Akiskal Unplugged, Part III - A Dying Breed

My last two pieces have discussed issues relating to a talk presented by Hagop Akiskal of UCSD to DBSA San Diego on Monday this week. As I commented in my first piece:

Basically, if you want to know about bipolar, you read the usual literature. If you want to know what is really going on, you read Akiskal (and Frederick Goodwin, and Robert Post and a few others).

Akiskal’s thinking is light-years ahead of just about all of his colleagues, but there is something very old-school to his approach. Like his hero Emil Kraepelin, Dr Akiskal’s insights are based on countless zillions of hours of exceptionally meticulous clinical observation. Yes, a PubMed search reveals 400 published articles to his name, but all are informed by a lifetime of listening to actual patients.

Listen - who has time for that any more? In a comment to my first piece, Louise observed that “doctors like Akiskal and Goodwin are a dying breed.” She pointed me to an article in the NY Times that came out the day before Akiskal’s talk. The article makes official what we have known for years. According to the piece, discussing the dilemma of PA psychiatrist Donald Leven, who first started practicing in 1972:

Then, like many psychiatrists, he treated 50 to 60 patients in once- or twice-weekly talk-therapy sessions of 45 minutes each. Now, like many of his peers, he treats 1,200 people in mostly 15-minute visits for prescription adjustments that are sometimes months apart. Then, he knew his patients’ inner lives better than he knew his wife’s; now, he often cannot remember their names. Then, his goal was to help his patients become happy and fulfilled; now, it is just to keep them functional.

According to Dr Levin: “I miss the mystery and intrigue of psychotherapy. Now I feel like a good Volkswagen mechanic.”

Actually, it’s a lot worse than that. At least good old-fashioned VW mechanics knew how to tear apart and put back together the whole car. In today’s scary new world of faux-psychiatry where insurance companies call all the shots, Dr Levin is more like the guy who performs oil changes at Jiffy Lube.

All that wealth of experience - wasted.

Perhaps you can see where I’m going with this. If psychiatrists no longer have time to listen to their patients and carefully observe, where are their insights going to come from?

A lot of what passes for academic psychiatry these days is performed by researchers who don’t even see patients. This explains why the DSM symptom lists are so spectacularly out of touch with clinical reality. This explains why the people putting together the new edition of the DSM don’t even deign to listen to Akiskal and Goodwin.

Psychiatry these days is a by-the-book exercise, and the book is wrong.

Eventually, all our new understanding of the science of the mind will come from brain science and genetic research. But two years ago I heard leading schizophrenia researcher David Braff at a conference caution against the devaluation of clinical experience. Basically, the lab hotshots require the insightful observers of reality tell them where to look and what to look for.

Indeed, Dr Akiskal has been doing that for years. In his talk on Monday, Akiskal made reference to his collaboration with psychiatric geneticist John Kelsoe of UCSD. Essentially, instead of searching for elusive bipolar genes, Akiskal pointed Kelsoe in the direction of genes that influence affective temperament, which promises to be a more fruitful exercise.

Trust me, a geneticist would never have thought of that on his own.

But with a new generation of psychiatrists performing lube jobs, with academic researchers not seeing patients, where are the clinical insights going to come from?

As Louise said, Akiskal and Goodwin - not to mention their generation - are a dying breed. When they go, there will be no one to replace them.