What makes an antidepressant effective? And what can the placebo effect teach us about patient care in the context of the current American healthcare system?
These are two of the questions I sought to answer when I picked up psychiatrist Peter Kramer’s book, Ordinarily Well: The Case for Antidepressants. But I was surprised by Dr. Kramer’s tendency to brush the placebo effect aside, and to be seemingly annoyed by its confounding existence. In my opinion, what the placebo effect illustrates is that humans respond to the simple act of being cared for by feeling better. How can we ignore that?
This is one way in which conventional medicine is failing us in America today; caring for people takes time, and time is money in a capitalist system. When we examine the nature of mental-emotional-spiritual health, we find that part of its complexity is due to the fact that it is so intertwined with the context in which we live that it cannot be separated. Adequate treatment of mental health requires raising the bar of complexity from, say, fixing a broken leg, which conventional medicine is so well equipped to treat. The context in which we live cannot be addressed with one remedy or several, for substances fall short in addressing the whole picture, whether they are pharmaceutical, botanical, or fermented. Here we must employ whole picture thinking if we are to create real healing.
The rise of holistic medicine is in itself a challenge to the linear, binary thinking of the patriarchal paradigm, and those challenges are often perceived as threats. The fact that holistic medicine has been so discounted over the last century can be squarely placed in this context. Why is this important here? Because fear is hindering our progress. “New” ideas can be threatening to a status quo that is enjoying its own dysfunctionality in the same counterintuitive way that a person will continue to make unhealthy choices that perpetuate bad feelings, because we are afraid of change. We are afraid of the one very certain truth, that nothing ever remains the same, and it is this irony that creates suffering. We are afraid of how much we need each other, of our yearning to be cared for, of the authenticity that asking for help demands, of the authenticity that giving help from a place of love and compassion demands. These raw states of feeling are what makes us human, and being human is challenging.
We are also afraid of what we do not understand. Met with the unfathomable, we tend to panic. We want to measure, to be sure of something. We want to see it spelled out in certain terms in a language that we can understand and repeat back. Instead of this reaction, what if we met that which we do not understand with awe and reverence? An honoring of complexity by meeting it with an equally complex response.
Measuring as a Coping Mechanism
When researchers began studying psychiatric medications they felt inclined to get reductionistic in a place where reductionism is a disservice. The rise of the double-blind, placebo controlled study as the gold standard of medical research is bemoaned by Dr. Kramer in “Ordinarily Well” and this for me was a true revelation! I had previously thought that conventional practitioners across the board believed this but alas, he does not, and neither do many of his colleagues. In fact, they were disheartened that this branch of science, not firmly based in clinical medicine, was discounting the actual interaction between practitioner and patient and the antidotal medical lessons that come out of this interplay. It seems that psychologists and psychiatrists felt a need to defend their observations and practices to researchers, which mirrors the defensiveness that I personally feel as a practitioner on the fringes, or edges, of medicine. It turns out then, that we are not so very different, an encouraging thought in divisive times.
What is clear to both Dr. Kramer and myself is that antidepressant pharmaceuticals can offer enough of a spark, can be enough of a catalyst, to move someone through a difficult state and out the other side. I have also seen botanical medicine, psychedelics, entheogens, and empathogens do the same thing. When effective, all of these remedies are catalyzing change. Is one better than the other? And how does the placebo effect and the act of caring play a role?
My own bias fully disclosed: I believe in the wisdom of nature. I believe that this wisdom is as close to the divine as we can see from our vantage point. The human brain cannot fabricate something more beautiful or whole than this. The human heart, however, has the capacity to embody this wisdom. When we attempt to override the divinity of the natural wisdom of the earth and of our bodies, as they are one and the same, we get into problems. This is where I think pharmaceuticals are ultimately not getting it quite right. In addition, I see in my own practice that patients are not receiving adequate care from either their PCP’s or their psychiatrists. I am going to define care here in terms of availability, accessibility, compassion, attention, consideration, and time. I want to be clear here that I am not faulting physicians themselves, but the systems in which they work.. Dr. Kramer for one seems to use a great deal of psychotherapy in his practice, but this is not typical of the field of psychiatry today. I have heard many stories of patients having four minute conversations with psychiatrists they have never met before and being put on one or several new medications solely based on that conversation, or perhaps worse, kept on medicines that are no longer serving them. Psychiatrist means “doctor of the soul”. As soul work is a long term project, deep in scope, either the practice needs to be reworked or they should change their name. I believe that we can and deserve to feel better than we think.
Many people don’t understand that If a person is in a mental health crisis and doesn’t already have a psychiatrist it could take months for them to get to see one. In this moment of crisis they are left with few options. The primary one is to go to the emergency room. First of all, the ER will only keep you if you are actively suicidal. And then, their job is to keep you from harming yourself, not to help you get better. This is an important role and I’m not undervaluing it, just telling it like it is. There are many levels of mental health crisis besides suicidal thoughts or impulses that the ER can not address. At the ER, they may give you a benzodiazepine (typically Lorazepam), or another tranquilizing medication, keep you for a few hours, and send you home. Occasionally they will give a script for an SSRI, which might be helpful in the longer run but typically take at least two weeks to take effect. Again, the limitation of the ER is not the fault of the practitioners, but of the system, and systems take a long time to change. This current health care system is not equipped to deal with the mental health crisis that we have on their hands. Fortunately, there is much that can be done outside of this system. When appropriate, fuck the system.
I often say to patients who are skeptical of plant medicines that they are just as effective as pharmaceuticals but smarter. It is a bit over an oversimplification, but as those go I do wholeheartedly believe this because this is what I have seen and experienced. I am saying that perhaps plants hold more power and potential than any drug we can create. In addition, they are not regulated by an overarching system that only allows their access in certain situations. Now let’s put this into a social context. I am not a conspiracy theorist but it is fairly obvious that antidepressant pharmaceuticals do not generally cause people to challenge societal systems of order, they are overall more placating than serving as catalysts for creating healthier societal structures. In regards to plant medicines that act specifically on the mind-body-spirit connection, psychedelics and entheogens in contrast tend to encourage outside of the box thinking, leading to a dissolution and questioning of previously held belief systems. They have a track record of thousands of years, are extremely safe, are not addictive (though they have abuse potential, this is rare), and most are just plants (or fungi). I’m sure most of us are familiar with the fact that a natural substance cannot be patented and therefore has limited income potential for companies who are trying to make money from selling medicines, which is why you hear a whole lot less about them than SSRI’s.
And what of placebo? Of care. Is it any less valuable than a remedy whose actions we can measure? It is of equal or greater value, it is the immeasurable value of love and compassion. If we were to infuse the current conventional medical system with more care for patients, if all different kinds of healers worked together, we would be on the way to mending something very broken. Placebo is not a confounding effect but is a very clear arrow pointing to the complexity of healing and this element should be infused in all mental health care. This is a case for honoring complexity in service to all.