Matt's Reviews > The Emperor's New Drugs: Exploding the Antidepressant Myth

The Emperor's New Drugs by Irving Kirsch
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Feb 19, 12

Read in January, 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.
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