HOOK & TANGLE DEPENDENCE?
an open letter to Thomas J Moore
Dear Thomas Moore,
I am so pleased we have made contact. I have read precious little of yours, but quite enough to know I have been much deprived. Your article on SSRIs is distinguished. I did think it curious that it should be published in the Washingtonian, but admire them for publishing it. And it's nothing like as curious as the fact that doctors would need to read a journal like this to get essential information about drugs they are now prescribing on an epidemic scale.
I'd glad you liked the citation to your article on this site, and shall add to it the review of your new book. I'd die for a review like that, or nearly. You must be basking.
I really want to pursue this question of "dependence", to try to get to the heart of the central question you asked: "Given high side-effect rates, marginal performance and lots of aggravating adverse effects, how do you (or I) explain the truly phenomenal popularity of these drugs? Could literally millions of people and tens of thousands of doctors really be so wrong?"
Well, yes, I'm afraid they could. That's what happened for over two decades with the benzodiazepines, and I am very nearly sure it is happening again with SSRIs. I know it seems almost incredible: indeed, how could such a serious and commonplace side effect have been completely overlooked by nearly all concerned? An important part of the answer is that relatively few people who ever tried BDZs were so affected, even if they number millions, world-wide. But there are many other possible factors which I'll come to later and probably list elsewhere. Watch this space etc.
Yes, the DSM-IV and ICD-10 definitions of "dependence" leave very much to be desired (Brit-English for something of a disaster). I think these definitions absolutely guarantee that both doctors and patients misunderstand the propensity of SSRIs to get people hooked. But remember we are talking here about very subtle hooks, with barbs well disguised. As they are baited with the finest of claims and intentions, they are of course swallowed with the highest of expectations too.
Dependence on SSRIs seems to me a sort of "hook and tangle" dependence, more like Velcro than the traditional, "chain-link" type of addiction. But if there are enough tiny, flexible hooks (numbers increasing with greater drug exposure) they would of course have a holding power to equal that of any chain.
This makes etymological sense too, in that the word "dependence" also has connotations of reliability and security. In 1964, the WHO turned to the word "dependence" to replace the term "addiction" but without excluding the notion of "habituation" - whereas the Latin root of "addiction" means "fetters", with the much starker implication of humans bonded and enslaved by chains.
The Velcro model illustrates other attributes of this particular kind of dependence. In some sense, you can wear it. You can 'wear' dependence, provided you are confident that "depression" can be defeated with the help of these brave new drugs. They promise to hold your head together, albeit not quite as reliably as Velcro holds up trousers or whatever. Hook+tangle dependence is certainly more easily worn than any chain.
Also unlike the chain-link model, Velcro-dependence requires a high degree of reciprocity to come on strong. I'll come on to your comments about 'psychological dependence' another time: the immediate point here is simply that no bond exists unless the hooks enjoy significant hospitality. It takes two surfaces to make the connection, which in turn signals another important difference and another major reason for non-detection - lack of dissonance.
Dissonance is the quality that probably best defines "dependence" as an addiction-like problem. The average smoker really wants to stop, and the typical community rejects addicts, especially if they turn to antisocial/criminal behaviour to sustain their habits. But lack of personal or social dissonance doesn't weaken the bonds of dependence, any more than a chain is weakened if its links are never flexed.
In the paper, I call it "iatrogenic dependence", and I think that's about right - both because and in spite of the fact it's unspecific. One can't yet be sure what kind of dependence this is, only that it is related to addiction, and that we've surely been here before. I would be thinking in terms of something like a sibling relationship between the two. But whatever it is, it is obvious enough that professional and commercial power feeds it, while government turns a blind eye.
I began writing this already quite late this evening (19-02-98), after talking on the phone to Frank van Meerendonk in Amsterdam. I think you've spoken to him: he's another pioneer in this field, but again someone I've not met. We were talking about how hard it is to effectively communicate unpalatable and unthinkable ideas - which in turn led me to think about images instead of wordy ideas.
Anyway, it's late and I'm stopping. I expect to write more on this topic, as and when - but not exactly sure when, because I'm out of circulation for the next few days. No need to acknowledge this, but do roll it round your mind. I hope the new book goes really well.
With best wishes - Charles Medawar