The Everyman Psychiatrist

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I Haven't Seen the Evidence for Evidence-Based Psychiatry

Patient! Are you a person or a collection of symptoms?

"Patients don't read the textbook" is a perennial truism in medical education, especially in teaching students, interns, and residents how to treat patients. And for good reason. 

Real patients present with multiple problems simultaneously and, furthermore, some of these issues are not suitable to being medicalized. There are existential, spiritual, social, and moral problems not amenable to facile categorization.

When you go see your doctor, would you rather be seen as a collection of sortable symptoms or as a real-live complex human being? One problem with evidence-based clinical research in psychiatry is that it looks at data collected from the grouping of multiple patients. This data may or may not pertain to you as an individual patient. 

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But a larger issue is the now widely recognized problem with accumulated research evidence tainted by conflicts of interest between researchers and their funding sources, namely large pharmaceutical companies. Red flags here include the massaging of statistics to present secondary findings as primary, the ghost-writing of academic articles by marketing professionals, and the habit developed by Big Pharma of trying to find diseases for drugs already on the market aka "drugs looking for diseases," the last of which turns the gold standard of prospective, randomized, double-blinded studies on its head.

There is a huge gap between research, both clinical and bench, and the practice of psychiatry that is currently a major focus for academic medical centers. It's called "translational research" and is often encapsulated in the aphorism "from bench to bedside." 

While the work that basic scientists do to understand the neurobiological and genetic underpinnings of the mind, brain, and behavior is incredibly important, seldom do these research findings translate and trickle down to the clinical standard of care. Often, the technology involved makes it too expensive to be widely applied.

Unfortunately, too many physicians and other medical providers use the evidence base to justify not treating patients, propagating what I call a "culture of timidity." Living in fear of malpractice lawsuits intensifies this phenomenon. This is what I would call a sin of omission, easily distinguished from the other end of the spectrum, the sin of commission, of ordering too many tests, performing unnecessary procedures, and prescribing too many (often expensive) medications.

Take a typical patient at the harm reduction clinic where I work with gay men who are trying to reduce and eventually stop their use of methamphetamine. How do you sort out a person who has a history of suffering from physical and emotional abuse, head trauma, HIV disease, hepatitis C, recurrent MRSA infections, type I diabetes, a personality disorder, a mood disorder, and a substance use disorder who is undergoing a spiritual and existential crisis? 

Sound impossible? Granted, that would be among my more complex patients but there are tens of thousands of patients just as complex as that one out there in the world. How would the evidence base address that patient?

At the end of the day, there is a mandate still for physicians to alleviate suffering and rarely do the dry academic constructs provided by the evidence base include a framework for the reduction of suffering.

I try to break the issues down by identifying a current collection of symptoms to possibly treat with psychotherapy or medications. In addition, I try to make a longitudinal working psychiatric diagnosis. So, yes, I use the evidence base to make a diagnosis and to select a treatment plan to address the presenting problems. I stay current with updates in diagnosis and psychopharmacology.

But, after that, it is my job to tailor a treatment plan meant to address my patient as a unique individual.

It is the frontline clinician whose job it is to bridge the gap between the bench and the bedside, even when that is a yawning chasm.

Paul R. Linde, M.D., is a San Francisco-based author and clinical professor of psychiatry at the UCSF School of Medicine.

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