1 Boring Old Man

ex·pert [kspûrt]   ·noun     a person who has extensive skill or knowledge in a particular field   ·adjective     1. skilful or knowledgeable     2. of, involving, or done by an expert – an expert job [from Latin expertus – known by experience, from experiri – to test…]

^{Last year, a friend called from the road, driving back from an overnight trip to South Georgia. He’d gotten sick on the trip and wanted some advice. After listening for a couple of minutes, I just knew what was wrong. He had an anomalous Appendix that had already ruptured, and I told him to drive straight to the Emergency Room. That night he had an emergency appendectomy for a ruptured anomalous Appendix. He thinks I’m a genius – a psychiatrist who can diagnose such a thing over a cell phone.}

^{I’m not a genius, but in this case, I was an expert. As a second year medial student fifty years ago, the first autopsy I attended was on a 12 year old boy who had died from an overwhelming pneumonia within hours of coming to the hospital [a sign in the autopsy suite said, "this is where the dead teach the living how to live."]. He’d been to the Emergency Room with a stomach ache a day or so before and had been sent home. The autopsy room was filled with house officers – pediatricians, surgeons, E.R. docs. What he had was an atypical Appendix that went backwards rather than forwards, so the typical symptoms of Appendicitis were absent on that E.R. visit. It later ruptured and the infection spread through the diaphragm up into the chest showing up as a fatal pneumonia.}

^{It was a very emotional moment for me: a twelve year old child killed by an almost routine curable illness; a room full of distraught doctors who had missed the diagnosis; and a very young me realizing that this doctoring thing was going to be some kind of serious enterprise – scared to death about all the potential mistakes looming up ahead in my own future. We each had to present an autopsy to the class at the end of the year. This was mine, and I showed up with a stack of slides of the anatomic variants of the Appendix and the many clinical faces of appendicitis. That’s why I was an expert – terror, not genius. I had seen a tragic medical error and its consequences at a formative moment in my life. I’m sure every one of us in the autopsy room that night became an expert on unusual presentations in cases of appendicitis – the expertise of experience.}

We assume that expertise and experience go hand in hand, whether in a medical professional or a petty thief. The more people have seen and done, the more they know the shoals of error and illusion, the better they get at realistic predictions. When an aging elm tree mechanic looks under the hood of your car and shakes his head, it’s time to hit the car lots looking for a replacement.

Treating Depression to Remission
ASCP Speaks Out
^{by Rush, A John, MD and Trivedi, Madhukar H, MD}
Psychiatric Annals 1995 12:704-705,709.

^{RATIONALE FOR THE GOAL OF FULL REMISSION}

^{Evidence for the efficacy of antidepressant medications and brief, time-limited formal psychotherapies, although robust, is largely based on a significant reduction [rather than complete remission] of depressive symptomatology. Most randomized, controlled efficacy trials [RCTs] do not document full symptomatic remission and restoration of psychosocial and occupational functioning to premorbid levels in their evaluations of comparative efficacy. However, evidence from efficacy studies suggests that patients who fare best during continuation phase treatment are those who have attained the most complete symptomatic remission at the end of the acute phase. Thus, clinically, acute phase treatment is most successful if a full symptomatic remission, rather than just a response, results at the conclusion of the acute phase.}

^{This recommendation is not surprising in light of the management of other chronic or recurrent general medical disorders such as diabetes, hypertension, cancer, arthritis, or congestive heart failure. For example, it is well established that complications secondary to diabetes are substantially reduced in those patients who have better physiological and clinical control of the illness. Similarly, the more prolonged and the more thorough the degree of remission, the better the prognosis, whether or not treatment is discontinued.}

^{Perhaps it is a general property of biological systems that complete removal of the clinical manifestations of a disorder is less likely to lead to recrudescence of the illness in the future. Alternatively, it may be the case that those with the most chronic forms of illness are the least likely to attain a full symptomatic remission. Thus, evidence suggesting that full symptomatic remission is predictive of a good prognosis may, in fact, simply reflect the variable degree of responsiveness of the illness [i.e., more chronic, less responsive] rather than a treatment-specific effect.}

Report by the ACNP Task Force on Response and Remission in Major Depressive Disorder
^{by A John Rush, Helena C Kraemer, Harold A Sackeim, Maurizio Fava, Madhukar H Trivedi, Ellen Frank, Philip T Ninan, Michael E Thase, Alan J Gelenberg, David J Kupfer, Darrel A Regier, Jerrold F Rosenbaum, Oakley Ray and Alan F Schatzberg}
Neuropsychopharmacology 2006 31:1841–1853.
[full text on-line]

^{This report summarizes recommendations from the ACNP Task Force on the conceptualization of remission and its implications for defining recovery, relapse, recurrence, and response for clinical investigators and practicing clinicians. Given the strong implications of remission for better function and a better prognosis, remission is a valid, clinically relevant end point for both practitioners and investigators. Not all depressed patients, however, will reach remission. Response is a less desirable primary outcome in trials because it depends highly on the initial (often single) baseline measure of symptom severity. It is recommended that remission be ascribed after 3 consecutive weeks during which minimal symptom status (absence of both sadness and reduced interest/pleasure along with the presence of fewer than three of the remaining seven DSM-IV-TR diagnostic criterion symptoms) is maintained. Once achieved, remission can only be lost if followed by a relapse. Recovery is ascribed after at least 4 months following the onset of remission, during which a relapse has not occurred. Recovery, once achieved, can only be lost if followed by a recurrence. Day-to-day functioning and quality of life are important secondary end points, but they were not included in the proposed definitions of response, remission, recovery, relapse, or recurrence. These recommendations suggest that symptom ratings that measure all nine criterion symptom domains to define a major depressive episode are preferred as they provide a more certain ascertainment of remission. These recommendations were based largely on logic, the need for internal consistency, and clinical experience owing to the lack of empirical evidence to test these concepts. Research to evaluate these recommendations empirically is needed.}

^{If these recommendations were adopted for daily practice, clinicians would need to:}

1. specifically and repeatedly measure core criterion depressive symptom severity to guide the implementation and timely modification of treatment,
2. conduct sufficient visits or measurements to establish that 3 consecutive weeks of minimal to no symptoms [ie, remission] has or has not been achieved,
3. systematically inquire about the magnitude and types of side effects and overall side-effect burden, so as to accurately gauge whether the dose or type of treatment needs modification in order to achieve remission in a time-efficient fashion, and
4. follow the trajectory of symptom change [or lack of change] such that treatments [dose, type] can be modified in a timely fashion, hopefully informed by empirically defined triage points.

^{The use of a depressive symptom measure to assess the nine criterion symptom domains that define an MDE by DSM-IV-TR would become routine.}

^{"These recommendations were based largely on logic, the need for internal consistency, and clinical experience owing to the lack of empirical evidence to test these concepts."}

^{"The percentage of all patients treated achieving symptom remission with initial antidepressant treatment peaks at 35% — the remaining require at least two or more pharmacotherapeutic steps.}