And now a post at total odds with this one.


My friend Barney Carroll has died, at 78,
his final view, from his apartment’s
picture windows, the glorious Carmel Valley.
He sent me a picture, last week, of what he saw.


Allen Frances, a fellow warrior against
corruption in medicine, wrote Barney’s obit.

Barney’s scientific contribution to psychiatric research was to introduce neuroendocrine techniques. He independently discovered the value of the dexamethasone suppression test (DST) as a biomarker of melancholia — the classic, biologically driven subtype of depression. This was the first, and remains one of very few, biomarkers in psychiatry. Barney’s 1981 paper on the DST was among the most highly cited papers in psychiatry. Its impact was immediate, with many replications and extensions.

Another of Barney’s enduring contributions was to educate colleagues in the discipline of proper clinical decision making. He clarified the Bayesian principle that context counts — that is, prior conditional probabilities greatly influence the utility of any clinical feature or laboratory test in making a diagnosis. Throughout medicine, biomarkers and clinical diagnostic features perform with much greater utility in high risk groups than in general populations.

Barney and Allen had both chaired Duke University’s psychiatry department, and they shared an anger at (to quote the subtitle of one of Allen’s books) “Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life.” Both certainly know and knew that, as David Bowie wrote toward the end of his life, “On the whole, this whole world is run by brutes for the common and the stupid.” So they weren’t terribly optimistic that their protest could do much. Once it’s all come down to late-night comedy, it’s a bit late in the day.

But if, as Barney explained to me in a recent email, you’re a hopelessly inner-directed person, you can’t live with yourself if you don’t make a serious daily effort toward de-brutalization. Barney saw in Donald Trump late-stage outer-directedness, and regretted that “I won’t be around to see how it finally plays out with the orange man in the white house.” But he was fundamentally stoic – and typically observant – about the process of dying.

I am watching with detachment as I move along the path to allostatic collapse… What’s allostatic collapse? It’s just a fancy term for the end state of chronic deterioration that comes with terminal illness. We begin to fail piece by piece but we may hang on for years in a new state of compensated but pathologic equilibrium until even that cannot be sustained. Related constructs are chronic life stress and aging before supervening disease appears. My point of collapse is shaping up to be respiratory failure.

I had many questions to ask Barney about allostasis. Can’t ask them now. But he already, in his final sign-off, told me the most important thing.

Be well and be happy.

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4 Responses to ““In the late 1950s I encountered David Riesman’s The Lonely Crowd and I imprinted immediately on his term inner-directed. That’s me to a tee, so taking unpopular positions came naturally to me.””

  1. dmf Says:

    sounds like a lovely man, I wish people understood how little of “evidence” based psychiatry/mental-health has any substantial basis in physiology/lab-science, a hospice nurse I trained with told us that in the end either the heart or the lungs give out perhaps there’s some poetry in that.

  2. theprofessor Says:

    I am part of both an internal group and a foundation that provides funds for undergraduate research projects with faculty, and all pretense of science in many social science projects is being dropped. In the bad old days, they at least attempted to do the usual null and alternative hypotheses; now, they flat-out say that they are going to “prove” a particular position. Data analysis now consists of learning how to throw out enough data to get the desired result.

  3. dmf Says:

    theprof, I’ve stopped being an outside reader for sociology and psychology dissertations in large part because the students (and too often the faculty) have very little grasp of the tools/maths they are employing in their methods, not much of a sense how things are foregrounded and no sense of what gets pushed into the background.
    Reminds me of my father fighting with his fellow profs over the use of calculators in classes, his point, generally ignored, was that it was rote use of heuristics, versus actual/informed understanding, that was the real problem and not the tool/method per say whether by hand or machine.

  4. theprofessor Says:

    One of the big problems with statistics taught in particular disciplines is that the students often don’t learn the real math underlying the calculations. I was the victim of one of these courses back in the 1970s, back when SPSS was run with punch cards on a mainframe. Stats was not a normal part of my discipline–this was the department trying to be on the cutting edge. The prof did not have a clue: his approach was to have us run every kind of test imaginable on data sets and then search for something “significant” (btw, the mainframe operators were mightily pissed off because of the amount of green-bar paper we were generating). It wasn’t until I actually worked through a real math-based textbook years later that I actually began to understand. Things don’t seem to have improved: I regularly have junior and senior social science majors in gen ed classes who don’t have a clue about what a standard deviation is.

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