Posted by linkadge on January 5, 2008, at 15:24:47
In reply to Re: STAR*D confirmed what patients already knew » linkadge, posted by Larry Hoover on January 5, 2008, at 13:31:01
>The methodology could not include placebo. It is >an ecological study. Has your doctor ever >offered you a placebo? Do you consider placebo >treatment to be a common clinical practise?
Well, then change the methodology. Its not so much that doctors can offer placebos, but if they knew that medications were essentially no better than placebos, they might decide against riskier treatments in favor of other treatments. For instance, they might choose lower (safer) doses, or choose drugs with a more benign side effect profile. Ie, you might be taking 25mg of trazodone as opposed to developing heart disease on 375mg of effexor etc.
>The methodology was not designed to show what >works. It was designed to deal with non->responders. How do you treat people who fail >with the most popular treatment option (i.e. >citalopram)? Subjects were allowed to choose >e.g. augmentation, but they didn't know which >augment they'd receive. If that failed, they >could choose a complete change in meds, but >again not knowing which they might receive. I >don't think placebo would have told us anything >about how to treat the non-responders to Level 1 >treatment.
Well, strong response to a placebo might have helped support the finding that pretty much all choices are essentially equivilant. That most treatment algorigthms essentially led to the same rate of response seems suggestive in itself of a potentially high response to placebo.
I do think it really matters that doctors know the true incidence of placebo response. Many of these treatments are not benign treatments and so, loading sombody up with neurotoxic doses of certain AD's may not be justified. That is important to know.
>These variables may go some way to predicting >responsivity, something that the artificial >construct of a placebo-controlled efficacy trial >can never show.
You could include these same types of analysis in a study that includes a placebo. It might even help to uncover exactly what factors predict placebo response.
I personally think that the study purposly did not include a placebo. This was an important study which was not funded by drug companies. It was intened in some ways to (re)establish the efficacy of treatments in general. The last thing they wanted in this study was to have a pesky little placebo response disclaimer tagged to the end.
Consider the fist round, %30 of people responded to citalopram. That is slightly less than what previous studies for citalopram have stated. However, in many of such studies, the placebo response comes in about the same rate. On to round two...Eventually, you're going to get a final result saying yeah sure %70 of patients can improve, with one drug or another, yet %60-80 can improve with placebo. Wow, all of a sudden that %70 is meaningless.
Its one of those things where sometimes the most basic assumptions are wrong IMHO.
Linkadge
poster:linkadge
thread:804126
URL: http://www.dr-bob.org/babble/20080105/msgs/804473.html