02/6/24

Psychedelics as the Newest Psychiatric Craze, Part 1

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In October California Governor Gavin Newsom vetoed a bill that would have decriminalized the possession and personal use of several plant-based hallucinogens, including psilocybin, mescaline and dimethyltryptamine (DMT), saying more work needed to be done on treatment guidelines. The legislation would have decriminalized possession before setting up regulatory treatment guidelines, with the California Health and Human Services Agency supposed to make recommendations to lawmakers after the consequences of decriminalization. The bill would not have arrested or prosecuted individuals who possessed limited amounts of plant-based hallucinogens. Also, the bill did not legalize the sale of these psychedelics. They are still illegal under federal law.

Public opinion was said to have shifted on using psychedelics to treat trauma and other disorders such as depression, and alcohol use disorder. There has been a significant amount of interest in the potential of psychedelics for mental health that includes encouragement and discouragement of treating psychiatric conditions with them. Sandy Cohen opened her article “Do psychedelics have a role in psychiatric treatment?” for UCLA Health, with the provocative question, “What if there was a medication that could significantly reduce symptoms of treatment-resistant depression in a single dose?” A UCLA Health psychiatrist, Walter Dunn, described two studies where psilocybin was found to have a significant reduction in symptoms of treatment-resistant depression. He said these results were unprecedented: “We have nothing that works this well.”

Dunn said the coverage in mainstream media and books aimed at lay audiences (such as Michael Pollan’s book, How to Change Your Mind) have raised interest and curiosity in psychedelics. He said when he goes to dinner parties and people discover his work is with psychedelic drugs, “I’m talking about them for the rest of the evening.” According to a UC Berkeley Psychedelics Survey, 61% of registered American voters support legalizing regulated therapeutic access to psychedelics. Thirty-five percent of those supporters said they strongly support such action. But there were 35% who opposed it and 69% did not see it as something “for people like me.”

We are in a historic moment in the space for psychedelic science, research and also mental health in general. . . There hasn’t been any time in modern psychiatry where there has been so much interest, awareness and discussion around a potential mental health treatment.

Dunn acknowledged the drugs come with risks, which was one of the reasons the FDA has been cautious about the trials being run. “These are not benign medicines. Anything that can help you can harm you.” He discussed how the FDA was set to consider MDMA-assisted therapy for PTSD in 2024. It’s still unclear whether or not the FDA will want a Risk Evaluation and Mitigation Strategy (REMS), if these treatments are approved. A REMS could require psychedelic-assisted therapy to included two specially trained and certified clinicians during the psychedelic experience. If a REMS is required by the FDA for MDMA-assisted therapy, it would reduce the pool of therapists who could administer the treatment and decrease access even as it enhances safety.

Joanna Moncrieff, a British psychiatrist, noted in “Psychedelics—The New Psychiatric Craze” where they were viewed as an increasingly fashionable medical treatment. But she wondered if they had any objective health benefits and were they safe. She noted where psilocybin, LSD, MDMA and ketamine were some of the psychedelics being recommended for an ever-lengthening list of problems that include depression, anxiety, addiction, and PTSD. She acknowledged some people might learn important about themselves through the effects of psychedelic drugs.

But these benefits are not medical or health effects. They are akin to the personal development people achieve through other sorts of activities and life experiences. . . And although the concept of drug-assisted psychotherapy acknowledges that it is the way the psychoactive effects of the drugs are used to promote a process of personal learning that is relevant, why not employ other, safer and cheaper methods? Why not nature-assisted psychotherapy (a walk in the park), for example?

Yet, the use of these drugs is portrayed as if they work by targeting underlying dysfunctional brain processes. Moncrieff is concerned that when psychedelics get a medical license, psychotherapy will be dropped or minimized. “As with ketamine, the tendency of all psychedelic treatment will be towards the provision of the drug in the cheapest possible way, which means the minimum of supervision and therapy.” Presciently, Moncrieff wrote her article two years ago, before the accidental death of Matthew Perry from the acute effects of unsupervised ketamine use.

She said most psychedelic research ignores the way the immediate psychoactive effects of the drugs impact people’s feelings and behavior in a way that will influence mood symptom ratings and may produce the impression of improvement. She singled out the American Psychiatric Association’s report on ketamine treatment, which said there was compelling evidence the antidepressant effects of ketamine infusion are rapid and robust. While the APA acknowledged the antidepressant effects were transitory, they did not explain how they could be distinguished from the euphoria and other mental alterations associated with acute ketamine intoxication. “If ketamine’s effects are ‘antidepressant’ then so are the effects of all the other drugs that produce short-term euphoria including alcohol, cocaine, heroin, amphetamines, etc.”

Any powerful mind-altering drug will likely have ‘placebo’ effects. Drug-induced experience will lead people to expect they will improve or think they have improved. Psychedelic research also neglects the hours of medical supervision and professional attention associated with psychedelic treatment. Clinical contact improves people’s outcomes in depression, as was seen in esketamine trials, where a high level of professional contact seems to have exerted a powerful effect on some people.

The current craze for psychedelics also means the adverse effects are being minimised or overlooked. The ‘bad trip’ is a well-recognised phenomenon, and may not be that uncommon. Psychiatrist Rick Strassman, author of DMT: the Spirit Molecule, described how half of the 60 volunteers he injected with the powerful hallucinogen, DMT (N,N-dimethyltryptamine), experienced terrifying hallucinations and anxiety, and he discontinued his research, in part because of these effects. Science journalist John Horgan describes months of depression and flashbacks following a ‘bad trip’, and also reminds us that Albert Hofmann, who first synthesised LSD, also had doubts about it, calling his 1981 memoir LSD: My problem child.

Moncrieff ended her article by noting that while one or two doses of any drug is unlikely to do much harm, the tendency for treating mental health concerns is for long-term use. And repeated use of psychedelics is unlikely to be completely harmless. “As with so many other medical treatments, they have become popular through the potent mixture of financial interests and desperation.” There are many safer routes to promote personal development through an unusual experience. But we will be faced with a decision to legalize psychedelic-assisted treatment sooner rather than later, as MDMA-assisted therapy is expected to be submitted to the FDA for review for approval in early 2024. See Part 2 of this article for more information on the approval process for MDMA-assisted therapy.

10/25/22

The Myth of the Serotonin Theory of Depression

A research article by Joanna Moncrieff, Mark Horowitz and others, “The serotonin theory of depression: a systematic review of the evidence”, published in the journal Molecular Psychiatry in July of 2022, continues to draw media attention to its findings. The researchers did a systematic umbrella review of the principle relevant areas of research and concluded that the main areas of serotonin research provide no consistent evidence of an association between serotonin and depression. “We suggest it is time to acknowledge that the serotonin theory of depression in not empirically substantiated.” In other words, it’s a myth.

The response from many psychiatrists to the article was that the serotonin imbalance theory has not been treated seriously within the field for many years. Neuroscience News & Research quoted several who thought the findings were not surprising. Dr. Michael Bloomfield a consultant psychiatrist and head of the translational psychiatry research group at University College London said he didn’t think he’d met any serious scientists or psychiatrists who thought that “all causes of depression are cause by a simple chemical imbalance in serotonin.” Allan Young, the director of the Centre for Affective Disorders at King’s College London said, “Most psychiatrists adhere to the biopsychosocial model with very few people subscribing to a simple ‘chemical imbalance’ theory.”

According to Ang, Moncrieff and Horowitz in Is the chemical imbalance theory an ‘urban legend’?, historically there was a considerable promotion of the serotonin hypothesis of depression in both the psychiatric and the psychopharmacology literature. Research papers supporting it were widely cited. While some textbooks were more nuanced, others could be seen to unreservedly indorse it. The American Psychiatric Association (APA) published a patient leaflet in 2005 that said, “antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.” See, “The Death of the Chemical Imbalance Theory?” on this website.

It is often assumed that the effects of antidepressants demonstrate that depression must be at least partially caused by a brain-based chemical abnormality, and that the apparent efficacy of SSRIs shows that serotonin is implicated. Other explanations for the effects of antidepressants have been put forward, however, including the idea that they work via an amplified placebo effect or through their ability to restrict or blunt emotions in general.

Moncrieff et al said surveys suggest that 80% of the general public now believe depression is caused by a ‘chemical imbalance.’ They said many general practitioners also subscribe to this view and popular website commonly cite the theory.

The chemical imbalance theory of depression is still put forward by professionals, and the serotonin theory, in particular, has formed the basis of a considerable research effort over the last few decades. The general public widely believes that depression has been convincingly demonstrated to be the result of serotonin or other chemical abnormalities, and this belief shapes how people understand their moods, leading to a pessimistic outlook on the outcome of depression and negative expectancies about the possibility of self-regulation of mood. The idea that depression is the result of a chemical imbalance also influences decisions about whether to take or continue antidepressant medication and may discourage people from discontinuing treatment, potentially leading to lifelong dependence on these drugs.

Writing for The Conversation, Moncrieff and Horowitz said the serotonin theory of depression has been one of the most influential and extensively researched biological theories of depression. Most antidepressants now in use are presumed to work through their effects on serotonin or noradrenaline. Yet their study shows that is not supported by scientific evidence. “It also calls into question the basis for the use of antidepressants.”

It is important that people know that the idea that depression results from a “chemical imbalance” is hypothetical. And we do not understand what temporarily elevating serotonin or other biochemical changes produced by antidepressants do to the brain. We conclude that it is impossible to say that taking SSRI antidepressants is worthwhile, or even completely safe.If you’re taking antidepressants, it’s very important you don’t stop doing so without speaking to your doctor first. But people need all this information to make informed decisions about whether or not to take these drugs.

The organization, Inner Compass Initiative, was able to get Joanna Moncrieff, Mark Horowitz and Irving Kirsch together for an online discussion in “Moving Beyond Myth: A Postmortem Analysis of Chemical Imbalances and Antidepressants Efficacy.” On its website Inner Compass Initiative said it is an organization that is “dedicated to helping people make more informed choices about taking and withdrawing from psychiatric medications.”

Irvin Kirsch has published several studies of the placebo effect and antidepressants, demonstrating that most of the efficacy with antidepressants is from the placebo effect. For more information on Irving Kirsch and his research, see, “Dirty Little Secret,” and “Antidepressant Fall From Grace, Part 2” on this website.

The Inner Compass Initiative moderator, Laura Delano, said the use of antidepressants in the West more than doubled between 2000 and 2015. One in seven Americans and one in six in England take an antidepressant. In October of 2004 the FDA issued a black box warning, indicating an increased risk of suicidal ideation and behavior in children and adolescents treated with SSRIs. However, their off-label use with children and adolescents has increased. In “Antidepressants in Children and Adolescents”, Boaden et al said: “From 2005 to 2012, the prevalence of antidepressant use has increased from 1.3% to 1.6% in the USA, from 0.7% to 1.1% in the UK.”

While the overall percentages are low, keep in mind that at least in the U.S. those increases took place after the FDA required a black box warning of an increased risk of suicidality with children and adolescents treated with SSRIs. In the UK, it represents an increase of over 36%; in the USA, by almost 19%.

“Moving Beyond Myth” begins with a description of how serotonin is measured within the body and a review of the history of the chemical imbalance theory. Joanna Moncrieff said it is not the case that there is a set normal level of serotonin against which people’s serotonin can be judged. She went on to say that the chemical imbalance theory of depression was one of a number of chemical imbalance theories of mental disorders that arose in the 1960s, “in the context of thoughts about drugs that are used to treat these disorders. So, they’re always directly related to the use of drug treatments.” Psychiatrists and researchers came to think that the drugs are working by targeting the underlying abnormality.

Initially they thought that noradrenaline might be relevant in depression. They hypothesized that depression might be due to lower levels of noradrenaline. But when the drugs that selectively target serotonin came out, “people started to think that the underlying abnormality was an abnormality of serotonin, rather than noradrenaline. And that is what the pharmaceutical industry took hold of and ran with in the 1990s when they started to market SSRIs.”

Her point is that chemical imbalance theories have always been dreamed up in the context of the use of different drugs to treat mental disorders. “They are based on the assumption that drugs are working by targeting the underlying abnormality, and that you can deduce the abnormality from the opposite of what the drugs do.” Mark Horowitz goes on to describe the findings of “The serotonin theory of depression: a systematic review of the evidence.”

An added bonus in “Moving Beyond Myth” is to hear Irving Kirsch describe his research into antidepressant efficacy and its relationship to the placebo effect. His most recent research was published in August of 2022 in the BMJ (British Medical Journal). Kirsch and the other researchers did a participant level analysis of randomized, placebo-controlled trials of acute monotherapy for the treatment of major depressive disorder submitted to the FDA between 1979 and 2016. The Conclusions section of the article said:

Patients with depression are likely to improve substantially from acute treatment of their depression with drug or placebo. Although the mean effect of antidepressants is only a small improvement over placebo, the effect of active drug seems to increase the probability that any patient will benefit substantially from treatment by about 15%. Further research is needed to identify the subset of patients who are likely to require antidepressants for substantial improvement. The potential for substantial benefit must be weighed against the risks associated with the use of antidepressants, as well as consideration of the risks associated with other treatments that have shown similar benefits. Because the benefits and risks might be categorically different (eg, reduced sadness v anorgasmia), weighting should be done at the individual level, jointly by patients and their care providers.

The belief that a chemical imbalance underlies depression and other mental disorders has begun to unravel. For some time, it has been set aside by researchers and some psychiatrists as an urban legend. The pharmaceutical industry may continue to hold on to the notion that drugs work by targeting an underlying abnormality and that you can identify the abnormality “from the opposite of what the drugs do.” But it is time the public became aware that the chemical imbalance theory of depression is just a myth.

09/20/22

The Death of the Chemical Imbalance Theory?

There was an article published recently in the journal Molecular Psychiatry that is getting a lot of attention online. The Hill, Psychology Today, Neuroscience News and other new outlets highlighted an umbrella review by researchers that questioned the serotonin theory of depression and the value treating depression with antidepressants. In an article for The Conversation, two of those researchers wrote, “Our study shows that this view is not supported by scientific evidence. It also calls into question the basis for the use of antidepressants”; and the chemical imbalance theory of depression.

Joanna Moncrieff and Mark Horowitz wrote that the serotonin theory of depression was widely promoted by the pharmaceutical industry in the 1990s with its marketing a then new class of antidepressant medications, selective serotonin-reuptake inhibitors (SSRIs). This strategy became known as the “chemical imbalance theory of depression.” The theory was endorsed by institutions like the American Psychiatric Association. But this has changed, with psychiatrists like Ronald Pies, saying as early as 2011 that, “the chemical imbalance notion was always a kind of urban legend.”

Pies said in another more recent article for Psychiatric Times that he influenced the APA to replace a statement on its public education website that referred to “imbalances in brain chemistry,” with: “While the precise mechanism of action of psychiatric medications is not fully understood, they may beneficially modulate chemical signaling and communication within the brain, which may reduce some symptoms of psychiatric disorders.” The statement quoted by Dr. Pies is in article titled, “What is Psychiatry?”

Moncreiff and Horowitz pointed to another article on the same website, “What is Depression?”, where it said while several factors can play a role in depression—biochemistry, genetics, personality and environment. For biochemistry, it said: “Differences in certain chemicals in the brain may contribute to symptoms of depression.”

Looking at these articles, the chemical imbalance theory may have been weakened, but I don’t think it was defeated. It seems that when medications can “beneficially modulate” and when “differences in certain chemicals” may contribute to symptoms of depression, the imbalance theory is present implicitly. That is why the new study by Moncrieff et al, “The serotonin theory of depression: a systematic review of the evidence,” in Molecular Psychiatry is so important.

Despite the fact that the serotonin theory of depression has been so influential, no comprehensive review has yet synthesised the relevant evidence. We conducted an ‘umbrella’ review of the principal areas of relevant research, following the model of a similar review examining prospective biomarkers of major depressive disorder. We sought to establish whether the current evidence supports a role for serotonin in the aetiology of depression, and specifically whether depression is associated with indications of lowered serotonin concentrations or activity.

Their comprehensive review indicated there is no convincing evidence that depression is related to or caused by lower serotonin concentrations or activity. Yet surveys suggest 80% or more of the general public believe depression is caused by a ‘chemical imbalance.’ This belief shapes how people understand their moods, leading to a pessimistic view on what they can expect from treatment. “The idea that depression is the result of a chemical imbalance also influences decisions about whether to take or continue antidepressant medication and may discourage people from discontinuing treatment, potentially leading to lifelong dependence on these drugs.”

Moncrieff and Horowitz said in The Conversation article that it was important for people know the idea that depression as a chemical imbalance is hypothetical. Moreover, we don’t understand what temporarily elevated serotonin or other biochemical changes produced by antidepressants do to the brain. “We conclude that it is impossible to say that taking SSRI antidepressants is worthwhile, or even completely safe.” And yet, the serotonin theory of depression has formed the basis for a significant amount of research over the past few decades.

Along with Benjamin Ang, Moncrieff and Horowitz explored the serotonin theory of depression in the scientific literature in, “Is the chemical imbalance an ‘urban legend’? They noted where the chemical imbalance theory was first proposed in the 1960s, focusing initially on the neurochemical noradrenaline instead of serotonin. “What came to be known as the ‘monoamine hypothesis’ (noradrenaline and serotonin are both classified as monoamines), was stimulated by the belief that certain prescription drugs targeted the basis of mood, particularly drugs that were named ‘antidepressants’.”

Following the introduction of the selective serotonin reuptake inhibitor (SSRI), the ‘serotonin hypothesis’ became embedded in the popular and professional consciousness. The pharmaceutical industry promoted the idea that depression was a result of an imbalance or deficiency of serotonin in the brain. SSRIs, which were just being brought to the market, were said to be the ‘magic bullets’ that could reverse this abnormality. In an advertisement for Zoloft, Pfizer said “while the cause is not known, depression may be related to an imbalance of natural chemicals between nerve cells in the brain” and that “prescription Zoloft works to correct this imbalance.”

Ang, Moncrieff and Horowitz more fully documented how the American Psychiatric Association (APA) supported the pharmaceutical company rhetoric from a patient leaflet produced in 2005, which said: “antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.” Despite what Dr. Pies said, it seems that the APA did not have many psychiatrists who knew this was a kind of urban legend.

The marketing of SSRIs and the serotonin theory led to a dramatic global increase in their use. Prescriptions in England tripled between 1988 and 1998; and then tripled again between 1998 and 2018. Similar increases took place throughout Europe, with some Eastern European countries where use was previously low, increasing 5-6 times since 2000. In the U.S., antidepressant prescriptions quadrupled between the late 1980s and the mid-2000s.

There is evidence that increasing numbers of people are taking antidepressants on a long-term basis. Research has shown that believing depression is caused by a chemical imbalance is widespread among antidepressant users, encourages people to ask for antidepressants and discourages them from trying to stop.

In 2005, Jeffrey Lacasse and Jonathan Leo published a paper in PLOS Medicine that received a lot of attention. It was the first time the media grasped that the serotonin theory might not be supported by the evidence. Their paper provoked a response by the chair of the FDA psychopharmacology committee, who admitted evidence for a neurochemical deficiency in people with depression was elusive. He thought it could be a ‘useful metaphor,’ but one he would not use with his own patients. While an SSRI may work well with an individual, that “doesn’t prove that there is an underlying imbalance, defect or dysfunction in the person’s serotonin system.”

Responding to a report published by the Citizens Commission on Human Rights, a Church of Scientology organization, Ronald Pies called the chemical imbalance theory an urban legend that no well-informed psychiatrist had ever believed. He claimed the theory was spread by the pharmaceutical industry, and opponents of psychiatry attributed the belief to psychiatrists themselves. A few months later, he wrote an article for Psychiatric Times admitting that there were psychiatrists and other physicians who used the term ‘chemical imbalance’ when explaining psychiatric illness to a patient.

My impression is that most psychiatrists who use this expression feel uncomfortable and a little embarrassed when they do so. It’s a kind of bumper-sticker phrase that saves time, and allows the physician to write out that prescription while feeling that the patient has been “educated.” If you are thinking that this is a little lazy on the doctor’s part, you are right. But to be fair, remember that the doctor is often scrambling to see those other twenty depressed patients in her waiting room. I’m not offering this as an excuse–just an observation.

In 2019 Pies said while some prominent psychiatrists have used the term ‘chemical imbalance’ in public comments about antidepressants, and possibly in their clinical practices, “there was never a unified, concerted effort within American psychiatry to promote a chemical imbalance theory of mental illness.” A good bit of psychiatric opinion follows Pies’ lead and says the idea that depression is caused by brain chemical imbalances is an over-simplified explanation that should not be taken seriously. The attempt by leading psychiatrists to deny that the serotonin theory was ever influential seems to be a tactic to deflect criticism, and allow it to continue in some modified form.

Ang, Moncrieff and Horowitz concluded that during the period 1990-2010, there was considerable coverage of, and support for, the serotonin hypothesis of depression in the psychiatric and psychopharmacological literature. Research papers on the serotonin system were widely cited, and most strongly supported the serotonin theory. Textbooks took a more nuanced approach, but at other points were unreservedly supportive of the theory. Critics of the theory were either ignored or marginalized as antipsychiatry. Yet it seems in 1987 at least one critic, the Irish psychiatrist David Healy, astutely described the neurochemical theory of depression as an exhausted Kuhnian paradigm in “The structure of pharmacological revolutions.” He said it was perpetuated because it served the professional purpose of convincing patients that depression is a biological condition.

Healy was referring to the seminal work by Thomas Kuhn on the philosophy and history of science, The Structure of Scientific Revolutions. According to Kuhn, normal science referred to research firmly based on one or more past scientific achievements that a particular scientific community “acknowledges for a time as supplying the foundation for its further practice.” The process of normal science takes place within a paradigm—like the monoamine hypothesis—where research occurs within the context of a scientific community committed to the same rules and standards for scientific practice. “That commitment and the apparent consensus it produces are prerequisites for normal science.”

Any new interpretation of nature, whether a discovery or a theory, emerges first in the mind of one or a few individuals. It is they who first learn to see science and the world differently, and their ability to make the transition is facilitated by two circumstances that are not common to most other members of their profession. Invariably, their attention has been intensely concentrated upon the crisis-provoking problems; usually, in addition, they are men [or women] so young or so new to the crisis-ridden field that practice has committed them less deeply than most of their contemporaries to the world view and rules determined by the old paradigm. How are they able, what must they do, to convert the entire profession or the relevant professional subgroup to their way of seeing science and the world? What causes the group to abandon one tradition of normal research in favor of another?

So in “The serotonin theory of depression: a systematic review of the evidence,” by Moncreiff at al, we may be witnessing the death of the old paradigm for depression.

Kuhn went on to observe that the proponents of competing paradigms are always at least slightly at cross-purposes. “Neither side will grant all the non-empirical assumptions that the other needs in order to make its case.” While each may hope to “convert” the other to his or her way of seeing science and its problems, the dispute is not one “that can be resolved by proofs.” Kuhn quoted the theoretical physicist Max Planck who said: “A new scientific truth does not triumph by convincing its opponents and making them see the light, but rather because its opponents eventually die, and a new generation grows up that is familiar with it.”

06/28/22

Time for a Fresh Look at Diagnosis

Allen Frances, chair of the DSM-IV Task Force, has been a vocal critic of modern psychiatry and diagnosis. He was selected by fellow psychiatrist Awais Aftab to do the first interview for Conversations in Critical Psychiatry, a series for Psychiatric Times that aimed to engage prominent individuals who have made important and constructive critiques of psychiatry. Dr. Frances said while he considered psychiatry to be one of the noblest of professions, it had drifted away from best practice. Too many psychiatrists, he said, are reduced to pill pushing with too little time to really know their patients well. And psychiatrists have not done enough to educate primary care physicians, who prescribe 80% of psychiatric meds, on “the principles of cautious prescribing, proper indications, full consideration of risks, and the value of watchful waiting and the tincture of time.”

I despair the diagnostic inflation that results from a too loose diagnostic system, aggressive drug company marketing, careless assessment, and insurance company pressure to rush to judgement. Diagnoses should be written in pencil, and under-diagnosis is almost always safer and more accurate than over-diagnosis.

With regard to the philosophy of diagnosis, he saw three approaches that he likened metaphorically to three kinds of baseball umpires. The first kind called balls and strikes as they are. The second called them as he saw them. The third said there were no balls or strikes until he called them. Frances likened Robert Spitzer, the architect of the modern DSM, to Umpire 1, along with most biological psychiatrists (See “The Quest for Psychiatric Dragons” Part 1 and Part 2 and “Where There’s Smoke …” for more on Robert Spitzer). “The credibility of this model has been destroyed as we have learned more about the unfathomable complexity of the human brain and the complete failure of genetics and neuroscience to provide useful answers about what causes psychiatric problems.” He thought most psychiatrists aspired to be like Umpire 2, doing their best to define mental disorders in useful ways without any pretention that it is the only way or that current constructs would withstand the test of time.

Dr. Frances expressed concern with the risks of over-diagnosis and advocated for a narrower system with higher diagnostic thresholds. He thought experts in each diagnostic area sought to expand their pet diagnoses and worried too much about missing patients (false negatives) rather than mislabeling patients (false positives). These experts were given a free rein in DSM-5, allowing mislabeling to dominate the field. This led to a checklist approach to diagnosis, which was not intended by the creators of the DSM.

The diagnostic exuberance of DSM 5 confuses mental disorder with the everyday sadness, anxiety, grief, disappointments, and stress responses that are an inescapable part of the human condition. DSM 5 ambitiously mislabels normal diversity and childhood immaturity as disorder, creating stigma and promoting the excess use of medications.

Frances thought if anything in DSM could be misused, it would be misused. “Data drawn from research studies on highly selected patients in the hothouse environment of a university research clinic generalize very poorly to the hustle and bustle of primary care.” On Twitter he pointed to a study he said “blows to bits any hope that statistical modeling” could eliminate the many inherent limitations of “Evidence Based Medicine.” This study, “Many Analysts, One Data Set” concluded that uncertainty in interpreting research results was not just a function of statistical power or the use of questionable research practices. It was also a function of the many reasonable decisions made by researchers as they conducted their research. This did not mean that analyzing data and drawing research conclusions from the data was subjective. Rather, it meant “that many subjective decisions are part of the research process and can affect the outcomes.”

Frances said “Evidence Based Medicine” often generalized poorly to everyday practice because: 1) patients in controlled studies aren’t like unselected patients; 2) research settings differ from real life; 3) biases influence data analyses. “EBM provides a necessary guide, but shouldn’t be worshipped.”

Returning to the interview for Conversations in Critical Psychiatry, he noted how there was an inherent financial, intellectual and emotional conflict of interest that leads every medical specialty to recommend over-diagnosis. He recommended that specialty groups like the APA, the American Psychiatric Association, should never be permitted sole power to determine the diagnostic guidelines for that specialty. Contributions from primary care, public health, health economics and consumers are important. With regard to psychiatric diagnosis, he thought the APA had a special conflict of interest because the DSMs were such a valuable publishing property. The income is crucial for meeting its budget. “This makes frequent revision too tempting and results in an unseemingly hyping of the product.”

Soon after the publication of the DSM-5 in 2013, Allen Frances published an article in World Psychiatry, “The past, present and future of psychiatric diagnosis.” He said psychiatric diagnosis is facing a serious crisis caused by diagnostic inflation. “The elastic boundaries of psychiatry have been steadily expanding, because there is no bright line separating the worried well from the mildly mentally disordered.” Drug companies have used their marketing muscle to sell psychiatric diagnoses by convincing potential patients and prescribers that life problems were really mental disorders caused by chemical imbalances and curable by pills.

We are now in the midst of several market-driven diagnostic fads: attention-deficit/hyperactivity disorder (ADHD) has tripled in rates in the past twenty years; bipolar disorder has doubled overall, with childhood diagnosis increasing forty-fold; and rates of autistic disorder have increased by more than twenty-fold. In the US, the yearly prevalence of a mental disorder is reported at 20–25%, with a 50% lifetime rate, and Europe is not far behind. A prospective study of young adults in New Zealand has reported much higher rates and another of teenagers in the US found an astounding cumulative 83% rate of mental disorders by age 21.

He said the DSM-5 was prepared without adequate consideration of clinical risk/benefit ratios and did not calculate the large economic cost of expanding the reach of psychiatry. It has been unresponsive to widespread professional, public and media opposition “based on the opinion that its changes lacked sufficient scientific support and often defied clinical common sense.” A petition endorsed by fifty mental health associations, that called for an independent review, “using methods of evidence-based medicine, was ignored.” It was time for a fresh look at diagnosis.

On the podcast The Recommended Dose with Ray Moynihan, Frances said the tendency over the last forty years has been to turn the stuff of life into mental disorder. “The best customer for a drug, is someone who is basically well.” We get advertisements for drugs as frequently as we get advertisements for cars or brands of beer. When it comes to most psychiatric problems, people get better on their own in a few weeks. “My concern is that we’re way overmedicating the problems of everyday life and that parallel to that, we are terrifically neglecting people who are really sick.”

One of the areas he gave as an example of transforming ordinary life into mental illness is with mild forms of depression, that really aren’t depression, but are being diagnosed as major depressive disorder. “The drug companies have convinced the world that major depressive disorder is one entity, and that it is always a chemical imbalance, and that it always requires a chemical solution in the form of a pill.” Eleven percent of Americans are taking an antidepressant. Grief in particular is often over diagnosed and over treated with medication. Then there is anxiety; children who have temper tantrums; and so on. “In general, we have taken every day experiences, that are part of the human condition, and we’re over diagnosing them as mental disorders, and we’re way too often providing a pill, when there’s not really a pill solution for every problem in life.”

Children have been over medicalized with Attention Deficit Disorder, which should be properly diagnosed at around 2 or 3 percent of the U.S. population. In the U.S., by the time a child is 18, they have a 15 percent chance of getting the diagnosis. “This is absolutely ridiculous. We are turning immaturity into a disease.” There are also unwarranted increases in diagnosing childhood Bipolar Disorder. And there is a terrific overuse of antipsychotics in children with behavior problems. “I think we are doing a massive, worldwide experiment on immature brains, bombarding them with very powerful chemicals, with no knowledge whatever about what the long-term outcome will be; and without informed consent.”

He thinks the DSM-5 set off on in the wrong direction. Psychiatrists were worrying about underdiagnosis, when they should have been concerned with overdiagnosis. He said we have gone overboard in the developed world in giving too much treatment to people who can afford it, while neglecting people who can’t.

Then he was asked to comment on the role of good evidence that comes from systematic reviews, from summaries of evidence. Frances said evidence is absolutely crucial in making medical decisions, even though you can’t trust all of it. It takes time to gather enough reliable evidence to be confident. “But without evidence it’s a crapshoot that will be governed by commercial, for profit elements that so determine how people are treated.

I think the biggest role for change will come from the evidence-based guidelines and from a press that is educated to advertise to the people reading the article, not just the possible miracle medical benefit, which is always exaggerated, but also the possible realistic risks of side effects.

The biggest problem for the doctor is too little time. The more time you have to get to know the patient, the less likely you’ll be inaccurate in your diagnosis. “It’s the easiest thing in the world to give a diagnosis and to write a pill prescription. It’s the hardest thing in the world, often, to get rid of a diagnosis once it’s been established. . . A wrong diagnosis made in ten minutes can haunt for life.” Medication, given casually, can do great harm and you should be as careful in taking medication as you would be for a major life decision.

Originally posted on 5/19/2020

04/5/22

The Psychedelic Pendulum and Psychiatry, Part 1

In November of 2020, Oregon became the first state to legalize the use of psilocybin in therapeutic settings. Measure 109 created a two-year time period during which regulatory details were to be worked out by the Oregon Psilocybin Advisory Board (OPAB). These details would include issues like what qualifications would be required of therapists overseeing those who chose to use psilocybin. Significantly, psilocybin treatment will not be limited to individuals struggling with mental health issues. Anyone 21 or older who passes a screening will be able to access these psychedelic services for “personal development.”

The first draft of rules recommended by the OPAB were made public in February of 2022. Manufacturers will only be permitted to cultivate one of about 200 different types of mushrooms containing psilocybin, Psilocybin cubensis. Some people were concerned with this recommendation, believing the board was also limiting potential benefits. “It is believed that different species promote different types of experiences.”

Psilocybe cubensis was chosen because it’s one of the most popular mushrooms consumed and one of the most studied. Advisory board members also thought that it would be best to start simple, with one mushroom. Other species might be introduced later.

The OPAB also recommended a ban on growing Psilocybe cubensis in wood chips. This is to prevent a rare condition known as wood lover’s paralysis that produces muscle weakness a few hours after hallucinogenic mushrooms grown in wood chips are consumed. Scientists don’t know why this condition occurs. “But it isn’t believed to happen with Psilocybe cubensis.”

The rules also prohibit the chemical synthesis of psilocybin. Measure 109 also requires the state to only license people to set up grow operations who have been Oregon residents for at least two years. Well, at least until 2025. These recommendations are attempting to allow small farmers to set up grow operations and limit the ability of large pharmaceutical companies to move in and potentially dominate the market.

There are other reasons for banning synthesized psilocybin. The synthesis requires using toxic chemicals that have to be extracted before sale so there’s no residue in the final product. Mason Marks, a member of the OPAB, said synthesizing psilocybin is a huge undertaking. “There was some sentiment that that might be maybe unrealistic or overly burdensome, at least initially to expect people to have that level of expertise or equipment in order to do that.”

Manufacturers will have to use clean, food-grade equipment in an area that can be locked. They won’t be permitted to make psilocybin products that may appeal to minors, like in the shape of cartoon characters. Psilocybin is only permitted to be used orally—not with an inhaler, a suppository or an injection. Students will have the opportunity to observe “non-ordinary states of consciousness.”

Facilitators (not therapists?) will have to take at least 120 hours of instruction, covering everything from the history of psilocybin use to safety concerns. They will have to have sufficient experience to teach classes for individuals interested in trying psilocybin. But what about ethical expectations and boundaries with clients under the influence?

Therapeutic facilitators of individuals doing psychedelic therapy from the time of its origins in the 1950s recommended two therapists, one male and one female. This was to minimize the possibility of sexual exploitation of the clients when they are under the influence of psychedelics. More about this in part 2 of the article.

These draft rules need to be discussed and adopted by the Oregon Health Authority. Other rules are still pending, such as how research with psilocybin should be conducted, and the conditions (i.e., schizophrenia) that would prohibit people from trying psilocybin treatment. There are more complicated issues that need to be decided as well. There’s a desire to permit microdosing psilocybin (taking one-tenth or one-twentieth of a normal dose), over a few days. This practice is thought to boost creativity and focus, as well as alleviate depression.

Oregon’s psilocybin system is scheduled to begin in 2023. The Oregon Health Authority will begin taking applications for licenses to manufacture, transport, deliver, sell and purchase psilocybin products on January 2, 2023.

Psychology Today has a page that introduces the reader to “Psychedelic-Assisted Therapy,” giving information on the most common psychedelic substances, their general effects and properties, as well as potential harms and proposed therapeutic uses. It also has a section on “Understanding Microdosing.” The most common psychedelic substances listed on the page were: psilocybin, LSD, ayahuasca, mescaline and MDMA. All but MDMA listed psychosis as a potential harm. Therapeutic uses being investigated include: PTSD, addiction to alcohol, tobacco and cocaine; anxiety associated with terminal illness; depression and general anxiety.

Dependence or substance misuse is not listed as a potential harm for any of the psychedelics, which do have a low risk for addiction. But the repeated therapeutic use of psychedelics increases the ritualized, long-term use of these drugs, and raises the possibility of misuse or dependence problems developing in users over time.

Information on microdosing said there was some evidence of positive effects performance and creativity, but it was mostly anecdotal. One 2018 study published in the journal Psychopharmacology, “Exploring the effect of microdosing psychedelics on creativity,” found support for its cognitive enhancing properties, but fluid intelligence was unaffected. The researchers concluded that while large doses of psychedelics can introduce several undesirable side effects, microdoses might be an alternative that could eliminate the risks of these side effects, while maintaining the benefits on emotion and thinking.

A 2016 study by Roland Griffiths et al, also published in the journal Psychopharmacology, found that when a high dose of psilocybin was administered to patients with a life-threatening cancer diagnosis under supportive conditions, there were “substantial and enduring” decreases in depressed mood and anxiety. It also resulted in increases in measures of quality of life, life meaning, the acceptance of death, and optimism. The effects were sustained for six months.

There has been a veritable flood of articles and research on the supposed benefits of psychedelics, particularly psilocybin and MDMA, over the last several years besides these two Psychopharmacology studies. In 2019, the FDA designated psilocybin therapy as a breakthrough therapy for Usona Institute, the second pharmaceutical company to gain such an approval in that year. The first company, Compass Pathways, is looking at how psilocybin may help with treatment-resistant depression, that is patients who have not improved after trying two different antidepressants. The significance of the second FDA breakthrough approval is related to how it expands the potential market from the relatively small population of individuals struggling with treatment resistant depression to the estimated 17 million with major depressive disorder, according to a statement by Usona:

This is a significant milestone for the over 17 million people in the US who suffer from MDD. Although there are several existing MDD treatments, Breakthrough Therapy Designation recognizes that psilocybin may offer a clinically significant improvement over these therapies. Psilocybin potentially offers a novel paradigm in which a short-acting compound imparts profound alterations in consciousness and could enable long-term remission of depressive symptoms.

Dr. Samoon Ahmad provided a helpful description of how psilocybin affects the brain in a Psychology Today article, “Understanding the Buzz About Magic Mushrooms.” He said psilocin, not psilocybin, seems to be the substance responsible for the psychoactive effects of “magic mushrooms.” Psilocybin and other psychedelics like LSD and mescaline activate the 5-HT1A and 5-HT2A receptors in the prefrontal cortex, which in turn has downstream effects on serotonin and dopamine. “The increase in dopamine is believed to be part of the reason for some of the psilocybin’s effects on mood, such as euphoria, and the commonly reported phenomenon of depersonalization.”

He said the probability of serious adverse events and abuse of psilocybin was low when compared to other classes of abused drugs. The association of the lifetime use of psychedelics and an increased likelihood of mental illness or suicidality “simply does not exist,” according to Ahmad. By associating “lifetime use of psychedelics” and an “increased likelihood of mental illness or suicidality,” Ahmad’s sidesteps how psychedelics can be destabilizing for some individuals who have a past history of psychotic disorders like schizophrenia. See Part 2 for more information on concerns with psychedelic psychotherapy.

Psilocybin can also produce side effects like hypertension, nausea, vomiting, anxiety, confusion and more. Ahmad also pointed out the importance of “set and setting,” the individual’s mindset and their environment.

A positive experience may inspire life-changing epiphanies and grant individuals a greater perspective on life. A negative experience may result in disturbing thoughts or hallucinations, which may lead to anxiety, disorientation, delirium, and, in extreme circumstances, temporary psychosis. Researchers have found that they can significantly diminish the likelihood of negative experiences by providing patients with more preparation and interpersonal support during the period of drug action.

There is still a risk if the interpersonal support is inadequate or inappropriate—not respecting clear, therapeutic boundaries between the support person and the client. And the preparation may not get the person ready for the actual psychedelic experience. Careful attention to the “set and setting,” the inner and outer environments of the drug event, is crucial for a positive experience.

Ahmad said research has shown that psychedelics hold a great deal of promise, “as long as they are administered in a controlled and clinical environment or under the guidance of individuals who are experienced in the use of psychedelics.” But stigma surrounds the use and research into these drugs. His hope is that there will be a loosening of restrictions and regulations in the U.S. as there is more research published, “and the case for the use of psychedelics becomes stronger.”

Dr. Ahmad and researchers like Roland Griffiths (see this Google scholar link for “Roland Griffths psilocybin”) are representative of those who see the potential for psychedelic therapy, particularly with psilocybin. Rick Doblin and his organization MAPS (Multidisciplinary Association for Psychedelic Studies) are attempting to bring MDMA to market as a treatment for PTSD see this Google scholar link for “Rick Doblin MDMA”). British researchers including Robin Carhart-Harris and David Nutt want to treat depression with psilocybin. Michael Pollan, author of a best-selling book on psychedelics, How to Change Your Mind, thought there has been a sea change in attitudes towards psychedelics. In “The Psychedelic Revolution Is Coming,” he said, “Given the mental health crisis in this country, there’s great curiosity and hope about psychedelics and a recognition that we need new therapeutic tools.”

But what are the risks in turning to psychedelics like psilocybin and MDMA as the next great hope in psychiatric drug treatment? As Andrew Jacobs noted in his NYT article, “The Psychedelic Revolution Is Coming,”

The question for many is how far — and how fast — the pendulum should swing. Even researchers who champion psychedelic-assisted therapy say the drive to commercialize the drugs, combined with a growing movement to liberalize existing prohibitions, could prove risky, especially for those with severe psychiatric disorders, and derail the field’s slow, methodical return to mainstream acceptance.

We’ll look at some of the concerns others see with the growing move towards psychedelics as the newest fad in the pursuit of therapeutic tools in Part 2 of this article. For more information on psychedelics as therapy, see the following articles on this website: “Psychedelics Are Not a Magic Bullet,” “The Long, Strange Trip of Psychedelic Psychiatry,” “Give MDMA a Chance?,” and “Psychedelic Renaissance?”

03/1/22

Withdrawal or Relapse When Tapering Antidepressants?

The number of antidepressant prescriptions written in primary care has continued to increase, and patients are remaining on them for longer durations of time. Yet research into maintaining or discontinuing antidepressants (ADs) in this setting has been almost nonexistent. “Maintenance or Discontinuation of Antidepressants in Primary Care,” published in September of 2021 in The New England Medical Journal, examined the relapse rates of primary care patients who expressed a desire to discontinue their antidepressant. The researchers, G. Lewis and L. Marston et al, found that patients who chose to discontinue their antidepressant therapy had a higher risk of relapse than those who maintained their current medication. However, others believed the results were misleading, because the authors misinterpreted withdrawal effects as relapse.

Lewis, Marston et al found that patients assigned to discontinue their antidepressant medication had a higher frequency of depression relapse than those who maintained their medication through the 52 weeks of follow-up done by the study. Eligible patients were between 18 and 74, and had reported at least two prior episodes of depression. All patients had been receiving and adhering to their daily regimens and had been taking their ADs for more than two years. The main exclusion criterion for the study was current depression. They investigated three SSRIs, fluoxetine (Prozac), citalopram (Celexa) and sertraline (Zoloft), which have similar pharmacologic profiles and similar mechanisms of activity, and mirtazapine (Remeron).

Relapse occurred in 39% of the patients in the maintenance group, while 56% of the patients in the discontinuation group relapsed. Quality-of-life measures and symptoms of depression, anxiety, and medication withdrawal were generally worse in patients who discontinued their ADs. “By the end of the trial, 39% of the patients in the discontinuation group had returned to taking an antidepressant prescribed by their clinician.” See the figures below.

In a critique published in The BMJ of Lewis, Marston et al, Mark Horowitz, Joanna Moncrieff and Beth Parkin said their conclusion that continuing antidepressants reduced the chance of relapse was not warranted. “Because the authors neglected to account for the possibility of antidepressant withdrawal effects being mis-classified as relapse, a fundamental problem in discontinuation trials.” Although the antidepressants were discontinued more slowly than in previous studies, the 8 weeks of discontinuation was still a relatively short taper for patients who had been taking the drugs for more than 2 years. While the approach was consistent with recommendations at the time of the trial (half the dose for one month, then half the dose every second day for one month, before stopping), they are no longer in line with the current guidance from the Royal College of Psychiatrists on Stopping antidepressants.

Antidepressant withdrawal symptoms overlap with most domains of the depression scale used to detect relapse in the study. There was also a high correlation between mean differences on the withdrawal scale and means differences on the depression scale and anxiety scale. “Together, with the overlap of withdrawal symptoms with measures of mood and relapse, this suggests that the withdrawal symptoms may account for the increase in symptom scores and relapse rate.” The reverse would be unlikely, since withdrawal symptoms included physical symptoms that were not intrinsically related to depression—dizziness, electric shocks, and headache. “Occam’s razor would suggest one condition causes several symptoms rather than requiring several conditions.”

Confounding withdrawal with relapse is consistent with the finding that most relapses occurred when withdrawal effects were at their peak, “within 6-12 weeks of when the drugs were stopped (at week 8).” Ninety percent of the total difference in relapse rates between the two arms of the study were present 12 weeks after the drugs were stopped, although this accounts for only 27% of the total follow-up time. Additionally, patients stopping fluoxetine had fewer withdrawal effects than other antidepressants, likely because of its longer elimination half-life. These patients relapsed 25% less than people stopping citalopram and sertraline, “again suggesting withdrawal effects.”

Anxiety and depression scores were the same for both groups at the end of the study. While 44% of the discontinued group had returned to their medication by this time, there was no difference in symptom scores—even with twice as many people on antidepressants in the maintenance group. “This suggests that discontinuation of antidepressants did not worsen mood after the period in which withdrawal symptoms had settled.” There were only small differences in DESS scores (Discontinuation-Emergent Signs and Symptoms) by the end of the 52 week study. Lastly, 71% of the patients in the discontinuation group correctly guessed their allocation to placebo; possibly because of experiencing withdrawal symptoms and then expecting they would get worse.

As there was no effort made to manage the potential confounding of relapse by withdrawal the current study suffers the same flaws as previous discontinuation studies and cannot provide evidence of the benefits of long-term treatment, only the difficulties of stopping it. The authors could resolve some of these concerns by analysing the correlation of withdrawal symptoms with mood scores and relapse amongst individual patients to verify if withdrawal symptoms might account for relapse. They could also re-analyse their data by excluding patients who experienced significant withdrawal symptoms (e.g. modified DESS ≥ 2) from qualifying for a diagnosis of relapse. This would provide a more robust measure of relapse, reducing the potential for the misclassification of relapse as withdrawal. They could also test whether unblinding was associated with relapse.Uncritical interpretation of this study may lead to the erroneous conclusion that antidepressants should be continued to prevent relapse, when in reality all they may be doing is preventing withdrawal symptoms. The more accurate conclusion would be that such symptoms are temporary withdrawal symptoms that can be minimised by stopping the drug more gradually, as recognised by the authors in media interviews, although not in the published paper.

Additional responses in The BMJ supported these points. Bryan Shapiro said, “Dr. Horowitz offers a valid critique of this discontinuation trial—that is, the confounding of illness relapse with antidepressant withdrawal symptoms.” Gary Singh Marlowe said, “For many patients who have been on anti-depressants for more than a few years a 2-month tapering period is insufficient.” Singh Marlowe said practitioners like him have “become increasingly aware that many of the symptoms these patients experience on stopping their anti-depressants are due to the drug withdrawal itself rather than a return of the ‘illness.’” See “Withdrawal Symptoms Cloud Findings of Antidepressant ‘Relapse’ Trial” by Peter Simon on the Mad in America website for more discussion of the Horowitz, Moncrieff and Parkin critique.

Concern that antidepressant withdrawal symptoms are being confounded with relapse symptoms of depression are not just coming from Mad in America and Horowitz, Moncrieff and Parkin. The Mental Elf reported on a systematic review done by the Cochrane Common Mental Health Disorders group on studies where antidepressants were taken for 6 months or more and then discontinued. Relapse rather than discontinuation was the primary outcome for 31 of 33 studies. Only one study reported data on withdrawal symptoms.

All included trials were at high risk of bias. The main limitation of the review is bias due to confounding withdrawal symptoms with symptoms of relapse of depression. Withdrawal symptoms (such as low mood, dizziness) may have an effect on almost every outcome including adverse events, quality of life, social functioning, and severity of illness.

Because of this flaw, the Cochrane group was not able to conclude whether any of the discontinuation strategies were safe and effective, also noting none of them employed tapering protocols beyond a few weeks. The Cochrane authors also doubted the validity of the evidence base for antidepressant continuation, as it depended “on the same and similar studies thoroughly confounded by withdrawal, which is probably mistaken for relapse.”

Consequently, it is unclear to what degree misclassified withdrawal symptoms contributed to “relapse” rates. Research suggests this could pertain to most relapses (El-Mallakh 2012; Greenhouse 1991; Hengartner 2020; Recalt 2019; Rosenbaum 1988). Moreover, withdrawal symptoms may have an effect on almost every outcome including adverse events, quality of life, social functioning, severity of illness, and anxiety and depression scores. For example, low mood and other withdrawal symptoms may register on the Hamilton Rating Scale for Depression (HAM-D) – the prioritised measure for depressive symptoms – and may result in people falsely allocated to having “severe” depressive symptoms.

Based on the review, the Cochrane review authors advised clinicians that:

Because of confounds, the evidence is unreliable for either discontinuation approach or risk of relapse after discontinuation.
It is unclear how long antidepressant treatment has to be maintained after remission. Current guidelines are based on consensus rather than evidence.
Evidence is lacking for appropriate discontinuation approaches for those who do not have “recurrent” depression, the elderly, and those taking antidepressants for anxiety.
The effect of short tapering regimens (≤ 4 weeks) was similar to abrupt discontinuation. Clinicians should expect to taper much slower, perhaps using liquid drug forms or tapering strips, while closely monitoring for withdrawal symptoms.
To taper effectively, clinicians will need to recognise withdrawal symptoms. Withdrawal symptoms differ from relapse or recurrence in timing of onset (within days rather than weeks), a rapid reversal after reintroduction of the antidepressant, and the emergence of somatic and psychological symptoms different from the original illness (e.g. shock-like sensations, dizziness, pronounced insomnia). Utilising the Discontinuation-Emergent Signs and Symptoms (DESS) Scale (PDF) may be helpful in monitoring reductions in dosage. When the patient’s DESS score returns to baseline after a reduction, further reduction is appropriate.
Mark Horowitz, who is a researcher and psychiatrist, was quoted in an article discussing the Cochrane review on Mad in America. He said:

For me, this is such a critical issue both from a personal and a professional perspective. I’m one of the hundreds of thousands of people who have had or are having long, difficult, and harrowing battles coming off long-term depressants because of the severity of the withdrawal effects. And yet, rather than being able to find or access any high-quality evidence or clinical guidance in this situation, I could only find useful information on peer support sites where people who had gone through withdrawal from antidepressants themselves have been forced to become lay experts. Since then, the Royal College of Psychiatrists has taken a great step forward in putting out guidance on Stopping Antidepressants in 2020. However, there is still a lack of research and, therefore, evidence in this area on what works for different people. I want other people to have the evidence base to come off without the same trouble I had.

American psychiatry has fallen behind Britain in protecting its citizens from the potential for iatrogenic harm of antidepressants. In May of 2018, the All-Party Parliamentary Group for Prescribed Drug Dependence published “Antidepressant Dependency and Withdrawal.” At the bottom of the first page is a disclaimer that says this is not an official publication of the House of Commons or the House of Lords. Yet it seems to have influenced the Royal College of Psychiatrists to make public the above linked information for anyone who wants to know more about “Stopping Antidepressants in 2020.”

The Executive Summary of “Antidepressant Dependency Withdrawal” said it was incorrect to view antidepressant withdrawal as largely mild, self-limiting (typically resolving between 1-2 weeks) and of short duration. Available research showed that antidepressant withdrawal reactions are widespread, with incidence rates ranging from 27% to 86%. Nearly half of those experiencing withdrawal described it as severe. Approximately 25% of antidepressant users experienced withdrawal reactions for at least 3 months after cessation; many experienced AD withdrawal for longer than 6 months.

Antidepressants fulfill the criteria for dependency-forming medications within the DSM, the ICD, and the WHO’s definition of dependency. “It is more reasonable to classify antidepressants as potentially dependency-forming medications than not.” Not only do they cause withdrawal in a large proportion of users, there is evidence antidepressants generate tolerance in up to 25% of users. About a third of antidepressant users report being “addicted”, according to their own understanding of the concept.

“The escalation of long-term antidepressant use combined with the misdiagnosis of withdrawal reactions warrants serious concern.” The length of AD use has doubled over the past decade, fueling a rise in prescriptions for the drugs. The evidence suggests this lengthening duration may be partly rooted in “the underestimation of the incidence, severity and duration of AD withdrawal reactions.” This underestimation may have led to many withdrawal reactions being misdiagnosed as relapse or as failure to respond to treatment with AD medications.

There is one final observation to make about the Lewis, Marston et al study. “Maintenance or Discontinuation of Antidepressants in Primary Care,” was of 150 general practices in the United Kingdom, and yet it was published in the prestigious American journal, The New England Journal of Medicine. I wonder if the researchers were attempting to reach a more receptive and less critical audience than if they had published in a prestigious British journal like The BMJ, which did publish the critique of Horowitz, Moncrieff and Parkin.

12/7/21

Misrepresentation in Biological Psychiatry

An intriguing article, “Medicine and the Mind,” by psychiatrists Caleb Gardner and Arthur Kleinman was published in The New England Medical Journal in October of 2019. They said that something has gone wrong with academic and clinical psychiatry. “Checklist-style amalgamations of symptoms have taken the place of thoughtful diagnosis, and trial-and-error ‘medication management’ has taken over practice to an alarming degree.” While facing less and less time to work with patients, they thought psychiatry was facing the “stark limitations” of biologic treatments.

While these limitations are widely recognized by experts in the field, the dominant message to the public—and the rest of medicine—continues to be that the solution to psychological problems means making the correct diagnosis and then matching it with the right medication. As a result, psychiatric diagnoses and medications flourish in the name of scientific medicine. Yet, “there is no comprehensive biologic understanding of either the causes or the treatments of psychiatric disorders.”

Psychiatry is plagued with three things, according to Gardner and Kleinman. First is the over-prescription of medications for a large segment of the population. Second, there has been the abandonment and incarceration of individuals with chronic, severe mental illness. Third, diagnostic systems have become increasingly unwieldy with their overlapping checklists of symptoms.

The problem is not simply one of scientific and intellectual integrity. This state of affairs influences training and reimbursement and does a great disservice to patients, practicing psychiatrists, and our medical colleagues who are striving to provide the best and most humane care to people with medically and psychologically complicated conditions.

Psychiatry should be uniquely positioned to help through example, scholarship and consultation. “Yet the field seems to have largely abandoned its social, interpersonal, and psychodynamic foundations, with little to show for these sacrifices.” Science historian Anne Harrington proposed that psychiatry limit its scope to only severe, mostly psychotic disorders. In her 2019 book, Mind Fixers, she said, “Today one is hard-pressed to find anyone knowledgeable who believes that the so-called biological revolution of the 1980s made good on most or even any of its therapeutic and scientific promises.”

We believe that a fundamental rethinking of psychiatric knowledge creation and training is in order. If only the highest-quality biologic research were supported, substantial funding could be redirected to psychosocial, cultural, public health, and community studies that directly support the work of practicing psychiatrists responding to the needs of patients, families, and communities. The most pressing work is research on addiction, elder care, community care programs, consultation aimed at improving the quality of care in medical clinics and hospitals, child and adolescent psychiatry, and global mental health, as well as cultural studies of vulnerable populations.

Misrepresenting the Truth

In “Messaging in Biological Psychiatry” for the Harvard Review of Psychiatry, researchers Estelle Dumas-Mallet and Francois Gonon noted the article by Gardner and Kleiman was the first time that psychiatrists acknowledged in a prestigious biomedical journal that they have been misrepresenting the truth of biological psychiatry to their non-psychiatric peers in medicine and to laypeople. Dumas-Mallet and Gonon believe that most psychiatrists do not intentionally deceive patients or the public. They are not aware they contribute to the doublespeak or recognize how they passively accept it. “Therefore, in the absence of convincing evidence supported by observational studies, they might miss Gardner and Kleinman’s important message.”

In their article, Dumas-Mallet and Gonon sought to review the academic literature that described the misrepresentation of biological psychiatry, what its sources were, how it is diffused through mass media, and what the social consequences have been. As documented in several academic studies, there is often a huge gap between the observations reported in biomedical publications and their presentation in mass media. Focusing on psychiatry, they described the misrepresentations of the scientific observations in the biomedical literature that were spread through the media. They reviewed academic works that examined how mass media covered biomedical research. Lastly, they discussed the possible reasons why journalists, scientists, and scientific institutions “contribute to the misrepresentation of biological psychiatry.”

The percentage of scientific articles that confirmed researchers’ initial hypotheses increased from 70% in 1990 to 86% in 2007. Dumas-Mallet and Gonon thought the preferential publication of positive biomedical findings could be the result of two tendencies. First, researchers could choose to not publish their negative results. Second, journal editors have increasingly rejected articles reporting negative findings. These tendencies can be illustrated by looking at how clinical trials reporting a beneficial effect to the FDA are more often published than those reporting no effect.

Among a total of 74 randomized, controlled trials of antidepressants registered with the FDA, 37 of the 38 trials reporting a positive effect were published in peer-reviewed journals. By contrast, among the 36 trials judged as negative by the FDA, 22 had not been published, 11 were published but reported positive outcomes, and only 3 trials published results in agreement with the FDA’s judgments.

Many articles reporting a correlational relationship between a pathology and a risk factor improperly suggested it to be causative. When this wrong interpretation is reported in press releases of the research, it is likely to appear in media reports covering the study. They gave an example with a brain-imaging study that said a link between brain abnormalities and ADHD confirmed that ADHD was a brain disorder. The authors themselves acknowledged that “structural changes in certain brain areas are not necessarily the cause of mental disorders.” A large international study suggested the modest atrophy of the hippocampus could be the result of chronic depression rather than the cause.

Since positive findings are preferentially published in biomedical journals, the first study on a new subject often reports a larger effect size than subsequent studies. Dumas-Mallet and Gonon conducted a large comparative study of initial studies. They found that an average of one in two initial studies was either contradicted or significantly weakened by the corresponding meta-analysis. They observed how the public was seldom informed of research that disproved initial studies. In a second illustration, they said “only 4 of 50 newspapers covering a story on genetic susceptibility to depression also reported a later meta-analysis that disconfirmed its results.”

This example illustrates a general observation: newspapers strongly favor studies published by prestigious scientific journals, even though the initial studies that they publish are as often disconfirmed by subsequent studies, as are the initial studies published by journals with lower impact factors. Newspapers preferentially cover these initial studies because these prestigious journals also produce press releases highlighting the studies they publish. Indeed, these press releases are the direct source of more than 80% of the press articles reporting biomedical findings.Moreover, most newspaper articles are very closely inspired by these press releases and take up their biases and exaggerations without criticism. Finally, newspapers further accentuate publication biases by almost exclusively covering studies reporting a positive effect.

Misrepresenting the results of biological psychiatry to the public reinforces the view that mental disorders are biomedical diseases. The percentage of Americans who believe that schizophrenia and depression are genetic brain diseases increased from 61% in 1996 to 71% in 2006. Patients that hold this view are more pessimistic about their recovery and focus their hopes on psychotropic medications. While it needs further investigation, some studies show that patients with less endorsement of biogenetic beliefs about depression appear more likely to recover, while other studies find no relationship.

Possible Causes

A scientist’s career primarily depends on the number and quality of their publications. Getting a study published in a prestigious journal ensures the author a lasting reputation, and increases the likelihood their grant applications will be funded. In order to gain publication in a prestigious journal like The Lancet or The New England Medical Journal, researchers may be tempted to exaggerate the interest of their work. On the publication side, editors of prestigious journals will select the most exciting results likely to interest a large audience. “In fact, mass media preferentially cover studies published by prestigious journals because they believe them to be the most reliable, although many of them are disconfirmed by subsequent studies.”

Scientific institutions favor researchers who publish in prestigious journals. They also encourage researchers to communicate with journalists and the public. Institutions have also strengthened their press services and are flooding national journalists with press releases. National newspapers also seem to preferentially cover biomedical publications whose authors are working in that nation. Since research is mainly funded on project-based proposals, researchers are encouraged to over-promise in their grant applications, and then to embellish their results in order to continue receiving grants.

Journalists may unwittingly worsen the distortions already present in the biomedical literature. Biomedical observations in scientific publications are frequently altered by different forms of distortion, including: partially falsified results, data spin or embellishment, improper interpretation, exaggerated conclusions. Press releases by biomedical journals and scientific institutions often aggravate these distortions. While journalists are not the main source of these distortions, they boost their distribution by preferentially covering initial studies and those reporting positive results. “Consequently, the journalistic ideal of independent and objective investigation of the facts seems to apply poorly to the media coverage of biomedical findings.”

All these observations illustrate why mass media almost never informs the public when a study they covered is contradicted by subsequent studies. To illustrate this, Dumas-Mallet and Gonon pointed to Caspi et al, “Influence of Life Stress on Depression,” where the authors suggested there was a genetic susceptibility to depression. This was covered by 50 newspapers during the week after its publication. Yet when later studies contradicted Caspi et al, there was essentially no media attention. “Only four newspapers covered the meta-analysis published in 2009.” They concluded that the psychosocial understanding of mental disorders was at least as important as the biological one to guide mental health professionals.

Dumas-Mallet and Ganon told Mad in America they were motivated to write their article because they were seeing signals that academic psychiatry was prepared to reflect on these misrepresentations and change course (See “If Not Psychiatry, What Then?”). They affirmed there is a doublespeak done with biological psychiatry that negatively effects patient care. The publication of the Gardner and Kleinman article prompted them to write theirs. “For the first time in a prestigious medical journal, the doublespeak of psychiatry was acknowledged.” The Mad in America author, Emaline Friedman, said:

The existing literature makes a compelling case that a psycho-social understanding of mental disorders is at least as important as a neuro-biological understanding. Such a shift in the dominant narrative has the potential to influence mental health treatments as well as the mental health literacy of the public, which impacts how mental health patients are treated by those around them.

11/16/21

If Not Psychiatry, What Then?

In June of 2021, the World Health Organization published a document, “Guidance on Community Mental Health Services.” The WHO document is seeking to provide quality care and support for person-centered, human rights-based and recovery-oriented mental health care and services worldwide. In a video launch of the event, Sir Norman Lamb said: “Our collective aim must be to end coercive practices, including seclusion and restraint, forced admission and treatment. And we must combat violence, abuse and neglect. This is an urgent imperative for all countries. It’s a global human rights priority.”

Reports from around the world highlight the need to address discrimination and promote human rights in mental health care settings. This includes eliminating the use of coercive practices such as forced admission and forced treatment, as well as manual, physical or chemical restraint and seclusion and tackling the power imbalances that exist between health staff and people using the services. Sector-wide solutions are required not only in low-income countries, but also in middle- and high-income countries.

The Executive Summary of the WHO report said global mental health services often face substantial restriction of resources, and operated with outdated legal and regulatory frameworks. There was an overreliance on the biomedical model, where the predominant focus of care was on diagnosis, medication and symptom reduction. Overlooked were the social determinants that impact people’s mental health, hindering progress towards a fuller realization of a human rights-based approach. “As a result, many people with mental health conditions and psychosocial disabilities worldwide are subject to violations of their human rights – including in care services where adequate care and support are lacking.” Key messages of the Guidance said:

According to the WHO Mental Health Atlas 2017, the global median government expenditure on mental health is less than 2% of total government health expenditure. In order to develop quality mental health systems with enough human resources to provide the services and provide adequate support of people’s needs, allocating adequate financial resources is essential. But the problems with mental health provision cannot be dealt with by simply increasing resources. “In fact, in many services across the world, current forms of mental health provision are considered to be part of the problem.”

The majority of existing funding is invested in the renovation and expansion of residential psychiatric and social care institutions. This represents over 80% of total government expenditure on mental health for low- and middle-income countries. “Mental health systems based on psychiatric and social care institutions are often associated with social exclusion and a wide range of human rights violations.” While some countries have taken steps towards closing psychiatric and social institutions, this action has not automatically led to dramatic improvements in care. The history of closing psychiatric hospitals in the U.S. illustrates this point.

The predominant focus of care in many contexts continues to be on diagnosis, medication and symptom reduction. Critical social determinants that impact on people’s mental health such as violence, discrimination, poverty, exclusion, isolation, job insecurity or unemployment, lack of access to housing, social safety nets, and health services, are often overlooked or excluded from mental health concepts and practice. This leads to an over-diagnosis of human distress and over-reliance on psychotropic drugs to the detriment of psychosocial interventions – a phenomenon which has been well documented, particularly in high-income countries. It also creates a situation where a person’s mental health is predominantly addressed within health systems, without sufficient interface with the necessary social services and structures to address the abovementioned determinants. As such, this approach therefore is limited in its consideration of a person in the context of their entire life and experiences. In addition, the stigmatizing attitudes and mindsets that exist among the general population, policy makers and others concerning people with psychosocial disabilities and mental health conditions – for example, that they are at risk of harming themselves or others, or that they need medical treatment to keep them safe – also leads to an over-emphasis on biomedical treatment options and a general acceptance of coercive practices such as involuntary admission and treatment or seclusion and restraint.

Reports from countries in all income brackets around the world highlight extensive and wide-ranging human rights violations that exist in mental health care settings. These violations include the use of coercive practices such as forced admission and forced treatment (as with Britney Spears), as well as manual, physical and chemical restraint and seclusion. In many services, people are exposed to poor, inhuman living conditions, neglect, and in some cases, physical emotional and sexual abuse. People with mental health conditions are also excluded from community life and discriminated against in employment, education, housing and social welfare. These violations further marginalize them from society, “denying them the opportunity to live and be included in their own communities on an equal basis with everyone else.”

A fundamental shift within the mental health field is required, in order to end this current situation. This means rethinking policies, laws, systems, services and practices across the different sectors which negatively affect people with mental health conditions and psychosocial disabilities, ensuring that human rights underpin all actions in the field of mental health. In the mental health service context specifically, this means a move towards more balanced, person-centred, holistic, and recovery-oriented practices that consider people in the context of their whole lives, respecting their will and preferences in treatment, implementing alternatives to coercion, and promoting people’s right to participation and community inclusion.

The End of Psychiatry as We Know it?

In Western society, this means challenging the biologically centered, medical model approach to psychiatry. Writing for Psychology Today, John Read noted how global critics of an overly biological approach to understanding and helping distressed people is often dismissed as radical or extremist. Critics of the dominant medical model approach, promoted by the drug companies and biological psychiatry, are often labeled as “anti-psychiatry.” However, Read replied, “We, however, view ourselves as anti-bad and anti-ineffective, unsafe treatments.” He then quoted Steven Sharfstein, then president of the American Psychiatric Association, who said in 2005:

If we are seen as mere pill pushers and employees of the pharmaceutical industry, our credibility as a profession is compromised. As we address these Big Pharma issues, we must examine the fact that as a profession, we have allowed the bio-psycho-social model to become the bio-bio-bio model.

Read also cited Robert Whitaker, who thought the WHO report was a landmark event. There is a global rethinking of how to treat and think about mental health. Whitaker said, “Model programs highlighted in this WHO publication, most of which are of fairly recent origin, tell of real-world initiatives that are springing up everywhere.” Read said it will be become harder for defenders of the medical model to dismiss organizations like the UN or the WHO as extremist, anti-psychiatry radicals. This can be illustrated by looking at how Psychiatric Times launched “Conversations in Critical Psychiatry,” a series of articles and conversations with prominent individuals who are critical of various aspects of psychiatry.

Dr. Awais Aftab, who is a psychiatrist, not only interviews other psychiatrists such as Dr. Ronald Pies, Dr. Giovanni Fava and Dr. Allen Frances, he also talks with individuals from the critical, so-called anti-psychiatry side of the debate, namely Dr. Joanna Moncrieff, Lucy Johnstone and Dr. Sami Timmi. His first interview in 2019 was with Dr. Frances, the Chair of the DSM-IV Task Force and a vocal critic of the DSM-5, over diagnosis and the state of mental health treatment in the U.S. Follow Drs. Frances and Aftab on Twitter to see what they have to say about the current state of psychiatry. One of the concerns for Dr. Fava has been how the psychiatric establishment uses the term “discontinuation syndrome” to describe “antidepressant withdrawal.” In “The Impoverishment of Psychiatric Knowledge,” he said:

If you teach a psychiatric resident that symptoms that occur during tapering cannot be due to withdrawal, he/she is likely to interpret them as signs of relapse and to go back to treatment (exactly what “Big Pharma” likes). In the UK, the NICE guidelines are changing to reflect the potentially malignant outcome with SSRI and SNRI discontinuation. I do not see anything similar happening in the US.

One of the staunchest defenders against so called anti-psychiatry has been Dr. Ronald Pies, professor emeritus of psychiatry, SUNY Upstate Medical University; and Editor in Chief emeritus of Psychiatric Times. Among the many articles Dr. Pies has written over the years defending establishment psychiatry and psychiatric practice are these on Psychiatric Times from the past year: “What Kind of Science is Psychiatry?”, “Do Psychiatrists Treat Diseases?,” and “Why Thomas Szasz Did Not Write The Myth of the Migraine.” He also wrote “Is Depression a Disease?”, about a report from the British Psychological Society whose central argument was that depression is best thought of as an experience rather than a disease; and “Poor DSM-5—So Misunderstood!”, which challenges the claim that the DSM-5 “offers a biomedical framing of people’s experiences and distress and impairment.”

In “The Battle for the Soul of Psychiatry,” Dr. Aftab and Dr. Pies talked about various issues he’s faced over his career. Dr. Pies agreed with Dr. Aftab that they could have done a better job of counteracting “the so-called ‘chemical imbalance’ trope.” Pies wished he had tackled that issue earlier than 2011. He acknowledged the field of psychiatry took a “fairly sharp turn” toward the biological from roughly 1978 to 1998, “which, to a considerable degree, persists to this day.” Dr. Pies thought the movement toward the biological/biochemical was heavily influenced by the pharmaceutical industry.

His hope for the future of psychiatry was to recover its pluralistic core. He said his department at SUNY Upstate Medical University emphasized the integration of psychopharmacology and psychotherapy, and explicitly endorsed “the biopsychosocial approach.” He supported constructive critics of psychiatry, whose aim was to improve the profession’s concepts, methods, ethics, and treatments. He rejected the “anti-psychiatry” critics, saying their rhetoric was clearly aimed at discrediting psychiatry as a medical discipline. This last charge by Pies seems to be true to a degree.

In their book, Psychiatry Under the Influence, Robert Whitaker and Lisa Cosgrove (two of the anti-psychiatry critics) said the time was ripe for a paradigm shift. Many Americans are seeking alternatives to psychiatry’s medication-centered care. Disagreeing with Dr. Pies, they believed psychiatry was facing a legitimacy crisis from a scientific standpoint. Second generation psychiatric drugs are no better than the first, belying the claim psychiatry is progressing in its somatic treatment of psychiatric diseases. “The disease model paradigm embraced by psychiatry in 1980 has clearly failed, which presents society with a challenge: what should we do instead?”

02/25/20

Rethinking and Transforming Psychiatry

“We believe that a fundamental rethinking of psychiatric knowledge creation and training is in order.” This statement was made in a commentary published in the New England Medical Journal, “Medicine and the Mind—The Consequences of Psychiatry’s Identity Crisis.” The authors are two prominent Harvard researchers in psychiatry, Caleb Gardner and Arthur Kleinman, so their words cannot be dismissed as ‘anti-psychiatry.’ They went on to say biologic psychiatry has so far failed to produce a comprehensive theoretical model for any major psychiatric disorder. However, they think it would be “too great a loss,” to diminish its role drastically as suggested by Anne Harrington. Rather than contracting to an exclusive focus on biologic structure, “the field needs to expand if we are to meet the needs of real people.”

I have mixed feelings about their proposal. Their critique of biological psychiatry, the acknowledgment of over prescribing psychiatric medication, the abandonment of its social, interpersonal, and psychodynamic foundations are concerns I share. But they balked at Anne Harrington’s proposal in Mind Fixers to limit its scope to severe, mostly psychotic disorders. She said there is hardly any knowledgeable person who believes the so-called biological revolution of the 1980s made good on its therapeutic and scientific promises. “It is now increasingly clear to the general public that it overreached, overpromised, overdiagnosed, overmedicated, and compromised its principles.” If psychiatry needed to be rebuilt, as the authors said, won’t there have to be some dismantling first? Otherwise, there is a danger of building on an unstable, unreliable foundation.

Harrington pointed to how in 2013, just before the publication of the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5), Thomas Insel, who was then the director of NIMH, said the agency was re-orienting its research away from DSM categories; that is was critical to realize that “we cannot succeed if we use DSM categories as the ‘gold standard’” for diagnosis. He said it was like using the nature of chest pain or the quality of a fever to create a diagnostic system. Harrington said, “Put another way, there seemed to be little if any sound biology undergirding the psychiatric enterprise.”

In Psychology Today, Jonathan Shedler wrote, “A Psychiatric Diagnosis Is Not a Disease.” He said there was a circular logic to psychiatric diagnosis. “How do we know a patient has depression? Because they have the symptoms. Why are they having symptoms? Because they have depression.” He elaborated that psychiatric diagnoses were categorically different from medical diagnoses like atherosclerosis, myocarditis, or pneumonia, because they are descriptive rather than explanatory. “Medical diagnoses point to etiology—underlying biological causes.”

In an addendum, Shedler said he appreciated the lively discussion his article inspired. He was surprised by some of the comments, from individuals he assumed to be psychiatrists, who had impugned his credentials to discuss psychiatric diagnosis. But he took comfort in knowing that Allen Frances, MD, Chair of the DSM-IV Task Force, had the same view. Frances also said mental disorders were not diseases, but constructs. They were descriptive, rather than explanatory.

There was a study published in Psychiatry Research, “Heterogeneity in Psychiatric Diagnostic Classification,” that examined the heterogeneous nature of categories within the DSM-5, and its consequences for clinicians, clients and the diagnostic model itself. Heterogeneity was found in specific diagnostic criteria, including symptom comparators, duration of difficulties, indicators of severity, and the perspective used to assess difficulties. Each of the three researchers called for dismantling, not expanding DSM diagnosis.

The lead researcher of the study, Kate Allsopp, said for Medical Express: “Although diagnostic labels create the illusion of an explanation they are scientifically meaningless and can create stigma and prejudice.” Peter Kinderman, another author, said: “This study provides yet more evidence that the biomedical diagnostic approach in psychiatry is not fit for purpose.” He added the diagnostic system wrongly assumed that all distress resulted from disorder. John Read, who was the third author, said: “Perhaps it is time we stopped pretending that medical-sounding labels contribute anything to our understanding of the complex causes of human distress or of what kind of help we need when distressed.”

Psychiatric Times published an interview with Allen Frances for Conversations in Critical Psychiatry. Although he thought psychiatry was among the noblest of professions, “I fear that too many psychiatrists are now reduced to pill pushing, with far too little time to really know their patients well and to apply the rounded biopsychosocial model that is absolutely essential to good care.” He despaired that diagnostic inflation resulted in a too loose of a diagnostic system. “Diagnoses should be written in pencil, and under-diagnosis is almost always safer and more accurate than over-diagnosis.” With regard to epidemiological studies that tend to exaggerate rates of mental disorders, Frances said:

Never believe the extremely high rates of mental disorders routinely reported by epidemiological studies in psychiatry—usually labelling about 25% of the general population as mentally ill in the past year, about 50% lifetime. This entire literature has a systematic, but unacknowledged, methodological bias that inherently results in over-reporting. Because epidemiology requires such huge samples—in the tens of thousands—it is prohibitively expensive to conduct clinical interviews. Instead phone surveys are done by non-clinicians following a highly structured format that allows no clinical judgment whether the symptoms reported cause sufficient clinically significant distress and impairment to qualify as a mental disorder. Since there is no sharp boundary between normal distress and mental disorder, not assessing for clinical significance includes among those labelled mentally ill many who are merely distressed. The rates reported in studies are really only upper limits, not accurate approximations of true rates. They should be, but never are, reported as such.

His final word on DSM was: “DSM should be seen only as a tool helpful in guiding clinical judgment, not as a replacement for it.”

Returning to “Medicine and the Mind” by Gardner and Kleinman, psychiatrist Sandy Steingard said she shared their wish that research funding would be allocated to fields other than basic biologic research. But she was surprised they appeared to support buttressing psychiatry’s hold as leaders in research and program development. “I need some convincing that the problems we agree exist will be best addressed within my profession. In recent years, I have been most impressed by approaches to mental distress that emanate from outside of psychiatry.”

Finally, there was an article published in Public Understanding of Science that aimed to analyze the ‘critical reception’ of the DSM-5—how it has been received, discussed and criticized by different categories of people: “The Critical Reception of the DSM-5.” They noted two major themes surrounding the critical reception of the DSM-5, the pseudo-scientific nature of the manual and its normalizing power. Mental health professionals, especially psychiatrists, were more invested in the debate on the scientific nature of the DSM-5. There was a more eclectic variety of audiences in the debate over the normalizing power of the manual.

In the first debate (the scientific nature of the DSM), we found opposing argumentative positions regarding whether or not the manual is a scientific tool and questioning the type of science to which the manual adheres. In the second debate (the normalising power of the DSM), opinions were also polarised: while some argued that the manual was potentially socially harmful, some pointed out its lack of inherent agency and others mentioned its potential benefits. Although these debates have been noted in previous studies (Demazeux, 2015; Ecks, 2016), our research aims to deepen the understanding of such discussions.

They concluded the DSM was not simply a scientific manual. Rather, it is “a social laboratory where political, sociological, ethical and psychological issues are discussed and confronted.” In order to critically analyze the DSM, the authors said it was important to consider the claims that challenge the APA’s narrative of the DSM, namely its scientific and democratic nature. They said a range of arguments interacted and overlapped “in differing and opposing ways.” This was said to nuance the idea often presented academic publications that critiques of the DSM were mostly fixed, repeating the same themes and antagonistic positions.

The above issues were not being discussed in fringe, antipsychiatry forums. Rather, they appeared in well-received, medical and psychological arenas: The New England Medical Journal, Psychology Today, Psychiatry Research, Medical Express, Psychiatric Times, the National Institute of Mental Health. The people addressing them: Allen Frances, Thomas Insel, Caleb Gardner, Arthur Kleinman and others are or were key individuals within the mental health, psychiatric, diagnostic fields. The time is coming where just discussing the issues and concerns will not be enough; change will be necessary.

Psychiatry and diagnosis need to be reined in. They have extended their “reach” too far as it is, and scaling back is a necessary and essential step before any future recasting of the role of psychiatric treatment for mental “disorders.” Anne Harrington’s suggestion to limit its scope to severe, mostly psychotic disorders is a good first step. Dr. Joanna Moncrieff, a psychiatrist, seems to share this view. In “Rethinking Modals of Psychotropic Drug Action,” and “The Psychoactive Effects of Psychiatric Medication,” she proposed a “drug centered model” of drug action, rather than the existing “disease centered model,” whose core assumption is that psychotropic drugs help correct “a biochemical abnormality that represents a biological substrate of a specific disease process.”

In The Myth of the Chemical Cure, Moncrieff acknowledged abandoning the disease-centered model would challenge “some of the most fundamental principles of modern psychiatry.” Yet she said it would also open the way “to a more honest practice” that requires its own specialist knowledge, and implements a more democratic treatment process:

Adopting a drug-centred model of drug action would require psychiatrists to become more informed about the effects of different psychoactive drugs, and become attuned to evaluating the subjective experiences of their patients in a more equal and reciprocal relationship. Where their function was to participate in mechanisms of social control this would be openly acknowledged and rigidly controlled rather than veiled, as currently, under the cloak of medicine.

In “The Psychoactive Effects of Psychiatric Medication,” she pointed out how re-orienting drug therapy towards a drug-centered model raised some questions about the validity and relevance of diagnostic systems like the DSM-5. The idea that psychiatric drugs exert “a disease- or disorder-specific action” has been one of the principal justifications for modern psychiatric classification. Using psychiatric drugs explicitly for their psychoactive effects would require a different understanding of the nature of psychiatric problems. It would break the link between diagnoses and treatment, “and enable a frank discussion about the purpose and ethics of the already frequent ‘off-label’ use of prescribed psychoactive medications, such as their use for behavioral control in children and the elderly.”

Gardner and Kleinman were not advocating going this far, but I think psychiatry needs a transformation. Long live the transformation!

05/1/18

Psychiatric Scientism

There is a curious phenomena within the debate over the evidence base of psychiatric drug treatment, namely whether psychiatry itself ever promoted or supported the chemical imbalance theory. Ronald Pies, an emeritus editor for Psychiatric Times, has repeatedly claimed that the chemical imbalance theory “was always a kind of urban legend—never a theory seriously propounded by well-informed psychiatrists.” Further, Pies said that to his knowledge, “No professional psychiatric organization has ever publically promoted a ‘chemical imbalance theory’ of mental illness in general.” But it seems his statements are incorrect.

The two above quotes by Ronald Pies were from blog articles he posted on the Psychiatric Times website in “Psychiatry’s New Brain-Mind and the Legend of the Chemical Imbalance,” and “Serotonin: How Psychiatry Got Over Its ‘High School Crush’”. He claimed “the ‘chemical imbalance’ trope” has been used by the opponents of psychiatry and erroneously attributed to psychiatrists themselves. Yet Robert Whitaker commented in his response to “Serotonin: How Psychiatry Got Over Its ‘High School Crush’” that it is quite easy to find numerous instances where prominent psychiatrists, including leaders of the APA [American Psychiatric Association], informed the public that “mental illnesses—such as depression or schizophrenia—are not ‘moral weaknesses’ or ‘imagined’ but real diseases caused by abnormalities of brain structure and imbalances of chemical in the brain.” This quote was in a 2001 Family Circle article, “Unlocking the Brain’s Secrets,” by the president of the APA, Richard Harding.

Another example given by Whitaker was in a 2005 brochure published by the APA, “Let’s Talk Facts About Depression.” In the section “How Is Depression Treated?” it says: “Antidepressants may be prescribed to correct imbalances in the levels of chemicals in the brain.” In 2005 APA press release, “Mental Illness Stigmas Are Receding, But Misconceptions Remain,” the results of an APA survey indicated that although 75% of consumers believe mental illnesses are usually caused by a chemical imbalance in the brain, they are more likely to consult a primary care physician rather than a psychiatrist—“a specialist specifically trained to diagnose and treat chemical imbalances and other determinants of mental illness.”

Whitaker’s thesis is that since the publication of the third edition of the DSM in 1980, the APA has been committed to the position that mental disorders are diseases of the brain; and that drugs for those diseases are safe and effective. “The chemical imbalance story comprised the heart of this disease-model narrative: Psychiatric researchers were discovering the pathology of mental disorders, and its drugs fixed that pathology, like insulin for diabetes.” He sees this narrative as serving psychiatry’s interests as a guild.

It told of how its disorders in DSM III had been “validated” as real diseases.
It told of a medical specialty that was making great scientific progress, which elevated its power and authority in our society.
It told of a medical specialty that had a product—e.g. drugs—that was of great worth in treating those diseases.
Most important of all, this narrative provided a reason for psychiatry, as a medical specialty, to have authority over this part of our lives.

Whitaker said our society has responded to this narrative by organizing itself around it, and assuming it is the legitimate “story of science.” In “The Scientism of Psychiatry,” Sami Timimi said this tendency has led mainstream psychiatric literature to prefer rhetoric to scientific accuracy. Psychiatric research and discourse, according to Timimi, “are now dominated and infected by scientism — the promotion of a belief … that because what you do and talk about sounds and looks like ‘science,’ it is ‘scientific’”.

In “What Is Scientism?” Thomas Burnett said philosopher Tom Sorell defined scientism as putting too high a value on natural science in comparison with other branches of learning. A more precise and extreme definition by physicist Ian Hutchinson was also quoted from his book: Scientism: Philosophy and the Infatuation with Science: “Scientism is a matter of putting too high a value on natural science in comparison with other branches of learning or culture.” Hutchinson also said the health of science was jeopardized by scientism.

Burnett gave a brief history of scientism up through the logical positivism embodied in The Vienna Circle. “In this system, there are only two kinds of meaningful statements: analytic statements (including logic and mathematics), and empirical statements, subject to experimental verification. Anything outside of this framework is an empty concept.” However Karl Popper pointed out there were very few statements that could be completely verified in science. “A single observation has the potential to invalidate a hypothesis, and even an entire theory.” So he proposed that instead of experimental verification, “the principle of falsifiability should demarcate what qualified as science, and by extension, what can qualify as knowledge.” Timimi noted how this has been incorporated into scientific methodology as a process of rejecting or disproving the null hypothesis.

Science uses a methodological approach involving hypothesis generation and then testing the hypothesis through empirical methods. The best scientists can live with and accept uncertainty as a prerequisite to being objective in the pursuit of knowledge. Knowledge develops and builds through generating a hypothesis (often using results from previous research) and then carrying out an investigation aimed at proving that something called a ‘null hypothesis’ can’t be true. The null hypothesis is a general statement or default position that there is no relationship between certain measured phenomena. Rejecting or disproving the null hypothesis — and thus concluding that there are grounds for believing that there is a relationship and the actual hypothesis may be true — is a central task in the modern practice of science.

He then said one of the major problems with the current concepts used in psychiatry traces back to the basic assumptions on which much of psychiatric research rests. In order to scientifically evaluate a proposition that there is a natural category of dysfunction/disorder, we must start with the null hypothesis. Until proven otherwise, there is no characteristic relationship between what we are investigating (put the disorder of your choice here) and some measurable biological/neurological feature. “This is a foundational assumption behind the development of knowledge through the scientific method.” ADHD, Depression and essentially all other psychiatric disorders fail to meet this standard. “Until we have demonstrated that this basic null hypothesis can’t be true, then scientifically, we cannot proceed with research that assumes that ADHD [or any other diagnostic category] as a concept has explanatory power for the behaviours it describes.”

Mainstream psychiatry has been afflicted by at least two types of scientism. Firstly, it parodies science as ideology, liking to talk in scientific language, using the language of EBM [evidence based medicine], and carrying out research that ‘looks’ scientific (such as brain scanning). Psychiatry wants to be seen as residing in the same scientific cosmology as the rest of medicine. Yet the cupboard of actual clinically relevant findings remains pretty empty. Secondly, it ignores much of the genuine science there is and goes on supporting and perpetuating concepts and treatments that have little scientific support. This is a more harmful and deceptive form of scientism; it means that psychiatry likes to talk in the language of science and treats this as more important than the actual science.

Contrasting medical and psychiatric diagnosis, Timimi then said:

In medicine, diagnosis is the process of determining which disease or condition explains a person’s symptoms and signs. Diagnosis therefore points to causal processes. Making an accurate diagnosis is a technical skill that enables effective matching of treatment to address a specific pathological process. Pseudodiagnoses, like for example ADHD, cannot explain behaviours as there are only ‘symptoms’ that are descriptions (not explanations) of behaviours. Even using the word ‘symptom’ may be problematic, as in medicine ‘symptoms’ usually refers to patients’ suffering/experience as a result of an underlying disease process and is therefore associated in our minds with a medical procedure leading to an explanation for the ‘symptom.’ But psychiatric diagnoses do not explain symptoms.

Using ADHD as am example, Timimi said once we start interrogating basic assumptions like the validity of psychiatric diagnoses, it should be easy to see that much of the psychiatric literature is built on assumptions lacking validity. Since ADHD is a descriptive classification and not a medical diagnosis, we have no reliable empirical method for defining what qualifies as a case of ADHD. Determining what qualifies as a case of ADHD is then arbitrary and depends on the standards used by the person doing the diagnosis, “influenced by whatever prevailing ideology concerning diagnosis they have been exposed to.” So as a consequence, we cannot eliminate wide variation in ‘diagnostic’ practice.

Timimi said in Western culture, science has become a cosmology—“an ideology/faith that believes that science has an undeniable primacy over all other ways of seeing and understanding life and the world.” This makes us vulnerable to scientism. He suggested psychiatry keeps faith in scientism despite its flaws because of the value we place in our culture on technology and technological achievement; and because, “this connects with that broader ‘cosmology’ that wants to use ‘science’ to explain everything.” In order to have credibility and leverage in our society, “we are inclined to use technological/scientific-sounding language.” Michael Foucault and others have pointed out, “this is how institutional power builds up and get authority to create ‘regimes of truth’.” Robert Whitaker said if psychiatry is ever going to reform itself in a way that will serve the public, “rather than its own guild interests,” it has to confront its past.

Why did it tell this false narrative—of drugs that fixed chemical imbalances in the brain—to the public? Perhaps then it could understand that its duty, as a medical specialty, is to tell a narrative to the public that is consonant with the relevant science. If that were so, then the public would be hearing that the biological causes of psychiatric disorders remain unknown, and that its drug treatments are of marginal efficacy over the short term, and that over the long-term, outcomes for medicated patients are very poor.

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag Archives: psychiatry