Thursday, October 9, 2008

Therapy Wins! News Coverage Gets It Totally Wrong. Totally.

Hi! A recent Reuters news story - carried by Yahoo News and some other news sites, reports some animal-model research that truly illustrates how depression can occur from EXPERIENCES, rather than by whatever genetic "illness" model promoted by Big Pharma. Also, smashingly, this animal-model study of depression illustrates how a BEHAVIORAL, rather than a pharmaceutical treatment, can work. Finally, the authors conclude that the pathways involved do NOT notably involve the serotonin pathways that are spoken of in such reverential, hushed tones in the halls of psychiatric academe.

In other words, Big Pharma, and their paid shills, look really wrong on this one.

This is a recent study from the journal Neuron.
Daniela D. Pollak,1 Francisco J. Monje,1 Lee Zuckerman,1 Christine A. Denny,3 Michael R. Drew,1 and Eric R. Kandel. An Animal Model of a Behavioral Intervention for Depression. Neuron 2008; 60: 149-161. October 9, 2008. No PMID identifier yet.

Basically, in short, they use the learned helplessness experimental paradigm that was explicated decades ago: put animals in bad situations, such as put a mouse in a tub of water, with nowhere to swim to, so they are not able to achieve anything for all of their swimming/escape efforts, and they eventually give up swimming when palced in the water yet again.

If, subsequently, you experimentally change the situation so that some effort WOULD result in avoiding the bad situation, such as putting an unseen platform in the water, the animal still does not respond- the animal has learned that effort does not improve things, and therefore stays passive, and depressed.

In this recent study, the authors conditioned a swim respone in the mice - before the mice were ever placed in the water. They classically conditioned the mice to swim at the sound of some tone. Then, they went and kept putting mice in the water until each mouse gave up trying to swim for safety when palced in the water. At that point, the learned helplessness point, the authors THEN rang the tone.

The mice responded as conditioned - they began swimming again.

Thus, experimentally, learned helplessness AKA depression was invoked, and was treated. How? With pills? No - the depression was invoked by circumstances, and was treated by some behavioral training.

Cool! Maybe this success conditioning could work in humans! Maybe successful tehrapy has actually worked in this way, if only we reflect back on successful cases, and reframe the change as some rekindling of hope!

Sure.

But all of that is not patent-able. Plus, does not fit the American Psychiatric Association / Big Pharma model that depression is an inherited, genetic "brain disorder," more specifically, one affecting the serotonin pathways.

SO: How does Reuters Health sell this news story?

The detection of the involvement of some other pathway means that maybe we can make a new drug! There must be a "natural Prozac" causing all of this, and we can make a drug to do the same!

No kidding. Gurgle "mice natural prozac" and this news story will pop up.

Quote in the news story from the lead author:
"This opens up new pathways that may profitable."

With all of the bad side effects of antidepressants, and the widespread recognition of behavioral theories including learned helplessness, why is this story not heralded as yet more strong evidence that we have a great alternative to antidepressants?


Meds vs. Therapy. Therapy wins this one hands-down. Nonetheless, the story targets in on the meds side of the issue. What a shame!
We get experimental

--I have not gotten hold of the actual study, yet. I may have more comments when I look this over. But the portrayal by the media, a large part of the "translation" from bench to bedside, is the upsetting piece.

Monday, October 6, 2008

Meds loses this one: Nemeroff resigns. Oct 06.

This link to the NYT story looks like it won't work.

http://www.nytimes.com/2008/10/04/health/policy/04drug.html?_r=1&scp=1&sq=nemeroff&st=cse&oref=slogin

Well, Google "nemeroff" and another key word, such as "grassley" or "emory" or "new york times." You will find the line of stories.

With ample funding support from pharmaceutical companies, Nemeroff has been a greatly influential "thought leader" in psychiatry. Part of this role involved fighting the eventual emergence of the recognition of the problem [in the form of black box warnings, etc.] that SSRIs increase likelihood of suicidal thoughts, and also the eventual but less common suicidal actions resulting from these thoughts.

He has also been strongly working on the vagal nerve stimulator as a treatment for depression. Hopefully, that effort will be slowed without his weight behind it. If it is as good as the meds he has been pushing for years, we are all in for a treat with this cute little implant.

While it is emerging that many of these leading psychiatrists were not more than hucksters, and that the meds often don't actually deliver what the ads and the reps say they will deliver, at least there still is good ol' talk therapy to treat depression. Now, if only the American Psychological Association could figure out a way to let the American public understand that psychotherapy treats depression, we might be able to comfortably wave goodbye to the rest of these pill shills.

Wednesday, October 1, 2008

Long-term Therapy Wins for Complex Cases (i.e., borderline etc.)

Wow. JAMA just published a stunning meta-analysis article evaluating the efficacy of long-term psychodynamic psychotherapy. This is gonna get blogged a lot. I was eager to peek at it, and post a note abt it.

Pubmed does not have this sited yet. Here is the ref:

Leichsenring F, Rabung S. Effectiveness of Long-term Psychodynamic Psychotherapy: A Meta-analysis. JAMA 2008; 300 (13): 1551-1565. October 1, 2008.

Long-term psychodynamic psychotherapy seems to have a good effect for patients with this mixed bag of difficult psychological problems. Problems include chronic depression, bipolar disorder, and others.

Especially to the credit of the authors is the section in which they assess the degree that results may have been biased by non-publication of any unknown studies which hypothetically could have, and reasonably would be expected to have, negative results. That is a long sentence, so I will say it another way: the authors reviewed all avalable decently conducted studies; they obviously can only review those published; there could be unpublished studies that failed to get published because they demonstrated no significant beneficial effect for long-term psychodynamic psychotherapy. The authors conducted some processes to add this unknown factor into their conclusions.

This is a conservative, cautious, judicious move. And commendable.

The conclusion, after that adjustment, or reinterpretation for hypothetical non-significant results that might be out there somewhere, in the "file drawer" of some researcher who could not or chose not to get it published, still remained.

I am gonna have to read the article more carefully than the one minute I spent looking this over.

But the bottom-line looks like: meds vs. therapy, and therapy has won this one. Long-term psychodynamic psychotherapy resaerch too often does not have the data to support this type of evaluation. It is commendable for the authors to pull all of this together.

Why all the big deal about this problem of hypothetical missing unpublished studies?

Well, on the other side of the meds vs. therapy issue, many of the unpublished studies CAN be discovered and included. When they ARE included, as was done last year, it greatly influences the result to show that antidepressants have a very modest effect for treating depression (and that is being generous to say 'modest').

Here is one main reference:
Kirsch I, Deacon BJ, Huedo-Medina TB, Scoboria A, Moore TJ, Johnson BT. Initial severity and antidepressant benefits: a meta-analysis of data submitted to the Food and Drug Administration. PLoS Med. 2008 Feb;5(2):e45. PMID: 18303940.

You just won't see this "file drawer" problem addressed in studies from Big Pharma. You won't see CME on this topic. It is likely rare that physician researchers are taught the issue and methods for addressing the file drawer problem. In my training, I was, which helps me appreciate the problem. And to understand how it is one of the ways that Pharma can lie with statistics.

Meds Vs. Therapy. Meds won this one. Good night.