Guest Blogger Dr. Mark Komrad on Evidence-Based Medicine and Clinician Experience

In my last post- Medications, Parrots, and Crazy Virginia Laws --, I talked about Robert Whitaker's post on Pete Earley's page.  I put a link to Pete Earley's blog, but not my Shrink Rap post, up on my personal Facebook page.  Now some of my Facebook friends are psychiatrists, so this turned my Facebook page into something of a blog post, with no cute animals.  You followed all that, right? (It's some weird version of social media hell, and yes, I tweeted it as well).  The commenters there gave me permission to put their responses as comments on Shrink Rap, but Dr. Mark Komrad's response exceeded the character count for a blog comment, so I'm giving him a guest post slot here.  Dr. Komrad is the author of You Need Help! an excellent book on how to get a loved one into treatment. His response is below:
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I think  there are some emerging intellectual "cults" or "fetishes,” maybe best called "overvalued ideas,” that are relevant to Whitaker’s blog post.   A major one now dominant in Medicine is “evidence based."  Not a bad concept, but an overvalued one.   My experience as a practicing clinician so often contradicts the evidence base. Can this just come down to the dismissal of the clinical experience of a seasoned clinician as invalid because of individual-bias? Should the wisdom of clinical experience be trumped (wow- a word whose meaning is changing!) by large statistical sets, or amalgamated statistical sets, as in meta-analyses? That seems very much black-and-white thinking. There is a dialectic between two different ways of knowing-- clinical experience vs. the study of large sets of patients under controlled conditions. We in psychiatry are familiar with many such dialectics: mind and brain, nature and nurture, biology and psychology, form and content, autonomy and paternalism, explanation and understanding, etc. See Philip Slavney, "Psychiatric Polarities."

In my own experience, I practice not too much differently from many other psychiatrists, and not radically different from what Whitaker wants. In schizophrenia, I follow "first break" research and go "low and slow." Early in the course I attempt to taper off antipsychotics slowly. That commonly fails, but not always. With long-term patients I have tried time and again to lower doses to the lowest possible dose. I make tiny changes over many months or even several years (yeah, I've been around long enough, and my patients stay with me)-- slow enough to rule out withdrawal effects. Yet time and again people end up eventually relapsing,  and we have to reverse course. With the majority of patients, reversing course doesn't work, and a few have never returned to their former (often excellent) baseline (prior to trying this oh-so-cautious tapering). For many patients on maintenance meds, the dose goes up, the dose goes down, as symptoms wax and wane-- like any other chronic illness. Make no mistake, schizophrenia IS a chronic, lifetime illness, and the chronicity is not CAUSED by meds, as ample evidence suggests, from the pre-antipsychotic era. It seems very compelling to me, from my 30 years of clinical experience in treating schizophrenia, that these meds don't only have acute efficacy (like antibiotics), but also prophylactic value, to minimize morbidity (like Lipitor). 

Of course, I cannot rule out the possibility that, as Whitaker suggests, long-term antipsychotic treatment might partially  cause the brittleness and dependency on meds for stability and remission. That could account for my frequent experience of failed-tapers. It's a good question for research. But it would take a few decades to be sure, by following parallel cohorts of persistently medicated patients and rarely medicated patients. Maybe enough time has passed in the antipsychotic era that some valuable evidence is now just emerging. But 4-5 year studies wouldn't be enough time. It would need to be 20-30 years. Those are quite difficult (and expensive) studies to do. I remember how expensive and complex it was to do the multi-center study 20 years ago that asked about maintenance meds in recurrent depression after patients get well-- can you stop, lower the dose, or should you sustain the same dose it took to achieve remission? (answer: the third). Many millions $,  20 centers, and that was only 5 years. 

I have shared the ambiguity of treatment choices, based on some of these studies, with some of my patients and families. It is, however, RARE that a patient who is doing well wants to take a chance. The overwhelming response has been, "if it's not broken, don't fix it." In patients that are doing well, with the current state of evidence, it's hard to ethically justify tapering them off antipsychotics entirely. Even patients doing poorly have done WORSE when meds are stopped. Maybe, EVENTUALLY they might do better, these studies suggest, but until then, their increased morbidity off meds, even temporarily (months, years), will be extremely bad for their lives, the lives of others, and even their very survival. 

Maybe 25 years from now there will be enough evidence and new EXPERIENCE by clinicians who have started early in the onset of schizophrenia to use more temporary courses of antipsychotics. Then, maybe clinical experience will corroborate some of these very preliminary studies. That might enable the power of more statistical studies to be complemented by the equally valuable power of clinical experience. As is typical, in the evolution of Medicine, the dialectic of these two ways of knowing will result in the synthesis of changing treatment approaches. By then, though, we may have entirely new and different inventions for treating schizophrenia!