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Dr. Bob is Robert Hsiung, MD,
[email protected]Shown: posts 1 to 15 of 15. This is the beginning of the thread.
Posted by Anyuser on September 24, 2002, at 9:49:24
The Psychiatric Times published “point/counterpoint” articles on the topic of antidepressants versus placebo. Here are the links:
http://www.psychiatrictimes.com/p020906.html
http://www.psychiatrictimes.com/p020909.html.These articles are mainly (boring) statistical arguments. The Phd knocking drugs says there is no meaningful difference between the benefits of antidepressants and the benefits of placebo. The MD defending drugs concedes that the benefits of antidepressants versus placebo are minuscule (!), but that miniscule benefits add up in a public health setting.
I believe that the benefits of antidepressants are much more than placebo effect for me, and not at all miniscule. That has been my subjective feeling, my experience. I think the placebo versus antidepressant debate is a product of two difficulties: (1) the difficulty of distinguishing between depressed patients whose malady is fundamentally biochemical and those whose malady is fundamentally psychological, and (2) the difficulty of measuring a mental state on the various “scales.” Whenever my pdoc asks me to fill out a questionnaire before a consultation, I feel like I'm indulging an eccentricity of his. It's something I have to do before I can tell him how I really feel.
For whatever reason, I am always deeply discouraged when the advocates of talk therapy knock antidepressant medication. I supposed that is a weakness in me, one of a long list. I hate to think the benefits of antidepressants are nothing more than wishful thinking. I know talk therapy is wishful thinking for me. Literally “wishful thinking.”
What do you think about this debate?
Posted by Eddie Sylvano on September 24, 2002, at 10:30:42
In reply to Antidepressants versus placebo smackdown!, posted by Anyuser on September 24, 2002, at 9:49:24
> For whatever reason, I am always deeply discouraged when the advocates of talk therapy knock antidepressant medication. I supposed that is a weakness in me, one of a long list. I hate to think the benefits of antidepressants are nothing more than wishful thinking. I know talk therapy is wishful thinking for me. Literally “wishful thinking.”
---------------------------------I think that there is a large pool of people taking ADs that don't need them, and their input is skewing the results in such a fashion.
Drugs definately affect the brain. Drink a beer or drop some acid, and you'll be convinced. The effects aren't placebo. The issue isn't about drugs, then, but about specific causation. SSRIs have an effect on the brain, but is that effect to make us less depressed? I guess it's possible that people are primed by the purpose of the drugs to interpret the effects it has as "happiness" when they're actually less specific. It raises a chicken and egg situation, though, as to why they came to be valued as antidepressants to begin with. The first ADs were discovered accidentally, when patients at a VA hospital began reporting that the drugs they were being given for tuberculosis (an MAOI), were making some happier. Obviously, no one had lead them to anticipate this.
It's also obvious to me that ceratin ADs seem to have no more effect on mood than a placebo, owing to a person's unique chemistry. That doesn't degrade the value the drug has to someone else, who actually benefits from it.
Ultimately, though, if all we had were effective placebos, they'd still be of more value than nothing.
Posted by MattDDS on September 24, 2002, at 13:27:59
In reply to Re: Antidepressants versus placebo smackdown!, posted by Eddie Sylvano on September 24, 2002, at 10:30:42
This is an interesting article. It has mirrored my experience with antidepressants,
namely, that I get ZERO response (other than annoying side effects).I don't understand why this is such an emotional issue for many people who are advocates
of antidepressants. It is almost like people defend the virtues of AD's with a religious
zeal! Personally, I am for whatever works. I really look forward to the day that we
do have an effective chemical (or other biological) treatment for depression.
Unfortunately, I do not believe that day has arrived. I definitely do not believe that the
answer lies in increasing brain serotonin (or monoamines, for that matter). We already
have a plethora of drugs that do this, and yet people are still depressed.Placebos consistently yield a 30-50% response! Antidepressants give maybe a 65-70% response
on average. In clinical trials, it has been shown that clinicians, as well as subjects, can
usually determine who is getting what treatment (the side effects give it away), and this
could potentially "unblind" the study. Why don't drug companies use active placebos, like
an antihistamine or something? Would you, if you were the CEO of a drug company, and your
livelihood depended on your drug working? I bet not. Anyway, I think this "unblinding"
effect could account for the (minute) difference between placebo and antidepressant.
Eddie says that effective placebo treatment is better than nothing. I politely disagree for
a number of reasons. I believe science is our ally. If we as consumers continue to take
medications that are not much more effective than placebos, then the drug companies will
have no reason to research out better treatments. Also, if placebos are as effective as
current antidepressants, why not just take a placebo with zero side effects: SUGAR!
Likewise, if antidepressants exert their action through "wishful thinking", why not just
work directly on the wishful thinking through the better researched forms of psychotherapy
(e.g. CBT)? The prices of these "effective placebos" are also outrageous! I have better
things to do with my money than spend it on drugs that are only marginally, ifat all,
better than placebo.Please don't interpret this as being "anti-meds". I am a huge advocate of brain and pharm
research. I am just not personally convinced that current AD's are that effective. I think
we as consumers should make informed decisions. If not, then we will see "more of the same",
as we have recently seen with Lexapro. Does anyone else think we really need another SSRI?Matt
Posted by Eddie Sylvano on September 24, 2002, at 13:58:40
In reply to Re: Antidepressants versus placebo smackdown!, posted by MattDDS on September 24, 2002, at 13:27:59
> I don't understand why this is such an emotional issue for many people who are advocates
> of antidepressants. It is almost like people defend the virtues of AD's with a religious
> zeal!
-------------------------I don't know that people are defending the drugs because they believe that deeply in them. They're pretty hit-and-miss right now, admittedly (as are most drugs). The fact that they do save some people's lives is probably why there's such support for them from certain people. My grandma uses a walker to shuffle around, but I'm sure she'd welcome a cane, or even a decent stick in lieu of nothing.
To say that current meds are useful isn't a sign of resignation to the current state of affairs, though. Every product sold is usually in a continual state of refinement, from drugs to televisions. As long as one company can make a better one than the others, progress will continue. Personally, most of the drugs I've had haven't been great, but they've gotten me out of a rut, and I'll take that.
You make a strong point for those who get no effect (at least good ones) from current medications. Taking useless meds is only going to make these people leery of psych meds altogether. Pdocs need to do their homework when prescribing.
Posted by MattDDS on September 24, 2002, at 14:32:29
In reply to Re: Antidepressants versus placebo smackdown!, posted by Eddie Sylvano on September 24, 2002, at 13:58:40
Eddie,
You make some good points. I think we are in agreement about most things. I was not minimizing the positive effects meds have had on some people's lives. That's great! If AD's work for someone, then by all means, take them!
I am simply saying that I am personally not convinced they are much, if at all, more effective than placebos, that's all.
Let's suppose, hypothetically, that a drug company scandalously marketed sugar pills as a powerful antidepressant. According to previous studies, approximately 30-50% of people would respond. If 1,000,000 people took the "drug", that would mean 300,000-500,000 people would respond! Imagine all the success stories you would hear! For many people, this sugar would have been "life saving" as you put it! Still, it would not change the fact that it is simply sugar.
So we are left with an ethical dilemma. Do we "pull the rug" out from underneath these poor people's feet and tell them they only were taking sugar? Or let them continue to take it and not inform them?
Personally, I think science is our ally! If we know that a particular treatment is not effective, then we can move on to develop better ones. That is why I am saying we should be better, more informed consumers. You say that antidepressants are in a state of development, much as are televisions and electronics. The only problem I have with that is that, over the last 40 years, we have not made much progress, if at all! Many people feel that the older AD's such as MAOI's and TCA's are more effective at treating depression than the SSRI's. You could argue that SSRI's are more tolerable as far as side effects, but this is definitely debatable. SSRI's were a miserable experience for me, SE-wise.
I expect to get a lot of flak for this. But I hope I am not misunderstood. All I am saying is that I have serious doubts about the efficacy of current antidepressants. But again, if something is working for you, GREAT!
Take care,
Matt
Posted by Anyuser on September 24, 2002, at 14:49:39
In reply to Antidepressants versus placebo smackdown!, posted by Anyuser on September 24, 2002, at 9:49:24
It is impossible for me to reconcile the thought that antidepressants give only placebo benefit with other things we "know" about about antidepressants. Such as, the side effects of ADs kick in right away, while the benefits kick in after weeks. If the benefits were placebo, wouldn't they kick in right away, witht the side effects?
Posted by Eddie Sylvano on September 24, 2002, at 14:56:49
In reply to Re: Antidepressants versus placebo smackdown! » Eddie Sylvano, posted by MattDDS on September 24, 2002, at 14:32:29
>The only problem I have with that is that, over the last 40 years, we have not made much progress, if at all! Many people feel that the older AD's such as MAOI's and TCA's are more effective at treating depression than the SSRI's.
-----------------------------It's true, and it makes me wonder if this trend is due to the growing overhead placed on drug development by litigation. I'm sure that if the typical pharmaceutical company discovered MAOIs (or aspirin, for that matter) today, they'd junk it for fear of lawsuits.
If Pfizer could make an antidepressant that cured 90% of the users, but injured or killed .01% of the users, they'd still make more money off of a moderately effective drug that didn't damage anyone. The public's demand for absolute safety (and jury punishments for failure) effectively limit the feasible drug choices companies have.
I hope that we see a change in the near future, with drugs being intelligently designed to have a specific mode of action, on a well understood receptor, instead of our current shotgun approach (screw with all the receptors in a class, and maybe a few other things).
Actually, it's quite feasible that some disorders may be beyond ever addressing by specific medications. Nobody really knows right now.
Posted by MattDDS on September 24, 2002, at 15:25:22
In reply to Re: Antidepressants versus placebo smackdown! » MattDDS, posted by Eddie Sylvano on September 24, 2002, at 14:56:49
>>Actually, it's quite feasible that some disorders may be beyond ever addressing by specific medications. Nobody really knows right now.
I think you've hit the nail right on the head. I agree, depression is likely to be much too complicated to fix by simply "crankin' up the serotonin".
I think of the brain as an electrical system, not a chemical system. The problem, I surmise, will more likely turn out to be "software" problem, rather than a "hardware" problem. This is, of course, speculation. As you say, it is just too early to say.
I do believe that some good has come from antidepressants. Namely, it has given us a starting point to do brain research, as well as sparked interest (financial as well as scientific) in the topic.
Posted by MattDDS on September 24, 2002, at 15:41:58
In reply to Re: Antidepressants versus placebo smackdown!, posted by Anyuser on September 24, 2002, at 14:49:39
>>It is impossible for me to reconcile the thought that antidepressants give only placebo benefit with other things we "know" about about antidepressants. Such as, the side effects of ADs kick in right away, while the benefits kick in after weeks. If the benefits were placebo, wouldn't they kick in right away, witht the side effects?
This is a good question. I have actually thought about this myself. Unfortunately, I don't have an answer. Neither, I imagine, does anyone else.
However, it appears you may be getting caught up in a thinking error. It does not logically follow that antidepressants are therefore effective simply because they have an unexplained delayed onset of action. Personally I don't see how this relates to the issue of their efficacy. Namely, that they fail to perform much better than placebos. Typical studies report that placebo effect accounts for over 75% of antidepressant efficacy. This is miniscule! Especially if one considers that this "statistically significant" difference could be due to the unblinding effects of clinical trials that we were discussing. I would love to see Pfizer or Lilly do an AD trial against diphenhydramine. Of course, they would not pay for it! We have to remember that drug companies, though not demonic and evil as some have portrayed, are human and have strongly vested financial interests which may bias clinical trials. Did you read about the "filing effect" in the article you posted?
Keep in mind I am not talking about **personal** efficacy, as I cannot argue whether they have been effective for one person in particular. Antidepressants can be effective for certain people, as can placebos. Unfortunately, we can only study effects of antidepressants on groups.
Posted by crepuscular on September 25, 2002, at 12:37:40
In reply to Antidepressants versus placebo smackdown!, posted by Anyuser on September 24, 2002, at 9:49:24
I challenge the naysayers to suck down 40mg of prozac for 2 months straight and tell me they feel like the same person...
Posted by MattDDS on September 25, 2002, at 13:12:32
In reply to Re: Antidepressants versus placebo smackdown!, posted by crepuscular on September 25, 2002, at 12:37:40
Crepuscular,
Actually, I have “sucked down” all different types of antidepressants: Every member of the SSRI family, TCAs, Serzone, Remeron, Wellbutrin. All of these at therapeutic doses for adequate lengths.
You are right, I did feel different. I was sexually numb, irritable, had worsened insomnia, and was depersonalized. But in terms of antidepressant effects, my depression did not budge. You seem to think I’m just talking out my ass here but I’m not. I am a veteran at this stuff. Of course, the fact that I personally did not respond is meaningless in terms of statistics. But that was never my point.
My point is this: Even looking at the manufacturers best studies (BTW, they only release the very best studies, the rest are suppressed, this has been termed the “filing effect”), the difference between placebo and antidepressant is not very large at all! In fact, in many studies (again, which never seem to get published) there is no difference at all!
I really don’t mean to sound pessimistic, but I’m just stating my opinion as I see things. If I believed there existed an effective antidepressant, I would have no problem whatsoever taking it. Hell, if we find one, let’s put it in the public water next to fluoride! Neither am I not saying they are dangerous (as extremists like Breggin might say), as there is no evidence that points this way. The main question I am raising is this: EFFICACY! That’s all!
I think you may be missing my point.
Matt
Posted by waterlily on September 26, 2002, at 13:47:39
In reply to Antidepressants versus placebo smackdown!, posted by Anyuser on September 24, 2002, at 9:49:24
I feel the same way as you. I guess it's the implication that I don't really need the medication, that the whole condition is my imagination. I can also take it to mean that if only I had the mental muscle, I could make myself better.
I've had great success with both Zoloft and Wellbutrin. I've been on Wellbutrin for five years and have tried about three times to get off the antidepressant, each time going into it with a very positive attitude and each time experiencing another major depressive episode before I was completely off the medication. I've also had major flops when starting other medications, each time fully expecting them to work.
I think I'm just going to say that for myself, medication is effective and needed and that opinion is shared by my therapist and pdoc. To heck with what the studies show. They didn't study me anyway.
>
> For whatever reason, I am always deeply discouraged when the advocates of talk therapy knock antidepressant medication. I supposed that is a weakness in me, one of a long list. I hate to think the benefits of antidepressants are nothing more than wishful thinking. I know talk therapy is wishful thinking for me. Literally “wishful thinking.”
>
> What do you think about this debate?
>
Posted by Mr. SadPuppyDog on September 27, 2002, at 11:32:52
In reply to Antidepressants versus placebo smackdown!, posted by Anyuser on September 24, 2002, at 9:49:24
The biggest problem with antidepressant drug clinical trials in the USA is the fact that new ADs are not tested on those with "severe" depression. Most of the people recruited into antidepressant clinical trials are those with mild depression (dysthymia) to moderate depression. Those with severe depression, such as those with melancholia features such as severe insomnia, losing large amounts of weight, severe loss of sex drive and function and severe cognitive decline are generally avoided in AD drug trials.
This leads to the so called "placebo" effect which many in the mental health field constantly talk about. Since many with mild to moderate depression arent really depressed in the TRUE sense of the word, they get a few side effects and get disgusted and quit. Or there depression is so mild, so about anything makes them "undepressed."
We'd read and hear much less about the antidepressant "placebo" response if more AD drug trials purposely recruited those with severe depressions. I also believe that many of the current drugs wouldnt even be FDA approved if these drugs were held up to the higher standards of creating a full remission in those with severe depression.
Such talk however is a pipe dream pretty much though, as the drug companies realize that there are many more with mild to moderate depression...thus a bigger market for antidepressants in this demographic area. So we end up with SSRIs that dont work good for severe depression and other "me too" drugs, like Lexapro which are about useless for anything other than dysthymia.
The placebo effect is a lie and frankly, Im sick of reading about it.
Mr. Sad PuppyDog
Posted by Dr. Bob on September 27, 2002, at 19:26:37
In reply to Re: Antidepressants versus placebo smackdown!, posted by Mr. SadPuppyDog on September 27, 2002, at 11:32:52
> Since many with mild to moderate depression arent really depressed in the TRUE sense of the word...
Please be sensitive to the feelings of others and don't post anything that could lead them to feel their experiences have been put down.
> The placebo effect is a lie and frankly, Im sick of reading about it.
Please also avoid overgeneralizing and posting anything unsupportive.
Bob
PS: Follow-ups regarding posting policies, and complaints about posts, should be redirected to Psycho-Babble Administration, thanks.
Posted by BrittPark on September 27, 2002, at 21:01:24
In reply to Re: Antidepressants versus placebo smackdown!, posted by Mr. SadPuppyDog on September 27, 2002, at 11:32:52
> The biggest problem with antidepressant drug clinical trials in the USA is the fact that new ADs are not tested on those with "severe" depression. Most of the people recruited into antidepressant clinical trials are those with mild depression (dysthymia) to moderate depression. Those with severe depression, such as those with melancholia features such as severe insomnia, losing large amounts of weight, severe loss of sex drive and function and severe cognitive decline are generally avoided in AD drug trials.
>
> This leads to the so called "placebo" effect which many in the mental health field constantly talk about. Since many with mild to moderate depression arent really depressed in the TRUE sense of the word, they get a few side effects and get disgusted and quit. Or there depression is so mild, so about anything makes them "undepressed."
>
> We'd read and hear much less about the antidepressant "placebo" response if more AD drug trials purposely recruited those with severe depressions. I also believe that many of the current drugs wouldnt even be FDA approved if these drugs were held up to the higher standards of creating a full remission in those with severe depression.
>
> Such talk however is a pipe dream pretty much though, as the drug companies realize that there are many more with mild to moderate depression...thus a bigger market for antidepressants in this demographic area. So we end up with SSRIs that dont work good for severe depression and other "me too" drugs, like Lexapro which are about useless for anything other than dysthymia.
>
> The placebo effect is a lie and frankly, Im sick of reading about it.
>
>
> Mr. Sad PuppyDog
I think you are right about a number of things in what you've said, but have come to the wrong conclusion. Clinical studies of AD effectiveness do tend to attract less severely depressed patients but it's not all the researchers' fault. Clinical studies are self-selecting. If you were suffering a crippling episode of depression would you take part in a clinical study? Most people would not; they'd rather see a psychiatrist and get the best possible treatment rather than risk being in the placebo group.There are instances of studies in which severely depressed patients have been the subjects. (I can't give you citations off the top of my head.) In these studies the difference between placebo and drug (if its a good drug) have been greater, and the response to medication has been greater in terms of reduction in HAM-D etc. One study in particular compared severely depressed patients on ADs (probably an SSRI), Cognitive Behavioral Therapy, and placebo, and found that CBT was statistically no better than placebo while ADs were significantly better than placebo. (I don't intend to diss CBT. It has it's place and has been shown to be effective for milder depressions.) So I think I disagree with your conclusion that most AD are not effective. I think most ADs are more effective than many of the clinical studies would suggest.
This is the end of the thread.
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