Head Case: Can Psychiatry be a Science? The article offers an excellent review of the key debating points concerning the psychiatry’s reaction to the metaphysics of depression, namely:
Is depression really an illness? Or is it a normal reaction to a crazy world? If antidepressants can fix the problem in six weeks, then why spend six years on the couch soliloquizing about your bad potty training? Or, if they can’t, then what the hell is wrong with psychiatry?
On and on it goes. If you want to get up to speed fast on a subject vital to your life, then I highly recommend the article.
The piece zoomed in on the same set of studies that Newsweek made the basis for its outrageous cover story, Why Antidepressants Don’t Work (see my highly-critical post). Consider the New Yorker piece chess to the Newsweek’s checkers, with a much more nuanced look at the issue.
As you will recall, Newsweek cited two extremely convincing meta-analyses by Irving Kirsch in support of the proposition that antidepressants are basically placebos with side effects. Over eight or so years, no one has been able to shoot holes in these studies. Trust me, the second Kirsch meta-analysis is bullet-proof, but the results are open to interpretation.
Namely: In the real world, patients are likely to try a second antidepressant if the first one fails. Various small studies at the time indicated that the odds of success go way up when patients adopt this approach. A later large-scale series of trials underwritten by the NIMH, STAR*D, confirmed this.
That was how I reported the issue eight years ago and in various follow-ups and this was the approach taken by the New Yorker. (Both the New Yorker and I also shot to pieces a bogus meta-analysis recently published in JAMA that Newsweek took at face value).
Not so fast, says Robert Whitaker, author of "Mad in America." In his blog on Psychology Today, Whitaker accurately points out that STAR*D used statistical hocus-pocus to come up with an otherwise unsupportable claim that two-thirds of the patients in the study recovered on antidepressants.
I too, found this conclusion difficult to believe, and didn’t feature it in my STAR*D reporting. What I did feature were two key results: 1) It is worth trying a second antidepressant after the first one fails. 2) Trying a third after the second one fails is problematic.
The second result is the real STAR*D story, one that features in many of the pieces I write here (and one the New Yorker hinted at) but that Newsweek and Whitaker and just about everyone else missed. Here’s the deal:
The DSM depression diagnosis is an emperor with no clothes. It doesn’t tell us anything we don’t already know. One of it’s nine symptoms is “depressed mood.” Huh? So, if you have “depressed mood” and aren’t sleeping right or eating right and have low energy and seem to be moving in slow motion, what state of mind are you in?
DSM depression is a plain vanilla diagnosis that disguises the fact that depression comes in many flavors with many different ingredients. The plain vanilla approach encourages clinicians and researchers to treat all depressions as if they were the same.
This is the major reason clinical drug trials - and for that matter talking therapy trials - tell us so little. In any given trial, we can predict in advance that 50 percent of patients are going to get 50 percent better. The catch is which 50 percent? No wonder the results for the treatment group and the placebo group are about the same.
This is plain vanilla diagnostics at work. In all likelihood, there is a subgroup that is getting 80 percent better 80 percent of the time, as well as a large group of those who should never be taking antidepressants. But who are these people?
Of all things, STAR*D serves up a hint. As Frederick Goodwin, former head of the NIMH, pointed out to me, about two-thirds of the STAR*D study subjects had recurrent depression.
It seems likely that those in the STAR*D study with recurrent depression would not have fared so well on antidepressants, as recurrent depression is a close cousin of bipolar, but we’ll never know. STAR*D made no attempt to separate out this population. To the investigators, depression was depression.
The other lesson to be gleaned from STAR*D is this: After your second antidepressant fails, you need revisit your diagnosis. Maybe you don’t have depression. Maybe you have bipolar or a depression that behaves like bipolar. Maybe you have borderline personality disorder. Maybe depression is part of your baseline temperament.
But plain vanilla DSM depression offers no guidance. Chances are a large population of individuals in the STAR*D study did not even have depression. Same with clinical drug trials. Treatment works only if the diagnosis is correct.
Now we’re getting to the moral of this story:
Yesterday, I premiered “The People’s DSM.” My first installment featured Part I to My Alternative Depression Diagnosis. In the intro to the piece, I joked that, “if you want anything done right, you have to do it yourself.” But I’m not fooling around.
The DSM-IV depression diagnosis is based on an antiquated and totally arbitrary symptom list from 1980. The people working on the DSM-5, if they are serious, need to rip up that list and start over. Maybe then, psychiatry will get serious about what is really going on in our brains and come up with answers. Instead, they plan to leave the list intact.
As I said, sometimes you have to do it yourself. I’m not joking.