Antidepressant Effectiveness and False Dualism: It's Time for a New Psychiatry

The JAMA study on the effectiveness of antidepressants has occupied everybody's attention--though perhaps excessively in light of the catastrophe in Haiti. I just read Richard Friedman's response to the study in the New York Times and I agreed with his argument, in which he criticizes the study's methodology, arguing that it is based on a relatively small number of studies, and that studies were chosen that maximize, rather than minimize, the placebo effect.

As I review the various comments about the study, both on my blog and elsewhere, what strikes me is how polarized the debate has become. On one side are those who defend the efficacy of drugs, and on the other side are those who denigrate the medication option and argue that psychotherapy is the true cure for depression. This is yet another version of the old and tiresome nature vs. nurture debate, which has been a staple of the rancorous psychiatrist vs. psychologist turf wars ever since I started my residency at Mass General in 1992.

In one corner of the boxing ring are those "biological psychiatrists" who argue that depression is essentially a biochemical disorder that is logically treated using agents that adjust the biochemistry. In the other corner are those who argue that depression is a response to life stress and is best treated by therapy techniques that help people cope.

But this dualism is illusory. When people become depressed, yes, their brains are disordered in some still mysterious way. The idea that a serotonin deficiency is responsible is only a hypothesis and one that has been weakened over the years by studies failing to demonstrate such a biochemical imbalance. I have confidence that someday we will locate the brain circuits involved and that we will be able to rationally target them with biological cures. But we are still very far from that; the current crop of antidepressants work on neurotransmitters but they may help depression through mechanisms that have little to do with serotonin or norepinephrine.

Meanwhile, we know that many people recover from depression without taking antidepressants--via the passage of time, or psychotherapy, or a placebo pill, etc.... PET scans have shown that cognitive behavior therapy leads to distinct brain changes in patients who recover from depression. Clearly, there are multiple different pathways leading to a "neurobiological" cure.

So my question is, why don't we embrace all these potential cures rather than lining up behind our favorite technique to defend its merits? Drugs work. Therapy works. Time works. And placebos work. If psychiatrists and psychologists could possibly call a truce in their various battles over therapy effectiveness and prescription privileges, we might be able to imagine a different kind of practitioner--one who is skilled in both psychopharmacology and psychotherapy. Isn't this the kind of doctor we would all want to see when it's our turn to get help?