A Garage Door Lesson

I learned a valuable lesson from a garage door today that I thought I would pass along to some posters who think they know something about psychiatry and psychiatrists.....

I came home early this afternoon and hit my garage door remote, like I had done thousands of times in the past.  This time the door went up and seemed to hesitate and drop back about 2 inches, then it went all the way up.  I stepped out and noticed a bolt laying on the floor.  I picked it up and it was a 5/8 x 1 1/2 inch self-tapping bolt.  Looking around, I noticed that it has fallen out of the plate that fastens the garage door to the door itself.  The plate was bent and there was only one bolt left holding the door.  I grabbed a socket wrench and a ladder and headed up to where the door was suspended to fix it - about 5 or 6 feet off the floor.  It was immediately evident that the plate was bent at such an angle that I could not gain any purchase in the door with the free end of the bolt - or it was stripped.  Without thinking, I thought I would pull the emergency door release hanging just to my right to give me just enough slack to fasten the bolt.

In an instant, the arm assembly jerked my left hand very hard toward the door opening as the door crashed from fully open to fully closed in a less than a second.  I was propelled about ten feet through the air landing on the floor at the base of the door with some serious neck strain and a few sprains but otherwise, none the worse for wear.  I was somewhat stunned by all of this.  When I looked up I noticed the coil spring over the left side of the double garage door was snapped in half.  Directly in front of me was a warning that I had read many times before:

The universal "Don't turn your own wrench" sign.  I apparently ignored some pretty basic information that any professional garage door mechanic would not have.  It resulted in me getting knocked around pretty good and putting me at serious risk for a head injury, a spinal injury or death.  A few data points and I ignored them.  I also knew that garage doors were dangerous.  Just a few years ago, my brother showed me a healed scar across his palm that resulted when he attempted to repair a snapped garage door spring.  But where in all of this is the lesson for the inappropriate criticism of psychiatrists?

I should probably define at least part of what I consider inappropriate criticism and what a poster here has touched on as important dynamic.  On the sites where it is common for psychiatrists to post or sites that claim some legitimacy in the area of criticism, there are also some thoroughly hostile and malignant posts that are at the minimum inappropriate and at their worst pathological.  I have received a few directly here last week, but have decided that posts such as these will not appear on this blog.  I am aware that some people think that anyone should be allowed to criticize psychiatrists in any manner.  They are wrong.  People suggesting that I should "burn in the hottest part of hell" of course would be one example, but there are many more.

The garage door incident is instructive for at least some of them.  I recently saw a number of anonymous posts saying that psychiatrists can "just say anything" and that psychiatric credibility could be "shredded" in forensic settings.  Interspersing those arguments among supposedly legitimate critics takes the level of their arguments way down.  If these types of posts were always the case, it would be very easy to ignore a thread inhabited by barbarians.  I could certainly come up with a neat little definition of the barbarians but what is the point?   A related question is why those sites feel compelled to include this posts?  I don't think that is a passive or well thought out decision.  Once the discussion has headed into abusive, threatening, or irrational territory and it remains in fair play - that says a lot about the intent of the administrator.  At the very minimum, the intent is no longer a reasonable discussion.  Granted that it is often difficult to determine what is reasonable, given the overall tenor of the site.  For example, if I wrote a book bashing all psychiatrists and was promoting it on a site, why wouldn't I include every possible irrational post as evidence that I am correct?

It is much more instructive to look at the garage door example and what it implies for the basic argument that there is no such thing as mental illness and the closely related arguments - psychiatrists are not needed for the diagnosis and treatment of mental illness or that they have simply made up mental illness so that they can all be rich and drive expensive cars (another e-mail from one of the fans).  The garage door is a simple scenario with three critical points of information that any experienced person could observe - arm plate screw missing, arm plate bent, and left main garage door coiled spring snapped in half.  As an additional historical point I should add that in my experience these springs snap about every 15 years and this one was only 5 years old.   I observed 2/3 of the points thought I could make the repair and nearly had a catastrophic result.

In the case of a psychiatrist seeing a new patient, there are hundreds of relevant points that all have to be acquired and examined in the initial evaluation.  The total number of critical points is unknown, but to use just the example of a basic instrument for the assessment of suicide potential they number in at least the 20-30 range.  This assumes that the patient is able to respond appropriately to the questions.  There are at least another 20 or 30 points when it comes to the prescription of medications and coming up with a treatment plan.  As any affected family member can attest, severe mental illness or addiction is at least as serious as a crashing garage door that knocks you off a ladder.  It leads to trying to shake off the acute effects and prevent any long term harm.  In that event many people are seen and treated successfully by psychiatrists.  As I have posted here before, we are the people who are trained to see significant problems and the psychiatrists I know do a good job.

In practically all of the irrational criticism of psychiatry, none of these information points are covered.  People seem quite content to tar and feather psychiatrists with whatever seems fashionable at the time.  So this lesson is really one about the information content not typically being covered and how missing even a small point in any information set can be potentially problematic, and in my analogy, not just in terms of my own safety but the liability issue if anyone had been working with me.

I know that this lesson may be a stretch for some and in that case consider this a public service announcement for not trying to fix your own garage door.  Do not try it at home like I did.  Leave it to the professionals.

Oh - and I am not sorry to disappoint those who would have just as soon seen another psychiatrist bite the dust.

As far as I know - I am OK.



George Dawson,  MD, DFAPA

Indignation Bias

"Moral indignation in most cases is 2% moral, 48% indignation, and 50% envy." - Vittorio De Sica


The New England Journal of Medicine has started a new series on conflicts of interest that should prove to be enlightening if the rest of the articles are as good as the first one.  In this article, Lisa Rosenbaum, MD  takes on typical cases that appear to be straightforward conflict of interest cases and thoroughly debunks the common thought process.  She provides a clear link between the outrage over the behavior of the pharmaceutical industry and an indignation based approach to regulation and conflict of interest considerations.

In the first example she looks at the issue of the 2013 cholesterol guidelines and the expansion of the target population for statin therapy.  There was the standard New York Times editorial by two physicians who concluded that the guideline "would benefit the pharmaceutical industry more than anyone else."  They referenced an article by one of the authors on the frequency of statin side effects that was later withdrawn due to an overestimate of the frequency of side effects.  They challenged the credibility of  the guideline writers suggesting that they needed to be free from "influence, conscious or unconscious".  Rosenbaum reviews the checks and balances in place for the writing of this guideline in a manner reminiscent of my analysis of a Washington Post commentary on the DSM-5 diagnosis of depression.  In both cases, the safeguards in place are overlooked, the benefit to the pharmaceutical industry  overestimated, and the authors of these critical articles are never challenged.  She asks the important question: "So why the rush to conclude that the guidelines were an industry plot?"  It is also interesting from the perspective of psychiatry where the field would never get that kind of break.  The question for psychiatry is:  "Why the rush to judgment to conclude that the guidelines were a plot between psychiatrists everywhere and industry?"

The Jesse Gelsinger case was examined next.  Mr. Gelsinger was an 18 year old man with ornithine transcarbamylase deficiency.  He volunteered for a research protocol examining gene therapy for the disorder.  The ethical considerations included the fact that the researchers were advised that it was not ethical for them to test the protocol in affected babies who might benefit if it was successful because that would be considered coercion.  There was also an issue relating to the reporting of a complication of the therapy by basic science researchers.  Rosenbaum points out that after Jesse Gelsigner's death due to the research, the popular explanation for what happened was that the lead researcher had an equity position in a gene-therapy company.  There were numerous safeguards in place including a lack of a direct connection between sponsorship of the trial, a university prohibition of the lead researcher in patient enrollment or interaction,  and that same researcher asking a colleague to be the lead investigator in that trial.  The research had also been approved by more than one Institutional Review Board (IRB).  Most IRBs require a review of the scientific merit of the research before considering it on ethical grounds.   Since this was a protocol for the first human experiment in gene therapy, the vetting was unusually rigorous:

"The OTCD gene therapy protocol and the associated consent document underwent extensive review including IRBs at three institutions, the Recombinant DNA Advisory Committee, the Oversight Committee of the General Clinical Research Center of the University of Pennsylvania, and the FDA."  (reference 2)

 Please read the entire paper on line for the complexities of this case.  For the purpose of the NEJM article the relevant section had to do with Wilson recommendations of why the appearance of conflict of interest maybe all that counts.  After disclosing everything that he did  to minimize financial conflicts of interest Wilson concludes:

"I conclude that it is impossible to manage perceptions of conflicts of interest in the context of highly scrutinized clinical trials, particularly where there is a tragic outcome....." (reference 2, p 155).

That is where Rosenbaum's article gets interesting.  She introduces a concept that gets very little play in clinical medicine and one that has not had much play in psychology until the past decade and that is emotional reasoning.  There are physiological and evolutionary reasons why emotions play a large role in day to day reasoning.  In patients with a pathological loss of emotional reasoning there are significant problems in day-to-day decision making.  Diagnostic reasoning in medicine on the other hand is often described as a purely intellectual  process.  Psychiatrists  encounter this in our colleagues.  I can recall for example, confronting a Cardiology resident with the fact that her agitated patient did not have an acute exacerbation of bipolar disorder like she suspected and  did not need transfer to Psychiatry, but in fact had just had a stroke and was aphasic.  "What the hell do you know about strokes?  What do psychiatrists know about neurology?"  she stated forcefully as she rapidly escalated herself.   I calmly back pedaled and said: "Get your attending to confirm the findings and the diagnosis and if he doesn't - call me back.  But right now your patient has aphasia and has right upper extremity weakness and needs to go to the Neurology service."  Within an hour that patient was under the care of the Neurology service.  My point being that level of emotion or in this case emotional biasing really doesn't show up in any of the case records or diagnostic reasoning in the New England Journal of Medicine.  Everything is cool, dry, and pure Bayesian analysis.

Rosenbaum likes the work of a social psychologist Robert Zajonc who was one of the pioneers in this area.  If most decisions begin with a feeling, what persisting feeling may be there in the case of decisions about conflict of interest.  She had previously cited numerous legal infractions and penalties against most of the major pharmaceutical manufacturers.  It should not be surprising that the persistent emotional decision making involving that industry is going to be rather negative and miss the complexities and information that runs counter to that emotion.  I think back to one of the basic admonitions of grandmothers everywhere from my generation: "If there is one thing I can't stand it is a liar!"  I reflected on that over the course of my years in medicine as I realized that the reality is that everybody lies and they lie all the time.  But if you are indoctrinated to that rule and you have a definite emotion associated with it, you should be able to predict the direction of the decision.  You only have to look as far as Cognitive Appraisal Theory (4) for the predictable results when anger is that emotion.  To make it real, in the case of ongoing problem with the pharmaceutical industry you will see their responsibility as high and any adverse outcomes as being totally in their control.  You will be very certain about your decision, irrespective of what the reality is.  One example previously mentioned is the idea that the new cholesterol guidelines would be a windfall for the pharmaceutical industry when the vast majority of the prescriptions are for generic statins.  There will be a contamination effect on everyone associated with those companies and as long as the underlying emotion persists the associates will be predictably condemned with the same level of certainty and any negative events will be perceived as being under the complete control of the individuals involved.  There can be no unanticipated adverse outcomes or complications.        

The most concerning aspect of this kind of emotional bias is that people seem to be completely unaware of the fact that they have been swept up in it.  To them, their decisions all seem reality based.  The biasing effect in emotional reasoning has the same predictable effect in paranoid psychotic states, road rage, and Little League parents.  It is certainly alive and well in practically all aspects of public opinion when it comes to psychiatry.  Many blogs and Internet sites seem nothing more than a lens to focus rageful commentary against the profession, and further indignation if any psychiatrist dares to speak out against many of these practices.

I think indignation bias explains a lot, particularly attitudes toward psychiatry but also overly rigid thinking in the case of complex decisions and unpredictable negative outcomes.  It has allowed an irrational connection between Big Pharma and psychiatry and for many people to profit from focusing anger against the profession.  And per Dr. Rosenfeld it is not conducive to rational regulations of the industry, but it seems that at least the marketing end of those businesses seem content to see their "pushback" as being the cost of doing business.  Even marketers could benefit from educating themselves about the negative future effects of emotional decision-making against their industry.


George Dawson, MD, DFAPA


References:


1:  Rosenbaum L. Reconnecting the Dots - Reinterpreting Industry-Physician Relations. N Engl J Med. 2015 May 7;372(19):1860-1864. PubMed PMID: 25946288.

2:  Wilson JM. Lessons learned from the gene therapy trial for ornithine transcarbamylase deficiency. Mol Genet Metab. 2009 Apr;96(4):151-7. doi: 10.1016/j.ymgme.2008.12.016. Epub 2009 Feb 10. PubMed PMID: 19211285.

3:  Lerner JS, Li Y, Valdesolo P, Kassam KS. Emotion and decision making. Annu RevPsychol. 2015 Jan 3;66:799-823. doi: 10.1146/annurev-psych-010213-115043. Epub 2014 Sep 22. PubMed PMID: 25251484.

4:  Lerner JS, Keltner D. 2000. Beyond valence: toward a model of emotion-specific influences on judgment and choice. Cogn. Emot. 14(4):479.



Supplementary 1:  According to UpToDate, the gene therapy trial mentioned in the above reference was cancelled after the death of Jesse Gelsinger.  He was the 19th patient in the trial and metabolic correction of the other 18 patients did not occur.  (Topic 2923)

Supplementary 2:  Image used at the top of this post is a Shutterstock standard license download.

Supplementary 3:  Quote from Vittorio De Sica is from Stereophile June 2015, p 125.

The Heuristic is Dead - Long Live The Heuristic

One of the latest non-scandals to rock monolithic psychiatry and psychiatrists everywhere is David Healy's commentary on serotonin and depression (1).  Certainly nothing new there from the Healian perspective - SSRIs don't work, SSRIs don't work for melancholic depression, no evidence that SSRIs raise or lower serotonin levels, SSRIs pushed tricyclic antidepressants out of the market, and SSRIs forced the abandonment of research on biological disturbances in depression like hypercortisolemia.  The only thing I did not see was the idea that SSRIs are somehow addicting because they cause discontinuation symptoms in a subgroup of people who take them.  Feel free to call that a withdrawal syndrome, but withdrawal does not constitute an addiction.  All of these premises allow him to reject serotonin and it's role in depression on the vaguest possible grounds while stating that it is not irrelevant:

"Serotonin is not irrelevant.  Just as with noradrenaline, dopamine, and other neurotransmitters, we can expect some correlation with personality and temperament."

Indeed - but I expect those to be a very weak correlations probably not on par with the mood disorder work.  I was glad to see his reference to the late Marrku Linnoila (2) or more specifically Linnoila and Virkkunen.  Linnoila had done some of the outstanding work in this area and work on serotonin metabolites (CSF HIAA) in alcohol use disorders remains a classic.  He talks about the serotonin based research running into the sand.  I did a Medline search of serotonin and major depression and plotted the papers per year and there does not seem to be any precipitous fall off (the 2015 references are through March).  If anything I would expect the research to increase with the availability of ligands for additional receptors and the further characterization of serotonin transporter (SERT) variants.

But the main problem with Healy's argument is that he is talking about serotonin as if there is a chemical floating around in the brain and that is it.  He is basically describing his own brand of chemical imbalance theory.  So if he is saying there is no serotonin chemical imbalance theory I would of course have to wholeheartedly agree with him.  And in fact, I would tell him the same thing I told the Prozac rep back in the 1980's:  "The brain is far more than a bag of chemicals.  Unless you can say something about brain structure and physiology naming a neurotransmitter is meaningless."  There is no such thing as a chemical imbalance theory and reading through the index of any psychopharmacology text printed in the past 30 years will confirm that.

Healy can't stop himself at that level.  He goes on to describe the impact of his chemical imbalance theory on clinicians:

"This history raises a questions about the weight doctors and others put on biological and epidemiological plausibility.  Does a plausible (but mythical) account of biology and treatment let everyone put aside clinical trial data that show no evidence of lives saved or restored function?"

Things get very tenuous at that point.  As a clinician who has made a career out of treating patients with the most severe problems  I don't care at all about the "biological and epidemiological plausibility" of a theory of a medication.  I got past that in the 1990s when the elegant Nobel laureate mechanism of action of aminophylline was debunked and the former first line drug for asthma and COPD exacerbations was suddenly relegated to tertiary status.  And even then, with the people I was running up on gurneys from the emergency department while calculating the parameters of their aminophylline drip - not a patient of mine was lost.  I suppose you could say it was all an elaborate placebo response, treating all of those people with acute shortness of breath bad enough to be brought in by paramedics.  I was after all using a tertiary treatment with a disproven molecular mechanism.  But really?  And my living, breathing pulmonary patients did not seem to mind.

The only thing that matters to me is if the medication works in my hands, has few side effects, and I am using it exclusively to save lives and restore functioning.  And without keeping anyone in suspense, I do prescribe SSRIs and they do work, and I do fully acknowledge to anyone willing to listen that the mechanism of action is unknown. Not surprisingly many patients want more than that and I can discuss speculative mechanisms as well as the next psychiatrist.  I don't think that makes me a drug company stooge or an idiot, because I am the only person with any accountability in the entire scheme of things.  It really doesn't matter to me what David Healy or anybody else thinks.  I am seeing very ill people and it is my job to get them better and not cause them side effects with the medication and not have the drug interact with one of their underlying medical conditions.  When you get right down to it, I don't need a mechanism of action to use a medication - only the approval of a regulatory body like the FDA.  At some point somebody may say that  SSRIs are no better for depression than aminophylline was for asthma, but so far (apart from Healy and various sympathizers) that has not happened.  I just attended a CME conference last weekend and they were still recommended.  As far as I know the FDA has not sent out any letter to doctors telling them not to prescribe them any more.

Healy also asks the irrelevant question:  "Do clinical trial data marketed as evidence of effectiveness make it easier to adopt a mythical account of biology ?"  Or I guess the real question is do these data make it easier to accept this strawman?  I strongly encourage any psychiatrist to read and reread the FDA approved package insert on any drug they prescribe and any drug their patient happens to be taking.  I encourage reading and rereading those package inserts especially if they are updated and sent out in a mass mailing by the FDA.  These package inserts need to be studied because they are not the final word in safe prescribing.  If you are an experienced psychiatrist you will routinely be called on to decide if a medication (based on all of the available evidence) is safe to prescribe to a patient with cardiac, liver and renal disease.  You will have minimal data to go by in most cases, because people with significant medical illness are typically eliminated from clinical trials.   Any psychiatrist reading those package inserts will recognize that for some time now, the package inserts have contained clinical trials data and that data is very useful.  It's utility has nothing to do with putative biological mechanisms, it has to do with safely monitoring and prescribing the medication.  The other consideration implicit in this question is that clinical psychiatrists are unaware that clinical trials are really a primitive technology.  Given that awareness exists, why would anyone accept clinical trials data as proof of much of anything.  How in the world does a double-blind placebo controlled study with an intent to treat analysis have anything at all to do with my practice of psychiatry?  It is totally irrelevant clinically and even less relevant theoretically.  Its only use is to get a new drug in my hands that my patients and I will accept as useful or reject as too toxic or worthless.

Why are reasonable people interested in serotonin despite Healy's commentary?

The complexity of serotonin or more appropriately serotonergic signaling for one.  Absolute levels of neurotransmitters are rarely the issue in complex disorders.  In the case of serotonin any bare bones discussion needs to consider the fact that there are 14 serotonin (5-HT) receptor subtypes coded by 18 genes.  Those receptors are organized into 7 families, 6 of which are G-protein receptor linked superfamily.  The remaining family is part of the ligand-gated ion channel superfamily.  The combinatorics of these receptor types, their specific locations, and their genetic variants can lead to a dizzying number of signaling variations that can easily be found in psychiatric research (4).  As an example, this is from a 2013 review of serotonin signaling in depression and suicide by Mann (3):

".......Part of the neurobiology observed in recurrent major depression, that is present between episodes as well as during episodes, is a series of abnormalities in the serotonergic system [19]. Cerebrospinal fluid (CSF) levels of the main serotonin metabolite, 5-hydroxyindoleacetic acid (5-HIAA), are low in more lethal suicide attempters, and predict the risk for future suicide with an odds ratio of 4.6 [20].  Convergent evidence comes from some reports of low CSF 5-HIAA in suicide attempters with other diagnoses such as schizophrenia [21,22], bipolar disorder [23] and personality disorders, although there are fewer studies and less consensus in these other disorders [24,25]. Nevertheless, if correct, such findings suggest that less serotonin transmission, as implied by less 5-HIAA, appears to be associated with suicidal behaviour across psychiatric diagnostic boundaries, as would be expected if it were associated with the diathesis for suicidal behaviour instead a specific psychiatric disorder. A review of post-mortem brain studies of suicides has found much the same thing: most studies find suicides have lower levels of serotonin and/or 5-HIAA in the brainstem serotonin neurons compared with psychiatric-matched groups [26–28]."
   
Apart from all of the disputed technical details, what is the importance of the Healy commentary?  It follows the political tradition of other commentaries mentioned on this blog by prominent psychiatrists.  People have sent me e-mails and asked me: "What do you mean by political?"  In the simplest analysis it is taking one end of a polarized position and running with it and bringing everything that you can to support that position.  That is the classic way that politicians work.  They are fueled by ideology.  On the surface, it seems that science operates like that as well, but ongoing scientific arguments don't include comments about marketing or words like "neurobabble".  They don't make assumptions about how clinicians think or whether they are confusing science and hypothesis testing with clinical work.  The best science encompasses complexity and contradictory data and we are past the point where neuroscience can be watered down for the masses in a 2 minute sound bite.

Neurobabble happens when a neuroscience discussion is reduced to a sound bite and debated the way that Democrats and Republicans discuss just about anything.  That is what happens when we are all polled "Serotonin - yes or no?"

If you really want to get your opinion out in the press that way that is one thing.  Let's not pretend that psychiatrists really think this way or that psychiatrists are just flunkies for Big Pharma talking about some crazy chemical imbalance theory or that we based our clinical practice on heuristics or for that matter marketing.

Psychiatrists are really bright people, time to stop pretending that we are not.


 George Dawson, MD, DFAPA



References:

1: Healy D. Serotonin and depression. BMJ. 2015 Apr 21;350:h1771. doi: 10.1136/bmj.h1771. PubMed PMID: 25900074.

2:  View my collection, "Marku Linnoila" from NCBI

3: Mann JJ. The serotonergic system in mood disorders and suicidal behaviour. Philos Trans R Soc Lond B Biol Sci. 2013 Feb 25;368(1615):20120537. doi: 10.1098/rstb.2012.0537. Print 2013. Review. PubMed PMID: 23440471

4:  KEGG.  The Serotonergic synapse.

5: Albert PR, Benkelfat C. The neurobiology of depression--revisiting the serotonin hypothesis. II. Genetic, epigenetic and clinical studies. Philos Trans R Soc Lond B Biol Sci. 2013 Feb 25;368(1615):20120535. doi: 10.1098/rstb.2012.0535. Print 2013. PubMed PMID: 23440469

6: Albert PR, Benkelfat C, Descarries L. The neurobiology of depression--revisiting the serotonin hypothesis. I. Cellular and molecular mechanisms. Philos Trans R Soc Lond B Biol Sci. 2012 Sep 5;367(1601):2378-81. doi: 10.1098/rstb.2012.0190. PubMed PMID: 22826338

How Does The IOM Ignore The Single Most Important Conflict of Interest?

Another free 28 minutes of work for corporate America on their prior authorization procedure.  I won't type out the dialogue and arbitrary holds along the way.  This time I was referred by the pharmacy to one of the major Pharmacy Benefit Managers (PBMs) and after negotiating their queue and listening to about 15 minutes of pure nonsense (privacy notifications for veterans, Medicare programs, etc) I reached a human being.  At that point he advised me that the PBM was not responsible for this particular prescription and I had to contact their insurance company.  He gave me the number and connected me, but of course it involved a queue that had similar recorded messages and then had a difficult time understanding my voice saying: "I am a provider."  I eventually spoke with a human being who had to look up the circumstances that would allow her to approve the prior authorization.  She had no apparent medical training and the criteria that she was reading out of a book could have been applied as easily on the front end by a pharmacist to save me from 28 minutes of free work for a PBM.  And keep in mind this was one prescription that the patient had already been taking.

There is really no excuse at all for this ongoing charade.  At the same time professional groups like the AMA are not able to take any action that would alleviate this burden.  Managed care companies have institutionalized these rules in most states for decades at this point.  It was shocking when I first discovered that.  Look at the state statues and realize that rules stacked against you and your patients are the law.  The law mandates that you need to do all of this work for free for a managed care company.

Today,  I came up with a new idea.  Attorney Generals in the State of Minnesota have a record of activism against health care companies and unfair practices.  I decided to send a letter of my most recent experience with a PBM to the Attorney General's Office along with a copy of a letter I wrote as an opinion piece the Minnesota Medicine a few months ago.  That letter details how these practices disproportionately affect psychiatrists and patients with mental illnesses.  The proposed solution to the problem is a very simple one.  Instead of expecting physicians or their surrogates to endure a 28 minute telephone gauntlet in order to speak to a non professional who is unsteadily reading approval instructions out of manual - give that manual directly to the retail pharmacist.  The 28 minute call would evaporate into a 2 minute call or less.  Better yet, take the physician out of the loop entirely.  There is no way that a physician should collude with a business decision to make money for a managed care company.   If the company refuses the physician order, it should clearly be documented and the next choice should be made (if possible) and designated as not the optimal choice by the physician.

That brings me to the all important issue of conflict of interest.  You can read blogs all over the internet that discuss the issue of pharmaceutical company influence ad nauseum.  The Pharmascolds remain preoccupied with this issue and are apparently unable to see that businesses run according to business ethics (whatever that might be),  clinical trials of practically all drugs are imperfect and no matter how many repeat studies the Cochrane Collaboration wants that basic fact will not change,  and that the FDA is a flawed politically biased agency rather than the guarantor of drug safety.  These are some of the common fallacies that I see played out each day across a number of settings.  At any rate,  just based on the frequency of enraged posts any casual reader would think that this is a daily crisis.  The only significant variant is that physicians and psychiatrists in particular are blamed for the ethical shortcomings of both American businesses and government.

But when you get right down to it - what is conflict of interest?  It is probably useful to use existing definitions rather than my direct observations for the purpose of this post.  There is no more respected body than the Institute of Medicine.  They routinely publish books on health care policy that are widely quoted and their definitions carry some weight.  I don't like their entire conflict of interest policy because they equate the appearance of conflict of interest with conflict of interest.  Congress would probably also have an issue with that definition.  Their basic introductory definition from the reference at the bottom of this page is included in the table below:

  
To keep it simple let's consider the primary interest in this case to be the welfare of patients.  The secondary interests in this case are defined as:  ".... financial gain but also the desire for professional advancement, recognition for personal achievement and favors to friends and family or to students and colleagues.." (p. 47).  They qualify this by saying that financial gain is not necessarily bad and that policies reasonably focus on financial gains but:  "When a secondary interest has inappropriate weight in a decision and distorts the pursuit of a primary interest, it is exerting undue influence."  They go on to define the conflict as any set of circumstances that arises that does not necessarily compromise the primary interest of patient welfare but that merely creates a risk for doing so.

How does this apply to prior authorization?  Prior authorization certainly sets up a secondary interest.  In this case the interest is the financial well being of the managed care company or PBM and in the case of publicly held companies - their shareholders.  From the perspective of the physician the secondary interest is maintaining employment which is the worst case scenario of "professional advancement."  Most employers and insurance companies stipulate that in order to stay employed you have to actively participate in all managed care prior authorizations and utilization review.  I am sure that astute politicians will claim that these surrogates are necessary to control runaway health care costs.  That does not explain how one could come up with a new sets of businesses worth tens of billions of dollars that make their money strictly from rationing pharmaceuticals.  These are companies that arise out of thin air based on the questionable theories of politicians and business people.  It does not explain why they are currently in the business of rationing very inexpensive generic drugs.  It certainly does not explain how there is a direct correlation between managed care rationing and an over 300% increase in health care administrators in the industry.  And most importantly it does not explain the complete failure of the managed care industry to contain health care costs.  In short, anyone espousing the need for expensive administrator heavy systems to control runaway prescribing does not have a leg to stand on.  The secondary interest in this case is clear.  Prior authorization is there to make money for companies and make a lot of it and physicians are forced to participate.    

The second issue here is an interesting and important one.  Physicians don't have to be convinced by flashy ads, salespeople, free samples, or financial inducements.  They are simply coerced.  When their patients are standing in a Walgreens or CVS, they don't have the luxury of saying no or even putting it off until the next day.  A patient who they have seen and assessed needs a medication and something has to be done.  They have to jump through a managed care hoop in order to get the medication that they have already prescribed - paid for.  The only question is: "How high is that hoop?"    

When people talk to me about all of the pharmaceutical company influence and evil marketing practices I don't even blink an eye.  I would like to know how the systematic coercion of the professional judgment of physicians by for profit companies on a national scale is not a far bigger problem than trinkets and pizza from the pharmaceutical industry?  There is no bigger risk of compromising the primary interest of patient welfare.  Patient welfare is always secondary to financial interest of the company involved.  The only case where it is not is if the company agrees with the prescriber, but even then they have created strong disincentives (the gauntlet-like telephone queue) to the accomplishment of the primary goal of prescribing what the physician considers the best possible medication.

I would like to know how the Institute of Medicine can ignore this?           


George Dawson, MD, DFAPA

References:

IOM (Institute of Medicine). Conflict of Interest in Medical Research, Education, and Practice. Washington, DC: The National Academies Press; 2009.

Supplementary 1:  I consider the quotes from the IOM reference to be fair use under the US Copyright Law.

Serotonin Syndrome at The Tipping Point

I spend a lot of my time trying to prevent Serotonin Syndrome (SSyn) and in recognizing it early enough prevent major complications.  I think that I have a fairly good record of doing this, but the statement is qualified by the fact that the likely incidence of SSyn is very low.  What is even more amazing is that if you look at the graphic, a large number of very common medications are implicated in serotonin (5-HT) turnover, signaling, and metabolism.  It is very common for me to see combinations of an SSRI or SNRI antidepressant and trazodone.  Some patients are also taking serotonergic migraine medications like sumatriptan, rizatriptan, zolmitriptan, frovatriptan, naratriptan, and almotriptan.  These migraine drugs are all 5-HT1 receptor agonists with varying affinities for subtypes of this receptor.  They are commonly encountered in clinical psychiatry in patients with chronic depression, chronic headaches and poorly controlled migraines.  In some cases these patients are also on valproate for migraine prophylaxis.  Any computerized drug interaction search will frequently flag 3 or 4 medication combinations that increase the risk for SSyn.  Reading the literature and practicing psychiatry results in a broad appreciation of SSyn including the broad range of precipitants and presentations.  The syndrome can be triggered by as little as a single dose of an SSRI type antidepressant.  On the other hand millions if not tens of millions of people tolerate combinations of serotonergic medications as suggested in the above diagram and in fact some of these combinations are recommended by experts for treating depression.

The presentation of SSyn will vary on who you ask.  If you are asking acute care internists or hospitalists, they are likely to say that it is an acute mental status change - usually delirium accompanying a toxic reaction to a drug.  If you ask movement disorder experts (1, 2), they may describe it as confusion, myoclonus, rigidity, and restlessness and list it in the differential diagnosis of those movement disorders and ataxia.  Psychiatrists should have the lowest threshold since we are prescribing more serotonergic medications, using augmentation strategies, and generally follow patients more closely.  I have seen it develop very gradually with onset of muscle pain secondary to hypertonia.  At that point the patient describes clear cut muscle pain and may have difficulty walking or with balance.  In consult settings, I have seen people with acute delirium completely unresponsive with ataxic breathing to the point I had to suggest an ICU setting and mechanical ventilation.

Harvey Sternbach is credited with coming up with the first diagnostic criteria for SSyn (3).  At the time his article was published in 1991, there were many descriptions of syndromes that were thought to be due to serotonergic hyperstimulation, both in humans and animals.  He analyzed 12 case reports covering 38 patients.  In the majority of these patients, the manifestations lasted for a period of 6 hours to 4 days.  There was one fatality in this case series,  where the patient developed seizures, hypotension, and disseminated intravascular coagulation.  Sternbach also discusses a second death from the literature where the patient presented with probably SSyn that was mistaken for Neuroleptic Malignant Syndrome (NMS).  As the patient was treated for NMS she developed disseminated intravascular coagulation, renal failure, hepatic failure and died.  In both of those cases, the patients were taking monoamine oxidase inhibitors with tryptophan and fluoxetine or lithium.  This was about the time that tryptophan was removed as a supplement from the American market and the author comments that this might reduce future risk.  Sternbach laid out his Suggested Diagnostic Criteria for Serotonin Syndrome based on that analysis:  

"A. Coincident with the addition of or increase in a known serotonergic agent to an established medication regimen, at least three of the following clinical features are present: 1) mental status changes (confusion, hypomania) 2) agitation 3) myoclonus 4) hyperreflexia 5) diaphoresis 6) shivering 7) tremor 8) diarrhea 9) incoordination 10) fever 
B. Other etiologies (e.g., infectious, metabolic, substance abuse or withdrawal) have been ruled out. C. A neuroleptic had not been started or increased in dosage prior to the onset of the signs and symptoms listed" (from reference 3, p. 713)

SSyn appears to be a major omission in DSM-5 (6).  The manual contains a cursory description of NMS in the section Medication-Induced Movement Disorders and Other Adverse Effects of Medication (pp. 709-714) but the only reference is in the differential diagnosis of NMS:

"Neuroleptic malignant syndrome also must be distinguished from similar syndromes resulting from the use of other substances or medications, such as serotonin syndrome; parkinsonian hyperthermia syndrome following abrupt discontinuation of dopamine agonists; alcohol or sedative withdrawal; malignant hyperthermia occurring during anesthesia; hyperthermia associated with abuse of stimulants and hallucinogens; and atropine poisoning from anticholinergics." (p. 711).

A syndrome this important needs at least equal time in the DSM-5.  In average clinical practice serotonergic medications and the flagged side effects in electronic databases probably far exceeds the concerns about medications for Parkinson's Disease and antipsychotic medications causing NMS.  The role of antidepressants in movement disorders especially myoclonus and akathisia should not be underestimated.

The most recent approach to diagnosis of SSyn has been the application of the Hunter Criteria (4).  In their original paper the authors point out that the diagnosis was typically made on the basis of recognizing 3/10 of Sternbach's criteria, but those features had low specificity and were present in other toxidromes.  The Hunter Criteria were developed by a toxicology service observing people with overdoses of serotonergic agents and were therefore more specific.  A single feature like spontaneous clonus or combinations of features like tremor and hyperreflexia or inducible clonus and diaphoresis leads to a diagnosis of serotonin toxicity (see the paper for all of the variations).

As a practicing and teaching clinical psychiatrist who has worked across a number of settings, it is critical that all psychiatrists known about SSyn and familiarize themselves with the diagnosis and acute treatment.  I have listed some of my preferred strategies in the table below on prevention and early recognition.  It is safe to say that the earlier the recognition, the better the outcome.  That is another reason why I don't suggest to anyone that they need to "get used to" a medication or even take an antidepressant if they tell me that they can't tolerate one.  It is also why the toxicity of the medications needs to be carefully explained to anyone taking them, and as a physician I have to believe that either that person or their representative will call me if there are problems.  There also needs to be a high level of vigilance for new agents that can potentially precipitate SSyn.  I recently investigated Suboxone and found a case report that when it was added to tricyclic antidepressants it precipitated the syndrome (5).
 

George Dawson, MD, DFAPA



1:  Stanley Fahn,  Joseph Jancovic.  Principles and Practice of Movement Disorders.  Churchill Livingstone Elsevier.  Philadelphia, PA, 2007.

2:  Mark Forrest Gordon,  Adena Leder.  Serotonin Syndrome.  in Movement Disorder Emergencies; Steven J Frucht, Stanley Fahn (eds).  Humana Press, Inc; Totawa, New Jersey 2005: pp 175-193.

3:  Sternbach H. The serotonin syndrome. Am J Psychiatry. 1991 Jun;148(6):705-13. Review. PubMed PMID: 2035713.

4:  Isbister GK, Buckley NA, Whyte IM. Serotonin toxicity: a practical approach to diagnosis and treatment. Med J Aust. 2007 Sep 17;187(6):361-5. Review. PubMed PMID: 17874986.

5:  Isenberg D, Wong SC, Curtis JA. Serotonin syndrome triggered by a single dose of suboxone. Am J Emerg Med. 2008 Sep;26(7):840.e3-5. doi: 10.1016/j.ajem.2008.01.039. PubMed PMID: 18774063.

6:  American Psychiatric Association.  DSM-5  Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition.  Arlington, VA, American Psychiatric Association, 2013.


Supplementary 1:

For an additional graphic of Serotonin Syndrome with a glossary of the abbreviations take a look at this link.

Interviewing 101

Interviewing seminars are a big part of the first year of psychiatric training.  I am not sure how it goes these days, but I can recall having to record interviews and being critiqued by the instructor and all of my peers in seminars.  I can remember not always agreeing with the critiques.  Every psychiatrist goes on to develop their own interview style around the basics.  Just about every interview is unique because it also depends on the person you are talking with.  The flow of information in the interview has always been fascinating to me.  At times you can cover all of the essential elements in 30 minutes.  At other time you can talk for 90 minutes and end up with 25% of the information.  Facilitating and directing that flow of information is one of the key elements of interviewing.  Against that backdrop I found this commentary on an interview of Robert Downey, Jr. somewhat interesting.  It seems surprisingly linear.  It reminded me of some of my media interview experiences where the predominate advice seemed to be: "No dead air.  Either I am talking over you or you are talking over me.  Got it?".  This clip has been widely broadcast for the past several days.  In it, the interview takes a bad turn and Downey politely gets up and walks out.  The discussion near the end of this brief clip suggests that there were probably just a few minutes left.







In the critique of this interview, Kathleen Kelley Reardon focuses on what is described as the human chemistry between the participants and how that potentially involves features like attractiveness, mood, timing and other features.  Reardon speculates that Downey may not have been up for the interview and the transition to personal questions may have been premature. She sees it as an excellent case study in what can go wrong with interviews.  I think that there are some good examples of what might go wrong but there are also some unknowns.  From my vantage point as a psychiatrist I have a few other observations and I have never had to worry about the tone of the interview, but then again I am never working on an interview as an infomercial.

1.  The introduction is very important, but we may have missed it.  Even though this is supposed to be the entire interview, it begins with Downey speaking.  This is an old Oral Boards style point - if you don't introduce yourself and set the context of the interview - come back and try it again next year because you have just failed the exam this year.  The interviewer could have saved himself a lot of problems by discussing the interview context ahead of time and setting ground rules for what the actor is or is not willing to discuss.  You don't have time to discover that in an 8 minute interview.

2.  Too many people in the room is never a good thing.  Because I am teacher, I still have people observing my interviews for teaching purposes and I never like it.  I have to be completely focused on the other person and how they are affecting me.  I did not see Downey as distracted or disinterested; I saw him look to his advisor several times until it got to the point he was overtly looking for advice.  I saw him make a clear announcement at one point: "Are we promoting a movie?" where he was clearly dissatisfied in the direction things were headed and that comment was directed to other people in the room.  The best way to maintain focus is to make sure that there are only two people in the room.

3.  What is the purpose of the interview?  There has to be a focus on that point and the interviewer needs to be aware of it.  In a psychiatric or medical interview the overriding agenda is that there is a mutual focus on a problem that needs to be solved for the patient.  Everything is as confidential as possible.  I heard a prominent psychiatrist and researcher say at a psychotherapy conference that some of the primary goals are: "Be nice to the patient and say something useful to them."  In a celebrity interview there are really dual agendas - publicity for both the interviewee and the interviewer.  Being a celebrity interviewer can lead to celebrity status on its own.  The interviewer is probably aware of how they want to come across to the viewers.  Where do they want to be along the famously provocative to famously uncontroversial spectrum?  Do they aspire to be a celebrity interviewer?  How focused are they on entertainment versus journalism?  I personally cannot think of a greater intrusion into the interview process.

4.  Contrary to the author's point, I don't think that the reporter (Krishnan Guru-Murthy) had a problem with transitioning or failing to read the cues of Downey. He seemed anxious to me. Downey came across as authoritative when talking about American cultural influences but then somewhat oppositional and defensive when talking about a past opinion that he gave during an embarrassing period in his life. He was aggressive when commenting on the interviewer's motor behavior and suggesting that he was running out of time to ask (what was probably going to be) a controversial question.  This would have been an entirely different interview if the focus had been maintained on superhero culture and the actors theories of where the film fits into that genre. He had a pretty good interpretation of some of the Stan Lee origins in Vietnam era America.  Just the time line of those developments and the further implications for the film would have filled the time.

5.  Sometimes the person being interviewed drops a gift at your feet and you have to go with it. As an example, if I am interviewing a person who has been incarcerated I rarely go directly after that information.  I can probably get the historical details elsewhere and it is a threat to the interview process.  I don't want the interviewee to develop the "cop transference" and start to experience it as a police interrogation.  And I usually have an hour compared to this less than 10 minutes session.  The  interviewer needs to be aware of the fact that he is not doing psychoanalysis and that all of those Barbara Walters interviews where there was a key emotional disclosure occurred after hours of interviewing and heavy editing.  In this case Downey talks about how he portrays the character and how his interpretation of the character had changed over time.  That leaves him talking to a small part of the audience for this interview - the people interested in art and acting but that would have ended a lot better.

6.  As I watched the interview, I had the question about whether there were any journalistic biases operating.  It becomes clear that Guru-Murthy wants Downey to answer questions that have nothing to do with the movie and were from a very difficult time in the actor's career.  It is clear that the reporter's anxiety level is building as he tries to force those questions.  And, it is clear that he is trying to force them into the smallest possible window in this interview - the final minutes.  It was anxiety provoking for me to watch that section of the interview.

7.  There is often a lot of focus on the process aspects of the interview.  It seems that the emphasis on the communication aspects of the interview are very linear - pick up this cue and make this intervention.  Interviews (at least the way I see them) are non-linear,  There are a lot of parallel processes going on and interviewers tend to elicit much different information based on their biases and techniques.   There may be times where I slow the interview way down to get at specifics and at other times I am looking for global markers and whether they are present or not.  

8.  Based on my past experience,  I also had to wonder if the gotcha dynamic was operative.  I have been called in for media interviews where the reporter has some preconceived notion of how the world works.  A good example is the fallacy that the Christmas Holiday season is the peak time of the year for suicides.  After I had spent some time explaining to the reporter over the phone that this is really not true, during the interview I was pummeled with comments and anecdotes about how people naturally get depressed and kill themselves more often during Christmas.  This has happened to me more than once and it is a good reason to avoid reporters.

The way this interview ended seemed quite civil to me.  It is not surprising to me that the media is making a big deal of it in spite of the fact that really catastrophic interview endings tend to occur with people who are accusatory, demanding, threatening and/or aggressive.  In an interview with an actor that is not likely to happen.

Despite all of our focus on interviewing in psychiatry, we seem to be loathe to look into the science of it all.  For the past 30 years we have been operating under the illusion that in order to make a DSM diagnosis, all it takes is getting the answers to the right questions.  Those questions were typically structured interviews using DSM or the precursor RDC criteria.  It gave way to the Diagnostic Interview Schedule (DIS) for early epidemiological work followed by the Schedule for Affective Disorders and Schizophrenia (SADS).  This work seems to have led to brief diagnostic checklists based on  the DSM criteria.   I read an article in the Journal of Clinical Psychiatry once that suggested if all of the clinicians in a clinic used the SADS as their diagnostic interview they would have better outcomes.  The idea that a structured interview or checklist elicits better or more useful information than an experienced psychiatrist interviewing the patient is another great fallacy in the field.  I would actually put that at the top of the list and rate it higher than needing a head to head comparison of antipsychotics based on time to discontinuation or whatever the Cochrane Collaboration has to say about "limitations of methodology / need more study" for practically any drug trial.  The evidence that I am right is replicated tens of thousands of times every day by psychiatrists out there doing the same work.  If you interview the same patient twice it is very unlikely that they will give  you the same history.  I have a standard flashcard that lists about 100 medications of all classes and they will not consistently endorse the same medications on this list.  We interview people about their subjective experience and that experience is always plastic.  That is much more interesting than storing the encyclopedia on computer chips.

In some cases we might put a metric like test-retest reliability on an interview metric or the global result of a structured interview.  Given that we are measuring something that reflects the functioning of a highly plastic organ, I don't know why we would expect reliability to be high.

That brings me back to this interview.  Our interview technology is a holdover from the 1950s.  We have evolved subtle modifications over the years but currently we are constrained to a small fraction of the conscious state and we do not know how to optimize the flow of relevant information.  This is a major limitation.  There have been some theorists who have looked at mapping diagrams of the interview process but none have gained any widespread acceptance.

The only good news for psychiatrists now is that we are not operating at the level of reporters.


George Dawson, MD, DFAPA

Cycling Tips From A Psychiatrist

I have been a serious cyclist for longer than I have been a psychiatrist.  At midnight on Labor Day in 1972, two friends and I took off on a trip that we hoped to accomplish the same day.  I was riding a CCM 10-speed bike built around Reynolds chromoly tubing.  We were traveling to a town 164 miles away.  My first friend dropped out at 57 miles.  The second made it all the way but for the last third of the trip he was falling asleep on his bike.  That trip and several others taught me valuable lessons about cycling.  The picture at the top of this post is me stepping off the bike after my initial test cruise yesterday.  When I was slightly younger, I would have been out biking as soon as the snow melted.  Less than 5 years ago I was out biking down the Gateway Trail on a mountain bike and I hit a patch of ice and went down hard.

As I was dusting myself off, I recalled a story from a gastroenterology colleague of mine who is about 10 years older than me.  He would always ride in the Minnesota Ironman,  a spring ride that is designed to be a century (100 mile) ride but also can be broken up to shorter rides.  It is scheduled this year for April 26th, with options to ride 14, 27, 29, 60, and 100 miles.  The problem in Minnesota at this time of the year is the weather.  My GI colleague told me he was sitting there waiting for the ride to start.  It started to rain and sleet.  By starting time, he was soaked, cold and his shoes were full of ice cold water.  He got off the bike, walked over to the van that would be at the finish line with T-shirts, picked up his T-shirt, and went home.  I guess the lesson there is that at some point, you realize that you can enjoy cycling and not be miserable doing it.  It is a lot easier to ignore misery when you are younger.

When you are younger, your physiology is also a lot better.  I was doing pretty well until about 7 years ago when I had an episode of atrial fibrillation.  By pretty well, I mean essentially unlimited exercise potential.  I could go as hard as I wanted for as long as I wanted up until that point and even after that point for a while.  But eventually I realized that even exercise induced tachycardia predisposes a person to atrial fibrillation.  I had to tone my very high heart rates down into a more conservative range in order to prevent episodes of atrial fibrillation and the conditions that predispose to atrial fibrillation.  Now when I am out in the country, I am always watching a heart rate monitor instead of my speed.  That is somewhat depressing and it has an impact on self image when you have to go from unlimited exercise capacity to somewhere on the deterioration spectrum.  My goals have varied over the past 30 years from biking 200-250 miles per week to doing more speedwork for racing.  My fastest race time occurred when I would do 2 - 50 mile rides on the weekend and 4-18 miles rides during the week.  For half of the 18 milers I would try to ride as fast as I could.  These days my goals are a lot more conservative and these are my modest goals for 2015.

That may be a little optimistic but for comparison I watched Fabian Cancellara lead the peleton at what appeared to be a leisurely pace into a small French town a few years ago.  They were doing 30 mph on the flat and his heart rate was 130 bpm.

I thought that I would share a few observations here about some other things I have learned over the years about cycling that might be useful.

1.  Use good gear and keep it in good working order:

The kind of bike you ride is highly subjective.  When I first started cycling, high end bikes could only be assembled from components.  I used to ride Vitus frames that were aluminum tubes that were glued together.  The mechanical components were made by Campagnolo, Shimano, and SunTour in various prices ranges.  My all time favorite components were SunTour Superbe Pro.  They seemed so light and effortless.  I just liked the way the gears changed.  It seemed like there was just a lot less rolling resistance.  But SunTour just went out of business one day.  I currently ride a Trek bike with a carbon fiber frame after riding aluminum frames for over 20 years.  Bikes today are so much better in just about every way than they used to.  If you bike a lot, it pays to ride the best bike that you can afford and go to a shop where people can explain it to you and fit you to the bike.  Don't ride a bike that gives you consistent pain in any part of your body.  You should always feel stretched out and ready to go.  Don't hesitate to buy a bike that you think looks cool.  Don't hesitate to buy as many bikes as you want.  These are both strong motivators for riding.

2.  Be safe and stay alive: 

Biking is in many ways like getting into an open Land Rover and driving out into the Serengeti among the predators and large animals.  Anything can happen and you have minimal protection.  Just pulling out of my driveway I always double check the air pressure (it should always be at the max) and I make sure my front wheel is not ready to fall off by pounding on it with my fist.  I am riding high pressure tires with tire liners to prevent a blowout.  I don't have time to fix flats out on the road.

And then I become hypervigilant......

I was screaming down a hill in Duluth one day and all it took was a split second for a large black Labrador to run out of a bush and right under my front tire.  Hitting that dog was like hitting a tree stump at that speed and I went right over the handle bars and onto the shoulder.  I personally know too many cyclists who were killed or became quadriplegic in accidents like this.  It is the main reason I continue to do a lot of upper body strength training to provide some elasticity in the event of a crash.

In another close call,  I was heading south on Cty Hwy 15 from Square Lake Trail just north fo Stillwater, Minnesota.  Washington County has the highest per capita income of any county in Minnesota and that is reflected in the state of their roads and what happens to the roads at the county line (they get worse).  It is the ultimate biking territory because most of the roads have 5 - 10 feet of pavement  to the right side of the white line.  That is a lot of biking space compared to most county highways.  Coming north in the other lane was a truck pulling a boat on a trailer.  I heard some scraping and saw some sparks.  Suddenly the boat and trailer reared up, disengaged from the back of the truck and was headed right at me.  It cut in front of me by about 5 feet.  I think I was saved by the ultra-wide shoulders in Washington County.

I always stay to the right hand side of the while line by as wide a margin as I can.  All it takes is this little experiment to prove to yourself that this is the best place to ride.  Count the number of cars out a hundred that you see crossing that line in proximity to you when you are riding.  The number I get is about 6% and that is when they see that you happen to be riding next to them.  Hopefully the new car designs with lane deviation alerts will train people to stay in the driving lane.  But it is going to be a long time before everybody has them and let's face it some of those drivers may be intoxicated even in the light of day.

3.  Stay as competitive as you want to be:

I was never a big time racer.  I rode only in an annual unsanctioned 40 mile event.  It was kind of a free-for-all and it was pretty dangerous.  It was a pack style race but in the end, some of the riders were using aero handlebars (ouch) and there was always a massive crash at about the ten mile mark.  Some of the riders were Cat 2 and rode in it for practice.

 I can recall reading Greg Lemond's book about the attitude to have as you get older - basically that you have more responsibilities and more time commitments away from cycling.  That is also true.  Ever since I left Madison, Wisconsin in 1986 - I have been a solo biker.  The only exception was a play date that my wife arranged.   He was a tri-athlete and the husband of one of her health club friends.  The plan was to do a 60 miler from Mahtomedi to the Chemolite plant in Hastings back up to Square Lake Park via Stillwater and back to Mahtomedi.  This guy took off like he was time trialling and I did not catch him until the 20 mile mark.  By then he had hit a wall and his speed started to fall of precipitously.  The last third of the way he was down into the 10 mph range and eventually fell off his bike and fractured his wrist.  The last few miles into Stillwater I was riding next to him trying convince him to stop so that I could call his wife and get him picked up.

That incident captures some of the problems of biking with other people.  What are the mutual expectations?  If it is some kind of competition is it at least a benign competition?  The skill level has to be in the same ballpark as well as the overall expectations of the ride.

What about people that you encounter along the way?  During my time of unlimited exercise, my rule was not to be passed (within reason).  I  would also try to catch anyone on the horizon, but to do it in the most unassuming manner possible.  As aging has taken its toll I have to pick my battles.  Two years ago I was out biking towards an average sized hill when I noticed a pack of about 8 guys quite a bit younger than me closing fast.  I naturally assumed that their social brain worked like mine and they were trying to trounce the old man going up the hill.  By this time I was trying to stick to my heart rate rule of not exceeding 130 bpm and I looked down and I was already at 120 bpm.  I increased my speed to match their figuring that some of them were maxed out trying to close the distance.  At the bottom of the hill I shifted to a bigger gear and hit it as hard as I could.  The group caught me halfway up the hill and then seriously faded.  I was the first guy up and over the top.  I won't tell you what my heart rate was at the time.  I was somewhat elated, especially when the last rider in that group looked over at me and said sarcastically: "Nice work Lance".

Some people view competitiveness as either a character flaw or the most desired personality characteristic.  I see it as neither.  To me it is the embodiment of training and study in the field as well as the third dimension of how long you can put off the ultimate deterioration of your body.  When I win these little competitions that I devise for myself, it is not about the anonymous opponents who I will never know.  It is a battle against my own death anxiety and mortality and a good way to stay physically fit in the process.

4.  Drivers are either not paying attention or they are trying to kill you:  

If you bike long enough or even pay attention to the newspapers, cyclists are always getting killed.  Seven hundred and thirty two cyclists are killed every year and 49,000 injured, but it is possible that the police only record about 10% of the injuries.  In my town it is about 1-2 people per year.  That suggests to me that the fatality estimate is also too low.  I personally know both experienced and inexperienced cyclists who were killed and seriously injured.  In one of the most noted cases a driver mowed down three cyclists while trying to adjust her CD player.  The only defense against the inattentive and/or drunk driver is to be as far to the right of the lane marker as possible and try to avoid sharing the actual traffic lane whenever possible.  There are some additional helpful approaches.

Avoid riding in traffic until you know what you are doing.  The basic skill requirement is to be able to bike in a straight line and not veer all over the road.  That seems easy but it is not.  Any type of distraction including talking with your fellow riders and looking over your left shoulder can cause you to drift into the traffic lane.  Don't ride in traffic if you are drifting all over the road for any reason.  Don't ride in traffic until you can glance over your left shoulder and not drift into the traffic lane.  If you know you can't do that - stop the bike completely, put your feet on the ground and look behind you.

Bike with people you know and trust.  If you are biking distances at speed you have to know that the person in front of you is not going to pull up all of a sudden without warning and cause a crash or lead you to veer into the traffic lane.  Ride single file most of the time,  except where you have enough shoulder surface to comfortably ride side by side.  You should have enough confidence in your fellow riders that you know they will not make any contact with you.

In some cases, the nature of the ride is just plain dangerous.  I can recall riding out of Aspen to Independence Pass.  The shoulder on that road gets down to 6 inches wide as it winds up to the pass.  The day that I did it, there was constant Airstream trailer traffic.  The vehicles pulling those trailers were all outfitted with very long side view mirrors to see around the trailers and they were dangerously close.  To make matters worse,  I was aware of a cyclist who was hit from behind by one of these mirrors.  That image of a mirror imprint on my back made the ride up a lot less enjoyable than it should have been.  Sometimes your cycling goals take you into dangerous territory in spite of everything you know about safety.

Aggressive drivers are an entirely different problem.  They come in several classes that I would described as the appropriately angry driver,  the enraged driver and the personality disordered driver.  There is a significant overlap between the personality disordered driver and the enraged driver and that depends on the assumption that a person can have defects in emotional reasoning in the absence of major character pathology.  As far as I know that study has not been done.  Prevention is always the best initial approach and by that I mean not doing anything to piss drivers off.  It does not take much.  After all they are in a two ton vehicle obligated to adhere to the rules of the road or risk legal penalties and suddenly the cyclist in the oncoming lane buzzes right through a stop sign.  That action is enough to cause the mild-mannered banker who you personally know to start pounding his steering wheel with both hands while screaming epithets out the window (Don't ask me how I know that).  Simply put you will anger fewer drivers by adhering to the same rules that they have to.  That will not prevent all angry encounters because there remains some ignorance about traffic laws.  For several weeks I encountered an angry young woman cycling toward me in the wrong direction on my side of the road.  She was riding against the traffic.  She was aggressively swearing at me and telling me I was going the wrong way until I politely told her to read the drivers manual.

But obeying all of the traffic laws will not keep you out of the cross hairs of our various personality disordered citizens.  I was biking up Myrtle Street in Stillwater, MN one day.  It is quite a haul and most road bikes don't come with small enough chainrings to make it up that hill very comfortably.  I was 2/3 of the way up when suddenly a young man in a large 4WD pick up truck (not that there is anything wrong with that) pulled up next to me and started to harass me all of the way to the top.  His basic heckle with the expletives removed was: "Yeah you're not so tough now are you?"  Wait a minute, I am the 55 year old guy riding up this hill on a bike and you are the thirty something guy sitting in a 400 horsepower truck going up the same hill and I'm not so tough?  Harassment like that can be disorienting, I flipped into my mindfulness mode and thought about all of the times I have biked this hill - while keeping an eye on how close the truck was to me.

In a previous incident, I was at the bottom of this hill when an elderly driver decided to turn right into me as we came up to the third or fourth cross street.  Luckily she was going at a low rate of speed and I was at the right place where I could slam my hand down on the roof of her car and spin myself and the bike out of the way.  She was oblivious to the whole situation and kept driving.

One of the worst things that you can do with the enraged or personality disordered driver is to escalate the encounter.  It took me a while to figure this out.  The best example I can think of involves being harassed by a motorcycle club on day toward the end of my ride.  I doubt that they were 1%ers, but they were all young very muscly guys wearing sleeveless motorcycle jackets and seeming quite intoxicated.  As I rode by one of them had climbed the cyclone fence that surrounded this establishment and started to shout "Wheelie! Wheelie! Wheelie!......" as I pulled up to a stop sign.  Several of his peers caught wind of this and started to do the same thing.  It was a scene out of a biker film from the 1970s.  Clearly they were expecting a response from me.  In the old days, I might have said something and it would have been off to the races.  Today the exchange went something like this:

Me:  "I can't do a wheelie."
Intoxicated Biker: "Why not?" (angry tone)
Me:  "Because I am too old!"
Intoxicated Bikers: Explode into laughter.  As I ride away they are reassuring me that I am not too old to do wheelies.

So the bottom line is that some of these ugly confrontations can be defused with humor.

5.  Fantasize your brains out:

Psychiatrists don't talk about fantasies any more.  I think that an active fantasy life can be very adaptive.  I have fantasies that I can pull up in any terrain.  In the hills or mountains I can imagine myself riding between the Schleck brothers in the Alps.  On level ground or into the wind, I can see Miguel Indurain time trialling in front of me and I am just trying to maintain the correct spacing between us until I can pull out and pass him.  The weeks of the Tour de France are generally the times of peak fantasy for me.  There is always the case of a solo rider who breaks away from the best cyclists in the world and stays away.  I can't think of anything as exciting in all of sports.  I am waiting to watch that clip and incorporate it into my fantasy world.  I can hear Phil Liggett calling out my name.....

6.  The cognitive versus the emotional aspects of life:

I have decades worth of meticulously detailed training information - all handwritten.  Distances and times, routes, intervals, heart rates, etc.   In the 21st century, none of that stuff is necessary.  You can automatically record all of that data and download it to your computer after the ride.  You can study whatever parameters that you want.  But don't get too lost in the details.  I live for the time during the year when I am cruising along in a fairly steep gear and can put my foot down and go.  Bam!  I am sure that any coronal section of my brain on fMRI at that point would show my nucleus accumbens lighting up, but the subjective experience is most pleasurable.  It can occur only with the right distribution of power and weight and I notice that it is advanced on in the season.  If it ever disappears, I know that I will miss it.    

7.  Wear the most radical clothing you feel comfortable with:

Most non-cyclists don't understand the utilitarian nature of cycling clothing.  I was speedskating one night and came off the ice with some biking gear on.  One of the hockey dads decided to give me a rough time and commented how I must think that I was pretty cool because I had special speedskating clothing on.  Keeping in mind that he had several kids with about a thousand dollars worth of hockey gear on,  I said:  "Well no, this is my cycling clothing."  On top of thermal underwear of course.

I have been in pursuit of the perfect biking shorts and saddle for the past 30 years.  When I find a pair that seems to meet the criteria, it doesn't take long for the manufacturer to change the design or the chamois.  It is a basic fact that you cannot expect to bike every day if your perineum is trashed or you develop saddle sores.  The best way to do that is to think that you are going to ride more than 10 miles in a pair of cotton Bermuda shorts over boxers.  I am currently trying out some very high tech shorts.  They were so high tech that I had to send an e-mail to the company.  I was concerned about what kind of chamois lubricant to use, because of all of the high tech materials used in the short.  Their reply was totally unexpected.  Don't use anything.  Wear these trunks dry.  So for the first time in 30 years I don't have some kind of lubricant between my ischial tuberosities and my bike saddle.

Live and learn.

8.  Inclement weather:

I don't bike in the rain or snow anymore.  I will also not be biking up to Independence Pass again unless they ban Airstream trailers.  I have an ergometer in my basement and I try to match the outdoor conditions.  I know that at many levels that is an illusion.  I do however always bike in extremely hot weather and in the wind.  It takes a certain mindset to overcome those conditions.  You have to be able to feel that you are going with the wind and benefitting from the temperature at some level.

This is a long post and that's all I can think of for now.  So the next time you see some old dude out on the road biking - he may be a narcissist wrapped in Lycra, but it is more likely he has a lot on his mind and he is trying to live the best way that he can.


George Dawson, MD, DFAPA




Supplementary 1:     

Disclaimer:  I am not a cycling coach or expert.  The point of this post was to look at some of the unspoken psychological aspects of biking from the standpoint of individual consciousness.  Don't take any of this as advice on how to cycle or live your life.  Follow the advice of your personal physician on all matters related to exercise especially if you have decided to start a new program or alter your intensity.


Supplementary 2:

I am a guy so this is written from a male perspective.  I know that women are as dedicated and serious about biking as I am, but I can't speak to their conscious state.  If you are a female cyclist feel free to comment about your conscious state in the comment section below.  Or better yet, send me an essay and I will post it as an invited commentary by a distinguished guest.  I am very interested in your motivations, cycling fantasies, and daydreams about cycling and any insights that you have developed as a result.  Not everyone can keep riding and I am very interested in the ways that people do.