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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 59 to 83 of 86. Go back in thread:
Posted by Larry Hoover on January 6, 2008, at 14:26:00
In reply to Re: STAR*D confirmed what patients already knew » linkadge, posted by Racer on January 5, 2008, at 18:27:25
> Your suggestion regarding lower doses directly contradicts what the study found: that in many cases, increased doses of tolerable medications increased response. That non-response may be a question of inadequate dosing in some (or even many) cases. As far as I'm concerned, that's something good to know.
There was an article published that addresses the "lessons learned" from STAR*D:
Translating Science Into Service: Lessons Learned From the Sequenced Treatment Alternatives to Relieve Depression (STAR*D) Study.
http://www.psychiatrist.com/pcc/pccpdf/v09n05/v09n0501.pdfI haven't read it yet, though.
Lar
Posted by Larry Hoover on January 6, 2008, at 14:29:35
In reply to Re: STAR*D confirmed what patients already knew » Larry Hoover, posted by Cecilia on January 6, 2008, at 4:41:25
> Perhaps they would be accepted into the study regardless of previous drug trials, but why on earth would anyone enter a study where they knew they would just be offered the same drugs they had already failed or couldn't tolerate-makes no sense. Cecilia
Well, I'm sure that there were many more candidates for the study than those who accepted the offer. If nothing else, the study protocol was rather exhaustive in fully testing each study medication, with dose adjustments, augmentation, etc. One can't assume that a previously failed drug trial was as thoroughly conducted.
Lar
Posted by Jamal Spelling on January 6, 2008, at 15:10:29
In reply to Re: correlation does not imply causality » Jamal Spelling, posted by Larry Hoover on January 6, 2008, at 14:20:10
> Are you suggesting that if you followed a group of untreated subjects comprised of ~50% recurrent depressives, and ~30% chronic depressives, that after 56 weeks, 67% would be in full remission?
My main point is that STAR*D does not prove that the drug/CBT regimen used remits depression with a 67% success rate, yet that is what many people are claiming. One can only say that 67% of patients who follow this regimen will remit after 56 weeks, but not necessarily as a result of the regimen.
For example, a similarly comprised untreated group might have a remission rate of 40% after 56 weeks, which would imply that the STAR*D algorithm really only works for 26% of patients. Then the abstract would have to read something like "The study demonstrates that 26% of depression patients can be brought into remission by 56 weeks as a result of following the STAR*D algorithm". And that doesn't sound as good.
Posted by seldomseen on January 6, 2008, at 16:08:03
In reply to Re: correlation does not imply causality » Larry Hoover, posted by Jamal Spelling on January 6, 2008, at 15:10:29
"For example, a similarly comprised untreated group might have a remission rate of 40% after 56 weeks, which would imply that the STAR*D algorithm really only works for 26% of patients. Then the abstract would have to read something like "The study demonstrates that 26% of depression patients can be brought into remission by 56 weeks as a result of following the STAR*D algorithm". And that doesn't sound as good."
Actually that's not how that data should be interpreted. If 40% of patients spontaneously remitted and 67% remitted on with drugs, then 67% still remitted on drugs.
The only valid conclusion is that more subjects remitted on drugs than with no treatment.
We don't know how many people the drugs actually helped, just that more remitted while on them.
I think everyone(and I'm not on one side or the other) have to be very careful how they interpret the data.
Posted by seldomseen on January 6, 2008, at 16:26:59
In reply to Re: What is so controversial here?, posted by Jamal Spelling on January 6, 2008, at 11:46:13
If a single cancer chemotherapy drug was effective in 30% of people that took it, the entire field would literally give itself the nobel prize, take the million dollars and go to Hawaii for a month.
I mean it would be BREAKTHROUGH. If a protocol acheived a 70% remission rate (imagine 70% of lung cancers brought into remission) I think the whole field would turn their work over to robots programmed to dispense that protocol and never return from Hawaii. Heck, oncologists could probably buy Hawaii.
No one would be talking about placebo effects (wouldn't care).
I know it is hard to see big picture when you are sick, but the advances in psychopharmacology over the past 50 years IMO have been amazing.
50 years ago it was thorazine and the benzos and a sprinkling of other terrible meds, now we have hundreds from which to choose. Is it perfect? Absolutely not, is it better? I think so.
Also, it is becoming readily apparent that depression, bipolar disorder etc... are very very complex illnesses. Like cancer, they are most likely mutligenic in origin and highly individual to the person. These kinds of illnesses are very difficult to treat in the landscape of medicine today. We are used to treating one illness with one drug and that's that (think anti-biotics). Where we are now, both in cancer and psychiatry, is really still in the infancy of treating and curing these disorders.
IMO there is hope. It's not there yet, but I do think it is coming. Look where we've been and where we are now.
Posted by SLS on January 6, 2008, at 16:32:59
In reply to Re: correlation does not imply causality » SLS, posted by Jamal Spelling on January 6, 2008, at 1:16:06
Hi.
Thanks for responding.
> > I thought the STAR*D claimed a success rate of 70%. Where can I find a reference stating that it was 67%? Just curious. Thanks.
>
> On page 63 of the article you have on your website, they give the following cumulative remission rates:
>
> Level 1 - 33%
> Level 2 - 57%
> Level 3 - 63%
> Level 4 - 67%Thanks.
> > Nearly 80% of the 2,876 outpatients in the analyzed sample had chronic or recurrent major depression
> Indeed, it may be true that nearly 80% had chronic *or* recurrent major depression. But when you break that down, the study shows that the bulk of this figure was recurrent depression, not chronic. In fact, the rates for chronic depression were 30% and 21% respectively for the primary care and psychiatric patients. So this does not invalidate my observation the 70% remission obtained after 56 weeks of treatment may have simply been> regression to the mean.
What is "regression"?
I am not, unfortunately, a student of statistics. I dropped out of school because my cognition and memory became so badly impaired due to a worsening of my depressive illness.
> I am not disputing the claim that the majority of depression sufferers can obtain relief when following the STAR*D algorithm. My observation is merely that the remission cannot necessarily be attributed to following that treatment algorithm.
Sure it can. Of course you would need to follow subjects longitudinally. Here, a placebo arm would help determine a baseline pattern of illness. One can then determine the average length of an untreated MDD episode, as well as the length of time between episodes. If the time to relapse is longer with treatment, one can present statistics to verify the ability of the drug to produce a higher remission rate as compared to treatment as usually or versus placebo.
- Scott
Posted by SLS on January 6, 2008, at 17:00:02
In reply to Re: correlation does not imply causality » Jamal Spelling, posted by seldomseen on January 6, 2008, at 16:08:03
> "For example, a similarly comprised untreated group might have a remission rate of 40% after 56 weeks, which would imply that the STAR*D algorithm really only works for 26% of patients. Then the abstract would have to read something like "The study demonstrates that 26% of depression patients can be brought into remission by 56 weeks as a result of following the STAR*D algorithm". And that doesn't sound as good."
>
> Actually that's not how that data should be interpreted. If 40% of patients spontaneously remitted and 67% remitted on with drugs, then 67% still remitted on drugs.
>
> The only valid conclusion is that more subjects remitted on drugs than with no treatment.
>
> We don't know how many people the drugs actually helped, just that more remitted while on them.This is where calculations of statistical power come in to play, no?
> I think everyone(and I'm not on one side or the other) have to be very careful how they interpret the data.
I may be wrong, but it seems to me that we do not have many PB members whom are well-versed in statistics. Of course, people who have an emotional investment in winning an argument such that they must defend an agenda rather than search for a truth. In my opinion, some people dissemble in order to win arguments. It becomes a well-honed skill.My point is that most of us lack the expertise to design, implement, and offer interpretations at the level of professional investigators. That's why I feel we are blessed to have members with various expertises to enhance our ability to locate, review, interpret, critique, and offer conclusions for an observed phenomena.
Thank you all.
- Scott
Posted by Jamal Spelling on January 6, 2008, at 17:04:47
In reply to Re: correlation -- justifies further investigation » Jamal Spelling, posted by SLS on January 6, 2008, at 16:32:59
> > regression to the mean.
>
> What is "regression"?
>
> I am not, unfortunately, a student of statistics. I dropped out of school because my cognition and memory became so badly impaired due to a worsening of my depressive illness.Your cognition and memory seem pretty sharp to me. I'm not sure why you keep putting yourself down like that. Anyway...
I know about as much statistics as anyone. "Regression to the mean" is a phrase I picked up on Ben Goldacre's "Bad Science" column, LOL! My understanding is that, in this context, it refers to the phenomenon in medicine whereby people get better on their own (a non-depressed state being the mean).
For example, pain is cyclical. It gets worse, and then on its own, it gets slightly better, and then slightly worse, etc. So people are most likely to treat pain when it is at its worst. But this is precisely the time when it partially remits on its own, so this remission is not necessarily as a result of the pain treatment. And that is the reason why there is such a high placebo response with pain treatment, and so many alternative pain treatments which probably do not work, but still have many satisfied customers.
Anyway, I have made my thoughts on STAR*D known. People may weigh the evidence and choose to agree or disagree with me.
Posted by seldomseen on January 6, 2008, at 17:23:07
In reply to Re: correlation does not imply causality » seldomseen, posted by SLS on January 6, 2008, at 17:00:02
Statistics plays a HUGE role in all of medical research. Reaching statistical significance is pretty much the ultimate goal of any intervention study.
The problem comes in when there is a disconnect between clinical significance and statistical significance, which can happen.
Some drugs get trashed as useless, when they are actually quite good, others get pushed forward with dangerous side effect profiles. All because statistically they didn't reach significance.
It's a numbers game folks.
That's why I say, no study can ever predict what any drug will do in an individual. It can only estimate the likelihood of something happening.
Posted by Jamal Spelling on January 6, 2008, at 17:53:43
In reply to Re: correlation -- justifies further investigation » SLS, posted by Jamal Spelling on January 6, 2008, at 17:04:47
When I said "I know about as much statistics as anyone", I meant that in the sense of "I know about as much statistics as the next person", i.e. not that much. And I never claimed to be a statistician. The figures I've mentioned here only relied on percentages and arithmetic anyway. And the difference between causality and correlation.
Why does it always have to be this way? Someone questions a 30% remission rate and suddenly you're an anti-psychiatry conspiracy theorist. And suddenly you have some agenda, and you're not really in search of truth, and you're dissembling yourself just to win an argument, etc.
Well, whatever... please can we argue the facts. I am as much in search of the truth as anyone else. I have my own 10+ year journey with depression and other issues, and the viewpoints I hold were formed out of this experience.
And even if I *were* and anti-psychiatry conspiracy theorist dissembling myself just to win an argument, then *still*, please argue the facts.
Posted by Jamal Spelling on January 6, 2008, at 18:03:07
In reply to Re: correlation -- justifies further investigation, posted by Jamal Spelling on January 6, 2008, at 17:53:43
Larry's observation that, if placebos and drugs had the same efficacy, then they should outperform one another equally often in clinical trials.
That is an interesting fact, one that got me thinking.
Posted by Dr. Bob on January 6, 2008, at 23:48:38
In reply to Re: blocked for week » linkadge, posted by Dr. Bob on January 6, 2008, at 0:31:23
> Follow-ups regarding these issues should be redirected to Psycho-Babble Administration.
Here's a link:
http://www.dr-bob.org/babble/admin/20071106/msgs/804765.html
Thanks,
Bob
Posted by Dr. Bob on January 6, 2008, at 23:52:19
In reply to Re: correlation does not imply causality » seldomseen, posted by SLS on January 6, 2008, at 17:00:02
> Of course, people who have an emotional investment in winning an argument such that they must defend an agenda rather than search for a truth. In my opinion, some people dissemble in order to win arguments.
Scott, it's great to have you back, but I'm afraid I need to remind you not to post anything that could lead others to feel accused.
If you or others have questions about this or about posting policies in general, or are interested in alternative ways of expressing yourself, please see the FAQ:
http://www.dr-bob.org/babble/faq.html#civil
http://www.dr-bob.org/babble/faq.html#enforceFollow-ups regarding these issues should be redirected to Psycho-Babble Administration. They, as well as replies to the above post, should of course themselves be civil.
Thanks,
Bob
Posted by SLS on January 7, 2008, at 6:19:53
In reply to Re: please be civil » SLS, posted by Dr. Bob on January 6, 2008, at 23:52:19
Posted by SLS on January 7, 2008, at 17:34:22
In reply to Re: for example..., posted by Jamal Spelling on January 6, 2008, at 18:03:07
> Larry's observation that, if placebos and drugs had the same efficacy, then they should outperform one another equally often in clinical trials.
>
> That is an interesting fact, one that got me thinking.Me too. It is an elegant way of affirming the results of 40 years of investigation.
Antidepressants work.
I am witnessing the miracle of magic pills. The object of my observation is me. It's about time.
- Scott
Posted by Phillipa on January 7, 2008, at 19:24:52
In reply to Re: for example... » Jamal Spelling, posted by SLS on January 7, 2008, at 17:34:22
Definitely Scott you so deserve to feel well. So Happy for you. Love Phillipa
Posted by Dr. Bob on January 8, 2008, at 1:34:56
In reply to Re: please be civil... OK (nm) » Dr. Bob, posted by SLS on January 7, 2008, at 6:19:53
Posted by Jamal Spelling on January 8, 2008, at 13:13:01
In reply to Re: for example... » Jamal Spelling, posted by SLS on January 7, 2008, at 17:34:22
> I am witnessing the miracle of magic pills. The object of my observation is me. It's about time.
That's great, Scott. You really deserve it, and I wish you continued improvement in your health.
Posted by Jamal Spelling on January 8, 2008, at 14:44:20
In reply to Re: correlation does not imply causality » Jamal Spelling, posted by seldomseen on January 6, 2008, at 16:08:03
> We don't know how many people the drugs actually helped, just that more remitted while on them.
Although sometimes, it may even be the other way around. For example, in the SJW trial that was published in JAMA in 2002, the remission rates at 8 weeks were 31.9% for placebo and 24.8% for sertraline.
I have the article in front of me right now. LOL, I still giggle when reading it. The way they conclude that the study does not support the efficacy of SJW, but they say nothing about Zoloft, even though SJW and Zoloft both failed to outperform placebo.
The full, original article can be accessed at
Posted by SLS on January 8, 2008, at 16:00:40
In reply to Re: placebo response, posted by Jamal Spelling on January 8, 2008, at 14:44:20
> > We don't know how many people the drugs actually helped, just that more remitted while on them.
>
> Although sometimes, it may even be the other way around. For example, in the SJW trial that was published in JAMA in 2002, the remission rates at 8 weeks were 31.9% for placebo and 24.8% for sertraline.
>
> I have the article in front of me right now. LOL, I still giggle when reading it. The way they conclude that the study does not support the efficacy of SJW, but they say nothing about Zoloft, even though SJW and Zoloft both failed to outperform placebo.
>
> The full, original article can be accessed at
>
> http://jama.ama-assn.org/cgi/reprint/287/14/1807
Interesting...Technically, this is a "failed study". Since it has already been well established that sertraline is more effective than placebo, this comparator acts as a fail-safe to judge the validity of the trial.
- Scott
Posted by trx resistant on January 12, 2008, at 16:55:03
In reply to Re: STAR*D confirmed what patients already knew » linkadge, posted by Larry Hoover on January 5, 2008, at 13:31:01
Sorry to bother this thread but I must get a hold of Larry Hoover and Astounder or any of you who know about the contraindications of local anesthetics and EMSAM. I need some surgergy and need to find out before Monday.
Thanks
Posted by trx resistant on January 12, 2008, at 17:10:44
In reply to Re: STAR*D confirmed what patients already knew » linkadge, posted by Cecilia on January 5, 2008, at 5:51:40
Cecila,
I'm sorry you feel that those of us who failed with other drugs are having "miracle" responses to MAIO becasue it's more likely we're so desperate we have placebo response to anything. In my case, I had the all SSRI, Lamictal etc types drugs and combos for 9 years but EMSAM (in 2-3 months) is my miracle and thank God for it. My brain was never given MAIO b inhihibitor for atypical depression. So why would you discount my experience with this drug as probably just placebo effect?
Posted by trx resistant on January 12, 2008, at 17:16:17
In reply to Re: STAR*D confirmed what patients already knew, posted by SLS on January 5, 2008, at 6:27:57
You sure stated that eloquently!
Posted by trx resistant on January 12, 2008, at 19:19:22
In reply to Re: STAR*D confirmed what patients already knew, posted by trx resistant on January 12, 2008, at 17:16:17
> You sure stated that eloquently!
Oops! I meant to direct that to Scott specifically and many others, not myself!
Posted by Phoenix1 on January 12, 2008, at 22:27:57
In reply to Re: STAR*D confirmed what patients already knew, posted by trx resistant on January 12, 2008, at 17:10:44
> Cecila,
> I'm sorry you feel that those of us who failed with other drugs are having "miracle" responses to MAIO becasue it's more likely we're so desperate we have placebo response to anything. In my case, I had the all SSRI, Lamictal etc types drugs and combos for 9 years but EMSAM (in 2-3 months) is my miracle and thank God for it. My brain was never given MAIO b inhihibitor for atypical depression. So why would you discount my experience with this drug as probably just placebo effect?I can't find the post your commenting on.
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