Wednesday, August 29, 2012

When recreational drug use is a factor

I blog about my own particular experience with Chris's diagnosis of schizophrenia. One thing that I have not had to grapple with is recreational drug use. This makes my experience dissimilar to that of some of other parents that I have been in contact with over the years.  I don't know the territory. Neither Chris, nor his two brothers, to the best of my knowledge, have ever taken street drugs, like marijuana, like LSD, etc. Or, if they has experimented with these drugs (I'm not totally naive), their behavior never brought it to my attention. I guess I am lucky that the only drugs Chris has been subjected to were the "legal" ones prescribed by his psychiatrists.  This makes our journey less complicated in some ways, as a war is not being conducted on two fronts.

But how does one handle a son or daughter who refuses to believe you when you say to them that their love of the weed is not helping their psychosis? What do you do or say if they insist otherwise? There is a part of me that believes their version of what is good for them, or needed at the time, should be respected. But, it is hard to sit by and watch someone deteriorate into paranoia, panick, and anxiety when the drug wears off following an initial happy, pleasant, and lucid experience. Habitual recreational drug use often chooses your friends for you, and may expose you to dangerous situations. Like prescribed medication, it becomes hard to sort out the effects of the drugs from the effects of the causative trauma.

There are special addiction programs, for individuals and for relatives. The trouble with these, as I see it, is that they treat the symptoms, not the person. The person, in their eyes, is considered an addict, a dual-diagnosed, and a problem in need of fixing. The goal is to get them clean. These programs may divert attention away from getting better help.

Where is good advice available on how to discuss your concerns about recreational drug use with your relative that is respectful of their own views on this matter? Is there a particular book that you recommend? A documented approach? Is there a more creative approach that a family member can use that will help a person resolve underlying emotional issues that doesn't allow recreational drug use to become a stumbling block in the conversation?

Tuesday, August 28, 2012

Overtreatment/Overkill: We are finally speaking up

From the Well Column of the New York Times: Overtreatment Is Taking a Harmful Toll

After several years of physical suffering and near financial ruin from the medical costs, the couple began questioning the treatment after consulting with other patients in online support groups. Mr. Power spoke with his own primary care doctor, who advised him to find a new specialist to oversee Ms. Power’s care. “It’s a really hard thing to determine when they’ve crossed the line,” Mr. Power said. “You think she’s getting the best care in the world, but after a while you start to wonder, what is the objective? He seemed caring, but he didn’t really consider my wife’s time and the suffering she was going through having all these tests done.”

Under the new doctor’s care, the regular testing stopped and Ms. Power was finally able to achieve remission. Now she sees the doctor only four or five times a year.

Read the rest here.

Monday, August 27, 2012

Consider an Intentional community

Chris is spending the week at a L'Abri community not far from where we live. I was pleased that he made the reservation on his own initiative and got there on his own steam. This is quite a step forward for him. For the past few months his treatment program (both psychiatric and alternative) has emphasized the need for him to become more independent. Chris, in the right environment, surrounded by the right people, is a different Chris than the sometimes nervous individual that we see at home. He spent a few days at L'Abri earlier this summer with his brother, Taylor, and was keen to go back.

From the L'Abri website:

L'Abri is a French word that means shelter. The first L'Abri community was founded in Switzerland in 1955 by Dr. Francis Schaeffer and his wife, Edith. Dr. Schaeffer was a Christian theologian and philosopher who also authored a number of books on theology, philosophy, general culture and the arts.

The L'Abri communities are study centers in Europe, Asia and America where individuals have the opportunity to seek answers to honest questions about God and the significance of human life. L'Abri believes that Christianity speaks to all aspects of life.
At this site you will find the latest information for each branch and an introduction to what L'Abri Fellowship is all about. If you still have questions after reviewing the information here, please contact the branch closest to where you live.

Coincidentally, my book editor was spending a few days in our home while Chris was away, and she brought up the idea of intentional communities, a type of communal living arrangement that I was vagely aware of, and that fit the description of L'Abri.

I don't know much about intentional communities (many of which are "eco" communities where environmental, farm and agricultural work is a focus), except that they are low cost, communal living arrangements focusing around a particular theme, generally one of self-discovery, service, and spirituality. Many if not most of these communities offer courses and lectures, and spiritual healing is is encouraged not just at the faith oriented communities but also in communities that offer shamanistic healing practices.

Directory of intentional communities:

Top 5 reasons to live in an intentional community:

These communities can be a transitionary phase and offer spiritual growth for an individual far enough along in recovery who is able to exercise a certain amount of independence while making a meaningful contribution to the life of the community.

Friday, August 24, 2012

Another urban legend: the old grey man's genes ain't what they used to be

My husband (Ian) sent me a link re Father's Age Is Linked to Risk of Autism and Schizophrenia." Well, of course, I gently reminded him that this is hardly breaking news, as these findings keep resurfacing at regular intervals. I recalled that he was the one who first brought the old man/schizophrenia information to my attention a few years ago. This latest "breaking news" has also become a thread in the ISEPP discussion forum. Member Randy Cima responded that "This is another nonsense psychiatric geneticist "study. You first have to buy the idea that "autism" is a "disorder," - it isn't - then you have to buy the idea that genes cause "disorders" - they don't.

Dr. Cima has written an interesting article refuting causal connections between genes and behavior.

According to the the author's bio, "For 35 years, Dr. Cima was the CEO of several MH agencies for children in California. He is a vocal opponent of psychotropics for kids. In his last agency, 26 of 30 children were medicated. In 3 years the number was 6 when he retired. He now writes and lectures on the subject."

Excepts from article:

If you are among those who periodically declare, when talking about human behavior, that “it’s genetic,” or “it’s hereditary,” or “it’s in the gene’s,” please, my friend, be aware you are perpetuating this growing – and so far completely false – urban legend. Heed Professor Garfield's cautionary words. Please stop. You have no scientific reason to continue this growing falsehood about our behavior.

Also, please consider, “psychiatric geneticists” do the vast majority of these “studies." Please make room for your well-placed disdain for “modern psychiatry” to include this growing industry. Why do they do this? You know why. To develop “medications” to provide “treatment” so that you will buy them to “fix” those “bad genes.”

There's a gene for everything," one of us said. "Google it," someone else said, so I did, on my very smart Smartphone. And that's how it started. Someone would think of a human trait, condition, emotion - anything - and I would insert that word and add "gene." For example, someone said "depression" so I googled "depression gene" and looked at the hits. You know how this works. I'd pick the most recent article or website, open it, and read the first few paragraphs, and add it to the list. Running out of ideas, we'd try anything. Someone yelled out "fairness!" Just as quickly, someone else said: "Fairness!? Oh come on! Fairness can't be in a gene!"

Apparently, it can.

There it was. The "fairness gene."

33. GAY MICE - 7/14/10 (POPSCI). A group of Korean geneticists has altered the sexual preferences of female mice by removing a single gene linked to reproductive behavior. Without the gene, the mice gravitated toward mice of the same sex. Those mice who retained the gene, called FucM, were attracted to male mice. (FucM is short for fucose mutarotase.) FULL ARTICLE -

53. PREAMATURE EJACULATION - 12/1/08 (NewScientist). The volunteers in Dr. Marcel Waldinger's study were 89 men who had so-called primary premature ejaculation, meaning they had always suffered from it from their first sexual contact onwards.For a month, their female partners were asked to use a stopwatch at home to measure the time until ejaculation each time they had intercourse. [Marcel D. Waldinger is a neuropsychiatrist and head of the Department of Consultative Psychiatry and the outpatient Department of Neurosexology at Leyenburg Hospital in The Hague in The Netherlands.] FULL ARTICLE -  

Rossa's point:
Yes, you might protest, but schizophrenia and autism are serious mental health disorders, unlike these rather frivolous examples above. There must be a gene causing these! Let's think of your objection  another way. Revenue from drugs for schizophrenia prescriptions filled by people who are convinced, in spite of the evidence to date, that schizophrenia is a genetic and biochemical brain disorder, no doubt fund the vast amount of these other studies. The so-called genetic disorders that inspire the most fear (e.g,. premature ejaculation) will be the ones that eventually find their way into the drug pipeline.

Thursday, August 23, 2012

Informed consent: 20 questions you should ask the doctor

Adam B is the father of two sons who are currently on psych meds. (He is struggling to get his sons off them.) Recently he shared his excellent advice to the ISEPP discussion forum about the questions people should ask to obtain informed consent when psychiatric drugs are being recommended. I have Adam's permission to reprint  his advice. Please disseminate his questions widely.

Adam writes:

I am of the opinion that better decisions regarding psychotropic drugs being given (or not given) would be achieved if proper "informed consent/informed dissent" processes took place.  Informed consent is a process, not just a piece of paper the Dr. tries to get you to sign to cover his/her behind.You must insist on being respected as a loving and caring parent.

To the extent your rights are being honored, I suggest a serious informed consent/dissent dialogue between you and the Dr.  I also suggest you not sign anything until such dialogue has been taken place and your parental rights are being honored.  To the extent your rights to consent/dissent are being violated, I would encourage legal assistance as has been suggested earlier.  In a nutshell, this entails being informed of the pro's and con's of the proposed treatment (use of drugs) as well as the pro's and con's of alternatives.  Specifically it includes some tough questions that the Dr. may not be able to give acceptable answers to. 

Questions you may wish to consider:
  • What is your diagnosis and more importantly what is the underlying cause?
  • What has been done to rule out medical explanations?
  • What adverse events are known with the use of this medication?
  • What side effects are known to take place?
  • What is the rationale for using this drug?
  • Discuss the science behind the answer to the above.
  • Is the proposed use of this drug off-label? 
  • If off-label, what science are you relying on in terms of its efficacy and safety?
  • How efficacious is this drug short-term?  Long-term?
  • What is the exit plan for this drug? 
  • How long do you intend on using it?
  • Is this drug addictive? 
  • Are there known problems tapering/withdrawing?
  • What effect does this drug have on developing brains?What effect does this drug have on DNA?What effect does this drug have on the endocrine system?
  • Would you give this drug to your child?
  • What are this drug's long-term effects.
  • In regards to any of the science discussed above, discuss the independence, or lack therof, with the pharmaceutical industry.
  • What alternatives should be considered and what are their related risks rewards, efficacy, costs, etc.

To expand on the first and second questions.  Often there is a medical cause for a psychological symptom.  For example, hypo-thyroid can cause depression (I would argue nutritional defficiencies can too).  As someone told me recently, psychiatrists forget they are MD's first.  Meaning in the above example, a good DR. would rule out hypo-thyroidism and other medical causes for depression before even considering using a dangerous drug.  Knowing the cause is paramount to choosing a treatment that does more good than harm.  Differential diagnosis seems to be lacking these days.  Throwing a dart at a page in the DSM is much more fashionable. The greater the difficulty in answering these questions, the greater the absurdity of giving these drugs.  

Imagine the likely response by a psychiatrist to these question compared to that of a surgeon being asked questions on removing an appendix that is about to burst or an orthopedic doctor on the wisdom of setting a broken bone.  The point being is that with the surgeon and orthopedic example, the science is clear, there is no real controversary, no bad science and they really know what they are doing.  The questions will likely be answered with grace and confidence.  In the psychiatrist example, as you know most of many of these very important questions can't even be answered because no one really knows the answer.  The questions that can be honestly answered for the most part will point away from giving the drug.  In contrast, how would we predict the psychiatrist to respond?  With defensiveness or anger or dismissiveness or embarrassment?  Anything but grace and true confidence.

Wednesday, August 22, 2012

Agnosognosia: A convenient "truth"

Today,  Mad in America blogger psychiatrist Sandra Steingard, MD*, debunks the term "agnosognosia" as it is popularly applied to a person experiencing psychotic symptoms.

Neurologists use the term anosognosia to describe a peculiar syndrome in which a person has a profound lack of awareness of an obvious deficit. For instance, a person who has a stroke on the right side of his brain and is paralyzed of the left side of his body has no awareness of the problem. He might not recognize his left arm as his own. When given a page to read, he might only read the words on the right side of the page. He would only put his shirt on his right arm but when asked if he was adequately dressed, he would answer, yes. This phenomena is regularly associated with damage to the right side of the brain in the section called the parietal lobe.

In the 1990′s, a psychologist, Xavier Amador, began to use this term in the context of describing a person who was experiencing psychotic symptoms and did not believe that his problems were due to an illness. For instance, if a person heard voices that no one else heard, he might conclude that he was communicating with dead relatives. When his doctors or family told him that he was sick, he would disagree. Doctors would call this “lack of insight” and Amador was one of the first to appropriate the neurological term, anosognosia to describe this.

There is a history in neuroscience of trying to apply what has been learned from studying the cognition and behavior of people who have had strokes to develop a more general understanding of the connection between brain function and behavior. In that spirit, there have been multiple studies to address whether there were changes in the brains of people who were psychotic and were described as having a “lack of insight” that were similar to the changes found in people who had right hemisphere strokes.

Readers on this site have wondered how the notion of a “chemical imbalance” could have been accepted by so many when the research did not actually support the concept. A recent paper from the Treatment Advocacy Center that summarizes studies of anosognosia in psychosis gives some clue as to how this type of thinking becomes entrenched and accepted.

READ the rest of her article, Anosognosia: how conjecture becomes medical “fact” here.

*Sandra Steingard, M.D. is the Medical Director of Howard Center and Clinical Associate Professor of Psychiatry at the University of Vermont College of Medicine in Burlington. She was educated and trained at Harvard and Tufts Universities in Boston and received her specialty certification in psychiatry from the American Board of Psychiatry and Neurology in 1986.

Her areas of interest include community mental health and the diagnosis and management of psychotic illnesses. She was named an Exemplary Psychiatrist by the National Alliance for the Mentally Ill of Vermont in 1996, and has been listed in the Best Doctors in America since 2003. She can be reached at:

Thursday, August 16, 2012

Mania, schizophrenia, immunity and Damon Courtenay´s legacy

April Fool's Day by Bryce Courtenay is the well-known Australian author's memoir of love for his son, Damon, a haemophiliac who was one of the first Australians to contract AIDS through blood transfusion. Damon died at the age of 24 in 1991 after a horrific struggle with an incompetent, largely uncaring and ignorant medical system, the blow of contracting AIDS further compounding the ravages of arthritis that usually cripples hemophiliacs in their teenage years.

Damon was becoming very, very sick with the many diseases that accompany the AIDS virus. His final two years of life should have taken a progressive, deteriorating course. Except there was one brief interlude when he actually began to get better.

One day, Damon visited his father, walking up the hill in record time. Damon, walking with a limp since the doctors had unwisely put a brace on his left leg many years earlier, his feet deformed from years of bleeding, was walking barefoot with comparative ease. His father noticed that his eyes were no longer dulled and had a clarity that he hadn't seen for years. "I'm cured, Dad!" Damon said. He took a step backwards and raising his hands in the accepted Bruce Lee fighting stance, he chopped into the wooden panel of the front door. Then to my astonishment, he suddenly leapt up and kicked, driving the ball of his left foot into the same part of the door."

His father writes. But I was suddenly aware that something else was about to occur that we couldn't possibly understand. I had seen him do enough in these few minutes to put himself into hospital with a series of bleeds which, given his present physical condition, could quite easily set him back for months. And yet, he seemed unharmed. He hadn't flinched as he'd slammed both the side of his hand and the ball of his foot into the door, nor had he as much as grunted when he jumped from the terrace wall.

Several months earlier, according to his girlfriend, Damon began getting higher and higher and not being able to sleep at night. Celeste thought it was the Ecstasy tablet that he tried a few times that pushed him into a higher state of consciousness, making him not feel pain. His newfound enthusiasm and pain-free body continued even after he stopped taking Ecstasy. The amazing thing was, he hadn't had a bleed since he started taking Ecstasy, or at least Celeste believed that Ecstasy was the reason for the cessation of bleeding. The Ecstasy could have kick started the mania, but hypomania can also be one of the symptoms of the latter stages of AIDS .

Damon then went on to develop many of the symptoms that most of us reading this blog are familiar with: honorary memberships in secret societies, unusual dress code (Ray-Bans at night!), manic behavior that frightens the family to death.

The bleeds which had occurred during the five weeks since he'd become manic, were all relatively small ones and none of them had transpired from the deliberate and often severe knocks he'd taken. The mind is a truly strange mechanism but, since his childhood, we'd known that bleed followed bump just as surely as night followed day.....Just why and how his mania should prevent the more serious bleeding occurrences remains a huge and still unresolved puzzlement.

Damon's experience rang a bell with me. I have long said in this blog that someone with a diagnosis of schizophrenia, or bipolar (the two are almost interchangeable) tend to be super healthy people. Dr. Abram Hoffer observed the same robust health in his schizophrenia patients. Of his patients´families he observed that close family members rarely got cancer, as if the condition of schizophrenia conferred a special evolutionary advantage on this group of people. I have also heard that when a person with schizophrenia develops another life threatening condition, such as cancer, the symptoms of schizophrenia go away. There must be researchers who are studying the health benefits conferred (resistance to pain, increased immunity) by mania and schizophrenia, but I am not aware of any. Instead, medical research begins with the premise that there is something wrong with the mind, not something right with it.

Damon subsequently got treated by psychiatry and put on Stelazine and Lithium, another addition to the horrendous cocktail of drugs he was on.

Stelazine, known in medical circles as a chemical straightjacket, when taken in combination with Lithium, is a real bitch; it flattened Damon out so completely that he seemed for a while to be a walking zombie. Damon crazy was difficult to handle and, while his cocked-up enthusiasm and desire to live sometimes took the most bizarre turns and his paranoia was extremely hard to cope with, he was still very much alive, an extreme form of the Damon we loved. Now he seemed dead.

Some months later, when he'd finally recovered from his manic condition, he would confide in Celeste that he missed the certainty, the sense of invincibility, of his own strength in mind and body that the mania had given him. As Damon grew increasingly frail and incapable in the final year of his life, he would sometimes say wistfully to Celeste, "It was so great, Babe! It was the first time in my life I felt completely whole! I was the might Damon. If only I could be well and have that same feeling again!"

Why isn´t medical research focusing on the immune protection of schizophrenia and bipolar? The mind´s sense of invincibility that Damon and others experience when psychotic, translates into ultra-normal good health. Based on my own observations of my son´s seeming imperviousness to the common cold and other aches and pains, I have always been suspicious when someone claims to have physical ailments co-existing with schizophrenia. ´Whatever they have that they think is schizophrenia, I conclude, has been misdiagnosed as schizophenia.

April Fool´s Day is a wonderful memoir that I urge you to read.

Wednesday, August 8, 2012

Bad literary advice from Carolyn Kaufman, The Writer's Guide to Psychology

I belong to an writers group called Query Tracker. Occasionally I receive e-mails from "experts" in specific topics of interest to writers. This one makes me throw up my hands. Carolyn Kaufman trots out all the stereotypes and the recovery movement seems to have completely passed her by.

Psychology Q&A: Schizophrenia & Police Work?

Posted: 08 Aug 2012 06:00 AM PDT
Disclaimer: The information provided in this post is intended for writing purposes only and does not represent psychological advice.
QUESTION: I keep returning to schizophrenia as an interesting disorder. I'm wondering what exactly can someone who's schizophrenic (and on his medications) do for a living? Can they be a detective or a police officer? Or is there a better disorder for me to use that would allow them to be a detective or a police officer? I wasn't sure if schizophrenia would keep them from being employed as such. Also,  is there a positive side to the schizophrenia -- a creativity or something along those lines that could be harnessed in the right situations? Finally, what type of inner conflict would someone with schizophrenia have to overcome in order to be successful?
ANSWER: Schizophrenia is really one of the most disabling psychological disorders someone can have -- only about a third of people with the disorder are able to live independently. By definition, schizophrenia is a psychotic disorder, which means that the person who has it isn't in touch with reality as other people experience it. Symptoms of psychosis include:

  • Hallucinations: seeing, hearing, feeling, smelling, or tasting things that aren't there; the most common hallucinations in people with schizophrenia are voices
  • Delusions: believing things that aren't based in reality despite all evidence and logic to the contrary
  • Disorganization: this doesn't mean the person is messy; it means their mind is disorganized. This leads to disorganized speech (which means  means that people wander from topic to topic enough that it's noticeably weird; in extreme cases you get a "word salad," which means the words are all just jumbled up) and disorganized behavior (which may be silly, childlike, or aggressive, but is always completely purposeless)

People with schizophrenia can be articulate and intelligent -- John Nash, the man on which A Beautiful Mind was based, is well-spoken and obviously extremely well educated. But he does see and hear things, and he has delusions.

Nonetheless, I think it would be very unusual for someone with schizophrenia to be able to be a detective or a police officer, even if he were taking medications. The meds can often suppress the psychotic symptoms, but that doesn't mean the schizophrenia goes away. And the meds tend to work better for what we call "positive" symptoms (like hallucinations, delusions, and disorganization) than they do for "negative" symptoms like catatonia, apathy, mutism, failing hygiene, and other tendencies to withdraw from society.

However, someone who has bipolar disorder (which used to be called manic depression) could be, assuming they'd never been institutionalized.  Like schizophrenia, bipolar disorder that can be crippling, and for some people it can also involve hallucinations and delusions, particularly during a manic phase.

I know that you can't get into the CIA or FBI if you have a history of mental illness of any sort, or have been to therapy for a psychological problem. Though I doubt the police are quite as stringent, they're still on the lookout for these kinds of disorders. So it would probably need to be something that hasn't officially been diagnosed.

Martin Riggs -- Mel Gibson's character from the Lethal Weapon movies -- comes to mind. He's a great example of a great character who went a little (ok, a lot) crazy and was still a police officer.  If you're not familiar with the movies, Riggs's wife dies, and he gets crazy suicidal, which makes him a complete loose cannon. If I had to diagnose Riggs off the top of my head in the first movie, I'd say a major depressive disorder, last (current) episode severe.

While some people have begun arguing that people on the schizotypy spectrum (of which schizophrenia is a part) are more creative than others, that creativity is often so different from the way other people think that it may not been seen as creativity...just as weirdness. People with bipolar disorder have more classically been seen as creative, though. They tend to be creative within the "rules" of society -- that is, their stuff looks creative, not just bizarre, to other people.

There isn't really an inner conflict someone with schizophrenia has to overcome -- it's very much a biological disorder. So is bipolar disorder, though the person with bipolar disorder may not seem quite as bizarre, and may function more within the norms of society.

Also remember that with any disorder there's a continuum from "not bad" to "really bad" versions of the disorder. So some people will have any given disorder worse than others, based on the genetics and how stressful their environment has been throughout their lives. Less severe cases may respond better to medications and therapy.

Remember, if YOU have a psychology in fiction question you want to see answered here, use the Q&A form on my Archetype site or send an email using my QueryTracker email address to the right. (Please use Q&A in your Subject Line!). 

Carolyn Kaufman, PsyD's book, THE WRITER'S GUIDE TO PSYCHOLOGY: How to Write Accurately About Psychological Disorders, Clinical Treatment, and Human Behavior helps writers avoid common misconceptions and inaccuracies and "get the psych right" in their stories. You can learn more about The Writer's Guide to Psychology, check out Dr. K's blog on Psychology Today, or follow her on Facebook or Google+
If your email address changes, please follow these instructions: 1. Scroll down to the bottom of an email from the QTB and click UNSUBSCRIBE to remove your old email addy from the database. Then 2. Go to http://querytracker.blogspot.
com/ and SUBSCRIBE (on the right-hand side, in the sidebar) with your new address!

Wednesday, August 1, 2012

The question NAMI families aren't asking

The Hidden Gorilla

Three weeks ago What would Batman do Now covered the issue of suicide in the military – an issue that had Batman missing in action, and the Joker suffering the adverse effects of psychotropic drugs. Then along came James Holmes to the premiere of Dark Knight Rises in Aurora.
Most drugs that can cause suicide, including the antidepressants, mood-stabilizers, antipsychotics, smoking cessation drugs and others, can also cause violence. The akathisia, psychotic decompensation, or emotional disinhibition these drugs trigger that lead some to suicide, lead others to violence (see Healy et al 2006).
A medical blind-spot
There is some awareness that these drugs can cause suicide but considerable resistance to the idea. There is less awareness and even greater resistance to the idea that they can cause violence. Treatment induced violence lies in a medical blind spot – no doctor wants to contemplate the possibility that she may have had a role in the deaths of innocent third parties.
This may be the grim prospect facing Dr. Lynne Fenton. Dr Fenton we are now told had been seeing James Holmes, the killer at Dark Knight Rises in Aurora, and had seen him just a week before the killings. Given the current reliance of American medicine on medications it seems likely that medications are involved in the Aurora case.
For many the instinctive reaction to Holmes will be that he is either mentally ill, evil or a street drug addict. This makes sense. Violence is one of the associations we all make to the ideas of evil, mental illness and illicit drug use. In contrast most of us know people on antidepressants none of whom are violent. This makes it difficult to accept a link to prescription drugs. For many even raising the idea that Holmes may have been crazed by a prescription medicine is likely to sound deranged or the excuse of a bleeding heart liberal.
No other risk so hidden
But in fact there is a great deal of publicly available clinical trial (Hammad 2004, p40-41) and other data highlighting the risks of violence from psychotropic drugs. There is far more hidden data. There is in fact no other area of medicine in which there is so much hidden data on a risk that has consequences for the lives of so many innocent third parties.
With each “outing” of suppressed data lately companies have been beating their breasts about the lack of transparency “in the past” and have committed themselves to greater transparency. Here’s a chance for our major companies to prove things have changed by making the data on hostility, aggression and violence on their drugs publicly available. These data might tell us something about who is at risk, and allow us to better manage these risks. If there were a conspiracy to keep the details of all plane crashes out of the public domain, would airlines or the authorities have any incentive to make travel safer?
Instead, we are likely to see a vigorous marketing of articles that deny the possibility of a link. It takes really great science to overcome our biases. But if an article fits in with our biases (our associations), almost anything can be published, and doctors can be depended on to treat it as respectable science.
While 9 + of us out of 10 find the idea that an antidepressant might have caused Holmes to behave the way he did unbelievable, those whose lives have been touched by these issues are in a completely different position. News of another mass shooting immediately raises the suspicion that an antidepressant or related drug will be involved. And as, Rosie Meysenburg has shown on SSRI Stories, the drugs are all too often involved.
Slogan for the NRA – no drugs, no killing?
The drugs have been involved so often in campus or mall shootings that for some the surprise is that the medication question is so slow to get asked, as Peter Hitchens who is not a bleeding heart liberal has pointed out. What political considerations keep the NRA out of the debate? When Batman tells America “no guns, no killing”, there must be a temptation to respond “no drugs, no killing”.
But if Holmes turns out to have been on a drug that can cause violence, it is a quite separate matter to establish that in his case the drug he was on did contribute to what happened. It may not have. Without details of the case it is difficult to offer a view.
But this will not stop the debate in the public domain about an easier question for drug companies to control – do psychotropic drugs cause violence. And here, even though in some jurisdictions companies are legally obliged to say their drug can cause violence, a recent article in Psychopharmacology by Paul Bouvy and Marieke Liem denying the possibility of a link is certain to be marketed heavily.
Bouvy and Liem’s article has much in common with recent articles by Robert Gibbons in Archives of General Psychiatry (see Coincidence a fine thing & May Fool’s Day). These articles may have no links to or input from industry, but they fall on the fertile ground of a distribution system complete with public relations companies geared up to make sure that messages like this get picked up and equally that messages about problems that treatment may cause do not get heard.
When it comes to Adverse Drug Reactions (ADRs) on prescription drugs, there is no such thing as an academic debate with equal airtime for both sides, although Psychopharmacology have published a response to Bouvy and Liem’s article unlike Archives of General Psychiatry which has refused to publish responses critical of Gibbons’ articles.
Bouvy and Liem correlated data on lethal violence in Holland between 1994 and 2008 against sales of antidepressants. The drug sales went steadily up and the number of episodes of lethal violence fell, leading the authors to claim that “these data led no support for a role of antidepressant use in lethal violence”.
This is a marvelous example of what is called an ecological fallacy. An ecological fallacy is when someone claims that if an increase in the number of storks parallels an increase in the number of births that storks must be responsible for births.
Doubt is our Product
The best known example of storkology in recent years were the graphs produced by tobacco companies showing rising life expectancies and even reduced deaths from respiratory illnesses in line with rising cigarette consumption. These were produced as part of a Doubt is our Product strategy to deny the risks of smoking.
Recent sightings of storks include claims that increased SSRI use is linked to falling national suicide rates. The articles making these claims offer data from the late 1980s but disingenuously omit some key facts. One is the fact that suicide rates in most Western countries were falling before the SSRIs were launched. Another is the fact that both suicide rates and antidepressant use rose during the 1960s and 1970s when antidepressants were being given to the most severely ill people at the greatest risk of suicide. This was when suicide rates should have fallen if antidepressants have any effects on national suicide rates (Reseland et al 2008).
Autopsy (post mortem) rates are also left out. The more autopsies done the more suicides and homicides are detected. Autopsy rates rose in the 1960s and 1970s and fell from 1980 before antidepressant consumption began to escalate dramatically. The rise and fall in autopsy rates perfectly mirrors the rise and fall in suicide rates.
Why would Psychopharmacology take an article like this?
For the purposes of this argument, let’s assume the data on episodes of violence in Holland that Bouvy and Liem use is correct. This may not be the case – British national suicide rates are no longer dependable. The national figure is in essence set by a bureaucrat in London, who has scope to make the rate rise or fall as needed. Let us also assume declining autopsy rates play no part.
Before considering what else could be involved, let’s look at the shape of the argument and ask why Psychopharmacology would take an article like this. First alcohol use has increased in Holland during this period but no-one is making the argument that increased alcohol use has led to a decline in acts of lethal violence or the further Bouvy and Liem argument that this means alcohol cannot cause violence. Why not? Because, we associatealcohol with violence.
SSRIs cause growth retardation in growing children. The clinical trial data show this retardation and the labels for the drugs mention it. During this period SSRI consumption among children has increased in Holland but the Dutch have become the tallest people in the world and are getting taller. Where is the article saying that the increasing height of the Dutch proves that SSRIs don’t retard growth?
In the case of violence, the published trials show antidepressants cause it, probably at a greater rate than alcohol, cannabis, cocaine or speed would be linked to violence if put through the same trial protocols that brought the antidepressants on the market. The labels for the drugs in a number of countries say the drugs cause violence. And there is at least one clear and well-known factor, just like autopsy rates, that can account for the findings – young men. Violence is linked to young men, and episodes of lethal violence are falling in all countries where the numbers of young men are declining.
For ADR read A Dr
Whatever Psychopharmacology were doing taking an article like Bouvy and Liem’s making claims that run counter to the warnings that are already on the drugs, without warning their readers that this was the case, from here on the game for industry is about managing associations. From conmen to hypnotists to Batman, the trick is to hold the audience’s focus so they miss something much more important in their peripheral vision field. This is what public relations companies excel at.
One of the best examples of how we can be tricked can be seen in the Hidden Gorilla video where selective attention can lead to us missing a Gorilla walking right across screen in front of us. But the very best trick must be the one that leaves us certain that serotonin reuptake inhibitors or amphetamines available on the street cause violence while in complete denial that almost identical  prescription-only drugs could do so.
In the case of prescription drugs, the key people are doctors, the Watsons. Always one step behind the smarter Holmes. While it would be nice to see Watson turn the tables for once, in this mystery Holmes has the last line once again. It’s elementary My Dear Watson. For an ADR you need A Dr.