Mental Health Blogs

I was bothered by a study that appeared in the American Journal of Psychiatry back in September which argued that atypical antipsychotics used as add-on treatments to anti-depressants were much more effective than a placebo add-on. The study was by J. Craig Nelson of UCSF and George Papakostas of Harvard/MGH. I was suspicious of the study’s findings, which I wrote about in September, since I’m fairly up to speed on the clinical literature and seen only weak effect sizes of atypicals used this way. The reason I am bringing this up is because the great CL Psych has posted something on his blog this week on this study and utterly guts it. (A link to the study is on my original post.)

My suspicions then:

“Now, here’s why you should be very suspicious of the apparent epic victory over placebo:

“‘The odds ratio for remission was 2.00, with a number needed to treat of nine.’

“The NNT as it’s known means the number of people who would have to try a treatment before one person would realize a treatment benefit. An NNT of nine people translates to an overall efficacy for atypical augmenters of about 11 percent. Staggeringly low. And hardly the victory researchers seemed to be claiming.”

And now for CL Psych, who is a stats jock par excellence:

“But the ‘evidence’ is not all that convincing. Here’s why… The authors pooled together the results of 16 randomized controlled trials. In these studies, patients had failed to respond adequately (using various definitions) to an antidepressant. Patients were then assigned to receive either an atypical antipsychotic or a placebo in addition to their antidepressant. Outcomes were then tabulated somewhere between 4 and 12 weeks later. The results seem clear cut — if your brain is turned to “off” — the response rates for atypicals was 44% compared to 30% for placebo. The remission rates were 31% for atypicals and 17% for placebo. The advantage for atypicals is statistically significant. Well, there you have it. Done deal. Ask your doctor about Abilify/Zyprexa/Seroquel today…

“But the most important thing in a treatment outcome study is… the outcomes. The authors of the meta-analysis did not bother to actually measure change in scores on rating scales. Instead, they only used response and remission rates. There is absolutely no good reason for doing this. It’s potentially quite misleading. Doctors like remission and response rates because they provide the illusion that we are measuring depression exactly. A “responder” got a lot better and is functioning reasonably well whereas a “non-responder” is in bed 12 hours a day while spending the rest of her time watching the E! Network, eating Bon-Bons, and sobbing constantly. But it’s not nearly that scientific. A “responder” is usually defined as someone who got 50% better on his or her depression rating score during the study period. So Bob’s depression rating score improved by 52% (he’s a responder), but Amy’s score only improved by 48%, so she’s a nonresponder. Is this 4% difference really meaningful?”

And that’s why the study itself, which wasn’t pharma-funded, produced an NNT of nine. In other words, atypicals are not effective augmenters as a class of drugs.

Go to Source

Related posts:

1. Study Uses Deception To Claim Antipsychotics Are Awesome Depression Treatments
2. Placebo Outperforms Seroquel In Teen Bipolar Depression Study
3. JAMA Study Slaughters Antipsychotics For Kids, Teens Paradigm
4. High Off-Label Use Of Antipsychotics For Depression In VA System
5. Study: Fewer Depression Diagnoses "Unintended Consequence" Of Suicide Warnings On Anti-Depressants