Depression Treatment Myths and Critical Thinking

[babycondor]

A noteworthy article by Bruce Levine at Counterpunch (I am prohibited from posting a link because I am new here; just Google "levine depression counterpunch") discusses 5 myths about depression treatment and the role of belief, with interesting implications for critical thinkers.

"Critical thinkers have difficulty placing faith in any depression treatment because science tells them that these treatments often work no better than placebos or nothing at all, and if one lacks faith in a depression treatment, it is not likely to be effective. In fact, it is belief and faith—or what scientists call “expectations” and the “placebo effect”—that is mostly responsible for any depression treatment working. Critical-thinkers can find a way out of depression when their critical thinking about depression treatments is validated and respected, and they are challenged to think more critically about their critical thinking."

 

[Dancing David]

Ah, yes and how did those studies measure resposne to treatment, did they use fine scale or gross scale measures like the BDI?

The BDI is meant to measure the precense of deperssion not response to treatment.

Hmmmmm. So if you use a gross scale that has a margin of error larger than the alleged treatment response is that an accurate way to measure the comparison to placebo?

 

[bookitty]

A noteworthy article by Bruce Levine at Counterpunch (I am prohibited from posting a link because I am new here; just Google "levine depression counterpunch") discusses 5 myths about depression treatment and the role of belief, with interesting implications for critical thinkers.

"Critical thinkers have difficulty placing faith in any depression treatment because science tells them that these treatments often work no better than placebos or nothing at all, and if one lacks faith in a depression treatment, it is not likely to be effective. In fact, it is belief and faith—or what scientists call “expectations” and the “placebo effect”—that is mostly responsible for any depression treatment working. Critical-thinkers can find a way out of depression when their critical thinking about depression treatments is validated and respected, and they are challenged to think more critically about their critical thinking."

Link: http://www.counterpunch.org/levine12032010.html

 

[godless dave]

I'm not sure I buy it, since most SSRI antidepressants work better than placebo.

 

[Emet]

Another member of the anti-psychiatry movement heard from.

Buy my books; hire me as a speaker.

linky $

linky Wiki

linky shrinks and big pharma stinks

 

[FattyCatty]

Why do none of these studies ever ask my opinion? I'd be more than happy to tell them what I think, and I sure that would give them valuable insight and probably lead them to form totally new hypotheses and look at treatment for depression in a whole new light. I've never met anyone who participated in any study on depression. I think they make it all up, based on what they're saying.

 

[bookitty]

Why do none of these studies ever ask my opinion? I'd be more than happy to tell them what I think, and I sure that would give them valuable insight and probably lead them to form totally new hypotheses and look at treatment for depression in a whole new light. I've never met anyone who participated in any study on depression. I think they make it all up, based on what they're saying.

A good point. I see the occasional ad in the paper for the UCLA medical center, asking for subjects for various studies. Depression comes up quite often.

Now I am wondering if that form of recruitment skews the studies. (If that is the most common kind. I don't know and if anyone has additional information, please post.) Some forms of depression would make it difficult to respond to the idea of a study.

Despite numerous medical advances, there is still a lot of public disinformation. People still hold the dark ages idea that depression is a sort of luxury disease. If someone is surrounded by people who don't understand depression, they might not want to participate because they wouldn't want to admit to it.

Unfortunately, I really don't know enough about how medical studies are conducted. This is all just pondering.

 

[babycondor]

I'm not sure I buy it, since most SSRI antidepressants work better than placebo.

You might be interested in reading the article, because this is #1 on the list of myths debunked.

“All antidepressants,” Kirsch reported in 2010, “including the well-known SSRIs [selective serotonin reuptake inhibitors], had no clinically significant benefit over a placebo.” While in aggregate, antidepressants slightly edge out placebos, the difference is so unremarkable that Kirsch and others describe it as “clinically negligible.”

 

[babycondor]

Ah, yes and how did those studies measure resposne to treatment, did they use fine scale or gross scale measures like the BDI?

The BDI is meant to measure the precense of deperssion not response to treatment.

Hmmmmm. So if you use a gross scale that has a margin of error larger than the alleged treatment response is that an accurate way to measure the comparison to placebo?

A good question, but not addressed in the Levine article.

 

[babycondor]

Why do none of these studies ever ask my opinion? I'd be more than happy to tell them what I think, and I sure that would give them valuable insight and probably lead them to form totally new hypotheses and look at treatment for depression in a whole new light. I've never met anyone who participated in any study on depression. I think they make it all up, based on what they're saying.

That's provocative! What are your insights on treating depression, then?

I've never met anyone that participated in a study on depression either, but there is a lot of evidence (published reports in medical journals, FDA requirements for getting drugs approved, etc.) that they have taken place. What are they saying that leads you to believe they are making it all up?

 

[Uncayimmy]

You might be interested in reading the article, because this is #1 on the list of myths debunked.

“All antidepressants,” Kirsch reported in 2010, “including the well-known SSRIs [selective serotonin reuptake inhibitors], had no clinically significant benefit over a placebo.” While in aggregate, antidepressants slightly edge out placebos, the difference is so unremarkable that Kirsch and others describe it as “clinically negligible.”

Sometimes you just gotta get the slop out of the numbers.

http://www.ncbi.nlm.nih.gov/pubmed/20800012
Recently there has been much debate on the true usefulness of antidepressant therapy especially after the publication of a meta-analysis by Kirsch et al. (PLoS Medicine 2008, 5, e45). The aim of the current paper was to recalculate and re-interpret the data of that study. Effect-size and mean-score changes were calculated for each agent separately as well as pooled effect sizes and mean changes on the basis of the data reported by Kirsch et al. The weighted mean improvement was (depending on the method of calculation) 10.04 or 10.16 points on the Hamilton Depression Rating Scale (HAMD) in the drug groups, instead of 9.60, and thus the correct drug-placebo difference is 2.18 or 2.68 instead of 1.80. Kirsch et al. failed to report that that the change in HAMD score was 3.15 or 3.47 points for venlafaxine and 3.12 or 3.22 for paroxetine, which are above the NICE threshold. Still the figures for fluoxetine and nefazodone are low. Thus it seems that the Kirsch et al.'s meta-analysis suffered from important flaws in the calculations; reporting of the results was selective and conclusions unjustified and overemphasized. Overall the results suggest that although a large percentage of the placebo response is due to expectancy this is not true for the active drug and effects are not additive. The drug effect is always present and is unrelated to depression severity, while this is not true for placebo.

 

[Arthur Mann]

Sometimes you just gotta get the slop out of the numbers.

The aim of the current paper was to recalculate and re-interpret the data of that study. Effect-size and mean-score changes were calculated for each agent separately as well as pooled effect sizes and mean changes on the basis of the data reported by Kirsch et al. The weighted mean improvement was (depending on the method of calculation) 10.04 or 10.16 points on the Hamilton Depression Rating Scale (HAMD) in the drug groups, instead of 9.60, and thus the correct drug-placebo difference is 2.18 or 2.68 instead of 1.80. Kirsch et al. failed to report that that the change in HAMD score was 3.15 or 3.47 points for venlafaxine and 3.12 or 3.22 for paroxetine, which are above the NICE threshold. Still the figures for fluoxetine and nefazodone are low. Thus it seems that the Kirsch et al.'s meta-analysis suffered from important flaws in the calculations; reporting of the results was selective and conclusions unjustified and overemphasized. Overall the results suggest that although a large percentage of the placebo response is due to expectancy this is not true for the active drug and effects are not additive. The drug effect is always present and is unrelated to depression severity, while this is not true for placebo.

This is a lot to digest, I'm not sure I understand all of it. Can you answer a few questions?

What methods were used to "recalculate" data? I can understand reinterpreting the data, but what does "recalculate" mean in this context? What was wrong with the original calculations?

What does all that mean about "effect-size" and "mean-score"? Why did their method lead them to calculate two different "weighted mean improvement" figures? Is either of their figure correct? Why don't both their methods produce the same result?

What is "HAMD threshold" and "NICE score"?

The passage quoted states the paper being criticized was guilty of selectively presenting data, yet says all "recalculations" would be made using the same data set. How did they receive unrevealed data if, as stated, they used only the data presented?

How are the proposed "revisionist" results shown to have any more external validity than the original conclusions published by the researchers? How much difference is there between the two data sets? Is the newly computed difference between these drugs and placebo "clinically negligible" as well? Does this criticizing paper put forth any new experimental evidence of does it simply attempt verbal refutation of the original paper?

 

[Cactus Wren]

A good point. I see the occasional ad in the paper for the UCLA medical center, asking for subjects for various studies. Depression comes up quite often.

Now I am wondering if that form of recruitment skews the studies. (If that is the most common kind. I don't know and if anyone has additional information, please post.) Some forms of depression would make it difficult to respond to the idea of a study.

I worked for a number of years in marketing research: you know the annoying ladies in the mall, with the clipboards? "Hi, I'm doing a survey, may I ask you a couple of questions?" That's us. Come down the access corridor to our office, answer some questions, and get a few dollars for your trouble. Most of our surveys were on new products and package designs, but a few were on other topics: military recruiting, movie advertisements, and a few on more esoteric subject. One was on the sexual habits of American adults.

It had a set of very strict age and sex quotas: our respondents were to be exactly half men and half women, with (IIRC) at least five separate age groups. No exceptions: if the client wanted seven men between 18 and 25, ten between 25 and 35, and ten between 35 and 45, that's what we had to interview.

Most survey clients require a certain number of "confirmation calls": the survey office takes every respondent's name and phone number, and usually five to ten percent will get a phone call from the client's office. "Hi, Mr. Blank? This is Jane, from AC Neilsen-Bases. Did you do a survey in Megamarket Mall on the 12th of last month? Do you remember what it was about?" ... and so on. If the number is bad, or Mr. Blank isn't at that number, or if in any other way the information he give doesn't match the information on his screener, the survey has to be replaced.

But the sexual-habits survey was entirely anonymous. No confirmation calls. And the rumor in our office was that the manager's end-of-year bonus varied in direct proportion to how much money was in the office's petty-cash fund: the less he paid out in interview incentives, the more he got.

Upshot: the sexual-habits survey was completed entirely by four teenagers -- two guys, two girls -- and three ladies between 65 and 75.

I am now highly, highly skeptical when I hear the results of such surveys.

 

[Uncayimmy]

Honestly, Arthur, I'm not familiar enough with the original report, and without access to the full reports, I can't comment on the specifics. There's been a lot of debate about the Kirsch numbers and not just the above.

http://www.ncbi.nlm.nih.gov/pubmed/20571143
In 'Initial severity and antidepressant benefits', Kirsch et al. conducted a meta-analysis of data from 35 placebo controlled trials of four newer antidepressants. They concluded that while these drugs are statistically significantly superior to placebo in acute depression, the benefits are unlikely to be clinically significant. This paper has attracted much attention and debate in both academic journals and the popular media. In this critique, we argue that Kirsch et al.'s is a flawed analysis which relies upon unusual statistical techniques biased against antidepressants. We present results showing that re-analysing the same data using more appropriate methods leads to substantially different conclusions. However, we also believe that psychopharmacology has lessons to learn from the Kirsch et al. paper. We discuss issues surrounding the interpretation of clinical trials of antidepressants, including the difficulties of extrapolating from randomized controlled trials to the clinic, and the question of failed trials. We call for more research to establish the effectiveness of antidepressants in clinically relevant populations under naturalistic conditions, for example, in relapse prevention, in patients with co-morbidities, and in primary care settings.

In the context of this thread it's not really fair to say that it's a myth that antidepressants work and simply cite the Kirsch meta-analysis without mentioning that professionals in the field disagree. When you have a such a subjective disorder such as depression that can also resolve itself and can affected by things like exercise and sunlight, it's going to be really tricky figuring out what works.

The one thing everybody agrees on are the side-effects - they definitely come up higher than with placebos.

 

[FattyCatty]

That's provocative! What are your insights on treating depression, then?

I've never met anyone that participated in a study on depression either, but there is a lot of evidence (published reports in medical journals, FDA requirements for getting drugs approved, etc.) that they have taken place. What are they saying that leads you to believe they are making it all up?

I'm sorry, I was being facetious. My only insights are opinions based on personal (anecdotal) experience. I certainly wouldn't have the oomph to look for a study when I'm depressed, so I wondered how they found the participants for their studies.

If they are doctor-referred, doesn't that imply that the participant is already getting some kind of treatment? How would that influence the study results? The fact that people are undepressed enough to show up in the first place is skewing the studies. They do say that their results in the CBT study are for "mild to moderate" depression. It is not clear what level of depression the other studies are using. If they have co-mingled all levels, I would think that would confuse their findings. Being in a serious depression is a lot different than being mildly depressed. I have a problem seeing seriously depressed individuals participating in any kind of study. So are the results different for serious depression? Are differentiations even made in the severity of depression (the CBT study did this)? I just want to say, "oh, really," or "so what," or "you can't prove it by me."

Myth #1 Antidepressants Are More Effective than Placebos

In my personal, anecdotal experience this is not always a myth. Prozac, for instance, helped me a lot until it suddenly stopped working. I don't think my expectations caused it to work, as I had taken other medications that didn't work, and it is on those I would have based my expectations. Also, the difference when it stopped working was significant.​

Myth #2 If the First Antidepressant Fails, Another Antidepressant Will Likely Succeed

Again, in my experience this isn't a myth. In the last 10 years, my psychiatrist tried several medications for my depression. They may have kept it from becoming severe, but they didn't succeed in getting rid of it. Most recently, she tried a combination that worked spectacularly. It happened almost immediately (probably within a week) and transformed my life. When I could no longer afford the second medication, back I went to where I was before.​

Myth #3 Electroconvulsive Treatment (ECT) is an Effective Last Resort

Once more, it wasn't a myth for me. It changed a deep, suicidal depression into a mere severe depression. Which is improvement.​

Myth #4 Cognitive Behavior Therapy (CBT) is the Best Psychotherapy for Depression

On this, I'm not as sure. It's seemed to help me is about all I can say.​

Myth #5 No Treatment for Depression Works

I don't think this is true. Medication has worked for me. I also was getting therapy both times a medication made a significant improvement. But then, I was getting therapy most of the times medication didn't seem to be helping. As far as I'm concerned, treatment can work. And therapy is my lifeline. This is something I don't think is addressed in their studies. Just talking to someone about your depression can help. In my case, therapists were all I had. I don't know if it makes a difference whether they try CBT or other approaches. I don't know that I was able to change behavior because of therapy. I just know that it kept me going during times I thought nothing could.​

 

[babycondor]

Thanks for sharing your experiences, FattyCatty, and for calling attention to the difference between mild-to-moderate and severe depression. To me it's very useful to consider "anecdotal" information like yours. It helps me to put the scientific stuff into perspective.

 

[Dancing David]

You might be interested in reading the article, because this is #1 on the list of myths debunked.

“All antidepressants,” Kirsch reported in 2010, “including the well-known SSRIs [selective serotonin reuptake inhibitors], had no clinically significant benefit over a placebo.” While in aggregate, antidepressants slightly edge out placebos, the difference is so unremarkable that Kirsch and others describe it as “clinically negligible.”

And have you read the Kirsch studies?

What scale do they use to measure the alleged effect?

Seriously, I think it is the BDI, which does a piss poor job of assesing insomnia. Unfortunately since Pearson Learning bought the rights to the BDI you can't find it online.

 

[Dancing David]

Thanks for sharing your experiences, FattyCatty, and for calling attention to the difference between mild-to-moderate and severe depression. To me it's very useful to consider "anecdotal" information like yours. It helps me to put the scientific stuff into perspective.

Well here is the issue Babycondor, the scales that Kirsch mentions in the study, while often used by all sorts of people are not adequate for actually assessing more that the presence of depression, even the Hamilton Depression Scale does a piss poor job and it is the 'gold standard'

they are adequate tools for taking 17-21 questions and assessing the presence of depression. But they are not good tools for assessing if a person has what level of depression.

Even the Hamilton scale which covers insomnia better will not really gauge the level of insomnia and response to treatment very well. A person may have a huge difference in sleep patterns and only score one or two points different.

Take someone like me, untreated I have early morning waking, frequent waking in the night and sometimes difficulty going back to sleep. Even on the HDS I will score 1-2 points different, even though the impact on my life is huge. There is often no scaling at all for anxiety and level of symptoms for anxiety, which is a huge component of major depression for some people (including me).

Now all sorts of clinical tools exist that are more effective, like the Duke structured interview and hundreds of others.

But an adequate assessment takes at least two hours. (I know because i have done about 750 of them at least).

 

[babycondor]

Well here is the issue Babycondor, the scales that Kirsch mentions in the study, while often used by all sorts of people are not adequate for actually assessing more that the presence of depression, even the Hamilton Depression Scale does a piss poor job and it is the 'gold standard'

they are adequate tools for taking 17-21 questions and assessing the presence of depression. But they are not good tools for assessing if a person has what level of depression.

How to assess depression is indeed an issue. I am here to learn, so I appreciate your comments.

The main question raised by Levine's article in my mind was: if belief in the effectiveness of the treatment plays such an important role in the effectiveness of the treatment, how does a critical thinker suffering from depression overcome their skepticism about treatment effectiveness? Because apparently, their skepticism could be an obstacle to their own healing. And the data seem to indicate that skepticism about treatment effectiveness is justified!

 

[Dancing David]

How to assess depression is indeed an issue. I am here to learn, so I appreciate your comments.

The main question raised by Levine's article in my mind was: if belief in the effectiveness of the treatment plays such an important role in the effectiveness of the treatment, how does a critical thinker suffering from depression overcome their skepticism about treatment effectiveness? Because apparently, their skepticism could be an obstacle to their own healing. And the data seem to indicate that skepticism about treatment effectiveness is justified!

That is only that data that is not the overwhelming data. One set of meta-analysis based upon the flawed use of the Beck or Hamilton depression scales does not mean treatment is not effective. It means that the scales used are not effective at measuring level of symptomology. If you go to PubMed you will find that there are many studies that Kirsch does not consider. m(type in fluoxetine vs. placebo)

When appropriate measures are used, which vary from person to person, as symptoms vary, then treatment can be effective, with many caveats.

1. That the person works with doctor who has experience, if the first line of treatment does not work. (True in about 50% of cases) Switching to another AD or category of AD will be effective in many cases, but careful assessment helps a lot.

2. That diagnosis is made carefully, so a GP will need to refer to a psychiatrist after first line does not have effect. This is a real issue in assessment, often people are unrealizable historians at best and diagnosis may take 6 months to year to be clarified. Especially since bipolar disorder is difficult to differentiate from major depression.

3. The person receiving treatment avoids substance abuse.

4. The person receiving treatment makes life style changes as needed.

Assesment for depression can be indicated by use of the BDI or HDS, they can help a person determine that depression is present, that is why they are gross level tools.