Earlier this year, Marcia Angell wrote a scathing attack on the field of psychiatry, in particular on the use of psychoactive drugs in treating mental illness. Her argument was essentially that the drug development, testing, and approval process is so flawed that it is close to impossible to tell whether a drug is more effective than a placebo, or even whether or not it is very effective at all
One author she cited was Irving Kirsch. Kirsch recently published a meta-analysis of antidepressant clinical trials in which he found that antidepressants were barely more effective than placebo except in cases of extremely severe depression. That is, in drug trials patients (on average) saw about the same improvement whether they were given sugar pills or antidepressants. Meaning antidepressants, which are the main tool of psychiatrists in treating depression, might not be effective because of the activity of the drug itself. Instead, they may work through the placebo effect.
This is a pretty big deal. As far as I can tell, if Kirsch and Angell are right, there’s not really anything to take the place of antidepressants in treating depression other than talk therapy — which is fine, but still less effective than both placebos and medication. There haven’t been any very convincing critiques of Kirsch or Angell either. One study maybe found some very minor methodological problems in Kirsch’s study, but his results look legitimate.
Here’s where I come in. I’ve suffered from pretty severe depression for many years. In the past, I tried to do a lot of different things to get better, but they all worked up to only a certain point. I eventually just accepted that there would be long periods of time when, for no reason at all, I wouldn’t be able to go outside without fantasizing about walking into oncoming traffic. And that I wouldn’t be able to stop this from happening. It’s funny what can start to feel normal.
What I did not try, however, was antidepressants. I’d read Angell’s work before, and one of her recurring themes has been the questionable efficacy of those drugs. She convinced me: I thought they were a fraud pushed onto the public by greedy pharmaceutical companies and the corrupt doctors who enabled them, and I refused to try them. Instead, I dealt with my craziness on my own — until I couldn’t anymore, and a friend persuaded me to at least give medication a shot.
I still lean toward agreeing with Angell, especially when she discusses the abuses of the pharmaceutical industry and their far too cozy relationship with psychiatrists. With Kirsch’s studies, she also has a convincing argument that there is no proof that antidepressants help with depression through any mechanism other than the placebo effect. In other words, at the moment there is no way of ruling out the possibility that the benefit of these drugs comes from the belief of the patients rather than from the activity of the drug itself. However, I also know that the period of time after I started taking bupropion is the longest I’ve ever gone feeling sane and (gulp) happy. These pills are really helping. Except that they very well could be a placebo, in which case I’m tricking myself. Does it matter if this improvement is built on a lie?
It shouldn’t really, but it does. A lot of that has to do with my own insecurities. It’s been incredibly tough for me to accept that what I was feeling could even be called a disease. For an embarrassingly long time I had generic, stupid ideas about depression — basically this. Eventually, I refined that into recognizing it as a disease, but not as a disease that could be affecting me. Sure, I had all the symptoms, but depressed people were really suffering. I, on the other hand, was just whining — probably because I was so stupid and useless. All of this kept me from seeking any treatment at all for a long while, and even when I did, a trace of shame over making a big deal about nothing stuck with me. I knew how dumb this was, but I couldn’t argue away my guilt.
Being prescribed antidepressants helped me get over that. Because if I needed medicine, I must really be sick. And if I was sick, it wasn’t my fault that I felt so bad so often and that I couldn’t make myself better. After all, a sick person can’t be blamed for their illness. Right?
But if antidepressants are placebos, I can’t stop my doubts from coming back, no matter how illogical they are. Because if a placebo only works if you believe in it, then…what? Did I not try hard enough to get well? Should I have done more? If a sugar pill and a pat on the back can make it go away, how real is my disease anyway?
I realize that I should know better. There’s obviously a ton of evidence showing that (it’s embarrassing even having to say this but still) depression is a disease, just as real as pancreatic cancer. In addition, there’s a pretty extensive body of evidence showing that the placebo effect has worked on many different diseases and conditions, including ailments that wouldn’t appear to have anything to do with thinking. So the question of whether or not antidepressants are placebos has no bearing on whether or not depression is a real disease to begin with.
Anyway, placebo as treatment is really only problematic on a population level, and that’s because of its unreliability. Some people will be positively affected and others won’t, but there is no way of controlling or even knowing which group a patient will fall into. And since there is no way at all of telling what effect a placebo will have on any one person, they wouldn’t be useful for doctors trying to figure out how to treat a disease. On an individual level, however, it doesn’t matter. If something is effective in treating a disease for a person, then it is effective for that person, period. And if its side effects are minimal (which they are in my case) then who cares how it’s working? Be grateful that you’re better and don’t worry too much about the details.
Even though I know that this is true, it’s hard for me to accept on an emotional level. It’s odd to admit since I work in a lab and believe in SCIENCE, but it’s hard for me to see myself as a piece of data. I can read papers and textbooks and New Yorker articles and understand the placebo effect as an abstract phenomenon. But it’s like those polls that show how everyone thinks that advertising works, but not on them. In my mind, the placebo effect is something cool that happens to people — a vague, general pronoun discussed in Nature and Science who consistently make irrational decisions. It’s a group to be sliced up and analyzed, and to be looked at with amused detachment. It is a group, however, that does not include me.
Even though they seem quite different and even contradictory, both of those things — the difficulty in accepting the placebo effect and the difficulty in accepting that I’m suffering from a disease as opposed to, say, a deficiency in willpower — draw from the same source. They’re both there because on some level I’m afraid of not being in control of my own mind (or maybe unwilling to completely reject a BS sort of dualism, but same thing). If depression is a disease that can be fixed with a pill, then my thoughts are subject to the vagaries of whatever the hell the rest of my brain is doing. And if the placebo effect works on me, then I can recognize something as irrational on one level while the rest of my brain decides to ignore that and fix me up. All this would mean that I’m a spectator in my own head. My brain has its own momentum regardless of my conscious thoughts, and I’m along for the ride. Which is to say that I don’t want to admit that I’m bound by the limitations of being made of bones and blood and viscera — or less pretentiously, that I’m human like everyone else. Accepting that would mean accepting that I’m subject to biases I can’t see and flawed thinking I can’t correct. It would also mean that large parts of my experience can be reduced to numbers and charts and figures. Above all, I’m scared that despite how special and unique my experience of the world feels, I am totally, hopelessly, in the worst sense of the word, normal.
You know what though? I’ve spent a comical number of hours in misery because of my inability to accept that the weaknesses of others could be my own. For years I treated my thoughts as sacrosanct solely because I was the one who thought them. Every idea that came through my head had to be considered and obsessed over for as long as they were stuck there. It didn’t matter how absurd or hateful they might be — they came from my perspective, and therefore their validity could not be questioned.
Surrendering to the idea that my brain is a machine that can fuck up like any other is what saved me. If I felt terrible, I didn’t have to cast about for reasons why and then legitimize them. I could just be feeling terrible for no reason other than bad wiring. In the same way, there was nothing profound about feeling isolated and desolate. It wasn’t a message passed down from above, it wasn’t an emotion justified by logic, and it wasn’t how things had to be. It was nothing more than my brain misfiring. Luckily, there was medicine out there that was supposed to fix that.
There’s every reason to try to find something that works better than the current lines of antidepressants. So many people suffer from their side effects without receiving any benefit or cycle through drug after drug without getting healthy. Researchers can fine-tune the theories behind why depression occurs until one day they come up with drugs that actually change whatever has gone wrong instead of ones that rely on the desperation of patients to believe that something can help them. Or it could be that we’ll find out that current studies weren’t sensitive enough to pick up the subtle effects of these drugs, and that they do work, only in a manner we don’t understand yet. Maybe all they need are minor adjustments to become more widely effective.
I don’t know. For me, it’s enough to have something to rely on. I wasn’t getting better without antidepressants, and regardless of the mechanism and regardless of their implications, they’ve fixed me a little bit. It’s easy to accept my own mortality if it means that my mind will run more smoothly. I can trade an unearned feeling of superiority for bliss without any remorse.
Depression’s the most boring thing in the world, especially to the person who has it, so part of me wanted to stay dry and academic and not go too much into my own experience of it. Too messy, too dull, too trashy. But it’s a bit of a cheat, isn’t it, to talk about emotions as if they’re only an abstraction, especially when all of this has been about how badly they fucked with my head. Not to mention that (hopefully) most of you don’t have experience with mental illness, and certainly not in the exact same way that I did. I’d hate for this to be words without meaning. Besides, I have a soft spot for personal accounts of people dealing with depression. Seeing yourself in other people’s writing is always kind of reassuring. So what the hell, right? Let me end this with a story.
Last winter was about as awful as I’ve ever felt. There weren’t any reasons, or rather, the reasons were arbitrary. I’ve always been good at coming up with excuses to torture myself no matter what was happening in my life. When cold days started popping up this year, hints of that dread came with them. It’s funny that I work in a lab that studies context memory because this is the same sort of thing. Shock a mouse in cage X, wait a day, return it to X (without a shock or anything else this time), and watch it freeze in terror. It’s made an association between the environment and the pain it received.
For me, the last few months stayed enough the same from last year to this one that they made me relive the past a little bit. Everything about Texas’s pitiful impression of fall — extra blankets and an emptying campus and wondering how the hell it’s so dark already every single day — is so close to what happened to before that any appearance of cold air made me tense up. I tried to calm down by telling myself this year would be different, but it wasn’t been very convincing. It’s not like I knew ahead of time what was going to happen last year or any other time before.
Now it’s almost exactly a year from when things went bad, and sure enough, not too much has changed. I’m wearing the same hoodie and eating at the same places and hanging out with (mostly) the same people. But recently I’ve been forgetting to be nervous. It’s not like I’m unusually happy, not exactly. My mood doesn’t feel like an artificial imposition from these pills. It’s more that I don’t have to think about my feelings at all. I can spend today trying to figure out what sandwich place to eat at for lunch and have serious discussions about why Grooveshark has a “Power Hour” feature now (which, what the hell). I can be alone without having to worry about what I’ll do to myself if no one’s there to watch. Today can be boring and tranquil, just like nearly all of my time has been after the meds settled down and kicked in. It will also be fucking amazing — a reprieve from years of bad feeling that will hopefully last a little while longer.
Maybe this all means that I’m a robot made of flesh deluded into thinking I have a choice in anything. None of that matters to me right now. Who cares if I’m not free when I can have days like these ones?