In a nearly 6,000-word essay, Louis Menand asks the question of the hour in the March 1 edition of The New Yorker. Menard lays out in excruciating detail the questions revolving around psychiatry these days, including the recent research into drug trials that suggests that some of the science psychiatry is founded upon is sometimes … Well, how shall we put it? Lacking.
But it is a thoughtful piece that just doesn’t review two recent books — Gary Greenberg’s Manufacturing Depression and Irving Kirsch’s The Emperor’s New Drugs — but provides a fairly balanced set of observations and valuable historical insights about these never-ending arguments that seem to pervade psychiatry (and psychology and mental disorders in general). Questions such as:
- What is the basis for labeling something a disease?
- Are these problems new or unique to psychiatry, or have they occurred previously in medicine?
- Do antidepressants work, or is it all just a glorious placebo effect?
I was at first a little skeptical in reading this piece, as it seemed at first to just tread ground well-covered in so many other articles on this topic. For instance, the author notes that Kirsch takes the stance that antidepressants are really no more effective than placebos, as the January JAMA meta-analysis study notoriously suggested. But as I explained to a colleague who recently asked me about the meta-analysis and what I now thought of antidepressants, I replied that a single meta-analysis doesn’t undo the hundreds of other peer-reviewed published studies on antidepressants. And when you examine the meta-analysis more closely, you see that it was very specifically designed to find the results it did (examining just two antidepressants out of dozens), a point Menard agrees with:
Kirsch’s claims appeared to receive a big boost from a meta-analysis published in January in the Journal of the American Medical Association and widely reported. The study concludes that “there is little evidence” that antidepressants are more effective than a placebo for minor to moderate depression. But, as a Cornell psychiatrist, Richard Friedman, noted in a column in the Times, the meta-analysis was based on just six trials, with a total of seven hundred and eighteen subjects; three of those trials tested Paxil, and three tested imipramine, one of the earliest antidepressants, first used in 1956. Since there have been hundreds of antidepressant drug trials and there are around twenty-five antidepressants on the market, this is not a large sample. The authors of the meta-analysis also assert that “for patients with very severe depression, the benefit of medications over placebo is substantial”—which suggests that antidepressants do affect mood through brain chemistry. The mystery remains unsolved.
But then I got to the point in the article where it turned from looking at these two new books toward a historical view of these concerns, and began placing the current argument into some much-needed context:
Science, particularly medical science, is not a skyscraper made of Lucite. It is a field strewn with black boxes. There have been many medical treatments that worked even though, for a long time, we didn’t know why they worked—aspirin, for example. And drugs have often been used to carve out diseases. Malaria was “discovered” when it was learned that it responded to quinine. Someone was listening to quinine. As Nicholas Christakis, a medical sociologist, has pointed out, many commonly used remedies, such as Viagra, work less than half the time, and there are conditions, such as cardiovascular disease, that respond to placebos for which we would never contemplate not using medication, even though it proves only marginally more effective in trials. Some patients with Parkinson’s respond to sham surgery. The ostensibly shaky track record of antidepressants does not place them outside the pharmacological pale.
The assumption of many critics of contemporary psychiatry seems to be that if the D.S.M. “carved nature at the joints,” if its diagnoses corresponded to discrete diseases, then all those categories would be acceptable. But, as Elliot Valenstein (no friend of biochemical psychiatry) points out in “Blaming the Brain” (1998), “at some period in history the cause of every ‘legitimate’ disease was unknown, and they all were at one time ‘syndromes’ or ‘disorders’ characterized by common signs and symptoms.”
So many of the opponents (and proponents) of psychiatry seem to take a lot of “new” research findings — like that some medications may work little better than placebo — as though they were the final word on the subject. Or that they told us something we couldn’t have guessed from other areas of medicine. Or that any of this is a set of black-and-white facts that are written into stone (and couldn’t be once again upturned by a new study published tomorrow).
Nothing could be further from the truth, of course. History is full of similar examples, and Menard’s article artfully paints a picture of the past about scientific progress that isn’t nearly as rosy or straightforward as some would believe. Science has always been as much about the artful, yet carefully measured exploration of different ideas as it has been about cold, hard statistics. And as regular readers of mine know, statistics are open to interpretation as well.
Indeed, he hits the nail on the head pointing out that in our single-minded search for biological determinism — to find the single set of biological or genetic roots at the cause of all of our problems — we tend to ignore the conscious mind that is making the decisions:
Many people today are infatuated with the biological determinants of things. They find compelling the idea that moods, tastes, preferences, and behaviors can be explained by genes, or by natural selection, or by brain amines (even though these explanations are almost always circular: if we do x, it must be because we have been selected to do x). People like to be able to say, I’m just an organism, and my depression is just a chemical thing, so, of the three ways of considering my condition, I choose the biological. People do say this. The question to ask them is, Who is the “I” that is making this choice? Is that your biology talking, too?
The decision to handle mental conditions biologically is as moral a decision as any other. It is a time-honored one, too. Human beings have always tried to cure psychological disorders through the body. In the Hippocratic tradition, melancholics were advised to drink white wine, in order to counteract the black bile. (This remains an option.) Some people feel an instinctive aversion to treating psychological states with pills, but no one would think it inappropriate to advise a depressed or anxious person to try exercise or meditation.
Mental health concerns — psychiatric disorders — are a complex combination of so many different variables, this search for some ultimate biological “truth” (or cause) is ultimately misguided. The questions that grief or depression pose can no more be answered by a pill than they can a single self-help article. But a pill or a self-help article can help — sometimes immensely. We would be unwise to ignore the track record of history when it comes to the multitudes of ways that we are helped by a multitude of treatments.
Is psychiatry a science? I leave that for you decide after you’ve read the article. Although it’s a lengthy article, it’s well worth your time grabbing a cup of your favorite beverage and settling down for the 20 minutes or so to get through it. I found it an enlightening and enjoyable take on the topic. For me, the amount of research done in psychiatry is breathtaking, and while not all of it is rigorous (nor is it all in medicine or other sciences), a great deal of it is well done and methodologically sound. It very much remains a science in my book.
Read the full article: Head Case: Can psychiatry be a science?