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Acupuncture and history: The “ancient” therapy that’s been around for several decades

Make the lie big, make it simple, keep saying it, and eventually they will believe it

– A. Hitler

It seems that just about every article about acupuncture makes some reference to it having been used in China for thousands of years. The obvious reason for such a statement is to make the implication that since it’s been around for so long, it must therefore also be effective. Of course, longevity doesn’t argue for efficacy, otherwise everyone would likely agree that astrology is the way to chart one’s life; astrology has been practiced for many more years than acupuncture.

What’s maddening about the acupuncture longevity myth is that it isn’t true, and demonstrably so. In human medicine, “needling” was illustrated in the 17th century by western observers: no points, no “meridians,” just a big awl-like “needle,” driven in with an ivory-handled circular hammer. In addition, the rationale for hammering these little spikes into various spots (of the practitioner’s choosing) was said to be “exactly the same” as Greek humoral medicine (see, Carruba, RW, Bowers, JZ. The Western World’s First Detailed Treatise on Acupuncture: Willem ten Rhijne’s De Acupunctura. J Hist Med Allied Sci (1974) XXIX (4): 371-398).

The same fallacious assertion is repeated (repeatedly) in veterinary medicine. Acupuncture proponents may assert, for example, that acupuncture is “4,000 years old.” While the assertion isn’t true, it’s also ridiculous, since the Chinese hadn’t invented writing 4,000 years ago. Even if the assertion were true, there would be no way to possibly know about it, since no one could have written anything down about the practice.

Regardless, recently, we published the first detailed research paper on the history of veterinary medicine in China. The paper was published in July, in the historical journal Sudhoffs Archiv (Buell, P, May, T, Ramey, D. Greek and Chinese Horse Medicine: Déja Vu All Over Again. Sudhoffs Archiv. 2010: 94: 31-60). It is one of the first papers published that looks at the actual historical source material, and the only one that compares the veterinary medicine of ancient China to contemporary practices in the ancient world.

Based on the historical source material, it can be stated that Chinese veterinary medicine isn’t unique, and it isn’t even particularly Chinese. That is, what is presented to the eager public as the essence of Chinese thought and practice is, in fact, just an adaptation of contemporaneous practices in Greece and the Middle East. In fact, most Chinese practices, such as bleeding, and burning at points, appear in Greek, Egyptian, and Arabic sources long before they were ever mentioned in China. Such practices first appear in China during a period of maximal western influence on China, corresponding with regular traffic on the Silk Road (during Han times, approx. 200 BCE – 200 AD), as well as with the coming of Buddhism, which brought in influences from Indian traditions.

It’s remarkable – and particularly so in the face of all of the modern crowing about the antiquity of acupuncture in animals – that there is no reference to what can even be remotely considered as modern acupuncture in any of the pre-modern Chinese veterinary works (which deal mostly with horses, camels, and water buffalo). This may be due to incorrect translation of the Chinese word zhen, which means “incision” or “penetration,” and also used to describe cauterization and bleeding, but which has been apparently somehow morphed into “acupuncture” anytime that the word appears in Chinese sources. It’s absolutely clear that zhen has nothing to do with modern acupuncture, even as it’s equally clear that acupuncture proponents will insist on misinterpreting the Chinese language to suit their preconceived notions.

The Chinese, as with every other ancient culture, didn’t have much of an idea of horse physiology, and their treatments were based on anecdote and tradition. The fact is that the Chinese didn’t have any better idea about what caused conditions such as colic (abdominal distress) or foot pain than did other cultures, and they really didn’t treat them much differently. Until scientific investigations came along, people didn’t really know what they were doing when it came to practicing medicine. There’s no reason to try to go back to such traditions; there’s especially no reason to do so when they didn’t exist in the first place.

Posted in: Acupuncture, History

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76 thoughts on “Acupuncture and history: The “ancient” therapy that’s been around for several decades

  1. adenacb says:

    I enjoy your blog, but I’m puzzled as to your particular obsession with acupuncture. Has no one in the science-based medicine staff of contributors ever tried acupuncture? There are some conditions – certain types of pain, insomnia, hot flashes, for example – that conventional medicine is less than helpful with. Why does it drive you crazy that for some people, acupuncture helps?

  2. Scott says:

    Because it doesn’t. It’s pure placebo, according to the great weight of the evidence. Selling it as anything else is dishonest, and bilks people out of their money via that dishonesty. And that’s leaving aside the risk of infection.

  3. Skeptinomicon says:

    Thanks for the post! I’m eager to share the article on the history of vet medicine with my girlfriend, who is a Chinese vet student. We are currently trying to fight the “holistic and alternative medicine” club at her school.

    @adenacb

    Because accupuncture doesn’t help beyond a simple placebo effect. The science is out, and it is a matter of particular annoyance that it persists with unshakeable devotion. Acupuncture is like the poster child for non-science based medicine, so it tends to come up a lot.

  4. @ adenacb – you’re falling into the “personal experience” fallacy. Just because you try acupuncture (or chiropractic, homeopathy, etc…) and it seems to work, all that means is that you are subject to expectation effects like most others. The evidence is clear, as Scott mentioned; acupuncture does not work.

    The only complaint I have about this article (and I may have just misinterpreted the author) is this statement: “…there would be no way to possibly know about it, since no one could have written anything down about the practice.”

    We know about “cavemen” and dinosaurs, but they didn’t write anything either. There are other ways to learn archeological information.

  5. Harriet Hall says:

    adenacb,

    Do you think that trying something for yourself is a reliable way to find out if something works? How about all those people who tried bloodletting to balance the humours and became convinced that it worked? How about all those testimonials for obviously quack remedies? Do you understand why post hoc ergo propter hoc is a logical fallacy?

    Acupuncture helps? We follow the evidence. If acupuncture had been proven to help, we would all accept it. A lot of people believe it has helped them, but when it has been properly tested, the evidence hasn’t supported their belief.

    And if you’re one of those who say “What’s the harm?” if people use it and think it helps, read Steven Novella’s post with that title from last week.

  6. squirrelelite says:

    @adenacb,

    I’m glad that you are enjoying this blog.

    I know that I have learned a lot about science and medicine from reading it over the last two and a half years.

    But I don’t think the editors and contributors are “obsessed” with acupuncture.

    Out of the hundreds of articles on this blog, only 53 are specifically linked under the category of acupuncture. This is a few more than for chiropractic and nutrition, but less than for homeopathy and herbs and supplements. It is only a third of the number for vaccines.

    One reason acupuncture does get a lot of coverage is because it is frequently touted as being effective for treating certain conditions and it is important to take a careful look at the evidence to support that assessment. Unfortunately, the conditions you mentioned vary from day to day and the assessment of results is based almost entirely on the subject’s personal estimate of the condition. This means that it takes a careful look at the results for a large number of people over an extended period of time to tell if an intervention like acupuncture is really helpful or just seems to be.

    A one person try it and see if it works test won’t be able to tell the difference.

    I suggest you click on the acupuncture category and read a few of the articles, especially ones that mention acupuncture in the title.

    Articles on the placebo effect will also help inform you about the difficulty in determining if an intervention has a real medical effect.

  7. From Ben Kavoussi’s post on acupuncture last week:

    “Indeed, an acute noxious stimulus from a prickle, heat, or any other painful stimulus – almost anywhere on the skin – can attenuate the perception of pain in another area of the body through a reflex called “counter-irritation,” also called the “pain-inhibiting-pain effect” or “diffuse noxious inhibitory control” (DNIC). DNIC was extensively studied by Fauve et al. in the 1980s, who showed in mice that it has an effect equivalent or superior to that of glucocorticoids. … The DNIC induced by needles is believed to be mediated by the release of endogenous opioid neuropeptides and/or monoaminergic neurotransmitters, mainly because naloxone, a central and peripheral opioid receptor antagonist, is reported to reverse its effects.”

    “There is also credible evidence that the stimulation of a myofascial trigger point (TrP), meaning a localized, hyperirritable nodule nested within a palpable taut band of skeletal muscle or fascia, can evoke short-term anti-nociceptive effects on the same segmental dermatome. This local hypoalgesic effect is reported to be greater than stimulation at remote dermatomes. … Therefore, two-arm studies cannot rule out the possibility that the observed results are due to anti-nociceptive effects on the same segmental dermatome, which can occur regardless of the classical theories for point selection and means of stimulation.”

    “In addition, both laboratory and clinical evidence have recently shown the existence of two-way interactions between the nervous system and the innate immunity. There is experimental evidence showing that percutaneous and transcutaneous neurostimulation can inhibit macrophage activation and the production of pro-inflammatory cytokines. … Again, two-arm studies cannot rule out the possibility that the observed results are due to the broad neurostimulatory effects of needling, and regardless of the needling regimen.”

    Many of the posts on acupuncture on SBM appear to repeat this pattern. They explain that acupuncture works, but not by meridians… therefore, acupuncture doesn’t work.

    I’ve asked about this apparent contradiction in the past and been told that ok, “acupuncture” (in the sense of sticking needles into people) might “work” (in the sense of relieving pain), but it doesn’t work well enough to be superior to accepted medical interventions for pain relief, therefore it doesn’t matter that it works. If it has no clinical relevance, then why focus on experiments that try to elucidate whether meridians or DNIC are behind the effect? If there is no effect, or it is a clinically irrelevant one, there is nothing to explain. Move on.

    I’ve also been told that this apparent contradiction is a figment of my imagination. But really, I don’t see how I could interpret Ben Kavoussi’s post in any other way.

    I’m perfectly happy to be told that sticking needles into people doesn’t offer an acceptable risk/benefit ratio, or offers one that is inferior to other pain treatments, or even that it offers no benefit at all. I have no attachment to acupuncture whatever. I get really annoyed when I hear acupuncture students going on and on about its magical powers. But this continuous “it works, but meridians don’t exist, so it doesn’t work” is something I just can’t get my head around.

    I think I’ve read one SBM post on acupuncture that focussed on whether “it” (sticking needles/toothpicks into/onto people) “worked” (relieved pain) which concluded that people reported that “it” relieved pain but that functioning two weeks later remained unchanged. That makes sense. That, to me, is more relevant to the question of whether “it” “works” than anything about meridians. But outcome measures seem to be treated trivially here compared to yet another exciting demonstration that there is no such thing as a meridian. I guess that’s the difference between SBM and EBM?

    EBM: wants to know if it works.
    SBM: wants to know if it ever had a traditional explanation that was a load of hooey. If yes, then whether it works or not is completely irrelevant even if the traditional explanation could be replaced by a plausible one. (Note that homeopathy, unlike acupuncture, has no plausible explanation that could be substituted for the hooey.)

    I get that we don’t want to waste our money studying implausible, imaginary interventions. I get what Bayes brings to the interpretation of positive results for implausible, imaginary interventions. But the way acupuncture tends to be written about here is just… odd.

    1. Harriet Hall says:

      Alison Cummins said
      “EBM: wants to know if it works.
      SBM: wants to know if it ever had a traditional explanation that was a load of hooey.”

      That is a complete misrepresentation of what SBM means. Please go back and read the pertinent posts on this blog and try harder to understand what the blog is all about.

      A better summary would be:
      Both EBM and SBM want to know what really works. EBM only asks whether studies have shown it to work. SBM recognizes that studies can be wrong, especially studies of things with low prior probability or that violate the known laws of nature, so it tries to assess the credibility of studies by also looking at factors like prior probability, and it asks for stronger evidence for less plausible ideas, a la Carl Sagan (extraordinary claims require extraordinary evidence).

  8. advancedatheist says:

    The Western obsession with Chinese “medicine” makes me laugh. Yes, the mainland Chinese, with their bad teeth, iodide deficiencies, tuberculosis, parasitic worms, chronic rashes, influenza-breeding livestock populations, etc., certainly know about staying healthy by keeping their “qi” balanced.

  9. Scott says:

    @ Allison:

    I can see how it can be confusing. Let me try to clarify.

    Let us assume that poking people with needles may have some effect. This assumption is highly questionable, given that we know that needles – or toothpicks – which don’t break the skin produce results indistinguishable from when the skin IS broken. But we’ll leave that aside for the moment and assume that poking people with needles is beneficial.

    But “poking people with needles” is not a complete description of acupuncture. Instead, “acupuncture” implies that the needles must be poked in a specific way, in specific places, based on the idea of meridians. There is EXCEEDINGLY strong evidence that the precise placements are entirely irrelevant. Hence, the discipline of “acupuncture” has nothing to offer. Indeed, it would be counterproductive because it insists on a false model of how things work, precluding proper understanding of how it DOES work.

    Or in other words, even if there were some benefit to be had by poking people with needles (though we have strong evidence that there is not), acupuncture would be an active impediment to maximally effective needling.

    So the point you’re missing is that what Ben was talking about as potentially beneficial is not acupuncture. And treating it as acupuncture prevents you from properly understanding (and therefore using) it.

  10. “So the point you’re missing is that what Ben was talking about as potentially beneficial is not acupuncture.”

    Well, Ben thought there was overlap.

    Of course acupuncture as a discipline is hooey. It has nothing to add and may subtract.

    Great. Now adenacb goes to a starry-eyed new-ager or to a clinic in chinatown and gets poked arbitrarily with needles. adenacb perceives themselves to be feeling better and concludes that acupuncture “works.” (They were poked and now feel better.)

    Ben thinks adenacb might be feeling better because of a combination of various *specific* physical phenomena associated with being poked/prodded with needles/toothpicks, *nonspecific* placebo effects associated with expectation and their relationship with the acupuncturist, and regression to the mean. Because the specific effects of being poked with needles would not have their action through meridians, Ben knows that adenacb obtained no benefit from seeing the acupuncturist: that is, adenacb does not feel any better than they would if they had had their horoscope cast. (This is a leap of logic I find hard to follow. If the specific effects of being poked with needles exist, they should exist even if the poker is an acupuncturist.)

    You, at least, know that adenacb is not feeling any better than they would if they had had their horoscope cast, because you know there are no specific effects from being poked/prodded with needles/toothpicks. Period. They don’t exist. Ben is flat-out wrong about all those specific phenomena. There is no explanation needed because there is nothing to explain.

    If Ben is right and there are specific effects associated with poking/prodding with needles/toothpicks, then people who get poked/prodded by acupuncturists could reasonably expect to experience those specific effects. That acupuncture as a discipline is hooey doesn’t make the specific effects evaporate. Someone like adenacb could still experience them and telling them that they do not experience them does nothing for your credibility.

    If Ben is wrong and there are no specific effects then there is nothing to explain. Meridians and TrPs do not need to compete for explanatory status. But this is not what most posts here on SBM say.

    The scientists here might be most interested in proving (yet again) that meridians do not exist and add nothing to our understanding of the body. That’s nice for them but seems kind of pointless. If you believe in chi and meridians and astrology, you presumably believe in crystals and chakras and angels as well and wave away binary reductionist theories of the body. I don’t have a lot of evidence that most laypeople are more attached to the notion of chi flowing along meridians than they are to the angel hypothesis of car mechanics.

    What laypeople usually want to know is whether they will feel better if someone pokes them. For most laypeople, getting poked is acupuncture. They haven’t thought a lot about why. They know people do it, they know someone who got poked and who swears by it, they know someone else who got poked and hated it. Telling them that there is no such thing as a meridian therefore they will not feel better is a non-sequiteur.

    If there are specific effects, then tell them better ways to get those specific effects than risking getting their lung punctured with a dirty needle.

    If there are no specific effects, then say that.

    There are a lot more people who get “acupuncture” (pay someone to poke them) than who seriously believe in chi flowing along meridians.

  11. pmoran says:

    Michelle is right. The contradiction she refers to is by no means confined to acupuncture. It deforms almost all SBM rhetoric.

    Jan Bellamy’s piece quite clearly brings out the point that the usual sham-controlled trial does not preclude a treatment program, especially procedural ones, “working” in other ways.

    This is of critical relevance to how we react to CAM use by our patients, especially when that is dictated by the limitations of available medical treatments.

    It determines whether we wish our CAM using patients well, or try to sour the whole experience for them. We can still advise where we think significant risks exist.

  12. Scott says:

    Well, Ben thought there was overlap.

    Acupuncture includes the poking. My statement is that they are not the same; this does not preclude overlap.

    Ben thinks adenacb might be feeling better because of a combination of various *specific* physical phenomena associated with being poked/prodded with needles/toothpicks, *nonspecific* placebo effects associated with expectation and their relationship with the acupuncturist, and regression to the mean.

    Such a belief would be inconsistent with the evidence. Or at a minimum, the specific physical phenomena produce such a small proportion of the benefit adenacb perceives that it is undetectable against the background of the various forms of placebo effect in play.

    Note that there is no inconsistency between the statements “there may be some specific benefits of poking” and “the benefits of acupuncture are not due to the poking.”

    Because the specific effects of being poked with needles would not have their action through meridians, Ben knows that adenacb obtained no benefit from seeing the acupuncturist: that is, adenacb does not feel any better than they would if they had had their horoscope cast. (This is a leap of logic I find hard to follow. If the specific effects of being poked with needles exist, they should exist even if the poker is an acupuncturist.)

    In all probability, adenacb probably feels better after seeing the acupuncturist than the astrologer, because acupuncture is a more dramatic placebo, and therefore carries a stronger placebo effect.

    But whatever specific effects of poking with needles exist, they do not account for a significant fraction of the benefit adenacb perceives.

    <blockquoteYou, at least, know that adenacb is not feeling any better than they would if they had had their horoscope cast, because you know there are no specific effects from being poked/prodded with needles/toothpicks. Period. They don’t exist.

    False. Placebo effects exist and can be powerful. But they must be acknowledged as such.

    Ben is flat-out wrong about all those specific phenomena. There is no explanation needed because there is nothing to explain.

    If one were to attribute the perceived benefits of acupuncture to these specific phenomena, then one would be going against the strong weight of the evidence which show that the perceived benefits of acupuncture may be equally achieved (within the precision of the studies) without penetrating the skin.

  13. Jann Bellamy says:

    @pmoran:
    “Jan Bellamy’s piece quite clearly brings out the point that the usual sham-controlled trial does not preclude a treatment program, especially procedural ones, ‘working’ in other ways.”

    I did? Which piece was that?

  14. “That is a complete misrepresentation of what SBM means.”

    Well, it’s a misrepresentation of what people say it means, and of what it seems to mean in every domain except acupuncture.

    But if I just looked at the acupuncture posts and hadn’t read any of the discussions of EBM and SBM, that’s what I would conclude.

    That poking/prodding people with needles/toothpicks could have specific effects is not an extraordinary claim and it is relevant to clinical effectiveness. Few posts on this site focus on this unextraordinary claim except to confirm that it is unextraordinary. I can recall one that concluded that the claim was unextraordinary but false; others seem simply to confirm that it’s unextraordinary, showing little or no interest in whether it is true, or if true whether it is clinically significant.

    That chi and meridians exist is an extraordinary claim but it is completely irrelevant to why most people think an acupuncturist might be able to help with their pain. Here at SBM we do like to challenge this extraordinary claim. But… why?

    (Interestingly, what is an extraordinary claim is that acupuncture can provoke abortions and cure cancer — but we don’t seem to talk about that here, even though it would neatly tie theory and practice into a tidy little ball of implausibility. But mostly we just review the unextraordinary claim that it could help pain.)

    If a scientific discipline of prodding with toothpicks were developed and shown to be superior for treatment of pain both to random jabbing with dirty needles (more effective and less risky) and to casting horoscopes, most laypeople would be perfectly happy to conclude that “acupuncture had been proven for pain” and in a very real sense they would be right. (Of course there would always be that subgroup who would insist that real acupuncture that can provoke abortions and cure cancer requires random jabbing with dirty needles for the full effect. They would be wrong. They would probably also be clinging to their meridians.)

    Take homeopathy for comparison. Both the practice (taking a teeny sugar pill with no active ingredient) and the theory (like cures like, memory of water) are extraordinary claims. If you address the theory you have by definition addressed the practice. Knowing anything about homeopathy means you don’t need to evaluate the clinical effect because there can’t be any. A perfect model for SBM.

    Still… let’s say someone claims that they were able to cure their hayfever by taking homeopathic granules made from the plant they are allergic to.

    1) Actually, this is theoretically possible. Those granules might be contaminated with small amounts of actual plant material; they might be serving as an oral desensitization protocol. While the probability is low, it would be wrong to tell the person that you know for sure that taking real life homeopathic granules can never help hayfever. It would make sense to talk about oral desensitization and to suggest they talk to an allergist if their hayfever ever came back.

    2) Even if true, it’s irrelevant to the theory of homeopathy, or to the treatment of anything else with homeopathic granules, contaminated or not. It’s irrelevant to whether oscillococcinum will cure your cold or whether calcarea carbonica will cure your warts. It’s relevant only to the theory of immunology.

    It seems to me that the treatment of acupuncture on this blog tends to be like reviewing in detail the evidence that commercially available homeopathic granules might be useful in oral desensitization for hayfever, demonstrating that yes, in theory they could be, explaining how and why, and concluding that homeopathy doesn’t work.

    That’s not how homeopathy is treated, but it’s considered damning for acupuncture. It’s just… odd.

  15. pmoran says:

    @pmoran:
    “Jan Bellamy’s piece quite clearly brings out the point that the usual sham-controlled trial does not preclude a treatment program, especially procedural ones, ‘working’ in other ways.”

    I did? Which piece was that?

    Oh, sorry, Jan. I meant “Ben Kavoussi’s piece”. He has a lot to say about possible non-mystical ways that acupuncture might benefit patients with some conditions. They would include, until the evidence clearly shows otherwise, placebo and other non-specific influences of medical attentions.

  16. Charon says:

    Alison, you seem to be okay with EBM, so please explain how one would show acupuncture worked. For an RCT of course you need a placebo. So people tried random needle placement v. acupuncture needle placement, and both worked equally well. “But,” you say, “I’m going to define acupuncture more broadly, as any needle insertion.” So they tried needle insertion v. sham acupuncture, with toothpicks or needle guides. This isn’t ideal, because it can’t be double blinded, but still, they found no real difference.

    So your conclusion that “acupuncture works” appear to be based on the idea that poking people in just about any way seems to produce an effect. You’ve taken all the placebos and redefined them as acupuncture treatment. You have to have a placebo against which to test your treatment, so what placebo do you propose?

    We all know acupuncture works in the sense that it produces a very real placebo effect. But as any good EBM person will tell you, that’s not “working” in an actual medical sense.

  17. The placebo I proposed above was having your horoscope cast. There’s a learned expert, some touch (examination of the palm), personal attention and a story to explain whatever it is that you want explained. All very nonspecific. If the benefit of prodding people with toothpicks over casting their horoscopes is small, then there’s no point in looking further. Any medical provider should be able to offer these nonspecific interventions.

    In terms of experiments, it depends on what you want to know. Ben Kavoussi put an awful lot of effort into looking at ways that needles or toothpicks could generate specific physiological responses. If you want to know which of these particular effects are active, you would have to do fairly specific experiments to tease them apart.

    My fantasy experiment would involve ten different interventions with varying intensities and types of touch. For instance acupuncture, foot massage, scalp massage, rolfing, whirlpool bathing, colonic irrigation and spanking, massage with an abrasive lotion, getting your nails done, lying on a bed of nails, body piercing, tattooing, light wind, breathing exercises while sitting in a circle holding hands with other people… anyway, a bunch. Then each subject/victim chooses three interventions to try and they all get their horoscopes cast. One intervention per week for a month in random order. Subjective reports of pain before and after, and tests of function daily for the next week are compared. If acupuncture is better than horoscopes for pain but not as good as sitting in a whirlpool tub (for people who like the idea of sitting in a whirlpool tub) or colonic irrigation and spanking (for people who like the idea of being properly worked over)… isn’t that what people really want to know?

    My point is, the whole chi and meridian thing is only relevant if you think acupuncture works for things like hepatitis or infertility. If you think acupuncture doesn’t work for those things but might work for pain, meridians are not the point any more. Relieving pain by sticking things into the skin is a plausible hypothesis that doesn’t require meridians. The point is whether “it” works at all (compared to horoscopes) and if “it” does, whether other types of touching or irritation work better or whether poking in other places works better. If we are considering poking to be a plausible intervention for pain, we shouldn’t be worrying about acupuncture points too much because we know meridians don’t exist.

    And yes, as a layperson, I would consider all poking to be acupuncture. Why wouldn’t I? If I were to go to a clinic in chinatown I would just accept the practitioner’s choice of needle and insertion point. If the practitioner told me that she used a modern, non-penetrative technique and that her school taught the use of particular sites, I’d accept that. I wouldn’t argue with her that if she were needling my shoulder instead of my neck that it was somehow “not acupuncture.” If I later saw someone else who used penetrating needles on a different set of sites, that would still be acupuncture. I’m just the customer.

  18. pmoran says:

    Alison: “ Any medical provider should be able to offer these nonspecific interventions.

    So others have said, but it is not so easy or simple. The CAM procedure (needling with acupuncture) can be an essential “hook” upon which a number of potentially helpful influences hang, such as the regular medical visits over some weeks, with the opportunity they provide for further useful medical and social interaction. The “time out” from daily preoccupations while the procedure is performed may enable a re-evaluation of symptom levels –one element of the placebo complex.

    The most common pattern of CAM use involves mainstream doctors having exhausted EBM-endorsed methods, or at least ones acceptable to the patient. There can be an unenthusiastic scratching of heads –”what to try next?”.

    For these reasons the true value of acupuncture to its clients is NOT assessed by comparing it to sham versions. A valid sham enables the exact same non-specific elements. It also fails to allow for potential nocebo effects from the doctor’s apparent loss of interest.

    The science of medical interactions is complex. I once thought I knew it all.

  19. pmoran,

    So your placebo for acupuncture would be something that should recur, not be a one-off. That makes sense. Horoscope casting would not work so well then.

    The nonspecific aspects of a learned expert, touch, personal attention and a story to explain whatever it is that you want explained should still be something a medical provider can offer with every interaction. Your point is that people don’t need this as a one-off, they need it regularly – weekly, say. Is that a hypothesis that could be tested by offering people the chance to attend a weekly pain clinic?

  20. adenacb says:

    “Because accupuncture doesn’t help beyond a simple placebo effect. The science is out, and it is a matter of particular annoyance that it persists with unshakeable devotion.”

    I understand that you need an N greater than 1 to prove that something works. I understand that it’s difficult to plan out an RCT with acupuncture because the placebo must also involve using needles of some sort. I understand that the clinical evidence doesn’t support acupuncture. But my point is this. If your husband, wife, son, or daughter was suffering with chronic pain, for example, that Western medicine was not helping with…wouldn’t you give it a shot? Or would you just tell your suffering family member “acupuncture doesn’t work” so you have to continue suffering?

    I know you are not interested in Ns of 1, but I was diagnosed with breast cancer 2 years ago. I entered a clinical trial that involved ovarian suppression and Tamoxifen. After a few months, I was having a bunch of difficult symptoms, including severe hot flashes several times a day, dizziness, heart palpitations. nausea. After stopping the study, many of these symptoms persisted. I went to a PCP, my oncologist, my surgeon, etc. etc. No one could do anything that helped. Eventually a friend suggested acupuncture, and the hot flashes immediately went away. I know, you are going to say it’s placebo effect. But it worked. That is why people use acupuncture. Because where Western medicine fails, sometimes, it can help.

  21. Here’s my take on acupuncture: The practice and underlying understanding of acupuncture are bunk.

    At this time, I can’t completely rule out some potentially useful effect from needling, though I don’t currently assign it a very high probability.

    Even if needling were determined to be a safe and effective therapeutic practice, that would in no way validate the practice of acupuncture anymore than transfusions validate the practice of bloodletting.

    The fact that the location in which you needle is irrelevant tells us the ideas of chi and meridians is invalid.

    The practice of needling may have some measurable physiologic effect, but the question is whether there is any therapeutic benefit to that effect and if so, is it a practical, lasting effect?

    The fact that it does not seem to matter whether you do actual needling or just poke with toothpicks makes it questionable whether the physiologic effects seen from needling are responsible for the claimed therapeutic effects of needling or just due to a placebo response. At the very least, you’d have to see the same physiologic effects from poking as you do from needling to even proceed down that line of thought.

  22. @adenacb
    “That is why people use acupuncture. Because where Western medicine fails, sometimes, it can help.”

    My revision of this statement:
    “That is why people use acupuncture. Because where Western medicine fails, sometimes, it is perceived to help.”

  23. @adenacb on knowing whether acupuncture helps: “I know you are not interested in Ns of 1, but … a friend suggested acupuncture, and the hot flashes immediately went away. I know, you are going to say it’s placebo effect. But it worked.”

    I’m not a doctor or a researcher, but my first thought is that your hot flashes might have gone away anyway. Women generally don’t have hot flashes all their lives. Anecdotes are fine for generating questions to test, but you really have to do the testing. If you conduct an experiment and 15/50 women who have acupuncture report that their hot flashes went away, you have no idea what that means unless you compare to women who didn’t get acupuncture. If 15/50 of the women who didn’t get acupuncture also found improvement in their hot flashes, then acupuncture adds nothing.

    That’s why N=1 is not helpful.

  24. adenacb, fortunately we do have studies on acupuncture for hot flashes where n>1 that can actually tell us something. Steve Novella discusses some here.

    http://www.sciencebasedmedicine.org/?p=3314

    Sadly, it appears most likely that your hot flashes would have gone away anyway.

  25. Todd W. says:

    @adenacb

    If your husband, wife, son, or daughter was suffering with chronic pain, for example, that Western medicine was not helping with…wouldn’t you give it a shot? Or would you just tell your suffering family member “acupuncture doesn’t work” so you have to continue suffering?

    Nope. Just as I would not recommend they try a pill that someone is hawking for which there is no scientific evidence of efficacy (or even safety, for that matter).

    With acupuncture, we know with pretty decent certainty that a) it doesn’t matter where you stick the needles and b) it doesn’t matter whether you break the skin or not. Given those two bits of information, pursuing acupuncture is not only a waste of money, but it also carries increased risk without any increase in benefit. That is, acupuncture’s effects are no greater than placebo, yet it carries the risk of infection, since the needles break the skin. If it were a pill, would you be so cavalier about recommending it?

    Instead, I would recommend getting a massage or doing something else relaxing and/or fun.

  26. Just a suggestion – SBM has done many articles on acupuncture. But the cult cargo piece, I noticed a brief mention of dry needling used on trigger points for myofascial pain.

    Recently, my BIL mention his PT using what sounds like a similar technique for a sports related elbow injury that he thought was quite effective, used along with other PT treatments and recommendations. He described it as using acupuncture needles, inserted repeatedly into the painful area and said that it “Hurt like hell, but seemed to help.”

    I’d be interested on a layman’s description of this technique, how much evidence there is for it’s use, etc. The cult cargo reference was a bit technical. Thanks

  27. pmoran says:

    Todd W: “ With acupuncture, we know with pretty decent certainty that a) it doesn’t matter where you stick the needles and b) it doesn’t matter whether you break the skin or not. Given those two bits of information, pursuing acupuncture is not only a waste of money, but it also carries increased risk without any increase in benefit. That is, acupuncture’s effects are no greater than placebo, yet it carries the risk of infection, since the needles break the skin. If it were a pill, would you be so cavalier about recommending it?

    Why are placebo influences regarded as being of no benefit to the patient? There is no reason why the cost/risk/benefit evaluation of a treatment should not encompass them. We now know that most of the benefits claimed for antidepressants are from placebo (along with an unknown contribution from spontaneous changes in symptoms and reporting bias). They have a lot of adverse effects. Are we going to drop them, or apply a different standard?

    BTW, the theatrical, invasive and recurrent attendance aspects of acupuncture favour enhanced placebo influences, as well as creating added opportunities for other non-specific benefits of medical and social interactions (reassurance, explanation, encouragement etc). So a placebo pill IS an inferior “treatment” in that regard.

  28. “We now know that most of the benefits claimed for antidepressants are from placebo.”

    Whoa! really? Are you talking about that report on mild/moderate depression and antidepressants or are you referencing other studies?

  29. pmoran says:

    Michele, I think it is generally accepted that antidepressants have only weak effects over placebo. The benefits shown in many placebo-controlled trials are being inflated by patients being unblinded by their side effects. Here is one relevant study of the question.–

    Citation: Moncrieff J, Wessely S, Hardy R. Active placebos versus antidepressants for depression. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD003012. DOI: 10.1002/14651858.CD003012.pub2.

    Copyright © 2010 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
    ——————————————————————————–

    Abstract

    Background
    Although there is a consensus that antidepressants are effective in depression, placebo effects are also thought to be substantial. Side effects of antidepressants may reveal the identity of medication to participants or investigators and thus may bias the results of conventional trials using inert placebos. Using an ‘active’ placebo which mimics some of the side effects of antidepressants may help to counteract this potential bias.

    Objectives
    To investigate the efficacy of antidepressants when compared with ‘active’ placebos.

    Search strategy
    CCDANCTR-Studies and CCDANCTR-References were searched on 12/2/2008. Reference lists from relavant articles and textbooks were searched.

    Selection criteria
    Randomised and quasi randomised controlled trials comparing antidepressants with active placebos in people with depression.

    Data collection and analysis
    Since many different outcome measures were used a standard measure of effect was calculated for each trial. A subgroup analysis of inpatient and outpatient trials was conducted. Two reviewers independently assessed whether each trial met inclusion criteria.

    Main results
    Nine studies involving 751 partcipants were included. Two of them produced effect sizes which showed a consistent and statistically significant difference in favour of the active drug. Combining all studies produced a pooled estimate of effect of 0.39 standard deviations (confidence interval, 0.24 to 0.54) in favour of the antidepressant measured by improvement in mood. There was high heterogeneity due to one strongly positive trial. Sensitivity analysis omitting this trial reduced the pooled effect to 0.17 (0.00 to 0.34). The pooled effect for inpatient and outpatient trials was highly sensitive to decisions about which combination of data was included but inpatient trials produced the lowest effects.

    Authors’ conclusions
    The more conservative estimates from the present analysis found that differences between antidepressants and active placebos were small. This suggests that unblinding effects may inflate the efficacy of antidepressants in trials using inert placebos. Further research into unblinding is warranted.

    ——————————————————————————–

    Plain language summary

    Tricyclic antidepressants compared with active placebos for depression
    This review examined trials which compared antidepressants with ‘active’ placebos, that is placebos containing active substances which mimic side effects of antidepressants. Small differences were found in favour of antidepressants in terms of improvements in mood. This suggests that the effects of antidepressants may generally be overestimated and their placebo effects may be underestimated.

  30. Doc says:

    Alison Cummins, a word of advice about anything debunkers (aka. “skeptics”) say.

    You should first assume they are either misinformed, incompetent, negatively biased or trying to deceive you. They may not be but you’ll need to do some work to find out.

    Next check out all the references they site and the ones they don’t.

    Keep in mind that studies can look good on paper but have little no relevance to how things are actually done in practice. Expert help will be needed but you won’t find it on these blogs.

    After doing your homework then you will see if how credible the debunker really is.

    The BIG mistake, especially with these organized “skeptics” is to take anything they say at face value.

    Good luck.

  31. pmoran – sorry, but are you aware if this overestimation of the effects of antidepressants and underestimation of placebo effect is also relevant for anxiety disorders where SSRIs are commonly prescribed?

  32. pmoran,

    The placebo effect of antidepressants may be significant for mild to moderate depression, but my understanding is that their specific effect in severe depression is pretty unambiguously dominant.

  33. SimonH says:

    Many of my chinese friends think it hilarious that we use “traditional” chinese medicine, the same medicine that Mao forced the chinese population to use when he closed the universities and sent the doctors into the countryside….a massive death toll ensued from a combination of starvation and preventable diseases. Of course this traditional medicine was OK for the workers, but dear old Mao preferred Western medicine because it worked!

  34. pmoran says:

    pmoran – sorry, but are you aware if this overestimation of the effects of antidepressants and underestimation of placebo effect is also relevant for anxiety disorders where SSRIs are commonly prescribed?

    @Michele: I have no specific information on anxiety disorders, but I would expect a similar phenomenon to apply to some extent.

    @Alison, for all I know you are right about antidepressants for severe depression. This is not my field.

    I just tripped over a recent Cochrane review of 29 studies of SJW for major depression. It may be of interest to some.

    Summary: “The available evidence suggests that the hypericum extracts tested in the included trials a) are superior to placebo in patients with major depression; b) are similarly effective as standard antidepressants; c) and have fewer side effects than standard antidepressants. The association of country of origin and precision with effects sizes complicates the interpretation.”

  35. I don’t have access to the Cochrane review, but a Medscape article http://www.medscape.com/viewarticle/575412_3 references it as follows: “A Cochrane review of 37* double-blind randomized controlled trials in adults concluded that St John’s wort may be useful in treating patients with mild to moderate symptoms of depression, but is of only minor effectiveness in major depression, possibly of no benefit in prolonged depression, and there was no evidence of benefit in severe depression.”

    This is the opposite pattern found with pharmaceutical antidepressants, where the greatest effect is seen among those most ill. That would be consistent with the effect of SJW being primarily due to unblinded placebo.

    ________
    *What is a bit odd is that the Cochrane review was of 29 studies but the Medscape article said it reviewed 37. There might have been some mixup, so the entire summary is somewhat dubious.

  36. Ben Kavoussi says:

    @Alison Cummins

    My last post was not about acupuncture working, but not by meridians, as it has been interpreted.

    It was about the inevitable Type I error (also known as a false positive) in two-arm acupuncture studies, due to several confounding factors such as DNIC. These studies inherently flawed. Three-arm studies, which rule out the placebo effect, indicate that “true” acupuncture is not better than “false” acupuncture, and both are better and a non-interventional control. This indicates that the observed effects are either due to DNIC, intramuscular stimulation, or neurostimulation.

    I need to add that DNIC is an effective but ethically-wrong method of pain management. Have you ever heard of psychiatric patients who cut, pierce or burn themselves because they feel better after the injury? Have you heard of “needle play” and “play piercing” in the bondage scene and the addicting high the “players” get? These are reprehensible ways people self medicate using DNIC associated with mechanical and thermal damage to the skin.

    As for dry needling, it is a method to release muscular tension and pain in myofascial pain syndrome (MPS) through intramuscular stimulation via needles or PENS. According to Gerwin, Dommerholt, and Shah, MPS is a myalgic condition characterized by local and referred pain that originates in a
    myofascial trigger point. One attribute is a motor dysfunction of the muscle that is characterized by a constant, discrete hardness within the muscle. It usually is palpable as a taut band or nodularity within the belly of the muscle. The other attribute is a sensory abnormality that is characterized primarily by pain. The needling of the nodule seems to be effective in MPS patients. Dry needling is not acupuncture, it is not based on the meridians and points lore, and does not aim to treat anything but MPS.

    As David Ramey argues here, acupuncture as we know it today is a modern construct, with a false claim of authenticity and antiquity. It reminds me of reclaimed wood furniture: It has an antique and genuine appearance but it was made recently.

    In my upcoming post I will provide evidence in support of David David Ramey’s view, and further argue that acupuncture arises out of a biased and ideology-driven assumption about Eastern cultures called “Orientalism.” Our knowledge about medicine in China is not generated from facts or reality, but from false assumptions that envision the East as an antithetical to the West.

  37. Dr Benway says:

    Moncrieff hasn’t yet encountered a psychotropic that she finds useful.

  38. Ben Kavoussi says:

    @Doc

    We are not misinformed, incompetent, or negatively biased. I am a traditionally trained licensed acupuncturist, and know about this fraud from inside…

  39. pmoran says:

    Ben: Three-arm studies, which rule out the placebo effect, indicate that “true” acupuncture is not better than “false” acupuncture, and both are better and a non-interventional control.

    I’m not sure what you mean when you say three arm studies ” — rule out the placebo effect”, Ben. In such studies at least part of the superiority of the “interventions” can be interpreted as due to placebo responses.

    Is it even absolutely necessary to invoke DNIC or other possible physiological influences to explain such results? We quite reasonably speculate that they may well play a part, but placebo influences, other non-specific influences of medical attentions and reporting biases would be expected to account for much of the reported benefits.

    I agree we cannot wholly dismiss this type of treatment with a confident “it doesn’t work” (in any way) — (if that is what you are saying).

    I also thought penetrative acupuncture with fine needles was relatively pain free, less so than many medical treatments, so is not the ethical argument and the analogy with self-mutilation a bit of a stretch?

  40. Ben Kavoussi says:

    @pmoran

    Three-arm studies provide the ability to precisely define the effect of the placebo response, and can measure the difference between the placebo group, the treatment group.

    Imagine you want to see if treatment A is effective for muscle pain. The response you get by providing A to pain patients includes:
    1- the effects of A, if any
    2- the placebo response
    3- the natural history of the disease, meaning the tenancy for people to get better or worse during the course of an illness irrespective of any treatment at all.

    It is therefore crucial to have 3 groups:
    Group 1 – the non-intervention group to determine the natural history of the disease
    Group 2 – the sugar pill group to determine the rate of the placebo response for this condition
    Group 3 – the treatment A group.

    The statistics are off if we just compare group 3 and 2, because do not know with certitude the role of the placebo effect and the effect of the natural history of the disease.

    Please read “Snake Oil Science: The Truth about Complementary and Alternative Medicine” by R. Barker Bausell.

  41. Ben Kavoussi says:

    @pmoran

    Penetrative acupuncture with fine needles that is pain free is not only useless, but is not what was practiced in China prior to the 20th Century.

    In my next post I will provide images of the instruments described in the Chinese classics of medicine. There are no fine needles. What the Chinese used is coarse needles, pins and lancets, all of which caused mechanical injury, bleeding and pain. They also used blistering and cautery, which caused thermal injury. I am certain all of this provided some relief due to the painful injury. This resembles the high seen in self mutilation and painful “needle play” and “play piercing.”

    Most acupuncture studies these days use electricity and attribute the observed results to needling, which is wrong. The effects must be due to electrostimulation.

  42. Sorry to pull the thread off topic, but I was just surprised by the SSRI placebo statement. That said, I am not too surprised if the placebo effect may be over estimated in mild to moderate depression or dysthymia, but I would be surprised in the case of severe depression and I would be surprised in the case of anxiety disorders such as severe OCD.

    But I also think it is a serious discussion attach to a SBM article that will draw in commentors with psychiatric backgrounds. I wish that the discussion had happened in Amy T. article many months back, but that article was not indepth and the discussion got pulled off topic due very quickly.

    Obviously depression can be life threatening and anxiety disorders can be crippling, so I wouldn’t want the choice of taking meds or not to be treated dismissively or lightly. But the side effects of anti-depressants can also be substantial, so I am curious about the most recent psychiatric evidence of benefit.

    Also, I’m apparently in the mood to hand out writing assignments for SBM contributors. :)

  43. anoopbal says:

    Hope you guys checked this study in Pain :

    Pain. 2010 Oct;151(1):146-54. Epub 2010 Jul 23.

    German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) – a pragmatic, controlled, patient-blinded, multi-centre trial in an outpatient care environment.

    Molsberger AF, Schneider T, Gotthardt H, Drabik A.

    Abstract
    The German Randomized Acupuncture Trial for chronic shoulder pain (GRASP) comprised 424 outpatients with chronic shoulder pain (CSP) > or =6 weeks and an average pain score of VAS > or =50 mm, who were randomly assigned to receive Chinese acupuncture (verum), sham acupuncture (sham) or conventional conservative orthopaedic treatment (COT). The patients were blinded to the type of acupuncture and treated by 31 office-based orthopaedists trained in acupuncture; all received 15 treatments over 6 weeks. The 50% responder rate for pain was measured on a VAS 3 months after the end of treatment (primary endpoint) and directly after the end of the treatment (secondary endpoint). RESULTS: In the ITT (n=424) analysis, percentages of responders for the primary endpoint were verum 65% (95% CI 56-74%) (n=100), sham 24% (95% CI 9-39%) (n=32), and COT 37% (95% CI 24-50%) (n=50); secondary endpoint: verum 68% (95% CI 58-77%) (n=92), sham 40% (95% CI 27-53%) (n=53), and COT 28% (95% CI 14-42%) (n=38). The results are significant for verum over sham and verum over COT (p<0.01) for both the primary and secondary endpoints. The PPP analysis of the primary (n=308) and secondary endpoints (n=360) yields similar responder results for verum over sham and verum over COT (p<0.01). Descriptive statistics showed greater improvement of shoulder mobility (abduction and arm-above-head test) for the verum group versus the control group immediately after treatment and after 3 months. The trial indicates that Chinese acupuncture is an effective alternative to conventional orthopaedic treatment for CSP.

    And read this to see why it worked: http://bodyinmind.com.au/acupuncture-and-chronic-shoulder-pain/

  44. pmoran – also thanks for taking the time to post the SSRI reference.

  45. More derailing: have we all seen this?
    The Economic Argument (against plausibility)

    http://xkcd.org/808/

  46. Dr Benway says:

    OK not to derail too much, but from pmoran’s quote above:

    Combining all studies produced a pooled estimate of effect of 0.39 standard deviations (confidence interval, 0.24 to 0.54) in favour of the antidepressant measured by improvement in mood. There was high heterogeneity due to one strongly positive trial. Sensitivity analysis omitting this trial reduced the pooled effect to 0.17 (0.00 to 0.34).

    That is one stinky post hoc data massage right there. You can’t just Photoshop outliers and re-run your tests. Readers will wonder how many weekends you spent playing with your nifty statistical software package until you got just what you needed to support your ideological mission in life.

    Moncrieff’s publication record here.

    The entire process of sorting out the role of medication in helping people with psychiatric symptoms would be much easier without CCHR ideologues, butthurt psychoanalysts, New Age gurus, and defensive fundagelicals filling up the airspace with anti-pharma propaganda.

    When you hear a statement like, “the benefit of the medication in comparison to placebo was small,” you need to ask what “small” means. If the difference between the treatment and placebo groups was statistically significant, it counts. That’s the rule we’ve been using to inch our way forward through the darkness, and so far it seems to be a good rule.

    Large differences between treatment and placebo groups aren’t typical of psychiatric studies.

  47. I wonder what Sam Harris would say if science showed that a belief in a factitious supernatural being was better for human’s over all well being?

    http://www.npr.org/templates/story/story.php?storyId=129528196
    “Is believing in God Advantageous?”

  48. Whoops, I wonder what Jesus would do when he posted his comment in the wrong thread.

    So sorry. :(

  49. ConspicuousCarl says:

    Alison Cummins wrote:
    > Many of the posts on acupuncture on SBM appear
    > to repeat this pattern. They explain that acupuncture
    > works, but not by meridians… therefore, acupuncture
    > doesn’t work.

    You can only interpret the counter-irritation effect as being evidence of acupuncture “working” if you greatly lower your expectations for what acupuncture supposedly does.

    Pickpockets use a similar concept in a more blunt form when they give you a bump in order to distract you from the tickling feeling of fingers reaching into your pocket. I don’t know if that effect takes advantage of the same underlying biology as acupuncture or if it is merely similar, but I wouldn’t be too proud of a medical procedure which operates on the same concept as theft.

  50. Pieter B says:

    Am I the only one to notice that in her proposal of a placebo, Alison Cummins confuses astrology and palmistry?

    The placebo I proposed above was having your horoscope cast. There’s a learned expert, some touch (examination of the palm), personal attention and a story to explain whatever it is that you want explained. All very nonspecific.

  51. I don’t confuse anything: I observe. Any time I have had my horoscope cast, the astrologer has examined my hand.

  52. pmoran says:

    DR Benway: When you hear a statement like, “the benefit of the medication in comparison to placebo was small,” you need to ask what “small” means.

    Agreed, but this arose purely in respect to apparent intellectual inconsistencies in common SBM rhetoric.

    If one of our most commonly prescribed drugs is 75% placebo (an entirely realistic figure according to some), why, exactly, should we regard “it’s mostly placebo and/or counterirritant” (all that we can truly say) as eliminating acupuncture from consideration as a medical treatment?

    And wriggle as much as you like, the active placebo studies suggest that any true activity of those antidepressants may be much weaker than that. In fact, if antidepressants were an implausible alternative treatment instead of a drug , we would have little hesitation in saying that the weak positive results are well within the range of error of clinical trials involving subjective outcomes. There seems to always be a bias towards positive outcomes.

    We would also, I’ll wager, not hesitate to dismiss the single outlying study (out of 29, for Pete’s sake!) that showed very positive results as due to poor trial methodology, perhaps also a loss of blinding.

    One of the reasons we need a very clear understanding of what goes on in medical interactions is that many studies are appearing, and in my view will unquestionably continue to appear, that show that alternative methods perform as well or even better than standard medical care in head-to-head studies with many conditions. This will be the final throw of the dice for alternative medical science, and I predict the results will be discomforting.

    If we are not to have to resort to even more Olympian mental gymnastics in trying to explain away such outcomes with entirely implausible methods we need to have no illusions as to the role of placebo and other non-specific influences in normal daily medical practice.

  53. Dr Benway says:

    In most studies “placebo” is merely the control for a variety of non-specific variables. Therefore to say, “the effect is 75% placebo,” is misleading. Better to say, “the med accounts for a real chunk of the variance we see, but maybe 75% is down to a sh_tload of variables that are hard to sort.”

    BTW, no wriggling here. I’m happy to follow the evidence wherever it may lead. But that’s not usually the case with people who publish papers on antidepressants, antipsychotics, and ADHD meds concluding in each that the meds are crap.

    Three months ago I wrote orders to taper a young woman’s Seroquel dose due to uncertain benefit, from 700mg daily to nothing, reducing by 100mg every 1-2 weeks. She was placed on the medication long before I began seeing her to target aggression requiring institutional care. I saw her emergently two weeks ago on 300mg daily, after four days of no sleep, constant swearing and wandering, disorganization –i.e., mania, basically. So I put her back on 700mg of Seroquel daily with a little extra prn. It took about a week but she’s returned to her prior cheerful yet impulsive baseline. No history of previous mood episodes. No family history of mood disorders.

    No way adding or subtracting a “placebo” would cause a moderately mentally retarded girl who calls me, “hey lady” to stop sleeping five nights in a row.

  54. Dr Benway says:

    If one of our most commonly prescribed drugs is 75% placebo (an entirely realistic figure according to some)…

    pmoran, you have to be aware that psychiatry is the only medical specialty with its own well funded, politically connected, highly organized hate group. Every negative report or opinion concerning a psychiatric treatment or a psychiatrist is amplified hundreds of times over in a variety of printed and electronic media.

    Repeat something often enough and it becomes “common knowledge.”

  55. WilliamOBLivion says:

    Finally some definitive proof that Acupuncture has a measurable effect:

    http://www.guardian.co.uk/science/2010/oct/18/dozens-killed-acupuncture-needles

    Oops.

  56. Calli Arcale says:

    Dr Benway — if I recall correctly, the complaints against antidepressants and other psychoactive drugs concerns their use for mild to moderate depression, when they’re approved for severe depression.

    My opinion is that the drugs are overprescribed, and this skews the data. Medical science needs to work out how to better judge who will benefit from the drugs. In the absence of this information, many patients have to go through a long and agonizing series of trials on various different drugs before finding one that works, and it would be nice if we could just cut to the chase and give the right drug (or no drug, where applicable) on the first try.

  57. pmoran says:

    “pmoran, you have to be aware that psychiatry is the only medical specialty with its own well funded, politically connected, highly organized hate group. Every negative report or opinion concerning a psychiatric treatment or a psychiatrist is amplified hundreds of times over in a variety of printed and electronic media.
    Repeat something often enough and it becomes “common knowledge.”

    You are reading me wrongly. I personally am not sure that it matters for many kinds of patients if a treatment is mostly placebo. If we worried about that we should be attacking a great deal of daily medical practice.

    Patients like and expect to be “treated”, but often the main therapeutic benefits derive from other aspects of the medical interaction. All that probably matters for “good medicine” — that is, for the patient — is that the global risk/benefit profile (including any placebo-related responses) of the overall management policy exceeds or matches other options.

    I am trying to ensure that we take this into account when professing to be science-based in our criticisms of CAM. We cannot assume that medical attentions centred around its interventions are unable to help patients with some conditions, just as its practitioners and clients claim.

    Certain specific claims definitely warrant rebuttal and they are the ones where the science is also clearer.

  58. Physiodawg says:

    HI Everyone,

    I’m a physical therpaist in Britain. I wonder what your opoinions on this piece of research is.

    BMJ 2006; 333 : 623 doi: 10.1136/bmj.38878.907361.7C (Published 15 September 2006)

    * Research

    Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain

    1. K J Thomas, reader1,
    2. H MacPherson (hm18@york.ac.uk), research director2,
    3. L Thorpe, research associate1,
    4. J Brazier, professor1,
    5. M Fitter, director2,
    6. M J Campbell, professor1,
    7. M Roman, general practitioner principal3,
    8. S J Walters, senior lecturer1,
    9. J Nicholl, professor1

    I came across your site after trying to research whther I should fork out my cash to learn acupuncture. It is considered a vauable add-on to our practice in the U.K and is requested often by patients in the private sector.

    However your analysis and info have reinforced somewhat my skepticism.:-)

    Still, however the pressure is on to jump onto the Acu bandwagon. And there is always the drip-feed of weak support for it’s efficacy reinforcing the idea that it works.

    So I’m always seeking the views of experienced reviewers of the value of the research.

    Anyone wanna read the above papaer and say whther the conclusions are validly drawn and whther it does indicate some true efficacy beyond placebo.

    physiodawg

  59. Dr Benway says:

    pmoran, I’m not critical or dismissive of patients who believe some alt med thing works. I’m more concerned about MDs pretending stuff is science based when it isn’t.

    Most patients I see aren’t fanatical followers of some alt med practice. They take an interest in it after hearing “studies have shown…” They are led to believe the supplement or practice has a bit of science behind it, just not enough to be officially accepted. But if doctors were clear that the product didn’t work any better than, say, chicken soup, they wouldn’t waste their hard earned money on it.

  60. Dr Benway says:

    Dr Benway — if I recall correctly, the complaints against antidepressants and other psychoactive drugs concerns their use for mild to moderate depression, when they’re approved for severe depression.

    Remember five years ago the evil psychs were making people go postal with their dangerous, mind altering antidepressants which all got blackbox warnings? Turns out they were only placebos. The tricky bastards!

    Anyway, nothing is simple in psychiatry. Study populations don’t match what walks through the door of an outpatient practice where everyone has a co-morbidity. And studies have to translate a number of subjective variables into numbers, else no fun with statistics. So subjects get rating scales, like the Hamilton. The scales have flaws, but they’re known flaws that don’t interfere with the effort to compare a treatment group to a placebo group.

    If all I cared about was the Hamilton-D, I could treat depression with Benadryl. Google it up and you’ll see that three of the seventeen items are insomnia ratings.

    In short, “mild depression” verses “severe depression” has a certain meaning in a research setting that doesn’t translate exactly to real life.

    People need to chill and not react to everything hyped up in the press. Let the science work things out in time.

  61. pmoran says:

    Anyone wanna read the above papaer —

    Here’s my interpretation.

    Apart from the unusual finding that the apparent benefits of acupuncture were better at 24 months than at 12 months, the results are more or less what you would expect whenever one treatment group is given special attention, another “ordinary care”, and predominantly subjective outcomes are being sought.

    Virtually all such studies of ANY treatment at all will give positive results. Yet when it is possible to provide the same “treatments” in such a way that the patients don’t know whether they are getting the “special” treatment or not there is often little or no difference. This applies with acupuncture, where various sham procedures seem to perform very nearly as well as the “real” acupuncture in now very many studies.

    We interpret this to mean that the reported benefits in less rigorously designed studies are mainly due to placebo responses and reporting biases (patients trying to give what they think is the “right answer”) in an unknown proportion.

    The acupuncture is therefore doing little other than providing the method with some mystique, and additional credibility for some users. Note that those who had higher advance expectations of acupuncture did better than those who didn’t, but that could also be in part from reporting biases.

    So the short answer is “it’s complicated”.

    We can be fairly sure that acupuncture does nothing much in and of itself, a belief supported by the fact that disability scores (i.e. more objective ooutcomes) were not affected much by acupuncture and only subjective outcomes were.

    Nevertheless treatment programs containing or mimicking acupuncture it may have some useful, mainly placebo, value, especially for those with positive expectations, or those in the hands of a particularly charismatic and confident therapist.

  62. “Remember five years ago the evil psychs were making people go postal with their dangerous, mind altering antidepressants which all got blackbox warnings? Turns out they were only placebos. The tricky bastards!”

    Chuckling – But, I have to say from a non-healthcare person’s perspective, I thought it was a good idea when they added the blackbox, although I don’t know if it’s done any good.

    Warning anecdotes ahead…

    I’ve know several people who have been prescribed anti-depressants with what I feel in inadequate supervision or education by their physicians. I believe all of these were either GP or other (non-psychiatric) doctors they were seeing for pain issues. Three of them discontinued their medication without tapering with predictable results. One of them had her medication discontinued without tapering, because her script ran out, the doctor wanted to see her in the office before continuing and the office refused to call in a temporary script. One of them almost died twice due to what appeared to be unnoticed (at the time) hypomania episodes.

    I have also seen many people benefit greatly from anti-depressants. I know they have saved peoples lives. It’s possible that they saved mine or at least helped to. But, I was hoping a blackbox warning would help people to take their use more seriously or seek better supervision/education from their doctors. Maybe I was being PollyAnna-esk.

  63. My anedote wasn’t clear – they weren’t all pain issues, A couple were stress related depression/sleeplessness, one PMS, two pain.

  64. The black box warning appears to have resulted in an increase in teen suicide.

    Teen suicide had been dropping steadily since the introduction of SSRIs. It increased suddenly after the black box warnings were introduced.

    So yeah, black box warnings are noticed and do make people more hesitant to use/ prescribe medication.

  65. Dr Benway says:

    michele, it’s true that antidepressants can cause an uncomfortable reaction in some people and so need to be monitored. But I’m in favor of deciding what that means on a case by case basis. For example, a reliable parent who knows when to call the doctor might be enough for four weeks.

    The blackbox warnings, like Homeland Security’s terror alert system, provoke confusion. How helpful is it to hear, “Your kid who is depressed and probably thinking life may not be worth living, may have more (how much more?) thoughts that life isn’t worth living on this drug.”

    What does that mean? A suicide attempt? A worsening depression? Uh… apparently not.

    So now we tell parents to be-on-the-look-out for a scary symptom they cannot see. Mean, I know, but the lawyers make us.

    And the lives saved by this intervention, per science?

    Zero.

  66. “And the lives saved by this intervention, per science?”

    No, not zero. Less than zero. Lives are lost.

  67. Fifi says:

    Alison – “Teen suicide had been dropping steadily since the introduction of SSRIs. It increased suddenly after the black box warnings were introduced.”

    To use your post as a jumping off point…(hopefully you don’t mind :-)
    f
    Correlation isn’t causation and if it was we’d have a wide variety of things to take into account regarding teen suicide other than Black Box warnings. I’m not saying there isn’t a nocebo effect to Black Box warnings, just that there may well be other factors. The black box warnings are important – despite how uncomfortable (or helpless) they may make the physician prescribing them. And, obviously, perhaps the real answer is to not have non-psychiatrists who don’t have the appropriate training and insight prescribing SSRIs. Mild and moderate depression can often be resolved through CBT or lifestyle/behavioral changes, and severe depression shouldn’t be treated by a GP – there should be appropriate intervention by a specialist. (Just as there would be for a severe non-mental illness. Of course, GPs don’t always have a choice and there is huge – and hugely inappropriate – pressure/marketing by pharmaceutical companies to get GPs prescribing these kinds of medications.)

    What the studies have shown is that SSRIs aren’t much better than placebo for mild to moderate depression but are more useful for severe depression. (Some research indicates that SSRIs’ action is in areas of the brain more related to anxiety than depression, the two are often comorbid. I’d advance, purely hypothetically, that this may make someone more likely to commit suicide since it may reduce fear/anxiety about suicide AND give the person the ability to act on their desire to kill themselves – when their depression, and associate apathy, made action less likely. It’s well known that there’s a sort of danger zone when starting to treat severe depression where the patient becomes more motivated and that this can lead to them enacting suicidal thoughts.)

    That doesn’t, of course, mean that SSRIs might not be useful as a placebo or boost for someone who is experiencing mild to moderate depression with anxiety if it’s in conjunction with therapy. (You can forgo the therapy but that means you’re just medicating the symptoms and not looking for the cause most of the time.)

    Dr Benway – I couldn’t agree more. The amount of people I know into alt med who believe that “studies show” is huge and most people are actually quite open to be shown good science if it’s done in a way that isn’t insulting (if they don’t make a living off of alt med so aren’t prone to a confirmation bias for all kinds of reasons, just as happens sometimes to doctors or medical researchers too). There’s a reason why alt med companies (and pharmaceutical companies, not to mention skincare and all kinds of domestic products) use pseudoscience – science, or the branding or aura of science, sells. Check the advertising, it’s as pervasive as “natural” and quite often its a combo of both (“studies show natural superfood”, etc).

  68. Okay, I can see the side of those against the blackbox warning. But perhaps there is another way to get the GP (or other doctor) who writes scripts for antidepressants without adequate monitor or education to do better? Or a better way to educate the general public?

    Should I just start sending photocopies of dead crows to doctors offices with the words “This is how my friend (niece, brother, etc) felt, cause you forgot to tell them to tapering off Paxil was important.” scrawled across it*? (or other appropriate warning?) Perhaps that would make just enough of an impression that they remember in the next 15 minute appointment?

    While vague and ominous black box warnings may unproductively discourage medication use, perhaps people sharing their reports of their negative experiences with SSRI’s (that didn’t need to happen) and how they were “addicted” to SSRI’s (which I believe isn’t accurate) may also discourage the use of the medication? Isn’t better education the best defense against the anti-medication mythology? How is that better education going to happen?

    *I wouldn’t do this. Firstly, for thematic effect it would clearly be better to use the letters cut from a magazine method. Secondly, the logistic are too complicated, you’ll probably just confuse some clerk. Thirdly, I still wouldn’t do it, cause it seems, overall, wrong. Fourthly, obviously there is a error in my analogy, because a dead crow doesn’t feel much of anything. Overall, it appears I’m not cut out for subversive, protest mailings. This leaves me no recourse, but to complain ineffectively in a SBM comments box, where the only truly subversive element (aside from the grammatical crimes) is being off topic.

  69. Fifi says:

    A thought about the medical potential of the doctor/patient interaction being part of the effect or main effect…

    If this is problematic when it’s the main effect in the case of a CAM practitioner/patient session (and there’s prescribing of a placebo involved), then why isn’t it a problem when it’s the main effect in the case of a GP/patient session (with placebo)? If the patient’s issue is one that responds(usually temporarily) to interpersonal interactions then it indicates that it’s something that could be very effectively treated by CBT or interpersonal therapy (so the patient can learn how to get their needs met in their life instead of through a GP or CAM practitioner, and avoids becoming dependent upon a GP or CAM practitioner that isn’t trained in psychotherapy and to handle transference and counter-transference, or to help the patient identify and learn how to fill their social/interpersonal needs).

  70. Fifi says:

    One of the problems is that treating depression is very much like treating pain.

    1. We still really don’t know a lot about either, even though we know waaaaaay more than we used to a couple of decades ago…that said, we’re still in the infancy of neuroscience really and not at all clear of the ideological woods regarding either.

    2. Both are measured by observation and subjective reporting, we still don’t have reliable biological tests or measures for either.

    3. Both have a huge cultural component – both in how people learn to experience and frame their experiences, and in how the general public and physicians see (and treat) people with both chronic pain and depression. Why? Because most of us, being empathetic, can only measure or imagine someone else’s experience against our own (that’s what empathy is, and why it’s qualitatively different than compassion and sometimes actually problematic…and why psychotherapists and psychiatrists are trained in transference and counter-transference). It’s also why people tend to tell people who are depressed or in pain to “get over it” as if that was just possible (well, that and people tend to find those in pain or depressed to be annoying and unlikeable because both conditions make many people annoying or unlikeable/cranky/frustrated).

    People like to believe they/we don’t carry cultural biases regarding pain and depression but we all do simply because we all learned to deal with our own feelings of pain and depression somewhere. We’ve got to recognize our own bias (transference) before we can account for and actually be compassionate towards someone else’s experience of depression or pain. It’s one reason why people who have had an experience and resolved an issue – addiction is a very good example – can be much more effect in helping people with the same problem than someone who just knows about it academically. It’s also why clinical experience is so important and why people who just know theory but have no practical experience can be quite misguided – even though they mean well.

  71. Fifi,

    Fewer teens kill themselves when SSRIs are prescribed more liberally. It’s correlational, sure, but when SSRIs are introduced teen suicides go down; when SSRIs prescriptions for teens slow down, teen suicides go up again. It’s not as though the correlation only happened once, or as if it were unexpected. If SSRIs work to treat the life-threatening condition of severe major depressive disorder, then this is *exactly* what you would expect to see. And taken together, the evidence points in this direction: SSRIs *do* work to treat the life-threatening condition of severe major depressive disorder.

    It’s reasonable to think that at least some of the teens who kill themselves were severely depressed and would have been appropriate candidates for a medication intervention. Whether it is more appropriate to treat mild depression in teens without recourse to SSRIs is completely irrelevant if we are talking about severe depression — which we are. The kind that kills you.

    Yes, that intermediate state where you still want to die and are now all of a sudden able to — and where you are perhaps also agitated and irritable and need to do something — is well-known. (I have someone in that state at home right now. Fortunately they are not a teen and have been through this before, otherwise I would be really scared.) One advantage SSRIs might have over other interventions or even just waiting it out is that you know when this dangerous window is: say, the first two months after starting treatment. Anyone recovering from a severe depressive episode passes through this window, no matter how they get there. SSRIs might plausibly shorten the time in the window.

    This speculation is irrelevant though, because we know there is a net excess of teen suicide when SSRI prescribing is conservative compared to when it is more liberal.

    Given how repelled most of us are by the idea of drugging children, I really have to doubt that SSRIs have ever been handed out like candy to all kids who complained that homework sucked and their parents were unreasonable and that society is corrupt. In my experience, most mental health workers who work with children are against psychiatric drugs for anybody at any time if they can possibly be rationalized away. Their strong bias against prescribing drugs to children carries over into a strong bias against prescribing drugs to the middle-aged.

    I’m not saying this bias is inappropriate; I think it’s probably completely appropriate, at least with respect to young people. What I am saying is that given that this bias exists, even when SSRI prescriptions for teens were being made more liberally they were probably being made very cautiously. The black box warnings for teens meant that SSRIs were being prescribed even more cautiously. Given the subsequent jump in teen suicide, it would appear to be too cautiously.

    You state that it’s not always possible to be treated for severe major depressive disorder by a psychiatrist and that people often have to settle for being treated by a generalist. This is true. I don’t see that it follows that generalists should not prescribe SSRIs. It takes no special skill to prescribe them. On balance, they save the lives of really ill people. Many laypeople are aware of the side effects of SSRIs and of tapering requirements, so I don’t see a huge impediment to generalists being aware of these things. (My brother is getting better treatment for his schizophrenia from his GP than he did from his psychiatrist, and his GP’s particular interest is… tropical medicine. And now we’re talking antipsychotics, not SSRIs.)

    It’s true, a skilled psychiatrist might be able to successfully treat a suicidal teen with psychological intervention alone. That’s great. Yay for the psychiatrist, yay for the teen. It’s unlikely that a GP would have these particular skills. If GPs must not prescribe any psychiatric medication, including SSRIs, then many people with mental illness will suffer and die with *no treatment at all.*

    micheleinmichigan,

    One option is to accompany your friend or relative to the doctor’s office and ask the doctor if they are aware that so-and-so is/was suffering. Depressed people may not think it’s worth the bother of speaking up. It’s their lot in life to suffer, if the doctor actually cared they would have asked and they didn’t, etc. They might secretly like that you want to go with them. Won’t work or be appropriate in all or even most situations, but if it is will probably be quite effective.

  72. Alison, thanks for the suggestion. So you are saying being polite and reasonably might work? Hmmm.

    Sadly most of my family* and many of my friends live quite far away, so generally attending doctor’s appointments with them is not an option. I do try to be informative and supportive given the opportunity. So because of the above events, when someone mentions to me that they have started taking an antidepressant, I will say, “so they told you not to just stop taking it when you feel better, right?”** etc.

    As to whether a good percentage of laypeople know about tapering off of anti-depressants or the very small chance that they can trigger a maniac episode, I would say not a lot do around here. I also have not heard a lot of anti-SSRI rhetoric around here (not very scientific I know.) Most of the anti-medication rhetoric I hear is Ritalin/stimulant based.

    *Including all the ones from my examples.

    **This is very easy for a socially anxious person to do and goes over very well in the mid-west were people generally are open and laid-back about their problems. ;)

  73. Dr Benway

    “michele, it’s true that antidepressants can cause an uncomfortable reaction in some people and so need to be monitored. But I’m in favor of deciding what that means on a case by case basis. For example, a reliable parent who knows when to call the doctor might be enough for four weeks.”

    Dr Benway – If by a case-by-case basis you mean a doctor looks at the patient’s symptoms, family history, considers risk and comes up with a monitoring plan as well as clearly informs the patient or guardian to call if they are experience a symptom off a list they are given, and to not stop taking the medication without calling for tapering instructions, I am fine with that. It would also be helpful (with an adult) if that list of symptoms was also given to someone close to the patient, since it appear that a person with hypomania symptoms is not great at self-reporting. I don’t know how realistic that is, though.

    So I guess what I’m saying is that in my opinion, writing a script for an anti-depressant should be more similar to out-patient surgery post-op instructions than writing a script for an antibiotic. Even in the cases such as PMS, FM, stress related anxiety, etc. not just severe depression.

    And I’m sure that a great many doctors already do this. I just wish more of them were treating my friends and family.

  74. The other thing you can do is send friendly notes to the doctor. If you’re afraid of being a whiner, buy yourself some karma by making a point of writing thank-you notes. My sister is really good at that. Every month at least I think she writes a smiley note to someone — to the grocery store manager to say how nice the fruit-stocker was, or something — which means that when she needs to write a frowny note, her conscience is clear. (My sister is close to perfect.)

    If you have documented your satisfaction with various people in your life, you are then free to write a little note to your loved one’s doctor to ask if they are aware of the suffering your loved one is enduring without feeling like a stalker leaving obscurely threatening messages of dead crows.

    Now that I think of it, my sister did that for me once. She was on the other side of the country and called up a CBT clinic that had me on a waiting list to ask if they were aware that I was researching the surest way to kill myself with a gun?

  75. It appears a few of the comments got lost in the hosting transition. So I’ll just repost a paraphrase of the comment that seems relevant to the current thread.

    Alison – Thanks for the suggestion. If I have to address this sort of issue again, I will keep it in minds.

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