Hard News: The drugs don't (always) work
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Placebo party anyone?
Your placebo or mine?
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You'd guess that
Sorry, it's just that I indelibly associate "talk therapy" with psychotherapists and "counselling" with "counsellors". I mentioned CBT up-thread a bit but I should have been clearer.
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A good party is a placebo.
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aren't they all much of a muchness.
Nope. Much to the annoyance of the psychoanalysts, it looks like the long let's-talk-about-your-childhood-trauma stuff doesn't do anything easily measurable, but CBT and related approaches do.
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Five of my immediate whanau have had severe clinical depression: may I emphasise SEVERE and CLINICAL? This is *not* bipolar, nor is it the
weirdity genes & brain chemistry have given me (dysthymia, or permanant grey Mondayitis - dont think it's called that but that is what it feels like!) Severe clinical depression, as numerous respondents here have very eloquently described, is a *crippling & life-threatening disease.*Trust me: I've been there when it happened. Family people have tried talk therapies, and counselling, and new age stuff and walk therapies. but what ultimately helped - enabling people to live- what we all think is our right & norm- ordinary lives was SSRI s (3 different ones, Aropax, Cipalopram, and venlefaxine (excuse spellings - I'm not immediately able to Google correct ones.) They took time to kick in - and the intervening time was horrible for those of us who were helping - but they worked (and work!) My horror at the Herald story (and others) was only matched by my appreciation of Russell's post which I was able to onsend together with later posts...I've had family die of cancer and emphysemia: severe depression is
even worse (as one who later died of cancer said-) -
Sue,
aren't they all much of a muchness.
further to what stephen said,
there are as many forms of therapy as there are drugs, and some forms of therapy are about as useful as a placebo.
some forms of counseling, can in fact be do more harm than good, or even mask symptoms.
the childhood stuff, mostly it's about a therapist getting a fix on how long you've been depressed, what triggers exist in your life, also what patterns you have.
I speak as someone whose found 2 years of intensive CBT extremely helpful (thank you capital coast health)
As a result of CBT I was able to reduce my medication, have a life.I can honestly say it was a life changing thing for me, something counseling never even came close to
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Sue,
well in Van Gogh's case would medication have dulled his creativity?
there are plenty of instances of artists going off prescription medication becuase they are less creative on it.(CCBT)
i really like that this is designed to go along side medical support, from GPS or nurses -
Sue,
that fry doco is awesome
i think it's being re aired on prime soonor UK TeeVee?
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"that fry doco is awesome
i think it's being re aired on prime soon
or UK TeeVee?"I haven't seen it traillered if it is going to be repeated here. I shall keep an eye out though.
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I want a job at one of these newspapers. Here are some of my medical article ideas.
- Studies have found that bandaids only aid in healing for people that actually have a wound. If you just have a tiny scratch, a bandaid is no better than a placebo. OMG BANDAIDS DON'T WORK!
- Studies have found that if you hit your funny bone, painkillers are no better than a placebo (or swearing at any innocent bystanders). They seem to do some good for people with migraines and broken bones and cancer, but still OMG PAINKILLERS DON'T WORK!
- Studies have found that people who are a bit puffed after running might as well take a placebo as a hit of ventolin. It does turn out that ventolin seems to work well for people with bronchospasms, but lets run with the obvious conclusion: OMG VENTOLIN DOESN'T WORK!
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Hmmm, placebos
Actually doctors love them, but for a placebo to be truly effective you can't *know* it's a placebo.
I tried to get at this in an earlier post. This analysis had a huge placebo response; bigger than expected. So there may be something about the placebo/control arms that is unusual.
Firstly, it's difficult to enrol and treat seriously depressed people in a clinical trial without very strong observational protocols to ensure that they don't get worse/commit suicide etc. These observational protocols may well act as a de facto form of counselling or CBT. This may imply the trial is really drug vs counselling.
Secondly, generally entry into these trials is optional, so those entering are a self-selected group who are hoping the new drug will be more effective than older therapies. This belief may lead to a bigger than expected placebo response.
Lastly all the people entering the trials have had their mood disorder 'recognised' or diagnosed which in itself can be therapeutic.
With all these phenomena, it's not hard to see how a control arm of diagnosis, enrolment, and observation could well have some therapeutic value, especially in those with mild depression.
Many of the trials analysed here were very short - 6w or so. It's generally accepted that antidepressants take 6w to work properly, and are maximally effective from 3m onward. Another confounding influence.
Most of the trials of SSRIs have been done with a comparator of an older antidepressant. These tend to show that the SSRIs are equally or slightly less effective but have significantly less side effects. SSRIs are also much much safer in overdose.
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I am only a layperson, not a doctor, but it would seem to me that the first approach to depression should be attention to the state of the person's endocrine function, nutritional status and look for obvious underlying biochemical states in the body that will affect biochemical states in the brain.
A huge number of women and children and some men are deficient in iron, and one of the first sypmtoms of iron deficiency is tiredness and depression. The prediabetic state of insulin resistance (which is shockingly common, there are going to be a lot of people with type 2 diabetes in a few years) also has depression as one of the first symptoms. Deficiency in various B vitamins (also common in the population) also shows up as tiredness and depression.
Then there's the HPA axis (hypothalamus, pituatary, adrenals) and it's a kind of biochemical Catch-22 where the abdominal fat acts as a kind of sinister pancreas, as the stress hormones will cause the accumulation ofabdominal fat, and the abdominal fat will in turn manufacture biochemicals that cause depression.
If you have too thick a layer of abdominal fat, that fat doesn't just remain a static set of fat cells, it is constantly secreting harmful cytokines that will cause anxiety and depression. That stress will in turn cause your abdomen to store yet more body fat.
Then there is Parkinson's disease, hepatitis, angina, also congestive heart failure, thyroid disease... all of these are often heralded by depression before the underlying disease is discovered.
Depression is the first symptom of almost every vitamin and mineral defiency you can name. Also a symptom of estrogen dominance or low testosterone levels, again affected by nutritional status.
My point is that when a person goes to see a GP for depression the first response should be a thorough physical and biochemical examination. Once the biochemical imbalances of the body and the attending endocrine misery is addressed, then it should be a concern that the brain chemistry is not all it should be. But an approach using nutrition, congnitive therapy and movement (exercise is not to be underestimated in its power to combat depression) should be tried before messing with the brain chemistry. Except in extreme cases of depression of course, where self harm is clearly a danger.
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Wow. Thanks for that set of documentary links Steven.
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I can go off meds for up to six months at a time but when I start not coping I can go back on them to mediate the extremes. They help me live my life when stress pushes me over the edge.
Spooky, dude. That's the exact line my alcoholic uncle used about his drinking. Timeline, symptoms, spot on. Mind, he was likely living with PTSD, so there may be some common cause.
SSRIs? Damned if I know. Made me act like a crazy person, which scared the shit out of me on top of not really wanting to be on them in the first place, so I chucked them.
Still, a handful of choice words from the shrink means I've never have really fallen back into that cycle of feeling bad about how bad I'm feeling. Though I'm still a little stuck on not doing stuff because of the stuff I don't do. -
the first approach to depression should be attention to the state of the person's endocrine function, nutritional status ... etc ...
You might well think so, but, I spent three years under the misdiagnosis of chronic fatigue syndrome, taking numerous medications which made no difference, injecting myself with B12, while the undiagnosed depression manifested in obsessive compulsive behaviours which eventually drove me to seek further help.
I cannot emphasise enough, and you see it in the thread here, that many/most? depressed people will go out of their way not to be diagnosed as such, or at least medicated. Following my diagnosis I then wrestled with SSRI's, going on and off them (not avisable) for a few years before actually seeing any benefits, which were gained by taking them daily with a mind that this would be an indefinite part of my life.
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"I can go off meds for up to six months at a time but when I start not coping I can go back on them to mediate the extremes."
Gotta be carefull there.
I did that once and forgot I shud start slow. It started with total euphoria then totally f&*ked up paranoia - & I remebered I shud had started slow. So held on tight and enjoyed the emotional ride for the next week - it wasn't boring!
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There was a little more detail on the drug trial findings in this week's edition of the BBC radio series More or Less.
In addition to the overall finding that there was a significant (average) difference in improvement between drugs and placebos only for cases of severe depression, the programme makes the point that an average response might not be such a useful measure of drug effectiveness in this case: different drugs seem to work to different extents for different people; so the fact that one drug might not work for you doesn't mean that there isn't some alternative drug available that will have a clinically significant effect. (The published trials tend to focus on average responses, and do not all cite the amount of variation in response, so there isn't enough evidence to eliminate this as a possibility.)
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