I took a break from my busy schedule at Our Lady Of An Undisclosed Location to attend another local Psychiatry Conference.
This conference consisted of a series of talks about all the most important issues of the day, like ‘The Menace Of Psychologists Being Allowed To Prescribe Medication’, ‘How To Be An Advocate For Important Issues Affecting Your Patients Such As The Possibility That Psychologists Might Be Allowed To Prescribe Them Medication’, and ‘Protecting Members Of Disadvantaged Communities From Psychologists Prescribing Them Medication’.
As somebody who’s noticed that the average waiting list for a desperately ill person to see a psychiatrist is approaching the twelve month mark in some places, I was pretty okay with psychologists prescribing medication. The scare stories about how psychologists might prescribe medications unsafely didn’t have much effect on me, since I continue to believe that putting antidepressants in a vending machine would be a more safety-conscious system than what we have now (a vending machine would at least limit antidepressants to people who have $1.25 in change; the average primary care doctor is nowhere near that selective). Annnnnyway, this made me kind of uncomfortable at the conference and I Struck A Courageous Blow Against The Cartelization Of Medicine by sneaking out without putting my name on their mailing list.
But before I did, I managed to take some notes about what’s going on in the wider psychiatric world, including:
– The newest breakthrough in ensuring schizophrenic people take their medication (a hard problem!) is bundling the pills with an ingestable computer chip that transmits data from the patient’s stomach. It’s a bold plan, somewhat complicated by the fact that one of the most common symptoms of schizophrenia is the paranoid fear that somebody has implanted a chip in your body to monitor you. Can you imagine being a schizophrenic guy who has to explain to your new doctor that your old doctor put computer chips in your pills to monitor you? Yikes. If they go through with this, I hope they publish the results in the form of a sequel to The Three Christs of Ypsilanti.
– The same team is working on a smartphone app to detect schizophrenic relapses. The system uses GPS to monitor location, accelerometer to detect movements, and microphone to check tone of voice and speaking pattern, then throws it into a machine learning system that tries to differentiate psychotic from normal behavior (for example, psychotic people might speak faster, or rock back and forth a lot). Again, interesting idea. But again, one of the most common paranoid schizophrenic delusions is that their electronic devices are monitoring everything they do. If you make every one of a psychotic person’s delusions come true, such that they no longer have any beliefs that do not correspond to reality, does that technically mean you’ve cured them? I don’t know, but I’m glad we have people investigating this important issue.
– I’ll come out and say it: cluster randomization is really sketchy. Today I got to hear about a multi-center trial which randomized by location – half of their hospitals were the control group, the other half were the experimental group. Problem is, the patients in each hospital were given group-appropriate consent forms – either “We will be treating you as usual, but monitoring you more closely for a study” or “We will be giving you extra experimental treatment”. Not only does that break blinding, but it implies a different population of patients in each group – the ones willing to consent to monitoring versus the ones willing to consent to treatment? Might sicker people be more willing to sign the treatment consent, since they don’t want to deal with monitoring but treatment offers the chance for personal gain? Might paranoid people be more willing to sign the control consent, since they’re not being used as guinea pigs? I don’t know. But I checked those pre-intervention inter-group comparisons they have to show, and there were big differences between the two groups (for example, I think one – I can’t remember which – had like twice as many black people). Either randomize peopple properly or at least keep people blind to condition.
– On the other hand, I’m quickly losing my prejudice that RCTs always beat naturalistic studies. I’ll write more about this later, but today’s showcase was long-acting injectable versus oral antipsychotics. Conventional wisdom is that long-acting antipsychotics, in the right patient population, decrease relapse because they remove the option of not taking the medication. The best randomized controlled trials don’t find that. The best naturalistic epidemiological studies do. The expert who spoke today theorized – and I agree – that the naturalistic studies are right. He argued that one feature of RCTs is very close monitoring, which means the patients in them comply with their medication at an unnaturally high rate – thus removing the long-acting drugs’ one advantage. The studies conducted in the real world of patients not taking their medications regularly are more relevant.
– They say psychotic people don’t take their meds because they hate the side effects, or because they’re too crazy to know better, or because they just can’t be bothered. But one of the doctors today raised a novel hypothesis: are antipsychotics anti-addictive? After all, some of the most addictive drugs are those that raise dopamine levels – cocaine, meth, and MDMA are all either dopamine releasing agents or dopamine reuptake inhibitors. Antipsychotics have pretty much the opposite effect as those, lowering dopamine in the brain. Suspicious. But I have a feeling this isn’t true. Dopamine is more complicated than that. Levodopa-carbidopa, which is one step short of pure dopamine and is given to dopamine-deficient Parksinson’s patients, is as far as I know not addictive at all. It’s also very clearly antagonistic to antipsychotics. Probably antipsychotics are the opposite of non-addictive levodopa, not the opposite of cocaine or anything. I don’t know how to phrase it more rigorously than that. Still, I like the way that person thinks.
– Ever since Indiana’s legislature debated a bill that implied pi = 4, Midwestern states have had a reputation for trying to legislate science. Maybe this had something to do with the claim by one psychiatry lobbyist that Kansas’ legislature is trying to ban the DSM. I can’t find anything on it online and it sounds like an urban legend to me. Tangentially related silly clickbait: Arizona lawmakers say horses aren’t animals.
– Unintentional puns are some of my favorite puns. I still remember fondly when the head of a psychiatric hospital where I used to work said that if Obamacare passed there would be too many patients and the place would “turn into a madhouse”. I collected another good one today when an activist was talking about gun rights for psychiatric patients: “Taking guns from psychiatric patients isn’t going to be a panacea for violence – would anyone like to take a stab at why?”
– Clozapine really is the best antipsychotic, hands down, and the evidence isn’t even subtle. It’s also the most dangerous, and the rules say that you should only prescribe it to a patient after you’ve tried and failed with two other antipsychotics. One of the speakers was a researcher who’s trying to get a grant to prove that it’s actually more effective to try clozapine after only one failed antipsychotic, but the NIMH rejected his proposal because “even if you proved that, no one would listen”. They’re probably right. A lot of psychiatrists hate clozapine because it’s messy, scary, and requires a lot of paperwork and monitoring. The speaker presented survey after survey of psychiatrists making lame excuses like “My patients wouldn’t want it”, and then survey after survey of those psychiatrists’ patients saying they do so want it but nobody asked them. Clozapine is messy and scary and requires lots of paperwork, but if you’re a good doctor you’ll give your patient the drug that will help them anyway.
– The APA representative says that 95% of candidates supported by the APA’s PAC get elected. I think it was supposed to be a boast, like “look how effective we are”, but that’s a bit much. Either the APA single-handedly controls all American politics, or else they’re very careful to always back the winning side. Properly understood, that number should probably be taken as a measure of exactly how cynical they are.
– Not that they didn’t admit their cynicism straight out. Our Political Activism Consultant explained that state legislators are all sorta new and confused and inexperienced all the time because of term limits. And if you put on a nice suit and a tie and tell them “Hey, I’m a doctor from your district, here’s how you need to do health care policy…” you have a pretty good chance of getting them to nod along and assume you know what you’re doing. I didn’t realize how easy this was, and I hope I never use this power for evil.
– This is basically how the Eternal War Against Psychologists Being Allowed To Prescribe Medications is being fought, but the psychologists have caught on and now they have nice suits and ties too. Also, it turns out senators have a hard time differentiating the APA (American Psychiatric Association, fighting tooth and claw against psychologist prescribers) from the APA (American Psychological Association, fighting tooth and claw for psychologist prescribers) and they end up freaking out and trying to figure out why the same people are lobbying for both sides and whether this is some kind of weird shrink mind game thing.
– Drug companies were giving out stress brains! Like stress balls, only they’re shaped like brains and have little sulci and gyri on them! If in ten years I’m one of those people who never prescribes clozapine, it’ll because I’m prescribing the drug by the company that gave me a stress brain instead.