Sunday, June 27, 2010

Are Antidepressants Better Than Nothing?

Thanks to Doug, Rambling Taoist, and yomamma for posting to the comment's section of May's blog entry, which touched on the topic of depression. I've since read a couple of articles on the question of whether antidepressants are any more effective than placebos (a placebo being any medicine which has no active ingredients, but which the patient believes will help). This issue has been in the news since a 2009 study showed that drugs like Prozac and Paxil, when used to treat mild-to-moderate depression, are hardly more effective than dummy pills.

Study author Robert DeRubeis says, "The message for patients with mild to moderate depression is, 'Look, medications are always an option, but there's little evidence that they add to other efforts to shake the depression...'" Studies have been suggesting this conclusion since at least 2002, when Shankar Vedantam wrote in the Washington Post, "After thousands of studies, hundreds of millions of prescriptions and tens of billions of dollars in sales, two things are certain about pills that treat depression: Antidepressants like Prozac, Paxil and Zoloft work. And so do sugar pills."

The Newsweek article that clued me in to this debate (The Depressing News About Antidepressants) speaks of it as a moral dilemma. It hardly seems right for a doctors to put millions of patients through the expense and side-effects of drugs that have no medical potency. Yet if the patients knew the truth, it might destroy the very real benefits they get from their belief in the drugs.

In the same article was a pro-antidepressant (heh) sidebar, in which a doctor claimed that based on observing the effects of the medications on his patients and himself, he's convinced that "antidepressants work." It's striking in how completely the doctor misses the point. There's no question that Prozac et al work. But there's a very real question of whether they work better than anything else you believe in. For non-severe depression, there's little evidence that the pills are more helpful than talking to a therapist. And little evidence that talking to a therapist is more helpful than chatting with a trusted friend.

The Avatamsaka Sutra (Buddhist scripture) says, "If you want to understand all the Buddhas of the past, present, and future, then you should view the whole universe as being created by mind alone." It seems that we have a tendency to underestimate the power of thinking (beliefs, assumptions, desires, expectations) to alter our experience of the world. "Thinking appears, all things appear; thinking disappears, everything disappears."

I've had many conversations re the mystical energy of holy temples, objects, or gurus. When spiritual people rhapsodize about such energies, I myself (being a trouble-maker) will often tell them, "You know, what you've experienced is entirely dependent on your beliefs and expectations etc." People sometimes get furious at such an assertion, even offended at the suggestion that their powerful experiences are "just in the mind."

I'd imagine that antidepressant users might similarly object to that suggestion that the power of pills is mostly in the mind. But it's often impossible -- without rigorous scientific method -- to know the actual cause of physical or mental changes. We can be entirely wrong when we speculate about ailments. And just because you happen to be the one who's experiencing the stomach-ache or panic-attack, doesn't give you any special insight into what causes or cures it.

It's a distinction between experience and belief. When we have depression (or a spiritual epiphany, or other mind-states), we can can speak with authority on the what of the experience. But as soon as we speak of the why (where the experience comes from, what causes it to come and go, what it means), we're in the realm of speculation and belief.

Funny how people resist so strongly the idea that their peak experiences or mood elevations are "just in the mind." The evidence is clear: it's hard to beat the power of mind. Even the multi-billion dollar pharmaceutical industry apparently has a tough time finding anything more powerful.


The Bad Yogi said...

Going through a tough time right now (death of my daughter), I have been offered the option of anti-depressants, as well as suggestions to have a drink or 2, or smoke some pot, all in the name of feeling better. And all of these, it is true, make me feel less bad. Or really, make me feel less, period.
And after they wear off, I feel worse, both physically and emotionally.
So a placebo would at least not make me feel worse later, right?
Or I can just feel. Boy, does that suck. Feel crappy, or feel crappier. Not much to chose from there, is there?

Stuart said...

Sorry for your suffering, Bad Yogi. Part of my interest in anti-depressants comes from the fact that when my mother was in heavy-duty mourning over my father's sudden death, her doctor prescribed Paxil. Previously, I thought that such medications were prescribed for long-standing depression rooted in body chemistry. But apparently, they're also frequently prescribed to people suffering due to specific difficult external situations.

Zen style is to maintain awareness of each moment, regardless of how crappy it feels. Like a mirror that never refuses to reflect anyone, no matter how ugly. The practice is to maintain clarity and attention just a little longer, a little further into the crappy experience, than we think we can.

But we all have our limits, and periodically most of us feel the need to drown it all out with drugs or other distractions. Then, whenever we've had enough distraction, each day, every moment, provides an opportunity to pay attention, to meet the moment with clarity.

The Bad Yogi said...

Yes, exactly what I was trying to head for. Feeling crappy is still being present to the moment.

My distraction comes mostly at night, else I don't sleep. Sooner or later I will have to confront that.

I have never meditated on that scale (bug bites, yes, major emotional trauma, not so much). We'll see how things roll out over the next while.

THanks for your thoughtfulness.


Doug said...

I'm of two minds on the matter; your subsequent comment about your mother's prescription actually points pretty clearly to those two minds. On the one hand these drugs were designed to correct specific chemical imbalances, and I think it's fair to say that for people who suffer from said imbalances, the drugs are probably effective. But it's a common and well studied phenomenon that doctors will prescribe medication for conditions other than the manufacturer's intent; and it seems that psychologists and therapists may be particularly guilty in this.

When someone takes a medication for a chemical imbalance that doesn't exist in their body, chances are that the drug won't help anything, and may end up creating new imbalances of it's own (i.e. side effects.) But the drug taker believes that the pill will cure them, which changes how they feel, think, and behave in anticipation of being cured; which in turn effects their own natural chemical generation and pulls them out of a funk. Seems to me like that might legitimately be called a side-effect of the drug, even if it would also have been a side effect of a sugar pill.

Bad Yogi, I find that alcohol just tends to exacerbate whatever mood I'm already in. If I have a couple drinks when I'm down, I just tend to get more down; or more happy when already happy. And either way I definitely feel worse afterward, even if only slightly. This may explain why I don't drink much. :)