The National Health Service in the UK released figures last month showing it gave out 71 million prescriptions for anti-depressants in England last year, which is double the figure from a decade ago. Seven million adults (14% of the adult population) are now on anti-depressants, as well as 300,000 children. Anti-depressants cost the NHS around £9 billion a year, which is 7.2% of its £125 billion annual budget.
This expensive national habit keeps growing, despite the fact that study after study shows anti-depressants are only slightly more effective than a placebo.
We have known this since 2008, when a psychologist called Irving Kirsch, who researches the placebo effect, published a meta-analysis of anti-depressant trials. It found only a modest difference between anti-depressants and placebos — an effect scale of 0.32 on the Standardized Mean Difference (where 0.2 is considered ‘small’ and 0.5 ‘medium’).
Kirsch concluded that around 75% of the impact of anti-depressants comes from the placebo effect. If 10 people with depression are given anti-depressants, and five recover, four out of those five recover because of the placebo effect. Only one in ten is actually getting better because of the anti-depressant drug — though even this may be a high estimate as Kirsch discovered pharmaceutical companies tend to only publish positive results, and not publish results where anti-depressants did as well or worse than placebos. In addition, anti-depressants have negative side-effects which placebo drugs do not have.
His study, and subsequent book ‘The Emperor’s New Drugs’, caused a lot of controversy, leading to headlines like ‘The drugs don’t work’ (which is not what he was saying — he said the drugs do work, but mainly because of the placebo effect).
There’s been a decade of arguments between psychiatrists and psychologists since then. Last year, The Lancet published another meta-analysis, which was seized on by the media as evidence that the drugs do work: ‘Anti-depressants work. Period.’ End of discussion. But in fact, as the Neuroskeptic blog explored, the new study found a similarly small effect size — 0.30. Less, in fact, than the effect found by Kirsch’s paper.
What is the placebo effect? A placebo means a fake pill, a pill that contains a non-active agent. Placebos are used in many randomized trials of medical treatments as controls, to test treatments against. They were first used by Benjamin Franklin in the 18th century, to prove that Mesmerism didn’t work by magnetizing water, that it only ‘worked’ through people’s imaginations.
The takeaway the Enlightenment took from this was that Mesmerism was bunk. This was the wrong takeaway. The real takeaway was that the imagination — belief, faith, the mind in general — is really powerful and can heal people from mental, emotional and even physical illnesses. Study after study has found that around 40% of depressed people treated with a placebo get better. That’s pretty impressive, for a free pill.
How and why do placebos work? There is, sadly, much less research on the power of the placebo than there is on the power of drugs. Pharmaceutical companies pay for expensive research into expensive drugs. Why should they pay for research into the equally impressive power of fake pills?
Yet some research exists. It suggests that the placebo effect works because of the power of belief and faith. People believe they are being cared for, and this activates a healing response in their mind, their emotions, and to some extent their body. Our physical healing is somewhat connected to our emotional state, through the auto-immune system, so if we feel cared for and optimistic about our recovery, we heal better. It’s not quite magic — the placebo effect probably won’t cure you from serious illnesses like cancer. But it can help. And it’s been shown to be healing for physical conditions like Parkinson’s, chronic pain and multiple sclerosis.
The power of faith and belief is connected to ritual, performance and theatre. Better props make us believe more. That’s why the placebo effect is more powerful when using bigger fake pills. It’s more powerful if the fake treatment involves an injection. It’s more powerful if the person administering the fake treatment is wearing a white coat. All these theatrical props make us believe in the treatment more.
The placebo effect is also culturally specific. Fake blue pills work better than red pills as tranquillizers, unless you happen to be Italian. Researchers have speculated this is because the Italian football team wears blue, so this colour excites Italians.
Our beliefs can harm us as well as heal us — this is called the ‘nocebo effect’. If you tell people a medical procedure will be painful, they experience more pain. There was a case in the 1970s where doctors diagnosed a man with terminal liver cancer, and he died. An autopsy revealed the doctors had been wrong — the tumour was tiny, but the man died anyway, apparently because he believed he was doomed. Medicine, like many other areas of human life, is filled with self-fulfilling prophecies.
The placebo effect is found not just in psychiatry, but in psychology as well. Talking therapies are proven to be as effective as anti-depressants, but here as well, they only marginally out-perform placebos. That’s why Cognitive Behavioural Therapy is less effective in trials today than it was in the 1970s. In the 1970s it was an exciting new treatment, and the novelty of it may have strengthened people’s faith in it. What really seems to make people better is their decision to try and recover, the feeling they’re being cared for, and the hope and faith that they are on the road to wellness.
It is likely that a large part of the miraculous results we now see for psychedelic therapy (such as 80% of people giving up smoking following a dose of magic mushrooms) is the placebo effect, and this effect will decline as people get more used to psychedelic therapy and stop seeing it as the new miracle treatment.
In the developing world, there is on the whole no access to anti-depressants, nor talking therapies. The main form of healing for mental (and even some physical) illness is faith healing. You go to your local shrine or medicine man, donate some money and pray for a cure. And it probably works about as often as other placebo treatments.
Now there are problems with this form of treatment as well — you’re giving your faith and your money to a religious system that might be toxic, prejudiced and hierarchical.
Still, economically it’s a hell of a lot cheaper than giving £9 billion to pharmaceutical companies. That is a very expensive form of faith healing. One could pay a lot of shamans, build a lot of monasteries and shrines, or buy enough fake pills to last a century, for £9 billion. The annual expenditure for the Church of England is around £1 billion. That’s a bargain in comparison. And religions contribute a lot more to the arts, philosophy and community than pharmaceutical companies.
Psychiatrists at the World Health Organisation campaign to roll out anti-depressants to the third world. They are motivated by very good intentions, to relieve people’s suffering. But are we so sure our mental health system — our pharmaceutical faith-system — is superior to their cultural faith-systems?
I am all for whatever works. If I fall victim to serious depression, I may very well take anti-depressants. I feel no stigma about that at all. I’m sure many of you are on anti-depressants or anti-anxiety pills. Good for you. Whatever works. I am not saying anti-depressants don’t work: they do. But 75% of that is because of the placebo effect.
Given the massive expensive of these treatments, and the zero cost of the placebo, shouldn’t we investigate the placebo effect — and the healing power of the mind — more? Shouldn’t we investigate how exactly our minds heal us? Alas, this immediately strikes some biomedical materialist scientists as fringe science. The mind healing itself? Poppycock!
I suggest to you that materialist biomedicine is in some respects an impoverished system, especially when it comes to the mind and mental health. It tells us we are just machines, and our consciousness and beliefs have no real power. Then, when we get depressed (and why shouldn’t we, with such a worldview) we put our faith in expensive pills to make us happier. We take the holy sacrament alone, in a privatized and atomized ritual. We feel better yet, ironically, it’s our mind that is doing most of the healing.
We don’t have to join any particular religion to tap into the power of the placebo. It’s in us, in our minds, not in pills, not in priests. The placebo effect suggests our minds are more powerful than we yet know or fully understand, more powerful than the faith-system of materialism suggests they are.
Perhaps one day we can stop giving away our power away to expensive third-parties (religions / pharmaceutical companies) and then buying it back from them at extortionate costs.
In the meantime, the drugs work, and why not take them. But let’s not ignore the fact it’s our own minds doing most of the healing.
NB: Doctors do not recommend stopping taking anti-depressants suddenly without consulting your GP. If you choose to come off anti-depressants it should be done gradually. More info here.