This book was very difficult to review. In Ordinarily Well: The Case for Antidepressants, Dr. Peter Kramer makes two arguments that I agree with. One is that clinical observation—the interaction by which a medical professional learns about a patient—counts for something. The other is that clinical trials, or evidence-based medicine more generally, are not a replacement for clinical wisdom. He values antidepressants, in particular the selective serotonin reuptake inhibitor (SSRI) class of drugs, and so do I.
Applying support for clinical observation and skepticism about controlled trials to the question of whether antidepressants work, Kramer concludes that these treatments work very well. En route, he focuses on the claims of psychologist Irving Kirsch, among others, that based on clinical trial data, the benefits of antidepressants are all in the mind—a placebo effect. Kramer makes a straw man of Kirsch, but I agree with Kramer that antidepressants do things that are not all in the mind. I too reject Kirsch’s arguments that most of what antidepressants do stems from a placebo effect.
So where did my difficulties in reviewing the book come from? The trouble for me is that Kramer’s clinical vision seems strangely rose-tinted. He is an advocate of using antidepressants to treat depression, but he doesn’t seem to see any of the problems antidepressants cause. The fact that over half of the patients put on them don’t take them beyond a month should be telling. For those who do stay on treatment, he claims, no one has difficulties going off antidepressants with a gradual reduction in dosage. I, however, have patients suffering badly months or even a year later. In the case of any enduring problems, Kramer puts these down to the effects of the illness being treated rather than the medication.
There is no discussion in this book of significant problems that the use of antidepressants can cause. These include SSRI-induced alcoholism, SSRI-induced birth defects, including autism spectrum disorder, or permanent post-SSRI sexual dysfunction. In a 336-page book, the topic of SSRI-induced suicidality gets dealt with in one page. I think many surviving relatives would be astonished to hear that once the psychiatrist Martin Teicher had identified the problem of treatment-induced suicide, it became manageable. Kramer claims that “no case [he has had], not one, has looked like those Teicher has described, drug driven.”
Kramer asks us to believe in clinical observations—his observations. Not yours or mine or anyone’s that might cause the antidepressant bandwagon to wobble. He cites me at multiple points, so he is well aware of my work. But he doesn’t engage with the evidence that I and others have put forth, based on both clinical observations and other material, that SSRIs can unquestionably cause suicides and homicides, and do so to a greater extent than they prevent any of these events.
On the issue of children, suicide, and the black box warnings that antidepressants now carry, Kramer notes that “some of the data have trended the other way, although authoritative studies correlate increased prescribing with reduced adolescent suicide.” This fails to acknowledge that the drugs haven’t been shown to work in this age group. There is no mention that suicidal acts show a statistically significant increase in clinical trials in this age group. Kramer also does not indicate that among all ages, when all trials of antidepressants are analyzed together, they show increased rates of death (mainly from suicide) compared to non-treatment. He seems to have no feel for how compromised the “authorities” are that he uses to downplay the risks.
There are good grounds to be skeptical of the evidence-based medicine that Kramer uses to make his case. Quite aside from the fact that almost all the research literature produced by clinical trials is ghost written by pharmaceutical companies, and the data from them entirely inaccessible, controlled trials aren’t designed to show that drugs work. They work best when they debunk claims for efficacy, rather than the reverse. What’s more, the structure of clinical trials and their statistical analyses are the best method to hide a drug’s adverse effects. Ordinarily Well does not address these significant problems.
If a drug really works, then clinical observation should pick it up. We can tell antihypertensives lower blood pressure, hypoglycemics lower blood sugar, and antipsychotics tranquilize within the hour—all without trials. We can see right in front of us that antipsychotics badly agitate many people within the hour and that SSRIs can do so too. But we cannot see anyone get better on an antidepressant in a way that lets us as convincingly ascribe the effect to the drug. There is much to be said for clinical observation, but also a lot to wonder about when clinical trials suggest that drugs work but we can’t actually see it. For anyone keen to defend clinical observation, Kramer’s book poses real problems and would leave many figuring we need controlled trials instead.
I live and work in the United Kingdom and am acutely aware of some differences between America and Europe that also made it difficult to review this book. There is much more “bio-babble” in America than in Europe, from talk of lowered serotonin to chemical imbalances to neuroplasticity and early treatment preventing brain damage—all of which Kramer reproduces. I felt a John McEnroe “you cannot be serious” coming on at many points. The tone in which some of these points are made suggests that everyone reading them will find what is being said self-evident, when in fact it’s gobbledegook.
All medicines are poisons, and the clinical art is bringing good out of the use of a poison. It strikes me as un-American to even suggest that a drug might be a poison, and Kramer’s book gives no hint of this; the book is, in this sense, deeply non-clinical. He is giving an account of a mythical treatment, as far removed from real medicine as an inflatable sexual partner is from the real thing. It seems to me that he would not see or hear many of the patients I see, or at least would not credit their view of what is happening to them on treatment. This book will misinform anyone likely to take an antidepressant.
It will also cause problems for physicians. This book does not balance the risks and benefits that are intrinsic to medical wisdom. If antidepressants are as effective as Kramer claims, and are as free of problems as he suggests, there is no reason why nurses and pharmacists couldn’t prescribe them. Given that they are much less expensive prescribers, the surprise is that health insurers haven’t moved in this direction.
There is a way to bridge the gulf between Kramer and myself, which involves clinical observation. Most of the beneficial effects Kramer describes can be reframed in terms of an emotional blunting, or the numbing of all emotions, not simply the bad ones. Just like people on an SSRI will nearly universally report genital numbing within 30 minutes of taking their first SSRI—if they’re asked—people will also report some degree of emotional numbing—if asked. They don’t necessarily feel better; they simply feel less.
Unlike the somewhat mystical brain re-engineering Kramer invokes, this emotional blunting can be verified by clinical questioning. If clinical trials were designed to assess whether patients are numbed by these drugs, there would be little need for the fancy statistics that pharmaceutical companies use to claim the targeted benefits of their drugs, since emotional blunting would be evident through clinical questioning. And Irving Kirsch’s arguments about placebo would be irrelevant.
If SSRIs numb emotional experience, this would explain why they help some and not others, and explain the results we see in clinical trials, which are similar to the results that might be expected from a trial of alcohol versus placebo in the milder nervous states in which antidepressant trials have been run. This, then, would present us with a question: what do we think about emotional blunting as a therapeutic tool? Emotional blunting is not a romantic option. It’s a much more ordinary one. If that is the process by which antidepressants work, it does patients an enormous disservice to avoid discussing it entirely, which this book does.
* * * * *
This article also appears
on David Healy’s website.
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.
SSRIs cause mania in a subset of the people put on them, and such SSRI induced manic states can cause people to want to engage in violence and substance use.
Dr. Healy, do you agree with psychiatrists who label people with “bipolar disorder” when SSRIs cause mania, even though such an episode never occurred prior to such use, and might never have occurred without them? What if some of these patients also have a relative who experienced SSRI induced mania?
P.S. I have a lot of experience with SSRI highs. They DO have a stimulant high in people like me. “High” to me, “hypomania/mania” in your jargon.
I’m more interested in the vitriol I’d receive, stating that B1 and B12 are useful in treating depression, should you know the indications for using each.
Yes, I wish MIA would address the findings of Integrative/Functional medicine on treating depression with nutrition. There’s some info buried in a video series, but MIA needs much more info on a regular basis on the home page, where it’s more accessible and updated.
Thanks for this review.
For me the most important part was this,
“Most of the beneficial effects Kramer describes can be reframed in terms of an emotional blunting, or the numbing of all emotions, not simply the bad ones. Just like people on an SSRI will nearly universally report genital numbing within 30 minutes of taking their first SSRI—if they’re asked—people will also report some degree of emotional numbing—if asked. They don’t necessarily feel better; they simply feel less.”
It does sound decidedly less romantic when you unmask “antidepressants” as what they really are – crude emotional numbing agents, not medications treating an illness. And it exposes that psychiatrists are not functioning as doctors treating a well-defined illness.
In that regard David, the only thing I could have suggested to add to your well-written review was a note about how “depression” is not a unitary illness, but a vaguely described syndrome – people feel depressed to greater or lesser degrees for loads of different reasons. The language used around treating this “illness” is completely misleading.
And lastly David, if you can have the insight that psychiatric drugs are blunt instruments that often do harm, perhaps at some point you can discuss the same for ECT.
David, in your intro you say you value ssri. What value do these drugs have for you?
$ame a$ for all p$ychiatri$t$ … $$$? It’s highly profitable to create mania in un$u$pecting patient$ with the $$RI$, because this get$ mi$diagno$ed on a ma$$ive $cale a$ “bipolar,” e$$pecially by the idiot American p$ychiatri$t$, who apparently can’t read their D$M.
And the “bipolar” drug cocktail recommendation$, e$$pecially combining the antidepre$$ant$ and/or the antip$ychotic$, can create the po$itive $y$tem$ of “$chizophrenia,” via anticholinergic toxidrome poi$ioning. And the antip$ychotic$ alone can create the negative $y$tem$ of “$chizophrenia,” via neuroleptic induced deficit $yndrome. And $ince neither of the$e p$ychiatric drug induced toxidrome/$yndrome is li$ted in the D$M, these toxidrome/$yndrome are also almost alway$ mi$diagno$ed as one of the billable D$M di$order$, $ince thi$ i$ the only way the p$ychiatri$t$ can get paid.
Today’$ p$ychiatric $y$tem i$ all one big, gigantic, wildly profitable, iatrogenic illness creation $y$tem. Of cour$e, making people $ick for profit i$ the oppo$ite of appropriate medical care though.
I’m pasting in a post I found on an Alzheimer’s forum. It’s a reminder of what we are up against, and also suggests that our messaging can be misunderstood as alarmism and perceived as harmful by people who still believe in The Drugs.
[start quoted material]
Re: Aricept Results
My Mom’s primary care prescribed Zoloft for her about 6 months ago. I was thrilled. She has needed help long before the dementia issues arose.
Well, she didn’t start taking it for weeks but I could tell when she did. I asked and, sure enough, she’d been on it 3 weeks at the time. Then she began to sink back down and, sure enough, she’d stopped.
She told me she heard one of those stories on the news about a teenager who killed his family because he was on Zoloft so she stopped it.
Of course, I can’t even begin to explain to her. I did mention that the boy (I’d heard the story too) had been a problem for years and that he’d only been on the Zoloft for 2 weeks. [Which is exactly when to expect it. Note that he’d “been a problem for years” but had not killed his family until starting on Zoloft.]
And that his defense attorney’s [sic] did that for a living, trying to find a reason other than personal
responsibilities for doing something. [I’m starting to think this is a pharma shill…]
Then I got off my soapbox and just let it go.
I also asked her if she was dropping a hint that she’d been thinking about killing her family. And, if so, to start with one of my brothers. [Ha ha ha]
She even got a giggle out of that. Sure wish she’d stayed on Zoloft.
[end quoted material]
(posted May, 2005 on healthboards.com/boards/alzheimers-disease-dementia/)
My mom insists on relying on celexa for her depression. I wish she didn’t. She’s sure she needs it to feel better because of her “brain chemical imbalance.”
Let’s see…she gets very little physical or mental exercise. Watches 7-9 hours of TV a day. More if she doesn’t go out. Does very little beyond basic housework and occasional errands since retiring. Not much of a social network either.
I can’t think of why she’s so depressed. It must be physiological in origin! 😛
What a disgusting liar Dr. Kramer is! I would trust a meth dealer before I would that self-serving hypocrite.
I believed in the drugs…. until they destroyed my life.
@randall: I’m glad to see the DRUGS only destroyed your life, and not ended it. I’ve never seen anybody come back from the DEAD. BUT, I HAVE seen destroyed lives rebuilt. That’s basically MY STORY….
Psych drugs and the pseudoscience drug racket of psychiatry, did me far more harm than good. Psych drugs only ALMOST killed me…. randall’s “10 little words” SAY SO MUCH!…. I’m glad you’re here, randall….
“All medicines are poisons, and the clinical art is bringing good out of the use of a poison.”
Please, tell me you’re kidding, David.
At least Dr. Healy tells the truth. If 90% of mainstream psychiatrists (not counting dissidents like Dr. William Glassner and Dr. Breggner) were as open and honest as Healy is that would be a huge improvement.
We would still have work to do, but it would be a step in the right direction!
I did not find that the SNRI I was taking blunted my emotions. It made me feel more and it made me hypomanic.
The “blunting” I experienced came with ECT, which acted as an emotional electrical lobotomy, destroying my feelings, my memory, and my intellect. Like Matt, I would like to see Dr. Healy address the “blunt instrument causing more harm than good” aspect of the Craniocerebral trauma that is ECT.
So-called “ECT” = ELECTRO-CUTION TORTURE…. ECT is electro-cution torture….. I spent some time today with my friend, who suffered ECT years ago. I can easily see the subtle, long-term damage done….. And the psych drugs she is FORCED to take, are hurting her, too…. Thank-you, “truth”….
I find this piece confusing. Healy seems to be coming down on both sides of the anti-depressant fence. I fail to see why, with everything we know about these drugs and how they are/were promoted, why anyone would take them. At all. For anything. Ever. I would exercise, start to load up on supplements as has been mentioned (Bs and D appear very significant, try the amino acids, St. John’s Wort…), do laughter yoga… in short do ANYTHING EXCEPT pop these drugs. Even IF they work, they only do so for a limited period (see Dr. Datis Kharrazian and his work) and then there’s the job of getting off of them. And I’m just thinking of myself as an adult here. I would NEVER, NEVER, NEVER allow my CHILDREN to take them (!!). So I’m baffled here.
@Liz Sydney: I think Dr. Healy was less than fully honest in failing to disclose that the author of this book, Peter Kramer, also wrote “Listening to Prozac”, which as you know was a huge popular hit 20 years ago…. And, Dr. Healy DOES say, in the first paragraph, that he “does value” “SSRI’s”….
While I agree with you more than it might look like, we have to admit, that sometimes, SOME folks DO seem to get relief and benefit from SSRI’s, and other neurotoxins. I think we’d be extremist fanatics, and stupid, if we claimed that “Nobody is ever helped by any psych drugs.”…. But, saying that anybody is helped, is NOT the same as saying that they *need* the drugs. Maybe they *do* *need* them. It makes little sense to me. And what most disturbs me, is there is NO legitimate research, or even talk of doing such, that would show who would, or would not benefit. It’s like “pharmaceutical roulette”…. I consider Dr. Healy an ally, and if anybody is gonna take neurotoxins, I’d rather they were prescribed by folks like Dr. Healy, say, than Dr. Frances! At least Healy *tries* to be logical, rational, and objective about drugs! That’s MY take, anyway! ~B./
This is a great review. It points out how profound venomagnosia can be. Imagine writing a whole book about these drugs and having no sense of the downside. “He is giving an account of a mythical treatment, as far removed from real medicine as an inflatable sexual partner is from the real thing.” (I love this quote).
I agree that the effect that the drugs have is to cause emotional numbing. Medicine is filled with hard decisions. At times some emotional numbing can be merciful.
There’s a difference between short-term use of codeine after an invasive surgery and long-term use of the drug.
No doctor would tell someone recovering from an appendectomy that he would always be dependent on codeine for his missing appendix because it was “like insulin for diabetes.” The only reason they do that kind of thing to folks they call mentally ill is because they, like most others despise us.
Since they think we have nothing to contribute to society–to their way of thinking–we are only useful as guinea pigs to experiment on. And society is happy to let them, under the delusion that keeping us drugged will keep them “safe.”