Ordinarily Well: The Case for Antidepressants Peter Kramer 2016
This book was very difficult to review. In Ordinarily Well, Dr. Peter Kramer makes two arguments that I agree with. One is that clinical observation—the interaction by which a medical professional learns about a patient—counts for something. The other is that clinical trials, or evidence-based medicine more generally, are not a replacement for clinical wisdom. He values antidepressants, in particular the selective serotonin reuptake inhibitor (SSRI) class of drugs, and so do I.
Applying support for clinical observation and skepticism about controlled trials to the question of whether antidepressants work, Kramer concludes that these treatments work very well. En route, he focuses on the claims of psychologist Irving Kirsch, among others, that based on clinical trial data, the benefits of antidepressants are all in the mind—a placebo effect. Kramer makes a straw man of Kirsch, but I agree with Kramer that antidepressants do things that are not all in the mind. I too reject Kirsch’s arguments that most of what antidepressants do stems from a placebo effect.
So where did my difficulties in reviewing the book come from? The trouble for me is that Kramer’s clinical vision seems strangely rose-tinted. He is an advocate of using antidepressants to treat depression, but he doesn’t seem to see any of the problems antidepressants cause. The fact that over half of the patients put on them don’t take them beyond a month should be telling. For those who do stay on treatment, he claims, no one has difficulties going off antidepressants with a gradual reduction in dosage. I, however, have patients suffering badly months or even a year later. In the case of any enduring problems, Kramer puts these down to the effects of the illness being treated rather than the medication.
There is no discussion in this book of significant problems that the use of antidepressants can cause. These include SSRI-induced alcoholism, SSRI-induced birth defects, including autism spectrum disorder, or permanent post-SSRI sexual dysfunction. In a 336-page book, the topic of SSRI-induced suicidality gets dealt with in one page. I think many surviving relatives would be astonished to hear that once the psychiatrist Martin Teicher had identified the problem of treatment-induced suicide, it became manageable. Kramer claims that “no case [he has had], not one, has looked like those Teicher has described, drug driven.”
Kramer asks us to believe in clinical observations—his observations. Not yours or mine or anyone’s that might cause the antidepressant bandwagon to wobble. He cites me at multiple points, so he is well aware of my work. But he doesn’t engage with the evidence that I and others have put forth, based on both clinical observations and other material, that SSRIs can unquestionably cause suicides and homicides, and do so to a greater extent than they prevent any of these events.
On the issue of children, suicide, and the black box warnings that antidepressants now carry, Kramer notes that “some of the data have trended the other way, although authoritative studies correlate increased prescribing with reduced adolescent suicide.” This fails to acknowledge that the drugs haven’t been shown to work in this age group. There is no mention that suicidal acts show a statistically significant increase in clinical trials in this age group. Kramer also does not indicate that among all ages, when all trials of antidepressants are analyzed together, they show increased rates of death (mainly from suicide) compared to non-treatment. He seems to have no feel for how compromised the “authorities” are that he uses to downplay the risks.
There are good grounds to be skeptical of the evidence-based medicine that Kramer uses to make his case. Quite aside from the fact that almost all the research literature produced by clinical trials is ghost written by pharmaceutical companies, and the data from them entirely inaccessible, controlled trials aren’t designed to show that drugs work. They work best when they debunk claims for efficacy, rather than the reverse. What’s more, the structure of clinical trials and their statistical analyses are the best method to hide a drug’s adverse effects. Ordinarily Well does not address these significant problems.
If a drug really works, then clinical observation should pick it up. We can tell antihypertensives lower blood pressure, hypoglycemics lower blood sugar, and antipsychotics tranquilize within the hour—all without trials. We can see right in front of us that antipsychotics badly agitate many people within the hour and that SSRIs can do so too. But we cannot see anyone get better on an antidepressant in a way that lets us as convincingly ascribe the effect to the drug. There is much to be said for clinical observation, but also a lot to wonder about when clinical trials suggest that drugs work but we can’t actually see it. For anyone keen to defend clinical observation, Kramer’s book poses real problems and would leave many figuring we need controlled trials instead.
I live and work in the United Kingdom and am acutely aware of some differences between America and Europe that also made it difficult to review this book. There is much more “bio-babble” in America than in Europe, from talk of lowered serotonin to chemical imbalances to neuroplasticity and early treatment preventing brain damage—all of which Kramer reproduces. I felt a John McEnroe “you cannot be serious” moment coming on at many points. The tone in which some of these points are made suggests that everyone reading them will find what is being said self-evident, when in fact it’s gobbledegook.
All medicines are poisons, and the clinical art is bringing good out of the use of a poison. It strikes me as un-American to even suggest that a drug might be a poison, and Kramer’s book gives no hint of this; the book is, in this sense, deeply non-clinical. He is giving an account of a mythical treatment, as far removed from real medicine as an inflatable sexual partner is from the real thing. It seems to me that he would not see or hear many of the patients I see, or at least would not credit their view of what is happening to them on treatment. This book will misinform anyone likely to take an antidepressant.
It will also cause problems for physicians. This book does not balance the risks and benefits that are intrinsic to medical wisdom. If antidepressants are as effective as Kramer claims, and are as free of problems as he suggests, there is no reason why nurses and pharmacists couldn’t prescribe them. Given that they are much less expensive prescribers, the surprise is that health insurers haven’t moved in this direction.
There is a way to bridge the gulf between Kramer and myself, which involves clinical observation. Most of the beneficial effects Kramer describes can be reframed in terms of an emotional blunting, or the numbing of all emotions, not simply the bad ones. Just like people on an SSRI will nearly universally report genital numbing within 30 minutes of taking their first SSRI—if they’re asked—people will also report some degree of emotional numbing—if asked. They don’t necessarily feel better; they simply feel less.
Unlike the somewhat mystical brain re-engineering Kramer invokes, this emotional blunting can be verified by clinical questioning. If clinical trials were designed to assess whether patients are numbed by these drugs, there would be little need for the fancy statistics that pharmaceutical companies use to claim the targeted benefits of their drugs, since emotional blunting would be evident through clinical questioning. And Irving Kirsch’s arguments about placebo would be irrelevant.
If SSRIs numb emotional experience, this would explain why they help some and not others, and explain the results we see in clinical trials, which are similar to the results that might be expected from a trial of alcohol versus placebo in the milder nervous states in which antidepressant trials have been run. This, then, would present us with a question: what do we think about emotional blunting as a therapeutic tool? Emotional blunting is not a romantic option. It’s a much more ordinary one. If that is the process by which antidepressants work, it does patients an enormous disservice to avoid discussing it entirely, which this book does.
Editorial Note:
This review was done for an American journal in 2016. It links to Kramer v Kramer and a prior review by Roy Porter – What Happened.
Why the image? Well the world is moving so fast now that inflatable sexual partners seem very last millenium. It’s all virtual reality. You too can take Prozac and now be spanked by Stormy Daniels.
Clinicians are given training in communication skills with an emphasis on listening but whatever skills many of them might have developed with experience is undermined when so many still don’t listen to (or with) but rather listen out for – a list of diagnostic ‘symptoms’ leading to – a label and a drug – or a psychological intervention for the few. Listening can become a shallow exercise unless it’s a joint collaboration where the clinician needs to ‘Talk’ as well, rather than suck out information they want to input on a computer or even to give the appearance of being ‘kind’ enough to listen whilst deciding already they know what a person ‘needs’. Usually they don’t even get to know a person at all – the next appointment will be with yet another note taker, prescription filler. A person’s pet will understand them better. I think decision aids have a place as they encourage collaboration but they are rarely used collaboratively. People find out too late that emotions are blunted by anti depressants but it’s not admitted as a problem and if the prescriber doesn’t even know the person ,they are not possibly going to meet them again – how much do they even care? Some people have described seeing and feeling the world for the first time again after getting off them – many would prefer to tolerate the pain even of chronic levels of depression than lose the ability to ‘feel’ a range of emotions. it’s not a secret it’s been written about and is still ignored. Some would prefer to blank out or damp down emotions but yes that should be their own choice and yes for sure people should be warned about it .The effects of ADs can be quite shocking, very few of us would have the words at first to express something so previously unknown. Maybe Kramer is a child of the 60’s/70’s when street drugs were relatively benign but doesn’t see the difference between a self controlled drug with time limited effects and emotional blunting induced by prescribed drugs. Seems incredible that even now the thousands of accounts by people who have suffered harms and of those who report and publish the evidence is suppressed
A song by Pink Floyd sung by the ScissorSisters with a beautiful watery video on You Tube.
Comfortably Numb
Hello, hello, hello – is there anybody out there? – Just nod if you can hear me. Is anybody home? – Come on now, I hear you’re feeling down- Well I can ease you’re pain and get you on you’re feet again- Relax I need some information first – Relax just to face the facts. -Can you show me where it hurts?
There is no pain you are receding- A distant ship floats on the horizon- You’re only coming through in waves.
When I was a child I caught a fever My hands felt like two ballon.- Now I’ve got that feeling once again.- I cant expalin you would not understand.
This is now who I am. – I’ve become comfortably numb.
Ok it’s just a little pinprick – there’ll be no more high- but you may feel a little sick – Can you stand up now? – I do believe it’s working – Uh Uh huh uh huh ………
The child is grown, the dream is gone – I’ve become comfortably numb
Uh huh, I’ve become comfortably numb.
Emotional Numbing:
I can see how these drugs may help some people short term or post a traumatic experience, or maybe even through a traumatic experience with psychiatric or CBT support, in the short term.
Beyond the fact that these ‘anti-depressant’ drugs apparently don’t work for people suffering from true depression or specifically for depression as such (nothing wrong with me that warranted drug treatment, Seroxat rather gave me my first experience of real depression as a withdrawal and post trauma symptom) the time must also come if not to inform patients on this also most prominent effect these drugs have (and with special consideration to their particular situation and/or why they may have turned up in the office) but it’s ramifications individually and socially. (There are conspiracy theories of course).
This effect, and with so much prescribe and forget, has serious implications for personhood, self development, spiritual implications. Not a chance I would have taken any could I have possibly known this also (and where my first prescription didn’t warrant drug treatment at all).
Regarding one implication, thanks to Seroxat and its legacy, I feel that a more normal emotional response to much later bad situations, and where emotions can be quite rational, less numbing (and when I wasn’t fully conscious of this effect) would have served its purpose to encourage me to act on things that had to be addressed or dealt with and sooner ie. you have to feel it to ascertain what should be done to stop feeling if it is a damaging or potentially dangerous situation. Just as reactive depression (though most doctors don’t appear to consider non clinical depression healthy in some cases or to be expected in a normal person in response to many situations) has its own messages.
I also read online that Zaltman’s (2016) study (for marketing purposes I believe: our emotions used very much against to us, especially in the US, to get people to take these numb drugs in the first place) showed that 95% of our cognition happens in our emotional brain. Damaioi’s 2000 seminal study found that when humans had damaged the area of their brain where emotions were generated and processed, despite still being able to use logic and function completely normally, individuals void of emotion seriously struggled to make any decisions, even simple decisions like what to eat for lunch.
Simple decisions. And Very Important Decisions. Self Care. Jumping.
All these drugs likely do for many, particularly if prescribed as coping drugs (most with no idea they may remain stuck on them for years) and without any action being taken if the stress or distress is normal and situational, is numb. Many may become less aware of it or be less affected by it, more dissociated from the gaseous molecules of water vapor around them or in their lives as such – but they remain be being slowly boiled alive.
(Worse, beyond the numbing, unaware that they may also be slowly and gradually ending up with far more problems than originally taken to a doctor. And no wants want to awaken years later post perhaps decades of numbing to an unattended boiling pot scenario to try to land in when fit to jump clean out of their skin by the sudden flames of akathisia and the shock of the bursting forth of overwhelming emotions etc.).
As a lay person, I don’t like to make an uniformed opinion on things I don’t know much about, regarding books I haven’t read (and have no inclination to), but from excerpts and in light of everything that is known now and which is apparently slowly, gradually, coming out, Kramer and others appear to have been comfortably numbed in another way to the heat in the kitchen or perhaps safely submerged in highly gaseous bubbles of their own.
Here’s one book I’ll certainly not bother to read then for sure – seems I’d be blowing a gasket from very early on!
I would agree that a person in the throes of a serious bout of anxiety – brought on by any of a range of life’s trials – could well do with a short period of emotional blunting, in other words the chance to rest a little while from their overwhelming thoughts and emotions. The problem is not with accepting that idea but, rather, with the fact that ‘a short period’ seems to have been lost as far as SSRI use is considered. A pill to provide respite cannot possibly work unless it’s accompanied by a listening and believing prescriber. During the ‘respite’, the patient needs assurance and suggestions of ways to bring about change in their ways of dealing with ‘life’ otherwise their coping skills will remain inadequate. Throwing more pills, or a variety of different brands, at the problem can do nothing more than add to the patient’s feelings of failing in a world where everyone else seems to thrive. It becomes a vicious circle. If that circle is finally broken, the suffering in learning to cope with the return of emotions – whether positive or negative – is another battlefield altogether. It takes a very determined person to reject the persuasion of their prescriber that their feelings are actually the return of their original problem and that the way forward is more of the same.
1. Yes, there is an ‘effect’ (physical/chemical/biologic) on a human if you use a SSRI.
2. It effects a wide range of essential human functions, in varying degrees, in different patients, ranging from unnoticable to life crippeling or threatening.
3. No science has yet proven, that the serotonin/serotonin re-uptake/Serotonin as an exclusive neurotransmittor, is in any way the right way to fight depression and anxiety or other mood issue.
4. SSRI’s give many patients a ‘numbening’ sensation, it too ranges from low or moderate to absolutely life crippeling inability to function.
5. If we cannot, through fully reliable and ethical science, describe the effects, and differentiate fully between benefits and harms, and fully inform the patients, this type of pharmaceutical should not be in use.
6. Leaving a patient, who might be suffering from sideeffects for years on end, is worse than to not intervene and have a patient fighting his issues without this pharmaceutical.
It is the very essence of “first, do no harm”. The SSRI’s history and underlying hypothesis was flawed to begin with, it will never become something that it hasn’t been to begin with. It must be considered ‘insanity’ to hope for future science to prove SSRI’s work flawlessly and cause no harm, such evidence would appear naturally.
7. The time period alone should stand in the patients favor, if we cannot explain the mechanisms of SSRI by now, 30 years after their intruduction, ‘science’ has had his shot, now we must listen to the patients.
Ove2019
Kramer argues like a defense lawyer, as if Prozac were a person whose civil rights we are bound to respect. And he does a very good job indeed. But it’s funny how all the potential confounders in clinical trials he identifies favor placebo. Are there no confounders that work in the opposite direction?
Dr. Kramer also offers this curiously backhanded defense of these nostrums: “Antidepressants work – ordinarily well, on a par with other medications doctors prescribe.” That’s cold comfort, given that many of the most lucrative classes of drugs, such as statins, produce no clinical benefits at all for the vast majority of patients who swallow them.
And of course all this is quite a comedown from Dr. Kramer’s extravagant promises of nearly twenty years before, of a new “cosmetic psychopharmacology” which had the power to make us “better than well.”
Oy, or oy vay, is defined as a Yiddish expression used to describe frustration, worry, grief or other strong emotion.
Books of The Times
Review: In ‘Ordinarily Well,’ Peter D. Kramer Goes to the Antidepressant Ramparts
https://www.nytimes.com/2016/06/07/books/review-in-ordinarily-well-peter-d-kramer-goes-once-more-to-the-antidepressant-ramparts.html
How eager Dr. Kramer had been to shake off the chains of his celebrity as the author of “Listening to Prozac,” published way back in 1993! He’d written a novel, hosted radio programs, scribbled a TED talk. But this book was inevitable, he suggests: Prozac needed defending. He describes taking solace in the words of Norman Mailer, who wrote in “The Armies of the Night” that he “learned to live in the sarcophagus of his image.”
Oy.
How Safe Are Your Medicines? Re – Channel 4 Dispatches 17June 2019
Try asking MHRA
Dispatches revealed that thousands of unsafe medicines have been given to patients in UK (and other countries) after falsified drugs were infiltrated and sold to companies such as Lloyds Pharmacy, The largest licensed wholesaler importing the drugs being American owned Trident Pharmaceutical, which owns Lloyds, They refused to be interviewed.
‘The agency responsible for ensuring our health is the MHRA -‘After changing their story several times the MHRA finally announced an urgent investigation into the scandal’. CEO Ian Hudson ‘ I take our responsibility very seriously ……ordered urgent internal review ….’ (usual tosh).
in total 25 different treatments and 10,000 units had arrived in UK. Dispatches sent FOI request to MHRA – at least 4 different types had been sold to UK pharmacies. MHRA ‘admitted they had no idea what had happened to numerous other falsified medicines that were imported into UK. But
In Fact MHRA initially said ‘they had no evidence of falsified medicines reaching patients’. After being challenged by Dispatches, 48hours later they changed their stance saying ‘ we have no information on what happened to affected medicines after reaching UK pharmacies’. Then 4 days later a further admission – ‘not only did they know but some of the stolen medicines had gone to some patients. And In Some Cases They (the MHRA) Had Sanctioned It.
People who were prescribed the medicines were not told. A day later the ‘the truth was finally squeezed out of the MHRA. They were forced to act telling Dispatches they were launching an urgent investigation. Re a further FOI MHRA admitted that at least 9 times in the last 10 years falsified drugs had entered the UK. 4 of the cases had involved life saving treatment. MHRA said there was no evidence they had reached patients.
Normal Lamb ex Health Minister said ‘ What I find extraordinary is that there hasn’t been openness about this having happened’.
Thanks to Exec Producer Niki Mistrati; Prod Dir Joannne Burge; Presenter Anthony Barnett; Production company TI Productions.
See duplicate, with Heather, Susanne, and full links to the News Release and Catch-Up Programme over on RxISK
recovery&renewal @recover2renew 12h
Harvard history professor traces the rise of psychiatric drugs
https://news.harvard.edu/gazette/story/2019/06/harvard-history-professor-traces-the-rise-of-psychiatric-drugs/ … via @Harvard
‘An era where it has never not been about drugs’
Royal College of Psychiatrists @rcpsych
We’re @BBCBreakfast ahead of Dr Tee’s interview on the aftermath of the Thai cave rescue. He’ll be discussing how the boys didn’t have any mental health issues despite being in the cave for two wks. Dr Tee will be presenting at our #Congress in early July.
How do we reconcile where it is ‘all about drugs’, with a promotion where a situation arose when it appears that it should be subjectively discussed why there was a ‘lack of mental health issues’ ?
This feels uncomfortable, that it is necessary to portray ‘resilience’ as something that surprises those in ‘psychiatry’ and although it is important to look after boys in a Thai cave for two weeks, afterwards, it seems odd to me that there is almost an assumption that ‘mental health issues’ might have occurred, but didn’t, and this is where ‘psychiatry’ seems at odds with itself?
Is this sort of thing, the very idea that Peter D. Kramer had in mind when ‘Ordinarily Well’ and ‘Listening to Prozac’ came out with romantic notions and that most of psychiatry, at least in the UK, seems to think the way he does.
Leaving out the morass of evidence, that antidepressants leave in their wake, which firmly puts them in the headlights…
Blinking in the daylight…