Pubdate: Thu, 23 Jul 1998
Source: New England Journal of Medicine (MA)
Volume: 339, No. 4

Book Review


Edited by Seymour Fisher and Roger P. Greenberg. 404 pp. New York, John
Wiley, 1997. $49.95. ISBN 0-471-14848-2

This book, written entirely by academic psychologists, is a dose of strong
medicine. A critical review of the psychoactive-drug literature, it asserts
essentially that there is inadequate scientific information to conclude
that psychoactive drugs are substantially more effective than placebos.
The editors remind us that the interpretation of any research data is
likely to reflect the researcher's bias: in this case, a bias toward
biologic treatment, the pharmaceutical industry's financial motives, or
both. They say, "We feel it is important to balance this bias by adopting a
counterattitude based on a determined skepticism." Their intellectual,
scholarly review is difficult to dismiss; yet the reader may feel their
conclusions are immoderate.

Part 1 deals with such conceptual issues as the interpretive problems posed
by placebo effects and the need for placebo controls. The authors of this
section point out that patients' ratings of improvement are often
considerably lower than those of the treating therapist. The abrupt
cessation of treatment with the drug and the substitution of a placebo are
strongly criticized for increasing the likelihood of a relapse and thus
strengthening evidence in favor of the drug. The problem of frequent
coexisting illness makes it difficult to evaluate the specificity of a drug
used for a given diagnostic entity or syndrome.

Robert C. Carson presents a devastating criticism of the fourth edition of
the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), which
he describes as representing a "prescientific stage of development with
respect to an attempt to bring taxonomic order to aberrant behavioral
phenomena." He further states that "research advance in the field is
seriously hampered by its [the DSM-IV's] pervasive influence." Carson
decries the emphasis of the DSM-IV on reliability and its failure to deal
with the question of its validity or its explanatory and predictive power.

Part 2 deals with the efficacy of psychoactive drugs for adults and part 3
with the efficacy of drugs for children. Part 4 presents an overview and

In their discussion of adult depression, Seymour Fisher and Roger P.
Greenberg note that short-term, "validated" psychotherapy programs are more
likely than antidepressant medication to produce behavioral change that
could have protective long-term effects; these programs also avoid the
all-too-prevalent side effects of drug treatments. They state that
drug-treatment studies have found that the effect of the specific treatment
setting and its overall clinical management interact with the efficacy of
the drug itself. With regard to lithium for the treatment of bipolar
disorder, they conclude:

"The history of the research relating to lithium follows a familiar
pattern. Once again, there is a cycle of exaggerated initial results
(fostered by enthusiasm and rents in the double-blind design); then,

increasingly more conservative reports... ; growing disappointment among
clinicians... ; and heightened efforts to find alternative treatments."

David Cohen concludes that a large percentage of schizophrenic patients do
not respond well to neuroleptic drugs; that social functioning is not
improved by these drugs; and that many patients experience such severe side
effects that treatment must be discontinued. William G. Danton and David O.
Antonuccio underscore the drawbacks of anxiolytic drugs, including
sedation, the return of symptoms after cessation of treatment, and the lack
of long-term efficacy. They state that behavioral therapies, such as
exposure to situations that generate anxiety, produce better and
longer-lasting effects, because patients are helped to develop strategies
for dealing with their anxieties and are therefore less vulnerable to
future problems.

With regard to drugs used to treat children, Rhonda L. Fisher and Seymour
Fisher conclude, "It is not an exaggeration to assert that, by and large,
the psychopharmacotherapy of the youth segment of the population is
scientifically unjustified." Physicians who prescribe "psychotropic drugs
for depressive and anxiety symptomatology are doing so without rational
support." Their views are somewhat more favorable regarding the amount and
quality of research confirming the efficacy of stimulants in treating
attention-deficit-hyperactivity disorder in children, the relative
immediacy of response to treatment, and the relatively low cost.

The book's greatest strengths are its scholarly citation and discussion of
a wide body of relevant literature and its willingness not to pull punches.
The book's message is shocking and nihilistic regarding drug therapies, but
if it makes us reflect on our practices, the authors will have made an
important contribution.

Ruth G. Matarazzo, Ph.D.
Oregon Health Sciences University
Portland, OR 97201
venue Arch Cape, OR  97102 - ---