Major depressive disorder (MDD) is a severe mental illness that affects 5 to 20% of the general population. Current antidepressant drugs exerts only a partial clinical efficacy because approximately 30% of depressed patients failed to respond to these drugs and antidepressants produce remission only in 30% of patients. This can be explained by the fact that the complex pathophysiology of depression has not been completely elucidated, and treatments have been mainly developed following the “monoaminergic hypothesis” of depression (...) without considering the key role of other factors involved in the pathogenesis of MDD, such as the role of chronic stress and neuroinflammation. Chronic stress acts as a risk factor for the development of MDD through the impairment of neurotrophins signaling such as brain-derived neurotrophic factor (BDNF) and transforming-growth-factor-β1 (TGF-β1). Stress-induced depressive pathology contributes to altered BDNF level and function in MDD patients and, thereby, an impairment of neuroplasticity at the regional and circuit level. Recent studies demonstrate that aerobic exercise strongly increases BDNF production and it may contribute as a non-pharmacological strategy to improve the treatment of cognitive and affective symptoms in MDD. Here we will provide a general overview on the possible synergism between physical activity and antidepressants in MDD. Physical activity can synergize with antidepressant treatment by rescuing neurotrophin signaling in MDD patients, promoting neuronal health and recovery of function in MDD-related circuits, finally enhancing pharmacotherapeutic response. This synergism might be particularly relevant in elderly patients with late-life depression, a clinical subgroup with an increased risk to develop dementia. (shrink)

Drawing on an analysis of Irving Kirsch and colleagues’ controversial 2008 article in PLoS [Public Library of Science] Medicine on the efficacy of SSRI antidepressant drugs such as Prozac, I examine flaws within the methodologies of randomized controlled trials (RCTs) that have made it difficult for regulators, clinicians and patients to determine the therapeutic value of this class of drug. I then argue, drawing analogies to work by Pierre Bourdieu and Michael Power, that it is the very limitations (...) of RCTs — their inadequacies in producing reliable evidence of clinical effects — that help to strengthen assumptions of their superiority as methodological tools. Finally, I suggest that the case of RCTs helps to explore the question of why failure is often useful in consolidating the authority of those who have presided over that failure, and why systems widely recognized to be ineffective tend to assume greater authority at the very moment when people speak of their malfunction. (shrink)

The paper presents major ethical, legal and methodological problems related to the use of placebo in mental disorders, especially in depression. It is pointed out that although authoritative groups of experts and numerous publications in the field of psychopharmacology indicate advisability of the double blind design with placebo in clinical trials of antidepressants, in recent years there have been more and more voices questioning legitimacy of this method. Objections of an ethical nature are raised, and reliability of this approach is (...) put into doubt from the methodological viewpoint. These issues are discussed in more detail in the paper. Available alternative solutions should be implemented in psychotropic drug studies. The author shares these objections and doubts of an ethical nature, and believes that the placebo procedure is not a necessity in clinical trials of antidepressants. (shrink)

In this paper, I explore the questions of how and to what extent new antidepressants (selective serotonin-reuptake inhibitors, or SSRIs) could possibly affect the self. I do this by way of a phenomenological approach, using the works of Martin Heidegger and Thomas Fuchs to analyze the roles of attunement and embodiment in normal and abnormal ways of being-in-the-world. The nature of depression and anxiety disorders — the diagnoses for which treatment with antidepressants is most commonly indicated — is also explored (...) by way of this phenomenological approach, as are the basic structures of self-being. Special attention is paid in the analysis to the moods of boredom, anxiety and grief, since they play fundamental roles in depression and anxiety disorders and since their intensity and frequency appear to be modulated by antidepressants. My conclusion is that the effect of these drugs on the self can be thought of in terms of changes in self-feeling, or, more precisely, self-vibration of embodiment. I present the idea of a spectrum of bodily resonance, which extends from the normal resonance of the lived body, in which the body is able to pick up a wide range of different moods; continuing over various kinds of sensitivities, preferences and idiosyncrasies, in which certain moods are favored over others; to cases that we unreservedly label pathologies, in which the body is severely out of tune, or even devoid of tune and thus useless as a tool of resonance. Different cultures and societies favor slightly differently attuned self-styles as paradigmatic of the normal and good life, and the popularity of the SSRIs can therefore be explained, not only by defects of embodiment, but also by the presence of certain cultural norms in our contemporary society. (shrink)

The expert clinical community is split about whether the difference between antidepressant treatment and treatment with placebos stems from the efficacy of the drug or from subjects’ heightened expectancy enhanced by side effects—i.e., enhanced placebo effects. Proving whether pharmacological efficacy has been established reliably by randomized controlled trials of antidepressant drugs is difficult, primarily because substituting a placebo for an effective treatment in the control arm of a trial is ethically questionable. I argue that clinical equipoise permits (...) the use of active placebo controls in trials that test antidepressants. Placebo controls for drug trials are ethically defensible and scientifically justified when we have evidence that a standard treatment might only work because of enhanced placebo effects, and when a respectable minority of the expert clinical community endorses these concerns. (shrink)

Traditional understanding of how psychotropic drugs work emphasize highly specific actions at subcellular levels. This model appears to have implications that seriously conflict with our usual view of human agency and autonomy, raising not just theoretical quandaries but contributing to patient reluctance to utilize these drugs. Furthermore, it discourages both meaningful treatment integration and appreciation of the uniqueness of patients. Through a consideration of antidepressants in particular, this paper argues for a more comprehensive model based on nonlinear dynamics (...) and chaos theory that can be applied across multiple domains. This model yields important suggestions for reconciling perspectives in neuroscience with traditional views of human agency. It also encourages real integration of clinical and research approaches in psychiatry, and further defines the components of respectful treatment of patients. (shrink)

Neuroenhancement offers the prospect of improving the cognitive, emotional and motivational functions of healthy individuals. Of all the conceivable interventions, psychopharmacology provides the most readily available ones, such as antidepressants which are thought to make people “better than well”. However, up until now, whether they possess such an enhancing ability remains controversial and therefore in this systematic review we will evaluate the effect and safety of modern antidepressants in healthy individuals. A search of MEDLINE and EMBASE databases and cross-references was (...) carried out and the pharmaceutical industry was contacted for suitable data. Trials published in any language through the third week of July 2007 were regarded. Included were single or double blind randomised or quasi-randomised controlled trials that compared a placebo to one or more of the following antidepressants: bupropion, citalopram, duloxetine, escitalopram, fluoxetine, fluvoxamine, moclobemide, paroxetine, reboxetine, sertraline or venlafaxine in any dose or dosing schedule. Eligible studies were those involving healthy people of any age and either sex who showed no evidence of a psychiatric disorder, cognitive decline or other disease. One hundred thirty-five articles met our inclusion criteria reporting single dose trials and trials with repeated drug administration. Sixty-five of these articles were eligible for a statistical analysis. Based on a linear mixed model, a meta-analysis and a fixed effects meta-regression were performed. Pooling of results by meta-analysis was stratified by the outcome measures mood, emotional processing, wakefulness, attention, memory, and executive functions. On a significance level of p < 0.05 the following significant results emerged: After a single dose of an antidepressant, a significant effect was shown in two of the analysed outcomes. Firstly, there was a small yet significant negative effect on wakefulness. On memory, a positive effect after several measurements was found, but this result could be traced to the results of the one study out of all included studies, which had that many assessment points. The analysis of trials with repeated drug administration yielded the following effects: on mood, a non-significant positive effect was detected that was continuously increasing and reached significance at the last assessment point. Regarding attention, a fluctuating effect was found, while for memory, the fact that the two groups started with a group difference confounded the results. For wakefulness there was no significant effect in any particular assessment point, while for emotional processing and executive functions, the small number of studies did not allow for any effect to emerge. In summary, no consistent evidence for enhancing effects of antidepressants could be found. There is little evidence so far to support the popular opinion that antidepressants have a positive effect on the mood of healthy individuals after repeated administration. No evidence of a significant adverse event profile could be found. The studies included in this systematic review not only provide insufficient evidence for or against any effect in healthy people, but they are inapt to be used for answering this question. This may be explained by the fact that most of them were not designed to examine neuroenhancement effects. The growing public interest in neuroenhancement stands in stark contrast to the paucity of data on enhancement effects of available psychopharmacological agents. (shrink)

This contribution to the “antidepressant debate” focuses on the validity of randomized controlled trials. We argue that: randomized controlled trials do everything possible to methodologically stamp out high placebo response rates rather than reveal the clinical implications, assessing a psychoactive drug’s effects greatly exceeds the purpose of a randomized controlled trial, requiring substantial investigation on normal volunteers, made-up psychiatric diagnostic categories destroy the purpose and logic of the randomized controlled trial as a medical experiment, and adverse drug reactions remain (...) under-studied, under-recognized, and under-appreciated, in parallel with the muting of subjects’ voice and the reliance on surrogate measures of efficacy. The standard psychopharmacotherapy trial has lost virtually all clinical and scientific relevance, and needs complete revamping. The backdrop for the discussion is American biopsychiatry’s insistence that personal difficulties must be viewed as the expression of idiopathic somatic diseases, and the pharmaceutical industry’s dominance of the entire drug treatment research enterprise. (shrink)

Attention deficit hyperactivity disorder is a developmental disorder with an age onset prior to 7 years. Children with ADHD have significantly lower ability to focus and sustain attention and also score higher on impulsivity and hyperactivity. Stimulants, such as methylphenidate, have remained the mainstay of ADHD treatment for decades with evidence supporting their use. However, recent years have seen emergence of newer drugs and drug delivery systems, like osmotic release oral systems and transdermal patches, to mention a few. The (...) use of nonstimulant drugs like atomoxetine and various other drugs, such as a-agonists, and a few antidepressants, being used in an off-label manner, have added to the pharmacotherapy of ADHD. This review discusses current trends in drug therapy of ADHD and highlights the promise pharmacogenomics may hold in the future. (shrink)

A relatively healthy forty-six-year-old woman with mild hypertension receives a prescription for an antihypertensive medication. One of the medication's adverse effects is its potential to cause severe depression. Four months later, she is diagnosed with anxiety, an early manifestation of depression. An antianxiety drug is prescribed, but her anxiety worsens. Her physician then diagnoses her as having a depressive disorder, and prescribes a new antidepressant medication. She is still on the same antihypertensive.A seventy-two-year-old man is given furosemide and digoxin (...) to control a mild case of congestive heart failure and hypertension. Because furosemide deletes potassium from the body, his physician also places him on a potassium supplement. Six months later, the physician tells the patient to stop taking the furosemide and prescribes an angiotensin converting enzyme inhibitor. An effect of ACE inhibitors is to reduce the body's excretion of potassium thereby reducing the digoxin's effectiveness. (shrink)

A relatively healthy forty-six-year-old woman with mild hypertension receives a prescription for an antihypertensive medication. One of the medication's adverse effects is its potential to cause severe depression. Four months later, she is diagnosed with anxiety, an early manifestation of depression. An antianxiety drug is prescribed, but her anxiety worsens. Her physician then diagnoses her as having a depressive disorder, and prescribes a new antidepressant medication. She is still on the same antihypertensive.A seventy-two-year-old man is given furosemide and digoxin (...) to control a mild case of congestive heart failure and hypertension. Because furosemide deletes potassium from the body, his physician also places him on a potassium supplement. Six months later, the physician tells the patient to stop taking the furosemide and prescribes an angiotensin converting enzyme inhibitor. An effect of ACE inhibitors is to reduce the body's excretion of potassium thereby reducing the digoxin's effectiveness. (shrink)

This study is rooted in the research traditions of cultivation theory, construct accessibility, and availability heuristic. Based on a survey with 221 subjects, this study finds that familiarity with direct-to-consumer (DTC) print advertisements for antidepressant brands is associated with inflated perceptions of the prevalence and lifetime risk of depression. The study concludes that DTC advertising potentially has significant effects on perceptions of depression prevalence and risk. Interpersonal experiences with depression coupled with DTC advertising appear to significantly predict individuals’ perceived (...) lifetime risk of depression. The study ultimately demonstrates that DTC advertising may play a role in constructing social reality of diseases and medicine. The findings strongly suggest that the social cognitive effects of DTC advertising are far-reaching, impacting pharmaceutical marketing strategy as well as presenting issues regarding public health and the business ethics of advertising drugs to consumers. (shrink)

BackgroundDepressive disorders are a common form of psychiatric illness and cause significant disability. Regulation authorities, the medical profession and the public require high safety standards for antidepressants to protect vulnerable psychiatric patients. Ketamine is a dissociative anaesthetic and a derivative of a hallucinogen. Its abuse is a major worldwide public health problem. Ketamine is a scheduled drug and its usage is restricted due to its abuse liability. Recent clinical trials have reported that ketamine use led to rapid antidepressant effects (...) in patients suffering from treatment-resistant depression. However, various flaws in study designs, and possible biased reporting of results, may have influenced those findings. Further analyses of ketamine use are needed to ensure patient safety.DiscussionThe use of ketamine in research and treatment of depressive disorders is controversial. Recently, mental health professionals raised ethical concerns about an ongoing ketamine trial in the UK. Also, a Canadian agency reviewed the existing evidence and did not recommend prescribing ketamine to treat depressive disorders. Findings obtained from tightly controlled research settings cannot be easily translated to clinical practice as substance abuse is commonly comorbid with depressive disorders. An effective antidepressant should reduce severity of depressive symptoms without liability problems. Although the US FDA has not approved the use of ketamine to treat depressive disorders, some psychiatrists offer off-label repeat prescription of ketamine. Prescribing ketamine for treating depressive disorders requires substantial empirical evidence. Clinicians should also consider research findings on ketamine abuse. Depressive disorders can be chronic conditions and the current evidence does not rule out the risk of substance abuse after repeat prescription of ketamine. Off-label ketamine use in treating depressive disorders may breach ethical and moral standards, especially in countries seriously affected by ketamine abuse. This article presents two real-world clinical vignettes which highlight ethical principles and theories, including autonomy, nonmaleficience, fidelity and consequentialism, as related to off-label ketamine use.ConclusionWe urge clinicians to minimise the risk of harming patients by considering the empirical evidence on ketamine properties and attempting all standard antidepressant therapies before considering the off-label use of ketamine. (shrink)

In A Logic in Madness, Aaron J. Hauptman presents the case of Mr. A, a college-age man suffering from the unexpected and cruel severance of a romantic relationship. This breakup caused Mr. A to become severely depressed, harboring a desire to starve himself. However, Mr. A adamantly refused any sort of pharmacotherapy for his condition. Being someone who has “a doggedness with rationality” and who cares deeply about being logical, he offered several arguments and reasons for his refusal. One of (...) these was: “I am depressed for a very good reason and if, because of that, I have these feelings then it is right for me to have these feelings”. He further regarded drug therapy as “dishonest,”... (shrink)

Recent years have witnessed an intensification of historical and philosophical research on the link between psychotropic drugs and psychiatric theories. For example, Kendler and Schaffner detailed how the dopamine hypothesis of schizophrenia was intimately linked to the dopamine theory of antipsychotic drug action. Here, a related case is explored: the use of antidepressants' neurochemical effects to speculate about the pathophysiology of depression.This rationale was central to American psychiatrist Schildkraut's landmark article on the catecholamine hypothesis of affective disorders. Accordingly, the (...) paper's hypothesis—that depressions may relate to decreased... (shrink)

This afterword extends and refines the arguments presented in Cohen and Jacobs . The main point made by the authors is that the antidepressant randomized controlled trial world is a make-believe world in which researchers act as if a bona fide medical experiment is being conducted. From the assumed existence of the “disorder” and the assumed homogeneity of the treatment groups, through the validity of rating scales and the meaning of their scores, to the presentations of researchers’ ratings as (...) the genuine outcome of interest — all aspects of such trials are make-believe. The continued acceptance of randomized controlled trials as appropriate mechanisms to ascertain the actual effects of psychoactive drugs on human beings in distress confirms that researchers are inextricably dependent on large-scale organizational and financial interests that require the sustained production of make-believe results about psychoactive drugs. (shrink)

There is a sense in which antidepressants are feminist drugs, liberating and empowering …A lot of things have been said about Prozac.1 We have been instructed both to "listen" and to "talk back" to Prozac (Kramer 1993; Breggin 1994), Prozac has been called a wonder drug (Schumer 1989; Cowley 1990), it has been described as capable of dramatically changing selves and dramatically changing our conception of what a self is (Kramer 1993), it has been accused of dulling our artistic (...) drive (Berlin 2008), of diminishing our authenticity (Elliott 2000) and has been called a modern-day Soma, à la Brave New World (Weisberger 1995, 72; PCBE 2003, 258). It has also been called a "feminist drug." It is this last claim that we .. (shrink)

Prozac has been lauded by Peter Kramer for instilling potentially “liberating” personality traits in women such as assertiveness, resilience, and confidence. Witnessing these effects, Kramer declares that there is a sense in which antidepressants like Prozac are “feminist.” In this paper, we scrutinize Kramer’s claim from myriad angles. We evaluate putatively “feminist” uses of antidepressants in both women who are diagnosed with clinical depression and women thought to use them instead for “enhancement” purposes. We conclude that there are, indeed, some (...) ways in which Prozac is feminist, and some ways in which it is decidedly antifeminist. (shrink)

Prominent consumer depression manuals issued in recent years circulate a standard depression script as scientific knowledge. The script, asserting that a broad spectrum of depressions are brain illnesses that require antidepressant treatment, is in fact highly contested among researchers. This paper reviews the logical problematics of these manuals, and how such discourse promotes the diagnosis and pharmaceutical treatment of behaviors ranging from mild symptoms to severe depression. In keeping with the trends of pharmaceutical advertising and State health policy, these (...) manuals encourage consumers to self-scrutinize risky behavior, and to treat common behavioral and mood distresses with antidepressants. Ultimately, these activities of self-management function to produce a more productive citizen population. (shrink)

We reply to the Ioannidis's paper "Effectiveness of antidepressants; an evidence based myth constructed from a thousand controlled trials." We disagree that antidepressants have no greater efficacy than placebo. We present the efficacy from hundreds of trials in terms of the percentage of patients with a substantial clinical response (a 50% improvement or more symptomatic reduction). This meta-analysis finds that 42-70% of depressed patients improve with drug and 21%-39% improve with placebo. The response benefit of antidepressant treatment is 33%-11% (...) greater than placebo. Ioannidis argues that it would be vanishingly smaller because systematic biasing in these clinical trials would reduce the drug-placebo difference to zero. Ioannidis' argument that antidepressants have no benefit is eroded by his failures of logic because he does not present any evidence that there are a large number of studies where placebo is substantially more effective than drug. (To reduce to zero, one would also have to show that some of the unpublished studies find placebo better than drug and have substantial systematic or methodological bias). We also present the empirical evidence showing that these methodological concerns generally have the opposite effect of what Ioannidis argues, supporting our contention that the measured efficacy of antidepressants likely underestimates true efficacy.Our most important criticism is Ioannidis’ basic underlying argument about antidepressants that if the existing evidence is imperfect and methods can be criticized, then this proves that antidepressant are not efficacious. He presents no credible evidence that antidepressants have zero effect size. Valid arguments can point out difficulties with the data but do not prove that a given drug had no efficacy. Indeed better evidence might prove it was more efficacious that originally found.We find no empirical or ethical reason why psychiatrists should not try to help depressed patients with drugs and/or with psychotherapeutic/behavioral treatments given evidence of efficacy even though our treatment knowledge has limitations. The immense suffering of patients with major depression leads to ethical, moral, professional and legal obligations to treat patients with the best available tools at our disposal, while diligently and actively monitoring for adverse effects and actively revising treatment components as necessary. (shrink)

We present evidence disputing the hypothesis that memories are processed or consolidated in REM sleep. A review of REM deprivation (REMD) studies in animals shows these reports to be about equally divided in showing that REMD does, or does not, disrupt learning/memory. The studies supporting a relationship between REM sleep and memory have been strongly criticized for the confounding effects of very stressful REM deprivation techniques. The three major classes of antidepressant drugs, monoamine oxidase inhibitors (MAOIs), tricyclic antidepressants (...) (TCAs), and selective serotonin reuptake inhibitors (SSRIs), profoundly suppress REM sleep. The MAOIs virtually abolish REM sleep, and the TCAs and SSRIs have been shown to produce immediate (40–85%) and sustained (30–50%) reductions in REM sleep. Despite marked suppression of REM sleep, these classes of antidepressants on the whole do not disrupt learning/memory. There have been a few reports of patients who have survived bilateral lesions of the pons with few lingering complications. Although these lesions essentially abolished REM sleep, the patients reportedly led normal lives. Recent functional imaging studies in humans have revealed patterns of brain activity in REM sleep that are consistent with dream processes but not with memory consolidation. We propose that the primary function of REM sleep is to provide periodic endogenous stimulation to the brain which serves to maintain requisite levels of central nervous system (CNS) activity throughout sleep. REM is the mechanism used by the brain to promote recovery from sleep. We believe that the cumulative evidence indicates that REM sleep serves no role in the processing or consolidation of memory. Key Words: antidepressant drugs; brain stem lesions; dreams; functional imaging; memory consolidation; REM deprivation; REM sleep; theta rhythm. (shrink)

In The Ethics of Food, Gregory E. Pence brings together a collection of voices who share the view that the ethics of genetically modified food is among the most pressing societal questions of our time. This comprehensive collection addresses a broad range of subjects, including the meaning of food, moral analyses of vegetarianism and starvation, the safety and environmental risks of genetically modified food, issues of global food politics and the food industry, and the relationships among food, evolution, and human (...) history. (shrink)

Children who experience well-being are engaging more confidently and positively with their caregiver and peers, which helps them to profit more from available learning opportunities and support current and later life outcomes. The goodness-of-fit theory suggests that children’s well-being might be a result of the interplay between their temperament and the environment. However, there is a lack of studies that examined the association between children’s temperament and well-being in early childhood education and care, and whether this association is affected by (...) ECEC process quality. Using a multilevel random coefficient approach, this study examines the association between toddlers’ temperament and well-being in Norwegian ECEC and investigates whether process quality moderates this association. Results reveal an association between temperament and well-being. Staff-child conflict moderates the association between shyness and well-being, and between activity and well-being. Moreover, high emotional behavioral support moderates the association between activity and well-being. Extra attention should be paid by the staff to these children’s needs. (shrink)

Philosophers have long been involved in the pursuit of a goal shared by researchers in psychiatry and the cognitive sciences: understanding the relationship between the functioning of the human mind and human well-being or suffering. For this reason there is a very large area of overlap between philosophical and psychiatric research. The overlap is particularly significant in the domain of practical ethics, which is concerned with understanding the moral dimension of policies and actions in the real world. This chapter reviews (...) two distinct domains in which psychiatry and practical ethics overlap. First, issues in practical ethics arise out of new advances in psychopharmacology, including clinical and non-clinical use of new antidepressants drugs, the clinical use of placebo medications, and psychiatric drugs which enhance human cognition; these issues are frequently grouped under the banner of "neuroethics." Second, the understanding of fundamental questions in moral philosophy is being driven forward by evidence from psychology and psychiatry. Evidence from autism and the personality disorders is shedding light on the nature of moral motivation, while evidence from addiction and compulsion is generating progress in understanding moral responsibility. Finally, some areas are highlighted in which the science of psychiatry may benefit from the application of existing work in moral philosophy and practical ethics. (shrink)

Long-standing psychiatric practice confirms the pervasive use of pharmacological therapies for treating severe mental disorders. In many circumstances, drugs constitute the best allies of psychotherapeutic interventions. A robust scientific literature is oriented on finding the best strategies to improve therapeutic efficacy through different modes and timing of combined interventions. Nevertheless, we are far from triumphal therapeutic success. Despite the advances made by neuropsychiatry, this medical discipline remains lacking in terms of diagnostic and prognostic capabilities when compared to other branches (...) of medicine. An ethical principle remains as the guidance of therapeutic interventions: improving the quality of life for patients. Unfortunately, psychotropic drugs and psychotherapies do not always result in an efficient remission of symptoms. In this paper I corroborate the idea that therapists should provide drug-resistant patients with every effective and available treatment, even if some of such interventions could be invasive, like Electroconvulsive Therapy (ECT). ECT carries upon its shoulders a long and dramatic history that should be better investigated to provide new insights. In fact, ECT has attracted renewed interest in recent years. This is due to the fact that antidepressant drugs in younger patients show often scarce effectiveness and unpleasant side-effects. Moreover, I show that, thanks to modern advances, ECT may work as a successful form of treatment for specific and rare cases, such as severe depression (with suicide attempts) and catatonia. (shrink)

We believe that this has been a constructive debate on the topic of memory consolidation and REM sleep. It was a lively and spirited exchange – the essence of science. A number of issues were discussed including: the pedestal technique, stress, and early REMD work in animals; REM windows; the processing of declarative versus procedural memory in REM in humans; a mnemonic function for theta rhythm in waking but not in REM sleep; the lack of cognitive deficits in patients on (...) antidepressant drugs that suppress or eliminate REM sleep; the disposition of conscious (dreams) and nonconscious material of REM sleep; and finally our theory of REM sleep. Although our position was strongly challenged, we still hold that REM sleep serves no role in the processing and consolidation of memory. (shrink)

We review Side Effects, a 2013 film involving bioethics, pharmaceuticals, and financial conspiracies. After the main character Emily unsuccessfully attempts suicide, she begins receiving care from a psychiatrist, Dr. Banks. Following numerous events, she is placed on a fictional antidepressant, Ablixa, which leads her to suffer from sleepwalking. During an episode of sleepwalking she commits a serious crime. The film poses an interesting dilemma: How responsible would the physician be in this instance? We analyze this question by applying numerous (...) ethical principles. (shrink)

It is a plausible speculation that conventional choices in outcome measures might influence the results of meta-analyses. We test that speculation by simulating data from trials on antidepressants. We vary real drug effectiveness while modulating conventional values for outcome measures. We had previously shown that one conventional choice used in meta-analyses of antidepressants falls in a narrow range of values that maximize estimates of effectiveness. Our present analysis investigates why this phenomenon occurs. Moreover, our results suggest the superiority of absolute (...) outcome measures over relative measures. This research program can be extended to test numerous other aspects of clinical research. (shrink)

Why do some people still choose psychoanalysis-Freud's so-called talking cure-when numerous medications are available that treat the symptoms of psychic distress so much faster? Elisabeth Roudinesco tackles this difficult question, exploring what she sees as a "depressive society": an epidemic of distress addressed only by an increasing reliance on prescription drugs. Far from contesting the efficacy of new medications like Prozac, Zoloft, and Viagra in alleviating the symptoms of any number of mental or nervous conditions, Roudinesco argues that the (...) use of such drugs fails to solve patients' real problems. In the man who takes Viagra without ever wondering why he is suffering from impotence and the woman who is given antidepressants to deal with the loss of a loved one, Roudinesco sees a society obsessed with efficiency and desperate for the quick fix. She argues that "the talking cure" and pharmacology represent not just different approaches to psychiatry, but different worldviews. The rush to treat symptoms is itself symptomatic of an antiseptic and depressive culture in which thought is reduced to the firing of neurons and desire is just a chemical secretion. In contrast, psychoanalysis testifies to human freedom and the power of language. (shrink)

This article will examine how the notion of emotional authenticity is intertwined with the notions of naturalness and artificiality in the context of the recent debates about ‘neuro-enhancement’ and ‘neuro-psychopharmacology.’ In the philosophy of mind, the concept of authenticity plays a key role in the discussion of the emotions. There is a widely held intuition that an artificial means will always lead to an inauthentic result. This article, however, proposes that artificial substances do not necessarily result in inauthentic emotions. The (...) literature provided by the philosophy of mind on this subject usually resorts to thought experiments. On the other hand, the recent literature in applied ethics on ‘enhancement’ provides good reasons to include real world examples. Such case studies reveal that some psychotropic drugs such as antidepressants actually cause people to undergo experiences of authenticity, making them feel ‘like themselves’ for the first time in their lives. Beginning with these accounts, this article suggests three non-naturalist standards for emotions: the authenticity standard, the rationality standard, and the coherence standard. It argues that the authenticity standard is not always the only valid one, but that the other two ways of assessing emotions are also valid, and that they can even have repercussions on the felt authenticity of emotions. In conclusion, it sketches some of the normative implications if not ethical intricacies that accompany the enhancement of emotions. (shrink)

Why do some people still choose psychoanalysis-Freud's so-called talking cure-when numerous medications are available that treat the symptoms of psychic distress so much faster? Elisabeth Roudinesco tackles this difficult question, exploring what she sees as a "depressive society": an epidemic of distress addressed only by an increasing reliance on prescription drugs. Far from contesting the efficacy of new medications like Prozac, Zoloft, and Viagra in alleviating the symptoms of any number of mental or nervous conditions, Roudinesco argues that the (...) use of such drugs fails to solve patients' real problems. In the man who takes Viagra without ever wondering why he is suffering from impotence and the woman who is given antidepressants to deal with the loss of a loved one, Roudinesco sees a society obsessed with efficiency and desperate for the quick fix. She argues that "the talking cure" and pharmacology represent not just different approaches to psychiatry, but different worldviews. The rush to treat symptoms is itself symptomatic of an antiseptic and depressive culture in which thought is reduced to the firing of neurons and desire is just a chemical secretion. In contrast, psychoanalysis testifies to human freedom and the power of language. (shrink)

Why do some people still choose psychoanalysis-Freud's so-called talking cure-when numerous medications are available that treat the symptoms of psychic distress so much faster? Elisabeth Roudinesco tackles this difficult question, exploring what she sees as a "depressive society": an epidemic of distress addressed only by an increasing reliance on prescription drugs. Far from contesting the efficacy of new medications like Prozac, Zoloft, and Viagra in alleviating the symptoms of any number of mental or nervous conditions, Roudinesco argues that the (...) use of such drugs fails to solve patients' real problems. In the man who takes Viagra without ever wondering why he is suffering from impotence and the woman who is given antidepressants to deal with the loss of a loved one, Roudinesco sees a society obsessed with efficiency and desperate for the quick fix. She argues that "the talking cure" and pharmacology represent not just different approaches to psychiatry, but different worldviews. The rush to treat symptoms is itself symptomatic of an antiseptic and depressive culture in which thought is reduced to the firing of neurons and desire is just a chemical secretion. In contrast, psychoanalysis testifies to human freedom and the power of language. (shrink)

When the University of Toronto withdrew a contract it held with me in December 2000, it initiated a sequence of events that led to a public letter to the University from senior figures in the world psychopharmacology community protesting against the infringement of academic freedom involved and a first ever legal action, undertaked by this author, seeking redress for a violation of academic freedom. The issues of academic freedom surrounding this case have been intertwined with a debate about the possibility (...) that the selective serotonin reuptake inhibitor (SSRI) group of antidepressants have the potential to trigger suicidality in a subgroup of patients. Whether the SSRIs do trigger suicidality or not, exploration of this issue has given rise to a number of worrying sets of observations. First, in my view, there is evidence that pharmaceutical companies have miscoded raw data on suicidal acts and suicidal ideation. Second, this author also maintains that there is a growing body of examples of ghostwriting of articles in the therapeutics domain. Many of the tensions evident in this case, therefore, can be linked to company abilities to keep clinical trial data out of the public domain — this is the point at which the pharmaceutical python gets a grip on academia. (shrink)

In lieu of an abstract, here is a brief excerpt of the content:Philosophy, Psychiatry, & Psychology 12.3 (2005) 235-237 [Access article in PDF] Determined by Chaos: The Nonlinear Dynamics of Free Will Jessica Wahman Keywords free will, chaos theory, determinism, materialism In "antidepressants and the Chaotic Brain: Implications for the Respectful Treatment of Selves," Douglas Heinrichs provides an intriguing justification of individuated and longer term therapy for depressive clients. He does not reject medication as a therapeutic strategy, nor does he (...) question the materialist basis of the traditional medical model. Rather, he offers a physically deterministic account of depression that is at the same time compatible with a sense of human agency and individuality. Heinrichs suggests that human physiology and its psychiatric disorders are better accounted for by the nonlinear dynamics of chaos theory than by the traditional account of neurotransmitter production and reuptake. Because the latter, microscopic, explanation suggests a direct cause-and-effect relationship between synaptic activity and subjective affect, it cannot account for the wide variation of responses to the same medications, nor can it satisfy the client's fears that her drug-induced well-being is not fully hers to control. Chaos theory, he asserts, can provide a better explanation by treating the human organism as a complex holistic system whose patterns resemble a topographical map of probability more than they do a unidirectional vector model of cause to effect. Like the weather, human affect and behavior are physically determined but difficult to predict, and so careful attention to both the individual history of the client and the uniqueness of responses to medication are a necessary part of any successful therapeutic program.Connected to this theory of nonlinear physiology is Heinrichs's account of autonomy and agency under this rubric. He notes that a psychology based on chaos theory is not only compatible with the notion of free will, it can better explain why the successful use of medication actually increases freedom and autonomy instead of limiting it. It is here that I wish to focus my comments, because his interpretation of free will may give us, to borrow a phrase from Daniel Dennett, a "variet[y] of free will worth wanting" (1984, title page). Free will, in this case, is not a metaphysical ability to act above and beyond our material causes, but is instead a property of the material system itself, namely when that system feels itself capable of greater psychic mobility around the topographical map of probabilistic patterns.According to this model, our ability to reason, plan, and act on the decisions we make is itself a [End Page 235] part of our chaotically determined neurologic system. When we are healthy, we are able to reason in our best interests and act on those reasons. This is modeled as an ability for the organism to metaphorically "move about" the map of its own possibilities, and more important, to both enter and escape certain states, known as chaotic attractors, into which it is likely to be drawn. "Where" we wind up, psychologically speaking, at any point in time is determined by our own system, and so we may say that in such a case we are autonomous and our choices are made freely. Depression, on the other hand, can be compared to a deep groove in the map, a chaotic attractor that is hard to escape, and so the system quite literally becomes "stuck in a rut." This is subjectively experienced as the tendency for thought processes and activities to fall into negative and self-defeating patterns despite the best efforts of the client to escape these habits. So long as the organism does not have a sense of being "trapped" in an attractor (whether a depressive or, for example, manic or compulsive state), then that organism may be said to be free. Medication and the therapy that accompanies it, so far as it facilitates our ability to escape deep chaotic attractors, promotes our own freedom of will. If a car cannot spin its way out of a ditch, does the tow truck hinder or promote its freedom by hauling it back onto solid pavement where it may again... (shrink)

In this paper, I explore the questions of how and to what extent new antidepressants (selective serotonin-reuptake inhibitors, or SSRIs) could possibly affect the self. I do this by way of a phenomenological approach, using the works of Martin Heidegger and Thomas Fuchs to analyze the roles of attunement and embodiment in normal and abnormal ways of being-in-the-world. The nature of depression and anxiety disorders — the diagnoses for which treatment with antidepressants is most commonly indicated — is also explored (...) by way of this phenomenological approach, as are the basic structures of self-being. Special attention is paid in the analysis to the moods of boredom, anxiety and grief, since they play fundamental roles in depression and anxiety disorders and since their intensity and frequency appear to be modulated by antidepressants. My conclusion is that the effect of these drugs on the self can be thought of in terms of changes in self-feeling, or, more precisely, self-vibration of embodiment. I present the idea of a spectrum of bodily resonance, which extends from the normal resonance of the lived body, in which the body is able to pick up a wide range of different moods; continuing over various kinds of sensitivities, preferences and idiosyncrasies, in which certain moods are favored over others; to cases that we unreservedly label pathologies, in which the body is severely out of tune, or even devoid of tune and thus useless as a tool of resonance. Different cultures and societies favor slightly differently attuned self-styles as paradigmatic of the normal and good life, and the popularity of the SSRIs can therefore be explained, not only by defects of embodiment, but also by the presence of certain cultural norms in our contemporary society. (shrink)

Despite their centrality to medicine, drugs are not easily defined. We introduce two desiderata for a basic definition of medical drugs. It should: (a) capture everything considered to be a drug in medical contexts and (b) rule out anything that is not considered to be a drug. After canvassing a range of options, we find that no single definition of drugs can satisfy both desiderata. We conclude with three responses to our exploration of the drug concept: maintain (...) a monistic concept, or choose one of two pluralistic outcomes. Notably, the distinction between drugs and other substances is placed under pressure by the most plausible of the options available. (shrink)

The documented efficacy and long-term benefit of antidepressants in patients with recurrent forms of severe anxiety or depressive disorders support their use in those individuals with these disorders, who experience suicidal thoughts or behavior. In general, it is assumed that antidepressants are beneficial for all symptoms of depression, including suicidality. However, some evidence suggests that Selective Serotonin Reuptake Inhibitors [SSRIs] may cause worsening of suicidal ideas in vulnerable patients. Systematic reviews and pooled analysis of experimental, observational, and epidemiological studies have (...) investigated the use of SSRIs and their association with suicidality. Taking account of the methodological limitations of these studies, the current evidence fails to provide a clear relationship between their use and risk of suicidality in adults. However, in children and adolescents, there appears to be a bit of increased risk of suicidal ideations and attempts, but not of completed suicides. This risk can be anticipated and managed clinically. Clinicians are, therefore, advised to maintain a close follow-up during the initial treatment periods and remain vigilant of this risk. This advisory, however, should not deter clinicians from the use of effective dosages of antidepressants for a sufficient period of time, in every age group of patients, when clinically needed, and if found suitable otherwise. (shrink)

This paper uses John Rawls' theory of justice to defend the patent system against charges that it has an unfair effect on access to medications, from the perspective of national and international justice. The paper argues that the patent system is fair in a national context because it respects intellectual property rights and it benefits the least advantaged members of society by providing incentives for inventors, investors, and entrepreneurs. The paper also argues that the patent system is fair in an (...) international context, provided that developed nations take steps to help disease-stricken countries secure internal justice. Fairness in a national or international context also requires that the patent system should include emergency exceptions to deal with short-term inequities. (shrink)