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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 72 to 96 of 139. Go back in thread:
Posted by Sobriquet Style on April 8, 2006, at 17:20:01
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by greywolf on April 8, 2006, at 10:24:31
Posted by SLS on April 8, 2006, at 19:01:56
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 8, 2006, at 16:46:21
> > Despite all of my treatment failures, I still >believe that, in capable hands, over 75% of MDD >people will respond well to the drugs we already >have available, especially when used as part of >a multimodal approach that may include >psychotherapy, nutrition, and even exercise.
> I don't think that drugs are responsible for getting 75% of people better. Clinical trials certainly don't demonstrate this,
What I attempted to convey is that an effective treatment regime can be produced for 75% if one were to use every drug currently available alone or in combination. Very few trials have been designed to study this.
That's 65% using only 3 antidepressants monotherapeutically.
> and even less when you remove possible effect of placebo,
The magnitude of the placebo response varies inversely with the severity of the depression being used as inclusion criteria.
http://ajp.psychiatryonline.org/cgi/content/full/157/3/327
- Scott
Posted by Squiggles on April 8, 2006, at 20:06:05
In reply to Drugs versus Psychotherapy - Backlash?, posted by SLS on April 6, 2006, at 9:43:54
> All of a sudden, psychotherapy is as effective as drug therapy for treating depression!
>
> That's right.
>
> Just look at the medical literature.
>Uhm, which medical literature is that?
> Less than a decade ago, nearly all of the double-blind studies demonstrated a clear advantage to drug therapy over psychotherapy for treating depression.
>
> Now, it is difficult to find such studies. Most of the current literature claims equal effectiveness between the two modes of treatment.
>
> How can this be?Indeed;
>
> Can it be that the emergence of CBT (cognitive behavioral therapy) as the psychotherapeutic treatment of choice has drastically improved the response rate to psychotherapy?Highly unlikely as there is nothing
to improve on - a questionnaire is
a questionnaire is a questionnaire;
>
> Have current investigations defined depression in a different way than they did ten years ago?Possibly;
>
> Have the rating methods or measurement standards that define treatment success changed?Very probable;
>
> Is there a backlash against using drugs to treat depression to be found in the field of psychiatric investigation?Well, maybe doctors are getting sick of
trying 100 more new drugs and have run
out of new diseases to invent;
> A little of all the above?
>
> What's going on?
>
I don't know Scott; I just hope common sense
and knowledge eventually meet at the crossroads
of signs and symptoms in medicine.Squiggles
Posted by linkadge on April 9, 2006, at 9:10:59
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 8, 2006, at 19:01:56
I can't interprate that last link.
Perhaps placebo responce to drugs goes down as severe depression goes up, but so does responce to active drugs. So this still doesn't determine whether the percentage of placbo responders goes down as sevarity goes up. Perhaps I inteprated incorrectly.
Linkadge
Posted by linkadge on April 9, 2006, at 9:13:23
In reply to Drugs versus Psychotherapy - Backlash? » SLS, posted by Squiggles on April 8, 2006, at 20:06:05
It wasn't too long ago that cocaine was used for nervous depression. I think that we are foolish to think that similar mistakes couldn't happen again.
Hey, cocaine even increases BDNF !
Linkadge
Posted by Squiggles on April 9, 2006, at 9:22:05
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 9, 2006, at 9:13:23
> It wasn't too long ago that cocaine was used for nervous depression. I think that we are foolish to think that similar mistakes couldn't happen again.
>
> Hey, cocaine even increases BDNF !
>
> Linkadge
>I'm not so sure that cocaine "isn't" a good
drug for some conditions for a short period
of time. Maybe doctors do use cocaine in
certain cases. I'm not suggesting dependence
is a good thing of course.Squiggles
Posted by linkadge on April 9, 2006, at 11:44:28
In reply to Re: Drugs versus Psychotherapy - Backlash? » linkadge, posted by Squiggles on April 9, 2006, at 9:22:05
I understand.
I guess I am trying to say that it has been the downfall of each generation in science to think that its answers are the safest, most complete and perfect.
It could well be that, (say in 20 years) SSRI's are labled addictive and taken off the market in favor of new drugs.
Linkadge
Posted by ed_uk on April 9, 2006, at 12:51:29
In reply to Re: Drugs versus Psychotherapy - Backlash? » Squiggles, posted by linkadge on April 9, 2006, at 11:44:28
Hi Link
>I guess I am trying to say that it has been the downfall of each generation in science to think that its answers are the safest, most complete and perfect.
So true. I've been exercising more lately btw. Haven't lost any weight though - I EAT TOO MUCH!
Eddy
Posted by ed_uk on April 9, 2006, at 12:56:30
In reply to Re: Drugs versus Psychotherapy - Backlash? » Squiggles, posted by linkadge on April 9, 2006, at 11:44:28
RE SSRIs, they have relieved me of anxiety.......but they have also turned me into a loser. My motivation was so poor I dropped out of university.......and I don't have the motivation to go back. I'm probably gonna be stuck on the minimum wage for the rest of my life being treated like sh*t because everyone things they're superior to people like me - who are apparantly not worth listening to either.
Sh*t
ED
PS. I have no libido. Will it ever come back? I stayed off SSRIs for a few months once and it barely came back.
PPS. I don't feel proper emotions. I don't feel love. How can a person start a relationship when they can't feel love?
Posted by SLS on April 9, 2006, at 13:20:51
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 9, 2006, at 9:10:59
> Perhaps placebo responce to drugs goes down as severe depression goes up, but so does responce to active drugs.
Yes! You have just hit the target!
It seems that if one limits the study population to those who have the severest of depressions that meet DSM criteria for MDD, antidepressants look more like wonder drugs. If, on the other hand, you were to give an antidepressant to a population of people whose mood depends entirely on how they think, a biological intervention will do little to affect them. In this case, the response rate is similar to placebo. Unfortunately, antidepressant trials in the past have included subjects with a psychologicaly driven depression. That's why the placebo rate is so high. Many of these people are very susceptible to suggestion.
It is my guess that the preponderance of people with severe depression have a biological disorder while those with mild to moderate depressions are more likely to have a strong psychological component. This is why I keep questioning what we mean when we use the word "depression". People whose depression evolves from a psychogenic diathesis are far more apt to demonstrate a placebo effect because it is their expectation that they will be helped. I believe this expectation changes their outlook and therefore changes their mood. With psychogenic depressions, you can change the way you feel by changing the way you think. With biogenic depressions, this is not true. The way you think is determined by the way you feel.
It would be ideal to identify the difference between an endogenous versus an exogenous depression when choosing a treatment modality. However, things are not that simple. I believe that there is an affective spectrum within which are an array of psychobiologies. At either end of the spectrum lie people whose depressions are either entirely biological or entirely psychological. In between lie those whose depressions are driven by a mix of both biological and psychological contributions. I find this framework appealing because it works well to explain the phenomenology of depression as a syndrome rather than a single illness. I find that the inferences that can be drawn from this model explains much about what we see happening in the diagnosis and treatment of depression.
- Scott
Posted by SLS on April 9, 2006, at 13:24:25
In reply to Re: Drugs versus Psychotherapy - Backlash? » linkadge, posted by ed_uk on April 9, 2006, at 12:51:29
> >I guess I am trying to say that it has been the downfall of each generation in science to think that its answers are the safest, most complete and perfect.
> So true.Surely, I never implied any such thing about our current treatments for depression. Who did?
- Scott
Posted by Squiggles on April 9, 2006, at 14:21:30
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 9, 2006, at 13:24:25
Are there doctors or medical personnel,
or medical students conversing with
posters here? If this is a confidential
question, you need not answer.Thank you
Squiggles
Posted by linkadge on April 9, 2006, at 14:34:05
In reply to Re: Drugs versus Psychotherapy - Backlash? » linkadge, posted by ed_uk on April 9, 2006, at 12:51:29
Its all about doing your best.
Linkadge
Posted by linkadge on April 9, 2006, at 14:46:50
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 9, 2006, at 13:20:51
> Perhaps placebo responce to drugs goes down as severe depression goes up, but so does responce to active drugs.
What I mean was...responce to active drugs goes down as sevarity of depression goes up. But then I already see you disagree.
I would think that is the same with a lot of severe mentall illnesses. Ie severe schizophrenia generally has a poor long term outcome with drugs. Severe bipolar and severe parkinsons generally fare poorly on drugs alone.
I guess I don't really have data on that claim, I would just assume.
Linkadge
Posted by linkadge on April 9, 2006, at 14:49:18
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 9, 2006, at 13:24:25
I just have a hard time thinking that these drugs are solving underlying biochemical abnormalities when we don't know the underlying abnormalities in "endogenious" depression.
Linkadge
Posted by Squiggles on April 9, 2006, at 14:52:35
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 9, 2006, at 14:49:18
> I just have a hard time thinking that these drugs are solving underlying biochemical abnormalities when we don't know the underlying abnormalities in "endogenious" depression.
>I'm not sure they are solving them - that would
be taking you to a perfectly "normal" state - but
they are taking you out of depression and
allowing you to cope and live a moderately
comfortable life, with the exception of a few
bad moments or days, or months sometimes.Squiggles
Posted by SLS on April 9, 2006, at 15:12:42
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 9, 2006, at 14:46:50
> What I mean was...responce to active drugs goes down as sevarity of depression goes up.
Perhaps, but that the active compound separates itself from placebo becomes clear.
- Scott
Posted by SLS on April 9, 2006, at 15:20:25
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 9, 2006, at 14:49:18
> I just have a hard time thinking that these drugs are solving underlying biochemical abnormalities when we don't know the underlying abnormalities in "endogenious" depression.
>
> Linkadge
That's why we must rely on empirical observations. That's basically what the DSM is all about and why must rely on blinded studies with placebo controls.It is frustrating dealing with a black box.
- Scott
Posted by Caedmon on April 9, 2006, at 15:25:52
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 9, 2006, at 14:46:50
> What I mean was...responce to active drugs goes down as sevarity of depression goes up. But then I already see you disagree.
>
> I would think that is the same with a lot of severe mentall illnesses. Ie severe schizophrenia generally has a poor long term outcome with drugs. Severe bipolar and severe parkinsons generally fare poorly on drugs alone.
Severe schizophrenia and bipolar have a poor prognosis in general. I'm sure that meds + therapy increase remission or response at least to a degree but primary Tx modality in both cases are drugs. Or anyway, ideally is.(Yes, I know they did some work on CBT and schizophrenia. Longitudinal studies show CBT does very poorly for psychosis. Actually, it does poorly for anxiety disorders too, but that's another story.)
I don't understand the Parkinson's reference. Being a progressive, degenerative neurological movement disorder, I don't know why it's included. (Unless you're talking about comorbid depression?) That's like saying that dementia doesn't respond well to drugs long-term. Well, of course not, it doesn't respond well to *anything* long-term.
- C
Posted by Squiggles on April 9, 2006, at 15:30:20
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by Caedmon on April 9, 2006, at 15:25:52
That's interesting - it is probably the reason
my doctor said I don't need a psychiatrist.But even in psychotic disorders like bipolar
or brain disorders like amnesias, Alzheimer's
etc., I think that instead of cognitive therapy,
a sympathetic ear might do wonders. People
are still people even when they are sick.Squiggles
Posted by linkadge on April 9, 2006, at 19:45:56
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by Caedmon on April 9, 2006, at 15:25:52
I guess the connection is that, like with mood disorders, drugs for Parkinson's don't really attack the underlying disease. They may be kickstarting a poorly working system. So if there is such thing as progressive dopaminergic degeneration, why could this not exist with other neurotransmiiter systems. Maybe chronic depression is actually due to progressive dammage to the serotonergic system. (Now I know nothing like that has been proven, but its possible)
There is some evidence that certain treatments for neurological disorders can actually worsen certain of the detectable underlying abnormalities. Ie, Dopa for Parkinsons, Haldol in Schizophrenia.
We are discovering things about the drugs now that we didn't know before. For instance, the TCA's have been avilable for a while, but only recently have warnings been put forward regarding possible exacerbation of suicidality in certain populations.
People just assume that if it has been around long enough that it is safe. Hopefully new technology can verify our assumptions, but perhaps they will verify our fears?
Linkadge
Posted by linkadge on April 9, 2006, at 19:51:39
In reply to Re: Drugs versus Psychotherapy - Backlash? » Caedmon, posted by Squiggles on April 9, 2006, at 15:30:20
Its the same story with drugs like Aricept. Alzheimers is due to plaques and tangles isn't it? Acetylcholinsterase inhibitors only offer symptomatic improvement. If thats your only option then fine, but we do know that other (proactive strategies) can actually put off Alzheimer's onset. Thats more significant.
I hate the idea of becoming a Darth Vader (more machiene now than man). I remember when I was taking like 6 drugs at one point, I was told I'd never see the light of day off drugs. I felt like a freak. My poor brain.Linkadge
Posted by Phillipa on April 9, 2006, at 20:22:47
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by ed_uk on April 9, 2006, at 12:56:30
Ed I love you my adopted Son and listen to you most of the time. Love PJ XXXXXXXX
Posted by Caedmon on April 9, 2006, at 21:18:11
In reply to Re: Drugs versus Psychotherapy - Backlash? » Squiggles, posted by linkadge on April 9, 2006, at 19:51:39
> Its the same story with drugs like Aricept. Alzheimers is due to plaques and tangles isn't it? Acetylcholinsterase inhibitors only offer symptomatic improvement. If thats your only option then fine, but we do know that other (proactive strategies) can actually put off Alzheimer's onset. Thats more significant.
There is a way to significantly put off dementia? Although I should only think it will provide short-term (i.e. a few years) worth of protection.
Why is that *more* significant? Is it more significant when you are finally an Alzheimer's patient? I don't understand, the dichotomy seems false. Regards,
- C
Posted by ed_uk on April 10, 2006, at 13:44:09
In reply to Re: Drugs versus Psychotherapy - Backlash? » ed_uk, posted by Phillipa on April 9, 2006, at 20:22:47
Thanks PJ! But what did I do?
Ed xxx
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Dr. Bob is Robert Hsiung, MD,
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