Existential Dilemma (With the Usual Windy Discussion)

The past week or so, I've been experiencing an internal struggle. It's somewhat akin to a loss of faith, if you will, similar to what I experienced at age 19 when I became an agnostic (from Southern Baptist--trust me, that's a big leap). I've felt lost, confused, somewhat abandoned, and angry. While the acute crisis has mostly passed, I'm still feeling the aftermath and haven't decided yet what to do.

What was bothering me so much?

I have been confronted with evidence that a good portion of what we do in psychiatry is based on a) ineffective medication b) bad evidence on medication, sometimes even manipulated by drug companies c) made up as we go along. It just seemed to happen all at once, however, and kind of rocked me: can I "believe" in psychiatry, and practice in this field, if so much of what we "know" we don't actually know?

Some of you are going "WTF?" and some are going "DUH!" I'll try to list examples of what I'm talking about.

1) I've known for some time that the evidence for certain "mood stabilizers" like Depakote isn't very good. In fact, it sucks. In the study linked above, Depakote was no different from placebo in preventing mood episodes. Yet, we put every freaking bipolar patient on Depakote. It does seem to be effective in acute mania, but not quite so much in maintenance. And the whole term "mood stabilizer"? Doesn't it imply that the mood is "stable", or non-fluctuating? Even in trials with relatively good improvement over placebo, like this one with lamotrigine, show that the mean time to intervention for mood episode while on maintenance was 200 days (versus 93 with placebo). So by 6.7 months, the average patient on lamotrigine was going to have another episode. It may have reduced the risk of relapse, or prolonged the time to relapse, which is good, but I'd hardly call that a "stable mood".

2) A recent meta-analysis shows that overall, SSRI's aren't terribly effective in all but the most severe depression. Yet, we're taught in medicine that roughly 2/3 of patients will respond to the first antidepressant you try. It all comes down to your criteria, I suppose; remission vs response vs decrease in symptoms on a clinical scale, etc. Interestingly, the study above re-analyzed ALL the data submitted to the FDA to get these drugs approved, and came up with this answer. Uh, where was the FDA? Aren't they supposed to do that?

What really bothers me about this one, though, is that some of the efficacy data that was used to get these drugs approved in the first place was deliberately manipulated to make these drugs look more effective. After reading "Side Effects" recently, and looking at the study the book discusses, I'm angry. Wading through that study is tough, but you could still come out and think, well, it showed SOME benefit over placebo, and the side effects weren't too bad. Turns out, what was coded as "emotional lability" was actually likely to be suicidal behavior or self-mutilation. AND, several kids' data disappeared from the analysis. AND, the study was ghost-written. AND, GlaxoSmithKline deliberately had the writer word the study to show that "Paroxetine is generally well tolerated and effective for major depression in adolescents" because they knew it would hurt their bottom line to write that it wasn't! (That's not so shocking, really...)

Whether you believe that SSRI's cause/increase/exacerbate suicidal behavior or not (I've seen convincing arguments both ways), it is highly disturbing that the evidence we've been basing therapy on was so deliberately manipulated. Yet, we use this "evidence" all the time. It came directly from a drug company that expected to make millions to BILLIONS of dollars off this medication.

3) People ask me all the time if I'm going to become a child psychiatrist. After all, I love children, and (if I may say so) I'm pretty good at interacting with them. (Maybe I'm just childish?) However, my answer is usually "No." Why? Because I don't like the way we medicalize childhood problems and then medicate them.

Is ADHD a real disease? Sure, why not? I've met kids who were really impaired by their hyperactivity and impulsivity, across settings, with good, appropriately firm parents. I've also met kids who were totally out of control in the doctor's office while mom chats on her cell phone and then looks at me funny when I tell the kid not to hit their sister with the otoscope.

I have seen the number of kids diagnosed with ADHD go up dramatically in my lifetime, and (concurrently) the number of kids getting put on stimulant medication. What happened to behavioral modification? Or family therapy? I've not once seen those prescribed for a patient with ADHD (though my experience is still very small).

And then there's the whole pediatric bipolar debate. Can a 4-year-old kid really be manic? I don't know. But apparently the FDA does, because they're willing to approve medications for use in pediatric bipolar, when even the DSM-IV doesn't have a criteria for it yet, because no one has agreed on what the criteria should be! And apparently Texas knows what it is, because 12% of 0-5 year olds and 2/3 of the teenagers in foster care are taking "psychotropic medication". Twelve percent of kids under 5, and we don't have any idea what these meds might be doing to their developing systems.

So no, I don't think I can be a child psychiatrist, unless I do only therapy, because a) there's very little evidence in kids, because who wants to do studies in kids? b) the studies we have may be flawed c) but we "have to do something" when little Johnny hits his sister, so here's your Risperdal, hope it doesn't zonk you out too much. Oh, it makes you too sleepy in the day? Well, we can try Concerta during the day! Side effects from the Risperdal? Take a Benadryl! We end up with young kids on 3-4 psychiatric medications, and we don't know what any one of them could do to these kids, let alone a combo of multiple.

4) We act like psych patients who are "non-compliant" are constantly wasting our time. I wonder, how many psychiatrists have ever taken, say, an antipsychotic? I've never taken Zyprexa, but I know people who have, and they were complete zombies (who got fat). We act like we're surprised that patients would prefer craziness to weight gain, or sedation, or extrapyramidal symptoms, or (god forbid) tardive dyskinesia. In reality, I think we're asking patients to make a tough choice. Schizophrenics don't get totally well on medication--there is no cure. So, they can have an improvement in their psychosis and mood with a ton of unpleasant side effects, and be quasi-functional, or they can be psychotic and flat and non-functional. This is a tough choice, and we need to appreciate that.
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I guess what's really been bugging me is the huge discrepancy between what we're being taught (in both med school and residency, now) and what is actually out there. We're so "evidence-based"--but so much of our evidence comes from drug-company studies. Or what we "know" is directly in conflict with the "evidence." I don't want to be taught how to dose a medication without knowing the evidence behind it. Is that too high a standard? I don't think so. Would it be any different in medicine or pediatrics? Probably not.

In so many ways, though, I feel like what we do in psych is far behind the rest of medicine. Look at how many options there are for treating hypertension: beta-blockers, calcium-channel blockers, thiazides, loop diuretics, salt restriction, potassium-sparing diuretics... Now look at our options for psychosis: typical or atypical antipsychotics. Possibly group or family therapy; hospitalization for "medical stabilization"; group homes for those whom we can't fix. For bipolar: anti-epileptic drugs, lithium, atypical antipsychotics, maybe SSRI's. When one med doesn't work, we just add more, despite having almost zero studies on combo therapy.

This is not what I wanted. I guess I wanted to feel like I could actually help people. Hopefully, by learning psychotherapy, I still can. I wanted to practice "evidence-based medicine"--how can I, when there's so little good evidence? I guess it's one thing to prescribe Depakote because "it's better than nothing" (although it may not be), because we don't have many better options, but I hate the sales job. Call it a "mood stabilizer" and you believe that it works. Your textbook says "used to prevent recurrence of mood episodes" and you see it as actually preventing episodes, as in all (or most) episodes, not delaying their occurrence by 100 days (like lamotrigine).

I really think basic pharmacology ought to have a segment where they examine (briefly) the best evidence for medications (like second-year med students need more to learn). I think we ought to be exposed to that stuff early. Like, study X showed a number needed to treat of 20 for cholesterol-med Y. Or if second year students can't do that, let's put it into the curriculum for clinical rotations in third year. Or in fourth year when we're lazing around on the beach. Or intern year.

I guess I wish someone had handed me a book that I could reference the actual numbers and studies used to say this drug works on this condition. To the best of my knowledge, no such book exists. Shame on us for not having such a book (and shame on me if there is something but I haven't found it.)

So I'm a little burned out right now. I'm getting plenty of sleep and I just had an easy month, so it's not that. I'm just concerned about my chosen profession and its integrity--scary, huh? And will it be enough for me to just "be with" patients (House of God) in the face of our inability to do much else?