The Wednesday Wellness threads are meant to encourage users to ask for and provide advice and motivation to improve their lives. It isn't intended as a 'containment thread' and any content which could go here could instead be posted in its own thread. You could post:
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Requests for advice and / or encouragement. On basically any topic and for any scale of problem.
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Advice. This can be in response to a request for advice or just something that you think could be generally useful for many people here.
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Encouragement. Probably best directed at specific users, but if you feel like just encouraging people in general I don't think anyone is going to object. I don't think I really need to say this, but just to be clear; encouragement should have a generally positive tone and not shame people (if people feel that shame might be an effective tool for motivating people, please discuss this so we can form a group consensus on how to use it rather than just trying it).
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If you are expecting a wide body of clear and convincing evidence you just aren't going to find it often in medicine, especially when something drifts more into psychiatry, nutrition, and the other more complicated domains.
CBT-I seems to have a good number of sources saying it does something helpful. That's enormously more efficacious than most of the medications which research often suggests do nothing or are counter productive.
Mechanistically this makes sense in the same sense that exercise is better for weight loss than medication. Yes implementation is hard, but working out actually works and medications of various kinds are significantly more variable.
Additionally some of the other sources (like the AAFP) are more positive.
Ultimately medical research is hard and is hampered by ethics and expense. The evidence base for ANYTHING is pretty poor but if it seems to work and makes biological sense, we run with it.
Most medications do not or run into clear issues which just doesn't apply to CBT-I.
To benchmark this, I looked up gabapentin for neuropathic pain, as an example of a common treatment for a heterogenous condition defined by a subjective, placebo-responsive symptom, which commonly has psychiatric comorbidities/involvement. The first review I found with clear figures was this 2017 Cochrane review for "Gabapentin for chronic neuropathic pain in adults", which found all placebo controlled trials favored treatment, even for the greatest, best defined improvement. (You'll have to take my word for it that I didn't cherry-pick, but a <10 year old Cochrane review of gabapentin for neuropathic pain hopefully isn't suspicious.) Should CBTi be held to the standard of gabapentin for chronic neuropathic pain or should gabapentin for chronic neuropathic pain be considered a superlative treatment, above and beyond the superlative you gave CBTi?
If I told you Gabapentin wasn't actually indicated for neuropathic pain would that alter your thoughts at all?
What does "not indicated" mean? "Off-label" (but widely recommended) vs "FDA/equivalent-approved?"
But if the evidence for a "not indicated" treatment with similar challenges is better than that for CBTi, what does that say about CBTi? What standard should we be using?
It's not actually FDA approved for neuropathic pain (or most of what it actually ends up using for) because there isn't enough evidence that the benefits outweigh the risks. Except you just pointed to a study? Shit is messy. One study does not equal consensus.
CBT-I is cheap and found to be effective in a variety of studies and has an extremely small harm profile. Medications for insomnia have been found to be ineffective more often than not and have side effects that include up to things like dementia and death.
CBT-I first.
Aren't off-label prescriptions ~25% of all prescriptions? And doesn't applying for FDA approval de facto require a positive return to be expected before the patent expires? And NICE and other meta-analyses came to the same conclusion as Cochrane. And CBT-I isn't FDA approved, either.
But what proportion of studies finding positive result is sufficient and what control problems are acceptable? If only a borderline majority of studies are positive and better controlled studies are less likely to have positive results, shouldn't we assign a low probability to a treatment being effective, rather than a high probability?
Yes there are a lot of considerations, that was my point.
I'm really not sure where you are going for this.
What is the minimum evidence needed for high confidence that a treatment is highly effective and why? If exactly half of all CBT-I studies favored CBT-I over placebo, rather than a borderline majority, How would that change your assessment? I think understand your assessment that drugs are riskier than CBT-I, but I don't understand your assessment that CBT-I is superlatively effective.
I'm not particularly interested in litigating how to analyze research quality which is an extremely complicated topic.
The thrust of my post is that several (referenced) practice guidelines all reports that medications are not a good option and suggest lifestyle modification be done first, which is the recommendation I relayed in my post.
If you want to discuss what appropriate exclusion criteria are I'm not your guy in this setting.
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