1 Boring Old Man

So Dr Szasz has been saying the same thing for 50 years. What makes Ben so wonderful?

Whether Szasz said anything, this TED talk is about really basic concepts in research methods, study design, and data analysis. Entering the mental health world after working in public health evaluation, I was really in disbelief about what was considered evidence in clinical decision-making, and how often process of that decision-making in general was arbitrary, presumptuous, and/or biased. This goes for medication, somatic therapies, and psychotherapies.

I like Goldacre because he still seems to value science in informing/improving medical/health outcomes. It seems to often that the exposure of terribly designed studies and unimpressive results of better designed studies have led a lot of people into two, similar but seemingly oppositional camps.

There are folks (often from the analytic community) who see this data and say “ah ha! See, experimental research and scientific methodology in mental health is wrongheaded and useless. Our clinical wisdom is what is important!” These are the folks who were always skeptical of evaluating treatment efficacy and effectiveness, and especially comparative/experimental studies. The corruption in mental health research is giving them a sense of vindication that they no longer have to hide what they truly do/want to do in practice, and rely primarily on non-specific dynamic principles when treating most anyone. It hearkens back to the doctors in the closed MD only analytic institutes who thought always knew best about mental health without having to document or show convincing evidence.

The other camp is led by the bio-enthusiasts who see the crappy evidence adn say “Regardless of what the data says, our practices show that people do get better (with drugs, this kind of therapy, etc.)! They work! If the data doesn’t show what is working, it was because of inappropriate participants, non-specific nosology, bad placebo controls, not enough time, etc.” The big problem I see with this mentality is that the whole rationale for more specific therapies (drug or otherwise) was based on the premise that researchers should and did demonstrate comparative efficacy and effectiveness of particular interventions for particular issues. This didn’t happen though. So like the more analytic camp, these bio-enthusiasts have decided to rely on their own clinical wisdoms/experiences despite the evidence. This is a little more contradictory for these folks I think, because the whole purpose of having clinical trials is produce research that should inform decision-making beyond personal bias and heuristics. These folks seemed to have wanted good research, but really what they want was data that confirmed their bias. This is not science either, just masking it.

Goldacre demonstrates a much better understanding of basic scientific methods in human research that before my experiences in treatment I naively assumed all doctors and mental health professionals with advanced degrees had. However, it takes lots of researchers with sophisticated understandings of research methods in clinical human sciences to design and conduct novel research that actually assesses key theoretical constructs evaluates treatments in in their effect on actually meaningful outcomes.

People might also find these videos from a recent statistics conference in London of interest:

How to smell a rat: Examples of scientific and regulatory failure – Dr Aubrey Blumsohn – http://www.youtube.com/watch?v=mDxwSr3itEA

Hiding the bodies – Prof. David Healy – http://www.youtube.com/watch?v=xqjjApAcDGY

Q&A – http://www.youtube.com/watch?v=xo8bRaLBcvo

1BOM,

Nathan’s comments is one of the best summaries of this problem that I have ever seen. It both summarizes one of the most powerful reasons that psychiatry was so prone to this poor utilization of clinical science, as well as why it’s been so hard to mount an opposition. Mental health providers seem to always put precedence on their “n of 1” experiments, whether they come from an analytic or psychopharmacology bent. One concerning reason may be the historical preeminence of analysis? The other might be that one can conduct more effective n of 1 experiments in one’s own patients in behavioral sciences than in other areas of medicine. If so, I haven’t hear this clearly articulated. I would really like to hear 1BOM’s take in a full post on the points Nathan is raising. They are fundamental, in my view, to why it seems impossible to ever use larger studie I counter clinical folk wisdom in child mental health. Why it’s impossible to have a negative study that ends up changing practice in psychiatry vs pediatrics. Nathan’s last line is not happening since everyone, pharmaphes and scolds alike, only pay attention to the negative findings that don’t contradict their own clinical experience. Nathan is right to say that none of the sides in mental health care (and I would say doubly so in child mental health) stop doing something they have felt works based on study findings. 1BOM, you were an analyst, what is your take on Nathan’s comment. In other areas of medicine they seem to feel that an individual clinician’s experience is not enough. That their cherished beliefs can be disproven by larger trials. Does this exist in psychiatry? 1BOM, would you apply it to your own sacred cows? Nathan, do you have a blog?

Search out a few Szasz vids. He was the genius that Ben only dreams of. I only say this here because of his dismissal by Mickey. His books were not exciting enough …. what do you want? Dan Brown?

Unfortunately there is no one to take up the mantle of Dr Szasz. He will just disappear into the sands of time. So… I will try and fail to keep his ideas alive for a little bit.

Sorry. I do not post here often. But when I do I mean what I say. I will leave the building now…

Pair this with David Healy’s Pharmageddon and you have a good case for not taking any drugs approved within the last 30 years (or at least those that have been promoted by advertising).

Ben Goldacre, like Szasz, is a Popperian. I don’t know David Healy’s stuff but iatrogenic disease is the third highest cause of death in the US. I just hope I can stay out of a hospital in the UK. I am an old geezer with a dodgy knee but the thought of going into an MRSA riddled ward for an operation fills me with a feeling of dread. Anyway, I digress, but Nathan’s comment makes a very good point. Thanks.