A physician’s introspective comments about why he and his fellow physicians often forego the same end-of-life treatments they offer to patients has spurred a national dialogue, led to renewed interest in the Johns Hopkins Precursors Study of physicians, and provoked discussions about advance directives (AD) (eg, a living will or durable power of attorney for health care) and “the good death.”

 a retired Clinical Assistant Professor of Family Medicine at the University of Southern California, wrote an essay, “How Doctors Die: It’s Not Like the Rest of Us, But It Should Be,” as part of Zcalo’s “Remedies” series.

“They [physicians] know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone,” Murray wrote. “They want to be sure, when the time comes, that no heroic measures will happen-that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR . . . .”

He condemned futile care, “when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day.”

In exploring why physicians administer so much care they wouldn’t want for themselves, Murray explained that often the patient has made no advance plan for the situation, and consequently, “shocked and scared family members find themselves caught in a maze of choices.”

In addition, Murray said, the lay public has unrealistic expectations of what physicians and certain interventions, such as CPR, can accomplish. Physicians are reluctant to impose their views on the vulnerable, and if physicians advise against further treatment, some people may characterize them as “acting out of base motives, trying to save time, or money, or effort.”

Other factors mentioned by Murray include patients being “victims of a larger system that encourages excessive treatment” and physicians’ fears about litigation or getting into trouble. He cited a case in which he turned off a life support machine, per the patient’s prior expressed and written wishes and after speaking to the patient’s wife and hospital staff: a nurse reported his action to authorities as a possible homicide. (He wasn’t charged.)

In an adaptation of his essay, “Why Doctors Die Differently,” published in 

 added data from the medical literature about physicians’ use of the ADs for themselves, low survival rates with CPR, and attributes of a “graceful death.”

Both national and international media have covered aspects of Murray’s essays. In April, his original essay was selected for the collection 

Still, Murray, who had a private practice in general medicine for some 25 years, is surprised by the widespread response to his essays.

“I have been astonished by the huge number of comments (over a thousand) that are almost universal-ly supportive of what I’ve written,” he told 

. “I have been especially pleased to see the virtually unanimous confirmation of my observations by other health care professionals.”

Murray added that he felt humbled by the large number of very personal stories related by posters, including professionals, often describing terrible end-of-life experiences of family members.

“Virtually all are stories of overtreatment, and they often describe considerable guilt over the poster’s actions,” he said. “It tells me that we have a long way to go in providing care that people want for themselves.”

Murray reflected that physicians “have always had a bit of a self-imposed stigma of death equaling failure. Some physicians get caught up in that, much as do family, and push treatment beyond reasonable limits.”

But when physicians are the patients, the perspectives are quite different, he said, “because there is no one else’s medical expectations to meet other than their own, and their attending physicians tend to respect their decisions as being much better informed.”

Asked about his attitudes toward life-sustaining treatments, Murray responded, “In a terminal situation, most life-sustaining treatments prolong the death process, not the living process, but I strongly believe in patient choice.”

One of the studies mentioned in Murray’s 

 piece was a 2003 article by Gallo and associates

 that examined what physicians’ want when it comes to end-of-life decisions. Among 765 physicians who responded to a detailed questionnaire, 64% said they had created an AD. This compares with about 20% of the general public.

That study was part of the ongoing Johns Hopkins Precursors Study involving members of Johns Hopkins School of Medicine classes of 1948 through 1964, who volunteer to keep a running medical chart of their entire lives with detailed annual updates. One of the longest longitudinal studies of aging in the world, the Precursors Study examines psychological, behavioral, and other characteristics that predict morbidity and mortality.

Joseph Gallo, MD, MPH, Precursors Study Director and Professor in the Department of Mental Health of Johns Hopkins Bloomberg School of Public Health, told 

that what makes the study so special is that some physicians have been part of it for 50 or 60 years and they have been very dedicated about responding to survey questions. What’s more, Gallo said, since the respondents are physicians and know about the end-of-life interventions, their watching a medical drama on TV or seeing a documentary about CPR, for example, doesn’t affect their decision making.

In their 2003 article, Gallo and colleagues

 reported that two-thirds of physicians had completed an AD. In comparison with physicians without an AD, they tended to be somewhat older, to have mean mental health scores of 86 (vs 83.4) on the Medical Outcomes Study Short Form Health Survey (SF-36), and to be more likely to report having discussed their wishes with their physicians or with a spouse or family member.

When presented with a scenario in which they had irreversible brain damage or disease that left them chronically unable to recognize others or to speak, the physicians with an AD were also more likely to refuse most if not all 10 life-sustaining procedures (eg, CPR and mechanical ventilation) listed on their questionnaire. But 86.7% did opt for pain medications, even if those medications dulled their consciousness and indirectly shortened their life.

While not reported in the article, Gallo said the researchers examined which physicians wanted the least interventions according to their specialty. “Surgeons wanted the least interventions, internists and pathologists were in the middle, and psychiatrists wanted the most,” he said, adding that the results were not statistically significant.

Since the 2003 article, several other articles emanating from the Precursors Study have been published.

 found that physicians with declining functioning and worsening depression were more likely to prefer high-burden treatment than those with-out such declines. These researchers concluded that there is a need “for continuous discussion of preferences for care, particularly in the context of dynamic changes in health status.”

 estimated the stability of preferences for life-sustaining treatments across 3 years and examined whether declines in physical functioning and mental health were associated with changes in preferences for end-of-life care. Those physicians who wanted the most aggressive end-of-life procedures at baseline were the most likely to change their preferences. Forty percent of the group who wanted everything stayed in that group, but 60% changed their minds over time and wanted less aggressive care. In contrast, 80% of physicians in the least aggressive category at baseline stayed in the same category at follow-up.

Currently, Gallo and his team are working on a 6-year follow-up study looking at the stability of preferences for end-of-life care. They are also analyzing the physicians’ end-of-life preferences and possible factors and characteristics related to changes in those preferences.

“For example, diabetes developed in some doctors after we started asking them about preferences for end-of-life care. We can look at how that diagnosis might be associated with any changes in their preferences,” he said.

Gallo and his team recently submitted a grant application to the National Institute of Nursing Research, part of the NIH, to conduct a mixed-methods study with the surviving 800 physicians in the Precursors Study group.

In addition to the questionnaire, the researchers hope to perform some telephone sampling in which they ask open-ended questions.

“We want to know, in the physicians’ own words, how they are thinking about their end-of-life preferences and who they would want to make decisions for them,” Gallo said. His research team, as part of the grant application, hopes to study what happened with physicians who have died, by using Medicare billing records to determine the services they received and by interviewing the deceased physician’s family members.

“We want to study whether their preferences actually drove what happened to them during the last months or year of their lives,” Gallo said. “If physicians cannot control what happens to them, then it’s going to be difficult for laypersons to control what happens to them.”

 Murray K. How doctors die: it’s not like the rest of us, but it should be. ZÃ³calo Public Square. 

http://zocalopublicsquare.org/thepublicsquare/2011/11/30/how-doctors-die/read/nexus

http://online.wsj.com/article/SB10001424052970203918304577243321242833962.html. Accessed April 20

 Gallo JJ, Straton JB, Klag MJ, et al. Life-sustaining treatments: what do physicians want and do they express their wishes to others? 

 Straton JB, Wang NY, Meoni LA, et al. Physical functioning, depression, and preferences for treatment at the end of life: the Johns Hopkins Precursors Study. 

 Wittink MN, Morales KH, Meoni LA, et al. Stability of preferences for end-of-life treatment after 3 years of follow-up: the Johns Hopkins Precursors Study. 

Articles

 “If physicians cannot control what happens to them, then it’s going to be difficult for laypersons to control what happens to them.”

Doctors Die Differently: Why-and How

Cases that come to our attention as malpractice claims, ethics claims, or Board of Registration complaints raise the question: why did the treating clinician not terminate the treatment before things got so out of hand?

The answers to this question embrace a wide range of issues, including rescue fantasies; beginners’ errors; transference/countertransference impasses; the drive or need to complete a task once begun; power issues; conflicts around abandonment; and narcissistic, sadistic, or erotic dynamics in the therapist and/or the patient. Often these difficulties play themselves out through boundary violations. Moreover, patients may, in some cases, employ a variety of strategies aimed at resisting termination, including threats of suicide, violence, or litigation and other forms of complaint.

Termination is the appropriate ending of therapy, but also it challenges the emotions of both parties in the dyad.

 We focus here on the therapist’s problem, recognizing that the particular chemistry of the dyad may be the wellspring of the issues leading to the impasse. Therefore, although patients may have difficulty in leaving treatment, this analysis addresses the matter from the therapist’s side.

 although it is difficult to achieve in today’s environment. The point is that treatment at impasse may be 

 prolonged under certain conditions-conditions that may lead to various forms of medicolegal trouble.

The case presented here is a composite of actual cases encountered by the authors. Although the case features a patient who has a personality disorder, termination problems can occur with a broad spectrum of conditions.

The italicized sections in the case are intended to indicate those ideas and postures that were pivotal tothe bad outcome, but the issues, of course, spread far wider than this one example.

Ms J is a 42-year-old married woman with recurring and persistent depression. She tells her psychiatrist, Dr S, that she terminated treatment with her 2 previous therapists out of frustration because they did not give her enough support and did not understand her depression adequately. She refuses to give Dr S permission to contact any previous treater, anxious lest those records “poison” this treatment. 

Dr S feels there is no patient he cannot treat, records or not, and decides to rescue her from her current depressed state that has apparently been mishandled by previous treaters. 

He agrees to treat her in his private home office, accessed by a separate entrance in his house. Ms J frequently passes, and interacts with, Dr S’s children as sheuses this entrance.

Early in the therapy, Ms J tells Dr S he is a miracle worker who, she hopes and prays, will never abandon her.

 Dr S, willingly accepting this description of himself, repeatedly reassures Ms J that he would never think of abandoning her.

Over time, Ms J demands that Dr S run over sessions if she is late, switch her session time to late in the day, and come to her house for a session-later, for every other session. 

After refusing all these requests at first, Dr S ultimately agrees to all of them, wishing not to be the disappointing therapist like her previous treaters. 

On one visit, she offers him wine, which he first refuses, then accepts. When she invites him to swim in her pool, he decides he should leave. 

He considers ending the therapy but feels that he should see it through, especially because of his patient’s obvious sensitivity to abandonment.

Invited in a demanding manner to visit again on a later occasion, he refuses on ethical grounds. The patient, enraged and arguing that she can only be treated in her home environment, states that, after all, he did come over before and if he really cares, he will come over again. When he does not do so, she leaves multiple messages stating that if he does not immediately call back, she will take her own life. 

Dr S rejects the idea of consultation because he perceives it as a sign of weakness. 

When he calls, she denies that she meant her threats and states she is “testing his loyalty.” She reminds him pointedly of all the sessions that ended with mutual hugs and of all the letters and e-mails signed “Love,” as though to say, 

Dr S decides to consult his insurer’s attorney.

Dr S writes the patient a letter indicating that because her calls and harassment have made the therapy unworkable, he believes it will be in her best interest to move on with another therapist. He offers 3 termination sessions and a 30-day supply of medication. The patient’s return letter is filled with recriminations, threats, reports of consultations with other therapists and plaintiffs’ attorneys, and reminders of his promise never to abandon her. Not so subtly, she threatens him with Board of Registration complaints, civil suits, and claims of ethics violations.

 She begs him to continue treatment, promising changed behavior according to his rules; 

if he refuses, he can discharge his obligations by a letter of apology and a full refund.

No specialized training is required to recognize how soon the situation in the case presented here spiraled out of control. Clearly, when the decision to terminate comes very late in the game, it often fails to “take.” We repeatedly encounter factors that delay the decision to terminate-even when that response is the only remaining appropriate one.

Clinicians enter the health field to help others and derive satisfaction from so doing. They have a sense of their own helpfulness and competence. However, these laudable attitudes may go astray into 

 and rescue fantasies. Informed consent represents the core of therapeutic work and should stand clearly at the outset.

The patient in the case refused to permit her previous records to enter into the treatment. A patient’s refusal to grant permission to obtain past records (or, at a minimum, to speak to the previous treater) should trigger active discussion of this matter. It may ultimately be a deal breaker to continuation of treatment, especially when the patient calls attention to problems in previous treatment. Many ominous pitfalls and therapeutic errors or impasses may be revealed by the records of, or remarks about, even failed previous treatments. Of course, great difficulty may attend locating previous treaters and obtaining records, assuming they kept records.

Grandiose and possibly counterphobic attitudes led Dr S to go ahead with treatment, despite being unable to obtain the patient’s past records. The expressed rescue fantasy (“I will save this patient”) and competitive strivings with devalued past treaters (“they failed, I will not”) also played a role in the decision. The narcissistic view that “I can treat anyone” is as erroneous as “anyone can be treated.”

 was met with reciprocal self-idealization by the therapist. This reciprocity may create the so-called magic bubble,

 a conceptual sphere that begins with a mutual admiration society containing super-patient and wonder-doctor. The doctor then becomes impervious to consultation, supervision, good judgment, and common sense.

We can infer some dynamic conflict around countertransference-derived sadistic feelings in Dr S, who bends over backward, as it were, to avoid abandonment-even when responsible termination and referral would have avoided that form of malpractice, although that was not the patient’s subjective feeling about it. Consultee therapists often report fearing the anger of the patient if they were to suggest termination. The unneutralized rage of individuals with personality disorder has the apparent ability to intimidate even seasoned therapists.

In addition to aggression, libido may play a role in delaying termination; gratifying erotic feelings and fantasies may account for the prolongation of some therapies beyond the appropriate point. A patient’s idealization of the therapist may have an erotic force.

A common precipitant to transference/countertransference problems is a personal crisis in the life of the therapist-for example, serious illness, divorce, or death of a loved one. Such stressors can easily weaken the therapist’s objectivity and ability to set limits early.

 . . Some features in the case presented above are commonly encountered and merit particular focus. One is the “you’ve already gone this far . . .” approach, in which the patient points out that some boundaries have already been crossed and thus further transgressions are required or demanded. In this situation, therapist guilt about past boundary transgressions may be the driving force behind agreeing to continue. Conversely, threats of complaint about early boundary issues may frighten or coerce the treater into continuing or expanding the crossings.

Consultee clinicians encountering “you’ve gone this far” report a complementary reaction of “it’s too late to change.” In reality, it is never too late to change one’s approach and terminate and refer as indicated, although in fact that response may not avert unfortunate consequences. The distance gone “too far” all too often leads to very undesirable results.

. The ability to say “No” to a patient’s demands, knowing that this response will frustrate, anger, or hurt the feelings of the patient, requires that the treater be comfortable with sadistic feelings, since one will be causing pain to another. We suggest that the widely acknowledged decline in awareness and teaching of dynamic theory has left many therapists unfamiliar and uncomfortable with this common yet problematic countertransference response.

Issues of power and control may also explain difficulty in terminating. Some therapists may be reluctant to give up a position of power over the patient and thus continue to hold on.

 A significant number of cases on which we have consulted reveal a highly disturbing unwillingness of the treater to obtain consultation, thus violating a sovereign principle of risk management, “never worry alone.” This reluctance empirically stems from 3 main sources: feelings of shame and guilt at what has already happened in the therapy; fear of reporting consequences (to Board or ethics committees) if the details are revealed; and, more regrettably, fear that the consultant will tell the therapist to get out of the relationship.

 While flexibility and willingness to negotiate are hallmarks of good therapy, a necessary and indicated termination should be sustained, even against psychological and other pressures from the patient to retract it, replete with promises to change, as in the case example. Some patients may attempt to exert pressure on the present therapist by refusing to see subsequent therapists, although that is the patient’s choice. Consultation may be helpful in strengthening the treater’s resolve.

 Appropriate documentation is extremely important in the charged situations described, but our experience is that the record can cut two ways. Recording inappropriate behavior by the patient, and the patient’s failure to be able to remedy such behavior after ample time and assistance, can be extremely helpful in refuting claims of negligence or abandonment. Inclusion in the record of all letters and e-mails to and from the patient avoids the appearance of concealing potentially damaging materials. However, e-mails and letters from the therapist that display an inappropriate tone, excessive informality, hints of intimacy, and expressions of endearment are damaging rather than protective.

 Even those therapists who are not highly compulsive may express an understandable wish to finish what they started: they resist the idea of terminating before the therapy is “completed.” This view acts as a strong deterrent to necessary termination.

 Efforts should always be made first, in the service of informed consent, to negotiate an alliance-based, boundary-respecting therapeutic relationship. Clear explanations of professional limits should be freely given. Barring physical attack or serious threat by the patient, which may require abrupt cessation of therapy, most terminations should be discussed in advance, negotiated, and enacted in a professional process. A responsible termination with appropriate referral does not constitute abandonment.

Given the complexity of the therapist-patient relationship, this brief review can only point to particular known trouble spots; it cannot cover the entire issue comprehensively. However, the ubiquity of this problem in leading to trouble for therapists requires at least a warning.

All of us who strive to be good therapists want to be helpful, to stick with the patient through the rough times, to finish a job once begun, and to assist the patient in meeting his or her clinical needs. But we cannot help everyone, and in some cases, we may need to stop. Breaking up is, in fact, hard to do, especially in a field that is largely based on sustained relationships. At certain points, however, it is necessary. Not everyone can treat everyone; not everyone can be treated. Awareness of the issues noted here may be helpful to clinicians struggling with essentially irreconcilable differences with their patients. Section 6 of the Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry states

A physician shall, in the provision of appropriate care, except in emergencies, be free to choose whom to serve, with whom to associate, and the environment in which to provide care.

Similar provisions are contained in other behavioral health specialties.

One approach has the therapist describe a treatment plan at the outset of therapy that requires such basics as on-time sessions, limited phone calls for emergencies, release of prior records, and a boundary-respecting approach going forward. The patient’s consent to this plan is sought (and usually given). If the plan is violated, the therapist explains that the patient is violating the agreed-on treatment plan, and the therapist cannot continue to provide treatment under those conditions. Such an approach makes informed consent the heart of the contract, as it should be.

The avoidance of consultation is a particular problem. We all have some hesitation in exposing our work to scrutiny, but the importance and clear value of consultation, not only as advice but also as protection, should be stressed for trainees and encouraged for peers among practitioners. Whether or not one consults through fear, one should never fear to consult. A patient who refuses to consult should be strongly urged to follow that advice. (Comparably, a patient should consider terminating with a clinician who refuses to consult.)

A point sometimes lost sight of by clinicians in crisis is this: if you realize you are practicing, by whatever means, below your 

 standard of care, you cannot defend your practice as being above the needed standard of care. No matter how far you fear you have gone astray, it is never too late to change your ways in the service of the patient’s welfare.

Few things are as valuable in the situations described as advice from an experienced health law attorney-preferably one who is familiar with psychiatric issues. In addition to valuable advice, an attorney can write termination letters to patients and intervene if the patient refuses to stop, threatens, calls excessively, or fills up your answering machine to a degree constituting harassment or other criminal acts.

In sum, clinicians must realize that in some cases, the best therapy is letting go.

 Levinson H. Termination of psychotherapy: some salient issues. 

 Hynan DJ. Client reasons and experiences in treatment that influence termination of psychotherapy.

 Hiatt H. The problem of termination of psychotherapy. 

 Martin ES, Schurtman R. Termination anxiety asit affects the therapist. 

 Dewald PA. The termination of psychotherapy. 

Preventing Boundary Violations in Clinical Practice.

 Gutheil TG, Gabbard GO. The concept of boundaries in clinical practice: theoretical and risk-management dimensions. 

 Gutheil TG. Medicolegal pitfalls in the treatmentof borderline patients. 

 Norris DM, Gutheil TG, Strasburger LH. This couldn’t happen to me: boundary problems and sexual misconduct in the psychotherapy relationship. 

The Principles of Medical Ethics With Annotations Especially Applicable to Psychiatry.

 Arlington, VA: American Psychiatric Publishing; 2010.

Breaking Up Is Hard to Do: Terminating Therapy Before Things Get Out of Hand

If only we could stop at each creaking dock,

loads of fresh linen, vacation paintings,

 I’m sprawled in the back, . . . riding out swells and storm tides . . . that toss this ship like a marriage.

The Laura B.

 reported that most physicians completed an advance directive (AD) following enactment of the Patient Self-Determination Act of 1990, which required most health care facilities to inform adult patients about their right to execute an AD.

But studies have found that only 18% to 36% of Americans have completed an AD. Among those who have, most of their physicians are unaware of the existence of the AD, according to a 2008 report to Congress.

Traditional ADs have been described as “often too vague to clearly direct the interventions a patient would want in specific illness scenarios” and poorly integrated into patients’ medical records and care.

Physician Orders for Life-Sustaining Treatment

 This form indicates patient preferences for resuscitation, the focus of interventions and hospital care, and specific treatments. Patients or surrogates complete the form in discussion with their provider.

The non-profit Aging With Dignity’s Five Wishes,

 a living will written in everyday language.

 The Five Wishes form indicates who the patient wants to make health care decisions, medical treatment preferences, choices for physical comfort, how the patient wants to be treated, and what the patient wants loved ones to know.

“I think the experience-based approaches are better when there is a supportive physician and a supportive family,” said Murray. “But because those approaches are somewhat subjective, I see the value in actual procedure-centered directives, because that is black and white. I guess that either works well, with a physician skilled in their use, and either is problematic if a physician is not supportive.”

In regard to his own end-of-life plans, Murray said, “I have prepared an AD and made sure my wishes are known and documented with everyone who might be involved.”

Advance Directives: Two Newer Approaches

It’s easy to give advice, hard to receive it, harder still to live it. The privilege of youth is action; of age, experience. Nature resists combining both. Experience is a comb you get when you’re bald.

I teach ignorance. Four years of medical school; and 4 more years of residency. Tens of thousands of dollars of debt, and years of minimum wage labor. You must think you have bought something with those funds and that toil; you must finally know something special. You graduate, and you get to work in this bewildering business. People pay you-and so you must know something. If decades pass and you keep getting paid and you don’t pause to reflect, you may end your life thinking that you know much. In fact, as newer generations come up, they see what you don’t.

I teach we don’t know; I teach that knowledge only increases our ignorance. This is what knowledge is: knowing what we know and, just as importantly, knowing what we don’t know.

Knowledge is 2-edged: it illuminates a fact or a part of experience. Usually, in so doing, it shows that what previously seemed sunlit truth is now utter darkness. As you learn something, you realize that much of what you “knew” was actually false. You become more ignorant as you become more wise.

Young psychiatrists need to learn, foremost, that they are ignorant. And they need to learn that their elders are even more ignorant, sometimes because they are wise-because the more you know, the more ignorant you are-sometimes because they are blind.

There is a beneficial and a baleful ignorance. The harmful kind is the ignorance of he who thinks he knows-end of story. This fellow doesn’t know and is simply “mind-blind.”

 He is not wisely ignorant: he doesn’t know that what seemed “true” is false; he just thinks it’s true. Most of your teachers are of this variety, and most of your patients, and most of your colleagues-and, most likely, you.

Look for the dogma. Whatever is believed by most, is likely to be untrue. The truth is not a matter of popular vote; it tends to prefer solitary homes.

Live on the sunny side of doubt. Some doubt darkly: they disbelieve everything and everyone; the truth saunters in front of them and is treated like a vagrant. Take a naive, childlike attitude toward ideas: accept everything-initially, then think on it and reject what seems wrong. Most of your colleagues do the reverse: they reject everything immediately, so as not to disrupt the feeble furniture of their minds; rarely, and with great languidity, do they ever come to accept a new idea.

Reject a superficial worldly skepticism: don’t read 

 as your main supply of psychiatric discourse. Read the old books and the journals-not the new books

 and the newspapers. Why do we all wrangle about the disputations in 

 is sent to an entire department e-mail list; the poor 

 meta-analysis sits ignored, except by an occasional half-dozen–member journal club.

So on our heels a fresh perfection treads
. . . born of us
And fated to excel us.

The best go unnoticed, and the least are loudest.

The greatest danger for your work is not that you don’t know enough about mental illness . . . it’s that you think you know more than you do. The danger is complacency and conformity, above all-above everything else. You will constantly be pressed to comply, to go along. Do so, on all that is unimportant. But where it is important, resist. Kick up, kiss down-if you dare; the world will punish you, but you will improve it.

 You think you know, or you think you don’t know, but in either case, you’re satisfied. Be dissatisfied. Your profession has not lived up-for over a century-to what it could be. It has gerrymandered diagnoses like politicians make up voting districts: on “pragmatic” grounds, for the good of the profession.

 Nature doesn’t obey politicians, whether in state houses or hospitals. And so the genetic and drug and biology studies refuse to line up with DSM labels. Science was degraded (previously) or applauded (recently)-and ignored, for the good of the profession. Your profession hasn’t fully accepted that what is good for the profession is to get at the truth.

Some say there are no truths, only powers that seek to hide behind claims to truth. God is dead, we are told, but the pharmaceutical industry lives. And science is just another interest group: there is no scientific truth, just the opinions of scientists.

I would like to visit God’s grave; someone tell me where it is. I think I will find Reason interred next door, and Science just beneath a weeping angel. With Him died Truth. No capital T’s are allowed, and even small t’s are suspected. But when your patients die, because of something you did-or, more commonly, didn’t do-then there are truths. The dead body attests to it, as do the living bodies you could save.

This postmodern belief that there are no truths, only wills to power, produces a dangerously medieval mindset that imagines itself to be avant-garde. The mind becomes blind and a profession stands still.

 Half a century ago, you would have pledged allegiance to the Trinity of id, ego, and superego-and you would have spent your time and inheritance in formal psychoanalysis. Today, you will treat your patients with the Trinity of antidepressants, antipsychotics, and anxiolytics-and you will buy the drug textbooks with the appealing synaptic cartoons. In each epoch, you conform to your profession; it is the standard of care, and you will be legally protected. You’ll have to make a living, and you’ll have children and mortgages, and you’ll need to protect them. I don’t fault you. But the profession needs something else. 

Your drugs aren’t as good as your colleagues believe, nor are they as bad as our critics say. Your colleague will say it’s easy: give a drug for a symptom-an anxiolytic for anxiety, antidepressant for sadness, neuroleptic for mood swings, amphetamine for concentration and energy and sex. It’s easy-like being a Volkswagen mechanic.

 But your patients’ brains are Porsches. They break down if treated this way. It’s easy: you don’t need an MD for 

We disparage the “medical model,” as if the phrase itself is proof of its fallacy. But we use the MD degree as a badge of expertise, and we practice with a legal privilege of dispensing potentially harmful drugs. It’s no sin to acknowledge biology; it’s a sin to say it, and not mean it.

Our siblings in medicine have already shown us the way. A century ago, we didn’t understand diseases and everyone got potions for symptoms-bleeding in particular. About half a century ago, we began curing, with antibiotics, then with other specific drugs (such as insulin and steroids).

 In medicine, we sometimes understand diseases; in psychiatry, we distrust the concept of disease. In medicine, we sometimes use drugs that cure; in psychiatry, we disbelieve in cure.

Of course, not all psychiatric problems are diseases; most aren’t. But some are. Not all drugs cure; most don’t. But some do. Until we realize which is which-which syndrome is a disease and which is not, which drugs cure and which don’t-we’ll keep guessing, mostly wrongly, while we complacently conform with the profession.

The mental and social aspects of illness matter, you will say; certainly, but not always, and not in the same way for all conditions. Until we know what’s what, all generalizations are false. And since you will want to prescribe pills to make your living, you should at least try to understand well what is biological and what is not.

We despise ourselves too little, and too much. Too much because our medical colleagues disparage us and we have enemies in the public, making us feel inferior. We are criticized wrongly, and rightly, and we protest both criticisms equally instead of rebutting the first and embracing the second. Don’t respond to stigma with stigma, doubting yourself: reject it as worse than racism, the deepest human intolerance, based not on a moral baseness, but on pure ignorance.

We despise ourselves too little: we reject too much and circle around each other, back-to-back. Our colleagues act as if criticizing their drugs is a personal offense against them. Child psychiatry can survive without overuse of amphetamines, and adult psychiatry, without excess antidepressants and neuroleptics. Here is where our loss of science hurts most, for the essence of science is to be self-critical. It’s not about being conventionally honest with others, it’s about being utterly honest with yourself.

 This attitude, which is the scientific attitude, is completely unnatural. Often we aren’t scientific enough, and then our practice becomes uneducated guessing, which we comfortably accept as just the way it is: “Behold, I show you the most despicable man of all: he who cannot despise himself.”

You have entered a difficult profession, not an impossible one. It is a profession that deeply needs honest workers who are willing to seek a knowing ignorance, to be dissatisfied, and to refuse to conform-doing so in the interest of the truth and of the profession, seeing both as inseparable. You need to make a living, but you also need to breathe life into your profession.

In a word, half of what you know is true, and half false, and you don’t know which is which. If you know this, you know all you can now know-a good start. Act so that future generations can have a better starting place.

 Ghaemi SN. Volkswagen psychopharmacology. 

http://www.psychiatrictimes.com/display/article/10168/1870665

Bad Medicine: Doctors Doing Harm Since Hippocrates.

 New York: Oxford University Press; 2006.

 Feynman RP. Cargo cult science. Some remarks on science, pseudoscience, and learning how not to fool yourself. Caltech’s 1974 commencement address. 

http://calteches.library.caltech.edu/3043/1/CargoCult.pdf

 Del Caro A, ed. Pippin R, trans. Cambridge, United Kingdom: Cambridge University Press; 2006.

Psychiatry is a profession that deeply needs honest workers who are willing to seek a knowing ignorance, to be dissatisfied, and to refuse to conform-doing so in the interest of the truth and of the profession, seeing both as inseparable.

Letter to a Young Psychiatrist

Cognitive decline with increasing age has emerged as one of the greatest health care problems worldwide. It is estimated that 1 in 10 persons older than 65 years and nearly half of those older than 85 have some degree of dementia.

Because age is a major risk factor for the development of Alzheimer disease (AD) and other dementias, the study of neural mechanisms of brain aging and the application of new technologies in brain imaging represent major advances in our ability to diagnose age-related cognitive and behavioral disorders and to care for individuals with these conditions.

Here we review new and innovative research in diagnosis, treatment, and prevention and present practical information to optimize patient care. We also offer an overview of the use of PET imaging of brain amyloid to define cognitive phenotypes that may be amenable to targeted early intervention with current therapies and with future disease-modifying therapies.

Clinical utility of brain imaging and CSF biomarkers


New methods to differentiate early Alzheimer disease from other dementias

The selective use of biomarkers can help with earlier diagnosis of AD and other dementias in persons who are at risk for these disorders. Detection of incipient dementia in persons with age-related memory and other cognitive problems can be enhanced with the findings of volume loss on MRI, biomarkers in cerebrospinal fluid (CSF) studies, and brain amyloid accumulation on PET imaging (

 (the 42 amino acid isoform of Î²-amyloid) levels have emerged as 2 biomarkers for early diagnosis of dementia, although the evidence to support the widespread use of CSF biomarkers to aid early diagnosis is limited by the results that show a lack of specifity.

Amyloid PET imaging is based on the hypothesis that amyloid accumulation is an early event in the process of neurodegeneration associated with AD.

 Large-scale studies are ongoing to determine whether PET imaging of brain amyloid with carbon 11–labeled Pittsburgh compound-B (

C-PiB) and other tracers (AV-45, FDDNP) can be used to accurately identify older individuals at risk for dementia. Earlier identification and treatment of persons at increased risk for dementia might delay the onset of cognitive and func-tional deficits and lead to improved quality of life and reduced health care costs.

In the future, amyloid imaging is likely to supplement clinical evaluation in selecting patients for disease-modifying therapies (eg, anti-amyloid therapy), while volumetric MRI and 

F-fluorodeoxyglucose PET may be better indices of clinical progression.

The Alzheimer’s Disease Neuroimaging Initiative (ADNI) was undertaken to help with the early detection and tracking of AD. The goal of the study is to collect and validate data from MRI and PET images and CSF and blood biomarkers as predictors of AD. The major contributions from the study include:

• The development of standardized approaches to acquire brain imaging procedures and to process CSF biomarkers

• The creation of the infrastructure to give investigators access to raw and processed data

• The overall result that baseline cognitive and/or MRI measures are the best predictors of future decline, whereas MRI measures of change from baseline (eg, volume loss in the hippocampal formation) are better predictors of treatment outcome

This large-scale initiative has been re-funded through 2016. The enrollment of additional persons and the follow-up of this larger cohort should facilitate earlier detection of pathology that will help clinicians identify and treat patients in the preclinical phase of disease.

In a cohort of adults with a diagnosis of early dementia, a strengthening exercise intervention over a 10-week period showed a beneficial effect on verbal memory coupled with EEG changes that suggest improved cognitive efficiency.

Another similar study of community-dwelling older adults showed improved performance on executive function tasks after a month-long nonaerobic exercise strengthening program.

 These 2 studies provide research-based evidence for the use of “prescriptive” exercise to maintain and/or to enhance cognitive function with increasing age.

Findings from a recent study designed to determine whether there is an association between exercise, cognitive engagement, and Î²-amyloid deposition on PET imaging suggest that persons with greater early- to mid-life cognitive activity had lower uptake of 

 Although exercise was not associated with Î²-amyloid deposition, greater cognitive activity was associated with greater physical activity. The researchers concluded that engaging in a variety of lifestyle practices may prevent or slow Î²-amyloid deposition, thus influencing the onset and progression of dementia.

Clinical advantage of early diagnosis and early treatment

Accurate diagnosis continues to be an important factor in disease course and quality of life. Although AD is the most common form of dementia in persons older than 65 years, there are other causes of progressive cognitive and behavioral decline, including comorbidities (depression, sleep disorders), that if treated can change the trajectory of disease.

A recent longitudinal population-based study showed that patients in the preclinical stage of AD deviated from the normal cognitive-aging curve earlier (by about 9 years) than individuals with preclinical vascular dementia (by about 6 years).

 Cognitive profiles differed in these 2 groups, which supports the view that specialized interdisciplinary teams of health care professionals, including, for example, behavioral neurologists and neuropsychologists, who conduct more extensive and validated cognitive and behavioral assessments enhance accurate and early diagnosis.

In the past 10 years, there has been an evolving clinical practice of using the diagnostic category of mild cognitive impairment (MCI) to characterize patients with cognitive deficits on standardized neuropsychological testing but who do not show significant real-world deficits in daily activities.

 MCI may represent an early phase in the evolution of cognitive decline associated with the future emergence of AD or another dementia subtype, although some persons with this early diagnosis may not convert to dementia (

Drug development: pathophysiology and treatment targets

Several therapies provide symptomatic benefit for some patients with AD (eg, medications that block the reuptake of acetylcholine; memantine, a glutamate antagonist that acts on NMDA receptors), but these medications do not provide neuroprotective benefit nor do they effectively target the pathophysiological characteristics of AD. Many disease-modifying treatments of AD and other dementias have been investigated, with mixed results. Potential treatment approaches include targeting impaired brain insulin signaling with intranasal insulin and targeting amyloid deposition with anti–Î²-amyloid monoclonal antibody treatment.

Intranasal insulin was found to preserve episodic memory and reduce the loss of functional independence in 64 patients with amnestic MCI and in 40 patients with mild to moderate AD.

Age is a major risk factor for the development of Alzheimer disease and other dementias. New technologies in brain imaging represent major advances in our ability to diagnose age-related cognitive and behavioral disorders.

Psychiatric Times Vol 29 No 6

Doctors Die Differently: Why-and How

Breaking Up Is Hard to Do: Terminating Therapy Before Things Get Out of Hand

The Laura B.

Advance Directives: Two Newer Approaches

Letter to a Young Psychiatrist

Brain Aging and Dementia: Practical Tips From Clinical Research

Practical Guide to Correctional Mental Health and the Law

The Cannabis-Psychosis Link: Mind Your Mind

Introduction: Understanding Common Sleep Disorders in Psychiatric Illness

The Effects of Antidepressants on Sleep

ADHD and Sleep Disorders in Children