Russ Roberts

Greenberg on Depression, Addiction, and the Brain

EconTalk Episode with Gary Greenberg
Hosted by Russ Roberts
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Gary Greenberg, psychologist and author of The Noble Lie and Manufacturing Depression, talks with EconTalk host Russ Roberts about the nature of addiction, depression and mental illness. Drawing on ideas in the two books, Greenberg argues that there are strong monetary incentives to define various problems as illnesses that psychiatrists "cure" with drugs. Greenberg argues that this distorts science and has strong impacts, good and bad, on how we view ourselves and the challenges of life. The conversation looks at the scientific basis for addiction and the role brain chemistry in depression. The conversation closes with a discussion of Greenberg's correspondence with the Unabomber.

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0:36Intro. [Recording date: September 16, 2010.] The Noble Lie suggests that our use of medicine is not always as scientific as we'd like it to be, but sometimes convenient. What's your argument there? What happens is science, especially in the post-religion age, has become our most reliable source of truth; and truth underlies our determinations of value. People try to determine how to live their lives or how to treat each other based on what they think the truth is about the way the world works. If I decide to ride my bicycle instead of driving my car in order to not contribute to the greenhouse effect, I do that because I place some kind of value on preserving the environment; I've come to think that that's something truly important. Once we aren't all united by the same religion or same belief in God, question of what makes life worth living and why--what the good is and why it's good--is thrown into disarray. We can disagree about it. Science helps us: scientists say that we've reached final decisions, determinations about the nature of reality. Very compelling if I say, scientifically speaking it is true that eating lots of eggs will increase your cholesterol, and that will make you likely to die young. There aren't any questions to be asked any more. Especially in the realm of medicine, the more we can say these kind of things, the less confusing life becomes. What my book is about is how that compelling power of science has become adopted, sometimes inappropriately, by people who are advocating for certain positions. Obvious example: brain death. Idea that if your brain has been destroyed, even if your heart is still beating, still breathing even with the help of a machine, you are dead. That is an idea that was developed in the late 1960s; developed to facilitate organ transplant. Problem is, you need to be able to get organs out of bodies quickly in order to transplant them into other bodies; quickly means ideally you take them out of a body when the blood is still circulating. As soon as the blood stops circulating, the organs start to deteriorate. Raises question: let's say you have someone badly injured who you know is not going to recover, whose brain is destroyed, still breathing; want to take out their organs. From a medical standpoint, you want to take them out while the person is still breathing. Notice you didn't say "alive." From a common sense point of view, that person is still alive: they are warm, flush, breathing, heart's beating, they are metabolizing. They just don't have any consciousness. In 1968 when this issue came up, the problem was that nobody wanted to facilitate heart transplants by condoning what amounted to murder. No doctors wanted to kill people by taking their hearts out. So rather than just grapple with that idea, they moved the line between life and death back a little bit. Rather than simply deciding we will take this person's heart out and then they will die, they made it so that the person would die, and then they could take the heart out. By changing the definition of death. And then they sold that as an idea about biology. Convoluted scientific explanations for why it was really true; we thought death was when the heart stopped beating, but we'd been wrong all along for thousands of years. Really, death occurs when the brain no longer functions. No way around it--that's a philosophical question. But the doctors who were trying to create a possibility of saving other lives with organ transplants didn't want to get into that debate. Rather just say scientifically speaking, that person's dead, even if they look alive.
6:35Fascinating about both books is that you force the reader to think about the reader to think about the interface between morality and science, philosophy, and medicine. Four things that merge together. Often we are encouraged culturally to think that medicine is just science, so all these decisions are just scientific. But usually deeply moral and philosophical about what kinds of lives we want to be, how we see ourselves. Make a nice contrast between, say, a tumor, which taking medicine to fight a tumor--which taking medicine to fight a tumor most people would think of as a good idea--and being unhappy, which people also now say is something like a tumor, perhaps. Not that simple. At the point that you see that paradigm expanding to encompass more and more of our lives; you see why the noble lie is such an important concept. In its original conception, "noble lie" was something the philosophers knew was not true, but which enabled people to do things that otherwise they wouldn't be able to do, or to have convictions which otherwise they wouldn't be able to have. A few people were the guardians of the truth, and everybody else benefited from that. So in the comparison you just made, really obvious why we would want to have medicine to treat tumors, diabetes; also obvious that nobody's going to frown on that, or very few people--perhaps Christian Scientists are. But most people in our society, to take drugs to feel better is considered a bad thing to do. But if you call the feeling bad, whatever it is, a disease, and say doctors have found that it is a disease, so that whatever I take for it, let's say Prozac, then I'm not breaking the more--cultural taboo--by taking those drugs. I'm treating a disease. Argue in both books that that's not necessarily a bad thing--the creation of that lie--enables something we otherwise wouldn't be able to do. But on the other hand, it starts with the assumption that we can't handle the truth, which I always find to be a dangerous assumption. Dangerous partly because it leads to manipulation and the accumulation of power in places we might not want it to be; but it also seems a bit inauthentic.
9:58Example you start The Noble Lie with: addiction. Used to be that the use of alcohol in excess--hard to define--drinking a lot, was viewed as a character defect; but it came to be viewed as a disease. Talk about the history of that and what you think is good and bad about it. Have to remember that before it was even considered to be a character defect, lots of drinking was considered to be normal. Long history, question of inebriation. Colonial America, for all its Puritan background, was still a place where a lot of drinking was going on. Beer, ale, rum--rum was big. The water wasn't so good--that was one reason. Life was the other reason. Second reason? Life. Source of hydration, but also life was sometimes not so easy. I don't really know this, but people who were in states of inebriation were first, more able to function because they learned better to function with their inebriation, and second, the expectation of their sobriety wasn't as strong as it is now. As time goes on, certainly by the 18th century in the United States, drinking shows up as problem. What kind of problem is it? Some people think it is a character problem--failure to live a righteous life. Others start to think of it as a sort of disease. In the 18th century, "disease" meant something a little different than it does today. Flash forward to the 20th century: the country has been torn apart in some ways by this issue. Women's temperance movement came in around late 19th, early 20th century, ultimately as part of a deal to facilitate suffrage, Prohibition comes into play. Amendment is passed; drinking becomes illegal; people find ways around it. One of the things that happen with Prohibition is that excessive drinking got pushed even farther underground. It couldn't be acknowledged as much of a social problem. So when Prohibition fails and was repealed in the early 1930s, and people started to drink again and the problem of excessive drinking was one we could look at, there was no infrastructure in place to deal with people who were having trouble with drinking. It fell back to the ministers--to the Church--and other forces of moral suasion in society to deal with alcoholics. But doctors, who had had an interest in this for a long time, thought that they should be the first line of treatment of people who were alcoholic. Lot of trouble getting purchase on the resources and the imagination of the people. They engaged a public relations expert, at the end of the 1930s, who was himself a recovering alcoholic--how doctors could sell themselves as the primary treaters of alcoholism. This guy came up with a very simple idea--wrote a paper, published in their Quarterly Journal of Alcohol Studies; said the way to do this was to turn alcoholism into a disease. If you convince the world that this was a disease, then they will come to you for treatment because you treat diseases. Happened to be about the same time that Alcoholics Anonymous (AA) was taking off. These two lines of thinking--disease and to be treated through AA--converged. Became a powerful and quickly the dominant idea. Important to remember that the idea that alcoholism is a disease was invented by a public relations guy. Doctors who study diseases--and what we usually mean by a disease is a kind of suffering that has a bio-chemical dysfunction behind it. Can find it under the microscope. They spent years looking for it under the microscope and have never succeeded even to this day. Always telling us they are on the verge of it; some combination of neuroscience and genetics. But, while they've been pretty good at figuring out some of the neurological consequences of drinking, and chemical consequences of addiction--the idea that it originates in the body still hasn't been proved. Frankly, I'm not sure it's ever going to be. What you have is a myth. The myth that alcoholism are diseases is a very effective myth; captures the imagination; allows people to go for treatment and take care of themselves. Allows people to allow doctors to take care of them instead of feeling like there is something pathological in the sense of a sin. Or a character flaw. In this way, it helps. No self-respecting doctor is going to say he knows what the chemical cause of addiction is. Among themselves doctors freely admit they don't know it yet. To their faces, they are going to tell patients it's a disease and here's what to do about it. People find that helpful. On the other hand, to call something a disease is also to open up the possibility--there's a certain kind of responsibility that people won't take for their behavior. It also has implications in the forensic realm. We see this over and over again: people using as legal defenses the fact that they have a disease.
17:34Two side-points: running through all of our conversation today, want listeners to think about parallels between this conversation and macroeconomics. Don't seem exactly parallel, but they ring a lot of bells with me. We have a complex system called the body; a lot of stories we tell about it, and a lot of insights--medical insights, genetic insights. There are pathological things, micro-organisms, viruses, tumors; physical, measurable things that go wrong with the body and we know how to fix them. But we don't totally understand it, and we don't really have a good understanding of the interaction of the mind and the body. Similarly, the economy is a complex organism. We like to talk as if we understand it scientifically, but a lot of times it's scientism--fake science, illusion of science, some support but mainly telling stories that support our views or biases, as doctors, economists, policy-makers. Second aside: other subtheme which runs through the books, the creeping expansion of power by doctors. Sometimes legally, sometimes through policy, and sometimes by culture. We turn to them for all that ails us. What doctors ask us as patients now is not what they asked us 30-40 years ago; feel totally comfortable doing it. Sometimes find myself telling my doctor: It's none of your business. They view much of my life as their purview in ways that I don't. Have a shamanism about them as well; your first point. We turn to doctors for not just truth, but comfort.
19:40Back to addiction. Are you suggesting there is no genetic basis for alcoholism? No physical aspect to addiction when you make the claim they haven't uncovered a biological basis? Not at all. What we are finding out with the Genome Wide Association Study and its failure to show association with much of anything. There was a time when scientists hoped they were going to find correspondences like for Huntington's Disease, where there is more or less a one-to-one correspondence. In fact, we are finding you are going to have is a small percentage of cases accounted for by a particular genetic variant. Clear that alcoholism is in families; points to possibility of genetic causes; but I think that we're a long way from finding those. As far as a physiological aspect to addiction--well, of course. If you pack your body full of poison, in the case of alcohol, or substances that work by changing your brain chemistry over and over and over again--if you don't think that's going to have an effect you have to wonder what you're smoking! But the key question is: nicotine is addictive; people do stop smoking. The word "addictive" can mean: obviously there's a chemical thing in your body that makes it harder and harder to do without it. It can also mean something you like a lot. Do we have any evidence for a scientific distinction between those two things. To take an example that's not chemical, at least doesn't seem to be--getting on the Internet. Some people have to check their email compulsively, use Facebook compulsively. What does compulsively mean? What does it mean to go without? Is there something physical, chemical going on in our bodies when we go without? I'm sure. Every experience we have--craving this conversation, love--is utterly dependent on chemistry, and particularly brain chemistry. To go back to the first thing, brain death--without a brain, you've got nothing. Don't doubt there is always a biochemical thing happening, and I think we should all be grateful for that. But, can we establish a distinction between, say, compulsion and addiction, between really liking something and being hooked on it, through biology? I really doubt it. And even if we could, I'm not sure we will know what we really need to know. For example, a lot of documented evidence that veterans returning from Viet Nam in the 1960s and 1970s with really big heroin addictions--and, by the way, addicted to really good heroin--stopped using it when they got back here. They didn't have to think of themselves as lifelong addicts. Methadone. Or they just stopped, because their context changed. The danger of answering "yes" with the biological thing and that's all there is to it, is at this point the major source of research in this country, if not the only one--certainly it's the stated position of the Director of the National Institute of Drug Abuse--the danger is that it fails to take into account the actual context in which people are abusing and suffering with these drugs.
23:51Depression. First came across your work in a podcast we did with Louis Menand. Your book and Irving Kirsch's book. You have some provocative and unpopular views on what pharmaceuticals can and cannot do for our mental problems. Talk about your view. One way to look at this is, in book, is our current understanding of depression is the tail wagging the dog. The drugs came first. Not that people don't get depressed or for all of human history. Book of Job, one of the earliest-written accounts that we have. At least in some cases, depression really is just like some other disease--body goes awry. What's happened over the last 50 years or so is that the question of who is depressed and exactly why has increasingly been answered by people who have an interest in selling drugs. The answer to the first question--who is depressed--is of course, all of us. Huge market. In real life, life is hard. Possible, given the context-free and somewhat official vague definition of depression, it is possible for an awful lot of people to meet the criteria. Furthermore, you don't have to meet the criteria to be told by your family doctor you have depression and you ought to take anti-depressives for it. On top of that, you don't have to have a disease of depression in order to feel better when you take the drugs. The potential is out there for lots of people be diagnosed with, or think of themselves, as depressed in a medical sense, and to think the problem they have is a biochemical imbalance in their brain and that the solution is to take drugs for it. Remarkable thing. It is. Where does this come from? Series of accidental discoveries in the 1960s that were really a convergence of accidents which ultimately resulted in a belief that brain chemistry determined our moods. Most of those accidental discoveries had to do with people taking drugs and unexpectedly feeling better. So, once the pharmaceutical companies were in possession of these drugs that made people feel better, they had a real interest in figuring how to medicalize that discovery. Solution to that problem had to do with convincing doctors, and eventually consumers, that their troubles constituted a disease. Third piece to it: increasing subsidy of medical care by third parties aided through tax deductions or outright government programs which make the price of indulging in this myth cheap. Funneled money. Frightening thing, not just because of the power and resource consequences, but what it does to us to us as human beings. What do we know scientifically about the impact of these drugs on deeply depressed people--not just people who are a little unhappy. Huge language issue, talked about in book. What is the evidence that there is an imbalance of brain chemistry to explain why people struggle to deal with life? Different kinds of evidence. Most immediate kind of evidence is drugs: the fact that they work. Work by chemistry. Something is changing in the brain and in a way that makes people feel better. Tempting to conclude there was something wrong in the brain in the first place. Of course, if you smoke a joint and it makes you feel better, you don't necessarily feel that you had cannabis deficit disorder. Seals the deal for a lot of people. Inductive. Not the strongest. The strongest would be a series of studies showing brain defects in people who commit suicide; increasing imaging studies showing the brains of depressed people, severely depressed people showing their brains functioning differently; studies that show in some cases the hippocampus--region of brain associated with mood--is smaller than in people who aren't depressed. Subgroup of depressed people who, if you give them a particular steroid, they metabolize it differently from other people. There are some indications that depression is biochemical. But all of our experiences are biochemical. The idea that depression is a disease is that it originates in biochemistry. That either it's just something that happens by accident--like getting a tumor--or because you have a stressor and a vulnerability, and once that stressor kindles your depression, it doesn't shut off. Scientific dimension to them. Studies that indicate these are true, but they all suffer from the same problem: Chicken and egg problem. Showing there is a biochemical signature to depression--is that the same thing as saying that it just sort of arises arbitrarily and best looked at as a biochemical problem. Let's look at that. Let's say we decide that's what depression is: What are some of the consequences of that? Centralization of power; flow of money; perhaps most disturbingly the attribution of important human experiences to arbitrary and impersonal forces like the chemicals rocketing around in your brain.
33:07As an economist, I'm supposed to be more interested in the first two, but as a human being, found the third one the most gripping. Moment in book: you go in, say you are not so happy, I'm down, I'm blue, or even worse, struggling to get out of bed to fulfill my normal responsibilities. You'd think you'd go in for a blood test that says your hippocampus is distorted and we just have to do surgery, or give you this drug. That isn't what they do. Shocked me to read about your experience participating in a study. Talk about that. You went in expecting to be diagnosed as minorly depressed, and were surprised to find out you weren't, and how that judgment was made. As a journalist, long wanted to be inside a clinical trial--interesting journalistically, scientifically, politically, socially. Hesitated to lie my way in to a clinical trial, though that wouldn't be very hard because there's no blood test. Being a clinician, I know the criteria so it would be easy for me to show up and say I had them. Then a scientific study came along for people who have minor depression; and minor depression is one of these quasi-diseases that they'd like to make an official disease. Only requires that you have a depressed mood for a couple of weeks and some of the other symptoms of major depression--and there are nine, can include trouble sleeping, appetite disturbance. Proving either we are all depressed or evidence expanding to be meaningless. Evidence in both directions. Did this during the George W. Bush Administration--how hard would that be for everybody to feel? So I went. Answered the questions. Give you a test tied to the diagnostic criteria. One of the things they want to know is: Have you been sleeping well? Maddeningly simplistic. Functions like a trouble-shooting chart. If you answer yes here, then he's directed to the question six questions later, and if you answer no, he's directed to another question. At the end of the process, they have a diagnosis for you. Takes about 45 minutes. Not generally done by therapists, usually done only in research settings this way; and has little to do with how you are coming across or what you think about your own experience. Diagnosis made as impersonally and as much like a blood test as possible. That's the whole point--they want to make this seem medical. Objective. And it is, because you are forced to answer these questions, like: Are you feeling excessively guilty? Forced to answer yes or no--when you don't even know what those words means? Compared to what? to you, to me six months ago? Compared to how we want to be? We all feel a little guilty. On and on and on. Objectivity is on the one hand compelling and on the other, illusory. Diagnosis was made that I didn't have minor depression--I had major depression. Which is supposed to be a debilitating illness. There I was. Talking about neuroscience with the guy, had shown up, had driven 90 miles to be there, got there on time, dressed, clean, joking. Shows how dangerous it is. Turns out I was really sick. They offered me a different trial than the one I had signed up for. This particular trial, for which I'm grateful, the drug under study was Omega-3 fatty acids, which are available in fish oil and other sources. Live it up. I was given a megadose--didn't know if they were omega-3s or a placebo. All these studies are compared to placebo. Every few weeks showed back up at the clinic and took same test over again to see if I was getting better. This is how all these drugs approved. Measure of efficacy is self-reported; and slightly contaminated by the fact that the person you are sitting across from has a stake in the outcome; you might want to please, or not please. No lab test. Problem with that isn't that there ought to be a lab test, but that we are trying to reduce a set of complex experiences to a test, whether it's a lab test or one of these paper and pencil tests. We should probably be more cautious and more smart about the extent to which we try to reduce these complex experiences to numbers on a page. Favorite moment: happened to be a time in the Jewish calendar of ten days of repentance. A person is supposed to look into his soul and try to be a better person. As I'm reading this, in your encounter you are asked the question: Are you excessively self-critical? You said, compared to what? Sparred with her a little bit. One could argue that should be the essence of the human enterprise: you should be excessively self-critical and improve yourself. Grow. What she's really trying to say is there's an optimal level of self-criticism. Which may well be. But she's not making those fine distinctions and not allowing that there are people out there that probably ought to be more critical of themselves than they actually are. Probably people who should be less so. No allowance for that--no allowance for context, whether you are upset by somebody dying or the cancellation of your favorite TV show. If you've suffered, are depressed, it doesn't matter why you are depressed; the fact is you are, and you have a disease.
41:53Interesting sideline: one of the problems. Just as the doctors wanted to get alcoholism under their purview, as psychiatrists were trying to get depression under their purview, one of the things they seized upon was redefining depression as a series of symptoms as opposed to an overall impression that a person has or makes. They did that quite nicely by coming up with these 9 criteria. But a study was done that shows that people who are recently bereaved show up as depressed. If you give this test to somebody who just had a death in the family, it's very likely they are going to show up with all the signs of clinical depression--trouble sleeping, etc. Flies in the face of common sense, and in the face of justice. Do we really want to be calling our bereaved people ill, sick? Not to mention, do we want to think about taking Prozac because your wife died. Happened that the woman who did that research was also on the committee that was making the definition of depression over again--in the early 1970s. So they decided you were not depressed if your symptoms were a result of bereavement, unless they persisted for a long time--ultimately two months. Could argue you should be depressed for a year. Arbitrary. But at least they carved out an exception. Achilles' heel in this whole scheme, the bereavement exception. Critics have been poking at it for a long time; finally managed to do some research where they showed that in many ways there is no difference between depression in losing your loved one and losing your job, getting a divorce, etc. Presented this evidence: you can't single out this one social stressor. You have to take all of them into account. The Diagnostic and Statistical Manual of Mental Disorders (DSM) is currently being revised, and this would be the time to decide what to do. And what they decided to do was remove the bereavement exception. So any time you show up with these criteria, you are depressed; doesn't matter why. Working on a story talking to psychiatrists--they don't seem to get why it's a bad idea, that if they are going to start calling this kind of thing illness, they are going to lose people. Every time I write a book or story, I get hate mail. Got mail the other day by a guy who said there was no way he'd sit for an interview with me because people who think that depression isn't a disease are like people who don't believe in evolution. Going to make people kill themselves. Maybe that's true, but if you continue to say to people whose wife just died are sick, you are going to lose the confidence of the American people. Maybe. The deep philosophical issue here is: being unhappy isn't pleasant. Should we medicate away our unhappiness or is there something authentic about human life that says that when we lose a loved one or a job or fail at something we expected to succeed at, is that an opportunity for growth or is that a time to take a drug or get drunk? On that question, I am really agnostic. But that's the issue you lay out. Lay it out in this fashion: I don't have an animus against people taking drugs to feel better. Write in this book about my own experiences with taking illicit drugs to do that, with some effects on my own depression. I actually think the problem isn't so much the drugs themselves, but the context in which they are used and what people think they are doing when they take drugs. If I think I'm taking a drug to feel better because I'm in the middle of some kind of crisis, it's very likely I'm going to look at that as a temporary relief from something I otherwise can't get away from, and maybe use it to recharge my batteries so I can come back. If I am taking a drug because I have a biochemical imbalance, in a whole different world. Fixing an illness; don't have to take the meaning of my unhappiness seriously. Isn't so much the drug as the meaning of the drug. Plenty of evidence that drugs effect change with what we're told to expect from them. People who take Prozac, one of the things that affects their experience is what doctors tell them their experience is about.
47:58Broader umbrella: efficacy. Making fun of this 9-question diagnostic with vague questions--put that to the side. There are definitely people who don't feel so well, definitely biochemical; maybe all of it's biochemical, complicated. What do we know about the efficacy of these pharmaceutical solutions for making people feel better? We don't know enough. What we know is if you measure the effect of anti-depressants on depression defined as those nine criteria, that if you have a mild to moderate depression, it's very difficult in populations to find an advantage of depressants over placebos. We know that in more severely depressed people, the antidepressants do slightly better than the placebos. Conclusion drawn is that antidepressants don't work, and really what they are is placebos. Side-effect causing placebos. That conclusion is based on the fact that the cure rate is not 100% and only slightly better than taking a sugar pill. The numbers are in the 40-60% range. You get a lot of hate mail not only from psychiatrists who see you as a threat, but from patients, who write about you and say: This saved my life. I took this medication and lived. This is the deep mystery. The drugs are only investigated as antidepressants. This is where the industry is hoisted on its own petard. I totally disagree with Irving Kirsch, psychologist mentioned before. Totally agree with him in terms of his findings. He has mined the data and he's a hero. He's the guy that shows that these drugs don't do the things the drug companies say they do. But I disagree with him because he concludes from that the drugs don't do anything. The drugs just don't do what the industry wants them to do; and the industry wants them to do those things because that's the only way they can sell the drugs. What is it they actually do? We don't know. Very few people have done the studies: where the 17-18 items on the Hamilton depression rating scale, how do people do on antidepressants? That's what the FDA wants them to do. Come up with lousy results; massage them a little bit. Do 75 studies to get 35 that work, get their drug approved; they don't care after that. Instead of that, what they should be doing is exploring what I would call exploring Prozac's consciousness. What are these drugs doing? People are trading in their sex lives for these drugs; in love with these drugs, or if not in love, willing to put up with their side-effects and not go through the difficulty of getting off of them. Think these drugs are powerful, change people's consciousness, in a more subtle way than smoking a joint does. But not in an entirely different way than a recreational drug does: change the way you experience yourself and your world. At least one study that shows that one major effect, and show up robustly, aren't on this one category, depression, but on personality. The way people structure themselves. The drugs make them more like the way they want to be. That goes along with observations made by good writers, like Peter Kramer--with whom I disagree about many things, but great writer and careful people-observer--who says that people say they feel less sensitive to rejection, more confident, more in control of their lives. Basic point: efficacy of these pharmaceutical treatments of depression is that they are very unclear on depression, help some people but so do placebos; but they have this powerful effect that has nothing to do with depression that makes people like taking them. People claim the studies showing the drugs don't really work means that the drugs don't do anything. The drugs do plenty, but there's no financial interest in figuring out what it actually is. In fact, there may be an anti-interest. If it only makes you feel more powerful then it's like Scotch; can't get your Medicare to cover it, or your employer. Argument for making Prozac over the counter, or making it illegal and let there be a black market for them. That's the scandal: the drugs are out there, barely squeaking by the licit/illicit line; being used in a way that in any other drug would be considered illicit. Brave new world, a little soma, pick yourself up every day. Don't think you are wrong, but I don't think we know. Prozac doesn't interest me as a drug. I've taken a lot of psychoactive drugs. From what I've heard about people's experiences I have not been tempted. More than I can say for a lot of other drugs. Come from a place of ignorance; not willing to turn myself into guinea pig.
55:19Want to talk about the major depression. That psychiatrist who writes the hate mail or angry email, you are dangerous, threatening opportunity to save people's lives. Somebody who is on the floor, can't function the way society expects them to. Open to possibility there are times you should lay on the floor and cry for yourself or your loved ones. But not socially normal, out in the tails of behavior. Psychiatrists who don't like your work say you are encouraging people to do without or be misled, when in fact there is a cure for them. We don't understand the biochemical part of it, but surely these drugs can help them. is that what they would say? Most reasonable argument to make. Are they right? Statistically, no. Even though Prozac does better with severely depressed people than with not-severely depressed, it doesn't do very well. The 60% is the best they can hope for? There are treatment approaches--we have to remember that when it comes to severe depression, the old anti-depressants do just as well: Imipramine, or Elavil. Developed in the early 1960s. In the right patients, maybe 60% of the people get better than the would have it were just a placebo. Others get shunted on to a different approach. The quiet, dirty secret of the psychiatry of mood disorders is that there is still a fair amount of electro-shock therapy going on. In fact, fairly effective procedure with a certain subpopulation of fairly depressed people. Think the problem is that even if we can observe a fairly homogeneous set of behaviors and experiences that we would describe the way you just mentioned, there may not only one brain pathway to get there. Probably many different ways to get there. One hundred trillion brain connections. Almost the size of our deficit. Many ways to have a depression. Not sure that the targeted molecule approach is every going to pay off in big ways. Don't doubt for a moment that there is a group of people depressed in a way they can't function. Whatever works best for them should be the treatment. Also don't doubt there are people who have depression for no reason at all, other than there's something wacky with their brain chemistry. We haven't gotten to the point where we can figure out who those people are, much less what to do for them.
59:29In other words, getting back to the question of science, we like to think that somebody who can't get out of bed in the morning has a serotonin deficiency, or a dopamine imbalance. We don't know that. Would your opponents agree with you? Yes; have to. A knowledgeable doctor will tell you something is going on that maybe in some cases involves serotonin. But at this point I think they've stopped looking at serotonin as the end and looking at it as the finger pointing to the end. It's a black box. Macroeconomics example: When a lot of people are unemployed, the black box says we have insufficient demand. Therefore government's got to spend more money. Then we have to assess whether that worked. Very difficult to do. Same issue: we have an inductive theory of cause and effect which we can't test directly. Apply the drug; if it works we might conclude it hit the nerve center, the transmitter. But hard to measure that. Difference: most of the Keynesian macroeconomists I talk to, they do believe in what they are saying. But if you go in there as a patient, and a doctor tells you it's a chemical imbalance, he's telling you something he knows isn't true, or ought to know it isn't true. But it could be true. No. I actually think that the serotonin theory of depression is dead. Book has 800 footnotes in it. Yes, something changes, but it's the means to an end. Thomas Szasz book: The Myth of Mental Illness. 50 years ago this year. He also enraged a lot of psychiatrists. How does your work relate to his? Szasz wants to draw a line in the sand between real diseases and what he calls problems of living. Thinks real diseases should fall under the purview of mental health people and problems of living should not. I don't think that line is going to be established or if it's worth trying. Have to assume we know what a disease is. What a disease is, is a form of suffering caused by a biochemical pathogen. That particular definition is only about 150 years old. Clearly driven by historical and economic rather than scientific forces. It is a definition that has yielded great results in terms of antibiotics, insulin, etc. But it's also beginning not to yield so much good fruit because there are so many diseases that are so complex that we can't even figure out if there is a pathogen, let alone what it is. A disease should be understood better as a form of suffering that a society decides it wants to devote resources to relieving. Science is one area we turn to to try to help us. Those that show up under a microscope are really diseases. I think that even if they are really stupid criteria, 30% of the people that show up positive on a test for depression, it means something. I don't think they've got a brain chemical problem. Something about way we live. Resources should be devoted to that problem; just that those resources maybe are not pills. Understand your point. Philosophical differences. Not hopeful we are going to draw that line in the sand any time soon. Is schizophrenia a disease? Probably a hundred diseases, as biochemical problems. Bi-polar; hoping it would show up as the result of a gene or biochemical problem; but turns out there is no single pathway to the hallucinations and other problems we call schizophrenia. Temptation to say we just haven't found it yet. Very similar to interview with macroeconomist: we've mastered monetary policy; fiscal policy we need to study a little longer. Seventy years? Keynes: In the long run, we're all dead. If you expand the time horizon far enough, probably true.
1:07:05Talk about your encounter with the Unabomber; struggle over whether he fit the definition of being schizophrenic. Tension between his lawyer's desire to call him crazy; and what he wanted. Ted Kaczynski was convicted and in jail; his lawyers, to save him from the death penalty which had just been instituted at the Federal level, wanted him to be declared crazy. Kaczynski refused to submit to psychiatric exams. Fired his lawyers; at which point judge said I have to show you are competent, which requires a psychiatric exam. Catch 22. In that exam, he was determined to be paranoid schizophrenic, and some of the evidence was that he wouldn't submit to psychiatric exams in the first place. Power, once collected in psychiatry, able to pathologize everything, can be used against all of us. Didn't do justice to his problems and represented; not to mention he didn't really meet any of the diagnostic criteria. My involvement with him was really just an attempt to write about that problem through his biography. Project I never did get to; did have a prolonged interaction with him. Chapter in book, Journal. Full circle: someone who struggles to cope with life could argue they are diseased, or trouble with life. If Kaczynski evil, leads to interesting questions. Same problem committed by John Brown; 100 years later he doesn't look like such a bad guy. If you decide he's crazy, that ends the problem right there. Kaczynski alive, in prison for the rest of his life. Has not been executed because deemed to be crazy. Suicide by execution? Fair to say that wherever he was, he wanted to be on the basis of the truth, not some fabrication. Where do you think we are headed on these issues? Medicine acquiring more power to settle our moral disputes, huge amount of momentum. Emerging complexity is going to make the answers less and less satisfying. As psychiatrists go to latest edition of the DSM, will have to grapple with the fact that psychiatrists still don't even really know what a mental illness is.

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COMMENTS (32 to date)
Nathan writes:

1. I think we should head in an Art Devany direction; where we acknowledge that we evolved to be hunter-gatherers, and than any pathology is likely to be rooted in how one or more parts of our modern lives differs from the hunter-gatherer existence. It's certainly not clear we will head in that direction though, given the power of the medical establishment noted in the podcast.

2. Isn't it ironic how often the "wonder-drug" is used in conversation in defense of American capitalism, given the point Russ made about how the existence of these drugs is to some extend made possible by government subsidy.

John Jensen writes:

I'm not really happy about Your recent show on depression, drugs and treatments.

In large parts of the show, You're suggesting that depression is natural and shouldn't be treated. Things do get a bit better in the later parts. But it smells a bit like people should learn to handle life without crutches.

Two years ago, I had a major clinical depression. I have recovered somewhat but will never be completely healed. Not even close. Therefore I've been placed on permanent disability at the age of 42.

The critique of the drugs are spot on. They didn't help me at all. I'm a scientist so I'm not very susceptible to placebo. The drugs only slowed my brain down and prevented me from thinking.

I was also offered electro-shock therapy but I put my foot down hard on that idea.

Tristan Band writes:

This would not be the same Gary Greenberg of the libertarian movement fame?

Trent Whitney writes:

I wasn't sure where this particular podcast was going until you made the analogy to the "science" of macroeconomics - brilliant point, and the analogy does indeed hold throughout.

The one time I laughed out loud was near the end, when you questioned Dr. Greenberg about the validity of part of his book, and he seemed incredulous that you could question it because it contained "800 footnotes." Because it was near the end of the interview, I thought you could have argued the point that the number of footnotes you have doesn't prove truth or validity - had he gotten offended and hung up, you still would have had enough for a podcast.

Max writes:

This seems like a curious subject of interest for anyone who's broadly sympathetic with the Austrian Economic worldview, and in particular for those who embrace the signature AE interpretation of entrepreneurial activity as the facilitated discovery/creation of previous unknown desires and preferences. To quote Kirzner, "How Markets Work" (1997):

The notion of 'serving the consumer' must be broadened to mean fulfilling consumer preferences, not as they were before the entrepreneur began his activities, but as they will be once the entrepreneur has made consumers aware of his product. The idea of 'manipulation of consumer demand by producers' then becomes unclear. It is part of the producer's function to acquaint consumers with what has been made available to them. So it becomes virtually impossible to distinguish in practice between selling activity designed to persuade consumers to buy something which they would not wish to buy and 'selling activity'13 designed to make consumers fully aware of the qualities of the product which satisfies a demand of which they were previously unaware.

Just to play devil's advocate for a moment, is there some consistent benchmark against which Greenberg et al. can distinguish those dubious, potentially harmful entrepreneurially manufactured needs which are inherently praiseworthy vs. those which should be categorically reviled? If so, I'd be grateful if someone could provide a pointer...

Max writes:

Interesting conjunction with the Economist's podcast of the same day (27-Sept), on "The Biology of Business"...

Related article here:
http://www.economist.com/node/17090697

Apparently the same diagnostic mechanisms that have been used to identify many psychological ailments and fine-tune many neuropharmacological products is now being repurposed to help pre-identify likely happy vs. potentially troublesome workers.

I wonder if Dr. Greenberg would be inclined to criticize the use of such diagnostic tools for this purpose, or to condone it as a private matter to be decided by individual employers...?

rhhardin writes:

Joseph Gussman The Culture of Public Problems: Drinking-Driving and the Symbolic Order covers the transition of drinking and driving from a personal moral failing to a public problem.

His later books generalize it as a route to political power, namely define a public problem and take ownership of it, along with pointers to pulling it off.

Mental illness as a disease was wonderfully done by Erving Goffman Asylums, which is really about life in organizations in general by way of the roles in mental institutions.

Both these sociologists are exceptionally good writers.

Terry writes:

What troubled me about the interview was the semantics. In a nutshell, "what is a disease?'" Is a disease not a disease unless it is visible, even if only under a microscope? Is a disease only a disease once its mechanism is understood?
This definition is unrealistically narrow. How about something being accepted as a disease if "it" produces a sudden,inexplicable and substantial loss of productive capacity, and is corrected or significantly improved by prescription medications . You must see a doctor to get a prescription and you would want to see a doctor to rule out one of those tangible tumors. Good enough reasons in my book to call it a disease.

Ralph Buchanan writes:

I'm not a psychiatrist, but it's worth noting that these drugs can have very dangerous side-effect profiles (especially the older ones), and are thus best handled by people who know how to dose them appropriately, and that can be all that's necessary for the distribution to be regulated. Similarly, shock therapy (ECT Electro Convulsive Therapy) shouldn't be tried at home because of the dangerous side-effects.

Their mechanisms of action are well known; most are designer drugs. What's not fully understood is WHY a specific chemical mechanism seems to work well for some. The specific therapy can be a process of trial and error with individual patients, and drugs can have harmful or beneficial interactions with each other, and with the body's native chemical processes.

I've seen the extremes of kids labeled with psychiatric disorders so they could be warehoused in mental facilities by government family services departments, and seen blatantly dangerous psychotic patients.
As to whether this is science or not: Medicine is not science, it's the art of applying science judiciously, research guided therapy, and as the test results change the therapies change, just as in Economics, data can be interpreted by economists more conservatively or liberally, with application and results providing justification for future research and judicious policy. And all this occurs within a regulatory and legal environment that tends to limit applications. Drug companies can peddle anything they want, but it has to prove safe and effective in actual use or it won't be used, or may become the subject of legal action.

I find legalizing Marijuana a more interesting topic. Legalizing for public distribution a drug which is associated with increased incidence of psychiatric disorders (however that's interpreted), and with lung disease, when it is already available in a pill form by prescription seems frankly ill-advised; however, it does bring the trade into the government's tax structure, so I suppose that's the rationale.

On Brain Death:
http://www.aan.com/professionals/practice/guidelines/pda/Brain_death_adults.pdf

Jason writes:

The problem seems cultural we are unwilling to say that chemicals can make life better. Instead we must constantly reclassify things that used to be "just part of life" into diseases to allow ourselves to take them. If we could remove this taboo and allow chemists to work more broadly on chemicals with physiological effects a lot of good could come from it. For example, an alternative to alcohol that would allow you to sober up quickly or not impair driving would save many lives.

Mike writes:

First off, I am not making light of John's problems.

The discussion of diagnosing depresssion with the checklist was fascinating. Especially triggers for depression. I think most of us experience an event or events in our lives that trigger depression.

In my own case, it was the failure of my business. I was depressed by any definition you might want to use, maybe I still am. But watching the commercials for the anti-depressant drugs was an amazing experience. I could take a pill to feel better? How would that work? Would I get my money, business and reputation back? If that were to happen, I'm certain my depression would go away. Would that pill help me find a job to replace my lost income? Or, more likely, would the pill just make putting up with the crappy situation created by me and the financial meltdown of 2008 more pleasant?

The power of the advertising drumbeat leaves you thinking that maybe the pills will help you pull through the situation. But when can you stop taking them, and is that a problem? This thought made me think Greenberg's point about the context in which you take drugs. It is an excellent point and I believe it needs emphasis. My having a stiff drink to help me feel better is a lot different context than a doc prescribing a pill.

And I do think the whole talk is an excellent metaphor for current macroeconomic and fiscal policy choices. Do we have to use the medicine precribed and ingested by force, or can we, some of us at least, experiment with self medication?

Russ Roberts writes:

John Jensen (and Max),

John, you wrote:

In large parts of the show, You're suggesting that depression is natural and shouldn't be treated. Things do get a bit better in the later parts. But it smells a bit like people should learn to handle life without crutches.

I think that's a little stronger than what Greenberg said or I agreed with. What Greenberg said is that depression is not defined in a scientific way. We don't know what it is exactly. Should people feel sad after a death in the family? Is mourning healthy? These are personal decisions but it is not scientific to call someone who is sad because of something that has happened to them, someone who has a disease.

Greenberg's point, and I think it is deep and true, is that many of us as well as our doctors, like calling something a disease as a way of avoiding personal responsibility for our actions. Of course many challenges in life (cancer, diabetes, and yes, maybe some forms of what is called depression) are beyond our control. And many of these challenges can be overcome through medication and medical treatment. Greenberg's point is that line for mental health is gray and ambiguous and has moved a great deal over time not because of improved diagnostics but because of innovation in the pharmaceutical industry and the incentives at play.

My point is that the rise in third-party payment has played a role in moving that line. Yes, people should be free to take Prozac if they wish, regardless of whether there "really" is a disease called depression. But I do not believe that they have the right to make other taxpayers foot the bill. When that happens, more Prozac gets prescribed and swallowed.

Greenberg's other point is that our culture shapes us and when we define alcoholism as a disease, that has implications for how we behave. Defining alcoholism as a disease may be comforting. It may be good for us. It may be healthy to define it as a disease. But it isn't science.

Happy writes:

Russ:

"Should people feel sad after a death in the family? Is mourning healthy?"

It is OK to have negative emotions, but there is an optimal or "normal" amount of them, depending on the person's life situation. If a person has too many negative thoughts with respect to her life situation, she is depressed. A depressed person feels bad even when she shouldn't. She may notice this herself by thinking about her emotions rationally. Her brain just isn't functioning biochemically, and that's why medication is necessary.

Even if antidepressants don't work as well as we want them to, it doesn't mean that they are unnecessary. We just need to develop even better medication.

Max writes:

Thanks to Russ for the indirect response.

Russ: "My point is that the rise in third-party payment has played a role in moving that line. Yes, people should be free to take Prozac if they wish, regardless of whether there 'really' is a disease called depression. But I do not believe that they have the right to make other taxpayers foot the bill. When that happens, more Prozac gets prescribed and swallowed."

Okay, so this was actually a proxy debate about the political legitimacy of publicly-provisioned health care, if not the moral/logical validity of concept of the public health itself, the assertion of any standardized definition of human health, etc. (?).

Presumably, in a world that was untroubled by such concepts, individuals who develop and prescribe treatments for psychological problems (or any other kind of notionally "medical" condition), and the patients who consume such products and services would occupy the same roles and have the same kind of relationship that entrepreneurs and consumers have in every other other sector of economic life. Presumably, in such a world, some clever entrepreneurs would inevitably take note of the variability of individual-level demand for "medical products", and create a third-party payment service to help smooth out the costs of such demands over time -- call it "insurance" for short. No doubt they too would have to grapple with the challenge of bracketing what sorts of demands and associated products would be covered vs. excluded by their payment-smoothing service. And, assuming that this hypothetical economy evolved and became ever more complex just as ours does, that task of defining coverage would would never be complete, as no doubt some other entrepreneurs would be constantly inventing novel "medical products" to demand, while the innovations of yet others would be constantly spawning various new externalities, some of which would inspire still other perceived opportunities for additional "medical" responses...

I wonder how such an alternate economy would fare compared to our own. Would the alt-insurance/third-party payment service entrepreneurs have better success over time resisting pressures to expand coverage and raise costs -- pressures that (to give credit where credit is due) have been invented by their more product-oriented entrepreneurial counterparts? Given an understanding how the mechanism of adverse selection works, would competing alt-insurance entrepreneurs be likely to encourage transparency and honest disclosure of information about "medical" conditions and "medical" products, or would they be more likely to engage with consumers using the same kind of anything-goes advertising approach that dominates late night TV in this world -- the approach that many Austrian economists (c.f., Kirzner, above) passionately champion?

Nathan Benedict writes:

Great podcast. An interesting point that was not raised--why don't we see similar expansions of the concept of disease in other fields of medicine, where it would presumably be just as useful? I have plastic surgery in mind. Right now, most insurance covers reconstructive surgery, or surgery to correct clearly identified defects like cleft palates. Why haven't plastic surgeons come up with an equivalent to the DSM, that expands every decade or so with new conditions like "too big nose," "small breast syndrome," or "over wrinkliness." Are they doing well enough financially that they feel no need? Do they think that this is pushing it too far, even in a country where psychiatry has expanded the definition of mental illness so far that virtually everyone suffers from some sort of mental illness?

David writes:

I married a woman who, by all indications had everything going for her. She was pretty, had lots of friends, a master's degree from USC. She was interesting, funny, athletic, and artistically talented. Soon after our first child was born, she began to suffer delusions -- she thought our house was bugged, people were following her, etc. After about six months she attempted suicide and was hospitalized for all of three or four days. She got better, for awhile. But, as time went on her behavior became more and more erratic. In the midst of all this, we had another child. Shortly afterwards, she began using drugs -- I'm not sure where or how she got them. But, to protect the children and maintain my own sanity, I had to get out of the marriage. She managed to quit using drugs, but her mental problems continued to worsen. Despite all of her problems, she loved her kids and continued to see them when she was able. Last spring, she killed herself in an extremely violent manner.

I bring this history up because it has given me experience and, I think, a unique insight into the mental health industry/profession. I came out this experience with several impressions. First, there is nothing remotely scientific about the diagnostic process. When we were still married, my ex-wife gave full permission to her doctors to speak with me. In my estimation, she saw about ten different psychiatrists/psychologists and was given about ten different diagnosis -- she was bi-polar, a paranoid schizophrenic, borderline personality disorder, severely depressed, paranoid personality disorder. In frustration, I consulted the DSM myself; it is like the weekly horoscopes. One disorder blends into another. Pick one, two or three. All or any of them could describe the symptoms of her mental illness. Cleaning her apartment out after her death was like walking into a pharmacy. Her doctors had her on so many drugs, many of which have serious, unpleasant side effects, I had to wonder if the cure wasn't worse than the disease itself.

After her death, I got to experience a totally different side of the mental health industry. I was amazed at all the unsolicited offers of professional counseling. They came in the mail, over the telephone, and through "friends" whose wives or husbands offered "grief counseling." Only two weeks after her death -- when I was trying to help my kids (ages 12 and 9) work through their emotions -- one person actually spoke to me about an "intervention" -- to force my kids and I into grief counseling. I guess we weren't cheerful enough or something.

Its been about six months since my ex-wife died and my boys and I are doing pretty well. But, I my experiences have led me to the belief that the mental health care system is really, really dysfunctional. For the seriously mentally ill, very little help is available even if one (as we were) is well insured. My ex-wife would get picked up by the police, go to jail for a day or two and then get placed in the local psych ward for 72 hours. Aside from heavy doses of psychotropic medications, jail and short stints in the psych ward were her "treatment". On the other hand, after she died, there was no shortage of counselors, etc. wanting me and the kids to sign up for groups, go to camps, etc. -- all for a price of course. Grief, as the DSM-V will state, is considered to be an affliction to be cured by these people. Those who listen to this podcast may not like Barbara Ehrenreich very much. But, I think her book "Bright-Sided" is an excellent critique of the "happiness" industry of which all the "grief counselors" etc. are a part.

Notwithstanding all of my criticisms and, perhaps, cynicism, I do have to say that there are some very good people in the mental health profession. In dealing with my wife's problems throughout the years, I have seen a psychologist. The guy has helped me immensely make sense of the craziness surrounding my ex-wife's illness. I think what makes him so good is that he is very willing to admit the limitations of his profession.

On a totally unrelated matter. Russ, at the end of the podcast, in talking about Ted Kaczynski, you opined that he was not executed because "he was crazy." I don't think this statement is completely (or even mostly) accurate. I work for the Federal Defenders of Montana as a lawyer. Our office handled his case initially, until it was moved to California. As a result, I have some familiarity with the litigation surrounding Mr. Kaczynski. The Government, I think, decided to give up on the death penalty for a number of reasons -- most prominently the fact that his brother turned him in. In light of that fact, they decided (very reasonably) that a jury would be unlikely to impose a death sentence. This may be a minor point, but I don't think it is accurate to imply that Kaczynski escaped a death sentence solely because he "was crazy."

Michael writes:

Russ,

Just got finished listening to your piece with Greenberg and I have to say, I was surprised by how strikingly unHayekian both of your takes on the whole thing was. Excuse me if I'm wrong, but the constant undercurrent assumption I kept hearing was that there was something illegitimate in either the use or production/sale of anti-depression drugs if some kind of hard empirical evidence couldn't demonstrate their bio-mechanics. But Hayek would say that that's a form of constructivist rationality. Most of our knowledge and experience is grown unconsciously If our choices prove successful for our survival and flourishing they are selected for cultural repetition into traditions. If not, those who insist on repeating them suffer disadvantage and the lessons of failure discourage others. If the insistence upon those choices is in some way genetically grounded, that genetic disposition is bred out biologically through reproductive disadvantage.

It seems to me these drugs are much the same thing. Your moral concern over what's right and wrong sounded like the tut-tutting central planning paternalist who knows better for everyone else. People will use the drugs and we'll see. If those -- like myself incidentally -- who couldn't function socially or professionally before using them actually have more successful lives as a consequence (whatever the reason for that affect) they will be continued to be used and it's the business of nobody else. If it turns out that the use of these drugs leads to some lesser life, as you seem to suggest, and if that lesser life has actual consequences, the drugs will be selected against culturally and/or biologically.

Better to let the spontaneous order play itself out than presume to judge those who want to try the drugs.

I do enjoy the podcast and rarely disagree with you this strongly, but felt on this occasion there may be some value in writing.

Regards,
Michael

James writes:

There is a GIANT elephant in the room throughout this whole conversation. The classic philosophical "noble lies" involve religion and free will. Belief in free will and heavenly judgement (or karma or whatever) are what enable these non-physical explanations for something like alcoholism or addiction is a "sin" or "character flaw" that if you just "tried harder" would be fixed.

Essentially what these well-meaning therapist types (I doubt many serious doctors are much interested in alcoholism) have done is create one noble lie (the lie that depression and addiction are similar to medical diseases like cancer) to counter another. The real lie is there is any such thing as a non-physical problem in the first place.

The truth is that humans are highly complex biological systems that are programed to seek pleasure and avoid pain. In the course of pursuing these goals they suffer a number of problems. They then categorize some of these problems as "diseases" and others as "character flaws", but the distinction is based more on how well they can represent the cause of the problem than some philosophical distinction.

In plain English, the only difference between a problem like "cancer" and a problem like "alcoholism" is how well we are able understand the causes of the problem. With cancer, we can identify the rogue DNA and put it under a microscope. With alcoholism, we can't. But that ignorance does not mean alcoholism is actually caused by "lack of willpower" or "a sinful nature" or some other non-physical phantom mover. It only means it is caused by biological "problems" (where "problem" is defined as extreme deviation from the norm) that are much more difficult to specify, and so are easier to approximate by speaking at higher levels. At this point we don't know what biological factors cause "character flaws", but we will in the future.

William Love writes:

Dear Russ,

I am phenomenally surprised at the outset of this podcast - It seems like the scientific method is erroneously presented, and this error taints the whole podcast.

The core idea: "Science helps us: scientists say that we've reached final decisions, determinations about the nature of reality." and that this idea is misapplied at times fundamentally misses the point of science.

It is totally uncontroversial that Science is not static, to quote Popper -
"Science does not rest upon solid bedrock. The bold structure of its theories rises, as it were, above a swamp. It is like a building erected on piles. The piles are driven down from above into the swamp, but not down to any natural or 'given' base; and when we cease our attempts to drive our piles into a deeper layer, it is not because we have reached firm ground. We simply stop when we are satisfied that they are firm enough to carry the structure, at least for the time being."


Moreover I find the acceptance of the dogma of scientist a bit disturbing. Even by arguing that it is misapplied in this case, it is implying that it is correctly applied in other cases. This premise is not science,
"A system such as classical mechanics may be ‘scientific’ to any degree you like; but those who uphold it dogmatically — believing, perhaps, that it is their business to defend such a successful system against criticism as long as it is not conclusively disproved — are adopting the very reverse of that critical attitude which in my view is the proper one for the scientist. "

The audience would be well served in understanding how the term "science" is mis-defined and used to manipulate people in general, which is really a shame since science, if properly interpreted, is quite useful.

Sincerely,

W

EPZEN writes:

Russ, Russ, Russ...if you would only become a Paul Krugman convert you might not be so skeptical of economics and psychiatry. But I fear that might make you truly depressed:).

Chuck writes:

Jason, you wrote:
"The problem seems cultural we are unwilling to say that chemicals can make life better. Instead we must constantly reclassify things that used to be "just part of life" into diseases to allow ourselves to take them. "

Excellent point. Your post was great.

I had trouble listening to this guy after he explained that he expected most people to be depressed since Bush was president. Wow, what an objective journalist! I'm no GWB fan, but this was shameful.

As for his take on mental illness, I really can't understand his issue. He should hang out with some schizophrenics for a while and then let me know if he still doubts whether a) they're really sick, and b) if he would recommend drugs that we know (experimentally) will make them better.

What would his objection be? That he doesn't like our definition of "disease"? That we don't know what the *exact* cause of this illness is?

This sounds like semantics and an argument for more research, respectively. Not a philosophical objection to treating these people.

I suspect that I'm misrepresenting his viewpoint. It's just that after an hour, I still couldn't understand his basic thesis.

Finally, Russ & his guest don't seem to understand what a double-blind study is. The whole point is that the patients don't know if they're taking the placebo or not. That's why his point that patients are trying to please the clinicians with their self-reported improvements is irrelevant.

John Berg writes:

Found in today's review of the new Moynihan book by George Will in the WashPost, "In 1998, he wrote to a British friend: "I have been sending around copies of the Fiftieth Anniversary Edition of Hayek's 'The Road to Serfdom.' . . . Introduction by Milton Friedman. The point is that conservatives are discovering a history they didn't know they had."

John Berg

Helena writes:

I am a psychiatrist and really was not happy with this podcast (surprise surprise). I started listening with interest and hoped it would shed some light on psychiatry's very real challenges and shortcomings, but found the arguments illogical and in the end really just to much of a conspiracy theory. There are some questions that definitely should be asked, but I think it would be more helpful to people who are suffering to get a view that doesn't throw the baby out with the bathwater.

Russ Roberts writes:

Helena,

Would love an example of the illogical. Are there psychiatrists who defend the definitions of minor and major depression that Greenberg mentioned? They don't seem very scientific to me. Was he wrong or missing something there?

EPZEN writes:

As a physician listening to this podcast I found myself repeatedly saying "So?" Decision making in medicine is based primarily on the history the patient gives not a lab test. Psychiatry has to rely on history more so than other fields of medicine but that does not automatically negate the field.

Lab tests in medicine are always interpreted based on the history of the patient using Bayesian analysis. For example, if one were to do EKG stress tests on people with no symptoms of coronary artery disease there would be a large number of false positives. In other words, the lab test would say that a significant number of people had coronary artery disease that did not. On the other hand, the same EKG stress test done on patients with symptoms compatible with coronary artery disease would have far fewer false positives. Hence the saying "Treat the patient not the lab test."

It is no different in psychiatry. A test for depression is going to have a significantly higher number of false positives when applied to a broad population base than it would for a group of patients who state that they feel depressed. The fact the author feels he was over diagnosed is not necessarily proof that the test was inadequate. All tests have false positives, even seemingly more "objective" tests such as EKG's.

As an observer of psychiatry I will say that I agree that the biologic model of addiction thus far has had limited benefits although it is starting to have more and more positive benefits for smoking. I would say that the biologic model of depression is sometimes overemphasized but it nevertheless has led to many advances in treatment and there has been increasing emphasis on successful nonorganic models as well (e.g. cognitive therapy).

All areas of medicine involve complex systems and subjective interpretations that we try and combine with objective data. In many ways, you are right that there are parallels to macroeconomics. However, the difference that I see is that fringe theorists in economics seem to have more clout within the profession of economics than they do within the profession of medicine.

Justin P writes:

EPZEN -

"All areas of medicine involve complex systems and subjective interpretations that we try and combine with objective data."

So what your really saying is that it's more art than science. As an art that means there is a lot more guess work than anything else.

The point Russ was trying to make (I think) is that medicine is trying to sell itself as a science, when by your own statements, is not true. It has some science thrown in there but overall it's still just guess work based on past history, which may or may not be true (patients don't always tell the truth).

EPZEN writes:

You're absolutely right Justin that there is an art to medicine but I would argue there is an art to all science.

I have degrees in both chemistry and medicine. Some areas of chemistry are even more guess work than medicine. For example, NMR spectroscopy which is used to identify unknown chemicals is based on quantum mechanics. At the heart of quantum mechanics is the wave function whose results yield probabilities(i.e. mathematical guesses as to what is happening, not black and white answers). The probabilistic answers led Einstein to make the comment that God does not play with dice. Yet we have used this model to develop NMR spectroscopy and in turn MRI machines in medicine.

Einstein may prove to be right. We may eventually come up with a model that gives us better answers than probabilities. However, the model has nevertheless given us NMR as well as MRI.

Furthermore the analysis of chemistry experiments often uses statistical models just like in economics and epidemiological medicine. A good correlation coefficient in chemistry is greater than 0.9 whereas I have seen epidemiological studies and economic papers that seem happy with 0.7. Is this objective criteria? No, the chemist knows his data is useless at 0.7 whereas the epidemiologist knows he can get useful answers at 0.7. In other words, there is hard data but a subjective interpretation of meaning depending which fields are using the statistical method.

Doctors frequently order chemistry panels with greater than 20 tests on a patient. This statistically likely means one of these tests has a lab error in it. Most of the time the lab error does not represent a significant deviation but sometimes it does. The biochemist or the physician must be able to subjectively recognize when a lab result does not make sense. In other words, the biochemist in a hospital has an art to his job...does this mean biochemistry is not a science? I don't think so.

Science is about the scientific method. The scientific method often gives us black and white answers but sometimes it gives us gray ones. I think we need to be careful not to assume because there is a gray answer that it is not science.

Christine writes:

Thanks, Russ and Gary, for a very interesting podcast.

One part that I found particularly interesting was about the tag wagging the dog - the pharmaceutical industry defining the disease population. I work with drug development (now as a researcher). About five years ago I had an interview for a job with a large pharmaceutical company who makes a very popular ADHD drug for children. In the interview I was asked how I would determine the demand for a drug. After giving a response regarding estimating the disease population based upon clinical data, I was told that I was wrong. If it was done that way, most markets would be too small. Very few blockbusters. He said that drug companies emulate Lilly's process with Prozac - where the company defines the disease population in a much broader fashion than a clinician would have originally done. When I replied that I didn't think that this was ethical, he said "some people don't believe that it is possible to be ethical and work in the pharmaceutical industry." Now I completely disagree with this. But this does give you a perspective into some (very large) companies' perspectives. What is most worrying here, I think, is that this company makes medicines for children. Needless to say, I didn't get the job.

Justin P writes:

EPZEN -

I'm a chemist as well. I haven't touched NMR in years, but thanks for the refresher. I know exactly what you mean dealing with Mass Spec. Same thing really, fragmentation patterns are based on a statistical model of how a molecule blows up in the ion source.

I agree that science is all about using the proper method. The problem with some medicine is that while they do try to follow the method, trying and actually doing are two different things. What I mean is that doctors will form a hypothesis, try some tests, evaluate and then get their conclusion (diagnosis).
The problem is, like in economics and any social science, they more often than not won't let the results of the test affect their conclusion. So to use your analogy, they might get a good R value, they won't reject the null no matter what their test statistic is. They will just do another test until they find one that will support their hypothesis.
I should have made clear that I mean this is a problem with some medicine not all. But it is a big problem with medical studies that don't use anything objective to determine the outcomes.

I mean they just came out with a study that says drinking a little bit while pregnant is okay. Well to what women? How much is too much for all women? There are too so many factors in there that could seriously distort their study? Not to mention how many people did they throw out as outliers? Its all based on a normal distribution, but people's biochemistry isn't normally distributed. The problem is part educational, people have been conditioned to accept anything a doctor says as a "fact." when you and I both know that isn't true. Part if it is the fault of the doctors for selling themselves as soothsayers instead of shaman.

Russ Roberts writes:

Michael,

Great comment. Very thought provoking. I think I disagree but it's a fine line.

Moral tut-tutting can be very Hayekian. Morality and norms emerge from tut-tutting, raised eyebrows, criticism, apathy, respect for the choices of others, patience, ignorance, intimate knowledge and so on. It becomes unHayekian when imposed by the state.

Your observation reminds me of the view that Hayek was against planning or that under laissez-faire, you don't have to do anything because the market will take care of it. The market is what allows planning to take place at the local, voluntary level rather than being done by the State. Markets work because people act.

We as parents and friends make moral judgments about each other all the time. The fine line I mention is that sometimes we go too far. We make mistakes in judgment out of selfishness or ignorance. But being judgmental is what creates all kinds of unseen emergent norms all around us.

I wouldn't tell someone when to medicate themselves or try to live through it. But I do think the general idea of taking drugs any time you are down or wish you were happier is a bad idea.

EPZEN writes:

Interesting point Justin. Confirmation bias (the selection of only data that confirms your position) is certainly one of the causes of medical error.

I also appreciated Christine's comments as it reflects a problem within the pharmaceutical industry which in turn impacts on the field of medicine. In the last decade, I have seen studies from pharmaceutical companies that have modified the primary endpoint half way through the study, used composite end points which include minimally relevant end points (to improve the chance for a positive outcome), used multiple statistical calculations which by chance alone would mean at least one random positive result as well as having physicians "participate" in studies but the results are never published (the study is just a way to make physicians comfortable in prescribing the medication). The behaviour of some of the pharmaceutical companies is one reason I strongly support regulation....markets provide for good economic decision making but they don't ensure good ethics.

SheetWise writes:

Thank you!

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