Tuesday, 28.09.2021

Amy A. F. Lutz: The Rise and Fall of the Dexamethasone Suppression Test: Stability, Consensus, Closure.

 

David Healy’s comment

 

 

        It is good to see the DST being discussed again and there are few forums where this could be done to better effect than in this one.

        The account offered here by Amy Lutz is intensely personal, drawing as it does on the views of three interviewees that I’m sure are absolutely genuine. What is unclear is what they were asked and what they might have responded to points not mentioned in this article

        Without full transcripts of the interviews, we are left in the position of most doctors vis-à-vis pharmaceutical company trials – somewhat in the dark and dependent on the bona fides of others.

        What else might have been brought into the frame?

        One is the switch at the time to operationalism in all of medicine but most obviously in psychiatry, exemplified by DSM III.  This was billed as bridging a divide between the medical and social sides of psychiatry or biological and psychological views but would likely have happened anyway.

        DSM III was committed to dealing with superficial features of conditions – just as medicine turned to blood pressure and cholesterol readings.  It effectively distinguished between Christians, Muslims and Jews on the basis of eating fish on Fridays, turning toward Mecca or having phylacteries rather than engaging with substantive theological issues.  As a result, patients, clients or consumers or whatever we want to call them can now be viewed as having ADHD today, depression tomorrow and can be bipolar next week. 

        None of this was envisaged by Spitzer and colleagues in 1980 – they had no sense they were importing neo-liberalism into medicine (or that the zeitgeist was using them to introduce neo-liberalism).  The DST would have driven a stake through what was being done or at least spilt some blood. And DSM steered clear of it.

        Older tests like the EEG which has comparable specificity and sensitivity to the DST were too established to be side-lined by the changing culture, but the DST was at just that stage of development that left it exposed to being harmed by the frost or blight or whatever it is that has killed off most of psychiatry and most of medicine as it was understood before 1980.

        It should have been a no-brainer for a psychiatry desperately looking for biomarkers to include the DST as a criterion for a form of depression that had been recognised for a century and seemed to predict response to a battery of treatments and non-response to others.  Instead, the DSM opted for the most godawful unholy mess of a category – Major Depressive Disorder.  One consequence of this is that antidepressants (SSRIs) are among the most commonly taken drugs, after hormonal preparations, by teenage girls and women of child-bearing years despite the toll in terms of miscarriages, abortions, birth defects and behavioural abnormalities in their offspring.  There are other consequences.

        To personalise this as though the fault lay in some prickles in Barney Carroll’s character or approach seems misguided to me.  The most profound change in health since the creation of the medical model around 1800-1820 was taking place – a change that has tons of people now taking drugs although they have nothing wrong with them, the very antithesis of the medical model. 

        Its not difficult to imagine a Barney Carroll, Cassandra-like, ranting that I don’t quite know where this is going to end but it ain’t going to be good – while Spitzer and others pulled the Horse into the City.  We don’t talk about Cassandra being prickly, we view the Trojans as foolish.

        If the DST had been adopted, the SSRIs might not have become antidepressants as they are ineffective in patients who are non-suppressors.  

        These drugs would have had to be branded as the anxiolytics or serenics they are – pretty useful for OCD but useless for anything vaguely melancholic.  When marketed as non-dependence producing anxiolytics or tranquilizers, doctors would have said “Oh Yeah, we’ve heard that one before” and might have been slower to adopt them.  They would have been less surprised at news from the UK for instance that within three years of the launch of paroxetine, there were more reports of dependence on it than in the prior 20 years from all benzodiazepines combined.

        Depression would never have become the greatest source of disability on the planet.

        Knowing their drugs were ineffective for melancholia, a question arises as to whether the pharmaceutical companies back then had any sense that it might be necessary to kill off the DST. It didn’t have to be a grassy knoll public assassination. Companies are adept at distributing the latest “science” that suits their interest.  Did pharma ever distribute much or anything about the DST?

        When we are talking about the Genesis of a Scientific Fact, its not acceptance by colleagues now that determines whether something becomes a Fact – it’s the extent to which the information suits key interests.  The “Facts” as with cholesterol can be close to completely bogus but they can still become Gospel enough for statins to kill or maim us. There might have been some elements of this in Fleck’s time, but our world is not Fleck’s.

 

 July 15, 2021