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-Adios- to antidepressants… As we know them




Enviado por Felix Larocca



  1. What
    are antidepressants?
  2. Prozac
    does not work in most depressed patients
  3. In
    summary
  4. Bibliography

Monografias.com

Disagreements over whether drugs to
combat depression are worth taking

What are
antidepressants?

An antidepressant is
a psychiatric medication used to alleviate mood
disorders, such as major
depression and dysthymia and anxiety
disorders such as social anxiety disorder. According to
Gelder, Mayou & Geddes (2005) people with a depressive
illness will experience a therapeutic effect to their mood;
however, this will not be experienced in healthy individuals.
Drugs including the monoamine oxidase
inhibitors (MAOIs), tricyclic
antidepressants (TCAs), tetracyclic
antidepressants (TeCAs), selective serotonin reuptake
inhibitors (SSRIs), and serotonin-norepinephrine
reuptake inhibitors (SNRIs) are most commonly associated
with the term. These medications are among those most commonly
prescribed by psychiatrists and other physicians, and
their effectiveness and adverse effects are the subject of many
studies and competing claims.

Many of my patients have heard me fulminate
against the indiscriminate and thoughtless use of antidepressant
medications. As time and again I have seen how miserably these
drugs perform when used at random — as it"s commonly done —
or when it"s done without being prescribed in tandem with
skillful psychotherapy a rare if useful skill among doctors, and
specially among (those from whom one would most expect it),
psychiatrists.

These are two recent articles that confirm
my long-held beliefs.

ANTIDEPRESSANTS have long been the
source of controversy. Amphetamines were widely used as an
antidote to neurotic depression into the 1960s, until such "pep
pills" came to be seen as doing more harm than good. Similar
worries are now engulfing today's antidepressants, like Prozac
and Paxil, which are among the most widely prescribed drugs in
the world. Two new studies have stirred things up: one warning
that antidepressants do not help most people very much, and the
other gushing that they are a marvelously cheap way to save
lives.

Most antidepressant pills prescribed
today are selective serotonin reuptake inhibitors (SSRIs), a type
of drug that boosts the amount of serotonin hanging around in the
brain. Serotonin is a brain chemical closely associated with
mood. Boosting its level this way might therefore improve a
person's mood. Earlier versions were less effective than modern
pills, which have fewer side effects and are less toxic in
overdose. The use of SSRIs worldwide has shot up from below 3
billion doses in 1995 to over 10 billion in 2004.

Is all this popping pills doing any
good? There is recent evidence that it can lead young people to
act on suicidal thoughts, prompting America's Food and Drug
Administration (FDA) to insist on warnings. SSRIs have generally
been seen as a way to ease depression in adults without killing
them. Derek Summerfield argued in the Journal of the Royal
Society of Medicine that, although there is no epidemic of
depression, "the case for an epidemic of antidepressant
prescribing is now cast iron."

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Blessing from the Medicine Man
by Howard Terpning

A study published in this week's Public
Library of Science (PLoS) Medicine, an open-access scientific
journal, raises doubts about dispensing such drugs so freely.
Irving Kirsch, of the University of Hull, and his colleagues
scrutinized the clinical trials for several new antidepressants,
taking care to include those never published (but which, by law,
have to be reported to the FDA). They found that SSRIs did not
help the vast majority of depressed people much more than
placebos did. The net benefits over placebos did not usually
reach the level considered big enough to be of clinical
significance by Britain's National Institute for Health and
Clinical Excellence (NICE).

This study points to two factors that
bedevil proponents of SSRIs: publication bias and the power of
placebos. Dr Kirsch believes published data "give an exaggerated
view of a drug's benefit." People with very severe depression did
see benefits above the NICE threshold, but even that was not a
ringing endorsement. Dr Kirsch explains that this was not because
SSRIs worked much better in the very seriously depressed, but
rather that the effectiveness of placebos dropped off sharply in
such people, making the drug look better.

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There are two sorts of criticism of the
idea that SSRIs are mostly a waste of money. One comes from those
who say the study itself is rubbish. David Nutt, of the
University of Bristol, says failed drug trials often remain
unpublished because their design is shoddy or their results
uninteresting. He criticizes the PLoS paper as a "mishmash of
quality trials and lousy trials leading to a false criticism of
these drugs", which he maintains do help those with depression
even if their effectiveness falls below the NICE's "arbitrary"
threshold. Dr Nutt thinks it is misleading to compare these drugs
with placebos, since what matters is that they work when compared
with some alternatives, such as "talk therapy", for which he
believes there is even less evidence of
effectiveness.

Good-news potions

Yet there is reason to think that
unpublished studies do reveal some important and rather
unflattering details about antidepressants. A well-designed study
published in January in the New England Journal of Medicine
looked at a larger group of antidepressants and concluded there
was indeed "a bias toward the publication of positive results":
94% of the published trials were positive, whereas only about
half of the unpublished ones were.

That bolsters the PLoS paper, but there
is another sort of critique that challenges its conclusions. A
recent study published by America's National Bureau of Economic
Research (NBER) analyzed data from 26 countries over several
decades to determine what effect SSRIs have had on suicides. Its
authors argue that antidepressants are in fact "a very
cost-effective means for saving lives".

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Vincent Van Gogh

Countries with both high and low
initial rates of antidepressant use saw similar trends in
suicides until SSRIs were introduced. Jens Ludwig, of the
University of Chicago, argues that countries that took to the new
drugs saw a relative decline in suicides. After controlling for
many variables, his NBER team reaches the cheerful conclusion
that an increase in sales of one pill per person per year (about
a 12% increase over the level in 2000) leads to a decline in
suicide mortality of about 5%.

So are SSRIs to be shunned or saluted?
The controversy will rage on, but Erick Turner, of the Portland
VA Medical Centre in Oregon, suggests a third way. As one of the
authors of the New England Journal of Medicine paper, he says the
study confirms that most antidepressants do not work as well as
published reports claim. That suggests many people, especially
children, should be more careful about using them. But that does
not mean they are pointless. He speculates that, if other
therapies fail, "maybe all you need is a minor or mediocre effect
in order to reduce suicides overall." That may be particularly
true for those who are closest to the edge of
darkness.

The one above appeared in The Economist, the one that
follows, in New Scientist.

Prozac does not
work in most depressed patients

The antidepressant Prozac and related
drugs are no better than placebo in treating all but the most
severely depressed patients, according to a damaging assessment
of the latest generation of antidepressants.

SSRIs, or selective serotonin reuptake
inhibitors, were supposed to revolutionize care of depression
– by treating symptoms without the side effects of older
drugs, such as tricyclics.

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But despite selling in vast quantities,
a new meta-analysis of these drugs, from data presented to the US
Food and Drug Administration (FDA), appears to suggest that for
most patients they do not work. A previous study had indicated
that the benefits of antidepressants might be
exaggerated.

UK and US researchers led by Irving
Kirsch of Hull University, UK, studied all clinical trials
submitted to the FDA for the licensing of the four SSRIs:
fluoxetine (Prozac), venlafaxine, nefazodone, and paroxetine
(Seroxat or Paxil), for which full datasets were
available.

They conclude that, "compared with
placebo, the new-generation antidepressants do not produce
clinically significant improvements in depression in patients who
initially have moderate or even very severe
depression".

Dishing out drugs

They did detect some benefits in the
most severely depressed patients. But conclude that in this group
the small effect is "due to decreased responsiveness to placebo,
rather than increased responsiveness to
medication".

Given these results, they say that
there is little reason to prescribe SSRI medications to any but
the most severely depressed patients.

David Healy, a psychiatrist at Cardiff
University, UK, specializing in the use of SSRI drugs, says the
latest study confirms suspicions that the drugs' effectiveness
had been dramatically overstated.

"Most importantly this new study shows
that the people who did respond to the drugs would have responded
to placebo, anyway.

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New panacea

"It confirms that GPs should not be
dishing these drugs out as first-line treatment for mild
depression," he told New Scientist. The drugs were, he notes,
"routinely being given to people who would get better without
them".

Positive results

Eli Lilly, which manufactures Prozac,
says that "extensive scientific and medical experience has
demonstrated it is an effective antidepressant". It adds that:
"More than 50 million people with depression have been treated
with Prozac since its launch."

A spokesman for GlaxoSmithKline, which
makes Seroxat, points out that the study only looked at a "small
subset of the total data available".

Healy notes however, that drug
companies have tended to publish studies showing positive results
of the SSRIs in mildly depressed patients.

He says too that there have been
concerns that SSRI drugs, particularly paroxetine, may cause
dependence in some patients, and this underlines the need to
avoid their unnecessary prescription.

Placebo benefit

Healy warns however, that anyone taking
SSRI antidepressants should not suddenly stop taking their
medication and should consult their doctor before coming off the
drugs.

David Nutt, a psychopharmacologist at
Bristol University, UK, points out that if SSRIs provided some
sort of placebo benefit, this should not be discounted. He notes
that "the true drug effect is that of the drug added to that of
placebo which is not the same as no treatment".

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Earlier this month, New Scientist
reported claims by US lawyers that they had obtained documents
suggesting that an inappropriate analysis of clinical trial data
by researchers at GlaxoSmithKline had obscured suicide risks
associated with paroxetine for 15 years.

In
summary

Psychotherapeutic involvement between
patient and doctor exists and has been tested from the beginning
of our history. That has been shunned in favor of impersonal
pills tells us more about the ignorance of doctors than about the
putative effectiveness of antidepressant medications.

Distrust the doctor who, without conducting
a thorough assessment reaches for the prescription pad, assuring
you of nirvana in "two weeks", for you could be facing a
charlatan.

Bibliography

  • Larocca, FEF: Losing weight:
    Truly
    a Balancing Act in
    monografías.com

  • Larocca, FEF: Lincoln and Marfan"s
    Syndrome
    in monografías.com

  • Larocca. FEF: Psychotherapy on the
    Road… To Nowhere
    in
    monografías.com

  • Larocca, FEF: The Neuroscience of
    Religion: Meditation, Entheogens, Mysticism
    in
    monografías.com

For an in-depth
all-inclusive article on depression go to:


http://health.nytimes.com/health/guides/disease/major-depression/print.html

 

 

Autor:

Félix E. F. Larocca
MD

 

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