Tuesday, April 25, 2017
Blog post 1 -- Ordinary Well
In Ordinarily Well by Dr. Peter Kramer, a practicing psychiatrist and Brown Medical School professor, lays out his support for the efficacy of antidepressants. Through a series of vignettes, the doctor seeks to address this main point: do antidepressants work? After Kramer’s close friend, Alan, had suffered from a stroke, Kramer recalled a medical study that examined stroke victims who received either Prozac or placebo to aid with their recovery. The patients who got Prozac recovered more arm and leg movement compared to the patients on placebo. Alan hadn’t been offered medication, so Kramer insisted he should bring this up to his treatment team. Antidepressants were added to Alan’s recovery plan, along with physical therapy, and he began to recover movement of his right leg within weeks.
During this ordeal, Kramer had a “disturbing interchange with a neurologist involved in Alan’s care.” The neurologist opined the antidepressants were “little better than placebos,” and he cited a news article that declared medication was effective only for very severe depression. Kramer read the news articles; in 2010 several news magazines ran articles that suggested “antidepressants may be little more effective than a sugar pill in most patients who take them.” Kramer, having worked with patients on antidepressants for over four decades, encountered the question of placebo regularly and recognized the growing mistrust of medication.
In 1998, an essay titled “Listening to Prozac but Hearing Placebo” which referenced Kramer’s book, utilized a peculiar selection of data to contend that antidepressants were more ineffective than previously thought. Kramer considered the piece a provocation but he did not respond. In 2011, he was approached to a write a piece for The New York Times to comment on the efficacy of Prozac, Zoloft, Lexapro, and other drugs, and adapt content when relevant news surfaced. Marcia Angell, a “formidable figure” who had served as provisional editor of The New England Journal of Medicine and was a stanch advocate of evidence-based medicine, penned a critical review of psychiatry. Drawing on a book that equalized antidepressants with placebos, Angell summarized her view as “psychotic drug are useless.. or worse than useless.”
Kramer responded with an article in the Times debunking her argument and asserted antidepressants were as “beneficial as most treatments that doctors are content to use.” In a letter to the editor, Angell rehashed her claim and contended that anecdotes do not supplement controlled clinical trials. Kramer had used Alan’s progress to support his views and drew on a controlled study from The Lancet: Neurology. Kramer wondered, “had I not shown myself to be Angell’s colleague — like her, a doctor obsessed with scrupulous experiments?” It now seemed the Angell and Kramer were in a “boxing match” and Angell continued with her view point that doctors should not use anecdotal clinical experience because it could mislead them and advised instead to have faith in “in rigorous, randomized, double blind, controlled clinical trials, and that’s the only way we can get at the facts.” Kramer was agitated by the suggestion that psychiatrist ignorable valuable clinical trials. Like many doctors, he kept up-to-date on research results but he “read them in the context” of what he saw in daily work.
Angell’s reply to Kramer’s essays clarified his task for him; he had to issues to undertake: answering the do-they-work question and elaborating on the thought process of doctors in the moment of decision making. I believe Kramer’s focus on the stories of the patients is vital; clinical tests are critical to establish medical integrity but to disregard the clinical observations of a practicing psychiatrist, like Angell supports, is silly.