1 Boring Old Man

That’s enough about my personal evolution – except to say that my academic snobbery was humbled by clinical medicine, but I’m afraid that instead of it disappearing altogether, I became something of a clinician snob. That’s one of the reasons I get so worked up about the DSM-5 Revision and a lot of other things about the current state of the specialty of psychiatry. For literally decades, the focus has been on the future – what’s in the pipeline, what’s coming soon, new directions in this or that, recent advances in this or that, novel approaches. The present is a collage of inadequacies and the future is either a glowing star or threatened, and in need of a booster shot. Psychiatry sometimes only seems to exist in the future.

• The bright shiny objects in the future, just over the horizon
• Terror that the hope of the future is all but lost
• A gloomy present – highlighting the desperate need for a future

Translating Discoveries into Medicine: Psychiatric Drug Development in 2011
^{by Linda S. Brady and Thomas R Insel}
Neuropsychopharmacology Reviews 2012 37(1):281–283.

^{Most of the blockbuster psychiatric medications have either become or will soon become available as generic drugs. Although this is oft-cited as a challenge for further development, what is less recognized is the failure of the current medications to reduce the prevalence or disability of any of the major mental disorders. Although current antidepressants and antipsychotics have been beneficial to industry, the extent of benefit for patients is less consistent, with too many patients left to settle for less than recovery from these highly disabling disorders…}

^{The need for a next generation of medications was emphasized by the large scale practical trials like CATIE, STAR*D, and STEP-BD, each of which revealed very modest effects with optimized use of the current generation of medications [Insel, 2007]…}

After decades of psychiatric future·think, one might think that the time has come for a re-evaluation of where we are rather than a call to hurl ourselves into the future again looking for shiny objects. This has been an age of unparalleled misinformation in psychiatry, driven more by financial and ideological forces than scientific clarity. It would seem to me that this is a time for questions like: Why doesn’t our current nosology help us select the patients that do respond to medications? Are there patients who specifically do not respond to medications? How can they be identified? What do they need instead? Are the medications themselves different in efficacy, or are the differences primarily in side effects? In which cases is there solid evidence of a biological substrate to the mental illness? In which cases is symptomatic depression instead a reflection of life, past or present? What about Robert Whitaker’s idea of intermittent rather than continuous treatment of psychosis? Is the widespread use of medications really ‘cost effective’? Does the notion of translational research get treatments from the bench to the bedside? or does it stifle creative research by insisting on focus? Is Tom Insel’s cheerleading for what we "need" driven by what mentally ill people need, or is it driven by the research/pharmaceutical/clinical trial industries being ‘too big to fail’? Is the managed care intrusion into psychiatric practice rational or an attempt to move treatment to primary care as a cost-cutter?

Well that just flowed out of nowhere [I had to stop myself before I ran out of blog]. I suppose I could have simply said that it’s a time for reflection. Tom Insel is not, and has never been, a clinician. Neither are many most of the people on the DSM-5 Task Force. They don’t sit in rooms and talk to people with mental illness. They sit in other rooms, and it shows. Clinical psychiatrists are not the interface between patients and the National Institute of Mental Health or the DSM-5 Task Force or the American Psychiatric Association or the Pharmaceutical Industry or the Managed Care Companies. It’s the other way around. The National Institute of Mental Health, the DSM-5 Task Force, the American Psychiatric Association, the Pharmaceutical Industry, and the Managed Care Companies are supposed to be resources for the dyad of psychiatrist and patient who are directly dealing with the patient’s mental illness. I currently experience none of them as resources. At present, each of those entities sees itself in charge of the conduct of psychiatric care, something no one of them actually knows how to do. The biases of Managed Care and the Pharmaceutical Industry are givens, but the NIMH? the APA? the DSM-5? Who are they working for?

Dr. Insel, how about attending to giving us a long overdue accurate assessment of what we already have before racing off to look for another pot of gold. Drs. Kupfer and Regier, how about giving us a revision of the DSM-5 that makes it useful to me when I’m seeing a patient [a depressed patient specifically], instead of to some non-clinician who is on a committee or some drug company looking for the broadest audience for a drug. And Dr. Oldham [APA-President], how about initiating an assessment of the last twenty five years of psychiatry that includes TMAP, the over-medication of Foster Kids, Biedermania [Childhood Bipolar Disorder], Study 329, ghost-writing, Speaker’s Bureaus, the conflict-of-interest epidemic, the Grassley list, off-label recommendations, etc. etc. – a state of the specialty that includes a frank look at some of the most corrupt practices in the history of medicine.