I searched the APA Program .pdf for "conflict of interest," "ghost writing," "scientific advisory board," "speakers bureau," etc. but got no hits. I guess those topics aren’t on the radar. I found all of the breakthrough freaks on the program except John Rush. Jeffrey Lieberman is presenting the OMH SHAPEMEDs checklist from NY State. It’s some checklist they want everyone to go through before prescribing antipsychotics. That’s called Type II Translation Science – getting doctors to all use the newest algorithms, kind of like Trivedi’s TMAP computer programs for depression.
with Jeffrey A. Lieberman, MD, Director, NYS Psychiatric Institute
Let’s face it. Medical care has become a whole lot more complex. The scientific knowledge base and practice of medicine has expanded exponentially as scientists have plumbed the human body and mind to reveal its genetic, molecular, anatomic, physiological and psychological mysteries and developed ever-more sophisticated means to diagnose disease, treat patients and prolong life. Although this acceleration in progress holds great benefits for an individual’s health, it poses a daunting challenge to physicians trying to keep up with the latest findings and developments. Who can provide state of the art care and deliver complex treatments to numerous patients day after day without error? No one. It is simply not humanly possible to be error free…
They think we won’t use their checklist because we’re arrogant, or busy, that it’s something about us. It doesn’t occur to them that we don’t trust what they say…
Back to the APA program: I was looking at all the things on the DSM-V at the APA. What I realized was that there was something specific I was looking for. I’ve been looking since the other day when I was reading about at the neoKraepelinians:
1. Psychiatry is a branch of medicine.
2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.
3. Psychiatry treats people who are sick and who require treatment.
4. There is a boundary between the normal and the sick.
5. There are discrete mental illnesses. They are not myths, and there are many of them.
6. The focus of psychiatric physicians should be on the biological aspects of illness.
7. There should be an explicit and intentional concern with diagnosis and classification.
8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.
9. Statistical techniques should be used to improve reliability and validity.
I was struck by numbers 8. and 9. Were I doing and redoing diagnostic criteria, I would be interested in doing a detailed statistical analysis of how the criteria selected by the committee panned out in practice. Did the various criteria cluster as predicted? Were there other clusterings that offered a more precise category. They may be doing that, but if they are, I can’t find it. I know they do field trials, but I think what they’re studying is reliability – not patterning.
I had the fantasy of some mega-questionnaire that had questions about history, family history, and symptoms galore that every subject in any clinical trial on depression or any affective disorder filled out – something that one could do factor analysis on. They are doing these huge-studies for personalized medicine taking all kinds of tests to look for biomarkers, but the APA could do it for symptoms and history and let a statistician come up with diagnostic categories – after all, the DSM claims to be "descriptive." Traditionally in medicine, a careful detailed history is the biggest biomarker of them all. Maybe if we could actually see some data, we’d believe what they say instead of seeing it as the arbitrary opinions of a bunch of psychiatrists with some kind of stake in the model.
If we did that, I’d predict that Melancholia would break out as a discrete syndrome, and that most of the rest of the subjects would split between what we used to call neurotic depression and people with personality disorders who were chronically misanthropic. And I’d be stunned if the current Bipolar diagnoses stood up to the test. In thirty years, I’ve never seen people who fit in some of those categories [maybe they all live in the Midwest and we Southerners don’t catch that kind of Bipolar-ness]. So I go for "…and a legitimate and valued area of research should be to validate them. Statistical techniques should be used to improve reliability and validity."
I used to wonder if my frustration with the APA and the DSM is justified or an expression of the things that happened in my own life in those years. I don’t much think about that distinction any more, because I can’t make the patients I see fit the DSM classification, even in a charity clinic in rural Georgia. The most self-effacing assessment I can come up with is that "my frustration with the APA and the DSMs is justified and also an expression of the things that happened in my own life in those years." And this morning, I realized that I was trying to find some evidence in that APA program that they’re trying to be as scientific about all of this as they’ve always claimed to be. It’s not there. Just like those things I was searching for like "conflict of interest" and "speaker bureaus" aren’t there…
http://www.medpagetoday.com/MeetingCoverage/APA/26544
This one is precious…patterned after STAR*D; lithium no longer a mood stabilizer…
Look at the conflicts of interest in this government study…..
The APA is very much like the DSM…both have psychobabbled their way into absurdity/obscurity, and need to go the way of the dinosaurs into extinction.
APA Li no help for bipolar :the photo from the presentation http://ping.fm/p/RIaHn read to bottom for COI$$ http://www.medpagetoday.com/MeetingCoverage/APA/26544
I want to let you know how much I appreciate your blog. I have been recommending it to all of my colleagues. You are crystallizing what has been a cranky dissatisfaction for me into something I can more clearly articulate.
For any diehards out there who believe that Li is a “mood stabilizer” – I suggest you read Moncrieff’s book, “The Myth of the Chemical Cure” (chapters 11 and 12).
I’m coming at this from the patient (family) point of view — my son has recurring major depression and maybe had some mania at onset eight years ago but none since. His meds have been tweaked many times, he’s had lots of adverse effects, and we’re all eight years older, but we plow on, trying to stay optimistic.
It is very dispiriting to see all the factions in psychiatry at such odds with each other. The egos, the money, the fudging of trials, while the patients are given short shrift.
I’ve been looking through medical journals in an attempt to help my son and now I don’t know if I can trust what’s in them. For example, I’ve read several times that lithium can stabilize mood (I don’t want to call it a mood stabilizer) but mostly in people with mania, or with bipolar that follows a Mdi course. If you have a Dmi course, lithium doesn’t help much. Now, I’m thinking, “Is that b.s.?” Is this or that author trying to sell something else?
How is a layperson supposed to see what’s reliable and what’s not, and make informed decisions about his or her own health?
These are rhetorical questions, btw.
Your excellent review of the major depression issue is great. Another example of what you term as the “acausal†influence of neo-Kraepelin dogma can be found in the proposed DSM-V definition of conversion disorder. Actually, it is no longer called “conversion disorder.†Why we have the much more scientific label of “functional neurological disorder.†Gotta love that science! Even in the Spitzer/Frances world of DSM, a criterion of diagnosis was “Psychological factors are judged to be associated with the symptom or deficit because the initiation or exacerbation of the symptom or deficit is preceded by conflicts or other stressors.†In other words, psychology trumps biology in this disorder. It’s kind of a Freudian idea. A nasty idea at that, as the Kupfer-led DSM-V task force would have us believe. Why, we must bury psychology and psychoanalysis in the grave it deserves! Freud is indeed dead. But we must rid ourselves, in our scientific psychiatry, of any remnant of psychogenic causation or, heavens help us, FREUD!!!
So in the proposed DSM-V criteria for “functional neurological disorder†the following is proffered: Psychological stressors or personally meaningful life
events may often be associated with onset of symptoms, but their identification is not
necessary for the diagnosis. Of course not.
To the DSM-V committee: Are you freaking kidding me? The only way you are going to help people afflicted with “functional neurological disorder†is to specify what psychogenic cause or causes is or are in play. Okay maybe you don’t have to “know†the cause at the time of diagnosis; but you certainly need to know it if you are going to alleviate the suffering occasioned by this disorder! I am sorry but this is just another example of the “dumbing down†of psychiatry in our “acausal†and “neo-Kraepelin†age.