also, that restless-leg thing is totally some bullshit they came up with to sell drugs.
My sense is that everything you're saying can be true, and yet anti-depressants might still be overprescribed, might regularly be prescribed in instances where they'll do know good (and sometimes some significant harm), and might be prescribed by physicians who either don't understand the medication they're prescribing or who have perverse incentives to do the prescribing in the first place. Which, for me, are the underlying issues in the discussion.
That said, I know people who have benefited greatly from taking SSRIs, who otherwise were in great pain and now are only in minor pain, and who thus can function because of their medication. But I don't think these cases do much to answer any of the questions above.
And yes, that restless leg thing is some serious bullshit. Control yourselves, you spazzes. I mean, really.
Holy hell, "know good"? I feel sick.
maybe you should take paxil? or read less yggles?
if doctors are really handing them out like candy then that's stupid, but I think we ought to consider the possibility that lots and lots of people suffer needlessly from depression. it's not going to make you stronger, even if it doesn't kill you.
I think we ought to consider the possibility that lots and lots of people suffer needlessly from depression. it's not going to make you stronger, even if it doesn't kill you.
I agree on both counts. But yes, by most accounts doctors are handing them out like candy.
If anti-depressants can save even one person from CSI:Miami then they've justified their existence.
For me, there was no feeling of peace when in the psych ward, only anger and frustration at not being allowed to leave. Which was, at least, a change in mood.
Except the one who is prescribing me Lexipro. And my sister. And LB's sister. And my friends who happen to be people with medical degrees. &c.
Holy hell, "know good"? I feel sick.
Andrew Sullivan's tentacles are everywhere.
Alameida just wrote the best unfogged post ever.
thanks md 20/400. note that the "fuck you's" only go to the hater doctors who think bitches, due to the fact that they constantly be trippin', are probably making up their symptoms and just need to get out of this tidy office with its tidy diagnoses and see the crazy doctor.
Good lord, was alameida being haunted by Andrew Sullivan? I hope it's better now.
thanks rob, and chris! good night all, I'm going to sleep.
Alameida just wrote the best unfogged post ever.
Damn, alameida, you can hell of blog. Someone should pay you for writing this stuff.
Here, here! Shit is a lifesaver, yo--I would be dead without 'em. Placebo my ass.
Whoop! Even if the effect is entirely psychosomatic and I might as well be forking over my co-pay for sugar pills, I don't care. And it's not like the Prozac makes me feel like everything in the garden is lovely - it just gives me the time I need to come up with healthy ways of dealing with how the world actually is.
You want to know what's wrong with 1 and 2? Try replacing Negro for restless leg syndrome.
also, that libertarian thing is totally some bullshit they came up with to sell drugs.
And yes, that libertarian thing is some serious bullshit. Control yourselves, you spazzes. I mean, really.
Looks right to me.
Yes, yes, yes! That's know-it-when-I-see-it major depression. And it's not being sad and it's not being stressed out and it's a fucking bag of dicks as a friend of mine might say.
And yes, doctors do over-prescribe because magic pills are easier than actually figuring shit out and treating and taking patients seriously. And it probably impedes some truly depressed people from getting medication because they see a lot of bullshit prescribing and then are all skeptical that sometimes drugs really are the answer. And I thank God for my special time with Zoloft because, as Julia F said, it gave me the time I need[ed] to come up with healthy ways of dealing with how the world actually is. But also fuck the fucking doctor who wouldn't believe I was having health problems unrelated to depression and just wanted to give me more Zoloft or maybe some Xanax which didn't help and maybe hurt.
If the second author linked in the earlier article is correct, then of course going off your meds is going to feel like howling death: the meds' function to addict you and exacerbate your depression so that you don't go off them.
If he's totally wrong, and only the first author linked in the earlier article is correct, and anti-depressants are just literally the equivalent of placebos -- and it seems pretty hard to get around experimental data that more-or-less unequivocally demonstrates that -- then there's some complicated interweaving of placebo effect / trust in medical authority / psychogenic ailment going on in modern "mental illness." (I know we daren't use the word "psychogenic" because then that's "blaming people for their illness," but I'm not like all those bad people who mean it in the bad, you're crazy way. I'm just one of those assholes who insists on pointing out that "you're just crazy" is not in the least little bit what "psychogenic" actually is supposed to clinically mean.)
I doubt that either of them are wrong, and I think the pharmaceutical and psychiatric industries deserve far heavier scrutiny than they get. As someone who's known several schizophrenics, chronic depressives and people diagnosed with bipolar disorder who were also addicts, I can say that medicating with glorified placebos certainly seems to be a damned sight better and more stabilizing than medicating with various combinations of booze, narcotics and prescription drugs (for those of them that survived the experimentation). But saying they were more stable in the former scenario than the latter isn't saying much, and I've seen nothing about those kinds of experiences to suggest to me that these authors must somehow be wrong in pointing up the basically inert or potentially actually harmful effects of these drugs. So I frankly don't really understand the point of this post.
(Feel free to season 26 with caveats and qualifiers to taste, I wrote it in a bit of a rush.)
26: My quibble is that I don't see any basis for rejecting a third possibility -- that antidepressants can have a beneficial effect that is more than just placebo and that, when prescribed and taken properly, do not create a life-long dependence. I haven't gone beyond the laziest of Google searches on the subject, but here is at least one article suggesting that antidepressants perform better than placebo in cases of truly severe major depression. Okay, here, a scholarly abstract saying the same thing.Which would be consistent with the conclusion that it's unhelpful to either (a) dismiss antidepressants out of hand as snake oil voodoo, or (b) to treat antidepressants as the wonderdrug cure to all discontent.
So not to presume to speak for Alameida on the point of this post, but the point I take from it is a challenge to the perception that "depression" is roughly on par with feeling really bummed and medication is a sham. That is, antidepressant might be sort of useless for depression that is roughly on par with feeling really bummed. But for really severe depression, it's a different story.
So what is the etiology of these disorders?
http://www.slate.com/id/2298453/
If you were a psychiatrist and someone presented with all the symptoms of Koro what would you prescribe? If they insisted that their condition was caused by a chemical imbalance, what would you tell them.
29: Every antidepressant on the market has done better than placebo in a clinical trial. That's how they get to the market. The question is the extent to which those clinical trials are conducted properly* and the extent to which those clinical trials correspond to how the medication is used**.
* There are issues, but generally that is rigorous research.
** A bigger issue for a variety of reasons.
I think that one of the reason that antidepressants don't do better against placebo than they do, also, is because of the inevitable presence of misdiagnosed patients in the trials.
29: Yeah, we're saying the same thing, I think. I just said it really poorly. I meant (but failed to type) something like "antidepressants performed way better compared to placebo when used to treat severe depression but only sort of or maybe not even (i.e., less) better than placebo when used to treat mild or moderate depression. Thus, the "how the medication is used" issue.
(I'm off my meds -- this is the best I can do.)
30: Every antidepressant on the market has done better than placebo in a clinical trial.
In a clinical trial that's not controlling for whether the presence of side-effects is biasing the placebo effect in supposedly double-blind placebo-controlled trials. I'm referring to this article that explains Kirsch's reasoning, linked in the prior post this one is responding to.
28: I haven't gone beyond the laziest of Google searches on the subject, but here is at least one article suggesting that antidepressants perform better than placebo in cases of truly severe major depression.
We already know there are studies out there saying this. What we don't know is whether those studies evaded the pitfalls that Kirsch discovered in positive studies about antidepressants. If Kirsch's conclusions are correct, then yes, we have pretty compelling reason to disbelieve that antidepressants have a clinical, more-than-placebo effect.
35: I'm struck that Kirsch was apparently struck (according to the review) by the "unexpected finding" that synthetic thyroid hormone was as effective as antidepressants in alleviating symptoms since depression is a well-known symptom of thyroid deficiency.
This thread is clearly crying out for my personal crackpot theory on how SSRIs work. Upon taking SSRIs, patients have an almost immediate increase in homeostatic serotonin levels, but any psychological effects take weeks or months. Additionally, seratonin reuptake enhancers have shown similiar clinical benefits. Both of these facts run counter to the Monoamine Hypothesis (which, at least as described to me, is a sort of chemical soup theory of the brain). What I think is actually going on is that these drugs interfere with the normal synaptic signaling, making them less reliable sources of information, and so over time, following Hebbian logic, other neurons will tend to ignore them. If networks using serotonin contribute to depressive thoughts in a patient and that patient takes an SSR[IE], the thoughts will effect them less.
34: I read the article, not the books, and I found Kirsch's thing new and interesting. I might pick it up. I never did much work with depression. I'm still a bit dubious about the broad claim. The article mentioned antipsychotic medication (as opposed to antidepressants, but didn't actually go into any of the research on that. That doesn't surprise me because and in fact I'd ignore Kirsch offhand if that book wasn't limited to antidepressants. I've seen enough low quality (not just the Scientology-fronted stuff) work arguing against antipsychotic medication (in general) and seen enough research supporting it that I stopped paying attention there.
Also, some of the article is ignoring obvious counter-explanations. SSI and SSDI for mental illness is increasing for a whole variety of reasons, including the fact that you can't draw them from a state mental hospital and of "welfare reform." Starting in the Reagan administration, people have been moved from other forms of welfare to disability.
People seem to consistently confuse the idea that anti-depressants may not beat placebos with the idea that they don't have any effect at all. It seems obvious they have a significant physical effect on the brain. But we have no deep medical/physical understanding of the etiology of depression, or even a clear definition of it, so there's no baseline for "effective" besides "it makes me feel better". Is it all surprising that severely depressed people are more likely to feel that a change in brain chemistry is an improvement than moderately depressed people are? To be simplistic about it, the more fucked up you feel, the more chance that a given set of changes in your brain are going to make you feel better. I mean, you can't feel much worse. (The same logic might apply to electroshock therapy, which also seems to be effective against severe depression).
Anti-depressants seem to have a lot of characteristics that recommend them as something to try with people with severe depression -- they have side effects but those side effects are moderate compared to most other psychoactive drugs and not life-threatening, that many people report that they create a certain feeling of distance from intense emotions and sexuality etc. You can see why those characteristics would recommend them as something to try with people who feel really bad. When they are presented as a "cure" for a chemical imbalance/physical disease called depression, all the authority of science gets behind them and you get the wild over-prescription.
I am friendlier to the "most mental disorders exist on a continuum with normal traits/states" than the consensus evolving here, so I'd like to make some observations.
The notion that depression is nothing like sadness is not the opinion of any mental health provider, or student provider, I know. I tend to know psychologists; they probably think differently than doctors. Everyone I know would say either sadness or anhedonia (which I guess is more like "why should I care about this arrangement of shapes") can be the core emotional state of depression, and indeed, the DSM requires the presence of depressed mood or anhedonia, but not both. Even if (general) you does not experience depression as a sad feeling, many people do. Obviously, there have to be other simultaneous manifestations for it to be MDD, but nevertheless, for many, depression is very closely related to, indeed, perhaps a result of, feeling very sad. Plenty of people with depression present as very sad -- that's the overwhelming feeling you get from being around them. Maybe the depression that is deep sadness and the depression that is "why should I care about this arrangement of shapes" are different things etiologically, and should be called by different names.
Sometimes, when I'm feeling very bad, I have more than 4 of 9 DSM symptoms of major depression, so that if it persisted for two weeks I would qualify for a diagnosis of MDD. (In my case, they are most commonly: depressed mood most of the day, nearly every day, suicidal ideation, reduced appetite, insomnia, and inability to concentrate. Sometimes feelings of worthlessness, sometimes mild psychomotor retardation.) It never persists for two weeks, but it is still my experience of the fluctuations of mood that I can cross a threshold into what our flawed, provisional consensus calls "what depression is like." It would be interesting to know to what extent this is normal -- how many people can be depressed, as in, very seriously symptomatic, for a few days, but not two weeks. Maybe some of the people in this thread have different ideas about what being sad is, but in my experience, the emotion "sad," when intense, brings along the thought patterns and physical symptoms that make major depression.
(I am very friendly to the existence and prescription of SSRI's, although I'm glad I've never taken them, in part because given that I can spontaneously recover to functional in a few days, feeling like shit is often usefully informative about what in my environment makes me so. This as well isn't different from major depression, which research strongly suggests has plenty of exogenous causes.)
Sorry, 40 was long and a little incoherent but you get the idea. Eggplant's 'crackpot' theory in 37 actually got at some of the same ideas.
Also, I'm unaware of anyone arguing that anti-depressants don't beat placebo for severe depression, and that seems to get lost in some of the comments here.
What I think is actually going on is that these drugs interfere with the normal synaptic signaling, making them less reliable sources of information, and so over time, following Hebbian logic, other neurons will tend to ignore them. If networks using serotonin contribute to depressive thoughts in a patient and that patient takes an SSR[IE], the thoughts will effect them less.
This isn't totally distinct from the neurotrophic theory of anti-depressant function. Are you familiar?
40: People seem to consistently confuse the idea that anti-depressants may not beat placebos with the idea that they don't have any effect at all.
Well, of course they'd be having an effect. A placebo effect. Enduring added expenditure and an array of siding effects for something functionally the equivalent of a placebo would seem -- if the contention that they're not genuinely outperforming placebos is correct -- to be irrational.
43: Kirsch is effectively so arguing. Or rather, he's arguing that side effects in supposedly double-blind experiments are biasing patient perceptions of treatment and improvement, to greater degrees when dosages are higher (as they would tend to be in cases of severe depression). He's arguing that the results aren't conclusively demonstrating that antidepressants are doing better in these cases.
In case anybody is under the mistaken impression that SSRIs are somehow the equivalent of sugar pills, I invite them to try a sample for a few weeks, and then just for kicks, stop taking them altogether.
Yeah, sugar pills sure won't do that, will they?
Along with everyone else, I love this post.
That said, I don't think there's any real tension between (a) acknowledging how hellish major depression is; (b) acknowledging that psychoactive substances sometimes help some people a great deal; and (c) recognizing that depression is often simultaneously (1) highly personal/private and (2) socially/institutionally enabled/exacerbated.
I'm going to gleefully violate the analogy ban and bring up unemployment. The circumstances that lead to any one person being unemployed, and exactly how that condition (not having a remunerative job, despite searching) plays out in day-to-day way, are quite diverse and individualized; the institutional and relational structures that lead some societies to have more unemployment and different sorts of unemployment than others--the fact that through most of human existence, "unemployment" isn't something that even makes sense to talk about--are at least as diverse and complex, but often irrelevant to the dealing with the former on a case-by-case basis. I think it's quite reasonable to worry that the "pharmaceuticals : depression :: antibiotics : bacterial diseases" frame of thinking makes it harder to trackle the big picture problem.
To push this even farther: cholera is caused by bacteria; antibiotics are apparently prescribed in severe cases; but tackling cholera through antibiotics, in a general sense, would be madness: it's a public-sanitation disease, which is why it's basically no longer an issue in the developed world. (NB: I know nothing about cholera or public health. If I'm wrong, pretend I'm talking about a disease about which I'd be right.)
And there's just no space to talk, or at least to Talk Seriously--e.g. by Serious People who might make policy--about depression or other mental health issues in the same way we can talk about the structural dimension of unemployment or infectious diseases.
47: In case anybody is under the mistaken impression that SSRIs are somehow the equivalent of sugar pills
The problem would seem to me to fairly obviously be that they're not. The sugar pill would be preferable if it's going to give you the same results without murderous withdrawal.
(I mean, this would be where Whitaker comes in. It's surely implausible to argue that all these pills aren't doing something to people's neurochemistry. The question is whether that something is in fact the touted clinical benefit.)
(taking credit for 46)
(acknowledging that 46 was prepwned by 40)
(just shutting up)
46: And there is at least one study to test that idea. That's what I would look at if I were going to put a bunch if time into this. Or even a little time, just to see what the n was.
This isn't totally distinct from the neurotrophic theory of anti-depressant function. Are you familiar?
No I am not! In writing 37 I was hoping someone who actually knows something would come along and give me search terms (or point out flaws), so thanks! Off to read.
I read an article by Kirsch a while ago, not sure if it's the same one under discussion, but I didn't realize he was trying to argue that *all* of the observed effect of SSRI's was from the added placebo effect of a pill with side effects. Apologies if this has come up already in the threads devoted to this topic, but rats, etc., show lots of responses to SSRI's in animal models of depression, above the effects of saline injections. It's true that an animal model of depression != depression, but it really seems to me like a tendentious reading of the totality of the evidence to suggest that because traditional comparisons to placebo might be insufficiently controlled, SSRI's don't work at all.
Oh, I would feel remiss, especially since it's been in the news, if I didn't mention the one drug that has helped me with depression: mushrooms.
I'm actually having a really hard time thinking about this issue because it brings out a conflict between two propositions I'm quite sure of.
1. Whenever anyone goes off their meds, bad things happen.
2. Everything drug companies say is a lie.
54: Well, the way I understand it, Kirsch is essentially arguing that this is a general problem, yes, and one based on a flawed premise about chemical imbalances that has distorted research and the interpretation of data. Presumably this would also include interpretation of animal research data, though I don't know whether he talks about that specifically in his book.
56: Why is it a conflict? It's easy to see that people experience extremely nasty withdrawal effects from many antidepressants, and perfectly possible that the "benefit" they're getting from putting up with side-effects and withdrawal is not clinically-speaking all that impressive. All sorts of precedent for that scenario in the history of medicine.
To go personal: I've been dealing with depression, varying from minor to major, for perhaps 15 of my 30 years; over the last 8, there have been extended periods of time--months continously; years in total--when I've spent 3-5 days a week in bed; major anhedonia combined with self-loathing, suicidal ideation, loss of energy, most of the rest of the typical stuff. I've been on a half dozen different drugs, none of which seemed to do all that much, though some of them may have helped, some of the time.
The single most helpful thing, for me, is exercise--but of course getting oneself to exercise when everything seems pointless, particularly one's own existence, is not so easy. Anything that makes going through the motions of personal agency seem like external necessity helps. (I feel like I'd also experience an inpatient psychward as a relief, as Thorn expressed.) Though of course this very fact--the need for externally imposed (or at least experienced) structure--is itself fodder for the self-loathing, suicidal ideation, &c.
So that's the micro-level, individual side. But looking to the institutional side--and this is why I'm completely unsurprised that so many people in The Mineshaft have struggled with depression--it's clear to me that a lot of elements of overeducated SWPL life enable or exacerbate this. Most obviously and personally: unstructured, minimally supervised PhD programs--not the best places for the depression-vulnerable!
But insofar as we're talking about an "epidemic" of depression, we're not just talking about UHB folks. And I think we're right to talk about such an epidemic, though I think that way of phrasing it is perhaps misleading; I'd call it a crisis of agency, with MDD being at the extreme end of a spectrum whose other extreme is a rarely achieved (and perhaps not really desirable) ideal: the Ayn Rand-style autonomous agent, for whom existence and goal-fulfilment are self-evidently meaningful, reason-giving, and (experienced as) causally motivating.
So possibly at the other end from the PhD students with unsupervised fellowships and existential angst are all those employees whose highly structured workdays and relentlessly, intentionally, deskilled tasks erode this sense of agency in a different and more straightforward way.
And yeah, this is armchair critical social psychology, with nothing to back it up in the way of detained cross-cultural studies showing how differently organized social institutions reliably lead to differently distributed populations along this (itself armchair psycho/philosophy) agency/depression scale. (Yes, I'm aware of e.g. The Spirit Level.) Even well-done, rigorous stuff, given how complicated the question is, is necessarily going to be tentative here. But I'd rather see funding and brainpower going into these questions than the "pure" neuropsychiatry side of things, just like the big gains in public health are from sanitation rather than antibiotics.
And with that, I'm going out to ride my bike, only 5 hours later than planned.
57: I'd been ignoring the "chemical imbalances" part. It's beside the point of a clinical trial and the whole field of critics of psychiatry is hugely overpopulated with people screaming "everything you know is wrong."
(1) and (2) were meant as vague representatives of the general forces pulling on me.
Other parts of (1) include: (a) major depression is an incredibly hellish condition (b) anti-depressants sure as shit seem to help with them (c) the price people pay for help with major depression is really quite trivial compared to the benefit of not wanting to die (d) the problems with going off your meds aren't limited to short withdrawal periods. They are at the very least a barrier that no one gets through and wouldn't be worth getting through anyway.
The other part of (2) is just that drug companies lie specifically about the efficacy and side effects of drugs.
and (e) if skepticism about the effectiveness of SSRIs prevents one person from getting better on SSRIs the way I have gotten better, that's a huge fucking tragedy and (f) everything Alameida said.
(d) the problems with going off your meds aren't limited to short withdrawal periods
Soft-soaping antidepressant withdrawal and dependency is no more excusable than soft-soaping the effects of depression.
I find the reference to late 90s Jay-Z in the OP somewhat depressing.
(2c) All the arguments I can muster in favor of widespread use of anti-depressants resemble the anecdotal arguments like the ones a student recently gave me for the claim that hemp oil cured her grandfather's cancer.*
*Except it didn't, because he's dead.
And yeah, this is armchair critical social psychology, with nothing to back it up in the way of detained cross-cultural studies showing how differently organized social institutions reliably lead to differently distributed populations along this (itself armchair psycho/philosophy) agency/depression scale.
There's an age-cohort effect in depression in this country and several other industrialized countries -- younger people have higher prevalence of depression -- that researchers have tried hard to rule out artifactual explanations for with highly structured interviews, etc. Here's a representative abstract. But it doesn't affect people uniformly. The age cohort effect doesn't exist among the Amish in this country, for example.
Other possible social psychological explanations for the increasing prevalence of depression include increasingly lofty expectations for what you should have or do in life, which create disappointment when you fail to reach goals that are actually very difficult to achieve -- this is perhaps a version of what you were saying -- and increasing deracination and isolation from social support. The two are sometimes related, in that people, academics especially, sometimes have to move for work, disrupting the formation of stable social networks, and have to spend a lot of time at non-social work.
41: Tia -- I would say the difference between sadness and depression is one of degree, not kind. Sadness that lifts in a few days still sucks, but it's just not the same as depression.
Rob: Whenever anyone goes off their meds, bad things happen. has not been true for me. Perhaps it might have been if I'd gone off too soon or stayed on too long?
The sugar pill would be preferable if it's going to give you the same results without murderous withdrawal.
This would, you know, be a more helpful observation if there existed any way to prescribe placebo for depression (and particularly if any of your interlocutors had any power to make that possible). Even if I grant the moral point (and I do), the practical value is nil. I suppose the closest thing you could get at the drugstore would be homeopathic remedies, but for people who know what homeopathy is, that's not so useful either... The problem is that name-brand antidepressants are the only currently available source of the antidepressant placebo effect, which is apparently -- apparently! -- better than a straightforward lack of placebo. Or is that not the case?
There are various 'dietary supplements' which pretend to help depression, which could act as standins for homeopathic drops among people who are not homeopathically inclined. My anecdata: I tried SAM-e for a couple of months on the advice of a friend, and on the third month couldn't bring myself to buy another $40 box for no evident reason. Within six months I was on an SSRI and did not have any doubt by the time of my first re-up.
Yes, I noticed side effects from the SSRI that I hadn't from the SAM-e. Yes, I had more confidence in the SSRI, but also had more than zero confidence in the SAM-e.
I maintain that a lot of the people in the placebo trials do not actually have clinical depression. There is no objective test for it; how could they not have some false positives in there?
Even if (general) you does not experience depression as a sad feeling, many people do.
...
Maybe the depression that is deep sadness and the depression that is "why should I care about this arrangement of shapes" are different things etiologically, and should be called by different names.
This separation of anhedonia and a sad affect feels right to me. There have been times when I felt "nothing is worth doing and I wish I were dead" and times when I felt "nothing is worth doing, so I'm just going to stay in bed." I think I've been feeling more of the latter recently, and I think that has been a sign of progress.
41: Tia -- I would say the difference between sadness and depression is one of degree, not kind. Sadness that lifts in a few days still sucks, but it's just not the same as depression.
This is sort of what I was trying to say; it's actually a little less qualified than what I meant to communicate. But yeah, I think that depression (the sadness kind) is on a continuum with other sadness, and depression (the anhedonia kind) is on a continuum with other anhedonia. It's a different experience to feel intensely crappy for a few days rather than a few weeks, certainly.
I get where you're coming from, rob, but surely you see the broad and disturbing implications of 62. It's not a good criterion.
||
I had a sad experience the other day with one of my clients who is in the hospital. She is probably going to be discharged from our services and put into an intermediate care bed, aka a state hospital. There aren't very many left, so they're hard to get into.
She's always psychotic, but she managed okay for a long time. Lately, though she's been smoking crack some and sleeping on park benches and off her medications she gets very aggressive.
Test results show that she had a heart attack which may be contributing to her depression. It sounds like she might be suicidal. I asked her whether she understood what they wanted to do with her. She said, "They want to put me in an institution." I said, "Yes, that's right." "Do I have to go?" she asked. "Yes, I think you will."
She asked me to stay a while. She needed to sleep a little longer (she a bit too sedated by her current meds--too little and she attacks people) but she definitely wanted to see me. At a certain point I had to go, and I walked over and said goodbye. She was half asleep, so I said quietly, "I miss you, [Name]." And she said, "I miss you too."
|>
I had some serious twitching side effects from Prozac. I'd been working on going off it (I still need meds--lamictal a mood-stabilizing anticonvulsant anti-depressant), and my doctor kind of accelerated it when he saw that. I don't think that the Prozac did much for me. Zoloft got me out of a bad depression once. I think the therapy did more when I was on the Prozac.
Restless leg exists for some people, but the drugs are stupid. Acupuncture or maybe magnesium would probably work well enough.
Further to 73. She managed okay for about 10 years in a 24-hour group home.
A really big hunk of magnesium right on top of your leg to stop it from bouncing.
Restless leg syndrome seems to me to be perfectly plausibly in the tic disorder universe, with its semi-voluntary quality. The name is somehow terribly stupid sounding, but whatever, motor tics are perfectly real.
62 was not meant as a rigid "no one left behind no matter what the cost" criterion. It was more like "Success in treating major depression should be given much more weight than people are giving it compared to most of the side effects"
Also, I haven't read any of the linked articles, because what's the point.
68: This would, you know, be a more helpful observation if there existed any way to prescribe placebo for depression
A dead-on observation, friend lurkey, I couldn't agree with you more. If of course the only solution we could think of is "prescribing something." It could be that a set of assumptions that offers us a) pseudo-placebos with side-effects including but not limited to dependency and b) nothing, is flawed. As I understand it, Kirsch's larger point is that the observation may be helpful in researching other solutions than prescribing a pill. Who knows but that the time may have come?
Encouraging the patient to seek out unprescribable pills with pleasant effects could work wonders.
The story in 73 is one of many poignant illustrations of why social work would break me, and why I admire the people who do it. Hope you're taking care of yourself BG.
On-topic with "meds" for the thread: Lately, though she's been smoking crack some and sleeping on park benches and off her medications she gets very aggressive.
Crack is also known to make people very aggressive. It may be tough to isolate the effect of the meds in this case, though that's probably a contributor too.
erm, for me depression is sort of what people think it is: taking up crying as your prime hobby. the "Depressed people are affectless, relentlessly negative" is more just a description of personlity flaws. On good days, i am still still staring long enough into abyss to see it stare back, but its with glee because i know it will blink first.
Namewise restless leg syndrome hasn't got a patch on alien hand syndrome.
On good days, i am still still staring long
enough into abyss to see it stare back, but its with
glee because i know it will blink first.
I love this.
84: And neither is as terrible as Patch Adams Syndrome.
30
Every antidepressant on the market has done better than placebo in a clinical trial. ...
If the NYRB article is to be believed this is less impressive than it sounds since negative results aren't counted so an antidepressant can do better than placebo in say 2 out 6 trials and be approved although the combined results show no significant effect.
64: what, you're all about weezy or something?
no, I know, it's Flo Rida. you love that muhfucker.
also obligatory, but fun, hi tia!!!
Maybe if neB does a few more swimming posts, Ogged will even come back.
82: She hadn't been in the hospital in ages and was hospitalized several months ago for about a week after threatening to kill me. She was out for a week, attacked somebody and then in for two months, out for a week or so and missing from the program for two days and then in for 3 weeks now. Fully medicated on clozaril (most powerful super-duper antipsychotic we have, still on the market despite potentially lethal effects which require blood monitoring because nothign works quite as well) she believes that she's got babies (they used to live in the walls) and a church in Bermuda. At lower doses of meds in the hospital, she was cornering people aggressively in the hospital saying that they were trying to take her babies.
In fact, she had said before that she'd done drugs, but nobody really believed her. At her last hospitalization, they found them in her urine. She told me on Monday that she had gotten high, because she was so sad. I asked her why she hadn't come to talk to somebody and she just continued, "I wouldn't have done it if I'd known I was pregnant." (She's 59 and not pregnant.) I just said, "I know."
87: I am assuming, solely because the techniques are so well known and widely required, that the FDA corrects for multiple comparisons* and that if the combined results don't show an effect it is because they shouldn't be combined (e.g. they are different types of trials or different populations). It isn't like nobody at the FDA took a graduate stats class.
*Granted, you can always argue about which other tests should be corrected for.
The File Drawer effect, or whatever you want to call it, is a very real problem but it is less of a problem for clinical trials as you can't hand out unapproved drugs without letting somebody know.
93
Here is the relevant paragraph from the first NYRB article:
The data he used were obtained from the US Food and Drug Administration (FDA) instead of the published literature. When drug companies seek approval from the FDA to market a new drug, they must submit to the agency all clinical trials they have sponsored. The trials are usually double-blind and placebo-controlled, that is, the participating patients are randomly assigned to either drug or placebo, and neither they nor their doctors know which they have been assigned. The patients are told only that they will receive an active drug or a placebo, and they are also told of any side effects they might experience. If two trials show that the drug is more effective than a placebo, the drug is generally approved. But companies may sponsor as many trials as they like, most of which could be negative--that is, fail to show effectiveness. All they need is two positive ones. (The results of trials of the same drug can differ for many reasons, including the way the trial is designed and conducted, its size, and the types of patients studied.)
Is this wrong?
Yes, I suspect the "all they need is two positive ones" part is incomplete or false.
95: It isn't that it's wrong per se, just that it is skipping over some important details. A lot of those "negative" trials are going to be dose-finding trials: not effective at 15mg, not effective at 20 mg... Oh hey! Thirty milligrams works! Also, the FDA sees all your trials and will look suspiciously at a drug that can't reliably reproduce efficacy data under differing statistical models. It's an incestuous industry, to be sure, but the FDA is definitely not a rubber stamp organization.
If two trials show that the drug is more effective than a placebo, the drug is generally approved.
This, on the other hand, isn't true. Two successful pivotal Phase III trials are *required* for approval, but they're certainly no guarantee. The efficacy benefits are weighed against the potential safety risks and, increasingly, you need to show some additional benefit over existing therapies (e.g., works better in certain sub-populations, fewer interactions with other commonly taken drugs, etc).
I always find it deeply unsettling when it turns out that Apo knows things and has a real job. I prefer to think of him sitting in a Chevy van, carpeted from floor to ceiling in purple shag, subwoofer kicking some Bootsy. In this mental image he's usually pirating a WiFi signal from a coffee shop up the street so he can download niche porn. Expert on the ins and outs of drug trials and FDA protocols? Don't crush my dreams, man!
Isn't it actually better that he's sitting in a cubicle, carpeted from floor to ceiling in a purple shag, subwoofer kicking some Bootsy, and downloading niche porn (I feel innocent now -- I had no idea there were people who found niches arousing) while he works on drug trials and FDA protocols? Kind of hard on the guy in the next cubicle, but I'm sure he's used to it by now.
I prefer to think of him sitting in a Chevy van, carpeted from floor to ceiling in purple shag, subwoofer kicking some Bootsy.
That's a close enough description of my cube.
Apo kind of has a hard-on for the guy in the next cubicle?
I have an office with a door (and two dry erase boards).
And a little closet and a little wooden built-in desk.
And a comb and a brush and a bowl full of mush.
Let me guess: they give you a door in case you need privacy to discuss sensitive stuff with your students, and then tell you to keep it open at all times in the interests of propriety?
And a quiet old department chair who was whispering "Fuck you, clown."
This reminds me of "I have a trainset and a garage full of cars and a soldier with a gun. My mother says I should have more resposibility as I'm nearly 31."
Jealous of you people with offices. For a while I was supposed to move into one of the rooms on the quad of the main Old building, which would have been cool. Now I'm in an open plan office with quasi-cubicles, and to make matters worse I share my cubicle with other people.
Bloody luxury! I'm in an open plan office next to the tea point and across the corridor from a call centre. It'd be quieter in an airport.
Don't crush my dreams, man!
If it helps, you could just focus on my weekend gig.
What I wouldn't give for an open plan office. We have to use each other as human chairs in the parking lot.
I agitated for two years until I got a (shared) office with a window. Seeing the sun instead of fluorescents during the day is like if there were things that were not pills that could make you less depressed.
I was recently promoted and as a result moved further away from the window WTF.
Seeing the sun instead of fluorescents during the day is like if there were things that were not pills that could make you less depressed.
In grad school I was in an interior office and it is totally crazy-making.
I used to have cubicle with a window and now I have an office with no window. It's still an improvement.
I do find it cheering to lie in the tropical sun. I always have. I am wicked tan. and wafer, apo's always in that van, in his mind.
re: 113/114
I am next to the window, but I always have the blinds closed because otherwise I get blinded by the sun in the afternoon. The other side of the building faces across open fields and the Thames. Bastards.
On the other hand, I do get to go out at lunchtime and wander along the river and through the little nature reserve near the office [hence all the photos of trees on my Flickr].
I really hate being in the sun except on cool days or maybe once or twice in the spring.
I have a window where I can see a tiny little patch of the East River, and a geranium which I haven't killed for three years now. And a door I can close. I am rich in officy luxury.
Unfortunately, my character flaws have rendered it a whirling maelstrom of hellishly unfiled paper.
I used to have a small ivy plant that I kept going for two years despite the fact that my cube was well away from the window and that I used its pot as a spittoon.
I just tried to kill it -- it was getting straggly so I hacked it back to ground level. But it's bouncing back admirably.
I have some Round Up in my garage I can mail you. (I needed to kill poison oak.)
I like all sorts of things associated with being in the sun, but hate the actual sun itself. Which is irritating.
128, 129: We're all at least part Irish, no?
My private office has 1 wall that is all windows overlooking downtown New Orleans and the Mississippi from the 26th floor of my building. This is entirely a fluke - my position is not very high up the food chain but it is grant-funded and doesn't really fit in with any other departments/research centers, so they stuck me in the first free space - and I am pretty sure that never again in my life, no matter my future eminence, will I have this spectacular an office.
Last year at the local Stewart/Colbert mirror rally, I got sunburned. The rally, you'll recall, was held at the end of October. So no, I don't much like time in the sun.
Sunlight is essential for my mood. Although I don't like to get tan. I wear dorky big sun hats.
I don't mind being outside in nice weather if I'm doing stuff, where stuff might encompass 'sitting in a nice beer garden with pints of something cold', but I'd never seek out the sun just for the sake of sitting in it. People who sunbathe are freaks. However, since my wife likes the sun, I expect I'll end up somewhere around the Med in a few weeks, trying to avoid being burnt.
hey, I'm not a fucking...oh, yeah, ok. but the sun is great, people, it lies on you like a golden blanket of lead, forcing you down against the earth, filling you up with light. let's go crabbing!!! let's go for a sail!!! that said, I tan easily, and have only been sunburned a few times, and when it happens I'm a giant baby about it. it huuurts! when I see those burnt danes that look like nothing so much as a hot dog split from boiling too long pulling themselves up for another day on the sun-loungers in phuket I get queasy. if I were burned like that you couldn't pay me to get back in the fucking sun, drunk or not. I would be in a tub of ice cubes, crying like a colicky two-month-old.
I'm moderately prone to burning, although not particularly so given that I'm from the frozen north. My skin isn't that pale.* I will tan OK if I don't go daft with exposure to the sun. But yeah. My mother, sister and brother all tan easily and don't burn much, and I think that does inform one's attitude to the sun.
* cue a chorus of UKfoggeders: 'you're a borderline-ginger pale bastard'.
Yeah, being badly sunburned sucks a lot. I forgot to wear sunscreen one day in Samoa when I was running a track meet (I was thinking of it as a school day, and it just didn't click that I'd be standing outdoors all day) and got burned so badly that all the skin on my face peeled off, to the point that it was scabby and bleeding off and on for a week.
My students (a) mocked me and (b) wouldn't believe that what was wrong with my face was the result of too much sun.
I once sunburned my feet so badly that the skin peeled off the whole top of the foot at once. The burn lessened as you got to the bottom of the foot so it stayed attached at the edges and formed a little pocket that filled with water while I was standing the shower.
You guys wouldn't believe the attention and thought I give to my tan. You have to ease into it in the spring, not over-expose too soon. My mid-summer, though, I can swim for an hour at noon, and come away a shade darker with no burn. These past few years have been good. No undesired tan lines; no farmer's tan; no flip-flop lines. Nice golden undertones; body hair all sun-bleached. This doesn't happen by accident, folks.
Notes:
1. The tan will last through Feb or March, but that undertone will be gone by October. It isn't the same after that.
2. Sunscreen is the devil. I never let it near me. (I am allergic to something in it, break out in swaths where I apply it. But I wouldn't use it anyway.)
3. I'm Irish on one side and Russian-Jew on the other. It isn't clear where we get the olive skin tones from.
As long as we all agree that anyone who would pay to sit inside a tanning booth is insane.
139: Feh. I would say something catty, but mostly I'm just bitterly envious. I would love to be able to get a tan, just once. (I've got enough muddled tiny freckles on my arms and shoulders than on average I'm less white than I used to be, but that's not a tan.)
After the grocery store, the liquor store, and the gas station (i.e. the necessities), the tanning salon seems to be the busiest shop in the little business district near my house.
I have freckles, but I can tan. Not quickly or darkly.
You have to ease into it in the spring, not over-expose too soon.
I've actually been amazed at how well I've--"tanned" maybe isn't really the right word... "turned less ghostly-pale"?--the few times I've done this. But unfortunately I rarely do, so I always wind up mid-summer in a position of needing to stay out of the sun (or the equivalent, slather myself with sunscreen) or I'll burn to a crisp. But regular, low-dose, nearly-full-body exposure really works wonders.
I hate all of you. I seem to build up sun resistance -- by the middle of the summer I don't need to be as careful about sunscreen as at the beginning (e.g., I don't wear sunscreen biking back and forth to work. That's an hour outdoors in shorts, but because it's early/late I don't seem to get too much sun from it.) but I never turn an attractive color. My options are white with spots, or bright pink.
But regular, low-dose, nearly-full-body exposure really works wonders.
Yes. It feels so good that it is hard to be moderate at the beginning. But one has to remember the longterm goal and pace oneself.
anyone who would pay to sit inside a tanning booth is insane
Seriously. Just go to Gina's house! All you need is a bottle of wine. Or alcohol.
I tanned mightily in my years as a lifeguard. But it left me hating the sun, swimming pools and fun. The skin cancer in my 60s will be the icing on the cake.
My options are white with spots, or bright pink.
This describes me exactly. In the last few years I have got fed up of it and about once a fortnight I will use a fairly light dose of fake tan.
Occasionally I wonder about buying myself a fake tan, but the potential for looking ridiculous seems too great.
150: Thundersnow tends to go a few times before weddings or some other event where she's wearing a dress. My initial reaction a sort of knee-jerk "Wait, what? Pay for sunlight?!" But her work leaves her with a farmer's tan and the fake bake evens that efffect out a bit and leaves her feeling comfortable. So, I dunno. It's not really something I'm inclined to feel too judgmental about, unless she starts showing up all Boehner-orange or something.
but the potential for looking ridiculous seems too great.
So not only did this lady have her ass stuck in her kitchen sink, but you could see that she had a fake tan.
145: I try to remember to put it on all the time. I use a spray so that I actually reapply.
I got horrifically sunburned once during spring break at school -- to the point that my face puffed up like a purple balloon and I showed up on campus with a crusty, burn scarred face that looked like one of the monstrous creatures from V. I literally watched people turn away with a look of nausea as I walked down the street. Good times.
113: My place is loud, and I have a hard time concentrating. I get most paperwork done out of the office. It is considered acceptable to listen to music at work to do paperwork as long as we aren't using up bandwidth streaming.
116: If we alll get there before one person, we can turn on all the lamps and keep the fluorescents off. There are no windows in anyone's offices. We are below ground.
my face puffed up like a purple balloon and I showed up on campus with a crusty, burn scarred face that looked like one of the monstrous creatures from V
Oh my god. I can't imagine a sunburn this bad. I've peeled on my shoulders a couple times, growing up in Florida, but I haven't been sunburnt as an adult.
Sounds like the one I talked about in 137. People who tan easily just don't know what it's like. (Thank heavens, tan-capability seems to be a dominant gene. While my kids are on the pale side of the spectrum generally, they bronze up nicely after a certain amount of sunscreened time at the beach, and don't burn easily at all.)
Occasionally I wonder about buying myself a fake tan, but the potential for looking ridiculous seems too great.
I hardly ever get a commercial one done because it still only lasts maybe 4-5 days tops, whereas DIY is cheap. But this is easier for a single person IMO as the last of about 4 crucial steps is to let it dry for maybe an hour or so while standing/sitting around in the nip. I don't think anyone with kids would have the necessary block of time.