The Fallacy of Antidepressants and the Placebo Effect

PlaceboI am answering Bill’s comment to an earlier blog post as its own post, because it’s so important. He said:

Did you catch the segment 60 Minutes did last year about the placebo affect in treating depression? What are your thoughts? I personally am anti-drug, but I am far from having the knowledge of any professional…in other words it’s an emotional choice.

No I did not see that.  But I do have some thoughts. Placebos certainly raise issues about antidepressants and the other psychiatric drugs. When the antidepressants are tested, the standard that is used to prove effectiveness is done by comparing them to placebos.  For instance, if placebos work 30% of the time and Prozac works 40% of the time, then Prozac is declared an effective treatment.  What this really means is that Prozac works 10% of the time more than a sugar pill. And what about the other 60%? The more important conclusion from this is that 90% of the time the actual drug effect isn’t doing anything. As you can see, this is significantly misleading. However, the accepted standards of science are so bizarrely low that this is taken to prove that Prozac is an effective treatment.  These standards are not only absurd on the face of it, but they have been corrupted by the power of the pharmaceutical companies.

In addition, the actual criteria being used to measure effectiveness for Prozac isn’t clearly defined. It isn’t even definable, since there has never been any proof of biochemical causation in the brain for so-called biological depression in the first place, nor a clear cut definition of depression.  Nonetheless we are led to believe that proof is just around the corner. But it never comes. Consequently measurements of Prozac’s effectiveness aren’t based on anything real. I give an explanation about what depression is, where it comes from, and how it is manifest in the brain, in my forthcoming book. (And I apologize that publication is still about two months away.)

I wouldn’t say that depression is exactly the result of a human choice, either.  It’s a common but false dichotomy to say it’s either a biochemical disease or an emotional choice. Its is actually a complicated break down of a person’s character under the duress of significant life struggles and losses. Real depression follows along the fault lines of a character composed of particular  temperamental elements, that had formed in concert with the impacts of deprivation and abuse. And suffice it to say, it is not ‘a biochemical disorder.’ It is not a brain problem, as pharmaceutical psychiatry promotes. It is a human problem, as is all the rest of psychiatric suffering.  This has been so since the dawn of humanity. Depression and other psychiatric suffering is very real and not something that can just magically be eradicated. Depression requires a real psychotherapy  to foster an actual recovery, where the suffering of the present is mourned in concert with its resonances with the past.

In the meanwhile, the placebo effect is intriguing, but rather straightforward to understand.  Basically the placebo effect is a form of belief. Short term effects can be seen as a result of belief systems all the time. Beliefs operate from what is called top-down cortical functioning. That is to say, if we believe something, it has considerable self-hypnotic power.  This is a built-in manifestation of human consciousness. But this only lasts as long as the flavor lasts.  There is no real change. The placebo-effect is simply a form of the temporary power of belief. I want to emphasize that it would be misleading, as well, to assume that placebos actually treat depression. To reiterate, neither a sugar pill believed to be magic, nor a Prozac pill believed to magic, addresses real human suffering and never can.

5 replies
  1. rachel malina
    rachel malina says:

    I found your article valid and eloquently written. I’m currently completing a Directed Study on Chronic Pain in the Outpatient Orthopedic Setting for physical therapists….more specifically Therapeutic Neuroscience Education. I’m in my final semester of PT school and have found this to be a necessary paradigm shift in our approach to patient care; utilizing a biopsychosocial approach rather than the traditional biomedical model to educate patients on their pain experience. I’m currently on the placebo portion of the presentation and have question on your input regarding its actual effect. It’s understood that believing a treatment will work helps and from a neurophysiological I’m reading that it’s due to an enhancement of endogenous mechanisms which would equate to an actual shift in neurotransmitter activation which may be from ion channel neuroplasticity(due to the shift in perception leading to an environmental change in brain chemistry)…so basically ion channels or gates are made according to the stresses or non-stresses encountered by the body. More gates for catecholamines will likely increase one’s pain experience…..and their belief in a solution decreases their elevated/chronic sympathetic stress response thus decreasing stress hormones and the brain will modulate ion channels production for the better. Is this what you’re posing, short-term change that occurs must be reinforced by one maintaining a positive psychology and build in a positive cognitive behavioral habits in order to buffer relapse into negative thinking patterns(neurons that fire together wire together) in order to maintain this neuroplasticity?

    • Robert Berezin
      Robert Berezin says:

      Placebos are fascinating. Your explanation, as far as my understanding goes is pretty accurate. It all follows from ‘belief’. Functionally it operates as a kind of self hypnosis, which operate along your pathways. However, placebos can only work for a relatively short period of time. I don’t go along with the idea that building a positive behavioral habit to buffer relapse into negative thinking is a path to extend the response. A mind trick can only work for a while. When there is real injury, the ongoing wear and tear will override the situation.
      Let me complicate the matter. Let’s say a patient has a amputation. If you put him to sleep and amputate he will wake up with tremendous pain, because his last memory, although he is unconscious, is from the sensory pain of the amputation. On the other hand, if you put the patient to sleep and in addition, anesthetize the pain nerves at the amputation site, his memory of the amputation will not include the pain memory. He will wake up with far less pain. In other words memory in the cortex also plays a major role in the experience of pain. And this is not placebo. In a regular operation, like an appendix, if you anesthetized the scalpel cuts before cutting, you will diminish the pain. This is not commonly recognized or is not in conventional practice. There is a fascinating book, by V.S Ramachandran, MD, “Phantoms in the Brain”. You might find it interesting.

  2. Evan Einstein
    Evan Einstein says:

    Would you not say that belief systems and cortical processing have the ability to alter plasticity long-term? I know you said that you believe placebos can only work for a short period of time, but I want to argue that they may have long-term implications for treating depression, etc.
    Hypothetical situation to follow.
    An SSRI is prescribed to a patient who has been diagnosed with MDD. Let’s say that this patient doesn’t actually have a serotonin pathology (highly likely, of course…). However, we see that the patient improves on the medication due to the potential placebo effect acting on belief systems. Perhaps even I would say the SSRI has the ability to elicit some sort of physiological response enough for the patient to notice “something” is changing, and thus this physical sensation will lead to the belief that “I’m going to get better now”. Belief and positive outlook may stem from the placebo effect or the physiological effect of the SSRI pharmacodynamics itself or a combination (of course).
    But why not take this as a possibility: the new belief of “I’m getting better” may induce long-term potentiation of circuitry that can plastically enhance positive thinking in a long-term sense. This may also lead to long-term depression of circuitry that induces negative thinking. Is this not a possibility for understanding potential long-term treatment of depression with placebos?

    • Robert Berezin
      Robert Berezin says:

      In my understanding belief and positive thinking can only go so far. Where the real dynamic of trauma effects on the play of consciousness, in different temperaments, the ongoing mapping of sadomasochism will overrule placebos. Pure self-hypnosis cannot keep those dynamics in check. They need to be dealt with so that the ongoing internal war is no longer in force. Placebos cannot manage real symptoms, and neither can drugs.

  3. Hypatia
    Hypatia says:

    Every time I read a post like this I am grateful. It is one thing for ‘patients’ to speak out against being over-medicated by those they trusted to help them (doctors, psychiatrists), but hearing these words from a doctor is powerful, and will help usher in the change that is needed to help our suffering fellow humans, rather than drugging them as a first-line treatment.

    Drugs are not evil, but nor are they a magical cure. They have absolutely awful side effects, which thankfully, not every one who takes them gets. Some of those who do get side effects go so far as to kill themselves and others (ssristoriesdotcom has a collection of such stories). Others live with debilitating side effects, being told their “illness” is getting worse. And as Robert points out, their efficacy is far from reliable, although this data is massaged to give a false impression, and the profits continue to roll in.

    There is no literature on withdrawal. So we have ever-increasing numbers of people on drugs whose safety has not been assessed for long-term use, unable to withdraw because the side effects are so bad. Interestingly, psychiatry is the only medical speciality that also has an ‘anti’ movement (the antipsychiatry movement is growing apace). It would be wonderful if there were more psychiatrists like Robert, who are trained to be with suffering, and to lead people through it.

    Life can be almost unendurable, and also joyous. The human condition lives on, unchanged since the dawn of time. As a culture, we can do so much better than drugging our (or god forbid, our children’s) distress away. *NOTE: For those who take drugs and find they help, that is wonderful; this is NOT an anti-drug post. I am merely urging caution, and that each potential psych drug user do their research before embarking on taking drugs that they may not be able to ever get off, drugs that will change their brain, in ways that no one can predict.


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