Wednesday, May 04, 2005

The Magic Bullet

Back in February, Shrinkette posted a sad email from a friend , which I saw when going through her archives:

Liz Ditz, of I Speak Of Dreams, sends e-mail:
My goodness. Today seems to be "let's talk about depression day." I had lunch with a friend today. Two weeks ago a mutual friend committed suicide. This friend was a year older than I am (55) and was very much part of a net of love and respect. He was a good father and husband, a leader in his men's prayer group, and part of warm and loving family. His wife's brother had recovered from a hellacious alcohol and cocaine problem, 15 or 20 years ago, so the family circle was no stranger to pain and struggle and redemption. Despite this love and affection, the friend dove under a train in motion. The big question at lunch was "Why"? Why would you so hurt your family and friends? Why did he walk and walk down the railroad right-of-way that runs through this sleek, privileged Silicon Valley town, just to leap from leafy hiding into the noise and metal?

Into the noise, and metal, and annihilation. We're left to guess why. For clues, I turn back to my previous post, "I was just going to take all my medications."

Liz goes on:
In talking with non-psychiatrist physicians, I find a touching faith in the magic-bullet nature of medication.
(I love that sentence!)

The post continues, and I recommend that you check it out. But the thing that caught my attention (besides the sad death of a friend) was the phrase "magic bullet nature of medication."

Notice also the phrase "non-psychiatrist physician" are the ones with a "touching faith" in the power of medications.

In the medical profession, we often refer to "magic bullets", which are what we call those treatments that miraculously "cure" a condition. There is, of course, a certain irony in this description, since there are few medications in any medical specialty that truly produce a cure (although there are some); and none that do it without side effects --some of them quite severe; and some of them that are worse than the disease itself.

Psychiatrists tend to be more humble about this reality than most physicians. And they should be.

None of the drugs that "cure" can be found in the psychiatric formulary. We have some good medications--even some very good medications-- but none are free of side effects and/or complications; and most are not that much better than placebo.

What that means is that all of the medications we use--for depression, for psychosis, or mania, for anxiety--all statistically make most people feel better, but only a little bit better than a sugar pill that people think is a drug for their disorder. In fact, the so-called "placebo effect" is a powerful component of how all medications work.

The placebo effect

is the measurable, observable, or felt improvement in health not attributable to treatment. This effect is believed by many people to be due to the placebo itself in some mysterious way. A placebo (Latin for “I shall please”) is a medication or treatment believed by the administrator of the treatment to be inert or innocuous. Placebos may be sugar pills or starch pills. Even “fake” surgery and “fake” psychotherapy are considered placebos.

Researchers and medical doctors sometimes give placebos to patients. Anecdotal evidence for the placebo effect is garnered in this way. Those who believe there is scientific evidence for the placebo effect point to clinical studies, many of which use a control group treated with a placebo. Why an inert substance, or a fake surgery or therapy, would be effective is not known.

Below is a rather typical result from a study that looked at a particular psychiatric medication (in this case it was for Mania) compared to a placebo. The medication is a real drug (although I haven't identified it specifically) and the graph represents the results of a real study. Improvement in manic symptoms over time was measured by a rating scale (the Young Mania Rating Scale- YMRS)and the results show a decrease in the YMRS score, meaning fewer manic symptoms; or less severe symptoms.
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As you can see from the graph above, the placebo has an effect all its own over the entire course of the study; and strangely enough, the medication is not that much better than that placebo effect. But it is somewhat better, and that's why this particular medication was approved by the FDA to treat Manic symptoms.

My point is, this is a "magic bullet"?? Not really--by my definition of "magic". If anything, it is the placebo that is magic. It supposedly, does nothing in reality, yet it does!

Many people believe that the placebo effect is a purely psychological phenomenon, and that it occurs because people believe they will get better on medication. Some researchers believe that most psychiatric medications (and a lot of non-psychiatric medications) work almost exclusively through the placebo effect (here is an example of a meta-analysis of antidepressant studies that concludes that 75% of antidepressant effects can be accounted for by a placebo effect). As the editor in which that study was published noted-- it is a controversial study, using a controversial statistical technique. But at the least, such analyses should make psychiatrist and their patients realize that medication may help, but it is not the be-all and end-all; or even the most fabulous, fantastical, magical, wonderful thing in the whole world.

And to further confound this complicated situation, the doctor's optimism and positive attitude toward the drug can have a profound effect on how well a patient responds to it. So, a doctor who is realistic and tells a patient that they will likely only get a small benefit from the medication, will --as a result of his or her honesty--have a lot of patients who don't get better.

Not very inspiring is it?

Consider this: con artists; medical frauds and fakes; quacks and really really bad doctors can all have fanatically devoted patients who swear by their treatments and insist that--no matter what science says--the medication their doctor gave them worked!

As a scientist, and as a physician, I frequently ponder these things. This is why I have come to believe that, while the biological is extremely important; and grows more important as we obtain more knowledge; the psychological and the social are equally (and often even more) important. I try to never forget this when I am dealing with someone suffering from depression or other emotional disorder.

As Voltaire (1694-1778) the great poet, historian and satirist, once commented, "Doctors prescribe medicine of which they know little, to cure diseases of which they know less, in human beings of which they know nothing." He also wisely noted that, "The art of medicine consists of amusing the patient while nature cures the disease."

If anything, the real "magic bullet" in medicine that fights disease and ameliorates physical and psychological suffering is the dynamic relationship between the patient, the doctor, and nature.

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