I would like to join Awais in congratulating Peter on the 30th anniversary of Listening to Prozac--surely one of the most influential books in psychiatry, over the past three decades. I was privileged to have contributed some comments on an early draft of Dr. Kramer's other influential book, Ordinarily Well, kindly acknowledged by Peter in the book's preface. As someone who "paid the rent" doing psychopharmacology consultation for over 20 years, I have just a few thoughts to add to this excellent discussion and interview:
1. I completely agree with Peter when he says, "In my view, the notion that antidepressants have no direct main effect on depressive episodes is untenable." We have only to examine the recent
seminal study by Stone et al--widely misrepresented in the popular press--to see that in at least 15% of patients with major depression--antidepressants have robustly greater efficacy than the placebo condition ("a substantial antidepressant effect beyond a placebo "). And bear in mind, this was based on "single agent" studies. [1] [2]
2. I also agree that "...SSRIs will look more consistently effective if researchers identify subgroups of patients likely to be especially responsive." This is precisely the lesson to be drawn from the Stone et al study--i.e., we need to figure out why this 15% is particularly responsive to antidepressants.
3. I am always surprised at how little attention is paid in the research literature to bupropion--a non-serotonergic antidepressant that is both effective (vs. placebo) and free of nearly all the common side effects of SNRIs and SSRIs. I believe this is a widely under-utilized agent in clinical practice, probably owing to poor "marketing" compared to the SSRIs.
Thanks to Dr. Aftab and Dr. Kramer for this interview, and all the best to you both,
Ron
Ronald W. Pies, MD
1. Stone MB, Yaseen ZS, Miller BJ, Richardville K, Kalaria SN, Kirsch I. Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: individual participant data analysis. BMJ. 2022 Aug 2;378:e067606. doi: 10.1136/bmj-2021-067606. PMID: 35918097; PMCID: PMC9344377.
Excellent interview. Thank you both. When the book originally came out I was already in practice in the UK.
Prozac’s manufacturer’s drug representatives repeatedly urged me to disregard it but I always wondered if this was a paradoxical injunction to make us think more about it. Any views?
So many clinical pearls. This is a wonderful read.
I thoroughly enjoyed reading this discussion. Thanks!
I would like to join Awais in congratulating Peter on the 30th anniversary of Listening to Prozac--surely one of the most influential books in psychiatry, over the past three decades. I was privileged to have contributed some comments on an early draft of Dr. Kramer's other influential book, Ordinarily Well, kindly acknowledged by Peter in the book's preface. As someone who "paid the rent" doing psychopharmacology consultation for over 20 years, I have just a few thoughts to add to this excellent discussion and interview:
1. I completely agree with Peter when he says, "In my view, the notion that antidepressants have no direct main effect on depressive episodes is untenable." We have only to examine the recent
seminal study by Stone et al--widely misrepresented in the popular press--to see that in at least 15% of patients with major depression--antidepressants have robustly greater efficacy than the placebo condition ("a substantial antidepressant effect beyond a placebo "). And bear in mind, this was based on "single agent" studies. [1] [2]
2. I also agree that "...SSRIs will look more consistently effective if researchers identify subgroups of patients likely to be especially responsive." This is precisely the lesson to be drawn from the Stone et al study--i.e., we need to figure out why this 15% is particularly responsive to antidepressants.
3. I am always surprised at how little attention is paid in the research literature to bupropion--a non-serotonergic antidepressant that is both effective (vs. placebo) and free of nearly all the common side effects of SNRIs and SSRIs. I believe this is a widely under-utilized agent in clinical practice, probably owing to poor "marketing" compared to the SSRIs.
Thanks to Dr. Aftab and Dr. Kramer for this interview, and all the best to you both,
Ron
Ronald W. Pies, MD
1. Stone MB, Yaseen ZS, Miller BJ, Richardville K, Kalaria SN, Kirsch I. Response to acute monotherapy for major depressive disorder in randomized, placebo controlled trials submitted to the US Food and Drug Administration: individual participant data analysis. BMJ. 2022 Aug 2;378:e067606. doi: 10.1136/bmj-2021-067606. PMID: 35918097; PMCID: PMC9344377.
2. https://www.psychiatrictimes.com/view/antidepressants-placebos-and-lithium-some-parting-thoughts
Excellent interview. Thank you both. When the book originally came out I was already in practice in the UK.
Prozac’s manufacturer’s drug representatives repeatedly urged me to disregard it but I always wondered if this was a paradoxical injunction to make us think more about it. Any views?