{"id":55901,"date":"2015-04-13T22:56:04","date_gmt":"2015-04-14T02:56:04","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=55901"},"modified":"2015-04-13T23:38:32","modified_gmt":"2015-04-14T03:38:32","slug":"under-fire-iii","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2015\/04\/13\/under-fire-iii\/","title":{"rendered":"under fire III…"},"content":{"rendered":"
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Under fire, Schulz stepping down<\/a><\/div>\n
The head of the U’s psychiatry department is leaving his role amid a swarm of criticisms.<\/font><\/strong><\/div>\n
The Minnesota Daily<\/font><\/strong><\/div>\n
By Christopher Aadland<\/div>\n
April 13, 2015<\/div>\n

<\/p>\n

With the controversies around the department, especially the two recent investigations, I felt it was most constructive for me to step down as the chair of the Department of Psychiatry,” Schulz said. Since he came to the University to lead the department in 1999, Schulz has spent his career working with patients, like Markingson, who have schizophrenia or borderline personality disorder. While Schulz said the department has made many accomplishments under his leadership, he said he regrets dismissing some of the concerns that surfaced after Markingson’s death. He said he wishes he would have met with Markingson’s mother, Mary Weiss, to discuss the concerns she raised during and after Markingson’s death.<\/font><\/strong><\/em> “You can imagine, for years now, that’s been on my mind,” Schulz said…<\/div>\n<\/blockquote>\n
In under fire I…<\/a>, I was talking about the evolution of Clinical Trial methodology in the area of psychoactive medications, and how the traditional tool of psychiatry [the clinical interview] was too subjective for the realm of drug trials. Not only was it a subjective opinion about a subjective illness [mental illness], it wasn’t very sensitive nor was it easy to quantify. The procedures, randomization, placebo control, double blinds, rating scales, techniques for dealing with inclusion and attrition, and the statistical analytic techniques all were oriented towards objectifying and quantifying the effects of these new medications on the subjectivity of the patients. Over time, these objectified parameters became the proxies for psychiatric ill·ness. The same thing happened in the realm of psychiatric diagnosis. The former narrative and subjective assessments were replaced, at least in the research realm, with structured interviews and rating scales. So things like the SCID, the K-SADS-L, the HAM-D, the MADRS, the CGI, the BPRS, the PANSS, etc. became the psychiatric equivalents of the white cell count, the TSH level, the blood chemistries – objective markers that could be quantified. And in  Clinical Trials, they were more sensitive – able to detect smaller differences between groups that might not be apparent to the traditional psychiatric interviewer.<\/div>\n

These proxies were a step forward in that they offered a way to attach an objective value to the symptoms of mental illness. But they also brought a bag-full of new potential errors into the mix<\/font><\/strong>. Because they seemed to objectify the subjective, they gave the illusion that mental illnesses were, indeed, objective in the same way physical illnesses are. That may or may not be true in any given instance, but that still needs to be proved rather than just assumed because something can be measured. So many think, or at least talk like they think, that all mental illnesses are physical – caused by some identifiable pathogen. But there are other pitfalls. A Clinician-Rated PANSS Form<\/font><\/em> is obviously not on the same level as a centrifuged blood sample measuring the % of the blood volume taken up by red cells [Hematocrit]. Just look at the PANSS Forms<\/a> for Dan Markingson. I don’t know who did the rating, but at a time when we know from his mother’s reports, his own personal journal, and the comments from people around him that he was still lost in a psychotic fog – those objective measures<\/font> [the PANSS ratings] said he was doing fine. That was not true, and those PANSS results were anything but a psychic hematocrit<\/font><\/em>. The rating scales were never intended to be used for diagnosis. They’re for registering changes. And the reason they’re clinician-rated is to have an actual<\/font><\/strong><\/em> clinician<\/font><\/strong><\/em> in the mix to recognize when a subject is just telling the raters what he thinks they need to hear get them out of his face – which is likely what happened with Dan.<\/p>\n

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I’m not questioning the rightness of the many things already declared wrong in the story of what happened to Dan Markingson [and his mother]. CAFE was, as many have said, an un-necessary Clinical Trial – what Dr. Bernard Carroll dubbed an experimercial<\/font><\/strong><\/em>, the Clinical Trials undertaken to advance the sales of a medication rather than to refine our scientific understanding of the drug. I don’t question that the design of the study was flawed [for example, leaving out criteria to determine a non-response to the assigned study drug]. I was as appalled by the way Dan was recruited into and retained in the study as anyone else. And I agree with the recent investigations that shut down the whole clinical research enterprise pending a lot of needed reform.<\/p>\n

But I want to add something else to the list. The notion of objectifying and quantifying mental illness is a laudable goal. I’m as much of a numbers\/graphs guy as anybody around. But mental illness, particularly severe mental illness, is a subjective experience – and the subjectivity of the person doing the evaluation is an important part of assessment. You can’t see a case in the proxies – you have to see the case. And the objective measures used in clinical trials like a PANSS score are soft proxies as opposed to the Hematocrit or blood chemistries. The people who saw Dan at the Theo House, at OT, at the Day Hospital, his mother – all knew that Dan was very ill all along, but the people in charge didn’t. The biggest ethical breach in this whole story was that his doctor, Stephen Olson, didn’t respond to the loud noises screaming "somethings wrong!" by stopping by the Theo House on the way home and spending some serious time evaluating Dan Markingson in depth, in person. In the article above, Dr. Schulz, the co-principle investigator, regrets that he hadn’t "met with Markingson’s mother, Mary Weiss, to discuss the concerns she raised during and after Markingson’s death.<\/font><\/em>" Instead, I want Dr. Schulz to regret that he didn’t drive over to the Theo House and interview Dan Markingson himself, in depth, in person, to have the kind of direct clinical knowledge he would’ve needed to have to have met with and responded to Mary Weiss [maybe he could’ve met her there].<\/p>\n

There’s a story of a Zen Master who comes upon a scholar pointing at the moon and lecturing on and on to his students. The Master comments, "that fellow is confusing his finger with the moon." In this case, I’m suggesting that the KOL brand psychiatrists have confused their soft proxies [clinical trials and rating scales] for the actual patients in many instances. In this case, I’m suspicious that they paid attention to the rating scales and not the patient. In other places, they’ve claimed that minor differences have clinical meaning when they don’t. But we often think that all examples portend bad motives, and in some cases they do. But this is an error one can make even without bad motives – by overvaluing secondary information without investigating further.<\/p>\n

There were more than enough warning signs to warrant re-evaluating Dan Markingson’s case in depth, in person, long before things went so very sour…<\/div>\n","protected":false},"excerpt":{"rendered":"

Under fire, Schulz stepping down The head of the U’s psychiatry department is leaving his role amid a swarm of criticisms. The Minnesota Daily By Christopher Aadland April 13, 2015 With the controversies around the department, especially the two recent investigations, I felt it was most constructive for me to step down as the chair […]<\/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":[5],"tags":[],"class_list":["post-55901","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/55901","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=55901"}],"version-history":[{"count":13,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/55901\/revisions"}],"predecessor-version":[{"id":55944,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/55901\/revisions\/55944"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=55901"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=55901"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=55901"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}