1. 20:30 31st Aug 2014

    Notes: 22

    Reblogged from madness-narrative


    Upon reviewing all of GlaxoSmithKline’s data from both published and unpublished trials of the antidepressant paroxetine*, researchers found the drug provided almost no benefits over placebo for either depression or anxiety, according to a study in PLOS One.

    The Wayne State University researchers, in collaboration with Harvard’s Irving Kirsch, stated that evaluating the efficacy of antidepressant medications on depression and anxiety has until now been hampered by a lack of access to pharmaceutical companies’ unpublished trials. “Here, for the first time, we assess the efficacy of a selective serotonin reuptake inhibitor (SSRI) in the treatment of both anxiety and depression, using a complete data set of all published and unpublished trials sponsored by the manufacturer.”

    They found that the published literature tended to overestimate the efficacy of the drug, and overall the drug provided tiny benefits of only 2-3 points** on common rating scales for depression and anxiety — much of which was due to placebo effects. “The available empirical evidence indicates that paroxetine provides only a modest advantage over placebo in treatment of anxiety and depression,” they wrote. “We demonstrated that individuals given placebo exhibited 79% of the magnitude of change compared to paroxetine.”

    “These findings have important clinical implications,” the researchers commented. “The obvious alternative for the treatment of both anxiety and depression is psychotherapy intervention. However, direct comparisons of acute phase treatment for pharmacotherapy and psychotherapy in the treatment of major depression generally have yielded no significant differences between the treatment modalities. Fewer clinical trials have directly compared antidepressants and psychotherapy in the treatment of anxiety disorders, although the available literature indicates similar comparability between antidepressants and psychotherapy.”

    "When given two seemingly equivalent alternatives with regard to symptom reduction, the decision may come down to patient preference and to the safety profile associated with the treatment.""Paroxetine and other SSRIs have also been associated with a number of adverse events during treatment. "

    The Efficacy of Paroxetine and Placebo in Treating Anxiety and Depression: A Meta-Analysis of Change on the Hamilton Rating Scales (Sugarman, Michael A. et al. PLOS One. August 27, 2014. DOI: 10.1371/journal.pone.0106337)

    *paroxetine is the generic name for SSRI Paxil
    **”a recent analysis of raw data from 43 antidepressant trials [50] compared HRSD change scores with clinician ratings of improvement on the Clinical Global Impressions Scale (CGI) [51] to establish the clinical relevance of HRSD scores. They found that change of three points or less on the HRSD corresponded to a clinician rating of “No Change” on the CGI. That is, changes of three points or less did not correspond to a clinically detectable change according to this clinician-rated measure. Thus, the drug-placebo differences that have been observed in the current and previous antidepressant meta-analyses [7], [28], while statistically significant, appear to be of marginal clinical significance.”

  2. I look to historians for their power to illuminate not just the invisible lineaments of the present, but also that which is not present. What are the roads that were not taken that most shape our own time? Lately, the historian who’s been doing that best is Nelson Lichtenstein, who parlayed a career writing about midcentury capitalism and industrial unionism into extraordinarily penetrating accounts of why the economic regime we live under today is so deeply unsatisfying. One abandoned idea documented in his most recent book, “A Contest of Ideas: Capital, Politics, and Labor,” haunts me. Powerful people in the Democratic Party, like Senator Robert Wagner of New York, used to insist that the job of liberalism was to penetrate the “black box” of the corporation and turn the workplace into a more democratic institution. They believed that to leave decision-making in the great firms that dominate our lives merely to owners (as opposed to, say, the system of “co-determination” between labor and management under which the German economy now thrives) was no less than a violation of the Constitution’s 13th Amendment, which outlawed involuntary servitude. Now that such thinking is rare as a unicorn — and workers all but belong to their bosses during their working day — no wonder it’s hard to win the allegiance of the white working class to the Democrats.
  3. Power and Money vs Patients’ and the Public’s Health 

    Mr Kislak saw himself as supporting physicians in “their mission to provide high quality and effective care to their patients.”  In the conclusion to his article, he asserted that physicians and MBAs “share the same overarching goals … - effective healthcare delivery….”  However, in the body of the article, Mr Kislak suggested that MBAs see their goals in terms of power and money…   

    4. Leadership. MBAs like to think of themselves as either nascent or actual leaders. It is understood that their intention is to build a career trajectory that will move them up in their organization (or in another organization) into positions of increasing authority and control. After all, this is an important reason why they become MBAs in the first place.

    Furthermore, Mr Kislak wrote

    8. Language. MDs and MBAs usually work for some type of business entity, whether that entity is for-profit, nonprofit, academic, government or sole proprietorship. To the MBA, however, it is all too apparent that with few exceptions MDs have little training in the language of business that all entities speak — the language of finance and accounting.

    He noted that “this is a significant disconnect and a root cause of why MDs and MBAs often find themselves talking past each other on even the most basic business issues.”  However, interestingly he did not even mention that MBAs may have as little facility with the language of medicine and health care as physicians have with the language of finance or accounting.  Furthermore, he seemed unaware that it makes as little sense to say that discourse in health care should be in the language of finance as to say discourse in finance should be in the language of health care… .

  4. … if there is any uncertainty at all about the risks and benefits of statins – and there is – then we have failed to competently implement the most basic principles of evidence based medicine. Statins are the single most commonly prescribed class of treatment in the developed world, taken by tens if not hundreds of millions of patients every day. That would be more than enough clinical experience to resolve any research questions, if we were competently identifying all outstanding uncertainties, and conducting well-designed trials to answer those questions in routine clinical care [1]. We need better data; better dissemination of that data; and better communication of that data, in ways that help people make decisions which reflect their wishes. Statins should be the crowning glory of evidence based medicine, our perfection incarnate: instead, they are a mess.

    full blog post here:

  5. When I hear the criticisms of the modern bio-bio-bio psychiatry, while I often agree, I add something else in my mind – motives. The upper layer of academic psychiatry is populated predominantly by people selected by their medical schools because they can do some version of what’s described in this post – bring home the bacon from the NIMH, industry, foundations, et cetera. And for thirty plus years, they’ve talked about little other than biological research and pharmaceutical studies, selecting their future academic colleagues from the like-minded pool [that got us where we are today]. Dr. Nemeroff isn’t an exception, he’s just bolder, more reckless – reckless enough to have been busted for a time. And that’s just the NIMH story. The financing from pharmaceutical companies was probably even more impressive, and flexed the same muscles as the NIMH grantsmanship. He’s just one among many. I recently described a $50M version from UT Southwestern [retire the side…] – equally expensive, with equally non-memorable results. And there are too many more examples.

  6. The problem is that white people see racism as conscious hate, when racism is bigger than that. Racism is a complex system of social and political levers and pulleys set up generations ago to continue working on the behalf of whites at other people’s expense, whether whites know/like it or not. Racism is an insidious cultural disease. It is so insidious that it doesn’t care if you are a white person who likes black people; it’s still going to find a way to infect how you deal with people who don’t look like you. Yes, racism looks like hate, but hate is just one manifestation. Privilege is another. Access is another. Ignorance is another. Apathy is another. And so on. So while I agree with people who say no one is born racist, it remains a powerful system that we’re immediately born into. It’s like being born into air: you take it in as soon as you breathe. It’s not a cold that you can get over. There is no anti-racist certification class. It’s a set of socioeconomic traps and cultural values that are fired up every time we interact with the world. It is a thing you have to keep scooping out of the boat of your life to keep from drowning in it. I know it’s hard work, but it’s the price you pay for owning everything.
    — Scott Woods (via andrewgibby)
  7. 03:41

    Notes: 22

    Reblogged from protoslacker

    Tags: discourse

    When I published No Logo a decade and a half ago, readers were shocked to learn of the abusive conditions under which their clothing and gadgets were manufactured. But we have since learned to live with it – not to condone it, exactly, but to be in a state of constant forgetfulness. Ours is an economy of ghosts, of deliberate blindness.

    Naomi Klein in The Guardian. Climate change is the fight of our lives – yet we can hardly bear to look at it

    We’re products of an industrial project, a project linked to fossil fuels. But humans have changed before and can change again

    This Changes Everything

    (via protoslacker)
  8. The following list, initially from “ALL I REALLY NEED TO KNOW I LEARNED IN KINDERGARTEN” by Robert Fulghum.  has been adapted (read ‘man-handled’) for applicability to US healthcare. You’ll find the original list here:  http://www.robertfulghum.com/

    An example from the full blog post:

    Be aware of wonder. Remember the little seed in the Styrofoam cup: the roots go down and the plant goes up and nobody really knows how or why, but we are all like that. Medicine is a cross between and art and a fledgling science.  Lets be clear that we know much less than we should, and that much of what we believe we “know” turns out to be wrong.  Lets always appropriately caveat our guidance with our uncertainty, admit that our understanding is substantially incomplete, and be willing to learn from each new encounter.

  9. … What if, my record lived on some commonly accessible platform; not open to anyone, but accessible by my providers and I? Maybe we have to do some kind of online handshake to mutually access it.

    What if we could both edit the record, at the same time? My doctors could put in their notes and I could add my own. Or I could edit theirs. And they could edit mine.

    Some readers may have concerns about the records’ integrity but as patient advocacy expert Trisha Torrey points out reviewing our own medical records can help spot and fix errors. And, as we know from Wikipedia, more eyes and contributors on a record increase its accuracy and reliability.

    Another important lesson from Wikipedia is the idea of revision log, which Wikipedia calls page history. Any registered user can make edits to almost any record in Wikipedia’s vast online encyclopedia. Every time an edit is made the changes are logged, including the name of the user who made them.

    Anyone can review the changes and roll back some or all of them, or make additional changes of their own.

    Imagine a medical record platform where patients can review the entries made by a doctor, and if appropriate make additions at it or even changes. For instance, after reviewing notes from my last physical, I discovered a small unimportant inaccuracy in my record.

    I take Vitamin D supplements, and in the record, it was noted that I take Vitamin E. Big deal? Probably not, but what if it was related to a prescription medicine? Providers are human and, as we know, to err is human, but by allowing patients to review and edit their own records, they would be able to fix errors… .

  11. Grief dispels anxiety.
    — a wise person who conventions and discourses of confidentiality restrain me from identifying more specifically.
  12. PLAINSONG by Kent Haruf
Several things have come together to have me thinking again about this novel. It is one of the most haunting works I have ever read. The places and people that Kent Haruf describes linger in the best of ways. The New York Times review says, “Haruf has made a novel so foursquare, so delicate and lovely, that it has the power to exalt the reader.” 
This is a narrative worth getting to know.

    PLAINSONG by Kent Haruf

    Several things have come together to have me thinking again about this novel. It is one of the most haunting works I have ever read. The places and people that Kent Haruf describes linger in the best of ways. The New York Times review says, “Haruf has made a novel so foursquare, so delicate and lovely, that it has the power to exalt the reader.” 

    This is a narrative worth getting to know.

  13. What gets measured gets managed — even when it’s pointless to measure and manage it, and even if it harms the purpose of the organization to do so.
    — Peter Drucker quoted by Nicholas Carr here.
  14. It’s dubious and dangerous, Drucker is saying, to take what’s measurable for what’s important. But he’s also saying something much more radical, even subversive: Some things that can be measured shouldn’t be.
  15. Any group of persons – prisoners, primitives, pilots, or patients – develop a life of their own that becomes meaningful, reasonable and normal once you get close to it.
    — Erving Goffman, Asylums (1962)

    (Source: literary-ethnography)