Treatment Of Depression Is One Of The Greatest Fallacies In The
History Of Medicine
S. Lehrman, MD
current drug treatment for depression represents one of the greatest
fallacies in the history of medicine.
is not a disease, such as pneumonia or malaria. Rather, depression
is usually a psychophysiological reaction to an individuals
current psychosocial interactions. Depressive reactions are also
seen in animals exposed to continuing levels of stress from which
they cannot escape.
thinking of depression, think of fever, which is also a reaction
of mind and body to a set of complex conditions.
has been known for centuries that talking with a caring counsellor
can help depressed people. If the counsellor is cheerful and confident
(which seems less frequent today), and conveys that confidence
to his client, the latters chances of relief will be greater.
Religion and its officiants have provided these services over
the years. And personal caring has been seen as an essential part
of the doctor-patient relationship and is known to have a considerable
impact on medical interactions; in psychiatry, that impact may
be even greater.
Effectiveness Of Counselling In Depression
therapeutic effectiveness of caring dialogue is still greater
if it addresses the real psychosocial issues evoking the depression
- a statement based on personal experience since I began the private
practice of psychiatry in 1953, long before the drug era.
was certain then, having just finished my psychoanalytic training,
that depressive and other psychiatric complaints were the products
of childhood traumata, and that these complaints could be resolved
by digging out those experiences. My confidence had a tonic, cheering
effect on my patients. But I soon found that recovery depended
more on attention to current problems than a focus on the past.
learned this most sharply from a patient, depressed in a foundering
third marriage, who wondered what in her childhood was responsible.
But before we could examine those earlier years, a current problem
forced itself upon our attention: difficulties with her adolescent
step-daughter. She had recently married a widower with two children,
whose first wife had died after a long illness. During that time
the daughter had been the woman in the house. She resented her
new step-mother, and took every opportunity to make her life miserable.
In this battle of the females, the husband, understandably sympathetic
to the girls loss, took a neutral position. But when it
was pointed out to him, and he accepted, that his new wife was
now mother in the house, and that she desperately needed his support,
the family dynamics changed radically and rapidly for the better.
While financial considerations made it necessary to stop treatment
before we ever got to childhood experiences, doing so proved not
to be necessary; the restructuring of current family relationships
was sufficient to overcome the wifes depression. Over the
nearly fifty years which followed, she and her step-daughter were
the closest of friends - and her depression never recurred. Had
she been seen by a modern, drug-oriented psychiatrist, her depression
would probably not have lifted and her marriage would probably
not have survived.
my ten years in full-time private practice, I saw perhaps half
a dozen patients I thought so profoundly depressed as to need
immediate hospitalization. While I could have sent them at once
to a distant private hospital, or to a state hospital, the best
hospital available - which was nearby and where I had recently
served a residency - had a three- week waiting period for admission.
I suggested that these patients apply at once for admission there,
and that I would see them in the office two or three times a week
(more if necessary) until a bed became available. When it finally
did, not one of these patients needed it; our working together
psychotherapeutically - and, of course, without anti-depressant
drugs, because there were none - had significantly improved their
found depressed patients relatively easy to treat after we established
the current causes of their distress. Correcting that distress
sometimes involved violating prevalent shibboleths. A depressed
woman, highly educated but at home full-time with two small children,
and whose husband traveled a great deal, spent most of her therapy
complaining about him. I saw that her depression lessened if I
agreed with her, worsened if I differed, and remained unchanged
if I stayed neutral . Recognizing that relieving her depression
by letting her blame her husband might break up her family, and
believing firmly in the importance of stable marriage, I did something
that was then utterly heretical: I called in her husband. We discussed
her complaints, he agreed that some were justified and changed
his behavior. They too then remained happily married for over
forty more years. (That experience led to my insisting that I
see the spouse of every new patient at the beginning of treatment,
so I could sense the interactions between them.) In this case
also, current methods of drug treatment would not have had this
of my other depressed patients and those of other psychiatrists,
recovered fully after defining and addressing their problems with
parents, spouses, children, work, and school.
Diagnosis Sometimes Occurs
of the myths of our time is that "depression," "anxiety,"
and the hundreds of other disorders listed in the American Psychiatric
Associations manual, represent separate entities, and that
their differences may even involve different biological processes.
In 1957, however, Dr. Michael Balint, studying how people came
to define themselves as patients, discovered the importance of
the patients interaction with the physician in creating
found that "people who for some reason or other find it difficult
to cope with the problems of their lives resort to becoming ill.
If the doctor has the opportunity of seeing them in the first
phases of their becoming ill, i.e. before they settle down to
a definite 'organized' illness, he may observe that these patients
so to speak offer or propose various illnesses, and that they...
go on offering new illnesses until between doctor and patient
an agreement can be reached, resulting in the acceptance by both
of them of one of the illnesses as justified. In some people this
'unorganized' state is of short duration and they quickly settle
down to 'organize' their illness; others seem to persevere in
it, and although they have partly organized their illness, they
go on offering new ones to their doctor." A patients
diagnosis, especially in psychiatry, may thus depend on his or
her interaction with a doctor, rather than on just biology.
Balint's statements about illnesses in general practice are equally
valid for psychiatry today. But diagnostic styles in the latter
have changed radically over the years. Todays psychiatrists
listen less to patients problems, focus more on their reactions
(anxiety, depression, disorganization), and then, on the basis
of those reactions, "diagnose" - and medicate - much
more quickly. But while these drugs may make patients feel better
(too often they have the opposite effect), they will not help
the patients in the long run unless they produce more effective
energy in the patients so they can then solve their problems better.
And this is quite rare.
a depressed patient improves with drug treatment may be completely
unrelated to the medication. Reduction or removal of the pressures
upon the patient, as often occurs when one is "sick,"
can alone produce temporary improvement. Sometimes improvement
follows other changed circumstances, of which the drug-prescribing
doctor is unaware. Whether such changes in circumstance cause
permanent improvement is a different question, which is rarely
asked because drug studies usually run only for a limited number
s extensive, widely-publicized research on new "anti-depressants"
can therefore be seen as faulty, and can be compared to investigating
new forms of anti-fever drugs (antipyretics) as the primary treatment
of pneumonia, typhoid, or malaria. Seeing drugs as the primary
agents in treating depression can be compared to substituting
new anti-fever drugs (antipyretics) for specifics in the treatment
of pneumonia and malaria, such as antibiotics and anti-malarials.
While some such new antipyretics might reduce symptoms slightly
in these diseases, none would be of significant value in combating
the illnesses themselves, and considerable harm would follow from
relying on them alone instead of on the tried and true remedies.
Yet. that is the type of approach that has developed in the treatment
And The Growth Of Depression
has become very big. Feelings of "helplessness, loss of hope,
sadness, crying, sleep or appetite disturbances, or difficulty
concentrating, for at least two straight weeks" are sufficient
for the very common diagnosis of "clinical depression."
Over the past half- century, hospitalizations for depression have
increased almost thirty times, from 9.8 per 100,000 in 1943 (in
New York, which had more per capita than any other state) to an
estimated 280 per 100,000 (nationally) in 1994.
thats only the beginning. Scientists estimated in 1997 that
18 million Americans suffer severe depression each year, with
one in five of us experiencing a depressive episode during his
or her lifetime (that_s 20,000 per 100,000).
Landers maintained that 80% of depressions "can be treated
successfully with medication" (listed first), "psychotherapy,
or a combination of both," and noted happily that on National
Depression Screening Day in 1998, more than 85,000 people visited
screening sites, with over 70% of them then "referred for
a full evaluation." Some experts, claiming that 50 percent
of "clinically depressed" people will have another episode,
note that a growing number of doctors are writing prescriptions
for them for years on end. One expert even insists "there
is a subgroup of people who will stay on medication for the rest
of their lives." These views of depression, based on todays
drug-oriented approach to treatment, conflict almost totally with
the experience of many, including myself, who treated depression
successfully before the drug era began.
is estimated that 28 million Americans now take prescribed (doctor-controlled)
anti-depressant medications. Production of these drugs has consequently
become a huge business, with "global sales estimated at $6
billion a year and rising." Prozac sales alone amounted to
more than $1.7 billion in 1999 - a third of the Eli Lilly and
Companys total business - while prescriptions for its major
current competitors, Zoloft and Paxil, also continue to rise rapidly.
Despite the side-effects experienced by a quarter of Prozac users,
Lilly recently spent $15 million to advertise the drug directly
to the public - to increase patients demand for it from
their physicians. And at a time that our churches, moral guides
to the nation, face many grave financial problems, the major backer
of the Public Broadcasting Systems "Religion and Ethics
Newsweekly" is the Lilly Foundation.
Dangers Of Anti-Depressant Drugs
all the long-term side-effects of these central nervous system
drugs are still not known, those which are known have evoked much
less attention than they should. Anti-depressant drugs greatest
danger is their evocation of suicidal and/or homicidal feelings
and behavior; both teenagers who attacked their fellow students
at Columbine happened to be taking anti-depressants. Another danger
from "feel-good" drugs is the creation of dependency
or addiction. Many who are hooked will turn to street drugs since
they are cheaper, more available, often stronger - and under a
users own control, rather than under a doctors.
find ourselves in this increasingly difficult situation because
psychiatry has badly mishandled depression in its all-consuming
reliance on drugs as the first line of treatment.
Dr. Nathaniel S. Lehrman is the former Clinical Director of the
Kingsboro Psychiatric Center in Brooklyn, NY