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In Defense of Psychiatric Diagnoses and Treatments

In Defense of Psychiatric Diagnoses and Treatments The Boston Globe is out today with a <a href="http://www.boston.com/news/local/massachusetts/articles/2009/04/02/some_who_set_policy_tied_to_industry/?page=1">story</a> about conflicts of interest involving American Psychiatric Association guidelines for treating depression, mania, and schizophrenia – disorders for which the market in medications is said to be $25 billion annually. Conflicts abound, it seems, and the consequent implication is that industry influence has led to guidelines that “focus heavily on medications and give relatively little attention to nondrug treatments.” The lead author of a forthcoming analysis, Lisa Cosgrove from the University of Massachusetts is quoted in the Globe as saying “…the lack of biological tests for mental disorders renders psychiatry especially vulnerable to industry influence." Maybe so, but it’s not just psychiatry. And this new study should not be taken to invalidate psychiatric diagnoses or to undermine the efficacy of psychiatric treatments. The existence of disease is not predicated on having a biological test. It’s nice when we do have one, but there are many disorders throughout medicine, not just in psychiatry, for which there is no conclusively defining biological test. Think migraine. Think multiple sclerosis. Think chronic pain. There is a distinguished tradition of clinical research, going back to the late 1950s, wherein disorders like depression, mania, and schizophrenia were studied for their genetic profiles, their clinically meaningful subtypes, their biological correlates, and their responses to treatments. This bottom-up approach yielded useful theories, which in turn led to better theories and to new treatments for depression, mania, and schizophrenia. Like any other branch of science, clinical science has a self-correcting function that distinguishes it from pseudo-science and propaganda. So, we welcome new theories even though most will not survive, and we welcome new diagnostic proposals and we welcome potential new treatments. All are subject to the test of independent confirmation, and nobody is surprised when many fall away. Since around 1990 that tradition has been corrupted by Pharma and Pharma’s money. There is no shortage of examples regularly in the news. Academic key opinion leaders lost their ethical compass and, with or without a figleaf, devolved into spokespersons for industry. One is reminded of Julien Benda’s term la trahison des clercs. Instead of moving on from undistinguished and problematic new drugs, key opinion leaders work with the marketing departments of Pharma to promote and defend the brand. Remember the <a href="http://www.beforeyoutakethatpill.com/2009/3/psychnet.pdf">PsychNetters</a>? Of course, psychiatry is not the only medical specialty corrupted in this way. Stents, anybody? Orthopedic devices, anybody? Lost in the marketeering and propaganda since around 1990 is the discipline of clinical therapeutics. As one <a href="http://www.margaretsoltan.com/?p=11166">commentator</a> put it, if there is no way to confirm biologically the existence of disease, then “…we cannot confirm with much confidence that this or that treatment treats mental disease.” It actually is possible to identify effective treatments for mental disease. We did it with lithium. We did it with the early antidepressant drugs. And we did it with the early antipsychotic drugs. There was room for improvement in all of these, but make no mistake – they were dramatic positive developments. Most of the work in the past 20 years, however, put marketing first and clinical therapeutics second. Humbug aside, the goal was not to improve the management of depression or mania or schizophrenia but to jump whatever bar the FDA was setting in order to get a product on the market. Indeed, the really hard clinical research issues were studiously avoided. Along the way, the clinical research enterprise became dominated by academic and for-profit contract research organizations in which, to put it gently, standards of recruitment of patients apparently suffered, so that response rates in placebo-treated patients skyrocketed. As a result, proving that a drug does work became harder, and the overall drug advantage over placebo in treating depression <a href="http://www.bmj.com/cgi/content/extract/331/7509/155">came into serious question</a>. In effect, the corruption of clinical research standards has brought us to an epistemologic quagmire about the efficacy of today’s most popular antidepressant drugs. As for the charge that psychiatrists and primary care physicians just throw drugs at mental health problems, that is nothing new. It is a reflection of the professional pragmatism that permeates medical practice. Think back to the 1950s when the new wonder drugs called antibiotics were handed out like Pez, mostly for people who did not really need them and who would not benefit from them. The working principle was misguided simplicity and pragmatism, which minimized and discounted the risks. Even today the over-use of antibiotics remains a public health concern. Just as in the 1950s patients with nonspecific upper respiratory symptoms were “given the benefit of the doubt” and were prescribed an antibiotic on the reasoning that it might help them while probably not hurting them, so today patients with nondescript depressive or anxiety symptoms are prescribed an SSRI drug on the same reasoning. The cost of this approach in wasted money, in unnecessary side effects, and in unproductive clinical management is non-trivial. So, the issues are more nuanced than today’s Boston Globe story would suggest. For good and for ill, psychiatry is not so very different from the rest of medicine. Corruption and compromise respect no subspecialty boundaries. We can have reliable and valid knowledge of disease without a biological test. We can show efficacy of treatments for disorders that lack a biological test. But when simplistic pragmatism and cutting corners dominate in therapeutics and in clinical trials, then we are in trouble.

In Defense of Psychiatric Diagnoses and Treatments

In Defense of Psychiatric Diagnoses and Treatments The Boston Globe is out today with a story about conflicts of interest involving America...

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ARIA for Google Calendar, Finance and News: In praise of timely information access

From time to time, our own <a href="http://emacspeak.sourceforge.net/raman/">T.V. Raman</a> shares his tips on how to use Google from his perspective as a technologist who cannot see -- tips that sighted people, among others, may also find useful. In our continued efforts to make Google applications more accessible, we have launched ARIA support for <a href="http://googleblog.blogspot.com/2008/11/accessible-view-aria-for-web-search.html">several Google applications</a> over the last few months. <a href="http://en.wikipedia.org/wiki/WAI-ARIA">W3C ARIA</a> is a set of HTML DOM properties that enables adaptive technologies like screenreaders to work better with dynamic web applications. As with previous ARIA-enabled Google solutions, screenreader users can now switch on ARIA support in the following applications by activating an invisible Enable Screenreader Support link. Alternatively, simply browse to the links in this blog with a supporting screenreader and Firefox 3.0 to experience the interface enhancements. If you do not have a screenreader installed, but are curious to experience what eyes-free interaction with these applications feels like, we recommend the freely downloadable Firefox enhancement <a href="http://www.clcworld.net/">Fire Vox by Charles Chen</a>. <ol><li><a href="http://www.google.com/calendar/render?axs=1">Google Calendar</a>: The ARIA-enhanced Google Calendar enables speech-enabled access to the day view in Google Calendar. You can use the keyboard to move through events, move through the days of the week, as well as to cycle through your various calendars. As you work with the calendar, the application raises appropriate DOM events through W3C ARIA to invoke the relevant spoken feedback through the screenreader.</li><li><a href="http://www.google.com/finance?axs=1">Google Finance</a>: The Finance page can be viewed as a set of logical panes, with related content appearing as items in each pane. The ARIA-enhanced version of Google Finance enables you to switch panes, and navigate the current pane with the arrow keys. Navigation produces spoken feedback through the screenreader. In addition, Google Finance provides several power user tools, including a stock screener, all of which are speech-enabled through ARIA. These power user tools provide interesting examples for Web developers experimenting with ARIA. (ARIA support for Finance was developed by intern Svetoslav Ganov as his starter project.)</li><li><a href="http://news.google.com/?axs=true">Google News</a>: Finally, we have added ARIA support to enable rapid eyes-free access to Google News. These enhancements follow the same pattern as seen earlier for Google Finance, and the ability to navigate between the different views provided by Google News, (e.g., World News vs Sports enables rapid access to the large volume of news that is accessible via the Google News interface).</li></ol>As with all of our ARIA-enhanced services, you can obtain additional help by pressing the ? key to hear the available list of shortcuts. If you're interested in discussing these enhancements, visit the <a href="http://groups.google.com/group/accessible/">Google Group for accessibility</a>. Posted by T. V. Raman, Research Scientist, and Charles L. Chen, Software Engineer

ARIA for Google Calendar, Finance and News: In praise of timely information access

From time to time, our own T.V. Raman shares his tips on how to use Google from his perspective as a technologist who cannot see -- tips th...

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CADIE awakens

CADIE awakens

We do lots of research here at Google, and we release lots of products. And we always hope that the research we do and the products that res...

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Local flavor for Google Suggest

Since the launch of Google Suggest <a href="http://googleblog.blogspot.com/2008/08/at-loss-for-words.html">last August</a>, you may already be used to the magic feeling of getting real-time suggestions just after typing a few keystrokes — that is, if you're searching on Google.com. But what if you're doing a search on Google in the U.K., India, Ireland or Australia? Today we're happy to announce the international launch of Google Suggest. We've localized our suggestions to account for various cultural and local factors to offer suggestions that look familiar to our users. For example, English users in different countries will get suggestions that feel natural: <ul><li>If you type [liver] in the <a href="http://www.google.co.uk/">U.K.</a>, you're probably a Liverpool fan (but in the <a href="http://www.google.com/">U.S.</a> you'll get more suggestions about liver diseases):</li></ul><ul><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2hUPCTZjBzjIUgvQLrt_q0GKjlqk2HIgKqr9LV1pBVngoYuzamRecfqFpEycctmoXwQcWH2A4m429Tji-QLkd4IbXchFAWMf6kQ6x46VvFU_gF04amiAfY0UN4tTaJSbZ2yLRFfBFp0LU/s1600-h/uk-liver.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468102450084466" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEh2hUPCTZjBzjIUgvQLrt_q0GKjlqk2HIgKqr9LV1pBVngoYuzamRecfqFpEycctmoXwQcWH2A4m429Tji-QLkd4IbXchFAWMf6kQ6x46VvFU_gF04amiAfY0UN4tTaJSbZ2yLRFfBFp0LU/s400/uk-liver.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 360px; height: 216px;" /></a><li>In <a href="http://www.google.com.au/">Australia</a>, typing [kan] will offer suggestions about Australia's most famous animal:</li></ul><ul><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCG2E2x9txOrYwDqWq1Jd6bh1Grk5CYBtEj92TA_gyEoWijQtEmvokQXMZ9sAr0evVd_jSqvJc0Yt0bf0tsHxJbkqCP77ER7eo4tyhSTyXX4B40cq5fWKRp_3AADJYx3yO4ti-OoZ4OxOc/s1600-h/au-kan.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468107498448626" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEiCG2E2x9txOrYwDqWq1Jd6bh1Grk5CYBtEj92TA_gyEoWijQtEmvokQXMZ9sAr0evVd_jSqvJc0Yt0bf0tsHxJbkqCP77ER7eo4tyhSTyXX4B40cq5fWKRp_3AADJYx3yO4ti-OoZ4OxOc/s400/au-kan.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 359px; height: 214px;" /></a><li>In <a href="http://www.google.co.in/">India</a>, where the mobile phone market is exploding, it's no wonder that typing [no] leads to:</li></ul><ul><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgudr51kzGb5QmiRAHt91i44hKECgVXMywMYFldmao8XqHxhPxao1PGuTLifCEtvtRs9Et3jTnKx_VtxTpeAeAVsCZS0iVcvjsP0eFwErrhB1cpYl9mt45BRHDJ_PSaDwDxEpuxWQMj10uH/s1600-h/in-no.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468108387078850" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEgudr51kzGb5QmiRAHt91i44hKECgVXMywMYFldmao8XqHxhPxao1PGuTLifCEtvtRs9Et3jTnKx_VtxTpeAeAVsCZS0iVcvjsP0eFwErrhB1cpYl9mt45BRHDJ_PSaDwDxEpuxWQMj10uH/s400/in-no.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 361px; height: 214px;" /></a><li>In <a href="http://www.google.ie/">Ireland</a>, there are [pubs] everywhere:</li></ul><ul><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhUXxaoe1NxQF7-T96OgyxuUJYoH0BWk5AhNJc8VZTjmjwIJKLU02h82KFIJMmLXP-Smbkk1DW1d2MGV72__yQbmNe9RJPdcFSMIsMnyNO1QqWbFAyj2QpT4biOE1D19KMZnjYiexDUNhB/s1600-h/ie-pubs.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468108426893698" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjhUXxaoe1NxQF7-T96OgyxuUJYoH0BWk5AhNJc8VZTjmjwIJKLU02h82KFIJMmLXP-Smbkk1DW1d2MGV72__yQbmNe9RJPdcFSMIsMnyNO1QqWbFAyj2QpT4biOE1D19KMZnjYiexDUNhB/s400/ie-pubs.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 359px; height: 214px;" /></a><li>While in the <a href="http://www.google.mv/">Maldives</a>, typing [ato] leads to:</li></ul><ul><a href="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOL49RaVmtAS27t5SaQ8qSAdK9ggN6p7Qu78N7EAb0ovp0icbBO_nx1MqpmV3ioHU84ODnZdMFt-S8DvfyJOIhJ4Asr-ICTQfS094nI2pC-bssp1IsZGizV-FjmtC40rzw9ziiGZmrTRET/s1600-h/mv-ato.png" onblur="try {parent.deselectBloggerImageGracefully();} catch(e) {}"><img alt="" border="0" id="BLOGGER_PHOTO_ID_5319468105204889554" src="https://blogger.googleusercontent.com/img/b/R29vZ2xl/AVvXsEjOL49RaVmtAS27t5SaQ8qSAdK9ggN6p7Qu78N7EAb0ovp0icbBO_nx1MqpmV3ioHU84ODnZdMFt-S8DvfyJOIhJ4Asr-ICTQfS094nI2pC-bssp1IsZGizV-FjmtC40rzw9ziiGZmrTRET/s400/mv-ato.png" style="display:block; margin:0px auto 10px; text-align:center;cursor:pointer; cursor:hand;width: 360px; height: 214px;" /></a></ul>Google Suggest now covers 155 domains in 51 languages. Special thanks go to the Suggest team in Israel for their hard work in making this a reality. So go ahead and start using Google Suggest wherever you are, and enjoy the special flavor of local suggestions. Posted by David Kadouch, Product Manager

Local flavor for Google Suggest

Since the launch of Google Suggest last August , you may already be used to the magic feeling of getting real-time suggestions just after ty...

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Analytics in Latin America

If you run an e-commerce site or use AdWords to direct traffic to your business' webpage, chances are you're interested in knowing what visitors to your site are clicking on, what content interests these potential customers and what avenues brought them there. The more you know about how people engage with your site, the better you are able to design successful advertising campaigns to help grow your business. In Latin America, online advertising is growing as more and more small businesses initiate an online presence and publicize their efforts through search and display advertising. But less than 5% of web properties throughout Latin America rely on analysis tools to improve their website's performance. Last week, our offices throughout the region hosted several Analytics-themed events to give agencies and other clients a better look at several Google measurement tools that provide people with the means to analyze their site's flow of data, interest and readership in order to build a better advertising campaign. In Mexico City, advertisers got together to learn about <a href="http://www.google.com/insights/search/#">Insights for Search</a>, <a href="http://adwords.blogspot.com/2008/06/introducing-google-ad-planner.html">Ad Planner</a>, <a href="http://googleblog.blogspot.com/2008/03/insight-into-youtube-videos.html">YouTube Insights</a>, <a href="http://www.google.com/analytics/">Analytics</a>, <a href="http://googlewebmastercentral.blogspot.com/2008/01/sitemaps-faqs.html">Sitemaps</a> and <a href="https://www.google.com/analytics/siteopt/splash">Website Optimizer</a>, as well as <a href="http://www.doubleclick.com/">DoubleClick</a> tools. Presentations were designed to give companies an in-depth look at the Google tools that can be helpful for planning their marketing budgets during an economic downturn. Being able to measure data on what content interests people and where consumers are searching for information can help advertisers be more selective about how they invest ad budget. Since the great majority of consumers go online for information before making a purchase, the goal of the seminar was to familiarize advertisers with tools that can increase the reach of their campaigns, while giving them a better idea of what works and what people are searching for. Meanwhile, our Analytics guru Avinash Kaushik visited São Paulo and Buenos Aires to speak to clients about web analytics and how to make the most of online marketing through analyzing metrics (check out his recent post on <a href="http://googleblog.blogspot.com/2009/02/stop-bouncing-tips-for-website-success.html">bounce rate</a> for related information). Avinash made web analytics fun and accessible with colloquial comparisons (referring sites as 'BFFs'), and demonstrated how to <a href="http://googleblog.blogspot.com/2009/03/make-sense-of-your-site-tips-for.html">optimize a website's performance</a> with changes in color and layout, among other things. He was accompanied by Google's Latin America managing director Alexandre Hohagen, Brazil's country manager Alex Dias, and Argentina's country manager Adriana Noreña at a succession of events revolving around web metrics and website optimization. <embed type="application/x-shockwave-flash" src="http://picasaweb.google.com/s/c/bin/slideshow.swf" flashvars="host=picasaweb.google.com&RGB=0x000000&feed=http%3A%2F%2Fpicasaweb.google.com%2Fdata%2Ffeed%2Fapi%2Fuser%2FJoscelin.Cooper%2Falbumid%2F5317535977028402929%3Fkind%3Dphoto%26alt%3Drss" pluginspage="http://www.macromedia.com/go/getflashplayer" height="267" width="400"></embed> The response and interest from customers and agencies to all of these events was indicative of the huge need for metrics and the ability to track ROI for their marketing investments, especially during these difficult times. For more information on Google Analytics tools, check out the <a href="http://analytics.blogspot.com/">Google Analytics Blog</a>, the <a href="http://websiteoptimizer.blogspot.com/">Website Optimizer Blog</a> and the <a href="http://conversionroom.blogspot.com/">Conversion Room blog</a>. Posted by Alfonso Luna, Marketing Director, Latin America

Analytics in Latin America

If you run an e-commerce site or use AdWords to direct traffic to your business' webpage, chances are you're interested in knowing w...

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Sham Studies and the Commercial IRBs that Approve Them, and Sham IRBs and the Government Department that Registers Them

We have occasionally posted about the activities of for-profit contract research organizations (CROs). These are commercial entities that conduct human research, including clinical trials for pharmaceutical, biotechnology and device companies. More clinical research is being done by such CROs rather than by academic investigators. CROs seem to operate under the radar of most physicians, academics, and policy makers, but sometimes stories surface that raise questions about them. For example, we discussed the trials by SFBC International (now <a href="http://www.pharmanet.com/">PharmaNet Development Group</a>) in Miami that enrolled immigrants, often undocumented, under questionable circumstances and in Montreal that resulted in the transmission of active tuberculosis (see post <a href="http://hcrenewal.blogspot.com/2006/03/consequences-of-sfbc-internationals.html">here</a> and links backward); and the trial by <a href="http://www.parexel.com/">Parexel International </a>in London that put most of its subjects in intensive care (see post <a href="http://hcrenewal.blogspot.com/2006/08/parexel-blues-again.html">here</a>, with links backward). Last year, as we discussed <a href="http://hcrenewal.blogspot.com/2008/06/clinical-trials-torture-economy.html">here</a>, two articles questioning the ethics of research done under the auspices of CRO appeared in two major medical journals. In academia, human research is supposed to be overseen by institutional review boards (IRBs). Research done by CROs is also supposed to be overseen by IRBs, but the IRBs that do so are often also commercial. Despite concern that commercial IRBs may be tempted to lower their standards to get more business, commercial IRBs have flown even lower under the radar than have CROs. However, last week, a story appeared about how a "sting operation" tested one commercial IRB with amazing results. Here are excerpts from <a href="http://online.wsj.com/article/SB123811179572353181.html">the article by Alicia Mundy in the Wall Street Journal</a>, <blockquote> The sting, detailed at a House Energy and Commerce Committee hearing Thursday, involved the creation of a fictitious company and a fake medical device, a surgical adhesive gel. The sham firm then applied to three for-profit oversight groups -- called institutional review boards, or IRBs -- for approval to begin a clinical trial using their adhesive on human subjects. Two IRBs contacted by the GAO's sting operators -- Argus IRB of Arizona and Fox IRB of Illinois -- rejected the Adhesiabloc proposal because of unanswered safety questions. 'We realized it was a terrible risk for the patient … It is the worst thing I have ever seen,' an Argus IRB reviewer said, according to a slide shown at the hearing. <a href="http://www.coastirb.com/">Coast IRB </a>LLC of Colorado Springs, Colo., did approve a study for the fictitious adhesive gel, 'Adhesiabloc.' </blockquote> The GAO also ran an experiment to see if the US Department of Health and Human Services (DHHS)would register a truly dubious commercial IRB <blockquote> The committee, working with the Government Accountability Office, Congress's investigatory arm, named the CEO of the fake IRB Truper Dawg, after a staffer's three-legged dog, now deceased. Other fake names included 'April Phuls' and 'Timothy Wittless,' which lawmakers said should have signaled irregularities to HHS. The department registered the IRB. </blockquote> On one hand, these anecdotes suggest, along with the stories discussed above, that CROs and the commercial IRBs that are supposed to oversee them deserve further scrutiny. Beyond that, one wonders if it is good for society for human research, including experiments involving drugs and devices, to be done by commercial firms dependent for their income on the companies that make these drugs and devices, overseen by other commercial firms also dependent on these same companies. The fundamental conflict is embodied by <a href="http://www.coastirb.com/page.asp?id=2&name=About">Coast IRB's self-description</a>: <blockquote>as an advocate and a catalyst for an ever-stronger pharmaceutical industry, ethically and economically. </blockquote>which also <blockquote>recognizes the vital importance of our role in protecting individuals in all clinical studies and in continuously raising the bar on professional standards. </blockquote> How can the company be an "advocate" for the industry while simultaneously protecting the people exposed to the industry's still experimental drugs? See also <a href="http://www.gooznews.com/archives/001363.html">comments</a> on the GoozNews blog.

Sham Studies and the Commercial IRBs that Approve Them, and Sham IRBs and the Government Department that Registers Them

We have occasionally posted about the activities of for-profit contract research organizations (CROs). These are commercial entities that co...

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Google's newest venture

Today we're excited to announce <a href="http://www.google.com/ventures">Google Ventures</a>, Google's new venture capital fund. This is Google's effort to take advantage of our resources to support innovation and encourage promising new technology companies. By borrowing the best practices of top-tier, financially focused venture capital firms and bringing to bear Google's unique technical expertise and brand, we think we can find young companies with truly awesome potential and encourage their development into successful businesses. At its core, Google Ventures is charged with finding and helping to develop exceptional start-ups. We'll be focusing on early stage investments across a diverse range of industries, including consumer Internet, software, clean-tech, bio-tech, health care and, no doubt, other areas we haven't thought of yet. Central to our effort will be our fellow Googlers, whom we view as a critically important resource to help educate us about potential investments areas and evaluate specific companies. Economically, times are tough, but great ideas come when they will. If anything, we think the current downturn is an ideal time to invest in nascent companies that have the chance to be the "next big thing," and we'll be working hard to find them. If you think you have the next big idea, or if you just want to to learn more, please see our website at <a href="http://www.google.com/ventures">www.google.com/ventures</a>. Posted by Rich Miner and Bill Maris, Managing Partners, Google Ventures

Google's newest venture

Today we're excited to announce Google Ventures , Google's new venture capital fund. This is Google's effort to take advantage ...

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