Anti-depressants, Serotonin and Depression

January 17, 2008 8:12 AM

"Researchers found that failing to publish negative findings inflated the reported effectiveness of all 12 of the antidepressants studied."See also: Serotonin and Depression: A Disconnect between the Advertisements and the Scientific Literature.

NEJM paper referenced. (Subscription required)

Older:
Antidepressants Versus Placebos: Meaningful Advantages Are Lacking,
but,
Small Effects Are Not Trivial From a Public Health Perspective.

posted by OmieWise (137 comments total)

Just so there’s no confusion: Depression is very real and very treatable. Seriously.
posted by OmieWise at 8:12 AM on January 17, 2008 [9 favorites]

Related earlier thread.
posted by daksya at 8:21 AM on January 17, 2008 [1 favorite]

It's treatable, OmieWise, but the question is whether behavioral or dietary changes might not be more effective than "chemical enhancement," as it were. Eliminating alcohol entirely is one thing which I've seen help people, for example, who seemed immune to or adversely affected by the effects of commercial antidepressants.
posted by sonic meat machine at 8:29 AM on January 17, 2008

It blows my mind that despite how common antidepressants are, so many people still overestimate what they do, and misunderstand what they DON'T do.
posted by hermitosis at 8:33 AM on January 17, 2008

Is the PLoS Medicine "journal" where the second link is published any good?
posted by shothotbot at 8:38 AM on January 17, 2008

I like to show my medical students an advertisement for Effexor that came out in the Journal of the American Medical Association in the mid-90s. It compares two antidepressants to placebo. Effexor relieved depression in 80% of cases, the outcome being whether after four weeks the patients reported less depressed. A rival antidepressant was successful 75% of cases. The placebo worked in 60% of cases. Even in this selected study that was deemed by Effexor as worthy of turning into an ad, it only helped 20% of patients above placebo.

My conclusions: depression is real. Antidepressants help about 20% of patients a number enhanced by the exaggerated world of medical advertising. Which is what the above linked article gets at. If you have depression and antidepressants work for you, you are one of the lucky ones.
posted by dances_with_sneetches at 8:41 AM on January 17, 2008 [4 favorites]

I'm not really surprised that the BigPharma withholds unfavorable study results. They publish those for marketing purposes, not because they are required to do so by regulatory agencies. McDonalds probably does studies about how use if its products cause some people to get giant asses, but you'll probably not see those results on mcdonalds.com.
posted by birdherder at 8:41 AM on January 17, 2008

There is also the very real issue of the doctors over diagnosing the condition itself. If the effect of not publishing the negative findings is so huge, it kind of implies the major effect of the pills was the placebo effect and that those taking them were not suffering from depression in the first place....
posted by fatfrank at 8:42 AM on January 17, 2008

If you have depression and antidepressants work for you, you are one of the lucky ones.

In a research study, the choices are real pill, fake pill or nothing, and the measure of effectiveness is the difference between the real pill and the fake pill. In the real world, the choices are real pill or nothing: a placebo isn't an option. If the objective is to reduce self-reported depression, real-world effectiveness should be the gap between the two choices, a real pill or no pill at all. So the statement should read:

If you have depression, there is an 80% chance antidepressants will work for you.
posted by Burger-Eating Invasion Monkey at 8:50 AM on January 17, 2008 [3 favorites]

In the real world, the choices are real pill or nothing: a placebo isn't an option.

Maybe it should be. Why should 60% of people pay $N/month for something when they could take sugar pills just as effectively?
posted by DU at 8:56 AM on January 17, 2008

Maybe it should be. Why should 60% of people pay $N/month for something when they could take sugar pills just as effectively?

A minor issue called 'informed consent'.
posted by docpops at 8:58 AM on January 17, 2008 [3 favorites]

If you have depression, there is an 80% chance antidepressants will work for you.

For that study. Read the first link. The number is much much lower, even if one takes your other strictures as true.

The placebo worked in 60% of cases. Even in this selected study that was deemed by Effexor as worthy of turning into an ad, it only helped 20% of patients above placebo.

And that's with using non-active placebo (in other words, a sugar pill instead of something that has some physical effects), which essentially un-blinds most studies. As anyone who's worked with or used anti-depressants knows, they do have effects. If you feel nothing, and you're in a study, there's a better than average chance you know you're on a placebo.
posted by OmieWise at 8:58 AM on January 17, 2008

I'm weaning off Zoloft after 6 years. Lifestyle changes and spiritual pursuits eliminated the depression. Zoloft did little beyond disabling my penis.
posted by Horken Bazooka at 8:59 AM on January 17, 2008 [2 favorites]

fatfrank,

Maybe they were depressed in the first place and the placebo effect does counter depression. I'm just sayin' is all.

Taking any sort of psycho-tropic drug is a double-edged sword. If it is prescribed by a physician for the treatment of some disorder (most pertinently depression) and the root cause of that depression isn't discussed and handled in analysis then all you're doing is treating the symptoms. This is assuming that the depression is non-chemical. With this kind of depression the drugs (or placebo effect) can assist in returning you to a state where you can adjust your mind to fix the problem that is making you depressed (like the death of a loved-one). But, did you need the drug in the first place? Maybe not, but... it might have helped.

If you've got a chemical imbalance in your body that makes you more prone to depression then the drugs can help, but perhaps there are more things you can do beyond popping pills to help with the depression. As mentioned by sonic meat machine something as simple (or not with the case of an alcoholic) as the reduction of alcohol consumption can do wonders. For me, it was (and still is) getting enough physical activity.

Basically, saying that because anti-depressants were no more efficacious than placebo in trials with people diagnosed with depression, or trials with people who had been diagnosed as borderline depressed, or people who just felt sad a bunch doesn't mean that they weren't depressed. It just means that the drugs don't work like we thought they did.

We really don't know that much about the human mind as it is.. hence, clinical trials. If we knew PRECISELY how the brain worked we wouldn't need to do clinical trials where we ask our patients "you've been taking pill A for a week now, how do you feel today?"

We'd just mix up a cocktail of drugs, give it to our patients and they'd be 100% better instantly.
posted by Sam.Burdick at 9:00 AM on January 17, 2008

If you have depression, there is an 80% chance antidepressants will work for you.

If as much as 60%, or 3/4ths of that 80% was due to a placebo effect rather than the action of the drug, then it's misleading to say that the antidepressant worked. Doing something that they believed could help worked. In 20% of cases, the action of the drug seems to have contributed to improvement, though this could have been the the existence of drug effects, which may or may not be valuable in themselves, reenforcing the patient's belief that the drug would help them.
posted by George_Spiggott at 9:00 AM on January 17, 2008

The other interesting point about the study dances_with_sneetches described is whether or not it included a group of people with self-reported depression who were given no pill at all (this does not mean a placebo, which is a fake pill).

Intuitively, if you select a group of people with depression and give them nothing, four weeks later nothing will have changed, right? Wrong; regression to the mean means that almost certainly some will report no longer being depressed, though the proportion of the population as a whole which is depressed is constant. The effect of regression to the mean is that if you give a group of depressed people any treatment, or a placebo, or even no treatment at all, you will find some degree of effectiveness even when in reality there is no effectiveness whatsoever.
posted by Burger-Eating Invasion Monkey at 9:06 AM on January 17, 2008 [2 favorites]

All I have to go on in this horse race is personal experience, and the difference its made to members of my family.

As my GP said to me, "for some people, it's like a miracle drug (even at a very low dose)... for others, it doesn't do much at all..."
posted by chuckdarwin at 9:07 AM on January 17, 2008 [3 favorites]

Is the PLoS Medicine "journal" where the second link is published any good?

I don't read PLoS Medicine, but I can tell you that PLoS Genetics and PLoS Biology are respected, so I would guess that PLoS Medicine is also. Impact factor isn't the best way to judge a journal, but 13.8 is a good score.
posted by Jorus at 9:08 AM on January 17, 2008

Sam

There is a vast, vast difference between clinical depression and just being a huge bit sad - the former will invariably need something prescribing, the latter will respond far better to a lifestyle change. The latter will also respond to the placebo effect, the former won't.

The point I was trying to make is the way in which the medical profession can have a tendency to prescribe there way out of a consultation.

I'm not saying being down isn't a problem, clearly it is, but it is not something that (a) you should be running to a doctor with in the first place, a counsellor for example would be more effective, and (b) certainly not something the doctor should be prescribing for. One has to wonder at their motives as a course of heavy anti-depressants is not something that should be dished out lightly.
posted by fatfrank at 9:09 AM on January 17, 2008

To follow what George_Spiggott just said, it's too simplistic to reduce the real-world dilemma to "pill or no pill," and suggest that nothing like a placebo option exists outside of a study clinic.

If a placebo shows an effect, the effect is certainly not attributable to the pill; therefore, it must be attributable to some other factor -- such as the change in routine that study participation brings about, the awareness that there are a lot of other people dealing with your problem (who you may even be able to meet and talk to as a result of study participation), the hopefulness resulting from the possibility that you will see improvement, the development of a willingness to try a new strategy, or simply being in a safe clinical environment focused on improving the condition.

Those factors are also available to people in non-pill, non-study form, and when people counter depression without drugs, those factors and others are the ones being maximized. I don't like the thought that we must say 'only pills work, because in the real world, people don't have placebos.' We may not call them 'placebos', but psychological boosts and mood changes from the same sorts of activities and involvements do really happen at least for some people. If a placebo is working, it's for reasons that can be replicated with treatment, but without the application of drugs.
posted by Miko at 9:11 AM on January 17, 2008 [7 favorites]

If the placebo effect is what has made the state of being seem suddenly so close to what I always wished it could be, I would now like more placebos.

Every SSRI is different. It is possible one of them will do little or nothing for you, yet one that is a little bit different will do everything for you.

In my experience, and in the experience of people I know and people I have read about, finding the right medication takes fiddling with dosage over a period of time and often takes more than one drug. If one drug you try only fixes one aspect of your depression, it's not a failure: it's a success, and now you find another drug that works on the other parts.

I would think any genuine psychiatrist will readily admit that it is a bit like playing Whack-a-Mole. But if you have enough mallets of sufficient whackingness, you can get the moles to stop popping up.

The efficacy of SSRI's is not understood, but it is significant.
posted by Darth Fedor at 9:12 AM on January 17, 2008 [2 favorites]

For that study. Read the first link.

Sure, I was talking about the study dances_with_sneetches mentioned. I'll try and read the study tonight.

And I meant to provide a Regression to the mean Wikipedia link my last comment.
posted by Burger-Eating Invasion Monkey at 9:13 AM on January 17, 2008

I'm weaning off Zoloft after 6 years. Lifestyle changes and spiritual pursuits eliminated the depression. Zoloft did little beyond disabling my penis.

How do you know those lifestyle changes and spiritual pursuits would have been possible without treatment? Not trying to be flippant, but when I Rx an SSRI my comment to the patient is less "this will eliminate depression" and more "SSRI treatment tends to give patients the capacity to start making changes that lead to recovery". Something as simple as picking up the phone to call a counselor, or showing up to work, or feeding your kids, can be impossible for a person with depression.

The placebo effect is well known and it's hardly surprising that a substantial one exists with depression. The scary thing about depression is that the rest of the world goes on without you, so that by the time you recover your job may be gone, you may have failed your classes, and your marriage may be wrecked, so rapid improvement can be paramount to keep from compounding the damage.
posted by docpops at 9:14 AM on January 17, 2008 [6 favorites]

Frank,

I can definitely agree on that point. But, there is a point that the system is broken. For instance, a person who is down and depressed and sick alot goes to see their GP who gives them a scrip to go see a clinician who scribes them for a depressant. That seems to be pretty common. Unless you have a GP who asks themselves and you "why are you sick all the time"? and "Is that why you're depressed?"

There aren't alot of those.

Some patients don't have an out in that case to get better than palliative care.
posted by Sam.Burdick at 9:23 AM on January 17, 2008

To follow what George_Spiggott just said, it's too simplistic to reduce the real-world dilemma to "pill or no pill," and suggest that nothing like a placebo option exists outside of a study clinic.

Sure, but studies aren't there to tell patients how to relieve their depression, they're there to tell academics and doctors about the effectiveness of medicines; the real-world decision the doctor has to make is whether to prescribe or not.
posted by Burger-Eating Invasion Monkey at 9:25 AM on January 17, 2008 [1 favorite]

I tried various anti-depressants over the years. At their best they did nothing for me but make me scatterbrained. At their worst they had me standing on a bridge desperate to step off.

I no longer take any medication. Meaningful work has made all the difference in my life. I'm no longer afraid of bridges and subway tracks; what was pretty much a constant desire (to off myself) never crosses my mind anymore. And by meaningful I mean meaningful to me--meaning I enjoy my time there; I look forward to going--not in a "you're saving the world" sense. After being a self-employed graphic designer for 13 years I've spent the past year working in a 800sf record store. It's made all the difference.
posted by dobbs at 9:25 AM on January 17, 2008

This is not really new; here is a list of journal articles detailing the influence drug companies have over research.
posted by TedW at 9:26 AM on January 17, 2008

Sure, but studies aren't there to tell patients how to relieve their depression, they're there to tell academics and doctors about the effectiveness of medicines; the real-world decision the doctor has to make is whether to prescribe or not.

Exactly my point. Isn't it important to know the limits, and be realistic about the limited effectiveness, of a medication you're going to prescribe? And isn't it important to recommend additional or alternative means of treatment to patients when they might be equally or more effective than the prescription?
posted by Miko at 9:29 AM on January 17, 2008

My conclusions: depression is real. Antidepressants help about 20% of patients a number enhanced by the exaggerated world of medical advertising. Which is what the above linked article gets at. If you have depression and antidepressants work for you, you are one of the lucky ones.

Then I'm prepared to call myself one of the lucky ones. For a long time I resisted the (inevitable) conclusion that there was a "problem" -- I was convinced I could "pull myself up by the bootstraps." When I finally did go to a doc, I was skeptical that the medication he prescribed would work. I had essentially written it off after four weeks with no noticeable improvement, when almost overnight, my world simply didn't feel so "dark." In the nine years since that time, I've gone off the drug (Celexa) twice, diagnosing myself "cured." Both times led, eventually (not immediately), to a return of the depression, and both times resuming the treatment (eventually) got rid of it. For me, this is not a placebo effect.

I know this doesn't make the point of the post or article more or less true. I just wanted to make sure there was a voice in the thread that could confirm the drugs do sometimes work.
posted by pardonyou? at 9:37 AM on January 17, 2008

Well said Miko. To expand a bit on that, most studies in psychiatric health and other conditions offer additional therapies to participants, whether they receive placebo or not, so it is generally not accurate to portray modern double-blind studies as "treatment" vs "no treatment/fake treatment". Most patients are receiving some sort of treatment as appropriate to their conditions, as it would be unethical not to provide such treatment. Point being, many of the patients in the depression studies were, I should think, getting some kind of counseling in addition to their medication/placebo; and even those who were not receiving some kind of counseling/talk therapy may have benefited from the structure and sense of purpose they feel when participating in the trial.

Here is what the APA says about combination pharmacotherapy and psychotherapy:

As noted in the guideline, studies examining combination treatment with psychotherapy and pharmacotherapy have shown mixed results. Although this has continued to be true in subsequently published studies (66, 67, 72, 73), a recent meta-analysis suggested that a combination of psychotherapy and pharmacotherapy is more effective than pharmacotherapy alone (74). Combination therapy may be particularly useful in improving treatment adherence (73, 74) and might be of some use in targeting particular symptoms or patient subgroups (75–77).

Source.

I wish I could read the full text of the NEJM article as the WSJ piece omits the important details of the trial designs.
posted by Mister_A at 9:37 AM on January 17, 2008 [1 favorite]

I was referring to this Miko comment, for the record.
posted by Mister_A at 9:40 AM on January 17, 2008

Miko: Yeah, I can't tell where exactly you disagree with me here. The effectiveness of counselling etc is really a separate question from the question of how to measure the effectiveness of the drug itself
posted by Burger-Eating Invasion Monkey at 9:42 AM on January 17, 2008

And isn't it important to recommend additional or alternative means of treatment to patients when they might be equally or more effective than the prescription?

Do studies show this isn't happening?

My doctor talks to me about all the options, the possible effectiveness, benefits, drawbacks, and charts how things go. Anti-depressants were a lost resort and what they did for me was quite rapidly restore appetite and help with sleep, which in turn helps one exercise again and rest makes most people feel miles better.

Reactions are incredibly varied for different people, as are the results. Hence we do have alternate means of treatment for patients unless you've got a bad doctor.
posted by juiceCake at 9:44 AM on January 17, 2008

A recent journal club at my institution discussed this interesting paper: Why most published research findings are false.
posted by peacheater at 9:47 AM on January 17, 2008 [3 favorites]

This is very similar to the discussion happening a few threads down, the one about appreciating melancholia.

Basically, I think there are people who need antidepressants. These are the people who are so depressed that they are literally teetering on the brink of suicide. They are too depressed to get out of bed in the morning. Due to their illness, they simply can't function. These people should take whatever they think will help them out. They have an honest-to-god illness, and I would think that even if a drug only has a 20% chance of helping them, they might as well try it.

However, I think that we live in a culture that has been largely over-diagnosed and over-prescribed. We're fed this image of "happiness" that has been created by TV execs and marketing departments to encourage us to buy things. We've internalized this image, and have begun to measure ourselves against it. Thus, you have a lot of people running around saying "I'm depressed" when really they are suffering from what, in a different age, would just be considered "garden variety unhappiness."

Unhappiness can be treated by changing something in your life to make it less unhappy. Clinical depression, not so much.

I suppose in the end, it's all a matter of tradeoffs. On the one hand, you have antidepressants, which have a host of side-effects and only work in a small percentage of cases. On the other hand, you can try changing something about your life instead of turning to pharmaceuticals. The choice is up to the individual, but I know which course I would take.
posted by Afroblanco at 9:57 AM on January 17, 2008

Like pardonyou?, I'd like to add a positive vote for antidepressants. I've been on Zoloft for five years for anxiety and depression. I've tried to stop it twice; the first time, I was back to an overwhelming obsession with death and being overwhelmed by the futility of it all within two months. The second time, I was off for a year before I became crazily anxious and depressed again. All three times that I've gone on it, my anxiety and depression have cleared up within a month, without any accompanying lifestyle changes beyond taking the drug. The only side effect I experience is an increase in my jaw clenching, so I wear a night guard now, which pretty much fixes that problem. I exercise regularly, meditate, see counselors, eat B-vitamins and omega-3 fatty acids, have on average 3 drinks a week, have a large set of close-knit friends, a great job, a loving wife and supportive family, etc., etc., etc. Without anti-depressants I'm a neurotic wreck, convinced I am going to be hit by a meteorite in my sleep and die, and unable to do any work because it's all so futile. With it, I'm happy and relaxed and totally functional. It's really quite freaky how well it works.

I know I am quite lucky in this. I know at least 2 people who stopped antidepressants because the side effects--including insomnia, sexual dysfunction, and hallucinations(!)--they experienced were worse than the depression itself, and one for whom it didn't really do anything. I know three other people who experience minor side effects and a significant improvement in their depression. But the fact remains, I've tried everything else, and the only thing that helps me is antidepressants.
posted by freedryk at 10:02 AM on January 17, 2008

Another resource of interest might be Journal of Negative Results in Biomedicine. They describe the journal as,"...ready to receive papers on all aspects of unexpected, controversial, provocative and/or negative results/conclusions in the context of current tenets, providing scientists and physicians with responsible and balanced information to support informed experimental and clinical decisions."
posted by Jorus at 10:03 AM on January 17, 2008

See also: Journal of
Unpublished Results.
posted by zippy at 10:07 AM on January 17, 2008 [2 favorites]

Maybe it should be. Why should 60% of people pay $N/month for something when they could take sugar pills just as effectively

The very nature of a placebo effect requires belief you're taking something real. Thus the only way to accomplish it would be without the informed consent docpops mentions.

And even aside from that ethical issue, if you have to involve others in convincing someone that they're taking a real product then there's labor and effort involved. And ain't nothing in this life free, my friend.

Compare that to my prozac, now available in its generic floxetine, for which I pay $14 every 3 months at Costco. Do you think it would be worth anyone's while to engage in shenanigans with my credulity for under $5 a month?
posted by phearlez at 10:11 AM on January 17, 2008

What the discussion on this has largely left out is that it's not only the pharmaceutical companies that perpetuate this-- it's the medical journals and the media.

No one likes to publish "null results"-- it's called the file drawer effect. So even if the pharm cos had tried to publish (which they likely didn't try hard to do), they might not have succeeded.

What it also leaves out is that it is very clearly the case that only a minority of people respond well to any given antidepressant, but for those 'strong responders,' the difference between antidepressant and placebo is HUGE..

An even smaller minority responds to the meds with suicidal or homicidal thoughts and even fewer, actions.

Another group has a minor positive effect, another has a minor negative effect and it all washes out to make antidepressants look closer to placebo than they are.

This explains both the "miracle drug" stories and the "horror drug" stories that are always dragged out and why the debate tends to get nowhere.

What we need is pharmacogenetic information to match drug to right person and avoid giving to wrong person.

Also, it's misguided to say that antidepressants only treat "symptoms" while ignoring the "underlying problem." Sometimes, there is no underlying problem other than that your chemistry puts you in a negative mood and you therefore respond negatively to people and you then get bad results. Fix the chemistry and the rest fixes itself.

Cognitive behavioral therapy-- which is one of the few therapies actually proven to treat depression-- helps when the thoughts have taken on a life of their own and are driving things even when mood improves or are pushing mood into relapse.

But it doesn't go "deep" either-- going deep actually can hurt with depression because you just ruminate on how much your past sucked and why it makes your life suck now and you can have great insights but insight doesn't automatically or even usually produce action.

I also resent the notion that "changing your life" is morally superior to "turning to pharmaceuticals." We wouldn't complain if a drug made stroke rehabilitation easier and ended the "character building" trials of arduous physical therapy-- but try to make mental illness recovery easier and people squawk about turning to drugs.

If you have the genetic advantage not to have depression, why shouldn't I take drugs to level the playing field? If you have the environmental advantage of not having been abused or traumatized, why should those who don't have to suffer both in the original experience and in recovery too?
posted by Maias at 10:13 AM on January 17, 2008 [8 favorites]

Do any of the studies effectively tackle amount of improvement? I can definitely see how 60% of people on placebo feel SOME improvement, while 80% on a drug feel some, but it seems likely to me, based on personal experience, that the drug would (in 20% or larger of cases) provide MORE improvement than placebo.

And, yeah, Prozac is ridiculously cheap, and a low dose gives me massive improvement with essentially no side effects. I see no problem with diagnosing someone with mild to moderate depression with a low dose of an affordable anti-depressant, if it improves quality of life. I DO object to high doses of high-side effect anti-depressants, and in some cases that will make people's lives worse. Everything is best in combination with therapy, of course.

I don't understand the very strong anti-pharmaceutical reaction we get these days. I think there's some fighting against strawmen going on, and it has the potential to make people who are being prescribed reasonable doses think that their doctor is incompetent, and stop taking the drug.
posted by JZig at 10:28 AM on January 17, 2008

Afroblanco, that's a false dichotomy. Making changes in my life (and, more importantly, my thought processes) has been absolutely essential at improving my day-to-day existence -- but without taking antidepressants, for all their downsides, I was never able to actually make any of the changes in my life I needed.
posted by nicepersonality at 10:33 AM on January 17, 2008

It’s true that this study isn’t exactly new, and it’s also true that antidepressants help some people some of the time. Nor, does this study suggest in any way that depression isn’t a serious problem needing serious treatment. It is and it does. What this study does cast doubt on is two different but closely related things: 1) medications may not be the best means of treating depression; and 2) depression may be better understood using a model other than the medical model.

We know that depression responds very well to treatment. Multiple published meta-analyses show an effect size of 0.6-1.0 for psychotherapeutic treatment of depression. Bruce Wampold, who has done a lot of work in this area suggests that 0.8 is a legitimate estimate for global effectiveness of psychotherapy to treat depression. Compare that number to the 0.36 general estimate for antidepressants found by the NEJM study. There’s a huge discrepancy there. On the other hand, those same studies indicate that there aren’t specific factors from any one psychotherapy that contribute to that effectiveness. Contrary to popular belief, for instance, CBT is no more effective than interpersonal or psychodynamic talk therapy. It is the general and not the specific effects that matter. This is mirrored in the current study which essentially says that the specific mechanisms of medications do poorly at treating depression. Instead, depression seems to respond well to the general context of therapy, to a helping relationship, hope, and a plan for change. In other words, the things that Miko points to.

I think responses to studies like these are always interesting. Some folks say that without the drugs there would be no treatment for depression, some say that the drugs were helpful for them and so the study must be missing something, some say that depression doesn’t exist anyway or people should just suck it up. None of these responses are supported by the study. The response I find most personally confounding is the one which says that therapy is too difficult and expensive, so thank god these drugs are saving lives. On the one hand that response suggests that depression is so serious as to need serious treatment, on the other, that it’s only serious enough to need treatment that doesn’t require much effort. But, let’s be clear, the average episode of psychotherapy is quite short, fewer than ten session, and people end up feeling significantly better. It’s difficult to imagine GPs not referring for, say, subspecialty surgery just because it might discommode the patient.

There is a serious argument to be made that therapy is not as available as it should be, but, again, I think that this study indicates that we should be angry about that, rather than resigned to it. If you think that the under-coverage of therapy is not related to the overselling of the efficacy of these medications, you’ve got another thing think coming. My argument with antidepressant treatment has never been that it doesn’t work for all people, no treatment does, but that it narrows the possibilities for treatment for all people because it’s sold as far more efficacious than it really is.
posted by OmieWise at 10:38 AM on January 17, 2008 [5 favorites]

Nicepersonality's point is also borne out the other way: when my doctor recommended treating my depression with exercise and therapy, there were other extremely beneficial effects that I wouldn't have had with medication alone - better cardiac health, new achievements, better relationships. I'm not knocking medication when useful, but if it's not part of a holistic treatment plan, something is being lost. As for the stroke victim analogy - if we were not worried about the 'character building' aspects of physical therapy, we might note that increased cardio-respiratory function, increased muscle strength, reduced atrophy, and increased range of motion would be benefits that improved quality and perhaps length of life for the patient, benefits which would not be guaranteed by a drug-only treatment.
posted by Miko at 10:39 AM on January 17, 2008

First of all, you can prescribe placebo as a doctor. There are ethical and lawsuit limitations to doing this. Second, you can direct the patient to alternatives. For example, therapy. Therapy will be either be harmful (I'm going to say this is rare), neutral (handholding equivalent to a placebo), or beneficial. With the exception of those for whom therapy is a harmful experience, you will get results equal to or better than placebo - without the drug side effects.

My guess is that it gets back to what was described before: good diagnosis. With correctly diagnosed major depression, I'm guessing these drugs work 50% of the time. Problem is, we diagnose unhappiness as an illness.

My brother-in-law's mother at 94 was prescribed Prozac after her husband died. She had a lot of nasty side effects. I would say: 1) Prozac isn't good for reactive depression. 2) She was prescribed a regular adult strength when she had a lower metabolism (being elderly) and she weighed about 95 pounds.

The problem is drug companies don't only want to prescribe drugs to the limited market of people for which they work.

We don't have pills for everything. In fact, there's probably some perverse correlation between how common an illness is and how futile the medicines are.
posted by dances_with_sneetches at 10:46 AM on January 17, 2008 [1 favorite]

My experience is similar (less severe) than pardonyou? and freedryk - just started up celexa again after going off, and sliding into anxiety and depression. Saw therapist, saw doctor, and got back on - a few weeks in, just a few days ago, the skies "cleared" (there's no other way to describe it) and perspective changed.

Taking them and doing nothing else doesn't work for me - I need to also see a therapist during the bad stretches, and for sure, exercise and eat right.

Depression sucks.
posted by parki at 10:56 AM on January 17, 2008

One of my main problems with antidepressants is the way in which they're used. People will start taking them and then never stop. Most of the people I've known who take the drugs see them as a permanent or semi-permanent fixture in their lives. Correct me if I'm wrong, but I thought that the whole idea was to use them as a temporary measure- something to carry you through until you've made the necessary changes in your life and habits. Given that the drugs are supposed to be a temporary measure, wouldn't it be better to never use them at all, if you can manage the same level of recovery?

Also, I think that the drugs really are over-prescribed. I believe that depression is real and it is treatable, but I also think that what a lot of antidepressant-users experience isn't full-on clinical depression. This isn't to say that they don't have problems, but that perhaps antidepressants aren't the best way to address whatever is going on in their lives.
posted by Afroblanco at 11:04 AM on January 17, 2008

In the nine years since that time, I've gone off the drug (Celexa) twice, diagnosing myself "cured." Both times led, eventually (not immediately), to a return of the depression, and both times resuming the treatment (eventually) got rid of it.

Switch out Celexa for alcohol/marijuana/whatever and come and see the cognitive dissonance inherent in the system.

I've known several people to have various breakdowns and go on pills - not my business exactly what pills. Some of them ended up with personality changes or walking around high all the time, leading to lost friendships and relationships and some foolish choices. Sad to think the pills likely weren't even doing anything to help them.
posted by TheOnlyCoolTim at 11:09 AM on January 17, 2008

Switch out Celexa for alcohol/marijuana/whatever and come and see the cognitive dissonance inherent in the system.

Switch out Celexa for insulin and come see your cognitive dissonance.
posted by Justinian at 11:12 AM on January 17, 2008 [3 favorites]

My body needs Celexa to live!
posted by mek at 11:16 AM on January 17, 2008 [1 favorite]

Afroblanco, because of attitudes like yours, the vast majority of people on antidepresssants don't ever try them until *everything else* has failed for them-- and they tend to come off them as soon as possible. So, I'd like to see you find someone who genuinely *is* an example of a person for whom the medication was "overprescribed."

In years of reporting on this subject, I haven't met that mythical person. I've met people who took the drugs and they didn't help, people who took the drugs and they did harm, people who took them short term and people who took them long term. But I've never met someone who says "Nope, the problem really wasn't that bad; I shouldn't have tried the meds."

And regarding staying on them, you wouldn't criticize a diabetic for doing so or a person with bipolar disorder or schizophrenia or heart disease-- all of which are chronic and all of which can be helped additionally by other things but usually require medication as well.

Regarding the stroke analogy-- it's certainly true that exercise is good for you. But in my hypothetical, I was talking about a drug that instantly reversed paralysis, rather than a person having to spend hours upon hours upon hours over months to years before they can go from strenuously wiggling a toe to moving a foot and then walking with crutches. Yes, exercise is great-- but that person would almost certainly far prefer to get on with life and choose to exercise for health when he feels like it (and do so far more vigorously than he could with the paralysis and early physio) and why should he be forced to do so because he has had a stroke and you didn't?
posted by Maias at 11:18 AM on January 17, 2008 [2 favorites]

Because we should be treating whole people, not single illnesses.
posted by Miko at 11:26 AM on January 17, 2008

...and also, I see a difference between "forcing" and recommending.
posted by Miko at 11:27 AM on January 17, 2008

Afroblanco, because of attitudes like yours, the vast majority of people on antidepresssants don't ever try them until *everything else* has failed for them-- and they tend to come off them as soon as possible.

Once again, I thought that was how antidepressants were supposed to be used. Why should drastically changing your brain chemistry through drugs be a first line of defense? And once again, I was under the impression that they were supposed to be a short-term solution to carry you through until more long-term and long-lasting therapies had taken effect.

I know that personally, I'd rather not be chemical-dependent for the rest of my life. But that's just me.
posted by Afroblanco at 11:29 AM on January 17, 2008

But I've never met someone who says "Nope, the problem really wasn't that bad; I shouldn't have tried the meds."

That's nice. I have met plenty of people who have suffered terribly from side-effects or withdrawals of medications that didn't help them in the least. But fortunately for you, I'm not stupid enough to project my personal experiences onto scientific analysis.
posted by mek at 11:30 AM on January 17, 2008

Once again, I thought that was how antidepressants were supposed to be used. Why should drastically changing your brain chemistry through drugs be a first line of defense?

Because people with depression HAVE drastically altered brain chemistry. The drugs are intended to make the chemistry normal again.
posted by agregoli at 11:33 AM on January 17, 2008 [1 favorite]

Well of course they didn't publish the negative findings. That's all depressing and shit.
posted by fungible at 11:39 AM on January 17, 2008

Because people with depression HAVE drastically altered brain chemistry.

Even if that's so (and the second link would suggest that at this point that is still conjecture, and, perhaps, marketing speak), the NEJM paper would suggest that our current medications (and the paper included SSRIs, SNRIs, and atypicals) don't effectively target that "drastically altered brain chemistry."
posted by OmieWise at 11:44 AM on January 17, 2008

I suspect that it is rather difficult to pursue an exercise regimen when your depression makes you feel as though the entire enterprise is completely futile.

Keep in mind that the advantage of anti-depressants for a lot of people is that the medication makes them realize that the depression they used to feel isn't normal.

I used to be very skeptical of anti-depressant medication because the people I knew who took them weren't getting better. However, those were just the people I happened to know at the time. As I got older, I met more people who had taken them and had good things to say about how helpful they were.
posted by deanc at 11:48 AM on January 17, 2008

For some people SSRIs and MAOs are temporary. For others they're not. So what?

I've yet to hear from someone on ADs who's excited about the prospect of taking them forever. I, and everyone I have known on them, have gone off them at different times for different reasons. Some people are off them a short time, some years, some forever.

But so what? If I get a significant improvement in the quality of my life - perceived or actual - what the hell difference does it make to anyone other than me and mine? If you think there's some moral superiority in alternate methods then nobody's stopping you from pursuing them yourself.

If you want to get your panties in a knot over the negative ways that capitalism impacts the pharma industry by motivating companies to produce and push new patented drugs over equally efficient generics, shit, I am with you 100%. Want to talk about how many of those new drugs were financed with public dollars yet they can be priced and guarded exactly the same as those produced with completely private money (if those even exist), I'm interested in that too.

But that has nothing to do with ADs, it's a problem that exists across the board. It may be that the problem manifests itself more significantly in the AD market because you're less likely to get life-threatening side effects - I really don't know. I also don't understand the rampant animosity towards ADs, unless it's just an animal-level fear of things that alter our minds.

So go after doctors for not adequately pursuing cheaper but equally effective drugs for their patients, go after the health care industry for not intelligently pushing those kinds of choices, go after drug makers for trying to make money if you really feel you have to. But leave my brain alone and don't be surprised when those of us who are living better lives because of these chemicals get a little wound up when you malign them as unnecessary or somehow wrong.
posted by phearlez at 11:53 AM on January 17, 2008 [3 favorites]

I know that personally, I'd rather not be chemical-dependent for the rest of my life. But that's just me.

The point is, we already are chemical-dependent -- it's just that your body regulates its neurochemisty properly without additional treatment, and unfortunately, mine doesn't. I assume you don't make pointed comments about insulin dependency to diabetics; the situation is analogous. (If I seem a bit defensive, it's because I used to hold a similar attitude to yours, and it kept me from seeking treatment until after a failed suicide attempt.)
posted by nicepersonality at 12:08 PM on January 17, 2008 [2 favorites]

I'm just amazed at how some medical issues become moral judgement arenas. This thread is like the Fibro thread a day or two ago. People who have never experienced the symptoms for which treatment is prescribed feel morally superior. Not only that, they feel as though they have the right to brag about their moral superiority, as if to say, "I've never experienced this, therefore you are making it up because you're a big crybaby."

Nice.

Rather than the discussion here being about the post; anomalies in data reporting, once again the Ubermensch Evangelists have taken it upon themselves to tell everyone how anyone who gains relief from these treatment modalities is a weak human, powerless to even control their own brain, pawns in the hands of Big Pharma.

Just like those crazy diabetics. Damn them and their insistence on insulin! If they weren't such pansie assed sugar eaters, they wouldn't have that problem, amirite? And epileptics? Twitchy fakers just doing it for the attention. Pain meds? Piffle, we just need to quit coddling those broken boned whiners.

Survival of the fittest, no? Anyone who isn't physically, mentally, and emotionally perfect can just be liquidated to save the ubermensch from the pain of falling off their high horse.
posted by dejah420 at 12:13 PM on January 17, 2008 [2 favorites]

Can someone please point me to the moral judgement in this thread? From what I can tell, the only moral judgement being expressed is towards doctors, pharma companies, ad agencies, and the media.

Nobody's calling anybody morally weak for taking antidepressants, and nobody's talking about taking away anybody's medication.
posted by Afroblanco at 12:18 PM on January 17, 2008 [1 favorite]

One of my main problems with antidepressants is the way in which they're used. People will start taking them and then never stop.

I thought I quoted this in my response above; I meant to, and to preface it all with:

Let's stipulate that you're right and they're used unnecessarily in some significant number. Posit as well that they're also used in cases where they're necessary but then continue to be used past the point where they could be discontinued.

So what?
posted by phearlez at 12:22 PM on January 17, 2008

I know that personally, I'd rather not be chemical-dependent for the rest of my life. But that's just me.

You already are chemical dependent. Antidepressants don't happen to be among the chemicals you are dependant on at present is all.
posted by Justinian at 12:22 PM on January 17, 2008 [3 favorites]

Let's stipulate that you're right and they're used unnecessarily in some significant number. Posit as well that they're also used in cases where they're necessary but then continue to be used past the point where they could be discontinued.

So what?

Once again, it's contrary to what my impressions were about how the drugs were supposed to be used. Any time I've talked to a doctor about them, I was always given the impression that they were meant as a short-term solution that people used while waiting for more long-term therapies to start working.

I could have had the wrong impression, though.
posted by Afroblanco at 12:25 PM on January 17, 2008

Can someone please point me to the moral judgement in this thread? From what I can tell, the only moral judgement being expressed is towards doctors, pharma companies, ad agencies, and the media.

okay.

However, I think that we live in a culture that has been largely over-diagnosed and over-prescribed. We're fed this image of "happiness" that has been created by TV execs and marketing departments to encourage us to buy things. We've internalized this image, and have begun to measure ourselves against it. Thus, you have a lot of people running around saying "I'm depressed" when really they are suffering from what, in a different age, would just be considered "garden variety unhappiness."

Unhappiness can be treated by changing something in your life to make it less unhappy. Clinical depression, not so much.

You claim there's external forces feeding us a line and that we've bought it, failed to accept that in times of old when everyone was smarter and stronger and walked to school, through the snow, uphill, both ways - back then, they'd have taken their malaise and LIKED IT.

To claim you're not making a moral judgment about personal strength and responsibility in the text above is disingenuous. The primary blame might be left at the doorstep of the Marketing Boogeyman but there's no doubt that it's accompanied by the blame on the recipients for not being more discriminating consumers and resisting the siren song, which you yourself are smart enough to resist.
posted by phearlez at 12:26 PM on January 17, 2008

Switch out Celexa for insulin and come see your cognitive dissonance.

Insulin isn't psychoactive.

Meanwhile, I have no problem with people deciding they'd like to be under psychoactive influences 24/7 and get themselves a nice addiction, whether it's Prozac, heroin, Celexa, or marijuana, if that's what works for them.
posted by TheOnlyCoolTim at 12:31 PM on January 17, 2008

The primary blame might be left at the doorstep of the Marketing Boogeyman but there's no doubt that it's accompanied by the blame on the recipients for not being more discriminating consumers and resisting the siren song, which you yourself are smart enough to resist.

You're reading things into my argument that I never stated. I think that we've been manipulated by various commercial entities. I also think that a lot of misguided notions have become prevalent in our larger culture. HOWEVER, this does not mean that I blame people for being manipulated or misled.

For example, you can look at impoverished people and examine the reasons for their impoverishment - bad environment, discrimination, lack of opportunity - without blaming them for being poor.

I'm sorry that I offended you, but I was not passing judgment.
posted by Afroblanco at 12:32 PM on January 17, 2008

Why should drastically changing your brain chemistry through drugs be a first line of defense?

What's wrong with restoring your drastically out of whack brain chemistry to normality with medication?

And once again, I was under the impression that they were supposed to be a short-term solution to carry you through until more long-term and long-lasting therapies had taken effect.

Each case is unique. Some only need a short term solution, some are chronically out of whack and these can help tremendously. Always? No. But many of us have different reactions to any numbers of things, chemical or otherwise. There is a large variety of terms on these in the real world.

The article says "doctors unaware of the unpublished data are making inappropriate prescribing decisions." It doesn't say how many, or the ratio of doctors unaware of data on the drugs and programs they are prescribing to doctors who are aware of the data.

Professionals that are unaware and uninformed are bound to make uniformed decisions. This is something we all know and it can be dangerous outside the arena of anti-depressants as well.
posted by juiceCake at 12:41 PM on January 17, 2008

Insulin isn't psychoactive.

Meanwhile, I have no problem with people deciding they'd like to be under psychoactive influences 24/7 and get themselves a nice addiction

This is so totally the problem with our approach to mental illness-- we believe that anything that is a "psychoactive" treatment is in somehow a different moral category than "physical" treatments.

There's no moral difference in taking Prozac to treat depression vs. taking a daily dose of aspirin to prevent heart attacks vs. runners who take glucosamine to relieve joint pain.
posted by deanc at 12:44 PM on January 17, 2008

HOWEVER, this does not mean that I blame people for being manipulated or misled.

Do you really believe that most people are not offended to be told that they've been manipulated or misled? If so I would suggest that your understanding of the average person is more than a little flawed.
posted by phearlez at 12:45 PM on January 17, 2008

There's no moral difference in taking Prozac to treat depression vs. taking a daily dose of aspirin to prevent heart attacks vs. runners who take glucosamine to relieve joint pain.

I wouldn't call it a moral difference, but only one of these things goes into your brain to affect your thoughts, which certainly opens up many more issues than something going to your knees.
posted by TheOnlyCoolTim at 12:52 PM on January 17, 2008

I suspect that it is rather difficult to pursue an exercise regimen when your depression makes you feel as though the entire enterprise is completely futile.

Rather difficult? Yes. Impossible? Not always. For some, yes, but not always. Everything is rather difficult when you're depressed, exercise not much more or less so than many other approaches. Again, I recognize that for some people this may not be the most productive approach in either the short or the long term, but I feel that all treatment options should be seriously discussed and placed on the table before immediate recourse to drugs.

I don't think an aversion to taking drugs unless strongly indicated, when there are other treatment possibilities, is unique to the world of psychological illness. There are drugs for high cholesterol, but it can also be well controlled through lifestyle change in many, many cases (not all, of course). Similarly, weight loss. Similarly, joint problems. Or infertility. Drugs may work well, but I do think their benefits are trumpeted out of all proportion to preventive and behavioral treatments that are often just as good. Not in every case, but often.
posted by Miko at 12:54 PM on January 17, 2008

OmieWise: Just so there’s no confusion: Depression is very real and very treatable. Seriously.

Look, I appreciate your point of view, and it's good that you made this disclaimer. Thank you for that.

Even so, this post implies several false conclusions.

First of all, this is not new information. It is a new study, and it is the first mainstream publication of this conclusion, but your second link has been around for three years, and people in the field have known these things since before then. It has been a commonplace for decades, in fact, that pharmaceutical companies inflate the effects of their drugs, and most doctors and psychiatrists that I know have a healthy amount of skepticism about their claims and tend to follow up on them in published and reviewed work.

Second, the second link indicates well in its abstract why there is some skepticism about the claims of pharmaceutical companies:

In the United States, selective serotonin reuptake inhibitor (SSRI) antidepressants are advertised directly to consumers [1]. These highly successful direct-to-consumer advertising (DTCA) campaigns have largely revolved around the claim that SSRIs correct a chemical imbalance caused by a lack of serotonin (see Tables 1 and 2). For instance, sertraline (Zoloft) was the sixth best-selling medication in the US in 2004, with over $3 billion in sales [2] likely due, at least in part, to the widely disseminated advertising campaign starring Zoloft's miserably depressed ovoid creature. Research has demonstrated that class-wide SSRI advertising has expanded the size of the antidepressant market [3], and SSRIs are now among the best-selling drugs in medical practice [2].

In other words, psychiatrists and doctors are skeptical, and ought to be skeptical, about SSRIs because use of these drugs is exploding, probably because of patient demand rather than patient need. Their concern is the gulf between scientific findings and advertising claims, and not between scientific findings and psychiatric/medical use. Everyone, from the NIMH on down, has been finding for decades that SSRIs have a great deal of therapeutic use, use that is even more interesting and compelling because it is generally adaptive, so that these drugs can sometimes create longer-term benefits even through short-term use.

If I may say so, I believe the second article you link brings up the difficulty of explaining SSRIs scientifically for no good reason and treats it badly. There is good research in the field that suggests that the Serotonin explanation is a good one, and, though that research isn't complete, I think that the paper linked gives a thin impression of the field. However, even if there is no explanation yet, there is solid clinical evidence, done decades before Zoloft was a glimmer in big pharma's eye, that SSRIs have a real therapeutic benefit.

If you don't have one of the eight disorders for which SSRIs are recommended, then it's unlikely that you should take one. People out there who take an antidepressant for the ups it gives them ought to speak with their doctors and see if they should stop, as they don't need it. But if you have depression or one of the other disorders for which they are recommended, and if you have a doctor who is well-informed and who you can trust, SSRIs are probably of benefit to you. It never hurts to talk to your doctor, but don't let this convince you that certain drugs are absolutely useless.

Full disclosure: I take an SSRI, hydrochloride sertraline (Zoloft), not as an antidepressant, but as a treatment for intermittent explosive disorder. It's been of some service to me, not in making me "happy," but in leveling my mood and in helping reestablish certain patterns of thought that I find necessary. I don't expect to take it forever, but it is of great use; and before I started taking it, my psychiatrist sat me down and said, "now, I know that this has been marketed ad nauseum as a happy pill, but you shouldn't think of it that way," and then proceeded to explain to me the state of current research and the theories behind it. Every doctor should be able to do the same.
posted by koeselitz at 12:55 PM on January 17, 2008

I suspect that it is rather difficult to pursue an exercise regimen when your depression makes you feel as though the entire enterprise is completely futile.

This may explain the placebo effect as well. Just as you are unlikely to possess the optimism to begin a new exercise regimen when in the grip of a clinical depressive episode, so are you dispossessed of the optimism that a physician can do anything about it. The seeking of therapy is an act of optimism and selects persons who enroll in studies for at least some glimmer of optimism. This probably means that to some extent the disease is abating at the time of enrollment and an upswing expected in the majority of study enrollees. Perhaps the results of the studies both positive and negative should be entertained in this light.
posted by Mental Wimp at 12:59 PM on January 17, 2008

intermittent explosive disorder

Whoa!
posted by Mental Wimp at 1:00 PM on January 17, 2008

Drugs may work well, but I do think their benefits are trumpeted out of all proportion to preventive and behavioral treatments that are often just as good. Not in every case, but often.

Generally, I agree. However, it strikes me that there's a tangible difference between changing your lifestyle to deal with your cholesterol and changing your lifestyle to deal with depression. In the latter case, the problem actively hinders you from pursuing a solution. That strikes me as the precise circumstance in which medication would be warranted.
posted by deanc at 1:03 PM on January 17, 2008

See, you have a good doc there koeselitz. Please don't take it personally that I find it amusing to note that the acronym for your condition is IED.
posted by Mister_A at 1:08 PM on January 17, 2008

HOWEVER, this does not mean that I blame people for being manipulated or misled.

I'm sure that some people are indeed manipulated or misled but such things are not unique to anti-depressants and mental health but to anyone who is unethical who can take advantage of you. Hence the second opinion dynamic. I have no doubt that people have the wrong impression of what these drugs do and how they work. This is, again, hardly unique to anti-depressants.

However, with just a few questions and a good doctor I've found that, bottom line, I have never been unaware that these drugs are not an exact science, that they are prescribed when judged appropriate (after talking about the situation extensively) and the results, positive or negative or null are charted in judging the effectiveness of treatment, that people react very differently to various drugs, including the degree of side effects, what the possible side effects are, that exercise and changes in lifestyle can be very helpful, that other options can and should be explored, particularly if you're opposed to taking medication long term, that your mental state is also subject to factors other than chemical, that they are not appropriate for event related depression unless it doesn't go away, that the medication most likely will not make you happy in the "Yay!" sense that some believe to be the case, but has, for many, helped them feel better than completely awful, has helped to restore motivation, appetite, and focus, and that furthermore, going off the medication when things have improved is also encouraged and monitored.

My doctor is not a member of a marketing firm and nor am I a person who just believes the messages in pharmaceutical advertising. I ignore them entirely. If this is not the case for most, and the health field is full of lazy doctors with poor ethics and full of patients who can't distinguish A from B then that is not limited to this class of medication.

Meanwhile, I have no problem with people deciding they'd like to be under psychoactive influences 24/7 and get themselves a nice addiction

First I've ever heard of these drugs being addictive. I'd be interested to read about that.
posted by juiceCake at 1:11 PM on January 17, 2008

Depression sucks.
posted by parki

Indeed.

Until you read parki's simple statement and truly understand it...then I would rethink the reactionary "get more exercise" statements.
posted by P.o.B. at 1:12 PM on January 17, 2008

From the research-quality perspective, this is related to something I've been annoyed about ever since I started reading journal articles. Nobody* publishes an "actually, I was wrong" paper, or even a "my earlier conclusions are looking a bit dubious" article. However, in my own experience, and that of friends across disciplines, there are numerous cases of bad research, mistakes in experiments and papers which are generally known to be outright wrong. On the few occasions that these are called out, they are always by another institution or group, never by the original authors.

I had the naive impression that academics were all about honest, scientific research, but this just doesn't always appear to be the case. Whether it's the way journals work, or dishonesty among some scientists, I don't know.

Mistakes in work are inevitable, and shouldn't be a problem, it's just that they need to be given the same exposure that the original result was given. I'm probably exaggerating the problem, and I can't be bothered to look for suitable examples right now, but it seems like a real issue.

*well almost nobody. There are a few exceptions.
posted by iso_bars at 1:32 PM on January 17, 2008

To add a little more perspective: SSRIs have been in development since 1983. They weren't foisted on the market with minimal research a few years ago; they've been considered for several decades now.
posted by koeselitz at 1:33 PM on January 17, 2008

Exactly-- and it's amazing to me how the people who are inflicting their moral judgments on people with depression are unaware of the morally-loaded terms they are using like "addiction" and even "turning to pharmaceuticals" as opposed to "changing your life."

When I used the stroke analogy, it was because if you look at public responses to advances that save time and energy in "medical" treatment and those to advances that save time and energy in "psychiatric" treatment, they are extremely contradictory.

When we have an advance that allows you to move from a treatment that takes hours of time (say dialysis) and replace it with one that takes none at all (transplant), no one has an issue with it. But when an advance allows you to skip hours with a therapist in favor of taking a pill, that's somehow cheating.

And, the therapists are always seen as these nice humanists with no financial interests (they'd be out of a job if everyone went to drugs though) while the drug companies are evil and are all financial interest, no caring. I am not saying this to defend drug companies-- but I do think that therapists get a free ride when they are defending their own livelihoods just as much as the drug companies are, just with different ideology.

Regarding the serotonin thing, raising serotonin doesn't lift mood: if it did, antidepressants would work within hours, not weeks. What does seem to be in common amongst all treatments that work (talk included, ECT included) is that in about 2 weeks, they spur re-growth/increased health of certain neurons in the hippocampus. Interestingly, these same neurons are damaged when the brain is under extreme stress and interestingly as well, extreme stress is linked with a high proportion of depression.

Regarding me using my personal experience as science, I wasn't doing that-- I was just saying that as a person who has written a lot about this and talked a lot about this and sought out a lot of opinions on this over many years, I haven't met anyone who decided, after taking medications, that their depression "wasn't such a big deal after all" and so they shouldn't have tried the medication. Not that they didn't have side effects, not that some didn't regret trying meds due to that.

What I was trying to express is that when *you* are the one in pain, describing any form of depression as "mild" or "moderate" is rather an insult. Consequently, people who suffer depression, although they may ultimately find that other things than drugs work for them personally, tend not to have the view that everyone is out there taking Prozac as "cosmetic psychopharmacology" and while *my personal pain deserves treatment*, everyone else is just a whiner who is being "overprescribed to."

Further, SSRI's are crap as cosmetic psychopharmacology because the sexual side effects are such a problem for so many people that unless the problem is really serious and they are getting a benefit, they tend to stop taking them pretty most. I believe most prescriptions for antidepressants, in fact, are not renewed-- but I could be wrong.

One last thing: addiction is NOT physical dependence, otherwise we are all air, food and water addicts. Addiction is compulsive use of a substance despite negative consequences-- if results are positive, it's NOT addiction.
posted by Maias at 1:36 PM on January 17, 2008

But if you have depression or one of the other disorders for which they are recommended, and if you have a doctor who is well-informed and who you can trust, SSRIs are probably of benefit to you.

koeselitz-

Your statement is contradicted by the NEJM study, which finds that the effect size for all anti-depressants, taken together, is 0.36. I'm not sure why you would suggest that this translates into the statement I quoted above. It most assuredly does not. It does translate into: "SSRIs were of benefit to a minority of people on whom they were tested." You are apparently one of those people. That's great.

Unless you want to argue with the study all of the rest of your comment is hand waving.

I understand that this is an issue about which many people feel partisan. I certainly have an agenda, which is to get people the treatment that will most effectively treat their depression. I have no idea what that treatment might be before I see a patient (I'm not a doctor, I'm a psychotherapist), but I think the available treatments are limited by overstatement of medication efficacy. I have thought that for a long time, this NEJM paper does a good job of showing just how much of an overstatement we're really talking about. It DOES NOT say that antidepressants are not helpful for anyone, but the conclusions are pretty damning to anyone who really has been paying attention to mental health treatment in the USA. As I explained above, saying that these medications are not effective for very many people is not the same thing as saying that there is no effective treatment, and it's a strange way to prove my overarching point (about the damage overstatement of their efficacy has resulted in) to argue that it is.

I do find it very interesting that folks who are seeking to dispute the conclusions here on their face (not with any substantive critique, mostly with anecdote) are making an argument that is at the same time both relying on their version of science and also rejecting the process of science. "Depression is a medical condition, and one needs medications to treat a medical condition" & "This study is faulty/not useful/not interesting/beside the point because it does not account for my anecdotal response to the medications it examines."
posted by OmieWise at 1:36 PM on January 17, 2008 [1 favorite]

I would suggest that your understanding of the average person is more than a little flawed.

In a few years, there may be a pill for that. Seriously.
posted by aeschenkarnos at 1:36 PM on January 17, 2008

oops "most" should be "fast" in second to last paragraph.
posted by Maias at 1:37 PM on January 17, 2008

To add a little more perspective: SSRIs have been in development since 1983. They weren't foisted on the market with minimal research a few years ago; they've been considered for several decades now.

I'm sorry, on non-preview: Now I think you really must not have read either the WSJ article or the abstract of the NEJM paper. The point is precisely that while they've been around for a long time, the selective publication of data led people to grossly overstate their efficacy. Your statement, again, suggests that this paper is more, rather than less, important.
posted by OmieWise at 1:39 PM on January 17, 2008

Omiewise, there is data to support the notion of 'strong responders" to particular meds-- from David Healy, in fact, who is hardly a drug company pawn by any stretch of the imagination. This study is no way explains these results because even more than individual studies, it blends everything into one number in a way that doesn't account for individual responses.

There is also no data that supports psychodynamic therapy compared to CBT-- interpersonal therapy yes, but not psychodynamic.

And yes, I know about the research showing that therapeutic alliance-- especially empathy-- is a better predictor of outcome than technique used. That doesn't mean that specific techniques aren't helpful.
posted by Maias at 1:41 PM on January 17, 2008

What the discussion on this has largely left out is that it's not only the pharmaceutical companies that perpetuate this-- it's the medical journals and the media.

No one likes to publish "null results"-- it's called the file drawer effect. So even if the pharm cos had tried to publish (which they likely didn't try hard to do), they might not have succeeded.

Exactly, and the file drawer effect is not new, nor is it confined to this particular area of study. My old social psych professor talked about this problem a lot, back in the mid-1990s. Question is, what can be done?
posted by Infinite Jest at 1:41 PM on January 17, 2008

Mental Wimp: See, you have a good doc there koeselitz. Please don't take it personally that I find it amusing to note that the acronym for your condition is IED.

I don't mind-- I thought it was funny when I was diagnosed, too. So long as you don't take it personally when I say that I find your user name a propos to this thread.

Also: if you say that again, twerp, I'll give you a cortical noogie.
posted by koeselitz at 1:54 PM on January 17, 2008

Omiewise, there is data to support the notion of 'strong responders" to particular meds-- from David Healy, in fact, who is hardly a drug company pawn by any stretch of the imagination.

Maias-Strong medication responders don't obviate this study, any more than strong placebo responders (often excluded from trials) obviate this study. It's looking at something else entirely: How effective, overall, should we consider antidepressants to be? All of my comments here have indicated that I recognize that meds help some patients, and I'll go further (since it seems called for) and explicitly say that meds are the only appropriate treatment for some patients.

See Wampold's (and Lambert's) meta-analyses for evidence on psychodynamic efficacy.
posted by OmieWise at 1:57 PM on January 17, 2008

and it's amazing to me how the people who are inflicting their moral judgments on people with depression are unaware of the morally-loaded terms they are using like "addiction" and even "turning to pharmaceuticals" as opposed to "changing your life."

Umm, no.

Yes, I do think that drugs should be used as a last line of defense. I think that if you can find a way to deal with your problems without using drugs, you may want to do that. The experience can teach you a lot about yourself and about life. The skills and habits that you pick up can lead to a long-term solution that does not involve taking drugs.

However, I realize that this option isn't open to everyone, because their illness prevents them. And for these people, we have the drugs.

I did not make any moral judgments. But if you want to take it that way, there isn't a damn thing I can do for you.

And finally, to use your (flawed) stroke/kidney failure metaphor - I'm sure there are a lot of people taking medicines for stroke and kidney failure who would love it if they had a non-drug alternative.

Once again, I'm sorry if I've offended, it wasn't my intention.
posted by Afroblanco at 2:01 PM on January 17, 2008

In other words, I don't think that choosing a drug route over a non-drug route makes someone a weak, immoral, or bad person. Nowhere did I say that.

However, I do think there are good, valid reasons for picking a non-drug route over a drug route.
posted by Afroblanco at 2:13 PM on January 17, 2008

Well, I could quit alcohol, as someone mentioned above, for my clinical depression--but wait, I don't drink! Or at least I can count on my fingers the times I have done so in my life.

I could exercise more, and that's a great help. But you have to be able to get out of bed to exercise.

I could, and do, go to therapy along with taking anti-depressants, but therapy alone doesn't cut it.

These studies, honestly, don't surprise me. Drug companies are all about making money. I understand that. But that doesn't mean that the drugs don't help people like me. I have a family, I have children. I have responsibilities. And I actually have a great life! But knowing that intellectually didn't make it any easier to take care of what I had to do, or appreciate the things I had.

Frankly, I wish we knew more about how SSRI's work. I wish we had a better understanding of mental illness in this country. But until we do, whatever gets me through my day is okay by me.
posted by misha at 2:15 PM on January 17, 2008 [1 favorite]

The strong and varied reaction to anti-depressants brings Criswell (YouTube) to mind.
posted by juiceCake at 2:24 PM on January 17, 2008

One last thing: addiction is NOT physical dependence, otherwise we are all air, food and water addicts. Addiction is compulsive use of a substance despite negative consequences-- if results are positive, it's NOT addiction.

I'm working from a definition of addiction as physical or pyschological dependence here. Under this, yes, I'm addicted to food and air, but the addiction isn't bad for me. All the same, I'd rather I didn't have to eat if I didn't want to.

I tend to think this is the societal definition for certain things: some guy with a dependence on pain pills or some guy smoking weed every day is probably going to get called an addict whether or not he's suffering significant negative consequences. If someone dependent on SSRIs is not called an addict, there's a consistency problem.
posted by TheOnlyCoolTim at 2:32 PM on January 17, 2008

ntil you read parki's simple statement and truly understand it...then I would rethink the reactionary "get more exercise" statements.

As long as we're throwing anecdotal perspectives in, why is it fair to discount mine and not someone else's? I've treated depression with assistance three times, twice with meds and once with exercise and therapy. The last treatment was most effective for me personally and created a skill set which has served well ever since. It may not serve forever, but I'm a person whose non-med treatment was effective.

I speak from as real an experience as anyone else's. Depressions certainly vary in type, trigger, and severity, so I wouldn't generalize my experience to everyone's, but neither should others generalize their positive experiences with meds to everyone else. I can say I was deeply relieved when I found the last doctor, who approached the problem differently than the other two had before, and whose treatment plan was more comfortable for me. So it's very important to realize that just as I must recognize that meds work for some people, they didn't work well for me. I'm saying that some effort should be spent on identifying the best treatment for each individual and his or her condition. Doctors don't always present the kind of perspective these articles suggest; my first two doctors never even suggested lifestyle changes or therapy. Is that a good approach?

My opinions aren't reactionary, they're based on reality, and I have walked a fair few miles in those shoes. There is no condemnation implicit in suggesting that consistent exploration of a wider array of treatment approaches would serve everyone best.
posted by Miko at 2:52 PM on January 17, 2008

If someone dependent on SSRIs is not called an addict, there's a consistency problem.

Not at all. Because the first thing that comes to mind to a random person on the street if you call someone an "addict" is not "oh, they're addicted in the same way that I'm addicted to food and water", it's "oh, they're addicted like someone gets addicted to heroin".

Calling someone an addict has a very specific connotation, and waving your hands and saying that dependency on food, water, light, or anything else could also be called an addiction doesn't change the connotation of the word "addict".
posted by Justinian at 3:05 PM on January 17, 2008 [2 favorites]

Miko, there is certainly a condemnation implicit in "suggesting that consistent exploration of a wider array of treatment approaches would serve everyone best."

Why?

Because of the assumption that PEOPLEON MEDS HAVEN'T ALREADY DONE THAT AND FOUND WHAT WORKS FOR THEM. You are assuming that people taking meds haven't tried exercise, therapy, etc and don't consistently re-evaluate what works and what doesn't for them. You're assuming that we don't exercise *and* take meds, for example.

And Tim, if you define addiction as physical or psychological dependence, you wind up with a system in which doctors and patients get sent to jail for pain treatment that is effective and safe and in which many, many others get under-medicated because docs are afraid to treat them. Until we make clear the distinction, we're going to stigmatize people on maintenance meds of any sort and make drug policy that makes no sense.

Afro, in who's world is the tone of this statement not one of judgment?

I do think that drugs should be used as a last line of defense. I think that if you can find a way to deal with your problems without using drugs, you may want to do that.

Why should you want to do that if the drugs work better and with less effort? Why is less effort *bad* when it comes to mental health but *good* when it comes to physical health? Sure the people with kidney disease would prefer *no drugs* to anti-rejection drugs-- but that isn't the choice they have: the choice they have is one of dialysis or transplantation in this example.

And for people who find meds more convenient for depression, it's no different. The choice isn't one of meds or no treatment. It's one of meds or a treatment that's a pain in the ass for them. Why should they have that extra hassle?

I don't think you can answer that in any other way but to say that "because it's better not to take drugs" and that "better" is a moral judgment.
posted by Maias at 3:06 PM on January 17, 2008 [2 favorites]

However, I do think there are good, valid reasons for picking a non-drug route over a drug route.

Such as?

Personally, if I could take a pill every day to keep myself slim and heart-healthy I'd much rather do that than have to do cardio workouts every day or whatever. So from my point of view, there are goodm valid reasons for picking a drug route over a non-drug route for a lot of things.
posted by Justinian at 3:06 PM on January 17, 2008

TheOnlyCoolTim: I wouldn't call it a moral difference, but only one of these things goes into your brain to affect your thoughts, which certainly opens up many more issues than something going to your knees.

Well, I guess the answer to this is so what? How many people in this thread have a caffeine addiction? We know that glucose changes how people think. Should we have a ban on jelly donuts?

Afroblanco: Yes, I do think that drugs should be used as a last line of defense. I think that if you can find a way to deal with your problems without using drugs, you may want to do that. The experience can teach you a lot about yourself and about life. The skills and habits that you pick up can lead to a long-term solution that does not involve taking drugs.

I think a lot of this hysteria over drug therapies have to do with overselling their effect as some sort of creepy mood-altering zombie-creating magic pill.

I'm a crank when I'm off an SSRI, I'm a crank when I'm on an SSRI. An SSRI does not make me a happy person, it doesn't pay my bills, wash the car, or scoop the cat litter. But what it does do is dial down some of the physical and cognitive weirdness that 10 fucking years of cognitive-behavioral therapy did nothing to prevent. Now cognitive-behavioral therapy was quite useful for making me mindful of the fact that panic attacks and the feeling of spiders under my skin are my body's primed over-reaction to mildly stressful events, so at least I'm aware of the fact that I'm not loosing my fucking mind.

And let's look at the other side of the coin here. Even when you factor out increased risk of suicide or falling into the criminal justice system, severe and chronic mood disorders are a serious long-term health risk. So we are not just talking about subjective states of mind, we are talking about a medical condition which greatly increases the risk of other fatal medical conditions and premature death. At least for me, an SSRI means that I'm no longer taking borderline-toxic levels of acetaminophen on a weekly basis. So by all means I'll gladly take the need for extra sleep, sexual side effects, and other weirdness over the very real physical problems that were plaguing me.

At least for me, I have good money that this isn't about situational or lifestyle factors. With autistic-spectrum conditions, we have some tantalizing evidence that those conditions involve extremes of attention and fixation. With schizophrenia-spectrum conditions, we have tantalizing evidence those conditions involve extremes of how we integrate the physical self. Likewise, I strongly suspect that at least some classes of mood disorder will be linked to some cognitive kink that is extreme compared to the central tendency of the population.

Now having said all this, I do think that SSRIs and related drugs are being marketed as a panacea and thrown at situational depression as well as significant long-term mood disorders.

On preview, you know, I tried the exercise route a few times now. It didn't work for me because I'd get obsessive about it to the point where I overtrained to injury. Knitting was great for my mood disorder until I obsessively knitted myself into RSI. Thank chemistry for the ability to put in a full day's work on something and leave it behind until the next day.
posted by KirkJobSluder at 3:22 PM on January 17, 2008 [4 favorites]

If you have the genetic advantage not to have depression, why shouldn't I take drugs to level the playing field?

Because you taking the drugs (sometimes) raises the cost of other people in your insurance pool, and you're not ponying up for the cosmetic surgery to fix my wretched, hideous face?
posted by Kwantsar at 3:46 PM on January 17, 2008

Kwanstar: Because you taking the drugs (sometimes) raises the cost of other people in your insurance pool, and you're not ponying up for the cosmetic surgery to fix my wretched, hideous face?

If your face is really so wretchedly hideous that it interferes with your ability to make a living, it causes you chronic pain and ulcers, and puts you at a higher risk of serious illness or death, then by all means, I think insurance should fork over the money for reparative surgery.
posted by KirkJobSluder at 3:54 PM on January 17, 2008

Because of the assumption that PEOPLE ON MEDS HAVEN'T ALREADY DONE [exploration of a wider array of treatments] AND FOUND WHAT WORKS FOR THEM.

Can you honestly say that this assumption isn't for the most part true? A lot of people are rendered helpless by depression -- do you really think that most of them have the get-up-and-go to go against the standard idea -- as sold to us by Big Pharm -- that "you cure depression with a pill"?

And would this not have been compounded by the fudged results in the FPP that seem to be totally ignored in this thread?
posted by lupus_yonderboy at 4:03 PM on January 17, 2008

Also: if you say that again, twerp, I'll give you a cortical noogie.

No! Those are the worst kind. And I didn't post the quote, Mister_A did, so give him the noogie if he strikes his impudent keyboard in that way again.
posted by Mental Wimp at 4:20 PM on January 17, 2008

lupus_yonderboy: Can you honestly say that this assumption isn't for the most part true?

I think it is profoundly rude to play armchair doctor and make assumptions about a person's medical history. It just so happens that depression and obesity are pretty much the only two medical issues where our culture offers a pat on the back for such blatant asshattery.
posted by KirkJobSluder at 4:26 PM on January 17, 2008 [1 favorite]

Indeed, Kirk!!

And I don't like arguments that assume that people aren't attempting to look out for themselves as best they can. I don't know these "take a pill first" people. I know drug addicts who like to play with drugs to get high; I was one.

But, ironically, many drug addicts absolutely refuse to take any psychiatric medication whatsoever because they see it as an attempt to control them, not help.

And everyone who *isn't* a drug addict tends to fear addiction, fear dependence, fear the stigma of psychiatric medication and the moral judgment of everyone who says "oh, why are you 'just' taking a pill-- you should be doing the hard, righteous work of therapy?" and the moral judgment that causes many people on antidepressants to hide them when a date stays over.

So, in my wide experience of talking to dozens of people about their depression and medication, I have yet to find one who took drugs as the "first resort." I certainly didn't-- I suffered through 7 years of 12 step programs (which were useful with addiction and as essentially, cognitive therapy, I later learned), 3-4 years of utterly useless psychoanalysis (in which I was told that my OCD was a result of bad toilet training) and lots of other well-meaning crap. Then I took the meds and got better.

Do any of you posting on this thread know someone personally-- or did you personally-- take drugs at the first sign of first depression, with no prior experience of therapy or other attempts at self-help?
posted by Maias at 4:59 PM on January 17, 2008

I find it profoundly rude to not RTFA and instead blather on about personal experiences which offer nothing of meaning or consequence in the face of science and statistics which are offered in the post, if only anyone had bothered to read it. Alas, I'm a simple man.

Maias, I'm not sure why you think the distinction you're making means anything. Yes, many people turn to anti-depressants as a last resort; that does not automatically make them effective treatment. Lots of people turn to Jesus as a last resort, that doesn't make him more effective than a placebo either.
posted by mek at 5:15 PM on January 17, 2008 [1 favorite]

mek: Maias, I'm not sure why you think the distinction you're making means anything. Yes, many people turn to anti-depressants as a last resort; that does not automatically make them effective treatment. Lots of people turn to Jesus as a last resort, that doesn't make him more effective than a placebo either.

I did RTFA, and the study posted does not support either of these two claims. Instead, the conclusion of the studies is that SSRI's are more effective that placebos, but less effective than advertising claims.

But alas, I'm not a simple man, I'm a man with a background in statistics.
posted by KirkJobSluder at 6:02 PM on January 17, 2008 [2 favorites]

"Luminous beings are we, not this crude matter." -- Yoda

I wonder what becomes of Jedi who rely on anti-depressants, after they're dead and they can't get their hands on astral-Zoloft?

How about human souls when they're done in this world?

You'd have to be pretty certain that humans are just biochemical machines to conclude that their mental state is a side effect of the way their body is constructed.
posted by tkolar at 6:10 PM on January 17, 2008

tkolar: Ahh, so then why the effects of alcohol, marijuana, coffee, or even a good turkey dinner? Why do many so religions consider sobriety to be a prerequisite for spiritual enlightenment, and so many others have sacraments involving psychedelics?
posted by KirkJobSluder at 6:20 PM on January 17, 2008

Of course, in that direction lies much peril, in my neck of the woods we are putting a minister on trial for trying to exorcise the demons from an autistic teen, a process that involved more than 12 hours of battery and forced vomiting. I'll take acceptance of my cognitive quirks over the belief that I'm possessed of the devil most days of the week, except when a good case of demons might help to ward off the evangelists.
posted by KirkJobSluder at 6:29 PM on January 17, 2008

Sweet! I just got my prescription of Obecalb!
posted by Balisong at 6:32 PM on January 17, 2008

KJS, I'm not sure what you think my post said, but it didn't in any way contradict or even disagree with your reply to me.
posted by mek at 6:55 PM on January 17, 2008

Ahh, so then why the effects of alcohol, marijuana, coffee, or even a good turkey dinner?

I don't think you'd find anyone who would claim that chemicals don't change your perspective. It's the converse that I'm questioning: that there are certain perspective changes that are only possible through chemicals.

Besides which, all the substances you mention have temporary distorting effects -- the dead jedi probably won't be able to get drunk, stones, highly agitated or sleepy either. Anti-depressants are touting as making permanent changes to personalities, which is a whole 'nother ballgame.

In any case, it seems to me that if there is such a thing as your personality continuing on after you die, then any issues in that arena shouldn't need physical solutions. (not that physical solutions wouldn't work, just that they shouldn't be necessary).
posted by tkolar at 6:58 PM on January 17, 2008

mek, you snarked about people commenting without reading the article, and followed that up with a paragraph that had absolutely nothing to do with the article. It confused me too.
posted by tkolar at 7:01 PM on January 17, 2008

This is one of the reasons I got out of doing science for a living. You have a hypothesis, spend months or years testing it. Depending on how it turns out, you either publish and advance your career, or not, with little or no bearing on your abilities.
posted by exogenous at 7:03 PM on January 17, 2008

It was a direct reply to Maias, hence why i prefixed it with "Maias," If that confuses you, apologies. Maias was fixated on the idea that because most people turned to SSRIs as a last resort (an assumption in and of itself), that somehow affected their efficacy for the better in a way which was not measured by any study.
posted by mek at 7:08 PM on January 17, 2008

"Luminous beings are we, not this crude matter." -- Yoda

Thanks, tkolar! I used to believe those "doctors" who told me I had a "treatable medical condition," but you've opened my eyes to the truth: my midichlorian count is too low!

Is there a pill for that?
posted by nicepersonality at 7:44 PM on January 17, 2008 [1 favorite]

KirkJobSluder said: I think it is profoundly rude to play armchair doctor and make assumptions about a person's medical history. It just so happens that depression and obesity are pretty much the only two medical issues where our culture offers a pat on the back for such blatant asshattery.

I'm gonna have to nominate Fibromyalgia for that list. As an example, see the Fibro thread lower down the Blue. Asshattery in abundance.

That said, returning to the topic of the original post, the study, if verified, is disturbing. I don't have a subscription to the NEJM, and I'm not sure if it would be bad form to email the study author and ask if he would send me a copy of the study, so I can read it in its entirety. I did find some interesting data at the Clinical Psychology and Psychiatry blog, if anyone wants to read more about the topic. Also for further reading, when the discussion of efficacy was raised in 2002 by the 4th link in the FPP, there was a counter-point article.

Is this study a good reason to be concerned? Probably. But not just because it's AD meds, but because it's probably indicative of a much larger problem in the pharmaceutical and medical industry. Should clinical trials be more transparent to people who may be considering the drugs? Absolutely. Should patient information be easier to understand. Oh yeah. But that holds true for all classes of drugs, not just psychotropics.

What would be interesting is to do a study of some other "market segment" of drugs and see if the data suppression/spin doctoring was at the same basic levels. I would be willing to bet money that there are tons of meds on the market with the same numbers.
posted by dejah420 at 7:59 PM on January 17, 2008

Selection Bias. Pretty well established principle.
posted by alms at 8:59 PM on January 17, 2008

See also Number needed to treat.
posted by alms at 9:19 PM on January 17, 2008

Maias was fixated on the idea that because most people turned to SSRIs as a last resort (an assumption in and of itself)

Presumably in response to the continuing exhortations throughout the thread that people should try diet, exercise, psychotherapy and sacrificing a chicken to the gods before they turn to the evil products of Big Phama.

Fortunately, we don't have these silly debates here in the UK. We pay NICE to critically evaluate the evidence on our behalf.
posted by PeterMcDermott at 7:45 AM on January 18, 2008 [1 favorite]

Do any of you posting on this thread know someone personally-- or did you personally-- take drugs at the first sign of first depression, with no prior experience of therapy or other attempts at self-help?

My concern is not with the patients and what they eventually chose to do, but with the doctors who have the power to prescribe treatments for those patients, and whether they present those treatments in context with information about the likelihood of success, the information about the full range of options and the relative efficacy of each, and a discussion with the patient about the patient's goals and preferences and how that treatment may fit within their daily lives. My concern is that the full spectrum of treatment options is not always presented to people, many of whom may respond readily to something otherthan medications.

But in answer to the question, since you seem to persist in believing that there's no problem with current diagnostic practices: Yes. The first time I received a depression diagnosis, it was from a college health services doctor during my senior year. He used a brief symptom checklist to which I answered questions with "often," "sometimes," "never," chatted with me for a minute about the prevalance of depression among college students and senior stress, diagnosed me with moderate depression, and wrote out a prescription for Wellbutrin. Under 15 minutes. The basic format of that experience was repeated with a psychiatrist to whom my doc referred me a few years later, with the added bonus of one follow-up visit. It wasn't until I went for help a third time, in 2004, I managed to link up with a therapist with a more holistic approach who happened to mention that drugs were not always effective or warranted and that other approaches often worked, as well.

Regardless of whether you as an individual feel it's irrational to want to resist drug therapies, many people do want to resist them, and they should be entitled to information about how to do so without judgement from the other side of the fence. Some people (I'm one of them) don't even want to take OTC cold medicines or pain relievers. Others feel completely differently about medications and obviously they have been near-miraculous for many. Having a treatment option that you feel good about, for whatever rational or irrational reasons, is pretty important. It would be just as wrong for a person who does not wish to take drugs to feel that there is no other solution as it would be for someone who does to be told the only option was to suck it up and hit the gym.

There's absolutely nothing wrong with making sure that all people with depression are presented treatment options and accurate information about the efficacy of each option. In demanding that, we'd only be demanding appropriate individual treatment with a focus on improvement for the patient. I see no judgement inherent in that and can't imagine a good argument against it.
posted by Miko at 11:30 AM on January 18, 2008 [1 favorite]

My concern is that the full spectrum of treatment options is not always presented to people, many of whom may respond readily to something other than medications.

This concern is often presented, but I have yet to see any real studies on the topic. The data presented here indicates that the prescribing physicians may have an over-optimistic view of ADs as a treatment option, but doesn't really address what else they might or might not consider viable options.

Of course, the research papers on other treatment options are almost certainly equally biased, so there's a good chance the whole thing is a wash from a "preferring one over the other due to research" standpoint.

I'd be interested to know how often the scenario you experienced plays out. When I was diagnosed with depression the drugs were trotted out as one of the easiest and least time consuming treatment options, but by no means the only one.
posted by tkolar at 12:32 PM on January 18, 2008

doesn't really address what else they might or might not consider viable options.

This is a good point. What actually happens in clinical conversations, and in what numbers? How usual/unusual are the experiences represented here? What do treatment protocols say? What are the recommended standards? If there are no studies about this, there must be some documents, hospital/practice protocols, or something of the sort that might shed some light.
posted by Miko at 1:27 PM on January 18, 2008

The concern about in-depth care and discussion of the wide range of solutions rather than just handing over a pill is certainly a valid one in the area of depression.

And cholesterol.

And high blood pressure. And constipation. And headaches. And - oh, you get the point.

As I said what seems like forever ago, this is not a depression treatment matter. It's a health care and general pharma issue. But as KirkJobSluder pointed out, when you get into brain and weight issues all of a sudden people get their knickers in a twist and pull out the judgmental language (and, I would contend, the judgmental attitude, but I'm uninterested in further arguing about whether there's a difference when your claimed intent doesn't at all mesh with your visible behavior and statements).
posted by phearlez at 2:31 PM on January 18, 2008 [2 favorites]

Indeed. And I certainly have never argued that people shouldn't be presented with options or that there's no problem with current diagnostic practices-- I simply said that the person who, when faced with a touch of depression, says, "OK, first thing I'm gonna try: drugs," is a basically a media myth (unless the drugs you are talking about are recreational as self medication).

Does overprescribing occur? It's very hard to tell because we've never had a decent range of treatment options for depression before.

And, there's actually a lot of evidence that many people with severe depression never get treatment at all so you can even make a case for underprescribing-- for example, most people who commit suicide are *not* on medication or in treatment (and yes, not all suicides are due to depression, but a large percent are and it's untreated depression that produces suicide, basically-- even though there are some people who do have increased risk due to bad drug reactions).

When antidepressant prescribing rates go up, suicide rates go down. Consistently.

Now, do doctors offer drugs easily? Yes, doctors prescribe drugs. They don't do therapy. So that's what you are going to get from most doctors. If you go to a psychologist, they are going to prescribe therapy and if you go to an acupuncturist, they're going to offer acupuncture.

This is a systemic problem but it has nothing to do with antidepressants per se.
posted by Maias at 3:13 PM on January 18, 2008

Maias: This is a systemic problem but it has nothing to do with antidepressants per se.

This bears repeating. It also bears connection to this fact: SSRIs aren't just anti-depressants; they're categorized for the treatment of seven other disorders, as well. Their effectiveness as antidepressants is only a small part of their overall use.
posted by koeselitz at 4:16 PM on January 18, 2008

Yes, doctors prescribe drugs. They don't do therapy. So that's what you are going to get from most doctors.

This isn't quite reality, though. Certainly, doctors can and do recommend forms of treatment other than drugs, daily, for all sorts of conditions. They not only prescribe, they recommend and refer. Just as a therapist will often recommend or refer a patient to a doctor or psychiatrist. It's not too much to ask a doctor, then, to understand and discuss the limits of medication. Doctors have the ability to recommend therapy and other treatments that may be effective, including lifestyle change. They do this all the time in cases of other types of illness. This New York Times piece discusses a movement toward 'lifestyle medicine' which revolves around that sort of counseling, and mentions some of the significant obstacles aside from drug marketing. It also references the need for the science which supports behavioral change as a treatment method:

The Centers for Disease Control and Prevention reports that 1.7 million Americans die and 25 million are disabled each year by chronic diseases caused or made worse by unhealthy lifestyles. And a 2005 study in The New England Journal of Medicine predicted that average life expectancy in the United States would decline in the next 20 years as a result of unhealthy lifestyles, reversing a trend dating to the 1850s. The American College of Lifestyle Medicine has 150 members in a wide array of specialties — nutritionists, ophthalmologists, gastroenterologists and oncologists, among others. Helping their cause is a new publication, The American Journal of Lifestyle Medicine, which appears every other month with peer-reviewed research on the way daily habits affect health.

“Bottom line is we want to promote the science, education and practice of lifestyle medicine,” Dr. Kelly said.

While they agree on the importance of questioning patients about their lifestyles and giving tailored advice on how to make improvements, there remains disagreement about who should provide such counseling and with what sort of training. Nor is there a widely accepted prescriptive approach for encouraging patient compliance.

“We know lifestyle interventions can be very powerful,” often more effective than drugs or surgery, said Dr. JoAnn Manson, a professor of epidemiology at Harvard’s School of Public Health and a member of the editorial board of the new journal. “But we need to provide the scientific evidence on how to incorporate that knowledge into practice.”

Doctors may vaguely recommend that patients lose weight or get more sleep, for example, but they do not necessarily know how to help them do it...

...“I don’t think it’s appropriate to segment it off,” said Dr. Thomas W. Rowland, chief of pediatric cardiology at Baystate Medical Center in Springfield, Mass., who routinely counsels children and parents on how to adopt healthy lifestyles. “It needs to be a fundamental part of every doctor’s practice” and therefore a part of every medical school’s core curriculum.

Still, he acknowledges that there are significant obstacles, because lifestyle counseling is time-consuming and is seldom compensated by Medicare or health insurers.

Reimbursement is a chief concern of the American College of Lifestyle Medicine. The group plans to lobby Congress to that end. And it wants Congress to require that patients be informed about the relative effectiveness of lifestyle changes before receiving certain medications — including blood pressure, acid reflux and cholesterol drugs — and before undergoing procedures like back surgery, bypass surgery and stent placement.

posted by Miko at 4:24 PM on January 18, 2008

Regardless of whether you as an individual feel it's irrational to want to resist drug therapies, many people do want to resist them, and they should be entitled to information about how to do so without judgement from the other side of the fence.

You people haven't bothered to read the guidelines, have you? OK, so let me sum up: the totality of the evidence -- as opposed to a single study here or there -- recommends a stepped approach, with CBT, exercise and brief interventions for mild depression of short duration, meds, psychological interventions and social support for moderate to severe depression, meds, complex psychological interventions and combined treatments for severe, treatment resistant and psychotic depression, and the latter with ECT where there is severe neglect and a significant risk to life.

Treatment needs to be appropriate to the severity of the condition. Anybody providing somebody with severe psychotic depression with information on diet and exercise would be negligent and would probably be barred from practicing here. People who propagandize *against* appropriate treatment are just as damaging, in my opinion, because they encourage people to continue treatment resistance and thereby encourage continued ill health in a condition that can be life threatening.

Conclusion of the final link in the original post:

"A final point of (largely) agreement: psychoeducation, exercise and proven, focused psychotherapies are underutilized as treatments of depression. I wish that all individuals with mild to moderate depression who wanted these interventions received them first, reserving pharmacotherapy for nonresponders (Thase et al., 1997a). But for patients with more severe or chronic depression, there is now good evidence that the combination of pharmacotherapy and psychotherapy is superior to either treatment alone (Keller et al., 2000; Thase et al., 1997b). I suggest that we work harder to ensure that more people with depression get adequate, evidence-based treatments and stop squabbling over the magnitude of specific and nonspecific elements of treatment."

And that's really the point of having NICE guidelines. When NICE issues a guideline, all NHS areas *must* proceed according to that guideline. 95% of their caseload will follow those regimens, and the reasoning for treatment decisions around the edge cases needs to be documented and subject to clinical audit.

And its nice to know that socialized medicine wins again.
posted by PeterMcDermott at 1:42 AM on January 19, 2008 [4 favorites]

PeterMcDermott: You people haven't bothered to read the guidelines, have you?

I had, by the way. And I'd found it extremely interesting. Made me feel as though that's precisely how medicine should work. Thank you for it.
posted by koeselitz at 11:18 AM on January 19, 2008 [1 favorite]

While I think that doctors, overall, have the best interests of their patients in mind, it has not been anything like my experience that most doctors present antidepressant medications as one among several options. The opposite has been my experience in ~10 years working in community psychiatry, in settings ranging from in-patient psychiatric wards to medical clinics unrelated to mental health per se. At the clinic where I currently work, where we serve patients whose lives are extremely chaotic (providing more than enough fodder for situational depression), and where we routinely give out disturbing diagnoses (it's an HIV clinic), AND where we offer free psychotherapy, medications continue to represent the first-line treatment option for most of the MDs and mid-level clinicians. I know this is just my anecdote, but it's been consistent across several different treatment facilities.

The British guidelines are good, and the BMJ came out with an editorial a couple of years ago arguing that antidepressants should not be a first-line treatment. Suggesting that it be so does not make it so, however. There is copious evidence that GPs prescribe early and often: "Antidepressants were prescribed during the first consultation 564 times in 1993 compared with 1,080 times in 1998. The first contact with a GP for depression led to an antidepressant prescription in 62% of cases in 1993 and 73% in 1998," and the press release mentioned here from the CDC that indicates that ADs are the most prescribed meds in the USA. Surely it isn't a stretch to associate high rates of prescriptions with overstatement of the meds effectiveness.

I'll admit that I'm curious about the insistence here that prescribing patterns are carefully tailored as part of a stepped response to depression. I suspect that the people arguing that are partisan to medications in the first place, and so simply want to discount the study linked here, which indicates that well fewer than half the people prescribed the medications get symptom relief because of it.

(Which again, I feel like I have to keep saying, does not mean they don't work for some people some of the time.)
posted by OmieWise at 6:56 PM on January 19, 2008 [1 favorite]

I'll admit that I'm curious about the insistence here that prescribing patterns are carefully tailored as part of a stepped response to depression.

I'm not sure who that's aimed at, OmieWise. Certainly all I've claimed is that ADs were offered as part of a list of alternatives in my case.

study linked here, which indicates that well fewer than half the people prescribed the medications get symptom relief because of it.

The weird thing here is that I've never heard anything different. Admittedly I have but a small window into the SF Bay Area therapist world and big pharma research, but the common wisdom I've always heard is that drugs on their own have a 40% success rate, therapy on it's own has a 40% success rate, and together they have a 75-80% success rate.

That GPs are handing out too many anti-depressants is also not particularly news to me, and furthermore I'm not sure it bothers me at all that much -- there is no "silver bullet" for depression and of the available options . . . well let's just say I'm a spoiled American consumer and if you tell me that I can a) dedicate time for therapy, or b) exercise, or c) take this pill once a day, I'll be choosing option C even if it only has a 30% chance of working. And why shouldn't I?

The articles you link to make a fair case that the brain is really complicated and nobody really knows how things work biochemically. They also make a good case that big pharma advertising is claiming to have solid knowledge where none exists, and that the "file drawer" effect applies to anti-depressants research as much as it does to anything else. I have no beef with any of that.

However, what I have yet to see is any evidence that there is widespread neglect of alternate treatments due to all of the above. You cite your time in a psychiatric community, and maybe (although I really hate to open this can of worms) that accounts for our differing impressions -- my interactions, social and professional, have largely been with psychologists.

the BMJ came out with an editorial a couple of years ago arguing that antidepressants should not be a first-line treatment.

Do you have a pointer to this? I'd like to understand their reasoning, but the BMJ search engine is not being cooperative.
posted by tkolar at 8:00 PM on January 19, 2008

Washing the numbers, selling the model
posted by homunculus at 2:46 PM on January 27, 2008

Just as a matter of info. OmieWise, I'm pretty sure that we didn't have NICE in 1998, or if we did, it was extremely new then. But the point of NICE guidelines and technology appraisals is precisely that they are mandatory. NHS doctors are subject to clinical audit to ensure that they follow the guidelines, and patients have recourse to PALS, the Patient Advocacy Liasion System - an independent advocacy system aimed at ensuring they do get the treatments the guidelines argue they should be getting.

I'll grant you that turning long standing practice around doesn't happen overnight, but having been involved in a guideline committee and a technology appraisal group, I honestly can't think of a better way of doing this stuff.
posted by PeterMcDermott at 12:44 AM on January 29, 2008