

Drugs May Aid Only Severe Depression - tokenadult
http://www.nytimes.com/2010/01/06/health/views/06depress.html

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tokenadult
"The team, led by Jay C. Fournier and Robert J. DeRubeis of the University of
Pennsylvania, found that compared with placebos, the drugs caused a much
steeper reduction in symptoms of severe depression (cases scoring 25 or higher
on a standard scale of severity, putting them in the top quarter of the
sample). Patients with scores of less than 25 got little or no added benefit
from the medications.

"'We were able to give an overall estimate of effectiveness for the first time
in this more moderate severity range, from 14 to 20 on the scale, in which
there’s no question that doctors would likely consider prescribing
medication,' Dr. DeRubeis said."

This is good that the study used a depression rating scale to categorize
patients in a way that shows which patients are most likely to benefit from
drug treatments. As the article notes, there are other approaches to treating
depression, and the friendly attention of doctors in a clinical trial is
beneficial enough in itself that drugs are hard put to beat placebos except
for patients who have more severe depression. Many other people bothered by
depression may gain much more benefit from cognitive therapy.

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hga
In partial response to tokenadult: There's absolutely no question that
cognitive therapy (nowadays cognitive behavioral therapy) is a critical tool
in fighting depression. On the other hand, it costs a lot more money than the
"band-aid" of a 15 minute visit with a psychiatrist and an prescription of
antidepressant. And "bending the cost curve" is the current zeitgeist....

The description of this study raises a few questions in my mind:

It's a meta-analysis of 6 studies, half with Paxil (paroxetine, which went
generic years ago) and the other half with imipramine, which is the Gold
Standard in the previous (pre-Prozac) generation of antidepressants. I'm a
little uncomfortable with their using Paxil as a proxy for all the current
generation drugs, e.g. not all are SSRIs, Lexapro is interesting because it's
_laser_ selective in acting only on serotonin, etc. etc.

Just to bring in some anecdotal experience: I have somewhat refractory
depression of a bipolar nature (I only go manic when taking the wrong
antidepressant, e.g. Paxil :-) and I've tried all of the above drugs plus
Serzone.

Self administered cognitive therapy made a _big_ difference (to the point that
talking therapy afterwords has been entirely useless).

When things get bad enough, each of the above drugs made a difference, but
weren't "miracles". And each was different in their own ways, not just in
terms of side effects (the new generation is _much_ better) but in terms of
how they worked and how well. And it's well known that if a patient doesn't
respond to the first drug at a sufficient dose, you try another till you
(hopefully) find one that works.

The whole field is at an extremely primitive state, akin to poking at the
brain with sticks. We've observed that sticks with certain shapes have good
effects, and we've guessed why, but the distance from those guesses to what's
really happening in terms of mood is _huge_.

So I wouldn't be inclined to push this study too hard, except to note what's
no surprise to anyone, I'd think, that those with less severe symptoms get
less benefit from these drugs. But I confess I'm not too interested in that
issue, mine is how to treat the hard cases like myself and a few of my
friends. And for us, antidepressants are most certainly a part of the picture.

~~~
tokenadult
_The whole field is at an extremely primitive state, akin to poking at the
brain with sticks._

Yes, there is still MUCH work to be done on the issue of treating human mood
disorders. And your point is entirely correct that a cost-benefit model of
evaluating treatments tends to make cognitive approaches to treatment
delivered by any person other the patient doing self-help look too expensive
(as compared to prescription medicines with very occasional psychiatrist
office visits).

I've been a lot more interested in prompting discussion of mood disorder
treament on HN since one thread a few months ago in which a participant
(perhaps using a screen name just for that thread) mentioned having repeated
bouts of depression that appeared to be seasonal and were definitely
recurrent. That thread had many comments self-reporting the same phenomenon in
other HN participants. Then, sadly, a few days later it was announced that a
YC co-founder with high HN karma had committed suicide. I hope that if one
person's anecdote is "antidepressant medication X didn't help me," the
response will be "maybe your individual pattern of mood disorder is better
helped by another medicine," rather than "people should try in all cases to do
without medicine." It does appear to be consistent with the newly reported
meta-analysis to say "people with severe depression should definitely try out
medicines under medical supervision while also trying out other therapies"
while people with milder cases of depression may not notice drug benefits
much, but may still benefit from other therapies. I agree that people with the
hard cases should keep seeking help and not give up. There is help even for
those cases, although it is discouraging that the help can't be specified just
by a simple blood test or something of that kind.

