{"id":17018,"date":"2011-12-08T17:17:45","date_gmt":"2011-12-08T22:17:45","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=17018"},"modified":"2011-12-08T17:33:22","modified_gmt":"2011-12-08T22:33:22","slug":"koan-ing","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/12\/08\/koan-ing\/","title":{"rendered":"k\u00c5\u008dan-ing&#8230;"},"content":{"rendered":"<br \/>\n<blockquote>\n<div align=\"center\"><a href=\"http:\/\/www.psychiatrictimes.com\/blog\/couchincrisis\/content\/article\/10168\/1968125\" target=\"_blank\"><u><strong><font color=\"#200020\">Antidepressants and the Sound of One Hand Clapping<\/font><\/strong><\/u><\/a><br \/>      <strong><font color=\"#200020\">Psychiatric Times<\/font><\/strong><br \/>           By Ronald W. Pies, MD<br \/>October 10, 2011<\/div>\n<p><\/p>\n<div align=\"justify\"><sup><em><strong><font color=\"#200020\">Two hands clap and there is a  sound. What is the sound of one hand?<\/font><\/strong><\/em><\/sup><\/div>\n<div align=\"right\"><sup>&mdash;Hakuin Ekaku [Rinzai Zen Master, 1686-1768]<\/sup><\/div>\n<p>     <\/p>\n<div align=\"justify\"><sup>&#8230; Nearly all  acute efficacy studies of ADs make use of  the HAM-D, which is actually subject  to a variety of confounds, such as  the training of the HAM-D raters. And,  depending on  whether one considers a mean change of 2 or 3 points on the HAM-D  to be  clinically significant, meta-analyses of acute AD efficacy studies lead   to different conclusions. Furthermore, placebo responses have been  rising in  recent years because of a variety of factors, such as  multisite studies and use  of less severely depressed patients.  It is hard to apply the results of  randomized, placebo-controlled  studies to clinical practice. Thus, in a superb  review, Prof  Hans-J&uuml;rgen M&ouml;ller  concludes:<\/sup><\/div>\n<ul>\n<div align=\"justify\"><sup><em>&ldquo;In interpreting  such mean  [HAM-D] score differences, it has to be stated that the mean  of the pre-post  differences of the placebo groups and the verum [active  medication] groups only  give a global estimation of efficacy under the  artificial conditions of  placebo-controlled trials, in which, due to  the principal characteristics of  the design, the verum response is  underestimated and the placebo response is  overvalued&#8230; One cannot  conclude very much from this for everyday clinical  practice,  especially not on the efficacy for special patient subgroups or even   for individual patients.&rdquo;<\/em><\/sup><\/div>\n<\/ul>\n<div align=\"justify\"><sup>Furthermore, as an extensive critique of  the much-discussed Kirsch  meta-analysis pointed out,<\/sup><\/div>\n<ul>\n<div align=\"justify\"><sup><em>&ldquo;Perhaps  the most overlooked aspect of  the data included in Kirsch et al. [2008] is that it is not about the effects  of antidepressants upon  depression, but rather about the effects of  antidepressants on the HAMD &#8230; [and the HAM-D] describes a construct of depression which  corresponds poorly to that found in DSM-IV&#8230;<\/em><\/sup><\/div>\n<\/ul>\n<div align=\"justify\"><sup>Having recently reviewed  the extensive antidepressant literature for a paper in press,  my own  conclusion is that ADs show, overall, modest-to-moderate  efficacy compared with  the placebo condition in acute treatment  studies &mdash; depending on the type and  severity of depression&#8230; The most  robust  AD effects in acute treatment studies seem to emerge in more severely   depressed patients &#8230; and  among those  with melancholic features. However, a recent re-analysis of the Kirsch  data by Ghaemi and V&ouml;hringer found acute antidepressant efficacy in both moderate and severe &mdash; but  not in mild &mdash; major depression. This should not really  surprise us. All  other factors being equal, the farther we move down the  continuum from  severe melancholic major depression toward normal sadness, the  less  pronounced the difference between specific and nonspecific interventions&#8230;<\/sup><\/div>\n<div align=\"center\"><sup>&#8230;<\/sup><\/div>\n<div align=\"justify\"><sup>And so, overall, what is my verdict on antidepressants? In my estimation, our present medications for depression are only mediocre. For moderate to severe, and especially melancholic, cases of major depression, ADs are effective and sometimes lifesaving, particularly when part of a comprehensive treatment plan that includes psychotherapy. And, there is convincing evidence that ADs prevent relapse at least during the 6 months or so after a bout of major depression. For mild, non-melancholic cases of depression, I generally favor beginning with psychotherapy, given the &ldquo;costs&rdquo; of antidepressant side effects. In this regard, we urgently need to find antidepressants that are more effective and better tolerated&#8230; <strong><font color=\"#200020\">In sum: I do not hear loud applause for our current antidepressant armamentarium. I believe I hear the sound of one hand clapping&#8230;<\/font><\/strong><\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">Well done, Dr. Pies. I&#8217;ll see your K\u00c5\u008dan and raise you one:<\/div>\n<div align=\"center\">\n<ul>\n<div><strong><em><font color=\"#200020\">Don&#8217;t Mistake the Finger Pointing at the Moon for the Moon<\/font><\/em><\/strong><\/div>\n<\/ul><\/div>\n<div align=\"justify\">Which just about summarizes all of my complaints about the entire DSM-5 Task Force in general and their Cross-Cutting Dimensional Assessments in the specific&#8230;<\/div>\n<div align=\"center\"><a href=\"http:\/\/www.awakeblogger.com\/2008\/11\/the-meaning-of-the-finger-pointing-to-the-moon\/\" target=\"_blank\"><img decoding=\"async\" width=\"180\" vspace=\"7\" border=\"0\" src=\"http:\/\/www.awakeblogger.com\/wp-content\/uploads\/2008\/11\/finger-moon-hotei.jpg\" \/><\/a>&nbsp;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Antidepressants and the Sound of One Hand Clapping Psychiatric Times By Ronald W. Pies, MDOctober 10, 2011 Two hands clap and there is a sound. What is the sound of one hand? &mdash;Hakuin Ekaku [Rinzai Zen Master, 1686-1768] &#8230; Nearly all acute efficacy studies of ADs make use of the HAM-D, which is actually subject [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-17018","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17018","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=17018"}],"version-history":[{"count":20,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17018\/revisions"}],"predecessor-version":[{"id":17038,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/17018\/revisions\/17038"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=17018"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=17018"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=17018"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}