Sunday, 21 September 2014

IS EVIDENCE-BASED PSYCHIATRY ETHICAL?

Mona Gupta has launched a full frontal assault on evidence based-medicine in her provocatively titled book "is evidence-based psychiatry ethical?"

Gupta, a psychiatrist at the University of Montréal and a former faculty member at McMaster's Department of Psychiatry, has a particular interest in bioethics and epistemology.

She combines her interests in psychiatry and philosophy to compose a razor-sharp and penetrating critique of evidence-based medicine (EBM), particularly as it applies to the practice of psychiatry.

Gupta undertook a qualitative study involving analysis of the primary texts of evidence-based medicine and interviews with many of the developers of EBM , mental health practitioners, and scholars who have studied philosophical and ethical aspects of EBM.

She pointedly asserts that there is no "evidence" that evidence-based medicine does what it claims to do i.e. lead to improvements in health outcomes.

Gupta dissects some of the implicit assumptions and values of EBM. She draws attention to some of the problems related to medical research: biases that derive from the social context and research culture; assumptions about what constitutes evidence; the impact of the sources of funding on research outcome; and publication bias.

She goes on to question the accepted wisdom regarding the hierarchy of evidence. She notes that "we're only able to measure what we are able to measure." Much evidence is automatically excluded if it does not fit a paradigm that is essentially derived from internal medicine.

With regard to psychiatry she argues that randomized controlled trials may be applicable to medication studies, but are too narrow a methodology to embrace the complexity of psychiatric practice.

"… The narrative structure and meaningfulness of personal experience are essential components of living with a mental disorder and, in particular, psychotherapeutic treatment of mental disorders. Mental states are complex, subjective experiences and these may be resistant to measurement, at least in the manner envisioned by EBM." (p.94).

Psychiatric research may have to be broader in scope and include subjective and intersubjective experiences that are not captured in the EBM paradigm. Even the definition of treatment outcomes is arbitrary and infused with implicit values as to what is most important both for individuals and groups. 

The patient's perspective is not taken into account i.e. which types of outcomes are most important for a particular patient. Is it changes in subjective feelings, meaning, and relationships or is it symptom change?

The author considers a number of other factors that may make EBM less suitable as a framework for psychiatric epistemology. The types of evidence accepted by evidence-based medicine do not take into account the range and depth of the experiences of mental disorders and more alarmingly may in fact lead psychiatrists to false beliefs about the effectiveness of clinical interventions:

"EBM's evidence is shaping our understanding of the nature of mental disorders and how we should intervene. This revision of psychiatry's subject matter has arrived on the coattails of EBM, and points to EBM's enormous influence: from shaping the conduct of research, to determining which interventions are deemed acceptable for consideration in clinical decision-making and even to redefining the object of inquiry. EBM is not only changing our approach to researching mental disorders, it is changing psychiatry itself by influencing how we understand mental disorders, and thus the tasks of psychiatrists." (p.113).

References:
Mona Gupta. Is evidence-based psychiatry ethical? Oxford University Press 2014.

Sunday, 29 June 2014

FINDING THE TRUE SELF IN JAMES SALTER'S NOVEL OF LOVE AND LOSS


 All great novels illuminate the human condition. By identifying with the characters of a story we experience as real what is fictionally portrayed.

James Salters erotic love story "A Sport and a Pastime", first published in 1967, is a classic exemplar of this.
Written in lyrical prose and set in rural France it unfolds the intoxicating love affair between an American university dropout and a young French woman.

The title is taken from a verse in the Koran:

"Remember that life in this world is but a sport and a pastime".

It is a tale of love, attachment, separation and loss that unfolds the relationship between Phillip Dean and Anne-Marie Costallat. The relationship becomes increasingly intimate and passionate yet is recounted in subtle and delicate tones.

One senses in the desperate longings of the young couple that they sense that this cannot last. Somewhere the sinister forces of Providence will gain the upper hand and bring the dream to a heart-breaking finale.
And indeed the couple must separate. The departure scene rivals that of Bogart and Bergman on the runway in the movie Casablanca:

"...a minute or two until the warning whistle.......the train begins to move. It picks up speed very quickly. I can see him waving....in that instant I think of her solitary, her head bent forward to the morning's work.......I cannot imagine what she feels. I can only sense it by her absolute, her utter silence as the train curves, crosses the viaduct high in the morning air."

And at the conclusion the narrator adds:

"Silence. A silence which comes over my life as well.......the fields are becoming dark, the swallows shooting across them......"

Yes the story is a universal one but told with great delicacy and poignancy. It touches our nostalgic longings for things lost, an idealized past. The narrator captures our fickle memory and the distortions we are prone to:

"Certain things I remember exactly as they were. They are merely discolored a bit by time, like coins in the pocket of a forgotten suit.....one alters the past to form the future. But there is a real significance to the pattern which finally appears, which resists all further change......the myriad past, it enters us and disappears. Except that within it, somewhere, like diamonds, exist the fragments that refuse to be consumed. Sifting through, if one dares, and collecting them, one discovers the true design".

This passage could be taken as an illustration of the  psychotherapeutic journey: the narrative reconstruction of the past in the service of a renewed future, the discovery of the true self.

Sunday, 4 May 2014

THE "AS IF" PERSONALITY

In a wonderful paper published in the Psychoanalytic Quarterly in 1942 Helene Deutsch describes an unusual personality type that she refers to as the "AS IF" personality.

Deutsch says that these individuals convey the impression of complete normality on the surface. They are intellectually intact and gifted. However on closer  observation it becomes  apparent that their "relationships are devoid of any trace of warmth, that all the expressions of emotion are formal, that all inner experience is completely excluded."

Helene Deutsch completed medical training in Vienna. She became interested in psychoanalysis and in 1916 she went to work with Sigmund Freud and underwent an analysis with him. In 1935 she left Europe and moved to Boston and worked at the Massachusetts General Hospital. Deutsch was a pioneer in exploring female psychology with a particular emphasis on female sexuality and motherhood.

In the article she states that these individuals behaved "as if" they had real feelings and emotional relationships. Deutsch compared them to actors who are "technically well trained" but cannot impart any sense of vitality to the role.

She described these patients as being extremely passive and having a "plastic readiness" to identify with other people's feelings, beliefs and ideologies. Their relationships lacked genuine emotional connection and felt hollow and devoid of real meaning.

Such individuals have no consistent moral or ideological beliefs. Rather their values and positions are taken from those to whom they attach and identify with.

Patients with "AS IF" personalities do not display aggression but rather present with a "mild amiability". They are prone to conform and on the surface are compliant and obedient.

Such individuals can be drawn into antisocial or criminal groups. There is no internalized conscience/superego. The AS IF personality completely identifies with external objects. They transiently take on the values and morals of the other person or the group. The authority for moral decisions only exists externally. The AS IF personality goes along with "the crowd".

The AS IF personality as described by Deutsch shares features in common with many patients who would now be diagnosed with borderline personality disorder. Borderline personality disorder is characterized principally by emotional dysregulation. The problem is too much unregulated emotion.  The AS IF personality's lack of emotion and the borderline's unstable emotion both give rise to an inner deficit in the sense of identity. In order to develop and maintain a consistent sense of identity one needs to have a predictable pattern of emotional responsiveness."

The parents of one of Deutsch's patients were described as remote and uninvolved. They showed no warmth or tenderness. The child's care was delegated to a series of different nurses and governesses. In today's language we would say that the patient did not have consistent attachment figures in her life and did not develop a secure attachment. Deutsch says that throughout her life this woman was never able to establish an emotionally warm or loving relationship.

References:
Helene Deutsch. Some Forms of Emotional Disturbance and their Relationship to Schizophrenia. The Psychoanalytic Quarterly  1942 (11) 301-321.
Alan Eppel. Formation of Identity in "Sweet Sorrow Love, Loss and Attachment in Human Life" 2009. p.27-35.

Sunday, 9 March 2014

New Consensus on Antidepressants in Bipolar




The International Society for Bipolar Disorders recently released the findings of a task force on the use of antidepressants in Bipolar Disorder. The evidence continues to accumulate that antidepressants alone and in combination with mood stabilizers have a very small role if any, in the pharmacological management of bipolar depression. There is increasing acknowledgement that antidepressants can be harmful. Antidepressants can lead to longterm mood instability, cycle acceleration, mood switching, mixed states and increased risk of suicide.

The results summary of the task force appears quite clear:

"There is striking incongruity between the wide use of and the weak evidence base for the  
efficacy and  safety of antidepressant drugs in bipolar disorder. 
Few well-designed, long-term trials of prophylactic benefits have been 
conducted, and there is insufficient evidence for treatment benefits with  
antidepressants combined with mood stabilizers. A major concern is 
the risk for mood switch to hypomania, mania, and mixed states..."

However the conclusion summary is a little more ambiguous:


"Because of limited data, the task force could not
make broad statements endorsing antidepressant use but acknowledged 
that individual bipolar patients may benefit from antidepressants...."
 
Undoubtedly this was the result of the need to reach 
consensus among several dozen international experts.It remains very difficult for some psychiatrists to 
concede that antidepressants do more harm than 
good because this is superficially counterintuitive. It is also hard to admit that one's longstanding clinical 
practice may have been erroneous.


Reference

The International Society for Bipolar Disorders (ISBD) task force report on
antidepressant use in bipolar disorders.


Am J Psychiatry. 2013 Nov 1;170(11):1249-62

Monday, 27 January 2014

HOW TO COMBAT STIGMA



1. Reduce the fear of difference

2. Provide education about mental health and mental illness in the schools.

3. Encourage those affected by mental illness to go public, especially celebrities and high profile individuals who can make an impact on public opinion.

4. Appoint individuals who have experienced mental illness to boards of hospitals, community agencies and mental health programs.

5. Challenge the media. Write to editor's, call television stations and comment on social media when there are inappropriate references or stigmatizing portrayals of people with mental illness.

6. Promote the restoration of the person's wholeness, subjectively and objectively, by facilitating their multiple roles, emphasizing that the person is not an illness but has an illness.