Why Antidepressants Work: Research Says It's A Matter of Faith
One of the pieces that I have linked to the Featured Article page of the website is entitled, “The Emperor’s New Drugs: An Analysis of Antidepressant Data Submitted to the U.S. Food & Drug Administration.” Readers will also find a companion article (both designated by “naked emperor” icons) called “Antidepressants: A Triumph of Marketing Over Science?” The latter article is a re-examination and commentary on the data interpreted by the former. Both articles were written by a host of researchers from various institutions of higher learning around the country and seem to me to be a bold and thorough examination and interpretation of the data generated by outcome studies submitted to the FDA by the drug companies themselves on antidepressant medication.
The researchers’ conclusion? “Kirsch et al. (2002) have convincingly demonstrated, using pharmaceutical industry data, that the image of antidepressants as powerfully more effective than placebo is not supported by the data. The small advantage over inert placebo credited to antidepressants is quite possibly a methodological artifact (Moncrieff, 2002). It could be argued that the patients randomly assigned to placebo are the lucky ones, because they derive a benefit virtually comparable with the medication condition without the associated medical risks.” The researchers furthermore conclude that “.. The psychiatrist, or at least something about the psychiatric relationship, and not the pill, appears to facilitate improvement in depression. Figuring out ways to enhance the therapeutic alliance, originally pioneered but recently marginalized by organized psychiatry, may prove more fruitful than modifying the selectivity of antidepressants. There is no doubt that antidepressants have a biochemical impact on the brain, but the valence of that impact is open for considerable debate, and whether it corrects a chemical imbalance is in grave doubt.”
These conclusive statements are found in the second article under the subheading “A Bitter Pill To Swallow.” Ah, not so for Witchdoctors-In-Training! For those of us that have worked our entire careers to master the art of talk therapy, they go down like a perfectly simmered pod of okra from my mama’s best gumbo. As a matter of fact, the companion articles affirm a variety of truths that have been intuitively accepted by WDITs for centuries and indeed may result in a hastening of the postmodern “paradigm shift” called for by Antonuccio, Burns, and Danton. In this installment of the blog, however, we will focus on the meaning of a key point made in the second article and save an examination of other corollary conclusions posited by our authors for future installments.
To re-quote Antonuccia, Burns, and Danton, “There is no doubt that antidepressants have a biochemical impact on the brain, but the valence of that impact is open for considerable debate.”
What do the researchers mean by “valence?” An illustration might help in grasping the meaning of this statement. It has often been suspected (and sometimes demonstrated) that certain faith healers administer a mild electric shock to their subjects during their healing rituals. The electric current is supplied without the knowledge of the subject through some concealed gadget and is typically part of a process that involves other ritualized elements, like incantations, preaching, prayer, scripture reading, etc. It is common that subjects report the abatement of various physiological and psychological symptoms--or “healing”-- after having participated in this kind of religious rite.
While the positive outcome of such rituals is well documented and undeniable, the exact nature of the "healing" transfomation is subject to interpretation. The healer (even when “busted” over the concealed gadget) usually asserts that the transformative element in the process that produced the healing is mystical and of divine origin. A staunch practitioner of molecular medicine would dismiss this claim, making the observation that the electric current itself, being the only application in the process that has been “scientifically demonstrated” to actually alter organicity in any measurable way, must somehow be credited with the change, though he or she may not be able to provide a concise cause-and-effect explanation. The subject, on the other hand, doesn’t care how the change was produced. For him or her, the desired outcome has been achieved and to dissect the experience too much might somehow “undo” the healing.
How would WDITs interpret this set of circumstances? While they might express concern over the apparent ethical dilemma produced by the use of the “concealed gadget” by their fellow healer, WDITs would well understand its purpose and place in this particular class of healing ritual. The gadget’s electric current is designed by the healer to produce a “visceral hook” for the subject that galvanizes and validates the subject’s belief about the ritual itself. The context co-created by the healer and the subject (preaching, singing, dancing, etc.) in turn informs the subject’s experience of and provides “meaning” to the novel sensations provided by the electrical shock. The result is a recursively energized and powerfully persuasive “healing” experience for the subject that is firmly rooted in what he or she believes is happening during the healing ritual, namely a connection with mystical forces.
Given this frame, if you asked WDITs to deconstruct the elements of the ritual and identify the valence of the electric shock in producing the positive report of the subject, they would explain that, though the electric current produced some neurochemical change in the subject that was potent enough to be “felt,” this change, outside the ritualized context provided by the healer, would most likely be experienced by the subject as annoying, but not a change that could produce a change like miraculous healing. If the subject had, for example, received a shock by accidentally sticking his or her finger in a light socket at home rather than from the healer’s gadget during a religious ritual, the change in the subject at the neurochemical level would be identical in both instances. It is unlikely, however, that the subject would interpret the “light socket” experience as a spiritual event that could bring about (or herald) a miraculous healing. WDITs would propose that this shift in context would most likely rob the electric current of any healing valence. In summary, WDITs would say that while producing a measurable neurochemical change in the subject, the valence of the electric current in creating the healing transformation was purely relative to the context in which it was administered.
So it is, the authors of our articles say, with antidepressant medication. Their research indicates that while antidepressants do alter the biochemistry of patients in some significant ways, it is doubtful that this “first-order” neurological effect corresponds directly to (alone has any valence in creating) the therapeutic outcome that some patients report. The neurochemical changes produced by the drug must be experienced by the patient in a certain “informing context” if the neurochemical flux is to be experienced as therapeutic. Again, for example, if the medication was secretly slipped into the patient’s oatmeal every morning, he or she might experience physical and/or emotional sensations related to the ingesting of the drug. However, the likelihood that patients would report the first-order changes in their neurology as resulting in a second-order change like an “improvement in mood” or “an abatement of their depression” is unlikely. On the other hand, if a person in a white coat announced in advance to patients that he or she was experimenting with “therapeutic oatmeal” that was designed to make depressed people feel better, then it is possible that this context, along with the visceral hook provided by the drug in the oats, might very well produce a positive report from patients similar to the healing that subjects describe after being shocked by the faith healer’s gadget. Interestingly enough, our researchers reveal that statistically about the same number of patients would experience improvement in their mood at the mere suggestion of “therapeutic oatmeal” without the visceral hook provided by the drug. To quote our authors, “It could be argued that the patients randomly assigned to placebo [in our example, drug-free oatmeal] are the lucky ones, because they derive a benefit virtually comparable with the medication condition without the associated medical risks.”
Now having fully explored their conclusions about the valence of the neurochemical impact of antidepressants, our authors’ next conclusion, that “ . . the psychiatrist, or at least something about the psychiatric relationship, and not the pill, [italics added] appears to facilitate improvement in depression,” can be analyzed from a WDIT’s point of view.
In the case of our faith healer, did the electric current produce the healing effect? WDITs would say, “Well, sort of.” They would explain that the nature of the circumstance might prohibit the gathering of any empirical evidence that the shock itself actually produced organic changes in the subject that corresponded directly to the subject’s positive report. However, they would point out that the electric current was a first-order element in a protocol that included a carefully constructed healing context. The collection of first- and second-order elements, ritualized in the right manner, produced what the authors of our articles would call a “placebo effect.” Rather than using this linear term, WDITs would prefer to say that the healer induced a condition of consciousness (the word "trance" might apply) that allowed for a second-order transformation, recalibrating the subject’s second-order experience of his or her status. WDITs would use the cybernetic rather than linear description to emphasize that the healing effect was a culturo-socio-psychological phenomenon, not something that happened exclusively “between the ears” of the subject.
In the same way, WDITs would work to avoid linear thinking in rewording their version of our authors’ conclusions about antidepressant medication. WDITs might instead propose that “the psychiatrist, or at least something about the interaction of the psychiatrist with the subject within the co-created healing context, appears to facilitate improvement in depression. The administering of the pill is an integral part of the healing ritual of the psychiatrist. The psychiatrist, wittingly or unwittingly, creates a context that allows the patient to suspend their disbelief in their ability to change and increase their belief in the likelihood that the sought-after change will take place. Put simply, it’s a matter of faith.”
After offering this explanation, WDITs might suggest a less sensational name for the second article by Antonuccio, Burns, and Danton, like, “Effective Marketing Proven to be an Important Element in the Healing Ritual of Psychiatrists.” WDITs' re-writing of the article from a cybernetic point of view would point out that the marketing through mass media of antidepressant medications--even calling them medications—is an element in a healing context co-created by the patient, the psychiatrist, and the pharmaceutical companies. They might then propose that a more collaborative (and honest) approach with patients and psychiatrists on the part of the pharmaceutical companies in explaining more fully the mechanism of action of the substances they produce could address some of the ethical and moral problems created by the current system. At least this would allow psychiatrists in their treatment of patients to claim a higher ethic than our faith healer and his gadget.
In the meantime, how should WDITs apply the conclusions of our authors to our work with our own clients? In the first place, we must acknowledge our kinship with psychiatrists that the authors of our articles reveal. Our work as talk therapists is admittedly dependent on our skill in creating a healing context that suspends our clients’ disbelief in their ability to change and promotes their belief in our ability to help them. We call this component of the therapy process “joining.” We do this with our clients’ permission and consent and within the ethical framework provided by the collective wisdom of our profession.
Do we proclaim ourselves to our clients as anti-medication or anti-psychiatry? No. Having reached a postmodern understanding of the data presented by the authors of our articles we must avoid harsh judgment of the psychiatrist, the faith healer, and the “gadgets” they employ in their healing rituals. Instead, we can invite both to engage with us in a trans-disciplinary dialogue about the differences and commonalities in our respective healing rituals as revealed by the elegant research of our authors. As part of this dialogue, we must certainly invite further consideration of a trans-disciplinary ethical framework for employing this class of healing ritual.
In summary, we as WDITs must have a particular level of sympathy rather than judgment for our psychiatrist brothers and sisters, the “emperors” of the mental health field, who have naively sought validation by clothing themselves in the pseudo-empiricism being peddled by the drug companies. We nonmedical mental health professionals who with envious deference have ridden those “magical coattails” for the last fifty years must not proclaim too loudly that “the emperor has no clothes.” We can, however, without hypocrisy, express relief that researchers and practitioners from within the psychiatric community are developing a body of evidence that validates our healing traditions and intuitions as talk therapists. We can with renewed vigor resist the annexing of our profession by the “medical model moguls.” We can without shame and with boldness embrace our identity as folk healers; and we can, with a Buddha smile ( perhaps even a chuckle), pat our pseudo-scientific brothers on the back and say, “I guess at the end of the day, we are all witchdoctors after all!”
Ooo. I feel the paradigm shifting. More to come.