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.