Dr Pink rightly pointed out in the last piece that:
Interestingly, one of the authors seems to suffer from linear thinking too:
There seems little reason to prescribe anti-depressant medication to any but the most severely depressed patients - Professor Irving Kirsch, University of Hull
Er, no. The study shows that antidepressants DO work in depression. It's just they don't work any better than placebo.
Now this is very, very, very important.
Studies that show something is no better than placebo do NOT show that that something is useless. For that you need a study showing that something is no better than nothing.
I'll repeat that. The fact that antidepressants are no better than placebo does NOT mean there is no point to prescribing antidepressants for mild to moderate depression. (That does not mean we should prescribe them, but neither does it mean that we should not).
It might mean that we should start giving out placebos, but that is tricky for doctors because we are not allowed to lie to patients. (Do placeboes work if you know you are taking a placebo? We don't know, because in placebo controlled trials placebos are no better than, well, er... placebos.)
It might mean that we should enlist the help of charlatans...er...I mean 'alternative practitioners' (who are the masters of the placbeo) but that takes us back to the problems of lying to patients. (If a lie helps, is it ok to lie?)
What it most likely means is that we need to train a lot more people in Cognitive Behavioural Therapy - although this is very time consuming and is not the 'one size fits all' solution it is sometimes portrayed as. However, I'd like to see a large meta-analysis of CBT vs placebo first.
So, to Prof Kirsh the learning point from all this is 'you, like, really need some logic training, Irvine'.
Oh, and Mrs Rant has given me grief: "I like Hull. Scunthorpe: now that's a shithole".
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Dr Pink also said: "(CBT is very think on the ground)" which is very Freudian.
Anyhoos.. totally agree with the skewiffery of Kirsch's phenomenal piece of meta-analysis - or as we like to refer: "No shit, Sherlock".
I was most fucked off with his sweepingly knowledgeable opinion about how A/Ds are as effective in life as placebo - like it wasn't known? Effectively, we've kept that one under wraps for a long time - why? Because the public demanded it - the 'need' for 'treatment' or I'll go somewhere else and get another GP to write me something up - much like how backstreet abortions continue, or the ABX saga. Or even "Mr I need Diazepam or I'll go mental and smash the surgery up" who will work his way round the various GPs til they get one and think the GPs are just being permissive (which some are) but mostly are seeing the bigger picture of monitoring and serving the higher interests.
I'm sympathetic to the GPs who prescribe and keep their patients monitored - than allow them to bounce off to the next GP for a 'cure'. This will be another issue of the polyclinics - who will prescribe based on keeping 'trade' rather than treatment integrity.
CBT is a viable alternative - but it's not ready and Kirsch is promoting his doctrine (by rubbishing the opposition - much like politics) too soon into the game play.
The meta analysis was no different to one done in 2002 - this is just a new 'spin' to promote the Talking Therapies at this time in line with Layards LSE proposals.
Love the tag line on Mrs Rant and Scunthorpe - any way to get ensure the word "cunt" continues to appear in each rant is a good way.
You asked if placebos work if patients know they're taking a placebo.
Well, Ben Goldacre in Saturday's Bad Science column reported a study which tested just that and found that they still worked.
http://www.badscience.net/?p=620#more-620
http://www.leecrandallparkmd.net/researchpages/placebo1.html
Sorry, the last part of that url should read:
/placebo1.html
I'm going to stick up for Hull because I think it gets an undeserved bad rap.
Once, I too was like Dr Rant and loved to poke fun at the city. However, one of my best friends from Uni was from Hull and I quote:
"Hull only ever gets slagged of by clueless southern gets like you who have never actually been there"
So I took him on his word and went up to see the place for myself and I was VERY impressed. It's actually far more fun than the city I grew up in. Each time I've been back since, I've had a fantastic time, so much so I applied for a job there in MTAS 2007.
But, don't just take my word for it. Have a look for yourselves. May I suggest that the Rant family goes and visits Hull this Easter and lets us know what they honestly thought?
Scunthorpe, however is a different matter...
May I suggest that the Rant family goes and visits Hull this Easter and lets us know what they honestly thought?
Yeah but take an inflatable dinghy just in case.
I should imagine that the placebo is a damn site easier to come off then Seroxat.
As a child, I would weep at the prospect of a trip to Portsmouth.
I think a major part of the entire "Depression" thing is people call themselves Depressed when in reality they're just unhappy.
Unhappy is a perfectly normal state to be in. It is not an illness.
Dr Mustard be nice, we have a lovley dockyard and all the ladies of the night a sailor could want in Portsmouth.
I enjoyed skipping stones into the water as a child on the beach,...believe me Portsmouth is much better as a child than an adult.
Good post Mr Ian.
Dr Rant do you know of this blog, you probably do but if not you might like it.
http://counterknowledge.com/
The problem with depression is that everyone thinks they know what it is!
Its only when you've had the real thing that you are actually aware just how unlike normal unhappyness it really is.
But please no more CBT / counselling - if anything qualifies as a placebo it has to be talk therapy, and if it doesn't work we can blame the patient again - they didn't want to get better, they arn't cognitively minded (wise souls) or well what does it matter its all the damn patients fault, and as for those people that wouldn't touch it with a barge pole well they are just dinosaurs/ negatively affected by the stigma of mental health etc etc. No mention of the fact that this nonsense is just a load of crap then.
We kinda know this anyway but if it works it works.
Pal of mine says that in his highly deprived practice he thinks he should just be allowed to give folk the money the antidepressants cost each month rather than the drugs themselves.
To be honest in a lot of cases this would be far more beneficial!
as far as talking therapy is concerned waiting lists in my area are so long that high numbers of people are better before their appointment ever arrives.
Gulp. There's a slim chance that I'll be sent to Hull at some stage, although they tend to send traines who haven't done any research, to act as Professor S's gimp and hopefully produce a publication or two.
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