March 5, 2008

DIAGNOSIS IS NOT DISEASE:

An Ill For Every Pill (Theodore Dalrymple, March 2008, New English Review)

In 1993, for example, a psychiatrist called Peter Kramer published a best-selling book entitled Listening to Prozac. In this book, he suggested that our scientific understanding of brain chemistry has advanced so far - as witnessed by the development of the serotonin reuptake inhibitor, fluoxetine, Prozac - that we would soon be able to make up our personalities and characters (there is an often-neglected difference between the two) much as make-up artists make up the faces of actors in films and on the stage. Dr Kramer quoted cases in the book of people who had taken Prozac and had become better than well. Formerly shy and retiring types became outgoing and boisterous (personally I prefer shy and retiring types, but that is a different question). Yes, soon we could be all we wanted to be, and merely by swallowing a pill!

This was always nonsense, of course, though exactly the kind of nonsense that people wanted to hear because it is only too human to want all our problems and anxieties to disappear with what in effect is a wave of a wand. After all, in the not very distant past people held on to the idea that if only the buried psychological treasure that lay within them could be found, that is to say the repressed trauma that had caused their undesired characteristics and behaviour to develop, with the help of course of a technically-proficient therapist, then the latter would disappear spontaneously, without further effort or ado on their part, and the beautiful real person that laid buried inside them would emerge as a butterfly from a pupa and fly off into the sunshine of eternal happiness.

All this was just as superstitious as magical incantations ever were. The idea that Prozac (and drugs still to come) would solve all of life’s little problems was no more realistic than the following, which I found in John Aubrey’s Miscellanies upon the Following Subjects: Omens, Dreams, Apparitions, Voices, Impulses, Knockings, Blows Invisible, Prophesies etc., published first in 1696 (my edition is the second, of 1721): To cure the Biting of a Mad Dog, Write these Words in Paper, Viz.: Rebus Rubus Epitescum, and give it to the Party, or Beast bit, to eat in Bread. A Gentleman of good Quality, and a sober grave Person, did affirm, that this Receipt never fails.

From the very first, Prozac was presented by its praise-singers as a fundamental advance, when it was perfectly obvious that it was nothing of the sort. It was no more effective than antidepressants which had been known since the early 1960s, though its side-effects were different and, for many people (though not all), more tolerable. The neurochemical theory that accounted for its very limited superiority over placebo in serious cases of depression was crude and reductive, to say the least.

Unfortunately, Prozac came on to the market just at the time when another product of a rather crude and reductive theory, or attitude, the Diagnostic and Statistic Manual of the American Psychiatric Association, became the object of almost universal superstitious awe and veneration. Here I rely on a brilliant book published last year by two professors of sociology, Allan V Horwitz and Jerome C Wakefield, entitled The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder. They point out what should have been obvious to any person with the most minimal knowledge of human nature, that the definition of depression in that manual is complete disassociated human mood from the actual lived circumstances in which it was experienced. It was sufficient to be diagnosed from depression to have a certain number of symptoms for a certain length of time: two whole weeks!

This not only was a retrogression in our understanding of human life by comparison with that held in the past by almost everyone, including psychiatrists, but had the effect of turning practically the whole of the human race into psychiatric casualties. The World Health Organization has recently stated that depression is the condition which imposes the second greatest burden of illness and disability on mankind, to believe which requires more suspension of critical faculties than to believe that Peter Pan is a real person, or that Father Christmas is currently in Lapland preparing for his next forays down our chimneys.

Now if people are depressed, it follows that what they need is Prozac, or a drug very similar to it. And of course, since one might define mankind as the only creature that is susceptible to the placebo effect, in many cases the drug will have worked (it is inevitable that someone will write to say, ‘Well, it worked for me, and that’s enough,’ just as it probably was enough for the Gentleman of good Quality, a sober grave Person). On the other hand, although the positive effects of these drugs are largely imaginary, many of their side-effects are only too real. Indeed, it is the reality of these side effects that persuades people that the therapeutic effects must be real too: for it is a deeply-ingrained belief in most humans that effective medicine must be nasty to take.

The beneficial effects of drugs such as Prozac were grossly overestimated because the results of trials in which they proved not to be effective went unpublished, partly because negative results are uninteresting, undramatic and unexciting, and no doubt partly because of deliberate suppression. At any rate there is no evidence, and never has been any evidence, that Prozac favourably affects ordinary unhappiness. And if mass prescription comes, can class action be far behind?

Does it really matter, though, in any wider sense, that huge numbers of people have been given drugs that don’t work to cure a condition that does not exist? (Let us leave aside the question of expense.) As we have seen, there are sometimes matters more important than intellectual honesty and consistency; and if in fact large numbers of them have benefited from a placebo response, why should we worry? As the late Deng Xiao Ping said, what does it matter if a cat is black or white, so long as it catches mice?

To quote another luminary, Albert Einstein, not everything that is measurable is important, and not everything that is important is measurable. I think there is an intangible harm to seeing life as a technical problem to be solved by neurochemical manipulation, namely that is unrealistic, crude, uncivilised and ultimately cruel. It induces a kind of wilful blindness in people, who see their own disastrous decisions as being the result of disordered chemistry rather than as that of inadequate thought and character, and places the responsibility on others - particularly, of course the medical profession - to repair the damage and prevent it from recurring.

Although there has recently been an upsurge in anti-religious writing, the scientistic view of human behaviour, that it is all a matter of too much or two little serotonin, represents a decline in understanding by comparison with that of the best divines (and I say this as an unreligious person). I wish I had a hundred dollars for every time I had overheard people saying to each other that their brains were chemically unbalanced, which explains why their lives were less than fulfilled.

The combination of the DSM and the availability of many different antidepressants has turned many doctors into check-list clerks: a sufficient score indicates treatment with Prozac. Judgement, let alone attempts at sympathetic understanding - which is not necessarily the same as complete agreement with the patient’s view of things - and compassion, are rendered completely redundant. And since a lesser number of symptoms than that required by the checklist might indicate depression of lesser severity, and it is best to nip depression in the bud before it develops into a more serious form, almost all degrees of expressed dissatisfaction, and indeed some that are not expressed, end up being treated with the pills. The unhappiness of their patients now acts on doctors as the ringing of the bell once acted on Pavlov’s dogs.


These are at least adults, though vulnerable ones, asking to be drugged. More insidious is the way in which adults now insist that active children have ADD and unsocial ones are autistic.

Posted by Orrin Judd at March 5, 2008 5:03 PM
Comments

I'm surprised we didn't get a post about yesterday's A.Word.A.Day word of the day: "nocebo," the opposite of "placebo," an intrinsically harmless substance that induces harmful effects because it is believed to be harmful.

Posted by: Random Lawyer at March 5, 2008 6:12 PM

You are seriously confusing me.

1. Canadian-style health care is worse than American-style health care, but...

(http://brothersjuddblog.com/archives/2008/03/raising_the_obvious_question.html)

2. American-style health care is just a rash of placebos that don't have any value, but...

(http://brothersjuddblog.com/archives/2008/03/why_wouldnt_cost_have_a_placeb.html)

3. It's terrible that these useless placebos are being given to "vulnerable" adults and children.

Did I get all that right? Because I'm afraid that all doesn't make much sense to me.

Posted by: Brandon at March 5, 2008 6:46 PM

Canadian style is better health-wise, because you don't get much. It just won't satisfy the American consumer. Central to that health consumerism is the consumption of quack remedies for fake problems.

Using drugs to control children's behavior is so obviously evil you probably ought not admit to not understanding why it's a bad thing.

Posted by: oj at March 5, 2008 8:17 PM

But if the drugs are just "quack remedies" and "placebos", how could it possibly be evil? Wouldn't that be the same as saying that giving them sugar pills is evil?

Posted by: Brandon at March 6, 2008 11:15 AM

You wouldn't say that attempted theft or conspiracy to commit a crime was not morally wrong - even though the actual theft/crime was not commited.

Posted by: flanman at March 6, 2008 12:15 PM

flanman,

What is morally wrong about theft and conspiracy is the goal. The goal in giving kids ADHD drugs is to improve their ability to function. I'll even accept OJ's cynical "control their behavior" as the goal.

But for it to be as morally wrong as theft, You'd have to say that improving their ability to function or controlling their behavior are evil goals.

But OJ claims both that the drugs are ineffective, and that they are wrong because they are effective. He can't have it both ways.

Posted by: Brandon at March 6, 2008 1:10 PM

I claim nothing of the kind.

Posted by: oj at March 6, 2008 1:59 PM

Yes, they should be given sugar pills. That would be harmless.

Instead they're drugged into submission.

Posted by: oj at March 6, 2008 2:00 PM

So you don't really mean it when you say that the drugs people are using are "nothing but placebos"?

(http://brothersjuddblog.com/archives/2008/03/why_wouldnt_cost_have_a_placeb.html)

Just tying to resolve conflicting messages.

Posted by: Brandon at March 6, 2008 2:35 PM

No, that's what I mean.

Posted by: oj at March 6, 2008 4:58 PM

So the kids are being "drugged into submission" with placebos?

Posted by: Brandon at March 6, 2008 5:49 PM

Bingo! Take someone like you, who believes in all this nonsense. You go to your doctor and tell him your son is impossible to control because of his ADD and the school can't handle him so they want him to have his own aide. You want a diagnosis so that you can tranquilize the kid. The school wants one so they can hire the aide and they'd prefer your kid be stupefied. The doctor wants you to stop annoying him.

You drug the kid. He's no longer capable of misbehaving much. You pat yourself on the back and imagine the treatment cured him.

That's the very definition of placebo effect. A treatment that does nothing for any underlying problem but is imagined by the customer to have been effective.

Posted by: oj at March 6, 2008 7:47 PM

No oj that's not the definition of a placebo. A placebo is benign, the psychotropic drugs are anything but.

Posted by: erp at March 6, 2008 9:02 PM

No, in modern medical testing they use placebos that are benign, but that's not historically been the case. Indeed, most quack remedies used to have alcohol or other drugs included, if not predominant. If the "remedy" effects anything at all it's easier to gull the dupes into thinking it's effective against their ill, real or imagined.

Posted by: oj at March 6, 2008 10:36 PM

Okay, that doesn't correspond to any definition of placebo that I can find.

http://dictionary.reference.com/browse/placebo

You know, you can't use words that have generally accepted meanings, assign to them another meaning, then expect anyone to have any clue what you're talking about.

Posted by: Brandon at March 6, 2008 10:53 PM

I don't expect you to understand. You're here to learn. The main definition you've chosen corresponds precisely to what I said, but if you look at a more detailed one (Wikipedia) it may be clearer:

"Although placebos are generally characterized as pharmacologically inert substances or formulations, sham treatments, or inactive procedures, they are only inert, sham, ineffective, or inactive in the particular sense that they have no known cause and effect relationship with any of the pre-designated, biochemical, physiological, behavioural, emotional and/or cognitive outcomes of the pharmacologically active and known-to-be-efficacious intervention that might have otherwise been applied (see below)."

A placebo does not have to do nothing, just nothing to "cure" the imagined problem.

Posted by: oj at March 7, 2008 7:39 AM

In general, I'm not here to learn. And certainly not on this particular subject.

Posted by: Brandon at March 7, 2008 12:15 PM

Thus, you don't. More's the pity.

Posted by: oj at March 7, 2008 2:25 PM
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