This is a skip and a jump ahead of where I am in this ramble.
As I've discussed, it tries to achieve different things because there are different reasons behind the concept.
Depression treatment should be to help people be less miserable or to treat their biological roots of misery. In an ideal world it would do what the patient wants and expects.
People go to their doctors in times of crisis. Carers and others may also use doctors to deal with other people's crises. Before the inception of psychiatry some people would go to their doctors to deal with the problems which are described as mental illnesses now but more often I think people went to priests or faith healers. Many still do, especially in countries where psychiatry is yet to establish a strong foot hold on the culture.
This can be times when grief gets too bad or misery too intense. It can be when a person becomes difficult to understand or dangerously withdrawn. It can be when a person is a danger to themselves or others. Priests, psychiatrists, doctors and wise people are where people go when they need expertise.
Regardless of the name of the system this human need for expertise in the human condition is fulfilled in different ways over the millenia. Psychiatry and mental health are the modern constructs which prevail in the Western world and like a religion it is spreading to developing world nations.
People need answers in their times of crisis. People need help for their emotional distress. When informal systems such as supportive social groups become inadequate or not utilised then people, carers and society turn to doctors.
Today their answers use the best available science. Psychiatric research, though underfunded, is still light years ahead of what it was a century ago. It's not perfect but if used strictly, I.e. if clinicians are very well trained to adhere to reference practices when making a diagnosis then there's a good chance the science fits together.
What this means is a person who is diagnosed with the accuracy used in research will have the other stuff which comes from the research. Or likely so anyway. It's not 100% accurate. They'll do worse in life. They'll die earlier. They'll be more likely to be isolated and unemployed. They're more likely to kill themselves or someone else. They'll have lower quality of life.
It is terrible what the prognosis really means and how the label relates to it. It is the role of doctors to fix it. Or at least this is the current request society makes to the psychiatric establishment. I assume this is what patients want too.
The label predicts a likely prognosis but it also selects the tailored treatment plan which works best for that particular human type, at least in theory.
Aside from outcome studies there are also treatment studies. Obviously. Modern treatments need to work. Obviously. The way we know it works is using scientific techniques. This is the modern paradigm of truth which replaces the power of god as the paradigm of truth. Science gives psychiatry power just as god's word gave religion its power.
Using the science they prove ways which work on diagnosis. The randomised placebo controlled trial is still considered the gold standard of evidenced based medicine. These expensive studies are replicated by different academics then review papers take an average of the results and apply meta-analytical techniques to further enhance accuracy - like the funnel plot. These are all ways to reduce errors from bias and other factors.
These reviews - systematic reviews and metaIanalyses - carry huge weight in the commissioning of national mental healthcare. They have the highest weighting of all evidence in the current hierachy of evidence used in best practice evidenced based mental health commissioning.
Some can include hundreds of studies and hundreds of thousands of subjects in all those studies. One of my favourites is the review on job satisfaction and health. On physical and mental health measures job satisfaction was associated with much better physical and mental health for the majority of people. The authors annoyed me though. There was no funnel plot to check for publication bias.
Still, antidepressants or psychological therapies - the current modes of treatment - are commissioned using these scientific methods, the methods which are designed to show what really works and what doesn't.
There are problems with this though. The first is that the science is at an early stage. The entire model of diagnosis might be fundamentally flawed. There are so many unexplained effects and unusual cases which the science is unable to explain.
We're talking about trying to truly understand people. This is why mental health as psychiatry is one of the greatest scientific goals in human history as well as the most challenging. We can split the atom and know the makeup of the fabric of the universe but we know fuck all about each other.
There are huge questions about whether mental health science is truly communicating or understanding the nature of what it is used on. It is science applied to people and the human condition and inviduals and personality and emotions.
The other problem is irrespective of these concerns about the success or correctness of the fundamentals - the first principles and core - of psychiatric science. It is about what the results say.
Too often as time goes on accepted treatments are shown to be poor. They look good in early trials but as time goes on more negative results are published, if they're published. Modern reviews are dispelling the efficacy of accepted treatments. As the science evolves and as other factors change, for example the enthusiasm of the practioners in exploratory trials for a new modality, the results seem to favour the control far too frequently.
In 2007 a review by Kirsch used unpublished data on antidepressants. With the unpublished data included the drugs were shown to be much less effective. This result was well publicised. Now more research shows that antidepressants aren't as effective as once thought. The same is true for psychological therapies when looking at high quality trials only. The same is true for electroconvulsive therapy. Too many reviews so accepted treatments to be ineffective, especially when the inclusion criteria excludes all but the best studies currently available.
Read Robert Whitaker or Dr. Joanna Moncrieff's work. I can reference some stuff but they communicate it so much better.
The one thing I would say is given a choice between a review of lots of studies of varying quality or a few very high quality studies I would go with the latter. The results from good science applied well is gold in an area which is full of shit.
So really...after all this stuff today...I've basically said that the mentally ill are going to have worse lives. The system isn't real in that it might not truly define an illness but it is definitely something which causes problems for patients and society.
Those that willing accept treatment do so based on an implicit and explicit trust. Some don't but that's another thing. Those that do might not be getting what they want, which is a predictably right solution which really works better than the placebo effect.
It's not doing nothing which is the comparison in trials. Doing nothing generally sucks whatever it is. Admittedly this may be my bias. The trials use something which is meant to be the same as the real treatment in the experience of taking it and using it except for one thing: the treatment. Science says if you want to really know something then test it using a suitable trial in an experiment with two groups, one which is only slightly different from the other only in the variable which is being tested. Did I say only enough? It is the most important word when apllying science to trials and what I'm talking about. A single trial derives signifcance from being as scientific as possible.
Good scientific experimental practice demands that everything but the variable in the experiment is the sole....the only.....difference between the two groups in the study. In my opinion. This is why I value reviews of very high quality studies above ones which include lots of studies of poorer quality. Oh, and the practical reason is the biases and errors of including poor quality results when studies reach the point of being accepted truths rather than things to think about is significantly reduced with increasing quality of trial.
What I mean is a half baked study is worth as much as nothing if you're like me and the pursuit of truth, by scientific standards, is paramount.
In practice the review which only looks at the very best studies holds a lot of weight anyway, even if it isn't truly recognised. If it was then there'd be more of these high quality trials done - at great expense - rather than the mass of cheap studies which show some hope of an effect but have signficant limitations in their application of science.
Low quality and experimental trials are obviously an important part of the prcoess of science and progress too. They're the steps to get the buy in, recognition and funding to do a truly scientific study. Anything without this paramount quality lacks the power of science. Science is about describing the truth. The absolute truth.
The absolute truth in mental health is when you're fucked up there is a perfect answer for you, something which is right first time.
This is a crazy idea but this is what good science offers. This is why science is accepted as the paradigm of truth by the modern consensus reality. This is what scientific principles achieve.
Two thousand years ago Romans were using seige catapults or some other projectile weapon which needed a range calculation to be made. Without science the weapon couldn't destroy its target. They needed to know physics but they had to invent it.
At first they assumed that, based on the understanding at the time, that a thing had energy to move then when it ran out it would instally drop. This isn't true. We could all see it when we throw a ball. It follows an arc. There's no cliff point where it suddenly drops. But at the time the Romans believed this was true.
I think it was Archemdies but it might have been someone else from his era who applied science to the problem. The powerful establishment didn't like it but they allowed his theory to be trialled.
It worked. Projectiles don't just drop when they've run out of energy. They keep going forward but start to fall by gravity.
This is science. It works because it asks that it works. A test shows what the test wants understood. If the test conditions can be replicated and the trial redone then a scientific result would be the same performance and results in every replication trial.
This is in a perfect scenario. But this is what scientists have to expect. Some might remember the cold fusion with palladium experiment which hit the news. Scinetists don't go to the press unless they've got something but what they had was the result of one trial. They got amazing results and could havebeen on the brink of inventing a new form of cheap, safe, green energy but it wasn't true. No study could replicate their findings.
If I'm depressed by any of this then I am sane.
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