Any engagement with the possible aetiology or cause(s) of ‘depression’ might begin by questioning whether it is even helpful to try to think about ‘depression’ in terms of cause-and-effect thinking. Indeed, both behaviourist and postmodernist approaches might end up being (very uneasy) bedfellows in agreeing that perhaps causal thinking isn’t at all helpful! Aetiology can commonly be seen in terms of:

• biological/genetic/materialist explanations;
• cognitive-behavioural explanations;
• psychoanalytic explanations;
• existential explanations;
• psychosocial/societal-level explanations; and/or
• paradigmatic/evolution-of-consciousness explanations.

One problem that the book under review does not address is the question of language, and the way in which specifying depression or ‘mood disorders’ as nouns has the effect of ‘thingifying’ human experience in a way that might be quite inappropriate to the human experience we are seeking to understand (as opposed to ‘explain’). In addition, any view on the aetiology of ‘depression’ necessarily entails irreducible metaphysical assumptions regarding what a human being consists in, and this is a crucial philosophical point that discussions in this field commonly either ignore or take for granted. Thus, any attempt to argue that a specifically pharmaceutical treatment is appropriate for treating ‘depression’ must either argue for a deterministic/materialistic philosophy of mind (which I believe to be philosophically unsustainable, and at the very least highly challengable), in which it is claimed that ‘abnormal’ brain functioning somehow causes ‘depression’; or it must claim that no matter what the cause of ‘depression’ might be, it is appropriate and helpful to use brain-chemistry-altering psychoactive drugs to treat it. I hope it is clear that the latter can by no means be taken for granted, and needs to be thoroughly argued through in a way that is rarely if ever attempted by those favouring pharmaceutical treatments.

Irving Kirsch is a clinical psychologist, a psychotherapist and a professor or psychology at Hull University. He begins by pointing out that global sales of the antidepressant industry amount to some US $19 billion a year – given which situation, one could be forgiven for assuming without question that in any allegedly rational society in which the totem of empirical science is claimed to hold sway, the clinical efficacy of these drugs must surely be beyond question. Think again. It was Thomas Kuhn who argued in his seminal book The Structure of Scientific Revolutions that within any given cultural-historical conjuncture, there will be a prevailing Zeitgiest and accompanying Weltanschauung which will define what is assumed to be ‘normal’ and, therefore, taken-for-granted and unquestioned. A decade after Kuhn’s book first appeared, Louis Althusser coined the term ‘The Ideological State Apparatus’, describing how, from a Marxist perspective, any ‘social formation’ will tend to have a built-in tendency to ‘reproduce’ and reinforce the existing order of things, including, crucially, the ideological assumptions underpinning the status quo. Under such conditions, ideology and material interest will have a very strong tendency to prevail, and take precedence over rationality and dispassionate evidence; and I want to argue that the way in which the myth of antidepressant efficacy has so comprehensively and uncritically colonised modern medical and cultural consciousness is a classic case of a non-scientific, ideological discourse holding sway, and in such an effective and previously unchallengable way precisely because it assumed the banner of ‘empirical science’ as its rationale – yet entirely spuriously, as Kirsch comprehensively demonstrates in this path-breaking book.

Notwithstanding the poignant challenges of penetrating postmodernist thinking and a rejuvenated ‘New Paradigm’ cosmology, the prevailing myth of our age is (still) one that privileges Cartesianism, ‘modernity’ and materialism – and it is within this cultural context that the the ‘pharma-complex’ has gained such ideological ascendency, and continues to hold such sway under the guise of its spuriously claimed scientificity. What Irving Kirsch does in this book is to show, first, that much of the clinical research into the efficacy of antidepressant medication (about 40 per cent of it – p. 4) has been surpressed and withheld by the pharmaceutical industry (see p. 39), when such research has yielded results that are inconvenient to and contradict its pro-medication bias; and that once, via the US Freedom of Information Act (see pp. 26–7), all such research data had been obtained by Irving and his colleagues, and incorporated into a meta-analysis of all the existing research, the finding was that statistically speaking, antidepressant medication is no more effective than placebo in the treatment of depression.

Of course the discussion is far more complex than this summary headline description might suggest. Not least, the book is notable for its detailed analysis of the notion of placebo, and the way in which so-called randomised controlled trials (RCTs) are often fatally flawed because often in excess of 80 per cent of those participants who are allocated the antidepressant treatment correctly guess before the clinical trial is over that they are taking the antidepressant as a result of the side-effects which they experience; and once they have guessed this, then they are far more likely to believe that the treatment will work, so artificially enhancing the placebo effect over what it would otherwise have been.

The book is divided into seven substantial chapters. Following an extensive and penetrating Preface, Chapter 1 gives the general background to the author and his colleagues’ discovery that the placebo dimension of antidepressant medical treatment is in reality far more significant than has previously been realised. Indeed, Kirsch makes it clear that what he and his colleagues (notably, Guy Sapirstein) discovered greatly surprised them. Chapter 2, evocatively titled ‘The "Dirty Little Secret"’, illuminates the notion of ‘publication bias’ (p. 29; so much for the much vaunted ‘objectivity’ of empirical scientific research); and describes how Irving and his colleagues reanalysed the data, what they discovered – and how their findings were received by the medical world. Irving is careful not to claim that they had discovered something new, for as one research team argued, ‘Many have long been unimpressed by the magnitude of the differences observed between treatments and controls, what some of our colleagues refer to as the "dirty little secret" in the pharmaceutical literature’ (quoted on p. 38). Yet what is extraordinary is that while both the drug companies and the regulatory agencies that approve them for marketing knew about this, neither prescribing doctors, nor their patients or the general public, did. Irving then goes on to show how the drug companies have used a range of manipulative devices to make their products look more effective than they actually are, and not least through procedures that, even at one’s most charitable, cannot be termed anything other than ‘fiddling the data’ (cf. pp. 38–44).

In a scarcely believable commentary to anyone with any residual faith in the proberty of the scientific community, and which would not have surprised Louis Althusser in the slightest, we are shown how the state regulatory agencies themselves actively and knowingly colluded with the pharmaceutical industry’s ‘dirty little secret’ (p. 45–8), exposing in all its starkness ‘the financial entanglement between the drug inductry and those who regulate it’ (p. 47). We also learn about what Irving calls ‘Voodoo science’ – that is, when drug companies conduct ‘as many trials as they want until they find two showing significant effects. The negative trials simply don’t count’ (p. 51).

Chapter 3, ‘Countering the Critics’, outlines the attempts by the medical and pharmaceutical establishment to refute Irving’s meta-analytic findings, and why they allege them to be inadequate. I was especially struck by how genuine long-term research into the efficacy of antidepressants is rare because before long, patients just drop out of the trials either because the drug isn’t working or because the side-effects are too distressing (p. 65); and by how the medication itself might well be ‘iatrogenic’ (i.e. the medicine itself induces ill-health). I have long argued the view that the taking of psychoactive drugs might well actually interfere with, and damage, the person’s natural self-healing capacities, thus self-fulfillingly creating a long-term dependency on the drug in question; and this view seems born out by Irving when he writes that ‘Patients who are being treated with antidepressants show a specific vulnerability to relapse that is not shown by recovered patients who have been treated without drugs... [A] biological vulnerability [may have been] induced by the medication in the first place’ (p. 65, emphasis added).

Chapter 4, ‘The myth of the chemical imbalance’, shows in detail just why the chemical imbalance theory of depression is false, or ‘dead in the water’ (p. 99). However, I am uneasy, verging on outright disagreement, with Irving’s statement (very much from within the prevailing paradigm) that ‘Depression certainly exists in the brain. All subjective states... are rooted in the brain’ (p. 100). There certainly needs to be a much sharper, and fully and coherently articulated, philosophy of mind than Irving offers here. (On page 121, for example, he revealingly writes, ‘If we are right in assuming that the mind is the brain...’; and for other examples, see also pp. 91–2, 100, 116–17, 121.) Yet these philosophical difficulties and lacunae do not detract from what is in my view the correct conclusion, that when a subjective experience of ‘depression’ is present, ‘the underlying brain mechanisms may be normal’. (ibid.).

Chapters 5 and 6 go into great and revealing detail about the notion of placebo (including the related ‘nocebo’ effect – pp. 124–30), showing the multitude of effects that placebos have been shown to have, and looking in depth at the theories about how such effects are produced. While I think there is a lot more to say about what ‘placebo’ might consist in which is not by any means fully addressed in these discussions (not least in terms of the arguably pervasive impact of anxiety, and its psychodynamics, upon both symptoms and people’s capacity to self-heal – see p. 112; amazingly for this reviewer, there are no index entries for the term ‘anxiety’), these chapters should nonetheless be indispensable reading for anyone and everyone who trains in the medical and helping professions. Chapter 6 ends by making an absolutely essential point in relation to the efficacy-obsessed, short-termist thinking in the NHS; that is, that ‘The amount of time that [doctors] have available for each patient is limited, and making more time available would cost money. Still, this might be money well spent, given the potential benefits for health and well-being that it could produce. In the longer run it might even be cost-effective’ (p. 148). There is a discussion of ‘non-specific effects’ (pp. 136–44); and though this is not strictly speaking an academic book, I was disappointed to see no reference to Shepherd and Sartorius’s seminal and much-neglected collection, Non-specific Aspects of Treatment (Hans Huber, 1989).