the first Lemming…

Posted on Sunday 22 April 2012

Having noticed last night that Dr. Tom Insel, Director of the NIMH, had reproduced last year’s post-APA blog post this year a couple of weeks before the APA Meeting, I went to bed. This morning, I had a spontaneous wakening thought. What the hell is the NIMH Director doing, pontificating about the direction of Psychiatry as a specialty? Is that in his job description? He does that kind of thing so often that I guess we’re used to it, but is that really kosher, directing the show? Is that what Director of the National Institute of Mental Health" means? that he chooses our direction?

The Clinical Neuroscience thing seemed to start with his publication [above] in the JAMA [also as a Director’s Blog]. And when he was apparently called to task, he published his resolution of the argument as a blog post:

NIMH, like all Institutes at NIH, has an advisory council that meets three times each year. The National Advisory Mental Health Council (NAMHC) is a distinguished group of scientists, advocates, clinicians, and policy experts. Each of our meetings includes a closed session to review individual grants considered for funding and a session open to the public that engages this diverse group in discussions about the larger issues that guide NIMH funding. At last week’s session, we heard a recurrent tension around one such larger issue. Some members of Council bear witness to the poor quality of care, the unmet medical need, and the diminishing investments by states on behalf of people with mental disorders. They reasonably ask, “How are we ensuring that the science that NIMH has produced is implemented where the need is greatest?”…
His conclusion was clear:
Let us hope we don’t short-change our grandchildren, sixty years from today, by failing to invest in the long-term promise of more effective diagnostics and therapeutics for mental disorders.
I’m not mounting an argument against neuroscience here. I think, instead, I’m realizing why Tom Insel grates on my nerves every time he opens his mouth. He has a fixed idea about Psychiatry, Research, and how things are supposed to go – and that set of ideas drives everything he says and does. The two blog posts on top are supposed to be addressing the problem that US medical students aren’t choosing Psychiatry as a specialty and programs are filling with Foreign Medical Graduates [if they can]. In the first article [last year], he points out:
    Traditionally, psychiatry has been the medical discipline that cultivates a rich relationship with patients, countering suffering with empathy and understanding. But a recent article in the New York Times reported that only 11% of psychiatrists perform psychotherapy and described a psychiatrist who ran his office “like a bus station,” seeing so many patients for 5 -10 minute medication checks that he had to train himself not to listen to his patient’s problems.
… that psychiatrists are now seen as pill pushers who have no involvement with their patients. His solution?
    NIMH has been running an annual “Brain Camp” for select psychiatry residents to give them a crash course in the most recent findings from cognitive science, neuroscience, and genetics. The residents we see at Brain Camp bring new perspectives.
… the MD/PhD group that came to his NIMH Brain Camp. In the second article [this week], Psychiatry as a specialty choice continues to decline. His solution?
    This year, 11 of the 17 psychiatric residents at Brain Camp were MD-PhDs. Many had been neuroscience majors in college, had published high impact papers in medical school, and were continuing to do research during their clinical training. Prior to residency, all 17 were medical students who had been at the top of their class and could have gone into any specialty…

    This year Brain Camp was largely focused on neuromodulation—using cognitive training and repetitive transcranial magnetic stimulation (rTMS) — to alter symptoms of depression and anxiety by modulating specific brain circuits. For this new generation, psychiatry already is clinical neuroscience. So maybe there is an identity crisis for psychiatry in the U.S. as well as the U.K. But the U.S. version seems filled with hope and excitement, with many of the best and brightest now deciding that they can bring new approaches to help people challenged by mental illness…

… it’s Brain Camp again [all six of the ones who might practice]. That’s his solution [and I hope the six are independently wealthy, because they’re only going to be paid "for 5 -10 minute medication checks"]. And I doubt that "using cognitive training and repetitive transcranial magnetic stimulation (rTMS) — to alter symptoms of depression and anxiety by modulating specific brain circuits" is going to make much of a dent in what psychiatrists do and how they are seen in the real world. Leadership means something more than being the first Lemming in a stampede…
    April 22, 2012 | 4:08 PM

    There’s all of that plus he is not the director of the National Institute of Psychiatry but of Mental Health. His direction for psychiatry is certainly problematic but he seems to forget the psychologists and other clinicians who are part of mental health organizations and treatment.

    My graduate education in clinical psych was funded by NIMH but of cours that was back before the revolution.

    April 22, 2012 | 4:14 PM

    Excellent point, among many more!…

    April 22, 2012 | 4:21 PM

    Thank you!!! I am much more blunt, and not as polite as you are. I’ve said it before, and I’m saying it again: Insel does not appear to be academically qualified, and he certainly does not have the ethical integrity required to be a doctor; let alone to be the Director of National Institutes of Mental Health.

    April 22, 2012 | 5:27 PM

    Thought this might cheer you up.

    An article by Tom Bartlett “Is Psychology About to Come Undone?”

    with a link to “the reproducibility project”.

    Do normative scientific practices and incentive structures produce a biased body of research evidence? The Reproducibility Project is the first known empirical effort to estimate the reproducibility of a sample of studies from the scientific literature. The project is a large-scale, open collaboration involving dozens of scientists from around the world. The investigation is currently sampling from the 2008 issues of three prominent psychology journals – Journal of Personality and Social Psychology, Psychological Science, and Journal of Experimental Psychology: Learning, Memory, and Cognition. Individuals or teams of scientists follow a structured protocol for designing and conducting a close, high-powered replication of a key effect from the selected articles. The project will evaluate the ability to reproduce the original study procedures and the overall probability of replicating the original results. Further, it will examine the predictors of replication success – e.g., publishing journal, number of conceptual/direct replications in the published literature, citation impact of the original article, closeness of the replication to the original circumstances: sample, setting, materials. Interested contributors can still join the project.

    Perhaps, the greatest gift young scientists have to offer any medical field is a respect for research to be open-source material.

    Joel Hassman, MD
    April 23, 2012 | 12:58 PM

    let all these people who want to embrace mental health as just a biochemical imbalance just go to PCPs/NPs/other non mental health care providers and just load up on pills, and then find out later how stupid the choice was. What I don’t get is why my colleagues take these cases from non psychiatric providers who just screw up the patient further and then literally dump this on our laps to “fix”.

    Yeah, thanks for the 6mg a day of Xanax, or 120mg of Cymbalta, here’s a favorite, 40mg XR Adderal a day as a STARTING dose, that these patients come in complaining are not helping. Sheesh, how do you help people who don’t want to accept the standards of care?

    If I had a nickel for every dazed glance or quick refute when I bring up psychotherapy as an intervention, I’d have a nice meal in front of me right now. As long as the field allows the like of Insels to be setting the pace of care, enjoying the fall off the cliff!?

    April 23, 2012 | 5:31 PM

    If I had a nickel for every dazed glance or quick refute when I bring up psychotherapy (since the nineties) I could afford maybe ten minutes of psychotherapy.

    I have managed to see a psychologist who was only interested in cognitive therapy and a psychologist who had the fixed expression that is called “the Prozac Mask” who looked at her nails the entire time I talked.

    My favorite psychiatrist works in the private sector now and charges $260 a fifty minute session. I’m sure he spends more time than that working for his clients but that doesn’t make it any more affordable for me.

    I have an appointment with a psychiatric nurse at the V.A. this week, and if it’s more than a fifteen minute med prescribing session, I’ll be pleasantly surprised.

    In the eighties I gained a lot through individual and group therapy. By the early nineties, the prescribing age was fully upon us, so I’ve long felt that I need psychotherapy to deal with the effects of psychiatry and its minions.

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