Effectiveness of antidepressants: an evidence myth constructed from a thousand randomized trials?

Antidepressants, in particular newer agents, are among the most widely prescribed medications worldwide with annual sales of billions of dollars. The introduction of these agents in the market has passed through seemingly strict regulatory control. Over a thousand randomized trials have been conducted with antidepressants. Statistically significant benefits have been repeatedly demonstrated and the medical literature is flooded with several hundreds of "positive" trials (both pre-approval and post-approval). However, two recent meta-analyses question this picture. The first meta-analysis used data that were submitted to FDA for the approval of 12 antidepressant drugs. While only half of these trials had formally significant effectiveness, published reports almost ubiquitously claimed significant results. "Negative" trials were either left unpublished or were distorted to present "positive" results. The average benefit of these drugs based on the FDA data was of small magnitude, while the published literature suggested larger benefits. A second meta-analysis using also FDA-submitted data examined the relationship between treatment effect and baseline severity of depression. Drug-placebo differences increased with increasing baseline severity and the difference became large enough to be clinically important only in the very small minority of patient populations with severe major depression. In severe major depression, antidepressants did not become more effective, simply placebo lost effectiveness. These data suggest that antidepressants may be less effective than their wide marketing suggests. Short-term benefits are small and long-term balance of benefits and harms is understudied. I discuss how the use of many small randomized trials with clinically non-relevant outcomes, improper interpretation of statistical significance, manipulated study design, biased selection of study populations, short follow-up, and selective and distorted reporting of results has built and nourished a seemingly evidence-based myth on antidepressant effectiveness and how higher evidence standards, with very large long-term trials and careful prospective meta-analyses of individual-level data may reach closer to the truth and clinically useful evidence.     

Lure similarity affects visual episodic recognition: Detailed tests of a noisy exemplar model

Summed-similarity models of visual episodic recognition memory successfully predict the variation in false alarm rates across different test items. With data averaged across subjects, Kahana and Sekuler demonstrated that subjects' performance appears to change along with the mean similarity among study items; with high interstimulus similarity, subjects were less likely to commit false alarms to similar lures. We examined this effect in detail by systematically varying the coordinates of study and test items along a critical stimulus dimension and measuring memory performance at each point. To reduce uncontrolled variance associated with individual differences in vision, the coordinates of study and test items were scaled according to each subject's discrimination threshold. Fitting each of four summed-similarity models to the individual subjects' data demonstrated a clear superiority for models that take account of interitem similarity on a trialwise basis.     

Phyloanalysis: Theoretical and Practical Considerations on Burrow's Group Analytic and Socio-Therapeutic Method by W. Riese and H. Syz

Abstract

Women in an eating disorders partial hospital program and a psychiatric partial hospital program were compared on a self-report measure of group climate following a psychodynamic-interpersonal therapy group. Those with eating disorders experienced their groups as more engaged and as more avoiding than those in the psychiatric partial hospital group. Therapists may be able to use initial heightened engagement in eating disorder groups to counteract the tendency to avoid content.     

The 9th annual INDUS-EM 2013 Emergency Medicine Summit, “Principles,Practices, and Patients,” a level one international meeting,Kerala University of Health Sciences and Jubilee Mission Medical College and Research Institute,Thrissur, Kerala,India, October 23–27, 2013

INDUS-EM is India’s only level one conference imparting and exchanging quality knowledge in acute care. Specifically, in general and specialized emergency care and training in trauma, burns, cardiac, stroke, environmental and disaster medicine. It provides a series of exchanges regarding academic development and implementation of training tools related to developing future academic faculty and residents in Emergency Medicine in India. The INDUS-EM leadership and board of directors invited scholars from multiple institutions to participate in this advanced educational symposium that was held in Thrissur, Kerala in October 2013.     

Is Television a Health and Safety Hazard? A Cross‐Sectional Analysis of At‐Risk Behavior on Primetime Television1

Twenty‐four top‐rated primetime television shows were observed weekly during 1997 and 1998 (242 episodes). The study examined behaviors of vehicle occupants; violence and risky sex; and use of drugs, alcohol, and tobacco. Findings were compared to studies conducted in the mid‐1980s and 1994. Characters in vehicles were unrestrained 74% of the time in 1998, compared to 73% and 78% in 1994 and 1986, respectively. Violence, risky sex, and substance use were shown in 47%, 29%, and 55%, respectively, of 30‐min intervals observed in 1998. Similar data were recorded in 1994, with some negligible improvements. Results indicated that risky behaviors were rarely followed by punishing consequences, and irresponsible behaviors were modeled on primetime television. The relevance to social modeling and public health is discussed.     

Personality disorders associated with substance use among American and Greek adolescents

A study was conducted to investigate the association between personality disorder (PD) symptomatology and substance use among adolescents in community settings in the United States and Greece. The Structured Clinical Interview for DSM-IV Personality Disorders and the Adolescent Health Behavior Survey were completed by 37 male and 84 female adolescents, ages 15 to 18, who were recruited from an adolescent medical clinic and schools in and near New York City (n = 71) and Heraklion, Greece (n = 50). Results indicated that: (1) adolescents with PDs reported more frequent alcohol consumption during the past year than did those without PDs; (2) adolescents with borderline PD reported more cigarette smoking and heavy alcohol consumption than did those without borderline PD; (3) adolescents with antisocial PD symptomatology reported greater alcohol, cigarette, and illicit drug use than did those without antisocial PD symptomatology; and (4) although more American (30%) than Greek (4%) adolescents reported illicit substance use, differences were not observed in the prevalence of alcohol use, cigarette use, or personality disorders as a function of nationality.