There was a news story about this a few weeks ago (around Super Tuesday, I think) but I don't remember seeing a thread about it. I'll dig up a link when I get back from lunch. My understanding of the finding was that while anti-depressants can be life savers in severe cases, a lot of people using them aren't getting a benefit greater than placebo.
Posted by Noemon (Member # 1115) on :
I think that it was mentioned in passing, but I could be thinking of another forum. It didn't get discussed in great detail, in any case.
Posted by Dr Strangelove (Member # 8331) on :
This is probably not what you are referring to, but it might apply.
Posted by orlox (Member # 2392) on :
*desperately wants to make a joke about pooka being on Tom Cruise's payroll*
Posted by pooka (Member # 5003) on :
I wish!
Posted by Samprimary (Member # 8561) on :
quote:Originally posted by pooka: There was a news story about this a few weeks ago (around Super Tuesday, I think) but I don't remember seeing a thread about it. I'll dig up a link when I get back from lunch. My understanding of the finding was that while anti-depressants can be life savers in severe cases, a lot of people using them aren't getting a benefit greater than placebo.
I kind of expected we would get to this point with SSRI's. If that's what they're talking about. I could guess probably pretty accurately as to why it's practically placebo in a majority of prescribed use.
Posted by pooka (Member # 5003) on :
quote:We obtained data on all clinical trials submitted to the US Food and Drug Administration (FDA) for the licensing of the four new-generation antidepressants for which full datasets were available.
I do believe this refers to SSRIs. So why do you think? I'm always happy to critique the prescription of SSRI's by doctors who are not psychiatric specialists.
Posted by Javert (Member # 3076) on :
I was going to mention it...but I was too depressed.
Posted by Dan_raven (Member # 3383) on :
I was going to mention it, but then my Med's kicked in and I couldn't disobey my pharmaceutical-derived lord and master.
Posted by mackillian (Member # 586) on :
quote:"We also find that efficacy reaches clinical significance only in trials involving the most extremely depressed patients, and that this pattern is due to a decrease in the response to placebo rather than an increase in the response to medication."
...so the clinically significant improvement of the most severely depressed people is due to... what? magic instead of the medication?
I have many thoughts on this study, but I'll just talk about a few (since I could ramble). It's a meta-analysis, first of all. And through their description of their methodology, it looks like they number-squished-modified some data to make it fit into their expected model. Okay, I can sort of understand needing the numbers from many different studies using different statistics to fit into an entirely different model.
Anyway. The main thing is that while the SSRI was shown to be no more effective than a placebo from very depressed people to depressed people, it still shows that there was some sort of efficacy. Shown in the bit I quoted above, there was clinically significant improvement in the most severely of depressed patients.
If SSRIs are over-prescribed, then of course it's only going to work (better than a placebo) in the most severely depressed people because at that point, you can really point it to being a persistent neurotransmitter issue rather that a situational and therefore transient neurotransmitter level. Basically, it's the difference between people who have to take it from 6 months to a year and never have to take it again and people who have to take it for the rest of their lives.
At least from my biased point of view.
Posted by MrSquicky (Member # 1802) on :
quote:...so the clinically significant improvement of the most severely depressed people is due to... what? magic instead of the medication?
I'm not sure, but it looks to me like you (edit: and most likely they) are treating all types of depression as having the same cause.
It is entirely possible for some types of depression to have a primarily biomedical cause that can be treated with an SSRI (and would make them non-responsive to a placebo), while other types to have a different cause that isn't going to be effected by SSRIs anymore than a sugar pill.
Posted by orlox (Member # 2392) on :
I remember reading the meta-analysis a few months ago when it was published in (I believe) the New England Journal of Medicine.
The most important fact to me wasn't that there were data questioning the efficacy of the drugs, but that the studies showing that the drugs were effective were significantly more likely to be published than those showing no effect. So looking at the published literature gives a very different picture than looking at all the studies combined.
At the risk of fanning some completely unrelated flames here, the implications that could be drawn for science in general seem more interesting than the implications for this specific class of drugs.
Posted by rivka (Member # 4859) on :
quote:Originally posted by Speed: At the risk of fanning some completely unrelated flames here, the implications that could be drawn for science in general seem more interesting than the implications for this specific class of drugs.
Agreed.
Posted by Samprimary (Member # 8561) on :
quote:If SSRIs are over-prescribed, then of course it's only going to work (better than a placebo) in the most severely depressed people because at that point, you can really point it to being a persistent neurotransmitter issue rather that a situational and therefore transient neurotransmitter level.
Yup. I mean, maybe I was thinking in a way which took it a bit farther than that, but I had guessed that perscribing SSRI's to people as an antidepressant cure-all even when the issue at hand was not best suited to treatment by altering brain chemistry would have .. um, mixed results.
Posted by MrSquicky (Member # 1802) on :
quote:At the risk of fanning some completely unrelated flames here, the implications that could be drawn for science in general seem more interesting than the implications for this specific class of drugs.
The meta-analyses of studies of drug efficacy broken down by funding by a large majority show more confirming studies and more positive reported results when the funding comes from drug companies than from other sources.
It's been long established that using drugs alone is one of the least effective treatments for depression, however it is still a very common treatment.
I think the therapists and drug companies bear the lion's share of the blame, of course, but there's also a very strong desire on the part of the public to define all depression as primarily bio-chemical in nature, which is very unlikely to be true.
Posted by pooka (Member # 5003) on :
quote: Yes, the study showed that the drugs often performed no better than a placebo. But what many of the media missed was that the placebo effect can be remarkably strong in psychological and neurological disorders, especially in mild depression.
(this is from the Nature link, the second one in orlox's post). Is it ethical to give someone a drug based on the placebo effect which is not a placebo? Wouldn't it be better to give an actual placebo than a drug which may cause weight gain and a loss of libido?
I wonder if the "I'm not myself" feeling of being on an anti-depressant is just as strong with placebo. I think it could be largely cognitive -- a loss of confidence that comes from relying on a drug. Is there a clinical name for this?
Posted by Sharpie (Member # 482) on :
"-- a loss of confidence that comes from relying on a drug" ...
What does this mean? Do diabetics have this loss of confidence from relying on insulin? Cancer patients from "relying on" chemo drugs? Or is it just psychiatric drugs you are wondering about here?
Posted by MrSquicky (Member # 1802) on :
Anecdotally, I've heard that one of the common reasons given for going off some forms of psychoactive drugs is that taking the drugs was interfering with who the person was. I imagine that this is sort of what pooka was talking about.
There's also the issue of locus of control, which is kind of hot in the field of (I swear I'm not making this word up) psychoneuroimmunology - the study of how one's psychological processes affect a person's health. I haven't actually looked into this - it strikes me as something I should now - but, as control and lack there is a central issue in many explanations of depression, I wouldn't be surprised if reinforcing the idea of an external locus of control in dealing with depression might lead to worse long term consequences both for depression and possibly for a person's overall health. I have no idea how you could ethically study that though.
Posted by Dr Strangelove (Member # 8331) on :
In lieu of the long post I had written but wasn't happy with, I'll be short and to the point. I was diagnosed with depression. I was prescribed drugs. I felt considerably better. I tried to stop taking drugs. I felt nasty physical side effects, plus the beginnings of nasty mental ones. I went back on drugs, then started to slowly wean myself off of them. Now, I've been off of them for a little bit and have felt fine physically. But I've slowly been getting more depressed, feeling more and more out of touch with the people around me, getting more and more frustrated with myself and who I am. Maybe this is a regular cycle of depression, not a result of me not being on antidepressants. Maybe this is the result of the placebo effect wearing off or whatever. I don't know the technical medical jargon. Whatever the case, I'm in a hard spot. I don't want medication. But I'm wondering if there's a distinct possibility that I need medication. And then there's these recent findings (this is not my first exposure to them) which seem to be telling me the medication doesn't actually do anything. It's all a confuzzled mess to me.
I think, in the interest of my own safety before all else, I'm going to start taking antidepressants again. I'll let y'all know if they work .
Posted by mr_porteiro_head (Member # 4644) on :
quote:Originally posted by Sharpie: "-- a loss of confidence that comes from relying on a drug" ...
What does this mean? Do diabetics have this loss of confidence from relying on insulin?
I wouldn't be surprised if people with type II diabetes, who could manage without insulin by changes in eating and exercise habits, but who fail to do so, could also have this loss.
Posted by MrSquicky (Member # 1802) on :
Dr, I want to emphasize that I am only talking in the general case and nothing I'm saying should be taken to apply to any specific case. I think you realize that, but I want to sure.
Posted by pooka (Member # 5003) on :
quote:Originally posted by Sharpie: "-- a loss of confidence that comes from relying on a drug" ...
What does this mean? Do diabetics have this loss of confidence from relying on insulin? Cancer patients from "relying on" chemo drugs? Or is it just psychiatric drugs you are wondering about here?
A standard spiel that is given to psych patients is to consider their meds as being as important as livesaving drugs for other conditions (I've always heard heart disease.)
A cycle many people go through is they get on the drugs, the drugs start working, the person thinks they are fine and don't need the drugs, and then they crash again. Why do the people consistently decide they don't need the drug when they are feeling fine? I believe this is a reflection of the same tendency that causes people to resist taking meds in the first place. They want to be independent. There are also lots of people who will try to reduce their meds because of the expense.
I know I seem really anti-drug, and a lot of that comes from my personal experience, but I also know people for whom drugs make the difference between being a productive member of society v. being chronically institutionalized.
Posted by Sharpie (Member # 482) on :
A lot of folks resist drugs or stop taking them because they believe they are not ill, though. My daughter firmly believed that she was not ill -- while lying in a bed in the emergency room at 3 am after hurtling out of a second story window because she didn't think it would hurt her, while being unable to have conversations because she was so feverishly irrational. By irrational I don't mean "disagreeing with her mother" . She had a fairly profound lack of insight about her condition.
I so often hear things like mental illness is overdiagnosed or people don't need all these darned medications -- in direct response to hearing that my daughter is mentally ill! So my own personal experience colors MY reactions. Which makes sense . I guess I set my jaw in anticipation of argument when I see conversations like this one, which is not really fair of me. But if one more person tells me that what my girl REALLY needs is a: the 23rd Psalm or, b: to look outside herself and do something for those less well-off... (not to imply that anyone here said this!)
Posted by Sharpie (Member # 482) on :
quote:Originally posted by mr_porteiro_head:
quote:Originally posted by Sharpie: "-- a loss of confidence that comes from relying on a drug" ...
What does this mean? Do diabetics have this loss of confidence from relying on insulin?
I wouldn't be surprised if people with type II diabetes, who could manage without insulin by changes in eating and exercise habits, but who fail to do so, could also have this loss.
Hrm. I come into this with my own biases, as I have mentioned. So I am proceeding with caution. My bias is that a WHOLE LOT of psychiatric disorders are physically caused and that medicines for physical disorders are not a sign of weakness of character. When we use words like "could manage but fail to do so" about psychiatric disorders, we (society) further stigmatize a population that is already suffering terribly. (I realize that you did not say this about psychiatric disorders specifically, but I am afraid that a lot of people DO think this about mentally ill people.)
My husband has cholesterol issues. These can be addressed with exercise and diet and weight loss, and we have instructions for doing so. However, high cholesterol in our age group has dangers of its own, and we, with the doctor, have decided to treat this condition with medication. Is that weakness of character? Is that "failing to manage his cholesterol"?
Posted by Shigosei (Member # 3831) on :
I read the study. It's quite interesting, and I hope everyone will take a look. (I love PLoS - open-access is a wonderful thing). I agree that this is quite an eye-opening study for many reasons. Publication bias is a well-known problem, and this seems like an effective means of getting around it. However, you're then limited to pre-market drug trials, which may not be the best indicator of efficacy, particularly in the long term. I wonder if we should consider having some sort of central repository for data sets that don't show any interesting conclusions. That would be an interesting way of dealing with publication bias.
The last line of the paper is quite interesting:
quote:Finally, although differences in improvement increased at higher levels of initial depression, there was a negative relation between severity and the placebo response, whereas there was no difference between those with relatively low and relatively high initial depression in their response to drug. Thus, the increased benefit for extremely depressed patients seems attributable to a decrease in responsiveness to placebo, rather than an increase in responsiveness to medication.
I'm not entirely certain what to make of that. If some of the effectiveness of medication is due to the placebo effect, and severely depressed people are less able to affect their own health through the placebo effect, you'd think you'd see a bit of a decrease in efficacy for the drugs as well.
Posted by pooka (Member # 5003) on :
I'm glad to hear I'm not the only person for whom that was not crystal clear.
I think I understand it now. They were saying that the placebos were unusually effective against non-severe depression.
Posted by MrSquicky (Member # 1802) on :
quote:If some of the effectiveness of medication is due to the placebo effect, and severely depressed people are less able to affect their own health through the placebo effect, you'd think you'd see a bit of a decrease in efficacy for the drugs as well.
Unless, as I've suggested, there are potentially multiple causes of what we call depression, with severe depression being not prone to the placebo effect but affected by some drug interventions while the less severe doesn't have an underlying biomedical cause but, as it is psychologically based, is amenable to a placebo effect, especially when taken over the short time scales that mnay drug effectiveness trials are looking at.
Posted by Dr Strangelove (Member # 8331) on :
MrS, yeah, I know, don't worry. My issues are ones that are not going to be solved or affected by generalized comments on a forum. I've just been very thoughtful about this issue lately and then, waddya know, a thread pops up on Hatrack, so I thought I'd try to process externally for a change .
As an aside, if I left a prescription bottle of Zoloft in a trunk for a few weeks in Florida (it hasn't been too hot, but hot enough that they most likely were in 100+ degrees for a prolonged period of time), are they still good?
Posted by orlox (Member # 2392) on :
Most of the direct criticism I have seen of the study is that by limiting the meta-analysis to 6-8 week periods, they ensure that the placebo effect is NOT discounted.
I wish I could claim that such studies occur in a political vacuum, but that is just not so. Anyone following the issue knows that the placebo effect for SSRIs has been around for a long time and has been further complicated by sometimes contradictory suicide data.
I think that a consensus has been building that SSRIs have been greatly over prescribed of late and this study seems to me, somewhat designed to provide data to support that consensus. Yes, this is probably not how things should be. No, I don't think anyone would actually cop to weighting a study design to support a desired outcome.
In the realpolitik of the situation, drug companies have been employing such practices and much worse in support of their position.
Fight deniable fire with deniable fire, etc., etc.
Which is why I pointed to the Nature editorial.
Filing Freedom of Information claims with the FDA is no way to collect clinical-trial data. I agree with Shigosei and the editors of Nature. It is well past time we had a clinical trial registry and a more transparent regulatory framework.
Posted by mr_porteiro_head (Member # 4644) on :
quote:Originally posted by Sharpie:
quote:Originally posted by mr_porteiro_head:
quote:Originally posted by Sharpie: "-- a loss of confidence that comes from relying on a drug" ...
What does this mean? Do diabetics have this loss of confidence from relying on insulin?
I wouldn't be surprised if people with type II diabetes, who could manage without insulin by changes in eating and exercise habits, but who fail to do so, could also have this loss.
Hrm. I come into this with my own biases, as I have mentioned. So I am proceeding with caution. My bias is that a WHOLE LOT of psychiatric disorders are physically caused and that medicines for physical disorders are not a sign of weakness of character. When we use words like "could manage but fail to do so" about psychiatric disorders, we (society) further stigmatize a population that is already suffering terribly. (I realize that you did not say this about psychiatric disorders specifically, but I am afraid that a lot of people DO think this about mentally ill people.)
My husband has cholesterol issues. These can be addressed with exercise and diet and weight loss, and we have instructions for doing so. However, high cholesterol in our age group has dangers of its own, and we, with the doctor, have decided to treat this condition with medication. Is that weakness of character? Is that "failing to manage his cholesterol"?
If you're asking whether I think it's a weakness of character in your husband, I have no interest in making that judgment.
If you're asking whether some people in that situation would judge it as a failure in themselves, then the answer is definitely yes.
Posted by scholar (Member # 9232) on :
I can not remember which drugs this is true for, but my friend's (being vague because I don't have permission to talk about his case) psychiatrist assumes nearly a month before you would see an effect. Then there is dosage adjustement time and so forth. He has tried just about every drug out there and they generally try for 2 months to make it work and then try something else. Some have been extremely effective, some have no effect at all and prozac made him way, way worse. I think brain chemistry is still not well understood and so there is a lot of trial and error still.
Posted by MrSquicky (Member # 1802) on :
Most SSRIs have a latency period before they take effect that, if I recall correctly often range from between 2 weeks to a month). SSRI stands for selective seratonin reuptake inhibitor. They use a variety of methods to prevent reuptake (that is reabsorbtion into the nerve cells, thus removing their effects) of the neurotransmitter seratonin at the synaptic gap in nerve cells. I'm a little hazy, but I think that they build up to the working level gradually. I could be totally wrong about that though.
I want to point something out:
quote:He has tried just about every drug out there and they generally try for 2 months to make it work and then try something else.
I realize you can't talk about the specific case, but this is described the entirety of a lot of people's experience when being treated by a psychiatrist for depression. They try out drug and if that doesn't work then they move onto another one.
This is despite, as I said, it being well established that, in most cases, drugs alone are a much less effective than many other treatments.
Posted by pooka (Member # 5003) on :
Yes, I've heard up to 6 weeks as well. It's hard to say at what point one would declare that the chemistry of the brain is well understood. I think doctors know way more than they used to, but there is still a lot to be discovered. That's not the same as saying it's complete trial and error.
Posted by mackillian (Member # 586) on :
quote: I also know people for whom drugs make the difference between being a productive member of society v. being chronically institutionalized.
...yes.
Dr Strangelove, if you call a pharmacy, the pharmacist would best be able to answer that question. They know a LOT.
quote: I think brain chemistry is still not well understood and so there is a lot of trial and error still.
yes
Posted by Shigosei (Member # 3831) on :
Oh, yeah, that's the other problem. Given that the antidepressant effects generally don't start for a few weeks, I'd expect the placebo effect to be much more significant in a shorter trial. It would be interesting to look at just the 8 week trials.
On the other hand, it's questionable whether the FDA should have approved these drugs based on the data they had. Of course, as the study pointed out, there's a statistically significant difference, but not a clinically significant one. I'm not sure which standard the FDA uses.
Posted by scholar (Member # 9232) on :
The person I know has both a therapist and a psychiatrist who work together.
Posted by pooka (Member # 5003) on :
Oh, look, you almost have a thousand posts.
Posted by orlox (Member # 2392) on :
If I have my Hatrack cast of characters right, then Sharpie's husband is one of the best minds that I have ever encountered. Period.
Posted by MrSquicky (Member # 1802) on :
The whole focus on blame for psychological problems and strength/weakness in overcoming them strikes me as very wrongheaded.
For one thing, they're called disorders for a reason. Psych disorders aren't some sort of external problem that you need to power through. They are often cases where either normal functioning of your brain is being disrupted or (I think) more commonly when normal, generally beneficial brain function and reactions aren't well suited to a situation you find yourself in.
A neutral example. Your eyes are wired a certain way that helps you perceive your surroundings in an accurate and useful way. However, many of the things these systems do can be hijacked by arrange stimuli that give rise to illusions. You see things that aren't there because that's how you are wired to respond to stimuli. It's not a matter of strength or weakness.
For many psych problems, it is the same thing. It's not a matter of not being strong enough. It's a matter of not knowing where the handles are that you can use to get a grip on things or not understanding that really it is an illusion.
Secondly, and this is probably the engineer in me, I think the proper focus should be on the outcome. How do we fix this as opposed to what do the various treatments say about me? I don't know if I can express this well on an individual case.
It's like, you're in a group and something goes wrong. At this point, you can either trying to figure out who is to blame for what went wrong or you can focus on fixing it. Now, in many cases, what caused the error is integral into developing a working fix, but in that case, it should be approached that way, as subordinate to fixing it.
A lot of what I perceive of the blame/strength issue is, to me, sitting around trying to affix blame.
Posted by Sharpie (Member # 482) on :
quote:Originally posted by orlox: If I have my Hatrack cast of characters right, then Sharpie's husband is one of the best minds that I have ever encountered. Period.
Whether or not the first part of your sentence is true, the second part is DEFINITELY true. Yeah, he is JVP. We got married in September! I'm still getting used to calling him "husband".
Posted by rivka (Member # 4859) on :
quote:Originally posted by MrSquicky: A lot of what I perceive of the blame/strength issue is, to me, sitting around trying to affix blame.
Agreed.
Posted by orlox (Member # 2392) on :
Congrats! Posted by pooka (Member # 5003) on :
I'm not sure what you are referring to as the blame/strength issue.
Okay, I guess I am getting it now. I thought it was something around that, I just hadn't seen where we were dealing with that in this thread.
I don't think resisting needed medication makes someone strong. But as I think you've been saying, the people who treat mental illness have apparently not done a good job of identifying who the medicine would help and who it would not be that helpful for.
I mean, if a placebo is as effective for you as the real medicine, could I venture to say that a different treatment might have been effective? I believe this is probably the same kind of group for whom it was found that exercising is actually more effective than medication.
Posted by Sharpie (Member # 482) on :
Mr. Squicky, I really like that neutral example a lot.
I also agree about the blame/strength issue. At a certain point, families of very mentally ill people can get to where they look around them for places to be advocates for their family members. I think this is often where I tend to focus my advocacy, for what it's worth: I try to fight what I perceive as thinking patterns that contribute to the ongoing stigmatization of mental health issues. One of them is the idea that people who are mentally ill can just "pick themselves up by their bootstraps", often followed by "if they really want to". So whenever I see someone suggest that mental illness can be gotten rid of by attitude adjustment or the like, I sort of wade in, arms akimbo. This is not always the best method for me to get my point across .
Anyway, add that to my belief that kids want to do well and that when they don't, it's because something is getting in their way, and my belief that your perception of the cause of the problem affects the way you address the problem... I'm probably one step away from thrusting pamphlets at passersby.
Posted by scholarette (Member # 11540) on :
quote:Originally posted by pooka: Oh, look, you almost have a thousand posts.
Uhoh! Time to create a new username to avoid the dreaded landmark. Posted by MrSquicky (Member # 1802) on :
quote:I believe this is probably the same kind of group for whom it was found that exercising is actually more effective than medication.
As of the review article I read maybe 3-4 years ago, regular aerobic exercise is gnerally as or more effective than medication for treating mild depression.
Posted by rivka (Member # 4859) on :
quote:Originally posted by Sharpie: We got married in September! I'm still getting used to calling him "husband".
Congrats! Posted by Irami Osei-Frimpong (Member # 2229) on :
I think my issues with these pills come at a few different levels.
The addictive ones I set equal to street drugs. The non-addictive ones, I set equal to steroids, where it's not that people take the pills because they are chemically dependent upon them, rather, they take the pills in order to produce at a consistent level. It's a performance-enhancer anda matter of nuanced vanity. The thinking becomes, "Everyone else taking pills so I have to take pills to keep up with the people taking pills." Barry Bonds and Sammy Sosa do the same thing, now it's engineers, students, and over-whelmed parents on the same train.
Out of curiousity, I'd love to randomly drug test students when they turn in their dissertations, to find out if a thesis is juiced. I do admit the idea of revoking tenure because of Ritalin use amuses me tremendously. I imagine a high level shrink being busted, and his list of patients going public, congressional hearings and the whole bit, a la BALCO.
For those people out of school or not taking auditions, it seems to me to be a matter of inadequate strategies to cope with the flood of responsibilities and expectations that attend being an adult American, combined with one's desire to live comfortably in a manner in which one is accustomed. When it seems to me that people should just lower their expectations concerning what they can produce. Do fewer things, and not all of them well. Get the smaller place, take the lower paying, lower responsibility job. Adjust your dreams.
[ July 31, 2008, 11:44 AM: Message edited by: Irami Osei-Frimpong ]
Posted by Puffy Treat (Member # 7210) on :
quote:Originally posted by Sharpie: One of them is the idea that people who are mentally ill can just "pick themselves up by their bootstraps", often followed by "if they really want to".
Man. I've had so many problems with this. For many years, -I- was in denial over my depression and anxiety, making excuses and hiding the truth from myself through distractions.
Even when I finally admitted it, it still took a while for me to break down and take something.
And even then, some of my siblings, friends, etc (not all of them, but some) ask me "why don't you just try not being depressed?"
I have. And for some reason, I really can't function without help.
![[Wink]](wink.gif)
.
![[Big Grin]](biggrin.gif)
. She had a fairly profound lack of insight about her condition.![[Smile]](smile.gif)
. I guess I set my jaw in anticipation of argument when I see conversations like this one, which is not really fair of me. But if one more person tells me that what my girl REALLY needs is a: the 23rd Psalm or, b: to look outside herself and do something for those less well-off... (not to imply that anyone here said this!)
![[Cool]](cool.gif)
![[Frown]](frown.gif)