The Psychiatrist’s Dilemma: In Defense of Placebo Psychiatry

In a recent post, Robert Whitaker asked us to consider the psychiatrist’s dilemma:

“Patients were told they suffered from a chemical imbalance in the brain, the public understood that was true, and all the while academic psychiatrists—and APA leaders—knew that it wasn’t. This obviously presented psychiatrists with a ‘cognitive dissonance’ moment: how could they reconcile those facts with their own self-image as medical doctors who treat their patients well, and in an ethical manner?”

In this regard, I began to wonder if the facts are really so problematic for doctors.  Let’s consider the situation from the perspective of an ethical and rational psychiatrist.

First:  The Way the Brain Works Is a Mystery

Most knowledgeable folks, psychiatrists included, agree that we have only a very crude understanding of how the human brain produces our mental and emotional experience.  So even if the serotonin theory of depression is debunked, that doesn’t necessarily invalidate drug treatment.  It just makes it a mystery about how the drugs work.  There are many (most?) prescription drugs for which the mechanism by which they produce their impact is unknown or merely hypothesized.

And telling stories they know are or may be untrue has become standard practice in psychiatry.  After all, we are dealing with mentally impaired patients; we know better than they what is best for them.  Telling them, for example, that antipsychotics are “like insulin for diabetes” is justified by the false belief that the drugs are highly effective, necessary, and safe.  Thus, psychiatrists feel justified in focusing their efforts on getting patients to take their medications.

Once you have such a conviction, it is a small step to set aside the need to provide truly informed consent, especially when you have technical training and expertise unavailable to lay persons.  Furthermore, there is a frequently unexplored assumption that patients suffering from “mental illness” are incapable of using reasonable judgment regarding their care.  So, even if you are just telling a story and you happen to be one of the psychiatrists who knows the story is untrue, there may not be a great deal of painful dissonance.  And, in my experience, it is simply a fact that many medical doctors, including psychiatrists, still don’t know that the “correcting chemical imbalances” story is untrue.

Second:  They Are Not Just Prescribers; They’re Users

A personal experience suggested to me that the “better living through chemistry” philosophy may be more than an approach to the treatment of others; it may be far along in the process of becoming a belief system—a way of life among mental health clinicians.

More than 20 years ago when I was the primary source of income for my wife and two young sons, I applied for a million-dollar life insurance policy.  The insurance company sent a phlebotomist to my home.  After I came out of my bathroom, she also measured the temperature of the urine sample I had just provided; for them to bet a million dollars that I wouldn’t die, they wanted to be sure they were getting blood and urine samples from the actual applicant.  Then, after having my blood drawn and answering detailed questions regarding my medical history, I was required to sign numerous forms allowing the insurance company to collect verifying information from just about anybody I had ever known.  There was no sense trying to hide anything in my medical history as I was giving them permission to check with everyone who had ever treated me.  So, like most such life insurance applicants, I told the truth.

When we were done, as she was leaving, she mentioned that I was the first of the psychiatrists or psychologists she had interviewed who was not taking an antidepressant and/or Ritalin.  She said she was repeatedly surprised to find that many were using both simultaneously!

I was stunned.  The first!  You have to realize that her service area was Newton, Massachusetts.  In Newton, there is a zoning law that requires at least one psychologist or psychiatrist on every block.  (Seriously, there are a lot of us in Newton.)  I asked her to sit down for just a minute while I asked questions to verify her offhand comment.  She had been doing this for years.  She had been somewhat surprised when she first started to learn about this unbroken pattern.  And she was then genuinely surprised that day to come across a psychologist who wasn’t taking an antidepressant, a stimulant, or both.

I immediately realized that there would be no way to get information like this from a research survey.  Anonymous surveys might, at best, get a 10% response rate that would be biased by the characteristics of those who were willing to report their drug usage.  This data was research gold.  Based on just this sample, we can be statistically certain that probably over 90% (but definitely over 80%) of those mental health clinicians applying for life insurance are taking an antidepressant, a stimulant, or both!  And while life insurance applicants may not be a random sample, we know from actuarial statistics that they are not all that different from the general population.  In fact, the whole purpose of interviewing and getting information releases is done to ensure that the applicant is not likely to be an outlier whose risk of death is outside of the norm.

Fuller disclosure

By the way, for full disclosure, about seven years earlier in an attempt to save my first marriage, I obtained a six-month supply of fluoxetine (Prozac) from my primary care provider.  And it almost worked.  I was less reactive and easier to get along with.  Unfortunately, the problems in my marriage had become deeply ingrained and were not just due to my reactivity; the changes were too little too late.

In any case, one day during this time I went to the gym.  As I was walking in, I noticed that my mouth was quite dry and I was very thirsty, which I recognized as a common side effect.  Then I was startled as I realized that, despite my thirst, I had walked by the water fountain without noticing it.  For me, Prozac wasn’t an “antidepressant.”  Rather; it made me less reactive, slightly less sensitive to impinging sensations whether they were thirst, hunger (they were originally going to market Prozac as a diet drug), sexual arousal (it made having an orgasm markedly more difficult), or emotional states.  Being less sensitive to one’s feelings can be experienced as either “emotionally deadening” (a commonly reported side effect of the antidepressants) or as a relief from chronically painful ruminations.

By the way, the reason these drugs weren’t marketed for weight reduction is that there is a tendency for the body to adjust to their effects; the appetite reducing effect would then go away and weight would not only revert back, but frequently there is unwanted weight gain.  You could then up the dosage but the process would be repeated.  Eventually, one would be on a fairly high dose and when the body again adjusted you couldn’t increase it further.  Now you’d have a person whose body was accustomed to the presence of a high dose of a drug that had none of the intended effect and plenty of adverse side effects.  Withdrawal, however, would often leave the drug-adjusted body without the chemical it had adjusted to, which then produced another set of problematic effects.  Though this scenario was not actualized with the drugs as diet pills, this is precisely what we now often see after those same chemicals were marketed as antidepressants.

Third:  We Have Evidence of Significant Improvement

As noted, for some people, being less reactive to unpleasant thoughts and feelings might very well be a relief.  In a recent meta-analysis of the drug trials submitted by the pharmaceutical companies to the FDA, a small proportion of folks who took an antidepressant did appear to experience a clinically significant decrease in the standard depression score used in research studies.  About 10% of those taking a placebo experienced this improvement vs 25% of those taking an antidepressant, yielding an improvement over placebo that appears to actually be due to the drug in about one in seven patients (15%).

Given my experience, I believe that the mechanism of additional relief over the placebo effect for those folks with a significant decrease in depression scores may have been the reduction in their reactivity to their worries and concerns.  15% of those in the drug trials may have benefited from reactivity reduction that doubled the average decrease in depression scores produced by placebos alone.  (A more detailed discussion of the meta-analysis is presented here.)

It is important to note that the majority of private practice psychiatrists and primary care providers who prescribe most of the antidepressants aren’t working in clinical psychiatric settings of the kind where the research was carried out.  Like my case, many people who are prescribed antidepressants don’t present themselves at clinics seeking relief from depression.  I was worried and very unhappy about my situation (my failing marriage), and often angry.

I may have been a member of a population with unease that is likely to resolve itself; throughout human history, most people recovered from painful losses and other temporary stresses without medication.  This population is probably underrepresented among truly depressed patients who seek help specifically for depression in psychiatric clinics and is probably overrepresented in the practices of those physicians who prescribe most of the antidepressants.  Thus, the real-world experience of many prescribers may not match the reality found in the clinical studies:  The drugs don’t work for the majority of depressed people who have long standing depression, especially when their depression is a response, as it often is, to overwhelming problems.

A colleague of mine consulted with a medical service run by a university medical school in a large city in an extremely poor black neighborhood rife with social problems.  She told me that when she asked the department chair about the effectiveness of drugs, “He just sort of shrugged and said, ‘The people we see have shitty lives. No drug is going to fix that.’”

In contrast, reducing reactivity in those who are just going through a temporarily stressful period may make the drugs appear to the prescribers to be more effective than they are for those who suffer from true clinical depression.  And though reactivity reduction may be helpful at times, it has its down side.

Regarding the latter, back in 2004 shortly before Loren Mosher died, I did a video interview with him and Bob Whitaker.  Loren told us that this decrease in reactivity to internal concerns appears to be the mechanism by which an increase in suicide and lethal violence is produced in a small percentage of young folks taking antidepressants.  Adolescence is a time of turmoil.  During turmoil, turning down one’s inhibiting thoughts and feelings can be dangerous.  And as of today, we have no way of identifying the 15% who may get significant relief from these drugs from the 85% who don’t, some of whom will suffer the negative and sometimes tragic effects of these medications.

The Limits of the Prescriber’s Perspective

Analyses of the clinical trials of antidepressants have found that there is only a very slight difference in symptom reduction between the antidepressant and placebo groups. However, the prescribing physician never sees the similarity between drug and placebo responses.  Having no comparison group in their clinical practice, the prescriber will naturally attribute all of the improvement to the drug.

Based on the recent meta-analysis, the clinician is likely to see that, on average, their drug-treated patients have some modest symptom reduction, which in the FDA trials was a 10-point decrease on the Hamilton Depression Scale.  They will attribute all of that improvement to the drug, forgetting the placebo response altogether.  They won’t be seeing that in those same trials the average placebo patient improved by 8-points.  Two points is a negligible, clinically insignificant difference on this 52-point scale.

In short, the clinicians have no access to the perspective and understanding that comes from comparing drug response to placebo response.

Furthermore, patients without any improvement along with those who experience significant adverse reactions are more likely to stop taking medication and drop out of treatment; not needing follow-ups for refills, they are simply less likely to continue to see the prescriber.  This means that those without improvement and those whose experience is negative will be less visible.  So, for the prescriber, the picture is of prescribing and getting generally positive results.  When patients with negative results do continue in treatment, then “that’s the disease coming back” or we are dealing with “treatment resistant depression,” a label, which, in one study of real life patients, was given to 41% of long-term patients.

Thus, most psychiatrists have treated people with antidepressants and seen improvements, with negative impacts being less visible to them.  Of course, the research shows us that the good results are seen in a fairly small minority of patients and are due in large part to the very real and significant placebo effect and the natural tendency for depression to remit.  But how are psychiatrists supposed to know the cause of the improvement based on their direct experience?  They prescribe.  On average, patients get better; sometimes dramatically so.  As David Hume noted in A Treatise of Human Nature:

“A CAUSE is an object precedent and contiguous to another, and so united with it that the idea of the one determines the mind to form the idea of the other, and the impression of the one to form a more lively idea of the other.”

Indeed, the function of research is to differentiate between what seems to be causal in our limited experience composed of sequential, contiguous events, from what is really operating in a causal manner (though Hume might insist that all we ever have are mental impressions of contiguous events and we then just call the precedents “causes”).

Yet, even if psychiatrists read the actual research to get a better grasp on the meaning of their limited personal experience, they would see that the evidence seems to indicate that, in addition to the small group for whom the drugs appear to double the average placebo effect, there may be some real improvement among the very severely depressed over placebo, though a recent study casts doubt on this and suggests that the severely depressed may benefit the least. Less uncertain, they would learn that placebos clearly show some limited improvement (the average eight-point reduction in depression scores).  So, the evidence shows that antidepressants are drugs that may help the very severely depressed (a little), about one in seven a significant amount, and they also provide all the (real) benefit of taking a placebo.

And in Short Term Use They Are Relatively Safe

If we were to try to hold psychiatrists responsible for the small but real increase in the risk of violence and suicide and other unpleasant side effects that antidepressants cause, we must keep in mind that many medications that medical doctors routinely prescribe can cause extreme damage (often even referred to as “death” in the warnings included in today’s endless TV ads for drugs).  And the long term poor outcomes (see Rush, et al. and Piggott, et al.) for those on antidepressants are not readily apparent in practice since so many intervening, real life events seem to be responsible for the ups and downs experienced by long term patients.  Additionally, as noted, a positive view of the medications is bolstered further by the fact that patients with adverse reactions are more likely to drop out of treatment making the negative effects less visible to the prescriber.

Back in 1995, a very large Consumer Reports survey showed that “patients benefitted very substantially from psychotherapy … and that psychotherapy alone did not differ in effectiveness from medication plus psychotherapy.”  So, the benefit from therapy versus therapy plus medication was identical; on average, there was no additional benefit from adding medication to psychotherapy.  If, as in the FDA drug trials, 15% of those in that survey sample who received antidepressants experienced a large improvement, then there must have been as much harm produced for the overall effect of drug vs no drug to have been the same.  That is to say, if medication was significantly helpful in some cases, it must have been equally harmful in others in order for the presence and absence of antidepressants to have shown no statistical difference.  However, since the medication plus therapy group tended to do as well as the therapy only group, all of whom on average “benefitted very substantially,” most of the medication patients in this study improved.  Thus, even though, on average, the medication did not help and in some cases probably caused significant harm, the clinician’s overall experience was that their patients who took medication improved.

So, we need to remember that, in their training to be medical doctors, psychiatrists had to come to terms with the fact that interventions with real power to change things for the better will, on occasion, produce tragic results.  (Which of course is what led Peter Parker’s uncle to warn Spider Man about the relationship between responsibility and power.)  Before they even start their training to become psychiatrists, they will have had to come to terms with the fact that unavoidably negative outcomes will occur in the practice of medicine.

Then, having no experience actually treating mental disorders, in their psychiatric residencies, they turn for instruction to the experts in their field, which is largely focused on the administration of psychotropic medications.  When they then compare what they were taught about how they can intervene helpfully with drugs with their actual experience, they appear to have a significant basis for accepting what they were told.  In their clinical experience, (1) antidepressants appear to be helpful, (2) there is no direct experience of the lack of a significant clinical benefit over placebo that the drugs provide to most people, (3) there is little experience of the non-existent benefit and not infrequently negative experience of those who are not responsive to the placebo effect provided by taking medication (many of whom drop out of treatment), and (4) there is even less experience of the very serious harm the drugs can occasionally cause.

The Profound Power of the Pen, Personality, and Placebo

There is no question that the act of writing a prescription for an antidepressant often provides a foundation for a hopeful bond between a psychiatrist and a patient.  And both — hope and human bonds — appear to be helpful when dealing with the inevitable pain of living.

Furthermore, we know that the impact of placebos can be greatly affected by their presentation.  In this regard, consider that some psychiatrists (like some people in general) are very good at appearing confident and forming a caring bond, which together provide the essence of a supportive and hopeful relationship.  This combination may, in turn, be essential in helping people recover from depression (with or without any form of “treatment”).  And some psychiatrists (like some people in general) are quite inept at forging this type of relationship.

This variability must be considered in the context of the fact that the research shows little difference for the vast majority of folks experiencing depression between antidepressants and placebos.  The advantage that the drugs may produce in many cases could be due to the fact that they simply function as psychoactive placebos, i.e., placebos that produce enough impact on patients’ experience to make it seem certain that they are taking a real medication and are not in the placebo arm of the research.  The significant improvements then experienced by a small subset of patients may be in large part due to what happens when more personable therapists with strong, confident personalities prescribe a psychoactive placebo.  If this is so, then the drugs are not directly more curative of depression than placebos; they just help create a stronger placebo effect.

In addition, I am claiming that some psychiatrists are very skilled at maximizing the (real and significant) placebo effect when they administer antidepressants (or other placebos).  In addition to the actual relief some may experience from taking a drug that makes one less emotionally reactive, a bond with a convincing, charismatic therapist may accentuate the placebo aspect bringing total relief into the realm of significance for the 15%.

So, to recap:  There appears to be a tendency for antidepressants to reduce emotional reactivity which for some people may include a significant decrease in distressing thoughts and feelings.  We also know that the placebo effect is clearly beneficial for a significant number of those suffering from depression.  Furthermore, it is likely that some psychiatrists are highly effective in forming a charismatic, caring bond that amplifies the placebo effect.  Such psychiatrists then are likely to see higher rates of improvement in their patients than the average that is reported in the literature.  These psychiatrists (and Aftab who accused Bob Whitaker of twisting the truth and misrepresentation and intentional embellishment may be one) then have a personal experience of improvements that are frequent enough to convince them that there is something of definite value in their prescribing practice.

This would be true even if antidepressants were nothing more than psychoactive placebos, even if they lose their reactivity reducing effect over time as the body adjusts to their presence, even if their overall impact is not infrequently negative, and even if, on rarer occasions, they are extremely harmful.  The personal experience of some influential psychiatrists such as Aftab and Peter Kramer, may thus be skewed.  After all, within psychiatry they are “influencers.”  It may not be farfetched to suggest that such highly persuasive individuals have personal charisma that may generate higher rates of apparently curative placebo responses.  And based on my life insurance “research,” there is a greater than 80% chance that Aftab and Kramer are users!

It’s a Religion

            [F]orgive them, for they do not know what they are doing (Luke 23:34)

In this light, it is illuminating that rather than counterattacking him for dishonest discourse, Whitaker sees Aftab’s attempt to minimize his cognitive dissonance as just normal human behavior.  While I agree, I would add that Aftab’s actual experience may provide a distorted picture that is markedly better than what the research indicates.  This may help him hold on to a false picture of medication’s effectiveness.  Somewhat less charitably, I think it might be more accurate to see Aftab as a beneficiary of his own delusions that, as Whitaker explains, are maintained to avoid painful cognitive dissonance but simultaneously also enhance self-esteem, and generate an excellent reputation along with a substantial income.  In this regard, Aftab is functioning like some of the leaders in the type of movements he claimed to be defending us from (and to which he likened Bob Whitaker), i.e., Trumpism, QAnon, and Covid-19 denialism.

Because of this, one might be inclined to call “Pharmachiatry” a cult, not a religion.  But when a religious belief system has gone mainstream, we stop calling the phenomenon a cult and we use the term religion.  And modern psychiatry is certainly mainstream.  Thus, we need to recognize what we are dealing with:  It’s a religion.  Yet, one might still object to using that term since there is no God in the Pharmachiatry dogma.  That’s true.  Yet, Buddhism is clearly a religion despite its lack of a deity.  And every mainstream definition of religion includes something like “a cause, principle, or system of beliefs held to with ardor and faith” (Merriam-Webster).

If I am correct in claiming that faith in psychopharmacology functions psychologically like a religion, then direct attacks on its beliefs, even if those beliefs fly in the face of the evidence, are only likely to make its adherents double down.  “Your supposed facts be damned!  We know the truth!  Whitaker is a dangerous heretic.”

Unfortunately, Bob Whitaker’s suggested solution — legal action — is likely to founder.  Based on many years of testifying as an expert witness in court, it has become quite clear to me that the judges who control legal proceedings also tend to be true believers of the dominant religion.

Still, I have faith in the persistent stubbornness of reality.  As Philip K. Dick (who had his own long struggles with psychotic paranoia) quipped, “Reality is that which, when you stop believing in it, doesn’t go away.”  Thus, as discouraging as being a minority member of an iconoclast belief system can be, I believe that in the end the truth will prevail.  And I believe it will prevail not only because it won’t go away, but also because there are folks like those at Mad in America who won’t let it be ignored.

Now, if only there were a psychoactive placebo that I could use to bolster that belief.