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The psychiatric drug crisis

newyorker.com

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Re: The psychiatric drug crisis

#121

Post by gohrt »

lutusp wrote: post #100
tokenadult wrote: post #99

"Gary Greenberg is a practicing psychotherapist" What evidence does Gary Greenberg provide in his writings that would convince a skeptical onlooker that what he does for his patients is helpful?

> What evidence does Gary Greenberg provide in his writings that would convince a skeptical onlooker that what he does for his patients is helpful? The same question could be asked of any psychologist, psychotherapist or psychiatrist, regardless of their publication record. There are no objective, scientific, rigorous evaluation criteria anywhere in the field, which explain why the mental health field has the reputat…

That quote may have been in context of a psychiatry study, but applies equaly well to huge swathes of medical research.

Re: The psychiatric drug crisis

#122

Post by refurb »

lutusp wrote: post #87
refurb wrote: post #58

Earlier quoted context omitted.

Whoa, wait a second here. Your reference article is arguing that there isn't any difference between these drugs and placebos, so by definition it was a "placebo controlled trial". To say that "double-blind prospective trials are nearly non-existent" is very wrong. Unless you are referring to very old psychiatric drugs, most of them have gone through such trials. There was a lot of disagreement about the paper you ref…

> To say that "double-blind prospective trials are nearly non-existent" is very wrong. You need to read each word and think about it. In a prospective trial, subjects are chosen in advance, they aren't drawn from an existing population of people who have already decided to seek psychological help. A "double-blind, prospective trial" would have to sign people up from a cross-section of the population who have no inter…

Wait a second, "prospective" trial does not mean that you draw patients from a pool who have no interest in treatment. Prospective simply means you have decided what the endpoints will be before the trial begins.

The inverse of a prospective trial is a retrospective trial where you have a set of data and you go looking for signals.

Re: The psychiatric drug crisis

#123

Post by phren0logy »

freyr wrote: post #119
pyre wrote: post #111

Earlier quoted context omitted.

> though it's true, some work no more effective than a placebo Do you have a citation for this? What drugs on the market today are "no more effective than placebo?"

There are many studies. Here's one: http://jama.jamanetwork.com/article.aspx?articleid=185157 This study found that SSRIs provided little to no benefit over placebo for patients suffering from mild to moderate depression. SSRIs did provide a benefit to patients suffering from severe depression. This raises the question, how many of the 30+ million Americans currently prescribed anti-depressants actually suffer from s…

You ignore people who take it for anxiety, where SSRI are uncontrovertibly effective.

Re: The psychiatric drug crisis

#124

Post by tokenadult »

lutusp wrote: post #100
tokenadult wrote: post #99

"Gary Greenberg is a practicing psychotherapist" What evidence does Gary Greenberg provide in his writings that would convince a skeptical onlooker that what he does for his patients is helpful?

> What evidence does Gary Greenberg provide in his writings that would convince a skeptical onlooker that what he does for his patients is helpful? The same question could be asked of any psychologist, psychotherapist or psychiatrist, regardless of their publication record. There are no objective, scientific, rigorous evaluation criteria anywhere in the field, which explain why the mental health field has the reputat…

I think you are saying that we can't be sure that the author of the article kindly submitted here really knows what he is talking about.

Diederik Stapel is a disgrace,

http://retractionwatch.wordpress.com/2013/08/02/measure-by-m...

but he also hasn't had any influence on the clinical practice of psychiatry in the United States, the main topic of the article.

Re: The psychiatric drug crisis

#125

Post by lutusp »

gohrt wrote: post #121
lutusp wrote: post #100

Earlier quoted context omitted.

> What evidence does Gary Greenberg provide in his writings that would convince a skeptical onlooker that what he does for his patients is helpful? The same question could be asked of any psychologist, psychotherapist or psychiatrist, regardless of their publication record. There are no objective, scientific, rigorous evaluation criteria anywhere in the field, which explain why the mental health field has the reputat…

That quote may have been in context of a psychiatry study, but applies equaly well to huge swathes of medical research.

With one important difference -- when a medical procedure or substance is shown to be useless or dangerous, doctors stop using it or go to jail. By contrast, psychologists just carry on with business as usual -- for example, there are still therapists offering recovered memory therapy.

If a medical drug were proven ineffective as anti-depression drugs have, doctors would have to stop prescribing it or be sued for malpractice. You can't sue psychologists for malpractice, because there's no such thing as good psychological practice for comparison.

If psychologists were forced to adopt evidence-based practice, they would be subject to lawsuits for the first time, which is why they have resisted such proposals:

Link: http://www.apa.org/monitor/feb05/pc.aspx

Quote: "Some APA members have asked me why I have chosen to sponsor an APA Presidential Initiative on Evidence-Based Practice (EBP) in Psychology, expressing fears that the results might be used against psychologists by managed-care companies and malpractice lawyers."

The critics were right -- evidence-based practice would have been a disaster for psychology -- and the proposal (2005) was shouted down.

Re: The psychiatric drug crisis

#126

Post by saber_taylor »

phren0logy wrote: post #115
kyro wrote: post #23

Good riddance. Psychiatry by and large is a sham field. Physicians who practice it love seeing themselves as artists who are experts in identifying the subtleties of human behavior. That's their way of saying there's very little underlying science guiding their practice. Many of the diagnoses given are pulled out of thin air and made to justify a patient's admission, or to appease a patient's desire to feel as if the…

I'm a psychiatrist, and I disagree with much of your post. I see below you mentioned going to a psychiatry conference many times, but if it was with the same docs why did you expect a higher level of scientific discourse? It's true that there are crummy psychiatrists, but please don't throw the rest of us under a bus. At our patient conferences, not being to cite articles to back up your treatment plan would be consi…

> We cannot really objectively measure or test pain.

http://en.wikipedia.org/wiki/Dolorimeter

Perhaps you meant in the brain.

Re: The psychiatric drug crisis

#127

Post by kirubakaran »

gohrt wrote: post #120
kirubakaran wrote: post #34

Earlier quoted context omitted.

Disproof : Richard Feynman

How many offspring did Feynman have?

"Feynman would marry twice more and have two children with his third wife." http://www-history.mcs.st-and.ac.uk/Biographies/Feynman.html

Anyway, my point is, being smarter is not an excuse for "cutting one's ears off when trying to woo girls" (re:my parent comment) or for otherwise being socially dysfunctional.

Re: The psychiatric drug crisis

#128

Post by dragonwriter »

lutusp wrote: post #125
gohrt wrote: post #121

Earlier quoted context omitted.

That quote may have been in context of a psychiatry study, but applies equaly well to huge swathes of medical research.

With one important difference -- when a medical procedure or substance is shown to be useless or dangerous, doctors stop using it or go to jail. By contrast, psychologists just carry on with business as usual -- for example, there are still therapists offering recovered memory therapy. If a medical drug were proven ineffective as anti-depression drugs have, doctors would have to stop prescribing it or be sued for mal…

> If a medical drug were proven ineffective as anti-depression drugs have, doctors would have to stop prescribing it or be sued for malpractice.

Anti-depressive (and other psychiatric) drugs are a subset of "medical drugs".

> You can't sue psychologists for malpractice, because there's no such thing as good psychological practice for comparison.

You can, in fact, sue a psyschologist for malpractice [1], but a psychologist isn't going to be prescribing anti-depressants in the first place (and, if they try to, they've got bigger legal problems than potential malpractice, starting with practicing medicine without a license.)

[1] e.g., http://www.insurancejournal.com/news/west/2007/11/19/85123.h...

Re: The psychiatric drug crisis

#129

Post by lutusp »

refurb wrote: post #122
lutusp wrote: post #87

Earlier quoted context omitted.

> To say that "double-blind prospective trials are nearly non-existent" is very wrong. You need to read each word and think about it. In a prospective trial, subjects are chosen in advance, they aren't drawn from an existing population of people who have already decided to seek psychological help. A "double-blind, prospective trial" would have to sign people up from a cross-section of the population who have no inter…

Wait a second, "prospective" trial does not mean that you draw patients from a pool who have no interest in treatment. Prospective simply means you have decided what the endpoints will be before the trial begins. The inverse of a prospective trial is a retrospective trial where you have a set of data and you go looking for signals.

> Wait a second, "prospective" trial does not mean that you draw patients from a pool who have no interest in treatment.

Then it's a good thing that I never said or implied that. The subjects must be drawn from a uniform population, not from a population that have already come forward for treatment -- otherwise the result is biased by the experimental population at the outset.

> Prospective simply means you have decided what the endpoints will be before the trial begins.

No, it means the experimental design doesn't recruit from a pre-existing population of subjects with a history or established preferences, instead you choose random subjects from the population at large.

> The inverse of a prospective trial is a retrospective trial where you have a set of data and you go looking for signals.

There's nothing stopping you from actually learning what these terms mean. A prospective study recruits subjects from the population at large, people with no particular interest in, or knowledge of, the topic being studied. A retrospective study relies on self-selected subjects, people who are already engaged with what you want to study.

For example, let's say I want to study the link between daily vitamin use and intelligence -- do people who take a daily vitamin become more intelligent as a result?

I begin to design a study. Shall I enlist people who already take a daily vitamin (retrospective), or do I enlist people with no interest in the issue, divide them into two groups, make one of the two groups take a daily vitamin, and make the other group take a placebo (prospective)?

See the difference? In the retrospective, any conclusion I make may result from a confusion of cause and effect -- for example, if the vitamin-takers turn out to be more intelligent, that might result from a factor like intelligent people taking a vitamin because of their increased awareness of health issues, in other words, it might be an effect, not a cause.

The prospective experimental and control groups, one of which got a vitamin, and the other which got a placebo, is much more likely to produce a meaningful result.

Re: The psychiatric drug crisis

#130

Post by lutusp »

pyre wrote: post #113
lutusp wrote: post #97

Earlier quoted context omitted.

> And a placebo controlled study is the best evidence for a medical treatment ... Yes, and with respect to the drugs we're talking about, subsequent meta-analyses show that the original studies were all biased in favor of their sponsors and all the drugs produce the same results, which argues for a massive placebo effect. For years, studies were published that appeared to support various drug approaches to mental ill…

If SSRIs are no more effective than placebo, then: * Why do some SSRIs work for some people while others don't? * Why does increasing the dose of a specific SSRI have an increased effect? Is it not possible that the real reason that SSRIs might be no more effective than placebo in clinical trials is that we don't quite understand the reasons that they work yet? (i.e. a specific SSRI might only have a real effect on 1…

> If SSRIs are no more effective than placebo, then:

> * Why do some SSRIs work for some people while others don't?

The placebo effect. Surely you don't think everyone has the same placebo effect? Also, you're not describing the same study with the same participants and different drugs, you're describing different studies, different subjects, and different drugs -- all of which can change the outcome.

> * Why does increasing the dose of a specific SSRI have an increased effect?

The placebo effect. If people believe that a placebo is working, then more placebo produces more illusion.

Also, your use of the term "increased effect" is misleading. The largest doses show an effect, smaller doses show no effect. One theory about that is that the large-dose drug's side effects alert the subjects that they're not in the control group. A proposal has been made to create "active" placebos, placebos that mimic the side effects of the drug under test but not the property under test. This idea hasn't been tried yet.

> Is it not possible that the real reason that SSRIs might be no more effective than placebo in clinical trials is that we don't quite understand the reasons that they work yet?

You're overlooking the fact that placebos produce the same effects as the drugs under test. Our understanding or not understanding isn't an issue, because they've been demonstrated to be indistinguishable from a sugar pill.

And our not having a mechanism is definitely a criticism of this kind of treatment -- it would be like administering a mystery drug that proves essential to health, then deciding to increase the dosage, without understanding that the mystery drug is fatal in large doses (like vitamin A).

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