Stephen Wisniewski, Brandon Gaudiano and David Karp all look at antidepressant medications through different lenses. But in each of their views, there are problems with the drugs.
Mr. Wisniewski is associate dean at the University of Pittsburgh's Graduate School of Public Health and an expert on the statistics of depression. Mr. Gaudiano is a psychiatry professor at Brown University's medical school and an advocate of psychotherapy. Mr. Karp has depression, and is a retired sociology professor at Boston College who has written three books about the experience of mental illness.
For Mr. Wisniewski, antidepressant medications are effective for many patients -- but not as potent as drug companies have claimed.
The best evidence of that is the STAR*D study, which compared various drug treatments and psychotherapy in thousands of patients drawn from doctors' offices and clinics. Pitt was one of 14 sites around the nation that participated.
The drug used in the first round of the trial was citalopram, or Celexa. Some drug firm studies have shown that antidepressants like citalopram achieved remission -- elimination of all symptoms -- in up to 40 percent of patients. But drug company trials often exclude people who have other medical or psychiatric conditions, or whose condition is severe, he said.
The STAR*D study didn't rule out those patients, and in the first round, the citalopram achieved remission in only 28 percent of those who tried it. People who agreed to go to a second round of therapy either switched to a new drug, added a drug or got cognitive behavioral therapy, a proven talk therapy for depression. In that group, about 25 percent achieved remission, showing that the more treatments people fail, the harder it is for them to find one that works.
The study, completed in 2004, did show that there was no difference between psychotherapy and medication in treating depression.
That is encouraging to Mr. Gaudiano. He said some studies have shown that depressed patients have a lower chance of relapsing into illness if they use proven talk therapy methods rather than antidepressants.
"It's not always clear what medications are doing to the brain," he said, "and research suggests people often do worse when they stop, because when you take those drugs out of the system the body has to readjust."
He believes good psychotherapy, on the other hand, teaches people how to resist depression, just as they learn any other complex skill.
But that doesn't mean he thinks psychotherapy has a clear advantage over drugs in the real world.
That's partly because many if not most counselors do not use the kinds of therapy that have been proven effective in treating depression. In a September opinion piece in the New York Times, Mr. Gaudiano said that not only does talk therapy have a marketing disadvantage compared to the drug companies, but "there has been a disappointing reluctance among psychotherapists to make the hard choices about which therapies are effective and which -- like some old-fashioned Freudian therapies -- should be abandoned."
"Once you are licensed to practice psychotherapy," he said in an interview, "you don't have to use evidence-based treatments. You can do that without any fear of any penalty. Because there are no real standards, there is a wild west mentality where people are basing their therapy on what they know."
Groups like the American Psychological Association "in some way need to clean up their act and say this is the way we go to make sure people get more access to care and that means we have to adopt evidence-based practices as best we can."
Mr. Karp takes an even more jaundiced view of antidepressant medications.
In his 2006 book, "Is It Me or My Meds?", he interviewed dozens of psychiatric patients on their feelings about taking such drugs, and one of his main findings is that those drugs have a much different impact on patients than the ones they might take for cholesterol or diabetes.
For one thing, they carry a stigma, he said.
"You don't castigate someone who has heart disease or cancer, but once they accept the notion they have mental illness, people are entering into a whole new realm where there is a great deal of stigma attached to their circumstance."
Some patients also worry that taking antidepressants means they have given up on themselves. "One person said to me, 'the moment I swallowed the pill, I swallowed my will.' "
For some people with depression or bipolar illness, their range of feelings is part of who they are, and the impact of drugs is often to blunt those emotions.
"I think if the medications work at all, the way they work often is by narrowing the band of what you can feel. I had a young man who used to be a student of mine who said he was going out with a girl, and she wanted to know, 'Look, do you love me or not?' and he told me that he couldn't answer the question, and part of the reason was the medication was making some of those emotions unavailable to him."
Beyond that, he is skeptical of how effective the drugs are, and thinks pharmaceutical companies have oversold how much they know about the biology of depression and the way that drugs alter that biology.
One result of that, he said, is that more and more people are now defined as needing antidepressants and other psychiatric medications.
"There is a line from normal to pathology, where you say someone has crossed from normal unhappiness to something that needs medical treatment," Mr. Karp said, "and that line is being drawn to include more and more people who need medical treatment.
"What I want people to know is that the question of how that line gets drawn between the normal pain of living and the pathological line of disease is as much political and cultural as it is scientific."
(Correction: Published Dec. 16, 2013): An earlier version of this story had the wrong diagnosis for retired professor David Karp. Also, his book was published in 2006, not 2007.
Mark Roth: firstname.lastname@example.org, 412-263-1130 and on Twitter: @markomar First Published December 16, 2013 12:05 AM