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Re: Shorter trials: believe it!

Posted by JohnL on May 3, 2000, at 5:05:30

In reply to Shorter trials: don't believe it! , posted by Peter S. on May 2, 2000, at 13:52:58

I think to assume that either long trials or short trials are appropriate is too narrow-sighted. That's because it assumes some common underlying cause of the depression. I just don't believe that. One person's chemistry may be such that a downregulation of receptors is needed, and thus a long trial is needed to accomplish that. In other people, it may have nothing at all to do with downregulation of anything, but simply a matter of raising serotonin, or calming down overly excited neurons, or stimulating sluggish ones, or whatever.

I don't think it's an either/or proposition. It's not like only one way is correct and the other isn't. It all comes down to basics...chemistry. To assume either approach is always correct and the other is always wrong assumes that we know more about psychiatry than we actually do.

I am an advocate of short trials in most cases (not all) simply because I've seen it over and over and over in real life. It is a very real phenomenon that occurs. I can't understand why more people haven't stopped to ask themselves, "Why does this phenomenon occur? Is there some way we can better grasp it and take advantage of it?" Rather than ignoring it as if it didn't exist.

But in NO case do I advocate short trials in place of long ones for longterm therapy. Instead I advocate short trials for identifying superior drug matches, and weeding out inferior ones. Once that is done, then the longer trials focus only on the superior matches. Those were the ones, or one, that showed remarkably fast results with few side effects. If everybody could sample every drug for one week each, I guarantee you everybody would discover one that fits that description. Everyone would discover they have a favorite, and that favorite is different than someone else's. Again, chemistry. Then once the weeding process has provided the needed clues to know what the heck is going on with this patient, we can then focus on getting them completely well with longer trials on the identified superior meds. I think too often patients submit to a drug for months or years that is working OK, not being aware that a much better drug was ignored. Without short trials--or as I prefer to look at it, short 'comparisons'--we would never know.

So I think there are two important points for consideration:
1. They aren't short trials, but rather comparisons. Purpose is to find a favorite for a longer trial.
2. Neither short comparisons or long trials are correct in all cases. Each patient is different. But the more time and the more drugs a patient has failed, the more crucial it becomes to do some quick 'probing'. The first-time patient with no drug experience is probably better off with standard long trial psychiatry. But after multiple failures, I feel standard psychiatry should step aside in embarrassment and let a different strategy take priority.

But the bottom line is, regardless of the many different opinions, we all know for a fact that some people do indeed respond fast to the right drug. We've seen it. We've heard of it. Search this board for a few hours going back months and you'll see the proof. And some doctor's office's see more of it than not. Why is that? Why should we not try to better understand this phenomenon? Are we intersted in getting the patient as quickly as possible or not? Are we open to discovery, or are we too set in our ways to think there isn't something else out there we don't know?
JohnL


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