Deficiency state, like diabetes
Return on investment unmatched
An essential utility service, with costs determined by need, plus 2%. This idea has yet to be sold.
Scandal each decade, inescapable. 1950’s: psychoanalysis; 1960’s: 90% schizophrenia diagnosis; 1970’s: hospitalizations for two years; 1980’s: recovered memory of abuse; 1990’s: “My husband’s got the bipolar;” 2000’s: left wing, PC elements; 2010’s: DSM V, a bookselling scam, and a disgrace.
Roughly 10% of kids have a serious condition, another 10% miserable but functioning.
Conduct disorder leads to antisocial personality disorder (most crime), marked increase in all social pathologies. Each criminal commits 100’s crimes a year. ADHD plus any bad habit, catastrophic, e.g. pyromania.
Out of home placement costs $300,000 a year
Medicalization, acceptance of scientific method (verification). Psychodynamic psychiatry gone.
New medications. Direct to consumer ads.
Factors increasing treatment: zero tolerance, and PC, lawyer attacks on authority outside of central government, regulation and litigation ending punishment
Structured interviews checklists of diagnostic criteria. Rating scales.
Target symptoms respond across diagnoses. Likely anatomically based. Anatomy = brain circuits.
Instrumental vs. affective aggression
Across settings. Difference between settings the most reliable indicator of (100%) failure to respond to meds.
Time of day variability
“Syndrome” from Sydenham (1624-1689)
Symptoms cluster. Symptoms reported by patient. Signs seen by doc.
Major: must be present
Implication: patho-physiology unknown
Risk factors: predate the syndrome, e.g. familial aggregation
Associated symptoms follow syndrome onset
Course of illness. Greatest value of syndrome is reliable prediction of future course. Otherwise, a way to communicate.
Problems with Current Syndromal Diagnosis in Psychiatry
19th Century superstitions (OK for that era). Kraepelin prevails.
Final common pathways
No replication of gene mapping for most familial condition, bipolar disorder
Political and fiscal considerations, subject to corruption.
FDA requires diagnosis, no target symptom permitted.
Sequence of Common Target Symptoms in Kids
No substance abuse, including caffeine. Puberty required to get high.
ADHD – stimulants, bupropion, alpha-adrenergic agonists, atomoxetine
Anger for no reason = irritability. Aripiprazole, other atypical neuroleptics, mood stabilizers
Dangerous acts, inability to function. Same sequence as anger.
Less Common Target Symptoms in Kids
Tics = twitches. Atypical neuroleptics.
Depression = sadness for no reason, and self Injury. Anti-depressants.
Anxiety = fear for no reason; compulsions = grooming for no reason. Antidepressants in regular and in high doses.
Psychosis = auditory hallucinations, delusions. Atypical neurolepticsOutpatient Approach
Start low, go slow, unless lonely.
Do not count on weight, because metabolism unknown
Pharmacokinetics – what the body does to the drug. Get logical blood level.
Pharmacodynamics – what the drug does to the body. Severe condition requires higher doses. Doses decrease with normalization.
Always grant patient request within a class. Nothing else has a chance of working.
Prior experiences likely repeated
Niches and Verispan
Substance abuse – quetiapine, ADHD meds
ADHD – no niches; sleep in ADHD – mirtazapine, clonidine
Anger – aripiprazole if under age 30.
Psychosis – risperidone, olanzapine, ziprazidone
Depression – no niche, add mood stabilizer, including anti-psychotics. Ziprazidone has anti-depressant properties, no hunger side effect. Should have a niche in depression.
Self-injury – anti-psychotics
Anxiety – no niche
The Non-Responder – Host Factors
Interference by other medications
Rapid metabolism (blood level) – pharmacokinetics.
Problems worsen same time of day, daily, meds running out
Problems worsen in same place but not others
Pharmacodynamics – unknowable today. Severity of illness.
Non-Response and Environment
Parental mental illness, criminality, substance abuse (no chance of improvement).
Single motherhood (diminished chance of improvement).
Non-adherence by parents
Substance abuse in adolescents (no chance of improvement).
Response to the Non-Responder
Second and third member of the class, especially if works by differing mechanism. If first helps 70%, the second will help half of the 30%, the third, half of the 15% remaining.
Add the member of another class, especially if target symptom atypical, or comorbidity accompanies
Revert to meds of the 1960’s
Clozapine for psychosis and mood disorder
Easy Psychopharmacology Mining
Off label large group tests, and in individual, on-off experiments.
Over the counter availability of low doses for mild conditions, and lower prices
End racial disparity of access
Patent term to 5 years, not 20.
Self-help to end plunder of clinical care, by land pirates. Deregulate research.
Deter single motherhood, and left wings attacks on family, school discipline, corporal punishment, other sources of authority, and structure
Demming approach to continual improvement, error reduction
Needs and Future Tools
Cool names for a) anger for no reason (not irritability); b) fearlessness disorder (opposite of anxiety)
Labs or PET scans of pharmacodynamics
First reliable gene locus
Identification of deficient neurotransmitter, location, by target symptoms.
Unsure if computers beneficial. Would permit data mining by clinician.Obstructions
Empiricism, contradictions to evidenced based medicine
Lawyer siege from all sides: self-dealing immunity to criminals, to insurance company, to regulators, to plaintiff lawyers, to violent patients (can’t be sued, charged, nor restrained). Ban FDA.
Difficult parent, battling parents with joint custody
Parametric statistics valid to predict larger population rates
Clinical care a series of on-off (works-does not work), single case design experiments, subject to binomial distribution
Garbage science per se, will change every two years
Written by academics, organization people, devoid of credibility. Often behind by years.
Rent seeking by docs, or crushing access by payer
Both oppressive to patient and doc
Verispan defines the national standard of care for $5000, local std for $9000. Use reflects insider knowledge of real time patient experience.
Number Needed to Treat (NNT) or to Harm (NNH). More clinical. Allows balance of risk of illness. If outcome of illness extreme, willing to accept higher NNT, lower NNH
MD chat rooms.
Number Needed to Treat, Needed to Harm (Side Effects)
More clinically meaningful. Counts events like a clinician. Implies real cost
Corrects for rarity (like a clinician)
Usually has two comparison conditions, drug vs placebo.
High NNT, low NNH OK if untreated outcome very bad.
Basic science discovery. Pharm exploitation
Clinical applications by desperate doc facing desperate patient. Most Rx off label
Clinical applications become ubiquitous
Academic submits grant proposal on ubiquitously successful application
Gets 1 in 9 approved.
Takes 4 years to complete.
Studies gathered in textbook, and by guideline makers, published two years later.
Research Applicability Problems
IRB from Fed regs, and an unapproved, uninformed, human experiment itself. Lawsuits. Make all legal research reviewable.
All non-clinical exclusion criteria violate central assumption of random selection.
Outcome measures continuous and irrelevant (scale scores)
No blood level to show any substance reached child’s brain
Inapplicability of parametric stats (continual) to on-off single case experiments described by binomial stats (like coin toss)
Doses too low due to FDA and IRB’s. Short term results.
IRB Legal Problems
Judged by competitors, with conflict of interest. (Intentional tort of interference with contract, subject to exemplary damages. To deter.)
Interference with Interstate Commerce.
Violates age discrimination, ADA.
Violation of Freedom of Association inherent in Free Speech Clause
Violates Thirteenth Amendment by interfering with adequate payment for subject participation.
Policy impact: drive out intelligent young people, decrease research, trivialize research, preclude useful negative outcomes. Telephone book thick consents useless. These are harmful effects.
There is no informed consent, not even by researcher.
IRB never considers central question of Nuremberg. Would the researcher be a subject? Exempt from review, if done.
Difficult Parents and Regulators
Others take consequences of treatment refusal.
Crazies, bullies, missing. (Total = ~5%)
Corporal punishment banned. Less restrictive than changing brain chemistry.
Court and lawyer intervention required, reporting for medical neglect if physical danger results.