January, 2010. During the holidays, my daughter asked me what I thought the most important technological advance has been during my lifetime, and without much thought, I said the cellphone. What I really meant was cellphone/iphone/ipod/wireless/email/texting/blogs/twitter/facebook/google/bing/… and the list keeps growing! It does truly amaze me to see oceans of humanity in every metropolitan center in the world, almost all of whom have personal communication devices that don't interfere with each other. And then to see photos of remote locations, say the Serengeti or the outback, with a lone figure, also on a cellphone. Communication technology has truly changed the world.
But communication is what psychiatry is all about, since it has to do with interpersonal human behavior, and I have always been struck with how hard it is to do it well. How quickly anxieties, opinions, or misperceptions can fuel rumors that gain momentum and become “established facts!” I believe that one of our biggest challenges is to remain open to and interested in the views of others, even when they differ radically from our own, but to reserve the right to respectfully question and “fact check” any information, and to keep our balance along the way.
In this issue of the Journal, Makhinson illustrates one aspect of the communication challenge, focusing on how certain we are of what we communicate. In this case, Makhinson argues that the wholesale replacement of first-generation antipsychotics with second-generation antipsychotics reflects a complicated mixture of phenomena, including initial research findings, strong opinion, the “honeymoon effect” when new compounds are approved by the FDA, industry marketing, and inherent biases that commonly influence individual decision-making. He argues that we need to know more about the science of decision-making, while doing the best we can to evaluate and rely on the most solid data we have. Decision-making is always critical in treatment planning, and when patients only partially respond to known effective treatments, we need to ask why. Preskorn regularly reminds us to consider pharmacokinetics and pharmacodynamics, as he does in his column in this issue of the Journal. Also in this issue, Uebelacker and colleagues suggest an atypical approach when treating depressed patients who only partially respond to traditional treatment interventions—in this case, utilizing hatha yoga as an augmentation strategy. Cuturic and co-workers emphasize the importance of considering carnitine depletion as a possible cause of cognitive symptoms that develop in patients receiving long-term treatment with valproate, suggesting that such patients might benefit from levocarnitine supplementation. Finally, Velligan and colleagues remind us of the importance of patient adherence to treatment, demonstrating the predictable gap between patient self-reports (as well as prescriber opinions) and actual adherence rates when measured objectively.
Communication is central to all of these treatment dilemmas, since in the end all treatment strategies emerge from a composite of multiple information sources (the best “facts” we can find, and the most reliable clinical consensus we can achieve, utilizing all relevant informants). Finally, in the spirit of the holiday season, I would like to communicate my wish to all for a very healthy and happy New Year.
John Oldham, MD