In Praise of Irving Kirsch

It is not often I am impressed by psychologists, after all, most of the time psychology just proves what deep down, we already knew to be the case in the first place. Carl Rogers is one of my heroes: he was a genius who reduced the process of therapy to its most simple and effective form. And I have absolutely no hesitation in conferring the title ‘genius’ on Professor Irving Kirsch, the greatest psychologist, thinker and scientist of the present age. 

h2Irving Kirsch, who is at the time of writing, resident at the University of Hull in the UK, has made the single most valuable contribution to medicine in the last century, even though the medical community aren’t aware of this fact. But the pharmaceutical companies are and Kirsch has seriously pissed them off.

Kirsch is an expert on suggestion. I first came across him about ten years ago when he conducted experiments in how to make even people who actively resisted hypnosis, hypnotisable. Having watched him conduct one of these experiments, I knew then that he had an impressive understanding of suggestion, all the more so because it neatly coincided with my own hard-learned opinions.

Kirsch has had the courage to repeat the heretical idea that in most cases, placebos work just as well as drugs. They are cheaper and they have no side effects. 

In 1998, Kirsch and his colleague Guy Sapirstein conducted an examination of 38 manufacturer sponsored studies which involved over 3,000 depressed patients. Their examination of the results showed that patients did indeed improve after being prescribed the relevant antidepressants. Living proof you would think, that antidepressants work. However, when Kirsch and Sapirstein compared the results with the improvements in the control groups who had been given the placebo, there was hardly any difference at all!

Kirsch points out that these manufacturer studies were the basis of the FDA’s approval of the drugs.

That leaves us with the inescapable conclusion that the placebo works just as well as the drug, or maybe it might be just as pertinent to say that the drug works only slightly better than the placebo! Another pertinent point to remember is that tens of millions of people in the world are routinely taking antidepressants. So maybe the cure really does lie in the healing power of our own brains. (I think it does by the way: always have – always will.)

It has long been accepted of course that psychotherapy, in all its guises, also works very well with people who suffer from moderate and even severe depression. The problem is, psychotherapy is time consuming and therefore expensive. But, and this is the big But, just as with hypnosis, most of the drug’s effectiveness almost certainly comes from the belief and expectancy of the patients themselves rather than from any chemical reactions in the brain.

Kirsch published a paper entitled Listening to Prozac but Hearing Placebo and that rather direct approach may have lost him some friends. Mesmer had the same problem, although Mesmer mistakenly put his faith in the curative powers of magnetism, rather than suggestion.

Kirsch decided to extend his study and looked at trials of Prozac, Paxil, Zoloft, Effexor, Serzone and Celexa, all well known brand name drugs. A lot of the trials (about 40%) had never been published and Kirsch had to use the Freedom of Information Act to get his hands on them. One of the first things he noticed was that more often than not, the unpublished trials “were those that failed to show a significant benefit from taking the actual drug.”

In just over half of the unpublished and published studies, the drugs performed no better than the humble placebo. Kirsch’s book The Emperor’s New Drugs: Exploding the Antidepressant Myth is one of the most brilliantly researched and reasoned pieces of work I have ever read.

As far as the drug companies are concerned, antidepressants may very well be regarded as a triumph of marketing over science. And remember, it’s a multi-billion dollar industry. Even the defenders of antidepressants are forced to admit that the benefits are relatively small compared with the hype. The actual difference between the treatment and the control group is totally unimpressive. Psychology researcher Steven Hollon of Vanderbilt University and a good many of his colleagues refer to this fact as “our dirty little secret.”

Astonishingly, very few doctors know of all this; they keep dishing out prescription antidepressants because it’s quicker than engaging in any meaningful exploration of a patient’s real problems. Who can blame them? Doctors are overworked enough.

Defenders of the drugs industry cannot seem to get their heads around the fact that the FDA approves these drugs after only two clinical trials. And doctors who prescribe them can see the effectiveness when the patient returns for a follow up visit. What they haven’t understood is the power of the placebo effect and the underlying power of suggestion.

Depression is an extremely personal problem: everyone’s depression is different, just as every individual views the world in their own particular way, with their own unique reality. So it begs the question, how can a uniform drug deal with individual issues? The answer, as unpalatable as it may seem to some, is that Expectation is the key. Counselling and lifestyle changes would be even more useful.

The indifference between the drug and the placebo is apparently well known to the FDA and to Pfizer, the manufacturer of Zoloft.

In fairness, Kirsch agrees that antidepressants are a tiny bit more effective than a mere placebo. But this could be a dangerous assumption because of the way drug trials are carried out.

Volunteers for drug trials are not told at the outset whether they will receive the real drug or the placebo. In other words, neither they, nor the scientists know who is getting what. A couple of weeks into the test, some of the volunteers may start to experience side effects. This is a clue that they are getting the real thing and not the placebo, so straight away, their judgement as to  the drug’s effectiveness is influenced. Approximately 80% guess right. Studies have shown that the more pronounced the side effect, the more effective the drug appears to be.

The perverse logic is ‘this drug makes me feel sick and hate food, so it must be relieving my depression.’ In clinical trials, patients who realise they are receiving the real thing get their expectations boosted and hey presto! a better result.

Belief in the power of medicine is often self fulfilling (have we just come full circle here?) The same can be said of the patients who figure out they are getting the placebo; no side effects so therefore we’re getting the placebo, so no improvement.

Kirsch is well aware that he is regarded as a trouble-maker, even a pariah, in certain circles. Some academics and institutions will have nothing to do with him. That’s not unusual when people come along with new and revolutionary ideas. Remember too, that not so long ago everyone believed the earth was flat and both Copernicus and Galileo were imprisoned for heresy.

True, patients with extremely severe depression do benefit from the drugs more than they would from the placebo, but that is almost certainly because they are on higher doses and quite often a cocktail of antidepressants. There is a catch though here too: research shows that patients who are given higher doses also have their expectations raised and some patients are told they are being given a higher dose even though they are not. The results are the same.

So what about the drug companies’ claim that their products work by raising the levels of serotonin in the brain: surely that must have some effect? The problem is, there are drugs that lower serotonin too, and yet patients who take both kinds of drug report the same levels of improvement. [Iproniazid raises levels of serotonin and Tianeptine lowers levels of serotonin.] Logic dictates that you simply can’t have it both ways.

Psychotherapy has much lower relapse rates so it might also be logical to conclude that that the talking therapies on offer are better than pill-popping. The real problem is the mind set of doctors and the public at large. We are so used to going to the quack for that quick fix when we’re feeling down, that we too often forget our own humanity. Depression can be treated without drugs.

Postscript:

In 2003, Prevention and Treatment magazine reported on tests of Diazepan in Turin. Half the subjects were given the wonder drug, but not told they were getting it. The other half were put on an inert drip and told that they were on Diazepan. The second group got all the benefit while the group that actually were taking Diazepan experienced little or no improvement. GOTCHA!

In the August 14th issue of New Scientist there appeared a very interesting article on how patients recover in Intensive Care Units (ICU’s.) Mervyn Singer, director of the Bloomsbury Institute Centre for Intensive Care medicine at University College London is quoted as saying “virtually all the advances in intensive care in the past ten years have involved doing less to the patient.” Going out of fashion are all the shiny machines that go ‘beep’ and into fashion is coming the argument that the best way to heal the body is to leave the body to its own devices. The body has its own natural defensive and healing mechanisms and seems to cope much better on its own. Our bodies have evolved so that blood clots to stop us bleeding to death, our immune system is very good at fighting off infection, tissue regenerates and bones fractures heal on their own, given time. Where patients survive multiple organ failure, normal function is rapidly restored. In some cases, drug and artificial breathing intervention has made the patient worse not better. It appears that evolutionary biology is not only lending a hand in patient recovery, but taking responsibility too. Multiple organ dysfunction is often only a temporary and strategic change, comparable to hibernation. Nature may well be using this temporary energy saving device as a way of preparing to recharge the whole system. Of course this is not going to be true in all cases and difficult decisions will face surgeons working with seriously injured patients in modern hospitals, but the theory that ‘less is more’ is catching on. In early 2010, a conference was held at Brunel University with the catchy title of Evolutionary Approaches to Disease and Health. Most there agreed that an evolutionary minded approach might serve ICU patients better.

At the Battle of Trafalgar, in which we whipped the French 21 to 4, there were thousands of wounded (not counting fatalities) after the game. On HMS Victory, Nelson’s flagship, the ship’s surgeon, William Beatty, aided by the very latest in early 19th century medical technology, (a sharp knife, a saw and a needle and thread) performed ten amputations. Without the benefit of antibiotics, only six of the 102 wounded subsequently died of their injuries. At the return match at Waterloo in 1815, only three of the 52 wounded soldiers from the 13th Light Dragoons later died of their wounds. Likewise during the American Civil War; around 75% of amputees survived to later take up careers as bit part actors/extras in spaghetti westerns. This has to be a testimony to the remarkable resilience of the human body. I think it goes much deeper than that: it is my belief that a determined mind also has a part to play in survival after trauma.

Copyright Andrew Newton 2013. All rights reserved.