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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 21 of 21. This is the beginning of the thread.
Posted by Phillipa on July 11, 2011, at 19:54:17
Someone sent a link that couldn't get to work to me on an article that Peter Breggin wrote for NYT's anyone know what it said? Thanks Phillipa
Posted by zonked on July 12, 2011, at 10:09:02
In reply to Peter Breggin in NYT anyone read?, posted by Phillipa on July 11, 2011, at 19:54:17
I wonder if anyone else has mixed feelings about Breggin, as I do. On the one hand, he says what few in his field are willing to say - certain treatments in psychiatry are overused and often the patients are never made aware of how they work or the severe, potentially permanent side effects they can cause. On the other hand, I do wonder if he's scared some people away from treatment who really do need it. Interesting guy, although I didn't find a recent NYT article with him in it. Phillipa, have you read any of his stuff? Anyway, have a good day all.
Posted by Phillipa on July 12, 2011, at 10:54:44
In reply to Re: Peter Breggin - mixed feelings » Phillipa, posted by zonked on July 12, 2011, at 10:09:02
No haven't read any of his stuff. I had meant written by Kramer my goof. But wonder why Breggin was the name I posted first. Strange Freudian slip? Phillipa
Posted by mtdewcmu on July 12, 2011, at 14:04:21
In reply to Re: Peter Breggin - mixed feelings » zonked, posted by Phillipa on July 12, 2011, at 10:54:44
> No haven't read any of his stuff. I had meant written by Kramer my goof. But wonder why Breggin was the name I posted first. Strange Freudian slip? Phillipa
Maybe because Breggin is usually the one sharing his controversial opinions. I wasn't very persuaded by the Kramer article. The flaws he points out in the "debunking" studies need to be addressed by experts. The public can't assess those problems. What I took from it is that Kramer earnestly wants to believe that ADs are good drugs. In the face of a lot of uncertainty, he is going to take the side of ADs. I am waiting for the definitive clinical study to be done, if it ever will be. I think that some of the debunkers, especially in the popular media, have come to believe that ADs are _literally_ placebos, as if you could replace them with sugar pills and no one would be the wiser. I think these people would be surprised, if they actually took the drugs, how intense the effects are, and how completely different they make you feel. The question is not whether ADs are literally nothing but placebos, but whether, for all that they do to alter your consciousness, you nevertheless wind up right where you started in terms of symptoms of depression. I know that, for me, the results haven't been overwhelmingly positive. Whether they have made things substantially better over the long haul is another question. I think it's an important question to ask, even though psychiatrists like Kramer seem happy to interpret the lack of knowledge as the glass being half full. It doesn't encourage me when boosters like Kramer advance obviously-fallacious arguments, like the one about maintenance studies where long-term depression patients were more likely to relapse into depression when their ADs were secretly replaced with placebos. Everyone who has gone through the AD merry-go-round knows that ADs cause withdrawal when you try to quit them, so how can you separate out depression caused by withdrawal from depression that is naturally-occurring? So I try to judge for myself if the pills are doing any good and try to limit how much I spend on them, and how much hope I invest in them, and in the meantime I'm waiting for either someone to do the definitive study to resolve the issue for good, or for something else to come out that is clearly better than placebo.
Posted by sigismund on July 12, 2011, at 14:14:54
In reply to Re: Peter Breggin - mixed feelings » Phillipa, posted by zonked on July 12, 2011, at 10:09:02
I prefer Breggin to Kramer.
Have I read Kramer?
Maybe he was forgettable?
Breggin I remember. Toxic Psychiatry, certainly.
Posted by mtdewcmu on July 12, 2011, at 15:40:52
In reply to Re: Peter Breggin - mixed feelings, posted by sigismund on July 12, 2011, at 14:14:54
> I prefer Breggin to Kramer.
>
> Have I read Kramer?
>
> Maybe he was forgettable?
>
> Breggin I remember. Toxic Psychiatry, certainly.Kramer is actually more famous. He wrote "Listening to Prozac," which was a mega-bestseller in the 90s.
Posted by joe schmoe on July 12, 2011, at 16:01:10
In reply to Re: Peter Breggin - mixed feelings » sigismund, posted by mtdewcmu on July 12, 2011, at 15:40:52
I read "Listening to Prozac" before starting any SSRIs and it actually got me real excited - as an introverted, shy, anxious person, I loved the idea of a pill that would make me outgoing, popular, and successful. Unfortunately, Kramer greatly overstates the effects of SSRIs. They certainly never changed my personality in the ways he describes in his anecdotes, where people go from hiding in the basement to millionaire pushy car salesmen and socially dominant corporate executives. (Okay, I am exaggerating a little, but not much.) I know a lot of people on antidepressants; none of them have had a change in personality from introvert to extrovert.
On the other hand, these things are definitely not placebos. Anybody who has tried a bunch of ADs, and finally found success on one of them while getting no benefit from the others, knows they can't be placebos, or the first one would have worked just fine.
Posted by floatingbridge on July 12, 2011, at 16:03:53
In reply to Re: Peter Breggin - mixed feelings, posted by sigismund on July 12, 2011, at 14:14:54
I guess what I took from his opinion piece was he was waiting for evidence, and for now, he was accepting what he
saw as possible benefits and pitfalls. In a way he tried to extricate the AD discussion from the obvious psychological or psychiatric applications when he talked about the study of the possible benefits of an AD (I forget if a particular one was mentioned) on stroke
recovery.I didn't really read him as pro-antidepressant, (which could be my
misreading). Maybe like a practioner
trying to cope with their advent--more
open-minded and accepting of them. While they may not *cure* mental illness, (and maybe the reactivity the
debate can engender suggests a massive disappointment of this to-date failure), they are part of the working answer, whether one opts to take or prescribe them.
Posted by mellow on July 12, 2011, at 16:29:20
In reply to Peter Breggin in NYT anyone read?, posted by Phillipa on July 11, 2011, at 19:54:17
Could someone please link the article.
Posted by floatingbridge on July 12, 2011, at 16:52:34
In reply to Re: Peter Breggin in NYT anyone read?, posted by mellow on July 12, 2011, at 16:29:20
I can't wrangle the link, mellow :-/
NYT, Sunday, July 10th, Opinions.
In Defense of Antidepressants
Peter Kramer
I can Google it....
> Could someone please link the article.
Posted by zonked on July 12, 2011, at 19:59:07
In reply to In Defense of Antidepressants by Peter Kramer » mellow, posted by floatingbridge on July 12, 2011, at 16:52:34
I really enjoyed and appreciated Kramer's article. Antidepressants do work, and even though so many of us here are harder to treat and end up on things like, well, Nardil, :) the mainstream SSRI drugs also work - ages ago, Zoloft worked for me and I know countless people for whom these drugs have worked. It's refreshing to see some positive press.
Posted by mtdewcmu on July 12, 2011, at 20:33:38
In reply to Re: Peter Kramer - mixed feelings, posted by floatingbridge on July 12, 2011, at 16:03:53
Marcia Angell's article that Kramer refers to is a lot more interesting and educational:
Part I
http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/Part II
http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/Here is the link to the NY Times article:
http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html
Posted by mtdewcmu on July 12, 2011, at 20:43:00
In reply to Re: In Defense of Antidepressants by Peter Kramer, posted by zonked on July 12, 2011, at 19:59:07
> I really enjoyed and appreciated Kramer's article. Antidepressants do work, and even though so many of us here are harder to treat and end up on things like, well, Nardil, :) the mainstream SSRI drugs also work - ages ago, Zoloft worked for me and I know countless people for whom these drugs have worked. It's refreshing to see some positive press.
It's important to listen to both sides. I'm rooting for science, and patients, not antidepressants. "Time discovers truth."
Posted by floatingbridge on July 12, 2011, at 21:42:40
In reply to Re: Peter Kramer - mixed feelings, posted by mtdewcmu on July 12, 2011, at 20:33:38
MtDew, good links. Thanks!
> Marcia Angell's article that Kramer refers to is a lot more interesting and educational:
>
> Part I
> http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/
>
> Part II
> http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/
>
> Here is the link to the NY Times article:
> http://www.nytimes.com/2011/07/10/opinion/sunday/10antidepressants.html
Posted by joe schmoe on July 12, 2011, at 22:35:55
In reply to Re: Peter Kramer - mixed feelings » mtdewcmu, posted by floatingbridge on July 12, 2011, at 21:42:40
I read a lot of bad logic in those articles, but this statement takes the cake:
"I believe doctors should be prohibited from prescribing psychoactive drugs off-label, just as companies are prohibited from marketing them off-label."
As if any company is going to spend hundreds of millions to get an already approved drug, approved for something else, just in time for it to go off-patent (or worse, if it is already out of patent). Such a ridiculous rule would keep effective drugs forever out of the reach of patients, if the (extremely expensive and time consuming) initial studies for a particular use did not cover something the drug was later found to effectively treat. What rubbish.
I wish I could inflict my pre-treatment brain chemistry on some of these authors and then watch them try to get through life without drug treatment.
Imagine if this paragraph was about the invention of penicillin, not prozac:
"The shift from talk therapy to drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that mental illness is caused primarily by chemical imbalances in the brain that can be corrected by specific drugs. That theory became broadly accepted, by the media and the public as well as by the medical profession, after Prozac came to market in 1987 and was intensively promoted as a corrective for a deficiency of serotonin in the brain. The number of people treated for depression tripled in the following ten years, and about 10 percent of Americans over age six now take antidepressants. "
It would read something like
"The shift from 'supportive therapy' such as keeping the patient warm, hydrated, quarantined, etc. to drugs as the dominant mode of treatment coincides with the emergence over the past four decades of the theory that physical illness is caused primarily by infection with microscopic life forms called 'bacteria' that can be combated by specific drugs. That theory became broadly accepted, by the media and the public as well as by the medical profession, after Penicillin came to market in 1945 and was intensively promoted as a corrective for infections by unspecified, unseen 'bacteria' supposedly causing a broad variety of illnesses from wound infection to pneumonia. The number of people treated for 'infection' tripled in the following ten years, and about 10 percent of Americans over age six now take antibiotics at least once a year."
Posted by mtdewcmu on July 13, 2011, at 0:07:54
In reply to Re: Peter Kramer - mixed feelings, posted by joe schmoe on July 12, 2011, at 22:35:55
> I read a lot of bad logic in those articles, but this statement takes the cake:
>
> "I believe doctors should be prohibited from prescribing psychoactive drugs off-label, just as companies are prohibited from marketing them off-label."
>
> As if any company is going to spend hundreds of millions to get an already approved drug, approved for something else, just in time for it to go off-patent (or worse, if it is already out of patent). Such a ridiculous rule would keep effective drugs forever out of the reach of patients, if the (extremely expensive and time consuming) initial studies for a particular use did not cover something the drug was later found to effectively treat. What rubbish.
>Actually, that sounded like a good idea to me. But you also raise a good point. Maybe doctors could be allowed to prescribe a drug off-label after the patent has expired, or after some set number of years. Keep in mind that if doctors were required to prescribe "on-label," the drug companies would have an incentive to get new drugs approved for the widest possible range of conditions. Right now there is little incentive to get an antidepressant approved for, say, GAD, when it can just be prescribed off-label. Older drugs could be grandfathered in.
> I wish I could inflict my pre-treatment brain chemistry on some of these authors and then watch them try to get through life without drug treatment.
>Some psych drugs undeniably work, and I don't think Marcia Angell is saying they don't. For instance, I don't think anyone doubts that lithium works for bipolar disorder. But if you're talking about SSRIs, how can you be sure that the drug cured you and you didn't just get better on your own?
> Imagine if this paragraph was about the invention of penicillin, not prozac:
>There is an important difference here. Penicillin can be proven to work better than supportive care in double-blind studies. Prozac can't.
One part of her article that raised questions in my mind that she didn't answer was the part about the exploding number of diagnoses in the DSM. Just because the diagnoses exist on paper doesn't mean that psychiatrists are going out of their way to find people to pin them on. Virtually anyone that walks into a psychiatrist's office can walk out with a prescription for antidepressants. Most of the dubious diagnoses in the DSM are not things that require heavy-duty drugs, they'll probably be treated with antidepressants. It doesn't follow automatically that just because there are more diagnostic categories that patients will be treated with more or heavier drugs.
Posted by joe schmoe on July 13, 2011, at 0:49:03
In reply to Re: Peter Kramer - mixed feelings, posted by mtdewcmu on July 13, 2011, at 0:07:54
> Actually, that sounded like a good idea to me. But you also raise a good point. Maybe doctors could be allowed to prescribe a drug off-label after the patent has expired, or after some set number of years. Keep in mind that if doctors were required to prescribe "on-label," the drug companies would have an incentive to get new drugs approved for the widest possible range of conditions.
No, only for conditions that would yield enough prescriptions to pay for the studies. Less common conditions would not be worth the investment by the company.
> Right now there is little incentive to get an antidepressant approved for, say, GAD, when it can just be prescribed off-label.
And for good reason - if a drug is safe, it's safe, and its interactions will be the same regardless of what it is prescribed for. A reason SSRIs are widely prescribed is because they are amazingly non-toxic.
> Some psych drugs undeniably work, and I don't think Marcia Angell is saying they don't. For instance, I don't think anyone doubts that lithium works for bipolar disorder. But if you're talking about SSRIs, how can you be sure that the drug cured you and you didn't just get better on your own?
The article was about antidepressants, and interestingly, mentioned at the beginning how they were discovered by accident (the original purpose of isoniazid and iproniazid was to treat tuberculosis). Despite the fact that no one was looking for a cure for depression (no placebo effect here!), the drugs worked for depression. The author of the article (and the books) blissfully ignore this fact for the rest of their discussions. Obviously, antidepressants work, and it has nothing to do with the placebo effect.
> There is an important difference here. Penicillin can be proven to work better than supportive care in double-blind studies. Prozac can't.I don't believe this for a minute. I believe the "no better than placebo" argument was debunked the minute it came out: the patient populations in these studies were not the patient populations psychiatrists actually see, but were adults who had never received treatment for depression before, in order to remove "complicating factors" like coming off another antidepressant. Talk about a skewed sample. Anybody with serious depression problems would not spend their lives waiting around for a pharm study, when there were already so many agents available (including, at the time of Prozac, imipramine).
It's easy in an antibiotic study to find people who just got infected. It's not so easy to find people who just "got" depression, especially if it is a genetic brain chemistry disease.
> One part of her article that raised questions in my mind that she didn't answer was the part about the exploding number of diagnoses in the DSM. Just because the diagnoses exist on paper doesn't mean that psychiatrists are going out of their way to find people to pin them on. Virtually anyone that walks into a psychiatrist's office can walk out with a prescription for antidepressants. Most of the dubious diagnoses in the DSM are not things that require heavy-duty drugs, they'll probably be treated with antidepressants. It doesn't follow automatically that just because there are more diagnostic categories that patients will be treated with more or heavier drugs.I think it's clear that when people find out there is a cure for something, they will seek out professional help instead of just enduring it. An example is restless legs syndrome (which the article also mocks). People who have this real disorder - and I suffer from it at times myself - suffered from it for decades with no diagnosis and no cure until fairly recently, when some light began to be shed upon it as a dopamine problem (and which a dopamine related drug could address). No doubt there is now a "skyrocketing" population of people seeking a cure, now that they have heard that doctors will actually give them one instead of giving a mystified shrug.
Who bothers to get a diagnosis for a condition when there is no cure? Of course people didn't bother in the past, especially when depression and other mental health issues were very heavily stigmatized. Frankly I am glad Big Pharma advertised these medicines enough to make the TV-watching non-patient general population realize that people with various issues were not "crazy" but simply had a common medical problem.
As I have stated elsewhere, for most of history, most people were farmers and did not have to deal with other people. Only in the 20th century did this pattern change, and I think it created a horribly stressful society for non-extroverts. It is no surprise to me that there has been an explosion of mental illness in the 20th century. What's amazing is how long stigmatization managed to keep it under wraps.
Posted by jono_in_adelaide on July 13, 2011, at 1:30:47
In reply to Re: Peter Kramer - mixed feelings, posted by joe schmoe on July 12, 2011, at 22:35:55
"That theory became broadly accepted, by the media and the public as well as by the medical profession, after Prozac came to market in 1987"
Dr William Sargent in England was promoting that theory in the early 60's using Tofranil, Nardil, Librium and Thorazine, and I am sure many prominent American psychiatrists were as well.
One could equaly say that talk therapy became popular when the only alternative was potasium bromide or opium.
Posted by joe schmoe on July 13, 2011, at 2:54:51
In reply to Re: Peter Kramer - mixed feelings, posted by jono_in_adelaide on July 13, 2011, at 1:30:47
> "That theory became broadly accepted, by the media and the public as well as by the medical profession, after Prozac came to market in 1987"
>
> Dr William Sargent in England was promoting that theory in the early 60's using Tofranil, Nardil, Librium and Thorazine, and I am sure many prominent American psychiatrists were as well.
>
> One could equaly say that talk therapy became popular when the only alternative was potasium bromide or opium.
Good point. In Kramer's book Listening to Prozac he actually explains in detail how researchers were deliberately trying to find a compound that was selective just for serotonin, to get the antidepressant effects without the side effects of the tricyclics. It was definitely not a case of 'they tried fluoxetine for depression and it worked, so they said serotonin imbalance was to blame for depression.'I remember being fascinated reading about the research techniques of the time.
"In 1971 both Molloy and Wong attended a lecture at Eli Lilly on neurotransmission given by Solomon Snyder, a researcher from Johns Hopkins University. Snyder had developed a technique that would prove immensely useful to the Lilly team. He had ground up rat brains, separated out the nerve endings, and created an extract of nerve endings that worked in the same way as living nerve cells. Wong used this technique to test the effects of Molloys compounds, one of which was found to block the reuptake of serotonin while affecting virtually nothing else. "
It was then I learned the strange word "synaptosome"
Posted by mtdewcmu on July 13, 2011, at 11:21:11
In reply to Re: Peter Kramer - mixed feelings, posted by jono_in_adelaide on July 13, 2011, at 1:30:47
> "That theory became broadly accepted, by the media and the public as well as by the medical profession, after Prozac came to market in 1987"
>
> Dr William Sargent in England was promoting that theory in the early 60's using Tofranil, Nardil, Librium and Thorazine, and I am sure many prominent American psychiatrists were as well.
>
> One could equaly say that talk therapy became popular when the only alternative was potasium bromide or opium.I think you guys are not giving Marcia Angell enough credit. She was editor of the Journal of the American Medial Association. She's undoubtedly a superlative scholar and writer, among the best in American medicine, so if you see something that doesn't make sense at first, try rereading it to see if you misunderstood.
When she writes, "That theory became broadly accepted, by the media and the public as well as by the medical profession," she is saying that the introduction of Prozac increased acceptance of the chemical imbalance theory among the popular media, the general public, and the medical profession in general, i.e. not just psychiatry but all of medicine.
Posted by mtdewcmu on July 13, 2011, at 11:28:38
In reply to Re: Peter Kramer - mixed feelings » jono_in_adelaide, posted by mtdewcmu on July 13, 2011, at 11:21:11
>
> When she writes, "That theory became broadly accepted, by the media and the public as well as by the medical profession," she is saying that the introduction of Prozac increased acceptance of the chemical imbalance theory among the popular media, the general public, and the medical profession in general, i.e. not just psychiatry but all of medicine.That's what she means by it becoming "broadly accepted." It had already been narrowly accepted by the psychiatric community prior to Prozac. Keep in mind that Angell is not a psychiatrist herself, so her viewpoint, and her former audience in JAMA, is that of the broader medical profession.
This is the end of the thread.
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