Posted on Saturday 30 March 2013

Dr. Roy Poses has a theme that plays in and out of his blog, Healthcare Renewal called the anechoic effect. Here’s how I understood it on my first pass:
    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.
I needn’t give examples. We all know what he’s talking about. Without even thinking about it, we almost automatically put it into the equation. Example: Ben Goldacre comes on the scene with his charming mix of humor, quirkiness, and brains telling us something we all sort of know. He’s got a book or two about it. He’s even got a solution. My immediate thought was how can this story grow legs – stay on the front burner. It may be doing that – Fiona Godlee, editor of the British Medical Journal and others jumped into the fray. The AllTrials site and petition got going quickly. There are enough stories appearing in the press. Maybe it will stick. When I read Dr. Healy’s comments which are something of a retort [Not So Bad Pharma], I actually agree with his main point that the more ominous problem is our love affair with Clinical Trials altogether, but I worried that it might still the momentum – dampen the echo. The way I see it, Ben’s is a right now point, David’s is a big picture point. They’re different, somewhat in opposition, but ultimately the same. Both need 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.

Hope is a good thing. But in my opinion, either using the past [the good old days] or the future [science fiction, future·think] to escape the confusion of the present is a danger. And in modern psychiatry, we’re prey to both. I’m pretty sure that mental illness will provide us with plenty of confusion no matter which direction we travel in time, so I hope that the problem future·think isn’t anechoic
    March 30, 2013 | 3:23 PM

    All of the sciences are suffering from privatization. In order to escape the toxic effects of monetizing scientific endeavor, we’re going to need to force industry to make all their data available, and to publicly fund universities and research a lot more. Which means more tax revenue.

    At this point, “future-think” appears to me to be a natural consequence of marketing and investment on top of the fact that psychiatry appears to be trying too hard to stake it’s claim as a science with too little evidence.

    March 30, 2013 | 7:17 PM


    Very nice post.

    March 31, 2013 | 10:34 AM

    the “corporatization of Academic Institutions” is a very public effort

    an example from the UK

    Strengthening Academic Psychiatry

    Summary| Working Group Membership| Terms of Reference

    The Academy has convened a high level working group to strengthen academic psychiatry in the UK. The objective of this group is to provide advice to further improve training in this area, work across traditional scientific and clinical discipline boundaries and draw upon best practice from other countries.

    For further information please contact:

    Working Group Membership:

    Sir David Carter FMedSci (Chair)
    Former Regius Professor of Clinical Surgery University of Edinburgh

    Professor Jeremy Hall
    Professor of Psychiatry, University of Edinburgh

    Professor Paul Harrison
    Head of Translational Neurobiology, University of Oxford

    Mr Peter Hutchinson
    Senior Surgical Fellow, University of Cambridge

    Professor Shitij Kapur FMedSci
    Dean, Institute of Psychiatry, King’s College London

    Professor Christopher Kennard FMedSci
    Head, Department of Clinical Neurology, University of Oxford

    Professor Geraint Rees FMedSci
    Director, Institute of Cognitive Neuroscience, University College London

    Professor Trevor Robbins CBE FRS FMedSci
    Head of the Department of Experimental Psychology, University of Cambridge

    Professor Simon Wessely FMedSci
    Vice Dean, Academic Psychiatry, Institute of Psychiatry King’s College London


    Professor Nick Craddock FMedSci
    Treasurer, Royal College of Psychiatrists

    Professor Jim Neilson
    Dean for Faculty Trainees, NIHR

    Dr John Williams
    Head, Neuroscience and Mental Health and Head, Clinical Activities, Wellcome Trust


    Dr Kathryn Adcock
    Mr Laurie Smith
    Terms of Reference:

    Identify the challenges and barriers, perceived or otherwise, in recruiting and retaining trainees in academic psychiatry and to make recommendations to strengthen the workforce in this area.
    Consider how psychiatry and the neurosciences can work across traditional boundaries to develop an academic training programme that will equip future generations with the knowledge and skills required to meet healthcare needs.
    Where appropriate, make comparisons of clinical academic workforce profiles in other countries, in particular the United States.

    March 31, 2013 | 10:39 AM

    a forthcoming article in BJPsych also tackles this theme

    The future of academic psychiatry may be social

    Stefan Priebe, Tom Burns and Tom Craig


    The past 30 years have produced no discoveries leading to major changes in psychiatric practice. The rules regulating research and a dominant neurobiological
    paradigm may both have stifled creativity. Embracing a social paradigm could generate real progress and, simultaneously, make the profession more

    Declaration of interest
    The British Journal of Psychiatry (2013)
    202, 1–2. doi: 10.1192/bjp.bp.112.116905

    March 31, 2013 | 10:40 AM

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