This book, written entirely by academic psychologists, is a dose of strong medicine. A critical review of the psychoactive-drug literature, it asserts essentially that there is inadequate scientific information to conclude that psychoactive drugs are substantially more effective than placebos. The editors remind us that the interpretation of any research data is likely to reflect the researcher's bias: in this case, a bias toward biologic treatment, the pharmaceutical industry's financial motives, or both. They say, "We feel it is important to balance this bias by adopting a counterattitude based on a determined skepticism." Their intellectual, scholarly review is difficult to dismiss; yet the reader may feel their conclusions are immoderate.
Part 1 deals with such conceptual issues as the interpretive problems posed by placebo effects and the need for placebo controls. The authors of this section point out that patients' ratings of improvement are often considerably lower than those of the treating therapist. The abrupt cessation of treatment with the drug and the substitution of a placebo are strongly criticized for increasing the likelihood of a relapse and thus strengthening evidence in favor of the drug. The problem of frequent coexisting illness makes it difficult to evaluate the specificity of a drug used for a given diagnostic entity or syndrome.
Robert C. Carson presents a devastating criticism of the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which he describes as representing a "prescientific stage of development with respect to an attempt to bring taxonomic order to aberrant behavioral phenomena." He further states that "research advance in the field is seriously hampered by its [the DSM-IV's] pervasive influence." Carson decries the emphasis of the DSM-IV on reliability and its failure to deal with the question of its validity or its explanatory and predictive power.
Part 2 deals with the efficacy of psychoactive drugs for adults and part 3 with the efficacy of drugs for children. Part 4 presents an overview and conclusions.
In their discussion of adult depression, Seymour Fisher and Roger P. Greenberg note that short-term, "validated" psychotherapy programs are more likely than antidepressant medication to produce behavioral change that could have protective long-term effects; these programs also avoid the all-too-prevalent side effects of drug treatments. They state that drug-treatment studies have found that the effect of the specific treatment setting and its overall clinical management interact with the efficacy of the drug itself. With regard to lithium for the treatment of bipolar disorder, they conclude:||The history of the research relating to lithium follows a familiar pattern. Once again, there is a cycle of exaggerated initial results (fostered by enthusiasm and rents in the double-blind design); then, increasingly more conservative reports... ; growing disappointment among clinicians... ; and heightened efforts to find alternative treatments.
David Cohen concludes that a large percentage of schizophrenic patients do not respond well to neuroleptic drugs; that social functioning is not improved by these drugs; and that many patients experience such severe side effects that treatment must be discontinued. William G. Danton and David O. Antonuccio underscore the drawbacks of anxiolytic drugs, including sedation, the return of symptoms after cessation of treatment, and the lack of long-term efficacy. They state that behavioral therapies, such as exposure to situations that generate anxiety, produce better and longer-lasting effects, because patients are helped to develop strategies for dealing with their anxieties and are therefore less vulnerable to future problems.
With regard to drugs used to treat children, Rhonda L. Fisher and Seymour Fisher conclude, "It is not an exaggeration to assert that, by and large, the psychopharmacotherapy of the youth segment of the population is scientifically unjustified." Physicians who prescribe "psychotropic drugs for depressive and anxiety symptomatology are doing so without rational support." Their views are somewhat more favorable regarding the amount and quality of research confirming the efficacy of stimulants in treating attention-deficit-hyperactivity disorder in children, the relative immediacy of response to treatment, and the relatively low cost.
The book's greatest strengths are its scholarly citation and discussion of a wide body of relevant literature and its willingness not to pull punches. The book's message is shocking and nihilistic regarding drug therapies, but if it makes us reflect on our practices, the authors will have made an important contribution.
Reviewed by Ruth G. Matarazzo, Ph.D.
Copyright © 1998 Massachusetts Medical Society. All rights reserved. The New England Journal of Medicine is a registered trademark of the MMS.
Product Description
FROM PLACEBO TO PANACEA
With the latest generation of psychoactive drugs, has pharmacology at last triumphed over mental illness? A close look at world scientific literature would suggest otherwise. The sobering truth is that many claims about the efficacy of drug therapies for everything from depression to schizophrenia have been exaggerated. What, then, accounts for the inflated confidence clinicians and the lay public alike often have in the new generation of "wonder drugs"? Find out in From Placebo to Panacea.
From Placebo to Panacea is not an indictment of drug therapy. Rather, it is a reasoned analysis of the efficacy of psychoactive drugs as compared to other forms of treatment--backed by hard empirical data. Above all, it is meant to function as a therapist's and patient's guide to making more informed decisions when considering treatment options.
The book begins with an in-depth discussion of salient problems with standard methods of measuring the usefulness of psychoactive drugs. Next is an exploration of a wide range of factors that can bias test results, both technical (e.g., patients participating in double-blind trials can usually tell whether they are receiving an inactive placebo or a psychoactive drug) and psychosocial. Also considered are problems arising from current systems for diagnosing mental disorders, including complications resulting from comorbidity.
Subsequent chapters focus on drug therapies for specific disorders in both adults and children. The authors cover depression and bipolar disorders, schizophrenia, anxiety disorders, borderline personality disorder, attention deficit, and hyperactivity. Each chapter carefully considers the published findings on the disorder under discussion, as well as questions of side effects, suicide, and potential long-term benefits.
A final chapter synthesizes the findings from previous chapters into a comprehensive picture of the current state of psychoactive drug therapy. Throughout, the book provides valuable suggestions for ways of improving and building upon existing knowledge.
Offering an empirically based appraisal of the strengths and limitations of drug-based treatment for psychiatric disorders, From Placebo to Panacea is must reading for psychiatrists, psychologists, and other mental health professionals, as well as psychopharmacologists and drug development researchers and patients.
"The long list of treatment failures, ranging from insulin coma to lobotomy, speaks for itself . . . skepticism should prevail with respect to all evaluations of research, particularly if they involve the welfare of large numbers of persons."--Seymour Fisher and Roger P. Greenberg
Is the new generation of psychoactive "wonder drugs" really as effective as it is purported to be? And, perhaps most significant, in an age of managed care, what are the dangers of uncritical faith in the usefulness of these drugs? From Placebo to Panacea examines these questions. It separates fact from fiction, and injects a note of healthy questioning into the otherwise unreserved chorus of praise for psychotropics. From Placebo to Panacea:
* Examines the clinical research into outcomes of common drug therapies for most major mental disorders in adults and children Offers analyses of the effectiveness of most common psychotropics in both controlled trials and clinical settings
* Explores technical and psychosocial factors that frequently bias test results in favor of drug therapies
* Provides critical, empirically based appraisal of the strengths and limitations of drug-based treatment for psychiatric disorders
* Compares the relative effectiveness of drug therapy versus nondrug therapies and placebos
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