The following is an addendum to the Letters column that appears in the Spring 2013 issue of Inquiring Mind.

Medication for Depression:
Help or Hindrance?

(Letters to Inquiring Mind)

We received many letters in response to our “Demons and Dharma: Practicing with Difficult Emotions” issue (Fall 2012)—especially with regards to B. Alan Wallace’s essay, “Popping Pills for Depression: A Buddhist View” (published online here, at Space did not permit us to print as many as we’d have liked.

A shortened version of Dr. Alexander Tribe’s critique of “Popping Pills” appears in our Spring 2013 issue; we’re publishing the original letter in its entirety here, with responses from psychotherapy professionals. (B. Alan Wallace is on a six-month retreat and thus unavailable to respond.) If you’d like to join this discussion, please visit Inquiring Mind’s Facebook page.

Dear Inquiring Mind,

Congratulations on devoting the Fall 2012 issue to “practicing with difficult emotions,” a very important and often neglected subject.

However, I feel compelled to take issue with the basic premise and tone of B. Alan Wallace’s article as well as many of its specific points.

I am not a Buddhist scholar or neuroscientist. I am a board-certified adult and child psychiatrist with over thirty years of clinical experience, treating people of all ages with pharmacotherapy and psychotherapy. I’m an ordained Soto Zen priest in the Suzuki Roshi lineage and have been practicing Zen in that lineage for forty-five years. I have also been in Jungian psychotherapy for over twenty years and have benefited greatly from antidepressants for many years as well.

Even the title of Wallace’s article, “Popping Pills for Depression,” immediately reveals the author’s negative bias. The phrase, “pill popping,” is clearly a pejorative reference to drug abuse and/or recreational drug use. There is no place for such inflammatory and inaccurate language in any well-reasoned discussion of antidepressants, which clearly are not addictive and have no potential for recreational use.

Later in the article there are more blatantly inaccurate statements alleging that antidepressants produce “long-term . . . prolonged drug dependence.” There is no evidence whatsoever for this claim and abundant evidence to the contrary.

The article is replete with straw man arguments. For example, no serious clinician or scientist would dream of claiming that “depression arises purely from chemical imbalances.” For many years, there has been universal agreement that depression, like virtually all psychiatric disorders, is a complex, multi-faceted condition with genetic, biological and psycho-social (and I would add spiritual) components. To claim otherwise is disingenuous and misleading. Of course the profit-motivated interest of “Big Pharma” can be justifiably criticized, but this fact has no relevance to the issue at hand.

Wallace then postulates a distinction between “neurological disorders” and “mental disorders.” This is an antiquated and vastly over-simplified view contradicted by a huge body of scientific study and clinical experience that point to a much more complex and nuanced view of the interaction of mind and body.

Wallace’s claim that “our rapidly growing knowledge of the brain has not resulted in a corresponding degree of progress in developing drugs to treat mental illness” would come as a shocking surprise to the countless patients whose quality of life has been immeasurably improved by antidepressant, antipsychotic, anti-anxiety and mood-stabilizing medications.

The attack on so-called “scientific-materialism” is another blatant straw man argument. No modern clinician or researcher would dream of claiming that “only physical processes have causal efficacy.” A cursory glance at any basic textbook of psychology or psychiatry would immediately reveal the absurdity of this claim.

The same is true of Wallace’s later statement, again simply an assertion, that “there are many researchers . . . who regard all mental disorders simply as brain disorders.” There are very few, if any, serious researchers who are so ignorant as to believe in any over-simplified, unitary hypothesis about the etiology of depression or any other psychiatric disorder.

Wallace does cite two studies which purport to show that antidepressants are not more effective than placebos, but he doesn’t even mention the many studies with conflicting conclusions. Interestingly, in the very same paragraph he states that “in patients with very severe depression, there was a statistically significant drug benefit,” but he glosses over that finding, which clearly negates his basic premise.

The fact that these medicines are not panaceas, and may be overused or used inappropriately, has no bearing whatsoever on their potential value for a multitude of suffering patients.

I find it baffling and deeply disturbing that such a widely respected Buddhist teacher and scholar would write something so full of inaccuracies and misleading overgeneralizations. I’m afraid that articles like this one can do a great disservice to the many sincere practitioners who are suffering from treatable psychiatric disorders as well as from dukkha, the five hindrances and the three poisons. Many of these people are already afflicted by harsh, self-critical thinking and could easily be dissuaded from seeking help by a respected authority figure trying to convince them that they simply want to “pop pills.”

Alexander Tribe, M.D.
San Rafael, CA

Dear Inquiring Mind,

This letter regards the article called “Popping Pills for Depression: A Buddhist View,” by Dr. B. Alan Wallace, and Dr. Alexander Tribe’s response to this article.

I have been a mental health clinician and Buddhist meditation practitioner for decades and I have read both the article and the letter in response. I appreciate and empathize with both views expressed. Tribe is correct in saying that depression is generally understood by most clinicians as a complex interaction between numerous psycho-social, biological, neurological and, in my opinion, also spiritual factors. As a clinician I also know that antidepressants have helped millions of people to find some respite and relief from the sinking and overwhelming experience of depression.

If depression can be compared to drowning at sea, medications can act as a hand pulling a drowning person’s head out of the water enough for them to breathe. Medication has a valuable therapeutic role—it can provide the energy to address what needs to be addressed in a depressed person’s life. But medication, which targets chemical imbalances, is not enough to cure and change all the possible factors in a person’s life that may have led them to becoming depressed in the first place and also, perhaps more importantly, what keeps people stuck. Medication will not directly address possible causal and maintaining factors of depression such as debilitating physical illness, rumination, worry, self-hatred, hopelessness, helplessness, worthlessness, life style, lack of exercise, poor diet, social failures, grief and loss, family fractures and more. Most empirically validated recommendations for the treatment of depression are that medication should not be used alone; it needs to be supported by other psycho-social interventions.

Unfortunately, medical practitioners (in my country, at least) too often prescribe medication for depression without considering other treatment options. It is as if depression is simply a physical illness that should therefore be treated by physical interventions such as medication. The medical model of depression is also popular with the lay public because it means that they need not confront their mental and emotional habits and lifestyles. If depression is only a physical illness, then the depressed person need not feel a responsibility to change anything. As long as they take the medicine for the illness they can carry on, continuing to do what they have always done.

Empathizing with Wallace’s perspective, I appreciate that he was trying to balance a dominant view that depression is a physical illness. Wallace points to the possibility of freedom from depression without being bound to incomplete and inadequate solutions that come from sources outside the individual.

I can understand Tribe’s concerns with the language that Wallace used. Those people who have confidence in the Buddha’s teachings and who are also using antidepressants could feel disempowered, inadequate and even guilty. For these people there could be the risk of feeling un-Buddhist because they use and benefit from medication. Unfortunately, this contradiction and inner conflict could be yet another factor in a descending spiral of feeling trapped by depression.

The Buddhist perspective is, of course, that we need not take depression and all the factors surrounding it personally. When we can see that depression (like all things) is impermanent and not self, we can start to exit the cycles of depression. Insight helps us find freedom from the descending spirals of clinging to destructive views, internalized aggression, misperceptions and misunderstanding. When there is no root cause for dukkha (which includes depression) then dukkha does not arise.

Depression, like all things, arises because of interdependent causes and conditions coming together. Medication has an important role to play, especially when the suffering of depression is severe. But in resonance with Wallace, I feel that the dominant view in our modern societies is lopsided toward materialism and needs to be balanced with a more holistic wisdom of awakening. I would like to express gratitude to both authors for beginning to shine the light of understanding on this very important issue.

Malcolm Huxter
Clinical Psychologist, Australia.

Dear Inquiring Mind,

As a long-term practitioner and teacher of satipatthana meditation and the Buddha’s Dharma, I find myself quietly applauding Alan Wallace’s contribution to the debate over the medicalisation of depression.

While clinicians can doubtlessly see benefits in the current approach to the explosion of depression in materially advanced societies, operating as they are on the front line of the struggle, I feel Wallace is more concerned with providing an alternative perspective than with condemning current approaches.

Perceiving a distinction between “mental” and “neurological” disorders, where mental implies a subjective, first-person response and neurological implies an objective, third-person response, is both true to the Buddha’s understanding of reality and opens up space for both responses to the problem of suffering to be applied in their proper place. Precisely where the border between these two ideal types of disorders may be found is, of course, an empirically messy problem that will never be conclusively resolved.

Clearly there are some people who need a pharmacological intervention if they are to live well with their pain. Equally, among the millions currently taking antidepressants, there would be those who would be better off without them. And there are practitioners who find they can engage with the challenges of meditation practice only with the aid of some kind of pharmacological support. Deciding on where any particular person stands on this spectrum will always require a close reading of the individual and a deal of experimentation.

In my experience as a meditation teacher, I find that people do easily become dependent on antidepressants, and that it seems much easier to get on these drugs than to get off them. Let us not close our eyes to the disadvantages of the pharmacological approach to working with our pain in our enthusiasm for interventions that seem to offer at least some relief. Certainly the practitioners I work with who are still dependent upon antidepressants are acutely aware of the handicap they create in their practice. A necessary handicap, but a handicap nevertheless.

However, we are not dealing with a simple either-or equation, and I don’t read Alan Wallace as presenting this. Rather, I read his article as presenting a side of the equation that has been underrecognized in our culture, even among practitioners of the Buddhadharma. It’s time to redress the balance, and Wallace’s work in mapping out the counterpart territories of the first- and third-person worlds is an immensely valuable contribution to this project.

Patrick Kearney
Brisbane, Australia

© 2013 Inquiring Mind