Cracked (10 page)

Toby: What do you mean?

Colleague: Let me give you an example. I once worked with someone who hated his job at an accountancy firm so much that he became very depressed. He consulted his doctor and was prescribed Prozac. After a while things began to change a little for the better. At least that's how he initially felt. He started to take less offense at his boss's criticisms, he stopped stressing so much about deadlines, and he began to relax a little more socially with his colleagues. In total, he developed that “what the heck” attitude which some people on the drug report. So the question is, was he helped? Had the drugs made his life any better?

Well, from one angle, I suppose they had: he was now slightly more tolerant of work and less conflicted about going in every day. Yet from another angle he wasn't helped at all, because once he stopped taking Prozac his old dislike of work returned. Worse still, once off the drug he wondered whether he'd actually drugged himself into staying in a job he should've left years ago. Perhaps his depression was an alarm that signaled he needed to change his life. But rather than listening to the alarm, he just turned it off with Prozac—pulling up the covers and going back to sleep.

Toby: So by dulling his suffering with pills, you are saying he failed to get up and make the changes he needed?

Colleague: That's what this man believed. By taking the pills he had merely tranquilized himself, and when he came off them he returned to a problem he should have confronted a long time ago.

Toby: And maybe that's what's happened to me? I've taken a drug that's interfered with my natural responses, and this may stack up problems for me in the future?

Colleague: This is of course a possibility. So at the very least I think it is something we should take seriously and explore …

4

The vision of antidepressants I have just articulated is not the vision embraced by mainstream psychiatry. In fact, as I've learned from experience, the above vision of antidepressants makes many conservative psychiatrists turn as red as tomatoes. But why is this so? What gets them so upset? The obvious answer is that it flatly contradicts their mainstream view, which is broadly consistent with that of the pharmaceutical industry.

So to understand that mainstream view and how it differs from the one above, let us talk for a moment to Dr. Joanna Moncrieff, a psychiatrist and senior researcher in the Department of Mental Health Science at University College London.

Moncrieff is today considered one of the most exciting figures in antidepressant research, earning a reputation almost as notorious as Irving Kirsch's for upsetting the status quo. As I sat with Moncrieff in her university office, sipping coffee and talking louder than usual to be heard over the drilling outside, she was more than eager to explain to me the difference between the vision of drugs largely embraced by the psychiatric establishment (a vision called the “disease-centered model”), and the vision of antidepressants outlined above (a vision she calls the “drug-centered model”). She traced their differences in the following way:

“In the disease-centered model,” began Moncrieff, “people are assumed to have a mental disease, a problem in their brain. And drugs are thought to be effective because they rectify or reverse that underlying brain problem in some way. This is the dominant model in psychiatry and the one that best serves psychiatric interests.

“But the drug-centered model,” Moncrieff continued, “offers an entirely different way of understanding how these drugs work. It rather emphasizes that drugs are drugs; they are chemical substances that are foreign to the human body but which affect the way people think and feel. They have psychoactive properties, just like recreational drugs do, which alter the way the body functions at a physiological level. So the drug-centered model does not say that psychiatric drugs heal brain problems, like the disease model claims; it rather says they alter people's states of mind in ways that may or may not be helpful.”

The interesting thing about the drug-centered model is that while there are growing numbers of psychiatric nurses, psychotherapists, and clinical psychologists who accept this version of how psychiatric drugs work, at the heart of the psychiatric establishment there is still considerable resistance to this view. “There are many psychiatrists who find the drug-centered model extremely challenging and simply don't want to hear it,” said Moncrieff candidly. “This is because it fundamentally undermines the notion upon which modern psychiatry is based: the idea that mental disorders are brain-based diseases which psychiatric drugs can remedy in the same way medical drugs remedy physical problems.”

Moncrieff's own academic research has shown that this current and widespread resistance to the drug-centered model has not always been so strong. “Prior to the 1950s, psychiatric drugs weren't understood to act upon underlying diseases like they are today. They were seen as drugs that would pep you up. They were accepted as sticking plasters or uplifters that might at best be able to suppress symptoms for a period, but never were they seen as reversing a disease state.”

But this all changed, Moncrieff explained to me, when in the 1950s the drug-centered model began to be discredited. “This happened because the pills being used at that time [tranquilizers like Valium and Librium] were discovered to have terrible withdrawal effects. It also became obvious that these pills had been doled out to millions of people who were unhappy with their lives, particularly women who were trapped in miserable marriages. So once people started to realize that these pills had been used to suppress appropriate emotional responses to unhappy situations, that whole drug-centered model of taking pep pills to pick you up fell into disrepute.”

Moncrieff therefore sees the rise of the disease-centered model as filling a vacuum left by the demise of the drug-centered model. “With the growing popularity of the older antidepressants during the 1960s, '70s, and '80s, the diseased-centered model began to take over,” continued Moncrieff. “This was especially the case in the 1990s, when the new SSRI antidepressants came on the scene. The drug companies were trying to capture that huge market of people who once took tranquilizers. But because the old model of how drugs work had been tarnished, they needed a new model to reassert their value and necessity. So now these drugs were cast as curing us rather than changing us.

“And that's where the idea of the chemical imbalance came in. It was perfect because it implied that these drugs actually corrected a defect in the brain. If you have a brain disorder, a chemical imbalance, and this pill is going to correct that imbalance, then obviously you must take it. Few questioned whether this new way of thinking totally obscured what these drugs really do. And this unthinking acceptance of the disease-centered view has dominated mainstream psychiatry for the last twenty or thirty years.”

5

Having now heard my imaginary exchange with Toby and my real one with Moncrieff, I imagine that some of you could now be feeling a little confused. After all, only two chapters ago we saw how Irving Kirsch's research revealed that antidepressants work almost no better than placebo pills. And yet, in this current chapter, we have understood antidepressants as altering how we feel and behave. So is there a contradiction here? Can Moncrieff's view—that pills change us—be reconciled with Kirsch's view that they help us little better than sugar pills? I decided to put this question to Moncrieff.

“I actually think our work is complimentary, not contradictory,” Moncrieff answered decisively. “I agree with Kirsch that the majority of benefit from these pills is due to the placebo effect. But also remember that Kirsch's research shows that active drugs can sometimes work fractionally better than placebos, especially with people who are severely depressed. And that's where the drug-centered model comes in. It can explain this small difference in terms of the psychoactive effects real drugs have. Either they produce uncomfortable side effects that convince people they're on the real drug (which in turn makes the placebo effect greater) or some of these drugs are so sedative that they put people into such a fog that they can no longer feel depressed or anything else.”

A recent study published in the
British Journal of Psychiatry
by a team of researchers from Oxford University strongly confirms the view that most psychoactive effects are neither useful nor beneficial.
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To reach this conclusion, the researchers assessed thirty-eight patients who had taken SSRI antidepressants for periods between three and forty-eight months (the median length being twenty-three months). The researchers then undertook in-depth interviews with all of the patients to find out how the pills affected them. The results they uncovered are so at odds with the modern myth of the “happy pill” that it is worth paraphrasing them almost in full:

• • Most participants described a general reduction in the intensity of all the emotions that they experienced, using words like “dulled,” “numbed,” “flattened,” or completely “blocked” to capture how they felt.
  
• • A few participants described feeling no emotions at all, while others reported their emotional experience had become more “cognitive” or “intellectual.”
  
• • A few participants described how the emotions that were at times present seemed “unreal,” “fake,” or “artificial.” And almost all participants, paradoxically, described a reduction in their positive emotions, including a reduction in emotions like happiness, enjoyment, excitement, anticipation, passion, love, affection, and enthusiasm.
  
• • Most participants also described feeling emotionally detached or disconnected from their surroundings. Most also described this detachment as extending to a detachment from other people. Specifically, they felt reduced sympathy and empathy, and felt detached during social interactions. Many participants also described an emotional detachment from their friends and family, including their partners or children.
  
• • Almost all participants described not caring about things that used to matter to them. They cared less about themselves, about other people, and about the consequences of their actions. Not caring could have both helpful and unhelpful consequences: it could reduce the sense of pressure and stress, but it could also increase the likelihood that important tasks were neglected.
  
• • Many participants described a general feeling of indifference to things in life that used to matter to them. Some felt they just did not care as much about the consequences to themselves of their behavior. A few participants went further, mentioning thoughts of self-harm or suicide that they related to their emotional detachment and numbness. One participant had started to self-harm in an effort to feel emotion. Many participants reported not caring as much about others, being less sensitive or courteous toward other people, having reduced concern for others' feelings, and reduced concern about other people's opinions of them. Some participants described being less concerned or even unable to care about responsibilities in their everyday lives.
  
• • All participants experienced a reduction of intensity or frequency of negative emotions. Most considered that at some stage the reduction in negative emotions was beneficial to them, bringing relief from distressing negative emotions like emotional distress, anger, irritability, aggression, anxiety, worry, or fear. Although this reduction was usually at some stage a relief, many participants also reported it impaired their quality of life. Participants described the need to be able to feel negative emotions when appropriate, such as grief or concern. Some were unable to respond with negative emotions, such as being unable to cry when this would have been appropriate or respond appropriately to bad news.
  
• • Some participants felt their personality had changed in some way. They felt they were not the person that they used to be. Participants also reported that specific aspects of their personality and, in particular, emotional aspects had been changed or lost. Some participants believed that at times their antidepressant had made them behave out of character. One participant believed that the medication had changed their personality permanently, having a lasting effect beyond finishing their medication.
  

When reading this study of how antidepressants make people feel, Toby's reaction to his pills suddenly seems less idiosyncratic. In fact, because Moncrieff is so familiar with research like the above, when I told her about Toby's experience she was completely unsurprised. “We know these pills can have this sort of numbing effect, creating a kind of emotional disengagement,” she said, “and sometimes this disengagement can also lead to a kind of dis-inhibition. Because people aren't in touch with their normal range of emotions, they can start to do odd things, like the man Toby you're describing.”

This final point about pills making us do “odd things” crops up again and again in the clinical research. Like Toby, or the woman on Kilroy's show, or the people surveyed in the research we've just seen, these pills can severely knock us off center. To illustrate the nature of this, let's have a quick look at some examples of such drug-induced behavior, as explored by Dr. Simon Sobo in his work. Sobo is a psychiatrist who has spent years documenting the strange and unwanted effects these pills can unleash.

Among the various examples Sobo provides is a female patient of his who worked as a computer consultant. She had very low self-esteem generally, and at work felt she wasn't as capable with computers as her five male colleagues. She needed constant reassurance, and when things went wrong she'd punish herself with violent self-accusations.

Yet on an SSRI antidepressant, things changed. She acknowledged that she wasn't as good with computers as her colleagues, but that she wasn't that bad either. More important, she realized she was necessary to her team. She was the only one with sufficient social skills to handle their clients. She was now also able to ask questions at conferences without feeling foolish.