from the NIMH Grant Description: The results of the STAR*D trial prompted the next follow-on effectiveness trial study for the treatment of MDD, "Combining Medications to Enhance Depression Outcomes [CO-MED]." The CO-MED trial, supported by this contract modification, addresses the following specific questions regarding the use of combination medication therapy:
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Do patients who receive combination medication therapy as initial treatment for the onset of a depressive episode recover [reach remission] faster than patients who receive the more traditional single medication therapy?
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Are patients who receive treatment initially with combination medications more likely to reach remission?
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Is the durability of remission [i.e., sustainable recovery] more likely in patients who receive combination rather than mono medication therapy?
My own drift into Psychiatry has been more than adequately documented along the way on this blog. I found "routine office Internal Medicine" kind of tedious – managing High Blood Pressure, Chronic Disease, doing diagnostic work-ups. Most of those "work-ups" were negative and I found that just asking about "life" often lead me into the tangles of my patient’s lives that were presenting as medical symptoms. Flash forward to the year before I left Academic Medicine for practice. Our new Chairman, bringing the gospel of the New Psychiatry to our Department, engaged me in a discussion. I guess he was aiming for the evidence-based medicine thing, or at least the 1980s version. I certainly would never argue with the idea of evidence-based medicine as I understood it then or now. But what I said then and I still think is that what I saw as interesting were the medical situations where there was no clarity, no general category, and where you had to go into the details of a person’s unique life to find the answers and perhaps the solutions. I guess I was arguing my own version of personalized medicine. The point of bringing this discussion up is that I said when the etiology and treatment of a particular condition became clear, it would no longer be "psychiatric" and gave as examples Syphilis and Epilepsy. I was arguing that psychiatry was the medical specialty that dealt with the things that didn’t fit, the ambiguous. By the time of that discussion, by the way, I had realized there was not going to be a future for me there and was making other plans.
He thought that I was arguing against science which was the furthest thing from what I thought. He thought because I was finishing up my analytic training that I was pushing psychoanalysis. That wasn’t true either. If I was pushing anything, it would’ve been Adolph Meyers’ "Common Sense Psychiatry" – a book I had actually read several times. I had just developed the idea that if you spent time listening to people in the right way and followed the clues, the ambiguity began to clarify. I still think that and for me that was a science, at least scientific. Every case was a research project and the more I learned, the more likely it was that I might be able to help the person ooch closer to a better life. The new Chairman thought I was a nut case or a dinosaur. I kind of think of it as applying the scientific method to unique problems. And if that unique problem turns our to be not so unique after all, like it fits a known "disorder," then good news – the treatment is at hand. But if it stays unique, that’s okay too. If there’s no algorithm at hand, tailor one that fits. The proof is in the result. My logic about that is really not that complicated. Patients don’t care about medical science’s problems. If they fit into one of our medical boxes and there’s a treatment for people in that box – great. If they don’t fit, they still have the problem they brought for evaluation, so why not try to figure out the n=1 case you’ve got?
So why did I start with CO-MED? There were a couple of comments on an earlier post that if our new meds are only a partial solution, or aren’t specifically targeting the root cause of depression, then psychiatry disappears. That makes no sense to me at all. If many depressions are "biologic," it means that the biological psychiatrists have their work cut out for them. If many depressions are in the life/mind ball park, then those patients need someone who thinks like me. Doctors didn’t give up on diabetics because they hadn’t yet discovered insulin. The notion that psychiatry is only clinical neuroscience as Dr. Insel says just seems strange to me. Sick people don’t much care about "future help." They’re more in a "right now" frame of mind.
We’re still hacking at mental illnesses, doing what we can. I occasionally think back on that conversation with the then "new chairman." I know I was playing devil’s advocate with him because like so many of his colleagues, he was living in the as yet unrealized future. I think I even said, "You think I’m stuck in the past, but I think I’m stuck in the present." I guess it didn’t matter so much. We both had good careers and are both retired, happily. And as for CO-MED, or for that matter STAR*D, the current generation of antidepressants are what they are. Thus far, "souped up" antidepressant therapy doesn’t seem to have added very much, but hope springs eternal for some. The problem for me is that the STAR*D and CO-MED studies have been so oddly done and reported that I can’t even tell if they answer their own stated questions either way…
http://bipolarsoupkitchen-stephany.blogspot.com/2011/05/new-framework-proposed-for-manual-of.html press release re new DSM5 revisions
OCD no longer anxiety based now apparently its ‘neurocircuits’ gone awry! nice new catch phrase huh? then why, are all of these broadened dx’s remaining in a made-up book by the APA to be used by psychiatrists? when clearly they are working the labels to sound “medical”?
The Medicalization of the human condition!$$$ that’s why!
Mickey, I think you were referring to my comment re: psychiatry “disappearing.”
What I wrote was: “psychiatry as we know it will cease to exist.” In other words, this ongoing attempt to categorize symptoms into “diseases” and then develop drugs (whose mechanisms may be absolutely irrelevant) to treat these diseases, may get us nowhere. And indeed, the evidence to date (STAR*D, CO-MED) certainly indicates that by taking this approach we’re probably barking up the wrong tree.
I am in complete agreement with what you wrote in this post. Remember, my alternative to the downfall of modern psychiatry is to “await the era of personalized medicine.” Unfortunately, that phrase has also been corrupted in ways that you have very eloquently described in this blog. Nonetheless, your recommendation to “go into the details of each patient’s unique life” is one form of true “personalized” therapy. Something these large-scale trials cannot and will not do.