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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 95 to 119 of 143. Go back in thread:
Posted by Squiggles on May 16, 2006, at 16:34:55
In reply to Re: Statistical question on SSRIs - ADDENDUM » Squiggles, posted by Larry Hoover on May 16, 2006, at 16:26:30
Sigh,
You're an enigma within an enigma, within
a 'Jack-in-the-Box'.I can imagine a utopia, where everyone is
equally well-off, and there are no social
problems. I can imagine every sick person,
regardless of his social status getting the
best possible care. And I know, with certainty
that if the medical establishment does not
have the right drug for disease x, every single
individual blessed with maximum hospital and
and medical care, will die.Squiggles
Posted by Larry Hoover on May 16, 2006, at 16:37:39
In reply to Re: Statistical question on SSRIs - ADDENDUM » Larry Hoover, posted by Squiggles on May 16, 2006, at 16:08:37
> It looks like we're going around and around and around.
>
> SquigglesI dislike the feeling that I am going nowhere with you, Squiggles. Please do not post to me.
Lar
Posted by Squiggles on May 16, 2006, at 18:10:42
In reply to Please do not post to me » Squiggles, posted by Larry Hoover on May 16, 2006, at 16:37:39
i guess you've hit the WALL Larry :-)
Pearls before swine;
chow.
Squiggles
Posted by SLS on May 16, 2006, at 20:13:13
In reply to Re: Statistical question on SSRIs - ADDENDUM » Larry Hoover, posted by Squiggles on May 16, 2006, at 16:34:55
I'm pretty much lost.
Not such a rare event, though.
:-(
- Scott
Posted by Squiggles on May 16, 2006, at 20:30:31
In reply to Re: Statistical question on SSRIs - ADDENDUM, posted by SLS on May 16, 2006, at 20:13:13
> I'm pretty much lost.
>
> Not such a rare event, though.
>
> :-(
>
>
> - ScottFor some mysterious reason Larry got
upset with my remark, that medication
takes priority over bed-side manner in
curing diseases. What is care? In
serious mental illness, it's got to be
drugs. I don't know why he go upset
at that.Squiggles
Posted by Larry Hoover on May 16, 2006, at 22:18:14
In reply to Re: Please do not post to me » Larry Hoover, posted by Squiggles on May 16, 2006, at 18:10:42
Do not post means do not post, does it not?
Lar
Posted by Larry Hoover on May 16, 2006, at 23:06:01
In reply to Deputy? Bob? Block?, posted by Larry Hoover on May 16, 2006, at 22:18:14
Upon further thought, I rescind my Do Not Post request to Squiggles, and ask that no administrative actions befall her. I do not like the rule, as it externalizes an internal issue. I will deal with it myself.
Squiggles, I will not answer any questions you put to me. I may, however, choose to answer selected questions you pose to the group, at my discretion.
Lar
Posted by Squiggles on May 19, 2006, at 15:54:49
In reply to I rescind the DNP, posted by Larry Hoover on May 16, 2006, at 23:06:01
I just dropped by ASDM and saw your post
to me. It was very clever of you to
post it there and not here, as it would
not have met the civility bounds here.
As for my relationship with my husband,
I would say, it's none of your business.Rescind, indeed.
BTW, I am no longer posted at ASDM, nor
reading there, nor reading your posts here.Squiggles
Posted by linkadge on May 20, 2006, at 2:13:31
In reply to Re: Statistical question on SSRIs - ADDENDUM » linkadge, posted by Larry Hoover on May 15, 2006, at 9:54:44
>If antidepressant drugs caused a suicide, how >would you demonstrate that to another person? >How could you show that it was this one lone >variable that made the difference?
Thats exactly it. We can't prove anything yet. I'm not claming that the reason for my conclusion is at all scientific or provable in any sence yet.
>Anecdote. What is anecdote? It is an >uncontrolled experiment with one subject. What >have you got when you collect one thousand >anecdotes? One thousand different uncontrolled >experiments with one thousand different subject >populations. Anecdote is a point in space. How >do you extrapolate from one point?Hopefully anecdotal instances might persuade the initiation of a host of more systematic experimentation.
>Anecdote spurs people to create hypotheses, and >to consider experiments not yet done. How could >you design an experiment which would >demonstrate this suicidality, this inductive >effect? The fact is that you can't. Any >experiment that could do so is absolutely >unethical to perform.
We do have some experiements that show some interesting things. You take a regular clinical trial for an SSRI. Throughout the trial, you ask both groups a whole host of question relating to feelings of akathesia, acute feelings of suicidiality, feelings of hostility, increased feelings of self hatred or intent to self harm.
You compare the incidences of such events between both groups, and you discover what many such trials are indicating, that SSRI's statistically seem to increase the likelyhood of such feelings.Perhaps nobody actually kills themselves in such trials, but the information will lend merrit to many of the anecdotal reports.
>All we can really do, IMHO, is to manage the >drugs better than we did before. Serious drugs >for a serious disease require serious >management. I cannot fathom how the latter was >allowed to detach itself from the former, but >we let that happen. Thalidomide taught us a >lot. It turns out that thalidomide is a miracle >drug, when used in other contexts than for >morning sickness.I think that part of the mannagment, is in coming to terms with the extent of the problem.
There is still such a devide. Either they cause people to kill themselves, or they do no such thing.>It's the human component that we can influence. >No amount of posturing will affect the drugs >themselves. They are what they are. We have a >people problem, not a drug problem, IMHO.
Lets suppose that there is something really quite unique about the individuals who have such negitive reactions to SSRI's. Its like we've skipped back 40 some odd years, when MAOI's were not known to interact with tyramine. Sure, only some people were dying, and nobody knew exactly why. We still have yet to discover why people are reacting this way. It is still a drug problem, just like MAOI dietary interactions were a drug problem. It is my belief that we simply don't know the mechanism yet.
Linkadge
Posted by linkadge on May 20, 2006, at 2:21:35
In reply to Re: Statistical question on SSRIs - ADDENDUM » Squiggles, posted by Larry Hoover on May 15, 2006, at 14:57:10
>If you sample a population enough times, you >can always find a significant result, no matter >how absurd the hypothesis being tested.
>Much of the research that has been published is >not proof of anything at all
I do think that certain clinical trials can help to develop a clearer picture of what the drugs are doing, and the way in which an antidepressant may induce suicidiality. I have actually seen a few clinical trials in which *healthy vaulenteers* were given placebo, or active SSRI. It seemed that the SSRI's were actually producing things like acute apathy, acute akathesia, insomnia, agitation, and suicidal feelings, whereas placebo group experienced no such events.
This is an important type of trial, since in studies such as this we cannot lean back to the old "well this population was depressed anyway".
I have seen reports of psychiatrists self testing SSRI's and having similar findings.
Linkadge
Posted by linkadge on May 20, 2006, at 2:48:48
In reply to Re: Statistical question on SSRIs - ADDENDUM » Squiggles, posted by Larry Hoover on May 16, 2006, at 10:04:04
>But it is not relevant, IMHO, to even do such a >study. What would it tell us? We already know >what's missing from the care received by >depressed people. It is management of the >treatment. That's where we fall short. You >can't just hand a depressed person powerful >drugs, and leave him on his own.
Granted, the SSRI market has taken a drop in sales since the introduction of such reports.
It is still absolutely necessary to guage the extent of the problem so long as SSRI's are being prescribed.Consider a lesser problem induced by the SSRI's. Sexual side effects are not argued against, (except by some doctors). Initially, such side effects were thought to occur in only a very small number of patients treated. As time progressed, we can piece together a better picture based on may different types of evidences, that a significantly greater proportion than originally estimated are thought to experiences such effects.
We need to get inventive. Where there is a will (plus a little cash) there is a way to find out what we are dealing with. No it won't be exact. But, I am willing to make decisions based on stastical significance.
The problem is important, and could be underestimated for many reasons. The "excuse" is that the patient group is depressed to begin with. Looking from another angle, this is an additional reason why the problem can be *underestimated*, these people are depressed to begin with. It is highly likely that such a group could confuse drug induced suicidiality with the feelings of their own illness. Same thing went with sexual side effects, its just going to be pawned off as a "consequence of depression".These are peoples lives, and if we cared, we'd get inventive.
>IMHO, the problem has never been the drugs. It >has always been the people who were let down by >other people. We haven't taken the illness >seriously enough. Don't forget, fifty years >ago, nobody talked about mental illness at all. >We built great buildings, and populated them >with people who otherwise virtually ceased to >exist. We haven't come too far from that period >of great stigma. Don't kid yourself.Management can only go so far, you first have to admit there is a problem, and understand the problem. Its like saying to an MAOI user, "call me if you start to have chest pain", thats useless; too little too late. Again, the patient may be suicidal to begin with. Suicidal means, I don't want to live anymore. You make sombody suicdial and they can go at any moment. You cannot underestimate suicidality, and you cannot make a paitent responsible for their own suicidiality. That is why it is absolutely necessary to try and identify who may be at increased risk of such occurances.
It has always been the drugs. Somebody would never say that SSRI induced anorgasmia and genital anesthesia was not an effect of the drugs. SSRI's are very effective chemical castration. That is a *real* drug induced side effect. I don't see how all of a sudden drug induced suicidialty falls a whole new category of "meh".
Oh, its too difficult to ascertain, so lets just sweep the notion under the carpet.
Its not too difficult to ascertain, but we need to be inventive.
Linkadge
Posted by linkadge on May 20, 2006, at 3:03:59
In reply to Re: Statistical question on SSRIs - ADDENDUM » Squiggles, posted by Larry Hoover on May 16, 2006, at 11:44:42
"It is a class effect of pharmacological treatment of mood disorders. If you're going to treat depression with drugs, you get this effect."
Thats not true at all. Its called SSRI induced akathesia. Some drugs induce more akathesia. Some drugs have a higher likelihood of inducing such events. To try and package it all as one deal is foolish, and reeks of carelessness.
The shear body of evidence, for instance, indicates that lithium prevents suicides better than depakote does. That is statistically significant. It is not a "bipolars are going to blow off their heads anyway so it doesn't really matter much what we give them".
There are better treatments, and there are worse treatments.
Some antidepressants made me suicidal, others did not. No, I don't know the exact mechanism, but I sure don't think that it was just coincidence. Just like citalopram gave me anorgasmia and remeron did not. Drug induced suicidality is not a general consequence of drug treatment of depression, and if it is currently, then it needent be. A drug should make you better, not worse.
Opium never made a depressed suicidal insomniac want to jump off a bridge. If somebody is about to jump of a bridge, shoot them in the leg with a dart of MDMA. I'm shure they'd first step off the ledge, then they'd come give you a warm hug for saving their life.
It's called SSRI's are lousy. We simply need better antidepressants.
Good antidepressants work.
Linkadge
Posted by linkadge on May 20, 2006, at 3:16:57
In reply to Re: Statistical question on SSRIs - ADDENDUM » SLS, posted by Squiggles on May 16, 2006, at 20:30:31
>For some mysterious reason Larry got
>upset with my remark, that medication
>takes priority over bed-side manner in
>curing diseases. What is care? In
>serious mental illness, it's got to be
>drugs. I don't know why he go upset
>at that.I agree with you. If soothing talk and kindness could relyably cure depression, then I'm sure a patient could get well from the comfort of their own home. They go to the doctor to get treatment for a debilitaing disease. Unfortunately depression is not as clear cut as treating other diseases.
It is wrong (IMHO) to conclude that drug induced suicidiality is somehow due to a flaw in the doctor-patient relationship.
Linakdge
Posted by SLS on May 20, 2006, at 8:28:01
In reply to Re: Statistical question on SSRIs - ADDENDUM, posted by linkadge on May 20, 2006, at 3:16:57
> It is wrong (IMHO) to conclude that drug induced suicidiality is somehow due to a flaw in the doctor-patient relationship.
I agree. However, I think that inadequate patient education and monitoring by the doctor will allow for a higher suicide completion rate.
I keep seeing the word "akathisia" thrown around as if it were a common occurrence with SSRIs. I question this. My guess is that it is agitation and anxiety that is producing suicidality, and not akathisia per se. Prozac probably produces more agitation and anxiety than the other SSRIs.
- Scott
Posted by Squiggles on May 20, 2006, at 14:34:25
In reply to Re: Statistical question on SSRIs - ADDENDUM, posted by SLS on May 20, 2006, at 8:28:01
> > It is wrong (IMHO) to conclude that drug induced suicidiality is somehow due to a flaw in the doctor-patient relationship.
>
> I agree. However, I think that inadequate patient education and monitoring by the doctor will allow for a higher suicide completion rate.Hi,
I'd like to say something about this. Are not
the two (i.e. doctor-patient relationship) and
monitoring/patient education of the patient
somehow similar? In either case, this would be
an interesting variable in explaining the results in the small "Prozac Survivor" group in a medically causal way.
>
> I keep seeing the word "akathisia" thrown around as if it were a common occurrence with SSRIs. I question this. My guess is that it is agitation and anxiety that is producing suicidality, and not akathisia per se. Prozac probably produces more agitation and anxiety than the other SSRIs.
>
>
Regarding "akathisia" - the word is from the Greek, a-kathisia, meaning non-restfullness. Restlessness in the midst of depression can be a very dangerous thing. This is so especially because restlessness can vary from nervousness, to anxiety, to mania. The word "akathisia" does not have a one-to-one reference in behaviour. It is a pointer to the many facets of a spectrum of behaviour under SSRI or other drug conditions. In some, "akathisia" can lead to suicide.Squiggles
Posted by linkadge on May 20, 2006, at 17:01:16
In reply to Re: Statistical question on SSRIs - ADDENDUM, posted by SLS on May 20, 2006, at 8:28:01
True. Although it is hard for a patient to identify a reaction that they have never been educated about.
I remember feeling absolutely horrid the first few weeks on my first SSRI. It wasn't till I later became educated that I could assign some names to it.
Linkadge
Posted by linkadge on May 20, 2006, at 17:04:51
In reply to Re: Statistical question on SSRIs - ADDENDUM » SLS, posted by Squiggles on May 20, 2006, at 14:34:25
The thing about akathesia is that (for me at least) time was the big thing.
Akathesia made me feel physically restless, but also very mentally restless. A strange feeling of urgancy. A feeling of having to get out, that something needed to be done right away.
Its a very ansy feeling. Like I can't wait till the next bus stop to pee, I have to go "NOW".
For me, I was luck that large doses of caffiene were able to restore some ballance.
Even when I got horrid akathesia on risperdal, caffiene was able to help.
Linkadge
Posted by Squiggles on May 20, 2006, at 18:12:57
In reply to Re: Statistical question on SSRIs - ADDENDUM, posted by linkadge on May 20, 2006, at 17:04:51
> The thing about akathesia is that (for me at least) time was the big thing.
>
> Akathesia made me feel physically restless, but also very mentally restless. A strange feeling of urgancy. A feeling of having to get out, that something needed to be done right away.
>
> Its a very ansy feeling. Like I can't wait till the next bus stop to pee, I have to go "NOW".
>
> For me, I was luck that large doses of caffiene were able to restore some ballance.
>
> Even when I got horrid akathesia on risperdal, caffiene was able to help.
>
>
> Linkadge
>That feeling you describe sounds very much
like the "fight or flight reaction". I am not
sure what sounds the alarm for that physically.It seems paradoxical that coffee should help, though.
Squiggles
>
Posted by linkadge on May 20, 2006, at 19:35:54
In reply to Re: Statistical question on SSRIs - ADDENDUM » linkadge, posted by Squiggles on May 20, 2006, at 18:12:57
I attributed the extreme inner restlessness as akathesa due to the SSRI causing acute decrease in dopamine activity. The caffiene probably couteracted some of the negitive effects of the SSRI on dopamine release.
Linkadge
Posted by Squiggles on May 20, 2006, at 19:43:27
In reply to Re: Statistical question on SSRIs - ADDENDUM, posted by linkadge on May 20, 2006, at 19:35:54
> I attributed the extreme inner restlessness as akathesa due to the SSRI causing acute decrease in dopamine activity. The caffiene probably couteracted some of the negitive effects of the SSRI on dopamine release.
>
> LinkadgeWhy would any chemist make an antidepressant
that interferes with the release of dopamine?
Isn't dopamine supposed to alleviate depression and other negative emotions?Squiggles
Posted by SLS on May 20, 2006, at 20:46:49
In reply to Re: Statistical question on SSRIs - ADDENDUM » SLS, posted by Squiggles on May 20, 2006, at 14:34:25
> > I keep seeing the word "akathisia" thrown around as if it were a common occurrence with SSRIs. I question this. My guess is that it is agitation and anxiety that is producing suicidality, and not akathisia per se. Prozac probably produces more agitation and anxiety than the other SSRIs.
> Regarding "akathisia" - the word is from the Greek, a-kathisia, meaning non-restfullness.
Akathisia is a term used in medicine to describe a specific syndrome. It is part of medical nomenclature and has a medical definition. It really doesn't matter what the etymology of the word is. Unfortunately, the description of akathisia is not unambiguous.
Akathisia (from the Greek "not to sit") was first described by Haskovec in 1901
Akathisia is generally acknowledged to have two components:
1. Subjective: feelings of inner restlessness and urge to move.
2. Objective: repetitive movements including rocking while standing or sitting, lifting feet as if marching in place and crossing and uncrossing the legs while sitting
There are several akathisia rating scales, but the Barnes's Akathisia Scale is the one most often employed.
- Scott
Posted by Squiggles on May 20, 2006, at 20:49:47
In reply to Re: Statistical question on SSRIs - ADDENDUM, posted by SLS on May 20, 2006, at 20:46:49
> >........
> There are several akathisia rating scales, but the Barnes's Akathisia Scale is the one most often employed.
>
>
I did not know that :-)I'm glad there is a scale.
Squiggles
>
Posted by Dr. Bob on May 20, 2006, at 22:07:51
In reply to I rescind the DNP, posted by Larry Hoover on May 16, 2006, at 23:06:01
Posted by linkadge on May 20, 2006, at 23:27:39
In reply to Re: Statistical question on SSRIs - ADDENDUM » linkadge, posted by Squiggles on May 20, 2006, at 19:43:27
>Why would any chemist make an antidepressant
>that interferes with the release of dopamine?
>Isn't dopamine supposed to alleviate depression >and other negative emotions?This is it. Fast acting antidepressants generally work via affecting dopamine release.
When you take an SSRI, you are stimulating a number of serotonin receptors that will indirecectly supress dopamine release (for a while at least untill some sort of compensatory adapation takes place)
5-ht1a, 5-ht2a/c, 5-ht1b, (and others) act as indibitory pathways on dopamine function.
Sure SSRI's are selective to serotonin, but not to specific serotonin receptors, as a result the final product is often a wild free for all.
In contrast however, consider some endogenious neuromodulators such as anandamide. Anandamide agonizes 5-ht1a but antagonizes 5-ht2, 5-ht3, and other. Very rarely in nature, will you find compounds that affect the system as bluntly as the SSRI's do. The result, like I said, is a free for all. Doctors often try to augment with atypicals, since they block some of the undesirable serotonin receptors.
Linkadge
Posted by Squiggles on May 21, 2006, at 6:45:11
In reply to Re: Statistical question on SSRIs - ADDENDUM, posted by linkadge on May 20, 2006, at 23:27:39
> >Why would any chemist make an antidepressant
> >that interferes with the release of dopamine?
> >Isn't dopamine supposed to alleviate depression >and other negative emotions?
>
> This is it. Fast acting antidepressants generally work via affecting dopamine release.
>
> When you take an SSRI, you are stimulating a number of serotonin receptors that will indirecectly supress dopamine release (for a while at least untill some sort of compensatory adapation takes place)
>
> 5-ht1a, 5-ht2a/c, 5-ht1b, (and others) act as indibitory pathways on dopamine function.
>
> Sure SSRI's are selective to serotonin, but not to specific serotonin receptors, as a result the final product is often a wild free for all.
>
> In contrast however, consider some endogenious neuromodulators such as anandamide. Anandamide agonizes 5-ht1a but antagonizes 5-ht2, 5-ht3, and other. Very rarely in nature, will you find compounds that affect the system as bluntly as the SSRI's do. The result, like I said, is a free for all. Doctors often try to augment with atypicals, since they block some of the undesirable serotonin receptors.
>
>
>
> Linkadge
>
>There seems to be a vogue for "agonizing" (i guess that is stimulating) serotonin receptors, which a friend of mine tells me are all over the the brain and body and the most numerous. I guess they are a bit like endocrine glands on a neurological level. BTW, I see here that anandamine is what cannabis stimulates:
http://www.steve.gb.com/science/nervous_system.html
But as you probably know, that really gets you stoned.
Are there any drugs that stimulate the dopamine receptors; Or even drugs that stimulate or are a clone of dopamine for depression? L-dopa is used in Parkinson's disease, and one of its side effects is the same as the effect of an anti-depressant.
p.s. It's amazing how simple and different the action of lithium is in comparison to man-made ADs.
Squiggles
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Dr. Bob is Robert Hsiung, MD,
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