Antidepressants are some of the most-prescribed drugs in the world. Yet they are also amongst the least well understood. We know little about how effective antidepressants are in the people who take them. Some antidepressants may work fantastically for most people. On the other hand some of them, perhaps all of them, may be useless or even worse. The truth is unclear.
This is a minority view. Opinions about antidepressants are polarized - most people either firmly believe that they do work, or firmly believe that they don't. Yet neither of these positions seems to me to be supported by the evidence available. I don't think that anyone ought to firmly believe anything about these drugs - except that better research is urgently needed.Another placebo meta-analysis
The issue is not a lack of studies. After fifty years of research, and untold millions of research dollars, there are hundreds of published clinical trials of antidepressants. It's when you try to make sense of the results of this great mass of trials that the problems become apparent. The latest attempt to do that is a paper from a German-American collaboration, Rief et. al.'s Meta-analysis of the placebo response in antidepressant trials. The authors set out to
Determine overall effect sizes of placebo and drug effects in antidepressant trialsIn other words, they wanted to find out how much people improve when given antidepressants, and how much of that improvement is due to the placebo effect. They had plenty of data to work with. Even after discarding hundreds of trials for being too small or otherwise unsuitable:
The final sample consisted of 96 trials that reported sufficient data to compute effect sizes. The placebo groups of these studies comprised 9566 people. Approximately half of the studies were published after 1996, 68% were conducted in the United States, and the mean sample size was 86 participants.And this is what they found after crunching the numbers:
The overall effect size [Cohen's d] of the placebo effect was 1.69 (95% CI=1.54–1.85), as compared to d=2.50 (95% CI=2.30–2.69) in the drug group. The ratio of the effect sizes suggests that 67.6% of the improvements in the drug group were attributable to the placebo effect [i.e. because 1.69 is 67.6% of 2.50].That seems like a nice, neat and tidy result. When you give depressed people antidepressants, they get loads better (a standardized effect size of 2.50 is enormous), but most of that enormous improvement is due to the "placebo effect". However, the truth is not quite so neat.
It's a Little Bit More Complicated Than That
1. First off, none of the studies included in this analysis measured the placebo effect. The "placebo effect" is supposed to be the power of treatments to make people get better purely through making them expect to get better. It's certainly plausible that there could be big placebo effects in depression. There is plenty of anecdotal evidence that it happens.
In these studies, patients took either antidepressant pills or sugar pills. The patients given sugar pills were assessed as having got a lot better, on average. Is that evidence for the placebo effect? No, because as I've explained before, the improvement reported in the placebo group could be huge even if there were no "placebo effect" at all. The patients might have just got better spontaneously, because people who are depressed do tend to get better with time. It might have been that old chesnut, regression to the mean. Or maybe the patients only seemed to get better on average because the ones who didn't get better dropped out of the trial.
According to a meta-analysis of trials which actually did examine the placebo effect - by comparing people given placebos to people who got no treatment at all - the placebo effect in depression is at best small (Hrobjartsson & Gøtzsche 2004). However, the authors of this paper are well known for being very skeptical of placebos, and the number and quality of the trials was very low. There were 7 trials with a total of 258 patients. That's it. The only reasonable view is that we just don't know how powerful placebos are in depression.
2. Rief et. al. found that the size of the effects of antidepressants and placebos was much bigger when using "observer-rating" to measure the severity of depression, as compared to when patients rated their own symptoms. The difference between the two types of rating scale was enormous, dwarfing the drug vs. placebo difference:
In the placebo groups, there was a substantial difference between effect sizes for improvements rated by observers (d=1.85; 95% CI=1.69–2.01; 93 studies) compared to those rated by patients (d=0.67; 95% CI=0.49–0.85; 28 studies)...The difference between self-ratings and observer ratings was also found in the drug groups (self-rating d=1.12 versus observer rating d=2.89).What does this mean? It could mean that psychiatrists tend to exaggerate small changes in their patients' depression. But it could mean that depression renders people unable to notice their own improvement. Perhaps the commonly used self-rating questionnaires, like the BDI, are just not very good at measuring depression, while observer rating scales, like the HAMD, are better. On the other hand it could be that self-rating scales are better, and observer-rating scales tend to exaggerate changes. Or...
Any or all of these could be true. Speaking as both a sufferer from depression and as a trained depression observer (I use the HAMD for research), I can confidently say that rating depression is one of the hardest things I ever have to do. Monitoring my own ups and downs, let alone putting a number on them, is extremely difficult. Trying to put a number on the mood of a patient who I've only known for an hour is even harder.
Poets and novelists struggle mightily to capture the purely qualitative aspects of our emotions. The idea that some guy reading a list off a printed list of questions could succeed at putting a number on a stranger's wellbeing in 5 minutes seems faintly absurd.
3. The results of this meta-analysis are much more favorable to antidepressants than was the analysis of Irving Kirsch et. al. (2008), Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration. This was the (in)famous paper that everyone in the media thought proved that "Prozac doesn't work".Poets and novelists struggle mightily to capture the purely qualitative aspects of our emotions. The idea that some guy reading a list off a printed list of questions could succeed at putting a number on a stranger's wellbeing in 5 minutes seems faintly absurd.
Kirsch et. al. reported an average difference between the drug improvement and the placebo improvement of d=0.32, as against d=0.81 in this study. Conventionally, a standardized effect size d of 0.3 would be called "small" while 0.8 would be called "large". So this is a big difference. Why?
Again, there are plenty of possible reasons. Kirsch et. al. included fewer trials - only 35 -and only considered "newer" antidepressants. Rief et. al. included trials of older drugs. Kirsch et. al. included unpublished drug company data; Rief. et. al. only included published trials, meaning that publication bias could have been a problem (although they say that there is no evidence it was.)
Differences in the statistical techniques used could also explain it. As a series of outstanding posts by P J Leonard and Robert Waldmann last year showed, there were serious problems with the Kirsch et. al. analysis; these are too technical to go into here but suffice it to say that if the authors of this analysis had chosen to use Kirsch et. al.'s methods they might have reached very different conclusions.
4. The most important message of Rief et. al.'s analysis is also the simplest. There are vast differences between trials in terms of what happened to the patients.
This is a plot of the degree of improvement experienced by patients in the placebo group in each trial. The average improvement ranges from zero to huge. In addition, more recently published trials tended to find greater improvements. Yet all of these patients were given the exact same thing - sugar pills. (This is not a new finding.)Clearly, something is seriously wrong here. People suffering from the same disease given the same treatment should show similar responses. The most likely explanation is that these groups of people were not all suffering from the same disease. The diagnosis of "major depression" is increasingly seen as problematic; almost certainly there is in fact no single disease called "depression" at all. Yet every antidepressant clinical trial operates under the assumption that there is one.
Given this, it's no wonder that antidepressants, and placebos, give such wildly different results in different trials. The wonder, perhaps, is that we are still conducting such trials without first establishing what exactly we think clinical depression is and how best to measure it.
[BPSDB]
Winfried Rief, Yvonne Nestoriuc, Sarah Weiss, Eva Welzel, Arthur J. Barsky, Stefan G. Hofmann (2009). Meta-analysis of the placebo response in antidepressant trials Journal of Affective Disorders DOI: 10.1016/j.jad.2009.01.029
30 comments:
hi, i'm a newbie to this subject, but i was wondering what your (and other experts') thoughts on using the MMPI to measure depression would be. since it's empirical derived, and has established reliability/validity, wouldn't it be a good measure?
I'm no scientist and the only data I have to go on is my own self and medication, but I'd have to say that it's not the placebo effect in my case. Being both depressed and ADD means that I sometimes forget to take meds. I could literally completely not remember if I had taken them that day. But my wife notices if I don't take them, just by my behaviour.
How I would love to have a simple test for depression, like diabetics have for BGL. Prick, beep, oh, my depression index is up today, better increase my med! As you said, it is soooo hard to measure depression and the results are so subjective that it makes it difficult not only to study, but to live with.
I do find it odd that people suffering from depression are invited in trials to monitor their own levels of happiness. Surely this encourages introspection and exacerbates the condition? Would love to see a trial where the impact of self-assessment itself is examined.
ben g: I've got no experience with the MMPI - I think it's rarely used in the UK. The fact that it's empirically derived would make it one step ahead of the commonly-used scales, though...
Beacon: Self-rating scales are quite rare in trials actually. "Observer rating" is more often used - but what this means in practice is almost the same thing because the observer makes his rating based on asking the patient questions about his depression. Which, depending upon how it's done, could be quite upsetting...
As CyberLizard says, often the best judges of changes in our behaviour are other people who know us well. It would be interesting to develop a depression rating scale designed for use by partners, coworkers, parents, etc. I'm not aware of any...
Thanks for the link
As usual, a very interesting article; thank you.
I do have a suggestion however (which I'm sure can be easily dismissed!):
"Clearly, something is seriously wrong here. People suffering from the same disease given the same treatment should show similar responses. The most likely explanation is that these groups of people were not all suffering from the same disease"
I do not see why we should assume that this is the case. I think it is pretty well established that the placebo effect differs in a consistent manner. The stronger the patient believes the drug is, the more profound the placebo effect. So patients given sugar-morphine experience a stronger placebo effect than those given sugar-paracetamol. Given this, could the individual differences not be explained by the individual's pre-existing attitude towards anti-depressants (you say yourself in the article that people range from very sceptical to complete acceptance)? Consistent changes between trials could be explained by the group administering the drug (because we can assume that those dispensing the drugs have similarly mixed beliefs) and consistent changes over time may demonstrate changes in widespread perception (i.e. a general belief that newer antidepressants are better). I am not saying that I believe this is the case, I am just saying that, perhaps, there are equally plausible options which don't require conspiracy theories or an eternal regression into biology alone, at the expense of societal factors.
G.
That's an excellent point, G.
It makes sense that if people differ in their expectation of improvement the placebo effect will differ. That probably does explain some of the variance here.
Also, I didn't mention that these trials differed in their duration, and longer trials are likely to report greater improvements than others. That could account for some of it too.
The truth is we don't know, but speaking as someone who knows how difficult the diagnosis of depression is, personally I think differing patient characteristics are probably the main culprit. But that's just my judgment. Ultimately, we don't know. That in itself is probably the main lesson here...
Fascinating article, and enough links to keep me wandering for hours. I love it! I've had similar thoughts as a psychology student. The distinction between a placebo effect and a regression to the mean is important. And the possibility that there are many causes of depression in the brain causing a slightly different constellation of symptoms should be taken seriously, and it may help explain why some patients will only respond to certain drug treatments and not others.
Quick nit-pick: "et. al." should be "et al." The word "et" is a complete Latin word, not an abbreviation, though "al." is an abbreviation, so should have the period.
Thanks, D. B. And nitpicks are always appreciated!
Thanks for a very balanced and thoughtful post on a difficult subject matter.
I am going to point people in your direction for a good view of the subject.
Nice analysis. I have never considered (or saw for that matter )an antidepressant, placebo, no treatment study. That would be a much better way of determining effect sizes of respective treatments (or lack thereof). I know many psychotherapy research studies use a wait-list as a control (which I think is a poor placebo. As it turns out, people who know they will eventually receive a treatment, tend to improve to a certain degree degree. I also appreciate all your comments on my blog as well. They're well thought out.
Thanks - I appreciate that.
My dream antidepressant trial would have at least 4 arms : antidepressant, placebo, no treatment, and an active placebo with psychotropic effects which is not considered to have mood effects. But it shouldn't make you feel worse, either. propranolol or a low dose benzo might work. Or a mild stimulant like ephedrine.
It would be long - at least a year - patients would be recruited from those seeking treatment for depression in primary care, there would be no exclusions based on "comorbidity" (except bipolar), and the outcome wouldn't be rated with the HAMD.
I can tell you that antidepressants DO WORK. Lexapro saved my life after my husband of 11 years left me for another woman when our son was only 13 months old. I thought my world had ended and I thought I was going mad. Lexapro allowed me to see things clearly and to handle things rationally. I would not have been able to survive my ordeal without it.
Excellent blog, neuroskeptic. As someone who was treated for three years with various antidepressants and bi-polar meds (usually anti-seizure drugs) by a psychiatrist, plus talk therapy with a psychologist, I am now depression-free. The answer for me was to take 2,000 mg. Omega-3 nightly, increase my aerobic exercise, take no mind-altering drinks or drugs and stop seeing any type of shrink. I have been happy & productive for eight years now and shudder of ever being a guinea pig like that again. It was like living in jello.
It is refreshing to see some *sanity* and honesty regarding the "science" behind anti-Ds. My documentary called GENERATION RX exposes not only the shoddy science, but collusion between FDA officials and Lilly dating back 20-25 years. They covered up the potential for violence and other deadly side-effects which, by all standards, should be considered a crime.
I write about this in my blog here on blogspot as well.
Great job — and thank you.
Kevin P. Miller
Writer/Producer/Director
GENERATION RX
Thanks Kevin, but remember, just because the evidence that something works is shoddy, doesn't mean it doesn't work.
For what it's worth, I take antidepressants, and I'm pretty sure they work, for me at any rate...
In the 1930s, physicians approached the mental illness of depression a bit differently that we do today.
While acknowledging typically the etiology for their patients is likely due to some great misfortune in their individual lives, the physician focused on what was known as a complex.
A complex is the disturbances of ideas and impulses that are the cause of consistent habitual patterns of thought, feelings, and behavior.
An example of this state of mind of one who is depressed is one who experiences an exaggerated or obsessive concern or fear. And the etiology for this mental disorder was often undefined.
People react differently to life stressors in their life, so depression cannot be empirically determined.
Also in the 1930s, at times, behavioral or cognitive therapy was recommended for treating the depressed patient, and not pharmacological treatment, overall.
Also considered for the depressed patient was positive lifestyle changes that may lessen the pain that the depression was causing them.
Try and be grateful, they would tell their patient, as well as thankful and appreciative for whatever good may be in their life, and normally the depressed patient would eventually recover.
Times have changed since then.
Presently, serotonin-enhancing drugs are the therapeutic regimens for those who are suspect of having a depressed state or mood disorder.
Patients believing they have such cognitive issues often ask for such medications. The drugs are known as SSRIs, or SRNIs.
What is remarkable is that the mood disorders which will be discussed are subject to debate that progresses in its intensity as the more of these certain types of drugs are used in others/
Such disorders, presuming they exist at all, have been brought to the attention to so many others through disease awareness campaigns by the makers of these classes of drugs.
So mental flaws claimed to be relieved by SSRI drugs may not be entirely accurate. Disease mongering takes many forms- including front groups wearing a mask.
With depression, the most severe cognitive and behavioral malfunctions are expressed in what is called a major depressive disorder, as well as clinical depression or major depression.
Depression is thought to affect twice as many women than men.
Symptoms of this type of depression, which is the most concerning to health care providers in particular due to its severity, contain several symptoms.
These include decreased or flat affect, decreased interest in activities once enjoyable, self perceptions of worthiness, guilt, regret, helplessness, and hopeless by the sufferer, to name a few of the diagnostic features that may be present with one who has such a major depressive disorder.
The disease has a vexing insistence on staying with the victim for a lengthy period of time- often continuing to progress symptomatically in severity and discomfort.
This disease is very disabling, and cannot be lifted by one’s will, so all health care professionals likely agree that depression is a potentially serious condition with their patients.
Suicidal ideation and attempts are associated with major depression.
Treatment, it appears, is reasonable and necessary for the depressed patient.
These SSRI drugs mentioned earlier are known by some health care providers as third generation anti-depressants. Such drugs, drugs that affect the mind, are called psychotropic medications.
SSRIs also include a few drugs in this class that include the addition of a norepinephrine uptake inhibitor added to the SSRI in one capsule, and these drugs are referred to as SNRI medications.
The combination of two different drugs has made them the top class of prescriptions for those suspected of some type of psychological misalignment.
There are several available SSRIs presently, and a few SRNIs. Both classes of medications are prescribed for similar mental conditions.
Some consider these classes of meds, the serotonin enhancers in these medications, to be the next generation mood enhancers- after the benzodiazepine hype decades ago, which was followed by what were called trycyclic drugs for depression for some time as well, it is believed.
Furthermore, regarding SNRIs, adding the additional agent of norepinepherine is presumed to increase the effectiveness of SSRIs by some, yet not everyone claims relief from these types of drugs included in the SRNI class.
Some Definitions:
Serotonin is a neurotransmitter thought to be associated with mood. The hypothesis was first suggested in the mid 1960s that this neurotransmitter may play a role in moods and emotions in humans. Yet to this day, the serotonin correlation with such behavioral and mental conditions is only theoretical.
In fact, the psychiatrist’s bible, which is known as the DSM, states that the definite etiology of depression remains a mystery and remains unknown with complete certainty. So a chemical imbalance in the brain is not proven to be the cause of mood disorders, it is only suspected as a result of limited scientific evidence.
Diagnosing mental diseases such as depression is based on subjective assessment only, as interpreted by the prescriber, so one can examine the accuracy of such diagnoses.
Then there is Norepinepherine, believed to be a stress hormone, which many believe help those who have such mood disorders as depression.
Basically, with the theory that by adding this hormone, the SSRI will be more efficacious for a patient prescribed such a med, as suggested earlier.
And the depressive state of a patient certainly can be aggravated by another mood disorder at the same time with some patients. Anxiety usually exists with one who has a major depressive disorder.
An objective diagnosis of such a mental condition is rather impossible to assess objectively.
Therefore any diagnosis made for a mental abnormality lacks complete accuracy and assurance.
So such speculated mental illnesses can only be assessed conceptually. As a result, the diagnosis or impression concluded by the patient’s health care provider is dependent on subjective criteria expressed by the suspected patient that is presumed to be not mentally sound.
At times, there have been screening programs that have been used for identifying depressed patients have proven to be largely ineffective.
A social patient history is uncertain and tricky as well, some have said, yet is obtained often from such patients.
There is no objective diagnostic testing for any mental malfunction to validate as to whether or not such a disease is present- just the perception of the health care provider, and survey questions related to a particular mental disorder.
A health care provider has to assess as to whether certain non-verbal or vocalized features are present with a patient in order to conclude confidently that one may have in fact some degree or level of depression or any other mental disorder.
To assess a suspected depressed patient is further complicated by the fact that the exact cause of major depression is unknown.
Research says that there is a strong genetic component to this illness, however.
The diagnosis of depression as well as mood disorders that may exist within patients has increased quite a bit over the past few decades.
Some have asked themselves, as well as others- actually how many people are really and actually depressed, or affected by any other mental disorder?
What is believed is that if one determined to be cognitively impaired from a mental paradigm, then this may be in fact major depression.
If this mental disorder is determined by a health care provider, it is possible that pharmacological therapy may be considered reasonable and necessary, as well as psychotherapy either suggested to be performed with or in place of medicinal therapy.
Studies show that both therapies working together may be of most benefit for the depressive patient, yet it is not a guaranteed protocol for treatment in this way.
It has been reported that around 10percent of the U.S. population will at some point be affected by an episode of what may be a major depressive disorder. This is much greater in number than just a few decades ago.
Perhaps media sources are to blame to some degree for the progressive increase in diagnosing mental disorders by suggesting to the public that they may have such disorders.
So the diagnosis and medicinal treatment have clearly increased in a relatively short period of time in the United States.
Of course, the expansion of those claimed and determined to be depressed does not sadden the makers of these drugs used to treat this mental disorder one bit, it is safe to say.
Some have said that so many more people seek treatment now for what they believe is a major depressive disorder they are experiencing, when in fact it may be possibly intense sadness, perhaps, due to a loss of some sort in their lives.
There is a difference, and health care providers should have the appropriate tools and knowledge to discriminate between the two states of mental conditions.
Sadness is not a medical problem.
Symptoms associated with an unfavorable mental state need to be excessive and chronic to be considered to have in fact the medical problem of a major depressive disorder, as stated by others.
In Time magazine’s June 16th 2008 cover story, it was reported that the military personnel in the Iraq war are pounding down SSRIs often.
Every time there is a new war, there is a new drug, it seems.
Yet the story may illustrate the frequent usage of these types of medications in a variety of different areas for different reasons.
Some reasons may be valid and appropriate, yet others perhaps may not be reasonable for such medicinal therapy.
However, as illustrated in this situation, they appear to be accepted as a treatment option without reservation.
In regards to those pharmaceutical companies who make and market such psychotropic drugs in the manner that their manufacturers do is largely unknown to others, such as with screenings performed essentially by front groups, and so forth.
However, what is known is that the psychiatry specialty, as they often treats and manages depressed patients, is the one specialty that receives the most monetary funding that is paid to them by these certain pharmaceutical companies for ultimately what they hope will be continued and additional support of the psychotropic meds that they currently promote to these doctors.
Needless to say, the desire and the aspect of the pharmaceutical industry clearly is primarily concerned with encouraging as much use out of their products as possible- with both doctors and patients being the route of that increased use they desperately hope will occur.
Regardless, SSRIs and SRNIs are the preferred treatment methods if depression or other mood disorders that are suspected and determined by the health care providers who treat such patients.
Yet these drugs discussed clearly are not the only treatments, medicinally or otherwise, for depression and other related and suspected mental disease states, moods, or disorders.
Patients should be aware of this fact as well as caregivers. And they may not be aware of the options available to them.
For example, tens of millions of prescriptions are written by health care providers for these types of medications for their patients.
These drugs are not inexpensive, either, as it is not unusual for a patient to pay greater than one hundred dollars to have their prescription filled for only a month’s worth of these particular drugs.
Presently, there are about ten different SSRI/SRNI meds available, many of which are now generic, yet essentially, they appear to be similar in regards to their efficacy and adverse events.
The newest one, a SNRI called Pristiq, was approved in 2008, and is believed to be launched as a treatment for menopause.
The first one of these SSRI meds was Prozac, which was available in 1988, and the drug was greatly praised for its ability to transform the lives of those who consumed this medication in the years that followed. Some termed Prozac, ‘the happy pill’.
In addition, as the years went by and more drugs in this class became available, Prozac was the one of preference for many doctors for children. A favorable book was published specifically regarding this medication soon after it became so popular with others.
Furthermore, these meds have received upon request of their makers to the FDA to have additional indications besides depression for these types of drugs they produce and market, and the indications they have received are for some really questionable conditions, such as social phobia and premenstrual syndrome.
Also included with indications that now exist with these types of medications are the quite devastating conditions of what may be mild anxiety and shyness, yet the makers of these drugs consider such patients as having chronic anxiety with severe anxiety disorder, which others have said is rather obsurd.
And it gets worse with the indications received for these types of drugs, which now include Obsessive-Compulsive Disorder, Panic Disorder, Agoraphobia, Post Traumatic Stress Disorder, Bulimia, and any form of stress disorders in general.
I understand they are seeking indications for pain management as well with these SSRI or SRNI pharmaceuticals.
Likely, they will get the indication for their drugs to treat such creative cognitive states apparently others have in great numbers.
With some of these indications for these classes of drugs, I question as to whether or not they are actual and treatable disease states or medical problems.
Yet with additional indications for particular drugs in these classes of medications, one can be assured that the market for these drugs will continue to grow- as more are prescribed to those patients who are progressively asking for them specifically for relief they anticipate they will receive from taking these drugs.
What such patients are not aware of is that studies have shown that this class of medications is only effective in roughly half of those who take them.
And some of the indications granted to drugs in these classes of medications may be considered disease mongering tacitly performed by the makers and marketers of these drugs to again grow the market share for particular drugs of this type.
This is combined with drug companies who make these types of meds either forming or creating front groups in order to have more diagnosed with various medical problems that may not exist so their medication can be utilized more.
And as mentioned earlier, such pharmaceutical companies have been known to either create or support front groups to ultimately encourage who may be normal people to get evaluated for the diseases indicated with these medications.
Of course, such tactics implemented by such pharmaceutical companies are deceptive, inappropriate, unreasonable, unnecessary, and potentially if not actually dangerous to others.
Perhaps of greater concern and danger with these particular psychotropic medications involve the adverse effects associated with these types of drugs, which include suicidal thoughts and actions, violence- including acts of homicide, and aggression- and this is only to name a few.
Such events are devastating and have been demonstrated by those who have or are taking these types of drugs.
It has been reported that the makers of such drugs are suspected to have known about these toxic and dangerous effects of their drugs and did not share them with the public in a timely and critical manner until forced to do so.
While most SSRIs and SNRIs are approved for use in adults only, prescribing these meds to children and adolescents has drawn the most attention and debate with others for understandable reasons, which have included those in the medical profession as well as citizen watchdog groups.
The reasons for this attention are due to the potential off-label use of these meds in this population of children.
Yet what may be most shocking is the fact that some of the makers of these meds did not release clinical study information about the risks of suicide as well as the other adverse events related to such populations.
This, combined with the true decreased efficacy of SSRIs in general, which is believed to be only less than 10 percent more effective than a placebo.
The makers of Paxil caught the attention of the government regarding this issue of data suppression some time ago, this hiding of such important information- Elliot Spitzer specifically was the catalyst for this awareness, as I recall.
Furthermore, that drug is in the spotlight once again years later. Some believe the drug maker knew about possible risk to the youth as early as 1991. Yet did not disclose such danger associated with their drug to the public or the FDA, and this was done with intent.
And there are very serious questions about the use of SSRIs in children and adolescents regarding the possible damaging effects of these meds on them as they get older.
These children and teenagers who are prescribed these drugs.
Others are asking if this is really necessary- and are these drugs doing more harm than good for their children.
For example, do the SSRIs correct or create brain states considered not within normal limits, which in effect would possibly cause harm rather than benefit a patient on such a drug?
Are adolescents really depressed, or just experiencing what was once considered normal teenage angst?
Do SSRIs have an effect on the brain development and their self identity of such young people?
Do adolescents in particular become dangerous or bizarre due to SSRIs interfering with the myelination occurring within their still developing brains?
No one seems to know the correct answer to such questions, yet the danger associated with the use of SSRIs does in fact exist, as demonstrated by others. It is observed in some who take such drugs, but not all who take these drugs.
Yet health care providers possibly should be much more aware of these possibilities, possibly, along with the black box warning now on SSRI prescribing information for the youth that has existed since 1994.
There are other medications health care providers could prescribe for such patients that have no less benefit for them then the serotonin drugs discussed.
Finally, if SSRIs or SNRIs are discontinued by a patient rapidly, abruptly, and without medical supervision, withdrawals experienced by many of these patients are believed to be quite brutal that follow soon after this drug is not taken anymore by a former patient.
This in itself may be a catalyst for one to consider or attempt suicide, others have suggested.
Many are aware and understand that discontinuing these SSRIs and SSNIs leaves the brain in a state of neurochemical instability for some great length of time as the neurons need to recalibrate after existing in a brain over-saturated with serotonin and neuron alteration.
This occurs to some degree with any psychotropic medication, yet the withdrawals can reach a state of danger for the victim in some classes of meds such as SSRIs and SNRIs, it is believed. And this seems to concern many, yet does not inhibit health care providers for continuing to select such therapy with these drugs for their patients.
SSRIs and SRNIs have been claimed by doctors as well as patients to be extremely beneficial for the patient’s well -being regarding their apparent mental issues that resolve in time. Yet overall, the factors associated with this class of medications may outweigh any perceived benefit for the patient taking such a drug that can harm themselves and others.
Before these medications mentioned were developed, doctors praised trycyclics, another class of anti-depressants mentioned earlier, in a similar manner since their advent in the 1950.
Considering the lack of efficacy that has been demonstrated objectively with these new serotonin specific psychotropics, along with the deadly adverse events with these SSRI and SSNI meds only recently brought to the attention of others, other pharmacological and non- pharmacological treatment options should probably be considered, but that is up to the discretion of the prescriber.
And the perception of the benefits derived by these types of drugs may be flawed, as there has been no decrease in incidences of suicide or remission of depression since these drugs have been available, many have concluded.
Yet antidepressants in general have been considered by others to create amotivational syndrome, which is a lack of interest in various activities, as well as creating a state of flat affect of users of antidepressants.
Furthermore, recent studies have suggested that the supplement, St. John’s Wart, has shown to be as effective as medicine for major depression. Deficiencies in vitamins B12 and Folate have been suggested as a cause for depression as well. One study showed that a small jog performed by a depressed patient offered similar if not greater relief than a SSRI drug.
It is my hope that such a prescriber rules out possible other etiologies for their patients’ mental conditions before they conclude that such a patient is suffering from true mental illness requiring the medications mentioned earlier.
To rule out other conditions, the health care provider may consider asking their patients about life stressors and other medications these patients have taken or are presently taking.
Because at times, a doctor can in fact do harm without intent.
“I use to care, but now I take a pill for that.” ---
Author unknown*
www.nmha.org
Dan Abshear
Placebo Gazebo. Effexor saved my life in 2003 and beyond
to be honest, when i was on anti depressents, i actually became more depressed, and i know a lot of you out there will agree that this has happened to you too. if you talk to a counseler, you'll find they are more screwed up than you! my advice..it is a walk you have to take alone to figure it out in your own mind how to deal with it.good luck.it worked for me
Here's a thought: Maybe it's okay that a good chunk of the improvement brought about by antidepressants can be attributed to the placebo effect. After all, the whole point of these meds is to help people recover from depression. And if you're not taking anything at all, you don't even derive the benefit of the placebo effect.
I know this isn't what the drug trials are trying to test, but from a patient perspective, improvement is improvement, no matter the cause.
I was terribly depressed. After the 6 month regiment of prozac, I couldn't even understand how I wanted to end my life before. Like I couldn't even think about it now. The stuff took away my depression. REALY WORKED FOR ME :)
I suffured from depression and anxiety for over 1 year. My doctor put me on Effexor ER. After 3 weeks I felt 100% better. Everyone at work noticed the difference in me. (I never told anyone at work that I was taking medication) 6 months later I recieved a glowing review from my boss. She made a point of saying that she thought I was a positive person. After 12 months I felt well enough to stop taking the medication, so I did. The medication fixed my problem.
They work for me. I wish my low dose antidepressant need was "all in my head" but it is not. It corrects what is wrong for me. I was not a believer at first when it took 2 weeks to feel a glimmer of hope, but slowly I found myself once again. I treat my depression as diabetes or heart disease--a disease that requires medication. I know several people who do not experience help from these drugs for whatever reason, so I agree that this is a patient by patient case as to whether they "work" or not.
A lot of the efficacy depends on what exactly you consider depression.
For me it basically means I don't feel like getting out of bed. I think a lot of the effect of the anti-depressant I take can be attributed to simply making me enjoy sleeping less, as opposed to actually making me less depressed.
The other problem is abnormal depression from normal depression, personally I think that the reason for the rise in depression in America (at least) as a whole can be largely attributed to modern life being simply more depressing than in the past (life may be better by many standards than 50 years ago, but most people don't have as much control over their own destiny as they used to, and I think that can be very depressing)
It's complicated. I have a wicked anxiety disorder, and I hate taking antidepressants. They are not perfect, and I hate the side effects, but they at least improve my functioning. I have tried everything else under the sun. I am a full-on health-oriented person too. It's frustrating that I have to rely on something that has such varying results in test subjects. However, I think the whole depression-anxiety axis of disease is very complicated and individualized, so that may explain some of what this study reveals.
To begin with, I was incorrectly diagnosed by 'experts' in depression working in important and influential medical centers as 'independent' researcher for pharmaceutical global corporation doing research for their anti-depressant and anti-anxiety. From 1983 to 1998 I was given every major new anti-depressant medication both individually and in cocktails, combined. The pharmaceutical bill came to about an average of $12,000 annually. Even that psychologists test indicated that I had no depression nor I had any psychological disorders, psychiatrist participating in corporate sponsored research in large medical centers kept telling me that my symptoms were due to depression caused by a biochemical imbalance and that if I took their prescribed psychiatric pharmaceutical I would improved and even cured the biochemically triggered depression that they had 'incorrectly' diagnosed. This went on for 15 years, mean while I lost my career, my job, my income and two marriages; not to mentioned my social and professional status and a bright professional future. I finally, in 1996, discovered that it was not depression at all when I decided to go see a Endocrinology & Metabolism Physicians. It was a congenital hormonal imbalance and metabolic syndrome that was causing the depression and all I had to do is to change my diet, increase physical activity, loose weight, sleep plenty, and managed stress. All this had been triggered by excessive stress. The 'top' psychiatric researcher working for 'top' medical centers were following the instructions of the 'top' pharmaceutical companies and making great amount of money personally as well as for the medical centers that they work for. These medical centers were associated to medical schools associated to major universities. All of the above were and continued to gain economically from the anti-depressant medications 'research'; these pharmaceutical for most part do not work, but do causes many side effects and some of these side effects are damaging to ones health and even social and professional life. None of the anti-represents ever worked for me and I lost 15 years of my life. When I stopped taken all the anti-depressant and anti-anxiety medications given to me for 15 years was when I was cured of both 'depression' and 'anxiety'. The placebo effect that had on me was a negative psychological effect. I actually believed the 'top' psychiatrist working 'top' medical centers associated to 'top' medical schools in 'top' universities and the placebo effect on me was that I really thought that I depressed and suffering from anxiety when this was never true at all. Both the diagnosis and the prognosis were wrong but it was economically, 'scientifically' and 'professionally' convenient for these
researchers-practitioners. They needed patients in order to participates in these lucrative research programs. They do no meet the the patients needs but instead were participant with the pharmaceutical companies to 'proof' via 'professional' and 'medical' scientific papers that such pharmaceutical brands worked to prevent and cure depression and anxiety. Many times, I noticed how the pharmaceutical reps would come to the doctors office paying for lunches, office supplies, and yes, offering 'medical conferences' in exotic and vacation resorts. The last of these 'top' researchers working in a 'top' medical center at a 'top' at a 'top' medical school at a 'top' university that I was under his care become very angry at me the day I announced to him that I dropping from his program and his medical practice. I was attended by some 12 psychiatrist and psychologist and they all followed the same script than the pharmaceutical companies gave them to follow. All the psychiatrists had the same literature from the 'top' pharmaceutical companies in their offices and where all working directly or indirectly for the pharmaceutical companies. The placebo effect can work against the patient when the patient actually believes that he or she is suffering from a biochemically and emotionally triggered depression or anxiety because the psychiatrist or researcher says so and prescribes anti-depression and anti-anxiety medication or it can work for the patient that believes that the pill is the magic solution. For the medical practitioner or the researcher it can be also a two side placebo. He or she can truly believe that these anti-depressive medications truly cured their patient or they can also believe that is an additional profit and revenue for their themselves, their office, their partnership or the department or institution; that an additional benefits that pharmaceutical companies provides in exchanged for their approval.
I am glad that I am beginning to see studies that show interest in questioning the 'scientific' and 'psychiatric' reports and information of 'medical researchers and practitioners' backed up by the pharmaceutical companies; many of these claims are 'doubtful'. Pharmaceutical companies, medical researchers, medical centers, medical schools and universities together have made billions using this truly and practically unproven 'scientific claims' that are very doubtful. Claims that are pushing hard the idea that all emotional and social problems that causes psychiatric or psychological disorders and syndromes are resolved by taking thise strong biochemical psycho-pharmaceuticals. The US government, medical insurance companies and health maintenance organization have been paying billions for these unproved but well 'publicized' and 'advertised' doubtful psycho-pharmaceutical; a multi-billion dollar market and not to say the lost of productivity and lost of lives, marriages, careers, and personal happiness that has been lost using 'doubtful' medications that are have more of a placebo effect, both negative and positive, than any truly proven scientific effect.
Simply stated, for whatever reason, antidepressants do seem to help some people. They can also take a 'happy' person and make them suicidal. (Think, for example, of someone taking it for pain who was not depressed until after they started taking the antidepressants.) I just wish *they* (companies and doctors) could understand that.
I just wrote a long post on my blog about this topic from a personal perspective. I was reluctant and skeptical to take Prozac, but I'm convinced it saved my life. It absolutely worked for me. Placebo? Maybe. All I know is I can get out of bed and live my life now.
It is obvious from some of these comments that drugs have saved people's lives.
On the other hand, the medications have also destroyed others' lives.
A client of mine was given anxiolytics 6 months ago, and is now a complete mess as she hyperreacted to the drugs, was given alternatives, and hyperreacted to those as well. She has run the gauntlet of most antidepressants and antipsychotics; until, having become suicidal and non-functioning, she decided to find alternatives. She is now following a detox programme under the guidance of an "alternative" GP, as well as seeing me for Ayurvedic treatment.
She is responding well to ayurvedic massage, which helps her reconnect with her body, and affords her moments of peace and rest - so precious to her.
What I am saying is that there are other ways of dealing with mental conditions - ways handed down from the ancients, ways which are humane, gentle and genuinely help restore wellbeing. This is part of every culture in the world.
I believe we must try to retrieve our cultural wisdoms of mental wellbeing and mutual care through massage, herbs, yoga and exercise, and community support.
Then far less people would need to resort to drugs - possibly the very people who would benefit from them.
Gerald Lopez
Auckland, New Zealand
www.ScienceOfLife.co.nz
www.twitter.com/gezz_nz
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