Stefan Molyneux is an atheist and anarchist philosopher. He is the host of Freedomain Radio, which is one of the most popular podcast series on philosophy on the internet. He is an author of many books such as “Universally Preferable Behavior: A Rational Proof of Secular Ethics”, “Against the Gods” and “How (Not) To Achieve Freedom”. He is also a popular speaker on many libertarian festivals and gatherings such as New Hampshire Liberty Forum, Libertopia and many others. Among his prime values are reason and evidence. This post is filed under anti-psychiatry, but Molyneux is by no means an enemy of reason or anti-psychiatry per se [Edit: there are now reasons to reevaluate the last statement. For more, see Stefan Molyneux’s Unfortunate Spiraling into Anti-Psychiatry]. His arguments about atheism, problems with many government programs and the benefits with peaceful parenting are very persuasive and worth taking a look at. Unfortunately, his laser-like rationality has been slightly subverted by problematic claims about antidepressants. This post will attempt to critically investigate some of them and see if they hold up against a rational examination.
I am by no means an expert on the topics of psychology, psychiatry or antidepressants. I am just a guy on the internet. Because of this, I fully accept the possibility that I am mistaken in my arguments below. These are complex and difficult scientific matters and it would not surprise me if I, as a relatively ignorant layperson, have made errors in my reasoning. If so, I hope that this post will be, at least, an entertaining failure.
The last thing I would want to do is to quote Stefan out of context, because that is a common method employed by various pseudoscientists and I do not want to use their methods. I will do my best to make an accurate representation of Molyneux’s position and I will link to the video and give a time stamp for where he says the things I claim that he does. Without further ado, let us get started.
1. The Claims
In an otherwise very thoughtful commentary on the Norwegian shootings, Molyneux makes the following statements at around the 06:30 mark. It is a very long quote to make sure that I present the claims in context and I have done my best to transcribe it accurately, but go watch the video just in case. Stefan says that:
I know where little about the childhood of this shooter, but the childhood is going to be something that is not going to be talked about, because it is never talked about and there is something else that is never going to be talked about, which is the possibility that he is on antidepressants or SSRIs or other forms of chemical pharmaceutical attacks upon the brain. It is a well-known side effect of these drugs that, they treat nothing, of course, there is nothing that can be seen…there is no before and after, there is no…nothing that shows up on any kinds of scan or a test and so these drugs go into the brain and begin to rewire it. One of the well-known side effects is homicidal and suicidal thoughts and impulses and one study, in fact, had to be shut down, because of the violence…the violent tendenices exhibited by by people who where on these drugs. So…like the guy who shot Giffords, will we ever find out? No, because the information is going to be buried or not examined…This is something we just don’t look at. Was this guy, obviously pretty deranged…was he on any kinds of antidepressants or any kind of mood stabilizer or any kinds of SSRIs? We will probably never know, but I think it is quite important to to ask that question. Now, there is only one mention that I had..got about this man’s childhood [Molyneux goes on to read an excerpt from a newspaper.]
This statement might be distilled into a four major points with respect to antidepressants:
- Antidepressants treat nothing.
- There are no tests or scans available.
- Antidepressants rewire the brain.
- Side effect of antidepressants include homicidal and suicidal thoughts and behaviors.
Let us examine each of them, in turn.
2. “Antidepressants treat nothing”
I found it difficult to interpret this statement, because it could conceivable mean two different things: (1) antidepressants treat nothing in the sense that antidepressants are not effective for treating clinical depression and/or (2) antidepressants treat nothing because there is nothing to treat, depression does not exist as a mental disorder. Both versions can be found in the anti-psychiatry literature. Now, I absolutely do not want to incorrectly characterize Molyneux’s position, so I decided to check out one of his podcast on depression (#1337). There, he states that “In its most extreme forms, depression is kind of the worst thing that you can get in terms of mental ailment aside from, perhaps, paranoia. [...] It is really brutal, it is dragging yourself through thick, impenetrable liquid; it is life lived at the bottom of a well; it is breath is an effort; it is feeling of intense alienation from your self, because you can’t even put into words or communicate to the people around you what is occurring for you in its more extreme forms” (my transcription from a few minutes in). This leads me to conclude that something closer to (1) is what Molyneux meant. He is clearly not saying that depression is not a mental illness or that it does not exist.
So the claim then can reasonable be portrayed as the classical claim that antidepressants are no better than placebo. This is usually backed up with references to Fournier et. al. (2010) or Kirsch et. al. (2008) or something similar. However, these two studies had several limitations that do not permit the conclusion that antidepressants are no better than placebo. I have discussed this in several other places on this blog, but let me summarize the criticism.
Fournier et. al. (2010) only looked at six studies out of several hundreds. Only three of these looked at an SSRI drug (Paxil). The other three looked at a tricyclic antidepressant (imipramine), which has not been the standard for over a decade. This is important because different SSRIs have different efficacy and side effects, so the results from Paxil cannot naively be extrapolated to most or all SSRIs. The study also used several arbitrary inclusion criteria such as available of patient level data. As most RCTs do not include this, the arbitrary criterion excludes most studies. The initial analysis identified 23 studies, but as the researchers could only gain access to the data in 6 studies, so they ignored the other 17, which may have biased the results (Tuteur, 2010).
Kirsch et. al. (2008) closely reproduced the findings of earlier studies such as Turner et. al. (2008). The effect size of all drugs tested where, compared with placebo, positive. None of the calculated confidence intervals overlapped zero, meaning that it is very unlikely that antidepressants tested and placebo are no different in efficacy. However, Kirsch made a radical new interpretation of those findings. Whereas Turner et. al. drew the conclusions that antidepressants where more effective than placebo, Kirsch drew the exact opposite, namely that antidepressants where not better than placebos, using an arbitrary cut-off standard for clinical significance of 0.5 devised by National Institute for Clinical Excellence, a standard which they no longer use. While it is true that a glass that is 1/3 full is not 1/2 full, a 1/3 glass is not empty. If Kirsch’s interpretation was reasonable, we would have to reject psychotherapy as a treatment as well antidepressants, because psychotherapy alone has an even lower effect size than antidepressants alone. This is why a lot of treatments for depression uses both antidepressants and psychotherapy. They work better together than any of them work alone (Hall 2010a, Hall 2010b).
There are many studies looking at the efficacy of antidepressants that show that they are more effective than placebo. I mentioned this in an earlier blog post, but one such example was published in NEJM (Walkup et. al. 2008), that compared the efficacy of sertraline (an SSRI) alone, cognitive behavioral therapy (CBT) alone, placebo, and sertraline and CBT together and the results where: improvement with CBT alone (59.7%), sertraline alone (54.9%) where both better than placebo (23.7%) and a combination of CBT and sertraine (80.7%) was the best option. Side effects where roughly equal in the group recieving the SSRIS treatment and the group receiving placebo. This study is not perfect, but it independently converges with other such studies showing that SSRIs are by and large effective compared with placebo.
3. “There are no tests or scans available”.
I also found this very hard to interpret. Does Molyneux mean that there are no tests or scans for depression or no tests or scans to see if antidepressants work? Again, both versions exists in the anti-psych literature. As I explained earlier, I do not want to misrepresent Molyneux’s position, so I will cover both versions of the claim and you can think of it as being “provided that this is what Molyneux meant, then…”. It is especially hard for me to pick a likely interpretation here, because both roads leads to contradictions.
It is true that there is no blood test for depression, or for any psychological disorder. But the same goes for migraine. No one would make an argument stating that just because there are no blood test for migraines, then migraine is a dubious diagnosis. Mental disorders are diagnosed by criteria in texts such as DSM-IV-TR or ICD-10. If criteria are too loose, a lot of individuals that do not actually have depression will be diagnosed with depression. If criteria are too strict, then individuals that genuinely have depression will not be diagnosed with depression. This means that it probably can be improved, but of course we should not through out the baby with the bathwater. It appears contradictory to believe that depression exists (which we established in the previous section that Molyneux) but cannot be tested. If it cannot be tested, what does it mean to say it exists?
For the second interpretation, it would be weird for Molyneux to both believe that (i.) antidepressants are no better than placebo and (ii.) there is no way to test the efficacy of antidepressants. Obviously one cannot believe both and be logically consistent. Again, it is true that there is no blood test for monitoring the improvement of patients with depression, but many ways to check the efficacy of treatment for treatment of depression. They are used both in medical treatment and treatment with psychotherapy and include therapist’s rating (using e. g. Hamilton Rating Scale for Depression), client’s self reports, ratings of client by acquaintances, client’s self-monitoring of behavior and behavioral observations etc. (Passer et. al. 2009)
As depression is a result of poor emotional regulation among various brain regions (Disner et. al. 2011), it would not even be useful to measure the levels of, say, a single neurotransmitter. Antidepressants are blunt methods of nudging brain function that is most effective when combined with psychotherapy.
When it comes to the questions of scans, it is actually incorrect (depending on the condition). This will be shown in the next section.
4. “Antidepressants rewire the brain”
It seems contradictory to state that there are no scans available to see how antidepressants affect the brain, but then claim that antidepressants rewire the brain. How could we possibly know this if it was not for brain scans?
It is an easy claim to address. It is true that antidepressants change brain function, but with the following caveat: so does psychotherapy and antidepressants and psychotherapy change brain function in very similar ways. Furmark et. al (2002) performed a randomized controlled trial of nine-weeks treatment with either SSRIs or psychotherapy (CBT) on patients with social phobia and anxiety. Patients where put in a PET-scanner before and after treatment and made to deliver a quickly prepared speech in front of people around the scanner and measured neural activity in the so called anxiety circuit (amygdala-hippocampus-tenporal cerebral cortex). The results where that both treatments showed similar neurological and behavioral changes. Change in brain function or rewiring of the brain does not need to be something bad.
5. “Side effect of antidepressants include homicidal and suicidal thoughts and behaviors.”
There are two questions here: is homicidal and suicidal thoughts and behaviors is a side effect of antidepressants, and if so, how common are they? If they are really uncommon, then they might be acceptable, because depression itself is associated with suicidal thoughts and behavior and if the medication is safer than depression, then medications are the better of the two options with respect to suicidal thoughts and behavior.
According to the Mayo Clinic (Mayo Clinic, 2011), most antidepressants are generally safe although, the FDA requires that all antidepressant medications carry black box warnings, which is the strongest warnings that FDA can issue for prescription medications. The warnings note that in some cases (children, adolescents and young adults 18-24 years old) may have an increase in suicidal thoughts and behaviors when taking antidepressants. However, does this state that there is a mere possibility, rather than a documented fact, or is it an uncommon side effect? However, the increase that media reported was just from 2 to 4% and this may have been due to increase in reports (Hall, 2009). Also, after the prescription rate fell by 18-20%, suicides increased by 18% (Hall, 2009). Of course, we have to keep in mind that just because B follows A does not mean that A causes B, but is an important fact to keep in mind.
The Olfson et al. (2006) study that appeared to show an increase in suicidal thoughts and behaviors was problematic, since it made the incorrect assumption that the two groups had the same risk for suicide, whereas it was likely that the group treated with antidepressants had more severely depressed patients and thus a higher risk for suicide. Furthermore, Bridge et. al. (2005) showed that suicidal behavior and thoughts in antidepressant tests where similar to psychotherapy trails and Simon et. al. (2006) showed that suicide rates before starting antidepressant treatment where higher and that this declined progressively after starting medication.
When it comes to homicides, I have not found any evidence one way or another, so I suppose we leave this one as inconclusive for now.
The author of this blog post is by no means an expert and can be mistaken, however, the conclusions seems reasonable and based on the scientific literature. Antidepressants a blunt tool that are more effective than placebo, although antidepressants work best with psychotherapy. If we reject antidepressants because of arbitrary standards of clinical significance, we would have to reject psychotherapy as well. There is no blood test for depression (or for migraine), but there are criteria for depression and different ways to evaluate the efficacy of both antidepressants and psychotherapy. Antidepressants do affect brain function, but so does psychotherapy in much the same way. While it is true that FDA has a black box warning on antidepressants, the study purporting to show that suicidal behavior and thoughts where associated with antidepressants was flawed and many other studies have shown that risk of suicide where not that different in antidepressants and psychotherapy trials. No evidence for or against the claim about homicides where found when writing this article.
6. References and Further Reading
Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, Fawcett J. Antidepressant drug effects and depression severity: a patient-level meta-analysis. JAMA. 2010 Jan 6;303(1):47-53.
Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008 Feb;5(2):.
Erick H. Turner, M.D., Annette M. Matthews, M.D., Eftihia Linardatos, B.S., Robert A. Tell, L.C.S.W., and Robert Rosenthal, Ph.D. Selective Publication of Antidepressant Trials and Its Influence on Apparent Efficacy. N Engl J Med 2008; 358:252-260 January 17, 2008
John T. Walkup, M.D., Anne Marie Albano, Ph.D., John Piacentini, Ph.D., Boris Birmaher, M.D., Scott N. Compton, Ph.D., Joel T. Sherrill, Ph.D., Golda S. Ginsburg, Ph.D., Moira A. Rynn, M.D., James McCracken, M.D., Bruce Waslick, M.D., Satish Iyengar, Ph.D., John S. March, M.D., M.P.H., and Philip C. Kendall, Ph.D. Cognitive Behavioral Therapy, Sertraline, or a Combination in Childhood Anxiety. N Engl J Med 2008; 359:2753-2766 December 25, 2008
Hall, Harriet. (2011a). Antidepressants and Effect Size. Science-Based Medicine. http://www.sciencebasedmedicine.org/index.php/antidepressants-and-effect-size/. Accessed 2011-07-19.
Hall, Harriet. (2011b). Angell’s Review of Psychiatry. Science-Based Medicine. http://www.sciencebasedmedicine.org/index.php/angells-review-of-psychiatry/. Accessed 2011-08-10
Hall, Harriet. (2009). Psychiatry-Bashing. Science-Based Medicine. http://www.sciencebasedmedicine.org/index.php/psychiatry-bashing/. Accessed 2010-06-26.
Tuteur, Amy. (2010). Study shows antidepressants useless for mild to moderate depression? Not exactly. Science-Based Medicine. http://www.sciencebasedmedicine.org/index.php/study-shows-antidepressants-useless-for-mild-to-moderate-depression-not-exactly/. Accessed 2010-06-26.
Passer, M., Smith, R., Holt, N., Bremner, A., Sutherland, E., & Vliek, M. (2009). Psychology: The Science of Mind and Behavior. New York: McGraw-Hill Education. p. 865.
Seth G. Disner, Christopher G. Beevers, Emily A. P. Haigh & Aaron T. Beck. Neural mechanisms of the cognitive model of depression. Nature Reviews Neuroscience 12, 467-477 (August 2011)
Furmark T, Tillfors M, Marteinsdottir I, Fischer H, Pissiota A, Långström B, Fredrikson M. Common changes in cerebral blood flow in patients with social phobia treated with citalopram or cognitive-behavioral therapy. Arch Gen Psychiatry. 2002 May;59(5):425-33.
Mayo Clinic. (2011). Depression (major depression): Treatments and Drugs. Mayo Clinic. http://www.mayoclinic.com/health/depression/DS00175/DSECTION=treatments-and-drugs. Accessed 2011-08-10.
Olfson M, Marcus SC, Shaffer D (2006). Antidepressant drug therapy and suicide in severely depressed children and adults. Arch Gen Psychiatry 63:865-872
Bridge JA, Barbe RP, Birmaher B, Kolko DJ, Brent DA (2005). Emergent suicidality in a clinical psychotherapy trial for adolescent depression. Am J Psychiatry 162: 2173-2175
Simon GE, Savarino J, Operskalski B, Wang PS (2006). Suicide risk during anti-depressant treatment. Am J Psychiatry 163:41-47.
Cuffe, Steven P. (2007). Suicide and SSRI Medications in Children and Adolescents: An Update. DevelopMentor. Acessed 2011-08-10.
Disner, S. G., Beevers, C. G., Haigh, E. A. P., & Beck, A. T. (2011). Neural mechanisms of the cognitive model of depression. Nat Rev Neurosci, 12(8), 467-477.