Qu'est ce qu'un traitement efficace en médecine?

What is efficiency in allopathic medicine?

Après l'étude de Kirsch sur les antidépresseurs dans Plos Medicine il faut se reposer la question.

Tout d'abord l'histoire naturelle de la maladie.
100 patients dépressifs: combien guérissent par eux mêmes, non pas spontanément mais par leur défenses naturelles. Il est difficile de répondre mais c'est d'après les médecins au delà de 50% et même 70%. Bigre! Un traitement est efficace s'il fait mieux cela parait évident. Sauf que c'est partiellement faux un traitement va guérir certains qui n'auraient pas guéri et aggraver certains qui auraient guéri seuls ou accélérer la guérison d'autres qui étaient sur la voie de la guérison. Cet imbroglio est à lui seul un argument de poids pour la réalisation d'essais cliniques. En effet la maladie est souvent décrite dans la médecine conventionnelle comme un état pathologique dont on ne peut sortir que par le iatros. Rien n'est moins vrai! Tout d'abord ce que l'on appelle symptome ou parfois maladie est tout bonnement un état physiologique de réponse et d'adaptation. Surtout dans les maladies chroniques dont la dépression . Le patient ne devient pas déprimé comme on bouche une artère!
"The Natural History of Depression
• Likelihood that a person will develop depression or dysthymia in his/her lifetime 6.1
• Likelihood that a person will suffer some depressive symptoms in his/her lifetime 23.1
• Average age of first/onset of major depression 18-29
• Average duration of depressive episodes 20 weeks
• Percent of patients who recover within a year after onset of symptoms 74%
• Likelihood of a second or more episode of major depression 80%
• Likelihood of a second or more episode of mild depression 100%
• Median number of major depressive episodes during a patient’s lifetime 4
• Percent of patients whose depression takes a chronic/unremitting course 12%
• Incidents of depression in women/men 3.62 vs 1.98 per 1,000 per year
• Rank of unipolar major depression in the world leading to disabling diseases in 1999 4
• Rank of unipolar major depression among disabling diseases in Westernized countries 2
• Rank of depression among disabling diseases the world wide projected in 2020 2"
D'une manière générale il est intéressant de se poser les questions suivantes:
-comment fonctionne la dépression au niveau du cerveau
-pourquoi la dépression survient ? Dans un système biologique aussi sophistiqué, résultat d'une évolution de plusieurs centaines de milliers d'années, la dépression a-t-elle une fonction, confère-t-elle dans certaines conditions un avantage de survie? C'est dans cette perspective que plusieurs auteurs ont mis en exergue le rôle positif de la dépression dans plusieurs situations. La première est celle d'objectifs difficiles ou impossibles à atteindre.
La première question est celle d ela physiopathologie du "désordre" ou du dysfonctionnement cérébral. Quels territoires sont activés, quels neuromédiateurs sont en cause. D'où la conception du manque du défaut et la réponse allopathique. mais il y a des paradoxes. dans un schéma expérimental où des rats sont précipités dans l'eau et obligés de nager jusqu'à l'épuisement et la noyade, certains prudents avant de s'épuiser se mettent au repos et flottent le nez au dessus de l'eau. En revanche les rats qui ont pris un antidépresseur vont nager à fond jusqu'à s'épuiser et se noyer...
La deuxième est celle de la compréhension de la dépression dans la phylogénie des êtres vivants et dans l'ontologie de l'individu en question.

Doctors, drugs and alternative therapies

By Michael Skapinker

When I was a child at summer camp, an epidemic of home-sickness broke out. Several campers presented themselves to the resident medic, who talked to them gently and asked who they were missing most. Those who were pining for their mothers got a pink-coated chocolate. Those missing their fathers (an apparently less virulent condition), received a blue one. From what I observed, the treatment was highly effective.

This was my introduction to the placebo effect. Last month, a team led by Irving Kirsch of Hull University reported that trial data submitted to the US Food and Drug Administration showed that antidepressants were, in most cases, only marginally more effective than placebos.

Now a new study shows expensive placebos are more effective than cheaper ones. Dan Ariely, a Duke University economist, and a team from the Massachusetts Institute of Technology, administered light electric shocks to the wrists of 82 volunteers before and after giving them what they said were painkillers but were really dummy pills.

Half the group were told the pills cost $2.50 each and half that they cost 10 cents each. Of those who took the more expensive placebos, 85 per cent reported feeling less pain, compared with 61 per cent in the 10-cent group.

What is striking is not just the difference between the two groups but how many people in both said the placebos worked.

As my colleague Clive Cookson pointed out on this page on March 1, this was also a notable feature of the Kirsch study, which did not show that anti-depressants were useless. They were not – it was just that placebos worked almost as well.

This has led to debate about whether doctors should prescribe placebos, with Stuart Derbyshire, a psychology researcher at Birmingham University, warning it “would undermine the trust between society and medicine”.

Less often noticed is how many doctors are already prescribing placebos. In her superb new book, Suckers: How Alternative Medicine Makes Fools of Us All, Rose Shapiro says 42 per cent of UK general practitioners prescribe homeopathic treatments or refer patients to homeopaths. Nearly half of Dutch family doctors prescribe homeopathy. In Belgium, 85 per cent do.

All these doctors must know that homeopathic remedies have performed no better than placebos in repeated clinical trials. Homeopathic medicines are so heavily diluted that there is in effect nothing left by the time they are administered.

Homeopaths contend the diluted medicines work because the water in which they are dissolved retains a memory of them. As Ms Shapiro says, water must then retain a memory of everything that has ever been dissolved in it. How, she asks, does water distinguish between homeopathic medicine and, say, the soap from Marilyn Monroe’s bath? “Can water have a selective memory?”

The dilemma for doctors is that people want homeopathy. In the US, where it had almost died out by the 1970s, at least 6m people now go to homeopaths. Boiron, the NYSE Euronext-listed homeopathic company, says 300m people worldwide use homeopathy.

The reasons are complex, but among them is a feeling that doctors do not give patients enough time.

In the UK, the average consultation with a family doctor lasts less than 10 minutes (six to eight minutes in London) and the patient speaks for 23 seconds before being interrupted. An initial homeopathic consultation takes an hour or more, giving patients the sense of being listened to and valued. Many doctors say they would love to do the same, but are under too much pressure to meet targets or clear backlogs of patients. Viewed that way, sending people to talk to homeopaths is a form of outsourcing.

Does it matter? While homeopathic remedies may not do any good, beyond the placebo effect, they do not do any harm either. That is in contrast to herbal medicines (which do have active ingredients and are occasionally effective) or conventional medicines, which can have side-effects that are not always disclosed. Last week, for example, the UK’s Medicine and Healthcare Products Regulatory Agency wrote a stiff letter to GlaxoSmithKline about the drugs group’s tardiness in reporting that children taking the anti-depressant Seroxat could experience suicidal feelings.

Yet, for all their occasional lapses, scientific medicine and the pharmaceutical industry have brought enormous benefits, from the disappearance of smallpox to better survival rates from heart attacks.

It cannot be right for doctors to undermine the scientific method that lies at the heart of their training and practice. The money that doctors are now sending to homeopaths would be better spent on in-house counsellors with time to talk. We could then study whether it is the hours of sympathetic chat that make the difference, or whether you have to prescribe a sugar-coated chocolate too.