Texas Medication Algorithm Project (TMAP)

From Health Care Renewal

Wednesday, December 20, 2006

Guidelines in Whose Interest? - Pharmaceutical Companies and the Texas Medication Algorithm Project (TMAP)

Out of Texas comes a story with allegations of pharmaceutical industry involvement in the crafting of state mandates for the treatment of psychiatric illness. Per the Dallas Fort Worth Star Telegram (edited, and re-ordered):

A recently unsealed lawsuit accuses Johnson & Johnson and related companies, including Janssen Pharmaceutical, of conning the state of Texas into spending millions of dollars on costly psychiatric drugs.

The suit targets a controversial state program that instructs doctors at state-funded healthcare facilities about which medicines to prescribe for a variety of mental illnesses.

The suit was filed in 2004 in Travis County by Allen Jones, a former employee of the Pennsylvania Office of Inspector General who investigated drug companies' ties to his state's officials. In the process, he learned of allegations related to Texas. The Texas attorney general's office has joined the lawsuit.

While the suit does not name a "state mental health program decision-maker" who it alleges received payments and other benefits, a spokeswoman for the Texas Health and Human Services Commission confirmed that the lawsuit refers to Dr. Steven Shon, who managed the program. Shon took more than 80 trips throughout the country and abroad to promote it, with his expenses often underwritten by drug companies.

Shon, who left the Department of State Health Services this fall while the investigation was ongoing, said he has not received money from drug companies in connection with his work for the state. Money paid for his travel expenses or to reimburse taxpayers for his time away from the office, he said.

'These assertions are really ridiculous, he said.

However, Shon said he received a few thousand dollars from Janssen several years ago for consulting work unrelated to his state job. He said he got approval from the department's legal staff, but commission spokeswoman Stephanie Goodman said the agency was unaware of payments and would not have approved them.

The lawsuit alleges that Johnson & Johnson and its subsidiaries misled state officials about the benefits of the antipsychotic drug Risperdal, including promoting it for treating children when the drug had not been federally approved for such use. The company's influence led the state to purchase the expensive brand-name drug instead of cheaper generic alternatives, according to the lawsuit. The result, it alleges, was that the state paid excessive amounts in claims for Medicaid, which covers medical costs for low-income people.

A major portion of the lawsuit focuses on the Texas Medication Algorithm Project, which Shon coordinated. That program offers a series of treatment plans, or algorithms, for various mental illnesses, including which drugs to use. In many cases, the plans recommend the newest drugs, which are the most expensive and are not available in generic form.

Such drugs generate much income for pharmaceutical companies. In a recent three-year period, more than $190 million was paid in Texas for outpatient Medicaid claims for Risperdal alone, according to the state Health and Human Services Commission. During those same years -- 2002 to 2005 -- almost $700 million was spent on all antipsychotic medications combined. That does not include care for those who are in state institutions.

Drug companies, including Janssen, gave the state more than $1 million to help promote the plan. And the Robert Wood Johnson Foundation, established by the founder of Janssen parent company Johnson & Johnson, gave $2 million. A company spokesman previously said the foundation is independent of the company.

The exact amount donated by the companies remains unclear. Shon has acknowledged that his agency did not always seek required approval from the department's governing board before accepting donations.

Shon left his job with the state in October.

Shon said he was given the option of resigning or being terminated, and he chose to leave.

In addition, per a reporter for an Austin television station,

Shon spent a great deal of his time traveling around the country promoting the TMAP treatment guidelines.

Shon made at least 84 trips. Many of the trips were courtesy of the drug companies whose drugs are specified in TMAP and have a financial interest in getting other states to adopt the program.

'So when ever you were going on trips to speak on behalf of this and the money was coming from the pharmaceutical companies were you ever aware that it might look like a conflict of interest,' CBS 42’s Nanci Wilson asked.

'I think that it possible could, but I thought that given the fact that this is how conferences and education works, I didn't think that this was really any different then what was going on anywhere else,' Shon said.

But Shon's trips to Pennsylvania weren't business as usual.

'The check originated as an unrestricted educational grant from Janssen to the Harrisburg State Hospital here in Pennsylvania,' Allen Jones said. 'However, the check was deposited to an off the books account and a separate check written out to Shon in the exact amount of the unrestricted educational grant. And while they called it an unrestricted grant, the supporting documentation clearly, clearly established that the purpose of the monies was to bring Shon to Pennsylvania to sell the TMAP program to Pennsylvanian officials.'

Before commenting, I need to acknowledge that the story above is based only on allegations, so far. The law-suit has not gone to trial, and there may be more than one side to this story.

Nonetheless, the allegations are striking. We have previously posted on allegations of attempts to influence guidelines by those trying to sell drugs, devices, or services that such guidelines may support. However, in the current case the allegations were of attempts to influence state mandated treatment algorithms (the Texas Implementation of Medication Algorithms, or TIMA), not mere guidelines. (As best as I can tell from the TMAP web-site, particularly its FAQ section, these algorithms are mandatory for all state mental health outpatient facilities.)

If nothing else, this reinforces the need for physicians, health care professionals, and patients to be extremely skeptical about how guidelines are written, and who has influenced their writing.

Parenthetically, note that this skepticism should extend to guidelines labelled as "evidence-based." The TMAP algorithms are described as evidence based, but I can find nothing on the TMAP web-site that explains how the process used to develop them fit this definition.

ADDENDUM (12/20/2006): See also these posts (here and here) on Clinical Psychology and Psychiatry.

From Clinical Psychology & Psychiatry

Thursday, March 08, 2007

TMAP and Bipolar: Where's the Beef?

Much has been made of the Texas Medication Algorithm Project. I have written about it earlier (1, 2), as have others (3). A lawsuit has been filed alleging that TMAP was a sneaky way to convince state mental health programs to switch their patients to newer, much more expensive medications. TMAP defenders, on the other hand, say that TMAP was simply allowing patients access to the state of the art, most effective medications.

What is TMAP? Essentially, TMAP is a program that used “expert consensus” to develop treatment guidelines for patients (depression, bipolar, and schizophrenia) in the public mental health system. On one hand, I can see why care should be improved – not many people seriously argue that patient care is very good in most public mental health systems.

According to the TMAP model, medication treatment is provided in stages according to these guidelines. If you are not responding to treatment #1, then you move to treatment #2, and if that does not work, then to treatment #3, and so on. Naturally, the “objective experts” who developed said guidelines stuck the newer, more expensive medications on the top of the list for treatments, especially as the guidelines have been revised during the past couple of years.

TMAP was unfurled in the mid 1990’s and similar programs have since been sweeping across many states.

Was this a way to backdoor newer medications onto patients? Well, I think that is probably the case, but the issue I am going to address here is one that I think is even more important…

Does TMAP Work? Do TMAP patients show more improvement than patients who were not on the TMAP treatment regimen? The TMAP team has produced some evidence in which they claim that TMAP treatment works better than “treatment as usual,” which was standard state mental health care. In this case, we’ll discuss TMAP for bipolar patients.

The Study: Some patients received TMAP, which included both a standardized medication algorithm as follows:

Manic:
Stage 1 – Depakote or Lithium or Tegretol
Stage 2 – Depakote + Lithium OR Tegretol + Lithium
Stage 3 – Depakote + Lithium OR Tegretol + Lithium
Stage 4 – Depakote + Tegretol
Stage 5 – Add atypical antipsychotic to mood stabilizer
Stage 6 – ECT
Stage 7 – Other (e.g., Lamictal, Neurontin)

Depressed:
Stage 1 – Wellbutrin or SSRI + mood stabilizer
Stage 2 – Wellbutrin or SSRI or Effexor or Serzone + mood stabilizer
Stage 3 – Mood Stabilizer + two antidpressants
Stage 4 – Mood Stabilizer and MAOI antidepressant
Stage 5 – ECT
Stage 6 – Other (e.g., Lamictal)

Note that in the 2005 revision of this standard, atypical antipsychotics are featured much more prominently. But when the study on bipolar patients was conducted, this was not the case.

Those who received “treatment as usual” (TAU) received whatever care they would normally receive.

The Results: On some measures, TMAP patients did modestly better than TAU patients. This could be interpreted as evidence that these strict treatment algorithms that involve a high frequency of prescribing Depakote and Tegretol, and to a lesser extent, newer antipsychotics, are a good idea for patients. However, one would be fooling oneself to buy this conclusion. Why?

The (Huge) Caveat: The TMAP patients all received: Group education, consumer to consumer discussion groups, individual patient education from the physician, referrals to therapy groups and more. These interventions were rolled out exclusively for the TMAP group. Why does this matter? Well, patients in the TMAP group were likely getting more time with their physician, which is likely going to boost their relationship with the physician, which will likely lead to better outcomes regardless of the medication taken. In addition, the patient education groups provide additional support for patients, which has been shown to improve outcomes.

Even the study authors, to their credit, admit this is a gigantic potential issue:

At this time, the relative contributions of different elements [i.e., medication versus the extra patient care] of the “disease management package” to the obtained results has not been evaluated.

A Better Idea for TMAP: If you wanted a study that would have compared the effects of a) extra patient education and support, b) use of medication algorithms that favored use of newer medications and c) “treatment as usual” – regular care in the state mental health system, then why not have a study that looks like this:

A) Treatment as usual (No extra patient support)
B) Extra Patient Support + TMAP Algorithms
C) TMAP Algorithms (No extra patient support)
D) Extra Patient Support + Treatment as usual

If C’s outcomes are better than A’s outcomes, then you can shout about the evidence base of your algorithms. If B is greater than D, then you can also do your evidence-based practice speech. However, the TMAP bipolar study as was actually conducted was A versus B, – that is a pretty lame comparison. Was it the patient support (which is my guess) or was it the algorithms?

Why Was TMAP Investigated This Way? This is where it gets interesting but murky. Could such a study have been designed because it was biased to find favorable results for the TMAP intervention (due to TMAP patients receiving extra support not received by treatment as usual)? Then, finding positive results, it becomes a lot easier to sell the program to other states because TMAP is now “evidence based”. Maybe I’m off in Conspiracyville, but one has to admit this is pretty weird stuff.

Where are we going wrong?

The Last Psychiatrist - November 9, 2006

Massacre of The Unicorns

The real problem of a critique of our own cultural models is to ask, when we see a unicorn, if by any chance it is not a rhinoceros.

It’s a convenient fiction that the difficulties with psychiatric diagnosis and treatment are due to incomplete knowledge- if we just knew more about dopamine!—but the real source of the failings is inherent in its structure. Psychiatry fails because it is designed to fail. (continued below...)

Massacre of the Unicorns

The real problem of a critique of our own cultural models is to ask, when we see a unicorn, if by any chance it is not a rhinoceros.[i]

It’s a convenient fiction that the difficulties with psychiatric diagnosis and treatment are due to incomplete knowledge- if we just knew more about dopamine!—but the real source of the failings is inherent in its structure. Psychiatry fails because it is designed to fail.

Semiotics and Psychiatry

The problem is with the signs of psychiatry. Signs are vehicles for conveying information. For example, the term “antidepressant” is a sign conveying the idea of a “drug which treats depression.” While tricyclics and SSRIs are both called “antidepressants” because they treat depression, the term otherwise carries no necessary value except that. Signs can be misused if they are expanded to take on new meaning in an inconsistent fashion. Consider the controversy over “antidepressant induced mania.” Tricyclics have been shown to be associated with higher manic rates, but SSRIs haven’t. So does that mean that most textbooks and articles are wrong—that antidepessants don’t cause mania? Actually, the problem is worse than that. It’s not that antidepressants don’t cause mania—it is that there cannot be any such notion as antidepressant induced mania.

Hydrochlorothiazide (a diuretic) and propanolol (a beta blocker) are both “antihypertensives,” but otherwise are very different drugs with very different side effects; only one makes you pee. There’s no such thing as “antihypertensive induced peeing.”

But this error is itself based on an earlier semiotic error, with the sign of “bipolar disorder,” and its implicit idea of two opposing poles. Depakote will cure and prevent mania; and Zoloft will cure and prevent depression. The treatment of one pole should surely move the patient closer to the next pole; hence, psychiatrists talk about “antidepressant induced mania” but “Depakote breakthrough mania.” See the difference? No? That’s because, in reality, there is no difference in the two manias, and absolutely no reason one should believe one is “induced” and the other “breakthrough,” except that the problem has arbitrarily been defined in this manner, i.e. a) mood stabilizers are a priori preventative, and b) Depakote is a mood stabilizer. But a) is a postulate and b) is an optimistic assumption.

A similar example is the often cited myth that diagnosis of bipolar disorder is frequently missed. A survey[ii] found that 69% of patients were actually misdiagnosed, most often as having regular depression. An average of 4 physicians were consulted “prior to receiving the correct diagnosis.” But who is to say what is the correct diagnosis, when the diagnosis is based on vague and overlapping descriptions (and not on objective pathology?) You can look at this the other way, and say only 1 out of 5 psychiatrists felt it was bipolar disorder, while the other 80% thought it was depression. So it pays to have the last word. Bipolar disorder is “frequently missed” not because it exists and doctors miss it, but because it is defined in a way which allows it, by 80% of doctors, to be legitimately called something else. The only way to say the diagnosis was correct or incorrect, in the absence of objective pathology, is to say that the treatment they received for “bipolar disorder” from the fifth doctor was better (read: safer or more efficacious) than the treatment they received from the first four. This is not evident.

Marco Polo's Dilemma

The problem in psychiatry is the problem in the epigraph at the beginning of the paper. When Marco Polo saw the exotic one horned quadruped, his frame of reference required that it could be none other than a unicorn, even though it did not conform exactly to his prior conception of it. Marco Polo made his observation fit his existing paradigm of zoology. While superficially (and in retrospect) this may seem silly and arbitrary, it is in fact the opposite, Marco Polo believed the only thing he could believe—because the alternative was to believe he had discovered an entirely new, unheard of, creature. This is the semiotic problem in psychiatry, wherein we are forced to interpret clinical signs with our available “encyclopedia,” because we lack both the newer encyclopedia, and its accompanying language, to interpret the signs differently. But here’s the extra credit question: is it really a rhinoceros or a unicorn?

Psychiatry is trying to move away from a symptom based field to a disease (or at least disorder) based science. We are deciding (note word choice) that a psychiatric disease exists a priori, and can present with different symptoms, the way cancer could present as the flu, but really is cancer. The diagnosis (or sign) becomes more important than the individual symptoms, because it demands a specific treatment. But if the paradigm is faulty, what of the treatment?

An example is the association of bipolar disorder with mood stabilizer. Through a series of laughable twists, psychiatrists came to believe that antiepileptics had special properties in bipolar because they could quell the chaos in the brain in the same way that they calmed seizure activity there. It is now common practice, as defined in numerous “Expert” guidelines and consensuses, that patients with bipolar disorder need to be on a mood stabilizer, specifically lithium or the antiepileptic Depakote. The problem with this is that there has never been a study that found that Depakote is a mood stabilizer. In fact, there is no evidence that any antiepileptics are mood stabilizers. What few studies have been done show no benefit over placebo for this purpose. Remarkably, very few psychiatrists know this. But worse, even when you show them data, they refuse to accept it.

I know, it seems—well, crazy—that psychiatrists would blatantly ignore the absence of data—the opposite of data. Ask your psychiatrist the following question: A patient with a history of bipolar disorder presents depressed. There are only two medications available: Prozac or a new antiepileptic for which no efficacy or safety data yet exist. Which do you use? That the mystery antiepileptic is even considered shows the power of the association, because I haven’t actually told you anything about the antiepileptic. Nothing about efficacy, safety, anything. And a doctor would consider it? It’s considered because it is assumed that it will share the same properties as other antiepileptics, i.e. that it is a mood stabilizer. But no other antiepileptics are mood stabilizers, so why the assumption? And even if one seizure drug was, in fact, a mood stabilizer, why would another one be? If antiepileptics have totally different efficacies with respect to seizure treatment, why should it be any different for bipolar treatment? The power of the paradigm compels us.

Can an antipsychotic be an antidepressant? Sure. Can an antidepressant be an antipsychotic? See? You’re hesitating. It is harder to imagine that an antidepressant can be an antipsychotic—as if there is anything in either term that allows us to predict other actions—because the paradigm has given value to terms that they don’t have.

There’s an analogy in the social sciences: racism.

The Knowledge Trap

But psychiatry is an applied discipline. What’s the harm if assumptions lead to efficacious treatments? This is a trap. Psychiatry has convinced itself that it needs to focus on expanding its knowledge (i.e. data) rather than re-evaluating its postulates and paradigms. New discoveries or information are used to build on a paradigm, not to test it. But now psychiatry is looking to see what it expects to find. And if a discovery flatly contradicts the tradition, then it is ignored or rationalized. How else to explain the comparative absence of articles critically discussing the placebo response? And the even fewer whose proposed solution is not the abandonment of the placebo arm, in favour of “active controls.” Active as defined by whom? Is Depakote an active control?

What Is Modern Psychiatry Seeking?

The fiction is that psychiatry is looking for more efficacious treatments. It is not. It is looking for different treatments; the paradigm does not allow for the creation of better treatments. For example, psychiatry can applaud itself from moving from a “noradrenergic hypothesis” to a “serotonin hypothesis” of depression, but it’s still the same paradigm. While first line medications have changed, they have not changed because of improved efficacy. Nothing has ever found anything to be more efficacious than the previous standard (SSRIs. vs. tricyclics, atypical antipsychotics vs. chlorpromazine, etc.) nor has any “model” been more or less correct than any other. That some medications have less side effects and greater versatility is useful, but a) this is almost never the result of intentional scientific discovery but rather the fortunate by-product of the invention of (yet another) efficacious treatment; b) this greater tolerability in no way reflects the accuracy or inaccuracy of an existing model. That Zoloft is more tolerable than imipramine has nothing to do with the viability of the “serotonin hypothesis.” And yet how many times have I heard that antipsychotics treat depression with no more rigorous explanation than because of their “activity” (note the vague term) on serotonin?

Psychiatry, which seeks to be like physics, becomes instead a caricature of it. It, too, tries to focus on expanding knowledge and not re-evaluating its principles. But unlike physics, psychiatry has no formal principles. They are made up. It is, strictly speaking, not a science but a paradigm, no different than psychoanalysis. It may seem as though Freud concocted the notion of the unconscious out of thin air and developed an entire field around it, but modern psychiatry has done nothing different in concocting the notions of kindling or “upregulation of receptors” as first principles and then constructing an equally arbitrary field around them. That medications help patients has everything to do with the medications and nothing to do with the incense and liturgy that surround them.

Paradigm shifts do not occur in physics because the principles do not change. Newtonian mechanics will always be useful for prediction because it is correct for the cases in which it is applicable (i.e. for measurable bodies.) It is furthermore not susceptible to political influence. Psychiatry is the opposite. The decision to accept or reject the paradigms in psychiatry are very clearly political, not evidentiary. We as individuals accept the idea that antiepileptics are mood stabilizers because psychiatry has decided to adopt this position, not because the evidence requires us to accept it (in fact, the evidence should require us not to accept it, or at least seriously question it.) No physicist could hope to “practice” physics without having read and understood what came before, without having worked the “block on an incline” problem. But there is no theoretical nor practical requirement to practice psychiatry of reading the papers on, for example, mood stabilization, let alone what came before. All that is required is to know what the current practice is (“Guidelines recommend prescribe antiepileptics.”) This may seem like science, i.e. “scientists have determined that antiepileptics are mood stabilizers, so we will trust their word and prescribe them,” but it is very clearly politics.

The current problem of psychiatry is that it seeks to be something that it is not: science. It may be, at some future date, readily described by scientific principles, but this is assuredly not the case now. It is most certainly a sociological construct, a paradigm, with a shared educational system, shared assumptions, and a mechanism to communicate discoveries (i.e. journals, meetings.) It also has a common language. But it lacks the predictive ability common to other disciplines.

An argument against the notion that psychiatry is an arbitrary paradigm is that it is a reflection of what actually occurs in the brain. This is sophistry. For example, saying the “serotonin system is relevant in mood disorders” is empty because it lacks context. Does it mean that no other system is relevant? Or that it is the most relevant? Or even necessary? Sufficient? What about Wellbutrin? Are you saying psychotherapy alters serotonin? (And not dopamine? Etc)

Why There Can Be No Progress in Biological Psychiatry Using The Current Paradigm

While there is a science of the brain, there is no science of thought. Another way to think of the problem is to question the nominalism of the field. Psychiatry talks about things like mood, emotion, depression. But are those actually real and distinct things? Is there some signal pattern in the brain that is mood that is wholly unrelated to the signal pattern for a thought? Just because something has a name, that does not mean that the thing exists in fact. These may be simply convenient fictions.

To say that because it is known that chemicals can alter what is called mood therefore proves the existence of mood is not satisfactory. The death of a loved one will alter mood as well, often dramatically and to an extreme. How is this possible, if no chemicals are introduced into the system? In fact, nothing new is introduced into the brain except, depending on the paradigm, a) information or b) energy (i.e. converted sound waves.) How does the introduction of a new piece of information trigger an alteration of mood? Why would one thought "My family is dead" trigger the release of some chemicals, but another thought "My family is alive" not trigger that same release? And how does a non-physical entity like a thought trigger a physical reaction? Are thoughts even discrete? Or does the brain operate on a flow of thoughts? Digital or analog?

Linear regression and statistics cannot address all of the problems of chemistry and mood; for one reason because it does not account for thoughts that a patient cannot have while on the drug-- but it is reasonable to think there are some. In other words, if there is some set of thoughts A, a subset B of which are negative and a subset C of which are positive, then is the introduction of a chemical in the brain able to block only subset C, or does it simply block set A? The reverse is potentially applicable: that there are certain thoughts that can be had only when on a drug. (This is obviously evident in the case of perceptions that can be had only on a drug.)

The simple analogy to computer hardware and software illustrates the difficulty in psychiatry. One can understand all of the hardware of a computer system, but this will not explain if or how the computer can run word processing software, video games, instant message or be susceptible to a virus, or make any predictions about the behavior of this software in the real world (for example, no computer technician could predict the writing of this paper, nor, by changing the hardware, alter the content of this paper.) Hardware is finite, but software is infinite, or as infinite as is thought. Without understanding the mechanism of thought, or at least how thoughts or states can affect mood, then a pharmacology of the brain will simply tread water with no progress towards either treatment or diagnosis. One cannot permanently alter mood without at least simultaneously altering thought. In a sense, there is more logic to the psychological approach, or at least in conjunction with medications, because if software (thought) is the problem, more software is the cure. While the applicability of “therapy” in schizophrenia may be debatable, there is no reason as yet to decide that any other approach is applicable to mood disorders such as depression or anxiety, and absolutely no evidentiary reason to assume that pharmacology is the superior approach. It is not necessarily faster nor more consistently reliable.

Myths of psychiatry such as those described above are not isolated examples of poor practice or lack of knowledge, but are the unavoidable manifestations of an artificial paradigm which is arbitrarily derived from unproven assumptions, justified by inappropriate logic. They often lead to ineffective, dangerous, and very expensive treatment. Psychiatry must be more vigilant about its own data. It is necessary to avoid laziness in our education and understand from where comes our knowledge. There are daily diatribes against the influence of pharmaceutical companies; but the effect of pens and detailing is surely much smaller than the effect of misunderstood data, poorly researched axioms, and signs run amok. Psychiatry will not survive as a medical subspecialty if it continues along this path. It will lose its dignity, and worse, it will become irrelevant.

“It would be good to conclude by recommending a short book, What Is Science?, that does things the right way. It takes a robustly objective view of the relation of evidence to conclusion, explains what laws of nature are, briefly shows how measurement, data, statistics, and mathematical models work in science, states which parts of science are well-established and which not, illustrates with engaging episodes in the history of science, and ends with some colorful rudenesses on postmodernist solecisms concerning science. Unfortunately, it does not exist.”[iii]

---

[i] Eco, Umberto (1998). Serendipities: Language and lunacy (William Weaver, Trans.). New York, NY: Harvest.

[ii] Hirschfeld RM, Lewis L, Vornik LA. Perceptions and impact of bipolar disorder: how far have we really come? Results of the national depressive and manic-depressive association 2000 survey of individuals with bipolar disorder. J Clin Psychiatry. 2003 Feb;64(2):161-74.

[iii] Franklin, James. Thomas Kuhn’s irrationalism. The New Criterion Vol. 18, No. 10, June 2000

April 11, 2007

The Trouble With Psychiatry-- "Not Even Wrong"

I recently read Martin Gardner's review in the New Criterion of Lee Smolin's The Trouble With Physics, and Peter Woit's Not Even Wrong: The Failure of String Theory.

I am almost finished Smolin's book, but I wanted to make a comment about Gardner's piece. Writing in the New Criterion, he should have appreciated a wider view of the books, that they speak to more than physics. They're just as much about psychiatry.

Because I suck at writing, I'm a much better speaker, I often have difficulty getting my ideas-- which are already baffling-- across to people indoctrinated in psychiatric mythology. But Gardner does a great job, so I'm simply going to quote him verbatim. I don't think he'll mind. Just substitute the word "psychiatry" anywhere you see "physics."

He sees string theory as not a theory—only a set of curious conjectures in search of a theory. True, it has great explanatory power, but a viable theory must have more than that. It must make predictions which can be falsified or confirmed.

Consider that the terms "borderline" and "narcissist" which have supposedly no predictive power, yet give you more information than the epidemiologically valid and "reliable" diagnosis "bipolar."

In a chapter on sociology, Smolin introduces the concept of “groupthink”—the tendency of groups to share an ideology. This creates a cultlike atmosphere in which those who disagree with the ideology are considered ignoramuses or fools. Most physicists tied up in the string mania, Smolin believes, have become groupthinkers, blind to the possibility that they have squandered time and energy on bizarre speculations that are leading nowhere.

The last part is key-- who among psychiatrists are willing to say, "holy crap, we just made this all up as we went along!"

The other book Gardner reviews is Not Even Wrong, the title coming from Wolfgang Pauli's quote that a theory was so ridiculously unscientific that it was "not even wrong." Quoth Gardner: "By this he meant it was so flimsy it couldn’t be confirmed or falsified."

Gardner quotes another writer (Glashow), in an indictment of why the masturbatory nature of psychiatry is detrimental to its own practitioners. Replace "string theory" with "bipolar model:"

Until string people can interpret perceived properties of the real world they simply are not doing physics. Should they be paid by universities and be permitted to pervert impressionable students? Will young Ph.D’s, whose expertise is limited to superstring theory, be employable if, and when, the string snaps?

And closing with a quote from the physicist Gerard ’t Hooft:

Actually, I would not even be prepared to call string theory a “theory” rather a “model” or not even that: just a hunch. After all, a theory should come together with instructions on how to deal with it to identify the things one wishes to describe, in our case the elementary particles, and one should, at least in principle, be able to formulate the rules for calculating the properties of these particles, and how to make new predictions for them. Imagine that I give you a chair, while explaining that the legs are still missing, and that the seat, back and armrest will perhaps be delivered soon; whatever I did give you, can I still call it a chair?

I wish I could write better, more clearly. I can't. But at least read Gardner and Smolin-- if the problem of loose science and groupthink occurs in the hardest of the sciences, physics, it most certainly occurs in psychiatry. The first step in recovery, of course, is admitting you have a problem. We may never get past this step. The second step is to stop pretending you're something you're not, stop trying to make judgments and pronouncements about which you know nothing: Wovon man nicht sprechen kann, daruber muss man schweigen.

Ten Big Mistakes

From The Last Psychiatrist - November 16, 2006

The Ten Biggest Mistakes Psychiatrists Make

1. Talk too much

It’s not a conversation, and it’s not a debate. You are either treating their symptoms with medication, or guiding them to “treat” their own symptoms. Neither requires much talking.

If the psychiatrist says more words than the patient, then the psychiatrist is the patient.

Many psychiatrists talk because they feel powerless. The patient is in distress. How can the session be worth the money unless they get some thing? A prescription is good, but what else—what now? So the psychiatrist thinks they need to say something, to appear as though you are giving something to the patient. The worse the situation is, the more the psychiatrist talks. You’re talking to make yourself feel better, to justify your value as a psychiatrist. Don’t do this. It’s not help.

And empathize, don’t sympathize. I cringe whenever I see a psychiatrist on the first visit try to sound genuine while they affect a sad and shocked voice, lean forward, grab a box of tissues, “oh my God, I’m so sorry, that’s terrible!” It’s fake, which makes it annoying, but it’s patronizing, which makes it countertherapeutic. A psychiatrist cannot sympathize—did the same thing happen to you?. What they need to do is empathize, to understand the feelings, to appreciate them—not to share them. Plus, you don’t know what the situation means to the patient. Maybe they’re secretly happy (and guilty about it), and now that you’ve confirmed that it’s “terrible,” they’ll never admit to you or themselves they’re happy about it. Simply saying, “I’m sorry. Can you tell me more about…” is all that’s necessary.

And enough with the tissues. If you stalled the interview to go get them a box of tissues, you have failed, you changed the energy of a key moment. And you did this—let’s be honest—not because they needed tissues, but because it took some pressure off the moment and allowed you to give them something. Leave tissues by the patient chair from the beginning, and focus on what you’re doing.

I had a great mentor who taught me to begin the first session with the words, “Where would you like to begin?” And then to shut up. Great advice.

2. Take too much history

This is going to be controversial. I can hear academics seizing.

I know psychiatrists are taught that careful, meticulous history taking is the cornerstone of good care. Well, it’s not.

Every session should be about the patient, not about you. You’re supposed to help them, not understand them. The two may go together, but they might not. It is possible for you to help without understanding, but it is not acceptable for you to understand without helping. You’re not CSI, you’re not Batman, you’re not trying to solve a mystery or make some aha! discovery. They’re telling you what’s wrong. Just listen. Taking a detailed history may seem like a good idea, but many times it is masturbation, it contributes nothing to the patient’s well being, it only makes us feel thorough. As in: well, I can’t do much for him, but I got a really good history. Remember, it’s not about you, it’s about them. It may seem as if a strong family history of bipolar disorder is important information, but it isn’t. I know, bipolar runs in families and blah blah blah. You couldn’t tell they were bipolar before you learned their family history? And how do you know the family’s diagnosis was correct, so that you can rely on it to make your diagnosis?

I’m not saying don’t get the information. I am saying devoting the first one or two sessions exclusively to this gains the patient nothing. Everything from the moment they walk through the door should be about their service. Forget about the notes, especially outpatient notes. Worry about the patient, the notes should come second.

Are you proud of your notes because they contain so much detailed patient information? You need to think about this. Did you break eye contact to write, “sad over husband’s loss?” Then you missed the moment. Just listen—write your notes after the session. And if I see one more psychiatrist with a note pad playing stenographer I am going to punch him in the neck.

3. Ignore smoking cessation

or at least make it a secondary outcome. Also applies to soda/juice/calorie reduction.

This may seem trivial. It’s not—after the treatment of the initial presenting acute symptoms and treating drug and alcohol abuse, this is more important than almost anything in psychiatry. The logic is as follows:

1. Smoking is obviously and severely detrimental to one’s health, arguably more damaging than hypertension and depression combined. Its effect on life expectancy rivals, well, arsenic.

2. It is an addiction, so it is psychiatry’s business.

3. It is highly comorbid with psychiatric disorders, and may be a relative symptom of them. (For example: half of all people who commit suicide smoke.)

4. Smoking itself has a significant impact on other medications (e.g. did you know it reduces Haldol by half?)

5. What the hell else are you doing with the session? Especially in the “maintenance” phase of psychiatric treatment (where symptoms are relatively controlled, etc).

All of this applies equally to soda consumption or even diet in general. Drinking 2 liters of soda a day may not seem like a psychiatric issue, but most of the medications used have the propensity to increase appetite, and excess eating, smoking, soda drinking are hardly psychologically meaningless behaviors. If your psychiatrist asks you to keep a mood chart or teaches you about “serotonin dysfunction,” but doesn’t tell you to quit smoking, run. He has missed the forest for the trees.

4. Blame lawyers/insurance companies/Big Pharma

In order to understand why this is such a popular mistake among psychiatrists (all doctors, actually) it’s useful to identify when psychiatrists do this. There are two specific times. The first is when psychiatrists seek to justify doing, or not doing, some clinical maneuver, as in, “I can’t discharge him from the emergency room, even though I don’t really believe he is suicidal, I think he is lying simply to get hospitalized-- but I don’t want to get sued.” The second time is when psychiatrists seek to explain a reduction in income, as in, “The insurance company only pays so much for a visit, so now I do only med checks.”

What is striking about these justifications is that they almost never relate to the specific problem at hand, they are scapegoats for some general anger about the difficulty of practice. For example, in the example of the malingering emergency room patient, discharging him has no increased risk of legal liability because if the patient is, in fact, malingering, then he will not kill himself. The operational issue here is not one of increased legal liability, but whether a physician can detect malingering. This has nothing to do with lawyers.

In the second example, while it is certainly true that the insurance company has set reimbursement rates, psychiatrists have not explored their responsibility in this. They have not, in any scientific, economic, and most importantly policy way, justified the necessity for a different (read: higher) reimbursement scheme. Consider psychiatrists’ attitudes towards psychologists acquiring prescribing privileges. It seems obvious that psychologists shouldn’t prescribe medications, but why not, exactly? To say that psychiatrists are trained in medicine and better understand drug-drug interactions, dosing, and toxicities presupposes that the average psychiatrist actually does know about drug-drug interactions, dosing and toxicities. Really? What’s the interaction between Prozac and hydralazine? Don’t know? Then why should psychologists know? And if you can look it up, so can they, etc, etc. Also, using this reasoning could backfire, as it can justify an insurance company refusing to pay for a psychiatric med check since the service could be performed by a primary care doctor (who will also handle everything else for the same low price.) Again, it is easy to complain, but it is on psychiatrists to explain, rationally, why it should not be.

Consider the common complaint that each insurance company has its own formulary, requiring doctors to prescribe alternatives, generics, or submit prior authorization requests. This is taken as bureaucratic interference of patient care. However, in the majority of the cases these restrictions are economically and clinically valid. No logic, let alone evidence, exists for prescribing two antipsychotics simultaneously. So why should the insurance allow it? Similarly, an insurance company should be allowed to approve drugs based on cost, because unless one can show that, for example, two SSRIs do not have the same general efficacy or tolerability across a population, than an insurance company cannot be reasonably obligated to provide both, especially if it can contract to receive one of the SSRIs at a cheaper cost. To be clear: it may, in fact, be true that (for example) two antipsychotics are better than one. But the burden of responsibility is on psychiatrists to show that this (or any clinical) maneuver is necessary, and not on the insurance companies to simply trust that doctors know best, because they have shown repeatedly that they do not.

Blaming lawyers has almost become a sport. It is certainly true that uncapped awards for damages hurts everyone (except lawyers.) However, lawyers are good at picking malpractice cases, not at inventing them. Consider informed consent: if one prescribes valproate for maintenance, one must not only discuss the side effects, but also the alternatives to treatment-- especially when the alternatives to Depakote (a drug which has neither approval for maintenance nor rigorous data backing it) do have such approval and data (consider lithium, Zyprexa, Lamictal, etc.) To prescribe Depakote because it is at the top of an algorithm or in the “guidelines”, or because “that is my practice” and not because of a reasoned analysis of the individual merits of the case, is at minimum not thoughtful practice. A similar example is psychiatry’s current obsession with antipsychotic induced diabetes. Assume that Geodon does indeed have a much lower risk of diabetes than Zyprexa; is a psychiatrist any less liable if the diabetes is induced by Geodon and not Zyprexa? No. You don’t get sued for using Zyprexa. You get sued for causing diabetes and never picking it up.

To state explicitly what seems the most obvious point of all: if a medication causes a side effect, and you catch it, there’s no lawsuit, because there’s no damage.

The above examples come from misunderstanding the available scientific literature, or not knowing it at all. Oddly, if a lawyer does not research the current state of case law and statutes before answering any legal question, it is legal malpractice. But doctors practicing medicine are not required to review current journal articles on any medical condition.

Pharma is the most maligned of all. On the one hand doctors resent the intrusion of the industry on their practice; on the other hand, industry is the primary—often only-- ongoing educational source for doctors, whether they believe this or not. Drug reps, throwaway journals and supplements, “drug dinners” and almost all CMEs (yes, CMEs too, stop lying) are all industry sponsored educational processes which are the de facto continuing education of most psychiatrists. Oh, right, right-- doctors learn by regularly reading numerous journals carefully and thoroughly. Ok--ask them to name one article in the most recent issue of the American Journal of Psychiatry. Not the results of the study; just the title.

One may want to ask why the FDA feels it necessary to hold pharmaceutical reps to extremely strict standards: they cannot mislead, they cannot speak off label, they must discuss side effects and toxicities, and they cannot use any promotional material that was not reviewed by the FDA. Used car salesmen are not held to any standards, and they sell to idiots. No one needs to tell you the rate of blowouts on a Firestone tire. Why would doctors—the most educated consumer group in existence—need protection from salespeople? Shouldn’t doctors, ultimately, know more about the medications than the sales reps do? Unless…

The sad truth is that the state of psychiatry is the fault of psychiatrists, who have failed to take full responsibility for their own education and practice. To blame anyone else at this stage is remarkably disingenuous.

5. Become social policy analysts

Remember how in May, 2005, the American Psychiatric Association endorsed same sex marriage? And you applauded the moral fortitude and progressive instinct of this august body? Well, instead of debating whether there should or should not be same-sex marriage, perhaps we should ask what modern psychiatry could possibly contribute to this discussion. The answer is nothing.

You can't get away with pat answers, such as psychiatrists see the psychiatric ramifications of discrimination or being unable to marry. There are psychiatric ramifications of bankruptcy, and war, but no one felt compelled to write a policy statement on it (and thank God.)

And no, there isn't a difference between bankruptcy and gay marriage-- not to psychiatry. That's the point. These are social problems about which modern psychiatry is definitionally ignorant. The APA did not endorse polygamy. What's the difference? If homosexuality is not a psychiatric disorder, than there is no more reason to be more for or against it than there is for any other kind of marriage. The APA is no better suited to answering these questions than, say, the NFL.

What if the NFL came out against antidepressants in children? This is a perfectly valid analogy, because neither the NFL nor psychiatry have special knowledge that make their statements anything more than opinions. What do psychiatrists know about same-sex marriage that the quarterback for the Patriots doesn’t? Don’t laugh—I’m serious. What’s the answer?

Medicine, or the APA, can legitimately express a policy only if the policy was grounded in science or logic. Perhaps the APA cares to release this intriguing scientific data? (While it is at it, perhaps it can also release the data supporting the use of half of the medications currently favored by APA Guidelines?) But this seems pretty much business as usual for the APA. Rather than work on its own serious failings, it involves itself in social policy.

“Modern” (read: pharmacological) psychiatry is obsessed with reinventing itself as a biological and scientific discipline. Well, if it wants to be a science, it better start acting like one.

The FDA effectively killed Vioxx, and not a peep was heard from the APA about the dangers of letting the government regulate their practice. You can say Vioxx has little to do with psychiatry, but it’s still a lot more than gay marriage.

Determining what is true and what is not, through serious and often disconcerting scientific enquiry, is very difficult. It is much easier to involve oneself in matters of opinion and debate, in activism, because it is both immediately rewarding and it is easy. It’s hard to measure things in psychiatry, and when it is possible the results are often disappointing. So it busies itself with matters of conviction because it feels some responsibility to have convictions. It doesn't. It has a responsibility to the truth, and if it doesn't want to invest any energy in that pursuit, it is on them. But don't mask it with whimsy and dilettantism.

I should point out that gays, far from being pleased with the APA’s stand, should actually be horrified. Do you-- does anyone-- want social policy suggested by psychiatrists? Think long and hard.

Imagine the outrage if the APA had come out against gay marriage, or for the war in Iraq. There would be battalions of people saying, "well, what the hell do psychiatrists know about war in Iraq? Who the hell do they think they are telling gays not to get married?" There is no protection in being confident of the rightness of your current position, as history is loaded with examples of how terribly bad doctors are at determining what is right and what is wrong. Not long ago homosexuality was considered a disease. See? The Tuskegee experiments were endorsed by the AMA, and the AMA gave its endorsement, after ethics concerns were raised by Peter Buxtun. Remember that? How about the speech to the1941 APA meeting, and the 1942 issue of the American Journal of Psychiatry in which euthanizing the “feebleminded” (IQ<65)>

Psychiatry would do well to remember Wittgenstein TLP 7: Whereof one cannot speak, thereof one must be silent.

6. Don’t refer to therapy.

Psychopharmacology without therapy is treating an infection with Tylenol.

Medications do not cure a psychiatric disease; we’re not even sure what the disease actually is. What they can do is reduce symptoms, give you strength—so that you can learn new behaviors. That’s the point of medications. Treating depression with an antidepressant is not the solution; it’s the preliminary step in allowing you to figure out how to handle depression later on. The adaptation, the adjustment, the physical altering of brain functioning is done by new learning, often this is therapy (though it doesn’t have to be.) I’m not saying therapy is that great, or necessary, either. I’m simply saying that trying to improve a person’s long term status using medications alone without some sort of education and training is a waste of time. It is maybe the most profound disservice of all to tell a patient that their depressive or bipolar symptoms are the result of biology or chemical imbalances and thus absolve them of the responsibility of learning new ways of interpreting and coping with their environment.

7. Don’t think strategically.

Psychiatry is fun, I’m sure, but it doesn’t help anybody when the patient refuses to play. Psychiatry telling us opiate abuse is a heritable disorder related to polymorphisms in dopamine receptors doesn’t stop your kid from stealing your money to buy smack. See? Sometimes you have to hide your wallet.

What is the goal? What do you have to do to achieve that goal? Sometimes you have to look beyond the DSM.

Do what you have to do. When a person needs treatment but is refusing it, neither the law nor psychiatry can help them. I can’t force someone into treatment. But you can. Take drug abuse: in my experience, the only way to get someone to (albeit reluctantly) accept treatment is a large scale intervention. 10 people, minimum, in a cramped room with the future patient trapped as far form the door as possible, all ten in energetic agreement that the person needs to get help-- now. Not tomorrow morning. Immediately. You’ve already packed his bags. This isn’t a five minute pep-talk—take the whole day off, you’re going to be there a while. Also, a psychiatrist cannot do this for you, he shouldn’t even be there, because no one ever listens to neutral third parties, much less psychiatrists. (And I'll just say it: you probably don't want a psychiatrist there in case you...have to take things… to the next level...) It has to be ten highly motivated, concerned people. If you are not motivated enough to stage this uncomfortable intervention, I assure you he won’t be motivated to go. This is the kind of thing a psychiatrist should be telling you, not trying to sell you on Suboxone. Nobody likes confrontation or to be confronted. Ten people. Minimum. Sure, you are partly guilting them into treatment, partly coercing. But getting them into treatment in this way is better than not getting them into treatment in a nicer way. Psychiatry is war.

Sometimes people don’t need to know. If a person’s life is changed on medication, it may be okay not to tell them all the side effects. I know, lawyers are standing by (see # (blame lawyers), but again, it’s strategy, and I think reasonable people (i.e. juries) will understand what you were doing. If lithium keeps the person from slitting their own throat, it’s okay to skip the part about how it can hurt your thyroid. It doesn’t exempt the doctor from checking for it, mind you. In these tricky situations, a) you have to be sure this medication is absolutely vital; b) recruit as many people as possible into the therapeutic umbrella. Tell the wife about the side effect; tell family what to watch out for. And monitor. There’s even a technical term for this therapeutic privilege, but I can’t remember what it was.

Save the environment. Here’s an all too common scenario involving no strategic thinking: Your adult child is living at home, no job, sporadic drug use, involved in an abusive relationship, frequent quasi-suicidal acts, etc. You’ve tried everything, nothing has worked. You don’t know what to do. You’re afraid to kick them out because they can’t manage on their own, you’re afraid they’d sink deeper into drugs/depression/etc; but on the other hand you have other kids you have to worry about, a finite supply of money, etc, etc. You’re paralyzed.

Here’s a question you might not have thought about: what happens to the kid when you die? They are suddenly going to be without support, suddenly without money, suddenly without resources. Will they simply manipulate your spouse into getting their needs met? Or worse, go somewhere else? Is that what you want? Plan today, now, for this eventuality. Maybe that means setting up a trust with a finite monthly payout only if they are living on their own and have a paycheck. Or only if they are seeing a therapist once a week. Or give clean urines. “What is this, probation?” Actually, that’s exactly what it is.

You have to save the environment you are in before you can help the other person. That means protecting your wife and other kids, and their physical assets. It means protecting your marriage. It may seem cold to worry about money when your kid’s on heroin, but I assure you that this is the most important thing you can do if the kid won’t get help. Ripping apart your marriage over this benefits no one, absolutely no one. So yes, it may mean kicking them out of the house, cutting them off. It also means doing an intervention. It means holding your breath that that phone is going to ring in the middle of the night and it’s going to be the police. But letting them eat, sleep, and watch TV in your house while their chaos continues does not lessen the risk of receiving that phone call.

It’s called enabling. Don’t do it. And a psychiatrist should be telling you this, not trying to give you Celexa to help you cope with it.

8. Polypharmacy

Polypharmacy isn't just common-- it's the codified standard. When two psychiatrists discuss a patient, inevitably one of them will say these four words: “You should consider adding…”

The paradigm is that if you fail a medication, you must be so sick that you need a second medication.

It's a useful paradigm; and by useful, of course, I mean wrong. Here's an alternative paradigm: maybe if the medication didn't work, you should try a different one?

Polypharmacy would be ok if there was at least some data justifying it. But there isn't. I know, controversial. Look it up.

Consider antipsychotics: if anyone can provide the logic-- not data, simply the logic-- for using two simultaneously, I'd love to hear it. Antipsychotics work by blocking dopamine receptors, of which there are supposedly a finite number. If one antipsychotic blocks most of them, where is the other supposed to go? Why couldn't you simply increase the dose of the first? And if side effects prevent this increase, why wouldn't you just switch to the second medication?

Same with antidepressants: Zoloft and Prozac are SSRIs, they target the exact same molecule, which is again finite in number. If most are blocked by one drug, where does the second go? Why are you offended that Medicaid doesn't let you prescribe two at the same time?

So you say: well, what about mixing two drugs of differing pharmacologies, like Zoloft (serotonin) and Wellbutrin (dopamine/norepinephrine)? At least there is logic to this one, but--surprise- no evidence. It may seem as though Zoloft + Wellbutrin, or Depakote + an antipsychotic, etc is better than one alone, but they're not. But here’s the point: even if it were true, so what? How do you know it’s necessary? Shouldn't prudence and common sense and fiscal responsibility and the cramp in your writing hand require you to at least try monotherapy a few times? Twice, at least? Because I can't prove two drugs are better than one, but I can prove they are twice as toxic and twice as expensive.

Polypharmacy is bastard child of the theory of maintenance treatment. If it took three medications to get you feeling better, then you need to continue these three medications in order to stay stable. Going off your medications results in disaster.

First of all, no. Secondly, take the example of mania. If you're manic, and it took three medications to bring the mania down, does that mean you need those three for the rest of your life? Because if so, what do you do the next time you get manic? Add a fourth? Don’t you get used to medications? Does tolerance not occur? Upregulation and all that? You see the problem-- maintenance begats polypharmacy. Also, medications have side effects, and so medications are given for the side effects of the other

medications, ad nauseum. At some point (four medications?) the symptoms you are seeing cannot be reliably ascribed to the disorder rather than the medications themselves. The patient is buried. The treatment now becomes getting them off these medications.

Again: it may be true that an individual person needs several medications. But you can't make polypharmacy a generalized treatment standard. It's too expensive and has too many side effects for a theoretical benefit. And what kind of message does it send to the patient? If you're on four medications, how can you be anything but severely ill, all the time? How can you be responsible for any of your feelings, or for controlling them?

9. Diagnose everything

The layman’s argument is that psychiatry pathologizes everything: “well, anyone would be depressed in those circumstances. How is that an illness? And why can you get SSI for it?”

But the truth is in the nuances. When psychiatrists ask you to keep a mood chart, and you report that on these two days your “depression was worse,” what allows the psychiatrist to know that wasn’t normal sadness? Can a bipolar ever be sad for a month and not be depressed?

If a person beats his girlfriends, kills cats, and gets brought by the police because he set fire to a rival’s car, is it possible that his Axis I diagnosis is—nothing? Ok—how many times have you actually written that down? How many times have you terminated the “treatment,” or refused to uphold an involuntary commitment order, because the case was not psychiatric? I know, the system does not have a good mechanism for doing this. I feel your pain. But every time we give some vague “Not Otherwise Specified” diagnosis or pass them along to the inpatient services, we are creating a social policy disaster. We are confirming to the laymen that we think these behaviors are psychiatric, that they are rightfully our purview, and ensuring that a) we will be held responsible for dealing with them; b) we will be held responsible for the outcome.