Do not think about, write about or deal with human behavior without determining the effects of incentives. It’s not their money, of course they’ll waste it.
One of the Great Pretends in the contemporary world is the belief that “He’s OK when he’s on his medications.”, the belief that psychopharmaceuticals have a normalizing effect on behavior. The belief appears to be much stronger than the effect of the drugs.
By David Brodwin
One of greatest threats to the U.S. economy in the long term is the absurdly high cost of U.S. health care. We spend nearly 18 percent of GDP on it, whereas the rest of the developed world spends around 11 percent and gets about the same results.
The difference damages the competitiveness of American businesses, and prevents American workers from prospering in the global economy. 7 percent of extra spending amounts to $1.2 trillion each year. If we didn’t waste that money on health care that didn’t work, we could double the number of K-12 public school teachers. And then we could make public colleges and universities completely tuition-free. After making both of those investments, we would still have more than half a trillion dollars left over. We could invest it directly in R&D or provide it as tax credits to boost privately-funded research. That would boost competitiveness quite a bit.
If individuals kept this money, the economic situation would improve much more than if government just spent it differently.
One of the major drivers of health care cost is mental illness. Spending on mental health care rarely makes headlines because it isn’t dramatic. It doesn’t grab attention like cancer and hepatitis drugs that cost over $100,000 per round of treatment. But the numbers add up because so many people are affected: In any given year about 20 percent of Americans are diagnosed with a mental health problem severe enough to interfere with daily functioning. About 270 million prescriptions are filled each year for anti-depressants alone. And because mental illness affects people in their prime earning years (whereas most diseases primarily affect older people) mental illness has a catastrophic effect on people’s earning power. The total earnings lost by Americans with mental illness – nearly $200 billion — is nearly twice as high as the costs of drugs and psychotherapy used to treat them.
Given the stakes, we should be immensely troubled by recent research which tells we don’t really understand what treatments actually work. Two researchers in Norway published a study last month on the effectiveness of cognitive behavioral therapy for treating depression. Cognitive behavioral therapy has long been a popular treatment (in addition to drugs like Prozac and Zoloft). The study was a "meta-analysis," which means that it was a study of studies: It looked at all the published research on the effectiveness of cognitive behavioral therapy conducted from 1977 through 2014. After analyzing more than 70 individual clinical trials the researchers found that the value of the therapy has fallen steadily and continuously over the years.
Several factors could explain the loss of effectiveness: perhaps novelty is an essential part of the success of any psychotherapeutic technique; once people get used to something, it loses its punch. (This is widely known in motivational research as the Hawthorne effect.) Perhaps the first generation of therapy practitioners was better trained, more gifted or more consistent in their approach than their followers. Perhaps the therapy never really worked that well, but negative research findings were suppressed. Such research is often suppressed when funding and careers hang in the balance.
This is the file drawer effect in research. Negative findings are filed away. There are an infinite number of ways to do things wrong.
The difficulty of evaluating treatment for mental illnesses is not limited to talk therapies. Psychoactive drugs draw skepticism as well; critics claim, with some justification, that many antidepressants are "only marginally better than placebos" for most people. The official diagnostic manual that guides the use of psychoactive drugs has been called "a product of unscrupulous politics and bureaucracy." Nonetheless, antidepressants are a huge business, "the most consumed class of medication in the U.S.," although revenues are shrinking as patents lapse on blockbuster drugs.
In a well-functioning market, consumers are supposed to be able to figure out for themselves what products are good and what products are bad. They are supposed to be able to recognize value when they see it. The process of competition should lead to effective treatments winning out, and ineffective treatments being driven from the market.
But the market for mental health treatments is not a well-functioning market. Customers can’t easily tell what works and what doesn’t. Patients and doctors can be manipulated by purveyors of solutions. The Food and Drug Administration’s system for drug approval makes it too easy for drug companies to bury studies that reach inconvenient conclusions. And drug companies have too many ways to curry favor among leading physicians and university researchers.
The misery wrought by mental illness and the terrible cost it inflicts on our economy make this a crucial problem to solve. We need more and better research into what actually works. Meanwhile, given the difficult of knowing what works and what doesn’t, a little modesty would be in order. For example, we can scale back some of the aggressive marketing of products that are barely better than a sugar pill. The stakes are too high to do otherwise.
The data on anti-depressant medications are clear Anti-depressants are most “effective” when compared to an inert placebo. The more side effects from the placebo, the less the difference between the drug and the placebo until the differences are negligible..
On the psychological side, one of the most effective programs to alleviate depression, Azrin and Besalel, has never been replicated.
Azrin, N. H., & Besalel, V. A. (1981). An operant reinforcement method of treating depression. Journal of behavior Therapy and Experimental Psychiatry, 12(2), 145-151.
Government Job or Respect–Which’ll It Be?
Cheerio and ttfn,
Grant Coulson, Ph.D.
Author, “Days of Songs and Mirrors: A Jacobite in the ‘45.”
Cui Bono–Cherchez les Contingencies