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Neuroskeptic in Hebrew

Wow. The author of Hebrew psychology blog alhasapa has done me the honor of offering to translate one of my posts, Commericalization vs Medicalization, into Hebrew. The translation is up here.

I have no idea what it means, but when I put it into Google Translate it comes back with some surprisingly recognizable English. Given that Google Translate is incredibly rubbish, I think it must be a pretty good translation...

Neuroskeptic in Hebrew

Wow. The author of Hebrew psychology blog alhasapa has done me the honor of offering to translate one of my posts, Commericalization vs Medicalization, into Hebrew. The translation is up here.

I have no idea what it means, but when I put it into Google Translate it comes back with some surprisingly recognizable English. Given that Google Translate is incredibly rubbish, I think it must be a pretty good translation...

Everybody Expects the Placebo Inquisition

An unexpected gem from last year's Journal of the American Psychoanalytic Association: Mind over medicine.

Surprisingly, it has nothing to do with psychoanalysis. Rutherford and colleagues performed a meta-analysis of lots of clinical trials of antidepressants. Neuroskeptic readers will be all too familiar with these. But they did an interesting thing with the data: they compared the benefits of antidepressants in trials with a placebo condition, vs. trials with no placebo arm, such as trials comparing one drug to another drug.

Why do that comparison? Because the placebo effect is likely to be stronger in trials with no placebo condition. If you volunteer for a placebo controlled trial, you'll know that you've got (say) a 50-50 chance of getting inactive sugar pills. You'll probably be uncertain whether or not you'll get better, maybe even quite worried. On the other hand if you're in a trial where you definitely will get a real drug, you can rest assured that you'll feel better - and that in itself might make your depression improve.

The paper only presents very preliminary results, but they say that:

Our group at Columbia has completed preliminary work involving metaanalyses of randomized controlled trials comparing antidepressant medications to a placebo or active comparator in geriatric outpatients with Major Depressive Disorder (Sneed et al. 2006). In placebo controlled trials, the medication response rate was 48% and the remission rate 33%, compared to a response rate of 62% and remission rate of 43% in the comparator trials (p < .05). The effect size for the comparison of response rate to medications in the comparator and placebo controlled trials was large (Cohen’s d = 1.2).

They only looked at trials of old age patients, but the same probably applies to everyone else.

Why does this matter? The authors suggest one very important implication. There are quite a few trials nowadays comparing the effects of psychotherapy, medication, neither, or both. How it works is that everyone gets pills, 50% of them real drugs and 50% placebos; also, half the people get psychotherapy while the others remain on the waiting list.

These trials often find that medication plus psychotherapy is better than just medication alone. This has led to the idea that therapy and drugs should be combined in clinical practice, a message which goes down really well, because it gives both psychopharmacologists and therapists the feeling that they have an important job to do. An example of this kind of trial is the influential TADS from 2004, finding that Prozac and therapy both work in depressed teens, and combining them is best. Everyone's a winner.

But as Rutherford et al. point out, there's a problem with this reasoning. The people who only get antidepressants don't know that they're getting any treatment, because they might be getting placebo. But the people who get antidepressants and therapy know that they're getting at least one real treatment (therapy). This is likely to improve their outcome through an expectation effect. (In fact, for some reason, in TADS, the people on combination treatment were told that they were getting both - they specifically knew they would never get dummy pills - which will have made this even worse.)

Now you could say that this doesn't matter: TADS and similar studies show that therapy and medication is better than just medication, and it's purely academic whether that's "just a placebo effect". But the key point is that in real life people always get medication knowing that it's real - so, like the therapy plus medication people in the trials, they get the benefit of the certainty that they are getting a real treatment. In the trials the medication-only group don't know that, but in real life they do - so the benefits of adding psychotherapy might be less, or even zero, in real life.

The authors of the TADS study did acknowledge this in their original paper, but only very briefly - here's all they say about it:

Blinding patients in the placebo and fluoxetine alone groups but not in the CBT alone group (participants knew they would not be receiving fluoxetine) and the fluoxetine combined with CBT group (participants knew that they would be receiving fluoxetine) may have interacted with expectancy effects regarding improvement and acceptability of treatment assignment.

Yet this limitation means they, strictly speaking, all TADS showed is that Prozac works in this group. It doesn't prove that adding (very expensive) therapy benefits anyone, in the real world. This is not to say that psychotherapy doesn't work of course, maybe it does, but the point is that therapy + medication trials may be best without a placebo.

Rutherford, B., Roose, S., & Sneed, J. (2009). Mind Over Medicine: the Influence of Expectations on Antidepressant Response Journal of the American Psychoanalytic Association, 57 (2), 456-460 DOI: 10.1177/00030651090570020909

Everybody Expects the Placebo Inquisition

An unexpected gem from last year's Journal of the American Psychoanalytic Association: Mind over medicine.

Surprisingly, it has nothing to do with psychoanalysis. Rutherford and colleagues performed a meta-analysis of lots of clinical trials of antidepressants. Neuroskeptic readers will be all too familiar with these. But they did an interesting thing with the data: they compared the benefits of antidepressants in trials with a placebo condition, vs. trials with no placebo arm, such as trials comparing one drug to another drug.

Why do that comparison? Because the placebo effect is likely to be stronger in trials with no placebo condition. If you volunteer for a placebo controlled trial, you'll know that you've got (say) a 50-50 chance of getting inactive sugar pills. You'll probably be uncertain whether or not you'll get better, maybe even quite worried. On the other hand if you're in a trial where you definitely will get a real drug, you can rest assured that you'll feel better - and that in itself might make your depression improve.

The paper only presents very preliminary results, but they say that:

Our group at Columbia has completed preliminary work involving metaanalyses of randomized controlled trials comparing antidepressant medications to a placebo or active comparator in geriatric outpatients with Major Depressive Disorder (Sneed et al. 2006). In placebo controlled trials, the medication response rate was 48% and the remission rate 33%, compared to a response rate of 62% and remission rate of 43% in the comparator trials (p < .05). The effect size for the comparison of response rate to medications in the comparator and placebo controlled trials was large (Cohen’s d = 1.2).

They only looked at trials of old age patients, but the same probably applies to everyone else.

Why does this matter? The authors suggest one very important implication. There are quite a few trials nowadays comparing the effects of psychotherapy, medication, neither, or both. How it works is that everyone gets pills, 50% of them real drugs and 50% placebos; also, half the people get psychotherapy while the others remain on the waiting list.

These trials often find that medication plus psychotherapy is better than just medication alone. This has led to the idea that therapy and drugs should be combined in clinical practice, a message which goes down really well, because it gives both psychopharmacologists and therapists the feeling that they have an important job to do. An example of this kind of trial is the influential TADS from 2004, finding that Prozac and therapy both work in depressed teens, and combining them is best. Everyone's a winner.

But as Rutherford et al. point out, there's a problem with this reasoning. The people who only get antidepressants don't know that they're getting any treatment, because they might be getting placebo. But the people who get antidepressants and therapy know that they're getting at least one real treatment (therapy). This is likely to improve their outcome through an expectation effect. (In fact, for some reason, in TADS, the people on combination treatment were told that they were getting both - they specifically knew they would never get dummy pills - which will have made this even worse.)

Now you could say that this doesn't matter: TADS and similar studies show that therapy and medication is better than just medication, and it's purely academic whether that's "just a placebo effect". But the key point is that in real life people always get medication knowing that it's real - so, like the therapy plus medication people in the trials, they get the benefit of the certainty that they are getting a real treatment. In the trials the medication-only group don't know that, but in real life they do - so the benefits of adding psychotherapy might be less, or even zero, in real life.

The authors of the TADS study did acknowledge this in their original paper, but only very briefly - here's all they say about it:

Blinding patients in the placebo and fluoxetine alone groups but not in the CBT alone group (participants knew they would not be receiving fluoxetine) and the fluoxetine combined with CBT group (participants knew that they would be receiving fluoxetine) may have interacted with expectancy effects regarding improvement and acceptability of treatment assignment.

Yet this limitation means they, strictly speaking, all TADS showed is that Prozac works in this group. It doesn't prove that adding (very expensive) therapy benefits anyone, in the real world. This is not to say that psychotherapy doesn't work of course, maybe it does, but the point is that therapy + medication trials may be best without a placebo.

Rutherford, B., Roose, S., & Sneed, J. (2009). Mind Over Medicine: the Influence of Expectations on Antidepressant Response Journal of the American Psychoanalytic Association, 57 (2), 456-460 DOI: 10.1177/00030651090570020909

CURIOSA OFERCE ROSAS!!!!

HOJE VENHO OFERECER ROSAS A TODOS. É COM MUITO CARINHO QUE ENTREGO O MEU CARINHO EM FORMA DE ROSAS.
VOCÊ É UM SER MARAVILHOSO. POR ISSO FLORES MUITO ESPECIAL PARA VOCÊ!!!

ESTE SELINHO É PARA VOCÊ!!!!
FIZ COM MUITO CARINHO...

OUVINDO DEUS..

As vezes é preciso dar crédito a voz do nosso CORAÇÃO...DEUS fala através dele.
Veja...

Você acredita no que ouve?????
Eram aproximadamente 10 horas quando um jovem
começou a dirigir-se para casa. Sentado no seu carro, ele
começou a pedir: - ' Deus! Se ainda falas com as pessoas, fale
comigo. Eu irei ouví-lo. Farei tudo para obedecer.
Enquanto dirigia pela rua principal da cidade, ele teve
um pensamento muito estranho: 'Pare e compre um galão
de leite'. Ele balançou a cabeça e falou alto:
'Deus? É o Senhor?'
Ele não obteve resposta e continuou dirigindo-se para casa.
Porém, novamente, surgiu o pensamento:
'Compre um galão de leite'. O jovem pensou em Samuel seu
filho e como ele não reconheceu a voz de Deus, ele continuou.
Isso não parece ser um teste de obediência muito
difícil... Ele poderia também usar o leite. O jovem parou,
comprou o leite e reiniciou o caminho de casa.
Quando ele passava pela sétima rua, novamente ele
sentiu um pedido:
'Vire naquela rua'.
Isso é loucura... - pensou - e, passou direto pelo retorno.
Novamente ele sentiu que deveria ter virado na sétima rua.
No retorno seguinte, ele virou e dirigiu-se pela sétima rua.
Meio brincalhão, ele falou alto :
'Muito bem, Deus. Eu farei'.
Ele passou por algumas quadras quando de repente
sentiu que devia parar. Ele brecou e olhou em volta.
Era uma área mista de comércio e residência. Não era a
melhor área, mas também não era a pior da vizinhança.
Os estabelecimentos estavam fechados e a maioria das
casas estavam escuras, como se as pessoas já tivessem ido
dormir, exceto uma do outro lado que estava acesa.
Novamente, ele sentiu algo: 'Vá e dê o leite para as
pessoas que estão naquela casa do outro lado da rua'.
O jovem olhou a casa. Ele começou a abrir a porta, mas
voltou a sentar-se.'Senhor, isso é loucura. Como posso ir
para uma casa estranha no meio da noite?'.
Mais uma vez, ele sentiu que deveria ir e dar o leite.
Inicialmente, ele abriu a porta...
'Muito Bem, Deus, se é o Senhor, eu irei e entregarei o leite
àquelas pessoas. Se o Senhor quer que eu pareça uma
pessoa louca, muito bem. Eu quero ser obediente.
Acho que isso vai contar para alguma coisa, contudo, se
eles não responderem imediatamente, eu vou embora
daqui'. Ele atravessou a rua e tocou a campainha.
Ele pôde ouvir um barulho vindo de dentro, parecido com
o choro de uma criança. A voz de um homem soou alto:
'Quem está aí? O que você quer?'
porta abriu-se, em pé, estava um homem vestido de jeans
e camiseta. Ele desconhecido em pé na sua soleira.
'O que é? '. O jovem entregou-lhe o galão de leite.
'Comprei isto para vocês'.
O homem pegou o leite e correu para dentro falando alto.
A mulher pegou o leite e foi para a cozinha. O homem a seguia
segurando nos braços uma criança que chorava.
Lágrimas corriam pela face do homem e, ele começou a falar,
meio soluçando:
'Nós oramos. Tínhamos muitas contas para pagar este mês
e o nosso dinheiro havia acabado. Não tínhamos mais leite
para o nosso bebê. Apenas orei e pedi a Deus que me
mostrasse uma maneira de conseguir leite'.
Sua esposa gritou lá da cozinha:
Pedi a Deus para mandar um anjo com um pouco...
Você é um anjo?‘ O jovem pegou a sua carteira e tirou todo
dinheiro que havia nela e colocou-o na mão do homem.
Ele voltou-se e foi para o carro, enquanto as lágrimas
corriam pela sua face. Ele experimentou que Deus ainda
responde os pedidos.
Agora, um simples teste para você:
Se você acredita em Deus, mande esta mensagem
para todos os seus amigos.
Quanto tempo você leva para
parar um pouquinho e ouvir Deus?
Essa é uma mensagem que um anjo mandou-nos para
refletirmos sobre a forma que Deus fala conosco!
Tenham muita Luz e muita Paz.
Que DEUS nos Ilumine!!!!!!!!!!!

AS VEZES NOSSA INTUIÇÃO FALA MUITO MAIS. É PRECISO SABER ENTENDER E OUVIR...
OBRIGADA ANA, PELO CARINHO...

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