Feb 04 2010
Study shows antidepressants useless for mild to moderate depression? Not exactly.
As Harriet Hall has written (http://www.sciencebasedmedicine.org/?p=353), psychiatry bashing is a popular media sport. There seems to be a bias against treatment of psychiatric disabilities, and a common claim is that antidepressants are no better than placebo. The New York Times illustrated both the perpetuation of the myth that antidepressants are ineffective, and the increasing and disturbing tendency of major media organizations to confuse the wholesale acceptance of medical press releases with medical journalism.
In Popular Drugs May Help Only Severe Depression The New York Times credulously publicized the findings of a recent study that claimed to show that antidepressants are ineffective in treating mild and moderate depression. Yes, that’s what the study showed, but the study itself is so limited, so fraught with problems, and the conclusions are so misleading that the article is a terrible disservice.
Before we consider what the study showed, let’s think about what kind of evidence we’d need to conclude that antidepressants don’t work.
First, although there are different types of antidepressants, the term used colloquially refers to antidepressants of a specific type, SSRI’s or selective serotonin reuptake inhibitors. There are other, older types of antidepressants that are rarely used today because of their unpleasant side effects. Hence any study that claims to show that “antidepressants” are ineffective, must look at SSRIs.
Second, there are literally thousands of studies of SSRIs, and it would be helpful to aggregate the results. Aggregating results can be done in a type of paper known as metaanalysis. Metaanlysis adds the results of multiple similar studies to find trends that might not be apparent in individual small studies. But a metaanlysis is subject to several important limitations that must always be considered. The most important limitation is that the authors of the metaanalysis choose the papers to be included. Bias can be introduced by examining only papers that have a desired outcome; that can be accomplished by restricting the inclusion criteria in arbitrary ways.
Let’s look at the study, Antidepressant Drug Effects and Depression Severity. According to the abstract:
Randomized placebo-controlled trials of antidepressants approved by the Food and Drug Administration in the treatment of major or minor depressive disorder were selected. Studies were included if their authors provided the requisite original data, they comprised adult outpatients, they included a medication vs placebo comparison for at least 6 weeks, they did not exclude patients on the basis of a placebo washout period, and they used the Hamilton Depression Rating Scale (HDRS). Data from 6 studies (718 patients) were included…
… The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.
According to one of the authors was interviewed for the NYTimes article:
“The message for patients with mild to moderate depression,” Dr. DeRubeis said, “is, ‘Look, medications are always an option, but there’s little evidence that they add to other efforts to shake the depression — whether it’s exercise, seeing the doctor, reading about the disorder or going for psychotherapy.’ ”
Let’s go back and compare the paper to the criteria we identified above. The first criterion was to look at the antidepressants currently used in clinical practice. But out of the 6 studies in the metaanalysis, 3 looked at imipramine, a tricyclic antidrepressant that has not been the standard of care for over a decade because of its unpleasant side effects. The other three studies looked at Paxil (paroxitene). Paxil is an SSRI, but it is only one member of the class of SSRIs. Although all SSRIs share the same mechanism of action, they have different profiles of effectiveness and side effects. Therefore, generalizing from Paxil to all SSRIs cannot be justified.
So in terms of clinically relevant information, the paper included only 3 studies of an SSRI. How did the authors whittle down thousands of papers on SSRI effectiveness to only 3? According to the authors:
The criteria for inclusion required studies to be randomized placebo controlled trials of an FDA-approved antidepressant in the treatment of the full range of patients with major or minor depressive disorder … In addition, the studies had to include an ADM/placebo comparison of at least 6 weeks’ duration and HDRS scores at intake and at the end of treatment. Studies were excluded if they excluded patients on the basis of a placebo washout period. The final inclusion criterion was that individual patient-level data had to be available for analysis.
Are these criteria relevant? Certainly, the inclusion of only RCTs is a reasonable criterion. However, it is not clear why the availability of patient level data is a relevant criterion. Most RCTs, from an enormous range of clinical investigations, do not include patient level data, and using that as a criterion is bound to exclude most studies.
Finally, the decision to remove studies that included a placebo washout period also excludes a vast swath of psychiatric studies. That decision is more defensible, however, since there is disagreement among psychiatric researchers about whether a placebo washout period introduces bias into the study. A placebo washout period involves treating everyone in both arms of the study with placebo for an initial period of time, often 3 weeks. People who respond to placebo are then excluded from the study. The theory is that excluding known placebo responders makes it easier to identify real effects.
Others have argued that excluding known placebo responders up front necessarily makes the drug effects look better than they would have. For example, in a traditional placebo controlled RCT, there might be 30% who respond to placebo and 50% who respond to the medication under study, for a difference of 20%. If some placebo responders are identified during a washout period, let’s say 20% of patients, they will be excluded. The final results may be that 10% responded to placebo and 50% responded to the medication under study, for a difference of 40%, making the medication under study look better.
There is one indisputably arbitrary criterion that is acknowledged by the authors. The initial analysis identified 23 studies, but they could only gain access to the data in 6 studies, so they simply ignored the other 17.
In summary, then, by using questionable exclusion criteria, the authors accessed only 3 clinically relevant studies (the Paxil studies), involving only one SSRI. It is not clear that these studies are representative of existing studies on SSRIs, or even if they can be generalized to other SSRIs. Dr. Rubeis’ assertion that for patients with mild to moderate depression there is little evidence that “medications” add to efforts to treat the depression cannot be justified by the findings in his study. I find his claims to be irresponsible. The paper adds to the literature on antidepressants but is so limited that it cannot tell us whether antidepressants are effective for mild to moderate depression.
280 Responses to “Study shows antidepressants useless for mild to moderate depression? Not exactly.”
I remember one of these sorts of studies coming out about 2 years ago and one interesting thing the University student health people did in response was get the psychiatrist to come in and do a talk about it.
One thing he said about these studies stuck in my head. As someone committing suicide while testing one of these medications would stop the testing cold and likely put the approval off for years it is likely that the people tested in many of these studies are right on the border of being diagnosed with depression. So it seems there’s a fair chance that some of these medications are more effective then their studies give them credit for.
Thank you very much for looking at this article on SBM. While I haven’t got around to a full deconstruction myself, I mentioned it recently: http://www.tsuken.co.nz/sadness-or-depression-midweek-medicine/ and also linked to another NYT piece where Dr. Richard Friedman discusses this meta-analysis nicely: http://www.nytimes.com/2010/01/12/health/12mind.html?em
In any case, I really do not understand how anyone can take seriously a study that out of 30 years of research, includes the results of only 6 trials, of 2 antidepressant medications, involving 718 people….
From. 30. Years. Of research.
The odd thing is that while I would say the results of this study are not valid, they might well be – at least in part – true. We’re not yet able to differentiate between the different entities that most likely make up our syndromal picture of “Major Depressive Disorder”; it seems likely that the more biological causes would respond better to pharmacological treatments than would a more psychologically-based problem – in the same way that ECT is more effective, the more severe the depression. I suspect that severity might be acting as a proxy for the degree of biological dysfunction, and therefore the more severely ill might well be expected to respond better.
The above is speculation … but in my opinion none of the three recent meta-analyses purporting to show antidepressants being ineffective for mild to moderate depression can truly provide an advance on said speculation.
A final note, on tricyclic antidepressants: they are still around, because they can be very useful treatments. The two main reasons advanced for using newer medications instead of TCAs are (1) side effects, and (2) toxicity in overdose. Regarding point (1), all our medications are pretty unpleasant; SSRIs simply have a different side effect load to TCAs – not necessarily better. That depends on the individual patient. Regarding (2), the best way to stop a depressed person killing him or herself is to treat the depression. If a TCA works best for that person, I would argue it’s best to use the TCA and control the supply and access, rather than avoid a treatment we know could be helpful.
Thanks for this post Amy.
I would be interested in seeing the evidence that serotonin had been established as causal in depression.
Once that was established a discussion about SSRI efficacy aside from placebo effects would make sense.
Two questions:
Why should a lack of “patient level data” be an exclusion criterion?
“The initial analysis identified 23 studies, but they could only gain access to the data in 6 studies, so they simply ignored the other 17.”
Why would you not exclude studies for which data could not be accessed?
“it is likely that the people tested in many of these studies are right on the border of being diagnosed with depression. So it seems there’s a fair chance that some of these medications are more effective then their studies give them credit for.”
That’s one possibility, and there are others.
Consider that if a patient failed to respond to several weeks of Paxil treatment (a not uncommon scenario), a provider would not conclude that “antidepressants” don’t work, or even that “antidepressants” don’t work for this particular patient. The provider would either change the dose or try a different SSRI. It often takes several tries to find the right SSRI and the right dose for a particular patient.
To me, it seems that this study is the equivalent of treating a mild gram negative infection with penicillin. If the patient didn’t get we wouldn’t conclude that “antibiotics” didn’t work. We’d conclude that we chose the wrong antibiotic.
“The above is speculation … but in my opinion none of the three recent meta-analyses purporting to show antidepressants being ineffective for mild to moderate depression can truly provide an advance on said speculation.”
Agreed!
“Why should a lack of “patient level data” be an exclusion criterion?”
I’m not sure why that would be a legitimate exclusion criterion in this setting.
It is distressing that the authors would draw the conclusions that they drew from such limited data. However, I find it particularly irresponsible for the authors to publicly claim that the study shows that “antidepressants” are ineffective in mild to moderate depression.
In other settings, the authors have acknowledged that they “don’t know” if their findings can be generalized, yet they generalized their findings to the greatest possible extent in their own press materials.
[...] Science-Based Medicine » Study shows antidepressants useless for mild to moderate depression? Not e… This is an excellent article on what happens when scientists report their findings irresponsibly, particularly when the study in question is poorly designed from the outset. When the desire for notoriety outweighs good scientific method and design, science and progress suffer. [...]
Dr Tuteur – “It is distressing that the authors would draw the conclusions that they drew from such limited data. However, I find it particularly irresponsible for the authors to publicly claim that the study shows that “antidepressants” are ineffective in mild to moderate depression.
In other settings, the authors have acknowledged that they “don’t know” if their findings can be generalized, yet they generalized their findings to the greatest possible extent in their own press materials.”
Dr Novella would have been a much more appropriate SBM blogger to tackle this subject, though an actual psychiatrist would have been more appropriate. What’s distressing is you setting yourself up as an expert on depression and psychiatric studies as a means to drum up yet another controversy when you’re clearly not an expert and there are very distinct dangers with inappropriately prescribing SSRIs to most people with bipolar disorder (and still questions regarding the role of serotonin in depression and the critiques are actually coming from people with much more expertise than yourself).
Like GPs who don’t have the appropriate training to diagnose and treat mental illness – who actually prescribe a lot of SSRIs for mild to moderate depression, the very conditions that experts have increasing doubts regarding SSRIs’ efficacy over and above a placebo effect – you seem to be overstepping the boundaries of your professional knowledge here. (To be clear, I’m not discounting the usefulness of creating a placebo effect when dealing with depression and anxiety related disorders.)
All in all, it’s pretty rich that you’re trying to call out the study’s authors all things considered. And that you assume that a press release is written by the actual researchers and not the university PR department yet you don’t even bother to mention the way the SSRIs are advertised and promoted as a panacea by pharmaceutical companies. It makes it appear like you’re simply writing a press release for drug companies about something you apparently have very little knowledge about (especially since you’ve chosen to ignore related studies that are extremely relevant…talk about cherry picking!). It’s as if you have a reflexive doubt of anyone who questions Big Pharma! Including experts in fields you’re not an expert in!
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0020392
And why are you focusing on the NYT article when the NEJM and many other reputable medical sources have also published on this topic? Why refer to the press release and the NYT article instead of the NEJM one where the authors were actually defending SBM. Really, you’re just distorting the science and using populist sources to further your own agenda that, once again, seems to really have little to do with SBM!
http://content.nejm.org/cgi/content/abstract/358/3/252
“Conclusions We cannot determine whether the bias observed resulted from a failure to submit manuscripts on the part of authors and sponsors, from decisions by journal editors and reviewers not to publish, or both. Selective reporting of clinical trial results may have adverse consequences for researchers, study participants, health care professionals, and patients.”
http://www.plosmedicine.org/article/info:doi/10.1371/journal.pmed.0050045
Citation: Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, et al. (2008) Initial Severity and Antidepressant Benefits: A Meta-Analysis of Data Submitted to the Food and Drug Administration. PLoS Med 5(2): e45. doi:10.1371/journal.pmed.0050045
“Conclusions
Drug–placebo differences in antidepressant efficacy increase as a function of baseline severity, but are relatively small even for severely depressed patients. The relationship between initial severity and antidepressant efficacy is attributable to decreased responsiveness to placebo among very severely depressed patients, rather than to increased responsiveness to medication.”
As noted by another poster already, the older class of tri-cyclic anti-depressants are still used and there’s still controversy regarding the role of serotonin in depression. It really is distressing that you’d exploit this topic to further your own agenda under the pretense that you actually care about people with mental illness. To be clear, I’m not against the use of medication for mental illness at all (or placebos for that matter). What I’m a proponent of is real SBM related to treatments for mental illness not creating the illusion that only pharmaceutical solutions are SBM.
What do the other 17 studies show for SSRIs for mild to moderate depression? Is there any other basis to the idea (besides this meta) that SSRIs don’t/minimally work for mild depression or that the side effects outweigh the (possibly small) benefits? What does Cochrane show?
Seems the burden of proof should be on those wishing to show they DO work, given the possible side effects.
Fifi – I disagree with your criticisms of this post. The scope was limited, but appropriate for SBM – focusing on a new study and the press that it is getting. This does not pretend to be an independent systematic review, or even a treatment of the entire question of anti-depressant use.
Amy’s criticisms of the study, its interpretation, and the mainstream media coverage are appropriate.
Further, having reviewed the literature myself, my impression is that SSRIs have a small but measurable benefit, either alone or in combination with psychological treatment, for mild to moderate depression. Given that there is a sizable effect for major depression also establishes significant plausibility.
The literature supports the use of SSRI’s in an individualized strategy. The media, in my opinion, is getting the story significantly wrong. And that is the thrust of this post.
Dr Tuteur – “psychiatry bashing is a popular media sport. There seems to be a bias against treatment of psychiatric disabilities, and a common claim is that antidepressants are no better than placebo.”
This is a strawman since the questions regarding the efficacy of SRRIs are actually coming from within the psychiatric profession who are calling out pharmaceutical companies for practicing pseudoscience. It is you who is actually doing the psychiatry bashing in this instance! Seriously, you’re acting like an apologist for pharmaceutical manufacturers and not a defender of psychiatry or SBM. Another strawman you erect in your first paragraph is that questioning the efficacy of SSRIs or anti-depressants is showing a bias against treatment of mental illness – it’s not, it’s questioning the efficacy of SSRIs or anti-depressants for treating specific conditions. If you were in the least bit familiar with psychiatric and neurobiological research you’d be aware that this happens within the profession all the time and wouldn’t be trying to demonize experts in the field who are actually defending SBM and asking very important questions about best possible treatment for particular conditions and the promotion of pseudoscience by pharmaceutical companies.
Fifi – There certainly are those within the profession raising questions about the efficacy of SSRI’s in mild to moderate depression – as their should be. That, however, does not mean it is a straw man to observe that the media seems to have a bias against the diagnosis and treatment of mental illness. I think there is such a bias. And this relates to the media handling of this research – not the research itself.
But it is a straw man to suggest that criticism this study or the media coverage is akin to defending pharmaceutical companies. That is dangerously close to the “pharma shill gambit” and is a non sequitur.
I agree that pharmaceutical companies tend to overstate the usefulness of their own drugs – that’s marketing. It should be viewed with suspicion. They are tightly regulated, but do skirt the lines of this regulation, even resulting in occasional sanctions.
Consumer marketing is also a separate and complex issue, but one where there is certainly a role for legitimate criticism. But also having nothing to do with this post.
Dr Novella – Thanks for weighing in – I still wish you’d actually tackled this topic or, better yet, a psychiatrists since this deals with psychiatry. The media is the media and this is a sexy story – mainly due to how well known Prozac and SSRIs are due to the massive over-prescribing by GPs and the amount of advertising done by pharmaceutical companies.
I have no objection to discussing this study – though doing so in isolation seems to be a means to cherry pick data to push a certain agenda, particularly considering how many strawmen Dr Tuteur erects at the outset. Since Dr Tuteur is talking about psychiatry bashing, it’s more than a little ironic that she’s actually doing it herself under the guise of promoting SBM. Defending pharmaceuticals isn’t equivalent to defending psychiatry – it’s simply defending pharmaceuticals (a legitimate thing to do but it’s not defending psychiatry) and when it’s also bashing psychiatrists then it’s certainly not defending psychiatry. Discussing one study is also valid, generalizing about it while criticizing experts in a field Dr Tuteur isn’t an expert for generalizing is just hypocritical.
Fifi,
Please explain how anything at all you said has any bearing on the fact that a meta-analysis which looked at only two medications is being presented as generalizable to all antidepressants. There is no need for specific psychiatric qualifications to recognize that as a massive flaw.
Most of your accusations also go far beyond what Dr. Tuteur actually said.
Just this week a big survey of anti-depressants was released by a dutch consumer affairs program about side effects of SSRI’s. Many people reported averse effects, which is one thing. What most worried me were the common stories of GP’s not taking the side effects serious when they were reported, saying that they were just part of the depression in the first place.
A spokesman for the GP’s disagreed with the presenters suggestion that they should stop prescribing anti-depressants, citing lack of psychiatrists and subsequent long waiting lists.
He did concede that they should make an effort to impress upon GP’s that there are side effects, and that people that report averse changes after beginning their course should be taken more seriously.
There was one woman who with one SSRI had a worsening of her depression, to the point of suicidal thoughts, but with another SSRI was getting better, so at least that helped to illustrate that the drugs themselves do work, just not every SSRI is the same, and that different people will respond differently to different drugs.
Dr Novella, if one is going to critique the media’s handling of this story then one needs to also contextualize it by acknowledging why it’s such a big story (and not blame the study’s authors for what a PR department does). If one’s going to bring up a press release, then one should at least understand that researchers don’t write their own press releases and discuss how and why science gets perverted by PR departments. However, even blaming a PR department would be an incorrect analysis of why this is story with legs.
It’s such a big story simply because pharmaceutical companies sold SSRIs as miracle drugs and promoted them so heavily to GPs, which resulted in them being over-prescribed. This means that there are a lot of readers with a very personal interest in the subject of SSRIs and that even people who don’t have a person interest are highly aware of SSRIs. While Big sCAM has also helped give this story legs, the reason why the media’s running with it is just as much about how pharmaceutical companies promoted SSRIs to the media, the public and medical professionals (particularly ones who aren’t mental health experts, and as the best treatment for mild to moderate depression). From a media reporting perspective, Dr Tuteur’s blog is much more poorly contextualized and just as unbalanced as the actual article she’s critiquing!
Ah, the you can’t call someone on being an apologist for pharmaceutical companies or at least appearing to be biased towards pharmaceutical use because it’s a pharmashill gambit gambit… No, I don’t think Dr Tuteur is taking money from drug companies, I just think Dr Tuteur is biased and reactionary and, in this case, seems to believe that psychiatry is all about drugs – which is just reinforcing the false image of psychiatry promoted by psychiatry bashers! And she likes to stir the pot – which I wouldn’t mind if she was actually cooking up something worthwhile that was nourishing and truly supports SBM (not just gives the illusion that she’s promoting SBM).
In some unfortunate cases, doctors are pharmashills. (There’s the case of Dr. Lawrence Dubuske who resigned from Harvard’s Brigham and Women’s hospital when they recently changed the rules regarding taking money from pharmaceutical companies, for instance.) I am by no means saying that anyone who prescribes pharmaceuticals or discusses their risks and benefits and reports when science shows benefits is a pharmashill. Medications can be lifesaving when properly prescribed – though they can also be deadly when improperly prescribed. I’m just pointing out that doctors who corrupt SBM for both Big Pharma and Big sCAM do actually exist….they are not unicorns!
http://carlatpsychiatry.blogspot.com/2010/01/dr-lawrence-dubuske-me-myself-and-irine.html
Dr. Carlat’s efforts to promote SBM and call out inappropriate influence in psychiatry seem worthy of a post themselves – particularly since he is a psychiatrist and is not alone in trying to defend psychiatry from drug company pseudoscience and meddling. (Sure it’s fun to castigate the woo merchants and media, they’re easy targets, but it’s also good to promote those fighting the good fight and to make it clear that there are many doctors and psychiatrists doing this!)
http://www.thecarlatreport.com/
Uh, Amy, you can’t do the most powerful form of meta-analysis on studies whose data you can’t get access to. What would you have had the investigators do? It is not an uncommon scenario at all for investigators seeking to do a meta-analysis not to be able to get access to adequate raw data from a significant fraction of relevant studies. The authors pointed out what happened in the methods, and this is exactly what they should have done. Readers then note it as a limitation.
The rest of the post was a fairly reasonable criticism, but that one sentence stuck out like a sore thumb.
“It’s such a big story simply because pharmaceutical companies sold SSRIs as miracle drugs and promoted them so heavily to GPs, which resulted in them being over-prescribed.”
I understood the marketing a bit differently. We already had effective antidepressants for very depressed people and psychiatrists were prescribing them. SSRIs are less effective but have fewer dangerous side effects, so they could be offered/marketed to people with mild to moderate depression who would not otherwise have received any treatment at all. They could also be prescribed by GPs. Being able to expand their customer base is great for pharmaceutical companies and they took full advantage.
Over-prescribed? I wouldn’t know. Not in my own experience certainly. What does over-prescribed mean? That they are prescribed to people to improve their quality of life — allow them to hold jobs, for instance — even though without them the individual might plausibly have remained alive, albeit on welfare?
Yes, a lot of people take them. There are various explanations for this. Perhaps misery is the natural human state, a result of the Fall, and given to us by God to bring us closer to Him. Perhaps misery is just the natural human state. Perhaps depression is one of those spectrum conditions that is very common because a little is advantageous (promotes introspection); in the past, perhaps all the moderately and very depressed people would have died from inability to care for themselves, while the introspective and mildly depressed people would have continued the genes to the next generation. Perhaps the isolation of modern life and the associated high demands on the individual create the conditions for depression. Perhaps the inequalities of capitalism do. Perhaps we eat the wrong food and get insufficient exercise. Maybe we were damaged in utero by chemicals in the water supply. Whatever, demand is high and a lot of people take them. And with the exception of the theological account where it would be a sin to use medication to deprive yourself of the full experience of the horror of separation from God, all accounts leave antidepressants at least a theoretical role to play in both saving lives and improving quality of life.
I mean, what do you do when your beloved hasn’t been able to get out of bed for two weeks? Call a priest? Tell them to get over themselves? Tell them that if they would just be a better person and lose weight, get more exercise, get a job and improve their social life that the depression would go away? Or tell them that they are absolutely right, life sucks and then you die, but in the meantime they aren’t having any fun and they are being a total downer for the household and there are alternatives, so call the doctor already.
Note that I’m perfectly prepared to believe they are over prescribed. It’s just that observing that a lot of people take them is not sufficient evidence in itself.
Fifi – your point about not putting the issue into a broader context is legitimate. I often think Amy needs to do that more in her posts, and add more caveats to be clear about what she is not saying, and I have expressed this to her.
However, the tone of your criticism goes way beyond the substance. You make many statements as fact that are little more than opinion. I don’t think you can definitively say why the media is running with this story. My guess is the primary reason is simply that it’s sensational – that’s it. But we can speculate about many other factors.
Further, you make certain accusations that are not based on the post itself, like that Amy believes treating depression is all about drugs. I don’t see that anywhere in her text. It is outside the bounds of this article – although certainly could have been one of those side issues that would increase the context of the article.
I think you need to step back an put your own criticism into context, just as you admonish Amy for not doing.
Alison – “I mean, what do you do when your beloved hasn’t been able to get out of bed for two weeks? Call a priest? Tell them to get over themselves? Tell them that if they would just be a better person and lose weight, get more exercise, get a job and improve their social life that the depression would go away? Or tell them that they are absolutely right, life sucks and then you die, but in the meantime they aren’t having any fun and they are being a total downer for the household and there are alternatives, so call the doctor already.”
Of course not and I wasn’t suggesting anything of the kind – do you truly believe it’s a question of medication or not treatment? There are all kinds of medical options and the first step would be getting a diagnosis from a professional that is a specialist in mental health if one is worried about one’s loved ones mental or emotional health. There are also all kinds of relevant questions to ask, such as if there’s a good reason for your loved one’s depression – is it event or context specific. If an emotional response is appropriate to a situation, it’s not actually a mental health issue but a healthy response and the actions needed may be to change the person’s environment or habits. Psychiatry (and psychology) offer treatment options other than just pharmaceuticals – ones that have no or fewer side effects and a lasting effect (CBT, for instance, and for mild depression exercise has been proven to help so being scornful of exercise is misplaced…I’m not in any way suggesting people should “just get over it” or shouldn’t be assisted in implementing needed changes). However, a great deal of SSRIs are prescribed by GPs who aren’t mental health professionals and without any recommendation for other treatments. (The best evidence for SSRIs and anti-depressants is when they’re used in conjunction with therapy.)
Alison – “Note that I’m perfectly prepared to believe they are over prescribed. It’s just that observing that a lot of people take them is not sufficient evidence in itself.”
No it’s not but there’s certainly enough evidence and questions from within the medical profession itself to indicate they often are for a variety of reasons that simply have to do with limited resources (and in some cases patients’ preference for a “magic pill”, which is how SSRIs have been sold by pharmaceutical companies until SBM called them on the dangers of prescribing to children, people with bipolar disorders, etc). In Canada and the UK there’s the matter of limited access to public mental healthcare and overloaded mental health systems, in the US there’s the matter of what insurance will cover (usually unlimited pharmaceutical treatments but limited talk or behavioral therapy). Part of the problem is when GPs end up treating conditions they’re not qualified to diagnose or treat (which is not necessarily the GPs fault, as noted above).
http://www.guardian.co.uk/science/2004/mar/30/drugs.sciencenews
Regarding the pharma shill gambit, the 3 physician authors of the study all have financial ties with various pharmaceutical companies as noted in the financial disclosures. To me it’s not surprising that the more severe the disease, the more evident the response to medication. This study is generalizable only to imipramine and paroxetine.
Fifi’s attack on Dr. Tuteur is out of line. Dr. Novella said he disagreed with her criticisms. I not only disagree, I find them offensive.
Comments like
“It really is distressing that you’d exploit this topic to further your own agenda under the pretense that you actually care about people with mental illness.”
are simply despicable.
“not creating the illusion that only pharmaceutical solutions are SBM.” It is really a stretch of the imagination to think that this post created any such an illusion.
We get it, Fifi: you don’t like Dr. Tuteur or anything she writes. But please let’s limit the comments to discussing the content of the post, not your personal feelings about the author.
I wonder if there are similar studies comparing CBT and exercise to placebo in patients with mild to moderate depression.
Fifi,
You can’t both argue that people could get superior treatment that wasn’t an SSRI, and also argue that SSRIs are prescribed because alternative treatments are not accessible.
That was my point. The choice people have available to them typically is between suffering pointlessly and taking an SSRI. It is certainly possible to buy a book and give yourself CBT and embark on an exercise program, but it’s a lot easier to carry out if you are first able to get out of bed. If people have to do it for themselves, then SSRIs can play a role in enabling them. Also note: combined CBT and SSRIs are more effective than either alone.
RE prescribing to children: the last I heard, adolescent suicide had been dropping steadily since the introduction of SSRIs. Since they started carrying a black box warning in the US about prescribing them to children, adolescent suicide has been rising. Prescribing them to children is not necessarily across-the-board stupid.
“It is not an uncommon scenario at all for investigators seeking to do a meta-analysis not to be able to get access to adequate raw data from a significant fraction of relevant studies.”
Why do you need raw data about each patient to do a metaanalysis?
Most metaanalyses that I’ve read have not involved the inclusion requirement that the authors of the paper hand over their raw data.
“Regarding the pharma shill gambit, the 3 physician authors of the study all have financial ties with various pharmaceutical companies as noted in the financial disclosures.”
In addition, the disagreement cannot be characterized as those who favor enriching pharmaceutical companies compared to those who do not. The field of psychiatry has been riven by conflicts about the efficacy of drug treatment vs. talk therapy.
Some insurance companies have favored drug treatment because it is cheaper and faster than talk therapy. Certain providers, on the other hand, have favored spending money on their services as opposed to spending it on medications.
In other words, both sides have a financial “dog” in the fight. That doesn’t mean that those who favor one treatment over another are insincere or are doing it only for financial reasons. It merely means that the pharma-shill gambit does not come close to characterizing what is at stake.
Fifi:
Another way of putting it.
You seem to be deducing that SSRIs are over-prescribed because non drug therapies also exist. This deduction is only valid if superior non-drug therapies are being displaced by inferior SSRIs.
For instance, if people used to exercise a lot, but now that they can take SSRIs for depression they don’t bother any more. I don’t have any evidence that this is true. Do you?
Alternatively, now that SSRIs are available, investment in reasearch into effective talk therapy has dried up. My superficial impression is quite the opposite. People know that SSRIs work and are part of a conventional armamentarium, and this makes intuitive sense as well as being intuitively appealing to certain people. This creates the idea of depression as being a treatable disease and not the moral failing that it subjectively feels like. They also hear, from the same popular sources, that CBT and exercise are equally effective for mild to moderate depression. There are a bunch of people who suddenly become much more interested in CBT, creating a market. Research into CBT has blossomed because if it can be classified as science-based medicine then insurance companies can pay for it on the same basis that they pay for SSRIs — because now that insurance companies are paying for SSRIs, cognitive-behabioural therapists want a piece of the pie.
In the real world, I see no evidence that the availability of SSRIs has caused a drop in exercise. I have a superficial impression that the willingness of insurance companies to pay for SSRIs has resulted in a concomitant increase in the availability of CBT. I could be wrong — I don’t have evidence in either case. But the simple existence of exercise and CBT cannot be used as proof that SSRIs are over-prescribed. You must also establish that people who would otherwise be exercising and seeing a CB therapist are being blocked from doing so and are being prescribed SSRIs instead.
Also, I repeat, cognitive-behavioural therapy works better when supported with an SSRI. People do get both: it’s not either/or.
What do people make of the role of publication bias in proper evaluation of the efficacy of SSRIs?
http://www.badscience.net/2008/02/619/
IMHO, there seems to be a lot of merit to the point several posters have made, that if there is over prescribing of SSRI’s by primary care MD’s … it is more the desire to do something for your patient than the influence of marketing. It is painfully difficult to find even a counselor for your patient, much less a psychiatrist or psychologist. If the delay is going to be several months, I can see where the PMD would feel the need to initiate some kind of therapy before then.
THANK you for the Goldacre article Plonit. Funny how people can have the similar premises and come to different conclusions. The publication bias/file drawer effect was a little scary. I also didn’t realize that there had been previous meta-analysis done. I still don’t know who to believe in this case, haven’t researched it enough, but I think I’d probably try other things first if I were mildly depressed.
Cue creepy Cymbalta music..
I enjoyed Dr. T’s article. I did not find it to be bias or inflammatory. Not being a research or meta-analysis junkie, I was confused on the point about patient level data, somewhat clarified in the comments.
The title in the NYT piece is obviously deceptive. One might as well say “Antibiotics are useless in mild moderate infections” Well, what kind of antibiotics, what kinds of infections?”
Alison
“I have a superficial impression that the willingness of insurance companies to pay for SSRIs has resulted in a concomitant increase in the availability of CBT.”
Agreed, the three times I asked for a referral due to depression/anxiety through my insurance, I was referred to a CSW. They each gave me the option to consult with an on site psychiatrist for medication, which I declined twice and was not pushed on. Their treatment plans suggested CBT, cognitive behavior therapy, during which they suggested lifestyle options targeted toward my condition and CBT exercises. I was never offered the option of medication only. If I had asked I’m pretty sure that they would have made it clear that it was not recommended in their treatment plan. This was the approved process by three different insurance companies and three different Mental Health Offices in my area.
Just a general point, CBT makes losing 200pounds , 1 pound a week look easy. To explain, CBT encompasses several methods, it may be the process of changing or attempting to change very ingrained and reflexive thought patterns that you have hundreds of times a day. Or it can be the process of exposing yourself to increasing levels of anxiety in order to acclimate yourself, etc. It can be very helpful, even essential, but I can honestly say for each 10 times I attempt to use CBT techniques to lower anxiety, I probably fail 8 times. That is one way that SSRIs can help. They can relieve some symptoms enough to increase success with CBT techniques. Once the CBT techniques become more habitual, those good habits will tend to continue, even after SSRI is discontinued. Of course these good habits often wan after a while or something triggers a flare in symptoms. That is why mental health issues or often chronic. At least that is my experience.
If I had gone to a GP with the same complaint, I may have been offered Paxil or the like. I’m not sure if my doctor would have, but probably someone in the office might. As I’ve said in another post, I’m not wild about that idea.
I do think some GP underestimate side effects, I also have known three people who were given SSRI’s by different GPs and not told that they needed to taper off when they stopped. That’s not good. I also think different SSRIs tend to work better with different issues or have different side effects and GP are not as qualified in diagnosing those issues or side effects.
Once again good post Dr. T. I can not agreed with you on some things, but I feel you are beginning to find your stride.
You don’t need the raw data about each patient to do a run-of-the-mill meta-analysis. (I realize now that I may have implied that in my comment. My bad.) However, the most rigorous meta-analysis methods do require the use of the original data if it is obtainable. Investigators calculate the common estimate and its confidence interval using these studies. To do this most accurately it’s best to have the original data from all the studies if they can be obtained. This data can then be combined into one large data file with study as one of the variables. Obviously, it’s not always possible to get this data; often it is not. That’s why, alternatively, investigators may only have the summary statistics obtained from publications themselves. Meta-analysis can be done with these statistics.
In fact, the reason the investigators decided to look only at studies whose original data they could access was listed right in the methods section of the paper you discussed. It’s not hidden; it’s right there in black and white:
Reference 17 is http://aje.oxfordjournals.org/cgi/content/abstract/145/10/917?ijkey=1ccdf76e59c411bc994e71e5b5f517082832ca5c&keytype2=tf_ipsecsha
So there you go. They wanted to do a more powerful analysis involving fine-grained multivariate analysis, and that’s why they chose their inclusion criteria. They didn’t just “ignore” the 17 other studies; they tell the reader why they decided not to include them. You can agree or disagree with their reasons, but their reasons are right there in the paper.
Again, while I agreed with the rest of your post, that one statement stuck out as not being a particularly valid criticism of the article.
FIFI – it’s pretty clear that your opinion of Dr. T falls within a certain framework. While you have a right to your opinion, four or more posts per topic restating the same arguments just gets a little dull and wearing.
Have you realized yet that if you don’t like Dr. T’s style, opinions, personal philosophy, you could NOT read her articles. It is a very viable option. I do it all the time with the Wall Street Journal. I just don’t read it.
Or perhaps you could limit your one sided critique to one post? That way any new readers would be appraised of your dislike, but regular readers would not have to scroll past the numerous accusations and defenses.
Dr. Tuteur takes way too much flak in my opinion. This was an enlightening post on a controversial topic.
Thanks for pointing out some interesting flaws in the study, Dr. Tuteur!
And thanks to Dr Gorski for pointing out some interesting flaws in Dr Tuteur’s pointing out of some interesting flaws.
micheleinmichigan,
Interestingly, the one person I know who bought a book and successfully gave herself CBT ran a marathon that year and had also, years previously, lost 100 pounds at a pound a week.
If insurance companies are using a patient’s refusal to participate in CBT as an excuse to refuse to pay for SSRIs, a cynical person might speculate about their enthusiasm. Interesting.
micheleinmichigan,
Interestingly, the one person I know who bought a book and successfully gave herself CBT ran a marathon that year — and years previously had lost 100 lbs at a pound a week.
If insurance companies are using a patient’s refusal to participate in CBT as an excuse to pay for SSRIs, a cynical person might speculate about their enthusiasm. Interesting.
… sorry, that should be “an excuse NOT to pay for SSRIs.”
” They wanted to do a more powerful analysis involving fine-grained multivariate analysis, and that’s why they chose their inclusion criteria”
Or they did it simply to exclude studies they wanted to exclude.
I’d have no trouble accepting your explanation if the authors had emphasized that because of their very strict inclusion criteria, and the fact that those criteria yielded a mere 3 studies of only one SSRI, their results cannot be generalized. Instead the did the opposite.
Can metaanalysis yield valid results when it includes only a fraction of the existing studies merely because the authors of the other studies refused to participate? I think it is up to the authors of the metaanalysis to demonstrate that the included studies are representative of all the existing studies before presuming to generalize about anything.
At a minimum the authors of the metaanalysis could have included a data level metaanalysis of all 23 studies to show how their patient level subset analysis compared.
The authors did not even put the citations for the excluded studies into their paper, but instead relegated them to a web only e-table that I cannot seem to access from the website, making it even more difficult to compare the included studies with the excluded studies. If anyone can gain access to it, I’d be grateful if he or she passed it along.
They did not hide the list of studies or, as far as I can tell, put them in a PDF on the website to make it hard to examine; listing such “peripheral” information in a file on the website is, unfortunately, just the way things are done these days in publishing scientific and medical studies. Readers can judge whether or not they excluded studies that shouldn’t have been excluded; a table lists the criteria and experimental design of each of the 23 studies. Based on my experience publishing studies during the last five years, I’d be willing to bet that the editors of JAMA made the authors list their studies and their table describing them in an extra file on the JAMA website for space reasons; it’s an extra table, and it’s a pretty big table, and the list of citations is a fair amount of text. In fact, I can’t prove it, but based on my experience I’d be willing to bet that the authors probably included the table in the first submission of their manuscript. Editors these days are insisting that more and more stuff be included as “Supplemental Data” or “Supplemental files” instead of being in the paper itself.
Be that as it may, here are the 23 studies, cut and pasted out of the e-document just for you:
1. Barrett JE, Williams JW Jr, Oxman TE, et al. Treatment of dysthymia and minor depression in primary care: a randomized trial in patients aged 18 to 59 years. J Fam Pract. 2001;50(5):405-412.
2. DeRubeis RJ, Hollon SD, Amsterdam JD, et al. Cognitive therapy vs medications in the treatment of moderate to severe depression. Arch Gen Psychiatry. 2005;62(4):409-416.
3. Dimidjian S, Hollon SD, Dobson KS, et al. Randomized trial of behavioral activation, cognitive therapy, and antidepressant medication in the acute treatment of adults with major depression. J Consult Clin Psychol. 2006;74(4):658-670.
4. Elkin I, Shea MT, Watkins JT, et al. National Institute of Mental Health Treatment of Depression Collaborative Research Program: general effectiveness of treatments. Arch Gen Psychiatry. 1989;46(11):971-982.
5. Philipp M, Kohnen R, Hiller KO. Hypericum extract versus imipramine or placebo in patients with moderate depression: randomised multicentre study of treatment for eight weeks. BMJ. 1999;319(7224):1534-1538.
6. Wichers MC, Barge-Schaapveld DQ, Nicolson NA, et al. Reduced stress-sensitivity or increased reward experience: the psychological mechanism of response to antidepressant medication. Neuropsychopharmacology. 2009;34(4):923-931.
7. Boyer P, Montgomery S, Lepola U, et al. Efficacy, safety, and tolerability of fixed-dose desvenlafaxine 50 and 100 mg/day for major depressive disorder in a placebo-controlled trial. Int Clin Psychopharmacol. 2008;23(5):243-253.
8. Cohn CK, Robinson DS, Roberts DL, Schwiderski UE, O’Brien K, Ieni JR. Responders to antidepressant drug treatment: a study comparing nefazodone, imipramine, and placebo in patients with major depression. J Clin Psychiatry. 1996;57(Suppl 2):15-18.
9. D’Amico MF, Roberts DL, Robinson DS, Schwiderski UE, Copp J. Placebo-controlled dose-ranging trial designs in phase II development of nefazodone. Psychopharmacol Bull. 1990;26(1):147-150.
10. DeMartinis NA, Yeung PP, Entsuah R, Manley AL. A double-blind, placebo-controlled study of the efficacy and safety of desvenlafaxine succinate in the treatment of major depressive disorder. J Clin Psychiatry. 2007;68(5):677-688.
11. Feiger AD. A double-blind comparison of gepirone extended release, imipramine, and placebo in the treatment of outpatient major depression. Psychopharmacol Bull. 1996;32(4):659-665.
12. Feiger AD, Rickels K, Rynn MA, Zimbroff DL, Robinson DS. Selegiline transdermal system for the treatment of major depressive disorder: an 8-week, double-blind, placebo-controlled, flexible-dose titration trial. J Clin Psychiatry. 2006;67(9):1354-1361.
13. Gastpar M, Singer A, Zeller K. Comparative efficacy and safety of a once-daily dosage of hypericum extract STW3-VI and citalopram in patients with moderate depression: a double-blind, randomised, multicentre, placebo-controlled study. Pharmacopsychiatry. 2006;39(2):66-75.
14. Hollyman J, Freeling P, Paykel E, Bhat A, Sedgwick P. Double-blind placebo-controlled trial of amitriptyline among depressed patients in general practice. J R Coll Gen Pract. 1988;38(314):393-397.
15. Lieberman DZ, Montgomery SA, Tourian KA, et al. A pooled analysis of two placebo-controlled trials of desvenlafaxine in major depressive disorder. Int Clin Psychopharmacol. 2008;23(4):188-197.
16. Liebowitz MR, Manley AL, Padmanabhan SK, Ganguly R, Tummala R, Tourian KA. Efficacy, safety, and tolerability of desvenlafaxine 50 mg/day and 100 mg/day in outpatients with major depressive disorder. Curr Med Res Opin. 2008;24(7):1877-1890.
17. Liebowitz MR, Yeung PP, Entsuah R. A randomized, double-blind, placebo-controlled trial of desvenlafaxine succinate in adult outpatients with major depressive disorder. J Clin Psychiatry. 2007;68(11):1663-1672.
18. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised controlled trial comparing problem solving treatment with amitriptyline and placebo for major depression in primary care. BMJ. 1995;310(6977):441-445.
19. Rickels K, Case WG. Trazodone in depressed outpatients. Am J Psychiatry. 1982;139(6):803-806.
20. Rickels K, Weise CC, Zal HM, Csanalosi I, Werblowsky J. Lofepramine and imipramine in unipolar depressed outpatients. A placebo controlled study. Acta Psychiatr Scand. 1982;66(2):109-120.
21. Septien-Velez L, Pitrosky B, Padmanabhan SK, Germain JM, Tourian KA. A randomized, double-blind, placebo-controlled trial of desvenlafaxine succinate in the treatment of major depressive disorder. Int Clin Psychopharmacol. 2007;22(6):338-347.
22. UK Moclobemide Study Group. A multicentre comparative trial of moclobemide, imipramine and placebo in major depressive disorder. Int Clin Psychopharmacol. 1994;9(2):109-113.
23. Versiani M, Nardi AE, Mundim FD, Alves A, Schmid-Burgk W. Moclobemide, imipramine and placebo in the treatment of major depression. Acta Psychiatr Scand Suppl. 1990;360:57-58.
As for the point of doing the summary statistics-level meta-analysis first, it is quite possible that they could not do it and make the results comparable for various outcomes. Personally, I consider concluding that the investigators are cherry picking studies, which is in essence what you are accusing them of, to be leaping to conclusions on the basis of no evidence, particularly given that it’s spelled out in black and white exactly how the studies were chosen. You might disagree with how the studies were chosen, but there’s nothing there to indicate cherry picking that I can find.
Thanks for the list! I’ll take a look at them.
What criteria do you think I should use in determining if the cherrypicked the studies? I want to give the authors the benefit of the doubt.
“If insurance companies are using a patient’s refusal to participate in CBT as an excuse to pay for SSRIs, a cynical person might speculate about their enthusiasm. Interesting.”
Did I say that? I didn’t mean to say that. I meant to say that the CSW didn’t push SSRI over therapy and it seemed they might discourage SSRI without therapy.
As to your one friend with the self-help book. Wow, I’m impressed. I did get some good effect practicing techniques from one self help book recommended by a CSW, really was feeling free from anxiety for about a month. Unfortunately the positives effects waned. Still good techniques but anxiety seems to adjudge even to CBT therapy.
micheleinmichigan,
No, you didn’t say that! I said that. I don’t know if anyone’s ever been denied drug therapy for minor/moderate/major depression or anxiety on the grounds that they weren’t interested in CBT. It’s just that your story suggested that possiblility to me — that it might happen — which had never occurred to me before.
sorry typo, anxiety adjusts to CBT therapy
It’s just that your story suggested that possiblility to me — that it might happen — which had never occurred to me before.
Oh good, sometime I don’t know what I’m say.
I don’t have any reason to believe that they would have ultimately denied SSRI without therapy. To much second guessing, that.
Okay, I just finished reviewing the abstracts for all 23 studies. The differences between the included studies and the excluded studies are dramatic.
Of the 6 included studies 5 showed no benefit for antidepressant treatment of mild to moderate depression. The sixth study did not mention HDRS scores in the abstract and I haven’t yet obtained the paper.
Of the 17 excluded studies 15 DID show effectiveness of the antidepressant treatment of mild to moderate depression. Two studies showed no difference compared to placebo.
By insisting on access to patient level data, the authors effectively excluded EVERY study that showed improvement of mild to moderate depression by treatment with antidepressants. And considering that fully 65% of the 23 studies showed antidepressants to be effective, there is no possible justification for Dr. DeRubeis’ public claim:
“The message for patients with mild to moderate depression is, ‘Look, medications are always an option, but there’s little evidence that they add to other efforts to shake the depression …”
Regarding the idea that study authors who don’t read the PR department Press Release.
I guess I’m the only one who thinks that would be a great opportunity to get a job in their PR department and get creative with the press releases.
“meta-analysis shows the uselessness of meta-analysis” and “95% of women think the author should shave off the ponytail” or of course the classic “Study shows that Bob is a Butthead”
I actually don’t believe any of those statements, but I’m pretty sure it would teach researchers to read their press releases.
“By insisting on access to patient level data, the authors effectively excluded EVERY study that showed improvement of mild to moderate depression by treatment with antidepressants. And considering that fully 65% of the 23 studies showed antidepressants to be effective, there is no possible justification for Dr. DeRubeis’ public claim:”
Well, I don’t know. Even before this study, I was concerned as to whether it is a good thing that doctors are using drugs like this like lollies, for common, mild, depressive states.
Any negative studies are a worry, because known biases tend to favour positive results. One important bias that is not mentioned even in relation to these selected studies is whether patients were able to tell that they were taking an antidepressant through their milder side effects.
One aspect — an effect size of 0.2 is LESS than that of placebos overall (0.3 — see Hrobjartsson et Al) , with presumably fewer ill effects depending on the one chosen. We cannot know for sure what the effect sizes were for mild depression in those studies that have not offered primary data.
I credit the fact that I’m even alive (and, thankfully, relatively happy , sane, and productive) to SSRIs. Right upfront: I know that my anecdotal experience is not data, and that I’m not immune to the placebo effect. But as someone who’s been on them for almost 20 years — and whose life went from a hellish cycle of suicide attempts, debilitating panic attacks and sleep entirely disrupted by obsessive compulsive problems, to a normal, productive life — I get weary reading about how SSRIs are “overprescribed” or perhaps ineffective for milder mental problems. That may well be, and yes, I’m interested in factual efficacy data, whether or not I happen to like that data.
But there are people out there who have suffered from severe, horrifying mental debilities, people like me, who have been saved from indescribable suffering and likely suicide through SSRI therapy. There’s no way to say that without sounding melodramatic, but it’s true. I would most certainly be dead by my own hand had my family not forced me to try medication. Given how mentally tormented I was with depression, panic, and OCD, I think I would have chosen death rather than continue suffering that way.
People with those severe problems don’t seem to rate much attention anymore. If SSRIs are discussed publicly, it’s usually to talk about how they’re “misused,” “over-prescribed,” “over-hyped,” etc. It’s easy to look down our societal nose at the worried well who get a pill they don’t need, but why is the conversation about SSRIs so focused on that? Why isn’t more attention paid to the tremendous difference they’ve made for people with severe mental illness?
Yes, it’s possible that my response to SSRIs is all placebo. We are, every one of us, capable of fooling ourselves. But given the severity of my illness, given the fact that no drug therapy of any sort did a bit of good, given how I gradually (almost unknowingly) became a *normal* person and “woke up” a few weeks into SSRI therapy, I find the placebo hypothesis unlikely. There are many people out there like me who thank fate, the universe or their God for these medications.
That’s enough self-indulgence from me. I just wanted to remind everyone there’s a crucial place for psychoactive medications, even if there’s legitimate doubt about their scope of efficacy.
JoshS – Thanks for your stories. I think you make some incredibly important points. The stories of all the people helped by anti-depressants often are not told because the social stigma that still remains attached to mental health issues.
CORRECTION: I meant to write, “given the fact that no non-drug therapy of any sort did a bit of good. . .”
That is to say, no talk-therapy of any stripe worked. The only thing that worked for me was medication.
I have to agree with pmoran, and am confused by why Dr. Tuteur is (possibly) assigning nefarious intentions to the authors. This is not the only analysis that has been done showing little to no effect- Ben Goldacre mentioned another in the linked to article in 2008.
Furthermore, it is certainly plausible that the risks of SSRIs for mildly depressed patients outweigh the benefits. It is also possible, that due to drug study funding, and publication bias, that people think SSRIs are more beneficial than they really are (again, for mild depression). Somebody mentioned antibiotics- these are drugs that shouldn’t be used for every last infection, and using them as such has lead to loads of unintended consequences. I am also curious, after reading Dr. Hall’s critique mentioned in the blog, why the media apparently lied about SSRIs being correlated with suicide in adolescents. Is there a reliable media source of medical/scientific studies for the layperson (besides this site!)? I guess NYTimes ain’t it.
So at this point, I don’t know who to believe. I guess I’d start by looking at RR and confidence intervals in the 17 other studies. Is is possible that severe depression is caused by chemical imbalances and mild depression is caused by something else, therefore explaining the (possible) reduction in efficacy?
“Furthermore, it is certainly plausible that the risks of SSRIs for mildly depressed patients outweigh the benefits. It is also possible, that due to drug study funding, and publication bias, that people think SSRIs are more beneficial than they really are (again, for mild depression).”
It is important to separate the analysis of this specific study from the larger issue of whether SSRIs are effective for mild to moderate depression.
My point about this study is pretty basic: you can’t use three studies on Paxil to draw ANY conclusions about the effectiveness of SSRIs as a class on mild to moderate depression.
In terms of the larger issue, the effectiveness of all SSRIs, the clinical question is not pharmaceuticals vs. nothing; rather it is medication vs. talk therapy. Both sides have vested personal and financial interests in the outcome. Both sides have the unfortunate tendency to look at it as a zero sum game, assuming that money given to pharmaceutical companies is money taken away from psychologists and other mental health professionals who don’t have prescribing power.
It seems to me that the data in total indicate that treatment of depression (whether mild, moderate or severe) needs to be individualized. Moreover, the combination of both modalities can be more effective than either alone.
Three studies on one SSRI cannot offer much guidance on the real clinical issues.
“Both sides have the unfortunate tendency to look at it as a zero sum game, assuming that money given to pharmaceutical companies is money taken away from psychologists and other mental health professionals who don’t have prescribing power.”
Yes, I hadn’t considered the financial interests on the other side. Goldacre mentioned the media having a “good stamp” and a “bad stamp.”
Thanks, JoshS. And… yes.
“Even before this study, I was concerned as to whether it is a good thing that doctors are using drugs like this like lollies, for common, mild, depressive states.”
pmoran, it’s the patients who use SSRIs. If a doctor is using them it’s because they are a patient. Nobody is forced to take them. In our puritan anglo societies most people are reluctant to have recourse to drugs for what is subjectively felt as a moral failing. (See JoshS, and he was not suffering from “mild” depression.)
No doctor I met with was handing out SSRIs like lollies. I actually found them quite hard to get. I was seeing a psychotherapist who actively blocked my access. My GP told me that there was nothing wrong with me that a nice long psychoanalysis wouldn’t fix; she also observed that it was too bad that I obviously didn’t have the self-discipline to see it through. And that ended that. When I eventually got a prescription for SSRIs because I was no longer able to keep it together and I was obviously disabled even to the casual observer, my pharmacist openly wondered why I would need them.
It would be nice to have some evidence that doctors handing out SSRIs like lollies is a problem.
1) That they do indeed hand out SSRIs like lollies.
2) That the harm caused by making SSRIs available to people who might not need them outweighs the harm that might be caused by making them less available to people who do.
It’s true, a lot of people take them. But you can’t deduce from that fact alone that they shouldn’t.
“Both sides have the unfortunate tendency to look at it as a zero sum game, assuming that money given to pharmaceutical companies is money taken away from psychologists and other mental health professionals who don’t have prescribing power.”
Certainly true in my experience. My psychologist used various methods to prevent or discourage me from using medication. When I finally did, I started functioning better and taking more control of my life. I also found talk therapy completely unengaging. When I told my psychotherapist this she said it was normal when taking SSRIs and that I should consider not taking them. When my doctor asked if I was seeing a psychotherapist I said yes, but that now that I was on SSRIs it was completely unengaging. My doctor suggested that I stop seeing the psychologist.
In this case, they were both getting paid and they still put me in the middle of their battlefield.
This was the first time I had been given permission not to engage in psychotherapy because “everyone knows” that it’s what you’re supposed to do. Psychotherapy didn’t help me, which I assumed was my fault. Whether because I wasn’t working hard enough, or because I wasn’t advocating for myself appropriately, or because I hadn’t shopped properly for just the right match for me. I’m really not sure how someone with major depression trying to survive day to day is supposed to do all these things, but all the patient-oriented literature is clear: you are supposed to see a psychotherapist, and if they don’t help you it’s because you’re doing it wrong.
Anyway, though I resented being the monkey in the middle between my psychotherapist and my GP, my GP did give me permission to quit psychotherapy. Which I did, to my great relief.
The huge advantage of SSRIs over talk therapy, from my perspective, is that they give control to the patient. Don’t like the meds? Nasty side effects? Not working? Then don’t take them. It’s the meds’ fault, not yours, and your doctor will prescribe something else or refer you to a specialist. Or you can just stop. Easy-peasy. Meds don’t make you feel guilty. They don’t tell you that if you are friends with your mother that you are in denial because all thirtyish women want to complain about their mothers. They don’t take your money and then spend your fifty minutes telling you about their new baby, or what it was like for them to be poor when they were a young newlywed. They don’t angrily demand to know who told you that you were incompetent when you were a child, when your experience was one of glowing expectations. Most of all, they don’t tell you that if you are more depressed and less functional than ever before in your life that it’s because you’re doing such wonderful work in therapy and it’s a sign of progress. When you take meds, getting worse is always a sign that something’s wrong.
Talk therapy has side effects too, and someone who is depressed may not be able to deal with them effectively. SSRIs have side effects that are much less emotionally charged, more concrete, and might be more easily dealt with by someone who is not coping with anything very well.
… anyway, I got sidetracked. Yes, MDs and psychologists fight over patients. Even when they are both getting paid.
I think that this blog proves that anyone can be deemed to be using the straw man argument no matter what side of the argument you take.
I love it when “skeptics” use their own jargon on themselves, and then, they defend themselves by calling the other side something similar to what they have been called.
For those of you who believe that Prozac is effective for moderate or severe depression will benefit from knowing about a randomized double-blind trial that compared Prozac with homeopathic medicines…it showed non-inferiority and greater safety to the homeopathic medicine.
So, either Prozac works and homeopathy works for moderate or severe depression OR neither works. What is it going to be?
ecam.oxfordjournals.org/cgi/content/abstract/nep114
I love this challenge for you because you are all officially in-between a rock and a healing place…
I have some anecdotal evidence about this situation and also about GP’s diagnosing mental illness and prescribing anti depressants.
As I mentioned in another post I have bipolar disorder, so I don’t fall into the mild-moderate category of depression. However, many of my family members do. This is kind of long winded, please bear with me:
I started having emotional and behavior problems when I was about 10 years old, by the time I was 14 (in 1987) I was severely depressed, I was barely attending school and my depressions were so bad I was barely functional, it was all I could do to get out of bed some mornings, I went days without taking a shower because I didn’t have the energy, I pretty much sat and cried, but there were times when I was overwhelmed with black rages that just came over me. At this point I’d been seeing a psyhcologist for about 4 years, not the same one I was on my third.
The best thing they could come up with is if I wanted to I could be like other girls, and if Iloved my Mom I wouldn’t keep doing things to make her cry. I’d also been tested for about every illness you can think of, gone to multiple specialists, and even had been evaluated at a children’s hospital, my mom was desparate to find out what was wrong with me. Finally she took me to a new GP, he evaluated me, gave me one of those mood checklists, and told me he could help me. He said he thought I had clinical depression and he told me there was hope. No cure, no magic pill, but medicine that would make me feel better but I’d need therapy. He recommended a therapist and I went to see. And sat in her office and cried for 8 consecutive visits.
She diagnosed me with atypical clinical depression started me on anti depressants and they seemed to help.
Obviously the GP and the therapist misdiagnosed me, I had pediatric bipolar disorder. But I can’t blame them, pediatric bipolar disorder didn’t come on the DSMV until 2 years after I graduated high school and even after that I ran into therapists who didn’t believe children could have mental illnesses.
The antidepressants helped more than they hurt me, it got me stable, made me able to work through some issues and able to live a mostly normal life.
But it also got my family help. My therapist talked to my parents and my brother, she took extensive family history, she talked to my paternal grandmother. She ended referring my father to a psychologist who diagnosed him with depression. He wasn’t unable to get out of bed, he has a PhD and a successful career but he had to work much harder at it because of his depression. He started taking antidepressants and his life got easier, it got better, he got better.
I now know that 2 of my father’s siblings have also been treated for mild-moderate depression, I have 2 first cousins who have been treated for depression. And we’re fairly sure that my paternal grandfather (and his mother) had some form of mental illness.
Both my brother and mother have used anti depressants for short term depression. Both of them have been in situations where changes needed to happen but because of the depression they couldn’t make those changes. With a combination of medicine and therapy they were able to work through those issues and end both medicine and talk therapy.
My maternal grandmother also had a rough several years where she needed a combination of medicine and therapy. She never wanted me to be on anti depressants and told my mother that it was a mistake. However, after my grandmother’s experience she apologized, she said she understood.
On my mother’s side I know of 2 cousins who have had mental health issues treated and one who is in serious denial.
Over my 20+ years dealing with various psychiatrists, GPs, psychologists, and therapists I’ve seen good ones and I’ve seen ones who should have had their licenses revoked. The good ones have always wanted me to be on as little medicine as possible.
When I was first diagnosed with bipolar disorder 10 years ago I was started on anti anxiety meds, mood stabilizer, and anti psychotic medication. I went from having multiple anxiety attacks per day to not needing any anti anxiety medication for nearly 7 years. I no longer get depressive episodes several times a year so I don’t take the mood stabilizers.
But when I’m off the anti psychotics my mind still races, I can’t concentrate, and I begin to start the cycle of self doubt and recrimination, but I’m tapering to a lower and lower dose of that.
It took about 3 years just to get to the right mood stabilizer and anti psychotic. I had terrible side effects with some I tried and others didn’t work.
But I’m here now healthier than I have ever been.
I’ve seen my family members have better, happier, more productive lives because of anti depressants. I’m fairly sure that if my great grandmother had access to mental health services she wouldn’t have been the bitter, needy, mean spirited woman she turned out to be.
I want to say that I’ve had some really awesome therapists and some really good talk therapy and I’ve had bad therapists. I’ve had good psychiatrists and bad pyschiatrists.
I haven’t tried CBT, I want to, but the last time I checked around either the therapists offering it didn’t accept my HMO or they weren’t taking new patients or I was considered to healthy for the program.
Alison,
I want to say how sorry I am you had that experience. I’ve never been put in the middle by my GP and my therapist and psychologist.
There was probably a better choice of therapist for you and the therapist and your GP should be working as a team for you.
I’ve had to fire therapists because they weren’t working out. And then I had to find a new one and luckily I only had to do it a few times.
It’s like trying to find the medicine that works, the first or second aren’t right so you try again.
Certainly that’s how I interpreted it, namely that Dr. T was assigning nefarious motives to the researchers with regard to how they designed the study, although I agree with her that in their public statements they went beyond what the study could justify. Let’s put it this way. I’m a researcher; I get a bit touchy when I see other researchers seemingly accused of shadiness or deception on the basis of no evidence and based on not knowing enough about meta-analyses to understand that wanting to use patient-level data is a perfectly legitimate thing in doing a detailed meta-analysis (hence my reaction). If Dr. T had simply stuck to pointing out that only 6 of 23 studies ended up being included because of the inclusion criteria, that would have been fine, but she had to go beyond that and insinuate that it was done in order to cherry pick negative studies.
Amy,
Just one nitpick. In paragraph 4 you define SSRIs as “selective serotonin receptor inhibitors”. They’re actually selective serotonin reuptake inhibitors.
Dr. T was assigning nefarious motives to the researchers with regard to how they designed the study,
++++++++
But that’s Dr Tuteur’s MO – surely you knew that before you made her part of the SBM team. See how she does the same thing over exclusions here….then refuses to concede the point in the comments….
http://homebirthdebate.blogspot.com/2008/10/new-cochrane-study-promptly.html
What she doesn’t seem to get is that researchers for the most part decide their method, including exclusion/inclusion criteria – and in the case of Cochrane publish their protocol – before they even do the literature search and start crunching the numbers.
In the case discussed above, they needed the data in order to do the analysis they wanted to do. So, they approached authors for the data and were declined. They had no way of knowing in advance which authors would decline to share the data on which their findings were based. As it turns out there seems to be some sort of correlation between having positive findings and being unwilling to share your data. That could be interpreted more than one way, if we are willing to assign nefarious intentions.
“So, either Prozac works and homeopathy works for moderate or severe depression OR neither works. What is it going to be? ”
Either or? Why do you suggest those are the only two choices? Why do you imply that ONE study is definitive?
Indeed.
That’s actually a rather interesting observation and one that I hadn’t thought of. Why would the researchers who had more positive results be less willing to share their data than the ones whose studies were mostly negative? One possible reason is that perhaps the ones who had positive results were funded by drug companies, and the company wouldn’t allow release of patient-level data. Other possibilities, such as a random quirk, also present themselves.
Be that as it may, unless Amy can demonstrate that they did a little post hoc rearranging of their methodology in order to make sure to exclude the positive studies, I consider her criticism about the study’s inclusion criteria to be off base, even as I point out that I do agree with her when she criticizes the investigators for going far beyond what this study can support when talking to the press.
I appreciate Dr Tuteur’s deconstruction of this research methodology as well as the honest criticism of her methods by her colleagues and others.
This discussion highlights the impossibility of simplifying the factors in antidepressant response to the degree that we can glean useful clinical information. As psychiatrists wanting science-based credibility, we have shot ourselves in the foot by seeking sensationalism, getting into bed with drug companies and promoting quick fixes for complex psychosocial problems. The diagnostic criteria used in psychiatric research are based on artificial constructs and have been broadened to a degree that I hypothesize many of the subjects with mild “major” depression have a condition that is far removed from that of the patient who is unable to get out of bed or feed himself.
As the 2013 release of new diagnostic criteria approaches, I would like to see a rational science-based evaluation of the factors that are important in diagnosis and treatment decisions. We are seeing lots of political and other agendas, but what does science actually know about psychiatric illness?
“that’s how I interpreted it, namely that Dr. T was assigning nefarious motives to the researchers with regard to how they designed the study”
I never used the word nefarious. That was someone else’s claim. Nor would I use the word nefarious to describe the way that data can be sliced and diced to show what the researchers hoped it would show.
Publication bias is not nefarious; financial ties to industry (if appropriately disclosed) are not nefarious; even cherry picking studies for inclusion is not nefarious. In many cases, it is simply human nature. The people who write papers that are affected with these issues are not evil people planning to deliberately hookwink the population. They believe what they write; they don’t think of themselves as either biased or having an agenda. But one of the reasons we insist on financial disclosures in scientific papers is because we understand that human beings are often unaware of how incentives can influence actions.
I looked at this study the same way I look at any study. The first question is whether the data in the study justifies the conclusions. As I said in the post, although the authors technically “showed” that their metaanalysis finds that Paxil has no effect on mild to moderate depression, their ultra strict inclusion criteria (which left them with only 3 studies) means that their findings are not generalizable in any way.
Although I understand why someone might choose patient level analysis over group level analysis in constructing a metaanalysis, I personally cannot see how that makes this paper more reliable. Indeed, I think it makes the paper far less reliable since the majority of studies were excluded by this requirement. My feeling is that if the authors were unable to obtain patient level data for the majority of the studies, they had no business writing a paper that claimed to be a metaanalysis of the existing research. The raw data was unavailable TO THEM, but it exists. They are not entitled to simply leave it out.
Everyone can judge the quality of the paper for himself or herself. I simply think that it is critical for people to understand what was in the paper and what was left out. As for me, I acknowledge that I don’t think it was a coincidence that ALL 15 papers that showed a beneficial effect of antidepressants in mild to moderate depression were excluded. And we haven’t even addressed the issue that 118 OTHER papers were excluded because they used a placebo washout period. As the sheer volume of those papers indicates, use of a placebo washout period is standard in research on antidepressants.
“in their public statements they went beyond what the study could justify.”
We agree on the claim at the heart of my post. The study does not show that “antidepressants” are ineffective for mild to moderate depression.
It is the authors’ public behavior that made me examine the paper very carefully. I have no trouble saying that the authors were highly irresponsible and clearly pushing a personal agenda in generalizing from such a tiny study, in The New York Times, no less. Newsweek has devoted a cover story to the “findings” of this paper, even though we agree that the paper is not generalizable. The authors have done some serious damage and journalists helped them do it.
Are the authors motives nefarious? I doubt it. I suspect that they genuinely believe that antidepressants should not be used to treat mild to moderate depression. However, that’s not what their paper showed; it didn’t really show anything at all.
“In paragraph 4 you define SSRIs as “selective serotonin receptor inhibitors”
Thanks! I am terrible at proof reading my own work.
“That’s actually a rather interesting observation and one that I hadn’t thought of. Why would the researchers who had more positive results be less willing to share their data than the ones whose studies were mostly negative?”
The explanation might be very simple. They’re professional rivals.
Prior to my clinical training, I did research in two rather arcane areas. In both areas, tiny as they were, researchers were divided into rival groups who could be counted upon to disagree violently with each other in print and at professional meetings. In the world of “publish or perish” and tight research funding, scientists can be competitive and cutthroat in pushing a personal agenda.
lillym,
“I’ve had to fire therapists because they weren’t working out. And then I had to find a new one and luckily I only had to do it a few times.
It’s like trying to find the medicine that works, the first or second aren’t right so you try again.”
I saw more than one as well: I think four over the course of three years. I was limited in who I could see because my income was so low.
I went to a family counselling clinic where I could see someone for $10. I’m not sure what her qualifications were, but I suspect the counsellor I saw didn’t have a university degree. I went to a couples therapist with my ex, who I was able to pay for because my ex chipped in. She was terrific, but then she moved out of town. I went to a CB clinic at a local hospital where I was interviewed by the head of the clinic. I wept during the interview, he listened carefully, and said that he thought I’d been depressed since I was fourteen and once the objective tests came back proving it he could refer me to psychiatrists who could prescribe medication for me. I said yes, I’d be interested in that. Feeling hopeful I went to fill out the stack of objective tests. “How has your libido changed in the last six weeks?” Well, I used to be very horny a long time ago but even though I’m in a relationship I haven’t had sex in four years and I don’t miss it. So, no change. “Do you cry all the time?” No, I lie on the couch for many hours at a time trying to will myself out of existence, or at least to stop breathing. So, no. “How do you feel right now?” Well, I’m doing a test and I love doing tests, and I’ve just met with someone sympathetic who offered me hope, so actually I’m feeling pretty good. Etc.
I was referred to an MSW who couldn’t understand what I was doing there. Most of who they saw were people with phobias, and I wasn’t complaining about phobias. I claimed to be depressed but the objective tests proved I wasn’t. So he had me listen to a relaxation tape and rate my stress level before and after. I didn’t feel stressed before and I didn’t notice any change in stress after, but it did make me cry. He thought that was odd. He gave me the tape to take home, and it still made me cry. Which he still thought was strange. So after that he filled time talking about himself.
I stopped going, but when I became worse a few months later I called the CB clinic again and asked to see someone else. I was on the waiting list for months until my sister realised that I was trying to figure out how to kill myself and called them and asked, are you aware she’s trying to figure out how to kill herself?
And I ended up with a PhD in psychology, a woman who, as far as I could tell, gave me very limited CBT and eventually took me out of the program so she could see me at home and charge me less and free us up to talk about my mother. At this point my income was about $100/week, and I was paying her a sliding scale of $35/week as well as paying my share of rent and utilities. My ex wouldn’t help me out with groceries, but she would make extra when she was cooking for herself and let me eat with her. I was/am vegetarian, and she ate meat-and-two-veg. So as not to starve, I ate meat. Bitterly. And when I got money I paid my therapist for weeks in advance so that I wouldn’t be tempted to divert it into groceries. That was fodder for therapy discussions about not taking responsibility for myself and making her into my banker.
If I wasn’t getting appropriate therapy, how was I supposed to know? I was seeing someone because my own judgement on how to live and think was obviously not serving me well. How could I use my own impaired judgement to decide that my therapist was not helping? That’s at the core of my issue with talk therapy: people who don’t trust their own judgement are to blame for not firing the people they have hired to help them. My psychologist had been assigned to me by a prestigious hospital clinic and was obviously successful. If she thought I was doing good work, who was I to question that? (Fortunately I was on the ball enough that when she suggested I have a child to give me focus in life I was able to tell her that was a very bad idea.)
Meds, besides being paid for by provincial universal medication insurance, were so much simpler to deal with. And they changed my life immediately – at least, I was able to change my life. Within a year I got well-paying work and moved to a better apartmen. I took lovers. A year after that I asked my ex to move out. All those things. I didn’t need to spend years of misery arguing with a therapist about whether my problems were the result of unresolved conflicts with my mother, or the result of my refusal to be accountable. I took the magic little pills and I was able to do the things I already knew I needed to do but hadn’t been able to.
In terms of talk therapy, the best thing I did was attend a six-week workshop for people at risk for depression where we learned about different therapies for depression. It was fun and informative. I got to meet other depressed people and we didn’t hate eachother, so maybe I wasn’t so awful after all. And I kept thinking “Oh, so that’s what she was trying to do! Why didn’t she just say so?” It wasn’t therapy but it was enormously helpful. When I got married I asked people to donate to this workshop series in lieu of wedding presents. (Yes, I am now happily married and a homeowner.)
No, meds are not for everyone. But neither is psychotherapy. Even the much lauded CBT can be hard to get, even when you go to a clinic that’s supposed to offer only that. And advocating for yourself when you question your own judgement – advocating for yourself with someone whose job is to question your judgement – can be an impossible task. It certainly was for me. I really don’t understand how other people can do it so easily, though clearly they do. (And other people can’t understand why I’m not trying to go off my meds, so that makes sense.)
But the moral hierarchy of Therapy Good, Meds… Inferior and a Marketing Ploy is one I simply can’t accept. The therapies I was able to get for myself did not have an acceptable risk/benefit profile and the meds I was able to get for myself did. That’s not me settling for second-best. That’s me self-advocating.
Alison – “Talk therapy has side effects too, and someone who is depressed may not be able to deal with them effectively. SSRIs have side effects that are much less emotionally charged, more concrete, and might be more easily dealt with by someone who is not coping with anything very well.”
That is an excellent point.
Can I say, your therapist was worth *#@%? It make me angry just hearing about it. I can’t even imagine how you felt. And I don’t think that’s uncommon.
I agree with you, it can be really hard and or impossible to find the right match, depending upon finances, insurance situation or local availability and when you are dealing with depression or anxiety…
The other reality there are a lot of good therapist (not the one Alison saw, who deserve a special purgatory) out there that are just not experienced with some conditions. They don’t recognize the borderline versions and they don’t know the best forms of therapy.
Alison I also can see how we came across my statement up-thread about the treatment plan with or without medication from a different angle.
I was making some assumptions based on my experiences. I think in my area (near university with teaching hospital, regular hospital and VA hospital) CBT is widely available and insurance programs seem to send patients to more CBT type clinical social worker and psychiatry offices within the hospital network. My wait has never been more than 2-4 weeks (and I always considered that too long). The CBT that has been recommended is some talk, but mostly a set of exercises on reframing your thinking, stopping all or nothing thinking, etc it is really quite dry stuff. Like I said it’s hard (for various reasons), but it can be very useful.
There are many other therapists, counselors, CSW and psychologist in our area that are in private practice (have never been an option with my insurance). I did see one psychologist years ago with an ex for couples counseling. She gave me the single most misguided piece of advice that I have ever received in my life. Luckily, I dumped both the ex and the counselor.
And even with CBT there are different approaches for different problems. I found if you have issues with ruminating, little charts analyzing and reframing specific thoughts (one feature of CBT) are useless. It’s like trying to count cars on the freeway (well, a Michigan freeway where everyone is going 85 mph).
And TESTING – testing is ridiculous. I never know what to say on those tests. My answer is never an option. I wish they had an essay section.
This is why I get uptight when people start going on about how other people should be treated for any psychiatric disorders mild or severe. I do have strong opinions about supervision when perscribing medication. I think patients should be aware of side effects, dangers and how to taper off. I think that doctors should evaluate patients for possible ill effects. The patient is not always the best judge of that.
Beside that,this really should be between the medical professional and the patient. That is hard enough. It is not for public opinion to decide.
“I haven’t tried CBT, I want to, but the last time I checked around either the therapists offering it didn’t accept my HMO or they weren’t taking new patients or I was considered to healthy for the program.”
Actually there are some excellent self-help books in the CBT arena. They are pretty dependent on your particular issue though, there are book tailored toward depression, ocd, anxiety, etc.
The nice thing about books is that you can work at your own pace and pick and chose methods that speak to you without the social pressure of working with a therapist. Of course they do tailor a plan to met your specific goals like a good therapist might, but I have found them to be very useful (could just be a personal preference)
DON’T tailor a plan, sorry.
Oh, come now. You sure implied that their motives were less than pure in picking the studies they did. Certainly it came across that way to me and some others.
Argument from personal incredulity. Just because you personally cannot understand it is not an argument against it.
Granted, that is also a possibility that I should have pointed out.
Because people at this site disparage homeopathy because of the uncertainty about its mechanism of action, does anyone want to comment on the mechanism of action on SSRIs and depression? There is a LOT of uncertainty about whether there is ANY real relationship between serotonin and depression.
It seems that people may be betting on the wrong horse.
The situations aren’t in the least comparable. Homeopathy has no possible mechanism of action that doesn’t require all of physics, chemistry, and biology to be completely discarded. The idea that a chemical which definitely has physiological effects may have beneficial effects by some insufficiently ascertained path is many, many, orders of magnitude more plausible.
“Because people at this site disparage homeopathy because of the uncertainty about its mechanism of action, does anyone want to comment on the mechanism of action on SSRIs and depression?”
First of all, we do know about the mechanism of action of SSRIs. Second, we know that homeopathy is quackery because it fails to meet virtually ALL criteria for effectiveness.
Showing that a substance “works” involves far more than a study that suggests effectiveness or a possible mechanism of action. It also involves a thorough elucidation of the pharmacokinetics and pharmacodynamics of the substance. Moreover, the purported mechanism of action must be consistent with what we know about the laws of physics and chemistry.
Claiming that dilution makes a substance more effective is like claiming that gravity makes objects lift skyward. It is simply impossible in light of the basic laws of physics and chemistry.
If you wanted to show that homeopathy “works,” you’d need to present detailed data on the pharmacodynamics and pharmacokinetics of homeopathic “remedies” AND you would need to explain how it could possibly work without violating known laws of chemistry and physics.
micheleinmichigan,
Yes, absolutely, there are plenty of good ones. And I’m sure the ones I saw were able to offer perfectly good psychotherapy to other people in other situations. It’s just that it can be difficult or impossible for a mentally ill person to identify bad psychotherapists or inappropriate psychotherapy. If your fourth-grader complains that math is useless, you don’t conclude that math is useless or that her teacher is necessarily complete crap. If your mentally ill patient complains that psychotherapy is useless, does that mean that psychotherapy is useless? that the psychotherapist is complete crap? or that your mentally ill patient is behaving like a fourth-grader?
The local hospital with the reputable CBT clinic is part of McGill Medical School. Lacking other input, I had to assume I was behaving like a fourth-grader.
I think the biggest problem for me was not having clear goals for psychotherapy. I knew I wanted my competent self back but I didn’t have concrete goals like sleeping or managing anxiety or coping with trauma that I could ask someone to help me with. I just presented myself: I’m depressed. Help me. And they would say, you’re not depressed.* Help yourself.
I had the same fuzzy goal for medical treatment: I wanted my competent self back. Meds addressed the fuzzy goal. That was it.
I actually have a talk therapist now who I see from time to time, usually in the winter when my beloved is at his hypercritical worst and I am at my hypersensitive worst. Now I have a clear goal for talk therapy: I want her to be nice to me. I told her that when we first met. She was surprised but went along with it. When I need someone to be nice to me I call her up, pay her $75, and we talk about things I feel inadequate about and how I should meditate and why I’m not getting more exercise and what I could do about it. And then I feel cheered up and competent and go home and tell my beloved where he can stuff it. It’s perfect. Because I’m clear about what I want it’s easy for me to identify whether I’m getting it or not. Not coincidentally, I am not incapacitated by mental illness at this time.
_________
* And I would think to myself, Well, I don’t look depressed to you because I have atypical depression, commonly assiciated with bipolar disorder, and you only see me when I’m sitting chatting with you in your nice sunny office. You don’t see me home alone, locked in the dark trying to die. But I couldn’t say that because teaching a psychologist about atypical depression would be presumptive on my part and saying I had it would be self-diagnosis, which is against etiquette when dealing with professionals. (When I finally did get a psychiatrist of my own, years later, she diagnosed me with Bipolar II. Unprompted. So I hadn’t been wrong.)
I looked at the authors of the included studies and noticed that of the 3 SSRI studies, two of them have authors that were also authors of this meta-analysis. They only got patient level data from one outside group for the SSRI.
To me, that is a pretty thin meta analysis to draw sweeping conclusions from.
As someone who has been depressed all of my life, figuring out if you have “depression” can be quite difficult if that is all you know because it is your “normal” state. You learn to hide it and deny it. It wasn’t until I was in my 40′s and on meds that worked quite well that I began to appreciate how non-depressed people feel every day.
Figuring out if what you have is “mild” or “severe” is simply not something that a naive depressed person can figure out on their own, particularly if that depression has existed since childhood.
Allison makes a number of excellent points.
What basis is there for the idea that too many antidepressants are prescribed? Suicide is the 11th leading cause of death. Is that an indication of too much treatment or too little?
daedalus2u:
“I looked at the authors of the included studies and noticed that of the 3 SSRI studies, two of them have authors that were also authors of this meta-analysis. They only got patient level data from one outside group for the SSRI.”
Ooh, good catch!
weing – “I wonder if there are similar studies comparing CBT and exercise to placebo in patients with mild to moderate depression.”
Not that I’ve seen, it’s difficult or impossible to create a placebo equivalent for CBT or exercise (and one would think unethical to do so in psychiatric terms since patient/doctor trust and relationship are of significant importance in terms of mental health – mental health issues very much involve the realm of emotions and our relationship to the world or, to put it another way, our social and physical environment and how we interact…after all, not functioning well in our environment and coping with our emotions are significant symptoms of many mental illnesses and mood disorders). This highlights the difficult of doing studies on conditions where emotion plays a significant role, as does the mind/body relationship, and the placebo effect.
So far the overall evidence is inconclusive regarding exercise for depression but there are also a lot of positive outcomes for specific studies in specific populations (and the general expert opinion seems to be that more studies need to be done). Either of us could easily find evidence to support either a positive or negative correlation between exercise and depression (though my bias and personal experience leads me to lean towards a positive effect, taking into consideration that the mere act of doing something regularly and a sense of achievement may also contribute to the beneficial effects of exercise on depression, as well as there being a neurobiological component).
The most common clinical trials compare the outcomes of treatments that include CBT and medication vs medication alone. The ones below – with conflicting results – focus on treatment resistant depression in adolescents.
http://bmjcom.highwire.org/cgi/content/abstract/335/7611/142
http://www.ncbi.nlm.nih.gov/pubmed/9294380?dopt=Abstract
http://www.ncbi.nlm.nih.gov/pubmed/18314433?dopt=Abstract
Not surprisingly, in light of recent discoveries regarding the neuroanatomy of anxiety and depression – which seem to indicate that SSRIs would actually be effective for anxiety but not depression – the outcome in a trial for panic disorder and CBT/SSRI combined, SSRI and CBT alone seem to indicate that SSRIs are very effective for panic disorders. I’m a big fan of Dr Nutt and this is an excellent paper – in my non-professional opinion – that also addresses some of the issues and challenges of conducting a trial of this nature.
http://www.cnsforum.com/commenteditem/6A752532-0081-45BE-BA2F-2FEF42E90BB9/default.aspx
It’s worth keeping in mind that we’re still really in the early days of understanding neurobiology and the wide variety of mental and mood disorders and their causes, and the most effective treatments. Also, since so much of psychiatry is about improving a patient’s subjective experience – much like chronic pain treatments – there are many more confounding variables than with studying other forms of illness (and the efficacy of a placebo is not a negligent or unimportant factor, and not as neutral as it may be in other types of clinical trials).
And, yes, this is a subject I’m passionate and intensely curious about having grown up around neurobiological research (and being well aware of how radically our understanding of the brain and mind has changed over the past 30 years) and psychology, with an awareness of how our own mind and cognitive processes create biases and our personal narratives influence how we understand the world and others. (And also working in the arts, which is all about communicating subjective experiences, cognition and culture/environment for some of us geekier types.) I find it frustrating when people make simplistic statements regarding mental illness or attack people asking relevant and highly appropriate questions. The history of psychiatry is certainly not without some ugliness – mainly due to ignorance and biases and not intentional cruelty, but cultural prejudices have led to some horrific practices historically – so it’s one area where being cautious and humble regarding making generalizations and grand claims is called for. Being able to say “we don’t know”, as the study’s authors did, is doing so and certainly not something for which they should be castigated. While it’s tempting to “tidy up” psychiatry or be reductive by trying to study only neurobiology, it’s not a field where you’re just treating a patient’s body or can really look at them isolation from environment (since being mentally healthy is about our subjective experience and how we function within our environment).
One confounding factor and a rich source of personal biases regarding mental illnesses and mood disorders is that we all have minds and most of us will suffer from some form of depression or mood disorder at some point in time. We also tend to extrapolate our own subjective experiences and to project them onto others (hence the tendency of people to think that depressed people are malingering and should just “get over it” since they themselves can do so when they feel a bit blue) and assume our experience of the world and emotions is exactly equivalent to someone else’s. The reality is that there’s a great deal of neurodiversity, that there’s a huge social component to mental illness and mood disorders, and we still have a great deal to learn before we’re experts regarding the brain (and the experts are generally very aware of this even while they try to find best treatments to alleviate suffering and help people be as functional as possible). Because of the many unknowns and complexities of creating clinical trials – and because psychiatry/psychology/cognitive science has a complex history not always actually tied into biology, rife with ideology and greatly influenced by culture – we should all remain open, curious and wary of making absolutist statements or abusing a highly personal and controversial subject like mental health to promote our own ideologies (particularly since this is where psychiatry has historically been the most problematic and led to, in retrospect, some quite dubious and harmful treatments). Though, interestingly enough, shock therapy – which is often held up as the most inhumane of treatments – may actually (in the much more refined version deep brain stimulation) actually be effective for some types of treatment resistent major depression.
This is a subject where I’m very biased – not towards a particular treatment but towards proper science-based studies of all forms of psychiatric treatments and a perspective that considers body/brain, mind and environment. As well as an ackowledgment of neurodiversity and the necessity of individualized treatments.
Has SBM done a good overview of evaluating meta-analysis? I know such an effort would require a good understanding of mathematics, but it would help us in the skeptical community.
Doctor Gorski I have to wonder why the authors couldn’t have used a tiered approach in evaluating the literature, which is to say, give a coefficient that values less those studies that don’t have the raw data published, or available. As another respondent claimed there is 30 years of research behind SSRIs, and while not all studies are close to the gold standard, I believe there are ways of including them in a meta-analysis, but ranking them as less reliable in one’s calculations.
Alison, “Now I have a clear goal for talk therapy: I want her to be nice to me. I told her that when we first met. She was surprised but went along with it.”
I would never be that brave. Good on you.
But, but, but….
Water has memory, don’t you know? Homeopaths tell us so!
Actually, it amuses me to no end when Dana Ullman shows up, because, as my friend has said, homeopathy is most akin to primitive sympathetic magic, using the example of Dr. Stephen Strange, Sorcerer Supreme and Master of the Mystic Arts (and one of my favorite comic characters of all time).
“If your mentally ill patient complains that psychotherapy is useless, does that mean that psychotherapy is useless? that the psychotherapist is complete crap?”
“If the patient is my friend, I concluded that the psychotherapist is crap. If the patient is me, I conclude I (the patient) am incompetent” Good point.
Claiming that dilution makes a substance more effective is like claiming that gravity makes objects lift skyward. It is simply impossible in light of the basic laws of physics and chemistry.
++++++++++
Huh? Theoretically that is only true at the point where dilution makes the substance “not present”. Prior to that point, it is certainly possible for less to be more effective without violating any basic laws.
alison “* And I would think to myself, Well, I don’t look depressed to you because I have atypical depression, commonly assiciated with bipolar disorder, and you only see me when I’m sitting chatting with you in your nice sunny office.”
# daedalus2u “You learn to hide it and deny it. It wasn’t until I was in my 40’s and on meds that worked quite well that I began to appreciate how non-depressed people feel every day.
Figuring out if what you have is “mild” or “severe” is simply not something that a naive depressed person can figure out on their own, particularly if that depression has existed since childhood. ”
Yes, one of the kinds of anxiety I have is social anxiety. It can be quite trying. When I shared this with a therapist. They told me that I looked quite relaxed. Sure I look relaxed, I have been working my whole life to not look foolish in front of people. I can not behave how anxious (angry, happy, sad) I feel because I am too afraid to act that way.
In fact people often remark on how relaxed and laid-back I am in stressful situations. It is a facade, folks.
Dr. Amy wrote:
“Okay, I just finished reviewing the abstracts for all 23 studies. … Of the 17 excluded studies 15 DID show effectiveness of the antidepressant treatment of mild to moderate depression. Two studies showed no difference compared to placebo.”
Hmm, I thought Dr. Amy had been one of those skeptics who spewed contempt when a non-MD dared to cite a study with only an abstract was publicly available, saying that you MUST read the whole paper to be able to mention it at all, as if many journal editors will let the authors outright lie about the results in the abstract. Well, never mind that. I too just finished reviewing the abstracts, and question Amy’s numbers.
To begin with, many of the abstracts do not specify the severity of depression. The original blog post said that the meta-analysis was willing to include studies with HAMD scores up in the 30s (severely depressed). Most of the abstracts do not specify severity either with a verbal label or score range, and it’s not possible to confirm just from the abstract that severely depressed patients were not included in the analysis.
Studies reporting drugs to be superior to placebo specifically for mild to moderate depression include DeMartinis et al. 2007, Gastpar et al. 2006 (which demonstrated equivalence and far lower side effects for hypericum as compared to citalopram), Hollyman et al. 1988, Philipp et al. 1999 (which demonstrated equivalence or superiority of hypericum compared to imipramine)
Studies reporting one or more drug treatments to be superior to placebo in depression of unknown severity were Boyer et al. 2008, Cohn et al. 1996, D’Amico et al. 1990, DeRubeis et al. 2005 (which studied people with “moderate to severe” depression and did NOT break down efficacy by initial severity), Feiger 1996, Feiger et al. 2006, Lieberman et al. 2008 (which apparently pooled data from two studies because neither initially got independent results), Liebowitz et al. 2008 (which included only patients with HAMD scores at or above 20, not broken down), Mynors-Wallace et al. 1995 (in which 52% “recovered” with amitryptyline vs. 60% with problem-solving treatment, so probably mild to moderate); Rickels and Case 1982; Rickels et al. 1982; Septien-Velez et al. 2007; and Versiani et al. 1990 (which had 25 patients per study group).
Then there are the remainder:
Barrett et al. (2001) studied dysthymia and minor depression, and found significant benefit for paroxetine only for dysthymia. The abstract concludes: “For minor depression, the 3 interventions [paroxetine, problem-solving treatment, placebo] were equally effective…”
Dimidjian et al. (2006) compared behavioral activation, cognitive therapy, and antidepressant medication in people with MDD of unspecified severity. It says “Among more severely depressed patients, behavioral activation was comparable to antidepressant medication, and both significantly outperformed cognitive therapy.” From the abstract, there is no indication whatsoever that antidepressants outperformed a placebo or any other treatment in less severely depressed patients.
Elkin et al. (1989) compared two types of therapy with imipramine and placebo. They found relatively little difference among groups overall, which they explained as follows: “Significant differences among treatments were present only for the subgroup of patients who were more severely depressed and functionally impaired…. In contrast, there were no significant differences among treatments, including placebo plus clinical manaagement, for the less severely depressed and functionally impaired patients.”
Liebowitz et al. (2007), no severity measures given, found no difference between desvenlafaxine and placebo on the primary endpoints or most secondary endpoints. The former did significantly improve measures of physical pain, at the expense of significantly greater side effects.
UK Moclobemide Study Group (1994), with initial HRDS of at least 17, reported that clinical improvement was similar in all 3 treatment groups (using a 50% score reduction as their primary criterion): 53% of patients on moclobemide, 50% on imipramine, and 51% on placebo.
Wichers et al. (2009) looked at 83 depressed patients (no severity given) and 22 healthy controls, who received imipramine or placebo for six weeks. They report improvement in “Stress-Sensitivity and Reward Experience,” but don’t say anything about their results from using the Hamilton scale, which suggests that they did not see any benefit versus placebo.
Now, Dr. Amy claims that 15 of these 17 studies showed antidepressants to be effective for mild to moderate depression. This means that she must have been able to determine this to be the case not only for every single study in the second group above (DeRubeis et al. and Liebowitz et al. included) but for four of the last six studies I just individually summarized. However, THREE of those – Barrett et al., Elkin et al., and the UK Moclobemide Study Group – all appear to state the exact opposite (while two others seem to have found no efficacy, in depression of unknown severity, with standard primary outcome measures, and the sixth hints that they did not find benefit in less depressed patients).
How frankly untrustworthy does one of your bloggers have to be, in terms of stating facts about data and literature that are just not true, before you recognize her as a drag on your team?
I think that can be done, but it introduces another problem. Somehow investigators would have to assign weights to each study, and that would be a process rife with possibilities for manipulation and accusations of manipulating ratings of various studies. It’s something that would have to be done very, very carefully, and even then would probably cast doubt on the methodology.
“It is a facade, folks.”
Yep.
I encountered two basic ways that people determined how sick I was.
Psychologists would ask me to fill out a depression scale. (After that first disastrous encounter with depression scales I learned to refuse to fill them out.)
The other was used by doctors and was more informal. The doctor would lay an imaginary stopwatch on the desk and see how many seconds it took to break my defences down until I cried. (I actually have no idea if they were consciously doing this, but after several repetitions with different doctors it certainly felt like it.)
Subjectively I felt like the stopwatch test was more accurate. Unfortunately, you can’t use the stopwatch test for research.
I’ve often wondered if the depression studied with scales and inventories is the same as the depression that people in doctors’ offices report. Research subjects are often college students who are recruited with ads asking if they’ve had sleep and appetite changes accompanied with feeling down for two weeks, the rationale being that depression is defined as six weeks but most people who have been depressed for two weeks will stay depressed for six weeks. And then their depression is rated on tools that capture some people but not others.
What does a student who has been unusually sad and sleepless for two weeks and whose depression is captured nicely on an inventory have in common with an adult who has been struggling with hopelessness for so long that it is their “normal” and “usually”?
The student with a “mild” depression score might be a very different person from the adult with a “mild” depression score. As a very biased, extremely subjective, non-researcher I am simply skeptical about depression scored on inventories. An individual’s scores going up and down from their own baseline is one thing. That’s fine. But is it actually possible to say that your “mild” depressives are the same as my “mild” depressives, if yours are college students and mine are adults highly invested in their facades?
Maybe the tools used for these groupings are different from the tools that I’m familiar with and they will always compare apples to apples. I know I’m not the first person to ask this question. But if we’re reviewing studies that distinguish between “mild,” “moderate” and “major,” could we have an overview of the tools used to make these groupings? It would help me understand the research better.
As the recounting of personal experiences here illustrates, it’s very hard to generalize about treatments for mental illness and mood disorders. Even if two people are diagnosed with moderate depression and score relatively the same on various tests (which themselves rely upon subjective reporting), they may both respond differently to different types of therapy depending upon a variety of factors (personality, both family and larger culture, contributing environmental/social factors, individual neurobiology, and on and on the list goes). It’s also seems important to recognize that anxiety disorders, while often associated with depression, aren’t actually depression and there are different parts of the brain involved. What works beautifully for one person, may be useless or actually quite negative or even damaging for another – this is true of medications, as well as different forms of talk and behavioral therapies – which is why proper diagnosis of each individual is so important and needs to consider not only neurobiology and general biological health, but also relationships and environment (including life events).
An interesting article about the neurobiology of depression…
http://www.sciencedaily.com/releases/2009/12/091208132724.htm
# daedalus2uon 05 Feb 2010 at 11:31 am
I looked at the authors of the included studies and noticed that of the 3 SSRI studies, two of them have authors that were also authors of this meta-analysis. They only got patient level data from one outside group for the SSRI.
Ummm, to a non-research person, that sounds very weird. It sounds like they are just repackaging their own study’s for re-release with a new and exciting spin on them.
I know someone said up thread that they come up with the criteria before hand, but isn’t there a point when it just seems too thin?
Dana Ullman said:
“So, either Prozac works and homeopathy works for moderate or severe depression OR neither works. What is it going to be?
ecam.oxfordjournals.org/cgi/content/abstract/nep114 ”
Maybe you could tell us:
The trial compared homeopathic drops to placebo drops identical in appearance to the homeopathic drops; and fluoxetine capsules to a placebo capsules identical in appearance to the fluoxetine capsules.
So, in your analysis of this trial…
1) Did the homeopathic drops work any better than the placebo drops?
2) Did the paroxetine capsules work any better than the placebo capsules?
Based on these results, what, if anything, can you conclude about homeopathic drops vs fluoxetine capsules in the treatment of moderate to severe depression?
Please also comment on the following:
“The research pharmacist randomly delivered homeopathy and placebo or fluoxetine and placebo, according to a randomized assignment sequence to either homeopathy or fluoxetine group….Only the senior author and the pharmacist had access to the code of the randomized sequence during the study. ”
The pharmacist delivered the treatment and he also had access to the code. Is that correct? If so, what possible effect do you think this could have on the outcome?
BJ
Hi Dr Gorski,
You wrote “However, the most rigorous meta-analysis methods do require the use of the original data if it is obtainable. Investigators calculate the common estimate and its confidence interval using these studies. To do this most accurately it’s best to have the original data from all the studies if they can be obtained.”
I’m not sure this is right. Meta-analyses using summary data from trials should produce pretty similar results to meta-analyses using individual patient data. The reason for doing a patient-level analysis is if you want to do an analysis that takes into account time (eg time-to-first event analysis) or you want to include baseline variables into the analysis, not to improve the accuracy of the analysis.
In this paper, the authors have divided the cohort into subgroups according to their baseline severity of illness. An important issue with this is that it breaks the randomization of the original trials, which may introduce confounding. For each subgroup, it is incorrect to assume that the placebo and treatment groups will have the same baseline characteristics and that any differences are due to randomization (ie chance). eg it is possible that the treatment group might be older/younger, or have different proportions of men and women etc than the placebo group which may contribute to the differences between the treatment groups. This was not addressed at all in the paper.
Dr Tuteur,
I also think the conclusion is too strong. My reason (that you may wish to comment on) is that the study addressed a question of whether treatment effect for depression varied by baseline severity and found it did. The study didn’t ask the question: are antidepressants effective in mild depression? So the authors shouldn’t try to answer that question, because the study wasn’t designed to answer it, and was underpowered to detect any effect in the subgroup with mild depression.
@ Daedalus2u
“I looked at the authors of the included studies and noticed that of the 3 SSRI studies, two of them have authors that were also authors of this meta-analysis. They only got patient level data from one outside group for the SSRI.”
I’m surprised that ALL the groups who supplied patient data don’t have an author. It would be fairly standard to write a protocol, send it to interested authors, invite them to join the collaboration, provide feedback on the protocol and then supply the data after the protocol was finalised. People generally need some incentive to give away data for free, especially to rival research groups.
To address the homeopathy canard being thrown into the mix here (putting aside for the moment that it’s simply prescribing a placebo to prescribe sugar pills or water). The biggest problem with the claim that homeopathy works for mental illness is that the homeopaths who are prescribing homeopathic remedies aren’t trained to be doctors, let alone mental health experts. This means they would probably miss biological factors that may be causing a depressive state, they would probably miss if someone is suicidal and, when dealing with mental illnesses that include psychosis or extreme delusions they’re more likely to encourage the delusions since they’re deluded and indulging in magical thinking themselves.
While the long chats that focus on the patient (and the details of their daily routine and how they feel) during the homeopathic “diagnostic” process may actually provide some temporary comfort to someone with mild depression that’s caused by feeling isolated and unheard – just as any non-medical social contact and concern would – the fact remains that a homeopath isn’t trained to recognize or manage mental illness, nor transference and counter-transference. This means that the homeopath would be creating a dependency without actually providing the patient with the necessary skills to have a real social life and there’s a great likelihood of the homeopath projecting onto the patient and not recognizing important signs and symptoms. (Though GPs and other medical professionals not trained in psychology or psychiatry are also less likely to be aware of or equipped to handle transference and counter-transference, they’re also less likely to be encouraging weekly visits and inappropriately playing therapist and blurring healthy boundaries or creating dependence. Many GPs are being put, often unwillingly, in the position of prescribing SSRIs simply because there are not enough mental health professionals available to diagnose and treat mild and moderate depression – and the benefits of SSRIs have been oversold.)
Both depression and chronic pain are conditions that are highly subjective and experiential (I’m in no way saying they’re not real, I’m just saying that we measure them using subjective reporting). This means that for some people the placebo effect can provide temporary changes in subjective experience. What many CAM treatments for chronic pain and depression do is take the placebo effect and bits and pieces of CBT, or they exploit certain cognitive quirks and/or basic human social needs, and then misrepresent them as being magical and a result of the CAM practitioners intervention rather than empowering the patient by teaching them how their own mind and body work, and how to manage their own thoughts, feelings and state.
Interpersonal talk therapy works somewhat differently than CBT. CBT is very self directed and focuses on recognizing and changing thoughts and feelings, and providing new coping tools (courses of treatment are generally shorter). Not everyone is a good candidate for CBT. Interpersonal talk therapies and analysis are about the relationship between the therapist and patient (and creating new relationship experiences, essentially relearning how to relate intimately) – this can sometimes mean years of therapy. Both have their time and place. And both can be do more harm than good when mis-prescribed. The thing is, sometimes it can take some time to find the right form of therapy and the right therapist. Just as sometimes it can take some experimentation to find the right medication or dose. Since people are in a very vulnerable state usually when they seek help for mental health issues, it’s incredibly important that the person seeing them not be promoting a personal agenda that overrides the patients real needs. (Or that they assume that because they’re equipped with a hammer that all patients are nails. You may be able to hammer a loose screw back into place but it does damage during the process and isn’t lasting!)
These are, of course, gross generalizations and oversimplifications but I bring it up to illustrate the differences between CBT (which is a behavioral therapy) and talk therapies (which are relational therapies). CBT is great for crisis intervention, PTSD and learning new coping skills. Talk therapy can be useful for exploring existential angst and unraveling and understanding the root emotional and psychological causes of personal angst and uncovering repressed issues (and I’m not using angst in a belittling way at all here, suffering is suffering). It’s the area where transference (and the therapists awareness of counter-transference) are highly applicable. All in all, mental health – both in terms of treatment and research – can’t be approached in the same way that many other purely biological conditions can be.
For anyone interested in these issues and a psychiatric perspective (and a good read), I highly recommend The Last Psychiatrist’s blog. His latest one looks at how Seroquil (an anti-psychotic) is being promoted as a treatment for depression and what’s wrong with the way the science is being presented.
http://thelastpsychiatrist.com/2010/02/how_seroquel_xr_works_part_1.html#c007362
And another interesting expert perspective on the subject…
http://clinpsyc.blogspot.com/2009/12/atypical-antipsychotics-for-depression.html
While there can certainly be (and is) rivalry between various factions within both psychiatry and psychology, and between psychologists and psychiatrists, and psychiatrists and neurologists – the questions around efficacy of different talk, behavioral and drug therapies aren’t simply due to this. These controversies exist within psychiatry itself so it’s erecting a strawman to make out it’s simply a matter of psychologists vs psychiatrists. Or to propose that those involved in asking these questions and trying to make sense of the data are simply pursuing personal or for-profit agendas rather than trying to discern what is in their patients’ best interests and what the most efficacious treatments are. Psychiatrists don’t only use drugs to treat their patients – and promoting this idea is actually damaging to psychiatry since it’s promoting the false accusations of Scientologists and Big sCAM. Analysis and talk therapy is as much a part of the psychiatric tradition and practice as it is part of psychology (and psychologists often work in tandem with GPs to prescribe anti-depressants).
Dr. Amy wrote:
“Okay, I just finished reviewing the abstracts for all 23 studies. … Of the 17 excluded studies 15 DID show effectiveness of the antidepressant treatment of mild to moderate depression. Two studies showed no difference compared to placebo.”
# apteryx:
“Now, Dr. Amy claims that 15 of these 17 studies showed antidepressants to be effective for mild to moderate depression. This means that she must have been able to determine this to be the case not only for every single study in the second group above (DeRubeis et al. and Liebowitz et al. included) but for four of the last six studies I just individually summarized. However, THREE of those – Barrett et al., Elkin et al., and the UK Moclobemide Study Group – all appear to state the exact opposite (while two others seem to have found no efficacy, in depression of unknown severity, with standard primary outcome measures, and the sixth hints that they did not find benefit in less depressed patients).”
Is this going to be addressed or is it not relevant?
“the study addressed a question of whether treatment effect for depression varied by baseline severity and found it did. The study didn’t ask the question: are antidepressants effective in mild depression? So the authors shouldn’t try to answer that question, because the study wasn’t designed to answer it, and was underpowered to detect any effect in the subgroup with mild depression.”
Unfortunately, the authors appear to think otherwise. Indeed, the final sentence of the paper is:
“… whereas ADM can have a substantial effect with more severe depressions, there is little evidence to suggest that they produce specific pharmacological benefit for the majority of patients with less severe acute depressions.”
The authors believed that they showed “antidepressants” to provide no benefit for patients with mild to moderate depression. That they believe this is confirmed by their public statements.
My main point their claims are irresponsible and deceptive:
They did not look at “antidepressants,” they looked at Paxil and a rarely prescribed older treatment for depression.
They excluded the 118 of 141 total papers involving RCTs of antidepressants because those studies included a placebo washout period (83.6% of relevant studies).
Then they excluded 17 of the 23 remaining studies because the authors refused to cooperate with them.
Ultimately, they performed a “metaanalysis” on only 4% of RCTs of antidepressants.
Only 3 out of the 6 included studies involved an SSRI. Out of the many members of the class of SSRIs they looked only at Paxil.
As daedalus2u pointed out, 2 out of 3 studies that looked at Paxil were from the authors themselves.
It is unfortunate the authors could not get other scientists to partcipate, but that does not entitle them to ignore those other studies.
The title of the paper, Antidepressant Drug Effects and Depression Severity:A Patient-Level Meta-analysis, is false and misleading. They did not perform a meta-analysis of anything beyond their own two papers and that of one other group.
I find their conclusions irresponsible, their public statements outrageous and the media treatment of their irresponsible and outrageous claims to be regrettable in the extreme.
“there is little evidence to suggest that they produce specific pharmacological benefit for the majority of patients with less severe acute depressions.”
The above is a “not shown to work” statement.
Whereas “The authors believed that they showed “antidepressants” to provide no benefit for patients with mild to moderate depression.”
describes a “shown not to work” statement.
There is a subtle but absolutely crucial difference between these two types of statements, and if you ignore the difference then you misrepresent what the authors have said. They don’t say, “the drugs don’t work”, they say “the drugs have not been shown to work”.
“There is a subtle but absolutely crucial difference between these two types of statements, and if you ignore the difference then you misrepresent what the authors have said. They don’t say, “the drugs don’t work”, they say “the drugs have not been shown to work”.”
You’ve missed my point. The authors have shown nothing! It doesn’t matter how they express their findings; their findings are not generalizable.
In my personal opinion, the only claim the authors can justify is:
In the 3 studies of Paxil we looked at (which may not be representative of any of the many studies we left out) we did not see evidence that Paxil was better than placebo in people with low to moderate initial HDR scores.
Dr. Tuteur,
I commend you for taking on this topic, and for doing it so well. I hope I can offer a few comments that might further the discussion.
Meta-analysis, as a retrospective examination, should never be used to make ANY grand, sweeping determinations like- “STOP YOUR MEDS, they are worthless!” But especially when suicide is such a major risk of untreated depression (and a leading public health problem with nearly 30K deaths a year.) The publication and editorial process for this journal is irresponsible to the public health interest. A multitude of epidemioligical studies in diverse populations demonstrate introducing SSRIs to adult populations reduces suicide rates (Japan, northern Europe…)
Furthermore, depression is an illness that ususally last months or longer, well beyond the time horizons studied in the clinical trials subjected to meta-analysis in this work. Six weeks is a blink of an eye, barely a blip for some people struggling with depression. The characterization of mild to moderate to severe depression is flimsy- it is not a strictly defined symptom cutoff point. For example, where on the Hamilton D Rating is the “severe point” and who sets it? Where is the point on the Beck rating scale and who sets it? Arbitrary, there is some general consensus, but still arbitrary. Patients with mild to moderate symptoms at week 1 may have severe symptoms at week 12 if left untreated (by that time, study is over and they are lost to follow up… convenient.) It is also a well known that some patients will minimize distress they experience, for many reasons. Some may have severe symptoms but rate them mild.
There is also evidence emereging that publications
(like this one) that discourage antidepressant medication treatment, or otherwise interfere with mental health access, lead to detrimental outcomes like higher suicide rates. This is a controversial topic, no doubt, but evidence is building that since the FDA labeled antidepressants with a black box warning regarding suicidality for young adults and adolescents, the suicide rates for this population has trended higher. Undertreatment is of course the leading suspicion for causality since the prescription rates for SSRIs from GPs and pediatricians have plummeted. Child and adolscent psychiatrists usually have 6-9 month waiting lists, at least in this community. (“Hold that suicidal thought, will get back to you on that…”)
The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) set of publications is an excellent informative resource for clinicians interested in treating depression.
In conclusion, meta-analysis should be a tool to look relationships that might need closer examination in future RCTs. It should not be used to make sweeping recommendations for treatment. This publication is another in a series of recent, methodologically flawed examinations of SSRI antidepressants that fail to appreciate its underlying logical shortcomings.
MW
Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, Erkens JA, Herings RM,
Mann JJ. Early evidence on the effects of regulators’ suicidality warnings on
SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry. 2007
Sep;164(9):1356-63. PubMed PMID: 17728420.
Gibbons RD, Segawa E, Karabatsos G, Amatya AK, Bhaumik DK, Brown CH, Kapur K,
Marcus SM, Hur K, Mann JJ. Mixed-effects Poisson regression analysis of adverse
event reports: the relationship between antidepressants and suicide. Stat Med.
2008 May 20;27(11):1814-33. PubMed PMID: 18404622; PubMed Central PMCID:
PMC2423233.
You’ve missed my point.
+++++++++
Hardly, one of your points depends on the false ellision of “not shown to work” and “shown not to work.”
It may be a bad study for a myriad of other reasons (in fact, looks to be so) but not because “The authors believed that they showed “antidepressants” to provide no benefit for patients with mild to moderate depression.”
They didn’t make this “shown not to work” statement that you falsely attribute to them. Given that there are so many other grounds for criticism, it’s not even clear why you would feel the need to make this false attribution unless it is a product of your own confusion.
Of course, the personal outrage of a non-expert in psychiatry and neurobiology aside, generalizing about the media is, well, generalizing and showing a great misunderstanding of not only how media functions but also the relationship between media and “experts”. Why not get outraged at JAMA who published the study and thereby lent it the weight of medical authority? Why not get
outraged at university and pharmaceutical PR departments that exaggerate study results to the media? Why get outraged at all media because of one NYT article when there’s actually another NYT article that takes the study to task in a reasonable and measured way? Why all the hysteria, emotionality and personal outrage regarding something that can easily be addressed in a rational manner?
This NYT article does just that…
http://www.nytimes.com/2010/01/12/health/12mind.html?em
Of course, Dr Friedman is a Director of Psychopharmacology so – if we’re going to propose that one’s specialty creates a bias (as has been proposed vis a vis psychologists) then he may have a bias towards pharmacological treatments since that’s his specialty (his tool of choice or hammer, if you will). I am certainly not accusing him of such, and I have no idea if he has any other conflicts of interest that may contribute to his position in this matter. However, from what I’ve read, he seems to not be an extremist.
http://www.nytimes.com/2010/01/12/health/12mind.html?em
“As you point out, medication and psychotherapy are often used together and for a very good reason: there is abundant evidence from clinical trials that combined treatment is more effective than either treatment alone….
The issue of matching the right patient with the right treatment is critical, and we are just beginning to understand what kinds of personal characteristics predict response to a specific psychotherapy.”
— Dr. Richard Friedman
Another interesting quote by Dr Friedman that is relevant to this discussion…
“For example, several studies comparing cognitive-behavior therapy and interpersonal psychotherapy with antidepressant medication in depressed patients showed nearly identical brain M.R.I. changes in patients who responded to either treatment. In other words, psychotherapy is ultimately a biological treatment.”
http://science.blogs.nytimes.com/2008/01/14/a-new-you-dr-richard-a-friedman-on-mental-health/
The psychotherapy vs medication gambit is a false dichotomy that misunderstand neuroplasticity (and also misrepresents the professional practices of both psychiatrists and psychologists). It’s also playing right into the hands of Scientologists and other anti-psychiatry types by presenting psychiatrists as pill pushers and not empathetic and compassionate physicians who seek the best treatment options for their patients with the fewest side effects.
Dr Wilson – “Meta-analysis, as a retrospective examination, should never be used to make ANY grand, sweeping determinations like- “STOP YOUR MEDS, they are worthless!”
Of course they shouldn’t and neither the meta-analysis nor the NYT article proposed that (and another NYT article actually did a much better dissection of the study that Dr Tuteur did, while also addressing the reality that anti-depressants aren’t a panacea and don’t always work – though it didn’t address how pharmaceutical companies often won’t release their data so it can be included in a meta-analysis).
M Wilson, MD,
Thanks for your comment.
“Furthermore, depression is an illness that ususally last months or longer, well beyond the time horizons studied in the clinical trials subjected to meta-analysis in this work. Six weeks is a blink of an eye, barely a blip for some people struggling with depression.”
That’s certainly true and it highlights another serious problem with this study, the decision to draw conclusions about clinical management when the study is not directly applicable to clinical decision making.
I can’t imagine that there is a clinician who says to a patient: We are going to treat your moderate depression with 6 weeks of low dose Paxil. If you are not substantially better by the end of 6 weeks, we must conclude that you do not respond to antidepressants.
Clinicians routinely counsel patients starting SSRI treatments are routinely advised that the first dose, and even the medication itself may not be effective. Patients are warned to expect a period of time during which dose is increased and different SSRIs are substituted until one is found that will be effective for that particular patient.
Finding the appropriate SSRI takes weeks, if not months. Moreover, if the patient does not improve with SSRIs, the next step would be to try antidepressants of a different class.
No clinician would ever conclude that lack of improvement after 6 weeks of Paxil was an indication that “antidepressants” are ineffective, so it is inappropriate to extrapolate from a study that shows that 6 weeks of Paxil without improvement means that “antidepressants” are ineffective.
@Plonit
“They didn’t make this “shown not to work” statement that you falsely attribute to them”
From the Comment section in the paper… “True drug effects (an advantage of ADM over placebo) were nonexistent to negligible among depressed patients with mild, moderate, and even severe baseline symptoms…”
The authors do claim that anti-depressants did not work in mild depression, as Dr Tuteur has stated.
Another major issue with this paper is the power of the study. There were only 434 people treated with antidepressants and 284 with placebo. To address the issue of mild depression, they split their sample into 3 groups. The authors should have stated how much of a difference between the groups the study had the power to detect. They didn’t. It is very likely that the subgroups were too small to detect anything other than a very large change in the rating score, which would not be expected in people with mild depression. So the author’s claim above is not correct. To claim this- they’d need to do a meta-analysis of all RCTs of all antidepressants in mild depression, and show no benefit of treatment.
Whilst waiting for a response from that hit and run merchant, Mr. Dullman…
I would like to thank Amy again for participating in the commentary (authors don’t always do that and, of course, they are not obligated to do so). I think she has done a reasonably good job at showing up the problems with this study, with only a few minor hiccoughs (and I agree a bit of stage setting could avoid many misunderstandings that occur in the commentary about the authors intentions).
I don’t know if anti-depressants are useful for mild or moderate depression, but this study certainly does nothing to answer that question for me.
It is kind of dangerous for a layperson like me to read studies like this without the guidance of more knowledgeable folks, for one simple reason– as pointed out by an earlier commenter, it is supremely difficult to self-evaluate the level of one’s own depression. Thus, I read this NYT article and thought, “Crap, I wonder if I should wean off the Paxil?” because to my own perception, CLEARLY my depression level is average.
Fortunately for me, I have a competent psychiatrist who quickly disabused me of the notion that I am deriving no benefit from my SSRI. 
But, seriously, how atypical is that reaction from a depressed person– EVEN one who has been suicidal many times in their life!– “Oh, my depression just isn’t that bad, I must be in the mild-to-moderate category,” because it is SO HARD to put one’s own experience into the perspective of the general population? Especially as one of the knee-jerk reactions of depressed people is to find insignificance in their own lives, including, ironically, their level of depression! Thus, I worry that articles like this, in the popular media, may do more harm than good in that a depressed person might become less likely to seek drug therapy when it might really help them.
Billyjoe: “The trial compared homeopathic drops to placebo drops identical in appearance to the homeopathic drops; and fluoxetine capsules to a placebo capsules identical in appearance to the fluoxetine capsules.”
Not really. There was no placebo group. The study compared homeopathic management to fluoxetine only. Because it was not possible to blind patients to the process of homeopathic individualisation they were blinded as to the “active” treatment supplied. All patients were thus required to take a placebo mimicking the other agent in addition to the supposedly active one.
We are bound to be offered many more results like this for dubious methods wherever conventional treatment has only modest benefits over placebo in subjective and self-limiting complaints.
It is the only way forward for the promoters of such methods. They cannot risk going to the trouble of performing high quality comparisons to placebo and merely adding to the list of negative results.
I also don’t know whether the study has really shown that the effectiveness of antidepressants varies by baseline severity of disease. The paper is quite dense and almost impenetrable, but what the authors appear to have done is to compare the change in the Hamilton depression rating scale (HDRS) following treatment with the baseline HDRS. On average, people with higher scores to start with (ie more severe depression) had greater changes in their HDRS.
One explantion for this could be that antidepressants improve depression by a similar amount no matter what the baseline severity is. For example- if antidepressants improve depression by 25% in 6 weeks, a starting HDRS of 40 would improve to 30, and a starting score of 20 to 15. Comparing the absolute difference in HDRS with the baseline starting score would show that higher initial scores are associated with greater changes in HDRS.
This is such a simple argument that it is hard to believe that it wouldn’t have been considered by the JAMA reviewers and editors, but it wasn’t addressed in the paper anywhere. Again, though it is not a sensible way of assessing whether antidepressants are effective in mild depression.
pmoran,
You are a spoilsport!
That was a question to test Dullman.
In my experience, he reads only the extracts of the studies he references and is seemingly unable to understand, or can’t be bothered to read, the details of the study themselves.
My gamble was that he would not attempt to answer this question because of the above requirement.
If he had read the study, he would have been able to embarrass me with a response similar to the one you gave, but my guess is that, even after reading your response, he will still be unable to do so.
(That is, if he even bothers to come back to this thread which I think is highly unlikely – would you like to take a bet?)
regards,
BillyJoe
“In my experience, he reads only the extracts of the studies he references and is seemingly unable to understand, or can’t be bothered to read, the details of the study themselves.”
That’s not very consistent of him. I would expect him to make the studies more powerful by serially diluting them and shaking until there was nothing left of them. On second thought, he’s probably deluding with them.
One problem I have in reading these studies is finding out how they determined adherence to the antidepressant. Patient’s with lower severity might think that they can beat it without the medication, particularly when the initial side effects of these meds manifest as opposed to the placebo group. In such a case, I would expect to see little difference between the 2 groups in efficacy.
A few things about depression from someone who knows …
1. Depression is incredibly difficult to treat. I know of people who have gone through dozens of treatment options over many years before finding relief. Measuring effectiveness of one drug against “depression” is measuring something that barely exists in the “real world”.
2. Depression is a symptom, not a disease. It has many causes (dozens at least) ranging from “chemical imbalance”, sleep problems, genetic problems, environmental problems etc. A “cure” will at best tinker with surface issues such as dopamine production. It’s like feeding a drunk six cups of coffee. You just get an awake drunk. Anti-depressant drugs can just give you a depressed person who’s not so much of a problem to everyone else.
“Depression is incredibly difficult to treat. I know of people who have gone through dozens of treatment options over many years before finding relief. Measuring effectiveness of one drug against “depression” is measuring something that barely exists in the “real world”.”
Agreed.
“A “cure” will at best tinker with surface issues such as dopamine production. It’s like feeding a drunk six cups of coffee. You just get an awake drunk. Anti-depressant drugs can just give you a depressed person who’s not so much of a problem to everyone else.”
That is simply untrue.
Because of the tremendous variability in responsiveness among patients, there is no way that one person’s experience can tell us the effects of antidepressant treatment. Perhaps you are someone you know felt that way after treatment, but if that’s the case, the treatment was only partially successful.
Most patients who report improvement on SSRIs do NOT feel sedated and do NOT feel that the symptoms are still there but being “masked” by the SSRI. Indeed, many patients report feeling “like themselves” without depression.
Dr Tuteur – “Most patients who report improvement on SSRIs do NOT feel sedated and do NOT feel that the symptoms are still there but being “masked” by the SSRI. Indeed, many patients report feeling “like themselves” without depression.”
That’s a bit self-evident since many people who do feel sedated (or manic) on SSRIs probably aren’t going to be reporting feeling sedated or manic as an improvement! Though, of course, some may and many people who take tricyclic antidepressents – who are generally people who suffer from severe depression – consider the unpleasant side effects worth the relief. Also, when we’re talking about patient self reporting regarding mild to moderate depression there are few means to account for confounding factors (from simply doing something about their condition and the relief that provides, undergoing therapy at the same time, or the ever present placebo effect when discussing mild to moderate depression).
Chillyfinger makes a good point. Depression can be a symptom of many organic diseases, as well as a symptom of a nutritional deficiency, an environmental/social problem or a sleep imbalance. There’s often a chicken/egg problem with mind/body conditions. That said, depression can also have genetic or purely biological causes as well (it can be a disease and not a symptom). Depression is also a symptom of Manic Depression/Bipolar Disorder so it’s very important to have a clear diagnosis (since SSRIs seem to be problematic for many people with MD/Bipolar Disorders). A good clinician will take the time to discern whether depression is a symptom or the disease itself, rather than simply assuming that all depression is a disease and should be treated with SSRIs. There are many approaches to changing neurobiology, a pharmaceutical one is only one (as valuable and incredibly useful as it can be for some people) and SSRIs are only one of many psychopharmaceuticals and aren’t appropriate for all psychiatric illnesses (and are highly inappropriate for some).
I’ve also seen cancer and diabetes present as depression.
Thyroid is the classic physical condition to look for on the differential. And then there’s looking at the differential from the other side: some subgroups have their own presentations. Apparently hispanic women sometimes present with abdominal discomfort that is fully treated with an SSRI.
What I still want to know is, how are “mild” and “moderate” even captured? And what makes us think that each study’s “mild” is the same as anyone else’s?
Depression can be an illness in itself, or it can be a symptom of another illness. It is like other medical conditions in that respect, having both a primary form and secondary forms.
It’s not surprising when you consider that depression is biochemically mediated. The biochemical derangement can occur spontaneously (perhaps due to genetic susceptibility) or it can occur as the result of other medical problems or as the result of hormone treatments and other medications that leave patients experiencing depression.
The bottom line, though, is that it is a real illness, just like diabetes, and may require medication, just like other illnesses.
Dr Tuteur – “The bottom line, though, is that it is a real illness, just like diabetes, and may require medication, just like other illnesses.”
Is anyone actually proposing that depression isn’t real? Or that medication can’t be a valid treatment and may be necessary? That’s a bit of a strawman you’re erecting. And, no, depression isn’t “just like diabetes” since depression involves both the body and mind, and is diagnosed using subjective measures.
“And, no, depression isn’t “just like diabetes” since depression involves both the body and mind …”
Yes, it is just like diabetes in that both have a biochemical basis. Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes. There is no magic to the mind, and no special “essence.”
To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.
weing, yes, I was thinking of cancer in particular, but there are also nutritional deficiencies that can present as depression. In either case, treating with SSRIs wouldn’t be the best course of action.
Alison – “Apparently hispanic women sometimes present with abdominal discomfort that is fully treated with an SSRI.”
That makes a lot of sense since most of the body’s serotonin is created and found in the intestines, it’s important in a huge array of biological functions. Only a small amount is actually found in the brain. The relationship between IBS and serotonin is a fertile area of research.
Dr Tuteur – “Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes. There is no magic to the mind, and no special “essence.”
Nobody is claiming that – I certain am not and haven’t at any point. In fact, I’ve been quite clear that the mind is not magical and cognitive therapies aren’t magic but are taking advantage of basic neurobiology. You’re erecting a strawman yet again. There’s actually quite a lot of good research that shows how neuroplasticity works and it’s really not very mysterious or hard to grasp. Certainly we don’t know everything about neuroplasticity but we do know quite a lot at this point and how the physical brain responds to repeated actions, thoughts and learning/experiences. The point is that we can change our neurobiology through other means than simply drugs (which is not to discount the usefullness of drugs). To dismiss everything outside of one’s own understanding – or to assume it’s all woo or magic – simply because one doesn’t understand it is being blinded by personal bias.
Dr Tuteur – “Yes, it is just like diabetes in that both have a biochemical basis.”
You’re missing the point, yet again. There are specific biological measurements and tests that are used to diagnose diabetes. We don’t have specific biological tests for depression, we rely upon self reporting and observation – neither are as objective as a biological test for diabetes. We also rely upon the DSM, which is in many ways a construct (that doesn’t mean it’s not useful or necessary, or that all mental illness is a construct or not biological). Also, one can’t use one’s mind to influence diabetes (it would be magical thinking to believe this) but one can change one’s brain by what one does with one’s mind (just as brain and biological illnesses like cancer can effect how our mind presents/works and we experience ourselves and life).
The brain/mind relationship is more complex and more of a two way street than you seem willing to acknowledge, and both are influenced by social/environmental factors (for instance, a baby that is never touched or is abused develops differently than a baby that is lovingly touched and nurtured). Nature AND nurture isn’t really a very controversial position in neuroscience at this point. Just as epigenetics is showing itself to be a very fertile field of understanding about how biology evolves.
Now, this doesn’t mean there aren’t brain disorders that the mind has no influence over or that drugs can’t be helpful and useful – I’m not and have never been making an either/or argument here. I’m arguing for not being absurdly reductionist in a way that actually goes against current scientific knowledge and irrationally fetishing psychopharmacology and promoting it as the end all and be all of SBM.
And to be very clear, I’m not arguing against the use of drugs for depression or saying that drugs can’t be useful. And I’m certainly not criticising anyone’s personal choice to use or not use drugs to treat their depression. Not everyone is a good candidate for cognitive and/or behavioral therapies – antidepressants are a perfectly viable option and it’s up to the individual and their doctor or therapist to decide which approach is most aligned with their condition, personality, current context and life options.
Having been diagnoses with Hypothyroidism, Depression/Anxiety and Asthma, all things that can mimic each other, I think I can attest what a lovely barrel of monkey’s it is trying to separate all the symptoms.
But for myself I can see distinct differences in some case. I was treated for the Depression/Anxiety (with Paxil) well after I started having thyroid symptoms but before I was diagnosed hypothyroid (due to normal tsh levels). Then stopped Paxil before being diagnosed hypothyroid and starting synthroid.
The Paxil mostly helped my mental symptoms. Significantly lowering my intense self-critical ruminating and dark moods and a feeling of despair and being overwhelmed. After a period of making my insomnia worse, it seemed to alleviate my 3:00am waking problem and I got more sleep.
On Paxil I still had period of intense tiredness or lethargy and I had many muscle ache and spasm symptoms, It seemed I was constantly going to PT or taking Ibuprofen for some tendon, muscle pain or spasm. I also had strange “vertigo symptoms” that the therapist thought was stress related
When taking synthroid, no Paxil (when my TSH is optimal) I don’t have the tiredness or muscle pains but the ruminating and mood are much more difficult to control . AND the synthroid also improves my sleeping, alleviate the 3:00am waking and I don’t have the vertigo symptoms.
On the other hand, every doctor I’ve talked to claims that I can’t have been having any hypothyroid symptoms with normal TSH levels. So go figure.
The side effects of the Paxil and some symptoms of hypothyroid I found to be so similar as to be indecipherable.
With asthma it’s easier. It’s only mistaking the tight chest stress sensation for the tight chest asthma sensation. But if I try to take a deep breath and can’t, it’s probably asthma. Also luckily a doctor can easily hear my wheeze with a stethoscope so I don’t have to argue about medication.
So I guess that my long winded way of saying, yup, it really can be confusing.
Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes.
To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.
Such unproven assertions detract from the discussion. (Although it is clear example of reflexive reductionism, SBM’s unhappy alternative to CAM’s reflexive doubt.)
It’s especially unfortunate to see, in that last quoted sentence, a declaration of ignorance and an assertion of absolute certainty derived from that ignorance.
Amy said: “To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.”
Lawrence said: “It’s especially unfortunate to see, in that last quoted sentence, a declaration of ignorance and an assertion of absolute certainty derived from that ignorance.”
It’s just the materialist’s position surely.
Amy must have assumed there’d be no dualists around here.
If there are, identify yourselves!
We’ll soon cut you down to size with our special purpose razor.
BillyJoe, I’m not sure if you’re joking or not. I’m hardly a dualist and it’s not a dualist position to propose that the brain is shaped by our thoughts and actions. Not only is it not dualist to propose the brain is shaped by thoughts and actions, it’s basic contemporary neuroscientific knowledge (though apparently Dr Tuteur thinks it’s magic). Neuroplasticity is hardly radical or dualist, or magic! Dr Tuteur’s prejudice against cogntivie and talk therapies, her fetishistic approach to psychopharmacology, and her blatant bias against psychologists displayed on an SBM blog is highly regrettable. As is her misrepresentation of psychiatrists as merely pill pushers. Psychiatrist are professionals who treat people not just brains, and they use more than drugs to do this and are as concerned with the minds of their patients as they are their brains.
I need to issue a correction to my previous comment. At some point while tabbing back and forth to look up the abstracts of the studies in Dr. Gorski’s list, I developed the notion that I was only looking up the studies that had not been used in the meta-analysis, whereas that list was of ALL the studies that met the criteria. Thus, the numbers in my comment made no sense at all (and I’m surprised none of you keen-eyed skeptics jumped all over that). When you’re criticizing someone else for using bogus numbers to support a baseless accusation, it is better not to use bogus numbers yourself – very embarrassing. My apologies; I will now slink off to look for some Tabasco sauce for this big plate of crow.
However, the fact that my numbers were garbage does not make Dr. Amy’s numbers correct. The correct way to look at that pile of abstracts would have been: could I identify 15 whose abstracts indicated significant efficacy against, specifically, mild to moderate depression? And I can’t.
Oh well, at least my Saints won.
Dr Tuteur said – “Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes. There is no magic to the mind, and no special “essence.”
FiFi said – Nobody is claiming that – I certain am not and haven’t at any point. In fact, I’ve been quite clear that the mind is not magical and cognitive therapies aren’t magic but are taking advantage of basic neurobiology. You’re erecting a strawman yet again. There’s actually quite a lot of good research that shows how neuroplasticity works and it’s really not very mysterious or hard to grasp.
Actually, I’m not sure nobody was claiming that it seemed some posters may have been alluding to that and historically there have been a large number of people that view depression as a personal failing rather than a biochemical process that can effect any of us.
I do not see that biochemical processes and neuroplasticity are different concepts. I far as I can see neuroplasticity is a biochemical processes.
As to diabeties and depression, Yes I would say they have some similarities. They are both a biochemical process that seems to have a genetic component. In mild moderate cases they may be acerbated or alleviated somewhat by behavior or stress factors outside of a persons control. In more severe cases behavior and outside influences offer little effective help. Our only best known treatment is drugs.
The differences, diabeties seems to much better understood. We have much better measures for it and as far as I know, the mechanism is pretty direct. Diabetes is not generally a symptom of something else. Depression is far less understood, the measures are by far subjective.
I personally have drawn the conclusion depression can be either a symptom of another health condition. It can also be a biochemical reaction caused by a stressor such as a traumatic life event in a none predisposed person. Or it can be a condition caused by the combination of personality*, genetic predisposition, and lifestyle/thought patterns. Lastly it can be a direct malfunction of the brains chemistry with no other conditions, events, lifestyle factors.
In all of these cases it is a biochemical process. We can not think, perceive, do, anything without a biochemical process. It is the nature of us beasts.
*ha, the old nature, nurture gambit.
michele – “Actually, I’m not sure nobody was claiming that it seemed some posters may have been alluding to that and historically there have been a large number of people that view depression as a personal failing rather than a biochemical process that can effect any of us.”
Can you please point out to me where I or anyone was claiming that the mind was magical and not an emergent property of the brain in this thread? Particularly where I was? Not only did I never do that, I also pointed out up thread that psychotherapies (talk and cognitive) take advantage of neuroplasticity.
Here it is the quote from Dr Friedman again, who did a much more on point critique of the meta-analysis for the NYT than Dr Tutuer did (and without all the obvious prejudices and misrepresentations that Dr Tuteur has shown)…
“For example, several studies comparing cognitive-behavior therapy and interpersonal psychotherapy with antidepressant medication in depressed patients showed nearly identical brain M.R.I. changes in patients who responded to either treatment. In other words, psychotherapy is ultimately a biological treatment.”
http://science.blogs.nytimes.com/2008/01/14/a-new-you-dr-richard-a-friedman-on-mental-health/
And it’s worth repeating again, the psychotherapy vs medication gambit is a false dichotomy that misunderstands neuroplasticity (and also misrepresents the professional practices of both psychiatrists and psychologists). It’s also playing right into the hands of Scientologists and other anti-psychiatry types by presenting psychiatrists as pill pushers and not empathetic and compassionate physicians who seek the best treatment options for their patients with the fewest side effects.
I really do understand that it can be hard to get people to understand depression and chronic pain – or any form of suffering that isn’t dramatically obvious – and that, like with addiction, people who don’t understand tend to see it as a moral failing or a weakness of will. I am truly sorry if you’ve had this experience and do understand if this is personal for you (and I point this out not to put you down or negate your opinion or experience, I’d assume that since you shared your personal experience you consider it relevant). I can understand the personal and general utility of being able to say depression is a disease and beyond one’s control – and I’m certainly not advocating anyone “get over it”, I’m advocating using the best treatment for each individual. To reject all but psychopharmaceutical solutions simply because of a mistaken belief that other treatments aren’t biological because they don’t involve a pill is to ignore reality and current scientific knowledge. And, to propose that using anything that isn’t a pill is woo is to have a rather profound misunderstanding of the brain and mind, not to mention that it shows a great deal of ignorance regarding psychiatry and cogntive science on Dr Tuteur’s part.
I’m curious, with your comparison of diabetes and depression, are you proposing that one can effect the structure of organs other than the brain via ones thoughts? That simply using one’s mind can have the same impact on the organs effected by diabetes as using insulin can in some cases? Or that it’s equivalent to the way cognitive and interpersonal therapies can influence the structure of the brain? Now that would be straying awfully close to magical thinking! (However, I suspect you’re just proposing that one’s stress levels and emotional state can influence insulin…though I’d like to see some evidence of this being true before I’d accept your theory. Particularly in relation to type 1 diabetes.)
I’d just add, nurture IS nature. It’s all nature. And, to the discomfort of some people, culture is also nature. We’re social animals, our brains are shaped by our environment…as are our genes. Since it’s all nature, it’s actually more of a dualist position to take to make out that environment, socialization and context aren’t a part of nature and don’t influence our brains. Denying complexity and being reductionist isn’t being more scientific or having a more accurate view of reality, even if it can be a usefull and necessary thing to do to study specific things
FiFi , sorry you lost me. but I’m not following the dualist – reductionist debate, just not my cup of tea.
nature vs nurture is always an entertaining debate, but unfortunately the dog needs to go out, I’ve got a pile of paperwork, behind on the artwork and birthday plans to make, so I’ll have to save my response for another article comment box.
michele – The nature vs nurture debate is pretty much dead in the water at this point for the most part, it’s quite widely accepted that both nature AND nurture are involved in brain development…that’s what neuroplasticity is all about. The field of epigenetics is very specifically about nature and nurture.
Really, Dr Tuteur was intentionally erecting a huge strawman and making an ad hominem attack by accusing me of being a dualist. Either that or she simply doesn’t understand even basic neuroplasticity! Either way, what she’s promoting isn’t SBM.
I’m also curious as to whether you truly believe what you seem to have been asserting about diabetes and if you believe that thoughts can influence the physical structure of organs in the body other than the brain? Do you also believe that thoughts can influence the structure of cancer tumors?
Fifi said “to propose that using anything that isn’t a pill is woo is to have a rather profound misunderstanding of the brain and mind, not to mention that it shows a great deal of ignorance regarding psychiatry and cogntive science on Dr Tuteur’s part.”
Dr. Tuteur never proposed any such thing!
“Dr Tuteur’s prejudice against cogntivie and talk therapies, her fetishistic approach to psychopharmacology, and her blatant bias against psychologists displayed on an SBM blog is highly regrettable.”
I do not see any evidence of such prejudice or bias in anything Dr. Tuteur wrote. What is regrettable is not what she wrote, but the fact that you are imagining she wrote things that she didn’t and that you are personally attacking her for something she didn’t do.
Please desist from personal comments about Dr. Tuteur. If you have evidence that something she wrote was incorrect, you can provide your own counter-evidence without being insulting.
Fifi,
1) Thoughts most certainly can affect organs other than the brain. For instance, one effect of chronic stress is hypertension.
2) I can’t figure out what you’re trying to say either. Amy says the brain is a physical organ, so any treatment for depression, no matter what it is, produces its effects by modifying the brain. She specifically says that talk therapy works. “To the extent that talk therapy of any kind works, it works through biochemical processes.” If you aren’t a dualist, what are you arguing with? If you aren’t claiming that talk therapy works by magic, or through the mediation of the soul, but you disagree that it works through biochemical processes, I don’t understand what you’re saying. Are you saying that neuroplasticity isn’t biochemical?
Dr Hall – Yes, I understand you’re a staunch supporter of Dr Tuteur and share many of her views regarding the controversial subjects she likes to post about. If Dr Tuteur wants to be treated with respect, she can start by extending the same respect to others. Instead, she indulges in ad hominem attacks and irrelevant accusations (not only directed at posters but also other scientists) that have absolutely no grounding in evidence. She has a tendency to infer things then claim she never said them, or to not consider the context and then misrepresent something by ignoring the context – it’s dishonest and she’s already been called on it in this thread. You may not have noticed but even some of the other SBM bloggers have questioned Dr Tuteur in this thread. I’m sorry if criticisms of Dr Tuteur are personalized for you because you share some of the same views. You seem very invested, are you the one who proposed she would make a good blogger for SBM or is it just because you share her perspective?
Quite frankly, the only problem I saw in what Dr. Tuteur wrote was her implying cherry picking of studies by the meta-analysis authors based on her apparently being unaware of a form of meta-analysis that requires patient-level data. I’ve already made my criticism explicit, called her out on it, and am done. I don’t want to rehash that whole issue again.
Otherwise, I agree for the most part with Dr. Tuteur’s contention that the authors of this particular meta-analysis went too far in their public statements about their study.
Dr Gorski – “I agree for the most part with Dr. Tuteur’s contention that the authors of this particular meta-analysis went too far in their public statements about their study.”
They may well have but certainly no further than pharmaceutical companies have gone in their public statements endorsing SSRIs outside of evidence.
Ben Goldacre’s take on the issue which put this kind of meta-analysis into the context of the broader evidence and debate, including the attempts by drug companies to bury or manipulate evidence, is an example of good SBM writing and analysis. Taking one meta-analysis out of context of the greater debate is, in many ways, cherrypicking.
http://www.badscience.net/2008/02/619/
If Dr Tuteur merely wanted to discuss the media aspect of this, she’s also cherrypicking one NYT’s article while ignoring another which actually is critical of the study.
http://www.nytimes.com/2010/01/12/health/12mind.html
If Dr Tuteur is going to call out others on being irresponsible, cherrypicking or promoting a professional bias, then why shouldn’t she also be called out on doing the same thing? Dr Tuteur isn’t simply questioning the study in her post, she’s inferring that the study is psychiatry bashing when she’s actually misrepresenting psychiatric practices herself by promoting the idea that psychopharmacology is the only effective tool used by psychiatrists. She’s also misrepresenting psychology because many psychologists do work in tandem with GPs and psychiatrists to prescribe drugs.
Straw man.
Where on earth did you get that idea? I criticized one aspect of the post, and even I didn’t see that as a problem. Dr. Tuteur never said any such thing, as far as I can see.
Fifi has chosen to interpret my comments as biased. Instead of understanding my plea to avoid ad hominems and stick to discussion of content, she just indulges in more ad hominems, now also directed at me. I am not “invested” in anything except science and reason. And polite discussion and fair treatment. I don’t agree with everything Dr. Tuteur says, and I second Dr. Gorski’s comments, but I think Dr. Tuteur has been attacked unfairly.
Oh please, first she infers that the psychologists who did the study have a professional bias (without providing any evidence), then she says that “to the extent that talk therapy of any kind works” which infers that cognitive and interpersonal therapies work to a questionable or limited extent. And yet she’s getting outraged that anyone is questioning the extent to which SSRIs work, when there really isn’t solid evidence that risk outweighs harm when it comes to using SSRIs for mild depression. (See Ben Goldacres analysis for a more evidence based assessment that Dr Tuteur’s.)
Dr Gorski – “Certainly that’s how I interpreted it, namely that Dr. T was assigning nefarious motives to the researchers with regard to how they designed the study, although I agree with her that in their public statements they went beyond what the study could justify.”
And, really, accusing me of being a dualist and lecturing me about the physical effects of cognitive and interpersonal therapy on neurobiology when I was the one that introduced that information to the thread in the first place is being deceptive and yet another example of how she tries to paint anyone who doesn’t agree with her or who critiques her posts as being some kind of woomeister. It’s particularly galling considering the fact that she’s not even standing up for SBM in psychiatry!
Fifi on 08 Feb 2010 at 12:15 pm
michele – The nature vs nurture debate is pretty much dead in the water at this point for the most part, it’s quite widely accepted that both nature AND nurture are involved in brain development…that’s what neuroplasticity is all about. The field of epigenetics is very specifically about nature and nurture.
Hmmm, if you were a parent dealing with any sort of behavior, learning or mood issue with your child, I would guess that you would soundly disagree that the nature vs nurture debate was pretty much dead.
In fact as a parent of two children who lived in orphanages for the first 1-2 years of their lives as well as a child born with congenital differences, I would say there is still a lot to be discovered or discussed about the interplay between genetics and environmental factors (prenatally as well as throughout life).
Would I defend a a position that say things are all genetic or all environment. Nope, but that is not what interests me. What interests me is picking out where the interdependencys are and using that to solve problems.
Fifi
“BillyJoe, I’m not sure if you’re joking or not. I’m hardly a dualist and it’s not a dualist position to propose that the brain is shaped by our thoughts and actions.”
I was not joking.
But I was commenting on Lawrence’s retort to Amy, not on anything you said. Here, again, are the quotes I was responding to:
Amy said: “To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.”
Lawrence said: “It’s especially unfortunate to see, in that last quoted sentence, a declaration of ignorance and an assertion of absolute certainty derived from that ignorance.”
See, you are not mentioned anywhere!
I agree that neuroplasticity is not a dualist position.
But what Lawrence said suggests that he is a dualist. At least I don’t know how else to interpret it. Whether he is or he isn’t, I suppose he will come back and justify his retort.
michele – “In fact as a parent of two children who lived in orphanages for the first 1-2 years of their lives as well as a child born with congenital differences, I would say there is still a lot to be discovered or discussed about the interplay between genetics and environmental factors (prenatally as well as throughout life).
Would I defend a a position that say things are all genetic or all environment. Nope, but that is not what interests me. What interests me is picking out where the interdependencys are and using that to solve problems.”
I agree, there’s certainly still a lot to be discovered regarding what is genetic and what is environmental when it comes to brain development (and associated issues such as behavior, personality, etc). My point was merely that we’re well beyond the point where anyone proposes that brain development is purely based in nature or nurture, the scientific understanding at this point is that both play a role.
BillyJoe – You may be right about Lawrence, I have no idea. I’ll admit that I was pretty pissed at being accused of being a dualist and proposing some kind of magic when I’d introduced the neurobiological effects of cognitive and interpersonal therapies up thread. Because Dr Tuteur seemed to be aiming the slur in my direction, I obviously personalized your response to Lawrence. My apologies.
Fifi,
I have to agree with some of the comments about you by others, but I sort of understand. Like you, I also tend to read too much into what Amy writes and assume things she hasn’t actually said. I think this could be corrected somewhat if she would place her comments in the context of her general thoughts on the subject so that we know where exactly she is coming from. However I have now made allowances for this and don’t assume anything about her views unless and untill she specifically gives voice to them. I’m actually suprised at how often I agree with her compared with my initial impressions. My remaining slight irritation is that she tends to try to explain away or gloss over mistakes instead of acknowledging them outright, but I guess we are all quilty if that to a greater or lesser extent.
regards,
BillyJoe
Fifi, to restate my comment upthread:
I can’t figure out what you’re trying to say. Amy says the brain is a physical organ, so any effective treatment for depression, no matter what it is, produces its effects by modifying the brain. She specifically says that talk therapy works. “To the extent that talk therapy of any kind works, it works through biochemical processes.” If you aren’t a dualist, what exactly are you arguing with? If you aren’t claiming that talk therapy works by magic, or through the mediation of the soul, but you disagree that it works through biochemical processes, I don’t understand what you’re saying. Are you saying that neuroplasticity isn’t biochemical?
BillyJoe – What Dr Tuteur does is infer things and then deny them, it’s a very common tactic used by people who promote woo. (We saw lizkat doing that repeatedly regarding HIV.) The fact that Dr Tuteur then tries to explain away or gloss over things when she makes a mistake or is called on a bias seems highly problematic to me on an SBM blog. (Just as the way she begrudgingly acknowledged that cognitive and interpersonal therapies have a biological effect eventually is problematic because of the way she did so.) After all, isn’t it central to science and discussion of science to be able to admit a mistake or a bias when it’s pointed out? Needing to be right at all costs or pretending to know everything is the realm of ideology and not science.
Yes, I’ve developed a very strong aversion to Dr Tuteur and the way she tries to use SBM without actually respecting SBM. If she didn’t use the tactics mentioned above, I wouldn’t feel the need to point them out or discuss how they get in the way of promoting SBM and engendering public trust of science and medicine. It’s a shame because there really aren’t that many good sites to send people to as reliable sources of good information regarding medical science. I guess I’ll stick with going off continent to Ben Goldacre and other writers who are actually interested in educating the public and promoting good science.
BillyJoe,
I’m not sure I am clear on what you mean by “dualist.” Would you kindly provide a working definition in context?
Alison – What she does is concedes, very after the fact and long after it was first raised, that talk therapy works and has a neurobiogical effect (or might work a little bit is what her phrasing really infers). She does so in the context of accusing me of being a dualist for bringing up cognitive and interpersonal therapies as being effective means to treat depression alongside drugs. Yes, she’s finally agreeing with me but is doing so in a way that makes out that she’s introducing this information and that I didn’t! And then goes on to accuse me of proposing that talk therapies are somehow magical and I’m a dualist! In light of the fact that she inferred in the original post that psychotherapists – who practice talk therapies – skewed the meta-analysis results out of some kind of professional competition with psychiatrists, it’s a bit late in the game to try to backpedal and pretend she’s not actually working from a biased perspective. On top of it, it’s just plain silly since psychiatrists also use talk therapies in their practices and also question the actual efficacy of SSRIs (particularly in light of how how drug companies keep getting caught misrepresenting the evidence and how heavily they promote this pseudoscience to the media).
“I think this could be corrected somewhat if she would place her comments in the context of her general thoughts on the subject so that we know where exactly she is coming from.”
I shared my general thoughts on this subject up thread:
It seems to me that the data in total indicate that treatment of depression (whether mild, moderate or severe) needs to be individualized. Moreover, the combination of both modalities (talk therapy and medication) can be more effective than either alone.
Trying to decide which modality is “more” effective strikes me as making as much sense as trying to decide whether diet and exercise vs. insulin is more effective in treating type I diabetes. Both are integral components of care, and, as in the case of depression, the relative contribution of each modality is highly dependent on the individual and his or her clinical situation.
Fifi,
“She does so in the context of accusing me of being a dualist for bringing up cognitive and interpersonal therapies as being effective means to treat depression alongside drugs.”
You really need to get a grip. I was never referring to you in my comments about neurochemistry; I was responding to Lawrence C. and did not have you in mind at all.
Perhaps this can be a lesson to you. You read far too much into my writing, going so far as to imagine that I am criticizing you when I am quoting someone else and addressing his comment.
# Fifion 08 Feb 2010 at 3:08 pm
“Oh please, first she infers that the psychologists who did the study have a professional bias (without providing any evidence), then she says that “to the extent that talk therapy of any kind works” which infers that cognitive and interpersonal therapies work to a questionable or limited extent.”
Well the common quoted statistic on CBT and SSRI for depression are CBT success rate 50% of the time, SSRI 50% of the time, Combination of the two 90 -100 %. I don’t know the study or the data, that is just the statistics I always see in articles or news.
To be fair, Dr. T. comment did follow a discussion of the pros and cons of CBT and how some people do not see good results with it (50% of them I presume) So, within the context of that discussion I think that is a fair sum up of CBT. I did not take it as a “tell” that she thought it didn’t work. The phrase allows that it does not work for some.
In conclusion, it is hard to have a real discussion on any topic when the subtext is “proving Dr. T is bad.”
#
# Lawrence C.on 08 Feb 2010 at 4:07 pm
BillyJoe,
I’m not sure I am clear on what you mean by “dualist.” Would you kindly provide a working definition in context?
Thank you! I have no idea what that means either. Is it another word for gunslinger?
Dr. Teuteur:
Then let me be clearer since my earlier remark seems to have produced a tangent and an injured bystander.
I have no objection at all to the scientific description of the functioning of the human brain (and nervous system) on a physical level, but I would maintain that to take consciousness as being limited to that physical mechanism is a metaphysical belief, rather than a scientifically proven fact.
Neurobiology is a very young field of study and while most promising it does not itself make the absolute claims you asserted in this post. To be fair, the assertions seem more like general comments than germane points. Such is the delight and peril of the blog.
“I would maintain that to take consciousness as being limited to that physical mechanism is a metaphysical belief, rather than a scientifically proven fact.”
What support do you have for that claim?
Alison
“1) Thoughts most certainly can affect organs other than the brain. For instance, one effect of chronic stress is hypertension. ”
Also, I think stress is believed to induce flare-ups in most auto-immune disorders. Type 1 diabetes is a autoimmune disorder.
Dr Tuteur – That’s a much more reasonable position than you expressed in your original blog post. If you’d actually included that in your original post – rather than inferring (intentionally or accidentally) that there were nefarious intentions on the part of the psychologists who performed the meta-analyis there would have been no need for anyone to call you out for doing so.
Dr Tuteur – “Trying to decide which modality is “more” effective strikes me as making as much sense as trying to decide whether diet and exercisevs. insulin is more effective in treating type I diabetes.”
Why? Isn’t the whole point of SBM to discern what treatments are effective and which ones aren’t? Certainly in a clinical context of individual treatment it’s about the individual but that’s not what clinical trials focus upon, they’re not an N of 1. Are you proposing that it’s futile to conduct clinical trials? Or should we be acknowledging the complexity of depression and treating depression and taking this into account (and the heightened influence of the placebo effect) when we design clinical trials? After all, if an SSRI does prove to provide no more help than a placebo in mild depression, isn’t it bad medicine and not SBM to promote their use?
Um, Dr Tuteur you were responding to Lawrence here, why did you start out quoting me?
10 at 1:34 pm
“And, no, depression isn’t “just like diabetes” since depression involves both the body and mind …”
Yes, it is just like diabetes in that both have a biochemical basis. Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes. There is no magic to the mind, and no special “essence.”
To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.
What support do you have for that claim?
The entire copus of neurobiological literature. In that ink-wet body, some things are apparently understood, much is hypothesized, and speculation of all kinds runs rampant. It is obvious that most ideas have not been proven as fact. It would be tempting to take current, exciting trends in this field and derive certainty from them but that would be a belief rather than a logical conclusion.
In the context of this post and also something you might appreciate, one need only look at the physician’s prescribing information for SSRI’s. Almost without exception, the language used to describe the mechanism of action of each drug goes like “It is presumed that…” or “It is supposed that…” or even “It is believed that…” This is hardly the language of certainty, and even goes to support your point here that the authors of the study in question really did reach an unsustainable conclusion.
Incidentally as regards some of the other comments, I am not advocating nor saying “Look, Magic!” As one kind of example, in terms of what is generally referred to as “matter,” medical science usually deals with it on the gross level. It is quite theoretically possible that what we call “mind” or “consciousness” exists on the quantum level. Such an existence would certainly seem “magical” to many people but I am hopeful that science will provide greater insight into this “matter.”
“The entire copus of neurobiological literature.”
That’s not an argument. You’ll have to do better than that if you want to persuade us to accept your claim.
@Lawrence:
And you have just defined ‘dualism’ for yourself, by supposing that mental functions (i.e. consciousness) are in some way non-physical.
I, on the other hand, would maintain that to take consciousness as NOT being limited to the functions of the brain is a metaphysical belief, and that it is contingent upon those (such as, it would seem, yourself) who believe otherwise to provide support for this claim. Occam’s Razor and all that, you know.
@Fifi–
For what its worth, I read your statement:
as dualist-ish, in that you seemed to be making a distinction between the body and the mind. I do, however, agree with what I think you were driving at, to wit that, although there are numerous examples of psychological effects on all manner of physical illnesses, mental illness as a freestanding complaint (rather than as a symptom of another physical ailment like cancer) seems uniquely reliant upon subjective reporting and/or assessment of behaviors and feelings to diagnose.
Logically, no. Lawrence C. is addressing the commonly held opinion that the mind is nothing more than an emergent property of complex biochemical processes (which, IMHO, does not exclude the capacity for voluntary action, although some uglier formulations of the hypothesis have suggested that mind is a useless epiphenomenon). He is not claiming to know that this belief is wrong – if he were, then it would be his job to supply evidence . He is only claiming that neuroscience assumes this to be a fact but has not yet proven it. If you think that this has been scientifically proven, it is for you to supply, at least, a reference to a review publication. (The fact that you can’t, presuming you can’t, is no evidence that some form of the hypothesis isn’t true. Something can be very likely, and yet very hard to prove. However, if we are told that we must believe it despite the absence of proof, it starts to look a lot like a religion….)
Sorry, that was for Dr. Amy.
“He is only claiming that neuroscience assumes this to be a fact but has not yet proven it. If you think that this has been scientifically proven, it is for you to supply, at least, a reference to a review publication.”
No, the burden of proof is his. He is the one claiming that the function of the brain involves processes that differ from the biochemical basis of every other bodily function.
apteryx,
I read it the other way around. You can’t prove a negative, so Amy can’t prove that a non-physical soul does not exist.
The opposite is possible, though. Someone who believes in a non-physical soul just has to prove its existence and all but a few contrary denialists will accept the evidence. Simple!
I am a frank dualist myself. My argument is ignorance: I don’t understand what it means to be me… therefore it must be teh Solz! I know this is a risible argument, never fear. Occam’s razor states that an explanation must be the simplest one that explains the evidence, and no simpler. From ignorance I assert that biochemistry is too simple an explanation for my me-ness, but since a posited non-physical soul cannot generate hypotheses it’s a pointless concept. Certainly it adds exactly nothing to any discussion of practical problem-solving of any kind, so in a clinical context (and almost any other context I can think of) Occam decrees that no, there is no non-physical soul. Whether you think there might be one or not, for practical purposes there is not. Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.
“And you have just defined ‘dualism’ for yourself, by supposing that mental functions (i.e. consciousness) are in some way non-physical.”
Sadly that is no where near as exciting as Val Kilmer rendition of Doc Holliday in Tombstone. “I’ll be your huckleberry”My very favorite dualist.
“Whether you think there might be one or not, for practical purposes there is not. Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.”
That is pretty much were I ended too. I don’t need proof regarding a non-physical souls existence or non-existence. I only need to know why it would matter in terms of the current problem. Unless someone shows me how, it doesn’t matter.
Apteryx’s post at time index 5:50 pm is what I was aiming at and I thank Apteryx for putting it in clearer terms than I was using.
He is only claiming that neuroscience assumes this to be a fact but has not yet proven it.
That’s it. Full-stop.
Laurence said: “I’m not sure I am clear on what you mean by “dualist.” Would you kindly provide a working definition in context?”
A materialist assumes that everything is physical.
A dualist believes that, as well as the physical, there is also the non-physical (or immaterial, or spirit).
michelleinmichigan said: “Thank you! I have no idea what ["dualist"] means either. Is it another word for gunslinger?”
Yes….without bullets!
Lawrence said: “I would maintain that to take consciousness as being limited to that physical mechanism is a metaphysical belief, rather than a scientifically proven fact.”
It is neither.
In fact, it is the underlying assumption of science that only the physical exists and the proof is a work in progress.
Lawrence said: “I am not advocating nor saying “Look, Magic!””
If you assume anything other than the physical, yes you are.
” As one kind of example, in terms of what is generally referred to as “matter,” medical science usually deals with it on the gross level. It is quite theoretically possible that what we call “mind” or “consciousness” exists on the quantum level.”
But quantum objects are physical objects.
“Such an existence would certainly seem “magical” to many people but I am hopeful that science will provide greater insight into this “matter.””
Lots of physical or material things seem magical, but the underlying assumption is that they are not. So far, nothing has turned up to invalidate that assumption.
apteryx said: “Lawrence…is only claiming that neuroscience assumes this to be a fact [that the mind is nothing more than an emergent property of complex biochemical processes] but has not yet proven it. If you think that this has been scientifically proven, it is for you to supply, at least, a reference to a review publication.”
Not only neuroscience, but the whole of science, is predicated on the assumption that everything is physical. Physical objects cannot interact with the non-physical, so that puts the non-physical outside the scope of science. And that is why science assumes that everything is physical. So far nothing has appeared to challenge or invalidate that assumption.
The corollary is that once you resort to non-physical explanations, you are no longer doing science.
Lawrence said: “Apteryx’s post…is what I was aiming at and I thank Apteryx for putting it in clearer terms than I was using.
He is only claiming that neuroscience assumes this to be a fact but has not yet proven it. That’s it. Full-stop.”
Science is a work in progress and so far that assumption has held up. On the other hand, as soon as you assume the non-physical, that’s when you come to a grinding fullstop.
Should “physical” be understood to be identical with “biochemical”? In every instance? Or simply in relation to this instance (discussion of brain/mind)?
Plonit on 09 Feb 2010 at 6:04 am
Should “physical” be understood to be identical with “biochemical”? In every instance? Or simply in relation to this instance (discussion of brain/mind)?
I was thinking the same thing myself. But I came to the conclusion that biochemical is such a broad term I think it would be quibbling to take exception with it without stating the particular physical attribute that one is reffering to.
Electrical? but I think that would be included in chemical. Magnetic? Honestly, my human biology is so sketchy I can not make a credible suggestion.
I would think those biophysicists who are not biochemists would be pretty pissed off to think that the former could be reduced to the latter. Electrophysiology is quite an important area of neuroscience (but not only neuroscience). We don’t completely know how the brain works, but from what we know we can certainly say it is not ALL biochemistry without any recourse to belief in non-physical entities.
“Should “physical” be understood to be identical with “biochemical”?”
No. It’s meant to exclude anything that cannot be apprehended with our five sense; in other words, it’s meant to exclude “life forces,” souls, and other spiritual concepts.
Yes, the methods of science can only deal with physical things; that doesn’t prove that all things are physical, although it is fine to operate on the assumption that they are in order to work on the things you can work on, so to speak. The range of phenomena in the physical universe that can be perceived and explored has increased greatly, and I wouldn’t assume that we have reached the theoretical limit.
I may have too generously, or broadly, represented the non-dualist position in saying that they think mind is an emergent property of chemistry. That’s actually my own opinion. I don’t believe I have an “immortal soul,” but I do think that we (and other complex animals) have a capacity for voluntary, deliberate decision-making, and that our emotional lives represent something more than meaningless neuron-firing.
Some reductionists deny those things, which suggests that they think there are no emergent properties, and we’re just a slightly more complex version of the chemical soup that makes up a nematode’s “mind.” Those individuals argue that anything we perceive as deliberate choice, for example, is really the operation of a carbon-based mechanism over which “we” (the very concept of selfhood then being problematic) have no control. And we are supposed to believe this because they are sure neuroscience will prove it any decade now. Well, that’s not how it works. Proof comes first; belief follows.
It’s meant to exclude anything that cannot be apprehended with our five senses
++++++++++
Ermm, oh dear.
There is quite a lot of scientific discoveries that cannot be apprehended directly by the physiological senses (which I assume you know number far more than five) but are surmised by our “sense of logic” on the basis of sensory input concerning their effects.
# Ploniton 09 Feb 2010 at 8:31 am
“I would think those biophysicists who are not biochemists would be pretty pissed off to think that the former could be reduced to the latter. Electrophysiology is quite an important area of neuroscience (but not only neuroscience). ”
Yup, I’m always irritating those biophysicists. They give me no end of trouble.
# apteryx on 09 Feb 2010 at 10:14 am
“Those individuals argue that anything we perceive as deliberate choice, for example, is really the operation of a carbon-based mechanism over which “we” (the very concept of selfhood then being problematic) have no control.”
I’m going to haul this back to CBT. One method of CBT for OCD (obsessive compulsive disorder) is to increase the awareness that the obsessive thoughts and the need for compulsive behavior are not generated by the individuals mind (as it feels), they are generated by a flawed mechanism in the brain.
So, someone with OCD feels that it is unsafe to leave the house without checking the door. If they feel that way, it must be unsafe and therefore good to check the door. The understanding that the feeling is not a true signal of danger but a misfired habitual brain mechanism can be helpful in breaking the OCD cycle.
I think this is not a great explanation. For a better explanation check out the book Brain Lock by Jeffrey M. Schwartz.
Amy said: “It’s meant to exclude anything that cannot be apprehended with our five senses”
Plonit replied: “There is quite a lot of scientific discoveries that cannot be apprehended directly by the physiological senses (which I assume you know number far more than five) but are surmised by our “sense of logic” on the basis of sensory input concerning their effects.”
If Amy is actually saying anything different I would be quite surprised. The clue is in the length of her sentence compared with the length of your reply.
Michelle makes a good point, in OCD, there is a “feeling” that one is unsafe without checking the door. The feeling is a real feeling, but the feeling does not correspond with the objective reality of safety regarding door checking.
This is a generic problem when we rely on “feelings” for input to how we should think or act.
The feeling is a physiological signal indicating a physiological state and the brain has evolved to take such signals seriously because at times they can be the difference between life and death.
Many people use their intellect to match their world view to how they feel. Skeptics use their intellect to match their world view with reality independant of how they feel.
Danio – “As dualist-ish, in that you seemed to be making a distinction between the body and the mind. I do, however, agree with what I think you were driving at, to wit that, although there are numerous examples of psychological effects on all manner of physical illnesses, mental illness as a freestanding complaint (rather than as a symptom of another physical ailment like cancer) seems uniquely reliant upon subjective reporting and/or assessment of behaviors and feelings to diagnose.”
There is a distinction to be made between the brain and the mind, they’re just not independent and one is an organ and the other is a product of that organ (well, I suppose we could argue that a dead brain can’t create mind so exists apart…but since we’re discussing living human beings let’s stick with the idea that brain and mind are interrelated – um, silly experiments with dead salmon aside
. The mind is the product of the brain, it’s how we experience all those neurochemical events and the illusion that is “me” that helps us navigate the world (and creates all kinds of narratives to allow us to do so, the brain is a meaning machine). That doesn’t in any way mean that the mind can exist without the brain and I in no way am proposing that and never have been.
My point was that there’s a special relationship between what we experience as our mind and the organ that we call the brain which generates the experience of mind. We can change the actual structure of our brain by how we use our mind – this is a direct influence of a much larger magnitude than changing stress responses which, as a side effect, may influence other organs and systems (not that anything in the body works in isolation, of course).
A better example than diabetes is cancer. We can’t cure cancer simply by using our thoughts – as much as woomeisters like to promote that idea. Certainly we can change stress responses through being mindful and that can have all kinds of positive or negative effects on health as a result, that’s more of a side effect than a main effect. We can’t just think away diabetes – or a brain tumor for that matter. There are limits to the ability of our mind to influence our brain structure too, we just don’t know what they are yet.
I’m by no means saying anyone shouldn’t use drugs if they need to or want to (be that for health or recreational purposes, I’m not opposed to people chemically engineering their intelligence…what people do with their brains is their own business in my opinion). Or use other treatments like deep brain stimulation (which some people find much more effective than pharmaceuticals for severe depression).
Mental illness is diagnosed on two subjective measures – how the patient feels (their experience of themselves and life) and how they function within society (also not a purely objective measure by any means). The same is true of chronic pain. At the moment, there are no viable objective physical tests to diagnose either. There are for diabetes and cancer. Also, cancer and diabetes aren’t diagnosed regarding how we relate to other people or function in society – there’s no social or cultural component vis a vis the diagnosis. There most definitely are regarding depression and chronic pain (at this point in time). Mental illness is much more complex than cancer or diabetes because it does have cultural and social components, it’s not just about the individual but how the individual feels and functions in their social environment.
It IS tempting to try to reduce mental illness to being merely a brain problem or a chemical imbalance for many reasons (one being that it gives us a sense of control, us humans like that). However it really is missing the bigger picture and ignoring the very basic fact that we’re social animals. We’re just apes, as much as we cling to (mainly religious) ideas of being incredibly different from other animals and special. One function of our brain is to create a mind that perceives us as being important in our own right, as having a heroic narrative and cosmic meaning/significance. It’s really an illusion – the universe doesn’t care (it’s not human), only we care about humans, our place in the universe and finding meaning. It’s this desire for meaning that tends to cause us existential angst when we can’t find any. Isn’t a major component of depression a loss of sense of meaning and purpose, a loss of appreciation of life and joyous experience?
BillyJoe – “If Amy is actually saying anything different I would be quite surprised. The clue is in the length of her sentence compared with the length of your reply.”
She may MEAN the same thing but what she’s saying is what she’s saying. We use the scientific method explicitly so we’re not just relying upon our “five senses” (which are a very subjective).
Alison – “Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.”
Since when is talk therapy and psychiatry not part of medicine? (Talk therapy is actually a bit of a misnomer, cogntive behavioral therapies and interpersonal therapies are more accurate terms since there’s not alway a lot of talking with CBT.) Biochemistry is part of an explanation for the treatment of depression with CBT and interpersonal therapies, it’s by no means really a complete explanation (and by this I’m not talking about magic or denying the biochemical component, I’m just pointing out that there are social, interpersonal and cognitive components that need to be considered to for any explanation to be adequate and complete).
apteryx,
“Yes, the methods of science can only deal with physical things; that doesn’t prove that all things are physical”
No, it is an assumption that has, so far, stood the test of time.
“…although it is fine to operate on the assumption that they are in order to work on the things you can work on, so to speak.”
Exactly. Making that assumption is the basis of science that has allowed scientist to find things out instead of wallowing in ignorance.
“The range of phenomena in the physical universe that can be perceived and explored has increased greatly, and I wouldn’t assume that we have reached the theoretical limit.”
We certainly haven’t, and we probably never will. The uiniverse may end too soon. The human mind may be incapable of understanding everything (maybe to the same degree that an ant is incapable of understanding quantum physics). But it is the only way to learn anything.
“I may have too generously, or broadly, represented the non-dualist position in saying that they think mind is an emergent property of chemistry.”
That’s about right I would have thought.
And chemistry can be defined as physics plus emergent properties.
“I don’t believe I have an “soul,” but I do think that we…have a capacity for voluntary, deliberate decision-making, and that our emotional lives represent something more than meaningless neuron-firing.”
(I have reduced your “immortal soul” to “soul”, but if it makes a difference I apolgise.)
It requires cognitive dissonance to hold those two views simultaneously. The “self” does not exist in science. It is a metaphysical concept like the “soul”. What exists is an “illusion of self”, but the illusion is so good that the “self” really does believe it exists. Unfortunately, it is just the physics and chemistry and biochemistry and paterns of neural firings of the brain that produces this illusion of self.
“Some reductionists deny those things, which suggests that they think there are no emergent properties”
I don’t think there are many reductionists of that type. The existence of emergent properties are undeniable. The assumption remains, however, that they are physical. As long as we keep assuming that, we may make progress. To assume anything else is to continue to wallow in ignorance.
“Those individuals argue that anything we perceive as deliberate choice, for example, is really the operation of a carbon-based mechanism over which “we” (the very concept of selfhood then being problematic) have no control.”
They are correct. That is the view of science, that is to say, that is what the scientific evidence says. Some of us just don’t like to outrun the evidence, we leave that to people of faith.
“And we are supposed to believe this because they are sure neuroscience will prove it any decade now. Well, that’s not how it works. Proof comes first; belief follows.”
No, that is not correct. We are not sure that it will be proved. We believe that this is the only way forward. To assume that everything is physical is the only way forward. And we are sure of this belief of that because the evidence for it is incontrovertible.
regards,
BillyJoe
“Many people use their intellect to match their world view to how they feel. Skeptics use their intellect to match their world view with reality independant of how they feel.”
Yes and I know this is beside your point but I want to be clear that the majority of skeptics have never had to cope with the symptoms of OCD and that being skeptical is only one fraction of the CBT treatment of OCD.
In other words, I don’t want to be dismissive of OCD as only being a condition of trusting your feelings non-skeptically. It is much more complex than that.
In fact, the hallmark of OCD (as opposed to OCPD) is that people have self-awareness of the problem. So they are questioning their anxiety, they just do not have the tools to free themselves.
Alison – “Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.”
Since when is talk therapy and psychiatry not part of medicine?
The word ‘medicine’ can mean a lot of different things in different contexts. Here I meant drug therapy as opposed to, for instance, surgical therapy. Feel free to substitute ‘drug therapy’ for ‘medical therapy’ if it helps you understand my meaning.
(Talk therapy is actually a bit of a misnomer, cogntive behavioral therapies and interpersonal therapies are more accurate terms since there’s not alway a lot of talking with CBT.)
Fifi, give me a correct word or short phrase that groups together all those therapies that use some form of communication as the intervention (as opposed to, say, drugs, surgery, radiation or lifestyle modification) and I’ll use it. I am trying to be general here. I don’t want to have to say “Biochemistry is a fully adequate explanation of the treatment of depression with drug or [long and exhaustive list of every single school of psychological intervention that has ever existed] therapy” to make a simple point.
Alison – Um, you used the term “medical” – it covers all kinds of medical treatments and procedures, not just drugs. Surgery, physiotherapy, psychotherapy and drugs are all “medical”. It’s good to understand what a word means so as to avoid creating misunderstandings. “Medical” is not equivalent to “medicine” as it is used when it refers to drugs. You inadvertently claimed that psychiatry isn’t medical so ended up saying something other than you apparently intended.
Sometimes trying to be simplistic or to generalize actually confuses things and misses the point when something actually has a slightly higher level of complexity. It can create more confusion to try to pretend something that has a level of complexity is simple or to generalize where there is actually a need for specificity. Prescribing drugs also requires communication between patient and doctor. What you don’t seem to understand is that CBT and interpersonal therapy work quite differently, CBT doesn’t even always involve much talking (the vast majority of the work in many cases is done by the patient outside of meeting with the therapist). If you don’t really understand what you’re talking about, you’re not really making a point (simple or otherwise) – you’re offering up an uninformed opinion about something you don’t actually understand. You’re entitled to your opinion, of course, but the fact that you don’t seem to understand the different between CBT and interpersonal therapy (and think you need to list every single form of psychological intervention) simply means you don’t understand what you’re talking about enough to know whether biochemistry is an adequate explanation or not.
Sometimes trying to be simplistic or to generalize actually confuses things and misses the point when something actually has a slightly higher level of complexity.
Hemingway and e.e. cummings are not simple. They just used fewer words. Sometimes you have to assume the reader is bright and will figure it out.
Surgery, physiotherapy, psychotherapy and drugs are all “medical”.
Yes, in many/most contexts you are absolutely correct.
“What you don’t seem to understand is that CBT and interpersonal therapy work quite differently.”
You will be happy to learn that I understand that very well, which is why I was so frustrated when I sought CBT and was offered some other school of something. But they have more in common with one another (both can be offered outside a medical practice by non-medical person; the non-medical person who offers them is often a clinical psychologist; neither directly modify the body or its function) than they do with drugs or surgery.
michele – “Hemingway and e.e. cummings are not simple. They just used fewer words. Sometimes you have to assume the reader is bright and will figure it out.”
They wrote fiction, they weren’t trying to communicate facts – there’s a very big difference. If you intend to say one one thing but use words that have a different meaning than what you intend to communicate, you’re actually saying something other than you intended (this is as true of fiction as it is non-fiction, it just doesn’t matter as much if one is constructing an imaginary world as it does when one is trying to accurately discuss or describe the real world). The fault doesn’t problem doesn’t lie with the reader in this case, it lies with the person doing the writing or speaking who doesn’t actually know what they’re saying. Really, saying or writing what you actually mean is communication 101. In medicine it’s particularly important for a wide variety of reasons – people can die if a doctor gets it wrong, for instance. (Obviously not the case here regarding Alison’s slip up – which is hardly the end of the world but it does raise questions if she just doesn’t quite understand what she’s talking about or if she’s expressing a subconscious belief that psychotherapy isn’t a part of medicine and a medical treatment.)
“but the fact that you don’t seem to understand the different between CBT and interpersonal therapy (and think you need to list every single form of psychological intervention) simply means you don’t understand what you’re talking about enough to know whether biochemistry is an adequate explanation or not.”
IMO – I don’t understand the need for this attack. It is downright ungracious. I think it should be possible to have a cordial disagreement without trying to make out that another commenter doesn’t know what they are talking about. Particularly over the use of one word or an innocuous phrase.
Really, FiFi – If you throw every pitch directly at the batter’s head, the game is no fun.
Alison said – “But they have more in common with one another (both can be offered outside a medical practice by non-medical person; the non-medical person who offers them is often a clinical psychologist; neither directly modify the body or its function) than they do with drugs or surgery.”
Yes they do have a lot in common. In fact two of the three therapists I saw used techniques from both CBT and IPT to address different problems. It is all psychotherapy, which I think can be called talk therapy in the vernacular (I’ve always wanted to used that word.)
The relationship is very similar to other medical/therapy systems. My son sees Doctors and Surgeons for his speech issues. He also sees a speech therapist (well, three actually) who are supposed to coordinate as needed with the Doctor or Surgeon.
The quality offering of speech therapist is very broad. They all have the same degree but can have widely different approaches and widely different specialties (aphasia, language disorders, articulation, hearing related, etc). So while speech therapy is essential for speech issues, it can actually be very hard to find the appropriate therapist.
And this is one advantage I see of a drug over a therapy applied by a human. The drug is consistent from patient to patient, practitioner to practitioner. This is not to say therapy doesn’t have other advantages over drugs.
Alison – “But they have more in common with one another (both can be offered outside a medical practice by non-medical person; the non-medical person who offers them is often a clinical psychologist; neither directly modify the body or its function) than they do with drugs or surgery.”
Certainly there are psychologists who work outside of the framework of medicine, there are also MDs who do this too (who often get taken to task by the bloggers at SBM). The point, which you seem to be missing entirely and arguing against, is that CBT does directly modify the brain (when done properly) as do other mindfullness practices such as meditation. Interpersonal or dynamic therapies can too. This is what neuroplasticity is all about! You can certainly argue that there is no biological effect and deny neuroplasticity but you’re certainly arguing a personal opinion and not the current science in this matter.
Clinical psychologists actually developed CBT, though many psychiatrists now use it, and it’s not uncommon that neuroscience departments in universities are connected with or even part of the psychology departments. There are certainly people who call themselves psychotherapists who aren’t clinical psychologists, which is why it’s important to know the qualifications of the person you’re going to see. And, yes, there are bad clinical psychiatrists just as there are bad MDs and bad surgeons who don’t do their job properly. And, like all specialists – be they surgeons or psychiatrists – there’s a tendency to think that all patients are nails because the tool they know how to use is a hammer. (Surgeons are likely to recommend surgical solutions, for instance.)
Your argument is a bit akin to arguing that drugs aren’t medical because they change the body through means other than directly cutting it open such as in surgery. Just because something is less invasive and works directly with changing the body on a more subtle level through less invasive means doesn’t mean it isn’t changing the body.
I use “medical” in the sense of “drug-based” all the time, and especially to distinguish between medical and surgical (disciplines, treatments). I knew what Alison meant in the contrast of medical and talk therapies, and didn’t presume a denigration of the latter.
On the other hand, physical = biochemical, or science as the narrowest variant of empiricism, is truly unhelpful.
michele – “And this is one advantage I see of a drug over a therapy applied by a human. The drug is consistent from patient to patient, practitioner to practitioner. This is not to say therapy doesn’t have other advantages over drugs.”
This simply isn’t true, drugs AREN’T consistent from patient to patient and don’t always have the same effect. (And practitioners have varied levels of knowledge regarding prescribing and managing drug treatments – GPs obviously don’t generally have the same knowledge and ability regarding diagnosing mental illness or prescribing psychopharmaceuticals as a psychiatrist does – that’s why one is a specialist and one is a generalist.) This variability – not to mention the subjective nature of diagnosing many mental disorders – is why it can take so long to find the appropriate drug and dosage for an individual, and why some people have very bad experiences with psychopharmaceuticals while others have very good ones. Finding exactlyt the right medication and dose for an individual patient can sometimes take years – just as sometimes it can be spot on from the start.
Plonit – “I use “medical” in the sense of “drug-based” all the time, and especially to distinguish between medical and surgical (disciplines, treatments).”
I find that an odd usage – perhaps because I grew up around doctors and medicine and have never heard “medical” used in a way that means “drug based”.
I checked it out with a dictionary and you are right that it can be used to exclude surgery or to mean procudures that aren’t surgical. Thanks, I appreciate learning something new – particularly when it comes to a more precise use of language. However, it still includes all kinds of therapeutical modalities other than surgery and doesn’t exlusively mean “drug based”.
http://dictionary.reference.com/browse/medical
med⋅i⋅cal
/ˈmɛdɪkəl/ Show Spelled Pronunciation [med-i-kuhl] Show IPA
–adjective
1. of or pertaining to the science or practice of medicine: medical history; medical treatment.
2. curative; medicinal; therapeutic: medical properties.
3. pertaining to or requiring treatment by other than surgical means.
4. pertaining to or giving evidence of the state of one’s health: a medical discharge from the army; a medical examination.
–noun
5. something done or received in regard to the state of one’s health, as a medical examination.
FiFi said, “They wrote fiction, they weren’t trying to communicate facts – there’s a very big difference. If you intend to say one one thing but use words that have a different meaning than what you intend to communicate, you’re actually saying something other than you intended, etc, etc”
This girl, this plum,
blemished but plump,
it’s cool sweetness,
will go untasted.
Well, I’m in healthcare, if it makes any difference. We (I mean, my hospital) offer (for example) termination of pregnancy and management of missed miscarriage. In those instances, “medical management” = using mifepristone and misoprostol, “surgical management” = D&E
For induction of labour, we could use medical, surgical and mechanical methods (prostaglandins, oxytocin, amniotomy, foleys, membrane sweeps)
Of course, people often use medical to include all of healthcare (including midwifery) and that irritates me more than using it to mean pharmacological, since the former is actually wrong, whereas the latter is correct in context.
“This simply isn’t true, drugs AREN’T consistent from patient to patient and don’t always have the same effect.”
The drug is consistent. The patient is different. Therefore has a different experience and side effect. But you are controlling one side. In therapy both sides vary, different therapist, different patient. If you are not getting a good result with a CBT therapist you may have to look for another CBT therapist (or IPT, etc). If you are not getting a good effect with Paxil you do not try another bottle of Paxil.
If you have a therapy book that would be as consistent as a drug, but would lack the interaction that is advantageous with a therapy practitioner.
I feel you are missing the point because your focus is looking for flaws.
FiFi
Did you get out the dictionary? What is this Scrabble? Am I supposed to be counting points here? I missed that part of the game. Where is the triple letter score in this comment box?
And of course if the Paxil works for you, you don’t have to worry about it moving away, retiring or changing practices. You do, unfortunately, have to worry about it not longer being covered by your insurance (same as a therapist in that regard).
Plonit – “Of course, people often use medical to include all of healthcare (including midwifery) and that irritates me more than using it to mean pharmacological, since the former is actually wrong, whereas the latter is correct in context.”
I’m showing my ignorance here, but by midwife do you mean a Masters Degree Nurse Midwife or another kind. It has always been my understanding that the former practiced medicine, just as a Nurse Practitioner does. Or is that also only a U.S. thing?
Might just be a US thing.
The best “definition” that applies across countries (not wanting to get out the dictionary or anything) is probably that of the WHO/FIGO/ICM
“A midwife is a person who, having been regularly admitted to a midwifery educational program, duly recognized in the country in which it is located, has successfully completed the prescribed course of studies in midwifery and has acquired the requisite qualifications
to be registered and/or licensed to practice midwifery. She must be able to give the necessary supervision, care and advice to women during pregnancy, labor and the postpartum period, to conduct deliveries on her own responsibility and to care for the newborn and the infant. This care includes preventative measures, the detection of abnormal conditions in mother and child, the procurement of medical assistance and the execution of emergency measures in the absence of medical help. She has an important task in health counseling and education, not only for the women, but also within the family and community. The work should involve antenatal education and preparation for parenthood and extends to certain areas of gynecology, family planning and child care. She may practice in hospitals, clinics, health units, domiciliary conditions or
in any other service.”
In the UK, there is only one designation: registered midwife, with two routes into it (18 month course for registered adult nurses, 3 year course for anyone else, including mental health, learning disability and paediatric nurses). But there’s no “nurse-midwifery” as such, and neither nursing or midwifery are the practice of medicine (which is essentially identified with “doctoring” here in my experience). The distinction might lie in primary focus on cure vs. care (normal pregnancy and birth not inherently requiring ‘cure’ is hence the domain of midwives in the UK) but to be honest I’ve not thought about it enough.
Michele – No, it’s not Scrabble and medicine isn’t poetry (so I’m not sure why you’re posting a poem). Clear communication in medicine is incredibly important for a wide variety of reasons. Just as a common understanding of words is important when trying to discuss a topic. This has actually been discussed by SBM bloggers quite a bit (the much missed and playful weekly look at how woo distorts language is the best example) and the original blog post was very much about communication and not just whether the meta-analysis was technically flawed. It’s quite odd really that you’re dismissing the importance of clear communication and clarity of meaning on a blog (which is all about communicating using words), particularly one that is centred around issues of communication (as well as the accuracy of a study).
Alison:
“Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.”
Fifi:
“The point, which you seem to be missing entirely and arguing against, is that CBT does directly modify the brain (when done properly) as do other mindfullness practices such as meditation. Interpersonal or dynamic therapies can too. This is what neuroplasticity is all about! You can certainly argue that there is no biological effect and deny neuroplasticity but you’re certainly arguing a personal opinion and not the current science in this matter.”
I really don’t understand how you get from my statement that “talk therapy” (which I will now rephrase as “psychological intervention”) and “medical therapy” (which I will now rephrase as “drug therapy”) both work through biochemistry to the conclusion that I believe that psychological intervention has no effect on the brain. I tried to be clear that I thought the opposite.
I repeat my earlier question:
“If you aren’t claiming that [psychological intervention] works by magic or through the mediation of the soul, but you disagree that it works through biochemical processes, I don’t understand what you’re saying. Are you saying that neuroplasticity isn’t biochemical?”
I will add more questions:
Are you saying the brain is not biochemical? Are you saying our bodies are not biochemical?
I am a layperson, so I miss distinctions that are important for you. If you want to restrict “biochemistry” to neurotransmitters and have it be a completely independent, non-overlapping concept from “neuroplasticity,” which would be neuron growth, I’m actually quite fine with that.
This came up in discussions of a soul independent of the physical brain. As a lay person, when Amy referred to biochemistry I made the link to the entire physical brain: the brain is made of biological chemicals, and what happens in the brain (including growth) is mediated through chemicals of various kinds. A simplistic, layperson’s kind of link.
Being more knowledgeable in this area, I am thinking that you took Amy’s statement to be a denial that neurons grow and an assertion that only the neurotransmitter activity of existing neurons was relevant. It’s possible that is what Amy meant, but at the time it didn’t occur to me as my understanding is that neuroplasticity is a well-accepted, non-controversial concept. In any case, it’s not what I meant. I’m sorry I wasn’t clear.
Am I getting closer?
Amy asked:
“Why do you need raw data about each patient to do a metaanalysis?”
I am one of the peer reviewers of the manuscript concerned. (I am a biostatistician and review many meta analyses for the journal concerned. I am ot a psychiatrist nor involved in any psychiatric studies). Most meta analyses do not need raw data. If I recall the article correctly, the reason the raw data were needed here was in order to examine how the effects varied by baseline depression status. This information is typically not available in the manuscripts on which the meta analysis is based.
Could this requirement have biased the results of the meta analysis? Yes – if the studies for which raw data were supplied are not representative of all studies. Is there any reason to suspect that authors of studies in which medications are effective in the mildly depressed were less likely to supply raw data?
Fifi, I said above that “If you want to restrict “biochemistry” to neurotransmitters and have it be a completely independent, non-overlapping concept from “neuroplasticity,” which would be neuron growth, I’m actually quite fine with that.” What I mean is that I would be fine with rephrasing my inflammatory statement as follows:
Inaccurate and inflammatory:
“Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.”
Better?
“Physical processes, including but not restricted to neuron growth and the actions of neurotransmitters, offer fully adequate explanations of the treatment of depression with drugs or psychological interventions.”
… keeping in mind that when I refer to physical processes this is to distinguish them from the actions of a soul and not to distinguish them from any other states, objects or processes that science can verify. Because the context of the conversation is with reference to dualism and I was trying to confess to being a dualist while maintaining that my soul has nothing to do with effective treatment for depression.
“I am one of the peer reviewers of the manuscript concerned. (I am a biostatistician and review many meta analyses for the journal concerned. I am ot a psychiatrist nor involved in any psychiatric studies). Most meta analyses do not need raw data. If I recall the article correctly, the reason the raw data were needed here was in order to examine how the effects varied by baseline depression status. This information is typically not available in the manuscripts on which the meta analysis is based.”
Thanks for commenting.
I’m curious how the reviewers could justify publishing a meta-analysis of the “literature” that included only 6 studies, of two antidepressants, one of which is rarely used today.
Didn’t the authors claims go far beyond the findings in their paper?
The poem was a loose play on a poem by William Carlos Williams, who was also a practicing doctor. http://www.poets.org/viewmedia.php/prmMID/15535
It was about how when you focus on the blemish you can’t enjoy the fruit.
but, I understand poetry is not everyone’s cup of tea.
My point was that in communication one expects that the other party will endeavor to understand the speakers point, rather than find fault with it. This is important in medicine, since one expects the doctor and patient to work together to come to a satisfactory outcome. Quibbling over words, correcting anothers words, or aurguing that another doesn’t know what they are talking about is not about communication. It is about winning.
If you are uncertain about a person’s point, you can always attempt to clarify by rephrasing. In communication, manners matter.
Alison has restated her position in several ways. I understood it upon first reading. You appear to be intelligent. So I can only assume that you are willfully ignoring her point. Which was in no way outlandish.
Instead of arguing semantics, why don’t you explain what mental processes you believes fall outside the biochemical (Biochemistry being the study of the chemical processes in living organisms) realm and how they are independent of biochemistry?
If you’d like to expound on how neuroplasticity is independent of biochemistry by all means do so. Other principles?
Otherwise it is much ado about nothing.
Alison – Thank you very much for clarifying. Perhaps some of the confusion is a result of your being a dualist who believes in a soul that exists apart from the physical body while also being a materialist when it comes to the brain? It can cause confusion in communication when we hold two ideas that may be mutually exclusive and try to communicate a belief about one or the other. I mean no offense by saying that! We all suffer from this at times…it’s the nature of human cognition and I’ve certainly been in that position myself!
From my perspective, as someone who has always been an atheist and who grew up around science, the concept of a soul is pretty useless when discussing science or used in a religious, immortal essence context. However, as a way to describe subjective experience in a creative sense, obviously it has it’s uses on a symbolic level and to communicate the experience of ourselves that we have. Art and science may inform each other but where science is about objectivity and trying to describe and understand the physical world, art is about subjectivity and trying to share our experiences of the world with each other. Both are important and useful in my opinion but we make a distinction between fiction and non-fiction, and science and art, for very good and important reasons.
I really do appreciate you taking the time to discuss this with me and to try to come to some common understanding. Better and more expert people than both of us are still researching and discussing the nature of the mind and brain so it’s not surprising that it is subject that can take a while to come to an understanding about.
Michelle, in no way did I mean to minimize the severity of OCD. I was trying to illustrate how a heuristic that works in some circumstances (go with your feelings) doesn’t work in other circumstances.
Distinguishing between ideas and actions brought about by feelings as opposed to by facts and logic is something I am thinking about a lot these days in the context of bigotry and xenophobia and why people “other” people who are not like themselves.
I think that “feelings” are a little bit closer to “primitive” physiological processes (primitive as in a hierarchical sense of lower level, not archaic or old) that we don’t have much control over. People can feel things and have no conscious understanding of how that feeling came about.
I think that feelings of depression are like this, that they reflect more of a physiological state and not a psychological state, and that to “fix” the depression, you have to fix the physiology. That can be done both by meds, or by talk therapy. Both work by fixing the physiology. The fact that we can’t measure what is “wrong” with physiology is not evidence that depression is not physiological. 100 years ago we couldn’t measure what was wrong with diabetes either. That didn’t make diabetes psychological.
If you don’t have the ability to think about your feelings on a meta-level, then you are pretty limited in how you can perceive the world. Your feelings become as “real” as other people’s facts and logic are to them, even if you are being delusional.
Alison – “… keeping in mind that when I refer to physical processes this is to distinguish them from the actions of a soul and not to distinguish them from any other states, objects or processes that science can verify. Because the context of the conversation is with reference to dualism and I was trying to confess to being a dualist while maintaining that my soul has nothing to do with effective treatment for depression.”
Out of curiosity, what do you consider “actions of the soul”? I’m quite willing and able to respect different beliefs than my own, including ones that include a belief in a soul that is independent from the body (even though I don’t share this belief and I take offense when people try to convert me). I suspect that what you consider actions of the soul, I probably see in terms of neurobiology and cognition and the experiences we have because the brain is a big of an kluge. Don’t worry, I won’t try to covert you to total materialism (it isn’t a religion for me). I’m just curious if your beliefs in both dualism and materialism are what I was picking up on in what you were trying to communicate and maybe influenced your view of cognitive and interpersonal therapies (or not
“[T]he concept of a soul is pretty useless when discussing science or used in a religious, immortal essence context. However, as a way to describe subjective experience in a creative sense, obviously it has it’s uses on a symbolic level and to communicate the experience of ourselves that we have.”
I think I’m more literal-minded than you. Personally I hate it when people use “soul” to refer to emotion or creativity! I don’t know if they mean it literally or as a metaphor. In the first case they are wrong and in the second case I don’t know what it’s a metaphor for. Physical processes, including but not restricted to neuron growth and the actions of neurotransmitters, offer fully adequate explanations of pleasure, ecstasy and creativity. So there!
Really, my dualism is strictly god of the gaps stuff. I don’t accept that physical processes can account for my subjective feeling of me being this particular me, here and now. But anything this particular me says/does/feels/bleeds can be accounted for without reference to a soul.
Out of curiosity, what do you consider “actions of the soul”?
I can’t think of any. That’s why I don’t consider them instrumental.
Alison – “Really, my dualism is strictly god of the gaps stuff. I don’t accept that physical processes can account for my subjective feeling of me being this particular me, here and now. But anything this particular me says/does/feels/bleeds can be accounted for without reference to a soul.”
Thanks for explaining your perspective – however you seem to be saying two contradictory things here to me. On one hand you seem to be saying all your experiences/feelings can be explained without reference to a soul, on the other than your subjectve feeling/experience of being you can’t be. Those seem like mutually exclusive ideas to me! If they’re not to you, can you explain why not? And why believe in a God rather than just be okay with not knowing some things? Sure there are gaps in our knowledge, why do they have to be filled with a God instead of simply being acknowledged for what they are?
My explanation for what people mean when they say “soul” is based on the fact that I’m an atheist and do see emotions, creativity and subject experience as being quite explainable using neuroscience and what we already know about how cognition works. (And also because I’ve worked in a clinical context where I’ve been explaining basic neurobiology and cognition to people who do believe in the soul and God. In that context it was mainly important for the patient to understand what I was explaining and be able to implement it so I modified my explanations to align with their cultural beliefs.)
I also work in the arts so I don’t take issue with poetic and symbolic language, in fact I enjoy it within the appropriate context and it’s much better for communicating how a subjective experience feels than scientific language is for most people. (Though poetic and symbolic language can have place in discussions of neurobiology, see the excellent A General Theory of Love by Fannon, Amini and Lewis, for an example. However, a lot of people aren’t very comfortable having their meaningful experiences reduced to strictly neurobiological terms. I find it fascinating however but I can understand why some people find it uncomfortable or hard to comprehend.)
http://www.amazon.com/General-Theory-Love-Fari-Amini/dp/0375503897/ref=tmm_hrd_title_0
Why would you propose there are “actions of the soul” if you can’t think of any? Clearly you believe there are “actions of the soul” since you brought it up, don’t you?
I don’t particularly believe in God: I’m on the atheist end of the agnostic spectrum.
“Sure there are gaps in our knowledge, why do they have to be filled with a God instead of simply being acknowledged for what they are?”
That one just feels different to me. I don’t have a better explanation to offer. In philosophy this is called “the hard problem,” so I don’t feel particularly bad about being unable to even describe it effectively. Apparently the proper way for philosophers to go about discussing The Hard Problem is for a dualist to say something about qualia and then for Stephen Novella to say they are silly. I really don’t have anything to add.
“I am a frank dualist myself. My argument is ignorance: I don’t understand what it means to be me… therefore it must be teh Solz! I know this is a risible argument, never fear. Occam’s razor states that an explanation must be the simplest one that explains the evidence, and no simpler. From ignorance I assert that biochemistry is too simple an explanation for my me-ness, but since a posited non-physical soul cannot generate hypotheses it’s a pointless concept. Certainly it adds exactly nothing to any discussion of practical problem-solving of any kind, so in a clinical context (and almost any other context I can think of) Occam decrees that no, there is no non-physical soul. Whether you think there might be one or not, for practical purposes there is not.”
I didn’t propose actions of the soul.
When I said, “… keeping in mind that when I refer to physical processes this is to distinguish them from the actions of a soul and not to distinguish them from any other states, objects or processes that science can verify” it was to ask you not to pick apart the idea of physical processes and ask me to define them further. I wanted you to accept a context of a discussion of dualist vs materialist, and to accept “physical” not as having a very particular meaning that excludes something you think should be included, but instead to be just whatever is not the non-physical soul. Which latter, as I stated earlier, is irrelevant.
Ok, I’m being unclear again.
I will rewrite “… keeping in mind that when I refer to physical processes this is to distinguish them from the actions of a soul and not to distinguish them from any other states, objects or processes that science can verify”
as
“… keeping in mind that when I refer to physical processes this is to distinguish them from the hypothetical actions of a posited, unverifiable, irrelevant soul and not to distinguish them from any other states, objects or processes that science can verify”
Not clear enough. Trying again.
“… keeping in mind that when I refer to physical processes this is to distinguish them from any hypothetical actions of an unverifiable, irrelevant soul that might be posited. I do not mean physical process in a specialised way that might exclude any states, objects or processes that science can verify”
The diagnostic criteria of many mental health problems are culturally biased in and of themselves.
daedalus2uon 10 Feb 2010 at 2:22 pm
“Michelle, in no way did I mean to minimize the severity of OCD. I was trying to illustrate how a heuristic that works in some circumstances (go with your feelings) doesn’t work in other circumstances.”
Sorry, I didn’t think you were minimizing. I was concerned that my initial post on the topic might read as trivializing, so I decided to clarify. Probably over thinking.
“I think that “feelings” are a little bit closer to “primitive” physiological processes (primitive as in a hierarchical sense of lower level, not archaic or old) that we don’t have much control over. People can feel things and have no conscious understanding of how that feeling came about.”
Yes, I find that all the time. It is very hard to explain to someone. I have explained it to CBT therapists. But as far as I can see they believe the negative thoughts comes before the feeling. Reframe the negative thought, avoid the feeling. In my case the feeling comes and I look for the cause, which must be negative, because the feeling is negative. (I must stop that.)
In some cases I have no idea were the feeling comes from. Could be a random physiological stress hormone surge caused by lord knows what. Could be a sort of trained physiological response (Pavlovian). Meaning I am so habituated to being anxious in certain circumstances that my body just kicks in the anxiety without the previous anxious thoughts.
Someone mention up thread (I think) that depression might be an evolutionary imperative. Likewise, I think a sensitive anxiety level has definite evolutionary value. A good ability to predict dangerous scenarios, spot predators or prey, etc can all be part of that anxiety related alertness. I am not sure if it’s as valuable in modern life, but I am famous in my family for being able to spot almost invisible birds or wildlife.
I might almost think that is why depression (a way of shutting down to conserve energy?) and anxiety (alertness to predict danger) can be so difficult to treat. Maybe because it is not a disease process, but an integral part of our….what? I don’t know the word, evolutionary makeup? Oh well, just an off the wall thought. So it’s like trying to train or medicate a pheasant to NOT run for the corn when frightened.
“Your feelings become as “real” as other people’s facts and logic are to them, even if you are being delusional.”
Yes, and this can be hard because there are some processes that we have learned so thoroughly that we process information intuitively. Such as reading people’s facial expressions or tone of voice. When we are using our intuition to inform us in that way we are more likely to get mislead by stray unconscious feelings. Malcolm Gladwell talks about this in regards to race and racism in “Blink.”
# Ploniton 10 Feb 2010 at 10:43 am
Might just be a US thing.
The best “definition” that applies across countries (not wanting to get out the dictionary or anything) is probably that of the WHO/FIGO/ICM
Oops, sorry. I keep stepping on the U.S./Britain medical system gaps.
micheleinmichigan,
I’ve noticed that many very effective people are also very anxious. They are conscientious, they plan ahead, they think of details, they figure out what could go wrong, they worry about other people. All things that can lead to being very effective, and also things that can make someone vulnerable to anxiety.
A friend asked me recently, in relation to the controversy over the effectiveness of SSRIs, “how can we trust science, when the scientific consensus changes from week to week?”
The answer is hinted at in this article. It’s not so much the scientific consensus that changes; it’s the headlines in news reports that change.
The more dramatic a claim made in a science paper, the less likely it is to be true, but the more likely it is to be reported as news.
When people hear a sound bite in the news, such as “according to a paper published in such and such journal, SSRIs are ineffective in treating depression,” they have a tendency to repeat the claim to their friends as a fact.
All of this creates an illusion that science waffles all over the place. The reality is that the scientific consensus changes much more gradually than news accounts lead people to believe.
micheleinmichigan,
I think I see where you are coming from. An obvious analogy that springs to mind is the genetic susceptibility to sickle-cell anemia that is a (potential) downside to a higher resistance to malaria.
So a susceptibility to depression or to an anxiety disorder could be the result of having a genetic makeup that, in other circumstances, provides cognitive/intellectual advantages. That is, I freely admit, totally unsubstantiated speculation.
It would be interesting to go through some of the more important political, artistic, and scientific figures of the past and see what can be found about whether they had any neurological disorders (if that is the correct terminology). For example, I believe Winston Churchill was subject to bouts of deep depression, and composer Robert Schumann was almost certainly bipolar.
[...] week I wrote about a study that purported to show that antidepressants have no effect in mild to moderate depression. A [...]
“actions of the soul” said by FiFi or Alison, could not find original reference up thread.
I am completely incapable of passing up such a lovely phrase.
Although not religious, I do think of myself as spiritual. In my mind, spirit being that capacity for a person or people to transcend their circumstances. The question being what are the factors that cause a person to be built or broken by hardship, for a people to submit or rise up when confronted with tyranny, for an individual to ignore or help someone in need. I guess (simplistically) these are the things that I would consider to be actions of the soul.
Our biology, evolution, history, culture and religion combined all certainly inform these actions. But to understand them completely from the perspective of science is like understanding a Goya painting based on it’s molecular structure. That is not to say science shouldn’t try… But at this point, in those spiritual decisions, science is not the best guide (for me). Or perhaps, more accurately science is only one of the stars to navigate by.
I guess the more obvious parallel is ethics. While science can inform ethics on possible consequences, to explore ethics is not the pursuit of science.
There, that is about as clear as mud. But at least it won’t be knocking around in my brain.
Alison and Composer99
After reading an article regarding the concept that depressed people are more able to accurately predict outcomes, I started wondering about the role of depression as an evolutionary advantage.
http://en.wikipedia.org/wiki/Depressive_realism
“Depressive realism is the proposition that people with depression have a more accurate perception of reality, specifically that they are less affected by the positive illusions of illusory superiority, the illusion of control and optimism bias. It must be understood that this refers specifically to people with borderline or moderate depression — while normal people see things in too positive a light and severely depressed people see things in too negative a light, the “grey” area in between leads to the most accurate perceptions of reality.”
Perhaps Winston Churchill fell into this category.
I believe this is the original study that the observation is based on called, “Judgment of contingency in depressed and nondepressed students: Sadder but wiser?”
http://www.ncbi.nlm.nih.gov/pubmed/528910
Thanks for this post, Dr T!
“I understood the marketing a bit differently. We already had effective antidepressants for very depressed people and psychiatrists were prescribing them. SSRIs are less effective but have fewer dangerous side effects, so they could be offered/marketed to people with mild to moderate depression who would not otherwise have received any treatment at all. They could also be prescribed by GPs. Being able to expand their customer base is great for pharmaceutical companies and they took full advantage.”
This assumption is incorrect. SSRI’s have been notorious for their side effects, specifically weight gain and sexual side effects. Unfortunately, these types of side effects also can have a profound effect on mood and self esteem. The advances in each newer generation of anti-depressants have sought to eliminate these. All too often, this also resulted in non-compliance with medications.
What concerns me about the big Pharma witch hunt within the context of implementing universal healthcare coverage, is that sensational media attention and lobbying of special interest groups may result in an arbitrary policy declining coverage of anti-depressants. All the patients who are benefiting from these medications, will have to fight the system to obtain their prescriptions. In a depressed state, these patients are particularly vulnerable and lack the ability to self advocate.
We’ve already experienced special interest groups inappropriately dictating medical treatment. Silicone breast implants, uphill battles for females in need of a hysterectomy, inadequate pain management, etc. On this very blog, we witness the anti-csection ideology. Fortunately, c-section is frequently an emergent procedure, so jumping through the hoops of obtaining prior-authorization is not part of the picture.
I see the same zealous approach to psychiatric medication. While the midwives have credibility and experience in obstetrics, they are completely unqualified in psychiatry or psychology. This is just a few steps away from the dogma of the Church of Scientology. I hope the significant number of mothers with PPD, seek treatment from the appropriate professionals. The wise midwives will direct these patients to a qualified professional and spare the Big Pharma rhetoric.
I do not think that it is appropriate to exclude studies that have a placebo run-in period.
Consider the null hypothesis: the SSRI is ineffective for treatment of mild-moderate depression. In this case, eliminating placebo responders in advance of the study will not convert a non-effect into an apparent effect. If the apparent effect of the SSRI is entirely a placebo effect, then perhaps a placebo run-in will reduce the magnitude of the effect for both the SSRI group and the placebo group, but it won’t make the SSRI more effective than the placebo.
The only plausible impact of a run-in would be if there is a real antidepressive effect of the SSRI on at least a subgroup of patients, *and* there is another subgroup of patients who are “strong placebo responders” (which I’m rather skeptical of–has anybody actually shown this to be true?), then the placebo run-in might increase the apparent magnitude of the SSRI effect relative to the placebo effect. But this is not a clinically relevant comparison, because doctors are not normally choosing between treating with a SSRI and treating with a placebo.
So the placebo run-in does no harm if the null hypothesis is true, and potentially increases the sensitivity of the trial to detect a genuine effect of the SSRI by eliminating an extraneous source of statistical variance.
laursaurus,
Yes, SSRIs commonly have side effects that may have a significant impact on quality of life. This is absolutely true.
What I said is that SSRIs have fewer dangerous side effects. Dangerous side effects may be worth the risk when treating someone who is at risk of killing themselves anyway; they are probably not worth the risk when treating someone who is just miserable and having trouble managing, but is not in immediate danger from their illness.
Dangerous side effects (from wikipedia):
Tricyclics: ease of suicide by overdose.
“TCAs may be involved in up to 33% of all fatal poisonings, second only to analgesics.[12][13] Another study reported 95% of deaths from antidepressants in England and Wales between 1993 and 1997 were associated with tricyclic antidepressants, particularly dothiepin and amitriptyline. It was determined there were 5.3 deaths per 100,000 prescriptions.”
MAOIs: require observing dietary restrictions to avoid possibly killing oneself even without an overdose.
“Due to potentially lethal dietary and drug interactions, MAOIs had been reserved as a last line of defense, used only when other classes of antidepressant drugs (for example selective serotonin reuptake inhibitors and tricyclic antidepressants) have failed.” (More recent
These just aren’t worth the risks for everyday misery that could (at least theoretically) be alleviated in other ways.
SSRIs have side effects, but they are very unlikely to kill you.
I’m not a midwife or any other kind of healthcare worker. I crunch numbers in business. I am completely unqualified in healthcare, which is why I try to phrase my statements carefully: “I understood the marketing differently.” I am often corrected here, which is good for everyone. However, highlighting the fact that SSRIs commonly have side effects including sexual dysfunction and weight gain is does not change my understanding of the marketing. To wit, that these side effects being less lethal than those of MAOIs and tricyclics made it possible for pharmaceutical companies to market SSRIs for treating a lower-risk population.
My understanding of the marketing of SSRIs is not that they were touted as being superior to MAOIs and tricyclics, which are actually more effective. It’s that they were safer and therefore worth a try for more people.
Laursaurus – “While the midwives have credibility and experience in obstetrics, they are completely unqualified in psychiatry or psychology.”
So are Ob/Gyns, I hope you’re recommending women with post-partem depression seek help from a mental health professional (with experience in post-partem depression) and aren’t inferring that an Ob/Gyn actually is one!
As primary health care professionals, midwives, like GPs, generally have quite a lot of experience in care for women with psychiatric disorders and work closely with their psychiatrists, GPs and other doctors involved in their care, social workers and particularly CPNs in ensuring good day to day care during pregnancy and particularly after birth. The midwives’ role in identifying and referral of women with psychological problems is an examined part of midwifery training in the UK, as is the role of the midwife in the multidisciplinary team that includes CPNs, doctors, social workers etc…
Of course, a midwife is not a qualified psychiatrist or psychologist (nor a qualified obstetrician, come to that) but I see no evidence in this thread of midwives claiming otherwise, or invoking “BigPharma” in opposition to SSRIs – so I’m not sure where that comment of laursaurus is coming from.
Plonit – I’m starting to wonder if the competition for patients in the US (and what private insurance will and won’t cover) doesn’t create issues there that don’t really occur in quite the same way in places that have universal healthcare… (And I don’t just mean higher costs. Not that there aren’t plenty of shared issues regarding healthcare in relatively wealthy nations around the world, or issues unique to universal healthcare.)
“Plonit – I’m starting to wonder if the competition for patients in the US (and what private insurance will and won’t cover) doesn’t create issues there that don’t really occur in quite the same way in places that have universal healthcare… (And I don’t just mean higher costs. Not that there aren’t plenty of shared issues regarding healthcare in relatively wealthy nations around the world, or issues unique to universal healthcare.)”
Maybe not only higher costs, but more tests, more drugs, and more procedures. For people with insurance that is, partly in an effort to offset the costs of caring for uninsured people.
Is there really competition for patients in US maternity care? I was given to understand (maybe wrongly) that there is an undersupply in the US of Obs/Family docs who practice obstetrics/midwives – no one wants to go into the business due to litigation etc…
There does seem to be a severe lack of primary/acute care distinction, with many obstetricians providing what is essentially primary care (which could be provided by midwives or GPs) – but that’s not really competition if there are more than enough clients to go around.
Plonit – I don’t know, it’s why I was wondering about it. It just seems like there’s a very different relationship between midwives and OBs and approach to maternity care in Canada (and the UK from what you’ve written).
“Is there really competition for patients in US maternity care?”
You’re right, Plonit; there’s no competition for patients in US maternity care. There is a shortage of obstetricians for just the reasons that you describe.
Could that shortage be rationally addressed by refocussing obstetricians on those who most need their skills in acute care and utilizing the skills of family docs and midwives for the provision of primary care and care in normal labour? Or does fear of litigation preclude such a response?
And if fear of litigation plays such a powerful role in obstetrics, what can individual patients do in this situation if they worry (quite rationally) that decision-making is as often guided by defensive practice, than by evidence- or science-based medicine.
“Could that shortage be rationally addressed by refocussing obstetricians on those who most need their skills in acute care and utilizing the skills of family docs and midwives for the provision of primary care and care in normal labour? Or does fear of litigation preclude such a response?”
Midwives and family docs cannot deliver babies without obstetrician backup.
The key point, though, is that obstetricians are hardly threatened by midwifery, since there are more patients for obstetricians than they can care for.
Midwifery and family doc provision of primary care and care in normal labour doesn’t imply working without obstetrician backup. No sane person would suggest that.
However, if there is a shortage of obstetricians (“more patients than they can care for”) does it make sense for obstetricians (the specialists with the skills to provide backup to midwives and family docs) to focus on primary care and normal intrapartum care?
In some sense, albeit not commercially, obstetricians clearly do feel threatened by midwives – your own efforts on previous blogs are an example of just that.
“obstetricians clearly do feel threatened by midwives – your own efforts on previous blogs are an example of just that.”
Threatened? That’s wishful thinking on your part.
Dr Tuteur – “Midwives and family docs cannot deliver babies without obstetrician backup.”
Actually, GPs do and can deliver babies without obstetrician backup when needed. So do taxi drivers every once in a while. Obviously having a baby in a taxi isn’t ideal but it can and does happen. And in a lot of Canada women can choose to give birth at home with a midwife. It is undoubtedly preferrable to have an obstetrician present during delivery in many cases but saying that other medical professionals or even non-professionals “can’t” deliver babies is just silly. It’s that kind of statement that makes it appear as if you’re threatened not only by midwives but by women having babies anywhere outside of an obstetrician’s control.
http://www.cbc.ca/health/story/2009/08/31/midwife-home-births.html
http://www.vancouversun.com/health/Midwife+assisted+home+births+riskier+than+hospital+CMAJ+study/1947568/story.html
http://www.cmaj.ca/cgi/content/short/cmaj.081869v1
You come off as sounding like you truly believe that women can’t give birth without an obstetrician – which is just silly since women give birth without obstetricians all the time all over the world. (I’m not saying it’s preferrable, I’m just saying it happens.) I doubt that’s what you actually mean and once again you’re just not communicating very effectively. (Maybe you mean it’s not legal in the US? It is in Canada.) Obviously it’s preferrable to have an obstetrician present if it’s a high risk birth or in case something goes wrong but that doesn’t mean women can’t and don’t give birth without your intervention or presence!
I’m not sure how much competition there is between doctors for patients in my area, but there is certainly competition between hospitals for deliveries. Both major ones in my area just built brand new wings for birth, with completely private rooms, offer waterbirths, and a slew of other services for moms and babies. It’s like a hotel and spa or something.
A lot of the older really good doctors around here are getting out of delivering babies, however, because of med mal rates, and focusing on things like urinary incontinence. That’s where the money is I guess.
Our system encourages a lot of specialists, partly because they get paid more. OB is an exception because of litigation. I believe that there is also a shortage of family doctors. I’m not sure how “specialized” your basic OB is- some really are more of a GP. They have high risk OBs to take care of the hard cases- and I guess c-sections are really simple to do. I have also heard OBs, along with FPs, disparaged amonst medical students. Not sure why.
There is some push to let NPs, PAs, midwives, (with supervision) and family doctors do more of the basic medical care, especially as well woman care is being more emphasized. Not every doctor is against that, just some more outspoken ones.
“It is undoubtedly preferrable to have an obstetrician present during delivery in many cases but saying that other medical professionals or even non-professionals “can’t” deliver babies is just silly.”
Duh!
I didn’t mean “can’t” as in “aren’t physically capable.” I meant “can’t” as in “it isn’t ethical to deliver babies without pre-arranged obstetric backup in case it is needed.”
“That’s where the money is I guess.”
No, that’s where there’s less worry and aggravation.
“obstetricians clearly do feel threatened by midwives – your own efforts on previous blogs are an example of just that.”
Threatened? That’s wishful thinking on your part.
++++++++++
Fair enough, if you say not then I believe not. Just my attempt to understand what appears, on the face of it, to be a rather extreme reaction to midwifery.
I meant “can’t” as in “it isn’t ethical to deliver babies without pre-arranged obstetric backup in case it is needed.”
+++++
Actually, your comment that “Midwives and family docs cannot deliver babies without obstetrician backup” was made in response to my question about whether the shortage of obstetricians
“Could that shortage be rationally addressed by refocussing obstetricians on those who most need their skills in acute care and utilizing the skills of family docs and midwives for the provision of primary care and care in normal labour?”
I didn’t even imply that this could or should be without obstetrician back-up, so I don’t quite know where that objection is coming from.
Thanks zoe, it’s clearly a very different situation and approach in Canada than it is in the US. It’s always interesting to hear about the differences in how medicine is practiced in different places.
Dr Tuteur, it’s always best to actually say/write what one means. “Can’t” and “shouldn’t” don’t mean the same thing at all, “can’t” certainly doesn’t mean “it’s not ethical”. It’s basic english…duh!
“I didn’t even imply that this could or should be without obstetrician back-up, so I don’t quite know where that objection is coming from.”
American medicine is not centrally controlled. Therefore, no one can tell obstetricians they must restrict their practice to high risk and back up other providers. In order for CNMs or family practice docs to deliver babies, they must arrange OB coverage, and there is no necessarily going to be an obstetrician who wants to cover them.
Moreover, plenty of homebirth midwives “practice” without obstetricians backup. When something goes wrong, they dump their patients in the emergency room.
My question was
“Could that shortage [of obstetricians] be rationally addressed by refocussing obstetricians on those who most need their skills in acute care and utilizing the skills of family docs and midwives for the provision of primary care and care in normal labour?”
You respond with an ought-is fallacy (“no one can tell obstetricians…”) but there’s a big clue that I’m not talking about what actually pertains (the “is”), but what might pertain if rationally addressed (the “ought”). If a different kind of primary/acute relationship is desirable – perhaps because it resolves certain kinds of problems, such as shortage of providers – then one pays attention to the mechanisms by which that could be achieved. Incidentally, there are ways to encourage and incentivise more productive, collaborative relationships between primary and acute care providers, short of central control.
“Incidentally, there are ways to encourage and incentivise more productive, collaborative relationships between primary and acute care providers, short of central control.”
Such as?
Dr Tuteur – “Moreover, plenty of homebirth midwives “practice” without obstetricians backup. When something goes wrong, they dump their patients in the emergency room.”
The Canadian system where there is cooperation instead of competition, and proper regulation, looks better and better all the time.
http://www.cmaj.ca/cgi/content/short/cmaj.081869v1
Background: Studies of planned home births attended by registered midwives have been limited by incomplete data, nonrepresentative sampling, inadequate statistical power and the inability to exclude unplanned home births. We compared the outcomes of planned home births attended by midwives with those of planned hospital births attended by midwives or physicians.
Methods: We included all planned home births attended by registered midwives from Jan. 1, 2000, to Dec. 31, 2004, in British Columbia, Canada (n = 2889), and all planned hospital births meeting the eligibility requirements for home birth that were attended by the same cohort of midwives (n = 4752). We also included a matched sample of physician-attended planned hospital births (n = 5331). The primary outcome measure was perinatal mortality; secondary outcomes were obstetric interventions and adverse maternal and neonatal outcomes.
Results: The rate of perinatal death per 1000 births was 0.35 (95% confidence interval [CI] 0.00–1.03) in the group of planned home births; the rate in the group of planned hospital births was 0.57 (95% CI 0.00–1.43) among women attended by a midwife and 0.64 (95% CI 0.00–1.56) among those attended by a physician. Wo men in the planned home-birth group were significantly less likely than those who planned a midwife-attended hospital birth to have obstetric interventions (e.g., electronic fetal monitoring, relative risk [RR] 0.32, 95% CI 0.29–0.36; assisted vaginal delivery, RR 0.41, 95% 0.33–0.52) or adverse maternal outcomes (e.g., third- or fourth-degree perineal tear, RR 0.41, 95% CI 0.28–0.59; postpartum hemorrhage, RR 0.62, 95% CI 0.49–0.77). The findings were similar in the comparison with physician-assisted hospital births. Newborns in the home-birth group were less likely than those in the midwife- attended hospital-birth group to require resuscitation at birth (RR 0.23, 95% CI 0.14–0.37) or oxygen therapy beyond 24 hours (RR 0.37, 95% CI 0.24–0.59). The findings were similar in the comparison with newborns in the physician-assisted hospital births; in addition, newborns in the home-birth group were less likely to have meconium aspiration (RR 0.45, 95% CI 0.21–0.93) and more likely to Abstract be admitted to hospital or readmitted if born in hospital (RR 1.39, 95% CI 1.09–1.85).
Interpretation: Planned home birth attended by a registered midwife was associated with very low and comparable rates of perinatal death and reduced rates of obstetric interventions and other adverse perinatal outcomes compared with planned hospital birth attended by a midwife or physician.
And a call for more research…
http://www.cmaj.ca/cgi/content/full/181/6-7/359
“The Canadian system where there is cooperation instead of competition, and proper regulation, looks better and better all the time.”
Better compared to what?
Better compared to the US from what you’re saying goes on, such as women being “dumped” in ERs and the apparent lack of regulation and cooperation to ensure that women and their babies have safe births. Plus women here can get care from both OBs and midwives for free (in most provinces), they get to make an informed choice based on the likelihood of complications and their personal preference and know they’ll not merely be “dumped in the ER” if something does go wrong. Seems much saner all round that the sort of wild west scenario that you’ve been painting where it’s either hyper-medicalization (with fear mongering and c-section happy OBs) or no medical backup at all and women get “dumped” in the ER when something goes wrong.
“Incidentally, there are ways to encourage and incentivise more productive, collaborative relationships between primary and acute care providers, short of central control.”
Such as?
+++++++++++
If I recall correctly, you have worked with midwives – providing back-up in the event of their clients needing referal to an obstetrician (whether in labour or pregnancy, presumably). Given the heel-digging “I don’ wanna” power of the obstetrician you outline upthread, something(s) other than central control must have positively motivated you to be involved in this arrangement. If one seriously analyzes what those factors were, then you find ways to incentivize a different way of working which can be tested.
It might be something as simple as wanting to provide a good standard of care to a wider population and capitalizing on the desire that most doctors have to do good?
“It is undoubtedly preferrable to have an obstetrician present during delivery in many cases but saying that other medical professionals or even non-professionals “can’t” deliver babies is just silly.”
Fifi, the OB doesn’t have to be present at the delivery. Just available to do a c-section if needed. Therefore, the OB can back up several midwives and FPs at the same time. Some hospitals also have “laborists” who just deliver the babies of whoever comes into the hospital without a doctor or midwife (usually people without health insurance).
In the U.S., there are also obstetricians officially backing up homebirth midwives- usually homebirth CNMs, but occassionally CPMs as well. It’s not as common as it should be though, mostly because of insurance issues. It really depends on the state. States that mandate insurance coverage are very friendly to midwives. Some hospitals/states are as backwards (very high c-sections rates, no choices for laboring women) as Dr. Tuteur describes, but many are progressive. Obviously the 300 year old “war” between midwives and OBs is still going on, but I think it’s getting better.
“That’s where the money is I guess.”
“No, that’s where there’s less worry and aggravation.”
Better hours too, I’m guessing. At least one OB I know, though, specifically couldn’t afford the malpractice insurance for births anymore, even though he hadn’t had any lawsuits.
Off the top of my head, a financial disincentive for OB’s to attend (ATTEND, not backup) a low risk birth. Or a financial incentive to care for more high risk patients. or a combination of both.
AT:
“The Canadian system where there is cooperation instead of competition, and proper regulation, looks better and better all the time.”
Better compared to what?
Canada’s perinatal mortality rate (28 weeks gestation to 7 days of life) was 6.3 in 2002 (range by province/territory from 3.0 to 12.5).
Using the same definition, the US perinatal mortality rate was 6.91 in the same year, down to 6.71 in 2003 (range by state from 4.15 to 9.62).
This is an odd discussion to be having in the comments to a post on antidepressants, but whatever. Canada seems to be doing something right. With respect to health care outcomes for the entire population, the US does not generally compare favourably to its less-privatized peers and I don’t see the point in getting defensive about it. (Canada doesn’t do as well as its peers either: by many measures the only country that does worse than Canada is the US. However, it doesn’t appear to be because Canada’s health care is over-centralized compared to its peers.)
Alison Cummins:
The problem with simply quoting perinatal mortality rates, is it does not address the underlying population diferences … what is: the rate of high risk pregnancies in Canada v the US? the rate of neonatal drug exposure? the rate of high risk intervention (such as ECMO)? the rate of elective abortion for high risk/lethal defects? Simple comparison of perinatal mortality rates is not sufficient.
Fifi:
I hope someone with more knowlege of your quoted study will look closer, but most of the studies I have read similiar to the one you are quoting have been found wanting in the area of selection bias. No matter how much good faith effort is made it is found that the the “matched sample” inevitably has significant selection bias … with more risk in the “hospital” group. Additionally, the listed “interventions” are: electronic fetal monitoring and assisted delivery – not exactly the most invasive “interventions”. I do agree however that midwifery and homebirth appear to be better regulated in Canada. I would like to know, however: what is the mortality rate for significant complications with homebirth v hospital birth in Canada?
zoe – Thanks for the additional info on the US, it doesn’t sound as dire as it was being painted out to be between midwives and OBs. That’s good to hear. Most women I know in Canada have just gone with an OB and their GP for prenatal care, though I do have a couple of friends who used coordinated care with an OB and midwife. All seem pretty happy with their experiences but most had pretty simply pregnancies and births (except for one friend who had triplets and then twins, so obviously it was more complicated for her).
Alison – Canadian healthcare certainly isn’t perfect. One of the biggest issues has been the slow erosion of services due to a confluence of factors (aging doctors and population, and politicians who were previously employed as lobbyists for private healthcare and insurance companies that keep trying to kill medicare via death by a million cuts mainly). Of course, aging populations and retirement age doctors are a problem in most places like the US, Canada, Australia and the UK from what I understand. Healthcare does vary from province to province since it’s run by individual provinces and not the Canadian government.
moderation – Both the study and discussion I pointed to are very up front about the real world factors that complicate doing these kinds of studies. In fact, the second link is particularly about that. Not that many women actually choose homebirths in Canada and when they do it’s not going to be for a high risk pregancy – I suspect that may partially be because there isn’t the polarizing debate and there’s more cooperation. It is a regulated profession here and midwives are part of the Society of Obstetricians and Gynaecologists of Canada, which represents OB/Gyns, GPs, midwives and other sexual and reproductive health workers. Of course, the general attitude towards sexual and reproductive choice and health in Canada are quite different and more practical than ideological (abortion, sex ed and access to birth control being the most obvious areas). In Quebec we also have substantial maternal and paternal leave as well.
http://www.sogc.org/index_e.asp
http://en.wikipedia.org/wiki/Society_of_Obstetricians_and_Gynaecologists_of_Canada
The Society of Obstetricians and Gynaecologists of Canada (SOGC) is a national medical society in Canada, representing over 3,000 obstetricians/gynecologists, family physicians, nurses, midwives, and allied health professionals in the field of sexual reproductive health. Since its founding in 1944, the society has promoted excellence in the practice of obstetrics and worked to advance the health of women through leadership, advocacy, collaboration, outreach, and education
moderation:
“The problem with simply quoting perinatal mortality rates, is it does not address the underlying population diferences … what is: the rate of high risk pregnancies in Canada v the US? the rate of neonatal drug exposure? the rate of high risk intervention (such as ECMO)? the rate of elective abortion for high risk/lethal defects? Simple comparison of perinatal mortality rates is not sufficient.”
I agree, which is why I restricted my observation to “Canada seems to be doing something right.” The fact that we have universal public health care — and for most people, universal public medication insurance — is not an isolated fact that can be separated from other aspects of Canadian society. The fact that universal public health insurance is such a hard sell in the US seems to be at least partly related to fear of government and to libertarian ideals that dictate that the poor and diseased have only themselves to blame.
If there are more desperately poor and marginalized people in the US and the American health care system is usually able to deliver their babies alive anyway, it’s possible to read that as a triumph of American obstetric technology. It’s also possible to read that as an absurd allocation of society’s resources.
If universal public health care and more coordinated health care delivery were possible in the US, the US would be a very different society. So I restrict myself to observations on the package: Canada seems to be doing something right.
I also observed that by many measures Canada does things right only by comparison with the US, which is often a strong outlier among its peers. Compared to Australia or Western Europe… not so much.
Fifi,
You say that not many women choose home births in Canada. Do you know what the statistics are relative to the US? I couldn’t find any. My impression that the relative costs of home vs hospital births is often an element of decision-making in the US.
Alison – “My impression that the relative costs of home vs hospital births is often an element of decision-making in the US.”
I’d wondered about that myself. I ran across some numbers for homebirths in Canada but can’t find them again (or perhaps I misread, always possible). I’ll post them if I can find them again. In Canada there is always the issue of actually being able to get to a hospital as well if we’re talking about living in a remote community in winter!
Back on topic… I haven’t read all the comments so perhaps this has already been discussed. Amy’s comments pertain to one study. I am interested in the bigger picture. Dr. Fabrizio Benedetti has written “Placebo Effects: Understanding the Mechanisms in Health and Disease” (2008, Oxford Univ Press), which received praise from NEJM and Journal of the Neurological Sciences. I haven’t yet read Benedetti’s book. Some chapter 5 sections (Mental and Behavioral Disorders) are titled “The rate of improvement in placebo groups is high and has increased over the past years” and “Placebos and antidepressants affect similar areas of the brain”. I would appreciate comments from anyone who has read this book. I am very familiar with placebo theories, but would like more information on Fabrizio’s work in particular.
A Sept 2009 Wired article by Steve Silberman mentions Fabrizio’s research as well as Dr. William Potter’s (currently with Merck) efforts with the NIH and several other pharma companies on a “hush-hush” project currently underway called the “Placebo Response Drug Trials Survey”. Any information on this would be appreciated as well.
http://www.wired.com/medtech/drugs/magazine/17-09/ff_placebo_effect?currentPage=all
The Wired article has an unfortunate title (according to Silberman he did not choose the title), but it is worth a read. I see some other Science Bloggers (Greg Laden and White Coat Underground) have commented on the Wired article, but both entirely skirted the issue of Fabrizio’s research (Laden explicitly stated he was skirting it, and WCU avoided the subject despite Silberman’s personal comments to the blog).
wales – I find your post very relevant – particularly when discussing mild to moderate depression (or chronic pain). Feeling states that are subjectively reported (and diagnosed using subjective means of measurement) and have a psychosocial basis as well have shown themselves to be the most susceptible to the placebo effect. It’s why the placebo effect is so hotly debated and discussed in chronic pain management and mental health.
It’s what makes testing drugs for depression or pain more complex than testing drugs for cancer. Combine that with the fact that there’s no biological test that measures depression or pain and you have all kinds of levels of complexity and subjectivity that simply don’t exist when testing most other kinds of drugs for conditions that we can measure via objective tests.
Alison Cummins:
“libertarian ideals that dictate that the poor and diseased have only themselves to blame”
Hyperbolic comments like this are the reason I, as someone in general support of universal coverage in this country, have such a difficult time discussing health care reform with those here opposed to it. Your comments are insulting and condescending and show a real lack of knowlege of on the ground medical issues in the US. I assume this is because you are Canadian and have no medical experience in this country.
In general it could be said that in the US there is a higher ceiling (ease of access to care for those covered, development of cutting edge technology and drugs) for medicial care but also a lower floor (more people without coverage), while in Canada there is the opposite (universal access, but difficulty accessing certain expensive sugeries and evaluation modalities). In the perfect world the US would raise its floor and other countries would find a way to raise their ceilings.
My bottom-line point remains the same, using the broad general statistic of neonatal mortality rate was irrelevant to the specific discussion of home v hospital birth, which is what AT’s question: “Better compared to what?” was addressing.
Now, back to Anti-depressants …
moderation,
My full statement was: “The fact that universal public health insurance is such a hard sell in the US seems to be at least partly related to fear of government and to libertarian ideals that dictate that the poor and diseased have only themselves to blame.”
I don’t think it’s hyperbolic to propose that these aspects of US culture seem to contribute to a complex problem. There’s no need to assume that all Americans firmly hold these positions for this to be true.
You’re right, I’m Canadian and have little experience with the US health care system. I do know that my grandfather, an internist in small town upstate NY, drove around with a “single payer healthcare” bumper sticker in the 80s and 90s. He treated a lot of his patients for free and often took payment in the form of game. His adult children talk about working their way through months of meals based on huge sacks of rice when that was what my grandmother could get for cheap. Speculation is that their teeth are so bad today because they didn’t get enough milk when they were young. This was in the forties, fifties and early sixties — not the thirties. He didn’t think it was fair for his patients to have to depend on his charity, but they did.
I also know that my uncle, an internist at the Cleveland Clinic, ended an family conversation about health insurance by declaring firmly that “nobody has to go without health care in America because of lack of funds. They just have to declare bankruptcy.” He didn’t see a problem with that; he thought it was fair.
I know that when my Canadian friends have needed expensive cancer treatments, that they could get them. For instance, a friend who had been recently laid off work in Montreal was aggressively treated for an unusual form of esophageal cancer seen mostly in Japan. The provincial government flew in a surgeon from Boston to help with the surgery. My friend didn’t have to pay a thing beyond the payroll tax that he and the rest of us pay to support Medicare. And in the eighties when another friend had breast cancer, she was able to get that whole-body irradiation treatment where they took bone marrow and reinfused it afterwards. It was an experimental and ultimately unhelpful treatment, but universal public health insurance covered it completely. Sure, it’s possible that we have rationing and the fact that my friends were respectively 33 and 48 at the time entered into these decisions, and that our universal public health insurance would not have been so generous had they been 85. That’s not necessarily a bad thing.
Indirectly, I know that there’s a contingent of US ED bloggers who seem to see themselves in opposition to their marginalized, “entitled” patients. They express anger toward their patients for being stupid, for being uneducated, for being poor, for not trusting that the system will work for them, for being ungrateful. Sure, these folks only speak for themselves and I’m not the person who has to deal with aggressive, irresponsible/ disenfranchised patients every day. Fair enough. But there is definitely a libertarian streak there and a fear that universal public health care would just encourage “entitlement” and make the ungratitude problem worse. I can’t imagine that this fear has no role at all to play in the discussion of health care in the US.
But you’re absolutely right, while I’m a US citizen I do not live there and I haven’t had the opportunity to experience the American health care delivery system at its best.