To my mind there are few things that tax intellectual ethics more profoundly than whether the psychotropic debate should be had in public. It is my general feeling that it should not.
My blog is not read by the general public but I will make no attempt to be transparent. Those in the know, know what I am talking about.
The important thing is this: to my knowledge no one disputes that effects exist. They dispute the source of the effects. If some folks are asserting that harm is being caused this is important and we should talk about it.
However, we should talk knowing that we are playing with fire, that discretion is needed and that the public space may not be the place for this discussion. Happiness matters and it matters a lot. Suffering matters and it matters a lot.
I understand the escalation and cocktail problem and I think it is more reasonable to address them directly. However, to address some of my intellectual counterparts I will say this: if we don’t have a model of infection then practically speaking, pain is caused by a lack of aspirin.
Pain is bad.
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Wednesday ~ June 8th, 2011 at 12:57 pm
Sister Y
You mean, outside the hearing of the consumers of psychotropics?
Wednesday ~ June 8th, 2011 at 3:45 pm
Karl Smith
yep
Thursday ~ June 9th, 2011 at 2:07 pm
Sister Y
Why drugs that treat mental illness and not other kinds of illness? Are mental patients as a class too fragile to be exposed to this debate?
People with other kinds of illnesses seem to do pretty poorly with the information they’re given as well, hence the financial lucrativeness of “alternative medicine.”
Wednesday ~ June 8th, 2011 at 2:24 pm
IVV
Wait, what psychotropic debate?
Thursday ~ June 9th, 2011 at 2:09 pm
Sister Y
The one where lots of them don’t actually work.
Wednesday ~ June 8th, 2011 at 6:19 pm
emerich
Must you be so coy about this “debate”? What are you talking about? Who? Pain caused by what? Is the a problem afflicting economists?
Thursday ~ June 9th, 2011 at 12:14 am
Chip Smith
I understand what makes this a special problem (though not especially for me), but it seems quite possible that a gated discourse could stagnate R&D incentives that could, in turn, offset the stakes with something real and better. It’s a gambit, I know.
Also: it would be helpful to know — maybe you know? — what happens with a transparent placebo + suggestion design. In other words, what happens to the response when subjects are told that they are receiving a placebo BUT are also told (truthfully) that there is reason to believe that the placebo itself may be effective in treating their condition? Does the outcome differ from a blind placebo trial? My guess is that the effect survives. If it does (and how much it does) might make a difference in how you weigh the trade-off, particularly if you’re willing to bet that R&D stagnation is likely to stall genuine innovation without open discourse.
Or have I said too much?
Thursday ~ June 9th, 2011 at 3:13 am
cathalism
People no longer believe that economists possess hidden knowledge that can be used to manipulate reality in ways mere mortals cannot comprehend.
The curtain has been pulled back and the man behind the curtain is less than impressive.
I suggest that the presentation of this subject aims to obfuscate — to bestow a power of impenetrable mystery upon Karl Smith (as knower of mystical secrets) and the illuminati he addresses.
Thursday ~ June 9th, 2011 at 10:46 am
Peter
In a recent article about alternative medicine, the Economist referenced an HMS study that found that the placebo effect “may persist even if patients are told that they are getting placebo treatments.” In any case, I don’t think we should treat sufferers in this case as stupid just because of the nature of their affliction. They have as much right to understand and participate in the debate around treatment for their maladies as someone suffering from high cholesterol who may be prescribed statins they don’t need.
Thursday ~ June 9th, 2011 at 5:51 pm
Sister Y
Assuming that as a mental patient, I’m only excluded from the first-order debate and not the second-order debate . . .
1. What counts as a mental illness versus a regular illness? Anything in the DSM-IV, like sleep disorders, depression, and anxiety? Is there a scientific basis for the distinction you make?
2. What counts as a “psychotropic”? Anything used to treat mental illness, whether or not it’s used to treat other things? Or only drugs NOT used to treat other things? Or some other definition? (For example, trazodone was developed as an anti-depressant, but worked very crappily; today, it’s commonly prescribed as a sleep aid, for which it’s very effective.)
3. Your “debate in private” thing seems to imply a distinction between experts and patients, which is odd since physicians are more likely than non-physicians to have a mental illness (as high as 28% of doctors, as opposed to 15% of the general population).
4. Consider homosexuality. If it were 1973, would you say the debate over whether gayness is a mental illness and how to treat it should be had outside the hearing of gay folks? (After all, the lack of efficacy might have caused many to refuse “treatment.”)
5. How about anti-vaccination folks? Aren’t they (and the harm they do) a sign that all medical debate should take place in private? If not, why psychotropics and not vaccines?
6. Does this apply not only to efficacy, but also the the serious, debilitating, PAINFUL, and often permanent side effects of psychotropic meds? Should mental patients be protected from knowing about that, too?
Friday ~ June 10th, 2011 at 8:54 am
Adam Ozimek
I think you’re most persuasive here in arguing that this should apply more widely than Karl is applying it, e.g. the vaccines example. But this example also shows how the second-order debate is even more important to be kept secret, or better yet to just have it implicitly: real conspiracies empower false conspiracies.
With respect to #6, I think Karl is agreeing that evidence of side-effects should be weighed in favor of open discussion when he says “If some folks are asserting that harm is being caused this is important and we should talk about it.” Like you say, whether knowing their are side effects impacts the presence of side effects.
Overall though I’m not taking a side in this yet. I think a real scientific conspiracy to not talk about something could do immeasurable harm to the credibility of experts, and I worry about that a lot. You can’t shut everybody up, and one high profile person copping to a conspiracy is all it takes. On the other hand, I put a lot of weight on the welfare of those suffering from mental illness.
Thursday ~ June 9th, 2011 at 7:00 pm
Chip Smith
What’s the chief concern? that people will refuse treatment altogether? Or that people the benefits of placebo will be diminished if patients are aware of the controversy?
Thursday ~ June 9th, 2011 at 8:24 pm
Sister Y
The main problem for me boils down to this: in reality, the idea that “meds work” is consistently used to justify coercive practices.
It’s cheating to, on the one hand, claim that meds work to justify coercive practices, and on the other, hide any evidence or controversy over whether the meds actually work.
Saturday ~ June 11th, 2011 at 1:02 pm
TGGP
Was this post inspired by this review from the NYRB? It uses the same line about a deficiency of aspirin.
Thursday ~ June 16th, 2011 at 10:14 am
Casey
What if my depression is caused by my lurking suspicion that experts and technocrats aren’t telling me the whole truth? Then having the debate in public would be the cure, right?