I hate to do this, because it’s old news. But then again, so is Peter Kramer’s argument in yesterday’s Times, in which he argues that the failure of antidepressants to beat placebo in clinical trials is not an indication that the drugs don’t work. Instead he blames it on the research.

Kramer’s problem is that he has to reconcile two apparently contradictory truths: that antidepressants don’t work (according to the FDA data) and that they do (according to his, and many others’, clinical experience, including mine).

The obvious , and scientific, way to deal with this conflict is to say that the evidence that they do work is anecdotal, and that the hard numbers–37 out of 74n trials failed to detect an advantage of drug over placebo, a lousy 2-Hamilton-point aggregate advantage, etc.–tell the real story. That;s the conclusion Kirsch draws and it leads him to say that even when they do work, antidepressants work by placebo effects (amplified by the side effects).

Kramer is right to say that Kirsch’s position is ideologically motivated. he wants to believe that drugs don’t work, so he listens to prozac and hears placebo, which to me simply indicates that he (Kirsch) hasn’t taken enough serotonergic drugs. But Kramer is wrong to say that the dismal results on the trials are an artifact of poor research design, at least in the way he imagines. I suppose the problem could be poor gatekeeping, as Kramer implies, and that the samp0le popuolation in the SSRI trials isn’t sick enough, but this is a pretty lame answer, especially when there’s another one that unties this knot.
It’s true that the Hamilton was standardized on hospitalized patients. it’s also true that it was never meant to be a diagnostic test. it was meant to measure improvement in a population already identified (by Hamilton himself in the old days, by something like the SCID now) with depression who were taking tricyclics (and, probably, MAOIs). The items, more than half of them neurovegetative signs and symptoms, are tailored to the drugs. But when the drugs changed, the tests didn’t. (Note that his is a purely commercial problem–the studies Kirsch looked at were conducted the way they were because they were the way to win the FDA approval game.) And it could be that the Hamilton is a a lousy tool for measuring the effects of SSRIs.

the conclusion that the SSRIs don;t work rests on the assumption that the Hamilton is both the best way to measure depression improvement and the best way to measure the effects of SSRIs; it also assumes that depression is the proper target for the drugs. I think all these assumptions are faulty. Of course, I think the whole idea of depression as a disease is vastly overrated. That’s my prejudice. But I also think the SSRIs do work, i.e., the chemical effect of tweaking serotonin metabolism is in part a change in consciousness. But it’s not one that the Hamilton is sensitive to. That’s why the drugs seem not to work. You can’t find feathers with a magnet.

to me, this outcome is the drug companies hoist on their own petard. They didn’t have to market SSRIs as antidepressants. That was a decision made for commercial reasons as much as scientific or medical and tough luck for them. Not that it matters. They got their indication and they laughed all the way to the bank.

What’s ironic about this is that the person who has done more to prove that antidepressants don’t simply relieve people’s depression is none other than Peter Kramer. But more important is the fact that this kerfuffle is in part due to a willful blindness. There are a few studies of the effects of SSRIs on personality, indicating that wahtever antidepressant effect they have is secondary to the way they change people’s personalities, but in general there’s not much incentive to do those studies. As a society, we’re pretty chary of drugs that change personality. Think about all those ads in which Pharma promises that the drugs won'[t change who you are. That would be a tough sell. It would also turn out that if what you want to do is to transform people’s personalities, there are other serotonergic drugs that do it much better and quicker (LSD, MDMA, etc.) and without daily intake, not to mention old-fashioned psychotherapy which at least doesn’t ruin your sex life.

People sometimes ask me how I got started in the writing racket. Sometimes they’re just curious. Sometimes they’re trying to figure out how to do it themselves. The short answer to the question is that I owe it all to the Unabomber. The long answer is to be found in my first published article, which appeared in McSweeney’s in 1999 and documents my long and fraught relationship with Ted Kaczynski. It turned out to be the lazy man’s way to getting published; after the article ran, all sorts of doors suddenly opened. I’m not recommending this method, but if you want to see how to get a serial killer to run interference for you, or if you’re just curious, you can read all about it right here.

Someone could make a living (or at least a blogging) hating on David Brooks. (Indeed, someones do. Try googling “I hate David Brooks.”) Today’s column, apparently the outline for a commencement speech (is it possible that no citadel of higher learning invited Brooks to give their grads a sendoff?), is the same old thing he’s been peddling in his columns and his book for awhile now: a hash of animus toward “expressive individualism” (see Habits of the Heart for maybe the best version of this argument and for a good example of how it inevitably ends up affirming the protestant work ethic), rejection of the idea of being-over-doing (as if this were the prevailing ethic of our time, rather than a straw man put up by people who think we just don’t do enough), affirmation of “expertise,” and wishful thinking about the innate goodness of us all (especially the successful and rich), but I’ve done my hating, and I have to agree with what a friend of Mark Engler’s said: “Mocking David Brooks is somehow both the lowest of low-hanging fruit and vital to our democracy. It’s a puzzle.” An important thing to do, in other words, but one that devolves into vice the more you do it. I’ve done my bit, but I don’t want to end up needing glasses, let alone going blind, so no more.

But here’s what’s worth hating on this morning. I paid my money to the New York Times so that I can legitimately read more than twenty articles a month. I promptly forgot how much that cost me, but whatever it is, shouldn’t it exempt me from those ads that darken whatever I’m reading, splash across my screen, take forever to load in, and withhold the “click here to close” X for a mercilessly long time? At least when a cat lies down on your newspaper, it doesn’t try to get you to buy anything.

Which says a lot about both ideologies.

Anyway, that would be David Brooks, and here’s the link to my review of his book,  The Social Animal

http://www.thenation.com/article/160752/dumbest-story-ever-told-david-brooks

My personal favorite absurd thing that got said at the APA convention: a statistician on the DSM task force said, “The DSM guides diagnoses. It doesn’t define disorders.”

Say what?

First of all, why can’t it do both? Come to think of it, doesn’t it have to do both? Unless they’re thinking of it like the Field Guide to the Birds, in which someone else’s taxonomy is taken for granted and then the book helps guide you in identifying whether that bird is a blue-footed booby or a grey-crested tit. Which, I think, is exactly what they wish were the case. But it’s not, and that is why they;ve spent, as they’re so fond of reminding all of us, ten years and 25 million dollars, wrangling over which disorders exist and how to define them. And really, if the DSM doesn’t define disorders, then who exactly does? God? Webster’s Collegiate? Google?

Second, and more important, why waste time trying to cover over the fact that you’re producing an authoritative document? I don’t think the APA has thought this one through all the way. This same statistician also repeated the party line about how the DSM is a living, breathing document. (Which sounds a little scary to me; I have visions of a book storming down city streets, eating cars and stomping on buildings.) Can’t you just see this in court, the defense having just proved that its client suffers PTSD, as defined int he DSM. and the prosecutor quoting the authors of the DSM saying that the book doesn’t define disorder and that it’s not a Bible, but a living breathing document? Or school systems holding off on providing services because the APA says the  DSM is still being beta-tested?

I don’t blame them for trying to have it both ways: the authority of medicine and the flexibility demanded by the complex human mind. But really, you can’t square that circle, and the closer they try to move toward this brain-based account of subjectiv e suffering, the more they’re going to have to try,.