Feminist Philosophers

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Depression, Serotonin, and the Reliability of high-class journalism February 23, 2010

Filed under: human rights,medicine,mental health — jj @ 12:14 am

Let me say at the start that I take very seriously the idea that many things we count as “mental disorders”  may be in large part the result of society’s finding ways to express pain.  There may be a sense in which they are not “real” the way a burn or a burst appendix may be real, for example.  But I also think that there may be a very genuine underlying pain and that, more generally, some so-called mental problems can ruin lives.  Further, I’m pretty sure some lives have been saved from ruin by medication.  I hope this counts as a nuanced take on the issues addressed below.

The topic of discussion is an article in the current New Yorker.  It is by Louis Menand, and it is on the current state of psychiatry.

——————————

I take it that the New Yorker is undeniably a high-class publication.  Among other things, it  is supposed to have really good fact checkers.  So what should one say about the following quote?

  There is little agreement about what causes depression and no consensus about what cures it. Virtually no scientist subscribes to the man-in-the-waiting-room theory, which is that depression is caused by a lack of serotonin, but many people report that they feel better when they take drugs that affect serotonin and other brain chemicals.

I  think Menand’s comment is really difficult to understand, but it seems to imply that the fact that people feel better is not indicated by the scientific evidence.  Well, that’s not the evidence I saw coming from many, many journals.  If that’s what he was saying, it is startlingly false.

Having heard of the article because of Dan Weiskopf’s tweet,  I went on the web to my university library’s Web of Science and decided to search for  “depression” and “serotonin” in the titles.  And what I found were thousands of articles on depression and serotonin.   A lot of them were about gene-evironmental interactions, and quite frankly beyond my understanding, though almost all of them seemed to be looking at the positive correlation between  serotonin irregularities and depression, along with other ‘mobidities’.  So after wading through about 30 abstracts, I went over to Academic Search, where I expected to find less technical articles.  Representative of what I was reading is this from (Pharmacology; 2010, Vol. 85 Issue 2, p95-109, 15p):

Serotonin (5-HT) is a monoamine implicated in a variety of physiological processes that functions either as a neurotransmitter or as a peripheral hormone. Pharmacological and genetic studies in humans and experimental animals have shown that 5-HT is important for the pathophysiology of depressive disorders. The 5-HT system is thus already a main target for the therapy of these diseases.

So why care about this?  Unfortunately, severe depression, panic disorder and social anxiety disorder run in my family.  We are not here talking about some shy people.  Rather, we are talking about people who will stay away from all social gatherings, or people who sit in movies and can’t hear the movies because they think their bodies are being so noisy.  In fact, most of my relatives are ordinary, fairly cheerful people, but then there NN, who had for some time a life blighted by severe depression.  Until around the mid-80s, most psychiatrists NN saw  believed what the New Yorker article is suggesting; anti-depressants may not be exactly a placebo,  but they really shouldn’t have much of a role in mental health.  So, because people  move around and so on, NN saw  three different doctors for severe depression  and a pattern eventually became  clear.  Severe depression then pills then recovery then tapering off then horrible breakdown.   Of course, it would be said that the breakdown was due to the failure of the previous psychiatrist, but to recover, pills were prescribed.  And once NN recovered, tapering off started, to be followed by severe  breakdown, etc.  NN was typically impaired for most of a decade, since we need to add that since no one really believed in the pills effectiveness, he didn’t get the dose he needed.

Severe depression is very, very horrible, and it can include quite disordered thinking that too often can lead to suicide.  It is very alarming that Menand article will reinforce the beliefs of the doctors whom NN saw and who are probably still practicing. 

But what is Menand going to say to someone like NN, who is a very gifted, creative artist who has put his life back together finally?  He does consider people just like that:

The recommendation from people who have written about their own depression is, overwhelmingly, Take the meds! It’s the position of Andrew Solomon, in “The Noonday Demon” (2001), a wise and humane book. It’s the position of many of the contributors to “Unholy Ghost” (2001) and “Poets on Prozac” (2008), anthologies of essays by writers about depression. The ones who took medication say that they write much better than they did when they were depressed. William Styron, in his widely read memoir “Darkness Visible” (1990), says that his experience in talk therapy was a damaging waste of time, and that he wishes he had gone straight to the hospital when his depression became severe.

This is his comment:

What if your sadness was grief, though? And what if there were a pill that relieved you of the physical pain of bereavement—sleeplessness, weeping, loss of appetite—without diluting your love for or memory of the dead?

I’d say that  counts as changing the topic.  However, perhaps we should say that the article has many topics.  One is whether we should try to medicate ourselves out of the human condition, with its ordinary pains, even the very severe ones.  What I am concerned about, though, is NN and others like him, who still are fortunate if they can get adequate treatment.  Their state is not simply ordinary; it is more horrible than humans should have to endure, though hospitals have had, and do have, many who do.  We do not need an article that appears to say no scientist thinks pills are a  good response to depression.

 

34 Responses to “Depression, Serotonin, and the Reliability of high-class journalism”

  1. Vishal Lama Says:

    Could you please fix the first link?

  2. Vishal Lama Says:

    Here’s a video of Stanford’s Robert Sapolsky speaking on the biological component of depression that I had come across some time ago.

  3. jj Says:

    VL, I hope the link works now.

    Thanks so much for the video link.

    I’ve only had time to view the beginning of it, but I am certainly mostly in agreement with it. Sapolshy does speak as though the onset of major depression – at least in the beginning – is a significant negative event. I don’t think that’s true, unfortunately. Just stress can set it off – e.g., the stress of having exams coming up, for example. I expect he was just trying to give some illustrations.

  4. jj Says:

    Let me add: Menand is asking a general question about whether psychiatry can be a science. I think his approach to the question is very seriously flawed. If one helps oneself, as he does, to what shows up in the literature over the last 40 years, and includes the UK and the USA, it’s going to be possible to ‘show’ almost any field is deeply chaotic. Included in this would be orthopedics and dentistry.

  5. anon Says:

    Briefly, and without having read the article, (but having read the quote), I can say that a friend of mine in med school focusing on the brain has related similar things to me regarding seritonin. Essentially, while the consensus is that anti-depressants that target seritonin work, the exact mechanism is unknown. This is what the quote seemed to be saying.

  6. jj Says:

    anon, I find it hard to believe that he just meant we don’t know how drugs that affect brain chemicals work.

    If that’s what he had in mind, he should have said so, or at least mentioned that there’s an intense amount of research dedicated to understanding the mechanism, which – at my quote indicates – places serotonin in a promising position. Instead he creates a contrast between what no scientist believes in and what people feel.

  7. Spike Says:

    I can’t speak to the merits of the article in question (to be honest, I think that it would take the testimony of an actual neuroscientist, and not merely a philosopher, however capable, perusing medical abstracts) to convince me that it is really dubious), but I have certainly wondered about the wisdom of the New Yorker editors before (and I love the magazine); that they keep Malcolm Gladwell on as a staff writer, for instance, I think is embarrassing.

  8. jj Says:

    Spike, revised response: Menand said virtually no scientist believes that P. I quoted an article from a reputable scientific journal that says that P is a standard view. That’s a refutation of what he said.

    Now one might argue that in saying P he meant something really nuanced that isn’t refuted by my quote. I think that’s unlikely, for the reasons I gave to anon.

    I should also add that many philosophers work closely with scientists in interdisciplinary research; one can no longer judge expertise from labels. In addition, I have a joint appointment and the other department is concerned with just such things as the causes of depression, among many other things.

  9. anon Says:

    jj, after having read the article, I stand by my previous comment, as it does appear that the author is (admittedly unclearly) claiming that the lack of understanding of the role of seritonin is leading to a lack of consensus regarding the mechanism by which drugs which impact seritonin levels are able to account for improvements in patients. This is, perhaps, due to the fact that the author intends to use such an inknown for more dramatic purposes, as the article quickly switches to talk of “cooking the studies” and problems with the DSM (of which there are many).

  10. jj Says:

    Anon, for my purposes it is enough to note that his statement is as misleading as saying “virtually no scientists believe that human activity is contributing to global warming.” There is tremendous debate among the scientific community about the mechanisms, and not everyone thinks human activity is the main cause. But there is wide-spread agreement about what are prudent ways to address the fact of global warming, what the best course of action is in a situation of uncertainty, etc. That’s not unanimous agreement, of course.

    I think we need to distinguish between pretty local disagreements/uncertainties about mechanisms and general views about likely causes.

    In addition, the following comment of his doesn’t seem to be about the ignorance of mechanisms:

    So the antidepressant business looks like a demolition derby—a collision of negative research results, questionable research and regulatory practices, and popular disenchantment with the whole pharmacological regime. And it may soon turn into something bigger, something more like a train wreck. If it does, it’s worth remembering that we have seen this movie before.

  11. amos Says:

    The article reviews two books which question the use of anti-depressant medication, but for different reasons. Menand does not clearly distinguish between what he believes and what the two books say, hence, the confusion. Since the two books contradict each other, it is never clear which of them, if either, Menand agrees with. Since I have no expertise on this subject, I have no opinion, one way or another, but whatever the merits of the case, the article is confused.

  12. Katherine Says:

    There is a general scientific consensus that SSRIs work better than placebo for many people with certain types of depression. This does not mean that a lack of serotonin is responsible for depression. Expressing doubt that serotonin levels are the prime or exclusive or best way to understand the physiology involved in depression is not the same as saying that antidepressants don’t work or ought not to be taken.

    SSRIs are not the only available class of drugs that act on brain chemistry to alleviate depression or anxiety. There are also the tricyclics, MAOIs (mono-amine oxidase inhibitors), atypical anti-convulsants, neuroleptics, typical anti-depressants that also affect the levels of norepinephrine and/or dopamine, lithium and physiological interventions such as vagus nerve stimulation. All of these treatments have been shown to work better than placebo in treating depression and anxiety but only some of them affect serotonin levels. Furthermore, SSRIs are only appropriate for treating some kinds of depression. If given for the depression experienced by those with bipolar disorder, they will make things actively worse. The same is true when some (but not all) SSRIs are given to paedeatric patients – they (can) act to make the depression worse. Then, there are many people for whom SSRIs are entirely ineffective.

    The controversy the article addresses is whether SSRIs and similar pills are appropriate, necessary or worth the risks for people with mild to moderate depression and not whether they are appropriate for someone with severe mental illness. It seems to me that your relative, NN, falls into the latter category, as I do myself. I have never encountered a psychiatrist or any other MH professional who was against or even ambivalent about using medication to treat severe depression or any other severe kind of MH problem. While there is no clear understanding of how medications work or of the physiological processes associated with mental disorder or even a good theoretical understanding of what a mental disorder is, there is a strong working consensus that medications are helpful and ought to be prescribed. (There are always outliers such as Kirsch but they are not representative of psychiatry/psychology as a whole).

    It is worth remembering that all SSRIs and most of the other drugs available to treat mental disorders are very new – the first of them became available in the mid 1980s. Prior to that, far fewer medications were available and many of the ones that were available caused extraordinary side effects that made them not worth taking – even dangerous to take long term – unless it was to counteract a very severe problem. Such circumstances probably account for the experience NN had. I think that he would be very unlikely to ever encounter a psychiatrist who would – with his history of relapse – encourage him to taper off medication unless NN found the side effects intolerable.

  13. jj Says:

    Thanks, Katherine, for your informative take. We’re basically in agreement with the underlying questions.

    I think that, as Amos has pointed out, the article is confused. It would have been good if he had distinguished between moderate and severe depression, but instead he mentions, e.g., Styron, who appears to have had very severe depression, as merely illustrating what people who take the pills say.

    Why is the New Yorker publishing such a thing? Idon’t know, but I’m afraid that the strong psychoanalytic presence in NYC has created a culture in which medication for mental health is not seen as anything like comparable to medication for anything else.

  14. jj Says:

    Katherine, I linked through to your interesting blog, which locates you in the UK. The UK psychiatric establishment seems to have been much less strongly impacted by psychoanalysis, as has indeed the culture, as far as I can see.

    One conjecture I used to have when I lived in England was that the idea that is still rampant in the US – that we are all doing what we want to do, though we too often don’t know those wants are – never seemed a very plausible assumption in the UK. It fits in with the anti-socialist capitalism of the US much better. All IMHO, of course.

  15. Alison Says:

    Speaking from the UK, I think there is a great deal about of the attitude with which jj is taking issue – essentially a work ethic that it’s better not to take medication but fight through your problems yourself -(at least in application to those with mild to moderate conditions not severe ones. I think there does seem to be a difference there.) My piece of evidence (amongst others I could mention) is this: I am currently seeing a cognitive behavioral therapist on the NHS, having also been taking anti-depressants for a while – to very good effect – and his focus has been very largely on how I need to come off the medication, not to say regarding me as overly inhibited for not wanting to do so! – which I not surprisingly am finding pretty counter-productive. So I think jj is utterly right to combat this sort of attitude, which evidently is not absent from the medical community itself.

  16. Anon Says:

    I also think jj is right. I’m hesitant to talk about my own health, but even for severe conditions people seem to think CBT (or something like it) is all there needs to be.

    But, honestly, my therapy sessions didn’t work that well without medication and I had to get more intense treatment after some of them because my meds weren’t built up in my system yet and therapy made some things worse.

    I don’t know why anyone would think meds don’t work for psych disorders as they do for other illnesses. If you have anxiety, as jj mentions in the post, taking a klonopin *will* help in most cases. And, frankly, after my own meds were adjusted properly, I needed a therapist less. Currently I only see a therapist if I have a bad break. I expect to be on meds for life, however.

    I also think that things like the stereotype of the NYC or Cali neurotic has made taking drugs like klonopin seem freaky.

  17. amos Says:

    The idea that taking a pill is a bad way to solve a problem seems to be a deep prejudice in contemporary society. For example, I suffer from insomnia, but when I ask for a prescription for sleeping pills, I always receive a little sermon from the doctor about the evils of drugging oneself. For some strange reason, taking a pill made from an herbal source is less sinful than taking one from a chemical source.
    I myself had an excellent experience with talk therapy about 20 years ago, but I don’t see why talk therapy should be considered as an ethically superior way to deal with one’s problems than taking a pill or even smoking a joint.

  18. jj Says:

    Amos, I’ve been thinking about Menaud’s comment about grief, part of which I quoted. A close relative of mine whose wife simply and unexpectedly dropped dead spent at least three months in often very acute pain. The following three months were more tolerable, but still pretty bad. I’m not at all certain that it is so bad to try to dull the pain, and in fact I expect that a lot of people do with alcohol. So I’m puzzled.

    One thing is that the behavior of people who are in grief and shock can be pretty destructive, both to themselves and others. Since he’s quite a “good catch,” he’s left a string of women who are pretty unhappy that his attempts to use them as crutches turned out to be just that. In fact, he was so confused it took him sometime to realize what he was doing.

  19. jj Says:

    Alison and Anon, I’m so sorry to hear your experiences have been close to what I’m worried about!.

  20. amos Says:

    Grief is complicated. I lost my 15 year-old son 8 years ago, and I felt and still feel that I owe it to him to feel grief. In fact, I often feel guilty about not feeling enough grief, although I am aware that people do fake grief. A psychologist suggested that I take anti-depressant medication after his death, but I indignantly rejected her suggestion.
    I wanted to grieve fully. I suspect that a lot of people feel that their grief is the only appropriate response to the loss of someone close to them. I have never been deeply depressed, but I suspect that one of the differences between grief and depression is that the grieving person feels that grief is the appropriate reaction, while the depressed person does not see her depression as an appropriate reaction.

  21. [...] February 23, 2010 by Jennifer Lawson Interesting discussion at Feminist Philosophers. [...]

  22. Jennifer Lawson Says:

    Isn’t the thing about depression just that it is, and not merely seems to be sufferer, an inappropriate response to the world. Grief seems an appropriate response to some thing, like the death of a spouse. But grief over other things, like, let’s say, a lost sock, seems inappropriate. So, it would seem that the appropriateness of treatment (and perhaps medication) depends–or, rather, perhaps, *should* depend–upon the appropriateness of the individual sufferer’s reactions. Or am I missing something?

  23. jj Says:

    I like the idea that grief is an appropriate response, but I’m wondering what one does about those whose grief seems not appropriate. E.g., I think it is not uncommon to feel intense guilt for anything negative one might have done. For example, I hear from my relative often enough that he’s feeling very guilty and unhappy about getting angry at his wife for having given things of his away without asking him. (I think getting angry in such circumstances, particularly the subdued anger he seems to manifest, is not something he should feel guilty about.)

    Other people in grief feel that the possibility of happiness is completely gone, and sometimes they act on it.

    Also, one of the principles some (?) cognitive therapy works on is the idea one’s bad feeling are appropriate to the way one is viewing the situation, so one has to change how one is cognizing it. In depression, at least some theories have it, often one’s feelings are not the foundational problem, it’s the thoughts.

    Perhaps one could argue that the difference between feeling very sad at having failed a major exam and feeling very sad because one thinks one just gets by on luck, not talent, isn’t the appropriateness of the feeling, but the accuracy of the thought. (The first looks like grief, the second more like depression.)

    Actually, perhaps cognitive therapy doesn’t work for some people without medication between the causal situation is more complicated with them.

    Well, some thoughts. I hope I haven’t just muddled everything beyond repair.

  24. Jennifer Lawson Says:

    Maybe your relative is overly conscientious. It’s poossible he has OCD. I’m assuming his wife could have bipolar, if she gives things away without asking.

    If he has OCD–and there are forms of OCD, like scrupolisity, that are moral–the goal of CBT, I think, would be to explain, on the C aspect, that everyone gets angry, etc. Getting angry is appropriate in some cases; we call is justified anger. The guilt or shame–whichever it is–could be minimized by dealing with the cognitive aspect of his anger and it’s appropriateness in certain situations. The behavioral aspect would, of course, be getting him to examine himself in times of guilt and purposefully engaging in behavior that might elicit his angery and guilt.

    He may also engage in psychoanalysis to find the source of his behavior, and take an SSRI for OCD. (I’m not diagnosing him; I wouldn’t do that.)

    I’m no therapist. I’m just guessing this is what good therapy for him would look like. What do you think?

  25. amos Says:

    From my experience, guilt feelings about not having been responsive enough or not having been loving enough are common in grief. Grief is not a rational process. Still, it seems like something so basic that if it occurs (at times, it doesn’t occur and people fake it, which is sad), it doesn’t seem wrong to me. People who grieve need support; maybe they can use some kind of light medication or even alcohol or marihuana in moderation, but grief should not be treated as a mental illness. Probably, the principle factor that affects many grieving people is seeing that after the tremendous outflow of support that comes with the funeral, other people forget so fast. Grief is a lonely process.

  26. Jennifer Lawson Says:

    I also wanted to add that understanding cognitive distortions, most of which are fallacies, is another part of CBT. But, again, tying everything back into this post, I assume that if someone were bad enough to be diagnosed with some disorder, they should probably be on appropriate meds in addition to getting something like CBT.

  27. Jennifer Lawson Says:

    I thought today’s short article from PsychCentral on the negative effects of psychotherapy might be of interest:

    http://psychcentral.com/blog/archives/2010/02/25/harmful-side-effects-of-psychotherapy/

  28. jj Says:

    Thanks so much, JL! I’m traveling & can’t do much with this iphone! It’s great, though, to have you commenting.

  29. Rob Says:

    Depression’s Upside, in this weekend’s NY Times Magazine, may be of interest.

  30. rbarry Says:

    Man, there are some really nice people on this website. You are being way too kind to Professor Menand. I read the New Yorker and other such magazines, especially the book reviews to learn about things. I expect, perhaps naively, that the writers and editors are acting in good faith – intellectualy and ethically. This article covered a topic that I know well. Its flaws -not discussing suicide or carefully distinguishing major depression from minor depression, not addressing brain-chemistry theory concering other mental illnesses and neurotransmitters other than serotonin, presenting a caricature of the drug industry and citing 1950s-era events as dire warnings, etc. , are profound. The article is only slightly more credible than Tom Cruise’s attack on psychiatrists. OK, I was obviously upset by this article, primarily because it seemed to promote “teaching the controversy” where the controversy is contrived. I sense that the two books reviewed were written, not to enlighten or to help, but to create a market for contrarian views of psycho-pharmacology, the very type of push-marketing strategy the article accuses the drug industry of. Nice pickup on your part to note the scientific and journalistic issues. And thanks for a place to vent.

  31. jj Says:

    Rob, I think this is an unfortunate piece. He’s not distinguishing clearly among 3 very different kinds of depression, among other things. One consequence is that the generalizations are all questionable.

    Rbarry: Thanks! It is pretty awful .

  32. Jonathan Leo Says:

    Several years ago Jeffrey Lacasse and I wrote an article titled “Serotonin and Depression: A disconnect between the scientific literature and the advertisments.” The article was published in PLOS Medicine. It pointed out that there are very few scientists who accept the serotonin theory as it is portrayed in the ads. The article is at:

    http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020392

    In short, the serotonin theory has much more to do with marketing than science. In a subsequent interview about the article, the head of the FDA psychopharmacology committee stated that the theory was a “useful metaphor.” Im not sure that when patients hear about the theory from a doctor that they understand that it is a metaphor and not science.

    About a year later, a follow up article examined the popular press version of the theory. For a year, every time a reporter mentioned the serotonin theory as an established fact we emailed the reporter and asked what their evidence was for this statement. Not a single reporter could provide any evidence to back up their claim. Some of them provided review articles, and websites, but no one provided a primary research paper. The second article is at:

    http://www.springerlink.com/content/u37j12152n826q60/fulltext.pdf

  33. jj Says:

    JL, thanks for the interesting link.

    I did say that it was difficult to tell what Menand was saying, but his statement “no scientist agrees …, but many people report they feel better,” suggests strongly that what they report is NOT warranted by what any scientist believes. Notice that he doesn’t say they do feel better, and he going to argue that the effect might just be that of a placebo. How many scientists working in the area think it is a placebo?

    He is, I argued, suggesting something strikingly false, it is refuted by the quote I gave, and I don’t think your very careful and exact article makes it look true. It is correct that he refers to a belief about a fairly specific mechanism but he never indicates in any way that his point is about that specific mechanism. Nor does he acknowledge the vast amount of research being undertaken to describe the machanisms involved.

    I wonder what the effect would be if the drug companies acknnowledge that things are a more complicated and less easy to understand. I would have thought that the public could take that news; from what I know of how advertising works, it doesn’t have to be all that simple-minded. Just think of all those scary remarks about how the pills being advertised could cause stroke, heart attack or death.

  34. rbarry Says:

    Check The Nation May 24, 2010. They have a psychotherapist reviewing Manufacturing Depression by Gary Greenberg, also a psychotherapist. The review refers to “depression doctors and their accomplices (drug industry)” and generally tracks Professor Menand’s points, but with a lot of incomprehensible (to me) comments – “The only therapies we should trust are the enemies of militant competence.” Perhaps The Nation is more yellow or muckraking than high journalism (I like it but take it with a grain of common sense), and the reviewer did disclose his potential bias, but I would still like to see a psychopharmacologist’s viewpoint presented fairly at some point in these types of reviews – to me that would be journalism. Personally, I predict a backlash from these types of reviews; I expect exposes of the psychotherapy profession and a drop in the profession’s prestige.


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