A Confederacy of Quacks: The War Against Antidepressants
Every year or so another pop therapist comes along to persuade depressed people that they should soldier on with their misery rather than try antidepressants.
When I was a kid, one of the first big self-help books was called “Be Glad You’re Neurotic.” You were supposed to be glad because you shared with all the “great men” of the past the pain and joy of being something more than a “normal.”
In the 1980s it was the Church of Scientology spreading lies about Prozac causing mass murders; more recently, self-described progressive therapists have been pushing a quasi-religious Transcendentalist appeal to stick with your natural neurochemistry, no matter how bad you feel. The arguments change with whatever fads are big at the moment, but the reason for the hostility is always the same: Antidepressants work, and that really upsets a lot of people.
I should know. Antidepressants gave me a second and a far better life. When I finally took them, everything changed, and yet I know I’m making a mistake acknowledging my profound debt to this drug, and to the woman who prescribed it for me. It’s never a good idea to admit you owe anything to a drug. Just ask Jose Canseco. Drugs in contemporary America are like prostitutes in Victorian Europe: Life could not go on without them, everyone depends on them one way or another, but no one ever thanks them. They don’t fit in with the global lie we tell about this life.
This big lie combines all the big American lies: self-reliance, the goodness of Nature, Calvinist smugness, and boastfulness in a big stinking stew.
Some of those helping to stigmatize antidepressants have very obvious reasons to promote the lie, like the Church of Scientology, the biggest and most powerful group fighting antidepressants. When American psychiatrists began to prescribe Prozac, the biggest of the new generation of SSRIs, in the 1980s, Scientology went all out to make sure this new, effective medication didn’t cut into their pool of miserably unhappy people to recruit. And I can tell you from my own experience that, although cool people may sneer at the Scientologists, their mass propaganda worked very well on me.
Their agents spread the lie that this new drug was lethal, turned people into homicidal and suicidal maniacs—and every newspaper and magazine in the country printed those claims without checking them out. I remember all too well the day I was reading the San Francisco Chronicle on the bus, and saw a mention of an antidepressant. For a second I was excited, then I read all those lies spread by—but not attributed to—the Scientologists, and dropped any idea of asking a doctor to prescribe it: “OK, there’s no hope. Got it. Thought so.” Nothing is easier than convincing a deeply depressed person that there is no hope. Shooting fish in a barrel is big-game hunting compared to that.
Prozac won, eventually, in spite of L. Ron Hubbard’s zombies.
And by the millennium, there were dozens of effective, fine-tuned SSRI’s available. That began to bother the talk therapists, who saw their incomes shrink radically. That’s why talk therapists are now swamping the net with articles trying to dismiss the efficacy of drugs, like Bruce Levine’s “Are Antidepressants a Scam? 5 Myths About How to Treat Depression”.
Among Levine’s claims are that antidepressants are no more effective than placebos and that Cognitive Behavior Therapy is not necessarily the best psychotherapy for depression.
Levine’s mentor and the high priest of this straight-edge cult is progressive psychologist Irving Kirsch, who claims to find bias in favor of medication in a survey of experiments involving antidepressants. The great irony of his work is that Kirsch, who is violently opposed to antidepressants, claims to have discovered an “expectancy bias” in the studies he meta-studied. The notion that his own deep conviction that the medications he was meta-studying are morally wrong doesn’t seem to come in for the same level of interrogation.
Kirsch and Levine share the same background: traditional Freudian talk therapy combined with faith in the Thoreau-Counter Culture “soft” Left.
As if to emphasise the grotesque mixture of mysticism and venality that defines his enterprise, Levine ends up saying that the therapist is a sort of faith healer, quoting William James,
“He came to understand that, “Faith in a fact can help create the fact.” So, for example, a belief that one “has a significant contribution to make to the world” can keep one from committing suicide during a period of deep despair, and remaining alive makes it possible to in fact make a significant contribution.”
In other words, if the patient believes, the therapy will work; if not, there’ll be no effect. It’s a bizarre assertion, which could never be made in any other branch of medicine or indeed any serious field of study. Penicillin and Prozac take effect whether you believe in them or not; faith healing, whether by a televangelist or a psychoanalyst, does not work, period. In fact, Levine’s deeply weird argument comes close to implying that therapy is simply an upper-middle class substitute for Pat Robertson. After all, faith healers have the same excuse when their voodoo fails: “You didn’t believe in me; that’s why you can’t get up from your wheelchair.” In another bizarre move, Levine invokes “critical thinking” to promote his own business, talk therapy, over antidepressants—and to counter the expected torrent of replies from grateful users of these drugs saying that they do work.
Let’s try some genuinely critical thinking. Let’s start with the fact that Levine (and Kirsch for that matter) are acting on behalf of a deeply threatened profession, talk therapy. Doesn’t truly critical thinking demand that one consider one’s own motives for making such assertions? In fact, as a psychologist rather than psychiatrist, Levine cannot prescribe medication. So, thinking critically, one might suspect that he and his colleagues feel a bit threatened by the new medications.
Levine cites clinical studies allegedly proving that antidepressants are no more effective than placebos, but his citations are, to say the least, highly selective. Many are, in fact, part of a counterattack by the talk therapists on the medications that have made them largely obsolete. And there are many more studies showing that antidepressants are in fact effective, like this one demonstrating that antidepressants combined with cognitive therapy (which Levine also denigrates as a non-Freudian heresy) is effective even on patients who have not responded to traditional talk therapy.
To quote the abstract of this study: “Of 12 patients completing the double-blind medication trial, all 5 assigned to imipramine had a clear-cut response, whereas none of the other seven benefited from placebo.”
It’s odd that this study and others like it are not mentioned in the current antidepressant vs. placebo debate. I found that 1993 study confirming the efficacy of Imipramine particularly memorable, because that was my first anti-depressant. And it was a long, long time coming. I lived the first 37 years of my life in perpetual terror and self-loathing. I used to walk around Berkeley whispering to myself, “There is nothing in my heart but fear.” And it wasn’t just to myself that I said this; I told several talk therapists the same thing, to no effect whatever.
What I got from these practitioners was often lame pep talks clothed in semi-religious exhortations of the Calvinist, “Excelsior!” variety. Weirdly enough, these sermons are still taken very seriously by talk-therapy advocates. Levine, for instance, urges us to follow William James, who “ultimately let go of his dallying with suicide, remained a tough-minded thinker with scientific loyalty to the facts, but also developed faith that, ‘Life shall be built in doing and suffering and creating.’” Levine is echoing (whether consciously or otherwise) Longfellow’s clunker, “A Psalm of Life”:
Let us, then, be up and doing, With a heart for any fate ; Still achieving, still pursuing, Learn to labor and to wait.
Through some metamorphosis too dismal for me to grasp, Levine and his ilk have managed to combine Longfellow’s Victorian sermonizing with their own cloth-headed understanding of progressive politics, arguing that antidepressants merely mask the fact that it’s our culture that’s out of joint, not our minds. This is one of their strangest premises, because it actually seems like a natural lead-up to the conclusion, “…therefore gimme those antidepressants NOW!” than for the one they offer, which amounts to “…therefore eschew these deceitful palliatives and let us be up and doing!” This little enthymeme makes no sense at all, a consideration which seems to have escaped its preachers. It’s as if a Siberian pastor, by way of forcing his exiled flock to face their grim reality, demanded that they stop wearing warm clothing. When you advocate pain, as these people are doing, you are not experiencing pain. Pain does not conduce to activism, and those who endorse it have simply forgotten what pain really means. If our culture is skewed, lonely, alienating, then it hurts us. If it hurts us, we are more or less disabled. Anything that allows us to suffer less pain allows us to function more effectively. Depressives are not good cadres.
These exhortations to stoicism are unconvincing as well as illogical. We are not a stoical culture—thank God. What we are is sentimental, and the real major premise behind all this anti-drug hysteria is pure sentimentality, the notion that Nature is somehow good, and being in balance with Nature is all we require. I have to do a quick cut here to a party in Berkeley, circa 1980: My guru-ish professor holding forth about his walk in the hills, “…and the feeling that nature loved me.” Woman with multiple sclerosis sitting next to me, under her breath: “Nature doesn’t love ME.”
Those who hold the benign view of Nature (who all tend to be American men who’ve had nice comfortable lives) believe that drugs, by insulating us from Nature, prevent us from communing with it. “Walden Pond” is just a few miles down the road from this idiocy.
“Nature,” in these people’s minds, never includes Darwin. Of course, no one really wants to live in Darwin’s world. But the harder you look at the neurochemical state we call depression, the more you see Darwin’s big bloody thumbprint on it. The theory that depression is an adaptive state was an idea waiting to be blurted.
Of course we were meant to feel this bad, in Darwin’s world. That world has no problem with pain. It has no problem with anything except death before mating. Darwin’s world is what you could call tolerant to a fault in the matter of misery.
Thoreau’s state of Nature was a tame suburban pond. Darwin and the geologists took us back, to a Nature no one really likes: The African Rift Valley a few hundred thousand years ago. That’s the lathe that scored those little rifts in the cortex.
Some of us, including me, have a brain chemistry that comes straight outta Ouldivai Gorge. I’m an anxiety depressive. I jump higher and faster than anyone at any sudden noise; I can hear a fight brewing in an apparently friendly conversation minutes before it starts; “This was adaptive once.” That saying applies very well to the brain chemistry of an anxiety depressive. The Rift Valley was no place to be smug and mellow. You were better off afraid and unhappy. In neurochemical terms, that means squirting out a steady stream of adrenals, with little or no indulgence in tranquility-promoting chemicals. (When the antidepressants first took effect, I felt like I’d shed a heavy winter coat, that the air was cooler. The shrink said, “Yes, you’ve been living on adrenals.”)
Studies comparing the neurochemistry of wolves and dogs show the adaptiveness of what we call “free-floating anxiety” to the wild state, and of a dopamine-heavy brainsoup to a domesticated existence. Wolves produce lots of adrenals; dogs, who have to cope with the slower, trickier anthropogenic habitat, have been bred to damp adrenal production, making them slower, calmer, less likely to react wildly to unfamiliar stimuli. http://www.americanscientist.org/issues/issue.aspx?id=813&y=0&no=&content=true&page=3&css=print The cultists fighting antidepressants exhort the wretched to cherish their primal, wild natures precisely because those people have no idea of the grim Darwinian/geological time that bred us. Nature means hunger, pain, thirst and, above all, fear. The atavistic and frankly ridiculous worship of these conditions would mean doing without everything from warm clothing to antibiotics, as well as antidepressants. The terrors of Oldivai Gorge are no longer adaptive. They’re not morally sanctioned; they’re not sacred; they don’t work.
If you’ve ever seen a wolf trying to live in an urban home, you know there’s nothing romantic or scary about it. Wolves cringe, flinch, whimper and hide in our world. It’s dogs who have a jaunty confidence, meeting and greeting like the people I hated in high school. I remember sensing sullenly the Darwinian origin of my wretchedness, resenting and envying those Ouldivai Gorge humans who stuck me with the hair-trigger fear reaction: “They had an easy out, God damn it—those bastards only had to live 20 years or so, long enough to raise kids who could run on their own. Now you have to go way longer ’n that, and you don’t even get to bash anybody’s head in with a rock.” And, reflecting wistfully on the blessed state of those famous, beloved hominid fossils, I’d look out at the Berkeley traffic, thinking how easy it would be to walk in front of that Pepsi delivery truck zooming past me. I knew something was wrong.
At the age of 19, I summoned up my courage and asked to see a psychiatrist at the Student Health Center at UC Berkeley. That’s not an easy thing to do when you’re as terrified as I was. Just getting to the door of the clinic was like walking across the Mariana Trench. And it was all for nothing—no, worse than nothing; it left me feeling much worse than before.
They assigned me to a Freudian psychoanalyst who treated me by asking about my childhood and listening to me tell him that I was the most worthless excuse for a human being ever born. He reacted to my confessions by nodding blandly.
You can imagine what effect that had on a friendless 19-year-old already consumed with self-loathing. I felt that my worst fears had been officially confirmed by a specialist.
Then there was the mystic guru in the Berkeley hills, who told me I needed to commit to long-term therapy and, when I explained that I went to UCB and worked nights in a packing plant, hinted, “Well, a lot of people feel my services are important enough to take another job…” There were better therapists, too—most of them women, it occurs to me—but most of them could only try to be ersatz friends. They tried, but they may as well have been talking me into being taller.
Then I moved from the US to New Zealand, where the Freud cult never really caught on. Desperately frightened, alone and miserable, I saw a psychiatrist, expecting no more than talk. Luckily, I was wrong: Ten minutes after I walked into her office, Dr. Margaret Nicholson, the brilliant woman I’d been lucky enough to draw as psychiatrist said, “You have a severe case of anxiety depression; you need antidepressants.”
I started taking Imipramine, but nothing happened for a long time. That’s one reason I know this was no placebo effect. Dr. Nicholson had guessed it would take effect within six weeks. It didn’t.
By this time, it’s unlikely I would have fallen for a placebo effect, because by this time, in an attempt to self-medicate, I’d tried every drug on the street and was well able to tell what was real and what was fake. I knew very well if somebody had sold me some fake shit. So I knew the Imipramine was not working; I even wrote Dr. Nicholson a letter telling her this, telling her it was hopeless and I would just have to struggle on—the neo-stoicist solution.
She must have laughed reading that, but she sent back a polite note saying that I should just stick with it a little longer. Almost eight weeks after I started taking it, the Imipramine took effect. I hardly know how to describe this moment. It was the only miracle I have ever experienced. I woke up one morning, prepared to do what I was expected to do and crawl home to sleep—and there was something new in my mind: a humming in my head that was on my side. I found that I was looking forward to the day, a sensation I had never felt in my life. There was a very quiet, calm confidence so blissful that my scalp tightened and I stood there by the bed, wondering what was happening.
And, by the way, don’t believe the lies that antidepressants “zombify” you. Contrary to what generations of romantic bathos have told us, unhappy people do not experience a great range of emotion. Fear, rage and grief: that’s about it. It gets pretty monotonous. But after the Imipramine came on, I felt emotions I’d long assumed were simply literary devices found only in novels and films. Whole aspects of existence suddenly flicked on, as if someone had turned a spotlight on them. Conversations became something more than the desperate effort not to reveal what a pig I was.
The strangest and most wonderful effect of all was the dilation of time. A whole field of time, in between me and disaster, became real. Severe depressives like me see time like something out of an Itchy & Scratchy cartoon: there’s me, the cat, on a log floating straight towards Niagara Falls. The interval between me and the falls is nothing but a brief delay designed to add to the torment before the inevitable doom. All that’s real is your gut churning with terror, your absolute certainty that this is what you deserve, and your vision of the falls ahead. Since my job at the time was teaching Composition to hundreds of sullen med students, Niagara Falls came every week, on Monday afternoon, when I had to face endless rows of faces who hated my guts. It was a job that would have terrified a much more confident person, and it nearly killed me—until the Imipramine kicked in. When that happened, it was as if the basic diagram changed. Instead of floating helplessly toward Niagara Falls, I was aware that there was a huge stretch of time and space between me and doom, time in which I could actually do things to change the outcome. I could even imagine positive outcomes, lectures that were something other than being fried like a bee under a magnifying glass.
It’s important to understand that I knew that positive outcomes existed, even before Imipramine. But knowing and experiencing are very different things. If you’d asked me, “Don’t you think there are alternatives to simply waiting for doom?” I’d have given the correct answer. In fact, several talk therapists did ask me questions similar to that one in the years before I got antidepressants, and I answered that of course I realized that. But it was like admitting that there were things such as neutrinos; I knew the proper answer, but had no experience of the phenomenon I was acknowledging.
That’s why it’s such mean-hearted bullshit to peddle positive thinking, Calvinist stoicism, and free choice to depressives: we know all those fancy words. Nobody tries harder to believe that shit than the wretched. Right now, millions of wretches still unlucky enough to live in the talk-therapy cult’s sphere of influence are reciting all those grand terms like a high-school football player with a broken leg repeating what Coach said, “Walk it off, walk it off.” It doesn’t work.
I know; I tried it, more times than I care to remember. I kept trying, not knowing that American psychotherapy in the 1970s was controlled by men – and I do mean men - who made a comfortable living by letting miserably unhappy people talk to them at obscene hourly rates.
Even when it was a popular fad, psychoanalysis was described by some of the finest intellects of the last century as a cult, a myth, or an outright scam. Peter Medawar called psychoanalysis “the most stupendous intellectual confidence trick of the twentieth century.” Karl Popper dismissed it as a cult founded on un-testable premises. Nabokov considered Freud “a figure of fun” and dismissed his therapy with this memorable phrase: “Let the credulous and the vulgar continue to believe that all mental woes can be cured by a daily application of old Greek myths to their private parts.”
Freudian therapy lost whatever remaining legitimacy it had in the second half of the twentieth century, as the homophobia and misogyny of mainstream psychotherapy became more apparent. When the American Psychiatric Association was finally forced to renounce its characterization of homosexuality as a mental illness, psychoanalysts lost one of their most powerful weapons: attributing any opposition or criticism to “latent homosexuality.” Publication in the 1980s of Freud’s early letters showed that he refused to believe female patients’ claims to have been abused and treated them as sexual fantasies rather than simple, criminal fact. The letters also highlighted Freud’s long involvement with an equally outrageous crank, Wilhelm Fleiss, who maimed female patients with mystical nose surgery, then blamed them for the subsequent infections. This association made it impossible to take psychoanalysis seriously even as an intellectual discipline, let alone an effective treatment.
And there was always evidence, of a surprising sort, that Americans knew psychoanalysis didn’t work. I’m talking about the truest expression of our group mind, popular culture. Decades of New Yorker cartoons parodied psychoanalysis, showing the analyst dozing, doodling or balancing his checkbook while the schmuck on the sofa babbles away. Compare those with this wonderful cartoon from the early 1990s, called “If They Had Had Prozac in the Nineteenth Century,” showing Marx, Nietzsche and Poe all cheered up. (The panel with Poe, showing the haunted poet saying “Hello Birdie!” to a huge raven on his desk is my favorite.)
Another sample of pop culture wisdom: a movie-industry joke from the Prozac era: “Half of Hollywood is on Prozac... the successful half.” Nobody ever made a joke like that about psychoanalysis.
When I finally went on the antidepressant Imipramine and knew happiness for the first time, I was so grateful to the drug that I looked it up.
When I found that this drug had been available all my life (it was developed a year before I was born), but had never been offered to me by the many psychotherapists I saw in California, I wept.
I don’t expect to convince Levine and Kirsch that they’re wrong. As historians of science love to point out, opinions rooted in training and guild-loyalty don’t change, the people holding them simply die out. I’m writing this to people who recognize themselves in my description of life before antidepressants. So let me repeat my key point: your depression makes it very easy for you to believe there’s no hope, and very hard to believe there might be help for you.
But there is help. For God’s sake, try it. Try antidepressants while you still can. It’s all too likely that soon the DEA will become involved in the war against antidepressants; after all, “mood alteration” is their purpose, and they help people, the two criteria for drug persecution.
We’ll probably have to wait many years for a complete understanding of what we mean by “depression.” But whatever they are, however they are imagined, antidepressants help.