1 Boring Old Man

In my last post, I talked about some of the emergent paradigms in the modern medical scene – evidence-based medicine, translational medicine, and personalized medicine. It was kind of boring, but I don’t know what I think until I say some things, then I figure out what I wanted to say but hadn’t quite formulated. What I really wanted to talk about was a much older medical paradigm that trumps these new pretenders to the throne – preventive medicine.

Descriptions of the development of medicine usually go like this: Doctors began by focusing on treating the illnesses that were solidly in place, trying to relieve suffering and prevent deterioration [now called tertiary prevention]. Then they figured out that if you could get there before the disease was firmly entrenched, you had a better shot [so Crawford Long took out the appendix before it ruptured, women get mammograms to find the earliest sign of breast cancer][now called early detection – secondary prevention]. Then doctors figured out an even better idea. If possible, prevent the disease altogether [don’t smoke, don’t use asbestos, get immunizations, kill mosquitoes, etc][that’s called primary prevention].

But that story leaves out the oldest medical principle of all, primum non nocere [first, do no harm]. It’s paradoxically called quaternary prevention – which seems odd. Shouldn’t it come first? Whatever. Here’s the official lexicon for preventive medicine:

• We need to find biomarkers to anticipate the development of illness.
• We need to find biomarkers that will direct our treatment of illness.

Depression will be the second leading contributor to the burden of disease by 2020. There is therefore an urgent need to identify objective indicators of risk for depression…

Whether my suspicions that personalized medicine is being coopted in psychiatry by the same people that embraced every psychopharmacologic intervention introduced by their own corporate sponsors is really immaterial. What’s cogent is that they are evoking preventive medicine principles prematurely [primary and secondary prevention]. We are, at best, struggling with tertiary prevention with the use of medications in depression. The medications "reduce the negative impact of established disease by restoring function and reducing disease-related complications" in only a percentage of patients, a smaller percentage than we’d like. And they are ignoring the growing body of evidence that we should be thinking more carefully about quaternary prevention [… activities that mitigate or avoid the consequences of unnecessary or excessive interventions in the health system]. Many recent books [The Anatomy of an Epidemic, Side Effects, Let Them Eat Prozac, etc etc] make it very clear that, if anything, we’re treating way too many people – not vice versa – and particularly with antidepressants.

In spite of worrying about living up to my 1boringoldman moniker, I’m lingering here talking about paradigms for a reason. It’s very easy to go after the profit motives of the pharmaceutical companies, the kols like Nemeroff whose track record invalidate their scientific prowess, or the best laid plans of the likes of Brain Resource. But attacks on profit motives aren’t really fair. That’s a human thing, underpinning almost any business enterprise. And though I expect I’ll make those assaults on the wave of personalized medicine that’s moving to psychiatry’s front burner shortly, right now I want to hang around in paradigm-land for a while because I think that’s where our real focus should be centered.

The down-side of evidence-based medicine has been that we’ve accepted corporate sponsored clinical trials from a questionable Clinical Trials Industry that showed statistical but underwhelming evidence of efficacy and allowed the drugs to be used as if they were digital [depression = antidepressant], which they aren’t. The down-side of translational medicine is that we’ve raced to market with some shaky medications and been caught up in a whirlwind of worry about new medications in the pipeline at the expense of being careful, or even honest, about the drugs being prescribed. Now we have personalized medicine. Biomarkers of depression may be of scientific interest, but there’s no "urgency" for patient care until we have a reason to measure them. Trolling for patients is not a preventive medicine principle. Likewise, the excitement about personalized medicine leading us to decide which antidepressant to use is the lucrative fantasy of people who do screening for a living. A more rational approach would be to find a biomarker to see if an antidepressant is even indicated at all, rather than which one. That would be a better fit for the state of the art than what our personalized medicine gurus have in mind.