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  • Avatar Dont_know_mind 
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    When you make the decision to go into psychiatry you make it knowing:

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    I’ll preface this post with the caveat that some of the most intelligent people I know and respect the most are psychiatrists.

    At the risk of throwing gasoline onto the fire (pun intended), the most negative stereotype folks from the other two parts of the brain medicine world (neurology/neurosurgery) seem to have about psychiatrists is the following: They function in a cognitive framework that is internally consistent and shrouded in its own lexicon, with some overlapping language (mostly related to either neurotransmitters, or anatomical words that aren’t simply related to the structures they refer to ‘limbic’/’frontal’/etc), but this framework does not have a well-articulated correspondence with the biological substrate (brain) that is the root of the disease. Psychiatrists then prescribe drugs to treat the framework, but these drugs have only limited efficacy and a lot of side effects because their widespread effects on the brain are not well-understood.

    My personal experience is that this stereotype is the one that is most infuriating to psychiatrists, and I suspect that there is some fundamental truth to it. However, given the complexities involved and how poorly we understand the brain network dysfunction that produce most psychiatric diseases, I do not see how it could be any other way. Psychiatry provides an incredibly important service and I feel that this will only grow, since the structure of our daily lives (and society in general) seems to be more and more adept at undermining the mechanisms that our brains evolved to reinforce decisions, actions, and outcomes.

    Is there a concerted attempt within psychiatry to integrate emerging systems neuroscience into the DSM structure (or vice-versa)? Isn’t there some truth to the accusation that psychiatric therapies for serious disease should integrate exercise and radical lifestyle change to alter how endogenous brain mechanisms are influenced by their environment? Isn’t this better than trying to accommodate people as they are with a heavy psychoactive drug regimen (not that it should be one or the other)? Wideopenspaces brought up diabetes and insulin, but as physicians we do encourage radical lifestyle interventions, including surgery, to bring down their weight and reduce their medication load.

    Anyhow, I hope that I have not offended, that is not my intent.

     

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    There are treatment centres where you get radical lifestyle interventions and interesting types of group therapy. It’s fascinating all the different group and psychotherapeutic treatments there are out there.

    I think biological Psychiatry is not alone in not being successful in treating what it is supposed to. I am skeptical and think a lot of back surgery and ENT tonsillectomies are not doing much either. I also think as a skeptical psychiatrist that a significant proportion of depression pharmacotherapy is not doing much either. I think the current classification systems are a dead end and it is a real problem for the field. Hopefully it can find a way around this.

    The neurobiology of attachment, cognitive biases, neurobiology of addiction, some of the work in this area is very interesting.

    DBS for anything other than very severe Parkinson’s I am skeptical of. It does seem to cause hypomania sometimes. There is still a lot of stigma about labotomies of the past, so DBS for mental disorders will probably not go anywhere. And for good reason, the drivers (localised theory of brain functioning) were also drivers of the earlier destructive neurosurgical solutions.

    I have no idea where things will go in the future. But it’s interesting to watch. I think it is ok to question everything.

    #196517 Reply
    Liked by childay
    Avatar FIREshrink 
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    ACPC, that does not offend me at all though I think you do not give enough credit in some cases. Some of our treatments are highly effective with minimal side effects, such as stimulants for ADHD. Lithium for bipolar is also highly effective though with more risks. Buprenorphine for opiate addiction is very safe and very effective. We also do routinely recommend exercise as the data is overwhelming it is as effective as medication in many situations (mild to moderate anxiety and depression). I do evidence-based psychotherapies every day (CBT, MI, IPT) and much of this is to help patients achieve “lifestyle change.” So let’s give credit where credit is due.

    Furthermore perhaps you overestimate our capabilities in physical medicine. Think in particular about chronic diseases such as IPF and terminal diseases such as ALS, and how limited our ability is to really reverse disease as opposed to manage disease. Think of the huge numbers of patients with unexplained physical symptoms. Think of how many diseases really don’t have a good explanation as to”why” the pathophysiologic cascade begins.

    You’ll get no argument from me that the DSM has major limits. It began as an attempt to standardize language, ie, when I say paranoid schizophrenia you knew what I was talking about. It evolved into a monster which now creates mental illness. There is rightful criticism of the process; Allen Frances, who headed the last DSM task force, wrote about this in his book Saving Normal. I use the DSM because I have to and because there is no alternative; nothing else exists. No superior tool has yet been created for the task. Surely you use less than ideal tools in your specialty, where technology is not where you’d like it to be.

    The limits of the DSM have been attributed to self-interest of the panel members, or to pharma influence, but the real cause is less conspiratorial: the brain is astoundingly complex, several orders of magnitude more complex than any other organ. We don’t have the data you’d like. Naturally there are ongoing efforts but it is painstakingly slow. The decade of the brain was thirty years ago! DSM V had every intention of incorporating neuroscience to a greater extent but it simply isn’t ready for primetime.

    I love what I do but there are elements which are definitely more religion than medicine or certainly science. But how much of medicine is directly evidence based? surprisingly little. So much of daily practice is grounded in experience, gut feeling, and personal preference. We just don’t like to admit it.

    #196545 Reply
    Avatar Antares 
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    When you make the decision to go into psychiatry you make it knowing:

    – you will get the crappiest office in the oldest building on campus, usually without HVAC

    – one of your med school attendings will tell you ‘it is a waste you are going into psychiatry’ and think it is a compliment

    – you will be asked by well-intentioned and concerned colleagues if it’s true that most psychiatrists have their own problems

    – your patients will be stereotyped and stigmatized, even by physicians, even in 2019

    Plus ça change, plus c’est la même chose.

     

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    Yes. On point. All of these have happened to me.

    #196553 Reply
    Avatar Antares 
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    To put it another way, regardless of the state of the field, regardless of our limited understanding of the neural underpinnings of psychiatric maladies, psychiatry is one of the more effective fields of medicine. Almost all of our patients improve with treatment, at a minimum.

    #196554 Reply
    Liked by childay
    Avatar Xeno 
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    But why do you think 30 percent of the population should not treat their medical condition with medication at some point in their lives? Why is it different than treating pain with pain medication? Or a bacterial infection with an antibiotic? **Why do you think mental illness should be different?**

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    I’m neither agreeing or disagreeing with @panscan but in my experience, those with mental illness will typically be on their medications for basically life whereas (most!) people with pain and infections will only be on those particular medications for a short period so those comparisons are probably not the best.

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    You know the research shows that in those with more than one episode of depression, staying on an SSRI for life decreases the chance of relapse by 70%? There’s a reason people stay on them long term. Not just doing it for funsies. I am not aware of similar data for antibiotics.

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    I sure hope there aren’t SSRI-resistance plasmids being formed by normal gut flora. When these are discovered, I’ll pay extra for SSRI-free meat.

    #196705 Reply
    Craigy Craigy 
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    To put it another way, regardless of the state of the field, regardless of our limited understanding of the neural underpinnings of psychiatric maladies, psychiatry is one of the more effective fields of medicine. Almost all of our patients improve with treatment, at a minimum.

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    Idk if that is really the case… in particular where nobody ever seems to be cured or healed, per se.  More like learn to live with your issues for the rest of your life.

    Of course that’s a fairly narrow-minded generalization, and exceptions apply, but from my layman’s perspective that’s how it appears.  Friends, family who see psychiatrists and other mental health professionals tend to be on a psychiatric dialysis for the rest of their lives, if you’ll excuse my rough analogy.

    If you were to say “psychiatry is one of the more effective fields of medicine for incurable diseases and conditions” I could probably buy that.  🙂

    LEVEL 1 WCI FORUM MEMBER.

    #196860 Reply
    Avatar Antares 
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    To put it another way, regardless of the state of the field, regardless of our limited understanding of the neural underpinnings of psychiatric maladies, psychiatry is one of the more effective fields of medicine. Almost all of our patients improve with treatment, at a minimum.

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    Idk if that is really the case… in particular where nobody ever seems to be cured or healed, per se.  More like learn to live with your issues for the rest of your life.

    Of course that’s a fairly narrow-minded generalization, and exceptions apply, but from my layman’s perspective that’s how it appears.  Friends, family who see psychiatrists and other mental health professionals tend to be on a psychiatric dialysis for the rest of their lives, if you’ll excuse my rough analogy.

    If you were to say “psychiatry is one of the more effective fields of medicine for incurable diseases and conditions” I could probably buy that.  🙂

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    I don’t see it quite that way, though I’m probably biased by my own practice. For the chronically mentally ill, we are not stamping out mental illness. But we help people both to improve and to manage their illnesses. But for many others, I see people who need short term help, and leave in much better shape.

    That said, I’d agree with you that pretty much all humans are better off learning to accept with grace and equanimity whatever their burdens are…

    #196864 Reply
    Liked by Craigy
    ACPC ACPC 
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    Some of our treatments are highly effective with minimal side effects, such as stimulants for ADHD. Lithium for bipolar is also highly effective though with more risks. Buprenorphine for opiate addiction is very safe and very effective.

    Furthermore perhaps you overestimate our capabilities in physical medicine. Think in particular about chronic diseases such as IPF and terminal diseases such as ALS, and how limited our ability is to really reverse disease as opposed to manage disease. Think of the huge numbers of patients with unexplained physical symptoms. Think of how many diseases really don’t have a good explanation as to”why” the pathophysiologic cascade begins.

    I love what I do but there are elements which are definitely more religion than medicine or certainly science. But how much of medicine is directly evidence based? surprisingly little. So much of daily practice is grounded in experience, gut feeling, and personal preference. We just don’t like to admit it.

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    FIREshrink – I appreciate your candor and honest assessment. You do seem like the kind of doctor I would want personally or for my family. However, I disagree with a few things you’ve said:

    – I’ve seen many kids on stimulants for ADHD, both in the US and Europe, who were essentially being treated for being little boys who didn’t like to sit in class for hours at a time (i.e. a common personality type being defined as a disease). Putting them on stimulants has long term neurological consequences (https://doi.org/10.1016/j.nicl.2017.06.003) and also behavioral consequences – they learn to function/socialize in a drugged state during a key portion of their growth, short-circuiting necessary socialization skill development.

    – Lithium is a hard-core therapy with a lot of large effects all over the body. Neither its mechanisms nor its targets related to bipolar are understood, and so it has not been refined to a more specific therapy despite 70 years of use.

    I would argue that a whole lot of medicine IS well understood and evidence-based, and everyday incrementally progresses towards better characterization and more principled intervention. Most diseases DO have a good explanation for why the pathophysiological cascade begins, right down to the gene(s) involved. Think about infectious disease – we not only target specific weaknesses on the infectious agents, but we also target human susceptibilities to them (even at the receptor level for HIV now). For what we don’t understand, our diagnostic and medically-scientific framework provides us with a path to better understanding and more targeted therapy. My concern is that psychiatry is structured (via the DSM) in a way that is divorced from neuroanatomy and neuroscience — the path to understanding and more targeted therapy lacks a coherent framework. I wonder whether the future of psychiatry will emerge as a branch of neurology rather than as a progression from today’s psychiatry.

    In many specialties, “experience, gut feeling, and personal preference” are steadily chipped away at every day. In my field, post-operative antibiotics have reduced use by protocol. More invasive procedures have given way to less invasive procedures or non-operative alternatives because of better understanding of the underlying disease and access to better technology. Although, as one commenter above noted, spine surgery grows and grows, pushed by an economic tide and disregarding evidence that less surgery would be better.

     

     

    #197221 Reply
    Liked by Lordosis
    Avatar Peds 
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    – I’ve seen many kids on stimulants for ADHD, both in the US and Europe, who were essentially being treated for being little boys who didn’t like to sit in class for hours at a time (i.e. a common personality type being defined as a disease). Putting them on stimulants has long term neurological consequences (https://doi.org/10.1016/j.nicl.2017.06.003) and also behavioral consequences – they learn to function/socialize in a drugged state during a key portion of their growth, short-circuiting necessary socialization skill development.

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    whoa whoa whoa. slow your roll.

    #1- your study is based off 29 ppl “This resulted in a final group for the Glx analyses of 38 subjects at baseline and 29 subjects after the MPH challenge.”

    i dont think you want to be shouting from the rooftops yet.

    #2- the whole basis of your study is that in rats, GABA+ is changed by stimulants. they go on to say that the basis of doing a post challenge MRI is that  “Also, a single administration of MPH increased GABAergic neurotransmission in healthy mice”. but in the discussion, the first problem is “In stimulant treatment-naive ADHD subjects, such increases in estimated GABA+ levels were not observed after an acute MPH challenge.”

    so wait. the point of the study is that in HEALTHY PEOPLE who have NEVER BEEN EXPOSED that we can CHANGE GABA LEVELS………in rats. but not humans.

     

     

    do you have anything else you think is worth submitting?

    #197290 Reply
    ACPC ACPC 
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    Status: Physician
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    Joined: 12/31/2018

    Aside from the all-caps and ad-hominem condescension, thank you for taking the time to think about this and looking at the reference. I think you might want to take a second look.

    A closer reading of the text would show that the primary experimental results were: 1) adults with ADHD who were treated with stimulants as children showed medial prefrontal increases in GABA following stimulant administration, whereas 2) adults with ADHD who were or were not treated with stimulants did not show this GABA increase. Brief relation to rodent studies in the introduction and discussion is (in my opinion) irrelevant to these findings one way or another, and not consequential for interpretation of the result. Also, 29 relevant patients from 3 matched groups in a quantitative MR paper is not so few, as within-patient effect size plays a significant role in the determination of significance.

    In the setting of what I was trying to ask about it being difficult to associate psychiatric disease and intervention with specific neuroanatomic/neurophysiologic substrate, I thought that this study at least (by construction) assessed specific neurotransmitters in a specific brain region.

    There are other relevant studies one might find, but I think that is tangential to the purpose of my post.

    #197329 Reply
    Avatar Peds 
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    Aside from the all-caps and ad-hominem condescension,

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    because i think your statement is actually dangerous. nothing in medicine supports your conclusion. it is irresponsible of you to think that:

    Putting them on stimulants has long term neurological consequences (https://doi.org/10.1016/j.nicl.2017.06.003) and also behavioral consequences – they learn to function/socialize in a drugged state during a key portion of their growth, short-circuiting necessary socialization skill development.

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    let alone promote it.

    Also, 29 relevant patients from 3 matched groups in a quantitative MR paper is not so few,

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    since when has a 29 patient group completely changed current management of care in one of the most common childhood disease categories?

    There are other relevant studies one might find

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    again, i asked you to cite.

    #197335 Reply
    ACPC ACPC 
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    Joined: 12/31/2018
    because i think your statement is actually dangerous. nothing in medicine supports your conclusion. it is irresponsible of you to think that:
    … let alone promote it.

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    Exactly how can I make a statement as an anonymous poster, to another anonymous poster, on a financial site, that is dangerous? How can my thoughts be irresponsible? – actions and authority define responsibility (my posts make it quite clear that I’m not a psychiatrist). Why would you say that nothing in medicine supports my conclusion, when I made a statement about my personal experience? Exactly what am I promoting?

    since when has a 29 patient group completely changed current management of care in one of the most common childhood disease categories?

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    This is a complete non-sequitur. Who argued that this article should be the basis for changing care?

    again, i asked you to cite.

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    With demeanor you’re presenting, why would I care what you ask? And as I said, I think it’s tangential to the purpose of my post.

    #197342 Reply

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