Do Psychiatric Medications Work?

At the moment the answer is: there is little evidence that they do and some that they cause a great deal of harm. In this essay Marcia Angel reviews three books on psychiatric medications that all argue they are overused and possibly dangerous, and I recommend it to anyone who takes or prescribes them (Part II is here). The basic datum is that despite what we like to think of as "advances in care," the number of people diagnosed with mental illness has risen enormously since World War II, and they stay sick longer. Nobody knows why, although part of the story is certainly better diagnosis and a broader definition of who counts as crazy. Psychiatric drugs may or may not be helping people, but unlike truly effective medications they are not curing anyone.

The first volume is Irving Kirsch's well known book on antidepressants. Kirsch used the Freedom of Information Act to get his hands on all the studies done of the effectiveness of of SSRIs --Prozac, Zoloft, and so on -- not just the ones used to get approval from the FDA. After reviewing them all, he found that the drugs are barely better than placebos at improving the moods of patients. What's more, whatever help they provide seems to be the result of side effects; "active" placebos that cause side effects are just as effective as SSRIs. When I first read this I thought, it can't be true, because I know so many people who have been helped by SSRIs to cope with depression. But there really seems to be no gainsaying Kirsch's science. The brain is a weird thing, and since we really have no idea what causes depression, how can we be sure what helps make it better?

At least Kirsch thinks antidepressants do pretty much nothing; Robert Whitaker thinks they are hurting people. Whitaker thinks that we keep people on psychiatric medications for decades because the drugs are, in effect, addictive. Not only that, but they cause such severe side effects that we have to prescribe other drugs to treat those. The mechanism Whitaker postulates depends on the effects drugs have in the brain. For example, they raise or lower the levels of certain neurotransmitters. The brain responds to this by making more or less of the effected neurotransmitter, leaving the level of chemical in the brain pretty much where it started. Once that new equilibrium is achieved, stopping the drug upsets it, leading in some cases to severe mental problems:

With long-term use of psychoactive drugs, the result is, in the words of Steve Hyman, a former director of the NIMH and until recently provost of Harvard University, “substantial and long-lasting alterations in neural function.” As quoted by Whitaker, the brain, Hyman wrote, begins to function in a manner “qualitatively as well as quantitatively different from the normal state.” After several weeks on psychoactive drugs, the brain’s compensatory efforts begin to fail, and side effects emerge that reflect the mechanism of action of the drugs. For example, the SSRIs may cause episodes of mania, because of the excess of serotonin. Antipsychotics cause side effects that resemble Parkinson’s disease, because of the depletion of dopamine (which is also depleted in Parkinson’s disease). As side effects emerge, they are often treated by other drugs, and many patients end up on a cocktail of psychoactive drugs prescribed for a cocktail of diagnoses. The episodes of mania caused by antidepressants may lead to a new diagnosis of “bipolar disorder” and treatment with a “mood stabilizer,” such as Depokote (an anticonvulsant) plus one of the newer antipsychotic drugs. And so on.

Angel is careful to point out that not all of Whitaker's science is very good, and she has some cogent criticisms. But she seems to agree that there are troubling questions about the harm done by medications whose benefits are hard to pin down.

The third book is by psychiatrist Daniel Carlat, who seems bitterly disillusioned by his profession. He thinks that in an effort to become more like other doctors, and to hold off competition from social workers, psychiatrists embraced drug treatments without much evidence that they work. This left them vulnerable to manipulation by pharmaceutical companies, and the drug companies and the psychiatrists have worked together to keep pumping unproven drugs into vulnerable people:

Why do psychiatrists consistently lead the pack of specialties when it comes to taking money from drug companies? Our diagnoses are subjective and expandable, and we have few rational reasons for choosing one treatment over another.

The picture of psychiatry one gets from these books is not encouraging. The only clear beneficiaries are the pharmaceutical companies, which are making billions. As I said, I know many people who believe they have been helped by psychiatric medications. Some may have been, even if Kirsch is right; if the drugs harm some people, and overall their effect is a wash, they must be helping someone. But overall they seem to do nothing. No other category of psychiatric drugs has been studied as thoroughly as Kirsch studied SSRIs, but the evidence of effectiveness is not very good for any of them. Meanwhile the system trundles on; is it a vast air castle like the humoral medicine of the Renaissance, and are meds our version of bloodletting? Or are we slowly groping our way towards medicine that will really help millions of people lead better lives? Right now, it is hard to say.

'Give me the first thing that comes to hand'; lithograph by Grandville, 1832