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Dr. Bob is Robert Hsiung, MD,
bob@dr-bob.orgShown: posts 1 to 11 of 11. This is the beginning of the thread.
Posted by SLS on March 30, 2008, at 6:49:34
Shall we use inductive reasoning rather than deductive reasoning when seeking a treatment for mental illness?
1) Inductive = detailed facts -> general principles (empirical observation)
2) Deductive = general -> specific (cause and effect)
I favor inductive reasoning. The precise clinical reactions to a series of drug trials can be observed. One can then make a statement as to the statistical rate of success using associations. Out of 100 cases of melancholia, if 65% respond to imipramine and 25% to fluoxetine, one may infer and generalize that imipramine is more effective than fluoxetine in treating this subtype of depression. However, if one takes all of the physiological information that neuroscience has gathered to apply deductive reasoning, one is probably less apt to guess right and predict the effects of a specific treatment for each patient. There are still too many unknown variables to be elucidated.
As the mountains of information gleaned from the study of the brain begin to be assembled properly, deduction may one day supplant induction as the way a clinician approaches treatment.
We here at Psycho-Babble might be doing ourselves harm by assuming we understand enough about the brain and pharmacology to choose drugs for each other. Arrogance plus ignorance can be a lethal combination.
- Scott
Posted by Glydin on March 30, 2008, at 8:08:47
In reply to Inductive versus Deductive Reasoning, posted by SLS on March 30, 2008, at 6:49:34
> We here at Psycho-Babble might be doing ourselves harm by assuming we understand enough about the brain and pharmacology to choose drugs for each other. Arrogance plus ignorance can be a lethal combination.
>
~~~ It's my belief that *most* users of messages boards and, specifically, internet resources are discerning and are aware of the complex variables in treatment choices. From my observation, I think suggestions are usually greeted with: "Hmmm, that's interesting and may merit more thought...." IMO, an appropriate response.I think there are a select few whos thought processes don't appear to fall into being "gray" enough to allow for the ability to: "Take it for what's it's worth, your YMMV..." Those folks are concerning to me but I think have have concluded sometimes there issues at play that really are bigger than finding a treatment plan.
In my own mind, I did not believe in the effectiveness of my treament until it WAS effective. I agree it could be harmful to believe we know what drugs are choices for others.
Posted by johnj on March 30, 2008, at 9:07:24
In reply to Inductive versus Deductive Reasoning, posted by SLS on March 30, 2008, at 6:49:34
We also have to look at the state of mind of the posters here. We have not meet them and to think face to face they would sound more reasonable than out doctors is probably not correct.
Sometimes a one or two time dose and then ditching it and then posting that it is a bad drug is a disservice to new posters. Lately, I feel the board is not of the same judgement that I saw a few years back. Unfortuntely, there may be posters that dominate who probably should not be giving advice. However, when I have been doing poorly I seem to listen to anything and I know my judgement it based on my mood at the time. Buyer Beware.
Posted by seldomseen on March 30, 2008, at 10:09:33
In reply to Inductive versus Deductive Reasoning, posted by SLS on March 30, 2008, at 6:49:34
you've actually hit on a big push in all fields of medicine.
It's called evidence-based medicine.
Essentially it is a statistics driven modality whose fundamental question is "does the treatment actually work".Evaluation of the quality of evidence is at the forefront.
Posted by Phillipa on March 30, 2008, at 10:34:16
In reply to Re: Inductive versus Deductive Reasoning » SLS, posted by seldomseen on March 30, 2008, at 10:09:33
Each piece of knowlege gained can sometimes shed knowledge. I remember when we really didn't suggest meds but said here is what happened to me . I'd ask your pcoc. As we are all different. Goodness look at all the cocktails posted. Just my thought. Phillipa
Posted by bulldog2 on March 30, 2008, at 10:49:55
In reply to Inductive versus Deductive Reasoning, posted by SLS on March 30, 2008, at 6:49:34
> Shall we use inductive reasoning rather than deductive reasoning when seeking a treatment for mental illness?
>
> 1) Inductive = detailed facts -> general principles (empirical observation)
>
> 2) Deductive = general -> specific (cause and effect)
>
> I favor inductive reasoning. The precise clinical reactions to a series of drug trials can be observed. One can then make a statement as to the statistical rate of success using associations. Out of 100 cases of melancholia, if 65% respond to imipramine and 25% to fluoxetine, one may infer and generalize that imipramine is more effective than fluoxetine in treating this subtype of depression. However, if one takes all of the physiological information that neuroscience has gathered to apply deductive reasoning, one is probably less apt to guess right and predict the effects of a specific treatment for each patient. There are still too many unknown variables to be elucidated.
>
> As the mountains of information gleaned from the study of the brain begin to be assembled properly, deduction may one day supplant induction as the way a clinician approaches treatment.
>
> We here at Psycho-Babble might be doing ourselves harm by assuming we understand enough about the brain and pharmacology to choose drugs for each other. Arrogance plus ignorance can be a lethal combination.
>
>
> - Scott
>I think the greater the efficacy of the inductive study one still has more ammo to make a statiscally accurate prognosis as to how one may react to a particular drug.
However babble is becoming flawed because of a couple problems.
1. People start a thread on a particular drug trial and if we're lucky another few ppl add their experiences.
2. They post for a week or two, quit the drug or stop posting. We know that ad's require 6-8 at a therapuetic dosage to evaluate the drug.
3. So for some people the thread becomes their inductive study as to how they think they may respond to a particular drug. However the thread is highly flawed as a study. To few people have posted and have not posted long enough to draw a meaningful conclusion.
4. We have the start of several promising threads where People posted on some promising combo and disappear after a few posts.I know people are busy but a few seconds out of your day to update others would be nice.
5.Scott I guess you remember andrewb and others who were committed to time on this board.
6. If one person comes in and posts I vomited on this drug you can't deduce the drug will make you vomit.
7. Also if one person comes in and posts I'm cured after a week on this drug you can't deduce that drug will be a miracle for you.
Posted by dbc on March 30, 2008, at 10:54:29
In reply to Re: Inductive versus Deductive Reasoning, posted by Phillipa on March 30, 2008, at 10:34:16
I always favor empirical evidence but do not always assume its correct with newer substances. Why? Because control group studies are rigged to favor whatever the company wants the outcome to be. They very selectively choose people for their studies and conduct them in a clinical environment with rigid guidelines. This does not translate well to the real world. Of course this is where peer review comes into play but its much harder to fund an indepdent study than one backed by a major pharm corp.
Certain substances have been studied so intensely that theres very little we dont know about them. Benzos, Amphetamine, Phenobarbital, Prozac. We can predict the outcome of ingesting these substances pretty well.
I dont feel comfortable telling people what they should take but if a certain circumstance comes up ill make a purely ancedotal post and reccomend a course of action to try based on my ancedote. But these have to be specific situations.
As you pointed out even in a clinical environment psychiatrists run on ancedotal evidence and dont sit there and tell you the facts about control studies. Most of medicine is like this, if every doctor told their patients 1 in 1000 people that take penicilian goes into anaphylactic shock no one would take it.
Posted by rskontos on March 30, 2008, at 11:18:39
In reply to Re: Inductive versus Deductive Reasoning, posted by bulldog2 on March 30, 2008, at 10:49:55
Bulldog,
I agree with you. Also, sometimes distance with a drug inability to work with you is sometimes needed. I feel that sometimes people have posted, myself included, with an emotional response to how the drug made them feel, and you get that baggage as well. I can now post more reflective about the AD's I have used in the past now that I am well past their side effects since i have been off of them and the emotional effects have subsided as well. I see the ups and downs of the drugs in a different light at this point and can give a much different response now, then I would have given in the throes of withdrawal.
rsk
Posted by SLS on March 30, 2008, at 11:38:57
In reply to Re: Inductive versus Deductive Reasoning, posted by dbc on March 30, 2008, at 10:54:29
Your points are very well taken. I can't find flaws in anyone's response along this thread. In essence, there can be a balance between inductive and deductive approaches. As time passes, I hope the two will merge into a unified structure where the inductive serves as the proof of the deductive.
My original post was meant to be provocative so as to challenge the status quo here. I, too, have been concerned with the number of aborted drug trials and the growing belief that you can predict the worth of a drug by how it behaves during the first week of treatment. Often, personal hypotheses and theories seem to take on the appearance of fact - at least in the mind of these individuals. I first proposed the involvement of dopaminergic systems in my own case in 1983. I was a bit of a loner at that time. The psychiatric team at Columbia would not hear of it and refused to prescribe to me bromocriptine and Wellbutrin. They were still hung up on norepinephrine at the time. Serotonin was the neurotransmitter of the future, but was without a representative drug available in the US. To my amazement, I found a researcher by the name of Randrup at the University of Chicago who also deduced a role for dopamine in depressive disorders, especially when bipolar disorder was considered.
Since then, I have hypothesized and found dopamine implicated in the actions of several different drugs that have been found effective for treating depressive and bipolar disorders. For example, it is my theory that Lamictal becomes pro-dopaminergic in its resultant action at the nucleus accumbens, which is the primary reward center in the brain. Lamictal produces a reduction in glutamate release in the thalamus. The inhibition in the firing of glutamatergic neurons in this circuit produces a disinhibition of limbic dopamine release. At least that's what I think. I was motivated to search for a role for dopamine in the actions of Lamictal once I responded favorable to it. Here, deduction followed induction. I had no idea Lamictal was dopaminergic when I first decided to try it. However, my intuition that it was somehow dopaminergic led me to continue with it.
It really doesn't matter whether I am right or wrong. What does matter is that some neurologists at the NIH observed that their depressed epileptic patients experienced an improvement of their depression upon the administration of Lamictal. All they had to work with was inductive reasoning that led them to notify the Department of Biological Psychiatry that they had witnessed something interesting in a series of depressed patients undergoing Lamictal therapy. It's pretty cool that this happened while I was down there, and motivated me to try it when it first became available. Any conjecture as to the mechanism of action of Lamictal is after the fact.
- Scott
Posted by seldomseen on March 30, 2008, at 12:19:44
In reply to Re: Inductive versus Deductive Reasoning, posted by dbc on March 30, 2008, at 10:54:29
"As you pointed out even in a clinical environment psychiatrists run on ancedotal evidence and dont sit there and tell you the facts about control studies. Most of medicine is like this, if every doctor told their patients 1 in 1000 people that take penicilian goes into anaphylactic shock no one would take it"
It has been my experience that most of medicine, including psychiatry is not like that at all.
Most doctors follow the guidelines for practice set forth by working groups of physicians in that field. The groups decide on the quality of evidence for a specific treatment and issue standards for physicians to follow.
The guidelines for practice for the APA are found in this link:
http://www.psych.org/MainMenu/PsychiatricPractice/PracticeGuidelines_1.aspxNow that is not to say that physicians do not deviate from these guidelines, there are specific reasons to do exactly that. Also, these guidelines are updated as the need arises.
These guidelines clearly do not preclude the provider from using his or her best judgement (which may or may not be based on good evidence) regarding an individual patient. They do, however, outline the treatment modalities that are most likely to be of benefit.
Regarding your penicillin example, in my opinion, it would be wholly improper for a physician to tell a patient that there is a 1 in 1000 risk of anaphylactic shock without also informing the patient of the risk of death from overwhelming infection.
With most meds it is about risk/benefit analysis which is figured into the guidelines.
Just my two cents.
Seldom
Posted by dbc on March 30, 2008, at 14:11:47
In reply to Re: Inductive versus Deductive Reasoning » dbc, posted by seldomseen on March 30, 2008, at 12:19:44
> It has been my experience that most of medicine, including psychiatry is not like that at all.
>
> Most doctors follow the guidelines for practice set forth by working groups of physicians in that field. The groups decide on the quality of evidence for a specific treatment and issue standards for physicians to follow.
>
> With most meds it is about risk/benefit analysis which is figured into the guidelines.Of course theres a system in place where the most obvious treatment is used for a problem (first line drugs). You get a patient presenting with clinical depression and the first drug you throw at them is an SSRI. If that doesnt work you move on to a second line drug but after that it gets a little fuzzy and you have to start thinking about past patient feedback and how it relates to the current situation, you're in no mans land as far as treatment. Sometimes this works great and sometimes its a disaster.
The previous poster brought up lamictal. Now my DX is complicated and im treatment resistant to all the common things so this doctor concludes finally that im bi-polar despite the fact that i lack any symptomes of mania cough.
I Grudgingly start taking lamictal and everythings going good and then i hit about 100-125mg and i start having minor delusions (oh god im being watched etc) and audio hallucinations. My doctor will not belive its the lamictal (she's never heard about this side effect yadda yadda) and assumes im flipping into some mania and forgot to mention for 2 years that i have them. So she starts giving me Atypicals...they do nothing to dent the crazyness.
I start trying to find cases online of similar situations with lamictal and come across people talking about dose dependent psychosis experiences with lamictal and also a study with a vague description of something similar.
I call her and explain that im still crazy but i have a solution and if it works you'll look silly. We bump the dose to 200mg and the hallucinations go away.
Whats my point? Eh well i guess that sometimes just sometimes anecdotes are useful and the tiered system of prescribing can be flawed because of anomalies like me. I kind of lost my point half way through that but you'll get the gist of it.
This is the end of the thread.
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