I recently heard parts of a lecture by a healthcare provider (not a psychiatrist), who was speaking to a group of general practitioners about psychiatry. She answered questions about the best approach for treating depression, anxiety, and other psychiatric disorders by relating anecdotes from her own experience and suggested by her favorite mentor. “Add a little of this, and if that doesn’t work, try adding some of that” she said. “Psych is all a gray area. You can be creative.”
J.T. Junig, MD, PhD is a Psychiatrist and PhD Neuroscientist in solo, private practice in NE Wisconsin. I treat adults, children and adolescents for all psychiatric conditions, with an emphasis on improving the strength of the doctor/patient relationship through longer appointments, greater access, and frequent e-mail communication. I teach psychiatry at the Medical College of Wisconsin, and provide psychiatric servicies for the U of WI Oshkosh Campus. Finally, I provided expert witness testimony for a wide range of cases related to psychiatry, neurology, addiction, and chronic pain. I am Board Certified by the American Board of Psychiatry and Neurology, and lifetime-Board Certified by the American Board of Anesthesiology.
Editor: Saad Shaheed
Now THAT’S crazy. Her recommendations, sadly, will likely be followed in a number of actual patients. No wonder patients coming to treatment often have a distrust for psychiatry, or a sense of being a ‘guinea pig’ during earlier treatments for psychiatric conditions.
At some point over the past decade, we began using the term ‘evidence-based medicine.’ The term is likely over-used for marketing purposes, but the original concept of evidence-based medicine is of great value, particularly in psychiatry.
Medical scientists, i.e. practitioners who have training in conducting and interpreting scientific research, know the risks of letting personal experiences guide treatment approaches. They know that human beings have a natural tendency to assign greater importance to personal observation than to the experiences described by others, even if the personal observation involved one patient, no blinding, and no control group. Even people with advanced degrees, who recognize the value of blinded studies and appropriate control groups, tend to rationalize that they know, in THIS case, that their observations are valid.
Evidence-based medicine encourages practitioners to ignore their own experience, and to instead anchor practice patterns to those supported by peer-reviewed research. Practitioners should know the difference in predictive value for comments by a mentor, the findings in a case report, and the results of a large, prospective clinical trial. Practitioners should appreciate the perils of using their knowledge of basic science to extrapolate findings from one set of conditions, to a case where some variables differ.
These distinctions are especially important in an era where insurance companies increasingly try to influence treatment patterns. For example, there is considerable evidence that Abilify effectively augments the antidepressant effects of SSRIs. Insurance companies often refuse to cover Abilify, instead demanding substitution with risperidone, a less-expensive medication from the same general class of ‘atypical antipsychotics.’ But there is no good evidence that risperidone provides any benefit for depression. There are a number of similar situations where insurers require ‘prior authorization’ for the treatment best-supported by clinical evidence. Many insurers even require a period of treatment failure with a bad medication, before they will consider the best medication. Insurers would argue that they recommend medications that are much less expensive, at the cost of ‘minor’ side effects. But practitioners who use evidence-based approaches to treatment know that the insurer’s medication selections are influenced by cost to a much greater extent than efficacy.
Back to the original discussion, those who practice evidence-based medicine know that someone who views psychiatry as a ‘gray area’ is someone who didn’t have a strong education in psychiatry or neuroscience, and who doesn’t read much of the psychiatric literature. To a Board Certified Psychiatrist, the field of endocrinology is a ‘gray area.’ But when treating depression, the psychiatrist knows—or should know– that adding a ‘one milligram sprinkle’ of Abilify has no scientific basis for treating major depressive disorder, whereas a dose between 2 and 15 mg has been effective in controlled, clinical trials. Nothing gray about it.