February 23, 2009

Why No Progress Will Ever Be Made In Psychiatry

Do the past 50 years, post psychoanalysis, seem like marking time in psychiatry?  A series of equally efficacious or toxic treatments being substituted for older versions that are ultimately not any different, all the while hearing the heralds proclaim the incredible advancements in "brain" diseases?  Genetics, serotonin, BDNF!

If it seems like countless billions in research money have not changed psychiatry at all over decades, it's because they haven't.

The first question a fertility doctor asks when she can't get pregnant: are you guys having sex?

In an editorial in Primary Psychiatry, Dr. Sussman writes,

I am constantly looking for sources of easily accessed information that may be relevant to clinical decision making, teaching, and writing...

However, just last week I was pleasantly surprised when my colleague at the New York University School of Medicine, David L. Ginsberg, MD, alerted me to a Website I had never visited

The site he had never previously visited turns out to be MedlinePlus.  Let's leave that aside.

That it took a Vice Chair for Clinical Affairs to tell another Vice Chair about the existence of this website, leave that aside.

That Dr. Sussman's very first positive comment about MedlinePlus is:

There is no advertising on this Website.
which I assume is meant to indicate it is free of bias, even as the very journal in which he writes and is editor has advertisements that I guess are less threatening than those on websites, leave that aside.

What he wants to do is stay current, as in this example:

My search directed me to a very helpful article2 from a neurology journal that I would not otherwise run across. I read the following...

That what he goes on to quote is actually from a consensus paper-- in other words, a secondary source, someone else reviewing the data-- leave that aside as well.

No, wait, hold on: I understand the complexities of medical practice, and that up to the minute investigation of the primary sources is nearly impossible.  But you must agree that the general public actually assumes we are incessantly investigating primary sources all the time, the same way they assume football players work out.  If they knew that when we prescribed a medication we were not actually using the latest information, not even listening to a drug rep who has current information, but, well, winging it based on what we once thought we knew-- they'd be beyond horrified.

So to be surprised at a review paper must mean he was even more unaware of the primary sources that it reviewed.  That's not a problem unique to him, unfortunately, and if the public found out that doctors only half heard about reviews that were published a year ago... leave that aside.

Let's leave all that aside, res ipsa loquitur.


"The finding of worse anatomic and neurodevelopmental outcomes following fetal valproate exposure in multiple studies suggests that it poses a special risk. Thus, it seems prudent not to use valproate as a first choice antiepileptic drug in women of childbearing age. When valproate is employed in women of childbearing potential, dosage should be kept as low as possible since its effect appears to be dose dependent..."
This is the section in the neurology review he found so interesting. Admittedly, to the average psychiatrist, it is interesting.  Despite awareness that valproate (Depakote) has significant teratogenic effects, the debate has been whether to stop it when she's pregnant, not whether to use it first line with any woman of childbearing potential.

In fact, the basic argument over the past ten years has been this: it's first line for every bipolar, men and women, at any age.  Even kids.  And since the teratogenic effects happen in the first few weeks, by the time she discovers she's pregnant it's probably too late anyway, keep using it.

So for a neurology journal to suggest valproate shouldn't even be first line for epilepsy, let alone bipolar, I can see why he'd find it interesting.  Fine.  Do you know what he says next about this passage, these recommendations?  Nothing.

As if this was completely self-evident, no controversy at all.  He doesn't say, "hmm, we've been doing it differently for ten years, were we wrong?"

This would be George Bush commenting in his autobiography that the American troops were not given biohazard suits as they were not expected to confront any bio-weapons.  Oh, okay.

There's no advancement in psychiatry because there's no real feeling of the validity of what came before.  Medicine is fashion.    No one would say, "we were wrong about Depakote in 2001" anymore than one would say "we were wrong about pantyhose in 1980"  (NB: I said both.)  What they say is, "that's what we did then."  No apology necessary.

The science part of psychiatry-- serotonin, kindling, relapse rates-- is only an excuse for marketing; it gives us today's soundbites.  Later we'll say something else using the same science, like we make new fashions using the same materials.  No one finds this disturbing.

The reason no progress will ever be made is because no one is contributing to the advancement of science, or medicine, they're contributing to their own careers.  Not selfishly or meanly, just myopically.  They're masturbating.  I don't use that word flippantly, either.  It is going over the same old ground, over and over, until a climax-- then it is done and you move on as if it never happened.  Then it's the next time, and though the technique is mostly the same, the content of the fantasy mostly the same, this time is different, it neither contradicts or repeals, nor does it augment or enhance the previous work.  It's just different.  But let someone today try and tell you you're doing it wrong...

Arguably, there should be at least a little shame at the end of it, but...