February 26, 2008

Yet Another Study On Antidepressants, And No One Notices The Timing

Are we on this again?

"Study doubts the effectiveness of antidepressant drugs."  Or, even better, as per The Independent: "Antidepressant drugs don't work-- official study."

I don't know what passes for official nowadays.  The data is the exact same data that has existed for 30 years.  Yes, these authors are acting like they FOIA-ed the second Zapruder film, but let me assure you it's the same old data.  These authors did the exact same study in 2002.  So have twenty other groups.  This is not new. 

But it is news.  The question is why.

1.  I have a side question.  Why is it that when an article says something works, people are suspicious of bias, but when an article says something doesn't work, everyone thinks it's objective science?   IT'S ALL BIAS.  

2. People are completely missing the point of this paper and all the other recent  re-investigations, the true social and clinical consequences of them.  For example: they're saying antidepressants are no good.  Ok.  What do you think doctors are going to use  instead?  Psychoanalysis?  Nothing?  They're going to prescribe antipsychotics.  Are you listening to me?  I'm not even saying this is clinically wrong to do, but do you not see the setup?  Abre los ojos, man.

3. Previously, when SSRIs were being shown to be super effective, people suspected Pharma bias.  Now they are being shown to be ineffective, and people fail to see the bias.  IT'S THE EXACT SAME BIAS-  Pharma.  That's why there are popular press stories on this now, as opposed to five years ago.  GSK doesn't care that Paxil is ineffective.  Do you know why?  Because they want you on Lamictal.  (Again, this isn't to diminish Lamictal's or antipsychotics' usefulness.  I'm just talking politics.)

4.  And the handmaiden of Pharma is the academic.  You can't make a career studying generic medicines, because no one but the NIH will fund you to do it.  And nowhere save  Hollywood is there more cronyism and prejudice than at the NIH, so just forget it. You're an academic looking to cover your salary?  Get promoted?  The address on your grant application better read "Bristol Myers, Makers Of Awesome Abilify."  If it says "Bethesda Maryland," slit your wrists now.

5.  The study does not say that antidepressants don't work; it says that they don't work better than placebo.  Placebo is not nothing. The question someone should be asking is how the hell placebo generates 35% improvement in all but the most severely depressed.

5b.  ...And why the placebo works worse in the severely depressed.  Before you jump to the obvious answer, note that antidepressants had similar efficacy, independent of severity.

6.  If the drug had been no better than placebo, but placebo had only 2% efficacy, then yes, the drug would be worthless.  See the difference?

6b.  But that isn't true, either.  If any of the structural classists over at The Independent would care to explain how failure in Major Depressive Disorder can be extrapolated to OCD, panic, multiple myeloma,  etc, I'm listening.  "Mexicans don't work-- official study." 

6c.  "Why did you add multiple myeloma?  How's that?  It's an antidepressant, a psych drug."  No, it's called an antidepressant, it's used by psychiatrists.  You have no way of knowing what it actually is.  Look at the history of thalidomide.  "Girls named Candi are sluts-- official study."   While I'll agree that any parents who name their kid Candi are probably at risk for having a brass pole set up in the basement, you can't make any judgments about Candi herself based on her name.  Do you know why?  Because she didn't get to name herself.

There's a lot we can learn from the recent controversies surrounding antidepressants, and by a lot I mean only one thing, best articulated by Lewis Black:  "Doctors don't know.  They pretend to know.  Because they have a rectal thermometer in their pocket.  As if it was an appeal to a higher authority."





Comments

Horrah~ haven't read a sati... (Below threshold)

February 27, 2008 10:24 AM | Posted by Jenny Pat: | Reply

Horrah~ haven't read a satisfying post like that for a while now.

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Must mention there's a simi... (Below threshold)

February 27, 2008 11:17 AM | Posted by AK: | Reply

Must mention there's a similar and very tiresome bias regarding vaccines. People seem eager to read that vaccines dont work and jeer if anyone presents an argument, buttressed by well chosen publications, that they are effective.

If you are skeptical, toddle over to Craigslist.org, go to the Health and Parenting fora, do searches on 'vaccine*' and see the endless justifications given for not getting vaccines--either for oneself or one's kids. Meanwhile on that parenting forum, do another search on 'chickenpox party/parties' and you will find posts from parents looking for a kid in thier area who has chickenpox so they can bring their own kids on over and expose them to it 'naturally.'

(Am wondering if people's reluctance to get immunized is based, not on rational thought, but on unconscious concerns about personal autonomy and boundary violation, and hang ups about intrusion by government-as-Bad parental surrogate?

This same hang out may account for people's continuing refusal to permit flouridation of the water supply. Argh. Its case of no one can tell ME what to do, dressed up as seemingly rational skepticism, but driven by unconscious agendas. Just my wee hunch. Dont know how to prove it, though, so maybe these ruminations are useless.

But.. I dont think Celexa was useless, at least not for me.

As I wrote in the ECT post, after a year of misery that got worse and worse, (despite my eating a great diet, getting enough sleep, using phototherapy for SAD, taking 1-2 gms of omega-3 fish oil, exercising aerobically for at least an hour every day, and trying hard to apply Cognitive Behavioral Therapy/mindfulness to my thoughts and emotions--

20 mg Celexa made me human again. I was yelling at people I loved best, in a manner that was atypical of me, getting so crabby that I was on the point of getting into combat with aggressive panhandlers who were taller than I was, and not caring if I got hurt. Now I can apply insight tools to my thoughts and emotions and get the benefit--its like being able to get traction where before I couldnt get a hand hold.

If all these benefits were produced by placebo effect, or a combo of neurotransmitter shift plus placebo effect than all I can say is thank GHOD for placebo effect.


And...ha ha, the 20 mg is below what's needed to saturate the serotonin re-uptake sites. Learned that from LP's series of articles using the rum fountain/single's bar analogies.

Glad you're back, LP. And I am glad I am back. I fought taking anti depressants for six months and in that time 5 people from very different backgrounds all urged me to try them--and 4 of the 5 had no tie to Big Pharma.

The other day I was preparing a room for a public event.

After several minutes I was aware that someone was running a vacuam cleaner--and that this did not bother me.

Before I went on the Celexa, I could not remain in the room if someone's cell phone began tweeting and was not turned off. If that happened, I went into a rage, got agitated and had to leave.

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Setup? It's happening alrea... (Below threshold)

February 27, 2008 12:27 PM | Posted by Christian: | Reply

Setup? It's happening already. I was prescribed Lamictal as an adjunct to Cymbalta a year ago. It works great! Maybe. Maybe the stress in my life changed. Perhaps a comet took a wrong turn at the Leveritt Circle and landed on the Bi-Polar clinic at MGH?

Read the comment here: "Very GOOD!! After six months, I can honestly say this is the most effective antidepressant I've ever tried. A welcome change from the typical SSRI."

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Great post. Very thought pr... (Below threshold)

February 27, 2008 1:53 PM | Posted by Doc Rock: | Reply

Great post. Very thought provoking. I never considered the connection between Pharma and the reports of the ineffectiveness of SSRI's (except Lexapro and Luvox CR, which are fantastic and clearly superior to everything). It makes sense from a marketing perspective. When I think about it, I realize I am not particularly concerned about Big Pharma so much as I am about Big Pharma Marketing. Pharma needs to do what it does in a capitalist, market economy, and despite considerable drawbacks, we are still better off for their efforts. What we physicians need to remain vigilant about is the influence of the marketing, and not to be caught up in it as spokesmodels ourselves. Although we are experts in mental illness and abnormal behavior, we are not always very conversant with normal human behavior and how we can be influenced. That is why I am very concerned about the influence the marketers have with us. And before you say "That drug company pen and prescription pads and CME and lunch talk won't change my opinion," don't forget that intellectualization, rationalization, suppression, and denial are very potent defense mechanisms. We of all people should realize that, unless of course we aren't taught anything about psychodynamics anymore.

A great question is why do our meds so often not separate from placebo in our clinical trials. People will talk about the relative merits of the meds, but I haven't heard much discussion of the trials themselves. And I don't mean clinical trial design, though that is obviously a fundamental necessity. I am referring to the ins and outs of actually doing clinical trials. I have PI on several industry sponsored studies, and I must say that it was a real eye-opener. Not that people were trying to do unethical things, quite the contrary; but that the patients enrolled in these studies are a very interesting, select group that have their own motivations and often bear little resemblance to my usual outpatients. I had great trouble recruiting patients because we tried very hard to get the proper patients; other centers seemed to have no problem at all, and I have always wondered why. That is why I am not ready to throw in the towel on the SSRIs, or therapy for my patients.

I know it was a long post, but I hope it contributed something to the discussion.

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Me again. Just thought of s... (Below threshold)

February 27, 2008 1:56 PM | Posted by Doc Rock: | Reply

Me again. Just thought of something else:

since the review covered studies already submitted to the FDA for drugs deemed safe and effective but are actually no better than placebo, does this mean that the FDA are complete idiots and should be taken out and shot?

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I've been harping about thi... (Below threshold)

February 27, 2008 2:11 PM | Posted by Stephany: | Reply

I've been harping about this on various blogs and my own, that antipsychotic use will and is going to increase[and has] due to the SSRI "scare", doctors rx'ing those less, and most importantly, because FDA approved drugs like Risperdal and Abilify for broad base use for many dx's. This is what the general public doesn't "get" or understand, is they might end up going to the PCP and getting an antipsychotic, told they have depression or anxiety and never realize they are on an antipsychotic originally trialed for schizophrenia. These goes for antipsychotic use in children under age 18 also. It's not acceptable, yet as long as people keep buying into the well planned marketing scheme of pharma, and the doctors pimp the shit out left for them by drug reps, then so be this world. No one will ever be able to turn back time on this one.

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Friend of mine was just pre... (Below threshold)

February 27, 2008 2:14 PM | Posted by Anonymous: | Reply

Friend of mine was just prescribed Lamictal as well. She seems very 'happy' after having been on ssri's for so long without too much change. After our conversation I was sorely tempted to jump on the bandwagon. I too have had medium to severe depression for several years. I have so far refused the prescription drug route, choosing instead to self medicate like so many do. Looking back I dont' see too much difference in the end result except I had an amazing time during my self treatment and she is still struggling through with hers (I think I'm mostly done with mine). I'll be interested to see where she ends up with her medication journey.

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Since you mentioned ECT in ... (Below threshold)

February 27, 2008 2:34 PM | Posted by Larry Smith: | Reply

Since you mentioned ECT in your other post, this reminds me of some papers from Dr. S*. Suddenly ECT has bad sides: cognitive impairment is demonstrated in the first large scale study. About the same time Dr. S* branches into a new area, VNS, which is pretty awesome. Despite the lack of efficacy in the sole placebo controlled study, it gets FDA approval! Well, at least the sides aren't so bad.

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It must be patent expiry se... (Below threshold)

February 27, 2008 3:19 PM | Posted by Glen: | Reply

It must be patent expiry season.

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I was waiting for your insi... (Below threshold)

February 27, 2008 7:46 PM | Posted by Andrew : | Reply

I was waiting for your insight into the recent study that's been plastered all over the news. Your perspective is incredibly interesting and appreciated by this up and coming doctor.

Posts like this are definitely reddit/digg worthy

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Christian, I also am on Cym... (Below threshold)

February 29, 2008 11:51 AM | Posted, in reply to Christian's comment, by M: | Reply

Christian, I also am on Cymbalta ...but it only partly works. Would you mind telling me the dose of Lamictal that you take with Cymbalta. I'm trying to get something that works, but don't like the other choices.

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Question: it seems likely t... (Below threshold)

March 2, 2008 1:27 AM | Posted by Jeff: | Reply

Question: it seems likely that we'll see a greater diagnosis of bipolar II to justify the use off-label use of antipsychotics. Is there any evidence that this is happening?

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Foucault's Pendulum, anybod... (Below threshold)

March 2, 2008 10:46 PM | Posted by Daniel Reeders: | Reply

Foucault's Pendulum, anybody?

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sorry this is off topic, bu... (Below threshold)

March 3, 2008 1:09 PM | Posted by alex: | Reply

sorry this is off topic, but do you have an e-mail i could reach you at? I read your post on geodon, it's making me miserable at only 20 mg a day, all the psychiatrists as my university are not helping just telling me to wait a month, and there is no way in hell i can consume 800 calories in one meal as you've suggested...

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Love your blog, but are you... (Below threshold)

March 3, 2008 7:12 PM | Posted by Steve : | Reply

Love your blog, but are you on vacation again?

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Alone did you read that sis... (Below threshold)

March 4, 2008 5:38 PM | Posted by sunnygirl: | Reply

Alone did you read that sister of Effexor XR Pristiq was approved by the FDA last week? Not sure how this is going to work with EXR on the market (which can be titrated up) and only a 50mg dose available for Pristiq. I would love your comments about Pristiq...

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My crystal ball says: wait ... (Below threshold)

March 6, 2008 5:41 AM | Posted by Larry Smith: | Reply

My crystal ball says: wait until NK-1 or CRF-1 antagonists hit the market. You're going to hear right from the Pharmalot how horrible atypical antipsychotics are for depression... For those that don't follow this:

http://www.nature.com/npp/journal/vaop/ncurrent/fig_tab/1301652t1.html

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I have Bipolar I. I tried s... (Below threshold)

March 7, 2008 1:18 PM | Posted by Anonymous: | Reply

I have Bipolar I. I tried six different antidepressants through the course of gettng my meds regulated. It wasn't until they kept me on ONLY ON THE LAMICTAL that my moods greatly improved. Effexor was a brutal antidepressant to take. I almost lost everything near and dear to me because of a manic episode. I had never had an episode that bad until taking that drug! The other antidepressants made me cycle rapidly but the depression was the most severe bothersome.

Antidepressants DON'T work and as far as I am concerned they should all be banned for sufferers of Bipolar Disorder.

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Dr. "Bling Bling" <a href="... (Below threshold)

March 8, 2008 10:13 AM | Posted by Larry Smith: | Reply

Dr. "Bling Bling" chimes in. NNT for SSRI over placebo: 18. Effexor NNT over placebo: 8.

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Your humor restores my soul... (Below threshold)

March 8, 2008 10:05 PM | Posted by Erin: | Reply

Your humor restores my soul.

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"5. The study does not say... (Below threshold)

March 23, 2008 4:27 PM | Posted by Anonymous: | Reply

"5. The study does not say that antidepressants don't work; it says that they don't work better than placebo. Placebo is not nothing. The question someone should be asking is how the hell placebo generates 35% improvement in all but the most severely depressed."

But does it? That pillar of research is no longer so solid. I used to uncritically believe in a placebo response of 30% or so, but after reading the work of Hrobjartsson and Gotzsche, I am no longer so sure.

And if the placebo response is not especially powerful (certainly nowhere near 30-35%), where does that leave us in both the research lab and the clinic?

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"5. The study does not say... (Below threshold)

March 23, 2008 4:27 PM | Posted by Obdulantist: | Reply

"5. The study does not say that antidepressants don't work; it says that they don't work better than placebo. Placebo is not nothing. The question someone should be asking is how the hell placebo generates 35% improvement in all but the most severely depressed."

But does it? That pillar of research is no longer so solid. I used to uncritically believe in a placebo response of 30% or so, but after reading the work of Hrobjartsson and Gotzsche, I am no longer so sure.

And if the placebo response is not especially powerful (certainly nowhere near 30-35%), where does that leave us in both the research lab and the clinic?

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Pardon the double post, not... (Below threshold)

March 23, 2008 4:29 PM | Posted by Obdulantist: | Reply

Pardon the double post, not sure what happened there.

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I found this log and am hop... (Below threshold)

March 23, 2008 10:30 PM | Posted by Anonymous: | Reply

I found this log and am hopeful that we will get a response. I have a close family-member that has just started on Geodon at 20mg BID; with meals. Dx is BP and/or Mood Disorder, NOS - and a host of other labels as well.

We were told to take with means - no problem; but I found the info you posted sometime back on metabolism of the product. This is intriguing because I quickly saw that low carloric intake appears to also have increased side effects? If a large (but healthy) meals is consumed; the uptake seems more balanced.'

Product usage is still new - just a few days; however, result if 180 degree difference - no more anger, aggression, etc. (most troublesome presenting symptoms).

Do you happen to have a link anywhere to the study that you mentioned - it looks like it was done by Pfizer in 2006; however, i was unable to locate it.

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Antidepressants are used co... (Below threshold)

March 24, 2008 4:49 AM | Posted, in reply to AK's comment, by click here: | Reply

Antidepressants are used commonly in medical and psychiatric practice. As a class, antidepressants have in common their ability to treat major depressive illness. Most antidepressants are also effective in the treatment of panic disorder and other anxiety disorders.

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Can you explain the idea he... (Below threshold)

April 19, 2008 10:52 PM | Posted by Diane Abus: | Reply

Can you explain the idea here.I like foucault but don't recognize the ideation?

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Respect to labor<a h... (Below threshold)

March 15, 2012 10:22 AM | Posted by Haber: | Reply

Respect to labor
Haber

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When we medicate away teen ... (Below threshold)

November 22, 2013 1:31 AM | Posted by Best Bankruptcy Attorney: | Reply

When we medicate away teen angst, grief and other normal -albeit uncomfortable- feelings, is there something else, something very precious that we take from them as well?

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Recent attacks on antidepre... (Below threshold)

June 17, 2014 8:59 AM | Posted by Jenna: | Reply

Recent attacks on antidepressants simplify a complicated picture about their effectiveness, and people with depression suffer for it.

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