October 20, 2006

What Political Propaganda Looks Like

This is what a subscription to JAMA gets you:

 from the abstract:

RESULTS: Among the 201 women in the sample, 86 (43%) experienced a relapse of major depression during pregnancy. Among the 82 women who maintained their medication throughout their pregnancy, 21 (26%) relapsed compared with 44 (68%) of the 65 women who discontinued medication. Women who discontinued medication relapsed significantly more frequently over the course of their pregnancy compared with women who maintained their medication (hazard ratio, 5.0; 95% confidence interval, 2.8-9.1; P<.001). CONCLUSIONS: Pregnancy is not "protective" with respect to risk of relapse of major depression. Women with histories of depression who are euthymic in the context of ongoing antidepressant therapy should be aware of the association of depressive relapse during pregnancy with antidepressant discontinuation.

Read it again.   What's the message they are trying to communicate?

The study found that pregnancy is not protective, and stopping your meds during pregnancy raises the risk of relapse.  Any other way to interpret this abstract?  Am I putting words in their mouths?

I read the entire article, with familiar horror.  This was a naturalistic study that followed 201 women with MDD and their medication dosages and saw what happened.  That this study had nothing  to do with the "protective effect of pregnancy" is right now a secondary issue.  The real problem is that the actual study says something very different than the Conclusions:

relapse JAMA 2006 

The study did find that more people relapsed if they stopped their medications.  But it also found that more people relapsed if they increased their medications.

Exactly how were you to know this if you only read the abstract? 

 Don't you think that might have been important?  Tthe medication changes themselves are not the cause of the relapse-- how could both stopping them and raising them both be bad?-- but are logically explained as representing  something else. 




The Conclusions should have read:

Conclusions:  Taken together, these findings suggest that pregnant women who are stable (on medication) tend not to relapse, but those who are unstable (and need  med changes or who go off them) relapse at higher rates.

The authors do address, slightly, this odd finding-- on the last page.  But so what?  Only liars read the last page.  What makes this misrepresentation so egregious that it is near unforgivable in a journal of JAMA's arbitrary status is that they and we know doctors are not reading these studies from start to finish; for the most part, we skim over the abstracts. So we're going to skim over this abstract, it supports our existing prejudices so we don't give it a second thought, and go on with our deluded lives.

So to write the abstract this way is absolutely volitional, and absolutely misleading. The problem is not with the study, which was excellent, but with the presentation of the findings, which is psychiatric propaganda.

I would demand my subscription to JAMA be cancelled immediately if I had one in the first place.


But this isn't really the disturbing part. 

What's really sad is that I am, apparently, the only one who noticed this.  None of the three Letters To The Editor about this article complained.  One of the three letters did complain, but not about the article-- rather about the authors' ties to drug companies.   Yes, that again.  That's what passes for ccritical thought nowadays.  That's now the default moral high ground soundbite of bitter doctors, akin to "the war is just about Halliburton" or some other half-thought  deduced from two hours of the Colbert Report and the table of contents of the New York Review of Books.

That's the problem.  We're not critical of our fundamental principles.  So we attack windmills.  We doctors are conditioned (yes, conditioned) to find Pharma bias everywhere, and never to see-- so that we don't have to see-- the real bias in the way we have set up psychiatry.  It's the same reason we spend so much time on statistics.  Pharma and statistics are witches in The Crucible.  

The bias isn't Pharma related.  It's much more fundamental.  What's at issue here is the approach, the worldview of the authors and psychiatrists everywhere.   They are seeking to support the notion that antidepressants work and prevent relapse-- not even because that's what they believe, but because that's what psychiatry is. They are not asking a theoretical question and impartially looking for the truth; they're unconsciously trying to validate their existence. So they see what they want to see, and anything that isn't obviously in support of these postulates, this paradigm, is cursorily dismissed-- or is altered to mean something else.  This is important: they're not hiding data, they just interpret it with the only paradigm they have.

Blaming Pharma is easy because it seems obvious-- money buys truth-- but also protects the blamer from needing to perform any actual critical thought, any internal audits of their prejudices.  So what if Pharma bought those doctors start to finish?  You still need to read the study and figure out how the buying altered the data, if it did.  But that would be work.


10/30/06  Addendum:  I sent a modified (i.e. nicer) version of this as a Letter to JAMA.  It was rejected in less than a day.