site banner
PaperclipPerfector  11mo ago (text post)   2819 thread views

Wellness Wednesday for November 22, 2023

The Wednesday Wellness threads are meant to encourage users to ask for and provide advice and motivation to improve their lives. It isn't intended as a 'containment thread' and any content which could go here could instead be posted in its own thread. You could post:

  • Requests for advice and / or encouragement. On basically any topic and for any scale of problem.

  • Updates to let us know how you are doing. This provides valuable feedback on past advice / encouragement and will hopefully make people feel a little more motivated to follow through. If you want to be reminded to post your update, see the post titled 'update reminders', below.

  • Advice. This can be in response to a request for advice or just something that you think could be generally useful for many people here.

  • Encouragement. Probably best directed at specific users, but if you feel like just encouraging people in general I don't think anyone is going to object. I don't think I really need to say this, but just to be clear; encouragement should have a generally positive tone and not shame people (if people feel that shame might be an effective tool for motivating people, please discuss this so we can form a group consensus on how to use it rather than just trying it).

4
Top Bottom Old Controversial Comments
Jump in the discussion.

No email address required.

SSRIs have pretty weak effect sizes, but that's not the same as them being entirely useless after all.

Thankfully, Scott has a deep dive on the subject, sparing me the trouble:

https://slatestarcodex.com/2018/11/07/ssris-an-update/

All this leads to the third thing I’ve been thinking about. Given that the effect size really is about 0.3, how do we square the scientific evidence (that SSRIs “work” but do so little that no normal person could possibly detect them) with the clinical evidence (that psychiatrists and patients often find SSRIs sometimes save lives and often make depression substantially better?)

The traditional way to do this is to say that psychiatrists and patients are wrong. Given all the possible biases involved, they misattribute placebo effects to the drugs, or credit some cases that would have remitted anyway to the beneficial effect of SSRIs, or disproportionately remember the times the drugs work over the times they don’t. While “people are biased” is always an option, this doesn’t fit the magnitude of the clinical evidence that I (and most other psychiatrists) observe. There are patients who will regularly get better on an antidepressant, get worse when they stop it, get better when they go back on it, get worse when they stop it again, et cetera. This raises some questions of its own, like why patients keep stopping antidepressants that they clearly need in order to function, but makes bias less likely. Overall the clinical evidence that these drugs work is so strong that I will grasp at pretty much any straw in order to save my sanity and confirm that this is actually a real effect.

Every clinician knows that different people respond to antidepressants differently or not at all. Some patients will have an obvious and dramatic response to the first antidepressant they try. Other patients will have no response to the first antidepressant, but after trying five different things you’ll find one that works really well. Still other patients will apparently never respond to anything.

Overall only about 30% – 50% of the time when I start a patient on a particular antidepressant, do we end up deciding this is definitely the right medication for them and they should definitely stay on it. This fits national and global statistics. According to a Korean study, the median amount of time a patient stays on their antidepressant prescription is three months. A Japanese study finds only 44% of patients continued their antidepressants the recommended six months; an American study finds 31%.

Suppose that one-third of patients have some gene that makes them respond to Prozac with an effect size of 1.0 (very large and impressive), and nobody else responds. In a randomized controlled trial of Prozac, the average effect size will show up as 0.33 (one-third of patients get effect size of 1, two-thirds get effect size of 0). This matches the studies. In the clinic, one-third of patients will be obvious Prozac responders, and their psychiatrist will keep them on Prozac and be very impressed with it as an antidepressant and sing the praises of SSRIs. Two-thirds of patients will get no benefit, and their doctors will write them off as non-responders and try something else. Maybe the something else will work, and then the doctors will sing the praises of that SSRI, or maybe they’ll just say it’s “treatment-resistant depression” and so doesn’t count.

In other words, doctors’ observation “SSRIs work very well” is an existence statement “there are some patients for whom SSRIs work very well” – and not a universal observation “SSRIs will always work well for all patients”. Nobody has ever claimed the latter so it’s not surprising that it doesn’t match the studies.

This is 2018, pretty sure the "SSRIs are a placebo" thing came out after that.

I strongly disagree, I'm quite confident it was a relatively mainstream argument well before 2018, Scott wrote a post in 2014 to which this serves as an update, and that was partially motivated by the claims that SSRIs were useless/placebos.

Edit: The placebo theory is clearly mentioned in the text excerpt I posted as well as in his original blog post.

I mean that there was some big meta-analysis released a lot more recently than Scott wrote his article, which got a lot of press coverage. I think it was this one but I'm not 100% sure.

What is this place?

This website is a place for people who want to move past shady thinking and test their ideas in a court of people who don't all share the same biases. Our goal is to optimize for light, not heat; this is a group effort, and all commentators are asked to do their part.

The weekly Culture War threads host the most controversial topics and are the most visible aspect of The Motte. However, many other topics are appropriate here. We encourage people to post anything related to science, politics, or philosophy; if in doubt, post!

Check out The Vault for an archive of old quality posts. You are encouraged to crosspost these elsewhere.


Why are you called The Motte?

A motte is a stone keep on a raised earthwork common in early medieval fortifications. More pertinently, it's an element in a rhetorical move called a "Motte-and-Bailey", originally identified by philosopher Nicholas Shackel. It describes the tendency in discourse for people to move from a controversial but high value claim to a defensible but less exciting one upon any resistance to the former. He likens this to the medieval fortification, where a desirable land (the bailey) is abandoned when in danger for the more easily defended motte. In Shackel's words, "The Motte represents the defensible but undesired propositions to which one retreats when hard pressed."

On The Motte, always attempt to remain inside your defensible territory, even if you are not being pressed.


New post guidelines

If you're posting something that isn't related to the culture war, we encourage you to post a thread for it. A submission statement is highly appreciated, but isn't necessary for text posts or links to largely-text posts such as blogs or news articles; if we're unsure of the value of your post, we might remove it until you add a submission statement. A submission statement is required for non-text sources (videos, podcasts, images).

Culture war posts go in the culture war thread; all links must either include a submission statement or significant commentary. Bare links without those will be removed.

If in doubt, please post it!


Rules


Recommended Posts And Communities

Recommended Realtime Chats