Tuesday, August 28, 2012
An edited version of the following article has been selected for and is competing in JPMS International Medical Writing Contest 2012. You are welcome to visit it on the JPMS site, and read, share and comment, because that will contribute in part to the final result.
Evidence-Based Medicine and Psychiatry
M. Awais Aftab
Evidence-Based Medicine (EBM) is rapidly becoming the mantra of modern clinical practice. It is being taught in medical schools and discussed in conferences as the ‘gold standard’ of health care decisions. The paradigm is making its impact on psychiatry as well, and one can see practitioners and journals attempting to reframe their approaches in the light of EBM. While this methodology is well-argued in medicine and is showing great success, its application to psychiatry is on shakier grounds. I will argue that this is because of two factors: Firstly, the general and recognized limitations of EBM are more acutely felt when applied to psychiatry. Secondly, there are inherent nosological difficulties in psychiatry which make the results of research based on DSM diagnoses challenging to interpret for actual clinical practice.
Evidence-Based Medicine can be defined as the practice of applying the best available scientific evidence to clinical decision making. Triple-blind randomized placebo-controlled clinical trials and their meta-analyses are held in highest regard as scientific evidence. EBM is often allegedly seen as a ‘cookbook’ approach by critics due its insistence on scientifically proven treatment for defined diagnosis. However, this allegation that EBM recognizes only evidence from systematic research as the sole and exclusive criterion of clinical decisions is more of a straw-man derived from the manner of EBM hyper-enthusiasts, something that is counter to the actual spirit of EBM that its pioneers have espoused. Sackett et al insisted in their frequently cited 1996 paper that “The practice of evidence based medicine means integrating individual clinical expertise with the best available external clinical evidence from systematic research. By individual clinical expertise we mean the proficiency and judgment that individual clinicians acquire through clinical experience and clinical practice.” They rightfully foresaw that neither clinical expertise nor scientific evidence alone is enough, and warned that “Without clinical expertise, practice risks becoming tyrannised by evidence, for even excellent external evidence may be inapplicable to or inappropriate for an individual patient.” Ranga Krishnan voiced a similar view in an interview with Medscape, being a vocal proponent of applying EBM to psychiatry: “What we mean by EBM is often misconstrued as "cookbook" medicine; in other words, see somebody, do A, B, C, and then D. But that is not what EBM is. EBM is taking all the available data on a particular question, synthesizing it, reviewing it, putting it into the context of what it really means, and then taking it and applying it to the patient. It is really contextualizing available information in a systematic fashion.” EBM therefore argues for a synthetic approach in which clinical judgment and research evidence are balanced. This is all well and good. However, the balance that exists between clinical judgment and evidence in psychiatry differs significantly from the balance that exists in other medical specialties.
Let us first look at the general limitations of EBM that are applicable to all medical specialties but present with greater relevance in psychiatry.
1) Time lapse between study and publication
Articles submitted to scientific journals often have to undergo considerable waiting time before they see the light of publishing, which could be a year or even more. Additionally, the various committees which take these published studies into account and recommend treatment guidelines for various disorders take years to come up with a final document. In a rapidly developing field such as psychiatry, this means that any treatment guideline will be years behind the actual advancement of scientific knowledge.
Evidence-based guidelines are riddled with the problem of generalizing available evidence to populations at large or to treatment course and outcomes over a prolonged period of time. The extent of extrapolation will remain a troublesome question. This is all the more acute in psychiatry because individual factors affect illnesses and treatment response in ways that are poorly understood.
3) Publication bias
A strong bias exists in favor of publishing only trials with positive results. This means there will be a large amount of scientific evidence that has not been made accessible, and therefore cannot be taken into account by evidence-based medicine, and yet that unpublished data can be of significant impact. Turner et al investigated 74 studies registered with FDA on 12 antidepressant agents involving 12,564 patients. Their results were shocking: 31% of studies were not published, and this had to do whether the studies had a positive or a negative result. Only 1 study out of 37 with positive results was unpublished, but the studies whose results FDA saw as negative or questionable were either not published (22 studies) or published with a falsely positive outcome (11 studies) with only 3 exceptions. This led to a discrepancy, such that 94% of trials in published literature were positive, while 51% were positive in FDA analysis.
The problem with applying EBM to psychiatry goes deeper than these limitations. It has to do with the very manner in which diagnostic system in psychiatry functions. DSM classifies psychiatric diseases into discrete disorders based on clinical signs and symptoms. These disorders are basically ‘symptom-complexes’ and not specific illnesses whose pathophysiology is distinctly worked out. The diagnoses of DSM-IV are operational definitions, based on consultation and consensus to make sense of varying presentations, and to facilitate researchers in using a uniform set of criteria. This was acknowledged even by the authors of DSM-IV: “. . . there is no assumption that each category of mental disorder is a completely discrete entity with absolute boundaries dividing it from other mental disorders or from no mental disorder . . . [and] boundary cases will be difficult to diagnose in any but a probabilistic fashion.” This classification system is far from a classification system that is based on a proper understanding of cause and effect. We do not know the exact etiology of any psychiatric disorder. The integrity of this nosological method is challenged by several observations, such as the high rates of over-lap and comorbidity of psychiatric disorders, lack of homogeneity in treatment response and the fact that a broad range of different DSM disorders respond to the same medications. EBM employs these very DSM diagnoses in attempt to create specified algorithms for treatment, and the diagnostic issues at hand makes the whole venture uncertain at a fundamental level.
Research driven by EBM is focused on treatment efficacy for a particular diagnosis, but what is required in clinical psychiatric practice is the alleviation of specific symptoms. Furthermore, the diagnostic approach blinds us to particular features of a patient’s condition and circumstances, which are often playing a central role in patient’s psychopathology. Once this crucial aspect is recognized it is easy to see that the insistence that EBM should monopolize psychiatry can be very detrimental. Psychiatric practice remains as much art as it is science, and there should be no shame for psychiatrists to acknowledge that treatment rationales ought to be driven not just by diagnosis-based statistically driven protocols, but also by sensible and reasonable conjectures based on the knowledge of particulars of an individual patient.
1. Sackett DL, et al. Evidence based medicine: what it is and what it isn't. BMJ. 1996 Jan 13;312(7023):71-2. URL: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2349778/pdf/bmj00524-0009.pdf
2. Medscape. Evidence-Based Medicine in Psychiatry -- A New Perspective: An Expert Interview With Ranga Krishnan, MB, ChB. URL: http://www.medscape.org/viewarticle/475415
3. Turner EH, et al. Selective publication of antidepressant trials and its influence on apparent efficacy. N Engl J Med. 2008 Jan 17;358(3):252-60. URL:
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders DSM-IV. Introduction.
Monday, August 27, 2012
#TS257 prompts: galactic, yak, tabernacle.
"I'll stay in ur arms in this tent for light years..." he yakked on, unaware that the galactic faux pas was the bane of his seduction #TS257
#TS258 prompts: curiosity, qawwali, bedlam.
"What does qawali sound like?" "An immersion into something ancient." "Would it cure the bedlam in my mind?" "It's music, not magic." #TS258
#TS259 prompts: horde, gourd, overlord.
As per tradition, the horde sought the dead overlord to carve out his manhood for the sacred gourd & discovered that he was a woman #TS259
#TS260 prompts: inchoate, concertina, never-never land.
Their inchoate relationship began with hopes of eternal youth & romance, but everything decays and love can fold up like a concertina #TS260
#TS261 prompts: crush, wine, blasphemy.
Dressed up as Jesus on Halloween he finally hit on her 'Can I get u a drink?' 'Only if u are better in bed than u are at blaspheming' #TS261
#TS262 prompts: Keyser Söze, kite-flying, eloquence.
"I suspect God is the Keyser Söze of religion" His kite drifted away,cut-loose, prompting an eloquent confession of his loss of faith #TS262
#TS263 prompts: craw, priorate, ka-boom.
Third time's the charm but as always the prior ka-boomed way too early for the nun's pleasure. It stuck in her craw as the last straw #TS263
Thursday, August 16, 2012
The following is an excerpt from a lecture Ernest Gellner gave in 1995 in Heidelberg at a conference in which he tried to explain some unexpected developments of the 20th century. The except below deals with the continued strength of Islam in a world where hold of religion over society appears to be declining in general.
"Tonight I will try to explain a few of the major striking events of our century – some very surprising, some a little less surprising. Very surprising is the tremendous success of Islam in maintaining and strengthening itself. Most social scientists accepted the secularization thesis, which argued that in modern or industrial societies the hold of religion over society and over the hearts and minds of men declines. This seems more or less true with one striking exception: the world of Islam, where the hold of religion over society and over men in the past hundred years has certainly not diminished and seems to have increased....
Why is lslam so astonishingly successful? Why is it resistant to secularization? I shall begin by offering a model of what traditional Islam was like (without going into the early History of Islam). To put it simply, Islam, at least that of the arid zone between the Hindu Kush and the Atlantic and the Niger bend, was divided between a high culture and a low culture – a high Islam and a low Islam – and these two coexisted in an unstable way. Most of the time they were peaceful, but nevertheless had conflicts at fairly regular intervals. The chief difference between the two is that high Islam does not permit mediators (it has a special name for the sin of mediation: shirk), while the world of low Islam is full of them. High Islam encourages a direct relationship between a unique deity and the individual believer; it is not attached to ritual, contains little magic and supernatural belief, and is heavily moralistic, scripturalist, puritan, monotheistic, and individualistic. It is the Islam of the scholars – the high Islam recognized as valid by the believers but not practiced by them. It is not practiced because it does not correspond to the needs of the lower classes and above all the rural Muslims, who for obvious reasons require a much more Durkheimian religion – in other words, a religion in which the sacred has its mediators, its incarnation, and which mirrors the social structure. Most of the rural Muslims were encadrés, incorporated in rural autonomous or semi-autonomous congregations, village lineages, tribes, clans, and the like. For their internal organization and life, they had a Durkheimian religion where the sacred is incarnated in periodic rituals, in sacred objects, sacred practices, sacred persons. One can say that an upper-class, urban, individualistic, puritan, "protestant" Islam (which is strangely united by the theologians and jurists who are its main carriers, despite the lack of a central organization and any kind of central secretariats and hierarchy) coexisted with a fragmented, "Catholic" Islam which had the "Catholic" characteristics of hierarchy, ritualization, employment of the sensuous forms of religion, of mystical exercises, and so on. One can see how this fits well with Durkheim's theories of religion having the function of underwriting, rendering visible, and legitimating the communal organization in which Muslims lived. During periodic attempts at self-reformation, these two forms came into conflict, but most of the time they coexisted harmoniously. On this issue I agree with the theory best formulated by David Hume about the oscillation in the religious life of mankind between Protestant-type and Catholic-type religions. In periodic outbursts of zeal and self-reformation, the puritans would temporarily prevail, but the exigence and the demands of social life would again lead to a swing-back to a personalized, hierarchical, ritualized, non-scriptural religion with an ethic of loyalty rather than an ethic of rules. Thus Islam existed in a permanent oscillation between unsuccessful reformations and reversions to the old cultural habits. And, of course, there is a specific difference between Islam and western European Christianity in this matter: in western Europe, the hierarchical, ritualized loyalty-ethics is at the centre and carried by an institution rather than by abstract doctrine, while the individualist, scripturalist, puritan version is fragmented and relatively marginal. In Islam, it is the other way around; the central tradition is individualist and scriptural, and the fragmented deviationists are hierarchical, ritualistic, and so on – a kind of mirror image.
As far as I can see, there is nothing to stop Islam oscillating between these two forms. The oscillation was noted by the superb Muslim sociologist lbn Khaldun around 1400, and echoed by Friedrich Engels in a passage where he obviously uses lbn Khaldun without actually quoting him. He says – contradicting the main thesis of Marxism – that all classes and class-societies are inherently unstable and due for internal destruction through their internal contradictions. In this passage, the dreadful ethnocentrism of the two founding fathers of Marxism comes out as he specifies that the instability of classes and class-societies applies to "us" Europeans, whereas "those" Orientals, especially Arabs and Muslims, are locked in a kind of cyclical world which never manages to break out. And, admittedly, our social conflicts are distorted through the prism of religious language, but at least when the religious conflict is over something new emerges and we reach a higher level. All the Orientals do is go around in a circle.
My theory of why Muslim fundamentalism has the astonishing strength that it does is the following: modern conditions unhinged the pendulum of this unstable oscillation and permanently and definitively shifted the centre of gravity away from the pluralistic, hierarchical, organizational, Durkheimian style to that of high Islam. Of course, the reason why this happened is that the process of modernization, the political and economic centralization employed by the colonial and post-colonial states, destroyed those communities that had provided the basis for the Durkheimian or low- culture style of Islam. By turning clansmen, lineage members, villagers, and tribesmen into labor migrants and shantytown dwellers, it atomized the population and prompted them to find their identity in a high religion, in a high culture, that provides an identity shared by all Muslims, uniting them against the outsiders. Previously there did not exist a national identity in Muslim countries. Most people were first and foremost members of a local community under a local authority. Modern Muslim nations, especially in ex-colonial countries, are simply the summation of Muslims in a given territory. But this does mean that lslam provided the identification against the other.
It provided a ratification of their transition from a rural to an urban world, and it provided an idiom for expressing their change of status from that of rustic ignoramuses to people aspiring to urban sophistication. It also provided them – as is presently visible in the bitter and tragic conflict in Algeria – with a means of criticizing their current rulers. It provided an idiom for those non-Westernized people who take their Islam seriously, as against the technocrat Mamlukes who govern them in virtue of their access to Western technology. I think it is in these terms – the reaction of recently urbanized, disoriented Muslims who are separated from their previous saint cults and local structures but who need to define themselves against an exploitative, semi-Westernized upper class – that the wave of Muslim fundamentalism should be understood."
Friday, August 10, 2012
The Dark Analyst confronts Derrida...
Alfred: You crossed the line first, sir. You squeezed them, you hammered them to the point of desperation. And in their desperation, they turned to a man they didn't fully understand.
Bruce: Philosophers aren't complicated, Alfred. Just have to figure out what he's after.
Alfred: With respect Master Wayne, perhaps this is a man that you don't fully understand, either. Some men aren't looking for anything logical. They can't be bought, bullied, reasoned, or negotiated with. Some men just want to watch the world burn.
Wednesday, August 8, 2012
I used to have a tradition on this blog of posting a poem by Sara Teasdale on the 8th of August, a date of birth that I share with the said poet. This year it is time to revive that habit:
Central Park at Dusk
by Sara Teasdale
Buildings above the leafless trees
Loom high as castles in a dream,
While one by one the lamps come out
To thread the twilight with a gleam.
There is no sign of leaf or bud,
A hush is over everything --
Silent as women wait for love,
The world is waiting for the spring.
Monday, August 6, 2012
Saturday, August 4, 2012
An excerpt from Has the Meaning of Nothing Changed? at Slate:
'It takes Holt 150 pages or so of travelling the world interrogating the nothing theorists to find one who gives what he believes to be an adequate definition of nothing—the nothing we seek to find, the one that qualifies for the “how do we get something from nothing” question.
This comes in his conversation with the physicist and cosmologist Alex Vilenkin, and it’s worth listening to what a stringent definition of nothing really is:
“Imagine,” Holt asks us, paraphrasing Vilenkin, “spacetime [the matrix we live in] has the surface of a sphere. ... Now suppose that this sphere is shrinking like a balloon that is losing its air. The radius grows smaller and smaller. Eventually—try to imagine this—the radius goes all the way to zero.”
Pause for a moment to think of a sphere whose radius has gone “all the way to zero.” No time. No space. It’s hard—but not impossible—to get your head around it. Now back to Holt:
“The surface of the sphere disappears completely and with it spacetime itself. We have arrived at nothingness. We have also arrived at a precise definition of nothingness: a closed spacetime of zero radius. This is the most complete and utter nothingness that scientific concepts can capture. It is mathematically devoid not only of stuff but also of location and duration.” Nothing is nowhere.'
Friday, August 3, 2012
Pak-India Social Media Mela covered by me for Us magazine of The News:
(To view in original size, right click and select 'open link in new tab')
The cover story is available on the Us magazine website, and the epaper of The News (3 August 2012).
The story also had a section of 'Twitter Timeline' originally, containing a small selection of tweets from the #socmm12 hashtag, which could not be published in print due to lack of space, and which I am now posting on the blog:
Sabeen Mahmud @sabeen
@SenRehmanMalik Thank you from the PeaceNiche team for all your support. Your accessibility and graciousness made #socmm12 possible :)
Komal Ali @Komalali92
#ThankyouRehmanMalik for supporting the #socmm12. Without your help, our Indian fellows wouldn't have been here.
Shiraz Hassan @ShirazHassan
Some technical issues :( hope we'll able to connect with @dillidurast and Barkha Dutt via skype #socmm12
Salman Latif @SalmanLateef
Vankat talks stages of unemployment: social media enthusiast, social media consultant and finally, social media expert :P #socmm12
Salman Latif @SalmanLateef
Ali Gul Pir and Ali Aftab asked to dance to 'Wadeira ka beta' onstage!! HILAARIOUS!! #socmm12
Salman Latif @SalmanLateef
'My mother doesn't think I work' - Raheel, speaking about online activism #socmm12 #TrueStory
Pir Faraz Ali @PiruSaein
Best part of #socmm12 was that... LUNCH WAS FOR FREEEE! #Mufta #FTW
Abdullah Syed @abdullasyed
"the process of globalization has helped us revive our heritage."-@Razarumi on heritage beyond English. #socmm12
Abdullah Syed @abdullasyed
Listening to the How @sanakazmi got to Mohali story! :D #socmm12
Salman Latif @SalmanLateef
Three panelists kind of discussing three different topics in the meme session. Pretty boring too #socmm12
Sanaa Jatoi @sanaajatoi
Excited for the upcoming panel on The Maya Khan Takedown! This should be goooooddd #socmm12
Hamza Dhedhi @HamzaDhedhi
Highlight: @faisalkapadia to @mehreenkasana "Speaking about sensationalism, Ghalib film dekhi hai aapne?" #Socmm12
Faizan Lakhani @faizanlakhani
"Twitter is new TV Ticker," says Indian Journalist @karunajohn while discussing 'ethical reporting in a hyper-connected world.' #SOCMM12
Nukhbat Malik @NukeMalik
#SOCMM12 @marvisirmed had it! :) "MQM sitting on my Left, PTIsitting on my Right and me wearing green...everything is political"
Salman Latif @SalmanLateef
@beenasarwar tries not to let @DrAwab and @abidifactor initiate a rather political discussion during the session :P #socmm12
Abdullah Syed @abdullasyed
Absolutely in love with the #socmm12 conference bag and the wonderful truck art inspired notebook.
Karuna John @karunajohn
Qawwali by Farid Ayaz, Abbu Mohd and their group caped a day of brilliant conversations at the #Socmm12 perfectly
Marvi Sirmed @marvisirmed
hahahaha RT @DrAwab Likewise - im making a T-Shirt - "I survived #SOCMM12 Dhobi Ghat"
Sundus Rasheed @SundusRasheed
Omg! My favorite film-makers speaking now! @IamOnir and @pseudorebel. Donon aik dum #SexyAndIKnowIt
Shahab Siddiqi @UncleFu
Sanjay Rajoura is the bomb!! #socmm12
Ammara Khan @ammarakh
Many sublime thoughts on social media at #socmm12 but the speakers represent an exclusive and aloof segment of society.
Sadya Sid @maverika
Lord have mercy on Iqbal Bano's soul - the Laal brigade/Taimur Laal are butchering 'Hum Dekhaingay' #socmm12
Wednesday, August 1, 2012
"As a young man, I often goaded my believing friends with crudely logical questions about God. But as the years have passed, I have found myself hankering more and more for a little cosy voodoo in my life. Increasingly, I regard my atheism as a regrettable limitation. It seems to me that my lack of faith is not, as I once thought, a triumph of the rational mind, but rather, a failure of the imagination - an inability to tolerate mystery: a species, in fact, of neurosis. There is no chance of my being converted, of course - it is far too late for that. But I wish it wasn’t."
Zoë Heller, Everything You Know
(hat-tip: Curmudgeon on Facebook)
(hat-tip: Curmudgeon on Facebook)