![[dr. bob]](/dr-bob-sm.gif)
Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 40 to 64 of 86. Go back in thread:
Posted by linkadge on January 5, 2008, at 19:55:03
In reply to Re: STAR*D confirmed what patients already knew » linkadge, posted by Racer on January 5, 2008, at 18:27:25
Antidepressnats will never die, because there are many people who base their lives on the notion of their efficacy. Its like a religion.
Linkadge
Posted by linkadge on January 5, 2008, at 20:07:24
In reply to Re: correlation does not imply causality, posted by SLS on January 5, 2008, at 19:40:16
>If you happen to be stricken with depression, >how long have you been trying unsuccessfully to >treat it? More than 56 weeks? If so, you might >want to try following a protocol similar to that >used in the STAR*D study.
That doesn't make sense since we have no idea of the length of time the average STAR*D patient has been depressed. Even so, to make such an assumption one would need to perform a subgroup analysis to determine that such a proposed efficacy extends to those who have been treating depression for such a lenght of time.
>So, you see how the STAR*D investigation thus >indicates that there were quite a few members of >the study population who were chronic and >difficult to treat, otherwise their depressions >would have remitted spontaneously during what >you acknowledge is an extended period of time. >Where is the selection bias here?
Where has the study indicated the percentage of participants who have been depressed for more than a year or so? Depression can be diagnosed after two weeks. What Jamal said is very important. If a good portion of the participants had the type of depression that generally remits within a year, then the length of the study is a major factor to consider. In my opinion, extended trials are only good in so much as they can work to show continued efficacy of treatments that initially work. That a patient gets better in the remaining minuates of a trial doesn't say much.
Linkadge
Posted by SLS on January 5, 2008, at 20:17:09
In reply to Re: SLS Tell Me More » SLS, posted by bleauberry on January 5, 2008, at 17:39:55
> Scott I am interested and was hoping you could answer a few questions for me?
Your hopes will be actualized, but let's discuss this along another thread.
http://www.dr-bob.org/babble/20080105/msgs/804533.html
-Scott
Posted by seldomseen on January 5, 2008, at 20:33:38
In reply to Re: STAR*D confirmed what patients already knew, posted by linkadge on January 5, 2008, at 19:55:03
I agree with you that a major concern of the STAR*D study is that the subject might have simply gotten better on their own without intervention. It's true in any study really.
However, there is a difference between an effictive drug and an efficacious one.
Placebos can be quite effective.
Perhaps one problem with the STAR*D design is that it was not an efficacy trial. It was an effectiveness trial. It showed that these drugs and this protocol can be effective in treatment resistant depression. Now whether it is an efficacious protocol? Now that's a different story.
There is plenty of evidence out there that drugs are efficacious against depression, and there is plenty of evidence out there suggesting that they aren't efficacious at all.
Does it matter? Yes and no.No study no matter how well designed can predict what a drug will do in an individual person. No drug is perfectly efficacious and no drug is 100% effective.
I had my response to the SSRI's, someone else might not and that's what it comes down to IMO.
I think what matters is how the docs present these drugs to us. I think it is irresponsible for a physician to say - hey take this pill it's going to cure you and there's going to be no side effects.
If we chose to, we consent to take these drugs and throw our ball on the roullete wheel and see if we are lucky enough to get a winner. I think that's the take home message.
It's the same whether it is a blood pressure med, or an anti-psychotic.
I don't think it is a religion, or some conspiracy to keep these drugs in play.
Posted by SLS on January 5, 2008, at 21:05:34
In reply to Re: correlation does not imply causality, posted by SLS on January 5, 2008, at 19:40:16
Hi.
Please thank Larry Hoover for providing us with the citation I used later in this post.
> > It may be true that 67%...
>
> I thought the STAR*D claimed a success rate of 70%. Where can I find a reference stating that it was 67%? Just curious. Thanks.
>
> > Whereof patients who follow the STAR*D algorithm can be brought into remission, but it is not necessarily as a result of following this algorithm.
>
> Thank God it was the result of something.
>
> > If each treatment phase lasted 14 weeks, that means this 67% figure was attained only after 56 weeks - more than a year!
>
> If you happen to be stricken with depression, how long have you been trying unsuccessfully to treat it? More than 56 weeks? If so, you might want to try following a protocol similar to that used in the STAR*D study.
>
> > Since major depressive episodes often only last a few months, the observed remission may be little more than regression to the mean.
>
> So, you see how the STAR*D investigation thus indicates that there were quite a few members of the study population who were chronic and difficult to treat, otherwise their depressions would have remitted spontaneously during what you acknowledge is an extended period of time. Where is the selection bias here?
>
> I'll tell you what. For as much as this treatment population remained unremitted at each step, I would conclude that there had not been terribly much conspiracy to be perpetrated. Maybe just a little? There would be no drama if there weren't just a little. Damned NIH liars.
>
> :-(
>
>
> - Scott-------------------------------------
http://ajp.psychiatryonline.org/cgi/content/full/ajp;163/1/28Evaluation of Outcomes With Citalopram for Depression Using Measurement-Based Care in STAR*D: Implications for Clinical Practice
Am J Psychiatry 163:28-40, January 2006
doi: 10.1176/appi.ajp.163.1.28
"RESULTS: Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression; most also had a number of comorbid general medical and psychiatric conditions"Brilliant deduction, I must say.
The STAR*D seems to present itself logically and simply to me; its results consistent such that they beg me to take them at face value.
Only a simple mind such as my own would find such a simple study to be so simple.
- Scott
Posted by Racer on January 5, 2008, at 21:09:34
In reply to Re: STAR*D confirmed what patients already knew » Racer, posted by SLS on January 5, 2008, at 19:20:14
>
> I would say that you have indeed - and with such eloquence.Thank you.
>
> How you have grown so smart, I still can't figure out.
>
> :-)
>
>
> - Scott
>
>That part's easy: it's because I have friends who share their smarts with me. You're one of them, and you are a blessing to me.
xoxo
Posted by Dr. Bob on January 6, 2008, at 0:31:18
In reply to Blocked » LostBoyinNCBecksDark, posted by Deputy Dinah on January 4, 2008, at 17:39:56
> I'll set the block length at twice the length of the former block length and ask Dr. Bob to review it.
On review:
duration of previous block: 6 weeks
period of time since previous block: 2 weeks
severity: 2 (default) + 1 (uncivil toward particular groups) = 3
block length = 16.98 rounded = 17 weeksBob
Posted by Dr. Bob on January 6, 2008, at 0:31:23
In reply to Re: STAR*D confirmed what patients already knew, posted by linkadge on January 5, 2008, at 19:53:31
> > most of us can point to effects of these medications.
>
> Placebos with a buzz.Please don't exaggerate or overgeneralize or jump to conclusions about others.
But please don't take this personally, either, this doesn't mean I don't like you or think you're a bad person.
If you or others have questions about this or about posting policies in general, or are interested in alternative ways of expressing yourself, please see the FAQ:
http://www.dr-bob.org/babble/faq.html#civil
http://www.dr-bob.org/babble/faq.html#enforceFollow-ups regarding these issues should be redirected to Psycho-Babble Administration. They, as well as replies to the above post, should of course themselves be civil.
Thanks,
Bob
PS: According to the new formula:
duration of previous block: 1 week
period of time since previous block: 26 weeks
severity: 2 (default)
block length = 1.48 rounded = 1 week
Posted by Jamal Spelling on January 6, 2008, at 1:16:06
In reply to Re: correlation does not imply causality, posted by SLS on January 5, 2008, at 21:05:34
> I thought the STAR*D claimed a success rate of 70%. Where can I find a reference stating that it was 67%? Just curious. Thanks.
On page 63 of the article you have on your website, they give the following cumulative remission rates:
Level 1 - 33%
Level 2 - 57%
Level 3 - 63%
Level 4 - 67%> Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression
Indeed, it may be true that nearly 80% had chronic *or* recurrent major depression. But when you break that down, the study shows that the bulk of this figure was recurrent depression, not chronic. In fact, the rates for chronic depression were 30% and 21% respectively for the primary care and psychiatric patients. So this does not invalidate my observation the 70% remission obtained after 56 weeks of treatment may have simply been regression to the mean.
I am not disputing the claim that the majority of depression sufferers can obtain relief when following the STAR*D algorithm. My observation is merely that the remission cannot necessarily be attributed to following that treatment algorithm.
Posted by Jamal Spelling on January 6, 2008, at 3:05:42
In reply to Re: Psycho-Babble practises intellectual fascism, posted by Jamal Spelling on January 6, 2008, at 2:55:11
It is interesting to note that 33% of STAR*D participants failed to remit after 56 weeks of treatment while between 21% and 30% of participants were chronic sufferers. I have no factual basis for making this claim, but it might be that the non-remitters were precisely the chronic sufferers, whereas the remitters were the patients with episodic depression. If this were true, that would enforce the possibility that the observed remission was just regression to the mean, i.e. people eventually getting better on their own.
Posted by Cecilia on January 6, 2008, at 4:36:18
In reply to Re: correlation does not imply causality, posted by Jamal Spelling on January 6, 2008, at 3:05:42
> It is interesting to note that 33% of STAR*D participants failed to remit after 56 weeks of treatment while between 21% and 30% of participants were chronic sufferers. I have no factual basis for making this claim, but it might be that the non-remitters were precisely the chronic sufferers, whereas the remitters were the patients with episodic depression. If this were true, that would enforce the possibility that the observed remission was just regression to the mean, i.e. people eventually getting better on their own.
Exactly, Jamal. Chronic depression and recurrent depression are totally different things. They shouldn't even be included in the same study, let alone lumped together. Cecilia
Posted by Cecilia on January 6, 2008, at 4:41:25
In reply to Re: STAR*D confirmed what patients already knew » Cecilia, posted by Larry Hoover on January 5, 2008, at 13:08:41
> > The other thing I don't understand about the study is where they found these depressed people who hadn't already tried these very common drugs already. They certainly didn't include anybody with chronic depression or they would have already tried them. So they probably got much better results than in the "real world". Cecilia
>
> The only exclusion factor with respect to the medications in levels 1 and 2 of this study was: "a clear history of nonresponse or intolerance (in the current major depressive episode) to any protocol antidepressant in the first two treatment steps ." Not never used, only not failed use in this actual depressive event. If you read the study demographics, you'll see that the majority of subjects were chronic recurrent depressives.
>
> The design of this study was absolutely "real world". Subjects were simply individuals who presented to their doctor, seeking treatment for depression. Comorbid medical conditions, past history of drug failure, yadda yadda, did not prevent enrollment. The exclusion factors were really quite limited. Again, reading the study methodology would answer these questions.
>
> Here's one such link:
>
> http://ajp.psychiatryonline.org/cgi/content/full/ajp;163/1/28
>
> LarPerhaps they would be accepted into the study regardless of previous drug trials, but why on earth would anyone enter a study where they knew they would just be offered the same drugs they had already failed or couldn't tolerate-makes no sense. Cecilia
Posted by Cecilia on January 6, 2008, at 5:28:06
In reply to Re: STAR*D confirmed what patients already knew, posted by SLS on January 5, 2008, at 6:27:57
> Hi Cecilia.
>
>
> > > Can you imagine if there were a 70% remission rate in Cancer treatment?
>
> > > People would be dancing in the streets!
>
> > Yes, but the people who don't respond to cancer treatments die and their suffering is over. Those of us in the 30% who don't respond to depression treatments continue suffering for the rest of our lives.
>
> ----------------------------------------------------
>
> I bet my doctor can get you well. He is allowed to use, among other things:
>
>
> adrafinil
> amantadine
> amisulpride
> amitriptyline
> amoxapine
> amphetamine
> aripiprazole
> buprenorhine
> bupropion
> buspirone
> carbemazepine
> citalopram
> clomipramine
> desipramine
> dothiepin
> doxepin
> duloxetine
> escitalopram
> fluoxetine
> fluvoxamine
> fluvoxamine
> gabapentin
> galantamine
> imipramine
> indalpine
> isocarboxazid
> lamotrigine
> levetiracetam
> levoprotiline
> lithium
> lofepramine
> lofepramine
> maprotiline
> memantine
> methylphenidate
> methylphenidate
> mexiletine
> mianserin
> milnacipran
> milnacipran
> mirtazapine
> moclobemide
> modafinil
> naltrexone
> nefazodone
> nifedipine
> nimodipine
> nisoxetine
> nortriptyline
> nortriptyline
> olanzapine
> opipramol
> oxcarbazepine
> paroxetine
> pergolide
> phenelzine
> phenytoin
> pindolol
> piribedil
> pirlindole
> pramepexole
> protriptyline
> quetiapine
> reboxetine
> risperidone
> rolipram
> ropinerole
> selegiline
> selegiline
> sibutramine
> sulpiride
> tianeptine
> toloxatone
> tomoxetine
> topiramate
> tramadol
> tranylcypromine
> trazodone
> trimipramine
> valproate
> venlafaxine
> verapamil
> vigabatrin
> viloxazine
> viqualine
> ziprasidone
> zonisamide
>
>
> What do you think? Do you think you have tried *everything*, including combinations of 2-6 drugs?
>
>
> > Yes, we can kill ourselves, but many of us are too afraid.
>
>
> Or too depressed. Some people are so severely depressed, that they don't have the energy or cognitive resources to kill themselves. That's why the second through forth weeks of antidepressant treatment must be monitored so closely by a specialist (psychiatrist). It can be a dangerous time. Sometimes, as someone is responding well to a drug, they become more activated and more able to act. Also, let us not forget that antidepressant are powerful and little understood, as is the brain. Antidepressants can make certain people biologically suicidal or more severely depressed. We don't know why or how to predict it. Again, this is something that a psychiatrist is responsible for acknowledging when treating affective disorders.
>
>
> - Scott
>
>
>No, I haven't tried everything on the list, but have tried most of the AD's and a sprinkling of the others. Sure there are thousands of possible combinations, but realistically the chances of success are miniscule and the horrible side effects I've gotten with most of the drugs I've tried virtually guaranteed. Cecilia
Posted by Phoenix1 on January 6, 2008, at 11:00:11
In reply to What have we learned from the STAR*D study?, posted by SLS on January 4, 2008, at 5:42:45
I really don't understand the controversy. Yes, it's a major study in the TX of depression. It certainly has a lot of value. Was it perfect? Of course not. Every study has it's weaknesses. I just don't understand the level of fierce debate here. What's so controversial?
Posted by Jamal Spelling on January 6, 2008, at 11:46:13
In reply to What is so controversial here?, posted by Phoenix1 on January 6, 2008, at 11:00:11
There seem to be two schools of thought on STAR*D. Some see it as a win for psychiatry, because it shows a 67% remission rate for depression using standard psychiatric devices. Others see a study that shows how, in the real world, only 30% of depression patients who take citalopram will remit within 14 weeks, and only 47% of patients will show a clinical response to the drug. This means that, more often than not, users of citalopram will neither remit, nor even show a clinical response to the drug.
And even though the study was not designed to test the efficacy of citalopram, with numbers like these, it raises serious questions about how citalopram fares against placebo.
So you have this multi-billion dollar industry, where tens-of-millions of people around the world are being prescribed these drugs, and these drugs do have problematic side-effects, and the question is: do these drugs really even work? Are they the best way to treat depression? Could there be more efficaceous and safer treatment alternatives?
Meta-analyses seem to indicate that SSRIs do work better than placebo, but only just, and only with a bit of wishful thinking.
So the question is, when faced with a depression patient, does a doctor treat the patient according to the STAR*D algorithm? Well, if you're happy with numbers like 30% and 67%, then yes. But some of us think these numbers are not good enough.
So 30 years ago, the fatality rate in general anesthesia was of the order 1 in 10,000. A combination of bad publicity and legal action forced the anesthesiology profession and industry to improve how they did things, and today the fatality rate is of the order 1 in 300,000.
And I think that in a similar way, psychiatry has to be held accountable to higher standards. Compared to other medical sciences, the state of psychiatry is poor, bordering at times on pseudoscientific. And you might say - but they are doing their best - and I'll say that, where you have pharmaceutical companies like Eli Lilly misrepresenting the safety data of Prozac and Zyprexa, or Warner-Lambert misrepresenting the efficacy data of Neurontin - clearly the industry is not doing enough.
So, the controversy is that STAR*D exposes the disappointing real-world success of psychiatry.
I believe that a comprehensive approach to treating depression may include medication, but should also include some form of counseling. And the fact is that, if your life is a mess, you're going to be depressed regardless of receiving medication. But of course, doctors don't tell you that. Most people just get a prescription for some SSRI and are left to their own devices after that. And after a while, you are referred to a psychiatrist, who starts experimenting on you with more exotic drugs, and this narrow-minded prescription-milling sometimes carries on for years, all the while the broader scope of your depression is ignored.
Posted by Larry Hoover on January 6, 2008, at 14:05:01
In reply to Re: STAR*D confirmed what patients already knew, posted by linkadge on January 5, 2008, at 15:24:47
> >The methodology could not include placebo.
> Well, then change the methodology. Its not so much that doctors can offer placebos, but if they knew that medications were essentially no better than placebos, they might decide against riskier treatments in favor of other treatments.
But medications are better than placebo. Some studies fail to show a significant difference, but there are methodological issues to consider. I don't want to turn this into a methodology lecture. The failure to find a difference between two groups is *not* evidence that they are similar.
If placebos and antidepressants had similar efficacy, then placebos would have come out ahead as often as behind antidepressants. We do not see that.
> Well, strong response to a placebo might have helped support the finding that pretty much all choices are essentially equivilant.
I can hypothesize too. Placebo and antidepressants have not been shown to be essentially equivalent.
> It might even help to uncover exactly what factors predict placebo response.
We are learning those things. The most commonly used methodology in efficacy trials actually promotes placebo response. Simply introducing variable dosing, and limiting subjects to the more severely depressed, drastically reduces the placebo artefact. I would argue that any study that failed to include these two considerations should be discarded as innately flawed.
> I personally think that the study purposly did not include a placebo.... The last thing they wanted in this study was to have a pesky little placebo response disclaimer tagged to the end.You're right, but for the wrong reason.
> Consider the fist round, %30 of people responded to citalopram. That is slightly less than what previous studies for citalopram have stated.
This is more than a trivial error. The standard applied in this study is remission, not response. This study "raised the bar".
> However, in many of such studies, the placebo response comes in about the same rate.
Many methodologically flawed studies, yes.
> On to round two...Eventually, you're going to get a final result saying yeah sure %70 of patients can improve,
No, the standard here was remission.
> ...with one drug or another, yet %60-80 can improve with placebo. Wow, all of a sudden that %70 is meaningless.
Where did you come up with that placebo figure? I have never seen even so much as a single study that assessed serial placebo treatments. To presume that a person who failed one placebo treatment might subsequently respond to another, and with the same likelihood as in the first instance, is a huge assumption.
> Its one of those things where sometimes the most basic assumptions are wrong IMHO.
Yes.
Lar
Posted by Larry Hoover on January 6, 2008, at 14:15:01
In reply to Re: STAR*D confirmed what patients already knew, posted by linkadge on January 5, 2008, at 15:24:47
> Well, strong response to a placebo might have helped support the finding that pretty much all choices are essentially equivilant.
Placebo response has been shown to be poorly maintained over time.
http://www.ncbi.nlm.nih.gov/pubmed/17854252
"The relapse rate in placebo responders was 24.1%, whereas the relapse rate in antidepressant responders was 7.4%"The drug fluoxetine was associated with broader changes in brain function than seen in placebo responders.
http://ajp.psychiatryonline.org/cgi/content/full/159/5/728
"...while comparable brain changes were seen with both drug and placebo administration, drug response was not merely the same as the placebo effect, as active fluoxetine treatment was associated with additional and unique changes in the brainstem, striatum, and hippocampus."Moreover, decreases in prefrontal cortical cordance were associated with reduction in depressive symptoms in a medication (fluoxetine) group, whereas an increase in cordance was associated with placebo response.
http://ajp.psychiatryonline.org/cgi/content/full/163/8/1426Whatever placebo response is, it is not the same as drug response.
Lar
Posted by Larry Hoover on January 6, 2008, at 14:20:10
In reply to Re: correlation does not imply causality » SLS, posted by Jamal Spelling on January 6, 2008, at 1:16:06
> > I thought the STAR*D claimed a success rate of 70%. Where can I find a reference stating that it was 67%? Just curious. Thanks.
>
> On page 63 of the article you have on your website, they give the following cumulative remission rates:
>
> Level 1 - 33%
> Level 2 - 57%
> Level 3 - 63%
> Level 4 - 67%
>
> > Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression
>
> Indeed, it may be true that nearly 80% had chronic *or* recurrent major depression. But when you break that down, the study shows that the bulk of this figure was recurrent depression, not chronic. In fact, the rates for chronic depression were 30% and 21% respectively for the primary care and psychiatric patients. So this does not invalidate my observation the 70% remission obtained after 56 weeks of treatment may have simply been regression to the mean.
>
> I am not disputing the claim that the majority of depression sufferers can obtain relief when following the STAR*D algorithm. My observation is merely that the remission cannot necessarily be attributed to following that treatment algorithm.Are you suggesting that if you followed a group of untreated subjects comprised of ~50% recurrent depressives, and ~30% chronic depressives, that after 56 weeks, 67% would be in full remission?
Lar
Posted by Larry Hoover on January 6, 2008, at 14:22:15
In reply to Re: correlation does not imply causality, posted by Jamal Spelling on January 6, 2008, at 3:05:42
> It is interesting to note that 33% of STAR*D participants failed to remit after 56 weeks of treatment while between 21% and 30% of participants were chronic sufferers. I have no factual basis for making this claim, but it might be that the non-remitters were precisely the chronic sufferers, whereas the remitters were the patients with episodic depression. If this were true, that would enforce the possibility that the observed remission was just regression to the mean, i.e. people eventually getting better on their own.
The implication of that hypothesis would be that this treatment algorithm was associated with ~90% remission rate in episodic depressives.
Lar
Posted by Larry Hoover on January 6, 2008, at 14:26:00
In reply to Re: STAR*D confirmed what patients already knew » linkadge, posted by Racer on January 5, 2008, at 18:27:25
> Your suggestion regarding lower doses directly contradicts what the study found: that in many cases, increased doses of tolerable medications increased response. That non-response may be a question of inadequate dosing in some (or even many) cases. As far as I'm concerned, that's something good to know.
There was an article published that addresses the "lessons learned" from STAR*D:
Translating Science Into Service: Lessons Learned From the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study.
http://www.psychiatrist.com/pcc/pccpdf/v09n05/v09n0501.pdfI haven't read it yet, though.
Lar
Posted by Larry Hoover on January 6, 2008, at 14:29:35
In reply to Re: STAR*D confirmed what patients already knew » Larry Hoover, posted by Cecilia on January 6, 2008, at 4:41:25
> Perhaps they would be accepted into the study regardless of previous drug trials, but why on earth would anyone enter a study where they knew they would just be offered the same drugs they had already failed or couldn't tolerate-makes no sense. Cecilia
Well, I'm sure that there were many more candidates for the study than those who accepted the offer. If nothing else, the study protocol was rather exhaustive in fully testing each study medication, with dose adjustments, augmentation, etc. One can't assume that a previously failed drug trial was as thoroughly conducted.
Lar
Posted by Jamal Spelling on January 6, 2008, at 15:10:29
In reply to Re: correlation does not imply causality » Jamal Spelling, posted by Larry Hoover on January 6, 2008, at 14:20:10
> Are you suggesting that if you followed a group of untreated subjects comprised of ~50% recurrent depressives, and ~30% chronic depressives, that after 56 weeks, 67% would be in full remission?
My main point is that STAR*D does not prove that the drug/CBT regimen used remits depression with a 67% success rate, yet that is what many people are claiming. One can only say that 67% of patients who follow this regimen will remit after 56 weeks, but not necessarily as a result of the regimen.
For example, a similarly comprised untreated group might have a remission rate of 40% after 56 weeks, which would imply that the STAR*D algorithm really only works for 26% of patients. Then the abstract would have to read something like "The study demonstrates that 26% of depression patients can be brought into remission by 56 weeks as a result of following the STAR*D algorithm". And that doesn't sound as good.
Posted by seldomseen on January 6, 2008, at 16:08:03
In reply to Re: correlation does not imply causality » Larry Hoover, posted by Jamal Spelling on January 6, 2008, at 15:10:29
"For example, a similarly comprised untreated group might have a remission rate of 40% after 56 weeks, which would imply that the STAR*D algorithm really only works for 26% of patients. Then the abstract would have to read something like "The study demonstrates that 26% of depression patients can be brought into remission by 56 weeks as a result of following the STAR*D algorithm". And that doesn't sound as good."
Actually that's not how that data should be interpreted. If 40% of patients spontaneously remitted and 67% remitted on with drugs, then 67% still remitted on drugs.
The only valid conclusion is that more subjects remitted on drugs than with no treatment.
We don't know how many people the drugs actually helped, just that more remitted while on them.
I think everyone(and I'm not on one side or the other) have to be very careful how they interpret the data.
Posted by seldomseen on January 6, 2008, at 16:26:59
In reply to Re: What is so controversial here?, posted by Jamal Spelling on January 6, 2008, at 11:46:13
If a single cancer chemotherapy drug was effective in 30% of people that took it, the entire field would literally give itself the nobel prize, take the million dollars and go to Hawaii for a month.
I mean it would be BREAKTHROUGH. If a protocol acheived a 70% remission rate (imagine 70% of lung cancers brought into remission) I think the whole field would turn their work over to robots programmed to dispense that protocol and never return from Hawaii. Heck, oncologists could probably buy Hawaii.
No one would be talking about placebo effects (wouldn't care).
I know it is hard to see big picture when you are sick, but the advances in psychopharmacology over the past 50 years IMO have been amazing.
50 years ago it was thorazine and the benzos and a sprinkling of other terrible meds, now we have hundreds from which to choose. Is it perfect? Absolutely not, is it better? I think so.
Also, it is becoming readily apparent that depression, bipolar disorder etc... are very very complex illnesses. Like cancer, they are most likely mutligenic in origin and highly individual to the person. These kinds of illnesses are very difficult to treat in the landscape of medicine today. We are used to treating one illness with one drug and that's that (think anti-biotics). Where we are now, both in cancer and psychiatry, is really still in the infancy of treating and curing these disorders.
IMO there is hope. It's not there yet, but I do think it is coming. Look where we've been and where we are now.
Posted by SLS on January 6, 2008, at 16:32:59
In reply to Re: correlation does not imply causality » SLS, posted by Jamal Spelling on January 6, 2008, at 1:16:06
Hi.
Thanks for responding.
> > I thought the STAR*D claimed a success rate of 70%. Where can I find a reference stating that it was 67%? Just curious. Thanks.
>
> On page 63 of the article you have on your website, they give the following cumulative remission rates:
>
> Level 1 - 33%
> Level 2 - 57%
> Level 3 - 63%
> Level 4 - 67%Thanks.
> > Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression
> Indeed, it may be true that nearly 80% had chronic *or* recurrent major depression. But when you break that down, the study shows that the bulk of this figure was recurrent depression, not chronic. In fact, the rates for chronic depression were 30% and 21% respectively for the primary care and psychiatric patients. So this does not invalidate my observation the 70% remission obtained after 56 weeks of treatment may have simply been> regression to the mean.
What is "regression"?
I am not, unfortunately, a student of statistics. I dropped out of school because my cognition and memory became so badly impaired due to a worsening of my depressive illness.
> I am not disputing the claim that the majority of depression sufferers can obtain relief when following the STAR*D algorithm. My observation is merely that the remission cannot necessarily be attributed to following that treatment algorithm.
Sure it can. Of course you would need to follow subjects longitudinally. Here, a placebo arm would help determine a baseline pattern of illness. One can then determine the average length of an untreated MDD episode, as well as the length of time between episodes. If the time to relapse is longer with treatment, one can present statistics to verify the ability of the drug to produce a higher remission rate as compared to treatment as usually or versus placebo.
- Scott
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