I think this should be investigated.The use of anti-depressants amount to performing medical experiments on people. E.g. Let's see this anti-depressant, then evaluate side-effects, if it doesn't work switch to different one or adjust the dosage. There is no scientific basis to do that. The supposed chemical inbalance is not being measured so the doctors really are giving people random drugs and those drugs are difficult to quit without medical supervision as well. When you quitting you feel so horrible you rather keep taking them. This is a huge money making racket for big pharma and make doctors look like charlatans at the same time casting doubts on medical profession. This only feeds to another camp like anti-vaxx.
Forgive me for being blunt, but that's just how modern medicine works. No one has the Star Trek tricorder that can scan your body, read your genome, and detect a quantum fluctuation in your synaptic waveform matriculation to calculate how many CCs to put in the hypospray.
We really only have one amazing piece of technology at our disposal: statistics. At the absolute best (and I'm not saying it's always the best...), what comes out of a pharmaceutical development pipeline is a drug that works for some people some of the time. Sure, sometimes you get broad categories to try to narrow down effectiveness, but at the individual level there is ultimately no choice but to try a drug and see if it works. And this is especially true in psych drugs, in no small part because there are so many unanswered questions about how our mind works.
And that sucks. I get it. It must be so frustrating to deal with a revolving door of new regimens and new side effects, all while yearning for relief from the underlying ailment. Not to mention navigating our nightmarish medical bureaucracy. But please understand that doctors, generally, are just doing their best to help given the tools they have. If you don't currently have that kind of trust and partnership with your doctor, I hope you are able to find one with which you can. I wish you the best, and hope that this perspective will make your frustrations somewhat easier to bear.
The situation is much worse than you outline, from a scientific perspective, and even well-meaning doctors aren't an antidote due to systemic distortions.
Ben Goldacre, a UK physician and medical researcher, captures it really well in the opening two paragraphs of his book 'Bad Pharma':
> Drugs are tested by the people who manufacture them, in poorly designed trials, on hopelessly small numbers of weird, unrepresentative patients, and analysed using techniques which are flawed by design, in such a way that they exaggerate the benefits of treatments. Unsurprisingly, these trials tend to produce results that favour the manufacturer. When trials throw up results that companies don't like, they are perfectly entitled to hide them from doctors and patients, so we only ever see a distorted picture of any drug's true effects. Regulators see most of the trial data, but only from early on in a drug's life, and even then they don't give this data to doctors or patients, or even to other parts of government. This distorted evidence is then communicated and applied in a distorted fashion.
> In their forty years of practice after leaving medical school, doctors hear about what works through ad hoc oral traditions, from sales reps, colleagues or journals. But those colleagues can be in the pay of drug companies – often undisclosed – and the journals are too. And so are the patient groups. And finally, academic papers, which everyone thinks of as objective, are often covertly planned and written by people who work directly for the companies, without disclosure. Sometimes whole academic journals are even owned outright by one drug company. Aside from all this, for several of the most important and enduring problems in medicine, we have no idea what the best treatment is, because it's not in anyone's financial interest to conduct any trials at all.
His book, which lobbed a grenade into the heart of the pseudo-scientific state of 'modern medicine', has resulted in more energy being put into trying to move to science-based medicine with things like https://opentrials.net/, but I don't closely observe that industry, so perhaps someone else within the sector could speak to how far the idea of publicly available trial data has gone in 2019.
I would argue that even the ideal medical system would likely produce the same outcomes experienced by the author of the parent post. In our present stage of scientific and technological advancement, the following might as well be a Law of Nature: even the best of drugs will have varying effects on various people in varying circumstances.
But yes, there are plenty of inadequacies in our healthcare industry (speaking from the US), but that's a much, much broader discussion.
Or doesn't work. We don't accept this in other areas why medicine? Modern medicine in a lot of cases is as modern as when the doctor went to school and stops evolving once school finishes.
There is a disconnect between research and medical knowledge by frontline workers.
> Modern medicine in a lot of cases is as modern as when the doctor went to school and stops evolving once school finishes.
I just wanted to point out that while I can empathize with this sentiment, in the United States at least, physicians must undergo yearly retrainings to earn continuing education credits (for medicine) and there is a certain number of credits that must be acquired on a yearly basis.
I'd argue qualitative data is far more valuable than mass quantitative data, the problem is that's expensive and difficult to gather accurately - especially on a timescale that is longer than the only the 2 weeks that many if not all behaviour changing psychotropic medications required for 'adequate' research under heavily controlled environment before unleashing them onto the masses.
Statistics can point you into a direction, however it won't account for nuances in most or perhaps all cases.
I am inclined to disagree. The N=1 anecdotes only become interesting against the rich background data. "Compared to what?" is the critical question to ask. Always.
Using this as a counterargument is absurd - it's not reasonable to assume qualitative data is compared and contrasted in a vacuum by itself; this is a good example of how perfectionism and statistics leads to failure.
Oh all of a sudden we should just accept some pathetically weak argument of "we just don't know". Billions at stake here and yes we can and will severely penalize anyone on the side of nonscience and profiteering where humans are harmed. We can do better. Sorry if it means consequences for certain people.
> Oh all of a sudden we should just accept some pathetically weak argument of "we just don't know".
But we don't know, despite enormous and ongoing effort. Hopefully we'll understand eventually, but right now we don't. I'm sorry if that fact is upsetting, but you can't will knowledge into existence.
You're commenting on such an investigation. As for the try-and-evaluate method of matching antidepressants to patients, that is the best medicine has to offer right now. There's not a better way that they're choosing not to use, and the drugs do have measurable, significant benefits for patients once they find one or more that's effective for them. The "supposed chemical imbalance is not being measured" because that's more a figure of speech than a scientific theory, and there is no practical way to measure it and correlate it to mood imbalance, depression or other symptoms. What alternative do you propose?
Until recently, few pharmaceutical companies pre-registered antidepressant trials, which allowed them to selectively publish. This means that antidepressants may be nowhere near as effective as commonly believed, and so doctors are overweighting the benefits compared to the costs of side effects. .
“While only half of these trials had formally significant effectiveness, published reports almost ubiquitously claimed significant results. "Negative" trials were either left unpublished or were distorted to present "positive" results.”
If this is true, then many people who currently take antidepressants may actually be better, not worse, without them, since at least they’d avoid the side effects.
Further, the “chemical imbalance” theory that is propagated through paid advertising has no applicability to a doctor prescribing an antidepressant, since the doctor has no way of measuring and monitoring that imbalance should one exist.
It’s become increasingly clear that genetics play a huge role in which psychiatric drugs are effective and which ones are not. Genetic testing for psych med effectiveness should become standard practice given how in some people, SSRIs (often the first line of defense in psych meds) can cause extended periods of psychosis.
Funny thing about psychosis — when you’re psychotic, your erratic and extreme behavior doesn’t feel abnormal. You don’t feel like anything has changed. This happened to me on Prozac — the most commonly prescribed antidepressant — and it took me 3 years to put my life back together after all the damage I did to my personal relationships during that period.
The anxiety I was dealing with was crippling, but it didn’t dismantle my life the way the side effects of that drug did. The treatment was absolutely worse than the disease. If they had done a genetic test first, they would have seen a red flag and avoided SSRIs all together.
This testing exists today, but it’s only used in patients who show strong resistance to pharmacological intervention. It should be standard.
I feel like we are so close to wirelessly monitoring all brain waves (next 50 years) we will probably be able to, in real time, recognize and diagnose abnormal brain patterns. I think it would be promising if we get this sensor tech up and then perhaps deploy nanotech to interfere with maladaptive brain patterns. The ethics of such a device is considerably sticky.
paraphrased: "wireless non-contact mind reading tech may be cheap and mass producible within the next 50 years."
the only rate limiting step with his method of decoding thoughts is that it takes time under a high energy device to pair associations in the brain.
Think of how much screen time we currently use. If we could pair a wireless 'headset' like headphones while looking at pictures on a screen it would be possible to build a brain bank of children->tenenagers. Currently we just need a lot of processing power and reserved bandwidth on the internet to do some cool stuff.
In my honest opinion as a neuroscientist, we are not that close. We have only an obtuse understanding of how the brain works. Most 'mind reading' demonstrations, though cool, occur within highly constrained circumstances and training and test data, and even then perform just a bit over chance. For context, we barely achieve good accuracy classifying ASD vs typical development, ADHD vs typical development using neuroimaging, much less the much harder problem of classifying and decoding the contents of our thoughts. Slightly more impressive results have been achieved in studies collecting data from actual brain implants found in epilepsy patients, but even then, I do not see this as something that can be a reliable technology in a long long time.
I appreciate someone in the field taking the time to respond. I think we have the ability to scale our knowledge with machine learning and mass monitoring. Again i recognize that 50 years is extremely optimistic. Ethics, money, and politics never agree.
The poster before you is presumably talking about physical limitations of the current measurement methods which leads to very high noise. I doubt machine learning can overcome that.
1. Our understanding of the brain is poor, and I think that will be necessary to have good machine decoding. In principal, a machine learning algorithm does not need to know how the brain works to make an accurate decoding prediction, but I suspect understanding will be needed to help construct and constrain machine learning models learn to deal with the myriad of mental states, intentions, emotions, etc that can occur. While we can train classifiers better than chance to identify whether one or another item is observed, remembered, etc, these training are quite constrained to a type of information or class. I imagine those classifiers are hopeless when you start performing another activity or mental state, and the machine would need to recognize the new state and apply different decoders.
Second, yes there is too much noise in most available methods (EG, fMRI, MEG) and the information is not dense enough (spatial, temporal resolution) and not specific enough to the type of activity (excitation, inhibition, chemical diffusion, etc). Electrodes have done cool things, but I suspect that even millions of wires would not provide enough information and types of information to provide a full fledged brain interface.
"Treatment is worse than the disease". This is also true in cancer treatment, where many drugs have measured effects on reducing tumor size and yet not increasing survival times...yet the side effects make the patients' quality of life significantly worse.
I don't think this is fair for several reasons. First, cancer treatment drugs are tested heavily in-vitro first, where the only significant metric is reduction of tumor mass. Clinical trials for cancer treatments are different from other drugs, as you don't generally do double-blind trials (would you want to get a placebo if you had a terminal cancer? No, probably not).
So many cancer treatments go into clinical trials with only the evidence that it shrinks tumors, and tends to kill tumors faster than it kills the rest of your body. Side effects are expected to be severe since most cancer treatments are quite literally killing any cells that divide... tumors just divide faster and thus get hit harder. The end result is cancer treatment often has very poor quality of life.
Clinical researchers _do_ perform analysis to see if survival increases relative to other treatments. But often you don't know until you've already tried it on a cohort of patients (with their consent, obviously).
There is push-back in the medical field in areas for what you suggest. For example, colonoscopies are becoming widely recognized as causing more problems than they solve. The complications they can induce tend to lead to a poorer patient outcome than missing colon cancer because you didn't screen (e.g. survivability is not affected by finding/treating colon cancer early).
I just don't think it's fair to paint cancer treatments with the same brush strokes, since dealing with terminal diseases is a totally different ball game.
Edit: I should say, there are some parts of cancer treatment which is moving towards the dont-treat opton. For example, there is growing evidence that treating prostate cancer is not necessary, since you'll probably die of something else long before prostate cancer kills you (it is very slow growing on average)
The other problem with cancer is that there are different types of cancer cells. There's the fast dividing and there's also the cancer stem cells which can lay dormant for years without dividing. This is the reason for most cancer returning. There's a promising new tech that hopefully pans out that activates these cells so standard chemo can attack them. Regarding clinical trials, they are very selective. You have to for a very specific criteria and your cancer needs to be measurable by a CT scanner typically to prove efficacy. Add to that the typical cancer patient is either a child or an older person and you're bound to have poorer results.
So... As a cancer patient myself going through chemo, I'll take the chemo over the cancer any day if the week. While some chemo treatments suck, it typically depends on what stage you're at, if you're curable, your comorbidities, and your personal genetics. I can say without any doubt whatsoever I'm alive right now because of chemo. Reducing the tumor allowed me to eat, which has kept me from wasting away into death. Survival times tend to increase with treatment, however quality of life of that survival time is reduced drastically for some people which I believe is what your point is not accurately reflecting, but again it's different for every single patient. I'm young, otherwise healthy, and I'm tolerating the chemo far better than expected with a far better response than average. I'm halfway through average expected survival time and if I live 2 more years I'll be drastically beating the odds. Right now that looks possible for me and that's because of the cancer treatment. There's also been a groundswell of new standard treatments, premeds, and novel treatments as better understanding of the disease in the past 10 years is just starting to bear fruit. If you look at survival rates of some common cancers in the United States many of them are downright not terrible odds of surviving through unless you catch them very late in their development.
only slightly beyond that, 23andme doesn't cover all of the relevant SNPs but it does cover the ones that allow you to infer that you are less likely to respond to p-glycoprotein based drugs like citalopram and paroxetine. You have to export your 23andme raw data and use something like promethease to reprocess the data.
Isn't this mostly from companies like GeneSight? Considering that they relied on 5-HTTLPR and HTR2A, which both had enormous edifices of completely useless (and now debunked) scholarship behind them, I wouldn't bet on those tests' effectiveness. (For reference, GeneSight's test relied on 7 genes. The five not mentioned deal with liver enzymes)
That is a very odd way of looking at the issue. The scientific literature certainly has a bias in favor of publishing positive results rather than failures. However, the scientific literature in no way affects FDA/regulatory approval. Drug/treatment candidates that fail regulatory approval are not on the market.
As far as negative results being "distorted" to present "positive results" is concerned, yes it is quite common to take a patient population that overall fails to show statistically significant benefit and see if there is a subset that does in fact show a statistically significant benefit. One could call that p-hunting, but as long as it is followed up and confirmed, it doesn't seem like a nefarious thing to do.
> the “chemical imbalance” theory that is propagated through paid advertising
I've never seen a pharmaceutical ad that used that term. The only thing I recall from the ads is them distinguishing clinical depression from feeling blue.
ok, I concede that one. They used the term "imbalance of chemicals". To be fair, though, that was a "vintage commercial" and undated. And everything else is not disputed: how to recognize the symptoms of depression. However, I don't fault Big Pharma for not figuring out how to explain the neurochemistry of SSRI's in a 30 second TV ad.
That's quite a statement. I mean, sure, the entirety of why selectively inhibiting serotonin reuptake might affect psychological outcomes may be a bit fuzzy at the end, but there is a pretty solid theory here isn't there? The drugs work by selectively inhibiting serotonin reuptake. This leads to more serotonin signaling. Sure it gets a little fuzzy from there to how this mechanism affects mood disorders with various competing theories, but "unknown" is quite a stretch here.
the mechanism that many drugs use, such as nitrous oxide aren't fully known. the wikipedia page for SSRI doesn't seem to look like marketing. a drug doesn't have to be fully understood in order for it to be effective.
For the last 40 years, people talked about psilocybin, weight lifting, lsd, fasting, meditation, wim hof and many other things that affect people's happiness.
We had 4 decades for doctors to get interested in them, study them, and make protocols for them for the public.
Only now are we, timidly, talking about them. It was considered hippie stuff at best, cult/lunatic ideas at worst.
But turning an entire nation into drug addict is apparently fine.
Frankly, a lot of this is the patient's fault too. The vast majority of people _do not_ want to change their lifestyle. They don't want to quit smoking, drinking, eating fried food and leading a sedentary life. They don't want to lose weight or start cardio, go hiking/biking/swimming/walking, limit their caloric intake or eat more vegetables and fiber.
What they want is the doctor to provide a pill to fix whatever the immediate issue is, so they can get back to their life. When providers push back on this and try to suggest lifestyle changes, many patients get _angry_. Like, yelling, shouting, complaining to administrators that the provider isn't "listening to them" or "not taking their problems seriously". People want to be fixed, not fix themselves.
There's plenty of blame to go around, but a healthy share falls on patients themselves.
Source: SO is a medical provider. My faith in humanity falls daily and I can't believe the crap providers have to put up with. It's like a service job dealing with irritated people all day long, except these people read a blurb on WebMD and think they are an expert.
> The vast majority of people _do not_ want to change their lifestyle.
Yes, but it's also very hard to do. I took me 30 years to actually have a nervous and hormonal system that was not fucked up.
Before that, I tried for decades to restrain myself and exercise, and it was just not sustainable. I had to read so much, go through so many experiments, meet and talk to so many people to find all the stuff I needed to actually fix myself. And the work is far from over, I have yet a lot to do.
I was kind of expecting medical professionals to pick up on what I needed, and actually helped me on the way. 2 did a little, out of probably 30. And I met them only because my close ones were atypical, and know original people.
What did you do that was key in your experience?
I myself have tried various things that are essential, but all works as part of a puzzle.
Stream-of-consciousness about these (sorry a bit off topic):
1) Detach yourself from "culture" and try to meditate, do breathwork, some people get into this zone better while doing stuff like Tai Chi, Yoga or Chi Gong. Go slower!
2) Exercise but find something that your body responds well to and don't over do it (many people exercise mindlessly)
3) Be social, you are a mammal and need to be touched and feel other peoples breath, warmth and voice close to you - it's a part of tribal nature, and balances your sympathetic nervous system
4) Get out in the sun and stroll around without purpose sometimes just walking, thinking, exploring the city/forest - again we are wanderers in our genetic heretage (you often think better when walking without purpose - french people call it Flâneur)
5) Create more than you consume: write, work, plan, set goals. Without a plan you are walking aimlessly and will run out of resources, feel left out and wither.
6) Eat and drink well. (fast sometimes, less junk food, more vegetables, enough protein for activity level, more organ meats if meats at all)
7) Be brutally honest towards yourself, but acknowledge that self image is malleable and mysterious like the rest of the universe. So always have an echo of awe in the back of your mind. This reality is amazingly absurdly weird, wonderful, mysterious, dreamlike, filled with obscure esoteric symbols of knowledge and history and tradition and truth in an all encompassing and infinite web all around you and your consciousness.
8) Read challenging fiction, do math, play and instrument. (or some one of these, it has to be difficult)
Understand this key is a chain where all parts are equally important like:
Learn to imagine so you can make a plan or have a vision. Imagination is a precursor to planning, and meditation and unplugging is a precursor to to this imagination. If your mind is clouded the first plan is to eat well, rest, and slowly introduce exercise until your mind is in a state of clarity, and you can actually feel "something" in your gut (ie intuition or your second brain), then you feel what you "want" in you gut, and create your plan with your non-clouded mind.
I recall having really bad fevers. I'd taken some Panadol and gone to the doctors at work. When they measured my temperature it was at a low point and in the normal range. They ignored my description of how bad I felt and sent me home with a "if you're still sick tomorrow come back". I went home and continued to get worse and worse. I felt like absolute death. The next day I made it back to the doctors and when they took my temperature it was nearly 41 degrees. Turns out I had a blood infection and I had to be hospitalised and placed on IV antibiotics.
They based their initial "he's ok" on a single temperature check after I'd taken Panadol. I get it, when a doctor hears hooves they think horses. It's just frustrating.
While I empathise with what you went through I don't think it's fully honest to expect the doctor to always start off suspecting serious disease when most of the time it's something banal. There's also the issue of patient-doctor trust, where he might have had a few poeple in the past make their symptoms out to be bigger then they really were. It's all about acting on the data available and while I guess he should have behaved differently he basically had 2 pieces of information: your description of how you felt and a normal temperature reading. What would you have done in his place?
It is also reasonable to conclude that the Pandol was working. If the Pandol is working, then there is no need for hospitalization. If you had arrived before taking the Pandol, they would probably have just given you the fever reducer, seen it working, and sent you home.
I'm not sure, I'm not a doctor. A normal temperature reading isn't unusual after taking Panadol. I'm not going to the doctors for fun, I knew I was really sick.
If a doctor prescribes medication without any further advice they are not even trying to find a real solution. It is quite hard to know if a person wouldn't try if never given advice from a trusted source.
I had severe depression and I was a victim of such experiments. I lost two years of my life to these drugs and failed suicide two times at the end. What helped me get out of this mess was CBT therapy to change the way I think about things and how to deal with emotions, how to defuse going into the loops of sadness. I didn't need any drugs but doctors insisted it will make me feel better.
Yes, I was feeling better initially - actually sometimes I could feel the effects to similar to those of cannabis. But after few months I was getting hallucinations, weird thoughts and sudden urges to kill myself. The doctors response was to change the dose or try different one. I think this should be illegal.
The reason doctors do this is because it does work for many patients. Once you find the right medication the results can be life changing. I went through nearly all the SSRIs before landing on the right tricyclic. CBT works for many people too, but not everyone.
While at the same time doctors say they won't prescribe cannabis for pain, because (they say) there is no evidence it works, when literally a patient says he or she gets their life back, they have no problem dispensing anti-depressants like candies. I just don't buy this reasoning. This profession is corrupt to the core. My very good friend couple of months ago went to her GP because of bullying at work and she came back with a script for Citalopram. I managed to persuade her to not take it and found her a therapist instead. She is happy now and has a new job. I have a feeling that I saved her life.
Anecdotally, I’m not sure how true this is. But I’m also not sure what’s slow enough. I cut down in dosage half a pill every two weeks, as my doctor recommended. He said it was slow enough to avoid problems but the withdrawal was awful.
Those several weeks were hell. I was having anxiety attacks all the time.
I initially thought something else was wrong and didn’t even consider withdrawal (since the doctor had said I should have no issues) but later googling revealed withdrawal was pretty common with the drug I was on.
"In a paper published Tuesday in Lancet Psychiatry, the authors argued that any responsible withdrawal regimen should have the patient tapering off medication over months or even years, depending on the individual, and not over four weeks, the boilerplate advice."
Except sometimes you can't quit them slowly because if you have severe side effects from them you need to quit immediately and then have to go through withdrawal which can be worse than the initial problem. Also you can't always get hold of your drugs for various reasons and sometimes have to take another medication that interacts with one you're already on and so have to come off quickly.
Here's my personal story over the last three or four years: I was put on aripiprazole (Abilify) as an adjunct treatment for major depression after having to come off Quetiapine, also used as an adjunct in combination with an SSRI, due to its long term side effects. This kicked off a manic episode with some mild psychosis so I had to stop it immediately. The withdrawal effect in my case was about three months of suicidal depression. I am currently using Lamotrigine as a mood stabiliser in conjunction with Prozac because the manic episode triggered off by the Aripiprazole has left me with fairly severe manic depression which I hadn't suffered from before my exciting Abilify episode (this is a known side effect). Previously it was "just" major depression. I recently couldn't get hold of Lamotrigine because we've been having drugs shortages in the UK due to stockpiling and drug diversion to more profitable markets. This kicked off another, milder manic episode, followed by a few weeks of moderate depression ("moderate" in my case meaning no suicide attempts or psychosis) After seven weeks I think now I'm just about ready to go back to work.
In the past I've also had to do wash outs (stop taking everything suddenly) twice, once because one of my meds was giving me liver damage and we didn't know which one, and once when I was hospitalised with a major injury and was kept in an induced coma for two weeks. Dealing with withdrawal along with multiple broken bones was not fun.
The ideal is you are taking one medication and can slowly reduce it an swap it out for another, or slowly come off, all the while being medically supervised. This is not what actually happens the majority of times because of issues like the above, and because a lot of us are on multiple medications. There's also the "you need to come off one SSRI / Tri cyclic in order to try another" issue which means you either reduce slowly and have a period of being essentially unmedicated before starting the next one, or you do a wash out, start the new one immediately and try to ride out the withdrawal effects / hope that the new med will counteract them.
The pharmaceutical side of psychiatry is basically throwing darts while blindfolded and drunk.
With the ways we’ve seen other systems work, I’d almost expect to be placed automatically on some kind of list that would get you a stonewall response from most doctors you visit for the rest of your life. In fact, there are such databases; here is an article about one in MS: https://www.sunherald.com/news/local/crime/article62959432.h...
I’m sure there will be/are places where these databases are run by private companies with no accountability and no way to issue a complaint.
I've successfully avoided this kind of crap (never fell for the medication frenzy). Somebody close to me was able to find a psychiatrist who would assist them in getting off meds only when a third party intervened.
The problem is not with individual doctors, it is that the structure {legal, economic} surrounding mental health favors getting people on medication, but doesn't create good paths for them to get off (at least in the US).
I'm absolutely not suggesting anyone should do this without their doctor's approval, but:
When I was in my 20's I tried various SSRIs - at least three, possibly four different ones - and my pattern was always the same, which was to take them for six months, get frustrated because they didn't do anything but make my hands shake, etc., then flush them down the toilet and quit cold turkey with no ill effects. Same thing with Ritalin. I was taking it for a few years because it (shockingly!) made me a more prolific computer programmer, then my doctor moved to California and I never got a new prescription. No withdrawal whatsoever that I noticed.
My personal, subjective, anecdote-based take on this is the stories of withdrawal are as overblown as the stories of effectiveness for a lot of these.
Some drugs are relatively benign to quit cold turkey (a sizable percentage of people may run into irritating side effects like nausea, etc) but it won't kill you.
Other drugs like benzos can be fatal to quit without tapering. And other classes can induce serious side effects even when properly tapering, let alone quitting cold-turkey (e.g. hallucinations, psychosis, insomnia, etc etc).
Withdrawal stories are definitely not overblown; you have to assume good faith and show some empathy to understand that your body and mind function differently from everyone else's. Some analog of the "typical mind fallacy" would apply here.
Just look up the video where Feynman is describing how two different people count to 100 in two completely different ways.
By "overblown", I mean it probably happened to someone, but they're an outlier who's getting more press than the thousand other people who stopped and had nothing bad happen.
Making recommendations like this across the board is dangerous. My wife’s psychiatrist had brought her up to 6 mg daily clonapin (which is a benzodiazepine). She decided she was tired of the emotional yo-yo it caused and flushed the remainder of her prescription.
A few days later, I came back from taking the trash out to find her on the floor, gray and wheezing and totally unresponsive, having suffered from a serious seizure due to medication withdrawal. On waking up, she had serious amnesia (couldn’t remember the year, who the president was, etc.) for a couple of hours.
Please don’t assume that anecdote == data, or that your personal experience with one medication is generalizable to other people and other medications.
1. The whole 'chemical imbalance' thing is a gross over-simplification that might help as an introductory mental model but breaks down quickly.
2. The right thing to be measuring is symptoms, not the mythical chemical imbalance. Studies do measure changes in symptoms, typically using various rating scales, e.g. HAM-D. Measuring this way has its issues and challenges, but is being done.
3. Yes, there is an element of experimentation to find the right medication, which is hardly unique to psychiatric medications.
4. Yes, some medications are hard to quit without doing so slowly. Too many doctors don't help their patients with this.
5. Antidepressants are surprisingly effective, at least compared with many other medications. A good metric for effectiveness is the "number needed to treat" (NNT). It basically means how many people do you have to give a treatment to before you get a positive response that you otherwise wouldn't. With antidepressants, it's generally low single digits, for many around 4. Only helping 1 in 4 doesn't sound great. But check out theNNT.com for some comparisons. Aspirin to prevent heart attacks (NNT of 50-200 for people with previous heart disease, NNT 2000+ for those without previous heart disease). Antihypertensives (NNT ~100). See what's considered successful in other areas of medicine...
Antidepressants are indeed effective, but those NNT numbers are based on outcomes (i.e. depression scores) that are more subjective and far more modest than the outcomes used to calculate NNT for things like aspirin or antihypertensives (cardiovascular events and/or death). I don't think they should be compared directly compared in that manner.
The NNT for antihypertensives to lower blood pressure is essentially 1, after all.
In a way, all drug usage is like performing experiments on people - some of them work better on certain people than others and some of them give terrible side-effects to some and not others. This isn't just true for anti-depressants.
I'd rather have the option of anti-depressants than nothing at all. They help a lot of people to live their life normally. It's true that it's hard coming off some of them, but it's worth it I think - a couple years of improvement in mental health vs a crappy week coming off it.
I agree with your overall message, but it's much more than a crappy week to come off of some commonly prescribed antidepressants. It takes months to taper off some of them safely.
A. There is no such thing as "chemical imbalance".
B. Medicine is as much of an art as it is science (if not more of an art).
C. Only some anti-depressants are the way you describe. The most promising anti-depressant, I.V. ketamine - acts rapidly, breaks through the most resistant depression is gone from your bloodstream within minutes/hours after infusion and there are zero withdrawal effects.
Not really. Doctors are trained to recognise symptoms and match the therapy to the symptoms. They of course know mechanism of some (well understood) afflictions. But many are not that well understood and yet therapies for them exist that help some patients with those symptoms. Then when asked about the causes or the mechanism doctors just act like all humans do. They repeat rumours they heard.
I suspect pharma companies and doctors have settled on the term "chemical imbalance" so they have something to tell patients that is simple enough to understand but medical-sounding enough to accept.
Also, general physicians have to be across such a vast range of ailments and treatment options, they don't have much ability to deeply understand the issues themselves.
I'm not one for any great conspiracy behind this.
For my own reasons I've researched the topic deeply, and I agree that the term "chemical imbalance" is fairly shaky, but I can accept a fairly innocent explanation for why it's come to be.
> B. Medicine is as much of an art as it is science (if not more of an art).
This seems like a rather novel point of view. I can’t speak to whether this view is common among medical practitioners, but as a patient I can say I dislike it.
I would like that treatment options be selected and evaluated on the basis of empirical evidence.
> I would like that treatment options be selected and evaluated on the basis of empirical evidence.
How do you balanced the subjective benefits against the potential risks and decide if (continuing) treatment is worth it? That would seem to be something without a "right" answer.
You say "performing medical experiments" like it's a bad thing or there was some alternative, but life is usually lived based on empirical trial-and-error.
This is still true after seeing the results of well-done scientific experiments. They can tell you the average effect and how much it varies, but not the effect on you personally.
That’s a political statement. You are trying to disqualify clinical experience and an empirical approach, despite both being part of the Western scientific method for several centuries. Your view is popular and is gaining momentum everyday. Your view suggests that only double blind studies and statistical analysis amounts to “real science”. Your view has powerful factions in business that are supportive. Your view is going to do tremendous damage. Your view is ahistorical. I can only hope that you will reevaluate your view, and realize how much richer and broader the Western scientific tradition is.
> You are trying to disqualify clinical experience and an empirical approach, despite both being part of the Western scientific method for several centuries.
Being treated by any doctor (other than a surgeon when on the verge of death) has only over the past century become something that was likely to extend your life rather than shorten it. This is a result of double-blind studies and statistical analysis.
"This is a result of double-blind studies and statistical analysis."
First of all, if you want to shrink all of medical research to seeing a doctor, do you have any evidence that your statement is true?
Second of all, most of the big breakthroughs in life extension were thanks to medical research that was neither double blind nor statistical, including:
1.) In the late 1700s, Edward Jennings invents the vaccine for smallpox.
2.) John Snow's theory of cholera in London 1854
3.) In the late 1800s Louis Pasteur and Joseph Lister develop the Germ Theory Of Illness, including such practical ideas as:
3.a) Louis Pasteur invents pasteurization.
3.b) Lister uses antiseptics to sterilize surgical instruments and clean wounds
For years I was told I was depressed and, as you described, “tried” one antidepressant after another. None of them helped with my symptoms (an otherwise healthy 20-something couldn’t get out of bed, sleeping constantly). It turned out I had lupus. I often wonder how many people who are being treated for depression have another illness entirely. I think a lot of times it’s just the best diagnosis currently available to many doctors.
The drugs used to treat autoimmune diseases are “tested” by patients much the same way as antidepressants. Though there’s at least some bloodwork to guide the way. I’m optimistic technology and our rapidly growing understanding of gut bacteria will greatly improve the current trial and error approach.
> Let's see this anti-depressant, then evaluate side-effects, if it doesn't work switch to different one or adjust the dosage.
Please tell us about the alternative treatment regimen you recommend, with references to the peer-reviewed, published literature supporting its efficacy.
Absolutely, even when the active compounds are the same but there are changes in composition.
For instance, I'm an asthmatic and I need to use a spray inhaler. The no-brand equivalent is exactly the same, and does work the same in normal circumstances, except has roughly 1/2 of the propellant. But I can tell you that the missing propellant makes all the difference when you're having a stronger attack and cannot inhale.
I'm a bit sceptical here. As it happens, my partner was taking Effexor (a branded formulation of venlafaxine) and was switched to the generic Enlafax. She complained to me that she was feeling a little bit worse starting around this point, and when patient groups started sharing stories of many people who began feeling worse following the switch (which is what led, eventually, to the media coverage), she requested switching back to Effexor (which required paying out of pocket, as it's no longer covered), resumed taking it, and started feeling better.
She will no doubt be part of the statistics that paper is using to suggest a nocebo effect, as she only complained publicly after the media coverage started, but she has notes showing she had noticed the effect prior to seeing anyone else complain about the generic formulation.
To be clear: her experience is absolutely not proof that Enlafax is in any way inferior or different than Effexor (for my partner specifically, or for people in general)! It's very possible her entire experience was a nocebo effect (triggered, perhaps, by the Enlafax packaging or something) followed by a placebo effect when she switched back to the branded drug. However, it could equally have been caused by Enlafax being actively inferior for her.
What I think is fairly clear from my partners experience, however, is that the study is not correctly designed to reject the null hypothesis here. It's assuming that the people who publicly complained about Effexor after the media coverage were fine with it until the media coverage, whereas it's just as plausible that they simply didn't publicly complain until they realised other people were also having an issue.
Ultimately, any study here that's not a proper double blind test is going to struggle pretty hard here, and I think this is no exception.
"These switches to generic medical and psychotropic medications have from time to time caused an increase in reported adverse events, and this is likely to be due to negative attitudes towards generic medicines rather than pharmacological differences between the branded and generic versions of the medication.
I don't know if I'd call that "in" the article. I suppose it's an explanation of a sort, but really? It looks like it was spit out by a science-bullshit generator.
NZ has socialized medicine, with a central drug buying agency (Pharmac) who tries to save costs where it can. It also has a drug safety agency (Medsafe). Not uncommonly, Pharmac reckons they can save money by switching brands, and Medsafe may raise concerns.
In 2017, Pharmac moved from funding a branded formulation of venlafaxine (Effexor) to a generic formulation (Enlafax). A lot of patients reported issues (almost 2k, which is a fair number given the size of the country), and it was a bit of a black eye for Pharmac. So Pharmac went and paid a researcher at a local university to study brand switches in general and the 2017 venlafaxine switch in particular, and show (hopefully) that the issues weren't real, hadn't caused significant problems, and that it was totally fine to switch psychiatric meds. (Which is relevant now, because Pharmac is looking at switching another medicine, Medsafe has raised strong concerns ("potential significant safety issues", "goes against international consensus", etc.), and Pharmac wants to find a way to move forward while covering their ass in case it turns out Medsafe is right.)
In any case, the result was this study. It could well be right, but uh, do keep in mind the context, which is that the researchers got paid hundreds of thousands of dollars to conduct it by an interested party hoping to save millions of dollars and fend off accusations that they had harmed people and risked lives.
Any study funded by people with such a strong interest in it having a specific outcome that then comes out with the exact outcome should be taken with a grain of salt. Doubly so when the study omits to disclose that funding!
Note: The article says that Petrie received NZ$400k from Pharmac for the study. For anyone wondering if that's right, the answer is: Yes! Although it took the NZ equivalent of a FoI request to find out. See https://www.pharmac.govt.nz/news/oia-response-2018-12-12-res... And note that the study itself disclosed nothing about funding. Given that Pharmac has a very strong and very obvious vested interest in this matter, I find this ethically troubling.
Except they used suicidal thoughts as their key symptom -- which is something that is widely already known to increase in prevalence with media attention, see: "13 Reasons Why"...
This article does not show any evidence of a nocebo effect. It shows increased reporting following publicity - without distinguishing whether the result was increased incidence of perceived harm, or just increased /reporting/ of perceived harm (for instance, if patients would not have previously attributed those somatic symptoms to their medication.)
This is also my take on this paper. It records an increase in reported side effects, which is not the same thing as an actual increase in side effects. Patients may have been experiencing these side effects anyway, but either didn’t report them, or didn’t associate them with the intervention.
Knowing these side effects are associated with the intervention would likely be enough for Confirmation Bias to increase the reported instance.
agree that it's crap study, but even worse than that it's an attempt to discredit symptom reporting in general
while talking extensively about the nocebo effect, it ignores the fact that without media coverage a patient may experience side effects but not connect that effect with the switch from one drug to another, or may think they're imagining the effect, etc
Absolutely. My long-term partner was in this exact situation: She did experience some fairly mild side-effects, complained about them to me, but didn't consider that the medication switch might be the cause until she saw others complaining, checked, and realised the symptoms had begun at the time she'd changed meds. She had simply assumed that she wouldn't have been switched to the generic if it wasn't identical, and thus initially assumed that any symptoms she was experiencing must be caused by something else; the exact opposite of what the study claimed, despite the fact that she will have been counted in that study as evidence of a nocebo effect.
Lots of things can influence the placebo effect, branding is one of them:
> and we know that two placebo sugar pills have a bigger effect than one, and that an intramuscular placebo injection is more effective than a placebo sugar tablet[...]
> And a four-way comparison, with either sugar pills or aspirin, in either unbranded aspirin boxes or mock-up packaging of the Dispirin brand, showed that brand-name packaging, and the wealth of advertising and cultural background material that packaging plays on, had almost as big an impact on pain as whether the pills had any drug in them. So in some ways, it's not irrational to believe that costly Nurofen is more effective than cheap unbranded ibuprofen, even if they've both got the same active ingredient.
