Sunday Dialogue: Seeking a Path Through Depressions Landscape

Do antidepressants work? Doctors and patients respond to a letter on Wednesday that questioned their liberal use.



To the Editor:

In Defense of Antidepressants,” by Peter D. Kramer (Sunday Review, July 10), reflects a high-stakes battle involving pharmaceutical companies, health care providers and patients.

Do antidepressants work? Doctors and patients respond to a letter on Wednesday that questioned their liberal use.


To the Editor:

In Defense of Antidepressants,” by Peter D. Kramer (Sunday Review, July 10), reflects a high-stakes battle involving pharmaceutical companies, health care providers and patients.

Billions in profits are at stake for the drug industry, which has sometimes suppressed negative data about antidepressants. Doctors have financial incentives to treat depression pharmacologically because quick medication evaluations are more profitable than more time-consuming psychotherapeutic treatment.  And then there are some practitioners wedded to psychological treatments who are eager to debunk the supposed superiority of pharmacologic treatment in part to expand their own practices.

While this battle rages, we must not lose sight of the patient. The arguments are complex, and a clear answer to whether antidepressants will work for an individual patient is often not easy to find. The data used and analyzed in the various studies — highly sophisticated and often not comparable — are not easy for patients or even practitioners to decipher.

What is a patient to do?

I would suggest to those suffering from depression that they find a provider who is willing to listen, asks probing questions about how well they are responding, spends an appropriate amount of time, is willing to switch course if they don’t improve, and is even willing to consult with another expert colleague. Fortunately many patients will improve over time.

Pasadena, Calif., July 12, 2011

The writer is president of the American Psychoanalytic Association and a clinical professor of psychiatry at David Geffen School of Medicine, U.C.L.A.


As a professional ethicist, I share Dr. Procci’s concerns about the medical-pharmaceutical complex and how the obsession with ever-greater profits can hinder, not promote, ethically intelligent patient care.

But as someone who has been using antidepressants successfully for many years, I can say from experience that some of that concern is misplaced. My life is richer and infinitely more satisfying because of this medication. I offer my profound gratitude to the dedicated researchers and conscientious clinicians who have made this possible.

New York, July 13, 2011

Dr. Procci is right that there is a continuing high-stakes battle over the use of psychiatric drugs, but it is more one-sided than he suggests. These drugs are greatly overused, mainly because of the pharmaceutical industry’s influence on the psychiatric profession.

Many have devastating side effects, especially in children and when used long term. Studies generally show that the benefits are small.

Contrary to the arguments of Dr. Kramer, many sound clinical trials have failed to find antidepressants effective at all in mild to moderate depression. Anecdotes of effectiveness are no substitute for clinical trials, since they can’t take into account the placebo effect or how often a drug is ineffective or harmful.

Despite the risks and uncertain benefits, the number of Americans taking psychiatric drugs is soaring, and the heavy reliance on drugs diverts resources from efforts to find better methods of treatment.

Mental illness is a serious problem, but in the absence of sound evidence, we should be skeptical about all treatment claims — particularly those promoted by the pharmaceutical industry.

Cambridge, Mass., July 13, 2011

The writer is a senior lecturer in social medicine at Harvard Medical School and former editor in chief of The New England Journal of Medicine. She is the author of two recent articles on psychiatric drugs in The New York Review of Books.

Dr. Procci’s advice is for the depressed patient to identify the ethical caregiver. That is not so simple in a medical care system that denies access, limits complex consultation, and rewards technology and procedures.

Questions about the efficacy of antidepressants are but one chapter in a larger moral and social tale without clear answers. Except perhaps one: The medical system we have today plainly does not work. What to do next is far more challenging than listening to Prozac.

Seattle, July 13, 2011

The writer is a professor of psychiatry, University of Washington in Seattle.

I agree with Dr. Procci’s suggestion for the type of doctor whom patients should seek, but good luck finding one who practices this philosophy of treatment and is willing to spend so much time with each patient. They do exist, but they’re few and far between.

Then, try to tell an insurance company that longer sessions are more cost effective in the long run and conducive to overall health than the 15-minute sessions with the script writers who ask how you feel on a 1-to-10 scale, then prescribe accordingly. After that, make up the difference between the insurance company’s paltry “reasonable and customary” fee schedule and the actual fee.

Derwood, Md., July 14, 2011

As a practicing psychiatrist, I have found antidepressants to be extremely effective. However, there are two main obstacles to finding an optimal medication regimen for patients: Each patient’s brain circuitry is unique, so what works well for one person may not necessarily do so for another; the severity of mental illness lies on a continuum, influenced by genes, life experiences and personality.

It is extraordinarily difficult, if not impossible, to design a clinical study that can truly take into account all of these differences. Thus, we are left with studies whose results often conflict.

Perhaps in the distant future, we will have a machine that will analyze each patient’s brain and create a customized medication regimen, but until then, clinicians are left with the reality that prescribing medication for depression remains much more of an art than a science.

New York, July 13, 2011

Without antidepressant drugs, there would be no psychiatry. Psychiatrists for more than 20 years, since serotonin-enhancing drugs were introduced, have, for financial reasons, elected to become psychopharmacologists, and many have given up traditional psychotherapy. Instead, they frequently shunt people who require talking therapy to psychologists.

If as suggested by randomized, controlled studies, the placebo response approaches that of the drugs, the individual psychiatrist really has no way to tell whether patients are better because of the drug or simply because they have been prescribed a drug.

If these drugs were taken away from psychiatrists, or if psychologists could legally prescribe these drugs, psychiatry would perish.

Hopatcong, N.J., July 13, 2011

The writer is a clinical associate professor of neurosciences, University of Medicine and Dentistry of New Jersey.

Dr. Procci’s suggestion that people seek help from clinicians who are willing to listen to and work with them is entirely reasonable — as far as it goes. But it does not capture a seismic shift that has been occurring in mental health care.

While the media focus has been on what the professional or the pill is going to do for the suffering person, the emerging recovery movement has made clear what individuals can and must do to help themselves — individually and collectively — and how central self-help and mutual aid are to recovery.

When it comes to dealing with psychiatric challenges, there are no magic doctors or magic pills. There is no effortless recovery.

With this in mind, I would add the following to Dr. Procci’s advice: Seek other people in recovery and recovery-oriented clinicians who can help support you while you learn how to do the work of recovery on your own.

Pittsburgh, July 13, 2011

The writer is an associate professor of psychiatry at the University of Pittsburgh.

When my patients respond to treatment for major depression, as a psychiatrist I am often not sure how much it is from the medication and how much from talking to an empathic listener. For depressions accompanied by agitation and psychosis, it is clear that medication, as part of the treatment regimen, is helpful and essential.

The type of provider that Dr. Procci suggests that patients seek should be a psychiatrist (at least for the initial evaluation) who is adept at both psychotherapy and psychopharmacology. If the depression is mild, I agree with Dr. Kramer that medication should be used sparingly and as a second line.

New York, July 13, 2011

The writer is a former president of the New York County Branch of the American Psychiatric Association.

I’m sure psychoanalysis is a good option for some depressives, those who can afford it. But taking a generic form of Celexa for $4 a month gives me a fighting chance to face my demons on my own, with some help from my friends.

Ames, Iowa, July 13, 2011


I tend to agree with the skeptics who question the efficacy of antidepressants and condemn their prolific use.

Marcia Angell has long highlighted the ways in which the pharmaceutical industry, the psychiatric profession and academia have at times colluded to erode appropriate boundaries.

Another problem is the insurers’ control over access to practitioners and the kind of care they can render.

Kippi Fagerlund poignantly exemplifies how third-party payers relentlessly limit treatment options to those seen as quickly “cost effective,” such as brief medication management visits rather than psychotherapeutic approaches.

Ronnie Stangler rightly sees this as a huge obstacle to quality care. I agree.

The hot crucible of the psychiatrist’s office is far removed from the cool sterility of research labs and academic offices. Patients in real-world settings often do find antidepressants singularly helpful. This doesn’t exonerate the excessive claims of the pharmaceutical industry. It only demonstrates the need for the individual practitioner to maintain his or her focus on the patient’s needs.

The bottom line: We doctors must push our professional organizations to disseminate only the highest quality data, free from conflicts of interest, to assist us in clinical decision making, and we must seek relief from obsessive cost-control management of patient care.

And those suffering from depression should insist on being given access to all available treatments and true information about their efficacy. It is unconscionable for patients to be held hostage to one form of treatment supported by such weak data.


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