Monday, July 11, 2011
More Controversy on Antidepressants
Given that in a previous post I wrote that I had not seen any persuasive rebuttals to Marcia Angell's New York Review of Books articles on antidepressants and Irving Kirsch's book, The Emperor's New Drugs: Exploding the Antidepressant Myth, I thought that I should note that a rebuttal has since appeared in the Sunday New York Times. The article, "In Defense of Antidepressants" was written by Peter Kramer, who is a professor of clinical psychiatry at Brown University, and the author of the 1993 book, Listening to Prozac. He may have a special reason to feel aggrieved by Kirsch's book. The title of the first chapter is "Listening to Prozac, but Hearing Placebo."
Catchy as it is, that title may be a touch misleading. No one argues that antidepressant drugs don't do anything; they are in fact powerful drugs. The issue is whether what they do is beneficial and whether they may do more harm than good, as some have charged. The online comments to Kramer's articles show that there are patients who feel they have been a life-saver; there are also more negative comments from other patients.
I did not find Kramer's article convincing, but then I have read Kirsch's book, where he addressed the criticisms of his research that Kramer repeats in this article. Since I have no particular expertise in this subject though, readers who care about this can read the book, which is not very long, as well as Kramer's article and judge for themselves.
One argument Kramer makes is that the unpublished research studies that Kirsch included in some of these analyses were not well done. It should be noted, though, that the studies were paid for and submitted by the pharmaceutical companies to the FDA and were performed in order to get FDA approval of the drugs. The burden of proof that a particular antidepressant drugs works should be on the drug companies. It should not be the burden of others to prove that they do not work in obtaining FDA approval.
Also, Kirsch does not address the arguments that Kirsch makes that there is no evidence that depression is the result of a chemical imbalance in the brain, nor does Kramer address concerns about the long-term effects of these drugs.
Of course, part of the problem in doing research on the efficacy of antidepressant drugs is that it is much more subjective than other areas of medical research. It is after all much easier to determine whether an antibiotic works than it is an antidepressant.
While this subject is somewhat outside the context of this blog, it is related to the policy issue of what to do about Medicare and healthcare generally. Pharmaceutical companies have introduced many useful drugs that have improved healthcare. However, the financial and other means they use to influence doctors are disturbing. Examining how they influence doctors and the medical consensus should be part of the process of reforming health care, as well as the price U.S. patients pay for non-generic prescription drugs.
Until recently, those raising doubts about these drugs could be dismissed as being on the fringe, but that is less possible with Angell and Kirsch. Kramer has decided he cannot ignore them; he should do a better job at defending his position than with an article that is sandwiched by an anecdote about a particular case in which he believes an antidepressant were very helpful.
Arguing with anecdotal evidence is not very convincing. Kramer does it in his article, but on the other side, another book reviewed by Angell, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America by Robert Whitaker, also relies too much on horror stories about patients who have taken antidepressant, antipsychotic, or tranquillizer drugs. There is no way to judge from these anecdotes whether they are representative.
However it turns out, it is good that a serious debate appears to have been initiated on antidepressant drugs.