I was stunned by the final two paragraphs of Peter Simons’ report No Evidence that Psychiatric Treatments Produce “Successful Outcomes.” In a viewpoint article in JAMA Psychiatry, the authors claimed that there is no system like Medicare collecting standardized data that is tracking changes in outcomes over time, and therefore we have no way to assess whether outcomes are continuing to improve. They define the target outcomes as “the prevention of undesirable events, such as death and disability, and the achievement of desirable ones, such as remission.”
They appear to ignore the abundant existing evidence that, on those specific targets, modern psychiatric treatment appears to lead to worsening outcomes. Like religious faith that often stands more firmly when faced with contradictory evidence, clinging to their belief that their treatments are beneficial, they don’t take up the serious challenge posed by evidence of worsening outcomes. Instead, they write as if the problem we have is a lack of a system that can chart how our treatments are continuing to improve outcomes.
Though there is no evidence of outcome improvement from the existing treatments and considerable evidence of the opposite, rather than questioning their use, we just need a system that can help us improve their efficacy. Stunning!
Earlier, I wrote a piece, “In Defense of Placebo Psychiatry,” in which I tried to see things from a prescriber’s point of view. Feeling there was no defense for this apparently willful misunderstanding, I decided to write a facetious “In Defense of Incoherent Psychiatry” in which I imagined things from the point of view of the authors of the JAMA Psychiatry piece.
The following email exchange was discovered subsequent to a discovery order in a suit against Farma News Corporation for claiming there is abundant evidence of efficacy for psychiatric treatment.
Dr. Abe Honestman:
Wow! This is really bad. We have no long-term data about whether our treatments have actually been producing improvement in outcomes. And we know there are damaging side effects. We’re sure the treatments work, but when we scoured the literature looking for clear evidence to support that conclusion, we couldn’t find any. Some studies even question the efficacy of the existing treatments, which we all know work.
Dr. Forth Rite:
That’s true. There are the clinical trials and short-term studies that show our treatments work. But other than our personal experience, we have no real studies of whether outcomes from our treatments are actually improving. And we know that the personal experience of many practitioners has historically supported practices that are now known to be useless or harmful. So, we have to tell the truth about this state of affairs; this is legitimate scientific information that our field needs to face.
Dr. Abe Honestman:
But if we say “There’s no evidence that existing psychiatric interventions improve outcomes,” those people who feel their treatment is helping might stop and lose that benefit. Some people will be worse off.
Dr. Fourth Rite:
Yes, but some who are experiencing negative effects will be spared. Those who are not experiencing any benefit will be able to use their resources to look for something that might actually help. It’s simply the truth and so, as scientists, that is what we have to report. It’s important for our profession to face this reality and develop real evidence of efficacy to justify our treatments.
Dr. Market King:
How about if we phrase it differently. How about pointing out how other medical fields have made significant progress over the past 30 years and we have not been able to do the same because we have no body of research that can clearly demonstrate efficacy at all. In order to make and demonstrate continuing progress like the other specialties, we need to find a way to do research that can actually show that treatment is effective.
Dr. Abe Honestman:
But the notion that we need this push to show that progress is continuing can only be based on the idea that significant progress has been made. And what we found was a lack of any studies able to demonstrate clear efficacy from our current treatments in reducing death, disability, and increasing remission. So, such a statement would be misleading. Some might even call it a lie.
Dr. Market King:
It doesn’t matter. No significant journal would print the results of our research if we said there is no evidence that psychiatry works. And, to boot, we’d get “cancelled” like Loren Mosher was. We’d never get another job in academia.
Drs. Honestman and Rite, on hearing the wise counsel of Dr. King, agree to his phrasing and the piece is published. But since everyone knows psychiatric treatments are effective, their report of a lack of evidence to support that belief was simply ignored.
Through the Looking Glass
Like the Red Queen, we simply don’t need evidence to support doing things we already know are the right thing to do.
“[T]here’s the King’s Messenger. He’s in prison now, being punished: and the trial doesn’t even begin till next Wednesday: and of course, the crime comes last of all.”
“Suppose he never commits the crime?” said Alice.
“That would be all the better, wouldn’t it?” the Queen said.
Alice felt there was no denying that. “Of course, it would be all the better,” she said, “but it wouldn’t be all the better his being punished.”
“You’re wrong there, at any rate,” said the Queen. “Were you ever punished?”
“Only for faults,” said Alice.
“And you were all the better for it, I know!” the Queen said triumphantly.
“Yes, but then I had done the things I was punished for,” said Alice, “that makes all the difference.”
“But if you hadn’t done them,” the Queen said, “that would be better still; better, and better, and better!”
(Lewis Carroll, Alice in Wonderland )
Like I said, stunning.
But then I realized I was wrong.
As in my piece “In Defense of Placebo Psychiatry,” if I stepped back and tried to look at the situation from the perspective of the prescribers, there is understandable confusion based on their actual experience. First, they are trained to accept the empirical findings in the research journals. They are generally not taught about the nitty gritty of doing research with its problems of pharmaceutical industry funding and bias, the interaction of levels of significance with unreported negative results, the failure to use psychoactive placebos, and much, much more. From these questionable studies that they were taught to trust, they learn that, in clinical trials, the medications do appear to reduce symptoms.
Next (again, as I described in my piece “In Defense of Placebo Psychiatry”), after they prescribe, they generally see positive results given that those who get worse or don’t feel they are benefiting tend to drop out of treatment. And given the power of the placebo effect and natural healing over time, they have no way of discerning if the positive results they see are truly due to treatment.
And finally, knowing that no treatment works for everyone, it is not hard to come up with explanations for the few people who remain in treatment long-term despite the fact that they don’t get better. For example, prescribers can conclude that those with negative outcomes have some form of “treatment resistant depression,” which is precisely why we need to continue to improve our treatments that our clinical trials and experience in practice have shown are, in fact, effective.
Given the clinical trials that led to drug approvals and the subsequent experience of prescribers, psychiatry has plenty of evidence of the “efficacy” of its treatments, which appears to tell a story of progress. But what is ignored is the key point of the viewpoint article in JAMA Psychiatry, which is that psychiatry actually lacks evidence of clinical “success outcomes” for its treatments.
This is key because we would assume that treatments that are found “efficacious” in short-term randomized controlled trials (RCTs) would translate into positive “success rate outcomes.” But, in this instance, the authors were acknowledging that there is no evidence that is so. In fact, on the target outcomes, there is evidence of the opposite. The actual outcome evidence we have shows a higher rate of death and disability and no signs of remission.
And I do have to admit, that’s not funny.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.
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