Tuesday, December 14, 2010

the truth wears off; or was it never on?

This New Yorker article is getting a lot of blogsploitation...
"Rethinking the scientific method." Oh, great. A NY journalist is going to fill us in on what we scientists have not been able to figure out.
"On September 18, 2007, a few dozen neuroscientists, psychiatrists, and drug-company executives gathered in a hotel conference room in Brussels to hear some startling news."
The Startling News? A bunch of cheating, unethical, greedy pharmaceutical people had a bunch of psychiatrists, who are not trained as scientists unless they deliberately go out of their way to do a science-based PhD in some spare 3 years, cooked up some data indicating that their new chemicals were superior to those whose patents had run out.

Now, just looking at this, you can begin to sniff the sweet smell of disaster. Clozaril was not really worth  a thousand dollars a month. Or worth the heavy monitoring for agranulocytosis. But hey, there's money to be made - I know  - I entertained the possibility of getting hired to go into doctors' offices and figure out who could be switched to Clozaril. Yes, the patent has run out - no one is doing this anymore - it was  a long time ago. But the opportunity was there for one brief, shining moment.

As time went by, and more studies were done under more circumstances, it became painfully obvious that Clozaril was not much better than the Haldol it had replaced. Same for the yellow one that was close on the heels - drawing a blank on the name. Give me a sec. Risperdal.

This has been the case with many new treatments: EMDR, etc. Initial optimism fades as the effect size shrinks like that perfect cotton t-shirt washed in hot water. A few times. The Thrill Is Gone. Same as the old one.

So, some person comes along, pretending to be the next philosopher of science, and declares that science is dead.

Science does not answer questions. It is a method for helping us discern what might be true. Withering efficacy does not change that. No need to change science.

If you can get behind the firewall, you will find this:
"Just because an idea is true doesn’t mean it can be proved. And just because an idea can be proved doesn’t mean it’s true. When the experiments are done, we still have to choose what to believe."

Does this disprove science? Is Lehrer the next Nietzsche? Is God alive again? If science is dead, can there still be a gay science?

Witheing results do not disprove the value of science.

This totally fits with the scietific paradigm, and, as a scientist, I have no problem with this.

Scientists, those people who have actually studied and practiced epistemology, scientific method, research design, likelihood/probability analysis, and such, have no problem with the quote above.

How? For starters: accept as a rule a few concepts:

"experiments" don't give us truth; they give us evidence that plays a role when attempting to discern truth.

no single studies proves anything. (ten lousy studies with consistent results don't prove it, either.)

all of our studies are based on models, and the map is not the landscape/ ceci n'est pas une pipe. with our measures and tests, the best we can do is confirm a model.

all measurement have some degree of error.

science never arrives at the truth; when working well, it approaches truth asymptotically.

science doesn't tell us what to study. we decide, then use scientific principles and methods to evaluate our pet theory. thus, we are always beginning with some agenda before the first trial is run.

physical reality is wildly more complicated than we can grasp. (not all scientists beleive this, but when you begin considering all of the machinations you would need to have a valid and generalizable medical outcomes study, it becomes incredibly daunting.)

finally: accept the reality that what we hold as our faith, science, is really only a method for approaching knowledge, and should not be regarded as a faith, or dogma; science only helps us be very systematic, in a certain way, in evaluating claims of knowledge. let's not be so dogmatic. you cannot swear allegiance to the idea that whatever findings might emerge from "science" will be your truth. it just doesn't work that way.

these concepts are in my mind whenever i read a journal article.

Especially if it is from Big Pharma.


evilrobotxoxo said...

I take issue with your characterization of clozapine. Clozapine isn't a magic bullet, but it's unquestionably superior to haldol and other antipsychotics in treatment-refractory schizophrenia, and there are tons of studies supporting this. I'm an active researcher and clinician in the field, and I can say that if anything, clozapine is massively underutilized. I think the primary reason for that is the blood monitoring, as it's difficult to get a treatment-refractory psychotic patient to adhere to it. I agree with 90% of what you say on your blog, but I think that in this case you're throwing the baby out with the bathwater.

MedsVsTherapy said...

Good point about treatment-refractory.

It is scary if anyone agrees with 90% of my blog, cuz I am quite opinionated, and use this blog so my family and friends don't have to hear me going on and on abt how atypicals are hardly better than the old lockjaw meds.

So, please keep reading - I am sure you will have additional valuable disagreements!

evilrobotxoxo said...

Well, maybe 90% is an exaggeration. But I think your most fundamental premise is that psychotherapy is vastly underutilized in favor of meds, which is something that I (as a psychiatrist) agree with 100%. Where I think I disagree with you is that the premise of "meds vs. therapy" implies that these things are in conflict with one another, when I think that the true art is using them to complement one another.

For example, in anxiety disorders, I see therapy (usually) as the main treatment with meds as a helpful adjunct, while in psychotic disorders I see meds as the main treatment with therapy as a useful adjunct. And there are a lot of cases in between.

As far as antipsychotics go, I think there is pretty much zero credible evidence that second-generation antipsychotics are any more effective than first-generation antipsychotics, with the notable exception of clozapine. A clozapine-specific effect has been shown in numerous animal models too, BTW, so it's not just based on clinical data. However, the mechanism by which clozapine adds its extra efficacy in treatment-refractory cases is still not known. Zyprexa was actually developed as an attempt to capture clozapine's superior efficacy in a drug with a (slightly) better side effect profile, but head-to-head trials have shown that zyprexa does not beat other antipsychotics, and clozapine beats zyprexa. With all that said, I do think that second generation antipsychotics are massively overutilized and first generation ones are underutilized, as their side effect profiles are just different, not necessarily better or worse. Part of the reputation of first generation antipsychotics causing such terrible EPS was also based on the fact that they were historically given at doses much higher than what is used today (and, as it turns out, much higher than is necessary to help patients).