I need to preface today’s interview by saying that I whole-heartedly support treatment of depression with the right pharmaceutical medication. For those readers who have just joined us, let me explain that I went through six doctors before I found the right one in Dr. Smith, and I received a lot of bad advice and prescriptions to drugs I could not tolerate. While I am a believer that persons with bipolar disorder and severe mood disorders absolutely should be on medication to treat their illnesses, I am more suspect now than I used to be of physicians who are too dependent on income from pharma companies. That is why I found Edward Shorter’s book so riveting and important. He exposes a piece of the puzzle that I wish I’d known back when I was interviewing shrinks like they were babysitters. Let me make this very clear: I do not believe, as some Scientologists do, that all pharmaceutical companies are part of a conspiracy, and that medication is never the answer. No. I just believe there is a lot of greed in this field, as in all fields. And we need to be aware of the that as we chose our health-care providers.
My mom always says that when you hear something twice that means God is trying to tell you something. So I received this e-mail from my blogging friend Kevin Keough about a podcast he had recorded with Edward Shorter about his book, “Before Prozac: The Troubled History of Mood Disorders in Psychiatry.” An hour later I receive an e-mail from Dr. Shorter’s publicist asking if I’d consider discussing the book on “Beyond Blue.” Coincidence?
I wish I would have read Dr. Shorter’s book four years ago when I suspected that the second psychiatrist I saw was fraternizing with a few too many pharmaceutical reps. In his words, Shorter’s book “exposes why depression runs rampant in America, and why pharma companies, academia, and the FDA are all to blame for setting modern psychiatry back fifty years.”
Thank you very much, Dr. Shorter for answering my questions. I found your book fascinating, indeed!
1. You say that it isn’t implausible for there to be some effective drugs in psychiatry that have simply been forgotten. This is because they are not profitable anymore for the drug companies to produce because the patents have expired. Would you include older drugs like Lithium and some of the Tricylics in this category? Because now many psychiatrists want to treat Bipolar with Atypical Neuroleptics like Seroquel and Zyprexa?
Lithium is one of the most effective drugs in psychiatry, and pharma doesn’t make a dime on it. Therefore, the patent “mood stabilizers” are widely promoted and the dangers of Lithium over-emphasized. Ditto the tricyclics, highly effective for serious depression, but pooh-poohed because of supposedly intolerant side effects (dry mouth, as opposed to such side effects of untreated illness as suicide).
Your question about “bipolar” implies that it’s a separate disease from unipolar depression. But that’s not at all clear. The atypical antipsychotics have been absurdly over-marketed for bipolar disorder.
2. You write that in the middle third of the twentieth century, the diagnoses did a better job of cutting Nature at the joins than many of the diagnoses we have today, “which are artifacts born of political compromises and sustained by pharmaceutical promotion rather than scientifically accurate descriptions of what is actually wrong with someone.” Can you discuss this a little more and explain some of those diagnoses that were clearer in the mid-twentieth century?
Melancholia was once a common diagnosis, as opposed to such non-melancholic illnesses as “neurasthenia.” These are two very different forms of what would later be collapsed into the diagnosis “major depression.” Major depression is an artifact born of a political compromise within the American Psychiatric Association. There are two depressions, and they are as different as mumps and measles.
Catatonia was once a common diagnosis, later virtually abolished (but nonetheless real). It’s now making a comeback.
The term “nerves” is a pretty good description of the dysphoria many people feel, much better, actually, than “depression.” Nerves has now been broken down into what are doubtlessly small artifactual categories, such as “social anxiety disorder.”
3. You say that the future of today’s psychiatry “does not lie in resurrecting the past but in respecting the scientific method, in abandoning diagnoses fashioned by consensus, and in doing away with ineffective therapies dictated by the corporate bottom line.” Could you try to summarize for my readers what you see as effective therapies … what you say about facing up to the question of evidence, whether a drug is working or not?
The benzodiazepines of the 1960s and after (Librium, Valium) were actually terrific drugs. They became unfairly indicted as “addictive” and are quite effective in non-melancholic mood disorders, such as depressive illness mixed with anxiety, reactive depression, depressive personality, and the rest of what were once called “psychoneuroses.”
The amphetamines were excellent drugs for minor depressive disorders, though not for melancholia, and got patients to feeling better swiftly, as opposed to the long lags that exist today between the onset of treatment and the relief of symptoms.
The barbiturates were formidable sedatives, and had as an achilles heel that they could be accumulated to commit suicide. But there are many ways to commit suicide, and it doesn’t make sense to stigmatize otherwise useful drugs on that ground alone.
Meprobamate (Miltown, Equanil) was the first real anti-anxiety drug, a blockbuster in its day and pushed aside for no better reason than the competition was better promoted.
4. And finally, given all this information, what would be your advice to a reader who is suffering from a mood disorder, wants relief, but is scared to see a doctor and seek treatment because of all this selling out that’s going on?
First of all, all doctors have not sold out [Please let me interject here to say that I know that's the case. Dr. Smith saved my life. I simply think there are too many doctors today with ties to the pharmaceutical companies, like the man who tried 14 medications on me within three months.], and many are competent diagnosticians who prescribe judiciously. It would be irrational to be afraid of doctors: illness is much worse than the possibility that your physician may have “sold out” because he has a pharma-company pen in his pocket. So, let’s not get carried away.
To answer your question about non-prescription ways of coping with dysphoria:
1) Exercise is actually a great antidepressant, unless you have melancholia. That would be my first choice.
2) Sleeping well at night is usually half the battle, and there are valid nonprescription aids to sleeping better, such as melatonin. Most antihistamines, such as Benadryl, require a RX but they aren’t hard to get and Benadryl (Diphenhydramine) is useful as a hypnotic.
3) This is not everyone’s cup of tea [as a recovering alcholic, I can say he's right on that!], but many use a good scotch just before bedtime as a sleep aid. It works.
But a note of caution: mood disorders are nothing to fool around with. If you feel you have lost all joy in life, that the future looks bleak, that you have nothing to look forward to, that your life has really been one big failure–and if you have no appetite and are insomniac–you are at risk of suicide. See a physician!