{"id":60955,"date":"2015-10-28T20:21:16","date_gmt":"2015-10-29T00:21:16","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=60955"},"modified":"2015-10-30T16:00:02","modified_gmt":"2015-10-30T20:00:02","slug":"spin-is-for-politicians","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/10\/28\/spin-is-for-politicians\/","title":{"rendered":"spin is for politicians&#8230;"},"content":{"rendered":"<div align=\"justify\" class=\"small\"><img decoding=\"async\" width=\"120\" hspace=\"4\" border=\"0\" align=\"left\" src=\"http:\/\/1boringoldman.com\/images\/neuroskeptic.gif\" \/>On has to be awed by blogger <em><font color=\"#200020\">Neuroskeptic<\/font><\/em> whose scope far exceeds the rest of us combined. Here, he clears up the dilemma I obsessed about recently. When the results of the RAISE study were published a few days ago, the extensive press coverage proclaimed that the NAVIGATE [<font color=\"#200020\">NAV<\/font>] patients received a much lower dose of antipsychotics than those with treatment as usual [<font color=\"#200020\">TAU<\/font>], yet the paper itself said nothing about the drug doses. That&#8217;s a hot issue at the moment. Traditional psychiatric teaching has been that maintenance medication [and plenty of it] was an important ongoing part of treatment to prevent psychotic relapses, whereas an initiative from <font color=\"#200020\">Mad in America<\/font>, the <font color=\"#200020\">British Psychological Society<\/font>, the studies of <font color=\"#200020\">Wunderink<\/font> and <font color=\"#200020\">Harrow<\/font>, etc. suggest that maintenance medication interferes with long term functional recovery. And the ideological and guild-driven overlay on this point hangs heavily over any and all opinions on this matter. So the difference between the media hype and the actual papers caught the eye of many [including yours truly &#8211; see <a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2015\/10\/22\/raising-a-dilemma\/\">raising a dilemma&hellip;<\/a>]. Says Neuroskeptic on this point:    <\/div>\n<blockquote>\n<div align=\"center\" class=\"big\"><a href=\"http:\/\/blogs.discovermagazine.com\/neuroskeptic\/2015\/10\/27\/medication-for-schizophrenia-less-is-more\/\" target=\"_blank\">Medication for Schizophrenia: Less is More?<\/a><\/div>\n<div align=\"center\" class=\"big\"><strong><font color=\"#200020\">Neuroskeptic: Discover Magazine<\/font><\/strong><\/div>\n<div align=\"center\" class=\"small\">By Neuroskeptic<\/div>\n<div align=\"center\" class=\"middle\">October 27, 2015<\/div>\n<p>     <\/p>\n<div align=\"justify\">According <a href=\"http:\/\/www.nytimes.com\/2015\/10\/20\/health\/talk-therapy-found-to-ease-schizophrenia.html?ref=todayspaper&#038;_r=0\" target=\"_blank\"><em>to the New York Times<\/em><\/a> [<em>NYT<\/em>] a week ago, a major new study found that lower doses of antipsychotics are better for the treatment of schizophrenia:<\/div>\n<ul>\n<div align=\"justify\">The findings, from by far the most rigorous trial to date  conducted in the United States, concluded that schizophrenia patients  who received smaller doses of antipsychotic medication and a bigger  emphasis on one-on-one talk therapy and family support made greater  strides in recovery over the first two years of treatment than patients  who got the usual drug-focused care.<\/div>\n<\/ul>\n<div align=\"justify\">The paper, by John M. Kane and colleagues and published in the American Journal of Psychiatry [AJP], is called <a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/26481174\">Comprehensive Versus Usual Community Care for First-Episode Psychosis<\/a> and it presents the results of the NIMH &ldquo;<a href=\"http:\/\/www.nimh.nih.gov\/health\/topics\/schizophrenia\/raise\/index.shtml\">RAISE<\/a>&rdquo; study. Three days ago the <em>NYT<\/em> accordingly issued a correction:<\/div>\n<ul>\n<div align=\"justify\">An article on Tuesday about a study of the treatment of  first-episode schizophrenia referred incorrectly to the conclusions of  the study. Though it studied a program intended to reduce medication  dosages, the researchers do not yet know for sure if dosages were  lowered or by how much. Therefore, the study did not conclude &ldquo;that schizophrenia patients  who received smaller doses of antipsychotic medication and a bigger  emphasis on one-on-one talk therapy and family support made greater  strides in recovery.&rdquo;<\/div>\n<\/ul>\n<div align=\"justify\">Which is more like it.<\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\">Well, it is more like it &#8211; but questions abound. The media reports were so what people want to hear that it&#8217;s hard not to wonder if expectations didn&#8217;t drive some of the reporting.<\/div>\n<p align=\"justify\" class=\"small\"><font color=\"#200020\">Actually, it&#8217;s what I want to hear too. I<strong> <em>never didn&#8217;t think<\/em><\/strong> that a broad intensive focus on the individual and the family with adequate resources [including brief hospitalization when required] along with the careful use of medications was the right approach to these patients. I thought it in the 1970s and in all the years in between. My only recent questions have been whether the RAISE version is the right version and whether it will convince the powers that be to implement some version widely.<\/font><\/p>\n<div align=\"justify\" class=\"small\">Neuroskeptic goes on, finding even more information:<\/div>\n<blockquote>\n<p align=\"justify\">The intervention was in fact a complex mix of family and individual  support and therapy, supported activities and employment, and a  computerized medication management system called COMPASS.<\/p>\n<p align=\"justify\">One of the features of COMPASS is that it recommends doctors to use  lower doses of antipsychotics than they otherwise might. The <a target=\"_blank\" href=\"https:\/\/raiseetp.org\/studymanuals\/Psychopharmacology%20Manual.pdf\">COMPASS manual<\/a>  advises that people suffering their first psychotic episode are more  sensitive to antipsychotics, and so lower doses will suffice, compared  to chronic schizophrenia patients. However, Kane et al. report no information on dosage so we don&rsquo;t know if the intervention group were actually <em>taking<\/em> lower doses than the controls.<\/p>\n<div align=\"justify\">So where did the focus on medication dosage come from? Possibly from <a target=\"_blank\" href=\"http:\/\/www.nimh.nih.gov\/news\/science-news\/2015\/team-based-treatment-is-better-for-first-episode-psychosis.shtml\">this NIMH press release<\/a> from 20th October, the same day the <em>NYT<\/em> story ran, which says that RAISE<\/div>\n<ul>\n<div align=\"justify\">Featured a team of specialists who worked with each  client to create a personalized treatment plan. The specialists offered  recovery-oriented psychotherapy, low doses of antipsychotic medications,  family education and support&hellip;<!--<div-->Featured a team of specialists who worked with each  client to create a personalized treatment plan. The specialists offered  recovery-oriented psychotherapy, low doses of antipsychotic medications,  family education and support&hellip;<!--<div-->Featured a team of specialists who worked with each  client to create a personalized treatment plan. The specialists offered  recovery-oriented psychotherapy, low doses of antipsychotic medications,  family education and support&hellip;<\/div>\n<\/ul>\n<div align=\"justify\">Which is technically true, but a little ambiguous. &ldquo;Offered low  doses&rdquo; could be read as implying &ldquo;provided low doses&rdquo;, and presumably  the <em>NYT<\/em> article was based on such a reading, yet there&rsquo;s no  evidence to suggest that the doses provided were actually lower than in  the control group. Even if the doses <em>were<\/em> lower, we don&rsquo;t know if the low doses  were contributing to the better outcomes in the intervention group,  because that group got all kinds of other extra treatments as well [e.g.  family therapy, supported education]. Theoretically the lower doses might have been <em>harmful<\/em> if the  harm was outweighed by the other beneficial stuff. Or equally, the  lower doses might account for all the benefit. We just don&rsquo;t know.<\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\">Reading the actual paper [<a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/26481174\">Comprehensive Versus Usual Community Care for First-Episode Psychosis<\/a>], there were two conclusions that were clear. First, they brought it off. Working in existing, non-academic centers, they had a program for Initial Schizophrenic Episode patients that worked. The graphs I [somewhat facetiously] called Quality Assurance graphs documented that they retained patients and it helped. With this population, that&#8217;s an accomplishment in its own right. The second achievement or finding was that the earlier the intervention, the better the results. So good for them. <\/div>\n<p align=\"justify\" class=\"small\">Looking over their Manuals [<a href=\"https:\/\/raiseetp.org\/studymanuals\/Psychopharmacology%20Manual.pdf\" target=\"_blank\">COMPASS<\/a>, <a href=\"https:\/\/raiseetp.org\/studymanuals\/IRT%20Complete%20Manual.pdf\" target=\"_blank\">INDIVIDUALIZED RESILIENCY TRAINING<\/a>] and the <a target=\"_blank\" href=\"http:\/\/www.nimh.nih.gov\/news\/science-news\/2015\/team-based-treatment-is-better-for-first-episode-psychosis.shtml\">NIMH Press Release<\/a>, I have complaints. The COMPASS Manual is algorithmic and recommends only second generation antipsychotics. I&#8217;m not at all sure I agree with that. The metabolic syndrome is not always less ominous than the neurological side effects of the first generation drugs in my hands. And I&#8217;m not at all in love with the IRT approach which is not as focused on the Schizophrenic cognitive problems as I would prefer. However, I&#8217;m no expert, and there&#8217;s plenty of room for iteration in both areas. <\/p>\n<p align=\"justify\" class=\"small\">But as much as I appreciate Neuroskeptic&#8217;s detective work, I don&#8217;t buy that &quot;<em><font color=\"#200020\">we just don&#8217;t know<\/font><\/em>&quot; about the medication doses. I&#8217;m suspicious that &quot;<em><font color=\"#200020\">we just weren&#8217;t told<\/font><\/em>.&quot; That data is in some perfectly adequate computer database and there are more than enough statisticians involved in this project to extract it for us. So I&#8217;m suspicious that it doesn&#8217;t quite show what they want it to show, and&nbsp; that&#8217;s why &quot;<em><font color=\"#200020\">we just don&#8217;t know<\/font><\/em>.&quot; Likewise, that confusing Table 2 in the paper is unnecessarily obtuse. There are a lot more intelligible ways to display the outcome that they didn&#8217;t choose. So I smell something fishy, hear something spinning. Time will tell. <\/p>\n<div align=\"justify\" class=\"small\">If there is &quot;<em><font color=\"#200020\">spin<\/font><\/em>&quot; in the reporting of this study, we need to know about it. I personally think that it&#8217;s more important for RAISE to be reported completely and honestly than whether it comes out like they [or I] want it to come out. <font color=\"#200020\">We don&#8217;t need some sanitized version of RAISE to tell us we need to turn our attention to a full bodied approach to the treatment of First Episode psychotic patients. We all already know that. What we do need is to have our confidence restored in our research community &#8211; that they will honestly and clearly report their findings whether they are clean as a whistle or an unholy mess. <em><strong>Spin is for politicians and pitchmen &#8211; not scientists<\/strong><\/em><\/font>&#8230;<font color=\"#200020\"><\/font> <\/div>\n","protected":false},"excerpt":{"rendered":"<p>On has to be awed by blogger Neuroskeptic whose scope far exceeds the rest of us combined. Here, he clears up the dilemma I obsessed about recently. When the results of the RAISE study were published a few days ago, the extensive press coverage proclaimed that the NAVIGATE [NAV] patients received a much lower dose [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[5],"tags":[],"class_list":["post-60955","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/60955","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=60955"}],"version-history":[{"count":14,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/60955\/revisions"}],"predecessor-version":[{"id":60986,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/60955\/revisions\/60986"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=60955"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=60955"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=60955"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}