Jung At Heart

...Ramblings About Psychotherapy and Whatever Else Comes to Mind...

Does Big Pharma Lie?

Yes it does. And it exaggerates.

I have written about this several times before knowing that I am fighting a strong current when I do. A while back Medscape, which requires free subscription to access, reports on an essay in Public Library of Science (PLoS)  looking at the claims that depression is a chemical imbalance:

The evidence that is usually used to support the claim of a serotonin imbalance... is the efficacy of SSRIs. Because SSRIs have an effect on depression, and SSRIs affect serotonin, the conclusion touted in the ads is that depression is due to serotonin imbalance. However, this line of reasoning may be inherently flawed; aspirin may relieve headache, but we do not therefore conclude that headaches are caused by low levels of aspirin in the brain.

Another difficulty with using the efficacy of SSRIs in depression to bolster the serotonin hypothesis is that the efficacy itself is problematic. A meta-analysis cited in the PLoS Medicine essay reviewed all clinical trials of antidepressants submitted to the U.S. Food and Drug Administration (FDA). This meta-analysis showed that placebo duplicated about 80% of the antidepressant response, and that more than half of pharmaceutical company–sponsored trials failed to show a statistically significant difference between antidepressant and placebo. Moreover, antidepressants that do not affect serotonin are as effective as SSRIs in reducing symptoms of depression, and even placebo and nonpharmacologic treatments have been shown to have robust effects.

"The etiology of depression and anxiety is still a mystery, and this is reflected in the scientific literature," senior author Jonathan Leo, PhD, a professor of neuroanatomy at Lake Erie College of Osteopathic Medicine in Bradenton, Florida, told Medscape. "The Diagnostic and Statistical Manual of Mental Disorders does not list serotonin as a cause of any mental disorder; it is simply one neurotransmitter that continues to be investigated. And the prescribing information for the SSRIs does not claim that their mechanism of action is to correct a chemical imbalance, although this is exactly what the advertisements claim."

Most consumers and not a few professionals would be surprised to learn that there is no clear causative link between serotonin and depression. These days depression is most commonly discussed as a "chemical imbalance" which has greatly facilitated the turn to medication without psychotherapy as the first line of treatment for depression. Because of course, chemical imbalances are best treated with chemicals.

Now, the FDA is supposed to regulate the kinds of drug ads we see on television, what they call Direct to Consumer Advertising (DCTA). And this should mean that any and all claims must be verified and verifiable.

"I don't really think [DTCA statements about serotonin in depression] are untrue, especially if they are presented with qualifiers such as 'research suggests' and 'scientists believe,' but they might be bordering a little on unbalanced, so I think the FDA could be doing a little better in this regard," Dr. McCarter said. "By implying that depression is 'only' a chemical imbalance, [the ads] are leaving out very important aspects of the depression story. A 'balanced' statement on the etiology and treatment of depression directed at consumers should note that certain forms of counseling or psychotherapy, in particular cognitive-behavioral therapy, is equally effective in the treatment of major depression as antidepressant medication, and that together they are even better."

Hmmm, I can't remember ever seeing an ad for Prozac or Zoloft or any of the SSRIs in which there is any mention of psychotherapy, much less that meds are most effective in combination with psychotherapy.

The article concludes --

"In terms of real-life effects of this advertising, we are concerned that this oversimplified theory has become the intellectual justification for 10-minute office visits which result in the prescription of antidepressants for a variety of ill-defined conditions," Mr. Lacasse concluded. "In general, people need to be more skeptical regarding claims of chemical imbalance as explanation for psychological distress."

I keep coming back to the meta-analysis which shows no significant difference in effect between SSRIs and placebo. I first read of this more than 5 years ago in an earlier study using meta-analysis. The title of that article, "Listening to Prozac, Hearing Placebo" captures it well. But with so much of research in this arena funded by drug companies, it is no wonder that these results get so little play. Big money has led most of us to believe that science has demonstrated that depression is due to a chemical imbalance and that pills will right that imbalance and make everyone happy.

Why isn't there more noise out there about this?

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