August 15, 2002

DEAD WRONG

By Nathaniel S. Lehrman, MD

The current drug treatment for depression represents one of the greatest fallacies in the history of medicine.

Depression is not a disease, such as pneumonia or malaria. Rather, depression is usually a psycho physiological reaction to an individual’s current psychosocial interactions. Depressive reactions are also seen in animals exposed to continuing levels of stress from which they cannot escape.

When thinking of depression, think of fever, which is also a reaction of mind and body to a set of complex conditions.

It has been known for centuries that talking with a caring counselor can help depressed people. If the counselor is cheerful and confident (which seems less frequent today), and conveys that confidence to his client, the latter’s chances of relief will be greater. Religion and its officiants have provided these services over the years. And personal caring has been seen as an essential part of the doctor-patient relationship and is known to have a considerable impact on medical interactions; in psychiatry, that impact may be even greater.

The Effectiveness Of Counseling In Depression

The therapeutic effectiveness of caring dialogue is still greater if it addresses the real psychosocial issues evoking the depression - a statement based on personal experience since I began the private practice of psychiatry in 1953, long before the drug era.

I was certain then, having just finished my psychoanalytic training, that depressive and other psychiatric complaints were the products of childhood traumata, and that these complaints could be resolved by digging out those experiences. My confidence had a tonic, cheering effect on my patients. But I soon found that recovery depended more on attention to current problems than a focus on the past.

I learned this most sharply from a patient, depressed in a foundering third marriage, who wondered what in her childhood was responsible. But before we could examine those earlier years, a current problem forced itself upon our attention: difficulties with her adolescent step-daughter. She had recently married a widower with two children, whose first wife had died after a long illness. During that time the daughter had been the woman in the house. She resented her new step-mother, and took every opportunity to make her life miserable. In this battle of the females, the husband, understandably sympathetic to the girl’s loss, took a neutral position. But when it was pointed out to him, and he accepted, that his new wife was now mother in the house, and that she desperately needed his support, the family dynamics changed radically and rapidly for the better. While financial considerations made it necessary to stop treatment before we ever got to childhood experiences, doing so proved not to be necessary; the restructuring of current family relationships was sufficient to overcome the wife’s depression. Over the nearly fifty years which followed, she and her step-daughter were the closest of friends - and her depression never recurred. Had she been seen by a modern, drug-oriented psychiatrist, her depression would probably not have lifted and her marriage would probably not have survived.

During my ten years in full-time private practice, I saw perhaps half a dozen patients I thought so profoundly depressed as to need immediate hospitalization. While I could have sent them at once to a distant private hospital, or to a state hospital, the best hospital available - which was nearby and where I had recently served a residency - had a three- week waiting period for admission. I suggested that these patients apply at once for admission there, and that I would see them in the office two or three times a week (more if necessary) until a bed became available. When it finally did, not one of these patients needed it; our working together psychotherapeutically - and, of course, without anti-depressant drugs, because there were none - had significantly improved their depressions.

I found depressed patients relatively easy to treat after we established the current causes of their distress. Correcting that distress sometimes involved violating prevalent shibboleths. A depressed woman, highly educated but at home full-time with two small children, and whose husband traveled a great deal, spent most of her therapy complaining about him. I saw that her depression lessened if I agreed with her, worsened if I differed, and remained unchanged if I stayed neutral . Recognizing that relieving her depression by letting her blame her husband might break up her family, and believing firmly in the importance of stable marriage, I did something that was then utterly heretical: I called in her husband. We discussed her complaints, he agreed that some were justified and changed his behavior. They too then remained happily married for over forty more years. (That experience led to my insisting that I see the spouse of every new patient at the beginning of treatment, so I could sense the interactions between them.) In this case also, current methods of drug treatment would not have had this successful result.

Most of my other depressed patients and those of other psychiatrists, recovered fully after defining and addressing their problems with parents, spouses, children, work, and school.

How Diagnosis Sometimes Occurs

One of the myths of our time is that "depression," "anxiety," and the hundreds of other disorders listed in the American Psychiatric Association’s manual, represent separate entities, and that their differences may even involve different biological processes. In 1957, however, Dr. Michael Balint, studying how people came to define themselves as patients, discovered the importance of the patient’s interaction with the physician in creating the diagnosis.

He found that "people who for some reason or other find it difficult to cope with the problems of their lives resort to becoming ill. If the doctor has the opportunity of seeing them in the first phases of their becoming ill, i.e. before they settle down to a definite 'organized' illness, he may observe that these patients so to speak offer or propose various illnesses, and that they... go on offering new illnesses until between doctor and patient an agreement can be reached, resulting in the acceptance by both of them of one of the illnesses as justified. In some people this 'unorganized' state is of short duration and they quickly settle down to 'organize' their illness; others seem to persevere in it, and although they have partly organized their illness, they go on offering new ones to their doctor." A patient’s diagnosis, especially in psychiatry, may thus depend on his or her interaction with a doctor, rather than on just biology.

Dr. Balint's statements about illnesses in general practice are equally valid for psychiatry today. But diagnostic styles in the latter have changed radically over the years. Today’s psychiatrists listen less to patients’ problems, focus more on their reactions (anxiety, depression, disorganization), and then, on the basis of those reactions, "diagnose" - and medicate - much more quickly. But while these drugs may make patients feel better (too often they have the opposite effect), they will not help the patients in the long run unless they produce more effective energy in the patients so they can then solve their problems better. And this is quite rare.

Whether a depressed patient improves with drug treatment may be completely unrelated to the medication. Reduction or removal of the pressures upon the patient, as often occurs when one is "sick," can alone produce temporary improvement. Sometimes improvement follows other changed circumstances, of which the drug-prescribing doctor is unaware. Whether such changes in circumstance cause permanent improvement is a different question, which is rarely asked because drug studies usually run only for a limited number of weeks.

Today s extensive, widely-publicized research on new "anti-depressants" can therefore be seen as faulty, and can be compared to investigating new forms of anti-fever drugs (antipyretics) as the primary treatment of pneumonia, typhoid, or malaria. Seeing drugs as the primary agents in treating depression can be compared to substituting new anti-fever drugs (antipyretics) for specifics in the treatment of pneumonia and malaria, such as antibiotics and anti-malarials. While some such new antipyretics might reduce symptoms slightly in these diseases, none would be of significant value in combating the illnesses themselves, and considerable harm would follow from relying on them alone instead of on the tried and true remedies. Yet. that is the type of approach that has developed in the treatment of depression.

Psychiatry And The Growth Of Depression

Depression has become very big. Feelings of "helplessness, loss of hope, sadness, crying, sleep or appetite disturbances, or difficulty concentrating, for at least two straight weeks" are sufficient for the very common diagnosis of "clinical depression." Over the past half- century, hospitalizations for depression have increased almost thirty times, from 9.8 per 100,000 in 1943 (in New York, which had more per capita than any other state) to an estimated 280 per 100,000 (nationally) in 1994.

And that’s only the beginning. Scientists estimated in 1997 that 18 million Americans suffer severe depression each year, with one in five of us experiencing a depressive episode during his or her lifetime (that_s 20,000 per 100,000).

Drugs For Depression

Ann Landers maintained that 80% of depressions "can be treated successfully with medication" (listed first), "psychotherapy, or a combination of both," and noted happily that on National Depression Screening Day in 1998, more than 85,000 people visited screening sites, with over 70% of them then "referred for a full evaluation." Some experts, claiming that 50 percent of "clinically depressed" people will have another episode, note that a growing number of doctors are writing prescriptions for them for years on end. One expert even insists "there is a subgroup of people who will stay on medication for the rest of their lives." These views of depression, based on today’s drug-oriented approach to treatment, conflict almost totally with the experience of many, including myself, who treated depression successfully before the drug era began.

It is estimated that 28 million Americans now take prescribed (doctor-controlled) anti-depressant medications. Production of these drugs has consequently become a huge business, with "global sales estimated at $6 billion a year and rising." Prozac sales alone amounted to more than $1.7 billion in 1999 - a third of the Eli Lilly and Company’s total business - while prescriptions for its major current competitors, Zoloft and Paxil, also continue to rise rapidly. Despite the side-effects experienced by a quarter of Prozac users, Lilly recently spent $15 million to advertise the drug directly to the public - to increase patients’ demand for it from their physicians. And at a time that our churches, moral guides to the nation, face many grave financial problems, the major backer of the Public Broadcasting System’s "Religion and Ethics Newsweekly" is the Lilly Foundation.

 

The Dangers Of Anti-Depressant Drugs

Although all the long-term side-effects of these central nervous system drugs are still not known, those which are known have evoked much less attention than they should. Anti-depressant drugs’ greatest danger is their evocation of suicidal and/or homicidal feelings and behavior; both teenagers who attacked their fellow students at Columbine happened to be taking anti-depressants. Another danger from "feel-good" drugs is the creation of dependency or addiction. Many who are hooked will turn to street drugs since they are cheaper, more available, often stronger - and under a user’s own control, rather than under a doctor’s.

We find ourselves in this increasingly difficult situation because psychiatry has badly mishandled depression in its all-consuming reliance on drugs as the first line of treatment.

Dr. Nathaniel S. Lehrman is the former Clinical Director of the Kingsboro Psychiatric Center in Brooklyn, NY.

(c) Nathaniel S. Lehrman M.D.