I'm not convinced that we should accept that GPs throw these around for 
transient low mood or emotional upsets.

If they are as effective as placebos (which we are not ethically 
permitted to use) that is worth having and maybe we should look at them 
more positively, as well as being grateful that they will also cover the 
odd case of severe depression that we thought was "not so bad" and 
without treatment may go on to self harm. It seems not time at all since 
we were beset by headlines about the number of people who had committed 
suicide within a month of seeing their GPs who had failed to recognise 
their depression or take it seriously.

I wonder whether it is justifiable to spend the huge sums of money that 
would be required for universal CBT for everyone with transient low mood 
/ emotional upset?
Fay

Paul Caldwell wrote:
> i think the point about the SSRI debate is that there is little 
> evidence that they are useful for mild depression let alone the low 
> mood/emotional upsets that we GPs frequently use them for almost as a 
> reflex. the large majority of these pts will get better in time 
> whatever one does and little interventions make a difference overall 
> to that natural history. pts are more at risk of the medication than 
> the disease. importantly prescribing ADs sends powerful messages to 
> pts not dissimilar to ABs for minor infection. 'Talking treatments' 
> are useful for these pts as they appear to give greater solace to 
> unhappy people than medication. just as importantly an essential part 
> of talking treatments is getting pts to be active about doing 
> something for themselves, gaining perspective+self esteem, and 
> crucially how to deal with it and recognise it the next time they get 
> depression (which is recurrent within 5 years in most). I freely admit 
> that profioundly unhappy pts want a quick fix for obvious reasons, as 
> did I. i'm happy to prescribe placebos as long as it is clear to pts 
> that they are so, i dont like lying to my pts! or being lied to. but 
> usually go down the route of talking therapies.
> Placebos. now there is a seriously interesting subject. any URL of 
> review on it?
> PS. granted the situation for talking therapies, will we get into the 
> era of ADs for the working classes and CBT for the middle class who 
> pay for it?
>
> > Date: Sat, 1 Mar 2008 11:13:43 +0000
> > From: [log in to unmask]
> > Subject: Re: Prozac et al
> > To: [log in to unmask]
> >
> > At 14:30 28/02/2008, you wrote:
> > >On Thu, Feb 28, 2008 at 9:30 AM, Paul Caldwell <[log in to unmask]> wrote:
> > > >
> > > > agreed. often used in 2 ways-like antibiotics "give me something
> > > to make me
> > > > well now" or as placebo for docs who do not have access to CMHTs 
> etc.
> > > > interestingly, the data is not knew and i am surprised that
> > > unpublished data
> > > > was allowed to remain so for so long. perhaps ben goldacre has a
> > > point: that
> > > > publsihing trials should be compulsory and not discretionary on the
> > > > trialist.
> > > >
> > > >
> > >
> > >There is a simple solution to this that all the regulatory agencies
> > >have declined to implement: only pre-registered trials should be
> > >admissible when applying for a licence. All trials would therefore
> > >have to be registered before starting (in case they produced good
> > >results), so the licensing agencies could immediately see what
> > >proportion of the total trials had produced positive results.
> > >
> > >Cheers Geoff
> >
> > I thought that's exactly what the FDA had done?
> >
> > Publication bias still remains, and who wants to publish a study that
> > an unheard of chemical entity doesn't work?
> >
> > That only becomes newsworthy AFTER a drug is in widespread use.
> >
> > OTOH the meta-analysis is probably not reliable either and is not
> > relevant to UK general practice where the treatment options are
> > different to those available in the studies.
> >
> > This is a long running saga. It's also deeply rooted in human
> > behaviour. The dangers of resorting to nicotine in times of stress,
> > the habit of "getting plastered" when life is hard seem to me to be
> > far more dangerous than the prescriptions that GPs
> > issue for anti-depressants, only some of which are ever used. In GP
> > land these do represent BOTH useful treatments for many patients, and
> > tokens of care with acceptance of the degree of human suffering - a
> > stark alternative to the minimalist "pull yourself together" approach
> > (though taking responsibility for self is of course the end point we
> > all aim for).
> >
> > In any case happy to work with patients own decisions, so long as
> > they don't ask me for something that doesn't exist / isn't accessible.
> >
> > Julian
>
>
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