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.

My plea­sure.

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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.