The apologists for homeopathy are upset again: this time with Professor Edzard Ernst and Simon Singh’s new book.  Why? Because once more homeopathy is exposed for what it is: a placebo.

Dr Damien Downing, the Medical Director for the Alliance for Natural Health (ANH), seems particularly put out.  So much so that he has released a rather silly critique. (This link seems to be down. Try here)

After some empty carping he suggests that Ernst is not a very good scientist and then goes on to wrap himself in the flag of good science, ”The scientific method ‘consists of the collection of data through observation and experimentation, and the formulation and testing of hypotheses’ (Wikipedia) – not of unsubstantiated dogmatic statements. Science has no room for dogma.”

This is one point I can agree with; compared to the statements of some other protagonists it’s pretty reasonable: science should have no room for dogma.  However, Downing is not averse to peddling some homeopathic propaganda. 

This is clearly seen in the way he handles evidence.  He refers to, what I would expect, is his best scientific evidence base for homeopathy: the homeopathy evidence section of “The National Library for Health“.  He points out that it currently, in his view, “contains 32 systematic reviews and meta‐analyses of [homeopathy's] use in a wide range of disorders“. He opines, “Of the 32, 7 report a statistically significant clinical effect from homeopathy, 6 show a non‐significant trend in its favour, and 3 show no effect; 16 concluded that there was “insufficient data” to draw a conclusion either way.”

Now I’ve very closely examined this database in the past and could not disagree more strongly with this ‘analysis’. It completely misses the main point: if you are concerned with either treating patients, or recovering from illness, what you really need to know is how many of these reports show that homeopathy works as well as the recommended conventional treatment: the answer is none. 

[three more items of ‘evidence' have been added since I looked at the database, none of these have, as yet, been through the complete review process so it would be premature to cite these - hence my review is still relevant.]

Next, the idea of a “statistically significant clinical effect” needs some thought.  Note that it does not claim that there is a clinically significant effect.  That is, an effect that would be worth having.  This is good, because none of the reports show any.

A statistically significant effect just means that the statistical tests used on the data indicate that if the study was repeated it is likely that the difference in outcomes between groups given homeopathic sugar pills and ordinary sugar pills would be seen again.  In other words, the difference between these two groups is not likely to be just the result of chance.  However, not likely here usually means nineteen times out of twenty.  Not too reassuring when you see the number of outcomes measured in some of these studies, or the number of researchers in the world looking at this issue.

Neither do tests of statistical significance account for a range of other impediments including experimenter bias, publication bias, lack of blinding, high drop-out rates from control groups etc.

One of the silliest things in Downing’s statement is the citing of studies that he contends show “a non‐significant trend” in favour of homeopathy.  If the trend is not statistically significant, then it’s very likely to be nothing more than random noise in the experiment.  This is non-evidence, not evidence.

So we have no evidence to support the use of homeopathy; the authors of these ‘positive’ studies actually ask for more research.  All we have is a small number that claim to reach statistical significance for the particular ‘homeopathic’ intervention showing an effect in excess of a placebo.

The next sleight of hand is the contention that, “16 concluded that there was “insufficient data” to draw a conclusion either way.”  The “insufficient data” part seems to be presented as a quotation.  This phrase does not appear in sixteen of the reports. 

Also, the observation that researchers have looked for an effect and not found one tells its own story.  Whilst, in an absolute sense absence of evidence is not evidence of absence; this is too simplistic.  We need to remember to account for prior probability.  If something genuinely doesn’t exist then, by definition, we are never going to find evidence of its existence: there is an absence of evidence of unicorns because they are a myth.  Similarly, absence of evidence for the deeply physically implausible practise of homeopathy is telling us something.

However, if we are looking for something that is likely to be real, the quality of the search for evidence is also important: absence of evidence in high-quality research is clearly informative in a way that a similar result in low-quality research is not.

Seen in this light one of the observations contained in this database, that Downing has mysteriously overlooked, is vital:  

“… Studies of high methodological quality were more likely to be negative than the lower quality studies …” [Cucherat et al]

In other words, the better the quality of the search for a homeopathic effect the less likely one is to be found! 

This moves us onto the oddly vexatious topic of the famous review by Shang et al.  For Downing, “…the authors identified 110 relevant studies and then excluded all but 8 of them from the final analysis – and declined to name them! This would seem to be blatant research misconduct.”

Reality is somewhat different.  The research progressively excluded studies on the basis of transparent quality criteria.  They were particularly interested in bias and found that is correlated strongly with sample size.  That only eight of over one hundred trials of homeopathy made the cut tells us something important about the quality of research conducted into homeopathy.  That the eight best studies, taken together, showed that homeopathy is no more than a placebo is an entirely proper conclusion – consistent with the findings of Cucherat et al.  Any plea to include more of the original 110 is a plea for the inclusion of bias: not good science. [this subject is excellently explored on Paul Wilson's blog]

Again, the better the quality of the search the more negative the findings about homeopathy.  This is, of course, what would be expected if there were no benefits from homeopathic remedies (aside from the placebo effect): seemingly positive results are just noise in the signal and can be removed by proper filtering.

The assertion that the authors refused to name the final eight studies is a persistent piece of homeomythology.  I have commented on this before at some length.  The truth is that Shang and his co-authors unwisely omitted the names of the eight studies from the original paper; some people pointed this out and they named them in the 17^th December 2005 issue of The Lancet.  They have also made the details of the included and excluded papers available on a website.  This all happened in 2005!  It would seem to me that to raise the banner of good science requires that one, at the very least, keeps up to date with developments! 

On the subject of Shang et al, Downing confuses proper scientific conduct with mis-conduct.  This egregious folly can only be the result of a shocking lack of competence or letting personal dogma cloud his judgement.  I prefer to think it is the latter.  In any event, given this woeful performance, it would seem rather embarrassing to vilify Ernst as a bad scientist.

Unfortunately Downing is not alone in perpetuating the myth of the secret eight; worse still others completely fail to understand Shang et al.

It’s worth noting that Downing’s much vaunted “National Library for Health” database contains one review that, taken at face value, is very problematic for a homeopathy advocate.

A meta-analysis of homeopathy for postoperative ileus by Barnes et al was not able to reach a definitive judgement.  However their data indicated that studies working with potencies below 12C (there could be some active agent left) provided a statistically significant reduction in time to first flatus (vs. placebo) whereas those using potencies above 12C (odds are that just the solvent is left) did not.  Now, because homeopathic ‘remedies’ are usually diluted to potencies beyond 12C it both flatly contradicts both usual homeopathic practise and the ‘less is more’ notion of the ‘law’ of infinitesimals.

Finally, the most positive review contained in this database, covering trails of a homeopathic ‘medicine’ for vertigo (that many homeopaths wouldn’t recognise as proper homeopathy anyway!) made this plea: 

“… The positive effects of Vertigoheel in vertigo are based on good levels of evidence, but larger trials are required …” [Karkos et al]

If this is the best evidence that apologists for homeopathy have to offer one wonders why they bother.  The real answer is that this debate is not about the evidence at all; it is about some believers in an out-moded quasi-religious system of medicine clutching at fig-leaves to cover their embarrassment.

Science certainly has no room for dogma. Propaganda isn’t that helpful either, but that is all Downing and other apologists are peddling.

Who’d be a homeopath at the moment?  It must be tough given the comprehensive demolition of homeopathy’s claims to be anything more than an interesting way of delivering a placebo, provided by Ben Goldacre in both the Guardian and The Lancet.  This comes hard on the heals of Nick Cohen’s Observer article.

Homeopaths in the UK are convinced that they face an organised campaign by sceptics.  One homeopath has even complained that “… most homeopaths in UK have seen a 50% drop in their practice in the last 2 years.”

The Lancet special report quoted Peter Fisher, clinical director at The Royal London Homoeopathic Hospital, as saying that “… referrals were down by around 20% in October compared with the same month last year …”

The Tunbridge Wells Homeopathic Hospital has lost its NHS funding.  Hard times indeed.

Peter Fisher’s counter point caught my eye.  The Lancet report has him conceding that the “evidence base is not as strong as we would like” for homoeopathy and adding that “patients are our best advocates. They tell us that we have helped them when nothing else could“.

So, what is the clinical evidence for homeopathy?  How strong is the evidence base? 

Peter Fisher is also the clinical lead for The NHS’ National Library for Health “Complementary and Alternative Medicine Specialist Library“.  Who else is involved in this project?  The website provides the following information:

“… The Complementary and Alternative Medicine (CAM) Specialist Library is being developed by a Project Team drawn from the following three organisations: the Royal London Homoeopathic Hospital, the Research Council for Complementary Medicine, and the School of Integrated Health at the University of Westminster.”

It also provides a states the aim of the project:

“The overall aim is to make good quality, relevant information on complementary and alternative medicine (CAM) available to health professionals and patients. The specific objectives are to identify relevant information on a regular basis, use appropriate evaluation tools or procedures to assess the quality of this information and to organise information that is of adequate quality in such a way that it is readily accessible.”

Given the involvement of the leading lights of UK academic and tax-payer funded homeopathy, this database should be as good as it gets.  So, I thought that I’d review it and see what the homeopathic community consider their best evidence to be. 

If you go to the heading for homeopathy this library currently contains 43 items under the ‘evidence‘ tab.  To try to get a view of the overall picture painted by the evidence I have graded the entries using a fairly crude scheme, shown in Table 1.

Table 1.  Rating Method 

Now, I didn’t find it easy to assign some of the studies to a category.  So I have provided a table identifying each piece of evidence by category (Table 2).  This way anyone can look at the choices that I have made and see if they agree with me or not.  Summaries of the evidence are also provided in an appendix at the end of this piece.  These are extracts from either the author’s conclusions or plain language summaries, where provided.

Table 2.  All Items of Evidence By Rating category.  Evidence reliant on single trials of shown in red and in (parenthesis) in the tally.

The picture is very clear:  the evidence base provides no evidence at all for treating anything but two conditions: fibromyalgia (and related syndromes) and vertigo.  In the case of the former, this is based on one single RCT (n=30).  Given the unrelibility of small single trials  it best to remove them, along with any reviews/meta-analyses that rely on single trials of homeopathy, from the analysis.  This, in effect, filters out low-quality evidence.  Taking this approach removes the fibromyalgia item (6) from consideration along with three negative items (10, 37, 39) and one strongly negative item (1).

In the case of vertigo items 7 and 43 reviewed the same studies and are therefore counted once.

Most of the items of evidence are inconclusive (17 out of 43): the reviews were not able to recommend homeopathy, but the authors did not think the data were strong enough to rule against homeopathy. 

However, to treat patients positive evidence is clearly required.

Twelve items of evidence in total (9 after removing single trials) were negative: no evidence of efficacy found.  Three were strongly negative (2 after removing single trials).

The evidence, in its totality, is clearly strongly skewed against being able to recommend homeopathic treatments to patients. Figure 1 provides a graphical summary of the analysis presented in Table 2.

Figure 1.  Distribution of Conclusions For The Evidence Items

Now, I must say that some of the items of ‘evidence’ are not as formal as others.  For instance, a review of media coverage of Shang et al is included (item 34), but not the paper itself. 

Also some well-known negative reviews have not, as yet, made it into the database at all.

• Kleijnen J, Knipschild P, ter Riet G. Clinical trials of homoeopathy. BMJ 1991; 302: 316-23.

• Boissel JP, Cucherat M, Haugh M, Gauthier E. Critical literature review on the effectiveness of homoeopathy: overview of data from homoeopathic medicine trials. Brussels, Belgium: Homoeopathic Medicine Research Group. Report to the European Commission. 1996: 195-210.

Still, this is probably a sign that the database is a work in progress.  As is the inclusion of, frankly,  irrelevant information.  A meta-analysis of homeopathic aggrevations (15) is not relevant to the question of whether or not homeopathic treatments offer any benefit.  Four of the items of ‘evidence’ refer to studies that are yet to be completed (17, 18, 22, 29).  Their inclusion is clearly premature, but the passage of time will correct this in any event.

Other studies had serious methodological flaws, from the point of view of assessing the effectiveness of homeopathic treatments.  The comparative cohort study by Witt et al (35) “… cannot be used to determine whether one or the other of the treatments is optimal for all patients of a given population …”.  In addition “… adults in the conventional group had greater use of medical services in the 12 months prior to evaluation …” ; hence this is not a fair comparison.

Trichard et al (36) is “… a post hoc cohort study… not appropriate for the hypothesis as the authors acknowledged that the patients in each treatment group were not randomly selected …”.  Without randomisation it is not a fair study. 

Finally, Paterson et al (42) used such a small sample (n=60; 21 of whom recieved homeopathy) that the authors concluded “… they were unable to determine any significant differences between the groups and nor were they able to determine any trends …”

There are, however, some other useful tidbits lurking in the evidence. 

A review by Grabia and Ernst (15) concluded that their “… systematic review does not provide clear evidence that the phenomenon of homeopathic aggravations exists …”.  Now I did not consider this relevant in my assessment of the evidence for homeopathic treatments; but it is very relevant in terms of the debate about evidence.  Sometimes homeopaths assert that scientific studies of their remedies are flawed because homeopathic aggrevations can make patient’s symptoms worse during the course of a trial.  This review makes it plain that there is no evidence that they exist.

A meta-analysis of homeopathy for postoperative ileus by Barnes et al (30) was not able to reach a definitive judgement.  However their data indicated that studies working with potencies below 12C (there could be some active agent left) provided a statistically significant reduction in time to first flatus (vs. placebo) whereas those using potencies above 12C (odds are that just the solvent is left) did not.  Now, because homeopathic ‘remedies’ are usually diluted to potencies beyond 12C, I have scored this as a negative study.  Were it to be used as a postive example it would flatly contradict both usual homeopathic practise and the ‘less is more’ homeopathic potency ‘theory’.

To summarise: the homeopath’s own database should limit their practise to the treatment of, at most, vertigo (though this, apparantly, needs more research!).

Also it demonstrates that their is no evidence that homeopathic aggrevations exist and includes data which flatly contradict the idea of homeopathic potencies.

This would seem scant justification for five homeopathic hospitals, in the UK,  funded by the NHS.

How can a ‘therapy’ with such a negative evidence base be, as a single subject, suitable for even critical study at undergraduate level; let alone the nonsense BSc’s on offer at some UK universities (see here and here for particularly egregious examples)?

Why do even the medical homeopaths continue to make claims that are unsubstantiated by even their own database?  Here are the “referral suggestions” from the Bristol Homeopathic Hospital‘s website:

“Homeopathy is useful in the management of:-

Rheumatology

Allergic conditions

Asthma

Eczema and other dermatology conditions

Menstrual and Menopausal problems

Digestive and Bowel Problems

Stress and Mood disorders”

No wonder Fisher remarked that the “patients are our best advocates …”.  Their data certainly isn’t.

Meehan T, Eisenhut M, Stephens D. A review of alternative treatments for tinnitus. Audiological Medicine, 2004; 2(1): 74-82

“… Homeopathy: the single RCT (n=28) found showed no statistically significant difference between homeopathy (sodium salicylate, ascaridole, conine and quinine) and placebo in tinnitus-related outcomes.”

2.         Are homoeopathic remedies effective for delayed-onset muscle soreness: a systematic review of placebo-controlled trials.

Ernst E, Barnes J. Are homoeopathic remedies effective for delayed-onset muscle soreness: a systematic review of placebo-controlled trials. Perfusion, 1998; 11: 4-8

“The published evidence to date does not support the hypothesis that homeopathic remedies used in these studies (mainly Rhus toxicodendron and Arnica montana) are more efficacious than placebo in addressing the symptoms of DOMS.”

3.         Are the clinical effects of homoeopathy placebo effects: a meta-analysis of placebo-controlled trials

Linde K, Clausius N, Ramirez G, Melchart D, Eitel F, Hedges L V, Jonas W B. Are the clinical effects of homoeopathy placebo effects: a meta-analysis of placebo-controlled trials. Lancet, 1997; 350: 834-843

“The results of this meta-analysis were not compatible with the hypothesis that the clinical effects of homeopathy are completely due to placebo. However, we found insufficient evidence from these studies to suggest that homeopathy is clearly efficacious for any single clinical condition.”

4.         ARIA update: I – systematic review of complementary and alternative medicine for rhinitis and asthma

Passalacqua G, et al. ARIA update: I – systematic review of complementary and alternative medicine for rhinitis and asthma. Journal of Allergy and Clinical Immunology 2006;117:1054-62.

“… Some positive results were described with homeopathy in good-quality trials in rhinitis, but a number of negative studies were also found. Therefore it is not possible to provide evidence-based recommendations for homeopathy in the treatment of allergic rhinitis …”

The CAM library also adds this ‘bottom-line’ conclusion: “Therapeutic efficacy of complementary-alternative treatments for rhinitis and asthma is not supported by currently available evidence.”

5.         Classical homoeopathy versus conventional treatments: a systematic review

Ernst E. Classical homoeopathy versus conventional treatments: a systematic review. Perfusion, 1999; 12(1): 13-15

“…Only few comparative clinical trials of homoeopathy exist. None is free from serious methodological flaws. Thus the value of individualised homoeopathy relative to allopathic treatments is unknown.”

6.         Complementary and alternative medicine in fibromyalgia and related syndromes

Holdcraft L C, Assefi N, Buchwald D. Complementary and alternative medicine in fibromyalgia and related syndromes. Best Practice and Research in Clinical Rheumatology, 2003; 17(4): 667-683

“… limited evidence for other interventions (Chlorella, relaxation, biofeedback, magnet therapies, homeopathy, botanical oils, balneotherapy, anthocyanidins and dietary modifications).”

The comment on homeopathy was based on “…1 crossover RCT with 30 patients …”

The CRD also noted that “… The level of supporting evidence was generally overstated and the authors’ conclusions may not be reliable.”

7.         ‘Complementary ENT’: a systematic review of commonly used supplements

Karkos PD, Leong SC, Arya AK, Papouliakos SM, Apostolidou MT, Issing WJ. ‘Complementary ENT’: a systematic review of commonly used supplements. Journal of Laryngology and Otology. 2006 Nov 24;1-4.

“… The positive effects of spirulina in allergic rhinitis and of Vertigoheel in vertigo are based on good levels of evidence, but larger trials are required …”

8.         Complementary therapies for reducing body weight: a systematic review

Pittler MH, Ernst E. Complementary therapies for reducing body weight: a systematic review. International Journal of Obesity. 2005, 29(9):1030-8.

“The evidence related to acupuncture, acupressure, dietary supplements, homeopathy and hypnotherapy. Except for hypnotherapy, Ephedra sinica and other ephedrine-containing dietary supplements the weight of the evidence is not convincing enough to suggest effectiveness. For these interventions, small effects compared with placebo were identified. In conclusion, our findings suggest that for most complementary therapies, the weight of the evidence for reducing body is not convincing.”

9.         Complementary therapies for the treatment of HIV: in search of the evidence

Mills E, Wu P, Ernst E. Complementary therapies for the treatment of HIV: in search of the evidence. International Journal of STD & AIDS. 2005, 16(6):395-403.

“The results suggest that stress management may prove to be an effective way to increase the quality of life. For all other treatments, data are insufficient for demonstrating effectiveness. Despite the widespread use of CAM by people living with HIV/AIDS, the effectiveness of these therapies has not been established. Vis à vis CAM’s popularity, the paucity of clinical trials and their low methodological quality are concerning.“

There were two trials of homeopathy included in this review.

10.       Complementary/alternative therapies for premenstrual syndrome: a systematic review of randomized controlled trials

Stevinson C, Ernst E. Complementary/alternative therapies for premenstrual syndrome: a systematic review of randomized controlled trials. American Journal of Obstetrics and Gynecology, 2001; 185(1): 227-235

“On the basis of the current evidence, no complementary or alternative therapy may be recommended as a treatment for PMS.”

The CRD abstract notes that:

“Homeopathy (1 RCT).

One study that investigated homeopathy had such strict inclusion criteria that only 10 of the 205 patients who were screened actually participated in the study.”

11.       Defining and managing chronic fatigue syndrome

Mulrow CD, Ramirez G, Cornell JE, Allsup K. Defining and managing chronic fatigue syndrome. Rockville, MD, USA: Agency for Healthcare Research and Quality. 2001:199.

“Complementary therapies

Evidence from trials is scant and insufficient to conclude whether complementary therapies, such as homeopathy, massage therapy and osteopathy are effective or ineffective.”

12.       Efficacy of homeopathic arnica: a systematic review of placebo-controlled clinical trials

Ernst E, Pittler M H. Efficacy of homeopathic arnica: a systematic review of placebo-controlled clinical trials. Archives of Surgery, 1998; 133(11): 1187-1190

“The hypothesis claiming that homeopathic arnica is clinically effective beyond a placebo effect is not based on methodologically sound placebo-controlled trials.”

13.       Efficacy of homeopathic therapy in cancer treatment

Milazzo S, Russell N, Ernst E. Efficacy of homeopathic therapy in cancer treatment. European Journal of Cancer, 2006; 42(3): 282-289

“Although the evidence for homeopathy was encouraging, there was insufficient evidence to support the use of homeopathy in patients with cancer …”

14.       Evidence of clinical efficacy of homeopathy: a meta-analysis of clinical trials

Cucherat M, Haugh M C, Gooch M, Boissel J P. Evidence of clinical efficacy of homeopathy: a meta-analysis of clinical trials. European Journal of Clinical Pharmacology, 2000; 56(1): 27-33

“… some evidence that homeopathic treatments are more effective than placebo; however, the strength of this evidence is low because of the low methodological quality of the trials. Studies of high methodological quality were more likely to be negative than the lower quality studies.”

15.       Homeopathic aggravations: a systematic review of randomised, placebo-controlled clinical trials

Grabia S, Ernst E. Homeopathic aggravations: a systematic review of randomised, placebo-controlled clinical trials. Homeopathy. 2003, 92(2): 92-98.

“This systematic review does not provide clear evidence that the phenomenon of homeopathic aggravations exists.”

16.       Homeopathic prophylaxis of headaches and migraine: a systematic review

Ernst E. Homeopathic prophylaxis of headaches and migraine: a systematic review. Journal of Pain and Symptom Management, 1999; 18(5): 353-357

“… the overall result of this review suggests that good quality homeopathic remedies are not superior to placebo in preventing migraine or headache. The paucity of good quality trials is disappointing and limits the validity of this statement.”

17.       Homeopathic remedies for acute respiratory tract infections in children (Cochrane protocol)

Becker C, Gottschling S, Graf N, Lüdtke R. Homeopathic remedies for acute respiratory tract infections in children. (Protocol) Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD005974. DOI: 10.1002/14651858.CD005974.

Not yet completed.

18.       Homeopathic remedies for preventing recurrent acute respiratory tract infections in children (Cochrane protocol)

Becker C, Gottschling S, Graf N, Lüdtke R. Homeopathic remedies for preventing recurrent acute respiratory tract infections in children. (Protocol) Cochrane Database of Systematic Reviews 2006, Issue 4. Art. No.: CD006307. DOI: 10.1002/14651858.CD006307.

Not yet completed.

19.       Homeopathic remedies for the treatment of osteoarthritis: a systematic review

Long L, Ernst E. Homeopathic remedies for the treatment of osteoarthritis: a systematic review. British Homoeopathic Journal, 2001; 90(1): 37-43

“There appeared to be a positive trend towards the effectiveness of combination homeopathic preparations for the treatment of patients with OA. However, the small number of trials performed to date preclude firm conclusions as to the effectiveness of combination homeopathic remedies for this indication.”

20.       Homeopathic treatment of headaches: a systematic review of the literature

Owen JM, Green BN. Homeopathic treatment of headaches: a systematic review of the literature. Journal of Chiropractic Medicine. 2004, 3(2):45-52.

“There is insufficient evidence to support or refute the use of homeopathy for managing tension type, cervicogenic, or migraine headache. The studies reviewed possessed several flaws in design. Given these findings, further research is warranted to better investigate the effectiveness of homeopathic treatment of headaches.”

21.       Homeopathy

NHS Centre for Reviews and Dissemination. Homeopathy. Centre for Reviews and Dissemination (CRD), 2002; Effective Health Care 7(3): 12

“… The evidence base for homeopathy needs to be interpreted with caution. Many of the areas that have been researched are not representative of the conditions that homeopathic practitioners usually treat. Additionally, all conclusions about effectiveness should be considered together with the methodological problems of the research. – There is currently insufficient evidence of effectiveness either to recommend homeopathy as a treatment for any specific condition, or to warrant significant changes in the current provision of homeopathy …”

22.       Homeopathy for adverse effects of cancer management (Cochrane protocol)

Kassab S, van Haselen R, Fisher P, McCarney R. Homeopathy for adverse effects of cancer management. (Protocol) The Cochrane Database of Systematic Reviews 2004, Issue 3. Art. No.: CD004845. DOI: 10.1002/14651858.CD004845.

Not yet completed.

23.       Homeopathy for anxiety and anxiety disorders: a systematic review of the research

Pilkington K, Kirkwood G, Rampes H, Fisher P, Richardson J. Homeopathy for anxiety and anxiety disorders: a systematic review of the research. Homeopathy 2006, 95(3):151-62.

“A comprehensive search demonstrates that the evidence on the benefit of homeopathy in anxiety and anxiety disorders is limited. A number of studies of homeopathy in such conditions were located but the randomised controlled trials report contradictory results, are underpowered or provide insufficient details of methodology. Several uncontrolled and observational studies reported positive results including high levels of patient satisfaction but because of the lack of a control group, it is difficult to assess the extent to which any response is due to homeopathy. Adverse effects reported appear limited to ‘remedy reactions’ and included temporary worsening of symptoms and reappearance of old symptoms. On the basis of this review it is not possible to draw firm conclusions on the efficacy or effectiveness of homeopathy for anxiety… Future research should be of pragmatic design and include qualitative studies.”

Notice this appeared in the journal Homeopathy.  The concluding comment is effectively conceding that as high quality trails produce negative results lower quality non-quantitative studies should be conducted.  Imagine the outcry if conventional drug testing was approached in that way.

24.       Homeopathy for attention deficit/hyperactivity disorder or hyperkinetic disorder

Coulter MK, Dean ME. Homeopathy for attention deficit/hyperactivity disorder or hyperkinetic disorder. Cochrane Database of Systematic Reviews 2007, Issue 4. Art. No.: CD005648. DOI: 10.1002/14651858.CD005648.pub2.

“… Four trials were retrieved and assessed with mixed results. Overall the results of this review found no evidence of effectiveness for homeopathy for the global symptoms, core symptoms or related outcomes of attention deficit/hyperactivity disorder.”

25.       Homeopathy for childhood and adolescence ailments: systematic review of randomized clinical trials

Altunc U, Pittler MH, Ernst E. Homeopathy for childhood and adolescence ailments: systematic review of randomized clinical trials. Mayo Clinic proceedings. 2007, 82(1):69-75.

“The evidence from rigorous clinical trials of any type of therapeutic or preventive intervention testing homeopathy for childhood and adolescence ailments is not convincing enough for recommendations in any condition.”

26.       Homeopathy for chronic asthma

McCarney RW, Linde K, Lasserson TJ. Homeopathy for chronic asthma. Cochrane Database of Systematic Reviews 2004, Issue 1. Art. No.: CD000353. DOI: 10.1002/14651858.CD000353.pub2.

“Not enough evidence from trials to determine whether or not homeopathy can help improve asthma…The review of trials found that the type of homeopathy varied between the studies, that the study designs used in the trials were varied and that no strong evidence existed that usual forms of homeopathy for asthma are effective. There has been only a limited attempt to measure a ‘package of care’ effect (i.e., the effect of the medication as well as the consultation, which is considered a vital part of individualised homeopathic practice). Until stronger evidence exists for the use of homeopathy in the treatment of asthma, we are unable to make recommendations about homeopathic treatment.”

27.       Homeopathy for dementia

Mccarney R, Warner J, Fisher P, Van Haselen R. Homeopathy for dementia. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD003803. DOI: 10.1002/14651858.CD003803.

“No evidence that homeopathy is effective in treating dementia … The researchers did not find any good quality trials and so cannot say whether it is or is not effective for treating this condition. As no information is available on how much homeopathy is used for dementia, it is difficult to say whether it is important to conduct more trials.”

28.       Homeopathy for depression: a systematic review of the research evidence

Pilkington K, Kirkwood G, Rampes H, Fisher P, Richardson J. Homeopathy for depression: a systematic review of the research evidence. Homeopathy, 2005; 94(3): 153-163

“Evidence for the effectiveness of homeopathy in depression is limited because of a lack of high-quality clinical trials.”

29.       Homeopathy for osteoarthritis (Cochrane protocol)

Munar A, Gamboa OA, Ortiz NI. Homeopathy for osteoarthritis. (Protocol) Cochrane Database of Systematic Reviews 2007, Issue 1. Art. No.: CD006402. DOI: 10.1002/14651858.CD006402.

Not yet completed.

30.       Homeopathy for postoperative ileus: a meta-analysis

Barnes J, Resch K L, Ernst E. Homeopathy for postoperative ileus: a meta-analysis. Journal of Clinical Gastroenterology, 1997; 25(4): 628-633

“There is evidence that homeopathic treatment can reduce the duration of ileus after abdominal or gynaecologic surgery. However several caveats preclude a definitive judgement. These results should form the basis of a randomised controlled trial to resolve the issue.”

The details of the results are interesting.  The authors separated out the results for homeopathic potencies of less than 12C and greater than 12C.

“Only studies of <12C potency (n=660): time to first flatus WMD between homeopathy and placebo = -6.6 hours (95% CI -2.6 hours, -10.5 hours), p <0.05.

Only studies of 12C potency or more (n=416): time to first flatus WMD between homeopathy and placebo = -3.1 hours (95% CI -7.5 hours, 1.3 hours), not statistically significant.”

Given that the most commonly administered potencies are above 12C this study is definitely negative for usual homeopathic practise (the 95% confidence interval spans zero – no difference).

Homeopathic theory also holds that the higher potencies are more effective.  This study contradicts that view.

31.       Homoeopathic Oscillococcinum for preventing and treating influenza and influenza-like syndromes

Vickers AJ, Smith C. Homoeopathic Oscillococcinum for preventing and treating influenza and influenza-like syndromes. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001957. DOI: 10.1002/14651858.CD001957.pub3.

The authors concluded that:

 ”… the data were not strong enough to make a general recommendation to use Oscillococcinum for first-line treatment of influenza and influenza-like syndromes … Current evidence does not support a preventative effect of Oscillococcinum-like homeopathic medicines in influenza and influenza-like syndromes.”

In plain language: “… Homoeopathic Oscillococcinum does not prevent influenza but might shorten the length of the illness“

32.       Homoeopathy for induction of labour

Smith CA. Homoeopathy for induction of labour. Cochrane Database of Systematic Reviews 2003, Issue 4. Art. No.: CD003399. DOI: 10.1002/14651858.CD003399.

“There is not enough evidence to show the effect of homoeopathy for inducing labour …”

33.       Interventions for cutaneous molluscum contagiosum

van der Wouden JC, Menke J, Gajadin S, Koning S, Tasche MJA, van Suijlekom-Smit LWA, Berger MY, Butler CC. Interventions for cutaneous molluscum contagiosum. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD004767. DOI: 10.1002/14651858.CD004767.pub2.

“There is not enough evidence to show that any particular treatment is effective for treating molluscum infection.

Molluscum contagiosum, in healthy people, is a self-limiting, relatively harmless viral skin infection. It affects mainly children and adolescents. People may seek treatment, however, for social and aesthetic reasons and because of concerns about spreading the disease to others. This review found that many common treatments for molluscum, such as physical destruction, have not been adequately evaluated. Since most lesions will resolve within months without leaving scars, molluscum contagiosum can be left to heal naturally until better evidence on treatment options emerges.”

34.       ‘Is this the end for homeopathy?’

Hitting the Headlines summaries produced by the Centre for Reviews and Dissemination offer an analysis of the evidence behind selected health stories reported in national newspapers.

“There are biases in placebo-controlled trials of both homeopathy and conventional medicine. When these biases are accounted for, there is strong evidence for a specific treatment effect of conventional medicine, but only weak evidence for a specific effect of homeopathic remedies. These findings are compatible with the hypothesis that the clinical effects of homeopathy are placebo effects.“

“This was a well-conducted study and the authors’ conclusions are likely to be reliable … The authors acknowledged that their findings concern the specific effects of homeopathy only, and that there may be context effects, such as practitioner-patient interaction, which may influence the effects of homeopathy. “

35.       Outcome and costs of homoeopathic and conventional treatment strategies: a comparative cohort study in patients with chronic disorders

Witt C, Keil T, Selim D, Roll S, Vance W, Wegscheider K, Willich S N. Outcome and costs of homoeopathic and conventional treatment strategies: a comparative cohort study in patients with chronic disorders. Complementary Therapies in Medicine, 2005; 13(2): 79-86

“…Patients seeking homoeopathic treatment had a better outcome overall than patients on conventional treatment, whereas the total costs in both groups were similar.”

However, there are some caveats here:

“The analysis was based on a cohort study, which was appropriate for the study question. As such, the results of the study cannot be used to determine whether one or the other of the treatments is optimal for all patients of a given population … adults in the conventional group had greater use of medical services in the 12 months prior to evaluation …”

36.       Pharmacoeconomic comparison between homeopathic and antibiotic treatment strategies in recurrent acute rhinopharyngitis in children

Trichard M, Chaufferin G, Nicoloyannis N. Pharmacoeconomic comparison between homeopathic and antibiotic treatment strategies in recurrent acute rhinopharyngitis in children. Homeopathy, 2005; 94(1): 3-9

“… The homeopathic strategy appeared to be more medically effective and to be associated with a better quality of family life in the treatment of infantile recurrent acute rhinopharyngitis (ARP) than the antibiotic strategy …”

Again, caution is required:

“The effectiveness data were derived from a single study and no other source. The study design, a post hoc cohort study, was not appropriate for the hypothesis as the authors acknowledged that the patients in each treatment group were not randomly selected and no sample size was determined in the planning phase of the study. The patients’ parents had chosen a particular type of treatment, which was probably correlated with many social, economic and cultural variables. Although the authors did try and test for some of these social variables, they did not test for differences in education, income level or size of housing, which could have a strong association with choice of treatment and health outcome. In addition, some baseline parameters were differently distributed in the two groups and such confounding factors were not taken into account in the analysis of effectiveness. The authors acknowledged that this non-homogeneity may have skewed the medical effectiveness results in favour of the patients in group H or in group A depending on the parameters.”

37.       Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more)

Dare MR, Middleton P, Crowther CA, Flenady VJ, Varatharaju B. Planned early birth versus expectant management (waiting) for prelabour rupture of membranes at term (37 weeks or more). Cochrane Database of Systematic Reviews 2006, Issue 1. Art. No.: CD005302. DOI: 10.1002/14651858.CD005302.pub2.

This review included: “… one trial using homoeopathic caulophyllum.”  The results of the trail were that “… Overall, no differences were detected for mode of birth between planned and expectant groups.”

Beer AM, Heiliger F. Randomized, double-blind trial of caulophyllum D4 for induction of labour after premature rupture of the membranes at term [Caulophyllum D4 zur geburtsinduktion bei vorzeitigem blasensprung: eine doppelblindstudie]. Geburtshilfe und Frauenheilkunde 1999;59:431-5.

Comparison 05. Caulophyllum versus placebo: by parity

38.       Randomized controlled trials of individualized homeopathy: a state-of-the-art review

Linde K, Melchart D. Randomized controlled trials of individualized homeopathy: a state-of-the-art review. Journal of Alternative and Complementary Medicine, 1998; 4(4): 371-388

“The results of the available randomised trials suggest that individualised homeopathy has an effect over placebo. The evidence, however, is not convincing because of methodological shortcomings and inconsistencies. Further research should focus on replication of existing promising studies. New randomised studies should be preceded by pilot studies.”

39.       Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache

Vernon H, McDermaid C S, Hagino C. Systematic review of randomized clinical trials of complementary/alternative therapies in the treatment of tension-type and cervicogenic headache. Complementary Therapies in Medicine, 1999; 7(3): 142-155

“… The existing RCTs on the use of CAM therapies in the treatment of non-migrainous headache demonstrate that clinical experimental studies of these forms of headaches can be conducted. Evidence from a subset of high-quality studies indicates that some CAM therapies may be useful in the treatment of these common forms of headache.”

The detail:

“… Homeopathy (1 RCT with 98 patients, of which approximately half had tension-type headache): the quality score was high (86%). The study was methodologically rigorous with double-blinded placebo control. No difference in efficacy between treatments was found.”

40.       Systematic reviews of complementary therapies – an annotated bibliography. Part 3: homeopathy

Linde K, Hondras M, Vickers A, ter Riet G, Melchart D. Systematic reviews of complementary therapies – an annotated bibliography. Part 3: homeopathy. BMC Complementary and Alternative Medicine. 2001;1:4. Epub 2001 Jul 20.

“Eighteen out of 22 potentially relevant reviews preselected in the screening process met the inclusion criteria. Six reviews addressed the question whether homeopathy is effective across conditions and interventions. The majority of available trials seem to report positive results but the evidence is not convincing. For isopathic nosodes for allergic conditions, oscillococcinum for influenza-like syndromes and galphimia for pollinosis the evidence is promising while in other areas reviewed the results are equivocal.”

41.       The effectiveness of interventions used in the treatment/management of chronic fatigue syndrome and/or myalgic encephalomyelitis in adults and children

Bagnall A M, Whiting P, Wright K, Sowden A. The effectiveness of interventions used in the treatment/management of chronic fatigue syndrome and/or myalgic encephalomyelitis in adults and children. University of York, NHS Centre for Reviews and Dissemination, 2002; CRD Report; 22: 118

“… The authors stated ‘overall, the interventions demonstrated mixed results in terms of effectiveness’. The methodological inadequacies of the studies should be considered together with the conclusions about effectiveness. The authors concluded that there was evidence of effectiveness for CBT and GET and that further research into these and other treatments, using standardised outcome measures, is required.”

Why didn’t homeopathy make it into the conclusions?

“Complementary/alternative interventions: all of the studies scored poorly on the validity criteria … Two RCTs assessed the effectiveness of homeopathy; one reported a positive effect and the second reported overall beneficial effects …”

42.       Treating dyspepsia with acupuncture and homeopathy: reflections on a pilot study by researchers, practitioners and participants

Paterson C, Ewings P, Brazier J E, Britten N. Treating dyspepsia with acupuncture and homeopathy: reflections on a pilot study by researchers, practitioners and participants. Complementary Therapies in Medicine, 2003; 11(2): 78-84

“The pilot study provided high-quality data on patient preferences, the number and costs of treatments, outcome scores and NHS costs. However, the authors also concluded that, with such a small sample, they were unable to determine any significant differences between the groups and nor were they able to determine any trends.“

43.       Treatment of vertigo with a homeopathic complex remedy compared with usual treatments: a meta-analysis of clinical trials

Schneider, B, Klein, P, and Weiser, M. Treatment of vertigo with a homeopathic complex remedy compared with usual treatments: a meta-analysis of clinical trials. Arzneimittel-Forschung/Drug Research 2005; 55:23-29.

“… The results show the applicability of meta-analyses on the data from studies with homeopathic drugs and support the results from the individual studies indicating good efficacy and tolerability of VH in patients with vertigo.”

 ”Method: Meta-analysis of four recent clinical trials evaluating the homeopathic preparation Vertigoheel (VH) compared with usual therapies … Two trials were observational studies and the other two were randomised double-blind controlled trials.”

“Results: The meta-analysis of all four trials showed equivalent reductions with VH and with control treatment: mean reduction of the number of daily episodes 4.0 for VH and 3.9 for control (standard error 0.11 for both groups); mean reduction of the duration (on a scale 0-4) for VH 1.1 and for the control 1.0 (standard error 0.03 for both groups); mean reduction of the intensity (on a scale 0-4) for VH 1.18 and for the control 1.8 (standard error 0.03 for both groups). In the non-inferiority analysis from all trials, VH was non-inferior in all variables.”