Placebo Nation



Over the past decade, psychiatrists and the news media have proclaimed the wonders of Prozac and the rest of a new generation of antidepressant drugs, known collectively as selective serotonin reuptake inhibitors. Now a report from the United States Department of Health and Human Services has confirmed what has long been an open secret among mental-illness  researchers: the S.S.R.I.'s are no more effective at treating depression than older classes of drugs,like tricyclics.

Buried within this report is a larger and more disturbing story. During the past century, while scientists have acquired ever more detailed information about the brain with ever more powerful technologies, there have been virtually no genuine advances in treatments for depression and other common mental disorders. From psychoanalysis to Prozac, all the therapies offered so far are roughly equivalent in their effectiveness, or lack thereof. Roughly two-thirds of patients receiving any form of treatment for depression show some improvement. On the other hand, as many as half of those who don't receive treatment improve anyhow.

The most common therapy in the first half of this century was the talking cure, popularized by Freud. There are now hundreds of talking cures, from Jungian dreamwork to cognitive behavioral therapy. Although each is touted as an improvement over its predecessors, scientific tests have found that all psychotherapies are basically equal.

The advent of drugs like tricyclics in the 1950's was initially seen as an enormous advance beyond psychotherapy in treating depression. In fact, various studies say that antidepressants and psychotherapy produce more or less the same outcomes.

The new report, summarizing many studies, concludes that about 50 percent of severely depressed patients taking the drugs improve, versus 32 percent of those taking a placebo. Even this apparent advantage may be illusory, according to researchers like Roger Greenberg, a psychologist at the State University of New York Health Science Center at Syracuse.

Clinical trials are supposedly double blind: neither the test subjects nor the researchers are told who is receiving the drug and who is receiving a placebo. But because all psychiatric drugs have side effects -- like dry mouth, constipation and sexual dysfunction -- both patients and researchers invariably see through the double blind, according to Dr. Greenberg. When patients realize they are taking the real drug, the placebo effect is especially strong, particularly if they have read books and magazine articles lauding the medication.

At least one prominent psychiatrist, Walter Brown of Brown University, has proposed that placebo pills be the initial treatment for patients with mild or moderate depression. Physicians would tell patients, in effect, "These pills have no active ingredients, but studies show they help in many cases." Dr. Brown cites evidence that patients will respond to placebo pills even after being told this.

A more time-tested method for achieving relief was highlighted by a recent study at Duke University. Researchers examined 87 depressed, elderly patients, about half of whom were receiving psychotherapy, antidepressants or a combination of the two. The best predictor of improvement was not these expensive remedies but the "religiosity" of the patient.

The psychiatrist Jerome Frank warned in his classic book "Persuasion and Healing" that the placebo effect might be the primary factor underlying all psychiatric remedies. The latest research supports Dr. Frank's finding: psychiatrists, psychologists and other "scientific" healers are really exploiting the power of human belief, just as shamans and witch doctors do.


John Horgan - author of `The End of Science' and, forthcoming `The Undiscovered Mind.'

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