1 Boring Old Man

^{He talks frequently about something called "the anechoic effect." It just means that when something gets exposed, it doesn’t echo – the story gets lost, forgotten, and loses the power it really ought to have [often as a result of the interventions of the exposed]. I guess it’s the opposite of that saying journalists use about a story "having legs" for one that grows bigger by the hour… So Dr. Poses uses Health Care Renewal to keep us focused on stories that didn’t get enough echos to grow any legs.}

So back to Dr. Poses. He has a post up right now that’s the biggest of points that needs the legs of a centipede, NYU Faculty Vote No Confidence in their President. Not long ago, he had another, At University of Miami, Faculty Without Confidence in their Hired Managers Afraid to Identify Themselves. The point is the corporatization of Academic Institutions with the loss of the academic mission, and it’s a mighty big point. In Atlanta, I watched the Department I left in the 1980s thrive under Dr. Charles Nemeroff while Emory University tolerated years of sheenanigans that should’ve been firing offenses, simply because he was a four star fundraiser. But it has happened in medical schools, departments of psychiatry,  as well as in our most esteemed colleges all over the country. echo echo echo echo echo echo…

I got to wondering if I had a theme. I’m sure there are a number, but the one that comes most quickly to mind is future·think. It’s an old one with me. I left a career in academic research because of it a thousand years ago. Forced to practice medicine by being drafted, I found that practicing medicine was something that I liked doing much more than I would’ve imagined, and that my immersion in studying things we didn’t yet know lost it’s relevance. That’s not really true, because I still love to read about the leading edge of science of all kinds. I guess a better way to say it is that I found that the future didn’t help the patient I was seeing right now, and that a better place to focus my attention was on mastering what we do know.

Modern psychiatry is so sick with future·think that I’m beginning to think it ought to be added to the DSM [why not? everything else is in there]. For the last thirty years, we lived on the promise of the neoKraepelinian Tenets, that the brave new world of biomedical psychiatry [AKA clinical neuroscience] is just around the corner. Don’t get me wrong here. I actually think some of the biological advances available now are impressive. They’re just so over-blown, so over-talked-about and so over-used that their worth gets lost in the din of BS. If my child has an acute schizophrenic episode, I’ll find her a psychiatrist who knows his/her drugs for the up-front treatment and is then obsessed with lowering doses aiming for zero while following closely [and is equally obsessed with informed psychosocial interventions]. If my spouse had Melancholia, I’d find her a biological psychiatrist and I wouldn’t let my personal distaste for the idea of ECT stop them if it came to that. Many will disagree with those comments, but I just know that’s what I would do.

But the general theme of future·think in psychiatry grates like fingernails on a chalkboard. It’s so prevalent that the whole DSM-5 was built around it. It’s leaders were so fixated on their notion of a future psychiatry with biomarkers [un·located] and biological treatments [un·specified] that they proposed building our diagnostic system around the idea [un·successful]. For years, our literature has been filled with articles with recent advances in, new horizons in, or novel approaches to in the title. It’s as if we knew nothing before 1980 [DSM-III] and are awaiting the just-around-the-corner things coming our way in the just-around-the-corner future. One of my personal laments is that because of the dis-satisfaction with what the likes of Freud, Meyer, and all the psychiatrists in between didn’t know, we threw out the basic skills of psychiatry they gave us in our love affair with clinical neuroscience.

I had an odd clinic day this week. When I left a busy clinic, I realized that I had written no prescriptions for an antidepressant, and I had seen three new adult patients who had all lived with the sequelae of childhood trauma, un·discussed for a lifetime. None brought it up, but it wasn’t hard to find – an averted gaze, some code-words, a history of fated self-exile. These are all things I would never have noticed as an Internist, but couldn’t miss now if I tried. I know it helped them to talk about these things [in part because they told me so]. This is a minor example of the things I came to psychiatry to learn to do, and I lament that they’re not being taught in the explosion of future·think. One of my best supervisors was a dedicated sleep-researcher obsessed with the REM sleep findings in depression, but that’s not what he taught me about. He was an absolute wizard as a clinician.

Another example of how much future·think has pervaded psychiatry came in the summer of 2011. It became apparent that the pharmaceutical companies were pulling out of CNS drug development. In spite of the fact that we’d known for some time that the "pipeline" of new drugs was empty, this mass exodus triggered a 911 level response. Article were written; conferences were held; the NIMH director’s blog filled with creative solutions; homilies were generated; and the ripples continue to be felt to this day. We’ve lived so much in the future that the loss of the future actually produced a Grief Reaction [maybe I should say a Major Depression]. And the notion that a new me-too drug must be better is another part of the clinical neuroscience future·think story [see Viibryd I…]. Best I can tell, the other option for a me-too is much more likely – the dregs.