That this House welcomes the double-blind study conducted at the outpatient clinic at Jundiai Medical School in São Paulo, Brazil, which consisted of patients with moderate to severe depression; notes that patients were randomly assigned to a double-blind treatment with individualised homeopathic Q-potencies or fluoxetine (Prozac); further notes that the non-inferiority analysis indicated that the homeopathic Q-potencies were not inferior as compared to fluoxetine in treatment of this sample; observes that the study is the first randomised controlled double-blind trial with a reasonable number of subjects to draw conclusions about the homeopathic treatment of depression; acknowledges that homeopathy is recognised as a medical specialty in Brazil; and calls on the Government to carry out further research into this area.

I guess he’s completely ignored … well, the fact that if homeopathy has any specific effect we might as well burn pretty much every textbook on Earth, but also the recent meta-analyses suggesting that antidepressants are not more effective than placebo for less than severe depression. While I do take issue with those studies, as I mention towards the end of this post – just above the lolcat and agree with the very nice analysis of Richard Friedman MD in the New York Times, I do think there is a kernel of truth. I wonder if severity here is a marker for biological illness (such as melancholia) as opposed to a reaction to the “slings and arrows of outrageous fortune”. In other words, I suspect that groups made up of milder depressions contain more people who – despite meeting the operational criteria in DSM or ICD – do not have a biological illness. If that is so, it is perhaps not surprising they don’t respond well to biological treatments such as medication. The corollary of that would be that groups of more severe depression might contain a higher proportion of biological illness, and therefore respond better to biological treatments (similar to the way that ECT works better the more severe the depression).

In clinical samples, 2/3 of depressed patients have a Hamilton Depression Rating Scale score indicative of severe disorder. This study (full text free, so go check it out yourself if you want) they used the Montgomery Asberg Depression Rating Scale. Scores of 35 and above on the MADRS are generally taken to indicate severe depression. The mean baseline MADRS scores in this study were 27 for the homeopathy group, and 28 in the fluoxetine group. Moderate depression – which I think 3 recent meta-analyses have said fluoxetine is no better than placebo at treating. After 4 weeks the mean MADRS scores had dropped to 9 and 12 respectively, with no statistically significant difference between the two groups.

Sadly (though unsurprisingly), there was no placebo arm. This is my main problem with the “non-inferiority” trials I’m seeing lately. The results for the study treatment are predicated on some other treatment working – and working well. In this case we can’t say that fluoxetine definitely works (compared to placebo) for moderate depression, so where does that leave the results of this trial?

I’m not amused either. If they want to prove that homeopathy works, do a properly-controlled randomised placebo-controlled trial – just don’t waste any public money on it, because:

I want in this post to talk about the notion that withholding belief does not require justification or evidence – rather, belief does. I want to try to clarify the difference between absence of belief and belief of absence, as they are very different, and many people seem to conflate them – in various areas of life.

Consider for a start, the sky. I believe the sky to be blue. I believe that based on the evidence of my eyes telling me so. However, the reason I am justified in accepting such weak evidence is that (a) there’s not any compelling evidence it’s not blue (spectacular sunrises excepted); and (b) there’s not really any forseeable consequence to being wrong – who cares if it’s actually green?

Now suppose that someone were to tell you that the sky on Mercury is pink. Suppose it was someone with authority who told you so. And further suppose you chose to suspend belief pending the production of some credible evidence for the sky being pink on Mercury (or in fact there being a “sky”, I know): photos say, or even some plausible astrophysics that suggests it’d be pink. Is there anything wrong with that position? Philosophically? Logically? Rationally?

Of course there isn’t. Rather, to believe that the sky on Mercury is pink simply because someone says so – and in the absence of any evidence – would be foolish, no?

It is not that one would believe that Mercury’s sky is definitely not pink; it is simply that one doesn’t believe it to be pink. There’s an important difference. Without evidence to support the belief the sky is not pink, that belief would be no more justifiable than believing without evidence that it is.

Absence of belief, not belief of absence.

In medicine, many claims are made – by drug companies, by researchers, by alt-med practitioners, by patients and families, by advocacy groups, by politicians and bureaucrats …. Not all of these claims will be true. It would be nonsensical to maintain that as doctors our default position should be to believe these claims until they are disproven – until we can justify non-belief. At that point we have in fact justified belief of absence, and we can say, for instance, that a pill does not work.

However, the sceptical position: withholding belief in that treatment until presented with evidence that it does in fact work, is simply absence of belief – and clearly needs no justification; any other approach would be irrational, unprofessional, and potentially dangerous.

While the consequences of belief/lack of belief are different in different situations, the logical or philosophical nature does not change. Therefore I say again: it is belief, not lack of belief, that requires justification.

- Obi Wan Kenobi, in Star Wars Episode IV: A New Hope

I bang on a lot about the importance of rationality, and critical thinking; not blindly accepting information as given, but checking it out first. However, there is a lot of information out there, and analysing in detail every piece of information received would actually be paralysing: every moment would be spent appraising information, leaving none available to act – thus rendering the information useless. So, how to approach all this information, from multiple sources?

I was thinking about it this morning, and realised I tend to lump sources into three major groups:

1. Sources I know to think critically, and to examine claims even when they are from sources they generally agree with (striking examples of this were found after James Randi, widely admired and respected skeptic and critical thinker, posted a blog article expressing some doubt about the degree of global warming that is anthropogenic).
   Generally I accept information from these sources unless there is particular reason not to – which could be a marked diversion from accepted knowledge, or various signs of poor analysis on their part, or it conflicts with something I know well…. Basically I guess my default position is set on “accept” for these people, but the switch can still be flicked to “analyse” if they say something that raises a red flag.
2. Sources that I know to spout bogus bovine bollocks (examples: Meryl Dorey, and Deepak Chopra (who laid this one recently: “The essential nature of the material world is not material; the essential nature of the physical world is not physical; the essential stuff of the universe is non-stuff.” – to which I would reply: “the essential reality of your words is non-reality”).
   I figure there are three options with these people: (i) read what they’ve said, then go to the trouble of investigating, and inevitably finding it to be bogus, despite often a veneer of attractiveness; (ii) read but ignore, despite any apparent plausibility; (iii) don’t read at all (this is my preferred option).
3. Sources in the middle, whose claims or information I will check out to a greater or lesser degree depending on its goodness of fit with what I already accept about the world, before accepting.

I suspect others – including people on the “other side” on (non-)debates such as the vaccine manufacturoversy might well have similar “agree, disagree, analyse” groups. They simply allocate sources to these groups differently from me.

If we are approaching this over-information problem in a similar way, I would say it’s not ok to cast aspersions on others’ thinking or intelligence – or perhaps even their overall approach to information: that being accepting as fact what their trusted source tells them, and not paying attention to what their “ignore” group say. To do so would be unfair, as well as causing needless offence – which would of course shut down any meaningful debate.

On the other hand, if you don’t have a sizable middle group (that is: sources whose contentions you require critical analysis of before accepting), then please, feel free to be offended by this: you’re a damn fool. – And by the way, that’s the case even if you’re “on my side”. If your world is divided wholly into people with whom you agree or disagree uncritically the result is that you will never apply any critical reasoning to anything: you will either believe or not believe, based entirely on the source, or the mouthpiece.

In this context it’s worth mentioning how I allocate to my ‘listen’, ‘ignore’, and ‘analyse’ groups, because this, I maintain, is where there is a difference between those in the rationalist/skeptic camp, and those who follow Chopra, and antivaxxers, and bioidentical hormones, and astrology, and homeopathy …. I will only decide a source is in my ‘listen’ or ‘accept’ group if there is good evidence that they (a) know what they’re talking about, and (b) display the kind of rational thinking and lack of bias that was displayed when prominent rationalists took James Randi to task. Conversely, I’ll only ignore a source once I’ve seen clearly that “the essential reality of their words is unreality” … or if they write for HuffPo, which seems to be basically the same thing

Everyone else is in the analyse category – even if I like what they say (hell, even if I particularly dislike it, such as the Kirsch et al meta-analysis purporting to show that antidepressant medications don’t work … btw there are problems with his study that are apparent once you analyse it and its relevance to the real world, but that’s not the point of this post).

The point (again) is simply that I think we need to get people to start thinking. About everything.

1. A summary of a new paper reporting the current state of play with antidepressants in pregnancy – always a difficult area.

2. A revamped version of a letter a colleague and I wrote, critical of a recent article in the Australian and New Zealand Journal of Psychiatry. It wasn’t published, as the editor thought the following article addressed our concerns. It didn’t. So I’m going to post it here, in some more detail.

3. I think I’m going to do a talk for our psychiatrists and psychiatry trainees about science-based medicine and critical thinking. For that I’ll be pulling together a bunch of stuff about evidence, critical thinking, and science. I think I’ll post it here when I’ve done.

Whew. That ought to keep me out of trouble.

“Integrative medicine”? you ask. “integrative medicine indeed. You might or might not have heard this term before, or paid it much mind. I certainly had not until I became a regular reader of Science-Based Medicine - which I recommend most highly. Proponents of “integrative medicine” will use words like “holistic”, to imply that regular (“disintegrative”??) medicine fails to take into account the people who are our patients, or in fact anything outside a narrow and excessively-rigid view of medicine and evidence. Of course, this is a nonsense, and nothing more than a smokescreen to promote use of “treatment” modalities with no evidence or scientific plausibility, such as homeopathy, chiropractic, naturopathy, acupuncture, allopathic medicine …. whatever. Some of them are probably anti-vax as well, though I have no evidence for saying that

Medicine, done properly, does indeed take into account the whole person, their illness, and their situation. Resources and pressures may well impact upon our ability to do what we know we should, but that doesn’t equate to a failing in “disintegrative medicine” (if I may continue to use my “counterpoint ad absurdum”). “Integrative medicine” is nothing more that the Complementary and Alternative Medicine (CAM) wolf in sheep’s clothing (“holistically” listening and taking into account the whole person, not like those other doctors).

What’s the harm? … http://whatstheharm.net/

There is clear evidence that these modalities do not work, and some suggestion they cause direct harm. Indirectly, by delaying or avoiding proper treatment, and/or by giving false hope and taking money, and by unwarrantedly denigrating proper medicine, they cause significant harm as well.

One last thing: the “Bravewell Collaboration” is mentioned in the flyer. I looked and it is all about “integrative medicine”. I will quote:

“In 1992, the US government founded what is now the National Center for Complementary and Alternative Medicine (NCCAM) with the express purpose of exploring complementary and alternative healing practices in the context of rigorous science. Because of this NIH-funded research conducted in leading medical schools across the country—and research by many other prestigious organizations such as the American Heart Association, the National Cancer Institute, and National Academy of Sciences—many therapies once thought to be “fringe” are now proving to be both effective and safe.”

This is either a bald-faced lie, or a complete and utter lack of any ability to understand the principles of science and scientific evidence. Small, uncontrolled studies with poor methodologies find small benefits of various CAM treatments – as they will tend to do with any modality of treatment: that is precisely why we do large, blinded, and properly controlled studies. When these larger, more rigorous, properly controlled studies are done, they consistently find no benefit from CAM treatments. This is then explained away in a number of ways – my personal favourite being that “placebo acupuncture must be an active treatment just the same as normal acupuncture” – to address studies that show the placebo arm to do as well or better than the acupuncture arm). “Integrative medicine” is a trick and a lie, aimed at bringing into the mainstream treatments with no true scientific plausibility or clinical evidence behind them.

I still have the invitations …