The Truth Wears Off. Is there something wrong with the scientific method? The tendency of the effect size of scientific results to decline over time. New Yorker [PDF]

Lo han colgado en Reddit en PDF. Mind Hacks le dedicó varias líneas y, además, está escrito por Lehrer, que es el autor de otro blog obligado y el escritor de Was Proust a Neuroscientist? Extiende los hallazgos del autor griego (¿Ionnadis?) que ya ha sido comentado en éste y en otros blogs (vendría a decir algo así como: cuanto más aparatoso sea un resultado científico, la posibilidad de que sea verdad disminuye notablemente). El artículo de Lehrer comienza con una historia significativa: la del hallazgo de que los antipsicóticos atípicos han perdido eficacia si se comparan los estudios aleatorizados a doble ciego de hace unos años con los de ahora.

The Truth Wears Off. Is there something wrong with the scientific method? The tendency of the effect size of scientific results to decline over time. New Yorker [PDF]: "submitted by sixbillionthsheep
[link] [1 comment]"

A Timeline of Psychoanalysis

No quiero que se me pase mencionar este texto de E Young-Bruehl et al., parece interesantísimo. No es posible conseguirlo a través de Amanzon.com, por ahora, porque se ¡les ha acabado! El video clip es claro y cuenta los detalles específicos del texto. Para todos aquellos con interés en la historia de la psiquiatría y del psicoanálisis (revisionista o no).

A Timeline of Psychoanalysis: "

Elisabeth Young-Bruehl demonstrates ‘One Hundred Years of Psychoanalysis a Timeline: 1900-2000 from Caversham Productions on Vimeo.

A timeline of the history of psychoanalysis, One Hundred Years of Psychoanalysis, A Timeline: 1900-2000, has recently been written by Elisabeth Young-Bruehl and Christine Dunbar. The nearly seven footling timeline is graphically depicts the activities of the various schools of psychoanalysis across the twentieth century. In the above video, Young-Bruehl demonstrates the timeline and discusses its content. As Young-Bruehl describes on the publisher’s website,

We felt that a timeline of psychoanalysis should be Darwinian in the sense that it should show a descent from an original ancestor, Freud. It should show graphically the evolution of different groups and concerns out of an original powerful impulse and vision. But it should not accept the assumption common among analysts that the early, pre-WWI, schismatic history of psychoanalysis produced groups -Adlerians, Rankians, Jungians-that simply had no place in the later history of psychoanalysis or stopped evolving or became extinct after they split from Freud. However, we did not want to imply that the sub-speciation of psychoanalysis was a “survival of the fittest” phenomenon… So we organized our story on what might be called Plutarchian principles, showing “parallel lives” or life forms of psychoanalysis.

"

¿Por qué a los Residentes nos decepciona la MBE/PBE?

La pregunta viene en relación a un seminario de investigación que se imparte a los residentes de psiquiatría del área norte y sur. La persona que lo imparte, sin lugar a dudas una de las personas más brillantes de la red, pronunciaba para mi asombro que para estudiar psiquiatría lo fundamental se encontraba en la medicina basada en la evidencia y que los libros estaban muy bien pero para estar al día y saber con profundidad de un tema había que recurrir a los artículos.

Curiosamente en un breve descanso comentaba con mi compañera de residencia el asombro por dicho comentario, estábamos de acuerdo en que al final es mucho más placentero leer un buen libro de psiquiatría que mil artículos por muy buenos que sean, no dejo de preguntarme qué pasa con la Psiquiatría Basada en la Evidencia que deja muchas veces indiferentes a los residentes de psiquiatría que concluyen que lo que le pasa a sus pacientes es más fácil de encontrar en un buen libro que en mil artículos; me pregunto dentro de cien años donde estará Eduardo Vieta en la historia de la psiquiatría y las dudas cada vez más profundas que me produce tanta evidencia supuesta.

Actualmente mientras pasaba a formato Word una escala sobre la adherencia al tratamiento, concretamente la B.M.Q., una de las preguntas era “si no cree que muchas veces el médico pone medicinas porque no dispone de tiempo para estar con el paciente”, pues eso, en fin, podría resumir el momento actual de nuestra psiquiatría; aquella que hace que cada vez más los residentes nos creamos menos el modelo sobre la depresión y mucho menos eso que llamamos trastornos mixtos ansioso-depresivo.

la separación entre la maravillosa M.B.E y la práctica clínica se hace cada vez más palpable entre los residentes que entienden que hay algo que nadie les explicó al coger esta especialidad y que tiene que ver con un conocimiento profundo de la psicopatología y una actitud critica cada vez mayor con una parte de la ciencia.

En unos años no habrá en los manuales histéricas ni narcisistas; pero, al menos sí en la consulta; algo que por mucho que quieran tapar no se podrá. Porque tal y como decía mi brillante compañera esta especialidad tiene una evidencia menos evidente que en otras especialidades por mucho que algunos se empeñen en decirnos lo contrario.

Nota: Lo anterior fue escrito por uno de los residentes con el que tuve el placer y la buena fortuna de trabajar en el Hospital Universitario de Gran Canaria Dr Negrín antes de venirme a tierras más frías. Lo he editado muy poco porque creo que capturo así la irritación y la frustración del psiquiatra en formación cuando las respuestas que se le ofrecen pasan por el alambicamiento nosotáxico de los engendros clasificatorios actuales (en realidad no son los sistemas clasificatorios per se los responsables de ello, es la “cosificación” de los mismos con el consiguiente reduccionismo implacable inherente a los estudios aleatorios con controles de la MBE bajo el control de Big Pharma).

What do we want our diagnoses to do?

La entrada de Ghaemi es certera y simpatizo con su crítica de la perspectiva postmoderna (sui generis - ya que no creo que a Allen Frances, el artífice del DSM-IV, se le pueda etiquetar de postmoderno). Su crítica es al "Anything goes" de Feyerabend y no creo que le hace justicia a Frances que ocupa un espacio menos relativista en lo concerniente a la psiquiatría clínica... Me temo que aquí hay rencillas o resquemores anteriores que salen a la luz, ya que mi lectura de Allen no es la que ofrece Ghaemi. Y sin embargo, este hombre - joven - del que hablaba el otro día en una reunión interesantísima con varios discípulos de Félix Letemendia, es uno de los pocos psiquiatras norteamericanos con cosas interesantes a aportar en Psicopatologia (así con mayúscula).

En otro momento escribiré acerca de Letemendia, que se formó con López Ibor el viejo, con Martín Santos (que era donostiarra como él) y, por supuesto, con Castilla del Pino.



What do we want our diagnoses to do?: "

In debates with some leaders of DSM-IV, it has become clear to me that they are postmodernists who view science as hardly more valuable than stargazing. Which is not to say that science is simplistically "true." There is some arbitrariness to science; there are hypotheses that need to be confirmed or refuted; scientists hold to their ideas beyond the data, against the data, frequently; scientists are humans. But science is, and has been, a self-correcting endeavor. Truth is corrected error; falsehood is accepted and studied, not proclaimed and rejected. Science is not religion.

But some of the leaders of DSM-IV have drawn postmodernist conclusions, and decided to replace science with "pragmatic" opinions, a psychiatric gerrymandering of diagnoses to the tastes of those sitting around the DSM table. This has produced a scientifically poorly-founded nosology; a diagnostic system that is "abused" because it easily is abusable.

The key is to ask the question: What do we want our diagnoses to do? It seems to me that there are two opposed answers: One answer is to find out the truth about mental illness; to understand it well so that, if present, it can be treated correctly. Another answer, based on a rejection of science and a cynicism about mental illness, is to view nosology as having only one purpose: to get along. In the case of psychiatry as a profession, it is a means for everyone to make a living. The authors of DSM-IV will proclaim this "pragmatic" goal as something that sounds more benign: to produce good outcomes in the real-world of practice. But what does this mean when science counts for little and you don't think you are actually capturing real diseases? In other words, what does it mean when there are no right answers? It means getting along. The problem is: people will not necessarily accept the made-up answers of DSM-IV, and they will use DSM in whatever way they think produces good outcomes in the real world. And we will disagree on what those good outcomes are.

There is, in the postmodernist DSM-IV worldview, no adjudication by truth. Thus, everyone does whatever they want. But many deny truth. It seems to me a bit embarrassing that physicians should do this, that anyone would practice medicine while explicitly denying value to scientific truth. Such practice seems hard to justify when one is practicing surgery or prescribing medications that can harm. But so it seems to be with some psychiatric leaders.

So let's take a step back, and think through, again, these two opposing perspectives.

There are two basic concepts of mental illness that underlie our debates about DSM. One approach is "pragmatic" and postmodernist: it focuses on the results of varying definitions, and tries to pick a definition that produces more good than harm. The other approach is called, in philosophical lingo, "scientific realism": it seeks to define the truth, as far as our science allows us, of the definitions of disease, come what may regarding consequences of such definitions. In the first definition, to put it concretely, if disease X leads to use of drug Y, and we do not want to encourage use of drug Y, we will define disease X in a very restricted way so as to make it hard to diagnose. In the second approach, we define disease X the way the best scientific research suggests we should, irrespective of how it impacts use of drug Y.

These differences explain the different goals of each group for our diagnostic system (or nosology). For the pragmatic/postmodernist, the primary goal of our nosology is to produce good consequences in the real-world of medical practice. So, based on our best current knowledge at the present time, these nosologists would nip and tuck (gerrymander might be the best word) our diagnostic definitions until they seemed to produce the best consequences. One looks around at the drugs that are out there; we examine how clinicians appear to be behave; we look at what patients want; we judge how the pharmaceutical and insurance companies will likely influence practice; we assess the goals of the government. Then we make up our criteria to try to produce the best consequences. Allen Frances, the leader of DSM-IV, has recently admitted explicitly that this was the process. The problem is the same as with utilitarianism in ethics; all this decision-making implies that we have sufficiently solid knowledge upon which to make our judgments. This is one limitation, but there is an even greater one. Even if all our practical judgments are correct, this approach would at best provide a serviceable nosology for today, this year, this era. It would not help promote a better nosology tomorrow, next year, for the next generation. This is a stagnant, static approach to nosology. In contrast to the claims of the founders of DSM-III, it has no inherent motor that might drive it forward; no progress can be assumed; there is no incremental advance.

Reliability becomes an end in itself, rather than a way-station to validity. All we have is a common language, a discourse in the sense that Foucault meant it, a pure fiction that represents the hegemony of our society. We may view this hegemony as benign; we may try to rig it so that the pragmatic results are 'good,' in our opinions. But it still is a fiction, one that has absolutely no correspondence with any reality or truth independent of our social structures and personal preferences.

Of course, postmodernists have no problem with these implications. They attack progress as a chimera; there never has been progress, they claim, and so we lose nothing by giving up our illusive hopes for it in the future. There is no reality of mental illness - or anything in fact - outside of our social and economic and human discourses; our civilizations create everything; everything is socially constructed, even the hardest science. Without society, there are no atoms, no electrons, no trees, no nature, and of course no schizophrenia. We can relabel and interpret all those things in a different way, and they would then be those different 'things.' Things do not exist; we do.

This is the 'pragmatic' postmodernist reality of psychiatric nosology today; and it will be the same reality tomorrow because such postmodernism has no future to build, for it has no criteria for what is better in any objective sense; postmodernism has only a past to attack, and, in the case of psychiatric nosology, a present to defend.

"

Medicina alternativa y homún(culos).

La revista BMJ publica en Diciembre un número con artículos "diferentes"; algunos recordarán un famoso artículo acerca de los paracaídas y la Medicina Basada en la Evidencia (aquí si que hubiera cabido lo de Medicina Basada en la Invidencia). En el número de este fin de semana se publica un artículo interesantisimo acerca de la "Culología" y la medicina alternativa, e incluso se puede descargar uno la diapositiva de las nalgas y los homúnculos. ¡No tiene desperdicio! El artículo es de acceso libre a través de la página web de David Colquhoun, aquí.

Disfruten y como dicen los anglosajones: Season's Greetings!

Looking Back

por una parte, bienvenido sea este artículo, pero por otra me da una pena terrible. Es esa tendencia a estudiar lo obvio la que me irrita de los anglosajones... redescubren la importancia de la historia clínica (algo de esto menciona la áurea Nancy Andreasen en una editorial que he citado ad nauseam).

En cualquier caso: ¿lo más curioso e interesante publicado hoy en día en psiquiatría (americana)? lo publicado en Psychiatric Times, por supuesto. No se olviden de añadirlo a su reader (RSS, etc).


Looking Back: "Patients’ stories (both content and structure) contain more therapeutically useful information than merely identifying and counting symptoms."