And The Award For Perfect Timing Goes To...
“Any man can go up—oh, almost indefinitely—but to go down, and down sure-footed, that is another thing entirely.” (Patrick O’Brian, HMS Surprise)
Is Newsweek saying antidepressants don’t work? Yes, they are, and isn’t that a cute cover. Any doubt which way is up?
And are they right? This one has sent me into a flurry of research over the past two days. My tentative answer is, They may be on to something, but watch for scholarly refutations over the next few weeks.
And, in this national climate of distress, isn’t their timing the coldest, most callous, most credulous act imaginable? Hmmm, you think? We’re vulnerable; we’re already worried about EVERYTHING, and we tend to believe what we read on the cover of a major news magazine, especially when big numbers are thrown at us between the covers. Thanks, Newsweek; can’t wait for your next issue!
I'm no expert, but here’s how the cover story looks to this reader:
Irving Kirsch, PhD, of Hull University, England, is saying that his method of statistical analysis shows that antidepressants do not beat placebos by enough of a margin to justify their use in most cases. Sharon Begley of Newsweek has given him a nation-wide plug for his new book, along with a cynical and somewhat overwrought treatment of a critically important subject. Caveat emptor, indeed, but is it antidepressants, Irving Kirsch, or Newsweek we should distrust more?
In an article written for the issue dated February 8, 2010, entitled “The Depressing News About Antidepressants,” Sharon Begley references research done in 1998, by Kirsch and Sapirstein at UConn., and expanded by Kirsch in 2008. Begley’s article might give the impression that Kirsch and team tested the 3000 patients themselves, which is not the case; they applied meta analysis, a statistical method, to studies published by the drug manufacturers for four antidepressants. Later, they included research that was done, but not published (leaving the impression that this research was withheld or kept secret); those studies were, in fact, sent to the FDA as part of the usual approval process for any particular drug.
Kirsch and team concluded that, of those respondents who reported improvement in placebo-controlled clinical trials of experimental antidepressant medications, the patients who got the medication improved only 25% more than those who claimed improvement on the placebo, and, when unpublished studies were included, the margin of difference between placebo effect and medication effect was reduced to 18%. Hardly worth it, Kirsch concludes. And it does sound like big news, but, before you throw out your antidepressant and confront your doctor, there are a few more things to consider.
The implications of Begley's article are that the facts are being withheld from patients and the public, presumably by a coalition of folks in the know and on the take; to operate as a conspiracy, this coalition would have to include big pharmaceutical companies, the Food and Drug Administration, The National Institutes of Health, The American Medical Association, the medical insurance industry that (from time to time) helps pay for the medications, and individual doctors just like yours or your mother’s or your best friend’s…for a short list. In other words, everybody but the patient. For those who study conspiracy theory, the rule of thumb is that the more entities said to be involved in the conspiracy, the less likelihood there is that secrecy and joint action can be maintained over time…or, too many cooks spoil the broth.
The study acknowledges that antidepressants show greater efficacy rates, as compared to placebo rates, for the most severely depressed, but discounts those results by concluding that the most severely depressed patients were under-responsive to placebo. There are lower drug benefits, as compared to placebo effect, demonstrated for milder depression
The article reminds patients who take antidepressants (and they don't differentiate between mild and severe in this warning) not to stop suddenly because, “That can cause serious withdrawal symptoms.” There is the assumption here that patients will read the article and immediately discontinue their antidepressant because it’s been revealed that the positive effects they’ve experienced are really all in their heads. There's a greater danger that some patients will read the cover headline, alone, and, regardless of the level of severity of their depression, the benefit they may have personally derived, or the history of their own treatment response to other modalities, they'll do what depressed people are prone to do: they'll give up.
Most patients, however, will think for themselves. They know what they tried before they turned to medication and they know what they’ve experienced since. In this country, with our self-reliant tendencies, we tend to go about as far as we can before we ask a doctor for help; hence the stats that everybody can agree on: fewer than half of the 13-14 million adults who experience clinical depression in this country in a given year will receive treatment of any kind and at least 32 million of us will have the disease (or disorder...and that's another blog post altogether, too).
The National Institutes of Mental Health do not recommend medication, alone, for depression. The recommendation in clinical depression is for medication with psychotherapy and lifestyle changes that include exercise and socialization, along with conscious efforts to solve contextual problems that have led to or exacerbated the illness. Good doctors, particularly specialists, know that they give their patients the best shot available at lasting benefit by urging their patients to follow those recommendations. Begley sloughs this off by saying, “…there’s the little matter of reality. In the U.S., most patients with depression are treated by primary care doctors, not psychiatrists.”
So, if we throw out our medications because prescribers aren’t following the national guidelines—put the baby out with the bathwater—then what? If, thanks to Begley, patients assume that their medication was no better than “expensive TicTacs,” as she calls them, will they turn to psychotherapy and alternative treatments, instead? Where I live, there is a large population of depressed patients who distrust psychotherapy far more than they do medication; without the benefit their antidepressants do afford them, they'd go on with lives that are burdensome to them, to their families, and to their employers...unrelieved. In their cases, I'm pulling for all the good of the placebo effect plus whatever boost the medication itself can provide them.
For prescribers, the patient's willingness to engage in the slower process of psychotherapy, the availability of sound and qualified therapists, and the patient's insurance coverage for non-medical treatments all have to factor into treatment planning. Where psychotherapy is chosen, the doctor and therapist have to work in close consultation...a practice that typically does not occur where the referring doctor is a primary care physician.
While Kirsch would obviously be persona non grata in the American medical community, he hasn't fared much better among academics, who have more stake in associating themselves with quality research . When the journal Prevention and Treatment published Kirsch's paper "Listening to Prozac but Hearing Placebo," they issued a warning in print with the article stating that the authors had used their statistical analysis "controversially." Begley's article does state:
Is Newsweek saying antidepressants don’t work? Yes, they are, and isn’t that a cute cover. Any doubt which way is up?
And are they right? This one has sent me into a flurry of research over the past two days. My tentative answer is, They may be on to something, but watch for scholarly refutations over the next few weeks.
And, in this national climate of distress, isn’t their timing the coldest, most callous, most credulous act imaginable? Hmmm, you think? We’re vulnerable; we’re already worried about EVERYTHING, and we tend to believe what we read on the cover of a major news magazine, especially when big numbers are thrown at us between the covers. Thanks, Newsweek; can’t wait for your next issue!
I'm no expert, but here’s how the cover story looks to this reader:
Irving Kirsch, PhD, of Hull University, England, is saying that his method of statistical analysis shows that antidepressants do not beat placebos by enough of a margin to justify their use in most cases. Sharon Begley of Newsweek has given him a nation-wide plug for his new book, along with a cynical and somewhat overwrought treatment of a critically important subject. Caveat emptor, indeed, but is it antidepressants, Irving Kirsch, or Newsweek we should distrust more?
In an article written for the issue dated February 8, 2010, entitled “The Depressing News About Antidepressants,” Sharon Begley references research done in 1998, by Kirsch and Sapirstein at UConn., and expanded by Kirsch in 2008. Begley’s article might give the impression that Kirsch and team tested the 3000 patients themselves, which is not the case; they applied meta analysis, a statistical method, to studies published by the drug manufacturers for four antidepressants. Later, they included research that was done, but not published (leaving the impression that this research was withheld or kept secret); those studies were, in fact, sent to the FDA as part of the usual approval process for any particular drug.
Kirsch and team concluded that, of those respondents who reported improvement in placebo-controlled clinical trials of experimental antidepressant medications, the patients who got the medication improved only 25% more than those who claimed improvement on the placebo, and, when unpublished studies were included, the margin of difference between placebo effect and medication effect was reduced to 18%. Hardly worth it, Kirsch concludes. And it does sound like big news, but, before you throw out your antidepressant and confront your doctor, there are a few more things to consider.
The implications of Begley's article are that the facts are being withheld from patients and the public, presumably by a coalition of folks in the know and on the take; to operate as a conspiracy, this coalition would have to include big pharmaceutical companies, the Food and Drug Administration, The National Institutes of Health, The American Medical Association, the medical insurance industry that (from time to time) helps pay for the medications, and individual doctors just like yours or your mother’s or your best friend’s…for a short list. In other words, everybody but the patient. For those who study conspiracy theory, the rule of thumb is that the more entities said to be involved in the conspiracy, the less likelihood there is that secrecy and joint action can be maintained over time…or, too many cooks spoil the broth.
The study acknowledges that antidepressants show greater efficacy rates, as compared to placebo rates, for the most severely depressed, but discounts those results by concluding that the most severely depressed patients were under-responsive to placebo. There are lower drug benefits, as compared to placebo effect, demonstrated for milder depression
The article reminds patients who take antidepressants (and they don't differentiate between mild and severe in this warning) not to stop suddenly because, “That can cause serious withdrawal symptoms.” There is the assumption here that patients will read the article and immediately discontinue their antidepressant because it’s been revealed that the positive effects they’ve experienced are really all in their heads. There's a greater danger that some patients will read the cover headline, alone, and, regardless of the level of severity of their depression, the benefit they may have personally derived, or the history of their own treatment response to other modalities, they'll do what depressed people are prone to do: they'll give up.
Most patients, however, will think for themselves. They know what they tried before they turned to medication and they know what they’ve experienced since. In this country, with our self-reliant tendencies, we tend to go about as far as we can before we ask a doctor for help; hence the stats that everybody can agree on: fewer than half of the 13-14 million adults who experience clinical depression in this country in a given year will receive treatment of any kind and at least 32 million of us will have the disease (or disorder...and that's another blog post altogether, too).
The National Institutes of Mental Health do not recommend medication, alone, for depression. The recommendation in clinical depression is for medication with psychotherapy and lifestyle changes that include exercise and socialization, along with conscious efforts to solve contextual problems that have led to or exacerbated the illness. Good doctors, particularly specialists, know that they give their patients the best shot available at lasting benefit by urging their patients to follow those recommendations. Begley sloughs this off by saying, “…there’s the little matter of reality. In the U.S., most patients with depression are treated by primary care doctors, not psychiatrists.”
So, if we throw out our medications because prescribers aren’t following the national guidelines—put the baby out with the bathwater—then what? If, thanks to Begley, patients assume that their medication was no better than “expensive TicTacs,” as she calls them, will they turn to psychotherapy and alternative treatments, instead? Where I live, there is a large population of depressed patients who distrust psychotherapy far more than they do medication; without the benefit their antidepressants do afford them, they'd go on with lives that are burdensome to them, to their families, and to their employers...unrelieved. In their cases, I'm pulling for all the good of the placebo effect plus whatever boost the medication itself can provide them.
For prescribers, the patient's willingness to engage in the slower process of psychotherapy, the availability of sound and qualified therapists, and the patient's insurance coverage for non-medical treatments all have to factor into treatment planning. Where psychotherapy is chosen, the doctor and therapist have to work in close consultation...a practice that typically does not occur where the referring doctor is a primary care physician.
While Kirsch would obviously be persona non grata in the American medical community, he hasn't fared much better among academics, who have more stake in associating themselves with quality research . When the journal Prevention and Treatment published Kirsch's paper "Listening to Prozac but Hearing Placebo," they issued a warning in print with the article stating that the authors had used their statistical analysis "controversially." Begley's article does state:
A nascent collaboration with a scientist at a medical school ended in 2002 when the scientist was warned not to submit another grant proposal with Kirsch if he ever wanted to be funded again. Four years later, another scientist wrote a paper questioning the effectiveness of antidepressants, citing Kirsch's work. It was published in a prestigious journal. That ordinarily brings accolades. Instead, his department chair dressed him down and warned him not to become too involved with Kirsch.
When you read Newsweek's cover story, keep in mind:
1. Most of the research cited here has been available for analysis since 1998; if Kirsch's method of analysis is standard and is logically applied to the data in question, are we left with no choice other than to believe the information has been deliberately withheld from us? Both too pat and too paranoid for me.
2. Kirsch holds a PhD in psychology. Research claiming the lack of efficacy of medications and the greater efficacy of psychotherapy and non-medical modalities has historically come from psychologists, a field which previously failed in its bid to be approved in most states to prescribe the medications it now denounces. (Exceptions: in LA and NM, psychologists who additionally complete a two year masters degree in psychopharmacology can prescribe). Most of the studies that have historically shown greater efficacy of meds over psychotherapy have been funded by medical entities. Go figure.
3. On his departmental website, Kirsch states,
“My main research interest is in response expectancy, suggestion, and suggestibility. Among the domains in which I investigate these phenomena are: placebo effects, antidepressants, hypnosis, pain perception, behavioural automaticity, memory distortions, complementary and alternative medicine, cognitive-behavioural psychotherapy, repetitive strain injury, irritable bowel syndrome, anxiety disorders, and depression."
If the placebo effect can color patient response to antidepressants, can researcher bias color the interpretation of statistics?
4. The Hawthorne effect posits that subjects can improve simply by virtue of being studied, which complicates the placebo effect numbers in studies where patients are followed over time by researchers wielding depression scales. So the placebo numbers cited by Kirsch are not so clear-cut, either.
5. Most importantly, Kirsch’s book, The Emperor's New Drugs: Exploding The Antidepressant Myth, was published in 2009 in the UK, but at the end of January, 2010, in the US. Time Magazine covered this study in May, 2009, and far less provocatively. The Newsweek article is timed as a book review cum medical alarm, not as timely research news.
6. About the only business in this country that rivals traditional medical treatment for its claim on the patient dollar is the big business of Alternative Medicine, a largely unregulated field where patient exploitation is rampant. In an atmosphere of national distrust of the traditional medical world (not misplaced, entirely), patients are flocking, not to the trained and regulated psychologists and social workers, but to the practitioners of alternative therapies, who base their conclusions on individual patient stories…the very type of anecdotal evidence that the researchers would deny to patients trying to make actual decisions about their care today.
8. The article makes the issue of treatment an either/or proposition: either meds or therapy. Remember that the NIMH recommends both in combination; our attention is better placed on obtaining insurance coverage for both medication and psychotherapy for everyone in this country. The decision on whether to use meds, talk therapy, or a combination could be put back in the hands of the patient and the doctor.
7. When Newsweek casts doubt on the efficacy of antidepressants for mild to moderate depression, they also sow those seeds of doubt, by implication, on other uses of those medications, such as in the treatment of depression associated with trauma for victims of disaster and veterans returning from war, or for obsessive-compulsive disorder or anxiety disorders. They sow distrust between patients and their doctors. And they sow doubt in the minds of patients who are being successfully treated. Begley admits, "To be sure, the drugs have helped tens of millions of people."
8. The article makes the issue of treatment an either/or proposition: either meds or therapy. Remember that the NIMH recommends both in combination; our attention is better placed on obtaining insurance coverage for both medication and psychotherapy for everyone in this country. The decision on whether to use meds, talk therapy, or a combination could be put back in the hands of the patient and the doctor.
At the very end of the article, Begley says, in reference to exposing the pill pushers, “Maybe it is time to pull back the curtain and see the wizard for what he is.” Yep. I agree that blind trust is a bad idea. And that patients must learn to act as self-advocates, which means more education about their own care. And that statistics aren’t always what they seem, no matter who publishes them. If we’re just looking at which player in this story is most against the ropes and most likely to stretch a point for effect, I’d say the print media is the most endangered of the three…that would be Newsweek.
And somebody licked the red off Sharon Begley's sugar pill, honey, 'cause this girl is PISSED; she's got an agenda with this article. Let's see, I think the telltale phrase was, "drug so strong it's making me vomit or hate sex." No, maybe the giveaway was her two references to Dumbo the Disney elephant to describe people who believe in their medication. And this is the cover story of a major news periodical? Now, I'm really worried about America.
Do you know someone who has been helped by medications for depression? How do you think they would react to this article? Do you distrust anything the FDA approves, period? Does Newsweek have a bias other than a desperate need to sell magazines? Could they possibly have picked a crappier time to go to press with this on their cover?
And somebody licked the red off Sharon Begley's sugar pill, honey, 'cause this girl is PISSED; she's got an agenda with this article. Let's see, I think the telltale phrase was, "drug so strong it's making me vomit or hate sex." No, maybe the giveaway was her two references to Dumbo the Disney elephant to describe people who believe in their medication. And this is the cover story of a major news periodical? Now, I'm really worried about America.
Do you know someone who has been helped by medications for depression? How do you think they would react to this article? Do you distrust anything the FDA approves, period? Does Newsweek have a bias other than a desperate need to sell magazines? Could they possibly have picked a crappier time to go to press with this on their cover?
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13 comments:
I lived for 50 years with a knot in my stomach. Thought everybody had one. Around menopause, my gyn suggested generic zoloft. I worried, I sighed, I researched and I filled the 'script. The knot's been gone, I'm less angry with the world, and I don't care if it's a placebo or chemical - IT WORKS!
Newsweek is holding on with both hands, it seems, to the 16 or 17 people who still read news magazines. How about the Let's Kill Granny headline last summer????
Do they work? Sometimes. Do they work better than other things such as intensive exercise, psychotherapy, ditching the problem--sometimes and for some people. But I agree with Ashleigh's comment--they have helped me and people I know, whether as a placebo effect or through actual science. My fear is that this will only make it easier for people who are themselves free from depression and inclined to think those affected with it are whiners to make a (facile and uninformed) case for their point of view.
I have two stories about anti-depressants, but first... Judging from the number of diet ads on the t.v. that make wild claims, and which are also "FDA approved" I tend to follow the school of thought that the FDA will approve some things based on the fact that it will neither kill nor (seriously) harm you. Most medication designed to bring us back into balance (either physically as in the case of weight loss, or mentally as with anti-depressants) should work better with a good diet and exercise. That just makes sense.
That being said, I used to work with a lady at the Wal-Mart that was on anti-depressants. She called them her "I don't give a ____ Pills." (Fill in the blanks yourselves... this is a family post) She stopped taking them. Not because they didn't work, but because they worked too well. She said she'd rather feel this incredible burden than to feel nothing at all.
My other story is about my somebody very close to me. She carried the burden of depression for some time, and boy did it weigh on us. She wasn't really capable of doing anything because of it... It's really hard to describe living with a person with chronic depression. That weight "seeps" out into every aspect of their lives. "Fixing" it with lifestyle changes is an uphill battle that is made more difficult by being bogged down in a mire of self doubt, loathing, and... well... depression.
The decision to try anti-depressant medication was a big one. Getting rid of the depression was a definite plus... but to do that at the potential cost of her core personality (eg "I don't give a ___ Pills)just didn't seem worth it. To make an already too long story short(er), she started them, and is much the better for it. We actually have her back.
As for this article convincing people to stop taking them? Who knows? I'd like to think that the "stupid/ignorant" Americans of stereotype are in the minority, and just get more airplay because they're louder than everybody else. So hopefully people reading this will see it for what it is (a cry for help from a medium that is struggling to find its way in a new world) and also know themselves well enough to move forward on their own paths.
Hi Nance
Great post. I left you a long comment on your last post. It either wasn't relevant and went bye-bye or it never made it thru. Either way, have a great weekend!
Yes, it is disturbing that this opinion is on the cover of such a respected rag. Personally, I am a believer and that is after multiple attempts without medication. It helps hold me together, along with everything else I can do. I am no expert but I am a little puzzled that the statistics are based on people's subjective comments. Isn't there objective data to back up the positive results produced from antidepressants? When I first started on an antidepressant, I was not aware of the difference, but my friends said it was notible. Then, as I stated earlier, I became a believer after trying to live without the use of an antidepressant. This article could negatively affect a number of people and sell a lot of books. Something is very wrong about that.
Ann
Dear Readers,
Your thoughtful comments matter! Each blog post, each comment, represent small acts of courage; whether we seek to abuse, inform, encourage, or create change, we build something together. Besides, I think you're fabulous!
Ann,
Your question is excellent! The tool used in most depression studies (and in all of the ones cited here, I believe) is the Hamilton Rating Scale of Depression, developed in 1960. It's short, multiple choice, and entirely self-rated. Similar to the ten-point subjective pain assessment scale, its use lies in its simplicity and its been almost universally accepted for research for decades.
A more objective means...that's The Holy Grail of mental health research. PET scans and fMRI's let researchers look at the actual brain for markers of depression, but they are not widely available and their interpretation is not standardized yet. When that kind of information becomes widely available, watch for it to change everything from diagnosis, to treatment, to the way we all think about "mental" health.
I, too, read this article with a keen interest as soon I received the issue. So I was glad to read your timely review. I was particularly intrigued with the following discussion by Kirsch. Per the article: “Patient volunteers are told they will receive either the drug or a placebo, and that neither they nor the scientists will know who is getting what. Most volunteers hope they get the drug, not the dummy pill. After taking the unknown meds for a while, some volunteers experience side effects. Bingo: a clue they’re on the real drug. About 80% guess right, and studies show that the worse side effects a patient experiences, the more effective the drug. Patients apparently think, this drug is so strong it’s making me a vomit and hate sex, so it must be strong enough to lift my depression. In clinical-trial patients who figure out they’re receiving the drug and not the inert pill, expectations soar.”
This would seem to have a profound effect and conclusions on these studies. Consider other disease studies. In consideration of your question: “If the placebo effect can color patient response to antidepressants, can researcher bias color the interpretation of statistics?” A researcher can manipulate the interpretation but then the science of statistics is defeated and that would be brought to light. But it is what is presented by the user of statistical data we should be weary of. We are subject daily to everyone’s interpretation – the feds, the media, the marketers, and the greedy. It’s easy to report that, as an example, 40% of the voters were against XXX – thus promoting the writer’s interest possibly. That means that 60% voted FOR XXX.
I interpreted Kirsch’s comment, “By and large, the unpublished studies were those that failed to show a significant benefit from taking the actual drug” as acknowledgement that in fact, statistically, these unpublished studies are significant for that very reason. He was later encouraged by Thomas Moore, GWU, to include these unpublished studies in to his own, and as you pointed the margin of difference was reduced. From the article: “About 82% (18%)of the response to antidepressants – not the 75 % (25%) he had calculated from examining only published studies - had also been achieved by a dummy pill”.
Who, really, is responsible for the possibility or impression that they were hidden or kept secret? The coalition? Timing may be unfortunate as you point out; it reminds me of the results of the studies about having mammograms last fall and the study about Hormone Replacement Therapy in 2007; but people in need of help have always been here. I agree with you too that blind trust is a bad idea so this may be an “educational moment”. Skepticism is useful; what if some of those patients had countered their expectations with some; the statistics might have been very different.
This is scarier than the attack on ADHD and it's medications. Just when you convince yourself and those around you that you're doing the right thing being on medication, there's some news article that stirs up doubt. No doubt in my mind though; antidepressants work here.
AARP Magazine, which has its own agenda, is a good example of a media using statistics (numbers, percentages, etc.) to persuade or impress its readers. Try flip-flopping some of the percentages and consider what THAT means. But it can be tricky; example: stating that 65% of people in a study reported that they love chocolate doesn't mean that 35% hate chocolate; maybe 10% hate it and 25% do not have a preference. Here’s one from AARP: “Buy oatmeal in those cardboard cylinders [instead] and you’ll trim up to 75% from the cost of breakfast” Breakfast? Shouldn’t that be off the cost of single serving packets which they referred to?
I'm afraid that print information is becoming as junky as the web.
If information is presented for the purpose of increasing links or sales, it hardly matters, we're all struggling in one big tabloid. So to speak.
I am not ashamed to say that I take an antidepressant for anxiety and it has made me a better person. When I first started taking it it was for crying and anger at any little thing. (start of PMS) I am a much happier person when I take the little pill and people around me are happier people also.
Thanks so much for commenting on Ronni's blog. This was helpful!
- Mary Jamison
Sorry for the slow response. You are brilliant...as usual. My only experience with an anti-depressant was Zoloft in 2001. I did not eat for a whole month. I lived solely on pepsi...and was completely unaware until my roommate corner me with a king size snickers because she though I was turning anorexic. So I quit the pills that day. I wasn't sad or depressed in the first place...but being a zombie didn't do me much good.
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