Wednesday, November 20, 2013

Now It's the Cardiologists' Turn



People like to rag on psychiatry: we've got our own anti-psychiatry movement, and one of the biggest issues for these groups is that "psychiatry" (whoever our singular voice might be) misrepresented itself by saying there are chemical imbalances responsible for mental illness, when no precise imbalance has yet been identified.  We're not like internal medicine and it's sub-specialties where there are numbers and a cut-off for when you have diabetes, and when your cholesterol raises your risk of heart disease.  Those numbers are reportedly precise science, but, actually, those illnesses are defined like psychiatric disorders: by consensus of a bunch of people on a committee. 

These days I follow the cardiology news with interest.  Today is the 6 month anniversary of my brother's death from coronary artery disease.  My brother did not know that his coronary arteries were quietly calcifying and by the cardiology predictors, he had no reason to believe he was at any imminent risk of death.  While he once had an elevated cholesterol level, he did what doctors recommend: he changed his eating habits, increased his exercise, and he died with wonderful numbers.  Never a smoker, the one clue that this might have happened was that our father also died of heart disease he didn't know he had, at a very young age.

For a field where things are supposed to be so much more clear cut than psychiatry, cardiology also has it's camps.  There are those who prescribe statins at a very low threshold, and those who feel they are over-prescribed.  Does this sound familiar?   In yesterday's LA Times, there was an article titled Cardiologists Cast Doubt on New Statin Recommendations, while USAToday's article notes Heart Experts Debate Who Should Take StatinsAnd if you'd like a more medical take on this JAMA has "dueling" viewpoints on whether healthy men should take statins HERE and HERE
I guess JAMA doesn't care about cardiac prevention in healthy women?

In psychiatry, we usually get second chances.  In cardiology the camps are frequently life-or-death and 1/3 of people will die during their first heart attack.  In psychiatry, we're nebulous about prognosis.  In cardiology, there are definitive treatments (such as bypass surgery), though cardiac stents are not free of their own angst these days.   Obviously, I now wish my brother had taken a statin and I wish he'd had a calcium score done so he would have known he needed more aggressive intervention.  With the statin's all-too-well publicized side effects, and his successful efforts to modify "risk," it's easier to look back and say what might have been.

In the meantime, the issue in cardiology is about risk, and they do have non-invasive (albeit expensive) ways of getting definitive answers about who does or does not have coronary artery disease.  I'm left to wonder why more at-risk individuals aren't encouraged to undergo such imaging given that the technology is available.

So let me ask this: if an expensive MRI would give you a definitive answer on whether a patient with a psychiatric disorder would respond to a medication, would you order that test?  Pretend the test costs a great deal of money (let's say $5,000), but the treatment is cheap (let's say $10/month)?  If you're the patient, would you pay for the test, or try the cheap medication first, knowing the medication has some risks?  What if you had no symptoms, but were told that a screening test would enable you to stop the progression of a life-changing illness?  What if there was a cheaper version (say $2000) but that entailed radiation while the more expensive test did not?