On May 7, Allen Frances, MD, posted an article on the HuffPost site. The piece was titled Antidepressants Work, But Only For Really Depressed People.
Superficially, the article presents itself as a call to limit the prescribing of the so-called antidepressant drugs to severe cases; but the piece can, I suggest, be more accurately characterized as Dr. Frances’s latest attempt to distance himself, and psychiatry in general, from the pill-peddling frenzy that has characterized the profession for the past thirty or forty years
Here are some quotes, interspersed with my comments and observations.
DSM-III’S “BIGGEST MISTAKE”
“The biggest mistake in DSM III was introducing the very broad and heterogeneous category ‘Major Depressive Disorder’. This combined under one rubric what had previously been two separate and quite different presentations: 1) severe, melancholic, delusional, or incapacitating depressions, and 2) reactive to stress, mild, and often transient depressions. The result is that many people get the label Major Depressive Disorder, even though their presentation isn’t really ‘Major’, isn’t really ‘Depressive’, isn’t really ‘Disorder’. Mild sadness in reaction to stress and disappointment is lumped together with the most severe suffering known to man.”
At issue here is the old psychiatric distinction between endogenous depression and exogenous depression. The later was conceptualized as a reaction to some external fact or circumstance, whereas the former was considered to have arisen from within the person – i.e. without any external loss or hurt. The distinction was always problematic, in that it’s impossible to know, with certainty, that a person’s depression is not a response to some external loss, hurt, or circumstance, but the distinction was considered important within the psychiatric community generally.
In any event, the terms “exogenous” and “endogenous” went out of vogue, though the underlying concepts remained in place in DSM-III. And, contrary to Dr. Frances’s assertion in the above quote, they remained in place as separate entities. These were: “major depressive disorder”, and “adjustment disorder with depressed mood”.
In DSM-III, adjustment disorder is defined as “A reaction to an identifiable psychosocial stressor…”. DSM-III made no provision for specifying severity of adjustment disorder (e.g. mild, moderate, severe), but in the text it states clearly that people may have “a more severe form of the disorder” or “only a mild form of the disorder”. Major depressive disorder in DSM-III could be formally and explicitly coded as mild, moderate, and severe.
Now it’s no part of my agenda to defend any edition of the DSM, a document which in my view has all the scientific rigor and practical usefulness of a witch-hunter’s manual. Rather, my purpose here is to point out that Dr. Frances’s assertion in the above quote is simply false.
Essentially what Dr. Frances is saying, or at least forcefully implying, is that since this great “error” in DSM-III, psychiatrists, misfortunate lambs that they are, have simply had no way to reflect in their “diagnostic assessments” that the individual’s depression “isn’t really ‘Major’, isn’t really ‘Depression’, isn’t really ‘Disorder’.”
And because of this truly arduous imposition, psychiatrists are constrained to lump “mild sadness in reaction to stress and disappointment” with “the most severe suffering known to man”.
It may well be that psychiatrists have been avoiding the use of “reaction to stress”, “mild” and “transient” qualifiers in their “diagnostic assessments”. But this is emphatically not because such qualifiers were rendered impossible by DSM-III. A much more likely explanation is that the use of these qualifiers militates against the notion, avidly promulgated by psychiatry for the past forty years, that depression, of whatever severity, is a chronic illness, (just like diabetes); a chemical imbalance in the brain, for which the “patient” must take so-called antidepressant drugs for an extended period, and possibly the rest of his/her life. For all of this time, it has been an integral part of psychiatry’s informal, but avidly asserted, message that although depression might have been triggered by an external event, it is essentially an illness residing within the person’s neurochemistry.
But, even if we put all that aside; even if we acknowledge that Robert Spitzer and his DSM-III co-authors made a dreadful error, a critical question remains: why did Dr. Frances himself and his DSM-IV co-authors, so uncritically follow suit? And why has Dr. Frances not acknowledged his own perpetuation of this so-called error in the present paper? It’s easy, and perhaps a little craven, to point fingers at the recently deceased Dr. Spitzer, when in fact, Dr. Frances himself followed precisely the same path.
And in fact, Dr. Spitzer was open enough to admit that he and his DSM-III co-workers had made a much more fundamental error. Here’s a quote from an interview he gave to British film maker Adam Curtis. The interview was screened by the BBC in 2007, and the 50 second excerpt can be viewed here, starting at minute 34:10.
Robert Spitzer, MD:
“What happened is that we made estimates of prevalence of mental disorders totally descriptively without considering that many of these conditions might be normal reactions which are not really disorders. That’s the problem. Because we were not looking at the context in which those conditions developed.”
“So you have effectively medicalized much of ordinary human sadness, fear, ordinary experiences, you’ve medicalized them.”
“Uh, I think we have, to some extent. How serious a problem it is is not known. I don’t know if it’s twenty percent, thirty percent, I don’t know. But that’s a considerable amount if it is twenty or thirty percent.”
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Back to the Huffington Post piece.
“Drug companies jumped on the opportunity to peddle a pill for every problem and misleadingly described all depressions as a chemical imbalance requiring a chemical solution. Treatment studies that previously showed clear superiority of medicine over placebo for severe depression showed little or no superiority with patients whose depression was mild or questionable. And biological marker studies that showed promise in tagging severe depression came up empty with the watered down Major Depressive Disorder.”
There it is again. Those mean old opportunistic drug companies! How could one ever trust them?
But again, a major distortion of reality. Drug companies can’t sell these products without FDA approval, and a physician’s prescription. It was psychiatrists who created and promulgated the questionable research that elicited FDA approval and legitimized the wholesale use of these products. Admittedly, these psychiatrists were handsomely paid by pharma, but they were not constrained. Dr. Frances is surely familiar with this process. In 1995, he and his two colleagues Drs. John Docherty and David Kahn, reportedly accepted $515,000 from Johnson & Johnson to write “Schizophrenia Practice Guidelines”, which blatantly promoted Risperdal (risperidone), a drug manufactured by Johnson & Johnson. For a full and compelling account of this sordid tale, see Paula Caplan’s very thorough exposé here.
The notion that psychiatric research would clearly support the use of the drugs and would identify biological markers for depression, if only the “mild or questionable” depressions were excluded, is fanciful. Depression has been extensively researched for decades, by psychiatrists, highly motivated by pharma largesse to find significant positive results. These studies routinely report that “diagnoses” were confirmed by scrupulously careful evaluations using psychiatric interviews and validated screening tools. So why would there by “questionable” cases in the studied samples? In fact, in his Introduction to DSM-IV (1984), Dr. Frances explicitly acknowledged DSM-III’s contribution in this area.
“The third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-III) represented a major advance in the diagnosis of mental disorders and greatly facilitated empirical research. The development of DSM-IV has benefited from the substantial increase in the research on diagnosis that was generated in part by DSM-III and DSM-III-R.” (p. xviii) [Boldface added]
An identical passage was included on page xxvi in DSM-IV-TR six years later (2000)
And furthermore, individuals whose depression is mild can be eliminated readily and legitimately from a study by limiting the scope to moderate and severe cases.
PSYCHIATRY DID PROMOTE THE CHEMICAL IMBALANCE THEORY
And what are we to make of Dr. Frances’s assertion that the drug companies “…misleadingly described all depressions as a chemical imbalance requiring a chemical solution”? In fact, it was psychiatry who promoted the chemical imbalance hoax. Pharma certainly tagged along, with their blatantly false commercials, but psychiatry could have stopped this fraudulent inanity in its tracks at any time, by issuing a clear and definitive press release disavowing the hoax, and by filing a formal complaint of false advertising with the Federal Trade Commission.
But psychiatry took no such action. Psychiatry blatantly, and without compunction, foisted this falsehood on their “patients”, on the public, and on other practitioners – knowing it to be false – for the purpose of promoting their own guild interests, and selling more drugs. It is simply beyond comprehension that Dr. Frances continues to try to slough off the responsibility for this hoax, this gross violation of the public trust, onto his erstwhile pharma benefactors.
If Dr. Frances has any residual doubts as to psychiatry’s role in the dissemination of this falsehood, he might usefully take a look at Terry Lynch’s book Depression Delusion or my post Psychiatry DID Promote the Chemical Imbalance Theory
Or … he might want to revisit something he himself wrote in 1998. Here’s a quote from Am I Okay? by Allen Frances, MD, and Michael B First, MD:
“Depression is really no different than hypertension. Medicines that treat high blood pressure are taken to reestablish the body’s ability to maintain a normal blood pressure. Antidepressants work in the same way—restoring brain neurochemistry to its original natural state. In contrast to drugs like heroin and cocaine, which make virtually everyone feel euphoric, an antidepressant does nothing for a person without depression except produce unpleasant side effects. There is no street market for antidepressants and they are not addictive. Finally, in the same way that it would be ludicrous to think that someone can simply will their elevated blood pressure down to normal, true grit is not by itself sufficient to cure clinical depression.” (p 49-50) [Emphasis added]
Incidentally, Dr. Frances’s promotion of the now defunct chemical imbalance theory of depression in the above quote is particularly interesting in the light of the statement made by the very eminent psychiatrist Ronald Pies, MD in his April 2014 article Nuances, Narratives, and the Chemical Imbalance Debate:
“To the extent the ‘chemical imbalance’ notion took hold in our popular culture, it was due mainly to distorted or oversimplified versions of the catecholamine hypothesis. These were often depicted in drug company ads; pop psychology magazines; and, in recent years, on misinformed Websites and blogs. In short, the ‘chemical imbalance theory’ was never a real theory, nor was it widely propounded by responsible practitioners in the field of psychiatry.”
Dr. Pies, meet Dr. Frances.
With regards to Dr. Frances’s assertion that there is no street market for antidepressants, here is a letter in the February 2007 issue of the American Journal of Psychiatry. The letter is from Greg Tarasoff, MD, a psychiatrist, and Kathryn Osti, and is titled Black-Market Value of Antipsychotics, Antidepressants, and Hypnotics in Las Vegas, Nevada. The letter reports that, at that time, antidepressants were selling on the street for $3-$5 per dose.
Also, here’s a 2013 article from globalnews.ca, Toronto, which describes an active street market in Wellbutrin. The article was written by Jennifer Tryon and Nick Logan, and it reports that Wellbutrin is referred to as “the poor man’s cocaine”.
I realize, of course, that Am I Okay was written before these articles, but here are two studies that predate the book:
Abuse of Amitriptyline by Cohen, Hanbury, and Stimmel: JAMA, Sept 1978:
“A survey of 346 persons enrolled in a methadone maintenance program showed that 86 (25%) had admitted taking amitriptyline with the purpose of achieving euphoria.”
And Identification of misused drugs in the clinical laboratory. I. Tricyclics, by Vasiliades, J; Clinical Biochemistry, February 1980:
“A systematic approach evaluating the abuse of tricyclic drugs in the hospital emergency room from the laboratory point of view is presented…Increasing misuse of tricyclic antidepressants requires that the clinical laboratory have a systematic approach to identify and confirm the presence of these drugs in emergency room patients.” [Emphasis added]
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FRANCES PROMOTED THE DRUGS
Back to Am I Okay? Here’s a quote in which Drs. Frances and First promoted the drugs as “very effective” in the treatment of “major depressive disorder”:
“For those suffering from Major Depressive Disorder, antidepressant medications are very effective—the overall odds that an antidepressant treatment will work eventually are probably at least 90 percent. But you have to be patient and forbearing along the way. It usually takes at least several weeks for the medication to begin working, and a couple of months before it has reached its maximum effect. It might also take time and effort to find the most effective medication for you and to determine its proper dose. Some people must endure several trials of different antidepressants until they find the one that is a winner for them. To give you some perspective, two thirds of depressed patients will have a good response to the first medicine that is tried. For those who do not respond initially, the odds of a second antidepressant working are about fifty-fifty—this gets us to about 80 percent total response rate. If you have still not yet responded after two tries, a third or fourth or even a fifth try may be necessary to find the medicine or combination of medicines that will eventually work. The good news is that there are close to thirty available antidepressants on the market and new ones are being developed all the time. Hopefully sooner, but almost certainly eventually, one of these or some combination will work for you.
The use of antidepressant medication has risen dramatically over the past several years, but many people who might benefit have misconceptions that make them reluctant to give one a try. One common concern is that the changes resulting from antidepressant use are artificial and, by implication, somehow illegitimate. Others worry that they will become physically dependent on antidepressants in the same way that a heroin addict cannot function without his daily fix. Yet others feel that having to rely on antidepressant medications to maintain one’s mood (and productivity) represents a weakness in moral fiber—that you should be able to get rid of the depression by sheer will power alone.” (p 49)
There are several noteworthy points in this quote.
Firstly, Dr. Frances does not limit his assertions to cases of “severe, melancholic, delusional, or incapacitating depressions“, even though such options were available within the psychiatric “diagnostic” system. The phrase “…those suffering from Major Depressive Disorder” clearly embraces mild, moderate, and severe unless otherwise delineated. In fairness to Dr. Frances, he does acknowledge elsewhere in the text that the drugs are not always necessary, but his assertions in this regard are generally less compelling, e.g., “antidepressant medications are probably overused.” (p 50) [Emphasis added]
Secondly, the tone of the quote with regards to taking the drugs is upbeat and optimistic. The drugs “…are very effective”; “the odds of successful treatment…are probably at least 90 percent”; “…there are close to thirty available antidepressants on the market…”; “…one of these or some combination will work for you.”
Thirdly, the authors acknowledge that antidepressant use has risen “dramatically”, but then go on to encourage further use.
Fourthly, there are clear efforts on the part of the authors to undermine people’s resistance to drug-taking. The authors dismiss concerns that the effects of the drugs are “artificial” and that the drugs might be addictive. Bearing in mind that the book was written for general audiences (A Layman’s Guide to the Psychiatrist’s Bible), the assertion that antidepressants restore “…neurochemistry to its original natural state”, with its almost Edenic connotations, is nothing short of outrageous.
And incidentally, here’s another quote from the same chapter:
“ECT is a terrifically effective treatment that is also relatively safe considering the great benefits that can often be gained. ECT is especially useful for psychotic mood disorders, people who need a really fast response, medication nonresponders, and for those who cannot tolerate antidepressant medication. Electroconvulsive therapy has a higher response rate (80 to 90 percent versus the 65 to 70 percent achieved by medication combinations) and also works more rapidly. However, it has the disadvantage of providing fewer clues as to what type of medication is likely to work to prevent recurrences in the maintenance phase. Due to misguided fears, ECT has been most typically considered a treatment of last resort when nothing else works. It probably deserves to be used earlier and more often.” (p 51-52)
Note that the success rate of antidepressants which on page 49 was given as “at least 90 percent”, is now, two pages later, given as “65 to 70 percent”.
Note also that Dr. Frances is advocating an expansion of the use of high voltage electric shocks to the brain as a “treatment” for depression, and makes no mention of the permanent memory damage that this “treatment” entails.
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Back to the HuffPost article:
“Critics of medication jumped on this to argue misleadingly that depression is a myth and/or that medication treatment for depression doesn’t work.”
I don’t know of anyone on this side of the debate who argues that “depression is a myth”. I myself argue – as do a great many others – that depression is not an illness. But depression is real, and I don’t believe that I’ve ever heard anyone suggest otherwise. My own position is that depression is the natural human reaction to loss or to ongoing hardship/drudgery, and that severe depression is the normal reaction to a major loss or to ongoing hardship/drudgery that is particularly arduous. It is not something that needs to be “treated”; rather, it can be alleviated, either by supporting individuals through their loss, or actively helping them identify and extricate themselves from the depressing circumstances. What the pills do, in some cases, is provide an altered mental state, which some people find preferable to the depression. But the pills produce no lasting benefits, and usually do a great deal more harm than good. The issue here is not whether people should or shouldn’t take these pills. That’s each person’s individual choice. The issue is psychiatry pushing these dangerous serotonin-disruptive chemicals on people, under the pretense that they have an illness, for which the pills are an effective and safe treatment.
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At this point in the article, Dr. Frances introduces Mark Kramer, MD, PhD. Dr. Kramer restates and elaborates on some of the points made by Dr. Frances, who in turn closes the article with some concluding remarks, including:
“The next point seems too obvious to be stated, but nonetheless desperately needs stating. Only people who are clearly clinically depressed and clearly need antidepressants should be included in research studies and should be taking antidepressants in everyday clinical practice. Depression has been too carelessly diagnosed- encouraged by the loose DSM definition, by Pharma’s desire to push product; by rushed doctors; and by people’s hope for a quick fix for life’s problems.”
It should be noted that the term “clinically depressed”, despite its widespread usage, has no formal meaning in psychiatry. In practice, it is used to mean having a “diagnosis” of major depressive disorder or dysthymia, but because of the medical connotations of the word “clinical”, it is also used to convey and promote the notion that depression is an illness. So Dr. Frances is telling us that only people who clearly meet the criteria for major depressive disorder or dysthymia, and who clearly need antidepressants, should be taking antidepressants. But this is nothing more than an empty platitude. What’s the alternative? Take antidepressants even though you don’t really need them? Who is suggesting that? And anyway, wasn’t the whole point of the DSM to provide rigorous definitions of the various “mental disorders”? Hasn’t this been the standard psychiatry patter since DSM-III? In fact, here’s the opening paragraph from the Introduction to Dr. Frances’s own DSM-IV:
“This is the fourth edition of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders, or DSM-IV. The utility and credibility of DSM-IV require that it focus on its clinical, research, and educational purposes and be supported by an extensive empirical foundation. Our highest priority has been to provide a helpful guide to clinical practice. We hoped to make DSM-IV practical and useful for clinicians by striving for brevity of criteria sets, clarity of language, and explicit statements of the constructs embodied in the diagnostic criteria. An additional goal was to facilitate research and improve communication among clinicians and researchers. We were also mindful of the use of DSM-IV for improving the collection of clinical information and as an education tool for teaching psychopathology.” (p xv)
and later, concerning DSM-III:
“DSM-III introduced a number of important methodological innovations, including explicit diagnostic criteria, a multiaxial system, and a descriptive approach that attempted to be neutral with respect to theories of etiology.” (p xvii-xviii)
So if the problem is “loose DSM definitions”, Dr. Frances needs to direct at least some of the responsibility for the present state of affairs in his own direction; firstly for drafting a document that slavishly followed the errors he now ascribes to DSM-III, and secondly for falsely hyping DSM-IV in that edition’s Introduction.
In should also be noted, that the “diagnostic” definitions in all editions of the DSM are notoriously vague and “loose”. But in addition, Dr. Frances’s own DSM-IV added an entire layer of looseness:
“The specific diagnostic criteria included in DSM-IV are meant to serve as guidelines to be informed by clinical judgment and are not meant to be used in a cookbook fashion. For example, the exercise of clinical judgment may justify giving a certain diagnosis to an individual even though the clinical presentation falls just short of meeting the full criteria for the diagnosis as long as the symptoms that are present are persistent and severe.” (p xxiii) [Emphasis added]
How short is “just short”? What duration would be considered persistent? In the case of “major depressive disorder”, we know that “persistent” means two weeks!
Dr. Frances tells us that depression (by which he clearly means the mythical illness) has been too carelessly diagnosed by
– pharma’s desire to push product;
– rushed doctors (note, not specifically psychiatrists); and
– people’s hope for a quick fix for life’s problems
In short: everyone is to blame for the drug-pushing except psychiatry; that dauntless and noble pillar of compassionate rectitude, standing valiantly alone against the surging tide of venality, corruption, disease-mongering, slovenliness, and disempowerment that characterizes all the other players in this epic tragedy.
The notion that the loose definitions, the inexorable expansion of the “diagnostic” net, and the broadening of “indications” for the drugs were errors, is simply not credible. If these were errors, then psychiatrists must surely be a most inept group of people. Rather, these developments were, and still are, an integral part of psychiatry’s plan to expand its scope and to strengthen its hegemony. And this plan, in the implementation of which Dr. Frances played a leading part, is still in place. Psychiatry, with the help of their pharma allies, is actively promoting early screening for various “diagnoses”. Active steps are being taken to have mental health services embedded in every school and in every GP’s office. Children as young as three years old are being given major tranquilizers to “treat” temper tantrums, and vulnerable individuals in nursing homes, foster care, and group homes are being drugged at unprecedented levels.
If Dr. Frances genuinely wants to distance himself from this institutional degeneracy, he must first acknowledge the role that he himself played in its creation.
THE FUNDAMENTAL PROBLEM
Important as all these issues are, there is a fundamental, over-riding issue that is much more critical.
The assertion that the so-called antidepressants are being over-prescribed implies that there is a correct and appropriate level of prescribing towards which reformative efforts should be directed.
And this premise is false, for three reasons. Firstly, because depression, regardless of its severity or persistence, is not an illness which needs to be treated with medication. Secondly, because the drugs, despite the psychiatric-pharma hype, are not particularly effective in ameliorating depression. And, thirdly, because these serotonin-disruptive drugs have a wide range of adverse effects, the seriousness of which has been routinely downplayed by pharma and by psychiatry.
The widespread and increasing use of the so-called antidepressant drugs is certainly a matter for concern, as is the assignment of depression “diagnoses” to more and more people. But these problems stem directly and inevitably from the fact that psychiatry invented these spurious illnesses and generated the bogus research to legitimize the use of the pills as safe and effective “treatments”. Given the inherent vagueness of the criteria and the absence of an identified and confirmable biological pathology, it was inevitable and predictable that “diagnosing” and pill-pushing would increase. To put the matter briefly, there is no way to determine who has the illness called depression and who doesn’t, because no such illness exists. Psychiatry invented this entity, concocted an inane checklist of “symptoms” to create the appearance of medical legitimacy, peddled the pills with abandon, and reaped the profits.
Allen Frances’s bemoaning the “over-prescribing” at this late stage in the game is not only hypocritical. It also serves to distract his readers from the real issue: that psychiatry is, at its very core, an enormous and destructive hoax, and cannot be saved from its own self-serving excesses by these kinds of platitudinous calls to clean house.