Data on antidepressant winners and losers

Hans Eysenck (1978) called meta-analysis an exercise in mega-silliness. To quote: “A mass of reports - good, bad, and indifferent - are fed into the computer in the hope that people will cease caring about the quality of the material on which their conclusions are based.” Cipriani et al (2018) in their recent network meta-analysis of 21 antidepressant drugs rated the risk of bias of the trials they put into their analysis. Only 18% were seen as low risk. Yet they hoped the results would compare and rank antidepressants for acute treatment in adults.

The article does list some winners and losers, although accepting that there were "few differences between antidepressants when all data were considered". Parikh & Kennedy (2018) add vortioxetine to their list of winners, which must please the manufacturers, as it is not yet off patent. Amitripyline actually had the highest efficacy but didn’t reach the ‘winners’ list, I think because of poor acceptability, defined as dropout rates, in the head-to-head trials, and low certainty of evidence (and maybe some bias against a traditional tricyclic). Unlike Parikh & Kennedy, Cipriani et al don't make any recommendations about antidepressant choice, merely hoping that their "results will assist in shared decision making between patients, carers, and their clinicians".

Such a weak conclusion to their main study may help to explain why in their publicity, which made the Sun, Guardian and front page of The Times, Cipriani et al concentrated on the statistically significant results for antidepressant efficacy, which actually aren't news (see my tweet), although may be for reboxetine (see previous post). I suppose it's not seen as being ideological to create publicity to increase the citation index of a paper! Or, to mislead and avoid dealing with the challenge of the placebo amplification hypothesis (eg. see previous post). To engage with this issue would actually be a more scientific way of proceeding, but the study by Cipriani et al doesn't have any bearing on it (even if they would like it to).

Actually the review paper itself (as opposed to the publicity) does recognise that the short-term benefits of antidepressants are "on average, modest" and that the "long-term balance of benefits and harms is often understudied". Several aspects of their findings do reinforce that there are biases in the data eg. smaller and older studies have larger effect sizes against placebo; novel or experimental drugs of comparison are more effective than when that same treatment was older (which they term the 'novelty effect'). I also wasn't sure whether they had got replies to all of their requests to the pharmaceutical companies for their data. Let's have a more measured debate about the evidence for antidepressant efficacy.

Transparency about the outcomes of Improving Access to Psychological Therapies

Graham Thornicroft's Lancet editorial on Improving Access to Psychological Therapies (IAPT) glosses over the effectiveness of the programme. True, he does say there has been little evidence of greater workplace productivity, which was the argument used to gain funding for the programme. He also acknowledges that although there has been a substantial increase in treatment of common mental disorders, admittedly particularly with antidepressants rather than psychological therapy, but still the prevalence of disorders has not decreased.

But, there is no questioning of the value of mandatory routine data collection, much of which is useless because it's uncontrolled (see previous post). By being so uncritical, Thornicroft could be said to be condoning the rhetoric of unrealistic claims for the effectiveness of the programme (eg. see another previous post). How much are outcomes just expectancy effects (see previous post)? I'm not wanting to undermine the work of IAPT therapists but we do need realistic assessments of the effectiveness of the programme. The title of the paper by Clark et al (2017), on which the editorial is based, is said to be about transparency about outcomes. I wish it was.

The promise of tranquility of mind

My recent post commented on the public understanding of the concept of bipolar disorder, at least as represented by internet bloggers. As I said in a book review, the aim of treatment of bipolar is euthymia, which means stable mood, neither manic nor depressed. In general parlance, euthymia is a relaxed state of tranquility. To quote from my review, "Democritus regarded this state of being as one in which the soul is freed from all desire and unified with all its parts. He believed it should be the final goal of everything we do in life."

No wonder people want mood stabilisers if this is what is being promised! However, mood instability is not well defined (see previous post). As I quoted in another previous post, "the term mood stabilizer sounds comforting and may reflect our fond and perhaps somewhat naive hopes".  Although a marketing ploy, there has never been any evidence that mood stabilisers are better than placebo in bipolar spectrum. It's also wrong and misleading to believe that mood stabilisers correct a brain abnormality.

Give up trying to explain the relationship of mind to brain

I attended a reading group today to discuss two quite technical papers by Georg Northoff. There is a Psychology Today blog, which makes clear that he is trying to bridge the gap between brain and experience. It's all very well to speculate about spatiotemporal psychopathology, but I think Kant was right that the link between mental and physical is an enigma that can never be solved.

Mind is of course enabled by brain, but it can't be reduced to it. Mind and brain need to be understood as a unity (eg. see previous post). Bodily organs are subject to the laws of physical necessity but consciousness is self-organising. An organic basis is, therefore, insufficient for understanding mental activity. Psychiatrists find it difficult to give up the notion that the understanding of mental activity must be derived from the brain. This doesn't make sense because such reductionism leads to the loss of meaning of human action (eg. see another previous post).

Being bipolar on the internet

Mandla et al (2017) have analysed internet blogs by self-identified bipolar sufferers. They found that most bloggers regard bipolar as consisting of extreme and fluctuating emotions. It encompasses a wide variety of problems and has fluid boundaries with normality. It often fulfils a moral function, in that it is conceived as an autonomous entity, which acts as a repository for disliked or disapproved aspects of the self and provides an explanation for bad behaviour or failure. It's become increasingly popular as a self-diagnosis (Chan & Sireling, 2010).

Bipolar has become so broad and inclusive that it has little in common with the original, narrower concept that was aligned with the diagnosis of "manic-depression" (eg. see previous post). There needs to be wider discussion about these issues.

The bio-bio-bio model of mental illness

A few years ago, Steven Sharfstein, when he was President of the American Psychiatric Association, said that psychiatry has "allowed the biopsychosocial model to become the bio-bio-bio model' (see Psychiatric News article). This was picked up by John Read in his The Psychologist article.

As I said in my last post, the problem is the eclectic, atheoretical way in which the term 'biopsychosocial model' is often used in modern psychiatry. Where this comes from is the psychiatric consensus, represented by Anthony Clare (see previous post), following the anti-psychiatry debate of the 1960/70s. To avoid the worst excesses of biomedical reductionism, Clare took an atheoretical approach to understanding mental health problems. The trouble with attempting to abstain from theory is that it results merely in the generation of an implicit theory. Despite his well-meaning humanism, Clare's position is still determined by biologism (see extract from my Critical Psychiatry book). As I said in another previous post, although modern psychiatry may not be 'narrowly biomedical', it is still biomedical.

Three cheers for the biopsychosocial model

There is a YouTube video of David Pilgrim's talk at the DCP conference last year. He only gives 'two cheers' for George Engel's biopsychosocial model, whereas I have regarded the model as a basis for critical psychiatry (eg. see previous post). I do this with the reservation that I am not supporting the eclectic, atheoretical way in which the term 'biopsychosocial model' is often used in modern psychiatry.

Where we agree is that the strength of Engel's model is its critique of biomedical reductionism. David accuses the model of being naive about medical knowledge. He argues that the model needs to be more of a theory about health and illness.

I do not think that David’s view sufficiently acknowledges the extent to which the model was not only a challenge to psychiatry, but also to medicine in general, creating the basis for patient-centred medicine (see previous post). As I said in my article:-

In his original paper, Engel talked about neutralizing ‘the dogmatism of biomedicine’ (1977, 135). He commented on the enormous investment in diagnostic and therapeutic technology that emphasizes ‘the impersonal and the mechanical’ (Engel 1977, 135). He quoted from Holman (1976), who argued that:

[T]he Medical establishment is not primarily engaged in the disinterested pursuit of knowledge and the translation of that knowledge into medical practice; rather in significant part it is engaged in special interest advocacy, pursuing and preserving social power. (Engel 1977, 135)

Engel acknowledged the interest in the biopsychosocial model amongst a minority of medical teachers, but also emphasized the difficulties in overcoming the power of the prevailing biomedical structure. 

None of my comments should detract from David’s contribution to recognising the importance of critical realism as a metatheory for psychiatry and clinical psychology (see his chapter in Routlege International Handbook of Critical Mental Health, a book which I have mentioned in a previous post).