The pain of this kind of depression feels like an unbearable pressure. Most people don't understand that the impulse to kill oneself doesn't typically arise in some kind of existential debate with the self about the value of life. All of my fantasies about killing myself were to bring a violent end to my suffering. I yearned for the moment the bullet struck my brain and, in a blinding light, ended the pressure inside my head. The fact that I would die in the process didn't matter.
My therapist made a pact with me. I would go on an antidepressant for a month before making a definite decision to kill myself. The first antidepressant I took was an older one and I later switched to Prozac. I remember the precise moment the antidepressant kicked in. I was talking to some people and, suddenly, I felt as though an engine in my chest -- my heart? -- turned on. I remember thinking, "So this is how other people feel." With Prozac, things began to change radically in other ways. I became more productive and sociable than I'd been in years, for example. Soon afterward, I interviewed Peter Kramer, author of Listening to Prozac, and discovered that I was experiencing what he termed "cosmetic effects" of the drug.
Prozac, in short, saved my life. Many of the cosmetic effects eventually wore off, and never really returned when I experimented with related drugs, but Prozac certainly left me with a real template for a better life.
Now antidepressants are under attack. Ironically, the reason is a reprise of a debate in 1991 when the Federal Drug Administration convened a panel to evaluate claims that Prozac and drugs like it could cause suicide and suicidal thinking.
That panel cleared the drugs -- members of the class called selective serotonin reuptake inhibitors -- and many millions of people like me have taken the drugs since. In June, however, British drug authorities reported that nine studies of Paxil, a cousin of Prozac, demonstrate that the drug causes adolescents to consider suicide at 3.2 times the rate of patients given placebos, especially during the first weeks of treatment. The FDA has endorsed the Brits' findings, which also include the news that Paxil is generally no more effective than a placebo in treating depression in young patients.
Not surprisingly, the regulating agencies have urged doctors to discontinue prescribing Paxil for young patients.
Perhaps the most disturbing aspect of this story, reported in the New York Times Aug. 7, is that Paxil's manufacturer conducted the nine studies itself and withheld all but one from publication. Thus doctors and the public have been led to believe the drug is safer for use among kids than it is. This bizarre situation, by which drug makers don't have to publicly disclose all results of studies, obviously can make mediocre drugs look like miracle cures.
In fact, most recent studies report that antidepressants on average reduce symptoms by 41 percent -- a mediocre statistic that grows even less impressive when you read that patients taking placebos have a 31 percent reduction. That means, basically, that the drugs don't work that much better than a sugar pill for a lot of people. And they don't work at all for many others. I was lucky.
Nobody suggests we discontinue the use of antidepressants. What has happened, though, is that the drugs have come to acquire such miracle status that insurance companies, true to the apparent intention of their makers' exaggerated claims, favor them over psychotherapy. Indeed, a growing number of companies won't even pay for therapy -- and even when they do, it's typically for short-term work, whose practitioners have generated their own mythology of miracle cures in recent years.
What we do know is that combined therapy is the best treatment for depression. The mean success rate for patients taking antidepressants alone is about 40 percent. It rises to 60 percent when regular psychotherapy is added. Not bad, but far from a miracle. We also know depression recurs in 75 percent of patients. But we know that depression recurs in 102 weeks on average among medicated people who go regularly to therapy, while it recurs in only 18 weeks for those with little or no therapy.
One has to grant that many people with ordinary sadness are being inappropriately prescribed antidepressants. After all, the majority of the drugs are prescribed by general practitioners with no involvement of mental health specialists. But these statistics still leave an enormous number of patients without much help under the psychology business' own best-case scenario. It's yet another reason we need to be looking deeper at our definitions of depression, its roots in culture and the ways pharmacology and psychotherapy still remain ineffective for many people.
Cliff Bostock's website is www.soulworks.net.
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