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VOLUME 3, ISSUE 1 PSYCHNEWS INTERNATIONAL March 1997
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SECTION B: GUEST EDITORIAL
BALANCING THE RISKS AND BENEFITS OF
CLINICAL CONSULTATIONS ON THE INTERNET
Steven L. Dubovsky, MD
InterPsych (IP), an international organization of electronic
mental health forums for professionals and patients, is one of
the best organized and most influential of a growing number of
Internet-based groups in which clinicians and patients share
information. One of the most important functions of IP forums
is to provide a medium for consultation about difficult cases.
On lists restricted to mental health professionals, clinicians
regularly provide brief case vignettes and ask for advice
about clinical management. These kinds of discussions can be
very useful, but they can also be risky.
One obvious issue is that no Internet discussion is confidential.
Even if access to a closed list could truly be restricted, and
even if patient material is disguised, the possibility exists
that an individual could be identified. To protect the confi-
dentiality of the clinician-patient relationship, many therapists
feel that it is necessary to ask a patient's permission to dis-
cuss any information with a third party for any reason, and there
is no reason to think that the same should not be true of Inter-
net discussions. Yet one rarely sees acknowledgement that
clinicians have obtained permission from their patients before
describing them on an electronic forum.
Research on the process of clinical supervision is beginning to
suggest that the impression that is gained by hearing about a
patient does not correspond well with the impression gained by
actually examining the patient. Internet consultations obviously
do not involve direct observation of the patient, and generally
time and space considerations as well as difficulty reading long
paragraphs on a computer make the information that is presented
fairly sparse. However, the marginal amount of patient material
does not seem to deter "consultants" from offering advice, some
of it cautious and some of it rather bold. When one considers
that many of the patients about whom advice is asked have complex
illnesses, the certainty with which suggestions are offered is
interesting. If predictable follow-up were available, it might at
least be possible for readers to know whether the advice worked.
However, much of the time we can only guess whether the
suggestion was followed and if so, whether it helped or hurt.
Since people don't ask for advice when things are going well,
most recommendations offered on the Internet do not involve
standard approaches, which have already failed. There is nothing
wrong with offering untested treatments so long as everyone
understands the nature of the suggestions. But to a surprising
degree, suggestions are offered with a greater sense of authori-
ty than would be justified by data about the patient or, for that
matter, about the treatment. Recent discussions on several lists
devoted to psychiatric medications illustrate this issue.
Last year, many Internet psychopharmacologists were recommending
both dexfenfluramine and phentermine/fenfluramine (phen/fen)
combinations for weight loss. Since weight gain is a common
problem with antidepressants and a number of other psychiatric
medications, this is an important issue. A number of experts
reported using these medications frequently based on a conviction
that they were safe and effective. What was missing from the
discussion was the proviso that solid data supporting their
assertions did not exist. In fact, a randomized study of 822
patients (average weight=97 kg) found a mean weight loss of only
9.8 kg with dexfenfluramine compared to 7.2 kg with placebo (1).
Another study showed sustained average weight loss of 9.4 kg over
3 years with dexfenfluaramine - generally 10% or less of body
weight (2).
How safe were the widely recommended medications? Shortly before
people on the Internet began singing the praises of dexfenflura-
mine, a large case controlled study in four European countries
showed that the risk of primary pulmonary hypertension (PPH),
which cannot be detected until it is irreversible and potentially
fatal, was increased tenfold in obese patients who took dexfen-
fluramine, with a somewhat smaller increased risk in patients
treated with fenfluramine (3). Patients who took these
medications for more than 3 months were a little more than
23 times as likely as untreated obese controls to develop PPH. In
a study of 32 Swiss patients who developed PPH on the appetite
suppressant aminorex during the 1960s and 1970s, four had taken
the drug for a month or less, and 7 patients did not develop PPH
for 3 months to a year after treatment was discontinued (4).
I was interested in the reaction on the Internet to a report from
the Mayo Clinic and the MeritCare Medical Center in Fargo, N.D.
of 25 obese women with no previous history of cardiac disease who
had been treated for about a year with phentermine/fenfluramine
combinations (phen/fen) and who were noted during routine
clinical evaluations to have heart murmurs. These patients
received echocardiography (ultrasound of the heart) that showed
damage to the aortic, tricuspid, and/or mitral valves (5). Eight
of the patients were also found to have PPH, and 5 of the entire
sample required surgery on their heart valves. Debate continues
about whether high blood serotonin levels caused by the phen/fen
combination could account for the damage, but at about the same
time a public health advisory from the U.S. Food and Drug Ad-
ministration noted that another 9 cases of heart valve damage had
been reported since the Mayo/Fargo study (6). In response to this
news, which was of course rapidly disseminated on the Internet,
the same psychopharmacologists who had recommended weight loss
drugs unequivocally began to advise against them, as if they were
right on the cusp of the latest breaking news. I recall seeing no
expressions of concern that international leaders in psycho-
pharmacology had missed the boat and no fears that they may have
been a little too quick to expose their patients to unnecessary
risk.
In the case of phen/fen and dexfenfluramine, the greatest
strength of Internet consulting was also its greatest weakness.
It is tremendously appealing to hear about the latest advance and
the newest treatment, and it is more than a little gratifying to
be able to tell others something new. However, in our rush to be
on the cutting edge and try the latest and greatest, we may be a
little too quick to accept opinions as authority, failing to make
the distinction between an observation in one or two patients, a
few clinical trials, and a prospective controlled study - the
"gold standard" of proof in clinical science.
A few weeks ago, a psychiatrist I know asked me what I knew about
lamotrigine, a new anticonvulsant medication that has gained
rapid popularity as mood stabilizer in bipolar mood disorder. I
said that there were not yet any controlled studies of this
application, so it could only be considered experimental. He re-
plied proudly that he knew of such a study, and he was surprised
that I wasn't familiar with it. I asked to see it, and he sent me
a list of "lamotrigine FAQ's" based on the experience of a single
expert. To this consumer of Internet data, the boundary between
fact and opinion was blurred in the same manner as the boundary
between intuition and knowledge.
This tendency to take the first new thing one hears about as
gospel may not be scientific, but it is hardly limited to the
Internet. Lamotrigine and gabapentin, another new anticonvulsant,
have come into widespread use, sometimes as initial treatments
for bipolar disorder, in the absence of a single published
controlled study of a short-term antimanic effect. Neither
medication has been available for a long enough period of time to
be subjected to any kind of study of their ability to prevent
recurrences of mania or depression, but many patients are taking
them as mood stabilizers. Do they work? Are they safe? In most
other clinical specialties, these questions would be as much a
subject of discussion as the treatments themselves.
Why do we seem so quick to accept as established treatments
approaches are supported only by the conviction that they help?
Perhaps our credulity is being strained by our need for answers
to the difficult clinical questions that plague us in an era in
which all of the easy disorders are being treated by specialists
outside the mental health field. Perhaps we are so anxious to
feel that we are at the cutting edge that we ingest information
without chewing, failing to distinguish between intriguing ideas
worthy of formal study and the latest and greatest treatment. But
in our rush to be in the know, we may lose that critical faculty
that is essential to our performance as clinicians.
The warp speed with which information circulates on the Internet
is a blessing, but uncritical acceptance of the published word of
opinion leaders has the potential to be a curse. No clinician
would accept the initial assessment of a patient as the last
word. If this did occur, the patient would end up being forced to
conform to the therapist's first opinion, and the opportunity
would be missed to revise the initial hypothesis in the light of
further data and find the best approach for that patient. As the
Internet matures, discussions will hopefully contain the same
level of data reporting and critical appraisal of one's own and
others' statements that would be expected in any scientific
setting.
References
1. Guy-Grand B, Apfelbaum M, Crepaldi G, Gries A, Lefebvre P, Turner
P. International trial of long-term dexfenfluramine in obesity.
Lancet 1989;2:1142-1145.
2. Rosenbaum M, Leibel RL, Hersch J. Obesity. N.Engl.J.Med.
1997;337:396-407.
3. Abenhaim L, Moride Y, Brenot F, et.al. Appetite- suppressant drugs
and the risk of primary pulmonary hypertension. International Primary
Pulmonary Hypertension Study Group. N.Engl.J.Med. 1996;335:609-616.
4. Mark EJ, et al. Fatal pulmonary hypertension associated with
short-term use of fenfluramine and phentermine. N.Engl.J.Med.
1997;337:602-606.
5. Connolly HM, Crary JL, McGoon MD, et al. Valvular heart disease
associated with fenfluramine-phentermine. N.Engl.J.Med.
1997;337:581-589.
6. Nightingale SL. Health advisory on concomitant fenfluramine and
phentermine use. J.A.M.A. 1997;278:379-379.
Dr Dubovsky is professor of psychiatry and medicine at the University
of Colorado School of Medicine and vice chair of the Department of
Psychiatry. He has been president of InterPsych in 1997. His research is
in mood, psychotic and psychosomatic disorders. He consults on difficult
patients around the United States and specializes in treating mental
health professionals and physicians. His latest book is "Mind-Body
Deceptions" (WW Norton, 1997).
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