Drugs, Placebos, and Life

I have recently read a very interesting book by Irving Kirsch, PhD. It’s called The Emperor’s New Drugs, and the central theme of the work is that antidepressants are only very slightly more effective than placebos (i.e. sugar pills), and that the difference is not clinically significant.

The logic is cogent and the research is rigorous. Read the book and decide for yourself.

Dr. Kirsch argues in favor of psychotherapy as a substitute for pills. And certainly talking is usually helpful. However, as long as depression is conceptualized as an illness, I don’t believe we will see real progress in this field.

Depression is not an illness. Depression is not an instance of something going wrong in an organism, but rather something going right. It is an adaptive response – a warning system (analogous to pain), alerting us to a need to make some changes in lifestyle.

The fact is that each person has within him or herself the resources needed to generate and maintain positive feelings. This is the essential point of the placebo research. It wasn’t the sugar pills (or the antidepressants) that generated the positive feelings. It was the individuals themselves starting to take appropriate corrective action in their lives.

The six natural antidepressants are:

– good nutrition

– fresh air

– sunshine

– physical activity, with frequent successes

– purposeful activity

– at least one good, open, honest relationship

When these factors are present in our lives to a significant degree, we feel generally positive; when one or more is largely absent, we feel down. These ideas are developed more fully in my post of July 28, 2009: Depression is not an Illness.

If you’re taking antidepressants, you owe it to yourself to read Dr. Kirsch’s book.

Cover of Kirsch's Book Irving Kirsch, Ph.D,
The Bodley Head, 2009
  • Anon

    Pain causes the organism to protect the area in pain in order to avoid more pain. Depression makes your six natural antidepressants more difficult. I’m not saying those are bad things, but chronically depressed people often have difficulty motivating themselves to get out and enjoy the fresh air and exercise. People are not meant to be depressed when that feeling is counterproductive to fixing the problem that causes the depression.

    Why can’t we treat depression as an illness with your six natural antidepressants as the primary treatment? Pharmaceutical antidepressants have their place too, but they should not be given so blindly. At the same time, they should not automatically be ruled out because they can help people.

  • Anon: Thanks for your very interesting and engaging comment. “Why can’t we treat depression as an illness with the six natural antidepressants as the primary treatment?” My answer to this question is simply this: depression is not an illness, and pretending it is an illness to somehow facilitate “treatment” seems to me a recipe for disaster – a disaster which is unfolding before our eyes as an increasing proportion of the population succumbs to the lure of pharmaceutical “remedies”.

    Secondly, as long as depression is conceptualized as an illness, the six natural antidepressants will never be adopted as the primary “treatment.” The medical profession – including its journals and publications – has been hijacked by the pharmaceutical companies. The practice of medicine today is virtually defined by the prescription pad, and a physician who tried to promote the six natural antidepressants instead of pills might find himself without clients. People go to their physicians for pills – increasingly psychotropic pills – and physicians who challenge these expectations do so at their economic peril. Medicine is as much a business as a helping profession. (These comments should not be read as a blanket criticism of the medical profession. I myself am chronically ill and literally require intensive medical intervention on a daily basis just to stay alive. Without medics – and their knowledge and skills – I would have died years ago. I have very positive feelings towards the medical profession generally. However, that doesn’t alter the fact that depression is not an illness, and medical meddling in this area has done more harm than good.)

    Thirdly, the antidepressants are very little better than sugar pills! And the difference is not clinically significant. Whatever improvement these pills induce in people’s mood stems from the individuals’ own abilities to improve their lives rather than the direct pharmaceutical effect of the products.

    Fourthly, the medicalization of negative feelings is a disempowering and counterproductive philosophy. What I mean is this. Negative feelings are an integral part of daily living. The minor bumps and scrapes, ups and downs of life, will always be with us. And our feelings follow our fortunes. If you miss your bus on a rainy morning, you probably won’t feel too great waiting for half an hour in the rain for the next one, etc.. But an essential part of child-rearing is teaching our children to cope with the setbacks and disappointments of life: teaching them that they are not emotional slaves to these vicissitudes, but that they can rise above them and develop positive feelings and a sense of empowerment through their own efforts. And that they can accomplish this by getting up and getting going. Tragically today many parents are being given the message that what they need to do when their children seem down or dispirited is run to a physician for an antidepressant prescription. The number of children taking psychotropic pills is increasing at an alarming rate, and is showing no sign of abating. These children are being given the false and destructive message that they cannot cope with life except through drugs.

    Here is a question that warrants scrutiny: if antidepressants are so effective, why have we not seen a marked decrease in the suicide rate over the past forty or fifty years?

    On the fundamental question of whether or not depression should be conceptualized as an illness, my reasoning is as follows. In essence, the term “illness” implies that something has gone wrong with the organism – either because of an inner malfunction or an external attack. There is an identifiable problem. Sometimes these problems fix themselves (e.g. a common cold); others require expert assistance (e.g. acute peritonitis). But the normal workings of the body would not be considered illnesses. For instance, if you go out this afternoon and run five miles as hard as you can, you will probably have severe leg pains tomorrow. But you know that this is because you have overworked your muscles and that the pain will subside in a day or two. Most people would not consider this an illness (even though the pain is quite severe). Depression bears no superficial resemblance to illness, and despite decades of efforts in this direction, and a great deal of misleading propaganda, no one has demonstrated that it is the result of something going wrong with the workings of the organism. In science, the onus of proof lies with the individuals making the claim. And the biopsychiatric lobby – for all their self-serving hyperbola – have never proved their point. Physicians who tell their depressed clients that they have a brain illness and that they need antidepressants “just like a diabetic needs insulin” are lying. It’s as simple as that – and frankly, needs to be said as bluntly as that. There is simply no truth to this statement.

    You make the point that “…chronically depressed people often have difficulty motivating themselves to get out and enjoy the fresh air and exercise.” And certainly this is a compelling point. Let’s consider the case of an individual who sits on the couch most of the day eating unwholesome foods and watching TV. The question arises: why is he behaving in this way – as opposed to going outside – trimming the hedges – playing catch with the children, etc.? The standard answer from the biopsychiatric lobby is: because he is depressed. But this is an unsatisfactory answer, because the sitting idly for hours in front of the TV is in fact one of the criteria for depression. So when they say: “he sits idly in front of the TV because he is depressed”, what they are in effect saying is that he sits idly in front of the TV because he sits idly in front of the TV. The “explanation” adds no new information or insigthts, and in fact is nothing more than a label. Which, of course, brings us back to the question: why is he sitting idly in front of the TV – what’s the true or genuine explanation? And this is where life gets complicated. The only way you can get a genuine answer to that question is to spend a good deal of time with the individual exploring his likes and dislikes; his history and his aspirations for the future; his attitudes towards work and recreation, etc., etc., etc., etc.. And the answer: firstly, will never be simple; and secondly, will be different for different people. People are infinitely complex, and attempts to encapsulate the diversity of human experience into the kind of simplistic cookie-cutter categories of DSM is not only spurious, but is downright insulting to humanity.

    You raise another very critical point, i.e. that depression can’t be an adaptive mechanism (as I maintain it is) because it can actually militate against the better interests of the organism. (In your words: “People are not meant to be depressed when that feeling is counterproductive to fixing the problem that causes the depression.”) The best way I can respond to this is to take the example of eating. Eating is an adaptive response, without which we would simply die. When we get hungry, we eat, and a good deal of child-rearing consists of teaching children what to eat, how to eat, etc… But the act of taking nourishment through the mouth and swallowing is present more or less from birth. However, in the case of obese people this response has been subverted to the point where it is working contrary to the organism’s best interests. But nobody – for this reason – would contend that eating in itself is a maladaptive response.

    The fact is that man is a learning organism. Consider spiders. Spiders don’t learn how to spin webs. In fact, spiders don’t know how to spin webs. It is probably reasonably accurate to say that a spider is essentially a web-spinning machine. I wouldn’t go so far as to say there is no learning involved (I’m no expert on spiders), but there doesn’t appear to be very much learning. People, on the other hand, have relatively few inborn responses, but have instead an enormous capacity to learn and to acquire new habits and practices. So although eating a box of candy and a gallon of ice cream can not be described as adaptive behavior, it is based on the very adaptive response of eating, overlaid by a complex and highly individualized series of experiences.

    Similarly with depression. Negative feelings are nature’s way of motivating us to make some changes: get up and go; make something; talk to someone about a problem, etc… If a person consistently ignores these ”prompts” of nature (for whatever reason) then it is certainly possible for that individual to slide into a pit of despair from which it is difficult to ascend. In the same way, a person who routinely ignores eating-satiation cues ends up obese. But depression, like eating, is nevertheless an adaptive response.

    As I indicated above, it would be difficult to discern in an individual case why a person ignored nature’s prompts and sank into the pit of despair. But actually, how it happened is probably less of an issue than climbing out. People in the pit need the six natural antidepressants, but they also need two other things: firstly, a sense of empowerment – a belief that they can turn their lives around, and secondly, a helping hand – someone to help, encourage, nudge, coax, be there. This is a far remove from a handful of pills and a quarterly med-check. Practitioners who promote the disease model will never provide what depressed people actually need. And depressed people who embrace the disease model very seldom get beyond the pharmaceutical “fix”.

    So there it is. Thanks for your very thought-provoking comment. As always, one thing leads to another, and I’ve probably gone on a little longer than you would have wished. If you’re still reading, thank you again for your interest, and best wishes.

  • cledwyn bastardo

    Depression can be a normal response to having to suffer the torment of Tantalus; to live with that which we desire always just out of our reach, tantalizing us. Happiness, good health, love, contentment, power, riches, fame, genius etc., the average man is tormented by desires for that which he cannot have, that which always eludes his grasp. Yet such is the absurdity of life, and more specifically, human desire, that upon attainment of the object of our desire, we realize it wasn’t worth it anyway, and that desire thrives on the unattainable, knowledge of which does nothing to stop a man from perpetually tormenting himself in the pursuit of it.

    When one realizes that life is just one long torment, punctuated by the odd flash of happiness whose only purpose is to render our misery all the more acute in the contrast between that exalted state and the one to whose depths we’ve just come crashing down; when one realizes that life is one big frustration, then you realize depression is normal, and quite, quite, sane.

    For these reasons, I would say there is a certain confusion in some of our customs. We should celebrate death and mourn birth yet, strange as it is to relate, it is death we mourn and birth we celebrate (against the visible protestations of the poor sod who has just been unceremoniously disgorged), and, on top of this, worship a god who, if he does exist, reserves all his worst iniquities for us, so that a man’s life is little more than a succession of afflictions visited upon us while, like Sisyphus, we push our boulders up life’s steep incline.

    From this it can only be deduced that man is a fool.