This week PostScript noted a flurry of reports, posts, and stories on the topic of happiness asking all sorts of things: How achievable is it, how sellable is it, do we stand to lose something human when we lose the blues, and at what cost?
At top, a meta-analysis in the New England Journal of Medicine that found a third of company-sponsored clinical trials on anti-depressants Prozac and Paxil went unpublished, effectively tilting the body of accepted wisdom on these popular drugs in favor of their efficacy. The NEJM study looked at 74 trials of 12 drugs, and found that using the published studies demonstrated significant improvements in depression levels over placebos. Once the unpublished ones are folded into the mix, the difference between pharmaceutical and placebo becomes modest.
The punch-line? According to the New York Times, “while 94 percent of the positive studies found their way into print, just 14 percent of those with disappointing or uncertain results did.” To the SSRI manufacturers, it seems that no news was good news – or at least better news.
“’This is a very important study for two reasons,’” NEJM editor Dr. Jeffrey M. Drazen told the Times. “One is that when you prescribe drugs, you want to make sure you’re working with best data possible; you wouldn’t buy a stock if you only knew a third of the truth about it." Second, Dr. Drazen continued, ‘we need to show respect for the people who enter a trial.’”
We take Drazen’s point – human participation in clinical trials is predicated, in part, on trust that those trials will be conducted fairly and reported accurately – but certainly reported.
Yet Drazen’s comments themselves are a strange one-two, and read like he’s comparing the health of trial participants to shares in a publicly traded company – a linguistic slip, perhaps, but one that’s disturbing as it is telling about the trouble with clinical trials disclosure and pharmaceutical company forthrightness: It’s about the shareholders, stupid.
And that harsh reality underscores the need for all clinical trials to be registered publicly before they are begun, a federal law that awaits implementation.
Over at Carlat Psychiatry Blog, Dr. Carlat points to a Furious Seasons post about how much depression psychiatrists should aim to relieve in their patients – and how many drugs that should take. According to Carlat, remission has replaced response (a 50 percent improvement) as the grail of psychiatrists, a shift that both he and Dawdy argue maybe at best industry-inspired and misguided, and at worst harmful, as polypharmacy becomes an ever-more common next step when a single-therapy regimen doesn’t do the trick. And what ever happened to psychotherapy?
Dawdy, who blogs as a patient in the mental health care system, writes, “I've noted previously how obsessed the psych world is with complete symptom remission in all forms of mental illness and how useless such a goal is for patients. Yes, it's a laudable public health goal, but within the limits of current technologies and practices does not seem to be achievable for many patients. If complete symptom remission is your polestar, then that could spell all sorts of practical problems for patients.” Especially if the studies patients rely on to gauge their chances for improvement aren’t the whole picture.
Last month, the New York Review of Books pondered these same questions in its pages. Frederick Crew’s “Talking Back to Prozac” is an insightful look at three new books on sadness and its salves that ask important questions about how and how much we are treating the blues. Like many good reviews, his analysis asks more questions than it answers, and frames each of these books as part of the bigger conversation about our shifting views of psychopharmacology – views that are sure to shift again in light of the new NEJM study.
If you’re looking for something a little lighter, then this Boston Globe piece is the way to go. It leads with Tom Brady and ends with Ogden Nash and doesn’t get much deeper in the middle. The Globe piece is all over the place, but it mentions Eric Wilson’s book, “Against Happiness: In Praise of Melancholy,” which has been adapted into an essay for the Chronicle of Higher Education online review. Wilson, a professor of English at Wake Forest University, has just written a book on how good the doldrums are for art and literature.
Wilson’s basic argument – we think – is that our culture is fighting melancholy (that’s English major for depression) and in doing so, chucking our potential to make good, sad art out the window.
“To foster a society of total happiness is to concoct a culture of fear,” Wilson writes. One expects such a big claim to be followed by examples, or at least a map of how he got there. But instead of explaining, Wilson just bowls on through. “Do we really want to give away our courage for mere mirth?”
Huh?
This may be the problem with adapting books into one-page essays – each sentence is a chapter gone unexplained and undefended. But why would a professor of English take it upon himself to draw this diagnostic line in the sand:
“Obviously, those suffering severe depression — suicidal and bordering on psychosis — require serious medications. But what of those who possess mild to moderate depression? Should these potential visionaries and innovators eradicate their melancholia with the help of a pill?”
Wilson’s outlandish assumption of clinical power to deem some depressed and others artists is one of the more egregious examples of academic arm-chair quarterbacking we’ve seen in awhile.
But if the melancholy Wilson favors is as unsavory as he makes it sound – “an almost infinite sounding of the exquisite riddles of Being” – PostScript can hardly blame those who believe we can and ought to treat that, or at least tone down all those chronic riddles for those to whom they are deafening.
Wilson doesn’t seem to have had the same problems getting published as some of those antidepressant studies did. And maybe that’s the most depressing thing of all.