Wednesday, March 25, 2009

APA Monitor: We Don't Need No Stinking Evidence

The American Psychological Association publishes two monthly publications for members, the well-regarded journal American Psychologist, and the APA's newspaper, Monitor on Psychology. I've been having issues with The Monitor for as long as I can remember. At times, I think the magazine makes claims that are not at all substantiated by evidence, which really bothers me. Why? Because psychology is supposed to be a science; it is what separates psychologists from life coaches or snake oil salesmen. I usually skim the Monitor for about 30 seconds per month, but when I saw the cover for this month's issue, my intuition told me to look out for voodoo. The title: Brain imaging: New technologies for research and practice.

So I browsed through the glossy pages, looking for something to catch my eye. Then, on page 36, there it was...

A pacemaker for your brain? Electric brain stimulation may give hope to people with unremitting depression

Oooh. Sounded promising, so I gave it my full attention. Keep in mind that this was in the "Science Watch" section. The article begins:

It's about the size of the letter "o" in this sentence and may have the power to lift deep, unrelenting depression.

OK, there's the attention-grabber. It then goes on to describe deep brain stimulation (DBS). Before long, I ran across:

Since 2005, more than 60 people worldwide have received DBS for treatment-resistant mood disorders. For about 60 percent of them, there's a "striking improvement in their symptoms of depression," says Andres Lozano, MD, PhD, a neuroscientist at the University of Toronto who performs DBS surgery.

Well, that practically screams "valid scientific findings," asking a surgeon if his technique works. What was he gonna say, "Nah, I think DBS is a bunch of hooey. I only do it because it pays really well." I'm willing to bet that physicians who practiced bloodletting were also quite confident that the majority of their patients showed "striking improvement," which is why we conduct controlled trials rather than rely on subjective opinion. Later in the article, the author notes that the results from DBS are "dramatic and promising." The author also notes that

A number of other behavioral and mood disorders might also benefit from DBS. Benjamin Greenberg, MD, PhD, a psychiatrist at Brown University in Providence, R.I., is using DBS to treat obsessive-compulsive disorder, with success rates similar to [Helen] Mayberg's and Lozano's. Also similar is Greenberg's claim that OCD people who've had DBS are then able to tolerate and respond to behavioral therapy.

This broad success leads Mayberg to believe that DBS is establishing itself as an important tool for treating disorders that otherwise won't budge.

OK, so Lozano claims that 60% of people make "striking improvement"; what about others? As mentioned above, Helen Mayberg has done some research on this topic. The article describes one of her studies. Here comes the most convincing evidence I've ever witnessed:

The initial trial included six people who met diagnostic criteria for major depressive disorder. The two researchers and their colleagues implanted electrodes in the white matter adjacent to their patients' subgenual cingulate cortexes and fired up their pacemakers. All the patients, who were awake during the procedure, reported a "sudden calmness or lightness," Mayberg and Lozano reported in the paper.

The researchers followed up with the patients by administering monthly depression scales. After six months, four of the six showed significantly fewer depressive symptoms. To make sure they weren't getting a placebo effect, Mayberg and Lozano secretly switched off the electrodes in their best-responding patient. After about two weeks, the patient's scores began to drop. After about a month, his depressive symptoms had returned. The researchers switched it back on and six weeks later he was back up to non-depressive levels.

So the author of the article, based on the subjective opinion of a psychiatrist and a neurosurgeon, along with and an uncontrolled study of six people concludes that DBS:

  • Has shown "broad success"
  • "A number of other behavioral and mood disorders might also benefit from DBS"
  • "May have the power to lift deep, unrelenting depression"
  • Has shown "dramatic and promising" results

The author threw in a few caveats about side effects (though he essentially gave it a clean bill of health), and also noted that DBS should be reserved for patients with longstanding depression and who have not shown positive results with other treatments. So it stopped short of being a blanket endorsement of DBS, yet it did really make it sound like a fantastic treatment for longstanding depression despite the very meager evidence cited in its support. I often complain about poorly designed studies, suppression of negative data, or misinterpreted results leading to drugs being touted as unrealistically safe and effective. But this article shows that it doesn't necessarily take drug company involvement to pimp a treatment well beyond the scientific evidence.

For all I know, DBS may turn out to be The Holy Grail in treating depression of all shapes and sizes. I cast no aspersions on the researchers mentioned in the article, as searching for ways to treat seemingly intractable cases of depression is doing God's work. But the writer did a horrendous job of overblowing the evidence in favor of DBS. This kind of article feeds the popular notion that psychologists are a bunch of flakes who know nothing about science. The APA Monitor can do much better than this.


Anonymous said...


NeuroPsych15 said...

The one thing that I hear frequently when it comes to DBS (regardless of the illness being treated) is the underplaying of side effects. It's brain surgery. they actually have to cut into the brain to implant these things (especially if implanted in the white matter). The most serious risk of all is post-operative infection, which is more common than people think.

CL Psych said...

You are such a cynic. How dare you! The article seemed to paint brain surgery as a minor procedure so who do you think you are to challenge it!?!?

OK, I can't keep up the sarcasm any longer. I'll agree that the lack of mention of side effects was pretty weird at best.

Steven Reidbord MD said...

This is a "human interest story," the type usually found in the back sections of a big Sunday newspaper. A pop-psychology report of pilot studies.

It's a serious problem I see more and more these days: No distinction between scientific/academic/scholarly dialog and simple whiz-bang "Hey look at this!". Made all the worse by the blogosphere, I'm sorry to say. Present blog excepted.

Dan said...

Hmm...this stuff's like, three years old. CL Psych, what do you think of the NYTimes article in comparison to the APA Monitor one?

therapyfirst said...

Do any of the readers remember the movie "Brainstorm", with Chris Walken and Natalie Wood (her last flick, how ironic). That is the technology we need, to record our brain waves so we can reexperience the moments and try to use this to 'share the wealth'.

I still love the scene when the tech guy endless loops the orgasm moment and is found lying in the recliner just spasming away until Walken turns off the machine.

Now I would pay bucks for that!!!

Anonymous said...

A local news program did a special on this DBS for depression. It was enough to scare the shit out of me. The guests included a psychiatrist, a guy who had it implanted in his wife's brain - he did all the talking so I think it was his idea, and another woman who had the procedure. The women didn't look right. And supposedly these were the success stories. One woman was on stage holding onto her stuffed animal (not exactly a sign of mental stability) and another woman looked pretty blank. This did not scream success to me. They're going to have to come up with some better examples.

Anonymous said...

the monitor is embarrassing. the women's magazine of psychology. did i just say that out loud? oops. i meant to say the reader's digest of psychology.

Anonymous said...

Of course the neuroscientist is going to say the patients experienced "striking improvement." But who else are you going to ask about how well the procedure works? Are you going to ask another neuroscientist who had nothing to do with the procedures? No. I'm sure any scientist worth his/her weight kept a good amount of data on each patient recieving any experimental treatment. I'm am even more certain the APA went over this in detail before publishing it in The Monitor. Some things may sound as if they are a bit fishy, but assume the latter, the APA is very strict, as is the AMA, about what they let into journals and anything with their seal on it. Would you back something that was bogus? No, and it is only saying 60% experienced an improvement. This is not saying it works every time, but it may very well be a step in the right direction and can lead to further exploration in different types of depressive treatments, just as any other experimental procedure or study. If a study or experiment leads to debate and further adventures into its realm, in my opinion, that is a success.