{"id":5813,"date":"2011-08-11T06:14:03","date_gmt":"2011-08-11T10:14:03","guid":{"rendered":"http:\/\/blog.beliefnet.com\/beyondblue\/?p=5813"},"modified":"2011-08-09T18:37:18","modified_gmt":"2011-08-09T22:37:18","slug":"are-the-puritans-behind-the-war-on-antidepressants","status":"publish","type":"post","link":"https:\/\/www.beliefnet.com\/columnists\/beyondblue\/2011\/08\/are-the-puritans-behind-the-war-on-antidepressants.html","title":{"rendered":"Are the Puritans Behind the War on Antidepressants?"},"content":{"rendered":"

\"\"<\/a>It is an honor for me to publish the following piece by Ronald Pies, M.D., professor of psychiatry at SUNY Upstate Medical University and Tufts University School of Medicine, because I find him to be one of the most fascinating psychiatrists in the Northern Hemisphere (I’m thinking the Southern is full of kooks). He always comes up with an intriguing angle on psychotherapy, antidepressants, the psychology of wellness … you name it, and he–like me–loves the intersection of faith and medicine, as is evident in his book, “Becoming a Mensch.”<\/a> So, here’s a curious piece about why the we might blame the Puritans for the anti-med movement in the US. Let me know your thoughts, because I know that you will have some after reading this piece. I should probably also tell you that he wrote the foreword to “The Pocket Therapist.”<\/a> I was once yelled at by a reader for not disclosing that … whatever.<\/em><\/p>\n

These are not good times for Prozac and its progeny. In the popular media, the use of antidepressants has been likened to swallowing \u201cexpensive Tic-Tacs\u201d, while in professional journals, the effectiveness of these medications has been challenged, if not discounted. And even a casual Google search under the terms, \u201cAntidepressants damage\u201d turns up thousands of websites and articles claiming that these drugs cause brain damage, induce suicide, or lead to \u201caddiction.\u201d Yikes! <\/p>\n

Most of these claims and concerns are either groundless or simplistic, based on the best available studies. The \u201cTic-tac\u201d claim, made in a prominent national magazine, was based on a misunderstanding of recent \u201cmeta-analyses\u201d\u2014studies that combine data from many other studies in order to reach a conclusion. What these studies show is that the milder the person\u2019s depression, the less difference there is between an antidepressant and a placebo\u2014famously but inaccurately defined as a \u201csugar pill.\u201d But this is not a novel discovery: it reflects a well-known phenomenon known as the \u201cfloor effect.\u201d Antidepressants were never intended to treat normal sadness, grief, or very mild cases of depression. The farther we move away from the \u201ctarget\u201d condition\u2014serious, clinical depression\u2014the closer we move to the \u201cfloor\u201d of normality, and the less likely we are to see a big difference between drug and placebo. Most of the recent meta-analyses show that in the most severe cases of major depression, antidepressants are more effective than the \u201cplacebo condition.\u201d
\n
\nThis last term is important, too. When patients enter a large, placebo-controlled study of antidepressants, and are placed in the \u201cplacebo group\u201d, they receive much more than a \u201csugar pill.\u201d They get many hours of attentive listening and evaluation by caring professionals\u2014probably more than many depressed patients get from their primary care doctors! So the comparison is not between medication and a sugar pill, but between medication and a kind of supportive therapy. Furthermore, there is good evidence that when major depression has features we call \u201cmelancholic\u201d\u2014such as severe weight loss and a total inability to experience pleasure\u2014the placebo condition is far less effective than medication. <\/p>\n

There is also no convincing evidence that antidepressants cause \u201cbrain damage\u201d or \u201caddiction\u201d among those who take them. In fact, the most recent evidence on how these medications work suggests that they actually enhance the growth of connections between brain cells\u2014perhaps leading to more adaptive brain functioning. They don\u2019t just \u201crev up\u201d brain chemicals like serotonin. And, there is no evidence that people get \u201chooked\u201d on antidepressants in the way we understand addiction to sedatives, opiates and related drugs. (That said, suddenly stopping a long-term antidepressant can lead to uncomfortable withdrawal symptoms, and there may be a small percentage of patients who develop delayed \u201cresistance\u201d to antidepressants, with a return of depressive symptoms). <\/p>\n

So why is there so much hostility directed at these medications? (The same question could be raised with respect to psychiatry and psychiatrists, but that\u2019s another story). I believe that a good deal of the animus arises from our Puritan heritage, and its attitude toward suffering, sin, and expiation. For the Puritans of New England, disease was essentially a divine punishment for Man\u2019s original disobedience to God. As historian An Vandenberghe has put it, for the Puritans, \u2018Even though there were more than two thousand different diseases\u2026the primary cause of all of them was the \u201cSin of our First Parents.\u201d\u2019 There was also a strong link between disease and personal sin: the person whose tooth ached probably did something nasty with his teeth! <\/p>\n

Now, when psychiatrists see patients with severe major depression, these unfortunate souls often express the view that their illness is a \u201cpunishment\u201d of some sort. Some believe that God is punishing them for their sins. But this attitude, in a less extreme form, pervades our society\u2019s views about depression\u2014that it is, in some sense, the \u201cfault\u201d of the depressed individual. Some clinicians who argue that depression has an \u201cadaptive\u201d value often begin with the premise that depression represents the person\u2019s \u201cfailure to resolve their social dilemmas\u201d\u2014a clinical euphemism for blaming the sufferer. The logical extension of this line of reasoning is that the depressed individual must somehow \u201crepent of his ways\u201d\u2014for example, by ruminating on his problem until it is solved, or by \u201cpulling himself up by his bootstraps.\u201d <\/p>\n

In this view of depression, taking a \u201cdrug\u201d\u2014the term \u201cmedication\u201d is almost never used by those opposed to antidepressants\u2014represents a weak-willed dodge. Antidepressants are seen as merely \u201ccovering up the real problem\u201d or as \u201ca crutch.\u201d This attitude is extraordinarily unhelpful for those struggling with a potentially lethal illness. Although I prefer to begin with psychotherapy in most mild-to-moderate cases of depression, the more severe bouts usually require medication. Often, the combination of medication and therapy works better than either one alone. And I use a non-Puritanical metaphor in framing the issue for my patients. I say, \u201cMedication isn\u2019t a crutch, it\u2019s a bridge between feeling awful and feeling better. You still have to move your legs to get across the bridge, and that\u2019s the work of therapy.\u201d <\/p>\n

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It is an honor for me to publish the following piece by Ronald Pies, M.D., professor of psychiatry at SUNY Upstate Medical University and Tufts University School of Medicine, because I find him to be one of the most fascinating psychiatrists in the Northern Hemisphere (I’m thinking the Southern is full of kooks). He always…<\/p>\n","protected":false},"author":17,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[6],"tags":[],"class_list":["post-5813","post","type-post","status-publish","format-standard","hentry","category-mental-health"],"yoast_head":"\nAre the Puritans Behind the War on Antidepressants? - Beyond Blue<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.beliefnet.com\/columnists\/beyondblue\/2011\/08\/are-the-puritans-behind-the-war-on-antidepressants.html\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"Are the Puritans Behind the War on Antidepressants? - Beyond Blue\" \/>\n<meta property=\"og:description\" content=\"It is an honor for me to publish the following piece by Ronald Pies, M.D., professor of psychiatry at SUNY Upstate Medical University and Tufts University School of Medicine, because I find him to be one of the most fascinating psychiatrists in the Northern Hemisphere (I’m thinking the Southern is full of kooks). 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