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Patient treatment preferences in an RCT (in this case antidepressants vs counselling for depression)

Dolphin

Senior Member
Messages
17,567
Patient preferences haven't got much attention in the ME/CFS area. Many patients don't want to undertake graded activity/exercise programmes, for example. So I thought this paper that James C. Coyne just highlighted on Twitter, was of interest.

It's from 2005, but the point is just as interesting today.


One size fits some: the impact of patient treatment attitudes on the cost-effectiveness of a depression primary-care intervention.

Pyne JM, Rost KM, Farahati F, Tripathi SP, Smith J, Williams DK, Fortney J, Coyne JC.
Source

Psychol Med. 2005 Jun;35(6):839-54.

VA HSRD Center for Mental Healthcare and Outcomes Research, Central Arkansas Veterans Healthcare System, Little Rock, AR 72114-1706, USA. jmpyne@uams.edu

Abstract

BACKGROUND:

Despite their impact on outcomes, the effect of patient treatment attitudes on the cost-effectiveness of health-care interventions is not widely studied.

This study estimated the impact of patient receptivity to antidepressant medication on the cost-effectiveness of an evidence-based primary-care depression intervention.

METHOD:

Twelve community primary-care practices were stratified and then randomized to enhanced (intervention) or usual care.

Subjects included 211 patients beginning a new treatment episode for major depression.

At baseline, 111 (52.6%) and 145 (68.7%) reported receptivity to antidepressant medication and counseling respectively.

The intervention trained the primary-care teams to assess, educate, and monitor depressed patients.

Twelve-month incremental (enhanced minus usual care) total costs and quality-adjusted life years (QALYs) were calculated.

RESULTS:

Among patients receptive to antidepressants, the mean incremental cost-effectiveness ratio was dollar 5,864 per QALY (sensitivity analyses up to dollar 14,689 per QALY).

For patients not receptive to antidepressants, the mean incremental QALY score was negative (for both main and sensitivity analyses), or the intervention was at least no more effective than usual care.

CONCLUSIONS:

These findings suggest a re-thinking of the 'one size fits all' depression intervention, given that half of depressed primary-care patients may be non-receptive to antidepressant medication treatment.

A brief assessment of treatment receptivity should occur early in the treatment process to identify patients most likely to benefit from primary-care quality improvement efforts for depression treatment.

Patient treatment preferences are also important for the development, design, and analysis of depression interventions.

PMID: 15997604 [PubMed - indexed for MEDLINE]
 
Messages
13,774
Ta D.

This made me think of another recent paper, this one being used to justify explanations of illness which downplay the role of bioloigcal mechanisms in an 'empowering' way. Although obviously, decisions about whether to do this cannot be done with informed consent:

http://www.sciencedirect.com/science/article/pii/S0272735813000883

The ‘side effects’ of medicalization: A meta-analytic review of how biogenetic explanations affect stigma

  • a Melbourne School of Psychological Sciences, University of Melbourne, Parkville, Australia
  • b Department of Psychology, John Jay College of Criminal Justice, City University of New York, New York, USA
View full text
Purchase $31.50
Highlights


Biomedical perspectives shape contemporary thinking about psychological problems.

We quantitatively reviewed how biogenetic explanations affect stigma.

Biogenetic explanations reduce blame, but induce pessimism about recovery.

Biogenetic explanations do not affect desire for distance.

Medicalization is no cure for stigma and may create barriers to recovery.
Abstract

Reducing stigma is crucial for facilitating recovery from psychological problems. Viewing these problems biomedically may reduce the tendency to blame affected persons, but critics have cautioned that it could also increase other facets of stigma. We report on the first meta-analytic review of the effects of biogenetic explanations on stigma. A comprehensive search yielded 28 eligible experimental studies. Four separate meta-analyses (Ns = 1,207 - 3,469) assessed the effects of biogenetic explanations on blame, perceived dangerousness, social distance, and prognostic pessimism. We found that biogenetic explanations reduce blame (Hedges g = -0.324) but induce pessimism (Hedges g = 0.263). We also found that biogenetic explanations increase endorsement of the stereotype that people with psychological problems are dangerous (Hedges g = 0.198), although this result could reflect publication bias. Finally, we found that biogenetic explanations do not typically affect social distance. Promoting biogenetic explanations to alleviate blame may induce pessimism and set the stage for self-fulfilling prophecies that could hamper recovery from psychological problems.
Keywords

  • Medicalization;
  • biomedical model;
  • biogenetic explanations;
  • stigma;
  • prejudice

To me, it seems like there's a real conflict in psychology/psychiatry between those who think that their remarkable expertise is such that they should decide how their patients should think and live their lives, and those who realise that our poor understanding of many psychological matters only lets them make quite limited claims to patients, and that much needs to be left to the preferences of patients. It really seems like two totally different approaches, that will not be able to find a compromise, but need to have one side win over the other.
 

SOC

Senior Member
Messages
7,849
Confession up front: I'm grouchy today.

I think this research is just stupid. The unstated assumption, as far as I can tell, is that talk therapy and antidepressant meds are interchangeable. It's like assuming antibiotics and pain meds are interchangeable because both make you feel better when you have a bug. "Nah, I don't want to take antibiotics. Give me pain meds instead so I won't notice that I'm sick."

If ya ask me, it's just another case of talk therapists trying to find another niche for themselves. "If your patient doesn't want to take the meds they need, send them to me and maybe I can convince them they're only imagining their physiological problem. At least I'll make some money and they might quit complaining."

Talk therapy and anti-depressant medication treat different things and most up-to-date psychiatrists know this. Some people develop self-destructive or counter-productive thinking processes. They need talk therapy to help them learn that they are not responsible for everything or they're not a terrible person because their cheating wife left them for another man or that they don't have to be perfect or yadda, yadda, yadda. Antidepressant meds can make them more numb, but is it wise to mess with the neurochemistry of normally functioning brains?

Other people have neurochemical disorders that affect emotions. You can talk all you want, it's not going to change the neurochemistry (significantly, at least). Those people need meds to correct a physiological disorder. Some people have both problems as one can lead to another. Those people need talk therapy and meds. That does not make the two interchangeable.

It's just another area where some psychologists think their brand of "magic" can cure physiological phenomena by thinking it away. Talk therapy to fix maladaptive thinking -- fine. Talk therapy to learn coping skills for difficult situations -- fine. Talk therapy to fix physiological dysfuntions -- snake oil. I don't buy faith healing in religion either, by the way.

[grumble, grumble, grumble]
 
Messages
13,774
The unstated assumption, as far as I can tell, is that talk therapy and antidepressant meds are interchangeable.

In some ways, I see the paper Dolphin posted as something of a challenge to that assumption, in that it could reflect that patients themselves can have an awareness of the nature of their problems that allows them to choose the more effective treatment for themselves.
 

biophile

Places I'd rather be.
Messages
8,977
Couldn't this paper also be used to claim that those who aren't "receptive" to anti-depressants are sabotaging potential benefits from them and should be "educated"? ME/CFS patients who aren't "receptive" to CBT/GET face similar attitudes.

Re the other paper, here is a shocking idea for when etiology is unknown: offer the patient a wide range of accurate information in the spirit of openness and let them decide for themselves what the cause of their symptoms is?
 

SOC

Senior Member
Messages
7,849
Re the other paper, here is a shocking idea for when etiology is unknown: offer the patient a wide range of accurate information in the spirit of openness and let them decide for themselves what the cause of their symptoms is?
What!? Give the patients all the info and give them choices!? Surely not! ;)
 
Messages
13,774
Re the other paper, here is a shocking idea for when etiology is unknown: offer the patient a wide range of accurate information in the spirit of openness and let them decide for themselves what the cause of their symptoms is?

Or even not decide for themselves, but instead just live honestly with the uncertainty rather than pragmatically formulating narratives of yadda-yadda.

I really wish that when I was first ill I had just been provided with access to the available evidence, and left to sort it out for myself. The psychosocial management that is routinely inflicted upon CFS patients is just not morally justifiable given how tenuous the evidence in this area is.