{"id":66749,"date":"2016-07-05T21:47:15","date_gmt":"2016-07-06T01:47:15","guid":{"rendered":"http:\/\/1boringoldman.com\/?p=66749"},"modified":"2016-07-06T06:37:10","modified_gmt":"2016-07-06T10:37:10","slug":"the-streams-iii-and-a-river-runs-through-it","status":"publish","type":"post","link":"https:\/\/1boringoldman.com\/index.php\/2016\/07\/05\/the-streams-iii-and-a-river-runs-through-it\/","title":{"rendered":"the streams III &#8211; and a river runs through it&#8230;"},"content":{"rendered":"\n<ul><sup> <\/p>\n<div><strong><u><font color=\"#200020\">A re<u>view<\/u> of the streams<\/font><\/u>:<\/strong><\/div>\n<li><font color=\"#200020\">a preference for case studies<\/font><\/li>\n<li><font color=\"#200020\">the consequences of the DSM-III unitary depression<\/font><\/li>\n<li><font color=\"#200020\">being questioned about focusing on &quot;old studies&quot;<\/font><\/li>\n<li><font color=\"#200020\">Peter Kramer&#8217;s snappy response to Ed Shorter&#8217;s review<\/font><\/li>\n<li><font color=\"#200020\">&#8230; and then the thread about Lewis, Kiloh, and Parker on Lewis&#8217; cases<\/font><\/li>\n<p>                      <\/sup><\/ul>\n<p align=\"justify\" class=\"small\">Based on his MD Thesis cases, Aubrey Lewis couldn&#8217;t confirm the classic separation between neurotic and melancholic depression. I read the Lewis papers [200+ pages], and I couldn&#8217;t confirm the diagnostic dichotomy either. So I can&#8217;t fault him for his conclusion. But it&#8217;s easy to see why his dataset might not be the best choice for evaluating the distinction. These were inpatient cases admitted to the Maudsley Hospital, and they were <em><font color=\"#200020\">severely ill<\/font><\/em> &#8211; a skewed sample of the general cohort of depressed patients by any read [the <em><font color=\"#200020\">hard cases<\/font><\/em>]. So I can fault him for generalizing from this sample, and for sticking to his conclusion throughout his influential career. I think he made a mistake.<\/p>\n<p align=\"justify\" class=\"small\">In my experience, the clinical differentiation of Melancholia from other depressive states is not so difficult as it sounds in <font color=\"#200020\">Aubrey Lewis<\/font>&#8216; papers. In <a href=\"http:\/\/1boringoldman.com\/index.php\/2015\/02\/09\/political-sabbatical\/\">political sabbatical&hellip;<\/a>, I provided links to articles with diagnostic criteria, including a follow-up article by <font color=\"#200020\">Gordon Parker<\/font> [furthering the use of latent-class analysis] and <font color=\"#200020\">Bernard Carroll<\/font>&#8216;s article on diagnosis [that also puts it to verse]:<\/p>\n<p align=\"center\"><img decoding=\"async\" width=\"350\" border=\"0\" src=\"http:\/\/1boringoldman.com\/images\/melancholia-poem-1.jpg\" \/><\/p>\n<div align=\"justify\" class=\"small\">So Dr. Kramer&#8217;s Letter to the Editor [<em><font color=\"#200020\"><a href=\"https:\/\/www.washingtonpost.com\/opinions\/book-reviewer-promotes-a-controversial-theory-about-depression\/2016\/07\/01\/367e9cbc-325f-11e6-ab9d-1da2b0f24f93_story.html\" target=\"_blank\">Book reviewer promotes a controversial theory about depression<\/a><\/font><\/em>] saying that Dr. Shorter was pressing some idiosyncratric idea of his own by mentioning Melancholia,<\/div>\n<blockquote>\n<div align=\"justify\"> &quot;Shorter&rsquo;s critique amounted to little more than a complaint that I  have disregarded a controversial theory he favors. He used the review  space to give a hobbyhorse a ride.&quot;<\/div>\n<\/blockquote>\n<div align=\"justify\" class=\"small\">seems way, way off base to me. Whether by intention or not, Kramer perpetuates the &quot;<em><font color=\"#200020\">all depression = brain disease<\/font><\/em>&quot; agenda of the KOLs whose motives are certainly suspect.<\/div>\n<p align=\"justify\" class=\"small\">But whether his conclusions turned out to be mistaken or not, Lewis&#8217; articles are absolute classics &#8211; particularly the last one [<font color=\"#200020\">Melancholia: prognostic studies and case-material, 1936<\/font>] which has his 61 case narratives with almost a full journal page each [<font color=\"#200020\">56 pages &divide; 61 cases = 0.92 pages\/case<\/font>]. You know they&#8217;re classics because two different solid investigators were able to find what they needed to do their sophisticated reanalyses using Lewis&#8217; case reports. It was as if those cases had waited patiently [pun intended] for a half century for the statistical methodology and the computing power to come along that could finally analyze them. <\/p>\n<div align=\"justify\" class=\"small\">Reading Lewis&#8217; commentary and particularly his patient narratives just reminded me of how much I missed case reports. As physicians, it&#8217;s the plight of people taken one at a time that matters. We collect them in groups of shared syndromes to see what we can learn from their similarities, but their differences are important too. And we may not be able to find the most important things just yet, but if the narratives endure, maybe some future reader can see what we missed, or bring some new pair of glasses that finds what we were looking for. And that&#8217;s exactly what happened here. So the next time I&#8217;m asked why I&#8217;ve continued to look at &quot;<font color=\"#200020\">old<\/font>&quot; studies, I&#8217;m going to say, &quot;<font color=\"#200020\">If the data&#8217;s faithfully recorded and maintained, there&#8217;s no such thing as an old study<\/font>&quot; and start talking about the Lewis cases and their reanalysis fifty years later.<\/div>\n<ul>\n<div align=\"justify\"><sup><em><font color=\"#200020\">I had a related experience almost 50 years ago myself. When I started a fellowship in rheumatology in a former life, my boss was in the process of happening onto an significant finding. Using an electron microscope, he was studying the capillary morphology in rheumatologic diseases in biopsies from uninvolved muscle. And in Scleroderma [Progressive Systemic Sclerosis] the technicians couldn&#8217;t find any capillaries to look at. So he developed a technique to quantify the capillary density, and sure enough, it was dramatically diminished &#8211; no small observation for a disease characterized by generalized scarring. So my first project was the literature review of previous reports of vascular problems in Scleroderma. I doubted I&#8217;d find anything. In those pre computer search days, it was no small task and I spent months in the dusty library stacks. The results were amazing. It was everywhere, vascular lesions recorded in the meticulous old reviews of pathology in journals from every specialty, every organ system. They didn&#8217;t realize the significance of what they were seeing, but they had written down what they saw for me to find years later. They just didn&#8217;t have our electron microscope to move them that final inch. We ended up having to radically trim our reference list to only the most pertinent papers.<\/font><\/em><\/sup><\/div>\n<\/ul>\n<div align=\"justify\" class=\"small\">And that&#8217;s it,<font color=\"#200020\"> a river that runs through it<\/font>. As much as I&#8217;d enjoy another good rant about why the distinction between Melancholia [<u><font color=\"#200020\">D<\/font><\/u><font color=\"#200020\">epression<\/font>] and the heterogeneous category, <u><font color=\"#200020\">d<\/font><\/u><font color=\"#200020\">epression<\/font> matters, the real lesson in this story is that it&#8217;s the patients and their data that&#8217;s important. I think Aubrey Lewis did the best he could with the data he had. I wish he&#8217;d taken a later look at a more representative cohort, but that doesn&#8217;t detract from what he did do. His legacy, in this instance, is the careful case histories he passed on to Kiloh and Parker. And the impressive thing is that even with this skewed cohort, they were able to convincingly detect the two populations that it represents.&nbsp; And that&#8217;s probably the river that runs through this whole blog and others like it. It&#8217;s the patients, their narratives, and the data generated in its rawest form that endures, not the interpretations of its contemporary custodians. Just imagine how much we could learn if we had this kind of data from all the subjects in the clinical trials of antidepressants that we write about.<\/div>\n<p align=center><iframe loading=\"lazy\" width=\"320\" height=\"180\" src=\"https:\/\/www.youtube.com\/embed\/OsDnrFBpsBk?rel=0&amp;showinfo=0\" frameborder=\"1\"><\/iframe><br \/><sup>[Norman Maclean, author of &#8220;A River Runs Through It&#8221;]<\/sup><\/p>\n","protected":false},"excerpt":{"rendered":"<p>A review of the streams: a preference for case studies the consequences of the DSM-III unitary depression being questioned about focusing on &quot;old studies&quot; Peter Kramer&#8217;s snappy response to Ed Shorter&#8217;s review &#8230; and then the thread about Lewis, Kiloh, and Parker on Lewis&#8217; cases Based on his MD Thesis cases, Aubrey Lewis couldn&#8217;t confirm [&hellip;]<\/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-66749","post","type-post","status-publish","format-standard","hentry","category-opinion"],"_links":{"self":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/66749","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=66749"}],"version-history":[{"count":37,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/66749\/revisions"}],"predecessor-version":[{"id":66809,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/posts\/66749\/revisions\/66809"}],"wp:attachment":[{"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/media?parent=66749"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/categories?post=66749"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/1boringoldman.com\/index.php\/wp-json\/wp\/v2\/tags?post=66749"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}