Friday, June 10, 2011

Magic Bullets

One of my favorite writers, Elisa Gabbert blogged this week about antidepressants, in response to an article in The New York Review of Books. Both the post and the article are fascinating, and raise questions about a national mental health crisis, health care in America, and the actual efficacy of drugs designed to treat depression.

In one of the books reviewed, The Emperor's New Drug: Exploding the Antidepressant Myth, Irving Kirsch has carefully examined clinical trials of popular antidepressants, and reveals that placebos could be as much as 82% as effective as the drugs themselves. He also posits that the trial participants getting the placebo could deduce that that's what they were getting, because they didn't have any side effects. So:

To further investigate whether side effects bias responses, Kirsch looked at some trials that employed “active” placebos instead of inert ones. An active placebo is one that itself produces side effects, such as atropine—a drug that selectively blocks the action of certain types of nerve fibers. Although not an antidepressant, atropine causes, among other things, a noticeably dry mouth. In trials using atropine as the placebo, there was no difference between the antidepressant and the active placebo. Everyone had side effects of one type or another, and everyone reported the same level of improvement.

Emphasis mine.

This is extremely alarming to me, and makes me wonder who the trial participants were. The book reviewer doesn't go into it, but I hope Kirsch does (I haven't bought his book yet). Who suffering from severe depression would agree to a clinical trial in which they may only receive a placebo? Because I wouldn't. I don't know very much about how these trials are conducted, but would someone without health insurance be more likely to sign up? (I'm assuming treatment is free?)

Last summer, I dated a guy who prided himself on going with the flow and living in the moment. One night at dinner he told me why he doesn't have health insurance: because it's all a big scam and if he was on the brink of death, he could always go to the ER, and it would be illegal for them to refuse him treatment because he couldn't pay. I listened and nodded, silently infuriated.

Finally I said, "It's fine for you to say all that because you've never been seriously ill. I have to have health insurance."

"Why?" he said.

"Because I'm mentally ill," I said.

He burst out laughing. "Is that how you think of yourself?"

"It's not how I think of myself, it's just true."

Last year, I spent over five thousand dollars on health-related costs. This was with insurance.


Elisa said...

No only is the treatment free, I think participants in trials get additional payment sometimes? So somebody might sign up for such a trial if they can't afford antidepressants and/or could use the money.

Elisa said...

P.S. I've spent a ton on health-related issues in the past few years, always with insurance. I hate insurance so much. Every year it seems less and less is covered while my base costs continue to go up. I hate having to buy into such a corrupt system.

Leigh Stein said...

See that's what I thought (about free treatment + $). Don't you think that adds a huge variable to the equation? If someone has had depression for a long time, is already on medication, and has insurance, why would they sign up for a trial? Maybe if there was a new drug that was supposed to do the same as their old drug, but better/with less side effects.

Health insurance is the absolute worst. But what choice do we have? I changed insurance between August and September last year, and there was no gap in my coverage so legally my new insurance HAS to cover all my pre-existing conditions, but I still get a letter in the mail if I see a new doctor, to check my eligibility.

Elisa said...

Do you mean, because it's mostly poorer people in the trial? Or because they might not really be depressed to begin with?

Pretty much all medical studies are flawed to some degree, but so it anecdotal evidence (lots of people saying something seems to work, which is pretty much old-wives'-tale territory).

Leigh Stein said...

Mostly poorer people, but also maybe more people having a single depressive episode. I'm totally guessing here, of course, but I see ads on the subway "Do you feel sad? Columbia University is currently looking for volunteers..." etc. As if someone might say to themselves, "Come to think of it...I DO feel sad!"

I would predict two things: 1) that a placebo would be more likely to work on someone having their first episode, who hasn't experienced the cycles and patterns of chronic depression and would read signals of recovery in a different way than someone who's gone through it for years. And 2) that a person having their first episode would be more likely to sign up for a trial than someone who has chronic severe depression. Therefore) the people signing up for the trial are exactly the kind of people who would respond so well to a placebo.


Elisa said...

I assume they put people through some kind of qualification process with a doctor first to make sure they actually are depressed. Anyway you may be right that they would be more likely to respond to placebo, but that doesn't account for why the people who got the actual drugs didn't respond any *better* than those who got placebo. Also, the fact that this was data collected over multiple trials.

Leigh Stein said...

You're right: that doesn't explain why the people who got real drugs didn't respond any better. And I don't mean that trial participants aren't "actually" depressed, I just mean they're probably not people who are already in treatment, and have been for a long time.

Elisa said...

I agree, they're probably not people who have been on treatment for years, and it would be interesting to see exactly how the participants get involved.