He successfully treated countless cases of depression before Prozac, the first SSRI-antidepressant, came to market in 1987.  To suppose that depression could not be overcome without a drug ran counter to his own experience. As he examined the studies that gave rise to the chemical imbalance theory, he kept finding remarkably poor research designs had been used.

In time Dr. Scott learned that most chemical imbalance studies were designed, conducted and written by pharmaceutical company employees and then signed by a physician who would simply read the study and agree to let his or her name appear as the author for a large payment (a very common practice known as ghostwriting).  He also regularly came upon facts that ran counter to the theory.  For example, levels of melatonin, testosterone, estrogen and serotonin all begin declining by age 30 (or earlier).  If the theory were correct, all old people should be depressed and no young people should be depressed.  “When the facts do not fit the theory, we must adjust or reject the theory—not the facts.”

Dr. Scott is devoted to educating physicians concerning valid vs. invalid research designs (“no skill is more important and yet most college graduates and most MDs lack that skill”), harmful side effects of antidepressants and antipsychotic drugs and more effective ways to treat depression, schizophrenia and other mental problems.

Question:  How can someone who is not a physician write a book that deals with medical issues like depression and antidepressants?

Dr. Scott Responds:  “I’ve been asked this question, or one like it, many times.  There are three facts which I believe I should share in answering the question.  First, the nation’s best medical writers including Marilyn Elias (USA Today), David Wellman (LA Times), Shankar Vedantam (Washington Post), Tara Parker-Pope (Wall Street Journal), Lindsey Tanner (AP) and Harris Gardiner (NY Times) are not physicians.  However, each is a careful investigator which means that though they are not qualified to treat patients (take a patient’s medical history, make diagnoses, run tests or give medical advice), they can carefully investigate an issue, interview leading authorities and then share what they have learned from their research.  Thus, they do not treat patients, but they do share medical information—information that is often heard or read by physicians and leads to better medical treatment.

“Second, having a strong research design background is the single most important factor in understanding which research can be trusted and which research is so poorly done that the results should be discounted or not even considered.  It is absolutely amazing that the American educational system places so little value on this issue and the consequences are frequently disastrous.  I discuss an example which is now universally acknowledged to have been a disaster in the first chapter of my book.  But examples of poor research designs are seen over and over even today.  During 2006 the New England Journal of Medicine (23 Mar, 354, 1231-1242) reported on a “much-anticipated government study of depression” that was part of a large, six-year, $35 million investigation.  One would think few studies would ever have been designed with more care.  Yet that study is simply junk science.  Its results are meaningless since the researchers are studying depression but did not even have a placebo control group--let alone an active placebo control group.  The placebo effect is not powerful if we are measuring placebo effects related to the treatment of cancer, heart disease or infection.  But numerous studies have demonstrated that it is very powerful for depression.  And then assumptions that no truly qualified researcher could possibly make were made in this study.  After two 14-week rounds of antidepressant treatment, 47% of the patients were still not over their depression.  Yet the assumption was made that those who did get over the depression only got over it because they were taking antidepressant pills.  The possibility that people do sometimes get over depression or sadness with just the passage of time was ignored.  Of course, my question is how can such a study ever make it into one of our leading medical journals?  My point is that many doctors (and many medical journal editors) may be brilliant and may be outstanding doctors and still not understand even the most basic principles of research design.

“Third, an MD degree does not have a focus on research design, but a PhD does have that focus.  That is why much of the medical research published by JAMA, the NEJM, Pediatrics, the Archives of Internal Medicine and other medical journals has at least one PhD on the medical research team.  Most physicians, including many academic physicians, know they do not have the background and training needed to design a research investigation.  Of course, that is also why private practice physicians are easily fooled into promoting drugs which are not in the best interest of their patients.  I just recently visited my physician for my annual checkup.  I was put in a room which had a Nexium poster on the wall (high-priced, patented Nexium is virtually the same drug as the now off-patent and cheaper Prilosec, see Boxes 4-1 and 4-2 in America Fooled).  I asked my physician when he entered, ‘Why do you have the Nexium poster on the wall?’  ‘Why do you ask?’ he responded.  I explained, and he admitted, ‘I do not really know much about these drugs other than what the drug reps tell me.’  My physician is a very intelligent, board-certified internist.  But he is also a typical private practice physician, though perhaps a bit more honest than most.”

Personal Note to Physicians:

 Each semester I discover I have several students who have been prescribed antidepressants.  I occasionally have students who are on antipsychotics.  Typically I learn these facts after one of my lectures on depression, mind drugs or the drug approval process.  The students who approach me often express anger that their physician would put them on Zoloft, Paxil or another mind drug in view of the research.  I want you to know what I routinely say to these students.  The following dialogue is reflective of those conversations and includes my standard response.

My response: I don’t think you should get angry at your physician.  She is probably very conscientious and works very hard to provide you good medical care.  The blame lies not so much with individual physicians as with the drug approval system and the drug companies which today are very knowledgeable about how to design a study that is fraudulent yet capable of getting their drug approved and still be used in marketing and advertising.

Student: But my physician should never have prescribed that drug to me unless she knows it’s safe!

My response:      You have to remember three facts.  First, the information they were taught in college and medical school, the information they receive at medical conferences and the information they are given by drug reps all say that these drugs work.  Second, they are seeing patients all day long.  I finish teaching my classes by 10:00 a.m. most days.  I can spend hours every day reading and critiquing mind drug studies—one issue among the hundreds of issues they have to know about.  And third, though physicians in private practice know a lot more than I know about hundreds of health issues, very few have a strong research design background.  Most academic physicians could look at many of the studies used to promote these drugs and know very quickly they are worthless, but this is not a skill that many private practice physicians have.

This is a conversation I have every semester—over and over.  I have always believed that the only reason you have routinely prescribed mind drugs is because you have genuinely believed that they help your patients.  I do not believe you would have done so, any more than you would have routinely prescribed estrogen for all post–menopausal women if you had known the facts we know today.  I have written this book to help educate both physicians and the public, not simply to criticize or to make money.  (All profits from this first edition will be contributed to Habitat for Humanity.)  I appreciate your taking the time to learn more about mind drugs.