Antidepressants

[Chula]

Something I think we all knew already:
http://www.newsweek.com/id/232781/page/1" onclick="window.open(this.href);return false;

[tiltbillings]

The other side:

http://www.newsweek.com/id/232782" onclick="window.open(this.href);return false;

[seanpdx]

The other side:

http://www.newsweek.com/id/232782" onclick="window.open(this.href);return false;

Indeed. Neurochemistry is a tricky thing. Can placebos help just as well as antidepressants? Certainly. Antidepressants don't do anything particularly fancy. And faith/belief/hope/mindset/etc can certainly bring about the same effective change that, for example, 5ht re-uptake inhibition can.

But sometimes people need a jump-start. If mere faith/belief/hope/mindset/etc doesn't help, or one is unable to muster enough to help, then exogenous drugs can supply such a jump-start to get things going.

There is no one "right" answer. The brain is complicated. (He says as he finishes ingesting caffeine before going to his meditation group... =)

[PeterB]

The other side:

http://www.newsweek.com/id/232782" onclick="window.open(this.href);return false;

Indeed. Neurochemistry is a tricky thing. Can placebos help just as well as antidepressants? Certainly. Antidepressants don't do anything particularly fancy. And faith/belief/hope/mindset/etc can certainly bring about the same effective change that, for example, 5ht re-uptake inhibition can.

But sometimes people need a jump-start. If mere faith/belief/hope/mindset/etc doesn't help, or one is unable to muster enough to help, then exogenous drugs can supply such a jump-start to get things going.

There is no one "right" answer. The brain is complicated. (He says as he finishes ingesting caffeine before going to his meditation group... =)

As a generalisation I would have no problem with that view. It is a generalisation though. There is a wide spectrum of response to anti -depressives which is not explained entirely by a placebo effect. For some subjects the right dose at the right time can literally save lives.The problem comes when depressive symptoms are not seen in context and anti-depressives are simply doled out on repeat prescription. Anti-depressants have their place though as part of a wider repetoire of responses.

[Chula]

There is a wide spectrum of response to anti -depressives which is not explained entirely by a placebo effect.

According to that article, aside from the side-effects which are a negative, the positive effects are not statistically significant compared to a placebo. It's not saying it doesn't work, just that if someone was given a sugar pill instead they'll probably get the same results. So anecdotal evidence like "I've seen it work" wouldn't apply because it could be argued that if the person was given a placebo as the "real" drug, they'll probably have similar responses.

The other side:
http://www.newsweek.com/id/232782" onclick="window.open(this.href);return false;

This guy's whole argument is based on an anecdotal "it worked for me", which misses the point of the other article. It's not that it doesn't work, the problem is that a placebo works too..

[Cittasanto]

Well Said Peter!

[PeterB]

There is a wide spectrum of response to anti -depressives which is not explained entirely by a placebo effect.

According to that article, aside from the side-effects which are a negative, the positive effects are not statistically significant compared to a placebo. It's not saying it doesn't work, just that if someone was given a sugar pill instead they'll probably get the same results. So anecdotal evidence like "I've seen it work" wouldn't apply because it could be argued that if the person was given a placebo as the "real" drug, they'll probably have similar responses.

The other side:
http://www.newsweek.com/id/232782" onclick="window.open(this.href);return false;

This guy's whole argument is based on an anecdotal "it worked for me", which misses the point of the other article. It's not that it doesn't work, the problem is that a placebo works too..

On a regular basis Chula I see anti depressives have a marked effect on some patients who are too clinically depressed to respond to other forms of intervention. Clinical Depression in some subjects appears to be a matter of brain chemistry, it may be possible to modify brain chemistry by non chemical means, in fact it almost certainly is possible, but not fast enough to turn around the cognitive processes of those with suicidal ideation. I repeat , for the right patient in the right dose at the right time anti depressants can save lives. I see it regularly. The patient is then able to respond to other treatments such as CBT.

[Chula]

From the article (pg 3):

"Right about here, people scowl and ask how anti-depressants—especially those that raise the brain's levels of serotonin—can possibly have no direct chemical effect on the brain. Surely raising serotonin levels should right the synapses' "chemical imbalance" and lift depression. Unfortunately, the serotonin-deficit theory of depression is built on a foundation of tissue paper. How that came to be is a story in itself, but the basics are that in the 1950s scientists discovered, serendipitously, that a drug called iproniazid seemed to help some people with depression. Iproniazid increases brain levels of serotonin and norepinephrine. Ergo, low levels of those neurotransmitters must cause depression. More than 50 years on, the presumed effectiveness of antidepressants that act this way remains the chief support for the chemical-imbalance theory of depression. Absent that effectiveness, the theory hasn't a leg to stand on. Direct evidence doesn't exist. Lowering people's serotonin levels does not change their mood. And a new drug, tianeptine, which is sold in France and some other countries (but not the U.S.), turns out to be as effective as Prozac-like antidepressants that keep the synapses well supplied with serotonin. The mechanism of the new drug? It lowers brain levels of serotonin. "If depression can be equally affected by drugs that increase serotonin and by drugs that decrease it," says Kirsch, "it's hard to imagine how the benefits can be due to their chemical activity."

[PeterB]

Other research contradicts that Chula. As seanpdx said the science of the brain is highly complex. On a regular basis I see Clinically Depressed patients respond to certain anti-depressants when they have not responded to an equally well known one. So their placebo response must be highly selective. What is your interest here Chula. How is your life affected by this issue ? How or whether you reply is of course entirely up to you, The reason that I ask is that in my experience people who have had a bad experience with antidepressants or have witnessed a bad experience in someone close, can become very selective in their reading concerning the issue. It cuts both ways of course. people who have had a positive experience of anti depressants may have rose coloured specs on regarding this issue.

The bottom line for me is this. We have a body in the UK called N.I.C.E. its role is to examine all of the evidence concerning any given medication or treatment, It has to be seen to work and it has to be cost effective, or the local Strategic Health Authority which governs the various regions of the British National Health Service will not pay. Remember under the British system all treatment is free at the point of delivery, in other words the patient pays nothing. Neither is the doctor paid accord to what she/he prescribes. In fact the pressure is NOT to prescribe drugs. The conclusion that N.I.C,E, has reached concerning anti-depressants on far longer and more thorough trials than the one you quote is that anti-depressants can be a valuable short term means of managing the symptoms of Clinical Depression.

[Ben]

Its interesting.
At the beginning of the week we had a speaker at our professional development day. I was keen to see him as he is a bit of a guru in Australia on mindfulness as he is also a senior lecturer of general medical practice at Monash University school of medicine. He also mentioned that antidepressants were no better than placebo and backed his claim with a citation or two. Having said that, I think that Peter's claim is equally valid and that drug intervention at the right time, place and dosage are life-saving. And I would never encourage anyone to change their current treatment regime before seeking the advice of their clinician. Most people, that I am aware of, don't go for treatment for depression until they're in crisis mode.
metta

Ben

[PeterB]

I added a bit while you were posting Ben. If one is around long enough in psychiatry one sees it all go round again. The research your speaker quoted, and which Chula quotes will without doubt be superceded within months by research demonstrating the opposite..absolutely guaranteed. All we clinicians can do is keep one eye on the research and the other eye on what actually happens to real patients who are really suffering.

[Ben]

Absolutely Peter!
metta

Ben

[Chula]

My interest is merely to promote a more solid evidence-based understanding of this than what advertisements and anecdotal evidence would have you believe. I think it's worth knowing that the scientific basis for a lot of the antidepressant claims are not clear-cut by any means.

Apart from that, I'm not claiming that antidepressants are useless - from the responses, it's clear that people have found use for it. However, it's debatable where that desirable effect is coming from.

About my experience with antidepressants - that would be a completely nil. I've been surprised by how much people seem to depend on them in the US.

I think my posts on this topic will end here.

Metta

[PeterB]

Personally I welcome intelligent questioning such as yours Chula. Its peoples minds we are talking about here. I am very aware of the enormous responsibilty that carries. One of my mentors used to say "psychiatry is not a science its an art " . That was in response to the prevailing view at the time which was somewhat mechanistic. I would now say thats both a science and an art, what we do must be evidence based, but a good psychiatrist will be one in touch with their gut.



metta.

[seanpdx]

The other side:

http://www.newsweek.com/id/232782" onclick="window.open(this.href);return false;

Indeed. Neurochemistry is a tricky thing. Can placebos help just as well as antidepressants? Certainly. Antidepressants don't do anything particularly fancy. And faith/belief/hope/mindset/etc can certainly bring about the same effective change that, for example, 5ht re-uptake inhibition can.

But sometimes people need a jump-start. If mere faith/belief/hope/mindset/etc doesn't help, or one is unable to muster enough to help, then exogenous drugs can supply such a jump-start to get things going.

There is no one "right" answer. The brain is complicated. (He says as he finishes ingesting caffeine before going to his meditation group... =)

As a generalisation I would have no problem with that view. It is a generalisation though. There is a wide spectrum of response to anti -depressives which is not explained entirely by a placebo effect. For some subjects the right dose at the right time can literally save lives.The problem comes when depressive symptoms are not seen in context and anti-depressives are simply doled out on repeat prescription. Anti-depressants have their place though as part of a wider repetoire of responses.

Ummm... I don't think you understood what I wrote. The point I was making was that anti-depressants do have their place. Thus my comment about exogenous drugs.