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I have first-hand experience of the devastation of depression, in myself and those close to me. Although I have been tempted to try antidepressants, I’ve never done so. Of course, like everyone reading this column, I know many people who have been treated with antidepressants—not surprisingly, because according to a 2005 survey, one in 10 Americans are now under such treatment. Some people I know have greatly benefited from their treatment. Others never find adequate relief, or they experience annoying side effects—such as mania, insomnia, emotional flatness or loss of libido—so they keep trying different drugs, often in combination with psychotherapy. One chronically depressed friend has tried, unsuccessfully, to stop taking his medications, but he experienced a surge of depression worse than the one that led him to seek treatment. He accepts that he will probably need to take antidepressants for the rest of his life.

We all, to greater or lesser degrees, have this kind of personal perspective on antidepressants. But what does research on these drugs tell us about their efficacy? The long-smoldering debate over this question has flared up again recently, with two medical heavyweights staking out opposite positions. In a New York Times essay, “In Defense of Antidepressants,” Peter Kramer, a professor of psychiatry at Brown, insists that antidepressants “work—ordinarily well, on a par with other medications doctors prescribe.”

Kramer’s article seeks to rebut a wave of negative coverage of antidepressants, most notably a two-part essay in The New York Review of Books (which can be found here and here) by Marcia Angell, former editor of The New England Journal of Medicine and now a lecturer in social medicine at Harvard. Angell cites research suggesting that antidepressants—including both selective serotonin reuptake inhibitors (SSRIs) and other medications—may not be any more effective than placebos for treating most forms of depression.

Angell highlights a meta-analysis, carried out by the psychologist Irving Kirsch, of trials of a half dozen popular antidepressants submitted by drug companies to the U.S. Food and Drug Administration. Many of the studies were never published because they failed to yield positive results. (The practice of burying negative results from trials is still quite common, as this recent Scientific American blog post points out.) After analyzing all the FDA studies, Kirsch concluded that placebos are 82 percent as effective as antidepressants. According to Kirsch, this difference vanishes if antidepressants are compared to “active placebos,” which are compounds such as atropine, an alkaloid that blocks certain nerve receptors and causes dry mouth and other symptoms, that have distinct side effects.

Angell quotes from Kirsch’s new book The Emperor’s New Drugs (Basic Books), in which he states that “the relatively small difference between drugs and placebos might not be a real drug effect at all. Instead, it might be an enhanced placebo effect.” This “startling” claim, Angell adds, “flies in the face of widely accepted medical opinion, but Kirsch reaches it in a careful, logical way. Psychiatrists who use antidepressants—and that’s most of them—and patients who take them might insist that they know from clinical experience that the drugs work. But anecdotes are known to be a treacherous way to evaluate medical treatments.”

So how does Kramer begin his defense of antidepressants? With an anecdote—about a friend who benefited from antidepressants after suffering from a stroke. This rhetorical strategy should not be surprising, since Kramer’s 1993 bestseller Listening to Prozac (Penguin), which contributed to the surge in popularity of Prozac and other SSRIs, relied heavily on anecdotal evidence rather than clinical data. Kramer told story after story of patients transformed by Prozac. He suggested that SSRIs might be ushering in an era of “cosmetic psychopharmacology” in which patients are not only cured of disorders but become “better than well.”

The Brave New World envisioned by Kramer was always a complete fantasy. When he wrote his book in the early 1990s, studies by Eli Lilly, Prozac’s manufacturer, showed that it was no more effective than older antidepressants, such as tricyclic drugs, or psychotherapy without drugs. Although Prozac was touted for its relatively mild side effects, it causes sexual dysfunction in as many as three out of four consumers. Kramer relegated a discussion of Prozac’s sexual side effects to the fine print, literally, in his book’s endnotes. His Times essay doesn’t provide any better data for antidepressants than Listening to Prozac did. Kramer delves into an arcane discussion of how difficult it is to distinguish genuine drug benefits from placebo effects, but he does not really grapple with the claim of Angell and Kirsch that antidepressants may be active placebos.

Kramer does not mention, for example, a recent analysis of STAR*D(Sequenced Treatment Alternatives to Relieve Depression), which has been called “the largest antidepressant effectiveness trial ever conducted.” According to a group of four researchers, STAR*D data show that “antidepressants are only marginally efficacious compared to placebos,” and even this modest benefit might be inflated by “profound publication bias.” The authors recommend “a reappraisal of the current recommended standard of care of depression.”

Angell agrees. She thinks that the surge in antidepressant prescriptions over the past two decades stems less from the drugs’ efficacy than from the marketing muscle of the pharmaceutical industry, which she says “influences psychiatrists to prescribe psychoactive drugs even for categories of patients in whom the drugs have not been found safe and effective.”

She recommends that doctors be prohibited from prescribing psychiatric drugs “off-label”—that is, for disorders and populations, notably children and even toddlers, for which they have not been approved. She also urges that we “stop thinking of psychoactive drugs as the best, and often the only, treatment for mental illness or emotional distress…. More research is needed to study alternatives to psychoactive drugs,” including exercise and psychotherapy (although of course studies of psychotherapy reveal that it may also work by harnessing the placebo effect).

Given what science is telling us about antidepressants, Angell’s recommendations seem wise to me. I sometimes suspect that psychiatric drugs work, to the extent that they do, simply by making people feeldifferent. The suffering person interprets this difference as an improvement, in the same way that someone who is in a rut may feel better by traveling to another country. But does that mean that any psychoactive drug—Caffeine? Beer? Antihistamines? Psilocybin?—can in principle produce the same benefits as an SSRI, as Angell and Kirsch seem to suggest? Even for a skeptic like me, that seems hard to believe. We clearly need more research not only on alternatives to antidepressants (yoga, meditation, jogging, reading groups, journal-writing) but also on the drugs themselves, to understand why some people benefit so much from them while others don’t. But more research will be helpful only if the results are reported—as all medical data should be but too often aren’t—with absolute candor and transparency.

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown 2010), by the journalist Robert Whitaker, is one of the most disturbing, consequential works of investigative journalism I’ve read in a long time. Perhaps ever. Whitaker has persuaded me that American psychiatry, in collusion with the pharmaceutical industry, may be perpetrating the biggest case of iatrogenesis—harmful medical treatment–in history. I’m even more impressed by Whitaker’s research and reasoning after hearing him speak at my school, Stevens Institute of Technology, on February 29. He is the kind of science journalist who makes me proud to be a science journalist. I’m thus printing here a modified version of an article I wrote aboutAnatomy last fall for The Chronicle of Higher Education. I also urge you to check out Whitaker’s Psychology Today blog, where he addresses his critics.

I first took a close look at treatments for mental illness in the mid-1990s while researching an article for Scientific American. At the time, sales of a new class of antidepressants, selective serotonin reuptake inhibitors, or SSRIs, were booming. The first SSRI, Prozac, had quickly become the most widely prescribed drug in the world. Many psychiatrists, notably Peter Kramer, author of the bestsellerListening to Prozac (Viking 1993), touted SSRIs as a revolutionary advance in the treatment of mental illness. Prozac, Kramer claimed in a phrase that I hope now haunts him (but probably doesn’t), could make patients “better than well.”

Clinical trials told a different story. SSRIs are no more effective than two older classes of antidepressants, tricyclics and monoamine oxidase inhibitors. What was even more surprising to me—given the rave reviews Prozac had received from Kramer and others–was that antidepressants as a whole were not more effective than so-called “talking cures,” whether cognitive behavioral therapy or even old-fashioned Freudian psychoanalysis, according to investigators such as the psychologists Seymour Fisher and Roger Greenberg. According to these and other researchers, treatments for depression and other common ailments work—if they do work—by harnessing the placebo effect, the tendency of a patient’s expectation of improvement to become self-fulfilling. I titled my article, published in Scientific American in December 1996, “Why Freud Isn’t Dead.” Far from defending psychoanalysis, my point was that psychiatry has made disturbingly little progress since the heyday of Freudian theory.

In retrospect, my critique of modern psychiatry was probably too mild. According to Anatomy of Epidemic by Robert Whitaker, psychiatry has not only failed to progress; it may now be harming many of those it purports to help. Anatomy of an Epidemic has been ignored by most major media. I learned about it only after Marcia Angell, former editor of the New England Journal of Medicine and now a lecturer on public health at Harvard, reviewed Anatomy in The New York Review of Bookslast year.

As recently as the 1950s, Whitaker contends, the four major mental disorders–depression, anxiety disorder, bipolar disorder and schizophrenia–often manifested as episodic and “self-limiting”; that is, most people simply got better over time. Severe, chronic mental illness was viewed as relatively rare. But over the past few decades the proportion of Americans diagnosed with mental illness has skyrocketed. Since 1987, the percentage of the population receiving federal disability payments for mental illness has tripled; among children under the age of 18, the percentage has grown by a factor of 35.

This epidemic has coincided, paradoxically, with a surge in prescriptions for psychiatric drugs. Between 1985 and 2008, U.S. sales of antidepressants and antipsychotics multiplied almost fifty-fold, to $24.2 billion. Prescriptions for bipolar disorder and anxiety have also swelled. One in eight Americans, including children and even toddlers, is now taking a psychotropic medication. Whitaker acknowledges that antidepressants and other psychiatric medications often provide short-term relief, which explains why so many physicians and patients believe so fervently in the drugs’ benefits. But over time, Whitaker argues, drugs make many patients sicker than they would have been if they had never been medicated.

Whitaker compiles anecdotal and clinical evidence that when patients stop taking SSRIs, they often experience depression more severe than what drove them to seek treatment. A multi-nation report by the World Health Organization in 1998 associated long-term antidepressant usage with a higher rather than lower risk of long-term depression. SSRIs can cause a wide range of side effects, including insomnia, sexual dysfunction, apathy, suicidal impulses and mania–which may then lead patients to be diagnosed with and treated for bipolar disorder.

Indeed, Whitaker suspects that antidepressants—as well as Ritalin and other stimulants prescribed for attention deficit disorder—have catalyzed the recent spike in bipolar disorder. Relatively rare just a half century ago, reported rates of bipolar disorder have spiked more than 100-fold to one in 40 adults. Side effects attributed to lithium and other common medications for bipolar disorder include deficits in memory, learning ability and fine-motor skills. Similarly, benzodiazepines such as Valium and Xanax, which are among the drugs prescribed for anxiety, are addictive; withdrawal from these sedatives can cause effects ranging from insomnia to seizures, as well as panic attacks.

Whitaker’s analysis of treatments for schizophrenia is especially disturbing. Antipsychotics, from Thorazine to successors like Zyprexa, cause weight gain, physical tremors (called tardive dyskinesia) and, according to some studies, cognitive decline and brain shrinkage. Before the introduction of Thorazine in the 1950s, Whitaker asserts, almost two thirds of the patients hospitalized for an initial episode of schizophrenia were released within a year, and most of this group did not require subsequent hospitalization.

Over the past half century, the rate of schizophrenia-related disability has grown by a factor of four, and schizophrenia has come to be seen as a largely chronic, degenerative disease. A decades-long study by the World Health Organization found that schizophrenic patients fared better in poor nations, such as Nigeria and India, where antipsychotics are sparingly prescribed, than in wealthier regions such as the U.S. and Europe.

A long-term study by Martin Harrow, a psychologist at the University of Illinois, found an inverse correlation between medication for schizophrenia and positive, long-term outcomes. Beginning in the 1970s, Harrow tracked a group of 64 newly diagnosed schizophrenics. Forty percent of the non-medicated patients recovered—meaning that they could become self-supporting–versus five percent of those who were medicated. Harrow contended that those who were heavily medicated were sicker to begin with, but Whitaker suggests that the medications may be making some patients sicker.

A caveat is in order here. Whitaker does NOT claim that medications have no value and that no one should take them. In his talk at my school, as in his book, Whitaker acknowledged that many people benefit from psychopharmacology, especially over the short term. But he does believe that the drugs should be administered far more sparingly.

Several possible objections to Whitaker’s case against psychiatry come to mind. First of all, the recent surge in mental disability may stem not only from iatrogenic effects of medications but from other factors, notably a decrease in the stigma associated with mental illness, which has spurred more people to seek and obtain taxpayer-supported treatment and assistance. Also, patients who are heavily medicated may not fare as well over the longer term as patients who receive fewer drugs because the former are truly sicker (as Harrow suggested). In her review, Marcia Angell called Whitaker’s book “suggestive, if not conclusive.”

Anatomy has received other recognition. It won the 2010 Investigative Reporters and Editors Award for Investigative Journalism. A review inNew Scientist concluded that Whitaker’s arguments seem “far-fetched” at first but on closer examination “are worryingly sane and consistently based on evidence. They amount to a provocative yet reasonable thesis, one whose astonishing intellectual punch is delivered with the gripping vitality of a novel. Whitaker manages to be damning while remaining stubbornly optimistic in this enthralling and frighteningly persuasive book.” At the very least, Whitaker’s claims warrant further investigation. Check out his book and make up your own mind.

The persistence of “color therapy” reveals the weakness of conventional treatments for mental illness.

I recently reported on the proliferation—or persistence—of treatments for mental illness that involve stimulating the brain with electromagnetism. These electro-cures (my term) confirm a thesis I advanced in my 1996 Scientific American article “Why Freud Isn’t Dead.”

Freudian psychoanalysis has been vilified as a pseudo-science ever since its inception. It nonetheless endures not because of its merits but because science has not produced an indisputably superior theory and therapy for the mind. (For evidence of the persistence of psychoanalysis, see this article in The New York Times Magazine.)

A corollary of my thesis is that treatments for mental illness never really vanish; they just go in and out of fashion. I recently came upon another example of this phenomenon. A friend who enjoys perusing the New York Times archives sent me an article, “Use Colors to Cure Insane,” published October 26, 1902.

The “color cure,” devised by physicians in an asylum on Wards Island, involved putting mental patients in rooms dominated by a “primary color.” “The walls are painted in vivid color, the bed and chair colored to correspond to the walls, and the light sifts into the room through a shade of the same color,” the Times explains. Patients with acute mania were put in black rooms, patients with melancholia in red rooms. “There are violent rooms for mild forms of insanity; blue and green rooms for the boisterous, and a white room for the person who is practically well.” The reporter described watching a melancholic woman who, when shown a red room,

“raised her head instantly, looked into the room, and then about her. The vibrations produced by this room had evidently been felt by her, while the [differently colored rooms] had no effect. In this way the room is generally selected for the patient. Of course, when the case of melancholia is so bad that nothing will attract attention, a red room cannot be supposed to have immediate effect, but after a week or two weeks in this room some slight improvement may be noticed; the glance of an eye, the motion of a hand or the head mean much to the doctors—more than the layman would ever imagine.”

The Times stated that “the color cure is new to alienists, but one that promises to become very successful.”

The “color cure” hasn’t become “very successful,” but it has never entirely vanished, either. Called “color therapy” or “chromotherapy,” it has persisted as a treatment for mental (and physical) disorders. See this 1982 New York Times article, which claims that “the ancient and once discredited field of chromotherapy has been rejuvenated”; and this 2005 review in the journal Evidence-Based Complementary and Alternative Medicine, which calls chromotherapy “a centuries-old concept used successfully over the years to cure various diseases.”

WebMD notes that while chromotherapy is used to treat a wide variety of disorders–from depression and anxiety to diabetes and high blood pressure—there is “no reliable scientific support” for the treatment, which is not a licensed practice in North America.

My online research turned up dead ends, such as “Color Cure,” which turned out to be a car wax. But see this website, which markets “color therapy workshops”; and this one, which sells color-therapy products, ranging from the “Photodynamic Therapy Device,” for $119.95, to the Pro Color Therapy Unit, for $1696.68. If you can figure out how these things (supposedly) work, please inform me in a comment.

Pardon my belaboring the point, but there would be no market for color cures if mainstream treatments for mental illness—namely medications and psychotherapies—were truly effective. Color cures aren’t dead for the same reason that Freudian cures, Jungian cures, behaviorist cures, electromagnetic cures and Buddhist cures aren’t dead.

I realize that my reporting on mental health is relentlessly negative. A friend recently made me squirm by asking: “What do you have to offer the severely depressed person? If there is no proven therapy, people will opt for unproven ones. What else can they do?”

This dilemma is similar to that posed by cancer and other diseases that mainstream medicine has difficulty treating. If someone you care about is suffering from a treatment-resistant disease, should you dissuade her from pursuing unproven therapies? Perhaps not, if the therapy gives her hope, or a feeling of empowerment.

But I would advise against unproven treatments that are costly, time-consuming and potentially harmful. That criterion would rule out some conventional as well as alternative treatments. But it would not rule out exercise, meditation, yoga, improved nutrition (such as reduced consumption of alcohol, sugar and caffeine) and free support groups (such as Alcoholics Anonymous).

The public is deeply skeptical about the profession—but given the problems of addiction, depression and other forms of mental illness, we need it more than ever

• By Nathaniel P. Morris on August 11, 2016

Psychiatry needs help.

Mental health has become a national issue, as growing numbers of mentally ill people have filled our streets and our jails. Yet the public remains deeply skeptical of psychiatrists, our doctors best equipped to care for these patients.

In a 2012 Gallup poll, 70 percent of Americans surveyed felt that medical doctors have “high” or “very high” standards of honesty and ethics. By comparison, just 41 percent attributed the same traits to psychiatrists, though psychiatrists are in fact medical doctors. That Gallup even separated psychiatry from the rest of medicine in the survey says a great deal about perceptions of the field.

Despite recent advances in the diagnosis and treatment of mental illness, many still view the work of psychiatrists as a kind of pseudoscience, somewhere between neuroscience and voodoo. A recent British studypresented to the Royal College of Psychiatrists found 54 percent of surveyed patients did not know that psychiatrists have a medical degree. Even more troubling, 47 percent of these respondents said they would feel uncomfortable sitting next to a psychiatrist at a party.

These misconceptions have a crippling effect on mental health care. In the US, psychiatry remains among the least desired specialties to apply into, struggling every year to recruit new doctors. Psychiatry programs attract medical students with lower board scores and fewer academic honors on average compared to other specialties. Friends and family often deride applicants for choosing psychiatry, including me when I joined the field.

So at a time when we need psychiatrists most, we instead face a growingshortage of these critical providers. According to a study published last month in Health Affairs, the ranks of practicing physicians in the US as a whole increased by 14.2 percent between 2003 and 2013, whereas the number of practicing psychiatrists actually declined by 0.2 percent. Many patients with mental health needs face lengthy waiting times and difficulty getting the right care.

So where do we go from here?

Mental health advocates have called for an array of policy changes. Better salaries might draw more providers into the specialty. More funding for mental health research could fuel discoveries like blood tests or novel therapies that propel psychiatric care in new directions. Tying the classification of mental disorders more closely to neuroscience might enhance public trust in the validity of these diagnoses.

These reforms are badly needed. But, to save the field, psychiatrists also need a wake up call. When it comes to reinforcing stigma against the profession, we can be some of the worst offenders.

In hospitals across the nation, psychiatrists often distance themselves from their medical training, refusing to perform physical exams on patients and consulting other specialists for basic medical questions. Don’t we also complete medical school and residency? Psychiatrists must be able to maintain their clinical skills and to recognize the varied medical causes of psychiatric symptoms. We need to work at the interface of mind and body in order to provide the best care for our patients.

Then there’s the matter of medications. Many label psychiatrists as “pill pushers,” and higher insurance reimbursements for drugs over talk therapy have indeed driven increased prescription practices. Yet psychiatrists also bear some of the blame for this reputation. Too often, we turn to the prescription pad when we should be taking the time to sit down and to figure out the root causes of a patient’s symptoms. It’s far easier to change a dose or add another pill than to do the hard work necessary to treat mental illness. These shortcuts are convenient, but detrimental to both the profession’s reputation and patient care.

In the media, psychiatrists who misuse their expertise further harm the credibility of the field. Despite warnings from the American Psychiatric Association, psychiatrists regularly analyze public figures, like President Obama or Donald Trump, without ever meeting these individuals. Others use their credentials to promote pseudoscientific ideas, whether claiming demonic possession is real or analyzing Superman’s emotional issues.

Psychiatry has come a long way from the barbarisms of lobotomy and the fallacies of Freud. Today, it can be among the most inspiring medical specialties. We stabilize the acutely suicidal and care for those gripped by depression, ensure the safety of the psychotic and save patients from the ravages of addiction.

But the field still struggles to be taken seriously, even as our patients need us more than ever. To restore it, psychiatrists must not only step into the policy arena, but we also have to address these self-inflicted wounds. In doing so, we can lessen the pervasive stigma against mental illness and help turn around our ailing profession.

A new law requires better insurance coverage for mental illness

It too often ends in tragedy, but specialized training for officers is starting to make a difference

You’ve undoubtedly heard about the recent report issued by the Civil Rights Division of the U.S. Department of Justice condemning various police practices in Baltimore. What has gone largely unmentioned, however, is the report’s detailed review of how encounters between police and people with mental illnesses result in “unnecessarily violent confrontations.”

This situation should resonate with every community and every law enforcement agency in the U.S., and the solution isn’t as straightforward as providing “more training” to police officers.

A few years ago, Behavioral Health System Baltimore collaborated with BPD, incorporating new dimensions to basic training for all officers to ensure that interactions with people with mental illnesses are safe and “mutually beneficial.” In partnership with the National Alliance for Mental Illness, BPD became an early adopter of “Crisis Intervention Teams (CIT),” providing additional, specialized training to select officers.

Why, then, despite these efforts, is the DOJ report so replete with examples of encounters between police and people with mental illnesses that result in someone getting hurt? And what does this say about the majority of police departments in the U.S. that have not begun to make the changes that Baltimore has already instituted?

The police department of Portland, Maine offers a helpful case study.

Portland Police Chief Michael Sauschuck has required 40 hours of CIT training for not just some, but all, police officers. He also hired a mental health clinician, Jo Freedman. He sent a clear message to all officers: Jo is one of us. When an officer is dispatched to respond to someone who is suicidal, homicidal or acutely psychotic, Jo accompanies them. Because of Jo, fewer officers find themselves spending hours trying to get a person mental health care. She has become so indispensable that the chief decided to hire a second clinician. Interactions with people in crisis happen every day at all hours, every day.

Before Jo joined PPD, police frequently dealt with one homeless man, who we’ll call “Bill.” Officers regularly tried to escort Bill out of the park. Bill resisted, and encounters grew tense. Bill often ended up in handcuffs, booked into jail and released days later.

Today, Jo looks out for Bill on the streets, and when she spots him, she invites him for a cup of coffee, which often concludes with her escorting him to the community mental health center. The chief and behavioral health providers in the city have worked hard to ensure an easy handoff and they review data to assess their partnership.

Is that success? Jo explains: “We wave goodbye at the community mental health center, but the next day, Bill’s back on the streets—still homeless, still using illegal drugs to calm the voices in his head.”

The Portland Police Department showcases the use of many innovative approaches to improve encounters between police and people with mental illnesses. But that example also reminds us that transformative change depends on nothing short of a comprehensive approach comprising five components.

Leadership: Police executives must instill the value that thoughtful responses to people with mental illnesses is the essence of good, smart policing, which increases officer safety. At the same time, administrators of health systems must prioritize work with law enforcement in the development of provider networks.

Training: Officers must be able to recognize symptoms of mental illnesses and have the skills to engage someone in crisis and deescalate incidents.

Data: Limited police and health resources need to be concentrated on those people with whom their systems are in regular contact. And, data provides an essential benchmark to determine whether the collaborative plan designed is yielding the intended results.

Crisis Care Response: Officers should be able to take a person with acute mental health needs to a nearby 24/7 facility, where the officer knows healthcare providers will serve the person. Mobile crisis teams and emergency rooms are other aspects of suitable crisis care response.

Continuity of care: A community-based system of care ensures that a person with a mental illness and a co-occurring substance use disorder stays connected to treatment, and receives other supportive services such as housing.

Who’s responsible for making all this happen? Neither police nor behavioral health can do any of the above single-handedly. There are approximately 18,000 independent local law enforcement agencies across the U.S. Each community has a different maze of overburdened mental health services, substance use treatment, and housing supports to be navigated. In many rural communities, there simply aren’t any of these services available.

But, none of this justifies inaction. Lives are at stake. The Washington Post reported that in 2015, 25 percent of uses of lethal force by police involved someone with a mental illness.

Officials in local and state government, along with their partners in the community and federal government, have access to relationships, policy levers and resources.  Working together, they can advance not just one, but all, of the strategies described above. That’s what it’s going to take to protect the safety of officers and to make sure that Bill, and millions of others like him, get the help and support they need.