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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 31 to 55 of 105. Go back in thread:
Posted by llrrrpp on September 18, 2006, at 8:20:47
In reply to Re: Tonight I don't feel that antidepressants work, posted by linkadge on September 18, 2006, at 7:19:45
Oh, I wanted to add one little thing about AD studies.
Where do they find research subjects who have a diagnosis of Major Depression, with no other concommitant substance abuse issues, psychological, medical or psychiatric disorders?
Maybe the reason why the placebo effect is so high is because these people had fairly simple depressions.
Maybe it's because their brains weren't really that out of whack to begin with.
I mean, depression usually comes with a side order of anxiety, and maybe some substance abuse issues sprinkled on top, an eating disorder, maybe some paranoia, panic, social and personality dysfunctions, and maybe there are other body systems out of whack too- hormones, digestive problems, migraine, metabolism, sleeping disorders, pregnancy, menopause...
Not only are the drugs crude tools, but the "disorder" is poorly conceived. We should treat the whole person. From the synapse level all the way up to the story of their life. Is it any wonder that a pill, or even a combination of pills simply push us from manifesting our problems in one realm (say- depression) to another (say- anxiety) to another (say- infertility)...
-ll
Posted by SLS on September 18, 2006, at 9:36:41
In reply to Re: Tonight I don't feel that antidepressants work » linkadge, posted by llrrrpp on September 18, 2006, at 8:20:47
> Oh, I wanted to add one little thing about AD studies.
>
> Where do they find research subjects who have a diagnosis of Major Depression, with no other concommitant substance abuse issues, psychological, medical or psychiatric disorders?Yes. I believe the inclusion criteria have become wider and wider, and the exclusion criteria perhaps less stringent. The numbers for the same drugs that were tested 20 years ago have changed significantly and demonstrate reduced efficacy with placebo response rates going higher and higher. How can this be? Clinical trials must be examined and redesigned with particular attention payed to the definition of Major Depressive Disorder or Bipolar Disorder, the revison of subject selection criteria, and the scrutinization and standardized of rating scales.
- Scott
Posted by linkadge on September 18, 2006, at 10:46:17
In reply to Re: Tonight I don't feel that antidepressants work, posted by SLS on September 18, 2006, at 9:36:41
Here is a good artle. A little lengthy, but it discusses many of the considerations of determining the real effectiveness of antidepressant medications.
http://www.findarticles.com/p/articles/mi_m1175/is_n5_v28/ai_17382257/pg_1
One particular point I liked was that when a survey of the studies involving imipramine were reduced to those which were compared to active placebo (ie placebo with side effects) the active drug margin is almost completely abolished.Linkadge
Posted by linkadge on September 18, 2006, at 10:47:14
In reply to Re: Tonight I don't feel that antidepressants work, posted by SLS on September 17, 2006, at 23:22:08
Hey, wait a second. I thought your only one true remssion was with nortryptaline ? ( :) )
Linkadge
Posted by SLS on September 18, 2006, at 16:56:53
In reply to Re: Tonight I don't feel that antidepressants work, posted by linkadge on September 18, 2006, at 10:46:17
> Here is a good artle. A little lengthy, but it discusses many of the considerations of determining the real effectiveness of antidepressant medications.
>
> http://www.findarticles.com/p/articles/mi_m1175/is_n5_v28/ai_17382257/pg_1
>
>
> One particular point I liked was that when a survey of the studies involving imipramine were reduced to those which were compared to active placebo (ie placebo with side effects) the active drug margin is almost completely abolished.
I don't know what to tell you, Linkadge. I can see right through most of the arguments presented in this article. I find them specious. I am familiar with them, and am also familiar with the material that has proven them wrong, one of which I have cited here. I don't know what set these authors off, but they have a conclusion to find evidence for. You know, when it comes down to it, I guess we can both find things in print that are going to support our arguments. But I bet my stuff will stand the test of time.
- Scott
Posted by SLS on September 18, 2006, at 17:44:45
In reply to Re: Tonight I don't feel that antidepressants work, posted by SLS on September 18, 2006, at 16:56:53
> > Here is a good artle. A little lengthy, but it discusses many of the considerations of determining the real effectiveness of antidepressant medications.
> >
> > http://www.findarticles.com/p/articles/mi_m1175/is_n5_v28/ai_17382257/pg_1
> >
> >
> > One particular point I liked was that when a survey of the studies involving imipramine were reduced to those which were compared to active placebo (ie placebo with side effects) the active drug margin is almost completely abolished.
>
>
> I don't know what to tell you, Linkadge. I can see right through most of the arguments presented in this article. I find them specious. I am familiar with them, and am also familiar with the material that has proven them wrong,I guess this means that I am supposed to do exactly that - prove them wrong.
Well, I think maybe I'll do that some time when these authors actually cite the literature they allude to when they make their arguments. I might then be tempted to invest what little energy I have to work with.
Example: Page 1When I searched Medline, I found only the title of the Kane and Lieberman study they spoke of. They couldn't even bother to provide that. The abstract was not available. "The efficacy of amoxapine, maprotiline, and trazodone in comparison to imipramine and amitriptyline: a review of the literature." First of all, amoxapine, maprotiline, and trazodone had been out for less than a few years and really suck as antidepressants. Then, they have the impudence to say that "When we examined the data..." for themselves, and opine as to their significance. In other words, they say they evaluated the data on their own, and do not refer to the authors' original conclusions!
Yeah. Right.
- Scott
Posted by SLS on September 18, 2006, at 18:56:09
In reply to Re: Tonight I don't feel that antidepressants work, posted by SLS on September 18, 2006, at 17:44:45
> > > Here is a good artle. A little lengthy, but it discusses many of the considerations of determining the real effectiveness of antidepressant medications.
> > >
> > > http://www.findarticles.com/p/articles/mi_m1175/is_n5_v28/ai_17382257/pg_1
> > >
> > >
> > > One particular point I liked was that when a survey of the studies involving imipramine were reduced to those which were compared to active placebo (ie placebo with side effects) the active drug margin is almost completely abolished.
> >
> >
> > I don't know what to tell you, Linkadge. I can see right through most of the arguments presented in this article. I find them specious. I am familiar with them, and am also familiar with the material that has proven them wrong,
>
> I guess this means that I am supposed to do exactly that - prove them wrong.
>
> Well, I think maybe I'll do that some time when these authors actually cite the literature they allude to when they make their arguments. I might then be tempted to invest what little energy I have to work with.
>
>
> Example: Page 1
>
> When I searched Medline, I found only the title of the Kane and Lieberman study they spoke of. They couldn't even bother to provide that. The abstract was not available. "The efficacy of amoxapine, maprotiline, and trazodone in comparison to imipramine and amitriptyline: a review of the literature." First of all, amoxapine, maprotiline, and trazodone had been out for less than a few years and really suck as antidepressants. Then, they have the impudence to say that "When we examined the data..." for themselves, and opine as to their significance. In other words, they say they evaluated the data on their own, and do not refer to the authors' original conclusions!
Well, maybe that's not such a bad idea afterall. That data is there to be scrutinized and evaluated using different statistical techniques and interpreted from different perspectives. Oh, well. I'm just getting too charged up by what I see as specious and deceptive arguments that may pursuade people away from effective treatments. This article is too cleverly written for the layman not to be influenced by it.Some of the concerns raised in this article are addressed in the article below. The issue of the need for active placebos is discussed.
Full text:http://ajp.psychiatryonline.org/cgi/content/full/157/3/327
Validity of Clinical Trials of AntidepressantsFrederic M. Quitkin, M.D., Judith G. Rabkin, Ph.D., Jessica Gerald, B.A., John M. Davis, M.D. and Donald F. Klein, M.D.
ABSTRACT:
OBJECTIVE: Recent reports have criticized the design of antidepressant studies and have questioned their validity. These critics have concluded that antidepressants are no better than placebo treatment and that their illusory superiority depends on methodologically flawed studies and biased clinical evaluations. It has been suggested that the blind in randomized trials is penetrable—since clinician’s guesses exceed chance—and that only active placebo can appropriately camouflage the difference between drug and placebo response. Furthermore, evidence has been cited to suggest that psychotherapy is as effective as antidepressants in both the acute and maintenance treatment of depression. These positions are often accepted as valid and have been broadly discussed in both the lay press and scientific literature. The purpose of this review is to reassess the cited data that support these assertions. METHOD: The authors examined the specific studies that were cited in these reports, evaluated their methodology, and conducted aggregate analyses. RESULTS: Analyses of the original sources failed to substantiate 1) that standard antidepressants are no more effective than placebo, 2) that active placebo offers an advantage over inactive placebo, or 3) that substantial evidence of a medication bias is suggested by raters’ treatment guesses exceeding chance. The authors also note that some researchers have suggested that the interpretation of psychotherapy trials can be complicated by "allegiance effects." CONCLUSIONS: The issue of bias or allegiance effects for both antidepressant and psychotherapy research is real. Investigators of all orientations must guard against potential bias. However, studies cited as supporting the questionable validity of antidepressant trials fail upon closer examination to support assertions that these trials are invalid.
- Scott
Posted by Jost on September 18, 2006, at 18:57:33
In reply to Re: Tonight I don't feel that antidepressants work, posted by SLS on September 18, 2006, at 17:44:45
The points made by Fisher and Greenberg seem useful, in a way-- but the article is from 1995, and one has to remember that they have a point of view, and therefore a bias, just as more biologically-minded psychologists do. They are, for one thing, PhDs-- and that alone means they have an interest (just as MDs do) in the efficacy of their treatment-- ie psychotherapy.
The year 1995 has a lot to do with why they focus so much on older ADs-- which wouldn't be the case with an article today. While it doesn't erase their points, it does diminish their relevance.
The argument about physical effects (ie side effects) that alert patients and researchers to who's taking the placebo and who's taking the "real" drug, for example, is one that researchers have tried to address. As to whether that accounts in some way for the narrowing of the gap between real drug effect and placebo effect or not, I don't know.
The question is: where does one come out?
Take one point they make: 1/3rd of ps respond to placebo, 1/3rd have an AD effect distinct from the placebo effect, and 1/3 have no effect from either placebo or AD.
They conclude that 2/3 have no AD effect. One could conclude that 2/3rd get some positive benefit-- since the placebo effect is a biologically significant effect-- Many of those who improved on the placebo might have done even better if they had had the drug-- because the relative effect of any regimen was not quantified. Indeed, it's very hard to quantify this, although the Star*d study, to its credit, did make relative claims of significance vs. full remission.
The question is where to come out.
Linkadge, you come on in a pessimistic place-- entirely understandably-- No one would argue that depression is understood biologically-- or can be treated reliably by any available drug. SLS and others are more optimistic-- again understandably. The treatments now available are better-- for at least 30% of people-- and more numerous-- perhaps yielding after several drugs are tried, a greater percentage who improve. (As Star*d also gives reason to think.)
They could be better; the varieties, and etiology of depression could (and will) be more fully identified.
This is a stage, perhaps crude, in a history. Now, we're afflicted with doubt and uncertainty, and all the bad side effects and mistaken attempts to treat with drugs that don't work, or don't work all that well.
We need better animal models, fuller exploration of the human and animal genomes, better brain imaging, etc etc. On the whole, it may be more useful to have a certain hopeful skepticism-- but of course, when nothing helps, that's pretty awful, too.
Jost
Posted by Jost on September 18, 2006, at 19:10:02
In reply to Re: Tonight I don't feel that antidepressants work » Jost, posted by Phillipa on September 17, 2006, at 19:54:59
Hi, Phillipa.
Emsam does work, very well, for me --at the right dose. I'm really impressed with what a good drug it is-- Of course, if I should have to stop it, I'd be as discouraged as Linkadge is-- or more.
I take xanax and ambien mostly for sleep, and sometimes anxiety, and also provigil, if I"m too tired. I want to say, though, that I was a good deal more anxious before Emsam,.
I think there are some others who are still taking it. Seems sleep is the worst problem--- I have always had insomnia-- and at this point, it really isn't worse than it has been in the past, although at the beginning, it was pretty bad.
Hope this helps.
Posted by Phillipa on September 18, 2006, at 19:21:47
In reply to Re: Emsam still working » Phillipa, posted by Jost on September 18, 2006, at 19:10:02
Thanks Jost not a lot of possitive responders left on EMSAM it seems wonder why? Love Phillipa
Posted by SLS on September 18, 2006, at 19:27:11
In reply to Re Fisher and Greenberg » SLS, posted by Jost on September 18, 2006, at 18:57:33
Hi Jost.
Thanks for posting that.
I think it helps to bring balance into the discussion.
However, it doesn't hide, in my mind, the lengths to which the authors (Fisher and Greenberg) go to pursuade people. I just hope that it becomes evident in their verbiage how desperate they are to plead their case.
- Scott
Posted by SLS on September 18, 2006, at 19:35:15
In reply to Re: Emsam still working » Jost, posted by Phillipa on September 18, 2006, at 19:21:47
> Thanks Jost not a lot of possitive responders left on EMSAM it seems wonder why? Love Phillipa
I think insomnia became an issue with some people and caused prompted them to discontinue it. I don't know how many weeks into treatment they were or what dosage they were taking. If you are going to get serious about trying an MAOI, you are going to have to also get serious about treating insomnia as a side effect and not allow it to be the thing that prevents you from getting well. You might need to add a sleeping medication to your Valium.
- Scott
Posted by jealibeanz on September 18, 2006, at 19:39:43
In reply to Re: Emsam still working » Phillipa, posted by SLS on September 18, 2006, at 19:35:15
Scott, remind me... do you have anxiety as well as depression? Is EMSAM the only med you're taking?
Posted by Phillipa on September 18, 2006, at 19:50:39
In reply to Re: Emsam still working » Phillipa, posted by SLS on September 18, 2006, at 19:35:15
Thanks Scott I know you're right. I'm so afraid of meds. Cause they killed my Mother when I was l7. That's why. Love Phillipa
Posted by SLS on September 18, 2006, at 20:27:20
In reply to Re: Emsam still working, posted by jealibeanz on September 18, 2006, at 19:39:43
> Scott, remind me... do you have anxiety as well as depression? Is EMSAM the only med you're taking?
Nope.
I'm not taking Emsam.
:-)
Currently:
Lamictal 150mg
nortriptyline 100mg
Topamax 100mg
Abilify 10mg
Lyrica 225mg
- Scott
Posted by Phillipa on September 18, 2006, at 20:56:18
In reply to Re: Emsam still working » Phillipa, posted by SLS on September 18, 2006, at 19:35:15
Scott what would go well with valium for sleep? Love Phillipa
Posted by jealibeanz on September 18, 2006, at 21:06:04
In reply to Re: Emsam still working, posted by SLS on September 18, 2006, at 20:27:20
Scott-
haha... my brains a little too full of schoolwork right now... must be imagining things!
Posted by cecilia on September 19, 2006, at 2:31:41
In reply to Re: Tonight I don't feel that antidepressants work » linkadge, posted by Racer on September 17, 2006, at 13:46:17
Well, if you define "respond" as having an effect, then the response rate is probably close to 100% (given a high enough dose). The trouble is, the responses I've had have never been exactly desirable!!!! What's a "response", what's a side effect? It depends what you're aiming for. Insomnia is a side effect if you have trouble sleeping, but a "response" if you can't stay awake. They use the "side-effect" of urinary retention for Cymbalta to market it for incontinence. Cecilia
Posted by SLS on September 19, 2006, at 4:06:18
In reply to Re: Tonight I don't feel that antidepressants work, posted by cecilia on September 19, 2006, at 2:31:41
> Well, if you define "respond" as having an effect, then the response rate is probably close to 100% (given a high enough dose). The trouble is, the responses I've had have never been exactly desirable!!!! What's a "response", what's a side effect? It depends what you're aiming for. Insomnia is a side effect if you have trouble sleeping, but a "response" if you can't stay awake. They use the "side-effect" of urinary retention for Cymbalta to market it for incontinence.
Yeah. I guess I've responded to a bunch of them - some of them only having numbers for names.
- Scott
Posted by linkadge on September 19, 2006, at 7:43:52
In reply to Re: Tonight I don't feel that antidepressants work, posted by SLS on September 18, 2006, at 16:56:53
>I can see right through most of the arguments >presented in this article. I find them specious.
I see.
>I am familiar with them, and am also familiar >with the material that has proven them wrong
I wouldn't say that they are all proven wrong. That is kind of not possable.
>But I bet my stuff will stand the test of time.
Well at least thats a fair phrasing of your claim.
Linkadge
Posted by linkadge on September 19, 2006, at 7:47:14
In reply to Re: Tonight I don't feel that antidepressants work, posted by SLS on September 18, 2006, at 18:56:09
[xxx] says it best.
"Faith in the integrity of biological psychiatry would be greater if the single strongest predictive factor in the outcome of any published clinical trial wasn't the identity of the funding body."
Linkadge
Posted by linkadge on September 19, 2006, at 7:51:47
In reply to Re Fisher and Greenberg » SLS, posted by Jost on September 18, 2006, at 18:57:33
I think its faily acurate to extend the findings of older drugs onto those of newer drugs. Many authors condend that newer AD's are really no more efficatious than older ones, although have an apparently more favorable side effect profile.
Drug companies fiercly oppose the use of active placebos in their clinical trials. This is because they know how hard it would be to prove their drugs usefull under such conditions.
Linkadge
Posted by SLS on September 19, 2006, at 7:53:17
In reply to Re: Tonight I don't feel that antidepressants work, posted by linkadge on September 19, 2006, at 7:47:14
> [xxx] says it best.
>
> "Faith in the integrity of biological psychiatry would be greater if the single strongest predictive factor in the outcome of any published clinical trial wasn't the identity of the funding body."
That is always the argument of last resort, isn't it?
- Scott
Posted by SLS on September 19, 2006, at 7:59:13
In reply to Re: Re Fisher and Greenberg, posted by linkadge on September 19, 2006, at 7:51:47
> Drug companies fiercly oppose the use of active placebos in their clinical trials. This is because they know how hard it would be to prove their drugs usefull under such conditions.
What leads believe this?
- Scot
Posted by linkadge on September 19, 2006, at 8:01:45
In reply to Re: Emsam still working » Jost, posted by Phillipa on September 18, 2006, at 19:21:47
My opinions are clearly not for those who are doing well on medications, but I am just trying to paint a realistic picture for those who don't.
But, personally, I am resistant to a lot of things. I remember in church wondering why I never had these "grand messages" from God, that all sorts of other people were having.
Linkadge
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