A Pill is Not Enough
You wouldn't know it from reading local newspapers, but the antidepressant revolution is in trouble. Last year, the British government concluded that for children, the popular antidepressant Paxil carried a host of troubling side effects (including an increased risk of suicide) that outweighed potential benefits. The warnings were soon broadened to include most major antidepressants, and sparked a flood of concern in this country. The U.S. Food and Drug Administration waffled for months, but was finally forced in March to ask the manufacturers of 10 antidepressants to warn doctors and patients that both adults and children taking the drugs should be closely monitored for worsening depression and thoughts of suicide.
The bad news opened a Pandora's box of sorts, and in recent months medical journals, the Washington Post, Los Angeles Times, and Wall Street Journal have carried a steady stream of horrifying disclosures: that clinical drug trials resulting in negative findings are routinely ignored; that the existence of these "file-drawer studies" is well-known among researchers, psychiatrists, and FDA policymakers; that the bulk of the studies concerning children show no benefit whatsoever from antidepressants; and that studies involving adults aren't much more convincing. Perhaps most shocking of all, FDA honchos even conceded that for some time they opposed adding warning labels to antidepressants because they feared it would expose the pharmaceutical industry to liability.
So far none of this seems to have had much effect on the sales of antidepressants in this country. According to a study published in the April issue of Psychiatric Services, use of these drugs by children and adolescents is growing by 10 percent a year; the fastest-growing user group is preschoolers. In 2003, sales of central nervous system drugs totaled $37 billion, $9 billion more than the combined total for all drugs that treat the heart, arteries, and blood pressure, according to the New York Times.
Dr. Michael Browne is a psychologist who has spent 25 years in private practice in Minneapolis and an adjunct University of Minnesota faculty member who supervises psychiatric residents learning to conduct therapy. About five years ago, he was asked to give a talk about mental health issues to residents training to be family practice doctors. In preparation, he started reading research on antidepressants. "I was just completely astounded by what I found," he explains. "The claims for the effectiveness of antidepressants were greatly exaggerated. I looked closely at the evidence, and it's not there."
Trained as an experimental psychologist at Indiana University, Browne went on to write and lecture critically about the mental health industry's growing dependence on antidepressants. His most recent paper, "The Medicalization of Emotional Distress and the Future of Psychotherapy," argues that the mental health profession needs to kick its drug habit, and lays out half a dozen reasons why that will be tough.
Browne presented the paper in April at the Minnesota Psychological Association's annual conference, held at the Bloomington Holiday Inn Select. As if to punctuate his thesis, attendees had to thread their way through a foyer where drug companies and other vendors were creating good will and handing out goodies. Groups of students wearing "Itasca Community College Psychology" sweatshirts snapped up GlaxoSmithKline's facial tissue, hand lotion, and some large turquoise clocks emblazoned with the Paxil logo. Apparently oblivious to the irony, several clinicians took notes with light-up pens courtesy of Seroquel.
Following his presentation, Browne sat down with City Pages to discuss his work. What follows are excerpts from that conversation.
City Pages: Before you started your research, had you been sympathetic toward the idea of antidepressants?
Michael Browne: I had always believed that they must be effective. Everyone said they were. It was disorienting for a while. Probably the biggest impact was that I really began to wonder if medication helped any of my patients.
I wrote a couple of papers about the subject, and I just kept pulling in more information. And I found that the evidence was exaggerated not just for antidepressants, but for virtually every single psychiatric medication. I talked to colleagues, and their reaction was, "Well, it can't be that bad. They wouldn't be giving out all of these drugs if they didn't work."
CP: All of a sudden the questions you've been asking are au courant. There's bad news out of the FDA, reports of negative studies. How do you hear about this stuff?
Browne: You know where psychiatrists get their information? They get their information from the drug companies. I think psychologists tend to get their information from psychiatrists. I think psychologists tend not to read and study the research on medication. They think it's the psychiatrists' responsibility.
Psychologists tend to have a couple of psychiatrists they have a good working relationship with. When somebody wants an antidepressant, they can say, "Go see Dr. Jones." But it goes the other way, too. "I saw this woman and she's on medication, but she also needs psychotherapy." So it certainly is an I'll-scratch-your-back-if-you'll-scratch-mine kind of relationship. I know psychiatrists here who do all psychotherapeutic work and not medication. But they are very much in the minority.
CP: When antidepressants came on the market, did you envision them becoming as popular as they are?
Browne: No, I didn't. But the drug companies have been exceedingly savvy in how they've tackled this. Twenty years ago people thought of depression as an emotion--depression meant you were sad. And you needed to find out why you were unhappy. The drug companies have done an exceedingly good job of convincing us all that depression is a medical disease. And that message has been one of the things that has led people to depend so much on these drugs.
As it turns out, and I say this based on looking very carefully at the research: These drugs have little or no effectiveness. They simply don't help that much. You can always point to individual patients who will say that any treatment is wonderful, it's cured them. That's why people go around wearing copper bracelets. There are people who say, "I had terrible arthritis and this copper bracelet cured my arthritis."
And it's not really so surprising that these medications don't work. If a person is very seriously unhappy, and it goes on for months and months, what does that mean? That means there's something very seriously wrong in that person's life. It's not for trivial reasons. And common sense tells us it's not likely to be easy to change that.
Now, it may be that some drugs will provide symptomatic relief. And there may be some times at which symptomatic relief can be important. And so there should be a respectable but small place for the use of drugs in treating emotional disorders. For instance, with Tourette's syndrome, children can develop facial tics and other symptoms that make them objects of ridicule by their friends. If medication, properly used, can reduce or eliminate those tics, we've done the child a great favor.
The problem that we get into is that again and again, we start prescribing a psychiatric medication for symptomatic relief and then we lose sight of that fact and we think that we are providing a cure, and the drugs can't do that. And that's been reenacted over and over again in the history of psychiatry in the last 50 years.
We know from reading the newspaper the last several months that medication is not a safety net. I think that what is less widely known probably is that for 10 years there's been research that shows that the antidepressants don't reduce the frequency of suicide. That's well documented. And now we've been finding recently that for some individuals the drug actually increases the suicide rate. What Peter Breggin [the author of the 1990s bestseller Talking Back to Prozac] says is that in some cases people are very despondent, and you give them a drug which artificially makes them more energetic, and that's not a good combination. Breggin thinks that's the danger of many of these drugs.
CP: That might make sense of why they don't mix well with children.
Browne: Yes. They're already impulsive. And when you have someone who's despondent and impulsive, and you give them something that probably increases their energy and maybe their impulsiveness, then you've got real trouble.
Psychologists and psychiatrists who talk about medication being harmful rather than helpful, and who talk about not referring patients for medication--they sometimes get treated like kooks. They can even be threatened with malpractice lawsuits. When I've said to people that I don't think we should be referring so many people for medication, that is one of the first things psychologists say back to me: "I agree with you, but I would never do that, because I am concerned about getting sued for malpractice."
I think what prevents people from committing suicide is not some drug. What prevents you from committing suicide is having a relationship with someone who cares. And if I can form a relationship with a patient and show them that I sincerely care about that person, that's what's going to keep them from committing suicide.
I've seen cases where the therapist not only refers the patient for medication, but stops seeing the patient. You need medication, not therapy. That can be experienced as supreme rejection for the patient. The other danger is that if you are talking to a person who is very depressed and you say to them, "Go see this psychiatrist," it can feel like you the psychologist are feeling hopeless or frightened about the patient's depression. So referring someone to a psychiatrist for medication is not simply a benign act. It has a lot of meaning for the patient and can be very disturbing to patients, and that is not sufficiently recognized by therapists.
The irony is that you take some kid or some adult, and he's been kicked around a lot, maybe abused in childhood, or neglected. He's had a lot of bad treatment. So what has that treatment made him? Mistrustful, angry, difficult to be around. It's the ultimate irony that we take people who've been badly treated, and they're somewhat obnoxious to be around, and the therapist who's supposed to treat this person then rejects them too. What psychologists need to do is be mentally healthy enough themselves that they can see the good in this person. No matter what they've done or what kind of trouble they've been in, you have to see the value of this human being. But it's exactly true that we often just don't want to look at these people.
It doesn't get talked about very much, but there's so much research that shows that the most valued part of psychotherapy is the relationship. It's the quality of the relationship between the patient and the psychotherapist that determines the success of the therapy. It's so easy to focus on technique, but so much of it comes down to the relationship.
Whether it's a child's mental health problems or an adult's, no mental health problem grows out of a vacuum. They grow out of the context of the relationships that they exist in. The way I understand it, bears spend a lot of time alone in the woods. That's just how the biology of bears is. Their biology suits them to spend months at a time in the woods eating nuts and berries. That's not true for human beings. For the millions of years of our biological history, we are beings that can only live in relationships. That's a fundamental fact of human nature, that we have to have relationships. And whatever the mental health problem is--whether it's depression, or anxiety, or schizophrenia--you have to look at the network of relationships within which that person has lived their life. And if you ignore that, you've missed the boat.
CP: In your paper you posit that the therapeutic relationship can actually be discredited by the introduction of drugs.
Browne: See, there are a couple problems here. If you treat somebody with psychotherapy you are saying to the person, "Okay, you've been quite depressed, and we can understand that in terms of what's been going on in your life for the last five years. We can understand that in terms of what happened in your childhood." So you start to create a story--a true story, not a fictional story--you start to create a true story of that person's life and how that's lead them to be depressed and that story also begins to show what the person must do to solve these problems. That's very important.
Now, if you then say to the person, "You need medication, too, because there's also some biological part of your depression," then it becomes confusing to that person. "Geez, am I depressed because of what's going on in my life or am I depressed because the chemicals are screwed up in my brain?" It detracts from the credibility of the therapy.
Especially when someone is seriously depressed, and they're talking about suicide, they're talking about quitting their job, but especially about suicide, that is very frightening. It's frightening to family members, to friends, to coworkers, and it's frightening to psychologists and psychiatrists. When a person says suicide, it scares us. And it should, we should take it very seriously. Suicide is a major problem. It's easy then to say, "Boy we can turn to this pill, medication will help us."
CP: You make a convincing case for the drug companies being behind a slow but subtle shift from the public perception of psych drugs as a means of controlling certain symptoms to chemical agents that actually get to the root of any mental illness.
Browne: When the drugs that we now call antipsychotics were first introduced, they were termed major tranquilizers, which indicates that the function of the drug was to sedate the person. So you have an unruly, difficult-to-handle patient, and you give them this drug and it makes the person lethargic. It's very much a symptomatic treatment; we're gonna reduce these troublesome symptoms so these people are less trouble. That was the idea. But *when the name was changed, and we now call these drugs antipsychotics.
When we call something antibacterial, or antiviral, the name implies that you're not treating a symptom, it implies that you're treating the cause of the problem. It's antibacterial, so you're killing the bacteria that causes the disease. Antipsychotic implies that you are getting to the source of the problem and treating it, rather than the fact that you are applying a symptomatic treatment, that you are slowing these people down.
In the same way, if you have a person suffering from Tourette's syndrome and you give them medication that eliminates the tic, that's helpful. Especially for children, these tics can make the child the object of ridicule and so to give them a medication that eliminates the tic is very helpful. But the tendency is then to think that we've cured the problem. That if we've given this drug to a psychotic person, that we've cured him. That if we've given a different drug to a person with Tourette's syndrome, that we've cured that person. And then we don't look any further to what we really need to do to cure this problem.
CP: Your colleagues swallowed this. Why?
Browne: If you take a really hard-nosed scientific approach and look at this research and find there's little there to support the use of psychiatric drugs, then why did these drugs become so popular? Why has that become perhaps the dominant treatment for mental illness in the United States today? I think there are several reasons.
First of all, the pharmaceutical companies just have enormous power, both financial and political. Second, psychiatrists have used an emphasis on drugs to make themselves a home in the medical profession: "We're just like you, we prescribe drugs, too." Because psychiatry has always been the stepchild in the medical community. The other people in the medical community have never known what to do with psychiatry. Everybody else is treating something that's tangible, that's concrete, and there you have the psychiatrist dealing with feelings and emotions. And often in medical communities, psychiatry has little prestige. So medication has been a way to shore up their credentials: "We're doctors."
It's also been a way for psychiatrists to compete with psychologists and social workers. Because here they say, "This is something only we can do, we give out drugs and no one else can." So the whole focus on medication has been extremely important for the psychiatric profession. One wonders where the psychiatric profession would be today if it didn't have drugs. Would it still exist?
It's not just psychiatrists. The whole medical community gains in prestige by saying, "We handle emotional problems, too; that's part of our bailiwick."
And we shouldn't overlook the fact that in the United States the biomedical research community is very powerful. And so long as you define emotional problems as biomedical then you can channel all kinds of government and foundation funds to psychiatric research. Unfortunately, we have a limited amount of money and the result of that is that you starve psychosocial researchers of money. And so often problems that really cry out for research money don't have it. Because we put our money into increasingly microscopic studies of the brain and of neurons and of neurochemicals.
It's not to disparage that kind of research, it's fine. But we're like the woman who every day lifts weights with her right hand while she sweeps with her left hand. Pretty soon she's got this enormous bicep on one side and the other one has atrophied. It's completely out of whack.
Another reason for this emphasis on drugs is that psychotherapy is an expensive proposition. And I really wonder if this isn't something that the managed care companies have gravitated toward as a way of reducing the expense of psychotherapy. On the other hand, right now the managed care companies are spending so much money on antidepressants and other drugs that I wonder if at some point they aren't going to see this as a failed strategy.
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