Evidence, Bias, and Anecdote

Sandra Steingard, MD
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I suspect that many people who come to this website are not fans of psychiatry.  Although I am also critical of various aspects of psychiatric practice, I continue to go to work every day, where I treat many people.  One of my goals with this blog is to try to articulate how I integrate into my work my own and others’ criticisms of the field.

There is much talk today in medicine about evidenced-based practice. This means that one bases treatment decisions on the best data available.  I suspect the current emphasis on evidenced-based practice is a reflection to some extent of how so many of us tend to use anecdote or habit to guide us even when research suggests otherwise. In addition, studies – especially double-blind controlled studies – are important, but often in the course of a day a physician needs to make decisions for which there is not an adequate database.  Anecdotal experience, on the other hand, can be compelling but misleading. In psychiatry we know that the placebo response in most treatment studies is high.  Dr. Irving Kirsch has studied this in detail and his book, The Emperor’s New Drugs, offers an excellent discussion of the placebo response.  When someone takes a pill and improves, it is impossible to know if that improvement is due to the specific physiologic actions of the drug or relate to non-specific effects (i.e., those that do not depend on the specific attributes of the drug in question) that we call the placebo response. The person is nevertheless improved – that is not in question. What we do not know is what is responsible for that improvement.

My experience with the drug lamotrigine taught me how easy it can be to be misled about the benefits of a drug.  When this drug was being touted as a treatment for depression in people diagnosed with bipolar disorder, I was far along in my skepticism about new medications.  Depression in that context can be very difficult to treat effectively.  There was one double-blind study to suggest lamotrigine might be effective. It was small but promising.  I work with many people who have been ill for many years and who have tried a variety of treatments – both pharmacologic and non-pharmacologic – without success.  Many of them suffer enormously.  I began to prescribe lamotrigine to appropriate patients. Frankly, I found it surprising that my patients seemed to get better. Colleagues had similar experiences and I decided that lamotrigine was effective. Several years later, I learned  that the larger studies that are required for FDA approval did not support the earlier findings.   Those results were not widely known or reported. Upon learning this, I talked with each of my patients who was taking that drug.  I found that most people were not significantly improved from where they had been before they started taking the drug. What happened?

What I found was that although initially patients reported improvement, over time the majority had either drifted back to their previous states of depression or had tended to experience waxing and waning levels of depression. As this happened, I would discuss various treatment options but I did not stop lamotrigine because in my mind the drug worked. I assumed that if I stopped it the patient would only get worse.  I informed my patients of the new information and most elected to stop taking the drug. Although they were no better after stopping the drug, they were no worse.

In future blogs I will describe how I am trying to reduce the effect of these sorts of biases in my clinical work.  I cannot eliminate the placebo effect but I hope that with systematic tracking of my patients, I will be less likely to remember the dramatic cases or the ones that fit my hypotheses about what is and is not effective treatment.

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6 COMMENTS

  1. I want to personally and publicly thank Sandy for her willingness to bring attention to Whitakers work in our community, and for her willingness to share her years of experience with others. She is , by far, one of the most thoughtful, talented and hard working physicians, and those working with her are fortunate to have her expertise. I look forward to following her blog regularly.

  2. This actually fits with my experience. At first, I felt great (even though I wasn’t severely depressed to begin with) but over time, it faded to nothing. I wasn’t enough of a quiet patient to continue taking what I had deemed a useless drug, though, so I discontinued.

  3. Anyone “diagnosing” anyone with a junk science DSM fraud stigma to push ANY lethal psychiatric drugs is committing 100% FRAUD as Dr. Fred Baughman, Neurolgist, exposes in many web articles, appearances before Congress and his book, ADHD FRAUD that alos covers bipolar and other bogus stigmas in the DSM Satanic “bible” of psychiatry based more on revelation than science per Dr. Marcia Angell in her excellent book, THE TRUTH ABOUT THE DRUG COMPANIES. “Dr.” Steingard should also read Dr. David Healy’s excellent book, MANIA: A SHORT HISTORY OF BIPOLAR DISORDER, which exposes how this latest fraud fad explosion of a new garbage can stigma like schizophrenia was more about new lethal drugs on patent than a frenzy of new manic depressive patients which had been very rare in the past per Dr. Healy and others with most recovering before the predations of the the mental death profession in bed with BIG PHARMA and government hacks.

    Because of the protests here of her bogus profession professing nothing but lies to do the most harm possible to make profit centers from others’ suffering, Dr. Steinberg will probably become more entrenched in her role as part of the power elite destroying any dissidents who dare question their totalitarian dictatorship with psychiatry as the latest SS thugs performing psychiatric rape in the guise of medicine.

    SHE is delusional and should read the book, THE PEOPLE OF THE LIE, by Dr. M. Scott Peck, Psychiatrist, as he wrestles with the harm done againt humanity by evil people. He demonstrates that they suffer from malignant narcissists who see themselves without any faults so they must scapegoat others and rob them of their lives and liveliness as is typical of the mental death profession. He notes that EVIL is LIVE spelled backwards and who robs people more of their lives and liveliness than the mental death profession totally incapable of seeing and “diagnosing” thier own evil predation on others to defend their sick selves. Dr. Steinberg’s willful blindness to others human, civil and democratic rights is very scary and also described well in the book, POLITCAL PONEROLOGY.

  4. Interesting to read about Lamictal here and placebo effect. Each medication I was on hold memories. While in hospital, it was Lamictal that the weekend doctor told me “this medication is going to make you feel better than you have in yearsssssss” I held onto those words. Upon returning to life, every two weeks, on a Monday I would increase the dose by 50mg and feel better. Then, the feeling better would taper until the next increase. Maxing out, we ultimately stopped the medication and moved onto the next.

    My realization of this experience, years later upon accepting once losing the bipolar diagnosis, whether that true or not in reality of any label, it felt odd and this odd feeling created contemplation which continues today.

    What I realized after coming off medications is that while on medications, medications were always an option…similar ingesting coffee for a headache in the AM, instead of going the two days to let it clear out of the system. So long as the coffee is available it is option. Choice has to come from within.

    Without medications, I have experiences and I have options. My continued option is to figure out from within the best way to navigate my journey. Until meds were out of the picture for the most part, meds were my first choice when not feeling well…there was always another option to try or revisit. Hearing the many reasons we have so much variety of medications as there are many people in the world. 25+ medications later and years evaporated, I live with a healthy presence in this beautiful world without a medication of any sort ingested on a daily basis.

    Today, I don’t wait for the next appointment to find out if my med will be increased, or or or. I look within and perhaps the placebo effect is I want to feel well, therefore I can? Our energy is best put where our desires are. WHen I wanted those pills to work, they did…but ultimately I was treatment resistant. Yet, without meds, I am well. Diet, exercise, spirituality, believing…relying on me and what I do to feel well. Yes, the placebo effect I understand quite well…but the placebo effect is not sustaining should other lifestyle changes not occur.