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Monday, June 11, 2007

The Life and Times of Martin B Keller, MD - Part II

by Matthew Holford.

Matthew writes exclusively for Seroxat Sufferers


I should preface this scholarly effort at disseminating the work of the good doctor by paying due deference to the colleague who heard my wails in the night, which were provoked by an inability on my part to find a single article of Dr Keller's for free, on the Net (not only am I lazy, but I'm cheap, as well). I have to say, it irks me somewhat to find that the work of our foremost academics is denied to those who cannot afford to pay the relevant fee. Perhaps I should bear that in mind.

Anyway, my colleague has kindly provided me with several pieces, which I found quite interesting. Any reader who finds my critique thought-provoking should contact Bob (or Marty) for the original article. I'm not saying that Bob (or Marty) will send it to you, but that's what you should do, logically. I think it makes sense to just summarize the text, as best I can, and then pass a few comments, based on what I have understood the article to be communicating. I should say that I have no idea who wrote these things - I know that there's a bunch of different people who have put their names to them, but as I mentioned to my colleague, the choice of language tends to be crucial. The person who wrote up the notes might be any one of the authors, or might be a secretary with an impressive vocabulary. Who knows? Anyway, onwards and upwards.

Differential responses to psychotherapy versus pharmacotherapy in patients with chronic forms of major depression and childhood trauma (2003)

Authors: Charles B. Nemeroff, Christine M. Heim, Michael E. Thase, Daniel N. Klein, A. John Rush, Alan F. Schatzberg, Philip T. Ninan, James P. McCullough, Jr., Paul M. Weiss, David L. Dunner, Barbara O. Rothbaum, Susan Kornstein, Gabor Keitner, and Martin B. Keller

Synopsis: The clue's in the name. Apparently, major depression not only has the effect of having people feel shite, such that they occasionally commit suicide, but comorbidity is not unusual. That is, there's a bunch of physical conditions that are typical of major depression. Heart disease, for example. Major depression is said to be most prevalent in that group that has had to endure childhood abuse, of one kind, and another. It's also reported to be inherited, to an extent, and women are more likely to experience it than men. The piece centres on efforts to establish what approach worked best, in treating this condition: drugs, therapy, or a combination of both. The last of these, apparently. Why, then, I hear you ask, does one have to wait up to six months, for a six-week course of CBT, on the NHS? I don't know, why is that?

Critique: One of the many explanations that I've dreamt up, as to what depression is, is founded upon the idea that it's about contradictions. I could go into a detailed analysis of what I mean by this, using my own experience as the example, but this is about Marty. I think, when a person has experienced physical, sexual, emotional abuse and neglect, that they are likely to start wondering first, what is so revolting about them, that they should be subjected to this; and, second, if they are, in fact, required to die. But nobody will explain. Even if one were to ask, there would be a denial, but the repulsive treatment would continue, which would effectively make the denial a lie. A contradiction, you see? Even an admission would be contradicted by the child's innate belief in their own goodness (or a lack of understanding as to what they did wrong, which probably comes down to the same thing). Nothing is ever "in the past," if one does not understand why it was done, you see?

Now, if one has spent one's life being treated as if one is a piece of shit, and one perceives that one is required to die, it ought not come as a surprise that one's condition improves, when somebody demonstrates unequivocally, as a counsellor should do, that that is not what is required. Now, vendors of drugs will find this suggestion particularly easy (necessary) to dismiss, but drugs do have a significant psychosomatic value - it's what underpins Seroxat, after all. As such, I would venture that even the giving of a pill has the value of conveying to a patient that somebody values them, but only on a short-term basis, as the person who gave the pill will not always be there. Moreover, it does not answer any questions - it doesn't solve any of the problems that life has set the individual. How could it? A pill can't communicate anything, can it?

Discussion: The question, unquestionably, is why anybody would want to have another understand that they are worthless? The second obvious question is whether anybody at Brown is capable of taking this mind-fuckingly simple idea, and using it, practically, or even acknowledging the value of it, and asking for clarification?

Prospective Study of Fluoxetine Treatment and Suicidal Behavior in Affectively Ill Subjects (1999)

Authors: Andrew C. Leon, Ph.D., Martin B. Keller, M.D., Meredith G. Warshaw, M.S.S., M.A., Timothy I. Mueller, M.D., David A. Solomon, M.D., William Coryell, M.D., and Jean Endicott, Ph.D.

Synopsis: It seems that there had been some adverse reportage about the link between suicidality and the use of fluoxetine (aka: Prozac). It was argued that there was no evidence to support these claims, and thus they were unfounded. I should admit that I am not entirely disinterested, here, because I experienced suicidal ideations, coincidental with taking fluoxetine.

Critique: I have nothing to offer on this one, other than my own experience, because I don't have the data, nor the patients. I don't believe in the use of drugs to treat depression, nor any other "mental illness," for that matter, and I'm not about to change my tune, now. The only reason I can think of for administering drugs in such instances is if the patient believes that they are valuable.

A 20-Year Longitudinal Observational Study of Somatic Antidepressant Treatment Effectiveness (2003)

Authors: Andrew C. Leon, Ph.D., David A. Solomon, M.D., Timothy I. Mueller, M.D., Jean Endicott, Ph.D., John P. Rice, Ph.D., Jack D. Maser, Ph.D., William Coryell, M.D., Martin B. Keller, M.D.

Synopsis: I have to be honest, I haven't got a clue what this one is trying to convey. Having said that, the authors conclude that clinicians should be prescribing anti-depressants in higher doses (I'll bet that was a popular conclusion, in some quarters). Presumably, the authors divined from the available data that patients showed greater improvement, the more drugs they took, broadly speaking. I wonder how this fits with the findings of Differential responses to psychotherapy..., above. Aside from that, I have no comment on the findings, given the unavailability of the data in question.

Critique: And this was deemed to contribute to the state of the art, such that it got published? Anyway, you know my position on the use of drugs in the treatment of depression (see above).

Maintenance Phase Efficacy of Sertraline - A Randomized Controlled Trial (1998)

Authors: Martin B Keller, MD, James H Kocsis, MD, Michael E Thase, MD, Alan J Gelenberg, MD, A John Rush, MD, Lorrin Koran, MD, Alan Schatzberg, MD, James Russell, MD, Robert Hirschfeld, MD, Daniel Klein, PhD, James P McCullough, PhD, Jan A Fawcett, MD, Susan Kornstein, MD, Lisa LaVange, PhD, Wilma Harrison, MD; for the Sertraline Chronic Depression Study Group

Synopsis: Sertraline Hydrochoride is better known as Zoloft, in case you were wondering. This study was intended to establish whether the drug was capable of influencing the recurrence of depressive episodes (relapse), in the trialists, as far as I can make out. It could, according to the findings.

Critique: Whatever. I don't have the data

Past, Present and Future Directions for Defining Optimal Treatment Outcome in Depression - Remission and Beyond (2003)

Author: Martin B Keller, MD

Synopsis: It seems that the experts are not in agreement as to what constitutes "remission". Moreover, it is the experts who are the only ones permitted to evaluate the presence of remission, when one would think that it was the patient who was best-placed. That's very nearly a contradiction, isn't it? It's certainly anomalous, given that there is potential for a scenario, where one expert will declare one in remission, but another won't.

Anyway, it seems that the good doctor regards the assessment of remission as lying in an analysis of symptoms, functional status and pathophysiological changes (changes in bodily operation, caused by disease or syndrome). I have an issue with this, not least because of the propensity of the experts to affix a smart-sounding name, usually reduced to an acronym, to any behaviour that they've decided needs to be treated (usually with drugs). I give you ADHD, as an example.

Telling somebody that their behaviour warrants the use of 15 syllables that they'd never heard in conjunction with one another, before, is very likely to make somebody nervous, especially if they understand that those 15 syllables, in combination, are regarded as "bad", in some sense. Worse still, if such a person were to say to themselves, "but I've always done that. If only I'd known that this was the problem..." And now they have a problem to solve. However, it is an insoluble problem, because their behaviour, whatever it is, is learnt, I maintain, and if one doesn't like a person's behaviour, one has to provide an alternative, not ply them with drugs, in order to effect change. In this context, a facet of "behaviour" is often referred to as a "symptom". Presumably, one will only be in remission, when one resembles the treating clinician, because only then will one look "normal". However, if the clinician displays behaviour that is socially unacceptable, then said clinician may continue to regard the patient as mentally ill, without reference to their own conduct, I would suggest.

Jesus, is this the Dark Ages? You've got a person, whose behaviour you don't like, so you ply them with drugs, and keep telling them that their behaviour is wrong. So they adjust their behaviour, so that they're not wrong, anymore, but they miss the point, for whatever reason (probably because you didn't instruct them adequately as to the behaviour that made you uncomfortable), and they don't adjust the bit of behaviour that you didn't like, so they start suppressing their behaviour (one of their means of communication, lest we forget), in order to not be thought of as wrong. Taken to its logical extreme, we have a zombie. Parents do this to their children, every day, and we should remember that children are only copying what they see around them, as they seek to adjust, in order to survive. So, who's at fault?

The upshot is, that having instructed people, both explicitly and by our conduct, that they may not express themselves verbally, we also instruct them to not communicate by any other means. We're instructing people to die, effectively, because we're telling them that their views don't matter. And, in truth, to some people, they don't.

Matt

More of Matthew's rants here

Copyright Matthew Holford, 2007
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