Sunday, June 12, 2011

All in the mind

Reading Marcia Angell's piece in the latest NYRB on the treatment of mental illness (an interesting read btw), I found myself wondering if it really makes sense to speak of placebo effects in the context of mental disease. If you believe you're less depressed, aren't you, in fact, less depressed? And if a course of treatment can make you believe you're less depressed, then doesn't that make it a valid cure for your condition, even if it has no chemical or physiological benefits whatsoever?

In other words, what if the most effective treatment for depression were to create the illusion of treatment: administering what are basically sugar pills, but convincing the patient, through a combination of advertising and pseudo-scientific research that he / she is getting better? A treatment that would work just so long as the illusion lasted?


Sheeba D'Mello said...

I don't know enough of psychology but I assume there is a feeling that not all of it is in the mind and the whole reason you prescribe possibly harmful pills is to effect a physiological change. That you can't always 'think' yourself better.

But if you could, then I think you need to clarify that the illusion is not that you are being treated - you are. The illusion is of the physical nature of that treatment.

km said...

If you believe you're less depressed, aren't you, in fact, less depressed?

But what about mental illnesses that have a physiological basis?

(I need to RTFA...)

Falstaff said...

km: You should, since part of Angell's point is that the physiological basis of mental illness is fairly questionable anyway.

But even if there is a physiological basis - would it matter? If you have the brain chemistry of a depressive, but don't feel depressed and don't exhibit any depressive behavior, are you in fact depressed? And if you're not, then hasn't the treatment 'cured' you?

Crystal Blur said...

Well, one of the most prominent and popular examples for prescriptions that are nothing but placebos is homeopathy. Sure there is no harm in prescribing sugar pills for minor ailments that resolve on their own. The trouble is when patients are deprived of medications that are effective and they (patients) have to endure undue pain and suffering.

My knowledge about psychological diseases and their cure is quite rudimentary I must admit. However, from whatever little I have come to understand, some of the diseases have been extensively characterised down to the molecular mechanisms and in these cases drugs have allowed to correct for the biological deficits which in turn helped patients to lead a functional if not 'normal' life.

Having said that, pharmaceutical industries can be quite ruthless and have on multiple occasions flooded the markets with drugs that should've never made it to the pharmacies. There are valid concerns and criticisms in the article you point to.

Scherezade said...

the physiology of any mental illness can't be negated or put in brackets. irrespective of what this article says. its very real and palpable. neuropsychology has enough proof to offer (sub:catatonic depression). so, on that level, the sugar pill may not be very effective.
i say this basis experience with my own patients. in any case depression is a spectrum disorder/condition. the range varies so its not necessary that every "depressive" displays the same quantity/quality of neurosis. if you have the chemical profile of a depressive and don't exhibit the behavior associated with it frequently (rarely true) in normative circumstances, there is still no guarantee that you will have a balanced coping mechanism during something more pathological. any cure has to take this into account. also depends on what exactly does one mean by exhibiting depressive behaviors.

aside from neurocognitive aspects, depression has a very significant behavioral undertone stemming from learned helplessness. in that regard, no medication (real/pretend) is ever effective in fully curing a psychological illness. therapy is key.

in most depression related cases we see within clinical practice, many patients who do not feel depressed at the onset, display it amplified manifold (as compared to non-depressives) at later stages and have ill defined mechanisms for dealing with ratio-emotive circumstances. also, with depression, one has to consider comorbidity. multi-headed hydra.

Falstaff said...

Okay, first, you're all taking this post too seriously. It's just an off-the-cuff speculation, focused on the philosophical question of what constitutes a placebo effect rather than on the medical question of how depression should be treated.

Think of it as science-fiction. Imagine that on the planet Notsosirius, treating patients with sugar pills that they believe to be breakthrough drugs causes them to permanently feel less depressed. Maybe the sugar pills trigger a physiological change in brain chemistry (why not?), maybe the problem was never physiological to begin with. In any case, so long as the patient continues to believe in the sugar pills, the patient is permanently over his / her depression. Now: are the sugar pills merely a placebo, or are they a legitimate treatment.

Scherezade: Sorry, but that comment is precisely the kind of biased,unscientific "I see it with my own patients" conclusion that Angell (and the book she's reviewing) is criticizing. Have you tried treating your patients with sugar pills then monitored their brain chemistry? If not, you don't really know what you're talking about, do you?

Scherezade said...

Fair enough. I'll abandon my unscientific ways and resort to sugar pills from tomorrow. Eye opening, this way. Thanks etcetra.

Scherezade said...

Also, while I may not have tried it with *my* patients (I work in a cure-based environment so can't possibly treat them as guinea pigs) others in the research arena have and its has some serious thorns. there is a ton of literature available for your perusal.

In my own unscientific way, I have learned that depression is primarily a result of lower than desired serotonin/norepinenphrine levels in the brain coupled with a few genetic and environmental factors. Sugar pills will, for a while, act upon the neural circuits in a similar fashion as any regular selective serotonin reuptake inhibitor providing the *illusion* of betterment. I mean, it is insulin utlimately. The whole idea is that it will cause immunosuppression. no prizes for guessing!
the point is, what of the damage that comes off of it? such as lowered reception to actual medication. or dependency? and
besides that, i am not opposed to human body's natural placebo effect/s.
however, the sugar pills, they dont work doc!
so, yeah, i kinda know what i am talking bout.

Falstaff said...

Scherezade: But the "tons of literature" is precisely what Kirsch (the book Angell's reviewing) is critiquing, and both his methods and his conclusions seem fairly sound to me.

Obviously, I'm no expert, and have no interest in becoming one. If you've read the Kirsch book, and have faults to find with his methodology / conclusions, I'm happy to hear them. All I'm saying is that "I've seen it in my patients" is a bogus argument.

You say "learned that depression is primarily a result of lower than desired serotonin/ norepinenphrine levels in the brain". How do you know this? Because a bunch of studies by other people say so. But those studies are precisely the ones that Angell, and the authors she cites are calling into question. And with arguments and empirical evidence that, to me, seems impeccable. So either you have other, more convincing empirical evidence for that claim, or you have a strong methodological reason for dismissing the critique these authors are offering.

If you have neither, then maybe you should open yourself up to the possibility that what you think you know is wrong.

Scherezade said...

All of this is to progressively starting sound very Hitchens-esque. Brr.

And clearly this is going nowhere. I can debate Kirsch's book with you but the point is what, as they'd say.

Tons of literature = Clinical trial data and fMRI studies to indicate the neurochemical bases for depression. (We sort of are forced to write these unscientific papers as part pf "Research Methods in Neuropsychology" in college after we have tortured enough people by attaching electrodes and whatnot to their heads. I'll link you to the data and the observational analysis if you have the time and the energy to sift through those texts.)

"I am not an expert" - Precisely. Read around more. You are debating a possible cure from a book without fully comprehending the biological/neural/chemical/cognitive/evolutionary bases for a rather delicate condition.

And "I see in it my patients" is NEVER a bogus argument, sir. Everything in the realm of applied psychology begins and ends right there.

Scherezade said...

i am fully open to the possibility that neurotransmitters may not be hold the key to treating depression patients. for once, some patients display prefrontal cortical abnormalities which has nothing to do with chemical bases and is more neuroanatomical in nature.
but what of this is news? it is the same story for biochemical bases for hunger and treating obesity and anorexia.

his problem with antidepressants in a sensible one, no doubt.i belong the same school of thought as far as avoiding or reducing the usage of antidepressants is concerned.
debating the effect of a psychoactive drug on a neurotransmitter doesnt fully negate the role a neurotransmitter plays in creating/aiding a condition. unhealthy correlation.
it just indicates that we might not have fully understood the impact of the said neurotransmitter are trying to fit square pegs in round holes.

in any case, as I was barking earlier, there is no substitute for actual therapy. in that sense the behaviorist in him appeals to me.

also, I am not opposed to Kirsch (response expectancy as determinant of experience & behavior is a seminal text), just that I don't agree entirely with the presumption that depression has no neurochemical base. it is absurd to think that.

till then, enjoy this -

Scherezade said...

and am sleepy so sorry bout the grammatical/syntactical errors.

Falstaff said...

Scherezade: Of course I don't have the time or inclination to sift through those texts. Why would I?

Here's what I know - Kirsch and Angell are offering me a very clear, concise, logical argument which casts doubt on the scientific basis for your claim that "depression is primarily a result of lower than desired serotonin/norepinenphrine levels in the brain". Nothing you've said so far negates any of their arguments. Which makes me think you don't have a counter-argument. But maybe I'm wrong. Whatever. Since I'm not, as you seem to think, "debating a possible cure" (where did you get that from? I'm beginning to be seriously concerned about your patients now) I don't really care. I remain open to the possibility that depression has no physiological basis. If you want to think that's absurd, be my guest.

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