05/6/15

Parallel Psychiatric Universes

© Balefire9 | stockfresh.com

© Balefire9 | stockfresh.com

“It is only really been in the last fifty years that psychiatry has established a scientific foundation for itself and developed treatments that truly work, beyond a shadow of a doubt, and are safe.”

I’m starting to think there is something to the belief in parallel universes. There just cannot be another explanation for how someone could believe what was said in the above quote. This person has to be from an alternative time line where An Anatomy of an Epidemic, Mad in America, Medication Madness, and The Myth of the Chemical Cure were never written. The story of psychiatry and “mad doctoring” contained in these and other books and articles I’ve read tell an entirely different story than what was stated above.

The opening quote is from an NPR interview with Doctor Jeffrey Lieberman, who wrote a new book, Shrinks: The Untold Story of Psychiatry. Dr. Lieberman is a past president of the American Psychiatric Association and is currently the Lawrence C. Kolb Professor and Chairman of Psychiatry at the Columbia University College of Physicians and Surgeons and Director of the New York State Psychiatric Institute. In other words, he has credibility within the field of psychiatry and he is a good choice to be the teller of a tale about the heroes of psychiatry. That is, if you believe the current state of psychiatry fits with the above statement. I don’t.

There is a suggestion in Lieberman’s interview that all is not sunshine and roses with the current state of psychiatry. At the end of the interview, he said that in order for psychiatrists to make a case for why psychiatry is a medical discipline that deserves “equal footing and respect as other medical specialties,” they needed to “fess up” to the unvarnished past. He asserted that things are different now, “and nobody should avoid seeking treatment if they think they need it because of uncertainty or fear.” I think that depends upon whether or not you believe in his version of psychiatry and its history.

I haven’t read Shrinks yet. Honestly, I’ll read Robert Whitaker’s new book on psychiatry before/if I ever get around to Shrinks. But Whitaker has read Lieberman’s book and shared his thoughts here.  He suggested that his readers watch a promotional YouTube video of Lieberman discussing what is unique about Shrinks. Whitaker pointed out how Lieberman intentionally dressed for the video in a doctor’s white coat. Seems to be a not-so-subtle hint at wanting to assert the “equal footing and respect” he hopes to gain for psychiatry alongside other medical specialties.

In the YouTube video, Lieberman did say that his book was the first to tell the “complete and unvarnished truth” about the history of psychiatry. But he seems to have crossed over into that parallel universe when, according to Whitaker, he wrote how the intellectual seed from a small band of psychiatrists saved psychiatry and led to the development of the “book that changed everything.” This book was the third edition of the Diagnostic and Statistical Manual (DSM III). Whitaker astutely said Shrinks was more a story of how psychiatry as an institution saw itself, than it was an accurate history of psychiatry:

 I think Shrinks ultimately provides a revealing self-portrait of psychiatry as an institution. Lieberman is a past president of the APA and he has reiterated the story that the APA has been telling to the public ever since DSM-III was published. And it is this narrative, quite unmoored from science and history, that drives our societal understanding of mental disorders and how best to treat them.

The history of the DSM described by Whitaker in his review article of Shrinks is one I’m already familiar with from reading Making Us Crazy and The Selling of DSM by Kirk and Kutchins. You can access an article written by them, “The Myth of the Reliability of DSM,” that elaborates on Whitaker’s description of the DSM III. Kirk, Gomory and Cohen have written Mad Science, which also tells the story of psychiatry and diagnosis from the perspective of Whitaker and the others.

Paula Caplan commented that as she listened to Lieberman’s NPR interview, she felt sad. She was glad Whitaker had written about Shrinks. She thought no one was in a better position to comment on its claims about the field of contemporary psychiatry.

I know that many people share my feelings of frustration and exhaustion about the ongoing misuses of the power, not only by some of the most powerful psychiatrists, but also some of the most powerful psychologists and members of other professions as they distort the facts and consistently close their ears to people whom their systems have harmed.

Whitaker closed his critique of Shrinks by pointing out that Lieberman took the Freudians to task, saying that if the psychoanalytic movement in psychiatry had itself diagnosed, it would have been found “all the classic symptoms of mania: extravagant behaviors, grandiose beliefs, and irrational faith in its world-changing powers.” Whitaker said the very same symptoms were present in Shrinks. He suggested there was also evidence of an institutional delusion too. Perhaps this is a better explanation for the radically different view psychiatry has of itself than saying it must be from a parallel universe. It is simply delusional.

Further illustration of the parallel universes (or delusions) regarding psychiatry was given when Dr. Lierberman was interviewed on the CBC radio program, The Sunday Edition on April 26, 2015. When asked by the interviewer if he was familiar with Robert Whitaker, he said “Unfortunately I am.” He proceeded to question (slander?) whether he is a journalist, saying: “God help the publication that employed him.” Lieberman asserted that Whitaker has “an ideological grudge against psychiatry.” In other words, Whitaker is one of those anti-psychiatry people. He dismissed Whitaker and his claims: “What he says is preposterous. He’s a menace to society because he’s basically fomenting misinformation and misunderstanding about mental illness and the nature of treatment.”

Lieberman went on to claim that there was no doubt in his mind that if randomized, controlled studies of various psychiatric illnesses, using the “state of the art” methods in psychiatry (including medication) “the outcomes will be extraordinarily superior in the treated group.” Whitaker responded to Lieberman’s claim by challenging him to provide “a list of randomized studies that show that medicated patients have a much better long-term outcome than unmedicated patients.”

We think this is important. This is the core issue for our society: Do these medications help people thrive over the long-term? Do they improve their lives over the long term? If there is such evidence, please let us know. I put up abstracts of the studies I cited in Anatomy of an Epidemic on madinamerica.com, which tell of worse outcomes for the medicated patients over the long term, and so here is your chance to point to the studies I left out.

Whitaker noted this wasn’t the first time Lieberman has denounced him as a “crappy” journalist. By the way, a series of articles Whitaker co-wrote on the abuses of psychiatric patients in research settings for the Boston Globe in the 1990s was a finalist for the Pulitzer Prize. He is a past winner of the George Polk Award for Medical Writing for the same series. One of the researchers he was critical of in that series was Lieberman. Whitaker said he took extra pride in being called a “menace to society” by Lieberman and thought he might just put that on his gravestone.

05/4/15

The Opioid-Heroin Cycle

© Ouroboros tattoo by Sahua | Stockfresh.com

© Ouroboros tattoo by Sahua | Stockfresh.com

Since the death of Philip Seymour Hoffman on February 2, 2014, there has been a series of calls for the distribution of naloxone or Narcan, which is a prescription medication that reverses an opioid overdose. But it seems that the price of Narcan has doubled over the past year. The Fix and others report that the price of naloxone has recently gone from $51.50 per kit, to nearly $100 per kit. These are the Luer-Jet™ kits sold by Amphastar Pharmaceuticals, the only US company currently selling nasal kits. There is a cheaper injectable form of narcan, but it is supposed to be less user friendly.

Within four days of Hoffman’s death, The New York Times published an article by an emergency physician, noting how greater availability of Naloxone could prevent deaths. He referred to a report in the Annals of Internal Medicine that suggested up to 85 percent of users overdose in the presence of others, providing the opportunity for others to intervene. In Forbes Magazine David Kroll said the CDC reported that naloxone was used in over 10,000 opioid-overdose reversals between 1996 and mid-2010. He also expressed his concerns over potential shortages of naloxone.

Victoria Kim for The Fix reported that Amphastar’s president blamed the price increase of their naloxone product on “steadily increasing” manufacturing costs. But Matt Curtis, the policy director for a New York advocacy group said there had been a fairly steady price for several years. “Then these big government programs come in and now all of a sudden we’re seeing a big price spike. . . . The timing is pretty noticeable.” The Hill reported that Senator Bernie Sanders and Representative Elijah Cummings sent a letter to Amphastar complaining about the price increase and how it is “an obstacle in efforts by police departments to equip officers with the drug.”

Areille Pardes of Vice said that after the CDC said there was an opioid epidemic in 2008, the manufacturer of naloxone, Hospira, increased the price of a dose of naloxone from $3 to a little more than $30. Pardes also reported that the supposed difficulty of a lay-friendly delivery system has also been used to justify the high costs of epipens (around $400) and the naloxone auto-injector, EVIZO (Over $600 for a kit of 2 auto-injectors at Walmart, Sams Club, Target and other retail outlets). However a study found few differences between trained and untrained overdose rescuers in their abilities to use the syringes in a naloxone rescue kit. “Anyone with common sense could figure it out, even without training.”

It does seem that the timing of the price increases for naloxone (a generic drug) and its delivery systems occurred just as the epidemic of overdoses took place. The CDC reported in a March 2015 NCHS Data Brief that from 2000 to 2013 the rate of drug overdoses quadrupled, from .7 deaths per 100,000 to 2.7 deaths per 100,000. Overdoses are now the number one cause of injury-related death in the US. While the overdose deaths involving (prescription) opioid analgesics have leveled off in recent years, those from heroin have almost tripled. See Figure 1 of the NCHS Data Brief. While the heroin overdose rates increased among all age brackets, the highest rate of increase was among 25-44 year olds. Geographically, while there were increases in all regions of the country, the greatest increase took place in the Northeast and the Midwest. See figure 5 of the NCHS Data Brief.

There is some sense that effort to curb problems with overprescribing pain medications has inadvertently led to a boom in the misuse of heroin. Richard Juman reported for The Fix that while some treatment providers suggest that is the case, others note that there is evidence that heroin use was increasing before any state or federal interventions with prescribed opioids were implemented. According to Andrew Kolodny, MD:

The idea that efforts to curb prescription drug misuse have led to a spike in heroin use or overdose has become a common media narrative, but the facts don’t support it. It is the overprescribing of opioids itself that has caused increases in opioid addiction of all kinds, not the efforts to control the prescribing. The transition from prescribed opioids to heroin has been happening since the beginning of the epidemic, and there is no evidence that the interventions brought forth to reduce the overprescribing have been fueling the increase in heroin use or overdoses. Because of the epidemic of opioid addiction, you now have markets for heroin that you didn’t have in the past. So there has been an increase in heroin overdose deaths, but that increase was prior to states’ implementation of Prescription Monitoring Programs or any of the changes from the FDA.

I tend to agree with Dr. Kolodny’s assessment. There is a price factor in the shift for many opioid users switching to heroin. And there has been a global market increase in heroin production that paralleled the rise of prescription opioid use. Increased heroin use in the US is market driven. What does seem to be related to increased heroin availability in the US is the diversification of Mexican drug cartels into growing opium poppies, as their market for marijuana dries up. See “The Economics of Heroin.”

There is something very wrong with the cycle of Pharma marketing for increased use of opioids, leading to overprescribing opioids, leading to increased heroin use and increased overdoses, leading to an increased need for narcan, leading back to increased profits with drug companies, where the cycle began. The ouroboros pictured above is a symbol in Greek mythology of a dragon eating its own tail. It symbolizes something that constantly re-creates itself, which seems to be happening here with the opioid-heroin cycle.

05/1/15

Evidence for Heaven

© Allan Swart | 123RF.com

© Allan Swart | 123RF.com

“Faith is the grace, and the only grace, whereby we are justified before God, by it we eat of the Tree of Life, (Jesus Christ) and live for ever.” (Edmund Calamy)

The above quote introduced “Evidence of Heaven,” the February 22nd daily meditation for Day by Day with the English Puritans. In typical Puritan fashion, the full title of the original work was: “Evidence for Heaven: Containing Infallible Signs and Real Demonstrations of our Union with Christ and Assurance of Salvation.” Day by Day listed Edmund Calamy as the author, and a Google search found a link to a digitized copy of the original work here. Evidence for Heaven was attributed to the Puritan preacher, but Calamy himself said its true author was an anonymous female member of his church.

While the author’s anonymity will seem odd to moderns, it was unusual for a ‘gentlewoman’ in 1657 to write and then publish something she wrote. As Clamay said in his introduction: “I hope no man will condemn this Book, because written by a Woman but rather admire the goodnesse, love, and power of God, who is able to do such great things, by such weak instruments.” He added that it was her “great desire” that her name be concealed. If anyone were to reap a spiritual advantage by reading it, “she hath obtained the height of her ambition.”

In the Preface, the author said it was her intention to “lay down some rules” by which a person that wants to have some assurance, or “Evidence for Heaven” can know that they have been chosen (predestined) to eternal life. They must seek it in Christ and in union with Christ, which is the only true touchstone we have to try ourselves. If they were to go to someone else or from person to person—like a bee goes from flower to flower—to find assurance of their salvation, the world would say: “We have heard of the fame thereof, but know not what it is.” Even God’s people would say, “We thirst after it, but know not where to find it.”

Her counsel was to go to Scripture: “it will tell thee in the Word.” She urged her readers to frequent the Word preached; to read the Word printed; to seek evidence in renewing grace; to seek it in the narrow way. “These are the paths wherein the flock of Christ have gone before us, and which they have trodden out unto us; follow their foot steps, if thou wouldest attain assurance.” And this search must be done diligently, orderly, humbly and perseveringly.

First is the need for diligence. As it says in 2 Peter 1:10, we are to be “all the more diligent” to confirm our calling and election. We should seek assurance as a treasure laid hidden deep in the bowels of Scripture. As Solomon taught us to strive for wisdom and understanding, we should: “seek it like silver and search for it as for hidden treasures” (Proverbs 2:4).  We should labor for it as those who work in the silver-mines.

Second is the need for the right order; we must follow the vein. We must begin with the branches of regeneration and justification for they issue out of predestination, which is the root of salvation. When Jesus instructed Nicodemus about his spiritual estate, he did not send him to Heaven “to read the records of the celestial court.” Rather, he sent him to search his own heart and life—to consider whether he was regenerate and born again. If someone wants good evidence of the love of God and their own salvation, they must begin with the workings of God in and upon themselves.

That he that would get assurance of his Election, must seek it in the workings of God, in, and upon himself; he must consider, how his justification is evidenced by his sanctification, and his election by both. Sanctification is Gods work in us, justification is Gods work upon us, both together are certain pledges of his good will towards us

Third, the person who seeks assurance should do it humbly; with fear and trembling (Philippians 2:12). Although it is possible for a child of God to know their estate, it is very difficult. A seeker of assurance must seek it with a holy fear and jealousy—humbly on their knees.

Fourthly, they must seek it perseveringly; never giving over until they have received. Never giving over until they find what they seek. They must follow the example of the Bride searching for her beloved (Song of Solomon 5:6f). They should persist like the Canaanite woman, who did not rest until she got her answer (Matthew 15:22-28). The Scripture exhorts all Christians to labor for assurance; to be diligent to confirm their calling and election (2 Peter 1:10).

They should make every effort to supplement their faith with virtue, and virtue with knowledge, and knowledge with self-control, and self-control with steadfastness, and steadfastness with godliness, and godliness with brotherly affection, and brotherly affection with love. “For if these qualities are yours and are increasing, they keep you from being ineffective or unfruitful in the knowledge of our Lord Jesus Christ” (2 Peter 1:5-8).

Assurance is a thing of incomparable worth, a thing which no man knoweth, but he that hath is, a thing that no man prizeth so much, as he that wants it; in a word, it is a thing of such incomparable worth, that a man cannot buy it at too deare a rate: Could a man but know its goodnesse, and taste its sweetnesse, he would think no labour too much to attain it, no sinne too sweet to part with for it, no sufferings too much to preserve it, no care and industry too much to increase it; for it is (indeed) next grace, the most precious and delectable love token, that we can possible receive from Jesus Christ the Bridegroom of our souls, in his bodily absence. And if this will not persuade thee, Reader, to seek after it, I leave thee to him to persuade, who persuaded Japhet to dwell in the tents of Shem; what God hath bin pleased to impart unto me on this Subject, I have committed to writing, more than this, I dare not do, for going out of my sphere, and lesse then this, I could not do, least I should be blamed of my Heavenly Father, for hiding my Talent in a napkin, and burying divine love in a dunghill; if ever this little draught of Evidence, which I penned for my own use, and hope to leave to my Children for theirs, should by any providence come abroad to publique view, my desire and hope is. That this little draught of Evidence may (through Gods Blessing) be helpful to some of Christ’s Lambs, to some poor souls, which thirst after assurance on Scriptures-grounds, and invite others of profounder judgments, and greater abilities, to search the Scriptures, by them to make discovery of the way to get this precious and invaluable Jewel of sound assurance.

There are still people today who struggle with doubt regarding their salvation. They would do well to spend time reading the thoughts of this anonymous gentlewoman, a member of the congregation of Alderman-bury. Our anonymous author suffered from an affliction for over thirty years that kept her, in great measure, from public and private spiritual helps which others enjoyed. And yet she could write of the assurance of salvation with confidence that speaks to us over 350 years after it was published.