{"id":10506,"date":"2011-06-21T22:13:33","date_gmt":"2011-06-22T02:13:33","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=10506"},"modified":"2011-06-21T22:19:13","modified_gmt":"2011-06-22T02:19:13","slug":"contrasts","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/06\/21\/contrasts\/","title":{"rendered":"contrasts&#8230;"},"content":{"rendered":"\n<p align=\"justify\">The other day, I encountered two things almost simultaneously. The first was a 2007 Journal Supplement on Melancholia that I found compelling. As I was reading through the articles, someone sent me a link to an abstract I hadn&#8217;t seen from Drs. Rush and Trivedi &#8211; a policy piece about <em>Measurement Based Care<\/em>. There was a striking contrast between articles in the Supplement and the later Abstract, and they lingered in my mind together through several busy days.<\/p>\n<p align=\"justify\">The 2007 Supplement in the <strong><font color=\"#660033\">Acta Psychiatrica Scandinavica<\/font><\/strong> was called <strong><font color=\"#200020\">Melancholia: Beyond DSM, Beyond Neurotransmitters<\/font><\/strong>  [I liked both &quot;beyonds&quot;]. It was from a conference in Copenhagen in  2006. I felt nostalgia as I read through the various  articles. They were like journals used to be before they got filled up with clinical  trials. The Preface set the stage for the conference:  <\/p>\n<ul>\n<div align=\"justify\"><strong><sup>There  has been rising unhappiness within psychiatry and psychopharmacology  over the heterogeneous nature of &lsquo;major depression,&rsquo; over the poverty of  current patent-protected offerings in the treatment of mood disorders,  and over the lack of innovative new approaches in drug discovery. In May  2006 a group of specialists in the biology, history and clinical care  of mood disorders met in Copenhagen to consider one of the principal  illness entities within the category &lsquo;major depression&rsquo;&ndash; melancholia.  The point of the conference was to identify new directions in the  biological understanding and clinical care of melancholic illness, a  robust historical diagnosis that now seems ripe for revival&#8230;<\/sup><\/strong><\/div>\n<p><strong><br \/>        <\/strong><\/p>\n<div align=\"justify\"><strong><sup>Melancholia  represents a disease in itself on the basis of psychopathology,  biology, and response to treatment. MMD is characterized clinically by  psychomotor change and symptoms of severe mood disturbance;  biologically, it demonstrates distinctive neuroimaging features, a  characteristic response to the dexamethasone suppression test, and shows  rapid eye movement sleep latency; in therapeutic terms, melancholia  responds preferentially to electroconvulsive therapy and to certain  psychopharmacologic approaches. Non-melancholic mood disorder, by  contrast, demonstrates few of these characteristics and represents a  mixture of anxiety, character disturbance, and situational reactions  that requires further elucidation&#8230;<\/sup><\/strong><\/div>\n<\/ul>\n<div>There was a clear description of the syndrome of Melancholia: <\/div>\n<blockquote>\n<div align=\"center\"><u><a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/17280566\"><strong><font color=\"#200020\">Resurrecting melancholia<\/font><\/strong><\/a><\/u><br \/>        <sup>by M. Fink &amp; M. A. Taylor<\/sup><br \/>        <strong><font color=\"#200020\">Acta Psychiatrica Scandinavica<\/font><\/strong> 115[s433]:14&ndash;20, 2007.<\/div>\n<p>        <\/p>\n<div><strong>Abstract<\/strong><\/div>\n<div align=\"justify\"><sup><strong><u>Objective<\/u>:  To define melancholia as a distinct mood disorder, identified by  unremitting depressed mood, vegetative dysfunction, and psychomotor  disturbances, verifiable by neuroendocrine tests, and treatable by  electroconvulsive therapy and tricyclic antidepressants. <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u>Method<\/u>:  A review of the literature of two centuries finds descriptions of  severe mood disorders, either depression or mania or circular, defined  as &lsquo;melancholia.&rsquo; In the 1980 diagnostic revision (DSM-III), melancholia  was relegated to a features specifier only. <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u>Results<\/u>:  DSM classification criteria develop heterogeneous patient samples that  are neither guides to prognosis nor to treatment response, and confound  studies of pathophysiology. Within the large population of mood  disorders, a syndrome of melancholia is identifiable by specific  behaviors, vegetative signs, and validated by neuroendocrine  abnormalities (cortisolemia). Populations so identified are clinically  homogeneous and have improved treatment responses. Patients meeting  criteria for melancholia are now identified as psychotic depressed,  geriatric depressed, postpartum psychosis, and pharmacotherapy  resistant. <\/strong><\/sup><\/div>\n<div align=\"justify\"><sup><strong><u>Conclusion<\/u>:  The review supports the establishment of melancholia by empirically  derived criteria rather than by a checklist is an alternative to the  major depression choice and offers an improved model for psychiatric  classification. <\/strong><\/sup><\/div>\n<\/blockquote>\n<div>Fink and Taylor even gave us some [DSM-III sounding] criteria for melancholia:<\/div>\n<div align=\"center\"><img decoding=\"async\" border=\"0\" vspace=\"5\" src=\"http:\/\/1boringoldman.com\/images\/acta-2.gif\" \/><\/div>\n<div>Dr.  Bernard Carroll [et al] was there [out of his watchdog mode and in his  researcher role] with a sophisticated study of cortisol dynamics in  Melancholia.<\/div>\n<blockquote>\n<div align=\"center\"><u><a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/17280575\"><strong><font color=\"#200020\">Pathophysiology of hypercortisolism in depression<\/font><\/strong><\/a><\/u><br \/>        <sup>by B. J. Carroll, F. Cassidy, D. Naftolowitz, N. E. Tatham, W. H. Wilson, A. Iranmanesh, P. Y. Liu, and J. D. Veldhuis<\/sup><br \/>        <strong><font color=\"#200020\">Acta Psychiatrica Scandinavica<\/font><\/strong> 115[s433]:90&ndash;103,2007.<\/div>\n<p>        <\/p>\n<div><strong>Abstract<\/strong><\/div>\n<div align=\"justify\"><strong><sup><u>Objective<\/u>:  The mechanisms mediating hypercortisolemia in depression remain  controversial. Adopting the biomarker strategy, we studied  adrenocorticotropin (ACTH) and cortisol dynamics in hypercortisolemic  and non-hypercortisolemic depressed in-patients, and in normal  volunteers.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup><u>Method<\/u>:  Deconvolution analysis of 24-h pulsatile secretion, approximate entropy  (ApEn) estimation of secretory regularity, cross-ApEn quantitation of  forward and reverse ACTH&ndash;cortisol synchrony, and cosine regression of  24-h rhythmicity.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup><u>Results<\/u>:  Hypercortisolemia was strongly associated with melancholic and  psychotic depressive subtypes. Hypercortisolemic patients had elevated  ACTH and cortisol secretion, mediated chiefly by increased burst masses.  Basal ACTH secretion was increased, ACTH half-life was reduced, and  mean 24-h ACTH concentration was normal. Cortisol secretion was  increased in a highly irregular pattern (high ApEn), with high ACTH &rarr;  cortisol cross-ApEn (impaired feedforward coupling). Cortisol-mediated  feedback on the secretory pattern of ACTH was normal. Hypercortisolemic  depressed patients had normal programming of the central  hypothalamo&ndash;pituitary&ndash;adrenal (HPA) axis pulse generator: ACTH pulse  frequency, cortisol pulse frequency, circadian acrophases, and ApEn of  ACTH secretion were normal. Responsiveness of the adrenal cortex to  endogenous ACTH was normal. Non-hypercortisolemic patients resembled  hypercortisolemic patients on ACTH regulatory parameters but had low  total cortisol secretion.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup><u>Conclusion<\/u>:  Increased ACTH secretion occurs in depressed in-patients regardless of  cortisolemic status, confirming central HPA axis overdrive in severe  depression. Depressive hypercortisolemia results from an additional  change in the adrenal cortex that causes ACTH-independent, disorderly  basal cortisol release, a sign of physiological stress in  melancholic\/psychotic depression.<\/sup><\/strong><\/div>\n<\/blockquote>\n<div>But the article that I found myself rereading was this one:<\/div>\n<blockquote>\n<div align=\"center\"><u><a target=\"_blank\" href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/17280565\"><strong><font color=\"#200020\">The doctrine of the two depressions in historical perspective<\/font><\/strong><\/a><\/u><br \/>        <sup>by E. Shorter<\/sup><br \/>        <strong><font color=\"#200020\">Acta Psychiatrica Scandinavica<\/font><\/strong> 115[s433]:5&ndash;13,2007.<\/div>\n<p>        <\/p>\n<div><strong>Abstract<\/strong><\/div>\n<div align=\"justify\"><strong><sup><u>Objective<\/u>:  To determine if the concept of two separate depressions &ndash; melancholia  and non-melancholia &ndash; has existed in writings of the main previous  thinkers about mood disorders.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup><u>Method<\/u>: Representative contributions to writing on mood disorders over the past hundred years have been systematically evaluated.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup><u>Results<\/u>:  The concept of two separate depressions does indeed emerge in the  psychiatric literature from the very beginning of modern writing about  the concept of &lsquo;melancholia&rsquo;. For the principal nosologists of  psychiatry, melancholic depression has always meant something quite  different from non-melancholic depression. Exceptions to this include  Aubrey Lewis and Karl Leonhard. Yet the balance of opinion among the  chief theorists overwhelmingly favors the existence of two quite  different illnesses.<\/sup><\/strong><\/div>\n<div align=\"justify\"><strong><sup><u>Conclusion<\/u>:  The concept of &lsquo;major depression&rsquo; popularized in DSM-III in 1980 is a  historical anomaly. It mixes together psychopathologic entities that  previous generations of experienced clinicians and thoughtful  nosologists had been at pains to keep separate. Recently, there has been  a tendency to return to the concept of two depressions: melancholic and  non-melancholic illness. &lsquo;Major depression&rsquo; is coming into increasing  disfavor. In the next edition of DSM (DSM-V), major depression should be  abolished; melancholic mood disorder (MMD) and non-melancholic mood  disorder (NMMD) should become two of the principle entities in the mood  disorder section.<\/sup><\/strong><\/div>\n<\/blockquote>\n<div align=\"justify\">I first encountered Dr. Shorter through his book <a target=\"_blank\" href=\"http:\/\/www.amazon.com\/Before-Prozac-Troubled-Disorders-Psychiatry\/dp\/0195368746\"><strong><font color=\"#400040\">Before Prozac: The Troubled History of Mood Disorders in Psychiatry<\/font><\/strong><\/a>  which was an invaluable resource in looking back at the genesis of the  DSM-III. The abstract doesn&#8217;t do justice to this article which reviews  the history of clinical depression classifications. He makes the point  that the collective clinical intuition throughout history is that there are two kinds of depression [except for the last thirty years]. He  goes on to discuss how modern science confirms the distinction, and concludes the obvious:<\/div>\n<ul>\n<div align=\"justify\"><strong><sup>This  argument of the two depressions has two important practical  implications. If one accepts the notion that there are two depressions,  then major depression of the DSM has no longer exists. As an amalgam of  the two depressions, major depression should be removed from the next  edition of the Manual.<\/sup><\/strong><\/div>\n<\/ul>\n<p align=\"justify\">In those early days of the DSM-III, one frequently heard the argument against &quot;<strong><em>n = 1<\/em><\/strong>&quot;  science. It was, of course, aimed at psychoanalysis which focused on  one case at a time, then generalized to groups. They were saying that  was backwards, it should be group findings generalized to individuals.  The point has been duly noted and taken. But there&#8217;s another way to  think about that discussion. For clinicians, it&#8217;s <u>always<\/u> an &quot;<em><strong>n = 1<\/strong><\/em>&quot;  situation &#8211; the one case before you at the moment. It&#8217;s how all of  medicine is practiced. As such, a meeting of a clinician and a patient  should be an encounter between a person with &quot;ill-ness&quot; and the history  of medicine&#8217;s experience &#8211; with an eye on diagnosis, treatment, and  management.<\/p>\n<div align=\"justify\">I thought all three of these  articles would inform my meeting with a depressed patient. Drs. Fink and  Taylor offer a set of criteria to separate out a <em>kind<\/em> of  depression that directs treatment and management. Dr. Carroll et al  furthers the understanding of the only thing close to a biologic marker  in psychiatry [an abnormality in cortisol metabolism] with a graph that  demonstrates the obvious difference between the two kinds of depressed  patient:<\/div>\n<p align=\"center\"><img decoding=\"async\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/acta-3.gif\" \/><\/p>\n<div align=\"justify\">  And finally, a historian who focuses on psychiatry reviews the history of medical views of depression, <u>including exceptions<\/u> to the prevailing view, and argues that separating out Melancholia remains clinically relevant. He says, &quot;<strong>&#8230;<\/strong> <strong>major depression should be removed from the next  edition of the Manual<\/strong>.&quot;<\/div>\n<p align=\"justify\">Besides the fact that I&#8217;m sympathetic to the conclusions in these articles, the things that struck me were their transparency and the fact that they seemed to be written to be read by colleagues. I&#8217;ve been reading clinical trial articles for months, and I&#8217;m always looking for what&#8217;s being buried and what spin is being put on the results &#8211; where I&#8217;m being lead. I found these articles a refreshing change of pace.<\/p>\n<p align=\"justify\">Then this abstract popped up in the middle of my reading:<\/p>\n<blockquote>\n<div align=\"center\"><a href=\"http:\/\/www.ncbi.nlm.nih.gov\/pubmed\/21295000\" target=\"_blank\"><u><strong><font color=\"#200020\">Measurement-based care in psychiatric practice: a policy framework for implementation.<\/font><\/strong><\/u><\/a><br \/>       <sup>by Harding KJ, Rush AJ, Arbuckle M, Trivedi MH, Pincus HA.<\/sup><br \/>       <strong><font color=\"#200020\">Journal of Clinical Psychiatry<\/font><\/strong>. Jan 11, 2011 [Epub ahead of print]<\/div>\n<p>       <\/p>\n<div><strong>Abstract<\/strong><\/div>\n<div align=\"justify\"><sup><strong>This  article describes the need for measurement-based care (MBC) in  psychiatric practice and defines a policy framework for implementation.  Although measurement in psychiatric treatment is not new, it is not  standard clinical practice.<font color=\"#990000\"> Thus a gap exists between research and practice outcomes.<\/font>  The current standards of psychiatric clinical care are reviewed and  illustrated by a case example, along with MBC improvements.  Measurement-based care is defined for clinical practice along with  limitations and recommendations. <font color=\"#990000\">This article  provides a policy top 10 list for implementing MBC into standard  practice, including establishing clear expectations and guidelines,  fostering practice-based implementation capacities, altering financial  incentives, helping practicing doctors adapt to MBC, developing and  expanding the MBC science base, and engaging consumers and their  families.<\/font> Measurement-based care as the standard of care could  transform psychiatric practice, move psychiatry into the mainstream of  medicine, and improve the quality of care for patients with psychiatric  illness<\/strong>.<\/sup><\/div>\n<\/blockquote>\n<div align=\"justify\">The contrast was jarring. These are the authors that brought us the algorithm studies: <strong><font color=\"#660033\">TMAP<\/font><\/strong>, <strong><font color=\"#660033\">STAR*D<\/font><\/strong>, <strong><font color=\"#660033\">IMPACT<\/font><\/strong> and <strong><font color=\"#660033\">CO-MED<\/font><\/strong>. The algorithms in each case were not based on science or actual studies,  they&#8217;re based on questionnaires sent to experts of various kinds. The  original <strong><font color=\"#660033\">Expert Guidelines<\/font><\/strong> came from researchers, clinicians, mental health officials, and advocacy groups.&nbsp; <strong><font color=\"#660033\">TMAP<\/font><\/strong>  was built largely from those guidelines and their revisions. It cost a mint,  had no real outcome advantage, was an ethical nightmare, and seems to  have evaporated with little trace. As seen in my recent posts [<u><strong><font color=\"#660033\">detestable&hellip;<\/font><\/strong><\/u>, <u><strong><font color=\"#660033\">a long awaited corner&hellip;<\/font><\/strong><\/u>], the pharmaceutical industry was the key background player in both sets of algorithms. Then came the $35 M NIMH <strong><font color=\"#660033\">STAR*D<\/font><\/strong>, again with an arbitrary algorithm of drugs all of which were conflicts of interest for Rush and Trivedi [<a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2011\/05\/30\/algorithmic-psychiatry-the-algorithms\"><u><strong><font color=\"#660033\">algorithmic psychiatry &ndash; the algorithms&hellip;<\/font><\/strong><\/u><\/a>]. <strong><font color=\"#660033\">STAR*D<\/font><\/strong> brought us confusion more than anything else [<a href=\"http:\/\/ebmh.bmj.com\/content\/11\/4\/97.full\" target=\"_blank\"><u><strong><font color=\"#0000cc\">The STAR*D trial: the 300 lb gorilla is in the room, but does it block all the light?<\/font><\/strong><\/u><\/a>]. <strong><font color=\"#660033\">IMPACT <\/font><\/strong>was heavily advertised but actually never even occurred [<a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2011\/05\/28\/algorithmic-psychiatry-%E2%80%93-the-fall%E2%80%A6\"><u><strong><font color=\"#660033\">algorithmic psychiatry &ndash; the fall&hellip;<\/font><\/strong><\/u><\/a>]. And <strong><font color=\"#660033\">CO-MED<\/font><\/strong> was a spectacularly negative outing [<a target=\"_blank\" href=\"http:\/\/1boringoldman.com\/index.php\/2011\/05\/03\/another-dud\"><u><strong><font color=\"#660033\">another &ldquo;dud&rdquo;&hellip;<\/font><\/strong><\/u><\/a>]. So&nbsp; I thought it was a bit presumptuous for the authors of this string of psychopharmacological mis-adventures to be suggesting policies to get us all to follow in their footsteps. It reminded me of the saying, &quot;Insanity is doing the same thing over and over again, expecting different results.&quot;<\/div>\n<p align=\"justify\">But beyond their presumptuousness, I&#8217;ve realized that it&#8217;s the way they write. They&#8217;re not writing to colleagues, they&#8217;re selling a product. In this offering, they&#8217;re thinking up ways to get us all to do their measurement-based care thing and proposing a campaign to bring us around &#8211; including &quot;financial incentives.&quot; Their track record is so lackluster that it&#8217;s hard to see why they think we&#8217;d want to follow their lead. The last time they did this was TMAP, the now defunct program that was mostly oriented towards getting people to use expensive in patent drugs &#8211; drugs made by companies that financed their initiatives and paid them to be consultants and speakers.They haven&#8217;t figured out that we read their articles with one eye trained on &quot;what are they trying to get us to do this time?&quot;<\/p>\n<div align=\"justify\">They would do well to read the Symposium that I began with. It models what medical researchers and &quot;Key Opinion Leaders&quot; actually ought to be doing. We don&#8217;t need people like Trivedi and Rush who are heavily contaminated by industry influences telling us how to practice medicine. I doubt many of us think they know much more than the rest of us. We need scientists and thinkers who are trying to help clinicians broaden our understanding of the patients we see and their diseases&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>The other day, I encountered two things almost simultaneously. The first was a 2007 Journal Supplement on Melancholia that I found compelling. As I was reading through the articles, someone sent me a link to an abstract I hadn&#8217;t seen from Drs. Rush and Trivedi &#8211; a policy piece about Measurement Based Care. There was [&hellip;]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_bbp_topic_count":0,"_bbp_reply_count":0,"_bbp_total_topic_count":0,"_bbp_total_reply_count":0,"_bbp_voice_count":0,"_bbp_anonymous_reply_count":0,"_bbp_topic_count_hidden":0,"_bbp_reply_count_hidden":0,"_bbp_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-10506","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/10506","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/users\/2"}],"replies":[{"embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/comments?post=10506"}],"version-history":[{"count":10,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/10506\/revisions"}],"predecessor-version":[{"id":42772,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/10506\/revisions\/42772"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=10506"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=10506"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=10506"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}