Pillshaming is real: here’s a new(ish) way to reduce it, and to reduce antidepressant use

(Note added 16th February 2019: see my latest piece on ‘Critical Psychiatry‘)

Some ‘Critical Psychatrists’ have gone too far in stating that ‘There’s no such thing as an ‘antidepressant’’.[1] Although the evidence shows that, even in moderate depression, nine out of ten people (maybe many more) will be getting largely a placebo effect, it is less clear whether the additional distress caused to antidepressant users by such talk is outweighed by the benefit to those who are warned off, and stay medication-free.

And anyway, UK antidepressant use has doubled in the decade since the publication of psychiatrist Dr Joanna Moncrieff’s Myth of the Chemical Cure (2008), and Harvard psychologist Irving Kirsch’s The Emperor’s New Drugs (2009). In that time, the patents on almost all UK antidepressants have expired: so while there are still profits in brands and generics, pharmaceutical marketing has reduced a lot.

It may be difficult to prove that this hectoringly negative approach has been counterproductive, and actually increased prescribing; but social science research published in 2015 shows that ‘pillshaming’ is real, and often more than a mild irritant. The University of Westminster’s Professor Damien Ridge has been studying this issue for a decade, and with his co-researchers he found that many users were ‘concerned about shameful antidepressant use and deviance’, some even struggling with the idea that they were ‘malingerers’.

It will be of concern, to people who have experienced pharmaceutical harm, that it does not feature more prominently. I myself wonder if Dr David Healy, who still maintains that antidepressants cause more harm than good, if not adequately monitored,[2] is not a little too focused these days on his expert witness work, rather than engaging with regulatory authorities and the wider public.

The first four words in the title of Professor Ridge’s 2015 paper, a quote from a person on antidepressants, is telling: ‘My dirty little habit’.[3] (academic paywall, but I will later do a longer Blog piece on Ridge’s work)

So, is there an alternative to ‘pillshaming’, that will still draw attention to the very limited direct pharmaceutical effect for at least nine people out of ten? Arguably, doctors should be telling patients about the latter anyway, and imminent new guidance from the GMC on ‘a doctor’s duty to disclose relevant information and risks’ may be an opportunity for ‘antidepressant’-skeptics like myself to foreground concerns again.[4]

I suggest that new patients (with non-severe depression) about to be offered antidepressants are offered a placebo as well. Note: ‘as well’ rather than ‘instead’, because for the patient not to be informed is unethical, and although there is some interesting research on people knowing they are taking ‘sugar pills’…well, let’s not go there.

I am talking about a parallel with randomised controlled trials, but as a routine structure of treatment, not as research. At its simplest, there would be a fifty-fifty chance of getting the placebo, and the treatment would be ‘unblinded’ after 8 weeks. A greater level of complexity would involve a longer period of, say, 12 or 16 weeks, with a crossover in the middle.

Who would provide these ‘blinded treatment trials’ first? Psychiatrists have more time for patients, but they tend to see either more complex cases or more severe depression. It might be best for those GPs, especially academics, who have a serious interest in mental health, to take this up. They would be well-placed to run pilot schemes identifying people presenting to GPs with more straightforward moderate depression.

Of course, many people would turn down the treatment trial, and opt for ‘unblinded’ antidepressants. But at least they would have been informed about placebo, and even potential harms, in a less shame-inducing way.

(Added 21st April: thanks to Dr Duncan Double MRCPsych for comments on a very early version of this piece)

(April 22nd: Paragraph 4, ‘it does not feature more prominently’ changed from ‘little awareness of it was reported’)

(Added September 19th: search my other Blog pieces for ‘Anti-Diagnosis’)

 

[1] https://joannamoncrieff.com/2013/11/27/why-theres-no-such-thing-as-an-antidepressant/

[2] http://data.parliament.uk/writtenevidence/committeeevidence.svc/evidencedocument/health-and-social-care-committee/suicide-prevention/written/37289.html

[3] https://www.sciencedirect.com/science/article/pii/S0277953615301568

[4] https://www.bmj.com/content/357/bmj.j2224

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About Dr Neil MacFarlane MRCPsych

Independent Psychiatrist providing culturally informed mental health opinion, advice, and a few new facts. Based near London, UK. Main qualifications: BA MBBS MA MRCPsych.

29 responses to “Pillshaming is real: here’s a new(ish) way to reduce it, and to reduce antidepressant use”

  1. 1itera11y says :

    How can there be “many more” than nine out of ten people? Isn’t there just one more?

  2. John says :

    It’s an interesting idea but I think it unravels when the patient realises the antidepressant must be useless or you would not be offering this choice, and the Placebo Effect, inasmuch as it relates to the pill itself, must evaporate. Of course there can be other placebo-like effects, such as sympathetic doctors and clinicians, which is where the open dialogue approach comes in. The placebo effect of antidepressants, and some antipsychotics even, is illegitimate and I’m sorry to say based on lying – it’s only because the psychiatrist has, with straight face, said the drugs work that you get the effect. Medicine by lying might actually work, but it must be a blind alley which would result in good treatments getting avoided because nothing has credibility anymore. I think the best we’ve got is painstaking honesty, empathy, psychosocial interventions and time – and, ok, medicine in emergencies. But trying to exploit the myth that chemicals cure depression – it’s an idea that’s perhaps cute but couldn’t be administered ethically. But never say never, the Placebo Effect is too good to dismiss out of hand.

    • Dr Neil MacFarlane MRCPsych says :

      Sorry John I don’t agree. Many people would turn down ADPs when properly informed about 9/10 placebo (and side effects, withdrawal etc), and those that still want to try would probably do so on the basis of either (depending on randomisation) ‘testing’ the placebo effect for themselves, or trialling the drug.

      There must have been at least some research done on those factors, and I will try to find it because I want to write another piece, on Peter D Kramer, who doesn’t accept 9/10 placebo for ADPs.

      I simply don’t accept Moncrieff & Gotzsche’s claim that they have shown ADPs are 10/10 placebo (although what they actually write varies a bit).

      I do agree that prescribing doctors over-attribute improvement to ADPs, but more extreme ‘lying’ is rare, I think. Would be interested to see some confidential survey research on that!

  3. Johanna says :

    As one who has been urged for over twenty years to rely on these medications, I wish with all my heart that just one doctor–just one!– had been honest with me, rather than acting as a cheerleader for the pills. I fail to see how anyone who warns me about their limited effectiveness and potential harms is “shaming” ME! Shaming the manufacturers, and their professional shills, maybe. But not shaming me. Just because the cure does not work as advertised, does not mean the problem is not real.

    I am sick to death of having all these “compassionate” medical authorities urge me “not to be ashamed” of taking psych meds. THEY are the ones who taught me for twenty years to blame my own biology for the fact that I was feeling worse and worse — and to regard myself as incurably ill “despite” all the wonderful medicines! That gave me no small amount of shame to wrestle with–and a great deal of unnecessary despair.

    It also damaged me, physically, cognitively and emotionally, in ways I shall have to struggle with for the rest of my life. With no help from the “compassionate” pill dispensers, who now insist my medication-induced problems are merely psychosomatic, and my refusal to load myself up with more meds is some sort of neurotic phobia.

    Now that, my friends, is genuine Shaming.

    • DrNMblog says :

      Johanna

      I think fewer people should start antidepressants, and more people should try to come off them. Your point that ‘don’t be ashamed’ talk often distracts from lack of proper information about benefits & harms is a good one.

      If ‘there’s no such thing as an antidepressant’ helped you, that’s fine. But it, and related statements, appear to be heard by many as ‘there’s no such thing as depression’. I don’t accept that, and nor do I accept that ‘depression was invented by Pharma’. I will be doing another Blog piece on these issues in 2-3 weeks.

      • Johanna says :

        I certainly do NOT believe that there’s no such thing as depression or that Pharma invented the concept. I believe there is, and also can accept that I am more **subject** to depression than the average. However, I do believe Pharma has had a hand in promoting two novel concepts in the past thirty years: First, that constitutional depression is very common, and that a very wide spectrum of emotional distress or dysfunction can be attributed to this condition that we used to think was fairly rare.

        The second is that it’s a chronic, unremitting and even “progressive” brain disease that demands chronic, lifelong medication. We used to recognize that spontaneous remission happened, and was actually the most common outcome. Maybe we used to see it a lot more often, before we started worshipping at the altar of maintenance medication.

        Based on my own experience, and on watching the results of medicating 20% of working-age women in my country (USA! USA!), I think we need to come to grips with the role of the medication itself in CREATING a new chronic disease–one that accounts for a rising number of disability claims that would have astonished previous generations of shrinks.

        As for “there’s no such thing as an antidepressant” — well of course this does not mean that no pill has ever helped someone who was depressed! Maybe what it means is that there’s no such thing as a magic bullet that selectively targets some depression center or depressive process in the brain. All drugs have effects. Some of them are helpful to some folks at some times. Most are not suitable for lifetime use. Amphetamines have been used as antidepressants (and are still commonly used as “adjuncts” to antidepressants although doctors don’t like to talk about that). So have tranquilizers of various sorts (ditto). So, increasingly, are neuroleptics.

        Alcohol worked wonders for my depression when I first tried it in my late teens. I promptly became a “maintenance’ drinker, which worked out pretty well for a couple of years. Until it didn’t, of course. I have learned my lesson and would never try that again. Still, I can’t say my decades of experience with “maintenance” medication went any better. Quitting alcohol was hard, but at least no one told me the problem was “psychological,” or that it proved my brain really needed the bourbon to normalize it …

        • DrNMblog says :

          All very good points Johanna. Any thoughts on my proposal to offer a trial of placebo in (eventually, maybe) routine clinical practice? I tend to think Pharma won’t like it, of course.

          • Johanna Ryan says :

            It might be interesting research, but I can’t see it being helpful at all in practice. And it exposes at least 50% of the patients to a chemical they probably don’t need and that may do them some harm. Plus you’re right I think, most people would decline.

            I think there’s really three “placebo” effects. One is when conditions improve on their own, and we give credit to the pill. Then there’s the psychological effect of believing you’re on treatment. In that scenario there are really two “placebos” at work – the pill, and the doctor. A talk with someone who says they are experienced in matters like this, they can see you have a real problem, and they are confident they can help you, can be pretty good medicine. In a sense, it’s not even a “placebo.”

            So why not use it—plus offer something that might actually help (or at least won’t harm)? Tell them: What you are going through is real—you’re not just a whiner. And it’s not something you can fix with willpower alone. The good news is, it usually gets better, and we have things that can help. Take exercise. Not just a commandment – You Should Exercise – but an invitation to do so in an actual fitness center, in a group of people somewhat like you, with a leader. Or a talking group, or relaxation group, or whatever you believe in. Add a nutritional supplement if you like – multivitamins, turmeric, SAM-e, fish oil, you name it. It doesn’t have to have huge proven effectiveness, but it can serve that third “placebo” function without doing harm. And it just might help.

            If none of that is available, consider the power of a two-week off-work note. I’m always amazed how many doctors will dose you with three chemicals at once, but relentlessly “stigmatize” the idea of a brief break from the job (which may just be part of the problem).

            If that doesn’t work, or the person insists on meds, you can always offer meds. With realistic advice about the pros and cons. Whaddaya think? (and thanks for asking!)

            • DrNMblog says :

              My original piece said: ‘I suggest that new patients (with non-severe depression) about to be offered antidepressants are offered a placebo as well’, which kind of assumed that they had already been ‘properly informed’ (as usually does NOT happen now) about efficacy & potential harms.

              GPs here will say that it is going to take more time. And if fewer people take ADPs, then they may need more forms of support. I think it would be worth it, but money is not especially plentiful right now.

  4. paulabrennan2015 says :

    Interesting article. But there is something nagging me about the reliance on the placebo effect in the critique of SSRIs. Does it not depend upon the subject being a bit “serotonergically naive”? I was prescribed Prozac twenty years ago. Years before that, as a teenager, I had experimented with mild doses of psychedelic mushrooms. There was a definite feeling of deja vu as the fluoxetine reached clinical levels. This was before I had trained as a psychologist and I’m not sure I even knew much about what these substances were or did in those days. Since then, I’ve been prescribed migraine meds, used St John’s Wort, etc., and noticed the same response, which seems to me to be just as identifiable as alcohol or caffeine intoxication. If somebody has been exposed to multiple serotonergic substances (clinical or recreational), don’t they become a bit more sophisticated in their responses?

    • DrNMblog says :

      Paul…very likely: maybe I should have used ‘never treated’ not just ‘new’ in my example. I am still catching up with these issues after my 3yr+ ‘Eng Lit sabbatical’. But I think there are potential ways placebo trials could be helpful to the antidepressant ‘non-naive’…if what you describe is quite subtle then some elements of placebo/nocebo…? For me as a migraine sufferer, though, the fancy new meds just can’t be…I was pretty skeptical of them at first.

      In a week or so I plan a piece including my own 8-week ‘semi-experimental’ trial of fluoxetine in late 1990s…nothing groundbreaking but will add to my account of meds-free depression…through luck not superhuman willpower etc.

      • paulabrennan2015 says :

        Very interesting thoughts. And here’s a related thought – when I was prescribed fluoxetine, there was no public narrative about discontinuation syndrome, and my experience of this was very mild. Nowadays it’s a huge deal and a lot of very dramatic discontinuation effects seem to be reported. It seems to me that if we are satisfied with the argument that the clinical effect is almost entirely placebo, then we should at least consider that the same thing might apply to discontinuation. I wonder what Healy’s take on that would be. (I’m not a psychopharmacologist so assume that some of my perspectives on this are not state-of-the-art).

        • DrNMblog says :

          Within what might be called the ‘Critical Psychiatry Spectrum’ I think David Healy believes the least in ‘psychological withdrawal’, and Duncan Double the most: https://criticalpsychiatry.blogspot.co.uk/2018/03/minimising-antidepressant.html . I would probably be in the middle of that.

          I started my first job in Psychiatry just after Prozac became available in the UK (February 1989). After a slow start I prescribed it quite a lot. It is recognised that it has fewer withdrawal problems partly because it has such a long half-life. I had no problems after my eight weeks.

          When Seroxat (paroxetine) came in a couple of years later we were skeptical about it as a ‘me too’ drug, and I am fairly sure that I never started anyone on it. It later became pretty clear (well before Panorama’s ‘Secrets of Seroxat’) that it has both more side effects and more withdrawal effects than other SSRIs.

        • Johanna says :

          Paul, the reason there was “no talk” about a discontinuation effect was that all our problems on trying to stop were labeled “depression.” There was also less talk about our sexual flatlining while on the pills because that was labeled “depression” as well. (For women, it still is, alas.) The cure in both cases was to get back on Prozac, increase the dose or try a new pill that would stay on-patent longer. I was stuck on that bus for twenty years.

          Another reason may be that withdrawal on some of the newer meds (maybe paroxetine, and certainly Effexor and Cymbalta) sets in much faster than on Prozac, and can be so ridiculously Gothic that it’s harder to miss. One popular withdrawal strategy is to first switch from whatever poison you’re on to Prozac, and then taper that down as it is thought to be not as difficult in many cases.

  5. Dr Rob Purssey says :

    Dear Neil – there are internal contractions abounding here – “the evidence shows that, even in moderate depression, nine out of ten people (maybe many more) will be getting largely a placebo effect, it is less clear whether the additional distress caused to antidepressant users by such talk” – from this phrase “such talk” is about properly informed consent, as “the evidence shows” – you state later “for the patient not to be informed is unethical” – and i fully agree. Including informed about physiological dependence, sexual numbing, PSSD etc, and so how do we square that with “this hectoringly negative approach” when we’re actually simply talking about properly informed consent? Btw re patent issue, the profits continue enormously, and the biggest “generic” sellers often made by the original patent holders (here in Australia and i daresay elsewhere).
    I appreciate concerns about stigma AND the evidence is also clear that biological attribution (chem imbalance myths) which are hugely increased by SSRI reliance VERY significantly worsens stigma.
    Thanks, nevertheless for your ongoing work, and warm wishes,
    Dr Rob Purssey – psychiatrist, ACT therapist, behavioral pharmacologist

    • DrNMblog says :

      Cheers Rob…I am suggesting there are two kinds of ‘negative talk’ about ADPs. The first, ‘no such thing as antidepressants’, is ‘hectoring’, because it leads to ‘pillshame’: that some people feel they are being accused of malingering is worrying for me as an ADP skeptic. I only came across this research three days ago.

      The second, about potential harms, did not emerge in the ‘My dirty little secret’ paper: but as an alternative explanation to my ‘David Healy’s message isn’t getting through’, maybe the people to whom it does get through avoid ADPs more?

      Re: fully informed consent, there are these same two aspects of it. How many GPs do that? How many psychiatrists? What about developing countries where most (I think) ADPs are bought over the counter or from a variety of Western and non-Western practitioners. See http://journals.sagepub.com/doi/abs/10.1177/1363461509102289

      Brands & generics: yes, of course, significant profit left. Must still be a factor. Perhaps I am trying to stretch to a parallel with ‘prohibition is counterproductive’ … something that I am not sure I believe!

      • DrNMblog says :

        Correction: in fact there is a small section on concerns about harms in ‘My dirty little secret’, so I changed the wording in paragraph 4 to ‘does not feature more prominently’, from ‘little awareness of it was reported’.

        • paulabrennan2015 says :

          From a talk-therapy perspective, your proposal reminds me of the “Miracle Question”, which I suppose is a placebo in metaphorical form. But I wonder if the proposal completely sidesteps the problem of pill-shaming. For me, to be told that ADPs are 90% placebo triggers mild shame, because it implies that I was probably duped by placebo when I recovered from depression. I’ll get over it of course (assuming I believe it to begin with). But the Miracle Question (and similar subjunctive or “what if.. ” approaches to talk therapy) attempt to construct the “placebo space” without actually handing out sugar pills. In some ways, this seems superior because the question “What if….” dupes nobody and shames nobody. Also, acknowledging that some people like Johanna have had a terrible time with discontinuation syndrome, which I fortunately did not.

          • DrNMblog says :

            Very good…like a thought experiment? Yes, some may want to leave it at that. I have never been in a depression trial, but I do quite like blinded wine tastings…at least if you get it wrong you are not being duped by the doctor who failed to provide proper information. Very different kind of duping, I think. Many thanks Paul, I have to head off now.

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