"ADs only act by placebo effect." Or, weasel words to that effect.

[peng]

Currently on MIA (madinamerica) website, there is a topic running where, if I understand correctly, some workers believe the "placebo-only effect of antidepressants".  These workers, include, I believe, our esteemed author of "Anatomy of an Epidemic" (Robert Whitaker), at least to some degree.

 

Speaking as someone with decades of personal experience on and off ADs (anafranil then fluoxetine and now venlafaxine) and all their "charms", positive and negative,  I totally disagree with this.  I am sure many others on here will, too.

 

I once questioned a clinical psychologist I was sent to.   "How can you understand what people like myself are feeling, when you have never suffered from this illness?"  I meant it, and I still do.

Needless to say, the big man squirmed in his chair and muttered something about how I should perhaps appreciate how much he had studied the appropriate subject(s).  

 

Going back, now, to a time a few years previous to that encounter.  Many on here will be able to relate to my initial response to being struck down by illness in 1977.  I was an outdoor person in my prime aged 32, but was in my 13th year of very irregular shift-pattern work in a stimulating, support job in aviation.  Perhaps, significantly, as an only child, I had audibly witnessed the death of my father (spontaneous pneumothorax) in 1954 when I was 9 years old.

 

"God, this is a nervous breakdown, then.  It is hell on earth, I never could have imagined such suffering.  To think when I heard of people off sick "with nerves" this is what they were suffering from and I could not get my head round it at all, and had dismissed them as frail.  Now I know, myself.  No one can relate to this, no matter how academic, without having experienced it themselves" I concluded, many times.

 

What about Peter Breggin (I have read his Anatomy....book twice now) and others we read of like Kirsch?  Do we know if they have suffered from mental illness, even acute clinical anxiety (panic attacks), for starters?

 

Who are the expert medical or scientific people we know of who can vouch for the personal experience? 

 

In a scientific career myself for 50 years, I know, or know of, academics in my own field who are nationally or internationaly respected, yet they are still not gods (whatever that may mean to each of us).

 

Hoping to find out some interesting views or facts from you folks.

 

Love & best wishes,

 

 

Edited September 16, 2017 by ChessieCat
Changed Breggin to Whitaker

[thetruthfairy]

Discussion and controversy regarding the relationship between placebo effects and antidepressants is wide-spread. See this blog post in Scientific American https://blogs.scientificamerican.com/cross-check/are-antidepressants-just-placebos-with-side-effects/ . 

 

I'm also very concerned about how I can expect a person who hasn't has had any lived experience of mental illness and/or has never faced any kind of adversity can help people like me. In my experience, some people are natural helpers and don't need any much training, other people can be educated or trained and some people don't ever understand and can do damage. When someone knows more, maybe a lot more, than I ever will that doesn't necessarily mean they know what's "better" for me.

[KarenB]

Hello Thetruthfairy,

 

If you are wanting information or help in withdrawing from psychiatric drugs, would you like to post an introduction in the Intro forum?  Of course you are also very welcome to simply read around the site. 

 

Welcome to SA,

Karen

[InvisibleUnless]

i am what you may term as a 'non-believer' in the placebo-only theory.  in what i have read of moncrieff, my views are better represented by her concept of drug alteration.  we know for certain that these drugs cause dysfunctional alterations in how our body, especially our brain, is working.  such alterations can change everything about our experiences, and will always be changing at least a few things, whether subtly or overwhelmingly.  this is usually an undesirable or even disabling effect, but i dont think it is inherently without the potential for situational benefits.  i think drugs need to be viewed as tools rather than liquid satan.  that is, how responsibly and appropriately we used these tools more strongly determines outcomes than what the tools are.  particularly, to note, because individual goals differ, as do what people feel is a fair risk or sacrifice for achieving those goals.

 

psychiatric drugs are rarely a fitting tool for the job, and i think it is possible that they are never the best tool for the job, ala breggin.  but i think people should get to make their own decision, about psychiatric drugs, other psychotropics, and whatever other drugs.  the importance there is informed consent, not just access.  and a large portion of the problem in abusive prescribing these days is the entire dynamic involved.  we have enculturated dependence, we have an exploitative prescribing environment, we have the limitation of non-drug options, we have active misinforming and disinforming of patients as well as professionals, we have a dearth of necessary research to support evidence-based practice, we have a lack of professional accountability for preventable harms, and so forth.  these undermine personal agency, and all contribute to the misuse and unnecessarily severe average outcomes of psychiatric drugging.

 

when we address the idea of efficacy, we have to take into account several interdependent layers:

• what does efficacy mean?  can we measure it objectively?  is it the same for everyone?  is efficacy the same as usefulness?  what sort of data are we collecting?
• do the standard clinical characterizations of drug use, drug efficacy, and drugging outcomes reflect the actual experiences and preferences of patients?
• is research honest, transparent, methodologically valid?  are conclusions evidenced, logically sound, and shared freely rather than selectively omitted?
• are professional sentiments accountable to real-life challenges to theoretical belief systems?  how often do we revise our systems of interpretation instead of simply telling patients that they have no idea what they are really experiencing?

this is a problem for psychotropic drugs, especially as applied to so-called "mental illness", because neither the concept of "psychological disorder" nor "drug efficacy" are objectively quantifiable.  indeed, the entire endeavor is patently non-scientific, which means we are not talking about or acting through medical science no matter how we dress up the studies or results.  we might as well be running an international scientific inquiry into the best tasting quesadilla.  so when contesting the meaningfulness of "clinical efficacy", as contrasting or failing to better that of placebo, we have to first disassemble all the ways in which our measuring and characterizing has led us to where we stand at present.  there is no way to truly address the disparities if we dont talk about what assumptions they arise from.  and i think it is clear that no small amount of the controversy here is about definitions rather than what the data support.

 

for instance, it is well accepted in some circles (such as ours) that meta-analyses show a lack of clinical efficacy for all antidepressants sufficiently studied.  in premarketing trials, more failures to demonstrate superiority exist than any sort of successes, however potentially marginal.  but what does that really mean?  what are we measuring for, and how are we measuring it?  it would be fallacious to say that psychiatric labels are somehow unitary phenomena that can be ascertained or 'treated' in a uniform and coherent manner.  so talking about "clinical efficacy for major depressive disorder" is strictly a marketing assessment, not something scientifically falsifiable.  it is not necessarily entirely devoid of meaning, but we are certainly not talking about a homogenized patient experience and single kind of patient being given drugs.  the entire apparatus of clinical trials are built around economic exploitation, not intellectual enlightenment or net gains for patients or human beings.

 

this also means the entire process is not a system of honesty or of presenting people with the best possible collection of options so that ideal outcomes are more common or more accessible.  the lack of focusing on what matters most to the people taking these drugs creates an inherent barrier between clinical research and real-world concerns.  that, as you mention, most prescribers lack a personal experience and stake in their prescribing practices is the provider-side echo of this disconnect.  we are not talking about intentions or good will--sometimes there are scientists or doctors who are quite interested in the sorts of goals that we, as patients or struggling persons, hold for ourselves and each other.  no, we are talking about whether the right tools are being used for the jobs at hand, and how honest we are being about the way we go about the whole thing.

 

so where does this all lead us when considering effects of antidepressants considered by patients or by arbitrary rubrics to be "beneficial"?  in a very obvious place, i think.  we know that placebo (which is just a word for "stuff affecting outcomes besides the active ingredient(s) of the antidepressant") is a relevant factor in immediate experiences as well as longer term outcomes.  we know that some people experience effects they consider positive without requiring an active drug at all.  the question of how much of everyones drug experiences come down to non-active influences is not something we could generalize.  it would be nonsensical, particularly when talking about psychotropically active substances which will be dynamically changing the context of experiences.  that is, even if no active mechanisms seem of use, the variable things filed under "placebo" can be responsive to the undesirable or unhelpful effects of active mechanisms.  we cannot approach psychotropic use as a reducible phenomena where all persons do or must experience some specific constellation of influences or progression of events.

 

i think it is important here to also emphasize the subjectivity and individuality of drug responses.  and i dont just mean that physically, but moreso psychologically.  health compromising alterations, and effects some patients would characterize as negative or problematic, can potentially be viewed by some few others as useful or even desirable.  this doesnt make antidepressants effective or ineffective, it just means that we cannot generalize objective or averaged effects to subjective experiences or interpretations.  perhaps some or all of those gains could be achieved through "placebo" being applied in a particular way.  but i think it is undeniable that the psychotropic alteration caused by antidepressants has inescapable implications for the experiences of at least some patients.  calling it "efficacy" is a marketing push rather than a scientific evaluation, and "placebo" is not an inactive factor.  how people choose to parse those concerns, definitionally or conceptually, can affect what they say about antidepressants in this context.

 

as for professionals...they dont really exist to understand us.  that could be potentially helpful, but it is not ultimately their job.  they are consultants and supportive services.  they are there to help US get where WE aim to go, whether by augmenting our understanding, facilitating interventions, or offering other sorts of aid.  we are the ones who choose what we want, how to go about getting it, and whether something is 'good' or 'good enough' to bother with.  you dont have to know jack to help people make changes in their own lives.  the purpose of professional options is that certain areas of expertise may offer more useful insight or support as compared to people that dont know much about those areas.  it is not at all a guarantee, and usefulness of consultation is still more contingent upon the specific provider than on their field of practice.  it is quite a human concern, overall, even if there may be medical or otherwise clinical aspects to some situations.

 

so, i think professional systems of conceptualizing and various career practitioners offer something that supplements or repackages what people can also find in their friends, or mentors, or in fellow struggling individuals.  as i have repeated at least twice now, we should keep our focus on using the right tools for the right jobs.  it isnt about how much someone knows or understands, but rather whether we can engage with them in a way that we feel is productive or beneficial.  that interactive potential is not subject to hard limits, whether boundaries around professionals or levels of experience or even factual accuracy.  i think we should expect transparency and accountability, including informed consent, and that we need to reject the theory of "one true way" to explain or address psychological difficulties and related phenomena.  talking as if "efficacy" or "placebo" or "mental illness" were real, tangible, enduringly defined propositions is writing artificial limitations into how we approach human experiences.

 

if someone finds those tools helpful in certain circumstances, that is totally fine, but we cannot apply them dictatorially and should not deny people the understanding of where they come from.  when talking about the legitimacy of professional beliefs, i think the focus should be on self-coherence (whether their ideas make sense amongst their other ideas) and meaningful application (whether those ideas are useful to us, as individuals).  we cannot always evaluate opinions in terms of "right ideas" or "wrong ideas", though trends can exist in whether an idea entails more harm or good in net.  a self-aware professional will also be aware that all their theorizing, even if based from some level of experience, is not an actual prescriptive explanation of the world, much less the experiences of other human beings.  we are philosophizing existentially, not doing mathematics.  many people do create systems which lack a truly informed starting point, but we should judge those systems by their own standards as well as by whether we find them helpful.  if they are not open to both of those criteria, it is a warning sign, and we can (or should be able to) choose to interact with more appropriate persons or ideas.