Book Review: The Emperor’s New drugs

October 29th, 2012

[ The Emperor’s New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch, PhD, Basic Books, 2010.]

I wouldn’t write this review if I did not highly recommend this book.  What is different about it?  Professor Irving Kirsch, PhD, explains that he did not begin researching the efficacy of antidepressants.  As a clinical psychologist he did therapy, and would refer patients to psychiatrists for antidepressants when he felt medication might help.  He sought to do research into placebos.  To get data he obtained the data of clinical trials the American Food & Drug Administration (FDA) used to approve antidepressants.  When he analysed the raw data, things started to unravel.  He did not expect to find that antidepressants have the limited efficacy that they do.

In essence he realised that although antidepressants scored slightly better than inert placebos (sugar pills), there was no difference when the drugs were compared against an “active” placebo.  [definition: a known medication, not having antidepressant properties, which produced side-effects so that patients in the clinical trials cannot guess if they are only on a placebo.]  Using active placebos changes the picture completely.  Ultimately his book shows that antidepressants “work” because they cause side-effects. (eg sexual dysfunction, dry mouth, drowsiness, diarrhoea, nausea, forgetfulness, nervousness, sweating) Patients think they are receiving a powerful drug, from a professional who believes it works.

Kirsch asserts there is no evidence that antidepressants are actually treating an ‘illness’ called depression.  Kirsch considers all the arguments that opponents presented when he first published his findings.  He painstakingly refers to the data of meta-analyses to argue convincingly antidepressants operate only as placebos.  He writes scholarly and entertainingly.

He was an overnight celebrity when his research was front page news on 26th February 2008.

•           Psychology Today – “The Emperor’s New Drugs absolutely dismantles the case for antidepressants as a pharmaceutically effective treatment.”

•           Times Literary Supplement – “In measured prose, Kirsch leads the reader through the labyrinth of more than 20 years of trials, studies, and meta-analyses, and shows that these pills are no better than placebos.”

According to Kirsch, the reaction of the pharmaceutical companies was amazing.

“They were not at all surprised by our findings – they knew it all along and they wondered what all the fuss was about.”  Two companies hired him for brief consultations.  “They were finding it difficult to demonstrate drug effects and were hoping to find a way to identify in advance those people who were likely to respond to placebo treatment. If they could accomplish this, they could exclude the ‘placebo responders’ from clinical trials, and with these people excluded it might be easier to show a drug effect.” (p76.)

Kirsch detailed a very striking study conducted by the University of Oklahoma, School of Medicine in 1957. After testing the subjects and selecting those who became nauseous and vomiting upon taking ipecac syrup, they were given a medication to see if it would prevent nausea and vomiting; then given ipecac again.  Then another drug was tried, and another, six times, and eventually 100% of people had found a drug which prevented the symptoms.  The twist is that all six drugs were placebos.

This is very similar to the “STAR*D” design trial for depression, which switches non-responding patients, to a different antidepressant.  It has been used to argue that different patients respond to different antidepressants, and perhaps they have different ‘illnesses.’ But the Oklahoma study shows, along with the rest of the book, that switching drugs and getting improvement, is no indication that a drug is more than a placebo (p59-60.)

The second half of the book has more of a focus on placebos in general, and is equally interesting.  It supports his thesis that antidepressants are only placebos.  Some favour continued use of antidepressants, since placebos certainly work better than nothing.  Some favour antidepressants in conjunction with therapy such as Cognitive Behaviour Therapy (CBT).

He states clearly that CBT alone is as effective as CBT with medication (p162-3), and considering the relapse rates, CBT is superior to medication.  He reminds us of the extensive (and serious) side-effects associated with antidepressants, and asks, “Why would you bother?”  For those unaware, he states that “when compared to placebos SSRIs double the risk of suicidal thoughts and behaviour in depressed patients up to the age of 24.”  Beyond age 24 “the interpretation of the data is disputed.” (p151.)

A “MUST READ” for all those who prescribe medications, or who are in the business of therapy.  The information contained in this book is vital for informed consent, and to enable good practice for managing depression.

For me this book casts serious doubts about the use of anti-depressants at all. It has made me question mainstream thinking, which suggests that there is a role for anti-depressants as a temporary or short term adjunct to other treatments. Fortunately psychology and good research has shown there are many alternatives to assist people with depression.

[ The Emperor’s New Drugs: Exploding the Antidepressant Myth, by Irving Kirsch, PhD, Basic Books, 2010.]


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