NOW, TIME AND RESOURCES AND EXPERTISE THAT MIGHT BE SPENT IN IMPROVING HEALTH POLICY WILL BE WASTED IN COMBATING THE NONSENSE OF HOMEOPATHY AND IN PROVING YET AGAIN THAT IT DOES NOT WORK…..
JMM

Bah.

HSC Many PCTs struggle to afford to implement NICE technology appraisals, as well as clinical guidelines. As more interventions are evaluated it is feared that the position will become unsustainable. Funding is essentially ring-fenced for technology appraisals, leaving PCTs little room for manoeuvre in their budgets to reflect local needs and priorities. (Paragraph 241)

NICE: Our Statutory Instruments and Directions do not allow us to take budgetary impact or affordability into account when advising on cost effectiveness.

(www.nice.org.uk/media/F51/D0/HSC2007OfficialResponseFINAL.pdf)

a real body for rationing is urgently needed, not one where this is a secondary outcome!

You mean, like sugar pills?

Every woman I know swears chocolate is medicinal, maybe we should register that…

Top Pain Scientist Fabricated Data in Studies, Hospital Says

online.wsj.com/article/SB123672510903888207.html

So what! Are you suggesting it somehow validates homeopathy?
Someone fabricates results. They get found out. The system works. It doesn’t discredit all studies and all evidence for all ebm.
As regards homeopathy, all claims of “evidence” that it performs better than a placebo are false because the basic premise of homeopathy is false.

“128. The absence of a requirement to show evidence of efficacy means that the MHRA’s current arrangements would allow a person to seek, for example, a licence for a confectionary product as long as he or she persuaded a number of people that it was a homeopathic product with therapeutic effects. Such a development would, rightly, bring the licensing arrangements into disrepute.”

It’s almost as though someone cut out the “.. but of course we would never suggest anyone try doing this, oh no!”

SCIENCE AND TECHNOLOGY COMMITTEE REPORT ON HOMEOPATHY23.02.2010

Tredinnick, David (he’s a Tory in case that matters to you)
That this House expresses concern at the conclusions of the Science and Technology Committee’s Report, Evidence Check on Homeopathy; notes that the Committee took only oral evidence from a limited number of witnesses, including known critics of homeopathy Tracy Brown, the Managing Director of Sense About Science, and journalist Dr Ben Goldacre, who have no expertise in the subject; believes that evidence should have been heard from primary care trusts that commission homeopathy, doctors who use it in a primary care setting, and other relevant organisations, such as the Society of Homeopaths, to provide balance; observes that the Committee did not consider evidence from abroad from countries such as France and Germany, where provision of homeopathy is far more widespread than in the UK, or from India, where it is part of the health service; regrets that the Committee ignored the 74 randomised controlled trials comparing homeopathy with placebo, of which 63 showed homeopathic treatments were effective, and that the Committee recommends no further research; further notes that 206 hon. Members signed Early Day Motion No. 1240 in support of NHS homeopathic hospitals in Session 2006-07; and calls on the Government to maintain its policy of allowing decision-making on individual clinical interventions, including homeopathy, to remain in the hands of local NHS service providers and practitioners who are best placed to know their community’s needs.

You’ll see that Ben is specifically cited as having “no expertise” in homoeopathy but, even if that’s the case, it kind of misses the point. This report was about the lack of evidence that homoeopathy was anything more than placebo and in that respect Ben has more than enough expertise to analyse and critique the research.
Apparantly they want the NHS to determine its own local needs – well big hurrah! If only that were true and Governments kept their hands off and let them get on with it. Greater Glasgow Health Board tried to close the Glasgow Homoeopathic Hospital beds in 2004 but chickened out in the face of a determined campaign which included many politicians:-

news.bbc.co.uk/1/hi/scotland/4552289.stm

I just feel increasingly frustrated by it all. I did sufficient homoeopathy training (3 years )that would allow me to sit the Membership of the Faculty of Homoeopathy exam. This was in the mid 1990s and I was a younger doctor trying to be open-minded. But the more I did the more I came to realise that is was nothing more that a charismatic con – pandering to the needy and offering a pill for every ill. In short – it’s crap.
Yet, despite this report, nothing will change. The homoeopaths are trotting out the same old tosh they did then – “homoeopathy doesn’t work like conventional medicine so you can’t test it like one”; “there’s no need to do RCTs because we see it working every day in our patients”;”only homoeopaths offer a true holistic approach”; blah, blah.

edmi.parliament.uk/EDMi/EDMDetails.aspx?EDMID=40517&SESSION=903

It’s an Early Day Motion, thankfully with only 4 signatures, basically slagging off the report. Seems to be part of an organised homeopath fight back,

www.homeopathy-soh.org/whats-new/latest-news/

A prominent Massachusetts anesthesiologist allegedly fabricated 21 medical studies that claimed to show benefits from painkillers like Vioxx and Celebrex, according to the hospital where he worked.

online.wsj.com/article/SB123672510903888207.html

So it’s only a “bit more complicated than stated” if the answer isn’t what you want. If the RCT’s disprove homeopathy we say ban it. I was just pointing out an uncomfortable fact (for me as much as you) that SSRI’s don’t do much better than placebo either.

So nobody likes me pointing this out, but what is the place of placebo’s when used by properly qualified doctors who know they are placebos???

Seriously, I don’t know how you guys stick it.

GPs are treated like a filter for hospital services. Double the numbers in training say I and double the time spent with each patient and give GPs the time to do what they want to be doing, which is great medicine.

Biological effect versus clinical effectiveness
——————————————————-

The first idea that makes me balk is that a rational argument about drug effectiveness in real world clinical sub-populations (versus efficacy trials) is not the same as questioning whether those drugs have a biological effect. They do. These drugs have all been through years of R & D including animal studies which demonstrate biological effects. Then the scientific community takes them out and shows what other cool stuff they can do – and they do. They are associated with brain change including probably (but not definitely) neurogenesis in the hippocampus. The fact that in some mildly ill people the risk-benefit balance lies in favour of not prescribing is not really the same as the Homeopathy versus placebo argument now is it?

There are a number of logical arguments that have been stated already. There is good evidence that SSRIs do not work better than placebo in mildly depressed patients who have been enrolled in randomised-controlled trials.

However, some of the problems with (for example) the Kirsch meta-regression are:

1)The use of the words mild, moderate and severe is a by-product of the pharma companies’ classifications. All or most of these studies use the Hamilton Depression Rating Scale (Hamilton 1960). This scale has one question about mood severity and three questions about sleep. It is by definition not fit for purpose. Despite this it has become the “gold standard” for measuring pharmacological efficacy in depression trials. The pharma companies ( in an effort to make it seem like they include severely depressed people in trials ) say that anything over about 24 on the HDRS is severe depression. It is not. GPs DEFINITELY see people with depression who would score >24 on the HDRS, and by this definition definitely see people who suffer from severe depression, as measured in these trials. Take another look at the Kirsch meta regression graphs. They stop at a level of severity that reduces their clnical relevance dramatically.

2)Suicidal patients are excluded from nearly all placebo controlled trials for the obvious reason that randomising suicidal patients to placebo is considered by (most) ethics committees to be at least moderately dodgy. This excludes even moderately depressed patents with any suicidality. This in turn reduces the external validity of the trials.

3)Irving Kirsch is pretty much an expert on the placebo effect. He knows that in placebo controlled trials the effect is mediated by a)statistical regression to the mean, b) baseline inflation of scores, c)the effect of time, d)the effect of being in a trial, e)the true placebo effect. He also knows how trials run and that they have limited external validity when it comes to clinical effectiveness ( not none but limited). He knows that active comparitor studies are better for looking at effectiveness not least because they – at minimum – act as an active placebo and -at most – provide useful information about relative efficacy of the drugs. He chose to ignore all this in presenting his findings, however and sensationally presentations were taken up in the press and widely touted. I don’t think that’s very nice. In fact I think it’s a bit stinky really.

I could go on …. but I think you get my drift. Essentially, it’s just a bit more complicated than stated.

PS. Just an afterthought but… most people I see with severe depression started out without depression, then they got a little bit depressed, then they got a bit better, but then they got REALLY f**ing depressed. So SSRIs might stop people getting more depressed, mightn’t they? Not to mention the evidence supporting reduced relapse rates on SSRIs versus placebo. They don’t measure that in RCTs for the FDA though.

While it is depressing to think of the use of SSRIs in most cases being placebo, policy is slowly changing, with several practices that I or colleagues have worked in only prescribing SSRIs in patients that are simultaneously being referred to tertiary care. But in a system of 60 million people and it only being 2 years since the damning meta-analyses were published it will take a while for these to slowly dissappear. Especially as it is extremely hard to deny a patient a drug which they’ve been prescribed by their doctor before ‘and works for them’.

@pv – I largely agree with your comment on self-delusion, though wonder if you are slightly oversimplifying the placebo effect (insert emoticon of choice here). But I am not sure that we are talking about the same sort of patients. I don’t know which patients get referred to the NHS homeopathic hospitals, but I doubt that they are mainly those with self-limiting ailments. The patients I am thinking of are more in the area of those sometimes labelled as having “medically unexplained symptoms” they are likely to have had symptoms for months or years, and been extensively investigated. I think SkyeSteve can think of examples of who I mean, though I’m afraid, much as I agree CBT and similar therapies badly need proper provision, I don’t think that the current official approach that CBT is the answer to every difficult problem is realistic either. I can think of many patients who have had as much psychotherapy as they have had physical investigation, and more who will not or cannot countenance psychological approaches to their complaints.

@kim – thank you for your diagnosis of patronisation. Let me suggest a thought experiment for you: Put a homeopathist in the situation of a a GP, give them the same case mix and, most importantly, the same few minutes per patient with more arriving al the time, all of the data collection demanded of us, etc, and watch those approval ratings plummet. Alternatively, give medical practitioners the time to give each patient a proper hearing, and watch satisfaction with conventional medicine climb.

@elvisionary – what I was trying, badly after a heavy day, to get across is the question of what Is appropriate, and that can only be answered once you decide what your objective is. If it includes helping people to feel better, I find it very hard to say bluntly that it Is inappropriate – but that does not make me any happier about homeopathy.

www.cochrane.org/reviews/en/ab007954.html

But you’re right – almost certainly they are of no value in mild depression and they are of limited (or perhaps even very limited) value in moderate depression.
The caveat to that is that depression as you know is not a homogenous disorder and the response is therefore not always predictable. In addition, there are clearly patients who become “dependent” on them.
So, yes, I do think long and hard before recommending someone with moderate depression to try an SSRI and I almost never even raise the subject until I have seen and assessed them once or twice.
What I never do is offer them an SSRI, tell them it is the thing that will help when all else has failed or talk it up way beyond what the evidence would suggest.
Anyway, we could ping pong this back and forth for a few more posts but let’s not (though feel free to respond to this post and I promise not to counter-post unless you say something too outrageous!).
Homoeopathy on the NHS just cannot be justified and that’s what we should be saying here loud and clear.