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485 thoughts on “Reflexive doubt

  1. micheleinmichigan says:

    “As I said, I’m not sure my details are correct, but when I read DeBecker I thought, I wish psychologists did more investigating and less theorizing.”

    I wish psychologists would all send me a dollar. :P

    But seriously, I don’t recall that part, which is not surprising. Read it years ago. Generally I find psychology fascinating, not only for the theories and opportunity for self reflection, but also for how they go about experimenting with human behavior or senses.

    IMO, yes, psychologist have come up with some fantastic failures, poorly planned studies, jumping to wrong conclusions based on little data. But I would not hazard to guess how they do in comparison to other fields.

  2. EricG says:

    @ StatlerWaldorf

    “you wouldn’t by chance be feeling superior to all of us nitwits who don’t have medical degrees or PhD’s in science and yet dare to question medical authority? ”

    Conveniently missing the point while proving the point. You are questioning authority as the default position (which against Dr. T appears to be rallying). Evaluate the claims, evaluate the evidence and reevaluate the claims. From there you are free to reject the particular authority. Questioning authority as the default position has always struck me as the child’s response to the cleverer friend first figuring out Santa wasn’t real.

    End @ Statler

    In any event, this concept of “authority” becomes ridiculous. Dr. T (for instance) has no remotely binding authority or influence over me or anyone else. That is just something a person may ascribe because *they feel* as if Dr. T is “imposing” or “forcing” something upon them (as if every statement is a direct attack – read “the four agreements” on how to stop this childish insecurity). In the sense of being an “expert” sure, the contributors here (and doctors everywhere) may be that, but there is this automatic and willfully blind attachment of this “control” and “imposition” to that knowledge that is *hardly* the case.

    I, personally, view Dr. T (and all contributors here) as mere mortals (*gasp*) that happen to have a great deal of knowledge that I may benefit from. I continue to read this site because I value and trust their recommendations and input on topics. They have no meaningful concept of authority to apply. Anyone here can read elsewhere, do whatever and listen to whomever. It’s just silly when, as a scientific lay person, anyone comes on the board and hollers “Listen up doctors! You must validate my opinion or I will surely post here incessantly until you agree or give up!”

    Having just read animal farm, it just tickles me to see this overt reaction to *anyone* offering *anything* about *any topic* as if you cave and agree for one microsecond, Napoleon will sweep you off your feet and enslave you to his will. Hysterical.

  3. wales says:

    “It constitutes unequal treatment to point out that Dr. Tuteur is no longer in clinical practice when no one has pointed out that Dr. Sampson and I have both been out of clinical practice for many years.”

    Hall’s and Sampson’s SBM profiles disclose their retired status. Tuteur’s profile does not. Unequal disclosure perhaps deserves unequal treatment.

  4. EricG,

    I think you’ve got something there. Authority can mean “the power to determine, adjudicate, or otherwise settle issues or disputes; jurisdiction; the right to control, command, or determine.” It can also mean “an accepted source of information, advice, etc.” or “an expert on a subject: He is an authority on baseball.” (From dictionary.com.) I suspect people aren’t distinguishing between the two kinds of authority when they say “I always question authority.”

    If someone is an expert on a subject, a go-to person who knows more than most people about something, it would be prudent to question them so that you can learn, if you’re interested in their field.

    If someone is drafting you into the military, it behooves you to ask a lot of questions about why that is happening and who that benefits.

    These are different authorities and the questions are different.

  5. lizkat says:

    [I understand my daughter and her arguments in favor of home birthing and her preference for “organic” foods so much better now. It is really all about control, isn’t it? She believes that no one ought to tell her what to do or how to do it, especially those who are better educated, who, by virtue of that knowledge and training, make her feel inferior.]

    Maybe your daughter understands some things you don’t?

  6. Joe says:

    @lizkat on 29 Jan 2010 at 5:28 pm “Maybe your daughter understands some things you don’t?”

    That is meaningless rhetoric. It’s like saying that a pedestrian always has a 50% chance of crossing the street safely because one either is hit by a car, or is not. In line with this, the likelihood that the daughter, as described, understands something special is small.

  7. Joe says:

    @Harriet Hall on 29 Jan 2010 at 4:23 pm “… our writings should be judged on their content alone.”

    I have not followed Dr. Tuteur’s threads closely because they are mostly on topics which concern me very little. (Although I appreciated Harriet’s input, some years ago, when my local NPR station advocated home-birth.)

    Back to the quote with which I opened: in my skimming of comments responding to Dr. Tuteur’s several posts, it seems to me that many are not substantive. I join Dr. Hall in hoping commenters will limit themselves to the subject at hand, rather than the person.

  8. Zoe237 says:

    “It constitutes unequal treatment to point out that Dr. Tuteur is no longer in clinical practice when no one has pointed out that Dr. Sampson and I have both been out of clinical practice for many years. And it shouldn’t matter: our writings should be judged on their content alone.”

    I actually agree with this ftmp. However, Dr. Tuteur DOES have some very shall we say old fashioned views about obstetrics. She edited out, for example, from the quote on the original “Journal of Consumer Research” article the part about lithotomy position no longer being common. Many OBs (most?) are just fine with delayed cord clamping (with active management), clear fluids in labor, intermittent EFM, and varied pushing positions, all of which Dr. Tuteur has spoken out against, only because midwives once practiced them.

    I’m not sure about Dr. Sampson, but Dr. Hall has quite an impressive resume of her activities since retiring from medicine and very rarely makes factual errors. Dr. Tuteur has an internet blog and a few letters to the editor.

    She’s also exhibit A for the mommy wars because she makes some moms feel like crap if they would prefer not to have a c-section, if possible She goes around on every single article pertaining to childbirth and accuses these moms of wanting to kill their babies because they care about the experience of birth. It’s really bizarre.

    However, I do think she’s loads of fun and definitely thought-provoking. I just wish SBM had two OB viewpoints on here to provide some balance.

  9. lizkat says:

    “the likelihood that the daughter, as described, understands something special is small.”

    The extremely condescending attitude expressed toward the daughter leads me to imagine the mother may be judgmental and close-minded. Just a wild guess.

    But aside from that, I want to express something about what it means to be a skeptic and why I am one. And why Dr. Tuteur’s post represents approximately the opposite of the ideal of skepticism.

    This country was born out of defiance and disrespect. Its founders were cynical about human nature. They knew that even with the very best of intentions, human beings will take advantage of whatever power they have. And they don’t always have the best of intentions.

    Human beings are all hypocrites — that’s because we all like to see ourselves in a good light, but we are all fallible. Therefore, we do not see ourselves clearly.

    This post was basically a diatribe against defiance. The old-fashioned paternalistic (yes a woman can be paternalistic) doctor doesn’t want to see physicians losing the reverence they used to get. Patients were childlike and trusting, and many still are.

    But not all. And trust is waning as people notice that mainstream medicine is only good for certain kinds of things, and that progress in certain areas just doesn’t seem to happen.

    Yes maybe people are expecting miracles like antibiotics and the polio vaccine to come along and save us from the current dreaded diseases. Maybe they expect too much. But really, the lack of progress has been quite surprising.

    The mainstream true believes deny any lack of progress and insist that cures are around the corner, any day now. And sometimes, like Dr. Tuteur, they see cancer as a sign of modern medicine’s great success.

    Well anyway, we should respect everyone and distrust everyone, and always be defiant.

  10. Harriet Hall says:

    wales said “Hall’s and Sampson’s SBM profiles disclose their retired status. Tuteur’s profile does not. Unequal disclosure perhaps deserves unequal treatment.”

    Perhaps not. Perhaps it reflects the author’s conviction that the information would be irrelevant.
    I did not disclose how many years I had been retired because I thought that was irrelevant.

  11. squirrelelite says:

    @Lizkat,

    Somehow, “respect everyone and distrust everyone and always be defiant” sounds more like the position of a polite but cynical contrarian.

  12. wales says:

    The information is not irrelevant to me. The retirement status disclosure appears on some of Tuteur’s websites and not others. I remain curious as to the rationale for the inconsistency.

    I have already had this discussion on this site and received no answer then so I do not expect one now.

  13. Zoe237 says:

    “The information is not irrelevant to me. The retirement status disclosure appears on some of Tuteur’s websites and not others. I remain curious as to the rationale for the inconsistency. ”

    Well, then she’s hardly trying to hide it. Big deal.

    “Well anyway, we should respect everyone and distrust everyone, and always be defiant.”

    I agree with a lot of what you write. But I have to agree that this sounds more like a “polite contrarian” rather than a doubter or a skeptic. Why always be defiant?

  14. BillyJoe says:

    lizKat

    “The old-fashioned paternalistic…doctor doesn’t want to see physicians losing the reverence they used to get. Patients were childlike and trusting, and many still are.”

    The “old-fashioned paternalistic doctor” is (hopefully and, I think, actually) a dying race.
    The problem is that there are those who are trying desperately to swing the pendulum in the complete opposite direction. The patient rules. Well he does, but he’d better take some professional advice before he makes his decision.

    “And trust is waning as people notice that mainstream medicine is only good for certain kinds of things, and that progress in certain areas just doesn’t seem to happen.”

    Are you are referring to the pharmaceutical companies or doctors? And it begs the question about what, other than mainstream medicine (let me substitute SBM), is good for those things that SBM is not good for.

    “Yes maybe people are expecting miracles like antibiotics and the polio vaccine to come along and save us from the current dreaded diseases. Maybe they expect too much. But really, the lack of progress has been quite surprising.”

    Only because of unrealistic expectations driven by hyperbolic press reports. But, there is the odd “miracle” (I hate that word) like eliminating smallpox, nearly eliminating polio, measles, mumps, rubella, whooping cough, diptheria, tetanus, and more recently epiglottitis from the developed world (with even more progress if not for the activities of the ignorant anti-vaccination altmed crowd)

    “The mainstream true believers deny any lack of progress and insist that cures are around the corner, any day now.”

    Where are these “mainstream true believers” who “deny any lack of progress and insist that cures are around the corner”? Are you talking about patients fed on a diet of “breakthrough” and “miracle” by the media, or about the professionals at the coalface.

  15. pmoran says:

    “Where are these “mainstream true believers” who “deny any lack of progress and insist that cures are around the corner”? Are you talking about patients fed on a diet of “breakthrough” and “miracle” by the media, or about the professionals at the coalface.”

    It’s mainly the media, but researchers do tend to inflate the significance of findings in order to attract funding. And we all went through a very optimistic phase midway through the last century, when it looked as though even the magic bullet for cancer might be just around the corner. I can understand some public disappointment.

    The glass is about half full, I would say. Once medical science finally got its act together a mere century or so ago it was inevitable that the easy problems and those with lower tech solutions such as antibiotics and vaccines and simple surgery and life support would be the first to be resolved.

    That leaves us now with the more complicated and difficult diseases. We are making slow progress with most.

  16. Plonit says:

    If the rapid transformation of HIV/AIDS from an invariably fatal condition to what is effectively a chronic disease is not a modern medical miracle then a don’t know what is.

    Of course the role of defiant patients in making that happen is quite an important part of the story.

  17. micheleinmichigan says:

    skepchickon
    “Thank you so much for this post. I understand my daughter and her arguments in favor of home birthing and her preference for “organic” foods so much better now. It is really all about control, isn’t it?”

    #v Lizcat

    “The extremely condescending attitude expressed toward the daughter leads me to imagine the mother may be judgmental and close-minded. Just a wild guess.”

    Yes, I got the same impression. Sounded like a mom engaged a personal battle with her daughter to me. Maybe trying to understand the daughter’s point of view, rather than trying to figure out what’s wrong with her could be more productive from a family relationship standpoint.

    Regarding organic food. I have seen commenters criticize it a few times in some of the SBM blogs. Never with any evidence to support their criticism (the is not to deny evidence may exist). People buy organic food for a lot of reasons. Some are environmental, some perception of safety, some are avoiding particular elements more common in non-organic food (a particular preservative, coloring or wax that disagrees with them).

    Me, I buy organic milk because I don’t like the idea of antibiotics being used injudiciously to promote growth and milk production. I am concerned about antibiotic resistances. I buy organic grapes because in our grocery store the organic ones taste a lot better and cost a buck more per/pack. I buy vegetarian chicken eggs because I like eggs and they are slightly lower in cholesterol. Also the practice of feeding ground up chickens to other chickens is pretty yucky by itself and from an infectious disease standpoint, I understand. I buy certain bands of organic cereal because they have less sugar AND they are cheaper. I don’t think that’s wacky or automatically rebelling against establishment, authority, whatever.

    I do not have the time to research every grocery store decision indepth (although, if I stopped following SBM, I might). There is a lot of guesswork. I’d welcome a reasoned science based discussion on whether I’m correct or incorrect.

    For one thing I realize that the “organic” label is poorly regulated. On the other had, I have a friend who works as a microbiologist in food and livestock inspection and I can tell you that is not a well oiled machine either. There are pro and cons.

    In conclusion, from a SBM advocacy position, I wonder if people could see a more production way to persuade patients when CAM is not the best route for them. I think that various observations on the flaws of CAM “types” (they are just anti-establishment, they are ODD, or controlling or insecure) may more alienating than convincing.

    From my point of view all people have strengths and weakness. But, all have many things we can agree on. If persuasion is the goal, maybe it is better to start with common goals and move toward solutions, than to criticize.

    But, hey, this is something I fail at all the time. So who am I to say.

  18. “Yes maybe people are expecting miracles like antibiotics and the polio vaccine to come along and save us from the current dreaded diseases. Maybe they expect too much. But really, the lack of progress has been quite surprising.”

    What I find amazing is the lack of knowledge about the progress made in medicine and the jaded attitude that greets each astounding development with a yawn.

    In my professional lifetime alone the following occurred, were developed or were brought into widespread use:

    Surgery

    laparascopic surgery which has entirely revolutionized both gynecology and general surgery
    stereotactic radiosurgery which has revolutionized neurology and neurosurgery
    relatively routine use of liver transplants and heart transplants
    arthroscopy

    Radiology

    MRI scans
    PET scans
    widespread use of ultrasound

    Oncology

    Stem cell transplantation
    Targeted chemotherapy such as herceptin
    preventive treatment for cancer such as tamoxifen

    OB-GYN

    pushing back the frontier of viablity by several weeks
    surfactant therapy for hyaline membrane disease of prematurity
    in vitro fertilization
    non surgical alternatives to hysterectomy
    identification and treatment of HPV to prevent cervical cancer

    Cardiology

    balloon angioplasty instead of triple bypass
    ECMO (extracorporeal membrane oxygenation)
    artificial hearts

    Psychiatry

    Prozac and other SSRIs that have revolutionized the treatment of depression and anxiety

    Immunology

    vaccine against H. flu
    vaccine against meningiococcal meningitis

    That’s 20 that I thought of off the top of my head. What’s particularly notable about these recent developments is that they do more than simply extend lifespan, they have dramatically reduced the risks, the pain, and the length of hospital stay for surgery, they have allowed for earlier diagnosis and more successful treatment of cancer, and they have improved quality of life for people suffering from psychiatric disease.

    And almost all of them are so commonplace that they are not recognized for the miracles that they are.

    Oh, and in the same time frame, “alternative” medicine has developed nothing and saved no one.

  19. lizkat says:

    Amy is a true true believer. The major breakthroughs were antibiotics, vaccines, anesthesia, surgical technology. We all know and we are impressed. Since then, the reputation of mainstream medicine has largely been coasting on past success. According to some experts anyway, some of the worst diseases are as deadly as ever. But it depends on your perspective and if you are unable to look objectively at the evidence — which is massive and confusing (and I am a statistician, so my confusion is not the result of ignorance) and none of us has time to assimilate more than a fraction — if you insist on seeing it one way, then no one can ever change your mind, not even the tiniest tiny bit.

    But anyway …

    “If the rapid transformation of HIV/AIDS from an invariably fatal condition to what is effectively a chronic disease is not a modern medical miracle then a don’t know what is.”

    That is the public relations spin churned out by the big drug companies. Please don’t start yelling that I’m an AIDS denier. I am not. But I am VERY skeptical about long-term use of those AR drugs. AZT, for example, is on a list of carcinogenic substances in the state of California. And I could tell you lots more about those drugs, but I won’t. When you read the reports, check where they’re coming from. And look at varied sources. Some of it is pretty darn horrifying. (No, don’t bother with the AIDS denier web sites).

    People should be a bit more skeptical about any information that comes bleating out of the big drug industry.

  20. lizkat says:

    “Prozac and other SSRIs that have revolutionized the treatment of depression and anxiety”

    Chemical lobotomies.

  21. “Chemical lobotomies.”

    Prejudice against those with psychiatric disabilities is always fashionable, not to mention the denial that psychiatric illnesses are disease every bit as real as other illnesses. Add a healthy dollop of self righteousness and you have the incredibly ignorant statement above.

  22. micheleinmichigan says:

    # lizkaton 30 Jan 2010 at 11:57 am

    “Prozac and other SSRIs that have revolutionized the treatment of depression and anxiety”

    “Chemical lobotomies.”

    OMG – appalling

  23. Oh my. I am extremely offended by the characterization of people who take SSRIs as having “chemical lobotomies.”

    Try “able to live a normal life because of modern medicine.”

  24. lizkat
    “Chemical lobotomies.”

    That’s such a simultaneously ridiculous and unkind thing to say that you appear to be a troll. (Maybe you are Amy Tuteur trying to make herself look good. Hm, lizkat, maybe the World Trade Centre was attacked by Bush and the CIA, whattaya think?)

  25. Plonit says:

    That is the public relations spin churned out by the big drug companies.

    ++++++++++

    No, that is the experience of millions of people on ARVs around the world. Check out the work of Partners in Health in Haiti and Rwanda, for examples. Talk to people at the sharp end of the AIDS crisis in the US, such as those who’ve come together in organizations such as ACT-UP. While it is important to reduce the toxicity of drugs, sometimes it is better to take a life-saving drug with side-effects than not to take it. That is true of ARVs and HAART.

    My point was that the speedy development of treatments for HIV/AIDS (and indeed, the modifications to therapies to reduce side-effects) was very powerfully influced by the ‘patient defiance’ and refusal to accept medical authority that is being slammed in this post. The medical authorities also contended that ARVs were not cost-effective in poor countries, and medical mavericks have had to unite with ‘defiant patients’ in order to challenge this orthodoxy.

  26. Fifi says:

    Dr Tuteur – “Prejudice against those with psychiatric disabilities is always fashionable, not to mention the denial that psychiatric illnesses are disease every bit as real as other illnesses.”

    That’s a bit of a strawman you’re erecting since the prejudice being shown is against SSRIs and not people with mental illness. One cannot make sweeping statements about psychiatric drugs or conditions either pro or con, it’s highly unscientific! To be clear, I fully support the use of drugs as one approach to treating mental illness and mood disorders when appropriate. However, something such as depression isn’t always as simple as it being just a physical illness – being a mental disease it’s also psychological, and it can also be social/environmental. This means that approaches that incorporate treating the whole person – mind, body and context/environment – can be incredibly effective. CBT has been shown to be very effective at curing certain disorders, for instance.

    There are very legitimate questions to be asked about SSRIs and best treatment for depression, and this is a much debated topic amongst experts. The best evidence shows that SSRIs alone don’t seem to be much better than placebos for treating depression (and recent discoveries regarding the biological aspects of anxiety and depression seem to indicate that SSRIs actually work on the part of the brain related to anxiety and not depression, the older and out of patent depression medications seem to be more effective for depression, even if they have more unwelcome side effects). There’s still a lot of research to be done regarding the relative effectiveness of various pharmaceutical interventions for mild to moderate depression versus or in conjunction with talk or behavioral therapies.

    Considering the way the drug companies fudged research around SSRIs and heavily promoted them to GPs to prescribe (who aren’t really qualified to diagnose psychiatric illnesses unless they have additional training in psychiatry or psychology), it’s not surprising there’s a lot of mistrust about SSRIs and very legitimate questions regarding their effectiveness.

    Obviously SSRIs are not a “chemical lobotomy” and that’s as sensationalist as screaming about dead babies. However, they’re also a drug that is controversial and not fully understood (which is partially because we still don’t fully understand neurobiology). Psychiatry, psychology and neurobiology are still really in their infancy in many ways – this is one area of medicine where making absolutist statements is simply ignorant and arrogant. Either side trying to use mental illness to promote an agenda or ideological position is being exploitative and not actually discussing SBM.

  27. Zoe237 says:

    Chemical lobotomies. Maybe it’s really Tom Cruise.

    Reading Dr. Tuteur’s list makes me wonder what percentage of medical research dollars goes into first world diseases/ injuries and what percentage goes into third world diseases (like malaria or yellow fever). I have no idea.

  28. lizkat says:

    I understand very well that some people need SSRIs just to function. I understand that there is such a thing as serious permanent mental illness that can result in complete disability. I am not trying to be insensitive to those who are afflicted with mental illness, which is a real tragedy for the patients and their relatives.

    But glowing statements about the wonderfulness of these drugs are just not called for.

    Psychiatrists and neurologists understand very little about how the brain works or how and why it malfunctions. They noticed that low serotonin correlates with certain conditions, such as depression, and they figured out a way to increase serotonin levels in the brain.

    This does NOT result in a cure, merely some relief from symptoms. People on SSRIs are not mentally healthy, from what I have heard, just anesthetized.

    I very strongly disapprove of the use of these drugs for anyone who is not disabled by mental illness. We don’t even know the long-term consequences.

    And the fact that children are given these drugs, and others such as ritalin, is heartbreaking.

  29. lizkat says:

    “While it is important to reduce the toxicity of drugs, sometimes it is better to take a life-saving drug with side-effects than not to take it. That is true of ARVs and HAART.”

    This is a matter of opinion. You will see very different evidence depending on where you look. It is all massively confusing and there are no simple answers. The drugs are causing many deaths and diseases. Many. Exactly how much is hard to tell. And long-term effects are not known.

    If HAART can extend a person’s life by 4 years, is it worth the “side effects?” And we don’t know, on average, how much life is extended. As I said, it’s hard to tell with all the drug company spin mixed into most reports.

    The drugs interfere with the functioning of cells, all the cells of the body. One lovely result can be early aging — VERY early aging. Like people in their 40s with the health of someone in their 80s.

    You won’t take my word, of course. Check it out. Be skeptical.

  30. Plonit says:

    lizkat, I won’t take your word for it because I have indeed already “checked it out” as part of my training and continue to follow the unfolding science of HIV treatment. Apart from the fact that ARVs improve quality of life, and allow adults who have been on the brink of death to have a productive life, you are way, way off with your estimate of 4 years increase in life expectancy. Perhaps you need to ‘check it out’.

    ARVs massively reduce vertical transmission of HIV from mother to child. Preventing vertical transmission doesn’t merely increase a baby’s lifespan, but give the possibility of a whole lifetime.

    I’m always skeptical about drug company spin, but clearly, it is you who has no idea what you are talking about.

  31. Dave Ruddell says:

    And I could tell you lots more about those drugs, but I won’t.

    No, go ahead, tell us lizkat. We’re all waiting with bated breath.

    As for this:

    The drugs are causing many deaths and diseases. Many.

    Citation, please?

  32. Plonit says:

    lizkat, can I recommend that you spend time here

    http://www.treatmentactiongroup.org/index.aspx

    Here you will find sensible discussion of the issues of drug toxicity, premature ageing in people living with HIV/AIDS and many other questions, from an organization that is independent of – and often highly critical of – drug companies.

  33. lizkat says:

    “Here you will find sensible discussion of the issues of drug toxicity”

    So how is this different from what I said?

    “Many of the best available ARV regimens, which include at least three different drugs taken together, cause distressing side effects. Some drugs can trigger life-threatening health problems that require expert medical care.”

    Just try to find any clear reports of how the typical AIDS patient on HAART is doing. You will find lots of breathless raving about the wonders of these treatments. You will also find creative theories about why so many AIDS patients die from non-AIDS diseases. Like, because the drugs have saved their lives, and now they are living so long they are getting cancer and heart disease. The kind of theory you would expect to hear from Dr. Tuteur, for example.

    Drugs that can kill HIV must be highly toxic, to all the cells of the body. Antibiotics, also, are toxic. But one difference is that antibiotics are only taken until the infection is gone, while ARVs never get rid of the infection and must be taken for life.

    And, of course, patients become resistant to certain drugs and may have to keep switching.

    The big drug companies would love to have you think that AIDS is now merely a chronic condition and AIDS patients can live relatively normal lives.

    No, it isn’t true. I am not accusing the drug companies of being completely unethical scoundrels. But the AIDS drugs are the perfect way to make gazillions of dollars. Maybe just a happy coincidence.

  34. Fifi says:

    lizkat – “Psychiatrists and neurologists understand very little about how the brain works or how and why it malfunctions.’

    We actually understand more and more every day. It’s remarkable what we’ve learned about neurobiology and cognition in the lasts 30 odd years. The issue with mental illness is that it’s not purely about objective markers but also subjective ones, it’s about a person having an experience (a bad experience or one that disrupts their ability to function). Mental illness and health aren’t just about the brain but also the mind, it means that we can approach treating many forms of mental illness from a variety of angles – including mental, physical and environmental/social/culture.

    The issue of over or mis-prescribing medications is a big one in regards to mental health, and obviously pharmaceutical companies play a part in this (as do a very overburdened mental health systems). However, that doesn’t mean that drugs are bad, just that pharmaceutical companies like to sell as many drugs as possible and are willing to do so by promoting pseudoscience. Once again, this is an area where it’s very important to distinguish between true SBM and cargo cult science posing as SBM. A belief that mental illness is only biological and has only biological causes isn’t actually being scientific and it’s trying to provide a simplistic answer to a complex area where there is still much research to be done and quite a bit of controversy.

  35. Plonit says:

    So how is this different from what I said?

    ++++++++++

    Because they don’t therefore conclude that the treatment is worse than the disease.

  36. Plonit says:

    And a chronic condition is never ‘merely’ a chronic condition.

    Where did I claim that it was? Oh, I didn’t. Nevermind.

  37. Fifi says:

    In the US a particularly issue is with what health insurers will cover regarding treatments for mental health problems and mental disease. Often a few visits with a psychiatrist will be covered but not full courses of CBT or talk therapy. In Canada, a big problem is with an overburdened mental health system and a lack of psychiatrists or psychologists who work on medicare. And, of course, there are issues with societal prejudices as well.

  38. Fifi says:

    Plonit – Thanks for the great link. And, yes, activism has played a very big role in moving AIDS research forward.

    Lizkat – Do you actually know people living with AIDS or who died of AIDS? The drug side effects aren’t worse than dying of AIDS related complications. If you’d ever taken care of someone with AIDS and accompanied them as they died, or celebrated a birthday with someone who is still here because of the advances in medication – I suspect you wouldn’t be using this as a platform. It’s not perfect, and it’s not a cure or a vaccine, but the drugs are allowing people to live longer and better than before.

  39. Harriet Hall says:

    Zoe237 said “Dr. Hall has quite an impressive resume of her activities since retiring from medicine”

    I never wrote a word until 2003. In 2003 my resume was nonexistent. Does this mean my writing in 2003 should have been discounted? At which point in the subsequent years did I become a credible writer?

    Dr. Tuteur’s writing should be judged solely on its content, not on number of things in her resume.

  40. Harriet Hall says:

    wales said “The information [about retired status] is not irrelevant to me.

    What is relevant to you and why? Isn’t the number of years I have been retired relevant? Why did you not criticize me for not disclosing that? Why is any of this relevant? Why do you need to know anything about the author to judge the quality of what she writes?

  41. weing says:

    lizkat,

    I started my internship when the first AIDS cases were described and their life expectancy and quality of life was, to put it mildly, very short and lousy. I have patients now that are doing fine over ten years after their first case of PCP pneumonia. Could we do better? Of course we could and we will.

    Regarding SSRIs, I have few patients on them chronically. In most cases I have been able to taper them off after the patient has been in remission for about 9 months.

  42. Fifi says:

    Transparency about one’s experience is relevant if one is setting oneself up as an authority on SBM – particularly if the content and style of the person’s posts seems to contradict their claims to be based in SBM. If there’s no transparency, you’re asking people to operate on faith. Trust is earned, faith isn’t. Since Dr Tuteur has herself brought up issues such as how hard it is to talk to practice obstetrics in the current climate, and at least given the impression she’s a practicing doctor to some readers here and that’s influenced at least one reader’s perspective, then when she last practiced becomes relevant. If Dr Tuteur had not brought up these issues herself and personalized her perspective and the discussion, then it wouldn’t be being discussed here.

    Harriet Hall – “Why do you need to know anything about the author to judge the quality of what she writes?”

    What an odd question when we’re talking about science! When discussing SBM and scientific studies, who publishes what and their affiliations and potential biases are very important to be transparent about. If Dr Tuteur wants to present herself as a credible authority on SBM and obstetrics then some basic transparency about her current and past experience isn’t an extraordinary request. She’s not being asked to reveal details about her personal life but merely to be transparent about her professional experience and affiliations since she used them as a starting point for some of her arguments and defenses of certain points.

  43. lizkat says:

    “they don’t therefore conclude that the treatment is worse than the disease.”

    I did NOT conclude that. I said it is very hard to find information that is clear and unbiased. A lot of research is correlational and therefore hard to interpret. And drug RCTs often compare new drugs to older drugs, and there are seldom any comparisons between drugs and no drugs (for ethical reasons they must provide treatment, but the result is a shortage of controlled research).

    In any case, whether it’s better to have the drugs or not, either way it’s bad, very bad. The best advice is to avoid getting AIDS, if possible. Because there is no cure and there is no safe treatment, in spite of what the drug companies’ PR says.

    And by the way, the AIDS/HIV deniers are just as crazed as the pro-drug screamers. So I am skeptical of both.

  44. lizkat says:

    “When discussing SBM and scientific studies, who publishes what and their affiliations and potential biases are very important to be transparent about. ”

    Good point.

  45. Plonit says:

    pro-drug screamers

    +++++++++

    Who or what is a “pro-drug screamer”? I’m for prevention, but I don’t counterpose treatment and prevention. No one who campaigns for better access to existing drug treatments, and development of better drug treatments, is opposed to prevention. In fact, those who campaign for greater and more effective prevention efforts are often the exact same people who campaign for increased access to treatment.

    I said “While it is important to reduce the toxicity of drugs, sometimes it is better to take a life-saving drug with side-effects than not to take it. That is true of ARVs and HAART.”

    You replied “This is a matter of opinion.” Which I took to mean that you disagreed with the above statement. That maybe the treatment is worse than the disease. Well, that is your opinion, but you are wrong.

  46. lizkat says:

    “The drug side effects aren’t worse than dying of AIDS related complications.”

    “the drugs are allowing people to live longer and better than before.”

    Yes of course that’s what the big druggos are telling us. But it’s very hard to know without controlled comparisons. If AIDS mortality has decreased somewhat, it would be unscientific to jump to the conclusion that it’s because of the drugs. There could be other explanations. Any evidence that seems to show advantages of HAART is immediately grabbed by the drug companies as absolute proof. And of course people want to believe it, so it spreads like wildfire through the mainstream press.

  47. Plonit says:

    big druggos?

    name and shame, please.

  48. lizkat says:

    [Who or what is a “pro-drug screamer”?]

    There are people who are screaming that anyone who does not recommend HAART for AIDS patients (even HIV patients, sometimes) is a murderer. They demand that every patient in the world be put on HAART, no matter what it costs.

    Ok, the expense would not be a concern if we were talking about a proven health-restoring treatment. But it isn’t. At least I am far from being convinced that it is.

  49. “If Dr Tuteur wants to present herself as a credible authority on SBM and obstetrics then some basic transparency about her current and past experience isn’t an extraordinary request.”

    Oh, please. Your motivation in attempting to discredit me personally is pathetically obvious. My credentials are rock solid; but perhaps you think that Dr. Novella and Dr. Gorski are incapable of running their blog properly and need you to advise them.

    What bothers you about my posts is that the ARE based on the scientific evidence. You’ve been totally stymied in discredting the science and find it much easier to smear me.

    Every time people resort to such childish tactics, it confirms that you are not capable of debating the science.

    It is rather ironic that some of you are questioning my credentials. I’ll put my credentials up against yours any day of the week. Indeed, what qualifies you to pass judgment on my professional accomplishments beyond your wish to derail debates that you cannot win?

  50. Zoe237 says:

    Zoe237 said “Dr. Hall has quite an impressive resume of her activities since retiring from medicine”

    HH: “I never wrote a word until 2003. In 2003 my resume was nonexistent. Does this mean my writing in 2003 should have been discounted? At which point in the subsequent years did I become a credible writer?

    Dr. Tuteur’s writing should be judged solely on its content, not on number of things in her resume.”

    I agree in theory, but she often uses anecdotes and appeal to authority in her arguments, so it becomes relevant. She also often uses present tense when talking about “counseling” patients rather than “counseled.” Not a big difference to the reader, but it’s rather odd.

    Why are there no non-doctors/scientists posting blogs on this website? Obviously resume matters somewhat.

    Regardless, I have no problem with people with who no longer practice writing opinions, and she’s not hiding it, so no problem there either. I merely was speculating about WHY she holds views that are contrary to the American College of Obstetrics and Gynecology, given that she hasn’t practiced in almost 20 years.

  51. Plonit says:

    Unbelievable. You seriously know nothing.

    Go read the research studies (there are plenty of RCTs demonstrating benefit).

    Go talk to people living with HIV/AIDS whose health has dramatically improved as a result of these treatments.

    There are plenty of treatments in the world of marginal benefit – with massive NNT and needing huge RCTs to demonstrate any statistically significant benefit and having questionable clinical significance. Drug therapies for HIV/AIDS are not in this category. If you don’t accept that it is a proven health-restoring treatment, well, that’s your choice. But it doesn’t change the fact that it is.

  52. Plonit says:

    That last comment was addressed to lizkat.

  53. weing says:

    “I agree in theory, but she often uses anecdotes and appeal to authority in her arguments, so it becomes relevant. ”

    Anecdotes help to drive the point home. I have not observed her to use the appeal to authority. Do you have any instances?

  54. Harriet Hall says:

    “If Dr Tuteur wants to present herself as a credible authority”

    SBM focuses on science and evidence. We do not ask you to believe what we say because we are authorities.

  55. “she holds views that are contrary to the American College of Obstetrics and Gynecology”

    Really? Please enumerate them. Otherwise that’s merely another smear attempt.

  56. micheleinmichigan says:

    “That’s a bit of a strawman you’re erecting since the prejudice being shown is against SSRIs and not people with mental illness.”

    Actually the statement suggests that someone on SSRIs have had chemical lobotomies. In essence, they are happy zombies.

    I have taken SSRI’s and family member’s who taken that and other psychiatric medication. I found the statement sickingly lacking in understanding and compassion. Not to mention perpetuating the myths that undermine the adequate support of mental illness.

    To anyone who chooses those words and thinks saying ‘I’m not trying to be insensitive’ is in any way adequate…FU

    You think SSRI’s are bad, try Thorazine, That’s a REALLY bad one. On the other hand you could watch you brother rip apart the house because he can’t figure out the pattern to the stereo, or your sister have to lock herself in the bathroom with your baby nephew because the same brother thinks she is trying to rip out the baby’s stomache when she is actually tickling him. Or find out he broke your dad’s rib because he was thought dad was trying to control his brain. Or you can watch your mother just cry and cry and cry. I wouldn’t recommend it.

    Yeah, Thorazine is really bad, but maybe better than being kicked out of the halfway house because you beat an old man senseless (for once again trying to control your brain) and then sobbing “I don’t want to be like this”, or ending up in the hospital for drinking drano.

    SSRI’s? How about a SSRI, anti-seizure, mood stabilizer cocktail? That’s gotta be bad. Well in my world it seems good, because a beloved family member (not my brother) who was diagnosed with BiPolar ended up in the hospital almost dead twice in one month on a overdose of alcohol and pain meds during a manic episode. And you know what. They are not like someone who has had a lobotomy. In fact they are a highly successful and charming academic with whose intellect and compassion exceeds Lizcat’s infinitely.

    As for me, when I reached a point in my life when I didn’t have good days and bad days, I only had days full of despair or days full of apathy and I was lucky to get 3 hours of sleep at night, I found SSRI helpful (sure not a miracle, the side effects listed in the bag are pretty accurate). This didn’t make me obliviously happy, it only gave me the capability to be happy and gave me a break from the constant negative ruminating that I was experiencing. This helped me be more successful in the CBT and exercise program I undertook.

    FiFi, I usually agree with your posts and I do agree that SSRI are not to be taken lightly, The fact that some GP don’t adequately inform or supervise is one of my complaints. But I think you totally missed on Lizcats comment.

    This automatic demonizing of psychiatric drugs and trivializing of the victims can only discourage adequate research and public mental health funding.

    And was a cheap shot to score a point totally at the expense of me and my family.

  57. weing says:

    I’ve seen lizkat use the appeal to authority.

  58. Plonit says:

    We do not ask you to believe what we say because we are authorities.

    ++++++++++++

    Ermmm, isn’t that what this post is all about?

  59. lizkat says:

    “This automatic demonizing of psychiatric drugs and trivializing of the victims ”

    When I said the drugs are a chemical lobotomy I meant that they fill a similar purpose — controlling violent or manic patients, dulling intense negative emotions, etc. Yes of course it is much better than actual lobotomies! I don’t know if lobotomies even had the desired effect, and they were a barbaric and permanent “treatment.” But it was better than chains or straightjackets.

    Mental illness is a terrible problem. My point was that modern medicine has not succeeded in understanding or curing it. The drugs treat the symptoms only.

    Yes if someone is clinically depressed there is a risk of suicide and they need anti-depressants. If someone is psychotic they need to be tranquilized.

    My argument was in no way an attack on mentally ill people or their families! I don’t understand how you got that message. If I am attacking anyone it’s the drug companies, who market psychiatric drugs to the general public, including children.

    I’m sure we all know people with non-clinical depression who prefer to take a pill than correct the things in their life that might be making them depressed. Speaking of lifestyle, physical inactivity is a probable cause of some cases of depression. And of course there are many other possible causes.

    I am in no way trying to trivialize the victims of mental illness. I know people who would have wound up in a mental hospital without SSRIs.

  60. lizkat says:

    “Go talk to people living with HIV/AIDS whose health has dramatically improved as a result of these treatments.”

    I would very much like to read case studies that illustrate this. I could not find any. I would appreciate links if you have them.

  61. lizkat says:

    “But it was better than chains or straightjackets.”

    I should have said some people thought it was better. I really don’t know. Either way it was bad.

  62. “People on SSRIs are not mentally healthy, from what I have heard, just anesthetized.”

    Ok, now you can hear different!

    I owe the following facts to my SSRI:
    - I am alive.
    - I work full-time and can support myself and another person.
    - I am alive.
    - I am in love.
    - I am alive.
    - I am going naked swimming tonight at a university athletic complex with the urban naturist society.
    - I am alive.

    I took Paxil for a while. I hated it. I didn’t feel depressed exactly, but I didn’t feel anything. Paxil is an SSRI, and I did feel anesthetised on it. So… I stopped taking it. I take Zoloft now, which is also an SSRI. I feel lots of things. Sometimes I feel depressed, though not suicidal. I do not feel anesthetised.

    I’ve never been a particularly anxious person, but people I know who are anxious and also depressed have taken Paxil and just loved it. It gave them their lives back. Apparently different SSRIs can be appropriate for different people.

    I’m not the epitome of mental health, but if I were I wouldn’t be taking psychiatric meds. SSRIs are not a panacea, but without them I wouldn’t be getting all I do out of life, or giving back.

    It’s true that some of the older drugs are more effective antidepressants than SSRIs. They are also less safe, so are not prescribed first because the balance of risk and benefit is not there. If someone responds well to an SSRI, why prescribe something less safe? If someone has tried three SSRIs and is still quite ill, the treating physician may try some of the older, riskier drugs. Like one of the ones my beloved takes.

    Yes, it would be better to not be mentally ill than to take psychiatric drugs. It would also be better not to be HIV positive than to have to take ARVs. But if you are mentally ill, or if you are HIV positive, then having access to effective medication is a huge benefit.

  63. weing says:

    The tricyclic antidepressants are probably more effective than the SSRIs. Before the SSRIs came out, TCA overdose was a common admission to the ICU. It’s difficult to OD on an SSRI, that fact alone has saved lives and money.

  64. lizkat says:

    This is just a small pilot study with no control group, but it’s an example of how difficult it is for skeptics like myself to find any clear evidence for the claims that HAART prolongs life and improves health.

    http://linkinghub.elsevier.com/retrieve/pii/S08853924000024515

    “This pilot study sought to measure the impact of HAART treatments on a wide range of clinical outcomes and psychological variables in a sample of patients with advanced HIV infection.”

    “Seventy patients with advanced AIDS who were protease inhibitor naïve were started on HAART regimens.”

    ” In addition to standard clinical and laboratory markers, a series of observer-rated and self-report instruments were used to measure various physical and psychological factors (e.g., pain and symptom distress, psychological well-being, depression). Data were collected at baseline and after 1 and 3 months of HAART therapy.”

    “As expected, the CD4 count increased and viral load levels decreased significantly over the 3-month study period.”

    “In addition, patients improved significantly in body weight, and serum albumin and ferritin levels.”

    “The only psychosocial measure that improved significantly with treatment was depression.”

    “Ratings of pain intensity, physical and psychological symptom distress, and overall quality of life did not change.”

    ” treatment failure (mortality and intolerance) were not uncommon in this sample (40%).”

    ——————-

    So according to this study anyway, HAART did not do wonders for these advanced AIDS patients. CD4 went up and HIV went down — that always happens with HAART. But is the assumption warranted that these factors are valid indicators of recovery from AIDS?

    The patients improved in body weight — maybe weight gain is a side effect of some of the drugs? And in depression ratings — that could easily be a placebo effect. There was no control group so we don’t know.

    More importantly, quality of life ratings and subjective health did not improve.

    And there was a 40% rate of treatment failure.

    So how effective is HAART really? We can’t tell from this abstract, that’s for sure.

    I have read many reports and abstracts on HAART and they all find HIV going down and CD4 going up. It is taken for granted that this means success. But does it really? How can we know. This abstract shows that you can have decreasing HIV and increasing CD4 even though NO real health benefit has been demonstrated.

    So that’s just one. Please correct me if you know of studies that contradict this one.

    And, as I said, HIV and CD4 levels always do what they’re supposed to. But does that mean what it’s supposed to mean?

  65. lillym says:

    As someone taking psychiatric medicine I can say I am NOT anesthetized I’m able to live a life like I never could before.

    I am ALIVE because of these medications and without them I would be dead.

    That isn’t rhetoric it’s the truth. I have bipolar disorder and I was diagnosed when I was taken to the hospital after a suicide attempt.

    Before finding the medication that worked for me I was a mess, I had panic attacks, I couldn’t hold down a job, I hated myself and my life. So much so I tried to take my own life.

    Now, I have a job I like and I get good reviews at. I held the same job before that for four years, something I’d never done before in my life. I’m in a relationship and most I like myself.

    And lizcat my medicine hasn’t taken away negative emotions or any kind of emotions. I still get sad, I still get mad, I still struggle with many issues.

    Right now I’m trying to control the rage I feel at what you are saying. You know NOTHING about mental illness and to talk like that it’s just… I can barely see straight when you are saying these things.

    My medicine has set me free. It’s not a mental straight jacket or chains.

    Of course, I’m sure you’ll say that I’m mis reading what you said or I’m just in the thrall of the pharmaceutical companies but that’s your problem.

  66. weing says:

    “And there was a 40% rate of treatment failure.”

    That means 60% success rate. The treatment failure rate used to be 100% when I started practice.

  67. Zoe237 says:

    “she holds views that are contrary to the American College of Obstetrics and Gynecology”

    “Really? Please enumerate them. Otherwise that’s merely another smear attempt.”

    I did, but I will again. Breech delivery (ACOG for in very strict instances), circumcision (ACOG against routine), the importance of breastfeeding (ACOG recommended) CEFM (intermittent is fine in low risk), NPO during labor (liquids now allowed). Your positions are those of an OB from the ’80s, when you did your training.

    I’m not sure about their position on midwives and childbirth without pain medication, but I doubt they’re against either. Not sure the position on cesareans either, but there is a great deal of effort worldwide to lower the 30-70% rate.

  68. lizkat says:

    http://www.informaworld.com/smpp/content~content=a910768432~db=all~jumptype=rss

    “Objective. To examine changes in individuals’ experiences of symptoms over the first six months of taking highly active anti-retroviral therapy (HAART) and to assess the impact of symptom experiences and attributions on adherence to HAART. ”

    “Overall, the number of HIV or HAART-related symptoms reported did not change significantly over follow-up.”

    So overall patients did not experience any improvement in 6 months of HAART. This study was done last year.

  69. weing says:

    “I’m sure we all know people with non-clinical depression who prefer to take a pill than correct the things in their life that might be making them depressed. ”

    Sure there are people like that. But guess what? The pill will do squat for them.

  70. lizkat says:

    [“And there was a 40% rate of treatment failure.”

    That means 60% success rate. The treatment failure rate used to be 100% when I started practice.]

    The 40% failure occurred within the time frame of the study. It might have been 100% eventually, we don’t know. And since HAART does not cure AIDS or eradicate HIV, as we do all know, the ultimate failure rate is 100%. When you started to practice and the AIDS death rate was 100%, how long did it take for patients to die on average, after diagnosis of HIV?

    Because the mainstream consensus is, as far as I know, that it can take 10 years or more.

    So you can see, I hope, that it is difficult for anyone to make sense of this. The death rate was 100%, but could take 10 or more years.

    And now the death rate is still 100%, but HAART hasn’t been around long enough to know how much it increases time.

    It seems to me that the claims for HAART go beyond the evidence, and we skeptics are supposed to base our opinions on evidence. Especially on RCTs. Where are the conclusive RCTS showing the effectiveness of HAART?

    We already know that AZT was not a success, supposedly because of resistance. Now we are supposed to agree that HAART has succeeded where AZT failed. But if we are skeptics we should ask for hard evidence before we are convinced.

  71. “Breech delivery (ACOG for in very strict instances), circumcision (ACOG against routine), the importance of breastfeeding (ACOG recommended) CEFM (intermittent is fine in low risk), NPO during labor (liquids now allowed).”

    Wrong, wrong, wrong, wrong and wrong. You’re batting zero. Here’s what you need to do: find the specific ACOG recommendations, then find EXACTLY what I wrote. Show us the comparison. Unless you can make the specific comparisons, and you cannot, you have not proved your claim.

  72. Diane Henry says:

    All right, since the thread is swerving off-topic anyway…
    I’m on SSRI’s due to a year so horrible that I hope it is the worst one I ever see. It never occurred to me that “a pill” would make it better, but when a friend kindly suggested that maybe my chronic nausea and malaise might be due to reactive depression, my doctor agreed. It made my burdens this last year survivable. It wasn’t that i wasn’t willing to “work” on my problems–the very severe problems happened to people I love. So please hold off on the judgement–there are stories that you don’t know.

  73. StatlerWaldorf says:

    Amy said, “It makes no difference. You inserted a non sequitur into the discussion for exactly the reason I described: “If they want to do THIS, you simply can’t trust anything they say.””

    Yes, it does make a difference. You are putting words down that I didn’t say. You just can’t get past your bias when dealing with my comment.
    ——————————————————————————-

    Alison Cummins, I’m Canadian originally but have been living in Europe, Middle East and Asia over the past decade. I’ve tried reading original studies on vaccines but I don’t understand enough. I’ve moved to secondary reviews of literature in books. For example, Sears “The Vaccine Book” has given me info on areas of concern in vaccine research and has given details of vaccine ingredients. I have considered some points of concern, like aluminium content etc. and tried to be conservative about my approach while still vaccinating. I realize that some people disagree with Sears interpretation of research on aluminium, but I don’t have knowledge to critique all the critiques. I just go ahead and vaccinate with lower-aluminium vaccines and spread them out. Decisions about vaccination has been stressful for me as a parent, because I’m doing something to protect them from diseases, but yet I don’t want to harm them either!

  74. micheleinmichigan says:

    “When I said the drugs are a chemical lobotomy I meant that they fill a similar purpose — controlling violent or manic patients, dulling intense negative emotions, etc.”

    Another bit of misinformation. A SSRI’s will do nothing to control a violent or manic patient. In fact, when starting SSRI medication, there is some risk it will trigger a manic episode in a person who has bipolar disorder. This can be very dangerous for that patient. That is one of the reasons for judicious monitoring.

  75. lillym says:

    micheleinmichigan makes a good point. Because I was misdiagnosed with depression (because with my bipolar disorder i have more depressive episodes than hypo-manic or manic episodes).

    My doctors gave me SSRIs. Which caused me to be come hypo-manic, and then I would feel so great I would stop taking my medcine (and seeing the doctor) and then I would “crash” with horrible depressions. Which led me back to the doctor and then I went back to the doctor, who would try another anti depressant.

    What ultimately happened is that I became manic, the worst mania of my life, and then the worst depression which led me to attempt suicide.

    I was taking a mood stabilizer and an anti psychotic. Right now I only take the anti psychotic. Not because I’m psychotic but it keeps my mind quiet. I’ve gone from a mind racing at 100 miles an hour, with the mental noise like multiple tvs, radios, and trying to read two different books and carry on a conversation all at the same time.

    I’m not saying I had audio hallucinations, but I had about 5 different track of thoughts all going on at the same time.

  76. squirrelelite says:

    For anyone interested in a more scientifically based assessment of the usefulness of HAART in treating HIV/AIDS, I suggest the following article by Nancy Wongvipat, M.P.H.

    http://www.thebody.com/content/treat/art4826.html

    She comments:

    “HAART stands for Highly Active AntiRetroviral (anti-HIV) Therapy. The first HAART treatments, in 1996, included a protease inhibitor along with two nucleoside analog drugs to fight HIV. Now HAART means any potent combination of three or more anti-HIV drugs.”

    “Just a few years after HAART became widely available, studies reported 60% to 80% reductions in new AIDS illnesses, hospitalizations and deaths. Because of HAART, many people with HIV/AIDS are living longer, more productive and more normal lives. Successful HAART can change HIV disease from an illness that was almost always a death sentence into a chronic (long-term), but usually manageable condition.”

    Of course, HAART is not a panacaea or even or a cure.

    “Drug side effects can be difficult to live with and sometimes quite serious over the long term. For these reasons, some experts recommend delaying treatment until it is necessary to prevent serious damage to the immune system. However, for many people, HAART has been a lifesaver.”

    For a quick look at the annual incidence of new AIDS cases and deaths, the following link has a nice graph.

    http://www.avert.org/usa-statistics.htm

    I note that annual HIV/AIDS cases peaked at 80,000 in 1993 and have now dropped below 40,000. Deaths from AIDS peaked at 50,000 about 1994-1995. From 1995 to 1997, AIDS deaths dropped from 50,000 to about 20,000 and they have continued to drop to about 15,000 per year.

    It may only be post hoc ergo propter hoc, but that’s a pretty impressive coincidence.

    The CDC says there were 1,051,875 total diagnosed cases of AIDS through 2007. 583,298 people diagnosed with AIDS had died, so 468,577 people diagnosed with AIDS were still alive as of 2007.

    There may have been other factors that contributed to the reduction in deaths but if anyone wishes to assert that they had an effect that was even a useful fraction of the benefit of HAART, it is incumbent on them to define what factor they think helped. A good reference and some useful numbers would be a major plus.

  77. Mark Crislip says:

    I started as an intern at the start of the HIV epidemic.

    The longer I have been in practice, the longer AIDS patients have lived. I have only had two AIDS deaths this century.

    Therefore, it is not the HAART, its me.

  78. Zoe237 says:

    Me: “Breech delivery (ACOG for in very strict instances), circumcision (ACOG against routine), the importance of breastfeeding (ACOG recommended) CEFM (intermittent is fine in low risk), NPO during labor (liquids now allowed).”

    Dr. Tuteur: “Wrong, wrong, wrong, wrong and wrong. You’re batting zero. Here’s what you need to do: find the specific ACOG recommendations, then find EXACTLY what I wrote. Show us the comparison. Unless you can make the specific comparisons, and you cannot, you have not proved your claim.”

    Me: Are you saying I’m wrong about the ACOG positions or your positions? It’s possible that I’ve misinterpreted you. ACOG is pretty clear though.

    BREASTFEEDING

    Dr. Tuteur: “As a clinician, though, I need to be mindful not to counsel patients based on my personal preferences, but rather based on the scientific evidence. While breastfeeding has indisputable advantages, the medical advantages are quite small. Many current efforts to promote breastfeeding, while well meaning, overstate the benefits of breastfeeding and distorts the risks of not breastfeeding, particularly in regard to longterm benefits.”

    http://www.sciencebasedmedicine.org/?p=3096

    ACOG Committee Opinion No. 361 (2007): Breastfeeding: maternal and infant aspects.
    “Evidence continues to mount regarding the value of breastfeeding for both women and their infants. The American College of Obstetricians and Gynecologists strongly supports breastfeeding and calls on its Fellows, other health care professionals caring for women and their infants, hospitals, and employers to support women in choosing to breastfeed their infants. Obstetrician-gynecologists and other health care professionals caring for pregnant women should provide accurate information about breastfeeding to expectant mothers and be prepared to support them should any problems arise while breastfeeding.”
    http://www.ncbi.nlm.nih.gov/pubmed/17267864\
    __________________________________________________________________________________

    EATING AND DRINKING IN LABOR
    Dr. Tuteur: I doubt it, since it is an anesthesia complication, not a surgical complication. Similarly, the decision to make labor patients NPO comes from the anesthesiologists, not the obstetricians.

    Dr. Tuteur: “Instead of claiming that the recommendation to remain NPO during labor is without any basis in science, you’ve acknowledged that there is scientific evidence on the topic and it shows that aspiration is a real risk.”

    http://www.sciencebasedmedicine.org/?p=2975

    ACOG (2009): “Washington, DC — Women in labor may be allowed to quench their thirst with more than just the standard allowance of ice chips, according to a new Committee Opinion released today from The American College of Obstetricians and Gynecologists (ACOG) and published in the September issue of Obstetrics & Gynecology. Although the guidelines on prohibiting solid food while in labor or before scheduled cesarean surgery remain the same, ACOG says that women with uncomplicated labor, as well as uncomplicated patients undergoing a planned cesarean, may drink modest amounts of clear liquids during labor if they wish. “

    “According to ACOG, women with a normal, uncomplicated labor may drink modest amounts of clear liquids such as water, fruit juice without pulp, carbonated beverages, clear tea, black coffee, and sports drinks.”

    http://www.acog.org/from_home/publications/press_releases/nr08-21-09-2.cfm

    American Society of Anesthesiologists: “Oral intake of modest amounts of clear liquids may be allowed for uncomplicated laboring patients”

    http://www.guideline.gov/summary/summary.aspx?doc_id=10807&nbr=005632&string=breech

    American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007 Apr;106(4):843-63.

    CIRCUMCISION

    Dr. Tuteur: “Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it… Not exactly. The disease is HIV and the simple surgical procedure is circumcision and anti-circ activists oppose it under almost any circumstances.”

    http://www.sciencebasedmedicine.org/?p=3310

    ACOG Committee Opinion. Circumcision. Number 260, October 2001.
    American College of Obstetricians and Gynecologists. Committee on Obstetric Practice.
    ACOG: “The American College of Obstetricians and Gynecologists supports the current position of the American Academy of Pediatrics that finds the existing evidence insufficient to recommend routine neonatal circumcision. Given this circumstance, parents should be given accurate and impartial information to help them make an informed decision. There is ample evidence that newborns circumcised without analgesia experience pain and stress. If circumcision is performed, analgesia should be provided.”

    http://www.ncbi.nlm.nih.gov/pubmed/11592271

    AAP: “Evidence regarding the relationship of circumcision to STD in general is complex and conflicting.13107-110 Studies suggest that circumcised males may be less at risk for syphilis than are uncircumcised males.107,111 In addition, there is a substantial body of evidence that links noncircumcision in men with risk for HIV infection.19112-114 Genital ulcers related to STD may increase susceptibility to HIV in both circumcised and uncircumcised men, but uncircumcised status is independently associated with the risk for HIV infection in several studies.115-117 There does appear to be a plausible biologic explanation for this association in that the mucous surface of the uncircumcised penis allows for viral attachment to lymphoid cells at or near the surface of the mucous membrane, as well as an increased likelihood of minor abrasions resulting in increased HIV access to target tissues. However, behavioral factors appear to be far more important risk factors in the acquisition of HIV infection than circumcision status. “

    http://aappolicy.aappublications.org/cgi/content/full/pediatrics;103/3/686

    CONTINUOUS EXTERNAL FETAL HR MONITORING (cEFM)
    Dr. Tuteur: “Indeed, the Cochrane review you linked to is about comparing EFM with intermittent auscultation (either using a doppler or a fetoscope). The protocol for auscultation is quite rigorous and requires one on one nursing care for the bulk of labor. That is simply not possible in today’s economic climate.”
    Dr. Tuteur: “The issue has more to do with the nature of the methods than anything else. EFM has a very low false negative rate and a high false positive rate. Intermittent auscultation has a high false negative rate and a high false positive rate, is profoundly dependent on attendant and technique and provides no permanent record for later analysis.”
    Dr. Tuteur: “On the other hand, homebirth midwives, who by their very nature provide 1 on 1 care, and use intermittent auscultation (supposedly rigorously) have a dramatically higher rate of intrapartum death. “
    Dr. Tuteur: “It is far too late to abandon EFM. It is both the medical and the legal standard. What we need is a better method of evaluating fetal oxygenation.”

    http://www.sciencebasedmedicine.org/?p=2507

    “Intermittent auscultation rather than continuous EFM has been associated with a decrease
    in cesarean delivery rates. Obstetric practitioners may use intermittent auscultation rather than continuous EFM.”

    http://images.ibsys.com/2005/0504/4450560.pdf
    American College of Obstetricians and Gynecologists. Task Force on Cesarean Delivery
    Rates.
    Evaluation of cesarean delivery, 2000

    ACOG (2009): “The false-positive rate of electronic fetal monitoring (EFM) for predicting cerebral palsy is high, at greater than 99%.
    The use of EFM is associated with an increased rate of both vacuum and forceps operative vaginal delivery, and cesarean delivery for abnormal fetal heart rate (FHR) patterns or acidosis or both.
    When the FHR tracing includes recurrent variable decelerations, amnioinfusion to relieve umbilical cord compression should be considered.
    Pulse oximetry has not been demonstrated to be a clinically useful test in evaluating fetal status. …
    The following conclusions are based on limited or inconsistent scientific evidence (Level B):
    There is high interobserver and intraobserver variability in interpretation of FHR tracing. …
    Reinterpretation of the FHR tracing, especially if the neonatal outcome is known, may not be reliable…. The labor of women with high-risk conditions should be monitored with continuous FHR monitoring. ”

    http://www.guidelines.gov/summary/summary.aspx?ss=15&doc_id=14885&nbr=7371

    American College of Obstetricians and Gynecologists (ACOG). Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Jul. 11 p. (ACOG practice bulletin; no. 106). [49 references]

    http://www.ncbi.nlm.nih.gov/pubmed/19546798?dopt=Abstract

    CESAREAN SECTION

    Dr. Tuteur: “You haven’t explained how ANY C-sections that turn out to be unnecessary in retrospect can be eliminated, let alone all of them.”

    Dr. Tuteur: “There are only two choices available: unnecessary C-sections or preventable neonatal deaths. Which do you prefer?”

    Dr. Tuteur: “Everybody knows too many unnecessary (in retrospect) C-sections are being done. No one knows in advance which ones they are. Until C-section activists can offer a reliable method for predicting which C-sections are necessary in advance (a method with a low false positive rate and a low false negative rate) they bring nothing useful to the table. One really has to wonder whether they want to solve the problem, or merely complain about it.”

    http://www.sciencebasedmedicine.org/?p=2507

    “The increase in cesarean delivery rates in the United States has concerned
    the American College of Obstetricians and Gynecologists (ACOG) and other
    interested organizations for the past few decades. In 1994, ACOG issued a
    policy statement on this topic, and in 1995, ACOG’s Health Care
    Commission held a focus session to determine ways to review and reduce
    cesarean delivery rates.

    The expert working group proposes the following cesarean delivery rate
    benchmarks:
    1. Nulliparous women at 37 weeks of gestation or greater with singleton
    fetuses with vertex presentations: The national 1996 cesarean
    delivery rate for this group was 17.9%; the expert working
    group goal at the 25th percentile for this group is 15.5%.”

    http://images.ibsys.com/2005/0504/4450560.pdf
    American College of Obstetricians and Gynecologists. Task Force on Cesarean Delivery
    Rates.
    Evaluation of cesarean delivery, 2000

    BREECH
    Dr. Tuteur: “That is something altogether different than claiming that the recommendation for C-section to deliver a breech baby is not based on the scientific evidence.”
    Dr. Tuteur: “I present evidence that various obstetric recommendations (like C-section for breech) are based on the scientific evidence.”
    Dr. Tuteur: “Really? The C-section rate for breech in the US approaches 100% and ACOG recommends C-section as the preferred mode of delivery for breech.”
    Dr. Tuteur: “The SGOC does not speak for obstetricians in any other country besides Canada, and it’s not clear that it even speaks for them. Their recommendations are new, and have not yet been tested in practice, and it isn’t even clear that obstetricians will follow them….In the US, C-section is still the standard recommendation for breech delivery for the reasons that I have discussed.”

    ACOG (2006): “Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.”

    http://www.ncbi.nlm.nih.gov/pubmed/16816088
    Obstet Gynecol. 2006 Jul;108(1):235-7.
    ACOG Committee Opinion No. 340. Mode of term singleton breech delivery.

    Me: (this recommendation has been changed as of 2006. From 2001-2006, after the TBT and before other trials, the recommendation was for breech delivery by c-section.)

  79. Zoe237 says:

    Okay, trying this again without the links since my first post disappeared (it’s a duplicate, sans links).

    Me: “Breech delivery (ACOG for in very strict instances), circumcision (ACOG against routine), the importance of breastfeeding (ACOG recommended) CEFM (intermittent is fine in low risk), NPO during labor (liquids now allowed).”

    Dr. Tuteur: “Wrong, wrong, wrong, wrong and wrong. You’re batting zero. Here’s what you need to do: find the specific ACOG recommendations, then find EXACTLY what I wrote. Show us the comparison. Unless you can make the specific comparisons, and you cannot, you have not proved your claim.”

    Me: Are you saying I’m wrong about the ACOG positions or your positions? It’s possible that I’ve misinterpreted you. ACOG is pretty clear though.

    BREASTFEEDING

    Dr. Tuteur: “As a clinician, though, I need to be mindful not to counsel patients based on my personal preferences, but rather based on the scientific evidence. While breastfeeding has indisputable advantages, the medical advantages are quite small. Many current efforts to promote breastfeeding, while well meaning, overstate the benefits of breastfeeding and distorts the risks of not breastfeeding, particularly in regard to longterm benefits.”

    ACOG Committee Opinion No. 361 (2007): Breastfeeding: maternal and infant aspects.
    “Evidence continues to mount regarding the value of breastfeeding for both women and their infants. The American College of Obstetricians and Gynecologists strongly supports breastfeeding and calls on its Fellows, other health care professionals caring for women and their infants, hospitals, and employers to support women in choosing to breastfeed their infants. Obstetrician-gynecologists and other health care professionals caring for pregnant women should provide accurate information about breastfeeding to expectant mothers and be prepared to support them should any problems arise while breastfeeding.”
    __________________________________________________________________________________

    EATING AND DRINKING IN LABOR
    Dr. Tuteur: I doubt it, since it is an anesthesia complication, not a surgical complication. Similarly, the decision to make labor patients NPO comes from the anesthesiologists, not the obstetricians.

    Dr. Tuteur: “Instead of claiming that the recommendation to remain NPO during labor is without any basis in science, you’ve acknowledged that there is scientific evidence on the topic and it shows that aspiration is a real risk.”

    ACOG (2009): “Washington, DC — Women in labor may be allowed to quench their thirst with more than just the standard allowance of ice chips, according to a new Committee Opinion released today from The American College of Obstetricians and Gynecologists (ACOG) and published in the September issue of Obstetrics & Gynecology. Although the guidelines on prohibiting solid food while in labor or before scheduled cesarean surgery remain the same, ACOG says that women with uncomplicated labor, as well as uncomplicated patients undergoing a planned cesarean, may drink modest amounts of clear liquids during labor if they wish. “

    “According to ACOG, women with a normal, uncomplicated labor may drink modest amounts of clear liquids such as water, fruit juice without pulp, carbonated beverages, clear tea, black coffee, and sports drinks.”

    American Society of Anesthesiologists: “Oral intake of modest amounts of clear liquids may be allowed for uncomplicated laboring patients”

    American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Practice guidelines for obstetric anesthesia: an updated report by the American Society of Anesthesiologists Task Force on Obstetric Anesthesia. Anesthesiology 2007 Apr;106(4):843-63.

    CIRCUMCISION

    Dr. Tuteur: “Imagine if we could save lives from a dread and often fatal disease simply by performing a minor surgical procedure. People would hail this simple victory and rush to adopt it… Not exactly. The disease is HIV and the simple surgical procedure is circumcision and anti-circ activists oppose it under almost any circumstances.”

    ACOG Committee Opinion. Circumcision. Number 260, October 2001.
    American College of Obstetricians and Gynecologists. Committee on Obstetric Practice.
    ACOG: “The American College of Obstetricians and Gynecologists supports the current position of the American Academy of Pediatrics that finds the existing evidence insufficient to recommend routine neonatal circumcision. Given this circumstance, parents should be given accurate and impartial information to help them make an informed decision. There is ample evidence that newborns circumcised without analgesia experience pain and stress. If circumcision is performed, analgesia should be provided.”

    AAP: “Evidence regarding the relationship of circumcision to STD in general is complex and conflicting.13107-110 Studies suggest that circumcised males may be less at risk for syphilis than are uncircumcised males.107,111 In addition, there is a substantial body of evidence that links noncircumcision in men with risk for HIV infection.19112-114 Genital ulcers related to STD may increase susceptibility to HIV in both circumcised and uncircumcised men, but uncircumcised status is independently associated with the risk for HIV infection in several studies.115-117 There does appear to be a plausible biologic explanation for this association in that the mucous surface of the uncircumcised penis allows for viral attachment to lymphoid cells at or near the surface of the mucous membrane, as well as an increased likelihood of minor abrasions resulting in increased HIV access to target tissues. However, behavioral factors appear to be far more important risk factors in the acquisition of HIV infection than circumcision status. “

    CONTINUOUS EXTERNAL FETAL HR MONITORING (cEFM)
    Dr. Tuteur: “Indeed, the Cochrane review you linked to is about comparing EFM with intermittent auscultation (either using a doppler or a fetoscope). The protocol for auscultation is quite rigorous and requires one on one nursing care for the bulk of labor. That is simply not possible in today’s economic climate.”
    Dr. Tuteur: “The issue has more to do with the nature of the methods than anything else. EFM has a very low false negative rate and a high false positive rate. Intermittent auscultation has a high false negative rate and a high false positive rate, is profoundly dependent on attendant and technique and provides no permanent record for later analysis.”
    Dr. Tuteur: “On the other hand, homebirth midwives, who by their very nature provide 1 on 1 care, and use intermittent auscultation (supposedly rigorously) have a dramatically higher rate of intrapartum death. “
    Dr. Tuteur: “It is far too late to abandon EFM. It is both the medical and the legal standard. What we need is a better method of evaluating fetal oxygenation.”

    “Intermittent auscultation rather than continuous EFM has been associated with a decrease
    in cesarean delivery rates. Obstetric practitioners may use intermittent auscultation rather than continuous EFM.”

    American College of Obstetricians and Gynecologists. Task Force on Cesarean Delivery
    Rates.
    Evaluation of cesarean delivery, 2000

    ACOG (2009): “The false-positive rate of electronic fetal monitoring (EFM) for predicting cerebral palsy is high, at greater than 99%.
    The use of EFM is associated with an increased rate of both vacuum and forceps operative vaginal delivery, and cesarean delivery for abnormal fetal heart rate (FHR) patterns or acidosis or both.
    When the FHR tracing includes recurrent variable decelerations, amnioinfusion to relieve umbilical cord compression should be considered.
    Pulse oximetry has not been demonstrated to be a clinically useful test in evaluating fetal status. …
    The following conclusions are based on limited or inconsistent scientific evidence (Level B):
    There is high interobserver and intraobserver variability in interpretation of FHR tracing. …
    Reinterpretation of the FHR tracing, especially if the neonatal outcome is known, may not be reliable…. The labor of women with high-risk conditions should be monitored with continuous FHR monitoring. ”

    American College of Obstetricians and Gynecologists (ACOG). Intrapartum fetal heart rate monitoring: nomenclature, interpretation, and general management principles. Washington (DC): American College of Obstetricians and Gynecologists (ACOG); 2009 Jul. 11 p. (ACOG practice bulletin; no. 106). [49 references]

    CESAREAN SECTION

    Dr. Tuteur: “You haven’t explained how ANY C-sections that turn out to be unnecessary in retrospect can be eliminated, let alone all of them.”

    Dr. Tuteur: “There are only two choices available: unnecessary C-sections or preventable neonatal deaths. Which do you prefer?”

    Dr. Tuteur: “Everybody knows too many unnecessary (in retrospect) C-sections are being done. No one knows in advance which ones they are. Until C-section activists can offer a reliable method for predicting which C-sections are necessary in advance (a method with a low false positive rate and a low false negative rate) they bring nothing useful to the table. One really has to wonder whether they want to solve the problem, or merely complain about it.”

    “The increase in cesarean delivery rates in the United States has concerned
    the American College of Obstetricians and Gynecologists (ACOG) and other
    interested organizations for the past few decades. In 1994, ACOG issued a
    policy statement on this topic, and in 1995, ACOG’s Health Care
    Commission held a focus session to determine ways to review and reduce
    cesarean delivery rates.

    The expert working group proposes the following cesarean delivery rate
    benchmarks:
    1. Nulliparous women at 37 weeks of gestation or greater with singleton
    fetuses with vertex presentations: The national 1996 cesarean
    delivery rate for this group was 17.9%; the expert working
    group goal at the 25th percentile for this group is 15.5%.”

    American College of Obstetricians and Gynecologists. Task Force on Cesarean Delivery
    Rates.
    Evaluation of cesarean delivery, 2000

    BREECH
    Dr. Tuteur: “That is something altogether different than claiming that the recommendation for C-section to deliver a breech baby is not based on the scientific evidence.”
    Dr. Tuteur: “I present evidence that various obstetric recommendations (like C-section for breech) are based on the scientific evidence.”
    Dr. Tuteur: “Really? The C-section rate for breech in the US approaches 100% and ACOG recommends C-section as the preferred mode of delivery for breech.”
    Dr. Tuteur: “The SGOC does not speak for obstetricians in any other country besides Canada, and it’s not clear that it even speaks for them. Their recommendations are new, and have not yet been tested in practice, and it isn’t even clear that obstetricians will follow them….In the US, C-section is still the standard recommendation for breech delivery for the reasons that I have discussed.”

    ACOG (2006): “Planned vaginal delivery of a term singleton breech fetus may be reasonable under hospital-specific protocol guidelines for both eligibility and labor management.”

    Obstet Gynecol. 2006 Jul;108(1):235-7.
    ACOG Committee Opinion No. 340. Mode of term singleton breech delivery.

    Me: (this recommendation has been changed as of 2006. From 2001-2006, after the TBT and before other trials, the recommendation was for breech delivery by c-section

  80. Plonit says:

    I would very much like to read case studies that illustrate this. I could not find any. I would appreciate links if you have them.

    +++++++++++

    http://www.impactaids.org.uk/lancet363.htm

    How about this?

    Look, we know that looking for the virus and CD4 counts are surrogate measures. However, the reason why those outcomes – rather than mortality or symptoms are used is because of the SUCCESS of ARTs.

    When we had NO treatment, then the difference between the treated and the untreated was starkly obvious in a relatively short time (i.e. you didn’t need a particularly big study to show that those who were treated lived and those who were untreated died). So, treatment became the standard of care (at least in the rich world).

    Now we are trying to see smaller differences between different drug regimes, different timing of initiation, and so surrogate endpoints are used. They may not be perfect, but since we are satisfied that HIV is the cause of AIDS, and the decline in CD4 levels is an important mechanism by which AIDS develops, these are reasonable surrogate endpoints. Obviously, for people who don’t believe that HIV is the cause of AIDS, these would be totally inappropriate endpoints – but then you are not one of these, right?

    Of course, there is a scientific literature on this complex issue – some of which advocate making more use of observational studies. What they don’t say is “The Drugs Don’t Work”.

    http://jac.oxfordjournals.org/cgi/reprint/47/4/371.pdf

  81. Fifi says:

    michelleinmichigan – “FiFi, I usually agree with your posts and I do agree that SSRI are not to be taken lightly, The fact that some GP don’t adequately inform or supervise is one of my complaints. But I think you totally missed on Lizcats comment.”

    I can see why you’d think that – what lizkat’s comment was quite offensive and insensitive, and propagandistic. That’s why I called her out on both using sensationalize language and discussed some of the real issues regarding mental health treatment and what we really do know and don’t know regarding SSRIs. However – referring to SSRIs as “chemical lobotomies” is actually talking about the drugs and not people. Even if there is the inference that people who take SSRIs have been lobotomized, that’s not what she actually said. I’m not standing up for lizkat or her ignorance here, I’m standing up for clarity of communication and not erecting strawmen (no matter how provocative and insensitive a statement may be).

    As the ensuing discussion indicated, SSRIs aren’t a panacea or appropriate for all people or disorders. They’re extremely useful for some people but quite dangerous to prescribe for others. My main point was that drugs can be very useful in treating mental illness and mood disorders but the idea that all mental illness and mood disorders are purely biological and require pharmaceutical intervention is equally as ignorant as claiming all drugs are “chemical lobotomies” and can be treated pharmaceutically (or require a pharmaceutical solution when there are sometimes less invasive therapeutic solutions that actually provide lifetime relief, such as CBT and other forms of talk therapy). Mental illnesses and mood disorders are about the mind as well as the brain so treating the mind (and person) and not just the body can be a very productive approach. Sometimes in conjunction with medications, sometimes not. It’s also worth noting that all kinds of factors can contribute to or cause depression or anxiety – including purely biological factors such as a severe vitamin or mineral deficiency, being in a highly dysfunctional environment and trauma. What kind of therapy and treatments are the most productive is something that needs to be considered according to the individual. It’s also worth understanding that our brain chemistry isn’t always the root cause of a mental health issue but a response and that the body/mind connection goes in both directions. Neuroplasticity and how the mind shapes the brain and the brain shapes the mind – it’s all pretty mind blowing, amazing stuff! :-)

  82. lizkat says:

    “Look, we know that looking for the virus and CD4 counts are surrogate measures. However, the reason why those outcomes – rather than mortality or symptoms are used is because of the SUCCESS of ARTs.

    When we had NO treatment, then the difference between the treated and the untreated was starkly obvious in a relatively short time (i.e. you didn’t need a particularly big study to show that those who were treated lived and those who were untreated died). So, treatment became the standard of care (at least in the rich world).”

    My comment with links is “awaiting moderation” and has been for 16 hours. There are problems with what you are saying here. The surrogate measures are valid because you already KNOW they are valid? And you KNOW that ARTs are successful, without any RCTs? How?

    When there was no treatment, people with HIV but no AIDS symptoms were not counted as AIDS patients. That is because HIV testing was less common. After HIV was determined to be the cause of AIDS, there was more HIV testing.

    The percentage of AIDS patients who died might have been lower after there was treatment because more were diagnosed.

    We really don’t know. And believing claims from the drug companies without RCTs is simply NOT science based medicine!

    Too bad my links never showed up, because I thought they show that some skepticism may be warranted.

  83. lizkat says:

    [equally as ignorant as claiming all drugs are “chemical lobotomies”]

    You did not understand what I meant. The drugs do not cure mental illness. Dr. Tuteur’s comment strongly implied that now we have cures for mental illness. In fact, we have little or no understanding of mental illness and certainly do not have cures.

    SSRIs cause the level of serotonin to rise, which may lessen the symptoms of certain mental illnesses, such as depression. The symptoms are merely dulled, the cause of the symptoms is not resolved.

    And by the way, I never said SSRIs are for bipolar disorder or schizophrenia. In that comment I was talking about psychiatric drugs in general. When given to psychotic patients, they dull the symptoms, and also tranquilize and anesthetize.

    The point is that psychiatric drugs do allow some patients to function who otherwise couldn’t, and they tranquilize some patients who would otherwise be out of control.

    So they are using chemicals to dull the symptoms of mental illness and control violent or manic patients.

    That was my point. The causes are mostly unknown, and there are no cures.

    And SSRIs should NOT be given to people who are suffering from normal grief. You are messing with complex brain chemistry just to avoid the normal pains of life.

    No one knows the long term effects. It is an especially stupid idea to give them to children whose brains are developing.

  84. Zoe237,

    Yes, just as I said, you are wrong about every single one, and you’ve demonstrated how you choose to twist what I write to what you wish to criticize.

    Breastfeeding

    ACOG:

    “Evidence continues to mount regarding the value of breastfeeding for both women and their infants. The American College of Obstetricians and Gynecologists strongly supports breastfeeding and calls on its Fellows, other health care professionals caring for women and their infants, hospitals, and employers to support women in choosing to breastfeed their infants. ”

    is completely consistent with

    AT:

    “As a mother, I am a passionate advocate of breastfeeding and I breastfed my four children. As a clinician, though, I need to be mindful not to counsel patients based on my personal preferences, but rather based on the scientific evidence. While breastfeeding has indisputable advantages, the medical advantages are quite small. ”

    Eeating and Drinking in labor

    AT:

    “Instead of claiming that the recommendation to remain NPO during labor is without any basis in science, you’ve acknowledged that there is scientific evidence on the topic and it shows that aspiration is a real risk.”

    Nothing in the multiple quotes you chose contradicts that. The existence of Mendelson’s syndrome is indisputable, the original decision to recommend NPO and any subsequent changes originate with anesthesiologists. Indeed any changes that have been made have occurred NOT because anyone thinks that Mendelson’s syndrome can’t happen, only because new anesthesiology techniques have reduced its incidence.

    Circumcision

    ACOG:

    “The American College of Obstetricians and Gynecologists supports the current position of the American Academy of Pediatrics that finds the existing evidence insufficient to recommend routine neonatal circumcision.”

    AT:

    “I was never particularly supportive of routine neonatal circumcision for health reasons, but new data has challenged my old assumptions.”

    cEFM

    Nothing you quote from me is in any way contradicted by anything you quoted from any organization or paper.

    C-section

    Nothing you quoted from me is in any way contradicted by anything you quoted from anyone else.

    The bottom line is that if you want to disagree with me, feel free to do so (be sure to bring some scientific evidence to the discussion), but don’t LIE about what I write because you’d prefer to address the lie rather than what I have said.

    The irony is that my positions are mainstream within the obstetric community. I am just the kind of obstetrician that “natural” childbirth activists rail about, the ones who place the scientific evidence on safety ahead of the birth “experience.” If ACOG officials came here and read my posts they would agree with almost everything, and if anything, would probably feel that I wasn’t forceful enough.

    If I represent anything at all, I represent the mainstream analysis of scientific evidence in obstetrics, so stop LYING about my positions, stop LYING claiming they contradict recommendations from obstetric societies, and stop your blatant attempts to SMEAR me because that’s easier than addressing the science.

  85. lizkat,

    You are perfectly illustrating my point. You know virtually nothing about ARVs or SSRIs but you reflexively oppose them because they are the standard of care.

  86. Plonit says:

    “And you KNOW that ARTs are successful, without any RCTs? How?”

    +++++++++++

    I KNOW that ARTs are successful, BECAUSE of RCTs. Read what I wrote. The efficacy of ARTs was easily detected in RCTs comparing placebo/no treatment vs. treatment. That’s because the difference in outcomes were very large and obvious, with clinical endpoints (e.g. death).

    And of course, having established that ARTs are sucessful (in RCTs) it would be unethical to have a control group receiving NO treatment. And that slightly complicates new RCTs, because they have to be very large or done over a long period to detect the kind of things we are interested in.

  87. Fifi says:

    lizkat – The problem is that by using the term “chemical lobotomies”, you were indulging in extremist and sensationalistic language – in particular, a type of language that has a particular ideological and emotional content. If you didn’t mean to be insulting or purely anti-drug, it’s not a very effective way to communicate since it IS an anti-drug and insensitive thing to say.

    There are legitimate discussion to be had around how specific drugs are prescribed and promoted, and about how the major drug companies can distort the scientific evidence. As well as what insurance companies will allow and disallow regarding treatments for mental illness or mood disorders in the US. Mental health is a complex subject and taking a purely anti or pro drug stance is naive and ideological.

    Just because we don’t know everything about a condition or disease doesn’t mean we shouldn’t still try to alleviate suffering as best we can and using all the tools at our disposal. For some people, medications are not only useful but life saving. These really are decisions that need to be made on a case by case basis and sometimes it does take a while to find the most effective form of therapy for an individual. And, yes, there are some conditions that we don’t have a “cure” for yet (and maybe never will) – that’s just reality. Getting mad at medicine because of reality is a bit silly (though not uncommon). Expecting perfection from medicine or absolute knowledge is unrealistic. What we do need is more research around mental health issues. Certainly the fact that mental illness and mood disorders are disorders of the body and mind, and can have environmental/social causes, makes some people uneasy – particularly if they’re more comfortable in the realm of the purely physical and a bit at sea when it comes to discussing the psychological, social/environmental and subjective aspects of mental illness and mood disorders. There is a level of complexity regarding mental illness and mood disorders that simply doesn’t exist when discussing a broken arm. It is also a topic that tends to be quite emotional for a lot of people due to the social stigmas around mental health issues. It’s a topic where a little bit of compassion – love AND understanding – goes a long way. As does a bit of humility regarding grand claims either pro or against medications since neither is actually discussing the science or the actual issues discussed within the profession regarding best treatment.

  88. Zoe237 says:

    “As a mother, I am a passionate advocate of breastfeeding and I breastfed my four children. As a clinician, though, I need to be mindful not to counsel patients based on my personal preferences, but rather based on the scientific evidence. While breastfeeding has indisputable advantages, the medical advantages are quite small. ”.

    No, they state exactly the opposite: the medical advantages of breastfeeding are significant (is that the opposite of “small?”).

    “Eating and Drinking in labor”

    AT:

    “Instead of claiming that the recommendation to remain NPO during labor is without any basis in science, you’ve acknowledged that there is scientific evidence on the topic and it shows that aspiration is a real risk.”.

    “Nothing in the multiple quotes you chose contradicts that. The existence of Mendelson’s syndrome is indisputable, the original decision to recommend NPO and any subsequent changes originate with anesthesiologists. Indeed any changes that have been made have occurred NOT because anyone thinks that Mendelson’s syndrome can’t happen, only because new anesthesiology techniques have reduced its incidence.”.

    No, you outright states that the recommendation is (not was) for NPO in labor. This is flat out false. But I agree that it’s because of better anesthetic techniques.

    “Circumcision

    ACOG:

    “The American College of Obstetricians and Gynecologists supports the current position of the American Academy of Pediatrics that finds the existing evidence insufficient to recommend routine neonatal circumcision.”

    AT:

    “I was never particularly supportive of routine neonatal circumcision for health reasons, but new data has challenged my old assumptions.”.

    Yes, this demonstrates your conflicts perfectly. Unfortunately, ACOG and the AAP have not yet challenged THEIR own assumptions.

    “I”Nothing you quote from me is in any way contradicted by anything you quoted from any organization or paper.”

    C-section

    Nothing you quoted from me is in any way contradicted by anything you quoted from anyone else.”.

    I guess we can let others decide on this one. There is TONS of research and committees going into preventing unnecessary c-sections for medical indications, and ACOG demonstrates that. In fact, much to my surprise, this is probably the single most controversial position you take- that there are only two choices, c-sections or neonatal death. Not to mention your support of elective cesareans (which you actually agree with ACOG, I believe). And I actually agree with you as well, but it is extremely controversial among even mainstream OBs.

    “I”The bottom line is that if you want to disagree with me, feel free to do so (be sure to bring some scientific evidence to the discussion), but don’t LIE about what I write because you’d prefer to address the lie rather than what I have said.”.

    I posted exactly what you said (thus the quotation marks) and exactly what ACOG says.

    “I”The irony is that my positions are mainstream within the obstetric community. I am just the kind of obstetrician that “natural” childbirth activists rail about, the ones who place the scientific evidence on safety ahead of the birth “experience.” If ACOG officials came here and read my posts they would agree with almost everything, and if anything, would probably feel that I wasn’t forceful enough.”.

    I agree with you about you agreeing with many mainstream OBs, certainly.

    “I”If I represent anything at all, I represent the mainstream analysis of scientific evidence in obstetrics, so stop LYING about my positions, stop LYING claiming they contradict recommendations from obstetric societies, and stop your blatant attempts to SMEAR me because that’s easier than addressing the science.”.

    I posted at least seven scientific links, and have on multiple occassions in the past. You choose to ignore them and go off on some tangential strawman about natural childbirth advocates and homebirth midwives, in general.

    Maybe another blog should do a “Dr. Tuteur and the assault on scientific evidence” post.

    And don’t take it so personally. The midwives you posted about didn’t on the scientific assault thread. Sheesh. And what’s the big deal if you aren’t in 100% agreement with ACOG and the AAP on breastfeeding, circumcision, and cesarean section?

  89. Plonit says:

    lizkat, there are links to hundreds of studies into the natural history of HIV/AIDS, and into the efficacy of treatments, available here

    http://www.aidstruth.org

    Go look at the RCT evidence for individual ARVs and for HAART. There is a particularly compelling RCT evidence on prophylactic treatment of aymptomatic HIV+ babies with HAART, showing differences in clinical outcomes (i.e. death)

    Actually, lizkat, I’m finding it hard to figure out what your agenda is. Do you believe that HIV is not the cause of AIDS? Do you believe that use of ARVs does not reduce the incidence of AIDS-related symptoms and mortality?

    I raised the case of HIV/AIDS because it is a field in which defiant patients who refused to accept that doctors know best have been crucial to the drive for new, better and more accessible treatments. I did not expect to get into a discussion about whether the drugs work.

  90. micheleinmichigan says:

    FiFi:
    Don’t need a lecture on psychiatric treatment from a layman. Thanks.

    SBM Bloggers Suggestion Box:
    One thing that would be great to see on SBM is a Psychiatrist or Social Worker who could write on modern Psychiatry, treatment, research. Even to get an occasion guest blogger in this field would be helpful.

    There is a good deal of poor education and mis-perception regarding any psychiatric illness, mood, personality or anxiety disorder. There seems to be a good deal of misunderstanding of how treatment works.

    Like a lot of complex and painful conditions, the SCAM, “Natural Lifestyle” and faith healer folks take advantage by telling victims they are causing their disease by not taking their supplements, eating their diet, exercising enough, believing in the right god enough, etc.

    The sad thing is, because of their condition, many people with mental health issues may be more inclined to believe or even seek out the SCAMers than patients with other issues.

  91. “And don’t take it so personally”

    Don’t take deliberate character assassination personally?

    Not only do I take it personally, but I believe I am owed an apology for your pathetic attempts to smear me. (“significant … is that the opposite of “small?”)

    You can backpedal all you want, but you have made it quite clear, by your own writing, that you have deliberately and repeatedly distorted what I said.

    I’m tired of the people who rail about my credentials, as if they were not rock solid, simply to derail an argument they are losing.

    I’m tired of the people who insist that being retired disqualifies me from writing about medicine (but only me, not any other SBM blogger), simply to derail an argument they are losing.

    Above all, I am tired of immature gratuitous insults (I’m thinking of you Alison, for your utterly inappropriate and bizarre accusation that I have created lizkat as an alternate identity and foil for my comments).

    Stick to the science, drop the personal attacks, and above all, grow up!

  92. I’m sorry Amy, no, I really didn’t think you’d made Lizcat up at all. I was trying (ineffectually) to make fun of her for being the utter personification of the irrational fringe conspiracy theorist you attack… the kind that thinks that the “druggos” invented AIDS and that probably believes that 9/11 was an inside job.

    I apologize for not being clear.

  93. Fifi says:

    micheleinmichigan – My intent wasn’t to lecture you, it was to discuss the complexity of mental health treatments. I apologize if you felt talked down to or if there was a misunderstanding that led you to believe that I in any way supported lizkat’s use of “chemical lobotomy” because I called out Dr Tuteur on erecting a strawman (a very emotionally potent one in response to lizkat’s very emotionally potent comment). I’m most certainly a lay person and make no claims to be a psychologist, psychiatrist or neurobiologist, this is just a topic I’m very interested in and grew up around (my mom’s an MD/psychologist, I grew up around neurobiological research and worked in a pain clinic AND I work in the arts so cognitive science and the interaction between and the relationship between the subjective/objective is a passion of mine that intersects with my professional life).

    I agree entirely that people with mental health issues are often targeted by sCAMmers, just as people with chronic and incurable diseases are. It’s also very unfortunate that sCAMmers have managed to make it so that discussions of exercise (which has a proven efficacy in helping to alleviate mild to moderate depression), diet and thinking/cognition become the realm of woo when they’re not at all and there’s some very interesting science going on in all these areas. To be clear, I’m in no way saying that people cause their disease or that diet and/or exercise are a panacea, or that cognitive therapies can cure everything – or even that medication may not be necessary in conjunction with CBT, talk therapy and behavioral changes that include diet and exercise. Or that it’s invalid to choose medication as sole treatment. I’m simply saying that we have a lot still to learn about mental illness and mood disorders and this isn’t considered controversial amongst mental health professionals.

    You may want to check out SBM’s sister blog Neurologica written by Steven Novella, which focuses on neuroscience and skepticism. Not so much on psychiatry, psychology or social work but he does touch on cognitive science controversies sometimes.

    http://www.theness.com/neurologicablog/

    That said, I’d also welcome a psychiatrist or psychologist blogger here who could discuss controversies from a SBM perspective that included not just neurobiology but also the various forms of talk therapy, which also constitute an important part of mental health treatments. Or a social worker who could discuss these issues from a social work perspective.

  94. Lizcat said:
    “Yes maybe people are expecting miracles like antibiotics and the polio vaccine to come along and save us from the current dreaded diseases. Maybe they expect too much. But really, the lack of progress has been quite surprising.”

    Amy replied:
    “What I find amazing is the lack of knowledge about the progress made in medicine and the jaded attitude that greets each astounding development with a yawn.

    In my professional lifetime alone the following occurred, were developed or were brought into widespread use:
    [...]

    Psychiatry
    Prozac and other SSRIs that have revolutionized the treatment of depression and anxiety”

    Plonit replied:
    “If the rapid transformation of HIV/AIDS from an invariably fatal condition to what is effectively a chronic disease is not a modern medical miracle then a don’t know what is.”

    Lizcat, Amy never said that SSRIs “cured” depression. She said they revolutionized its treatment. And if you think there were millions of perfectly healthy people with HIV/AIDS undetected in the population before Big Pharma discovered them in 1983, you are being wilfullly blind. You are not being a skeptic, you are being a denialist. There is a difference.

  95. Amy, I happen to think Zoe237 has some points in that you may not be in 100% alignment with some ACOG recommendations as published. If that’s true, that would be interesting to talk about. (It’s possible that ACOG recommendations are not entirely science-based, for one thing.) If it’s not true, then there are some rational, not-stupid people trying to follow your thinking here who are failing. It would be more helpful to clarify where we go wrong than to accuse Zoe237 of lying.

  96. Fifi says:

    Dr Tutuer – Did anyone actually saying that you being retired disqualifies you from writing about medicine? I certainly didn’t, nor do I think that being retired disqualifies one from sharing their experience, knowledge and perspective. What I said is that when one wants to be considered an authority and is discussing science then transparency is needed regarding experience, affiliations and so on. It’s the basics of being able to discern bias, it’s a little thing called “context” and it’s highly relevant to SBM and science in general. What’s weird is that you don’t think it applies to yourself in regards to SBM. Whether one is currently practicing can be relevant if the blogger brings it up themselves (you opened this can of worms yourself in the birthing thread). So, simply being clear about one’s credentials and whether on is currently practicing is about transparency and providing context. None of this would be an issue if you yourself hadn’t actually made it one by personalizing and also cherry picking evidence to suit your purposes.

    You keep accusing others of distorting what you say – even when you’re quoted back to yourself you seem to have problems owning your own words! – and yet you consistently distort what others say so as to paint anyone who doesn’t uncritically support your positions as out to get you for no reason and an enemy of SBM. If you’d actually stuck to the science in the first place instead of taking personalized and ideological positions – and being unnecessarily emotionally provocative and sensationalist – and vilifying anyone who calls you on this as personalizing and being ideological, this discussion would be very different. Once again, you really do seem more concerned about yourself and using SBM for personal ends than actually supportive of SBM. This is why it seems like you’re doing cargo cult SBM blogging rather than SBM blogging intended to clarify scientific understanding and defuse pseudosience.

  97. “I happen to think Zoe237 has some points in that you may not be in 100% alignment with some ACOG recommendations as published.”

    Where’s your evidence?

    Moreover, being in 100% alignment with ACOG is hardly a measure of the accuracy of my writing. In other venues, I have criticized certain ACOG recommendations in the past, and that does not mean that my criticisms are inaccurate.

    The real problem here is that several people, you among them, have been casting about for reasons not to accept what I have written. In most cases, the “concerns” expressed are thinly veiled personal attacks.

    Let’s review.

    Retirement: To my knowledge that is not a criticism that has been raised about other SBM bloggers who are retired.

    “Disclosure” of retirement: 1. I have hardly hidden the fact that I am retired. 2. Since when is disclosure of retirement a factor in assessing the accuracy of science writing?

    My credentials: I’ll put my credentials up against anyone’s credentials.

    Style: My style is my choice, subject to the wishes of Drs. Novella and Gorski. I welcome any advice they have to offer, based on the fact that this is their blog, but more importantly, based on the respect that I have for them and their writing.

    If a few commenters don’t like my style, they don’t have to read what I write. As far as “advice” about my style is concerned, I will refer to the immortal words of MAD Magazine: “If people wanted unsolicited advice, they’d ask for it.”

    I consider the motivations of the criticisms to be transparent and the tactics distasteful.

  98. Harriet,

    I wouldn’t recognise Amy Tuteur if I met her on the street and I had never heard of her before she started posting here. I have nothing against her personally, I agree with her on many things, and I am interested in her point of view on obstetrics. (Which seems to be summed up as live baby good, dead baby bad.)

    I am frustrated with the way she presents her posts, however. Sometimes her logic is hard to follow and she offers little or no help to others trying to figure out how she got from A to B and why we should go there too. She treats her logic as self-evident science, but if her logic is hard to follow and this is a popular blog, it’s a bit odd that she often seems so reluctant to walk us through it.

    She is also a problematic representative of science, as I have never seen her acknowledge an error, even a minor, non-substantive one. (By comparison, David Gorski acknowledges errors a lot.) Instead, when people bring up apparent errors or contradictions, she first denies their existence; when presented with quotes, she accuses people of nitpicking or lying.

    If people are attacking her personally, it probably reflects a general frustration as they try to figure out why they respond so strongly to her posts.

  99. Amy, I think Zoe237 made the case that you are not always 100% in alignment with ACOG – particularly with respect to NPO during labour, where you appear not to be aware that the recommendation has changed.

    “Moreover, being in 100% alignment with ACOG is hardly a measure of the accuracy of my writing. In other venues, I have criticized certain ACOG recommendations in the past, and that does not mean that my criticisms are inaccurate.”

    I agree completely.

    “The real problem here is that several people, you among them, have been casting about for reasons not to accept what I have written.”

    “I consider the motivations of the criticisms to be transparent and the tactics distasteful.”

    Why on earth would I be casting about for reasons not to accept what you have written? I often do accept what you have written, and say so. I also think you often make statements that are broader than you can support. Sometimes I can’t follow your logic and ask for clarification.

    I actually really like the live baby vs dead baby analysis you apply to obstetrics and midwifery. It brings clarity to a very complicated and emotional life event.

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