I was immediately taken by this picture showing the antecedents of depression when it was projected on a screen last week in a lecture on medical nihilism. The lecture was given by Jacob Stegenga, a philosopher of science, who defined medical nihilism “as the view that we should have little confidence in the effectiveness of medical interventions.”
I was there because I’d been asked to respond. I argued that good doctors were instinctively medical nihilists, trained to be sceptical of claims for new treatments and cautious in prescribing them. I used one of my favourite quotes to illustrate the point: “Good surgeons know how to operate; better surgeons know when to operate, and the best surgeons know when not to operate.” The professor of philosophy chairing the meeting, a terrifyingly skinny and humourless person, was annoyed that I’d agreed with rather than refuted Jacob. (I also argued that although doctors may be medical nihilists, most of the public are not–fuelling exaggerated expectations of the effectiveness of medicine, rising costs, and an unhealthy denial of death.)
Jacob’s point in showing the picture was that there is something simple minded in the idea that a drug could “cure” depression when it is such a complex condition with so many interlinked antecedents. He quoted a Time article that praised Prozac for hitting depression with the precision with which a Scud missile hits an enemy’s bunker. He also dwelt on the Hamilton scale, the standard way of measuring depression, and illustrated how small–and quite probably meaningless changes–could make the difference between “having” and “not having” depression and deciding that a drug “worked” or “didn’t work.”
There are great challenges in working out whether antidepressants “work” when they have such a powerful placebo effect, but what I am sure about is that they don’t “work” as antibiotics work in killing a bug. Rather they have some general effect on the brain–just as alcohol has a general (but not necessarily the same) effect. But I find it impossible to believe that 60 million prescriptions for antidepressants in Britain are doing more good than harm.
Looking again at the picture, I reflect how it in some ways matches William Styron’s brilliant and insightful first person account of the complexity of depression. Science and literature come together. http://blogs.bmj.com/bmj/2016/06/06/richard-smith-depression-a-description-of-the-near-indescribable/