E127 - Can Tony Robbins Cure Depression? (Talking Research with Dr. Anya Borissova)

Can Tony Robbins self-help course cure depression? Do people prefer ketamine or electroconvulsive treatment for depression and does preference matter? Today Alex and Anya break down mental health studies to deliver fascinating insights from research, discuss the difference between good and bad science, and understand how science can be (for better and worse) leveraged to market products. 

Tony Robbins Study:

https://pmc.ncbi.nlm.nih.gov/articles/PMC9107501/

Ketamine vs Electroconvulsive Treatment:

Primary analysis: https://pubmed.ncbi.nlm.nih.gov/30572160/

Secondary analysis: https://www.sciencedirect.com/science/article/abs/pii/S0165178125000605

With Dr. Anya Borissova and Dr. Alex Curmi. Dr. Alex is a consultant psychiatrist and a UKCP registered psychotherapist in-training. Dr. Anya is a psychiatry registrar and academic trainee at the South London and Maudsley NHS foundation trust. 

If you would like to invite Alex to speak at your organisation please email alexcurmitherapy@gmail.com with "Speaking Enquiry" in the subject line.

Alex is not currently taking on new psychotherapy clients, if you are interested in working with Alex for focused behaviour change coaching , you can email - alexcurmitherapy@gmail.com with "Coaching" in the subject line.

Give feedback here - thinkingmindpodcast@gmail.com -
Follow us here: Twitter @thinkingmindpod Instagram @thinkingmindpodcast Tiktok - @thinking.mind.podcast 

Give feedback here - thinkingmindpodcast@gmail.com Follow us here: Twitter @thinkingmindpod Instagram @thinkingmindpodcast

Transcript

 Welcome back to The Thinking Mind, a podcast all about psychiatry, psychotherapy, psychology, self development, and related topics. Today we're gonna try out a new format for the show. Myself and my co-host, Dr. Anya Bova, will be discussing scientific research, by which I mean we're gonna break down real scientific papers, and we wanted to do this format for a few different reasons.

We wanted to, of course, discuss the insights that new research can give us as to the nature of mental health problems and how we can treat them. But we also wanted to discuss and teach our listeners a bit about the scientific method itself, like how science actually works and what makes good science versus bad science.

And we really wanted to discuss how science is interpreted and reported in the media, and especially by people who want to sell stuff and products. To use science as an evidence base to sell certain products, [00:01:00] because obviously we now know we're living in an ecosystem full of misinformation. And I think the more people understand a little bit about how science works, the limitations of science, but also what makes really good science, the better equipped people are to look at what's being reported and see for themselves and engage in a little bit of critical thinking.

So today we're gonna be discussing two papers, both about depression. The first one, a study that examines whether or not Tony Robbins four day immersive self-help program can treat depression. And the second one, looking at the difference between ketamine treatment and electroconvulsive therapy, otherwise known as electroshock therapy for depression, and whether or not patient preference had any impact on the treatment outcome itself.

So very interesting stuff. As you'd hear in the interview itself, Anya is the best person on the team to discuss this stuff with 'cause she's an academic trainee, which means she's very much immersed in the research [00:02:00] world and looking at and thinking about research all the time. We hope that you, the listeners, will enjoy and get a lot out of this episode.

If you'd like to support the podcast, do check out some of the services we offer in the description below. Thanks for listening. And now here's today's conversation with Dr. Ania Bova.

Today we're gonna be discussing can Tony Robbins cure depression? How does ketamine compare with electroconvulsive therapy for depressed patients? These are all topics we're gonna discuss through the lens of science and scientific research. And with me to discuss these topics today is Dr. Ania Bova.

Ania. Thank you so much for joining me. Thanks, Alex. I hope you don't mind that I kind of think of you as our scientific correspondent. As I say on the podcast, I'm a clinician obviously, but I'm not a researcher. I'm not really done research. You're an academic trainee, which means you're involved in doing research and thinking [00:03:00] about research a lot.

So we very much value your expertise in this regard. And today we're gonna talk about two scientific papers. First paper we're gonna discuss today. So I thought we would start with the Tony Robbins paper, and I guess some things to say before we dive into it, just to give everyone a bit of, I guess, a bit of a base of how we're gonna be thinking about these different papers.

What I guess you and I would like to try to do is not only talk about what these papers found and what the implications of it might be. But actually be a little bit critical of how well done was the study, how well done was the, uh, interpretation of the results. Were there any problems with it, and what does the field need in the future to take the ideas forward?

And we will, uh, put the links to all of these papers in the description. But what, what, what is the Tony Robbins paper? What's the study they carried out? So it was a [00:04:00] study and actually not done by Tony Robbins, a researcher called Ariel Gans. And the senior author was Michael Schneider. So the paper asked the question of whether a psychosocial training program, which is one of the ones run by Tony Robbins, um, what effects that would have on depression and wellbeing.

And they recruited a selection of people who had symptoms of depression. And they put them through either this program, this psychosocial training program, or through a control condition. Which was gratitude journaling. Mm-hmm. So big thing to explain here, what's a control condition? So it's a really, really key thing to look out for in any study that is saying that it's showing the effects of an intervention in terms of judging the quality of that study.

So what a control condition does is it allows us to measure the general effects on a [00:05:00] condition that occur just by virtue of the person being in a trial. Right? So when someone enters a clinical trial or, or a clinical study of some sort, they are instantly exposed to. Way more psychosocial supports than they've had before.

So by that I mean just contact with people. Just contact with people, contact with people, and contact with people who are interested. And usually people who are really, really nice because they want people to stay in the study. Mm-hmm. And to complete the study. So they also have, and the contact with interested people is another really important point.

So they, for some people, especially when you're talking about the US where this study was conducted and where the healthcare system is, you know, often kind of very much paid for. And it can be very difficult to access healthcare and especially mental healthcare. When people enter these kinds of studies, it will sometimes be one of the first times where they've been able to talk about their symptoms and talk about how they feel to an interested person.

And as you and [00:06:00] I both know Alex, in the field that we work in, uh, good quality listening, so interested, caring, listening is, is a therapeutic intervention. It's Right. Right. Mm-hmm. So, so in this paper, they're comparing. A group of people. Some, my understanding is some with depression, some without, who underwent Tony Robbins self-help program, which I think is a four day immersive program, and then with some exercises to do after and to, to make sure that they're, you know, getting the actual beneficial effect of that.

They're comparing it to the control group, as you mentioned, which is also a mixture of depressed and non-depressed individuals. And instead of giving them, no, they're not, they're, they're not giving them no intervention. They're giving them a, a small intervention in this state, in this case, you said gratitude journaling is, that's right.

Yeah, exactly. And it, it's an interesting study off the bat because there's this interesting split between the [00:07:00] self-help world, which is generally in the private industry world, uh, and can make lots of people, lots of money, sometimes in more or less ethical ways, and the, the, the more formal mental health world.

So, I mean, I was really curious to see this study because you think of someone like Tony Robbins who has so much success, uh, and who seems to, on the face of it, have affected so many people in a, in a positive way, really interesting, compelling for me to see. Okay, so maybe his method's been studied scientifically.

I wonder what it shows. Uh, and if you hear him talking about it, he talks about it as a kind of resounding success. He says basically incredible treatment for depression. His, his, his intervention is an incredible treatment for depression as shown by this study. Can you tell us more about what happened in the study and is this, is this the unilateral success that he claims that it is?

Mm-hmm. [00:08:00] Yeah. Really interesting. 'cause I saw that on the website as well. You know, the, when, when you look at the, the intervention that they used, um. They, they make a big deal out of the findings of this study. Um, you know, sort of a hundred percent of people with depression got better. Uh, which sounds obviously fantastic.

Guess is that, is that, what was that the result? Well, interesting. So a few things to pull out. So the number of people that were participating was about 20. So I think they had sort of 23 and 22, um, participants in each group. Now of those, about 13, 14 in each group met thresholds for depression. Now. So when we start to think about studies, we start to think about the population that was studied and is it representative of, you know, and if we're thinking about applying that study more broadly, you know, is it representative of.

The kind of patient cohorts that we might see. So 13, 14 people with depression out of a group of about 20. Um, [00:09:00] the way that they measured depression was using a scale called the PHQ nine, which is a very well validated, very widely used scale generally as a screening measure rather than as a diagnostic tool.

Mm-hmm. And I would say this is probably the first point, um, of improvement where the study to be done again, is that the, the diagnosis wasn't confirmed by any kind of professional. So it was purely based on this scale. And that's sort of scale is what the patient's report about themselves. Exactly. Which is known to be unreliable.

It's not necessarily known to be unreliable actually. So it's, it's increasingly recognized in, in I think, depression, mental health research that actually what the patients say about their symptoms is often reasonably well correlated to what clinicians think about their symptoms. Um, but also that. It may be as more important than what clinicians think about their symptoms.

So I think it's not, it's not necessarily that it's unreliable, but it is that it's [00:10:00] probably not the standard that Okay. Is applied across the field. So generally in depression research you would have both. So you would have both the self-report and, and the clinician sitting opposite them saying, yes, I think I would confirm this diagnosis.

You are depressed at the moment. Exactly. Exactly. Um, because there's a lot of reasons for why someone might fill in a scale to say that they've been feeling sad to say that they've not been sleeping that well, to say that they've been feeling a bit more tense in the last two weeks. Um, the second point to pull out about the population itself is that the numbers are pretty small.

So this is probably a pilot study, sort of feasibility study level. Um, so having 20, you know, having 20 people is, is not huge. Having 14 people is obviously even less. I. Um, if we're looking to really get a good idea of whether a new treatment works, we're sort of wanting to have, so, well, the rules that I think the American licensing, um, organization has for medications [00:11:00] is two, two big trials.

And by big it's, you know, over, over hundreds of people being involved. So this is a small study, which doesn't mean it's not an important study, but it's a small study. So, and it, you know, that kind of affects what we do with the interpretation of it. So it's the right kind of study. Right. 'cause it's, am I right in saying it's a randomized control trial?

It is, yeah. And so that's important. So people were assigned to the conditions randomly, um, and they had the controlled bit is what we were talking about before, so that there was a, uh, a control condition so that there was a group of people that were made to do something that wasn't like the intervention.

But that aims to control that is to, um, is it like simulate simulating an intervention? So yeah. To to to account for basically some of the non-specific bits of that, that might also, that will also lead to someone feeling better like placebo. Would that account for the placebo effect? Exactly. Yeah, exactly.

So placebo effect not isn't just medications, it's [00:12:00] any, any intervention mm-hmm. Will have a placebo effect as well. And am I right in saying the, um, this randomized controlled trial was single blind, and what does that mean? What is blinding in a trial? So blinding refers to whether people know what intervention they're getting or not.

Now, it's particularly difficult to achieve in intervention in trials that try to measure a psychotherapy or, you know, psychological type intervention. It is also difficult to do in some of the kind of latest medication trials that we're seeing with psychedelics. The reason why it's difficult to do is because basically people kind of know what they're getting.

So people in this situation will know if they went to the Tony Robbins course or not. Right, exactly. There's no way for them to not know. And the problem with that is that you, you then get into the problems of expectancy effects. So now I don't know how this trial was advertised, you [00:13:00] know, I don't know whether it was, uh, do you want to go to the Tony Robbins, like fantastic self-help course?

Um, or you know, if it was advertised a bit more blandly as just, do you have, are you feeling a bit sad? Do you want to try a new, do you want to try a new treatment? And so even the marketing Oh, for sure. 'cause it would create an effect. Yeah. Because, because all of that stuff leads to, leads to like an expectation.

So the person going in, if they're expecting to get better with the treatment, they, they will do better. So, and that's part of the placebo effect. That's again, a huge problem in the psychedelic, in the psychedelic field. Um, and another related problem is the no SIBO effect. So people who don't get put into the group that get the fancy dazzling new intervention are then disappointed.

You know, they know that they're getting the dud. Um, in this study, I think one of the helpful things that they did is that everyone was told that they would then get a ticket to go to the self-help intervention later. And [00:14:00] that's, I think, kind of a bit of a double-edged sword. It's good because I think it probably removes some of the disappointment that the non-active treatment group mm-hmm.

Might have felt, but it also obviously kind of amps up, uh, the how good the, uh, the self-help program is. But doesn't it also reemphasize to that group that they're not really getting any meaningful treatment and isn't that something you want to avoid in the control arm? It's tricky. So I guess another key principle of doing research is that you.

You want to have what's called equipoise. So you want to, as the person setting up the study, genuinely not know whether the thing that you are testing is better or worse than, than the alternative. Um, and that's kind of a principle of ethics. It's obviously really important when it comes to drugs, medications, things that have potentially serious side effects.

But as we know, psychotherapy and self-help can have side effects as well, and it can have adverse effects. Yeah. And in [00:15:00] the case of the Tony Robbins course, I think it cost thousands of dollars per person, right? Yeah. Which is, you know, to be, to be noted. For sure. And obviously everyone here got it. For people with people here.

Got it. For free. And actually the, um, the course was donated to the research study as well, so the researchers. You know, they didn't have to get a, a multimillion pound grant mm-hmm. To be able to run the study. Um, so, so, so this, this trial was single blind, which means does that mean only the researchers were blind to where the participants were allocated?

Yeah, exactly. So, uh, and this is a very good point of what they did, is that the people who sort of received the results and analyzed the results just got them labeled as group A and B. So they didn't know whether what group A and B related to. So as they were looking at the different, uh, different depression scores, different anxiety scores, they didn't know which group, uh, had [00:16:00] received which treatment.

Um, which is, which is helpful and which is important. I think one really important thing that I want to pull in about the interventions is that, so the, the self-help program was, it's a six day immersive program, so yes, so they go. I dunno how many hours it is, but you know, I assume it's sort of a whole day and someone's getting really excited on a stage and you're coming up on the stage and hugging, hugging the person and you are, um, you know, they were sort of doing, um, being taught things like meditation, goal setting, the importance of exercise, reframing ideas, kind of working on their goals, new beliefs.

Um, quite an intensive thing. Lots of those interventions we know from the psychological literature are very helpful things. Right. To, to patients. The control group, they did 10 minutes of gratitude journaling a day. Now that controls for some of what people did then in the, after they'd gone to the course.

So after they'd gone to the course, they then spent 10 minutes a day sort of doing exercises related to [00:17:00] the course. But it, it doesn't control for going to a week's session where you are sort of around with people where you are. Um, spending a lot of time reflecting, spending a lot of time moving your body.

So, so, so what do you think might have been a better control? Oh, so the, I mean, the problem of how you control for psychological, um, therapies is, uh, a huge, a huge one. So it's, this is way better than having a wait list control, which is what a lot of trials have. Um, but I think you, you know, it's difficult because I think the self-help program has so many components to it.

You may be take the hit and accept that you are gonna have to have some kind of training program with people that involves some of those components. Mm-hmm. You know, so you send people just to like a meditation retreat, right. For a week. Um, or you do something where people have to go somewhere for a [00:18:00] week but not do any of those things.

So like. Be with people, but maybe, and do activities without a psychological Exactly. Intention. Yeah. So then, you know, you may be taking the hit on the social aspect and the exercise bit. Um, but if, you know, if you're saying that the, it's about really what's happening at the intervention. So if you're saying it's the cognitive reframing, it's the meditation, it's the, the goal session visualization, the goal setting, that's, you know, the guided hypnosis, that's important.

Then it's maybe less about being in a room full of people. So, yeah. So if you, you know, maybe send everyone to a conference or something Right. For a week on a topic not related to mental health, you know, on a topic related to like chocolate gardening. Gardening, exactly. Yeah, yeah, yeah. Send 'em to a gardening course.

No, don't send 'em to a, gardening courses are really good. Um, yeah, so those, so those are some of the problems I guess with the setup of the study, but also some of the good things, 'cause at least they did try to have a control arm. They, but again, it's worth noting that, uh, a lot of those people didn't have depression.

And a lot of those people, well, it's not a lot of people in the first place. [00:19:00] A lot of them, perhaps, and I think it's fair to assume that a proportion of them wouldn't be diagnosed with depression if they, um, if they had been seen by a clinician. Right. And they are certainly not going to be the same kinds of people that we see with depression in sort of in hospitals or in psychiatric services.

So this is, this is not the same population. It's on the milder end of the spectrum. It's going to be on the milder end. Um, it is potentially some of these people wouldn't even get to their GP if we're thinking about, um, a UK population. Okay. In terms of the severity. So then what did the results show? I know let's get to the actual, um, enough of the, enough of the faf, but so what the results showed.

You know, it, it, it was brilliant. And actually on the first, um, one thing that's worth noting is that the authors did something that was really good as they found some errors in their analysis and they released a, uh, a correction to the paper. So on the first iteration, they did show that [00:20:00] a hundred percent of people with depression got better with the intervention.

Um, so that's 14, outta 14, um, by the end of the six weeks, um, is, and the six week being sort of the total duration of the, of the study. And that compares two, and I'm referring to my notes that compares to four outta 14 people in, sorry, four outta 13 people in the gratitude journaling group, which is, I've written 41%.

Yeah, I guess that's probably about right. So just under, just under half of people in the gratitude journaling group got better. Um. Which is a reasonable placebo rate. You know, sort of that's a similar placebo response rate to what we see in medication and psychotherapy trials. Pretty good. Adver for gratitude journaling?

Pretty good advert for gratitude. Absolutely. Um, and so the, the actual sort of remission rate was 93%. Um, so they do need to update their [00:21:00] website, um, on the basis of the correction that was released to the paper. So, so the remittance rate in the group receiving the self-help treatment Mm, was 93%, was 93% of the people with depression.

So the, the 14 people. And after how long, how long did they follow up people for? So this was really interesting. So people kind of did most of their improvement after the first week. And I, and I, to be honest, I don't know entirely what to make of it. So people got the most benefit just from going to the self-help course.

Mm-hmm. Um, in the first week. So I think they both in the. In the gratitude journal group and in the, going to the self-help course group, they dropped their scores on depression or something like, you know, 50, 60% of people were, were getting better already. And then they continued to improve after that first week in the self-help intervention group.

So they continued to get better until the point where, as we say, 93%, um, were feeling better by the end of six weeks, uh, [00:22:00] which is the total time that they did the study for. And that's a good duration. I mean, it's, we know that depression's a chronic condition. So actually we love to see trials that go on for six months a year.

That's the ideal. A lot of people don't do that. Mm-hmm. So a lot of the antidepressant trials go on for eight to 12 weeks. Um, a lot of them make a big deal out of what happens in the first couple of weeks. So it's. It's a general criticism of the field, and I think it, so it's not fair as a criticism to level, I think, at this study, but as, as with the rest of the field, you know, let's see how these people were doing a year down the line.

Let's see how these people were doing six months down the line. I think that's the bit that as clinicians, you know, that's, that's what we want to know. And not just as clinicians, I think people with depression, that's what they want to know. So normally at the end of the paper, the authors will have a discussion of sorts and draw some conclusions.

What conclusions did they draw and do you agree with them? I think some of [00:23:00] what their discussion was about was comparing the effects of this intervention to other, um, to kind of response recovery rates in other interventions. And I think that's a, actually a reasonable comparison to make. So kind of going back to your first point.

How well does this psychosocial training program do in comparison to antidepressant medications? So they can't answer that question with the trial that they've done because they haven't compared, they'd have to do a direct comparison. So one group antidepressants, one group, I guess control one group psychosocial training.

Exactly. That would, that would be the ideal way of doing it. Um, because then, you know that everyone's kind of gone through the same kind of procedures. I think it, it's not as good, but I think it's reasonable to look at, you know, response and remission rates that you get in other trials as a bit of an indicator.

Again, this is something that a lot of people will do in their papers. So whilst it's not kind of the best quality of evidence, um, it's probably [00:24:00] reasonable. Um, and they, they compare it to a very specific. Studies which tested psilocybin, um, and psychological therapy in people with depression. Um, probably not a completely fair comparison given the diagnostic differences.

So in the trial that they, that, you know, the trial that they compared to, they were people with clinician diagnosed major depressive disorder as in, and did you say treatment resistant? Not treatment resistant. Not treatment resistant, but, but clinician diagnosed major depression as opposed to the more milder depression of the people likely to be included in this study.

Exactly. Um, and, and we know that, you know, they only had one person with severe depression in this, in, in this study. So, so we know that the people that they're kind of comparing to would've had more severe depression. Um, but they, you know, nonetheless kind of, if you look at the, the big picture [00:25:00] in, in the literature, so if you look at what's called meta-analyses, so studies that.

Pull in loads and loads of loads of studies together and give you an idea of average averages across, you know, 50, a hundred studies. Mm-hmm. Um, you get sort of, you, you get a response remission, um, of like 33 to 41%. Mm-hmm. In psychological therapy trials, you get, uh, 54, 50% remission in medication trials. So it, it does compare well.

Mm-hmm. Um, with the provision that it's a small study. And, uh, I know we had David Taylor on the podcast last week, and, you know, he's talked, he talks about how early on trials tend to show much bigger effects than as an intervention gets more popular. Not more popular, sorry, I guess more widely used.

Mm-hmm. Um, and the, the more that you repeat and try [00:26:00] to replicate a study, the more that that. The size of effect tends to come down. Mm-hmm, mm-hmm. And I think, so it's, it's, again, it's not quite a fair comparison for me to be saying this one study with 20 people had, you know, had a 30% greater remission rate, right.

Than these hundreds of studies with thousands of patients. Because there's just the chance that what you are getting is random error and kind of random variation. And I suppose one thing we haven't talked about yet, which I'd be, it'd be great to get your take on, is the idea of bias. And, you know, participants like self-selecting for studies.

So just on the face of it, a study like this, including someone like Tony Robbins, who's very famous and well known, and again, has amazing marketing, better marketing than any pharmaceutical company could ever hope for, you can imagine it would attract a certain kind of person who might already know who he is, who might be interested in self-help, [00:27:00] self-development type strategies, who might be like.

Dispositionally at a personality level, more ready to accept some of the ideas in his training, like reframing ideas and goal setting, et cetera. And I say that as someone who I kind of resonates with that way of thinking, but I can imagine not everyone does. And so it might be quite different from a medication where like your disposition in that personality sense might make that difference.

So would you worry that a study like this could select for a very particular kind of person? Mm, I think it, I mean, definitely I think it could, and I think it's the point that the authors make and they, you know, they, again, they draw parallels with the psychedelic literature where, again, same there, there's, there's very much a risk that the people who are volunteering for the psychedelic trials are people who, especially the early ones, are people who were really invested in that psychedelic treatment, working for them.

Um. So again, I think [00:28:00] it's, it's, it's a problem that can probably be leveled at more of the field, and it's what I, what I'd love to know, and I, I may have missed it in the supplementary information, but I'd love to know what the, what the advertisement for this study was. So whether people knew when signing up that it was going to be, you know, so whether they were trying to attract Tony Robbins fans, um, or whether they were just trying to attract people who might be interested in a self-help program, which would kind of give you, I think, slightly different levels of bias and slightly different, um, or whether people, you know, whether they were just people wanting to try, uh, a new kind of treatment for depression, but I imagine they would've been giving them a bit more information than that.

Um, but it leads, you know, it will lead well to the next paper that we'll talk about in terms of patient preference and sort of the, mm-hmm. The, what that means for outcomes. So yeah, it's, it's an important thing to, to manage and, and I think the management of it probably comes at the recruitment stage. So, so [00:29:00] ideally in a study like this, would you just want it advertised as plainly as possible?

Oh my God, yeah. Boring. We're looking for boring. We're looking for people, but I guess you want it as undifferentiated as possible. Yeah. And that's really hard because recruitment for research is really hard, so you've got to stand out, you know, you, you are, you're going to want to use, um, anything at your disposal.

'cause I think they had a really short recruitment period. They recruited over like two weeks or something, which is wild. Like, I've never Okay. Um, unless, unless I missed a year in between that. But I think it was, it was just really quick. You know, they sort of had the course coming up in December and they recruited in the couple weeks before the course.

Um, and they, they just got people straight onto it. And to you, does that suggest that it was like the normal Tony Robbins marketing involved that they could recruit people so quickly? I mean, maybe, maybe. Um, or they sort of already had a pool of volunteers that they regularly use and they were able to [00:30:00] kind of recruit, you know, they had sort of a well-oiled machine and they had lots of research assistants working to screen people and recruit people.

Um, but yeah, so it's unfortunately, I think the best science is kind of the most boring science. A lot. Science is boring science. Yeah. It should be boring. Are there any other limitations or strengths of this study that you wanted to point out? I think another, I think another important strength is the range of outcomes that they looked at.

So they, they make a big deal out of the improvement in social functioning that people had as a result of the. Um, as a result of the cell help intervention that, is that also measured by the PHQ nine? No, so they use a different scale. So it's sort of again, a questionnaire scale that people filled in, but that will ask them things like how much their symptoms affected, their ability to go to work, engage in their [00:31:00] relationships, partake in home tasks.

Um, and it's addressing again, a problem that we see in the field that, or not, not that we see in the field, but a problem that's being recognized in the field that what are the outcomes that actually matter to people. Um, and arguably it's not necessarily their, you know, a two point difference in their sleep or anxiety score, but it's whether they were able to go out for dinner with their partner, you know, whether they were able to do their weekly shopping, whether they were able to manage their bills, do their cleaning.

So measuring how well people are functioning and showing that they improved in that. I think is, is the, you know, right. Rightly so, that they, they're making a big deal out of that. Is that, is that, um, not so common you find in other studies? I think it's, I think it's happening more, but it's certainly reported and less of a fanfare is made about it.

And it's certainly not the thing that will enter the [00:32:00] textbooks when deciding, uh, which treatments interesting to kind of rate as being, you know, when saying which treatment is better than which treatment. That will be based on changes in the symptom scores. Maybe in five to 10 years that will be different, but, but at the moment that's, that's kind of where our knowledge base is.

Any other limitations of the study you think? Oh no, sorry. I did, yeah, I did have one. And this is, um, this is again, a really good general one for people to look out for if they're ever reading blogs or interpretations or reading the study itself. Um. Who's funding the study. Oh, okay. Yeah, of course. Um, so, so no, so in this case, the study itself I think was funded, um, sort of by research grants, um, that, that people had, or, you know, I think one person had a pre-doctoral fellowship, which will be sort of a pot of money given to someone to complete work towards what will then be a PhD dissertation.

Um, but in the [00:33:00] correction that they released where they, where they dropped the remission rate from a hundred percent to 93%, they also noted that the senior author, I think, had opened some kind of business that the corporation related to Tony Robbins had invested in. Mm-hmm. And that this had happened after the, I think, you know, after the publication of results and after the completion of the study.

And they don't think that it had an impact on any of the results that were discussed. But for openness, they're reporting it, which is great practice, you know, good for them for doing that. But I guess it does raise eyebrows. Um, just of, 'cause it makes you wonder if they have a preexisting personal relationship.

Yes, exactly. And did that, did that in any way affect the way that the study was? Again, subtle things that might introduce bias, the way that the study was sold to people, the way that the study was. 'cause not, you know, numbers can't lie. So, um, participants report the scores that they report and those scores are compared with an analysis.

And you, unless you're [00:34:00] doing really atrocious science, you're not gonna be fudging the numbers. Mm-hmm. But I guess the bits that you can introduce biases, just again, how the studies explained to people, how people are taken through the study, uh, how much hype there is in the research team about one part of the, you know, the main intervention rather than the control intervention.

Um, whether, yeah. I'm trying to think other ways, but, you know, so, so who's funding the study and these kinds of conflicts of interest, as we've talked about quite a lot on the podcast mm-hmm. When pharma companies mm-hmm. Our world is really important because obviously that could influence subtle ways in how studies are designed to emphasize or underemphasize the effectiveness of an intervention, I guess for sure.

Um, and, and one way of getting around that is, and I guess this is the other thing that we don't know is, and I think David Taylor talked about this, is pre-registering studies. So before the study's done, having, uh, listing out all of the things that you're gonna be asking [00:35:00] people, all of the measures that you're gonna be collecting, you know, all the questionnaires that you're gonna be doing, and exactly what comparisons you're gonna be running, which groups you're gonna be mm-hmm.

Comparing if you're gonna be splitting groups in some way, and then, and you can then do extra analyses after the study's done, but you have to label them as exploratory analyses so people take them with a bit more of a pinch of salt. Um, so here, you know, I guess what we don't know, because it wasn't preregistered.

We don't know if there's some extra questionnaires, right? Yeah. That showed something awful happening. Mm-hmm. Unlikely. Very unlikely. Um, but in, but as a general point, that's the thing to look out for if you're reading other studies, um, where, where you're trying to assess their quality. Okay, cool. So we've, we've talked about the nuts and bolts of this study.

So the, so the takeaway sounds something like, it suggests that a psychosocial intervention similar to the Tony Robbins program or the Tony Robbins program can be having some benefit, but we need to study it with wider groups of people. Ideally, if [00:36:00] you are really interested in how effective it is for depression, probably more severe levels of depression confirmed by a clinician, would those be the main takeaways for you?

Yeah, and I think, I think it is definitely too much to say that this is. A program that shows a hundred percent benefit to people with depression or even, would you say it shows 93% benefit or even 90? Oh, yeah, yeah, for sure. You know? Yeah. That, I think I, I don't think we can say that this is representative of the average person with depression.

I think it is representative of a particular kind of person with depression, and I think that's fair to have as a message. Mm-hmm. Um, but I don't think it is fair to say whoever you are, whatever kind of depression you have, come and do this, it's gonna be great. Um, so more data required. More data required for sure.

And more data and wider groups. Okay. Yeah. I wanna ask you one more question on this study before we [00:37:00] move on, which is, you know, as it stands now, flaws and all. Does this study stimulate your thinking in any way? Does it change your mind about anything? Did it make you have any novel thoughts? Would it change your practice?

Anything along those lines? I think it, it probably wouldn't change my practice, but that's because I'm already really bought into the idea that actually anything that helps people to reflect on their life, to get more active, to do things that are in line with their values that they've reflected on. Um, anything that gets kind of people to take a step back, be that in a mindful way, in a meditation way, in a goal setting way, hypnosis way, whatever, um, I think can have really big impacts on people's wellbeing.

And I think in the kinds of depression, anxiety that we see in psychiatry, I think is an important part of the [00:38:00] treatment package. Mm-hmm. So I guess it confirms for me that that can certainly be the case. And I mean, I guess as you say, gratitude journaling. Um, like not bad, not bad. Not bad at all. Not bad.

Bit of gratitude. I'll tell you one thought I had about this study, again, more my, my thinking being stimulated is really, for me, the word immersive stands out. Mm mm-hmm. We don't really have any immersive treatments with a unilaterally positive bent. Mm-hmm. In psychiatry, things get immersive when you're very unwell typically, and you might get admitted to a hospital.

And yes, that's immersive. Some, in some ways that are helpful, in some ways that are really not helpful. So this paper, although I think I'm, I fully agree with you, more data required, it made me think maybe that's something in the immersive aspect and having a program, again with a wholly positive bent, helping people when they're [00:39:00] having, uh, difficulties with their mental health.

It might, you know, cost more and require more investment at the front end. But if it's effective and you can, you know, give people a package of care that's very intensive for. Few days a week, a couple of weeks, and then transition slowly to a less intense, more outpatient kind of treatment. That might be something worth thinking about because immersion has a lot of advantages.

It gives you a community, it takes you out of your setting where a lot of your more unhelpful patterns have a chance to set in. It can kind of give you that sense of like how different your life can be for a little bit of time, even if it's a few days in a way, a visit to a therapist's office say, or a doctor's office can't really do that.

So one takeaway for me is like, maybe we should be thinking about more like positively immersive treatments. I think that really makes sense. And I guess [00:40:00] it, it kind of exists, but not at the front end, you know? So where, where you and I have both worked in South London, there's the recovery colleges. Which actually tends to be a feature of, I think lots of, um, mental health trusts in the UK have something like this, and it's something that's run by the mental health trust.

But it's a place where people who are linked, who have received treatment can and their family members can go and attend courses that are, you know, either related to the condition and, you know, understanding anxiety, understanding depression, understanding psychosis, um, or the principles of wellbeing. Or they have apparently a super popular improvisation, you know, eight week course that people can attend there.

Or like radio program making or podcasting, you know, so these, we actually, we have something that's a little bit like this. Um, it's [00:41:00] often added as a bit of an afterthought to treatment plans. I think it can be very hard to get people bought into the idea of going to it. Um. And we, and it's, and we tend, and you know, it tends to be thought about as well towards the point at which a person's reaching the end of their treatment.

Yes. But I guess, as you say, what this makes us think is actually can we get people going to it the moment they come through the door? And can we get something that exists, not in what we are in secondary care, you know, in hospitals, the bit that people have to be referred to the specialist bit, but can it exist more at a community level?

And it exists for other disorders, you know, it exists for when someone gets first diagnosed with diabetes, they go on a, um, residential type pro, or they can go mm-hmm. Uh, onto a program where they learn everything about diabetes and how to manage it. And I guess it, it's less necessarily wellbeing focused, rather, you know, it's focused on the disease.

And one that makes me think about is also the value of having like [00:42:00] a charismatic front man that's shepherding people to your treatment. This has been discussed before. 'cause you think of like really famous psychotherapy clinicians across the years. So like your Freud, young Carl Rogers. It was often said anecdotally that people like that had a special effect all of their own because they were so charismatic and they were leaders in their field.

And I imagine getting treatment from someone like that, or someone like a Tony Robbins who's incredibly charismatic will have a placebo effect if you like all of its own, but obviously just attract more people. You know, your marketing is better. And so by getting more people through the door, you're obviously going to be able to help more people in a way that a recovery college, which might teach all the right staff might struggle with just to get people through the door.

So there might be that sort of charisma factor as well, which unfortunately is hard to replicate when you're thinking about how do you, uh, treat people in the hundreds and [00:43:00] thousands. Mm-hmm. So that, that issue occurred to me as well. Mm-hmm. Yeah. Okay. So I think we've picked this study apart to death.

Does, does Tony Robbins, can Tony Robbins cure depression? Answer is more data required? Yeah. Sorry, Tony. Yeah. Um, what's, could you introduce the next study you'd like to talk about? Yeah, sure. I'll, so I'll, I'll bring in the one that I guess follows on a little bit from some of the issues that we talked about, um, which is a study that compared the outcomes from people being given ketamine or electroconvulsive therapy for their depression.

Now the study that I'm actually going to talk about is a secondary analysis of that study. So I'm not gonna talk about the results of the study other than sort of in a brief one, two lines, because I'm sure people will be really mad if I don't actually tell them the answer to. Mm-hmm. [00:44:00] Is ECT, uh, electric convulsive therapy or ketamine better for depression.

Um, but the thing that the secondary analysis did was look at whether what patients preferred to get in terms of treatment, whether that had an impact on outcomes and on adverse events. Um, which is a really, really interesting question and is links in with the things we've been talking about in terms of the placebo effect, in terms of what the effects of expectation is and builds on a literature that exists already.

In both mental health treatments, but actually treatments generally, so for physical illness as well, that what patients prefer in terms of treatments. It matters. It matters, yeah. Um, and I guess it's part of the basis for patient-centered care. So the idea that clinicians need to really involve patients in making decisions about their care.

Um, and I think this paper, and I guess a bit of a spoiler, but this paper really underlines the importance of that again, but it underlines it in an [00:45:00] interesting way and in a way that I, I think I don't completely know what to make of, so it it'll be interesting to, to discuss our ideas about it. So, so what did the first study show, like what, so the first study was attempting to compare how effective ketamine was versus electroconvulsive therapy.

Is that right? Exactly. I guess in terms of a bit of background, um, electroconvulsive therapies are most effective and fastest treatment for depression that has been difficult to treat in psychiatry. It's one of the safest treatments that we have, so it's kind of got potentially very few side effects, although some, uh, potentially quite important and serious side effects.

Um, but it's, it's our go-to for depression that hasn't got better with other things. So it's a really important part of our treatment. Ketamine is a new-ish. Medication treatment, um, I say newish because actually it's in the [00:46:00] US certainly for, it's been around, it's been around, so it's been around as a non-psychiatric treatment forever.

So it's, no, sorry, not forever, obviously not forever, but it's, you know, it's used as an anesthetic, it's used as a painkiller. It's on the WHO list of, sort of must have medications because it's such a good anesthetic medication, um, as in something that can put people to sleep. And I, I think there was also a famous researcher named John Lilly, who was researching ketamine extensively, I believe, in the sixties and seventies, and used it in like sensory deprivation tanks and also gave it to dolphins.

Oh my gosh, I have not heard of that. This is real. We don't have time to go into this, but, okay. John Lilly researched extensively with ketamine and gave it to dolphins. Dolphins. Oh my gosh. Okay. With mixed results. I thought you were gonna bring up the horse tranquilizer a bit when you started to talk about No, but, um, I'm, I'm glad we can leave that, but yeah, so ketamines, as most treatments [00:47:00] come about, was a bit serendipitous.

I think it was being used as something that can lead to symptoms that in some ways mimic psychosis. So it kind of the, the key and speaks to the key side effects. But, you know, people feel kind of detached from reality. People can feel like their thinking gets quite muddled, so they sort of struggle to make sense of their own ideas and they get a bit disorganized in how they speak and how they act.

So it was being tested there, um, found to unexpectedly have an impact on mood and then tested. For people with problems with their mood. And you know, from there we've had loads and loads of research. It's now licensed as a nasal spray, um, which is available really across the world, although not in the uk because it's not felt that the evidence is strong enough to, to merit its costs.

So we, we don't, we can't [00:48:00] really prescribe it in the uk, um, because it's not, it's not costed by the people that pay for treatments Not prescribed as a nasal spray. Sorry. As a nasal spray. Yes. Because they do have ketamine clinics in the uk, don't they? They do. They do. So, yeah. So there, there, there's a few NHS ketamine clinics, now there's more private ones.

Um, in the US you can get mail order ketamine, um, which is kind of terrifying. Uh, I mean, I'm, I'm interested in your view because you're familiar with the literature on ketamine, like. What, what would your stance be on using ketamine in a public health system? Would it be quite similar to the NHS where there are set up sort of prescribed clinics with a relatively high barrier to entry based on your knowledge of ketamine?

Do you agree with, um, other countries who are more liberal with this? I think, I don't agree with just how liberal it's got because it's like all of our treatments, it's not without [00:49:00] its drawbacks. And so I think some of the really prominent clinicians who use ketamine in the UK call for things like registers of how it's being used so that it can be kept track of, uh, so that people can't do things like shop around clinics so that people can't 'cause ke ketamine, people can undo, and I've met them in addiction clinics, become addicted to ketamine and have serious physical health consequences.

Exactly. Um, and people who use ketamine as a recreational drug tend to use much higher doses than what is used in, in when ketamine is used as a depre, as a depression treatment. Um, but nonetheless, you see that tolerance can develop, um, as people get more and more doses even in a clinical setting. And that's, you know, so the idea that you kind of need more of the drug to get to the same effects.

So, and we've seen plenty of high profile cases that, um, [00:50:00] to show that actually it's very possible to develop an addiction to ketamine, especially if it's not being prescribed in a judicious, careful way. Um, so if you, if there's no, you know, if you can be turned down at one clinic and go to another clinic and there's no record and there's kind of no follow up, anything could happen.

Anything could happen. And actually it. You know, and if you can be therefore getting instead of twice or three times a week, prescriptions of ketamine, you manage to get it seven days a week, you are clearly entering the realms of how people are using it recreationally, where we know that certainly a lot of problems, um, a lot of problems occur.

So how does Ketamine compare with, uh, electroconvulsive therapy, that first study? Yeah, let's get back to the point. Good. Thank you Alex. Um, so what that study basically showed is that ketamine is non-inferior to electroconvulsive therapy. Um, which is a wordy way of saying, um, it doesn't look like [00:51:00] it's better.

It doesn't look like it's worse, and that's sounds like a boring outcome, but actually it's a really useful outcome because they are drugs that have different side effects. They have different reasons for why you would exclude someone from receiving it as a treatment. As I said before, ECT is right now, you know, kind of our, our end of the line.

This treatment, if nothing else has worked, this, this has a chance of working. Um, so to have another drug that we can maybe add into that segment is really useful. And because some people and, and some people might prefer to have ketamine to have, which we get onto Yes. Yeah. But just before we do that, we don't have time to go into the nuts and bolts of the first study.

But based on your reading of it, do you think that's a reliable result that we can, that we can bank on? That it, that ketamine is non-inferior? It's okay if you don't, you don't necessarily know, but yeah, I do. You know what, I actually, I haven't [00:52:00] read it in the detail that I've read the second study, so, um, I will be fully honest and say I'm not sure.

What I will say is that it was conducted in a. In a reasonable way. They had, um, a good, they had sort of, I think 400, 500 people participating. Okay. So it's a big, big study. Um, and so those are really good signs. Okay. So on the surface, on the surface, possibly it, it looks reasonable. Um, not still, maybe not quite enough to change practice, but, um, but yeah, I think worth paying attention to.

And we'll put the link to that study as well so people can check it out and, and they could see if there are any criticisms made, uh, online. So could you walk us through the second study? So the, so they're looking at what exactly, how, how patient preference plays into all of this and this choice between ketamine and electroconvulsive therapy.

Yeah, so it was pretty simple how they did it. [00:53:00] So they basically just, uh, I think so, I think an interesting part is that they realized part through running the study that this is something that they should do. Which means that the re the numbers in this study are smaller. There's about 260 people, um, who were asked the Haitian preference question.

Interestingly, they chose to ask people at the very end of the study, so once people had already received all of the treatments and they said they did this, so that the, I guess so that asking the, the question didn't in any way bias patient's course through the study or lead to increases in dropout, for example, by which I guess they mean, uh, on the off chance that someone hadn't yet thought about which treatment they preferred, and then they got asked the question and then they self-reflected and they realized what they really wanted was the electroconvulsive therapy and they ended up in the ketamine group.

They would just drop out. Right. I guess that that's the thing that they were worried [00:54:00] about. Mm-hmm. I think it's a, it's a reasonable concern, but it, it's a, it's a big limitation in terms of the interpretation that we can put. Yeah. And I mean, what were they asking, you know, which treatment did you prefer at the beginning or which treatment do you prefer now, having had it, so they were asking the first one, so they were asking people to think back to the best of your ability before you received any treatment.

Which treatment did you want to get? And, uh, they had sort of a, a seven point scale, so they either, and so what they could measure with that is kind of a moderate preference for ketamine. A strong preference for ketamine, a moderate preference for ECT, a strong preference for ECT or just a neutral position.

Don't really mind. Mm-hmm. Okay. Um, but the, you know, the way that you frame that question is really interesting because unfortunately, the danger of asking it that way. Because you're asking it after the people have had the treatments, is that their answering of the question? There's every chance it's being [00:55:00] colored by their experience of having received the treatment.

Um, and the, and, and I guess it's a, it's a different, uh, it's a different view on the problem of asking it before in just that what ends up happening may, well, you know, or just thinking about it may well affect, um, what, what the outcome is. So, you know, it's, it's not perfect, but it's still still worth seeing what happened after that.

Um, which I, yeah, I'll go on to. So I guess I'll just pull out the two sort of most, to my mind, kind of stark findings. Um, and then we can discuss a bit about what it means. But, so people who were preference matched as in, so people who said that they would prefer ketamine and got ketamine. Did better with ketamine or did worse with ECT.

Um, but that wasn't the case with people who said they had a preference for ECT and sort of, [00:56:00] um, went either way. So for some reason, something about preferring ketamine and getting ketamine means you do better. Right. Um, but if you prefer ECT and get ECT, that doesn't make a difference to how well you do with the treatment, which is surprising.

You know, you'd kind of expect that if there was, you'd, you'd, well, you'd perhaps expect that if there was a preference effect, it, it would matter either way. Yeah. Like, I would've expected maybe more people having a preference for ketamine over ECT just because ECT is like quite stigmatized and has a bad reputation.

Ketamine is newer. Mm-hmm. More in vogue has a better reputation. But assuming you did have a preference for ECT, I'm surprised that that didn't carry over in the same way as ketamine. Yeah, exactly. They, they didn't go into much as to why they thought that might be happening. Um, and, and so perhaps you and I can, can try to come up with our own ideas for why it could be happening.

And then the other thing that, that was interesting is [00:57:00] that what it did affect, however, was side effects. So if you preferred, if you didn't prefer, um, uh, let me get this the right way around. So if you didn't prefer ECT, but you got it, you were more likely to report side effects or experience side effects than if you preferred and, and got ECT.

Um, it didn't seem to matter with ketamine. So kind of the rate of side effects didn't seem to matter with whether you preferred or didn't prefer. That's interesting as well. It is. Um, and, and it, it is almost sort of two sides of the same coin in the sense that. Yeah, if you have a preference for ketamine, you do better with ketamine and you sort of do overall worse with ECT 'cause you get more adverse effects 'cause you're getting something that you didn't want.

So, you know, maybe you are just more likely to pay attention to the side effects. You are sure you're a bit missed. Um, [00:58:00] but, but again, I think it's, it's really curious as to why the preference for ketamine makes such an impact on, on the outcomes with ketamine. And it links with some of the research that's been done, which, um, so there was an interesting study that showed that you potentially lose quite a lot of the effects of ketamine if you deliver it under anesthetic.

Um, there were many limitations with that study. So it's, that's not to say that, um, ketamine only works if you know that you're getting ketamine, but, but it, again, it, it, you know, it was an interesting signal that. Is there something about kind of the, again, the expectation that people have with getting this treatment.

Is there something about the, um, uh, their appraisal of the experience in receiving this treatment? Because e cts delivered on under anesthetics, so people are asleep, unconscious, you know, they mm-hmm. All they know is that they go into the room, then they're [00:59:00] asleep and they wake up in the recovery area.

It's a, it's more like severance. Yeah, yeah, yeah, yeah. Oh God, yeah. Yeah, completely. Except there's no bit, well, as far as we know, there is no bit of you that is no aware during the anesthetic, but I guess we'd never know, um, unless there's a whole world of anesthetic in his I do, I guess it does make me think about ketamine as a dissociative.

Mm-hmm. And so does ketamine help people have a more I. Slightly dissociative frame of mind in and around the time they're getting treatment such that, for example, side effects matter less. Yes. And does it matter what you make of that dissociative experience? So, you know, do you experience that dissociation as in some way more good for good as a, as a, you, you hear about this in antidepressant [01:00:00] trials, you know, when people get the nausea with medications like sertraline, which are really commonly used, sometimes people think like, okay, this is, you know, that I feel a bit sick.

But it's good. It means that the treatments, it means it's working. It means it's working. Mm-hmm. Exactly. Um, that's like with with Listerine mouthwash making you feel that tingling in your mouth, even though we know that doesn't mean your mouth is cleaner. Yeah, yeah, yeah, yeah. But God, yeah, without the tingling, you'd be like, what's going on?

Um, were there any other important results from the study? I think those were the key ones that I guess, that I, that I wanted to focus on. So I think it's a useful part of the picture and it aligns, aligns with what we know about the importance of patient preference, which we've seen, uh, there's some nice studies that compare outcomes with getting antidepressant medication versus psychotherapy and basically, you know, whether you, if you wanted to get therapy and you get the therapy you do better and vice versa, right?

So it, it fits into the field quite nicely. [01:01:00] Um, but I think it also then raises questions about what, what are the active ingredients, um, of what's getting people better. And, and it fits into the conversations that are happening in the psychedelic world of is the strange experience that you have on these drugs, is that part of the treatment?

Is it a really annoying side effect? Um, I. And does what expectations people go into it, go into it with matter really seems like it does. Mm-hmm. Um, and for some, so some people will argue that that diminishes the effectiveness of the treatment. So some people will say, well, that's just a placebo effect.

Mm-hmm. Um, but, uh, I guess a counter argument to that is the placebo effect is a, that's a real thing. You know, that's, that is really making a change to how people feel. So how do we, how do we harness it? How do we understand our brain's abilities to make ourselves feel [01:02:00] better? Can we use that understanding to take us towards new, better, less side effect prone treatments.

And I guess, and so aside from highlighting the fact that patient preference matters, I suppose the study also highlights, there's something about ketamine, at least in this instance, that's unusual, less ability to note side effects or less tendency to note side effects and, and somehow different, somehow more aligned with patient preference than ECT.

Mm-hmm. Yeah, exactly. And, um, and, and I guess, well the key, so preference for ketamine meant that people got more side, more out of ketamine than, than for ECT. Yeah, sorry. And more side reported more side effects with the ECT right? Than, than the people who, you know, than if. So if they preferred ketamine and they got ECT, they reported more side effects.

So it's sort of a, an anti preference, um, for the ECT was happening. Uh, and I wonder if the legacy [01:03:00] stigma of ECT plays a role in all of this. Mm-hmm. Like did they also, did they mention how many people preferred ketamine versus how many people preferred ECT? Yes. So about 40% of people said that they would prefer to receive ketamine treatment, and about 20% said that they prefer to receive ECT treatment.

Um, and so interestingly, you know, there was a, you know, a, a nice group in the middle who didn't have a preference. Okay. But still twice as many people were more keen on getting kein than ECT. And this was a group of people who were referred who, so, who hadn't got better with two previous treatments and who were being specifically referred to have ECT treatment.

Mm-hmm. Um. So, and it was just at the point that they kind of got to the clinic that would be offering them ECT treatment. Right. That, that they'd be offered the po the possibility of participating in this trial. I mean, that's probably, uh, a massive simplification of what actually happened. Um, yeah. So there could be the legacy effect of ECT stigma mm-hmm.

[01:04:00] Playing a role here and it, and it, and it perhaps being thought to be a more dangerous or side effect laden intervention. That's interesting. And, and how reliable do you think these results are? So like, similar to the Tony Robbins paper, are these, do we need more data or what would you do differently to, to investigate this question?

I think the, I think they are reasonably reliable in terms of the numbers of people that they've, they've had coming through. I think the key problem is asking people the question before they come for the treatment. So maybe at the point of. Screening, you know, maybe at the point at which they just put themselves forward for the study to try to get away from the fact that reflecting on the answer might increase people's possibility of dropping out or might affect the outcomes in some way.

Um, but I think, I don't know, if I ask myself and if I was going for a treatment, would I be reflecting on [01:05:00] which treatment I'd prefer when I'm entering a clinical trial? Probably, almost certainly. Almost certainly. So I think most people who have probably thought about the answer to that question beforehand.

Um, and is it also fair to say when entering a trial, most people understand that they just may not get the treatment they want and that's the point of it, and that's kind of how science works. Is that fair, do you think? Yeah, they should definitely understand. So that should be a key part of the con of the consent process, that they could get either treatment, that we don't know that one of these treatments is better than the other.

That's why the study's happening. I. Um, and checking with the person that they will still continue with the trial regardless of which treatment they get. Having said that, there's a difference between nodding along and saying yes, you understand that information and actually then having the experience of being put into a treatment group that you didn't want to get.

Um, we, we know that people get disappointed when they, when they get the treatment, that isn't the new and exciting treatment. Mm-hmm. So, yes, [01:06:00] I think it's a hundred percent fair to say that people will know that they could get either one. They should, um, but they may well still be leaning one way or another in a way that will affect their excitement or disappointment at where they end up.

Anything else you'd want to change about this particular study? I think for this particular one, that's probably the main thing because they asked a very simple question and they asked a very, any conflicts of interest or questionable sources of funding, was it funded by. Ketamine coal. Oh, ketamine. Yeah, yeah, yeah.

Um, no, so it was funded by, um, and I'm gonna get this probably slightly wrong, but it was funded by something like an organization that is interested in understanding patient choice or something like that. Right. Um, or yeah, some, something like that. So I think the funding itself is probably okay. Um, it's, it had a big list of authors and I haven't gone through all their conflicts of interest, but, um, [01:07:00] the, generally speaking, I think, and I can't remember which of our guests on the recent episodes talked about this, there's, it's always worth being aware that there's, when clinical academics or researchers get big in their field, they are often involved in drug companies in some way.

For example, delivering lectures that are paid for in, uh, being paid to run their clinical trials. Relationships occur in part because that's just a normal way, you know, a lot of these, a lot of companies will need researchers to help run their clinical trials and they will want someone who really knows what they're doing.

And that generally will be an academic. Um, they'll want someone good to give their talk. Again, that will be that person. But, um, the, again, the subtle sources of bias that, that introduces, right. Yeah. Important to take that into account. Yeah. Yeah. Always. And I think what that just means is you take it with a pinch of salt and you look [01:08:00] for someone doing a similar study.

Mm-hmm. Mm-hmm. Um, and replicating the effects. Yeah. So we have, replication is very important in science to make sure that, okay, just because one study found this effect, was it studied? Was it replicated? And then they have those meta-analyses. You mentioned, studies, which look at all of the studies or hopefully, you know, most, or a lot of the studies that have been done in that area to kind of get the aggregate result as well.

Again for this study, key takeaways that stimulate your thinking. Does it change your practice? So I think that we really need to be mindful of understanding our patient's preferences in, in whatever, you know, I think it's a good reminder whether we're sending someone for psychotherapy or medication, that understanding what the patient wants.

And as I say, this exists in other areas of medicine as well. So if you're sending 'em for surgery or physiotherapy, understanding what the patient wants and perhaps exploring why it is that they want it, and [01:09:00] dealing with any misconceptions that they might have. Um, obviously this study didn't test this, but because you, you have the opportunity, if they have, uh, expectations which aren't real or may, which you know, expectations which may distort their.

Expectations, which distort their experience. You have the opportunity beforehand as a clinician to clear up any assumptions or misconception or misconceptions. Yeah, for sure. And people talk about, you'll, you'll hear some clinicians talking about working in a way that enhances the placebo effect. So to acknowledge that there are things going on when someone gets a treatment, that is nothing to do with the, the treatment itself.

But actually, yeah, using the opportunity and the conversation to, if they have kind of positive expectations or really negative expectations, making sure that you enhance things that are positive in a balanced way so that they don't have too high expectations and then have crashing disappointment. Um, but that you really give them a sense of [01:10:00] hope to go into that treatment with, um, and that you temper any expectations that they might have about adverse effects.

So. Giving them an idea of, you know, sure, a lot of people will experience this side effect, but actually if we look at the trials, you know, a lot of people in the in inactive treatment group and the placebo group, they, you know, 20, 30% of them also got this side effect. So actually there's no, you know, you, you may well not get the side effect.

Um, see, see how it goes. Yeah. Yeah. That's great. That's all we have time for, but I really enjoyed it. Thank you, Dr. Anya, for helping us unravel the mysteries of science. Oh, it's a pleasure. I hope they are much less mysterious now, and I imagine that's not the case. I definitely want to continue doing more episodes like this every so often, and we can find papers that are interesting and see, you know, what about them works well or doesn't work well.

Uh, if any of you guys, the listeners come across any studies you'd like us to [01:11:00] talk about, send them our way. Our emails are in the description. And similarly, if you have any questions about mental health, psychology, psychotherapy, all those topics. Do feel free to send out those questions our way. In the meantime, thank you very much for listening and we'll see you back here next time.

Thanks so much. Thanks, Alex.