Posts by Bart Janssen
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Up Front: Good Counsel, in reply to linger,
the nocebo effect is described in the second of the two Goldacre links above
I should have clicked through :(.
But I'll offer this article in compensation, where unlike the placebo effect people have found at least one biochemical mechanism for the nocebo effect.
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Up Front: Good Counsel, in reply to linger,
the nature of the placebo effect
It is a profoundly interesting effect. It's possible that talking therapy might just in fact be a very very good placebo effect - which would kind of make it a really good treatment really.
BTW there is also something called the nocebo effect - really. That's where people will have side effects more often if they are told what the side effects might be. So you may actually be doing a patient harm by notifying them of possible risks. To say this messes with medical ethics would be an understatment.
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Up Front: Good Counsel, in reply to James,
This meta-analysis of all the drug company data on 6 of the 7 SSRIs found that drug is better than placebo ONLY for people who were severely depressed.
It is worth noting two things about this. Placebo's do work. And importantly, the more complex the placebo, the better it works. So a pill with side effects actually works better than a pill without side effects even if the only effect from the pill is the placebo effect.
The second thing is a problem with meta analyses in particular and large scale trials in general. It is that the data averages the effects from all participants. So if one person is very positively helped by a drug and 19 people have no effect then the average becomes statistically indistinguishable from no effect. Think of it as one person saying yes while at the same time 19 others say no then what you hear is "no". With really good statistics you can tease some of that data out but it is really hard.
This latter effect is particularly important for SSRIs because we know for certain that each person responds differently in both efficacy and side effects. It's almost certain that part of that is a result of the specific set of liver enzymes each person has to degrade the drug (pretty much each person's liver is different).
The take home message is that even though on average we can't see any positive effect from the drugs - it's very likely that for some people the drugs are very helpful, even for mild depression. This is one reason it would be really cool to link drug studies to genome analyses, because it may become possible to predict who will respond and who will just get the shitty side effects.
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There's something I'd like to add to this discussion.
I'm lucky to have had really good parents in the sense they had good genes. They both suffered badly through WWII and so were less able to teach some social skills but hell they gave me good genes. I'm fit(ish), mostly healthy, and my brain can pick up and remember knowledge pretty quickly. I have learnt many diverse skills outside my profession as a scientist (housebuilding, gardening, woodwork) and have learnt to play any sport. I am lucky! Up until a few years back I was pretty confident there wasn't anything I couldn't do at least adequately given a bit of time to read up and practice.
Then I got depressed.
And I discovered not only was there a whole class of things I was demonstrably really bad at, but also that some of those things I really struggled to learn.
It was my therapist/counsellor who showed me my limits and showed me what I had failed to realise I was not doing well. He also showed me how to do better at those things. And in the process I learnt that his skill as a counsellor was not a skill I would ever be even remotely competant at.
There is a sick culture is NZ that revolves around being tough mentally. It is strongest in men but is there in women as well. That culture dismisses the skills of counsellors, it dismisses their value and it does so because to acknowledge their contribution would be to acknowledge a weakness. Or in the case of some insurance companies, it would cost money.
We need people to talk with, to listen to, and to listen to us and time to do it. We need people we can share our worries and pain with, even/especially when there is nothing that can done except to listen. Sometimes those people can be friends but sometimes we need people who are really skilled.
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Thank you for stepping up to the plate and posting on this.
When a combination of my father's death, issues at work and mid-life threw me into depression I was lucky enough to have good medical insurance and a good GP. We talked about it, he offered either talking therapy or drugs or both. I went with talking therapy because I wasn't sure I wanted to alter my brain chemistry. I was lucky that my GP knew me well and recommended a therapist who was right for me and I got through depression.
I know the signs - I know the things I have to work on in myself and with the people around me. I know I need my friends, especialy those who are able and willing to listen. I learned to focus on the people and things that are actually important to me. I learned those things and many more from my therapist over four years and it really took that long.
But I was very lucky in that I had enough money to pay for that myself. Very very lucky.
I've seen people for whom drugs have worked brilliantly. But I've also read some of the literature and had close experience with someone for whom the drugs were a disaster. The combination of an incompetant GP, a not so good therapist and the bad luck to have the wrong biology came close to being very bad. SSRIs are crude tools for altering brain chemistry, that they work for some people is bloody amazing given how little we know about them and the brain. And for some people they can be life threatening.
No, counseling doesn't work for everyone. And yes drugs do work for some. But to argue that taking away an effective therapy just because it ruins the bottom line for an insurance company??? What the f*ck are the premiums for anyway? Do they really think "harden up" works?
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Hard News: The Real Threat, in reply to Richard Aston,
Bart just want to say thanks for holding this side of the argument
I'm not arguing because I have a strong sense that I'm right - I hope I'm ... er... trying to discuss what I think is actually a really complex issue.
I think there is a mixture of things going on with the discussion. One part is a real need to allow genuine investigative journalism to act as "the watchdog". We desparately need people like Jon Stephenson to pick at questions about the behaviour of organisations like NZDF and highlight where they are stepping beyond what most kiwis think is right and proper. I certainly don't think he deserves to be a target of spying. And certainly we don't want spying to become a weapon used to supress that kind of watchdog.
But at some point most folks also are happy to have the nation state spy on some people, whether that be by judicial order or as a security service.
It's the grey ground in the middle where for example the NZDF knows a person is investigating NZDF activities but don't know that person's motivations. You can't just go and ask them because if they are a spy they are going to lie - so what do you do?
I can see situations where you might know you have a good chance of spying an innocent person but you can't afford to take the risk they are not innocent.
At that point the public has to trust some system of oversight. You'd hope if innocence was determined data would be destroyed, but we know that was data is gathered nobody wants to throw it away. The whole thing gets horribly messy.
What I do think though is that IF as a govt organisation, you do stuff up, THEN you ought to apologise. If nothing else that increases trust that your motivations were honest in the first place.
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Hard News: The Real Threat, in reply to Richard Love,
Who is doing the spying and why is an objective difference.
Who is objective
Why is subjective -
Hard News: The Real Threat, in reply to Aidan,
There is literally no comparison to be made between a Nation State and tabloid newspaper.
I'm sorry but I disagree. I think we've seen ample evidence of the harm, personal and political, that can be done by a tabloid newspaper. It's worth noting that some of the media empires have revenues that are equivalent to nation states.
It's also worth remembering that the NZDF is charged with trying to not have it's employees killed. The stakes are higher for them if they get it wrong. We are all happy that Jon Stephenson was not a genuine threat to the NZDF - but how can you expect them to be certain?
But if you are happy that anyone can distinguish between jouranlist vs tabloid, how about this for a more difficult comparison ...
Surveilance of a known drug smuggler suspected of bringing into NZ illegal weapons.
Surveilance of an importor suspected of failing to pay duty, say a million dollars worth of duty.The point I'm making is that it is difficult to distinguish when it is appropriate, except after the fact. So how do we (the public) want it policed? What do we want to happen if they get it wrong, as in this case?
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Hard News: The Real Threat, in reply to Idiot Savant,
Most papparazi don’t get to steal your telephone metadata
No they just record the entire conversations - or had you forgotten the recent events in Britain.
Don't get me wrong I think the NZDF failed completely when they chose to target Jon Stephenson, who has a record of fair and sensitive reporting. He doesn't report information that could put the NZDF at risk. I don't think they had any reason to suspect him of being a threat. An embarrasment yes, but a threat no.
The problem I have is that in this instance they were clearly wrong. But for the life of me I can't see an objective way of knowing when it is appropriate to spy before you do it. It seems like it is always a matter of subjective judgement. Only after the fact can you know if it was genuinely warranted, unless you argue that it is never warranted, which I think is a bit silly.
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Hard News: The Real Threat, in reply to Richard Aston,
Its the power and intention behind the “spying” that’s the concern
I agree but that is the key difference. There doesn't appear to be an objective measure that defines one spying as innocuous tattle and another as a threat to personal freedom.
Instead it's the intent that makes the difference.
And BTW NZDF can't call in a drone strike.