a clinic·ian…

Posted on Monday 19 November 2012

"Giovanni Fava has written perceptively about self-interested power elites within academic psychiatry…" Bernard Carroll

Dr. Carroll’s comments are always welcomed, but his response to the last post contains a reference to an article by Dr. Giovanni Fava that puts words to a music I haven’t heard in a while. Here’s the abstract, but the full text is available online:
Clinical judgment in psychiatry. Requiem or reveille?
by Fava GA
Nordic Journal of Psychiatry. 2012 July 23. [Epub ahead of print].
[full text on-line]

Background: There is increasing awareness of a crisis in psychiatric research and practice. Psychopathology and clinical judgment are often discarded as non-scientific and obsolete methods. Yet, in their everyday practice, psychiatrists use observation, description and classification, test explanatory hypotheses, and formulate clinical decisions.
Aim: The aim of this review was to examine the clinical judgment in psychiatry, with special reference to clinimetrics, a domain concerned with the measurement of clinical phenomena that do not find room in customary taxonomy.
Methods: A MEDLINE search from inception to August 2011 using the keywords "clinical judgment" and "clinimetric" in relation to psychiatric illness for articles in English language was performed. It was supplemented by a manual search of the literature. Choice of items was based on their established or potential incremental increase in clinical information compared with use of standard diagnostic criteria. The most representative examples were selected.
Results: Research on clinical judgment has disclosed several innovative assessment strategies: the use of diagnostic transfer stations instead of diagnostic endpoints using repeated assessments, subtyping versus integration of different diagnostic categories, staging, macro-analysis, extension of clinical information beyond symptomatic features. Evidence-based medicine does not appear to provide an adequate scientific background for challenges of clinical practice in psychiatry and needs to be integrated with clinical judgment.
Conclusions: A renewed interest in clinical judgment may yield substantial advances in clinical assessment and treatment. A different clinical psychiatry is available and can be practiced now.
He introduces his paper with this:
    George Engel differentiated between “scientific physicians” [clinicians who fully apply the scientific method in their care of patients and in their understanding of the disease] and “physician-scientists” [physicians whose primary commitment is to scientific research pertaining to medicine and who have little or no familiarity with the clinical process]. Clinical practice is the source of fundamental scientific challenges for scientific physicians, whereas the application of basic [including pharmaceutical] research is the preferred focus of physician-scientists. Part of the challenge and, at the same time, fascination of being a clinician lies in applying scientific methods in the care of patients and in understanding disease. Greater knowledge should result in significant benefits for the patients, and in a sense of continued development on the part of the physician. We are witnessing, however, a progressive detachment of clinicians from research, which is often accompanied by a sense of personal stagnation and tiredness. This detachment is mainly the reflection of an intellectual crisis that became more and more manifest in recent years. Psychiatrists are constantly reminded that genetics and neurosciences are going to transform and improve their practice. Biomarkers are considered the stairway to such a shift and leading journals, such as the American Journal of Psychiatry and the Archives of General Psychiatry, are pursuing this perspective. Psychiatrists may share this optimism and wait for this event. Nothing has really come in the past two decades, as exemplified by the field of psychiatric genetics, but we may be really close. Psychopathology and clinical judgment are discarded as non-scientific and obsolete methods. Yet, in their everyday practice, psychiatrists use observation, description and classification, test explanatory hypotheses, and formulate clinical decisions. In evaluating whether a patient needs admission to the hospital [or can be discharged from it], in deciding whether a patient needs treatment [and in case what type] and in planning the schedule of follow-up visits or interventions, the psychiatrist uses nothing more than the science of psychopathology and clinical judgment…
My only response is to say I wish I’d said that. I just didn’t know how. And as often is the case for old men, it reminded me of my own story. I didn’t leave a career in research in hard science because I didn’t like it. I liked it a lot. I left it because I found something I liked better – clinical medicine. And as strange as it might seem, I gravitated to psychiatry because it seemed the most scientific of the lot, more like the kind of scientific method research I really liked than practice in Internal Medicine where there’s a lot of rote. I’m not much of a rote person. In psychiatry, every case was different. Sometimes, there was a disease to treat like Schizophrenia or Manic Depressive Illness, but even then, there’s never anything routine. Most of the rest of the time, there’s a whole narrative to parse looking for the problem[s]. Then there are interventions to consider. Once made, there’s a whole new narrative to evaluate to see if the intervention had an impact, needed revising, or was wrong altogether and issued a call to start over. The only guide was the method and experience, and both were iterative. What could be more interesting or scientific than that?

And then psychiatry went off and left me. The meetings began to feel like Dr. Fava’s description, "Psychiatrists are constantly reminded that genetics and neurosciences are going to transform and improve their practice. Biomarkers are considered the stairway to such a shift and leading journals … are pursuing this perspective. Psychiatrists may share this optimism and wait for this event. Nothing has really come in the past two decades, as exemplified by the field of psychiatric genetics, but we may be really close. Psychopathology and clinical judgment are discarded as non-scientific and obsolete methods." That is how it felt. We were gathering in meetings to wait together for the future, to hear about what exciting thing might be coming down the pike, or about what had just dribbled from the mythical pipeline that offered promise. So I gravitated to other meetings, sought other counsel. Some of my friends and former students thought I had withdrawn because I was a psychoanalyst and that was the new out-group. That’s not what I thought, but I found there’s no arguing with that particular charge. I thought it was a super-science phase in psychiatry that would pass or find its right place, and I went about my business with a smaller circle of colleagues, obviously enough for me. But the semi-isolation that was good for me and my work had a price. I was unaware of the magnitude of corruption and the melding of academic psychiatry with industry. I guess you see what you want to see, and the "phase" turned out to be much more than that and kept on going. But enough of that. Dr. Fava says it all so much better than I and it’s there to read.

Friday, I was in the clinic seeing a new patient, and I felt kind of good about something I said. The patient reported being depressed and wanted to add to or change the medicine she was already taking because she was having trouble functioning. I thought she was more oppressed than depressed. She was the "executive daughter" in her biological family, managing all of her mother’s affairs long distance since a recent stroke; functioning as her sister’s marriage counselor [also long distance]; being a mother to her three kids [two of whom lived with her ex-husband because they couldn’t get on with her current husband]; living with oldest son, her demanding alcoholic current husband, his ne’er-do-well addict son, and her own 38 year old brother because her mother can no longer care for him [who, by the way, thinks he’s Jesus and awaits the rapture]; doing all the cleaning and cooking; working full-time as an assistant manager of a busy store with a not-very-busy manager; going to school full-time in business administration. There was more but you get the picture. What I said was that I didn’t have a pill that would make her feel good functioning in her situation, but if I did, I wouldn’t prescribe it because I’d be helping her continue to live a life that she badly needed to do something about. Fortunately, she liked what I said too, and we set about trying to figure out how she got there, and how to make some changes. I felt like a clinic·ian…
  1.  
    November 19, 2012 | 12:18 PM
     

    I felt sorry for all these academics who can’t come up with any data that would really help people, so I posted a blog with a list of 11 mental health research ideas. Hope they can use good clinical judgement and stop wasting our medical on genetic stuff. http://wellnesswordworks.com/mental-health-research-ideas/

  2.  
    November 19, 2012 | 9:19 PM
     

    Also see

    Psychother Psychosom. 2002 May-Jun;71(3):127-32.
    [b]Long-term treatment with antidepressant drugs: the spectacular achievements of propaganda.[/b]
    Fava GA.

    full text at http://www.mediafire.com/file/4xd79ph5iw1z2l9/02_LT%20treatment%20propaganda_fava.pdf

  3.  
    rigel
    November 20, 2012 | 3:15 AM
     

    This post gives me hope, something I have in rather short supply as a medical student.
    I wonder if maybe we can apply those clinical-scientific-analytical skills to the care of the patient, patient being the practice of small-p psychiatry (contrasted with Psychiatry, the field you criticize with ample helpings of what i would consider wisdom). maybe it’s time to coin a new name and spin off a new field into which you can either entice the drug-shillers, or move into yourself. excuse me, ourselves.

  4.  
    jamzo
    November 20, 2012 | 8:23 AM
     

    a timely journal editorial

    http://content.karger.com/ProdukteDB/produkte.asp?Aktion=ShowFulltext&ArtikelNr=343002&Ausgabe=257520&ProduktNr=223864

    Editorial

    Modern Psychiatric Treatment: A Tribute to Thomas Detre, MD (1924–2011)
    Giovanni A. Fava

  5.  
    annonymous
    November 20, 2012 | 9:39 AM
     

    Still not being addressed:

    What will generate evidence that a medication does NOT work for particular groups of patients? In other words, inter-clinician reliability on what treatments do NOT work for particular groups of patients. Generated not by KOLs and/or fashion.

    The argument appears to be that a physician using “the science of psychopathology and clinical judgment” is superior to all other alternatives. For every one of you and Dr. Carroll there are 9 (99?) whose application of “the science of psychopathology and clinical judgment” leads to the use of treatments that you both might feel are unjustified. E.g., wholesale use of second generation neuroleptics for behavioral control in nursing homes, wholesale use of Seroquel for insomnia, wholesale use of Abilify for behavioral control of kids in the foster care system, …etc. These physicians do NOT appear to be applying trial results, nor their understanding of neuroscience or genetics. They appear to be applying their understanding of psychopathology and their clinical judgment. Fundamentally: They’ve SEEN IT WORK with their own eyes.

    In every revolution there are many who genuinely were hoping for a good outcome before the enterprise gets hijacked by the few and used for the hoarding of money, power, prestige.

    If every psychiatrist out there were like you and Dr. Carroll the attempts at revolution in the 70s/80s may not have happened. But they’re not. There are some very good reasons that have driven people to be wary of the way psychiatrists were applying their clinical judgment. Psychiatry exhibited many of the same adminirable traits pre-revolution that you rail against today. I’m not convinced that there was so much a vacuum as psychiatry has long been dominated by those who treat it in a more cult-like way and who are fine with changing paragidms as long as they maintain power. I suspect that psychiatry is in the state it is today not because psychoanalysis was driven from power but because it was run by psychoanalysts in the first place. I see the shift as a group of analysts who realized that psychoanalysis would not allow long-term for psychiatry to maintain power and so co-opted the biological approach. I wonder if this is why “true” biological psychiatrists like Drs. Carroll, Klein, Fink, …etc have in some ways found themselves out in the cold.

    Viewed this way: the revolution to actually improve clinical decision making in psychiatry has never actually occurred. It remains a promised unfulfilled.

    Double blind placebo controlled trials as they are currently applied have turned out not to be the answer. Much of the talk about neuroscience and genetics parallels the way analysis would parse texts that could seem increasingly removed from clinical reality.

    There will always be perceptive thinkers within a profession of clinicians. You and Dr. Carroll were then, and continue to be. I do not say that for show; each of your writings make this clear. However, the environment within which the best of thinkers thrives is not always the one which best supports the average.

    Psychiatry had been run, has been run, and is being run, by Cargo Science. There are those in power througout who have not practiced this, but they have been more the exception than the rule.

    Pscyhiatry has never seemed to be able to put forward a sophisticated AND clinically useful (how do we measure that?) paradigm for clinicians to assess that a treatment larglely does NOT work for a defined set of patients.

    Lack of disprovability, not seeking disprovability, seems the hallmark of cargo science.

    I really wonder if that is what really drew big pharma to psychiatry: It doesn’t matter if a treatment doesn’t work, because they can never tell?

    I’m not clear on how beating back this hegemony of double-blind placebo controlled multicenter clinically irrelevant trials and neuroscience/genetic scienticism, but without some replacement paradigm (is what Fava is proposing enough?) that is at least an enhancement of what we had in the 50s and 60s, gets us away from that.

    Away from: It doesn’t matter if a treatment doesn’t work, because they can never tell?

    And, in a way that works for the average joe shmo (what’s the female equivalent) psychiatrist and not just the upper tail of the bell curve.

  6.  
    Allen Jones
    November 20, 2012 | 9:52 AM
     

    Way to go Mickey!

  7.  
    annonymous
    November 20, 2012 | 10:34 AM
     

    For Example: Dr. Neal Ryan’s apparent belief that children could be best served by much more widespread use of SSRIs for depression was likely driven by what he believed he had seen in clinical practice. It seems to be, at least in part, what drove him so hard to not want the findings of Study 329 to be misinterpreted. I think that is a big takeaway from the letter he wrote to JAACAP in response to Dr. Jureidini. The true believers, the zealots, often seem driven by what they have witnessed in their own practice. When you marry them to the power brokers, such as you had in the combination of Drs. Ryan and Keller, that contributes to things like Study 329. Disproving what he had seen in practice may have been the furthest thing from Dr. Ryan’s mind. Obviously, the huge financial and logistical support from Big Pharma to support those with particular views has skewed the field. But a lot of the original drivers for these phenomena seems to come from clinical experience. It then got given a megaphone (club?) by Big Pharma.

    Once the hegemony of neuroscience/genetics over clinical judgment is addressed then the question appears to be:

    How can psychiatry move away from the KOL model that has dominated it throughout most of its history?

    Wasn’t the analytic institute system rife with the KOL idea?

  8.  
    Nathan
    November 20, 2012 | 9:43 PM
     

    I guess I’m a little confused about what is considered the science of psychopathology and clinical judgement. What is scientific about about clinical observation, pathologization, judgement, and decision-making? I guess my understanding of both basic and applied sciences involve experimental research with falsifiable hypotheses, where in the former you go about building confidence in “in-context” causal phenomena (theory building) and the latter you use that confidence to act in ways (predict, decide, intervene) that are considered helpful beyond the capacity previously attained.

    Perhaps because I come from a social and behavioral science background, I tend to consider science a methodology, divorced from the hard sciences. So while I think genetics and neuroscience and psychopharmacology sound “science-y,” I know that the quality of science behind them as applied to mental health has not been strong and the quality science done has shown their application not to be robustly helpful (at least as yet and beyond risks of greater harm). From this perspective though, I can’t the “science” of psychopathology and clinical judgement has shown to be of better quality or of more use/help.

    I don’t think what you describe as the applied science of psychopathology and clinical judgement is scientific, even if you use scientific process words like “observation,” “classification,” and “explanatory hypotheses,” if you haven’t already done quality research demonstrating things like classifications (discreet diagnoses?), ways to usefully observe (what are you looking for, what would tell you someone is part of a “classification,” what tools have been validated for helping with that and how were they validated?), explanatory hypotheses (etiology!?), and hence decisions and deployment of useful intervention/treatment (there are treatments for many people with diagnoses/classifications as seen by changes in observations/reports that people have used to propose explanatory hypotheses whether they are valid or not [ex. “cognitive distortions” and/or synaptic serotonin deficiency in Major Depressive Disorder, internal or Oedipal conflicts for neurotic anxieties]).

    So, I just don’t know why somehow our concept of clinical judgement of applied psychopathology is better than scientific approaches in mental health. I want the best kinds of policy, practices, and care that yield the best outcomes, and I don’t know how I would go about assessing those than by systemic, (at least quasi-)experimental research, regardless if it involves something from the hard sciences (drugs, implants, nutrition, etc.) or not (psychotherapies, intentional living, mindfulness, sustainable political/economic power, etc.). At the end of the day, I still think the we would expect that quality basic research can be used to develop applied practices/policies/etc. that lead to predictably better outcomes. I don’t see how the way folks who enshrine the value of clinical judgement and applied psychopathology are showing that they are doing that or that the science of psychopathology/analysis is any truer than other “explanatory theories” or any more helpful. And even though it has taken a backseat in the last few decades, it has had the most time (over a century) to do so.

    I mean, of course the current neuroscience/drug paradigm of mental health care and research is corrupt. It doesn’t mean engaging in scientific methodology is intrinsically corrupt or “detached” or unhelpful, just that it can be. Weren’t psychoanalytic institutions corrupt? Wasn’t their hegemony causing a lot of undue harm? Weren’t research dollars “wasted” in a lot of their research? Didn’t they publish a lot of sham science? Science that influenced policy and healthcare systems in ways that many would consider detrimental? Does this all mean that clinical psychopathology is intrinsically detaching (as many dynamic psychiatrists have felt in their work) or unhelpful? No, but it also can be. What matters more to me is that we have transparent science focused on making people’s lives better and reduce suffering in ways that people are willing and able to engage in.

  9.  
    November 20, 2012 | 10:48 PM
     

    Nathan,

    In this post, I mentioned a case:

    The patient reported being depressed and wanted to add to or change the medicine she was already taking because she was having trouble functioning. I thought she was more oppressed than depressed. She was the “executive daughter” in her biological family, managing all of her mother’s affairs long distance since a recent stroke; functioning as her sister’s marriage counselor [also long distance]; being a mother to her three kids [two of whom lived with her ex-husband because they couldn’t get on with her current husband]; living with oldest son, her demanding alcoholic current husband, his ne’er-do-well addict son, and her own 38 year old brother because her mother can no longer care for him [who, by the way, thinks he’s Jesus and awaits the rapture]; doing all the cleaning and cooking; working full-time as an assistant manager of a busy store with a not-very-busy manager; going to school full-time in business administration. There was more but you get the picture.

    This lady would meet the criteria for Major Depressive Disorder or come very close. She was on an antidepressant, had been on others in the past. I made the clinical judgement that the thing that might actually help her would be an exploration of the reasons past and present for why she ended up being the caretaker of so many others to her own detriment, rather than engage in trying yet another antidepressant. Would you say that that judgement was unscientific?

  10.  
    November 21, 2012 | 12:14 AM
     

    Annon,

    While I’ve never heard the term KOL until I started looking into the PHARMA connection, all of medicine in structured as a hierarchy – the Analytic Institutes being no exception. The term KOL [key opinion leader] is a PHARMA creation. In neither Internal Medicine, Psychiatry, or Psychoanalysis, I never encountered an authority who was connected with a particular drug or had a relationship with a drugmaker until the recent era in psychiatry. That would’ve been a mega-nono in the past. So, yes analytic Institutes are heirarchies as have been all other specialties. But this idea of a Key Opinion Leader using expert status to push a commercial product is still something of a shock to me. When I look at those coi disclosures, it gets me every time. I’ve never seen anything like that. The notion of KOLs giving talks using a drug company’s slides? I never even imagined that, until a couple of years ago when I learned to look at the acknowledgements. Sorry to go off on simply part of your comment, but it’s a sore spot for me. There ought to be a law against all of that kind of sheenanigans…

  11.  
    Jane
    November 21, 2012 | 8:06 AM
     

    BOM,
    WRT your comment on Nathan’s comments (I totally agree with you, Nathan): engaging in a little logical thinking should not be confused with conducting a scientfic analysis.

  12.  
    Nathan
    November 21, 2012 | 8:26 AM
     

    Mickey,

    My question would be how did you come to your decision? Why the intervention “exploration of the reasons past and present for why she ended up being the caretaker of so many others to her own detriment.” I agree that another antidepressant does not seem to be indicated (not only are they not that helpful for most people’s experience of distress, whatever effect they have had for her have not been helpful on domains of her life that are more important/pressing to her). But there are lots of things potentially to be done with all sorts of reasons why. I mean, even your intervention formulates an etiology (a psychodynamic inflected one), that not fully understood elements of her care-taking are making things detrimental for her. Why focus on that as primary?

    I can probably generate quite a few explanatory hypotheses for the case description. I mean, just working full time and being in school full time can be overwhelming, let alone everything else that is on her plate. Symptoms of depression can be If someone is working full time, in school full time, and has a more full time responsibility of caring for familial others and reports “trouble functioning,” I might say they are super high functioning! A lot of folks have trouble just working. This person might have expectations of herself, or other people might have expectations of her, that are unrealistic or unsustainable. This is similar to your explanation and might lead to similar intervention. Or she could just be really stressed out and overworked! Depressive symptoms can be anxiety/stressed link, and perhaps problem-oriented approaches might be helpful in dealing with several key areas of stress (relationship with her sister and/or boss, class schedules, etc.). Or maybe she just needs some time to focus kindly on herself in order to feel more at ease and capable to handle her big plate, as she is so busy and overwhelmed. Going to weekly psychotherapy with you could be a potentially helpful way to do that, but there are also other ways to intentionally build structured self-reflection and compassion into one’s life (meditation, exercise regime/class, religious practice, etc.).

    So in terms of science. I don’t know what was scientific about your approach, save the some use of more systemically gathered data showing diminished rate of likelihood of helpfulness of antidepressant trials. I think then it was “scientific” to consider other forms of intervening. Beyond that, there is less evidence of the kinds of intervention you use to lead the proposed goals (feeling better, making life changes), when perhaps there was stronger evidence for others being more likely to help with more people. It is up to you and your potential patient to decide on treatment, and your judgement and her values are important in putting some of that evidence in context for the particular/person situation, but at the end of the day, I believe, and there is evidence to back this up, that the more we make decisions based on probabilities of helpfulness (when we have some confidence in those probabilities from prior research), the more likely we are to see more frequent better outcomes than when we don’t. This idea owns that it will never be 100% correct and of course values treatment monitoring and modification when things are not going as well as expected or getting worse (unlike some approaches/clinicians who assume getting worse is part of the process), but maintains it will still be better for more patients than overemphasizing judgement to try to be 100% correct with each one and being off the mark and risking increased harm.

    There will never be enough science to inform clinical decision-making in mental health, but this does not mean that we should not use it to make the best predictions and decisions for treatment, and when we rely more on our own clinical judgement, be more humble and admittedly less confident in our ability to be of help (and in our ability to mitigate harm).

    As for KOLs, if your replace “drug” with “theory” or “approach,” we do see KOLs all over the history of psychoanalysis. Warring Kleinians and Anna Freudians in Britian, the split offs of Adler and Jung. The mentalizing enthusiasts vs the transference cheerleaders (ex Kernberg) for borderline treatment. The Betteheim’s of autism come to mind as well. Not much in-camp disagreement was tolerated. That the field is so influenced by KOLs I believe is due to the lack of investment in scientific process and like ANON said, the maintenance of a kind of hegemonic power and a true belief in their theories/practices from what they’ve seen in their practice when their judgement was correct (and a forgetting or explaining on external/patient/cultural/etc. factors when their judgement was wrong).

  13.  
    annonymous
    November 21, 2012 | 8:49 AM
     

    Hi 1BOM,

    Fair point. My use of the term KOL in relation to the analytic institutes was unfair and detracts from an appreciation of how incredibly concerning is this relatively newer phenomenon in medicine, and particularly in pschiatry. Will admit that without caveat. Even the term “opinion leader” (which is more what I think I had in mind when I wrote the comment) has a specific usage, and I realize that that term is not relevant to the institutes either: http://en.wikipedia.org/wiki/Opinion_leader
    In other words, it was substantively wrong of me to say:
    “How can psychiatry move away from the KOL model that has dominated it throughout most of its history? Wasn’t the analytic institute system rife with the KOL idea?” As you point out, saying that is wrong in both letter and spirit.

    However, I would also like to speak to “all of medicine in structured as a hierarchy – the Analytic Institutes being no exception” and ” yes analytic Institutes are heirarchies as have been all other specialties.” To my reading that seems to imply that the nature of that heirarchical organization, for example in terms of concentration of power and level of organizational and academic transparency, was relatively similar between medical specialties and the institutes. Including their evolution over the decades.

    My thoughts, for better or for worse, on this topic were heavily influenced by reading portions of Douglas Kirsner’s book “Unfree Associations: Inside Psychoanalytic Institutes.” You’re likely more familiar with this book than I, but here is some information anyway:
    http://www.apadivisions.org/division-39/publications/reviews/unfree.aspx
    http://internationalpsychoanalysis.net/2009/10/14/excerpts-unfree-associations-by-douglas-kirsner/
    http://www.google.com/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&cad=rja&ved=0CC4QFjAA&url=http%3A%2F%2Fbooks.google.com%2Fbooks%2Fabout%2FUnfree_Associations.html%3Fid%3DWhMCYJ4dwSEC&ei=iMCsUI7PLqTTiwKokoDoAg&usg=AFQjCNGn3TX49LtWk5du52uWanpvSWFkKg

    While I would agree that institutes and medical specialties were both heirarchies, my takeaway from Kirsner’s book was that on the former bore a closer resemblance to oligarchies than the latter. Of particular concern to me was the seeming lack of transparency, with myriad justifications provided, but in the end primarily used to maintain power.

    The prologue and epilogue to Kirsner book in particular seem to argue that he good that psychoanalysis can do, practically and conceptually, has been hampered by the degree of secrecy and concentration of power in the field as a whole. I think it may be a mistake to imply that this has been no greater in the analytic institutes than in medical specialities, that they were not more opaque.

    Columbia, particulary in recent years, has more of a reputation for openness so perhaps your view is also more informed by that experience.

    The opacity and cargo science of psychiatry today may have some of its roots in how the analytic institutes operated then.

    I would wholeheartedly agree that the KOL concept does not.

    And, upon further reflection, I think I may have way oversold the impact of the nature of the institutes on the shape of modern psychiatry. Perhaps its more the feeling that organized psychiatry has always had an overblown sense of relative good vs relative harm of its primary interventions and an overblown sense of how many people out there should be receiving them.

    However, I think Kirsner makes a strong argument for viewing analytic institutes as organizations existing for a long time as oligarchies that operated in relative secrecy. That at times they better served the consolidation of power and agendas than the power of the wisdom and knowledge their membership had accrued.

    If all that is true, then the APA appears to have succeeded in throwing out the baby and keeping the bathwater.

    To sum up: I deserved to have you go off on the part of my comment about KOLs.

    I hope that at some point you speak more to:
    It doesn’t matter if an approach doesn’t work (in particular circumstances), because they can never tell?
    An important corollary question to this: when is your standard careful longitudinal observation in everyday clinical practice insufficient to address the question of whether or not an approach should be used, and whether another approach should initially be used in its place?

    I am finally starting to appreciate that your blog style is to riff off of published writings. When I can find something out there that speaks eloquently to the the question I just posed (hopefully in the process also further clarifying the question itself) I will post it.

    In the interim, hope you have a Happy Thanksgiving.

  14.  
    Sandy Steingard
    November 21, 2012 | 10:08 AM
     

    Thanks for this post and a most interesting discussion. I agree with Nathan and anonymous that clinical judgement is difficult to define. Many treatments are offered under the umbrella of good clinical judgement.
    I am sorry to harp on the Open Dialogue but it is a focus of study for me right now. I am struck by how that group used clinical work to inform research and research to inform clinical work so that their approach did not become dogmatic but evolved over time. Their research is naturalistic. As David Healy has pointed out,the dominance of RCT’s as the ONLY source of reliable data is a problem.

  15.  
    annonymous
    November 21, 2012 | 10:11 AM
     

    Cross-posted with Nathan so just read his latest post and reread 1BOMs query. I enjoy both of your writings very much and hope that this is not the last of the discussions that you have because, even though you each cover similar territory to the original discussion you had many posts back, I continue to learn new things from each of you.

    A few thoughts:
    Since the term KOL is used to represent someone that is identified by an outside group and then utilized for their own ends, I would agree that it is a newer phenomenon. It is important to recognize this as a newer phenomenon that has to be addressed and that organized psychiatry has done a terrible job of addressing. You just did not have deep pocketed outside organizations both bribing and selectively promoting the power of individual psychiatrists in this way in the past.
    That having been said, the more I think about it the less certain I am of the point 1BOM has appeared to make in the past that a main problem is that true clinicians are not in control. I agree with Nathan’s examples and particularly that some of the virulence comes from the feeling having directly experienced “the truth” coupled with wanting to be “in” and with certain individuals and held in esteem.

    I remain uncertain of how clinicians should best synthesize knowledge to reach clinical decisions.

    Nathan, you speak of “lack of investment in the scientific process.” Here are some quotes that stands out for me from Feynman’s Cargo Cult Science speech:

    1. “Yet these things are said to be scientific. We study them. And I
    think ordinary people with commonsense ideas are intimidated by
    this pseudoscience. A teacher who has some good idea of how to
    teach her children to read is forced by the school system to do it
    some other way–or is even fooled by the school system into
    thinking that her method is not necessarily a good one.”

    2. “A great deal of their difficulty is, of course, the difficulty of
    the subject and the inapplicability of the scientific method to the
    subject. Nevertheless it should be remarked that this is not the
    only difficulty.”

    3. Part 1:”The first principle is that you must not fool yourself–and you are
    the easiest person to fool. So you have to be very careful about
    that.
    Part 2:”After you’ve not fooled yourself, it’s easy not to fool other
    scientists. You just have to be honest in a conventional way after
    that.”

    The 1937 Young Experiment story in that speech is amazing. Wasn’t sure what it suggested in terms of the current discussion so I’m not including it, but abolutely worth the read. Very hard to go wrong recommending Feynman.

    Re #3: There appears to be a sociological aspect, an organizational aspect, that influence the extent to which researchers and clinicians acheive part 1. To me the question of how that quality can be fostered is absolutely critical. Where I think the new KOL concept is particularly toxic is that it tends to ossify existing biases for commercial ends, above and beyond all the ossification that was happening already.

    Re #1: We all want to have a situation where that teacher can use the available body of knowledge and her expertise to deliver the most effective reading teaching approach to each child. That she neither has to rely simply on her own experience and biases nor does she need to rely on cargo science to then deliver less effective, possibly detrimental, instruction.

    To me that’s at the heart of the tension.

    To my mind 1BOM is right to fear that example #1 and the desire to make decisions “scientifically” would lead to that woman in his example being given an antidepressant and/or a manualized treatment approach that might improve clinically/humanly insignificant endpoints. That he may be fooled by the system into thinking that his approach is not a good one.

    To my mind Nathan is right to fear another possibility from example #1 and the desire to simply make “commonsense” or “clinically sensible” decisions. That there may be reading interventions for particular kids in her class that could be wildly successful but the teacher is going to ignore that. That in another clinic example someone comes in with classic OCD and instead of receiving a CBT approach that could be very successful they receive a much more ecclectic approach based on personal experience that leaves them suffering much more at the end. Or, a psychiatrist who chooses to give Abilify to almost every child they evaluate because he has seen it work with his own eyes and rarely sees any side effects.

    Of course, both 1BOM and Nathan would say that you need a hybrid. The devil is in the details of what that hybrid looks like. Which hybrid you think has the highest chance of addressing all of those possible scenarios above. This is a very nut to crack.

    If/when I see a paper/book/blog out there that provides further fodder for this discussion I’ll bring it back.

  16.  
    November 21, 2012 | 10:19 AM
     

    Anon,
    I have no argument with your point about the Psychoanalytic Institutes, particularly in America. Indefensible and often silly. My reaction was to the commercialization of the KOLs in psychiatry.

    Nathan,
    That the field is so influenced by KOLs I believe is due to the lack of investment in scientific process and like ANON said, the maintenance of a kind of hegemonic power and a true belief in their theories/practices from what they’ve seen in their practice when their judgement was correct (and a forgetting or explaining on external/patient/cultural/etc. factors when their judgement was wrong).
    Good point. No argument.

    Jane,
    Thanks. I go for logical thinking as the thing that clinics need.

    Universe,
    When I read my post, I don’t see it as having to do with psychoanalysis. I see it as about clinical decision making, hypothesis generation. That’s what lead to my personal isolation for a lot of years. Because I’m analyst, all discussions drifted to tired points about cardboard analysts who foisted theories on equally tired patients, a point with which I agree. In analytic circles, often discussions drifted to other tired discussions. I like Dr. Fava’s article because it’s about trying to bring some critical thinking to what goes on in dealing with patients and navigating the waters of infinite choices that face clinicians and patients in an everyday interview. My choice was to inquire about how she came to be a person who was taking care of everyone else – family, boss, etc. and not herself. What she actually told me in the interview was unexpected, but pretty explanatory. In this case, I would say ‘hypothesis confirmed.’ But it could’ve gone the other way.

    My point would be that Dr. Fava is looking at the processes that go on with individual cases, not groups of other people. In this case, she immediately began to talk about the most important figure in her childhood, a grandfather who was a fundamentalist minister who taught that “we’re not here to be happy, but to love God and serve others” – and from her perspective, he practiced what he preached unlike others in her world who seemed selfish and chaotic. New hypothesis, her propensity to get in situations like the one she’s in now had to do with her relationship and identification with her grandfather. Supporting evidence? She said the same thing happened in her first marriage – which is why she finally left.

    My point is that in clinical medicine, hypotheses come from what the patient brings to the table, neither analytic institutes nor neuroscience labs. What the clinician brings is some ability to generate hypotheses and how to confirm or discard them based on further evidence. The only things I really know about her is that it’s way unlikely that she has a chemical imbalance and that symptomatic drug treatment is unlikely to help her because my colleague [a GP] who referred her has already given it the college try.

    Clinical judgement is the slippery-est slope on the planet and it’s what goes on in most any doctor’s interaction with most any patient on most any day. My own hypothesis is that clinicians often fall back on theories of one kind or another because it’s a land of constant confusion to stick with the patient as the source of evidence. Theories may inform hypothesis generation, but not confirmation. Fava is saying, in my reading, that clinical decision making is something to look at very carefully. I agree. And if things like psychoanalysis or evidence-based medicine interfere with either clinical decision making or examining how that process works, they both deserve a good spanking. I don’t know Dr. Fava, but my hypothesis is that he’d agree…

  17.  
    Nathan
    November 21, 2012 | 11:10 AM
     

    I think Sandy’s description of Open Dialogue is what I would push as a useful way to do clinical research. We notice things as clinicians in treatment, without background evidence we try something based on our most informed judgement, and if something stands out as particularly helpful or harmful, we do more intentional research, and use that research to plan predictably better treatments, and we evaluate our treatments themselves and in comparison to others to see if they are actually predictably better.

    Mickey, for your patient, I am curious about the outcome of of explanation as intervention had. Did understanding help her function better given her circumstance, did it help her change things in her life to better suit her needs, was she happier, etc.?

    I do agree that we need more critical thinking in regards to clinical judgement and decision-making. I think part of that is having a rationale of why we do something particular given a myriad of options. I believe, as I think you do, that clinicians need to behave rationally/logically in an uncertain world and clinical encounter.
    I find a research base helpful in that, perhaps even (sometimes falsely) comforting. At the very least, it helps me put my own biases in context and be intentional with weighing the infinite options available in ways that have been shown to yield more frequent and/or better outcomes. To do that, I ask to what ends are we planning to do a treatment/intervention? Why do we think it will help? Why do we think it will help better than something else? Does a patient have particular values or goals or constraints that would affect what we would do? How do we know if something is helpful? How do we change course after we introduce something not helpful or even harmful? How are risks communicated? What will I need to do what I think will be helpful? And so forth.

    As for annonymous’s example 1, we can actually test various teaching methods on particular outcomes. Even if it is comparing what a teacher does regularly vs some more administratively assigned curricula. If a particular teacher’s methods yields to student outcomes more robust than the curriculum guided one, that teacher should not switch to the curriculum. If a teacher’s students are not experiencing outcomes as strong as if folks who teach with a particular curriculum, perhaps they should at least switch to the curriculum, as it is shown to be more helpful for engendering particular important outcomes. Moreso, the teacher’s who do well should be studied, so that perhaps what they do (or how they connect, or engage, or plan, or whatever) can be taught to others. So my issue with clinical judgement is that to me it often seems like something kept secret, something innate, something magical or particular about a clinician, something that lets them take credit for “brilliant” successes but disavow disappointing (and often very preventable failures). An actual science of applied practice, as seen in richly described and compared methodologies’ (or other aspects of intervention) effects on important outcomes can be done in an open way and that leads to increased clinical utility for everybody. As I said earlier, there will never be enough clinical science to inform all clinical judgement. Sometimes clinicians are on their own, but that does not mean that when they are they should not then systematically evaluate the outcome of their judgement or use the experience to meaningfully inform a research base (and not just as a biased, confessional, or defensive case study).

    There is also a growing science of decision-making (clinical or not), that if clinicians are trained in and value can become more logical and logically responsive in clinical encounters. Many experts, whether physicians, therapists, stock brokers, admissions committees, political pundits, or whatever, actually on average make worse predictions about future events, treatment effect, value, etc. when relying on their expertise than when with a logical algorithm. It does not speak much to someone’s years of training, experience, and expertise if they cannot attend to information that is most important in making most accurate predictions, associations, and hence useful interventions. I am so thankful that Nate Silver is getting the attention he is as he demonstrates high predictive power using rational thinking in uncertain world with limited information so well.

  18.  
    November 21, 2012 | 11:48 AM
     

    I am curious about the outcome of of explanation as intervention had. Did understanding help her function better given her circumstance, did it help her change things in her life to better suit her needs, was she happier, etc.?

    It was a thirty minute shot in a clinic where I volunteer. I felt that she was engaged and did seem a bit lighter at the end. My other information not in the vignette was limited. The clinical decision making continued. It’s a clinic where I see lots of people and can’t really do what I did in practice. We have a clinical psychologist and a Licensed Professional Counselor who also volunteer, both pretty good. She had actually seen one who she liked, but hadn’t followed up. I suggested Alanon for obvious reasons [and it happens to be a good resource here in the woods]. She knew about it, but hadn’t gone because it was in a church [interesting in light of the grandfather connection]. I scheduled an appointment for her with both me and the counselor together next time I’m in the clinic to see if we can get her into a situation where she can work on some understanding and practical problem solving.

    She seemed to like the idea and talked about her social isolation. Her only real confidante is a former sister-in-law who’s her best [and only] friend, but she always suggests the same thing. “Throw him out [any number of hims].” “Quit your job.” “Drop that class.” “Tell your sister to get a divorce.” She’s a real scorched earth adviser who makes her feel heard, but whose advice is monotonous and isn’t too helpful. I felt pretty good about our 30 minutes, and hope we can piece together something that helps her get out of the rut she’s in. In this setting, a lot of the clinical decision making is predicated on the limited resources available in a beyond busy charity clinic in rural Appalachia, but I’m both surprised and pleased that our little makeshift team can get a whole lot more done than I would’ve ever guessed before working there.


    I missed this.

    I can probably generate quite a few explanatory hypotheses for the case description. I mean, just working full time and being in school full time can be overwhelming, let alone everything else that is on her plate. Symptoms of depression can be If someone is working full time, in school full time, and has a more full time responsibility of caring for familial others and reports “trouble functioning,” I might say they are super high functioning! A lot of folks have trouble just working. This person might have expectations of herself, or other people might have expectations of her, that are unrealistic or unsustainable. This is similar to your explanation and might lead to similar intervention. Or she could just be really stressed out and overworked! Depressive symptoms can be anxiety/stressed link, and perhaps problem-oriented approaches might be helpful in dealing with several key areas of stress (relationship with her sister and/or boss, class schedules, etc.). Or maybe she just needs some time to focus kindly on herself in order to feel more at ease and capable to handle her big plate, as she is so busy and overwhelmed. Going to weekly psychotherapy with you could be a potentially helpful way to do that, but there are also other ways to intentionally build structured self-reflection and compassion into one’s life (meditation, exercise regime/class, religious practice, etc.).

    Sounds good to me. All reasonable hypotheses. Except this one Going to weekly psychotherapy with you could be a potentially helpful way to do that. It might be helpful, but I don’t do that. I’m an old retired guy working in a clinic where if I did that, I’d fill all my time in one week and never see the new patients that need seeing. My job is to assess the patients and make the best judgement I can, then mobilize the best resources we have that fit the patient. In this case, I think your suggestions are great. Mine wasn’t too shoddy either. The “way station” to return to Fava was to locate the ballpark of the problem and aim at a solution.

    Now, I’m off to start cooking for tomorrow. Happy Thanksgiving to all..

  19.  
    SameOldSong
    November 21, 2012 | 1:16 PM
     

    Very few clinic·ians, so many doctors of death…

    Interesting tidbits of old news playing out as new news – it’s the same old song…

    Example 1: Dr. Michael Jay Reinstein (still licensed to practice medicine)

    http://bipolar-stanscroniclesandnarritive.blogspot.com/2010/10/astrazeneca-novartis-paid-chicago.html

    http://www.propublica.org/projects/reinstein/docs/essary.rein.depo.opt.pdf

    Latest: http://articles.chicagotribune.com/2012-11-16/news/ct-met-reinstein-lawsuit-20121116_1_reinstein-clozapine-patients

    The money energized & pharma backed rabbit doctor keeps on going & going….no accountability

    Example 2: The death of Dan Markingson – the stepping stones from CAFÉ to CATIE

    Background: http://bipolar-stanscroniclesandnarritive.blogspot.com/2010/12/human-life-for-sale-death-of-dan.html

    a recent series of articles well worth a read – http://loathingbioethics.blogspot.com

    again, no real accountability…..

    Unfortunately psychiatry isn’t some magic trick or light switch that can be turned on & off simply upon a whim…especially noting that the so called “transparency” movement hasn’t produced much fruit….the greed mongers continue to control the talk, own the walk, and are singing in chorus all the way to the bank; It still appears truth & care will continue to take a long arduous & darkened stroll down the path toward relative futility…

    Happy Thanksgiving :)

  20.  
    Annonymous
    November 21, 2012 | 5:40 PM
     

    “The best hope to provide ethical guidance and to exert peer pressure lies in the professional organizations and peer-reviewed journals.”

    http://www.scientificamerican.com/article.cfm?id=how-drug-company-money-undermining-science&offset=8

  21.  
    Annonymous
    November 21, 2012 | 5:48 PM
     

    The new KOL concept is particularly toxic in that it tends to ossify existing biases for commercial ends, above and beyond all the ossification that was happening already.

    At the same time this increasingly looks like there may be some outright bribery out there.

    Your field better do something substantive about this because at some point the states and/or federal government may be forced to come after larger number of physicians in the courts and then it may get very very ugly.

    At that point taking measured action is going to be much more difficult.

  22.  
    Annonymous
    November 21, 2012 | 5:58 PM
     

    Or you’ll be barred from off-label prescribing and then your prescribing will be yoked to the FDA and the cr*ppy literature and the DSM even more so than it is now.

    Where the heck are your colleagues?

    What’s your hypothesis as to why so many of them seem checked out?
    Corollary: why has no one come up with a way to market this to/galvanize them?

    I’ll look for a paper on that too.

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