Are placebos — sugar pills — just as effective as antidepressant medications in the treatment of mild and moderate depression? That’s what a 60 Minutes piece last night tried to find out.
In discussing her reaction to discovering that the placebo effect may be more powerful than we previously knew in antidepressant research, CBS’s 60 Minutes correspondent Lesley Stahl says, “I walked away really confused.”
After viewing her piece, I walked away with the same reaction.
What’s an ordinary person supposed to gain from watching this segment, boiling down decades’ worth of antidepressant research and thousands of studies into less than 20 minutes? I’m not sure.
Irving Kirsch is the Harvard researcher and psychologist who is featured prominently in the 60 Minutes’ piece that ran last night. He wrote a book a few years ago detailing the power of placebo in depression trials, The Emperor’s New Drugs: Exploding the Antidepressant Myth. So you know where his bias is — that antidepressants aren’t any more effective than a sugar pill when it comes to mild or moderate depression. (He even explains their impact in severe depression as a result of the flawed methodology of blinded drug trials.)
What wasn’t mentioned in the 60 Minutes piece, because it was opinion journalism forwarding a specific viewpoint, is that Kirsch’s research is selective. He hasn’t looked at every antidepressant study ever done (now numbering in the thousands). He only looked at the clinical trials required to gain U.S. Food and Drug Administration approval for 6 antidepressant drugs (there are over a dozen on the market).
This is important for a number of different reasons. FDA clinical trial approval studies are rarely very long, so they don’t reflect how antidepressants are prescribed in real life — for months and even years at a time. Subjects in these studies are also very much not like ordinary people, because anyone who has any other condition or health concern is often excluded from the study. They only look at people who have straight-up depression, with nothing else going on in their lives, and who are on no other medications or taking any other kind of treatment.
Last, these studies are the absolute beginning of research into these antidepressants — not the end, and certainly not the last word. It would be like looking at the effectiveness of a form of psychotherapy like dialectical behavior therapy (DBT) after its first 2 or 3 studies were published and drawing conclusions from those studies alone. You can do so, but you’re purposely blinding yourself to the decades’ worth of research that followed those first 2 or 3 studies.
Kirsch has been beating the placebo drum for years. Back in 2009, we noted in a blog about the efficacy of antidepressants that meta-analyses can never give you much of a picture of how individuals will react to a specific treatment. They also make assumptions that how researchers define things like “depression” are consistent (they should be — one of the reasons for the DSM — but they are often not), as well as how treatment is rated (measured by the same scale, remission rates, relapse rates, some other measure?).
We also dutifully reported when Kirsch published his book nearly two years ago. He indicts all placebo research in the interview we link to, suggesting no placebo research is really blinded, and that explains all positive drug effects found. In all psychiatric research that use blind drug trials.
At the end of the day, such pronouncements make me scratch my head. What is an ordinary person supposed to do with this information… Are we supposed to dump our antidepressants? Picket government for some sort of change?
Will Lesley Stahl’s husband, who’s been taking antidepressants for years, stop taking them knowing he might as well be putting candy in his mouth?
No. Why?
“He knows it works for him…. ‘But I know they work for me, because I feel better when I take them… I get better.'”
This is what psychologists call “confirmatory bias,” believing that something must be true because it aligns with one’s own beliefs about it. But at the end of the 60 Minutes Overtime piece, she backtracks yet again:
“If a sugar pill is just as good, how can we keep prescribing these [antidepressant] pills?” asks Stahl.
I’m left scratching my head, and like Stahl, walking away from this piece really confused.
I suspect antidepressants do work, for the reasons mentioned above about the selectivity of Kirsch’s own research into this issue. He has, however, clearly demonstrated that we may underestimate the power of placebo. There may be ways to harness this power in some way, some day… but it has to be done in an ethical manner — meaning that you can’t just lie to people about their treatment in order to gain similar benefits.
Perhaps it will also inform future FDA drug trials, so they are designed with a better understanding of these effects.
For further reading…
Transcript of the 60 Minutes segment
60 Minutes Overtime video: How the powerful placebo effect works
Read Dr. Kramer’s view in the NY Times: In Defense of Antidepressants
Read Dr. Grossi’s take on this criticism: Are antidepressants expensive placebos?
23 comments
I am a practicing psychiatrist with over 30 years experience. I came away from Ms. Stahl’s segment with a strong feeling of frustration. I am concerned that such a complex subject was addressed in such a short time and such a superficial manner. Possibly because the current widespread use of antidepressants has been the subject of much discussion and controversy, particularly in cases of mild to moderate depression, the topic of the segment was “hot”. Ms. Stahl came across as having a, “Gee whiz” reaction to many of Dr. Kirsch’s statements, and I believe I detected a slight bias on the part of the psychiatrists interviewed in favor of Dr. Kirsch’s position. In any event, antidepressants, like any other potent drugs, need to be utilized judiciously, and by appropriately trained professionals. The fact of the matter is that psychiatrist’s are the best trained mental health practitioners when it comes to prescribing antidepressants, but these are prescribed more frequently by general practitioners and internists, particularly in areas where psychiatrists are in short supply. This certainly adds to the problem of appropriate usage. There are many other factors in play, and I am all in favor of further research with respect to the issue. Most of all, I would like to hear more from psychiatrists than from psychologists regarding an area where the latter have no first-hand clinical experience with the medications in question.
As a non-professional who suffers from depression, I wanted to describe my experience with psychiatrists vs. “other medical doctors” when prescribing anti-depressants. Your comment implies that psychiatrists have special knowledge over other medical doctors when it comes to the expertise required to prescribe an anti-depressant. Anyone who has ever been diagnosed with depression and who has tried medication to treat it knows that it’s basically a shot in the dark–xyz drug may work, and it may not. It may make you worse, it may not. In my own experience, the psychiatrists I have consulted with have asked no more questions than the other medical doctors I’ve seen, and both groups handed out the prescriptions with ease. Furthermore, there is such a stigma attached to depression that most people find it difficult to seek *psychiatric* help for it, and are far more likely to surreptitiously ask their primary care physician for help during some other exam.
I must take objection to this statement, “I am concerned that such a complex subject was addressed in such a short time and such a superficial manner.”….because you just described nearly ALL patient-psychiatrist encounters. With the average patient being seen for a few minutes, imagine how the patient feels, about being rushed through a visit for approximately 15 minutes, being asked a few questions, and having a prescription scribbled. A very complex subject (the patient’s complaint!) in such a short time (15 minutes, less time than the Leslie’ Stahl interview!) and such a superficial manner!
So now you have an idea! Will wonders ever cease!
Completely agree with this statement. This guy is critical of a short story, but what about the sixty-second commercials that bombard the airwaves peddling SSRIs? Hypocrisy?
In all these years of SSRI development, is there any concrete proof that 10s of millions (!!) of people lack serotonin? You know the answer…
They to any of these emotional issues is changing how we approach problems, no pill will ever solve these.
Dr. Grohol, you state “FDA clinical trial approval studies are rarely very long, so they don’t reflect how antidepressants are prescribed in real life — for months and even years at a time.”
Therefore, the research base analyzed by Irving Kirsch does not reflect what actually occurs in clinical practice and therefore his results may not apply to clinical practice.
You imply that long-term studies of antidepressant use would confirm efficacy, showing a result different from Kirsch’s.
However, those studies do not exist. What is taking place is an uncontrolled, unmonitored 30-year field study of long-term medication on millions of people.
How can you conclude, based on anecdotal reports that some people like the result they get from medication that, long term, antidepressants meet any level of statistical significance of efficacy?
Your own “confirmatory bias†is at work here. The fact is, after 30 years of this unmonitored field study, we don’t know the long-term effects of these medications — good or bad.
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@Dr. Darell — Agreed. I too was frustrated how much of a mouthpiece the segment was just for Kirsch’s views, with little airtime or emphasis given on (a) how complex this issue was and (b) how Kirsch’s word on the matter is not the last or necessarily “best.”
@Altostrata — There are, in fact, more than a handful of longitudinal studies done on antidepressants. Heck, I like any study that looks at patients longer than 16 weeks, since I don’t know of anyone who’s ever been prescribed an antidepressant for such a short time in the real world.
But your point is well taken and applies to all medications approved by the FDA. Since longitudinal studies are not required for FDA approval, they are rarely done or underwritten by the drug company.
While this is indeed a concern for adults, it is a far greater concern for children, whose brains are still under development and growth. That’s why I would be very uneasy giving my child any medication that didn’t have a relatively short half-life, or keeping them on a medication longer than a few months. I would try every intervention and treatment that wasn’t a medication for a child long before I’d turn to medications, because we just don’t know what the long-term effects of many of these medications will be on children.
We still have a huge hole in our knowledgebase, and I’m afraid stories like this 60 Minutes segment just minimizes the complexity of these issues.
Seems complexity is the default argumenet for those who don’t have one. The elephant in the room is, once again, the well-tested point that the patient’s mental state, his or expectations, are what alter the human condition. From surgery to drugbased therapies, the evidence is consistent. The bias is clear in one’s refusal to believe that, or to cry complexitiy or lack of enough studies. I doubt that will end anytime soon. Society is beginning to acknowledge, even embrace, what drug- physicians are fighting.
There are a lot of medications and a lot of conditions we don’t know jack about. We don’t know much about epilepsy, but anticonvulsants seem to work (Which the Bipolar crowd often take, and yes, people object to those folks taking the drugs rather than those with epilepsy). Migraines, which may or may not be a cousin to epilepsy, responds to triptans and/or anticonvulsants – why, no clue. Skelaxin seems to be a total mystery – researchers just know it’s a CNS depressant – but it makes people feel better. Even though we really don’t know why muscles stay contracted in many cases, and we’re just now entertaining the idea that it isn’t lactic acid build up but rather something else. The list goes on. A lot of medicine, not just psychiatry, is in the realm of theory (Don’t get me started on obstetrics – I think a lot of women who have received prenatal care can understand what I mean by that).
I think psychiatry, psychology, and the whole mental health bit tends to get a bad rap because people can get stuck on the notion of souls and/or a permanent self (Yes, I’m going to get philosophical here, bear with me). Some people equate emotions, perceptions, motivation, sociability, etc. as being an extension of the soul/self. The idea that a soul/self can be marred is frightening to some, and others perhaps don’t take it all that seriously because it isn’t possible for such degradation for the soul/self to occur without serious neglect from the individual. Then there are of course those who have been severely affected by a loved one’s psychiatric issues, and they take all of the hurt and sadness to heart – as it was the doing of a soul/self, then it was completely intentional and therefore personal. So to medicate someone for a psychiatric issue, particularly depression, is seen as incredulous – why would you medicate something that is all you? – i.e., your fault.
Whether you believe in souls/selves or not, the brain is physical like every other body part. Severe enough head trauma can significantly change someone’s personality. Trauma results in nightmares, a heightened sense of awareness, dissociation, and other delightful things. Violent images lead to aggressive behavior in children.
Much like you can chop off a finger and it bleeds profusely, you can “hurt” your brain and psychiatric symptoms can result. And also like having a chopped off finger, you either “reattach it” (therapy and medication as needed), or you deal with one less finger (self-care measures). Either way, you’re not coming out the same physically. Not the greatest analogy, considering untreated psychiatric issues can lead to an early death, but it’s the best I have at the moment.
Of course, there is that pesty bit about psychiatric issues that do not spur from an obvious source. Perhaps there is a source overlooked, or it could be hereditary. Some people are born missing a digit, you know?
Now, while the brain is physical, it does not mean that YOU, the real YOU, are the symptoms of a disorder. Everyone has a “baseline” (ick, clinical speak), and that baseline is often quite a bit different than what the symptoms produce. Hopes, dreams, interests, the people you love, all that sunshine and rainbow stuff – those are what make up who you are. Often times those may still exist when one is not well, a recent memory during depression and sometimes on steroids during mania or psychosis, and may affect them, but they are still there. There are aspects of a person a disorder can’t change – only the individual can change them by choice or as they evolve through life.
So this whole notion of “pulling up by the bootstraps” is ridiculous. People need to get over it.
(For the record, I don’t believe in souls or permanent selves, but I do believe that my disorder is some malfunctioning in the brain chemistry line and hence it is not something I consciously choose)
/end soapbox
Thank you Anna, very well said.
What I don’t understand is that if it turns out that the placebo effect actually works just as well, how would doctors prescribe “sugar pills” to their patients in an ethical way? I mean, if we come to the findings that they actually work just as well, why would there be a need to give drugs that inhibit neurotransmitters and effect the individuals chemical balance/hormones? But also, if the patient actually has a severe case of depression, how would the placebo effect work in comparison to drugs that are designed to help depression? would the depressed feeling come back faster with “sugar pills” compared to the actual drug once the placebo effect has worn off, or would it last just as long? Not to mention the long term effect; would we see an actual improvement in those taking the placebo pills, due to the fact that it’s their own body making them feel less depressed rather than a chemical?
I hold no credentials in medical science nor am I an expert. I do, however, have an opinion. I think the reason everyone is so “confused” is because people don’t want to believe that antidepressants — powerful, expensive drugs with terrible side effects — are no better than sugar pills. I read years ago that the naming of this class of drugs was one of the greatest marketing ploys ever. I believe that. It has been shown that for many types of depression, exercise can be very effective. Meditation can also work wonders. Methods such as these require long-term commitment and a lot of time. . .
Exactly! This is a case study in cognitive dissonance. Evidence is presented challenging assumptions, but people have difficulty changing their minds because of an investment in their beliefs.
AMEN ORGANIC,IT’S ALL ABOUT $$$$$$$$$$$$$$$
I think that the noble attempts of medical model “it is not your fault, you are ill” is a huge problem. Willpower seems to be a curse word in contemporary psychiatry, because you “cannot will yourself out of depression no more than you can will yourself out of cancer” (I do believe though that you can die of relativelly mild diseases, if, despite treatment you give up. And on the other hand we have stories of almost miraculous recovery stories. Of course, science plays part there, but if those people did not have strong will to live and go on… science wouldn’t save them, that’s my opinion).
We need to return back to believe in people.
In science you have two choices what to do if theories don’t work. Alter the theory, or alter the evidence. Sadly, it seems many want to take the second path. Whom will it help? Surely not the people.
Social sciences (and psychiatry just isn’t a hard science, and it is not bad or good, it is what it is) are pretty complex and acknowledging that is first step to moving somewhere.
That antidepressants treat severe depression is NOT controversial, and the 60 Minutes segment and Kirsch himself point that out. It is a shame that the take-away message is “antidepressants are as good as sugar pills” when the take-away should be “antidepressants save lives for people with severe depression but are probably vastly overprescribed, not to mention depression being over-diagnosed.”
To argue that antidepressants do NOT treat those with severe depression is to question all clinical trials and research ever completed in the history of medicine. There is a line where it is obvious that a medication is clearly working, not placebo. It is obvious to anybody looking at the research that antidepressants help people with severe depression. It is horrifying that this message keeps getting lost in the argument.
my site:
mentalhealthsurvival.com
Susan,
All clinical trials have a 2 fatal flaws. 1) They don’t accurately outline what “better” means. (Often times they make the patients problems different, but not better. That is an old magicians trick.) 2) And this is big. They ask the patient. I recently surveyed 100 people wasted at the bar. 100% of them said they were alright to drive. 80% said they actually drove better when they were drunk. Therefor woe should start handing out booze to people who have driving problems. It makes them better drivers! It also makes people more intelligent, interesting, sexier, and better fighters, just ask the “patients” at the bar.
Why can’t we start prescribing booze, coke, and weed for depression? We can run some trials and ask the patients if they feel better when they are on them? As long as they say “yes” then we have some competition. We won’t bother to ask their family about their behavior.
A friend of mine put it this way. “I told the doctor I was a bit depressed because I hadn’t found work and was about to loose my house. He gave me an AD, I wasn’t down any more. I was still out of work, and ended up loosing my house, but I didn’t care.”
Humans always had their woes — except in the prosperous world they can afford to “treat” their woes with pills and therapies. Poorer people have had their share too; they just hadn’t much luxury to dwell on it for long.
So the modern manwoman when faced with woes can afford to eat away, drown in expensive alcohol and drugs. Poorer people ,still, use cheaper versions of the same “solutions” for the same age-old woe.
But as some have pointed out here, we also have the capacity to do better. We’ll do better to look First inside ourselves.
As was raised by the author at http://www.1boringoldman.com in a post yesterday, why is this being addressed now by 60 minutes? I think the role of big pharma is a factor to letting this topic be avoided until patents are lost.
As I have noted here and at other sites for the past few years, the issue that should be addressed in shows like 60 Minutes is this: why are PCPs/Family Docs/Nurse Pracs writing more than 70% of antidepressant scripts and not getting more flack for prescribing meds these practitioners have no real training to write for the frequency and intensity they do now. I mean, really, non psychiatrist writing for Abilify, Seroquel, and antiseizure meds for mood management?
Let’s not even address those writing for ADD meds of late. Or, should we?
There are many good points made in this discussion. I may have missed reference to it, but I found the most interesting part of the “60 Minutes” segment the reporting on the UK’s NHS response to this now long known finding. For mild to moderate depression, they prescribe psychotherapy. This really should be absolutely a no-brainer here as well.
Also not discussed in the segment was the well confirmed finding that the older, now generic and thus not a cash cow anti-depressants preform just as well as the pricey ones that get all of the advertising.
For those who want to read more on this, Wired’s Steve Silberman wrote an excellent article on placebos back in 2009:
http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect?currentPage=all
You know. I wish these pills had the same affect as a sugar pill. I am finishing up a week of vacation with my daughter. Then it is back to 4 days a month. (A long story where the judge decided a house filled with alcoholism violence, drug use, and personality disorders were better off the the crazy guy who wanted to home school his kid.) I Can tell you that the Drug companies fought tooth and nail not to have to include the suicide warning. Just as they fought not to have included that “Doctors should keep in close contact with the family members and care givers of the patients when starting or changing the dosage to monitor for abnormal (think “bad”, good behavioral changes are what is hoped for) changes in mood or behavior.” WHY NOT ASK THE PATIENT? Oh yeah, cause that would be like asking a drunk if he thinks he is alright to drive!! Of course they feel better, they are high as a kite!! There is plenty of “we haven’t don any studies or can’t tell you why mania appears in people who have never had it when given these pills, AND there is no benefit for us to figure out why. But the FDA makes us mention a causal relationship between manic episodes and use of SSRI/ SNRI’s. Especially when a patient is bipolar. We have managed to keep the mentions of “borderline” off our pamphlets though. Oh BTW bipolar is one of the most under diagnosed personality disorders. This is cause few people show up at the docs office going, “I am spending all my money, getting wasted every night, having orgies and multiple sex partners, scream at my coworkers whenever I feel like it, and I FEEL GREAT!!”
Let me tell you, when a 6 month long manic episode enters into a 10 yr relationship that has never experienced one, especially one that is being stretched because of the change of having a new born first child in the home, the going out drinking every night, having sex with all your neighbors, lashing out and getting arrested for domestic violence, spending all your money on cloths and drinking, and delusions of grander tends to strain that relationship beyond the breaking point. Next thing you know, you get to raise another child in a broken home.
No, I wish this crap had the same affect as a sugar pill. over 50 years we have known what damage to the PFC looks like. And it looks a lot like what happen when people take SSRI/ SNRI/ and Benzo’s. I would ask that A) Doctors follow protocols. B) Nothing psychological is released with out an exact description on how the brain works and how these pills affect it. Not medications based off theories. The “chemical imbalance” has been debunked 27 ways from Friday, yet that false theory is what all AD’s are based upon. The Preforntal Cortex is damaged by taking these drugs. Period. It is as obvious as world is round. But nobody wants to explore it.
http://ssristories.com/index.php
John, I really have been struck by this news story wanting to learn more about this “Placebo Affect”. After doing some digging and some reflecting on what I have learned about AD’s, I have come up with this.
If we believe that a child is born with no “Ego Ideal” only with an Id. A baby cries with no regard to your feelings cause they want food, changed, or held. If we believe that as toddlers children have a thought enter their head from their “Id” saying, I want that toy, I am going to just take that toy.” Or “somebody is trying to take my toy, so I am going to stop them by hitting them.” This behavior continues until they are exposed to negative reinforcement enough times that they “learn” not to. If we consider this “learning” process as exposure to anxiety about a bad choice (Think Stephenson monkey experiment here) then anxiety becomes a good thing. The reality is that the reason why the suppression of the behavior to just take and hit are repressed to the subconscious and only the behavior is conscious. (This evolutionarily advancement is designed to streamline thinking process.) That doesn’t mean our inner child is still there wanting what it wants, kept in check only by the anxiety of either talk lessons or physical experiences we have had. The same thing goes on as they become teenagers. A more manipulative phase as we have some of skills and understandings of an adult, but still just using them to grab and hit. By the time we reach adulthood, we are supposed to have a long list of anxieties about bad choices and behaviors and no such anxieties about good ones. Now IF we an accept that (and some schools of thought do), it could be conceived that giving on physical conscious excuse to unleash our inner child will result in immediate happiness. “Take this pill. If you do, you are allowed to be happy.” That is not healthy and functional necessarily. IF that is acceptable, then what other physical/ conscious triggers do we as a culture offer. For example, a girl her whole life is feeling neglected and unsatisfied. She hears all about from mom, aunt, big sister, TV ads that when she gets her period she is allowed to act out on her moods. Could this explanation of the placebo not only explain why some people go off the deep end on AD’s but also explain reasons for PMS, PMDD, and other life driven triggers? If there is anymore studies or materials you might suggest about this topic, I would love to read it.
I wish that ALL mental health facilities were required to use the ideas of Dr Abraham Low .Recovery Inc has been around for MANY years and has helped millions of people .
Recovery Inc teaches the mentally ill INSIGHT ,without this they are locked into the dreadful world of psychiatry ,far from an exact science .