Steering Psychiatry in the right direction

ClocksForward

Hi folks, this is my second post so just bare with me. I am very concerned at the increasing rate in which SSRI's and other classes of newer Antidepressants, not to mention stimulants like Ritalin are being prescribed despite evidence countering claims of high efficacy rates. Please consider the following articles to stir up some points.

Marcia Angell: "The illusions of biological Psychiatry"
Carl O Brien(Irish Times): A conflict of Interest?
Dan Buckley and Fiachra O Cionnaith(examiner.ie):
Doctors risk "professional suicide" with Drug Alerts
Dr Ben Goldacre: "This is a very broke system"
Dr Peter D Kramer: "In Defense of Anti Depressants"
Gary Greenberg:"Inside the battle to define mental illness"

There is much interesting and valid talk about homeopathy here, and while I respect that discussion and it's intentions, I don't feel this issue is recieving enough due attention. Homeopathy will be discredited by any reasonable person, but the pharma research is published in the hopes that the research is fully legitimate with best intentions. Most will dispell the alternative medicine quacks outright, but it's a little sinister to push this bad science into the mainstream without questioning it's validity and outcomes on the frontline.

FWIW I do not claim that mental illness isn't debilitating for any individual unlucky enough to suffer from one, just that medical science has not progressed in a sufficient capacity to discern the non mentally ill from the mentally ill, and I do have my sympathies. I do not however accept that treating mentally ill mental patients with drugs marginally better than a placebo is the best way forward. We need to move in the direction of Neuroscience for these answers, not lying to ourselves by stating "it's a chemical imbalance" etc etc.

Hopefully this thread will spark some reasonable thought provoking discussion on the way forward for mental illness, not by being a zealot and simply denying this misunderstood concept. Mental Illness exists, it's just we don't know how to objectively measure it yet. There is alot of money and power at stake here, so while I don't believe I will get balanced views all of the time, I am open to considering any comments no matter how unreasonable.

This really is a matter of national safety and civil liberty at stake. What if the long term outcomes from these drugs result in severe medical problems down the line? Now is the perfect time to revolutionize Psychiatry through Neuroscience:http://www.nimh.nih.gov/about/director/publications/psychiatry-as-a-clinical-neuroscience-discipline.shtml The sooner this area advances, the more respect this field of Medicine will gain from the general populace. The game isn't over yet. Not by a long shot. The brain is without a doubt the most complex organ left to fully uncover.

Thanks for reading this.

nesf

Come back to me after you've seen someone in a nasty depression being given badly needed relief after being put on Prozac or whatever. Or learn that there's more to antidepressants than SSRIs, that'd be handy too. Or perhaps look at all the other areas of psychiatry and the treatment of psychosis and similar.

I don't mean to be rude, but it's a lot broader than you're making out and there's a large push to use every and any treatment with evidence behind it (psychotherapy, mindfullness etc) by the medical profession here which is overlooked by many of the antipsychiatry people.

ClocksForward

nesf wrote: »

Come back to me after you've seen someone in a nasty depression being given badly needed relief after being put on Prozac or whatever. Or learn that there's more to antidepressants than SSRIs, that'd be handy too. Or perhaps look at all the other areas of psychiatry and the treatment of psychosis and similar.

I don't mean to be rude, but it's a lot broader than you're making out and there's a large push to use every and any treatment with evidence behind it (psychotherapy, mindfullness etc) by the medical profession here which is overlooked by many of the antipsychiatry people.

Psychosis is another matter entirely which I have not researched properly, I will agree with you there. Most anti-psychotics are leaps and bounds ahead of anti depressants. It's not a question that people in the depths of suicide inducing Depression should be denied Prozac or even the newer SNRI's, that is a medical judgement. I am more concerned with the vast overprescription of these drugs despite poor efficacy rates.

Is it not reasonable to question the anatomical changes caused by these drugs may not show physical changes in subjects for at least several years? What happens if we have a situation whereby millions of people end up with altered brain structures as a result of throwing foreign chemicals into a finely tuned machine for decades on end?. A spanner in the works so to speak.

I am concerned about what the fallout from mass prescription will be in say....20-40 years. Should these drugs continue to be widely administered despite a poor understanding(if any) of their respective mechanism of action, not to mention the fact that a shift away from these drugs would instead focus more resources into Neuroscience, where a blackbox view of the brain will be smashed into pieces. Money would be much better spent in that arena I think.

Granted, these drugs are probably the best we have at present. It's a shame Depression is such a complex illness:( It's a shame that the general public is misinformed about how much is actually understood about Mental Illness, despite the actual findings.

nesf

ClocksForward wrote: »

Psychosis is another matter entirely which I have not researched properly, I will agree with you there. Most anti-psychotics are leaps and bounds ahead of anti depressants. It's not a question that people in the depths of suicide inducing Depression should be denied Prozac or even the newer SNRI's, that is a medical judgement. I am more concerned with the vast overprescription of these drugs despite poor efficacy rates.

Is it not reasonable to question the anatomical changes caused by these drugs may not show physical changes in subjects for at least several years? What happens if we have a situation whereby millions of people end up with altered brain structures as a result of throwing foreign chemicals into a finely tuned machine for decades on end?. A spanner in the works so to speak.

I am concerned about what the fallout from mass prescription will be in say....20-40 years. Should these drugs continue to be widely administered despite a poor understanding(if any) of their respective mechanism of action, not to mention the fact that a shift away from these drugs would instead focus more resources into Neuroscience, where a blackbox view of the brain will be smashed into pieces. Money would be much better spent in that arena I think.

Granted, these drugs are probably the best we have at present. It's a shame Depression is such a complex illness:( It's a shame that the general public is misinformed about how much is actually understood about Mental Illness, despite the actual findings.

Well the issue is:

We don't have better options in some cases.
They're the best we have pharmacy wise.
Depression is seriously dehabilitating and needs to be treated.


Now where I'd agree there is a problem is that in many cases of mild depression and similar where psychology would be a better option drugs are prescribed by GPs. Some of this is a lack of knowledge but most of it due to drugs being cheap and psychotherapy being expensive to provide and there just aren't enough public psychotherapists out there to fulfil demand and private psychotherapy is another €60 a session at minimum for a therapist and upwards of €150 a session if you need a clinical psychologist. It's just not an option for many/most people.

ClocksForward

nesf wrote: »

Well the issue is:

We don't have better options in some cases.
They're the best we have pharmacy wise.
Depression is seriously dehabilitating and needs to be treated.


Now where I'd agree there is a problem is that in many cases of mild depression and similar where psychology would be a better option drugs are prescribed by GPs. Some of this is a lack of knowledge but most of it due to drugs being cheap and psychotherapy being expensive to provide and there just aren't enough public psychotherapists out there to fulfil demand and private psychotherapy is another €60 a session at minimum for a therapist and upwards of €150 a session if you need a clinical psychologist. It's just not an option for many/most people.

It's true that Psychotherapy would tend to be alot more expensive than drug treatment. Regardless of the mechanism, nobody should go through the hell of Depression or any other mental illness. While drugs are probably the best treatment available at the moment, efforts into researching other solutions should be put forward instead of relying solely on drugs for every patient. I don't think any of the above links questions the damage of these illnesses, just that other options should be put forward on the table when drugs don't work very well for mild/moderate depressed folk. Who knows, in 20 years we might be able to pinpoint Depression with pinpoint accuracy through Neuroscience:) I hope this approach will eventually lead to a much lower suicide rate. Progress is badly needed in this underfunded area of research.

Best of luck,
ClocksForward

dissed doc

ClocksForward wrote: »

Hi folks, this is my second post so just bare with me. I am very concerned at the increasing rate in which SSRI's and other classes of newer Antidepressants, not to mention stimulants like Ritalin are being prescribed despite evidence countering claims of high efficacy rates. Please consider the following articles to stir up some points.

Remember of course that 95% of SSRIs are prescribed by non-psychiatrists - mostly GPs/family doctors, and that the evidence for methylfenidate shows efficacy higher than even triple therapy antibiotics for H Pylori (causing acid reflux).

Perhaps you are mixing up psychiatry with non-medical problems. Psychiatric treatments work well for psychiatric disorders diagnosed by trained psychiatrists. The increase in prescribing rates is mostly due to lack of psychiatric assessment in the "diagnosis". This includes ADHD.

So, please focus on non-psychiatrists attempting to diagnose and critically assess mental health disorders; everyone seems to be an expert in this it appears, despite lacking the 14 years of training usually needed.

WalterMitty

There have been people on SSRI like drugs for decades. Clomipramine is effectively a ssri and used since 60s i beleive and prozac since late 80s. No disastrous results of using such medications have been disvoered.For many people the use of medications long term is not ideal but essential when talk and behaviour therapy doesnt do enough by itself. There is only so much talk and behaviour therapy can do.

boardswalker

WalterMitty wrote: »

No disastrous results of using such medications have been disvoered.

For someone to make that statement they cannot have read any of the articles in the OP. There has been a major debate about this in many fora over the past year.

Maybe you could explain, why the Irish Medicines Board had to issue a statement in Dec 03 which included the following

“The Irish Medicines Board today confirmed that Selective Serotonin Reuptake Inhibitors, (SSRIs) are not and have never been licensed for use in children (under 18 yrs) in the treatment of Major Depressive Disorder (MDD) in Ireland. The IMB is fully aware of the review undertaken by the UK expert group, details of which were announced today and wishes to re-emphasise that SSRIs are not recommended for use in the treatment of MDD in children in Ireland, as the risks of treatment with certain SSRIs are considered to outweigh the benefits of treatment in this condition.”

It is now accepted that SSRIs can increase suicidal tendencies in children, teenagers and young adults.

As an aside SSRI's can be prescribed in Ireland for that group despite never having been licensed for that purpose and despite their being no evidence to support their efficacy. How is that Evidence Based Medicine?

RobFowl

boardswalker wrote: »

As an aside SSRI's can be prescribed in Ireland for that group despite never having been licensed for that purpose and despite their being no evidence to support their efficacy. How is that Evidence Based Medicine?

All medications can be prescibed "off licence" but the prescribing Doctor takes on full responsability for any effects.
Off licence use does not mean there is no evidence btw.

ClocksForward

It's very disturbing when you consider Dr Patricia Casey has issued statements to the press claiming that Depression is a purely biological disease that requires lifelong medication. How apt, a disease which "requires" SSRI's despite a lack of empirical evidence:) Vested interests are the key here. The Iona Institute is a religious organisation with ties to Psychiatric services in Ireland. I don't mind Religion, but I don't want it influencing medication decisions.

Dr Casey has stated in the past that:

“Around 50% of people do not have a trigger or risk factors for depressive illness”, she said. “The outcome for those who get treatment is very good. It is also important to be aware too that antidepressants are not addictive”. The newer antidepressants also begin working much faster, within days, compared with older treatments. These medicines also help ‘re-wire’ the brain so that thinking processes work better." http://www.irishhealth.com/article.html?id=5342

Now, where is the empirical evidence to back up these claims? If the above links are anything to go by, the IMB and the Psychiatric profession in this country serves simply as a vehicle to sell drugs and label people for profit despite the problems associated with these "medications". This is most worrying. It's up to the people making the claims that these drugs are safe, not for others to disprove a claim. The Null hypothesis is a key element when you consider the claims made without evidence here.

boardswalker

RobFowl wrote: »

All medications can be prescibed "off licence" but the prescribing Doctor takes on full responsability for any effects.
Off licence use does not mean there is no evidence btw.

What it does mean is that there was insufficient evidence to allow the product be licensed. That's still not evidence based.

And we have since learned that the evidence submitted in supporting a licensing application may well be incomplete.

saa

This might be more relevant to welfare but people in the US can claim disability if they are unable to work because of a mental illness, I wonder what stance our government has on people unable to work because as mentioned above it can be difficult to "prove" a person is mentally ill and furthermore that they cannot work especially if they are not in an program or institution.

ClocksForward

saa wrote: »

This might be more relevant to welfare but people in the US can claim disability if they are unable to work because of a mental illness, I wonder what stance our government has on people unable to work because as mentioned above it can be difficult to "prove" a person is mentally ill and furthermore that they cannot work especially if they are not in an program or institution.

Well a big part of the problem is that Psychology and Psychiatry follow the "normative" theory devised by a nutter called BF Skinner. Behaviors are regulated by a statistical curve where the norms are defined as what most people are doing ie going to work and not appearing weird or strange and such. They want you slap bang in the middle. A drone for corporatism.

A deviance from these norms is considered most worrying, ie a person who is suicidal and refusing to get out of bed to go to work is not seen as suffering due to their disgust with modern society, simply that it's a lifelong condition that requires treatment. Is it any wonder people feel this way when you consider we are compelled to drug people who do not agree with western practices into oblivion?

Behaviorism underlies the entirety of the Psychiatric system. You don't follow our norms, you will be judged and medicated as required. The DSM is designed in such a manner that you could walk into a Psychiatric office and come out with at least one "label". Oppositional Defiant Disorder - A truly terrifying Mental Illness:rolleyes: No matter what, they will find something wrong with you.

Apathy/Depression + context = true empathetic understanding
Apathy/Depression - context + biological explanation + drugging = not getting to the core of the problem. Namely society is mostly to blame for these ills.

This is a lot of philosophical jibber jabber I admit, but these explanations underlie the very core values that make up the Psychiatric profession in this country. google "bf skinner behaviorism". It's actually fascinating to read how the bible of mental health is derived from this practice of not treating people as humans, but simply animals that require social conditioning:cool:

nesf

boardswalker wrote: »

What it does mean is that there was insufficient evidence to allow the product be licensed.

No it doesn't! What it means is that the company did not spend the millions required to get the drug licensed for a particular purpose. That is all. You can have a mountain of evidence showing a drug is good for a purpose and the company might never bother to licence it for the purpose since doctors are prescribing it off-label for it anyway. An example is the anti-epileptics used as mood stabilisers, very effective but for the most part not all are licensed for that purpose. There's an absolute ton of evidence showing they work though.

nesf

ClocksForward wrote: »

Well a big part of the problem is that Psychology and Psychiatry follow the "normative" theory devised by a nutter called BF Skinner. Behaviors are regulated by a statistical curve where the norms are defined as what most people are doing ie going to work and not appearing weird or strange and such. They want you slap bang in the middle. A drone for corporatism.

A deviance from these norms is considered most worrying, ie a person who is suicidal and refusing to get out of bed to go to work is not seen as suffering due to their disgust with modern society, simply that it's a lifelong condition that requires treatment. Is it any wonder people feel this way when you consider we are compelled to drug people who do not agree with western practices into oblivion?

Behaviorism underlies the entirety of the Psychiatric system. You don't follow our norms, you will be judged and medicated as required. The DSM is designed in such a manner that you could walk into a Psychiatric office and come out with at least one "label". Oppositional Defiant Disorder - A truly terrifying Mental Illness:rolleyes: No matter what, they will find something wrong with you.

Apathy/Depression + context = true empathetic understanding
Apathy/Depression - context + biological explanation + drugging = not getting to the core of the problem. Namely society is mostly to blame for these ills.

This is a lot of philosophical jibber jabber I admit, but these explanations underlie the very core values that make up the Psychiatric profession in this country. google "bf skinner behaviorism". It's actually fascinating to read how the bible of mental health is derived from this practice of not treating people as humans, but simply animals that require social conditioning:cool:

Um, have you ever talked to a psychiatrist about diagnosing people? It's way more subtle than that.

I think you may be confusing GPs and such overdiagnosing mental illness with psychiatrists doing so.

ClocksForward

nesf wrote: »

Um, have you ever talked to a psychiatrist about diagnosing people? It's way more subtle than that.

I think you may be confusing GPs and such overdiagnosing mental illness with psychiatrists doing so.

No doubt there are some very empathetic and knowledgeable Psychiatrists out there who slip through the cracks and actually want to help their patients and their ills. You need a degree in medicine to be even considered for this subset of medicine. It's just slightly worrying how closely tied Psychiatry is to the pharma industry. Money corrupts as they say.

However, to truly understand the general principles behind this modern practice it is necessary to understand why and how these practices came about and how they were integrated into modern society. It's not enough to simply dismiss the whole field as rubbish, but to research the theories behind the practice and evaluate how we can improve this area of medicine.

It's not enough to simply say enough has been done. I truly believe Psychiatry will be revolutionized with the introduction of Neuroscience. Medication may be the best we have at present, but that is not enough to say that it's how things should be. We can do better. Mental Illness is the scourge of modern society. We should stop treating people like robots.

boardswalker

nesf wrote: »

No it doesn't! There's an absolute ton of evidence showing they work though.

You are obviously totally unaware of the debate currently raging about the benefits of SSRIs.

A meta-analysis, was carried out in 2008/2009 by the psychologist Irving Kirsch, of trials of a half dozen popular antidepressants submitted by drug companies to the U.S. Food and Drug Administration. Many of the studies had never been published because they failed to yield positive results.

Kirsch’s analyses of the FDA data showed that the difference between antidepressant drugs and placebos is not clinically significant, according to the criteria used by the National Institute for Health and Clinical Excellence (NICE), which establishes treatment guidelines for the National Health Service (NHS) in the UK.

Instead of shooting from the hip, please do a small bit of research.

In July of this year, in response to several articles and books highlighting failures of psychiatric drugs, the NY Times ran a piece by a defender of SSRIs. This has provoked a lot of discussion and I am very surprised that you are not aware of it.

At best, you could conclude that the jury is out.

nesf

boardswalker wrote: »

You are obviously totally unaware of the debate currently raging about the benefits of SSRIs.

A meta-analysis, was carried out in 2008/2009 by the psychologist Irving Kirsch, of trials of a half dozen popular antidepressants submitted by drug companies to the U.S. Food and Drug Administration. Many of the studies had never been published because they failed to yield positive results.

Kirsch’s analyses of the FDA data showed that the difference between antidepressant drugs and placebos is not clinically significant, according to the criteria used by the National Institute for Health and Clinical Excellence (NICE), which establishes treatment guidelines for the National Health Service (NHS) in the UK.

Instead of shooting from the hip, please do a small bit of research.

In July of this year, in response to several articles and books highlighting failures of psychiatric drugs, the NY Times ran a piece by a defender of SSRIs. This has provoked a lot of discussion and I am very surprised that you are not aware of it.

At best, you could conclude that the jury is out.

I was obviously not talking about SSRIs but drugs in general. There's plenty of evidence for off-label use of some drugs etc.

ClocksForward

nesf wrote: »

I was obviously not talking about SSRIs but drugs in general. There's plenty of evidence for off-label use of some drugs etc.

I suppose SSRI's are demonzied in the media, but I would agree with you when you that not all medications are bad, the anti-psychotics do serve a very usefull purpose for example. These drugs don't sell on the same level as SSRI's though.

These medications have their purpose, nobody is debating that. Individual cases is not the focus of this attention, any physician worth their salt would know when these drugs should be prescribed. You are 100% correct when you state GP's are handing these drugs out willy nilly. There is financial incentive to do this.

The bigger issue is that there is deliberate collusion between the drug firms and medical staff to over prescribe even in cases of mild/moderate Depression. To be fair, the drug firms are mostly to blame for this. Profitable, but not exactly ethical.

FWIW - psychosis and suicidal inducing depression are very serious, nobody can dispute that or any other real illness. On the other hand, It's worrying how the diagnostic criteria is stretched far and wide to include people who really aren't truly mentally ill.

Mental Illness is a big big problem. It's just the integrity of treating the real sufferers is compromised by focusing too much attention on the periphery cases. I would prefer more research going into psychosis and the like instead of pumping little johnny full of whatever new drug because he is oppositionally non compliant with whatever the teacher up front is saying.

boardswalker

nesf wrote: »

I was obviously not talking about SSRIs but drugs in general. There's plenty of evidence for off-label use of some drugs etc.

You responded to a very specific post about SSRIs so you were talking about SSRIs, whether you realised it or not.

By the way, I love the way you use scientific data to back up your posts.

Plenty of evidence! Really?
Have you read any of the links at all. Read Irving Kirsch's study. That's not just about SSRIs. He compared anti-depressants to placebos.

Jimoslimos

boardswalker wrote: »

You are obviously totally unaware of the debate currently raging about the benefits of SSRIs.

A meta-analysis, was carried out in 2008/2009 by the psychologist Irving Kirsch, of trials of a half dozen popular antidepressants submitted by drug companies to the U.S. Food and Drug Administration. Many of the studies had never been published because they failed to yield positive results.

I have no doubt that serious questions need to be answered regarding rife publication bias by pharma companies

But the fact that this study was carried out by a psychologist, not an actual medical doctor - never actually prescribed a drug in his life makes me automatically suspicious. There is a conflict of interest here.

boardswalker

Jimoslimos wrote: »

I have no doubt that serious questions need to be answered regarding rife publication bias by pharma companies

But the fact that this study was carried out by a psychologist, not an actual medical doctor - never actually prescribed a drug in his life makes me automatically suspicious. There is a conflict of interest here.

It was a meta-analysis and he specifically included data from all trials carried out whether published or not, not just the data that was included in submission. So he did not carry out the underlying studies.

By the way, his findings seem to be generally accepted at this stage.

ClocksForward

Jimoslimos wrote: »

I have no doubt that serious questions need to be answered regarding rife publication bias by pharma companies

But the fact that this study was carried out by a psychologist, not an actual medical doctor - never actually prescribed a drug in his life makes me automatically suspicious. There is a conflict of interest here.

Evaluate the argument on the strength presented, not on the lack of his medical credentials:pac: Marcia Angell was editor in chief of arguably the most respected medical journal in the world. She is a highly respected medical professional and knows what she is talking about. She basically is in agreement with his argument.

The fact that the man who wrote the DSM is calling bull**** on the diagnostic procedures in relation to overprescription is also pretty worrying. This is a matter of public interest. Public Health is at stake here.

nesf

boardswalker wrote: »

You responded to a very specific post about SSRIs so you were talking about SSRIs, whether you realised it or not.

By the way, I love the way you use scientific data to back up your posts.

Plenty of evidence! Really?
Have you read any of the links at all. Read Irving Kirsch's study. That's not just about SSRIs. He compared anti-depressants to placebos.

If I was making a controversial point I'd back it up with studies, however the point I made about the evidence for off-label use in some circumstances is well known and accepted in general. Trileptal an anti-convulsant, is widely used as a mood stabiliser in bipolar despite not being licensed for it. Widely prescribed and if you do a search on PubMed you'll find plenty of studies showing its effectiveness. Some of the actual doctors on here could give you far more examples.

I also responded to a general far reaching point made in a SSRI specific post. It was clear as far as I'm concerned that I was arguing against your assertion that if something is being used off-label then it has to not have enough evidence.

RobFowl

nesf wrote: »

If I was making a controversial point I'd back it up with studies

nesf wrote: »

Um, have you ever talked to a psychiatrist about diagnosing people? It's way more subtle than that.

I think you may be confusing GPs and such overdiagnosing mental illness with psychiatrists doing so.

I think allegations that GP's are overdiagnosing mental illness is controversial.
Most evidence suggests that GP's underdiagnose it...

For example this famous study http://archpsyc.ama-assn.org/cgi/content/abstract/48/8/700

Jimoslimos

boardswalker wrote: »

It was a meta-analysis and he specifically included data from all trials carried out whether published or not, not just the data that was included in submission. So he did not carry out the underlying studies.

By the way, his findings seem to be generally accepted at this stage.

ClocksForward wrote: »

Evaluate the argument on the strength presented, not on the lack of his medical credentials:pac: Marcia Angell was editor in chief of arguably the most respected medical journal in the world. She is a highly respected medical professional and knows what she is talking about. She basically is in agreement with his argument.

The fact that the man who wrote the DSM is calling bull**** on the diagnostic procedures in relation to overprescription is also pretty worrying. This is a matter of public interest. Public Health is at stake here.

I wonder, would he be so keen to put his name on a paper showing no significant differences in treatment outcomes between clinical psychologists and homeopaths, faith healers, astrologers or <insert quack of choice>.

But yes, I can agree that it is of the utmost importance that the trial data was brought to light. Psychiatry suffers most from its subjective nature in diagnosing and then in treatment prognosis. Pharma have been able to jump on this flaw and exploit it so their products reach the widest possible audience. It is much harder to do this with a drug that has a measurable physiological effect, although not impossible and drug companies have often succeeded in blurring the lines between this and actual treatment efficacy.

I'll also throw in a possible hypothesis on the observed increase of suicide in young people treated with SSRIs.

• People who are very seriously clinically depressed don't often commit suicide - Suicide requires a certain level of determination and commitment missing from severely depressed individuals.
• Patient prescribed anti-depressants - they work, to a point, but by reaching a level where the individual feels motivated enough to take their own life.

Feel free to throw any criticisms this way, as I said its only a suggestion.

ClocksForward

Jimoslimos wrote: »

I wonder, would he be so keen to put his name on a paper showing no significant differences in treatment outcomes between clinical psychologists and homeopaths, faith healers, astrologers or <insert quack of choice>.

I am going to flak for this but anyway...I would probably consider psychology as more akin to a secular belief system/religion than a science. I mean you can't really falsify most psychological theories as you could in say physics.

You sure as hell don't have the same degree of control over variables as you would in say Physics. Not to mention any of the psychs I have had the displeasure of dealing with simply hide behind the argument that "because the brain is so complex, of course our study is limited":)

Not saying psychology isn't scientific outright, some theories may or may not have merit, but on the whole, there is alot of bull**** in this field. Think I might send one of these items on the way to that psych: http://www.amazon.com/Gemmy-Bullsh-t-Button/dp/B000L70MQO

BF Skinner had some questionable theories. No if's or but's here.

boardswalker

nesf wrote: »

I also responded to a general far reaching point made in a SSRI specific post. It was clear as far as I'm concerned that I was arguing against your assertion that if something is being used off-label then it has to not have enough evidence.

Speaking very specifically about SSRIs and teenagers, they were widely used off label but now we know that the evidence shows they increase suicidal tendencies. That's a fact. There was a lot of publicity about it at the time.
A drug was widely prescribed off label for teenagers and young adults and there was no evidence that it was effective for teenagers and young adults.

In fact, the manufacturers had evidence to the contrary but chose not to publish. However, it all came out.

boardswalker

Jimoslimos wrote: »

I wonder, would he be so keen to put his name on a paper showing no significant differences in treatment outcomes between clinical psychologists and homeopaths, faith healers, astrologers or <insert quack of choice>.

I suspect he might, because his studies originated in work about the placebo effect. I am sure he could do the study you suggest and link any results into the placebo effect.

nesf

RobFowl wrote: »

I think allegations that GP's are overdiagnosing mental illness is controversial.
Most evidence suggests that GP's underdiagnose it...

For example this famous study http://archpsyc.ama-assn.org/cgi/content/abstract/48/8/700

I'll accept that counterargument. My thinking was coming from the overprescription of anti-depressants by GPs (in many countries from what I've read). Don't have any links to hand though.

ClocksForward

Just came across a really interesting article in reference to the future of Psychiatry. It's moving towards Neuroscience. No reasonable person can deny mental illness as a life threatening problem , it's just the real mental illnesses are extremely hard to detect due to the borders not being very clearly defined.

It's a shame Psychiatry at present is a bit of a mess, because in the near future, things won't be as bad. These are difficult issues to discuss, but they need to be publicized not for the interest of pharma companies but to the people who actually suffer in silence while being drugged and not listened to.

The way the system is setup at present, serves to only let the patient down in favor of lining the pockets of the companies. This is changing. Rapidly. Their concerns will be taken seriously. There are already efforts underway to correct undue industry influence:

http://www.economist.com/node/17248900

WalterMitty

ClocksForward wrote: »

Just came across a really interesting article in reference to the future of Psychiatry. It's moving towards Neuroscience. No reasonable person can deny mental illness as a life threatening problem , it's just the real mental illnesses are extremely hard to detect due to the borders not being very clearly defined.

It's a shame Psychiatry at present is a bit of a mess, because in the near future, things won't be as bad. These are difficult issues to discuss, but they need to be publicized not for the interest of pharma companies but to the people who actually suffer in silence while being drugged and not listened to.

The way the system is setup at present, serves to only let the patient down in favor of lining the pockets of the companies. This is changing. Rapidly. Their concerns will be taken seriously. There are already efforts underway to correct undue industry influence:

http://www.economist.com/node/17248900

The gap in knowledge between subjectivly extremely negative mental states and any underlying biological pathology needs to be bridged rapidly and is being so. Pharma company quacks and also anti psychiatry quacks both currently tussle to fill the gap and sell their own brand of treatment.

ClocksForward

nesf wrote: »

No it doesn't! What it means is that the company did not spend the millions required to get the drug licensed for a particular purpose. That is all. You can have a mountain of evidence showing a drug is good for a purpose and the company might never bother to licence it for the purpose since doctors are prescribing it off-label for it anyway.

This is a good point.

I haven't read much in the way of anti-epileptics or anti-psychotics, but I would imagine these medicatiion are more stable than SSRI's. These drugs have probably been around for much longer, hence research would probably be further ahead.

You won't hear these drugs in the media too much, as they aren't the main cause for concern. Not every medication that is prescribed is BS, it's mostly the SSRI's that represent a major cause for concern. Off label does not mean quackery outright.

boardswalker

ClocksForward wrote: »

Off label does not mean quackery outright.

The question I have is whether medicine is really evidence based or not.

In a study in 2006, conducted by David C. Radley, MPH; Stan N. Finkelstein, MD; Randall S. Stafford, MD, PhD Titled Off-label Prescribing Among Office-Based Physicians and published in the Archives of Internal Medicine, the following were the findings

"In 2001, there were an estimated 150 million (95% confidence interval, 127-173 million) off-label mentions (21% of overall use) among the sampled medications. Off-label use was most common among cardiac medications (46%, excluding antihyperlipidemic and antihypertensive agents) and anticonvulsants (46%), whereas gabapentin (83%) and amitriptyline hydrochloride (81%) had the greatest proportion of off-label use among specific medications. Most off-label drug mentions (73%; 95% confidence interval, 61%-84%) had little or no scientific support. Although several functional classes were associated with increased off-label use (P<.05), few other drug characteristics predicted off-label prescription."

The conclusions reached were as follows
"Off-label medication use is common in outpatient care, and most occurs without scientific support. Efforts should be made to scrutinize underevaluated off-label prescribing that compromises patient safety or represents wasteful medication use.

ClocksForward

boardswalker wrote: »

The question I have is whether medicine is really evidence based or not.

In a study in 2006, conducted by David C. Radley, MPH; Stan N. Finkelstein, MD; Randall S. Stafford, MD, PhD Titled Off-label Prescribing Among Office-Based Physicians and published in the Archives of Internal Medicine, the following were the findings

"In 2001, there were an estimated 150 million (95% confidence interval, 127-173 million) off-label mentions (21% of overall use) among the sampled medications. Off-label use was most common among cardiac medications (46%, excluding antihyperlipidemic and antihypertensive agents) and anticonvulsants (46%), whereas gabapentin (83%) and amitriptyline hydrochloride (81%) had the greatest proportion of off-label use among specific medications. Most off-label drug mentions (73%; 95% confidence interval, 61%-84%) had little or no scientific support. Although several functional classes were associated with increased off-label use (P<.05), few other drug characteristics predicted off-label prescription."

The conclusions reached were as follows
"Off-label medication use is common in outpatient care, and most occurs without scientific support. Efforts should be made to scrutinize underevaluated off-label prescribing that compromises patient safety or represents wasteful medication use.

You raise an interesting point. Peronally speaking, you would not pay me to go through medical school. These people are on average exceptionally hard working, but the system of modern medicine is mixed togerther with sound scientific practice and alot of hocus pocus rubbish perpetuated by corporate yes men and pharma reps.

I would imagine if you put down on the medical application "I want to help people" your application will be long listed. If you however put down "to further the practice" you would be favoured. At the end of the day, most Doctors are doing it for the money and the prestige, not because they truly want to help their patients. "You can't question the research, I am a doctor you simpleton":)

Bit of advice. Just because somebody wears a white coat and talks in a convincing manner, does not mean you aren't allowed to question their judgement. Nobody is always right. Anytime a Doctor has reccommened a product, I always research it myself. Never go by their word alone.

Jimoslimos

ClocksForward wrote: »

You raise an interesting point. Peronally speaking, you would not pay me to go through medical school. These people are on average exceptionally hard working, but the system of modern medicine is mixed togerther with sound scientific practice and alot of hocus pocus rubbish perpetuated by corporate yes men and pharma reps.

I would imagine if you put down on the medical application "I want to help people" your application will be long listed. If you however put down "to further the practice" you would be favoured. At the end of the day, most Doctors are doing it for the money and the prestige, not because they truly want to help their patients. "You can't question the research, I am a doctor you simpleton":)

Bit of advice. Just because somebody wears a white coat and talks in a convincing manner, does not mean you aren't allowed to question their judgement. Nobody is always right. Anytime a Doctor has reccommened a product, I always research it myself. Never go by their word alone.

You've made some sound arguments sofar on this thread but I feel obliged to step in and defend the good doctors' honour. (I'm not a doctor BTW!).

Do I think a certain level of prestige is attached to a medical degree? Well yes and I daresay there are a few who apply for this and the money attached. However the rigourous nature of the course is more than enough to weed those type out - and those it doesn't have usually changed their tune by the time they graduate.

As for researching your treatment, yes good to a point. No amount of internet browsing will make you a subject matter expert but you may find it easier to understand and ask relevant questions when a doctor explains a course of treatment. IMO its the quacks that don't allow questioning of their judgements. Unfortunately doctors suffer most from the type of patient hostility you describe - I wonder if homeopaths are innundated with demands for evidence based treatment by their patients customers :rolleyes:

ClocksForward

Jimoslimos wrote: »

You've made some sound arguments sofar on this thread but I feel obliged to step in and defend the good doctors' honour. (I'm not a doctor BTW!).

Do I think a certain level of prestige is attached to a medical degree? Well yes and I daresay there are a few who apply for this and the money attached. However the rigourous nature of the course is more than enough to weed those type out - and those it doesn't have usually changed their tune by the time they graduate.

As for researching your treatment, yes good to a point. No amount of internet browsing will make you a subject matter expert but you may find it easier to understand and ask relevant questions when a doctor explains a course of treatment. IMO its the quacks that don't allow questioning of their judgements. Unfortunately doctors suffer most from the type of patient hostility you describe - I wonder if homeopaths are innundated with demands for evidence based treatment by their patients customers :rolleyes:

Depends on the doctor tbh, but most are extrememly trustworthy. It's the bad apples that give the rest a bad name. No way would I ever have the capacity to study medicine, I have to at least respect these physicians. I will not however, accept quackery. While I am no expert on any of these matters, I will still do some legwork at least to understand what I am getting myself into:)

These people put their names on the line to save other people. No doubt you need a very high level of integrity. It's the bad apples that misrepresent the real heros. Not to mention some of em just go into it for the money. I won't go into any more detail, but one Doctor in particular in particular has caused me alot of grief. Can't go into more detail I am afraid due to legal stuff. Shame on the bad ones tbh.

My bad experiences have warped my perception, it's wrong of me to bring out the tar brush and generalise. You are correct here.

ClocksForward

Jimoslimos wrote: »

IMO its the quacks that don't allow questioning of their judgements.

Nail on the head with this one. I have no problem with the decent ones, it's the "Doctors" that demean patients that get me. Not going to name names or anything, but a truly arrogant truly Doctor is a sight to behold. Especially one that claims having done no wrong despite being accountable for their actions. It's the hiding behind lawyers game that gets me:) I value honesty like most.

nesf

RobFowl wrote: »

I think allegations that GP's are overdiagnosing mental illness is controversial.
Most evidence suggests that GP's underdiagnose it...

For example this famous study http://archpsyc.ama-assn.org/cgi/content/abstract/48/8/700

You deserve a better answer than I gave, I apologise I was suffering from bad nausea that day (Abilify) and wasn't in the mood to explain my thinking.

We've a generally agreed problem of overprescription of antidepressants especially SSRIs far and above the level that should be there to treat the things the drugs are meant to be used for. This means GPs and similar are either prescribing a drug to shut someone up or they are overdiagnosing mental health problems. The former might apply with antibiotics but I'm slow to say it about antidepressants because of their much worse side effect profile. This is where my thinking was going with the comment you zeroed in on. I'd fully agree that GPs lack the training and experience to accurately diagnose mental health problems all of the time and that they will through no fault of their own not diagnose them in genuine cases. I think this might be a problem of giving them to people who are going through "normal lows" and similar but then I've no medical training so, eh, I'm probably completely wrong.

RobFowl

Thanks Nesf

I'm a GP so there is bias here!

There is world wide research which consistantly shows GP's under diagnose mental health probles,
SSRI prescribing is shooting upwards though so it's a very reasonable question to ask why?
Poor prescribing is undoubtadly part of it.
Training shouldn't be an issue certainly in GP's who've trained in the last 15-20 years (soem confusion in Ireland still as not all GP's are actually trained GP's).
Lack of access to councelling/psychotheraphy is thought to be part of the problem as is the tendency for doctors and society to "medicalise" social problems.
PS
Thank you to the OP and all contributers here as although I strongly disagree with a lot of whats said it's challenging and is for one making me examine my own practice....

ClocksForward

RobFowl wrote: »

Thanks Nesf

Thank you to the OP and all contributers here as although I strongly disagree with a lot of whats said it's challenging and is for one making me examine my own practice....

There is no doubt these drugs are being overprescribed. Medication isn't evil or anything, and it does serve a purpose. The question now though is how can rules and procedures be implemented to combat the handing out of heavy duty medications to people in the low-medium depressed range? I've known far too many people to have been given these drugs off label. This is a disturbing trend, espectially in the US where most of the problem lies.

No doubt these are controversial findings to most, but if history is anything to go by, a strong warning is really a blessing in disguise. I would be in favour of far less medication being prescribed in favour for more psychotherapy. This won't fly with the drug companies though. Maybe you could also consider the alternative medicine quacks as a runner?:pac: I think the IMB is going to have to stand up to these claims. These concerns are simply too important to ignore. The patient is the one who loses ultimately in cases like this.

nesf

RobFowl wrote: »

Thanks Nesf

I'm a GP so there is bias here!

There is world wide research which consistantly shows GP's under diagnose mental health probles,
SSRI prescribing is shooting upwards though so it's a very reasonable question to ask why?
Poor prescribing is undoubtadly part of it.
Training shouldn't be an issue certainly in GP's who've trained in the last 15-20 years (soem confusion in Ireland still as not all GP's are actually trained GP's).
Lack of access to councelling/psychotheraphy is thought to be part of the problem as is the tendency for doctors and society to "medicalise" social problems.

Thanks Rob, I appreciate getting a viewpoint from a man at the coalface of this issue. I imagine the last point is a crucial one, why go through a normal everyday low after something bad happens if the doctor can give you a pill for it? Etc.

ClocksForward

Jimoslimos wrote: »

You've made some sound arguments sofar on this thread but I feel obliged to step in and defend the good doctors' honour. (I'm not a doctor BTW!).

My view is warped, I am currently dealing with a legal issue, so please don't take my statements at all seriously. Saying Doctors are in it for purely monetary reasons is plain idiocy. Do you want to know why? Because the training is extremely stringent.

No trying to suck up or anything, but I can't actually think of any other profession that requires the same degree of investment and hard work. Med school is a bit like the SAS - 99% need not apply:)

nesf

ClocksForward wrote: »

No trying to suck up or anything, but I can't actually think of any other profession that requires the same degree of investment and hard work. Med school is a bit like the SAS - 99% need not apply:)

High level academics comes close. No life for a good few years. Etc.

ClocksForward

nesf wrote: »

High level academics comes close. No life for a good few years. Etc.

PhD level work is very serious stuff no matter what the field. Guy I knew spent at least 6 years on his research. No way could I commit myself to that level of study. I mean an Undergrad or even a Masters is within reach for most, but PhD level work is another thing entirely.

boardswalker

Just came across this article

"ScienceDaily (July 19, 2011) — Patients who use anti-depressants are much more likely to suffer relapses of major depression than those who use no medication at all, concludes a McMaster researcher.

In a paper that is likely to ignite new controversy in the hotly debated field of depression and medication, evolutionary psychologist Paul Andrews concludes that patients who have used anti-depressant medications can be nearly twice as susceptible to future episodes of major depression.

Andrews, an assistant professor in the Department of Psychology, Neuroscience & Behaviour, of McMaster University in Canada is the lead author of a new paper in the journal Frontiers of Psychology.

The meta-analysis suggests that people who have not been taking any medication are at a 25 per cent risk of relapse, compared to 42 per cent or higher for those who have taken and gone off an anti-depressant.

Andrews and his colleagues studied dozens of previously published studies to compare outcomes for patients who used anti-depressants compared to those who used placebos.

They analyzed research on subjects who started on medications and were switched to placebos, subjects who were administered placebos throughout their treatment, and subjects who continued to take medication throughout their course of treatment.

Andrews says anti-depressants interfere with the brain's natural self-regulation of serotonin and other neurotransmitters, and that the brain can overcorrect once medication is suspended, triggering new depression."

It's widely referenced around the web.

http://dailynews.mcmaster.ca/story.cfm?id=8146

nesf

boardswalker wrote: »

Just came across this article

"ScienceDaily (July 19, 2011) — Patients who use anti-depressants are much more likely to suffer relapses of major depression than those who use no medication at all, concludes a McMaster researcher.

In a paper that is likely to ignite new controversy in the hotly debated field of depression and medication, evolutionary psychologist Paul Andrews concludes that patients who have used anti-depressant medications can be nearly twice as susceptible to future episodes of major depression.

Andrews, an assistant professor in the Department of Psychology, Neuroscience & Behaviour, of McMaster University in Canada is the lead author of a new paper in the journal Frontiers of Psychology.

The meta-analysis suggests that people who have not been taking any medication are at a 25 per cent risk of relapse, compared to 42 per cent or higher for those who have taken and gone off an anti-depressant.

Andrews and his colleagues studied dozens of previously published studies to compare outcomes for patients who used anti-depressants compared to those who used placebos.

They analyzed research on subjects who started on medications and were switched to placebos, subjects who were administered placebos throughout their treatment, and subjects who continued to take medication throughout their course of treatment.

Andrews says anti-depressants interfere with the brain's natural self-regulation of serotonin and other neurotransmitters, and that the brain can overcorrect once medication is suspended, triggering new depression."

It's widely referenced around the web.

http://dailynews.mcmaster.ca/story.cfm?id=8146

Even not accepting that (it'll have to be replicated to really move me), is not shorter depressions worth a higher relapse rate? Untreated major depressions can last a very long time after all.

boardswalker

nesf wrote: »

it'll have to be replicated to really move me

? That was a meta-analysis - combining the results of several studies that address a set of related research hypotheses.