It’s hard not to be skeptical about new scientific developments in matters psychiatric after the last several decades of confusion and misinformation. SSRIs, SNRIs, Mood Stabilizers, Atypical Antipsychotics – each came with inflated or distorted claims of efficacy and illusions of safety that evaporated with widespread usage. While that’s an expected danger in any medical advance, the widespread collusion of academic and organized psychiatry with the pharmaceutical industry upset the balance between restraint and innovation, leaving patients and practitioners alike fumbling in the dark on a what started out to be a bright, shiny day.
Personalized medicine is a medical model emphasizing in general the customization of healthcare, with all decisions and practices being tailored to individual patients in whatever ways possible. Recently, this has mainly involved the systematic use of genetic or other information about an individual patient to select or optimize that patient’s preventative and therapeutic care.
Many drugs may increase or decrease the activity of various CYP isozymes either by inducing the biosynthesis of an isozyme (enzyme induction) or by directly inhibiting the activity of the CYP (enzyme inhibition). This is a major source of adverse drug interactions, since changes in CYP enzyme activity may affect the metabolism and clearance of various drugs. For example, if one drug inhibits the CYP-mediated metabolism of another drug, the second drug may accumulate within the body to toxic levels. Hence, these drug interactions may necessitate dosage adjustments or choosing drugs that do not interact with the CYP system. Such drug interactions are especially important to take into account when using drugs of vital importance to the patient, drugs with important side-effects and drugs with small therapeutic windows, but any drug may be subject to an altered plasma concentration due to altered drug metabolism.
Matters genetic are not so simple as they were in high school biology. Genes encode proteins – which about covers everything there is, so the breakthrough of sequencing the Human Genome only opens a new door but says little about what’s on the other side. The possibilities are both exciting and daunting – so genomics, proteomics, and metabolomics are quite the rage but remain obscure. In psychiatry, the focus is on using genotyping to predict drug response. Such a hypothesis requires skipping an ocean of scientific steps, but that never stopped anyone. There are two approaches – one is to look at genes that might have some effect on known mechanisms of a medication [like serotonin metabolism] and compare the genotypes of responders to various drugs. Another approach is to measure as many things as humanly possible and look for any associations with drug response – going "fishing." Both methods are underway in multiple foci as we speak.
Something else familiar? It’s the Clinical Trial Model so typical for the last few decades. Out go the protocols. Clinical evaluators select patients with structured interviews or standardized ratings. Off go the samples to the outside lab. Meds are given. Data is gathered. Results are returned. The current buzz-word is Translational Science – getting things from the bench to the bedside quickly. Well whose bench? What bedside? Perhaps a better definition would be Translational Science – from the printouts to the journal [or to the editorial assistant]. It’s ‘hands off’ ‘guest author’ research and it shows in the monotony of the papers and their obfuscated statistics and graphs.
So my skepticism about personalized medicine in psychiatry is justified by the players involved and their collective track record. But there’s more. The focus is on Major Depressive Disorder, a clearly heterogeneous group of patients. They’re testing drugs that barely separate from placebo in the first place and using subject gathering techniques known to insure heterogeneity. And in some cases, the experiment has already been done and failed. For example. In STAR*D they used Citalopram followed with Bupropion with diminishing returns. In CO-MED they compared Escitalopram with and without Bupropion – no difference. What would make Dr. Trivedi think responders are two different populations? Beats me! Those are the drugs he’s picked for his NIMH STUDY.
Even more worrisome than the academic studies, the proprietary versions will produce reports with associations – no question about it. For example, genOmind compares your phenotype against 18 antidepressants and 8 antipsychotics and makes suggestions based on a traffic light motif – red light, yellow light, green light [how they make those distinctions wasn’t on the podcast]. Independent of the science, it offers a fine antidote to the growing complaints about poor efficacy for the antidepressants, "you must’ve on the wrong one for your phenotype."
OK I just conceptualized what psychiatry is these days. Basically, the process of new research (whether it be personalized medicine, translational science, or the psych med developments of the last 25 years) migrating to the average psych patient is akin to one big corrupt digestive tract.
The “science” (such as it is) passes through the corrupt esophagus (the original researchers of studies that rig the studies and have COIs and corrupt psychiatrists at APA and NIMH who steer “science” to fit their agendas), travels down to the stomach (the FDA, which has largely been a victim of regulatory capture by pharma), then through the colon (ghostwritten and corrupt articles appearing in major medical journals), and then passed through the rectum of your local psychiatrist’s office.
The result? A steaming turd for the patient.
But my oh my, how STUPENDOUS psychiatry is at polishing turds!
Mickey, thank you for your excellent posting. SG, thank you for starting my day with a chuckle. More than a smile. A real chuckle.
Actually, your earlier writing from two years ago, last year on politics has gone full-circle… back to political writing.
And it’s understandable.
Because to conduct an honest and thorough study of conventional psychiatry… to become cognizant of the falsified research and the perpetuation of a myth to sell drugs and to keep a medical profession alive, is to study politics.
Conventional psychiatry is not based on medical science.
It’s based on political science.
I appreciate the National Debt Counter on the top of your blog.
Here’s another one, that breaks down the spending by category/programs-
http://www.usdebtclock.org/
When you look at the spending in the areas of Medicaid, Medicare and Social Security; and consider the disability that’s been caused by placing psychiatric labels on people, drugging their bodies, minds and spirits into oblivion; the federal tax money spent on the fraudulent research; it becomes obvious that conventional psychiatry has done an enormous amount of damage – to our youth, elderly, military service members… and treasury as well.
Conventional psychiatry.
50 years of a failed psycho-pharmacological approach.
A millennium of damage to a nation and its people.
Duane Sherry, M.S.