04/28/17

Psychiatric Huffing and Puffing

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For awhile now I’ve been aware of the ongoing dispute between mainline psychiatry and what is disparagingly referred to as the “anti-psychiatry” movement instead of the critical psychiatry movement.  Over time I have come to identify with the “anti-psychiatric” types. The term sets up a false dichotomy, implying you can only be “for” or “against” psychiatry. Critiques of psychiatric diagnosis or the use of psychiatric medications are regularly dismissed out-of-hand by mainline psychiatry. One of the ongoing dialogues of dispute occurs between the author and journalist Robert Whitaker and the eminent psychiatrist Ronald Pies.

Robert Whitaker is the author of three books that relentlessly drive their readers to question the narrative for mental illness and psychiatry verbalized by mainline psychiatrists like Ronald Pies. These books are: Mad in America, Anatomy of an Epidemic and Psychiatry Under the Influence.  His articles on the mentally ill and the drug industry have won several awards. A series he wrote for The Boston Globe was a finalist for the Pulitzer in 1998. Anatomy was the 2010 winner for best investigative journalism by Investigative Reporters and Editors, Inc. Mad in America is also the name of a nonprofit organization and webzine, madinamerica.com, whose mission is “to serve as a catalyst for rethinking psychiatric care in the United States (and abroad).”

Ronald Pies is a noted psychiatrist, a Clinical Professor of Psychiatry at Tufts University and SUNY Upstate Medical University, Syracuse NY. He is also Editor in Chief Emeritus of Psychiatric Times. A bit of a Renaissance man, he’s published poetry: The Heart Broken Open, a novel: The Director of the Minor Tragedies, nonfiction: Becoming a Mensch: Timeless Talmudic Ethics for Everyone, as well as psychiatry: Psychiatry on the Edge, Handbook of Essential Psychopharmacology and psychotherapy: The Judaic Foundations of Cognitive-Behavioral Therapy.  He has authored or coauthored several other books as well.

Whitaker and Mad in America authors have disagreed with Pies on several issues. For example, they disagreed on whether psychiatrists widely promoted the chemical imbalance theory (see “Psychiatry DID Promote the Chemical Imbalance Theory” and “My Response to Dr. Pies” on madinamerica.com); or whether the long-term use of antipsychotics is helpful (see “Dr. Pies and Dr. Frances Make a Compelling Case that Their Profession is Doing Great Harm on madinamerica.com).

Into this mix Pies has written three articles for Psychiatric Times: “Is There Really an ‘Epidemic’ of Psychiatric Illness in the US?,” “The Bogus ‘Epidemic’ of Mental Illness in the US” and “The Astonishing Non-Epidemic of Mental Illness.” He’s clearly playing off of Whitaker’s book: Anatomy of an Epidemic. In his third article, “The Astonishing Non-Epidemic of Mental Illness,” Pies said that the epidemic of mental illness narrative is (with a few qualifications) “mostly fear-mongering drivel.” It sells books and makes for good online chatter, but “The so-called epidemic of mental illness among adults in the US proves largely illusory.”

He did some rhetorical sleight-of-hand, stating that by pulling out the bottom card of the epidemic narrative, the entire house of cards of the anti-psychiatry movement would collapse. In order to do this, he first quoted what he said was the CDC definition of epidemic: “ . . . an increase, often sudden, in the number of cases of a disease above what is normally expected in that population in that area . . .” Pies then said the CDC definition of epidemic applied to actual cases of disease; not to changing rates of diagnosis, which are subject to many socio-cultural variables. The distinction was critical,

Since psychiatry’s critics do not claim merely that there is more diagnosis of schizophrenia or major depression; rather, they claim there are actually more people sick with these illnesses, owing to misguided or harmful psychiatric treatment.

Remember that in psychiatric diagnosis, there are relatively few diagnoses that can be confirmed by medical tests. The vast majority of psychiatric disorders are assessed by a diagnostic process alone. If you demonstrate to a clinician that you meet the diagnostic criteria for a psychiatric disorder, you are treated as if you actually have the disorder. So Pies seems to be splitting hairs with his distinction between actual cases and diagnoses. And I don’t think he really hasn’t made as telling a point as he thought.

It would seem he is suggesting that psychiatric diagnostic rates for a disorder are overstated from the actual cases because of the influence of socio-cultural variables.  Yet how can you distinguish the actual cases from the false positives due to socio-culturally influenced diagnosis? The same diagnostic criteria are used. Is there an unstated assumption that diagnostic inflation is due to factors beyond psychiatry? Namely, that if a trained psychiatrist follows the structured clinical interview process, only actual cases of a psychiatric disorder will be identified?

Pies also said the “epidemic” claim was largely based on the increasing US rates of psychiatric disability over the past 50 years. Here he cited an article by Whitaker without mentioning Whitaker’s name. He dismissed the validity of using disability determinations, saying they cannot be used as “a legitimate index of disease incidence or prevalence.” He then shifts the focus to affirm there is a growing population of “persons with serious psychiatric illness who are not receiving adequate treatment.” Here he named two well-known psychiatrists who have written of their concerns with the “epidemic” of neglect with our most severely impaired citizens. But one of the persons he mentioned, Dr. Fuller Torrey, wrote The Invisible Plague about the rise of mental illness from 1750 to the present.

In the Introduction to The Invisible Plague Torrey described what he saw as “the epidemic of insanity.”  He said a major impediment to understanding the epidemic of insanity was that its onset occurred over so many years. Few people fully appreciated what was happening. “Those who did raise an alarm were largely ignored.” He said the suggestion today that we are living in the midst of an epidemic of insanity strikes most people as unbelievable.

Insanity is an invisible plague. There are no body counts with which one can compare the present with the past. In most countries, there are remarkably few statistics that can be used to assess insanity’s prevalence over time. Professional textbooks assume that insanity has always been present in approximately the same numbers as now.

Fuller Torrey is a believer in insanity as an epidemic of brain dysfunction. And he blames the likes of Michel Foucault, Thomas Szasz, Ronald Laing and others for emptying the insane asylums that have been “the mainstay for containing the epidemic for a century and a half,” without insuring these individuals received the treatment needed to control the symptoms of their illness.

When looking at the costs of this epidemic, Torrey said the combined costs in 1991 for the US were $110 billion. “And this included the single largest disease category for federal payments under the Supplemental Security Income (SSI) and Social Security Disability Insurance (SSDI) programs.” So in quantifying the cost of the epidemic of insanity, Torrey used the same statistic to make his point that Whitaker did. Pies either didn’t realize this, or ignored it in his critique of Whitaker. I wonder if Pies sees what Torrey said as fear-mongering drivel or one of the few qualifications?

Pies dismissively cited two articles written by Marcia Angell for The New York Review of Books in 2011 (“The Epidemic of Mental Illness: Why?” and “The Illusions of Psychiatry”) in all three of his articles as an example of the promotion of the false narrative of “the raging epidemic of mental illness.” Her articles discussed three books and their implications for psychiatry: The Emperor’s New Drugs, Anatomy of an Epidemic, and Unhinged: The Trouble with Psychiatry. Angell’s review of Whitaker’s book drew it to the attention of a wide audience; so it seems this may be at least partly why Pies is dismissive of it.

However, read her articles. They will give you a thumbnail sketch of issues Pies goes to great lengths to deny and minimize. Then read the books she discusses. Remember that Marcia Angell is a Senior Lecturer at Harvard Medical School and was the first woman to serve as editor-in-chief of the New England Journal of Medicine. Don’t be dismissive of what she has to say; she has great credibility.

There is one final point to be made with regard to Pies’ third article. In the conclusion, he references Thomas Kuhn’s idea of “paradigm,” saying it is misleading and unfair to suggest that psychiatry is laboring under a “failed paradigm.” This was, he said, because “there is no one paradigm the defines all of psychiatry or that dictates practice on the part of all psychiatrists.” But I wonder if he truly understood the implications to his comment. If you apply Kuhn’s notion of paradigm (“a paradigm is what members of a scientific community share”) with Pies’ application of the term to psychiatry, then you would have to conclude that psychiatry as it’s practiced, is NOT a science. Rather, it would either be what Kuhn called a “pseudoscience” or pre-scientific. He also seems to be oblivious to the possibility of an implicit paradigm generated in psychiatric practice with DSM diagnosis—that it classifies a real “illness” or “disease” of the brain.

I’m reminded of what Robert Whitaker pointed out in his review of Jeffrey Lieberman’s book Shrinks, “The Untold Story of Psychiatry.” Whitaker noted how speeches given by the presidents of the American Psychiatric Association at their annual meetings regularly sounded the same theme: “Psychiatrists are true heroes.” He said it struck him that Shrinks served as an institutional self-portrait of psychiatry. “What you hear in this book [Shrinks] is the story that the APA and its leaders have been telling to themselves for some time.” Similarly, it seems Pies is preaching to the psychiatric choir—a message that there really isn’t an epidemic increase in mental illness; the argument of the anti-psychiatry movement is just a house of cards. Yet it seems to me that house is still standing despite the huffing and puffing of Pies and others.

06/24/15

Debating the Harm from Psychotropics

© iqoncept | 123RF.com

© iqoncept | 123RF.com

In mid-May of 2015, there was a public debate on whether the long-term use of psychiatric medications causes more harm than good. Before saying “Boring” and moving on to something else, realize that prescriptions for antidepressants are on the rise —increasing by 7.5% in Britain since 2013 and over 500% since 1992. Recent research has shown that more people are taking antidepressants for longer periods of time, “often because they become dependent upon them and cannot stop.” Yet there is no good research into the safe long-term use of these drugs.

It seems that the challenge for the debate grew out of several prominent British psychiatrists publically criticizing the launch of the Council for Evidence-Based Psychiatry, an organization aimed at starting a dialogue about the use of psychiatric drugs and treatments. The two sides of the debate jointly published a paper in the British Medical Journal (BMJ).  The original BMJ press release, now removed from the site, inexplicably did not include a declaration of interests for one of the speakers against the motion, Alan H. Young. So what?

Young was initially in print as saying he had no interests to declare, while in fact he had several. This was important information to reveal, not only because it is a BMJ policy, but also because Young was planning to challenge the premise of whether long-term use of psychiatric medication causes more harm than good. In other words, his financial and professional ties to the pharmaceutical industry were initially not reported in a debate where he was defending the use of psychiatric medications. You can view the original press release here; the revised one here. Look at the bottom right column on page 2 for both.

This mistake was caught by one of the speakers for the motion, Peter Gøtzsche, who also reported a series of actions that appeared to be aimed at undercutting  Gøtzsche’s credibility and the information he presented. You can read his description of these “bizarre events” related to the Maudsley debate here. You can review the debate here. Gøtzsche opened his time to speak during the debate by estimating that psychiatric drugs were the 3rd leading cause of death among people aged 65 and over.

I have estimated, based on randomised trials and cohort studies, that psychiatric drugs kill more than half a million people every year among those aged 65 and above in the USA and Europe. This makes psychiatric drugs the third leading cause of death, after heart disease and cancer. The drugs furthermore cripple tens of millions. There are no benefits that can justify so much harm.

Gøtzsche also described how clinical trials include patients already taking other psychiatric medications. These participants are then rapidly withdrawn for their medication. If they are randomly placed in a placebo group, they often experienced withdrawal symptoms. “This design exaggerates the benefits of treatment and increases the harms in the placebo group, and it has driven patients taking placebo to suicide in trials in schizophrenia.”

He called for the establishment of withdrawal clinics to help patients slowly and safely taper off of psychiatric drugs. He estimated that 98% of all psychotropic drugs could be stopped without causing harm. In the revised BMJ press release, it says “we could stop almost all psychotropic drugs without causing harm.” Gøtzsche said this replaced his original statement. This could be accomplished by dropping all antidepressants, ADHD medications, and dementia drugs. Only a small percentage of the antipsychotics and benzodiazepines currently used should be continued.

This would lead to healthier and more long-lived populations.  Because psychotropic drugs are immensely harmful when used long term, they should almost exclusively be used in acute situations and always with a firm plan for tapering off, which can be difficult for many patients.

The Council for Evidence-Based Psychiatry (CEP) began on April 30th of 2014 with an event at the House of Lords and the release of a publication entitled: Unrecognized Facts about Modern Psychiatric Practice. This is linked on the CEP website. You can get a quick introduction to some of the CEP members and what they believe by viewing some short videos linked on their homepage. One of the innovative ways they have attempted to provide a bridge between the public, policy makers and legislators, and the research community that investigates the areas where psychiatry has caused harm, although the intention has been to help.

Unrecognized Facts is a nifty slide show that presents various facts about modern psychiatric practice, with links on each slide to further available information. Here are a few of examples of what you can find there.

Myth of the Chemical Imbalance

Psychiatric drugs have often been prescribed to patients on the basis that they cure a ‘chemical imbalance.’ However, no chemical imbalances have been proven to exist in relation to any mental health disorder. There is also no method available to test for the presence or absence of these chemical imbalances.

Worse Long-Term Outcomes

There has been little research on the long-term outcomes of people taking psychiatric drugs. The available studies suggest that all the major classes of psychiatric drugs add little additional long-term benefit, and for some patients they may lead to significantly worse long-term outcomes.

 Long-Lasting Negative Effects

Psychiatric drugs can have long-lasting negative effects on the brain and central nervous system, particularly when taken long term, which can lead to physical, emotional and cognitive difficulties.

Negative Effects Are Often Misdiagnosed

Psychiatric drugs can have effects that include mental disturbance, including suicide, violence, and withdrawal syndromes. These can be misdiagnosed as new psychiatric presentations, for which additional drugs may be prescribed, sometimes leading to long-term use of multiple different psychiatric drugs in the same person.

10/29/14

Creating Chemical Imbalances

“Rather than fix chemical imbalances in the brain, the drugs create them.” (Robert Whitaker, Anatomy of an Epidemic)

One of the most enlightening books I’ve read recently was Anatomy of an Epidemic, by Robert Whitaker. In the foreword, Whitaker said he originally believed that psychiatric drugs were like “insulin for diabetes.” He believed that psychiatric researchers were discovering the biological causes of mental illnesses and that this led to the development of a new generation of psychiatric drugs that helped “balance” brain chemistry. Then he stumbled upon some research findings that challenged that belief, “and that set me off on an intellectual quest that ultimately grew into this book.”

What follows is a collection of quotes from Anatomy of an Epidemic and a chart containing data on psychiatric medications.  There is little additional commentary by me. The power of the quotes is underscored by the sales and prescription data in the chart.

Some of the quotes were handily gathered together for me on Goodreads. My chart is a combination of a listing of the top 25 prescribed psychiatric medications in 2013 found on PsychCentral and data for 2013 pharmaceutical sales on Drugs.com. It follows the rank order given by John Grohol on PsychCentral for the top 25 most prescribed psychiatric medications in 2013.  I then included the sales data found on Drugs.com from its list of the top 100 pharmaceutical drugs by gross retail sales for the listed drugs.

Drug

Prescriptions-2013

Use

Sales-2013

Xanax (alprazolam)

48,465,000

Anxiety

Zoloft (sertraline)

41,416,000

Depression, anxiety, OCD, PTSD, PMDD

Celexa (citalopram)

39,445,000

Depression, anxiety

Prozac (fluoxetine)

28,258,000

Depression, anxiety

Ativan (lorazepam)

27,948,000

Anxiety, panic disorder

Desyrel (trazodone)

26,242,000

Depression, anxiety

Lexapro (escitalopram)

24,920,000

Depression, anxiety

Cymbalta (duloxetine)

18,573,000

Depression, anxiety, fibromyalgia, diabetic neuropathy

5,083,111,000

Wellbutrin XL (bupropion)

16,053,000

Depression

Effexor (venafaxine)

15,796,000

Depression, anxiety, panic disorder

Valium (diazepam)

14,754,000

Anxiety, panic disorder

Paxil (paroxetine)

14,335,000

Depression, anxiety, panic disorder

Seroquel (quetiapine)

14,326,000

Bipolar disorder, depression

1,183,989,000

Amphetamine salts (Adderall)

12,785,000

ADHD

727,892,000

Risperdal (pisperidone)

12,320,000

Bipolar disorder, schizophrenia, iirritability in autism

Vyvanse (lixdexamfetamine)

9,842,000

ADHD

1,689,091,000

Concerta ER (methylphenidate)

8,803,000

ADHD

Abilify (aripiprazole)

8,747,000

Bipolar disorder, schizophrenia, depression

6,293,801,000

Wellbutrin SR-W (bupropion)

8,238,000

Depression

Buspar (buspirone)

8,065,000

Sleep, anxiety

Vistaril (hydroxyzine)

8,052,000

Anxiety

Amphetamine salts ER (Adderall)

7,925,000

ADHD

Zyprexa (olanzapine)

5,101,000

Bipolar disorder, schizophrenia

Concerta/Ritalin (methylphenidate)

5,335,000

ADHD

1,383,814,000

Pristiq (desvenlafaxine)

3,217,000

Depression

Of the top 25 prescribed psychiatric drugs in 2013, 13 were to “treat” anxiety; 13 were to “treat” depression; 4 were to “treat” panic disorder; 4 were to “treat” bipolar disorder; and five were to “treat” ADHD. As the chart indicates, some of the medications are used for two or more disorders. In fact, 11 of the top 13 prescribed medications in 2013 could be used for anxiety; 10 of the top 13 could be used for depression.  Three of those were benzodiazepines (Xanax, Ativan and Valium); nine were antidepressants of some type (Zoloft, Celexa, Prozac, Desvrel, Lexapro, Cymbalta, Wellbutrin, Effexor and Paxil); and one, Seroquel, was an antipsychotic.

In addition to causing emotional distress, long-term benzodiazepines usage also leads to cognitive impairment (137). Although it was thirty years ago that governmental review panels in the United States and the United Kingdom concluded that the benzodiazepines shouldn’t be prescribed long-term … the prescribing of benzodiazepines for continual use goes on (147). Antidepressant drugs in depression might be beneficial in the short term, but worsen the progression of the disease in the long term, by increasing the biochemical vulnerability to depression. . . . Use of antidepressant drugs may propel the illness to a more malignant and treatment unresponsive course (160). In a recent survey of members of the Depressive and Manic-Depressive Association, 60 percent of those with a bipolar diagnosis said they had initially fallen ill with major depression and had turned bipolar after exposure to an antidepressant (181). Given that the biology of ADHD remains unknown, it is fair to say that Ritalin and other ADHD drugs ‘work’ by perturbing neurotransmitter systems. . . . Cocaine acts on the brain in the same way (227).

Disturbing, huh?

Only six of the most widely prescribed medications were among the 100 best sellers. The six best selling psychiatric medications in the order of their sales were: 1) Abilify ($6.294 billion); 2) Cymbalta ($5.083 billion); 3) Vyvanse ($1.689 billion); 4) Concerta/Ritalin ($ 1.384 billion); 5) Seroquel ($1.184 billion); 6) Amphetamine salts (found in Adderall, $727.9 million). Part of the explanation for the difference is that the majority of the prescribed psychiatric medications are now off patent and available as generic drugs. So they typically don’t make as much money for pharmaceutical companies. An example would be how Abilify was the top grossing prescription for all medications in 2013, but only the 18th most prescribed medication.

With the exception of VyVanse, I’d expect most of the six to also drop out of the top 100 selling drugs of the next few years. Abilify’s patent expires in October of 2014. Cymbalta’s patent expired in December of 2013. Vyvanse’s patent will expire in 2023. Concerta’s patent expired in 2011. Seroquel’s patent expired in 2012.

If you expand the boundaries of mental illness, which is clearly what has happened in this country during the past twenty-five years, and you treat the people so diagnosed with psychiatric medications, do you run the risk of turning an anger-ridden teenager into a lifelong mental patient? (p. 30) We have been focusing on the role that psychiatry and its medications may be playing in this epidemic, and the evidence is quite clear. First, by greatly expanding diagnostic boundaries, psychiatry is inviting and ever-greater number of children and adults into the mental illness camp. Second, those so diagnosed are then treated with psychiatric medications that increase the likelihood they will become chronically ill. Many treated with psychotropics end up with new and more severe psychiatric symptoms, physically unwell, and cognitively impaired. This is the tragic story writ large in five decades of scientific literature (209). Twenty years ago, our society began regularly prescribing psychiatric drugs to children and adolescents, and now one out of every fifteen Americans enters adulthood with a “serious mental illness.” That is proof of the most tragic sort that our drug-based paradigm of care is doing a great deal more harm than good. The medicating of children and youth became commonplace only a short time ago, and already it has put millions onto a path of lifelong illness (246). For the past twenty-five years, the psychiatric establishment has told us false story. It told us that schizophrenia, depression, and bipolar illness are known to be brain diseases, even though … it can’t direct us to any scientific studies that document this claim. . . . Most important of all, the psychiatric establishment failed to tell us that the drugs worsen long-term outcomes (358).