The Emperor's New Drugs [Kindle Edition]

I have conflicts of interest to declare. I'm a physician but I also write. I share a publisher (Random House UK) with Irving Kirsch and have written for them about the damage done by doctors who don't subject their ideas to reliable tests. Because of this I was asked if I'd provide a recommendation to go on the dust jacket of Kirsch's book. I was familiar with his work, having read his medical journal articles analysing the evidence behind antidepressant tablets. On that basis I sat down to his book expecting that I'd probably be able to say something nice about it. I thought it'd most likely amount to saying that Kirsch's research is important and interesting and should be mandatory for doctors involved with antidepressant prescriptions.

This book, though, isn't worthy & technical - it's fascinating. It's a remarkably readable account of how we got carried away with an idea about the brain that isn't true. You don't need to have an interest in depression and you don't have to be a medic; this is a thoughtful look at how bright & well-meaning people get enchanted with an idea & go on to fool themselves and everyone else. It isn't a doctor-bashing book, nor one that pushes the author's own pet therapy. Instead it gives a lovely insight into the way science works, and the way it can sometimes gets done so badly that it doesn't work at all. Kirsch argues antidepressant tablets are based on a false pharmacological model of the brain, and that the balance of evidence shows they don't work except as placebos. Even if you're not persuaded by Kirsch's thesis - and I think you should be - you'll find his ideas thought-provoking.

For most of human history, going to see a doctor was a bad move. We did more harm than good. We trusted our intuitions instead of performing experiments capable of testing them. The people who used leeches for thousands of years were smart, motivated and thoughtful and they killed their patients. They believed they could figure out what worked without decent scientific method, even when the nature of that method was widely understood. Kirsch's modern story gives an insight into why we used to be so bad and it reminds us we're still a long way off being perfect. An enjoyable and an intellectually captivating read.

I've often felt that there should be an Anti-Nobel Prize for Medicine. This would be given not for discovering something new, but for discovering that something we believed deeply wasn't true. If there were such an award, Irving Kirsch would be up for it.

We have known some fundamentals about depression for decades: It is caused by a biochemical imbalance, the imbalance is in the serotonergic system, antidepressant drugs targeting this system somehow correct the problem, and they do so safely and with an excellent risk to benefit ratio. As the data have accumulated, however, the elegance and sense of these ideas have given way to confusion. In terms of Kuhn's concept of paradigm shifts, the evidence is tilting us uncomfortably from a belief in the origins, nature, and pharmacological treatment of clinical depression, toward a period of confusion where the older ideas collapse but have yet to be replaced by a newer model.

Few have done more elegant and powerful work in this area than Kirsch. As a psychologist specializing in depression, I have followed his articles closely since his work on this topic began coming out over ten years ago. As you read the book, you can begin to get a small chirping annoyance that takes a while to find its way into awareness. With all due respect to Kirsch: "This seems like good work, but it's not exactly rocket science. It's a bit obvious to go back and look at all the data to see what has actually been done, which of it has been published, and what it actually shows in terms of effectiveness. How is it that no one did this before?" You are led to two possibilities: Either people connected with the work see the problems and ignore them, or the quality of the science in this field is pretty low. And if it's this low for antidepressants, then...?

Kirsch writes in a beautifully clear style, carefully stating each problem, the means to investigate it, and the outcomes of the analysis. He does so in a very accessible way. No one should have difficulty understanding the implications or following how he reaches his conclusions.

I'm not certain, but I don't believe I have ever used the term "required reading" in a review before, either on Amazon or elsewhere (I may be mistaken). For mental health professionals and for all prescribers, THIS book (or the peer-reviewed research on which it is based) should be required reading. For those suffering from depression, I have to say it's a discouraging read, both because of the pessimistic conclusions toward which the data inevitably point, but also because it casts the fields of psychopharmacology and mental health in such an unflattering light.

The goal of some forms of therapy is to relinquish one's illusions. Disillusionment is painful medicine, but it may be more helpful than what we have so far been dishing out.

Irving Kirsch presents exquisite and exhaustive research which concludes antidepressant drugs are in fact, placebos. He explains why and how placebos work. He argues against the chemical imbalance theory of depression and says it has never been proven. He also compares outcomes of Cognitive Behavioral therapy with and without antidepressant medication and concludes that a patient's "hope" for recovery is the fulcrum on which successful treatment rests. As a clinician, I have experienced the power of hope in alleviating suffering in moderately and severely depressed diagnosed patients and those in the throes of an existential crisis, which often is misdiagnosed as depression or an anxiety disorder. Sometimes in treatment, less is more. Kirsch states that SSRIs can help ... as much as any placebo... but instilling hope in a patient is what really works; there are no detrimental side effects, and hope and tools aquired in CBT have been shown to have more lasting results.