Comparative efficacy and acceptability of 21 antidepressant drugs • Hacker News Board

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#71

Post by joncrane » Thu, Feb 22, 2018, 2:50 PM UTC

tyu100 wrote: post #55

evincarofautumn wrote: post #25

Earlier quoted context omitted.

Likewise, if storebought doesn’t do the trick, some people (myself and my partner included) have better luck with the recreational variety—mushrooms were the thing that kicked me in the psychological ass and started me on the path to recovery from alcoholism (which was partly self-medicating for anxiety). To be clear, this is absolutely not something I’d recommend lightly. Taking (who knows how strong) mushrooms or L…

This study, along with long-accepted clinical practice and the generic cheapness of most anti-depressants now, and the effectiveness of CBT/therapy if it's available to you, means you should really avoid self-medicating for major depression. Why take risks with your health when there are lots of safe, cheap and efficacious treatments that can be monitored by your doctor?

One issue worth mentioning is that psychiatrists are one of the hardest specialists to find that participate in health insurance. This is only anecdotal in my area, but many that take insurance have multiple month waiting periods for new patients. Or you can pay $200 to see one on your dime.

It's not the cost of the medication that's the problem. It's access to the professional to prescribe the medication that drives people to self-medicate, IMHO.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#72

Post by markroseman » Thu, Feb 22, 2018, 2:56 PM UTC

imperio59 wrote: post #35

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.

Yes the science has a long way to go, but you're ridiculously generalizing. Some people stay on antidepressants long term, but most don't. Many psychotropics are used only short term. I think your test/cure paradigm is a bit of a "red herring"... maybe it would be nice if it were the case, but symptom (and impact) based diagnosis plus subjective improvement to symptoms, functioning and quality of life still counts to people actually suffering, as well as their families.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#73

Post by mnw21cam » Thu, Feb 22, 2018, 3:10 PM UTC

alex_hitchins wrote: post #53

kqr wrote: post #39

Earlier quoted context omitted.

"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 th…

What foods should I avoid? I'm been taking Amitriptaline for 8 years now for pain management and wasn't given any advise on substances to avoid. Although I'm on another Anti-Depressant, I certainly notices a positive effect from Amitriptaline that outweigh the bad effects.

Basically, the foods you need to avoid are any that might cause constipation, because Amitriptyline kind of does that for you already. The parent post was possibly confusing Amitriptyline with a different drug.

It is very weird to be mixing two different antidepressants. Depending on what your other antidepressant is, it could be dangerous. Were your two medications prescribed by the same doctor, and if not, have the two doctors talked to each other? A very simplistic view is that some antidepressants cause the body to make more serotonin, and others prevent the body from destroying serotonin as quickly. Doing one is fine, but doing both at the same time can lead to serotonin syndrome.

Amitriptyline does have higher risk from overdose than SSRIs, but has much gentler withdrawal symptoms.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#74

Post by markroseman » Thu, Feb 22, 2018, 3:11 PM UTC

anticnstrctv wrote: post #28

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…

Attitudes towards mental health in the US and the west in general are quite frustrating, and I hope they are improving. On the right there seems to be a tendency to deny nuanced views of mental illness from economic, religious, or simply conservative cultural motivations, or to push sedative (using this term metaphorically) medication as a panacea. On the left there are many influenced by the (understandable but deep…

The anti-psychiatry folks are extreme enough that they deny mental illness altogether, though many other "psychiatric survivor" communities do not deny, and often celebrate "lived experience", but are critical of psychiatric treatments.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#75

Post by markroseman » Thu, Feb 22, 2018, 3:14 PM UTC

jkmcf wrote: post #17

PSA: The first thing to realize is that psychiatrists, and regular practitioners, have no clue what will work for you. In my case, it took 8+ years of trying, giving up, and trying again. E.g., Prozac didn't affect me at all, but the doctor never suggested increasing the initial dose. Paxil didn't work, Lexapro kinda worked, and now on the maximum dose of Effexor. The biggest difference makers were the doctors perfec…

Close enough to accurate. The better ones can apply useful heuristics (symptom matching, family response, etc.) as well as more sophisticated management of dose, side effects, etc. to converge on the solution much faster, but at this point, there's definitely still trial and error involved.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#76

Post by itschekkers » Thu, Feb 22, 2018, 3:16 PM UTC

gehwartzen wrote: post #13

Reading through the paper it seems like all the statistics are presented as Odds Raios vs placebo. But I couldn't find the actual efficacy of placebo. Did I miss it or does someone know? Something being twice as effective as a placebo is great when the placebo effect helps 30% of patients, not so much when it's 3%

placebo rates would be something in the 15-40% remission rate range, in small RCTs. it varies more than you would think from one trial to another. antidepressant efficacy would be something like 20-45%. recovery rates are usually higher in smaller trials, and lower in bigger trials, partly because people get more high-touch service in smaller academic studies

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#77

Post by markroseman » Thu, Feb 22, 2018, 3:19 PM UTC

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…

Glad that worked for you. Having seen many psychotropics poorly chosen/prescribed, your experience is certainly not uncommon, though far from universal.

Best thing would be understanding that different solutions are right for different people, and we get in trouble by generalizing (whether it's about meds, therapy, nutrition, exercise, etc.). One illness, many root causes, many different presentations, and the appropriate solution depends on a multitude of variables.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#78

Post by tyrex2017 » Thu, Feb 22, 2018, 3:20 PM UTC

jdietrich wrote: post #54

tyrex2017 wrote: post #43

Earlier quoted context omitted.

NNT might be 7 for one drug and one try, but the therapist will try several drugs and doses. I could imagine that NNT might significantly improve if you consider “use antidepressants” instead of “use 1 antidepressant 1 time”

Assuming that efficacy is randomly distributed, you're left with some very frustrating math. You'd need to try five drugs to have a better than 50/50 chance of getting a positive outcome. After seven drugs, there's still a 34% chance that none of them have worked. After fifteen drugs, there's still about a 10% chance that nothing has worked. I expect that most patients will give up on drug treatment well before that…

i agree with your points, but 50% is already good i think.

it is less than anyone might spontaneously guess, but it is still good, considering that you will try a couple of other things in addition, like cognitive therapy.

So getting some good months long treatment by a doctor can lead to (lets say) 70% curation rate. It then becomes sad if people choose to stay away from doctors and I just commented to not discourage possible ill persons.

You probably just wanted to stress that such pills are far away from doing guaranteed miracles and you are right.

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#79

Post by tachyoff » Thu, Feb 22, 2018, 3:21 PM UTC

jdietrich wrote: post #34

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…

I agree with all of this, and I can’t help but ask: when did we start ignoring people’s environment and their circumstances? I have tens of thousands of dollars of student loan debt (my monthly payment is basically a mortgage payment) and I’m not particularly satisfied at work. Is it any wonder I find it impossible to get out of bed? Now, I try to be careful because, sure, perhaps the depression was already there and is just making my life complicated, but that seems less likely. I KNOW I’m not happy at work; I KNOW my debt burden makes me feel trapped and helpless. Look at Harlow’s monkeys. Turns out putting creatures in helpless, depressing environments makes them feel helpless and depressed. If seeing your friend get blown up by a roadside bomb can give you PTSD, couldn’t falling wages, no social safety net, stressful news media, crushing debt, and poor job mobility make you depressed?

Re: Comparative efficacy and acceptability of 21 antidepressant drugs

#80

Post by mnw21cam » Thu, Feb 22, 2018, 3:23 PM UTC

jkmcf wrote: post #17

PSA: The first thing to realize is that psychiatrists, and regular practitioners, have no clue what will work for you. In my case, it took 8+ years of trying, giving up, and trying again. E.g., Prozac didn't affect me at all, but the doctor never suggested increasing the initial dose. Paxil didn't work, Lexapro kinda worked, and now on the maximum dose of Effexor. The biggest difference makers were the doctors perfec…

Yeah, with me it took a few tries as well. My doctor tried me on a few, before giving up and referring me to a specialist, who basically said that none of the doses I had been given so far were very high, so why don't we just increase the one you are on now. It worked.