“in my beginning, is my end”…

Posted on Monday 3 December 2012

In the DSM-II, the Mental Disorders without known physical cause were partitioned into two groups: The Psychoses [III. PSYCHOSES NOT ATTRIBUTED TO PHYSICAL CONDITIONS LISTED PREVIOUSLY] and the Neuroses [IV. NEUROSES]. The Psychoses were Disorders that would more likely be found to have a biological cause  at some future juncture and were treated with biological interventions. The Neuroses probably developed from the circumstances of life, were less likely biological, and were treated at the time with psychotherapy and symptomatic medications. In the drive to remove psychoanalysis ["hypothetical but unproven theories about etiology"] from psychiatry with the DSM-III, the categorical distinctions of the DSM-II [psychosis vs neurosis], [probably·biological vs probably·not·biological] were ablated. That move had many roots: the speculative nature of psychoanalytic theories; the untestable clinical outcome of psychoanalysis or its derivatives; the threat posed to third party medical coverage by long therapies of any kind; the inflexibility of the analysts/psychotherapists around these issues; and the political dominance of the psychoanalysts in American psychiatry in general [to mention a few]. And we’re all aware of the neo-Kraepelinian Tenets that fueled that revision:
    1. Psychiatry is a branch of medicine.
    2. Psychiatry should utilize modern scientific methodologies and base its practice on scientific knowledge.
    3. Psychiatry treats people who are sick and who require treatment.
    4. There is a boundary between the normal and the sick.
    5. There are discrete mental illnesses.  They are not myths, and there are many of them.
    6. The focus of psychiatric physicians should be on the biological aspects of illness.
    7. There should be an explicit and intentional concern with diagnosis and classification.
    8. Diagnostic criteria should be codified, and a legitimate and valued area of research should be to validate them.
    9. Statistical techniques should be used to improve reliability and validity.
The combination of the DSM-III’s etiological neutrality, the neo-Kraepelinian injunction ["The focus of psychiatric physicians should be on the biological aspects of illness"], and the third party payers limiting payment to psychiatrists for medication management created a fertile soil for the flowering of the psychopharmacologic treatment of mental illnesses. The change in mental health treatment was dramatic. Psychiatrists drifted to medication management and the other mental health disciplines who were much more amenable to negotiation than psychiatrists took over psychotherapy and counseling. Access to treatment was tied to diagnosis and determined by the third party carriers through contracted panels of approved providers. Many patients had both a therapist and a psychiatrist. Those practicing traditional psychotherapy practiced off the grid.

The idea of biological causation was both on the forefront [at least in the research laboratories] and in the background [in the ubiquitous Clinical Trials focused on symptomatic improvement rather than cause] – nowhere more apparent than in the treatment of depression. The DSM-III destroyed diagnostic distinctions among the clinical depressions – essentially shutting down biological research on the probably·biological depressive syndromes by diluting them with the larger group of probably·not·biological symptomatic depressions. The primary focus of psychiatric research turned from etiology to treatment effect and moved from academic centers to private enterprise – the clinical research industry.

By 2002, the psychopharmacology business was booming, managed care was in charge of clinical care, the psychoanalysts were elsewhere, but basic psychiatric research had gone nowhere in spite of the new technologies and much ado:

By David Kupfer, Michael First, and Darrel  Regier, 2002

Need to Explore the Possibility of Fundamental Changes in the Neo-Kraepelinian Diagnostic Paradigm

The DSM-III diagnostic system adopted a so-called neo-Kraepelinian approach to diagnosis. The approach avoided organizing a diagnostic system around hypothetical but unproven theories about etiology in favor of a descriptive approach, in which disorders were characterized in terms of symptoms that could be elicited by patient report, direct observation, and measurement. The major advantage of adopting a descriptive classification was its improved reliability over prior classification systems using nonoperationalized definitions of disorders based on unproven etiological assumptions. From the outset, however, it was recognized that the primary strength of a descriptive approach was its ability to improve communication among clinicians and researchers, not its established validity.

Disorders in DSM-III were identified in terms of syndromes, symptoms that are observed in clinical populations to covary together in individuals. It was presumed that, as in general medicine, the phenomenon of symptom covariation could be explained by a common underlying etiology. As described by Robins and Guze [1970], the validity of these identified syndromes could be incrementally improved through increasingly precise  clinical  description, laboratory studies, delineation of disorders, follow-up studies of outcome, and family studies. Once fully validated, these syndromes would form the basis for the identification of standard, etiologically homogeneous groups that would respond to specific treatments uniformly.

In the more than 30 years since the introduction of the Feighner criteria by Robins and Guze, which eventually became the DSM-III, the goal of validating these syndromes and discovering common etiologies has remained elusive. Despite many proposed candidates, not one laboratory marker has been found to be specific in identifying any of the DSM-defined syndromes. Epidemiologic and clinical have shown extremely high rates of comorbidities among the disorders, undermining the hypothesis that the syndromes represent distinct etiologies. Furthermore, epidemiologic studies have shown a high degree of short-term diagnostic instability for many disorders. With regard to treatment, lack of treatment specificity is the rule rather than the exception…
The DSM-5 Task Force was in its infancy, and impatient to move psychiatry further into the biological realm. They seemed to think that the diagnostic system itself was to blame for the lack of progress in etiological research, and aimed towards making some sort of mid-course correction:
Concerns have also been raised that researchers’ slavish adoption of DSM-IV definitions may have hindered research in the etiology of mental disaorders. Few question the value of having a well-described, well operationalized, and universally accepted diagnostic system to facilitate diagnostic comparisons across studies and to improve diagnostic reliability. However, reification of DSM-IV entities, to point that they are considered to be equivalent to diseases, is more likely to obscure than to elucidate research findings.

All these limitations in the current diagnostic paradigm suggest that research exclusively focused on refining the DSM-defined syndromes may never be successful in uncovering their underlying etiologies. For  that to happen, an as yet unknown paradigm shift may need to occur. Therefore, another important goal of this volume is to transcend the limitations of the current DSM paradigm and to encourage a research agenda that goes beyond our current ways of thinking to attempt to integrate information from a wide variety of sources and technologies.
While I’ve never been in love with the neo-Kraepelinian mandate, this last paragraph seems irrational. They’re proposing that the problem is in the paradigm itself, rather than in the categories it created. To take the most glaring example of all, the foremost problem in depression research is that the Major Depressive Disorder diagnosis encompasses a menagerie rather than defining a clinical entity. In my reading, Drs. Sabshin and Spitzer created this category and refused to fractionate it to insure that the psychoanalytic Depressive Neurosis disappeared, but in the process, they threw out the time honored disease of Melancholia and other discrete depressive syndromes, likely targets for probably·biological research. They ushered in the endless Clinical Trials of antidepressants and the drug strategies that followed for treatment resistant depression.

And that became the general approach of the DSM-5 Task Force – a search for something new. Rather than attempting to refine and revise the DSM-III/DSM-IV system and criteria [their assigned task], the DSM-V Task Force thought we needed something else – some as yet unknown paradigm shift and they focused on the ever exciting tools of neuroscience instead of the nuances of clinical diagnosis. They put on an series of expensive planning conferences that went on for four years – forgettable and forgotten. Little wonder that they developed an adversarial relationship with their predecessors who wondered at their secrecy and when they were going to get around to the task of revising.

And as they fiddled, Rome began to burn. The golden age of drug treatment morphed into an era of a corrupt academic/industrial complex with its conflicts of interest, ghost-writing, fallen KOLs, and suits galore alleging fraud in the pharmaceutical industry. Their early decision to put revision and refining on the back burner and pursue new vistas backfired when nothing new came along and their new, quirky diagnoses went up in smoke. They were left with an unrevised diagnostic system that failed its Field Tests, bringing the whole enterprise into question.

Which was the bigger error? Chasing the shiny objects of new horizons and new technologies? Wanting to make their mark with yet another paradigm shift? Failing to see the flaws in the system they were intended to revise? Being unwilling to change directions when things went awry and the critics appeared? Some conviction that all mental illness is biologic? A persisting influence of industrial interests [managed care, pharmaceuticals]? An assumption of the hegemony of psychiatry in the pantheon of mental health professions? Whatever the cause, the misbegotten fate of the DSM-5 was apparent from its inception and never wavered. Dr. Frances says it’s a sad day. It is a sad day and a prelude to many more…
    Mark Kramer
    December 3, 2012 | 8:01 PM

    Hi Mickey. This is very moving. I hope this particular day’s blog is kept open, because there are sections of what you’ve written which I think are very on target, and others not so. Where not, I’d like to provide what to me is a detailed accounting. I hope I can get to this later tonight. Regards, Mark

    Mark Kramer
    December 4, 2012 | 4:47 AM

    Thank you for the opportunity to post here. I am dictating this “speech to text.” ; I’m not making much of an effort to polish this. So please don’t judge the book by its cover. I am interested in putting these notions out there. If the internet is a time capsule, then this might have been worthwhile. It can do nothing except personal harm to me, but might be worth it if just the right people get it at some point.

    To the main point DSM III was enough to do biological research. Beyond this, the revisions were a pain. The DSM is not what affords great research, as I will talk about later anyway.

    I think we are in a situation today in biological psychiatry that parallels in some respects the fall of psychoanalysis. However, I would not hang the crepe just yet on biological psychiatry. Its rise has been meteoric, its knowledge voluminous yet preliminary, and much has been accomplished in 50 years, although imperfectly. [BTW, as someone asked: the published industry studies to trust are the prospectively powered ones which are active and placebo controlled: they generally depict phase II/IIB. Phase III can be selectively published. That needs to change. Post marketing studies unless pristinely designed and powered are generally methodologically rigged to illustrate a point: infomercials. The point may be preliminarily true or not. If you see one you need to take to your bank, then look up the ideal design by the competitor: pretty simple 🙂 ]

    If Biological Psychiatry is on its way out, who then is waiting in the wings? At this point we’d better stock up on “sugar ” pills, massage certificates, and create mental health accounts for feel good shopping sprees.

    Well, the following is where we agree, Mickey. For me it was either going to be neurology, endocrinology, or psychiatry. However, the new age of biological psychiatry in the 60s seemed to be the most exciting of the three. I also was never much one for literature/Greek Tragedy.

    As resident physicians we were wowed by psychoanalytic theory / case formulation, behavioral therapy, family therapy (Nagy psychoanalytic and Satir/Framo structural), network therapy, to name a few. As residents we could appreciate the therapeutic effects and adverse experiences / intolerabilities of psychotropic medications. In those days, the canon for conducting empirical medical research in psychiatry was just forming – owing a great deal to the Early Clinical Drug Evaluation Unit and RDC (Research Diagnostic Criteria) of NIH. We, as residents, were encouraged to combine as many modalities of treatment as feasible, with and without drug therapy to help the patient recover. Significantly, and without change to the non-drug part of the multimodal treatment plan, clinician residents at my training facility were encouraged to conduct N of 1 “studies” in which placebo could be substituted for psychotropic medication on a patient by patient basis. Thus, our direct experiences strongly supported the biological nature of serious depression, bipolar Disorder, and schizophrenia. The rampant polypharmacy of today was vilified back then. We also thought that prohibitively expensive private inpatient psychoanalytic treatment facilities for schizophrenia – possibly Shepherd Pratt? – were also dangerous given the severity of illness that we saw.

    As you say, the literal political environment was pro-drug; the promise of Thorazine , haloperidol, and fluphenazine long acting injectable would theoretically clear out expensive inpatient housing of the seriously mentally ill. The age of community satellite clinics began. Hospital stay duration was now being tracked by a new profession – the Hospital Utilization Nurse. (aptly abbreviated HUN as in “Attila THE”.) The state would not pay for protracted psychoanalytically oriented talk therapy; so I became interested in short term psychoanalytic treatment (Davanloo) along with all the other modalities. Yet at heart I was a physician-biologist feeling keenly that Freud may have for all of his brilliance delayed the field of psychiatry from entering an age of enlightenment – and that perhaps he would have been better off studying the pharmacology of cocaine – which many do not know he introduced.

    The so-called neo-Kraepelin movement seemed appropriate enough. I took the tortuous road of becoming an MD PhD -physician researcher – instead of a philosopher, psychologist, or primarily a musician (I came to that too late) as I wanted to help patients in a profession in which (at least at the time) I would have the most autonomy to do so. I had wonderful basic science mentors in pharmacology and neuro-chemistry – Drs. Aldler and Salganicoff primarily. And as a resident, I’d been prepared very well: as able to suture a slit wrist, order an xray, treat a pneumonia, discover a thyroid tumor and organic dementia, – as much as to talk with my patients kindly and for hours, as Wolpe was in the building, (along w/ other leaders in the field of pyschiatry and behavior) behaviorally flood a patient with severe OCD. Upon request of their supervisor, I shared my growing knowledge of psycho pharmacology with the psychology interns there, not realizing that in just a few years they’d want prescribe too.

    Although I am not in active practice anymore, to me Psychiatry will always be the treatment of the whole person. “And you know why Jim”, (as Scotty said to Kirk) “because I’m a doctor Jim. I am a doctor, man.” We suffered to make that passage; it was particularly egregious for a kid from a working class family, of no means, or pedigree. I am a jealous guard of medicine as a profession; high ideals were inculcated. Accompanying a family member today I met a physician who healed by his demeanor, and then by his knowledge, and then with his medicine. Shortly he will heal with a scapel. When I was a resident the social workers were social workers, nurses nurses, Psychologists psychologists. Today ‘everybody’ including the people at Starbucks are therapists. ‘Everybody’ seems to want to dispense some sort of herbal treatment.

    Your list of items 1-9 is flawed to a minor extent, as it was back then. Arguably, there were only 3 (+2 supportive) reasons for putting the Biology in Psychiatry Bin and they were pretty good:

    1. the rationale for the notion of a specific drug treatment tailored to an operationalized Dx was the close specificity of antidepressants and antipsychotics for depression and schizophrenia respectively. (not what is going on today.)
    2. At the very beginning Bipolar Disorder (BPD) strained the “one drug class” per diagnosis approach. But from this we understood: 1) once the patient was discharged from a depressed phase or mania, many patients would remain in remission on Lithium, and 2) the overall umbrella for a specific drug responsive psychiatric disease includes its longitudinal course. This course is in the primordially stereotypical case, and in the absence of a biological benchmark one phase or another may mask the another (see the three stages of mania)
    3. the far less elegant but apparently over the top efficacy of ECT in depression. (to be clear, it always seemed to require last resort status, because it seems so blunt a tool. But it is the only thing that snaps people out of some the depressions or obsessions.

    4. Reserpine depleted the monoamines and caused a seriously depressed state in humans (and animals).
    5. Stimulants mimicked mania

    The original list upon which the enlightened age of Biological Psychiatry debuted could have been less ambitious as follows:

    1. Psychiatry is a branch of medicine. The first time trephination actually relieved Intracranial pressure and in temporal relationship removed the ideas of reference and intermittent disorientation in the person’s brain under that pressure, Psychiatry was born as a medical specialty.
    2. Psychiatry should utilize the scientific method, its practice based on scientific knowledge wherever possible to an extent that is commensurate with other medical specialties.
    3. Psychiatry treats people who are in distress and who request treatment, or who are referred for diagnosis and treatment.
    4. As in other fields of medicine sometimes the boundary between the normal and the sick may not be quantifiable; be cautious.
    5. Two to three classes of psychotropic medication have been discovered which when used as monotherapy, differentially treat ~three subgroups of patients based on clinical diagnosis, often based on cross sectional and longitudinal observation, not by psychoanalytic formulation alone or if ever. Using the wrong medication in a given diagnosis will cause problems (trigger psychosis, or trigger/exacerbate depression)
    6. The focus of the psychiatric physician shall be on the whole patient, and shall include physical diagnosis, biological treatments, which may extend to any organ system as warranted, and in addition general and specific non-drug support. [Some of the early psychiatrist physicians who abrogated their responsibilities as physicians caused semantic mayhem.]
    7. Diagnostic criteria required to define the populations that these three drug classes selectively treat need to be refined; by that, to understand the limitations of lumping or splitting diagnostic entities. The Nosology to do so can also include that of mainstream psychoanalysis (if operationalized) as that is also tied to attempts to explain a pre-Victorian Nosology.
    8. The above shall be a legitimate form of medical scientific research in which validation must proceed.
    9. It is not clear yet whether any other constellation of Signs and Symptoms, aside from those for schizophrenia, Major Depression, and BPD shall constitute a psychiatric diagnostic group unless accompanied by a specific Treatment response.
    10. All codification shall be based on extreme, clear case examples, refined over time.

    The DSM system very well may have caused the dilution of which you spoke, Micky, and which has now caused much unintended pain. This is particularly egregious, because as depression is now being redefined in practice as relatively mild, how will we ever test for biological benchmarks? That is why I am quite frustrated over the badly needed studies which attempt to biomark. These otherwise bright researchers are collecting samples from patients who include those who are simply neurotically depressed – and perhaps much better off with placebo or psychoanalytic formulation or you name it. I figure when the severe cases are defined, we can then exclude them, and then do pristine research in the milder depressions.

    All in all Biological Psychiatry has only had ½ century so far. I for one think that despite the stink in the stables – not my metaphor – just now is on track to move into its next still early stage. Predictably, It will vastly shrink before it emerges whole.

    Where we might differ is here Mickey:

    1. The idea of biological causation of depression was actually based on the success of ECT and early Tricyclic antidepressants, supported by the clinical effects of depleting biogenic amines by reserpine. Before these new innovative treatments (warts and all) people with severe depression languished in an extra bedroom in a relatives’ house (neatly out of sight, an embarrassment), or simply in the state hospital.

    2. Pre-Thorazine, the thought disorder of schizophrenia went on and on for years, at least for the patients in the back wards, as a rule. More than a few patients treated with CPZ did make it out.

    3. Before the natural course of Major Depressive Disorder had been understood, you could throw just about any treatment at it; the early cases, no matter their remarkable severity, went into natural remission within the year; then would recur after a period in many. With Imipramine (warts and all) it could be relieved in over 65% of them in 2-3 weeks to the day. (Just like a light switch going off and on.)

    4. The shiny new drug trials and epidemiological studies were conducted by meticulous tracking of Diagnosis and Si and Sx to measure clinical improvement; yet there was no attempt to impose an etiology – none was really known. But there were working hypotheses which made their way into clinical lore.

    5. massive amounts of preclinical bench work has been accomplished over the years, and is still being accumulated. I am excited by the discrepancies in some of the work (e.g., Seemans findings D2 hypothesis of schizophrenia), intrigued with the possibility that many of the key implicated neurotransmitters are vasoactive and found in glia.

    6. Posited non- biological causes for these conditions ranging from evil spirits to psychodynamic formulation had already been dead ends, w/ Rx based on those “causes” seen as leading to appalling outcomes – much worse than today [the best epidemiology cannot refute this] even for those patients who could afford pastoral inpatient settings.

    Basic preclinical and clinical psychiatric research has continued at the NIMH, and in academia into the etiology of not only the big three core psychopharmacologic related illnesses, but also into basic brain biology. Some of the work (nerve growth factor, energy metabolism etc ) in many ways quantitatively and creatively parallels the early prosaic brilliance of psychoanalytic formulation. These are interesting internally consistent canons, presently still not linked to anything pragmatic.

    For the testing of biological hypotheses, three issues currently prevent success especially with the newest technology
    1. Watered down clinical diagnosis
    2. Animal models based on old pharmacological theories can’t predict new mechanisms
    3. No new probes linked to specific Diagnosis aside from NE, DA, 5HT as explained above.
    4. Because of its high risk adjusted return on investment, there is a general reluctance of a seemingly very wealthy industry to test astonishingly interesting molecules with novel mechanisms in batteries of patients with clear primordial stereotypical diagnostic constructs in clinical studies.

    i am going to bold this for emphasis:

    The major funding, for basic research shifted to the pharmaceutical industry, a free enterprise entity. Many idealistic preclinical and clinical scientists both outside of and within the non-marketing arms of that industry hoped that when rational drug discovery failed, at least serendipitous discoveries of molecule(s) with known mechanisms of action that could serve as probes into mental illness. This after all was much as had amytripyline, CPZ, and lithium served. All of the latter began as discoveries for “orphan indications”; originated in the bigpharma of old, or had been shepherded by it.

    In recent years, a slightly more hungry bigPharma became a tad more enlightened. Some managers, perhaps with mental illness running in their kin, began to see the wisdom of testing new molecules with vitally new mechanisms (e.g., neuropeptide molecules [agonists and antagonists) in a battery of clinical trials in patients with cross sectional and longitudinal patterns defined by mainly DSM III like mentality (the best we can do! )

    The only problem w/ that is that some of the orphan indications got shorted – such as OCD, PTSD, severe episodic anxiety (PANIC), fugue states, certain PERSONALITY DISORDERS. If the psychoanalysts had the political wherewithal to present its own system of dynamics formulation, and if it were judged by SPONSORS to have at least face validity and CATEGORICAL reliability, it could test these too. God knows – the industry might have even today – had it not jettisoned psychiatry – have tested these drugs in a Kohut model of Borderline personality – which he defined quite well as a stereotypical constellation.

    But here is why bigPHARMA isn’t the answer unless it does act very very very soon. Big PHARMA realized within the last decade that the Clinical trials were non informative – at a rate approaching 3:1. They did not understand why this was happening. (Also people who talk glibly about negative, failed, and positive studies generally do not know exactly what they are saying. And then when they attempt to do meta-analyses and explain the data they sometimes get it wrong. However, it is small Pharma who will find the bona fide investigators who will now be unencumbered and certainly not pressured to find the “real” classical primordial sterotypic patient.

    As you said: “Basic psychiatric research has gone nowhere.”

    I’d like to say that the sentiment of that headline would not be shared by many who devoted their entire lives to that pursuit. I’d say this:

    Basic psychiatric research has amassed enormous preclinical and clinical data over the past 50 years which is waiting for new clinically validated probe(s) before these data can blossom suddenly into a spectacular new series of insights. In addition until the work of the last 10 years is repeated in much more pristinely defined psychiatric populations – as TCA and CPZ’haloperidol or Lithium/Carbamezepin responsive – most of that work is for nil.

    This idea of sudden insights in Science is not primarily wishful thinking to defend a losing postiion. Every new age in science occurs according to abrupt shifts as predicted by catastrophe theory. What has been said, with possible impatience re the field of Biological Psychiatry, could also just as well apply to the whole of deep translational medicine. This is nowhere better illustrated than our search for the genetic links to disease, even after identifying the basic genome. The headline might as well have read “Basic Genetic research has gone nowhere” or “Medicine has gone nowhere.”

    The basic researchers who do the work of testing hypotheses with today’s advanced technology are as confused as the clinicians who really are trying to do the best for their patients – KOLs or not.
    There are 3 potential competing explanations for this state of affairs:

    1) Mental illness is not like physical disease. Biological Psychiatry is bogus

    2) Biological Diagnosis and Treatment has become over generalized, pseudo specific, dissociated from the very material observations which spawned the notion in the first place

    3) New molecular probes (new potential drugs) are not being tested in batteries of primordial stereotypical clinical presentations [as to the latter we know they exist]

    The implications of #1 are terrible – exorcism anyone? Prove scientifically that psychoanalysis or holistic medicine is better than placebo, that psychoanalytic formulation or naturalistic or structural family or behavioral therapy, cripes – ouch even CBT – is reliable and valid, effective and is more worthy of reimbursement than the friend who took you out to dinner – and made you feel just a little lighter. The burden of proof is not on biological psychiatry.

    The implications of #2 are: get back to basics. The old codger (sorry guys and gals >>> aged 40) investigators understand with a general specificity of “who is stereotypical” and “who is not” in terms of primordial sterotypical diagnosis and response to old treatments. Unfortunately (as they are getting ready to go poof off the planet) only these can provide safe passage to the coming good. The young residents of today – and more disturbingly some of the youngest KOLs, can’t do this. Without the old timers and their living apprentices no near-specific biological benchmark will be found – except possibly in entirely new primordially preserved stereotypical targets such as OCD, Bulimia and Anorexia, Borderline Personality Disorder.

    Progress cannot be made in biological psychiatry until the random stains on the bathroom floor are mistaken for a Picasso. Primordially stereotypic major depression or true Thought Disordered or Paranoid Schizophrenia are things of tortured beauty, that happen to reside in otherwise intact at times delightful personalities . Having been their direct advocate for over 15 years, some of which they consented to long controlled periods in wh they were medication-free sometimes doing so poorly on closed wards (on which I insisted to also have my office), I can say that any other framework aside from the biological would take them and their families back to a less healthy time. And then if experts in permanent placebo therapy, or publishing the DSM 6 try to block that, well. ..

    Just look at the beyond brilliant psychoanalytic formulations for the eating disorders, PTSD, or OCD . The outcomes are miserable when not anecdotal. At least most biologically oriented psychiatrists know nothing works well for OCD except luck and general support until natural remission occurs. Maybe the SSRIs, CBT, Chlomipramine help. But really, to what degree? The results are dismal.

    The implications of #3: A government-academic-industrial program must be developed to unshelve dust collecting drugs with sexy mechanisms (from bigPharma and which have passed the hurdles to get into Proof of Concept testing), and only to test these compounds in the most stereotypical patient populations. (especially the ones that would be orphan indications.) In this case all you need after a spectacular positive, is to replicate it 2-3-x – QUIETLY, and then you’ve got the proper molecular probe to advance the field. We have everything we need. Good people are already working this out quietly. No hoopla is needed. No false hope is needed.

    I also want to say in closing that the field of Biological Psychiatry is very new, as is modern medicine. As much as we may be scared by it, some angry at it. we also see that its present incarnation has lost its luster. This is what happens to most things. Modern Medicine is far from perfect and its treatments not nearly as effective as some would like, but many here who have aged with some difficulty might already know that they would not be alive if not for the medical hand that has fed us. I also think that for the many people who are revolted at the decline of Biological Psychiatry, and who have taken to the blogs with abandon to be MAD in America or otherwise complain (actually understandably), they’ve somehow forgotten all of those who are doing well on some of these meds – with few side effects and at conservative dosing regimens. Perhaps these are the people who might consent to be randomized to psychoanalysis, placebo or their old” horrible” pharmacotherapies. We could be surprised that these so vilified drugs are not such an easy target.

    And that brings this to mind. Why don’t we do the economic modeling just a little differently for mental “distress” as treated by biological psychiatry, neurology, endocrinology, faith healers, specific talk therapies, religions. Then measure cost of treatment, cost of managing side effects, entire cost of ancillary medical or other care, Productivity, Qol, mortality. Now that would be an interesting study. Components are already done. Anyone without a COI want to fund the srudy.

    Stray responses:

    The Last I looked Melancholia and other discrete depressive syndromes, likely targets for probably•biological research were in DSM IV T. Unfortunately I had to resort to Melancholia, to get a positive study. But sure as rain that was the substrate. The problem is there are only so many of them in the world. To be clear it is not just melancholia. It is severe depression with some of those very objective features.

    The idea of Treatment resistant depression is only troubling when you realize that the yardstick by which we measure depression at all is warped. It’s not that “they” ushered in the endless Clinical Trials of antidepressants and the drug strategies for treatment resistant depression, as much as the drug trials which have mistakenly recruited anxiety-depressive neurosis! Perhaps that’s what you mean. If so agreed.

    1BOM said: “And as they fiddled, Rome began to burn.” What Heracles, Augeus Nero – what’s next Oedipus and Electra? A greek tragedy. 🙂

    1BOM said: “Their early decision to put revision and refining on the back burner . . . ” Agreed. If I knew then what I know today –

    “Which was the bigger error? :
    Being unwilling to change directions when things went awry: Yes, an error – but it is Monday morning and the game was yesterday. [i.e. MMQB syndrome]
    Some conviction that all mental illness is biologic? Yes,. [i.e. MMQB ]
    A persisting influence of industrial interests [managed care, pharmaceuticals]? Yes [i.e. MMQB ]

    An assumption of the hegemony of psychiatry in the pantheon of mental health professions? NO. That was not an error. It was an ideal. It was just implemented so poorly as to be draw ire from other professions. I would fight for that hegemony (in the most neutral sense of the word) until the end, if supported by the merits of being able to take a metaposition that spans both the body, and metaphorically its metabolism of impressions. The issue here is not power, it is authority. This is for an authority reclaimed through merit. For that authority to be reclaimed by Psychiatrists, much will need to change in training and in accreditation and in the KOL groups. The psychiatrist must never abrogate medical responsibility or skills, They really must treat the whole person like never before – more like a specialized family practice physician with good skills across the board – referring when swamped to sub-specialties which can be staffed by other professions who incessantly compete for that authority.

    As long as medicine is alive, so will be psychiatry – just not as we now know it. The hegemony of Psychiatry has been much preferred to that of Social Worker therapists, Clinical Psychologists, Lay analysts, reflexology, Naturopaths, Homeopaths, chiropractors, Orgone therapists, womb therapist, gestalt, and behavior therapists. However, if things get much worse I am thinking that hegemony by Massage therapists wouldn’t be so bad.

    I’d become very close with an old friend who is a superb multimodal Social worker therapist. Of all the things expressed – this was most memorable, “I think the most important part of what I do is to be with my patients.” That is not biological psychiatry. It is also quite terrific, quite honest, quite refreshing


    Barney Frank
    December 4, 2012 | 10:15 AM


    December 4, 2012 | 11:24 AM


    I’m going to read it again, but first time through – I found nothing to disagree with. Well put. Thanks…

    Mark Kramer
    December 4, 2012 | 3:58 PM

    Errata 1

    Progress cannot be made in biological psychiatry until the random stains on the bathroom floor are not mistaken for a Picasso.

    Sandy Steingard
    December 4, 2012 | 8:21 PM

    This essay by Peter Bracken and colleagues published in the British Journal of Psychiatry eloquently describes the drive of modern psychiatry towards a technological approach and it argues persuasively that this drive is misguised and problematic. It put into words a struggle I have been trying to sort out. I am not prepared to give up on the brain but at the same time, I do not think that brain research is necessarily going to point the way to a deeper understanding of or effective treatments for many of the people who come into our offices.

    December 4, 2012 | 9:22 PM

    Just for the record, I’m not seeing biological psychiatry “on the way out” or even dichotomous with psychological psychiatry, nor do I see psychological formulations in competition with those from neuroscience. What I do see is a focus on the treatment mode rather than on clarity in diagnosis. There is and has been much confusion of the type in the Zen story of mistaking the pointing finger for the moon. We would do well to train clinicians in the ways of Adolf Meyers Common Sense Psychiatry with the judicious and careful use of medications when indicated, rather than in the as yet unrealized possibilities of some future psychiatry…

    Mark Kramer
    December 5, 2012 | 4:33 AM

    Sandy – I am interested in that article. Its been a very long day. So I hope to comment later. Thanks! Mark

    Mark Kramer
    December 5, 2012 | 4:35 AM

    “We would do well to train clinicians in the ways of Adolf Meyers Common Sense Psychiatry with the judicious and careful use of medications when indicated, rather than in the as yet unrealized possibilities of some future psychiatry… “

    Yep. As long as they continue to do the science. Anyway Serendipity is the key.

    Mark Kramer
    December 6, 2012 | 5:30 PM

    Hi Sandy,

    Read it. Elegant. Pragamatic for the struggling practitioner in short term. It’s seeming political correctness a disaster if enabled in the long term.

    To paraphrase Kant when he had been identified as a key figure of the Enlightenment – ‘We are nowhere near the age of enlightenment. ‘ OK. But, just like as the first master of materializing something more gross from something musch finer Whatever age this i [post analystic, post Biological] remember: Even as Freud blogged, the newly enlightened mobs gathered at the Viennese tower and threw garbage at the mentally ill of the day. Why? It was b/c the mentally ill appeared to lack reason, rationality (proportion/balance.)

    Psychiatry as literally coined is “Medicine of the Soul.” And it and Neurology are indelibly linked, and both generally way too narrow in scope. All branches of medicine are in reality indelibly linked to the whole patient, and the environment.

    The issue for Psychiatry just now reverts back to Dualism – an old chestnut wh should have already been terminally roasted.

    It is important to keep asking questions. My own questionable vision of the future includes a mechanistic understanding of the finer level of materiality we now call the Soul. What was magic yesterday, is simply a lawful exposition of principles that guide the seemingly unknowable. Ultimately, sometime deep into the eternal, at the very finest level of materiality, the penultimate question will arise, and it will be: “What, Why, Where, When, How is a “question?”

    Clinical Psychiatry, no matter its emphasis, requires a series of indelible mathematical laws, in much the same manner as physics. V=IR is a thing of beauty, as are thermodynamics I-III. We have no such thing YET in human behavior, except In=Organism=Out which is our version of modern. Today’s technology – whether for fun or business – is the pure magic of yesteryear. V=-IR cannot make an iPod. But V=IR is the “soul” of an iPod. Mathematics w/ feeling is God.

    I guess pragmatically, we will keep an ear and eye out for the V=IR in psychiatry, and adjust accordingly. Until then we shall stay mostly in the prequel to Enlightment, hoping not to slip back into an age of Faith.


    Mark Kramer
    December 6, 2012 | 5:31 PM

    Errata –
    Strike ; “But, just like as the first master of materializing something more gross from something musch finer . . .” [It was going to riff about Reverend Ike and the theorems of Physicality” ]

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