Nothing wrong with benefiting from the placebo effect

placebo[1]

In days gone by, I’ve not been in the habit of posting full articles from online publications. Much better to post a salient extract and a link.

Then, The Times pulled down the shutters and erected a paywall, so that approach no longer works properly. This leaves a couple of alternatives – either don’t use material from The Times, or post the entire article.

On most reporting matters, this doesn’t present a problem – The Times just rehash the same AP/PA/Reuters piece that the Telegraph does, so the Telegraph gets my link.

Recently, there’s been a new round of debate on the validity of treating depression with pills. A report said that talking therapies work better. Sherlock Holmes would agree, but would point out that talking therapy costs upward of £200 a month, against the £10 cost of a month’s supply of generic Prozac.

For your £10 you get what you were expecting – 20mg of fluoxetine – regardless of the vendor.

For your £200 of talk therapy, you have no idea what you are getting. There are no KPIs for therapists. It’s fluffy and fuzzy. What this means is that the ‘profession’ is awash with charlatans and imbeciles, Labour voters to a man, who are likely to do more harm than good.

So, with a nod to a friend who has been prescribed anti-depressants, but won’t take the bloody things, here’s the best thing Robert Crampton has ever written for The Times.

image

Well it works for me. I started on fluoxetine, popularly known as Prozac, five years ago this October, when I was 41. I’ve been taking 20mg every morning ever since, green and white pill, down it goes with the first coffee of the day. There have been big benefits, and no side-effects as far as I’m aware. I see no reason to stop. Neither does my wife. Neither does my GP, Dr Cahill. “I know the years of disquiet you had, and I also know how much better you felt when you started the medication.” These are the opinions that matter to me, rather more than the opinion of Professor Irving Kirsch.

I feel better with antidepressants than I did without them. I can’t say whether this is a result of a placebo effect. I suppose it would be arrogant to discount it. But two factors make me think that whatever is helping me is more likely to be the result of an actual chemical change, rather than a psychological trick.

First, it took two weeks for any change in my state of mind to register. If the change was wrought simply by taking a pill, rather than by real pharmacological effects that pill was causing in my head, why the delay? It seems illogical that you would pop a placebo then not feel the effect for a fortnight.

Just to interrupt for a moment, this is easily explained by the fact that your doctor and every online source will tell you that you will not feel any effect for up to 2 weeks. Carry on.

Second, the biggest change in my behaviour, once I was on the pills, was too dramatic to have been caused by mere self-deception. That change was that I stopped losing my temper. I was someone who had always lost his temper a lot. When I started taking Prozac I became, and have remained, someone who loses his temper infrequently. I am more stable, less prey to paranoia and panic, less prey to pride, too, the sort of paralysing pride that can barricade you into a dead-end for decades.

This represents a huge improvement in my life and a huge blessing for the people around me. Losing my temper — smashing things, shouting — was a blight. It got me into all sorts of trouble as a child and young man. It never solved a damned thing. It was frightening. I’m ashamed of it.

I don’t believe this behaviour would have stopped without the medication. And I don’t believe it stopped because of a placebo effect. It wasn’t as if I started taking Prozac to cure my temper. I started taking it because I felt miserable, lethargic, morose, sometimes unable to function. Depressed in other words. Stopping the temper has been the best outcome but not one I was expecting.

Professor Kirsch says that in the long term “talking therapies” work better than antidepressants. Maybe he’s right, for some people, maybe most people, possibly all people, if they have the time, if they find the right therapist to talk to, if their long term lasts long enough. For me, however, talking therapies have not been a success. I was sent to see a child guidance counsellor when I was 7. And again when I was 10.

And again when I was 17, except by then it was called an educational psychologist. We talked. Maybe it did me some good. And maybe it did me some harm, in that the talking, the special treatment, served to legitimate in my juvenile mind behaviour (temper again) that was unacceptable and should stop.

Later, in my twenties, I tried the talking cure again, a full-on shrink this time. She stuck religiously to the Freudian playbook, no guidance, no opinion. In about week six, she said that by now I viewed her as an object of sexual desire. No I don’t, I said. Yes you do. No, really, honestly, no disrespect, I don’t. It was hopeless.

A few years ago, before I started on Prozac, my GP suggested some cognitive behavioural therapy, or CBT. I went for a couple of sessions. The guy was fine, but we didn’t truly hit it off and by then, mid-career, father of two young children, I was quite busy, too busy to spend hours bringing someone up to speed on the ins and outs of my life history.

Because the thing is, on the subject of what it is to be me, I’m an expert. I don’t need a novice’s take on the nuances of what it is to be Robert Crampton. I am not, to put it mildly, a stranger to introspection, to thinking, talking (and indeed writing) about myself. Other people, of course, people who haven’t had the privileges I’ve had, or people who’ve been better at snapping out of it and pulling their socks up and all those clichés, people who’ve coped, and who then for whatever reason can cope no longer, for them talking to a therapist might be revelatory. But talking is not something I do too little of. I come from a family of talkers. Sometimes I think we’ve talked too much.

What I’ve got, I think, is a chemical problem. There is a history of depression — going back generations, including suicide and institutionalisation — in my family. Certain families are prone to heart problems, or breast cancer. Mine, I think — not all of us, but some of us — has a predisposition towards depression, a tendency towards a personality that makes life more difficult than it ought to be. I think it is legitimate that we get a little chemical assistance, a jolt, a shove in the right direction. Not a panacea, just something to put us back in the game.

“There’s still a stigma attached to being depressed,” Dr Cahill says.“If you had high blood pressure and I said ‘you need to take these drugs for the rest of your life’ you wouldn’t blink, you’d say ‘yes doctor’. I view the antidepressants that work in the same manner.”

Nice work.

AJ

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About Al Jahom
Anti-social malcontent, misanthrope and miserable git.

17 Responses to Nothing wrong with benefiting from the placebo effect

  1. Vladimir says:

    I’ve been meaning to write an article on this for a while, and you’ve inspired me to finish it and post it up. The short version is that I don’t think your friend should take the anti-depressants, because they’re harmful. It would be nice to think that they’re placebos at worst, but they’re not. They have nasty side effects, particularly during withdrawal, and from personal experience I believe they actually prolong depression. I don’t think anyone should be prescribing them.

    • Al Jahom says:

      Do you mind me asking which SSRIs you have experience of?

      • Vladimir says:

        Sertraline hydrochloride and escitolapram. However, I understand that they are all pretty similar. Both of those drugs have the same weird side effects and nasty withdrawal symptoms.

        I know it’s controversial, but I really don’t think these drugs are helpful in dealing with depression. There is something worse than not taking your medication – and that’s taking the wrong sort of medication, the sort that makes your problems worse. These drugs are not like painkillers, those being well-understood with known mechanisms and proven efficacy. They are more like 18th century quack medicines: not understood and merely believed to be helpful. I look forward to reading more from you on this topic, and I hope your friend will feel better soon.

  2. Curmudgeon says:

    My experience is that SSRIs (escitalopram) turn you into a quasi-zombie incapable of decision-making, and also dramatically reduce sexual potency. Obviously drugs affect different people in different ways, but I would strongly advise against these.

    • Al Jahom says:

      But all of the SSRIs have different effects, and side-effects, on different people.

      No-one can say, “they didn’t work for me and had all these really bad effects, so no-one else should even try.”

      The withdrawal effects are also different for different people, and for each drug. moreover, to argue against taking a potentially beneficial drug on the grounds of potential withdrawal problems is to suggest non-terminal patients shouldn’t be prescribed opiates or tranquilisers.

      Vladimir’s analysis is wrong (as a matter of fact rather than personal experience) for these reasons, and I’m afraid yours is too. UPDATE: I was overly harsh on you, but I need to compose a response to Vladimir’s article.

      On the matter of libido, I put Crampton’s neglecting to mention that down to my assumption he’s been married for some time.

  3. Curmudgeon says:

    AJ – I know “all of the SSRIs have different effects, and side-effects, on different people.”

    I’m sure they do work for some people, simply saying they didn’t work for me. All knowledge is just the sum total of human experience.

    I do think such conditions aren’t properly managed, though – I simply reported with symptoms, was prescribed the drugs, got a repeat prescription, eventually gave them up, never saw the doc again.

    It isn’t a simple case of Solution A vs Solution B, but I’m sure more emphasis on talking cures would be beneficial. The problem being that their availability is very limited, and even where they are available they aren’t tailored to people who are still working.

  4. Furor Teutonicus says:

    Prozac? They gave me that once. In two weeks I had trashed my flat, and everything in it, and two neighbours cars for “looking at me funny”.

    BAD stuff Prozac, and Xeroxin (?) is not much better.

    • Al Jahom says:

      But Prozac doesn’t have that effect in many cases – certainly not in Robert Crampton’s case. Or mine.

      Conversely, the effect you described is exactly what happened to me on Venlafaxine & I know I’m not alone in that.

  5. Pods says:

    As the partner (for want of a better word) of someone with schizophrenia and attendant depression, I’m with Crampton and Al. Over the years he’s been prescribed pretty much every SSRI going, and with varying effects/success. One made him completely moronic (Reboxetine), one worked brilliantly on the depression but resulted in a heart condition (Venlafaxine). After which he decided that, as he felt OK depression-wise, he would knock antidepressants on the head. Everything was OK for about 6 weeks, then the crying, the lethargy and all the rest started again (just like before he had any SSRIs). It took ages to get through to him that it was depression again. Eventually he told his consultant how he was feeling and was prescribed Sertraline. This seems to work fine: he even has his pre-schizophrenia sense of humour back. But now, because he feels well, he occasionally says that he thinks he could manage without the tablets (like me, he is averse to taking unnecessary medication). I do all I can to persuade him to continue to take them.

  6. Furor Teutonicus says:

    Pods. Try and keep him on them. My Brother-in-law died about threew months ago becuse he did not take his medication. Last week, I was told I now have to inject insulin..
    Different illnesses, I know, but it is important to give SOME trust to your doctor, even if it is sometimes a pain in the arse with all the sugar tests, and doctors visits, and tablet taking.

    Good luck, and I hope your partner “gets right”.

  7. Mrs R says:

    Luckily I’ve never been directly affected by this, but have close friends who have. There are indeed whole families of morose people, which can’t be solely down to ‘nurture’. Medication works in almost all cases of those who have sought help and support, talk therapy works in some cases. In others the talking can be a bit like opening Pandora’s Box. The ‘patient’ gets asked to remember and talk about only bad things from their past, and that’s where they focus, and can spiral rapidly downwards because they’re never allowed to talk of the nice things that might have happened in their lives.

  8. Roue le Jour says:

    There seems to be two patient reactions to Prozac. The first, and most common, is that nothing happens for a couple of weeks and then a mood lift is noticed. These patients predictably view Prozac as a mild drug. The second, rarer reaction, is immediate ‘zombification’, lethargy, lack of will and suggestibility. These patients naturally see Prozac as a powerful psychotropic.

    Purely anecdotaly, it seems to me that people who benefit from Prozac all fall in the first group. The standard advice to ignore side effects seems to me to be quite wrong. People who have an immediate bad reaction to Prozac should not take it, it is probably only going to make things worse.

  9. Furor Teutonicus says:

    XX There seems to be two patient reactions to Prozac.

    Comment by Roue le Jour — June 22, 2010 XX

    Three. See my post above. I have heard other people say they drove them beserk, as well.

  10. Roue le Jour says:

    Furor, did you experience any side effects immediately on taking it? I approached Prozac with a positive attitude as I have a friend who swears it is a life changer. I was a completely unprepared for the devastating zombie effect. As soon as I arrived at work everyone said how awful I looked. I mumbled something about a virus and pretended to work, but I couldn’t actually do anything. But the thing that really, really scared me was the suggestibility. While I was under the influence of the drug, pressing on and hoping the side effects would abate seemed a reasonable course of action. Once it had worn off, the idea was totally ridiculous. To this day I tremble to think about what would have happened if the first one hadn’t worn off before it was time to take the second.

  11. Furor Teutonicus says:

    I don’t disagree that it can be a GREAT help to people.

    For me, however, it just sent me “overboard”, after about five days (Xeroxat (sp?) did similar).

    Something to watch for.

  12. Furor Teutonicus says:

    Roue le Jour.

    Na good. Five days may not be a long time. ButI did try them a second time, for three or four weeks. It was O.K at first. But these “anger attacks” became more and more regular, AND more intense.

    Just MY experience.

    As I said, for some people they are a bloody “Godsend”.

    It IS, however, something for any one taking them, plus their family and friends, to watch out for.

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