As do 99% of bicycle manufacturers producing CF frames - the expertise and manufacturing base are primarily in Taiwan, and everyone from Trek to Canyon are sourcing from the same few people. There are some boutique brands still doing lugged carbon builds that may be assembled in the USA with the AL components manufacturer here as well, but they'll be more expensive and worse performing models for the crowd who hasn't moved on from their "steel is real" phase.
Incredibly bearish. To summarise a few decades of common factors research poorly, our understanding of therapy's mechanism of action is limited, and it's not clear that any given technique or modality has superior curative power compared to another. The most important component is pantheoretical, the strength of the relationship between client and therapist. Alexa, Siri, et al. can not reliably determine whether I want the lights switched off in my bedroom or the living room, and we are seemingly decades away from the sort of strong AI required to hold meaningful conversations about the purpose of life or the nature of our interpersonal relationships. The Heart & Sould of Change is an approachable text on the topic if you're curious.
That's not to write it off completely; there have been adaptions of CBT and DBT into text and electronically-mediated forms that show promise among subclinical populations or as an adjunct to conventional therapy, but by and large a human is going to be necessary for a long, long time.
My uneducated guess is that therapy's effective mechanism is related to the placebo effect. There is a line of thought that the placebo mechanism may be related to reduction in stress, because something else will take care of the problem.
If I go to a therapist, and they put time in to help me get better, my stress response decreases, and I feel better.
Completely made up, in case that wasn't obvious. But that's my guess.
My point is that I believe even though very smart and dedicated people work in the field, and research it, the "state of the art" seems to be little more than opinion anyhow.
That is to say, it appears to me that even "dense scientific books" are either sharing opinionated descriptive analyses or just making this shit up.
While I can appreciate you trying to defend a field of research, I am also OK with keeping my own mental model of operation.
Since here we are talking about placebo, I wonder if it has a meaning to say "placebo" when speaking about psychotherapy, since there is no "substance". Of course there is going to be a placebo effect as long as people think it's going to work. I think the point is that since in mild and moderate depression we have to choose between the placebo of a drug and the placebo of psychoterapy, let's choose the one with less side effects.
On the topic of placebo, I found Irving Kirsch's talk about anti-depressants vs placebo in depression [1] very interesting.
For anyone debating whether to pick up the book discussed in the article, I'm about halfway through right now and would highly recommend it. Harrington's a clearly talented writer and has done an amazing job weaving together the separate threads of thought and history to produce our modern conception of psychiatry. If you're familiar with Sarah Bakewell's writing, this is similarly compelling.
The least expensive Model 3 in Germany is 57.900 EUR with 540km (wltp cycle) of range – part of this is that they've only been exporting the high margin long-range AWD models. The more expensive "First Edition" id.3 will have approx 425km of range for 35.000 > x < 40.000EUR. Even taking the top end of that range, it seems the $:km ratio is in favour of the VW. If the First Edition battery is equal in size to the yet-to-be-released 58kWh battery, it seems the efficiency is at least comparable to the M3 as well.
Plus, you probably get a better interior. Certainly a better built one…
Looking at Tesla Germany, Standard Range Plus is 44.5k euros, which includes partial premium interior and autopilot. The SR+ Model 3 is price competitive with Kia/Hyundai, so I'm skeptical that VW will be able to pull some rabbit out of a hat and change that.
Note there are Skoda and SEAT cars based on the same platform also coming soon, which are in many ways more obvious competitors for Kia/Hyundai. I would not expect the Volkswagen Group's VW product to be the low end of their pricing.
If the interior is anything like my Tiguan... I would greatly prefer my Model 3 any day. I don't think the ID3 is going to come with a premium interior... haven't seen any photos of it so I could be wrong.
I dont get people keep complaining about Tesla interior. I love the interior on my model 3 much better than any car I have been in. Can you list some of the things you dont like
Though much improved since the early days, both the 3 and the S have considerably worse fit and finish and material quality than competitively priced vehicles. Whether for weight, cost, or complexity savings, they also eschew a lot of sound deadening material.
A $50,000 C class or A4 has a far nicer cabin than anything Tesla has produced, and when you start moving up into E or F segment vehicles the difference is even more pronounced. My 2010 B8 wagon with 115k on it has fewer creaks and rattles than a coworker's 2016 S with a third of that.
Infotainment wise, I find Audi's Virtual Cockpit to be incredibly well done and quite like MMI as a whole. I've not used the latest BMW or MB product that's just been released recently, but both seem to be garnering quite good reviews.
Definitely it has come long way, the model 3 i have has not creeks or anything like that and with infotainment sure Tesla needs bit more features to be added on bluetooth integration but, I love the simplicity of the car is hard to describe and cockpit on the car almost feels like a spaceship. I almost feel I am outside the car and not inside.
Unless it comes with Elon's Reality Distortion Generator(tm) these days, no, it doesn't.
Unless your goal is getting an EV for the sake of getting an EV (Tesla's are certainly best here so far), thew only thing that spending more than a day in a Tesla changes is that I want to go kick Elon's behind even harder.
> reading self-help books…is similarly effective to in-person psychotherapy
That was not the outcome of the CPR paper, and even the authors' statement in the abstract is considerably more hedged than you imply here.
iCBT and bibliotherapy have both demonstrated the greatest efficact in subclinical or extremely high functioning populations; their utility in more severe cases or those where there are comorbid psychiatric or bio-social issues is less clear.
I absolutely believe in using telehealth to broaden access to behavioural health services and think they're an excellent first line treatment, but stating there's nothing to suggest that they're a fungible good with equivalent value to human-delivered psychotherapy risks dissuading people who're already struggling and fail to improve with self-guided resources from seeking out more comprehensive services.
Teletherapy outcomes have yet to be thoroughly researched, but anecdotally most clinicians report a strong preference for face-to-face sessions. Part of the discomfort stems from legal concerns – how do you handle a patient who reports intense suicidal ideation with a plan being one of the big ones – but also the limitations of teleconferencing. Neither the typical therapist nor their patient is like to have access to a fancy $$$ teleconferencing setup; both are likely stuck using whatever $0.50 on the BOM selfie camera Apple chose for their latest iDevice. Seeing only the face, and a 720p at that, denies the clinician a lot of valuable information about the client's internal state, their physiological responses, and their body language. Not to mention connection issues. Imagine being someone who's kept a secret about their sexuality or childhood abuse and finally developed enough trust and worked up the courage to discuss it to your therapist only to be met with a "Connection lost…" or frozen image of their face.
Additionally, licensure for mental health professionals is handled on a state-by-state basis, making CoL arbitrage difficult.
Even at the top end of that range it's less than what a competitive internships annualised compensation would be. Are you really able to hire people at those rates?
There is a both a large and strong evidence base for the usage of ECT in cases of severe, treatment resistant depression. Many aspects of modern medicine can be made to sound barbaric with the right framing; those who disparage ECT are not so quick to characterise chemotherapy as “poison by any other name” or dialysis a “vampiric ball and chain”.
By the time ECT is on the table, every other option is exhausted and the sufferer has been through multiple acute hospitalisations for suicidal ideation, if not unsuccessful attempts.
It is certainly fair to say the effect is not always permanent, that maintenance courses are a burden, and that their long-term efficacy does not justify the risks of the procedure itself or the anaesthesia it requires. Nonetheless, for someone who has been depressed for many years, plagued by crippling ennui and a nihilistic view of existence not even Schopenhauer’s grimmest passages can match, any respite is welcome. To deny them that option, with full knowledge of the risks, is to deny them agency.
"But he acquiesced when told that if he resisted, the hospital would seek a court order to overrule him."
Are you claiming they would do this, yet have the deeply depressed patient's honest agreement ?
I don't buy that. This was forced, under threat of force. To protect the hospital against having a successful suicide attempt on their record.
Symptoms return. Normal cognitive function does not. That tells you more than enough. This person is now (hopefully lightly) mentally handicapped, and this has been done to her under threat.
You might as well shoot the person. That has the same demonstrated effect. Seriously. Shooting someone with mental problems can fix those mental problems, many documented cases of that happening.
>You might as well shoot the person. That has the same demonstrated effect.
This is ludicrous hyperbole. The majority of people who receive ECT are successfully treated and go on to live fulfilling lives. ECT is an evidence-based treatment for a life-threatening medical condition.
If it truly was, then why was that person threatened into doing it ? If what you're saying is true, then what possible motivation could the doctor have to threaten his patient into accepting this treatment ? (I get that someone else had to say "yes", but that doesn't change the situation)
Second, I resent psychologists using "evidence based" as a term. This, one might think, implies that they have proof. Well no, no proof. It doesn't mean that.
Ok, but surely it means that they have double blind statistical studies ? I mean, that makes "evidence" very misleading, but ... Yes, but those studies say there is no effect beyond placebo (in fact there are valid studies that say that all of psychiatry does not survive a double blind study). So statistical analyses actually says this does not work.
Ok, so what does "evidence based" mean ? Well, it means they have a few anecdotes of mostly temporary improvement (and lots of anecdotes of disastrous outcomes, conveniently left out). Which certainly exist for shooting depressive patients as well. Also they exist for not doing anything.
So why did the doctor force this treatment on her ? Well, to get her out of his clinic. You see, the way you get fired in a psychiatric department is to have a few patients commit suicide in the department. And observation and isolation only helps for so long. In practice, given 4-12 weeks of trying people successfully commit suicide, even under 24 hour observation with no tools in an isolation cell. This patient had gotten really close to doing that, as mentioned in the article (which, incidentally, would be the conditions this patient was held in prior to her getting asked if she'd agree to this treatment. Which of course also means she is mostly happy with the treatment because it got her out of an isolation cell, and still lives under threat of returning to those conditions. Reality of psychiatric patients).
So this is fact: this doctor forced permanent brain trauma on a patient because he was calculating that this trauma would temporarily prevent the patient from committing suicide, long enough so that she'd be out of his department before she actually succeeds.
So reality is simply that this patient was forced to get ineffective treatment that introduced permanent brain trauma against her wishes, with the decision made under extreme stress (introduced by this doctor), and under threat. That she got lucky and seems to be happy with it does not change that. PLUS she might merely be happy that it got her out of the isolation cell she was forced into for weeks/months before.
So let's go through your statement:
> The majority of people who receive ECT are successfully treated
If you don't count the permanent cognitive impairment, and the fact that most would have recovered without any help, then sure "successfully".
> and go on to live fulfilling lives.
Nope, most relapse. Unless you count redoing suicide attempts after ~4 months a sign of a fullfilling life. But of course, that's long enough to get them out of the hospital and let the doctor/hospital "not be responsible".
> ECT is an evidence-based
Nope. I know this term "evidence-based" is used in psychiatric literature, but that doesn't change the fact that it's bullshit, as explained.
> treatment for a
Nope. This is not a treatment by medical standards. For that to be the case there would need to be validation. This wouldn't even satisfy the standards for "experimental treatment", as that would require case-by-case review of an ethics board, which hasn't happened here.
> life-threatening
Nope. The vast majority of patients recover from this without any help. So it was not life threatening. Or at least, not any more
> medical
Nope, psychiatry is still not considered part of medicine by doctors.
> condition.
Well this is the only word in your sentence that was actually correct.
>Nope, psychiatry is still not considered part of medicine by doctors.
Psychiatry is a branch of medicine. Psychiatrists are medical doctors. Psychiatric disorders are recognised as diseases by the World Health Organisation in the International Classification of Diseases. The Merriam-Webster dictionary defines psychiatry as "a branch of medicine that deals with mental, emotional, or behavioural disorders". Psychiatrists are eligible for full membership of the American Medical Association, the British Medical Association and every other medical association I am aware of, because they are medical doctors.
The rest of your comment is just as wrong as this sentence and just as readily debunked. Due to the length of your comment and the sheer density of falsehoods, I am not inclined to debunk it point-by-point; I would suggest that anyone with an interest in the topic should consult the National Institute for Clinical Excellence's Technology Appraisal on ECT.
Psychiatrists are medical doctors because they need to responsibly prescribe medication. That's all.
That doesn't mean it is considered medicine.
You still haven't explained why the threat of force (and thus force) was used against this patient ... to enforce an elective treatment that results in permanent cognitive damage. I am very curious how you'll explain that one.
(I would like to point out that any treatment that does not prevent death or long-term injury is one that's considered elective)
Medicine generally relies on “informed consent”: you have the right and responsibility to know and understand the treatments you are receiving and their possible effects.
Mental illness is tricky because the condition itself impairs patients’ ability to provide this consent. Maybe you’ve got extreme lassitude and refuse everything, for example, even contradictory options. Maybe you clearly do not understand the options presented to you.
Nevertheless, we also don’t want doctors making decisions unilaterally, so the next best thing is to involve a third party. If the patient has a guardian, it’s their call. If you don’t, a court can act as one temporarily, with the idea being that they’ll get you to a state where you can take over. Obviously, this isn’t ideal, but it’s not clear what would be a better approach.
This article VERY clearly states that the patient REFUSED, and then was forced to let it happen under threat of force:
The actual quote: "her husband was alarmed when the doctor suggested ECT. But he acquiesced when told that if he resisted, the hospital would seek a court order to overrule him." (note: author is talking about herself in the third person)
So I really do not "feel" force is mischaracterized. The threat was explicitly made AFTER the patient "was alarmed" (which means refused, let's get real). And threats are use of force, of course. (if I threatened to shoot you unless you did X, you would certainly call that force regardless of whether I actually shoot you, not even if I say "please". You would strongly disagree with me calling that "informed consent", rightly so)
And it's not just force. This is forcing a treatment that does permanent cognitive damage to the patient against their will. This was done knowing full well that given enough time, odds are pretty high it will disappear by itself (most suicidal patients "recover", very few actually commit suicide. I did a quick Google search and we're talking 4% apparently. Unfortunately, public opinion REALLY punishes any hospital where it happens. But that doesn't change that there was a 96% chance this patient would get cured without any action, never mind permanently crippling them)
Let's not pretend this is a moral grey area. It's not. This is far over the line.
How do you even know that this article isn't positive because the patient fears being readmitted (again with force) into the psychiatric facility and/or resumption of convulsive "therapy" ? (where she would be locked up in dismal conditions).
When I was an infant, I (apparently) struggled valiantly to avoid getting shots or having blood drawn. It hurt and the benefits of (e.g.) vaccines don't really make sense to a kid who has just learned to string a few words together. Nevertheless, my parents forced me to get them, and, as an adult who does not have several debilitating diseases, I'm glad for it. The idea is pretty similar here: the patient herself can be in a state where she's (not) making decisions that their unaffected self would. I'm a little surprised at the lack of deference to her husband, but 'alarmed' can cover a lot from "NO, NEVER" to "My God, is it really that bad?"
As I wrote above, I don't think ECT is great, but the evidence indicates it is one of the better options for drug-resistant depression. The side effects, especially for older approaches, can be pretty bad, but so is depression (and newer approaches seem to have weaker effects on memory).
I think you pretty much have to take her at her word here that she eventually appreciated the treatment. There's no way in hell someone is getting recommitted due to an article, especially not 30-40 years later.
Would you feel even remotely the same if the treatment was not vaccination, but let's say you already had the measles. A bad case.
The odds would be 99%+ that you would get better on your own (essentially nobody stays depressed, after all), BUT the process of getting better would involve 2 weeks nausea, painful pimples all over, and of course generally feeling very bad. You would need to be locked up during that time to prevent spread of the disease. In < 1% of cases it would feed back onto itself, and those weeks would repeat, progressively getting worse.
The treatment is amputation, say of a foot (because ECT does permanent cognitive damage). And, even though they can give you something to prevent you from remembering the pain or the process afterwards, they can't actually sedate you. This has a decent chance of making you better in a shorter time "without" (visible) pain/issues. They may need to redo it several times, taking off some more every time. Let's say they start with a few toes, but progressively they'll take off more, and you can reasonably expect to lose at least all your toes, with your entire foot being a possibility. Of course, there's also odds you'll lose your foot, but remain ill. (there is widespread disagreement on what those odds are, so let's leave it at "not zero, and not very small either, so >10%, but not 90% like some claim either"). And there's a tiny chance you die.
Would you still feel as positive about the treatment ? What if your parents got threatened while making this decision with having you taken away by social services and having this imposed on you ? (with some small odds of you never getting returned to them, ever)
The ethical issue is more complex than you present it. You conveniently leave out that it mutilates the patient, just not visibly. You leave out that there's extreme pain involved, and they can't sedate you (that would defeat the treatment, because the point is that the brain learns to associate absolutely extreme pain and stress with "the problem"), but they can give you the date rape drug (yes, really). You won't remember. You'll still be mutilated though. Cognitive impairment. You won't remember how it happened. Usually you won't, that is. There may be some lingering trauma, and PTSD. So there's a 10% chance (it's pretty high for ECT) that you'll have extreme (fear or violent) reactions to things you associate with the treatment room.
> I'm a little surprised at the lack of deference to her husband.
Really ? What do you think about the "doctor thinking of his career" explanation ? Can you at least agree it's pretty consistent, that some doctors might think like that ?
As in, can you at least agree that giving psychiatrists that option at all presents a "moral hazard" ?
I don't know why this is being downvoted; the correct term is "completed suicide", because "successful suicide" implies that death is a desirable outcome.
It really is the last resort; even if you were able to find a psychiatrist willing to administer a course of it without extensive trials of multiple classes of psychotropic medication as an adjunct to psychotherapy, your insurer is definitely not going to spring for it. The NHS’ NICE guidelines outline what’s to be considered before ECT is even proposed (https://www.nice.org.uk/guidance/cg90/chapter/1-Guidance#seq...), and criteria are at least as stringent in the US.
