Wednesday, May 20, 2009

Tooting from San Francisco - IV: Dang- This is Interesting!

This is my fourth day in San Francisco at the American Psychiatric Association’s annual meeting. To recap:

Morning: Time off.

1:00 PM: I’m back on the job, checking out the posters. “Deep Brain Stimulation [DBS] of the Ventral Capsule/Ventral Striatum for Treatment-Resistant Depression” reads the heading to a poster.

“That does it,” I tell the researcher in an accusatory tone. “Now you’ve really gone out and confused me.” Helen Mayberg and others have already been applying the same technique to Brodman area 25 in the anterior cingulate, and yesterday I was treated to an equivalent of a masters class on the topic.

Now I have to learn about another area of the brain? I hold my ground. I demand my masters class.

1:45: I’m early for a session on “me-too” medications. Frederick Goodwin is on the panel, and we greet each other warmly. This is the first time I’ve seen Dr Goodwin since the NY Times published an account that irresponsibly smeared him in relation to a show that aired on “The Infinite Mind,” which used to be run on NPR.

The NY TImes piece was a mugging, and clinicians who should know better such as physician blogger Dan Carlat and psychologist John Grohol of PsychCentral engaged in the equivalent of kicking Dr Goodwin in the face. Antipsychiatry bloggers such as Philip Dawdy of Furious Seasons predictably piled on without checking the facts.

To the best of my knowledge, I am the only blogger who defended Dr Goodwin. I wasn’t sticking my neck out. The facts were - and still are - on his side. I was very pleased to see Dr Goodwin in a chipper mood. We enjoyed a very pleasant conversation, then I took my seat in the audience.

The first speaker, William Carpenter of the University of Maryland, made the telling point that new meds development is held up by the prevailing single disease mindset (Dr Carpenter used “paradigm,” but I forgive him). For example, we tend to equate psychosis with schizophrenia. Psychosis, however, features in other illnesses and conditions. Individuals with schizophrenia, in the meantime, have a lot more to contend with than just psychosis.

For instance, avolition (lack of motivation) looms large in schizophrenia. Yet, there is no med for this, and there may never be one if drug companies have to run clinical trials based on old precepts. Suppose, for instance, a drug company tested an “avolition med” on a population of individuals with schizophrenia. But if only say one-third of those being tested had to contend with avolition, then, said Dr Carpenter, the trial would fail.

Ironically, such a cognition med may be efficacious across a whole range of disorders. Dr Carpenter informed his audience that the FDA is aware of the situation and is working to fast-track cognition meds (Google “MATRICS”).

Dr Goodwin pointed out that clinical trials do not reflect clinical practice. For instance, those with severe mania can’t get into trials as it is impossible to obtain from them “informed consent.”

Clinical trials are based on finding results that apply across large populations. This, combined with “hierarchies of evidence” (which devalue smaller studies and clinical experience) are forcing patients “into a one-size-fits-all straightjacket.”

Here’s where the danger lies, according to Dr Goodwin: Treatment guidelines based on unrealistic clinical trials (but which are at the top of the evidence hierarchy) create uniform menus. These menus are increasingly being employed by government and private insurance to ration services.

For instance, what if third-party payers decided not to approve of the use of an antidepressant added to a mood stabilizer for bipolar patients because a large STEP-BD study did not find them effective across a large population?

Dr Goodwin described his experiences dealing with out-of-touch academic researchers back in the nineties. “I couldn’t imagine them ever managing a patient,” he said. (And they didn’t.)

Evidence-based medicine, Dr Goodwin said, is based on what we already know. Innovation tends to come from clinicians breaking the rules, which is how lithium and antipsychotics found their way into psychiatric practice. It isn’t just about the NIH translating scientific research into treatment.

4:00 PM: Afternoon posters. The first one I bump into is about unidentified “threadlike and/or spherical particles” in the cerebrospinal fluid of bipolar patients.

Dang! This looks interesting. Now I really have to budget my time. A few posters down: “Inhaled Loxapine Rapidly Improves Acute Agitation in Patients with Bipolar Disorder.”

Recall what Dr Carpenter had to say about the need to test for a specific part of the illness (such as avolition), not just the illness. Loxapine is an ancient antipsychotic, so we’re not talking about a new med, but the principle is the same. The treatment, if approved, would be taken on an as-needed basis, say when you felt yourself freaking out over a missed plane at midnight in Las Vegas airport (which happened to me). Unlike “popping a Klonnie,” sucking into the inhaler would work instantly, presumably without sedating effects.

Right now, we’re simply talking promising. Maybe the promise of the med won’t play out, but - dang! This looks interesting. There is only 30 minutes to go to this poster session and I’m still not out of the first aisle ...

This is John McManamy, live from my fleabag hotel room, on my way out to grab a burger.


Anonymous said...

I'm not sure why you argue that furious seasons is an anti psychiatry blog. It may be almost anti-pharma, and critical of lazy psychiatry, but not anti.

John McManamy said...

Hi, themadandwild. I acknowledge your point. There are smart critics of pharma and psychiatry who do their homework. Dawdy does not do his homework, he gets his facts wrong, he jumps to ridiculous conclusions, he personally attacks individuals based on his own inability to process facts, he has delusional beliefs about his own accomplishments, he subscribes to conspiracy theories, and presented with a contrary argument he always responds with unprincipled personal attacks based on fiction he makes up, plus he allows readers to ideate physical violence against others.

I think I'll stop there. Antipsychiatry fits - no more Mr Nice Guy with this unprincipled idiot.

Gina Pera said...

Well said, John.

Blogger just munched my more cogent response to this, and I don't have time to re-write it. So here's this:

In a nutshell, the problem with self-proclaimed "journalists" like Dawdy and his fear-mongering is that he is pandering to the very problem experienced by many people with brain dyfsunction: an overactive limbic system and an underactive prefrontal cortex.

They overreact to (and mis-perceive) threats,instead of thinking things through more rationally. It's so easy to "goose" their amygala. It even feels good to some -- revs 'em up. And that's exactly what Dawdy is doing: pandering to the reptilian brain.

He's not offering information that elevates people's lives. He's self-medicating by first drumming up his own adrenaline-stoked "fury" and then his readers. They don't want to take real medication? No problem! But they do others an injustice by making it hard for them to seek medication treatment.

I just wish he'd stop calling himself a journalist. And I can't imagine what psychiatrists and psychologists who refer to his blog are thinking.

John McManamy said...

Hey, Gina. Read you in full. Grohol and Carlat have been totally clueless in legitimizing this idiot and in failing to pick up his nutjob behavior. Makes you wonder about their competence as clinicians.

Gina Pera said...

I don't think Grohol is a clinician, is he?

As for Carlat, I was heartened to see him adding some reason to the Biederman issue, attempting to calm the pitchfork crowd, as it were. And I was also glad that he mentioned that the APA's industry-sponsored event on ADHD was worthwhile.

Heaven knows pharma AND physicians need watchdogs, so I think he's doing a service.

John McManamy said...

Hi, GIna. I definitely agree that Pharma and psychiatry need watchdogs. But I do take issue when they bite indiscriminately. :)

As for Grohol. I don't know if he sees clients. I know you lose touch with reality if you're not seeing patients. That's one reason I'm active in DBSA and NAMI. And that when I give talks it's practically all question and answer.

Gina Pera said...

Yes, rabid watchdogs are dangerous! :-)

Same here on problems inherent in losing touch with reality. When these issues become but abstractions, all capacity for compassion and empathy (if it ever existed) is lost.

That is why I am so impassioned, I guess. I've heard too many stories of the good that happens when psychiatric treatment goes right to let bad psychiatric treatment stand unchallenged.

I also know that many people with conditions such as ADHD and bi-polar do not feel empowered to self-advocate. In fact, for many late-diagnosis adults, they often cannot conceive that life could possibly improve. They've tried everything they can think of, including medications sometimes, and nothing has gotten better (and often got worse). So, they often are not the best judges of when they are getting good or mediocre care.

Stephen Blau said...

OK, branching off here; I'm glad to read Dr. Goodwin was in a chipper mood. I hope it's true. The drubbing he took by these so called journalists and advocates was embarassing.

John McManamy said...

Hi, Stephen. I really appreciate you standing up for what is right and calling out the unprincipled idiots who attacked him. I can assure you the facts completely vindicate Dr Goodwin. Moreover, his reputation was not harmed.

Unlike the unprincipled idiots who attacked Dr Goodwin, I happen to get out in the real world. (And so does Dr Goodwin.) The individuals I have talked to long ago dismissed The NY Times and Dawdy and others as pure bullshit.

But - yes - no one likes to see their name in the NY Times the way Dr Goodwin saw his name. And yes, it was an extremely stressful experience for him. But unlike the people who attacked him, Dr Goodwin is a man of character, and he came out of this strong.

Gina Pera said...

John wrote:
"Unlike the unprincipled idiots who attacked Dr Goodwin, I happen to get out in the real world. (And so does Dr Goodwin.) The individuals I have talked to long ago dismissed The NY Times and Dawdy and others as pure bullshit."
I am glad to hear this. I have to remind myself constantly that others are not following the b.s. like we are. They are going on with their science, their treatment, their lives, and not swirling in the distorted muck.

I feel as though I must keep abreast of these manufactured "controversies," though, so I know where off-the-wall comments that I might hear are coming from. But too much of it and well, it's like toxins in the brain!

Have a nice trip home, John.


John McManamy said...

Many thanks, Gina. And great to meet up with you in San Fran. That's what we need to keep reminding ourselves: Web 2.0 is not real. It is not an accurate representation of the real world.

A cultural anthropologist a hundred years from now simply poring over the data from the blogosphere and places like Facebook would have no choice but to conclude that the first part of this millennium was a very bizarre age dominated by crackpots.

In the real world, people are too busy intelligently managing their lives to concern themselves with Web 2.0.

Or - to change this slightly: They will concern themselves with Web 2.0 when they see it as an advantage in intelligently managing their lives.

I, for one, think Web 2.0 is way overstated. Hopefully, in time, things will settle down. The signal-to-noise ratio of this new medium will improve - or at least the public will have the means to separate the signal from the noise.