Jul 20, 2010
Technology as the missing link to enable a brain-based model of brain care: interview with Dr. John Docherty
Dr. John Docherty is an Adjunct Professor of Psychiatry at the Weill Medical College, Cornell University, Director of Post Graduate Education there, 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. He oversaw the landmark National Collaborative Study of the Treatment of Depression and served as a member and Chairman for over 10 years on the NIMH and then NIDA Treatment Research IRGs. Dr. Docherty has wide experience in successfully implementing innovation in both clinical operations and managed health care. He founded Northeast Psychiatric Associates in 1985. As National Medical Director for National Medical Enterprises, he oversaw medical control and quality improvement in 74 hospitals in 34 states. He was the Executive Vice-President and Chief Medical Officer for Merit Behavioral Care, which then covered 30 million people. In 1998, he founded Comprehensive NeuroScience (CNS). Its Care Management Technologies are currently implemented in 17 state Medicaid plans. Dr Docherty has received numerous honors and awards and has authored over 100 scientific publications.
(Editor’s note: this interview with Dr. John Docherty was originally published in SharpBrains’ market report Transforming Brain Health with Digital Tools to Assess, Enhance and Treat Cognition across the Lifespan, published in July 2010)
Alvaro Fernandez: Dr. Docherty, it is a pleasure to be with you today to discuss the main theme of SharpBrains’ 2010 market report – how the convergence of scientific findings and technology platforms and tools is reshaping how as a society and as individuals we will take care of cognition and mental wellness along the lifecourse, giving birth to the emerging digital brain health and fitness market. Can you first briefly discuss your career trajectory and your current role at Brain Resource?
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. Within Psychiatry there was standard setting advance in the 1960’s through the NIMH-VA cooperative studies to the methodology of assessing the efficacy of psychopharmacological drugs. This work established principles adopted for the study of medications in the other areas of medicine. The study of psychotherapy, however, lagged in development. In my role of Chief of the Psychosocial Treatments Branch of the NIMH , I helped contribute to the advance of that work by supporting the efforts of an extraordinary group of individuals led by Irene Waskow who carried out the TDCRP. This study established the methodologies that made possible the effective scientific study of the efficacy of psychotherapies. The evidence base and of such treatments as CBT, DBT, Motivational Enhancement Treatment and other evidence-based psychotherapies derives directly from this study and its seminal influence. This was a contribution to the science of Clinical Treatment Development research.
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.
In order the help the field moved forward, I have worked for the last 20 years in the development and implementation of methods to effectively transfer knowledge into practice. Since 1994, I and my colleagues have published 22 Expert Consensus Guidelines using an innovation method of quantifying expert opinion. Our goal was to put the combined voice of the nation’s experts in each Doctor’s office to help making all those day-to-day decisions that benefit from a thorough knowledge of current evidence and thoughtful inferences from that knowledge. 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% of clinical decisions,. The remaining 85%, 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 other area of medicine in evaluating and diagnosing the health of the major organ that it treats. We diagnose only on the basis of manifest symptoms that reflect some degree of decompensation of the brain’s functional capacity. Yet, our underlying clinical science has advanced to the point that, like cardiologists who can diagnose underlying disorders in the heart ( atherosclerosis, myocardiopathy, arrhythmias, etc.) before and separate from symptoms of cardiac decompensation, we can also diagnose the underlying problems in brain health. These problems in brain health are reflected in neurocognitive dysfunction. 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 gains saliency and urgency. Cognitive enhancement and remediation technologies are now emerging. This is a nascent area of innovation and industry – and a welcome one. We are in the phase now where the offerings are multiplying rapidly, but are entering the next phase of field maturation that will require companies to demonstrate the efficacy and effectiveness of their offerings. That next will lead to the beneficial consolidation and narrowing of the field to the companies which are able to empirically validate the positive impact of their products.
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 cognitive and self-regulation 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.
You seem to be saying that there is a growing gap between neuroscience and psychiatric practice, between what we know about the brain and how to maintain/ enhance its functionality and how its “disorders” are diagnosed and treated. Do you see a way to bridge this gap?
I do, which is precisely why I am now involved with Brain Resource. Today we have brain-based models for most mental illnesses, both those traditionally studied by psychiatry and neurodegenerative ones, like Alzheimer’s Disease, studied by neurology. 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.
We often call this new model a “brain fitness” one to emphasize 2 things: first, everything we can do before diagnosable disorders appear. As you said earlier, mental health disorders are really dysfunctions, so the more function we have to start with, the less likely the dysfunction will result in a diagnosable disorder. This is the value of the Cognitive Reserve is helping reduce the probability of developing Alzheimer’s Disease symptoms, even when pathology is present. Second, we need to adopt a new framework, based on functionality, on mental muscles if you will, but that will require a new language and new culture. Are health professionals ready? for example, how many doctors today could correctly define working memory?
I’d say probably no more than 5%. And you are right, that is precisely the new type of culture and frameworks we need to start promoting coupled, in my opinion, with careful scientific validation of the effectiveness of any proposed interventions.
Now, doctors really learn by doing, but they don’t have much time to learn interesting things that are not directly relevant to their work. In this regard, I believe WebNeuro can become a knowledge translation tool. Once doctors, probably specialists first and primary care physicians later, see how they can objectively and conveniently measure key aspects of the brain’s function.
Dear John, thank you very much for a very stimulating conversation.
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.