The Emperor's New Drugs: Exploding the Antidepressant Myth. Irving Kirsch. New York: Basic Books, 2010, 226 pp., $23.95.
The Emperor's New Drugs adds to a growing list of publications premised on questioning current medication-based treatment approaches for mental health issues. Over the past several years, several books have challenged the use and treatment efficacy of antidepressant medications for clinical depression (see for example, Breggin, 2008; Kramer, 1993; Valenstein, 2002). As suggested by the title, Kirsch focuses on erroneous conclusions in testing, marketing, and ongoing clinical use of antidepressants currently available. In contrast to the theme of invisibility from the Hans Christian Andersen fairy tale, Kirsch asserts a myriad of concerns about antidepressants that are far from invisible when looking closely at clinical trial methodology, data analysis, and results.
Kirsch, a clinical psychologist, has completed extensive research related to clinical usage of antidepressants, and he began his detailed discussion in the context of his own psychotherapy practice. Prior to in-depth research, Kirsch acknowledged that he regularly referred clients with significant depression for medication consideration. Based on a general review of available data, Kirsch (1990) first concluded that antidepressants, specifically Imipramine, did, indeed, result in significant improvement relative to the effect of placebo treatment. However, prompted by the awareness that "people . . . can experience symptom improvement just by knowing they are being treated" (p. 2), Kirsch translated this curiosity toward a meticulous look at the role of the placebo as used in clinical trials with antidepressants.
In the course of extensive investigation, Kirsch and colleagues completed meta-analyses of published and unpublished data, rendering surprising and unexpected conclusions. Describing drug companies as a "$19 billion-a-year industry" (p.1), Kirsch presents data that discredit the robust claims of these companies relevant to antidepressants and the significance of the effects of these medications. Kirsch's synopsis regarding his own journey through the research has been one in which ". . . I moved from acceptance to dissent, and finally to a thorough rejection of the conventional view of antidepressants" (p. 3). The Emperor's New Drugs is a detailed account of Kirsch's process toward this conclusion along with frank responses to critiques of his research. Four of the seven chapters that comprise the book are chocked full of details from drug company research, much of which refutes conventional wisdom as well as ideas used in clinical practice.
UNCOVERING THE FIRST LAYER
Kirsch and colleagues initially completed a meta-analysis of 38 studies in which approximately 3,000 individuals with depression were represented. The specific focus of this analysis was to compare the effects of antidepressants to placebo, to psychotherapy, and to no-therapy (or waiting list controls). When controlling for "spontaneous recovery" by inclusion of the control group, Kirsch and colleagues found:
People got better when given either form of treatment [antidepressant or psychotherapy], and the difference between the two was not significant. People also got better when given placebos, and here too the improvement was remarkably large, although not as great as the improvement following drugs or psychotherapy. In contrast, the patients who had not been given any treatment at all showed relatively little improvement. (Kirsch, 2010, p. 9)
The most surprising result when comparing the four groups was that there was a relatively small drug effect beyond that experienced by those in the placebo group. When considering effect size, placebo had a large effect (approximately 1.2), as did antidepressant (1.6). Translation of these findings suggested that:
improvement in patients who had been given a placebo was about 75 per cent of the response to the real medication. …