Dorothy Rowe

OpenMind - Journal of the mental health association MIND

July/August 2004

Should We Put Our Faith in Drugs?

Dorothy Rowe

The basis of the debate over whether drugs or therapy is the best cure for mental distress seems to be quite clear. The benefits of therapy are hard to measure, and there are lots of different therapies and therapists, but drugs have been rigorously tested and their benefits and side effects are known. Go to a therapist and you don't know what you're getting. Take a prescribed drug and you'll know it's reliable because it's been carefully researched.

That's the theory, but should we believe it?

Researchers both in the UK and in the USA examined the published reports of studies where one drug was compared with another and found that when pharmaceutical companies fund the research that research usually produces results which favour the drug company's own product but when a disinterested organisation funds the research the results are not so clear-cut. Somehow, who puts the money up for the research affects the outcome of the research.

Research on the effectiveness of drugs can take place in two very different settings, in the academic setting of a university department or in what is called a 'real world' setting of a hospital ward, an outpatients department or a GP surgery. It's been found that real world research doesn't produce as good results as academic studies. There are probably many reasons for this discrepancy but one of them may be that for busy hospital doctors and GPs research is just one of their many duties and may come low on their list of priorities while for academics research is of prime importance. Their careers depend on it. Reading about this research reminded me of how, many years ago, a consultant psychiatrist told me how he got good results for the drugs he was researching. He said, 'I put a notice on the outside of my office door which reads, "Do not fail to tell the Doctor that you are much better, otherwise he will be very angry."' He was joking but his joke had a kernel of truth.

Extensive research has shown that when we consult a doctor we remember only part of the advice we are given, and what we think we remember we often get wrong. Less than 50% of the prescriptions written are actually taken according to directions. Sometimes we take too much of a drug, sometimes too little, and sometimes we don't bother to take the drug at all. In the publications of the Royal College of Psychiatrists there are endless complaints about 'non-compliant patients' and 'treatment-resistant patients'. Patients could equally complain about 'non-listening doctors'. Doctors don't listen is because if they did they're likely to find that their patients had ruined their pet theory.

The drugs currently used in psychiatry have been developed from a theory about how the brain works. For the past 40 years depression has been explained by psychiatrists as a mental disorder which is caused by low levels of the neurotransmitters in the brain called monoamines, namely serotonin and noradrenaline. These pass signals from one neurone to the next. If there isn't enough of these two neurotransmitters communication between the neurones slows down. This is felt by the person as depression. How this slowing down on communication between neurones produces thoughts concerning one's worthlessness and wickedness, utter despair and unforgivable guilt is not explained by this theory.

From this theory came the new antidepressants, the SSRI drugs which increase serotonin levels, the NARIs which increase noradrenaline levels, and the SNARIs which increase both. However, of the patients who are prescribed these drugs only about 50% have a complete remission of their symptoms, while, apart from a small number of severely depressed people, most patients appear to have normal monoamine levels in their brains.(1)

Nowadays many psychiatrist say that, while monoamine levels in the brain are very important, there are other factors which play a part in a person becoming depressed and may play a small part in recovery but that antidepressant drugs are vital in the management of depression. Dr Robert King, a psychologist at the University of Queensland, brought together a huge collection of research reports concerned with the outcome of different treatments for depression. He looked at the kinds of drugs used and the conditions under which they were used, whether drugs were used on their own or in combination with different kinds of therapy, the different kinds of patients and the different circumstances in which they were treated. He wanted to see which of all these treatment methods was the best predictor of whether or not the person would recover. He found that the best predictor of recovery was the strength of the therapeutic alliance. It's not the drugs you take but whether you've found someone to talk to who's not personally involved with you but whom you can trust. But surely the very best therapeutic alliance is the one you can have with yourself.(2)

(1) Peter Farley 'The Anatomy of Despair', New Scientist May 1, 2004.

(2) Dorothy Rowe Depression: The Way Out of Your Prison third edition, Brunner-Routledge.