Psychiatric Diagnosis in the Lab: How Far Off Are We?
Medscape News
by Jeffrey A. Lieberman, MD
09/28/2011
…we anticipated that this iteration of the DSM would incorporate biological markers and laboratory-based test results to augment the historical and phenomenologic criteria that traditionally are used to establish psychiatric diagnoses. Sadly, this has proved to be beyond the reach of the current level of evidence…
In recent years, however, we have seen the emergence and refinement of a number of different technologies that I predict will, within our professional lifetimes and hopefully within the next 5 years, lead to the incorporation of laboratory-based tests for psychiatric diagnosis. When these will be proved to a satisfactory level of evidence and when they will be reimbursable by third-party payers, we can’t know specifically, but I predict this will happen fairly soon. We are seeing the evidence of that even now.
The tests that appear to be emerging as the first to be marketed are ones that are based on the proteomic or metabolomic or biochemical analyses of plasma or cerebrospinal fluid. A series of different types of microarray panels have been developed that examine the profile of a series of analytes in plasma, serum, or cerebrospinal fluid… Several companies have developed data, applied for approval from the US Food and Drug Administration, and are beginning to market these tests. …they are not paid for by third-party reimbursement agencies or organizations. Nevertheless, this is the cusp of the implementation of this method of diagnosis: proteomic, metabolomic-based analytes that yield a certain diagnostic signature.A second modality that is likely to be implemented for psychiatric diagnosis is that of imaging techniques; here we’re talking about both nuclear medicine imaging with PET and MR imaging with either structural, spectroscopic, or functional imaging applications… They yield clear differences between, diagnostic groups such as schizophrenia or depression on one hand and healthy volunteer controls or nonaffected individuals on the other. The problem is that the distributions of the values of the control vs patient groups still have too much overlap and are not sufficiently differentiated as to provide high enough positive predictive value at the individual patient or subject level. But I predict that it won’t be too long before these are refined, the results will become more robust, and these will contribute to a profile or augment the information that clinicians have to establish their diagnosis.
Finally, genetic testing will also come into play. As you probably know, commercial companies already are marketing DNA testing. They provide a "readout" of your genotypes for all of the known coded human genes along with associations with specific diseases in the different organ systems that these correspond to, to the best level of evidence that currently exists. …there is no reason psychiatry cannot begin to use these as other fields of medicine have done. Because all mental disorders will almost certainly prove to be polygenic or multigenic, we will need a gene profile to utilize in terms of diagnostic information…
Dr. Lieberman wants his title, How Far Off Are We?, to be taken to mean "how much longer before we have the dreamed of Psychiatric Diagnosis in the Lab?" But I’m taking the title’s question to mean "how far off the mark is Dr. Lieberman in this presentation?" He’s way off the mark. He speaks as if he’s the C.E.O. of a company, Psychiatry Inc, that’s failed to make its yearly corporate sales goals, and he needs to shore up the confidence of the stockholders by introducing a new five year plan. He’s actually not the C.E.O. of Psychiatry Inc, he’s the Chairman of a Department of Psychiatry at a University.
To my mind, the "We" in "How Far Off Are We?" is the cohort of interest in this piece. It contains a particular sub-set of biological psychiatrists who rose to prominence with the coming of the DSM-III and increasingly occupied leadership positions in academic and organized psychiatry. As a group, they presided over an era of merger/alliance with the pharmaceutical industry, and shepherded the generation of medication oriented psychiatry that predominates today. While research has been their watchword, much of it involves clinical drug trials, often performed by commercial Clinical Research Organizations and financed by the pharmaceutical industry, dripping with marketing-oriented bias. Dr. Lieberman’s presentation smacks of the same kind of dependence on the companies measuring "proteomic, metabolomic-based analytes," "structural, spectroscopic, or functional imaging," and "genotypes for all of the known coded human genes." He’s as much as adding the medical testing and imaging industries to the "We" consortium, and awaiting delivery. Sound familiar? It appears that Psychiatry Inc is looking to diversify.
But look how well a 5-year-plan has served other chronic disease servicers. Not only does it spur the industry, but allows all the adjuncts (the charitable advocates, the add-on marketers) to blossom into full-fledged businesses themselves.
For 55 years, my diabetic husband has been told a cure is just around the corner OR only five years away. We have seen ADA and JDRF grow into multi-million dollar businesses themselves . . . and all the niche companies grow from cottage industries to flourishing businesses. Marketers find creative ways to get their little piece of the pie while distracting patients. No longer do we demand cure research leading to a cure; instead we settle for color-coordinated bG meters that are ‘faster’ and ‘less painful’ and bang the drums when a new analog supplants the last ‘latest-greatest’ insulin substitute.
In his recent rant, Professor Ian Hickie praised Tom Insel for supporting the reforms advocated by himself and Professor Pat McGorry.
By the way, I just noticed that Dr. Lieberman is the Vice President North America of McGorry’s International Early Psychosis Association. I should’ve realised these men were all connected as I could have been forgiven for thinking you were writing about Hickie & McGorry rather than Insel & Lieberman.
You know, I was about to write a lengthy response to this excellent post, but I’d like to instead just draw a parallel between Insel, Lieberman, McGorry et al’s propaganda and the AIDS vaccine propaganda of the 80s.
Below is a passage from the avert.org page on AIDS history. Pay careful attention to the quotes (especially the last one!) — they are eerily similar to what Insel and his buds are saying about mental illness and the future of psychiatry. In fact, if you substitute “laboratory tests for mental illness” for “AIDS vaccine” they are both essentially saying the same thing! And even within roughly the same time-frame (2 years for the development of an AIDS vaccine, 5 years for development of laboratory tests for mental illness)!
—————————–
On April 23rd, 1984, the United States Health and Human Services Secretary Margaret Heckler announced that Dr. Robert Gallo of the National Cancer Institute had isolated the virus which caused AIDS, that it was named HTLV-III, and that there would soon be a commercially available test able to detect the virus with “essentially 100 percent certainty”. It was a dramatic and optimistic announcement that also included:
“We hope to have a vaccine [against AIDS] ready for testing in about two years.”
And it concluded with:
“yet another terrible disease is about to yield to patience, persistence and outright genius”.
Thanks SG. Real scientists don’t make that kind of prediction. The scientific method won’t allow it…
John,
They all seem to be part of the same thing, don’t they? I wonder if they vacation together…
And let’s not forget that Jeffrey Lieberman was a co-author of the now infamous letter in Wall Street Journal September 19, 2006 defending Charles Nemeroff in the scandal that resulted in Nemeroff’s resignation as editor of Neuropsychopharmacology. So much for Dr. Lieberman’s good judgment.
Lest we forget…
Letters to the Editor
Needless Furor Harms Outstanding Psychiatrist
The furor arising from your article about the absence of a potential conflict of information statement in a scientific paper on vagal nerve stimulation therapy for depression ("Medical Journal Editor Nemeroff Steps Down Over Undisclosed Ties," Aug. 28) has potentially harmed the fields of medicine and psychiatry.
Dr. Nemeroff was the lead author of the article in question, and all of the required individual conflicts were submitted to the journal, of which he was the editor, but they weren’t included due to a regrettable oversight at the level of administrative publication. Thus, the concern about this is much overdone, as Dr. Nemeroff has reported his collaboration with the maker of vagal nerve stimulators in numerous other publications, as well as public and academic presentations. Dr. Nemeroff’s decision not to pursue another appointment as editor of Neuropsychopharmacology is highly unfortunate, as this journal is more focused on the biological mechanisms of psychiatric diseases and their treatments than any other, and Dr. Nemeroff is extremely well-qualified to lead it.
Due to Dr. Nemeroff’s extremely productive and successful career as a leader in academic psychiatry, he and others like him are asked to be on the boards of many pharmaceutical firms specializing in central nervous system agents. Through such collaborations, the development and testing of novel treatments are greatly enhanced and the safety of research subjects strengthened. Yes, these companies must make profits, but they also share with researchers a desire to find scientific truth, which usually isn’t as clear-cut as many believe. The overwhelming majority of academic researchers are proud of their independence and are dedicated to advancing their fields through quality research. At a time of diminishing funding, does it not make sense for industry-sponsored support to provide a viable alternative, especially if available in a no-strings-attached way with sufficient academic research oversight?
We are academic psychiatrists and researchers who are colleagues of Charles Nemeroff, and we have the utmost respect for his science and ethics. Some of us receive research support from pharmaceutical companies, some from federal agencies, some from both and some from neither. All of us want the best for the fields of science, medicine and psychiatry in their endeavors to better humanity.
Kerry Ressler, MD, PhD
Peter Ash, MD
Elisabeth Binder, MD, PhD
Rebekah Bradley, PhD
Douglas Bremner, MD
Frank Brown, MD
Michael Burke, MD
Linda L. Carpenter, M.D
Linda Craighead, PhD
Shannon Croft, MD
Miles Crowder, MD
Joseph Cubells, MD, PhD
Michael Davis, PhD
Marina Demetrashvili, MD
Arden Dingle, MD
Barbara D’Orio, MD, MPA
Karen Drexler, MD
Erica Duncan, MD
Scott Firestone, MD
C. Frederick Gillespie, MD, PhD
Robert N. Golden, M.D.
Christine Heim, PhD
Martin B. Keller, M.D.
Clinton D. Kilts, PhD
Becky Kinkead
Jeffrey A. Lieberman, M.D.
Andrew Miller, MD
E. Chris Muly, MD, PhD
D. Jeffrey Newport, MD, M.Div
Opal Ousley, PhD
Michael Owens, PhD
Giuseppe Pagnoni, PhD
Donald Rainnie, PhD
Charles Raison, M.D.
Barbara Rothbaum, PhD
Mar Sanchez, MD
Thomas Schlaepfer, MD
Ann Schwartz, MD
Michael E. Thase, M.D
Larry Tune, MD
B. Vidanagama, MD
Larry Young, PhD
Jay Weiss, PhD
All not in red were Emory junior faculty
Remember: The former USSR was big on 5 year plans for their planned economy. And we all know what happened to the USSR!
Two days later, Robert Rubin and I, who first called out Dr. Nemeroff’s nondisclosure, responded as follows in WSJ.
As of 11:06 p.m. EDT Thursday, September 21, 2006
LETTERS
An Insufferable Smear Of Our Staff Officers
The Sept. 19 Letter to the Editor defending an academic physician who failed to disclose his financial ties (“Needless Furor Harms Outstanding Psychiatrist”) is naïve and misguided. Particularly offensive is the allegation that staff members of the American College of Neuropsychopharmacology were responsible for the nondisclosure “due to a regrettable oversight at the level of administrative publication.” To the contrary, the ACNP policy on disclosure explicitly requires that information on financial conflict of interest be included in the acknowledgements section of the manuscript at the time of submission. As lead author, Dr. Charles Nemeroff was required to conform to that policy. As editor in chief of the journal, he can’t claim ignorance of the policy that he was being paid to enforce. To now have his supporters issue such a smear on ACNP’s administration of the journal is insufferable. The responsibility was Dr. Nemeroff’s and his alone.
Dr. Bernard Carroll
Pacific Behavioral Research Foundation
Carmel, Calif.
Dr. Robert T. Rubin
Vice Chair
Department of Psychiatry and Biobehavioral Sciences
University of California at Los Angeles
Chief, Psychiatry and Mental Health
Veterans Affairs Greater Los Angeles Healthcare System
Los Angeles
(Drs. Carroll and Rubin are Fellows of the American College of Neuropsychopharmacology.)