{"id":17295,"date":"2011-12-15T18:56:45","date_gmt":"2011-12-15T23:56:45","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=17295"},"modified":"2011-12-15T19:32:07","modified_gmt":"2011-12-16T00:32:07","slug":"a-blind-eye","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/12\/15\/a-blind-eye\/","title":{"rendered":"a blind eye…"},"content":{"rendered":"
As a young science-type, I think I accepted a hierarchical notion that academic research was the true science, and the clinician was the interface between that science and the patient. But during an academic research fellowship, my view began to change as I noticed that the people I most respected were the academics who were master clinicians. Then I was teleported from academia by the forced call to military service into the world of clinical medicine in a decidedly non-academic environment where I was the final step in the medical chain, where when I turned around, there was no-one behind me. The object of my attention was no longer the leading edge of medical science, it was some ailing person, and the complexity of clinical medicine was revealed in short order. When you’re sick, the only thing that matters is the state of the art right·now<\/em>, not what it might be in some later day. And internally, the audience I played to changed. I was no longer the bright young guy playing to the audience of teachers or mentors. The audience was the person in front of me, and sick people can be a tough audience. In medicine, we call the people we see patients<\/em>. That’s a wish, not a given. In truth, sick people have to learn to be patient<\/em>, to adapt to the state of the art which can be painfully slow and often requires dramatic revision of expectations. It doesn’t come naturally. They at least deserve an accurate view of the state of the art. <\/div>\n

That’s enough about my personal evolution – except to say that my academic snobbery was humbled by clinical medicine, but I’m afraid that instead of it disappearing altogether, I became something of a clinician snob. That’s one of the reasons I get so worked up about the DSM-5 Revision and a lot of other things about the current state of the specialty of psychiatry. For literally decades, the focus has been on the future – what’s in the pipeline<\/em>, what’s coming soon, new directions in this or that, recent advances in this or that, novel<\/em> approaches. The present is a collage of inadequacies and the future is either a glowing star or threatened, and in need of a booster shot. Psychiatry sometimes only seems to exist in the future.<\/p>\n

Dr. Tom Insel, Director of the National Institute of Mental Health is my personal benchmark for this ubiquitous future·think<\/em> mentality. Of course, his job is to keep one eye on the future, but I’m afraid that his eye on the present is a lazy eye<\/em> at best, maybe a blind eye<\/em>. His speeches tend to move among three poles, none really right·now<\/em>:<\/div>\n
    <\/p>\n
  • \n
    The bright shiny objects in the future, just over the horizon <\/div>\n<\/li>\n
  • \n
    Terror that the hope of the future is all but lost<\/div>\n<\/li>\n
  • \n
    A gloomy present – highlighting the desperate need for a future <\/div>\n<\/li>\n

    <\/sup><\/ul>\n

    This, from the January issue of Neuropsychopharmacology<\/font><\/strong>:<\/div>\n
    \n
    Translating Discoveries into Medicine: Psychiatric Drug Development in 2011<\/font><\/strong><\/u>
    by Linda S. Brady and Thomas R Insel<\/sup>
    Neuropsychopharmacology Reviews<\/font><\/strong> 2012 37(1):281–283.<\/div>\n

    <\/p>\n

    Most of the blockbuster psychiatric medications have either become or will soon become available as generic drugs. Although this is oft-cited as a challenge for further development, what is less recognized is the failure of the current medications to reduce the prevalence or disability of any of the major mental disorders. Although current antidepressants and antipsychotics have been beneficial to industry, the extent of benefit for patients is less consistent, with too many patients left to settle for less than recovery from these highly disabling disorders…<\/sup><\/div>\n<\/blockquote>\n
    Thanks for finally noticing<\/em>, comes to mind. In spite of a great cheering squad, we fielded a losing team. In fact, the real winner was the pharmaceutical industry, not the psychiatrists and the patients they treat. The current medications getting this lackluster review were the objects shining in the future not so very long ago. In fact, they glowed so brightly that we redesigned psychiatry to fit their radiance.<\/div>\n
    \n
    The need for a next generation of medications was emphasized by the large scale practical trials like CATIE, STAR*D, and STEP-BD, each of which revealed very modest effects with optimized use of the current generation of medications [Insel, 2007]…<\/sup><\/div>\n<\/blockquote>\n
    I’m not so sure that CATIE<\/font><\/strong>, STAR*D<\/font><\/strong>, or STEP-BD<\/font><\/strong> cried out for the next generation of medications<\/em>. Instead, they documented the very modest effects … of the current generation of medications<\/em>, clarifying the state of the art of psychopharmacology in the treatment of mental illness. <\/div>\n

    After decades of psychiatric future·think<\/em>, one might think that the time has come for a re-evaluation of where we are rather than a call to hurl ourselves into the future again looking for shiny objects. This has been an age of unparalleled misinformation in psychiatry, driven more by financial and ideological forces than scientific clarity. It would seem to me that this is a time for questions like: Why doesn’t our current nosology help us select the patients that do respond to medications? Are there patients who specifically do not respond to medications? How can they be identified? What do they need instead? Are the medications themselves different in efficacy, or are the differences primarily in side effects? In which cases is there solid evidence of a biological substrate to the mental illness? In which cases is symptomatic depression instead a reflection of life, past or present? What about Robert Whitaker’s idea of intermittent rather than continuous treatment of psychosis? Is the widespread use of medications really ‘cost effective’? Does the notion of translational research get treatments from the bench to the bedside? or does it stifle creative research by insisting on focus? Is Tom Insel’s cheerleading for what we "need" driven by what mentally ill people need, or is it driven by the research\/pharmaceutical\/clinical trial industries being ‘too big to fail’? Is the managed care intrusion into psychiatric practice rational or an attempt to move treatment to primary care as a cost-cutter?<\/em><\/p>\n

    Well that just flowed out of nowhere [I had to stop myself before I ran out of blog]. I suppose I could have simply said that it’s a time for reflection. Tom Insel is not, and has never been, a clinician. Neither are many<\/strike> most of the people on the DSM-5 Task Force. They don’t sit in rooms and talk to people with mental illness. They sit in other rooms, and it shows. Clinical psychiatrists are not the interface between patients and the National Institute of Mental Health or the DSM-5 Task Force or the American Psychiatric Association or the Pharmaceutical Industry or the Managed Care Companies. It’s the other way around. The National Institute of Mental Health, the DSM-5 Task Force, the American Psychiatric Association, the Pharmaceutical Industry, and the Managed Care Companies are supposed to be resources for the dyad of psychiatrist and patient who are directly dealing with the patient’s mental illness. I currently experience none of them as resources. At present, each of those entities sees itself in charge of the conduct of psychiatric care, something no one of them actually knows how to do. The biases of Managed Care and the Pharmaceutical Industry are givens, but the NIMH? the APA? the DSM-5? Who are they working for? <\/p>\n

    Dr. Insel, how about attending to giving us a long overdue accurate assessment of what we already have before racing off to look for another pot of gold. Drs. Kupfer and Regier, how about giving us a revision of the DSM-5 that makes it useful to me when I’m seeing a patient [a depressed patient specifically], instead of to some non-clinician who is on a committee or some drug company looking for the broadest audience for a drug. And Dr. Oldham [APA-President], how about initiating an assessment of the last twenty five years of psychiatry that includes TMAP, the over-medication of Foster Kids, Biedermania [Childhood Bipolar Disorder], Study 329, ghost-writing, Speaker’s Bureaus, the conflict-of-interest epidemic, the Grassley list, off-label recommendations, etc. etc. – a state of the specialty that includes a frank look at some of the most corrupt practices in the history of medicine.<\/p>\n

    Psychiatrists and mental patients meet each other in the world of right·now<\/em>.  And the state of play in psychiatry right·now<\/em> is in bad need of a comprehensive look-see – future·think <\/em>comes later… <\/div>\n","protected":false},"excerpt":{"rendered":"

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