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The Emperor's New Drugs: Exploding the Antidepressant Myth
Everyone knows that antidepressant drugs are miracles of modern medicine. Professor Irving Kirsch knew this as well as anyone. But, as he discovered during his research, there is a problem with what everyone knows about antidepressant drugs. It isn't true.
How did antidepressant drugs gain their reputation as a magic bullet for depression? And why has it taken so long for the story to become public? Answering these questions takes us to the point where the lines between clinical research and marketing disappear altogether.
Using the Freedom of Information Act, Kirsch accessed clinical trials that were withheld, by drug companies, from the public and from the doctors who prescribe antidepressants. What he found, and what he documents here, promises to bring revolutionary change to the way our society perceives, and consumes, antidepressants.
The Emperor's New Drugs exposes what we have failed to see before: depression is not caused by a chemical imbalance in the brain; antidepressants are significantly more dangerous than other forms of treatment and are only marginally more effective than placebos; and, there are other ways to combat depression, treatments that don't only include the empty promise of the antidepressant prescription.
This is not a book about alternative medicine and its outlandish claims. This is a book about fantasy and wishful thinking in the heart of clinical medicine, about the seductions of myth, and the final stubbornness of facts.
How did antidepressant drugs gain their reputation as a magic bullet for depression? And why has it taken so long for the story to become public? Answering these questions takes us to the point where the lines between clinical research and marketing disappear altogether.
Using the Freedom of Information Act, Kirsch accessed clinical trials that were withheld, by drug companies, from the public and from the doctors who prescribe antidepressants. What he found, and what he documents here, promises to bring revolutionary change to the way our society perceives, and consumes, antidepressants.
The Emperor's New Drugs exposes what we have failed to see before: depression is not caused by a chemical imbalance in the brain; antidepressants are significantly more dangerous than other forms of treatment and are only marginally more effective than placebos; and, there are other ways to combat depression, treatments that don't only include the empty promise of the antidepressant prescription.
This is not a book about alternative medicine and its outlandish claims. This is a book about fantasy and wishful thinking in the heart of clinical medicine, about the seductions of myth, and the final stubbornness of facts.
256 pages, Paperback
First published January 1, 2009
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June 5, 2010
I was attracted to this book for a few reasons:
1. I like good debate over hot topics in the medical field, and the use and efficacy of antidepressants is a hot topic.
2. I have struggled with depression off and on for a few years and (once again) have taken myself off my antidepressant. There are many reasons for my choice, one of them is that I simply do NOT want to rely on a pill if I don't have to.
(DO NOT ATTEMPT REMOVING YOURSELF FROM YOUR MEDS WITHOUT MEDICAL SUPERVISION!)
3. It has a very sexxxy font. (okay, not really.)
Don't even think about offing yourself with this book nearby, so your family can sue the crap out of the author and his publisher and become rich. Kirsch VERY CLEARLY states: DO NOT remove yourself from meds without doctor approval. As much as he does not believe the drugs work to fight depression, he appears very aware that stopping use may cause suicidal ideation and action.
The author, a British psychologist and professor, makes some very solid arguments as to why he believes antidepressants are nothing more than a sham.
One of his main arguing points is the unpublished clinical studies that show various antidepressants (Paxil, Prozac, Zoloft....) are no more effective than a placebo and cause people to suffer from rather annoying and sometimes deadly side effects. He pushes the power of the placebo hard, showing study after study where people were given placebos and felt relief. He even talked about a placebo arthroscopic surgery where the patient swore his bad knee was healed! There was also a haunting story about a man who entered the hospital with very low blood pressure and asked the staff to help him, stating he had taken his entire bottle of antidepressants. Turns out he was on a clinical trial. So what were the pills that caused his physical symptoms, the pills he "overdosed" on? A harmless placebo. Such is the power of the placebo and the mind.
The "chemical imbalance" between neurotransmitters in the brain, that doctors and big pharma say can be cured by their pills... the author says is pure poppycock. As much evidence as he puts against the chemical imbalance theory, I'm still holding on to it. Some people don't process certain enzymes correctly (think lactose intolerance), so why can't people have reactions to different levels of brain chemicals?
Like any good psychologist, he believes that cognitive behavioral therapy (CBT) with a trained, compassionate therapist is more effective over the long term for treating depression. He also supports physical exercise as a non drug therapy. (Side effects include increased libido, weight loss, endorphin high, and so on...) He also mentions St. John's Wort as an herbal remedy, but the debate over that as an effective treatment rages on. Kirsch also calls for social change. (cynic alert!!) Yessir. That unequal distribution of wealth is depressing!
I agree with him that going to therapy and finding destructive thinking patterns and learning how to stop them is indeed helpful. I also agree that exercise is a GREAT way to fend off the blues. However, the problem with going to therapy and going out to exercise (again, forgive the cynic in me) is that they require some effort on the part of the patient. It is much easier (the AMERICAN WAY!) to be passive and swallow a pill in the comfort of your home and get INSTANT RESULTS!!!
I'm on the fence about St. John's Wort. I mean, if you are gonna take a pill, why not take one that your insurance plan will cover? And as far as social change? There is not enough room here for me to get into that.
I was surprised he did not mention nutrition. Perhaps that would lead back to chemical imbalances somehow. Say, the patient does not eat well, does not get the vitamins and minerals needed to... make happy brain chemicals!!!
So here's my plan. Since everyone gets suckered by the placebo effect, let's tell the public that their tap water may now be infused with fairy dust, unicorn toots and rainbows. One glass a day keeps the blues away! The only problem with that is that there's no profit to be had for the doctors or pharmaceutical companies.
Oh well.
1. I like good debate over hot topics in the medical field, and the use and efficacy of antidepressants is a hot topic.
2. I have struggled with depression off and on for a few years and (once again) have taken myself off my antidepressant. There are many reasons for my choice, one of them is that I simply do NOT want to rely on a pill if I don't have to.
(DO NOT ATTEMPT REMOVING YOURSELF FROM YOUR MEDS WITHOUT MEDICAL SUPERVISION!)
3. It has a very sexxxy font. (okay, not really.)
Don't even think about offing yourself with this book nearby, so your family can sue the crap out of the author and his publisher and become rich. Kirsch VERY CLEARLY states: DO NOT remove yourself from meds without doctor approval. As much as he does not believe the drugs work to fight depression, he appears very aware that stopping use may cause suicidal ideation and action.
The author, a British psychologist and professor, makes some very solid arguments as to why he believes antidepressants are nothing more than a sham.
One of his main arguing points is the unpublished clinical studies that show various antidepressants (Paxil, Prozac, Zoloft....) are no more effective than a placebo and cause people to suffer from rather annoying and sometimes deadly side effects. He pushes the power of the placebo hard, showing study after study where people were given placebos and felt relief. He even talked about a placebo arthroscopic surgery where the patient swore his bad knee was healed! There was also a haunting story about a man who entered the hospital with very low blood pressure and asked the staff to help him, stating he had taken his entire bottle of antidepressants. Turns out he was on a clinical trial. So what were the pills that caused his physical symptoms, the pills he "overdosed" on? A harmless placebo. Such is the power of the placebo and the mind.
The "chemical imbalance" between neurotransmitters in the brain, that doctors and big pharma say can be cured by their pills... the author says is pure poppycock. As much evidence as he puts against the chemical imbalance theory, I'm still holding on to it. Some people don't process certain enzymes correctly (think lactose intolerance), so why can't people have reactions to different levels of brain chemicals?
Like any good psychologist, he believes that cognitive behavioral therapy (CBT) with a trained, compassionate therapist is more effective over the long term for treating depression. He also supports physical exercise as a non drug therapy. (Side effects include increased libido, weight loss, endorphin high, and so on...) He also mentions St. John's Wort as an herbal remedy, but the debate over that as an effective treatment rages on. Kirsch also calls for social change. (cynic alert!!) Yessir. That unequal distribution of wealth is depressing!
I agree with him that going to therapy and finding destructive thinking patterns and learning how to stop them is indeed helpful. I also agree that exercise is a GREAT way to fend off the blues. However, the problem with going to therapy and going out to exercise (again, forgive the cynic in me) is that they require some effort on the part of the patient. It is much easier (the AMERICAN WAY!) to be passive and swallow a pill in the comfort of your home and get INSTANT RESULTS!!!
I'm on the fence about St. John's Wort. I mean, if you are gonna take a pill, why not take one that your insurance plan will cover? And as far as social change? There is not enough room here for me to get into that.
I was surprised he did not mention nutrition. Perhaps that would lead back to chemical imbalances somehow. Say, the patient does not eat well, does not get the vitamins and minerals needed to... make happy brain chemicals!!!
So here's my plan. Since everyone gets suckered by the placebo effect, let's tell the public that their tap water may now be infused with fairy dust, unicorn toots and rainbows. One glass a day keeps the blues away! The only problem with that is that there's no profit to be had for the doctors or pharmaceutical companies.
Oh well.
August 30, 2016
Full disclosure: it's no secret I struggle with severe depression. Sometimes I stop my meds, because I feel fine, and then I end up trying to hurt myself. So for me, this is indeed personal.
The book is based on this published paper (open access). There's a summary here.
Kirsch's main argument is that "the overall effect of new-generation antidepressant medications is below recommended criteria for clinical significance" and psychotherapy is "at least as effective as antidepressant drugs and more effective than placebos" (p. 181). Please note that antidepressants are, by his admission, more effective than placebos. The crux of his argument is that a 1.8 point difference on the Hamilton Rating Scale for Depression during blind clinical trials is lower than the three-point difference mandated by the FDA for drug efficacy.
Kirsch argues that by undertaking therapy, creating social change (caution: do not hold breath while waiting), and addressing issues of unemployment, homelessness, and family dysfunction, depression could be treated in more meaningful ways, and for less money, over the life of the patient. Sounds good to me: if only this was covered by my insurance!
Critics of Kirsch point out that his meta-analysis highlights the flaws in blind clinical trials, rather than flaws in antidepressant effectiveness. There's a good summary of the arguments, pro and con, in the British Journal of Psychiatry here.
Kirsch's book is good in that the writing is clear and unambiguous, and is based on a sound methodology (accepting that the limits of BCTs are outside of the scope of the study). Kirsch suggesting that people with depression will be helped by therapy is somewhat of a no-brainer. It isn't his fault that popular media jump on the bandwagon with headlines like, ANTIDEPRESSANTS DON'T WORK and talk about the anti-depressant "hoax" (nice work, Huffpost *eyeroll*).
This is only one of many terrible media misrepresentation of Kirsch's arguments e.g. depression isn't real, antidepressants do not work and people should stop taking them.
Additionally, media misreport the issue of placebos i.e. if antidepressants improve patients' well-being by only two Hamilton points more than placebos, then it means antidepressants don't work. An alternative argument, that Kirsch addresses, could be that placebos might be helping too. The placebo effect is interesting and not fully understood. In a meta-analysis of placebo treatment in oncology (that's motherfucking cancer, man), up to 21% of patients found placebos helped with pain relief, and 2.7% of patients had tumors that responded favorably to placebo treatment (that article cites a whole bunch of interesting articles on placebos).
Kirsch's work is worth reading, because information is power. But save some time and cut to the chase with the original paper.
The book is based on this published paper (open access). There's a summary here.
Kirsch's main argument is that "the overall effect of new-generation antidepressant medications is below recommended criteria for clinical significance" and psychotherapy is "at least as effective as antidepressant drugs and more effective than placebos" (p. 181). Please note that antidepressants are, by his admission, more effective than placebos. The crux of his argument is that a 1.8 point difference on the Hamilton Rating Scale for Depression during blind clinical trials is lower than the three-point difference mandated by the FDA for drug efficacy.
Kirsch argues that by undertaking therapy, creating social change (caution: do not hold breath while waiting), and addressing issues of unemployment, homelessness, and family dysfunction, depression could be treated in more meaningful ways, and for less money, over the life of the patient. Sounds good to me: if only this was covered by my insurance!
Critics of Kirsch point out that his meta-analysis highlights the flaws in blind clinical trials, rather than flaws in antidepressant effectiveness. There's a good summary of the arguments, pro and con, in the British Journal of Psychiatry here.
Kirsch's book is good in that the writing is clear and unambiguous, and is based on a sound methodology (accepting that the limits of BCTs are outside of the scope of the study). Kirsch suggesting that people with depression will be helped by therapy is somewhat of a no-brainer. It isn't his fault that popular media jump on the bandwagon with headlines like, ANTIDEPRESSANTS DON'T WORK and talk about the anti-depressant "hoax" (nice work, Huffpost *eyeroll*).
This is only one of many terrible media misrepresentation of Kirsch's arguments e.g. depression isn't real, antidepressants do not work and people should stop taking them.
Additionally, media misreport the issue of placebos i.e. if antidepressants improve patients' well-being by only two Hamilton points more than placebos, then it means antidepressants don't work. An alternative argument, that Kirsch addresses, could be that placebos might be helping too. The placebo effect is interesting and not fully understood. In a meta-analysis of placebo treatment in oncology (that's motherfucking cancer, man), up to 21% of patients found placebos helped with pain relief, and 2.7% of patients had tumors that responded favorably to placebo treatment (that article cites a whole bunch of interesting articles on placebos).
Kirsch's work is worth reading, because information is power. But save some time and cut to the chase with the original paper.
July 14, 2013
I wanted to read this book critically and remain skeptical of the author's controversial conclusions, that depression is not a chemical imbalance and that antidepressants work no better than placebos. And I would still be open to reading an intelligent, thoughtful rebuttal. But until that happens I have to say, Kirsch's arguments are quite convincing.
According to Kirsch, the evidence for antidepressants' superiority to placebos (by a margin which is statistically but not clinically significant, according to Kirsch) comes from double-blind studies where, presumably, neither subjects nor researchers know who is getting the antidepressants and who is getting the placebos. However, Kirsch points out, subjects are likely to realize whether they are getting antidepressants or placebos based on the side effects. And when that happens, subjects who are experiencing side effects realize they are getting antidepressants and become hopeful about their improvement, leading to a self-fulfilling prophecy, while subjects who are getting placebos have the opposite experience. Further, Kirsch adds, once side effects' influence are controlled for by giving active placebos (i.e., placebos which mimic the side effects of antidepressants but are otherwise inert), the small difference between antidepressants and placebos is no longer statistically significant.
But wait -- there's more. Apparently, drug companies are anxious for you to think their antidepressants work. So anxious, in fact, that if ten studies are performed comparing antidepressants to placebos and only three of those studies find a stronger effect for antidepressants, those three studies will get published. The remaining seven will not, skewing our views of antidepressants' efficacy. This is but one example of cherrypicking by the pharmaceutical companies.
Kirsch goes on to deconstruct much of the research which served as the (apparently quite flawed) basis for the idea that depression is a chemical imbalance. Given all the conflicting results out there, depression does not actually seem to be about serotonin or norepinephrine. Rather, Kirsch subscribes to the theory that depression is about negative beliefs and changing depression is about changing beliefs. This is why the placebo effect is actually highly relevant when it comes to depression, and Kirsch describes psychotherapy as "the quintessential placebo" -- providing hope that things will get better, which can then become a self-fulfilling prophecy.
Lest you think that Kirsch, a clinical psychologist, wrote this book to promote psychotherapy by discrediting antidepressants, it's worth noting that he is also a fan of self-help, exercise, and to a lesser extent, St. John's wort. Although he feels psychotherapy is superior to these, he acknowledges their worth and that a depressed person can successfully remediate their depression by committing to an appropriate program.
I found this book readable, though not quite as light as say, Malcolm Gladwell and writers of that ilk. I did find the arguments far more convincing than those of typical popular science books, though, so I guess the two go together. While my being a psychologist definitely enhanced my interest in the topic, I think this exploration of the placebo effect can be fascinating for anyone.
According to Kirsch, the evidence for antidepressants' superiority to placebos (by a margin which is statistically but not clinically significant, according to Kirsch) comes from double-blind studies where, presumably, neither subjects nor researchers know who is getting the antidepressants and who is getting the placebos. However, Kirsch points out, subjects are likely to realize whether they are getting antidepressants or placebos based on the side effects. And when that happens, subjects who are experiencing side effects realize they are getting antidepressants and become hopeful about their improvement, leading to a self-fulfilling prophecy, while subjects who are getting placebos have the opposite experience. Further, Kirsch adds, once side effects' influence are controlled for by giving active placebos (i.e., placebos which mimic the side effects of antidepressants but are otherwise inert), the small difference between antidepressants and placebos is no longer statistically significant.
But wait -- there's more. Apparently, drug companies are anxious for you to think their antidepressants work. So anxious, in fact, that if ten studies are performed comparing antidepressants to placebos and only three of those studies find a stronger effect for antidepressants, those three studies will get published. The remaining seven will not, skewing our views of antidepressants' efficacy. This is but one example of cherrypicking by the pharmaceutical companies.
Kirsch goes on to deconstruct much of the research which served as the (apparently quite flawed) basis for the idea that depression is a chemical imbalance. Given all the conflicting results out there, depression does not actually seem to be about serotonin or norepinephrine. Rather, Kirsch subscribes to the theory that depression is about negative beliefs and changing depression is about changing beliefs. This is why the placebo effect is actually highly relevant when it comes to depression, and Kirsch describes psychotherapy as "the quintessential placebo" -- providing hope that things will get better, which can then become a self-fulfilling prophecy.
Lest you think that Kirsch, a clinical psychologist, wrote this book to promote psychotherapy by discrediting antidepressants, it's worth noting that he is also a fan of self-help, exercise, and to a lesser extent, St. John's wort. Although he feels psychotherapy is superior to these, he acknowledges their worth and that a depressed person can successfully remediate their depression by committing to an appropriate program.
I found this book readable, though not quite as light as say, Malcolm Gladwell and writers of that ilk. I did find the arguments far more convincing than those of typical popular science books, though, so I guess the two go together. While my being a psychologist definitely enhanced my interest in the topic, I think this exploration of the placebo effect can be fascinating for anyone.
Want to read
February 12, 2011THE VERY TITLE OF THIS BOOK IS DANGEROUS! Whether the antidepressants are working because they work or because of a placebo is irrelevant: they are still working for a lot of people and the vast majority have almost no side effects and no serious ones. But suggesting that their antidepressant may not work or is all in their head is enough to send a person with a serious depressive illness into a downturn that could prove fatal. It messed with my head and I was skeptical to begin with.
I'm willing to read the book and will try to do so with an open mind but I feel I must comment because of the potentially very dangerous action some people may have of stopping medication without working with a doctor. Never mess with brain chemicals without a doctor's supervision. DO NOT STOP TAKING YOUR MEDS until you've talked to your doctor!
I am very skeptical from my own experience and from the kids I work with. I have seen kids who hated taking meds, who refused unless rewarded in some way, be completely changed by antidepressants. Since depression is on a spectrum from Major Depressive Disorder to Bipolar Disorder to Schizophrenia, and it's completley obvious that anti-psychotics work, there is no reason why antidepressants shouldn't work. It's also interesting that this is written by a professor of psychology not a psychiatrist, a medical doctor with experience prescribing and managing antidepressants. There has long been an antagonism in some circles between psychiatrists and psychologists and this is classic. Fortunately, most modern day mental health professionals realize that it is a combination of medicine and therapy that is most affective.
I'm willing to read the book and will try to do so with an open mind but I feel I must comment because of the potentially very dangerous action some people may have of stopping medication without working with a doctor. Never mess with brain chemicals without a doctor's supervision. DO NOT STOP TAKING YOUR MEDS until you've talked to your doctor!
I am very skeptical from my own experience and from the kids I work with. I have seen kids who hated taking meds, who refused unless rewarded in some way, be completely changed by antidepressants. Since depression is on a spectrum from Major Depressive Disorder to Bipolar Disorder to Schizophrenia, and it's completley obvious that anti-psychotics work, there is no reason why antidepressants shouldn't work. It's also interesting that this is written by a professor of psychology not a psychiatrist, a medical doctor with experience prescribing and managing antidepressants. There has long been an antagonism in some circles between psychiatrists and psychologists and this is classic. Fortunately, most modern day mental health professionals realize that it is a combination of medicine and therapy that is most affective.
February 1, 2021
Do I really need to say it? Big pharma is horrifying and the world is corrupted.
I just loved hearing that a medication I used to be on (citalopram) had various studies showing it’s complete ineffectiveness compared to placebo pills—but those got swept under the rug. I actually have taken multiple medications mentioned by Kirsch, and look back on those experiences with disdain.
I don’t know exactly how I feel about all of the claims made in this book, but it was still worth reading. If anything, you will learn about the cherrypicked data and skewed science that results from the greed and dishonorable principles of these large pharmaceutical companies.
Now that I have the studies drilled into my brain, I definitely want to read a book about the psychology of the placebo effect.
I also had no idea that the whole “chemical imbalance in the brain” thing was a theory and not concrete fact. So there’s that.
I just loved hearing that a medication I used to be on (citalopram) had various studies showing it’s complete ineffectiveness compared to placebo pills—but those got swept under the rug. I actually have taken multiple medications mentioned by Kirsch, and look back on those experiences with disdain.
I don’t know exactly how I feel about all of the claims made in this book, but it was still worth reading. If anything, you will learn about the cherrypicked data and skewed science that results from the greed and dishonorable principles of these large pharmaceutical companies.
Now that I have the studies drilled into my brain, I definitely want to read a book about the psychology of the placebo effect.
I also had no idea that the whole “chemical imbalance in the brain” thing was a theory and not concrete fact. So there’s that.
February 16, 2024
It’s good. It’s defensive. Which I get if you’re trying to argue something that’s pretty radical to your field. But like as somebody who kind of already suspects the conclusions, I thought it got a little repetitive and rote.
Basically, antidepressants are negligibly better than placebo. And to the extent they are, it’s probably not worth the secondary effects. This is just a ham and cheese sandwich in my theory of the world. I’m probably not writing home about it but you know it fills out the belly.
So I agree with it and think most psychological drugs are tenuous at best and harmful for the most part. I’m not sure that this book is convincing me or someone else necessarily either way. It is a good read. I picked out a few talking points.
Basically, antidepressants are negligibly better than placebo. And to the extent they are, it’s probably not worth the secondary effects. This is just a ham and cheese sandwich in my theory of the world. I’m probably not writing home about it but you know it fills out the belly.
So I agree with it and think most psychological drugs are tenuous at best and harmful for the most part. I’m not sure that this book is convincing me or someone else necessarily either way. It is a good read. I picked out a few talking points.
February 19, 2012
This book is fascinating from several different points of reference. I expect that the title draws people who are interested in depression and antidepressants specifically, and that question is certainly an important part of the story he's telling. Clinical depression is a particularly difficult disease in many respects. There is no consensus on its causes, although there are clear environmental and genetic factors that make people more prone to depression. Consequently, there is no one-size-fits-all solution either. Kirsch emphasizes that the widespread idea that depression is caused by chemical imbalances in the brain is unproven. And as you might expect from the title, he argues that the effectiveness of antidepressants is a myth as well. But what makes this story especially compelling is that he's not arguing that they don't work. On the contrary – they do work. The problem is that they don't work very significantly (meaningfully) or very reliably, and more to the point, they don't work better than a placebo. And because antidepressants are expensive and frequently cause unwanted side effects, it means Kirsch is telling us that we've made a pretty big mess of things.
Kirsch didn't start out interested in antidepressants. His interest is in placebo studies. And that is really where this book shines. The power of the placebo is fascinating on its own. A placebo won't make someone grow taller and it won't prevent HIV, but for certain diseases – like depression – it offers the potential to make a difference. A key part of the story here is that antidepressants can act as an "extra-strength" placebo, because patients suffer side effects like nausea and drowsiness. And because they are certain they are getting a drug and not a sugar pill, it makes it even more likely to work. According to Kirsch, drug trials of medication that doesn't cause side effects tend to fail because the side effects make a big difference in activating that placebo effect. The implication is that we have a lot of approved drugs on the market that work, but none work as well as they should, and all offer negative side effects. From a bioethical standpoint, this causes a great dilemma. Ultimately, Kirsch argues that psychotherapy is a much more advisable route, since it works as well as existing medications but without side effects and without the questionable ethics.
By far the most disturbing part of this book is what it suggests about the drug approval process and about medical testing in general. On the one hand, it offers a good logical explanation as to why we have approved all of these drugs: Antidepressants produce more side effects than a standard placebo, so patients in clinical trials typically know they are not getting a standard placebo, so consequently, those drugs 'work' as an 'active' placebo, better than a standard one. But on the flip side, these active placebos don't work so much better than standard ones that they should have been approved by the FDA. There are several things about our current process that are extremely disturbing. First, not all studies are appropriately designed as double-blind. Even in cases where the active drug has side effects, those side effects could be replicated for the control cases. Second, not all studies are published. This is a very big and more general problem we have in that most research only gets published if it produces a positive result. Consequently, there is pressure on researchers to get positive results, and most meta-analysis of published studies would give a result that would be biased in favor of positive results. Finally, the FDA doesn't solely have consumer interests at heart when it comes time to decide whether the drugs should be approved for the market. Even with all the relevant data available to it, the FDA tends to act more in the interests of the drug companies than the consumers, which is unfortunately a story that's pretty easy to believe.
The book is pretty short, considering the number of things it touches on. Like many science-centered books, you don't exactly get raw data to chew on when you read an account meant for popular consumption. But what Kirsch does offer is a lot of sensible, compelling, and intuitive arguments and explanations, which is enough in this setting.
Kirsch didn't start out interested in antidepressants. His interest is in placebo studies. And that is really where this book shines. The power of the placebo is fascinating on its own. A placebo won't make someone grow taller and it won't prevent HIV, but for certain diseases – like depression – it offers the potential to make a difference. A key part of the story here is that antidepressants can act as an "extra-strength" placebo, because patients suffer side effects like nausea and drowsiness. And because they are certain they are getting a drug and not a sugar pill, it makes it even more likely to work. According to Kirsch, drug trials of medication that doesn't cause side effects tend to fail because the side effects make a big difference in activating that placebo effect. The implication is that we have a lot of approved drugs on the market that work, but none work as well as they should, and all offer negative side effects. From a bioethical standpoint, this causes a great dilemma. Ultimately, Kirsch argues that psychotherapy is a much more advisable route, since it works as well as existing medications but without side effects and without the questionable ethics.
By far the most disturbing part of this book is what it suggests about the drug approval process and about medical testing in general. On the one hand, it offers a good logical explanation as to why we have approved all of these drugs: Antidepressants produce more side effects than a standard placebo, so patients in clinical trials typically know they are not getting a standard placebo, so consequently, those drugs 'work' as an 'active' placebo, better than a standard one. But on the flip side, these active placebos don't work so much better than standard ones that they should have been approved by the FDA. There are several things about our current process that are extremely disturbing. First, not all studies are appropriately designed as double-blind. Even in cases where the active drug has side effects, those side effects could be replicated for the control cases. Second, not all studies are published. This is a very big and more general problem we have in that most research only gets published if it produces a positive result. Consequently, there is pressure on researchers to get positive results, and most meta-analysis of published studies would give a result that would be biased in favor of positive results. Finally, the FDA doesn't solely have consumer interests at heart when it comes time to decide whether the drugs should be approved for the market. Even with all the relevant data available to it, the FDA tends to act more in the interests of the drug companies than the consumers, which is unfortunately a story that's pretty easy to believe.
The book is pretty short, considering the number of things it touches on. Like many science-centered books, you don't exactly get raw data to chew on when you read an account meant for popular consumption. But what Kirsch does offer is a lot of sensible, compelling, and intuitive arguments and explanations, which is enough in this setting.
May 16, 2017
Terrific read. Crucial for consumers of antidepressants and clinicians. The book does not attack the medications as much as it deconstructs the faulty-fraudulent methodologies of the pharmaceutical researchers.
I feel much more informed after reading it and I feel more equipped to assist my clients in making healthier, more informed choices.
I feel much more informed after reading it and I feel more equipped to assist my clients in making healthier, more informed choices.
October 17, 2021
Compelling argument (largely drawing on FOIA’ed FDA trials) that SSRIs function no better than placebos in the treatment of depression.
Particularly interesting: his point that all available evidence comparing different anti-depression drugs suggests the chemical-imbalance theory of depression is completely bonkers; for ex, patients see the same rates of efficacy when switching from one antidepressant to another, no matter what type of antidepressant is being switched to (SSRIs vs NDRIs vs SSREs).
Particularly interesting: his point that all available evidence comparing different anti-depression drugs suggests the chemical-imbalance theory of depression is completely bonkers; for ex, patients see the same rates of efficacy when switching from one antidepressant to another, no matter what type of antidepressant is being switched to (SSRIs vs NDRIs vs SSREs).
April 11, 2014
I started this book skeptical. Antidepressants are nothing but placebos? Really?
How do I justify that with all the people I know whose life and mental health have been changed for the better due to these drugs? All the people who felt for certain that their brain was different as soon as they went on the medication?
It took me a few weeks to get through the book because I had these moments of frustration on behalf of myself and other people, and I'd put the book down for a few days because of it.
But, by the end I was pretty convinced. The references in the book check out- this guy is a well-established academic and he's got footnotes to studies published in major academic journals. I looked up a few of the more interesting ones and they look like solid studies. What really surprised me is how the consensus among the academics is turning tide- I read this quote from a leading researcher in another article: "But the attempt to measure the mind has led to nothing but dead ends like the old, now discredited theories about depression and serotonin."
Really? Old? Discredited? How come more doctors and lay people aren't aware of this huge paradigm shift? Well, there are plenty of people shouting that it's not true- that antidepressants really do work. And a lot of them receive funding for their research from the drug companies. But I'm not sure how they'll refute some of the evidence against the standard antidepressants, such as:
"If depression can be equally affected by drugs that increase serotonin, drugs that decrease it, and drugs that do not affect it at all, [then depression can not be caused by an imbalance in the levels of serotonin]." p 97
In double blind clinical trials, there is no significant difference between the placebo and the drugs. Thyroid hormone, barbituates, stimulants, herbal remedies, anti-psychotic drugs, and drugs that increase OR decrease seratonin, or increase OR decrease norepinepherine, or drugs that alter levels of dopamine in the brain--- ALL of these drugs, when tested for antidepressant properties, show a significant antidepressant effect.
The question is not whether or not antidepressants work. THEY DO WORK. For most people, there will be significant improvement in their depression when they start taking a regular medication for it. The question is WHY do antidepressants work? And the answer, according to this book, is that their effect is almost entirely due to the placebo effect.
So how in the world were they ever approved for use as drugs in the first place?
Because drug companies paid for the studies, and drug companies fund 40% of the budget for the FDA and 70% of the budget of the EMEA and all of the budget of the MHRA (European agencies). This conflict of interest is unfortunate, but real. Imagine that you spent several million developing a drug that you believe will help people and the studies are "inconclusive." Would you be motivated to try more studies and ignore the data that didn't support your hypothesis? Probably.
So negative studies were not published, positive studies were published multiple times, and this 'salami slicing' and 'cherry picking' of the data is part of the reason that so many people are convinced that antidepressants work due to their chemical action in the brain. Another reason this false belief has persisted so long, I think, is that it's human nature to have a hard time turning down a "simple fix" if it seems plausible.
If only depression was a simple imbalance of seratonin easily fixed by an SSRI. It's not. It's much more complicated than that. And, unfortunately, there's evidence that antidepressants tend to worsen depression over time. People who take antidepressants are more likely to have relapses and experience depression years later from the initial onset, and the drugs themselves create a dependency. A lot of the standard antidepressants have a 'whiplash' kind of withdrawal effect that can make a person much more depressed when they stop the drug than they were before.
"If the antidepressant effect is largely or entirely a placebo effect, it is important that we know this. If placebos can make people better, then depression can be ameliorated without reliance on drugs that have potentially serious side effects and that foster dependency." p 81
This book spent a couple chapters on the placebo effect (which is much stronger in mental health than any other area)- always fascinating material. It also delved into other treatments for depression (exercise, therapy) and explored some of the studies that have been done on that. These chapters, I thought, were very encouraging. Turns out that consistent regular exercise and therapy, when compared in controlled studies against antidepressants, often fare better in the long run for curing depression.
One last quote: "The good news [is] that there are many effective treatments for combating depression. This is necessarily true given the strength of the placebo effect. If placebos produce improvement, then any credible bona-fide treatment will also alleviate depression." p175
How do I justify that with all the people I know whose life and mental health have been changed for the better due to these drugs? All the people who felt for certain that their brain was different as soon as they went on the medication?
It took me a few weeks to get through the book because I had these moments of frustration on behalf of myself and other people, and I'd put the book down for a few days because of it.
But, by the end I was pretty convinced. The references in the book check out- this guy is a well-established academic and he's got footnotes to studies published in major academic journals. I looked up a few of the more interesting ones and they look like solid studies. What really surprised me is how the consensus among the academics is turning tide- I read this quote from a leading researcher in another article: "But the attempt to measure the mind has led to nothing but dead ends like the old, now discredited theories about depression and serotonin."
Really? Old? Discredited? How come more doctors and lay people aren't aware of this huge paradigm shift? Well, there are plenty of people shouting that it's not true- that antidepressants really do work. And a lot of them receive funding for their research from the drug companies. But I'm not sure how they'll refute some of the evidence against the standard antidepressants, such as:
"If depression can be equally affected by drugs that increase serotonin, drugs that decrease it, and drugs that do not affect it at all, [then depression can not be caused by an imbalance in the levels of serotonin]." p 97
In double blind clinical trials, there is no significant difference between the placebo and the drugs. Thyroid hormone, barbituates, stimulants, herbal remedies, anti-psychotic drugs, and drugs that increase OR decrease seratonin, or increase OR decrease norepinepherine, or drugs that alter levels of dopamine in the brain--- ALL of these drugs, when tested for antidepressant properties, show a significant antidepressant effect.
The question is not whether or not antidepressants work. THEY DO WORK. For most people, there will be significant improvement in their depression when they start taking a regular medication for it. The question is WHY do antidepressants work? And the answer, according to this book, is that their effect is almost entirely due to the placebo effect.
So how in the world were they ever approved for use as drugs in the first place?
Because drug companies paid for the studies, and drug companies fund 40% of the budget for the FDA and 70% of the budget of the EMEA and all of the budget of the MHRA (European agencies). This conflict of interest is unfortunate, but real. Imagine that you spent several million developing a drug that you believe will help people and the studies are "inconclusive." Would you be motivated to try more studies and ignore the data that didn't support your hypothesis? Probably.
So negative studies were not published, positive studies were published multiple times, and this 'salami slicing' and 'cherry picking' of the data is part of the reason that so many people are convinced that antidepressants work due to their chemical action in the brain. Another reason this false belief has persisted so long, I think, is that it's human nature to have a hard time turning down a "simple fix" if it seems plausible.
If only depression was a simple imbalance of seratonin easily fixed by an SSRI. It's not. It's much more complicated than that. And, unfortunately, there's evidence that antidepressants tend to worsen depression over time. People who take antidepressants are more likely to have relapses and experience depression years later from the initial onset, and the drugs themselves create a dependency. A lot of the standard antidepressants have a 'whiplash' kind of withdrawal effect that can make a person much more depressed when they stop the drug than they were before.
"If the antidepressant effect is largely or entirely a placebo effect, it is important that we know this. If placebos can make people better, then depression can be ameliorated without reliance on drugs that have potentially serious side effects and that foster dependency." p 81
This book spent a couple chapters on the placebo effect (which is much stronger in mental health than any other area)- always fascinating material. It also delved into other treatments for depression (exercise, therapy) and explored some of the studies that have been done on that. These chapters, I thought, were very encouraging. Turns out that consistent regular exercise and therapy, when compared in controlled studies against antidepressants, often fare better in the long run for curing depression.
One last quote: "The good news [is] that there are many effective treatments for combating depression. This is necessarily true given the strength of the placebo effect. If placebos produce improvement, then any credible bona-fide treatment will also alleviate depression." p175
November 20, 2011
I cannot decide if the author of this work is a crackpot pushing a dubious agenda or someone who is in fact on to something about the way "Big Pharma" can, does and will do anything in their power to keep the current status quo regarding anti-depressants in place. And how in pursuit of this end basic science is tossed aside, the methodology for the approval of new -- and theoretically better -- medicines has been turned into something resembling a joke with a bad punchline, and even that a great many clinicians seem to have embraced the current state of psychopharmacology with what I can only think of as almost a religious fervor.
Without doubt, the biggest shock delivered to MY system was contained in the chapter "The Myth of the Chemical Imbalance." Kirsch here attacks not the "branches" of the tree of antidepressants but aims straight at the "roots." He describes the central dogma of the whole theory behind anti-depressant effectiveness, that an excess or deficiency of neurotransmitters is behind many forms of depression, has little empirical evidence in its support. And that there is at least as much -- if not more -- evidence against such a theory as in favor of it. Not only that, the history behind the theory is as dubious as anything else related to it.
There is a great deal in the book on the "placebo effect" and how it used to "prove" the effectiveness of such and such a drug. Unfortunately, Kirsch seems to think the average reader will find this whole topic both exciting and as something of a revelation. It is not that -- insofar as I can tell -- Kirsch is wrong, just that he probably spends more time on this topic than any other. And I submit that it is hardly as earth-shattering a topic as he seems to think, though admittedly the bits commingled with the topic on how clinical trials that work against a drug are deliberately buried, and trials in their favor published and re-published to make a drug appear more effective perhaps was...but that goes into areas not directly related to any placebo effect.
Still and all, a very thought provoking read. But as I noted at the outset of the review I'm a bit reluctant to jump on his bandwagon; I simply lack the scientific background to evaluate his claims. But must admit I'm intrigued that if any direct rebuttal to the work has been written, I've not seen it. It is almost as though the "true believers" want this swept under the rug in preference to offering any sort of defense.
Without doubt, the biggest shock delivered to MY system was contained in the chapter "The Myth of the Chemical Imbalance." Kirsch here attacks not the "branches" of the tree of antidepressants but aims straight at the "roots." He describes the central dogma of the whole theory behind anti-depressant effectiveness, that an excess or deficiency of neurotransmitters is behind many forms of depression, has little empirical evidence in its support. And that there is at least as much -- if not more -- evidence against such a theory as in favor of it. Not only that, the history behind the theory is as dubious as anything else related to it.
There is a great deal in the book on the "placebo effect" and how it used to "prove" the effectiveness of such and such a drug. Unfortunately, Kirsch seems to think the average reader will find this whole topic both exciting and as something of a revelation. It is not that -- insofar as I can tell -- Kirsch is wrong, just that he probably spends more time on this topic than any other. And I submit that it is hardly as earth-shattering a topic as he seems to think, though admittedly the bits commingled with the topic on how clinical trials that work against a drug are deliberately buried, and trials in their favor published and re-published to make a drug appear more effective perhaps was...but that goes into areas not directly related to any placebo effect.
Still and all, a very thought provoking read. But as I noted at the outset of the review I'm a bit reluctant to jump on his bandwagon; I simply lack the scientific background to evaluate his claims. But must admit I'm intrigued that if any direct rebuttal to the work has been written, I've not seen it. It is almost as though the "true believers" want this swept under the rug in preference to offering any sort of defense.
June 5, 2010
A specialist in the placebo effect discusses his findings, based on extensive reviews of pharmaceutical trials by manufacturers and regulators, that antidepressants' effects are no better than placebos -- that, in fact, they are active placebos. He also discusses the placebo effect more generally and gives a critical evaluation of the chemical-imbalance theory of depression.
A persuasive scientific argument that came as no surprise to drug manufacturers though it has been upsetting and controversial to many in the medical community.
A persuasive scientific argument that came as no surprise to drug manufacturers though it has been upsetting and controversial to many in the medical community.
October 20, 2013
Compelling, important information in this book but it should have been called "THEY'RE JUST PLACEBOS!!!!" because at least 75% of the book is just an explanation about the placebo effects of psychiatric and other medications. Although the author is a psychotherapist(though not an MD and so not able to prescribe meds himself) he doesn't include case studies, real life experiences, interviews with other doctors or people in the pharm industry. This is strictly about the studies the pharm industry has been trying not to make public. Important, but not really enough to sustain an entire book.
July 20, 2021
Man oh man does this guy have a boner for CBT therapy.
I have no personal experience with CBT therapy. I've only done DBT.
I just didn't like how the solution to all the conflicts of interest and pharma influence on doctors and mental health treatment as a whole was "let's do psychotherapy instead!" He didn't delve into how even the basis of most therapy today is a model that greatly benefits pharma: the biomedical model.
He did explain a bit about the history of the biomedical model and why the biomedical theory doesn't make sense. He actually got pretty deep into the scientific nitty gritty-explaining neuroplasticity theory and neurotransmitters. That part was really good, but I don't see how he can be so pro-therapy when the basis of therapy is the biomedical model. The "brain disease" model, as Ethan Watters calls it. How can therapists truly treat the root of a patient's negative mindset or self-destructive behavior, if the theory behind all mental illness is that it's nothing more than a chemical imbalance?
That would be my biggest criticism of that book: that he didn't get into how drug influence may affect patient treatment, even when it is treatment of psychotherapy without drugs. Therapy and drug treatment go hand in hand today, so to criticize SSRIs without shedding any critical light or therapy, or at least looking into how patient care may be compromised in psychotherapy due to the insidious influence of pharmaceutical companies, it feels incomplete. He didn't go far enough with his criticism. I'll say it once and I'll say it again: you can be pro-therapy and also pro-make therapy better.
All of that being said, it was still a very strong book. This is a doctor who has done a good deal of research into SSRIs and other psychiatric drugs. Through his research (which he does a wonderful job of explaining in the book) he found that the positive affects of SSRIs may be nothing more than a placebo effect-and holistic treatments such as exercise or even taking St. John's Wort may be safer and more effective.
He addressed some of the most common criticisms of his work; one of them being the argument that even if patient recovery on SSRIs IS a placebo effect, shouldn't doctors keep prescribing them? If they work, they work, right? Kirsh explains that this is not an acceptable answer to the question of whether or not SSRIs are effective, because these drugs come with terrible side effects. These side effects can include PSYCHOSIS. Drugs like Prozac can actually cause hallucinations and delusions in people. Several heartbreaking stories were recounted, including a teenage boy who shot and killed his grandparents after Prozac induced psychosis in him, and a woman who shot her own jaw off. If anyone is interested in reading more stories of violent psychosis induced by SSRIs, I highly recommend checking out the advocacy site psychrights.org. http://psychrights.org/horrors.htm
These drugs can cause people to become violent or suicidal. They can cause a lifelong condition known as Akathisia (to learn more about this, I highly recommend the Russia Today documentary 'Overpill.' It is available for free on youtube).
In short, these drugs HARM people. So if, as Kirsch's research indicates, the positive effects of SSRIs are a placebo effect, and they come with so many horrible negative effects, then no, continuing to prescribe them because "they work for some people" is not acceptable. All of that "working" is a mental illusion. As Kirsch explains, these patients get better only because they expect to get better, and if you gave them a sugar pill, they will still get better.
Kirsch also explains many of the terrible conflicts of interest in the mental health field, and how his fellow researchers and doctors are bullied into silence by those in power. Doctors who start to talk about the negative effects of psych drugs are told "be quiet if you ever want funding for a clinical drug trial again" and when they are not tenured professors, but independent researchers whose livelihood depends on funding, it's true that they can't "bite the hand that feeds them."
Despite the flaws in this book, it is an incredibly in-depth look at the myriad of problems with SSRI research and a scathing commentary on why more doctors aren't talking about this. Kirsch takes shots at everyone from pharma to the FDA and I'm so here for it.
I have no personal experience with CBT therapy. I've only done DBT.
I just didn't like how the solution to all the conflicts of interest and pharma influence on doctors and mental health treatment as a whole was "let's do psychotherapy instead!" He didn't delve into how even the basis of most therapy today is a model that greatly benefits pharma: the biomedical model.
He did explain a bit about the history of the biomedical model and why the biomedical theory doesn't make sense. He actually got pretty deep into the scientific nitty gritty-explaining neuroplasticity theory and neurotransmitters. That part was really good, but I don't see how he can be so pro-therapy when the basis of therapy is the biomedical model. The "brain disease" model, as Ethan Watters calls it. How can therapists truly treat the root of a patient's negative mindset or self-destructive behavior, if the theory behind all mental illness is that it's nothing more than a chemical imbalance?
That would be my biggest criticism of that book: that he didn't get into how drug influence may affect patient treatment, even when it is treatment of psychotherapy without drugs. Therapy and drug treatment go hand in hand today, so to criticize SSRIs without shedding any critical light or therapy, or at least looking into how patient care may be compromised in psychotherapy due to the insidious influence of pharmaceutical companies, it feels incomplete. He didn't go far enough with his criticism. I'll say it once and I'll say it again: you can be pro-therapy and also pro-make therapy better.
All of that being said, it was still a very strong book. This is a doctor who has done a good deal of research into SSRIs and other psychiatric drugs. Through his research (which he does a wonderful job of explaining in the book) he found that the positive affects of SSRIs may be nothing more than a placebo effect-and holistic treatments such as exercise or even taking St. John's Wort may be safer and more effective.
He addressed some of the most common criticisms of his work; one of them being the argument that even if patient recovery on SSRIs IS a placebo effect, shouldn't doctors keep prescribing them? If they work, they work, right? Kirsh explains that this is not an acceptable answer to the question of whether or not SSRIs are effective, because these drugs come with terrible side effects. These side effects can include PSYCHOSIS. Drugs like Prozac can actually cause hallucinations and delusions in people. Several heartbreaking stories were recounted, including a teenage boy who shot and killed his grandparents after Prozac induced psychosis in him, and a woman who shot her own jaw off. If anyone is interested in reading more stories of violent psychosis induced by SSRIs, I highly recommend checking out the advocacy site psychrights.org. http://psychrights.org/horrors.htm
These drugs can cause people to become violent or suicidal. They can cause a lifelong condition known as Akathisia (to learn more about this, I highly recommend the Russia Today documentary 'Overpill.' It is available for free on youtube).
In short, these drugs HARM people. So if, as Kirsch's research indicates, the positive effects of SSRIs are a placebo effect, and they come with so many horrible negative effects, then no, continuing to prescribe them because "they work for some people" is not acceptable. All of that "working" is a mental illusion. As Kirsch explains, these patients get better only because they expect to get better, and if you gave them a sugar pill, they will still get better.
Kirsch also explains many of the terrible conflicts of interest in the mental health field, and how his fellow researchers and doctors are bullied into silence by those in power. Doctors who start to talk about the negative effects of psych drugs are told "be quiet if you ever want funding for a clinical drug trial again" and when they are not tenured professors, but independent researchers whose livelihood depends on funding, it's true that they can't "bite the hand that feeds them."
Despite the flaws in this book, it is an incredibly in-depth look at the myriad of problems with SSRI research and a scathing commentary on why more doctors aren't talking about this. Kirsch takes shots at everyone from pharma to the FDA and I'm so here for it.
August 7, 2021
Kirsch makes a compelling case that most of the benefits of antidepressants are due to the placebo affect. It's something I'd have to research a lot more, of course, but this is a fascinating introduction, with lots of stats and studies broken down in an easy-to-understand way. I've known many people to be helped by antidepressants so it's hard to think, oh, it's just a placebo affect. (Although, maybe "just" isn't the right word—if placebo affects really "work," in terms of reducing symptoms, then that's great. That's the goal, right?)
I entirely sympathize with Kirsch's desire to reduce the number people put on medications with not-so-great side affects as much as possible. I'm also suspicious of studies funded by companies who profit greatly from a certain outcome, and I'm thankful for U.S. laws that allow people to access all studies, even unpublished ones. I'm not ready to chalk all antidepressant success stories up to placebo, but I'm very open to the possibility that they may not work as well as—or in the precise way—we think they do.
In the end, I think Kirsch wants the best for people, and I appreciate that. We don't need to fear the truth, and I hope this book is a catalyst for more research into what exactly the truth about antidepressants is.
I entirely sympathize with Kirsch's desire to reduce the number people put on medications with not-so-great side affects as much as possible. I'm also suspicious of studies funded by companies who profit greatly from a certain outcome, and I'm thankful for U.S. laws that allow people to access all studies, even unpublished ones. I'm not ready to chalk all antidepressant success stories up to placebo, but I'm very open to the possibility that they may not work as well as—or in the precise way—we think they do.
In the end, I think Kirsch wants the best for people, and I appreciate that. We don't need to fear the truth, and I hope this book is a catalyst for more research into what exactly the truth about antidepressants is.
September 10, 2011
I think we all like to read things that support the way we feel, so, I liked this book. Clearly I now need to go and read the other side of the viewpoint to balance it all out.
I was unaware of the details about the anti-depressant drug studies, but I have always felt that we JUST DON'T KNOW ENOUGH about any of it, and I really have had a hard time believing in the 'depression as a simple medical problem' theory. Clearly there is a medical aspect, but the human brain is such a magnificently complicated thing.
I appreciated immensely that he didn't just spew out all of the placebo info and then leave you hanging. He's not saying, too bad for your, your medicine doesn't work, there is no cure. He spends the last few chapters discussing options that have been clinically proven to be JUST AS EFFECTIVE, or even more effective in the long run. His point is that there are other forms of treatment that have proven to be equally as effective, without the harmful side effects. But he is always careful to point out that if a treatment is working, don't stop! And don't ever take yourself off of an anti-depressant, always talk to your doctor!
If anything, this book made me more amazed by the power of the human mind. He talks about one study where, after being told that ipecac was a medicine that would abolish nausea, it did, and not just mentally. The gastric activity within the stomach actually subsided. The human brain is amazing.
Sometimes depression is way beyond simple techniques. I am not talking about serious cases. But in general, I feel like we, as a world, are becoming less and less able to understand how to reconcile and deal with feeling bad. As factors in our regular everyday life, in today's world, we don't have to do as much manual labor, we don't have close neighbors to chat with about our day. There are skills that have to be taught and learned, to understand how to pull your mind out of a downward spiral, find the positives, plan for the future. He talks about psychotherapy/CBT, that are just as effective in the short term, but clinically show to have longer lasting results due to actual changes that you can make in thinking patterns, etc. But it requires work and effort, and belief that there is an end and belief in oneself...that you CAN overcome.
I think the section on exercise as an effective tool rang true for me because that is definitely one of my 'drugs' of choice. Although, I've always used it more as a vitamin (preventative) than a drug (cure) so I can't speak for it's effectiveness in other ways from personal experience.
I don't know all of the answers, but my conclusion asserts itself even more powerfully after reading this book....neither do "they". There's not a quick fix. We are still learning. I truly hope that better answers come soon. Because it's real. Of that I am sure.
I was unaware of the details about the anti-depressant drug studies, but I have always felt that we JUST DON'T KNOW ENOUGH about any of it, and I really have had a hard time believing in the 'depression as a simple medical problem' theory. Clearly there is a medical aspect, but the human brain is such a magnificently complicated thing.
I appreciated immensely that he didn't just spew out all of the placebo info and then leave you hanging. He's not saying, too bad for your, your medicine doesn't work, there is no cure. He spends the last few chapters discussing options that have been clinically proven to be JUST AS EFFECTIVE, or even more effective in the long run. His point is that there are other forms of treatment that have proven to be equally as effective, without the harmful side effects. But he is always careful to point out that if a treatment is working, don't stop! And don't ever take yourself off of an anti-depressant, always talk to your doctor!
If anything, this book made me more amazed by the power of the human mind. He talks about one study where, after being told that ipecac was a medicine that would abolish nausea, it did, and not just mentally. The gastric activity within the stomach actually subsided. The human brain is amazing.
Sometimes depression is way beyond simple techniques. I am not talking about serious cases. But in general, I feel like we, as a world, are becoming less and less able to understand how to reconcile and deal with feeling bad. As factors in our regular everyday life, in today's world, we don't have to do as much manual labor, we don't have close neighbors to chat with about our day. There are skills that have to be taught and learned, to understand how to pull your mind out of a downward spiral, find the positives, plan for the future. He talks about psychotherapy/CBT, that are just as effective in the short term, but clinically show to have longer lasting results due to actual changes that you can make in thinking patterns, etc. But it requires work and effort, and belief that there is an end and belief in oneself...that you CAN overcome.
I think the section on exercise as an effective tool rang true for me because that is definitely one of my 'drugs' of choice. Although, I've always used it more as a vitamin (preventative) than a drug (cure) so I can't speak for it's effectiveness in other ways from personal experience.
I don't know all of the answers, but my conclusion asserts itself even more powerfully after reading this book....neither do "they". There's not a quick fix. We are still learning. I truly hope that better answers come soon. Because it's real. Of that I am sure.
May 13, 2010
Interpreting data from a meta-analysis, Kirsch sets out to debunk the myth put forth by the multi-national pharmaceuticals that antidepressants are revolutionary, blockbusters drugs. He looked at clinical trials that compared the efficacy of various treatments for depression. "Drug effect," the response to drug minus the response to placebo minus the response to spontaneous response or doing nothing, was surprisingly, significantly small. Rather, he claims, the efficacy of these drugs in managing depression are largely due to the placebo effect--except technically placebos are inert substances without appreciable side effects, and most of us know the small print that comes along with SSRIs, SNRIs, etc. Kirsch gives some history of the chemical imbalance theory, claiming that it's way too weak and way to sketchy to support the explanation that ADs work.
Kirsch gives a good critique of the research process, pointing out serious flaws in various studies as he plods through the material.He also gave accessible, clear explanations of complex brain processes. Incomplete citations were a big problem for me, though. The biggest disappointment was the conclusion, which gave alternate suggestions for dealing with depression. Beyond some superficial recommendations of some self-help books and glib mention of exercise, there's not much there of substance. He mentioned the need for social change--e.g. it's not the level of a country's poverty that makes its citizens more susceptible to depression; it's the disparate distribution of wealth and resources. Exploring the imperative of social change was certainly not the intent of his book, but it's hugely important.
Kirsch has a long history of civil rights activism and participation in anti-war movements. In his pre-psychological career, he was a violinist who backed up Aretha Franklin. As a grad student in 1975, he worked with the National Lampoon to produce an album that won a Grammy for Best Comedy Recording. Judging from the fall-out he has received for his interpretation of the pharmaceutical industry's research, although he likes to "rock the boat," that boat won't be tipped over easily or soon.
Kirsch gives a good critique of the research process, pointing out serious flaws in various studies as he plods through the material.He also gave accessible, clear explanations of complex brain processes. Incomplete citations were a big problem for me, though. The biggest disappointment was the conclusion, which gave alternate suggestions for dealing with depression. Beyond some superficial recommendations of some self-help books and glib mention of exercise, there's not much there of substance. He mentioned the need for social change--e.g. it's not the level of a country's poverty that makes its citizens more susceptible to depression; it's the disparate distribution of wealth and resources. Exploring the imperative of social change was certainly not the intent of his book, but it's hugely important.
Kirsch has a long history of civil rights activism and participation in anti-war movements. In his pre-psychological career, he was a violinist who backed up Aretha Franklin. As a grad student in 1975, he worked with the National Lampoon to produce an album that won a Grammy for Best Comedy Recording. Judging from the fall-out he has received for his interpretation of the pharmaceutical industry's research, although he likes to "rock the boat," that boat won't be tipped over easily or soon.
January 6, 2015
This book confirmed what I had long suspected - antidepressants don't really do what they are touted to do.
Years ago, when I was prescribed an antidepressant after being diagnosed as having chronic clinical depression, I had serious doubts that a tiny pill would be able to help me feel better. Despite some initial unpleasant side effects, I kept taking the little buggers in the hopes they would subside and the benefits would kick in.
Some weird stuff I was experiencing did go away, so I figured the drugs must be working so I kept taking them. I didn't otherwise feel any better - every day was just another to endure.
Eventually I wasn't able to afford the antidepressants anymore and went off them. And guess what? I felt absolutely NO different off the drugs as when I was on them. Yup, I had a feeling that those little pills were too good to be true and they are.
I know they must do SOMETHING to me because for a short while after I stopped taking them, I could HEAR myself blinking. Yup, every time I blinked, I could hear myself doing so. Weird and scary. But that stopped after a few days. And I felt no different at all, then or months later.
I suspect the placebo effect of the drug didn't work on me because I never really believed they would work as advertised from the beginning.
Reading the book reassured me that I had made the right decision - to stop putting a bunch of chemicals in my body that no one REALLY knows what they do to it.
Years ago, when I was prescribed an antidepressant after being diagnosed as having chronic clinical depression, I had serious doubts that a tiny pill would be able to help me feel better. Despite some initial unpleasant side effects, I kept taking the little buggers in the hopes they would subside and the benefits would kick in.
Some weird stuff I was experiencing did go away, so I figured the drugs must be working so I kept taking them. I didn't otherwise feel any better - every day was just another to endure.
Eventually I wasn't able to afford the antidepressants anymore and went off them. And guess what? I felt absolutely NO different off the drugs as when I was on them. Yup, I had a feeling that those little pills were too good to be true and they are.
I know they must do SOMETHING to me because for a short while after I stopped taking them, I could HEAR myself blinking. Yup, every time I blinked, I could hear myself doing so. Weird and scary. But that stopped after a few days. And I felt no different at all, then or months later.
I suspect the placebo effect of the drug didn't work on me because I never really believed they would work as advertised from the beginning.
Reading the book reassured me that I had made the right decision - to stop putting a bunch of chemicals in my body that no one REALLY knows what they do to it.
August 26, 2012
Very interesting book (if you can muddle through some of the more dry statistical paragraphs). Kirsch makes a compelling argument really in the effectiveness of placeboes. Beyond the anti-depressant research, there are fascinating notes about placebo knee surgeries and even placebo heart surgery and more that may make you question the efficacy of healthcare as we know it. Note to other "readers" who had a few negative comments- this is a book that you should read through to the end before tossing aside whether you end up agreeing with the author or not; skimming it misses quite a bit beyond the AD argument. Also, Kirsch makes a point of noting that you absolutely should NOT stop taking ADs without working with a dr.
March 6, 2013
Kirsch makes a rather convincing argument for the controversial claim that antidepressant medication works no better than placebo, and may even be due to an active placebo effect rather than the result of a biochemical change caused by the medication. I was fairly sceptical when I read the claims of the book, but he has presented the evidence for his argument well and in an easy-to-read fashion. I still wonder if his hypothesis will be embraced by the broader scientific community. Only time will tell.
February 11, 2016
GETTING to the truth that lies behind the widely promoted and, apparently, scientifically validated view that depression derives from a chemical imbalance in the brain may seem a daunting task. But to Professor Kirsch, author of this impressive book, it appears to have been an enjoyable ‘feather-ruffling’ exercise. From the book’s bold title right through to the final paragraph under the heading, “Don’t ask, don’t tell”, Professor Irving Kirsch’s use of the Hans Andersen metaphor is surprisingly apt while the underlying message is seriously disturbing.
Kirsch’s book is an account of how, with meticulous research and a firm resolve to find answers, he gathered documented data from the Food and Drug Administration’s (FDA) vast vaults of unpublished material on clinical drug trials, using the Freedom of Information Act to do so. Although Kirsch originally set out to test the placebo effect in treatment of depression, he sensationally stumbled over enlightening data on the ineffectiveness of antidepressant drugs when compared to therapeutic interventions (chiefly cognitive-behavioural therapy, as it is evidence based). His resolute tenacity led him to analyse clinical trials involving over 3,000 depressed patients, which has resulted in astonishing fact after fact falling over each other on every page. The answers Kirsch arrived at plainly show that strong prescription drugs for depression offer only marginal improvements over placebo.
His book gives details of how President Bush Snr signed bills allowing the FDA to charge drug companies fees to evaluate new products. Ironically, instead of helping to smooth the process of getting much needed healing drugs onto the market quicker, which was the intention, this action enabled ethical boundaries to be breached by seemingly unscrupulous industry executives keen to line their own pockets. Canny drug companies saw this as a loophole in their favour: as they commissioned the research, the power to publish only the positive studies lay in their hands – thus benefiting their profit margins. Hence, in similar vein to the Emperor’s fabricating tailors, representatives of the pharmaceutical industry appear to have wasted no time in weaving their marketing magic to put the best gloss on their merchandise.
Early on, Kirsch kindly issues a warning that the technicalities of clinical trials and subsequent number crunching may prove a little difficult for the layperson to grasp. What comes across in his surprisingly easy-to-read and often entertaining text is that he agrees with clinical practice evidence. Even his own meta-analysis in the book shows that the administration of antidepressants can offer meaningful improvement in a patient’s life. What Kirsch is concerned about is why they work, when they do. To illustrate his point, he lists some very vile brews and torturous practices that have been tested throughout history in clinical practice. For instance, lizard’s blood and crocodile dung were particular favourites, while dolphin’s genitalia and frog’s sperm were also cast into the cauldron. Kirsch quotes Morris and Shapiro’s 1978 study that found many patients were “purged, poisoned and punctured, blistered, bled and leached” and “if the patients weren’t killed by these treatments, they were deemed to have made them better”. So, convoluted concoctions seem to have worked equally as well in the Emperor’s days as the ‘pill for every ill’ appears to do today.
However, the main point Kirsch makes in his book is that true comparisons of effectiveness cannot exclude placebo effects from the statistical data. For instance, one graph highlights results that show little improvement from patients given placebos, and only marginal improvement in the response of chronically depressed patients who were administered strong drug doses. Why, he asks, is there is such a small difference in statistical evidence when comparing heavy-duty drugs to the apparently ineffective placebo? One of the answers repeatedly underlined (and one which the human givens perspective has confirmed since its inception) is that people appear to gain benefits simply as a result of being treated. For example, in a Dutch study on medication for ulcers that Kirsch unearthed, patients whose doctors administered four doses a day were understood to “improve at a significantly greater rate” than those given the same medication twice a day. However (and here’s the crunch), what both patient groups had taken were placebos.
Kirsch’s attempts to act in an ethical manner are admirable and his book details the extreme lengths he goes to in order to ensure that his extracts from studies are fair – because, as he shows, even though studies are carried out carefully, they may not yield true answers. For instance, double-blind studies of antidepressant drugs are commonly not double blind in practice, as patients very often know when they are taking a placebo or active drug. When asked how they know what they are taking, when even their doctor doesn’t know, their answer is inevitable: drugs give side effects. If patients don’t experience side effects, they suspect that they have been given a placebo and so may sink back into depression. However, those who do experience side effects are more likely to think that they are ‘getting something for their money’; therefore, improvements follow. Thus, in spite of (and, in many instances, because of) dangerous and, at times, life-threatening side effects, being administered medication by someone in authority satisfies a need in a depressed person. In this case, it is the emotional need for attention.
Thankfully, Kirsch reassures his readers that guidelines issued by organisations such as the American Psychiatric Association (APA) and the UK’s National Institute for Health and Clinical Excellence (NICE) encourage health professionals to act in good faith when assisting a depressed person back to health. However, it is somewhat disturbing to read that APA and NICE can only ‘require’ and ‘request’ data commissioned from the drug companies – and that these requests are often defiantly refused. Even when the data are handed over, it is only after they have undergone rigorous analyses known within the industry as ‘cherry picking’, ‘salami slicing', ‘pooled analysis’, ‘assay sashaying’ and comparison controls – all tricks of the trade to enable positive reports to be published rather than negative ones. Equally alarming, Kirsch found that information on trials deemed of ‘no value’ (ie data that produced negative results) was deliberately hidden by the FDA.
Kirsch’s book reveals startling evidence of how these important organisations, initially set up to act in the best – and legal – interest of public health, appear to end up adhering to the whims of a profit-greedy industry instead of serving the doctors whose intent is to heal. Kirsch writes of some quite disturbing stumbling blocks he faced in his effort to give a fair representation of the data. For instance, certain drug trials (for Seroxat, Lustral and Cipramil), were missing data – even in the FDA medical and statistical reviews. Similarly worrying, he found that only two studies showing positive results are required to show that a drug works, yet any number of studies can be commissioned until two that produce positive results are achieved (presumably after the ‘rigorous analyses’ described above) and those positive studies can be published multiple times.
Another serious concern Kirsch raises in his book is the chemical-imbalance theory. He questions why this theory was so widely accepted when the only controlled scientific studies on it were completed by doctor–researchers David Healy and Michael Shepherd, who could find little direct evidence for it and concluded that it was a mistaken belief: their work was ignored. Also, even though during the last 50 years researchers have tried to find more direct evidence for the chemical-imbalance theory of depression, they have failed. Kirsch even goes as far to say “Much of the evidence found is contradictory or runs counter to the theory”. Mind boggling!
Now that many people, from academics to tabloid journalists and the general public have been made aware of the placebo effect and the ‘dirty little secrets’ that Kirsch highlights, there’s a grim question that lingers. Are those acting on behalf of public health turning a blind eye to double-blind studies in an effort to line their own pockets with cash commissions and flyaway freebies? If Kirsch and other academics are, time after time, drawing attention to the dearth of facts to support the chemical imbalance theory, then is it not time for the ethical diligence of the drug companies be called into question?
Since its publication The Emperor’s New Drugs has helped to usher in sweeping changes in the way prescriptions are handled by those who practice ethically. And, apart from encouraging doctors to offer alternative treatments to antidepressants, Kirsch’s research has also led to continued fervent debate on the entire practice of prescribing. His work has certainly played the Emperor’s tailors at their own game.
Kirsch’s book is an account of how, with meticulous research and a firm resolve to find answers, he gathered documented data from the Food and Drug Administration’s (FDA) vast vaults of unpublished material on clinical drug trials, using the Freedom of Information Act to do so. Although Kirsch originally set out to test the placebo effect in treatment of depression, he sensationally stumbled over enlightening data on the ineffectiveness of antidepressant drugs when compared to therapeutic interventions (chiefly cognitive-behavioural therapy, as it is evidence based). His resolute tenacity led him to analyse clinical trials involving over 3,000 depressed patients, which has resulted in astonishing fact after fact falling over each other on every page. The answers Kirsch arrived at plainly show that strong prescription drugs for depression offer only marginal improvements over placebo.
His book gives details of how President Bush Snr signed bills allowing the FDA to charge drug companies fees to evaluate new products. Ironically, instead of helping to smooth the process of getting much needed healing drugs onto the market quicker, which was the intention, this action enabled ethical boundaries to be breached by seemingly unscrupulous industry executives keen to line their own pockets. Canny drug companies saw this as a loophole in their favour: as they commissioned the research, the power to publish only the positive studies lay in their hands – thus benefiting their profit margins. Hence, in similar vein to the Emperor’s fabricating tailors, representatives of the pharmaceutical industry appear to have wasted no time in weaving their marketing magic to put the best gloss on their merchandise.
Early on, Kirsch kindly issues a warning that the technicalities of clinical trials and subsequent number crunching may prove a little difficult for the layperson to grasp. What comes across in his surprisingly easy-to-read and often entertaining text is that he agrees with clinical practice evidence. Even his own meta-analysis in the book shows that the administration of antidepressants can offer meaningful improvement in a patient’s life. What Kirsch is concerned about is why they work, when they do. To illustrate his point, he lists some very vile brews and torturous practices that have been tested throughout history in clinical practice. For instance, lizard’s blood and crocodile dung were particular favourites, while dolphin’s genitalia and frog’s sperm were also cast into the cauldron. Kirsch quotes Morris and Shapiro’s 1978 study that found many patients were “purged, poisoned and punctured, blistered, bled and leached” and “if the patients weren’t killed by these treatments, they were deemed to have made them better”. So, convoluted concoctions seem to have worked equally as well in the Emperor’s days as the ‘pill for every ill’ appears to do today.
However, the main point Kirsch makes in his book is that true comparisons of effectiveness cannot exclude placebo effects from the statistical data. For instance, one graph highlights results that show little improvement from patients given placebos, and only marginal improvement in the response of chronically depressed patients who were administered strong drug doses. Why, he asks, is there is such a small difference in statistical evidence when comparing heavy-duty drugs to the apparently ineffective placebo? One of the answers repeatedly underlined (and one which the human givens perspective has confirmed since its inception) is that people appear to gain benefits simply as a result of being treated. For example, in a Dutch study on medication for ulcers that Kirsch unearthed, patients whose doctors administered four doses a day were understood to “improve at a significantly greater rate” than those given the same medication twice a day. However (and here’s the crunch), what both patient groups had taken were placebos.
Kirsch’s attempts to act in an ethical manner are admirable and his book details the extreme lengths he goes to in order to ensure that his extracts from studies are fair – because, as he shows, even though studies are carried out carefully, they may not yield true answers. For instance, double-blind studies of antidepressant drugs are commonly not double blind in practice, as patients very often know when they are taking a placebo or active drug. When asked how they know what they are taking, when even their doctor doesn’t know, their answer is inevitable: drugs give side effects. If patients don’t experience side effects, they suspect that they have been given a placebo and so may sink back into depression. However, those who do experience side effects are more likely to think that they are ‘getting something for their money’; therefore, improvements follow. Thus, in spite of (and, in many instances, because of) dangerous and, at times, life-threatening side effects, being administered medication by someone in authority satisfies a need in a depressed person. In this case, it is the emotional need for attention.
Thankfully, Kirsch reassures his readers that guidelines issued by organisations such as the American Psychiatric Association (APA) and the UK’s National Institute for Health and Clinical Excellence (NICE) encourage health professionals to act in good faith when assisting a depressed person back to health. However, it is somewhat disturbing to read that APA and NICE can only ‘require’ and ‘request’ data commissioned from the drug companies – and that these requests are often defiantly refused. Even when the data are handed over, it is only after they have undergone rigorous analyses known within the industry as ‘cherry picking’, ‘salami slicing', ‘pooled analysis’, ‘assay sashaying’ and comparison controls – all tricks of the trade to enable positive reports to be published rather than negative ones. Equally alarming, Kirsch found that information on trials deemed of ‘no value’ (ie data that produced negative results) was deliberately hidden by the FDA.
Kirsch’s book reveals startling evidence of how these important organisations, initially set up to act in the best – and legal – interest of public health, appear to end up adhering to the whims of a profit-greedy industry instead of serving the doctors whose intent is to heal. Kirsch writes of some quite disturbing stumbling blocks he faced in his effort to give a fair representation of the data. For instance, certain drug trials (for Seroxat, Lustral and Cipramil), were missing data – even in the FDA medical and statistical reviews. Similarly worrying, he found that only two studies showing positive results are required to show that a drug works, yet any number of studies can be commissioned until two that produce positive results are achieved (presumably after the ‘rigorous analyses’ described above) and those positive studies can be published multiple times.
Another serious concern Kirsch raises in his book is the chemical-imbalance theory. He questions why this theory was so widely accepted when the only controlled scientific studies on it were completed by doctor–researchers David Healy and Michael Shepherd, who could find little direct evidence for it and concluded that it was a mistaken belief: their work was ignored. Also, even though during the last 50 years researchers have tried to find more direct evidence for the chemical-imbalance theory of depression, they have failed. Kirsch even goes as far to say “Much of the evidence found is contradictory or runs counter to the theory”. Mind boggling!
Now that many people, from academics to tabloid journalists and the general public have been made aware of the placebo effect and the ‘dirty little secrets’ that Kirsch highlights, there’s a grim question that lingers. Are those acting on behalf of public health turning a blind eye to double-blind studies in an effort to line their own pockets with cash commissions and flyaway freebies? If Kirsch and other academics are, time after time, drawing attention to the dearth of facts to support the chemical imbalance theory, then is it not time for the ethical diligence of the drug companies be called into question?
Since its publication The Emperor’s New Drugs has helped to usher in sweeping changes in the way prescriptions are handled by those who practice ethically. And, apart from encouraging doctors to offer alternative treatments to antidepressants, Kirsch’s research has also led to continued fervent debate on the entire practice of prescribing. His work has certainly played the Emperor’s tailors at their own game.
October 31, 2023
Provocative books like this are dangerous, and I have to admit I approached The Emperor’s New Clothes with a fair degree of skepticism because of the hyperbolic title, “Exploding the antidepressant myth”. Candidly, I only read it because Irving Kirsch is an academic with a fair degree of experience with what appears to be the right credentials.
In short, Irving claims that antidepressants have zero efficacy (in the therapeutic definition of the term) at curing depression. This is an extremely provocative statement, and candidly I have no expertise to contest this claim. The problem is that unless you are literally a psychiatrist - do you really know what you’re reading?
There is no doubt that psychiatry is the most fraught field of medicine, having long been within the provinces of psychotherapists and “alienists” in the 19th and 20th century. Because of its distinctive lack of pathology, patients have historically been subject to bizarre (and Nobel Prize winning) barbaric procedures such as lobotomy and insulin-induced comatoses. Even today, the biological underpinnings of psychiatry have remained largely elusive. As a result, most of the drugs for depression are subpar, in contradistinction to cancer or heart disease, for example.
Given this backdrop, course there is validity to skepticism behind antidepressants. However, the idea that all antidepressants are essentially a placebo effect and have zero chemical effect on neurobiology struck me as outlandish. To be specific, Kirsch is critical of a consistent finding in psychiatry, which is that antidepressants offer minimal advantages over placebo on the Hamilton Depression Scale (a widely used clinician-administered depression assessment scale).
I don’t think anyone disputes the improvement is small, nor that only a subset of patients improve due to antidepressants. But Kirsch further asserts that this minor improvement is due to what he calls “breaking the blind” - i.e because these drugs have side effects, patients know they’ve gotten the drug, and therefore believe themselves to be better. How true is this? Well, there have been plenty of antidepressants with side-effects, but patients don’t report feeling any better. Some are certainly better than others.
This is a book that’s both fascinating in the questions it presents and comes across as rigorous, but is somewhat unconvincing - at least to my non-expert eyes. I found myself constantly opening my browser to do some background reading, and I can’t imagine the average reader would do the same unless this happens a subject they are deeply interested in.
In short, Irving claims that antidepressants have zero efficacy (in the therapeutic definition of the term) at curing depression. This is an extremely provocative statement, and candidly I have no expertise to contest this claim. The problem is that unless you are literally a psychiatrist - do you really know what you’re reading?
There is no doubt that psychiatry is the most fraught field of medicine, having long been within the provinces of psychotherapists and “alienists” in the 19th and 20th century. Because of its distinctive lack of pathology, patients have historically been subject to bizarre (and Nobel Prize winning) barbaric procedures such as lobotomy and insulin-induced comatoses. Even today, the biological underpinnings of psychiatry have remained largely elusive. As a result, most of the drugs for depression are subpar, in contradistinction to cancer or heart disease, for example.
Given this backdrop, course there is validity to skepticism behind antidepressants. However, the idea that all antidepressants are essentially a placebo effect and have zero chemical effect on neurobiology struck me as outlandish. To be specific, Kirsch is critical of a consistent finding in psychiatry, which is that antidepressants offer minimal advantages over placebo on the Hamilton Depression Scale (a widely used clinician-administered depression assessment scale).
I don’t think anyone disputes the improvement is small, nor that only a subset of patients improve due to antidepressants. But Kirsch further asserts that this minor improvement is due to what he calls “breaking the blind” - i.e because these drugs have side effects, patients know they’ve gotten the drug, and therefore believe themselves to be better. How true is this? Well, there have been plenty of antidepressants with side-effects, but patients don’t report feeling any better. Some are certainly better than others.
This is a book that’s both fascinating in the questions it presents and comes across as rigorous, but is somewhat unconvincing - at least to my non-expert eyes. I found myself constantly opening my browser to do some background reading, and I can’t imagine the average reader would do the same unless this happens a subject they are deeply interested in.
October 28, 2019
In my late teens and again in my early twenties, I was prescribed psychopharmaceutical drugs within minutes of initial appointments with medical and mental health practitioners. The near immediate pathologizing of my experience felt profoundly reductive and, for me, harmed more than it helped. This has been the experience of far too many people I know. Kirsch's work contextualizes these problems. It's about the countless studies Big Pharma has buried finding that anti-depressants are often no more effective than placebos, dangerous anti-depressant withdrawal issues, potentially fatal side effects of medicating children, and it's about the 'chemical imbalance' theory from which drug companies have made billions in profits. Kirsch is thorough, level-headed, easily readable. I'd love a discussion about his conclusions with anyone, any time.
January 8, 2020
I don't think this is a must read necessarily unless you are into research. Basically antidepressants have been shown to be not much more effective, if at all more effective, than placebos. This author presents an analysis of the research that drug companies have not published. It's definitely an interesting look at the placebo effect.
June 7, 2023
A must-read for primary care physicians at all levels, Kirsch has mastered the research and nailed the explanation, but misses in his application and conclusion.
February 23, 2024
Interesting discussion of antidepressants, placebos, CBT, and exercise as well as recommendations for other books that are supposed to help with depression.
Read
April 7, 20202016.10.30–2016.11.08
Contents
Kirsch I (2009) (07:18) The Emperor's New Drugs - Exploding the Antidepressant Myth
Brand Names
Acknowledgments
Preface
1. Listening to Prozac, but Hearing Placebo
• Are all drugs created equal? Double-blind or double-talk
• Antidepressants as active placebos
2. The ‘Dirty Little Secret’
• The vanishing drug effect
• Depression severity and antidepressant efficacy
• A little goes a long way
• Secrets and revelations
• Pharmaceutical companies keeping mum
• Picking cherries and slicing salami
• Regulatory agencies keeping mum
• Why were the drugs approved? Voodoo science
• The assay sashay
3. Countering the Critics
• ‘Antidepressants work in clinical practice’
• Clinical practice versus clinical trials: The STAR*D trial
• Clinical trials are flawed
• The trials were too short
• The subjects were not depressed enough
• The subjects were too depressed
• The patients were not representative
• The burden of proof
• Subsequent trials show different results
• Oil and water or guns and knives?
4. The Myth of the Chemical Imbalance
• How the brain works
• Invention of the chemical-imbalance theory
• The empirical basis of the chemical-imbalance theory
chemical-imbalance theory
• The myth of reserpine-induced depression
• What happens when serotonin is reduced
• Too many antidepressants work too well
• SSREs: The last nail in the coffin
• Theorists leaving a sinking ship
• Depression, disease and the brain
5. The Placebo Effect and the Power of Belief
• The discovery of the placebo effect
• The power of placebo
• Placebo surgery
• Mind and brain
• Brain and body
• The nocebo effect
• Depression as a nocebo effect
6. How Placebos Work
• The therapeutic relationship
• Feeling good
• The specifics of ‘non-specific’ effects
• Classical conditioning
• Expectancy and conditioning
• Harnessing the placebo effect in clinical practice
7. Beyond Antidepressants
• Warning: Do not discontinue anti-depressants without consultation
• Prescribing placebos
• Placebos without deception
• Psychotherapy: The quintessential placebo
• Psychotherapy, medication, or both?
• Is psychotherapy a placebo?
• The costs of psychotherapy
• St John’s wort
• Physical exercise
• Psychotherapy without psychotherapists
• Social change
Epilogue
• ‘Don’t rock the boat’
• ‘Don’t ask, don’t tell’
Notes
Bibliography
Index
Contents
Kirsch I (2009) (07:18) The Emperor's New Drugs - Exploding the Antidepressant Myth
Brand Names
Acknowledgments
Preface
1. Listening to Prozac, but Hearing Placebo
• Are all drugs created equal? Double-blind or double-talk
• Antidepressants as active placebos
2. The ‘Dirty Little Secret’
• The vanishing drug effect
• Depression severity and antidepressant efficacy
• A little goes a long way
• Secrets and revelations
• Pharmaceutical companies keeping mum
• Picking cherries and slicing salami
• Regulatory agencies keeping mum
• Why were the drugs approved? Voodoo science
• The assay sashay
3. Countering the Critics
• ‘Antidepressants work in clinical practice’
• Clinical practice versus clinical trials: The STAR*D trial
• Clinical trials are flawed
• The trials were too short
• The subjects were not depressed enough
• The subjects were too depressed
• The patients were not representative
• The burden of proof
• Subsequent trials show different results
• Oil and water or guns and knives?
4. The Myth of the Chemical Imbalance
• How the brain works
• Invention of the chemical-imbalance theory
• The empirical basis of the chemical-imbalance theory
chemical-imbalance theory
• The myth of reserpine-induced depression
• What happens when serotonin is reduced
• Too many antidepressants work too well
• SSREs: The last nail in the coffin
• Theorists leaving a sinking ship
• Depression, disease and the brain
5. The Placebo Effect and the Power of Belief
• The discovery of the placebo effect
• The power of placebo
• Placebo surgery
• Mind and brain
• Brain and body
• The nocebo effect
• Depression as a nocebo effect
6. How Placebos Work
• The therapeutic relationship
• Feeling good
• The specifics of ‘non-specific’ effects
• Classical conditioning
• Expectancy and conditioning
• Harnessing the placebo effect in clinical practice
7. Beyond Antidepressants
• Warning: Do not discontinue anti-depressants without consultation
• Prescribing placebos
• Placebos without deception
• Psychotherapy: The quintessential placebo
• Psychotherapy, medication, or both?
• Is psychotherapy a placebo?
• The costs of psychotherapy
• St John’s wort
• Physical exercise
• Psychotherapy without psychotherapists
• Social change
Epilogue
• ‘Don’t rock the boat’
• ‘Don’t ask, don’t tell’
Notes
Bibliography
Index
April 23, 2014
As I've been reading The Emperor's New Drugs: Exploding the Antidepressant Myth, I've found that when I mention the book and its ideas to friends, those ideas generate a healthy amount of skeptical resistance. The claims the book makes are rather surprising -- that there is no difference in clinical efficacy between SSRI drugs used to treat depression (such as Prozac) and an active placebo (i.e. a placebo with active biochemical side effects), that depression is a condition which responds particularly well to the placebo effect and it is this response to placebo which makes SSRIs effective, and that 'chemical imbalance' neurotransmitter centric theory of depression is mistaken.
At first glance, these ideas seem to be some Jenny McCarthy level psuedoscience. I would be quite skeptical of these ideas myself, if it weren't written by an author who has published peer reviewed papers on the same topic in respectable medical journals. I would be skeptical if the explanation about how SSRIs have received FDA approval weren't so convincing -- specifically that placebo controlled studies often compare an inert placebo, rather than an active placebo, to the treatment in question, and that drug companies do multiple trials before selecting a favorable result to be published. I would be skeptical if the author hadn't so clearly explained the many surprising medical results which seem to be rooted in the placebo effect.
However, The Emperor's New Drugs is convincing. Irving Kirsch has done his homework, going so far as to use the Freedom of Information Act to retrieve records of unpublished clinical trials submitted to the FDA for drug approval, and performing a meta-analysis on those trials which does indeed seem to show that antidepressants as we know them are no more than active placebos. And, to be clear, that is a very different statement from saying that antidepressants don't work. Antidepressants do work. They do provide many people with real problems a measure of relief. It just turns out that the mechanism through which they work might have been, until recently, quite misunderstood.
At first glance, these ideas seem to be some Jenny McCarthy level psuedoscience. I would be quite skeptical of these ideas myself, if it weren't written by an author who has published peer reviewed papers on the same topic in respectable medical journals. I would be skeptical if the explanation about how SSRIs have received FDA approval weren't so convincing -- specifically that placebo controlled studies often compare an inert placebo, rather than an active placebo, to the treatment in question, and that drug companies do multiple trials before selecting a favorable result to be published. I would be skeptical if the author hadn't so clearly explained the many surprising medical results which seem to be rooted in the placebo effect.
However, The Emperor's New Drugs is convincing. Irving Kirsch has done his homework, going so far as to use the Freedom of Information Act to retrieve records of unpublished clinical trials submitted to the FDA for drug approval, and performing a meta-analysis on those trials which does indeed seem to show that antidepressants as we know them are no more than active placebos. And, to be clear, that is a very different statement from saying that antidepressants don't work. Antidepressants do work. They do provide many people with real problems a measure of relief. It just turns out that the mechanism through which they work might have been, until recently, quite misunderstood.
November 20, 2011
Kirsch starts the book by stating some simple facts from his original metastudy of efficacy of the antidepressant drugs, then continues deeper into the possible meanings of those results, and ends up debunking the whole chemical imbalance theory. Nice job!
The whole book is interesting read. It gives insight on how the drug approval process works, and also about the double standards evident in the field. Even if you take out the debunking of antidepressants, it has plenty of information about how the placebos work - after all, researching placebo effect was Kirsch's original goal.
Regarding the concerns that some reviewers have stated about this being dangerous if people stop taking their drugs... The book states several times you shouldn't do decisions on your medication on your own. It also suggests several alternative treatments, and points towards research to back those suggestions up.
The most important message this book has, I think, comes after about ten pages and is in some way or another reinforced throughout the book. The message is: Do something. Whether it's drugs, therapy or half a dozen other choices, the important thing is to take action.
The whole book is interesting read. It gives insight on how the drug approval process works, and also about the double standards evident in the field. Even if you take out the debunking of antidepressants, it has plenty of information about how the placebos work - after all, researching placebo effect was Kirsch's original goal.
Regarding the concerns that some reviewers have stated about this being dangerous if people stop taking their drugs... The book states several times you shouldn't do decisions on your medication on your own. It also suggests several alternative treatments, and points towards research to back those suggestions up.
The most important message this book has, I think, comes after about ten pages and is in some way or another reinforced throughout the book. The message is: Do something. Whether it's drugs, therapy or half a dozen other choices, the important thing is to take action.
September 10, 2011
Based on his analysis of all of the published and unpublished clinical trials submitted to the FDA, Kirsch argues that antidepressants (SSRIs) do work but aren't better than placebos. This in itself isn't a problem except that antidepressants come with a host of undesirable side effects including increased risk of suicide, sexual dysfunction, seizures, anxiety, increased cost to patients, etc. He also explains the "theory" of chemical imbalance and why it isn't a plausible explanation for depression. If the data seem to line up against the use of antidepressants, why do people continue to use them? Kirsch explores the reasons for their continued widespread use.
The second half of Kirsch's book examines the placebo effect, and how it might be used to treat depression. This to me is the most fascinating part of the book. Kirsch offers plenty of examples of clinical research that illustrate his points. In the end, he recommends Cognitive Behavioral Therapy (CBT) as the most clinically-proven, long-term treatment for depression.
The second half of Kirsch's book examines the placebo effect, and how it might be used to treat depression. This to me is the most fascinating part of the book. Kirsch offers plenty of examples of clinical research that illustrate his points. In the end, he recommends Cognitive Behavioral Therapy (CBT) as the most clinically-proven, long-term treatment for depression.
Displaying 1 - 30 of 105 reviews