The Importance of Two-Sided Arguments

This is a topic I was meaning to write a post about for some time. I encountered this topic while doing some social psychology reading last year, and it touches upon a lot of other posts I've written, having to do with decision-making and persuasion. It touches on the huge issue of bias which appears in so much of the medical and health literature.

Here is what some of the social psychology research has to say on this:

1) If someone already agrees on an issue, then a one-sided appeal is most effective. So, for example, if I happen to recommend a particular brand of toothpaste, or a particular political candidate, and I simply give a list of reasons why my particular recommendation is best, then I am usually "preaching to the converted." Perhaps more people will go out to buy that toothpaste brand, or vote for that candidate, but they would mostly be people who would have made those choices anyway. The only others who would be most persuaded by my advice would be those who do not have a strong personal investment or attachment to the issue.

2) If people are already aware of opposing arguments, a two-sided presentation is more persuasive and enduring. And if people disagree with a certain issue, a two-sided presentation is more persuasive to change their minds. People are likely to dismiss as biased a one-sided presentation which disagrees with their point of view, even if the presentation contains accurate and well-organized information. This is one of my complaints about various types of media and documentary styles: sometimes there is an overt left-wing or right-wing political bias that is immediately apparent, particularly to a person holding the opposing stance. I can think of numerous examples in local and international newspapers and television. The information from such media or documentary presentations would therefore have little educational or persuasive impact except with individuals who probably agree with the information and the point of view in advance. The strongest documentary or journalistic style has to be one which presents both sides of a debate, otherwise it is probably almost worthless to effect meaningful change--in fact it could entrench the points of view of opposing camps.


It has also been found that if people are already committed to a certain belief or position, than a mild attack or challenge of this position causes people to strengthen their initial position. Ineffective persuasion may "inoculate" people attitudinally, causing them to be more committed to their initial positions. In an educational sense, children could be "inoculated" against negative persuasion, such as from television ads or peer pressure to smoke, etc. by exploring, analyzing, and discussing such persuasive tactics, with parents or teachers.

However, such "inoculation" may be an instrument of attitudinal entrenchment and stubbornness: a person who has anticipated arguments against his or her committed position is more likely to hold that position more tenaciously. Or an individual who has been taught a delusional belief system may have been taught the various challenges to the belief system to expect: this may "inoculate" the person against challenging this belief system, and cause the delusions to become more entrenched.

An adversarial justice system reminds me to some degree of an efficient process, from a psychological point of view, to seek the least biased truth. However, the problem here is that both sides "inoculate" themselves against the evidence presented by the other. The opposing camps do not seek "resolution"--they seek to win, which is quite different. Also, the prosecution and the defense do not EACH present a balanced analysis of pro & con regarding their cases. There is information possibly withheld--the defense may truly know the guilt of the accused, yet this may not be shared openly in court. Presumably the prosecution would not prosecute if the innocence of the accused was known for sure.

Here are some applications of these ideas, which I think are relevant in psychiatry:

1) Depression, anxiety, and other types of mental illness, tend to feature entrenched thinking. Thoughts which are very negative, hostile, or pessimistic--about self, world, or future--may have been consolidated over a period of years or decades, often reinforced by negative experiences. In this setting, one-sided optimistic advice--even if accurate-- could be very counterproductive. It could further entrench the depressive cognitive stance. Standard "Burns style" cognitive therapy can also be excessively "rosy", in my opinion, and may be very ineffective for similar reasons. I think of the smiling picture of the author on the cover of a cognitive therapy workbook as an instant turn-off (for many) which would understandably strengthen the consolidation of many chronic depressive thoughts.

But I do think that a cognitive therapy approach could be very helpful, provided it includes the depressive or negative thinking in an honest, thorough, systematic debate or dialectic. That is, the work has to involve "two-sided argument".

2) In medical literature, there is a great deal of bias going on. Many of my previous postings have been about this. On other internet sites, there are various points of view, some of which are quite extreme. Those sites which are invariably about "pharmaceutical industry bias", etc. I think are actually quite ineffectual, if they merely are covering the same theme, over and over again. They are likely to be sites which are "preaching to the converted", and are likely to be viewed as themselves biased or extreme by someone looking for balanced advice. They may cause individuals with an already biased point of view to unreasonably entrench their positions further.

Also, I suspect the authors of sites like this, may themselves have become quite biased. If their site has repeatedly criticized the inadequacy of the research data about some drug intended to treat depression or bipolar disorder, etc., they may be less likely to consider or publish contrary evidence that the drug actually works. Once we commit ourselves to a position, we all have a tendency to cling to that position, even when evidence should sway us.

On the other hand, if there is a site which consistently gives medication advice of one sort or the other, I think it is unlikely to change very many opinions on this issue, except among those who are already trying out different medications.

So, in my opinion, it is a healthy practice when analyzing issues, including health care decisions, to carefully consider both sides of an argument. If the issue has to do with a treatment, including a medication, a style of psychotherapy, an alternative health care modality, or of doing nothing at all, then I encourage the habit of analyzing the evidence in two ways:
1) gather all evidence which supports the modality
2) gather all evidence which opposes it

Then I encourage a weighing, and a synthesis, of these points of view, before making a decision.
I think that this is the most reliable way to minimize biases. If such a system is applied to one's own attitudes, thoughts, values, and behaviours, I think it is the most effective to promote change and growth.



References:
Myers, David. Social Psychology, fourth edition. New York: McGraw-Hill; 1993. p. 275; 294-297.

Social Psychology

Social psychology is a wonderful, enchanting field.

It is full of delightful experiments which often reveal deeply illuminating facets of human nature.
The experiments are usually so well done that it is hard to argue with the results.

Many people in mental health fields, such as psychiatry, have not studied social psychology. I never took a course in it myself. I feel like signing up for one now.

Applications of social psychology research could apply to treating anxiety & depression; resolving conflict; improving morale; reducing violence on a personal or social level; improving family & parental relationships; building social relationships, etc.

My only slight criticism of typical social psychology research is that it tends to be quite cross-sectional, and the effects or conditions studied are most often short-term (i.e. results that could typically be obtained in a study lasting a single afternoon). My strongest interest is in applied psychology, and I believe that immediate psychological effects can be important, but long-term psychological effects are of greatest importance. The brain works this way, on many levels: the brain can habituate to immediate stimuli, if those same stimuli are repeated over weeks or months. Learning in the brain can start immediately, but deeply ingrained learning (akin to language or music learning) takes months or years. So some results from a day-long study may only be as deeply insightful as administering a medication for a single day -- the effects haven't had a chance to accumulate or be subject to habituation.

In any case, I strongly encourage those interested in mental health to read through a current social psychology textbook (examples of these tend to be very well-written, readable, and entertaining), and to consider following the latest social psychology research. The biggest journal in social psychology is the Journal of Personality and Social Psychology.

The Psychology of Happiness

So-called "positive psychology" is, in my opinion, a very important evolving field. Surprisingly, it is a relatively new field, in terms of formal academic study. Much of the past study of psychology, psychotherapy, and psychiatry has been focused on "pathology" or on treating symptoms of illness, rather than studying or understanding happiness.

Positive psychology need not be criticized as a discipline which defines normality as a continuous happy state. Rather, I think it is a different way of looking at, and nurturing, psychological health.

I'd like to discuss this subject further, but for now, here are a few authors to look at:
-Sonja Lyubomirsky
-Barbara Fredrickson
-Martin Seligman
-Richard Layard

Some insights from this field include the following:

- a "steady diet" of positive emotion increases a sense of meaning and purpose in life, and increases the likelihood of "flourishing" in life. * While this may seem like a truism, it really isn't: it is possible to make changes in lifestyle practices, and to practice skills, to increase positive emotion in daily life. Many people coast through their daily lives, lacking positive emotion, or a sense of meaning.

-Specific suggestions for increasing positive emotion include paying attention to kindness (giving and receiving); consciously increasing awareness in the present moment; simply going outside in good weather; or meditation techniques such as "loving kindness meditation."

-Also, a variety of research has suggested that a ratio of "positivity to negativity"-- in terms of dialog with others, personal emotional experience, and I would add, dialog within your own mind--should exceed 5 to 1. Some of this research comes from looking at dialog in marriages, and interactions in other groups. We all have a tendency to criticize too much--with others and with ourselves--which leads to the positive:negative ratio diminishing, often way below 5 to 1. This suggestion does not advocate suppressing criticism or negative dialog; rather it is about balancing the negative with a large abundance of positive. If you think of any teacher or guide who has ever helped you learn something or grow as a person, I'm pretty sure you'll find that the feedback given to you was mostly positive, with only occasional, concise, gentle, criticisms. I recommend this approach in dealing with negative thoughts within your own mind -- try to balance them, aim for that 5 to 1 ratio.



*see the article "Are you Happy Now?", interview of Barbara Fredrickson by Angela Winter, Utne Sep-Oct 09, p. 62-67.


Here are some more references, which I'll comment more on later:
http://www.ncbi.nlm.nih.gov/pubmed/17716102
http://www.ncbi.nlm.nih.gov/pubmed/17115810
http://www.ncbi.nlm.nih.gov/pubmed/16045394
http://www.ncbi.nlm.nih.gov/pubmed/11894851
http://www.ncbi.nlm.nih.gov/pubmed/19485613
http://www.ncbi.nlm.nih.gov/pubmed/18954193
http://www.ncbi.nlm.nih.gov/pubmed/17356687
http://www.ncbi.nlm.nih.gov/pubmed/11934003
http://www.ncbi.nlm.nih.gov/pubmed/19301241
http://www.ncbi.nlm.nih.gov/pubmed/11315250
http://www.ncbi.nlm.nih.gov/pubmed/19056790
http://www.ncbi.nlm.nih.gov/pubmed/19056788
http://www.ncbi.nlm.nih.gov/pubmed/19227700
http://www.ncbi.nlm.nih.gov/pubmed/18841581
http://www.ncbi.nlm.nih.gov/pubmed/18356530
http://www.ncbi.nlm.nih.gov/pubmed/17479628
http://www.ncbi.nlm.nih.gov/pubmed/17327862

Increasing anxiety in recent decades...continued

This is a sequel to a previous posting (http://garthkroeker.blogspot.com/2009/06/increasing-anxiety-in-recent-decades.html)

A visitor suggested the following July 2009 article to look at regarding this subject--here's a link to the abstract:
http://www.ncbi.nlm.nih.gov/pubmed/19660164

The author, "Ian Dowbiggin, PhD", is a history professor at the University of Prince Edward Island.

I found the article quite judgmental and poorly informed.

I thought there were some good points, exploring the interaction of social dynamics, political factors, secondary gain, etc. in the evolution of diagnostic labels; and perhaps exploring the idea that we may at times over-pathologize normal human experiences, character traits, or behaviours.

But, basically the author's message seems to be that we cling to diagnostic labels to avoid taking personal responsibility for our problems--and that therapists, the self-help movement, pharmaceutical companies, etc. are all involved in perpetuating this phenomenon.

Another implied point of view was that a hundred years ago, people might well have experienced similar symptoms, but would have accepted these symptoms as part of normal life, and carried on (presumably without complaint).

To quote the author:

"The overall environment of modern day life...bestows a kind of legitimacy on the pool of
anxiety-related symptoms"

This implies that some symptoms are "legitimate" and others are not, and that it is some kind of confusing or problematic feature of modern society that anxiety symptoms are currently considered "legitimate."

I am intensely annoyed by opinion papers which do not explore the other side of the issues--

here's another side to the issue:

1) perhaps, a hundred years ago, people suffered just as much, or worse, but lacked any sort of help for what was bothering them. They therefore lived with more pain, less productivity, less enjoyment, less of a voice, more isolation, and in most cases died at a younger age.

2) The development of a vocabulary to describe psychological distress does not necessarily cause more distress. The vocabulary helps us to identify experiences that were never right in the first place. The absence of a PTSD label does not mean that symptoms secondary to trauma did not exist before the 20th century. The author somewhat mockingly suggests that some people misuse a PTSD or similar label--that perhaps only those subject to combat trauma are entitled to use it, while those subject to verbal abuse in home life are not.

The availability of financial compensation related to PTSD has undoubtedly affected the number of people describing symptoms. But the author appears to leave readers with the impression that those seeking compensation via PTSD claims are "milking the system" (this is the subtitle of the PTSD section of this paper). There is little doubt that factitious and malingered symptoms are common, particularly when there is overt secondary gain. And the issue of how therapeutic it is to have long-term financial compensation for any sort of problem, is another matter for an evidence-based and politically charged debate. But to imply that all those who make financial claims regarding PTSD are "milking the system" seems very disrespectful to me. And to imply that a system which offers such compensation is somehow problematic again seems comparable to saying that the availability of fire or theft insurance is problematic. A constructive point of view on the matter, as far as I'm concerned, would be to consider ways to make compensation systems fair and more resistant to factitious or malingered claims.

With regard to social anxiety -- it may well be that "bashfulness" has been valued and accepted in many past--and present--cultures. But I suspect that the social alienation, social frustration, loneliness, and lack of ability to start new friendships, new conversations, or to find mates, have been phenomena similarly prevalent over the centuries. Our modern terminology suggests ways for a person who is "bashful" to choose for himself or herself, whether to stoically and silently accept this set of phenomena, or to address it as a medical problem, with a variety of techniques to change the symptoms. In this way the language can be empowering, leading to the discovery and nurturance of a voice, rather than leading to a sense of "victimhood."

Perhaps the lack of a vocabulary to articulate distress causes a spurious impression that the distress does not exist, or is not worthy of consideration. A historical analogy might be something along the lines of this: terms such as "molecule", "Uranium", or "electromagnetic field," may not have been used before 1701, 1797, or 1820, but this was merely a product of ignorance, not evidence of the non-existence of these phenomena in the 1600's and prior.

It may well be true that many individuals misuse the vocabulary, or may exploit it for secondary gain. And it may well be true that some diagnostic labels introduce an iatrogenic or factitious illness (the multiple personality disorder issue could be debated along these lines). But to imply that the vocabulary itself is harmful to society is akin to saying that fire insurance is harmful, since some people misuse it by deliberately burning their houses down.


3) Similarly, the so-called self-help movement may be part of some individuals fleeing into self-pathologizing language, while ironically neglecting a healthy engagement with their lives. But in most cases, it has actually helped people to recognize, label, and improve their problems. For a start on some evidence to look at regarding this, see the following reference to a meta-analysis on self-help for anxiety disorders: http://www.ncbi.nlm.nih.gov/pubmed/16942965).

---
So, in conclusion, it is interesting to hear a different point of view. But I would expect a distinguished scholar to provide a much more balanced and insightful debate in such a paper, especially when it is published in a journal which is supposed to have high standards.

And I would certainly expect a much more thorough exploration of research evidence. The presence of 35 references in this paper may fool some readers into thinking that a reasonable survey of the research has been undertaken. Almost all of the references are themselves opinion pieces which merely support the author's point of view.

Is Seroquel XR better than generic quetiapine?

A supplement written by Christoph Correll for The Canadian Journal of Diagnosis (September 2009) was delivered--free--into my office mailbox the other day.

It starts off describing the receptor-binding profiles of different atypical antipsychotic drugs. A table is presented early on.

First of all, the table as presented is almost meaningless: it merely shows the concentrations of the different drugs required to block 50% of the given receptors. These so-called "Ki" concentrations have little meaning, particularly for comparing between one drug and another, UNLESS one has a clear idea of what concentrations the given drugs actually reach when administered at typical doses.

So, of course, quetiapine has much higher Ki concentrations for most receptors, compared to risperidone -- this is related to the fact that quetiapine doses are in the hundreds of milligrams, whereas risperidone doses are less than ten milligrams (these dose differences are not reflective of anything clinically relevant, and only pertain to the size of the tablet needed).

A much more meaningful chart would show one of the following:

1) the receptor blockades for each drug when the drug is administered at typical doses

2) the relative receptor blockade compared to a common receptor (so, for example, the ratio between receptor blockades of H1 or M1 or 5-HT2 compared to D2, for each drug).

The article goes on to explore a variety of other interesting differences between antipsychotics. Many of the statements made were theoretical propositions, not necessarily well-proven empirically. But in general I found this discussion valuable.

Despite apparent efforts for the author to be fair and balanced regarding the different antipsychotics, I note a few things:

1) there are two charts in this article showing symptom improvements in bipolar disorder among patients taking quetiapine extended-release (Seroquel XR).

2) one large figure appears to show that quetiapine has superior efficacy in treating schizophrenia, compared to olanzapine and risperidone (the only "p<.05 asterisk" was for quetiapine!) -- this figure was based on a single 2005 meta-analysis, published in a minor journal, before the CATIE results were published. No other figures were shown based on more recent results, nor was clozapine included in any figure.

I think quetiapine is a good drug. BUT -- I don't see any evidence that quetiapine extended release is actually any better, in any regard, than regular quetiapine. In fact, I have seen several patients for whom regular quetiapine suited them better than extended-release, and for whom a smaller total daily dose was needed.

Here is a reference to one study, done by Astra-Zeneca, comparing Seroquel with Seroquel XR, in healthy subjects: http://www.ncbi.nlm.nih.gov/pubmed/19393840 It shows that subjects given regular quetiapine were much more sedated 1 hour after dosing, compared to those given the same dose of Seroquel XR. It implies that the extended release drug was superior in terms of side-effects. Here is my critique of this study: first of all, sedation is often a goal in giving quetiapine, particularly in the treatment of psychosis or mania. Secondly, problematic sedation is usually the type that persists 12 hours or more after the dose, as opposed to one hour after the dose. In this study, the two different formulations did not differ in a statistically significant way with respect to sedation 7, 8 or 14 hours after dosing. In fact, if you look closely at the tables presented within the article, you can see that the Seroquel XR group actually had slightly higher sedation scores 14 hours after dosing. Thirdly, dosing of any drug can be titrated to optimal effect. Regular quetiapine need not be given at exactly the same dose as quetiapine XR--to give both drugs at the same dose, rather than at the optimally effective dose for each, is likely to bias the results greatly. Fourth, this study lasted only 5 days for each drug ! In order to meaningfully compare effectiveness or side-effects between two different drugs, it is necessary to look at differences after a month, or after a year, of continuous treatment. For most sedating drugs, problematic sedation diminishes after a period of weeks or months. Once again, if immediate sedation is the measure of side-effect adversity, then this study is biased in favour of Seroquel XR. Fifth, the study was done in healthy subjects who did not have active symptoms to treat. This reminds me of giving insulin to non-diabetic subjects, and comparing the side-effects of the different insulin preparations: the choice of population is an obvious strong bias!


Regular quetiapine has gone generic.

Quetiapine extended-release (Seroquel XR) has not.

I am bothered by the possibility of bias in Correll's article.

It is noted, in small print at the very end of this article, that Dr. Correll is "an advisor or consultant to AstraZeneca, Bristol-Myers Squibb, Cephalon, Eli Lilly, Organon, Ortho McNeill-Janssen, Otsuka, Pfizer, Solvay, Supernus, and Vanda." AstraZeneca is the company which manufactures Seroquel XR.

In conlusion, I agree that there are obviously differences in receptor binding profiles between these different drugs. There are some side-effect differences.

Differences in actual effectiveness, as shown in comparative studies, are minimal. But probably olanzapine, and especially clozapine, are slightly better than the others, in terms of symptom control.

Quetiapine can be an excellent drug. Seroquel XR can be an excellent formulation of quetiapine, and might suit some people better.

BUT -- there is no evidence that brand-name Seroquel XR is superior to generic regular quetiapine.

One individual might respond better to one drug, compared to another.

The author, despite including 40 references, seems to have left out many important research studies on differences between antipsychotics, such as from CATIE and SOHO.

(see my previous post on antipsychotics: http://garthkroeker.blogspot.com/2008/12/antipsychotic-medications.html )