Saturday, August 30, 2008

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?

12 comments:

Captain Atopic said...

Tiny Shrink, I've really enjoyed reading your blog for a couple of months, and I really appreciate your honest writ and frankness. This is one helluva insightful post.

The Child Psych dilemma is a huge one - whether to move for change from within or without. Even in my short time in practise, I've seen a marked change in both the way ADHD medications are prescribed and attitudes. It's certainly made me consider how I'd approach Paeds Psyche.

The trial and error method of treatment certainly begs some questions; I think you've summarised them brilliantly, especially the glazing over of NNT in a psych setting. Oy veh!

Anyhoo, I guess from the smouldering ashes of burnout, you can capture what really stokes the fire.

Love your work,

Capt. Atopic

sara said...

I think that's the most important part of being a doctor - NOT believing much of what you hear...instead, being observant, skeptical, and not selling yourself to some doctrine...and doing as little as possible.

And having dealt with so many drug company whore psychiatrists...I'm glad you're still out there thinking for yourself.

shrinknit said...

Very good discussion. I've had similar thoughts about anti-depressants. Previous attending repeatedly said, "you won't get well with medication and therapy. buy a self help book or something," to patients being discharged from an inpatient unit.

I am sure they felt their money was well spent.

I've thought about changing specialties. But to what?!

Kelley B. said...

Foster children on psychotropic medication that only ever approved for adults is a huge problem. I'm glad that as a psychiatrist you are exploring why there is such much medication is out there. I fall under the "duh" category. Please check out my blog at http://fosterchildrensrights.blogspot.com/

Casey and Chris said...

I guess I feel and know from personal experience that although it is a difficult struggle to find the right combination of drugs to help one balance out in the end it was worth it. Yes, being on zyprexa sucked and yes, it triggered my bipolar disorder but that was because it was a strong anti-psychotic prescribed by a general practioner who had no clue about my families history of bipolar disorder. It was given to treat my depression. I regret that it lost me a month of my life and made me fat. However, when I finally went to a psychiatrist he and his nurse helped me to get better. It took going on depakote which turns out didn't work because my body metabolized it too fast. We then tried trileptal at increasingly higher doses along with wellbutrin, trazadone, and atavan as needed. Without those drugs I would not not finished college. I am glad that I have been fortunate enough to go back off of them and yes I love the fact that life has a richness to it that it didn't have when I was on medication but because of that medication my ability to reason returned and enabled me to self-talk myself through the negative, harmful thoughts because it muted the emotions. I would go back on those medications in a heartbeat if I ever need them again.

My brother who also suffers from bipolar disorder as well as a long list of other conditions has had a much longer and harder time of finding the right combination of drugs for him and therapy just doesn't always help. You can always lie in therapy. He will always have to have medication and I am grateful for the fact that there are doctors out there willing to take the time to find out what is working and what doesn't work. Although it has been a long and painful struggle for him and us as a family, we appreciate that now he has a regimen of medicine that lets him laugh again.

Keep in mind that it is this way in all medicine not just psychaitry. Medicine does different things for every person. It takes doctors who are willing to look at the medications and the patient and are willing to just try to make a difference. I promise that all patients appreciate your patience with us and our individual body chemistries and unique reactions to any medication that you may prescribe. Just don't give up.

A Kipp said...

Tiny Shrink,

First of all, congrats for not drinking the Kool-Aid! So many of my (3rd year medical student) peers get sucked into the medical model of psychiatry, and only know to treat psych issues with medications.

Luckily, you are definitely not alone! I probably won't go into psychiatry, but I've attended a few conferences and lectures from ISPS (International Society for the Psychological Treatment of the Schizophrenias and other Psychoses), and they have all been excellent sources of information regarding the non-medical choices doctors and patients have. (Check it out at http://www.isps-us.org/)

Also, I'm not sure if you've heard of Rene Muller, but he's an excellent doctor and author, particularly of "Doing Psychiatry Wrong," that discusses openly and honestly many of these issues.

You are definitely not alone in your concerns, and I hope you keep this skepticism throughout your training, as difficult as it may be!

Peace,
Alex

Rach said...

I've read this post 5 times, just to swallow it and digest a bit.

First - no matter what subspecialty of psych you choose, if you choose to subspecialize at all - you'll be amazing...

Regarding child psych - it takes a certain kind of person to be able to sit on the floor with a child and really be able to talk to them, not at them, and communicate and engage - and not just throw meds at the situation. There sometimes (not always) comes a point where meds will better a situation, make it more manageable or tolerable, as the case may be, and in some cases, it's the only solution, but to be open minded enough to try other things is certainly noble and necessary in the profession.

Mayhem said...

Don't be burned out, look at the potential silver lining. There is a lack of solid evidence in psychiatry (though I didn't know it was this big) but that can also be an opportunity. It's a researcher's dream, if you're so inclined. There's so much to investigate, so much to learn.

Still, I agree with the general sentiment. The situation you describe is vastly different from the psychiatry I was sold during my rotation. You definitely opened my eyes.

The Gonzfather said...

Worry not, you're too early in to see the forest for the trees. When you hit outpatient clinics, you will see that things are not as bleak as the studies lead you to believe.

As for the oft-quoted "ineffective SSRI" studies, they usually only look at 12 week studies. Given that a Major Depressive Episode can last only a few weeks and remit on it's own, its unsurprising that it's difficult to separate SSRIs out from placebo. I wonder what the study would have shown with 1 year of placebo?

As for ADHD, I think it is generally over-diagnosed, but when doctors use actual objective data (and periodically re-test off the meds), it is something real and treatable.

I agree that pediatric bipolar is probably rare, and takes a LOT of patience to diagnose.

Deidre said...

You don't even have to wait for outpatient clinics, just wait for inpatient psych. You get to watch people get better, much better, right in front of you. It's not perfect, and all your points are valid...but you can, and will, help people in very tangible ways.

medicine girl said...

It seems like there are similar concerns in every medical specialty. You're obviously conscientious & caring enough that you'll do a lot of good despite limitations of psychiatry. Necessity may also lead you to blaze new trails in & shape your chosen field. I look forward to reading more about your journey!

medicine girl said...

Encouraging: http://www.nytimes.com/2008/10/01/health/01psych.html