Hippocratic vs Galenic psychiatry

Interesting question....though I'm not braining too good today.

Honestly, this sounds like it could be a really fun thread, and about 3 times I've started to reply to it and written a few paragraphs, but for some reason it just entirely exhausts me. This is heady stuff, requires a pretty in depth critique and criticism of what evidence-based medicine is and isn't.

I just did it again, writing about 5 paragraphs, being thoroughly unsatisfied, and deleting them. So it goes.

Between Farmville and SDN, I'm pretty sure my wife is considering divorcing me.

Not boring. Just that I'm working my tail off and have very little time. The times I have posted were more on the order of sanity breaks from work.

I think the differentiation is absolutely key. It's fascinating to read Hipoocrates' critique of colleagues who overprescribed since it echoes a common current complaint.

In general, I do think we should be parsimonious about meds, especially when the evidence is lacking (as it often is). It's awfully easy to toss meds at every random symptom rather than carefully consider the diagnosis (eg, PTSD, Borderline PD, insomnia) and then apply an efficacious treatment that may not even include meds. It reminds me that if you have one tool in your toolbox, it's pretty clear what tool you'll use (ie, learn multiple treatments!).

The Kraepelin vs Freud dichotomy of theories of psychiatric praxis seems roughly analogous w/ Kraepelin as Galen and Freud as Hippocrates. With regards to psychopharmacology I am firmly entrenched in the Stahl/Kraepelin/Galen camp.

I am quite surprised that Ghaemi thinks that the neurobiological etiology of psych diseases is well understood. Take mood disorders, for instance. Our best theories of monoamine deficiencies/malfunction don't jibe with the fact that monoamine reuptake inhibitors take on average 4-6 weeks to show efficacy despite raising levels in vivo instantly. As Stahl argues, it is likely that second messenger pathways and transcriptional factors such as CREB are causing the antidepressive or anxiolytic effect, and I don't think we can yet say we have a very good understanding of these pathways and their link to mood.

If there are tools that can a help a patient find psychic relief I see no reason to withhold them. Like with any type of medicine, a Bayesian analysis of the situation should be performed and the option that looks to provide the most benefit with the least risk of adverse effects should be chosen. Of course, sometimes the most effective meds also come with the greatest risks.

Take an apathetic responder to SSRIs who cannot tolerate bupropion but nevertheless is less depressed than before pharmacotherapy. Options include augmenting with a stimulant or switching to an SNRI (among other things). I think stimulant augmentation would be a better option because apathy/anhedonia has shown to be highly correlated with low DA in mesolimbocortical pathways, however I think a majority of psychiatrists would go with the more defensive option of the SNRI. The term 'polypharmacy' is used as a pejorative, but I think the most pernicious and widespread psychiatric malfeasance is a direct result of polypharmacy's antithesis, under-treatment and defensive medicine.

To the initiated it might seems like an esoteric debate but it is far from it. It is just these sort of distinctions that will define the success or otherwise of a practitioner.

One’s goal is concordance with a treatment plan that you and the patient have devised together. (Neanderthals will out themselves by using terms like adherence and compliance). All the evidence suggests that it is the quality of the relationship between the Doctor and the patient that distinguishes between successful and unsuccessful outcomes. This is true of psychotherapy and if you are prescribing antidepressants, so it’s a powerful effect.

Concordance with a treatment plan has the best chance of being achieved when the patient and the doctor agree about the theoretical basis for any prescription. For instance if that theoretical basis is that a medication is projecting an altered state on the patients brain, its much easier for a discussion to take place about the attendant benefits of taking the medicine and balancing them with the attendant risks. Rather than insisting that each medicine is acting at the level of correcting an underlying pathology.

Notice that the first framework involves the patient in the discussion allowing for joint decision making rather than the second approach which leaves all the power with the Doctor. The second framework just leaves the Doctor arguing the case for what may be the same prescription! A rather unhappy and stressful way to practice to boot!

In both cases the prescription will be the same but the theoretical framework chosen by the Doctor makes all the difference.

Not an esoteric debate by any means.

A perceptive attending during my residency caught me planning to prescribe medication based on "he has these symptoms which are most often linked to these transmitter systems, so we'll prescribe this medicine to counter that effect." He asked me, "You think you know enough to play 'receptor pharmacology? None of us do. Stick with what you believe will work, and don't go trying to pinpoint receptors or neurons that we have no way to accurately target."
He was right.

Now, when I see patients who are medication naive being started on 3-5 medicines I cringe. I've been known to "forget" to continue a couple at the next discharge or admission. Not everyone with any sort of agitation needs depakote 500mg BID and not everyone needs Trazodone because "he's probably not sleeping well," and not everyone with any sort of mood problem does better with the addition of an atypical antipsychotic.

(Well, maybe Nemeroff wouldn't have made some of those decisions had he been on that cocktail.)

Ibid said:

Notice that the first framework involves the patient in the discussion allowing for joint decision making rather than the second approach which leaves all the power with the Doctor. The second framework just leaves the Doctor arguing the case for what may be the same prescription!

Click to expand...

MINOR RANT ALERT
I completely concur that the best outcomes are the most likely when the practitioner and the patient agree on the treatment plan. And that should be our default position.

However, about 10% of my patients are either so distraught or so distracted (usu. by internal stimuli) that they cannot make a decision or they have lost all faith in their own decisions. Those patients often look at me with saucer-sized eyes and say, "I don't know. I don't know anything anymore. I need you to decide." When patients are needing us to take a more authoritative approach, we need to be prepared to do that (with the hope of returning to a "team" approach as soon as possible). I think it is unethical to leave the patient in the lurch by demanding a decision from someone who cannot provide it because of the very condition we are treating.

Also, the "theoretical" framework of a treatment plan agreement might not always have to be a pathophysiologic or even a psychologic theory. Sometimes, the theory upon which we agree to begin treatment is as basic as, "I have some medicines that can help block those thoughts from getting into your brain. And if the first one I try isn't just right, I'll keep working on changing the dose or the medicine to get it right. My goal is to quiet those voices enough that you can go back to functioning. If we get lucky enough to block them out completely, well that's wonderful, but we're going to start with trying to get you back to being the kind of husband/father that you know you're supposed to be. You're job is to let me know if it's working, if the medicines make you feel bad in any way, and tell me about anything at all that you need. Does that sound like a plan?"

For patients that is often just as valid, and much more salient, than trying to talk about "dopaminergic" and "mesolimbic" and "reuptake inhibitor." All that is useless if you have not discussed what it is The Patient wants out of this partnership. And that is often outside the realm of KaplanAndSadock or Stahl or even Freud.

Kugel

It didn't read like a rant to me. It made perfect sense. Regarding the ten percent, the only thing I would add is that it's not beyond the realm of possibility that they may have an advance directive recorded in their notes. Clearly you won't be bound by it but their is nothing to stop you taking account of it if one exists.

For people presenting with a first episode it's my own opinion that you should have the option to use your discretion and not medicate straight away. In the UK that is not what the NICE guidelines recommend but like I say your judgement should be paramount.