Comment by Douglas Berger Psychiatrist in Japan on: Weighing the Benefits of Genetic Information in Clinical Psychiatry, Psychiatric Times, July 17, 2017 By Rebecca M. Allen, MD, MPH

The open-label GeneSight and unblined Genomind studies are at high-risk for researcher bias and should be suspect to extreme caution. We would never allow anti-depressants to be approved with these kinds of studies (although unblinded/no-blindplacebo psychotherapy studies are unreasonably and widely “accepted” as robust data by our profession all the time).

The issue of whether “adverse effects” are related to anxiety are easily investigated with zero-cost means. Patients’ significant others can manage all the medications, crush up the pills, and blind to the patient put them in patients’ morning small glass of orange juice. Do this a few days on and a few days off, keep a record, and see which days corresponded to the patient’s anxiety.

Regardless of a patient being a slow metabolizer, all patients should be started at low doses and can be told to break their starting dose pills in half, crush them, or empty capsules out so that every patient can start low and go slow for a number of days before going up to the low starting dose even. In addition, normal metabolizers may still have adverse effects at usual starting doses due to pharmacodynamics reasons (effects on the receptors etc in the brain) and not pharmacokinetic reasons (ie peripheral metabolism) which is not measured by metabolic genetic testing.

Proper clinical instruction and close follow up (which is necessary regardless of metabolic status) makes the use of these costly tests unnecessary in all but the rare patient with treatment resistance and/or those that have extreme reactions-only when drug is put in their OJ. I strongly suggest we never do a genetic test on any patient having “adverse reactions” on OJ with no drug in it and all the pills accounted for.
No genetic testing company is likely to be happy with what this advice may do to their market.

Doug Berger, MD, PhD
U.S. Board-Certified Psychiatrist
Tokyo, Japan

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RE: Deferring to the Mastery of Death: Hippocrates, Judge Gorsuch, and the Autonomy Fallacy

Psychiatric Times, April 03, 2017,  By Ronald W. Pies, MD

http://www.psychiatrictimes.com/blogs/deferring-mastery-death-hippocrates-judge-gorsuch-and-autonomy-fallacy

We all know about the slippery slope of giving psychiatric patients to right to request suicide from a medical professional. However, terminally ill medical patients who have terrible pain and suffering and are near death (perhaps on a respirator, have multi organ failure, frequent sepsis, oozing blood from skin and other orifices, repeated seizures, etc), are vastly different from psychiatric patients. Pies and Geppert’s argument does not deny that a physician could not induce a comatose state in these persons, perhaps even a permanent coma until death. Coma (without brain death) is not death medically or legally, although it essentially accomplishes the same thing as death does in removing the patient’s awareness and experience from a living state.

I would have trouble thinking that physician-assisted coma should be illegal or unethical as a form of medical treatment with specific indications just like any other medical treatment (i.e., it would not be indicated for psychiatric illness), and encourage further debate about it. One could argue that these patients can still be aware of things, but the same could be said of patients on morphine. Coma still racks up medical bills, and it may still be painful for a family to see their loved one in this state. Notwithstanding these caveats, we don’t have to argue about physician-assisted dying if we consider coma is good enough.

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Dr. Douglas Berger Psychiatrist Tokyo’s response to THE QUIZ: Headaches: Page 2 of 2, Scientific American, March 30, 2017

http://www.psychiatrictimes.com/psychopharmacology/quiz-headaches/page/0/2

Dr. King, regarding acupuncture, perhaps you can comment on this article:

Research Casts Doubt on the Value of Acupuncture, Scientific studies show that the procedure is full of holes, Scientific American, August 2016

https://www.scientificamerican.com/article/research-casts-doubt-on-the-value-of-acupuncture/

The article makes these statements below, and it seems to me that because of the subjective nature of endpoints used in any clinical trial of pain or migraine treatment, whether acute or prophylactic treatment, that it seems a bit too early to make definitive conclusions about acupuncture worthy of a “True” or “False” in a quiz because there is no way to filter out bias of hope or expectation and/or researcher/treater bias effects on the subject even with masked raters as they only record the report of the patient:

1. effects of acupuncture are the same whether needles are placed along the meridians or at random locations around the body.

2. acupuncture studies are extremely difficult to double-blind—a methodological approach in which neither the researchers nor patients know who is receiving the treatment under investigation and who is receiving the placebo or sham.

3. researchers know which patients receive or do not receive real acupuncture, likely biasing the results.

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Douglas Berger Psychiatrist Tokyo’s Letter to the Editor of The New York Times, RE: “Tell it about You Mother ” by Casey Schwartz, June 24, 2015

FW: New York Times: Letter to the Editor RE: “Tell it about You Mother ” by Casey Schwartz, June 24, 2015

The article “Tell it about You Mother ” by Casey Schwartz, June 24, 2015, (http://www.nytimes.com/2015/06/28/magazine/tell-it-about-your-mother.html?_r=1) is a review of a study that suggests there is a link of psychoanalysis with specific brain changes. The article reports the fMRI images of one-patient which is neither a report of results nor analysis, and the one-patient data is a personal contact from the study authors to the NY Times article author, not a publication of the results (“Images from Andrew J. Gerber and Katherine R. Surrence/Columbia University”).

I could not find any results from this fMRI study on a literature search. I asked the authors of the original paper Gerber and Peterson for some data or analysis, and received no reply. One article I did find was a description of the of the study plan but no results are reported: Measuring Transference Phenomena with fMRI, Andrew J. Gerber and Bradley S. Peterson, Am Psychoanal Assoc. 2006; 54(4): 1319–1325 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2367227/. This article noted that the study planned only 10 subjects and was not blinded to the therapist nor the subject as to the content of the procedures (so there was no blinded control group). The NY Times article had the term “Preliminary research” under the image, however, In spite of only presenting the data of one unblinded subject, and the data having no publication or analysis, the NYT article says “ goes on to state, “… indicates that brain regions involved in transference include the left and right insula”. The research article itself stated, “It is crucial that the paradigm be designed for optimal reliability and clinical relevance at this stage, before it is applied broadly to questions of development, psychopathology, and psychotherapeutic change.”

Changes in the brain are also seen in other activities. For example, this study, http://www.nature.com/neuro/journal/v12/n11/full/nn.2412.html, Nature Neuroscience 12, 1370 – 1371 (2009); 11 October 2009 | doi:10.1038/nn.2412, found an increase in white matter underlying the intraparietal sulcus following training of a complex visuo-motor skill. This study was not blinded and there was no placebo control group. Mindfulness meditation has also been found to alter regions of the brain associated with memory, awareness of self, and compassion, according to a brain imaging study: Psychiatry Research: Neuroimaging (Jan. 30, 2011). http://www.health.harvard.edu/mind-and-mood/mindfulness-meditation-practice-changes-the-brain. The subjects in this study were not blinded and there was no placebo control group.

The brain is clearly an organ that can modify itself to various stimuli, changes are not necessarily indicative of effects of a specific psychotherapy. There is data on only one subject presented, the study is not blinded, there is no comparison group, no blind placebo group, and no analysis of any cohort of data that can be found in the literature at this time. The NYT should look into whether there is any published data

and analysis of this data, and make an addendum to the Schwartz article of what is or isn’t published, the robustness of any study presented (i.e., number of subjects, blinding, placebo, comparison group, etc.), and revise any suggestions of effects of psychoanalysis on the brain in a new article written by a panel of clinical trial experts or as least by the Editors.

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Dr. Douglas Berger’s response to “Top Papers That Can Change Your Practice” by By, Sy Atezaz Saeed, MD, MS and Richard M. Bloch, PhD, Article Originally Published in the ‘Psychiatric Times’ on February 23, 2017

http://www.psychiatrictimes.com/psychopharmacology/top-papers-can-change-your-practice#comment-51647

Drs. Saeed and Bloch,

You quoted a paper on IPT as showing IPT to be more effective than placebo or waiting list and comparable to pharmacotherapies.

Did this paper, or any paper, ever study IPT with single-blinding (=subject blind) or double-blinding (and thus with blind placebo)? I think not as it is impossible to blind a psychotherapy study, using the term “placebo” in a psychotherapy study is misleading as it is not a blind placebo.

In addition, comparing IPT to medications that show efficacy vs blind placebo (thus the rigor in showing efficacy is higher than in unblinded studies) invalidates clinical trial logic because the methods to prove efficacy are very different in blinded medication studies vs psychotherapy studies. MDD is studied with subjective endpoints and an unblinded study can not filter bias from the expectation and hope of knowing the therapy one is given. Blind raters only record the unblinded report of the subjects.

Because MDD psychotherapy trials cannot be single- or double-blinded, nor can they have blind placebo, the rigor of these trials for psychotherapy in MDD is low so that it is premature to make claims of efficacy for IPT in MDD. These kinds of papers do not belong in a “Top Ten” list unless you want to include “papers with problems to be aware of” in the list.

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Douglas Berger Tokyo Psychiatrist repsonse to “Practical Tips for Managing the Agitated Patient: Avoiding Violence in the Clinical Setting”

Psychiatric Times

February 27, 2017 (originally published)

http://www.psychiatrictimes.com/special-reports/practical-tips-managing-agitated-patient-avoiding-violence-clinical-setting#comment-51644

Drs Lofchy and Fage write a nice article on violent patients. They rightly note that, “The risk of violence in psychiatric practice is a frightening aspect of our work”. The problem is that few of the many articles like this ever talk about what to do when a punch is on it way, you are getting pushed, or worse, getting strangled.

These articles are great-up to the point of attack assuming that the end-game is pushing a personal panic alarm. However, there needs to be a discussion of what we should do if things get out of hand, if there is no alarm and if security is not around the corner. Actual martial arts self-defense training, which also necessarily entails some offensive practice as part of defense, is the only thing to do next because by definition, all the processes, structures, and verbal de-escalations are not part of the equation at this point. My opinion is that kung fu would be the best training to have, but the best type could be subject to discussion and opinion.

Drs. Lofchy and Fage are right, there is a danger, and psychiatry needs to get over the “political correctness” of the assumption we should never discuss that we should learn how to physically defend, control, neutralize, or even attack back as a defense. Psychiatrists are too cerebral, once a week they need to get into a martial arts gym and train.

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