If the trials are flawed, it is incumbent upon scientists to design better experiments. Although anti-depressants are largely experienced as helpful by the people who take them, the same can be said for crystal therapy and aura-combing. What separates science from pseudo-science is evidence and good theory about causal pathways. We must be especially careful to recognize and report research findings that go against monetary interests because there are huge forces that work against publication of these findings. As scientists, we are obligated to recognize this evidence that suggests that (often extremely expensive) antidepressant medications are no more helpful than placebo to people who are not severely depressed, even if it goes against reported experience. We are obligated also to recognize that these medications may mean the difference between life and death to someone who is severely depressed. Finally, the placebo effect is important and psychologists are best-suited to discovering the most effective active ingredients of placebo treatments, which are highly beneficial and often safe and cost-effective.
Wendi K. Born, Ph.D. Licensed Clinical Psychologist & Assistant Professor of Psychology Baker University 618 8th Street PO Box 65 Baldwin City, KS 66006-0065 -----Original Message----- From: Allen Esterson [mailto:[email protected]] Sent: Tuesday, February 09, 2010 6:52 AM To: Teaching in the Psychological Sciences (TIPS) Subject: Re: [tips] Newsweek's Begley bashes antidepressants ?Mike Palij's 8 February post (below) on antidepressants raises a number of interesting issues, few (if any) of which TIPSters are likely to have the expertise to do more than discuss in general terms, e.g., the problems with meta-analyses of studies. Here are a few more items to throw into the mix. The recent study by Fournier et al (2010) published in JAMA concludes: "The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial." http://jama.ama-assn.org/cgi/content/short/303/1/47 An article in Psychiatry Times discussing the Newsweek Sharon Begley article notes that on the basis of Fournier et al's conclusions as reported by Begley: "Begley acknowledges the benefit of antidepressants in severely depressed patients, but minimizes its importance, noting that only 13% of patients meet this severity threshold. But based on a 2004 SAMHSA study,4 “only” 13% means that about 2 million adults in the United States may suffer from severe depression in a given year. http://www.psychiatrictimes.com/display/article/10168/1520550?verify=0 There is a perceptive discussion of Fournier et al (2010) on the Neuroskeptic blog, well worth reading: http://neuroskeptic.blogspot.com/2010/01/severe-warning-for-psychiatry.html Neuroskeptic also raises the question of how realistic drug trials are in relation to real-life patients: http://neuroskeptic.blogspot.com/2009/04/antidepressants-clinical-trials-versus.html On this issue, see Wisniewski et al (2009): http://ajp.psychiatryonline.org/cgi/content/abstract/166/5/599 One more item to add to the pot. Efficacy studies by their nature do not encompass the fact that if one type of anti-depressant does not work, it is likely that another may be prescribed. A study by A. John Rush et al (2006) published in the New England Journal of Medicine concludes that "After unsuccessful treatment with an SSRI, approximately one in four patients had a remission of symptoms after switching to another antidepressant." http://content.nejm.org/cgi/content/abstract/354/12/1231 It should be evident that there are no simple answers to any of these issues. Allen Esterson Former lecturer, Science Department Southwark College, London http://www.esterson.org ------------------------------------------------------------ Re: [tips] Newsweek's Begley bashes antidepressants Mike Palij Mon, 08 Feb 2010 09:11:32 -0800 I just want to make a few points about issues regarding the use of antidepressants and Begley's presentation: (1) Although some may take issue with Begley's style or choice of words, if one gave the article to a group of students and asked them to locate research on the key points of her arguments in PsycInfo and Medline, one would find literature on both sides but with a growing consensus that there are problems with the "monoamine" hypothesis as it has been traditionally conceived as well as maintained by some (remember, up to his death Skinner believed that cognitive science and neural science were frauds -- there a folks like Skinner who hold on to old beliefs/positions even when it it no longer fruitful to do so). One of the key issues when it comes to the use of SSRIs is how do they produce a therapeutic effects? I do not have a reference handy but I distinctly remember reading/hearing that the major structural changes caused by SSRIs occur within 72 hours of initiation of drug treatment. The problem with this is that most people, if they show a positive response to SSRIs, do not do so until 4-6 weeks after drug treatment was initiated. One interpretation of this is that whatever effect SSRI or SNRI or other current antidepressants are providing, it is likely affecting some other system in the brain. This is one reason why researchers are looking at the role of Substance P, neurosteroids, and other brain chemicals in depression. That is, SSRI/SNRI/etc feed into a process that corrects whatever the neurochemical imbalance or sturctural abnormality that produced depression but it is not because it simply increases the amount of a neurotransmitter. One might be able to short-circuit the process by providing drug that affect the more fundamental processes. One article that articulates a view like this is has its abstract available on www.pubmed.gov ; see: Sümegi A. [Domino principle--monoamines in bottom-view] Neuropsychopharmacol Hung. 2008 Jun;10(3):131-40. Review. Hungarian. Erratum in: Neuropsychopharmacol Hung. 2009 Sep;11(3):149. PMID: 18956617 [PubMed - indexed for MEDLINE] (2) Kirsh is not the only one to raise questions about the effectiveness of antidepressants. Begley refers to a recent meta-analysis in the Journal of the American Medical Association (JAMA) that examined the response of individual persons to antidepressant relative to placebo and showed that only the most severely depressed people benefit from antidepressants. The reference and abstract are provided below: |Fournier JC, DeRubeis RJ, Hollon SD, Dimidjian S, Amsterdam JD, Shelton RC, |Fawcett J. Department of Psychology, University of Pennsylvania, |3720 Walnut St, Philadelphia, PA 19104, USA. [email protected] | |Antidepressant drug effects and depression severity: a patient-level meta-analysis. | |JAMA. 2010 Jan 6;303(1):47-53. | |CONTEXT: Antidepressant medications represent the best established |treatment for major depressive disorder, but there is little evidence that |they have a specific pharmacological effect relative to pill placebo for |patients with less severe depression. | |OBJECTIVE: To estimate the relative benefit of medication vs placebo |across a wide range of initial symptom severity in patients diagnosed |with depression. | |DATA SOURCES: PubMed, PsycINFO, and the Cochrane Library |databases were searched from January 1980 through March 2009, along |with references from meta-analyses and reviews. | |STUDY SELECTION: Randomized placebo-controlled trials of antidepressants |approved by the Food and Drug Administration in the treatment of major or |minor depressive disorder were selected. Studies were included if their |authors provided the requisite original data, they comprised adult outpatients, |they included a medication vs placebo comparison for at least 6 weeks, |they did not exclude patients on the basis of a placebo washout period, |and they used the Hamilton Depression Rating Scale (HDRS). Data |from 6 studies (718 patients) were included. | |DATA EXTRACTION: Individual patient-level data were obtained from |study authors. | |RESULTS: Medication vs placebo differences varied substantially as a |function of baseline severity. Among patients with HDRS scores below 23, |Cohen d effect sizes for the difference between medication and placebo |were estimated to be less than 0.20 (a standard definition of a small effect). |Estimates of the magnitude of the superiority of medication over placebo |increased with increases in baseline depression severity and crossed the |threshold defined by the National Institute for Clinical Excellence for a |clinically significant difference at a baseline HDRS score of 25. | |CONCLUSIONS: The magnitude of benefit of antidepressant medication |compared with placebo increases with severity of depression symptoms |and may be minimal or nonexistent, on average, in patients with mild or |moderate symptoms. For patients with very severe depression, the benefit |of medications over placebo is substantial. |PMID: 20051569 [PubMed - indexed for MEDLINE] Given that no meta-analysis (or research) is perfect, there are likely to be some questions about the study (e.g., is it limited to the antidepressant used in the study or are the conclusions applicable to all antidepressants?). One implication of a study like this is that non-psychiatrists will probably reduce the number of antidepressant prescriptions they write and refer the more severe cases of depression to psychiatrists or clinical psychologists. (3) There are many issues raised in the Begley article such as: (a) how do we really know if a drug is effective for a condition especially if the drug company sponsors most of the research involving that drug and can refuse to publish or make public research results for maintaining "trade secrests"? (b) one should remember that theories are tentative explanations for phenomena and given that not all relevant observations can be made or all relevant cases tested, there is a probability that several errors of inference will be made -- additional research may show the flaws in currently held theories which should lead to their modification or replacement with a theory that more adequately explains and interperts the facts. Does mental illness, specifically depression, have a biological component? Quite likely but we are far from adequately understanding what it is -- or even if understanding it is necessary to effectively treat a condition (e.g., the use of cognitive therapy along to treat depression). I suspect that these issues may be more factually and forcefully argued on the clinical psychology research mailing lists and discussion groups, but I think that those discussion may mirror what has been said on TiPS. Mike Palij New York University [email protected] --- You are currently subscribed to tips as: [email protected]. To unsubscribe click here: http://fsulist.frostburg.edu/u?id=13550.98f958ee1bb503e1fba9c90574ecbdb8&n=T&l=tips&o=455 or send a blank email to leave-455-13550.98f958ee1bb503e1fba9c90574ecb...@fsulist.frostburg.edu The information contained in this e-mail and any attachments thereto ("e-mail") is sent by Baker University ("BU") and is intended to be confidential and for the use of only the individual or entity named above. The information may be protected by federal and state privacy and disclosures acts or other legal rules. If the reader of this message is not the intended recipient, you are notified that retention, dissemination, distribution or copying of this e-mail is strictly prohibited. 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