Tuesday, March 2, 2010

science of socially shared stories

Quotation from

HEAD CASE: Can psychiatry be a science
by Louis Menand
The New Yorker, March 1, 2010, pp. 68-74.

In this article, Louis Menand, a professor of English at Harvard, reviews The Emperor's New Drugs: Exploding the Antidepressant Myth by Irving Kirsch, a professor of psychology at the University of Hull, United Kingdom, and professor emeritus at the University of Connecticut in the United States.

Kirsch, according to Menand, concludes from his meta-analyses of antidepressant drug trials that antidepressants are just fancy placebos. But, then, how come that each drug had statistically significant superiority over the placebo when it was approved in the drug trial?

Kirsh argues that despite the scheme of double-blind tests, the patients (who are paid) can assume whether they're taking the drug or not by detecting in them side effects such as nausea, restlessness, dry mouth, and so on, which the placebo does not cause. Menand summarizes Kirsch's argument:

This means that a patient who experiences minor side effects can conclude that he is taking the drug, and start to feel better, and a patient who doesn't experience side effects can conclude that she's taking the placebo, and feel worse. On Kirsch's calculation, the placebo effect ― you believe that you are taking a pill that will make you feel better; therefore, you feel better ― wipes out the statistical difference. (p. 70)

The placebo effect is an established fact in experiments.

He [=Kirsch] cites a 1957 study at the University of Oklahoma in which subjects were given a drug that induced nausea and vomiting, and then another drug, which they were told prevents nausea and vomiting. After the first anti-nausea drug, the subjects were switched to a different anti-nausea drug, then a third, and so on. By the sixth switch, a hundred percent of the subjects reported that they no longer felt nauseous ― even though every one of the anti-nausea drugs was a placebo. (pp. 70-71)

It seems to me that science of the placebo is more important than science of developing new drugs, if your drive is science, not profit.

Menand reports that the effects of different treatments are only mixed:

Later studies have shown that patients suffering from depression and anxiety do equally well when treated by psychoanalysts and by behavioral therapists; that there is no difference in effectiveness between C.B.T. [=cognitive-behavioral therapy], which focuses on the way patients reason, and interpersonal therapy, which focuses on their relations with other people; and that patients who are treated by psychotherapists do no better than patients who meet with sympathetic professors with no psychiatric training. Depressed patients in psychotherapy do no better or worse than depressed patients on medication. There is little evidence to support the assumption that supplementing antidepressant medication with talk therapy improve outcomes. What a load of evidence does seem to suggest is that care works for some of the people some of the time, and it doesn't much matter what sort of care it is. Patients believe that they are being cared for by someone who will make them feel better; therefore, they feel better. It makes no difference whether they're lying on a couch interpreting dreams or sitting in a Starbucks discussing the concept of "flow." (p. 71)

Is this then, science of care, rather than science of the placebo, that should be explored? Or is it science of social expectation?

A narrative becomes a story when it matches social expectation; when it is socially (and/or culturally) accepted and shared. What we may need may be science of socially shared stories.


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