
There are seventy years of reports of permanent extensive amnesia and memory dysfunction in a large percentage or majority of patients. Reviewing the evidence to date, in 1985 the NIMH Consensus Conference on ECT found that the average loss was eight months of life and that the majority of ECT patients had chronic memory impairment three years after “treatment”. More recently, the first-ever systematic review of all the evidence to that date (2003) found that at least one-third of ECT patients experienced permanent memory loss. An even more recent prospective study found that at least 45% of patients experienced permanent amnesia, and 40% reported loss of intelligence.
The research on permanent amnesia can be summarized as follows: researchers have mostly avoided conducting any long term, six months or longer, studies, but
whenever they have looked for permanent memory deficits, they have found them. There have been only two long term (e.g. six month) studies of amnesia done in the past 33 years, and both, despite serious methodological problems, show that permanent extensive amnesia is common. One found “provocative evidence for autobiographical memory loss lasting at least six months” and the other, the largest study of memory ever done, concluded “adverse effects can persist for an extended period, and (usage) characterizes routine use of ECT in community settings.”
In seven decades there here have been only two methodologically sound randomized controlled clinical trials investigating whether ECT is more effective than drugs, and neither of these studies compared shock to drugs currently in use today. Interestingly, it has never been compared to other forms of treatment.
In 1992 and again in 2006 researchers systematically reviewed the literature on real vs. sham ECT and concluded the studies show no advantage for real ECT. Even the most recent American Psychiatric Association Task Force report, though it asserts ECT’s efficacy, did not cite a single study showing real ECT having a superior outcome to a sham ECT, when treating depression.
In 1985, the NIMH found there was no evidence for any benefit of ECT lasting more than four weeks, and there are no studies since 1985 showing any longer benefit other than Huuhka, Viikki, Tammentie’s study just published in the Journal of ECT (Apr., 2012). Huuhka et al acknowledged the relapse rate of short term c/mECT for depressed patients is 40-60% even with anti-depressant medication continuing, and for patients with more severe pathology (e.g. schizophrenia, bipolar), patients were even more likely to relapse within 8-12 months.
Another large recent study indicated approximately one half of patients had no significant improvement to ECT, even in the very short term, and the majority who relapsed within one and six months later were suffering long term adverse effects, while overall only 10% were in remission. And an even more recent study found claims of 70-90% efficacy to be wildly inflated, with the actual rates from 30 to 46%; however, these positive outcomes were measured only in the few days immediately after ECT.
Despite claims repeatedly made that ECT is safe and effective for severe depression and helps with suicide, research shows that ECT has no protective effect against suicide either in the short or long term. In one of the very few studies ever performed, researchers in 1985 found that ECT patients committed suicide more frequently than those who had not received ECT, even when level of depression was taken into account.
Finally, in the January 2007 journal Neuropsychopharamacology researchers highlighted in a large scale study how current ECT techniques used still produce cognitive effects immediately and after six months post ECT. They state ECT produces “pronounced slowing of reaction time” and significant “persisting retrograde amnesia”. Dr. Harold Sackheim, the chief researcher had been a strong ECT advocate.
Recall, prior to modern brain imaging technology, dozens of human and animal autopsy studies documented brain damage from ECT. In the modern era, brain scan studies of psychiatric patients show a correlation between treatment with ECT and cerebral atrophy. The very few studies which set out to investigate the question of ECT’s effects on brain structure are both seriously methodologically flawed and inconclusive (i.e. they did not use normal controls, and allowed patients who had previously had shock to be considered as “before shock” or non shock subjects.)
The literature on permanent memory loss from the 1940s through 2009 is summarized in L. Andre, op. cit.
‘ “Consensus Conference: Electroconvulsive Therapy,” Journal of the American Medical Association 254 (15), (1985, October 18), 2103-2108.
D. Rose, P. Fleischmann et al, “Patients’ Perspectives on Electroconvulsive Therapy: Systematic Review,” British Medical Journal 326 (7403), (2003, June 21), 1363-1367.
M. Philpot, C. Collins et al, “Eliciting Users’ Views of ECT in Two Mental Health Trusts with a User Designed Questionnaire,” Journal of Mental Health 13(4), (2004, August), 403-413.
R. Weiner et al, “Effects of Stimulus Parameters on Cognitive Side Effects,” Annals of the NY Academy of Sciences 462 (1986), 315-325; H. Sackeim, J. Prudic et al,“The Cognitive Effects of Electroconvulsive Therapy in Community Settings,” Neuropsychopharmacology 32 (2007), 244-254.
A. Rivkin, “Shock Therapy: A History of Electroconvulsive Treatment in Mental Illness” (book review), New England Journal of Medicine 358(2), (2008, January 10), 204-205.
G. Shepard, S. Ahmed, “A Critical Review of the Controlled Real vs. Sham ECT Studies in Depressive Illness,” paper presented at the First European Symposium on ECT, Graz, Austria, March 1992. C. Ross, “The Sham ECT Literature: Implications for Consent to ECT,” Ethical Human Psychology and Psychiatry 8(1), (2006), 17-28.
H. Sackeim, R. Haskett et al, “Continuation Pharmacotherapy in the Prevention of Relapse Following Electroconvulsive Therapy,” Journal of the American Medical Association 285(10), (2001, March 14), 1299-1307.
J. Prudic, M. Olfson et al, “Effectiveness of Electroconvulsive Therapy in Community Settings,” Biological Psychiatry 55 (2004), 301-312.
V. Milstein, J. G. Small et al, “Does Electroconvulsive Therapy Prevent Suicide?” Convulsive Therapy 2(1), 1986, 3-6.
T. Munk-Olsen, P. Videbech et al, “All-Cause Mortality Among Recipients of Electroconvulsive Therapy,” British Journal of Psychiatry 190 (2007), 435-439.
H. Huuhka, M. Viikki, T. Tammentie et al, “One-Year Follow Up After Discontinuing Maintenance Electroconvulsive Therapy,” Journal of ECT (April 24, 2012).
Harold A. Sackeim, et al., “The Cognitive Effects of Electroconvulsive Therapy in Community Settings, Neuropsychopharamacology (2007) 32: 244-254.