“Any man can go up—oh, almost indefinitely—but to go down, and down sure-footed, that is another thing entirely.” (Patrick O’Brian, HMS Surprise)
Is Newsweek saying antidepressants don’t work? Yes, they are, and isn’t that a cute cover. Any doubt which way is up?
And are they right? This one has sent me into a flurry of research over the past two days. My tentative answer is, They may be on to something, but watch for scholarly refutations over the next few weeks.
And, in this national climate of distress, isn’t their timing the coldest, most callous, most credulous act imaginable? Hmmm, you think? We’re vulnerable; we’re already worried about EVERYTHING, and we tend to believe what we read on the cover of a major news magazine, especially when big numbers are thrown at us between the covers. Thanks, Newsweek; can’t wait for your next issue!
I'm no expert, but here’s how the cover story looks to this reader:
Irving Kirsch, PhD, of Hull University, England, is saying that his method of statistical analysis shows that antidepressants do not beat placebos by enough of a margin to justify their use in most cases. Sharon Begley of Newsweek has given him a nation-wide plug for his new book, along with a cynical and somewhat overwrought treatment of a critically important subject. Caveat emptor, indeed, but is it antidepressants, Irving Kirsch, or Newsweek we should distrust more?
In an article written for the issue dated February 8, 2010, entitled “The Depressing News About Antidepressants,” Sharon Begley references research done in 1998, by Kirsch and Sapirstein at UConn., and expanded by Kirsch in 2008. Begley’s article might give the impression that Kirsch and team tested the 3000 patients themselves, which is not the case; they applied meta analysis, a statistical method, to studies published by the drug manufacturers for four antidepressants. Later, they included research that was done, but not published (leaving the impression that this research was withheld or kept secret); those studies were, in fact, sent to the FDA as part of the usual approval process for any particular drug.
Kirsch and team concluded that, of those respondents who reported improvement in placebo-controlled clinical trials of experimental antidepressant medications, the patients who got the medication improved only 25% more than those who claimed improvement on the placebo, and, when unpublished studies were included, the margin of difference between placebo effect and medication effect was reduced to 18%. Hardly worth it, Kirsch concludes. And it does sound like big news, but, before you throw out your antidepressant and confront your doctor, there are a few more things to consider.
The implications of Begley's article are that the facts are being withheld from patients and the public, presumably by a coalition of folks in the know and on the take; to operate as a conspiracy, this coalition would have to include big pharmaceutical companies, the Food and Drug Administration, The National Institutes of Health, The American Medical Association, the medical insurance industry that (from time to time) helps pay for the medications, and individual doctors just like yours or your mother’s or your best friend’s…for a short list. In other words, everybody but the patient. For those who study conspiracy theory, the rule of thumb is that the more entities said to be involved in the conspiracy, the less likelihood there is that secrecy and joint action can be maintained over time…or, too many cooks spoil the broth.
The study acknowledges that antidepressants show greater efficacy rates, as compared to placebo rates, for the most severely depressed, but discounts those results by concluding that the most severely depressed patients were under-responsive to placebo. There are lower drug benefits, as compared to placebo effect, demonstrated for milder depression
The article reminds patients who take antidepressants (and they don't differentiate between mild and severe in this warning) not to stop suddenly because, “That can cause serious withdrawal symptoms.” There is the assumption here that patients will read the article and immediately discontinue their antidepressant because it’s been revealed that the positive effects they’ve experienced are really all in their heads. There's a greater danger that some patients will read the cover headline, alone, and, regardless of the level of severity of their depression, the benefit they may have personally derived, or the history of their own treatment response to other modalities, they'll do what depressed people are prone to do: they'll give up.
Most patients, however, will think for themselves. They know what they tried before they turned to medication and they know what they’ve experienced since. In this country, with our self-reliant tendencies, we tend to go about as far as we can before we ask a doctor for help; hence the stats that everybody can agree on: fewer than half of the 13-14 million adults who experience clinical depression in this country in a given year will receive treatment of any kind and at least 32 million of us will have the disease (or disorder...and that's another blog post altogether, too).
The National Institutes of Mental Health do not recommend medication, alone, for depression. The recommendation in clinical depression is for medication with psychotherapy and lifestyle changes that include exercise and socialization, along with conscious efforts to solve contextual problems that have led to or exacerbated the illness. Good doctors, particularly specialists, know that they give their patients the best shot available at lasting benefit by urging their patients to follow those recommendations. Begley sloughs this off by saying, “…there’s the little matter of reality. In the U.S., most patients with depression are treated by primary care doctors, not psychiatrists.”
So, if we throw out our medications because prescribers aren’t following the national guidelines—put the baby out with the bathwater—then what? If, thanks to Begley, patients assume that their medication was no better than “expensive TicTacs,” as she calls them, will they turn to psychotherapy and alternative treatments, instead? Where I live, there is a large population of depressed patients who distrust psychotherapy far more than they do medication; without the benefit their antidepressants do afford them, they'd go on with lives that are burdensome to them, to their families, and to their employers...unrelieved. In their cases, I'm pulling for all the good of the placebo effect plus whatever boost the medication itself can provide them.
For prescribers, the patient's willingness to engage in the slower process of psychotherapy, the availability of sound and qualified therapists, and the patient's insurance coverage for non-medical treatments all have to factor into treatment planning. Where psychotherapy is chosen, the doctor and therapist have to work in close consultation...a practice that typically does not occur where the referring doctor is a primary care physician.
While Kirsch would obviously be persona non grata in the American medical community, he hasn't fared much better among academics, who have more stake in associating themselves with quality research . When the journal Prevention and Treatment published Kirsch's paper "Listening to Prozac but Hearing Placebo," they issued a warning in print with the article stating that the authors had used their statistical analysis "controversially." Begley's article does state:
Is Newsweek saying antidepressants don’t work? Yes, they are, and isn’t that a cute cover. Any doubt which way is up?
And are they right? This one has sent me into a flurry of research over the past two days. My tentative answer is, They may be on to something, but watch for scholarly refutations over the next few weeks.
And, in this national climate of distress, isn’t their timing the coldest, most callous, most credulous act imaginable? Hmmm, you think? We’re vulnerable; we’re already worried about EVERYTHING, and we tend to believe what we read on the cover of a major news magazine, especially when big numbers are thrown at us between the covers. Thanks, Newsweek; can’t wait for your next issue!
I'm no expert, but here’s how the cover story looks to this reader:
Irving Kirsch, PhD, of Hull University, England, is saying that his method of statistical analysis shows that antidepressants do not beat placebos by enough of a margin to justify their use in most cases. Sharon Begley of Newsweek has given him a nation-wide plug for his new book, along with a cynical and somewhat overwrought treatment of a critically important subject. Caveat emptor, indeed, but is it antidepressants, Irving Kirsch, or Newsweek we should distrust more?
In an article written for the issue dated February 8, 2010, entitled “The Depressing News About Antidepressants,” Sharon Begley references research done in 1998, by Kirsch and Sapirstein at UConn., and expanded by Kirsch in 2008. Begley’s article might give the impression that Kirsch and team tested the 3000 patients themselves, which is not the case; they applied meta analysis, a statistical method, to studies published by the drug manufacturers for four antidepressants. Later, they included research that was done, but not published (leaving the impression that this research was withheld or kept secret); those studies were, in fact, sent to the FDA as part of the usual approval process for any particular drug.
Kirsch and team concluded that, of those respondents who reported improvement in placebo-controlled clinical trials of experimental antidepressant medications, the patients who got the medication improved only 25% more than those who claimed improvement on the placebo, and, when unpublished studies were included, the margin of difference between placebo effect and medication effect was reduced to 18%. Hardly worth it, Kirsch concludes. And it does sound like big news, but, before you throw out your antidepressant and confront your doctor, there are a few more things to consider.
The implications of Begley's article are that the facts are being withheld from patients and the public, presumably by a coalition of folks in the know and on the take; to operate as a conspiracy, this coalition would have to include big pharmaceutical companies, the Food and Drug Administration, The National Institutes of Health, The American Medical Association, the medical insurance industry that (from time to time) helps pay for the medications, and individual doctors just like yours or your mother’s or your best friend’s…for a short list. In other words, everybody but the patient. For those who study conspiracy theory, the rule of thumb is that the more entities said to be involved in the conspiracy, the less likelihood there is that secrecy and joint action can be maintained over time…or, too many cooks spoil the broth.
The study acknowledges that antidepressants show greater efficacy rates, as compared to placebo rates, for the most severely depressed, but discounts those results by concluding that the most severely depressed patients were under-responsive to placebo. There are lower drug benefits, as compared to placebo effect, demonstrated for milder depression
The article reminds patients who take antidepressants (and they don't differentiate between mild and severe in this warning) not to stop suddenly because, “That can cause serious withdrawal symptoms.” There is the assumption here that patients will read the article and immediately discontinue their antidepressant because it’s been revealed that the positive effects they’ve experienced are really all in their heads. There's a greater danger that some patients will read the cover headline, alone, and, regardless of the level of severity of their depression, the benefit they may have personally derived, or the history of their own treatment response to other modalities, they'll do what depressed people are prone to do: they'll give up.
Most patients, however, will think for themselves. They know what they tried before they turned to medication and they know what they’ve experienced since. In this country, with our self-reliant tendencies, we tend to go about as far as we can before we ask a doctor for help; hence the stats that everybody can agree on: fewer than half of the 13-14 million adults who experience clinical depression in this country in a given year will receive treatment of any kind and at least 32 million of us will have the disease (or disorder...and that's another blog post altogether, too).
The National Institutes of Mental Health do not recommend medication, alone, for depression. The recommendation in clinical depression is for medication with psychotherapy and lifestyle changes that include exercise and socialization, along with conscious efforts to solve contextual problems that have led to or exacerbated the illness. Good doctors, particularly specialists, know that they give their patients the best shot available at lasting benefit by urging their patients to follow those recommendations. Begley sloughs this off by saying, “…there’s the little matter of reality. In the U.S., most patients with depression are treated by primary care doctors, not psychiatrists.”
So, if we throw out our medications because prescribers aren’t following the national guidelines—put the baby out with the bathwater—then what? If, thanks to Begley, patients assume that their medication was no better than “expensive TicTacs,” as she calls them, will they turn to psychotherapy and alternative treatments, instead? Where I live, there is a large population of depressed patients who distrust psychotherapy far more than they do medication; without the benefit their antidepressants do afford them, they'd go on with lives that are burdensome to them, to their families, and to their employers...unrelieved. In their cases, I'm pulling for all the good of the placebo effect plus whatever boost the medication itself can provide them.
For prescribers, the patient's willingness to engage in the slower process of psychotherapy, the availability of sound and qualified therapists, and the patient's insurance coverage for non-medical treatments all have to factor into treatment planning. Where psychotherapy is chosen, the doctor and therapist have to work in close consultation...a practice that typically does not occur where the referring doctor is a primary care physician.
While Kirsch would obviously be persona non grata in the American medical community, he hasn't fared much better among academics, who have more stake in associating themselves with quality research . When the journal Prevention and Treatment published Kirsch's paper "Listening to Prozac but Hearing Placebo," they issued a warning in print with the article stating that the authors had used their statistical analysis "controversially." Begley's article does state:
A nascent collaboration with a scientist at a medical school ended in 2002 when the scientist was warned not to submit another grant proposal with Kirsch if he ever wanted to be funded again. Four years later, another scientist wrote a paper questioning the effectiveness of antidepressants, citing Kirsch's work. It was published in a prestigious journal. That ordinarily brings accolades. Instead, his department chair dressed him down and warned him not to become too involved with Kirsch.
When you read Newsweek's cover story, keep in mind:
1. Most of the research cited here has been available for analysis since 1998; if Kirsch's method of analysis is standard and is logically applied to the data in question, are we left with no choice other than to believe the information has been deliberately withheld from us? Both too pat and too paranoid for me.
2. Kirsch holds a PhD in psychology. Research claiming the lack of efficacy of medications and the greater efficacy of psychotherapy and non-medical modalities has historically come from psychologists, a field which previously failed in its bid to be approved in most states to prescribe the medications it now denounces. (Exceptions: in LA and NM, psychologists who additionally complete a two year masters degree in psychopharmacology can prescribe). Most of the studies that have historically shown greater efficacy of meds over psychotherapy have been funded by medical entities. Go figure.
3. On his departmental website, Kirsch states,
“My main research interest is in response expectancy, suggestion, and suggestibility. Among the domains in which I investigate these phenomena are: placebo effects, antidepressants, hypnosis, pain perception, behavioural automaticity, memory distortions, complementary and alternative medicine, cognitive-behavioural psychotherapy, repetitive strain injury, irritable bowel syndrome, anxiety disorders, and depression."
If the placebo effect can color patient response to antidepressants, can researcher bias color the interpretation of statistics?
4. The Hawthorne effect posits that subjects can improve simply by virtue of being studied, which complicates the placebo effect numbers in studies where patients are followed over time by researchers wielding depression scales. So the placebo numbers cited by Kirsch are not so clear-cut, either.
5. Most importantly, Kirsch’s book, The Emperor's New Drugs: Exploding The Antidepressant Myth, was published in 2009 in the UK, but at the end of January, 2010, in the US. Time Magazine covered this study in May, 2009, and far less provocatively. The Newsweek article is timed as a book review cum medical alarm, not as timely research news.
6. About the only business in this country that rivals traditional medical treatment for its claim on the patient dollar is the big business of Alternative Medicine, a largely unregulated field where patient exploitation is rampant. In an atmosphere of national distrust of the traditional medical world (not misplaced, entirely), patients are flocking, not to the trained and regulated psychologists and social workers, but to the practitioners of alternative therapies, who base their conclusions on individual patient stories…the very type of anecdotal evidence that the researchers would deny to patients trying to make actual decisions about their care today.
8. The article makes the issue of treatment an either/or proposition: either meds or therapy. Remember that the NIMH recommends both in combination; our attention is better placed on obtaining insurance coverage for both medication and psychotherapy for everyone in this country. The decision on whether to use meds, talk therapy, or a combination could be put back in the hands of the patient and the doctor.
7. When Newsweek casts doubt on the efficacy of antidepressants for mild to moderate depression, they also sow those seeds of doubt, by implication, on other uses of those medications, such as in the treatment of depression associated with trauma for victims of disaster and veterans returning from war, or for obsessive-compulsive disorder or anxiety disorders. They sow distrust between patients and their doctors. And they sow doubt in the minds of patients who are being successfully treated. Begley admits, "To be sure, the drugs have helped tens of millions of people."
8. The article makes the issue of treatment an either/or proposition: either meds or therapy. Remember that the NIMH recommends both in combination; our attention is better placed on obtaining insurance coverage for both medication and psychotherapy for everyone in this country. The decision on whether to use meds, talk therapy, or a combination could be put back in the hands of the patient and the doctor.
At the very end of the article, Begley says, in reference to exposing the pill pushers, “Maybe it is time to pull back the curtain and see the wizard for what he is.” Yep. I agree that blind trust is a bad idea. And that patients must learn to act as self-advocates, which means more education about their own care. And that statistics aren’t always what they seem, no matter who publishes them. If we’re just looking at which player in this story is most against the ropes and most likely to stretch a point for effect, I’d say the print media is the most endangered of the three…that would be Newsweek.
And somebody licked the red off Sharon Begley's sugar pill, honey, 'cause this girl is PISSED; she's got an agenda with this article. Let's see, I think the telltale phrase was, "drug so strong it's making me vomit or hate sex." No, maybe the giveaway was her two references to Dumbo the Disney elephant to describe people who believe in their medication. And this is the cover story of a major news periodical? Now, I'm really worried about America.
Do you know someone who has been helped by medications for depression? How do you think they would react to this article? Do you distrust anything the FDA approves, period? Does Newsweek have a bias other than a desperate need to sell magazines? Could they possibly have picked a crappier time to go to press with this on their cover?
And somebody licked the red off Sharon Begley's sugar pill, honey, 'cause this girl is PISSED; she's got an agenda with this article. Let's see, I think the telltale phrase was, "drug so strong it's making me vomit or hate sex." No, maybe the giveaway was her two references to Dumbo the Disney elephant to describe people who believe in their medication. And this is the cover story of a major news periodical? Now, I'm really worried about America.
Do you know someone who has been helped by medications for depression? How do you think they would react to this article? Do you distrust anything the FDA approves, period? Does Newsweek have a bias other than a desperate need to sell magazines? Could they possibly have picked a crappier time to go to press with this on their cover?
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