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Is acupuncture as effective as antidepressants? Part 2. Blinding readers who try to get an answer

This is the second blog post about a recent PLOS One review claiming that alternative therapies such as acupuncture are as effective as antidepressants and psychotherapy for depression. The article gives a message to depressed consumers that they should consider alternative therapies as a treatment option because they are just as effective as conventional treatments. It gives promoters of alternative therapies  a boost with apparent evidence from a peer-reviewed journal that can be used to advertise their treatment and to persuade third-party payers that alternative treatments are just as effective as antidepressants and should be reimbursed.

In my first post, I could not reconcile what was said in this article with the citations that it provided. The authors also failed to cite some of their own recent work where it would have been embarrassing to arguments they made in the review. Most importantly, other meta-analyses and systematic reviews had raised such serious concerns about the quality of the acupuncture literature that they concluded that any evaluation of its effectiveness for depression would be premature (more…)

Posted in: Clinical Trials, Neuroscience/Mental Health

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The antivaccine movement and “autism biomed” versus “outgrowing” autism

A commonly misunderstood aspect of autism and autism spectrum disorders (particularly by antivaccinationists and believers in the quackery known as “autism biomed”) is that autism is not a condition of developmental stasis. It is a condition of developmental delay. Autistic children can and do exhibit improvement in their symptoms simply through growth and development. However, parents who subject their children to “autism biomed” quackery of the sort championed by Jenny McCarthy and others seem to view autism as a condition of developmental stasis. That’s why they so easily and predictably attribute any improvement in their children to whatever quackery du jour they are using on them. It’s also why, in order to determine whether a given intervention in autism has any real effect, randomized controlled trials are required. Indeed, it’s not so difficult to see why, if you take into account the widespread belief that autistic children do not improve, along with parents’ imperfect human memories riddled with confirmation bias, confusing correlation with causation, and other confounders like regression to the mean, so many parents believe that “autism biomed” treatments have actually helped their children. Moreover, improvements observed in autistic children tend to be uneven, with periods of little change interspersed with periods of rapid development. Should such a period of rapid development appear after a “biomed” intervention, guess what gets the credit for the improvement?

But how much improvement is possible? Do autistic children “recover,” and, if they do, how much can they recover? The autism biomed movement is rife with stories of “recovered” children, but often, if you investigate these stories, they turn out to be less than convincing, not unlike the way that alternative medicine cancer “cure” testimonials tend not to be so impressive when examined closely. However, in the case of autism, this isn’t always the case. There are clearly children who lose their diagnosis of autism or ASD, with observations published as far back as 1970, when Rutter reported that 1.5% of adults who had been diagnosed with autism were functioning normally, while 30 years later Sigman et al reported that 17% of autistic children in their group lost their diagnosis and 10 years after that Kleinman et al reported that up to 19% of autistic children “lose their diagnosis.” The reason for this observation is hotly debated, and until fairly recently it was often assumed that these children’s recoveries were in fact not true recoveries but children who were either misdiagnosed or overdiagnosed. Such an assumption made intuitive sense because such an outcome is more likely with children diagnosed with Asperger’s disorder or pervasive developmental disorder, not otherwise specified (PDD-NOS), both of which are categories that resulted from the expansion of the diagnostic criteria for autism. Be that as it may, when you boil it all down, it is estimated that between 3% and 25% of autistic children “lose their diagnosis.” However, few of these studies explicitly address whether the social and communication abilities of these children are fully typical.

A recent study might help clarify what degree of recovery is and is not possible. Most of the previous studies before this have been small and did not look specifically at the outcomes people are curious about. Published in The Journal of Child Psychology and Psychiatry by Fein et al and entitled Optimal outcome in individuals with a history of autism, this study got some news coverage last week under titles such as Some With Autism Diagnosis Can Overcome Symptoms, Study Finds; Scientists seek clues in kids who outgrow autism symptoms; Some children outgrow autism: study; Health Buzz: Can Autism Fade Over Time?; and Children ‘may grow out of autism’. The authors set the stage in their introduction after surveying the literature, some of which I’ve touched on above:
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Posted in: Neuroscience/Mental Health, Vaccines

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Systematic Review claims acupuncture as effective as antidepressants: Part 1: Checking the past literature

acupuncture

A recent systematic review in PLOS One raised the question whether acupuncture and other alternative therapies are as effective as antidepressants and psychotherapy for depression. The authors concluded

 differences were not seen with psychotherapy compared to antidepressants, alternative therapies [and notably acupuncture] or active intervention controls

or put it differently,

antidepressants alone and psychotherapy alone are not significantly different from alternative therapies or active controls.

There are clear messages here. To consumers: Why take antidepressants with their long delay and uncertainty in showing any benefits–but immediate side effects and potential risks–when a few sessions of acupuncture work just as well? To promoters of acupuncture and alternative therapies: you can now cite an authoritative review in the peer-reviewed PLOS One as scientific evidence that your treatments is as effective as scary antidepressants and time-consuming psychotherapy when you make appeals to consumers and to third-party payers.

The systematic review had five co-authors, of whom three have been involved in previous meta-analyses of the efficacy of antidepressants. However, fourth author Irving Kirsch will undoubtedly be the author most recognizable to consumers and policymakers, largely because his relentless media campaign claiming antidepressants are essentially worthless, no better than placebo. For instance, in an interview with CBS 60 Minutes Irving Kirsch: The difference between the effect of a placebo and the effect of an antidepressant is minimal for most people.

Irving Kirsch: The difference between the effect of a placebo and the effect of an antidepressant is minimal for most people.
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Posted in: Acupuncture, Neuroscience/Mental Health, Science and the Media

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Anti-psychiatry and anti-vaccine activists shamelessly taking advantage of the Sandy Hook Elementary School shootings

Quacks detest science-based medicine (SBM) in general, but there are certain specialties that they detest more than others. For instance, you won’t find too many quacks attacking trauma surgery because even they know that when a person’s body has been on the losing end of a confrontation with a bullet or a car, no amount of laying on of hands, homeopathic nostrums, “energy healing,” or herbal remedies are going to stop the hemorrhage, mend broken bones, or repair holes in various internal organs. That’s why even homeopaths will concede that “allopathic medicine” is good for emergencies. It’s also why sketches like this one resonate:

However, from there the distrust of promoters of unscientific and pseudoscientific medical systems and treatment modalities for SBM appears to increase in direct proportion to the urgency and need for direct physical repair of damaged organs, with the possible exception of cancer, for which the standard physical treatment (surgery) is attacked nearly as much as chemotherapy.

Be that as it may, arguably the specialty most attacked by quacks is psychiatry. Many are the reasons, some legitimate, many not. For example, the Church of Scientology in particular despises psychiatry, even going so far as to maintain through its anti-psychiatry front group the Citizens’ Commission on Human Rights (CCHR) a risibly nonsensical “museum” in Hollywood dedicated to psychiatry that they charmingly call Psychiatry: An Industry of Death. It’s so ridiculously, painfully over-the-top, a veritable self-parody of anti-psychiatry hyperbole, that it inadvertently undermines the very attacks on psychiatry frequently leveled by Scientologists and quacks that it’s meant to reinforce. Indeed, not having visited its website for several years, I notice that the CCHR has totally revamped it, now including a virtual 3D tour of the museum, along with video clips from its many “exhibits” available online. I’ll have to file that away for later blog fodder, because the misinformation, cherry picking, and pseudoscience flow freely, as one would expect from a Scientology propaganda project. In the meantime, suffice to say that it’s not just the Church of Scientology that despises psychiatry. It’s founder L. Ron Hubbard and his disciples merely represent the most ridiculously over-the-top and vociferous anti-psychiatry group that I’m currently aware of.

Let’s face it, psychiatry hasn’t always had the best history. It’s a very hard to study human behavior and disorders of human behavior in a rigorous fashion, but to my mind that didn’t excuse the the widespread acceptance for many decades of the ideas of Sigmund Freud, which were little removed from pseudoscience in many respects. Also, psychiatry has not always had the best history, particularly in the early part of this century. Too often, psychiatry has been used as a tool of control rather than a means of helping people who are suffering. Perhaps the worst example is the misuse of psychiatry by various totalitarian regimes, be it the Nazis using it as a primary tool of its T4 euthanasia program or the Soviet Union declaring enemies of the state to be mentally ill and shipping them off to Gulags.

Although there is a ways to go, however, psychiatry in 2012 is much better than psychiatry, say, 50 or 75 years ago. It wasn’t so long ago that, popularized by Walter Freeman, thousands of “ice pick lobotomies” were performed for all manner of indications, few of which had what we would consider to be compelling scientific support to back them up. Over the last half-century, better psychiatric drugs to treat different conditions have been developed, leading to their widespread use for a number of indications.
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Posted in: Neuroscience/Mental Health, Politics and Regulation, Public Health, Vaccines

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Brain-Machine Interface

We spend a great deal of time in the pages of Science-Based Medicine taking down every form of pseudoscience in medicine. Of course, what we see as pseudoscience, proponents often see as emerging or cutting edge science. They are taking advantage of the fact that there is a great deal of legitimate emerging science, and they hope they can sneak past the gates by cloaking themselves in the trappings of real science (jargon, studies, their own journals, etc.). Emerging science, however, no matter how plausible and earnest, still has yet to prove itself (by definition), and has to go through the rigorous process of scientific evaluation to slowly gain acceptance. That process – sorting out what works from what doesn’t, the real from the fake – is where all the action is in SBM.

It is refreshing sometimes to talk about an emerging field that, while still experimental, is legitimate and has the potential to usher in a genuinely revolutionary treatment.

I have been following the research into brain-machine interfaces for some years, and reporting on many of the significant “baby steps” in the advance of this new technology. A recent study published in The Lancet represents another incremental and encouraging advance. Researchers at the University of Pittsburgh implanted two strips of 96 electrodes into the motor cortex of a 52 year-old woman with tetraplegia. The electrodes are capable of detecting the firing of neurons in the motor cortex and transmitting those signals to an external processor that in turn controls a fairly sophisticated robotic arm. The arm is described as having seven degrees of freedom – three dimensions of translation, three dimensions of orientation, and one dimension of grasping.

After two days the subject was able to move the robotic arm with her thoughts alone. Over the course of the 13 week study she progressively gained control of the arm and eventually was able to feed herself with the arm. While this is still very far from a “cure” for paralysis or a restoration of full function, for someone who is tetraplegic (all four limbs are paralyzed) having any independent function is a huge improvement in quality of life.

So where are we with this technology?

Posted in: Neuroscience/Mental Health

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Journal of Clinical Oncology editorial: “Compelling” evidence acupuncture “may be” effective for cancer related fatigue

Journal of Clinical Oncology (JCO) is a high impact journal (JIF > 16)  that advertises itself as a “must read” for oncologists. Some cutting edge RCTs evaluating chemo and hormonal therapies have appeared there. But a past blog post gave dramatic examples of pseudoscience and plain nonsense to be found in JCO concerning psychoneuroimmunology (PNI) and, increasingly, integrative medicine and even integrations of integrative medicine and PNI. The prestige of JCO has made it a major focus for efforts to secure respectability and third-party payments for CAM treatments by promoting their scientific status and effectiveness.

Once articles are published in JCO, authors can escape critical commentary by simply refusing to respond, taking advantage of an editorial policy that requires a response in order for critical commentaries to be published. An author’s refusal to respond means criticism cannot be published.

Some of the most outrageous incursions of woo science into JCO are accompanied by editorials that enjoy further relaxation of any editorial restraint  and peer review. Accompanying editorials are a form of privileged access publishing, often written by reviewers who have strongly recommended the article for publication, and having their own PNI and CAM studies to promote with citation in JCO.

Because of strict space limitations, controversial statements can simply be declared, rather than elaborated in arguments in which holes could be poked. A faux authority is created. Once claims make it into JCO, their sources are forgotten and only the appearance a “must read,” high impact journal is remembered. A shoddy form of scholarship becomes possible in which JCO can be cited for statements that would be recognized as ridiculous if accompanied by a citation of the origin in a CAM journal. And what readers track down and examine original sources for numbered citations, anyway?
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Posted in: Acupuncture, Cancer, Clinical Trials, Energy Medicine, Neuroscience/Mental Health, Traditional Chinese Medicine

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Ecstasy for PTSD: Not Ready for Prime Time

Hundreds of desperate combat veterans with Post-Traumatic Stress Disorder (PTSD) are reportedly seeking experimental treatment with an illegal drug from a husband-wife team in South Carolina. The Bonhoefers recently published a study showing that adding MDMA (ecstasy, the party drug) to psychotherapy was effective in eliminating or greatly reducing the symptoms of refractory PTSD. It was widely covered in the media, for instance in this article in the NY Times. It was only a small preliminary study, and the treatment is not yet ready for prime time; but media reports have sparked enthusiasm not justified by the evidence. (more…)

Posted in: Clinical Trials, Neuroscience/Mental Health

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Chiropractic “Research” on Tourette Syndrome: The Trouble with Case Reports…..

I can think of few conditions with clinical features more ideal for establishing a pattern of abuse at the hands of practitioners of so-called alternative medicine than Tourette syndrome. Tourette syndrome (TS), which first manifests itself in early childhood in the overwhelming majority of patients, is a neurological disorder with infamous motor and vocal manifestations and a troubled past. Historically the condition was blamed on everything from emotional disturbances to outright faking to demon possession. But over the past few decades it has increasingly been recognized as a primarily organic disorder caused by negative genetic and environmental influences on areas in the brain which control movement and behavior.

I have a particular interest in Tourette syndrome, not just because I am a pediatrician but because I was diagnosed with the disorder at the age of seven. I have been lucky in that my symptoms, after a few rocky years in middle school and early high school, have been fairly mild. It is obvious to most people that I have a movement disorder, but it has never impacted my ability to function in society and succeed in my chosen profession of pediatric medicine. In fact, I often think of my Tourette’s as a positive aspect of my life, believing that it helped shape who I am as a person. I feel that it has helped instill in me positive personality attributes that are beneficial in the practice of medicine, such as empathy and compassion.

Patients that would have been institutionalized a hundred years ago, or worse as you go farther back in time, are now treated based on scientific advances in neuroscience and pharmacology, typically very successfully — that is if they manage to avoid involvement with quacks and charlatans. A 2009 survey of TS patients, or parents of patients with TS, revealed that nearly two thirds partake in alternative therapies with no proven benefit.

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Posted in: Chiropractic, Neuroscience/Mental Health

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Is There a Treatment for Tinnitus

There are several features of a symptom or illness that make it a convenient target for proponents of unconventional therapies. Subjective symptoms are more likely to be targeted than objective conditions – you don’t see many so-called “alternative” birth control treatments. Symptoms for which placebo effects alone are likely to produce the illusion of effectiveness are good targets for ineffective treatments. Symptoms that vary naturally over time also are good targets – patients are likely to seek treatment when their symptoms are maximal, which means spontaneous regression to the mean will provide an effective illusion of efficacy for any intervention.  Illnesses with a substantial psychological component (such as those that are worsened by emotional stress or that are emotional, such as anxiety) are likely to benefit from non-specific effects of the therapeutic interaction, rendering the treatment itself irrelevant.

Finally, any condition or symptom for which there is currently no effective treatment provides a market ripe for exploitation.

Tinnitus has many of these features. Tinnitus describes the subjective experience of spontaneous noise perceived in one or both ears, which can be a buzzing, hiss, tone, or ringing sound. The severity of the tinnitus, its loudness, can vary over time, but perhaps more importantly the degree to which the tinnitus is bothersome can vary considerably. The sound is distracting and can have a significant impact on quality of life. Those with tinnitus can ignore the sound at times (depending on its severity), can be distracted from the sound, and may even learn through cognitive therapy to become accustomed to it. Therefore we might expect that tinnitus is amenable to placebo effects.

Finally, there is no proven effective treatment for tinnitus, which means that those who suffer from tinnitus may be desperate for a treatment. Desperation is a commodity highly prized by snake-oil salesmen.

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A PANDAS Story

One of the skills I try to teach medical students on their journey to becoming experience clinicians is to consider and address the patient’s “narrative.” Patients have a certain understanding of their illness, its cause, and its role in their life. They make sense of their situation as best as they can, resulting in a story they tell themselves. This is how humans generally deal with the complexities of life.

There is a potential problem when the clinical narrative of the health care provider conflicts significantly with the illness narrative of the patient. Patients, for example, often feel that a highly specific diagnosis is necessary for optimal treatment of their condition. Until they are given such a diagnosis they feel they need to keep looking – for better diagnostic tests or different specialists (what I call the “Dr. House” narrative). The appropriate diagnostic and therapeutic algorithm for that patient, however, may not require a specific diagnosis, but rather eliminating certain diagnoses and then treating the probable category or clinical syndrome that remains. The clinical narrative, in other words, may be one of considering risks vs benefits with incomplete and imperfect knowledge.

Increasingly, it seems, the conflict of narratives is taking on a larger scale – not just between one doctor and one patient, but between the medical community and patient communities. Perhaps this is one manifestation of the new social media generation. Take, for example, a recent controversy over a patient diagnosed with PANDAS (pediatric autoimmune neuropsychiatric disorders associated with streptococcal infections).

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