Peter Kramer: Antidepressants Are Effective

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Peter Kramer, M.D., writing in the July 9 issue of the New York Times Magazine, responded to a number of recent articles in the media that criticize the efficacy of antidepressant medications. One of the reviews mentioned was an essay in the New York Review of Books, wherein Marsha Angell, former editor of the New England Journal of Medicine, wrote that “psychoactive drugs are useless.” There have been other recent articles in this vein as well.

Kramer is an expert on this topic. He is clinical professor of psychiatry at Brown University, and during the 1990s he wrote the intriguing and engaging Listening To Prozac. Although some may view Kramer as an unabashed proponent of medication, I have found his views to be realistic, intelligent, and related to the latest research findings.

Here is a brief summary of what Kramer comes up with when he analyzes what we now know about antidepressants. One recurrent finding is that antidepressants are effective in treating dysthymia, chronic and recurrent depression. Antidepressants also bolster confidence and diminish excessive vulnerability in what is called “neuroticism”; although this finding may not be specially addressed in studies. Antidepressants are known to cut the odds of relapse in depressed patients who display a range of severity levels.

Kramer is attuned to discussions and research on the relationship between psychotherapy and medication, a synergy that has been difficult to quantify. This relationship must also vary when different conditions are compared, i.e., schizophrenia versus depression. Different therapies as well as therapists are other variables to consider. Much more work is needed on this relationship as well as on the overall effectiveness of antidepressants in the range of conditions they are prescribed for. Kramer offers this intriguing summary:

“It is hard to locate the judicious stance with regard to antidepressants and moderate mood disorder. In my 1993 book, ‘Listening to Prozac,’ I wrote, ‘To my mind, psychotherapy remains the single most helpful technology for the treatment of minor depression and anxiety.’ In 2003, in ‘Against Depression,’ I highlighted research that suggested antidepressants influence mood only indirectly. It may be that the drugs are ‘permissive,’ removing roadblocks to self-healing.

“That model might predict that in truth the drugs would be more effective in severe disorders. If antidepressants act by usefully perturbing a brain that’s ‘stuck,’ then people who retain some natural resilience would see a lesser benefit. That said, the result that the debunking analyses propose remains implausible: antidepressants help in severe depression, depressive subtypes, chronic minor depression, social unease and a range of conditions modeled in mice and monkeys; but uniquely not in isolated episodes of mild depression in humans.

“Better-designed research may tell us whether there is a point on the continuum of mood disorder where antidepressants cease to work. If I had to put down my marker now; and effectively, as a practitioner, I do. I’d bet that ‘stuckness’ applies all along the line, that when mildly depressed patients respond to medication, more often than not we’re seeing true drug effects. Still, my approach with mild depression is to begin treatments with psychotherapy. I aim to use drugs sparingly. They have side effects, some of them serious. Antidepressants help with strokes, but surveys also show them to predispose to stroke. But if psychotherapy leads to only slow progress, I will recommend adding medicines. With a higher frequency and stronger potency than what we see in the literature, they seem to help.

“My own beliefs aside, it is dangerous for the press to hammer away at the theme that antidepressants are placebos. They’re not. To give the impression that they are is to cause needless suffering.”

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