Thursday, November 20, 2003

here, an idea, just like that

A graduate student was complaining to me the other day about how The Faculty In This Department never have ideas for projects that graduate students can do. Especially an idea that wasn't related to whatever, in her words, "stupid" projects they themselves happened to be working on at the time. So, as a bravura performance, I right there spun a research question that I'm not going to pursue but would think it would be intriguing if someone did. Oh, and the other requirements are that it had to be something that would be primarily an in-depth interview project and related to some other topic we had been talking about in the previous five minutes.

One such eligible topic was psychiatric medications. So here was my research question, now being made available to the weblog reader world for free.

The set-up: All kinds of people take antidepressants. Many of those people come to believe that the medication is doing them some kind of good. Practitioners, who see all kinds of patients, also believe that medications do many of their patients good, although some other patients do not appear responsive to medications. Now, if you look at the studies that are used to demonstrate the efficacy of the various popular antidepressants, you will notice that the positive effect of the medication is basically value-added on top of a "placebo" effect. Another way of saying this is that, depending on what meta-analytic conclusion you believe, either some, much, most, or almost all of the positive effect that beginning a regimen of antidepressant medication will have for a group with depression is actually a positive effect that they would have if they had never taken the drug to begin with. Meaning that there are some people out there who will attribute their improvement in mood to a drug that actually didn't really affect their mood. For that matter, you regularly hear people make claims about how they were helped by taking an antidepressant much more immediately than the time required for the drug to work its alleged neurochemical wonders. In other words, you have people claiming improvement after four days of taking a drug that isn't supposed to have appreciable physical effects for four days.

The question: How is it that people make inferences about whether or not an antidepressant medication is working? In a clinical trial, the efficiacy of the drug is demonstrated through statistics--you never know for an individual case if the drug helped them or if they would have just started feeling better anyway. But we don't get to live clinical trials, we have to make inferences about our own personal case study all the time. Moreover, it's not like one gets to live one's life holding everything constant except for the drug--instead, starting a medication regimen happens in the context of the welter of all the other events in one's biography. Plus, one is usually told that the medication won't work for awhile, which means you are comparing psychological states not extremely proximate in time. How do people come to infer that their moods are better or worse than they had been at some point in the past? And, if they are better, how is it that people come to attribute that improvement to the drug? Is it that the concept of regression to the mean is so unnatural to the mind that if people perceive themselves as getting better and they have started to take a drug, they will always credit the drug with their improvement? Do people ever think, sure I started taking Prozac, but I think what it really was was [some positive biographical event happening]? Or, better, sure I started taking Prozac and started feeling better, but given that I started taking Prozac at a low point in my life, the reasonable guess would be that things would get better. If people do use different logics for assessing whether or not a drug has done them any good, is there any logic to their choice of logics?

I wonder to what extent this project has been studied in clinical psychology. Even if it has been studied, I bet there are things I wouldn't like about how it had been studied.

Someone in academia could probably do this study without ever having to leave their building to find people to interview.

Anyway, the ultimate point is that ideas are easy. It's everything that comes after the idea that's hard. Especially, in my case, sticking with the idea.

(BTW, regarding the placebo effect, I'm actually pretty skeptical of whether there is such a thing for drug interventions for various kinds of physical ailments. This skepticism is based on some evidence comparing the results of drug trials that included both placebo and no drug conditions. However, I presume that it is obvious how skepticism about whether giving somebody with heart disease a placebo will sometimes improve their cardiovascular health is not contradictory with the belief that giving somebody a placebo for a mood problem will sometimes improve their mood. For that matter, my skepticism about the placebo effect only extends to studies where the health measurement is "objective," I'm not skeptical that giving somebody a placebo may lead them to report an improvement in self-reports about their health.)

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