3 ms·

Most of your points pertain to placebo controlled trials of antidepressants. No argument there... it's a very difficult area ripe for abuse. I wouldn't however

by Gatsky 14y ago

Most of your points pertain to placebo controlled trials of antidepressants. No argument there... it's a very difficult area ripe for abuse. I wouldn't however use this as justification that all trials of all drugs are rubbish. Your arguments regarding non psychiatric medicines are weaker. For example, in oncology trials you state that the practice of excluding patients who are elderly or frail is 'not a good way to find out how to treat most cancer patients.' The reality is that it is very difficult to show any evidence of benefit in patients that aren't fit to start off with. This is because not being fit is a strong determinant of poor outcome. If you include them in the trial then it will be negative, and even those patients who might benefit won't ever get the treatment. This isn't bad science, it is just the required degree of pragmatism when resources for running trials are scarce. The way the research is done in reality is first you give the drug to the people most likely to benefit, and then if it works for them, test it in other groups less likely to benefit by running trials specifically in the elderly or frail groups. When these trials don't exist, and they often don't, the oncologist discusses the options with the patient and family based on the available evidence. They don't, as you seem to imply, give chemotherapy to everyone that walks in the door because Pfizer took them to lunch. So definitely agree for antidepressant trials. But not for everything else. Although I haven't read Ben Goldacre's book. Yet.

Alex3917 14y ago
"This is because not being fit is a strong determinant of poor outcome. If you include them in the trial then it will be negative" I think this would be an extremely valid argument, except for the fact that these drugs are in fact targeted at, and mainly used by, the population that is older and more frail. And this doesn't just apply to cancer drugs, it applies to NSAIDs and all sorts of other garden variety treatments. I realize there are limited resources, but the end result is that the vast majority of the elderly (by far the biggest consumers of drugs) are taking medicines that have never been tested for safety or efficacy in people like them. Also, it's not just SSRIs. There are a wide range of psychiatric and non-psychiatric drugs that are either no more effective than placebos or generics: SSRIs, benzos, ADHD drugs, anti-psychotics, statins, calcium-channel blockers, evergreens like nexium and clarinex, claritin, COX-2 inhibitors (now pulled from the market), etc. Of the 20 most-prescribed drugs overall, it looks like just under half are no more effective than placebos or generics.[1] And if you look at the top 25 psychiatric drugs, something like 22 or 23 of them are no more effective than placebos or generics for longterm use, which is the vast majority of the usage. [1] Statins are arguably useful for people who have already had a heart attack, but the vast majority of people taking them don't fall into this category, and it's not even clear whether they're really helpful for people who have had one. Meanwhile, longterm use basically causes at least mild dementia and muscle problems in everyone, meaning there is a negligible chance of benefit that's vastly lower than the benefit from giving up smoking or even moderate exercise, whereas there is basically a 100% risk of harm. Also, there is zero evidence that the new statins are better than the old statins, so even if you believe that statins are effective then my original argument still stands since there's no evidence that they're better than the generic ones.

by Gatsky 14y ago

Alex3917 14y ago

"This is because not being fit is a strong determinant of poor outcome. If you include them in the trial then it will be negative" I think this would be an extremely valid argument, except for the fact that these drugs are in fact targeted at, and mainly used by, the population that is older and more frail. And this doesn't just apply to cancer drugs, it applies to NSAIDs and all sorts of other garden variety treatments. I realize there are limited resources, but the end result is that the vast majority of the elderly (by far the biggest consumers of drugs) are taking medicines that have never been tested for safety or efficacy in people like them. Also, it's not just SSRIs. There are a wide range of psychiatric and non-psychiatric drugs that are either no more effective than placebos or generics: SSRIs, benzos, ADHD drugs, anti-psychotics, statins, calcium-channel blockers, evergreens like nexium and clarinex, claritin, COX-2 inhibitors (now pulled from the market), etc. Of the 20 most-prescribed drugs overall, it looks like just under half are no more effective than placebos or generics.[1] And if you look at the top 25 psychiatric drugs, something like 22 or 23 of them are no more effective than placebos or generics for longterm use, which is the vast majority of the usage. [1] Statins are arguably useful for people who have already had a heart attack, but the vast majority of people taking them don't fall into this category, and it's not even clear whether they're really helpful for people who have had one. Meanwhile, longterm use basically causes at least mild dementia and muscle problems in everyone, meaning there is a negligible chance of benefit that's vastly lower than the benefit from giving up smoking or even moderate exercise, whereas there is basically a 100% risk of harm. Also, there is zero evidence that the new statins are better than the old statins, so even if you believe that statins are effective then my original argument still stands since there's no evidence that they're better than the generic ones.