10 ms·

> Other clinicians say, however, that the notion of depression being because of a simple chemical imbalance is outmoded anyway, and that antidepressants remain

> Other clinicians say, however, that the notion of depression being because of a simple chemical imbalance is outmoded anyway, and that antidepressants remain a useful option for patients alongside other approaches including talking therapies. This is the key line in the summary. The concept of attacking an idea no one really believes is really a straw man. More importantly the modern practice of medicine is "evidence based medicine", not "mechanism based medicine". That means treatments are tested as to if they work, not how they work. Ideally in multiple well run double blinded randomised controlled trials with at least some against treatment as usual. Unlike the past when we thought more about how they might work, theorising something is off about someone's humors and adjusting with leeches. Anyone looking for a truly mind bending result should look at Hjorth et al. 2021 [0], the study recruited people with social phobia and gave them all an SSRI (escitalopram). Half were told they were getting a sham active placebo and "should not expect to get better", half were told "you're getting the known effective treatment". Headline result being told you are being treated leads to 4x as much response with brain changes in the dopamin networks. In the meanwhile, rather than worry about how antidepressants work, why not take a look at electroconvulsive therapy which has proven time and again to be the most effective treatment for depression. Yet we have no idea how it works, other than knowing a decent seizure in those without epilepsy makes you less sad? What on earth. [0] https://www.nature.com/articles/s41398-021-01682-3 https://www.nature.com/articles/s41398-021-01682-3

varispeed 4y ago
> are tested as to if they work, not how they work Should they be doing both? I can't imagine shipping code that I don't know how it works, but it passes tests... Otherwise, you'll get pseudoscience - just mix random chemicals and see how patient reacts, rinse and repeat until something works...
- boesboes 4y ago
  > shipping code that I don't know how it works, but it passes tests We call that machine learning
  - rmbyrro 4y ago
    What isn't machine learning is sometimes called "tested code"
- fragcula 4y ago
  The psychiatrists themselves don't need to do both, as doctors practicing EBM they are interested in proven results. The decision to recommend a treatment (and to accept it) is based on the pros and cons only. What people really care about is side effects. That's one of the reasons modern pharmas are so fixated in testing old drugs for new disorders (the other reason is they might be able to get a new patent case in point when Eli Lilly made pink fluoxetine for girls with a new indication for PMS [0]). Similarly, the best way to identify side effects is by looking at the molecule and guessing (static analysis), testing with cells, animals or other non-human biological systems (I guess this is alpha testing as we rarely think of the testers as human...), and then in human studies (early access). Even then we roll out incrementally (phase 2), before widely testing in phase 3 and collecting feedback. [0] https://money.cnn.com/2000/07/06/companies/lilly/ https://money.cnn.com/2000/07/06/companies/lilly/
- vkou 4y ago
  > Should they be doing both? I can't imagine shipping code that I don't know how it works, but it passes tests... If that were the criteria, then we would not have medicine at all, because biological systems are so incredibly complicated, nobody understands even a tiny fraction of how a particular chemical will affect them.
  - harshreality 4y ago
    I don't think that's quite accurate. We know first-order biochemical effects for a lot of drugs. There are always side effects, but they're side-effects, and those are largely understood as well. Psych drugs have difficulties because they aren't used for their biochemical effects, they're used for their psychological effects, and psychological effects of biochemical processes are poorly understood.
    - fragcula 4y ago
      An extra foible is that many medications have psychiatric side effects. So even if you're prescribed a statin for the biochemical effect on cholesterol you might get some of the purported psychiatric effects.
- kurikuri 4y ago
  >Should they be doing both? Yes, but with different aims. The learning about ‘how a treatment works’ is useful for developing new potential treatments and new hypotheses, but the mechanism itself is not necessary nor sufficient in its potential treatment efficacy.
- workingon 4y ago
  Welcome to modern medicine.
openplatypus 4y ago
IMO key quote the study you referenced: > In conclusion, the anti-anxiety properties of SSRIs appear to be largely dependent on expectancy effects on dopamine signaling while SERT blockade is not sufficient for symptom remission. Drug works, if you believe it does :)
- fragcula 4y ago
  It's a shame that the imagining is so expensive, because I'd love to see a true control arm with placebos and follow up scans. i.e. if you are on a placebo and are told you will get better how many do?
  - daniel_iversen 4y ago
    Don’t they do truckloads of tests and comparisons on anti depression medicine all the time including blind trials etc?
    - fragcula 4y ago
      The interesting bits, for me, are the imaging scans which are expensive and slow and you need more than one for comparison per subject. Secondly the 'covert treatment' aspect, and as far as I know only Hjorth et al. do in any reasonable numbers is the giving someone the treatment and usual and tell them it's a placebo and they "shouldn't expect to get better". It's ethically tricky to do that with an anxiety disorder but I imagine a doctor telling someone with depression that will be painfully close to "you're not getting better", "we're not going to help you" and other quite rejecting disheartening ideas. But plain placebo controlled SSRI trials I think show about a 0.2 absolute benefit in SSRIs in depression. i.e. if you compare SSRI with placebo you need to treat 5 people with SSRI to see one more person respond. If you compare SSRI with no treatment, you only need to treat 3 people with depression, to have 1 more respond. Those 3 and 5 are called the 'number needed to treat' and can be compared to the 'number needed to harm'.
- kokey 4y ago
  I wouldn't be surprised about this when it comes to panic disorder. Just knowing you have some emergency fast acting anti anxiety medication nearby, just in case you need it, can reduce the number of panic attacks. There's probably all kinds of psychological feedback loops when people have anxiety about anxiety and then it escalates because they're anxious about it escalating. I am guessing that medication can help mitigate some components of that feedback loop for some people.
pineaux 4y ago
Most effective treatment for depression = psychedelics. They have been used by shamans for eons for this reason. A lot of modern research into this (including 1000s of research studies from the 50s and 60s) confirms it. It was only because Nixon didn't like the fact that kids were not going to war, that the war on drugs was started.
- MrDresden 4y ago
  Psilocybin has done wonders for my anxiety and depression in the past.
- DFHippie 4y ago
  > It was only because Nixon didn't like the fact that kids were not going to war, that the war on drugs was started. Was it this or that he saw asserting dominance over youth culture as a political winner? Judging from the present moment, bullying the less powerful seems to have a lot of political juice. People want to keep the uppities down.
- woevdbz 4y ago
  I'm not sure we know about the side effects very well yet though?
- sneak 4y ago
  Please do not assert pet theories as established scientific consensus or fact.
  - pineconewarrior 4y ago
    Lack of citation does not make it a "pet theory". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767816/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767816/ https://www.nature.com/articles/s41591-022-01744-z https://www.nature.com/articles/s41591-022-01744-z Go search it before being rude
    - wkearney99 4y ago
      Or, include the links yourself when making such claims? Unsupported comments are perhaps just as rude?
webmobdev 4y ago
> why not take a look at electroconvulsive therapy ... Yet we have no idea how it works ... Or you can stick with something that has been already been scientifically studied and proven to be as effective as anti-depressants in curing depression - Cognitive Therapy. In fact, it even prevents relapses more than anti-depressants: > Depression is one of the most prevalent and debilitating of the psychiatric disorders. Studies have shown that cognitive therapy is as efficacious as antidepressant medications at treating depression, and it seems to reduce the risk of relapse even after its discontinuation. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/ For those considering going to a CT therapist you can search for certified CT therapist from here: https://cares.beckinstitute.org/get-treatment/clinician-directory/ https://cares.beckinstitute.org/get-treatment/clinician-dire... (the Beck Institute was started by the founder of CT and is now run by his daughter who is also a professional in this field. Nowadays most therapist learn about CT during the education but only have the base knowledge of it and thus don't apply CT techniques properly during therapy, and remain ignorant of the advances in this field. Those who actually train and specialise in it are more effective.)
- Pigalowda 4y ago
  It’s not an either/or scenario. CBT is recommended already for pretty much all comers. ECT is last line in treatment refractory MDD.
- fragcula 4y ago
  We also don't know who CBT works for what it's worth. It's also fairly limited in suitability (good luck with someone with catatonic depression trying to get them do a hot cross bun), availability (thankfully online therapies are more common now, but it takes 2 mins a day to take a pill and about an hour per week for CBT), affordability (a year of sertraline will cost less than the initial session of session of CBT can).
ZeroGravitas 4y ago
I don't think that's an accurate summary of the state of the art on ECT: https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#electroconvulsive-therapy-for-depression https://www.nice.org.uk/guidance/ng222/chapter/Recommendatio... It sometimes works, it's contraindicated for certain people, comes near the end of the list of things to try (wait to see if you get better and get some excercise/sleep/sunlight being low risk interventions for mild depression) and even when it is used and does work, starting/continuing antidepressants and other treatments is recommended. It's just one more tool in an incomplete and inconsistent toolbox, not 1 weird trick your pharma company hates. I know of one person who recently had some success with it, but they tried other things first.
- fragcula 4y ago
  I'm not sure what part of what I said you disagree with. Nothing in the NICE guidelines explains how ECT works - because like the rest of the world NICE does not know. Once odd aspect with ECT is that it seems to transiently improve parkinson's, again no one knows why.
  - ZeroGravitas 4y ago
    I was disagreeing specifically with this bit: > electroconvulsive therapy which has proven time and again to be the most effective treatment for depression Switch "the most" for "an" and we agree I think.
    - fragcula 4y ago
      Oh I see. No ECT is most certainly the most efficacious treatment for depression we have. Talking therapies have a respone rate in depression of circa 40% [0], probably just slightly higher for antidepressants up to about 50% and faster [1], ECT respone rate is well over than even for those with treatment resistance but as high as 90% [2]. Vitally, the reposnse to ECT is fast and is often under 10 days. The fact that ECT is burdensome, limited in availability and stigmatizing (which is why it's got so much legislative structure around it) is not relevant for it's efficacy. This is spelled out relatively well in the UK's Royal College of Psychiatry statement on ECT [3] > ECT IS A FIRST-LINE TREATMENT FOR PATIENTS ... where a rapid definitive response for the emergency treatment of depression is needed This is because it works quickly and reliably to treat depression. [0] https://onlinelibrary.wiley.com/doi/full/10.1111/acps.13335 https://onlinelibrary.wiley.com/doi/full/10.1111/acps.13335 [1] https://journals.sagepub.com/doi/pdf/10.1177/070674371005500303 https://journals.sagepub.com/doi/pdf/10.1177/070674371005500... [2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650296/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650296/ [3] https://www.rcpsych.ac.uk/docs/default-source/about-us/who-we-are/electroconvulsive-therapy---ect-ctee-statement-feb17.pdf?sfvrsn=2f4a94f9_2 https://www.rcpsych.ac.uk/docs/default-source/about-us/who-w...
s1artibartfast 4y ago
>That means treatments are tested as to if they work, not how they work. Ideally in multiple well run double blinded randomised controlled trials with at least some against treatment There are some concerning departures from this with medical approvals based not on treatment, but biomarkers. Without getting too political, two noteworthy recent examples come to mind. The first is abelacimab for alzheimer's, approved based on plaque, not disease progression. The other is juvenile covid vaccines, approved based on antibody presence.
- fragcula 4y ago
  abelacimab in particular was quite worrying. The BMJ (the journal OP posted) contained a criticism of that. Similarly as you say is that because numbers are easy to think about antibody titres somehow took over the world when it came to covid vaccination. Despite good evidence t-cell activity is important for preventing severe disease.
sinecure 4y ago
Belief dictates reality. This is the fundamental driver behind the common effectiveness of placebo. Which leads to the question, does depression exist as a flaw in the brain? A malfunction? Or is it like a mind virus, that it becomes an inescapable suffering because we are told we are broken and powerless to fight these feelings? If a person is feeling sad, often, and without reason, and you tell them "Sorry, your brain is broken, you have depression, we will give you these pills to fix your brain chemistry." You have taken that person's autonomy away. They are now the victim of a disease. I think the reality is that our society and civilization leads to a certain despair and sadness in many people, one that can be fixed by changing one's lifestyle, mindset, or overcoming challenges. This is not a disease, not a mental illness, not some health problem you cure with a pill. It's a spiritual dilemma that must be faced individually and overcome with effort and belief that one can change. Essentially, I believe that by diagnosing people with "clinical depression" we are creating a self fulfilling prophecy and condemning them to a victim status that perpetuates their suffering.
- hirvi74 4y ago
  How would you describe a condition like Bipolar Disorder where the brain swings in both directions? Depression is half of Bipolar, but is the brain broken in this case? What about the manifestation of psychotic features? Based on my understanding of the condition, typical anti-depressants tend to be a contraindication for Bipolar Disorder (can induce mania), so in some regards it seems like the medications not only work for Bipolar, but they work a little too well. If depression is not a disease, is Bipolar a disease -- half a disease? I am curious what you think. I do not suffer from BP, but I was misdiagnosed with it at one time (I never had psychotic episodes or anything), and doctors wanted to load me up with medications. Luckily, I refused, and I later found out that wasn't the issue, which caused me to lose a lot of faith in psychology/psychiatry. However, the whole process made me more empathic to those with the disorder.
  - sinecure 4y ago
    A childhood friend of mine developed schizophrenia at 25, so I am surely convinced of the existence of true mental illness. To me a mental illness is defined as a clear defect in the workings of the brain, such that you have uncontrollable hallucinations and mania. I am not as familiar with bipolar disorder, but my overall argument is not that mental illness is non-existent, it's that depression is either vastly over-diagnosed or should not be categorized in the same group as schizophrenia and the like. Where is the line between "I've abused my brain with the comforts and overstimulation of modernity and now I am not happy" with "I was born to be sad because I'm genetically broken"? In the end psychology is just too political and too lacking in scientific rigor to handle these questions. the DSM is essentially a politically motivated group of academics voting on what is or isn't a mental illness. At one point homosexuality was a mental illness, seen as a deviance in brain function leading to the end of reproduction. But the political tides changed and now it is no longer classified that way. How can we drug people for a lifetime based on the changing tide of academic bureaucrats who vote on what is or isn't normal? Is it too cynical to believe that the pharmaceutical companies making massive profit off of the mental health drug industry are not backing the psychologists making DSM decisions? A kid comes in saying he's depressed all the time. They ask him what's wrong, why he is unhappy? He complains about feeling sad all the time without reason. They give him anti-depressants. But what about the fact that he plays video games all day, watches porn constantly, is on booze and weed and stimulants, is constantly browsing novel media on his smartphone, constantly entertained with netflix, he's blasted with supernormal stimuli 24/7 and then wonder's why his brain chemistry is out of whack... yet the mental health industry would rather see him drugged up on profit making anti-depressants rather than struggle through the years of effort and therapy to change his lifestyle.
gentleman11 4y ago
It seems to work, by definition, but I don’t think this approach qualifies as science. For a theory to be science, there has to be at least some mechanism. This is just statistics. Again, it works

varispeed 4y ago

> are tested as to if they work, not how they work Should they be doing both? I can't imagine shipping code that I don't know how it works, but it passes tests... Otherwise, you'll get pseudoscience - just mix random chemicals and see how patient reacts, rinse and repeat until something works...

boesboes 4y ago
> shipping code that I don't know how it works, but it passes tests We call that machine learning
- rmbyrro 4y ago
  What isn't machine learning is sometimes called "tested code"
fragcula 4y ago
The psychiatrists themselves don't need to do both, as doctors practicing EBM they are interested in proven results. The decision to recommend a treatment (and to accept it) is based on the pros and cons only. What people really care about is side effects. That's one of the reasons modern pharmas are so fixated in testing old drugs for new disorders (the other reason is they might be able to get a new patent case in point when Eli Lilly made pink fluoxetine for girls with a new indication for PMS [0]). Similarly, the best way to identify side effects is by looking at the molecule and guessing (static analysis), testing with cells, animals or other non-human biological systems (I guess this is alpha testing as we rarely think of the testers as human...), and then in human studies (early access). Even then we roll out incrementally (phase 2), before widely testing in phase 3 and collecting feedback. [0] https://money.cnn.com/2000/07/06/companies/lilly/ https://money.cnn.com/2000/07/06/companies/lilly/
vkou 4y ago
> Should they be doing both? I can't imagine shipping code that I don't know how it works, but it passes tests... If that were the criteria, then we would not have medicine at all, because biological systems are so incredibly complicated, nobody understands even a tiny fraction of how a particular chemical will affect them.
- harshreality 4y ago
  I don't think that's quite accurate. We know first-order biochemical effects for a lot of drugs. There are always side effects, but they're side-effects, and those are largely understood as well. Psych drugs have difficulties because they aren't used for their biochemical effects, they're used for their psychological effects, and psychological effects of biochemical processes are poorly understood.
  - fragcula 4y ago
    An extra foible is that many medications have psychiatric side effects. So even if you're prescribed a statin for the biochemical effect on cholesterol you might get some of the purported psychiatric effects.
kurikuri 4y ago
>Should they be doing both? Yes, but with different aims. The learning about ‘how a treatment works’ is useful for developing new potential treatments and new hypotheses, but the mechanism itself is not necessary nor sufficient in its potential treatment efficacy.
workingon 4y ago
Welcome to modern medicine.

openplatypus 4y ago

IMO key quote the study you referenced: > In conclusion, the anti-anxiety properties of SSRIs appear to be largely dependent on expectancy effects on dopamine signaling while SERT blockade is not sufficient for symptom remission. Drug works, if you believe it does :)

fragcula 4y ago
It's a shame that the imagining is so expensive, because I'd love to see a true control arm with placebos and follow up scans. i.e. if you are on a placebo and are told you will get better how many do?
- daniel_iversen 4y ago
  Don’t they do truckloads of tests and comparisons on anti depression medicine all the time including blind trials etc?
  - fragcula 4y ago
    The interesting bits, for me, are the imaging scans which are expensive and slow and you need more than one for comparison per subject. Secondly the 'covert treatment' aspect, and as far as I know only Hjorth et al. do in any reasonable numbers is the giving someone the treatment and usual and tell them it's a placebo and they "shouldn't expect to get better". It's ethically tricky to do that with an anxiety disorder but I imagine a doctor telling someone with depression that will be painfully close to "you're not getting better", "we're not going to help you" and other quite rejecting disheartening ideas. But plain placebo controlled SSRI trials I think show about a 0.2 absolute benefit in SSRIs in depression. i.e. if you compare SSRI with placebo you need to treat 5 people with SSRI to see one more person respond. If you compare SSRI with no treatment, you only need to treat 3 people with depression, to have 1 more respond. Those 3 and 5 are called the 'number needed to treat' and can be compared to the 'number needed to harm'.
kokey 4y ago
I wouldn't be surprised about this when it comes to panic disorder. Just knowing you have some emergency fast acting anti anxiety medication nearby, just in case you need it, can reduce the number of panic attacks. There's probably all kinds of psychological feedback loops when people have anxiety about anxiety and then it escalates because they're anxious about it escalating. I am guessing that medication can help mitigate some components of that feedback loop for some people.

pineaux 4y ago

Most effective treatment for depression = psychedelics. They have been used by shamans for eons for this reason. A lot of modern research into this (including 1000s of research studies from the 50s and 60s) confirms it. It was only because Nixon didn't like the fact that kids were not going to war, that the war on drugs was started.

MrDresden 4y ago
Psilocybin has done wonders for my anxiety and depression in the past.
DFHippie 4y ago
> It was only because Nixon didn't like the fact that kids were not going to war, that the war on drugs was started. Was it this or that he saw asserting dominance over youth culture as a political winner? Judging from the present moment, bullying the less powerful seems to have a lot of political juice. People want to keep the uppities down.
woevdbz 4y ago
I'm not sure we know about the side effects very well yet though?
sneak 4y ago
Please do not assert pet theories as established scientific consensus or fact.
- pineconewarrior 4y ago
  Lack of citation does not make it a "pet theory". https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767816/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6767816/ https://www.nature.com/articles/s41591-022-01744-z https://www.nature.com/articles/s41591-022-01744-z Go search it before being rude
  - wkearney99 4y ago
    Or, include the links yourself when making such claims? Unsupported comments are perhaps just as rude?

webmobdev 4y ago

> why not take a look at electroconvulsive therapy ... Yet we have no idea how it works ... Or you can stick with something that has been already been scientifically studied and proven to be as effective as anti-depressants in curing depression - Cognitive Therapy. In fact, it even prevents relapses more than anti-depressants: > Depression is one of the most prevalent and debilitating of the psychiatric disorders. Studies have shown that cognitive therapy is as efficacious as antidepressant medications at treating depression, and it seems to reduce the risk of relapse even after its discontinuation. - https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2748674/ For those considering going to a CT therapist you can search for certified CT therapist from here: https://cares.beckinstitute.org/get-treatment/clinician-directory/ https://cares.beckinstitute.org/get-treatment/clinician-dire... (the Beck Institute was started by the founder of CT and is now run by his daughter who is also a professional in this field. Nowadays most therapist learn about CT during the education but only have the base knowledge of it and thus don't apply CT techniques properly during therapy, and remain ignorant of the advances in this field. Those who actually train and specialise in it are more effective.)

Pigalowda 4y ago
It’s not an either/or scenario. CBT is recommended already for pretty much all comers. ECT is last line in treatment refractory MDD.
fragcula 4y ago
We also don't know who CBT works for what it's worth. It's also fairly limited in suitability (good luck with someone with catatonic depression trying to get them do a hot cross bun), availability (thankfully online therapies are more common now, but it takes 2 mins a day to take a pill and about an hour per week for CBT), affordability (a year of sertraline will cost less than the initial session of session of CBT can).

ZeroGravitas 4y ago

I don't think that's an accurate summary of the state of the art on ECT: https://www.nice.org.uk/guidance/ng222/chapter/Recommendations#electroconvulsive-therapy-for-depression https://www.nice.org.uk/guidance/ng222/chapter/Recommendatio... It sometimes works, it's contraindicated for certain people, comes near the end of the list of things to try (wait to see if you get better and get some excercise/sleep/sunlight being low risk interventions for mild depression) and even when it is used and does work, starting/continuing antidepressants and other treatments is recommended. It's just one more tool in an incomplete and inconsistent toolbox, not 1 weird trick your pharma company hates. I know of one person who recently had some success with it, but they tried other things first.

fragcula 4y ago
I'm not sure what part of what I said you disagree with. Nothing in the NICE guidelines explains how ECT works - because like the rest of the world NICE does not know. Once odd aspect with ECT is that it seems to transiently improve parkinson's, again no one knows why.
- ZeroGravitas 4y ago
  I was disagreeing specifically with this bit: > electroconvulsive therapy which has proven time and again to be the most effective treatment for depression Switch "the most" for "an" and we agree I think.
  - fragcula 4y ago
    Oh I see. No ECT is most certainly the most efficacious treatment for depression we have. Talking therapies have a respone rate in depression of circa 40% [0], probably just slightly higher for antidepressants up to about 50% and faster [1], ECT respone rate is well over than even for those with treatment resistance but as high as 90% [2]. Vitally, the reposnse to ECT is fast and is often under 10 days. The fact that ECT is burdensome, limited in availability and stigmatizing (which is why it's got so much legislative structure around it) is not relevant for it's efficacy. This is spelled out relatively well in the UK's Royal College of Psychiatry statement on ECT [3] > ECT IS A FIRST-LINE TREATMENT FOR PATIENTS ... where a rapid definitive response for the emergency treatment of depression is needed This is because it works quickly and reliably to treat depression. [0] https://onlinelibrary.wiley.com/doi/full/10.1111/acps.13335 https://onlinelibrary.wiley.com/doi/full/10.1111/acps.13335 [1] https://journals.sagepub.com/doi/pdf/10.1177/070674371005500303 https://journals.sagepub.com/doi/pdf/10.1177/070674371005500... [2] https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650296/ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3650296/ [3] https://www.rcpsych.ac.uk/docs/default-source/about-us/who-we-are/electroconvulsive-therapy---ect-ctee-statement-feb17.pdf?sfvrsn=2f4a94f9_2 https://www.rcpsych.ac.uk/docs/default-source/about-us/who-w...

s1artibartfast 4y ago

>That means treatments are tested as to if they work, not how they work. Ideally in multiple well run double blinded randomised controlled trials with at least some against treatment There are some concerning departures from this with medical approvals based not on treatment, but biomarkers. Without getting too political, two noteworthy recent examples come to mind. The first is abelacimab for alzheimer's, approved based on plaque, not disease progression. The other is juvenile covid vaccines, approved based on antibody presence.

fragcula 4y ago
abelacimab in particular was quite worrying. The BMJ (the journal OP posted) contained a criticism of that. Similarly as you say is that because numbers are easy to think about antibody titres somehow took over the world when it came to covid vaccination. Despite good evidence t-cell activity is important for preventing severe disease.

sinecure 4y ago

Belief dictates reality. This is the fundamental driver behind the common effectiveness of placebo. Which leads to the question, does depression exist as a flaw in the brain? A malfunction? Or is it like a mind virus, that it becomes an inescapable suffering because we are told we are broken and powerless to fight these feelings? If a person is feeling sad, often, and without reason, and you tell them "Sorry, your brain is broken, you have depression, we will give you these pills to fix your brain chemistry." You have taken that person's autonomy away. They are now the victim of a disease. I think the reality is that our society and civilization leads to a certain despair and sadness in many people, one that can be fixed by changing one's lifestyle, mindset, or overcoming challenges. This is not a disease, not a mental illness, not some health problem you cure with a pill. It's a spiritual dilemma that must be faced individually and overcome with effort and belief that one can change. Essentially, I believe that by diagnosing people with "clinical depression" we are creating a self fulfilling prophecy and condemning them to a victim status that perpetuates their suffering.

hirvi74 4y ago
How would you describe a condition like Bipolar Disorder where the brain swings in both directions? Depression is half of Bipolar, but is the brain broken in this case? What about the manifestation of psychotic features? Based on my understanding of the condition, typical anti-depressants tend to be a contraindication for Bipolar Disorder (can induce mania), so in some regards it seems like the medications not only work for Bipolar, but they work a little too well. If depression is not a disease, is Bipolar a disease -- half a disease? I am curious what you think. I do not suffer from BP, but I was misdiagnosed with it at one time (I never had psychotic episodes or anything), and doctors wanted to load me up with medications. Luckily, I refused, and I later found out that wasn't the issue, which caused me to lose a lot of faith in psychology/psychiatry. However, the whole process made me more empathic to those with the disorder.
- sinecure 4y ago
  A childhood friend of mine developed schizophrenia at 25, so I am surely convinced of the existence of true mental illness. To me a mental illness is defined as a clear defect in the workings of the brain, such that you have uncontrollable hallucinations and mania. I am not as familiar with bipolar disorder, but my overall argument is not that mental illness is non-existent, it's that depression is either vastly over-diagnosed or should not be categorized in the same group as schizophrenia and the like. Where is the line between "I've abused my brain with the comforts and overstimulation of modernity and now I am not happy" with "I was born to be sad because I'm genetically broken"? In the end psychology is just too political and too lacking in scientific rigor to handle these questions. the DSM is essentially a politically motivated group of academics voting on what is or isn't a mental illness. At one point homosexuality was a mental illness, seen as a deviance in brain function leading to the end of reproduction. But the political tides changed and now it is no longer classified that way. How can we drug people for a lifetime based on the changing tide of academic bureaucrats who vote on what is or isn't normal? Is it too cynical to believe that the pharmaceutical companies making massive profit off of the mental health drug industry are not backing the psychologists making DSM decisions? A kid comes in saying he's depressed all the time. They ask him what's wrong, why he is unhappy? He complains about feeling sad all the time without reason. They give him anti-depressants. But what about the fact that he plays video games all day, watches porn constantly, is on booze and weed and stimulants, is constantly browsing novel media on his smartphone, constantly entertained with netflix, he's blasted with supernormal stimuli 24/7 and then wonder's why his brain chemistry is out of whack... yet the mental health industry would rather see him drugged up on profit making anti-depressants rather than struggle through the years of effort and therapy to change his lifestyle.

gentleman11 4y ago

It seems to work, by definition, but I don’t think this approach qualifies as science. For a theory to be science, there has to be at least some mechanism. This is just statistics. Again, it works