{"id":4648,"date":"2011-02-01T20:54:44","date_gmt":"2011-02-02T01:54:44","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=4648"},"modified":"2011-02-01T20:57:55","modified_gmt":"2011-02-02T01:57:55","slug":"evidence-based-medicine-vi-a-case","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2011\/02\/01\/evidence-based-medicine-vi-a-case\/","title":{"rendered":"evidence-based medicine VI: a case&#8230;"},"content":{"rendered":"\n<ul>\n<div align=\"justify\"><sup><em>Leah&#8217;s a friend of my daughter&#8217;s since late Middle School. They&#8217;ve kept up and I still periodically see her when my daughter visits us. She&#8217;s a 40 year old single mother with 9 year old twins, lives in the City, has a good job, something to do with computers in the advertising business. When I saw her last summer, I heard them talking on the porch. <\/em><em>Leah<\/em><em> was saying that she and her Psychiatrist had &quot;finally gotten her meds right&quot; [I think she mumbled the word &quot;Bipolar&quot;]. She said she was on two medications that she named. I cringed. A couple of months later, my daughter called from North Carolina. She&#8217;d gotten a call from <\/em><em>Leah<\/em><em> [in Atlanta] who was driving around crazed and suicidal, would I call her? I tried and failed, but found out that she&#8217;d driven to a mental hospital and checked herself in.<\/em><em> I&#8217;ve known <\/em><em>Leah<\/em><em> for a long time. Her own family situation was a mess, but she weathered it fairly well. She&#8217;d married someone in the fast lane and paid the price, but seems to have landed on her feet. She can be &quot;mopey&quot; at times, but never big time depressed<\/em><em>. I vaguely know her Psychiatrist, a decent enough guy, but one who has definitely drunk the kool-ade of modern <strong><font color=\"#200020\">evidence-based medicine <\/font><\/strong>[trained at Emory under you-know-who].<\/em><\/sup><\/div>\n<\/ul>\n<div align=\"justify\">I was thinking about why those Trivedi articles [<strong><a target=\"_blank\" href=\"http:\/\/www.ps.psychiatryonline.org\/cgi\/content\/full\/55\/8\/879\">A Computerized Clinical Decision Support System as a Means of Implementing Depression Guidelines<\/a><\/strong>, <strong><a target=\"_blank\" href=\"http:\/\/www.biomedcentral.com\/1472-6947\/9\/6\">Barriers to implementation of a computerized decision support system for depression: an observational report on lessons learned in &quot;real world&quot; clinical settings<\/a><\/strong>] set off such a firestorm of posts from me in the last couple of days, and Leah came to my mind &#8211; an example from the <em>real <\/em>real world. Psychiatrists are essentially functioning as symptom doctors, often seeing patients who are in some kind of counseling or therapy with someone else. The patient is referred for &quot;meds,&quot; and that&#8217;s what they get [it&#8217;s little wonder that the people who manufacture and sell &quot;meds&quot; have taken over the specialty]. <\/div>\n<ul>\n<div align=\"justify\"><sup><em>Leah had been through a contentious divorce and returned to Atlanta., buying a house at the exact wrong time, and was caught in the mortgage crisis, paying off a mortgage way above the current value of her house. She was awaiting for foreclosure before moving. Her family was as little support as always. She was beginning to date again. Plenty of stress on top of raising two 9 year-old boys.<\/em><\/sup><\/div>\n<\/ul>\n<div align=\"justify\"> Actually, Leah was treated using something like <strong><font color=\"#200020\">Dr. Trivedi<\/font><\/strong>&#8216;s algorithm for <strong><font color=\"#200020\">Major Depressive Disorder<\/font><\/strong> [something she didn&#8217;t qualify for in any diagnostic scheme]. She was referred by her therapist for &quot;meds&quot; and treated with several different <strong><font color=\"#300030\"><em>Monotherapies<\/em><\/font><\/strong> [Antidepressants] without change. She had thereby qualified to become a case of <strong><font color=\"#200020\">Treatment Resistant Depression<\/font><\/strong>. Next on the protocol came <strong><font color=\"#300030\"><em>Augmentation Therapy<\/em><\/font><\/strong> with an Atypical Antipsychotic. They started one, and after a dosage increase, she felt calmer and slept better &#8211; <em>she and her Psychiatrist had &quot;finally gotten her meds right.&quot;&nbsp;<\/em><\/div>\n<ul>\n<div align=\"justify\"><sup><em>After a month or so, she noticed she was gaining a lot of weight, so she stopped taking the Atypical Antipsychotic and she went absolutely crazy and felt intensely suicidal. She didn&#8217;t know it was withdrawal. She just thought she was going insane [and she was]. At the mental hospital, they finally put her back on the Atypical Antipsychotic, and she was &quot;weaned&quot; over the course of a few months.<\/em><\/sup><\/div>\n<\/ul>\n<div align=\"justify\"> In Leah&#8217;s story, there was only one supportable,<em> <\/em><strong><font color=\"#200020\">evidence-based<\/font><\/strong> diagnosis &#8211; <strong><font color=\"#200020\">Abilify Withdrawal<\/font><\/strong>. While the discussion of the forces of change in Psychiatry, the ontogeny of the DSM III+, Conflicts of Interest, the decline of the Psychoanalysts, the rise of the Biologists, Medical Economics, etc. are interesting, they are ancillary to the central issue in the case of Leah. This was lousy medicine &#8211; very lousy medicine &#8211; and such stories are all too common. <\/div>\n<p align=\"justify\">It should be obvious that I think the term <strong><font color=\"#200020\">evidence-based medicine<\/font><\/strong> has been perverted. It means to its proponents that the only valid treatment modalities are those that can be validated by statistically significant studies in groups of people. So, almost by definition, the only things that lend themselves to study are mass interventions like drug treatment. But there is no group of Leahs. If we were to categorize her, she would fall into the <em><strong><font color=\"#200020\">emotional turmoil in the face of difficult life circumstances<\/font><\/strong><\/em> category. Knowing her, I also know that she would fit in the <strong><em><font color=\"#200020\">people who make bad decisions because of an unfortunate biography that predisposes to such problems<\/font><\/em><\/strong> category. Some short-term anti-anxiety medication might&#8217;ve helped her think through the contemporary problems more clearly. Talking things over with someone who isn&#8217;t part of the problem might really help too. It&#8217;s called Crisis Intervention, a well described approach to the psychotherapy of such cases. In addition, Leah made a bad choice in her marriage, in her house-buying, and there have been other examples. It would be to her future advantage while the consequences of those bad decisions are fresh on her plate, to consider working with a therapist who might help her learn some things that would help her make better choices in the future. That&#8217;s Psychiatry as practiced by <a target=\"_blank\" href=\"http:\/\/en.wikipedia.org\/wiki\/Adolf_Meyer_%28psychiatrist%29\"><strong><font color=\"#200020\">Dr. Adolf Meyer<\/font><\/strong><\/a> in the first half of the last century. I think Leah would&#8217;ve been better off then. <\/p>\n<div align=\"justify\">Instead, her therapist referred her to a Psychiatrist who treated her with a group algorithm recommended for <strong><font color=\"#200020\">Major Depressive Disorder<\/font><\/strong> that landed her in a dangerous spot, ending in a mental hospital. One might say that it&#8217;s her fault. She shouldn&#8217;t have abruptly stopped the medicine. First, she wasn&#8217;t warned about either the weight gain or the withdrawal. But beyond that, I would say that she never should have been put on it in the first place. Her encounter with Psychiatry was not informed by either rational science or practical experience. It was the product of the intrusion of Pharmaceutical Manufacturers, mediated by cooperating Key Opinion Leaders [Physicians], and effected by a practicing Psychiatrist who was in the symptom treating business rather than acting like a doctor [and doing a sloppy job of symptom treating at that]. Can we generalize about a whole specialty of medicine from the case of Leah? After all, she&#8217;s just one case. I&#8217;m afraid that the answer to that question is closer to &quot;yes&quot; than anyone would like to admit. This <em><strong><font color=\"#200020\">n<\/font><\/strong><\/em> is a whole lot greater than <strong><em><font color=\"#200020\">1<\/font><\/em><\/strong>&#8230;<\/div>\n","protected":false},"excerpt":{"rendered":"<p>Leah&#8217;s a friend of my daughter&#8217;s since late Middle School. They&#8217;ve kept up and I still periodically see her when my daughter visits us. She&#8217;s a 40 year old single mother with 9 year old twins, lives in the City, has a good job, something to do with computers in the advertising business. When I [&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_forum_subforum_count":0,"footnotes":""},"categories":[2],"tags":[],"class_list":["post-4648","post","type-post","status-publish","format-standard","hentry","category-politics"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/4648","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=4648"}],"version-history":[{"count":0,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/4648\/revisions"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=4648"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=4648"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=4648"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}