Pseudonymph

Lately I've been doing a lot of study and research into the placebo effect. Most particularly having to do with antidepressants. It seems that this effect has a pretty influencial impact on the "recovery" of depressed patients.

This begs the questions...Who really is depressed(chemically inbalanced)and are the ways we measure success and recovery reliable? Did the medicine do its job, or did the patient, believeing that the drugs would work, recover on thier own?

<a href="http://skepdic.com/placebo.html" target="_blank">http://skepdic.com/placebo.html</a>

Good article. It discusses the placebo effect not only on anti d's but on other "fake" treatments as well, including the ethics of it all.

<a href="http://www.apa.org/releases/placebo.html" target="_blank">http://www.apa.org/releases/placebo.html</a>

Also a good article from the APA.


I have long been interested in this type of study, and we have another open topic paper coming up. I am thinking about choosing this as my topic. What do you think about this?

Amalthea

Where are you getting the information about the placebo effect and antidepressants? What kind of sources are you looking at? Is this an opinion (I remember reading a thread a while back and you seemed to be rather dismissive of the usefulness of medication to treat depression). And what do you mean by "recovery". Are you implying that the patients are still depressed, or never were really depressed in the first place?

Sorry, just trying to clarify.

Good question, but how do you suggest looking at this issue? Are you suggesting that only people with "legitimate" depression are those with chemical imbalances? Why make the distinction in the first place? Maybe a question you need to ask is "do the causes of the depression (chemical vs situational) matter once it has been decided to treat with medication?"

I personally think not.

I am not au fait with the ways in which success is measured, but I would have thought it would be a mixture of:
1)the indicators which led to the diagnosis of depression in the first place being absent (such as from the Beck's Inventory) and;
2) personal judgement from the patient, in consultation with the treating doctor.

The first is a more objective measure, the second a subjective one. Both equally as important in deciding treatment, I would have thought.

If it is an open topic, what aspects do you think are important in looking at this topic? I get the impression that what you are really interested in is the diagnosis of depression, and whether medication is being used to treat people who aren't really depressed. Is this correct or have I got the wrong end of the stick.

I think that the placebo effect in the treatment for depression is the wrong angle. If the patient isn't clinically depressed, but feels that they are, then they are likely to benefit from medication (I would have thought).

If they are actually depressed (for whatever reason) and get better from the medication, how can you measure whether that is from the placebo effect or from the actual drug working?

Since it isn't really understood how most of these medications work in the first place this is a tricky question to answer on a case by case basis. Different medications work for different people.

Maybe you need to clarify exactly what aspect of this is important. Placebo effect (widely documented) or the diagnosis of depression and over prescription of medication (another topic entirely).

Small aside here: this topic is of interest to myself as well as I have spent the last few years trying various things to get rid of depression (long term depression- approx. 12 years).

[Anecdotal evidence]
Although I could not tell you what the causes were (probably genetic predisposition and environmental factors) I can tell you that of the three thing that I have tried, 2 have failed and one has clearly worked. I too was keen for a cure, but talking to a psychologist didn't help (option 1), neither did the first antidepressant that I tried (option 2).

Option 3, however, worked a treat. I am still in amazement every day in regards to the difference that it has made. What I can tell you though, is that from my experience, the side effects alone when starting to take an antidepressant, would put many people off. I think that this is important. Do you know what the compliance rates are with antidepressants? I would have though that a lot of people who take it because they ask their doctor for it, but maybe aren't really depressed, would be put off at this hurdle, as it can take months for the side effect to subside. Would this factor in your discussion? [/Anecdotal evidence]

NialScorva

I'm pretty sure double blind studies are a standard practice in the approval process. These are designed to make sure that the medicine has an effect above a placebo, in an environment where neither the testers nor the testees know the difference between the two.

For anecdotal evidence, I had a similar experience to Amalthea. I tried two types of antidepressants before prozac, and they did nothing for me. Prozac made a dramatic difference.

Amalthea

Yip, I had meant to say that as well. Clinical trials will show that they have an effect above that of a placebo. Problem is determining exactly why they are having the desired effect...

Amazing, isn't it when it works Dramatic doesn't even begin to describe it!

Pseudonymph

Thank you, Amalthea and NialScorva for your replies! I will try to answer most of your points one by one.

A lot of it is sources that we have at school. The APA is also a good source to check out. Almost every psychological organization I've seen has done studies about this effect and what happens as a result.

Yes we all remember that thread Yes I am personally against anti d's because of personal reasons. However I realize that some people may require them, so no, my sources are not opinions.

The latter, in most cases. And in some more diffucult cases, the former. I feel that anti d's are often times used as a "quick fix" that never really addresses the problem. But the patient, believing that they will work, somehow gets "better". The distinction that we must
learn to make, is... did the drugs do it...or did the patient?

As objectivly as I can...It may be hard, but I cant let my own bias against these things distort my judgement.

No I dont suggest that, if by legitimate you mean curable by treatment with drugs. I've been depressed lots of times, but I just made a few changes in my life, over a period of time and did the best I could with what I had. Certainly this can't work for everyone, but why did I get better when every psych I went to tried to give me drugs?(that I didnt take)


Because that's part of the diagnosing process. It's important to know the ins and outs...aka the CAUSE must be identified before the cure can be found. Or at least, thats the way it should be. (also not my opinion, this is part of the interaction that needs to take place between patient and doctor)


Of course it matters! Why treat situational distress with medication? Shouldnt you know which is responsible BEFORE giving medication or not? Of course. Is a chemical inbalance responible for your husband hitting you? or your mothers death?

Studying what I have, I feel that the process to distinguish these from each other, is insufficient.


Right.

Decidedly no! When one is depressed, it is difficult to make accurate judgements about your present situation. This akin to hearing people say, go to a professional not your friends etc.

Patient input is valued and important surely, but not nearly as much as a trained, professional doctor.

I am interested in that as well. It goes hand in hand with this study. People may see "success rates" with a certain drug and not realize that those numbers may not be accurate.

Possibly, but we must address the ETHICS of such an issue. Is issuing medication when not really needed ethical? Is not fully understanding the cause of the problem, but dolling out medication ethical either?

The first article I referenced touches on that...

Excellent question. Unfortunantly the buisness of psychology is driven by results and not methods these days.

Hence it is not really even studied that much anymore, all that is known is that what they have been doing is "working" and if it aint broke, why fix it?

You just made an intesting point...Since it isn't really understood how most of these medications work in the first place .

This is true, as I said results not methods. "its working? who cares how then!"

These two are close relatives. I hope you can see what I mean.

Despite the general misconception about me, I understand depression and have been through it myself. So I do feel for you ...smile!

NialScorva:

Yes, it is required to have a "control" group or constant. But "recovery" was documented in the placebo group as well, hence this problem.

Part of the root of this problem is that depression is such a mutating animal. it changes, dissapears, comes back and hides again. And thats just MINE...YOURS is completely different!(for example)it changes from person to person.


Right, these are the two groups, the "variable" amd the "constant." But as I said before, its near impossible to have a real "control group"(since no two people are the same, no two cases of depression are the same either.)

Hope this helps explain myself! I hope to see a few more responses from more people as well. Take care for now!

[ April 17, 2002: Message edited by: SirenSpeak ]</p>

Amalthea

I hope the comments I made were in some way helpful . I just wanted to maybe throw up a few issues, but you have obviously been doing quite a bit of research.

One point I wanted to clarify was that when I said that patients should be involved in treatment, I didn't necessarily mean in deciding whether or not to take medication, but whether or not it is actually having the desired effect, and whether something else should be tried. I am fully aware that patients don't always make the best informed decisions

I have no doubt that antidepressents are generally over prescribed, I am just not sure whether this is really that bad a thing. I had this conversation with someone recently, actually.

She was very much of the opinion that there were too many people being prescribed pills who didn't need them. My brother, who works in the pharma industry (but not for a pharma company before you ask!) and knows a lot about the various issues involved, was very much of the opinion that this really was a non issue.

If it doesn't do them any harm (as far as I know, apart from a few unpleasant side effects), and might make a difference for the better(even if it is a placebo effect), then is there any harm in them taking them. The only concern I would have is that these kinds of people might not be addressing the real issues behind their depression, and that they would be back to square one when they stopped taking it (possible even if it is working for the "right" reasons).

One last point. In deciding the reasons behind the depression, from personal experience I know how difficult it is to pin down the causes. I would have said that in the judgement of both myself any my doctor, we would have pinned it on my situation/past situation. However, the only thing that has been of any benefit has been medication.

Going with your way of thinking, then we would never have tried pills:

But perhaps there was a chemical component to my depression that could only have been treated by pills (it certainly looks that way). The fact was, it was really hard to tell before we tried both.

Anyway, good luck with your paper and I will shut up now!

MadMordigan

As a person who is currently undergoing SSRI therapy to deal with depression, I have some perspective on the nature of anti-depressant therapy. My experience leads me to believe that the doctors who are dealing with me are at best pseudo-scientists, and at worst outright quacks.

The diagnosis of clinical depression was rendered based exclusively on a single verbal interview. No attempt was made to verify the authenticity of my self reported symptoms. The minor physical tests (pulse, blood pressure) all gave readings within the normal healthy range. In my opinion, there was no way for my doctor to determine whether I was actually depressed or simply lying about being depressed.

A determination was made that the cause of my depression was an imbalance of brain chemicals. At NO TIME did the doctor measure these chemicals. Instead, proceeding directly from his own diagnosis, the doctor perscribed an SSRI (Celexa), without giving me as much as a printout of the drug's characteristics. When asked how this drug works, the answer from both the doctor and the JAMA website was 'We don't know'.

Consider a similar scenario. A man walks into the hospital and says his arm is broken. Without so much as an xray, a doctor proceeds to bandage and cast the arm, and percribe 'magic crystals' for the pain. We would consider such a doctor a menace to society, and forbid him from practicing medicine. But because the alledged ailment is within the mind, this is standard operating procedure for a shrink.

Amalthea

And surely, therein lies the problem. There are few outward, definitive, physical signs, so the doctor has to go on what the patient is telling them. It does sound as though your doctor was less than thorough. Unfortunately, this happens all too often. The first one I went to neglected to ask one of the most important questions (any suicidal thoughts) - I found a better doctor.

Um, am I being dense, but how the hell would you do that? I am sure that it would be much easier if there was a physical test for depression (or depressive tendencies), but there isn't.

They are unlikely to tell you any more than what info comes with the medication. I am under the impression that SSRIs (what I am taking too) are pretty tame when it comes to side effects, drug interactions and the like, so the doctor might not have been thinking that it was worth saying (no excuse, though, for not giving you enough information to decide for yourself).

I don't know about where you are, but here you get so little time with your GP that you really have to be armed with knowledge to ask the right questions, or you lose your chance. I personally think that people should take more of an active interest in their own health care, but then I have been unlucky in my GPs up until this point and I have had to have been

They don't. All they know is that it works, not exactly why it does. Sucks but it's true.

I don't think that you can compare the two scenarios, so I am not quite sure what the point is. It sounds like you have had a rather dismissive doctor who probably hands out antideps like candy.

Unfortunately, sometimes you can be too far in the other direction. The first doctor I spoke to about depression (who had been my doctor for a couple of years) was very reluctant to do anything about it. She was certainly very wary of prescribing drug therapy (and she didn't), and as a consequence has added something like 3 years onto the time that it has taken me to get better. (Damn, I just thought of that ).

Because of this attitude, it took me about 7 years to seek help, and another 5 to get the right treatment. Many people are the same as me in this regard. An uphill battle.

So I question which is better: being so wary of prescribing drugs that getting help is made difficult, or overprescribing what basically seems to be a harmless drug which can do nothing but help? (I am aware that this is simplifying matters, but you get the idea, I hope)

Gurdur

A few things:

We do know a little of how the major anti-depressants work, and it's already been pointed out.

Measuring neurochemical balance in people is difficult and expensive, and not all that conclusive unless you take out the whole brain and do the job properly, a procedure many object to.

The SSRI's vary in effectivity; the normal daily dose for Cipramil is 20 mg, while for Zoloft it's 100 mg (for depression; Zoloft at 50 mg a day is also very good for raising blood pressure in chronic-low-blood-pressure victims).

Other psychomeds start at 600 mg a day, and veer sharply upwards if it doesn't work.

I attended a very interesting collegial seminar on this at a hospital complex in Australia when I visted there last month.

sullster

I see the point that Madmordigan is making. It has validity. I have an expanded view.

It is true enough that SSRIs are prescribed usually after a brief visit to the physician. It is also true that neuroscientists have a patchy knowledge of how they work. But look at the alternatives and the bigger picture.

Aside from some wacky-types, most people won't seek out an anti-depressant until they feel that despair that only the depressed know. Once someone gets the nerve to see a doctor, the doctor usually knows that the patient is suffering.

There are vast amounts of pseudo-scientific and outright mystical junk treatments out there for depressed people. Virtually all of them do not work, excepting the placebo effect I will admit.

The SSRI drugs have been studied and have a proven track record. Besides if people are feeling better, it becomes an academic aspect to know exactly how it works, though an important one for science.

The argument about the man with a broken arm seeing a doctor in comparison with a doctor seeing a depressed person is not conclusive. True enough, if a doctor prescribed,"magic crystals", for a broken arm he would be a quack,(or a new age therapist), but a broken arm is a causation of pain which is exactly related to an observable problem with the body. A depressed person's type of pain is harder to pinpoint yet would you say that the pain is not as real as the pain of the broken arm? I disagree that SSRI's are "magic crystals".

In conclusion, why should medical science leave the relief of depression to the true quacks and charalatans of the world, when a scientific path exists using SSRIs?