Friday, February 18, 2005

So what do we know about depression anyway?

Drugs Raise Risk of Suicide (

A meta-analysis is reported to claim that the SSRIs increase suicide risk. This WaPo article didn't mention the effect size, but suicide is, in technical terms, a "hard end point". It can be measured fairly clearly. If the suicide-outcomes are unclear then that's important. The study suggests the SSRIs are not dramatically lowering suicide risks compared to placebo. I doubt this study really answers questions; but it may tell us we know even less than we thought we did.

This doesn't mean, but the way, that non-SSRI anti-depressants are safer. Maybe they increase suicide rates too compared to placebo. I remember 20 years ago that my teachers warned of "activation" during early treatment being associated with suicide. (As soon as the depressed patient gets more energy, they get around to actually getting something done -- but that something is suicide.)

At the end of the day the main lesson is that we (meaning the quite corrupt government that we electand reelect) let the pharmas get away with selective publication of efficacy and safety data. As a result we lack important answers. That has to change.

Another lesson concerns all the beatings primary care physicians get about "undertreating depression". I've long been skeptical of those studies because:

1. Even when primary care docs treat depression payor rules and patient preferences often mean euphemistic ICD-9 codes are used.
2. I've not felt comfortable about the data we had on the disorder. I don't feel we understand the disorder(s) or the therapies very well -- especially outside of referral clinics treating depression with psychotic features.

This doesn't mean I or my primary care colleagues did a great job with depression. Instead I'd say more humility is needed from every quarter.

By the way, we also need to do something about corruption in government.

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