The Medical Model
Drug therapy for depression and anxiety fit within the assumptions which make up the medical model. In this section I will be explaining the components of the medical model and how each component specifically relates to antidepressants. The medical model includes four components: biological reductionism, the doctrine of specific etiology, mind-body dualism, and body as machine. Biological reductionism is the belief that illness is reducible to biology within the body. Physicians who use this practice solely look at the physical implications of illness rather than the social ones. The doctrine of specific etiology infers that every disease has a specific cause. A part of this assumption is known as the magic bullet approach, which implies that a drug is needed to bring wellness to the patient. Mind-body dualism is an assumption influenced by Cartesian philosophy. This idea views the body and the mind as being two distinct objects, namely that the body is material while the mind is immaterial. Body as machine approaches human bodies in a fashion similar to a mechanic approaching machines. The goal of this method is to either fix or replace parts of the body that are not operating properly (Weitz and Strohschein, 2014: 4-5).
A physician who practices biological reductionism would likely infer that a patient suffering from depression or anxiety would have a chemical imbalance. This physician would diagnose the patient and prescribe the drug, without concern for the how the chemical imbalance came about. The doctrine of specific etiology would hold a similar approach. It would suggest that depression or anxiety was the result of a chemical imbalance, and that the imbalance is best treated through medication. The relation between mind-body dualism and antidepressant use is not as simple. However, Weitz and Strohschein elaborate with clarity on the matter: “…patients who are treated for depression may come to believe that it is the treatment that is responsible for any improvement in mood and that a cure lies outside their own efforts” (2014: 5). Mind-body dualism encourages medically treated patients to accept a sense of helplessness, rather than give them any empowerment over the problem. With regard to the body as machine assumption, I would imagine that doctors who operated with this mindset would see antidepressants as a medication that works for virtually anyone who is experiencing the correct symptoms. If humans are approached as machines, their individuality is overlooked because there is a generic method in which problems are handled.
The Efficacy of Antidepressants
Are antidepressants effective in treating patients with depression and anxiety? The results appear to be ambivalent. In one patient-level meta-analysis, the goal was to understand how successful antidepressants were compared to placebo. The total number of patients looked at was 718, and these patients ranged in severity of depression. The study revealed that the higher the severity of depression was, the more likely the drug itself proved to be effective. But for patients with mild or moderate depression, the drug itself was either slightly effective or ineffective. For patients who scored below 23 on the Hamilton Depression Rating Scale (HDRS), the difference between medication and placebo was unsubstantial, as the effect size was approximately less than 0.20. This is a small number in terms of efficacy (Fournier, DeRubeis and Hollon, 2010: 47-53).
On the contrary, a systematic review and meta-analysis performed in Italy showed that antidepressants were effective in helping patients with anxiety. The overall purpose of the review was to compare benzodiazepines (BDZ) and tricyclic antidepressants (TCA) and examine their efficacy, as TCA is more commonly prescribed than BDZ. Ten investigations were used in meta-analysis. The results rendered that there was a lack of consistent evidence to show that TCA was a more effective drug than BDZ. It was actually shown that BDZ had some benefits over TCA, including less negative side effects and being more successful at decreasing the number of panic attacks compared to TCA (Offidani, Guidi and Tomba, 2013: 355-362).
At this point, I would like to briefly elaborate on the side effects that come with taking antidepressants. One article documented a cross-section of reports from patients who used antidepressants, and the side effects that followed from taking them. The specific antidepressants used by these patients were SSRIs. Out of the 700 patients surveyed, 38% reported a side effect caused by the drug, 25% being reported as “very bothersome” or “extremely bothersome.” The most common side effect was sexual dysfunction, at a rate of 56 respondents. The second most popular side effect was drowsiness/sleepiness, at a rate of 53 respondents. The third most common was weight gain, in which 49 people reported this (Cascade, Kalai and Kennedy, 2009: 16-18).
The efficacy of antidepressants is a topic that is a lot more complex than what these few studies might make it out to be. There are other implications that could be looked at. However, with the knowledge that these studies supply, the following can be recognized: for some users placebo has been more helpful than the drug itself, there may be a difference in the usefulness of antidepressants between treating depression and anxiety, and side effects are experienced by a fair amount of users.
Structural-Functionalism
For the structural-functionalist, it is important that the members of society can keep operating. This perspective views society as a system built of functioning parts that work together (Moffitt, n.d.). Talcott Parsons was an important figure in this area of sociology for two reasons. First, he recognized the threat of illness (Weitz and Strohschein, 2014: 7). Second, he introduced the sick role (Medley-Rath, 2012). Parsons saw illness as a threat to society because it could prevent people from attending to their responsibilities, resulting in a lack of social order. The sick role follows from this as it allows for individuals to resign from their responsibilities for a certain amount of time (2014: 7). How does this relate to the usage of antidepressants? As we saw from looking at the statistics, there are a lot of people who are taking these drugs. If these drugs are effective in helping people who struggle with depression and anxiety, then this would be an advantage from a structural-functionalist point of view.
For example, one of the symptoms of clinical depression is fatigue. It is also common for someone with clinical depression to be especially depressed in the morning (Web MD, n.d.). Let us consider the following situation. An employed adult with clinical depression has a past of being unable to get out of bed in the morning, causing them to miss work days. This person has been diagnosed with clinical depression but has avoided taking their medication. They finally decide to use the prescribed medication, and eventually they are able to show up to work, no longer missing any days. A structural-functionalist would view antidepressants as being successful in this case, because they have caused the individual to attend to their job.
Conflict Theory
Conflict theory is the perspective that dominant groups have power over the subordinate groups in society (Weitz and Strohschein, 2014: 8). There are a number of ways in which this perspective can be applied to the case of antidepressants. The pharmaceutical industry (sometimes referred to as Big Pharma) could, for instance, be understood as the dominant group while the patients might be understood as the subordinate group. In the words of Shane Ellison, a former pharmaceutical chemist: “You have a billion dollar industry making a lot of people sick and profiting on it.” Ellison further elaborates on the techniques that the pharmaceutical industry uses with regard to psychiatric medication. He mentions that the business model is to treat symptoms rather than to create cures, and emphasizes the negative effects of antidepressants. He also mentions that Big Pharma creates “diseases” for the sake of obtaining patients (Why Big Pharma Profits from Keeping You Sick, 2010). To summarize Ellison’s point of view, the pharmaceutical industry does not only profit on sick people, but they actually have techniques to assure that people will be sick.
Another way that conflict theory could be applied to antidepressants is by considering the chemical imbalance debate. Similar to Ellison’s perspective, a conflict theorist might suppose that Big Pharma is the dominant group while the patients are the subordinate group. Wi
th this in mind, they could further assume that the pharmaceutical approach is deceptive, namely the chemical imbalance explanation. This is the explanation that pharmacies employ because the antidepressants they prescribe are used to balance out neurotransmitters, as previously mentioned under the general remarks heading. Joseph Mercola, an osteopathic physician, is opposed to the chemical imbalance explanation (Mercola, n.d.). He says: “The low serotonin theory arose because they understood how the drugs acted on the brain; it was a hypothesis that tried to explain how the drug might be fixing something.” The following quote is from an investigation performed by the National Institute of Mental Health in 1983: "There is no evidence that there is anything wrong in the serotonergic system of depressed patients” (Mercola, 2011). Considering how many people use antidepressants, this particular conflict theory approach is by no means a popular approach to take.
Social Constructionism
Social constructionism is an ideology which asserts that reality is formed through interpretation and meaning making. “From this viewpoint, illness is recognized as being real through social interaction rather than the objective identification of disorder in the body” (Weitz and Strohschein, 2014: 8). An important factor within social constructionism is symbolic interactionism, a theory which looks at the subjective meanings that humans connect to objects, events, and behaviours (Crossman, n.d.). I would also like to note an idea from Canadian sociologist, Erving Goffman. Goffman supposed that mental hospitals persuaded patients into thinking that they were mentally ill (Weitz and Strohschein, 2014: 8). What Goffman was implying was that patients were not objectively ill, and that their “illness” was created by the subjective interpretation of the mental hospitals.
This can be applied to the topic of antidepressant users and the drugs themselves quite easily. An advocate of the social constructionist theory could suggest that no person objectively has depression or anxiety, but that these diagnoses are subjective. They could further allege that medication does not objectively help or harm people, but that the effects range from person to person. It might even be understood that medication is or is not successful for an individual based on how they interpret the drug. Basically, there is a lot of room for interpretation when this ideology is utilized. As one article make note of, different illnesses are understood in different ways. An example of this is that some illnesses attract stigmatization while others do not. From a social constructionist point of view, these ways of understanding illness exist for social and not biological reasons (Conrad and Barker, 2010).
Conclusion
In considering the accounts presented in this paper, the cultural, physical, and sociological implications of antidepressants are substantial. By looking at the statistics, it is recognized that antidepressant usage is quite significant in both Canada and the United States. By looking at the physical implications, it becomes clear that there is ambivalence in terms of efficacy and side effects. For some people, antidepressants directly help, while others are helped by means of placebo. Many users experience side effects as a result of taking the drug, but it is not shown that all users experience such. Theoretically, ambivalence is also present, as we saw by looking at the topic through the lenses of the three sociological perspectives. From the examples I gave, the structural-functionalist approach seems most likely to look upon antidepressants with favour, while the conflict theory and social constructionist approaches seem more likely to criticize usage (though not necessarily). In terms of the research regarding antidepressants, it seems to me that there is a greater emphasis on how depression is treated instead of anxiety. This, however, is a minor complaint as there is a plethora of information on antidepressants. Ultimately, whilst exploring the topic of antidepressants, it is visible that many aspects render mixed results rather than conclusive ones.
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A Sociological Exploration of Antidepressants Page 2