When antidepressants are compared to placebos, they do only slightly better. This is not a problem for psychiatrists. People get better, they can charge money for access — that’s what matters. The rest of us, who would benefit from a better understanding of depression, do not feel bad because we have no idea what we are missing. But the puzzle of weak effectiveness remains. If the theory used to justify the antidepressants is correct, shouldn’t they work better? If the theory is totally wrong, why do they work at all?
John Horgan, a science writer, commented about this recently:
I first took a close look at treatments for mental illness 15 years ago while researching an article for Scientific American. At the time, sales of a new class of antidepressants, selective serotonin reuptake inhibitors, or SSRI’s, were booming. The first SSRI, Prozac, had quickly become the most widely prescribed drug in the world. Many psychiatrists, notably Peter D. Kramer, author of the best seller Listening to Prozac, touted SSRI’s as a revolutionary advance in the treatment of mental illness. Prozac, Kramer said in a phrase that I hope now haunts him, could make patients “better than well.”
Clinical trials told a different story. SSRI’s are no more effective than two older classes of antidepressants, tricyclics and monoamine oxidase inhibitors. What was even more surprising to me—given the rave reviews Prozac had received from Kramer and others—was that antidepressants as a whole were not more effective than so-called talking cures, whether cognitive behavioral therapy or even old-fashioned Freudian psychoanalysis. . . . Psychiatry has made disturbingly little progress since the heyday of Freudian theory.
To psychiatrists, psychiatry has made great progress since Freud. First, it is much easier to prescribe a pill than listen to a patient talk for 50 minutes. Second, the new pseudoscience of serotonin deficiency is far more respectable (more “scientific”) than the old pseudoscience of psychoanalysis (ego, id, super-ego, repression, etc.). It is harder for other doctors to make fun of psychiatrists.
But Horgan was not thinking like a psychiatrist. He was thinking like the rest of us. From that point of view, he should not have been “disturbed” by “little progress”. Antidepressants will never work well. Poor effectiveness is inherent in the situation. Antidepressants must do two things: (a) people must get better and (b) psychiatrists must make a living. Those are different goals (“misaligned incentives”) and they conflict.
Suppose a repairman comes to fix your dryer. One part is broken. The repairman orders a replacement and installs it. Your dryer now works fine. Because you could not diagnose the problem nor fix it, the repairman continues to be necessary. Suppose, on the other hand, the repairman can not replace the broken part. He must do something else. Maybe use duct tape. In this situation, the repair cannot possibly work well. Whatever he does can be better than nothing, but it cannot be a good repair
That is the situation of psychiatrists. I’m sure depression is due to the wrong environment. My work suggests we need to see faces in the morning for our mood-controlling system to work properly. Jon Cousins’ work suggests we need to believe others care about us. Those are two possibilities. Psychiatrists cannot fix the environment. The pieces of the environment we need to be healthy must have been abundant during the Stone Age. This means they must be cheap. Psychiatrists cannot supply things that are cheap and abundant. If that’s what they did, they couldn’t make a living. This means they can only supply something that is not what is missing. Like a repairman who cannot replace a broken part, they are stuck with second-rate solutions. This is the fundamental reason that all mainstream treatments for depression, whether talk or drug, have roughly the same effectiveness — and none of them work very well.
Thanks to James Lucoff.