Book World: 'Comfortably Numb'
Tuesday, March 4, 2008; 3:00 PM
Charles Barber, author and lecturer at the Yale School of Medicine, was online Tuesday, March 4, at 3 p.m. ET to discuss his book, "Comfortably Numb: How Psychiatry Is Medicating a Nation," which was reviewed in
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A transcript follows.
Washington, D.C.: I was born in 1950 and succumbed to the extreme anxieties of the 1950s. I was afraid all of the time. In a sense, I was numbed by anxiety. I didn't experience much else. Ten years ago I discovered what life could be like taking a minimum dose of Zoloft originally & now Celexa. This drug has changed my life. I am far from numb. Now I experience joy, sadness, excitement etc -- all emotions that were blocked to me when anxiety ruled my life. So I wonder -- aren't you afraid that the title of your book alone will discourage people from exploring the possibility that these drugs can actually enhance emotions, not numb them?
Charles Barber: In my book I am very clear that the drugs can be very effective for those that need them - those with clear psychiatric diagnoses. It is their over-use, and the lack of attention to other approaches, that I write largely about in the book. I am nothing if not a pragmatist - if it works for you, god bless!
Washington, D.C.: I think that you are really onto something big and thank you for raising this issue. Two years ago I became severely depressed and also suffered from debilitating anxiety disorder. I went to a psychiatrist who prescribed Celexa. The medication enabled me to become stable enough to undertake successful talk therapy and recondition myself to avoid panic attacks. A year after I began taking the Celexa I told my psychiatrist that I wanted to stop taking it, which surprised him. I said I did not want to live my life on medication unless it was absolutely necessary. Without encouragement from him, I stopped the meds successfully. I rediscovered the feeling of absolute joy, as meds limit the highs as well as the lows. I sometimes get anxious and mildly depressed, but I work through it. I find it troubling that every time I describe any unpleasant feeling to my psychiatrist he recommends that I go back on Celexa. Celexa helped me and I am comforted by the fact that I could go back on it if I encounter a real crisis again but my psychiatrist seems to think I should go back on it every time I have a nightmare.
Charles Barber: Thanks for your comments. What you are addressing is what I write about in a chapter in the book, Cogito Ergo Sum, about cognitive therapy (and to some degree, other therapies), which can take a deeper approach - helping the patient look at the underlying issues beyond their depression, and teaching skills to master or better control depressive feelings in the future. For mild to moderate depression, the outcomes for CBT are very strong for many people - and often with lower relapse rates (i.e. return of depression), which only makes sense because patients are fundamentally looking at the beliefs and attitudes and cognitive distortions that can underly depression, at least in its milder forms.
Which leads me to some thoughts regarding the Post review of my book, which was the proverbial not so good review. The reviewer contended that a lot of my alternative approaches were sort of mushy-headed. Not so. There is a lot of data to support these "psychosocial approaches" (CBT for example has almost 400 outcome studies to support it) She also critiques very interesting new models of understanding the complexity with which people change, and how to help them change (specifically Motivational Interviewing and the Stages of Change model) which she describes as "wooly." I think these are elegant theoretical models, very helpful in actually working with people, and Motivational Interviewing in particular has a lot of studies that support its effectiveness for many people.
Roanoke, Va.: How applicable are the techniques proposed by Freud in treating patients these days?
Charles Barber: Well, not so applicable, in many ways. Partially for pragmatic, economic reasons - not so many people have the time and money to get to daily or nearly daily psychoanalysis. Also the kinds of therapies and approaches i write about in the book are far more practical, targeted, goal-oriented, which generally speaking, result in far more practical results, and attainment of those goals. However psychoanalysis has its place. My personal take on it is that when it suits the learning style of its recipient (for analysis, verbal, narrative and insight-oriented people) it can be very effective. But most people don't meet that profile exactly. WHat i try and get at in the book is that people should become aware of an array of treatment choices. For some people, analysis may be the correct one.
Harrisburg. Penn.: What percent of high school students are on prescription medication for psychological reasons? Is this leading to any changes, positive or negative, on their abilities to learn?
Charles Barber: The rates have gone up dramatically in recent years, including for drugs that were rarely prescribed for young people before, like antipsychotics. It used to be true a long time ago that the use of these kinds of meds for young people was all but taboo - those days are long gone. The ADD/ADHD drugs can be very effective, and help kids learn. But again, I think they are over-prescribed and parents are sometimes not looking at commonsensical issues like diet and parenting styles.
Freising, Germany: In the Washington Post's review of your book, when I read, "when a therapist speaks to a patient . . . the action of neuronal machinery in the therapist's brain is having an indirect and, one hopes, long-lasting effect on the neuronal machinery in the patient's brain", I was reminded of reading once that the longer a person suffers from depression, the more likely that there'll be a permanent change in the person's brain-chemistry. These changes will increase the likelihood that the person will lapse back into a state of depression.
Is there any truth to the statement that depression can permanently alter the chemistry of the brain, or as you call it, the neuronal machinery? Does medication allow the brain to return to its original condition, or does the depressed patient tend to rely on medication for the rest of their lives?
Charles Barber: That quotation is from Eric Kandel, a psychiatrist who won the Nobel Prize in 2000. (And here again I respectfully take issue with the reviewer. SHe cited that quote as being from "a researcher": well in this case, it's a research who won the Nobel Prize, who arguably has been the most influential psychiatrist in the world in recent years, and whose work, in my view, is unassailable. So to call this and my other citation, that psychotherapy can result in detectable changes in the brain, as "questionable neurological arguments" is misguided in any case.
But to try to answer your question -- the more i spoke to neuroscientists (and I am not a neuroscientist), the more i learned that depression is a murky business indeed. What causes it, what remediates it, what exact path to follow to address it, is very difficult. I spoke to one top researcher who said that we now think of as depression is probably 30 different illnesses. Some day we will identify much better what those typologies are, and come up with more rational treatment plans, and understand much better how meds and therapy alter the chemistry of the brain, but my take is that we are in the very early stages of appraoches that ultimately be a tonic to the world's ills.
Richmond, Va.: What's your take on those for whom the meds don't really work? What are their options if cognitive therapy & meds keeps things from getting tragic (i.e. suicide) but they still have crippling anxiety and other disorders that run their lives and the lives of those close to them?
Charles Barber: Well, that's very hard. There are people who are treatment resistant or who just don't respond to meds or therapy. It sort of goes back to my reply to the earlier question -- as we perhaps understand depression or anxiety in all its expressions better, we will expand the array of treatment choices (and there are some areas of work in depression that explore entirely new paradigms for treating them).
I was struck by an interview i did with an eminent neuroscientist for the book. Most psych drugs deal with one or two of about 4 neurotransmitters, dopamine and serotonin are the best known. I asked this person: why just these 4, when there are potentially dozens, hundreds of neurotransmitters. Is it because the 4 we are working with now have the most impact on thought and mood problems. He said, no, potentially there are dozens of other neurotransmitters that might have as profound an impact on problems like depression and schizophrenia. and so again what we have available now doesn't work now for someone may change, and we may have an array of choices later.
and i should probably add here my usual caveat -- i am not a psychiatrist or psychologist, just an informed writer, and someone who has worked with people with severe mental illness for many years. but i am not here to give clinical advice.
Silver Spring, Md.: Dr. Barber,
What is the ratio of SSRIs and other drugs intended for psychiatric practice being prescribed by non-psychiatric practitioners compared to psychiatrists or psychiatric nurses? Diagnosis by a non-specialist is concerning and I understand that it is a reaction to a number of problems such as public health cost and stigmas regarding psychiatric care.
Charles Barber: The majority of antidepressants are now being prescribed by non-psychiatrists, usually family doctors and ob-gyns. As you say, this is a big concern. Family doctors are often not wholly versed in diagnostic criteria for depression and other psych disorders (and even if they are, they don't have the time, in the managed care environment, to do a proper screening). And studies have shown that docs are influenced in their prescribing patterns by people who have seen the drug ads on TV and ask their doctors for the prescription. For psychiatric care, a critical issue is follow-up and regular contact with a professional. That realistically doesn't happen with many family doctors. So this move away from psychiatrists' prescribing can have some scary implications, particularly when dealing with drugs like antipsychotics.
You're right, stigma is a problem. People don't want to go to a psychiatrist necessarily, and to be fair - it's hard to get to see them, particularly child psychiatrists. But whenever possible, go to someone who is really expert in the drugs and diagnosis.
New York: How do you respond to the general accusation (not specific to you or your book, necessarily) that folks like you are akin to those who a few years ago were bemoaning a welcome increase in the amount of pain medication we were entitled to, and that your real interest is saving the insurance companies money?
Charles Barber: Well I'm not working for the insurance companies!
Durham, N.C.: Can you say approximately what percentage of Americans are on psychiatric medication now?
Charles Barber: There have been studies that have shown more than 11 percent of American women and 5 percent of American men were taking antidepressants, in a given year, a few years ago. That does not include antipsychotics and mood stabilizers. If I recall correctly, there was a study that showed that 48 million Americans took psychiatric drugs between 2002 and 2004. The numbers are huge.
Salinas, Calif.: Charles, thanks for holding this chat. I don't know if this is addressed in your book, but I am concerned about what I feel is the undue influence that the pharmaceutical industry places upon the medical profession and the public. When TV viewers are encouraged to "ask your doctor if ________ - [fill in the blank] is right for you", are physicians able to resist the public demand for prescription medications driven by drug industry marketing considering the economic stresses that doctors are faced with today?
Charles Barber: I quote a study in the book in which an enterprising researcher hired actors and other people to act depressed. (they were not depressed, they were acting depressed.) When the actors asked for an antidepressant by name, they got one half the time; when they asked for any antidepressant, they were were prescribed one 3/4 of the time; and when they asked for no drug, they were prescribed one a third of the time.
Other studies have shown that docs can prescribe a particular drug that patients ask about (and probably have seen on TV), even if the doc feels ambivalent about the appropriateness of the drug choice.
So clearly it influences clinical practice. These TV ads for drugs are unpopular with many doctors, and some i believe have called for them being banned. (It is only in New Zealand and the US that TV advertising of drugs is legal).
If there were one reform to make, in my opinion, that would be it.
And yes, it is addressed in my book.
Silver Spring, Md.: Some people with only mild disorders may be taking anti-depressants. Many other people with more severe problems, however, self-medicate with alcohol or other substances because of the stigma still attached to taking anti-depressants among many people. In macho fields like law enforcement and the military, many people will not take or acknowledge taking anti-depressants or anti-anxiety medications. In those communities, despite the increasing information about PTSD and other stress-related conditions, even talk therapy for depression still carries a stigma. Therapy is seen as somewhat acceptable if it is for marital problems, grief counseling, or dealing with wayward adolescents. Taking anti-depressants and getting therapy still raise certain red flags when pursuing a security clearance.
Charles Barber: Yes, stigma abounds.
But one of the more positive aspects of the medication revolution is that stigma has been reduced, at least for milder conditions. As I say in the book, it's okay to say you're a little depressed and say you're on Lexapro, at a cocktail party. And it's okay to say it on Oprah if you're also publicizing a hit movie.
But the reduction in stigma has only cut so far. Try telling the person at the cocktail party that you're hearing voices. It is no longer so chic. And so what we've seen is that people with serious and persistent mental illness (like the homeless mentally ill, with whom i've worked for many years) are still largely not in any treatment (and it is for this population that the meds can be very effective), and people with milder conditions are almost more likely to be in treatmetn (or at least taking antidepressants.) I quote a medical historian who says, one's chances of being in treatment almost go up as the severity of one's condition goes down.
Harrisburg, Penn.: Is there any data indicating the number of violent incidents are increasing due to people who are under medication? Is it possible to hypothesize that some types of violence in our society are related to side effects of legal medication?
Charles Barber: I don't have the data on that. I'll just make a general comment.
Violence perpetrated by the mentally ill is vastly over-reported and sensationalized by the media. The true risk for violence with the mentally ill is hurting themselves, not other people. I ran facilities for people with schizophrenia for many years - we had one aggressive incident by a client, but we had 3 suicides. I didn't worry about my clients hurting other people, i did worry about them hurting themselves.
Research has also shown that it is not mental illness that makes people violent; it is the addition of substance abuse with mental illness that can increase the violence. i quote a study in the book of people leaving a pscyh hospital. they were no more violent than their neighbors. but when substance abuse was added, the rates of violence were higher.
also people with mental illness are about 11 times or something more likely to be murdered and have violence and perpetrated on them than the average person.
Chevy Chase, Md.: Thank you for articulating these important issues. I wonder if you can address "discontinuation syndrome," ie withdrawal. Tolerating the side effects from Cymbalta no longer outweighs the benefits of taking the drug for me, so I've decided to try alternative therapies, like meditation. But trying to come off the drug has been a nightmare. Even slow tapering hasn't worked. Shouldn't doctors be wary of prescribing these things if they seem to have addictive tendencies? Thank you.
Charles Barber: Some patients seem to have a great deal of difficult getting off the drugs, and in particular, for certain drugs. It is important that the tapering off occur slowly and under supervision. The web is filled with stories by patients who describe bad withdrawal and discontinuation symptoms. This was an aspect of the SSRIs in particular that was overlooked in the optimistic glow when the drugs first came out. The SSRIs by contrast with an earlier generation of antidepressants appeared to have far less side effects, and they generally do. But that contrast lulled people into thinking there were little to no side effects, or difficulty getting off the drugs for some people.
Drugs are powerful agents, often very important and effective (and I am very clearly in my book that they can be life-saving for people with major psychiatric conditonis), but they are powerful and need to be taken and monitored responsibly.
And that would be another point i would respectfully take issue with the Post review. He or she thinks that i have a confused perspective on the drugs - and I would grant that these issues are very complicated. But to say that antidpressants are of great help in some cases, and useless or worse at other times, is not to me a contradictory or confused statement, merely a nuanced one.
And mental illnesses are nothing if not complicated. There is a great temptation to want simple explanations and simple solutions. I quote someone who says that people cling to simple and easy solutions for mental illness the way that poor swimmers cling to a raft.
I caution against anything that is supposed work all the time, or even most of the time. Most treatments in my expereince work very well for some of the people some of the time. (and this, i argue is true in most of medicine. very rare is the treatment that cures something, or stops it dead in its tracks). but we as Americans are very impatient with complexity and waiting - we want answers, now dammit, and we want them often with a minimum of hassle, and better yet, we are very happy if the answer can be supplied by a technology that is outside of us. But life and certainly depression does not merit simple solutions.
So again, the importance of exposing patients to an array of things, help them find the thing or the combination of things that works for them, and help them understand that the treatment is rare that will fix everything. There is a rule in medicine - a rule of thirds -- a third of people get better, a third stay the same, a third get worse.
Charles Barber: I am going to sign off here.
Thanks for the questions. The interest in the book has been profound. I've had about an interview a day in the last month that the book has come out -- national TV, national NPR, many newspapers, tons of radio - and i seem to have hit some nerve. The piece i published in the Post on Feb 10 produced 350 emails - to me!
I tend to be pretty good at responding to further questions, via my website: www.charlesbarberwriting.com, though I can't guarantee a timely response, and again, i'm not comfortable with clinical advice to specific questions.
Thanks again, and I am also sort of on the speaking circuit these days, if anyone is interested.
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