Saturday, 31.10.2020

Edward Shorter’s comment

Trudo Lemmens: Promoting pharmaceutical treatment in a context of knowledge deficit: the case by the CINP Task Force in Depression

 

             When the troubled history of psychopharmaceuticals is written 50 years from now, a separate chapter will be given to one of the main dramas in the story:  How a drug class of indifferent efficacy – the SSRIs – could have swallowed four-fifths of the field of psychiatry, elbowing aside past medications of proven efficacy and creating billions of dollars in Pharma profits.

             This victory march proceeded under the banner of “depression,” said by the ill-rumored CINP Task Force on Depression to be vastly underdiagnosed and unacknowledged.  Sadly, the contrary is true.  Depression has become a yawning, dark cave into which the study of psychopathology has disappeared:  Today, untold numbers of patients  receive the diagnosis “major depression” and are treated with “SSRIs,”  although reuptake inhibition may be more a commercial concept than a therapeutic one  (It is, of course a scientific concept, but of questionable therapeutic importance).   Given that there is today only one form of depressive illness – “major depression” – and that its psychopathology is reduced to a brief DSM-style symptom checklist – who needs the study of psychopathology?  Psychiatry has one principal diagnosis and one principal class of agents for it.  The hand fits the glove perfectly.           

             When this story is written 50 years from now, the small clutch of whistleblowers, whose piercing yells are largely ignored, will receive more than footnote status.  Their number includes David Healy, Thomas Ban and Trudo Lemmens.  And right now under discussion is Lemmens’ contention that the CINP Task Force was a con job, and that Pharma has managed the control of knowledge in such a manner as to make the SSRIs seem the safest and most effective drug class on offer, and “depression” appears to be a devastating global epidemic that all of us struggle bravely to combat.  Lemmens is right.  This is nonsense.

             As historians 50 years from now take to their work, they will want the chapter to begin not with the CINP Task Force, but with DSM-III in 1980.  It was this third edition of psychiatry’s diagnostic “bible” (to use this hideously inappropriate phrase) that began the mischief.  DSM-III, of course, abolished psychiatry’s two traditional depressions – melancholia and non-melancholia – and gave us “major depression.”  (A veritable cornucopia, DSM-III also gave us “bipolar disorder,” created in 1948 by German psychiatrist Karl Leonhard.)  Major depression then became the flag under which Prozac (fluoxetine), the first SSRI, marched forth in 1987.  From a study of the DSM-III files in the archives of the American Psychiatric Association, I can vouch that the pharmaceutical industry had nothing to do with the creation of “major depression.”  It was a category that Robert Spitzer created in order to convince the psychoanalysts that their favorite diagnosis, “depressive neurosis,” was really a bit old hat and that there was actually only one depression, so don’t feel bad, you chaps with the couches.

             But even though industry had nothing to do with the birthing of “major depression,” it was a great gift to them because now they had a fixed, supposedly specific, disease target to shoot at.  And, as Lemmens demonstrates, it was with a good deal of data twisting and turning and behind-the-scenes influencing at FDA that industry gained approval of the new SSRIs.  Victory goes to the swift.  Lilly originally wanted to bring out fluoxetine as a weight-loss drug and now it was the world’s best “antidepressant.”

             Tom Ban was right.  Lemmens quotes him as advocating the identification of “treatment-responsive subpopulations,” and this is exactly what’s needed.  Breaking up “major depression” into smaller, homogeneous groupings, not all of which will be mood disorders.  There is a huge interpenetration of psychosis and mood.  The Kraepelinian firewall, continued in DSM, between the two should be dismantled, and we will see what the real entities are.  Then we can develop real medications to treat them.

 

June 15, 2017