By Prudence L. Gourguechon on 8/19/2009 9:10 AM
I was glad to see a story in last Tuesday's New York Times Business Section (August 18, B1) about the struggles Diabetes experts are encountering with nationally promulgated treatment guidelines.
APsaA has long argued that one size fits all doesn't work in psychoanalysis and psychotherapy--or in all of mental health for that matter. Treatment guidelines that specify when must be done for "depression", even though they may be based on large evidenced based randomized controlled studies, risk engendering absurdity because of the vast differences between individuals. As a psychiatrist as well as a psychoanalyst, I use medication frequently. I am aware of national treatment guidelines based on respectable studies that show that in a significant number of patients with "depression" a particular drug--let's say fluoxetine-- is effective some good percentage of the time (usually around 50%). I have seen fluoxetine work. I have also seen it not work. I have seen the second antidepressant I try with a particular patient not work, and the 7th and the 10th but the 11th works. Or nothing works and psychoanalysis does. So it has always been clear to me that treatment guidelines that dictate a particular course of treatment for all patients with a particular diagnosis--and these guidelines do exist--is anathema to the work we do as psychoanalysts and mental health professionals which must always be tailored to the needs of an individual.
But one could argue that our profession, or the problems we treat, are the zebras of the health care world. The exception.
So reading that some Diabetes specialists--if we are zebras, Diabetes and its doctors must be the domestic pets of the health care world--are distraught at the promulgation of national standards of treatment was quite satisfying.
Critics of the guidelines for Diabetes, which endorsed aggressive lowering of blood glucose, argued that these guidelines were not appropriate for patients with Diabetes and co-morbid conditions like heart disease. Further, the critics suspected that those who would profit from more aggressive guidelines (pharmaceutical companies and device manufacturers) influenced the body that wrote the guidelines by the old fashiond way of giving the standards setting body money.
The problematic diabetes standard was abandoned last year after being in place only 2 years when a new study showed increased deaths in older diabetics with cardiovascular disease who were treated aggressively according to the new guidelines.
Personally, I find the lust for national treatment rules not just problematic but strange. I can't prove it, but my hunch is the cost saving and quality improvement claims such approaches are associated with have shaky foundations at best.
Is there a national wish to erase individuality when it comes to illness? To eradicate the importance of a relationship between sick person and doctor? To perpetuate a fantasy that we can be cook-booked back to health? |