Saturday, January 17, 2015

The 31% Solution

In writing a book on mental illness (which is topping out, now, at 113K words), I find that although I haven't exactly written an anti-psychiatry screed, I've come about as close to that designation as you can come without sounding like a full-on psychiatry-bashing lunatic. Where's the dividing line? For one thing, I stop short of saying there's no such thing as mental illness; I believe that the utility of the illness model is (just barely) useful enough not to discard it completely. I also stop short of saying psychiatry has nothing to offer, or that drugs have nothing to offer, whereas many anti-psychiatry zealots are willing to go there. I can't go there unless that's where the evidence points. We know the evidence doesn't 100% point there, so let's not pretend it does.

On the other hand, psychiatry (not only psychopharmacology, but modern psychotherapy) deserves criticism on many fronts, and it's not hard to produce evidence on many of those points, so that's all fair game. My book is full of criticism. (And footnotes. Hundreds of footnotes.)

In medicine, there are many "31% solutions," which is to say therapeutic options that work for about 31% of people who try them. This includes placebos, antidepressants, antipsychotics, herbal cures, cures for alcoholism (the year-over-year retention rate for Alcoholics Anonymous is about 31%), various psychotherapies, low-dose electroconvulsive therapy, sham ECT, trans-cranial magnetic stimulation, and probably diets, exercise, and much else. Frankly, a 31% response rate, whether it's for a cancer treatment or a mental disorder, whether it involves "real medicine" or placebos or sham treatments, is not something you just walk away from. When people are desperate for relief, they'll try something that works 31% of the time. And well they should!

But we should be honest about response rates, remission likelihoods, etc., in treatment of mental illness, as in treatment of cancer or any other malady. And this is where the "mental health industry" (if you can call it that) has done a remarkably poor job. Patients are led to believe antidepressant drugs mostly work, when in fact they mostly do not. They've also been told ECT (electroconvulive therapy) mostly works, when in fact the benefits beyond the one-month point are essentially nil and there's no difference in long-term outcome between sham ECT (placebo) and real ECT, something I go into it the book (citing FDA's own internal literature review).

Also, CBT (cognitive behavioral therapy) has been so grossly oversold as a treatment modality, with claims of its superiority to other modalities, that I felt an obligation to counter some of the misleading claims made for CBT. So in the book, I devote a few pages to that. Again, not because CBT doesn't work for some people (it clearly does) or doesn't have any utility at all, but because it's been preposterously oversold. I'll devote a future blog post to that.

For more information about my upcoming book and how to get free sample chapters, please add your name to the mailing list (no updates have been sent out yet; I'm not interested in spamming anyone). And please check back here often. Thank you!


  1. As a former CB therapist I shall look forward to your post on how it has been oversold, which I agree with BTW. Not only that but CBT is going down paths that I think stretch its core principles to breaking point, and furthermore therapy in general is oversold as something nice and fluffy almost, which if it is going to be effective is anything but nice and fluffy.

    1. Ashley, you make a great point abut therapy, which I address in my book, which is that if it's working, it's not necessarily going to be pleasant, and if you choose a therapist based on rapport and ability to make "comfortable conversation," you're going down the wrong road. The point of therapy is not to stay in your comfort zone, but to venture safely out of it.

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