This article first appeared in Ipnosis magazine, issue 37, 2010, pp. 52–5, and
is reproduced here by kind permission of the Editor, Yvonne Bates
Welcome to the ‘Paradigm War’:
The Case of Antidepressant Medication
Irving Kirsch, The Emperor’s New Drugs: Exploding the Antidepressant Myth, The Bodley Head, London, 2009, xii + 226 pp, ISBN 978-1-847-92083-6, price £11.99
Reviewed by Richard House
The belief that antidepressants can cure depression chemically is wrong... There is a ton of data indicating that the chemical imbalance theory is simply wrong... We seem to be on the cusp of a revolution in the way we understand and treat depression.
In issue number 18 (2005) of Ipnosis, I reviewed an important book byDavid Servan-Schreiber entitled Healing without Freud or Prozac: New Approaches to Curing Stress, Anxiety and Depression without Drugs and without Psychoanalysis. A search on the term ‘depression’ on the Amazon website reveals that, some six years after its first publication, Servan-Schreiber’s book is currently the 18th best-seller out of almost 100,000 hits on this term, which seems to confirm Irving Kirsch’s claim of a ‘revolution’ being underway in our understanding and treatment of ‘depression’. The current book under review can only have the effect of accelerating that much-needed revolution, and for that reason alone it is a Godsend to those with anti-psychiatry and critical-psychology allegiances who have, for many years, been challenging the prevalence of psychoactive drug treatments for what the medical world defines as ‘depression’.
The ‘Emperor’s New Clothes’ has always been my favourite fairy tale, so it was with some excitement that I opened the pages of this new book. I have written in the past about the highly dubious assumptions that are made in what we might call ‘depression’ discourse, with a ‘medical-model’ approach commonly assuming a kind of ‘malfunctioning machine’ metaphor whereby ‘depression’ is a consequence of some kind of abnormality of brain chemistry, such that if we can only find the right kind of psychoactive substance to ‘normalise’ such brain-chemistry malfunctioning, then the person’s ‘depression’ will be cured. Such a quasi-deterministic, materialistic view of the ‘mind–brain’ is so saturated with problematic and quite unsubstantiated assumptions that it’s difficult to know where to start in deconstructing them. Certainly, I have long suspected, and argued, that antidepressant medication is not effective in the simplistic way that is commonly assumed and claimed by the proponents of these medications, but my assertions were based on an alternative, non-materialistic ontology of what ‘depression’ and ‘mind’ might consist in, and not on empirical research per se. Now, at last, those of us who have long challenged the pharmaceutical medicalisation of people’s ‘difficulties of living’ have had our philosophical speculations amply confirmed by Irving Kirsch’s empirical tour de force, in which he demonstrates that at the level of empirical positivistic science, the claim that antidepressant medication per se cures depression is simply false, and is not supported by a comprehensive empirical meta-analysis of the available research data.
An interesting place to start is with the reviews of Kirsch’s book on the Amazon website, as in many ways that are emblematic of the unfolding ‘paradigm war’, of which the controversy over psychoactive medication is just one aspect. Five of the six reviews (as I write, in February 2010) are very positive, and one is entirely negative. In the latter review, ‘Michael Levin, MD, MS in Pharmacology’ writes the following: ‘… [Kirsch has] ventured into the field that he neither practices nor fully understands. This brief review in not the right forum to educate professor Kirsch (professor of what?) about psychopharmacology or questions [sic.] his motives about writing the volume on the topic he knows so little about. I will say, however, that his passions are misdirected. Armed with 20 years of psychiatric practice, two advanced degrees, and lots of common sense I advise Dr Kirsch (Dr. of what?) to go back to teaching about sex and stop bothering psycho-pharmers.’ I did some Googling, and came up with these details about a Dr Michael Levin, who is presumably the same person as the Amazon reviewer: ‘Dr Levin’s private practice is specialized in behavioral, developmental, and learning disorders of children & adolescents and pediatric psychopharmacology’ – or in other words, he apparently and presumably administers psychoactive medication to children and young people.
Unusually for such Amazon reviews, Dr Levin’s particular review has precipitated five comments, one being from Professor Richard Bentall (established and well-known author of a number of books on mental health), who responds: ‘Kirsch’s meta-analyses of the effects of antidepressants have been published in peer-review academic journals, and conform to internationally recognised standards of evidence based medicine. The reviewer’s appeal to his "20 years of psychiatric practice, two advanced degrees, and lots of common sense", on the other hand, is reminiscent of the way in which previous generations of psychiatrists attempted to justify insulin coma and the prefrontal leucotomy.’ Other respondents refer to Levin’s ‘ex cathedra statements backed up only by tedious claims to authority’ and that ‘Ad hominem arguments for a book review are utterly unhelpful’. Yet another respondent refers to how they ‘would be more convinced if the reviewer commented at all on the content of the book rather than trying to discredit the author Irving Kirsch, [who] has written several books on Expectation, Evidence Based Clinical Hypnosis, Clinical Hypnosis and Self-Regulation. He’s also published meta analyses on anti-depressants vs placebo – especially controlling for active side effects.’
The other reviews of Kirsch’s book are far more complimentary, referring to the ‘chicanery’ that can go on before, during and after the clinical trial process; the ‘mind boggling’ manipulation of data ‘in its subtlety and deviousness’; the pharmaceutical industry’s ‘dirty little secret’; Kirsch’s undermining of the (very big) ‘depression business’, with ‘science being side tracked by profit’, raising ‘a lot of important questions about the mental illness industry and modern evidence based practice’; insight into the relationship between drug companies, the regulators and the academic establishment that is so dependent upon funding from these bodies; and perhaps most telling of all, ‘the failure of the authoritative bodies to adequately respond’ (to his challenges).
Any engagement with the possible aetiology or cause(s) of ‘depression’ might begin by questioning whether it is even helpful to try to think about ‘depression’ in terms of cause-and-effect thinking. Indeed, both behaviourist and postmodernist approaches might end up being (very uneasy) bedfellows in agreeing that perhaps causal thinking isn’t at all helpful! Aetiology can commonly be seen in terms of:
One problem that the book under review does not address is the question of language, and the way in which specifying depression or ‘mood disorders’ as nouns has the effect of ‘thingifying’ human experience in a way that might be quite inappropriate to the human experience we are seeking to understand (as opposed to ‘explain’). In addition, any view on the aetiology of ‘depression’ necessarily entails irreducible metaphysical assumptions regarding what a human being consists in, and this is a crucial philosophical point that discussions in this field commonly either ignore or take for granted. Thus, any attempt to argue that a specifically pharmaceutical treatment is appropriate for treating ‘depression’ must either argue for a deterministic/materialistic philosophy of mind (which I believe to be philosophically unsustainable, and at the very least highly challengable), in which it is claimed that ‘abnormal’ brain functioning somehow causes ‘depression’; or it must claim that no matter what the cause of ‘depression’ might be, it is appropriate and helpful to use brain-chemistry-altering psychoactive drugs to treat it. I hope it is clear that the latter can by no means be taken for granted, and needs to be thoroughly argued through in a way that is rarely if ever attempted by those favouring pharmaceutical treatments.
Irving Kirsch is a clinical psychologist, a psychotherapist and a professor or psychology at Hull University. He begins by pointing out that global sales of the antidepressant industry amount to some US $19 billion a year – given which situation, one could be forgiven for assuming without question that in any allegedly rational society in which the totem of empirical science is claimed to hold sway, the clinical efficacy of these drugs must surely be beyond question. Think again. It was Thomas Kuhn who argued in his seminal book The Structure of Scientific Revolutions that within any given cultural-historical conjuncture, there will be a prevailing Zeitgiest and accompanyingWeltanschauung which will define what is assumed to be ‘normal’ and, therefore, taken-for-granted and unquestioned. A decade after Kuhn’s book first appeared, Louis Althusser coined the term ‘The Ideological State Apparatus’, describing how, from a Marxist perspective, any ‘social formation’ will tend to have a built-in tendency to ‘reproduce’ and reinforce the existing order of things, including, crucially, the ideological assumptions underpinning the status quo. Under such conditions, ideology and material interest will have a very strong tendency to prevail, and take precedence over rationality and dispassionate evidence; and I want to argue that the way in which the myth of antidepressant efficacy has so comprehensively and uncritically colonised modern medical and cultural consciousness is a classic case of a non-scientific, ideological discourse holding sway, and in such an effective and previously unchallengable way precisely because it assumed the banner of ‘empirical science’ as its rationale – yet entirely spuriously, as Kirsch comprehensively demonstrates in this path-breaking book.
Notwithstanding the poignant challenges of penetrating postmodernist thinking and a rejuvenated ‘New Paradigm’ cosmology, the prevailing myth of our age is (still) one that privileges Cartesianism, ‘modernity’ and materialism – and it is within this cultural context that the the ‘pharma-complex’ has gained such ideological ascendency, and continues to hold such sway under the guise of its spuriously claimed scientificity. What Irving Kirsch does in this book is to show, first, that much of the clinical research into the efficacy of antidepressant medication (about 40 per cent of it – p. 4) has been surpressed and withheld by the pharmaceutical industry (see p. 39), when such research has yielded results that are inconvenient to and contradict its pro-medication bias; and that once, via the US Freedom of Information Act (see pp. 26–7), all such research data had been obtained by Irving and his colleagues, and incorporated into a meta-analysis of all the existing research, the finding was that statistically speaking, antidepressant medication is no more effective than placebo in the treatment of depression.
Of course the discussion is far more complex than this summary headline description might suggest. Not least, the book is notable for its detailed analysis of the notion of placebo, and the way in which so-called randomised controlled trials (RCTs) are often fatally flawed because often in excess of 80 per cent of those participants who are allocated the antidepressant treatment correctly guess before the clinical trial is over that they are taking the antidepressant as a result of the side-effects which they experience; and once they have guessed this, then they are far more likely to believe that the treatment will work, so artificially enhancing the placebo effect over what it would otherwise have been.
The book is divided into seven substantial chapters. Following an extensive and penetrating Preface, Chapter 1 gives the general background to the author and his colleagues’ discovery that the placebo dimension of antidepressant medical treatment is in reality far more significant than has previously been realised. Indeed, Kirsch makes it clear that what he and his colleagues (notably, Guy Sapirstein) discovered greatly surprised them. Chapter 2, evocatively titled ‘The "Dirty Little Secret"’, illuminates the notion of ‘publication bias’ (p. 29; so much for the much vaunted ‘objectivity’ of empirical scientific research); and describes how Irving and his colleagues reanalysed the data, what they discovered – and how their findings were received by the medical world. Irving is careful not to claim that they had discovered something new, for as one research team argued, ‘Many have long been unimpressed by the magnitude of the differences observed between treatments and controls, what some of our colleagues refer to as the "dirty little secret" in the pharmaceutical literature’ (quoted on p. 38). Yet what is extraordinary is that while both the drug companies and the regulatory agencies that approve them for marketing knew about this, neither prescribing doctors, nor their patients or the general public, did. Irving then goes on to show how the drug companies have used a range of manipulative devices to make their products look more effective than they actually are, and not least through procedures that, even at one’s most charitable, cannot be termed anything other than ‘fiddling the data’ (cf. pp. 38–44).
In a scarcely believable commentary to anyone with any residual faith in the proberty of the scientific community, and which would not have surprised Louis Althusser in the slightest, we are shown how the state regulatory agencies themselves actively and knowingly colluded with the pharmaceutical industry’s ‘dirty little secret’ (p. 45–8), exposing in all its starkness ‘the financial entanglement between the drug inductry and those who regulate it’ (p. 47). We also learn about what Irving calls ‘Voodoo science’ – that is, when drug companies conduct ‘as many trials as they want until they find two showing significant effects. The negative trials simply don’t count’ (p. 51).
Chapter 3, ‘Countering the Critics’, outlines the attempts by the medical and pharmaceutical establishment to refute Irving’s meta-analytic findings, and why they allege them to be inadequate. I was especially struck by how genuine long-term research into the efficacy of antidepressants is rare because before long, patients just drop out of the trials either because the drug isn’t working or because the side-effects are too distressing (p. 65); and by how the medication itself might well be ‘iatrogenic’ (i.e. the medicine itself induces ill-health). I have long argued the view that the taking of psychoactive drugs might well actually interfere with, and damage, the person’s natural self-healing capacities, thus self-fulfillingly creating a long-term dependency on the drug in question; and this view seems born out by Irving when he writes that ‘Patients who are being treated with antidepressants show a specific vulnerability to relapse that is not shown by recovered patients who have been treated without drugs... [A] biological vulnerability [may have been] induced by the medication in the first place’ (p. 65, emphasis added).
Chapter 4, ‘The myth of the chemical imbalance’, shows in detail just why the chemical imbalance theory of depression is false, or ‘dead in the water’ (p. 99). However, I am uneasy, verging on outright disagreement, with Irving’s statement (very much from within the prevailing paradigm) that ‘Depression certainly exists in the brain. All subjective states... are rooted in the brain’ (p. 100). There certainly needs to be a much sharper, and fully and coherently articulated, philosophy of mind than Irving offers here. (On page 121, for example, he revealingly writes, ‘If we are right in assuming that the mind is the brain...’; and for other examples, see also pp. 91–2, 100, 116–17, 121.) Yet these philosophical difficulties and lacunae do not detract from what is in my view the correct conclusion, that when a subjective experience of ‘depression’ is present, ‘the underlying brain mechanisms may be normal’. (ibid.).
Chapters 5 and 6 go into great and revealing detail about the notion of placebo (including the related ‘nocebo’ effect – pp. 124–30), showing the multitude of effects that placebos have been shown to have, and looking in depth at the theories about how such effects are produced. While I think there is a lot more to say about what ‘placebo’ might consist in which is not by any means fully addressed in these discussions (not least in terms of the arguably pervasive impact of anxiety, and its psychodynamics, upon both symptoms and people’s capacity to self-heal – see p. 112; amazingly for this reviewer, there are no index entries for the term ‘anxiety’), these chapters should nonetheless be indispensable reading for anyone and everyone who trains in the medical and helping professions. Chapter 6 ends by making an absolutely essential point in relation to the efficacy-obsessed, short-termist thinking in the NHS; that is, that ‘The amount of time that [doctors] have available for each patient is limited, and making more time available would cost money. Still, this might be money well spent, given the potential benefits for health and well-being that it could produce. In the longer run it might even be cost-effective’ (p. 148). There is a discussion of ‘non-specific effects’ (pp. 136–44); and though this is not strictly speaking an academic book, I was disappointed to see no reference to Shepherd and Sartorius’s seminal and much-neglected collection,Non-specific Aspects of Treatment (Hans Huber, 1989).
Finally, Chapter 7 explores some of the alternatives to medication in the treatment of depression (e.g. St John’s wort, physical exercise, self-help bibliotherapy and social change), assessing the evidence of their efficacy, and considering the major issue of the side-effects of treatments for depression. I agree with Irving’s suggestion that withdrawal effects from psychoactive medication are often confused with relapse (by both patients and physicians – p. 153); and for me, the discussion on pp. 156–7 is crying out for the kind of self-healing explanation mentioned earlier in this review. Particularly interesting to Ipnosis readers, perhaps, is Irving’s characterisation of psychotherapy as ‘the quintessential placebo’ (pp. 157–65) – a characterisation I am happy with as long as we remain open to a much expanded view of what ‘placebo’ might consist in, compared with the definition offered in the book (e.g. on page 108). I especially like Irving’s willingness to countenance the non-self-serving view that it could well be the indefinable and the mysterious (Merleau-Ponty) which might be far more significant in a healing encounter than any modality-specific content of the therapeutic approach offered (and this view applies just as much to CBT as it does to any other of the therapeutic modalities). For Irving, ‘The greatest advantage of psychotherapy over medication is that it reduces the likelihood of relapse after having got better’ (p. 160). Moreover, with psychotherapy, change comes about through the active relational involvement of the patient, rather than being precipitated by some ‘external substance’ (p. 162); meaning and hope are seen as being central to the healing experience; and analysis of the relevant research findings seems to show that the effect of psychotherapy alone is as great as the combined effect of psychotherapy and antidepressants combined (p. 163).
Finally, in an interesting epilogue, we read about the way in which those, like Irving, who have challenged the prevailing pharmaceutical Zeitgeist have had their very careers threatened; that ‘depression... is not cured by medication’ (p. 177); and CBT is apparently favoured (p. 181) in a way that it surely not warranted by a methodologically sophisticated consideration of the extant research data. Irving finishes off with the highly apposite statement, ‘I enjoy rocking boats, especially when they are in need of sinking’ (p. 181). There is also an extensive bibliograhy and a more-than-adequate index.
The notion of ‘temperament’ and its historical rootedness in the ancient Greek notion of the four humours (i.e. choleric, sanguine, melancholic and phlegmatic) is one which one hardly ever finds considered in discussions about ‘depression, and it certainly doesn’t in this book (cf. Jerome Kagan’s having brought this way of thinking about human experience into mainstream psychology; see his Galen’s Prophecy, Free Association Books, 1994). On this kind of view, then, some 25 per cent of the human population will be born with a naturally predominating melancholic temperament; and it might well be that this group is most susceptible to ‘depression’, given the kind of environmental stressors etc. that reinforce a pre-existing natural temperament. This is a field, surely, that is ripe for extensive psychological research in the future.
Kirsch’s revolutionary findings in this book are also entirely consistent with the writings of the great Jerome Frank, who nearly 40 years ago argued in his seminal book Persuasion and Healing that healing appears to ‘work’ with much the same degree of success across different cultures because specific forms of healing within a given culture are culturally sanctioned and legitimated, and are commonly believed in, too, by those who experience those healing practices. Such a view coheres with some notion or understanding of the placebo effect (about which Jerome Frank has also written most incisively), and with the (possibly transpersonal) idea that human beings are great self-healers, and treatment commonly works not because of the ‘active ingredients’ within the treatment per se, but because the culturally sanctioned healing practice becomes the experiential vehicle for, and thereby effectively triggers, the patient’s own ‘self-actualising’ (Carl Rogers) healing process.
To return, finally, to the ‘paradigm war’. One might predict with good reason that these devastating findings will remain largely ignored, and it will be ‘Big Pharma business’ as usual; and that rationality will have little or no impact on the massive $20 billion a year economic vested interests and the modernist materialist Zeitgeist that still dominate. What might be termed ‘mood, culture and modernity’ (cf. David Michael Levin’s work) raises a number of questions: not least, is ‘depression’ a valid category that can be applied equally in all cultures across the globe? The postmodern view that different epochs of human evolution have different characteristic ‘psychopathologies’ that typify the prevailing Zeitgeist deserves extensive consideration. Certainly, the seemingly dramatic increase in the incidence of depression diagnoses in recent decades at least suggests that depression might be a cultural symptom of ‘modernity’, which manifests in depression at the individual level.
There are certainly some hopeful signs that the mooted revolution in the treatment of depression might be at hand (a Kuhnian paradigm shift, or ‘scientific revolution’, perhaps?). Thus, we read from Irving that ‘there has been a growing acceptance of [my controversial conclusions]. NICE has acknowledged the failure of antidepressants treatment to provide clinically meaningful benefits to most depressed patients; the UK government has instituted plans for providing alternative treatments; and neuroscientists have noted the inability of the chemical-imbalance theory to explain depression’ (p. 6). However, as a balancing cautionary remark, we also read that ‘many doctors are extremely reluctant to drop treatments that seem to work in clinical practice, even when clinical trials show tha these treatments are really placebos’ (p. 56).
The great healer-cum-psychoanalyst Georg Groddeck once wrote,‘Without the arrow of Eros no wound can heal, no operation succeed...’; and we might even end up embracing a spiritually informed, transpersonal view of what healing consists in, which takes us far beyond the confines of empirical, measurable science, and into a much expanded notion of what ‘placebo’ might conceivably mean in theory and practice. One thing is sure; the psychiatric establishment and the pharmaceutical industry will never be the same again following this book’s welcome publication – an ‘outcome’ that will lead to no little rejoicing amongst those of us who have been challenging the pharmaceutical Zeitgeist for longer than we care to remember.
Richard HousePh.D. is Senior Lecturer in Psychotherapy, Counselling, and Counselling Psychology at Roehampton University. Among his published books are Therapy Beyond Modernity (Karnac, 2003), Against and For CBT (co-editor, PCCS Books, 2008), Childhood, Well-being and a Therapeutic Ethos (co-editor, Karnac, 2009) and In, Against and Beyond Therapy (PCCS Books, 2010, forthcoming). Richard is an active member of the Open EYE Campaign and of the Alliance for Counselling and Psychotherapy, and a founder-participant in the Independent Practitioners Network (IPN).