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Did The APA Miss A Defining Moment?

Sometimes an organization or individual facing a potential public-relations disaster can use the incident as a way to send a powerful message, as well as change the way that organization or individual is perceived.   I wonder whether the American Psychiatric Association (APA) may have missed its opportunity to do exactly that.

Several weeks ago, the CBS news program 60 Minutes ran a story with the provocative argument that antidepressants are no better than placebo.  Reporter Lesley Stahl highlighted the work of Irving Kirsch, a psychologist who has studied the placebo effect for decades.  He has concluded that most, and maybe all, of the benefit of antidepressants can be attributed to placebo.  Simply put, they work because patients (and their doctors) expect them to work.

Since then, the psychiatric establishment has offered several counterarguments.  All have placed psychiatry squarely on the defensive.  One psychiatrist (Michael Thase), interviewed on the CBS program, defended antidepressants, arguing that Kirsch “is confusing the results of studies with what goes on in practice.”  Alan Schatzberg, past APA president and former Stanford chairman, said at a conference last weekend (where he spoke about “new antidepressants”) that the APA executive committee was “outraged” at the story, glibly remarking, “In this nation, if you can attack a psychiatrist, you win a medal.”  The leadership of the APA has mounted an aggressive defense, too.  Incoming APA president and Columbia chairman Jeffrey Lieberman called Kirsch “mistaken and confused, … ideologically based, [and] … just plain wrong.”  Similarly, current APA president John Oldham called the story “irresponsible and dangerous [and] … at odds with common clinical experience.”

These are indeed strong words.  But it raises one very important question:  who or what exactly are these spokesmen defending?  Patients?  Psychiatrists?  Drugs?  It would seem to me that the leadership of a professional medical organization should be defending good patient care, or at the very least, greater opportunities for its members to provide good patient care.  The arguments put forth by APA leadership, however, seem to be defending none of the above.  Instead, they seem to be defending antidepressants.

For the purposes of this post, I won’t weigh in on the question of whether antidepressants work or not.  It’s a complicated issue with no easy answer (we’ll offer some insight in the May issue of the Carlat Psychiatry Report).  However, let’s just assume that the general public now has good reason to believe that current antidepressants are essentially worthless, thanks to the 60 Minutes story (not to mention—just a few weeks earlier—a report on NPR’s “Morning Edition,” as well as a two-part series by Marcia Angell in the New York Review of Books last summer).  Justifiably or not, our patients will be skeptical of psychopharmacology going forward.  If we psychiatrists are hell-bent on defending antidepressants, we’d better have even stronger reasons for doing so than simply “we know they work.”

But why are psychiatrists defending antidepressants in the first place?  If anyone should be defending antidepressants, it should be the drug companies, not psychiatrists.  Why didn’t 60 Minutes interview a Lilly medical expert to explain how they did the initial studies of Prozac, or a Pfizer scientist to explain why patients should be put on Pristiq?  (Now that would have been fun!!)  I would have loved to hear Michael Thase—or anyone from the psychiatric establishment—say to Lesley Stahl:

“You know, Dr. Kirsch might just be onto something.  His research is telling us that maybe antidepressants really don’t work as well as we once thought.  As a result, we psychiatrists want drug companies to do better studies on their drugs before approval, and stop marketing their drugs so aggressively to us—and to our patients—until they can show us better data.  In the meantime we want to get paid to provide therapy along with—or instead of—medications, and we hope that the APA puts more of an emphasis on non-biological treatments for depression in the future.”

Wouldn’t that have been great?  For those of us (like me) who think the essence of depression is far more than faulty biology to be corrected with a pill, it would have been very refreshing to hear.  Moreover, it would help our field to reclaim some of the “territory” we’ve been abdicating to others (therapists, psychologists, social workers)—territory that may ultimately be shown to be more relevant for most patients than drugs.  (By the way, I don’t mean to drive a wedge between psychiatry and these other specialties, as I truly believe we can coexist and complement each other.  But as I wrote in my last post, psychiatry really needs to stand up for something, and this would have been a perfect opportunity to do exactly that.)

To his credit, Dr. Oldham wrote an editorial two weeks ago in Psychiatric News (the APA’s weekly newsletter) explaining that he was asked to contribute to the 60 Minutes piece, but CBS canceled his interview at the last minute.  He wrote a response but CBS refused to post it on its website (the official APA response can be found here).  Interestingly, he went on to acknowledge that “good care” (i.e., whatever works) is what our patients need, and also conceded that, at least for “milder forms of depression,” the “nonspecific [placebo] effect dwarfs the specific [drug] effect.”

I think the APA would have a pretty powerful argument if it emphasized this message (i.e., that the placebo effect might be much greater than we believe, and that we should study this more closely—maybe even harness it for the sake of our patients) over what sounds like a knee-jerk defense of drugs.  It’s a message that would demand better science, prioritize our patients’ well-being, and, perhaps even reduce treatment costs in the long run.  If, instead, we call “foul” on anyone who criticizes medications, not only do we send the message that we put our faith in only one form of therapy (out of many), but we also become de facto spokespersons for the pharmaceutical industry.  If the APA wants to change that perception among the general public, this would be a great place to start.

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24 Responses to Did The APA Miss A Defining Moment?

  1. Nathan says:

    Looks like we mostly agree on this one, Dr. Steve. Psychiatry missed an opportunity to demonstrate its concern and striving towards better science, better care, and more efficient care. Psychiatry, in outrage expressed against the 60 minutes piece, without citing any relevant evidence for refutation or disagreeing but resorted to comments like “plain wrong,” “irresponsible and dangerous,” “mistaken and confused,” and “ideologically based”. Gee, these are some of the words I might use to describe contemporary psychiatry precisely BECAUSE there is evidence to suggest all of them (ideological driven theory of mental illness/health and politically/financially motivated DSM, huge publication bias and poor quality research, and a history of making clinical decisions not based on evidence but solely and demonstrably fallible experience/expert opinion). Instead of concern of the health of the people they purport to work for (patients), it seems that they went on defense of their biggest sellers (antidepressants) for the the people that the defense indicates they actually work for (drug companies).

    It almost appears that psychiatry has gone the model of the free social networks in that instead of viewing their users as their clients, they view their advertisers as their clients and turn their users into products that they sell to them. The weak defenses to Marcia Angell’s review (especially Peter Kramer’s “In Defense of Antidepressants”), the NPR piece, and the 60 Minutes piece indicates to me that the drug companies are who keep psychiatrists in business so they are seen as clients, while patients who seek support are turned into products that psychiatrists sell to the drug makers.

    My language is bit tough, but I can’t come up with a better explanation. Much of psychiatry is probably regretting the inappropriately close ties it made with the pharm industry, but it seems the APA is stuck between a rock and a hard place. If it doubles down with letting pharm industries lead and develop mental health research/treatments, it can keep some money rolling in, but more and better research done elsewhere will slowly expose how psychiatry has sold out its authority as the expert discipline on mental health. If it backs away now, then the past 30 years of research and practice is called into question and they also risk a great tarnish to their professional reputations, with the chance to side on better research for the future but not without a huge hit to the pocket book, prestige, and perhaps the existence as a recognizable profession. Either way, the defenses the APA mounted and the responses they could have mounted only show that the science underpinning psychiatric practice is not only flawed (poor research methodology) but corrupted (based on greed/ideology/prestige) and often enough at the expense of patient health.

    I think it would have been great if the APA or Thase could have offered the response you suggested, and I think it would allow psychiatrists to leverage their respectability, experience, and knowledge and actually start using it to promote patient outcomes and health, and show that being a physician has something unique and valuable to contribute to mental health care. The potential real risk of losses to prestige and wealth are too high for too many psychiatrists.

  2. Altostrata says:

    I agree, Nathan, psychiatry has lost sight of who their customers are and its responsibility towards them. When a business does that, it’s going downhill.

    (One can only feel sorry for poor Michael Thase, U Penn psychiatrist and drug company consultant, defending antidepressants by effectively saying statistical significance for efficacy in drug studies was unimportant to clinical practice!! So much for evidence-based medicine in psychiatry.)

    As David Healy said on his blog http://davidhealy.org/professional-suicide, instead of taking the position (from 2004) “The American Psychiatric Association believes that antidepressants save lives,” it should be saying “The American Psychiatric Association believes that psychiatrists save lives.”

    Why is the APA continuing to promote drugs? Or does it have doubts about psychiatrists?

    • mara says:

      “The American Psychiatric Association believes that antidepressants save lives,” it should be saying “The American Psychiatric Association believes that psychiatrists save lives.”

      That was perfect. Thank you for posting that. That may be why psychiatry doesn’t look like such an appealing field to a lot of people anymore.

    • Anonymouus says:

      Did you say customers???! I can not write the explitive you deserve! Have you ever seen mental illness. Just, please, stop.

  3. Duane Sherry says:

    A better title for this post would have been –
    “How do we get the toothpaste back in the tube?”

    And of course, the answer is you can’t.
    It’s too late for your profession to regain any sense of respect.
    Psychiatry sold its soul long ago.

    Duane

  4. cristeen says:

    Interesting when you follow Dr. Olman’s statement to the APA site, the program highlights featured speakers for the upcoming conference are all psychologists with therapy based treatments. Was this planted before their response? or highlighted thereafter?

    • Altostrata says:

      Opening session: “Cognitive Therapy and Psychodynamic Therapy: More Alike Than Different? A Conversation Between Aaron T. Beck, M.D. and Glen O. Gabbard, M.D.”

      Hmmm, do they see a need to add another dimension to psychiatry? The placebo issue must be scaring the heck out of them. My bet is this is a double-down on the desirability of a medication-therapy combination — something a GP can’t provide.

  5. Jay says:

    If antidepressants are merely placebos, why do they carry Black Box warnings?

    Yep, this entire class of medications has been grossly oversold. They certainly can work, but they do not have the universal response rate we’ve been led to believe. In my opinion, the biggest enemy in this matter has been direct-to-consumer marketing. We need to eliminate this once and for all.

    • Nathan says:

      Review of the data suggests the beneficial effects (reducing depressive symptoms) of medications approved for treating Major Depressive Disorder (antidepressants) are mostly or all related to placebo effect. Placebo effects can be very powerful and beneficial, as can be seen by people feeling a lot better taking antidepressants, even though pills with active “antidepressant” chemical make-up do not outperform pills with no active ingredients intended to treat depression . The chemical compound of the drugs do distinguish themselves from non-active pills by producing side effects, potential increased risk of suicide for younger people being a serious enough one to put a black box label on them (though this is being debated again).

      • mara says:

        Nathan, I know this is anecdotal, but having been on pretty much all of the SSRIs in my preteen and teen years, I can say that I know without any shadow of a doubt that they can make you suicidal.

        I actually think its bizarre that it is even debated. If your patient was not suicidal before going on the drug and then becomes intensely more depressed, complete with plans to commit suicide or an actual suicide, I’m pretty sure it was the drug. I can remember getting a severe panic attack on zoloft and when my father asked the doc if the zoloft caused it he responded, “I don’t think the drug caused it. I think it brought out something that was already there.” And I know that is the typical response. If you become manic on an antidepressant, that means you are bipolar because the theory is that the drug brought something out that was already there. If it’s a panic attack, it means you had underlying panic disorder. If it’s suicidal tendencies, then it would have happened sooner or later even without drugs because the thought is that you were already predisposed to feeling that way and it means you have severe major depressive disorder.

        But how can you ever really prove that these people all had a preexisting condition? It’s not like we test their genetics for suicidal tendencies. And even if the drugs are not causing it (they’re just bringing out a preexisting condition in some people), that’s still not any better in my mind. Yes, cats don’t cause cat allergies. Genetics cause it. But the cat might as well be causing it, because the cat is what is bringing it out. I think people get too caught up on semantics. The point is that some people, especially younger people, become more suicidal on antidepressants. And whether that is because the drugs brought out an underlying condition or because the drugs are changing them and making them that way is just splitting hairs. The only way it would matter is if we could test for a predisposition to a severe form of MDD that is triggered specifically by antidepressant use and is limited to the teen/young adult years. That way we can screen all those people out for safety reasons. But we can’t.

    • Duane Sherry says:

      Jay,

      The Black Box warnings are in place because these drugs are very dangerous.

      The placebo effect takes place with sugar pills, but it unfortunately also takes place with harmful drugs.

      Marcia Angell, M.D. calls these drugs “worse than worthless” for a reason –

      http://www.nybooks.com/contributors/marcia-angell/

      Duane

    • Altostrata says:

      “If antidepressants are merely placebos, why do they carry Black Box warnings?”

      A common misinterpretation. Antidepressants are not MERELY placebos. Kirsch called them “placebos with side effects,” dramatizing the issue.

      The biochemical action of antidepressants is not placebo-like, the statistical efficacy of antidepressants is placebo-like (at best).

      We’re going to see a lot of diabetes, stroke, and cardiac problems coming out of those “placebos with side effects.”

  6. Nathan says:

    Hey Mara,

    I didn’t mean to imply that I agree that a debate is warranted, that I don’t believe many people report onset or increasing suicidal ideation when on SSRIs, or that SSRIs linkage to increased suicidality doesn’t constitute a need for a black box warning, just that there is some new evaluation of previous evidence being conducted.

    A review of the literature on Prozac, youth, and suicidality was recently published, stirring up the debate again. http://www.medscape.com/viewarticle/758917

    • mara says:

      It’s alright Nathan. You’re post doesn’t bother me. I just get bothered by doctors who go way beyond defending the drugs to no end. It’s the fact that they blame the patients that bothers me the most. It’s never the fault of the drug (or at least when I was growing up). It’s always the patient. It’s just so selective. If things go right on the drug, it’s not because the patient has done such a good job of getting his/her life back together. It’s because the drug worked. But if things go wrong on the drugs, it’s the fault of the patient (such as preexisting condition like bipolar). I hated that when I was a growing up. When I did well it was the drug. But if I was upset or not doing well, then I was always to blame (even when it was so obviously the drug screwing me up). Any time I got upset, it was linked to medication. My family would make comments like, “Did you take your medication?” I could never just have an argument or be legitimately upset about something without it being linked to a chemical imbalance. It was maddening.

      Later on, in my adult years, I met someone who got really teary eyed telling me that one of the worst things about the drugs she was on as a teen was that if she started doing well in school her parents always praised the drug (instead of her). Her good grades, her successes, were always linked to having found the “right” medication. And that hurt her more than a lot of the drugs her parents had her on.

      If drugs get credit for success, then they also need to get credit for failure.

      • Nathan says:

        “If drugs get credit for success, then they also need to get credit for failure.”

        Such an astute comment! It is something I have noticed as well but had never put into such succinct words. I don’t think this is only an issue about how drugs are talked about, though I definitely see how easy it is to attribute credit to drugs when things are well, question whether drugs are being used properly when things aren’t, and blaming patients for when drugs don’t work. Such a bind between powerlessness and self-blame.

        I think this extends to other psychiatric/mental health treatment that does not have a strong evidence base. Somehow it’s ok to think a certain intervention/drug is great and a provider can pat themselves on the back for helping a client when things go well, but can disavow their impact when things don’t. Particularly in many psychotherapies, providers attribute clients getting better to understudied treatments but not improving/getting worse to all sorts of external or client factors (rarely therapist/intervention ones). It seems ok for providers to take personal credit for successes, but at the same time disavow responsibility for failures.

        Not having good data on treatment outcomes leads to this fallacy that often binds patients into either self-blaming (or directly blamed by providers/others) for treatment failures or takes any agency they might have had in treatment success and place it in providers/drugs/treatments. You can’t have any real confidence in an intervention (drug or otherwise), without basing it on solid research.

        Evidence-based treatments also takes some blame out of the equation because you already have some information about how likely a treatment has worked for people in similar situations (and through some reasoning many providers don’t get, how likely it won’t work). We don’t have any meaningful information of moderating factors of treatment success/failures (other factors like demographics, developmental history, etc. that help predict whether many treatments will help or not). But having at least rigorous outcome data allows patients/providers to say to each other “hey, we’re going to try this approach, because X% of people in a similar situation respond well. We’ll monitor how it’s going along the way, be as open as we can about problems we see, but as long as it’s working the way we agree is helpful, we’ll go with it. If it doesn’t, there was a 100-X% chance of it not working so well despite all of our efforts, so we can talk about other options and try something else.”

  7. Altostrata says:

    Nathan, you may want to read 1boringoldman.com about this issue and associated studies. One of his posts is at http://1boringoldman.com/index.php/2012/03/14/super-tuesdaythe-age-of-molecular-diagnosis-and-the-dawn-of-the-age-of-companion-diagnostics/

    He’s written several articles about this; search on 1boringoldman.com for Gibbons.

    This latest campaign of denial regarding antidepressants and youth suicidality is another entry in the “have you no shame” category.

  8. Tom says:

    Psychiatry has no choice but to double down on Big Pharma. Residency programs stopped serious training in psychotherapy about 20-25 years ago. Aside from MD’s trained at analytic institutes, there really aren’t many psychiatrists under the age of 55 or 60 who know how to do therapy. And Big Pharma has proved to be a harsh mistress: They are pulling out of mental illness research to focus on greener pastures. So the field is in trouble.

  9. While psychiatrists are contemplating their navels in the wake of this 60 minutes broadcast, Americans are given the simplified message “antidepressants are bad.” How many of them are going to simply stop cold turkey and experience even worse side effects? I have bipolar disorder and was only able to benefit from therapy after I was on medication. Sure, they are blunt instruments, but they are the only ones we have right now. So please DO think of the patients and don’t dismiss these drugs out of hand.

    • Tom says:

      Ann: Get real. 60 Minutes didn’t say that “ANTIDEPRESSANTS ARE BAD.” The program simply cited research that documented antidepressants are not much more effective than placebo for mild to moderate depression. The program said specifically that efficacy for medication was demonstrated for severe depression and that people shouldn’t stop medication without first consulting their doctors. The FACT that most people taking antidepressants would benefit as much from taking a placebo is not saying that antidepressants don’t work. They just don’t work better than placebo, without the side effects.

    • Altostrata says:

      I agree with Tom. The risks of antidepressants have been deliberately hidden by the drug companies and are insufficiently addressed in the medical literature.

      Every time a particle of truth leaks out questioning whether antidepressants are God’s gift to humanity, people who believe they have benefited from them plead, essentially, “don’t take our drugs away” and accuse the whistleblower of endangering the public health.

      Please have some sense of proportion.

      If you love your drug, no one is going to take it away. Think of the patients? You, personally, may not be at all representative of the 30 million in the US on antidepressants, most of whom do not have a diagnosis justifying any kind of psychiatric medication.

      So think of the patients — all the millions of people who trusted their doctors who, in turn, trusted garbage information — who are suffering all the risk for no benefit at all from antidepressants. We’d all be better off if they were prescribed a tenth as often as they are prescribed now.

  10. […] line with this is Dr. Steve Balt’s recent post, Did The APA Miss A Defining Moment? « Thought Broadcast. I think Steve is right. The APA seems to be defending psychiatric medications rather than a […]

  11. […] line with this is Dr. Steve Balt’s recent post, Did The APA Miss A Defining Moment? « Thought Broadcast. I think Steve is right. The APA seems to be defending psychiatric medications rather than a […]

  12. truthman30 says:

    Nice to see a psychiatrist that can self reflect, and who cant give -and take criticism- of the profession itself. Bravo. 🙂

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