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The authors, a mix of psychiatrists and therapists, begin early on to point out the iniquitous state of mental health care despite massive spend over the last 100 years. They mention the usual problems including some that are less well know. For instance, most people on medication for behavioral conditions never finish their treatment, and indeed, most don't even fill the second script for antidepressants. They certainly do mention the dismal findings of STAR-D(epression) study: just over 30% of patients get better on one drug, two thirds will require up to four changes. CATIE, which they also mention, finds that about three quarters of patients with Schizophrenia will fare poorly on their medication. The authors appear to believe that a collaborative effort will improve this.
They would not have had the opportunity by 2006 to view the recent findings on data gleaned from FDA material, that most drugs don't beat placebo in depression, and when they do, it's in those groups where the placebo response is most muted.
One-size fits all treatments don't seem to guarantee success. Most care is in the hands of often poorly-tooled PCP's as is the case with disability pronouncements. The annual cost to the USA is a $2.2 trillion spend with little outcome worthy of pride, about equal to the total GDP of China, and set to double within a few years. Americans pay up to 70% of some scripts, and despite not having universal healthcare for free, the USA pays up about $8000 per year per citizen in medical care, whereas countries like the UK and Australia, which do have universal free healthcare, pay about $2500 per head.
It's a dismal scenario overall, and in behavioral health, it's even worse. The reality is that when a drug company produces a behavioral management compound for approval, about half don't make it. Of those that do, placebo is the most active ingredient. Alternative treatment clinics are growing in size and influence. We don't have any cures for these things, despite the clarity of the growing cost to the US economy in people and money terms, per year. It's billions.
This is what the book offers in 2006:
Firstly, it acknowledges that the clinicians involved may not actually have any real understanding of the brain or its constituent parts, and just 11 pages are devoted to this subject, but includes the entire nervous system in tightly written text. Five pages are devoted to how psychotropic drugs work, citing pharmacodynamics and pharmacokinetics along the way. Not since Bill Bryson has anyone crammed so much into everything you need to know texts, and obviously they have been extremely selective.
Moving on to Mood disorders, and thus following the DSM idea of nosological categories is an obvious approach, but given recent critiques of that entire categorical system, such as by Steve Hyman, past President of the NIMH, it leads down a path they do not entirely deal with. Namely this: if these categories are too categorical, in other words, ignorant of the continuum of disorders, then drug discovery based on these categories is likely to be handicapped. This has happened. For instance, removing the category of anxiety disorder from mood disorders has not resulted in a single new drug for the treatment of anxiety that is not already a treatment for depression; similarly, most antipsychotics and anticonvulsants have properties across the spectrum of DSM categories as well.
So sadly, I do not believe that an understanding of brain or disorders categories in itself adds a thing to the treatment of behavioral disorders if we continue to replicate the baseline problem of how we define the targets of pharmacology. The modern issue of personalized medicine is not addressed her, although it is hinted at from time to time in the book. The issue of an integrated approach is not much addressed in that context, there is a two page summary table though; markers and biomarkers are not mentioned at all, nor is critical path analysis. This is a burden for a book written sometime in 2004-2005 or so to be published in 2006. There is some elaboration of these and other issues in the latter appendices of the book, but the future is now for this book. Not crippling, but limiting. The Pharma world is rapidly changing, so is the idea of biomarkers, which is apparently not limited to genes anymore, but to any brain marker of who will respond to what treatment.
Hence, as they discuss, the decision to give a drug is always a work in process with the risk of being wrong, and prescribing is trialing the drug, in that patient. The right drug, for the right patient, at the right time, is not clearly delineated on an identified target, as they acknowledge tacitly. They may not be looking at a depression when it turns out to rapidly cycle when given a stimulating antidepressant.
The collaborative approach is on the face of it a better approach than the single clinician with a single patient model. They acknowledge that some will have to give up cherished beliefs, or skills, and learn new ones, and a shift in attitude. In general they say, the therapist relinquishes the role of expert on the mental health and emotions of a shared patient, and instead embraces a more holistic view of the medical and mental health of the patient. In other words, if you want to work with medical practitioners including psychiatrists, you have to adapt to them, give up some protected information, understand that psychiatrists have less focus on the patient's story and life history, or what Miller has described as a failure to engage with patient suffering owing to a focus on evidence based medicine. Respect for the hierarchy and respect for perspective are the key features in dealing with this latter group (page 243).
Collaboration with the family is another issue of course. The authors are surprised at how seldom family are asked to provide collateral, and in terms of the family therapy movement of the 50's, engage with systems theory to elaborate on that relationship.
I think that two years ago, this book was really most helpful, and today, it still is a good primer for those it sets out to target. It focuses nicely, is tightly written, but I am not sure if it doesn't pretend to be more than it is at this stage in 2008. This is now a vast and complex field, and dumbing it down is very useful, although detail is often an interesting way to dumb things down. The arguments today in Pharma, Personalized Medicine, Genomic and other biomarkers, integrated and integrative approaches, the value of the new studies such as iSPOT-D which is a neuromarkers and placebo version of STAR-D, all are turning the field over on its head.
What the authors need is to hurry a second version to press, two years or more is a long long time in this field.
Are the sentiments timeless? I think the book represents, but does not present, an indictment of the way behavioral health is practiced. The mere fact of the absence of collaboration, and family centered and client centered approaches, and the fact that the science of psychopharmacology and the way drugs are discovered is so poor when compared to other fields of medicine, makes it hard to read these things without becoming angry. Recent works querying the DSM categorical approach, the value of the depression diagnosis instead of melancholia, the valueless application of evidence in ignorance of human engagement, all of these things illuminate that if you do become ill, the system to preserve and enhance you is not yet there. Any approach which combines a team with a family and neuroscience is to be applauded, and regularly updated.
© 2008 Roy Sugarman
Roy Sugarman PhD, Brain Resource Limited
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