Feeling depressed? If so, you may decide to consult with a psychiatrist or other medical doctor. By doing so, chances are your description of your feelings will be translated into a language of symptoms, diagnosis, and mental illness, and you will leave the doctor’s office with a prescription for pills marketed as “antidepressants.” Unfortunately, this medicalization approach is so inconsistent with scientific evidence that many people view it as a remarkably successful flimflam funded by the enormously wealthy pharmaceutical industry.

To throw light on this, today’s post briefly summarizes the scientific theory that runs counter to the mainstream psychiatric pathologizing “antidepressant” approach. Then, it addresses the question, Are doctors and the pharmaceutical industry supporting the pathologizing of depression really engaging in deliberate deception?

The Theory That Is Inconsistent With The “Antidepressant” Approach

A few weeks ago I presented a post about a study. Here’s how the authors summarized their findings:

Our work shows that the more people hold beliefs that others expect them not to experience negative emotions, the more frequently and intensely they are likely to experience those negative emotions. Such ironic effects also relate to indicators of well-being, such as satisfaction with life and depression. Moreover, our findings suggest that these relationships are at least partly mediated by negative self-evaluations that people have when they experience undesired emotions. Attempts to promote the value of feeling good over the value of feeling bad by emphasizing social norms for these emotions may therefore have the effect of making people feel bad more often.

While keeping this research in mind, let’s turn to some other ways to look at the nature of depression that runs counter to the pathologizing view.

People Who Get Over Depression Without “Antidepressants” Do Better Than Those Who Had Taken Them

Prior to the availability of modern pills to treat depression, numerous examples exist of people recovering without them. Psychologist William James, back in 1902, in his classic book, The Varieties of Religious Experience, provides us a ton of such examples. Most of them involve a religious conversion experience, but James also provides examples that appear to be a result of “…the eruption into the individual’s life of some new stimulus or passion, such as love, ambition, cupidity, revenge, or patriotic devotion.”

One particularly insightful example is the story of William James’s own recovery. There we learn that three events provided the essential ingredients–a change in his philosophical understanding of the nature of depression, marriage to a very helpful wife, and finding a career that suited him (for a more complete story of his transformation, see HERE).

Since those early days of psychology, a clearer understanding of the nature of depression has emerged from careful scientific study. A recent publication in the journal American Psychologist by Professor Steven Hollon neatly summarizes what I am referring to.

Depression is an inherently temporal phenomenon. Any given episode tends to remit spontaneously even in the absence of treatment but recurrence is common (at least among people seeking treatment). There is reason to believe that depression may be an evolved adaptation (like pain or anxiety) that increases reproductive fitness (the likelihood that one’s gene line will pass on). If so, then any treatment that facilitates the functions that depression evolved to serve is likely to be preferred to one that only anesthetizes the distress.  

After this opening statement, Prof. Hollon provides a more complete description of his theory:

Depression is an adaptation that evolved because it keeps organisms focused on (ruminating about) complex social issues until they can be resolved and that medications work not so much by addressing a nonexistent deficit in neurotransmitters in the synapse as by perturbing underlying regulatory mechanisms to the point that they reassert homeostatic control over those systems. If the latter is true then medications may work to suppress symptoms in a manner that leaves the underlying episode unaddressed and patients at elevated risk of relapse whenever they are taken away. 

Prof. Hollon then begins to review the evidence to support this theory. For example, he describes studies that demonstrate depressed individuals who are treated to remission with cognitive therapy are less than half as likely to relapse following treatment termination as a matched group of depressed folks treated to remission with antidepressant medications. He goes on from here to argue that some people have trouble working through their depression efficiently because they misinterpret life events in a negative fashion and that cognitive therapy helps them examine the accuracy of their beliefs, and by so doing it relieves their distress more quickly. Prof. Hollon goes on to say, “it is likely that cognitive therapy works by making rumination more efficient so as to facilitate the resolution of the complex social issue(s) that brought the episode about.”

Although Prof. Hollon focusses on the benefits of cognitive therapy, other research has found that counseling that focusses on resolving interpersonal problems, and humanistic approaches to therapy that empathetically values what each person is going through, are also often helpful. Such approaches avoid the numerous side effects of “antidepressants” and the awful withdrawal reactions that occur upon ending one’s reliance on drug treatment.

For the links to the actual studies documenting the long term harm of the “antidepressant” approach, see my post “Do Antidepressants Worsen Depression?” and my post “Do Antidepressants Increase the Risk of Adult Suicide?” To get a much better understanding of the nature of depression, see HERE.

Are Doctors Promoting “Antidepressants” Deliberately Engaging In A Flimflam?

Early in my career of providing psychological services, having reviewed the scientific evidence regarding the effectiveness and safety of “antidepressant “drugs, I assumed medical doctors were well aware of this research. The fact that they were prescribing them despite the evidence that they are far more harmful than beneficial in the long run led me to wonder if these doctors were deliberately ignoring the research for financial gains.

While reflecting on this, I was hired by a medical doctor to provide counseling to his son who was struggling with depression. It soon became quite clear to me that this doctor dearly loved his son, and yet, in addition to having me provide counseling, he had arranged for his son to take daily an “antidepressant.” In my mind, there is no way this father would go along with the drug approach for his son merely for money and, therefore, it seems to me he must have come to genuinely believe the drug plus counseling approach was the best way to address his concerns about his son. In an effort to understand this doctor’s reasoning, I decided to ask him a few questions.

It quickly became apparent that the doctor was familiar with a very few short term studies that appear to support the value of the drugs, but none of the studies that found the opposite results. In his defense, he noted that it was not billable time to go to the library to review the evidence. Moreover, in any given week he was prescribing dozens of other very different types of medications, and new drugs were regularly becoming available. To be up to date on the research for all of them would be just way too much to expect of medical doctors. Instead of reading the research, he relied on the Physicians’ Desk Reference which is a compilation of prescribing information provided by the drug companies. There, you can find, among some other very limited information, if the drug is approved by the Food and Drug Administration (FDA) to treat the patient’s complaint, such as depression. He went on to say, and I am paraphrasing here, for I don’t remember his exact words:

As long as the drug has been approved by the FDA for depression, then I’m willing to give it a try with my patients. In time, I carefully monitor whether or not the drug is being helpful. With the antidepressants most of my patients have done well on them, and several have told me it has saved their life. I also want to add that the leading experts in the field support the use of these antidepressants as first line treatments for depression and argue that it would be malpractice to not prescribe them to depressed patients. Even if I was to agree with your research analysis, I could not risk getting sued for malpractice.

Since my discussion with this medical doctor, I have had other opportunities to discuss this issue with medical doctors. These discussions have led me to conclude that most of them use a similar set of reasoning for why they prescribe “antidepressants.” My impression is that rather than a flimflam, they truly believe they are doing something helpful for their patients.

Is The Pharmaceutical Industry Engaging In A Flimflam?

As far as the pharmaceutical industry engaging in a flimflam, here I have little first hand knowledge to draw any firm conclusions. My knowledge chiefly comes from reading The Truth About the Drug Companies: How They Deceive Us And What To Do About It. It was written by Marcia Angell, M.D., the former editor in chief of the prestigious medical journal The New England Journal of Medicine and she is currently a member of Harvard Medical School’s Department of Social Medicine. I came away from reading her book thinking that the enormous profit motive in the industry does lead to substantial bias in how research is carried out and the information they provide to medical doctors.

The FDA’s approval process, Dr. Angell tells us, relies extensively on information provided by the pharmaceutical industry. This clearly raises concerns about bias.

I do think the FDA does serve a valuable function for evaluating treatments for diseases that have clearly objective criteria for identifying their existence. For example, when patients who have a cancerous tumor, it can be objectively seen by doctors with the use of an imaging device. How large each of the patient’s tumor is can be assessed objectively by measuring its circumference. In a clinical trial that has half of the patients randomly assigned to a group that gets a placebo, and the other half to a new drug, if, after three months, the placebo group’s subjects tend to have tumors that grew larger, while those getting the new drug have shrunk, this shows a clear benefit for the drug treatment.

As another example, let’s say the drug company develops a vaccine for Covid 19. When tested against a placebo, let’s say far more people who took the placebo end up dying than those who took the vaccine. This provides clear objective evidence that the drug is effective at preventing death because we have an objective way to tell if someone is alive or dead.

Unlike these types of objectively identifiable conditions, with depression doctors rely on a subjective indication of effectiveness, that is, a conversation. Moreover, the studies that the FDA looked at to approve the “antidepressants” were done with patients who took the actual drugs for a mere few weeks, even though doctors regularly advocate that their patients take the drug for far longer, often for the rest of their life. It is the long term studies that came out after the FDA approval process that has begun to indicate that these drugs are likely to be worse than non-drug approaches.

There are far more problems with the control studies that had been used by the FDA to approve the various “antidepressants” on the market, and the links I provided earlier in this post describe them. But for now, let’s move on to discussing the wisdom of doctors relying on what their patients say in order to evaluate whether or not their “antidepressant” prescriptions are working.

Relying On The Reports Of Patients Regarding the Effectiveness of “Antidepressants”–Is That Wise?

Recall that doctors often will defend their use of “antidepressant” by saying, “With the antidepressants, most of my patients have done well on them, and several have told me it has saved their life.” The problem with this, as noted earlier in this post, is that people with depression spontaneously recover at a high rate even without treatment. It is this fact that leads to the doctor’s misattribution.

Thus, consider an example. Upon prescribing an “antidepressant” for depressed patient Judy, Dr. Smith hear’s from her after a few weeks that she has recovered. Did she recover as a result of the drug treatment, or because of the natural rate of spontaneous recovery of depressed patients. Because she began to feel better shortly after she began to ingest the drug, she and her doctor are likely to mistakenly attribute her improved mood to the drug’s effectiveness.

Consider another example. Dr. Smith has prescribed an “antidepressant” for depressed patient Marc. Not feeling any better despite taking the drug for several weeks, Dr. Smith tells Mark, “It takes time for the drug to have an effect, so give it a little more time.” A few more weeks go by with no improvement, so Dr. Smith tells Marc, the dose of the drug needs a little adjustment because some folks need a little more than others. When a few more weeks go by with no improvement, Dr. Smith responds by prescribing a different “antidepressant.”

Notice that more and more time is going by, thus further increasing the likelihood that some of the doctor’s patients would recover without the drug approach. If the patient does recover during this process, rather than attributing it to the natural recovery process, the improvement is misattributed to the drug treatment. In this way, doctors fall under the illusion that by assessing their patients responses to their prescribed “antidepressants” they can come to know how effective they are.

Conclusion

I have presented the case that medical doctors typically genuinely believe their prescriptions for”antidepressants” are effective, and therefore are not deliberately seeking to mislead their patients in order to make more money. Their process of coming to their belief about the effectiveness of these types of drugs is indeed deeply flawed, but a quality evaluation appears to be a too arduous process for each doctor to perform. I have heard that in my area doctors in medical practice for a medical company find their company advocates each patient be seen for a mere few minutes. I do think medical doctors must understand that their drug information is coming from people selling the drugs. Although I respect doctors for their life saving efforts, I would respect them more if they would ban together and hire a team of epidemiologists to provide an independent evaluation of the risk and benefits of these treatments.

As for the pharmaceutical industry, in a recent New York Times, I happened to notice an article indicating drug distributors and the drug company Johnson and Johnson have reached a $26 billion deal to end opioid lawsuits that came about because of the hundreds of thousands of overdoses. The vast majority of those who died began their addiction as a result of prescriptions from doctors that relied on the Physicians’ Desk Reference, which, as I have said, bases the information it supplies to doctors on information provided by the pharmaceutical industry. From what I have read about the opioid crisis and the way research on “antidepressants” has been carried out, my best guess is that there has been some flimflamming going on within that industry.

When I discuss problems with the “antidepressant” approach for dealing with depression, some folks who are currently taking such drugs sometimes decide to stop taking their pills. Suddenly stopping them all at once can be risky because of a variety of distressing withdrawal reactions possibly including waves of suicidal feelings. For help in deciding on the safest way to go about the withdrawal process, I recommend tapping into Mad In America’s “Drug Withdrawal Resources” page (see HERE). The madinamerica.com website is an excellent nonprofit resource for finding out a host of information about psychiatric drugs that seeks to be free of the pharmaceutical industry’s financial influences.

My Best,

Jeff

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Some people will enjoy reading this blog by beginning with the first post and then moving forward to the next more recent one; then to the next one; and so on.  This permits readers to catch up on some ideas that were presented earlier and to move through all of the ideas in a systematic fashion to develop their emotional intelligence.  To begin at the very first post you can click HERE.