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Dr. Bob is Robert Hsiung, MD,
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Posted by linkadge on May 3, 2007, at 17:46:59
In reply to Re: Do antidepressants work ? )) Linkadge, posted by Shortstop on May 3, 2007, at 16:43:08
No I never said AD's were 100% placebo. I would just tend to think that depression is probably one of the most sensitive illnesses to placebo.
As such, many antidperessants could very well could be undetected placebos.
I think a lot of their effect is hyped.
I also don't know (for example) if more than half of all blood pressure medication clinical trials failed to distinguish from placebo, or more than half of all asthma medication clinical trials failed to outperform placebo.
Linkadge
Posted by linkadge on May 3, 2007, at 17:48:00
In reply to Re: Do antidepressants work ? )) Linkadge, posted by jenny80 on May 3, 2007, at 16:58:34
I agree with you. I am by no means trying to close doors to treamtnet options. I just personally think they are (mostly) placebo.
But don't take my words as 100% fact.
Linkadge
Posted by linkadge on May 3, 2007, at 17:51:14
In reply to Re: Do antidepressants work ? » linkadge, posted by Ines on May 3, 2007, at 16:59:30
>I agree that is true for some cases.
I don't think it is just *some* cases. The truth is that in more than half of all clincialy trials, antidepressants failed to outperform placebo.
>And the thing is, if AD's sometimes make people >better due to a placebo effect, that's fine too >no? Same outcome :-)
True enough.
>I must say though, if placebo effect was all >there was, I'd be cured right now, last trial of >ADs I was so convinced it would work- but no...
Susceptability to placebo effect varies from person to person. (I don't mean to portray this as any kind of character flaw)
Linkadge
Posted by Ines on May 3, 2007, at 18:33:52
In reply to Re: Do antidepressants work ?, posted by linkadge on May 3, 2007, at 17:51:14
Hey Linkadge,
Don't get me wrong, I agree with you in a way. I just think that the placebo effect will be strong in cases where the depression would solve itself anyway, but not so strong in many other cases. In a lot of clinical trials- though not all- all these cases get bunched together, so it confounds the results in my view. A good clinical trial would match individuals in placebo and treatment groups according to subtype of depression, age of onset, recurrency of depression, whether the depression was precipitated by a specific event or not...all these factors. I understand it's impossible to carry out a large clinical trial with all these matches, but without that it's difficult to be clear about the results in my view. Of course the absolutely ideal clinical trial would be within subject, the same person gets placebo and then treatment or vice versa. There you eliminate most of the variability.
Posted by Racer on May 3, 2007, at 19:30:48
In reply to Re: Short answer: yes, they do, posted by kaleidoscope on May 3, 2007, at 16:27:19
Posted by Declan on May 3, 2007, at 22:32:45
In reply to Re: Do antidepressants work ? )) Linkadge » jenny80, posted by linkadge on May 3, 2007, at 17:48:00
Would it be possible to see if the placebo effect is stronger in those who are lonely and in need of attention and care (as are many depressed people)?
Is the placebo effect stronger in the elderly?
Posted by polarbear206 on May 3, 2007, at 22:43:28
In reply to Re: Do antidepressants work ?, posted by Ines on May 3, 2007, at 14:52:47
> First- Jenny, you say you have dysthymia. Is that your formal diagnosis? Dysthymia is almost always more difficult to treat than major depression, partcularly if you have dysthymia + episodes of major depression. And it also takes longer to treat. Maybe it'll help to be aware of that- you may need more experimenting than other people but you'll get there. I think I've said before (as has Racer above) that it looks like you've tried a lot of things, but in a lot of cases not had an adequate trial- i.e. not for long enough at an adequate dose. I know it's difficult to stick to something that makes you feel worse to begin with, but the problem with doing that is you may end up feeling that nothing works and giving up. You really have to give the medication a chance to kick in, othersise you're setting yourself up for failure. Why not make a commitment to try whatever's precribed to you for at least 3 months? Then find a good pdoc with a good reputation, maybe send him a letter in advance of the appointment with all your symptoms, age of onset, sleep and eating patterns, all of those details, and a list of all the meds you've tried, with length of trial and details of your reactions to them. And then put yourself in his hands and do what he says for as long as he says. You could finally find relief- imagine how that would feel. Best of luck, keep us updates.
>
> Re: antidepressant efficacy. I think it's really unfair to suggest that antidpressants do nothing at all. They clearly do for a lot of people. When it comes to difficult cases, it's finding the right medication, or combination of medications, for each individual person that will be difficult. I think a lot of that (but not all) has to do with finding the right, experienced, pdoc and getting the right diagnosis. Clearly different types of depression respond better to different treatments, but a lot of GPs will still deny that and say it doesn't matter which AD you give someone, they're just as likely to repond well to it. That's just silly as far as I'm concerned.
>
> Then we come to the placebo effect, an the issue of whether people will get better overtime regardless. I think that's true for episodic depression that has clear external causes (like a bereavement, excessive stress at work etc). In those cases people will likely get out of it on their own, but they may be pushed along by an AD. But if you're talking about chronic recurrent depression, dysthymia, atypical depression... I don;t believe that's true at all. People will struggle and fight and get a bit better only to get worse again. I think it is unfair to suggest to those people (and I include myself here) that they will get better on their own. They need long term medication, and therapy to get to know their patterns better and prevent relapse. Then there are the cases where depression is recurrent/ chronical but clearly cause by some horrible external event like childhood trauma. There we will probably still need medication, but therapy will play a major role and may be the difference between sucess and failure.
>
> I have quite a strong opinion on this because I undermined myself by not getting adequate treatmtent for years, trying to get out of it on my own, and only managing to keep my head floating above the water but never really getting better. By letting it go on for so long I've made it much worse to treat because the patterns of behaviour associated with the depression become so ingrained and hard to get out of.
>
> Re the placebo effect, I do believe it is very real, but not sufficient in chronic cases. I do believe that if someone reallly wants to get better, and really wants a medication to work, they'll help themselves along. On the other hand, if someone goes on meds reluctantly, or thinking at the outset that they won't work, they'll hinder the process. Everything to do with the mind is just so complex and influenced by so many factors. That's what makes it so difficult for the doctors trying to treat it.
>Well put Inez.
Thanks,
Polarbear
Posted by polarbear206 on May 3, 2007, at 23:45:38
In reply to Re: Do antidepressants work ?, posted by jenny80 on May 3, 2007, at 16:34:28
> Thanks for you posts.
> I have suffered from dysthymia with episodes of major depression that last weeks to months at a time. When i am dysthymic i manage to function, go to work occasionally watch a film at the cinema or go for a meal. I always tend to feel that I'm not really enjoying myself. I always feel tired and tend to want to sleep a lot.
> At the moment i guess i'm in a major depressive eipsode. Here i feel hopeless, cry a lot, don't have much of an appetite. I also feel i can't actually speak to any of my family. Its as if i don't have the energy to open my mouth. I feel emotionally numb. Sleep has always tended to be normal to oversleeping. I have never really had insomnia. I can't concentrate either and just want to lie in bed. I don't even have the energy to feed my self. My sister helps by making me an evening meal otherwise i would lie in bed.
> I went through a few years where i was suffering from body dysmorphic disorder too.
> The anorexia and bulimia are completely over too. They were a for of the body dysmorphic problem.
> I just don't think the SSRIs do anything for me. The venlafaxine did nothing. I took it while i was having CBT at university. I still stayed in most of the time, did not have friends and at times became suicidal again. I tool the dose of 150 mg once a day which i believe only exerts serotinergic effect at this dose. Its difficult to say if venlafaxine did anything. I certainly remember crying most days and lying in bed while taking it.
> what do you think about moclobemde or a more noradrenergic type ?
My symptoms of atypical depression are associated with my soft bipolar,abated with Lamicatal and effexor.http://www.psycom.net/depression.central.lieber.html
http://www.psycom.net/depression.central.atypical.htmlPolarbear
Posted by Racer on May 4, 2007, at 12:55:19
In reply to Placebo effect, posted by Declan on May 3, 2007, at 22:32:45
> Would it be possible to see if the placebo effect is stronger in those who are lonely and in need of attention and care (as are many depressed people)?
>
> Is the placebo effect stronger in the elderly?
>
>Also, the history of lithium should teach us something else: what elements are actually being used in the placeboes? It could be that something in the binders or fillers of those placeboes are actually active compounds. After all, some of us have experienced weird things with generics versus name brands -- I had an allergic reaction to generic fluoxetine, but have taken Prozac for years with no trouble.
And yes, your questions are interesting, too.
Posted by Ines on May 4, 2007, at 13:32:01
In reply to Placebo effect, posted by Declan on May 3, 2007, at 22:32:45
I would say the placebo effect would be strongest in those who really want help and believe whatever they have can be cured by taking a pill. I think in a way the less you know about your condition, and the more faith you have in doctors, the more likely you are to have the 'benefits' of a strong placebo effect; my guess would be that most of us here are too engaged with the process and knowledgeable about what depression is and how it works to benefit from a strong placebo effect- and also too opinionated about what will work for us! Unless of course you've been wanting to get a hold on some particular medication for ages and finally get a prescription- then you probably will get some placebo effect [Like me with the parnate I'm about to start :-)]
I have a close friend who's a family doctor, and is also very compassionate and generous with his time. He has a private practice but also volunteers at a community hospital a couple of times a week. He told me he almost invariably gets elderly patients come in on a regular basis when clearly there is nothing wrong with them, they just want some company.... He said very often he will diagnose them with something very vague like 'general malaise' and give them 'the pill that will definitely sort that out'. It's a sugar pill... he carries them around all the time in official looking containers. It may sound condescending but I think he really helps them (of course he doesn't charge). He's incredibly popular and some of these patients will regularly come in for refills- this is a rural hospital and patients keep leaving gifts at the hospital for him, like produce and the such, but sometimes also well meant cumbersome gifts like live hens and even sometimes puppies! (he's got 5 dogs; guess why...). Anyway, the power of placebo... (I'm sure this wouldn't be possible in the US btw)
Posted by linkadge on May 4, 2007, at 14:53:20
In reply to Placebo effect, posted by Declan on May 3, 2007, at 22:32:45
Good point. Thinking back to my first SSRI prescription, I don't know if it was the drug or everything that came with the drug (ie attention, counselling, and of course hope.
Linkadge
Posted by linkadge on May 4, 2007, at 15:04:57
In reply to Re: Placebo effect, posted by Ines on May 4, 2007, at 13:32:01
I think that some of the information here can work as a reverse placebo. If people believe the meds can work, they have a higher probability of working. As I became more familliar with the pitfalls and shortcomings of conventional antiepressant medications, they seemed to work less well.I guess the first placebo is the strongest.
Linkadge
Posted by kaleidoscope on May 4, 2007, at 15:40:00
In reply to THANK YOU! (nm) » kaleidoscope, posted by Racer on May 3, 2007, at 19:30:48
Hi Racie,
Why thank you?
Ed
Posted by Phillipa on May 4, 2007, at 18:51:07
In reply to Re: Placebo effect, posted by linkadge on May 4, 2007, at 15:04:57
Link yup my next door neighbor loves her pdoc in Florida and when her lexapro pooped out he sent a script to go with her xanax of effexor. Three days and she feels much better and is out cutting the lawn. That has to be a placebo as it doesn't work in three days. Love Phillipa
Posted by Cecilia on May 5, 2007, at 7:42:12
In reply to Do antidepressants work ?, posted by jenny80 on May 2, 2007, at 19:19:53
None work for me and I've tried pretty much everything there is. Clinical trials are a joke. They play with statistics until they get the results they want. There was a book out quite a while ago called "How to Lie with Statistics" The careful selection of patients for trials has nothing to do with real world depression. For example if you have both anxiety and depression, no way will you be accepted. When I applied for an rTMS trial I was told I wouldn't be accepted because there was no time in the past 5 years I hadn't been depressed. There's been no time in the last 40 years I haven't been depressed. (I did have the rTMS in Canada for $5000 with no benefit). Obviously, meds do help some people, but there are lots of us who can keep trying different things til we die with no benefit whatsoever. Cecilia
Posted by Cecilia on May 5, 2007, at 8:03:00
In reply to Re: Placebo effect, posted by Ines on May 4, 2007, at 13:32:01
I don't care how nice he is, that doctor who gives his elderly patients placebos is a quack. There are probably docs in the U.S. who do it too but it's undoubtedly illegal and definitely unethical. I've read about doctors who do this with pain meds for cancer patients because they don't believe the patients have as much pain as they say, even if you have cancer, doctors won't believe you, forget depression. Doctors are jerks. Cecilia
Posted by Cecilia on May 5, 2007, at 8:21:36
In reply to Re: Do antidepressants work ?, posted by Cecilia on May 5, 2007, at 7:42:12
Also it annoys me when people say well if an AD doesn't work you just must need a higher dose. Some us of get more and more depressed the higher dose we try and/or unbearable side effects. And the people who are lucky enough to respond to AD's say well, it's your own fault you didn't get better, you weren't willing to put up with side effects long enough or try a high enough dose. I'm not talking about trivial side effects like reduced libido, big deal. I'm talking eye pain so severe you feel like you're going blind, or not being able to sleep for a week or not being being able to get out of the bathroom for a week unless you want to wear Depends and carry an emesis basis around with you. Cecilia
Posted by Ines on May 5, 2007, at 9:19:10
In reply to Re: Placebo effect » Ines, posted by Cecilia on May 5, 2007, at 8:03:00
> I don't care how nice he is, that doctor who gives his elderly patients placebos is a quack. There are probably docs in the U.S. who do it too but it's undoubtedly illegal and definitely unethical. I've read about doctors who do this with pain meds for cancer patients because they don't believe the patients have as much pain as they say, even if you have cancer, doctors won't believe you, forget depression. Doctors are jerks. Cecilia
Hey Cecilia,
It sounds like you feel very angry. I'm sorry you've had such bad experiences with doctors- there are many caring doctors out there, it's a shame you've been made to feel otherwise.
The doctor I was talking about is certainly not a quack. He cares enough about his patients to work for free and give his time to them over and over again, even when they are just lonely and in need of someone to chat to. He believes he his helping and I happen to agree. Of course you are entitled to a different opnion. Also, I have personally been treated by doctors who were concerned, overworked people who did their best to help their patients in the time they had; like every profession, there's a bit of everything, but I would say there are a lot of doctors out there who are very very far from being jerks (and no, I am not a doctor myself, nor do I come from a family of doctors)
Ines
Posted by linkadge on May 5, 2007, at 9:41:31
In reply to Re: Do antidepressants work ?, posted by Cecilia on May 5, 2007, at 7:42:12
>None work for me and I've tried pretty much >everything there is. Clinical trials are a joke. >They play with statistics until they get the >results they want.
This is true. I have heard that most clinical trials for AD's eliminate something like 70% of applicants.
Linkadge
Posted by linkadge on May 5, 2007, at 9:45:00
In reply to Re: Do antidepressants work ?, posted by Cecilia on May 5, 2007, at 8:21:36
>Also it annoys me when people say well if an AD >doesn't work you just must need a higher dose.
>Some us of get more and more depressed the >higher dose we try and/or unbearable side >effects.Exactly!. Innefective for depression doesn't mean it is a benign drug.
>And the people who are lucky enough to respond >to AD's say well, it's your own fault you didn't >get better, you weren't willing to put up with >side effects long enough or try a high enough >dose.
Some people only see what they want to see.
>I'm not talking about trivial side effects like >reduced libido, big deal. I'm talking eye pain >so severe you feel like you're going blind, or >not being able to sleep for a week or not being >being able to get out of the bathroom for a week >unless you want to wear Depends and carry an >emesis basis around with you.
Sometimes I think the drugs work by attempting to distract you from one bad thing with another.
Linkadge
Posted by linkadge on May 5, 2007, at 9:56:32
In reply to Re: Placebo effect, posted by Ines on May 5, 2007, at 9:19:10
But what if some of these patients complaints were genuine?
What if a patient was experiencing the beginning of a more serious disease that could perhaps be brushed off with a placebo for a while.
I suppose the misconception is that a disease that responds to a placebo is no disease at all, but this is not true. The placebo effect is not passive, it is infact an active employment of internal disease fighting resources.
Suppose an elderly patient comes in with general weakness and milaise. What if they are infact having cardiac problems?? The doctor gives them a placebo, which they are obviously going to refill if they believe it is geniuinly helping them, but their cardiac condition is not being adressed. They are going to get worse simply because the doctor is too lazy to do a more thorough check.
The patient might simply be complaining less since he feels "well, I've visited a doctor which was the right thing to do, and this is what the doctor prescribed". Ie they feel the problem is at least being adressed (which it isn't).Linkadge
Posted by Ines on May 5, 2007, at 16:08:05
In reply to Re: Placebo effect, posted by linkadge on May 5, 2007, at 9:56:32
Hey,
I completely agree with you that it would be completely wrong to use this indiscriminately. The situation you are describing is one where the patient is presenting new symptoms, and obviously that should never be ignored. When I think it is justifiable is if you know the patient very well, you know nothing more can be done for wathever the patient is complaining about + you know the patient is highly responsive to being given something that they believe will help them. If they believe it will help them there's a high chance that it will do something for them just because of that belief, and in the end the outcome is what matters in my view. Anyway, I won't post more about this because I understand it is controversial and I would never advocate it being used as a rule. But I do believe that sometimes the best doctors are the ones who think outside the box.
Ines
Posted by Phillipa on May 5, 2007, at 18:59:51
In reply to Re: Placebo effect, posted by Ines on May 5, 2007, at 16:08:05
I believe placebos are now illegal although they didn't used to be. If a patient was requesting a pain med very frequently the nurses would be given an order by the doc to admister a shot of normal saline. Love Phillipa
Posted by Cecilia on May 6, 2007, at 5:08:50
In reply to Re: Placebo effect, posted by Ines on May 5, 2007, at 9:19:10
> > I don't care how nice he is, that doctor who gives his elderly patients placebos is a quack. There are probably docs in the U.S. who do it too but it's undoubtedly illegal and definitely unethical. I've read about doctors who do this with pain meds for cancer patients because they don't believe the patients have as much pain as they say, even if you have cancer, doctors won't believe you, forget depression. Doctors are jerks. Cecilia
>
> Hey Cecilia,
> It sounds like you feel very angry. I'm sorry you've had such bad experiences with doctors- there are many caring doctors out there, it's a shame you've been made to feel otherwise.
> The doctor I was talking about is certainly not a quack. He cares enough about his patients to work for free and give his time to them over and over again, even when they are just lonely and in need of someone to chat to. He believes he his helping and I happen to agree. Of course you are entitled to a different opnion. Also, I have personally been treated by doctors who were concerned, overworked people who did their best to help their patients in the time they had; like every profession, there's a bit of everything, but I would say there are a lot of doctors out there who are very very far from being jerks (and no, I am not a doctor myself, nor do I come from a family of doctors)
> InesWell, I sure hope he gives it for free, when all the patient is getting is a sugar pill!!!!! No, of course all doctors aren't jerks, but anyone who tries to fool a patient by giving them a placebo is. Patients have the right to be told the truth at all times, regardless of whether they're elderly or the doctor thinks they're neurotic or hypochondriac or whatever other judgement he/she thinks they have the right to make. Doctors may think they're God, but that doesn't make it true. Cecilia
Posted by kaleidoscope on May 6, 2007, at 13:54:48
In reply to Re: Placebo effect » Ines, posted by Phillipa on May 5, 2007, at 18:59:51
Hi P
In the UK, doctors cannot write prescriptions for placebos anymore. Instead, if they feel that a placebo is necessary, they will prescribe a very low dose of something relatively benign.
Ed
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