The drugs don’t work. Or do they?

June 24, 2011 by
Filed under: Public policy, The RSA 

Across the developing world there is an explosion in the use of drugs to treat mental illness. But is there really an increase in mental ill health and do these drugs work? 

These are huge issues with implications for how we view modern society, for public health, for state spending and for our trust in pharmaceutical firms, some of which are amongst the world’s most powerful global corporations.

On the grounds of fairness I have to declare a personal interest. In response to my general tendency towards gloominess and low level anxiety I did try out one drug myself. It didn’t work but I’m not suggesting this is of any relevance (it may have been the wrong drug for me and perhaps I didn’t stick with it long enough). My own experience did however get me interested in the growing literature about the mental illness epidemic and the burgeoning global industry in psychoactive drugs.

If the issue interests you then you really must read this article from the current New York Review of Books. It summarises three new books which argue that:

Despite the growth in diagnosis and treatment, there is no evidence of an underlying increase in mental health morbidity. Neither – in relation to the fastest rising disease diagnoses – is there any evidence of chemical imbalances in the brains of patients. In other words, the problem the drugs are supposed to solve is an illusion.

There is similarly very little evidence of the efficacy of psychotropic drugs. ‘Active placebos’ work just as well (or as badly depending how you look at it). But there is growing evidence that psychotropic drugs may create chemical imbalances leading to more and more patients having to take a cocktail of drugs as one counteracts the effects of the others (or the effects of trying to come off the others).     

One reason this evidence is doing nothing to stem the tide of prescription and state and private spending on these drugs is that the big pharma has managed to rig the process of drug assessment. Remarkably, while the occasional trials which find positive outcomes are published the much more frequent ones that don’t are routinely suppressed. This system is kept in place is probably not unrelated to the huge monies invested by pharma in lobbying the medical establishment, media and politicians.

Many people have been trying for years to raise awareness of these profound issues and in this blog I am just riding on their coat tails. But if the evidence in the NYRB article is true this is one the great mass delusions and corporate scandals of our time. So why hasn’t the issue become an urgent public debate?

My theory is that the tide of public and professional concern is held back by a dam comprising:

The massive power of big pharma

The commendable desire of doctors to want to offer their patients a simple solution to genuine difficulties in their lives

The deep craving among the public for such solutions

Confirmation bias and the difficulty we all have in distinguishing between anecdotal and statistical evidence 

And something which is less obvious, the predisposition of the political left (the people you might expect to spearhead a critique) to embrace the idea that modern consumer capitalism drives people to depression and madness.

So here are my questions:

Do readers share my view that this is potentially one of the biggest social and public policy issues of our time?  

Are the concerns I raise real or is just that I have only heard one side of the debate?

If the issues are real and important should the RSA be using its capacity to reach a global audience to highlight them? Should we perhaps be seeking to convene a short sharp commission of experts to try to make an independent and authoritative statement about what is really happening to our mental health and drug budgets?

This is all very heavy stuff so I should end with today’s pathetic joke (in tests seven out of ten of my blog readers say my jokes are better for their well-being than anti-depressants). I’m afraid this is an aural joke and only succeeds if you know who is the MP for Richmond Park and North Kingston…

What is the difference between a leading anti-depressant brand and the diligent Parliamentary Assistant to the MP for Richmond Park and North Kensington?

They are both pro-Zac but – allegedly – only one of them really works.

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18 Comments on The drugs don’t work. Or do they?

  1. Claude Borenzweig on Fri, 24th Jun 2011 1:37 pm

    2. In my training I worked at a New York State mental hospital. The population was almost entirely indigent. Access to benefits and services was based on having a diagnosis. Though our mission was supposedly to help our “consumers” (yes that is officially mandated language) regain healthy productive lives back in the mainstream, any improvement that threatened the diagnosis also threatened access to benefits and services. You get the picture. All this while the staff enjoyed fine free lunches/sales pitches a couple of times a week by big pharma reps.

    Snapshot: One monthly injection of a neuroleptic med could cost $900 but there was little to no money available to support vocational rehab without the diagnosis. This is “first world” government policy.

  2. Ahmed Zghari on Fri, 24th Jun 2011 1:42 pm

    3. The physiology of anxiety, stress & depression are intertwined. Often the best way to find out which a person suffers from is to ask them, because the physical signs are indistinguishable.

    At a macro level, the NHS (as well as most healthcare systems around the world) is under pressure because of the latent and delayed effects of anxiety, stress & depression.

    The variety of conditions and treatments linked to alcohol, smoking, obesity & drugs have their ultimate causation rooted in behaviour that begins or is linked to one of these conditions. The long-term effects being reduced life expectancy or reduce disability free life expectancy. The Glasgow effect is largely linked to these causes.

    Traditionally, people have turned to smoking, alcohol or other recreational drugs to ease their stress or sustained anxiousness. As these have become the targets of policy measures, people have shifted (mostly added) their sources of help to medical treatments and food.

    The reality behind the drugs that are used for depression and anxiety is that the scientists don’t really know why they ultimately work. They know they change the levels of neurotransmitters in the brain, but they don’t know the cascade impact they are actually having on individual brain cells, connections and the regulatory components of individual brain cells.

    To that end, the process of developing drugs is trial and error. Prozac as a treatment for depression was created in error, but happens to be very good, for some. St John’s Wort is just as effective, but it can’t be so easily controlled by big businesses, so you don’t hear about it.

    Talk therapy is equally as good as some drugs, because therapy helps the brain change its own levels of active brain chemicals. But who is around to advertise the fact that talking to your best mate or your Nan is just as effective as a box of expensive pills that helps to pay for thousands of children to be privately educated?

    There are some fundamental issues here such as drug companies hiding behind smoke and mirrors and pedalling drugs which they don’t really know why or how they work, at best they know they won’t kill people. But because the scientists hide behind PhD, we all assume they know better or would behave more responsibly. The financial system suffered from the same presumptions. We should be holding PhD’s for hire to account and asking more detailed questions, in public forums.

    Secondly, in a modern world anxiety, stress and depression are manifestations of social and societal problems. That is where the longer-term action is really at and where Oxford University is making positive strides at laying out the underlying issues.

    The most interesting treatments being investigated at the moment recognise the limitations of any drugs as being effective over the longer-term. The new research is focused on introducing low-level viruses into the areas of the brain where anxiety, stress and depression manifest themselves. Would love to see these researchers speaking at the RSA.

  3. Dennis Sklyarenko on Fri, 24th Jun 2011 2:04 pm

    4. I believe it is one of the most important issues of our time, it is quite alarming to see how big pharmaceutical companies lobby their interest via politics especially here in the Ukraine, sometimes i feel it has become a tasting ground for new drugs (and what is scarier to think of is that it is very hard for a consumer or patient to know what exactly is in them or do they even work).

    They are driven by the desire of a bigger profit margins and not by the desire to serve the humanity.

    They protect (by political laws) those who sell the drug, and if it the drug which actually works, you can only get it in one pharmacy out of 50 in the city, and pay outrages cost for it. (ex. would be Interferon).

    It is definitively right time to raise people awareness about the drugs, and companies who produce them, make the process of creating new drug open to everyone, for if we will let the pharmaceutical companies to be driven by the profit, it is terrifying to imagine what we will have in a near future….. not everything should be treated with the drug.

    Sorry for not fully developing my thoughts, only today came across the RSA website, it is fantastic, i regret not finding it sooner…….. i’ll will study it thoroughly and promise to be more concise on my thoughts.

    Keep the thinking going :)

  4. Susan J Royce on Fri, 24th Jun 2011 3:45 pm

    5. When and why did we collectively decide that it was the natural condition of humans to be happy, well adjusted and content all the time and that, if you were not, you should rush off to your doctor or therapist for a cure? I am continually struck by how ‘normal’ our ancestors appear despite living with levels of loss and pain we now view as unbearable.

    PS Thank you for continuing to blog. Your blogs always make me think, even and perhaps especially, when I do not agree with you!

  5. Patrick Andrews on Fri, 24th Jun 2011 3:57 pm

    6. Good blog – thanks.

    Completely agree about this being a major issue of our time. Very tempting to blame big pharma, but where do you stop? You have to also implicate politicians, doctors, patients, all of us looking for a quick fix. I admit I am not exactly neutral – my wife is a homeopath, and I see how alternative medicine is demonised. Yet we have got to the state when alternative simply means things like change your diet, change your friends, do some exercise, watch less TV. None of these are encouraged by the system – taking more drugs is.

    My own particular perspective is to link this with the incessant drive for growth in our economy – I see no encouragement anywhere for people to consume less (food, drugs, rainforest, energy, tv, sugar) when all the evidence is that consuming less of these would solve most of the problems we face. But what such behaviour would certainly do is cause our economy to crash – it is simple mathematics, an inevtiable consequence of the way our money is created and put into circulation. Since the priority for every business and every politiician is economic growth, there is massive subtle and not so subtle pressure on us to increase our consumption of all of the above.

    I would love us to have a sensible conversation about whether our economy crashing would really be such a bad thing. It is anyway inevitable as soon as peak oil hits, so let’s start preparing. Could the RSA start that conversation?

  6. Tom Brookes on Fri, 24th Jun 2011 4:43 pm

    7. 5-minute TED talk on this issue – Joshua Walters on being just crazy enough:

    http://www.ted.com/talks/joshua_walters_on_being_just_crazy_enough.html

    I’m sure Barry Schwartz would tell us that the paradox of choice is making us mentally ill too – & I seem to recall Ken Robinson suggesting that ADHD is a fictitious epidemic attributed to overstimulated kids.

    The evidence is mounting to suggest that quite a few mental conditions, medicated ones, are a byproduct of our obsession with labelling mingled with hypochondria. This is definitely worth the RSA’s time. We can’t have perfectly healthy eccentric people convinced they’re ill & doped up; unable to come up with anything innovative. Perish the thought.

  7. Kelsey Elder on Fri, 24th Jun 2011 5:21 pm

    8. Also declaring a personal interest here: I used to struggle with severe depression and anxiety, and the meds seem to have worked for me. I hesitated for years before going on them, worrying that they were just a “quick fix,” that I should work harder to cure myself, or that they would change my personality.

    When I finally reached a point of desperation, I was willing to try anything. Going on medication was anything but a quick fix. I worked for several months with a psychiatrist, trying different medications and dosages until we found one that worked and had few side effects. Now, I actually have a chance at working on the issues underlying my depression and anxiety, instead of constantly fighting just to survive.

    I understand the concerns being expressed here, but we also need to remember that the hellish suffering brought about by mental illness is very real. The stigma surrounding these conditions and the medications used to treat them doesn’t help. This may be public health issue, but it’s also very much a personal issue, and I would like to see a greater understanding and appreciation of that personal dimension in discussions such as these.

    Thank you.

  8. Graham Wilson on Fri, 24th Jun 2011 7:05 pm

    9. Declaration of personal interest: I’m a psychotherapist with a PhD.

    I don’t dispute that there are issues here, but as a test case, I would personally have chosen something like painkillers, antibiotics or antihistamines before tackling psycho-pharma products.

    At the end of the day, whether there are social reasons why psychological conditions are being diagnosed more frequently or not, the person suffering is an individual and they deserve the respect of individual attention. They don’t deserve to be hidden as a statistic.

    Tackling social issues is not going to be achieved by effectively denying the experience of a lot of individuals.

    Best wishes
    Graham

  9. G on Fri, 24th Jun 2011 9:34 pm

    10. Do you ever read Ben Goldacre’s ‘Bad Science’ column in (predictably) The Guardian??

    He’s good in this area – probably less philosophical and more mathematical but interesting nonetheless.

    http://www.badscience.net/2011/05/asking-the-wrong-question-how-crap-research-gets-drugs-to-market/

  10. Rob on Fri, 24th Jun 2011 11:08 pm

    11. RSA could do a commission on legal drugs? Check out Sami Timimi on children and Ritalin http://onlinelibrary.wiley.com/doi/10.1111/j.1070-3535.2006.00418.x/abstract

  11. Lynn Howard on Sat, 25th Jun 2011 1:53 am

    12. I’m 54 and have been on an antidepressant for 12 years (Effexor). It saved my life, my marriage, and enabled my kids to stop being frightened of their (previously) unpredictable, bad tempered mother. Nevertheless, I live in hope of one day weaning myself off. So far, such attempts have been unsuccessful. I LOVE the modern pharmaceutical industry.

  12. Joel F on Sat, 25th Jun 2011 2:50 am

    13. We just need more social interaction! This is a colder, more secluded world!

    My classmate said his doctor put him on something once and he wasn’t sure of the benefit after taking them. I told him to come with us to drink and go bowling. We formed a group of friends, all with only a few similarities, and met up at the local bowling alley with some alcohol. ;-) We had a great time and everybody was completely happy for the next few days.

    We’re all college students but I’m older than them and what I found is that this is certainly a cure for some occasional gloom.

    Honestly, I think we have a reason for gloom. This is our bodies telling us that we need something. I’m sure an evolutionary biologist would have something here to say about it but we need other people; we need social interaction. This connects us and helps motivate us all to fairly contribute to the group and to enjoy those benefits. It’s a wonderful thing. ;-)

    I say most people ought to put down the meds and interact. Those medications HELP you to remain anti-social. You don’t need the pills, you NEED the people.

  13. Graham Rawlinson on Sat, 25th Jun 2011 7:31 pm

    14. I seem to be commenting in relation to Ian Stewart and Jack Cohen a lot lately, their views as in their book, Figments of Reality. Not sure if they have given a talk at the RSA yet, you should book them. Basically, amongst other things, they talk about the evolution of systems in a complicit way. Now that sounds like your curator friend, so let’s translate. In all social groups there will evolve healthy and unhealthy response systems. At work, in families, in clubs, even in political parties, the unhealthy response systems are as natural a part of group evolution as the healthy ones. What makes them much more unhealthy is interference in such a way as to disallow the natural resolution of those response systems.
    Interference can be overprotective parentalism and or drugs. Or bullying!
    With invasive attacks on people, like cancers, there is some justification for some drugs, but even then interference with the ‘natural order of things’ should be considered.
    What is needed is not Jim’ll fix it’ but an attitude of ‘I will fix it’ with a little help from my friends. If we took away everything but the benefits of sewage systems and dentistry I wonder how different life spans would be, not much I guess, and a lot of people would be much happier. Someone needs to start a no drugs campaign which could allow people to ‘come off them’ one at a time. Or maybe we should have doctors who can volunteer to be on the no psychotropic drugs list of practitioners, like we have family friendly solicitors we have people friendly doctors. Now that’s a thought! That would be a choice I would make.

  14. Michael on Mon, 27th Jun 2011 12:57 pm

    15. Worth bearing in mind that that the debate about the nature of mental illness and the effectiveness of drugs and other treatments, and the role of professionals and drug companies, is highly contentious and extremely polarised, and there are several individuals who take extreme and entrenched positions on the spectrrum of debate.
    At times it makes the debates about Iraq/Climate change look friendly, polite and consensual.

    I would say that many people who have used precribed drug treatments, and many doctors, would challenge the the claims made in the three books you refer to, if your two paragraph summary is a fair one. Also, based on that summary, books arging the same/similar have been coming out annually for many years, so whatever else they may be, these are not all necessarily new claims.

    Because of this and more, anyone with a high public profile would be wise to enter the debate somewhat warily.

    I would suggest that:
    - Drugs have allowed countless numbers to remain functional, leading productive lives, reducing impact of their illness on thermselves, and family and friends, and in many cases saving lives.

    - outside the extremes of this debate, there is actually is a consensus among patients and doctors that, correctly prescribed, used, and monitored, the drugs DO work. (Although as these books show, some writers and thinkers disagree strongly).

    - A very significant majority of patients and doctors would say that advances in science have hugely improved effectiveness (and reduced side effects) of mental health drugs over last 20 years.
    (the advances you have talked about in neuro-science have been a big part of this. I expect you are using “big pharma” primaliry as shorthand, rather than pejoratively, but who do you think has done and paid for all that research?).

  15. matthew taylor on Tue, 28th Jun 2011 6:28 pm

    16. There are some brilliant thoughts here and I can’t do them justice in a short response. Suffice to say that I am determined that the RSA host a debate on this topic as soon as we can. When we’ve got something lined up I’ll be sure to add another comment or mention it in my main blog.

    Thanks to you all for convincing me this is something we should discuss and in a way that hears and respects all sides.

  16. Michael on Wed, 29th Jun 2011 7:55 am

    17. Matthew,

    Worth bearing in mind that the debate about the nature of mental illness and the effectiveness of drugs and other treatments, and the role of professionals and drug companies, can often be highly contentious and polarised, with very entrenched positions on the spectrum of debate.

    I would say that many people who have used prescribed drug treatments, and many doctors, would challenge the claims made in the three books you refer to, if your two paragraph summary is a fair one. Also, based on that summary, books making similar claims have been around for some time, so whatever else they may be, these are not all necessarily new claims.

    I would suggest that:
    - Drugs have allowed countless numbers to lead functional and productive lives, reducing impact of their illness on themselves, and family and friends, and in many cases saving lives.

    - outside the extremes of this debate, there is actually is a consensus among patients and doctors that, correctly prescribed, used, and monitored, the drugs DO work. (Although as these books show, some writers, disagree strongly, and some of them are doctors and other health professionals).

    - A very significant majority of patients and doctors would say that advances in science have hugely improved effectiveness (and reduced side effects) of mental health drugs over last 20 years.
    (the advances you have talked about in neuro-science are part of the picture – the drug companies that have funded/paid for the a least a good deal of the research in this area).

    (note – I originally posted a version of this on Monday 27 June, but it never went through to the live page.)

  17. Graham Rawlinson on Wed, 29th Jun 2011 11:02 am

    18. Hi Michael,

    I would not dispute that people have benefited, but one would need to put that against people being harmed, directly through misuse or underuse, or that they have been harmed indirectly by a disabling belief system which puts the actor in charge as the health professional and not the patient. Even if ‘the consensus’ of patients and doctors was that the majority benefit as people complicitly entangled in the business this would not be good evidence in its own right. On so many issues society does not have a good system for balancing different kinds of evidence. On health, education, crime or even business development, we have scatterings of evidence which are hard to interpret, and then some kind of attempt at synthesis of measures which are just not comparable. So we end up with simplistic political attribution theories where almost every citizen is a hard working tax paying good guy and the small number of bad people should be treated, got rid of, or even publicly shamed?? Bring back the stocks!
    On health people are well behaved but misinformed , almost never lazy in mind or greedy or selfish. My own view, and it is just a view, not a scientific conclusion, should that be possible, is that our drug taking of all kinds is a symptom of a pretty sick society, where work is something you do for the money, which therefore comes first, where legal redress is more important than moral rectitude, where opinion rules over judgement, where celebrity is everything even for murderers and thieves, where money buys you anything you want.

  18. Alex on Thu, 30th Jun 2011 8:03 am

    19. I’m currently a therapist who works at a MHMR center, where there are an incredible array of diagnoses clients’ have that are found in the DSM-IV. I enjoyed your blog post and agree that this is a monumental issue for millions of Americans. The issue with psychotropic medications is that people think that are “magic pills” that will solve every problem they have. In order for meds to be effective, they must be used for a duration of time (for ex., SSRI’s often wont have a noticeable affect until two weeks) and while trending therapy to address the psychological, social, and possible biological factors that has caused there life to become unmanageable. Oftentimes just finding meds that work can be very frustrating and expensive, and “cocktails” are common and very dangerous. I interned at a crisis center for a year where the staff would require each patient to take some sort of meds. No joke. While sometimes it was beneficial, 9 times out of 10 it was a frustrating time for he patient.

    That being said, psychotropic meds are absolutely necessary for certain diagnoses. I have had a few bipolar patients who did not consistently take Lithium. There is absolutely no way someone can simply “get over” a manic episode that may last for days or weeks, and is especially hard for their friends and family who watch their cycling from manic to depression. Now just because they get on lithium and are consistent, that only neurological functioning. Problems happen to all of us, and our lives are defined by how we deal with them. Meds are only a portion of the solution, not the “end all ad be all” of a good prognosis. Each person must be viewed individually, which is crucial in the world of psychotropic meds.

    The real issue here is pharma charging an arm and a leg for meds, and insurance companies who say they will only pay for four counseling sessions or for a certain number of refills. They have created a monopoly and are making tons of money off of people who simply want to get better and lead a happy, normal life. I have worked with people who ave prescribed meds to patients simply because they were paid to have their brochures in their office. Instead of caring for people and wanting to improve their life, people care more about making a profit. I’m nit saying everything should be free and we all need to be hippies, but I believe pharma’s priority of making money over helping people is the root of the problem. I can’t tell you how frustrating it is to see a client who was making progress in therapy, but then gets worse because they couldn’t afford his/her meds anymore. This is a huge issue and one that must be discussed with caring for people being the main objective, not money.

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