266 of 282 people found the following review helpful
on February 12, 2010
I have conflicts of interest to declare. I'm a physician but I also write. I share a publisher (Random House UK) with Irving Kirsch and have written for them about the damage done by doctors who don't subject their ideas to reliable tests. Because of this I was asked if I'd provide a recommendation to go on the dust jacket of Kirsch's book. I was familiar with his work, having read his medical journal articles analysing the evidence behind antidepressant tablets. On that basis I sat down to his book expecting that I'd probably be able to say something nice about it. I thought it'd most likely amount to saying that Kirsch's research is important and interesting and should be mandatory for doctors involved with antidepressant prescriptions.
This book, though, isn't worthy & technical - it's fascinating. It's a remarkably readable account of how we got carried away with an idea about the brain that isn't true. You don't need to have an interest in depression and you don't have to be a medic; this is a thoughtful look at how bright & well-meaning people get enchanted with an idea & go on to fool themselves and everyone else. It isn't a doctor-bashing book, nor one that pushes the author's own pet therapy. Instead it gives a lovely insight into the way science works, and the way it can sometimes gets done so badly that it doesn't work at all. Kirsch argues antidepressant tablets are based on a false pharmacological model of the brain, and that the balance of evidence shows they don't work except as placebos. Even if you're not persuaded by Kirsch's thesis - and I think you should be - you'll find his ideas thought-provoking.
For most of human history, going to see a doctor was a bad move. We did more harm than good. We trusted our intuitions instead of performing experiments capable of testing them. The people who used leeches for thousands of years were smart, motivated and thoughtful and they killed their patients. They believed they could figure out what worked without decent scientific method, even when the nature of that method was widely understood. Kirsch's modern story gives an insight into why we used to be so bad and it reminds us we're still a long way off being perfect. An enjoyable and an intellectually captivating read.
89 of 94 people found the following review helpful
on September 21, 2010
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.
59 of 65 people found the following review helpful
Irving Kirsch presents exquisite and exhaustive research which concludes antidepressant drugs are in fact, placebos. He explains why and how placebos work. He argues against the chemical imbalance theory of depression and says it has never been proven. He also compares outcomes of Cognitive Behavioral therapy with and without antidepressant medication and concludes that a patient's "hope" for recovery is the fulcrum on which successful treatment rests. As a clinician, I have experienced the power of hope in alleviating suffering in moderately and severely depressed diagnosed patients and those in the throes of an existential crisis, which often is misdiagnosed as depression or an anxiety disorder. Sometimes in treatment, less is more. Kirsch states that SSRIs can help ... as much as any placebo... but instilling hope in a patient is what really works; there are no detrimental side effects, and hope and tools aquired in CBT have been shown to have more lasting results.
24 of 24 people found the following review helpful
on December 6, 2011
I am a Senior Ombudsman in the State of California, which means I go out to care homes for the elderly, inspect, and take complaints.
I got this book because of a seminar on the elderly being over medicated. I see it every time I go out. It is sad to see people looking up at the ceiling, comatose, withering away. And at the heart of it for many people is over medication.
The book is well researched and accurate. It is readable. But it is not pleasant reading because it is the truth. It made me angry.
28 of 32 people found the following review helpful
on March 15, 2011
It's common knowledge now that antidepressants are no better than placebo for the majority of patients. It's true that antidepressants successfully treat depression. The problem is that sugar pills ("placebos") also successfully treat depression, and the sugar pills are about as effective as antidepressants, without any of the drugs' side effects.
Irving Kirsch, a researcher who pioneered the use of meta-analysis in studying antidepressants, writes about the chimera of antidepressant effectiveness in his book. Kirsch's main argument is that placebos are effective treatments for depression, and that antidepressants add very little except side effects.
After analyzing 38 clinical trials involving more than 3000 depressed patients, Kirsch found that only 25% of the benefit of antidepressant treatment was due to the drug effect. The placebo effect, the patient's hope that he will improve from treatment, was twice as powerful as the drug effect.
When analyzing the data, Kirsch also found that the newer antidepressants (e.g. SSRI's) were no better than the older antidepressants. Even more surprisingly, he found that sedatives, barbiturates, antipsychotic drugs, stimulants, opiates, and thyroid medications were as effective as antidepressants in treating depression. The only thing that these drugs have in common is that they produce easily noticeable side effects. Kirsch explains that in a clinical trial, patients are randomly assigned to either a treatment (drug) group or a placebo group. If the patient knows that he's been assigned the drug, he'll feel more hopeful and optimistic--i.e. he'll feel less depressed. Since the studies are supposed to be double-blind, the only way the patient can know this is if he gets side effects. If he tells his doctor about the side effects, then the doctor will also know that he's been assigned the treatment. The doctor may have a different attitude toward the patient if he knows that he's been assigned the treatment. So the supposedly double-blind study isn't really double-blind. That's the reason why the other drugs also were effective for depression. Any drug that causes side effects will make both the patient and doctor more confident and hopeful, since the side effects make them know that the patient is receiving the actual treatment. The placebo effect, not the chemical action of the drug, treats the depression.
As part of his research project, Kirsch used the Freedom of Information Act to obtain unpublished clinical trial studies from the FDA. Combining this data with the published studies, Kirsch found that the drug effect was less than 20%. By contrast, the drug effect for pain medication is about 50%. Kirsch also found that the therapeutic effect of antidepressants, unlike most other medications, is not dose dependent. Higher doses of antidepressants produce more side effects, but don't reduce the symptoms of depression more than lower doses.
These above-mentioned results were well known by researchers, regulatory agencies, and drug companies, but not by most doctors and patients. Pharmaceutical companies have used some tricks to keep this "dirty little secret" from the general public, including:
1) Withholding negative studies from publication
2) Publishing positive studies multiple times
3) Publishing only some of the results from multi-site studies
4) Publishing data that was different from what they submitted to the FDA
Why were the drugs approved, when they show so little benefit over placebo? Regulators only require two clinical trials having positive results. Negative trials don't count. Drug companies can conduct as many trials as they want until they find two with positive results. Kirsch calls this "voodoo science." It makes things too easy for drug companies.
In the last three chapters, Kirsch discusses at length the placebo effect. Placebo effects are examples of how suggestion can change how people feel and behave. Expectancies are important in placebo effects. If people expect to get better, depending on how strong they believe this, and what kind of disorder they have, there's a chance that they will get better. Depression and pain are two disorders that respond well to placebos.
Since placebos work so well for depression, why not prescribe placebo pills to depressed patients instead of medications? Placebo pills are cheaper and don't have any side effects. Kirsch argues that this is wrong because it involves deception. A better alternative is psychotherapy, especially cognitive-behavioral therapy. Therapy is the "quintessential placebo," a treatment that utilizes the placebo effect (i.e. the relationship between therapist and client, and the client's expectancies of getting better), but does so without deception. Psychotherapy has a number of advantages over medication, including no side effects, reduced likelihood of relapse, and less long-term cost.
One problem with this book is that Kirsch seems to think that placebos will effectively treat all kinds of depression, including the more severe kinds. He acknowledges that the placebo response is reduced for the most severe types of depression. In other words, medications are more effective relative to placebos for the most severely depressed. He explains this by saying that because the severely depressed patients are more likely to have been on antidepressant medication before, and have higher dosages prescribed, they can more easily recognize whether they are on the actual drug or placebo. This will reduce the placebo effect for those assigned the sugar pill, which means that the drug effect is really a placebo effect in disguise. I don't agree with this explanation. I think that some of the severe types of depression are biologically based, not responsive to placebos, but responsive to antidepressant medication.
In conclusion, "The Emperor's New Drugs" is an excellent account of the ineffectiveness of antidepressants, written by a pioneering researcher. It makes one wonder how so many people were fooled for so long into thinking that antidepressants treated patients by correcting chemical imbalances. Its weakness is that the author doesn't distinguish between the majority of cases of mild to moderate depression in which drugs are no more effective than placebo, and the small number of biologically-based more severe cases in which placebos aren't effective, but drugs are.
10 of 10 people found the following review helpful
on August 21, 2011
This is a well researched book that provides shattering evidence from the drug companies own data that convincingly demonstrates that anti depressant medications are no better than placebos.
I could not put the book down, and afterwards felt compelled to take action regarding the colossal waste of time and money that has been put into these medications and into fooling governments and the medical profession that they work.
I found the book well written, and covers the complex territory in an informative way that can be understood by non professional people. It avoids the sensationalism of the topic by being understated, without the need to provide personal touch case stories to embellish what is a compelling story anyway. I have to invoke the cliche that this is a "life changing" book for anyone who has been touched by the medical profession in the realm of psychiatry.
10 of 11 people found the following review helpful
on August 28, 2012
I read this book recently after having already read Anatomy of an Epidemic a couple years ago. Because I had already read Whitaker's book first, I didn't expect to learn nearly as much from this book as I did. In fact the two books were very different, and there wasn't even significant overlap. Essentially Robert Whitaker's book looks mostly at the idea that most psychiatric drugs show no benefits over long term use, and most of them are actually probably quite harmful. Whitaker draws on a variety of different types of data to support this hypothesis, including clinical studies, epidemiological data, comparisons with third-world countries, the rebound theory, patient reports, etc.
Kirsch on the other hand is mostly focused on whether or not antidepressants are superior to placebos. He concludes that they are not, based mostly on clinical trials. He also completely debunks the monoamine hypothesis, which is the theory that depression is caused by a chemical imbalance. Whitaker does this too, but Kirsch is actually much more thorough on this point. Kirsch also explains many problems with the FDA drug approval process, some of which Whitaker touches on, but most of which are different. In short this is a highly informative book, even if you have already read Anatomy of an Epidemic. In fact, I would strongly recommend reading them both, as you'll have a much better understanding of mental illness than if you read only one. (And, as a free bonus, if you want a third book recommendation then I'd go with Crazy Like Us by Ethan Watters, which is another must-read if you really want to understand this stuff.)
19 of 23 people found the following review helpful
on September 16, 2010
Drug companies need to generate two clinical trials that demonstrate statistically significant improvement of their drugs over placebo to get FDA approval. There are several issues with this protocol. The first is that statistical significance is easy to reach with a large sample; and, it can be associated with a trivial difference between drug and placebo. The second one is that the drug companies can repeat clinical trials until they get the results they need by disregarding the trials that failed to show drug benefits. Drug companies hide 40% of the clinical trials (the ones that failed) from the health-care community and the public. As a result, the FDA approves anti-depressants that are no better than placebo. Doctors and patients have no idea of the industry's admitted own "dirty little secret."
Kirsch uncovers a classic conflict of interest between the FDA's mission to protect the public and its funding sources provided by drug companies. Kirsch mentions an FDA researcher who is reminded that the FDA's customers are the drug companies. Stunned the researcher responds: "I thought it was the public." Soon after, he left the FDA. The ones who stay don't question the mentioned conflict of interest. This is a caveat emptor whenever you see the label "FDA approved."
Kirsch was able to cut through this fog by using the Freedom of Information Act to obtain from the FDA the data on 38 unpublished clinical trials. He then conducted three meta-analysis between 1999 and 2008 by using the data from the published trials and the 38 unpublished ones. And, he invariably got the same overall results.
His main finding is that all anti-depressants are no better than placebo. Kirsch fleshes out what that really means. The drugs performed a bit better than passive placebo as the latter accounted for 75% of the drug benefits (see graph on page 10). The reason the drugs performed better is because they had stronger side effects. The latter signaled to the patients in the clinical trials that they were receiving an active drug and not a placebo. And, it changed their expectations which triggered an extra-strength placebo effect. He was able to measure this in two ways. The first one was by adjusting the results by factoring the difference in side effects. Once adjusted for the difference in side effects, the drugs showed no difference vs passive placebo. The second one was by focusing on trials that compared an anti-depressant vs another active drug which had similar side effects that was not an anti-depressant (active placebo). Invariably, the anti-depressant did not perform better than an active placebo. He proposed to drug companies to test this a third way by using a balanced placebo experimental design (pg 78). This method allows you to disaggregate precisely the passive placebo-, active placebo-, and drug-effect. But, the drug companies showed no interest. They knew their drugs would certainly not pass Kirsch test that explicitly factor the active placebo effect.
Kirsch states that anti-depressants are not good for you. He recognizes that many doctors and patients feel that if they work (regardless if 100% of the effect is due to placebo) why not use them. Well the reason is that they have nasty side effects including suicide, and akathisia that leads to violent behavior.
Kirsch shares how other researchers who confirmed his findings have been ostracized by the medical establishment. This entailed losing jop opportunities and being threatened to lose grants. This has not deterred the self-assured Kirsch one bit as he conclude the book by stating: "I also enjoy rocking boats, especially when they are in need of sinking."
As a better alternative to drugs he recommends cognitive-behavioral therapy (CBT). CBT has been abundantly tested. It works a heck of a lot better than drugs in the long term; and, it has no side effect. CBT is a learning experience so improvements are not dependent on an external placebo effect that subsides the minute patients stop taking the drug. CBT can even work without a therapist. He strongly recommends two CBT books: Feeling Good: The New Mood Therapy Revised and Updated and Control Your Depression, Rev'd Ed. Both books have been clinically tested. And, they found that patients who read and applied the principles from those books fared over the long term as well as the ones who followed CBT with a therapist. He also recommends exercise that has proven effective in treating depression. The advantage of exercise is that it has a multitude of positive side effects including overall well being, longer life span, increased cardio vascular capacity, improved cognitive functions. He also states that the herbal remedy St. John Wort is as effective as anti-depressants with fewer and milder side effects.
Kirsch dismantles the myth of chemical imbalance in the brain. This theory states that depression is caused by a deficit of neurotransmitters (serotonin) in the brain. Anti-depressants (Prozac, Paxil) focus on boosting serotonin levels. Yet, many studies for decades have confirmed that levels of serotonin have no influence on depression. Even more baffling, a French drug company developed an anti-depressant that lowered serotonin level instead of increasing it. In trials, it was just as successful as Prozac and Paxil that boosts serotonin level. Thus, drugs that either increase, decrease, or do not affect (active placebo) serotonin levels all have identical effect on patients. Thus, it is not the serotonin level that affects the patient, it is simply the active placebo effect. Therefore, the concept that anti-depressants can cure depression chemically is plain wrong.
Kirsch explores the placebo effect in different domains. He found that knee arthroscopic surgery worked actually worst than a placebo surgery (they really did that). Arthroscopic surgeons fought the results of the study. But, a second study generated the exact same results. Unfortunately, very few surgeries are tested against placebo. And, as shown even when tested the medical profession ignores the results. The pocketbook prevails over the science and the stockholder over the patient.
If you enjoy this book, I also strongly recommend: Overtreated: Why Too Much Medicine Is Making Us Sicker and Poorer,Worried Sick: A Prescription for Health in an Overtreated America (H. Eugene and Lillian Youngs Lehman), and The Last Well Person: How to Stay Well Despite the Health-Care System.
12 of 14 people found the following review helpful
on December 13, 2010
This book looks so thoroughly at the "reality" of depression, brain chemistry & drugs that it's jarring. The author is evenhanded and grounded in his approach. He comes off as someone who wants to do an altruistic thing - halt worldwide brainwashing and institute some genuine paradigm change.
So many of us suffer from depression these days. I believe it's vital to look closely @ the phenomena and what we can do to help people - from a grounded standpoint. This book provides a wonderful service by helping us question our clinging to simplistic solutions to complex problems. Depression can be helped, but by masking it we are not doing ourselves a real service.
Kirsh is one of those authors that really just lays it all out there for you to see for yourself - with all those crunchy references. Those references are important because they let us know it's NOT just some guy writing down his opinion. Instead, the author is a person who cares to surround himself in the good work of others. This, to my mind, reflects integrity.
As a consequence, Kirsh writes with authority that is compelling. I recommend this book along with a request; please do the same study for anxiolytics. I've believed for a long time that the same data that's true about antidepressants is also true about anxiolytics. So if we're really going to turn this on it's ear, let's do the two major bad boys. Let's start to look into what can work to help these issues.
If we want to begin looking for genuine solutions to mental health issues, we need to de-hypnotize ourselves first. As long as we are quelled into believing in fairy tales, we won't respond with urgency in trying to solve these common and debilitating problems. So please Mr. Kirsh, do this study on anxiolytics too. Of course, we need to re-think the way we depend on many drug classes. But if we could just crack the delusion of the two most common drug classes, I believe the whole thing may come down. Then we can be a bit closer to reality - provided we don't let ourselves be easily cajoled again.
So, don't let yourself be bamboozled - read this book and be enlightened.
Enjoy the read!
17 of 21 people found the following review helpful
on March 23, 2010
I'm glad I read this book, as it is a fearless critique of the current crazefor prescribing antidepressants for patients even slightly depressed. Kirsch makes the convincing case, with empirical evidence, that antidepressants do not work significantly better than placebos in the vast majority of patients. He also attacks the common belief that depression is a brain disorder. It is a fascinating read--especially the part on "placebo surgery"-- that I highly recommend to anyone who is depressed and seeking help. What you know may not necessarily be so.