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The Good Psychiatry Does: A Brief Review: Page 2 of 4

The Good Psychiatry Does: A Brief Review: Page 2 of 4

Second, the Kirsch study looked only at antidepressant trials in the FDA database done before 1999—an analysis of more recent trials might have produced different results. More subtle questions are raised by this study, relating to placebo responders. For example, placebo response rates have actually been rising in recent years, perhaps in part because of recruitment of less severely ill subjects for study. The less ill the subjects, the more likely a “sugar pill” is going to work for them.6 The unimpressive results of the Kirsch findings may, to some degree, reflect this confounding factor. Since the Kirsch study, another meta-analysis by Fournier et al7 has reached similar conclusions. My editorial in the April 2010 issue of the Journal of Clinical Psychopharmacology offers a detailed analysis.

Indeed, clinicians who have treated many severely depressed patients know that with sufficient time and effort, the majority can experience remission—if not necessarily full recovery. This was certainly my experience when I was seeing so-called treatment-refractory depressed patients (many of whom proved to have undiagnosed bipolar spectrum disorder8). Eventual success with antidepressants, even in refractory cases, is supported by a recent series of carefully controlled, multistage studies known as STAR*D, sponsored by the NIMH. STAR*D looked at remission rates in patients with treatment-resistant major depression. These patients had gone through several levels of intensive antidepressant treatment, without full recovery. By the time the subjects had jumped through the fourth and final “hoop,” the cumulative rate of remission (few or no depressive symptoms) was about 67%.9

The nature of the STAR*D study precluded use of a placebo group. However, the cumulative remission rate of 67% is certainly much higher than generally reported rates of remission with placebo, which average around 30%. I would venture to suggest that if a cancer chemotherapy regimen produced remission in 67% of patients with previously refractory disease, it would be hailed as a therapeutic breakthrough!

The bottom line: if you stick to it long enough, and make the right pharmacological “moves,” antidepressant treatment works.

Lithium

Another underappreciated—and underutilized—treatment in psychiatry is lithium. This agent is not heavily promoted by “Big Pharma,” and it costs only a few pennies per tablet. As my colleague, Seyyed Nassir Ghaemi, MD, has observed:

Lithium has been shown to be effective in over 20 randomized clinical trials of prophylaxis, most of which are 1 year or longer, some of which last up to 3 years. Although some of these studies are small and use research designs that are not optimal . . . the replicability and consistency of these results greatly strengthens proof of lithium’s efficacy. . . . There is also increasing evidence that lithium prevents suicide, reduces lifetime mortality, and lengthens life span in bipolar disorder. . . . Lithium has also been shown to improve neuronal viability in animals and enhance in vitro the effect of neuroprotective factors, and this effect in humans also appears to prevent or reduce long-term hippocampal atrophy and cognitive decline in bipolar disorder.10

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