Sunday, June 27, 2010

Are Antidepressants Better Than Nothing?

Thanks to Doug, Rambling Taoist, and yomamma for posting to the comment's section of May's blog entry, which touched on the topic of depression. I've since read a couple of articles on the question of whether antidepressants are any more effective than placebos (a placebo being any medicine which has no active ingredients, but which the patient believes will help). This issue has been in the news since a 2009 study showed that drugs like Prozac and Paxil, when used to treat mild-to-moderate depression, are hardly more effective than dummy pills.

Study author Robert DeRubeis says, "The message for patients with mild to moderate depression is, 'Look, medications are always an option, but there's little evidence that they add to other efforts to shake the depression...'" Studies have been suggesting this conclusion since at least 2002, when Shankar Vedantam wrote in the Washington Post, "After thousands of studies, hundreds of millions of prescriptions and tens of billions of dollars in sales, two things are certain about pills that treat depression: Antidepressants like Prozac, Paxil and Zoloft work. And so do sugar pills."

The Newsweek article that clued me in to this debate (The Depressing News About Antidepressants) speaks of it as a moral dilemma. It hardly seems right for a doctors to put millions of patients through the expense and side-effects of drugs that have no medical potency. Yet if the patients knew the truth, it might destroy the very real benefits they get from their belief in the drugs.

In the same article was a pro-antidepressant (heh) sidebar, in which a doctor claimed that based on observing the effects of the medications on his patients and himself, he's convinced that "antidepressants work." It's striking in how completely the doctor misses the point. There's no question that Prozac et al work. But there's a very real question of whether they work better than anything else you believe in. For non-severe depression, there's little evidence that the pills are more helpful than talking to a therapist. And little evidence that talking to a therapist is more helpful than chatting with a trusted friend.

The Avatamsaka Sutra (Buddhist scripture) says, "If you want to understand all the Buddhas of the past, present, and future, then you should view the whole universe as being created by mind alone." It seems that we have a tendency to underestimate the power of thinking (beliefs, assumptions, desires, expectations) to alter our experience of the world. "Thinking appears, all things appear; thinking disappears, everything disappears."

I've had many conversations re the mystical energy of holy temples, objects, or gurus. When spiritual people rhapsodize about such energies, I myself (being a trouble-maker) will often tell them, "You know, what you've experienced is entirely dependent on your beliefs and expectations etc." People sometimes get furious at such an assertion, even offended at the suggestion that their powerful experiences are "just in the mind."

I'd imagine that antidepressant users might similarly object to that suggestion that the power of pills is mostly in the mind. But it's often impossible -- without rigorous scientific method -- to know the actual cause of physical or mental changes. We can be entirely wrong when we speculate about ailments. And just because you happen to be the one who's experiencing the stomach-ache or panic-attack, doesn't give you any special insight into what causes or cures it.

It's a distinction between experience and belief. When we have depression (or a spiritual epiphany, or other mind-states), we can can speak with authority on the what of the experience. But as soon as we speak of the why (where the experience comes from, what causes it to come and go, what it means), we're in the realm of speculation and belief.

Funny how people resist so strongly the idea that their peak experiences or mood elevations are "just in the mind." The evidence is clear: it's hard to beat the power of mind. Even the multi-billion dollar pharmaceutical industry apparently has a tough time finding anything more powerful.