my old Greek

Posted on Monday 4 April 2011

Sometimes an idea comes along that sticks in the mind like it belongs there – like there was already a space patiently awaiting its arrival. After that, it might fade or seem to disappear into a cloud of other ideas and thoughts, but then it reappears with the unexpected familiarity of an old friend who just happens to be in the neighborhood and gives you a call. Later visits never reproduce the wonder of the first encounter, but they bring a calm that approximates the meaning of the word wisdom.

For me, such ideas are usually personified – Einstein, Joshu, Eliot, Freud, Mandelbrot. They seem oddly connected in that they poked holes in how I’d been thinking, and offered me another perspective that I didn’t even know was there. A few years back, I added another luminary to the cloud. I had been asked to give a short graduation address by the graduates of our Psychoanalytic Institute [short, because the speaker at the previous graduation had exceeded our endurance by leagues]. It was an honor, but I was skeptical that I could come up with a short topic that would rise to the occasion.

I knew what I wanted to say. I wanted to attack the dogmatic way many analysts have approached this whole business of theories of mental life and psychotherapy in general. On the other hand, I wanted to say something about what our graduates had learned along the way. Then I remembered something an old iconoclastic mentor, a Pathologist, had said when I was a Fellow in Immunology in a previous life. He was talking about the difficulty of giving talks to peers. The gist of what he said went like this: "Talking to peers is a pain. Either they taught you what you know, or you’ve already taught them what you’ve learned – so you have to come up with some new angle. But since there’s nothing new under the sun, I always look for something old that we’ve all forgotten. And it really helps to find an old Greek." I hadn’t thought about what he said for years.

But armed with the triad of words and phrases [skeptical, dogmatic, and old Greek], I did the modern thing and hit the Internet. Within a short period of time, the talk wrote itself as Pyrrho of Elis clicked into the space in my mind that had long been waiting for him. In fact, I got there immediately – I googled skepticism, looked at the Wikipedia entry, and there was Pyrrho. Here’s the short version.

Pyrrho was from Elis, a suburb of Athens. He started life as a painter, but gravitated to Philosophy. He became one of the Philosophers that traveled with Alexander the Great on his campaigns of conquest and he was influenced by the Philosophers in the East that he met on those travels. When he returned to Greece, the dominant school of Philosophy was Dogmatism. We know a jaded version of Dogmatism, largely from the excesses of the Catholic Church centuries later. At the time of Pyrrho, Dogmatism was something  lofty, like the "search for absolute truth." Pyrrho taught that there was no absolute truth, and his teachings became known as Skepticism. What we know of Pyrrho outside later writings about his philosophy are stories that we know aren’t true. They’re the jokes the Dogmatists made about him – parodies of his indecisiveness. They told the story that Pyrrho was walking down the road and saw a man fall face down in the mud. While Pyrrho pondered, the man died from asphyxiation. Or a story that his students followed him everywhere to make sure that he decided to eat [those old Greeks weren’t so great with jokes].

Since there were no absolute truths, Pyrrho taught that we had to accept relative truth, always maintaining a questioning attitude, vigilant for things that might cause us to revise our former approximations. We call it "healthy skepticism" these days, and it’s the essence of the scientific method. Pyrrho was perfect for my talk. Psychoanalysis at its best is a benevolent skepticism about the anachronistic meanings that our patients live by as if they were true, even when they cause havoc in living. And Freud was a grand skeptic, skeptical of his own ideas as well as others, constantly revising his theories even as he defended them. Pyrrho’s story offered a way to talk about paradigm ascension and exhaustion – and about the perils of dogma in general. Pyrrho was a welcome comrade in my pantheon of personified ideas.

So why was Pyrrho in my mind this morning? It wasn’t hard to figure out. I’d spent a week looking at the NIMH funded STAR*D depression study, and in a way I’d found it even more troubling than the Mifepristone chronicles or the Seroquel/Zyprexa  narratives that have preoccupied me for months. While the antics of the Pharmaceutical Companies probably did more actual damage to patients and to the state of modern Psychiatry, at least their motives were pure – just plain old human greed. I understand greed. STAR*D seemed different. STAR*D wasn’t a bad idea. It’s what people do in practice these days. When the depressed patient doesn’t respond, add something, try something else.
    In my volunteer job at a rural clinic, I see people every time I go there on two, three, four, maybe more psychoactive drugs – afraid to stop taking any of them. They’ve been added along the way by doctors chasing symptoms. I’ve learned to walk softly and pick my battles carefully. Stop the dangerous ones first. Remember that there’s some kind of withdrawal from most of them. Form an alliance before making too many changes. Don’t preach. If you come on like gangbusters, you chase people away. You might feel more righteous, but they aren’t helped. It’s slow going – undoing irrational medicine. I call it country psychiatry, and it’s not altogether easy work, but it has its rewards over time.
But back to STAR*D, I’d actually like to know what happens if you add treatments in depression or change treatments. Is it a good idea? Does it even work? Is treatment-resistant-depression even a valid way to look at things. Maybe it ought to be called depression-that-didn’t-need-drug-treatment-in-the-first-place. I don’t know if it was worth $35M, but maybe. But you can tell by the end of the opening paragraph that the authors aren’t there to answer those questions. They were there to make a point, to further a set of strongly held beliefs – a dogma.

Maybe those beliefs came from all those industry connections listed at the end of the paper. Maybe the beliefs came first and Pharma gathered like the Carpenter bees that come to eat my cabin this time of year. Whichever, those beliefs pervaded the article. I could see them in the assumptions, the way they handled drop-outs, the way they presented results. Then I read Robert Whitaker and Ed Pigott’s findings as they dug into the more primary sources. The STAR*D authors even leaned things toward the desired outcome as the study was in progress.

Where was the hovering skepticism that defines a genuine scientific endeavors? As Dr. Carroll points out, there are 60+ publications from this study, but none pull STAR*D together and tell us what it really said, or shows us the raw data in a way we can figure it out for ourselves. It helped me to think of my favorite old Greek, Pyrrho of Elis, this morning. It’s not the neuroscience that bothers me about all of these studies. It is what it is. And as much as I decry the pharmaceutical companies’ brash invasion of our scientific community bearing dangerous gifts, shiny gold coins, and the morality of derivative traders, that’s not the whole story either. There is a dogmatic adherence to a set of ideas in our scientific community that are way into a period of paradigm decline. And Pyrrho‘s skepticism is sadly missing. The dogmatists are trying to hold the floor of the Senate long past their prime.

Most of the Psychiatric literature I’ve been reading lately sounds like it was written by former members of the cheer-leading squad, not trained scientists – promising whatevers, emerging new this, novel approaches to that, the neurobiology of something else. This is a time for the rational psychopharmacologists among us to examine where they’ve been, and to clarify where we really are, not to try to turn things into what they hoped they might be. From another one of those personifications in my cloud [my oft-quoted favorite]:
    What might have been is an abstraction
    Remaining a perpetual possibility
    Only in a world of speculation.
    What might have been and what has been
    Point to one end, which is always present.
              Burnt Norton, T.S.Eliot, 1935
STAR*D had a real chance to say something worth knowing. What would happen if we treated depressed people based on diagnosis alone, and then followed them carefully, adding new treatment modalities if the earlier ones failed? The only thing I know for sure from their study is that their reported 67% remission rate is not close to right. Maybe someone can look at their data and figure out what it said, but I really doubt that it will be the authors/designers. They’ve taken a lot of shots without bringing it off. Their dogma is in the way.

Psychoanalysts had a forced encounter with Pyrrho at the dawn of this era of psychopharmacology. In the end, it was good for us. It happens in any science just like Kuhn said it would. It’s the rare scientist that can maintain a balanced skepticism in the excitement of new discovery, elegant theories, and grand dreams. But these people, fueled as they are by a corrupting pharmaceutical enterprise, are long overdue for some serious soul searching. They’re becoming an agent of harm and don’t seem to realize it [speaking of old Greeks]…

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