![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 38 to 62 of 116. Go back in thread:
Posted by Shadowplayers721 on April 17, 2008, at 15:15:33
In reply to They just don't work. FACT., posted by Betula on April 16, 2008, at 11:51:18
I would like to read the actual case study. Do you know where I may find that link? Thank you.
Posted by Larry Hoover on April 17, 2008, at 15:27:51
In reply to Re: They just don't work. FACT., posted by Shadowplayers721 on April 17, 2008, at 15:15:33
> I would like to read the actual case study. Do you know where I may find that link? Thank you.
I did a critique of the actual article, within which is a link to the full text. See: http://www.dr-bob.org/babble/20080221/msgs/815551.html
Lar
Posted by 10derHeart on April 17, 2008, at 15:56:49
In reply to Re: They just don't work. FACT. - Who cares? :-), posted by Betula on April 17, 2008, at 9:13:07
I believe in some cases - maybe I'd even say many cases - people aren't at all "just using drugs to mask the symptoms." For example, say someone does want to get to the root of the illness (and I'm not at all sure that concept applies across the board) through therapy, they first have to somehow find a therapist, call a T. for an appointment, and get themselves to that therapist's office. For people with crippling depressive or anxiety symptoms, well, you might as well ask them to climb Mt. Everest.
If you can't get out of bed, can't eat, sleep, and/or suffer from symptoms such as severe apathy, lethargy, anxiety, tearfulness, etc., you often can't even imagine doing things like picking up a phone, dressing yourself or driving to a therapist's office.
I'm just saying you can't be helped by therapy if you are too ill to "do" therapy. This is where even a somewhat effective AD can be a life-saving and critical tool for some people.
Posted by Larry Hoover on April 17, 2008, at 16:01:27
In reply to Re: They just don't work. FALLACY. » Shadowplayers721, posted by Larry Hoover on April 17, 2008, at 15:27:51
> > I would like to read the actual case study. Do you know where I may find that link? Thank you.
>
> I did a critique of the actual article, within which is a link to the full text. See: http://www.dr-bob.org/babble/20080221/msgs/815551.html
>
> LarI just took a quick read through what I wrote earlier, and I realize that I might have expressed one point a little more clearly. What I said was:
"Now, here's a very illustrative figure, Figure 4: http://medicine.plosjournals.org/perlserv/?request=slideshow&type=figure&doi=10.1371/journal.pmed.0050045&id=96831
First, the zero line is no difference (i.e. superiority) of drug or placebo. Below zero is placebo superiority, whereas above it is drug superiority. What's the pattern tell you? Do we find just as many points below the zero line, and just as far from it, as we do above it? "
What I should then have done is answer the question. The answer is a resounding NO! But, that's what we'd see if there was no difference between placebo and drug response. We'd see similar scatter above and below the zero effect size line. Instead, we see near absolute dominance of drug over placebo, and often times very substantial dominance, in individual trials.
The paper's conclusions are unsupported by the evidence.
In fact, Kirsch might have argued that the cost of psychotherapy could be eliminated by sugar pills, but I doubt he'd have suggested that.
Lar
Posted by 10derHeart on April 17, 2008, at 16:01:58
In reply to Re: They just don't work. FACT. - Who cares? :-) » Betula, posted by 10derHeart on April 17, 2008, at 15:56:49
I didn't mean in some cases there are people who don't want to get to the root, i.e., find out the basics of what might be causing their illness. I meant I'm unsure - and I think so are the "experts" - that there is any specific "root" to be able to get down to...biology, situational, both, etc. it's just so often about as clear as mud 'why' any given person is suffering from depression.
Hope *that* was a little clearer than mud.
Posted by SLS on April 17, 2008, at 16:31:13
In reply to just to clarify one part..., posted by 10derHeart on April 17, 2008, at 16:01:58
BIOLOGY OR PSYCHOLOGY?
The best answer to this question may be "either and both".
Many of us here have been diagnosed as having a mental illness. Mental
illnesses are NOT mental weaknesses. The diagnoses that we are most
familiar with include:1. Major Depression (Unipolar Depression)
2. Bipolar Disorder (Manic Depression)
3. Dysthymia (Minor Depression)
4. Seasonal Affective Disorder (SAD)
5. Schizophrenia
6. Schizo-Affective Disorder
7. Obsessive-Compulsive Disorder (OCD)
8. Post-Traumatic Stress Disorder (PTSD)All of these disorders have one thing in common. They are not our fault.
Each has both biological and psychological components. We all begin our
lives with a brain that is built using the blueprints contained within the
genes we inherit from our parents. Later, hormones change the brain to
prepare it for adulthood. The brain can be changed in negative ways by
things such as drugs, alcohol, and injury. The brain is also changed by
the things we experience.How we think and feel are influenced by our environment. Probably the most
important environment during our development is that of the family, with
the most important time being our childhood. We all have both positive and
negative experiences as we travel through life. How we are as adults is in
large part determined by these positive and negative experiences. They
affect our psychology, our emotions, and our behaviors. All of us can be
hurt by unhealthy negative experiences.Some of us are also hurt by unhealthy brains. Medical science has long
recognized that many mental illnesses are biological illnesses. Even
Sigmund Freud, who we know for his development of psychoanalysis, proposed
a role for biology in mental illness. The first solid evidence for this
concept in modern times came with the discovery of lithium in 1947.
Lithium was found to cause the symptoms of bipolar disorder (manic-
depression) to disappear completely, allowing people to lead normal lives.
Lithium helps to correct for the abnormal biology that is the cause of
bipolar disorder. Later biological discoveries included the observations
that the drug Thorazine (an antipsychotic) successfully treated
schizophrenia, and that Tofranil (an antidepressant) successfully treated
depression. Again, these drugs help to correct for the abnormal biology of
the brain that accompanies these illnesses.What about psychology? What role does it play in mental illness? This can
be a two-way street. The abnormal biology that occurs with some mental
illnesses affects our psychology how we think, feel, and behave. On the
other hand, our psychology can also affect our biology. As we now know,
the emotional stresses and traumas we experience change the way our brains
operate. This is especially true of things we experience during childhood.
These stresses can trigger the induction of abnormal brain function that
leads to major depression, bipolar disorder, schizophrenia, and other
major mental illnesses. In order for this to happen, however, there must
be a genetic or some other biological vulnerability to begin with.Unfortunately, there are still too many people who cannot bring themselves
to believe that the most common mental illnesses are actually brain
disorders. However, the vast majority of our top researchers in psychiatry
and neuroscience do.The National Institutes of Health, the federal governments official
repository of medical research, has made available to the public free
publications describing the current research into psychiatric disorders.
They include descriptions of the biological and psychological aspects of
major mental illness. Each of their press releases and research
publications begin by stating emphatically that these are indeed brain
disorders.NIMH Public Inquiries
6001 Executive Boulevard, Rm. 8184, MSC 9663
Bethesda, MD 20892-9663 U.S.A.
Voice (301) 443-4513; Fax (301) 443-4279
TTY (301) 443-8431It is important to understand that not all psychological and emotional
troubles are biological in origin. Again, we are all products of our
environments family, friends, enemies, school, work, culture, climate,
war, etc. Environments that are unhealthy often produce unhealthy people.
This, too, is not our fault.In conclusion, regardless of the cause of our mental illnesses, it is
important that we treat both the biological and the psychological. We will
all benefit most if we do.
Posted by antiserial on April 17, 2008, at 17:24:22
In reply to Re: just to clarify one part..., posted by SLS on April 17, 2008, at 16:31:13
"Unfortunately, there are still too many people who cannot bring themselves
to believe that the most common mental illnesses are actually brain
disorders. However, the vast majority of our top researchers in psychiatry
and neuroscience do."Of course NIMH would say something like that, as they're just another tentacle of the Psychopharmaceutical Industrial Complex.
Posted by SLS on April 17, 2008, at 19:16:28
In reply to I'm sorry, but NIMH isn't a trustworthy source » SLS, posted by antiserial on April 17, 2008, at 17:24:22
> "Unfortunately, there are still too many people who cannot bring themselves
> to believe that the most common mental illnesses are actually brain
> disorders. However, the vast majority of our top researchers in psychiatry
> and neuroscience do."
>
> Of course NIMH would say something like that, as they're just another tentacle of the Psychopharmaceutical Industrial Complex.
Ok.
- Scott
Posted by okydoky on April 17, 2008, at 21:37:47
In reply to Re: I'm sorry, but NIMH isn't a trustworthy source, posted by SLS on April 17, 2008, at 19:16:28
Scott,
Have not heard from you in a while. I see you are doing very well and I am enormously glad for you.Wishing all the best for you and that everything continues to go well. Live life to its fullest, you deserve it. I think just from reading some of the posts through the years most of us have come to know you as a very good caring kind person and appreciated you for reaching out to some of us in our times of need and sharing your stories.
Take care of yourself,
Irene
Posted by Shadowplayers721 on April 18, 2008, at 0:17:14
In reply to Re: They just don't work. FALLACY. » Shadowplayers721, posted by Larry Hoover on April 17, 2008, at 15:27:51
Based on my examination of the study, I did not find conclusive evidence that these medications were ineffective.
It appeared to me, the study was actually trying to obscure improvements made by participants receiving medications.
Those graphs in the study were quite unusual.
Mr. Hoover, you did an exceptional job of reviewing this study. To be sure, it wasn't an easy task. I think that I read over this study at least four times.
Posted by antiserial on April 18, 2008, at 4:04:24
In reply to Re: Wierd Some I know In real Life Feel Better off, posted by SLS on April 15, 2008, at 20:16:27
>There are magic pills.
The only true magic pill in existence is called placebo. No adverse effects and no dependancy.
Posted by SLS on April 18, 2008, at 5:28:22
In reply to Re: I'm sorry, but NIMH isn't a trustworthy source, posted by okydoky on April 17, 2008, at 21:37:47
Hi Okydoky
> Have not heard from you in a while. I see you are doing very well and I am enormously glad for you.
Thanks!
I am enormously thankful for your well-wishes.
Take care.
- Scott
Posted by SLS on April 18, 2008, at 5:30:46
In reply to Re: They just don't work. FALLACY., posted by Shadowplayers721 on April 18, 2008, at 0:17:14
> Mr. Hoover, you did an exceptional job of reviewing this study.
Larry's the man!
We are indebted to him for his contributions.
- Scott
Posted by SLS on April 18, 2008, at 5:31:33
In reply to Magic pills » SLS, posted by antiserial on April 18, 2008, at 4:04:24
> >There are magic pills.
>
> The only true magic pill in existence is called placebo. No adverse effects and no dependancy.Ok.
- Scott
Posted by Phillipa on April 18, 2008, at 13:23:24
In reply to Re: Magic pills » antiserial, posted by SLS on April 18, 2008, at 5:31:33
Fellow babblers since I started this thread I'd just like to add that some have medical chronic problems which can present as anxiety and depression so treatments may vary.Not all chose to disclose all the medical problems. Thanks for your understanding. Phillipa
Posted by Betula on April 19, 2008, at 3:41:34
In reply to They just don't work. FACT., posted by Betula on April 16, 2008, at 11:51:18
Hello all!
Its great we have an open debate about these sorts of things.
Here is the link to the webpage of the lead author of that article:
http://psy.hull.ac.uk/Staff/i.kirsch/
So. I'm going to make some points.
1) One paper doesn't prove a theory - it takes quite a few for something to become universally accepted.
2) The author is a PROFESSOR at a large civic university in the UK. (note its harder to become a professor in the UK - there doesn't exist sub categories such as 'assistant professor' etc as there does in other countries.) I doubt any of us here are actual professors. He has quite a distinguished publication record - again, something I'm sure none of any of us have.
3) The paper got published in a reputable, peer reviewed journal. That means that it was reviewed by other academics working in precisely the same field as him. They must have thought it acceptable for publication, otherwise, it would be sent to the trash. And it took a year from submission to acceptance, so that would imply it had a couple of revisions at least. So the peer reviewers would have been doing their job properly.
4) The journal the paper appeared in, PLoS Medicine. Journals do not want to lose money. The reputation of a journal (and also of the authors for that matter) quickly goes down the drain if they publish something that is trash. Other academics quickly see through fudged results etc. This means that journals select the very best papers they can. Therefore, I highly doubt that this paper is 'flawed' in any way.
5) Therefore I personally believe that this paper would not have been published if it were faulty/flawed/trash in any way. IT WAS PEER REVIEWED for heavens sake!
6) I personally do not believe dismissals of the paper coming from people in general, unless they are a) the authors of the paper or b) suitably qualitifed academics working in the field i.e. the 'peers'. Its as simple as that.
7) Of course, science evolves and develops and new things come to light, but at this time, I think that this paper is valid and the conclusions should be accepted into the bigger the scheme of things, including papers that show 'the drugs work'.
Posted by Betula on April 19, 2008, at 6:26:49
In reply to OOOOOOOOOOOOooooooooo, posted by Betula on April 19, 2008, at 3:41:34
And oh, I meant to say, why is it so that people can not accept the conclusion of the paper?
Does it challenge your world view in such a way that you simply have to deny the findings of it? Well, it would appear so.
Of course things are never black and white. This paper might be a complete and utter anomaly, (like I said before one paper doesn't really 'prove' anything) but that doesn't mean we can't consider it, relfect on it, and see that the authors may have some very good points.
We shouldn't readily dismiss it because it challenges our beliefs. It makes me sad to see that people are so very narrow minded.
Goodday to everyone, and I'm leaving now.
I do not want to inhabit a playground for people with personality disorders.
So please block me.
Posted by SLS on April 19, 2008, at 7:20:02
In reply to Re: OOOOOOOOOOOOooooooooo » Betula, posted by Betula on April 19, 2008, at 6:26:49
> And oh, I meant to say, why is it so that people can not accept the conclusion of the paper?
Kirsch is well known for his history of hystrionic papers condemning all of psychiatric medicine as a conspiracy of capitalists.
I have read several of his papers. In response, there have been papers who have focused on Kirsch's lack of recognition of treatment efficacy of drugs for what I consider to be his emotional attachment to his own ideas. He takes papers that conclude that drugs works and takes snippets from them and uses them out of context.
That's just a start.
If you want more of an arsenal for your hatred of drugs, you might want to look at the work of Peter Breggin. I've read his stuff, too. Again, I find an emotional attachment to his need to decry modern psychiatry.
Why are you so angry? You don't think modern medicine is actively pursuing better treatments for psychiatric disorders? Even if it is a matter of profit, it escapes most people that it is easier to make money off of a good drug than a bad one. To develop a novel drug that works better is goal of both R&D and sales.
Why are you angry at the use of the best treatments science has yet come up with to date? Imperfect drugs are better than none at all.
By the way, drugs work.
If you feel such an urgent need to leave this forum, perhaps it would reduce your psychosocial stress to do so. This would greatly reduce the pressure you put on your brain. Just a thought.
There has got to be a more effective way to get your points across other than to get blocked from posting on purpose for calling people names. As a community, we welcome new ideas.
Personally, I have never been wrong. One time, I thought I was wrong, but it turns out that I was mistaken.
- Scott
Posted by Racer on April 19, 2008, at 8:45:08
In reply to OOOOOOOOOOOOooooooooo, posted by Betula on April 19, 2008, at 3:41:34
>
> 2) I doubt any of us here are actual professors. He has quite a distinguished publication record - again, something I'm sure none of any of us have.
>We do have a few professors, and a few of us here do have fairly impressive publication records. Not necessarily in psychopharmacology, but I hope that you will consider offering your praise of others without having to include the contrast to posters here.
It's fine to say, "Hey, this is a professor, and he's got a great publication record," without adding in, "...unlike all of you here." In fact, for some of us, it would carry more weight if you did.
Posted by linkadge on April 19, 2008, at 10:30:17
In reply to Re: OOOOOOOOOOOOooooooooo » Betula, posted by SLS on April 19, 2008, at 7:20:02
Hi, I know I said I quit psychobabble and for the most part I have, but I was passing by and can't resist a good argument of this nature.
I have to completely agree with Betula (no surprise) and cannot let him go on this solo mission.
It reminds me of some good Simon and Garfunkle lyrics, domething along the lines of "a man hears what he wants to hear and disregards the rest", I think it was "The Boxer".
Anyhow, the point is with these drugs, is that it doesn't matter how much you talk to people about their lack of established efficacy, you are still going to get people who refuse to look at good science like this.
Then you get those babblers who are resorting to the very devices they condemn. The very babblers that suggest that single case reports are weak seem return to the logic that "they work for me, and that's all that matters". To some extend they're right, this is all that matters.
I think the study that Betula brought up is very important, becase it is infact *not* just one study. It is a meta analysis of 47 other studies and the largest one of its kind to date. As mentioned it includes data that the drug companies conveniently left out which increases its validity beyond any one single study or any previous subgroup of *more positive* released trial data.
Saying that Kirsh is biased only goes so far. If you are going to make a substantial argument that he has somehow biased this data than do so. I have not seen one person pose a good reason why his methodology is flawed in some way. He was using standard methods of statistical analysis as far as I know, can you or anyone point to his flaws?
Even those of you who publicly dismiss this study are probably saying to themselves "man, this really sucks".
The clinical trial is unfortunately the only real way to scientifically establish the efficacy of antidepressants. Other forms of persuasion are not scientific and therefore don't mean a whole lot. People poked holes in sick patients heads to let the "evil spirits" out for years and it was hard to convince them that their practice was flawed. You see, when you believe there is an association between two things, there is a tendency to only see information that favors that association and to dismiss contradictory information as being flawed. I am young enough that I can get out of the "antidepressant cult" but there are others that have been in it too long and it is unlikely that they will be able to ever get out. Its called "belief perseverance" I think. When people make certain faulty conclusions, it tends to stick even in the face of contradictory information.
Another thing to consider is this: Most people are here because their antidepressant is not working the way they would like it to. That's why I take their proclamations with a grain of salt. Many of the people here arguing may just be doing so to re-establish their faith in the drugs. It's like...it seems like you're more trying to convince yourself. Its just like my brother at Bible college. Even he admits that arguing for Christianity bolsters his faith when even he is doubting it. After all, arguing a particular point of view is the first step to believing it.
The idea that it is hard to distinguish antidepressants from placebos is not new and has long preceded this study.
What always surprises me though is that if this kind of meta analysis occurred for a cholesteral lowering drug ie. you found out that you were taking a certain cholesterol lowering drug that was generally no better than placebo, most people would note get all defensive. Probably because there isn't the same kind of surge in introspection upon initiation of a cholesterol drug.
The argument for endogenous depression is a valid one. But, provide me any data anywhere that the current line of antidepressants addresses any one proven chemical imbalance. For instance, the majority of the findings suggest that SERT activity is in fact low in depression. You're not targeting any imbalance by giving SERT inhibitors to these individuals. Other studyies suggest that NET is low and even MAO is decreased.
People can, and often do feel better off drugs. This is in no way a sign that their depression is not due to some biochemical abnormality. Like mentioned above, it would seem reasonable to me that an individual with an already abnormally low level of the serotonin transporter takes a drug that lowers it further, they may just feel worse. I know severely depressed individuals who simply feel worse on drugs period. Psychiatry does not have all the tools and all the answers.
If anything I would hope that some of the current studies could help liberate certain individuals. You see people on this board who have never (or rarely) helped by an antidepressant, yet they somehow feel that the drugs work and there is something wrong with them when they don't. I would hope that data like this would be liberating. I.e. perhaps by seeing that they don't work for others too, they might stop beating themselves up about the issue and go look for answers somewhere else.
So, I digress. The establishment of a solid logical arugument does not depend on the ability to convince of any one individual. The more I am away from babble the more I realize how much "GroupThink" goes on here. One person talks about a drug then all of a sudden another person needs it. Also, the more time you spend on a board discussing drugs, the more you don't see the other ways that you can address your problems. Petting a dog will raise your serotonin you know.
Its just like some of the issues brought up by Bulldog. Many people are just at their wits end in terms of who to believe about who has the answers for their problems. Believing that prescription antidepressants are the only ways to solve your problems is seductively convenient. It allows you to narrow your focus and disregard other useful information. It makes life easy, or does it?
If the drugs work for you, then great: live happily ever after. For the rest of us, don't be so surprised and upset when you're not getting prozac.com type results. Trust yourselves for a change, and reflect critically upon data like this. It may be more liberating than you know.
Anyhow, I just thought I'd stop by and say hi.
To somebody who was on lithium, zoloft, depakote, zyprexa, clonazepam and ritalin, (all at once) and told by top psychiatrists that I will never be able to live medication free, diet, exercise, and certain supplements have gone a long way.
Obviously not all cases are like this, but the point I am trying to make is to never stop rethinking and reasessing exactly what the meds are and are not doing for you.
Linkadge
Posted by Racer on April 19, 2008, at 11:23:03
In reply to Re: OOOOOOOOOOOOooooooooo, posted by linkadge on April 19, 2008, at 10:30:17
I'm cynical about all of this, but will say this:
Depression is a convenient word to describe a variety of symptom complexes. It's very possible that those studies which have been done to date have included multiple different underlying etiologies. (I won't even point out that they also exclude anyone who has any comorbidities or other confounding conditions.) In my considered opinion, it's also worth considering that depression itself alters psychological functioning, which introduces another variable: how much of the recovery from depression involves being able to replace maladaptive coping mechanisms with more effective, healthier strategies?
What I'm trying to say is that there are so many variables involved in the effectiveness of these medications, it's hard to distinguish just how effective they actually are.
What I've seen over the years, in life, online, wherever, is that some people would very much like to believe that their depression is *solely* biochemical, and that behavioral interventions are entirely unnecessary. It almost seems as though they see as insulting the suggestion than their behavior has any bearing whatsoever on their condition, and they seem unwilling to consider that perhaps addressing some behavioral issues might improve their outcome.
Using a physical example, I have a problem with one hip. My options are more than a little limited -- hip replacement, a surgical procedure to inject medications directly into the joint, medications with lots of side effects which would have a negative impact on my quality of life, etc. The problem is clearly physical, it shows up very clearly on MRI and X-Ray, and it can be addressed chemically or mechanically. And the one thing I have insisted on with each and every one of the doctors I've been referred to is this: I want physical therapy. It can't necessarily fix the underlying problem, but it can sure improve the functioning of the joint.
I believe that the same can be said of psychotherapy for depression. It may not fix any biochemical disturbances, but it certainly can improve functioning -- even in depression which is entirely endogenous. (And I believe in a more holistic view of depression -- that ALL depression stems from some interaction of genetics and environment.)
I'm one who believes that medications are more effective than placebo. In my reading, it looks to me as though there is a pretty robust initial response to placebo -- which is far overshadowed by the more sustained response to medication. That's my reading, my understanding -- and I believe quite strongly that I am more correct than you are. You, of course, believe that your understanding is more correct than mine. I can't see any hope that I can convince you of any strengths to my position, and so I will end here, having had my say.
Good luck in your life, and I wish you well.
Posted by linkadge on April 19, 2008, at 13:02:49
In reply to Re: OOOOOOOOOOOOooooooooo » linkadge, posted by Racer on April 19, 2008, at 11:23:03
>What I've seen over the years, in life, online, >wherever, is that some people would very much >like to believe that their depression is >*solely* biochemical, and that behavioral >interventions are entirely unnecessary. It >almost seems as though they see as insulting the >suggestion than their behavior has any bearing >whatsoever on their condition, and they seem >unwilling to consider that perhaps addressing >some behavioral issues might improve their >outcome.Thats why I think stepping back from boards like this can be a good thing. Although I have no studies to support the assertion, I would tend to think that people who consider medications just one tool in the box can probably go a lot further in recovery.
>I want physical therapy. It can't necessarily >fix the underlying problem, but it can sure >improve the functioning of the joint.
Yes. People use the analogy that depression is like diabeties, (ie you wouldn't tell a diabetic not to take insulin). This is true, but even my diabetic roomate (with an insulin pump) tells me that his effort improve his situation with dietary interventions and exercise has dramatically altered the way his body needs/utlizes insulin.
>I believe that the same can be said of >psychotherapy for depression. It may not fix any >biochemical disturbances, but it certainly can >improve functioning -- even in depression which >is entirely endogenous.
Absolutely. Its just like mice with Huntingons (an absolutely 100 percent genetically inherited disease attributed to a single faulty gene) can dramatically increase life expectancy and disease progression with simple things like exericse. There you have it, proof that environemntal manipulations can alter the way that genetic abnormalities express themselves.
>That's my reading, my understanding -- and I >believe quite strongly that I am more correct >than you are.You're entitled to your opinions.
>You, of course, believe that your understanding >is more correct than mine.
I personally wish that the case for antidepressants was stronger.
>I can't see any hope that I can convince you of >any strengths to my position, and so I will end >here, having had my say.
In science opinions are of limited usefullness. Other meta analysis before this have reached similar conclusions: that antidepressants are only very marginally more effective than placebo, and that this insignificant margin decreases even further when active placebos are used. I wish it weren't true. Please show me a meta analysis involving more clinical trials in which antidepressants overall fair better against placebo.
Publication bias in these sorts of things is strong too. This study is one of the first that attempts to reduce the effects of publication bias. In analysis of clincial trials of modern AD's it has been found that the single greatest predictive factor for the outcome is the identity of the funding body (i.e. if Lilly sponsors the study, Prozac comes out ahead). That says to me two things: that a) the data is flawed and that b) even in its flawed stated it still can barely proove its case!
Linkadge
Posted by Phillipa on April 19, 2008, at 13:24:00
In reply to Re: OOOOOOOOOOOOooooooooo, posted by linkadge on April 19, 2008, at 13:02:49
You know I feel as Racer does for different reasons. I feel like a total failure cause meds don't help me do the opposite of what they seem to do for others that they post. And for various reasons, age, money, physical conditions and I don't understand that article on thyroid. Guess I'm stupid. But my husband said if he knew I'd get sick which was when the thyroid condition started he would never have married me as he's younger. I warned him I would age faster than him. If my pdoc and others have said absolutely no to MAOI's I will listen to them and try to sort my thyroid endos and internists recommendations out first. And that is not easy the internist is an associate professor at Chapel Hill and the endos arent'. Internist says keep dose the same endo says lower it. So I'm in utter chaos. Can a med fix this. I say no. Sure it could drug me so I can't think can't anyway. And backpain is excruciating my guess is besides the degenerative discs and arthritis its anxiety. Uggg don't get old. Phillipa
Posted by bulldog2 on April 19, 2008, at 13:26:29
In reply to Re: OOOOOOOOOOOOooooooooo, posted by linkadge on April 19, 2008, at 13:02:49
I believe that the AD effect of maois was found by accident. The first maoi was an antibiotic given to people with TB.It was noticed that their mood was significantly boosted by the drug.This cannot be explained away by placebo effect when this drug was being used for TB and no one had reason to expect an AD effect.
Now this may have no relevance to any other class of AD drugs but it does point us in the direction that it is possible for drugs to have benefit in the treatment of depression and other mood disorders.
Now it is my belief that you still treat the entire body and be as healthy as you can be. That's proper diet, exercise, and treating any hormonal problems etc. It's just my feeling that meds can be a useful adjunct in the battle against depression.
Since this is a forum for a discussion of meds I just feel once you believe that meds don't work it's time to move on. It may be a valid conclusion for your depression. If I reached that conclusion I would not post that here.Someone may stop their meds or not start them and I don't want to be responsible for the consequences which could be devastating for that person.I may not believe that chemotherapy works and that natural alternatives are better but I wouldn't go into a forum for chemotherapy and start a thread on how chemo doesn't work.
Posted by Larry Hoover on April 19, 2008, at 13:33:57
In reply to OOOOOOOOOOOOooooooooo, posted by Betula on April 19, 2008, at 3:41:34
> Hello all!
>
> Its great we have an open debate about these sorts of things.I'll restrict my commentary to debate.
> Here is the link to the webpage of the lead author of that article:
>
> http://psy.hull.ac.uk/Staff/i.kirsch/
>
> So. I'm going to make some points.
>
> 1) One paper doesn't prove a theory - it takes quite a few for something to become universally accepted.Then why did you conclude that your proposition was "FACT", and on the basis of but one publication?
Science doesn't prove things. Scientific proof is a fallacy. Science *disproves* things. Science is advanced on falsification. What is left is either consistent or inconsistent with hypotheses or theories.
> 2) The author is a PROFESSOR at a large civic university in the UK. (note its harder to become a professor in the UK - there doesn't exist sub categories such as 'assistant professor' etc as there does in other countries.)We are not debating Kirsch, but the quality of his arguments.
> I doubt any of us here are actual professors.
And how do you come to believe that? You know nothing of the qualifications possessed by members of this anonymous group.
> He has quite a distinguished publication record - again, something I'm sure none of any of us have.
Again, how do you know? And how does prior publication come to bear on an analysis of this one?
> 3) The paper got published in a reputable, peer reviewed journal.
That's debatable, on its face. We're not talking about JAMA, BMJ, Lancet, Science, Nature et al. It got published, period.
> That means that it was reviewed by other academics working in precisely the same field as him. They must have thought it acceptable for publication, otherwise, it would be sent to the trash.
You have an entirely naive belief in what transpires during peer review. Primarily, it is a search for errors, or blatant inconsistencies among the hypothesis, method, data, results, and conclusions. It is not an assessment of the "value" of the work.
> And it took a year from submission to acceptance, so that would imply it had a couple of revisions at least.
Not necessarily. And one year is very typical.
> So the peer reviewers would have been doing their job properly.
That is a gross fallacy. Here are what a couple of experts in peer review have stated (from wiki):
"Drummond Rennie, deputy editor of Journal of the American Medical Association is an organizer of the International Congress on Peer Review and Biomedical Publication, which has been held every four years since 1986. He remarks, 'There seems to be no study too fragmented, no hypothesis too trivial, no literature too biased or too egotistical, no design too warped, no methodology too bungled, no presentation of results too inaccurate, too obscure, and too contradictory, no analysis too self-serving, no argument too circular, no conclusions too trifling or too unjustified, and no grammar and syntax too offensive for a paper to end up in print.'"
"Richard Horton, editor of the British medical journal The Lancet, has said that, 'The mistake, of course, is to have thought that peer review was any more than a crude means of discovering the acceptability not the validity of a new finding. Editors and scientists alike insist on the pivotal importance of peer review. We portray peer review to the public as a quasi-sacred process that helps to make science our most objective truth teller. But we know that the system of peer review is biased, unjust, unaccountable, incomplete, easily fixed, often insulting, usually ignorant, occasionally foolish, and frequently wrong.'"
Note the statement that peer review does not assess validity. Peer review is merely the beginning of the process of scrutiny. Validity is determined by the world at large, not an editorial board or peer review committee. You will note that my critique depended heavily on issues of validity, which Kirsch et al failed to even discuss.
> 4) The journal the paper appeared in, PLoS Medicine. Journals do not want to lose money.
Relevance? It certainly has no bearing on scientific validation, in any case.
> The reputation of a journal (and also of the authors for that matter) quickly goes down the drain if they publish something that is trash.
Indeed. As I earlier stated, it is perhaps relevant to consider that the paper was *not* published by BMJ, JAMA, Lancet, NEJM, Science, Nature or other top tier journals.
> Other academics quickly see through fudged results etc.
No, they do not. Fudged data cannot be assessed by any review mechanism. Failure to replicate is usually the beginning of such challenges. It certainly cannot be determined by peer review.
> This means that journals select the very best papers they can. Therefore, I highly doubt that this paper is 'flawed' in any way.
I'll address flaws (other than those I found) momentarily.
> 5) Therefore I personally believe that this paper would not have been published if it were faulty/flawed/trash in any way. IT WAS PEER REVIEWED for heavens sake!
The idea that peer review should be the limit of critical review is absurd. What would you do with two papers, both peer reviewed, with absolutely contradictory and mutually exclusive results? It is incumbent on readers to engage critical thinking processes, which did *not* occur with this paper. Its conclusions were swallowed whole by the lay press (and some scientists, too), without aforethought.
> 6) I personally do not believe dismissals of the paper coming from people in general, unless they are a) the authors of the paper orYou expect the authors to diss themselves?!?
> b) suitably qualitifed academics working in the field i.e. the 'peers'. Its as simple as that.
Well, let's see what his peers have said, shall we? From the reviews appended to the original article, and BMJ:
"In conclusion, the paper of Kirsch and his colleagues presents nothing that was not previously known, but it does introduce empirically unsupported conclusions and erroneous interpretation that are potentially misleading."
Oh, I said the same things in my critique.
"Among other things, these applications have revealed that the misuse of ordinal scaled data can produce erroneous data and drive inaccurate conclusions. Consequently, concerns must be raised over the accuracy of the results of the meta-regression performed by Kirsch et al, given they have undertaken sophisticated mathematical operations on data which do not support such activities. Moreover, it is worth noting that even the calculation of a mean, a standard deviation, and a change score are invalid on ordinal data, given that these all assume equal interval scaling."
Translation: The statistical methods applied during the meta-analysis (of the ordinal Hamilton Depression Scale scores) are not meaningful. Ergo, any conclusions therefrom suffer from the same limitation.
"In each case the null hypothesis that the Kirsch et al estimator is unbiased has been tested and overwhelmingly rejected."
Re-analysis of Kirsch's methods demonstrate that his methodology negatively biased the outcomes.
And, even if one accepts the premise that these data are analyzable via this methodolgy, a recalculation under more rigorous procedures provides this outcome:
"If the weighted mean difference is used (an equally, or more valid approach given that all studies utilised the same outcome measure, namely the HRSD) effect sizes expressed in HRSD scores are larger than reported in this study (2.8 vs 1.8), and paroxetine and venlafaxine reach the NICE criteria for 'clinical significance' (HRSD change > 3)."
Aside, I had estimated the effect size plotted on Table 4 at about d=3, so I feel validated that my common-sensical critical-thinking test of Kirsch's stats is supported mathematically.
> 7) Of course, science evolves and develops and new things come to light, but at this time, I think that this paper is valid and the conclusions should be accepted into the bigger the scheme of things, including papers that show 'the drugs work'.
The paper is not valid. That was the point of my critique, and of other reviewers.
Appending your other post here:
> And oh, I meant to say, why is it so that people can not accept the conclusion of the paper?
It fails when subjected to critical thinking. I do not form conclusions about a paper until I have done so. As the paper fails on multiple fronts, its conclusions are irrelevant. I form my own conclusions.
> Does it challenge your world view in such a way that you simply have to deny the findings of it? Well, it would appear so.
My world view is totally unknown to you. In debate, it does not enter into the exposition in any way. I deny the findings because they are methodologically unsound. I deny the conclusions because they are not supported by the data. And I deny the external validity of the paper because it is not representative of the body of evidence available to me.
> Of course things are never black and white. This paper might be a complete and utter anomaly, (like I said before one paper doesn't really 'prove' anything) but that doesn't mean we can't consider it, relfect on it, and see that the authors may have some very good points.
I did not see any "very good points". If only he had similarly criticized psychotherapy, which has an apparent effect size against placebo of only 0.149, *way* below the NICE criterion.
J Consult Clin Psychol. 2003 Dec;71(6):973-9.
Establishing specificity in psychotherapy: a meta-analysis of structural equivalence of placebo controls.Baskin TW, Tierney SC, Minami T, Wampold BE.
Department of Counseling Psychology, University of Wisconsin-Madison, 53706, USA.Placebo treatments in psychotherapy cannot adequately control for all common factors, which thereby attenuates their effects vis-a-vis active treatments. In this study, the authors used meta-analytic procedures to test one possible factor contributing to the attenuation of effects: structural inequalities between placebo and active treatments. Structural aspects of the placebo included number and duration of sessions, training of therapist, format of therapy, and restriction of topics. Results indicate that comparisons between active treatments and structurally inequivalent placebos produced larger effects than comparisons between active treatments and structurally equivalent placebos: moreover, the latter comparison produced negligible effects, indicating that active treatments were not demonstrably superior to well-designed placebos.
> We shouldn't readily dismiss it because it challenges our beliefs.It has nothing to do with my beliefs. I didn't get that far.
If his evidence was sound (in my perhaps not so humble scientific opinion), I would say that.
> It makes me sad to see that people are so very narrow minded.
<Spock eyebrow>
> Goodday to everyone, and I'm leaving now.
Why? I thought you welcomed open debate.
> I do not want to inhabit a playground for people <snip>.
I cannot grasp the basis for this remark.
Lar
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