The Emperor's New Drugs: Exploding the Antidepressant Myth

Irving Kirsch presents exquisite and exhaustive research which concludes antidepressant drugs are in fact, placebos. He explains why and how placebos work. He argues against the chemical imbalance theory of depression and says it has never been proven. He also compares outcomes of Cognitive Behavioral therapy with and without antidepressant medication and concludes that a patient's "hope" for recovery is the fulcrum on which successful treatment rests. As a clinician, I have experienced the power of hope in alleviating suffering in moderately and severely depressed diagnosed patients and those in the throes of an existential crisis, which often is misdiagnosed as depression or an anxiety disorder. Sometimes in treatment, less is more. Kirsch states that SSRIs can help ... as much as any placebo... but instilling hope in a patient is what really works; there are no detrimental side effects, and hope and tools aquired in CBT have been shown to have more lasting results.

My first awareness of Dr. Kirsch was on a DVD called Placebo: Mind Over Medicine?, where he participated in a segment regarding antidepressants. It's available from Films for the Humanities and Sciences. It's a real eye opener with respect to the placebo effect! Both informative and entertaining, The Emperor's New Drugs tell a chilling tale of Big Pharma, Inc, and the machinery that brings to market the drugs that are the mainstay of modern medicine. While we have many life enhancing drugs available to us, the history of antidepressants is both revealing and disturbing. It appears that the creation and propagation of antidepressants is less about science's quest to treat a debilitating condition, and more about profits made at the expense of the uninformed consumer. Kirsch doesn't argue that antidepressants don't work, but reveals that the reason they work is largely the result of the placebo effect. In other words, what makes them effective is our belief in them, not the active ingredient in the pills themselves. Maybe it's time for placebo pills to make a come back from the early days of medicine, where the active ingredient is belief, and there are no dangerous side effects. If patients understood how to leverage the power of beliefs to trigger the self-healing response, modern medicine would take a giant leap forward, and patients could take a more active role in their own healing process. In addition to the research about antidepressants, I believe the most important message in Kirsch's book to clinicians and lay people alike, is that our beliefs can powerfully affect our health and general wellbeing. When will modern medicine stop trying to factor the placebo effect out of the equation for health, and start figuring out how to leverage the mind as medicine? The honest answer is, the day the placebo effect can be bottled and sold commercially. Sad, but probably true. It seems that the use of the mind as medicine will be left to mind/body researchers who are willing to look beyond the current medical model.

The significance of this book cannot be understated. Dr. Kirsch carefully examines the data derived from research that was primarily funded by pharmaceutical companies. The data doesn't lie. Antidepressants are effective agents in the treatment of depression. Dr. Kirsch reiterates this finding over and again. The effectivness of these drugs, however, is not the result of their bio-chemical impact on the patient. It is the result of the positive expectations patients/subjects have when they take medications they believe will help them. The fact that research shows that almost any medication that is presented as an antidepressant ends up having the same postive outcomes suggests that the chemical impact of the meds are apparently irrelevant. The only medications that are not more successful that sugar pills are antidepressants that have no side effects at all. These meds simply do not allow subjects to know that they are on an actual medication and therefore, they do not increase their expectations of a result more so than those subjects on a sugar pill (they don't "break blind"). Of special significance is Dr. Kirsch's exposure of the clinically insignificant difference between antidepressants and sugar pills when a statistical significance is noted. A difference of 1.8 points on a 52 point scale is meaningless; and this is the difference between the the sugar pill groups and the active drug groups in research that is used to justify these medications. Dr Kirsch appropriately points out that understanding the power of placebo is in fact, understanding the power of hope. Hope is the effective force behind these medications. Therapies exist that can make a long-term difference in the lives of depressed patients. Cognitive/Behavioral interventions have a proven record of success. They restore hope - and this may be the key to their success as well.

This is exactly the kind of book that I would have eagerly assigned to a collection of my most discerning patients when I was practicing psychiatry. It is a relentlessly authoritative argument that antidepressants have only placebo effects enhanced by their non-therapeutic side effects. The principal tool that Irving Kirsch uses is meta-analyses, i.e., studies of studies. It is well written and an effective presentation. For a completely different view from the opposite end of the spectrum, may I suggest my own short book,Diagnosing and Treating Mental Illness: A Guide for Physicians, Nurses, Patients and their Families (Demers Books Health and Well-Being series) It is a firsthand report straight from the mouths of thousands of my own patients describing precisely how their emotional interiors were altered by the medications I prescribed for them.

I have conflicts of interest to declare. I'm a physician but I also write. I share a publisher (Random House UK) with Irving Kirsch and have written for them about the damage done by doctors who don't subject their ideas to reliable tests. Because of this I was asked if I'd provide a recommendation to go on the dust jacket of Kirsch's book. I was familiar with his work, having read his medical journal articles analysing the evidence behind antidepressant tablets. On that basis I sat down to his book expecting that I'd probably be able to say something nice about it. I thought it'd most likely amount to saying that Kirsch's research is important and interesting and should be mandatory for doctors involved with antidepressant prescriptions. This book, though, isn't worthy & technical - it's fascinating. It's a remarkably readable account of how we got carried away with an idea about the brain that isn't true. You don't need to have an interest in depression and you don't have to be a medic; this is a thoughtful look at how bright & well-meaning people get enchanted with an idea & go on to fool themselves and everyone else. It isn't a doctor-bashing book, nor one that pushes the author's own pet therapy. Instead it gives a lovely insight into the way science works, and the way it can sometimes gets done so badly that it doesn't work at all. Kirsch argues antidepressant tablets are based on a false pharmacological model of the brain, and that the balance of evidence shows they don't work except as placebos. Even if you're not persuaded by Kirsch's thesis - and I think you should be - you'll find his ideas thought-provoking. For most of human history, going to see a doctor was a bad move. We did more harm than good. We trusted our intuitions instead of performing experiments capable of testing them. The people who used leeches for thousands of years were smart, motivated and thoughtful and they killed their patients. They believed they could figure out what worked without decent scientific method, even when the nature of that method was widely understood. Kirsch's modern story gives an insight into why we used to be so bad and it reminds us we're still a long way off being perfect. An enjoyable and an intellectually captivating read.