personalized medicine: prequel to an epilogue…,

Posted on Monday 25 April 2011

In those sleepy afternoon World History classes, I used to wonder if the people in the empire of this week knew that they were just a chapter away from obscurity. We never talked about them very much [the people] – just their Kings. Years later, when we lived in Europe and saw those castles and the battle-fields, they were peaceful. They didn’t seem to have much to do with the lives of the people on the streets. Tourists gawked, but the locals didn’t even look up as they hurried by. I grew up on the scene of a fierce battle in the Civil War with cannons, monuments, and plaques everywhere – but they were things to climb on for whatever reason kids climb on things. It never occurred to me to wonder if the soldiers memorialized there knew their moment would slowly drift into world history – important maybe, but forgotten.

Should I have started my chart with Thorazine, and added all the neuroleptics [whose differences mattered so much when I was a resident but are now forgotten]? or the tricyclic antidepressants? the benzodiazepines? When did it start, this Age I’m trying to define? I think it actually began with the DSM III – though, of course, there is a history of the why of the DSM III too. And what will we call it, this Age that’s not yet ended? Might it be called the Age of Psycho-Neuro-Pharmacology [from the literary titles of the era, the Age of Emerging-New-Psycho-Neuro-Pharmacology seems more appropriate]. I doubt that the framers of the DSM III would’ve seen it as the beginning of an Age of Emerging-New-Psycho-Neuro-Pharmacology, any more than the personalized medicine aficionados see themselves as ushering in an ending, but that’s the way it seems to be playing out.

As we learned from the Model A Ford, you can only soup up a car so much – then it’s time to move on. After a decade of glory competing for who had the most SSRI-ish SSRI and it dawned on us that their potency was disappointing, the move to soup them up began in earnest. There was Augmentation [Lithium, Thyroid, Atypical Antipsychotics, other SSRIs, SNRIs]. That was followed by Sequencing [STAR*D – something of a bust by my reading]. Recently there’s been Doubling-Up [CO-MED, coming soon to a journal near you]. The next thing on the agenda is personalized medicine, exemplified by iSPOT [it strikes me as similar to the word "customizing" as it was used in the world of 1950 "hot-rods"]. As we were told at the American Psychiatric Association meetings last May:
    This is where the future of psychiatry is going. The task before us is very large because each of these subtypes of depression is biologically distinct and will have different predictors of treatment response. But there is no doubt that what we will be able to do is end this interminable trial-and-error method that all of us are stuck with treating depressed patients.[link]
It’s interesting to speculate why the Pharmaceutical Industry is throwing money at the personalized medicine companies like Brain Resources and PsychoGenics. On the face of it, personalized medicine offers to be a lucrative money-maker for the companies themselves involved in the screening/testing business, but even if it refines antidepressant use, the antidepressants are still the same – soon to be generics if not already. The answer seems to be in the possibility of new drug discovery – a promise from both Brain Resources and PsychoGenics.

I’m writing this as a prequel to an epilogue because that’s where I think we are today. It’s certainly not an end for either neuroscience or psychopharmacology. Those are established basic sciences in medicine that will proceed at whatever pace their scientific creativity supports. But I think we may be approaching the end of the era where bold promises of future glory substitute for current reality, and the financial health of the pharmaceutical industry is any of our business. Oh, I’m not naive. They’ll keep throwing money at KOLs and their boys from the wonder years [many of whom are graying and balding former fairhaired boys]. But I think the days of bullshit science, psychiatrist detail-men, and ghostwritten articles won’t go so well in the coming several years. Science and experience don’t support their hopes for personalized medicine and their credibility quotient has maxed out. The antidepressants have been terminally souped up and are unlikely to yield to any of the genetic tweaking they envision. They seem to have run out of neurotransmitters to turn up and down. Depression is just bigger than drugs. Maybe they’ll find something useful, but this time, it’ll have to work, rather than be just new, novel, promising, or emerging.

Where will Psychiatry be after the Age of Emerging-New-Psycho-Neuro-Pharmacology? In Tom Insel’s Psychiatry as a Clinical Neuroscience Discipline, he has a few sensible things to say, but his fundamental point seems far from the mark. A medical specialty is defined by the people it serves, not by a body organ [brain] or a methodology [neuroscience or, for that matter, psychoanalysis]. No one has a bit of trouble defining the psychiatric patients. The problem these days is defining the psychiatrists who treat them. And we can’t count on our current thought leaders to know that their Age is on the wane any more than those old kings we read about in World History. They’re too much a part of the drama. One would hope that the coming Age [which Insel called the Decade of Translation] is really one where we rediscover who we are and who we work for – that other kind of personalized medicine…

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