Sally: The essence of a randomized clinical trial, just to go back to that, is something
that it's hard to assess in the clinical encounter, and goes to the virtue of these trials, which
is placebo.
And the placebo issue is one with lots of resonance for your book.
Let's just start with the fact that I think it inspired your book.
Peter Kramer: Right.
There was all this talk about these medicines just being placebos with side effects, which
means dummy pills that make you feel like you're on a drug, and you're not getting better
because of the inherent efficacy of the drug because of the way the drug interacts with
your brain, it alters it and allows you to behave differently, the whole complicated
series of things that may inform recovery.
No, the claim was, any pill, a sugar pill would do the same thing, if you believe it
was an antidepressant.
And that claim, I think, started causing doctors, even though these medicines are widely prescribed
in critical situations, not to turn to the medicines when I would say they should.
I think that is a canard.
I don't think depression is very placebo responsive.
I mean, I think we want to distinguish two things.
To know that the medicines work, what we'd like to do is set up a situation where we
see how people do on the medicine and we see what's causing the hypothetical counterfactual
"What would have happened if they had the same weather, the same spouse, the same contact
with doctors, but didn't get the active ingredient in the drug?"
So, how would they do without treatment?
How do they do with treatment?
And that gets confused with this much more particular idea, which is people get better
because they have faith in a pill.
That seems to me a much narrower belief, and there's a lot less evidence for that.
Sally: But some people do get better, surprisingly better, with social stimulation and connection.
Peter Kramer: Right.
Sally: I remember seeing a patient who I thought for sure would need shock therapy.
I mean, that's how almost immobilized this woman was.
She lived with her mother.
It was almost like a "Now, Voyager" situation where she lived with her mother well into
her adult life, and the mother died.
And on the one hand, of course she found it liberating, but there was an enormous burden
that came with it.
That was the first visit and then she of course was coming back, and I thought "For sure we
need hospitalization."
She was living with a sister otherwise.
I thought maybe we'd need it that day.
But I was shocked at how she could rally a bit.
Now, I hate to admit, she dropped out.
So, she may well have relapsed into that.
Peter Kramer: Yeah.
But maybe not, right?
I mean, I think we see this.
The reason we as psychiatrists like to sit with people a while is that if you can...you
know, it's not urgent, you don't have to worry about suicide immediately or loss of a job,
or divorce, whatever it is, and you have a little time to sit, sometimes you find listening,
supporting, teasing things apart, passage of time, people get remarkably better.
People got better from depression, sometimes, before anyone invented...
Sally: Yeah, and that doesn't mean it's any less real.
Peter Kramer: No, no.
And that's why...
Sally: Although, I think people can think it's any less real.
Peter Kramer: That's why you want to do these trials, right?
Because when you have people come in, you take their blood pressure, you talk to them,
you ask them about their depression, do a long inventory, spend a lot of time with them
week after week in the course of a drug trial, maybe it's all that human contact that's helping.
Maybe I take people in the book to a drug trial center and I go out in the van.
You know, the van picks people up where they live and brings them to the center.
And just the conversation in the van is very supportive.
So, lots of things go on in a drug trial and we don't want to attribute that kind of benefit,
if it's beneficial, to the drug.
We want to know what is the drug doing beyond all that human contact.
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