Furious Seasons

December 29, 2009

Senate Health Care Bill Contains $1.25 Billion Gift To Sen. Stabenow

There's been a lot of coverage of amendments to the recently-passed Senate health care reform bill over the last 10 days, especially the Medicare giveaways for the State of Nebraska reportedly employed to capture the support of Sen. Ben Nelson (D-Nebraska) as well as giveaways to other Democratic senators. But one provision of the amendments, which were introduced on December 19, has escaped notice of the mainstream media and the political blogosphere alike. That would be $1.25 billion included in the amendments, apparently to secure the vote of Michigan Senator Debbie Stabenow. Sen. Stabenow, a Democrat, was a passionate advocate for the so-called public option who voted to support a bill without a public option in exchange for inclusion of $1.25 billion in new federal spending to support "centers of excellence" in depression treatment. (A list of so-called cash for cloture is here.)

In October, Stabenow introduced the so-called ENHANCED Act of 2009 on the Senate floor. But the Act was not included in the original Senate health care reform bill. Instead, it showed up virtually unnoticed in the manager's amendment (as the Senate amendments are known) on December 19. Was this inclusion in exchange for Sen. Stabenow's vote? What would these depression centers do (the relevant text begins on page 277)? Are they really needed? Depression is, after all, a well-researched and understood phenomenon and has been for decades and billions of dollars federal, state and pharma have been focused upon it. Why does the Senator believe that depression and bipolar disorder exist at twice the rate as does NIH? Is she engaging in scare tactics? How would these centers improve access to health insurance coverage for uninsured Americans, which is what I thought health care reform was supposed to be about?

Why is Sen. Stabenow proposing to spend $1.25 billion and saying, as she did in a floor speech, "My bill is based on work done informally" by the University of Michigan and 16 other academic centers? Shouldn't taxpayers, much less other senators, have a reasonable expectation that whatever program Sen. Stabenow proposes would be based on formal studies that a network of depression centers of excellence can make a marked improvement of some kind in depression treatment. Perhaps the Senator is resting on informal work because the formal, peer-reviewed, published evidence for current depression treatments shows that they don't work especially well, as I'll outline later in this post.

I made repeated requests for comment to Sen. Stabenow's office to clarify all of this. To date, I have received no reply.

THE ENHANCHED ACT OF 2009, A SENATOR'S EXCESSIVE CLAIMS

The ENHANCED Act is of course an acronym, in this case for "Establishing a Network of Health-Advancing National Centers of Excellence for Depression Act of 2009." The Act (here it is as introduced in the Senate on October 22, 2009) encompasses both depression and bipolar disorder, which has depressive episodes as one of its hallmarks. The Act's goals, as expressed in the amendment, are for the centers to:

"Each Center shall— ‘‘(A) integrate basic, clinical, or health services interdisciplinary research and practice in the development, implementation, and dissemination of evidence-based interventions; ‘‘(B) involve a broad cross-section of stakeholders, such as researchers, clinicians, consumers, families of consumers, and voluntary health organizations, to develop a research agenda and disseminate findings, and to provide support in the implementation of evidence-based practices; ‘‘(C) provide training and technical assistance to mental health professionals, and engage in and disseminate translational research with a focus on meeting the needs of individuals with depressive disorders; and ‘‘(D) educate policy makers, employers, community leaders, and the public about depressive disorders to reduce stigma and raise awareness of treatments. ‘‘(2) IMPROVED TREATMENT STANDARDS, CLINICAL GUIDELINES, DIAGNOSTIC PROTOCOLS, AND CARE COORDINATION PRACTICE.—Each Center shall collaborate with other Centers in the network to— ‘‘(A) develop and implement treatment standards, clinical guidelines, and protocols that emphasize primary prevention, early intervention, treatment for, and recovery from, depressive disorders; ‘‘(B) foster communication with other providers attending to co-occurring physical health conditions such as cardiovascular, diabetes, cancer, and substance abuse disorders;"

The Act as it appears in the amendment is a bit more watered down than its October version. Then it had language that would in essence seek to increase the number of Americans diagnosed with depression, as well as the number of Americans treated for depression and bipolar disorder. Sen. Stabenow also claimed in her floor speech that too many Americans went undiagnosed and untreated. Really? With 30 million Americans taking an anti-depressant every day? I don't buy that for a minute. I'll come to all the evidence-based interventions and practices in a moment.

Anyway, the Act would reach its ends by granting, in its first five years, $500 million to 20 universities or non-profits to work in the community to spread the word about depression and get folks into "evidence-based" treatment. More on the evidence in a minute. These centers, modeled on the University of Michigan's Depression Center, would get $5 million a year apiece for five years. In its second five years, the Act would fund 30 depression centers for five years at $5 million apiece per year for a total of $750 million. That brings the total for the 10-year life of the Act to $1.25 billion.

What university psychiatry department wouldn't want a piece of that action?

In her October 22 floor speech introducing the Act (officially S. 1857), Sen. Stabenow stated:

"Depression and bipolar disorders affect one of every five people in the United States...."

That's a wildly inflated claim regarding the prevalence of depression and bipolar disorder in America. The National Institute of Mental Health estimates major depression affects 6.7 percent of adults in America at any one time and that bipolar disorder (types 1 and 2) affect 2.6 percent of adults in America at any one time. That works out to 9.3 percent of adult Americans.

Why is Sen. Stabenow more than doubling the rate of depression and bipolar disorder in America? What is the source of her prevalence claim? Her office did not return repeated requests for comment.

Personally, I think the Senator either doesn't know what she's talking about or was fed a bum steer by someone in the world of mental health advocacy. After she concluded her floor speech, Sen. Stabenow had introduced into the Congressional Record letters of support from the following mental health advocacy groups: Mental Health America, the American Association for Geriatric Psychiatry, the American Academy of Child and Adolescent Psychiatry, and the American Foundation for Suicide Prevention. (Scroll to the bottom of her speech to read them.)

Mental Health America is one of almost three dozen medical advocacy groups currently under investigation by Sen. Charles Grassley (R-Iowa) for undisclosed contributions from pharmaceutical companies.

Sen. Stabenow also made other excessive claims in her speech.

"Clinicians lack universally accepted multi-disciplinary approaches and real-time clinical and care management guidelines."

The American Psychiatric Association has a set of easily-accessible guidelines for the treatment of depression. I'm sure psychiatrists, PCPs and family physicians know where to find them. While I don't necessarily endorse them, to claim that guidelines don't exist is flat wrong. What's more, in recent years NIMH has completed two separate long-term, real-world clinical trials of both depression treatments, including medications and psychotherapy, and treatments for bipolar disorder. The trials are called STAR*D and STEP-BD, respectively. Their results have been widely-disseminated in the medical literature.

It strikes me as re-inventing the wheel to fund 30 depression centers at $1.25 billion over 10 years when much of what the Senator argues for is already well-researched, understood by clinicians and mental health workers and is already abroad in the land. How well it all works is a different story.

The Senator also played the suicide card in her floor speech.

"And tragically, one of the preventable costs of undiagnosed, untreated and undertreated depression is suicide. The World Health Organization recently reported that suicide causes more deaths around the world every year than homicide or war. Across all age groups nationwide, more than 90 percent of those who commit suicide have a diagnosable psychiatric illness at the time of death: usually depression, alcohol abuse or both. Clearly, we need better diagnostic approaches to depression in primary care, other medical settings, and mental health programs."

No mention, of course, of the role that some depression treatments can play in suicide and suicidality (I refer to the black box warnings on all anti-depressants and growing body of research showing links between anti-depressants and suicidality, especially in teens and young adults). There's even some evidence that suicidality in the STAR*D trials may have been covered up. No mention either of the increasing evidence base showing that anti-depressants are linked to a range of ailments such as sudden cardiac death, especially in women. (need link here) No mention that the 1999 HHS initiative Healthy People 2010 has utterly failed to meet its goal of a 50 reduction in the suicide rate (it's about the same as in 1999, give or take), despite leaning very heavily on precisely the kinds of education and interventions that Sen. Stabenow seeks to enshrine in health care reform.

WHY SPEND $1.25 BILLION TO PROMOTE WEAK TECHNOLOGY, CORRUPT EVIDENCE BASE?

As I've noted on this site often over the last four-plus years, when it comes to depression treatment we are working with weak technology. For example, in the STAR*D depression trials--funded by NIMH--researchers found that the best anti-depressant treatment could muster was about a 30 percent effect size and things were even worse for anti-depressants in the NIMH-funded STEP-BD trials of treatments for bipolar disorder where placebo outperformed anti-depressants. Psychotherapy, in particular CBT, performs in the 30 percent-ish effectiveness range as well.

What's more, the evidence base for depression (and other treatments) is notoriously corrupt. For instance a recent study found that the authors of the APA's practice guidelines (for several disorders) were deeply-tied to pharma monies. And a 2008 study by OHSU psychiatrist Erick Turner found that the pharmaceutical industry had significantly overstated the efficacy of anti-depressants for decades by keeping negative trials of anti-depressants unpublished. Meanwhile, Sen. Stabenow's colleague Sen. Grassley has been exposing academic researchers who are making millions from pharma companies while doing federal research on depression (and other disorders) and not disclosing the same, bringing into question the quality of the evidence base. (The two senators should talk. Seriously. My extensive Sen. Grassley back catalogue is here.)

So what evidence base and what excellent methods Sen. Stabenow is exactly proposing to spread across the land with $1.25 billion escapes me.

If you go to the University of Michigan's Depression Center looking for something new and innovative, you're going to walk away disappointed. The center's web page for depression and treatments reads like pretty much anything else you've ever read on any other center or advocacy group's website. Causes of depression? Unknown. Treatments? Medications, CBT, interpersonal therapy and, ick, ECT. Not a single mention of diet or exercise that I could find. That's kind of interesting in light of the fact that the UK's National Health Service has backed away from meds as first line depression treatments in recent years and begun to emphasize watchful waiting, diet and exercise and, then, psychotherapy as treatments in advance of using medications in treating mild to moderate depression. Anyone seen a spike in depression or suicide in the UK as a result? Didn't think so.

So much of what Sen. Stabenow is proposing sounds like it's straight out of 1993, back when anti-depressants were assumed to always work and had no side effects whatsoever and taking them was really, really good for you. We know better now. Or at least you do.

Look, we've been chasing our tail in America for the last 20 years or so trying to address depression, but it's a race that appears to have been run. While I cannot question Sen. Stabenow's good intentions, I can question the cost of these depression centers and what they would actually accomplish much less their inclusion in a health coverage reform bill. It'll be interesting to see how this all gets sorted out, or not, in the House-Senate conference committee next month.

Posted by Philip Dawdy at December 29, 2009 12:03 AM

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Comments

When treatment for depression is so often what you can get if you can get anything at all, what we don't need are more putative "centers of excellence." The notion that knowledge somehow rushes down from "centers of excellence" - if they indeed provide excellent care as reflected in excellent outcomes - into the care received in the community doesn't seem to have empirical support. I fear the term is nothing more then another mental health shibboleth and merely promotes the illusion that those of us suffering from depression receive excellent care as we also receive "evidence based care", care predicated on the "principles of Wellness & Recovery", "person centered care", "strengths based care", "care on demand", etc. What we usually receive is ordinary care using "safer and more effective" and highly promoted brand name antidepressants and increasingly antipsychotics adjunctively.

Posted by: Joe at December 29, 2009 03:36 AM

Philip, Great work in breaking this. Here's a worse case scenario I came up with that I don't think is unlikely.

We could always cheer us depressed Americans up with a jobs program, maybe repair the infrastructure, provide money for science, technology, education, additional teachers and teachers aides in schools, computers and tech instructors in schools, have the government hire yoga teachers to work at community gyms, anonymous peer counseling and cost effective, humane, Soteria like centers, but no we get this, a jobs program for "mental health professionals." As the economy heads downhill if this cr*p is made into law someone who bursts into tears at the local unemployment office begging desperately for some sort of job lead (at least partly because unemployment benefits are so low that they're the equivalent of giving a person half as much food a day as s/he needs to survive), that person won't get a job, there are none. Illegals are going back to their own 3rd world countries because they can't get work at sub sub sub min wage. Anyway, so a person desperate shows up a the unemployment office begging for work. He or she doesn't get a job, he or she gets a mandatory referral to the new, shiny ENHANCED center in town.

Mandatory means if you don't report to mandatory counseling you don't get your check, oh, and you then become a danger to society and get committed. Do these ENHANCED centers have inpatient facilities for involuntary commitment? Bet there's funding for such.

Folks angry about the economy get labeled bipolar unless they discuss radical politics then they get labeled schizophrenic. But if you're just sad, you get labeled depressed.

The "good" news is that "mhps" on all levels are given jobs. Of course as part of treatment you'll get drug tested as all non corporate sanctioned drug use is a symptom of your new psych disease. And though there's every reason to think that prescription drugs don't just not make you better, they actually f*ck you up so bad you really do act "crazy" you're forced to take them, another new reason for drug tests, to make sure you're taking the drugs you're ordered to take, the ones that forcibly intoxicate you, that kill you. Fail the test too many times and it's AOT for you you dangerous mental defective.

And don't worry about funding, in that legally mandated health insurance you'll be forced to pay for, though you have no job, the insurance company will be forced to provide coverage for "mental health treatment."

The good news is that opposition to this bill is uniting the progressive left with the active right.

Posted by: Sally at December 29, 2009 06:03 AM

Outstanding investigative journalism.

Posted by: Stephany at December 29, 2009 08:01 AM

Thanks for breaking this story. I had never heard of it!

My experience with depression "treatment" is that I would have been much better off without it. I don't think throwing treatment at people is going to do any good. It will help some, and hurt others, and won't be worth $1.25 billion, anyway.

Some mental illnesses are real medical disorders, while others are just immaturity, normal emotions and stress, and life being unfair. I think it's time to really draw a line in the sand between medical illnesses and people having life problems.

Sadness is not the same as depression! People use those words interchangeably, but I want to shout to the rooftops that they are not the same! I just know these depression centers are going to be treating sadness, laziness, bitterness, and lack of direction in life. But, 99% of the time, sadness, laziness, bitterness, and lack of direction are NOT medical conditions, just stuff that people go through from time to time.

It's like they're spending taxpayer money to try to cure us of our humanity. I have found that sadness is not so bad. It comes and goes, and is part of life. Also, there can be dignity in sadness, while there is no dignity at all in being a drugged up mental patient.

Posted by: A at December 29, 2009 08:27 AM

Great sleuthing, Philip.

Do we really need more "depression centers"? What about the people who are so-called 'misdiagnosed bipolars' and they murder someone while on their antidepressant after having been diagnosed with depression.

If these people had taken LSD, crack or meth, then we would know that the drug did it but, if they take a legal antidepressant, then their underlying 'misdiagnosed illness' did it.

There are over 800 murders on SSRI Stories and over 200 completed murder-suicides where this scenario happened. Here is a case out of Santa Clara, California.

http://www.ssristories.com/show.php?item=1359

Second paragraph from the end reads: "Hathaway repeated statements she made during the trial that her client has bipolar and dissociative disorder but was misdiagnosed with major depression and misprescribed medication. That medication, in concert with alcohol and his own illnesses, disconnected him with reality at the time of the crime, she said."
__________________________________________________SAN JOSE
Former Executive Gets 26 Years to Life in Murder
THE SAN FRANCISCO CHRONICLE
October 21, 2000
Estimated printed pages: 2

A Santa Clara County Superior Court judge has sentenced a former high-tech executive to 26 years to life in prison for the February 1999 stabbing death of his wife.
Colman M. Bowers, 46, once was a vice president with San Jose computer software firm Baydel North America Inc. On July 17, a jury convicted him of murdering his wife of 20 years, Georgina, by stabbing her in the heart with an 8-inch kitchen knife at their home in Santa Clara.

Posted by: Rosie at December 29, 2009 10:39 AM

I wonder if the senator's focus on depression has to do with it being a thing that's accessible (everyone knows someone on antidepressants) and not scary. (Not like the scary people who shout at nothing, or the bad drug users -- better not put any funding within two zip codes; they will use it to buy drugs!) Just throwing that out there.

There's plenty of community mental health centers that would love the funding and would know exactly what to do with it (probably whatever they were doing before their funding got cut! The infrastructure is already in place). Plenty of people who currenty can't get in for treatment. You are absolutely right, Philip, in that this senator obviously isn't familiar with this issue, which makes one wonder who's been whispering in her ear.

Posted by: Sarah at December 29, 2009 10:41 AM

As usual, I'd say follow the money. How much pharma co. support does this senator have? How many pharma companies are in her state?

Fascinating that the UMich site says the cause of depression is unknown. WTF? Haven't we known forever that among other things, it can be triggered by life events (and also that it is possible to fully recover from an episode of depression)? One would think if we wanted to put billions into a depression program, and depression's cause is "unknown," then the first order of business would be to research its etiology. It's much easier to treat something if you know what caused it, duh.

By the way, thanks for your terrific reporting. I am more than broke but things are looking up, so I plan to contribute to your next fund drive.

Posted by: Miranda at December 29, 2009 10:53 AM

Ridiculously long response to A...

I also was treated more for not-depression than for depression. I was emotionally immature (Well, i was 20!) but instead of helping me grow up and live my life, they looked for every reason to pathologize what i was experiencing. (It occurs to me that they were probably freaked because i was cutting myself.) I never did learn to deal with my emotions, and so i shut them down so hard that it took a course of antidepressants several years later to bring them back.

Now i'm going off my SSRI (down to a quarter of my max dose, yay!), and i made the mistake of mentioning it to a friend who got really worried and actually hit me with the diabetes analogy... You are sick, and you must take your medicine. The reason you are better now is because you took your medicine. If you stop taking it, you will get sick.

That's a terrible analogy! (People who take insulin for type 1 diabetes are simply replacing a hormone that is _necessary in order to live_. I admit that i'm an excessively literal person, but i don't see the correlation.) I mean, good job, psychiatry, for spreading the "medical" message so we're not blaming patients anymore, but they overshot the mark, so let's bring it down a notch.

I'd like to liken depression to high cholesterol instead. Many people can change their habits -- exercise, eat different food -- and get their cholesterol down, and they'll be healthier overall for it. Every once in awhile you come across someone like my mom, who has always exercised a lot, eats healthy, is super skinny, and has high cholesterol anyway and no one knows why; for her, meds are the best option (in addition to continuing to exercise, eat well, etc). She could just take the meds and skip all the lifestyle stuff, but they wouldn't work near as well. (Actually she can't tolerate any meds, even niacin.)

My bad habits are cognitive in nature. I depersonalize, i resort to self-deprecation, things like that. I could say, "Oh, i can't help depersonalizing because it's part of my disease." Well, it IS due to the way i'm wired, and i accept that, but then it becomes my responsibility to MANAGE it. It really didn't take much therapy. A couple sessions. Once i started feeling my emotions, i knew what to do.

Maybe the cholesterol analogy only holds for _my_ depression, though.

I do think that a lot of people could use help dealing with the life issues mentioned by A. But not necessarily in a mental health setting, or maybe in a group setting. In the short time i volunteered for a crisis line, i talked to some perfectly self-aware people who were just isolated. They had just moved, or they had no friends because they spent all their time working, or they were old and all their friends were dead. Having closer, functional communities would go a long way in helping these folks... but now we are getting into my utopian vision, so i'll shut the fuck up for now.

Posted by: Sarah at December 29, 2009 11:20 AM

I do think depression is a very real and serious condition but not a medical disease. The fact that as unemployment increases, as hunger increases, as homelessness increases, depression increases, homicide and suicide increase, should tell us that if we attempt to shut up the symptoms in individuals without addressing the problems in society we're making a terrible mistake, especially since there's no proof these "treatments" help anyone except the people getting paid to provide them.

The worst things for depression are psychotherapy and corporate drugs. Again, if there's so much money to be had, so many problems could be solved. This is a tragically bad idea that will harm lots of people. Still it ain't passed yet thank goodness.

Posted by: Sally at December 29, 2009 11:29 AM

I was also emotionally immature. I probably still am, but I'm getting better. I have come to believe in the community thing, in joining support groups, etc. For me, just observing regular people and hearing what they do about their problems is pretty illuminating. I come from a background with addictions and craziness, and so I think that I missed out on some lessons about how to live and how to cope. Unsurprisingly, taking a pill didn't help me grow up, it just made me too dumb to care anymore.

The diabetes analogy drives me nuts, too, but for a different reason. Before they give people a syringe filled with insulin, they test their blood insulin levels to make sure they have a real deficiency!

What we have with antidepressants is as if people went to the doctor saying they have unexplained bruises and headaches, and the doctor just handed them insulin without performing any blood tests or attempting to eliminate other possibilities. Needless to say, if this occurred with physical medicine, people who were anemic rather than diabetic, and people who drank too much leading to hangovers and falling down, would drop dead from insulin overdose.

And then, if endocrinologists were like psychiatrists, they would ignore the overdoses and say that the people who were helped by insulin are proof that every single person with the symptoms of headaches and bruises has a chemical imbalance in their blood, and that maybe the people who had a bad reaction needed a different and more expensive sort of insulin.

I think the symptoms of depression can be caused by a chemical imbalance, but they can be caused by many, many other things. Without a blood test to verify an imbalance, I think doctors need to be very careful.

Posted by: A at December 29, 2009 02:06 PM

top notch journalism by a top notch guy.

You are the lede in my blog today. ;-)

Posted by: susan at December 30, 2009 10:51 AM

Hi, Sally - How is psychotherapy one of the "worst things" for depression? Are you referring to decent, normal, empirically validated psychotherapy, or specific cases of exploitative therapists, or what?

Posted by: medsvstherapy at December 30, 2009 11:00 AM

How could psychotherapy possibly be empirically validated?

Posted by: Sally at December 31, 2009 12:50 AM

Short- and long-term changes in mood and other indicators of depression can be quantified, and different treatment modalities can be compared. Are you referring to the fact that it can't be double-blind?

Posted by: Sarah at January 1, 2010 05:25 PM

Sarah,

In response to your comment, short and long term changes in mood cannot be quantified. Psych researchers usually rely on notoriously unreliable test instruments like the Beck and the Hamilton.

Different treatment modalities is hog wash as no two therapists are the same. Also, the fact that "it" by which I assume you mean a study can't be double blind is a huge problem.

Where the studies are that MvT think "empirically validate" some sort of psychotherapy and what is it these studies purport to empirically validate?

Posted by: Sally at January 2, 2010 05:38 AM

Sally,

Perhaps we can agree that mood can be quantified, but not quantified _well_. I still think that incomplete or not-entirely-accurate data can be a useful starting point, for example for showing trends. Maybe someone who knows more about research can help me out here with some specifics.

I don't think that our current black-and-white, linear approach to categorizing people with psychiatric issues should be applied as generally as it is. So, for instance, i would disagree strongly with a statement like, anyone who experiences recurrent major depression should be placed on a trial of antidepressants combined with cognitive-behavioral therapy; because there's a bunch of generalizations inherent in that statement, that may or may not apply to any given individual.

However, there needs to be some objective way of measuring any kind of treatment, for any condition. Otherwise we're just practicing phrenology. So for example (and as i'm sure you know, so i must be missing some major part of your question), cognitive-behavioral therapy has been extensively studied, and dialectical-behavioral therapy as well... but again someone who knows more than i do will have to go into that.

Do you have an alternative in mind for determining whether or not a type of psychotherapy works? Or are you criticizing the entire field of psychotherapy? Just curious and trying to clarify where you're coming from. (I apologize if you've answered this question elsewhere; in which case, maybe you won't mind pointing me to that comment thread? Thanks!)

Please also feel free to ask me for clarification as needed; i confused myself a number of times while typing this!

Posted by: Sarah at January 2, 2010 05:53 PM

By the way, when i think of Depression Centers i visualize all these little domes on googlemaps, with lettered flags popping out of them, droning, "Depression is a chemical imbalance; Cymbalta can help" ('cause in this vision of mine, locations on googlemaps can talk out loud). Just thought i'd share.

Posted by: Sarah at January 2, 2010 07:48 PM

Sarah,

I'm criticizing the entire field of psychotherapy which I wouldn't do if it weren't considered medical treatment, if there were no way anyone would consider filing a medical insurance claim for it. I realize this is a minority opinion and lots of folks I know and respect disagree. In my opinion we really are just practicing phrenology.

The fact that when someone is in emotional distress, compassion and someone to confide in provide relief and improvement tell me that emotional distress is not a medical disease whereas to advocates of psychotherapy it seems to go the other way, because compassion relieves emotional pain, the bio med folks argue, emotional pain must be a medical disease and psychotherapy a medical treatment.

I would argue that quite literally psychotherapy is not brain surgery and the idea that a problem needs to be labeled medical to be valid is a real problem. It would seem that a lot of "therapists" realize the dsm is bs but don't feel wrong for assigning psych labels they know to be erroneous to their "patients" so they can get paid when having that label especially when so many are not frank with their "patients" about what is going on, will cause way more harm than therapy can undo...the treatment is worse than the disease.

As for your question: "Do you have an alternative in mind for determining whether or not a type of psychotherapy works?"

Remember, it's not that I don't think psychotherapy works, it's that I don't think it's medicine or science. That said, I'd say that just like word of mouth is the way, unscientific but valid, of finding out what's the matter with someone emotionally, word of mouth is a great way to determine which therapists help which people.

Posted by: Sally at January 3, 2010 10:15 AM

Sally: I see a lot of truth in what you say. Thanks for giving me some things to think about! I'd like to come back to this conversation sometime.

Posted by: Sarah at January 3, 2010 07:18 PM

Phil, are you confusing point prevalence with lifetime prevalence here?

Philip Dawdy responds: i don't think so since the senator doesn't specify whether she's talking lifetime prevalence or yearly prevalence. besides i have never read a peer reviewed claim of 20 percent lifetime prevalence for depression plus bipolar.

Posted by: Fangster at January 4, 2010 07:05 AM

The 20% (+/-5%) lifetime prevalence figure is well-accepted across culture and so that's probably why she was referring to it. Bipolar rates are much lower, hence the condensation of the figure.

You could try:

http://www.ncbi.nlm.nih.gov/pubmed/19422724?dopt=Abstract

http://www.ncbi.nlm.nih.gov/pubmed/15756910

http://www.ncbi.nlm.nih.gov/pubmed/10789524?dopt=Abstract

Philip Dawdy replies: well the senator and her office have not replied and the figures i quoted from nimh are the ones we use around here. case closed.

Posted by: Fangster at January 4, 2010 05:34 PM