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...


I totally agree! I have bee... (Below threshold)

February 23, 2009 6:56 PM | Posted by survivor: | Reply

I totally agree! I have been on almost 50 drugs in over 25 years. Most for things I was never even diagnosed with. NONE of them ever helped. I decided enough---I have been going off all the meds after all these years, having to educate myself about withdrawal because almost no doctor knows about it or if they do they aren't telling. ALL my symptoms that started this are gone and I found out that it wasn't me that was crazy, first it was my family then it was most of the mental health system. Thank God!!!!!--- I have a doctor now that is "letting" me do what I need to do to recover from the meds and the system. I also have the support to build my life over. I have had doctors refuse to take me off meds that didn't help and actually made things worse and almost killed me physically---while they were trying to "save" my life. They are not making things better with their medicine and exactly what chemical imbalances do we have? There are no tests. They are still guessing. They are playing with ou brains and our lives and our bodies. Will it ever end? All I needed was someone to listen and show me some coping skills and that feeling was OK.
For our children now and those still caught in the mess I really hope someone higher up in the system wakes up and sees what is happening. I am doing all I can to change things on my end.

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Quick feedback:You... (Below threshold)

February 23, 2009 7:05 PM | Posted by Kevin: | Reply

Quick feedback:

Your use of latin phrases makes your writing less readable. Almost every time they come up I have to stop what I'm doing to cut and paste them into Wikipedia to find out what they mean.

Why not just write out the gist of the term in English?

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Superb. That's all.... (Below threshold)

February 23, 2009 7:51 PM | Posted by abysmal musings: | Reply

Superb. That's all.

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You should read one of the ... (Below threshold)

February 23, 2009 8:33 PM | Posted by Fargo: | Reply

You should read one of the very few P. K. Dick stories I really enjoyed - The Zap Gun.

To Kevin- learning is good for you. It's the only thing we, as a species, excel at, but for some reason people go out of their way to avoid it. Don't be like that.

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Not to mention original tho... (Below threshold)

February 23, 2009 10:47 PM | Posted by Dyson: | Reply

Not to mention original thought is discouraged. My primary research interest is Spirituality and there are maybe four or five clinical psychology programs that list that as an interest, let alone have a lab devoted to studying it. If I say I want to research Spirituality, I have to quickly follow it up with "as a moderating force or a coping mechanism" to avoid the full onslaught of dirty looks.

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Although I agree that there... (Below threshold)

February 23, 2009 11:03 PM | Posted by Busy-Dad-E: | Reply

Although I agree that there is an overabundance of "repackaging old-for-new" in psychiatric research, I question the utility of saying that "no progress will ever be made in psychiatry." Such a stance both undermines psychiatric research/thinking that truly represents a paradigm shift, and discourages those in pursuit of a career in academic psychiatry.

As an example of the former, I would cite Kirkpatrick et al., "A separate disease within the syndrome of schizophrenia." Arch Gen Psychiatry 2001. Sadly, few outside of academia, or even schizophrenia research circles, have heard of "deficit schizophrenia." This idea is fundamentally important because it details how what clinicians think of objectively (i.e., DSM-criteria) as schizophrenia is not a single disease entity. That a subgroup of patients with schizophrenia have a completely different set of risk factors, neurobiology, symptom profile, and response to treatment has important implications for understanding both the disease process and its treatment. Sadly, such an opportunity is, almost without exception, overlooked in research.

Researchers themselves represent one of the greatest barriers to progress in research. Say anything different than the "status quo", and your papers will be met at the door at gunpoint. For example, it is generally accepted that factors such as side effects of antipsychotics, smoking, poor nutrition, and other health habits contribute to the burden of cardio-metabolic morbidity and mortality in schizophrenia. To suggest that the pathophysiology of the disease itself also contributes to these risks, independent of all of the aforementioned factors, is considered blasphemous. And yet, there is a growing body of evidence to support just that--schizophrenia is not just a brain disease, but a disease with abnormalities throughout the body.

Without training a new generation of psychiatric researchers to "think outside the box", and to question what is accepted as gospel by most, we are doomed to repeat these mistakes which impede our progress.

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You could just call it "no ... (Below threshold)

February 24, 2009 1:12 AM | Posted by Lexi: | Reply

You could just call it "no progress will ever be made in modern medicine" of course, the reason you just mentioned is one, many Dr.'s do not read primary research. Another good many refuse to discuss medical research with patients (maybe this interferes with 'informed consent' but so do the six minutes the insurance co's give Drs).

For example, there is a correlation between accelerated cognitive decline and drugs with anticholinergic effects (blocks acetylcholine), such as coumadin, detrol, paxil, zantac, adalat etc

Elderly patients often take multiple drugs with some range of anticholinergic effects. This can't be good for their well being, or for their mental health . . . how many elderly do we have with dementia or alzheimers?

Personally, I'd rather stroke out than loose my mind slowly. If Dr.'s aren't talking to patients about these side effects, or even aware of these side affects, how can they properly give patients informed consent?

Anyway, none of these ideas are mine/things I put together on my own, but they sure seem like reasonable questions to ask/be aware of. They're from people that I appreciate hearing from as much as I enjoy reading your articles. Especially the ones on narcissism. Really. I don't know why.

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Don't feel bad. Research is... (Below threshold)

February 24, 2009 6:10 AM | Posted by varangianguard: | Reply

Don't feel bad. Research is like this everywhere, not just psychiatry. Stick with the safe path. Help me to expand my theory. You don't get research money for failures.

It sneaks up on you. And since everyone else is doing it, and promoting it, you too are seduced into thinking that this is the right path.

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@Kevin: I don't believe Alo... (Below threshold)

February 24, 2009 10:36 AM | Posted by La BellaDonna: | Reply

@Kevin: I don't believe Alone aspires to writing for the lowest common denominator. Some of his readers actually DO understand the Latin phrases. The others can look it up and learn something - or not, as they choose. I imagine he's covered a few other areas that may not be your specialty, either. If he leaves out everything you don't already know or understand, what are you reading him for? I don't understand how to read the gold/platinum charts (yet) that he's posted in previous entries; I don't think that's a reason for him to stop posting them in his entries about economics.

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I'm curious, how are you ab... (Below threshold)

February 25, 2009 2:48 AM | Posted by ItsTheWooo: | Reply

I'm curious, how are you able to function as a psychiatrist if you have such a cynical view regarding the efficacy of psychiatric medications?

You compare medical trends to fashion trends, and I would agree that you are correct partially. Ultimately you must admit we can control mental illness better than ever, even in spite of the tendency to let fashion dictate practice. Every decade it gets better, people with mental illness can live fuller lives because of this research. Pharmaceutical industries do use science words as soundbites to promote their drugs, but what does it matter if the drugs work? Serotoninergic drugs might not work because "low serotonin causes depression", it might be that reuptake inhibitors for serotonin also work on dopamine... or it might be that they inhibit cortisol which allows the brain to heal... or any number of reasons. If the drug works, it works.

I know my grandmother died in a psychiatric hospital... who knows, she might not have had to if some of the newer antipsychotics were available then.

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fantastic post again... (Below threshold)

February 25, 2009 7:48 AM | Posted by the0ther: | Reply

fantastic post again

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I think main improvements i... (Below threshold)

February 25, 2009 3:37 PM | Posted by spriteless: | Reply

I think main improvements in psychiatry are in follow up care, deciding something isn't a problem if it doesn't harm the patient or others, you know: everything but meds. Like institutions. People aren't institutionalized nearly as often as they used to be. And now they have slightly less incentive to go control freaky. http://www.autistics.org/library/conversation.html

Last, do you imagine neurology will overtake psychiatry?

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"If a drug works then it wo... (Below threshold)

February 25, 2009 8:05 PM | Posted by mo: | Reply

"If a drug works then it works"
Wow. I am a chronic pain patient after spinal cord injury who had the wonderful opportunity to experience Cymbalta in all it's glory.

It was a drug and it worked. It worked so well that when the twitching,jerking and shuffling started i ignored it, my neurologist ignored it, my neurosurgeon ignored because the drug worked. It settled the burning and all of us agreed that the pain was more important.
We kept on ignoring the worsening tremors until one day we couldn't anymore and now I wait and take a different pill in the hopes that I stopped the Cymbalta in time, that just maybe I could just be that girl with the agonizing pain again and not that girl with parkinsonian tremors and chronic pain.

Just because a drug works doesn't mean it's worth taking.

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But you DID go to wikipedia... (Below threshold)

February 25, 2009 11:48 PM | Posted, in reply to Kevin's comment, by Anon: | Reply

But you DID go to wikipedia to look it up. And now you know a latin phrase. Readers will rise to the level of writer expectation.

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I have been living with a b... (Below threshold)

February 27, 2009 4:46 PM | Posted by Chris Fallows: | Reply

I have been living with a bipolar condition for almost thirty years--off and on, currently on, meds--and my perception of psychiatry has spread along the spectrum of thinking it was quackery to something wonderful for the freedom its treatment has provided to formerly institutionalized "patients." The phrase, "Psychiatry is more of an art than a science," probably comes closest to hitting the mark, I think, problematic as that may be for a branch of science with an inferiority complex, in relation to the rest of medicine, to establish itself.
It does seem that much of the efficacy of medication lies with the individual's experience. Before I was able to stay on medication consistently (forced, initially, through a court order), I made period trips to in-patient units; while on meds I have now gone six years without a hospitalization, had my first long-term relationship, worked consistently at a job and was able to develop my spiritual life. Have I been symptom or episode free? No. But my life is a lot better than before, and it is most certainly the medication, as a foundation, that has allowed me to develop various areas of my life. I know medication is nasty stuff that is idiosyncratic in its effectiveness on a particular person and seems to need constant adjustment but, hey, this is an illness that needs constant treatment, in whatever way a person does that (even if it's without meds). That's all.

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Well, it's not generally th... (Below threshold)

March 5, 2009 10:38 AM | Posted by Joseph Bergevin: | Reply

Well, it's not generally the job of psychiatrists or neurologists to research new cures. They're there to translate symptoms into pathologies, and then tap the source of actual advancement - the drug companies. A good psychiatrist only needs to know first line treatments and how to tease truth from an unreliable narrator.

On the drug front, I'm surprised we have as much progress as we presently do. Emotion and cognition emerge like a ghost from a sloppy sea of systems. The control panel has a thousand buttons, and we've learned to push a few and break a few. I'd like to think that we'll eventually learn to play the buttons like a piano, but I'll settle for knowing the best ones to break, for now.

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Bergevin is on the money.</... (Below threshold)

March 6, 2009 11:08 PM | Posted by Jack Coupal: | Reply

Bergevin is on the money.

The human brain is so complex, brain chemistry is so little understood, there are so many back-up redundant systems within it. For decades, we've tried to understand the "blood-brain barrier". Why does one solid part of our body have a special system to repel invaders? There is no liver-blood barrier, no thyroid-blood barrier, no eye-blood barrier.

Serotonin, norepinephrine, and dopamine are currently the hot brain chemicals. I'll guess that they actually do their work (if they're the ones actually doing it) through some other chemicals or their pathways that academic and pharmaceutical scientists haven't even found yet.

Which buttons do you feel need breaking?

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Good points. All these sci... (Below threshold)

March 8, 2009 4:21 AM | Posted, in reply to survivor's comment, by Dr Claude Windenberger - Unconditional Freedom Process: | Reply

Good points. All these scientific theories and disciplines (and the businesses that based their marketing on them) thrived only because human beings weren't willing to take care of themselves. As people get tired of it, they will naturally look inside again for the answers to their illnesses, discomforts and other challenges in life.

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