Amen, Carlat, SPECT and Psych Evidence for ADD/ADHD: Don't look, don't tell?
Posted Sep 16 2008 4:49am
Carlat says we shouldn't use SPECT for diagnosis? We shouldn't use SPECT tools that we know work to help discover the many missed diagnoses often found under the large umbrella of ADD/ADHD? This question regarding the use of SPECT is more than it's use as simple, high-end-price-point-tool for ADD diagnosis.
These comments, taken from a previous CorePsychBlog post highlight changes present in psychiatry today... challenges for how we begin to rethink matters.
As we review the issues with Carlat and Amen the broader issue of *what evidence counts* arises for all of us, from the editors of Wired magazine, to the man on the street, - boxed in by all this limited thinking.
The comments: Carlat is remarkably obvious in his hysterical hyperbole... and I couldn't agree more that his position with Wired raises the question of Wired's editorial objectives. His unscientific, slanted views just don't match with Wired's sharp and clear edge on edge.
I personally love Wired's work elsewhere, and having a shrink on Wired's staff with good credentials ["writes a pharma Report"] - makes editorial good sense on the front end. Indeed we should be talking about all of this psych stuff with more transparently. But...
Carlat is an example of several problems currently facing psychiatry nationally: The larger question is...
- do we simply wait for the approval of stats from some external group? - do we accept information already approved by the FDA, but not appreciated as the standard of care by the community? - do we presume *the edge* is only present in highly controlled numbers which take out any commonly seen complex variables? - do we expect the *only answers* are somewhere buried in the psychoeconomics of pharmaceutical companies and connections with academia? - do we hope to find real truth in minimalist stats: small n numbers of 200-300, and meta-analytic reviews that take the numbers up to 5000 [but cut our all the variables we see in the office everyday] when thousands go unheard? - do we know who actually sets the *standard of care* - and in the meantime accept *less than standard of care* work as standard? - do we sit on our hands and ignore everything else going on with brain science, until someone in academia is paid for the research to anoint the numbers - when the research has been on the books for more than 20 years [SPECT]?
- do we stride forward, searching for new evidence that might help those who aren't helped by the "standard of care?" - do we ask the basic, more challenging question, of our colleagues who have some experience with new data - for example: "Can you teach me how to understand that new neuroscience for my office work?" - do we take a hard look at these "anecdotal" laboratory findings from functional imaging to findings in molecular and cellular brain physiology that effect thousands of people every day? - do we actually start to examine the complexity of the drugs, and their metabolism [a remarkably hot topic, addressed many times here at CorePsychBlog] in relation to the many somatic variables and immune challenges that effect somatic/brain function?
With new laboratory and medical measurement tools we are rapidly, even in just the last 5 years, finding many new answers that are surprisingly transferable to everyday office practice -
Just because you don't understand it doesn't make it snake oil - however, it does makes practice a bit more difficult in the short run.
-And it shifts the responsibility for teaching SPECT tools to those who have the SPECT experience.
We professionals do have to know more to move ahead...
And we must consider these other revealing real numbers: - the smiling faces of patients who do improve following new biologically based evidence - the satisfaction of knowing you got it right after years of difficulties when others didn't, long after all the previous timid placebo hopes have been repeatedly dashed, and everyone is running on cold, frozen reality, with no hint of hope fueling the tank.
Those real numbers of patient improvement provide true satisfaction - for both the practitioner and the patient.
The abundant other numbers from peer reviewed research are not invalid - this note is not a condemnation of science, as some have indicated in reductionistic straw man representations.
Actually I am so conservative regarding the need for the regular use of brain and biologic evidence, that I appear, oddly enough, inordinately liberal!