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For Those Still Convinced Antidepressants Have Non-Placebo Value

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Even though meta-analyses of antidepressant studies have repeatedly shown that antidepressants’ effects are barely distinguishable from placebo, many opponents of suicide rights still point to meds as a proper course of action for those who wish to die. Those unlucky enough to be hospitalized after a suicide attempt (like me) are still administered antidepressants in hospital – by force, if necessary.

Anyone who still thinks antidepressants have non-placebo value should listen to this 20-minute interview with Dr. Irving Kirsch, the lead investigator on the major meta-analyses of antidepressant drugs.

Major points:

  1. The serotonin hypothesis is “dead in the water.” Studies have repeatedly failed to demonstrate that serotonin deficiency is responsible for depression.
  2. The effects of antidepressants are indistinguishable from placebo, especially when data is included from studies that have not been published because they did not get a positive result. (Dr. Kirsch and others obtained these unpublished studies using the Freedom of Information Act.) Both the publication bias in general, and specific monetary incentives, are implicated.
  3. Antidepressants’ “effects” are independent of the drug mechanism. Antidepressants that work on inhibiting serotonin reuptake have the same effect as antidepressants that work on other neurotransmitters or even other chemicals; that is, their effect is indistinguishable from placebo.
  4. Antidepressant “effects” are independent of dosage.
  5. SSRIs (selective serotonin reuptake inhibitors) show the same level of response as SSREs (selective serotonin reuptake enhancers) – that is, drugs with the opposite mechanism show the same result!
  6. Contrary to my previous suppositions, the antidepressants’ effects are dismal regardless of the severity of depression. Severely depressed patients (who make up most of the study groups!) are not significantly more likely to respond to antidepressants than less severely depressed individuals.

As Dr. Kirsch puts it, “that’s what I call a placebo.”

The next time you see someone recommend drugs as a course of therapy for depression, please point them here, or to the podcast.

Meanwhile, the only drug that consistently cures depression in laboratory studies is only available on the black market.


(In the interests of full disclosure, I take one of these yummy placebos every day – citalopram. Similarly, millions of people feel better every day by using quack therapies such as chiropractic, homeopathy, and prayer. The folks making money off those therapies feel even better.)

Written by Sister Y

March 7, 2011 at 6:12 pm

Is High IQ a Treatable Medical Condition?

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I have argued for a right to suicide grounded in personal freedom and dignity; I have argued that there is, in addition, no right to forcibly prevent people from committing suicide. My views on this extreme example of patient choice still apply; but what about less extreme solutions to suffering?

The predominant view of medicine seems to be a doctor-controlled, paternalist one. We must all get a doctor’s permission to access most drugs; most people apparently do not find this to be a serious intrusion into privacy and dignity. I think a better view of medicine is that of a doctor as a consultant, who assists the patient with medical knowledge and advice, but does not ultimately control the patient’s treatment.

What is the purpose of medicine? (Please feel free to answer this below – it’s not just rhetorical.) Is it to relieve suffering? To enforce proper behavior? To extend life? Certain definitions of medicine’s purpose (like that last one) rely on idiosyncratic values that perhaps should not be forced on others. A fairly radical, but I think value-neutral, definition of the purpose of medicine might be: to assist patients in maximizing their own values by providing knowledge of human biological systems and applying available medical techniques as chosen by the patient.

One of these might be a prescription for Nembutal.

But another of these “available medical techniques” might help a patient reduce his general intelligence in various ways if it is a burden to him.

The DSM-IV definitions of diseases tends to include the rider that the symptoms “cause marked distress” to the patient. Perhaps it is time to consider whether conditions thought to be desirable that “cause marked distress” should also be treatable.

High intelligence is clearly treatable with a variety of substances and treatments, from ECT to antipsychotics to medical cannabis. If, say, extremely good memory or other symptoms of high intelligence are a burden to the patient, shouldn’t he be entitled to use available technology to eliminate them? And why not have a physician’s advice on how to do it in a manner that maximizes the patient’s other values?

Is it different from suicide?

Written by Sister Y

October 1, 2009 at 6:44 pm

Suicide Rate Is Highest Just After Psychiatric Hospitalization

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If psychiatric hospitalization is so effective, why is the suicide rate highest immediately after release from the hospital?

A massive study (1,185,727 patient-years) published in January (“Higher-risk periods for suicide among VA patients receiving depression treatment: Prioritizing suicide prevention efforts,” M. Valenstein et al., Journal of Affective Disorders, Volume 112, Issues 1-3, January 2009, Pages 50-58) on a military veteran population being treated for depression found that suicide rates were dramatically elevated immediately following a psychiatric hospitalization.

The base suicide rate of the population was found to be 114 per 100,000 person-years. Clearly, the depressed VA patients are at a much higher suicide risk than the general population of the United States, for which the suicide rate is estimated at only 16.7 per 100,000 person-years. But the suicide rate for these depressed veterans shot up to 568 per 100,000 person-years during the 12 weeks following a psychiatric hospitalization – five times the already high base rate for the non-hospitalized depressed veterans, and 34 times that of the overall American suicide rate.

But if hospitalization were actually effective in “treating” suicidality, wouldn’t we expect the suicide rate to be quite low after a hospitalization?

One problem with this line of thinking is that we might expect only the most seriously suicidal patients to be hospitalized at all. One hypothesis is that hospitalization is effective in reducing suicidality, and that the suicide rate of hospitalized depressed veterans would have been much higher if they hadn’t been hospitalized. No study I am aware of attempts to compare the suicide rates of patients who meet criteria for hospitalization, but who are randomly assigned to be or not to be hospitalized. Given the widespread faith in hospitalization as a suicide treatment mechanism, to conduct such a study would probably be considered a breach of professional ethics toward the non-hospitalized group.

However, in the absence of data from such a study, I think the alternative hypothesis needs to be considered: that hospitalization is so horrible, demeaning, and above all ineffective, that it does nothing to prevent suicides and may actually increase one’s resolve in that direction. Far from showing caring and compassion, forced psychiatric hospitalization demonstrates to the patient that he is a prisoner. For a prisoner, there is a clear method of escape. Yes, there are people who claim to have benefited from involuntary psychiatric hospitalization, just as there are people who claim to have benefited from childhood beatings and from those wilderness camps they send bad kids to. But there are also people who have suffered involuntary hospitalization and found it to be a life-changing, demeaning experience. In fact, I think we must be suspect of the “glad it happened” group. The psychological defense mechanism of denial, the discomfort of cognitive dissonance, contribute to people interpreting past events with unwarranted optimism. As long as you can convince yourself that the involuntary hospitalization was good for you, you don’t have to admit to yourself what an insult to your dignity was done to you.

Sadly, the authors of the study are using the results to recommend yet more coercive practices. What is really needed is more intensive “treatment” following a hospitalization, they say – or a “firm connection to outpatient services,” in the Orwellian words of the study’s authors.

For those whose link to the study is gated, here’s a Washington Post summary of the study: “With Depression, Vets Face Higher Suicide Risk.”

Update: Commenter Jessa continues the discussion on coercion at her site, Made with Awesome.

Update: Zarathustra responds to my arguments here.

Update: Jim adds to the discussion here and here.

Written by Sister Y

January 12, 2009 at 10:09 pm

Thomas Szasz: "Suicide is not a medical matter"

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Thomas Szasz traces the parallels between suicide, contraception, and abortion – especially the “mental illness” (depression and threatened suicide) that, before the days of Roe v. Wade, was a pregnant woman’s only hope of getting a “therapeutic abortion”:

Regrettably, our memory of the history of medicalization is short and selective: We remember its glories and forget its infamies, especially as they relate to sexual behavior. When I was born, contraception was under complete medical control and abortion was illegal. When I was an intern in a Boston hospital, offering contraceptive advice, much less providing a contraceptive device, was a criminal offense. Only in 1965, in the celebrated case of Griswold v. Connecticut, did the Supreme Court strike down as unconstitutional the statute that made it a crime for a person to “artificially prevent contraception.” In that landmark case, the Court repealed the law that prohibited a conduct the law deemed illegal. It did not medicalize the alleged “condition” that motivates such conduct: The Court did not call the fear of pregnancy and the desire to avoid it a “disease,” nor did it call engaging in the formerly prohibited conduct “physician-assisted contraception” or classify it as a “treatment.” In short, the right to practice contraception was placed in the hands of the people, not in the hands of physicians.

Abortion underwent a similar metamorphosis, from sin to crime to right, with a brief stop-over as a treatment. When abortion was legalized, the mental illness whose treatment justified therapeutic abortion vanished. When suicide is legalized, the mental illness whose treatment justifies its therapeutic prevention will also vanish.

Although performing an abortion and developing effective methods of birth control entail the use of medical knowledge and skill, abortion and contraception are not medical matters. The same is true for suicide. Although killing oneself with a drug entails the use of medical knowledge and requires access to the necessary substance, suicide is not a medical matter. We ought to deal with death control the same way we have dealt with birth control: by removing it from the purview of Medicine and the State, by repealing all medical and legal interference with the act. [Bolded emphasis mine; italics in original; citations omitted.]

From Fatal Freedom: The Ethics and Politics of Suicide, by Thomas Szasz.

Written by Sister Y

November 10, 2008 at 6:34 am

The "Unwanted Life" Diagnosis

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When providing a medical treatment of any sort, physicians are generally expected to produce a diagnosis of a medical problem that the treatment is intended to correct. In most cases, the medical problem is one that anyone would recognize as a medical problem, such as diabetes or a broken leg. However, one of the most widely prescribed medical treatments is contraception. But what “medical problem” do you diagnose in order to prescribe contraception?

People in institutional settings (locked hospitals, homes for the developmentally disabled, etc.) are, of course, sexually active. The doctors that care for them must provide contraception to prevent pregnancy – usually injected hormone contraception. The surprising (to me) diagnosis you most commonly see on the chart of an institutionalized patient, when a doctor is prescribing contraception to her, is “unwanted fertility.” Fertility is something we think of as healthy – but doctors may diagnose “unwanted fertility” as a medical problem for which contraception is the preferred treatment.

I think this is an interesting solution, although the diagnosis is often, strictly speaking, a fiction, as many female residents of group homes and such will tell you they definitely want to get pregnant – what is really meant is that the patient’s fertility is unwanted by her guardian.

A similar diagnostic possibility is necessary in the case of the rational suicide. A diagnosis of “unwanted life” could form the basis for the provision of lethal means of suicide that require a prescription, without requiring general legalization of the lethal drugs. The diagnostic criteria might even include more than just a wish to die – requirements might include that the wish be persistent (repeated requests over a period of time), that it not be accompanied by (or motivated by) delusions, and that the wish to die be clear and unambiguous.

Although I do not think there is a moral right to procreate (for anyone), I am concerned with the use of the “unwanted fertility” diagnosis against the expressed wishes of patients, even though these patients would likely not be able to care for any children borne by them. It is a convenient solution, but it stretches the truth a bit. This worry is even more important in the analogous “unwanted life” case. The “unwanted life” diagnosis would never be appropriate in cases where the life of the subject is unwanted by someone other than himself (his guardian, say) rather than unwanted by the subject of the diagnosis. Likewise, if a person met the criteria for the “unwanted life” diagnosis, despite having some sort of mental illness as defined by the DSM-IV, it would be inappropriate for his wish to be denied because others disagreed with his wish to die.

Written by Sister Y

July 17, 2008 at 7:25 am

Does Suicide Contagion Exist?

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It is commonly accepted – I have been accepting it – that highly publicized media reports of suicides cause a phenomenon known as suicide contagion. That is, highly publicized suicides function as “social proof” that suicide is an acceptable option, and people in the area of publicity commit suicide using the publicized method in greater numbers. These are sometimes called “suicide clusters” and are apparently most common among young people.

The studies that provide the basis for the phenomenon of suicide contagion are, apparently, somewhat questionable. Many suffer from lack of control for important variables; those that are controlled suffer from problems with the control groups or small sample size. Using another method, some ecological studies have indicated that the suicide contagion phenomenon is real; others have contradicted those findings.

So say the authors of a 2001 study in the American Journal of Epidemiology, entitled “Is Suicide Contagious? A Study of the Relation between Exposure to the Suicidal Behavior of Others and Nearly Lethal Suicide Attempts” (Mercy et al., Am Epidemiol Vol. 154, No. 2, 2001). These authors set out to determine the strength of the suicide contagion phenomenon – whether suicidal behavior in parents or relatives, or (separately) friends or acquaintances, or recent media reports of suicide, affected serious suicidal behavior in young people.

The study authors interviewed 153 people, ages 13-34, who were “victims” of nearly lethal suicide attempts and who had been treated at local emergency rooms in the Houston, Texas, area. A control group of 513 subjects was similarly interviewed. The conclusion? Not only did the study fail to demonstrate any sort of “suicide contagion,” but the authors note a statistically significant protective effect when a subject heard a news report of suicide within 30 days prior to the suicide attempt or had a friend or acquaintance make a suicide attempt. That is, the ER suicide-attempt group was actually less likely than the control group to be aware of a recent media report of a suicide, or to have experienced the suicidal behavior of an acquaintance! The suicide attempt of a parent or relative had no statistically significant effect on suicidal behavior, whereas the usual “suicide contagion” sources had a statistically significant protective effect – the opposite of what the suicide contagion model predicts. The authors are, of course, careful to note that more study is needed “to understand the mechanisms underlying these findings,” but it does seem that the contagion hypothesis is worth questioning. The appearance of a contagion effect may be little more than apophenia, as with news reports attributing New York physician Douglas Meyer’s jump-from-heights suicide to a contagion effect from Ruslana Korshunova’s highly publicized suicide. From the study:

In this study, we found no evidence that exposure to the suicidal behavior of others is a risk factor for nearly lethal suicide attempts. Even among groups at relatively higher risk for suicidal behavior (i.e., males, alcoholics, depressed persons, adolescents), we found no indication of an effect. On the contrary, we found that exposure to accounts of suicidal behavior in the media and, to a lesser extent, exposure to the suicidal behavior of friends or acquaintances were associated with a lower risk of nearly lethal suicide attempts; however, this appeared to be evident only when the emotional and temporal distance between the exposed individual and the suicide model was greatest. . . . Greater temporal and emotional distance between an individual and a suicide model may enable a person to more fully appreciate the negative consequences of suicide. [Citations omitted. Emphasis mine.]

Note that this study also appears to call into question the statement of a psychologist, from the story I reported in my earlier post, that suicide contagion disproportionately affects those already severely depressed. This study found no effect, even among depressed people.

Much to their credit, the authors propose a couple of alternative readings of their data:

[W]e examined the effects of media exposure over a 30-day interval, in contrast to most prior studies, where media effects were examined immediately after exposure. It is possible that media exposure has its greatest impact on suicidal behavior immediately after the event and that its effects are diluted or even reversed as time passes. Alternatively, it is possible that suicide attempters may be more socially isolated than other groups and are therefore less likely to be exposed to suicide models in their social networks or in the media. [Citations omitted.]

Written by Sister Y

July 2, 2008 at 11:52 pm