Are Antidepressants Effective? A Review of “The Emperor’s New Drugs” by Irving Kirsch

It’s common knowledge now that antidepressants are no better than placebo for the majority of patients. Only ten years ago, however, this was a very controversial idea. Back then, doctors, patients, the media, and the general public believed that Prozac, Paxil, Zoloft, and other “wonder drugs” helped millions of people overcome their depression by correcting chemical imbalances. It’s the story that drug companies, regulators, and academic psychiatrists told us. Many people still believe this, and doctors write out millions of antidepressant prescriptions, but it’s contrary to evidence. It’s true that antidepressants successfully treat depression. The problem is that sugar pills (“placebos”) also successfully treat depression, and the sugar pills are about as effective as antidepressants, without any of the drugs’ side effects.

Irving Kirsch, a researcher who pioneered the use of meta-analysis in studying antidepressants, writes about the chimera of antidepressant effectiveness in his book The Emperor’s New Drugs: Exploding the Antidepressant Myth. Unlike Robert Whitaker’s book The Anatomy of an Epidemic, which talks about all the major psychiatric disorders and classes of drugs, Kirsch restricts his analysis to depression and antidepressants. Kirsch’s main argument is that placebos are effective treatments for depression, and that antidepressants add very little except side effects.

Before conducting his research project, Kirsch, like most people, believed that antidepressants worked. A clinical psychologist, Kirsch used to refer depressed people to psychiatrists so that they could obtain prescriptions for antidepressants. He trusted the data in the published literature that demonstrated the effectiveness of antidepressants. He changed his view after doing his research.

After analyzing 38 clinical trials involving more than 3000 depressed patients, Kirsch found that only 25% of the benefit of antidepressant treatment was due to the drug effect. The placebo effect, the patient’s hope that he will improve from treatment, was twice as powerful as the drug effect.

When analyzing the data, Kirsch also found that the newer antidepressants (e.g. SSRI’s) were no better than the older antidepressants. Even more surprisingly, he found that sedatives, barbiturates, antipsychotic drugs, stimulants, opiates, and thyroid medications were as effective as antidepressants in treating depression. The only thing that these drugs have in common is that they produce easily noticeable side effects. Kirsch explains that in a clinical trial, patients are randomly assigned to either a treatment (drug) group or a placebo group. If the patient knows that he’s been assigned the drug, he’ll feel more hopeful and optimistic—i.e. he’ll feel less depressed. Since the studies are supposed to be double-blind, the only way the patient can know this is if he gets side effects. If he tells his doctor about the side effects, then the doctor will also know that he’s been assigned the treatment. The doctor may have a different attitude toward the patient if he knows that he’s been assigned the treatment. So the supposedly double-blind study isn’t really double-blind. That’s the reason why the other drugs also were effective for depression. Any drug that causes side effects will make both the patient and doctor more confident and hopeful, since the side effects make them know that the patient is receiving the actual treatment. The placebo effect, not the chemical action of the drug, treats the depression.

Additional evidence for this hypothesis that drugs are only active placebos is that there’s a near-perfect correlation between improvement and the experience of SSRI side effects. The more side effects the patient has, the more he improves on the drug. Another way to interpret this, however, is that patients who actually benefit from the chemical action of the drug also tend to experience more side effects.

As part of his research project, Kirsch used the Freedom of Information Act to obtain unpublished clinical trial studies from the FDA. Combining this data with the published studies, Kirsch found that the drug effect was less than 20%. By contrast, the drug effect for pain medication is about 50%. Kirsch also found that the therapeutic effect of antidepressants, unlike most other medications, is not dose dependent. Higher doses of antidepressants produce more side effects, but don’t reduce the symptoms of depression more than lower doses.

These above-mentioned results were well known by researchers, regulatory agencies, and drug companies, but not by most doctors and patients. Pharmaceutical companies have used some tricks to keep this “dirty little secret” from the general public, including:

• Withholding negative studies from publication
• Publishing positive studies multiple times
• Publishing only some of the results from multi-site studies
• Publishing data that was different from what they submitted to the FDA

Why were the drugs approved, when they show so little benefit over placebo? Regulators only require two clinical trials having positive results. Negative trials don’t count. Drug companies can conduct as many trials as they want until they find two with positive results. Kirsch calls this “voodoo science.” It makes things too easy for drug companies.

Part of the reason for the popularity of antidepressants is that doctors and patients have been told that depression is a brain disease, a chemical imbalance that can be treated by medication. Kirsch tears apart the chemical imbalance myth. “Not only is the chemical-imbalance hypothesis unproven, but . . . it is about as close as a theory gets in science to being disproven by the evidence” (p. 81). The chemical imbalance theory states that depression is caused by inadequate levels of neurotransmitters in the brain. The two neurotransmitters that are most associated with depression are norepinephrine and serotonin. The theory came about from the supposed successes of antidepressant medications in treating depression. These drugs either block the destruction of norepinephrine and serotonin, or inhibit their reuptake, which result in more of the neurotransmitters in the brain. Additional evidence in favor of the chemical imbalance theory came from studies of a depression-causing drug resperine. These studies found that resperine decreased brain levels of norepinephrine and serotonin.

The problem with the chemical imbalance theory is that it doesn’t fit the data. Reanalysis of the data showed that resperine doesn’t actually cause depression. Antidepressants don’t really help treat depression, either, since most of their effectiveness is due to the placebo effect. Studies have been conducted in which norepinephrine or serotonin is experimentally reduced. This neurotransmitter reduction does not cause depression in healthy volunteers, or depressed people off medication. Rapid depletion of serotonin only triggers depression in patients currently taking SSRI’s. The final nail in the coffin of the chemical imbalance theory is the effectiveness against depression of tianeptine, a new antidepressant that has an opposite chemical effect as that of SSRI’s. Tianeptine is a selective serotonin reuptake enhancer, increasing the amount of serotonin in the brain. Depressed patients respond identically to tianeptine as they do to SSRI’s. Since it has an opposite chemical effect compared to the SSRI’s, any improvement in depression symptoms can’t logically be due to the chemical action of the drug.

In the last three chapters, Kirsch discusses at length the placebo effect. “The word placebo is Latin for ‘I shall please’” (p. 102). Placebo effects are examples of how suggestion can change how people feel and behave. Expectancies are important in placebo effects. If people expect to get better, depending on how strong they believe this, and what kind of disorder they have, there’s a chance that they will get better. Depression and pain are two disorders that respond well to placebos. The way in which the placebo is administered (e.g. pills, injection, or surgery), along with its brand name, color, price, and dosage are factors controlling its effectiveness. Placebos, like drugs, can produce changes in brain activity. For example, both patients given Prozac and those given placebo had reduced brain activity in the limbic system, the area of the brain associated with sadness and depressed mood.

Since placebos work so well for depression, why not prescribe placebo pills to depressed patients instead of medications? Placebo pills are cheaper and don’t have any side effects. Kirsch argues that this is wrong because it involves deception. A better alternative is psychotherapy, especially cognitive-behavioral therapy. Therapy is the “quintessential placebo,” a treatment that utilizes the placebo effect (i.e. the relationship between therapist and client, and the client’s expectancies of getting better), but does so without deception. Psychotherapy has a number of advantages over medication, including no side effects, reduced likelihood of relapse, and less long-term cost.

One problem with this book is that Kirsch seems to think that placebos will effectively treat all kinds of depression, including the more severe kinds. He acknowledges that the placebo response is reduced for the most severe types of depression. In other words, medications are more effective relative to placebos for the most severely depressed. He explains this by saying that because the severely depressed patients are more likely to have been on antidepressant medication before, and have higher dosages prescribed, they can more easily recognize whether they are on the actual drug or placebo. This will reduce the placebo effect for those assigned the sugar pill, which means that the drug effect is really a placebo effect in disguise. I don’t agree with this explanation. I think that some of the severe types of depression are biologically based, not responsive to placebos, but responsive to antidepressant medication.

Another problem is that Kirsch doesn’t once mention bipolar disorder. Would placebos successfully treat symptoms of depression associated with bipolar disorder? I doubt that they would for the majority of people with this disorder. What about seasonal affective disorder? Would placebos treat symptoms of depression for most people with this disorder? I doubt it. Like with severe (unipolar) depression, I think that bipolar disorder and seasonal affective disorder are biologically based, and don’t respond well to placebo. How about OCD, which although is not classified as a type of depression, has been successfully treated with SSRI antidepressants? Having had OCD, I don’t think that my core symptoms would have responded to a placebo pill. I know from experience that my symptoms didn’t respond well to psychotherapy (although I appreciated the advice from one therapist).

In conclusion, The Emperor’s New Drugs is an excellent account of the ineffectiveness of antidepressants, written by a pioneering researcher. It makes one wonder how so many people were fooled for so long into thinking that antidepressants treated patients by correcting chemical imbalances. Its weakness is that the author doesn’t distinguish between the majority of cases of mild to moderate depression in which drugs are no more effective than placebo, and the small number of biologically-based more severe cases in which placebos aren’t effective, but drugs are.

Soldiers Survive War Only to be Killed by Drugs

I read a heartbreaking article in the New York Times today. Soldiers with PTSD, who come home from war with insomnia, anxiety and chronic pain, are prescribed powerful drug cocktails. The cocktails include pain, anti-anxiety, antidepressant and antipsychotic medications. Some soldiers also combine the prescribed medications with other illegally-obtained drugs. The result is a toxic combination. The article describes three cases, but there are many more.

I question the logic of "drug cocktails". How can you know the effect of a drug when it's combined with many other drugs? There are so many interactions and side effects to disentangle. I understand that these soldiers are in pain, but can't psychiatry provide better care for them?

Do Psychiatric Drugs Do More Harm Than Good? A Review of “Anatomy of an Epidemic” by Robert Whitaker

The idea that people with psychiatric disorders should “take their meds”, that these meds control their symptoms, that they’d better off on than off their drugs, is a noncontroversial position today. Decades of advice from doctors, nurses, therapists, academics, and drug company spokesmen have pushed people with disorders such as schizophrenia, bipolar disorder, major depression, and anxiety to take prescribed medications. We think of someone who decides not to take medications as acting in an irrational manner. Patients who are hospitalized don’t have a choice—they must take their medications.

Is this virtually monolithic societal support of the use of psychiatric drugs a group delusion, similar to the delusions that (nonmedicated) schizophrenics experience? Robert Whitaker takes up this question in his book entitled Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America.

Whitaker has two main points in the book. One, is that there has been an epidemic of mental illness in America in the recent past. There is twice the rate of disabled mentally ill in 2007 compared to 1987, and six times the rate compared to 1955. This trend is even more obvious for children, where the number of disabled mentally ill children multiplied thirty-five fold between 1987 and 2007.

Whitaker bases these claims of an epidemic on SSI (Supplementary Security Income) and SSDI (Social Security Disability Insurance) statistics. He compares these figures in 2007 and 1987 to hospitalization figures in 1955 (most disabled mentally ill in the 1950’s were cared for in state and county mental hospitals). These SSI and SSDI figures are not true prevalence figures, of course, since there are people disabled by mental illness not on these programs, and people on these programs who aren’t truly disabled. Since diagnostic criteria for mental illness has changed significantly in the past half century, it’s impossible to arrive at a true prevalence figure. But his general point of a mental illness epidemic is hard to deny, considering that America spent $25 billion in 2007 on antidepressants and antipsychotics. If there was little or no mental illness, why are doctors prescribing so many pills?

Whitaker’s second point is much more controversial. He says that this epidemic of mental illness is, in large part, caused by the very drugs that are being used to treat psychiatric disorders! Whitaker presents evidence in his book that psychiatric drugs do more harm than good when looked at from a long-term perspective. He acknowledges that these drugs make the patient better in the short term, such as the 6 week period in which clinical trials of new drugs occur. But, looked at over the period of years, not weeks, patients do better off drugs than on them.

Whitaker uses several pieces of evidence to craft his argument. One, is that the epidemic of disabling mental illness occurred during the period in which psychiatric drugs were used. During the early phase of psychiatric drugs (mid 1950’s through the mid 1980’s), antipsychotic drugs were used primarily on people with schizophrenia. Anti-anxiety and antidepressant drugs were prescribed for people with anxiety and depression. Lithium was used as a mood stabilizer for people with bipolar disorder. Most of these early drugs (with the exception of the anti-anxiety drugs) had terrible side effects, such as tardive dyskinesia for the typical antipsychotics. These side effects limited the number of people willing to take these drugs. (The anti-anxiety drugs Miltown and Valium were very popular, especially among women, but also very addictive.) Studies showed that those on the drugs, including the anti-anxiety drugs, had worse long-term outcomes than those off the drugs. These studies were never widely publicized, and doctors continued to prescribe the drugs to adults (children rarely were prescribed drugs in this period, with the exception of Ritalin for ADHD).

The second period, beginning with the FDA approval of Prozac for depression in 1987, saw the release and aggressive promotion of “second-generation” psychiatric drugs, which included SSRI antidepressants (e.g. Prozac, Zoloft, and Paxil), and atypical antipsychotics (e.g. Risperdal, Zyprexa, and Seroquel). Drug companies heavily marketed these drugs both to the public and to doctors, with the help of academic leaders in psychiatry. This period also saw a major increase in the diagnosis and drug treatment of pediatric psychiatric disorders.

The second-generation drugs had fewer and less-severe side effects than the older drugs, but weren’t any more effective than these drugs. They still had some serious side effects, however, such as increased risk of suicide for Prozac, and weight gain for Zyprexa. These adverse effects were generally swept under the rug as the pharmaceutical marketing machine (with the aid of drug-money soaked academic psychiatrists) promoted them as miracle drugs.

The release of the psychiatry reference manual DSM-III in 1980 led to a major change in diagnostic criteria, leading to more reliable diagnoses based on symptoms. The DSM-III (followed by the DSM-IV in 1994) made psychiatry appear more scientific and objective, since it dispensed with vague Freudian notions like “neurosis.” But the problem was that it wasn’t accompanied by any breakthroughs in the understanding of the biology of mental illness. The “chemical imbalance” theory, i.e. that schizophrenia was a result of too much dopamine, and depression a result of too little serotonin, was demolished by research findings. But drug companies and psychiatrists continued to tell people that this imbalance theory was true. Whitaker makes a good argument that the drugs actually cause chemical imbalances, not treat them. These iatrogenic (drug-caused) imbalances force people on the drugs to continue taking them, as they get terrible withdrawal symptoms if they try to stop. Getting children addicted to these drugs was a pharmaceutical marketing home run, as the kids would be hooked for life, a reliable long-term source of income.

It was during these last 25 years of widespread prescription of psychiatric drugs that the disability numbers soared. These drugs didn’t seem to be helping people over the long term, or else why would they be forced to go on disability? Large numbers of children started becoming disabled. According to Whitaker, the second-generation drugs had as dismal a long-term effect on patients as the first-generation drugs. The problem for society was that many times more people were taking them than took the earlier drugs. The few academic psychiatrists who questioned the efficacy of drugs were stripped of their positions and funding, and marginalized. Millions of dollars in drug money flowed to virtually all the academic leaders in psychiatry.

Whitaker weaves in anecdotes along with his research findings, enhancing the readability of his book. Some of the stories are haunting, such as the case of “Jasmine,” a girl prescribed an antidepressant for bed wetting in fifth grade. The agitation she got from this drug led psychiatrists to put her on a drug cocktail that included Zyprexa. She was hospitalized in high school, and the drug merry-go-round to which she was subjected fried her brain, leaving her perpetually psychotic and mute. Of course, Jasmine is an exception, and most children and adults on drugs have much more positive outcomes, but the reader is left to wonder, “what would have happened if she never got on drugs the first place?”

Whitaker provides examples of how drugs used to treat one condition (e.g. Ritalin for ADHD) led to some children developing manic symptoms, which led them to be diagnosed with bipolar disorder, which led them to receive drug “cocktails” including powerful and harmful antipsychotics. They end up on a long-term trajectory of serious physical and mental problems, an outcome which probably would have been much more benign if they hadn’t been prescribed any drugs in the first place.

My own experience with psychiatric drugs was generally a positive one. I didn’t start on drugs until I was 27. I had many years of dysfunctional behavior, of cognitive and emotional problems. Virtually any intellectual activity at all (e.g. reading or writing) would trigger horrible “states” that would last for days. These “states” would include severe obsessions, difficulty concentrating, emotional suppression, and tics. Although I had a job, I was working well below my ability, and had little social life. It was under these conditions that I decided to try Anafranil, a drug used to treat OCD, and it did help improve my functioning for a while. I tried combining Anafranil with many other drugs that were less helpful, although I usually never took more than two at a time. Being very sensitive to side effects, I stuck to low or moderate dosages. After ten years of Anafranil, I felt that it was no longer needed, and convinced my psychiatrist to allow me to stop taking it. I followed up with 3 years of low doses of Xanax, then got off medication completely. I’ve been basically medication-free for 3 years. I think the late onset of starting with drugs, the small number and doses of drugs, and the eventual getting off drugs made me one of the few long-term medication success stories.

Whitaker is not anti-drug, and acknowledges that “there is a place for the drugs in psychiatry’s toolbox” (p. 333). But he wants psychiatrists to “think about the medications in a scientifically honest way and to speak honestly about them to the public” (p. 333). Certainly the vast majority of drug prescriptions are unnecessary and possibly harmful. After reading this book, (although Whitaker doesn’t suggest this) I think that a strong case can be made to outlaw prescribing psychiatric drugs for children. If they cause more harm than good in the long run, then it is children who have the most to lose by taking these drugs. Exceptions can be made for children already on drugs, and for the few children who are completely out of control, and whose behavior cannot be managed by any other means. Psychiatrists would howl about any such legislation, but let them (and their drug company masters) put forward studies that show children benefit long-term from drugs. If Whitaker is right, and there are no such studies, then let’s ban the prescribing of drugs for children.

I found this book to be one of the most powerful and thought-provoking books I’ve read in years. I recommend it to anyone concerned with the mental illness epidemic that plagues our country.

Are We Overmedicating Our Kids? A Review of "We’ve Got Issues" by Judith Warner

Judith Warner answers the controversial question of whether or not children are being overdiagnosed and overmedicated in her new book We’ve Got Issues: Children and Parents in the Age of Medication. One interesting thing about the author that motivated me to read this was that she changed her mind on this question during the course of writing the book. At first, she held the view that kids were being overmedicated by their affluent, competitive, perfectionistic parents. She changed this view 180 degrees in the course of researching the book. The book argues that mentally ill kids are in fact undertreated and undermedicated. Most parents are very reluctant to drug their children, and do so only as a last resort. Many children with mental health issues (about 70%) are not being treated, partly due to parental neglect or opposition, but mostly due to lack of quality, affordable mental health providers and resources in many communities.

Warner first tackles the question of whether or not there is in fact an epidemic of pediatric mental illness. There’s no question that in recent decades there has been a massive increase in both diagnosis and medication treatment. Since the early 1990’s, the number of children receiving diagnoses of mental health disorders has tripled. From 1991 to 2006, there was a 3,500 percent increase in autistic children participating in special-education programs. Prevalence of depressed children has increased from near zero in the early 1970’s to between 2 and 15 percent today. Before the mid-1990’s, there weren’t any children diagnosed with bipolar; today prevalence is up to one percent. Prevalence of ADHD went from 1.5 to 2 percent in the mid-1970’s to about 8 percent today.

With the increased diagnosis, comes increased medication usage. Prior to the 1990’s, kids usually weren’t prescribed antidepressants or antipsychotics. Now 1 to 2 percent of kids are prescribed antidepressants. Atypical antipsychotic drugs, which can cause serious metabolic changes and weight gain, were used by over half a million children in 2003. Ritalin and other stimulant use has skyrocketed along with the increased number of children diagnosed with ADHD.

Warner argues that much of the increase is due to changing diagnostic patterns; what she calls “increased visibility.” Many children who suffered from mental illness in the period from 1945 until 1980 were, depending on the symptoms, punished for misbehavior or conduct disorder, kicked out of school, institutionalized, or labeled as retarded. They weren’t diagnosed with psychiatric disorders because there were no effective treatments (this was a time when psychoanalytic techniques were dominant). Quoting Edward Shorter, “Physicians prefer to diagnose conditions they can treat rather than those they can’t” (p. 46).

Warner tackles the contentious issue of the fortyfold increase in juvenile bipolar disorder diagnosis between 1994 and 2003. She presents evidence skeptical that many of these children in fact have bipolar: the connection between the doctors promoting the diagnosis and the pharmaceutical industry; the fact that mood disorders occur predominantly in women, but juvenile bipolar is largely diagnosed in boys; and that the symptoms of extreme irritability that the supposedly bipolar children have is not a valid predictor of adult bipolar disorder. On the other hand, children diagnosed with bipolar disorder do have serious problems, and probably need some type of medication.

Warner also presents research that indicates that there has been in fact an increase in mental illness prevalence separate from changing diagnostic standards. For example, one study found that successive generations of Americans born after World War II seemed to have a greater incidence and earlier onset of depression. Anxiety seems to be increasing, also, as the number of teens between the ages of 14 and 16 who agreed with the statement that “Life is a strain for me much of the time” quadrupled between the early 1950’s and 1989.

The truth is that there’s no way to know if actual prevalence of pediatric mental illness has increased. According to Warner, “The research that could provide solid answers—epidemiological studies conducted in a parallel manner over time, asking the same questions, looking for the same disorders, using consistent language and definitions—for the most part doesn’t exist” (pp. 56-57).

My view is that she’s right, we can’t be sure of this. But it does seem that something in the environment is making kids more depressed, anxious, and autistic than before. Warner focuses on the post-World War II period, in which parents of young children today grew up. But what about if you go further back in history? It must be remembered that psychiatry, clinical psychology, and other mental health professions didn’t exist before 1900, nor did any mental health treatments. If there were so many mentally ill children (and adults) back then, wouldn’t someone have noticed it? There was no safety net; people had to pull their own weight or starve. If there were as many children and adults with disorders back then, and no way to treat them, wouldn’t society have come to a standstill?

Another way to look at things is the flip side of mental illness: creativity. Many mentally ill people are also creative. Many creative achievers of the past had mental illness. While there is no consistent way we’ve diagnosed mental illness over time, creative achievement is, by definition, public and visible. Michelangelo, Beethoven, Shakespeare, Einstein and others achieved things that make them household names today; there are no contemporary equivalents. As I’ve argued elsewhere, the rate of creative achievement in the arts and sciences declined precipitously in the 20th century, to near-zero today. People who would have achieved in the past are not achieving. There are many explanations for this, but one is that they are acquiring severe, debilitating mental illness that prevents them from achieving. Another explanation, that they are taking emotion and motivation-blunting drugs, is something that I’ll discuss below.

Warner next makes her central argument, bolstered by a variety of anecdotes and quotes from parents, doctors, and researchers. She argues that most parents don’t want to medicate their children, that they usually try a variety of useless alternative treatments before reluctantly agreeing to medication, and that they are usually pleased by the results. While medications don’t work miracles, and some of them produce side effects, they result in improvement. Children who were unable to cope or function in school can now function at a tolerable level. We should stop blaming parents and doctors for overmedicating children, and instead focus on the large percentage of children who, for various reasons, are denied effective treatment for their mental illness.

I found it interesting that Warner didn’t include any examples of cases in which medications did more harm than good. She didn’t include any examples of parents who were eager to use medication on their children. While she says that she couldn’t find such examples, a reviewer indicated that this is an example of her selection bias. There’s no evidence in the book that she took a random sample of medicated children and then tracked down and interviewed the parents. She’s a popular writer, not a researcher, so she can be excused for this unscientific methodology, but the reader must be wary of any generalizations that she draws.

It isn’t hard to find examples of unhappy results from pediatric use of medications. Stephany, the author of the blog Soulful Sepulcher, writes poignantly about her daughter, currently institutionalized, who is such an example. I would have preferred to seen a more balanced presentation from Warner.

Of course, the fact that some children don’t excel with medication isn’t an argument that medication is ineffective. No treatment is successful 100% of the time. All drugs have side effects, and sometimes the side effects are worse than the treatment effect. Another reviewer is critical of the scientific evidence that Warner presents in favor of medication use. Warner says that there are treatments for kids that “actually work” (p. 211), that allow children to “improve and live their lives to the fullest” (p.210). Warner is basing these Pollyannish assessments on short-term measures of success, especially in school. The reviewer is skeptical about how much we know about the long-term effects of drugs on children’s developing brains.

My view is that we can’t be sure of the long-term efficacy of drugs unless we do longitudinal studies, comparing control versus experimental (drug) groups, that extend up to about age 50. The reason for such a long time frame is that by the age of 50, we should know whether or not someone has been successful in his or her career. What if children on drugs do well in school, but not so well in their adult life? Since most of the drugs (except Ritalin) haven’t been used in children for more than 20 years, we’re being premature about declaring a success.

I’m not saying that we shouldn’t prescribe these drugs in children, although I do think that they should be a last resort, after every type of therapy has been tried. We also need to distinguish between the more serious types of disorders and less serious ones. For less serious childhood disorders, the ones in which children can function in some contexts (e.g. home) but not in school, I think we need to think about changing the school environment. The typical public school classroom is OK for an average student, but ones with special needs and/or abilities don’t thrive there. There are some special education classes, but to get a child into them a parent has to have significant time to deal with public school bureaucracies, or money to get into a private school program. Warner mentions this in her book; these services are effectively denied to the lower middle and working classes. We need to try to expand these services, and also think about coming up with less expensive alternatives that focus on vocational or artistic training.

As I mentioned earlier, psychotropic drugs are one of the causes of the lack of creative achievement in arts and sciences today. The legal, prescribed ones blunt emotions and motivation. The illegal ones can cause destructive addictions. Even if a child does better in school while taking drugs, will he contribute more to society than he would have otherwise? In another blog post, I mention that our society has a narrow (academic) definition of talent, that lacks context and empathy. Both context and empathy are necessary for good decision making, and in recent decades America’s political and economic leadership has made some poor decisions. Probably some of these deficits are due to the effects of drugs on people. These effects are hard to quantify, and won’t show up in a typical study, but they are incredibly important for society.

For the more serious types of disorders, in which the child can’t function anywhere, medications are an unfortunate necessity. Warner admits in her book, echoing many parents, that medication is not going to make these kids successful. It may make them less disabled than they would have otherwise been. The most important thing for us to do is to find out genetic and environmental causes of serious psychiatric disorders, to prevent them from happening in the future.

On the environmental side, we’ve covered just about every base imaginable, including diet, chemicals, vaccines, infections, etc. One thing we haven’t looked at is the effect of artificial magnetic fields. The reason for this is that scientists don’t think that humans have the ability to perceive magnetic fields. I present evidence in my research paper contradicting this. I found that I’m sensitive to artificial magnetic fields when sleeping, but not when I’m awake. If I’m sensitive now, as an adult, I was probably much more sensitive as a child. My hypothesis is that some children with serious psychiatric disorders are sensitive to artificial magnetic fields, especially when sleeping. My hypothesis would explain the increased prevalence in recent decades of serious pediatric psychiatric disorders. When I was growing up in the late 1960’s through mid 1980’s, the only artificial magnetic fields I had to worry about when sleeping were the innerspring mattress, steel bed frame, steel building structure, and a fan that I used in the summer to keep cool. Today, we have wireless Internet, home security, cordless phones, cell phones, baby monitors, computers, widescreen TV’s, iPods, central air, etc. Many of these devices and appliances emit strong magnetic fields, and are kept on while sleeping. It would be easy to test my hypothesis. Start turning things off, change to a non-magnetic bed, and see if the disturbed child becomes a little less disturbed. See if he can sleep better, which will make him function better the next day.

In conclusion, I found Warner’s book to be well written, with a lot of useful information for those interested in pediatric mental health. Its major flaw was a lack of balance in presenting evidence in favor of medication use in children.

Antidepressants Are No Better Than Placebo

Newsweek’s cover story reinforces what researchers concluded in a recent article in JAMA—that for the vast majority of patients, antidepressants are no better than placebo. In fact, antidepressants are worse than placebo, because they have side effects. Only for patients with more severe forms of depression do these pills have any significant benefit.

Considering that 2008 antidepressant sales in the U.S. were $9.6 billion, it seems that if one wants to control spiraling health care costs, substituting sugar pills for antidepressants would be effective. If anything, we’re going in the opposite direction. Antidepressant users doubled in the 10 years from 1996 to 2005. Aggressive marketing by Big Pharma to both doctors and customers has expanded antidepressant use, even while the evidence of their effectiveness has been seriously questioned. As the Newsweek article states, “antidepressants are basically expensive Tic Tacs.”

Antidepressants are also used to control OCD. I feel that my OCD/tic disorder was helped by Anafranil, an older antidepressant. While this benefit could be due to the placebo effect, I doubt it. I think that from a biological perspective OCD is more similar to severe depression than to anxiety disorders, with which it is classified by the current DSM. Both OCD and severe depression are helped by antidepressants.

The distinction between antidepressant effectiveness in severe and light/moderate depression reinforces my view that a more individualized/case-by-case approach is needed for psychiatric disorders. As Dr. Klitzman says in a separate Newsweek article, paraphrasing Tolstoy, “every unhappy individual is unhappy in his or her own way.” It’s possible that light/moderate depression is a reaction to negative life events, while serious depression, OCD, and bipolar disorder are something completely different.

My human magnetoreception hypothesis connects these serious disorders with the Earth’s magnetic field. Since magnetoreception is dependent on childhood experience, i.e. where and when someone grew up, each of these magnetoreceptive people needs to be tested and evaluated individually. While the same drug may work in many people, the location of their magnetic home will vary based on their childhood experience. Also, their sleeping behavior and environment is likely different, so recommendations on changing this behavior and environment need to be tailored to the individual circumstances. This is similar to psychotherapy, in that therapy needs to be cognizant of the individual’s background, interests, intelligence, and personality.

In conclusion, we need to stop prescribing antidepressants to people for whom they have no benefit over placebo. For those with more serious disorders like severe depression, OCD, and bipolar disorder, antidepressants and other medications are useful. In the future, if my human magnetoreception hypothesis is confirmed, there will likely be more effective treatments that combine behavioral changes and futuristic devices.