Tuesday, July 12, 2011

Could antidepressants really be a hoax, a mistake or a concept gone wrong?

The New York Times Sunday review has an article by Peter Kramer 'In defense of antidepressants'. He finds it worrisome that antidepressants may be merely placebos with side effects (see previous blog entry).

He suggests that the way pharmaceutical companies produce data submitted to the FDA to obtain a licence for antidepressants is "sloppy" because subjects who don't really have depression are included. He argues that this recruitment bias of an "odd bunch" of people increases the placebo response rate for so-called mild depression, but he doesn't explain why this complication should necessarily change the finding of a small statistical difference between active and placebo groups.

He thinks studies done in specific disorders, such as depression in neurological conditions, eg. stroke, multiple sclerosis and epilepsy; depression caused by interferon; and anxiety disorders in children, have greater external validity. Furthermore, he suggests that results in chronic and recurrent mild depression, such as dysthmia, are more trustworthy, but doesn't give a reference.

He goes on, "Scattered studies suggest that antidepressants bolster confidence or diminish emotional vulnerability — for people with depression but also for healthy people." It was this aspect that was perhaps most questionable about his book Listening to Prozac. He seems to think the placebo effect is a good thing, without realising that what he is describing is a placebo response.

Nor does his argument on maintenance studies wash. He suggests that withdrawing placebo shouldn't have any effect. Again, this does not seem to demonstrate much understanding of the placebo effect. Withdrawing a substance which is believed to have improved mood inevitably will produce a nocebo effect.

Kramer is also critical of a JAMA study picked up by a USA Today piece 'Study: Antidepressant lift may be all in your head'. He suggests the selectivity of the study made it one that "could not quite meet the scientific standard for a firm conclusion". He thinks the media should not embrace what he calls "debunking studies".

He concludes that "it is dangerous for the press to hammer away at the theme that antidepressants are placebos. They’re not. To give the impression that they are is to cause needless suffering." I guess that it's just too difficult to accept that antidepressants could "really be a hoax, a mistake or a concept gone wrong".


Anonymous said...

Kramer is at Brown. And we all know what the Department of Psychiatry at Brown is like-- chock full of paid Pharma hacks and not-so honest researchers who end up being outed and defrocked by Senators and even a student newspaper. Think Martin Keller. Kramer is just another of this ilk.

Jeff Johns, MD said...

It's interesting that Kramer undermines his own argument by pointing out flaws in the database. His selective scrutiny of certain studies is laughable. The "maintenance studies" that he cites are better called abrupt discontinuation studies that, to no one's surprise, show that going cold turkey off medications is sometimes not good.

Outrageously, Kramer had the gall to question the motives of those with contrary views in two consecutive paragraphs when he plugged his own books in the next.

Kudos to Angell, Carlat, Whitaker, Kirsch, Healy, and, of course, Double. However, Joanna Moncrief has the best review of psychotropic medications with her "The Myth of The Chemical Cure."

Anonymous said...

As a kid, I ran amok all over the place. I could just see my mother sitting in front of a child shrink complaining about this, but in no way admitting that she fed me sugar-laced drinks 24/7, along with sugary candies from her store, and dishes loaded with carbs. Please. No doubt the diagnosis would've been ADHD. In my twenties I saw all kinds of shrinks for "depression" and "anxiety" and not a one could agree on what was wrong with me. I received more diagnoses than religion has denominations. All could agree on one thing though: I surely needed lots and lots of medications. I finally saw one woman that was so disgusting and laughable in dispensing some 13 prescriptions for me before she ran off to an all-expense pharmaceuticals paid trip to attend a conference in Europe that I never saw a psychiatrist again. Funny, how I seem to have done so well in life despite no medications or their constant meddling into my emotions. In my opinion, this is a disgusting profession with no shred of respectability or credibility.