warned…

Posted on Thursday 6 October 2011

 

It’s hard not to be skeptical about new scientific developments in matters psychiatric after the last several decades of confusion and misinformation. SSRIs, SNRIs, Mood Stabilizers, Atypical Antipsychotics – each came with inflated or distorted claims of efficacy and illusions of safety that evaporated with widespread usage. While that’s an expected danger in any medical advance, the widespread collusion of academic and organized psychiatry with the pharmaceutical industry upset the balance between restraint and innovation, leaving patients and practitioners alike fumbling in the dark on a what started out to be a bright, shiny day.

Comes now personalized medicine – the name given to the treatment possibilities hypothetically opened up now that genetic testing is available. A number of psychiatric disorders have long been thought to be inherited, though the familial associations are statistical rather than Mendelian and likely represent a level of genetic complexity yet undeciphered – Schizophrenia, Manic-Depressive Illness, Attention Deficit Disorder, etc. So the exciting genomic technology available offers a new avenue for that research, but that’s not what personalized medicine means. Says Wikipedia:
Personalized medicine is a medical model emphasizing in general the customization of healthcare, with all decisions and practices being tailored to individual patients in whatever ways possible. Recently, this has mainly involved the systematic use of genetic or other information about an individual patient to select or optimize that patient’s preventative and therapeutic care.
The classical example has to do with the Cytochrome P450 family of enzymes that moderate drug metabolism:
Many drugs may increase or decrease the activity of various CYP isozymes either by inducing the biosynthesis of an isozyme (enzyme induction) or by directly inhibiting the activity of the CYP (enzyme inhibition). This is a major source of adverse drug interactions, since changes in CYP enzyme activity may affect the metabolism and clearance of various drugs. For example, if one drug inhibits the CYP-mediated metabolism of another drug, the second drug may accumulate within the body to toxic levels. Hence, these drug interactions may necessitate dosage adjustments or choosing drugs that do not interact with the CYP system. Such drug interactions are especially important to take into account when using drugs of vital importance to the patient, drugs with important side-effects and drugs with small therapeutic windows, but any drug may be subject to an altered plasma concentration due to altered drug metabolism.
The list of drugs affected is impressive [including many of the psychopharmacologic medications] and clarifies a lot about drug reactions and toxicities, but even that’s not where all the excitement about personalized medicine in psychiatry centers. It’s in the area of treatment choice.

Matters genetic are not so simple as they were in high school biology. Genes encode proteins – which about covers everything there is, so the breakthrough of sequencing the Human Genome only opens a new door but says little about what’s on the other side. The possibilities are both exciting and daunting – so genomics, proteomics, and metabolomics are quite the rage but remain obscure. In psychiatry, the focus is on using genotyping to predict drug response. Such a hypothesis requires skipping an ocean of scientific steps, but that never stopped anyone. There are two approaches – one is to look at genes that might have some effect on known mechanisms of a medication [like serotonin metabolism] and compare the genotypes of responders to various drugs. Another approach is to measure as many things as humanly possible and look for any associations with drug response – going "fishing." Both methods are underway in multiple foci as we speak.

Other than a new vocabulary, it all has a familiar ring. Personalized medicine has become the new future, the new leading edge in psychiatric research. What’s familiar? The voices for one thing seem to come from a familiar chorus. Last week we listened to Dr. Jeffrey Lieberman talk about the topic. And here’s a sampling of some other voices:
      "This application brings together researchers with extensive experience in conducting large clinical trials and experts at the forefront of the neurobiology of depression, including: clinical trials [Trivedi, Fava, Schatzberg, Nierenberg, Shelton, Gaynes, Hollon], genetics [Smoller, Binder, McMahan, Perils], neuroimaging [Phillips, Sheline, Etkin, Pizzagalli, Buckner], qEEG [losifescu, Ellenbogen], neurotrophins/cytokines [Duman, Sanacora, Turck, Shelton], clinical predictors [Shelton, Hollon, Trivedi, Fava, Nierenberg, Goodman, Yehuda], neuroendocrine markers [Holsboer, Schatzberg, Shelton, Yehuda], epigenetics [Nestler, Yehuda],and cognitive behavior therapy [Hollon, Manber, Arnow]. This team will also be guided by internationally known biomarker scientists [Holsboer, Schatzberg, Krystal, Charney, Goodman], as well as a highly qualified group of biostatisticians [Kraemer, Wisniewski, Schoenfeld]."
      "by Leanne M Williams …, A John Rush, Stephen H Koslow, Stephen R Wisniewski, Nicholas J Cooper, Charles B Nemeroff, Alan F Schatzberg, and Evian Gordon"
We’ve heard from many of them before: STAR*D, CO-MED, TMAP, IMPACTS, Senator Grassley, Speaker’s Bureaus, Advisory Boards, the long COI lists at the ends of articles, countless drug trials, etc.

Something else familiar? It’s the Clinical Trial Model so typical for the last few decades. Out go the protocols. Clinical evaluators select patients with structured interviews or standardized ratings. Off go the samples to the outside lab. Meds are given. Data is gathered. Results are returned. The current buzz-word is Translational Sciencegetting things from the bench to the bedside quickly. Well whose bench? What bedside? Perhaps a better definition would be Translational Sciencefrom the printouts to the journal [or to the editorial assistant]. It’s ‘hands off’ ‘guest author’ research and it shows in the monotony of the papers and their obfuscated statistics and graphs.

So my skepticism about personalized medicine in psychiatry is justified by the players involved and their collective track record. But there’s more. The focus is on Major Depressive Disorder, a clearly heterogeneous group of patients. They’re testing drugs that barely separate from placebo in the first place and using subject gathering techniques known to insure heterogeneity. And in some cases, the experiment has already been done and failed. For example. In STAR*D they used Citalopram followed with Bupropion with diminishing returns. In CO-MED they compared Escitalopram with and without Bupropion – no difference. What would make Dr. Trivedi think responders are two different populations? Beats me! Those are the drugs he’s picked for his NIMH STUDY.

Yet another reason for my skepticism has to do with the power of hypothesis [power as in exponent]:

    hypothesis: depression is a unitary category = doubtful
    hypothesis: depression is biological = sometimes
    hypothesis: the biology is related to neurochemistry = maybe
    hypothesis: that neurochemistry is genetic = possibly
    hypothesis: drugs work by altering the neurochemistry = probably
    etc.

[ doubtful x sometimes x maybe x possibly x probably x … ] = hypothesis5+. My example may be forced but I stand on my point – this is way too speculative, and from a group whose history with speculation is decidedly challenged. The problem is, they’re going to find something. Measure enough things and you’ll find some combo of parameters that correlates with something else. Even statistics themselves become speculative in the situation of such fishing expeditions – arbitrary corrections that hopefully adjust for the sea of parameters.

Even more worrisome than the academic studies, the proprietary versions will produce reports with associations – no question about it. For example, genOmind compares your phenotype against 18 antidepressants and 8 antipsychotics and makes suggestions based on a traffic light motif – red light, yellow light, green light [how they make those distinctions wasn’t on the podcast]. Independent of the science, it offers a fine antidote to the growing complaints about poor efficacy for the antidepressants, "you must’ve on the wrong one for your phenotype."

I have little doubt that genomics will ultimately produce some powerful medical advances, maybe even in psychiatry, but the current efforts to discriminate among the current medications for the treatment of depressed people is suspect from the start. At issue: Are we going to tolerate the kind of fuzzy math and trivial differences that we’ve accepted in the recent past? Or are we going to insist on reasonable scientific rigor, reproducability, and robust rather than trivial differences this time around? We’ve been more than amply warned…
  1.  
    SG
    October 7, 2011 | 1:46 AM
     

    OK I just conceptualized what psychiatry is these days. Basically, the process of new research (whether it be personalized medicine, translational science, or the psych med developments of the last 25 years) migrating to the average psych patient is akin to one big corrupt digestive tract.

    The “science” (such as it is) passes through the corrupt esophagus (the original researchers of studies that rig the studies and have COIs and corrupt psychiatrists at APA and NIMH who steer “science” to fit their agendas), travels down to the stomach (the FDA, which has largely been a victim of regulatory capture by pharma), then through the colon (ghostwritten and corrupt articles appearing in major medical journals), and then passed through the rectum of your local psychiatrist’s office.

    The result? A steaming turd for the patient.

    But my oh my, how STUPENDOUS psychiatry is at polishing turds!

  2.  
    Peggi
    October 7, 2011 | 6:53 AM
     

    Mickey, thank you for your excellent posting. SG, thank you for starting my day with a chuckle. More than a smile. A real chuckle.

  3.  
    October 7, 2011 | 7:18 PM
     

    Actually, your earlier writing from two years ago, last year on politics has gone full-circle… back to political writing.

    And it’s understandable.

    Because to conduct an honest and thorough study of conventional psychiatry… to become cognizant of the falsified research and the perpetuation of a myth to sell drugs and to keep a medical profession alive, is to study politics.

    Conventional psychiatry is not based on medical science.
    It’s based on political science.

    I appreciate the National Debt Counter on the top of your blog.
    Here’s another one, that breaks down the spending by category/programs-

    http://www.usdebtclock.org/

    When you look at the spending in the areas of Medicaid, Medicare and Social Security; and consider the disability that’s been caused by placing psychiatric labels on people, drugging their bodies, minds and spirits into oblivion; the federal tax money spent on the fraudulent research; it becomes obvious that conventional psychiatry has done an enormous amount of damage – to our youth, elderly, military service members… and treasury as well.

    Conventional psychiatry.
    50 years of a failed psycho-pharmacological approach.
    A millennium of damage to a nation and its people.

    Duane Sherry, M.S.

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