Letter citing my psychiatry work misleading

Ann Bracken, who cites some of my work, raises important issues regarding psychiatric treatments. Unfortunately, her letter unduly emphasizes side effects sometimes associated with psychiatric treatments and greatly understates the devastating effects of psychiatric illness. She also cites statistics from several studies without understanding their context or limitations. (“Forget ‘Field of Screams,’ psychiatry has more than an image problem,” Nov. 4.)

First, the so-called “chemical imbalance theory” of depression was largely the creation of pharmaceutical company advertising and has never been the official position of psychiatric organizations, academic psychiatrists or psychiatric textbooks. For over 40 years, psychiatrists have viewed mood disorders as the outcome of biological, psychological and social/environmental factors. And contrary to Ms. Bracken’s claim, antidepressants are not prescribed “to address a chemical imbalance theory”; rather, they are prescribed because they help seriously depressed patients recover.

Indeed, Ms. Bracken’s claim that “antidepressants only work for 15% of the people who take them” is misleading in several respects. First, it is based on a meta-analysis of clinical studies that looked at response to a single antidepressant prescribed for a short period of time — usually six to 12 weeks. The analysis found that antidepressant treatment was much more effective than a placebo in about 15 out of 100 patients.

Now, imagine that you or a loved one had a life-threatening illness and knew there was a treatment that led to remission of the illness for 15 in 100 patients. Would you not take advantage of that treatment? To say that “only” 15 in 100 patients will have a robust response to an antidepressant completely ignores the debilitating and sometimes fatal effects (e.g., suicide) of severe depressive illness. Furthermore, in clinical practice, psychiatrists will often use several antidepressants in sequence, over many months, until the patient achieves remission. In my experience of over 25 years, remission is eventually achieved in well over 50% of antidepressant-treated patients. The addition of psychotherapy further boosts remission rates.

Ms. Bracken also cites a 2006 study that seems to show that 85% of depressed individuals who go without somatic treatment (such as medication or electroconvulsive therapy) spontaneously recover within one year. So, if most depressed people get better without medical treatment, why take an antidepressant? But subjects in this study were not seeking treatment for their depression; rather, they were “recruited” by the study authors, who point out that their results can’t be generalized to treatment-seeking depressed patients. Nor did the study examine the risk for recurrence of depression, which can be as high as 50% in the first year following recovery. The authors noted that “… it is possible that patients whose depressive illness spontaneously remits might still benefit from [somatic treatment] as prophylaxis against future recurrences.”

Finally, Ms. Bracken’s remarks concerning electroconvulsive therapy (ECT) are also misleading. ECT is usually reserved for the most serious cases of major depression, and no psychiatrist simply “administers” ECT without a thorough process of informed consent, in which possible side effects are carefully discussed with the patient. Yes, some memory problems often follow ECT, but these usually improve significantly by six months, and treatment of the patient’s severe depression often leads to improved ability to plan, concentrate and attend to things. There is no credible evidence that modern ECT leads to brain “trauma” or damage, and a recent comprehensive review concluded that “ECT is a potentially lifesaving treatment for severe [major depressive episodes].”

In short, somatic treatments in psychiatry, while far from ideal or without some risk, are generally safe; well-tolerated, and effective. They should always be used conservatively, as part of a comprehensive “bio-psycho-social” approach.

— Dr. Ronald W. Pies is professor emeritus of psychiatry at SUNY Upstate Medical University and a clinical professor of psychiatry at Tufts University School of Medicine.