Peer Review Is Mediocre at Best

Regarding bias in "science" and the utter balderdash that passes for peer-reviewed science, I sometimes feel like a lone voice in the wilderness. Well, thank God -- another blogger has thrown down the gauntlet on the topic. The Last Psychiatrist has a great post on the topic in which he notes a few huge problems with medical journals, of which I'll highlight a few in upcoming posts. Let's start with peer review...

"Most people think peer review is some infallible system for evaluating knowledge. It's not. Here's what peer review does not do: it does not try to verify the accuracy of the content. They do not have access to the raw data. They don't re-run the statistical calculations to see if they're correct. They don't look up references to see if they are appropriate/accurate."

Couldn't agree more with the Last Psychiatrist. We just assume the raw data are accurate. Every study likely contains some small data entry or calculation errors, but what if the whole paper is based on a significant misrepresentation of the raw data? Wouldn't that be a, large problem? What is reported and what is not reported? To put it in layman's terms, anybody can make up whatever the hell they want, and the peer reviewers are under the assumption that it is true. We're working on the honor system here and who knows how often the final paper reflects the real data, or if we are dealing with undisclosed errors due to sloppiness, an accident, greed, or just wanting to cover up the bad news, like in the following...

There is no way that even the world's greatest peer reviewer would catch this, as without access to raw data, we're trusting that relevant information is presented in the manuscript. Reviewers might catch an obvious statistical error, but they sometimes miss the most blatant errors, such as a paper that makes an important conclusion based on no evidence whatsoever.

What do peer reviewers do?

Again, quoting from The Last Psychiatrist...

They look for study "importance" and "relevance." You know what that means? Nothing. It means four people think the article is important. Imagine your four doctor friends were exclusively responsible for deciding what you read in journals. Better example: imagine the four members of the current Administration "peer reviewed" news stories for the NY Times.

And what determines if they think an article is important? Their bias, hopefully mixed with some basic understanding of research methodology and statistics. In maintream psychiatry, you are raised to believe that meds are safe and effective and that newer meds are better than older ones. Is this based on evidence? Sometimes, but quite often it is based on marketing that would make a user car dealer proud. Peer reviewers are often somewhat of an echo chamber than reflects whatever hooey marketing is going on lately. For example, consider that many poorly done studies on second generation antipsychotics were featured prominently in journals -- the mainstream psychiatry culture was overflowing with excitement about heavily promoted new antipsychotic meds, to the point where peer reviewers were willing to gloss over the flawed studies (for example, often using a control group receiving an unreasonable dose of an older antipsychotic) -- and now we have these drugs selling at a clip of well over $10 billion annually in the U.S.

No, I'm not claiming I don't have my own bias. Duh. You can see the cards I'm holding pretty clearly if you read this site with much regularity. The point is that peer reviewers need to realize their bias and take a better, more objective look at research they are reviewing. Too many industry-cheerleading pieces in journals leads to uncritical acceptance of treatments that nearly always fail to live up to their initial hype. After all, after a few trials have been published (even if poorly done and/or overstating efficacy, understating risks), the drugs are now based on "science," which leads to yet more marketing. Check the actual track record of benzos, SSRIs, Depakote, and atypical antipsychotics if you doubt me. Each treatment "revolution" is closely linked to peer review. So if you are pleased as punch with the current state of affairs in mental health treatments, then please make sure to send letters to your favorite medical journal editors thanking them for the present system. Don't let it change.

Or maybe the whole system needs a fundamental overhaul. More on that later.

Promo Time. I'll take yet another lead from the LP and humbly suggest that you promote this post via Digg, Reddit, or any other favorite service. I'd even more strongly suggest you hit up the LP's post and promote it. While you're sharing posts with the world, you should you read my take on SSRI's, Suicide and Dunce Journalism and send it to all of your friends. And while I'm in promotion mode, give your money to Philip Dawdy if you like good journalism on mental health issues. If you want to pledge money to support the operations of this unpaid anonymous blogger (and you know you do!), thanks, but take it and give it to Philip. Now!

Prescribing Multiple Antipsychotics, Eh?

The Last Psychiatrist has a highly impressive (and hilarious) post on why prescribing multiple antipsychotics to the same person is not such a hot idea. I strongly encourage everyone to read it as soon as humanly possible.

Psychiatry is Entering the Manic Phase

Well, those aren't my words. It's actually the Last Psychiatrist, who stepped up to the plate and blasted a mammoth shot to left center with his post. I'm going to quote a few choice snippets...

But without academics pushing SSRIs, their use will wane--and, importantly, so will their support of the diagnosis "Major Depression." This is going to sound controversial, inane, but it will happen.

Look for upcoming articles finding that "Depression" is overdiagnosed, that it is really just-- life. Look for articles that now find SSRIs aren't that effective after all, that the old "10% better than placebo" is a statistical trick with little clinical utility. That they are way overused in kids.

You might say, wait, isn't the decline of polypharmacy a good thing; that SSRIs are overused in kids; that they aren't that great; and that depression is overdiagnosed? All of this is true, but this isn't psychiatry finally coming to its senses; this is psychiatry entering the manic phase. Sure, it's less SSRIs for kids; but it's more antipsychotics.

Because simultaneously there will be articles pushing the idea that recurrent unipolar depression is really bipolar depression; that there are common genetic or heritability patterns; that the epidemiology and course is similar, etc. The move will be to squeeze out MDD into "life" and bipolar. This done, antipsychotics become first line agents. Oh, and look for antipsychotics to get FDA approvals for kids.

SNIP

And polypharmacy will only be reincarnated-- in the form of multiple simultaneous antipsychotics (Abiliquel, anyone?), with preposterous pharmacologic justifications ("this one acts on serotonin, so it's the antidepressant, and this one on dopamine, so it's the antimanic.") If anyone says that to you, stab them.

Nice to see a great post by another person who has noticed the sea change toward antipsychotics, er, "broad spectrum psychotropics." And bipolar disorder -- Oh yes, some academics have been saying for years that many cases of depression were bipolar in disguise, and now we're finding that more and more folks are jumping on that bandwagon. How convenient.

Brief History of Diagnostic Trends: When benzos were the big drugs, everyone had anxiety. When the SSRI era was born, depression was the disease of the day. When depression was saturated, the move was on to raise awareness about social anxiety, generalized anxiety, PTSD, etc, as the SSRIs still had patent life to spare, and hence markets to conquer. The new frontiers are depression with pain, for which Cymbalta is allegedly the drug of choice (despite rather meager supportive evidence), and bipolar, for which Seroquel, Abilify, Zyprexa, and Risperdal/Invega have already made significant inroads. Lilly cleverly tried to expand the bipolar market with the Viva Zyprexa and Zyprexa Limitless campaigns, but it was just the first step in a much larger campaign.

Again, here's the link to the Last Psychiatrist's post.

Caffeine Withdrawal and ADHD

The Last Psychiatrist has a very interesting piece about caffeine withdrawal. He details his own experience of withdrawing from caffeine, symptoms of which he had mistaken for an illness. He closes with the following:

Has anyone else wondered if the prevalence of ADHD doesn't parallel caffeine use and sleep deprivation, especially in kids (kids don't take naps anymore)? And that the main treatments are-- stimulants?

Interesting...

Child Bipolar Infuriates Bloggers

Three excellent posts have hit the blogosphere regarding bipolar disorder in children.

Intueri rips the diagnosis apart with pinpoint logical thinking and by pointing out that the “science” behind this disorder is remarkably thin.

Furious Seasons jumps on board as well, adding on to Intueri’s excellent analysis with some of his own characteristically amusing sarcasm. Nice work.

The Last Psychiatrist is also in the house, chiming in with his comments regarding psychiatry’s double standard, why no psych drugs will be getting pediatric indications, and more.

Nice work, bloggers. Keep it coming. If you like their posts, you may also want to check out my latest post on this very topic.