PROZAC VERSUS PLACEBO: AN EDITORIAL REVIEW

Introduction:

In May of 2002, the general public was introduced to the following: the use of Prozac compared with a placebo made no difference with two groups of depressed patients. At least that was the headline. We suggest that the popular print literature is filled with relatively similar interpretations of the study with minor deviations in detail. Thus, the general impression for the ordinary reader is that one should not bother with anti-depressants because they don’t work. Further, in the back of their minds, readers may be thinking about other related issues such as the huge cost of prescriptions in general and the dubious nature of psychiatric procedures and related topics Snell et. al (1989.) We want to suggest another alternative.

Review:

The study that generated headlines was the functional neuroanatomy of the placebo

effect Mayberg et. al. (2002) American Journal of Psychiatry, 159, 728-737.  To the credit of the authors/researchers, this is one of the first studies that used a PET scan. They discovered that both groups (prozac vs. placebo) had “similar” changes in cortical (thinking) and limbic-Para limbic (emotional) regions.

Additionally, the talent of the authors, the prestige of the journal, and the esteem generally given to the university of the research scholars increased credibility of the study.

Criticism:

We want to place our criticism at the press rather than the research. The media simplified and over generalized the findings in the study. We want to indicate why we take this position.

First, the study deals with 17 unipolar depressed males who were hospitalized. We want to emphasize that 17 patients do not warrant inferences to general or depressed populations.

Second, they were given either the placebo or Prozac for six weeks. That is too short of a time for some patients to respond to the medication.

Third, they were only given Prozac. The general impression in the medical field and from the expertise of the second author (M.M.) is that a number of different anti-depressants are used until there is one that the patient identifies as efficacious.

Fourth, all the patients experienced other variables that were conducive to depression reduction including rest, hospitalization, support from medical staff.

Fifth, the senior author of the study indicated that the placebo effect on the patients had a short-term effect and that the entire group was put on Prozac after 6 weeks.

Sixth, the authors mentioned that placebos do not work as well as antidepressants in previous studies as indicated in the rather extensive review of the literature.

Seventh, we cannot imagine that a psychiatrist in a legal setting would be able to say that s/he is not liable if they had not used an anti-depressant because it is just like a placebo and thus they are not lawfully accountable for the suicide of a patient.

Eighth, we cannot emphasize how much damage the general press headline has done to the patient and the psychiatric community, when numerous important details and caveats were omitted.

Ninth, we are not here to defend antidepressant therapy as a singular experience. Rather, antidepressant should be given in the context of some form of psychotherapy, particularly a therapy that provides life skills to a patient. We disagree with the “third wave” psychiatrists that the medication alone can heal the patient Snell et. al. (1989), Snell (1994) Snell, Marsh, (1995) Snell, Marsh ,Wakefield (1995.)

Tenth, this rejoinder is meant to defend psychotropic medications when they are properly used and under the care of a psychiatrist and supporting psychotherapist. This is not a defense of pharmaceutical companies.

Conclusion:

The authors believe that the media simplified and over generalized the findings of a small sample of patients, who took medications for a short period, did not take into account the placebo effect of the hospital setting seriously, nor rotate numerous anti-depressants, or take into effect the placebo implications of a hospital setting. In the end, all the patients took the antidepressants and the authors were the first to mention numerous other studies that indicated that the placebo has a short duration in terms of relapse. Other implications were also mentioned.

References Cited:

Snell, Joel (1989) A Note on educational management and third revolution lithium regime, a reassessment and commentary” Psychology: A Journal of Human Behavior, V. 26, #213, and p. 65-69.

Snell, Joel (1994) A prozac future? may help but human touch figures large” Cedar

Rapids Gazette, July 31, p. 4.   

Snell, Joel and Mitchell Marsh (1995) “The efficacy of psychotropic medications for treatment and management of incarcerated offenders” Academy of Criminal Justice Sciences, Panel 198, March 7-11.

Snell, Joel; Marsh Mitchell and Bill Wakefield (1995) The viability of psychotropic medications for incarcerated offender populations” Midwest Criminal Justice Association, Panel 3, October 4-6.