Leah’s a friend of my daughter’s since late Middle School. They’ve kept up and I still periodically see her when my daughter visits us. She’s a 40 year old single mother with 9 year old twins, lives in the City, has a good job, something to do with computers in the advertising business. When I saw her last summer, I heard them talking on the porch. Leah was saying that she and her Psychiatrist had "finally gotten her meds right" [I think she mumbled the word "Bipolar"]. She said she was on two medications that she named. I cringed. A couple of months later, my daughter called from North Carolina. She’d gotten a call from Leah [in Atlanta] who was driving around crazed and suicidal, would I call her? I tried and failed, but found out that she’d driven to a mental hospital and checked herself in. I’ve known Leah for a long time. Her own family situation was a mess, but she weathered it fairly well. She’d married someone in the fast lane and paid the price, but seems to have landed on her feet. She can be "mopey" at times, but never big time depressed. I vaguely know her Psychiatrist, a decent enough guy, but one who has definitely drunk the kool-ade of modern evidence-based medicine [trained at Emory under you-know-who].
Leah had been through a contentious divorce and returned to Atlanta., buying a house at the exact wrong time, and was caught in the mortgage crisis, paying off a mortgage way above the current value of her house. She was awaiting for foreclosure before moving. Her family was as little support as always. She was beginning to date again. Plenty of stress on top of raising two 9 year-old boys.
Actually, Leah was treated using something like Dr. Trivedi‘s algorithm for Major Depressive Disorder [something she didn’t qualify for in any diagnostic scheme]. She was referred by her therapist for "meds" and treated with several different Monotherapies [Antidepressants] without change. She had thereby qualified to become a case of Treatment Resistant Depression. Next on the protocol came Augmentation Therapy with an Atypical Antipsychotic. They started one, and after a dosage increase, she felt calmer and slept better – she and her Psychiatrist had "finally gotten her meds right."
After a month or so, she noticed she was gaining a lot of weight, so she stopped taking the Atypical Antipsychotic and she went absolutely crazy and felt intensely suicidal. She didn’t know it was withdrawal. She just thought she was going insane [and she was]. At the mental hospital, they finally put her back on the Atypical Antipsychotic, and she was "weaned" over the course of a few months.
In Leah’s story, there was only one supportable, evidence-based diagnosis – Abilify Withdrawal. While the discussion of the forces of change in Psychiatry, the ontogeny of the DSM III+, Conflicts of Interest, the decline of the Psychoanalysts, the rise of the Biologists, Medical Economics, etc. are interesting, they are ancillary to the central issue in the case of Leah. This was lousy medicine – very lousy medicine – and such stories are all too common.
It should be obvious that I think the term evidence-based medicine has been perverted. It means to its proponents that the only valid treatment modalities are those that can be validated by statistically significant studies in groups of people. So, almost by definition, the only things that lend themselves to study are mass interventions like drug treatment. But there is no group of Leahs. If we were to categorize her, she would fall into the emotional turmoil in the face of difficult life circumstances category. Knowing her, I also know that she would fit in the people who make bad decisions because of an unfortunate biography that predisposes to such problems category. Some short-term anti-anxiety medication might’ve helped her think through the contemporary problems more clearly. Talking things over with someone who isn’t part of the problem might really help too. It’s called Crisis Intervention, a well described approach to the psychotherapy of such cases. In addition, Leah made a bad choice in her marriage, in her house-buying, and there have been other examples. It would be to her future advantage while the consequences of those bad decisions are fresh on her plate, to consider working with a therapist who might help her learn some things that would help her make better choices in the future. That’s Psychiatry as practiced by Dr. Adolf Meyer in the first half of the last century. I think Leah would’ve been better off then.
Instead, her therapist referred her to a Psychiatrist who treated her with a group algorithm recommended for Major Depressive Disorder that landed her in a dangerous spot, ending in a mental hospital. One might say that it’s her fault. She shouldn’t have abruptly stopped the medicine. First, she wasn’t warned about either the weight gain or the withdrawal. But beyond that, I would say that she never should have been put on it in the first place. Her encounter with Psychiatry was not informed by either rational science or practical experience. It was the product of the intrusion of Pharmaceutical Manufacturers, mediated by cooperating Key Opinion Leaders [Physicians], and effected by a practicing Psychiatrist who was in the symptom treating business rather than acting like a doctor [and doing a sloppy job of symptom treating at that]. Can we generalize about a whole specialty of medicine from the case of Leah? After all, she’s just one case. I’m afraid that the answer to that question is closer to "yes" than anyone would like to admit. This n is a whole lot greater than 1…
I think the answer to your question is indeed closer to “yes” and it is baffling yet, – as you’ve artfully elucidated and revealed the historical picture from 19th -c. cure-alls and traveling medicine shows – “understandable”.
Leah would likely be hard pressed to describe the difference between a PET scan and the family hamster. Your average bloke needs to trust that there is a “smart” (at least a highly educated and supposedly qualified) class of people who can help him in his pain. This class of uber-menschen are frequently inclined to wrap themselves in a gossamer cloak of scientistic certitude.
I’m not sure you picked up on an earlier “physics envy” comment I made earlier but indeed, the “approaching significance” graphs that annoyed you were apt to “achieve” significance given the addition of a few thousand cases. There were little clusters around the means of the several treatment conditions – moreover, the experimenters were “blind” to the experimental conditions which means you can divide p values in one way or another and still meet usual and customary standards of statistical inference.
The approach and so called results were enough for Big Pharma to go to the bank and it was no real concern to them that the study was poorly designed and the “outcomes” (read “evidence”) impermeable to rational understanding (i.e., if meaning cannot be determined, does that mean the same thing as meaningless?, and, doesn’t it depend on what your definition of “is” is?). As long as quarterly performance met or exceeded Morningstar’s expectations, nothing else really mattered.
Clinicians tend to rely on the scientistics to inform them on best practices. One could argue that they should themselves be keenly tuned to the mistakes the scientistics are apt to make but then they have practices to run, payrolls to meet, liabilities to cover and so on.
Good science is hard work. Good medicine is hard work. The normative nature of the beast may be closer to avoidance of the hard work of science and medicine as opposed to acceptance of it. Everyone is constantly on the lookout for the silver bullet – less work, more money, a better quality of Scots whiskey, the ability to simply write the check to an Ivy league institution…
It is relatively easy work to manipulate columns of data and determine the statistical tests that will shed the most favorable light on your columns. Any Wall Street banker understands this quite well and to his great profit – he enjoys his 50 year old single malt, contemplating Long Island Sound from the sunken living room in the Hamptons, every bit as much as any drinking man in Eufala, Alabama would his shine. What’s not to like? Who was it said “there are lies, damned lies and statistics”?
The real pain is that there are no straightforward “answers” – at all – and damned few seekers of truth when you get right down to particulars. However, it seems clear enough that the behavior of H. sapiens holds the key, the grail, the meaning of Bodidharma’s coming from the West and that the concerted study and understanding of the behavior of human beans is the absolute best place to start.
And, dear friend, you are right smack dab on top of the case. Solving for n=1 may indeed solve for x. Thank you!
Count me “n.”
Dallas was at a standstill tonight due to an ice storm. I settled in to reread your series—about a fascinating time that I lived through but did not thoroughly understand. Then I read Leah’s story, which was similar to my own experience with lousy medicine. Ironically, my crisis was precipitated by an altercation with Madhukar Trivedi. After the final blow, I spiraled down. First I endured an extended course of lousy medicine, prescribed by a psychiatrist who trained on Trivedi’s stomping ground. Then, fortunately, I found my Dr. Adolf Meyer(s).
I skimmed your reflections which popped up on my Google alert for “evidence based counseling” and enjoyed the ride. I have a question on which I would enjoy reading your reflections. How does one know when the patient is being medicated to “adjust” to conditions against which they should rally their defenses and grow? I am a pastoral counselor and I teach pastoral care, among other roles. I don’t prescribe. Many people are coming from their primary care doctors with prescriptions. Two people asked me yesterday to reflect on if the medication was affecting their ability to reflect and engage their lives. Their families seem to prefer to have them medicated rather than empowered. These are both high functioning professional people. Your thoughts?
Thank you, Cathy.