Explore the controversial realm of homeopathy with us as we delve into its role in evidence-based and integrative medicine, focusing on its claims in treating depression. Our meticulous review includes meta-analyses and randomized controlled trials, offering insights into real-world practice. The conversation intensifies with a study comparing homeopathy and Prozac in menopausal women battling depression, sparking a lively debate on research replication. We emphasize the need for strong evidence and eagerly await Dr. Davis's expertise in a future episode. Join our community on social media, share your reflections, and be part of the ongoing conversation. Whether skeptic or enthusiast, this episode is a must-listen for the inquisitive soul.
https://www.sciencedirect.com/science/article/pii/S1876382018304451
Petter Viksveen, Philippa Fibert, Clare Relton, Homeopathy in the treatment of depression: a systematic review, European Journal of Integrative Medicine, Volume 22, 2018, Pages 22-36.
Learn more and become a member at www.DrJournalClub.com
Check out our complete offerings of NANCEAC-approved Continuing Education Courses.
Explore the controversial realm of homeopathy with us as we delve into its role in evidence-based and integrative medicine, focusing on its claims in treating depression. Our meticulous review includes meta-analyses and randomized controlled trials, offering insights into real-world practice. The conversation intensifies with a study comparing homeopathy and Prozac in menopausal women battling depression, sparking a lively debate on research replication. We emphasize the need for strong evidence and eagerly await Dr. Davis's expertise in a future episode. Join our community on social media, share your reflections, and be part of the ongoing conversation. Whether skeptic or enthusiast, this episode is a must-listen for the inquisitive soul.
https://www.sciencedirect.com/science/article/pii/S1876382018304451
Petter Viksveen, Philippa Fibert, Clare Relton, Homeopathy in the treatment of depression: a systematic review, European Journal of Integrative Medicine, Volume 22, 2018, Pages 22-36.
Learn more and become a member at www.DrJournalClub.com
Check out our complete offerings of NANCEAC-approved Continuing Education Courses.
Welcome to the Doctor Journal Club podcast, the show that goes on to the hood of evidence-based integrative medicine. We review recent research articles, interview evidence-based medicine thought leaders and discuss the challenges and opportunities of integrating evidence-based and integrative medicine. Continue your learning after the show at www. doctorjournalclub. com.
Josh:Please bear in mind that this is for educational and entertainment purposes only. Talk to your doctor before making any medical decisions, changes etc. Everything we're talking about that's to teach you guys stuff and have fun. We are not your doctors. Also, we would love to answer your specific questions. On www. doctorjournalclub. com you can post questions and comments for specific videos, but go ahead and email us directly at josh@ drjournalclub. com. That's josh@ drjournalclub. com. Send us your listener questions and we will discuss it on our pod. Hello, Dr Sadaski. How's it going, sir?
Adam:It is going great. How are you, Josh? How was your holidays? How was your New Year?
Josh:Holidays good, New Year's good. My wife started packing up all our decorations yesterday, so that was cool. I still have to take down all the stuff from the outside. My son is obsessed with decorating stuff. Like with holidays, he's like the master of ceremonies. So you should have seen our house. We probably tripled our electric bill, every year. There needs to be more blow-ups, more lights. We're not festive enough, so it may take a while to break it all down.
Adam:Did he get any good gifts? Did Santa bring any good gifts?
Josh:Oh yeah, he's loaded up with Legos for the end of the days and Willow's loaded up with, I don't know if you know, you don't have little kids, but Paw Patrol is a big thing right now.
Adam:I'm aware. It's now actually relaxed from a hard day at clinic. I think I'm going to make myself a nice cocktail, throw on Paw Patrol.
Josh:I'm going to tell Willow that she should watch some Paw Patrol with you. Yeah, no, we're big fans over here. I actually got her. It's so cool you can do these days. So I got her a Paw Patrol book with her picture in it and her favorite Paw Patrol. You could personalize these and they personally print them with her name on it and she's just obsessed with it now.
Josh:She loves it, and so it's like Willow and the Paw Patrol are on mission type of thing Anyway. So shall we? First of all, how about you? How was your holiday season, new Year's, all that, jazz?
Adam:Holiday was great. Brother asked me to be his best man at his wedding, so that was actually really cool.
Josh:Wow, that's cool. Awesome Big deal. Did you know that they were getting married? Is that a surprise? Or the best man request is a surprise?
Adam:I knew they were getting married as the best man request. That was a surprise, and the way he presented it was like a complete surprise. That got me off guard. It was really cool.
Josh:Oh, that's so cool. I feel like that's like what's the word, I don't know. I feel like that's like a spiritual thing, but that's like a big deal.
Josh:Sacred. That's the one I'm looking for. It's like a sacred thing, anyway. Okay, so shall we jump back? So I'm getting a little sick of homeopathy. I never thought I'd say that because I've been obsessed with it forever, but I'm thinking I've got like two to three more in me and then I think we should close this down.
Adam:Two to three more than I got. Yeah, okay.
Josh:Well, like we over committed, I over committed, so like, okay, so we've got, we did our. So people are listening Like we're doing this and give us some feedback. If you even like this idea of doing like a series, like a deep dive on something, full event, we're going to package this into a continuing ed course too, so you'll be able to get credits for it and just listen to it start to finish. But we've gone through some of the competing meta analysis on is homeopathy real? Is it not real? And then today we're going to do a systematic view meta analysis on a specific condition. And then we're going to have a guest.
Josh:Dr. Mark Davis wants to talk about a particular study on a systematic view on diarrhea, and that, I think, lines up with our concern for replication studies. I think that's the niche there. And then we're going to do one, because we have to, on mechanism, because I think that's really important, like what are the proposed mechanisms here? And honestly, I found some papers and it's like so far beyond me I don't even know, like I feel like we're going to need a physicist or something to come in and explain some of these papers. But we will need to do that and then we're going to close this up and so, dear listener, thanks for bearing with us. We will get back to our regularly scheduled material after this. Okay, so enough of a preamble.
Adam:Before we get into this one, do you want to give a quick recap of the first two papers?
Josh:Sure, do you want to go forward? Do you want me to go forward? Do you want to do the first?
Adam:You go forward.
Josh:Okay, so here's my super speedy summary of where we are in the state of things. Homeopathy is commonly used throughout the world. It boggles the mind as far as mechanism. As you could tell, adam and I are probably quite skeptical about it, but we're also you know, you're curious folks and critical evaluators of literature, and so we're taking a deeper dive. So the first paper we did was a systematic review and meta-analysis Excellent quality found all the randomized controlled trials on homeopathy and this is compared to placebo. So if there is a difference compared to placebo, it is in theory is not placebo.
Josh:And they did this meta-analysis something like 90 studies that were found which blew my mind and they saw a very large effect. And they did all these controls for bias and this, that and the other thing, and they're like no, the effect is still there. That came out in the Lancet major journal, blew everybody away. A few years later another group came out also in the Lancet and said no, no, no, no, no, no, no, no, no. If you do standard meta-analysis, yes, there's definitely an effect and it's a large effect. You corrected for risk of bias and you corrected for publication bias, meaning you're missing negative small studies. But you didn't do the two together, and we have evidence that both are playing a role here. And when you correct for both together, there is no longer a difference between the homeopathy and placebo.
Josh:And so their argument is what we're seeing is placebo. The reason it doesn't look like placebo is a combination of a risk of bias thing and a publication bias thing. And then they did the same techniques with conventional medicine and the effect was still there, although much smaller. And that's where we are. And then we said, okay, well, that's sort of interesting, let's look at some mechanisms and then let's look at some specific conditions as well. And that's where we got to today. And our friend and Dr. Mark Davis, send us a couple of papers, this one included on homeopathy for depression. Anything else you wanna throw in there as far as like background for a new listener?
Adam:No, I think if you want some more background, go back to the other two podcasts, as we kind of talk about it in quite detail.
Josh:Yeah, perfect, okay, so let's jump in. I thought, and we'll, of course, link to the paper and Michele hold me to that. I feel like I keep on forgetting to send her the actual citation links, but so this is a. It was a pretty standard systematic review. I thought Should we just kind of go through the basic setup and then have a discussion? Yeah, okay, you wanna jump in? Start us off.
Adam:Yeah, sure.
Adam:So this was a systematic review that was published in the European Journal of Integrative Medicine in 2018 by a team out in Norway, in the United Kingdom, and basically what they were looking at was essentially that homeopathy for the treatment of depression and basically they dated their paper back to 1982, when the or they dated back their search criteria to 1982, when the first piece of literature was published looking at homeopathy for individuals with depression.
Adam:They looked at 30 databases and basically they checked. In addition to the 30 databases that they looked at, they looked at papers and looked or reached out to 44 different researchers in 19 countries to look for additional studies that they may have missed from their search For an inclusion criteria standpoint. They looked at individuals who are diagnosed or self-reported depression from 1982 all the way to July of 2016, which is when they were basically done with their literature search, and they had no language restrictions, but they did exclude studies that did not report outcomes in individuals who were suffering from depression as the primary focus, and they also did not include studies with less than 10 participants in the trial and they excluded conference abstracts or anything that was presented in books, and basically what they were looking at was to see if homeopathy compared to placebo or some sort of intervention could have a positive outcome on depression.
Josh:Awesome, yeah, and a few things I wanted to highlight that I thought were notable. First of all, I thought the methods were pretty good. I didn't have any complaints there. It seemed like a very well done study. The one thing I wanted to highlight well, a few of them was like the search. I mean 30 databases and they're reaching out to 44 researchers, 19 different countries, so this is probably one of the most exhaustive searches that I've ever seen in a systematic review, and I think that is directly related to that paper that came out in 2009 that we talked about, which is like.
Josh:The issue here is publication bias, meaning that we're missing literature, gray literature that is maybe small, maybe not well funded, and it didn't have impressive results, so it never got published. And so one way to deal with gray literature issues or publication bias issues is just to do an insanely exhaustive search. And that's my assumption that the reason this was so extreme was that they wanted to really say look, we know this is an issue in the literature, and so we just look, we combed the world for these studies and, if it existed, we basically found. It is sort of the argument there, so I think that was kind of cool.
Adam:categorized the intervention into three different groups, looking at the efficacy of not only homeopathic preparations, but they also looked at the effectiveness of treatment by homeopaths and then also looked at basically patient reported outcomes and how their assessment of the treatment was.
Josh:Yeah, I thought that was really cool. So just to dwell on that a little bit, so, and maybe you could speak to this, so like, basically, it's like efficacy versus effectiveness versus like patient outcomes. Can you speak a bit to the difference there and why that might be relevant like here, specifically with homeopathy?
Adam:Are you looking at like the difference in definition between efficacy and effectiveness.
Josh:Yeah, and like what they're looking at and that type of thing.
Adam:Yeah, so with efficacy. What they're trying to look at is is the homeopathic preparation as good or better than a standard of care treatment or placebo? And then effectiveness is more so. Real world setting is the intervention in sort of like a less controlled environment able to provide any sort of treatment effects on the condition and then with patient reported outcomes. So how did the patient feel? Their symptoms improved? Oftentimes, when it comes to depression, we have some sort of like an objective scale. So commonly used in clinical practice is something like the PHQ. In these studies, I believe they use like the Hamilton depression index. Sometimes they use one that's based out in, I believe, in Sweden or one of the Nordic countries. It's like the MADRS. I forget what exactly it stands for, but essentially it's another depression scale and so from an objective standpoint you can use that and then from like a patient reported standpoint, you can just ask them how do you feel that you know this went? Do you feel like your depression got better? Yes or no type of thing.
Josh:Yeah, no, nailed it. So I think it really depends on your question. So, if you're interested in this philosophical question of is homeopathy real, like we've been talking about, you want the efficacy so very well controlled. We're comparing it specifically to a placebo. Everything else is controlled as a laboratory, like environment, right, and so that's the is it real question, right, but then, like out in the wild, like you said, like effectiveness, it's like okay, like given all the messiness of real life practice, like what does it look like? So, yeah, I think so, if it depends on your interest. So if you're like no, no, I'm going out and giving homeopathy and I want to see what to expect, you might be more interested in the effectiveness studies. And if you're more in this like philosophical, like well, is it even real or is it placebo, you'd be more interested in the randomized control trials, these efficacy studies, if you will.
Adam:Cool, I was just going to say. Unfortunately, they were not able to meta analyze the studies they found. They were only able to review the studies. The reason being was that there just wasn't enough studies of essentially of similar comparison that they could pool all the data together to try to give some sort of, you know, final treatment effect of homeopathy compared to an inter, compared to, let's say, placebo or compared to standard of care.
Josh:Yeah, and that was a bummer.
Josh:Yeah, I was hoping we'd get at least some meta analysis, but then the last thing before we jump in the results, though, is I really like the model validity thing that they did.
Josh:Like I haven't seen that a lot and it makes sense. And basically, it's like you know, we see this a lot with integrative medicine. It's like you have you have people who are outside the integrative medicine space, do a study, and because they don't know the space very well, like the questions asked, the setup, the methods of the study aren't really designed appropriately, at least according to the people that practice it, and so there's these concerns of sometimes called external validity or model validity, where it's like no, no, like the study is matched up in the way that this should be practiced, and so they used a cool little scale there, but basically they were saying is this study implementing homeopathy, as homeopaths would say, is appropriate or not, which I thought was a good extra check in there, because that would be that would always be the counter, right. If it was a negative finding, you'd say, yeah, but that's not homeopathy, right? So, yeah, that was cool. Okay, great. Should we anything else on the methods, or should we jump into what they found.
Adam:I would jump into what they found. Basically, the number of studies that we're working with, I believe was 18. Yeah, of those, I think three were randomized controlled trials and then the rest were sort of uncontrolled studies and surveys.
Josh:Yep, yep, yep, yep. And so I don't know it's up to you, but I think, maybe, maybe we focus mostly just on the randomized controlled trials, sort of the highest level, yeah.
Adam:And honestly that's what I did. All of the observational studies and the surveys and whatnot are just going to be of such high bias and we already know that that's influencing part of the problem with what's going on that I did not really even pay attention to that Because I knew that that was going to be such an influencing component to the outcome that I really just focused on the clinical trials.
Josh:Yeah, let's do those, let's jump into them. And what, in particular, I thought was particularly good? So let's jump into those RCTs. Look, the thing is we don't do this for money. This is pro bono and, quite honestly, the mother ships kind of eeks it out every month or so.
Josh:Right, so we do this because we care about this, we think it's important, we think that integrating evidence-based medicine and integrative medicine is essential and there just aren't other resources out there the moment we find something that does it better, we'll probably drop it. We're busy folks, but right now this is what's out there. Unfortunately, that's it. And so we're going to keep on fighting that good fight. And if you believe in that, if you believe in intellectual honesty and the profession and integrative medicine and being an integrative provider and bringing that into the integrative space, please help us, and you can help us by becoming a member on Dr Journal Club. If you're in need of continuing education credits, take our Nanciac approved courses. We have ethics courses, pharmacy courses, general courses, interactions, that's on social media, listen to the podcast, rate our podcast, tell your friends. These are all ways that you can sort of help support the cause.
Adam:Yeah, so the first RCT that they talked about was actually a really well done, random mass control trial. It was a double blinded, double dummy trial Meaning.
Josh:So what does that mean? Let's break that down.
Adam:Yeah, yeah, yeah. So meaning that when it comes to the double blinding, both the participants who are receiving treatment don't know what they're getting and the people administering the interventions don't know what they're giving. So everybody doesn't know basically what's going on. And then the double dummy is basically there were three groups and in each group, so if group one got homeopathy plus a placebo, group two got a medication In this case it was phyloxatine, brand name Prozac. We have no conflict of interest by saying that it's just you don't own stock in Prozac.
Adam:What's that?
Josh:You don't own stock in Prozac.
Adam:I don't.
Josh:Or homeopathy clinic, for that matter.
Adam:And then the third group received two placebo interventions. And so the reason why they're doing this. My assumption is that if you were to compare homeopathy just to the phyloxatine or to Prozac, one argument would be that you don't know if you're actually just comparing Prozac to placebo. And so by having a third placebo group, we can actually say and we can actually compare both the homeopathy group not only to Prozac, but we can also compare homeopathy to the group receiving nothing but placebo.
Josh:Which is kind of nice. I mean, it's neat to be able to have that One of my favorite teaching example studies comparing to it's for anxiety. But basically I think they underdosed the pharmaceutical and so, and then they did a non-inferiority trial and so it's like well, did you just say it's non-inferior to placebo essentially? So it's nice to be able to say this is what's often given for depression, prozac, and this is as good as or better than, but then also to be able to say and it's real, here's the placebo, and compared to how Prozac did against placebo as well, and we look at that comparison too. Yes, I thought that was a really neat study design.
Adam:Yeah, and there was also some pragmatism involved too, because if participants weren't feeling like they were getting any sort of benefit from the Prozac after four weeks, they were allowed to actually increase the dose to a more therapeutic dose of 40 milligrams. Yes, I like that. It's still not the max dose. The max dose goes up to 80 milligrams, so that is something that you would have to take into consideration, and the participants in this study were menopausal women with moderate to severe depression, so I think that's also another thing to take into consideration.
Josh:So let me ask you as far as model validity on the other side because I don't do prescribing anymore but would you say that's reasonable for like what? Was it four to six weeks to start at 20, get up to 40? It's not like you don't feel like they were underdosing or underperforming that or anything like that.
Adam:No, I think that that's reasonable. Okay, and I think that the 40 milligram dose is more of a therapeutic dose and, of course, if they weren't responding, you could certainly go higher and then you could compare a more sort of efficacious dose to homeopathy and go from there.
Josh:But no red flags from your perspective, as far as like.
Adam:No.
Josh:No, okay, cool.
Adam:Yeah, and they even did an intention to treat analysis. So I mean, just from the, based off of this systematic review, the way that they're describing this study is that it's a very well done study, very low risk of bias. You know, there's really no complaints from a methodological standpoint for this.
Josh:I would agree. And one thing I did triple check, because it's come up, is in this design the people that got the drug and not the homeopathy still had the homeopathy intake. So a lot of people argue that some of the benefit is the theater of medicine around, this very intensive, long therapeutic relationship with the homeopath and the way you control. For that is, everybody gets that intake with the homeopath and then the homeopath doesn't know if they're getting homeopathy or placebo. They just put the remedy and the pharmacist either gives you a placebo or gives you the remedy, and only the pharmacist knows. So that's what they did here too. So really the only difference in experience for the patients were, you know, were they getting Prozac and a placebo? Were they getting a placebo and a placebo or were they getting the homeopathy and a placebo?
Josh:And I think that was solid, really really good and, yeah, I also loved it. I also love that they talked about you know we harp on this a lot minimal important differences they talked about maybe you can touch on that a bit the minimal important difference here, or the clinical response and then response rate. I think they used a little bit of different language there, but can you speak to?
Adam:that a bit. Yeah sure, and so just to recap in case anyone's confused in this study there were three groups one group that got homeopathy plus placebo plus a homeopathic intake. Group two got placebo plus Prozac plus a homeopathy intake, and then group three got placebo plus placebo plus a homeopathic intake and they were compared against each other for to assess the response to depression symptoms.
Josh:And you can see how this is an efficacy study right. Because, everything is so controlled, even that intake, with the doctors, with the homeopaths, that really the only thing we're measuring is this little homeopathic pill, and that's exactly the type of design that will never happen in real life. It's not an effectiveness study, it is to literally measure is this real and what is the effect in the lab? If you will.
Adam:Yeah, and so they use the Hamilton rating scale for depression.
Josh:Totally legit, and that's pretty common, right, yep.
Adam:Yep, and I don't know the total score of it. But I know that there's 17 items, but I don't know if the total score is a 17 on it or not, so forgive me about that. However, a minimally clinically important difference would be a change in the score by three. So let's say it's on a scale of zero to 10. If you scored a 10 initially and you went down to a seven, that would be considered a clinically significant result. Both the homeopathic group and the Prozac group achieved a minimally important difference in their response rate. The homeopathic group was nominally higher than the Prozac, with a score of five, and the Prozac scored a 3.2. So both outperformed placebo. However, there was no statistically significant difference between homeopathy and Prozac, right.
Josh:And then they had this, what they called response rate, which is a 50%. They defined it as a 50% reduction of their baseline score which I thought was kind of a and that I think that's an FDA sanctioned outcome. Like I know, for IBS, the formal FDA outcomes are response rate, which is defined in a similar way 50% reduction from baseline. So that's again, these are not hard outcomes, but strong, well-chosen outcomes, I think.
Adam:Yeah, and they showed that both again that homeopathy achieved a nominally higher rate of achieving that 50% reduction than the Prozac group, the difference there being 54 versus 41% In that actually that was considered statistically significant as well.
Josh:That's really cool. So everyone, so people are responding to both, and homeopathy seems to be having clinically relevant and statistically significant effects.
Adam:However, that was really the only study I was waiting for your, however, yeah, that we can kind of base the data on. It's a small trial of 133.
Josh:Well-conducted randomized control trap.
Adam:Yes, I'm not taking away from the trial. It was a very well-done trial with very great methods. Very, very well-engineered design. However, it's the only study in this entire systematic review that we can actually reliably look at, and so we still need to be able to replicate this and see if we're getting similar results. If we were to repeat the trial, we don't know if we can extrapolate this out to other patient populations or people with more, let's say, if they had refractory depression, so depression that's not really responding to standard of care. We don't know if this would work for anxiety or if it would work for less severe forms of depression. This is really the only trial that we have. They did report on two other trials. One was a non-inferiority, placebo-controlled double dummy trial. Again, however, there was no sample size for that one to sufficiently establish what the non-inferiority would be, and there was also a high dropout rate 40% of participants in both groups dropped out. So there's a big lack of data on that one.
Josh:High risk of bias. Just that alone, yeah.
Adam:Yeah, and then the third placebo-controlled trial was only had 44 out of 228 participants that were recruited and was underpowered, so there was no statistical testing that was actually performed, even though it was considered to be at low risk of bias. So we just have this huge dearth of data. Granted, it was a really good study, but we don't have any replication of it and it's really the only thing that we got.
Josh:Yeah, I think that's fair and I was trying to think they didn't do grade, which is a way of talking about how much confidence you can put in saying that it works for depression. But that's kind of ballparking. What do you think the grade level would be here and how we would translate that in a sort of evidence confidence what do you think Like high, moderate, low, very low, Like where do you think this would fall?
Adam:I think moderate would be reasonable. I think if there were like two or three trials and they had similar results, then I probably would bump it up to maybe high just because of how well the methods were done. But I mean, it's a small sample size, it's a very specific patient population and we don't have replicative data.
Josh:Yeah, I think you ranked it even a little higher than I. I was thinking it was a bit low. So, like, definitely I think you're. Like, on sample size, we'd rank down for imprecision, just, I'm sure, just because the sample size is so low. And yeah, I guess, via question, if you ranked down for something else that would take it from moderate to low. I'm not sure you know. One of the questions that I had is, like you know, do you rank down for publication bias here? Right, if you have evidence that throughout the overall field there's publication bias and homeopathy, but then in this specific case there's no evidence for it and they did this really thorough gray lit review. So you probably wouldn't rank down for that.
Josh:Directness is pretty good. You know you're measuring depression. It's a low risk of bias study. Yes, I don't know, maybe moderate or moderate or low. I guess you could kind of go either way and like the language that Cochrane uses for low level of so for high level evidence, they'd say if this was high level evidence, they would say homeopathy works for depression. For moderate they'd say homeopathy may work for depression. For low, they'd say what is it? Very low, is like we can't determine. Maybe I'm messing this up, does may, could, I don't know, I can't remember, but basically that's sort of. The translation is like yeah, it may work, but we're not really sure. And that speaks to the fact that we really just have this like one study but yeah.
Adam:And I think another thing to consider too is that it's pretty well known that not everybody responds to the first anti-depressants that they're placed on, and so another thing to consider is okay of those who did not respond to the Prozac, what would their scores have been had they switched to another anti-depressant agent?
Josh:Yeah, but to be fair, they did see a response over placebo, so it was working that they had enough to have something real. And also for homeopathy, like you don't always get the remedy right and so oftentimes you have to retake the case, like that's pretty standard with like I was curious about, like model validity that they didn't mention that because you know, like I mean, it's been a long time since I studied homeopathy but like I think you know, you do your remedy, you come back, like you can change the dose or the potency, whatever the language they use. You could change the remedy, so analogous to you know, increasing the dose of Prozac, right, and yet, and they didn't do that, but they scored it high on model validity anyway. So yeah, interesting findings.
Adam:And then, I'll be honest, that's kind of where I stopped reading the paper, because I knew that the rest was just gonna be really high risk of bias, yeah, yeah it is, and so, even if they had like positive or negative results, you really you'd have to interpret cautiously.
Josh:Yeah, I think that's true and if we read this study in light of what we know from our previous papers that we've been reading, the biggest issue with homeopathy is publication bias and risk of bias on an individual study level. And so, to your point, if we know that individual study level bias is a major player here, it makes sense to me that you would only look at the low risk of bias studies. So I think that's fair and you're right. The observational stuff is gonna be high risk, just by definition, essentially. And then the publication bias issue. I mean again, I'm really impressed with how they approach that. It would be shocking to me if there was a whole bunch of studies that they didn't know about that were really there, but I guess it's theoretically possible.
Adam:Yeah, and for those who think that I'm still being too critical, again we have to recognize that extraordinary claims require extraordinary evidence and we just don't have it.
Josh:Yeah, yeah, I think that's where I was thinking about. Like, how do I summarize this? Like I think and I'm pissed at you for making me play your foil and because I've been like anti-homeopathy like my entire life wrote a paper on it and all this got in a lot of trouble and now I find myself defending it. Thank you very much. So, but one thing I'd say is yeah, I think the take home is if you and tell me if you would agree with this if you were to use the standard tools we use for all of medicine, this is pretty convincing evidence that there's something here. I mean not super strong, but it's like huh, you sit up and take stock. But if you apply a very strict lens because of the argument of extraordinary claims, require extraordinary evidence, then we're not quite there yet and we would need something really impressive, like grade level high evidence on a single condition, repeat randomized control trials, to maybe have that, have that confidence. I don't know, is that? Would that be a fair summary, you think?
Adam:Well, I think that the issue with the medication so more so from, like, a pharmaceutical standpoint, I think part of the issue is that we get treatment effects. They're just not as robust as we would like them to be, which can be disappointing, whereas with homeopathy, we're trying to say that this substance, which has nothing in it, is causing something. That is not placebo.
Josh:I know it's so hard.
Adam:And so I think that it's somewhat of a subtle difference, but it's also a very important difference, and so I kind of disagree with what you are trying to allude to.
Josh:Okay, let's unpack that a bit. So you're saying let me see if I got you right. So you're saying it's a little bit of a different question in that we walk in with priors for something like Prozac, where we have a mechanism, we have all this basic science work with the assumption that this should work.
Adam:We also have more consistent replicable data, kind of showing the effects.
Josh:Right, and so the question is not. You know, the question is like how much does it work? How relevant it's, almost like let's talk more about clinical relevance and the effect size Versus, like is this even real? Yes with it, whereas with homeopathy that's just such a high burden of believability that you do have to look a lot closer at those. You know, is it even real questions and the standard tools that you would use really Shouldn't apply? Is that a better approximation?
Adam:Yes.
Introducer:Yeah.
Josh:I agree with that. Yeah, I think that. I think that's true, cool, okay, so I am like so done with homeopathy. However, we should at least do so. Dr. Davis is gonna join us. We'll do one with him. But I found we got to do a mechanism one and I don't know how to handle this, because I looked at two mechanism studies and it just like they're talking about like like memory of water and molecular structures at these like super tiny levels and there's like interesting evidence across disciplines for this, but I just don't know how to. I don't even know how to evaluate these studies. That's the problem. Like it's so beyond my knowledge base. I don't know how to.
Josh:I mean, like these are, these are proper. These are studies from different disciplines, like you know, like how water, on a molecular level, responds to Like the glass. I mean, it's just weird stuff, man. Um, we need. So if you are listening and you understand this stuff, maybe you can help us find a way to, uh, to approach this. But I think at the very least, we should try to summarize some of the proposed mechanisms.
Adam:Anyway, If we must.
Josh:Your facial expression, which the dear listeners cannot see, says it all. Um, all right. So, uh, thank you, dear listener. We will tune in for us next time. We'll do one, maybe two more and then we promise we're done. Um, please give us some feedback if you thought this was interesting, useful, and if you like this format of going deep on something. I feel like there could. There could be value in doing three, four presentations on a particular topic, um, as opposed to just jumping all around. But I can see the argument for for all of them. Um, all right, should we leave it there?
Adam:I think so.
Josh:All right, take care everyone and thank you for listening. If you enjoy this podcast, chances are that one of your colleagues and friends probably would as well. Please do us a favor and let them know about the podcast and, if you have a little bit of extra time, even just a few seconds, if you could rate us and review us on apple podcast or any other distributor, it would be greatly appreciated. It would mean a lot to us and help get the word out to other people that would really enjoy our content. Thank you, hey y'all. This is josh. You know we talked about some really interesting stuff today. I think one of the things we're going to do that's relevant. There is a course we have on dr Journal club called the ebm Boot camp. That's really meant for clinicians, to sort of help them understand how to critically evaluate the literature, etc, etc.
Josh:Some of the things that we've been talking about today. Go ahead and check out the show notes link. We're going to link to it directly. I think it might be of interest. Don't forget to follow us on social and interact with us on social media at Dr Journal Club, Dr Journal Club on Twitter. We're on facebook, we're on Linkedin, etc, etc. So please reach out to us. We always love to talk to our fans and our listeners. If you have any specific questions you like to ask us about research evidence, being a clinician, etc. Don't hesitate to ask. And then, of course, if you have any topics that you like us to cover on the pod, please let us know as well.
Introducer:Thank you for listening to the Dr. Journal Club podcast, the show that goes under the hood of evidence-based integrative medicine. We review recent research articles, interview evidence-based medicine thought leaders and discuss the challenges and opportunities of integrating evidence-based and integrative medicine. Be sure to visit www. drjournalclub. com to learn more.