Could you please tell me what does work?
Thanks in advance.
Donna
Column in question. According to which, a big fat placebo is your best bet.
Anecdotally: Prozac worked for me. It helped a lot, I took it for about a decade.
What worked better was finally quitting the job that was stressing and depressing me. Within six weeks of walking off that job, I was off Prozac and haven’t felt truly depressed at all.
Depression does run in my family, on my mother’s side for sure, and if Prozac had been invented in the 60’s my life would have certainly been better (or alternatively I would have never been born).
But of course you have to somehow manage to take the placebo without knowing it’s a placebo otherwise it will be totally ineffective.
When a treatment’s only measure for success is “how you feel” placebos will always be effective to some degree. The brain is the center for how we perceive everything we “feel”, so if someone truly believes they’ve taken a magic bullet that is going to make them feel better, they very often will start to feel better.
This is true of pain medication too. The percentage of people reporting an improvement in pain after taking a placebo vs. real pain medication is similarly high to that of patients reporting improvement in depression after taking placebos vs. anti-depressants. That is really no surprise to anyone and doesn’t mean anti-depressants are ineffective, any more so than morphine is ineffective as a pain killer just because a high percentage of people feel less pain after taking a sugar pill.
IANAD, but my understanding is that anti-depressants are a lot more effective than placebos when you get into severe cases of depression. A placebo isn’t going to make someone with 3rd degree burns feel much less pain, and a placebo isn’t going to make someone with a major depressive disorder feel much better.
Anti-depressants, especially newer ones in the SSRI class show significantly better results than placebos in cases of major depressive and anxiety disorders. They couldn’t even get approval from the regulatory agencies if clinical trials didn’t suggest greater than placebo effectiveness. The fact they may be over prescribed, or prescribed for more minor cases of depression, doesn’t make them ineffective in the cases where they are warranted.
Much as I hate to recommend a second opinion over Cecil, in this case I would strongly urge anyone suffering from depression to talk to a qualified therapist about treatment options.
Chemical imbalances that cause depression come in several different forms.
So, a pill that helps with one type of imbalance won’t help the others and in some cases actually make things worse. (This means a shrink will run a patient thru several different ones till they find one that works. With the downside that a depressed person might get the wrong one at first and get even more depressed. Hence the suicide warnings for these drugs.)
So a study of a pill’s effectiveness is fairly hard to do. Some get better, some stay the same, some get worse. Are the ones who got better the placebo effect?
Note that blind re-testing the ones that got better with the real drug or a sugar pill is hard since the side effects are usually quite noticeable. Once you had the real thing, you’re going to know if you’re getting it again or a fake pill.
In the early days of anti-depressants it was fairly easy to tell. Enough people got substantially better there was no question. The low hanging fruit had been picked.
Since there are still people who don’t get better regardless of medication, drug companies want to find something new that works for them. (As well as having a new product that “works better” and can be patented vs. older drugs that can be sold by anyone.)
The testing is much harder. The number of people it is expected to help is even smaller. The expected effects are likely to be smaller. Etc.
Now the noise in the data due to the placebo effect is a problem.
But to say the whole area is iffy is completely wrong and is harmful to people with serious problems that can be greatly helped.
Could you please tell me what does work?
If there’s an underlying cause, then correct this cause. Stressful job, unhappy marriage, being a New York Mets fan; just changing these factors may be enough to break someone out of their depressive state. Is there a biological issue? If your body is busy fighting some manner of viral infection, this effort may well be depriving other biological functions that manifests as depression. Human nature as it is, just taking a pill at the same time as your body eliminates the infection or you realize the New York Rangers still have a decent shot at the playoffs doesn’t mean the pill fixed anything, no matter how much you want to believe it did.
On the other end of the spectrum, we have situations like ftg pointed out, and The Master acknowledges, where there is a serious problem and here these antidepressants have a tendency to work as expected.
I once mentioned to my therapist that I’m prone to depressive states and she asked my about my diet. At that moment in time I hadn’t actually eaten anything in over 24 hours. Well, she poked me in the chest a couple of times and made me promise to eat two meals a day. That turned out to be complete curative, haven’t had a serious bout with the blues since. I just thought that was interesting that my therapist picked up on that right away, first and foremost.
Even if there are other reasons for the depression, a healthy diet is a great first step towards ending the problem.
Oddly enough, not so. “Scientists tell us” that a placebo effect exists even when patients are told that the treatment is a placebo.
The size of a placebo effect depends on many factors: famously, injections are more effective than pills. “What the doctor tells you” is known to be a not very important factor in any medical intervention. Of course, that’s true for a lot of things: we often don’t pay much attention to what people are telling us…
It’s an odd situation knowing about placebos and being something of a skeptic. I did a basic psych subject at college the lecturer for which happened to have medical psych as his speciality, and consequently I recall a lot of examples about how a bedside manner with gravitas, stereotypical indicators of medical authority (white coat, stethoscope), and apparent careful consideration of the medical issue all improve patient outcomes even if the actual treatment is no different to that prescribed by a doctor who is far more casual.
My current Dr is the best I’ve ever had. He runs through long lists of questions about symptoms and listens and makes careful notes of my answers, conducts substantial physical examinations, and has a stern and authoritative manner. And I get good outcomes if I follow his advice. But in the back of my mind I know that his manner may be having substantial placebo effect. However, I have no doubt his advice and prescriptions etc are as effective as they can be, and if I’m getting some extra apparent benefit because of “medical theatre”, great. No point in thinking about it too much, may as well go with it.
Now that is weird. I can understand the body responding when the patient believes that he’s taken a medicine; belief is a powerful thing. But when the patient knows that the ‘medicine’ isn’t that at all it’s difficult to see what the body would be responding to.
The idea that, even though it’s a placebo, the doctor has said it will work, and it does. Or just that it naturally got better over time, and that was attributed to the placebo.
I do want to add, however, that it’s not just what you think. If you take a opiod antagonist, the pain killing effects of placebos actually decrease. So the placebo actually causes you to create your own pain killers. It’s not just “positive thinking.”
And then, in the different strokes for different folks department, I also have a lot of depression in the family tree (Dad’s side!) and have been diagnosed for well over a decade. My first antidepressant was Effexor, which just made me nasty. Prozac made me a zombie. Wellbutrin, on the other hand, seems to be my happy pill, for whatever reason.
Two cents. You’re welcome.
Cecil is not a MD and should not be providing medical advice. As an attorney, I’m really glad that I’m not his attorney with regard to this unqualified provision of advice.
I’m also a PhD Cognitive Scientist who has worked as an expert on mental disorders and the diagnostic processes for these disorders, as well as the detection of patient malingering and deception. This was with regard to litigation centered on causation of mental disorders and memory disorders.
And I have been quite accurately diagnosed with an anxiety disorder and a depressive disorder. These are being treated with medication supplemented by changes in behavior to the extent that such things are reasonable.
There is a huge difference between problems that can be solved by rather simple behavioral modifications (e.g., negative emotional states caused by not eating properly) and those requiring more extensive intervention. These can be both targeted analysis of behavior and chemical intervention, and often should be both.
Extensive research and testing has produced huge amounts of evidence for the efficacy of various chemical and behavioral treatments. Are there issues with placebos? Yes. Are there issues with maintaining a double-blind protocol for pharmaceutical development? Yes. Issues with the profit motive during drug development and distribution? Yes. Poor practitioners who rely too heavily on drugs, or fail to recognize when they are needed? Yes.
Is Cecil the first one to point this out, or are there academic researchers, medical, and pharmaceutical specialists working in the field, at companies, and within government agencies like FDA, NIH, and NIMH who have studied these issues for decades? Yes, there are specialists who have decades of experience, thousands of specialists with decades of experience.
It’s one thing to figure out the origin of song lyrics and other sorts of cultural and anthropological curiosities, or provide a brief summary about what killed the dinosaurs based on popular science journalism. It’s another thing to spout beliefs about medicine or other complex professional subjects, like the law, without specialized training.
That sort of thing is dangerous. Potentially deadly. I wouldn’t go to Cecil for advice on how to defend myself against legal charges of, well, anything at all. And the same goes for medicine.
Cecil should know better.
Also certain suggestions about non-clinical treatment for depression are far too facile.
Quitting your stressful job and getting another one is not a simple matter for many people. This is, in itself, a major life stressor that can increase depressive symptoms, especially if the process of changing jobs is going poorly. People have financial and social obligations that may make this highly difficult. The most common source of difficulty is having children to support.
In many cases, getting a new job means moving to another location. Depending on your job, this may be another town, or another state, or another country. Your spouse may not want to move because that may mean that your spouse also may have to get a new job. They may be perfectly happy with their job, or finding a new job may be extremely difficult for them.
You, your spouse, and your children may not want to lose their relationships with friends and family. Your change of job may make you happier but may make them unhappier, perhaps to the point where they are as depressed with their new situation as you were with your previous situation.
But you can just ditch that spouse, right? Nothing complicated about that. Divorce is just signing some papers. Your children won’t mind. You won’t upset your relationships with friends. Nope.
Divorce is another major life stressor. Even if it ultimately is the best thing for you, you will probably become much more stressed and perhaps more depressed, for quite some time if you take this route.
You may consider pharmaceutical treatment to be preferable to such major life changes.
So let’s treat these options with the gravity they deserve and with the recognition that they may be nearly impossible, or in fact impossible.
We are also getting some erroneous opinions here.
Sorry ftg, but the history of pharmaceuticals for mental disorders is not one of increasing difficulties due to the plucking of the low-hanging fruit.
In fact, early treatments were often of low efficacy. They may have had terrible side effects. Let’s recall the “Hitler” of mental illness remedies for depression and other issues: the lobotomy.
New pharmaceutical treatments for depression and other health problems are often sought because they have fewer negative side effects and because they work better than the old ones.
Welbutrin (bupropion) is one of these medications. Among other benefits, it has a smaller negative impact on sexual functioning and on energy levels in general. This is why many patients find it to be preferable to Effexor and Prozac.
Also, the major reason for the suicide warnings isn’t that an ineffective medication may make someone more depressed and take their life. It’s pretty much the opposite. The problem is that a severely depressed patient may be so depressed that they think that they shouldn’t even bother killing themself and/or will just fail if they try. Then they’re given an antidepressant that improves their mood and confidence. The result is that they now believe they have the competency to kill themselves successfully and that it will be worth doing. Getting better can be deadly. That was a surprise, and that’s why the warnings were created.
Mileage Variations:
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Prozac was my first. In the initial dose it seemed to help, so my psychiatrist increased it to the point of diminishing returns. My maintenance dose is 40mg in the morning and a 20mg booster in the afternoon because I process it real fast. Downside is that my 3D vision vanishes at any dose, making me a cautious driver–objects may be closer or farther than they look. It comes back about two days after I stop taking it.
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Doctors don’t like negative side effects, so they keep trying out Welbutrin. I keep telling them it does nothing, that a month of it while weaning off Prozac is very uncomfortable. One said it takes a month to get your levels up high enough to notice. I said that other drugs, like cocaine and heroin, work right away.
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Tried a month of Effexor samples. Comparable to Prozac, maybe better vision, but the past few years my insurance has ranged from non-existent to crappy and Vitamin P is on the $4 menu at Walmart.
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Trazadone helps me sleep and is handy for [del]panic attacks[/del] cases of the whim-whams.
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Mr Cecil Adams is starting to show his age and should not be trusted regarding medicine, the spiciness of food (“Is there garlic in this? You know that gives me the bloat.”), and whatever that crap is that kids listen to these days.
From the article in question:
In other words, antidepressants worked more often than placebos, by a ratio of 46/38 (approximately 1.21) . Conversely, antidepressants failed less often than placebos, by a ratio of 62/54 (approximately 1.15).
In other words, antidepressants worked better than placebos by a ratio of either 100/68 (approximately 1.47) or 100/84 (approximately 1.19).
So Cecil’s own sources say that antidepressants are roughly 20% better than placebos.
In the world of medicine, an improvement of even a few percent can be highly valuable. Suppose you have 25 million cancer patients and there’s two treatments available: one work 34% of the time and the other works 36%. Using the latter instead of the former translates into saving the lives of an extra half a million people. That’s totally worth it. When you find a treatment that works a whopping 20% better than something else, you jump on it.
One approach that many people find helpful is participation in user-run self-help groups, mutual support networks of folks who have cognitive or emotional issues.
There are some people who say that this, by itself, is not sufficient for them, but almost no one has found it harmful.
There are some user-run orgs that are very anti-psychiatric-system in attitude (and part of the mutual support is validation of each other’s anger at what the psychiatric system has perpetrated), but for the benefit of folks who don’t share that sentiment, there are others that describe themselves as “psychiatric consumers” organizations —and both types of organization tend to embrace self-help as a good thing.
Being part of such a group tends to keep you out of the locked ward. And out of the morgue, for that matter.
You can open up and tell people things that you’d often be self-conscious about saying to someone who has never had a psychiatric diagnosis. You can talk about stuff without worrying as much about what they will think of you, or whether they’ll be condescending and treat you like broken merchandise from then on, because we’ve all been there ourselves.
Unfortunately, this is some of Cecil’s worst work… some of the comments here are worthwhile but basically ignore everything and go to a professional if you have questions about depression…
The ironic thing about this is on a site about the truth Cecil answers a question about medicine by bringing up one of the most damaging and false conspiracy theories - basically the “qui bound” theory of modern medicine.
I hear it all the time. Basically we (the medical establishment) benefit from human sickness, we make money when people are depressed or get cancer…
Therefore, since it’s in our interest we must also be the cause of the sickness or st the very least be motivated to suppress permanent cures in favor of palliative care…
Logical. But totally false. When a patient comes in w Non-Hodgkins lymphoma we cure them. We hope never to see them again. In recent years we have managed HIV. We have a low cost vaccine and the health care industry we make far less of HIV related health problems. We are not evil. It’s just hard to cure a lot of things. Health care isn’t run by a cabal of industrialists! It’s a complicated group of interests… Heres an example far more realistic than Cecil’s.
Pull business Cecil doesn’t want to cure you. That’s fine. But there are tons of scientists doing basic research at universities across the country. They want to cure you and are more motivated by a nobel prize in medicine and the ego boost associated with curing depression than making money. When one of them makes progress on a permanent “cure” for depression… it will be big news. Pharma Cecil doesn’t have to invest. But his competitor will. Most pharma companies have an entire branch for rare disease (i.e. Disease that doesn’t make a profit). Pharma Cecil will be out of business and depression will be cured, people will live longer and we can make more money off them in old age!
Not only is this column one of Cecil’s poorer efforts, it features the dumbest statement I have ever seen in such an article:
"For starters, if I’m in the antidepressant business, I’m not about to sell a product that permanently cheers people up. What I want is something they need on a regular basis, like a nice glass of wine — an antidepressant that works on a lot of levels, including financially for the winemaker and therapeutically for everybody else.
This is similar to the conspiracy crap that we commonly hear from the woo-prone and promoters of quackery - the idea that we don’t have cures for cancer and many chronic diseases because drug companies are suppressing them in favor of keeping you on pills for life. Could it have anything to do with the fact that it’s really hard to devise permanent cures, which would benefit Big Pharma workers, executives and their families just like everyone else (not to mention making a fortune for whoever invented and marketed them)? Nah.
"Summing up, it’s fair to say a common attitude in the medical community is basically take your Prozac and don’t come back.’
Cecil is basing this conclusion based in part on evidence of the frequency of antidepressant prescriptions, along with the claim that there is no psychiatric diagnosis in a high percentage of such cases. Apparently he means there is no diagnosis by a psychiatrist (as opposed to a primary care doc) but it’s hard to tell. The article also doesn’t differentiate between major depression as opposed to much milder forms which may be overmedicated, and assumes (on what basis, we can’t tell) that primary care physicians never inquire about lifestyle and job stressors or suggest non-pharmaceutical interventions for milder depression (exercise, diet, various coping strategies etc.) and just hand out pills, a meme that’s straight out of the playbook of NaturalNews and similar sites.
Lousy job, Cecil.
Meantime, there’s been a recent study suggesting that relatively poor performance of SSRIs against depression based on reviews of clinical trials is related to use of an insensitive clinical rating scale (the Hamilton questionnaire) where answers commonly overlap between depressed and non-depressed people. When the researchers reviewed such studies and concentrated on the response from patients simply regarding depressed mood, they found that SSRIs did significant better than placebo in a very high percentage of patients.