It is an honor for me to publish the following piece by Ronald Pies, M.D., professor of psychiatry at SUNY Upstate Medical University and Tufts University School of Medicine, because I find him to be one of the most fascinating psychiatrists in the Northern Hemisphere (I’m thinking the Southern is full of kooks).
He always comes up with an intriguing angle on psychotherapy, antidepressants, the psychology of wellness … you name it, and he — like me — loves the intersection of faith and medicine, as is evident in his book, “Becoming a Mensch.” So, here’s a curious piece about why the we might blame the Puritans for the anti-med movement in the US. Let me know your thoughts, because I know that you will have some after reading this piece. I should probably also tell you that he wrote the foreword to “The Pocket Therapist.” I was once yelled at by a reader for not disclosing that … whatever.
These are not good times for Prozac and its progeny. In the popular media, the use of antidepressants has been likened to swallowing “expensive Tic-Tacs”, while in professional journals, the effectiveness of these medications has been challenged, if not discounted. And even a casual Google search under the terms, “Antidepressants damage” turns up thousands of websites and articles claiming that these drugs cause brain damage, induce suicide, or lead to “addiction.” Yikes!
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I’ve used the analogy of drowning vs. swimming. If you’re not clinically depressed but melancholy or something, you are treading water. Depression can be like drowning. You do not try to teach someone drowning how to swim. You throw them a life saver and keep them afloat. Medications are that life saver. Some people with therapy learn “to swim” without the life preserver. Others will always need it no matter how much they learn about swimming. This helped my “Puritan” family understand better that it wasn’t my choice to drown and that medication may or may not be a lifetime situation. But until I’ve been in therapy long enough to know I can swim, I’m keeping the life preserver as an option.
I work as a trainee clinical psychologist in the NHS and I agree with most of the comments in this article. The Puritanical angle is an interesting one that I haven’t thought of before. However, with respect to the ‘placebo condition,’ I agree with the idea that antidepressants were developed to cope with severe, disabling depression. In practice, though, I often find that GPs will prescribe them for very mild cases and (often in the case of Chronic Fatigue in my experience), for conditions where they are not even indicated or where the person has not even expressed that they may have depressive symptoms. Perhaps in order to truly prove the efficacy of antidepressants (or otherwise), prescribing should be limited to those who understand their effects on mental health (i.e. psychiatrists) or some GPs should receive better training on who to administer them to.
I very much appreciate the “hosting” by Therese and Dr. Grohol! I’m happy to reply to all fully signed questions or comments of a collegial nature, time permitting.
One point I would like to clarify to head off any misunderstanding. In most large, randomized studies of antidepressants, both the “medication” group and the “placebo” group (so-called) actually receive about 8-12 hours of supportive and educative meetings with professional staff and researchers. So, being in the placebo group does not mean just getting a “sugar pill” at all!
Also, for complex reasons, the placebo response rate
in these studies has been rising in recent decades. Many professionals believe this is due, in part, to recruitment of less ill volunteers, rather than very sick subjects from clinical settings. This “inflation” effect may be one reason placebo response rates have crept up and diminished the difference between placebo and active medication. Still, when we look at the most severe types of major depression, there is little question that the medication outperforms the “placebo condition”, as defined above. And, once again, I prefer to reserve medication for the more severe, and particularly, “melancholic” forms of major depression.
Best regards, Ronald Pies MD
But Dr. Pies, your repeated point that the placebo group is receiving counseling and attention, not “just” a sugar pill, doesn’t make sense to me.
The purpose of placebo-controlled studies is to isolate one factor (the medication); BOTH the medicated and placebo patients receive the same level of counseling. If both improve at similar rates, then clearly the medication is having minimal effect. To point out that the placebo group received counseling is irrelevant to the study of when these medications are effective.
I very much appreciate the “hosting” by Therese and Dr. Grohol! I’m happy to reply to all fully signed questions or comments of a collegial nature, time permitting.
The stigma on medication for those dealing with depression or any other mental health condition is disheartening. Many people experience depression through no fault of their own, no sin. I am a strong believer in therapy and medication hand in hand. I think it is rather recklace for any doctor to prescribe antidepressants without some kind of therapy plan.
What is the hardest thing for people to understand is , some variations of depression don’t respond to talk therapy , therefore medication is required , and yes they do work.
The life that antidepressants have allowed me to live is indescribable. Fifteen years ago I suffered a major depressive episode and those who have not gone through such anguish do not understand the relief that the medication provided. In fact I had never felt so ” well”; I was not ” high” and I was not simply using the medication as a crutch. An individual would not tell a person who is suffering from a ” physical” illness that they should simply get over it, and imply that they are weak-willed. Depression is a disease and maybe it would be a good idea for those who are not afflicted to remain quiet about a matter they do not understand.
The puritanical knife cuts both ways. What about the puritanical parent who cannot accept that her adolescent child is gay, or atheist, or mentally ill, misbehaved, or just quirky, and so she sends him to a psychologist who diagnoses the child’s “deviancy” as depression, social anxiety, OCD, or a host of other maladies and then refers him to his G.P. to get a prescription for SSRIs that will have the effect of blunting his emotions and making him more easily controllable by his puritanical parents?
“There is also no convincing evidence that antidepressants cause ‘brain damage’ or ‘addiction’ among those who take them. In fact, the most recent evidence on how these medications work suggests that they actually enhance the growth of connections between brain cells—perhaps leading to more adaptive brain functioning.”
You can’t have it both ways. Either the antidepressants mediate long-term neurological changes in the brain or they do not. You don’t get to decide what changes are “damage” and what changes are “enhancement.” That’s subjective and there is not enough data.
Dr. Pies wrote: “There is also no convincing evidence that antidepressants cause ‘brain damage’…”
I suppose that “convincing” is in the eye of the beholder. Robert Whitaker recently wrote a whole book on the subject of the harmful effects of antidepressants (and of other psychotropic drugs). The book is well worth reading. It’s called, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, and you can view the Amazon page here:
http://www.amazon.com/Anatomy-Epidemic-Bullets-Psychiatric-Astonishing/dp/0307452425
There are signs that the psychiatric establishment is starting to take these criticisms seriously. Robert Whitaker (the author) recently presented at Grand Rounds at Massachusetts General — something that never would have happened even three or four years ago.
As for myself, I used to work for a pharmaceutical company, from 1995 – 1998. The company made one of the major SSRI drugs. I actually worked on the team that was responsible for managing the drug. At the time, I believed in the product. But I maintained my interest long after I left the industry, and eventually my views changed quite a bit. I think the drugs are ineffective at best, and harmful at worst.
Dr Pies:
Ok, but is there a conflict of interest when you have advocated, for what I interpret as at least somewhat more a liberal policy, medicating people who are dealing with grief? I know your standard reply is stating it is denying care for those who meet the DSM criteria for depression, but that is not how I read the original argument you made in supporting medication interventions, I think made originally here or at Dan Carlat’s blog site more than 2 years ago.
Complicated bereavement is a complicated presentation, but I feel you painted a rather broad stroke in advising treatment options. Maybe you have reconsidered your position, or will clarify it here for readers if it is of value to do so.
Besides, the real work is educating our non-psychiatric colleagues who write for these meds like pez these past 10 or more years. But that matter we addressed in an earlier post and thread.
Hey, interested in advising readers how to address the new hassle for us in the office: with Wal Mart and Target having these $4 prescriptions, what do you tell patients who are economically disadvantaged how to access cheap meds when only about 8 of 20 or more antidepressant meds are on that list? Especially when they come to us after exhausting the $4 ones from PCP prescriptions first in more often a less than efficacious way, leaving us to offer meds 40 years in availability with side effect profiles that won’t excite patients too quickly. I hope you have an interesting idea, because if PPACA stays in place past mid 2012, the government is going to ride that notion a long way, just no significant quantity of patient success stories to enjoy the ride.
If I am right, isn’t it at least a bit feasible to see a few antidepressants made extinct because of cost alone? Maybe some should be made way of the Dodo, but, some are a bit gray in their options in access versus cost, but does government think in gray? Me don’t think so, but, having a libertarian bent more often than not, that puts me in the negative column?
This has nothing to do with “Puritianism”. This has everything to do with ordinary people finding most of their relatives and friends have completely changed personalities while on Prozac and other SSRIs. They act biazarre & hostile, among other things. Even Web MD has said that one out of three people will become worse or even develop bipolar disorder on antidepressants.
The Physicians Desk Reference states that SSRI antidepressants and all antidepressants can cause mania, psychosis, abnormal thinking, paranoia, hostility, agitation, etc. These side effects can also appear during withdrawal. Also, these adverse reactions are not listed as Rare but are listed as either Frequent or Infrequent.
Go to a search engine and type in SSRI Stories where there are over 4,700 cases, with the full media article available, involving bizarre murders, suicides, school shootings/incidents [65 of these] and murder-suicides – all of which involve SSRI antidepressants like Prozac, Zoloft, Paxil, etc, . The media article usually tells which SSRI antidepressant the perpetrator was taking or had been using but sometimes the media article just says “antidepressant” or “medication for depression”.
On December 15, 2010, PLoS Medicine released a study which showed that, in regard to prescription medications and violence, the FDA had received the most reports of violence from the SSRI & SNRI antidepressants (except for Chantix, the smoking cessation drug.) The evidence of an association with violence was weaker and mixed for antipsychotic drugs and absent for all but one of the mood stabilizers. Yet, the antipsychotics and mood stabilizers, given for the most serious mental illnesses, bipolar disorder and schizophrenia, would be the most likely culprit involved in violence but, instead, it was the antidepressants which had the most reports of violence. They were given to patients that traditionally were the least likely to commit violence, the depressed and the anxious.
All I know is that antidepressants saved my life. I was in therapy and finally my therapist told me she couldn’t help me unless I got more help for my depression and tried meds. So I saw my first psychiatrist and was prescibed Effexor. After about 4 weeks I began seeing things in colour again, and noticing little things that made me smile. It’s taken years of talk therapy and meds adjustments and experimentation but after experiencing at least 9 MDD episodes pre-meds, I’m quite happily on meds at the moment.
I did want to try to reduce one of my meds, an anti-psychotic, because I don’t like some of it’s side effects and I’d like to get off it at some point, so my psychiatrist and I agreed we’d try a very small dose reduction. I lasted 10 days. My mood just plumitted, and once I went back up to my regular dose my mood was back to normal within a week. So I know meds work for me.
I’ve now been completely free of depressive symptoms for over a year, for the first time in my adult life. I believe that the combination of meds and talk therapy is the best treatment, but I couldn’t have done it without meds.
Thanks to all who have written so far. Many good questions have been raised, and I will respond substantively very soon. –Ronald Pies MD
Aside from yet another ad hominem attack on imagined enemies (not only are they Puritans but they *always” use the term “drugs” instead of “medication”), Dr. Pies article completely disregards the many documented side effects of antidepressants.
With so many people taking these, ahem, medications, many inappropriately for less-than-severe depression, many people have had the opportunity to experience side effects that may be severe and long-lasting.
Everyone knows someone who’s been injured by these, ahem, medications.
It’s bad word of mouth that’s killing antidepressants, Dr. Pies. All of your rationalizations, all of your excuses, all of the drug company advertising, the corrupted research — all of it — cannot stand in the way of bad word of mouth. You simply can’t control it. The more people are exposed to these, ahem, medications, the more people are complaining.
Nothing kills a bad product like good advertising. It’s the over-reaching that’s tarnished your profession, Dr. Pies, not psychiatry’s critics. Your search for a conspiracy is making you look, ahem, more like one of those Southern hemisphere psychiatrists.
Ronald and Therese,
Thank you so much for writing and hosting this article.
I find the attitude of hostility in our society towards psychiatric medications so disheartening.
A number of my family and friends with serious psychiatric conditions have benefited enormously from including medication in their treatment. Some of them would have died or, in earlier times, been permanently institutionalized. Those folks have normal lives now.
I myself would still be in dire straits without including medication in my treatment. Psychotherapy was futile for me without it. The psychic pain and the disability associated with my depression was truly horrific and, as another poster says, relief from it is indescribable.
The meds aren’t perfect – meds for every medical condition can have side effects. But when you’re fighting to salvage your existence, they can be a godsend.
Wow, we’re really at the end of the road, aren’t we Mr. Pies? I can see your overly academic and tortured logic at work to try to explain away your cognitive dissonance about how the psych meds you and psychiatrists everywhere prescribe may actually be harming some patients in the long run.
Puritanism? Really? There’s a backlash against psychiatric meds now because the corrupt core of the psych med trials (dating back decades) is coming out, as are the long-term side effects. Meds don’t cause brain damage? Maybe not, but they’re certainly doing something very bad to a growing number of people. In his latest lecture, Robert Whitaker talks of a growing number of young adults who are seeing seemingly permanent sexual dysfunction from taking SSRIs long-term. Even once they get off the SSRIs, the sexual dysfunction remains. It’s called PSSD and it’s very real. This is backed up by rat studies. What kind of new brain cells are being grown in this situation? I don’t know, but I do know I don’t want any of them.
There’s a video of Whitaker’s talk on youtube. At 2:17:21 he speaks about PSSD. End your ignorance at the link below.
Now I already know ahead of time what you’ll say about long-term sides and PSSD: “Yes, for a distinct minority of patients, long-term sides like PSSD and persistent anhedonia are a worrying issue. We need to do more research on these long-term side effects.”
But where’s the research, Ron? And how small is that minority? Why are people like Whitaker the only ones sounding the alarm bells about the dangers of psych meds and how over-prescribed they are? Could it be that psychiatrists such as yourself can’t admit to themselves that they may be at least partially wrong, and perhaps have made some patients worse with these meds? It sure helps explain the logic behind your Puritan analogy.
Outside the Scientology lunatic fringe, there is no war on antidepressants; there’s a corrective backlash. Patients are furious they were lied to (chemical imbalance anyone? What about the suppressed side effects reports from drug companies? Or the fact there are no long-term safety studies even though almost everyone on psych meds is on them long-term?). It really is that simple.
But psychiatry has never been about simple common sense. It would be out of business if it were.
Whitaker Lecture Link: http://www.youtube.com/watch?v=5bu1uApqIr4
Actually, the backlash should not be leveled at psychiatry alone, but to the minority alleged Key Opinion Leaders (KOLs) who had political and academic control of the American Psychiatric Association and leading University Programs that erroneously and harmfully tarnished the training programs to buy into this false notion of biochemical imbalances. In no particular order, I think Harvard, Johns Hopkins, and Stanford were the main leaders at the beginning and then others who saw the gravy train just leaving the station jumped on board. Guess they never saw who were the conductors of this monolith railway, Big Pharma who saw the opportunity and rode it as far as they could.
And just remember, more than 70% of antidepressant precriptions were and still are written by non-psychiatrists, who in the end have really no standard of care clue how to implement meds responsibly and effectively. Attacking the people who try to handle mental health care alone appropriately is just not fair.
But, while maybe you can’t escape politics in any endeavor of profession or service, you have to watch what alleged leaders say versus what they do in the end. Like, writing a book and then having someone review it, practically gushing it was the sequel to the bible, in the writer’s own professional publication.
Not very Mensch like in my opinion.
I agree with Iatrogenia. For example, if you go to google search engine and type in Prozac +violence, it states that there are 13,900,000 articles. Almost 14 million articles about Prozac and violence must be telling us something.
I don’t know one person who doesn’t have a horror story about Prozac or Zolft, Paxil, Effexor, Celexa, etc.
The mania being caused by these drugs is of a different nature, too, than the regular mania of an unmedicated person. For example in the 28 won cases on SSRI Stories, a jury found a woman innocent who had stabbed her husband of 43 years to death by stabbing him over 200 times. Also, in the won cases, a woman school teacher in Canada was found innocent of molesting a 15 year old male student because her Effexor had caused her to go insane.
This so-called nymphomania has affected woman school teachers all over the country. There are 15 cases on SSRI Stories alone where this has happened, including Debra Lafavre [Paxil].
Bill O’Reilly of the TV Talk show “The Factor” reports that they are receiving at least one case a week to their network of woman school teacher molesting their minor male students. He called it an epidemic.
It is amazing that SSRI Stories is even able to find this many media articles as the newspapers and TV stations are reluctant to report this – probably because of TV adertising for medications.
This is a National Tragedy and only the medical community seems “blind” to what is happening.
I would like to thank all of you who have written in the spirit of a respectful exchange of views. This is a complicated and controversial topic, and I realize that the discussion evokes strong feelings and opinions, on both sides. Some individuals who have had bad experiences with psychiatry in general, or with antidepressants in particular, are understandably bitter, and their vituperative comments clearly reflect this. My sincere hope is that a presentation of the facts may persuade these individuals to re-examine some of their prejudices, and that they will eventually desist in their ad hominem attacks on psychiatry and psychiatrists.
That said, I do want to put my view of antidepressants in a broader perspective, prior to responding to some specific questions and comments from readers. First, I am not one who sees antidepressants (or any psychiatric medication) as “miracle pills”, panaceas for life’s slings and arrows, or even as tremendously effective medications. Though I recently retired from clinical practice, I used to have a consultation practice that focused mainly on treatment-refractory depression. Since the patients I saw, over more than 25 years, were mostly those with more severe depressions, I often saw very impressive benefits from antidepressants, when the diagnosis was truly unipolar major depression. (Those who actually had bipolar disorder did not usually fare well with antidepressants (ADs), and sometimes had adverse responses to them).
But what we “see with our own eyes” is not always a reliable guide to the best science. In the past five years or so, my reading of the literature says to me that, in mild-to-moderate depression, ADs don’t have a very robust advantage over non-specific interventions and support, or over psychotherapy. In this less severely afflicted group, antidepressants are actually just “so-so” agents, and their side effects may indeed outweigh their benefits. On the other hand, for very severely depressed patients with melancholic features (e.g., severe weight loss, profound loss of pleasure in all activities, psychomotor retardation, etc), ADs can be very effective and even life-saving. This conclusion is borne out by numerous reviews and meta-analyses, and the reader is directed to the first 2 references. For mild-to-moderate, non-melancholic major depressive disorder (MDD), I believe psychotherapy is the treatment of “first-choice”.
[Refs: see Brown WA Acta Psychiatr Scand Suppl. 2007;(433):125-9; and the review by Dr. HJ Moller, available freely at: http://cinp.org/cinp-perspectives/perspectives/?tx_mmforum_pi1action=list_post&tx_mmforum_pi1tid=9;. Also see the excellent website of Dr. Sheldon Preskorn, at http://www.preskorn.com.
In addition, patients must understand that ADs are “serious medications for serious problems”, and should not be dispensed casually for every-day stress, brief periods of normal grief [see my response to Dr. Hassman in a subsequent posting] or as a substitute for making constructive changes in one’s life. To the extent any physician has ignored these caveats, he or she must be deemed culpable.
ADs can indeed have significant, and sometimes serious, side effects, depending on the specific AD; most notably, drowsiness, nervousness, sexual dysfunction (mostly with serotonergic agents), dizziness, and GI problems, such as nausea. Many side effects are related to dose, and are manageable with dose adjustment, or change to another agent; for example, sexual dysfunction very rarely occurs with bupropion. A careful “risk-benefit” discussion with the patient is always mandatory, balancing the potential risks of the medicine against the very serious (and sometimes lethal) risk of MDD itself; e.g., there is at least a 4% lifetime risk of suicide, many magnitudes higher than in the general population. This is besides the devastating effects that severe major depression has on the person’s vocational, social, and family life.
Regarding the risk of violence, suicide, homicide, etc: a careful examination of the statistical evidence shows that these are very rarely associated with use of ADs, much less causally linked with AD use. The reader who cited the PLoS study by Moore et al [PLoS One. 2010; 5(12): e15337] should look carefully at the actual numbers of instances in which “violence” was associated with AD use. For example, the authors found that the number of violence cases was 3.9 times greater for the antidepressant bupropion than for all other drugs combined after adjusting for the volume of reports. That sounds pretty scary! But when you examine the actual numbers, they represent a tiny fraction of cases. For example, violence cases accounted for 35/3689 (0.95%) of all cases for the drug bupropion. For all the other drugs, violence cases accounted for 1902/776480 (0.2%). That’s a big statistical difference, but it says that fewer than 1% of adverse reports with the medication were related to violence—and this study included “violent thoughts” in their analysis.
Similarly, while a small percentage of individuals may experience suicidal thoughts while taking an AD, there is no convincing evidence showing an actual increase in completed suicides associated with AD use. In fact, a recent 27-year observational study of antidepressants [Leon et al, J Clin Psychiatry, 2011;72:580-586] concluded that “…antidepressants were associated with a significant reduction in the risk of suicidal behavior” –i.e., a reduction in actual suicide attempts or completed suicides, while taking ADs.
Furthermore, there is no credible evidence of a rising tide of public outrage or discontent regarding ADs, and there is considerable evidence to the contrary. Indeed, it is ironic that critics often trumpet such public outrage while also condemning rising rates of AD prescription and use! These critics might want to ask themselves why doctors have not gotten a strong “Stop!” signal from the general public, if ADs are as noxious and toxic as is sometimes alleged. In truth, there has been a marked increase in AD prescription over the past 30 years, such that ADs are now the third most commonly prescribed medications in the U.S.
To be sure, there are both positive and negative elements in this trend. By far the majority of AD prescriptions are written by non-psychiatrists, and often, for patients without a clear psychiatric diagnosis. Though not necessarily a sign of “bad practice” on the part of PCPs most psychiatrists find this trend quite worrisome, since the patient typically spends so little time with the primary care doctor. (In my experience, some of these patients wind up having bipolar disorder, which has been “missed.”). Nevertheless, a recent review of rising AD prescribing rates concluded that “Expansion of antidepressant treatments in recent years has not changed the community prevalence of depression overall, but it has reduced the prevalence of more severe depression and suicidal ideations.” [Mojtabai, R J Affect Disord. 2011 Nov;134(1-3):188-97. Epub 2011 Jun 17.]This is good news!
Furthermore—contrary to the claims of critics—there is good evidence that patients treated with ADs usually report improvements in “quality of life” and overall satisfaction with the medication. For example, a Belgian study of the AD escitalopram found that “Treatment with escitalopram results in a significant improvement of quality of life enjoyment and satisfaction in patients with MDD or GAD (generalized anxiety disorder) [Demyttenaere et al, Int Clin Psychopharmacol. 2008 Sep;23(5):276-86.]. And, a recent study by pharmacists (not psychiatrists) found that among monitored patients taking antidepressants:
“Fifty-seven percent of patients reported feeling better a lot of the time, and an additional 30% reported feeling better some of the time. Nearly 75% reported that the antidepressant did not bother them or only bothered them a little of the time. Being very satisfied was reported by 47% of patients, and an additional 28% were satisfied with the antidepressant.” [Dara et al, J Am Pharm Assoc. 2002;42(1); viewable at: http://www.medscape.com/viewarticle/436594_7.
This concludes my general comments, and I will respond in a separate posting to some specific comments and questions raised by readers. I appreciate your patience in considering this long discourse!
Ronald Pies MD
I would just like to ad here a comment that demonstrates my point. Many of these “Side affects” are consider minimal and of low consequences. However, if you are married to somebody who becomes irritable, melancholic, and/ or reduced libido it can start that “karmic wave” headed into the negative direction. Add in the life changing conditions (in the 10 year myself and the ex had been through many and in the past it had drawn us together.) and the turbulence begins. It is AMAZING how psychiatrist can actually be so naive at to think the change on a persons behavior remains in a bubble and doesn’t become an social environmental problem tainting the waters with negativity. Look down that list of “manic behaviors” and stop and ask yourself if you were treating a couple for marriage problems, what impact would each of those individually have on the marriage. Then ask yourself if being from a broken dysfunctional family will increase the child’s potential to suffer from anxiety and depression.
A tiny fraction of suicide and homicide cases is alright as long as it isn’t your loved one. The number of deaths caused by drunk driving is minimal, but we still have strict enforcements on the practice. BTW the UAW union leader here in Ohio just committed suicide and left a note blaming it on the antidepressants. Now his opinion matters and is accurate when they ask him “are you feeling better”. But surely they will discount his opinion given in the suicide not as the words of a distrought and trouble man.
The backlash is caused by distinct changes in a patients behavior on the drugs that , make the persons life more miserable and the powerlessness those of us who try to get our loved ones off them are exposed to. As an analogy, lets consider that a Dr. prescribed alcohol to a patient to cure bad driving The patient gets drunk and, as we all know, drunk people think they are better drivers. In fact from their perspective they ARE better drivers (and better looking, and can beat up anybody). The doctor doesn’t ride along with the patient and only has the rights (and motivation) to ask the patient about his driving. If the patients family try to tell the doctor about the dangerous driving while under the influence the doctor says he is not allowed to talk about it. The Alcohol companies list “worse driving” as a possible side affect. The FDA mandates that the doctor talks to the family and other drivers and what they observed. However bound by Dr./ Patient privilege the doctor can’t and won’t. The doctor gets paid by the alcohol company kickback and often prescribes a higher does or switches from beer to vodka. When the bad driving leads to an accident and death, they say that the patient was a bad driver before and “the drug just didn’t help this one”. The whole time, their loved ones have 3 choices. Keep getting in the car with them, get out of the car and let them crash on their own, or remain oblivious. That is with futility of antidepressants.
I saw my ex who I knew for more then a decade, was my best friend, my companion change into something I didn’t know inside of 3 months of taking Prozac. Pull out the list of “Manic behaviors” and put a check next to every one of them. In that time, she had a close relative die and she said she “couldn’t cry”, She started drinking heavily every night, threatened to kill herself, and “shake the baby”. She cut off all her normal friends and started hanging out with a lass admirable crowd. She was arrested for assault on me (we had never even had a raised voice argument prior to this) and ended a 12 yr relationship. The things and the statements that came out of her mouth were just dizzying. Yet nobody with any control to do anything would believe me. Upon contacting her GP with the incidents, her response was to double her does of Prozac and giver her birth control for the manic behavior. She was given them for mild anxiety. My daughter now gets to be a statistic.
The problem as I apply what I observed with what I have researched is this. Antidepressants basically don’t change anything, they suppress what Freud called the “Ego Ideal” or “Super Ego”. (This is more then likely physically located in the PFC as we saw the same results from lobotomies.) This is the part of our personality the applies learned results of consequences to our Id’s desire. This is why patients feel “liberated” for those pesky consequences for their actions. So there is a part of them that has always wanted to act that way. How the drugs affect each person really depends on that Id that was developed during their upbringing. The result can be found on forums like “marriages destroyed by SSRI/SNRI’s. And you can hear the testimony about the crazy affects and withdraws on forums like Paxilprogress.org. This is a window into the users and the spouses dealing with the part the drug companies and the doctors don’t want to know.
Thank you for the more thorough explanation of the PLoS article.
Should physicians then say, “I am going to prescribe to you the antidepresant bupropion [Wellbutrin/Zyban] and there is approximately one chance in one hundred that you will become violent while on this drug. Or should the physician say, “I am giving you a different antidepressant than Wellbutrin because only one in five hundred people became violent on these SSRIs or SNRIs”.
It is relevant to mention that this study came from the FDA Med Watch where the FDA cliams that only one in ten adverse reactions are ever reported to the FDA.
What patient is going to report violence anyway? Usually those who are hypomanic on the drug are having a great time and they don’t mind beating a few people up now and then because to them it is fun. There is actually a case of a 15 year old girl on SSRI Stories who killed her nine year old neighbor girl just to see what it felt like to “kill someone”.
Sure, a lot of people feel better on an antidepressant. Even more feel better when they exercise according to a Duke University study relicated at Southwest Medical Center in Texas.
Also, many people feel better on a placebo.
It is too bad that you worked with only the most severly depressed as you did not see a true clinical picture of what is happening out there.
The book “Listening to Prozac” consisted of six ancedotal stories and it helped put a whole nation on Prozac.
Yet physicians yawn when they see almost 5,000 cases of murders and suicides on SSRI Stories. I wonder why this is!
Response to specific comments:
Again, thanks to those who have shared their personal experiences, both good and not-so-good, with the use of antidepressants.
Before commenting on some technical issues raised by some readers, I’d like to clarify my original point about the “Puritans”. I do not see some sort of dark “conspiracy”, in which a cabal of neo-Puritans is sitting around, plotting ways to disparage those who use (or prescribe) antidepressants! My thesis is that we are living in a culture that reflects unconscious attitudes and prejudices, some of which are remnants of this country’s original Puritan settlers. (Interestingly, the Boston Globe just reported that the current debate over gambling casinos in Massachsetts is being colored by “the state’s Puritan heritage”). And I’m not the first psychiatrist to point to religious-cultural attitudes as a factor in how we judge psychiatric medications. The late Gerald Klerman MD, in 1972, used the term “pharmacologic Calvinism” to describe something similar to what I argued. (According to psychiatrist Peter Kramer, in his book, Listening to Prozac, Klerman later wished he had instead used the phrase ‘pharmacological puritanism,’ as “more expressive of the judgmental and prohibitive quality of the objection to medication.”
Recently, the science writer Judith Warner, in an interview about her book, We’ve Got Issues, pointed out that
“…The notion that strong people tough it out, weak, self-indulgent people give in to seeking chemical salve for life’s blows, persists among many Americans today, however. You hear it all the time in criticisms of Americans’ antidepressant use: the idea that we’ve become a medicated nation, unable to bear any sort of adversity. Once again, this kind of moralizing shows little concern for reality – the lived reality of people who do suffer from depression – and a sort of blind adherence to dogma. “
http://bnreview.barnesandnoble.com/t5/Interview/Judith-Warner/ba-p/2214
I fully agree! My colleague, Cynthia Geppert MD, PhD, recently explored a similar “theological” debate about benzodiazepines (Valium, Xanax, and others) [see http://www.psychiatrictimes.com/display/article/10168/54151
Now some specific points and responses, based on several readers’ comments:
• Re: the placebo group in randomized controlled studies, and my insistence that we need to realize that these subjects actually get quite a lot of attention, support, education, and what I would call “TLC”. It is perfectly true that both the placebo (PBO) and active medication group (MED) get all this attention in a typical study; so, in theory, it ought to be “a wash”, with the two interventions cancelling out, and leaving us with a clear comparison of the specific MED effect with the “sugar pill” (PBO). But this assumes that there is no interaction or “synergy” between the PBO pill and all the attention/support/TLC—perhaps producing a total effect that is greater than the sum of its parts. We really don’t know whether this occurs or not, but it remains the case that nobody has literally studied MED vs. PBO in depression, apart from the environment of the clinical study’s support, education, and “TLC”. We therefore have no reason to infer from these studies that if a doctor just gave a depressed patient a sugar pill or vitamin and sent her out the door, that in 6 weeks the patient would show as much improvement as PBO subjects in a clinical study. In short, in clinical studies, there is far more than a “sugar pill” involved, and we can’t assume that the results reflect the inherent power of the sugar pill vs. the active drug. All that said, I will acknowledge that many such studies do not show a big difference in MED vs. PBO outcomes, in cases of mild-to-moderate depression.
• On the issue of “brain damage” and antidepressants: we have far more than our own subjective feelings to decide this matter. Sure, we need to respect the patient’s experience: if he or she says, “I feel like my brain is foggy on this medication”, we need to respect that and investigate—but that is not the same as finding “brain damage.” Numerous studies of brain function (using Positron Emission Tomography, or PET) have shown that subjects with major depressive disorder (MDD) have characteristic abnormalities when compared with non-depressed controls; and that antidepressants (like psychotherapy) help correct and reverse these abnormalities. This improvement has been correlated with reports of improved mood, as well as with improvement on objective tests of cognitive function, such as memory. Indeed, recent data has raised the prospect that MDD itself can actually cause damage to the brain, particularly if it repeatedly recurs. For more on these issues, see references 1-3, below. That said, we do need more research on the long-term effects of ADs on brain function and structure. Way back in 1997, for example, I called attention to a very small percentage of patients—probably, a “handful”—who developed persistent abnormal movements after taking serotonin reuptake inhibitors (“SSRIs”, like Prozac, Paxil, Zoloft, etc.)—see Journal of Clinical Psychopharmacology: December 1997 - Volume 17 - Issue 6 - pp 443-445. Although such problems appear to be very rare, they should be part of a risk-benefit discussion with patients.
• On the issue of sexual side effects, and the possibility that some patients taking SSRIs may experience persistent sexual dysfunction (PSD), even after they have stopped taking the medication: this is certainly an important, albeit rarely reported, phenomenon. The context for this is that, when SSRIs first came out, much of the drug-company literature reported very low rates of sexual dysfunction—probably because the investigators failed to ask the right questions! Later study uncovered quite high rates of sexual dysfunction—perhaps as high as 40%, with SSRIs, but not nearly as high with bupropion and some newer agents, like mirtazepine. From my research into the literature, there is, at present, just a handful (well, fewer than 25) case reports of this PSD phenomenon in the published literature [see R.P Kauffman, http://www.primarypsychiatry.com/aspx/articledetail.aspx?articleid=1479; and
Csoka et al, J Sex Med 2008;5:227–233]. Given the millions of people taking SSRIs world-wide, this does not seem like a common phenomenon, but we do need to take it seriously. And, bear in mind that sexual dysfunction is a common presenting complaint with major depression itself, prior to treatment, so that reports of such problems must be evaluated very carefully (not, please, via journalists’ anecdotes, posted on youtube!).
• Dr. Hassman (in his first message) raised the issue of whether or not I advocate the use of antidepressants for those experiencing (uncomplicated) grief. My answer is an unequivocal, no, I do not! I have really stressed this in several online postings, and Dr. Hassman can find an extended dialogue/debate on this issue (Michael First MD; Sidney Zisook MD, and myself) by going to the Medscape website http://www.medscape.com/viewarticle/740333
As Dr. Zisook and I discuss in the debate, the “inner worlds” of grief and MDD are really quite different:
“Grief and major depression are fundamentally different conditions. To be sure: both can and often do occur after the death of a loved one, and both may be exquisitely painful. Both can make a person sad and withdrawn. Both grief and major depression may show marked variability, with some cases relatively mild and short lived, and others, severe and persistent. However, unlike major depression, ordinary grief is adaptive and characteristically contains a broad mixture of negative and positive emotions. Thus, at times, the bereaved may experience longing, loneliness, yearning, preoccupation with the deceased, and waves of distress triggered by memories or reminders of the deceased. At other times — or admixed with such negative emotions — the grieving person may experience feelings of relief, pride in past accomplishments, and pleasant memories of the deceased. The key emotion in ordinary bereavement is a feeling of loss. (Interestingly, the etymology of the word “bereavement” precisely reflects this, and is derived from O.E. bereafian: “to deprive of, take away, seize, rob”). In contrast, the key emotion in major depression is sadness tinged with hopelessness and despair. Moreover, in major depression, anhedonia and diminished self worth are usually pervasive and intractable. Pleasant memories, feelings of relief or pride, and expressions of humor are not characteristically part of the emotional repertoire in major depression… Most bereaved individuals grieve and feel “depressed” (small d); some develop MDD (large D). Some grieve intensely and for extended periods (months or years) without ever meeting criteria for [MDD]; in contrast, many individuals with depression — whether mild or severe — have never been bereaved. In short, ordinary grief and major depression are simply different constructs with differing phenomenology (the “inner experience” of the sufferer).
Dr. Hassman also raises the issue of so-called “complicated grief” (CG), and that is, well—really complicated! Sometimes called “pathological grief”, this is a condition under active investigation and being considered as a possible new diagnosis in DSM-5. Whether antidepressants are useful for CG or not is still unsettled. For more on CG, please see the paper available on line: Zisook and Shear, http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2691160/
I wish I had some advice for the financial conundrums Dr. Hassman describes, but I don’t—other than to say that our health care system as a whole needs some drastic revision, along the lines advocated by Physicians for a National Health Program [see: http://www.pnhp.org/.
I will now plan to take a break from this blog, and I thank Therese Borchard and John Grohol for the opportunity of presenting these views. I also thank those of good will who have expressed their sincere views and feelings on this website. –Best regards, Ronald Pies MD
Refs:
1.Warner-Schmidt JL, Duman RS: Hippocampal neurogenesis: opposing effects of stress and antidepressant treatment. Hippocampus. 2006;16(3):239-49.
2. Jorge RE, Acion L, Moser D, et al: Escitalopram and enhancement of cognitive recovery following stroke. Arch Gen Psychiatry. 2010 Feb;67(2):187-96.
3. Brody AL, Saxena S, Silverman DH et al: Brain metabolic changes in major depressive disorder from pre- to post-treatment with paroxetine. Psychiatry Res. 1999 Oct 11;91(3):127-39.
Mr. Pies:
I find it more than a little condescending when you suggest that journalists such as Whitaker are not doing careful evaluations of issues like PSSD just because it’s not in a clinical setting. Need I remind you how tainted so much of the clinical research was for psych meds? And why do you think the researchers weren’t asking “the right questions” about sexual sides? It’s because they wanted to present the most favorable side effect profiles for the drugs!
Also, there are far more than 25 people suffering from PSSD. There is currently a forum for sufferers of PSSD (SSRIsex) in which there are over 1,000 members, and their symptomology is quite similar: genital anaesthesia, orgasmic anhedonia, and lack of response to visual stimuli. Nearly all of them state THEY NEVER FELT THIS WAY BEFORE TAKING THE MEDS, EVEN IF THEY WERE DEPRESSED. They all say it is an utterly alien, inhuman feeling.
Or, as was stated in a 2008 Journal of Contemporary Psychotherapy article (Bahrick, A. S., & Harris, M. M. (2009). Sexual side effects of antidepressant medications: An informed consent accountability gap. Journal of Contemporary Psychotherapy, 39(2), 135-143.), “Genital anesthesia and pleasureless orgasm are not known in the general population and are unassociated with the conditions for which the medications are prescribed, thus these symptoms provide a clear link to the treatment rather than the condition being treated.”
Now, it is very easy for psychiatrists to sweep such patients under the rug by drawing the conclusion from sparse journal reports that this must be a rare problem. That’s where someone like Whitaker comes in, who gives a voice to the voiceless and advocates for these poor souls and gets the psychiatric community — kicking and screaming — to acknowledge it and hopefully research it. When research into PSSD begins, we may just find out it’s more common than once thought. It’s premature on your part to draw the conclusion that it’s rare based on reading a few journal articles (I’ve also read the journal articles you cited, as well as a few more on the subject). After all, just because something is under-reported doesn’t mean it’s rare. I seem to remember a time in the not-too-distant past when SSRI withdrawal was considered rare.
And “anecdotal” evidence is the springboard for scientific inquiry. Both are equally important. Do you honestly think psychiatry is interested in cleaning up its messes (that is, its mistakes)? To do so would be to admit it was wrong and caused egregious harm to more people than previously thought. No, much easier to dismiss those suffering with PSSD or long-term side effects as “anecdotal” and “statistically insignificant” and move along to the next psychiatric hula-hoop, whether it be personalized medicine, genetics, or brain imaging.
Remember this, Mr. Pies: us patients have to live with psychiatry’s mistakes.
If it were not for people like Whitaker, those suffering in silence would CONTINUE to suffer in silence. I, along with many other psych patients, would be taking a dirt nap by the time psychiatry got around to researching PSSD and other long-term symptoms. I have my life to live and can’t wait, Mr. Pies.
In an era of unprecedented medical corruption, we need all the gadflies like Whitaker we can get.
Dr. Pies, I would like to see you using your quasi-celebrity status to insist on more studies of adverse effects of antidepressants from research psychiatry, rather than being an apologist for what are emerging as clear flaws in biological psychiatry.
Pharma has assiduously hidden adverse effects for 30 years, their pro-business lobby crippled the FDA’s monitoring of post-marketing adverse drug reactions, but mainstream psychiatry still has not stepped up to the plate to correct the gaps in a truthful risk-benefit analysis of antidepressants.
Speaking of prejudices, in your last post you have dismissed reports of PSSD as inconsequentially rare — with no evidence whatsoever of its rate of incidence.
May I point out that the FDA would consider a rate of incidence of only .1% as significant? Given the approximately 30 million in the US on antidepressants, if PSSD affected only 30,000 people, it would be considered a serious drawback to prescribing antidepressants.
Without psychiatry doing its duty to protect patients and seriously investigating adverse reactions, all we have to go on is anecdotal reports from patients — and they are all over the Web. Thousands upon thousands of reports of lasting damage from antidepressants.
Another nightmare for you: PSSD is a subset of prolonged antidepressant withdrawal syndrome, which can last years. Dr. Carlotta Belaise, a colleague of Dr. Giovanni Fava, is gathering cases for publication. The details are at http://tinyurl.com/3zuaxo9
Dr. Pies, you seem to be trying very hard to come to grips with criticisms of psychiatry, but failing to integrate what’s worthy in them with your own unconscious attitudes and prejudices.
This cognitive dissonance must be causing you a lot of stress. May I suggest Paxil or Effexor for 18 months? As Peter Kramer says, they can make anyone “better than well” — surely there’s no harm in trying them yourself?
Forget the focus on antidepressants these days, just ask why so many non psychiatrists are writing for benzodiazepines like pez of late, then when they get pts on dosages that would respiratory impair at least 1/2 the population, they then dump these patients on us to “fix the problem”. No exaggeration to that quote, I have had several somatic colleagues in my career use those exact words. Yeah, dosages of xanax above 6mg a day, ativan above 4 a day, oh, and now they think that clonazepam, ie Klonopin, is so much safer they are sending me patients on 4 to 6 mg a day. Let me tell those of you who either have no idea what these dosages mean, or to medical colleagues who innocently do not know what are high dosages, here is a mean equivalent table to guide you:
5mg Valium= 0.5 Ativan= 0.25 xanax = 0.125 Klonopin
If I gave the average person a dose equivalent of 20mg of valium today with no prior hx of use or alcohol abuse hx, at least 50% of you would be unconscious if not struggling to breathe. Yeah, the patients come to me having been titrated to these obscenely high dosages, but, I see more reckless prescribing these days, and it is poor judgment to get patients on dosages that cause frank dependency.
Maybe write a post about this in the next few weeks, Dr Grohol. After all, the fastest rising population of substance abuse is prescription abuse, and god knows it is not just optiates.
Thanks again to those of good will and genuine openness, who wrote in! This will conclude my contributions to this particular blog, but…stay
tuned on Psychcentral and Psychiatric Times! –Best regards, Ronald Pies MD
I would like to add that when it comes to mental health and studies, they have the same problem mental heath and sympathetic response for our culture. We can see a broken arm and trace the source of it. But we can’t trace a broken “Id” to its source. Lots of behaviors make people “happy” but don’t lead happier lives. We are a more then our individual and part of a community, and likewise, many behaviors make people happy, but not functional as members of family units or community members. I have to laugh when the AD commercials tell potential users to “Tell your doctor if you are experiencing abnormal behaviors.” I am not sure when the last time a GP got a call from a patient saying “Doc, I have been out parting every night, sex with multiple partners, I am into shoplifting, gambling, and driving really fast. I no longer set along with my friends from the church and have met a few convicts online that are way more my speed to hang out with, I am leaving my husband cause he is boring, I would leave my kid, but everybody is criticizing me for it, so I will fight for the child (besides the drama is fun).” You can’t test for dysfunctional choices. With in 3 months of taking these drugs my ex was staring at some considerable jail time that would have lead to her loosing her job and limiting what she could to in the medical field in which she worked. How do you test for “bad behavior”. The frustrating lashing out from me was because every person with the power to do anything some how either justified her “abnormal behaviors” or ignored them all together. Unfortunately me and my (then 2 yr old) daughter couldn’t (and can’t) ignore them. Our lives are adversely changed from my exes “relived anxiety” forever. You can’t test for indirect adverse impact or for the happiness and success that would have happened without the drugs affects.
Here’s a little tidbit for those of you who come to this thread in future times: the FDA has come out with a warning about using doses of citalopram, ie Celexa, above 40mg for those with underlying heart conditions. How interesting this comes out now after the prior antidepressant trials of Star*D (I think) used citalopram as the initial drug of use up to 60mg, and, oh, also, why is it the FDA did not mention Lexapro, a purified form of Celexa, and at doses of 20mg equals approximately 60-80mg of Celexa, as a possible risk as well?
You don’t think Forrest who makes Lexapro had anything to do with influencing the FDA to not examine Lexapro’s effect on cardiac arrythmias as well, do you? I honestly do not know, nor really care these days, as profit margins really do not take into account what poisons occur once a drug is out for several years to a decade. The profit margins account for serendipitous findings of consequences down the road. Oh, and did I mention Forrest made Celexa as well, but, hey, Lexapro is bigger and better.
Well, at least it validates my not using dosages of Lexapro above 15mg too whimsically. Oh, by the way, what do you think non physicians who write for lexapro do when patients do not have a robust response to a 10mg dose? Yep, they double it to 20mg.
Here is the site to confirm what I note above per celexa’s new bad rap:
http://www.fda.gov/Drugs/DrugSafety/ucm269086.htm
So, I’ll end with this to intrigue you all, patients and colleagues alike: do you really think it will become standard of care to get EKGs on ALL our patients who are candidates for psychotropics, at least newer antidepressants since the mid 1990′s?
Good luck with that plan!
There is a major flaw in logic of the article. USA, country with Puritan herritage, consumes far more anti-depresants than countries with different socio-historical profile (and I am not talking about the third world. There are some 12 countries with higher development index).
on contrary, the USA can be viewed as very hedonistic society. And not all country have are-you-sad-there-is-a-pill-for-that commercials on TV…
So it is actually kind of refreshing to see the culture of “better living through chemistry” to be challenged and move in direction of informed choice. Meds may help some but not all, and one should be aware there are risks and there is a trade off.
Whilst I agree with the many criticisms on here, I think it important to point out that Whitaker’s reputation as someone who offers a voice to oppressed humanity is nonsense, something flatly contradicted by those of us who can attest that on his website he has banned patients who speak their own mind, yet gives coercers and con artists a platform to advertise their despicable profession, hardly the behaviour of a man deserving of the reputation he’s fastly accumulating amongst the survivor movement (who have invested him, in their longing for a hero, with messianic qualities), as a champion of the oppressed. Pish!
Don’t get me wrong though, credit where credit is due, he’s done much good work in anatomizing and exposing a mass delusion.
The MIA site is like some sort of thought and emotion control cult, devolving into a kind of “mutual veneration and admiration society”, where one must pepper one’s comments with soul-numbing insipidities and blandishments, all done in an obscene display of bourgeois hypocrisy, where most tellingly, the most welcome are the experts, not the angry patients, especially those of us who are angry with the system and whose anger has an experiential, and perhaps even pharmacological, basis.
Although tactical concessions and compromises are made, so that some are allowed to be angry and vitriolic without fear of expulsion, most likely because of their standing within the community.
People who think they have the right to torture, poison and abuse are welcome (I won’t name any names), as they always are in any human society, but not angry social lepers, oh no, this offends decent, right-thinking people’s sensibilities, and Martin Luther Whitaker can’t be having that!
He rationalizes this sanitization of speech and by implication of thought as not wanting to drive people away, though he has absolutely no problem alienating patients. Yet, absurdly, one regularly encounters the invocation of the constitution on such a site, the wisdom of its framers summoned in a general atmosphere of their document’s systematic violation.
Giving voice to the oppressed? Yeah right.
Cledwyn,
Thank you for pointing out the problems with the MIA website. I have reached similar conclusions. Particularly disheartening to me is the silencing of those harmed by ECT in deference to David Healy and the unwitting class bias that too often prevails among contributors and moderators.