Tuesday, August 30, 2011

Mental health front groups

I subscribe to a newsletter called Natural News (http://www.naturalnews.com/). Don't know how I first started subscribing, but it arrives in my in-box daily. I myself have wondered if it is a front for a certain unnamed American politician, whose name keeps cropping up affirmatively in the newsletter. Here's what the website has to say about itself.

The NaturalNews Network is a non-profit collection of public education websites covering topics that empower individuals to make positive changes in their health, environmental sensitivity, consumer choices and informed skepticism. The NaturalNews Network is owned and operated by Truth Publishing International, Ltd., a Taiwan corporation. It is not recognized as a 501(c)3 non-profit in the United States, but it operates without a profit incentive, and its key writer, Mike Adams, receives absolutely no payment for his time, articles or books other than reimbursement for items purchased in order to conduct product reviews.

Whatever this organization is, many of its news items are right up my skeptical and holistic alley, like this item from today's newsletter:

"Don't believe all the goody-goody "mental health groups" that claim to help teens and adults with their brain problems. Many of these are really just psycho-pharma front groups, and CCHR has exposed them all:

(NaturalNews) A highly effective public relations technique is the "third party technique" of creating front groups to endorse or promote the need of any service or product. The first party is the original group or client that would benefit more from increased public trust or affinity. The second group is the public or consumers. A third group is created with a contrived name to appear publicly as a disinterested party endorsing the industry of the first party.
Learn more: http://www.naturalnews.com/033453_psychiatry_front_groups.html#ixzz1WWaj0fwt

A link inside the body of the article takes you over to the CCHR (Citizens Commission on Human Rights) for website, which readers of this blog probably already know was founded in 1969 by Dr. Thomas Ssasz and the Church of Scientology. Many people say CCHR is a front for Scientology. Be that as it may, and because I'm catholic in my tastes and opinions, here's what the CCHR website has to say about these front mental health front groups, who are listed by the way, on the CCHR website.

Certainly any organization claiming to be for the rights of patients diagnosed mentally ill would have as their primary goal, full informed consent in the field of mental health – including full and complete disclosure of all drug risks, the right to refuse treatment, the right to know that psychiatric diagnoses are not medical conditions (evident by the fact there is not one confirmatory medical/scientific test). Above all such groups would provide patients with an abundance of information on non-harmful, non- drug, medical solutions and options considering the dangerous and well documented risks of psychiatric drugs by international drug regulatory agencies.

These groups do not.

Monday, August 29, 2011

Losing my organized religion

From the New York Times, Teaching patients writing and hope. The article is about the writing program that is led by clergy at the Creedmore Psychiatric Center in Queen's, New York. 

Read the article here

“We provide a sense of almost refuge,” said the Rev. Jeff C. Williams, an evangelical Protestant minister. “It’s nonjudgmental, nonconfrontational. In all the other parts of their lives, there are limitations based on their diagnoses.” To bring ministry into a setting like Creedmoor is to wrestle with particular challenges as well. It is to hear patients pray to be discharged, knowing that may never happen. It is to discern the difference between the devout and the delusional. One of the Catholic chaplains, the Rev. Augie J. Iantosca, recalled a patient who confided, “I know I got a lot of competition here. But I’m the real Messiah.”       

I hate to be so critical, I really do, of the well-intentioned writing program, because, otherwise, it is an excellent idea to bring open ended discussions of God and faith into a psychiatric hospital.  People who are considered "delusional," often in a religious way, are usually those patients who have keen interest in why we are here in the first place. They are closer to God than most of us. It is outrageous then to read that the clergy, too, sits in judgment. There are the "devout" (normal people . . .  I guess) and the crazies. This coming from churches that were built by the clearly delusional, er, I mean the excessively devout. Help the patients open up about their concerns, by all means, but please don't patronize them. I really believe the church is on shaky ground believing that there are those loonies and then there is us. Anyone who reads my past posts probably knows that I am quite critical of churches'  idea of who's sane and who isn't. Chris's so called mental illness has had the effect of distancing me from the church. I know longer feel like going.

It's not really fair, either, that I feel this way. Our particular church in so many ways has been supportive. I am truly grateful for all the acts of kindness my family received. Chris was regularly called upon, even when he was quite fragile, to stuff envelopes, fix the computer, or set up tables for events. He was in a protective and caring environment. At the same time, I cannot speak to my own minister about Chris without him alluding in some way to Chris's "mental illness." He is more sad than hopeful about the diagnosis, despite the clear evidence that Chris is like any other so-called normal person. He wonders if Ian and I would like to join a support group. For what, I'm thinking, supporting the idea that mental illness is a death sentence? The time for wanting the kind of  support that I thought I needed at the beginning is long past. To think that people who are "called by God," don't see the huge hypocrisy in failing to see a similarity between devout and delusional, has forced me to reconsider my own religous beliefs. I am bowing out of organized religion, while being mindful of the many good things it does for so many people.

For all the good that the clergy is doing in the hospital's writing program, there also fair chance this may come undone when the inmates suspect that the clergy thinks they, not Jeremiah and the Messiah, are delusional. The clergy should stop humoring psychiatric patients by siding with state psychiatry and learn how they can do their best work. To quote Jung again, "A schizophrenic is no longer schizophrenic when he feels understood by someone else."

Saturday, August 27, 2011

Go Parsippany

Nearly half of the 432 patients at Greystone Park Psychiatric Hospital have signed a petition or boycotted therapy sessions this month to protest new rules they say further limit their activities and force them to attend programs that don’t help in their recovery, patients and an advocacy groups say.

Read the rest of the here .

Thanks to Susan Schecter for spotting this one.

Thursday, August 25, 2011

Autism, journalistic integrity and (gasp) pharma conflict of interest

Remember Andrew Wakefield,  the U.K. medical researcher and surgeon judged guilty of professional misconduct, dropped from the U.K. medical register, original article retracted by The Lancet, and all-round condemned because he suggested that the link between the MMR vaccine and autism merited further study?

Well, cracks are appearing surrounding the case for the "evidence" against him, and they're getting larger. The British Medical Journal (BMJ)  has published a letter to the editor (23 August 2011) that publically raises the pharmaceutical industry/BMJ Group conflict of interest. Cracks routinely appear where pressure is brought to bear on an object.

Here's the letter. You will need to know that GlaxoSmithKline manufactures the MMR vaccine.

Re: Guilty by association?

Mark Struthers, GP and prison doctor

Bedfordshire, UK mark.struthers@which.net

James Murdoch, son of Rupert, is in deep water and struggling. [1]

James Murdoch, chairman and chief executive of News Corporation Europe and Asia, and chairman of BSkyB, apparently has strong ties to the pharmaceutical industry. In May 2009, Murdoch was appointed a non- executive director of GSK, to serve on GSK's 'corporate responsibility committee' with a remit to review "external issues that might have the potential for serious impact upon the group's business and reputation". [2]

It is now understood that the BMJ Group exists in a 'complex commercial environment' and the editor of the BMJ has acknowledged the potential for 'perceived' as well as 'actual' conflicts of interest over ties to industry. [3]

May I humbly suggest that the association between a large British vaccine manufacturer and this particular media baron ... is an unhelpful one.

Competing interests: None declared
Submit rapid responsePublished 23 August 2011

You might also want to know that there was a partial admission by the BMJ of conflict of interest in March 2011.

In a less than forthcoming clarification to its accusatory article "Wakefield’s article linking MMR vaccine and autism was fraudulent", way back in March 2011, the BMJ wrote:

The BMJ should have declared competing interests in relation to this editorial by Fiona Godlee and colleagues (BMJ 2011;342:c7452, doi:10.1136/bmj.c7452). The BMJ Group receives advertising and sponsorship revenue from vaccine manufacturers, and specifically from Merck and GSK, which both manufacture MMR vaccines. For further information see the rapid response from Godlee (www.bmj.com/content/342/bmj.d1335.full/reply#bmj_el_251470). The same omission also affected two related Editor’s Choice articles (BMJ 2011;342:d22 and BMJ 2011;342:d378).

Cite this as: BMJ 2011;342:d1678

[1] James Murdoch: Man of many fabrications and few friends. Mail&GuardianOnline, Brian Cathcart: Analysis, Aug 19 2011. http://mg.co.za/article/2011-08-19-james-murdoch-man-of-many-fabrications- and-few-friends/

[2] Glaxo brings in James Murdoch. Chris Tryhorn, The Guardian, Tuesday 3 February 2009 http://www.guardian.co.uk/business/2009/feb/03/glaxosmithkline-james- murdoch

[3] Correction: Wakefield's article linking MMR vaccine and autism was fraudulent. BMJ 2011; 342:d1678 (Published 15 March 2011). http://www.bmj.com/content/342/bmj.d1678.full

Wednesday, August 24, 2011

Another book refuting childhood bipolar DX

There is a groundswell of books appearing on the market that refute the basis of the bipolar diagnosis in childhood. Here's an interview in the Huffington Post with Stuart Kaplan, MD, author of Your Child Does Not Have Bipolar Disorder: How Bad Science and Good Public Relations Created the Disorder.

There is, indeed, a psychiatric diagnosis called childhood bipolar disorder that used to be reserved for the rare child, but that diagnosis has gotten way out of hand in the past two decades, leading to medicating this "disorder" in growing numbers of children under eighteen. Now, everybody's child is that "rare" child. I can hear parents complaining, sure, it's easy for you to say this, just try living with MY child and see what you think. I think I can speak from experience as a parent and having to struggle with mind-blowing odd behavior in my adult child. Years ago, my elementary school aged middle child drove me to seek out a psychologist, who was very helpful in helping me to understand him. I changed my attitude and he changed his behavior. It's a two way street. My youngest was inexplicably termed ADD by a psychologist who had never even seen him in action. Parents of young children are understandably under stress and sometimes don't feel they have the luxury of taking a step back from the situation. Even in the 1990s, ADHD and ADD was the diagnosis du jour. Everybody seemed to have it.

Its one thing to be given the label, but it's another thing to know what to do about it. And that's where most of us fall down, knowing what to do about it. Science hasn't been much help. More emphasis is needed on family therapy in learning how to deal with the surprising ways that children can react to their home environment. Especially that "rare" child.

Reviews of "Disaster Was My God"

From the New York Times

“Disaster Was My God” delivers a Rimbaud who forces literary true believers to ponder an unwelcome thought: that artistic ambition may sometimes be, as the guidance counselors say, just a phase that troubled teens — even geniuses — go through.

Review on Amazon
"Disaster Was My God" is a blazing trip through fascinating characters, the tortured trajectory of a brilliant man's life, and the revolution in poetry brought on by Arthur Rimbaud. Bruce Duffy has a knack for writing about pain and extreme awkwardness in a style that keeps it light and sometimes laugh-out-loud funny. The characters in this book, they are characters. Rimbaud is first a child prodigy, then a poet who changes the fundamentals of poetry, then a gun runner in Africa. Duffy finds a way to do what I thought could not be done- connect the seemingly unconnectable dots that form Rimbaud's life. This book is about a bizarre and unique man, and about all of us. It is about what can happen when we emerge from the unrealistic thinking of our adolescence and bump up clumsily against the adult reality of the outside world. Read the book. He says it better than me. Then there is Rimbaud's mother, the mother of all mothers, who apparently could have written the book on controlling, narcissistic, queen-of-martyrdom parenting. If I was a Hollywood actress of a certain age, I would be putting this book down, calling my agent, and saying "Get this book. I want to be Rimbaud's mother." And finally, Verlaine, who brings Rimbaud to Paris, and is honest enough to admit that he fell for him and got kicked in the teeth. I have never read a funnier tragic book.


Arthur Rimbaud, the enfant terrible of French letters, more than holds his own with Lord Byron and Oscar Wilde in terms of bold writing and salacious interest. In the space of one year—1871—with a handful of startling poems he transformed himself from a teenaged bumpkin into the literary sensation of Paris. He was taken up, then taken in, by the older and married poet Paul Verlaine in a passionate affair. When Rimbaud sought to end it, Verlaine, in a jeal­ous rage, shot him. Shortly thereafter, Rimbaud—just shy of his twentieth birthday—declared himself finished with literature. His resignation notice was his immortal prose poem A Season in Hell. In time, Rimbaud wound up a pros­perous trader and arms dealer in Ethiopia. But a cancerous leg forced him to return to France, to the family farm, with his sister and loving but overbearing mother. He died at thirty-seven.

Product description
Bruce Duffy takes the bare facts of Rimbaud’s fascinating existence and brings them vividly to life in a story rich with people, places, and paradox. In this unprecedented work of fictional biography, Duffy conveys, as few ever have, the inner turmoil of this calculating genius of outrage, whose work and untidy life essentially anticipated and created the twentieth century’s culture of rebellion. It helps us see why such protean rock figures as Bob Dylan, Jim Morrison, and Patti Smith adopted Rimbaud as their idol.
Disaster Was My God: A Novel of the Outlaw Life of Arthur Rimbaud, by Bruce Duffy
Hardcover: 384 pages
Publisher: Doubleday (July 19, 2011)

Monday, August 22, 2011

Do shamans lose consciousness on airplanes?

Does the ability to achieve unconsciousness on a plane signify a higher consciousness? is the somewhat  misleading intro on the home page (upper right) of today's New York Times.

How to Sleep on a Plane
Does the ability to achieve unconsciousness on a plane indicate, in fact, a higher consciousness?

On reading  the blog, it turns out to be a pop culture take on higher consciousness, purely a fluff piece. I wonder what the author really knows about shamanism. She doesn't develop a provocative idea beyond the banal. To be fair, the unnamed front page title picker got it wrong.

With the closed-mouth solemnity of a dignitary lying in state, airplane sleepers seem to me shamanistic. They’re at one with the Virgin Atlantic or JetBlue heavens. In the passenger murmur, overhead beeps and engine hum they hear a lullaby.

Maybe Virginia is on to something. Despite feeling lied to by the title, I have occasionally wondered about the association between air travel and a higher consciousness, and I'm not talking about the ability to sleep.  I had the unfortunate experience landing in Vancouver with Chris a couple of weeks ago, when he passed out briefly on our descent. This is the second time I have sat next to him on an airplane and something unusual happened. The first time was when we flew back from  England after his university interview in 2001 and he got a cracking head pain as we began our descent. I mark that occasion as the first clue that he would go on to develop psychosis. The pain mysteriously vanished on landing, but Chris began tapping his head in the same way that Russell Crowe portrayed John Nash sliding into psychosis.

The rational explanation is the first thing we look for, but the explanation may not be rational. The doctor in the seat next to me in Vancouver asked if Chris is diabetic (I sure hope not!) and hearing that he wasn't, he thought it might be low blood pressure. Chris's psychiatrist, Dr. Stern, thought it might be anxiety. Who knows? I favor the higher consciousness explanation.

Has anyone else experienced something similar on a plane or thinks that, indeed, there is something godlike going on?

Sunday, August 21, 2011

Brand Chris

I watched several good films while flying across the pond recently, both of which got me thinking about advertising and image make-overs. The first, L'Amour Fou (Crazy Love) is an excellent documentary about the late, great fashion designer Yves Saint Laurent. Go see it if you get a chance. The movie is a mesmerizing look at both Saint Laurent himself and the world of high fashion, and it has English subtitles. I wept when Saint Laurent announced his retirement with words evoking his favorite author, Marcel Proust. That speech alone is worth seeing the film, but there are also glamourous supermodels and glimpses of the jet set of the nineteen sixties.

I laughed when Saint Laurent said that his greatest achievement was putting women in pantsuits, but of course, he's no oil exec, he's a fashion designer and pantsuits for women caught the spirit of the women's liberation movement, so it was entirely appropriate that he said so.

Yves Saint Laurent had his own fashion house, despite being painfully shy and suffering intense bouts of depression throughout his life. He and his business partner and lover Pierre Bergé created and marketed the YSL brand.

Morgan Spurlock, the director of The Greatest Movie Ever Sold, a documentary about product placement, marketing and advertising, is the antithesis of YSL; he's more of an everyman, more Walmart than haute couture. In one scene in the movie, he goes to Pittsburgh, or someplace like that, to consult with a product placement firm, and the person he interviews helps him to determine how to place himself as a product. She decided after interviewing him that he was playful and mindful.

Seeing both these documentaries naturally got me thinking about Chris. I'm getting to old to be repositioned in any case. I've been into just maintenance for the past ten years and I can see years of intensified maintenance work ahead. Chris seems keen for product positioning. It's a good time for a launch. He's 27 going on 28, the age of his first Saturn return. His learning that he's numerologically a number 3, has helped him focus on his creativity as an eventual career direction. He wears hats well. Hey - we can work with this. Musicians look good in hats, so do chefs. As part of his repositioning strategy, he's now determined to lose weight.  Chris has put on a noticeable number of pounds over the past few months which coincided with his newfound joy in cooking. His lifelong dormant tastebuds have kicked into gear, and he's making up for it with a vengeance. A fun idea, to think of what brand he would like to be, may help him gain more confidence in the spin he would like to put on his life.

Chris has come a long way, but still doesn't have a highly developed sense of self. It's starting slowly, and has been helped by many things such as Tomatis, sound therapy, psychotherapy, the Alexander Technique, and other things discussed in this blog. He told me today that he doesn't feel ready to take on big challenges, he's talking about further education, so it looks like nothing big is going to happen next year. It's so nice to hear Chris being able to express this thought. As a teenager he kept everything close to his chest. If he's not ready, he's not ready. Sigh. In the meantime he's auditioning for a role in the Christmas pantomime, Jack and the Beanstock. Now that's progress!

Thursday, August 18, 2011

Temple Grandin movie hints at something polite society avoids

I stayed up all night watching three movies on the plane ride home, one of which was Temple Grandin, an HBO movie starring Clare Danes. Temple Grandin is a scientist at Colorado State University who focuses on the humane treatment of stockyard animals. She is more widely known for also being on the autistic spectrum, showing characteristics of Aspergers Syndrome. Autism, like schizophrenia, used to be widedly seen as a reaction to an unnurturing mother.

The movie begins in 1966 when Temple enters college for the first time and then flashes back and forth through her early life and her growing sense that her Aspergers allowed her greater understanding of the psychology of stockyard cattle. I haven't read Grandin's book, so I don't know how closely the movie followed it, but it is the relationship with her mother that shows that the old view of autism may be making a comeback. This is more a cause for hope, not despair. In one scene in the movie, the doctor giving the original diagnosis of autism, or juvenile schizophrenia, as he called it, when pressed by the mother, said that the origin of autism was thought to be a lack of physical warmth on the part of the mother. The mother replied in words to the effect that she was the same mother to her other child who was fine, but that Temple was unresponsive. Though linking autism to a lack of the maternal mothering instinct has been roundly dismissed in the era of the biochemical brain disease model of the "illness," lack of physical responsiveness is a childhood clue that someone may develop schizophrenia or autism. Certainly, this was my experience with Chris, and Dr. Abram Hoffer has noted the same kinds of observations from mothers of his patients.

We could conclude that the theory of emotionally distant mothers has been overturned by science, as most of this generation believes. But the movie hints that the emotional bonding connection to autism is valid. It shows this at least two ways. First, the mother (Julia Ormond) definitely comes across as cool. The director could have insisted that the mother be portrayed as palpably warm, the type of mother seen in TV commercials giving out chocolate chip cookies and kissing bruised knees, but instead the mother played it cool. Not that she wasn't well-intentioned, not that she didn't love her daughter, but she was educated, rich, and well, cool in demeanor. I'm assuming that Temple Grandin herself had a lot of say in the content of this film and how her mother was portrayed.

The second way of showing that Temple had failed to bond with her mother (it's a two-way street, of course) is the rather startling way that Temple had of calming herself down when she got violently agitated. She built herself a containment box, just as she had seen in the stockyards to calm down the cattle. Wikipedia describes it below. Note the amusing term "sensory integration dysfunction," newspeak for mother/child bonding, but trying to make it look like it's all about the biochemistry.

During Temple's college years, she conceptualized the squeeze machine, which was designed for herself because she had a sensory integration dysfunction and disliked physical affection by people. The machine hugs both sides of her to calm her down, as she controls the pressure, and it makes her relaxed whenever she becomes tense.

The reason I'm promoting and endorsing, to some degree, this unpopular stereotype of the mother is that the importance of mother/baby bonding has been deliberately sidelined when it comes to understanding and treating autism and schizophrenia. Mothers are understandably sensitive on this issue and, knowing this, pharma has been quick to seize a market opportunity. What have we given up by doing this? Lots. Real help is the most important thing. We are afraid to even look at the family environment, the impact of our ancestors on the present generation, and how we repeat patterns of behavior without even being aware of it. We shouldn't be so afraid. Confrontation with ourselves can subtly change family dynamics, for the better. There are several psychotherapies that fill the bill in this respect and wonderful sensory integration therapies like the Tomatis Method, that can help the individual flourish in body and mind. But we lose all of that by being overly sensitive to the truth, that mothers (and fathers) do matter in the child's personal landscape.

Mother/child bonding may be only one contributor to the expression of schizophrenia and autism, but I have noticed that seeking out certain kinds of psychotherapies and body/mind therapies has done Chris a world of good and I get good reports from others about what it did for their relative. Non-pharmaceutical alternatives are a valid avenue to explore. Diet matters, too, though diet is not the focus of this particular post. Temple appeared to exist on yoghurt and green jello. There's obviously something biochemical going on, that the psychology of nutrition (is there a psychology? there must be!) could address. Many people have reported that their symptoms cleared up or were greatly alleviated by rigorous attention to diet.

This movie may be an example of how the accepted view of schizophrenia and autism over the past fifty years is now changing.

Sunday, August 14, 2011

Kris Carr

I had never heard of Kris Carr, until today. Kris Carr is a wellness warrior, a woman who got a devastating diagnosis at the age of 31, and turned it into an empowering way to take control of her life. She "gets" the idea.  Read more about how she did it here. A diagnosis of "cancer" is really no different than "schizophrenia". Both can be an opportunity and a pathway to growth. Why not also have some fun along the way?

 “And at the bookstore, all I could find was all this old, sad, pass-the-tissues Hallmark stuff.” So she developed a style that’s a mash-up of “Eat, Pray, Love” and the expletive-laced pro-vegan “Skinny Bitch” books, her voice frilled with easy intimacy and bedecked with hot-pink chick-to-chick flourishes. Carr’s cancer world is a place where prostheses are for “boobies,” medical binders are “bitchin’ ” and patients are encouraged to become “ ‘Prevention Is Hot’ cheerleaders.” In one of her books, she suggested you deck out your bathroom like “a detox ashram” before giving yourself an enema. Through her looking glass, there is the time, money and energy for vigorous dry brushing and eco-friendly “shopping therapy” and long, meaningful moments spent signaling the wellness muse in a self-built “sacred space” garlanded with flowers. She has created an aspirational fantasia, and she has implemented it in a place nobody dared try it before: the realm of illness. Just because you are giving yourself an enema with a hose, she wrote in one passage, “doesn’t mean you have to be in an antiseptic environment. Surround yourself with style and beauty.” This is, in a way, her call to arms.

Saturday, August 13, 2011

Daniel Carlat response to Marcia Angell review

Daniel Carlat had a strange response to the review that Marcia Angell wrote in the New York Review of Books of his book. Despite what he wrote in his book, that psychoactive drugs are hardly better than placebos, in his response to Marcia Angell, he now says the majority of psychoative drugs are robustly better than placebos, which flies in the face of the evidence, as Angell points out below. He even seems to be critical of Angell, who, on the whole, wrote a rather kind review of his book. What I think is going on with Carlat is rather simple. It's one thing to fearlessly say what you want in your own book, it's another thing to see it in print in someone else's review, particularly when Carlat said many things in his book that are deeply unflattering to his own profession. I think Carlat may be beginning to panic about his standing with his peers. He espouses that psychiatry, as many practice it, is money grubbing in the extreme and there is dubious science behind the drugs that are prescribed. This is probably controversial only with his peers.

Rather than reprint Carlat's response, I have reprinted Angell's rebuttal below. (Marcia Angell is the former editor in chief of The New England Journal of Medicine.) I apologize that this post is so long, but the message is important.

Marcia Angell responds to Carlat et al.

All three of these letters simply assume that psychoactive drugs are highly beneficial, but none of them provides references that would substantiate that belief. Our differences stem from the fact that I make no such assumption. Any treatment should be regarded with skepticism until its benefits, both short-term and long-term, have been proven in well-designed clinical trials, and those benefits have been shown to outweigh its harms. I question whether that is so for many psychoactive drugs now in widespread use. I have spent most of my professional life evaluating the quality of clinical research, and I believe it is especially poor in psychiatry.

The industry-sponsored studies usually cited to support psychoactive drugs—and they are the ones that are selectively published—tend to be short-term, designed to favor the drug, and show benefits so small that they are unlikely to outweigh the long-term harms. The problem with relapse studies, like that of John Geddes, which is cited by Friedman and Nierenberg, is that they don’t distinguish between a true relapse and withdrawal symptoms that result from the abrupt cessation of drugs.

Both the pharmaceutical industry and the psychiatry profession have strong financial interests in convincing the public that drug treatment is safe and the most effective treatment for mental illnesses, and they also have an interest in expanding the definitions of mental illness. Even Dr. Carlat, whose excellent book I reviewed, admitted that he and other psychiatrists make nearly twice as much money prescribing drugs as providing talk therapy. In his letter, which seems somewhat inconsistent, he states that the “unequivocal, if perplexing truth about psychiatric drugs” is that “they work” (his italics), and that all the major psychoactive drugs “are robustly more effective than placebos in double-blind controlled trials.” (In fact, the trials yield varying outcomes, many of which fall far short of robustness.) But elsewhere in the letter, he says, “There is no question that among the medical professions, psychiatry is the most scientifically primitive,” and in his book, although he claims anti- depressants work, he comes close to Kirsch in concluding that “much of this response is undoubtedly due to the placebo effect.”

Carlat mischaracterizes Kirsch’s work by suggesting that he contradicted himself. Kirsch did indeed find that the six antidepressants he studied were more effective than placebos, but the difference was very small (similar to the difference found by Turner and his colleagues, in the study cited by Carlat). Kirsch then speculated that even this small effect might not be real, because patients who received the antidepressant instead of an inert placebo would experience side effects that might enable them to guess that they were receiving an active drug, and therefore might make them more likely to report an improvement in their depression. In support of this hypothesis, Kirsch pointed to a few trials employing placebos that themselves had side effects, where no differences were found between drug and placebo. But despite the persuasiveness of his theory, Kirsch acknowledged that it remains to be proven.

The UK’s National Institute for Health and Clinical Excellence (NICE) develops treatment guidelines for the National Health Service on the basis of benefits and costs. It concluded that because improvements in the 51-point Hamilton Depression Score (HAM-D) of less than three points are not clinically discernible, antidepressants that on average fail to provide at least that level of improvement could not be recommended. While that cut-off is indeed arbitrary, as Carlat says, so are many other conventions in medicine, e.g., the number of symptoms required for a diagnosis of a major depressive episode or the accepted standard (P less than 0.5) for statistical significance. The NICE cut-off strikes me as eminently reasonable. Friedman and Nierenberg point out that a reanalysis found a 2.68 point difference instead of a 1.8 difference, but that is still below NICE’s threshold for clinical significance.

Contrary to Dr. Oldham, I did not say that mental disorders were invented in order to create a market for psychotropic drugs. What I did say is that the boundaries of mental illness are being stretched for a variety of reasons—to increase drug company sales, to enhance the income and status of the psychiatry profession, and to get insurance coverage or disability benefits for troubled families. It may be that, as Oldham says, the disorders that these medications treat have been around for all of recorded history, but they weren’t necessarily considered “disorders,” rather, simply emotional states or personality traits. Just as a cigar is sometimes only a cigar, unhappiness might have been considered just that, not a medical condition.

The letter by Drs. Friedman and Nierenberg is filled with inaccuracies and assertions masquerading as fact. They are simply wrong in asserting that psychiatry, in using drugs to treat signs and symptoms of illness without understanding the cause of the illness or how the drugs work, is no different from other medical specialties. First, mental illness is diagnosed on the basis of symptoms (medically defined as subjective manifestations of disease, such as pain) and behaviors, not signs (defined as objective manifestations, such as swelling of a joint). Most diseases in other specialties produce physical signs and abnormal lab tests or radiologic findings, in addition to symptoms.

Moreover, even if the underlying causes of other diseases are unknown, the mechanisms by which they produce illness usually are, and the treatments usually target those mechanisms. For example, we may not know what causes arthritis, but we do understand a great deal about the mechanism, and we know how anti-inflammatory agents work. Even when there are only symptoms, such as nausea or headache, other medical specialists, unlike psychiatrists, would be very reluctant to offer long-term symptomatic treatment without knowing what lies behind the symptoms.

Contrary to Friedman and Nierenberg, I do not “deny that depression has any biological basis at all.” I know very well that all thoughts, emotions, and behaviors have their origin in the brain. But it is a great leap from recognizing the obvious fact that mental states arise in the brain to knowing why and how they arise. Friedman and Nierenberg make much over recent advances in neuroscience research, but so far this research hasn’t produced much improvement in diagnosis and treatment.

In fact, Allen Frances, the chairman of the task force that wrote the current version of the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), opposed undertaking the ongoing revision because he thought there had not been sufficient new data on the biological causes of mental illness to justify a new edition. As for the chemical imbalance theory of depression being a straw man, I still hear it invoked frequently. Even Oldham seems to entertain it in his letter, saying “…there is no consensus on whether these imbalances are causes of mental disorders or symptoms of them.”

Friedman and Nierenberg are right that the National Comorbidity Survey showed very little change in the prevalence of three particular types of mental disorders in adults between 1991 and 2003, although the increase in the percentage of people treated was dramatic. But the frequency of some diagnoses, such as bipolar disease and autism, has soared. Moreover, the survey showed a prevalence of mental illness of about 30 percent, which surely represents either a major epidemic or rampant overdiagnosis. One of the most remarkable findings was that 20 percent of randomly selected adults were undergoing treatment for emotional disorders at the time of the later survey, about half of whom did not even meet the DSM-IV criteria for a mental disorder.

Friedman and Nierenberg refer to the death of Rebecca Riley, who was diagnosed with bipolar disorder as well as ADHD when she was just two years old, as a “tragic anecdote.” While that is true, I believe it should also be seen in the context of the extraordinary epidemic of juvenile bipolar disease that was stimulated largely by the teachings of some of Dr. Nierenberg’s colleagues at the Massachusetts General Hospital. Three of them were recently disciplined by the hospital for not having disclosed some of their hefty payments from drug companies.

If readers check the NYR website, they will see that Dr. Nierenberg discloses his external sources of income, which include consulting arrangements with some of the major manufacturers of psychoactive drugs. While I am not in a position to, and will not, comment on Dr. Nierenberg’s consulting work, it seems to me that in general, one of the risks of close collaborations with industry is that even the best of physicians might develop an insufficiently critical attitude toward a company and its products, as well as to pharmacologic treatment generally.

Dr. Friedman seems to agree. In a review of a book by Alison Bass, published in The New England Journal of Medicine (June 26, 2008), he refers to the handsome payments by drug companies to physician researchers who test their drugs, and goes on to say, “Bass’s riveting and well-researched account of these disturbing ties should be widely read by members of the medical profession, many of whom continue to believe, despite all evidence to the contrary, that they are immune to the influence of drug companies.”

Finally, Friedman and Nierenberg accuse me of downplaying the devastating consequences of untreated psychiatric illness. I do no such thing. But it is no favor to desperate and vulnerable patients to treat them with drugs that have serious side effects unless it is clear that the benefits outweigh the harms.

Wednesday, August 10, 2011

Government primate centers

Living out of cramped hotel rooms and having limited access to a laptop while on my vacation (current stop Vancouver, home of the homeless and the urban grocery cart), I am itching to blog again. It'll have to be short and to the point, so ......

Here's a great article by Martha Rosenberg about the marketing of the dual diagnosis, entitled Out of New Diseases and Blank Checks from Insurers, Pharma Targets Alcoholics.

Pharma is mongering the "dual diagnosis" of alcoholics and addicts--they have both an addiction and a psychiatric illne$$ --with so much unbranded advertising and Madison Avenue spin, nationally known major rehab centers are telling their patients they have "co-occurring disorders," in a repudiation of basic recovery theory.

Wednesday, August 3, 2011

Researchers rediscover ......the obvious

Once again, researchers are hard at work replicating studies that have been done many times in other people for similar mental health issues. Apparently, asking the patients what is effective treatment is just "not done."

Extract from today's New York Times

Drugs widely prescribed to treat severe post-traumatic stress symptoms for veterans are no more effective than placebos and come with serious side effects, including weight gain and fatigue, researchers reported on Tuesday.

The surprising finding, from the largest study of its kind in veterans, challenges current treatment standards so directly that it could alter practice soon, some experts said.

Ten percent to 20 percent of those who see heavy combat develop lasting symptoms of post-traumatic stress disorder, and about a fifth of those who get treatment receive a prescription for a so-called antipsychotic medication, according to government numbers.
The new study, published in The Journal of the American Medical Association, focused on one medication, Risperdal. But experts said that its results most likely extend to the entire class, including drugs like Seroquel, Geodon and Abilify.

“I think it’s a very important study” given how frequently the drugs have been prescribed, said Dr. Charles Hoge, a senior scientist at the Walter Reed Army Institute of Research, who was not involved in the study but wrote an editorial accompanying it. He added, “It definitely calls into question the use of antipsychotics in general for PTSD.”