The study illustrates a common difficulty in extrapolating the results of randomized controlled trials to real-world practice. RCTs are designed to focus in on narrow populations to prove the effectiveness of a method or intervention, yet the results are generalized (in part by clinical need and in part by pharmaceutical company marketing efforts) to larger populations, such as patients with milder types of depression not represented in studies.
Patients in antidepressant studies are often not representative of all the patients we treat in family medicine. Study patients are volunteers and are generally more ‘treatment motivated’ and may be more likely to respond to placebo. Placebo patients get a lot of attention and frequent follow-up and monitoring. This is typically much more attention than patients receiving no treatment in real-world practice.
Publication bias in antidepressant studies is known to exist. Two studies published in 2008 (by Turner and Kirsch) demonstrated how the exclusion of unpublished trials in analyses and the emphasis on positive studies rather than negative ones, resulted in an overestimation of antidepressant effectiveness. The current JAMA study adds weight to this concern.
Despite these limitations, I still believe that antidepressants are reasonable choices for family physicians to consider. The Fournier analysis concluded that the number needed to treat with antidepressants to achieve one additional remission compared with placebo ranged from 4 for very severe depression to 16 for milder depression. A NNT of 16 is consistent with other studies' estimates of antidepressant treatment effectiveness and is in the ballpark for treatments of other conditions.
The preponderance of evidence (supported by the Fournier analysis) shows that antidepressants are effective for severe depression. In fact, combining antidepressants and psychotherapy is most effective in severely depressed patients. None of the studies in the Fournier analysis compared antidepressants to psychotherapy.
Our Kaiser Permanente national guideline systematic review found that psychotherapy and antidepressants are equally effective for mild to moderate depression. Patients may not have access to trained therapists, or might not choose psychotherapy if offered. However, shared decision-making studies show that we tend to overestimate our patients' preference for medication.
Many patients, especially those from different cultural or ethnic backgrounds, will choose or prefer psychotherapy if offered, so one of the lessons from this study is to ask the patient before whipping out the prescription pad.
DR. DAVID PRICE is depression clinical lead for Kaiser Permanente's Care Management Institute in Oakland, Calif., and professor of family medicine at the University of Colorado, Denver. He reports having no conflicts of interest.
(The 'My Take' section commentary came with source article. I separated it for clarity.)
The both/and isn't discussed here, oddly. Many patients get a combination of counseling and medications.
The placebos however don’t have the benefit of turning you into a drug addicted mass murderer like the real thing.
Also, is Tofranil and Paxil the best they could do? The old tricyclics had a reputation of being weaker than the even older (but hypertension risky) MAO inhibitors, and SSRIs often generate unacceptable side effects.
<
They work!!!
At a party, I went through a window 4 stories up, while holding a small African green monkey, we both landed on this guys hot dog cart...Both survived.
I would prescribe skydiving or some other extreme sport for depression. It is pretty hard to be depressed when your life is on the line and it is completely up to you to ensure you survive. And even if you fail, you will have cured your depression. Its a win win treatment.
It's an absolute joke to call this study a "meta-analysis" or to attempt to draw any conclusions from it about "antidepressants" in general. This study ended up considering only 6 of 2134 randomized controlled studies published over the past 30 years, and these 6 studies only represented 2 of the many antidepressant drugs currently in use, which happen to be the 6th and 13th most frequently prescribed (paroxetine is 6th and imipramine 13th). Together these drugs represent less than 10% of antidepressant prescriptions (2007).
And as the article notes, some of the data (particularly on imipramine, which was what 3 of the studies used) is probably from the 1970s or 1980s, before the newer antidepressants were available. To the extent that any of these studies were recent, they almost certainly were heavily weighted with patients who had already tried and failed other antidepressants -- normally the only reason a doctor would prescribe a rarely used antidepressant is when the more commonly prescribed ones have already been tried and failed for the patient in question. If any of these studies actually screened out such patients and were also done in recent history, then the doctors doing the prescribing were real oddballs, whose ability to diagnose depression accurately would be in question.
This is junk science, but it's hardly the first time JAMA has published junk science. I'm sure there is a significant placebo effect from antidepressants (as there is from most drugs), but this sloppy study doesn't illustrate anything of the sort.
PS: One of the best ways to evaluate the non-placebo effects of drugs is to see how they work in animals. I can personally attest to the efficacy of amitriptyline (9th most frequently prescribed antidepressant in the US in 2007) in cats. Many years ago, I had a dear little kitty who had, um, “issues”. The manifestation of these issues which prompted intervention with psychoactive drugs was a habit of peeing on things to get attention — even though he knew full well the attention would be in the form of getting walloped, and to express anger (ditto on the consequences). This cat would pee on the coffee-maker (only when someone was making coffee), pee on the sugar bowl (only when someone was eating at the table upon which the sugar bowl sat), pee on the cable box on top of the TV (only when someone was watching the TV), and would also pee on any object left where it didn’t belong (that one didn’t bother me at all — made for a tidy house, since people quickly learned not to leave backpacks lying on the living room floor, etc). If somebody shut him out of their bedroom at night, he’d leave a giant puddle right in front of their door.
ALL of this behavior stopped immediately when he was put on amitriptyline, which apparently relieved whatever kitty depressions and anxieties were triggering the non-stop pee-assaults. Unless the kitty managed to understand the conversation between me and the vet, and thus understood what the thing getting pushed down his throat every day was *supposed* to do, and also *wanted* to achieve this effect (even less likely than understanding the conversation and the effects the humans were hoping for), then this wasn’t a placebo effect.
First Blinded Study of Venous Insufficiency Prevalence in MS Shows Promising Results
Mandelbulb - The Unravelling of the Real 3D Mandelbrot Fractal
Stem cells rescue nerve cells by direct contact
FReepmail me if you want on or off my health and science ping list.
I was convinced I was depressed, took one version after another and only got a range of side effects that make great party talk. It wasn’t until a year after the real cause of my depression divorced me that I got better. Imagine that.
IMHO anti depressants should not be allowed to be prescribed by GP’s but only by Doctors who specilize in mental health. Perhaps everyone should be given a placebo as a first step to observe the reaction of the patient?