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Comparative efficacy and acceptability of 21 antidepressant drugs

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Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#31

Post by ggm »

amputect wrote: post #9
ggm wrote: post #6

A professional I know in the field (who repudiates drugs for CBT, and so is probably biassed, but still...) says that the lack of clarity over how an antagonist and a suppressant can both be claimed to operate on the same underlying problem and have adherents, points to bad understanding of what actually causes the problem.

I basically agree with your friend, but I'm pro-drugs for pepole who find them helpful. I very strongly suspect that the underlying "problem", like with cancer, is actually an enormous variety of problems that cluster into vaguely similar symptom groups. I am absolutely not an expert here, this is a layperson's opinion, but it's really hard to imagine that there's just one specific cause that we're treating. I think…

Yes, but we need professionals to be more overt we are groping in the dark I think.

The recent news about why ketamine works is a very specific aha moment, they showed a focussed impact on a brain functional element which seems to re-stim negative ideation and so blocking it relieves a cycle and then permits some kind of reset. Layman's analogies.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#32

Post by JamesBarney »

ggm wrote: post #6

A professional I know in the field (who repudiates drugs for CBT, and so is probably biassed, but still...) says that the lack of clarity over how an antagonist and a suppressant can both be claimed to operate on the same underlying problem and have adherents, points to bad understanding of what actually causes the problem.

True, but man found fire very useful for millennium before we understood it.

And as little as we know about how drugs work we know less about how CBT works.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#33

Post by entropyneur »

djsumdog wrote: post #21

> meta-analysis I knew a lot of other grad students, myself included, who would throw anything with meta-analysis in the introduction in the trash. You cannot deal with controls across completely different studies in meaningful ways. I'm also hesitant about anything that tries to claim things definitively without question. Science is about continually questioning your axioms. Without doubt[1] there is no progress. As…

> Dulling the pain for me also meant dulling life.

I've heard quite a few people say similar things (including my therapist), but it's such a sharp contrast to my own experience. There are indeed very good reasons not to use these drugs (I currently don't and it's costing me dearly), but "dulling" is not a word that would ever come to my mind if I tried to describe the experience of being on them. The years I was medicating are actually the brightest patch of my adult life.

Well, I guess such differences are to be expected when we don't know what depression is and why these drugs work.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#34

Post by jdietrich »

amputect wrote: post #8

I think that the United States is getting better about dealing with mental health, but we still have a long way to go. This is a little soap-boxy and anecdotal, and I apologize if it's inappropriate here. If I hadn't gotten a prescription for Prozac I probably would have killed myself by now. And I definitely would have destroyed my marriage and most of my important friendships. That's not an over-dramatization, it's…

>If I hadn't gotten a prescription for Prozac I probably would have killed myself by now.

The majority of people with depression just get better of their own accord, for no obvious reason. The NNT for most antidepressants is ~7, meaning you need to give them to about seven patients for one patient to see a clinically-significant improvement.

The evidence suggests that there's no significant relationship between SSRI use and suicide risk except for young people, for whom SSRIs may actually increase the risk of suicidal behaviours and self-harm.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3353604/

>If you can't make your own neurotransmitters, store bought are fine.

There is no evidence whatsoever that people with depression are "deficient" in neurotransmitters. We don't really understand the mechanism of action of any antidepressant. Plenty of drugs that have no effect whatsoever on serotonin are equally effective as SSRIs.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4471964/

Antidepressants can be useful for some patients, but they aren't miracle drugs - they aren't even particularly good drugs. If you're depressed then you should certainly consider pharmacological treatment, but you should regard it as only one tool among many. Talking therapy is equally effective and the combination of drugs and talk therapy is more effective than either alone. You might need to try several different drugs before you find one that works for you and has tolerable side-effects, especially if you have been depressed for some time or have comorbid conditions. If your depressive symptoms are relatively mild, you should probably look at lifestyle interventions like diet, exercise, sleep hygiene and self-help before considering drug treatment.

https://www.nice.org.uk/guidance/cg90

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#35

Post by imperio59 »

Horrible side effects, no tests for diagnosis, no actual cures (have you heard of these drugs actually curing depression? No. Once you get on them you are basically on them for life...)...

I think this "Science" of psychiatry has a long ways to go to actually get repeatable, scientifically proven results.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#36

Post by askvictor »

This analysis look at effects over 8 weeks. The first four weeks on antidepressants you're feeling terrible due to onset side effects (on top of your depression). Once that settles, you feel better. But there is no way to tell if you feel objectively better than before the medication started.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#37

Post by contingencies »

fernly wrote: post #23
random_throw wrote: post #5

Key bit: "In head-to-head studies, agomelatine, amitriptyline, escitalopram, mirtazapine, paroxetine, venlafaxine, and vortioxetine were more effective than other antidepressants (range of ORs 1·19–1·96), whereas fluoxetine, fluvoxamine, reboxetine, and trazodone were the least efficacious drugs (0·51–0·84)."

Also significant, the next sentence, "For acceptability, agomelatine, citalopram, escitalopram, fluoxetine, sertraline, and vortioxetine were more tolerable than other antidepressants (range of ORs 0·43–0·77), whereas amitriptyline, clomipramine, duloxetine, fluvoxamine, reboxetine, trazodone, and venlafaxine had the highest dropout rates." It appears that agomelatine[1] and vortioxetine[2] are effective and well-tol…

I didn't read the paper but going off your comment and the parent - escitalopram was in both lists, whereas vortioxetine wasn't. http://en.wikipedia.org/wiki/Escitalopram

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#38

Post by grzm »

askvictor wrote: post #36

This analysis look at effects over 8 weeks. The first four weeks on antidepressants you're feeling terrible due to onset side effects (on top of your depression). Once that settles, you feel better. But there is no way to tell if you feel objectively better than before the medication started.

> "But there is no way to tell if you feel objectively better than before the medication started."

Would you elaborate at what you mean here? Two reads I have are either (a) you're getting at whether feelings like this are subjective, which is true definitionally but seems to me to be uninteresting, or (b) assessment tools (such as the Beck inventory) are imprecise, which is also true, but can still provide some basis for comparison. Or something else that I'm missing?

That said, I would like to see a longer time scale to see if the changes are maintained.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#39

Post by kqr »

icantdrive55 wrote: post #12
tyu100 wrote: post #4

Earlier quoted context omitted.

SSRIs are generally indicated for what's called mild/moderate depression, the most common form, not for the serious conditions that you highlighted. There were some older meta-studies that called into question their general efficacy vs. placebo even for mild/moderate depression but this new meta-study (with the additional previously unpublished data from their initial approval trials) looks like it has finally settle…

I am obviously confused, as usual. I'm not used to reading these studies. I'm looking at the study. I'm looking at the #3 graph under Tables and Functions Tab. It says amitriptyline is the best drug? Isn't that an older drug, or am I misreading the chart?

"Best" is a complicated concept. Yes, amitriptyline has the greatest efficacy, i.e. response rate in a clinical setting. It may still have poor effectiveness (how well it works in the real world) because it belongs to a class of medications which, if you use them, you have to exclude many types of common foods from your diet. It also has less safety margins in terms of overdosing than many modern alternatives.

And then there's also the odd fact that earlier trials of antidepressants show better effect than recent ones -- even for the same treatment and all else held equal. We don't know why.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#40

Post by raducu »

ggm wrote: post #6

A professional I know in the field (who repudiates drugs for CBT, and so is probably biassed, but still...) says that the lack of clarity over how an antagonist and a suppressant can both be claimed to operate on the same underlying problem and have adherents, points to bad understanding of what actually causes the problem.

I don't understand the part about " an antagonist and a suppressant".

Do you mean agonist-antagonist mechanism of action of some drugs that treat the same condition?

As far as I know different drugs can work on serotonin/dopamine/norepinephrine but in different parts of the brain and produce different results.

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