Qualms about balms: perspectives on antidepressants.
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Antidepressive Agents↗
Biomedical subjects
R P Greenberg
Publications and source records attributed to R P Greenberg.
Raising questions about antidepressants.
Antidepressant medication has apparently become the most popular treatment for depression in the USA. Several beliefs about the efficacy of antidepressant medications prevail among mental health professionals and the public. This paper explores relevant research data and raises questions about these beliefs. Many of the common beliefs about these medications are not adequately supported by scientific data. The following issues are raised: (1) industry-funded research studies which result in negative findings sometimes do not get published; (2) placebo washout procedures may bias results in some studies; (3) there are serious questions about the integrity of the double-blind procedure; (4) the 'true' antidepressant drug effect in adults appears to be relatively small; (5) there is minimal evidence of antidepressant efficacy in children; (6) side effects are fairly common even with the newer antidepressants; (7) combining medications raises the risk for more serious complications; (8) all antidepressants can cause withdrawal symptoms; (9) genetic influences on unipolar depression appear to be weaker than environmental influences; (10) biochemical theories of depression are as yet unproven; (11) biological markers specific for depression have been elusive; (12) dosage and plasma levels of antidepressants have been minimally related to treatment outcome; (13) preliminary evidence suggests that patients who improve with cognitive-behavioral psychotherapy show similar biological changes as those who respond to medication, and (14) the evidence suggests that psychological interventions are at least as effective as pharmacotherapy in treating depression, even if severe, especially when patient-rated measures are used and long-term follow-up is considered.
Adult↗
Antidepressant quandaries.
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Antidepressive Agents↗
Placebo washout is not a meaningful part of antidepressant drug trials.
Most trials testing the effectiveness of psychotropic drugs begin with a placebo washout phase. Hypothetically this technique rids studies of placebo responders before randomization of subjects to drug and placebo groups. In theory, this lowers the level of response to placebo in the study and magnifies the superiority of the response to medication. An analysis of 10 years of research literature demonstrates that the washout technique does not do what it was designed to do in antidepressant studies. Within placebo or drug groups neither measures of depression nor dropouts were affected by including a preliminary washout in the design. The findings are consistent with the two other studies that have addressed this issue.
Antidepressive Agents↗
Suspended judgment. Seeing through the double-masked design: a commentary.
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Antidepressive Agents↗
A meta-analysis of fluoxetine outcome in the treatment of depression.
A meta-analysis was conducted on all the double-blind, placebo-controlled efficacy trials of the antidepressant fluoxetine (Prozac). This drug has become the antidepressant most frequently prescribed by psychiatrists and has been hailed by the media as a "wonder drug." Results produced a relatively modest overall effect size that was no greater than effect sizes obtained by previous meta-analyses of tricyclic antidepressants. This study also examined the possibility that bias may have contaminated study outcome ratings. Because past studies suggest that the greater frequency of side effects in active drug groups unblinds study participants, we examined the relationship between study effect sizes and the percentage of patients reporting side effects. As predicted, both clinician and patient outcome ratings correlated significantly with the percentage of patients experiencing side effects. Questions are raised about the role of side effects in mediating drug outcome results.
Adult↗
Four decades of mental health trends: an empirical analysis of Hospital and Community Psychiatry.
OBJECTIVE: The authors examined important trends and developments within the mental health field since the 1960s as reflected in articles published in Hospital and Community Psychiatry. METHODS: A total of 798 articles were reviewed, representing all contributions to the journal in 1962, 1967, 1972, 1977, 1982, 1987, and 1992. Articles were classified into one of six categories, and empirical research articles were further classified by primary topic. In addition, all articles were indexed by primary setting (hospital, community, or both); academic credentials and gender of first author, and economic or public policy focus. RESULTS: The number and percentage of empirical research articles increased over time, while articles describing programs and professional roles declined. Some changes were observed in the primary topics of empirical research. Other findings reflect a shift in the setting of articles from hospitals to the community and a growth in the percentage of women who were first authors and of authors with a Ph.D. degree. CONCLUSIONS: The documented growth of empirical research in psychiatry suggests a greater emphasis on methodological rigor in the design and implementation of mental health services. Moreover, increases noted in scholarly contributions by women and nonmedical professionals indicate a broadening of disciplinary perspective over time that is likely to strengthen psychiatric research and services.
Community Psychiatry↗
How sound is the double-blind design for evaluating psychotropic drugs?
Sufficient data have accumulated to raise serious doubts about the integrity of the double-blind design that is presumed to shield psychotropic drug trials from bias and expectations. A major deficit in most drug trials has been the use of inert rather than active placebos. The deficiencies of the double-blind paradigm call for a questioning stance with respect to previous studies of psychotropic drug efficacy. Various possible ways of strengthening the double-blind paradigm are reviewed.
Clinical Trials as Topic↗
A meta-analysis of antidepressant outcome under "blinder" conditions.
A meta-analysis of 22 studies of antidepressant outcome assessed the level of medication effects under conditions thought to be less subject to clinician bias than those in the typical double-blind drug trial. Studies were included only if, in addition to a newer antidepressant group, they also contained both standard antidepressant and placebo control groups. Effect sizes were quite modest and approximately one half to one quarter the size of those previously reported under more transparent conditions. Effect sizes that were based on clinician outcome ratings were significantly larger than those that were based on patient ratings. Patient ratings revealed no advantage for antidepressants beyond the placebo effect. Effect sizes were unrelated to sample sex ratios, patient age, inpatient or outpatient status, dosage level, and treatment duration. Findings highlight the fragility of the antidepressant effect.
Antidepressive Agents↗
Comparison of three depression rating scales.
We directly compared scores on the self-rated Beck Depression Inventory with two other common rating scales that assess a wider range of psychopathology, including depression, the self-rated Symptom Check List-90--R (SCL-90--R), and the clinician-rated Brief Psychiatric Rating Scale for 71 inpatients who suffered from depression (n = 50) and other disorders. All measures of depression showed robust correlations among themselves. The self-rated scales correlated better between themselves than with the clinician-rated scale. Since the SCL-90--R assesses depression as well as the Beck inventories, is also a self-report instrument, yet provides a richer description of psychopathology with little extra effort, it may have some advantage over the latter.
Adult↗
Dependency and eating disorders in female psychiatric inpatients.
Research indicates that oral dependent and eating-disordered individuals have similar personality traits, attitudes, and behaviors, suggesting that dependency may be a factor in the dynamics of anorexia and bulimia. To investigate this issue, we compared the proportions of dependent and food-related percepts in the Rorschach protocols of matched samples of eating-disordered (N = 16), obese (N = 18), and non-eating-disordered, normal-weight female psychiatric inpatients (N = 17). Eating-disordered patients reported significantly more dependent Rorschach imagery than did obese or normal-weight control patients, but no difference in the proportion of food-related imagery was found among the three groups. These results support the hypothesis that unresolved dependency issues underlie anorexia and bulimia.
Adolescent↗
Defense mechanism correlates of orality.
Although there has been a great deal of research assessing behavioral correlates of oral dependency, the defensive style of the oral dependent person remains unexplored. This paper describes two studies investigating the orality--defense mechanism relationship. In the first study, 154 undergraduate subjects (74 males and 80 females) completed the Defense Mechanisms Inventory (DMI; Gleser and Ihilevich, 1969), and were administered the Group Rorschach test which was scored for oral dependent content in the standard manner (Masling, 1986). In the second study, 64 undergraduate subjects (30 males and 34 females) completed the DMI and the Lazare-Klerman Trait Scale (Lazare, Klerman & Armor, 1966, 1970). Results of both studies indicated that orality is positively related to the use of turning-against-self (TAS) defenses, and negatively related to the use of turning-against-object (TAO) defenses in male subjects. In both studies, orality scores were negatively related to scores on a DMI-derived index of outward-directed aggression (AGG) in males. In Study 2, neither obsessiveness nor hysteria scores were related to TAS, TAO or AGG scores in subjects of either sex. Findings are discussed in the context of previous research on oral dependence.
Aggression↗
Psychosocial variables and hypertension: a new look at an old controversy.
This paper reviews the recent evidence (1979 to 1986) from investigations of whether there is a link between psychosocial variables and elevations in blood pressure. Forty-eight empirical studies are summarized, discussed, and contrasted with reviews and methodological criticisms of past investigations. Strong support is found for an association between hypertension and such psychosocial factors as the identification and expression of anger, the use of inhibiting defense mechanisms (i.e., denial and repression), and interpersonal anxiety. Even when criticisms of the older literature are taken into account, the current finding show surprising continuity with past theoretical statements about the hypertensive personality.
Adaptation, Psychological↗
The construct validity of the MMPI alexithymia scale with psychiatric inpatients.
Relatively few studies have addressed the issue of the Minnesota Multiphasic Personality Inventory (MMPI) alexithymia scale's construct validity. In this study, the validity of the scale is supported by the finding of a significantly lower percentage of alexithymic individuals in a large sample of psychiatric inpatients than in samples of patients with a variety of physical disorders (i.e., migraine headaches, asthma bronchitis/emphysema, and hypertension). Validity of the scale is further supported through a comparison of the alexithymic and nonalexithymic psychiatric inpatients on a series of Rorschach and MMPI variables. As predicted, alexithymics were less verbally productive, displayed less ability to fantasize, and demonstrated greater defensive pseudonormality. Results suggest the measure may be of value in studies of psychiatric patients as well as those with physical disorders.
Adolescent↗
Menstrual symptoms and up-down vectors.
Multiple studies considered the somatic symptom correlates of up-down asymmetries in women. In four samples, involving a total of 81 women, menstrual symptoms were significantly linked with the up-down distortion of the space surrounding self. In addition, there were borderline relationships between menstrual symptoms and other indices of up-down asymmetry. The findings suggested a possible link between menstrual symptoms and concerns about possessing versus not possessing power. Over-all, the results support previous studies indicating that spatial sets reflect important attitudes or conflicts that seem to play a role in somatic symptomatology. However, they point up the importance of considering sex differences.
Adolescent↗
The effect of the calcium antagonist nimodipine upon local cerebral glucose utilization in the rat brain.
The new calcium antagonist Nimodipine has been shown to have more powerful dilator action on cerebral than peripheral vessels. The effect of the drug on cerebral metabolism was studied in conscious rats using the /14C/-2-deoxyglucose quantitative autoradiographic technique. Intravenous injection of Nimodipine, 2 mcg/Kg, determined significant increases in local cerebral glucose utilization that appeared to be homogeneous in magnitude and anatomic distribution throughout the brain. This study raises the question whether Nimodipine affects brain functions by other mechanisms than an increase in cerebral blood flow.
Animals↗
Body perception and somatic discomfort in relation to right- versus left-handedness.
Multiple studies analyzed differences in body perception and body complaints between right- and left-handed subjects. Both male and female samples were included. The findings indicated that the left-handed exceeded the right-handed in feelings of body security and degree of body boundary differentiation. In addition, handedness was shown to be linked with different modes of distributing attention to the major sectors of one's body. An adequate explanation of the link between handedness and body perception is not at present available.
Adolescent↗
Evoked potentials in severe head injury.
Provided herein is a summary of findings by the authors and other investigators regarding the application of evoked potential studies to the assessment of neurologic function in severely head-injured patients in the acute and subacute stages postinjury. Multimodality Evoked Potentials (MEP's) are reportedly useful in three primary areas: 1) diagnosis; 2) prognosis; and 3) monitoring recovery. In diagnosis, the abnormalities in MEP's can be associated specifically with focal sensory/motor deficits such as hemiparesis and, generally, with the severity and extent of brain dysfunction. MEP abnormalities that are severe reflect irreversible damage while the mild abnormalities point to transient, reversible CNS dysfunction. Definition of the severity and extent of brain dysfunction by MEP's allows an accurate prediction of outcome, or the potential for recovery. Their accuracy is superior to many commonly used indices and MEP results add strength to clinical indicators of prognosis. Changes in MEP results obtained within a patient over time can be used to trace recovery and assess, for an individual, the functional consequences of secondary neurologic insult or medical complication. The authors conclude that MEP studies may serve a useful function as noninvasive indices of neurologic function in the management of severely head-injured patients.
Adult↗