The return of Dana Ullman, homeopathic apologist, 2010 edition

By oracknows on April 21, 2010.

I tell ya, I go away for a few days, let the blogging slow down, decrease the usual logorrhea. Heck, I even go for the lazy blogger trick of an open thread. In the meantime, while I was busy learning about real science at the 2010 AACR Meeting, the forces of pseudoscience have not been quiet. No, they've been active; indeed, there is so much that requires Orac's not-so-Respectful Insolence and so little time for me to apply it. That means that, almost certainly, "deserving" candidates will be missed. That is a shame, but even Orac needs his rest from time to time.

None of this means that I can resist (at least not easily), when everyone's "favorite" font of burning stupid, homeopathic apologist, derailer of comment threads, and someone who has no idea when he's not just whipped but whipped, pureed, and stomped, pops up and deposits a turd of pseudoscience on that repository of pseudoscience, quackery, and woo, The Huffington Post. And I don't intend to, given that Dana has supplied me with--shall we say?--an exceedingly "target-rich" environment. In particular, his article could provide rich fodder for a game of "Name That Logical Fallacy," but that alone doesn't make it "worthy" of the loving application of a heapin' helpin' of not-so-Respectful Insolence. This time around, Dana, filled with the arrogance of ignorance and clearly deeply resenting the justified criticisms of his favorite form of quackery (homeopathy, for those of you not familiar with him) and his hilariously inept attempts to defend it, has apparently decided it's time to strike back. Since he has failed miserably to provide one iota of evidence that homeopathy is anything other than magic-based medicine (to steal Jamy Ian Swiss' line) or, as I like to put it, Dr. Strange's medicine, Ullman has apparently decided to go on the attack against science-based medicine. The result, as usual, is hilarious, as Ullman has produced a post entitled How Scientific Is Modern Medicine Really?

I have to say this: Even if every accusation laid on science-based medicine by Dana Ulman weren't a huge bunch of distortions and cherrypicking, modern medicine would be orders of magnitude more scientific than Dana's preferred modality, homeopathy. But let's move on to Dana's woo-ful whine. The first thing I noticed is that it appears to be a rehash of a very similar article that Ullman published two and a half years ago (and which I had some fun with when he posted it), except that he appears to have found a little more recent material to throw in, some more recent anti-SBM attacks to cherry pick. Consequently, rather than taking on the whole article, I refer the reader to my old deconstruction and will concentrate mainly on what is different in the 2010 edition of Ullman's rant about how "medical science was wrong before" and, "Oh, by the way, doctors are poopyheads." Ullman starts out very similarly to his old article:

Doctors today commonly assert that they practice "scientific medicine," and patients think that the medical treatments they receive are "scientifically proven." However, this ideal is a dream, not reality, and a clever and profitable marketing ruse, not fact.
The British Medical Journal's "Clinical Evidence" analyzed common medical treatments to evaluate which are supported by sufficient reliable evidence (BMJ, 2007). They reviewed approximately 2,500 treatments and found:

13 percent were found to be beneficial

23 percent were likely to be beneficial

Eight percent were as likely to be harmful as beneficial

Six percent were unlikely to be beneficial

Four percent were likely to be harmful or ineffective.

46 percent were unknown whether they were efficacious or harmful

The "study" to which Ullman refers is the introduction to BMJ's ClinicalEvidence. It sounds pretty damning, doesn't it? Except, as many attacks on SBM are, this is an exceedingly deceptive way of presenting information. For one thing, there is no discussion of how frequent the treatments are or for what conditions. Every "treatment" is treated as a single treatment, regardless of how uncommon the disease or treatment may be. It's quite possible, for instance, that the 13% of treatments that were found to be beneficial were beneficial for far more than 13% of patients or 13% of conditions. No mention is made of what the 46% of treatments whose efficacy is supposedly unknown are, either. They could well be treatments for uncommon conditions or experimental treatments or holdovers.

Another thing that's rather interesting about BMJ ClinicalEvidence is that it apparently doesn't just cover conventional medicine. It covers alternative medicine as well. For example, look at this review of therapies for tension headache. Well, actually you can't, and neither can I, because I don't have a subscription to BMJ ClinicalEvidence, and neither does my institution. However, it's possible to find summaries of the reviews in the lay press sometimes, and this is one case where the evidence was summarized by the BMJ team for The Guardian. It lists treatments that work (amitriptyline, mirtazapine) and treatments that are likely to work (cognitive behavioral therapy, for instance), but what's interesting is what BMJ lists as treatments of unknown efficacy. These include "alternative" modalities, such as acupuncture, which really should have been listed not as "needing more study but under "does not work," based on multiple studies--which tells me right there that the reviewers for BMJ are giving too much leeway to some alternative medicine modalities. Also included was Indian head massage and biofeedback. You get the idea.

But here's something more interesting. Look at what therapies are listed as harmful. It is argued that taking over the counter painkillers is potentially harmful, but this is probably only true if headaches are frequent. If a person is not getting a headache every other day, if a person is, for instance, getting a headache only once or twice a month, it is unlikely to be harmful to take Tylenol or ibuprofen. Although pointing out that taking such drugs for headaches that occur 15 times a month may be harmful is probably true, when a bunch of such reviews are lumped together, a lot of therapies get thrown into the "harmful" or "unknown" categories. More importantly, it appears that the BMJ doesn't just confine itself to "conventional" or "science-based medicine." It appears to include all sorts of alternative therapies in its list. So Ullman is--surprise! surprise!--being either clueless (if he didn't bother to look at a few reviews) or intellectually dishonest (if he did) by implying that the overall summary by BMJ represents the percentage of conventional therapies that don't work. In fact, it looks at conventional medicine and various "alternative" modalities, like herbal remedies, acupuncture, etc.

In fact, lumping together all these therapies as a huge list is, in essence, meaningless other than a couple of things. First, I'm heartened at the low percentage of treatments that are likely to be harmful. Second, given that BMJ apparently includes a whole bunch of "alternative" therapies in its reviews, it's actually not so bad that only 46% of treatments are of unknown effectiveness. In any case, as a commenter pointed out, for individual conditions, SBM does quite well--asthma, for instance, where 67% of treatments are beneficial or likely beneficial;
24% of treatments are of unknown effectiveness; 9% of treatments are unlikely to be beneficial. And, depending on the disease or condition, even conventional medicine's efficacy can vary wildly.

Of course, homeopathy's efficacy remains very constant, no matter what the condition. Homeopathy doesn't work and would thus fall into "unlikely to be beneficial," but only if you can say wildly, extravagantly, ridiculously unlikely to be beneficial. After all, it's just water.

Another new bit that Ullman grafted onto his 2007 article is this:

Today in America, every man, woman, and child is prescribed around 13 prescription drugs per year (and this doesn't count the many over-the-counter drugs that doctors prescribe and that patients take on their own) (Kaiser, 2006). Just 12 years earlier, Americans were on average prescribed less than eight drugs per person, a 62 percent increase! The fact of the matter is that drugs are not tested for approval in conjunction with other drugs, and the safety and efficacy of the use of multiple drugs together remains totally unknown.

This practice of "polypharmacy" is increasing substantially, and Big Pharma is pushing it hard and benefiting from it in a big big way.

According to a 2008 nationwide survey, 29 percent of Americans used at least five prescription medications concurrently (Qato, Alexander, Conti, 2008), while just three years previously, 17 percent took three or more prescription drugs (Medscape, 2005). Even conservative publications such as Scientific American can no longer deny the increasing serious problems from pharmaceuticals. A recent article highlighted the fact that there has been a 65 percent increase in drug overdoses leading to hospitalization or death just in the past seven years (Harmon, 2010).

One notes that, while it's clear that polypharmacy is a problem, one can't help but note that the very same source that Ullman cites also points out that the percent of the population with a prescription drug expense in 2003 was 61% (for those under age 65) and 91% (for those 65 and older), which has changed little since 1996, when they were 62% and 88%, respectively. One possible implication is that people who are on a prescription drug are now more likely to be on more prescription drugs than they were in the past. One thing that bugs me about these number, though, is that it is not clear whether these prescriptions represent new prescriptions or refills or both. My guess is that it's both. In any case, Ullman clearly chose the number that sounds the worst, given the rate of increase in prescription drug spending is decreasing, from 4.5% in 2007 to 3.2% in 2008, although projections are that this spending will increase by 6% every year for the next decade, which is not suprising or out of the ordinary given that the Baby Boomer generation is heading into retirement and that senior citizens tend to use far more prescription drugs than do younger people. It just sounds scarier to make it sound as though every American is on at least 13 prescription drugs. Again, I'm not saying that polypharmacy and arguably too much spending on prescription drugs are not problems. However, practitioners of science-based medicine are aware of these problems and are trying to do something about them. In marked contrast, Ullman remains blissfully unaware or unwilling to admit that homeopathy is nothing more than water.

Similar comparisons can be made to the observation that there has been an increase in prescription drug overdoses over the last seven years. What Ullman neglects to mention is that the vast majority of this increase is due to prescription opoids and tranquilizers:

The biggest percent increase in hospitalizations for poisoning for a specific drug was a quintupling for methadone, according to the team's report published in the American Journal of Preventive Medicine. This may be due to the more than 10-fold increase in overall retail sales of this drug from 1997 to 2006, they state.

Poisoning by benzodiazepines such as Xanax and Ativan -- drugs that possess sedative, hypnotic, anti-anxiety, anticonvulsant and muscle relaxant activities -- rose 39 percent over the study period.

Poisoning by barbiturates, which also have sedative, hypnotic and anti-anxiety actions, actually fell 41 percent, as did hospitalizations for poisoning by antidepressants (a decrease of 13 percent).

One also notes that there is a thriving black market for illegally selling many of these prescription drugs, as well as overprescription and wider availability of much drugs of a potency that could until recently only be obtained through intravenous injection. In any case, Ullman, not surprising, disingenuously makes it sound as though it's all prescription drugs, not primarily drugs from one category, that are responsible for this increase in hospitalization. Once again, no one is arguing that unintentional overdoses of opiods and tranquilizers are not a problem. Once again, it is the medical profession, not homeopaths, who are sounding the alarm. Ullman is just cribbing reports done not by homeopaths or "alternative medicine" practitioners but by practitioners of science-based medicine and scientists. Once again, it is useful to point out that an overdose of any homeopathic remedy--true homeopathic remedy, that is, not homeopathic remedies that contain actual drugs or herbs in pharmacologically active concentrations--is nearly impossible to achieve, aside from drowning or water intoxication.

Ullman also can't resist adding a different take to his attacks on big pharma, other than the pharma shill gambit and conspiracy mongering:

An even stronger case can be made for the epidemic of "elder medical abuse" due to the much larger number of drugs prescribed to and for our senior citizens. It is no wonder that so many of them have become mental zombies, while Big Pharma profits big time and insurance companies simply raise their rates.

If we were living a lot longer and the quality of our lives was improved by medical care, one could make a case for why today's medical care is providing more benefits than problems, but this is simply not true.

Although we are commonly told that we are living longer than ever now, this is simply a clever, even tricky, use of statistics. The fact of the matter is that there has been a considerable reduction in deaths during the first five years of life ... and this reduction in deaths has resulted primarily from a medicinal agent called "soap," not from the use of any specific conventional pharmaceutical agent.

Ultimately, an American who was 40 years old in 1900 and an American who was 40 years old in 2000 has a similar chance of living to 80 years old today.

Ullman is just plain wrong here. As these life tables from the Department of Health and Human Services, National Center for Health Statistics; National Vital Statistics Reports, vol 54., no. 19, June 28, 2006. show, in 1900, life expectancy at age 40 was 27.74 years for white males and 29.17 years for white females. In 2000, the same numbers were 37.1 years and and 41.3 years, respectively, impressive increases. For age 60 over the same period life expectancy in men has increased from 14.35 years to 20 years; women from 15.23 years to 23.2 years. Ullman's either mistaken or lying, take your pick. Or perhaps Ullman considers a 33% increase in life expectancy in men and a 42% increase for women from age 40 over the last century to be "similar."

The bottom line is that we are living longer than ever and staying active longer than ever, and it sure isn't homeopathy that is making that possible. In light of the flowing swaths of burning stupid that Dana laid down in his article, I can't help but point out that Dana promises a part 2. I also can't wait, as I'm sure it will be as entertaining as this rehash of his 2007 article, which, by the way, I did deconstruct back in 2007, which is the main reason I didn't rehash the not-so-Respectful Insolence that I laid down on the parts of Ullman's latest HuffPo travesty that are more or less identical (or at least very similar) to his 2007 piece.

Finally, I will close by citing what is perhaps the most disingenuous bit that Ullman included in his post:

NOTE: This article focuses on the issue of the amount of "science" in medical care today. I predict that many commenters below will choose to attack me or the subject of homeopathy, even though THIS is not the subject of this article. I sincerely hope that commenters will stick to the subject at hand. For those of you who wish to comment on homeopathic medicine research, I urge you to do so at articles on that subject.

Unfortunately for Dana, the one part he did keep from the older article is his rant against the AMA for having tried to suppress homeopathy back in the 1800s. In essence, Ullman is doing what apologists for homeopathy and various forms of alt-med have done for decades, if not centuries. Because they can't present any convincing positive evidence for the efficacy of their favorite woo, they point out--and exaggerate, if necessary--the problems of science-based medicine. Unfortunately, these problems do not invalidate science-based medicine, nor do they validate homeopathy. Ullman means to imply that they do, because he really can't do anything else. That's why I did two things: I addressed the distortions in Ullman's distortion-packed article, and I contrasted science-based medicine with homeopathy. In the end, even if everything Ullman said were utterly true and completely unexaggerated or cherry picked, science-based medicine would still be effective, and homeopathy would still be water.

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Lets hope someone asks him how many of the "unlikely to work" treatments in the study he cites are homeopathic .

I really like that note at the end because when I looked for the comments on his article, I saw this :

"Featured Comments
ChristyRed
I've used homeopathy for the past dozen years and give thanks every day for the wonderful homeopath who introduced this magnificent system of medicine to the people in this area. It's been so.."

his supporters should really read that note and not comment about wateropathy on an article about "science"

What Ullman, like so many other alties who do tu quoque attacks on mainstream medicine seems oblivious to is that his source material for deficiencies in mainstream medicine is a mainstream medical journal. This is another example of how medicine is self-criticizing and self-correcting. Contrast that with the frequency with which alt med journals and homeopathy proponents review homepathy's failures and urge that it be drastically overhauled or discarded - approximately never.

And even if we accepted Ullman's fulminations about lack of efficacy and greed in mainstream medicine at face value, why should we then turn to magic water instead?

I plugged Dana's note into Google translator (translating from Homeopath to Rational) and this is what I got:

Note: I've written this article to take pot shots at my opponents. However, because I didn't mention what it is I'm trying to defend, I'm really hoping that you will fall for my distraction and join me in bashing people people who are more credible than I. I really hope that by scolding you before you comment that you will be shamed into not criticizing me. If you cannot refrain from pointing out that I am a complete loon, please do it elsewhere so I can ignore you. Na Na Na boo boo.

Another point about the BMJ Clinical Evidence's assessment of treatments is that they use a very rigid yardstick to evalute treatments.

Among the nearly half of all treatments for which there is "unknown effectiveness" are many for which the current available evidence does not meet with the standards of evidence being measured (ie no clear cut RCT or similarly strong evidence). For many of the treatments used which fall into this category there is some evidence, it is just not robust enoughto be categorised.

The irony is that at the same time Dana regards any minimal/anecdotal froth as conclusive "proof" that homeopathy works, and wouldn't know what robust evidence was if it bit him in his sorry ass.

I thought one of the worst parts was:

The fact of the matter is that drugs are not tested for approval in conjunction with other drugs, and the safety and efficacy of the use of multiple drugs together remains totally unknown.

Yet again, you're either utterly, staggeringly ignorant or you're lying, Ullman. There are many, many well-documented cases of adverse drug interactions, both with other prescription drugs and with other substances in general. Part of a pharmacist's job is to know about these interactions.

Methinks you'd benefit from some anger management. Or male member enlargement.

@DT:

Absolutely spot-on. One is reminded of the fact that there are no RCTs supporting the use of parachutes to prevent deceleration fatigue, and that this intervention would therefore fall under the category of "unknown effectiveness."

You kind of touch on one of the questions I have about the BMJ article when you discuss how the treatments for asthma are generally supported (and I would still love to see the "non-effective" treatments for asthma - let me guess? Acupuncture? Chiropractor?)

What are the ailments for the 46% of non-effective treatments? Common cold? Fatigue? Insomnia?

A patient goes to the doc for a common cold, and the doctor recommends bedrest and chicken soup. Well, yeah, but it really hasn't been shown to cure the cold. A patient with insomnia, and the doctor says drink a glass of warm milk. These recommendations are of dubious use, and the doctor knows it, but they appease the patient in a case where no real treatment is indicated.

I recently went to the doctor for a heart arythmia, and what did I get? Nothing. Whoa, is that an effective treatment? Not at all, but given the presentation, medical treatment wasn't indicated. If I were the type to worry about it, he could have recommended a non-efficacious treatment, if nothing else to get me out of the office. And it would have been perfectly acceptable.

I am not at all surprised at the amount of non-effective treatment given. A very large amount of the time, the best approach is to do nothing. However, I think you will find that as the specificity of the diagnosis gets better, and the severity of the ailment increases, the reliance on scientifically viable techniques increases.

Methinks you'd benefit from some anger management. Or male member enlargement. -- Posted by: Jilian Gastronicus

...Created by a homeopathic "doctor", no doubt.

Orac:

One thing that bugs me about these number, though, is that it is not clear whether these prescriptions represent new prescriptions or refills or both. My guess is that it's both.

If I'm not mistaken, it's worse than that -- it also doesn't indicate whether these 13 prescriptions are being taken concurrently. Polypharmacy is when a person is taking several drugs together; how many people are really taking 13 drugs together all year long?

Now, Ullman shocking does touch on a real point: polypharmacy is a growing practice, as we discover more treatments for more conditions, and it deserves continued study. But he seems to step from that to validating homeopathy, which is often intentionally polypharmaceutical -- homeopaths will tailor treatments to the individual, mixing up a whole bunch of remedies to address the specific person's imbalances. But why does his criticism of mainstream polypharmacy not apply to homeopathic polypharmacy? Perhaps because different homeopathic drugs generally cannot interfere with one another -- they're all solvent, so mixing them will just increase the dose of solvent. But that would involve admitting that homeopathy is bunk. Hmm..... Curious.

Dullman recommends naturopathy. Case closed.

-r.c.

*Le sigh* Comments section on HuffPo filled with whale.to citations.

I was having a conversation with a guy last night who was lamenting the fact that he is no longer in university. He said that the people he thought were stupid in school are actually GENIUSES compared to the stupid he now faces in the real world.

I was having a conversation with a guy last night who was lamenting the fact that he is no longer in university. He said that the people he thought were stupid in school are actually GENIUSES compared to the stupid he now faces in the real world.

That explains Sarah Palin, for example.

(seriously, listening to Palin totally reminds me of the answers I see on essay problems by college undergraduates. e.g. Step 1: restate the premise of the question as your answer)

Orac sez,"Ullman's either mistaken or lying,take your pick." I don't know, but this seems to be a common "Back to Eden" urban legend in Woo-topia, with a few variants:1.our ancestors lived in a "purer" world,free of toxins,Big Pharma,stress,etc.(Hah!)2.people who live "simply" today(e.g. "back to nature" types,indigenous people in say, oh, Ecuador and their neighbors, like Adams)actually live *longer* than we do.Gary Null has a nearly endless spiel about how rural Italians have these long, relaxed vegan meals, how everyone works hard in the fields,drinks pure water, etc.and similar nonsense about the lives of Americans 200+ years ago(e.g. "the 'Founding Fathers' lived to be over 80".A few did,but it was hardly average).I doubt that these ideas are based on data, more like movies and novels.(BTW,I actually studied psych of aging)

If I'm not mistaken, it's worse than that -- it also doesn't indicate whether these 13 prescriptions are being taken concurrently. Polypharmacy is when a person is taking several drugs together; how many people are really taking 13 drugs together all year long?

In particular, consider things like SSRIs or triptans, where different people have different responses to different members of the same class of drug. In such cases it's pretty routine to try several different drugs in succession to find out which works best for the patient in question.

Homeopathy is clearly bogus, but criticism of the psycho-pharmacology is on target. Psychiatrists are prone to automatically write a script rather than practice psychotherapy. Many of the mind-altering drugs carry stiff penalties in side-effects and are of less than stellar efficacy.

I should modify the previous sentence. They are of tremendous efficacy in reducing the costs of treatment that the insurance industry must pay. They are also efficacious for the bottom line of the big pharma.

Then there is iridology, emdr, naturopathy, reiki, and so many more--how about crystal energy. You have so much grist for your mill.

Regarding polypharmacy, FDA actually is thinking about this. They have, for example, this guidance document discussing design of drug-drug interaction studies. There is also this page discussing the issue of drug interactions, with lots of other links to follow.

In short, FDA is strongly encouraging companies to test their new products in combination with other products that are likely to be used concurrently. Wow. Science-based medicine actually working to figure these issues out?

"Psychiatrists are prone to automatically write a script rather than practice psychotherapy. "

This sounds so much like the "all OB's just schedule inductions/c-sections so they can go golfing!" tripe, that I would like to see some evidence that this is the case, more often than not (of course, you will always find examples of professionals behaving badly - which says nothing of the overall profession).

"Homeopathy is clearly bogus, but criticism of the psycho-pharmacology is on target. Psychiatrists are prone to automatically write a script rather than practice psychotherapy. Many of the mind-altering drugs carry stiff penalties in side-effects and are of less than stellar efficacy...They are of tremendous efficacy in reducing the costs of treatment that the insurance industry must pay. They are also efficacious for the bottom line of the big pharma."

They're also pretty damn efficacious for treating, say, depression in many people, who no longer have to endure extended psychotherapy sessions of higly dubious value, wasting time having their ids and superegos probed instead of getting on with life (with the aid of "the big pharma").

I would also add that there are many situations where the drug is needed before the therapy will even do any good - depression for example: if a person is so depressed and hopeless that they can barely crawl out of bed each morning, how are they going to get through long, often painful sessions exploring the deep recesses of their minds/personalities/life experiences?

This is not always the case of course.

Then there are those who refuse therapy, for whatever reason. Are they to have NO relief, simply because they didn't choose the non-medication option?

Sorry, I tend to get a little ruffled when people start claiming that doctors are just writing pills for people with mental illness, instead of giving them therapy. It's not really a black and white issue.

They're also pretty damn efficacious for treating, say, depression in many people, who no longer have to endure extended psychotherapy sessions of higly dubious value,

...speaking of non-effective treatments...

"We should abandon those darn pharmacological treatments that are found to work is a large number of cases in favor of ... psychotherapy, which doesn't fix the problem."

It's just the same crap that denies that mental illness is actually an illness, and thinks it is just a "state of mind." Using psychotherapy for mental illness is like teaching someone with a broken leg to walk on crutches. It might help them get around, but it doesn't address the cause of their problem.

I object to the claim that homeopathy is just water. Sometimes it's wax, too. :P

Pablo--

In some cases, psychotherapy may be like teaching someone to walk on crutches. But we don't always have a better option, at least not yet. It seems (I am not a professional) as though it depends to some extent on the nature and causes of the symptoms. That mental illness is an illness doesn't mean that drugs are always the best way to treat it.

In other cases, I think talking therapy may be somewhat like physical therapy. They don't just teach you to walk with crutches, or not to lift heavy weights, they strengthen the body. Even with physical ills, neither surgery nor pharmacological interventions are always the best choice, or the best place to start. (When I had rotator cuff problems, the surgeon's plan of action was PT; if that didn't work, cortisone; and if that didn't work, surgery. He sent me off with a recommendation for PT and the hope that he would never see me again. He hasn't.)

In some cases, psychotherapy may be like teaching someone to walk on crutches. But we don't always have a better option, at least not yet.

Which is why paraplegics are confined to wheelchairs.

Absolutely there are times when we can't fix the problem and need to provide other means of assistance. The same applies to treatment of mental illness. We can try things to fix the underlying cause, but until we do that, we provide a means to help the person cope.

People with broken legs DO use crutches, while we use other means to fix the leg - i.e. there is role for therapy with drugs. But just because there are crutches available doesn't mean we shouldn't fix the leg.

Sorry, Ullman, but when you state your belief in Homeopathy, you also state your complete and utter lack of qualification to make any scientific claims. I'd just as soon hear the wizard of Oz discourse on particle physics.

If you look at randomized trials of cognitive behavioral therapy (CBT) vs. anti-depressants or anxiolytics, both forms of treatment typically perform similarly well. CBT obviously has the advantage of lacking physiological side-effects, and it shouldn't have any major withdrawal issues after you decide to stop taking the drug. CBT gains are apparently maintained at long-term follow-up.

Combining drugs and CBT seems to work even better than either one alone.

so..if I, as a member of the BIGPHARMA conspiracy develop a new drug.. we have two choices, right?

submit all the research and information that proves efficacy and safety for the drug/chemical/potion, and ask for formal review by educated scientists, with goal of hopefully gaining approval from the FDA for prescriptive use.

Call it HOMEOPATHIC... dilute it beyond recognition, and sell it with a disclaimer posted on the label.

and remember folks ...

go over to the PEPSI site... and cast your 10 votes for something above or below GENERATION RESCUE... help prevent a $250,000 grant from being tragically wasted.

"CBT obviously has the advantage of lacking physiological side-effects, "

Are you certain of that?

If it has the physiological effect of reducing the depression, it could have other physiological effects.

This is another example of how medicine is self-criticizing and self-correcting. Contrast that with the frequency with which alt med journals and homeopathy proponents review homepathy's failures and urge that it be drastically overhauled or discarded - approximately never.

I think the point of view of Ullman (and others who make similar criticisms) is that if the philosophy behind conventional medicine were sound, then the self corrections would all have taken place soon after conventional medicine had been founded, with it rapidly converging on perfection, at which point it would remain unchanged for the rest of eternity. Thus, to him, the fact that self corrections are still happening indicates that conventional medicine is bogus.

@Matthew Cline

In other words, the Nirvana fallacy?

CBT is not without risks. Though it isn't likely to have significant physiological effects, as it isn't a physiological intervention, it can go badly wrong. Much like surgery, the practitioner can screw up, and if you embark upon CBT, you are taking the risks that your practitioner is not going to be able to help you and may even make you worse.

This could be as simple as the patient struggling with ineffective CBT for weeks, deciding this proves they're beyond hope, and killing themselves. Or it could be much more dramatic, and clearly into the realm of malpractice. There was a woman here in Minnesota not too long ago who I believe had her license revoked for seriously bad CBT -- she basically pandered to her patients' delusions, even to the point of arranging a meeting between two of them and taking them to her home to help keep them safe from the government mind-control agents which they were convinced lurked outside. The investigation found that she was not acting maliciously -- just very, very misguidedly. You're not supposed to actually contradict your patient, I suspect, and she took that to its logical extreme....

Obviously, that wouldn't often be a risk. But if you're working to change a person's behavior, you could inadvertently change it for the worse.

J. J. Ramsey @ 23:

I object to the claim that homeopathy is just water. Sometimes it's wax, too. :P

Or sugar, or ethanol! I like those better. More fun. ;-)

You're not supposed to actually contradict your patient, I suspect, and she took that to its logical extreme....

I'm pretty sure that's not even "bad" CBT, but basically "not CBT." A major part of CBT (ant is predecessor, REBT) involves challenging irrational, unrealistic and fantastic beliefs and worldviews.

I admit I am a software engineer, not a therapist, and do not know what CBT actually entails, nor the distinctions between various different types of "talk therapy". I underwent therapy once, but I don't really know what the correct term for it would be. In any case, isn't the objective supposed to be to guide the *patient* to challenging those beliefs and worldviews? If the therapist just says "you know, that's all bullshit", there probably won't be a second appointment.

@Poogles

This sounds so much like the "all OB's just schedule inductions/c-sections so they can go golfing!"

Interestingly enough I was at a journal club on Monday where we were discussing the factors that influence OB decisions to schedule C-sections. A group in the USA tried to create a mathematical regression model to test whether it was due to a local (same hospital) or regional (same health authority) effect. Most of the variance in the model went unexplained, meaning that those hypotheses were not supported by the data (1600 physicians in NY and FL).

One of the members of the group said she was part of a similar effort to discern why C-section rates were so high in one of the health authorities here in my province - the provincial health service keeps excellent records. They specifically tested the assumption that rates could be explained as a time-of-day or day-of-week phenomenon and found no association.

Here is a picture of an otter.

Since this post appeared, Ullman's article has been moved off the top banner position to significantly lower on the page. (Correlation does not imply causation, of course.)

"It's just the same crap that denies that mental illness is actually an illness, and thinks it is just a "state of mind." Using psychotherapy for mental illness is like teaching someone with a broken leg to walk on crutches."

You are making a very strong claim there about the ultimate 'cause' of psychological illness - especially something as complex as depression, which probably has multiple genetic, developmental and sociological factors involved in its genesis and maintenence.

In fact, I've heard the inverse of that argument - SSRIs are a crutch, and therapy is needed to help you fully recover. This is is a good metaphor for how the combination of CBT and SSRIs is presumed to work on a neurobiological level (SSRIs 'boost' the signal from the more emotional parts of the brain to the more rational parts, and CBT boosts the signal from the more rational parts to the more emotional parts).

If you have to choose just one, CBT is actually preferable to drug treatment alone as it has a lower rate of relapse. Don't buy into the drug company hype about depression being 'chemical imbalance' - it's neurologically meaningless, and it denies the brain the ability to do what it excels at - rewiring itself.

A major part of CBT (ant is predecessor, REBT) involves challenging irrational, unrealistic and fantastic beliefs and worldviews.

@Joseph,
If that's the case, all these homeopathy quacks could use a good dose of it!

It is just as bad as Ullman for all you armchair psychiatrists to be offering your views (mostly anecdotal or completely undocumented) on mental health and its various treatment approaches.

Having raised a child with a serious chemical imbalance, I can tell you that talk is great, and a part of treatment, but without the drugs, my child (and many others according to actual research) would be dead or in jail at best. I take my advice on mental health from medical doctors, including the specialty of psychiatry, not from lay people who hold highly personal and ideological views on mental health. I don't have a TV and see very few drug ads, and I tire of people commenting that I have "just put my kid on drugs because of TV ads" and other such ignorant quips.

------

Hey Orac--my suggestion for threads was Ullman--glad you agreed. You should check out his last couple of posts--supposedly offering "documentation" and "studies" that prove homeopathy. Most of his sources were his own books!

Anthro, been there, done that with a relative, who unfortunately died last month.

Oh, Anthro, I should add the healthiest time she had was right after leaving the psych ward. Then she went to a naturapath and was prescribed homeopathy. She found out very quickly that homeopathy does not work, which she shared with our extended family in a long letter. She went back to the real meds (though unfortunately she failed to follow up with the other recommendations from the doctors, like talk therapy, getting outside for walks, etc).

Oh, I strongly disagree. CBT can be EXTREMELY painful!

Wait. Wrong CBT? Never mind.

Not wanting to wade into the morass,(i.e. the relationship between meds /psychotherapy,psychosocial education,vocational,etc.,which of course, varies with the particular MI being addressed):for a *start*,google up NIMH,then "Mental Health Topics",then by condition.Tons of other related material via NAMI.

Not only is homeopathy venerable woo, but woo-busting goes back nearly as far. The link is to a surprisingly well-designed trial of homeopathy that was done in 1835!

http://www.sciencebasedmedicine.org/?p=4750
The link appears to have been stripped off in my posting.

Something a little bit better from HuffPo:

http://www.huffingtonpost.com/2010/04/21/hitler-finds-out-that-dow_n_54…

stuv, my initial thoughts were the same. That is one term to bring out the weirdos;-)

Ullman plugs naturopathy, enough said!

His argument overall, to borrow an analogy from Kim Atwood, is like saying that because jets are dangerous, flying carpets are the better choice.

They're safe. Certainly safer.

-r.c.

Would Phase 4 clinical trials be considered a hallmark of the scientific method in conventional therapy? If so how and why? If physicians are encouraged by pharmaceutical companies to prescribe any drug for a separate condition not indicated by the drug company initially, nor passed by the FDA for such use would this qualify as an application of the scientific method? Is prolific experimentation permissable devoid of scientific studies with toxicologic drug products justifiable, as long as only physicians do this? If drug companies hire private consultants or other scientists to ghostwrite papers on their behalf, or to allow scientists to place their names to articles endorsing new drugs that they have not written, would this also be considered a necessary practice supporting objective science and the scientific method?

http://thestar.blogs.com/ethics/2010/02/only-onequarter-of-us-medical-c…

And finally if a drug can stand firmly on it's own merits than why would it be necessary to rig the game or game the system? Is this what science is all about?

http://www.thefreelibrary.com/Uncover+bias+in+clinical+trials:+drug+res…

Would Phase 4 clinical trials be considered a hallmark of the scientific method in conventional therapy? If so how and why? If physicians are encouraged by pharmaceutical companies to prescribe any drug for a separate condition not indicated by the drug company initially, nor passed by the FDA for such use would this qualify as an application of the scientific method?

This is kind of foolish. The only difference between a phase 4 trial and a phase 3 trial is that a phase 4 trial is conducted after a drug has been initially marketed. Do you imagine that somehow, once a drug has been marketed for a particular condition, there is nothing more to be discovered about it? Even a pharmaceutical company does not have the resources to carry out studies of every plausible use of a drug. So they initially focus on the most likely, and most profitable, applications. Subsequent studies may examine other possible applications.

SRDavid - you appear to think that psycho-pharmacology being cheaper than psychiatry is an argument against using them. In fact it's an argument *for* using them. Of course, there may be other arguments against using a cheaper treatment system that outweigh the benefits of saving money, but that doesn't mean that it's always a bad thing to reduce the costs of treatment. Resources are limited, skilled psychotherapists are expensive. Something has to give somewhere.

And please don't take this as a comment about the state of the US medical system in particular. I personally am a NZer and thus used to a government-paid health care system, where costs come home to the taxpayer, but in a private system where insurance companies cover costs, insurers in their turn recover their costs from their customers so the point is the same. And I note that the USA and NZ have both seen rapid increases in health care spending from 1990-2007 - so in that at least both systems are similar.

OT, but here's another project to vote for on the Pepsi Refresh Everything contest. The applicant is a doctor at Massachusetts General Hospital and is researching the possible causes of Alzheimer's disease. Currently, he's ranked 67th, but if we can get enough votes, we can probably put him at least above GR/AoA.

@trll
Since the majority of Phase 4 studies will never be submitted to the FDA, they may be totally unregulated. Few of them are published. In fact, like all industry sponsored trials, they are not likely to be published at all unless they show something favorable to the sponsor's drug. If they are published, it is often in marginal journals, because the quality of the research is so poor. Whereas companies generally prefer phase 1 through phase 3 studies to be done by experienced research investigators, phase 4 programs offer sponsors the opportunity to initiate and develop strategic relationships especially with high volume prescribers. In other words, it isn't really research, so don't worry about it's scientific validity.
And devoid of a mechanism of action of the drug towards a specific symptom set or syndrome, why does guesswork replace rigorous scientific assessment?

Tracy W: "SRDavid - you appear to think that psycho-pharmacology being cheaper than psychiatry is an argument against using them. In fact it's an argument *for* using them. "

On the subject of psycho-pharmacology vs. psychiatryâ¦there are other reasons, at least in the US's corporate culture, that Americans love their pills. We don't want to wait to get better, and even if we do, our employers REALLY don't want to wait for us to get better.

This was my experience when I was on disability leave from my job, because of major depression and panic disorder (which developed after the chronic pain condition started). And the disability benefit administrators thought that after six weeks on an antidepressant, one should be back to work full-time! All better! When we know that isn't how depression always works.

A lot of people have had similar experiences when trying to use their "employee benefits" for psychiatric reasons. The idiot companies that administer corporate short-term disability benefits understand, "Patient is on a trial of 60 mg fluoxetine; Dr. Bob will evaluate progress in two weeks" far better than, "Patient is undergoing talk therapy, behavior modification, and exercise, and will be re-evaluated in four weeks."

Our Corporate Feudal Overlords don't really want us to have time to heal and recover from anything. Rest and care isn't seen as being "proactive", but taking a pill is.

I have nothing against pills â Effoxor gave me "myself" back, and medications for asthma and pain ensure that my quality of life is pretty darn good â but I don't like that as a society we ONLY value pills.

Of course, that doesn't mean that I think homeopathy or crystal therapy aren't quackalicious.

Toxicosis: part of what you're alluding to is "publication bias". Positive studies are far more likely to see the light of day than negative ones, and that's actually not restricted to studies sponsored by drug companies. (Not all trials are run by drug companies; universities do a lot of studies as well, and though one might hope their motivations to be more pure, academics suffer from the "publish or die" phenomenon, and may feel that positive studies look better when applying for tenure.)

Oleander Tea:

Our Corporate Feudal Overlords don't really want us to have time to heal and recover from anything. Rest and care isn't seen as being "proactive", but taking a pill is.

I have nothing against pills â Effoxor gave me "myself" back, and medications for asthma and pain ensure that my quality of life is pretty darn good â but I don't like that as a society we ONLY value pills.

Of course, that doesn't mean that I think homeopathy or crystal therapy aren't quackalicious.

I think our Corporate Feudal Overlords aren't really to blame for that -- our culture is. As you say, we as a society would rather take a pill than do something that involves a significant time commitment -- or admit to actually being physical unfit in some way. Truthfully, I think our bias towards pills actually makes us more receptive to quackery, not less; to the average Joe, the appeal of homeopathy is exactly the same as the appeal of aspirin. "Take two and call me in the morning." If our doctor could wave a magic wand and make us better, we'd be all over that, and not entirely unreasonably; of course that sounds more appealing than interrupting our schedules.

The biggest reason we resist improving leave policies is not evil bosses. It's the Puritan work ethic. We see time off as "slacker time" and while we like to joke about how much we'd like to slack off for a while, we joke to set ourselves at ease that we're not really slackers. We're dedicated hard workers. We'd rather slack, but because we're good, upstanding people, we don't. That's not entirely bad, but not entirely good either, and we end up feeling very conflicted about a lot of things.

The adage I remember from med school and residency is that it's generally not a good idea to challenge a paranoid schizophrenic's delusion that the black helicopters are out to get him or her. Really. Not a good idea. However, it's OK to challenged a depressed person's feeling of helplessness or worldview that only bad things happen to him or her when good things do happen. The distinction may seem subtle, but it's there.

Challenges to getting mental health care includes: lack of coverage (which includes insurances only covering X number of visits where X is clearly an insufficient number of visits), lack of access to services, not finding a therapist that you like that your insurance covers, not finding a psychiatrist that you like that your insurance covers, time, willingness to work with therapy (which can be challenging).

In an ideal world (or my ideal world) people would do counseling/therapy as well as meds. In my reality, my patients have easier access to me to do do meds than they do counseling. Completely effed-up.

More on topic, the more I read Ullman, the more I have to shake my head. Oy. So much stupid in so little space. It hurts us, my precious. It hurts us.

Since the majority of Phase 4 studies will never be submitted to the FDA, they may be totally unregulated. Few of them are published. In fact, like all industry sponsored trials, they are not likely to be published at all unless they show something favorable to the sponsor's drug. If they are published, it is often in marginal journals, because the quality of the research is so poor. Whereas companies generally prefer phase 1 through phase 3 studies to be done by experienced research investigators, phase 4 programs offer sponsors the opportunity to initiate and develop strategic relationships especially with high volume prescribers. In other words, it isn't really research, so don't worry about it's scientific validity.

Clinical trials in progress are required to be listed on clinicaltrials.gov, so if the results are never published, people are likely to assume that the results were negative. While there have certainly been instances of Phase 4 studies being misused as marketing devices, this seems to be the exception. There are many examples of the indications for drug use being expanded based on Phase 4 studies, which can be highly profitable for the manufacturer. To achieve this, the research has to be of high caliber. Such studies also may reveal risks that were not apparent in smaller studies prior to approval. For example, it was Merck's Phase 4 studies of Vioxx published by Merck that revealed that Vioxx carries cardiovascular hazards, which ultimately led to the withdrawal of Vioxx from the market. Subsequent studies revealed that these cardiovascular hazards are shared by almost all NSAIDs, something that might well not have been discovered if not for Merck's published phase 4 studies.

In fact considering the widespread belief (particularly among advocates of "alternative" therapies that lack any reliable clinical studies showing benefit) that drug companies cover up negative results or even fabricate favorable results, isn't it remarkable that the business news is full of reports of major studies of drugs in which pharmaceutical companies have invested hundreds of millions of dollars coming out negative. For small companies, a negative outcome can often be the end of the company, yet this happens all the time.

And devoid of a mechanism of action of the drug towards a specific symptom set or syndrome, why does guesswork replace rigorous scientific assessment?

In most cases, by the time that a drug is released, its mechanism is fairly well understood, so additional applications are inferences, not guesswork. But physiology and pharmacology are complicated, so reasonable inferences can still turn out to be wrong. Which is why the FDA requires phase 4 studies to expand the indications for a drug, even when the proposed new use seems obvious based upon the drug's mechanism.

In most cases, by the time that a drug is released, its mechanism is fairly well understood, so additional applications are inferences, not guesswork.

Wasn't Rogaine a high-blood pressure medication? Or was that Viagra? I think Viagra was something else.

Just to tie into trrll's comment about clinicaltrials.gov, there is, IIRC, legislation either in the works or already passed with an implementation timeline that all trials, in addition to the registration requirement, are (or will be) required to post results. That would include phase 4.

Wasn't Rogaine a high-blood pressure medication? Or was that Viagra? I think Viagra was something else

It is not uncommon for a molecule to be initially synthesized with one action in mind, but for it eventually to be discovered to have another effect. In general, it is not possible to predict what function a molecule will have on the body without testing, other than by similarity to known molecules (and even that is often misleading). Big pharmaceutical companies have huge compound libraries, which they will screen for action against new biological drug targets.

Both minoxidil (Rogaine) and sildenifil (Viagra) were somewhat fortuitous discoveries. Nobody decided out of the blue to test minoxidil (Rogaine) for treatment of hair loss or sildenifil (Viagra) for erectile disfunction. Rather these were side effects noted during clinical testing for another indication. Both were initially developed as vasodilators for treatment of hypertension, which makes a certain amount of mechanistic sense. It is speculated that minoxidil may increase blood supply to hair follicles, whereas sildenafil turns out to be particularly good in inducing vasodilation in a specific body part.

On the subject of homeopathy, Roger Ebert made this interesting comment in his review of a bad movie today:

http://rogerebert.suntimes.com/apps/pbcs.dll/article?AID=/20100421/REVI…

"The movie deals with artificial insemination, romance, sex and organic goat cheese, which are promising areas for investigation, but it's so watered-down, it approaches homeopathy."

On the Huffington Post Ullman is described as a Homeopathy expert in his bio. So does that mean he only knows 1 ten millionth or less of what he is talking about?

@jonmc,

That's probably right.

But, at least he can support it with a "proving".

Yet again, you're either utterly, staggeringly ignorant or you're lying, Ullman. There are many, many well-documented cases of adverse drug interactions, both with other prescription drugs and with other substances in general. Part of a pharmacist's job is to know about these interactions.

In the UK, and most countries have similar regulations, a quick look at either the Specification of Product Characteristics (SPC) or the enclosed Patient Information Leaflet (PIL) will show numerous warnings about Contraindications (See here for examples - http://www.medicines.org.uk/emc/)

As for the thought that drugs pass Phase III clinical trials and that's it, they're let loose on an unsuspecting public - balderdash. Most countries have something similar to the UK's [url=http://www.mhra.gov.uk/Safetyinformation/Reportingsafetyproblems/Report… Triangle Scheme[/url], which means the drug is monitored closely by the whole range of healthcare professionals

Hmmmm - didn't like the link tags...

This should be better

http://www.mhra.gov.uk/Safetyinformation/Reportingsafetyproblems/Report…

I'm sure this has been asked (possibly answered)somewhere on this site before, but if water has memory then where/how do homeopaths obtain "pure water" for use in their dilutions?

trll:

It is speculated that minoxidil may increase blood supply to hair follicles, whereas sildenafil turns out to be particularly good in inducing vasodilation in a specific body part.

Just to elaborate, because I think it's very cool, sildenafil is used in a number of non-ED applications. For instance, there are women who take it, and it's not for sexual problems. (Viagra has been rather disappointing in female sexual dysfunction.) Cooler still is its use in neonatal intensive care units. It has saved the lives of a number of "blue babies", increasing blood flow in their bodies to compensate for their inefficient hearts until surgery could correct the underlying problem.

@Sauceress:

Water has a memory, but it is a particularly ill-motivated pupil:

It forgets rather easily: distillation makes it forget, obviously, but the water containing a homeopathic solution will also forget its lessons if it is dumped into a body of water such as a lake or river. This is fortunate, because otherwise we'd all be at the mercy of hundreds or thousands of competing preparations-- homeopathic goofballs, if you will.

It learns only with difficulty: lessons must be literally beaten into it by a willful instructor. The preparation must be "succussed" after each dilution, and this includes bashing the container against the wall. Preferably wooden, as I recall.

It is left as exercises for the reader to show how, say, a waterfall with fallen trees in it fails to generate homeopathic solutions, and how any homeopathic solution dumped into said waterfall is destroyed.

@Sauceress:

Sorry, I forgot to add that one can conclude from the foregoing that any old water the homeopath finds will suffice.

AFAIK they use double distilled water (that still has impurities in it, many if not all of them in higher concentration than the "active ingredient" will be in the final product - and those are succussed, too, so one has to wonder how intelligent water has to be to understand it's not supposed to remember those impurities and make them "remedies"). Of course even if water had a memory (the way homeopaths think it has), it still wouldn't explain
a) why other solvents (e.g. ethanol) can be used
b) how the memory can be transferred to sugar pillules
c) how this memory is kept once the "remedy" enters the body
...
Of course none of this matters as long as homeopaths can't even show that their remedies work at all - with studies that are both clinically significant positive AND replicable.
So I guess madder is right, they may use double distilled water, but as water seems to be incredibly intelligent it doesn't really matter what kind they use.

Homeopathy is great since based on totality of symptoms of the whole person, not just disease he\she is suffering. I suffered from allergy and had lost all hope.. somebody suggested homeopathy.. i doubted if it will work fast enough or will it work at all... it did... and i got well. Since then i keep on trying more ab't homeopathy.. homeopathic remedy is not just magic water... if u think so.. then try it... and u will amazed at the results!!

homeopathic remedy is not just magic water... if u think so.. then try it... and u will amazed at the results!!

Really? And how do you know that the "results" I get from homeopathy are any different from the results I'd get from simply waiting for the condition to subside on its own, as many conditions do?

The answer is that you don't see what happens to any one person, you study it scientifically by looking at an experimental group and a control group. When this has been done the results indicate that those getting the homeopathic remedies don't actually improve any faster or more thoroughly than those getting placebo.

A major part of CBT (ant is predecessor, REBT) involves challenging irrational, unrealistic and fantastic beliefs and worldviews.

@Joseph,
If that's the case, all these homeopathy quacks could use a good dose of it!

@66, Dullman is staggeringly ignorant and a compulsive liar.
I'm waiting for him to produce one (only one) fully documented, incontrovertible example of homeopathy having cured a non-self-limiting condition. I've posted this request several times over the last 3 or 4 years to any homeopath who care to stump up the goodies. But no case has been forthcoming. 200+ years of patient care and meticulous record keeping, and there should be case examples crawling out of the woodwork. But in fact after 200 years the total number of case examples is zero... fuck all.
Homeopaths are medical frauds and I'd say most of them know it. They take money under false pretences to "cure" self-limiting or invented illnesses, which by definition need no medical intervention. If it were the financial industry they would quite rightly be in prison.