agger

So I'm reading Gary Greenberg's book “Manufacturing depression”. It's not an ironclad scientific demonstration of the ineffectiveness of much of the modern psychiatric medicine such as you may find in the work of (say) Joanna Moncrieff, but it is an entertaining and critical journalistic narrative of the pharmacological history of depression.

At one point he's comparing depression and SSRIs with diabetes and insulin, mocking the psychiatrists who, unlike real doctors prescribing insulin to diabetics

don't have to convince their diabetic patients that they have a “real illness”. A diabetes doctor doesn't have to worry about the clinical appropriateness of treatment. He doesn't have to wait for a new definition of diabetes to be hashed out in committees of his brethren and then learn the new diagnostic criteria. (...) All he has to do is to take a urine or blood sample. He doesn't have to talk about chemical imbalances that he knows aren't the problem or contend with package inserts that say, in plain black and white, that the drug makers have no idea why their drug works.

The prevailing narrative is still, if you ask doctors, that depression is caused by low levels of serotonin in the brain and that antidepressants work by increasing the levels of serotonin. It's hard to understand, though, how this narrative can still exist given that Irving Kirsch (lecturer in medicine at the Harvard Medical School and Beth Israel Deaconess Medical Center) thoroughly debunked the idea in 2009, 15 years ago.

What Kirsch demonstrated by a thorough analysis of a vast number of clinical trials of SSRIs was

• Antidepressants fare very badly in clinical trials. They are statistically better than placebos, but the difference is so small that it's not clinically significant. I.e., clinically they're not proven to be any better than placebos.
• They are speculated to work by lowering serotonin levels, but in fact there is no evidence at all that depression is related to serotonin levels – the evidence that is often cited is that the SSRIs seem to work on depression, but the clinical trials suggest they actually don't.
• It has been shown that if people have the levels of serotonin in the brain depleted, it doesn't affect their mood at all.
• One outlying anti-depressant in use in France is actually a Selective Serotonin Reuptake Enhancer, i.e. it lowers levels of serotonin in the brain, and it fares no better and no worse than the SSRIs.
• the small statistical difference between SSRIs and placebo can probably be explained by the placebo effect – patients in clinical trials realize that they're on the real drug because of the onset of (often unpleasant) side effects, thus increasing their expectation of a positive effect.

I won't claim to know how to cure depression, except that I'd guess that it's not a disease whose root causes lie at the neurochemical level and hence it probably isn't curable with medication (even though such medication may be helpful in shorter periods). I'd really love for someone to come up with a real answer.

But why do we allow ourselves and the industry to carry on, 35 years after introducing these drugs, 15 years after Kirsch thoroughly debunked them, to continue treating this very serious disease with medicine

• whose own manufacturers still can't say why it would work
• except by referring to a serotonin hypothesis which has never been proven,
• a hypothesis which has in fact been debunked?

I'm afraid we're in need of some reforms here. Maybe, just maybe, the abolishment of medical patents and of any and a nationalisation of medical research, so that new drugs and treatments will be developed according to patients' needs – and not according to the drug companies' chances of commercial success.

Follow me on Mastodon!.