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November 21, 2007 10:11 AM   Subscribe

Talking back to Prozac. Review article in The New York Review of Books, covering some issues concerning the diagnosis and treatment of depression.
posted by hydatius (57 comments total) 12 users marked this as a favorite

 
A bit thin, don't you think?
posted by Mister_A at 10:15 AM on November 21, 2007


Prozac helped this turtle immensely, and continues to do so. If you have not been depressed you do not understand how fundamentally debilitating it is. If some physicians prescribe SSRIs inappropriately, fine. But do not demonize a medication that brings sad, hopeless, tired people out of their houses and reintroduces them to productivity, happiness, and hope.

kind of passionate about the issue of 'happy pills'
posted by Turtles all the way down at 10:35 AM on November 21, 2007 [4 favorites]


Yes, this sauce is weak. Spice it up some with a leaden leavening of Stephen Fry's Secret Life of the Manic Depressive. Hrm, looks like the first hour is only available in [miniature YouTube snippets], but you can watch all of [part 2] in a contiguous chunk. Good stuff. Also: what the turtle above me said.
posted by mumkin at 10:38 AM on November 21, 2007


Let's thicken it.

If you don't like the DSM-IV, why not try the CCMD-3. Apparently Chinese diagnostic criteria for depression are somewhat different from those used by North American psychiatrists.
posted by justsomebodythatyouusedtoknow at 10:42 AM on November 21, 2007


T.a.w.d., I thought that rather than demonizing the drug, the author was demonizing the pharmaceutical industry for medicalizing the normal range of personality, and for pushing very powerful drugs for situations where the risks may outweigh the benefits.

Also, Mister_A, I am humbled by your reading speed if 4 minutes was sufficient for you to condemn a 4,000-word article as "a bit thin".
posted by Horace Rumpole at 10:42 AM on November 21, 2007


Horace Rumpole: After reading the article, I confess I may have been a bit quick off the mark, but I've read so many of similar genre I assumed from reading the beginning that this would be trotting out the same tired old themes.

But what I said stands, of course.
posted by Turtles all the way down at 10:54 AM on November 21, 2007


Interesting article, to me particularly in its extension of a theme we're seeing in scientific research all over the place at the moment: there are many things you cannot even look at without grave risk to your career as a researcher.

In this case,

[David] Healy is a distinguished research and practicing psychiatrist, university professor, frequent expert witness, former secretary of the British Association for Psychopharmacology, and author of three books in the field.
...
Healy suspected that SSRI makers had squirreled away their own awkward findings about drug-provoked derangement in healthy subjects, and he found such evidence after gaining access to Pfizer's clinical trial data on Zoloft. In 2001, however, just when he had begun alerting academic audiences to his forthcoming inquiry, he was abruptly denied a professorship he had already accepted in a distinguished University of Toronto research institute supported by grants from Pfizer. The company hadn't directly intervened; the academics themselves had decided that there was no place on the team for a Zoloft skeptic.


The case of James Watson shows us that even a Nobel Prize for elucidating the structure of DNA cannot protect a scientist from being destroyed for sufficiently unpopular (albeit pernicious and mistaken) ideas.

I do think we are heading for a society in which almost everyone will be on some form of anti-depressant-- and that this will be better than the alternatives.
posted by jamjam at 11:03 AM on November 21, 2007


I read the article. My opinion remains that Peter Breggin is a nitwit.
posted by a robot made out of meat at 11:03 AM on November 21, 2007


Crews, the reviewer of these 3 books, is indeed going after the drug industry. But after all it remains the doctor who perscribes the drugs and not the industry. Crews also does not like Freudian therapy. But here is what is left out:

Insurance companies began to set time limits on talk therapy because it "was not science," so those in the game who had MD degrees moved over to drug peddling since that was considered by the insurance industry to be "real science." And that means patients can come back for more and more through a lifetime and get partially funded by their insurance. Whn you find a good game, don't change the rules.
posted by Postroad at 11:09 AM on November 21, 2007


One thing that blows me away about selective Serotonin reuptake inhibitors: you need a prescription for them. SSRIs are raising Serotonin levels in particular parts of the brain. Meanwhile, you can purchase 5-HTP at a well-stocked supermarket's 'vitamins and supplements' section and raise your Serotonin levels wholesale, all over your brain. This is a popular practice with conscientious MDMA abusers who have depleted their Serotonin levels over the weekend.
posted by mullingitover at 11:12 AM on November 21, 2007 [2 favorites]


Postroad: Do you just say these things because you're angry at someone, or the world, and need to express it in some other way? Do you have any friends? Do you think?
posted by Turtles all the way down at 11:26 AM on November 21, 2007


thin is in and less is more.
posted by cytherea at 11:29 AM on November 21, 2007


To be more precise: it seems that you explain the existence and success of a family of drugs designed very specifically to counter a deficiency in the brain of one or more synaptically active chemicals as a conspiracy on the part of a number of insurance companies to make more money than they could with traditional therapy.

To paraphrase my psychiatrist friend Frasier Crane, What colour is the sky in your world, Cliff?
posted by Turtles all the way down at 11:33 AM on November 21, 2007


You're less of a turtle and more of a parrot.
posted by cytherea at 11:38 AM on November 21, 2007


cytheria: I regret to say I have no idea what that means. But it seems you're being unkind.
posted by Turtles all the way down at 11:52 AM on November 21, 2007


I am condemning the post, not the article. A single link to the New York Review of Books is a weak post.
posted by Mister_A at 12:04 PM on November 21, 2007


so those in the game who had MD degrees moved over to drug peddling since that was considered by the insurance industry to be "real science."

I've read less informed statements, but not very many.
posted by docpops at 12:05 PM on November 21, 2007


Excuse me? You just attacked someone for summarizing a book review. An excellent imitation of a drug industry shill.

I was fair--if I had wished to be unkind I would have said "Eat some more pills, pill-head" or "The sand is under your feet, not in your ass, Ostriches all the way round."
posted by cytherea at 12:06 PM on November 21, 2007


If we were discussing the advisability & economics of a new heart medication or a new surgical technique, I sincerely doubt that there would be such aversion to critically evaluating its impact against the financial interests of its developer. For some reason, though, when the same sort of healthy skepticism is brought to bear on psych meds, some people get all up in arms about it. I wonder if that's because some [not all] segment of the users of such drugs have permitted themselves to be defined according to the marketing plan of a multinational corporation. Having given up an element of their self-determination, they're accordingly obliged to defend that corporate anthropology with all the vigor of the true disciple lest their sense of self become unstable. That's not to say that there aren't some people who are in dire straits and in need of such therapies. But there are many many people who speak about psych meds with the same eye-gleam sees only in the most fervent evangelicals.

It's a shame, really.
posted by felix betachat at 12:06 PM on November 21, 2007 [1 favorite]


This post is sucking less and less!
posted by Mister_A at 12:09 PM on November 21, 2007 [3 favorites]


So we live in a world where it's tacitly OK to seek treatment for urinary dribbling, diminished erectile tumescence, periodic tension headaches, having a fat ass, and constipation...

But once people who are pained by shyness or sadness, much less full-blown depression, have the temerity to use medication to augment their own efforts [that is, most of them have developed healthy relationships, jobs, hobbies, to lack of full effect] we feel like it's appropriate to scrutinize the medical community for prescribing to them?

Pharmaceutical companies want to make money and don't care if you feel better. That's not news. Most doctors just want to see you feel better, even if their only motivation is so you'll leave them alone. OK, the thesis and axe-grinding in these articles is now valid. Can they finally go off and get fucked so people with emotional debility can be left to get the help they need?
posted by docpops at 12:11 PM on November 21, 2007 [8 favorites]


It's a deal, just as soon as they stop prescribing them for children.
posted by words1 at 12:14 PM on November 21, 2007


It's a deal, just as soon as they stop prescribing them for children.

When you have a kid with depression get back to me.
posted by docpops at 12:17 PM on November 21, 2007 [1 favorite]


Also - this is an excellent article.
posted by docpops at 12:23 PM on November 21, 2007


When you've lost your fiance to suicide in the first week after starting Prozac for a minor depression, why don'y you get back to me.
posted by cytherea at 12:24 PM on November 21, 2007


Isn't that a reference to a story a little while back about how teenagers on certain antidepressants were more likely to kill themselves?
posted by agregoli at 12:25 PM on November 21, 2007


(I was speaking about words1's comment)
posted by agregoli at 12:25 PM on November 21, 2007


we feel like it's appropriate to scrutinize the medical community for prescribing to them?

Yep. It's what a healthy society does. Protecting the interests of the individual against the corporate is, in anything other than a fascist state, a praiseworthy act. Nobody disputes the suffering of people who turn to these pharmaceuticals. Why...really...why should it ever be taboo to ask if people are being taken advantage of? I take psychological health and emotional suffering extremely seriously. Corporate interests? Not so much.
posted by felix betachat at 12:29 PM on November 21, 2007


So then Cytherea, whose fault is your fiance's suicide?
posted by docpops at 12:31 PM on November 21, 2007


Well, I think cytherea and docpops have establish a criteria that guarantees that they are the only people in this thread qualified to comment on it.

Excellent.
posted by Astro Zombie at 12:31 PM on November 21, 2007 [1 favorite]


Consumer Reports on Restless Leg Syndrome, somewhat connected to the idea that Drug Companies are amplifying issues and then suggesting drug solutions.
posted by drezdn at 12:35 PM on November 21, 2007


Felix, I agree with you. But the interests of MD's and corporations are completely different in all but a few egregious situations. Family docs and internists aren't out beating the bushes for more mental illness to come into their offices. It's flooding us more by the year. And despite what these articles say, it's real, it's severe, and for most people it's hopeless.

The treatment of heart disease and cancer is far more duplicitous than mental illness. In a practice of more than thirty primary care physicians, we've never had a severe adverse outcome from antidepressants (side effects, yes) in over ten years.

I'd love to see these people get their jobs back after a year of unemployment, or undo the sexual abuse they finally can speak of, or give them non-pharmacologic opitons to manage the alcohol abuse that so helped the last three generations of the family, or maybe unwind time and change out their parents for people that didn't ignore or berate or beat them, but I can't.
posted by docpops at 12:38 PM on November 21, 2007 [2 favorites]


I bet you would be able to find a clue in the article, Doctor Holmes.
posted by cytherea at 12:39 PM on November 21, 2007


Astro, comments based on real world, longitudinal experience are different that comments based on what you might have gleaned from the media. Comments from users of SSRI's have more credibility than from those who haven't and probably never will.

Does that surprise you?
posted by docpops at 12:41 PM on November 21, 2007


The vital importance of anti-depressive medication for literally millions of people AND the abuses of the pharmaceutical industry in promoting the most profitable drugs are NOT two mutually exclusive concepts. They both exist in the real world.

Personal anecdote: when accompanying my ex-wife to some of her appointments with a prescribing psychiatrist, the doctor took me aside and asked how I was doing. At one point, concerned that I was getting depressed, he prescribed me some of the then-newest-and-shiniest anti-depressants. They didn't do diddly for me. Years later, I had lost my insurance and fallen into serious depression, and a doctor at a public hospital with a bad reputation tried out some cost-effective generic prozac (fluoxitene). That helped. A lot. Once again insured, other doctors have tried me out on other 'more-advanced' medications, but I keep going back to what worked for me the first time. Your Mileage WILL Vary. A Lot. But I love my fluoxitene and distrust the newer drug-company-promoted drugs.

So BOTH turtles all the way down and Postroad are right. And I liked Postroad's characterization of pills as "considered by the insurance industry to be "real science"" while talk therapy is not. Regular appointments with a Counselor have helped me too, (but more Cognitive than Freudian). Lots of things can help when you need help. It's a sometimes frustrating process to find your best combination, and corporations promoting the most profitable medicine don't help.
posted by wendell at 12:49 PM on November 21, 2007 [2 favorites]


Astro, comments based on real world, longitudinal experience are different that comments based on what you might have gleaned from the media.

Is that really what "When you have a kid with depression get back to me" means? Because it sounded more exclusionary.

And, based on the number of parents who are convinced, without evidence, that their children's autism is caused by vaccines, I suspect that real world, longitudinal experience might sometimes be deceptive.
posted by Astro Zombie at 12:49 PM on November 21, 2007


It is a sad truth that most 3rd-party payers don't reimburse "talk therapy", or if they do, they won't pay for very many sessions.
posted by Mister_A at 12:53 PM on November 21, 2007 [1 favorite]


docpops: I get where you're coming from. Honestly. And I owe you a belated thanks actually. I made an anonymous AskMe some time back on exactly these issues, got my ass handed to me by a bunch of shrill and unsympathetic jerks, and had you both stand up for me and give me measured and kind advice. I have a lot of respect for you and the work you do.

That said, please take a step back and question your presuppositions here. You say that you've never seen an adverse reaction, and I believe that. But for some, a lifelong and total dependency to a foreign substance whose procurement depends on the policies and interests of an entity whose first concern is financial does, in fact, constitute an "adverse" condition. For someone whose chief philosophical value is human freedom, this situation, viewed objectively, looks a lot like bondage.

I agree totally that it's better to have people discussing their problems and receiving appropriate therapies from trained professionals than to have them drinking to excess or engaging in self-destructive behavior. But somewhat better doesn't equal beyond critique. You say you'd love to have non-pharmacological options for your patients and again, I believe you. Raising doubts about the advisability of wide-prescription of psych meds is, I'd suggest, one precondition for the development of those options. Without it, administration of powerful drugs becomes the default, even the canonical option, and it becomes impossible to imagine alleviation of emotional suffering by means other than chemical.

It is possible to engage in this sort of institutional critique without casting aspersions on those who are suffering.
posted by felix betachat at 12:53 PM on November 21, 2007


And, based on the number of parents who are convinced, without evidence, that their children's autism is caused by vaccines, I suspect that real world, longitudinal experience might sometimes be deceptive.

I don't follow. The fact that after fifteen years I've seen every weird vaccine side effect but not a single case of autism is precisely why and how I reassure my patients to vaccinate, beside that lack of actual supporting meta-analyses.

And wendell said it better than I ever could. Every drug you can get by prescription can kill you - some treatment paradigms make better targets.
posted by docpops at 12:54 PM on November 21, 2007


Felix, I've made the exact comments you did above to medical and PA students about treatment of a lot of illness, not just depression. How asinine is it to take high blood pressure medication forever or reflux drugs when losing twenty pounds would fix both? I hate the way medicine has to make do with shortcuts and less than ideal long term solutions for serious problems. I have to do the best I can with what is available. As Wendell said, one should rarely trust Big Pharma, but sometimes their products can have dramatic impact on insoluble problems. Antibiotics kill more people than antidepressants, remember.
posted by docpops at 12:59 PM on November 21, 2007


"When you have (the same experience I have had), come back to me" is NOT a valid response to anything.

My suicide attempt happened before I got the prozac, which is more info than I wanted to give, but some people are projecting their own very specific experiences onto the debate. Notice I already used the term "personal anecdote" for MY personal anecdote.

And as I wrote above (slowly working on my comment while battles raged unseen by me), YOUR MILEAGE WILL VARY. A LOT. We are all individuals with differing need and body chemistries. No drug should be prescribed "lightly".
posted by wendell at 1:00 PM on November 21, 2007


Or, what docpops said I said.
posted by wendell at 1:03 PM on November 21, 2007


American patients have the expectation that there's a quick 'n' easy fix, in pill form, for whatever ails them. Unfortunately, many people will move on to another physician if their PCP won't prescribe some new-fangled drug that they heard about on the TV or the internet. The healthcare system we have does not encourage a partnership approach between patient and physician; therapy has become commoditized, and physicians often find themselves feeling pressured to prescribe according to patients' wishes.

Direct-to-consumer advertising is one very important reason for this phenomenon.
posted by Mister_A at 1:05 PM on November 21, 2007 [1 favorite]


Opinions on this issue seem to be getting ever shriller. I don't like corporations any more than the next guy, but you will have to pry my ant-depressant out of my cold, dead hands. I'd rather not have to take something but I really can't survive without it. At the same time I have known people with extremely adverse reactions to it.

Just because some people are allergic to penicillin doesn't mean it hasn't saved countless lives, or that it should be banned.

All medicines should be used responsibly.
posted by maggiemaggie at 1:09 PM on November 21, 2007 [1 favorite]


Just to flesh out the point I'm trying to make: my sense is that a lot of these sorts of psychological ailments depend on radical changes in human lifestyle over the last 100 years. Lack of a solid connection with an extended family, growing itinerancy, increasing financial and professional pressure, separation from undeveloped geographical spaces, all these things can impact upon a person's emotional state and sense of themselves. They are non-medical but very real factors. If we take it for granted that only medical/chemical interventions are appropriate for treating peoples' emotional maladies, then we are obliged also to take for granted that these changes in human lifestyle are also beyond critique.

I'm not saying we should all strap on loincloths and go back to living in a primitive state of nature in order to be happy and to free ourselves from Big Pharma. But until fairly recently, the way that human beings coped with these sorts of radical environmental changes was through corresponding cultural changes. It was the task of the philosopher, the statesman and the clergy to wrestle with redefining human dignity in order to create a bridge between a society's sense of itself and the new conditions in which it was living. By such means and through this kind of debate, everyone's interests are, at least potentially, served.

Under the present regime, I'm afraid, the only people who are tangibly benefiting over the long term are the corporations who are convincing us that we need their pills in order to be who we want to be.
posted by felix betachat at 1:14 PM on November 21, 2007 [4 favorites]


Just to flesh out the point I'm trying to make: my sense is that a lot of these sorts of psychological ailments depend on radical changes in human lifestyle over the last 100 years. Lack of a solid connection with an extended family, growing itinerancy, increasing financial and professional pressure, separation from undeveloped geographical spaces, all these things can impact upon a person's emotional state and sense of themselves. They are non-medical but very real factors. If we take it for granted that only medical/chemical interventions are appropriate for treating peoples' emotional maladies, then we are obliged also to take for granted that these changes in human lifestyle are also beyond critique.

That can't be said enough.

But the model I use frequently is hypertension. As obesity increases, so does high blood pressure. But some people with the worst pressure in the world are lean, non-smoking marathon level athletes. Some people with depression have it as a lifelong, physiologic anomaly, despite having accomplished quality careers, relationships, and self-awareness that supercedes 99% of their peers, and often are the ones you hear of on medication for life.
posted by docpops at 1:21 PM on November 21, 2007


Isn't the real problem that psychiatry lacks any credible theoretical foundation? The tensions between it and psychoanalysis arise because we need a story here. A better account of ourselves. Both camps have failed us, and neuroscience is not doing a whole lot better. But our twisted relationship to our inner tensions and fault lines would be greatly improved if we could make progress in understanding our subjective nature, where suffering is defined.
posted by fcummins at 2:36 PM on November 21, 2007


There aint no pill out there that will cure the blues when you have no money. Nosireee! It's just the God's honest truth, that's all. True depression. Plum brokedness. 'Sides if you don't have the money..you can't get them happiness pills noways.
posted by doctorschlock at 2:46 PM on November 21, 2007


I think Mose Tolliver just joined the thread.
posted by docpops at 2:52 PM on November 21, 2007


Shucks! I took me a couple of them happy pills and washed em down with some wild turkey. I plum near fell over dizzy. Next day...didn't feel no more happy than I did before.
posted by doctorschlock at 2:59 PM on November 21, 2007 [1 favorite]


God bless ya docschlock: you got yo' self a true case o' the blues. Now go write some songs and make yourself useful. ;-)
posted by Turtles all the way down at 3:35 PM on November 21, 2007


But how often is a true case of the Blues misdiagnosed as depression? Especially since you can cure the Blues just by cooking it longer.
I LOVE when threads dovetail in weird ways
posted by wendell at 3:48 PM on November 21, 2007


So then Cytherea, whose fault is your fiance's suicide?

I'm a bit calmer now, so hopefully I can answer your question without being as mean as I felt when you asked it.

It's my fault. I'm selfish and needy and unstable and blind and I'm not nearly strong enough. And I blame myself everyday, still. But it would not have happened without the Prozac. My fiance wasn't like me. My fiance was strong and responsible and stable. The suicide was bizarre and completely uncharacteristic. Apparently I'm not alone in that conviction.

The psychiatrist explained to me that patients are often at elevated risk of suicide at the start of treatment because, while they may have had latent suicidal tendencies during their depression, they didn't have the energy to act on them, hence the actuated suicide attempts were the result of the drug's positive effects.

Which, it now seems, was the talking point misinformation used by Eli Lilly to cover it's ass against the mounting wave of litigation while fighting to keep their own damning clinical data buried. It's rather discouraging to discover that the received wisdom of medical professionals varies so neatly with the expiration of a patent.

I'm sure most doctors are well meaning, and I'm sure SSRI's have helped lots of people. But that's got nothing to do with the sociopathic, morally abhorrent behavior of the pharmaceutical industry, nor the amount of influence they have over doctors and the FDA.

Was there anything in the article that was counter factual? Anything you disagree with?

Finally, exactly what kind of question was that? Perhaps if you had asked that in person there would be something in your tone of voice or facial expression that would lead me to infer something well meaning. Because if a doctor were to ask me that--accusation--in his office, I would get up and leave without another word.

Which is probably what I should have done here.
posted by cytherea at 4:59 PM on November 21, 2007 [2 favorites]


I've seen psychotropics trading on the black market in Philly recently, there's so many anti-depressants out there that it's become very common for people to misuse them as "pick me ups" when they're feeling down. They'll buy a bottle off the streets and take it whenever they remember to until it's gone, not following any set schedule. It's incredibly dangerous. Anti-psychotics like Seroquel are starting to trade like Xanax and Valium because enough people have been given it off-label as a substitute for benzos in rehabs and detoxes that people know to seek it out on the streets as a sleep aid. The same goes for Trazadone.

There's a lot of pills floating around out there, and in the inner city people are more likely to take them without even knowing what they are or what the possible side effects might be. I've seen muscle relaxants touted as "just like Percocet." Some people will take a handful of whatever's there and not even know what the fuck they just took if they get desperate enough.
posted by The Straightener at 5:57 PM on November 21, 2007


Ricky Williams, by the way, may be making his return to the NFL this weekend after being banned for substance abuse. Seems the Paxil didn't quite alleviate his social anxiety disorder, so he smoked a lot of pot, did a lot of yoga, and walked the earth for a while. He's a great player, and a really interesting man. I wish him well.
posted by schoolgirl report at 7:31 PM on November 21, 2007


I have to mention that I know another person who commited suicide after using prozac for a while. Looks like this kind of drug un - inhibits persons. That's why it's really important to check whether persons being prescribed prozac do or do not have expressed suicidal tendencies. Prozac is a far cry from being a simple cure for those tendencies. It's a positive threat to trigger an action which had been so far prevented by the person's inhibitions.
posted by nicolin at 5:28 AM on November 22, 2007


I see the same thing, The Straightener, here in Baltimore. Really, Neurontin as a chill-out drug? Yup.

My issue has never been with medications per se, or with their use. There is a lot of evidence that they are helpful for some people some of the time. There is, however, also a lot of evidence that the positive results are overstated. They aren't all that much better than placebos, and some of the side-effects (the sexual ones in particular) are not acceptable to many patients. I strongly object, also, to the implication, fostered often by drug companies, that because these medications have some effects, and have some anti-depressant effects, depression or other mental illnesses are therefore "biological" in nature and best treated by medications. There is very little (or no) evidence for the serotonin hypothesis of mental illness.

What the research actually demonstrates is that talk therapy is effective for ~79% of patients who choose to enter treatment. That's a pretty staggering number. There are people who do not have access to psychotherapy, who may have access to medications, and there are also people for whom medications may work better than therapy does. Where marketing enters the equation, however, is when talk therapy is deemed somehow less good than meds, or when people want to suggest that promoting therapy to treat mental illnesses is somehow irresponsible or a covert way of suggesting that people should just suck it up. I tend to take that pretty personally, since the actual, research-confirmed, implications are quite the opposite.

There is a real problem with people thinking that because a treatment has worked for them, it is somehow beyond the bounds of rational thought or scientific examination.
posted by OmieWise at 1:22 PM on November 26, 2007


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