I've often felt that there should be an Anti-Nobel Prize for Medicine. This would be given not for discovering something new, but for discovering that something we believed deeply wasn't true. If there were such an award, Irving Kirsch would be up for it.
We have known some fundamentals about depression for decades: It is caused by a biochemical imbalance, the imbalance is in the serotonergic system, antidepressant drugs targeting this system somehow correct the problem, and they do so safely and with an excellent risk to benefit ratio. As the data have accumulated, however, the elegance and sense of these ideas have given way to confusion. In terms of Kuhn's concept of paradigm shifts, the evidence is tilting us uncomfortably from a belief in the origins, nature, and pharmacological treatment of clinical depression, toward a period of confusion where the older ideas collapse but have yet to be replaced by a newer model.
Few have done more elegant and powerful work in this area than Kirsch. As a psychologist specializing in depression, I have followed his articles closely since his work on this topic began coming out over ten years ago. As you read the book, you can begin to get a small chirping annoyance that takes a while to find its way into awareness. With all due respect to Kirsch: "This seems like good work, but it's not exactly rocket science. It's a bit obvious to go back and look at all the data to see what has actually been done, which of it has been published, and what it actually shows in terms of effectiveness. How is it that no one did this before?" You are led to two possibilities: Either people connected with the work see the problems and ignore them, or the quality of the science in this field is pretty low. And if it's this low for antidepressants, then...?
Kirsch writes in a beautifully clear style, carefully stating each problem, the means to investigate it, and the outcomes of the analysis. He does so in a very accessible way. No one should have difficulty understanding the implications or following how he reaches his conclusions.
I'm not certain, but I don't believe I have ever used the term "required reading" in a review before, either on Amazon or elsewhere (I may be mistaken). For mental health professionals and for all prescribers, THIS book (or the peer-reviewed research on which it is based) should be required reading. For those suffering from depression, I have to say it's a discouraging read, both because of the pessimistic conclusions toward which the data inevitably point, but also because it casts the fields of psychopharmacology and mental health in such an unflattering light.
The goal of some forms of therapy is to relinquish one's illusions. Disillusionment is painful medicine, but it may be more helpful than what we have so far been dishing out.
