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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by mikes on April 16, 2001, at 13:06:54
I'm not sure how much this has been discussed already on this board or around the net, but I wanted to bring it up. What do you think the actual level of efficacy for antidepressant medications is? I personally think it is quite low. Once you subtract the placebo percentage from the medication percentage (70-30, approximately) you get 40 percent. Maybe half of those people are responding to the real medication because of the side effects, which boosted the placebo effect. So a rough estimate is that 20 percent of people will respond to any one medication (by actual pharmacological mechanisms), if that.
I think many of the people on this board are those who would not respond to a placebo, and that is why they have tried so many different medications. I personally do not respond to placebos because my depression has lasted for as long as I can remember, and is fairly severe. St. John's Wort worked very well for a little while. Being stoned does too, however, I prefer not to be in that state during the day. I had a very bad reaction to paxil, and I haven't felt anything from zoloft after two weeks (I used marijuana once after the first week, I'm not sure if this would kill the efficacy).
It really annoys me that so few studies have been done on active placebos (placebos that produce side effects) in comparison to antidepressants. Why do psychiatrists say that antidepressants are very effective, when in reality most of the users are cured of their depression by placebo effect? What about the rest of us who don't respond? We just get screwed over? I guess so.
Posted by SalArmy4me on April 16, 2001, at 13:19:16
In reply to thoughts on active placebos and true efficacy? , posted by mikes on April 16, 2001, at 13:06:54
What's your story? Did you try a few antidepressants and they did not work? Try a different medication or you will suffer a lifetime full of endless torture and pain.
Posted by stjames on April 16, 2001, at 13:58:14
In reply to thoughts on active placebos and true efficacy? , posted by mikes on April 16, 2001, at 13:06:54
Why do psychiatrists say that antidepressants are very effective, when in reality most of the users are cured of their depression by placebo effect? What about the rest of us who don't respond? We just get screwed over? I guess so.
james here....
No one has been cured by a placebo. The studies with a placebo just last 1-2 months (generally) and I suspect if you were to follow the subjects
longer the placebo effect would not last and the depression would return.james
Posted by blackjack on April 16, 2001, at 16:41:14
In reply to Re: thoughts on active placebos and true efficacy? , posted by stjames on April 16, 2001, at 13:58:14
Also, depression is an episdic illness. It comes and goes. Most of the people whose depression goes away while on placebos are not responding to a "placebo effect." The depression would have gone away on its own during that time window one way or another.
Posted by SLS on April 16, 2001, at 19:06:20
In reply to thoughts on active placebos and true efficacy? , posted by mikes on April 16, 2001, at 13:06:54
Frederick Quitkin, MD has addressed some of the issues involving the use and interpretation of placebos when studying the effectiveness of treatment modalities.
- Scott---------------------------------------------------------
Validity of clinical trials of antidepressants.
Quitkin FM, Rabkin JG, Gerald J, Davis JM, Klein DF.
Department of Therapeutics, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
-------------------------------------------------------------
Am J Psychiatry 1999 Jun;156(6):829-36
Placebos, drug effects, and study design: a clinician's guide.
Quitkin FM.
New York State Psychiatric Institute, NY 10032, USA.
-------------------------------------------------------------
Neuropsychopharmacology 1996 Oct;15(4):390-4
Can the effects of antidepressants be observed in the first two weeks of treatment?
Quitkin FM, McGrath PJ, Stewart JW, Taylor BP, Klein DF.
Department of Therapeutics, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institution, New York 10032, USA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8887993&dopt=Abstract
--------------------------------------------------------------------
Br J Psychiatry 1998 Sep;173:242-8
Placebo run-in period in studies of depressive disorders. Clinical, heuristic and research implications.
Quitkin FM, McGrath PJ, Stewart JW, Ocepek-Welikson K, Taylor BP, Nunes E, Delivannides D, Agosti V, Donovan SJ, Ross D, Petkova E, Klein DF.
Department of Therapeutics, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institution, USA.
http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9926101&dopt=Abstract
--------------------------------------------------------------
Posted by mikes on April 16, 2001, at 23:23:16
In reply to Re: thoughts on active placebos and true efficacy? , posted by SLS on April 16, 2001, at 19:06:20
I don't think that ad's are a farce (how could they be, remember how the first maoi was discovered?), I was saying they working for maybe 20 percent. Which could still be true considering all of quitkin's writings. Furthermore, I am taking those writings with a grain of salt for two reasons. First, I don't have access to the actual paper (unless I want to spend seven dollars), and second, I haven't read any article that argues against Quitkin's findings. Quitkin is not God. I'm not going to believe what he says just because he is a doctor and can use big words.
> Frederick Quitkin, MD has addressed some of the issues involving the use and interpretation of placebos when studying the effectiveness of treatment modalities.
>
>
> - Scott
>
> ---------------------------------------------------------
>
> Validity of clinical trials of antidepressants.
>
> Quitkin FM, Rabkin JG, Gerald J, Davis JM, Klein DF.
>
> Department of Therapeutics, Columbia University College of Physicians and Surgeons, New York, NY 10032, USA.
>
> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10698806&dopt=Abstract
>
> -------------------------------------------------------------
>
> Am J Psychiatry 1999 Jun;156(6):829-36
>
> Placebos, drug effects, and study design: a clinician's guide.
>
> Quitkin FM.
>
> New York State Psychiatric Institute, NY 10032, USA.
>
> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=10360119&dopt=Abstract
>
> -------------------------------------------------------------
>
> Neuropsychopharmacology 1996 Oct;15(4):390-4
>
> Can the effects of antidepressants be observed in the first two weeks of treatment?
>
> Quitkin FM, McGrath PJ, Stewart JW, Taylor BP, Klein DF.
>
> Department of Therapeutics, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institution, New York 10032, USA.
>
> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=8887993&dopt=Abstract
>
> --------------------------------------------------------------------
>
> Br J Psychiatry 1998 Sep;173:242-8
>
> Placebo run-in period in studies of depressive disorders. Clinical, heuristic and research implications.
>
> Quitkin FM, McGrath PJ, Stewart JW, Ocepek-Welikson K, Taylor BP, Nunes E, Delivannides D, Agosti V, Donovan SJ, Ross D, Petkova E, Klein DF.
>
> Department of Therapeutics, Columbia University College of Physicians and Surgeons, New York State Psychiatric Institution, USA.
>
> http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&list_uids=9926101&dopt=Abstract
>
> --------------------------------------------------------------
Posted by stjames on April 16, 2001, at 23:56:20
In reply to Re: thoughts on active placebos and true efficacy? , posted by mikes on April 16, 2001, at 23:23:16
I'm not going to believe what he says just because he is a doctor and can use big words.
James here....I do not see your logic here, this seems an ineffective way to judge knowlage. Knowlage is full of big words.
james
Posted by JohnL on April 17, 2001, at 5:24:46
In reply to thoughts on active placebos and true efficacy? , posted by mikes on April 16, 2001, at 13:06:54
.....So a rough estimate is that 20 percent of people will respond to any one medication (by actual pharmacological mechanisms), if that.
My pdoc told me that 70% to 90% of patients will respond to medication if they try three different classes. At least one of them is likely (70%) to work.However, he also told me that only about 20% to 30% get totally well. The rest experience improvement, but they don't get totally cured. They are restored to a functioning state, but shy of a normal baseline state. He said the key to getting totally well is to keep experimenting, which most patients don't or won't do.
He believes that placebo responses and side effects can be confused with response, but that these are short term and do not endure the test of time.
And of course, ten different doctors would probably have ten different views. My pdoc though, being Head of Psychiatry and being in practice since before ADs were invented, offers insights gained from decades of experience and observation in real life clinical practice. I don't think any of his opinions are based on scientific principles, but rather they are based on what he actually saw occur in the real world.
True efficacy, as I see it, occurs when the particular drug is a superior match for the patient, in terms of chemical, genetic, and molecular variables. Our body chemistries will embrace the correct medication, but reject or ignore inferior matches, so to speak. Just my opinion.
John
Posted by SLS on April 17, 2001, at 11:44:16
In reply to Re: thoughts on active placebos and true efficacy? , posted by mikes on April 16, 2001, at 23:23:16
> I don't think that ad's are a farce (how could they be, remember how the first maoi was discovered?), I was saying they working for maybe 20 percent. Which could still be true considering all of quitkin's writings. Furthermore, I am taking those writings with a grain of salt for two reasons. First, I don't have access to the actual paper (unless I want to spend seven dollars), and second, I haven't read any article that argues against Quitkin's findings. Quitkin is not God. I'm not going to believe what he says just because he is a doctor and can use big words.
My reasons for producing the citations are that Quitkin and his team are the only psychiatric researchers I have come across that have looked at the dynamics of placebo in investigations of the treatment of depression. He also attempts to identify and quantify the bias that can exist in both clinician and investigator, as well as patient allegience. I don't see an obvious agenda in his methods and conclusions except to be better able to interpret investigative results and possibly refine experimental methodology. It seems to me that he tried to be objective, especially since he made it a point to recognize the potential for investigator bias.I had no agenda in citing Quitkin's work except to add to this thread some recognition that the placebo phenomenon in psychiatric investigations has actually been studied. I knew of Quitkin's studies, so I thought it might be a good idea to see something other than a pronouncement of our own beliefs. I don't know how best to interpret the results of these studies and reviews when taken together. I'm not sure that Quitkin does either. I don't know what he believes. The one thing that does tend to evolve from his findings is that antidepressants are substantially better than taking nothing at all. They are even substantially better than placebo, even active placebo. What is interesting is that people who reported feeling a slight improvement during the standard ten-day placebo run-in introductory phase of a study seem to have a better chance of responding well to the active agent. I don't think this observation is consistent with an agenda determined to equate placebo with nul. I imagine this result was as surprising to Quitkin's team as it is to me.
Anyone is free to interpret these citations in any way they want to. If I feel frisky, maybe I'll try to do so for myself.
Just some info... Not the word of God.
* If not by using scientifically meaningful words that just happen to be big, then how best should science report its results and interpretations?
- Scott
Posted by mikes on April 17, 2001, at 23:06:35
In reply to Re: thoughts on active placebos and true efficacy? , posted by JohnL on April 17, 2001, at 5:24:46
I can agree with that figure. I was saying that the 70% response rate(response meaning cured, or merely feeling something?)given for individual drugs in clinical trials is misleading.
That's unfortunate that only 30% are able to get well. When I find something that works for me I will always wonder if there isn't something else that might work a little better.
I would like to see some articles about long term response to placebo compared to meds, it would make sense for placebo to not work over time(at least for most people) if the depression was chronic, however, situational depression could arguably be cured permanently by a placebo.
What I was trying to point out with the initial post is that it's not accurate to say the medications available today (individually) are very effective at curing depression. We still have a long way to go. Is it possible to make one medication that will help 90% of patients? Maybe, maybe not.
> .....So a rough estimate is that 20 percent of people will respond to any one medication (by actual pharmacological mechanisms), if that.
>
>
> My pdoc told me that 70% to 90% of patients will respond to medication if they try three different classes. At least one of them is likely (70%) to work.
>
> However, he also told me that only about 20% to 30% get totally well. The rest experience improvement, but they don't get totally cured. They are restored to a functioning state, but shy of a normal baseline state. He said the key to getting totally well is to keep experimenting, which most patients don't or won't do.
>
> He believes that placebo responses and side effects can be confused with response, but that these are short term and do not endure the test of time.
>
> And of course, ten different doctors would probably have ten different views. My pdoc though, being Head of Psychiatry and being in practice since before ADs were invented, offers insights gained from decades of experience and observation in real life clinical practice. I don't think any of his opinions are based on scientific principles, but rather they are based on what he actually saw occur in the real world.
>
> True efficacy, as I see it, occurs when the particular drug is a superior match for the patient, in terms of chemical, genetic, and molecular variables. Our body chemistries will embrace the correct medication, but reject or ignore inferior matches, so to speak. Just my opinion.
> John
Posted by mikes on April 17, 2001, at 23:22:19
In reply to Re: thoughts on active placebos and true efficacy? , posted by SLS on April 17, 2001, at 11:44:16
Okay, sounds good.
What exactly is meant by "What is interesting is that people who reported feeling a slight improvement during the standard ten-day placebo run-in introductory phase of a study seem to have a better chance of responding well to the active agent. I don't think this observation is consistent with an agenda determined to equate placebo with nul. I imagine this result was as surprising to Quitkin's team as it is to me." Could you please rephrase(I'm stupid)?
You're right about the big words; I just didn't want to take everything Quitkin said as fact.
This is the end of the thread.
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