More from the mailbag
September 5th, 2013
Remember when the New Yorker didn’t run letters to the editor? I’m guessing it was because Mr Shawn thought it would be vulgar, but whatever the reason, the practice frustrated enough people that there were, as I recall, a number of other places where letters were published, arch little columns. There was probably one in Spy, but who knows? This was before the Internet, I’m afraid, so I can’t be more specific or provide links. And given my multifarious character flaws, I may just be making this up.
Well, times have changed. The magazine has a letters page, and the website…well, the website would make Mr Shawn blanch, what with its open invitation to the hoi polloi to express itself ungrammatically, unconcisely, and with numerals. And my post on the elements blog has elicited quite a few comments (in addition to the surprising amount of email I’ve gotten, much of it vitriolic, much of that from psychiatrists, like the one reproduced here).
Now I suppose I could just reply on the New Yorker’s website, but that would be vulgar. It would convey that I am thin-skinned, that I care what the hoi polloi think, that I want everyone to love me and get my feelings hurt when they don’t, and I just don’t want my editors there to get the wrong idea. But I am all of those things, of course, so I must respond to at least a couple–as in the old days, in a different venue.
First, there are a number of comments about placebos and antidepressants, of which the best is surely this one
The canard that SSRI’s are equivalent to placebo, at least in moderate to severe depression, has been repeatedly and convincingly rebutted (1,2). Paul Krugman calls these sorts of arguments “Zombie lies” -
(1,2) are references to a couple of papers that reanalyzed the FDA data used by Irv Kirsch to show that half of the clinical trials run by drug companies for antidepressants failed to show a therapeutic effect of the drug, and in the successful ones the drug effect was just barely significant, statistically speaking. These papers argued that in moderate to severe depression, the drugs were effective, and that the problem was really that too many mildly depressed people were getting into the clinical trials.
Whatever the virtues of this argument (and it may have some, but it is hardly a conclusive rebuttal, let alone a killer argument), what’s important here is that while some people do conclude from the FDA data that SSRIs are “equivalent to placebo,” I’m not one of them, and in the New YOrker piece all I write is that they have “proven to be no more effective than placebos in clinical trials.” That is not a canard, let alone a zombie lie. It’s just what the FDA data show, no more, no less. I actually believe, as I have written elsewhere, that the SSRIs are powerful psychotropic drugs whose effects don’t show up well on trials with depressed people because their main effects aren’t on mood (which is the industry’s fault; they want the drugs to be antidepressants because that’s a good way to market them).
So why are defenders of the psychopharmacological regime so eager to say that I’m attributing an equivalency? Because they cling to those reanalyses like Titanic passengers to the lifeboats, and unless they can make it sound like I’m saying what I am not saying and don’t believe, and what is just plain stupid to say, then they are just left to flail about in the frigid waters.
Nice article, but it’s explicitly false that there’s “nothing new on the horizon.” Brain network analysis is finally putting a meaningful (although still incomplete) neurobiological face on mental disorders. For example, with depression, remarkable results are being achieved with ketamine (e.g., http://www.plosone.org/article/info%3Adoi%2F10.1371%2Fjournal.pone.0044799), a broad glutamate antagonist that reduces cortical over-activity. Functional connectivity imaging has now strongly implicated over-active cortical control, rumination, and decision-making networks in depression (http://www.pnas.org/content/107/24/11020.short), and this can be addressed chemically or through other more direct means. Similar stories are emerging w/ other mental disorders.
I like this formulation: “meaningful neurobiological face on mental disorders.” It’s just spooky enough, no doubt inadvertently so, to function as its own critique of the neurobiological approach to mental suffering. Myself, I think the human face is meaningful enough, would much rather gaze into someone’s eyes than into their gray matter. But it’s the ketamine thing I want to respond to. Speaking of lifeboats, this ketamine research has been the great white matter hope for neurobiologists of depression. The research shows that a single dose of ketamine relieves depression. (THis, by the way, is another accidental finding–anesthesiologists have observed that depressed patients on whom they have used ketamine often emerge from the surgery feeling better.)
But two things: first, just because ketamine is active at glutamate receptors and modulates “cortical over-activity,” that, to paraphrase tje New York Times’s Richard Friedman, does not mean that glutamate or cortical overactivity are the cause of depression. Nor can a target as amorphous as cortical overactivity, whatever that is (and how do we know it’s “over-activity”? how much cortical activity is normal? will cortical activity become the new chemical imbalance?), be particularly useful to drug makers–I’m sure that Thorazine reduces cortical activity too. So it’s only the Prozac problem, shifted from serotonin to ketamine. The second thing is that no one in the ketamine world seems to want to talk about the psychological effects of ketamine, which has been known for decades as a psychedelic drug. Euphoria and other effects are sometimes noted as adverse reactions in the studies, but the scientists are so enamored of the notion that biochemistry must be the signal and psychology merely the noise that they ignore the experience of the patient completely. There’s a whole world of meaning in that elision; mayb there’s more going on here than brain chemistry. (I’d also point out that the other drug that seems to relieve depression in a single dose is psilocybin, and at least in those studies they don’t sidestep the question of the actual effects on the subject’s psyche.)
And the third thing: when this commenter writes, “this can be addressed chemically or through other more direct means,” am I the only one who gets a little worried?
Psychiatry is hardly unique when it comes to serendipitous discoveries. The same can be said of virtually every other therapeutic area. What makes the “chemical imbalance” theory compelling is not its scientific foundation but its rhetorical appeal. The same can said of the LDL-HDL (bad cholesterol, good cholesterol) theory. What Greenberg and other sophisticated skeptics often lose sight of, however, is that for many — myself included — these drugs have made an extraordinary difference. For patients like me, the question is not so much “how these drugs may work” but rather “do they work for me?”
It is, of course, true that every medical field has its accidental discoveries. Only in psychiatry, however, have none of those accidents eventually been explained. More significant is the point about how the drugs work. It is of course not fair to say that I have lost sight of this fact, although it is true that I don’t directly address it in the New Yorker piece. (And interesting that in the absence of an explicit statement to the contrary, the assumption is that I think psychiatric drugs don’t make a difference.) But what the commenter points out is one of the deeper scandals of the psychopharmacological era. The researchers have been so busy trying to fit the empirical evidence into the magic bullet model that they have failed to give us a solid account of what the drugs do for people. Of course, and apologizing for two Titanic references in one post, that would steer them dangerously close to the recreational drug iceberg, for they would quickly find themselves talking with people about how the drugs changed their sense of who they are.
Where the bear shits in the buckwheat
September 4th, 2013
That’s one of my friend Russell Perry’s expressions. Russ is an old school mechanic, the kind who tries to actually fix cars rather than just swapping out expensive parts until the car runs. He’s got forearms like Popeye’s, and even though he’s 74 years old, he’s still at it full time. But he does spend part of each day telling stories to whoever happens to drop by, and sometimes those stories include a person telling another person something that should be obvious but nonetheless needs to be pointed out, like the fact that it’s not okay to drive with the oil light on. Which is what the expression is meant to convey, since, if you think about it (and I have), bear shit in buckwheat is not very hard to discern.
Anyway, a reader of a piece posted last night on the New Yorker’s elements blog has located the ursine excrement in the grain for me in an email. I’ll reproduce it in its entirety, save for his name, which I will change to Dr. Benway. I will tell you that he’s a psychiatrist, although, like the bear shit, that is probably obvious.
Message: Your “damn book” tweet drew my attention. [I tweeted this morning about a mistake in the article, and about how I should have known better since the correct version was in my "own damn book."] I read “The Psychiatric Drug Crisis”. Although you make a few valid points, you are obviously a polemicist and a gadfly, not a scientist. Until we are permitted to do biopsies on living brains (which I of course oppose), or come up with the equivalent, psychiatry will remain an art as well as a science.
Many discoveries in medicine (e.g. penicillin) were also made via serendipity. Anybody in my profession, which has plenty of flaws like any other, knows that true depression, on average, will remit in about 6 months. Antidepressants shorten that, as long as a proper diagnosis is made in the first place and a competent practitioner, by a necessary trial and error process, finds a medication that is at least reasonably effective and has a tolerable side-effect profile.
Rather than flacking your latest book on Twitter and elsewhere, I suggest you learn some science. You are obviously a gifted journalist, and any target is legitimate, but the article referred to above is deceptive, irresponsible, and self-serving. Any competent psychiatrist who is not wearing blinders knows that simplistic explanations of mental illness that are tied to neurotransmitters have been proven wrong. So what? That’s how science proceeds. We all know about the mind-brain debate. And incidentally, some of the most vocal and influential critics of prevailing models of mental illness and the practice of psychiatry have been psychiatrists themselves, like Thomas Szasz, R.D. Laing, and E. Fuller Torrey. At least they didn’t cobble their writings together based upon Cliff’s Notes or Psychiatry for Idiots.
Further, we know that mental illnesses can be misdiagnosed, overdiagnosed and even mislabeled. Again, that’s the way the world works. Physicians and scientists are human and the entire medical profession is currently under attack by persons much better qualified than you.
As to your comments about people being told that their condition is due to a chemical imbalance, would you rather they be told that they are crazy? Most of these “explanations”, even if ultimately proven wrong, are made in good faith, based upon what is hypothesized or “known” at the time.
Irresponsible, inaccurate (imipramine=Elavil)journalism like yours, as exemplified by the article in question, does a disservice. Just because a “chemical imbalance” may be an inadequate, or even false theory of mental illness, doesn’t mean that progress has not been made, and that, again, antidepressants work very well when judiciously utilized, but don’t work for everyone. That’s why treatment-resistant depression is a recognized entity.
In my opinion, psychiatrists have been their own worst PR people, and should be more proactive in informing the public about new developments, etc. Freudian theory and the dogmatism of its dwindling adherents have done tremendous damage to the public perception of psychiatry and a significant percentage of the population don’t know the difference between a psychiatrist, a psychologist, an analyst, a psychiatric social worker, a counselor and a therapist.
You would be doing the world a much greater service by presenting unbiased and constructive information instead of the poorly-targeted, deceptive, superficial and semi-informed work you bring out. BTW, I am aware of your personal experience with treatment. That experience is in and of itself a potential double-edged sword with respect to the objectivity of your views regarding psychopharmacology.
You have lost all credibility with me, and I certainly won’t be buying your “damn book”.
I really like this letter. It’s heartfelt, direct, and nicely written. He’s correct in many ways–surely that I am trying to sell books on Twitter and elsewhere, that I am a gadfly (although I’m not sure I am a polemicist) and not a scientist, that my article confused the names of two antidepressants, and that he probably isn’t going to be buying my damn book–although that’s a pity, because he might learn a thing or two from it. Plus he’s honest enough to admit how closed-minded he is.
But he does have a few things wrong. I never said progress hadn’t been made. I didn’t argue that psychiatry was the only medical specialty indebted to accident, and I didn’t cobble together my argument from Cliff;s Notes or Psychiatry for Idiots. I cobbled them together from two books that collectively took me more than five years to write, and which each run more than 400 pages with extensive bibiliographies. But that doesn’t matter, except for one thing: that accusation is, like the rest of the email, a nearly perfect example of one of the most common species of reactions to my work about psychiatry. Let’s call it the ad hominem gambit, in which the shortcomings of my character are somehow taken to invalidate what I am saying, and which reaches an apotheosis in this letter. I don’t think all these adjectives–self-serving, irresponsible, deceptive, superficial, polemical, ill-informed, dangerous, and personally experienced with treatment–have ever been gathered together in a critique of my stuff before. So my hat’s off to Dr. Benway for his efficiency.
But go ahead and read my article and then try to find exactly what Dr. Benway is saying is incorrect, other than that stupid error (now corrected) about the antidepressant names. I think what my article says is fairly simple: the drug industry is giving up on making psychiatric drugs because mental disorders simply don’t respond to medication in the same way that many (but not all) physical disorders do. Or, to put it another way, the germ theory of disease, out of which the drug industry grew and which it adopted as its model, doesn’t work very well when it comes to psychological suffering. While once it was thought that neurotransmitter imbalances would play the same role as germs in understanding and treating mental illness, this has proven to be far too simplistic an approach, and the drug companies, having watched the wagon to which they hitched their hopes crash and burn, are unhitching themselves as fast as they can. And, I speculate, it’s possible that consumers, who have yet to fully understand that the neurotransmitter imbalance theory (NIT) works better as myth than as science, may not be far behind.
This last bit is, I think, where Dr Benway’s ire comes from. I think people tend to think of “myth” as a derogatory term; surely he does. But even if a myth is not the truth, it isn’t a lie. It’s a powerful way of knowing the world. The NIT has served its purpose. As he himself points out, it’s better than just calling people crazy. But does that mean it’s the best account of mental suffering? More to the point, when your myth relies for its power on a claim to scientific accuracy, and when science proves the myth inaccurate, is it a good idea to cling to the myth? And even more to the point, when the psychiatrists have abandoned the myth, is it a good idea to continue to pr0mulgate it among the laity?
That’s the point at which Dr Benway and I disagree about good and bad faith. Of course the myth originated in good faith. Contrary to Dr Benway’s belief about me, I havce studied those origins deeply. I’ve talked extensively with the scientists, at least the ones still alive, who originated it, and found them to be brilliant, engaging, compassionate people who really thought that the NIT was going to be the key to the mysteries of mental illness. (And many of these discoveries and theories were indebted to LSD, which really predisposes me to be sympathetic.)
But once the myth been discredited, once doctors are saying one thing to each other and another thing to the rest of us, then I think that is a definition of bad faith. And when simply saying it out loud, as I did in the New Yorker blog, inspires this kind of vituperation, I think what we are seeing is the attempt to divert attention from the fact that there is nothing with which to replace the myth. This is indeed disconcerting and worrisome to doctors and patients alike. It calls psychiatry’;s authority into question and leaves patients to wonder what will become of them. (Only corporations are well-equipped to respond to the end of the myth, which they are doing by abandoning it.) And it leaves psychiatrists without a response other than the one their training prepares them for: diagnosing the messenger. But regardless of my character, the bear shit is definitely in the buckwheat, and it really does stink.
I told you so
August 20th, 2013
In media interviews and public appearances, there almost always comes a point when I tell people that the chemical imbalance theory of depression is a myth. I generally add that I mean “myth” in the best way possible: a powerful explanation of a complicated and disturbing phenomenon, but one that is not necessarily true in the sense that we expect scientific explanations to be true. I explain that the credibility of the myth hinges on a faulty logic: People take antidepressants and feel better. Antidepressants increase the availability of serotonin. Therefore a lack of serotonin was the cause of feeling bad. That’s a post hoc fallacy at best, but it is not too simplistic to say that this is the main source of the myth.
My comments are often met with incredulity, which makes sense, given how widespread this myth is, and given its role as a linchpin in the depression industry. After all, how many people are taking antidepressants because they have been told that they are suffering from a chemical imbalance that the drugs will rectify in the same way that insulin does for diabetes? And the corollary: that if you don’t take the drug, it will be like leaving diabetes untreated. So my comment is discomfiting and hard to believe. I generally acknowledge this and then suggest that people buy Manufacturing Depression if they want to get the whole story. Never pass up an opportunity for a plug.
The question that hangs in the air in this discussion is how it is possible that there can be such a disconnect between what doctors know and what they tell the public. That is a hard one to explain without resorting to conspiracy theories or attributing bad faith to doctors. I don’t like either of those explanations, and I am sure that neither does justice to the phenomenon. But so long as doctors say one thing to their colleagues and another to the public, the question looms. So I was pleased to see in today’s New York Times an article by Richard Friedman, a professor at Weill Cornell Medical College in New York City, and a frequent contributor to the Times. Friedman is anything but a psychiatric renegade, and here is what he says about the chemical imbalance theory:
Knowing how a drug works in the brain doesn’t necessarily reveal the cause of the illness. For example, just because an S.S.R.I. antidepressant increases serotonin in the brain and improves mood, that does not mean that serotonin deficiency is the cause of the disease; many depressed patients get better with medications that have no effect on serotonin.
So there you have it. Right from the horse’s mouth.
(One thing Friedman doesn’t mention: that many depressed patients get better with no medication at all.)
Turn on, Tune in, Drop out
May 31st, 2013
Well, I don’t know about the drop out part. But if you turn on your radio and tune in to Science Friday, an NPR show, today at 215, you will hear Tom Insel, head of NIMH, Jeff Lieberman, president of the APA, and me talk about whatever Ira Flatow wants us to talk about.
Insel and Lieberman reprise their rendition of Kumbaya, attributing their differences to a division of labor–the NIMH does research, which needs to detach itself from DSM, while the DSM is for clinicians, who need it.
Insel and Lieberman will team up to defend psychiatry against antipsychiatrists like me. But they will be very nice about it.
I will try to explain why I am not an antipsychiatrist, which is sort of like explaining that you don’t beat your wife. I will also be very nice about it.
Insel and Lieberman will say that I indict the DSM because its diagnoses don’t have any biology to them, but that this is a straw man argument. They will point out that many medical diagnoses are like DSM diagnoses, and that it is unreasonable to hold psychiatry to a standard that the rest of medicine does not meet.
I will try to explain that I never said I think biology is a necessary condition for determining that a particular suffering is a disease. I will then try to explain that nonetheless the biology thing is the myth that gives us confidence in what doctors tell us, and that the DSM is an attempt to command confidence by suggesting that psychiatry knows more than it does. I will try to invoke history, the way that the DSM-III was a response to a crisis of confidence. I may even invoke David Brooks, who accused psychiatry of having Physics Envy. But I probably won’t get far, since this is a hard one to get into NPR-=sound-bite shape.
They will say that we can’t do without the DSM, for the sake of the patients.
I will say that this is what people in bad marriages say all the time–that it’s bad but must be preserved for th sake of the children. I will allow that sometimes the parents are right, and sometimes they are wrong.
We will agree that psychiatry has a long way to go.
And, most important, I will talk about “my book” as often as possible.
May 31st, 2013
And so much to catch up on. First has to be the David Brooks column from earlier this week, in which he called psychiatrists “heroes of uncertainty,” praising them as “daring adapters, perpetually adjusting in ways more imaginative than scientific rigor.” Take away the sermonizing and the sentimentality, take away Brooks’s compulsion to turn every event he writes about into an object lesson in the virtues Burkean social theory leavened by his half-baked notion of negative capability, and what you’re left with is only the damning praise. Psychiatry is not a science, Brooks says, but a “semi-science” (I’ve never heard that one before either), one that suffers from Physics Envy (and note the capitalization here; the Times style book says you don’t capitalize the names of mental disorders, but I guess they make an exception for op-ed columnists) and needs to stop claiming more knowledge than it has.
Now where have I heard this argument before? I have no idea if Brooks read my book. He’s surely not saying, and I don’t blame him. AFter all, writing in the Nation I did call his last book “the love child of Malcolm Gladwell and Kilgore Trout,” which wasn’t terribly kind, even if it was true. I also don’t blame him for going out of his way to mention Al Frances’s Saving Normal, as I’m sure he recognizes Frances’s underlying notion that psychiatrists can (and should) moderate their power as a version of his own noblesse oblige, his faith in the aristocracy to limit their own power. The irony here, by the way, is that Frances and I spent a fair amount of time parsing our mutual dislike of Brooks, and he might loathe Brooks (and by this I mean his work, not his person) more than I do. Not only that, but I suspect Frances would reject this idea that he and his colleagues are heroes of uncertainty as just so much bullshit, especially to the extent that it demotes psychiatry to a semi-science.
But whatever Frances thinks, it’s hard to imagine that the folks at the APA want to accept the David Brooks Medal of Uncertainty, even if they agree with him. It’s a tight spot. Acknowledging the uncertainty of psychiatric diagnosis, ratcheting back its claims, is at once honest and dangerous. To the extent that psychiatry is, scientifically speaking, in its infancy, the honesty is refreshing and even necessary. That’s why Tom Insel’s comments were so important–he was only saying out loud what he and other psychiatrists have been saying for years, and what is undeniable. But to the extent that psychiatry must command the confidence of it patients and patrons, acknowledging its immaturity is very risky. That’s why Insel’s comments were also inflammatory.
Brooks, of course, is completely tone-deaf when it comes to this last point. His instincts are anti-political, so he doesn’t understand, or even perceive, the complex dance that goes on between a public desperate to believe that psychological suffering can be understood and treated like pneumonia and a profession desperate to fulfill that hope.