The Healthy Skeptic » depression

Depression

Chris — Tue, 16 Sep 2008 02:29:34 +0000

Healthy Skeptic articles

selected offsite articles

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Placebos as effective as antidepressants

Chris — Sun, 27 Apr 2008 21:25:19 +0000

THS reader Chad sent in this question:

Antidepressants - effective or placebo?

The use of antidepressant medication has become so widespread and commonly accepted that it seems almost sacrilegious to question it. But alas, questioning is the name of the game here at The Healthy Skeptic!

And what do you know? Antidepressants aren’t all they’re cracked up to be. In fact, a recent meta-review of published studies on the efficacy of antidepressant drugs revealed that selective serotonin reuptake inhibitors (SSRIs), which are the most commonly prescribed drugs to treat depression, have no clinically meaningful advantage over placebo.

What that means is that in most of the trials reviewed, patients who took a sugar pill recovered from depression just as often as those who took the active drug. This study may come as some surprise to both physicians and the general public, whose faith in the efficacy of these drugs has led to over 118 million prescriptions in 2007 and over $16 billion in sales.

But should this really come as a surprise? Antidepressant drugs are thought to act by altering levels of brain neurotransmitters; however, it takes several weeks before these changes can be measured. Yet patients often report symptomatic relief within hours or days of receiving an antidepressant.

Available data suggests, in fact, that SSRIs are no more effective than placebos and have considerable adverse effects and risks, including increased suicidality amongst both children and adults. Sapirstein and Kirsch conducted a meta-analysis of 3,000 patients who received either antidepressants, psychotherapy, placebo or no treatment at all. They found that 27% of therapeutic responses were attributable to drug activities, 50% to psychological factors, and 23% to “non-specific” factors. In other words, 73% of the response to the drug was unrelated to its pharmacological activities - and antidepressants may be no better or more specific than placebos.

This of course raises grave questions about why the National Institute for Health and Clinical Excellence (NICE) still recommends that antidepressants should the be first line treatment for moderate or severe depression. Their message is identical to that of the Defeat Depression Campaign in the early 90s, which contributed to the 253% rise in antidepressant prescribing in 10 years.

In a review published in the British Medical Journal in February of 2006, researchers Joanna Moncrieff and Irving Kirsch point out that the NICE recommendations ignore even their own study data. Although the NICE meta-analysis of placebo controlled trials of SSRIs found statistically significant differences in levels of symptoms, these were so small that the effects were deemed “unlikely to be clinically important.”

After analyzing several published studies and reviews, Moncrieff and Kirsch reached the following conclusions:

Summary points

SSRIs have no clinically meaningful advantage over placebo
Claims that antidepressants are more effective in more severe conditions have little evidence to support them
Methodological artifacts may account for the small degree of superiority shown over placebo
Antidepressants have not been convincingly shown to affect the long-term outcome of depression or suicide rates

The response to a drug or placebo in a clinical trial for depression is often measured using the Hamilton rating scale, a multiple choice questionnaire which doctors use to rate the severity of a patient’s condition. The questionnaire rates the severity of symptoms observed in depression such as low mood, insomnia, agitation, anxiety and weight-loss; it is considered to be a highly reliable physician-rated scale and has been reported to be more sensitive than patient-rated scales to drug/placebo differences. (Murray, 1989)

In the NICE meta-analysis, the difference between drug and placebo groups was one point. The most commonly used 17 item version of the Hamilton scale has a maximum score of 52. It is highly unlikely that a difference of one point on a 52-point scale is clinically significant, a fact that the FDA has admitted in memoranda (Laughren, 1998; Leber, 1998) reviewed by Moncrieff and Kirsch.

Other studies have yielded similar results. A study by Khan et al. found a 10% difference in levels of symptoms between placebo and active drugs in two different meta-analyses. In a more recent review, Kirsch et al. invoked the Freedom of Information (FOA) act to obtain access to previously unpublished studies (the drug companies are under no requirement to publish a study they have sponsored if the results don’t suit them). The overall difference between drugs and placebos in that analyses was 1.7 points on the Hamilton scale.

Moncrieff and Kirsch also point out that the Hamilton scale contains seven items concerning sleep and anxiety, with each item on sleep scoring up to six points. Therefore any drug with some sedative properties, including many antidepressants, could produce a difference of two points or more without exerting any specific antidepressant effect.

Follow-up studies that track patients for a significant length of time have also shown very poor outcomes for people treated for depression both in the hospital and in outpatient settings, and the overall prevalence of depression is rising despite increased use of antidepressants. Suicide rates have increased in some groups and some countries, despite increased prescribing of antidepressant, and there are continuing concerns that SSRIs may increase the risk of suicidal behavior in obht cildren and adults.

In children, the balance of benefits to risks in antidepressant treatment is already recognized as “unfavorable”. The analyses performed by Moncrieff and Kirsch strongly suggests that the same is the case for adults, and that the ongoing uncertainty about the possible risk of increased suicidality as well as the adverse effects of antidepressant drugs warrant a “thorough re-evaluation of our current approach” to treating depression.

I couldn’t agree more. One question the authors failed to pose, which I believe to be at the root of the matter, is why are so many more children and adults depressed now than before? You might not be surprised to learn that I have some thoughts about this. But I’ll save them for another post.

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Our children: well-fed but malnourished?

Chris — Fri, 25 Apr 2008 15:42:12 +0000

The Healthy Skeptic reader Jessica wrote in with this topic suggestion:

“I like the “what to feed children” idea. But it has to be food they will actually EAT.”

The question of how to nourish our children so they develop into healthy adults is one of the most important questions we can ask. Tragically, the answers that the medical mainstream has come up with have contributed to unprecedented epidemics of childhood disease and endangered the health and well-being of our children.

The numbers of overweight and obese children worldwide are expected to climb dramatically by 2010, according to a study by Youfa Wang, PhD, MD at the Johns Hopkins Bloomberg School of Public Health. By the end of the decade, 46 percent of children in North and South America are projected to be overweight and 15 percent will be obese. It’s been assumed that U.S. life expectancy would rise indefinitely, but a new data analysis which was published as a special report in the March 17, 2005 issue of New England Journal of Medicine suggests that this trend is about to reverse itself - due to the rapid rise in obesity, especially among children.

Increasing numbers of children are being treated for depression, according to a 2004 study in the British Journal of Medicine. A 1999 report in California from the state’s Department of Developmental Services found that autism had increased by 273 percent from 1987 to 1998. Current estimates for the incidence of autism are as high as 1 in 120. A national review by The Advocacy Institute in 2002 revealed that learning disabilities in children increased by 30 percent from 1990 to 2000.

These studies show that our children are more obese, more depressed, and have more learning disabilities and behavioral problems than ever before. What could be the cause of such a dramatic change?

Although each of these diseases is complex and multifactorial, it is safe to say that diet and nutrition play a significant role in all of them. For example, consider the key nutrients for brain development in children:

Key nutrients for brain development

Vitamin A
Vitamin D
Choline
DHA
Zinc
Tryptophan
Cholesterol

Many parents probably know that these nutrients aren’t found in the refined carbohydrates, vegetable oils and sugars which form the bedrock of the standard American diet. Yet many parents may be unaware that even foods widely assumed to be nutritional - including packaged foods commonly described as “organic”, “natural” or “fortified” - are themselves highly processed and stripped of nutritional value, and little better than their “non-organic” alternatives.

So what should we be feeding our children to ensure healthy growth and development? The following “First Steps” recommended by children’s health advocacy group Nourishing Our Children will get you started:

First steps to healthier children

Replace sugar with natural sweeteners like honey and rapadura.
Replace fruit juices with whole, raw milk.
Replace breakfast cereals with non-nitrate bacon, eggs from hens on pasture, whole milk yogurt, homemade kefir, soaked oatmeal or soaked, wholegrain pancakes.
Replace pasteurized dairy products with raw and cultured dairy.
Eliminate all processed soy foods from your household (this includes soy milk, “protein bars” with soy, baked tofu products and all “soy fast food”).
Replace polyunsaturated vegetable oils and trans fats with traditional fats such as butter, olive oil, coconut oil, palm oil, lard, and tallow.
Replace processed, convenience foods (boxed, packaged, prepared and canned food items) with fresh, organic, whole foods
Provide a daily dose of high vitamin cod liver oil (with no synthetic vitamins added)

In contrast to the bland, unsatisfying (and dangerous) low-fat diet recommended by medical authorities, kids naturally love the foods in a nutrient-dense, whole foods diet. However, it is true that if they’ve been on a diet high in sugar and refined carbohydrates for a long time, there will be an adjustment period as they transition away from those highly processed foods.

My suggestion is to take one item on the list above at a time, and be gentle with yourself. It may take a while longer that way to get to where you want to be, but it’s worth the effort! Some of the changes will be more difficult than others. For example, most children (and adults) prefer the taste of saturated fats like butter, cream and whole-fat dairy to low-fat alternatives such as vegetable oil and skim milk - but may not yet have acquired a taste for cod liver oil!

I’ve provided links to some articles below with some helpful ideas on how to encourage even the most finicky eaters to enjoy nutrient-dense foods and some ideas for quick and healthy brown-bag lunch suggestions for parents.

The Healthy Skeptic » depression

Depression

Healthy Skeptic articles

selected offsite articles

Books: serotonin hypothesis & antidepressants

Books: holistic treatment of depression

tapes & cds

nutrition

handouts

Placebos as effective as antidepressants

Summary points

Our children: well-fed but malnourished?

Key nutrients for brain development

First steps to healthier children

Recommended links