I attended a day long seminar by Russell Barkley, PhD. It is part of my ongoing mission of seeing the experts in person who I have read and collected in my library over the past 30 years. My earliest exposure to Dr. Barkley's work was the book Hyperactive Children that I acquired while I was in Medical School and used when I was treating children in the first clinic I worked in as a psychiatrist. Interestingly he was working at the same medical school I had attended. Dr. Barkley has an impressive surveillance system for current literature and in the seminar was presenting work that had literally been published or put into prepublication the day before. His scholarship is impressive and he is one of the most widely published authors in the field. He has a clear scientific approach and does not recommend treatments that have not gone through randomized and blinded clinical trials. He gave many examples of ADHD treatments that seemed effective until the raters were blinded to the treatment or the methods were used by researchers who had no vested interest in the outcome.
All of his information was presented on PowerPoint as is the standard. His PowerPoint slides were information dense, frequently presenting dimensions and data points from several studies on the same line.
A few of the highlights that you will not read in the New York Times:
1. On the "overdiagnosis" issue - at this time about 40% of kids and 10% of adults with the disorder are treated.
2. On the DSM issue - the categories of ADHD are going away. Like categories of schizophrenia and autism spectrum disorder they are not unique entities. This of course runs counter to the usual DSM criticism that there is a proliferation of diagnostic categories Another positive was that the age of onset criteria is changing from age 7 to age 12. Barkley points out that an age cutoff for a developmental process is arbitrary and suggested a further change to "onset in childhood or adolescence". On the other hand, it does appear that the committee in charge is responding to political pressure from the government and insurance companies to not make any changes that would increase the prevalence of the disorder. He presented clear criteria that would improve the diagnosis of ADHD in adults that will apparently not be included or possibly on a parenthetical basis.
3. The problem with the treatment of children is not overtreatment, but that fact that most children who need treatment discontinue their medications as teenagers.
4. The resulting complications of untreated ADHD are significant from an educational, public health, and psychiatric perspective. As one example, untreated ADHD is associated with high risk of dropping out of school. Every person who drops out and does not complete school represents a cost of $450K to the community.
5. Stimulant medications have a 40 year record of use and there have been over 350 studies documenting the efficacy and safety. They have the greatest effect size of any psychiatric medications and that includes up to 90% response rates across all stimulants.
6. Response to treatment is robust and the best of any psychiatric disorder. Evidence based studies show that patients treated with stimulants show improved outcomes across 20 parameters and that treatment with atomoxetine is associated with improvement across 23 parameters.
7. These medications have an unprecedented safety record.
8. There is a potential steep cost in many areas of not adequately treating the disorder.
It is very disappointing to hear that the DSM committee may be yielding to political pressure when it comes to implementing new evidence based DSM criteria particularly give the poor quality of these arguments. A professional organization should be above political influence when it comes to scientific findings and this revision of criteria was supposed to be based on science. The APA does have a long history of not providing any resistance to the managed care industry or government initiatives to reduce the quality of psychiatric care in favor of the managed care industry. If true it will be ironic that the ADHD section of the DSM5 will be be directly influenced by the usual managed care forces and that they are aligned with all of the media rhetoric about the proliferation diagnoses and increased prevalence.
So the usual media hype is wrong - psychiatrists and pharmaceutical companies are not plotting to put more people on medication. The government, managed care companies, and the anti-biological antipsychiatrists are trying to keep them off even when they are indicated. In that political divide - the science is left out.
George Dawson, MD, DFAPA
Dr. Russell A. Barkley, PhD. Official Web Site.
Dr. Russel A. Barkley, PhD. Professional Workshop on ADHD. ADHD Across the Life Span: Diagnosis, Life Course, Management, and Comorbidity. Minnetonka, Minnesota. Thursday November 15, 2012.
International Consensus Statement on ADHD (excerpt) - read this statement signed by scientists explaining that this diagnosis is not controversial and that the percentage of patients treated is about the same in the past decade.
Thursday, November 15, 2012
Saturday, November 10, 2012
Being Flynn - Another Cinematic Portrayal of Alcoholism
My previous post looked at the accurate portrayal of alcoholism in the film Flight. I recently saw Being Flynn starring Robert De Niro in the role of an alcoholic father and self proclaimed novelist. This film is also a study of alcoholism.
Like Denzel Washington, De Niro accurately portrays the ways that alcoholism impacts the lives of some men. In this case we meet De Niro's character Jonathan Flynn in a downward spiral. We first meet his son Nick Flynn and learn through a series of flashbacks that the elder Flynn abandoned Nick and his mother for unclear reasons and he has not seen his father in about 18 years. We first see Jonathan Flynn when he is driving a taxi. He is drinking vodka on a regular basis. We see him lose his job and then his housing and end up at a homeless shelter. Nick is floundering as a poet and author. He lacks direction and the flashbacks suggest that childhood adversity has played a big role. He comes to be employed at a homeless shelter where his father eventually seeks shelter.
The trajectory of that story line is impacted by the fact that Jonathan is a very volatile and generally unlikable character. Although it is certainly dangerous to live on the street, he has an aggressive attitude at times that is not warranted. It is the reason he was evicted. At other times he is able to keep quiet when he witnesses some street thugs beating one of his drinking buddies. He uses a lot of expletives and at times seems incoherent. In his interaction with Nick he is unapologetic and grandiose - describing himself as one of America's greatest authors. When he allows Nick to read his manuscript, the first chapter shows some promise but the rest is incoherent.
Nick is on his own parallel journey. He is lucky to get the job at the homeless shelter and initially blends in seamlessly with the staff. The shelter staff and the environment at the shelter is expertly portrayed and very realistic. The tension at the shelter between caring for desperate and sometimes disagreeable men and the required altruism is palpable. Eventually Jonathan's disagreeable temperament creates a situation where Nick has to vote on whether to expel him. He does despite a staff person trying to convince him not to send his father out on one of the coldest days of the year. Jonathan predictably acts like he relishes the thought and that living on the street is nothing. When we see what actually happens out there it is clear that his attitude is another manifestation of his pathology. There is a time when we are not sure whether Jonathan will survive or not.
There are a number of fascinating articles available that look at the process of making this film. The gold standard for any film is the book and many critics suggest reading that as a starting point. The real Nick Flynn has some fascinating interviews talking about the evolution of homelessness in America. When did it become acceptable? The motion picture business is averse to producing any films that portray characters or themes that the general public would find to be distressing and the main reason is how that translates into box office numbers.
As I contemplated the Flynns' predicament I naturally thought about all of the homeless alcoholic men I have seen in the past 25 years. At some point in time they all create the anger, frustration, and hopelessness portrayed in this film. Many of them are not only grandiose and paranoid, but permanently delusional or amnestic. The good news is that they are also a stimulus for the altruism apparent in the shelter staff in this film and eventually Nick Flynn himself. This film is similar to Flight in that there are no proposed solutions. The are no public policy statements. It is an accurate depiction of real people dealing the the problem of addiction in their daily lives. Despite those significant problems there are hopeful messages everywhere. After reading an interview with the author, I am skeptical of the origins of those messages, but based on my experience they seem real.
I also had associations to what I consider to be some of the most important work in alcoholism. The first was a study of inner city alcoholics by George Vaillant in the 1980s and several subsequent studies by the same author. Most of the original articles online are available only with steep fees for a one time read. It is probably easier to look at The Natural History of Alcoholism - Revisited in your local library. It contains most of the important graphics from the research articles and Dr. Vaillant's views circa 1995. The summary section looks at seven very important questions about the nature of alcoholism and the answers provided by prospective research on the problem. In looking at this research, Jonathan Flynn probably most closely resembles the follow up study of 100 consecutive admissions to a detoxification unit in Boston. At the end of 8 years of follow up, about 32% were abstinent, about 30 % were still drinking and 32% were dead or institutionalized. One of Dr. Vaillant's characterizations of the recovery process in alcoholism: "... alcoholics recover not because we treat them, but because they heal themselves. Staying sober is not a process of simply becoming detoxified, but often becomes the work of several years or in a few cases even of a lifetime. Our task is to provide emergency medical care, shelter, detoxification, and understanding until self healing takes place." (p384). Self healing was evident in this film.
The other work that I routinely discuss with people I have seen for alcoholism and the associated comorbidity is the work of Markku Linnoila. Dr. Linnoila was a prolific researcher in both basic and clinical alcoholism research. He did some of the early studies looking at cerebrospinal fluid metabolites, especially serotonin metabolites and how they correlate with depression, aggression, and impulsivity over time when men consume alcohol. These studies continue to provide a scientific basis for advising patients on basic dietary changes and in some cases pharmacological interventions that may assist in recovery. An important aspect of the work of shelters like the one depicted in this movie is getting protein back into the diet of the homeless with alcoholism.
This film is harder to watch than Flight but it is no less accurate a depiction of how alcoholism can impact the person and their family. It speaks to the spectrum of intervention necessary to provide safety and assist with recovery.
George Dawson, MD, DFAPA
Vaillant GE. Alcoholics Anonymous: cult or cure? Aust N Z J Psychiatry. 2005 Jun;39(6):431-6. PubMed PMID: 15943643.
Like Denzel Washington, De Niro accurately portrays the ways that alcoholism impacts the lives of some men. In this case we meet De Niro's character Jonathan Flynn in a downward spiral. We first meet his son Nick Flynn and learn through a series of flashbacks that the elder Flynn abandoned Nick and his mother for unclear reasons and he has not seen his father in about 18 years. We first see Jonathan Flynn when he is driving a taxi. He is drinking vodka on a regular basis. We see him lose his job and then his housing and end up at a homeless shelter. Nick is floundering as a poet and author. He lacks direction and the flashbacks suggest that childhood adversity has played a big role. He comes to be employed at a homeless shelter where his father eventually seeks shelter.
The trajectory of that story line is impacted by the fact that Jonathan is a very volatile and generally unlikable character. Although it is certainly dangerous to live on the street, he has an aggressive attitude at times that is not warranted. It is the reason he was evicted. At other times he is able to keep quiet when he witnesses some street thugs beating one of his drinking buddies. He uses a lot of expletives and at times seems incoherent. In his interaction with Nick he is unapologetic and grandiose - describing himself as one of America's greatest authors. When he allows Nick to read his manuscript, the first chapter shows some promise but the rest is incoherent.
Nick is on his own parallel journey. He is lucky to get the job at the homeless shelter and initially blends in seamlessly with the staff. The shelter staff and the environment at the shelter is expertly portrayed and very realistic. The tension at the shelter between caring for desperate and sometimes disagreeable men and the required altruism is palpable. Eventually Jonathan's disagreeable temperament creates a situation where Nick has to vote on whether to expel him. He does despite a staff person trying to convince him not to send his father out on one of the coldest days of the year. Jonathan predictably acts like he relishes the thought and that living on the street is nothing. When we see what actually happens out there it is clear that his attitude is another manifestation of his pathology. There is a time when we are not sure whether Jonathan will survive or not.
There are a number of fascinating articles available that look at the process of making this film. The gold standard for any film is the book and many critics suggest reading that as a starting point. The real Nick Flynn has some fascinating interviews talking about the evolution of homelessness in America. When did it become acceptable? The motion picture business is averse to producing any films that portray characters or themes that the general public would find to be distressing and the main reason is how that translates into box office numbers.
As I contemplated the Flynns' predicament I naturally thought about all of the homeless alcoholic men I have seen in the past 25 years. At some point in time they all create the anger, frustration, and hopelessness portrayed in this film. Many of them are not only grandiose and paranoid, but permanently delusional or amnestic. The good news is that they are also a stimulus for the altruism apparent in the shelter staff in this film and eventually Nick Flynn himself. This film is similar to Flight in that there are no proposed solutions. The are no public policy statements. It is an accurate depiction of real people dealing the the problem of addiction in their daily lives. Despite those significant problems there are hopeful messages everywhere. After reading an interview with the author, I am skeptical of the origins of those messages, but based on my experience they seem real.
I also had associations to what I consider to be some of the most important work in alcoholism. The first was a study of inner city alcoholics by George Vaillant in the 1980s and several subsequent studies by the same author. Most of the original articles online are available only with steep fees for a one time read. It is probably easier to look at The Natural History of Alcoholism - Revisited in your local library. It contains most of the important graphics from the research articles and Dr. Vaillant's views circa 1995. The summary section looks at seven very important questions about the nature of alcoholism and the answers provided by prospective research on the problem. In looking at this research, Jonathan Flynn probably most closely resembles the follow up study of 100 consecutive admissions to a detoxification unit in Boston. At the end of 8 years of follow up, about 32% were abstinent, about 30 % were still drinking and 32% were dead or institutionalized. One of Dr. Vaillant's characterizations of the recovery process in alcoholism: "... alcoholics recover not because we treat them, but because they heal themselves. Staying sober is not a process of simply becoming detoxified, but often becomes the work of several years or in a few cases even of a lifetime. Our task is to provide emergency medical care, shelter, detoxification, and understanding until self healing takes place." (p384). Self healing was evident in this film.
The other work that I routinely discuss with people I have seen for alcoholism and the associated comorbidity is the work of Markku Linnoila. Dr. Linnoila was a prolific researcher in both basic and clinical alcoholism research. He did some of the early studies looking at cerebrospinal fluid metabolites, especially serotonin metabolites and how they correlate with depression, aggression, and impulsivity over time when men consume alcohol. These studies continue to provide a scientific basis for advising patients on basic dietary changes and in some cases pharmacological interventions that may assist in recovery. An important aspect of the work of shelters like the one depicted in this movie is getting protein back into the diet of the homeless with alcoholism.
This film is harder to watch than Flight but it is no less accurate a depiction of how alcoholism can impact the person and their family. It speaks to the spectrum of intervention necessary to provide safety and assist with recovery.
George Dawson, MD, DFAPA
Vaillant GE. Alcoholics Anonymous: cult or cure? Aust N Z J Psychiatry. 2005 Jun;39(6):431-6. PubMed PMID: 15943643.
Sunday, November 4, 2012
Zemeckis portrayal of addiction in "Flight"
I went to see Robert Zemeckis film Flight starring Denzel Washington as pilot Whip Whitaker yesterday. Spoiler alert - if you are a person who likes to see new films knowing nothing about the plot - stop reading this post right here. I work at a large residential addiction facility and ran into one of my colleagues in the lobby. He told me he was there to see the film because it was a good film about addiction. I was completely surprised. Robert Zemeckis made the film that I have seen more times than any other - Forrest Gump. I generally see anything that Denzel Washington does. Like everybody else, I like his work and he does not make any bad movies. His last transportation themed movie Unstoppable cast him the role of a wise engineer trying to stop a runaway train. The trailers I had seen for Flight suggested a similar role. I expected a heroic pilot with a similar outcome.
From the outset, it is obvious that Whip Whitaker has a tremendous problem. He wakes up hung over, snorts some cocaine, drinks what is left of a beer and heads out the door with his pilots uniform on. Almost incredibly he proceeds to inspect his commercial airliner, fly it through extreme turbulence, drinks some additional vodka in flight and takes a 26 minute nap before the critical scene in the movie where he performs a complicated series of maneuvers to save most of the crew and passengers from a mechanical failure. Subsequent analysis proves that he is the only pilot who could have saved the plane. But even those facts are not enough to preserve his fleeting hero status.
Throughout the film we see Whip drinking in an uncontrolled manner. There is some ambivalence. He gets out of the hospital post crash and goes to the family farm where he proceeds to dump out all of the beer and hard liquor. He dumps out his stash of marijuana. There is the implicit recognition that somewhere there are toxicology results that he is going to have to deal with. As that part of the plot unfolds, he resumes drinking, smoking marijuana, and snorting cocaine with a vengeance. In one scene he walks out of a liquor store with a case of beer and what appears to be a three liter bottle of vodka. As soon as he gets into the car he is drinking the vodka like water and drives around with an open can of beer. There are several scenes where the interpersonal toll of alcoholism is evident with his potential love interests, his son and ex-wife, and friends and business associates who are rooting for him. The business associates have a common interest in seeing that he is exonerated for any crimes related to substance abuse.
This film succeeds in its depiction of alcoholism and how it hijacks the life of an otherwise highly successful pilot. On the surface he is a "functional alcoholic." His friend and former fellow Navy pilot describes him as a "heavy drinker" rather than an alcoholic He appears to be successful in one aspect of his life but it does not take long to figure out even that is a charade. He can't tolerate even the suggestion that he has a problem on the one hand and on the other makes the promise that he will stop and he can stop at any time. He walks out of an AA meeting when the speaker asks people to raise their hand if they are an alcoholic. There is a contrast between Whip and his girlfriend Nicole illustrating that addiction has no socioeconomic boundaries. There were so many scenes in this film that captured the problems of addiction.
As an audience member you cannot help getting caught up in his fight with alcohol. He is after-all the hero of this film and that is firmly established in the first 20 minutes. You are hoping that he will not pick up another drink. You are left with a situation where the hero will be dealt with according to technicalities. His heroism does not count. The only thing that matters is that he has an addiction.
This is a compelling film about addiction for families who deal with this problem on a daily basis and for those who do not. It accurately portrays the central problems of addiction and recovery as not just avoiding punishment or making a conscious decision to stop. It is a lot more than that and hopefully that message will be clear from watching this film.
George Dawson, MD, DFAPA
References (Doug Sellman has done a great job of distilling out the scientific points of addiction):
1. Sellman D. Ten things the alcohol industry won't tell you about alcohol. Drug Alcohol Rev. 2010 May;29(3):301-3. PubMed PMID: 20565523.
2. Sellman D. The 10 most important things known about addiction. Addiction. 2010 Jan;105(1):6-13. Epub 2009 Aug 27. PubMed PMID: 19712126.
3. Alcohol Action New Zealand web site (various resources)
4. Alcoholics Anonymous. Grounded. Alcoholics Anonymous World Services, New York City, 2001.
From the outset, it is obvious that Whip Whitaker has a tremendous problem. He wakes up hung over, snorts some cocaine, drinks what is left of a beer and heads out the door with his pilots uniform on. Almost incredibly he proceeds to inspect his commercial airliner, fly it through extreme turbulence, drinks some additional vodka in flight and takes a 26 minute nap before the critical scene in the movie where he performs a complicated series of maneuvers to save most of the crew and passengers from a mechanical failure. Subsequent analysis proves that he is the only pilot who could have saved the plane. But even those facts are not enough to preserve his fleeting hero status.
Throughout the film we see Whip drinking in an uncontrolled manner. There is some ambivalence. He gets out of the hospital post crash and goes to the family farm where he proceeds to dump out all of the beer and hard liquor. He dumps out his stash of marijuana. There is the implicit recognition that somewhere there are toxicology results that he is going to have to deal with. As that part of the plot unfolds, he resumes drinking, smoking marijuana, and snorting cocaine with a vengeance. In one scene he walks out of a liquor store with a case of beer and what appears to be a three liter bottle of vodka. As soon as he gets into the car he is drinking the vodka like water and drives around with an open can of beer. There are several scenes where the interpersonal toll of alcoholism is evident with his potential love interests, his son and ex-wife, and friends and business associates who are rooting for him. The business associates have a common interest in seeing that he is exonerated for any crimes related to substance abuse.
This film succeeds in its depiction of alcoholism and how it hijacks the life of an otherwise highly successful pilot. On the surface he is a "functional alcoholic." His friend and former fellow Navy pilot describes him as a "heavy drinker" rather than an alcoholic He appears to be successful in one aspect of his life but it does not take long to figure out even that is a charade. He can't tolerate even the suggestion that he has a problem on the one hand and on the other makes the promise that he will stop and he can stop at any time. He walks out of an AA meeting when the speaker asks people to raise their hand if they are an alcoholic. There is a contrast between Whip and his girlfriend Nicole illustrating that addiction has no socioeconomic boundaries. There were so many scenes in this film that captured the problems of addiction.
As an audience member you cannot help getting caught up in his fight with alcohol. He is after-all the hero of this film and that is firmly established in the first 20 minutes. You are hoping that he will not pick up another drink. You are left with a situation where the hero will be dealt with according to technicalities. His heroism does not count. The only thing that matters is that he has an addiction.
This is a compelling film about addiction for families who deal with this problem on a daily basis and for those who do not. It accurately portrays the central problems of addiction and recovery as not just avoiding punishment or making a conscious decision to stop. It is a lot more than that and hopefully that message will be clear from watching this film.
George Dawson, MD, DFAPA
References (Doug Sellman has done a great job of distilling out the scientific points of addiction):
1. Sellman D. Ten things the alcohol industry won't tell you about alcohol. Drug Alcohol Rev. 2010 May;29(3):301-3. PubMed PMID: 20565523.
2. Sellman D. The 10 most important things known about addiction. Addiction. 2010 Jan;105(1):6-13. Epub 2009 Aug 27. PubMed PMID: 19712126.
3. Alcohol Action New Zealand web site (various resources)
4. Alcoholics Anonymous. Grounded. Alcoholics Anonymous World Services, New York City, 2001.
Tuesday, October 30, 2012
Who Runs My Drug Plan?
The real issue in pharmaceuticals used to treat mental illness is the business practices that looms as an obstacle between the psychiatrist prescribing the medication and the patient who wants to receive the medication. I have posted about the managed care practices - specifically pharmacy benefit managers (PBMs) that get in between physicians and patients. That previous post shows a diagram from an internal memo that reveals some perspective on the PBM attitude. The goal for them is to come up with a business argument that will either improve profits for the managed care company or justify the billions of dollars in costs that PBMs add to the health care system every year.
The National Community Pharmacists Association fights back against PBMs from this web site. A lot of what you find is relevant for pharmacists also applies to physicians - especially wasting physician time, indirectly affecting reimbursement, and disrupting the patient-physician relationship by dictating medications that need to be prescribed that are financially advantageous to the PBM.
Some of the details provided on this site are very interesting. One example is a $10 price spread on up to 4 billion prescriptions per year. I once read that PBMs made up an $80 billion per year industry and it is easy to see how they can get there. In fact, the volume strategies that they use are very similar to the financial services industry. In both cases, political advantage has added businesses that levy another tax on consumers and do not provide any added efficiency. It is easy to see how managed care strategies fail to contain health care inflation when the intermediaries with government advantages are set up to maximize profits and waste the time of physicians and pharmacists.
If you are a physician, watch the "Fed Up With Phil" video and ask yourself if it isn't time to get rid of health care middlemen that are increasing costs and in many cases detracting from the quality of health care? If you are a physician, isn't it time that you or your professional organization starting putting up web sites like this one to educate the public about managed care and all of its problems? Isn't it time that we stopped wasting our time and money with politicians?
George Dawson, MD, DFAPA
The National Community Pharmacists Association fights back against PBMs from this web site. A lot of what you find is relevant for pharmacists also applies to physicians - especially wasting physician time, indirectly affecting reimbursement, and disrupting the patient-physician relationship by dictating medications that need to be prescribed that are financially advantageous to the PBM.
Some of the details provided on this site are very interesting. One example is a $10 price spread on up to 4 billion prescriptions per year. I once read that PBMs made up an $80 billion per year industry and it is easy to see how they can get there. In fact, the volume strategies that they use are very similar to the financial services industry. In both cases, political advantage has added businesses that levy another tax on consumers and do not provide any added efficiency. It is easy to see how managed care strategies fail to contain health care inflation when the intermediaries with government advantages are set up to maximize profits and waste the time of physicians and pharmacists.
If you are a physician, watch the "Fed Up With Phil" video and ask yourself if it isn't time to get rid of health care middlemen that are increasing costs and in many cases detracting from the quality of health care? If you are a physician, isn't it time that you or your professional organization starting putting up web sites like this one to educate the public about managed care and all of its problems? Isn't it time that we stopped wasting our time and money with politicians?
George Dawson, MD, DFAPA
Sunday, October 28, 2012
The diagnosis of anosognosia
Follow up on another blog today where the author proclaims "It is not possible to diagnose anosognosia in schizophrenic patients on brain scan."
No kidding. Here is another shocker and you can quote me on this - it is not possible to diagnose anosognosia in stroke patients based on a brain scan. Quoting an expert: "Anosognosia refers to the lack of awareness, misbelief, or explicit denial of their illness that patients may show following brain damage or dysfunction. Anosognosia may involve a variety of neurological impairment of sensorimotor, visual, cognitive, or behavioral functions, as well as non-neurological diseases." I encourage anyone who is interested in this topic to find a copy of this book chapter listed in the references below. The author thoroughly discusses the fascinating history of this disorder, specific protocols used to make the diagnosis, various neurological subtypes with heterogeneous lesions and the fact that no specific mechanism has been determined.
No kidding. Here is another shocker and you can quote me on this - it is not possible to diagnose anosognosia in stroke patients based on a brain scan. Quoting an expert: "Anosognosia refers to the lack of awareness, misbelief, or explicit denial of their illness that patients may show following brain damage or dysfunction. Anosognosia may involve a variety of neurological impairment of sensorimotor, visual, cognitive, or behavioral functions, as well as non-neurological diseases." I encourage anyone who is interested in this topic to find a copy of this book chapter listed in the references below. The author thoroughly discusses the fascinating history of this disorder, specific protocols used to make the diagnosis, various neurological subtypes with heterogeneous lesions and the fact that no specific mechanism has been determined.
In a more recent article available online, Starkstein, et al provide an updated discussion in the case of stroke. They discuss it as a potential model of human awareness, but also point out the transient nature and difficulty in developing research diagnostic criteria. They provide a more extensive review of instruments used to diagnose anosognosia and conclude: "Taken together, these findings suggest that lesion location is neither necessary nor sufficient to produce anosognosia, although lesions in some specific brain areas may lower the threshold for anosognosia. Strokes in other regions may need additional factors to produce anosognosia, such as specific cognitive deficits, older age, and previous strokes."
The experts here clearly do not base the diagnosis of this syndrome on imaging. It is based on clinical findings. For anyone interested in looking at the actual complexity in the area of anosognosia in schizophrenia I recommend reading these free online papers in the Schizophrenia Bulletin in an issue that dedicated a section to the topic in 2011. You will learn a lot more about it than reading an anti-biological antipsychiatry blog. But of course you need to be able to appreciate that this is science and not an all or none political argument.
George Dawson, MD, DFAPA.
Patrik Vuilleumier. Anosognosia in Behavior and mood disorders in focal brain lesions. Julien Bogousslavsky and Jeffrey L. Cummings (eds), Cambridge University Press 2000, pp. 465-519.
E. Fuller Torrey on the New Anti-biological Antipsychiatry
This post by E. Fuller Torrey was noted on another blog especially the phrase "the new anti-biological antipsychiatry". Torrey explains anosognosia both as a biological phenomenon and why it may be "deeply disturbing" to the new antipsychiatrists. Basically it represents the difference between social behavior based on choice versus social behavior based on brain damage. The former might be a civil rights issue but the latter is a medical problem that benefits from identification, study, and treatment. Torrey is also clear about the consequences of no treatment, facts that the antipsychiatrists conveniently often leave out of their arguments or more conveniently blame on treatment.
There is a lot of technical information apart from the data on anosognosia that is ignored by the new anti-biological antipsychiatry. There are studies on the prefrontal cortex that go back for decades and the implications for social behavior and the neurobiology of everything from addiction to dementia.
Here is a link to the original blog post by Duncan Double entitled: "E. Fuller Torrey attacks 'The new antipsychiatry.'" Defending against attacks by the new antipsychiatry is more like it. Dr. Double laments the fact that at times he is seen as an antipsychiatrist, even though he essentially maintains many of the positions of mainstream antipsychiatry. He includes a variation of the old antipsychiatry argument that if you don't have a specific test for a disease - the disease does not exist. That opinion fails to take into account studies about what is or is not a disease as well as a massive literature of biological psychiatry. It also fails to take into account the fact that these arguments are political in nature and have very little to do with science.
A good example is the chemical imbalance red herring. Any psychiatrist trained since the 1970s is aware of the complex neurobiology of human behavior. I can recall reading Axelrod's paper in Science over 30 years ago. Since then there have been eight editions of The Biochemical Basis of Neuropharmacology and five editions of the ACNP text Neuropsychopharmacology. Since then a psychiatrist has won the Noble Prize for contributions in neuroplasticity and wrote a seminal article on neuroplasticity and learning in psychotherapy. That is apparently ignored by the anti-biological antipsychiatry crowd and those who would characterize the field as prescribers versus therapists. The Internet is currently full of diagrams of cell signalling pathways with the associated proteins and genetics. The idea that chemical imbalance reflects some central central theory of biological psychiatry or represents anything beyond pharmaceutical company marketing hype reflects a gross misunderstanding of the field.
Any psychiatrist who tries to respond to these crude arguments is at a disadvantage for a couple of reasons. It is certainly seems true that the antipsychiatrists political stance is really not conducive to scientific discourse. Suggesting that the appearance of conflict of interest invalidates psychiatry is an obvious example. Discounting the amassed research on the neurobiology of mental illness is another. A political argument is well outside the scope of hypothesis generation and testing. Dismissing the science by attributing it to the "worldview" of a single person is consistent with that political approach.
There is a lot of technical information apart from the data on anosognosia that is ignored by the new anti-biological antipsychiatry. There are studies on the prefrontal cortex that go back for decades and the implications for social behavior and the neurobiology of everything from addiction to dementia.
Here is a link to the original blog post by Duncan Double entitled: "E. Fuller Torrey attacks 'The new antipsychiatry.'" Defending against attacks by the new antipsychiatry is more like it. Dr. Double laments the fact that at times he is seen as an antipsychiatrist, even though he essentially maintains many of the positions of mainstream antipsychiatry. He includes a variation of the old antipsychiatry argument that if you don't have a specific test for a disease - the disease does not exist. That opinion fails to take into account studies about what is or is not a disease as well as a massive literature of biological psychiatry. It also fails to take into account the fact that these arguments are political in nature and have very little to do with science.
A good example is the chemical imbalance red herring. Any psychiatrist trained since the 1970s is aware of the complex neurobiology of human behavior. I can recall reading Axelrod's paper in Science over 30 years ago. Since then there have been eight editions of The Biochemical Basis of Neuropharmacology and five editions of the ACNP text Neuropsychopharmacology. Since then a psychiatrist has won the Noble Prize for contributions in neuroplasticity and wrote a seminal article on neuroplasticity and learning in psychotherapy. That is apparently ignored by the anti-biological antipsychiatry crowd and those who would characterize the field as prescribers versus therapists. The Internet is currently full of diagrams of cell signalling pathways with the associated proteins and genetics. The idea that chemical imbalance reflects some central central theory of biological psychiatry or represents anything beyond pharmaceutical company marketing hype reflects a gross misunderstanding of the field.
Any psychiatrist who tries to respond to these crude arguments is at a disadvantage for a couple of reasons. It is certainly seems true that the antipsychiatrists political stance is really not conducive to scientific discourse. Suggesting that the appearance of conflict of interest invalidates psychiatry is an obvious example. Discounting the amassed research on the neurobiology of mental illness is another. A political argument is well outside the scope of hypothesis generation and testing. Dismissing the science by attributing it to the "worldview" of a single person is consistent with that political approach.
Tuesday, October 23, 2012
Conflict of interest and psychiatry - what's missing?
A new article looking at conflict of interest in psychiatry
was presented on another blog to suggest that new rules are required to improve
transparency. The article takes a look at six cases and the process used by
Sen. Charles Grassley to publicize these cases. The article suggests
that the reason for publicizing these cases was in order to support Grassley
legislation (Physician Payment Sunshine
Provision). According to the article it was attached to the Patient Protection and Affordable Care Act
and was never voted on alone.
These cases were repeatedly publicized in the popular media and some of the problems with these cases and Grassley's analysis were never adequately discussed. The clearest example is the case of Alan F. Schatzberg, MD of Stanford University. He was the chairman of the Department of psychiatry and when Grassley investigated the matter at the level of Stanford University and several pharmaceutical companies. You can read the exact details in this paper but the bottom line is that Stanford University has always maintained that it handled potential conflicts of interest in an appropriate manner consistent with their policies. They actually published a statement on their web page at the time. He remained the department head and although he was apparently temporarily removed as the principal investigator on a federal grant but he was later reinstated. The authors of the article in this case suggest that exposing the conflict of interest had negligible effect on the outcomes in this case, but the fact is the case was handled according to university policy.
Chimonas S, Stahl F, Rothman DJ. Exposing conflict of interest in psychiatry:
Does transparency matter? Int J Law Psychiatry.
2012 Oct 1. pii: S0160-2527(12)00072-6. doi: 10.1016/j.ijlp.2012.09.009.
These cases were repeatedly publicized in the popular media and some of the problems with these cases and Grassley's analysis were never adequately discussed. The clearest example is the case of Alan F. Schatzberg, MD of Stanford University. He was the chairman of the Department of psychiatry and when Grassley investigated the matter at the level of Stanford University and several pharmaceutical companies. You can read the exact details in this paper but the bottom line is that Stanford University has always maintained that it handled potential conflicts of interest in an appropriate manner consistent with their policies. They actually published a statement on their web page at the time. He remained the department head and although he was apparently temporarily removed as the principal investigator on a federal grant but he was later reinstated. The authors of the article in this case suggest that exposing the conflict of interest had negligible effect on the outcomes in this case, but the fact is the case was handled according to university policy.
There are really two key elements in this paper that are
critical. The first is why Grassley went after psychiatry in the first place.
The article suggests this occurs because his aide Paul Thacker "Combed the media for stories of influential
physicians with industry ties. He then requested the physicians conflict of
interest disclosures from their AMCs and compared them to payment schedules
obtained from companies." I had
always wondered why physicians from other specialties were never mentioned or
consultants from other departments. It is fairly well known that scientists and
engineers can make substantial incomes to supplement their university salaries
based on their expertise. So why was the "media combing" restricted to
psychiatry?
If I had to speculate, I would suggest that media bias
against psychiatry is a well known fact. It has actually been investigated and
the frequency of negative press that psychiatry receives relative to other
specialties is well known. (see paragraph 4) The popular press has an automatic media bias
against psychiatry and it should come as no surprise that prominent
psychiatrists are investigated and reported more frequently than other
specialists. This is why “combing the media” is really not a legitimate
research method. It should be fairly obvious that prominent university
affiliated physicians of all specialties have similar conflicts of interest and
that the business stake in other specialties is probably significantly higher.
The second element that should be obvious to anyone
skeptical of Congress is Grassley's quote in the article "The whole field
of medicine is connected by a tangled web of drug company money. For the sake
of transparency and accountability should the American public know who their
doctor is taking money from?" That sounds like there is an obvious answer in there
somewhere but the U.S. Congress is the best case in point that transparency is
essentially meaningless. There is probably no better example than Sen. Grassley
himself. You don't have to look too far
to find campaign donations that align with the votes and the Senator's denial (see paragraph 8) that there is any connection.
These simple facts are left out of the Journal article and
that represents a serious flaw to me. Is the U.S. Congress is a shining example of
disclosure becoming a license to do whatever you want to do? If that is the
case you really don't have the basis to suggest that
transparency will allow the "power of sunlight to disinfect". It
clearly does not have that effect in Congress. That is at the minimum an appearance of a conflict of interest on par with any scenario described in this article. When I point this out - the usual rebuttal is that doctors should have a higher standard when it comes to the appearance of conflict of interest. Is that really true? Should a doctor who already has a fiduciary responsibility to a patient and the patient's well being have a higher conflict of interest standard than one of the 100 most important law makers in the country?
The other issue here of course is that psychiatrists are
conveniently thrown under the bus. Despite the qualifier in this paper is that
"Nor did Grassley ever assert that psychiatry was more problematic than
other specialties." (p 5). You
really don't have to make an assertion when psychiatry is apparently the only
field you are investigating. That bias is totally consistent with one of the
themes of this blog.
When all else fails you can more easily scapegoat psychiatrists. So why look for anybody else?
George Dawson, MD. DFAPA
Does transparency matter? Int J Law Psychiatry.
2012 Oct 1. pii: S0160-2527(12)00072-6. doi: 10.1016/j.ijlp.2012.09.009.
[Epub ahead of print] PubMed PMID: 23036364.
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