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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 59 to 83 of 139. Go back in thread:
Posted by SLS on April 8, 2006, at 10:33:09
In reply to You just know I have an opinion, right? » SLS, posted by Racer on April 6, 2006, at 12:57:07
Hi Racer.
I'm sorry I didn't get around to responding to your post. All I can say is that you hit the target better than I did.
- Scott> Lucky for you, I don't have time to go into it right now...
>
> Briefly, though, I think there are a couple of factors that are probably coming into play:
>
> 1. CBT probably is part of it, although I'm gonna back away from offering my opinions on that. I'd ask how long after the end of CBT treatment the assessments were done, and I'd look very, very closely at the pre-treatment baseline. Oh, and I'd do another follow up study a year or two later, to see how much LASTING benefit CBT had.
>
> 2. With SSRIs so heavily advertised to consumers, and a few changes in the world that really do affect functioning for a lot of people, I think taking a pill seemed perfectly reasonable to a lot of people for a long time. This is where my longer opinion comes in, but it's basically that a lot of the people on SSRIs in the past decade have really and truly needed non-medication interventions. They needed the things that talk therapy -- actually, more like coaching in life skills -- can provide.
>
> 3. I do think there's a wider range of what's being called depression in these studies. The studies I've read have been pretty consistent on the matter, really: for MILD depression, talk therapy can be as effective as medication. For moderate depression, talk therapy can be pretty helpful, as can medications, but both together are optimal. For severe depression, though, all the studies I've seen have consistently said that medications really are required, but talk therapy can be a very valuable adjunct.
>
> Then again, you know I have opinions... So many, in fact, that I have to give them away to all who'll take them...
Posted by linkadge on April 8, 2006, at 10:54:02
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 7, 2006, at 21:57:18
I would never tell sombody who is benifiting from medications to stop in them in favor of exercise, I am saying that before somebody takes an antidepressant exercise should be tried / and considered for those who aren't responding to drugs as an alternitive or adjunctive.
Linkadge
Posted by linkadge on April 8, 2006, at 10:55:42
In reply to Re: Drugs versus Psychotherapy - Backlash? » linkadge, posted by SLS on April 7, 2006, at 22:14:29
Just because a study design is flawed doesn't imply directly that exercise is innefective. It just means that its effects have not been fully explored.
Linkadge
Posted by SLS on April 8, 2006, at 11:10:15
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 8, 2006, at 10:54:02
> I am saying that before somebody takes an antidepressant exercise should be tried
This is precisely where we are in disagreement.
> and considered for those who aren't responding to drugs as an alternitive or adjunctive.
If one can exercise, I agree that it makes sense to do so.
If you were to prescribe exercise for someone who is severely depressed, how would you administer it? How many weeks do you allow to elapse before declaring it a treatment failure?
- Scott
Posted by SLS on April 8, 2006, at 11:14:07
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 8, 2006, at 10:55:42
> Just because a study design is flawed doesn't imply directly that exercise is innefective. It just means that its effects have not been fully explored.
Properly explored.
In the meantime, people are making critical decisions based upon spurious reports.
- Scott
Posted by linkadge on April 8, 2006, at 13:16:14
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 8, 2006, at 11:10:15
Not everbody with severe depression is low in energy. Severe suicidal depression can exist completely independantly of any psychomotor retardation.
If a person with severe depression was capable of exercise I would recomend trying it first.
Antidepressants have a degree of toxicity and potential for dependance, they can also poop out. Many people with severe unipolar depression don't see results with an antidepressant for a few months anyway.
Remember, we must not start this argument under the assumption that antidepressants work flawlessly.
Linkadge
Posted by linkadge on April 8, 2006, at 13:21:22
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 8, 2006, at 11:14:07
Exercise has not been properly explored or sufficantly explored.
I would say the case for antidepressant usage is also equally spurious. Some drug companies have the full rights to fail eight clinical trials, and get the drug approved based on the questionable and marginal results of the nineth. If thats no spurious, I don't know what is.
Again, we can't start this argument under the assumption that antidepressant drugs work flawlessly. It only makes sence that recovery would be greatly benifit from the usage of the least evasive yet effective treatment. Don't start with a sledghammer when a regular hammer might do, otherwise the regular hammer will never work properly again.
Linkadge
Posted by Phillipa on April 8, 2006, at 13:27:32
In reply to Re: Drugs versus Psychotherapy - Backlash? » Sobriquet Style, posted by SLS on April 8, 2006, at 6:43:10
Scott post your homepage again and then people will see how fit you were when you lifted. You were olympic material and what a hunk but then again you still are. Love Phillipa
Posted by Phillipa on April 8, 2006, at 13:33:38
In reply to Re: Drugs versus Psychotherapy - Backlash? » SLS, posted by Sobriquet Style on April 8, 2006, at 8:01:36
Oh so you're a guy boy these screen names can be deceiving since I'm been in a gym for years I know the different types of training females usually do more reps and at low wts. And females don't gain muscle mass as men do due to hormones. Love Phillipa
Posted by SLS on April 8, 2006, at 14:20:53
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 8, 2006, at 13:16:14
> Not everbody with severe depression is low in energy. Severe suicidal depression can exist completely independantly of any psychomotor retardation.
It is true that agitated depressives have psychomotor activation. These people are probably more at risk for having suicidal ideation. Others are just too anergic, psychomotor retarded, or vegetative to contemplate suicide.
One reason people develop suicidal ideations while taking antidepressants is that they regain enough mental energy to contemplate and plan. This occurs as they begin to respond favorably to treatment, but before they have responded well enough to feel substantially less depressed. It is an irony of sorts. Unfortunately, not enough psychiatrists take this into consideration when they treat people. They don't council patients to be aware of this risk, and they don't monitor patients closely enough during this critical period early in treatment. Of course, some of these drugs can also produce idiosyncratic exacerbations of depression. Just giving patients the insight that these are possible response scenarios would help keep them safe.
> If a person with severe depression was capable of exercise I would recomend trying it first.
I doubt we will agree on this point.
> Antidepressants have a degree of toxicity and potential for dependance,
As do many other types of drugs prescribed for various ailments. Prednisone?
> they can also poop out.
Yes. I know. It is obvious that our current armament of medications is lacking.
Still, you have a better chance of responding robustly to an antidepressant than you do to exercise if you are severely depressed (MDD). This is my contention. I doubt we will agree here.
> Many people with severe unipolar depression don't see results with an antidepressant for a few months anyway.
From what I have seen with the doctors I have worked with, I think this number represents a minority. I think the majority of responders will demonstrate subtle improvements during weeks 3 and 4 of treatment at a therapeutic dosage. I have yet to meet a doctor who routinely uses a rating scale to evaluate the condition of their patients (outside the arena of investigative work). I bet an improvement would become evident earlier in treatment if they were to do so.
> Remember, we must not start this argument under the assumption that antidepressants work flawlessly.Nor do the doctors who prescribe them.
Despite all of my treatment failures, I still believe that, in capable hands, over 75% of MDD people will respond well to the drugs we already have available, especially when used as part of a multimodal approach that may include psychotherapy, nutrition, and even exercise.
- Scott
Posted by SLS on April 8, 2006, at 14:22:48
In reply to Re: Drugs versus Psychotherapy - Backlash? » SLS, posted by Phillipa on April 8, 2006, at 13:27:32
> Scott post your homepage again and then people will see how fit you were when you lifted. You were olympic material and what a hunk but then again you still are. Love Phillipa
Thanks for the warm fuzzies...
- Scott
Posted by linkadge on April 8, 2006, at 16:46:21
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 8, 2006, at 14:20:53
>It is true that agitated depressives have >psychomotor activation. These people are >probably more at risk for having suicidal >ideation. Others are just too anergic, >psychomotor retarded, or vegetative to >contemplate suicide.
Or just people who's depression doesn't impact their energy levels at all. I never really had much psychomotor activation or retardation, it was just inexplicable sadness.
>One reason people develop suicidal ideations >while taking antidepressants is that they regain >enough mental energy to contemplate and plan. >This occurs as they begin to respond favorably >to treatment, but before they have responded >well enough to feel substantially less >depressed. It is an irony of sorts.
Yes, that is one theory as to why suicidiality can increase in the short term. There is also the theory of drug induced akathesia.
>> Antidepressants have a degree of toxicity and potential for dependance,
>As do many other types of drugs prescribed for various ailments. Prednisone?
I guess I mean that if a person could be made well without drug, it would probably make for a better long term outcome. How many people are driven back into dispair when they decide to discontinue their antidepressant?
>Still, you have a better chance of responding >robustly to an antidepressant than you do to >exercise if you are severely depressed (MDD). >This is my contention. I doubt we will agree >here.That one study I showed, the zoloft vs. exercise for MDD, showed a more robust outcome for the exercise group after a few months. I think we simply need more studies to quantify the extent of its potential.
>From what I have seen with the doctors I have >worked with, I think this number represents a >minority. I think the majority of responders >will demonstrate subtle improvements during >weeks 3 and 4 of treatment at a therapeutic >dosage.As one would expect to see some improvements with exercise. After about 3 weeks there was no doubt I was sleeping better.
>Despite all of my treatment failures, I still >believe that, in capable hands, over 75% of MDD >people will respond well to the drugs we already >have available, especially when used as part of >a multimodal approach that may include >psychotherapy, nutrition, and even exercise.
I don't think that drugs are responsible for getting 75% of people better. Clinical trials certainly don't demonstrate this, and even less when you remove possible effect of placebo, and natural recovery. I think their effects are vastly overrated.
Linkadge
Posted by linkadge on April 8, 2006, at 17:02:03
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 8, 2006, at 16:46:21
I think exercise should be recomended in depressed youths where the data seems simultanioulsy suggest lack of effect and increased rates of suicidality.
http://www.newmediaexplorer.org/chris/2004/12/08/the_antidepressant_fraud_no_better_than_placebo.htmLinkadge
Posted by Sobriquet Style on April 8, 2006, at 17:20:01
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by greywolf on April 8, 2006, at 10:24:31
Posted by SLS on April 8, 2006, at 19:01:56
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 8, 2006, at 16:46:21
> > Despite all of my treatment failures, I still >believe that, in capable hands, over 75% of MDD >people will respond well to the drugs we already >have available, especially when used as part of >a multimodal approach that may include >psychotherapy, nutrition, and even exercise.
> I don't think that drugs are responsible for getting 75% of people better. Clinical trials certainly don't demonstrate this,
What I attempted to convey is that an effective treatment regime can be produced for 75% if one were to use every drug currently available alone or in combination. Very few trials have been designed to study this.
That's 65% using only 3 antidepressants monotherapeutically.
> and even less when you remove possible effect of placebo,
The magnitude of the placebo response varies inversely with the severity of the depression being used as inclusion criteria.
http://ajp.psychiatryonline.org/cgi/content/full/157/3/327
- Scott
Posted by Squiggles on April 8, 2006, at 20:06:05
In reply to Drugs versus Psychotherapy - Backlash?, posted by SLS on April 6, 2006, at 9:43:54
> All of a sudden, psychotherapy is as effective as drug therapy for treating depression!
>
> That's right.
>
> Just look at the medical literature.
>Uhm, which medical literature is that?
> Less than a decade ago, nearly all of the double-blind studies demonstrated a clear advantage to drug therapy over psychotherapy for treating depression.
>
> Now, it is difficult to find such studies. Most of the current literature claims equal effectiveness between the two modes of treatment.
>
> How can this be?Indeed;
>
> Can it be that the emergence of CBT (cognitive behavioral therapy) as the psychotherapeutic treatment of choice has drastically improved the response rate to psychotherapy?Highly unlikely as there is nothing
to improve on - a questionnaire is
a questionnaire is a questionnaire;
>
> Have current investigations defined depression in a different way than they did ten years ago?Possibly;
>
> Have the rating methods or measurement standards that define treatment success changed?Very probable;
>
> Is there a backlash against using drugs to treat depression to be found in the field of psychiatric investigation?Well, maybe doctors are getting sick of
trying 100 more new drugs and have run
out of new diseases to invent;
> A little of all the above?
>
> What's going on?
>
I don't know Scott; I just hope common sense
and knowledge eventually meet at the crossroads
of signs and symptoms in medicine.Squiggles
Posted by linkadge on April 9, 2006, at 9:10:59
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 8, 2006, at 19:01:56
I can't interprate that last link.
Perhaps placebo responce to drugs goes down as severe depression goes up, but so does responce to active drugs. So this still doesn't determine whether the percentage of placbo responders goes down as sevarity goes up. Perhaps I inteprated incorrectly.
Linkadge
Posted by linkadge on April 9, 2006, at 9:13:23
In reply to Drugs versus Psychotherapy - Backlash? » SLS, posted by Squiggles on April 8, 2006, at 20:06:05
It wasn't too long ago that cocaine was used for nervous depression. I think that we are foolish to think that similar mistakes couldn't happen again.
Hey, cocaine even increases BDNF !
Linkadge
Posted by Squiggles on April 9, 2006, at 9:22:05
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 9, 2006, at 9:13:23
> It wasn't too long ago that cocaine was used for nervous depression. I think that we are foolish to think that similar mistakes couldn't happen again.
>
> Hey, cocaine even increases BDNF !
>
> Linkadge
>I'm not so sure that cocaine "isn't" a good
drug for some conditions for a short period
of time. Maybe doctors do use cocaine in
certain cases. I'm not suggesting dependence
is a good thing of course.Squiggles
Posted by linkadge on April 9, 2006, at 11:44:28
In reply to Re: Drugs versus Psychotherapy - Backlash? » linkadge, posted by Squiggles on April 9, 2006, at 9:22:05
I understand.
I guess I am trying to say that it has been the downfall of each generation in science to think that its answers are the safest, most complete and perfect.
It could well be that, (say in 20 years) SSRI's are labled addictive and taken off the market in favor of new drugs.
Linkadge
Posted by ed_uk on April 9, 2006, at 12:51:29
In reply to Re: Drugs versus Psychotherapy - Backlash? » Squiggles, posted by linkadge on April 9, 2006, at 11:44:28
Hi Link
>I guess I am trying to say that it has been the downfall of each generation in science to think that its answers are the safest, most complete and perfect.
So true. I've been exercising more lately btw. Haven't lost any weight though - I EAT TOO MUCH!
Eddy
Posted by ed_uk on April 9, 2006, at 12:56:30
In reply to Re: Drugs versus Psychotherapy - Backlash? » Squiggles, posted by linkadge on April 9, 2006, at 11:44:28
RE SSRIs, they have relieved me of anxiety.......but they have also turned me into a loser. My motivation was so poor I dropped out of university.......and I don't have the motivation to go back. I'm probably gonna be stuck on the minimum wage for the rest of my life being treated like sh*t because everyone things they're superior to people like me - who are apparantly not worth listening to either.
Sh*t
ED
PS. I have no libido. Will it ever come back? I stayed off SSRIs for a few months once and it barely came back.
PPS. I don't feel proper emotions. I don't feel love. How can a person start a relationship when they can't feel love?
Posted by SLS on April 9, 2006, at 13:20:51
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by linkadge on April 9, 2006, at 9:10:59
> Perhaps placebo responce to drugs goes down as severe depression goes up, but so does responce to active drugs.
Yes! You have just hit the target!
It seems that if one limits the study population to those who have the severest of depressions that meet DSM criteria for MDD, antidepressants look more like wonder drugs. If, on the other hand, you were to give an antidepressant to a population of people whose mood depends entirely on how they think, a biological intervention will do little to affect them. In this case, the response rate is similar to placebo. Unfortunately, antidepressant trials in the past have included subjects with a psychologicaly driven depression. That's why the placebo rate is so high. Many of these people are very susceptible to suggestion.
It is my guess that the preponderance of people with severe depression have a biological disorder while those with mild to moderate depressions are more likely to have a strong psychological component. This is why I keep questioning what we mean when we use the word "depression". People whose depression evolves from a psychogenic diathesis are far more apt to demonstrate a placebo effect because it is their expectation that they will be helped. I believe this expectation changes their outlook and therefore changes their mood. With psychogenic depressions, you can change the way you feel by changing the way you think. With biogenic depressions, this is not true. The way you think is determined by the way you feel.
It would be ideal to identify the difference between an endogenous versus an exogenous depression when choosing a treatment modality. However, things are not that simple. I believe that there is an affective spectrum within which are an array of psychobiologies. At either end of the spectrum lie people whose depressions are either entirely biological or entirely psychological. In between lie those whose depressions are driven by a mix of both biological and psychological contributions. I find this framework appealing because it works well to explain the phenomenology of depression as a syndrome rather than a single illness. I find that the inferences that can be drawn from this model explains much about what we see happening in the diagnosis and treatment of depression.
- Scott
Posted by SLS on April 9, 2006, at 13:24:25
In reply to Re: Drugs versus Psychotherapy - Backlash? » linkadge, posted by ed_uk on April 9, 2006, at 12:51:29
> >I guess I am trying to say that it has been the downfall of each generation in science to think that its answers are the safest, most complete and perfect.
> So true.Surely, I never implied any such thing about our current treatments for depression. Who did?
- Scott
Posted by Squiggles on April 9, 2006, at 14:21:30
In reply to Re: Drugs versus Psychotherapy - Backlash?, posted by SLS on April 9, 2006, at 13:24:25
Are there doctors or medical personnel,
or medical students conversing with
posters here? If this is a confidential
question, you need not answer.Thank you
Squiggles
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