What "60 Minutes" Didn’t Say About Antidepressants
The inability of antidepressants to prove more effective than placebos in many clinical trials has been discussed widely during the past few years, but CBS's "60 Minutes" gave the topic new life with an "explosive" segment on February 19, 2012. What they failed to acknowledge to the detriment of millions of depressed people was that experienced clinicians get much better results in practice.
Richard J. Metzner, M.D.
Clinical Professor
Semel Institute for Neuroscience and Human Behavior at UCLA
Founder, DepressionConsultant.com
In a multi-site study we have been undertaking, we have seen clinicians using the algorithm of the Clinaptica Depression Consultant app obtain remission rates as high as 59% or better -- about twice what placebos usually get. (Can Clinicians Improve Antidepressant Remission Rates with Better Algorithms? Metzner RJ and Ho AL, 2009)
The disparity may reflect a fundamental difference in the mindset of researchers and clinicians. When researchers perform clinical trials on antidepressants, they typically treat all depressed patients the same way. Matched heterogeneous populations of patients who meet the criteria for major depressive disorder are randomly and blindly assigned to receive either a single antidepressant or a placebo. At the end of the study, the amount of improvement is compared between the two groups. In recent years the antidepressants show clear superiority to placebos only among severely depressed patients.
In contrast, the mindset of the clinician is that no two patients are the same. Clinicians are trained to expect differences. They vary their treatments on the basis of those differences. They know, for example, that different antidepressants have varying degrees of ability to sooth or energize, and prescribe them to different people to take advantage of those effects when needed. That is why the Clinaptica Depression Consultant app works as well as it does.
So what exactly goes wrong in the research? If you combine the one-size-fits-all study designs imposed by the FDA, the pharmaceutical company strategy of marketing each antidepressant to every possible customer, and the cooperation of researchers who, until recently, were willing to let the drug industry decide what to do with their data, you have a perfect storm for minimizing important differences between antidepressants. We’re talking about differences as critical as whether patients are anxious, angry and agitated versus lethargic, unmotivated and sleeping all the time. Not evaluating those subgroups separately is analogous to testing antibiotics without considering the type of infection.
As long as the evidence for antidepressant effectiveness depends on that kind of mindset, researchers will continue to confuse medications dispensed blindly with ineffective treatment. The damage done will be minimized, however, if people understand that experienced clinicians who pay careful attention to the differences between patients can prescribe individualized antidepressant treatments that work substantially better than sugar pills. The Clinaptica Depression Consultant app is designed to make that experience more widely available.
Copyright 2012, Scaled Psychiatric Systems, Inc. All rights reserved.