Depression, Diabetes, and Treatment

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In February, Newsweek published a report by Sharon Begley, “The Depressing News About Antidepressants.” Begley, citing a recent study in The Journal of American Medical Associations, and the previous work of psychology researchers, Irving Kirsch and Guy Sapirstein, argues that in most cases a placebo pill can be as effective in treating depression as an antidepressant – or in Begley’s words, “antidepressants are basically expensive Tic Tacs.”

As someone who suffers from depression and has taken Prozac on and off since 1998, I was shocked by Begley’s article. While I have no doubt that placebo effects can be real and, in some cases, powerful, in my own case and in the cases of many other depressives I have spoken with, the placebo effect simply makes no sense as an explanation for the benefits of antidepressants.  I suffer from diabetes as well as depression, and I believe that in many cases, taking a placebo antidepressant would be the equivalent of taking placebo injections of insulin.

Like most people who have tried antidepressants, I have gone on and off the medication many times and tried many different treatments for my depression, from psychotherapy to natural remedies to exercise.  What I have learned through these trials is that nothing has come even close to being as effective as Prozac.  And it took me nearly a decade of on-and-off misery and on-and-off Prozac use to come to terms with the drug, not as a demon or a panacea, but as a simple drug that alleviates my psychic pain.  To suggest that I would have improved equally well had I unknowingly been taking a placebo is not only wrong, it is also humiliating, and fuels the stigma that exists around depression and its treatment.   It makes those of us being helped by the pills feel foolish, it may prevent people from getting help they need, and it encourages intolerance from non-depressed people.

Andrew Solomon, who won the National Book Award for The Noonday Demon, his masterful and comprehensive work on depression, put it this way when I asked him about this point:

“I’ve taken at least twenty different drugs and some have worked for me, and others not, and some better and some less, and the idea that that’s all in my imagination is profoundly alien,” Solomon told me. I don’t believe I had some underlying prejudice that caused me not to get a placebo effect out of Topamax but to get a huge response from Zyprexa.  My having a breakdown when I decided the Zyprexa was good and that I’d try stopping my Zoloft was also not in my imagination.”

Perhaps the most serious problem with the JAMA study and Begley’s article is that the placebo effect is not generally sustained. Depressed people might initially report positive responses from placebos, not only because they are full of hope but also because regular attention of doctors as part of a study protocol can break them out of their isolation. But there is no evidence that this effect is sustained. According to Solomon, doctors who he has interviewed have found that over time, the placebo effect fades, and the ones who are on placebo have a much higher relapse rate than the ones on medication. “This could be demonstrated in research,” Solomon says, “but because the FDA does not require longer-term studies, and because they would be hideously expensive, no one does them.”

It is true, as Begley notes, that we still don’t know exactly how SSRIs work, which is why after more than 20 years of SSRI research new ideas are still being put forth. And to complicate this matter even more, depression is entirely a subjective experience.  There is no reliable way for doctors and scientists to measure it, and there is no way to pinpoint what causes it.  The opposite is true of my diabetes.  I know that I have diabetes because, as a result of an autoimmune attack, my body does not produce enough insulin.  I can measure my blood sugar at any moment of the day and know whether I am too high or too low.  Unlike blood sugar levels, however, moods cannot be measured in precise numbers, but that does not make the medication for my depression any less critical.

There is no question that SSRIs do have a very real impact on the chemical make-up of the brain.  Ronald Duman, a researcher in the department of psychiatry at Yale University School of Medicine  has demonstrated that SSRIs can lead to neurogenesis, or the growth of new brain cells, which could turn out to be the explanation for how SSRIs effect mood.  And moreover, a newly published study conducted at the University of Iowa shows that the drug Lexepro helped stroke victims preserve brain function.

As Begly and Dr. Kirsch certainly know, the stakes in this debate could not be higher.  “I believe that Sharon Begley and Dr. Kirsch will discourage people who need them from taking them, and that some of those people will have ruined lives, and others will end up committing suicide,” Solomon said.  “I believe they have blood on their hands.”  Arguing that antidepressants are no better than placebos without long term data on the placebo effect to bolster their claims is an ethical lapse of enormous proportions.  It’s no less dangerous than suggesting a diabetic could cope without her insulin.

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