How Well Do We Understand Probabilities in Medicine? (2016)

Mad in America makes reference to an approach to psychosis from Finland called "open dialogue". http://psychrights.org/Research/Digest/Effective/OpenDialogu...

It was recently re-established that psychosis is linked to cortisol deficiency: https://psychcentral.com/news/2016/06/04/low-morning-cortiso... - the first such linkage was in the 1950's, but this observation was never put to mainstream use.

Psychosis is fundamentally a condition of metabolic stress. Vitamin B-3 (niacin/niacinamide) was found to help patients recover: https://riordanclinic.org/2014/11/niacin-and-schizophrenia-h... http://orthomolecular.org/resources/omns/v13n23.shtml http://orthomolecular.org/resources/omns/v10n18.shtml

> If you can point me to a treatment for schizophrenia tested in quality randomized trials with the success rate of antipsychotics (which is really miserable), please do.

It will be 15-20 years for a randomized trial initiated today to get such a result. Who would pay for such studies? The businesses who've been making $billions on their FDA-approved drugs for decades? The status quo defends itself, and refuses to admit they made a mistake in forcing palliative treatments on vulnerable patients.

Reading some comments in this thread you might think physicians are unable to apply Bayesian statistics to medical care. As a physician myself, I'd encourage a more considered line of thinking.

Clearly, physicians here failed to calculate an exact positive predictive value in the example. The question is does that inability affect their 1) medical care delivered and 2) communication with the patient and the patient's own informed decision-making.

In speaking to 1-- there are many examples to choose from from probably any medical specialty but let's stick to breast cancer screening since that's the example from the article. USPSTF presents their recommendations[1]. I'd encourage anyone with interest to at least skim the rationale presented on the page below those recommendations. They very well consider prevalence as well as efficacy of specific tests given the presence of different risk factors in a patient (age, family history, etc). Importantly, those and many other screening guidelines are applied by primary care physicians who may not otherwise be able to calculate exacting probabilities.

[1] https://www.uspreventiveservicestaskforce.org/Page/Document/...

In speaking to 2-- patient autonomy of course requires an appropriate understanding of the tests they receive, any risk to those tests and the benefits and harms of true positives, false negatives, etc. The associated frequencies, albeit with some degree of imprecision are avaialble by reference and I'd suspect they're memorized by most radiologists reading mammograms and the breast surgeons involved in tested positives-- even if they may not be able to calculate them. If the doctor doesn't have them memorized-- they should be available by referencing the relevant guideline.

I've never once in my life been able to give real informed consent to a physician, because I've never had one able to inform me quantitatively of the risks and benefits of accepting or refusing treatment. So like, I assume, everyone else I pretty much just have to take what the doctor says on blind faith. Since the vast majority of physicians are good people who actually want to help their patients, I'm not entirely uncomfortable with this, but it's still troubling given how many people die every year as a result of interventions or complications thereof.

As I'm sure you're aware, there's a thing called the Dunning-Kruger effect, which predicts that people with less knowledge are more confident in their grasp of the situation than people who really do know what's going on. Reading your comments makes me wonder if perhaps you might want to reflect on whether you've seen 10,000 psychiatric patients on the in-patient wards. If not, I'm guessing you may want to revisit the possibility that the thousands of psychiatrists and nurses on the floors, who have invested their lives in caring for the sick might have a better appreciation for the signal-to-noise ratios that matter in the present topic of discussion.

It seems you consider yourself wise. If that's true, I suspect you will recognize the value of at least projecting humility in the face of the cummulative lifetimes of effort others have invested in a problem.

The opposite side of Dunning-Kruger's coin is that "competent students tended to underestimate their own competence" [0]. I have no idea where I fall on the spectrum, I just try to be observant. I read books, and check references when it seems important. The science library at the nearest State University is quite useful for this purpose. I'm working on a model to help me understand what's going on. There are lots of holes in my model, and I'd certainly take myself straight to the hospital if I sustained a sudden injury (broken bone, etc).

[0] https://en.wikipedia.org/wiki/Dunning%E2%80%93Kruger_effect#...

I have videos from 2 weeks before my friend ran out of alcohol that show she was not psychotic when on her maintenance dose of alcohol. She was with me the weekend her mother said she "disappeared" -- I'd encouraged her to call her mother, but she did not do so. She ran out of alcohol when I took her home. She called me the next morning. I knew something was happening, but I didn't know anything about "psychosis" at the time. If I'd known then what I now know about withdrawal psychosis, I'd have called her mother right away...

I have the affidavits from the hospital's application for court-ordered evaluation, and the psychiatrists' affidavits from her first prosecution for having a "persistent or acute disability" (ambiguity in statute), even though the statutes distinguish between "mental disorders" and conditions resulting from "drug abuse, alcoholism or intellectual disability." I witnessed her deterioration while getting the finest of the mental health industry's standard of care. I drove five hours to retrieve my friend the day after she was released from a "stabilization" that left her more delusional at the end of the week than at the beginning.

There is a resistance against conventional psychiatry because of the field's long history of harmful treatment: Lobotomies, water torture, palliative medications, [edit: electrocution], etc. Robert Whitaker examined the predicament of the "mentally ill" in his first book, Mad in America: https://books.google.com/books?isbn=0786723793

The tragedy of the situation is that the Quakers figured out how to compassionately care for people while they had mental episodes (Ref: Whitaker's book). This was without the benefit of the sciences' contributions to humanity's understanding of our condition. Furthermore, 20th Century Science figured out the physiological considerations behind most so-called "mental" conditions. For some reason, psychiatry didn't incorporate these findings into clinical practice. Whitaker makes the case that psychiatry has been compromised by profiteers in the drug industry in his third book, Psychiatry Under the Influence: https://books.google.com/books?isbn=113751602X

People have rights, even people who are declared to have a "mental disorder", but most such patients have trouble asserting their rights on their own. I had a breakthrough last month, and am now confident that my last 3 years of efforts have not been in vain.

Thank you for reminding me of the importance of humility.