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Does Lithium Slow ALS?

Posted Jul 09 2010 12:00am

In 2008, an article in Proceedings of the National Academy of Sciences (PNAS) reported that lithium had slowed the progression of amyotrophic lateral sclerosis (ALS), which is always fatal. This article describes several attempts to confirm that effect of lithium. Three studies were launched by med school professors. In addition, patients at PatientsLikeMe also organized a test.

One of Nassim Taleb’s complaints about finance professors is their use of VAR (value at risk)  to measure the riskiness of investments. It’s still being taught at business schools, he says. VAR assumes that fluctuations have a certain distribution. The distributions actually assumed turned out to grossly underestimate risk. VAR has helped many finance professionals take risks they shouldn’t have taken. It would have been wise for finance professors to wonder how well VAR does in practice, thereby to judge the plausibility of the assumed distribution. This might seem obvious. Likewise, the response to the PNAS paper revealed two problems that might seem obvious:

1. Unthinking focus on placebo controls. It would have been progress to find anything that slows ALS. Anything includes placebos. Placebos vary. From the standpoint of those with ALS, it would have been better to compare lithium to nothing than to some sort of placebo. As far as I can tell from the article, no med school professor realized this. No doubt someone has said that the world can be divided into people focused on process (on doing things a certain “right” way) and those focused on results (on outcomes). It should horrify all of us that med school professors appear focused on process.

2. Use of standard statistics (e.g., mean) to measure drug effects. I have not seen the ALS studies, but if they are like all other clinical trials I’ve seen, they tested for an effect by comparing means using a parametric test (e.g., a t test). However, effects of treatment are unlikely to have normal distributions nor are likely to be the same for each person. The usual tests are most sensitive when each member of the treatment group improves the same amount and the underlying variation is normally distributed. If 95% of the treatment group is unaffected and 5% show improvement, for example, the usual tests wouldn’t do the best job of noticing this. If medicine A helps 5% of patients, that’s an important improvement over 0%, especially with a fatal disease. And if you take it and it doesn’t help, you stop taking it and look elsewhere. So it would be a good idea to find drugs that only help a fraction of patients, perhaps a small fraction. The usual analyses may have caused drugs that help a small fraction of patients to be considered worthless when they could have been detected.

All the tests of lithium, including the PatientsLikeMe test, turned out negative. The PatientsLikeMe trial didn’t worry about placebo effects, so my point #1 isn’t a problem. However, my point #2 probably applies to all four trials.

Thanks to JR Minkel and Melissa Francis.

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