{"id":35796,"date":"2013-04-28T00:47:17","date_gmt":"2013-04-28T04:47:17","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=35796"},"modified":"2013-04-28T00:57:25","modified_gmt":"2013-04-28T04:57:25","slug":"running-on-empty","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2013\/04\/28\/running-on-empty\/","title":{"rendered":"running on empty…"},"content":{"rendered":"
<\/sup>"My optimism is based partly on the extraordinary vitality of neuroscience and perhaps, even more important, on the emergence of remarkable new tools and technologies to identify the genetic risk factors for psychiatric disorders, to investigate the circuitry of the human brain, and to replace current animal models that have failed to predict efficacious new drugs that act by novel mechanisms in the brain."<\/em><\/strong><\/sup><\/div>\n
Psychiatric Drug Development: Diagnosing a Crisis<\/a>  Steven E. Hyman M.D.<\/strong><\/em><\/sup><\/div>\n

One of the more helpful things I learned along the way in early psychiatry training was something called Crisis Intervention. It was an idea that came from the military experience during World War II. It was incorporated into the Community Mental Health Movement rhetoric of the late sixties and seventies, and then sort of sank under the waves of biology that swept over psychiatry in the 1980s. It was conceptualized as a preventive strategy<\/em>. It’s origins were humble and based on a simple definition of crisis. <\/p>\n

A crisis occurs when some important life trajectory is blocked. In such situations, emergency emotions are activated to focus attention on the problem. Normal coping mechanisms fail and more desperate mechanisms are engaged – fight, flight, etc. If they fail, the emotions escalate, and at some point, a crisis state appears. What is that? It’s when the problem is no longer whatever is trying to be accomplished and becomes the heightened emotions themselves. So the person on top of a burning building jumps, even though the ladder is being cranked into place. Or the soldier in the heat of battle climbs out of his foxhole and tears across the battlefield – an easy target.<\/p>\n

In World War II, when a soldier showed signs of cracking on the front lines, they put him in a Jeep and took him out of the fray, gave him clean clothes, a good bed, some decent food, maybe a flick or a cocktail or two. Let him talk to a psychiatrist [usually some medic or doctor declared "psychiatrist" by lottery]. Three days later the Jeep took him back to his unit. It was a raging success, returning 82% to the lines whereas it had been 18% before. The soldiers went back to doing what soldiers do. They didn’t deteriorate or declare themselves mentally ill because they returned to function. They called it "combat fatigue." Those of us who treated these soldier’s children a generation later learned that there were enduring consequences, but even at that, the outcome was much better than after World War I where a generation was essentially lost.<\/p>\n

The point of Crisis Intervention is not to solve the problem. People in crisis will do that themselves. The point is to keep them from doing the kinds of maladaptive crazy things people in the throes of a crisis state do just to feel better [and suffer the consequences in perpetuity<\/em>]. So getting people off the front lines, liberal use of anxiolytics, and calm support are the first order of business. The next thing is to recognize that crisis states are caused by unsolvable problems, so one wants to hone in on the specific problem and reframe it into something more manageable. People can finally learn things that they’ve avoided learning for years because the crisis is so painful. And although people in crisis bring up every problem they’ve ever had when they’re in such a state, the point is to stay on the front burner, the problem at hand, and get the patient back into the stream of life as soon as possible. Crisis Intervention techniques are basic elements of any mental health worker’s skill set. I can’t imagine not knowing about Crisis Intervention.<\/p>\n

Armed with our Crisis Intervention skills, what about Dr. Hyman’s crisis? Well, we can’t talk about that yet, because there’s another thing to consider when you think about doing Crisis Intervention. When dealing with a person in the throes of an emotional crisis, you pull out all the stops, go the extra mile, do almost anything it takes to get the patient’s emotional state out of the red zone. But there’s another kind of crisis – a manufactured crisis. People know that others respond generously to people in crises. We’ve watched that happen for two weeks in Boston. And there are people who manufacture crises to get what they want – sometimes unconsciously, sometimes on purpose. How can you tell the difference? Seasoned clinicians make that assessment quickly by experience, almost without thought. They’ve been taken for enough rides to have a sixth sense about these things.<\/p>\n

One can say some things about how the old hands make that assessment. People in emotional crises come in many flavors, but they don’t lie and they don’t manipulate. And I’ve got to say that the people who are crying "Crisis!" here are doing both of those things. They start with the global burden of mental illness argument and portends of its rising incidence based on the fictive WHO predictions. They hide in the sheep’s clothing of concerned doctors without mentioning more unsavory motives. They focus on the empty pipeline as the precipitant of the crisis. Nothing acute there, we’ve known about it for years. The real precipitant is the exit of PHARMA from CNS drug development taking with them the generous financial contributions to academic departments, research, professional organizations, journals, the clinical research industry, and the KOL set. They claim to not understand why PHARMA would desert such a lucrative market knowing full well that PHARMA couldn’t get away with the things they did to make it so lucrative in today’s environment. There are just too many lies and manipulations for a genuine crisis.<\/p>\n

And who is it crying wolf? They’re only the people who stand to lose when the PHARMA money goes away.  Of course we need for  basic neuroscience research to continue. Of course it’s reasonable to continue to try to understand basic pathophysiology of the mental illnesses of biological origin. Of course basic drug research is important. But we don’t need a continuation of the antidepressant and atypical antipsychotic story we’ve lived with for a quarter century. And we sure don’t need the academic\/industry alliance that has accompanied it. This is a manufactured crisis.<\/p>\n

But there is an actual crisis. The psychiatry that’s left behind is too heavily focused on psychopharmacology, is constrained and controlled by managed care, is operating at a low approval rating, and is strapped with a ruling class that thrived in, condoned, and wants to perpetuate a corrupted environment. It is, indeed, a time to learn things that have been avoided for a long time – but that’s not going to happen along the current path. Psychiatry’s real crisis isn’t an empty pipeline, it’s empty leadership…<\/div>\n","protected":false},"excerpt":{"rendered":"

"My optimism is based partly on the extraordinary vitality of neuroscience and perhaps, even more important, on the emergence of remarkable new tools and technologies to identify the genetic risk factors for psychiatric disorders, to investigate the circuitry of the human brain, and to replace current animal models that have failed to predict efficacious new […]<\/p>\n","protected":false},"author":2,"featured_media":0,"comment_status":"open","ping_status":"closed","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_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-35796","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/35796","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=35796"}],"version-history":[{"count":28,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/35796\/revisions"}],"predecessor-version":[{"id":35825,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/35796\/revisions\/35825"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=35796"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=35796"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=35796"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}