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280 thoughts on “Study shows antidepressants useless for mild to moderate depression? Not exactly.

  1. Fifi says:

    To address the homeopathy canard being thrown into the mix here (putting aside for the moment that it’s simply prescribing a placebo to prescribe sugar pills or water). The biggest problem with the claim that homeopathy works for mental illness is that the homeopaths who are prescribing homeopathic remedies aren’t trained to be doctors, let alone mental health experts. This means they would probably miss biological factors that may be causing a depressive state, they would probably miss if someone is suicidal and, when dealing with mental illnesses that include psychosis or extreme delusions they’re more likely to encourage the delusions since they’re deluded and indulging in magical thinking themselves.

    While the long chats that focus on the patient (and the details of their daily routine and how they feel) during the homeopathic “diagnostic” process may actually provide some temporary comfort to someone with mild depression that’s caused by feeling isolated and unheard – just as any non-medical social contact and concern would – the fact remains that a homeopath isn’t trained to recognize or manage mental illness, nor transference and counter-transference. This means that the homeopath would be creating a dependency without actually providing the patient with the necessary skills to have a real social life and there’s a great likelihood of the homeopath projecting onto the patient and not recognizing important signs and symptoms. (Though GPs and other medical professionals not trained in psychology or psychiatry are also less likely to be aware of or equipped to handle transference and counter-transference, they’re also less likely to be encouraging weekly visits and inappropriately playing therapist and blurring healthy boundaries or creating dependence. Many GPs are being put, often unwillingly, in the position of prescribing SSRIs simply because there are not enough mental health professionals available to diagnose and treat mild and moderate depression – and the benefits of SSRIs have been oversold.)

    Both depression and chronic pain are conditions that are highly subjective and experiential (I’m in no way saying they’re not real, I’m just saying that we measure them using subjective reporting). This means that for some people the placebo effect can provide temporary changes in subjective experience. What many CAM treatments for chronic pain and depression do is take the placebo effect and bits and pieces of CBT, or they exploit certain cognitive quirks and/or basic human social needs, and then misrepresent them as being magical and a result of the CAM practitioners intervention rather than empowering the patient by teaching them how their own mind and body work, and how to manage their own thoughts, feelings and state.

    Interpersonal talk therapy works somewhat differently than CBT. CBT is very self directed and focuses on recognizing and changing thoughts and feelings, and providing new coping tools (courses of treatment are generally shorter). Not everyone is a good candidate for CBT. Interpersonal talk therapies and analysis are about the relationship between the therapist and patient (and creating new relationship experiences, essentially relearning how to relate intimately) – this can sometimes mean years of therapy. Both have their time and place. And both can be do more harm than good when mis-prescribed. The thing is, sometimes it can take some time to find the right form of therapy and the right therapist. Just as sometimes it can take some experimentation to find the right medication or dose. Since people are in a very vulnerable state usually when they seek help for mental health issues, it’s incredibly important that the person seeing them not be promoting a personal agenda that overrides the patients real needs. (Or that they assume that because they’re equipped with a hammer that all patients are nails. You may be able to hammer a loose screw back into place but it does damage during the process and isn’t lasting!)

    These are, of course, gross generalizations and oversimplifications but I bring it up to illustrate the differences between CBT (which is a behavioral therapy) and talk therapies (which are relational therapies). CBT is great for crisis intervention, PTSD and learning new coping skills. Talk therapy can be useful for exploring existential angst and unraveling and understanding the root emotional and psychological causes of personal angst and uncovering repressed issues (and I’m not using angst in a belittling way at all here, suffering is suffering). It’s the area where transference (and the therapists awareness of counter-transference) are highly applicable. All in all, mental health – both in terms of treatment and research – can’t be approached in the same way that many other purely biological conditions can be.

    For anyone interested in these issues and a psychiatric perspective (and a good read), I highly recommend The Last Psychiatrist’s blog. His latest one looks at how Seroquil (an anti-psychotic) is being promoted as a treatment for depression and what’s wrong with the way the science is being presented.

    http://thelastpsychiatrist.com/2010/02/how_seroquel_xr_works_part_1.html#c007362

    And another interesting expert perspective on the subject…
    http://clinpsyc.blogspot.com/2009/12/atypical-antipsychotics-for-depression.html

  2. Fifi says:

    While there can certainly be (and is) rivalry between various factions within both psychiatry and psychology, and between psychologists and psychiatrists, and psychiatrists and neurologists – the questions around efficacy of different talk, behavioral and drug therapies aren’t simply due to this. These controversies exist within psychiatry itself so it’s erecting a strawman to make out it’s simply a matter of psychologists vs psychiatrists. Or to propose that those involved in asking these questions and trying to make sense of the data are simply pursuing personal or for-profit agendas rather than trying to discern what is in their patients’ best interests and what the most efficacious treatments are. Psychiatrists don’t only use drugs to treat their patients – and promoting this idea is actually damaging to psychiatry since it’s promoting the false accusations of Scientologists and Big sCAM. Analysis and talk therapy is as much a part of the psychiatric tradition and practice as it is part of psychology (and psychologists often work in tandem with GPs to prescribe anti-depressants).

  3. Zoe237 says:

    Dr. Amy wrote:

    “Okay, I just finished reviewing the abstracts for all 23 studies. … Of the 17 excluded studies 15 DID show effectiveness of the antidepressant treatment of mild to moderate depression. Two studies showed no difference compared to placebo.”

    # apteryx:
    “Now, Dr. Amy claims that 15 of these 17 studies showed antidepressants to be effective for mild to moderate depression. This means that she must have been able to determine this to be the case not only for every single study in the second group above (DeRubeis et al. and Liebowitz et al. included) but for four of the last six studies I just individually summarized. However, THREE of those – Barrett et al., Elkin et al., and the UK Moclobemide Study Group – all appear to state the exact opposite (while two others seem to have found no efficacy, in depression of unknown severity, with standard primary outcome measures, and the sixth hints that they did not find benefit in less depressed patients).”

    Is this going to be addressed or is it not relevant?

  4. “the study addressed a question of whether treatment effect for depression varied by baseline severity and found it did. The study didn’t ask the question: are antidepressants effective in mild depression? So the authors shouldn’t try to answer that question, because the study wasn’t designed to answer it, and was underpowered to detect any effect in the subgroup with mild depression.”

    Unfortunately, the authors appear to think otherwise. Indeed, the final sentence of the paper is:

    “… whereas ADM can have a substantial effect with more severe depressions, there is little evidence to suggest that they produce specific pharmacological benefit for the majority of patients with less severe acute depressions.”

    The authors believed that they showed “antidepressants” to provide no benefit for patients with mild to moderate depression. That they believe this is confirmed by their public statements.

    My main point their claims are irresponsible and deceptive:

    They did not look at “antidepressants,” they looked at Paxil and a rarely prescribed older treatment for depression.

    They excluded the 118 of 141 total papers involving RCTs of antidepressants because those studies included a placebo washout period (83.6% of relevant studies).

    Then they excluded 17 of the 23 remaining studies because the authors refused to cooperate with them.

    Ultimately, they performed a “metaanalysis” on only 4% of RCTs of antidepressants.

    Only 3 out of the 6 included studies involved an SSRI. Out of the many members of the class of SSRIs they looked only at Paxil.

    As daedalus2u pointed out, 2 out of 3 studies that looked at Paxil were from the authors themselves.

    It is unfortunate the authors could not get other scientists to partcipate, but that does not entitle them to ignore those other studies.

    The title of the paper, Antidepressant Drug Effects and Depression Severity:A Patient-Level Meta-analysis, is false and misleading. They did not perform a meta-analysis of anything beyond their own two papers and that of one other group.

    I find their conclusions irresponsible, their public statements outrageous and the media treatment of their irresponsible and outrageous claims to be regrettable in the extreme.

  5. Plonit says:

    “there is little evidence to suggest that they produce specific pharmacological benefit for the majority of patients with less severe acute depressions.”

    The above is a “not shown to work” statement.

    Whereas “The authors believed that they showed “antidepressants” to provide no benefit for patients with mild to moderate depression.”

    describes a “shown not to work” statement.

    There is a subtle but absolutely crucial difference between these two types of statements, and if you ignore the difference then you misrepresent what the authors have said. They don’t say, “the drugs don’t work”, they say “the drugs have not been shown to work”.

  6. “There is a subtle but absolutely crucial difference between these two types of statements, and if you ignore the difference then you misrepresent what the authors have said. They don’t say, “the drugs don’t work”, they say “the drugs have not been shown to work”.”

    You’ve missed my point. The authors have shown nothing! It doesn’t matter how they express their findings; their findings are not generalizable.

    In my personal opinion, the only claim the authors can justify is:

    In the 3 studies of Paxil we looked at (which may not be representative of any of the many studies we left out) we did not see evidence that Paxil was better than placebo in people with low to moderate initial HDR scores.

  7. M Wilson MD says:

    Dr. Tuteur,

    I commend you for taking on this topic, and for doing it so well. I hope I can offer a few comments that might further the discussion.

    Meta-analysis, as a retrospective examination, should never be used to make ANY grand, sweeping determinations like- “STOP YOUR MEDS, they are worthless!” But especially when suicide is such a major risk of untreated depression (and a leading public health problem with nearly 30K deaths a year.) The publication and editorial process for this journal is irresponsible to the public health interest. A multitude of epidemioligical studies in diverse populations demonstrate introducing SSRIs to adult populations reduces suicide rates (Japan, northern Europe…)

    Furthermore, depression is an illness that ususally last months or longer, well beyond the time horizons studied in the clinical trials subjected to meta-analysis in this work. Six weeks is a blink of an eye, barely a blip for some people struggling with depression. The characterization of mild to moderate to severe depression is flimsy- it is not a strictly defined symptom cutoff point. For example, where on the Hamilton D Rating is the “severe point” and who sets it? Where is the point on the Beck rating scale and who sets it? Arbitrary, there is some general consensus, but still arbitrary. Patients with mild to moderate symptoms at week 1 may have severe symptoms at week 12 if left untreated (by that time, study is over and they are lost to follow up… convenient.) It is also a well known that some patients will minimize distress they experience, for many reasons. Some may have severe symptoms but rate them mild.

    There is also evidence emereging that publications
    (like this one) that discourage antidepressant medication treatment, or otherwise interfere with mental health access, lead to detrimental outcomes like higher suicide rates. This is a controversial topic, no doubt, but evidence is building that since the FDA labeled antidepressants with a black box warning regarding suicidality for young adults and adolescents, the suicide rates for this population has trended higher. Undertreatment is of course the leading suspicion for causality since the prescription rates for SSRIs from GPs and pediatricians have plummeted. Child and adolscent psychiatrists usually have 6-9 month waiting lists, at least in this community. (“Hold that suicidal thought, will get back to you on that…”)

    The Sequenced Treatment Alternatives to Relieve Depression (STAR*D) set of publications is an excellent informative resource for clinicians interested in treating depression.

    In conclusion, meta-analysis should be a tool to look relationships that might need closer examination in future RCTs. It should not be used to make sweeping recommendations for treatment. This publication is another in a series of recent, methodologically flawed examinations of SSRI antidepressants that fail to appreciate its underlying logical shortcomings.

    MW

    Gibbons RD, Brown CH, Hur K, Marcus SM, Bhaumik DK, Erkens JA, Herings RM,
    Mann JJ. Early evidence on the effects of regulators’ suicidality warnings on
    SSRI prescriptions and suicide in children and adolescents. Am J Psychiatry. 2007
    Sep;164(9):1356-63. PubMed PMID: 17728420.

    Gibbons RD, Segawa E, Karabatsos G, Amatya AK, Bhaumik DK, Brown CH, Kapur K,
    Marcus SM, Hur K, Mann JJ. Mixed-effects Poisson regression analysis of adverse
    event reports: the relationship between antidepressants and suicide. Stat Med.
    2008 May 20;27(11):1814-33. PubMed PMID: 18404622; PubMed Central PMCID:
    PMC2423233.

  8. Plonit says:

    You’ve missed my point.

    +++++++++

    Hardly, one of your points depends on the false ellision of “not shown to work” and “shown not to work.”

    It may be a bad study for a myriad of other reasons (in fact, looks to be so) but not because “The authors believed that they showed “antidepressants” to provide no benefit for patients with mild to moderate depression.”

    They didn’t make this “shown not to work” statement that you falsely attribute to them. Given that there are so many other grounds for criticism, it’s not even clear why you would feel the need to make this false attribution unless it is a product of your own confusion.

  9. Fifi says:

    Of course, the personal outrage of a non-expert in psychiatry and neurobiology aside, generalizing about the media is, well, generalizing and showing a great misunderstanding of not only how media functions but also the relationship between media and “experts”. Why not get outraged at JAMA who published the study and thereby lent it the weight of medical authority? Why not get
    outraged at university and pharmaceutical PR departments that exaggerate study results to the media? Why get outraged at all media because of one NYT article when there’s actually another NYT article that takes the study to task in a reasonable and measured way? Why all the hysteria, emotionality and personal outrage regarding something that can easily be addressed in a rational manner?

    This NYT article does just that…
    http://www.nytimes.com/2010/01/12/health/12mind.html?em

    Of course, Dr Friedman is a Director of Psychopharmacology so – if we’re going to propose that one’s specialty creates a bias (as has been proposed vis a vis psychologists) then he may have a bias towards pharmacological treatments since that’s his specialty (his tool of choice or hammer, if you will). I am certainly not accusing him of such, and I have no idea if he has any other conflicts of interest that may contribute to his position in this matter. However, from what I’ve read, he seems to not be an extremist.

    http://www.nytimes.com/2010/01/12/health/12mind.html?em

    “As you point out, medication and psychotherapy are often used together and for a very good reason: there is abundant evidence from clinical trials that combined treatment is more effective than either treatment alone….
    The issue of matching the right patient with the right treatment is critical, and we are just beginning to understand what kinds of personal characteristics predict response to a specific psychotherapy.”
    — Dr. Richard Friedman

  10. Fifi says:

    Another interesting quote by Dr Friedman that is relevant to this discussion…

    “For example, several studies comparing cognitive-behavior therapy and interpersonal psychotherapy with antidepressant medication in depressed patients showed nearly identical brain M.R.I. changes in patients who responded to either treatment. In other words, psychotherapy is ultimately a biological treatment.”

    http://science.blogs.nytimes.com/2008/01/14/a-new-you-dr-richard-a-friedman-on-mental-health/

    The psychotherapy vs medication gambit is a false dichotomy that misunderstand neuroplasticity (and also misrepresents the professional practices of both psychiatrists and psychologists). It’s also playing right into the hands of Scientologists and other anti-psychiatry types by presenting psychiatrists as pill pushers and not empathetic and compassionate physicians who seek the best treatment options for their patients with the fewest side effects.

  11. Fifi says:

    Dr Wilson – “Meta-analysis, as a retrospective examination, should never be used to make ANY grand, sweeping determinations like- “STOP YOUR MEDS, they are worthless!”

    Of course they shouldn’t and neither the meta-analysis nor the NYT article proposed that (and another NYT article actually did a much better dissection of the study that Dr Tuteur did, while also addressing the reality that anti-depressants aren’t a panacea and don’t always work – though it didn’t address how pharmaceutical companies often won’t release their data so it can be included in a meta-analysis).

  12. M Wilson, MD,

    Thanks for your comment.

    “Furthermore, depression is an illness that ususally last months or longer, well beyond the time horizons studied in the clinical trials subjected to meta-analysis in this work. Six weeks is a blink of an eye, barely a blip for some people struggling with depression.”

    That’s certainly true and it highlights another serious problem with this study, the decision to draw conclusions about clinical management when the study is not directly applicable to clinical decision making.

    I can’t imagine that there is a clinician who says to a patient: We are going to treat your moderate depression with 6 weeks of low dose Paxil. If you are not substantially better by the end of 6 weeks, we must conclude that you do not respond to antidepressants.

    Clinicians routinely counsel patients starting SSRI treatments are routinely advised that the first dose, and even the medication itself may not be effective. Patients are warned to expect a period of time during which dose is increased and different SSRIs are substituted until one is found that will be effective for that particular patient.

    Finding the appropriate SSRI takes weeks, if not months. Moreover, if the patient does not improve with SSRIs, the next step would be to try antidepressants of a different class.

    No clinician would ever conclude that lack of improvement after 6 weeks of Paxil was an indication that “antidepressants” are ineffective, so it is inappropriate to extrapolate from a study that shows that 6 weeks of Paxil without improvement means that “antidepressants” are ineffective.

  13. Reviewer 3 says:

    @Plonit

    “They didn’t make this “shown not to work” statement that you falsely attribute to them”

    From the Comment section in the paper… “True drug effects (an advantage of ADM over placebo) were nonexistent to negligible among depressed patients with mild, moderate, and even severe baseline symptoms…”

    The authors do claim that anti-depressants did not work in mild depression, as Dr Tuteur has stated.

    Another major issue with this paper is the power of the study. There were only 434 people treated with antidepressants and 284 with placebo. To address the issue of mild depression, they split their sample into 3 groups. The authors should have stated how much of a difference between the groups the study had the power to detect. They didn’t. It is very likely that the subgroups were too small to detect anything other than a very large change in the rating score, which would not be expected in people with mild depression. So the author’s claim above is not correct. To claim this- they’d need to do a meta-analysis of all RCTs of all antidepressants in mild depression, and show no benefit of treatment.

  14. BillyJoe says:

    Whilst waiting for a response from that hit and run merchant, Mr. Dullman…

    I would like to thank Amy again for participating in the commentary (authors don’t always do that and, of course, they are not obligated to do so). I think she has done a reasonably good job at showing up the problems with this study, with only a few minor hiccoughs (and I agree a bit of stage setting could avoid many misunderstandings that occur in the commentary about the authors intentions).

    I don’t know if anti-depressants are useful for mild or moderate depression, but this study certainly does nothing to answer that question for me.

  15. It is kind of dangerous for a layperson like me to read studies like this without the guidance of more knowledgeable folks, for one simple reason– as pointed out by an earlier commenter, it is supremely difficult to self-evaluate the level of one’s own depression. Thus, I read this NYT article and thought, “Crap, I wonder if I should wean off the Paxil?” because to my own perception, CLEARLY my depression level is average. :) Fortunately for me, I have a competent psychiatrist who quickly disabused me of the notion that I am deriving no benefit from my SSRI. :D

    But, seriously, how atypical is that reaction from a depressed person– EVEN one who has been suicidal many times in their life!– “Oh, my depression just isn’t that bad, I must be in the mild-to-moderate category,” because it is SO HARD to put one’s own experience into the perspective of the general population? Especially as one of the knee-jerk reactions of depressed people is to find insignificance in their own lives, including, ironically, their level of depression! Thus, I worry that articles like this, in the popular media, may do more harm than good in that a depressed person might become less likely to seek drug therapy when it might really help them.

  16. pmoran says:

    Billyjoe: “The trial compared homeopathic drops to placebo drops identical in appearance to the homeopathic drops; and fluoxetine capsules to a placebo capsules identical in appearance to the fluoxetine capsules.”

    Not really. There was no placebo group. The study compared homeopathic management to fluoxetine only. Because it was not possible to blind patients to the process of homeopathic individualisation they were blinded as to the “active” treatment supplied. All patients were thus required to take a placebo mimicking the other agent in addition to the supposedly active one.

    We are bound to be offered many more results like this for dubious methods wherever conventional treatment has only modest benefits over placebo in subjective and self-limiting complaints.

    It is the only way forward for the promoters of such methods. They cannot risk going to the trouble of performing high quality comparisons to placebo and merely adding to the list of negative results.

  17. Reviewer 3 says:

    I also don’t know whether the study has really shown that the effectiveness of antidepressants varies by baseline severity of disease. The paper is quite dense and almost impenetrable, but what the authors appear to have done is to compare the change in the Hamilton depression rating scale (HDRS) following treatment with the baseline HDRS. On average, people with higher scores to start with (ie more severe depression) had greater changes in their HDRS.

    One explantion for this could be that antidepressants improve depression by a similar amount no matter what the baseline severity is. For example- if antidepressants improve depression by 25% in 6 weeks, a starting HDRS of 40 would improve to 30, and a starting score of 20 to 15. Comparing the absolute difference in HDRS with the baseline starting score would show that higher initial scores are associated with greater changes in HDRS.

    This is such a simple argument that it is hard to believe that it wouldn’t have been considered by the JAMA reviewers and editors, but it wasn’t addressed in the paper anywhere. Again, though it is not a sensible way of assessing whether antidepressants are effective in mild depression.

  18. BillyJoe says:

    pmoran,

    You are a spoilsport!

    That was a question to test Dullman.
    In my experience, he reads only the extracts of the studies he references and is seemingly unable to understand, or can’t be bothered to read, the details of the study themselves.

    My gamble was that he would not attempt to answer this question because of the above requirement.

    If he had read the study, he would have been able to embarrass me with a response similar to the one you gave, but my guess is that, even after reading your response, he will still be unable to do so.

    (That is, if he even bothers to come back to this thread which I think is highly unlikely – would you like to take a bet?)

    regards,
    BillyJoe

  19. weing says:

    “In my experience, he reads only the extracts of the studies he references and is seemingly unable to understand, or can’t be bothered to read, the details of the study themselves.”

    That’s not very consistent of him. I would expect him to make the studies more powerful by serially diluting them and shaking until there was nothing left of them. On second thought, he’s probably deluding with them.

  20. weing says:

    One problem I have in reading these studies is finding out how they determined adherence to the antidepressant. Patient’s with lower severity might think that they can beat it without the medication, particularly when the initial side effects of these meds manifest as opposed to the placebo group. In such a case, I would expect to see little difference between the 2 groups in efficacy.

  21. Chillyfinger says:

    A few things about depression from someone who knows …

    1. Depression is incredibly difficult to treat. I know of people who have gone through dozens of treatment options over many years before finding relief. Measuring effectiveness of one drug against “depression” is measuring something that barely exists in the “real world”.

    2. Depression is a symptom, not a disease. It has many causes (dozens at least) ranging from “chemical imbalance”, sleep problems, genetic problems, environmental problems etc. A “cure” will at best tinker with surface issues such as dopamine production. It’s like feeding a drunk six cups of coffee. You just get an awake drunk. Anti-depressant drugs can just give you a depressed person who’s not so much of a problem to everyone else.

  22. “Depression is incredibly difficult to treat. I know of people who have gone through dozens of treatment options over many years before finding relief. Measuring effectiveness of one drug against “depression” is measuring something that barely exists in the “real world”.”

    Agreed.

    “A “cure” will at best tinker with surface issues such as dopamine production. It’s like feeding a drunk six cups of coffee. You just get an awake drunk. Anti-depressant drugs can just give you a depressed person who’s not so much of a problem to everyone else.”

    That is simply untrue.

    Because of the tremendous variability in responsiveness among patients, there is no way that one person’s experience can tell us the effects of antidepressant treatment. Perhaps you are someone you know felt that way after treatment, but if that’s the case, the treatment was only partially successful.

    Most patients who report improvement on SSRIs do NOT feel sedated and do NOT feel that the symptoms are still there but being “masked” by the SSRI. Indeed, many patients report feeling “like themselves” without depression.

  23. Fifi says:

    Dr Tuteur – “Most patients who report improvement on SSRIs do NOT feel sedated and do NOT feel that the symptoms are still there but being “masked” by the SSRI. Indeed, many patients report feeling “like themselves” without depression.”

    That’s a bit self-evident since many people who do feel sedated (or manic) on SSRIs probably aren’t going to be reporting feeling sedated or manic as an improvement! Though, of course, some may and many people who take tricyclic antidepressents – who are generally people who suffer from severe depression – consider the unpleasant side effects worth the relief. Also, when we’re talking about patient self reporting regarding mild to moderate depression there are few means to account for confounding factors (from simply doing something about their condition and the relief that provides, undergoing therapy at the same time, or the ever present placebo effect when discussing mild to moderate depression).

    Chillyfinger makes a good point. Depression can be a symptom of many organic diseases, as well as a symptom of a nutritional deficiency, an environmental/social problem or a sleep imbalance. There’s often a chicken/egg problem with mind/body conditions. That said, depression can also have genetic or purely biological causes as well (it can be a disease and not a symptom). Depression is also a symptom of Manic Depression/Bipolar Disorder so it’s very important to have a clear diagnosis (since SSRIs seem to be problematic for many people with MD/Bipolar Disorders). A good clinician will take the time to discern whether depression is a symptom or the disease itself, rather than simply assuming that all depression is a disease and should be treated with SSRIs. There are many approaches to changing neurobiology, a pharmaceutical one is only one (as valuable and incredibly useful as it can be for some people) and SSRIs are only one of many psychopharmaceuticals and aren’t appropriate for all psychiatric illnesses (and are highly inappropriate for some).

  24. weing says:

    I’ve also seen cancer and diabetes present as depression.

  25. Thyroid is the classic physical condition to look for on the differential. And then there’s looking at the differential from the other side: some subgroups have their own presentations. Apparently hispanic women sometimes present with abdominal discomfort that is fully treated with an SSRI.

    What I still want to know is, how are “mild” and “moderate” even captured? And what makes us think that each study’s “mild” is the same as anyone else’s?

  26. Depression can be an illness in itself, or it can be a symptom of another illness. It is like other medical conditions in that respect, having both a primary form and secondary forms.

    It’s not surprising when you consider that depression is biochemically mediated. The biochemical derangement can occur spontaneously (perhaps due to genetic susceptibility) or it can occur as the result of other medical problems or as the result of hormone treatments and other medications that leave patients experiencing depression.

    The bottom line, though, is that it is a real illness, just like diabetes, and may require medication, just like other illnesses.

  27. Fifi says:

    Dr Tuteur – “The bottom line, though, is that it is a real illness, just like diabetes, and may require medication, just like other illnesses.”

    Is anyone actually proposing that depression isn’t real? Or that medication can’t be a valid treatment and may be necessary? That’s a bit of a strawman you’re erecting. And, no, depression isn’t “just like diabetes” since depression involves both the body and mind, and is diagnosed using subjective measures.

  28. “And, no, depression isn’t “just like diabetes” since depression involves both the body and mind …”

    Yes, it is just like diabetes in that both have a biochemical basis. Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes. There is no magic to the mind, and no special “essence.”

    To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.

  29. Fifi says:

    weing, yes, I was thinking of cancer in particular, but there are also nutritional deficiencies that can present as depression. In either case, treating with SSRIs wouldn’t be the best course of action.

    Alison – “Apparently hispanic women sometimes present with abdominal discomfort that is fully treated with an SSRI.”

    That makes a lot of sense since most of the body’s serotonin is created and found in the intestines, it’s important in a huge array of biological functions. Only a small amount is actually found in the brain. The relationship between IBS and serotonin is a fertile area of research.

  30. Fifi says:

    Dr Tuteur – “Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes. There is no magic to the mind, and no special “essence.”

    Nobody is claiming that – I certain am not and haven’t at any point. In fact, I’ve been quite clear that the mind is not magical and cognitive therapies aren’t magic but are taking advantage of basic neurobiology. You’re erecting a strawman yet again. There’s actually quite a lot of good research that shows how neuroplasticity works and it’s really not very mysterious or hard to grasp. Certainly we don’t know everything about neuroplasticity but we do know quite a lot at this point and how the physical brain responds to repeated actions, thoughts and learning/experiences. The point is that we can change our neurobiology through other means than simply drugs (which is not to discount the usefullness of drugs). To dismiss everything outside of one’s own understanding – or to assume it’s all woo or magic – simply because one doesn’t understand it is being blinded by personal bias.

  31. Fifi says:

    Dr Tuteur – “Yes, it is just like diabetes in that both have a biochemical basis.”

    You’re missing the point, yet again. There are specific biological measurements and tests that are used to diagnose diabetes. We don’t have specific biological tests for depression, we rely upon self reporting and observation – neither are as objective as a biological test for diabetes. We also rely upon the DSM, which is in many ways a construct (that doesn’t mean it’s not useful or necessary, or that all mental illness is a construct or not biological). Also, one can’t use one’s mind to influence diabetes (it would be magical thinking to believe this) but one can change one’s brain by what one does with one’s mind (just as brain and biological illnesses like cancer can effect how our mind presents/works and we experience ourselves and life).

    The brain/mind relationship is more complex and more of a two way street than you seem willing to acknowledge, and both are influenced by social/environmental factors (for instance, a baby that is never touched or is abused develops differently than a baby that is lovingly touched and nurtured). Nature AND nurture isn’t really a very controversial position in neuroscience at this point. Just as epigenetics is showing itself to be a very fertile field of understanding about how biology evolves.

    Now, this doesn’t mean there aren’t brain disorders that the mind has no influence over or that drugs can’t be helpful and useful – I’m not and have never been making an either/or argument here. I’m arguing for not being absurdly reductionist in a way that actually goes against current scientific knowledge and irrationally fetishing psychopharmacology and promoting it as the end all and be all of SBM.

  32. Fifi says:

    And to be very clear, I’m not arguing against the use of drugs for depression or saying that drugs can’t be useful. And I’m certainly not criticising anyone’s personal choice to use or not use drugs to treat their depression. Not everyone is a good candidate for cognitive and/or behavioral therapies – antidepressants are a perfectly viable option and it’s up to the individual and their doctor or therapist to decide which approach is most aligned with their condition, personality, current context and life options.

  33. micheleinmichigan says:

    Having been diagnoses with Hypothyroidism, Depression/Anxiety and Asthma, all things that can mimic each other, I think I can attest what a lovely barrel of monkey’s it is trying to separate all the symptoms.

    But for myself I can see distinct differences in some case. I was treated for the Depression/Anxiety (with Paxil) well after I started having thyroid symptoms but before I was diagnosed hypothyroid (due to normal tsh levels). Then stopped Paxil before being diagnosed hypothyroid and starting synthroid.

    The Paxil mostly helped my mental symptoms. Significantly lowering my intense self-critical ruminating and dark moods and a feeling of despair and being overwhelmed. After a period of making my insomnia worse, it seemed to alleviate my 3:00am waking problem and I got more sleep.

    On Paxil I still had period of intense tiredness or lethargy and I had many muscle ache and spasm symptoms, It seemed I was constantly going to PT or taking Ibuprofen for some tendon, muscle pain or spasm. I also had strange “vertigo symptoms” that the therapist thought was stress related

    When taking synthroid, no Paxil (when my TSH is optimal) I don’t have the tiredness or muscle pains but the ruminating and mood are much more difficult to control . AND the synthroid also improves my sleeping, alleviate the 3:00am waking and I don’t have the vertigo symptoms.

    On the other hand, every doctor I’ve talked to claims that I can’t have been having any hypothyroid symptoms with normal TSH levels. So go figure.

    The side effects of the Paxil and some symptoms of hypothyroid I found to be so similar as to be indecipherable.

    With asthma it’s easier. It’s only mistaking the tight chest stress sensation for the tight chest asthma sensation. But if I try to take a deep breath and can’t, it’s probably asthma. Also luckily a doctor can easily hear my wheeze with a stethoscope so I don’t have to argue about medication.

    So I guess that my long winded way of saying, yup, it really can be confusing.

  34. Lawrence C. says:

    Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes.

    To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.

    Such unproven assertions detract from the discussion. (Although it is clear example of reflexive reductionism, SBM’s unhappy alternative to CAM’s reflexive doubt.)

    It’s especially unfortunate to see, in that last quoted sentence, a declaration of ignorance and an assertion of absolute certainty derived from that ignorance.

  35. BillyJoe says:

    Amy said: “To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.”

    Lawrence said: “It’s especially unfortunate to see, in that last quoted sentence, a declaration of ignorance and an assertion of absolute certainty derived from that ignorance.”

    It’s just the materialist’s position surely.
    Amy must have assumed there’d be no dualists around here.
    If there are, identify yourselves!
    We’ll soon cut you down to size with our special purpose razor.

    ;)

  36. Fifi says:

    BillyJoe, I’m not sure if you’re joking or not. I’m hardly a dualist and it’s not a dualist position to propose that the brain is shaped by our thoughts and actions. Not only is it not dualist to propose the brain is shaped by thoughts and actions, it’s basic contemporary neuroscientific knowledge (though apparently Dr Tuteur thinks it’s magic). Neuroplasticity is hardly radical or dualist, or magic! Dr Tuteur’s prejudice against cogntivie and talk therapies, her fetishistic approach to psychopharmacology, and her blatant bias against psychologists displayed on an SBM blog is highly regrettable. As is her misrepresentation of psychiatrists as merely pill pushers. Psychiatrist are professionals who treat people not just brains, and they use more than drugs to do this and are as concerned with the minds of their patients as they are their brains.

  37. apteryx says:

    I need to issue a correction to my previous comment. At some point while tabbing back and forth to look up the abstracts of the studies in Dr. Gorski’s list, I developed the notion that I was only looking up the studies that had not been used in the meta-analysis, whereas that list was of ALL the studies that met the criteria. Thus, the numbers in my comment made no sense at all (and I’m surprised none of you keen-eyed skeptics jumped all over that). When you’re criticizing someone else for using bogus numbers to support a baseless accusation, it is better not to use bogus numbers yourself – very embarrassing. My apologies; I will now slink off to look for some Tabasco sauce for this big plate of crow.

    However, the fact that my numbers were garbage does not make Dr. Amy’s numbers correct. The correct way to look at that pile of abstracts would have been: could I identify 15 whose abstracts indicated significant efficacy against, specifically, mild to moderate depression? And I can’t.

    Oh well, at least my Saints won.

  38. micheleinmichigan says:

    Dr Tuteur said – “Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes. There is no magic to the mind, and no special “essence.”

    FiFi said – Nobody is claiming that – I certain am not and haven’t at any point. In fact, I’ve been quite clear that the mind is not magical and cognitive therapies aren’t magic but are taking advantage of basic neurobiology. You’re erecting a strawman yet again. There’s actually quite a lot of good research that shows how neuroplasticity works and it’s really not very mysterious or hard to grasp.

    Actually, I’m not sure nobody was claiming that it seemed some posters may have been alluding to that and historically there have been a large number of people that view depression as a personal failing rather than a biochemical process that can effect any of us.

    I do not see that biochemical processes and neuroplasticity are different concepts. I far as I can see neuroplasticity is a biochemical processes.

    As to diabeties and depression, Yes I would say they have some similarities. They are both a biochemical process that seems to have a genetic component. In mild moderate cases they may be acerbated or alleviated somewhat by behavior or stress factors outside of a persons control. In more severe cases behavior and outside influences offer little effective help. Our only best known treatment is drugs.

    The differences, diabeties seems to much better understood. We have much better measures for it and as far as I know, the mechanism is pretty direct. Diabetes is not generally a symptom of something else. Depression is far less understood, the measures are by far subjective.

    I personally have drawn the conclusion depression can be either a symptom of another health condition. It can also be a biochemical reaction caused by a stressor such as a traumatic life event in a none predisposed person. Or it can be a condition caused by the combination of personality*, genetic predisposition, and lifestyle/thought patterns. Lastly it can be a direct malfunction of the brains chemistry with no other conditions, events, lifestyle factors.

    In all of these cases it is a biochemical process. We can not think, perceive, do, anything without a biochemical process. It is the nature of us beasts.

    *ha, the old nature, nurture gambit.

  39. Fifi says:

    michele – “Actually, I’m not sure nobody was claiming that it seemed some posters may have been alluding to that and historically there have been a large number of people that view depression as a personal failing rather than a biochemical process that can effect any of us.”

    Can you please point out to me where I or anyone was claiming that the mind was magical and not an emergent property of the brain in this thread? Particularly where I was? Not only did I never do that, I also pointed out up thread that psychotherapies (talk and cognitive) take advantage of neuroplasticity.

    Here it is the quote from Dr Friedman again, who did a much more on point critique of the meta-analysis for the NYT than Dr Tutuer did (and without all the obvious prejudices and misrepresentations that Dr Tuteur has shown)…

    “For example, several studies comparing cognitive-behavior therapy and interpersonal psychotherapy with antidepressant medication in depressed patients showed nearly identical brain M.R.I. changes in patients who responded to either treatment. In other words, psychotherapy is ultimately a biological treatment.”

    http://science.blogs.nytimes.com/2008/01/14/a-new-you-dr-richard-a-friedman-on-mental-health/

    And it’s worth repeating again, the psychotherapy vs medication gambit is a false dichotomy that misunderstands neuroplasticity (and also misrepresents the professional practices of both psychiatrists and psychologists). It’s also playing right into the hands of Scientologists and other anti-psychiatry types by presenting psychiatrists as pill pushers and not empathetic and compassionate physicians who seek the best treatment options for their patients with the fewest side effects.

    I really do understand that it can be hard to get people to understand depression and chronic pain – or any form of suffering that isn’t dramatically obvious – and that, like with addiction, people who don’t understand tend to see it as a moral failing or a weakness of will. I am truly sorry if you’ve had this experience and do understand if this is personal for you (and I point this out not to put you down or negate your opinion or experience, I’d assume that since you shared your personal experience you consider it relevant). I can understand the personal and general utility of being able to say depression is a disease and beyond one’s control – and I’m certainly not advocating anyone “get over it”, I’m advocating using the best treatment for each individual. To reject all but psychopharmaceutical solutions simply because of a mistaken belief that other treatments aren’t biological because they don’t involve a pill is to ignore reality and current scientific knowledge. And, to propose that using anything that isn’t a pill is woo is to have a rather profound misunderstanding of the brain and mind, not to mention that it shows a great deal of ignorance regarding psychiatry and cogntive science on Dr Tuteur’s part.

    I’m curious, with your comparison of diabetes and depression, are you proposing that one can effect the structure of organs other than the brain via ones thoughts? That simply using one’s mind can have the same impact on the organs effected by diabetes as using insulin can in some cases? Or that it’s equivalent to the way cognitive and interpersonal therapies can influence the structure of the brain? Now that would be straying awfully close to magical thinking! (However, I suspect you’re just proposing that one’s stress levels and emotional state can influence insulin…though I’d like to see some evidence of this being true before I’d accept your theory. Particularly in relation to type 1 diabetes.)

  40. Fifi says:

    I’d just add, nurture IS nature. It’s all nature. And, to the discomfort of some people, culture is also nature. We’re social animals, our brains are shaped by our environment…as are our genes. Since it’s all nature, it’s actually more of a dualist position to take to make out that environment, socialization and context aren’t a part of nature and don’t influence our brains. Denying complexity and being reductionist isn’t being more scientific or having a more accurate view of reality, even if it can be a usefull and necessary thing to do to study specific things :-)

  41. micheleinmichigan says:

    FiFi , sorry you lost me. but I’m not following the dualist – reductionist debate, just not my cup of tea.

    nature vs nurture is always an entertaining debate, but unfortunately the dog needs to go out, I’ve got a pile of paperwork, behind on the artwork and birthday plans to make, so I’ll have to save my response for another article comment box. :)

  42. Fifi says:

    michele – The nature vs nurture debate is pretty much dead in the water at this point for the most part, it’s quite widely accepted that both nature AND nurture are involved in brain development…that’s what neuroplasticity is all about. The field of epigenetics is very specifically about nature and nurture.

    Really, Dr Tuteur was intentionally erecting a huge strawman and making an ad hominem attack by accusing me of being a dualist. Either that or she simply doesn’t understand even basic neuroplasticity! Either way, what she’s promoting isn’t SBM.

  43. Fifi says:

    I’m also curious as to whether you truly believe what you seem to have been asserting about diabetes and if you believe that thoughts can influence the physical structure of organs in the body other than the brain? Do you also believe that thoughts can influence the structure of cancer tumors?

  44. Harriet Hall says:

    Fifi said “to propose that using anything that isn’t a pill is woo is to have a rather profound misunderstanding of the brain and mind, not to mention that it shows a great deal of ignorance regarding psychiatry and cogntive science on Dr Tuteur’s part.”

    Dr. Tuteur never proposed any such thing!

    “Dr Tuteur’s prejudice against cogntivie and talk therapies, her fetishistic approach to psychopharmacology, and her blatant bias against psychologists displayed on an SBM blog is highly regrettable.”

    I do not see any evidence of such prejudice or bias in anything Dr. Tuteur wrote. What is regrettable is not what she wrote, but the fact that you are imagining she wrote things that she didn’t and that you are personally attacking her for something she didn’t do.

    Please desist from personal comments about Dr. Tuteur. If you have evidence that something she wrote was incorrect, you can provide your own counter-evidence without being insulting.

  45. Fifi,

    1) Thoughts most certainly can affect organs other than the brain. For instance, one effect of chronic stress is hypertension.

    2) I can’t figure out what you’re trying to say either. Amy says the brain is a physical organ, so any treatment for depression, no matter what it is, produces its effects by modifying the brain. She specifically says that talk therapy works. “To the extent that talk therapy of any kind works, it works through biochemical processes.” If you aren’t a dualist, what are you arguing with? If you aren’t claiming that talk therapy works by magic, or through the mediation of the soul, but you disagree that it works through biochemical processes, I don’t understand what you’re saying. Are you saying that neuroplasticity isn’t biochemical?

  46. Fifi says:

    Dr Hall – Yes, I understand you’re a staunch supporter of Dr Tuteur and share many of her views regarding the controversial subjects she likes to post about. If Dr Tuteur wants to be treated with respect, she can start by extending the same respect to others. Instead, she indulges in ad hominem attacks and irrelevant accusations (not only directed at posters but also other scientists) that have absolutely no grounding in evidence. She has a tendency to infer things then claim she never said them, or to not consider the context and then misrepresent something by ignoring the context – it’s dishonest and she’s already been called on it in this thread. You may not have noticed but even some of the other SBM bloggers have questioned Dr Tuteur in this thread. I’m sorry if criticisms of Dr Tuteur are personalized for you because you share some of the same views. You seem very invested, are you the one who proposed she would make a good blogger for SBM or is it just because you share her perspective?

  47. David Gorski says:

    I do not see any evidence of such prejudice or bias in anything Dr. Tuteur wrote. What is regrettable is not what she wrote, but the fact that you are imagining she wrote things that she didn’t and that you are personally attacking her for something she didn’t do.

    Quite frankly, the only problem I saw in what Dr. Tuteur wrote was her implying cherry picking of studies by the meta-analysis authors based on her apparently being unaware of a form of meta-analysis that requires patient-level data. I’ve already made my criticism explicit, called her out on it, and am done. I don’t want to rehash that whole issue again.

    Otherwise, I agree for the most part with Dr. Tuteur’s contention that the authors of this particular meta-analysis went too far in their public statements about their study.

  48. Fifi says:

    Dr Gorski – “I agree for the most part with Dr. Tuteur’s contention that the authors of this particular meta-analysis went too far in their public statements about their study.”

    They may well have but certainly no further than pharmaceutical companies have gone in their public statements endorsing SSRIs outside of evidence.

    Ben Goldacre’s take on the issue which put this kind of meta-analysis into the context of the broader evidence and debate, including the attempts by drug companies to bury or manipulate evidence, is an example of good SBM writing and analysis. Taking one meta-analysis out of context of the greater debate is, in many ways, cherrypicking.

    http://www.badscience.net/2008/02/619/

    If Dr Tuteur merely wanted to discuss the media aspect of this, she’s also cherrypicking one NYT’s article while ignoring another which actually is critical of the study.

    http://www.nytimes.com/2010/01/12/health/12mind.html

    If Dr Tuteur is going to call out others on being irresponsible, cherrypicking or promoting a professional bias, then why shouldn’t she also be called out on doing the same thing? Dr Tuteur isn’t simply questioning the study in her post, she’s inferring that the study is psychiatry bashing when she’s actually misrepresenting psychiatric practices herself by promoting the idea that psychopharmacology is the only effective tool used by psychiatrists. She’s also misrepresenting psychology because many psychologists do work in tandem with GPs and psychiatrists to prescribe drugs.

  49. David Gorski says:

    Dr Tuteur isn’t simply questioning the study in her post, she’s inferring that the study is psychiatry bashing when she’s actually misrepresenting psychiatric practices herself by promoting the idea that psychopharmacology is the only effective tool used by psychiatrists.

    Straw man.

    Where on earth did you get that idea? I criticized one aspect of the post, and even I didn’t see that as a problem. Dr. Tuteur never said any such thing, as far as I can see.

  50. Harriet Hall says:

    Fifi has chosen to interpret my comments as biased. Instead of understanding my plea to avoid ad hominems and stick to discussion of content, she just indulges in more ad hominems, now also directed at me. I am not “invested” in anything except science and reason. And polite discussion and fair treatment. I don’t agree with everything Dr. Tuteur says, and I second Dr. Gorski’s comments, but I think Dr. Tuteur has been attacked unfairly.

  51. Fifi says:

    Oh please, first she infers that the psychologists who did the study have a professional bias (without providing any evidence), then she says that “to the extent that talk therapy of any kind works” which infers that cognitive and interpersonal therapies work to a questionable or limited extent. And yet she’s getting outraged that anyone is questioning the extent to which SSRIs work, when there really isn’t solid evidence that risk outweighs harm when it comes to using SSRIs for mild depression. (See Ben Goldacres analysis for a more evidence based assessment that Dr Tuteur’s.)

    Dr Gorski – “Certainly that’s how I interpreted it, namely that Dr. T was assigning nefarious motives to the researchers with regard to how they designed the study, although I agree with her that in their public statements they went beyond what the study could justify.”

    And, really, accusing me of being a dualist and lecturing me about the physical effects of cognitive and interpersonal therapy on neurobiology when I was the one that introduced that information to the thread in the first place is being deceptive and yet another example of how she tries to paint anyone who doesn’t agree with her or who critiques her posts as being some kind of woomeister. It’s particularly galling considering the fact that she’s not even standing up for SBM in psychiatry!

  52. micheleinmichigan says:

    Fifi on 08 Feb 2010 at 12:15 pm

    michele – The nature vs nurture debate is pretty much dead in the water at this point for the most part, it’s quite widely accepted that both nature AND nurture are involved in brain development…that’s what neuroplasticity is all about. The field of epigenetics is very specifically about nature and nurture.

    Hmmm, if you were a parent dealing with any sort of behavior, learning or mood issue with your child, I would guess that you would soundly disagree that the nature vs nurture debate was pretty much dead. :)

    In fact as a parent of two children who lived in orphanages for the first 1-2 years of their lives as well as a child born with congenital differences, I would say there is still a lot to be discovered or discussed about the interplay between genetics and environmental factors (prenatally as well as throughout life).

    Would I defend a a position that say things are all genetic or all environment. Nope, but that is not what interests me. What interests me is picking out where the interdependencys are and using that to solve problems.

  53. BillyJoe says:

    Fifi

    “BillyJoe, I’m not sure if you’re joking or not. I’m hardly a dualist and it’s not a dualist position to propose that the brain is shaped by our thoughts and actions.”

    I was not joking.
    But I was commenting on Lawrence’s retort to Amy, not on anything you said. Here, again, are the quotes I was responding to:

    Amy said: “To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.”

    Lawrence said: “It’s especially unfortunate to see, in that last quoted sentence, a declaration of ignorance and an assertion of absolute certainty derived from that ignorance.”

    See, you are not mentioned anywhere!
    I agree that neuroplasticity is not a dualist position.
    But what Lawrence said suggests that he is a dualist. At least I don’t know how else to interpret it. Whether he is or he isn’t, I suppose he will come back and justify his retort.

  54. Fifi says:

    michele – “In fact as a parent of two children who lived in orphanages for the first 1-2 years of their lives as well as a child born with congenital differences, I would say there is still a lot to be discovered or discussed about the interplay between genetics and environmental factors (prenatally as well as throughout life).
    Would I defend a a position that say things are all genetic or all environment. Nope, but that is not what interests me. What interests me is picking out where the interdependencys are and using that to solve problems.”

    I agree, there’s certainly still a lot to be discovered regarding what is genetic and what is environmental when it comes to brain development (and associated issues such as behavior, personality, etc). My point was merely that we’re well beyond the point where anyone proposes that brain development is purely based in nature or nurture, the scientific understanding at this point is that both play a role.

    BillyJoe – You may be right about Lawrence, I have no idea. I’ll admit that I was pretty pissed at being accused of being a dualist and proposing some kind of magic when I’d introduced the neurobiological effects of cognitive and interpersonal therapies up thread. Because Dr Tuteur seemed to be aiming the slur in my direction, I obviously personalized your response to Lawrence. My apologies.

  55. BillyJoe says:

    Fifi,

    I have to agree with some of the comments about you by others, but I sort of understand. Like you, I also tend to read too much into what Amy writes and assume things she hasn’t actually said. I think this could be corrected somewhat if she would place her comments in the context of her general thoughts on the subject so that we know where exactly she is coming from. However I have now made allowances for this and don’t assume anything about her views unless and untill she specifically gives voice to them. I’m actually suprised at how often I agree with her compared with my initial impressions. My remaining slight irritation is that she tends to try to explain away or gloss over mistakes instead of acknowledging them outright, but I guess we are all quilty if that to a greater or lesser extent.

    regards,
    BillyJoe

  56. Fifi, to restate my comment upthread:

    I can’t figure out what you’re trying to say. Amy says the brain is a physical organ, so any effective treatment for depression, no matter what it is, produces its effects by modifying the brain. She specifically says that talk therapy works. “To the extent that talk therapy of any kind works, it works through biochemical processes.” If you aren’t a dualist, what exactly are you arguing with? If you aren’t claiming that talk therapy works by magic, or through the mediation of the soul, but you disagree that it works through biochemical processes, I don’t understand what you’re saying. Are you saying that neuroplasticity isn’t biochemical?

  57. Fifi says:

    BillyJoe – What Dr Tuteur does is infer things and then deny them, it’s a very common tactic used by people who promote woo. (We saw lizkat doing that repeatedly regarding HIV.) The fact that Dr Tuteur then tries to explain away or gloss over things when she makes a mistake or is called on a bias seems highly problematic to me on an SBM blog. (Just as the way she begrudgingly acknowledged that cognitive and interpersonal therapies have a biological effect eventually is problematic because of the way she did so.) After all, isn’t it central to science and discussion of science to be able to admit a mistake or a bias when it’s pointed out? Needing to be right at all costs or pretending to know everything is the realm of ideology and not science.

    Yes, I’ve developed a very strong aversion to Dr Tuteur and the way she tries to use SBM without actually respecting SBM. If she didn’t use the tactics mentioned above, I wouldn’t feel the need to point them out or discuss how they get in the way of promoting SBM and engendering public trust of science and medicine. It’s a shame because there really aren’t that many good sites to send people to as reliable sources of good information regarding medical science. I guess I’ll stick with going off continent to Ben Goldacre and other writers who are actually interested in educating the public and promoting good science.

  58. Lawrence C. says:

    BillyJoe,

    I’m not sure I am clear on what you mean by “dualist.” Would you kindly provide a working definition in context?

  59. Fifi says:

    Alison – What she does is concedes, very after the fact and long after it was first raised, that talk therapy works and has a neurobiogical effect (or might work a little bit is what her phrasing really infers). She does so in the context of accusing me of being a dualist for bringing up cognitive and interpersonal therapies as being effective means to treat depression alongside drugs. Yes, she’s finally agreeing with me but is doing so in a way that makes out that she’s introducing this information and that I didn’t! And then goes on to accuse me of proposing that talk therapies are somehow magical and I’m a dualist! In light of the fact that she inferred in the original post that psychotherapists – who practice talk therapies – skewed the meta-analysis results out of some kind of professional competition with psychiatrists, it’s a bit late in the game to try to backpedal and pretend she’s not actually working from a biased perspective. On top of it, it’s just plain silly since psychiatrists also use talk therapies in their practices and also question the actual efficacy of SSRIs (particularly in light of how how drug companies keep getting caught misrepresenting the evidence and how heavily they promote this pseudoscience to the media).

  60. “I think this could be corrected somewhat if she would place her comments in the context of her general thoughts on the subject so that we know where exactly she is coming from.”

    I shared my general thoughts on this subject up thread:

    It seems to me that the data in total indicate that treatment of depression (whether mild, moderate or severe) needs to be individualized. Moreover, the combination of both modalities (talk therapy and medication) can be more effective than either alone.

    Trying to decide which modality is “more” effective strikes me as making as much sense as trying to decide whether diet and exercise vs. insulin is more effective in treating type I diabetes. Both are integral components of care, and, as in the case of depression, the relative contribution of each modality is highly dependent on the individual and his or her clinical situation.

  61. Fifi,

    “She does so in the context of accusing me of being a dualist for bringing up cognitive and interpersonal therapies as being effective means to treat depression alongside drugs.”

    You really need to get a grip. I was never referring to you in my comments about neurochemistry; I was responding to Lawrence C. and did not have you in mind at all.

    Perhaps this can be a lesson to you. You read far too much into my writing, going so far as to imagine that I am criticizing you when I am quoting someone else and addressing his comment.

  62. micheleinmichigan says:

    # Fifion 08 Feb 2010 at 3:08 pm

    “Oh please, first she infers that the psychologists who did the study have a professional bias (without providing any evidence), then she says that “to the extent that talk therapy of any kind works” which infers that cognitive and interpersonal therapies work to a questionable or limited extent.”

    Well the common quoted statistic on CBT and SSRI for depression are CBT success rate 50% of the time, SSRI 50% of the time, Combination of the two 90 -100 %. I don’t know the study or the data, that is just the statistics I always see in articles or news.

    To be fair, Dr. T. comment did follow a discussion of the pros and cons of CBT and how some people do not see good results with it (50% of them I presume) So, within the context of that discussion I think that is a fair sum up of CBT. I did not take it as a “tell” that she thought it didn’t work. The phrase allows that it does not work for some.

    In conclusion, it is hard to have a real discussion on any topic when the subtext is “proving Dr. T is bad.”

  63. micheleinmichigan says:

    #
    # Lawrence C.on 08 Feb 2010 at 4:07 pm

    BillyJoe,

    I’m not sure I am clear on what you mean by “dualist.” Would you kindly provide a working definition in context?

    Thank you! I have no idea what that means either. Is it another word for gunslinger?

  64. Lawrence C. says:

    Dr. Teuteur:

    Then let me be clearer since my earlier remark seems to have produced a tangent and an injured bystander.

    I have no objection at all to the scientific description of the functioning of the human brain (and nervous system) on a physical level, but I would maintain that to take consciousness as being limited to that physical mechanism is a metaphysical belief, rather than a scientifically proven fact.

    Neurobiology is a very young field of study and while most promising it does not itself make the absolute claims you asserted in this post. To be fair, the assertions seem more like general comments than germane points. Such is the delight and peril of the blog.

  65. “I would maintain that to take consciousness as being limited to that physical mechanism is a metaphysical belief, rather than a scientifically proven fact.”

    What support do you have for that claim?

  66. micheleinmichigan says:

    Alison
    “1) Thoughts most certainly can affect organs other than the brain. For instance, one effect of chronic stress is hypertension. ”

    Also, I think stress is believed to induce flare-ups in most auto-immune disorders. Type 1 diabetes is a autoimmune disorder.

  67. Fifi says:

    Dr Tuteur – That’s a much more reasonable position than you expressed in your original blog post. If you’d actually included that in your original post – rather than inferring (intentionally or accidentally) that there were nefarious intentions on the part of the psychologists who performed the meta-analyis there would have been no need for anyone to call you out for doing so.

    Dr Tuteur – “Trying to decide which modality is “more” effective strikes me as making as much sense as trying to decide whether diet and exercisevs. insulin is more effective in treating type I diabetes.”

    Why? Isn’t the whole point of SBM to discern what treatments are effective and which ones aren’t? Certainly in a clinical context of individual treatment it’s about the individual but that’s not what clinical trials focus upon, they’re not an N of 1. Are you proposing that it’s futile to conduct clinical trials? Or should we be acknowledging the complexity of depression and treating depression and taking this into account (and the heightened influence of the placebo effect) when we design clinical trials? After all, if an SSRI does prove to provide no more help than a placebo in mild depression, isn’t it bad medicine and not SBM to promote their use?

  68. Fifi says:

    Um, Dr Tuteur you were responding to Lawrence here, why did you start out quoting me?

    10 at 1:34 pm
    “And, no, depression isn’t “just like diabetes” since depression involves both the body and mind …”
    Yes, it is just like diabetes in that both have a biochemical basis. Although depression involves the “mind,” the mind is nothing more than a bunch of biochemical processes. There is no magic to the mind, and no special “essence.”
    To the extent that talk therapy of any kind works, it works through biochemical processes. We don’t know what those processes are, but there is no doubt that it all comes down to biochemistry.

  69. Lawrence C. says:

    What support do you have for that claim?

    The entire copus of neurobiological literature. In that ink-wet body, some things are apparently understood, much is hypothesized, and speculation of all kinds runs rampant. It is obvious that most ideas have not been proven as fact. It would be tempting to take current, exciting trends in this field and derive certainty from them but that would be a belief rather than a logical conclusion.

    In the context of this post and also something you might appreciate, one need only look at the physician’s prescribing information for SSRI’s. Almost without exception, the language used to describe the mechanism of action of each drug goes like “It is presumed that…” or “It is supposed that…” or even “It is believed that…” This is hardly the language of certainty, and even goes to support your point here that the authors of the study in question really did reach an unsustainable conclusion.

    Incidentally as regards some of the other comments, I am not advocating nor saying “Look, Magic!” As one kind of example, in terms of what is generally referred to as “matter,” medical science usually deals with it on the gross level. It is quite theoretically possible that what we call “mind” or “consciousness” exists on the quantum level. Such an existence would certainly seem “magical” to many people but I am hopeful that science will provide greater insight into this “matter.”

  70. “The entire copus of neurobiological literature.”

    That’s not an argument. You’ll have to do better than that if you want to persuade us to accept your claim.

  71. Danio says:

    @Lawrence:

    I have no objection at all to the scientific description of the functioning of the human brain (and nervous system) on a physical level, but I would maintain that to take consciousness as being limited to that physical mechanism is a metaphysical belief, rather than a scientifically proven fact.

    And you have just defined ‘dualism’ for yourself, by supposing that mental functions (i.e. consciousness) are in some way non-physical.

    I, on the other hand, would maintain that to take consciousness as NOT being limited to the functions of the brain is a metaphysical belief, and that it is contingent upon those (such as, it would seem, yourself) who believe otherwise to provide support for this claim. Occam’s Razor and all that, you know.

    @Fifi–
    For what its worth, I read your statement:

    And, no, depression isn’t “just like diabetes” since depression involves both the body and mind, and is diagnosed using subjective measures.

    as dualist-ish, in that you seemed to be making a distinction between the body and the mind. I do, however, agree with what I think you were driving at, to wit that, although there are numerous examples of psychological effects on all manner of physical illnesses, mental illness as a freestanding complaint (rather than as a symptom of another physical ailment like cancer) seems uniquely reliant upon subjective reporting and/or assessment of behaviors and feelings to diagnose.

  72. apteryx says:

    Logically, no. Lawrence C. is addressing the commonly held opinion that the mind is nothing more than an emergent property of complex biochemical processes (which, IMHO, does not exclude the capacity for voluntary action, although some uglier formulations of the hypothesis have suggested that mind is a useless epiphenomenon). He is not claiming to know that this belief is wrong – if he were, then it would be his job to supply evidence . He is only claiming that neuroscience assumes this to be a fact but has not yet proven it. If you think that this has been scientifically proven, it is for you to supply, at least, a reference to a review publication. (The fact that you can’t, presuming you can’t, is no evidence that some form of the hypothesis isn’t true. Something can be very likely, and yet very hard to prove. However, if we are told that we must believe it despite the absence of proof, it starts to look a lot like a religion….)

  73. apteryx says:

    Sorry, that was for Dr. Amy.

  74. “He is only claiming that neuroscience assumes this to be a fact but has not yet proven it. If you think that this has been scientifically proven, it is for you to supply, at least, a reference to a review publication.”

    No, the burden of proof is his. He is the one claiming that the function of the brain involves processes that differ from the biochemical basis of every other bodily function.

  75. apteryx,

    I read it the other way around. You can’t prove a negative, so Amy can’t prove that a non-physical soul does not exist.

    The opposite is possible, though. Someone who believes in a non-physical soul just has to prove its existence and all but a few contrary denialists will accept the evidence. Simple!

    I am a frank dualist myself. My argument is ignorance: I don’t understand what it means to be me… therefore it must be teh Solz! I know this is a risible argument, never fear. Occam’s razor states that an explanation must be the simplest one that explains the evidence, and no simpler. From ignorance I assert that biochemistry is too simple an explanation for my me-ness, but since a posited non-physical soul cannot generate hypotheses it’s a pointless concept. Certainly it adds exactly nothing to any discussion of practical problem-solving of any kind, so in a clinical context (and almost any other context I can think of) Occam decrees that no, there is no non-physical soul. Whether you think there might be one or not, for practical purposes there is not. Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.

  76. micheleinmichigan says:

    “And you have just defined ‘dualism’ for yourself, by supposing that mental functions (i.e. consciousness) are in some way non-physical.”

    Sadly that is no where near as exciting as Val Kilmer rendition of Doc Holliday in Tombstone. “I’ll be your huckleberry”My very favorite dualist.

  77. micheleinmichigan says:

    “Whether you think there might be one or not, for practical purposes there is not. Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.”

    That is pretty much were I ended too. I don’t need proof regarding a non-physical souls existence or non-existence. I only need to know why it would matter in terms of the current problem. Unless someone shows me how, it doesn’t matter.

  78. Lawrence C. says:

    Apteryx’s post at time index 5:50 pm is what I was aiming at and I thank Apteryx for putting it in clearer terms than I was using.

    He is only claiming that neuroscience assumes this to be a fact but has not yet proven it.

    That’s it. Full-stop.

  79. BillyJoe says:

    Laurence said: “I’m not sure I am clear on what you mean by “dualist.” Would you kindly provide a working definition in context?”

    A materialist assumes that everything is physical.
    A dualist believes that, as well as the physical, there is also the non-physical (or immaterial, or spirit).

    michelleinmichigan said: “Thank you! I have no idea what ["dualist"] means either. Is it another word for gunslinger?”

    Yes….without bullets! :D

    Lawrence said: “I would maintain that to take consciousness as being limited to that physical mechanism is a metaphysical belief, rather than a scientifically proven fact.”

    It is neither.
    In fact, it is the underlying assumption of science that only the physical exists and the proof is a work in progress.

    Lawrence said: “I am not advocating nor saying “Look, Magic!””

    If you assume anything other than the physical, yes you are.

    ” As one kind of example, in terms of what is generally referred to as “matter,” medical science usually deals with it on the gross level. It is quite theoretically possible that what we call “mind” or “consciousness” exists on the quantum level.”

    But quantum objects are physical objects.

    “Such an existence would certainly seem “magical” to many people but I am hopeful that science will provide greater insight into this “matter.””

    Lots of physical or material things seem magical, but the underlying assumption is that they are not. So far, nothing has turned up to invalidate that assumption.

    apteryx said: “Lawrence…is only claiming that neuroscience assumes this to be a fact [that the mind is nothing more than an emergent property of complex biochemical processes] but has not yet proven it. If you think that this has been scientifically proven, it is for you to supply, at least, a reference to a review publication.”

    Not only neuroscience, but the whole of science, is predicated on the assumption that everything is physical. Physical objects cannot interact with the non-physical, so that puts the non-physical outside the scope of science. And that is why science assumes that everything is physical. So far nothing has appeared to challenge or invalidate that assumption.
    The corollary is that once you resort to non-physical explanations, you are no longer doing science.

    Lawrence said: “Apteryx’s post…is what I was aiming at and I thank Apteryx for putting it in clearer terms than I was using.
    He is only claiming that neuroscience assumes this to be a fact but has not yet proven it. That’s it. Full-stop.”

    Science is a work in progress and so far that assumption has held up. On the other hand, as soon as you assume the non-physical, that’s when you come to a grinding fullstop.

  80. Plonit says:

    Should “physical” be understood to be identical with “biochemical”? In every instance? Or simply in relation to this instance (discussion of brain/mind)?

  81. micheleinmichigan says:

    Plonit on 09 Feb 2010 at 6:04 am

    Should “physical” be understood to be identical with “biochemical”? In every instance? Or simply in relation to this instance (discussion of brain/mind)?

    I was thinking the same thing myself. But I came to the conclusion that biochemical is such a broad term I think it would be quibbling to take exception with it without stating the particular physical attribute that one is reffering to.

    Electrical? but I think that would be included in chemical. Magnetic? Honestly, my human biology is so sketchy I can not make a credible suggestion.

  82. Plonit says:

    I would think those biophysicists who are not biochemists would be pretty pissed off to think that the former could be reduced to the latter. Electrophysiology is quite an important area of neuroscience (but not only neuroscience). We don’t completely know how the brain works, but from what we know we can certainly say it is not ALL biochemistry without any recourse to belief in non-physical entities.

  83. “Should “physical” be understood to be identical with “biochemical”?”

    No. It’s meant to exclude anything that cannot be apprehended with our five sense; in other words, it’s meant to exclude “life forces,” souls, and other spiritual concepts.

  84. apteryx says:

    Yes, the methods of science can only deal with physical things; that doesn’t prove that all things are physical, although it is fine to operate on the assumption that they are in order to work on the things you can work on, so to speak. The range of phenomena in the physical universe that can be perceived and explored has increased greatly, and I wouldn’t assume that we have reached the theoretical limit.

    I may have too generously, or broadly, represented the non-dualist position in saying that they think mind is an emergent property of chemistry. That’s actually my own opinion. I don’t believe I have an “immortal soul,” but I do think that we (and other complex animals) have a capacity for voluntary, deliberate decision-making, and that our emotional lives represent something more than meaningless neuron-firing.

    Some reductionists deny those things, which suggests that they think there are no emergent properties, and we’re just a slightly more complex version of the chemical soup that makes up a nematode’s “mind.” Those individuals argue that anything we perceive as deliberate choice, for example, is really the operation of a carbon-based mechanism over which “we” (the very concept of selfhood then being problematic) have no control. And we are supposed to believe this because they are sure neuroscience will prove it any decade now. Well, that’s not how it works. Proof comes first; belief follows.

  85. Plonit says:

    It’s meant to exclude anything that cannot be apprehended with our five senses

    ++++++++++

    Ermm, oh dear.

    There is quite a lot of scientific discoveries that cannot be apprehended directly by the physiological senses (which I assume you know number far more than five) but are surmised by our “sense of logic” on the basis of sensory input concerning their effects.

  86. micheleinmichigan says:

    # Ploniton 09 Feb 2010 at 8:31 am

    “I would think those biophysicists who are not biochemists would be pretty pissed off to think that the former could be reduced to the latter. Electrophysiology is quite an important area of neuroscience (but not only neuroscience). ”

    Yup, I’m always irritating those biophysicists. They give me no end of trouble.

  87. micheleinmichigan says:

    # apteryx on 09 Feb 2010 at 10:14 am

    “Those individuals argue that anything we perceive as deliberate choice, for example, is really the operation of a carbon-based mechanism over which “we” (the very concept of selfhood then being problematic) have no control.”

    I’m going to haul this back to CBT. One method of CBT for OCD (obsessive compulsive disorder) is to increase the awareness that the obsessive thoughts and the need for compulsive behavior are not generated by the individuals mind (as it feels), they are generated by a flawed mechanism in the brain.

    So, someone with OCD feels that it is unsafe to leave the house without checking the door. If they feel that way, it must be unsafe and therefore good to check the door. The understanding that the feeling is not a true signal of danger but a misfired habitual brain mechanism can be helpful in breaking the OCD cycle.

    I think this is not a great explanation. For a better explanation check out the book Brain Lock by Jeffrey M. Schwartz.

  88. BillyJoe says:

    Amy said: “It’s meant to exclude anything that cannot be apprehended with our five senses”

    Plonit replied: “There is quite a lot of scientific discoveries that cannot be apprehended directly by the physiological senses (which I assume you know number far more than five) but are surmised by our “sense of logic” on the basis of sensory input concerning their effects.”

    If Amy is actually saying anything different I would be quite surprised. The clue is in the length of her sentence compared with the length of your reply.

  89. daedalus2u says:

    Michelle makes a good point, in OCD, there is a “feeling” that one is unsafe without checking the door. The feeling is a real feeling, but the feeling does not correspond with the objective reality of safety regarding door checking.

    This is a generic problem when we rely on “feelings” for input to how we should think or act.

    The feeling is a physiological signal indicating a physiological state and the brain has evolved to take such signals seriously because at times they can be the difference between life and death.

    Many people use their intellect to match their world view to how they feel. Skeptics use their intellect to match their world view with reality independant of how they feel.

  90. Fifi says:

    Danio – “As dualist-ish, in that you seemed to be making a distinction between the body and the mind. I do, however, agree with what I think you were driving at, to wit that, although there are numerous examples of psychological effects on all manner of physical illnesses, mental illness as a freestanding complaint (rather than as a symptom of another physical ailment like cancer) seems uniquely reliant upon subjective reporting and/or assessment of behaviors and feelings to diagnose.”

    There is a distinction to be made between the brain and the mind, they’re just not independent and one is an organ and the other is a product of that organ (well, I suppose we could argue that a dead brain can’t create mind so exists apart…but since we’re discussing living human beings let’s stick with the idea that brain and mind are interrelated – um, silly experiments with dead salmon aside ;-). The mind is the product of the brain, it’s how we experience all those neurochemical events and the illusion that is “me” that helps us navigate the world (and creates all kinds of narratives to allow us to do so, the brain is a meaning machine). That doesn’t in any way mean that the mind can exist without the brain and I in no way am proposing that and never have been.

    My point was that there’s a special relationship between what we experience as our mind and the organ that we call the brain which generates the experience of mind. We can change the actual structure of our brain by how we use our mind – this is a direct influence of a much larger magnitude than changing stress responses which, as a side effect, may influence other organs and systems (not that anything in the body works in isolation, of course).

    A better example than diabetes is cancer. We can’t cure cancer simply by using our thoughts – as much as woomeisters like to promote that idea. Certainly we can change stress responses through being mindful and that can have all kinds of positive or negative effects on health as a result, that’s more of a side effect than a main effect. We can’t just think away diabetes – or a brain tumor for that matter. There are limits to the ability of our mind to influence our brain structure too, we just don’t know what they are yet.

    I’m by no means saying anyone shouldn’t use drugs if they need to or want to (be that for health or recreational purposes, I’m not opposed to people chemically engineering their intelligence…what people do with their brains is their own business in my opinion). Or use other treatments like deep brain stimulation (which some people find much more effective than pharmaceuticals for severe depression).

    Mental illness is diagnosed on two subjective measures – how the patient feels (their experience of themselves and life) and how they function within society (also not a purely objective measure by any means). The same is true of chronic pain. At the moment, there are no viable objective physical tests to diagnose either. There are for diabetes and cancer. Also, cancer and diabetes aren’t diagnosed regarding how we relate to other people or function in society – there’s no social or cultural component vis a vis the diagnosis. There most definitely are regarding depression and chronic pain (at this point in time). Mental illness is much more complex than cancer or diabetes because it does have cultural and social components, it’s not just about the individual but how the individual feels and functions in their social environment.

    It IS tempting to try to reduce mental illness to being merely a brain problem or a chemical imbalance for many reasons (one being that it gives us a sense of control, us humans like that). However it really is missing the bigger picture and ignoring the very basic fact that we’re social animals. We’re just apes, as much as we cling to (mainly religious) ideas of being incredibly different from other animals and special. One function of our brain is to create a mind that perceives us as being important in our own right, as having a heroic narrative and cosmic meaning/significance. It’s really an illusion – the universe doesn’t care (it’s not human), only we care about humans, our place in the universe and finding meaning. It’s this desire for meaning that tends to cause us existential angst when we can’t find any. Isn’t a major component of depression a loss of sense of meaning and purpose, a loss of appreciation of life and joyous experience?

  91. Fifi says:

    BillyJoe – “If Amy is actually saying anything different I would be quite surprised. The clue is in the length of her sentence compared with the length of your reply.”

    She may MEAN the same thing but what she’s saying is what she’s saying. We use the scientific method explicitly so we’re not just relying upon our “five senses” (which are a very subjective).

  92. Fifi says:

    Alison – “Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.”

    Since when is talk therapy and psychiatry not part of medicine? (Talk therapy is actually a bit of a misnomer, cogntive behavioral therapies and interpersonal therapies are more accurate terms since there’s not alway a lot of talking with CBT.) Biochemistry is part of an explanation for the treatment of depression with CBT and interpersonal therapies, it’s by no means really a complete explanation (and by this I’m not talking about magic or denying the biochemical component, I’m just pointing out that there are social, interpersonal and cognitive components that need to be considered to for any explanation to be adequate and complete).

  93. BillyJoe says:

    apteryx,

    “Yes, the methods of science can only deal with physical things; that doesn’t prove that all things are physical”

    No, it is an assumption that has, so far, stood the test of time.

    “…although it is fine to operate on the assumption that they are in order to work on the things you can work on, so to speak.”

    Exactly. Making that assumption is the basis of science that has allowed scientist to find things out instead of wallowing in ignorance.

    “The range of phenomena in the physical universe that can be perceived and explored has increased greatly, and I wouldn’t assume that we have reached the theoretical limit.”

    We certainly haven’t, and we probably never will. The uiniverse may end too soon. The human mind may be incapable of understanding everything (maybe to the same degree that an ant is incapable of understanding quantum physics). But it is the only way to learn anything.

    “I may have too generously, or broadly, represented the non-dualist position in saying that they think mind is an emergent property of chemistry.”

    That’s about right I would have thought.
    And chemistry can be defined as physics plus emergent properties.

    “I don’t believe I have an “soul,” but I do think that we…have a capacity for voluntary, deliberate decision-making, and that our emotional lives represent something more than meaningless neuron-firing.”

    (I have reduced your “immortal soul” to “soul”, but if it makes a difference I apolgise.)
    It requires cognitive dissonance to hold those two views simultaneously. The “self” does not exist in science. It is a metaphysical concept like the “soul”. What exists is an “illusion of self”, but the illusion is so good that the “self” really does believe it exists. Unfortunately, it is just the physics and chemistry and biochemistry and paterns of neural firings of the brain that produces this illusion of self.

    “Some reductionists deny those things, which suggests that they think there are no emergent properties”

    I don’t think there are many reductionists of that type. The existence of emergent properties are undeniable. The assumption remains, however, that they are physical. As long as we keep assuming that, we may make progress. To assume anything else is to continue to wallow in ignorance.

    “Those individuals argue that anything we perceive as deliberate choice, for example, is really the operation of a carbon-based mechanism over which “we” (the very concept of selfhood then being problematic) have no control.”

    They are correct. That is the view of science, that is to say, that is what the scientific evidence says. Some of us just don’t like to outrun the evidence, we leave that to people of faith.

    “And we are supposed to believe this because they are sure neuroscience will prove it any decade now. Well, that’s not how it works. Proof comes first; belief follows.”

    No, that is not correct. We are not sure that it will be proved. We believe that this is the only way forward. To assume that everything is physical is the only way forward. And we are sure of this belief of that because the evidence for it is incontrovertible.

    regards,
    BillyJoe

  94. micheleinmichigan says:

    “Many people use their intellect to match their world view to how they feel. Skeptics use their intellect to match their world view with reality independant of how they feel.”

    Yes and I know this is beside your point but I want to be clear that the majority of skeptics have never had to cope with the symptoms of OCD and that being skeptical is only one fraction of the CBT treatment of OCD.

    In other words, I don’t want to be dismissive of OCD as only being a condition of trusting your feelings non-skeptically. It is much more complex than that.

    In fact, the hallmark of OCD (as opposed to OCPD) is that people have self-awareness of the problem. So they are questioning their anxiety, they just do not have the tools to free themselves.

  95. Alison – “Biochemistry is a fully adequate explanation of the treatment of depression with medical or talk therapy.”

    Since when is talk therapy and psychiatry not part of medicine?

    The word ‘medicine’ can mean a lot of different things in different contexts. Here I meant drug therapy as opposed to, for instance, surgical therapy. Feel free to substitute ‘drug therapy’ for ‘medical therapy’ if it helps you understand my meaning.

    (Talk therapy is actually a bit of a misnomer, cogntive behavioral therapies and interpersonal therapies are more accurate terms since there’s not alway a lot of talking with CBT.)

    Fifi, give me a correct word or short phrase that groups together all those therapies that use some form of communication as the intervention (as opposed to, say, drugs, surgery, radiation or lifestyle modification) and I’ll use it. I am trying to be general here. I don’t want to have to say “Biochemistry is a fully adequate explanation of the treatment of depression with drug or [long and exhaustive list of every single school of psychological intervention that has ever existed] therapy” to make a simple point.

  96. Fifi says:

    Alison – Um, you used the term “medical” – it covers all kinds of medical treatments and procedures, not just drugs. Surgery, physiotherapy, psychotherapy and drugs are all “medical”. It’s good to understand what a word means so as to avoid creating misunderstandings. “Medical” is not equivalent to “medicine” as it is used when it refers to drugs. You inadvertently claimed that psychiatry isn’t medical so ended up saying something other than you apparently intended.

    Sometimes trying to be simplistic or to generalize actually confuses things and misses the point when something actually has a slightly higher level of complexity. It can create more confusion to try to pretend something that has a level of complexity is simple or to generalize where there is actually a need for specificity. Prescribing drugs also requires communication between patient and doctor. What you don’t seem to understand is that CBT and interpersonal therapy work quite differently, CBT doesn’t even always involve much talking (the vast majority of the work in many cases is done by the patient outside of meeting with the therapist). If you don’t really understand what you’re talking about, you’re not really making a point (simple or otherwise) – you’re offering up an uninformed opinion about something you don’t actually understand. You’re entitled to your opinion, of course, but the fact that you don’t seem to understand the different between CBT and interpersonal therapy (and think you need to list every single form of psychological intervention) simply means you don’t understand what you’re talking about enough to know whether biochemistry is an adequate explanation or not.

  97. micheleinmichigan says:

    Sometimes trying to be simplistic or to generalize actually confuses things and misses the point when something actually has a slightly higher level of complexity.

    Hemingway and e.e. cummings are not simple. They just used fewer words. Sometimes you have to assume the reader is bright and will figure it out.

  98. Surgery, physiotherapy, psychotherapy and drugs are all “medical”.

    Yes, in many/most contexts you are absolutely correct.

    “What you don’t seem to understand is that CBT and interpersonal therapy work quite differently.”

    You will be happy to learn that I understand that very well, which is why I was so frustrated when I sought CBT and was offered some other school of something. But they have more in common with one another (both can be offered outside a medical practice by non-medical person; the non-medical person who offers them is often a clinical psychologist; neither directly modify the body or its function) than they do with drugs or surgery.

  99. Fifi says:

    michele – “Hemingway and e.e. cummings are not simple. They just used fewer words. Sometimes you have to assume the reader is bright and will figure it out.”

    They wrote fiction, they weren’t trying to communicate facts – there’s a very big difference. If you intend to say one one thing but use words that have a different meaning than what you intend to communicate, you’re actually saying something other than you intended (this is as true of fiction as it is non-fiction, it just doesn’t matter as much if one is constructing an imaginary world as it does when one is trying to accurately discuss or describe the real world). The fault doesn’t problem doesn’t lie with the reader in this case, it lies with the person doing the writing or speaking who doesn’t actually know what they’re saying. Really, saying or writing what you actually mean is communication 101. In medicine it’s particularly important for a wide variety of reasons – people can die if a doctor gets it wrong, for instance. (Obviously not the case here regarding Alison’s slip up – which is hardly the end of the world but it does raise questions if she just doesn’t quite understand what she’s talking about or if she’s expressing a subconscious belief that psychotherapy isn’t a part of medicine and a medical treatment.)

  100. micheleinmichigan says:

    “but the fact that you don’t seem to understand the different between CBT and interpersonal therapy (and think you need to list every single form of psychological intervention) simply means you don’t understand what you’re talking about enough to know whether biochemistry is an adequate explanation or not.”

    IMO – I don’t understand the need for this attack. It is downright ungracious. I think it should be possible to have a cordial disagreement without trying to make out that another commenter doesn’t know what they are talking about. Particularly over the use of one word or an innocuous phrase.

    Really, FiFi – If you throw every pitch directly at the batter’s head, the game is no fun.

    Alison said – “But they have more in common with one another (both can be offered outside a medical practice by non-medical person; the non-medical person who offers them is often a clinical psychologist; neither directly modify the body or its function) than they do with drugs or surgery.”

    Yes they do have a lot in common. In fact two of the three therapists I saw used techniques from both CBT and IPT to address different problems. It is all psychotherapy, which I think can be called talk therapy in the vernacular (I’ve always wanted to used that word.)

    The relationship is very similar to other medical/therapy systems. My son sees Doctors and Surgeons for his speech issues. He also sees a speech therapist (well, three actually) who are supposed to coordinate as needed with the Doctor or Surgeon.

    The quality offering of speech therapist is very broad. They all have the same degree but can have widely different approaches and widely different specialties (aphasia, language disorders, articulation, hearing related, etc). So while speech therapy is essential for speech issues, it can actually be very hard to find the appropriate therapist.

    And this is one advantage I see of a drug over a therapy applied by a human. The drug is consistent from patient to patient, practitioner to practitioner. This is not to say therapy doesn’t have other advantages over drugs.

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