Question:
Placebo test for homeopathy treatment of depression only?
Answer:
Critics have charged that organized "skeptics" are reactionary
defenders of the establishment selectively applying scientific
standards only to new and alternative hypotheses and claims.
For example, organized skeptics have waged a long-term war
on homeopathy (a war I agree with) using the standard that
homeopathic medicines are not better than plaebo. However,
despite the fact that evidence has been availabe for many
years that FDA-approved antidepressants are no better than
placebo, I have yet to see any skeptics group apply the
same scientific standard to antidepressants that they apply
with a vengeance to homeopathy. Will the following new study
cause any skeptics group to challange the establishment? Ian
http://www.washingtonpost.com/wp-dyn/articles/A42930-2002May6.html
After thousands of studies, hundreds of millions of prescriptions
and tens of billions of dollars in sales, two things are certain
about pills that treat depression: Antidepressants like Prozac,
Paxil and Zoloft work. And so do sugar pills.
A new analysis has found that in the majority of trials conducted by
drug companies in recent decades, sugar pills have done as well as
-- or better than -- antidepressants. Companies have had to conduct
numerous trials to get two that show a positive result, which is the
Food and Drug Administration's minimum for approval.
What's more, the sugar pills, or placebos, cause profound changes in
the same areas of the brain affected by the medicines, according to
research published last week. One researcher has ruefully concluded
that a higher percentage of depressed patients get better on
placebos today than 20 years ago.
Placebos -- or dud pills -- have long been used to help scientists
separate the "real" effectiveness of medicines from the "illusory"
feelings of patients. The placebo effect -- the phenomenon of
patients feeling better after they've been treated with dud pills --
is seen throughout the field of medicine. But new research suggests
that the placebo may play an extraordinary role in the treatment of
depression -- where how people feel spells the difference between
sickness and health.
The new research may shed light on findings such as those from a
trial last month that compared the herbal remedy St. John's wort
against Zoloft. St. John's wort fully cured 24 percent of the
depressed people who received it, and Zoloft cured 25 percent -- but
the placebo fully cured 32 percent.
The confounding and controversial findings do not mean that
antidepressants do not work. But clinicians and researchers say the
results do suggest that Americans may be overestimating the power of
the drugs, and that the medicines' greatest benefits may come from
the care and concern shown to patients during a clinical trial -- a
context that does not exist for millions of patients using the drugs
in the real world.
"The drugs work, and I prescribe them, but they are not what they
are cracked up to be," said Wayne Blackmon, a Washington
psychiatrist whose practice largely comprises patients who suffer
from depression. "I know from clinical experience the drugs alone
don't do the job."
Still, drugs may have become the reflexive treatment for the vast
majority of Americans receiving medical attention for depression: As
the number of doctor visits for depression rose from 14 million in
1987 to almost 25 million last year, medications were prescribed for
nine in 10 patients, according to research published last week.
It is not clear how many patients received medicines in a context of
therapy, although research has indicated that combining medicines
with psychotherapy produces the best results.
But Randall Stafford, the Stanford University physician who
conducted the study on doctor visits, found that less than one-third
of them in 2001 were to psychiatrists and two-thirds of them were to
primary care physicians. The former are more likely to situate the
medicines in a larger context of therapy, while the latter are less
knowledgeable about therapy, more pressed for time and less likely
to offer patients anything like the attention they would receive in
a clinical trial.
The average participant in an eight-week trial spends about 20 hours
being examined by top experts and highly trained caregivers, said
Seattle psychiatrist Arif Khan, who studied the placebo effect in
trials submitted to the FDA. Participants -- including those being
given sugar pills -- are asked detailed questions about how they are
feeling, and their every psychological change is closely noted.
In comparison, Khan noted, the average patient with depression sees
a doctor perhaps 20 minutes a month.
His analysis of 96 antidepressant trials between 1979 and 1996
showed that in 52 percent of them, the effect of the antidepressant
could not be distinguished from that of the placebo. Khan said the
makers of Prozac had to run five trials to obtain two that were
positive, and the makers of Paxil and Zoloft had to run even more.
He analyzed trials that were made public in the medical literature,
which tend to show positive results, and those that were not.
"It speaks to the difficulty we have in classifying and identifying
the disorders we deal with," said Thomas Laughren, who heads the
group of scientists at the FDA that evaluates the medicines.
"Psychiatric diagnosis is descriptive. We don't really understand
psychiatric disorders at a biological level."
Patients with similar symptoms, he explained, may have different
problems with their brain chemistry. Scientists don't understand the
neural mechanisms of depression -- or why medicines like Prozac and
Paxil work.
"We like to think we give people treatments and they get better,"
said Andrew Leuchter, a professor of psychiatry at UCLA. "We have
this fallacy of success, but we don't know in any individual why
they get better. Undoubtedly one of those factors is the time we
spend with people and the connectedness that gives patients."
In January, Leuchter published a study in the American Journal of
Psychiatry, in which he tracked some of the brain changes associated
with drugs such as Prozac and Effexor, which are called selective
serotonin reuptake inhibitors. When Leuchter compared the brain
changes in patients on placebos, he was amazed to find that many of
them had changes in the same parts of the brain that are thought to
control important facets of mood.
Patients who got better on placebos showed heightened activity in
the prefrontal lobe, and that activity continued to rise during the
eight weeks of the study. Those who responded to medicine initially
showed a decline in prefrontal brain activity, then a rise that
eventually tapered off. Thirty-eight percent of patients responded
to the placebo, and 52 percent to the medicines.
Once the trial was over and the patients who had been given placebos
were told as much, they quickly deteriorated. People's belief in the
power of antidepressants may explain why they do well on placebos.
Patients in trials are not told which they are receiving.
Likewise, sea changes in the treatment of depression -- including
the reduction in the stigma attached to mental illness, the
widespread use of antidepressants and the immense marketing efforts
by their manufacturers -- may explain why Timothy Walsh, a
psychiatrist at Columbia University, recently found that the placebo
effect has grown in recent years. He found that greater percentages
of people tended to get better on placebos during trials of
antidepressants in 2000 than in 1981.
Some observers assert that the medicines themselves work because of
the placebo effect, but most psychiatrists believe the drugs do have
an effect of their own. Drugs are a "placebo-plus" treatment, said
Helen Mayberg, head of neuropsychiatry at the Rotman Research
Institute at the University of Toronto.
In a study published last week in the American Journal of
Psychiatry, Mayberg evaluated brain changes during trials using a
sophisticated brain imaging technique. She found that medicines,
besides working on areas that are activated by placebos, also work
on areas deep in the brain stem, the hippocampus and striatum.
Since both depression and the effect of the medicines are still not
well understood, it's not clear what these changes mean. While they
could be irrelevant effects, Mayberg said a better explanation is
that the drugs affect areas deep within the brain and then work
upward to affect parts of the brain that control mood. Placebos may
work in the reverse direction. In part, this may explain why drug
effects tend to be more reliable than placebos in the long run.
Mayberg likened depression to a room with a hole in one window.
"You are trying to set a thermostat -- it's 100 degrees outside and
you want it to be 70," she said. "If you set the thermostat to 70,
that doesn't work. But if I set my thermostat to 50, that fools the
system and gets the temperature back to 70."
Both drugs and placebos -- chemicals and beliefs -- may impose
different chemical pressures on the brain that reset the
"temperature." The real problem, of course, is that no one knows how
to fix the hole in the window, or even where exactly it is. "This is
a thousand-piece puzzle with no picture on the box," sighed Mayberg.
Blackmon, the Washington psychiatrist, said it behooved mental
health clinicians to better integrate the power of biological
treatments with the effects of belief and therapy.
"We would say it's absurd if an internist says, 'I believe in
penicillin, so everyone should get penicillin whether they have
cancer or a broken bone," he said.
http://IanGoddard.net
I would rather reserve judgement until these allegations and the study
that raises them have been subjected to peer review. I'm not willing
to accept a Washington Post article as a stand-alone reference to
medical therapeutics.
