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We Need to Reinvent Brain Care

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Dr. John Docherty is an Adjunct Professor of Psychiatry at the Weill Medical College, Cornell University and Chief Medical Officer of Brain Resource. Trained as a clinical research fellow in neuropsychopharmacology at NIMH, he later returned as Chief of the Psychosocial Treatments Research Branch, responsible for all federally supported psychosocial treatment research in mental health nationwide. Dr. Docherty has wide experience in successfully implementing innovation in both clinical operations and managed health care.

Alvaro Fernandez: Dr. Docherty, it is a pleasure to be with you today to discuss the main theme of SharpBrains' 2010 market report, Transforming Brain Health with Digital Tools to Assess, Enhance and Treat Cognition across the Lifespan. Can you first briefly discuss your career trajectory and your current roles?

Dr. John Docherty: Sure. The main theme of my work since the 1960s has remained the same, "How do we put knowledge into effective use to improve mental health?" Over the last century, medicine made tremendous progress in generating scientific and clinical knowledge. Basic research, discovery science, and clinical treatment development science have made great progress. The study of psychotherapy, however, lagged in development. In my role of Chief of the Psychosocial Treatments Branch of the NIMH , I supported the efforts of an extraordinary group of individuals to make possible the effective scientific study of the efficacy of psychotherapies.

I would say that my major interest, however, has been in the next step, the science of knowledge transfer. There has been and remains a long and costly (in terms particularly of unnecessary suffering) lag between the development of new knowledge and its common and effective use in practice.

Right now I am working on a plan to provide personalized, performance-based support for mental health professionals to progressively expand their range of competencies and to stay current in those areas of established competence. As Chief Medical Officer of Brain Resource, my role is to ensure the integrity of the clinical data in our platforms and systems.

Based on those experiences, and also the companies you have been involved with, what are your reflections on how to put knowledge to good use?

I may suggest the following. One, that putting good evidence to work in practice requires more than publishing good research. I'd say that scientific evidence is directly relevant to perhaps 15 percent of clinical decisions,. The remaining 85 percent, demands some degree of inference where we need other translational tools such as well-done quantitative studies of expert opinion.

Second, we require technologies that translate emergent knowledge into practice. Continuously updated Expert Decision Support systems embedded in EHR's are absolutely necessary to close the gap between the development of new knowledge and its effective use.

In Psychiatry, another specific technology that is required is one that provides a reliable and valid assessment of brain health at an affordable price. Psychiatry has unfortunately badly lagged behind other areas of medicine in evaluating and diagnosing the health of the major organ that it treats. In my opinion an assessment of basic neurocognitive function should be an essential part of any psychiatric evaluation. To do this, however, requires a technology that makes such an assessment convenient and affordable. Fortunately, we now have some technologies such as the Brain Resource WebNeuro program, among some others, that makes this possible.

Once we have recognized the fundamental importance of underlying brain function to mental health, the need for technologies, drugs and other lifestyle interventions and considerations to protect and improve brain health increases in urgency. Cognitive enhancement and remediation technologies are now emerging. This is a nascent area of innovation and industry -- and a welcome one.

Finally, in order to truly encourage continuous innovation and improvement, we need to preserve both creativity and integrity. We need soft touches to guide the field in the right direction -- as in fact I believe SharpBrains is doing very well -- more than strict regulations that may be premature at this point.

I appreciate those words, thank you. We see the opportunity to improve brain care through the life course by upgrading the very basic framework for care, moving from the prevention and treatment of a collection of symptom-based diagnoses towards the enhancement and maintenance of underlying brain-based functions. Do you see any progress in that direction?

First, let me say that I fully share that point of view. As I noted, today's diagnostic framework is outdated in its limitation to symptom based diagnosis. All the organs in the body have a function, and the brain is no exception. Let's think of this analogy: the main function of the heart is pumping blood -- and when that function starts to fail a variety of symptoms appear, and may end in heart failure. Cardiovascular health has seen major improvements over the last 50 years precisely because of its understanding of the heart as a system with a function. The brain's main function is information processing, yet psychiatry basically ignores it. It doesn't take into account that so-called disorders, which are diagnosed and treated as if they were each separate and binary (you have them or you don't) illnesses, are primarily signs of decompensation, By that I mean, when the brain gets overwhelmed and can't perform its function well.

What we have learned from neuroscience over the last decade is that we can, to a significant extent, start to identify the brain-based cognitive and self-regulation dysfunctions that often precede disorders. So, we should be asking, what are the brain-based risk factors, the main reasons underlying the appearance of mental health problems? at what point of dysfunction do problems -- and which ones -- appear?

In short, the mental health field should adopt a brain-based model for diagnosis and treatment.

What would be key next steps in that direction?

Today we have brain-based models for most mental illnesses. What we need, to put that knowledge into practice, are useful tools that help us provide best care at the individual level, selecting from the broad types of interventions available and systematically and quantitatively monitoring their impact. Heretofore, a doctor who wanted to evaluate neurocognitive function had to refer his or her patient to a neuropsychologist which is very expensive. It can cost $4,000, and insurance coverage is highly variable. WebNeuro, the clinical decision support system by Brain Resource, helps automate an informative basic form of that evaluation. Since it is cheaper to administer and easier to obtain than a full evaluation by a neuropsychologist , it opens a whole new realm of possibilities. For example, you could measure and track the brain health of a whole population. A doctor or healthcare system could easily monitor the brain health of several hundred patients, identify who is experiencing dysfunctions and would benefit from specific interventions, track progress over time and refine his or her own clinical practice based on data.

I believe that, the more doctors we have using practical tools like this, the more obvious it will become that we need to change our existing diagnostic model and adopt a brain-based model of psychiatric diagnosis and treatment.

Dear John, thank you very much for a very stimulating conversation.

My pleasure.

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Note: this is a condensed version of the interview with Dr. John Docherty. You can read the full interview Here.

To learn more: you can read the Executive Summary of Sharp­Brains' market report Transforming Brain Health with Digital Tools to Assess, Enhance and Treat Cognition across the Lifes­pan, published in July 2010.

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