Wednesday, February 27, 2008

Up on sugar pills, we go walking

A study published on Monday by British researchers has apparently shown that antidepressant medications are effective, but only in people that have the most severe forms of the disease. Predictably, this has been spun by the mainstream media into something that it is not. A quick Google News search turns up some of the following headlines:

Antidepressants just a placebo: study
Study concludes that antidepressants are ineffective

Antidepressants 'have no impact'

And my favorite: Antidepressants don't work.

As a health care professional, it's not the turning on the ear of commonly believed medical conventional wisdom that bothers me. That happens all the time. Case in point, when I was in pharmacy school, I was docked points on a case presentation I did because I did not recommend hormone replacement therapy to a 94 year-old female nursing home patient with severe dementia. Now, you rarely if ever see HRT given to any post-menopausal woman. (I'd like those points back, please, for being ahead of the curve.) But what does bother me is the misrepresentation of the data by news outlets that just want to sell papers, get ratings, or generate traffic to their web site.

While the caveats to the "antidepressants don't work" headline are in the articles, they are usually buried about a paragraph or two from the end. Most people don't bother reading newspaper articles past the first couple paragraphs, so for the majority of people the take-home message is "Antidepressants: They're Utter Shit."

The thing about the actual study is that it's a meta-analysis, which means that they took data from other studies and pooled them all together to create one big gargantuan study, hoping to glean new information. What the researchers did here was take clinical trials for three of the most common antidepressants (Prozac, Effexor, and Paxil) and one that does not enjoy the popularity of the other three (Serzone). All this data was pooled into one big pot and statistics applied to them. I'll be the first to admit that I'm no statistician, so I don't know much about what tests they applied to the data. When the data came out the other end of the statistics, the researchers found that there was no statistically or clinically significant difference between the antidepressants and placebos in all groups studied except for the most severely depressed patients.

This is all well and good but one thing is missing out of the mix here. Drug efficacy studies are not done by meta-analysis. They're done by randomized, double-blind, placebo-controlled clinical trials. Whenever an efficacy study fails to meet these criteria, you can bet that there will be a slew of letters written to criticize the design of the study. Now, that having been said, it is exceptionally unlikely that we'll ever see a new round of randomized, double-blind, placebo-controlled clinical trials because it is not financially advantageous to the drug companies. Sad, but true. And don't even get me started on studies that show negative results being buried by drug companies. That is truly shameful.

The other thing I will say is that, as someone who lives with depression and has a nearly 10 year history with antidepressants, the idea that the drugs will cure people is sadly misguided. They are but a component of a comprehensive treatment plan. For so many people, they have been miracle workers, yours truly included. My experiences with depression have mostly skewed toward the mild-to-moderate end of the spectrum. When I read Andrew Solomon's The Noonday Demon: An Atlas of Depression, his experience with depression made mine seem like Sunday afternoon in the park. But nonetheless, I know that I personally benefited from drug treatment. However, the drugs will only take you so far. There's work that you have to do and that does not fit in very well with our "a pill will fix you" culture. You have to do the mental work, you have to make the changes in outlook and mindset that are needed. What antidepressant medication does, in my opinion, is give you the boost out of the mud. When I was at my worst, getting dressed in the morning required incredible effort, let alone doing my job and being a functional partner and parent. To even begin to think about trying to make the mental changes in mindset required to lift myself out of the muck was more than I could bear. But once the drugs kicked in, that kind of mental effort was easier to bear. Relying on the drugs to fix everything would have been foolhardy.

We've known for a long time that the combination of drugs and talk therapy are more effective than either of the two on their own, which was conveniently ignored by the meta-analysis and the mainstream news stories that followed. In my estimation, what we need to take from this data is that folks who suffer from depression can't expect a pill to do all the work.

But they do work. I've witnessed it. I've lived it. That may be anecdotal evidence (which is held in even lower esteem than meta-analysis) but it is some of the most powerful evidence I have. They work but like everything else in life, you can't have unreasonable or unrealistic expectations regarding their abilities.

(Props to Dolly for providing the inspiration for the title of this post. I've had that damn song stuck in my head for days!)


Heidi Cullinan said...

I just wish we lived in a culture where reporters' first instincts would have been to go to experienced, intelligent professionals like you for a translation instead of opting for more yellow journalism.

Well said, hon.

God said...

Nice post. As someone who knows absolutely nothing about antidepressants, this was definitely enlightening.

L K Tucker said...

The fact that you take a drug and have a positive outcome does not mean that the drug was effective.

Sounds crazy right? There is a problem discovered in the 1960's that no drug test controls. Subliminal Distraction is so simple that almost any one can create the "special circumstances" for exposure.

SD has been causing psychiatric outcomes including depression when users of Qi Gong and Kundalini Yoga perform too many sessions in a compact time frame for over 3000 years.

Now it really does sound crazy.

SD was discovered when it caused mental breaks for office workers in the 1960's. The cubicle was designed to prevent SD exposure and stopped the mental events after 1968.

If SD exposure increases depression increases. Decrease the exposure and depression will remit.

Any drug being used will be credited with the improvement.

VisionAndPsychosis.Net is a five year investigation of SD.

Myfizzypop said...

that was an amazing write up. I have taken anti-depressants for about 6 years on and off, and i truly notice a difference when i am on them. But am i the most severely depressed? I'd like to think not. The news about it was very similar here in the UK and i hate to think the damage it may cause to people who could benefit from some relief via effective medication,.

Matt said...

Interesting post.

I find that the newspapers are basically terrible at reporting all science/medicine news. Often, reporters covering this subject have no background in the relevant disciplines.

Two great books about the public's misunderstanding of science:

1) Voodoo Science by Robert Park
2) Demon Haunted World by Carl Sagan

Both books influenced me greatly and gave me a respect for the objectivity of pure science that I've never lost.