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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 3 to 27 of 75. Go back in thread:
Posted by chumbawumba on May 11, 2009, at 0:07:35
In reply to Antidepressants Hardly Help ( Time Magazine), posted by rvanson on May 10, 2009, at 23:31:50
I saw this on the interweb and was going to post it I'm glad you did.
My experience has been that antidepressants helped me greatly, at least initially. Then without fail they "pooped" out. It's been frustrating since the initial effect was always good, very good, maybe even a little too good (as in hypomanic). And after taking them for many years I found myself becoming very irritable.
So now I just take thyroid medication and deal with the low level depression as best I can with therapy. I've given up on pharmacological psychiatry for the most part. Sigh.
Posted by jedi on May 11, 2009, at 2:31:59
In reply to Antidepressants Hardly Help ( Time Magazine), posted by rvanson on May 10, 2009, at 23:31:50
"Researchers from the U.K., U.S. and Canada analyzed results for fluoxetine (better known by the brand name Prozac), venlafaxine (Effexor), nefazodone (Serzone) and paroxetine (Paxil or Seroxat) all members of a class of drugs known as selective serotonin reuptake inhibitors (SSRIs)."
Kind of makes you wonder, when the person writing and the people editing the article don't know the difference between a SSRI(Prozac, Paxil), a SNRI (Effexor) and Serzone which is neither a SSRI or a SNRI.
Maybe they should let the people on this site proof read their stuff before they print it for the masses.
Jedi
Posted by yxibow on May 11, 2009, at 2:40:08
In reply to Re: Antidepressants Hardly Help ?????????, posted by jedi on May 11, 2009, at 2:31:59
> "Researchers from the U.K., U.S. and Canada analyzed results for fluoxetine (better known by the brand name Prozac), venlafaxine (Effexor), nefazodone (Serzone) and paroxetine (Paxil or Seroxat) all members of a class of drugs known as selective serotonin reuptake inhibitors (SSRIs)."
>
> Kind of makes you wonder, when the person writing and the people editing the article don't know the difference between a SSRI(Prozac, Paxil), a SNRI (Effexor) and Serzone which is neither a SSRI or a SNRI.
>
> Maybe they should let the people on this site proof read their stuff before they print it for the masses.
>
> Jedi
>
I would tend to agree.The statement:
only patients who are diagnosed "at the upper end of the very severely depressed category" get any meaningful benefit from the widely prescribed drugs.
sounds like a gross canard.
What is a "severely depressed category" ? There are multiple kinds of depression. Unipolar. Bipolar, with multiple variations. Psychotic depression. Dysthymia. Situational depression. Secondary depression.
But they all can be debilitating and since no two individuals responds to the same set of medications at the same milligrams because we're all different, it creates more false doubt than reality.
I'm not a great fan of pop medicine articles, at least those who don't quote significant journals with widespread studies.
Sure, there's some truth to all of these sorts of reporting but they're vastly oversimplified.
-- Jay
Posted by greywolf on May 11, 2009, at 2:58:11
In reply to Re: Antidepressants Hardly Help ????????? » jedi, posted by yxibow on May 11, 2009, at 2:40:08
I have found the experience to be true. SSRIs, SNRIs, NDRIS, etc. all had just about zero positive effect on me.
But what I wonder is whether the study was populated to any extent by those with serious, TREATMENT RESISTANT depression. If so, it's hopelessly skewed.
Greywolf
Posted by SLS on May 11, 2009, at 5:56:32
In reply to Re: Antidepressants Hardly Help ?????????, posted by greywolf on May 11, 2009, at 2:58:11
This claim comes up every so often.
It is untenable.
The article is almost as flawed as the studies it cites. The selection procedure for subjects used in clinical trials of antidepressants almost never includes a diagnostic processing of each candidate thoroughly enough to conclude with certainty that the investigators are treating the right disease - major depressive disorder (MDD) or bipolar disorder (BD). That's why it is so often observed that the more severe depressions benefit the most. A much higher proportion of these subjects have the genuine diseases being investigated. Of course, this does not indicate that less severe cases of MDD or BD respond to treatment. It is just that severe cases are more likely to be the real thing when selection criteria are so liberally inclusive.
These drugs work. It seems misanthropic to me that certain people should set out to prove otherwise.
- Scott
Posted by SLS on May 11, 2009, at 6:53:25
In reply to Re: Antidepressants Hardly Help ?????????, posted by SLS on May 11, 2009, at 5:56:32
I misspoke in my last post.
I said:
"That's why it is so often observed that the more severe depressions benefit the most. A much higher proportion of these subjects have the genuine diseases being investigated. Of course, this does not indicate that less severe cases of MDD or BD respond to treatment."
I meant to say:"Of course, this does not indicate that less severe cases of MDD or BD do not respond to treatment. They do."
- Scott
Posted by Larry Hoover on May 11, 2009, at 8:12:22
In reply to Antidepressants Hardly Help ( Time Magazine), posted by rvanson on May 10, 2009, at 23:31:50
I'm sorry, but that Kirsch et al study is complete garbage. I offered a detailed critique of it here: http://www.dr-bob.org/babble/20080221/msgs/815551.html
There were other significant criticisms that ended up in other posts, but this was my main set of issues with it.
I really wish this man would go away. He gives a bad name to cherry-pickers. (Cherry-picking is the act of mining statistics for the rare examples that support an argument that is contradicted by the body of the evidence.)
Lar
Posted by Garnet71 on May 11, 2009, at 10:37:13
In reply to Re: Antidepressants Hardly Help ?????????, posted by SLS on May 11, 2009, at 5:56:32
"The selection procedure for subjects used in clinical trials of antidepressants almost never includes a diagnostic processing of each candidate thoroughly enough to conclude with certainty that the investigators are treating the right disease - major depressive disorder (MDD) or bipolar disorder (BD)."
I think this reflects the reality of clinical practice more than it refutes it. Some doctors either 1) do not know the diagnosis or misdiagnose-especially for first time mental health patients and 2) do not investigate thoroughly to conclude if the right disease is being treated.
Posted by chumbawumba on May 11, 2009, at 14:22:31
In reply to Re: Antidepressants Hardly Help ?????????, posted by SLS on May 11, 2009, at 5:56:32
> This claim comes up every so often.
>
> It is untenable.
>
> The article is almost as flawed as the studies it cites. The selection procedure for subjects used in clinical trials of antidepressants almost never includes a diagnostic processing of each candidate thoroughly enough to conclude with certainty that the investigators are treating the right disease - major depressive disorder (MDD) or bipolar disorder (BD). That's why it is so often observed that the more severe depressions benefit the most. A much higher proportion of these subjects have the genuine diseases being investigated. Of course, this does not indicate that less severe cases of MDD or BD respond to treatment. It is just that severe cases are more likely to be the real thing when selection criteria are so liberally inclusive.Actually there was a different study you may have seen that addresses this issue and they found that when study inclusion criteria are narrow (like they are in Phase III clinical trials), the results seem to be skewed towards antidepressants. When they are broad so as to reflect more real life clinical practice conditions, efficacy drops.
http://ajp.psychiatryonline.org/cgi/content/abstract/appi.ajp.2008.08071027v1
Posted by SLS on May 11, 2009, at 15:11:05
In reply to Re: Antidepressants Hardly Help ?????????, posted by chumbawumba on May 11, 2009, at 14:22:31
> > This claim comes up every so often.
> >
> > It is untenable.
> >
> > The article is almost as flawed as the studies it cites. The selection procedure for subjects used in clinical trials of antidepressants almost never includes a diagnostic processing of each candidate thoroughly enough to conclude with certainty that the investigators are treating the right disease - major depressive disorder (MDD) or bipolar disorder (BD). That's why it is so often observed that the more severe depressions benefit the most. A much higher proportion of these subjects have the genuine diseases being investigated. Of course, this does not indicate that less severe cases of MDD or BD respond to treatment. It is just that severe cases are more likely to be the real thing when selection criteria are so liberally inclusive.
>
> Actually there was a different study you may have seen that addresses this issue and they found that when study inclusion criteria are narrow (like they are in Phase III clinical trials), the results seem to be skewed towards antidepressants. When they are broad so as to reflect more real life clinical practice conditions, efficacy drops.
>
> http://ajp.psychiatryonline.org/cgi/content/abstract/appi.ajp.2008.08071027v1
As much as I respect this syndicate of authors, two of whom I have seen personally, I must disagree with the premise of their argument.I have participated in phase III studies and have read the full articles of many more. I am convinced that it is not the selection criteria that are the problem, but, rather, the execution of the selection process. These authors ask us to assume that this process was executed properly in the studies they refer to. This is an assumption that cannot logically be made unless the authors can cite studies targeting this issue to prove it. There are very few studies of studies. I have never encountered a study of the execution and fidelity of selection procedures in phase III clinical trials of antidepressants. Selection is the most critical aspect of these studies, not the blinding of participants nor the presence of a placebo arm.
The authors of this article state:
"Phase III trials do not recruit representative treatment-seeking depressed patients"
This is absolutely true, and I am shocked that this study group is so unsophisticated as to forget to describe the many types of depressions that are part of this treatment-seeking population that they refer to. Who actually walks through the door? People can feel depressed for reasons ranging from the biological to the psychological to the situational for periods of time that are well over the two week minimum that is the criterion of the DSM IV. Someone with no biological depression can certainly be chronically depressed because of a multitude of psychological and emotional reasons. This is precisely the part of the population of treatment-seeking people who must be EXCLUDED rather than included. I contend that these subpopulations DO NOT suffer from having a biological illness that should be the target of these investigations.
- Scott
Posted by chumbawumba on May 11, 2009, at 16:47:28
In reply to Re: Antidepressants Hardly Help ?????????, posted by SLS on May 11, 2009, at 15:11:05
>Someone with no biological depression can certainly be chronically depressed because of a multitude of psychological and emotional reasons. This is precisely the part of the population of treatment-seeking people who must be EXCLUDED rather than included. I contend that these subpopulations DO NOT suffer from having a biological illness that should be the target of these investigations.
>
>
> - Scott
I think all depression is biological in that a depressed persons brain is physically different, on the cellular level and the gross anatomic level. Regardless of etiology.I think what you are saying is that study inclusion criteria should be made even more narrow so as to only include people who have a genetic proclivity for depression. Pure depressives so to speak. People who just seem to be depressed for no apparent reason. Who are born that way. Is that right or am I putting words in your mouth?
I suppose that would be helpful in that you kind of isolate one subset and focus on treating the root cause and eliminate confounds. I'm not sure how you would do it other than genetic testing and I don't think those test exist yet.
But I think this group of "pure depressives" would be a rather small segment. What about the rest of us? People who might not be homozygous (pure depressives) but heterozygous. Maybe we have some genetic vulnerability, but we were beaten as children or bullied. Or went through a bad marriage, or drink too much, or have Axis II personality features, or a co-morbid medical condition.
This is the larger group of people I suspect. And I think it would probably help a greater number of people to find treatments for us heterozygotes than it would to find treatments for the pure homozygote. Homozygotes being less common in a population almost by definition.
(I'm using the single gene dominant-recessive model for depression here, I know its not that simple)
Posted by Zana on May 11, 2009, at 18:51:02
In reply to Re: Antidepressants Hardly Help ( Time Magazine), posted by Larry Hoover on May 11, 2009, at 8:12:22
Nice critique Larry. You should publish it.
Zana
Posted by chumbawumba on May 11, 2009, at 19:10:06
In reply to Re: Antidepressants Hardly Help ( Time Magazine), posted by Larry Hoover on May 11, 2009, at 8:12:22
> I'm sorry, but that Kirsch et al study is complete garbage. I offered a detailed critique of it here: http://www.dr-bob.org/babble/20080221/msgs/815551.html
>
> There were other significant criticisms that ended up in other posts, but this was my main set of issues with it.
>
> I really wish this man would go away. He gives a bad name to cherry-pickers. (Cherry-picking is the act of mining statistics for the rare examples that support an argument that is contradicted by the body of the evidence.)
>
> LarI read your critique and don't really have a strong feeling one way or the other about the study, but it does seem like you have a dog in this fight.
The phrase "I have profound contempt for this latest work." just makes me think you're pro-medication? Just a wild guess. Nothing wrong with that, it just suggests a bias.
Posted by Larry Hoover on May 11, 2009, at 20:22:53
In reply to Re: Antidepressants Hardly Help ( Time Magazine), posted by chumbawumba on May 11, 2009, at 19:10:06
> The phrase "I have profound contempt for this latest work." just makes me think you're pro-medication? Just a wild guess. Nothing wrong with that, it just suggests a bias.
I *revealed* bias. I am pro-science. Your "wild guess" is completely off the mark.
Lar
Posted by chumbawumba on May 11, 2009, at 20:30:46
In reply to Re: Antidepressants Hardly Help ( Time Magazine) » chumbawumba, posted by Larry Hoover on May 11, 2009, at 20:22:53
Well science is unemotional , contempt is not.
Posted by Larry Hoover on May 11, 2009, at 20:56:40
In reply to Re: Antidepressants Hardly Help ( Time Magazine), posted by chumbawumba on May 11, 2009, at 19:10:06
> The phrase "I have profound contempt for this latest work." just makes me think you're pro-medication? Just a wild guess. Nothing wrong with that, it just suggests a bias.
Well, here's another in a lengthy thread on the subject.
https://www.dr-bob.org/babble/20080420/msgs/824891.htmlI have contempt for "scientists" who resort to deception in furtherance of an argument that has no factual basis. His paper was political, not scientific.
For example, the HAM-D is not an interval scale, it is ordinal. It is inappropriate to submit HAM-D scores to the statistical methods employed by Kirsch.
From another post I made, I quoted from other scientists' criticisms of the paper:
(Me)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."
(Me) 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."
(Me) 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."
(Me)Re-analysis of Kirsch's methods demonstrate that his methodology negatively biased the outcomes.
(Me)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)."
(Me)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.
Regards,
Lar
Posted by Larry Hoover on May 11, 2009, at 20:57:44
In reply to Re: Antidepressants Hardly Help ( Time Magazine), posted by chumbawumba on May 11, 2009, at 20:30:46
> Well science is unemotional , contempt is not.
You are right, contempt is personal. Does that somehow invalidate my arguments?
Lar
Posted by chumbawumba on May 11, 2009, at 21:11:40
In reply to Re: Antidepressants Hardly Help ( Time Magazine) » chumbawumba, posted by Larry Hoover on May 11, 2009, at 20:57:44
> > Well science is unemotional , contempt is not.
>
> You are right, contempt is personal. Does that somehow invalidate my arguments?
>
> LarNo not at all. Also I happen to agree that medications can be very helpful.
But you have invested a fair amount of time in critiqueing this particular study. It just seems like you've taken a side pretty passionately.
Posted by Larry Hoover on May 11, 2009, at 21:19:40
In reply to Re: Antidepressants Hardly Help ( Time Magazine), posted by chumbawumba on May 11, 2009, at 21:11:40
> > > Well science is unemotional , contempt is not.
> >
> > You are right, contempt is personal. Does that somehow invalidate my arguments?
> >
> > Lar
>
> No not at all. Also I happen to agree that medications can be very helpful.I wish they had been for me, but my negative experiences are anecdotal.
> But you have invested a fair amount of time in critiqueing this particular study. It just seems like you've taken a side pretty passionately.
Indicating why a political treatise masquerading as science is false can require some effort.
Lar
Posted by sowhysosad on May 11, 2009, at 21:37:29
In reply to Re: Antidepressants Hardly Help ?????????, posted by SLS on May 11, 2009, at 5:56:32
> These drugs work. It seems misanthropic to me that certain people should set out to prove otherwise.
Too right. The traditionalist right-wing tabloid press over here (the UK) has an agenda to discredit modern AD's which just seems like sheer malevolence.
Or perhaps they think that treating a mental illness is somehow "un-British". "Stiff upper lip" and all that ****. After all, they wouldn't try to discredit chemotherapy or insulin. (Mind you, they have printed mounds of unexpurgated, unscientific crap trying to link autism to the MMR vaccine, which has directly caused record levels of measles cases.)
Why don't they just **** off and let us take our meds in peace?
Posted by Sigismund on May 11, 2009, at 21:47:34
In reply to Re: Antidepressants Hardly Help ?????????, posted by sowhysosad on May 11, 2009, at 21:37:29
>These drugs work. It seems misanthropic to me that certain people should set out to prove otherwise.
They work a bit but they don't work very well.
And if they work well they will likely be banned.
Posted by sowhysosad on May 11, 2009, at 21:50:45
In reply to Re: Antidepressants Hardly Help ?????????, posted by sowhysosad on May 11, 2009, at 21:37:29
It's also just occurred to me that perhaps some unsavoury hacks highlight these scientifically-bankrupt studies because they think they're being pioneering in exposing some "big lie" and revealing the "truth" about particular treatments.
That would explain why the MMR/autism nonsense still has legs in the UK years after the original research was debunked. In a journalist's mind, it's far more appealing to portray a useful and innocuous medical intervention as scary and sinister than it is to reflect actual science.
> > These drugs work. It seems misanthropic to me that certain people should set out to prove otherwise.
>
> Too right. The traditionalist right-wing tabloid press over here (the UK) has an agenda to discredit modern AD's which just seems like sheer malevolence.
>
> Or perhaps they think that treating a mental illness is somehow "un-British". "Stiff upper lip" and all that ****. After all, they wouldn't try to discredit chemotherapy or insulin. (Mind you, they have printed mounds of unexpurgated, unscientific crap trying to link autism to the MMR vaccine, which has directly caused record levels of measles cases.)
>
> Why don't they just **** off and let us take our meds in peace?
Posted by chumbawumba on May 11, 2009, at 22:13:18
In reply to Re: Antidepressants Hardly Help ( Time Magazine) » chumbawumba, posted by Larry Hoover on May 11, 2009, at 21:19:40
> Indicating why a political treatise masquerading as science is false can require some effort.
>
> Lar
>OK, I think somewhere I missed the point tremendously. I thought we were just talking about whether or not it was good science.
Why do you think this is a political treatise? Is it because the socialized medical system in Britain (and possibly soon the US) wouldn't have to pay for these drugs if they were discredited?
No wonder you're passionate if politics are involved :)
Posted by sowhysosad on May 11, 2009, at 22:18:11
In reply to Re: Antidepressants Hardly Help ?????????, posted by Sigismund on May 11, 2009, at 21:47:34
They've been almost entirely effective and tolerable for me on a number of occasions, and anecdotal evidence would suggest for many other people too. I don't think research reflects exactly how successful meds can be because of candidate selection issues outlined earlier in this thread.
Still, I appreciate that we probably all have subtly different underlying causes for our depression, so SSRI's will be useless for some.
> >These drugs work. It seems misanthropic to me that certain people should set out to prove otherwise.
>
> They work a bit but they don't work very well.
>
> And if they work well they will likely be banned.
Posted by SLS on May 11, 2009, at 22:25:58
In reply to Re: Antidepressants Hardly Help ?????????, posted by chumbawumba on May 11, 2009, at 16:47:28
> I think all depression is biological...Let us start at the beginning.
1. What is depression? How do you know it when you see it? What are YOUR criteria for identifying depression?
> in that a depressed persons brain is physically different
2. Is it your contention that every person that you identify as depressed according to the criteria you established in question number one demonstrates morphological, physiological, or genetic aberrations that can be measured and deemed to be pathological?
- Scott
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