Hi all,

I posted these responses in the "Realities of Psychiatric Disease" thread on the gen res forum, but I think I may have inadvertently killed the thread in doing so...so I thought I'd repost here and see what you all thought.

In a nutshell: has psychiatry become reduced to not much more than a branch of pharmaceutical science, as some people say?

What do people think of psychiatrists like Peter Breggin, who has written extensively about the damaging consequences of psych meds?

I think Breggin's take on the issue is extreme, and I am NOT arguing against pharmacotherapy (certainly not in seriously ill populations anyway,) but I am wondering how the future generations of psychiatrists might be able to reclaim some ground that belonged to them historically and expand the field once more to include other kinds of valid (scientifically validated, if possible) non-pharmacologic therapies and interventions to the end of greater mental health and well-being.

And what about the notion of preventive psychiatry (which might include mediation training, stress management, mindfulness, diet and exercise, education, family counseling...)?

Anyway, here is a distillation of the posts:

"Desperado makes a great point about the problem of psychiatrists getting little or no reimbursement for non-pharmacologic treatments--how can psychiatry and the pharmaceutical industry NOT be seen as bedfellows when this is the case?

The movement among the general public to question the ties between psych and the pharm industry, seems, in some circles, to have cast doubt on the entire profession. If psychiatry could cultivate a more reputable standing among coming generations of patients and providers and public, might it not even go some way towards reducing the stigma of mental illness? It might at least make some people less reluctant to seek help from psychiatrists...

Demanding (better) reimbursement for psychotherapy done by psychiatrists could be another means to maintaining/enhancing the integrity of the discipline. This may be more likely to succeed as more and better quality research is done to demonstrate value and cost-effectiveness of such treatments.

Both NPR and The New Yorker recently have covered therapies that are in widespread use in the US (generally via practitioners who are not psychiatrists, it seems) that have not been proven to work--namely the anger management industry and a certain division of the grief counseling industry--and are now being scrutinized more closely for their effects (or lack thereof.) It's amazing and unfortunate how such practices can become widely accepted (ie: actual industries!) without evidence that they are of any real value. As these topics were covered by general media outlets for a largely lay audience, I wonder if this does not reflect some growing cultural eagerness to sort out what does and doesn't work in the realm of mental health care, and--rightfully so--to find greater accountability and assurances of efficacy.

This just makes rigorous study of psych therapies (and dissemination of the findings and close adherence to the practice guidelines that will come out of such findings, inasmuch as one can do that in psychiatry) that much more critical.

Part of the reason our health care system continues to be so screwed up is that people think things have to be the way they are."


Would love any comments or ideas you have about the future of psychiatry...!!

nobody can predict any field of medicine. some people say that CT Surgery is going to die out with cardiologists becoming more interventional and able to do more. I just don't think so.

Originally posted by gyri

In a nutshell: has psychiatry become reduced to not much more than a branch of pharmaceutical science, as some people say?


Nope, most psychiatrists went into psych because of the opportunity to talk to their pts and get to understand them better. Otherwise, if we want pills, we could have gone into internal medicine. If we simply want to work with the marginalized sector of the society, we could have pursue ID fellowship and focus on HIV.

Originally posted by gyri

What do people think of psychiatrists like Peter Breggin, who has written extensively about the damaging consequences of psych meds?

sorry, don't know his work too well.

Originally posted by gyri

I am wondering how the future generations of psychiatrists might be able to reclaim some ground that belonged to them historically and expand the field once more to include other kinds of valid (scientifically validated, if possible) non-pharmacologic therapies and interventions to the end of greater mental health and well-being.



Psychiatrists have not lost much ground (except in New Mexico and Indiana with prescription rights). However, psych MD can still do and bill for psychotherapy. It is just a matter if you want to or not. There are psych residents who graduate and enter psychoanalytic programs and will become mostly psychoanalysts or use psychodynamic psychotherapy only. Therefore, it is a matter of personal preference.

As for more non-pharm approach, there simply needs to be better research. It is hard to recruit and retain psych pts. It is even harder to have good enough end-points and measurements that apply across different studies so you can compare them. But that dependes on the future psych MD's to figure out.


Originally posted by gyri


And what about the notion of preventive psychiatry (which might include mediation training, stress management, mindfulness, diet and exercise, education, family counseling...)?


Those things are best not taken up by psychiatrists. the problem with mental health is that it is a spectrum. psych MD usually deals with the mentally illed and if you are not careful, you will be stepping into the norms. I don't know if I agree with that because most of these issues are what all the "self-help" books are about.

In a way, it is similar to psychoanalysis because analysis has become just a cultural phenomenon that people are using it in film analysis, self-help, writings, or other stuff. I am sure that psychoanalysis has a place in curing the mentally illed. But most of the stuff out there are not related to that. In the end, people might undergo psychoanalysis because of lifestyle (i.e. I have somebody to talk to every week and I cannot live without them. I am willing to shell out $150/hr every week because of that and even though I am technically not mentally ill).

Hi all,
An interesting research(?) which shows why psychiatry is so controversial.
http://www.guardian.co.uk/weekend/story/0,3605,1134329,00.html
BTW we don't have to defend bad practice of psychiatry.

mdblue,

Great link! Fascinating stuff.

Thank you for the link MD Blue. It is important to find out how the public views psychiatry, especially those that have experienced bad medicine. I added a link below for a website created by a group of people that have experienced mistreatment from the mental health industry. As future psychiatrists, we need to listen to the voices of the people we hope to care for. I think we can do a BETTER job in the care of the mentally ill in America.

http://www.freedom-center.org/index.php

just testing...

Great topic...

The future of Psychiatry is bright. As with any field of medicine, we are going to take our hits. There are many things we should do to help our field as well as the overall field of medicine. I was reading an editorial by Henry Nasrallah, MD not too long ago. He talked about his "rants," about the field in a humorous way, and he was 100% spot on. One of the major points that he mentioned and I agree with is as follows:

---We've trained ourselves, and our patients to think of every other specialty as the "real MD's." "Have a headache? Go see your Medical Doctor...." At least from looking at my diploma on the wall, I have an MD as does everyone else here (DO's included). Why do we refer to ourselves as less than a Medical Doctor?

We allow management, nurses, patients, to marginalize and refer to us as "psychs." More and more patients confuse us with psychologists. I encourage everyone to find your own personal style when addressing this with patients/staff. Personally, I tell patients that I'm referring them to their Family practioner, internist, cardiologist, etc. We need to maintain the link of Psychiatry branded with Medical Doctor, and nothing less than that.

I hope I didn't deviate too much from the topic of this thread.... it does deal with the future of psychiatry...

^Not sure if it's in here, but a number of his articles seem relevant to the topic. Thanks.

http://www.currentpsychiatry.com/CollectionContent.asp?CollectionID=35&UID=

---We've trained ourselves, and our patients to think of every other specialty as the "real MD's." "Have a headache? Go see your Medical Doctor...." At least from looking at my diploma on the wall, I have an MD as does everyone else here (DO's included). Why do we refer to ourselves as less than a Medical Doctor?

We allow management, nurses, patients, to marginalize and refer to us as "psychs." More and more patients confuse us with psychologists. I encourage everyone to find your own personal style when addressing this with patients/staff. Personally, I tell patients that I'm referring them to their Family practioner, internist, cardiologist, etc. We need to maintain the link of Psychiatry branded with Medical Doctor, and nothing less than that.

I hope I didn't deviate too much from the topic of this thread.... it does deal with the future of psychiatry...

I believe we have to look at ourselves, in a lot of cases, to blame for this phenomenon. Where I trained and is now practicing, many of my colleagues, current psychiatry trainees, and medical students often tell patients to go see their medical doctors and we as 'psychs'.

The acronym is here to stay, however, just like GI, ID,optho, ortho, neuro, etc....

I suppose things can be a lot worse than being confused with psychologists, whom are well trained people themselves. And interestingly they call themselves 'psychs' too.

I do try to correct trainees/juniors whenever I can but alot of psychiatrists I've met seem to have an aversion to anything medical and don't see themselves as medical doctors. Probably aversion to general medicine is the main reason why they had pursued psychiatry in the first place.

I believe we have to look at ourselves, in a lot of cases, to blame for this phenomenon.

Agree. I remember as a resident, I tried, several times in vain, to talk my attending out of a medical consult for a BP on the order of 135/82, with only one reading done, citing "hypertension."

One problem I've encountered is most insurance companies only want us doing psychiatry and will not cover our practice outside the psychiatric. I mentioned this in another thread, but a PCP I've worked with was delivering below the standard of care practice, and I was readily able to detect this. I attempted to bring this up to the PCP's attention, but he ignored my calls.

(e.g. cholesterol is > 300, and there's no statin, and no recommendations from the PCP to use diet and exercise. When I informed the patient of his cholesterol (and the PCP did not do this), the patient said he would've liked a cholesterol-lowering medication. I already changed his meds from Zyprexa to Abilify with no problem and his cholesterol remained elevated).

I too, have noticed my medical skills somewhat waning. I noticed myself rusty on the name of that pediatric disorder where the intestines are outside the body, I don't remember which fungi are in which are of the country etc.

I however, believe I'm still very sharp on disorders that are seen in primary care and regularly encountered by psychiatric patients who are not following their own health, and it's only because I've decided to continue monitoring on the medical side what's going on with the patient in addition to their PCP.

One problem I've encountered is most insurance companies only want us doing psychiatry and will not cover our practice outside the psychiatric.

(e.g. cholesterol is > 300, and there's no statin, and no recommendations from the PCP to use diet and exercise. When I informed the patient of his cholesterol (and the PCP did not do this), the patient said he would've liked a cholesterol-lowering medication. I already changed his meds from Zyprexa to Abilify with no problem and his cholesterol remained elevated).

I too, have noticed my medical skills somewhat waning. .

Yes, generally one needs 3 years of internal medicine or general pediatrics or FP in order to get malpractice insurance coverage for practice outside our specialty. We're not covered for gen medicine issues just as optho, ortho, radiology, derm, etc people can't either. Unless they did 3 years of the aforementioned residencies before specializing. We can continue or discontinue current medications but can't start new treatment.

I once faxed a lipid panel of chol 330, ldl 170 hdl 25 to a FP. Pt has BMI of 29. Patient says his FP looked at it and says 'you're fine, keep up the good work".

Just as the surgeons, cardio, endo, ped, rad, anes etc forget their general psychiatry; we tend to forget their materials too. Especially the zebras. I am, however, keep myself up to date with the bread and butter general medicine/ped knowledge largely because I encounter these issues everyday. They do factor into my treatment/asessment planning. Additionallly, patients and parents will ask me questions about their physical health. Patients seem to like the holistic approach (supportive therapy, medication, general medicine issues) on every visit.

Yes, generally one needs 3 years of internal medicine or general pediatrics or FP in order to get malpractice insurance coverage for practice outside our specialty. We're not covered for gen medicine issues just as optho, ortho, radiology, derm, etc people can't either.

Great points, and I do agree that we are part of the problem in regards to not taking ownership of the "medical doctor brand." Though I'm in the pain medicine realm now, when I was doing 100% psychiatry, I filled out my forms stating 80% Psychiatry and 20% General Medicine. They accepted and approved this without any significant increase in premiums.

Though I understand that they wish to limit exposure and liability, it is difficult to limit yourself just to psychiatry. What about overlapping medications like propranolol, prazosin, etc.? As we move forward, with the limited amount of PCP's out there, we may be asked to provide basic medical services to our patients----and I don't think that this is unreasonable.

Yes, generally one needs 3 years of internal medicine or general pediatrics or FP in order to get malpractice insurance coverage for practice outside our specialty. We're not covered for gen medicine issues just as optho, ortho, radiology, derm, etc people can't either. Unless they did 3 years of the aforementioned residencies before specializing. We can continue or discontinue current medications but can't start new treatment.

I haven't really experienced the outpatient world, but a gyn onc or a gen surg would rather shoot themself than consult medicine on the inpatient side. I kinda feel the same way.

I filled out my forms stating 80% Psychiatry and 20% General Medicine. They accepted and approved this without any significant increase in premiums.

Though I understand that they wish to limit exposure and liability, it is difficult to limit yourself just to psychiatry. What about overlapping medications like propranolol, prazosin, etc.? As we move forward, with the limited amount of PCP's out there, we may be asked to provide basic medical services to our patients----and I don't think that this is unreasonable.

I agree. With many of my adult patients, and for minor stuff in pedi ones, we all have to chip in and help out in the interests of patient care.
There is clonidine, periactin, etc. we use in addition to the other medicines.

I think 20-30% of general medicine is ok for most insurance companies as we are medical doctors after all. My insurance agent says they may have issues if we start managing DM, CHF, RA, etc. as primary MDs which we really don't have the time to do.

masterofmonkeys- i'm sure the gyn onc and surg people at your hospital consult IM and if needed, psychiatry, for pre op stuff. Just as we consult IM for med clearance prior to ECT. there is a federal guideline book somewhere at each hospital requiring consultations. At all the hospitals i have trained and worked at, internal medicine get consulted for everything by everybody. I feel bad for them as they do seem to get dumped on a lot for trivial things by everyone.

I haven't really experienced the outpatient world, but a gyn onc or a gen surg would rather shoot themself than consult medicine on the inpatient side. I kinda feel the same way.

I dislike calling IM or even surgery over things that we could do ourselves too, but the problem is our attendings who have forgotten every shred of medicine they ever learned, and cannot supervise us even to start, for example, 12.5 mg of HCTZ in an asymptomatic hypertensive patient (which would be every psych inpatient I've ever seen. Which is why residency becomes very annoying when you have to irritate IM by consulting them for EVERY PATIENT on your service.)

It doesn't matter if you can read an EKG yourself, MOM, or anything else. What matters is what your attending is able to supervise you for, at the end of the day. There's a corollary to this, where people don't realize that each field has things they just CAN'T do. I once was ordered by a surgery consult resident to do an NG lavage for a psych inpatient with a GI bleed. The surgery resident screamed at me that I was the "primary team" and therefor was responsible for "getting it done," and then left our floor. I had no idea what to do--I could have done the lavage, sure, but in no way is this something my attending would approve of or know how to do himself. Luckily medicine was following this patient, and they kindly did it for us. In this case I cannot really justify a role for NG lavages within psychiatry, but still, it's a bit sad that our profession won't get within a mile of anything medical.

I actually imagine that if a definitive lab test came along for bipolar disorder--and it required doing an LP, say--that psychiatry would then hand "bipolar d/o" off to neurology rather than require psychiatrists to become trained in the onerous and "procedural" task of doing LPs... Likewise if a test came along that could help us understand depression better, but it required sophisticated lab analysis--we'd hand depression off to IM. That's psychiatry for you...

Getting back to your comment--surgery consults IM for pre-op risk stratification all the time, and they have no compunction about it. It involves labs, an EKG, a carotid doppler, and a few other tests, which I suppose surgery could do themselves if they were ambitious, but they leave that to IM.

I haven't really experienced the outpatient world, but a gyn onc or a gen surg would rather shoot themself than consult medicine on the inpatient side. I kinda feel the same way.

Ok, I just had this thought--do you really think this is true? The stuff we're talking about wanting to treat more of is HTN, DM, HLD--what else? COPD at most. (Can you name a few others?) Our floors couldn't handle anything acute like a PE. Even a fever is too much for inpatient psych. Outpatient would be even less acute.

What I've seen surgery handle medically was things that were actually surgical complications--like PE or an infection. But I bet surgery is not keen to handle HTN, DM, etc. They obviously have protocols for dealing with those meds when patients come in for surgery. But actually "managing hypertension"--I doubt surgeons enjoy that. They are busy enough doing surgery. I bet it's only us--psych--that is complaining that we don't get to do enough medicine...

Family medicine, internal medicine, and pediatric physicians complete full residencies to practice primary care medicine. Primary care medicine is a specialty unto itself. While I agree there are plenty of very basic things psychiatrists are more than competent to manage, depriving our patients of an appropriate level of specialty-trained provider is not good patient care.

OB/Surgery and even medical subspecialties consult IM all the time to manage things that are taking up too much of their time.

This is what hospitalists are used for often times.


As far as psychiatry, I think it is important that we continue with basic physical exams, labs, basic imaging (we dont have to read it...yet) and continuation/evaluation of medication...even if its non psychiatric in purpose.
This is especially true in inpatient units.

Doh! I thought I posted a reply this morning before everyone jumped down my throat.

Basically I think 20-30% medicine is plenty, if insurance will cover that much, I'm happy.

As for other specialties consulting medicine, part of it will be regional culture, as well as academic vs. private. But I can tell you that gen surg here and where I went to school, as well as gyn onc, rarely if ever consult medicine. Ortho, on the other hand, is a different story.

I said the 'rather shoot myself' comment somewhat in jest. I will consult medicine if I don't think I can provide standard of care, as I did for my bipolar patient with CLL, to name a recent example.

On the other hand, I DO think that 4 years of medical school, time on general inpatient wards, and my MEDICAL LICENSURE, as well as the large amounts of time I spend keeping up to date on general medical issues, does provide me expertise to address certain general medical problems.

Family, Internal Med, and Gen Peds are primary care specialties, but their expertise goes far beyond the kind of routine issues a psychiatrist should reasonably be expected to manage. A family physician can deliver a baby, diagnose rashes, and even do simple surgeries and colonoscopies, none of which you'll find me attempting. An internist can manage a CHF exacerbation, hepatorenal syndrome, and acute kidney failures, none of which I'd do. A general pediatrician can handle DKA, asthma exacerbations, bad croup, and stabilize patients with a host of other diseases. Not something I'm going to run around doing.

I work very hard to be able to provide standard of care on the issues I will manage though, and I always do it with my attendings' blessings. The gen peds and medicine peeps I rotated with LOVED that I was willing to get my hands dirty on general medical issues and wanted to maintain and expand my knowledge. They all encouraged me to do so throughout the rest of my career, after I told them I refused to switch lol. Also my mom (an internist) said she'd shoot me herself if I didn't...

So I'll continue to say things like 'hmm I think your HCTZ is throwing off your lytes, we'll start you on lisinopril instead...oh look it resolved!!!!!!!!!!' or 'Hey I know what those FSBGs mean! you have diabetes. But your Cr is >1.5, so I won't start metformin. We'll try glipizide instead and monitor for hypoglycemia.'

Something which I feel is just as important, is I can at least begin the workup for my consultant and save them a little time.

In at least a couple of cases in the past year, the fact that I was more familiar with medical diseases as they apply to psych populations helped a few patients. Hydralazine isn't a drug of choice for htn urgency with sx of encephalopathy (headache or blurry vision) as it has little effect on cerebral vasculature a dihydropyridine CCB or labetalol is a better choice as both of those do. None of the medicine residents I worked with knew that. Up to 40% (in some series) of panic disorder patients actually have secondary panic in response to an arrythmia. They often get misdiagnosed because they present complaining of panic sx rather than with sx of cardiovascular instability, so an EKG is never done. Even then, EKGs and Holters only work well if you actually capture the event, but can still miss it. And then there's SIADH, which can be a result of the psychiatric disease itself, rather than meds, which are typically blamed.

I'll admit, given my primary interest of the interplay between medical and psychiatric disease, I'm going to have a more medically-minded POV than most here. *shrug*

Family medicine, internal medicine, and pediatric physicians complete full residencies to practice primary care medicine. Primary care medicine is a specialty unto itself. While I agree there are plenty of very basic things psychiatrists are more than competent to manage, depriving our patients of an appropriate level of specialty-trained provider is not good patient care.

I don't think anyone is suggesting that a patient be deprived of a specialty trained provider. Whether that equates to good patient care is debatable. Am I going to take care of a simple UTI -- yes. Would I start HCTZ or a beta blocker in a hypertensive patient while waiting for the medical consult? -- yes. Would I start pioglitazone or something else for diabetes? -- no, although there are some psychiatrists who may be confident with this.

It is appropriate to start the work up process, or even a medication for the basic conditions while referring the patient for follow up with the appropriate specialist.

Wearing my pain medicine hat, a consult was called to me by a psychiatry resident for a patient with an already existing pain condition. He wanted the consult (per attending) prior to giving Advil, Tylenol, etc. The pain also was exacerbating the patients underlying hypertension, etc. so other services were called. I had to explain to the resident that it is appropriate to give an opiate analgesic to cover rather than leave the patient in pain, and I told him to ask his attending to call me.

Simple conditions = treatment.

Complicated conditions = supportive treatment, work up, referral.

NG lavage as someone suggested above. In residency, we had to insert NG tubes, so I guess this might be fair game. The surgery resident should have at least taught you or guided you as to how to do this.

As far as psychiatry, I think it is important that we continue with basic physical exams, labs, basic imaging (we dont have to read it...yet)

This is where I see the future of Psychiatry going, and it can only be a positive move. Psychotherapy is being handled mostly by social workers and psychologists. With mid level providers being employed to provide medications, etc., then it will be ever so important for Psychiatrists further define our scope of practice. Many of the advances will be in the area of neuro-imaging and this is where we psychiatrists should seize the opportunity.

...Wearing my pain medicine hat, a consult was called to me by a psychiatry resident for a patient with an already existing pain condition. He wanted the consult (per attending) prior to giving Advil, Tylenol, etc. The pain also was exacerbating the patients underlying hypertension, etc. so other services were called. I had to explain to the resident that it is appropriate to give an opiate analgesic to cover rather than leave the patient in pain, and I told him to ask his attending to call me.
. :eek:

...NG lavage as someone suggested above. In residency, we had to insert NG tubes, so I guess this might be fair game. The surgery resident should have at least taught you or guided you as to how to do this.
I think that all I did in my inpatient neuro month as an intern was place NG tubes... Thanks for that unpleasant reminder!

:eek:


I think that all I did in my inpatient neuro month as an intern was place NG tubes... Thanks for that unpleasant reminder!

:laugh: And what about on the anorexic patients on the psych inpatient units!!

As far as psychiatry, I think it is important that we continue with basic physical exams, labs, basic imaging (we dont have to read it...yet)

This is where I see the future of Psychiatry going, and it can only be a positive move. Psychotherapy is being handled mostly by social workers and psychologists. With mid level providers being employed to provide medications, etc., then it will be ever so important for Psychiatrists further define our scope of practice. Many of the advances will be in the area of neuro-imaging and this is where we psychiatrists should seize the opportunity.

But that would take all the fun out of it!

Not to mention, increased use of neuro-imaging in psychiatry would be a great way to drive up health care expenditures for tests of dubious value.

But that would take all the fun out of it!

Not to mention, increased use of neuro-imaging in psychiatry would be a great way to drive up health care expenditures for tests of dubious value.

Yeah, I agree. I'm just starting a research fellowship (literally today!) that will involve learning and utilizing neuroimaging. As a research tool, it's in it's infancy and, I feel, has huge potential to help drive our field into a deeper understanding of mental illness. This will ultimately improve treatment and can eventually be used to link a better understanding of pathology with clinical judgement and skills. However, I have a hard time believing it will be used as a diagnostic tool anytime in the near future. Those scans aren't cheap!!!! Besides, although it MAY eventually help clarify our clinical judgement, I'm not sure it would do much more and have a hard time seeing how helpful it would be in the vast majority of cases we see.

As someone who is a big fan of imaging, I'm happy to be wrong! Maybe I'm being too short sighted?

Yeah, I agree. I'm just starting a research fellowship (literally today!) that will involve learning and utilizing neuroimaging. As a research tool, it's in it's infancy and, I feel, has huge potential to help drive our field into a deeper understanding of mental illness. This will ultimately improve treatment and can eventually be used to link a better understanding of pathology with clinical judgement and skills. However, I have a hard time believing it will be used as a diagnostic tool anytime in the near future. Those scans aren't cheap!!!! Besides, although it MAY eventually help clarify our clinical judgement, I'm not sure it would do much more and have a hard time seeing how helpful it would be in the vast majority of cases we see.

As someone who is a big fan of imaging, I'm happy to be wrong! Maybe I'm being too short sighted?

Not short sighted at all; and thank you for being one of the researching pioneers in this field.

I would agree that it is at least 10 years away, and will still be very expensive for some time to come. On the other hand, if competition remains high, the cost of imaging will come down somewhat. If the imaging can be reliable enough to show clinical/diagnostic efficacy, then we may be able to target our treatments more effectively and efficiently thereby reducing overall treatment costs (pharmacotherapy, psychotherapy, etc.)

We shall see... but for now, we'll stick to our crystal balls!

Yeah, I agree. I'm just starting a research fellowship (literally today!) that will involve learning and utilizing neuroimaging. As a research tool, it's in it's infancy and, I feel, has huge potential to help drive our field into a deeper understanding of mental illness. This will ultimately improve treatment and can eventually be used to link a better understanding of pathology with clinical judgement and skills. However, I have a hard time believing it will be used as a diagnostic tool anytime in the near future. Those scans aren't cheap!!!! Besides, although it MAY eventually help clarify our clinical judgement, I'm not sure it would do much more and have a hard time seeing how helpful it would be in the vast majority of cases we see.

As someone who is a big fan of imaging, I'm happy to be wrong! Maybe I'm being too short sighted?

Look at it from another angle. Go ahead and think about what we do on PACT teams and inpatient and outpatient for ALL those people who malinger, are abusing drugs and want to be on disability, and antisocial trying to get away from an arrest warrant. If your image is worth several thousands but can really tell if someone has a mental illness or not, that $10k will save ten times it's costs in welfare and disability.

If the government was smart enough, it would totally dig into this as a way to deny mental disability for many who seek it. I'm predicting once someone up there notes the possiblity and the saving, we'll see things become more solid.

Unfortunately, you know how inaccurate the imaging is now and a psychiatrist clinical assessment wont be obsolete anytime soon.

However, I have a hard time believing it will be used as a diagnostic tool anytime in the near future. Those scans aren't cheap!!!!

Besides, although it MAY eventually help clarify our clinical judgement, I'm not sure it would do much more and have a hard time seeing how helpful it would be in the vast majority of cases we see.

As someone who is a big fan of imaging, I'm happy to be wrong! Maybe I'm being too short sighted?

I started out with structural imaging some years ago and now have moved on to fMRI and DTI. The neural connectivity studies have been promising but you are right, neuro imaging is still in its infancy stage. However, the scans have gotten cheaper and with more useage, the prices will fall further.

On the contrary, neuro imaging findings are not dubious at all. There have been good findings out there. Otherwise the NIH wouldn't be funding all these grants and so many bright people wouldn't be so interested.

what you will find is that there are plenty of cynics. They have a lot to lose if we find more biological evidence. Scientology being one of them.
Even genomic studies have been criticized of late.

If the critics can offer some helpful solutions, I'd love to hear it.

I commend you for pursuing research. Biological studies, in the long run, along with psychosocial research, will improve and even save the lives of countless patients.

I started out with structural imaging some years ago and now have moved on to fMRI and DTI. The neural connectivity studies have been promising but you are right, neuro imaging is still in its infancy stage. However, the scans have gotten cheaper and with more useage, the prices will fall further.

On the contrary, neuro imaging findings are not dubious at all. There have been good findings out there. Otherwise the NIH wouldn't be funding all these grants and so many bright people wouldn't be so interested.

what you will find is that there are plenty of cynics. They have a lot to lose if we find more biological evidence. Scientology being one of them.
Even genomic studies have been criticized of late.

If the critics can offer some helpful solutions, I'd love to hear it.

I commend you for pursuing research. Biological studies, in the long run, along with psychosocial research, will improve and even save the lives of countless patients.

Thank you also Snarfer for being a pioneer in the field!

I started out with structural imaging some years ago and now have moved on to fMRI and DTI. The neural connectivity studies have been promising but you are right, neuro imaging is still in its infancy stage. However, the scans have gotten cheaper and with more useage, the prices will fall further.

On the contrary, neuro imaging findings are not dubious at all. There have been good findings out there. Otherwise the NIH wouldn't be funding all these grants and so many bright people wouldn't be so interested.

what you will find is that there are plenty of cynics. They have a lot to lose if we find more biological evidence. Scientology being one of them.
Even genomic studies have been criticized of late.

If the critics can offer some helpful solutions, I'd love to hear it.

I commend you for pursuing research. Biological studies, in the long run, along with psychosocial research, will improve and even save the lives of countless patients.

And I commend you too for your contribution to the field.

I agree that neuroimaging is a fascinating field of study, and has the potential to vastly increase our understanding of psychiatric disease. However, the place for neuroimaging is primarily the research setting. Neuroimaging is useful for identifying neurobiological correlates of psychiatric disease. Indeed, there is much to be gleaned.

On the other hand, a useful diagnostic test has very different requirements; it must be sensitive, specific, cost effective, and useful (i.e. results have the potential to guide management decisions). At present, neuroimaging has none of these attributes and it does not appear to be making much progress in this regard.

The major roadblocks are the incredible diversity and the overlap of manifestations in mental illness, which preclude the design of a highly sensitive and specific neuroimaging test. Human behavior is incredibly complex and in the vast majority of cases cannot be reduced to brain abnormalities. Though many would argue otherwise, psychiatric illness is part of a spectrum, and imaging is not going to help us differentiate healthy individuals from those who are mentally ill. If anything, those in whom we can clearly discern pathology via neuroimaging are those with severe disease; individuals in whom the diagnosis has already been made.

Now, although I think diagnostic utility is limited, if we could someday inform drug therapy decisions with neuroimaging or genetic testing (more likely), perhaps there will be a role for both.

Only time will tell.

what you will find is that there are plenty of cynics. They have a lot to lose if we find more biological evidence. Scientology being one of them.
Even genomic studies have been criticized of late.



The future is going to be decided by patients on the whole. So not so much cynics, just people who are better informed. Patients have access to far more information now than they have in the past. Society has changed as well so families and society at large are no longer going to be safisfied to leave their loved ones at the mercy of the whims of the psychiatric profession.

The future is further segmentation of providers as patients chose how they prefer their illness/emotional distress to be interpreted and what the response to that interpretation will be.

One only has to look at sites like*http://www.patientopinion.org.uk/

Soon this will be done Dr. by Dr. and patients will decide who survives in the market place.

So let me rewrite the above:

What you will find is people are becoming more and more informed. Some traditions have a lot to lose if people decide to reject what they have on offer. Strict biological reductionists having the most to lose as the current dominant paradigm falls out of favour. Copy number variation studies continue to cost much and demonstrate nothing with no hope of ever doing so.

The other great change is that student doctors now have easy access to a greater range of ideas. No longer are they limited by stuffy proffs with particular vested interests and their own academic axe’s to grind. No more using a paper hand out of a biased reading list as a starting point on any one topic. Its student doctors, especially those who take the scientific method at its word and look genuinely critically at the science who will find they are able to offer what patients really want.

In short Doctors will decide how they want to practice and patients will decide which doctors survive to earn a crust in the long run.*

As an aside how long has the genetic cause for downs syndrome been known? What did the people with that condition get out of that little nugget of information? Nothing. All the changes that made a difference in their lives have been down to a change in society.

The same has been true for people who experience mental distress. The large state institutions did not close because of the introduction of medication. They closed because of the introduction of Medicare and Medicaid. The patients who were prescribed Benzodiazepines were the ones who stayed in hospital to the bitter end. U.S. census data shows it.*

Another point. Why should genetic studies be beyond criticism? Plenty of work has shown that what is quoted in Psychiatry text books has no relation to the work done. The deeply flawed monozygotic twin studies for one. It’s depressing that this is not more widely understood.

Snaffer – Stop calling every one who disagrees with you a scientologist. It makes you appear rather intolerant and ignorant to boot when I am sure you are not really. Why don’t you address the issues rather than just call people names. An aricticle from the Lancet for you.
http://www.thelancet.com/journals/lancet/article/PIIS0140673610605326/fulltext

I'm pessemistic about fmri as well. The jump from the quantum effects being measured and the statistics used to generate the image means that the choice of mathematical parameters have far to much to do with what you see on the screen. (we love to see those pretty blobbs, not much fun if the stats don't come up with anything for the CRT is it?) Basically all the people earning a living doing geography have been left with nothing to do with thier fancy machines now that every thing has been mapped out. Pity they can't wean them selves off and find something truely usefull to do.

Thank you also Snarfer for being a pioneer in the field!

thank you. It is a lot of work and at times can be very stressful. We are hopeful because in the end, positive outcome is what matter the most.

thank you. It is a lot of work and at times can be very stressful. We are hopeful because in the end, positive outcome is what matter the most.

Funny how the most recovered patients, the ones with the best outcomes, are the ones who have the least contact with mental health services. Best ignored and swept and the carpet eh?

To paraphrase Ray Kurzweil...

Technology moves forward exponentially while humans think linearly.

Imaging, including advanced EEG, advanced NMR, Isotope based scans and the basic scans we have today will be used on a regular basis in psychiatry.

20 years ago, these were technologies that werent yet invented or in their very infancy. 20 more years and you will see a massive improvement in the use. We have imaged the brain. Imaging the mind is the next step and we will do it in soon. Everything is expensive initially but as technology moves forward it becomes cheaper. Imagine being able to "cure" schizophrenia. It is going to happen soon.

Manicsleep Perhaps you could apply yourself to the common cold first.

Twenty years ago Psychiatrists were busy sticking hot knitting needles into peoples brains. Miniaturising that process doesn’t make it anymore palatable. Essentially a “cure” for schizophrenia is not really on the cards, firstly because as a diagnosis it’s gradually fading from view and secondly people are already learning to live with the forms of mental distress that have been so called already. As a form of mental distress the stigma associated with it is disappearing from society as well and as that process continues most of the challenges associated with occasional altered states of consciousness disappear and or certainly diminish as well.

Health improvement generally has not been the result of technological advance, it is a story of better diet and improved sanitation that accounts for most of decrease in the burden of disease. The same general process is at work in mental health.

All the technology you mention is merely of academic interest and no doubt will lead to an increase in the sum total of human knowledge but as for leading to a cure I think not. That process is well underway and has little to do with technology.

The villainy of academic psychiatry needs to be separated from its practical application. When more practical practitioners are able to let go of some of the sacred cows of the academic world instead of clinging to them like outraged homoeopathists then we will see more swift and appropriate progress in peoples care and treatment.

All the technology you mention is merely of academic interest and no doubt will lead to an increase in the sum total of human knowledge but as for leading to a cure I think not. That process is well underway and has little to do with technology.
The villainy of academic psychiatry needs to be separated from its practical application. When more practical practitioners are able to let go of some of the sacred cows of the academic world instead of clinging to them like outraged homoeopathists then we will see more swift and appropriate progress in peoples care and treatment.

You're right. Let's turn our backs on academic psychiatry, and while we're at it, why don't we just forget about that whole evidence based treatment thing too. Once we turn our backs on the sacred cows of empirical inquiry and scientific grounding for our actions, we will be liberated to provide better quality patient care. Certainly some of our basic science/neuroscience research is not immediately clinically relevant, but translational and clinical research is impossible without it.

I'm actually currently working in a neuroimaging lab studying schizophrenia using some of these new techniques, such as fMRI and DTI (diffusion tensor imaging, looking at white matter tracts in the brain). I will be the first to admit that the stuff we're doing is years away from being clinically useful. Part of that, however, is because some of these techniques are in their infancy. DTI, which is showing awesome potential in the study of schizophrenia, has really only become widely used in the last 5 years or so. I mean Lord, give something a chance before you call it useless or irrelevant to clinical care.

One of the biggest problems most researchers have currently is that our techniques are still frustratingly imprecise. MRI and other imaging techniques are very error prone, and we are forced to rely on indirect measures to try and get a peek at the brain. Such is the nature of the beast. Like many others on this thread have said, however, we are light years away from where we were even 15 years ago. The first paper linking schizophrenia with specific brain abnormalities was published in 1992. Only 18 years ago. Think of the astronomical amount we have learned since then, and then extrapolate it 5, 10, or 20 years into the future. Information we thought we knew 5 years ago is being rendered obsolete. Crazy thought right?

So obviously, I remain completely unconvinced by those who claim that imaging is merely a useless academic exercise with no real world utility. I have some sympathy for those who are skeptical of the validity of some empirical research. I am just as much a fan of Carl Rogers as I am of the latest psychiatric neuroscience research. I see nothing contradictory between the two, and I feel like they both only have the opportunity to improve patient care. I'll check back in 10 years, and see how things went. My guess is that we'll learn 5x as much in the second decade of the new millennium as we did the first. And that can only improve our field as a branch of medicine, science, and patient care.

Ibid... agreed; let's turn our backs on academic psychiatry. It's time to break out the voodoo dolls and needles! But we all know that e-meters are the best tool in making you a better operational thetan... ooops, I meant Psychiatrist:rolleyes:

I would agree that it is at least 10 years away, and will still be very expensive for some time to come. On the other hand, if competition remains high, the cost of imaging will come down somewhat. If the imaging can be reliable enough to show clinical/diagnostic efficacy, then we may be able to target our treatments more effectively and efficiently thereby reducing overall treatment costs (pharmacotherapy, psychotherapy, etc.)

I could see that. However, I could see it more in terms of using imaging research to predict effective treatment (medications, therapy, as you said) and then link that information to clinical predictors. That way clinicians to look for those predictors in practice and then match the best treatment to the patient. I know this is already being looked at in clinical research, but imaging work could help augment this area.

Look at it from another angle. Go ahead and think about what we do on PACT teams and inpatient and outpatient for ALL those people who malinger, are abusing drugs and want to be on disability, and antisocial trying to get away from an arrest warrant. If your image is worth several thousands but can really tell if someone has a mental illness or not, that $10k will save ten times it's costs in welfare and disability.

If the government was smart enough, it would totally dig into this as a way to deny mental disability for many who seek it. I'm predicting once someone up there notes the possiblity and the saving, we'll see things become more solid.

Unfortunately, you know how inaccurate the imaging is now and a psychiatrist clinical assessment wont be obsolete anytime soon.

Perhaps this could a potential use. But I still question if this would be financially feasible. Your point about accuracy is also a big problem. But maybe that could change down the road.

I started out with structural imaging some years ago and now have moved on to fMRI and DTI. The neural connectivity studies have been promising but you are right, neuro imaging is still in its infancy stage. However, the scans have gotten cheaper and with more useage, the prices will fall further.

:thumbup: It seems like this is the way to go for the most promising research.

You're right. Let's turn our backs on academic psychiatry, and while we're at it, why don't we just forget about that whole evidence based treatment thing too. Once we turn our backs on the sacred cows of empirical inquiry and scientific grounding for our actions, we will be liberated to provide better quality patient care. Certainly some of our basic science/neuroscience research is not immediately clinically relevant, but translational and clinical research is impossible without it.

I'm actually currently working in a neuroimaging lab studying schizophrenia using some of these new techniques, such as fMRI and DTI (diffusion tensor imaging, looking at white matter tracts in the brain). I will be the first to admit that the stuff we're doing is years away from being clinically useful. Part of that, however, is because some of these techniques are in their infancy. DTI, which is showing awesome potential in the study of schizophrenia, has really only become widely used in the last 5 years or so. I mean Lord, give something a chance before you call it useless or irrelevant to clinical care.

One of the biggest problems most researchers have currently is that our techniques are still frustratingly imprecise. MRI and other imaging techniques are very error prone, and we are forced to rely on indirect measures to try and get a peek at the brain. Such is the nature of the beast. Like many others on this thread have said, however, we are light years away from where we were even 15 years ago. The first paper linking schizophrenia with specific brain abnormalities was published in 1992. Only 18 years ago. Think of the astronomical amount we have learned since then, and then extrapolate it 5, 10, or 20 years into the future. Information we thought we knew 5 years ago is being rendered obsolete. Crazy thought right?

So obviously, I remain completely unconvinced by those who claim that imaging is merely a useless academic exercise with no real world utility. I have some sympathy for those who are skeptical of the validity of some empirical research. I am just as much a fan of Carl Rogers as I am of the latest psychiatric neuroscience research. I see nothing contradictory between the two, and I feel like they both only have the opportunity to improve patient care. I'll check back in 10 years, and see how things went. My guess is that we'll learn 5x as much in the second decade of the new millennium as we did the first. And that can only improve our field as a branch of medicine, science, and patient care.

:thumbup: Nice post!

The first paper linking schizophrenia with specific brain abnormalities was published in 1992.

Great post!

Yes, the classic meta analysis paper written by M.Shenton at brigham and women's hospital. 100% of schizophrenia patients had reduced STG volume. the n was in the thousands.

Because this is a psychiatry forum. Sometimes we have treatment nonadherent individuals visiting. And at other times we get visitors from a certain 'religious' organization who can just be as concrete.

Regardless, as physicians i believe we all should take the high road in these instances. No point in trying to reason with these folks and just wish them the best.

Uh, can we get back to NG tubes, please?

Seriously, since some of our own patients need these tubes, why isn't putting one in required psychiatry training? It's like, our only procedure. If we put our minds together, I bet we could even devise special floroscopic guided NG tube insertions, which would make this the world's first IR-guided psychiatric procedure. Currently, there are.... none.

I also notice that people here seem to be debating the role of psychiatry on the most benign fringe of primary care--i.e. starting management of simple hypertension and type 2 diabetes in patients who I'm guessing are already on the inpatient psych ward and thus really have no choice in who will manage their medical issues, or else are outpatients with no PCP at all and no hope of an appointment before next Christmas. Ok, this is underwhelming to say the least. Where are the psychiatrists who want a greater role in CT surgery, who want to manage vent patients, put in central lines, intubate the worst airways, or deal with the world's next lethal pandemic?

Come on... I can't seriously believe that there is that much overlap between psychiatry and simple primary care.

NG lavage as someone suggested above. In residency, we had to insert NG tubes, so I guess this might be fair game. The surgery resident should have at least taught you or guided you as to how to do this.

On the psych floor? You had those supplies? At my hospital, they are locked up on other floors. Anyway, my attending would have had a fit--I know it. I would have loved to have done it though.

Also--granted this patient was psychotic, had a TBI and spoke only portuguese and meanwhile I had all the experience of a 3rd or 4th month intern--but wouldn't doing an NG lavage on a patient hinder the therapeutic alliance, such that it was? I've seen fully competent adults leave AMA over those things.

Regardless, as physicians i believe we all should take the high road in these instances. No point in trying to reason with these folks and just wish them the best.

You think so? I wonder, however, if that is always the best approach. While it may be futile to think we can change the mind of someone that already comes with an ingrained (neurologically speaking, of course ;)) world-view, I wonder if it ultimately does more harm when those "on the fence" about psychiatry are observing and "listening" to the conversation. I'll be the first to admit that I often don't respond to adverse comments just out of sure laziness. But perhaps as a profession we should have our responses more polished?

You think so? I wonder, however, if that is always the best approach. While it may be futile to think we can change the mind of someone that already comes with an ingrained (neurologically speaking, of course ;)) world-view, I wonder if it ultimately does more harm when those "on the fence" about psychiatry are observing and "listening" to the conversation. I'll be the first to admit that I often don't respond to adverse comments just out of sure laziness. But perhaps as a profession we should have our responses more polished?

Sorry, no criticism was intended toward anyone who have responded. Yes, I agree we should try to reason certain individuals but only when there is an alliance. However, in a public forum with an individual who appears obviously fragile, it is somewhat controversial what is the right course. But I would like to avoid inflamming the poster who may need our help.

Marantha- Great post and I agree that imaging may be best applied to predicting treatment outcome... I believe that we are on the cusp of major breakthroughs in Psychiatry and the neurosciences as a whole, and I believe that imaging is going to be a major part. However, all points above are excellent and we'll just have to see where things go.

Nancy - fortunately, we were able to procure the supplies needed for what needed or could be done rather quickly. Due to politics and liability, some attendings may be more reticent to allow certain procedures to be done on the unit. It also depends on the patient - a more complicated patient may need more experienced hands or a more controlled setting.

How does this apply to the future of psychiatry? I'm a firm believer in cross training! In my opinion, we should go back to prelim internal medicine/surgical years with the specialty years beginning at the GY2 level. Therefore, adult psychiatry would be PGY2-4, general surgery being PGY2-5, etc. The camraderie amongst physicians would improve, and there would be ample training in general medical conditions. If it were up to me, Psychiatry residents would need to be ACLS trained, interpret basic EKG's, draw ABG's and do basic suturing and treat / start treatment on a variety of basic medical conditions.

At least where I trained, ACLS, peripheral lines, NG tubes, foley catheters and EKG's were requirements. I suppose most of these are still in place at other institutions.

It's time to break out the voodoo dolls and needles! But we all know that e-meters are the best tool in making you a better operational thetan... ooops, I meant Psychiatrist:rolleyes:

Regardless, as physicians i believe we all should take the high road in these instances. No point in trying to reason with these folks and just wish them the best.

However, in a public forum with an individual who appears obviously fragile, it is somewhat controversial what is the right course. But I would like to avoid inflamming the poster who may need our help.

I hope I’m not the only one that finds these posts nauseating, particularly the last one...classic argumentum ad hominem.

Frankly, it's frightening that a mental health professional would attempt to undermine an argument by attacking the speaker instead of addressing the argument, and evermore so when doing so by questioning the speaker's mental health.

Though I understand that it may seem daunting to engage in debate with someone that has virtually polar opposite views to your own, a number of responses have been downright childish. I can only hope that the smug attitude and penchant for derisive comments rather than intelligent debate will cause others to be more wary of associating with your allegedly infallible ideology.

Ibid's post is absurd. He feels that most medical treatment is only due to sanitation and an improved diet? By that absurd logic, if your child gets diabetes or cancer or any number of genetic diseases that have nothing to do with diet or sanitation, you will clean them and give them fruits and vegetables?

Do you even remember what was routinely available for scanning the brain in 1990? How many people got MRIs in 1990? Even CT technology has advanced greatly. Can you imagine a world without spiral CT?

You will be saying the same thing in 20 years about gene therapy, nanomachines and organ transplant/cell transplant. Schizophrenia may be a syndrome, a lot of diseases that present similarly or perhaps a lot of disease states that cause similar damage to the brain. You can treat the underlying cause or the damage but hiding in the corner and closing your eyes wont do anyone any good. It is very likely that the mind is that last thing to be treated but before that we will see real cures for the body, then the brain and then the mind.

The idea that imaging is ONLY for predicting outcomes is not true. It will be for targeting. Gene therapy is progressing at an amazing rate. They are already growing cells, organs and nanomachines. Gene therapy has been use to "cure" mice of diabetes. These things are still in their infancy but give it a decade or 2.

Ibid's post is absurd. He feels that most medical treatment is only due to sanitation and an improved diet? By that absurd logic, if your child gets diabetes or cancer or any number of genetic diseases that have nothing to do with diet or sanitation, you will clean them and give them fruits and vegetables?

You clearly missed the point.

Ibid hit the nail on the head, though she(?) may have been more provocative than necessary.

This isn’t a psychiatry vs. scientology debate. It’s simply a push back against the reductionistic bio-bio-bio model that has left unfulfilled promises and now threatens to discredit the entire profession. If anyone missed it in the Breggin thread, read this article. Former APA president, Steven Sharfstein, laments the replacement of the biopsychosocial model with the reductionist’s bio-bio-bio model.

Big Pharma and American Psychiatry: The Good, the Bad, and the Ugly (http://pn.psychiatryonline.org/content/40/16/3.full)

As far as imaging as the future of psychiatry, there are a number of problems with this scenario, and the technical difficulties are the easy ones.

Take a look at APA position statement published in 2005 on the use of imaging in the clinical setting:

“… no published investigation in the field has determined that any structural or functional abnormality is specific to a single psychiatric disorder. Additionally, imaging studies examine groups of patients and groups of healthy controls; therefore, findings may not apply to all individuals with a given disorder. Even when significant differences are identified between groups, there is a substantial overlap among individuals in both groups.”

Schizophrenia is an incredibly heterogeneous “disorder” as are many in psychiatry. No amount of fine tuning of imaging techniques will allow brain imaging technology to diagnoses mental illness. The key problem being that there will always be substantial overlap between healthy and mentally ill cohorts. As for drug targeting, I suppose it's possible, but it's naïve to think a biological "cure" is attainable for schizophrenia, much less around the corner.

RedPakotaSea

Thank you. Snaffer does himself no favours. Pejorative comments like those above are distasteful and I think will be seen to be so by most impartial observers. It’s not hard to see that taken as a whole they are rather disingenuous as well. If one didn’t want to inflame some one, why be rude about them? Thankfully it is not a typical attitude but sadly it is not entirely uncommon either as I am sure you know.

For my own part I stand by what I have posted about the future of psychiatry, it only an opinion after all. I believe its a very important question as the profession will always have the lions share of resources devoted to it and have the loudest voice when it comes to informing the way that people who experience mental distress will be treated.

If I have been inflammatory it is in part because a discussion about the future will necessarily need to take account of the past. Sadly psychiatry, and it is not alone in this respect has skeletons in the cupboard and addressing these should be something that psychiatry and medicine as a whole, being the epitome of a profession, should comfortably be able to address with out resort to juvenile name calling and defensiveness.

Thank you for posting the Steven Sharfstein link I was going to post it as well.


To all that kindly responded my points to reiterate are that:

Patients will increasingly have a role in deciding the way they are treated. This happens a lot already but it will become increasingly prevalent.
Patients will increasingly have a say in the way that entire services are designed. Patients played more than a little part in the design of the National Service Frameworks that led to the creation of Home Treatment Teams, Early Intervention in Psychosis Teams, and Assertive Outreach teams. The continueing theme of moving away from building based services is informed in great part by patients.

Thirdly I alluded to the way that information technology is influencing not just patients but Doctors as well as they have easy access to alternate points of view that exist with in the psychiatric profession. I would point to the debate that took place in the Psychiatric Bulletin throughout 2009 (Now call the The Psychiatrist). Indeed my own thinking is informed partly by this debate so I don’t feel at all marginalised at all even if my point of view is not universally popular.

My other point is that it is not so much technology that is going to influence Psychiatry in the years a head so much as changes in society itself. Following deinstitutionalisation the general public is much better informed about mental distress and on the whole are much less inclined to hold prejudiced views about people. The disposition of society has been responsible for the bulk of the totality of difficulties people with mental health problems have faced not so much clinical signs and symptoms, clearly the signs and symptoms are not irrelevant to peoples difficulties but they have been emphasized at the expense of the totality of peoples experience. Social isolation and inability to secure employment and the like. At the moment western society demands pills(apologies for the oversimplification) but tomorrow that may not be the case. Increasingly the popular demand is for greater access to psychological therapy.

Rather distressingly it is from with in the ranks of psychiatry that negative attitudes about people persist most strongly. Indeed they persist within most strongly in all the psychiatric professions, while not the rule it is still a source of shame that these attitudes exist at all. Of course academic psychiatrists have always been at the top of the tree in the hierarchy of villainy from some points of view. But they have the least contact with patients so its not surprising. Much of the difficulty here is to do with communication and language but negative attitudes and old fashioned value systems play a part as well. Front line psychiatrists will always be more popular with patients and patients will regard them more fondly even if they don’t always agree with them.

The other area that patients will influence is setting the priorities for research. I do mean influence not entirely determine. This will be a good thing in my own view as I personally believe there has been a misallocation of resources away from lines of research that could prove productive and into work like fmri that is merely fashionable. Note I am not saying fmri should be abandoned for instance.

Finally as an example I would note that patients now sit on NICE committees and many such other bodies. One thing is for sure it may be possible to ignore people that one thinks may be patients on the internet but they will be increasingly hard to ignore in reality if one hopes to be a psychiatrist in any capacity.

On a final note as it has been mentioned in passing, forums where patients post in there own communities (often visited by student psychiatrists I might add) are often punctuated by quite florid postings. The disposition in those communities is to treat the florid and visiting psychiatrists with gentleness, sympathy and empathy and rarely if ever does one come across a patronising demeanour. A lesson for some here perhaps.


Manic sleep - My posting was to convey that most advances in health generally and the global lessoning in the burden of disease in the last 150 years are due to better sanitation and better nutrition. With respect that point is beyond all doubt. Technology has played a minor role by comparison.

On a final final note for this post if psychiatrists talking about chakras and other spiritual matters worry you don't google for the Royal College of Psychiatrists special interest group on spirituality. Scratch that - look away now for the bio bio bio mob -
http://www.rcpsych.ac.uk/members/specialinterestgroups/spirituality.aspx

If you are a student doctor of a very sensitive disposition I really don't advise you to click that link and what ever you do don't read the minutes. lol

double post.

Manic sleep - My posting was to convey that most advances in health generally and the global lessoning in the burden of disease in the last 150 years are due to better sanitation and better nutrition. With respect that point is beyond all doubt. Technology has played a minor role by comparison.


I understand what you are trying to say with the sanitation point. My point is that this is about the future and not the past.
Just because we understand germ theory doesn't mean cleanliness will solve everything. They certainly have little to do with DM and Cancer. The top killers of today and tomorrow are will not be solved because of sanitation.

Pakota's idea that bio, bio, bio is not the answer is only partially correct. Because it is a big part of the answer. The more we understand the more we can do with the biological aspect of psychiatry. Humans are 100% bio. If we can understand the psychosocial in a bio context then so what. The problem is that you are equating what people are doing today to what will happen tomorrow.

I think it is absurd not to embrace what is happening. That does not mean doing SPECT scans for 3000 dollars as part of some crazy visit to solve all your problems (i will mention no names of psychiatrists who may work at UCI) but being realistic. It just means that doing the best based on the evidence based medicine but understanding that the technology is advancing rapidly and it will be integrated. The mind is the last frontier but it will be conquered. That doesn't mean instant, overnight cures for anyone but eventual cures are absolutely in sight.

I hope I’m not the only one that finds these posts nauseating, particularly the last one...classic argumentum ad hominem.

Frankly, it's frightening that a mental health professional would attempt to undermine an argument by attacking the speaker instead of addressing the argument, and evermore so when doing so by questioning the speaker's mental health.



Reviewed all the posts and I'm with the others. Sounds like the pot calling the kettle black here.

It is more frightening and shocking reading what you and Ibid have written.

Ibid's post is absurd. He feels that most medical treatment is only due to sanitation and an improved diet? By that absurd logic, if your child gets diabetes or cancer or any number of genetic diseases that have nothing to do with diet or sanitation, you will clean them and give them fruits and vegetables?

Do you even remember what was routinely available for scanning the brain in 1990? How many people got MRIs in 1990? Even CT technology has advanced greatly. Can you imagine a world without spiral CT?

You will be saying the same thing in 20 years about gene therapy, nanomachines and organ transplant/cell transplant. Schizophrenia may be a syndrome, a lot of diseases that present similarly or perhaps a lot of disease states that cause similar damage to the brain. You can treat the underlying cause or the damage but hiding in the corner and closing your eyes wont do anyone any good. It is very likely that the mind is that last thing to be treated but before that we will see real cures for the body, then the brain and then the mind.

The idea that imaging is ONLY for predicting outcomes is not true. It will be for targeting. Gene therapy is progressing at an amazing rate. They are already growing cells, organs and nanomachines. Gene therapy has been use to "cure" mice of diabetes. These things are still in their infancy but give it a decade or 2.

:thumbup:

Manicsleep

I do understand what you are saying.

My point is that this is about the*futureand not the past

I on the other hand am simply using the past as a general guide and positing that it potentially tells us something useful about the likely future.

Pakota's idea that bio, bio, bio is not the answer is only partially correct. Because it is a big part of the answer. The more we understand the more we can do with the biological aspect of psychiatry. Humans are 100% bio. If we can understand the psychosocial in a bio context then so what.

What you have posted above (apologies for the italics, I’ve not got the hang of multi quoting) contains the knub of our differing opinions, I think….

Of course I’m not suggesting we are not 100% bio and for the time being I’m setting aside spiritual questions so as not to muddy the water. How ever just stating that we are all 100% bio does not move us much further along. In the specific context of mental distress it doesn’t differentiate between mental distress with an environmental determinate and those with out. I’m sure you are familiar with this theory http://www.imperial.ac.uk/college.asp?P=7349
I’m sure you understand I’m not supporting that theory, just illustrating a point. Again with genetics as a possible bio bio bio explaination for all kinds of things, for instance child abuse runs in families but it doesn’t mean that the propensity to child abuse has a large genetic component. That would be to muddle up correlation with causation. There are other examples that, forgive me, escape me at the moment that would have appeared to have a large genetic component until the correct environmental causation was found.

After that slight diversion what is really at the heart of the difference between us is a difference of emphasis. I am positing that the biology of human distress needs to understood with in its social context and a persons biographical history. Of course you will say this has always been the case but to me it’s the matter of emphasis that is critical. Above you just say so what? That I believe misses the point because as I have said I believe it is critical.

I appreciate your clarification. Thank you.

After that slight diversion what is really at the heart of the difference between us is a difference of emphasis. I am positing that the biology of human distress needs to understood with in its social context and a persons biographical history. Of course you will say this has always been the case but to me it’s the matter of emphasis that is critical. Above you just say so what? That I believe misses the point because as I have said I believe it is critical.

I appreciate your clarification. Thank you.

I agree that there needs to be integration and in todays world attention should be given to biological, psychological and social. As psychiatrists that is our job and it is what we are trained to do better than anyone else. But the final goal is only the cure and nothing more.

As far as human distress being understood in the social context and biographical history, I think thats great. For example if you have a patient with cancer who is elderly, perhaps they can't live by self for a while after having curative surgery and family must be involved or they need a SNF etc. But if its a healthy person, youre cutting out a skin lesion...they dont need anything else other than a follow up on the cancer.

Lets say a blood test for diagnosing schizophrenia is developed with excellent sensitivity and specificity. With it a 100% effective cure is developed as well. Are you really going to sit around and try to incorporate psychosocial aspects of treatment in someone who has not had symptom onset yet or would you cure them and let them go on their merry way?

At that point I would place very little emphasis on the person's psychosocial situation or biographical history unless there was some other reason for it. The problem with your statement is that you are same with the people who see bio as the only way to go.

We have a skillset and we should use the skills that are the most appropriate. To place emphasis on certain skills is wrong, plain wrong. In today's world you are right but your ideas will be incorrect at some time in the not so distant future. Perhaps you have a spiritual aspect that is coloring your views (you have hinted at it) or you can't see a place where cures are possible. Whatever the case, when the time comes for biolgical cures, the psychosocial will be secondary at best while in other arenas, the psychosocial will be more important. So what if one trumps the other as long as the patient is treated optimally?

Manicsleep

Thank you for your answer. I will try and clarify my position. I have put your words in italics as I have not got the hang of the multi-quote function.

I agree that there needs to be integration and in todays world attention should be given to biological, psychological and social. As psychiatrists that is our job and it is what we are trained to do better than anyone else. But the final goal is only the cure and nothing more.

Forgive me but psychiatrists are educated and absorb an abstract body of knowledge. Training is what plumbers do.

As far as human distress being understood in the social context and biographical history, I think thats great. For example if you have a patient with cancer who is elderly, perhaps they can't live by self for a while after having curative surgery and family must be involved or they need a SNF etc. But if its a healthy person, youre cutting out a skin lesion...they dont need anything else other than a follow up on the cancer.

The analogy you present I accept as far as it goes but I am suggesting that all of what is described as mental illness is best understood as human distress which takes place in a social and biographical context,not as a disease. This being the critical difference between psychiatry and the rest of medicine.

Lets say a blood test for diagnosing schizophrenia is developed with excellent sensitivity and specificity. With it a 100% effective cure is developed as well. Are you really going to sit around and try to incorporate psychosocial aspects of treatment in someone who has not had symptom onset yet or would you cure them and let them go on their merry way?

I’ll indulge the prospect as this is about the future. To answer with an illustration. What if the person who took the test is a forth generation shaman living in central Africa, who has a valued role in their community because of their perceived ability to communicate with the spirit world. Are you going to take that away from them? Granted an extreme example but so is yours.

Why a blood test? Why not posit a genetic test? What will you do now, especially with all the people you identify as homozygous recessive? Are you going to cure them as well? Would this notional blood test work for say post natal depression?


At that point I would place very little emphasis on the person's psychosocial situation or biographical history unless there was some other reason for it. The problem with your statement is that you are same with the people who see bio as the only way to go.

I am sorry I thought I made it clear I am suggesting a change of emphasis not recommending throwing the baby out with the bath water.

We have a skillset and we should use the skills that are the most appropriate. To place emphasis on certain skills is wrong, plain wrong. In today's world you are right but your ideas will be incorrect at some time in the not so distant future.

Thank you. I will happily change my mind if new evidence comes to light.

The trouble with what I call a jam tomorrow approach is that it has negative consequences today ust as it has in the past. For the sake of a hypothesis that may or may not be right(in Scottish law the verdict would be unproven) it lumbers the very same people one desires to help with the notion that they have something biologically wrong with them that needs to be put right. I am sure you can see how this is distorted in to the prejudice and stigma that people who experience mental distress experience all the time and in quite a different way to people with cancer or skin lesions. This is a point that imo traditional psychiatry fails to address. Its is an epistemological certainty in the biological paradigm that pushes these the unintended consequences of the biological approach into the back ground as its easier to ignore the irrefutable rather than be honest and face it head on.

Perhaps you have a spiritual aspect that is colouring your views (you have hinted at it) or you can't see a place where cures are possible.

Infact I was trying to eliminate spirituality temporarily from the discussion because it tends to obscure things in this sort of conversation as we are quite far from a common understanding.

I think I am as capable as any one at separating a personal view from an objective analysis of any issue that is to hand. Although I am not so arrogant as to assume that somehow the evolutionary pressure that has led to our human predisposition for spirituality is something I have somehow managed to ellude by want of some freak of nature. I am sure you don’t either, unless of course you are claiming to be one of Nietzsches Ubermensch. How ever plenty of people do want their experiences to be understood in the context of a spiritual experience and that is huge challenge for traditional psychiatry.

For arguments sake, if you found the gene for spirituality would you recommend drug therapy or psychosurgery or gene replacement therapy for that matter? That would be consistent with the line you are taking.

I would say that no one is immune from taking account of their personal experiences. Is that not what clinical experience is all about, the very thing that allows a deviation from evidence based medicine when it seem appropriate?

Consider for a moment Schrödinger’s cat, waiting in its box for a gun to go off as a radio active isotope decays. I assume you are familiar with this thought experiment. The variation where one considers ones self to be in the position of the cat with a magnificent human brain is instructive regarding the dangers of epistemological certainty.

Btw it’s interesting that nuclear physicists as a breed tend to be rather open minded and comfortable with ambiguity, rather like the best psychiatrists.

Whatever the case, when the time comes for biological cures, the psychosocial will be secondary at best while in other arenas, the psychosocial will be more important. So what if one trumps the other as long as the patient is treated optimally?

The difference between us is that I am hopeful that ways of ameliorating human distress will continue to be refined and I am suggesting that the best way to do that is to disinvest in the lanquage of pathology and the fruitless quest for biological markers that don't exist. You are suggesting the equivalent of searching for a safe way to eliminate people with the autosomal recessive trait that leads to hitchhikers thumb when you don’t yet and can not yet know, what the future utility of that trait might be.
Sure, science can set you free but it can also bind you in ways you didn’t expect.

To make myself clear I am not denying psychosis or trying to romanticise it but I am posting a different paradigm that I believe will continue to bear fruit.

Thanks for the response; as you are as intellectually wedded to your position as I am to mine, I can only wish you well. Sticking to the one partner has many benefits I am sure. May your bio bio bio lover serve you well and if they turn out to have a much more attractive sibling, no fault divorce is rather common these days I understand.

In the mean time I look forward in a few years time to the publication of your magnus opus and if instead it ends not with some pious notion about further investigation leading to the betterment of mankind, but with the phrase quad erat demonstrandum I will salute you.

Ibid what are you exactly? I am not sure you have an understanding of psychiatry or medicine in general.

I agree that there needs to be integration and in todays world attention should be given to biological, psychological and social. As psychiatrists that is our job and it is what we are trained to do better than anyone else. But the final goal is only the cure and nothing more.

Forgive me but psychiatrists are educated and absorb an abstract body of knowledge. Training is what plumbers do.

:lol:
That must be why residency programs are also known as training programs and why physicians refer to their residencies as "where I trained."

The analogy you present I accept as far as it goes but I am suggesting that all of what is described as mental illness is best understood as human distress which takes place in a social and biographical context,not as a disease. This being the critical difference between psychiatry and the rest of medicine.

:bullcrap:

Not true. Schizophrenia is not simple human distress distress, delirium and dementia is not simply distress, mania is not just distress. Mood disorders, psychotic disorders, sleep disorders, dementias and deliriums can occur with relatively little 'social and biographical' context. These are disease states as much as cardiovascular disease is a disease state.

You are wrong.

Lets say a blood test for diagnosing schizophrenia is developed with excellent sensitivity and specificity. With it a 100% effective cure is developed as well. Are you really going to sit around and try to incorporate psychosocial aspects of treatment in someone who has not had symptom onset yet or would you cure them and let them go on their merry way?

I’ll indulge the prospect as this is about the future. To answer with an illustration. What if the person who took the test is a forth generation shaman living in central Africa, who has a valued role in their community because of their perceived ability to communicate with the spirit world. Are you going to take that away from them? Granted an extreme example but so is yours.

Why a blood test? Why not posit a genetic test? What will you do now, especially with all the people you identify as homozygous recessive? Are you going to cure them as well? Would this notional blood test work for say post natal depression?


:wtf:

Your first example makes no sense. Does this shaman have a disease? Are you implying that they are schizophrenic?

As far as blood test vs a genetic test. You understand that blood contains genetic information or no? But either way is fine we do genetic testing for many things already. As far as homozygous recessive, I dont understand what you are trying to say (not sure that you do either). What does that mean as far as disease penetrance?

A blood test COULD be developed for anything in theory. A test for schizophrenia would not work for post partum depression...most likely.

The difference between us is that I am hopeful that ways of ameliorating human distress will continue to be refined and I am suggesting that the best way to do that is to disinvest in the lanquage of pathology and the fruitless quest for biological markers that don't exist. You are suggesting the equivalent of searching for a safe way to eliminate people with the autosomal recessive trait that leads to hitchhikers thumb when you don’t yet and can not yet know, what the future utility of that trait might be.
Sure, science can set you free but it can also bind you in ways you didn’t expect.

:boom:

Right. No markers for any disease state have been found. Next time I meet someone who had breast surgery without cancer because they had a "fruitless marker" and a few deaths in the family to breast cancer I will tell them that they made a horrible mistake because who knows what that breast could have done.

The really annoying thing is you actually have the nerve to talk of epistemological certainty in the context of schrodinger's cat when illustrating your point. If you really believe all you say give up all that science has provided and live in the wild then as a hunter gatherer.

Manicsleep

Don’t be annoyed and casting aspersions is undignified. Now before you spit your dummy out again, yes, the dumbing down of the English language is a pity and trained is the common parlance but that does not make it correct. Strictly one reads a subject. Perhaps you have not been burdened with a classical education.

Now, saying not true in a loud voice adds nothing to your argument. I have posited that schizophrenia is not best understood or helped by naming it as a disease. You are getting muddled up when you try and equate mental distress with true illness like cancer. That is my whole point and why we are so far apart.

In this case and in every case it is up to the hypothesiser to demonstrate the worthiness of their case. In this instance you need to find the biological marker for schizophrenia. Its no good getting upset because you can’t find it. That’s your problem. I don’t think it exists and so far all the evidence is on my side sunshine, not yours. Forgotten Carl Popper so fast have we? How convenient for you.

I did think we were making progress but I see that you have wilfully disregarded the point I made about your fantasy paradigm having real life negative consequences for people now. Well keep you head in the sand and bio-bable away to your hearts content. The tide of history is against you. Psychiatry is not like the rest of medicine despite what you like to think.

I think the lab is probably the best place for you as even contact with people on the internet seems to be all rather to much for you. God knows what you would be like with patients in the flesh.

With all your 'classical education' you failed to understand my simple words. I will ask again.

Ibid. Are you a physician?

Manicsleep

Why are you trying to make this personal and about me?

You have not answered my questions either. In fact your are purposefully avoiding the issues that I have raised. I have given my view to each and every point you have made. You have not done the same in return.

With all your 'classical education' you failed to understand my simple words. I will ask again.

Ibid. Are you a physician?

Great question. I think many of us would like to know as well.

In this case and in every case it is up to the hypothesiser to demonstrate the worthiness of their case. In this instance you need to find the biological marker for schizophrenia. Its no good getting upset because you can’t find it. That’s your problem. I don’t think it exists and so far all the evidence is on my side sunshine, not yours. Forgotten Carl Popper so fast have we? How convenient for you.

Paint me confused, but there are biological markers for schizophrenia. Yes, schizophrenia is polygenetic, and yes, no person with the disease is exactly alike. A biological predisposition is influenced by the psychological and sociological context, no one (I presume) would argue with this. But there are plenty of biological markers for the disorder. There are common genetic mutations and changes in the brain (to both grey and white matter) that have been found to be prevalent in people with this diagnosis. Do all people have every marker? No, because schizophrenia is so polygenetic that clinical presentations vary widely from one person to the next.

So schizophrenia is not a single gene autosomal recessive disorder, but neither is, say, diabetes. Diabetes (let's take type 1 for simplicity) is marked by a genetic predisposition, but inheriting said genes does not mean you will necessarily inherit the disorder. Such a thing is influenced by the environmental context. This does not mean, however, that the biological markers don't exist, or that genetics and biology do not play a very strong role in the course of the disease.

The same thing goes with schizophrenia. Or bipolar disorder. Or depression. Biology is not destiny. But neither is it irrelevant.

Manicsleep

Why are you trying to make this personal and about me?

.

Because you have personally insulted anyone who disagree with your views. The pot is calling the kettle black here as another poster wrote.

Snafer how nice to see you again. Another one who likes to play the man and not the ball.

I would remind you that this is a student network, not the Nobel Prize winners after party.

So far between you and Manicsleep you have singularly failed to post anything that someone with a high school attendance certificate wouldn't grasp.

Evidencebased

Well put but what you are saying is still ultimately conjecture. I do understand what you are saying and why I read the latest Copy Number Variation studies with interest with the caveat that traditional early work found zip. I don’t want to start swapping journal refs but just to say that is my interpretation of them.

I do think the stress vulnerability model you allude to has had its day. I would like to see something closer to a working model that incorporates the latest evidence but for the time being the SV model is rather crowding out anything that doesn’t fit with it.

I would remind you that this is a student network, not the Nobel Prize winners after party.
.

True. So are you or aren't you?

A lot can be said for proper education or lack thereof.

Snafer, sweetheart, go away and take a few deep breaths with your head in a paper bag and come back when you can deal with the issues at hand.

I won't be swapping biographical details, OK sweetie.

<Gruff Moderator Voice>

Play nice - all of you. The core issue here is getting lost amongst all the posturing. Find it quickly or you'll find this thread locked.

With that ticking off, I certainly apologize if I have offended anyone.

I think I will go with :troll:
I will just ignore him and would ask others to do the same. (If you think I am the troll, don't respond to me).

Anyways.
The future of psychiatry is going to be modulated by several factors. Here are a few that I can think of.

Ever increasing stressors due to greater population density and paradoxical concomitant isolation that humans suffer.

Increased awareness of mental illness as well as fluctuating stigma.
i) I think overall the stigma is decreasing even with the scientologists and other fringe groups.
ii) there is going to be an upswing in the forensic aspect I think. It has already happened to a degree and if more events like VT happen, it will get worse for the severely mentally ill. The pendulum is starting to swing the other way.

The new health care system. Who knows what that will bring but it will be a game changer. This can be bad in the short run but ultimately I think it will be good for the patients and psychiatrists.

Technological and scientific advances. Psychiatry and Neurology are both primed for major breakthroughs and I think we are going to come full circle where the two specialties start to merge again. The countdown has begun, its time for liftoff.

I think I will go with :troll:
I will just ignore him and would ask others to do the same. (If you think I am the troll, don't respond to me).

Anyways.
The future of psychiatry is going to be modulated by several factors. Here are a few that I can think of.

Ever increasing stressors due to greater population density and paradoxical concomitant isolation that humans suffer.

Increased awareness of mental illness as well as fluctuating stigma.
i) I think overall the stigma is decreasing even with the scientologists and other fringe groups.
ii) there is going to be an upswing in the forensic aspect I think. It has already happened to a degree and if more events like VT happen, it will get worse for the severely mentally ill. The pendulum is starting to swing the other way.

The new health care system. Who knows what that will bring but it will be a game changer. This can be bad in the short run but ultimately I think it will be good for the patients and psychiatrists.


I really hope you're right on this. The current health system is getting very frustrating to work in. And I'm still in training! Let's just hope it will ultimately provide better access for patients and cut down on paper work!!!

and scientific advances. Psychiatry and Neurology are both primed for major breakthroughs and I think we are going to come full circle where the two specialties start to merge again. The countdown has begun, its time for liftoff.

I'm very excited about the possibilities of utilizing technology and scientific advances in psychiatry, especially as we learn more about the brain and mind. However, I have a hard time seeing the benefit of merging neurology and psychiatry. Although we both are treating the same organ, the skills and training are so different. How would that look with things like therapy training?

Yeah that paperwork aspect is a burden but I don't see it getting better. With more government, I anticipate more paperwork not less. At least in the early stages.

I'm very excited about the possibilities of utilizing technology and scientific advances in psychiatry, especially as we learn more about the brain and mind. However, I have a hard time seeing the benefit of merging neurology and psychiatry. Although we both are treating the same organ, the skills and training are so different. How would that look with things like therapy training?

I don't see the two disciplines becoming the same but I do see a much greater crossover. A blurring of the lines in many areas.

I don't see psychiatrists treating stroke but I can see interventional psychiatry or psychoradiology as distinct subspecialties. On the other hand you may have multispecialty fields where many specialties are needed and as a result you have a blending of specialties. One field that psychiatry already does that with others is sleep medicine. When these crossovers start to happen you end up doing a lot more than originally intended. I hadn't planned on treating OSA with CPAP, reading EEGs/PSGs/MSLTs, performing detailed oral exams (without saying much at all:D ) when I started psychiatry residency. I didn't expect to have my sleep CBT 'supervisor' be a neurologist either.

I think therapy is still therapy but you may find neurologists doing more of it. When I found out my sleep CBT supervisor was a neurologist I laughed, not because she wasn't good, but because she had been my senior when I was an intern and she had always said she didnt want to deal with 'mental' patients and that was why she was going into sleep. She did a behavioral sleep fellowship along with a regular fellowship and was excellent. The TD let the psychologists train the pulmonary/neurology people because he knew I already knew CBT and because it was this attending's first year. We had a great time.