4 ms·
> the most comprehensive review of the SSRI studies (by Irving Kirsch et. al.) found no clinical significance beyond placebo for the vast majority of patients.
by logjam 13y ago
> the most comprehensive review of the SSRI studies (by Irving Kirsch et. al.) found no clinical significance beyond placebo for the vast majority of patients.
No. Biological theories of mental health and mental illness are very much established.
And yours is a complete mischaracterization of the work of Kirsch et al.
Their meta-analysis found that in ALL cases of depression, there is statistically significant improvement in quantitative measures of depression treated with SSRI. In moderate to severe cases of depression, the improvement was clinically significant (ie a clinician and patient clearly note the improvement). The meta-analysis done on clinical trials were overwhelmingly trials of 6 weeks of SSRI or less. Suicidal patients are almost all excluded from such trials. Treatment groups were treated with SSRIs via research protocols, and not usual clinical practice: there were no attempts made to match patients to an SSRI that would be most likely to help, to wait on a response, to use SSRIs that were helpful based on a family history; dose adjustments were typically prescribed by study protocol and not by patient response, patients were not switched to another SSRI when there was no response or if intolerable side effects developed, often no attempt to treat side effects with other agents were done, etc. In other words, none of the things any physician routinely does to optimize treatment were done in those trials, and yet there were STILL improvements in measures of depression across the board.
No reputable psychiatrist or physician will fail to recommend an SSRI in cases of moderate to severe depression. Therapy can also be helpful, but the evidence is overwhelming that SSRIs help in clinically significant ways in moderate to severe depression. There is no credible doubt about it.
Despite your assertions about what "people very much want to believe" - in my experience, people very much want to believe that the brain is somehow different - that something beyond biology is at work. Believing that somehow depressed or otherwise mentally ill people can just "snap out of it" or "pull themselves up by their bootstraps" is erroneous, unhelpful, but fits nicely into really completely shitty and cruel narratives about human beings.
But please. Perhaps you'd like to advance a theory on how an organ like the brain differs from every other organ and does its work in ways not explainable by biology, chemistry, physics, etc.
- gruseom 13y agoAnd yours is a complete mischaracterization of the work of Kirsch et al. It isn't my characterization so much as a paraphrase of various sources I've read/heard on this, including Kirsch himself. My understanding is that Kirsch and Sapirstein's findings are two: (a) for all but severe depression, the improvement of SSRIs over placebo is measurable but too small to be clinically significant; (b) even that small measurable difference is questionable, because the studies were not really double-blind. (Patients could figure out which group they were in because of the SSRIs' side effects.) Is either of those descriptions of their findings wrong? I haven't kept a list of sources, but one I remember is [1]. Is Kirsch mischaracterizing his own work? I noticed that you didn't use the word 'placebo' in what you wrote. My understanding is that Kirsch et. al.'s findings were specifically about lack of clinical significance beyond placebo. Could that explain the discrepancy between your description and mine? Perhaps you'd like to advance a theory I would not. Do you think that lack of a better theory has anything to do with whether this one is substantiated or not? [1] http://www.huffingtonpost.com/irving-kirsch-phd/antidepressants-the-emper_b_442205.html http://www.huffingtonpost.com/irving-kirsch-phd/antidepressa...
- Retric 13y agoShouldn't the default position be "we don't know"? No that's a common misunderstanding. Science is the search for the best model/theory as such it's hard to rank something as better or worse than we don't know. Thus the default theory is "There is no relationship between X and Y". Even if not clinically useful there does appear to be a connection and as such you can replace the default theory. After even more research the current theory is something like. "They appear to beat placebo's which have no side effects." Which again is far more useful than "We don't know." As it suggests comparing them to placebos that have side effects. Again not because they are going to help you treat patents directly, but because it tells you more about the disease and possible what research could be useful.
- gruseom 13y agoScience is the search for the best theory as such it's hard to rank something as better or worse than we don't know. Thus the default theory is "There is no relationship between X and Y". For the purposes of this discussion, that's a distinction without a difference. (BTW I edited my comment before your reply showed up, and had deleted the bit you quoted.) More significantly, your suggestion of comparing SSRIs to placebos with side effects strikes me as an excellent idea; it is what Kirsch's study would naturally seem to suggest. I wonder if such studies will ever be undertaken. Edit: I did find at least one such study: http://psychrights.org/research/Digest/CriticalThinkRxCites/Moncrief2004.pdf http://psychrights.org/research/Digest/CriticalThinkRxCites/... Authors' conclusions: The more conservative estimates from the present analysis found that differences between antidepressants and active placebos were small. This suggests that unblinding effects may inflate the efficacy of antidepressants in trials using inert placebos. Further research into unblinding is warranted.