Should We Treat Depression with drugs or psychological interventions? A Reply to Ioannidis

We reply to the Ioannidis's paper "Effectiveness of antidepressants; an evidence based myth constructed from a thousand controlled trials." We disagree that antidepressants have no greater efficacy than placebo. We present the efficacy from hundreds of trials in terms of the percentage of patients with a substantial clinical response (a 50% improvement or more symptomatic reduction). This meta-analysis finds that 42-70% of depressed patients improve with drug and 21%-39% improve with placebo. The response benefit of antidepressant treatment is 33%-11% greater than placebo. Ioannidis argues that it would be vanishingly smaller because systematic biasing in these clinical trials would reduce the drug-placebo difference to zero. Ioannidis' argument that antidepressants have no benefit is eroded by his failures of logic because he does not present any evidence that there are a large number of studies where placebo is substantially more effective than drug. (To reduce to zero, one would also have to show that some of the unpublished studies find placebo better than drug and have substantial systematic or methodological bias). We also present the empirical evidence showing that these methodological concerns generally have the opposite effect of what Ioannidis argues, supporting our contention that the measured efficacy of antidepressants likely underestimates true efficacy. Our most important criticism is Ioannidis’ basic underlying argument about antidepressants that if the existing evidence is imperfect and methods can be criticized, then this proves that antidepressant are not efficacious. He presents no credible evidence that antidepressants have zero effect size. Valid arguments can point out difficulties with the data but do not prove that a given drug had no efficacy. Indeed better evidence might prove it was more efficacious that originally found. We find no empirical or ethical reason why psychiatrists should not try to help depressed patients with drugs and/or with psychotherapeutic/behavioral treatments given evidence of efficacy even though our treatment knowledge has limitations. The immense suffering of patients with major depression leads to ethical, moral, professional and legal obligations to treat patients with the best available tools at our disposal, while diligently and actively monitoring for adverse effects and actively revising treatment components as necessary.     

Observation and physical practice: coding of simple motor sequences

An experiment was conducted to determine the coordinate system used in the development of movement codes during observation and utilized on later physical practice performance of a simple spatial-temporal movement sequence. The task was to reproduce a 1.3-s spatial-temporal pattern of elbow flexions and extensions. An intermanual transfer paradigm with a retention test and two transfer tests was used: a mirror transfer test where the same pattern of muscle activation and limb joint angles was required and a nonmirror transfer test where the visual-spatial pattern of the sequence was reinstated on the transfer test. The results indicated a strong advantage for participants in the physical practice condition when transferred to the mirror condition in which the motor coordinates (e.g., pattern of muscle activation and joint angles) were reinstated relative to transfer performance when the visual-spatial coordinates were reinstated (visual and spatial location of the target waveform). The observation group, however, demonstrated an advantage when the visual-spatial coordinates were reinstated. These results demonstrate that codes based in motor coordinates can be developed relatively quickly for simple rapid movement sequences when participants are provided physical practice, but observational practice limits the system to the development of codes based in visual-spatial coordinates. Performances of control participants, who were not permitted to practise or observe the task, were quite poor on all tests.     

Coronary Intervention Improves Disease Specific Health-Related Quality of Life but Not Individualised Quality of Life: A Potential Response Shift Effect?

To explore potential response shift effects with different quality of life (QoL) instruments in cardiac patients undergoing coronary intervention. Study Design and Setting: Recalibration was assessed with the disease specific health-related quality of life (HRQL) instrument MacNew in combination with a then-test approach. Reconceptualisation and reprioritisation were assessed with the individualised QoL instrument SEIQoL-DW. Significant treatment effects were seen on the MacNew (global Δ: 0.6 ± 1.1, p = 0.004) but not on the SEIQoL-DW (Δ: 3.3 ± 16, p = 0.37) 6 months after coronary intervention. No recalibration effect was found on the MacNew then-test, while with the SEIQOL-DW potential response shift effects of reconceptualisation and reprioritisation were seen. For the first time response shift effects were explored in cardiac patients undergoing coronary intervention. This study confirmed that there is a clinically significant improvement in disease specific HRQL over time following successful coronary interventions. However, no treatment effect was seen for individualised QoL with the SEIQoL-DW. This might be due to reconceptualisation and reprioritisation response effects. Future studies need to focus on exploring response shift effects, and the interrelationship between its different components, captured by different patient reported outcome instruments in larger patient groups undergoing coronary interventions.     

Kontroverse zu Beschwerdenvalidierungsverfahren bei der Begutachtung psychischer St?rungen

The value of symptom validity tests in a forensic context is currently the subject of a controversial debate in Germany. The discussion primarily focuses on neuropsychological symptom validity tests, however, tests specific for mental disorders are neglected. Unfortunately, no assessment tools for symptom validation of mental disorders of German origin are available and adaptations of available English state of the art instruments have not yet been tested. Further research of assessment development and qualitative analysis of the decision-making process in medicolegal evaluation is needed in German speaking countries.     

Perceived impact of socially anxious behaviors on individuals' lives in Western and East Asian countries

The current study compared the predicted social and career impact of socially withdrawn and reticent behaviors among participants from Western and East Asian countries. Three hundred sixty-one college students from 5 Western countries and 455 students from 3 East Asian countries read hypothetical vignettes describing socially withdrawn and shy behaviors versus socially outgoing and confident behaviors. Participants then answered questions following each vignette indicating the extent to which they would expect the subject of the vignette to be socially liked and to succeed in their career. Participants also completed measures of their own social anxiety and quality of life. The results indicated significant vignette-by-country interactions in that the difference in perceived social and career impact between shy and outgoing vignettes was smaller among participants from East Asian countries than from Western countries. In addition, significant negative correlations were shown between personal level of shyness and experienced quality of life for participants from both groups of countries, but the size of this relationship was greater for participants from Western than East Asian countries. The results point to the more negative impact of withdrawn and socially reticent behaviors for people from Western countries relative to those from East Asia.     

Culturally adapted CBT (CA-CBT) for Latino women with treatment-resistant PTSD: a pilot study comparing CA-CBT to applied muscle relaxation

We examined the therapeutic efficacy of a culturally adapted form of CBT (CA-CBT) for PTSD as compared to applied muscle relaxation (AMR) for female Latino patients with treatment-resistant PTSD. Participants were randomized to receive either CA-CBT (n = 12) or AMR (n = 12), and were assessed before treatment, after treatment, and at a 12-week follow-up. The treatments were manualized and delivered in the form of group therapy across 14 weekly sessions. Assessments included a measure of PTSD, anxiety, culturally relevant idioms of distress (nervios and ataque de nervios), and emotion regulation ability. Patients receiving CA-CBT improved significantly more than in the AMR condition. Effect size estimates showed very large reductions in PTSD symptoms from pretreatment to posttreatment in the CA-CBT group (Cohen’s d = 2.6) but only modest improvements in the AMR group (0.8). These results suggest that CA-CBT can be beneficial for previously treatment-resistant PTSD in Latino women.     

Sequential treatment of a feeding problem using a pacifier and flipped spoon

Parents may be reluctant to treat the feeding disorder of a chronically ill child who exhibits distressed behavior during feeding. In this study, we identified a child with chronic medical problems and a feeding disorder who cried during feedings. We introduced treatment components sequentially to address parental concerns about crying. First, we used a pacifier to reduce crying, and then we used a flipped spoon to increase mouth clean. The results showed that a sequential approach to treatment can be effective for children with complex medical and behavioral problems.     

Effects of age and the relationship between response time measures and psychometric intelligence in younger adults

The major goal of the present study was to investigate the potential influence of age on the relationship among performance measures derived from a Hick reaction time task and general intelligence (psychometric g). Participants were 130 male and 130 female younger adults (mean age: 24.6 years) covering a wide range of individual levels of intelligence. Results from structural-equation modelling analyses clearly indicate that there is no evidence for the notion of a general speed factor underlying psychometric g. A much more sufficient model is provided by the assumption that median reaction time (RTmd) and intraindividual variability of reaction time (RTSD), though highly correlated, reflect two distinct sources of variance for psychometric g. While age was negatively associated with RTmd, no such relationship could be established for RTSD.     

Is there a structural limit to ‘branch’ recursively between more than two tasks?

The term ‘branching’ refers to processes needed for successful reuptake of a task after interruption by another task. Based on a model of human prefrontal cognitive architecture, it has been postulated that people cannot branch recursively between more than two tasks due to a capacity limit built into the cognitive architecture (Koechlin and Hyafil in Science 318:594–598, 2007). As an alternative to a structural limit for recursive branching between more than two tasks we put forward the hypothesis that working memory capacity is the limiting factor in recursive branching. We tested this hypothesis by independently varying working memory load and number of recursive branching steps. Successful branching between up to four tasks was observed, as long as working memory load was kept low. Our data, thus, do not support the proposition of a structural limit to recursive branching beyond two tasks. Instead, they suggest that working memory capacity limit is the most important factor that limits the capacity for branching. We further observed that the requirement to retain task sets and task contents additively contributed to the difficulty of recursive branching. In a broader context, our data thus support working memory models that conceptualize working memory and executive functions not as separate modules, but as tightly interactive processes.