03/9/18

Psychiatry Needs a Revolution

Peter Gøtzsche wrote a January 2018 editorial in the British Medical Journal, where he elaborated on why he thinks, “Psychiatry is a disaster area in healthcare that we need to focus on.” In his editorial, Gøtzsche said the prevailing paradigm in psychiatry was to say psychiatric drugs have specific effects against specific disorders; and that their actions do more good than harm. However, he asserted that as a consequence of its liberal use of psychiatric drugs, psychiatry actually does more harm than good. Gøtzsche and other so-called “antipsychiatry,” critics are often dismissed by psychiatry. But there was a study that surveyed the attitudes of medical teaching faculty towards psychiatry and psychiatrists; and the results had more in common with the antipsychiatrists than you might think.

Stuart, Sartorius and Linamaa published “Images of Psychiatry and Psychiatrists” in the open access journal, Acta Psychiatra Scandinavica. They surveyed 1,057 teaching medical faculty members from 15 academic teaching centers in the United Kingdom, Europe and Asia. The overwhelming majority of respondents held negative views towards psychiatry as a discipline, psychiatrists and psychiatric patients. Some of their findings were startling: 90% thought psychiatrists were not good role models for medical students; 84% thought psychiatric patients should be treated only within specialized facilities.

When the survey asked about the perception of psychiatry as a profession, 8.9% thought psychiatry was unscientific; 7.7% thought it was not evidenced-based; and 8.0% thought psychiatry was not a genuine, valid branch of medicine. Perceptions of psychiatric treatment thought psychiatrists had too much power over their patients (25.0%); treatments were not as effective as in other branches of medicine (22.6%); and most who receive treatments do not find them helpful (20.4%). Then 28.6% said they would not encourage a bright student to enter psychiatry; and 75.4% said many students at their medical school were not interested in pursuing psychiatry as a career.

Results highlight the extent to which non-psychiatrist medical faculty hold negative opinions of psychiatry as a discipline, psychiatric treatments, psychiatrists as role models for medical students, psychiatry as a career choice, psychiatric patients, and psychiatric training. The most outstanding findings were that psychiatrists were not considered to be good role models for medical students, and psychiatric patients were considered to be emotionally draining and unsuitable to be treated outside of specialized facilities or in general hospitals.

“In Search of an Evidence-Based Role for Psychiatry,” by Read, Runciman and Dillon noted this was not the only study indicating negative views of psychiatry by other medical professionals. They cited a study by Curtis-Barton and Eagles that found medical students were discouraged from choosing psychiatry as a career either a lot or a little because of a perceived lack of evidence base (51%); and the scientific basis of psychiatry (53%). Only 4-7% of UK medical students saw it as a ‘probable/definite’ career because of its poor evidence base. Commenting further on “Images of Psychiatry and Psychiatrists,” Read, Runciman and Dillon said:

Even more revealing than the survey findings was psychiatry’s response to it. The researchers themselves, including a former President of the World Psychiatric Association, wondered whether their colleagues’ opinions are ‘well founded in facts’ or ‘may reflect stigmatizing views toward psychiatry and psychiatrists’. Their own answer to that question becomes abundantly clear when, instead of proposing efforts to address the problems identified by the medical community, such as having little scientific basis, they recommend only ‘enhancing the perception of psychiatrists’ so as to ‘improve the perception of psychiatry as a career.’

The responses to the survey, all written by psychiatrists, dismissed each concern “and blamed everyone but their own profession, including their supposedly ignorant, prejudiced medical colleagues and the biased media.” Read, Runciman and Dillon then described problems with how mental health issues are conceptualized, what causes them and how to treat them. “Despite all this, biological psychiatry is trying to expand the reach of what others consider to be an unscientific, reductionistic, simplistic and pessimistic ‘medical model’.” A truly evidence-based psychiatry would recommend psychiatric medications at a last resort (and for a short time period). The adverse effects of medications should be fully disclosed and “no medical treatment should be forced on anyone against their will.”

Read, Runciman and Dillon said there were three core research areas that psychiatry should be demonstrating progress in, if it is a legitimate scientific, medical discipline. They are: conceptualization, causation and treatment of the disorders.

With regard to the conceptualization of psychiatric disorders, “psychiatry’s primary contribution is an ever expanding list of labels.” Many do not reach even minimal scientific reliability levels and calling them ‘diagnoses’ is often a misnomer. Significantly, the NIMH announced when the DSM-5 was about to be published that it was abandoning the DSM diagnostic approach to classifying mental health problems for its research to develop scientifically robust ‘research domains.’ See “Patients Deserve Better Than the DSM” for more information on this.

“In terms of causation, psychiatry has focused predominantly on chemical imbalances, brain abnormalities and genetics.” But has repeatedly failed findings of any substance in support of that premise. Genetics has an important role, if the research is done on constructs that actually exist. There is also “the role of epigenetic processes whereby genes are activated and deactivated by the environment.”

Research suggests that the safety and efficacy of psychiatric drugs has been grossly exaggerated. Documentation in support of this claim is overwhelming. See the websites for Mad in America, Peter Breggin, and David Healy and RxISK for starters. You can also search this website or start with: “In the Dark About Antidepressants,” “Blind Spots With Antipsychotics.”

Peter Gøtzsche similarly noted concerns with the “liberal use of psychiatric drugs.” He identified four concerns with the prevailing paradigm in psychiatry and gave supporting evidence for each.

First, the effects of the drugs are not specific. “They impair higher brain functions and cause similar effects in patients, healthy people and animals.” For instance, not only does serotonin (SSRI antidepressants influence serotonin levels) seem to have a role in maintaining mood balance, it can effect social behavior, appetite and digestion, sleep memory and sexual desire and function.
Second, research in support of the paradigm that psychiatric drug have specific effects against specific disorder is flawed.
Third, the widespread use of psychiatric drugs has been harmful for patients. In every country where the relationship has been examined, an increased use of psychiatric medications has accompanied an increase in the number of chronically ill people and the number of people on disability pensions.
Fourthly, all attempts to use brain scans to show that psychiatric disorders cause brain damage have failed. “This research area is intensely flawed and very often, the researchers have not even considered the possibility that any brain changes they observe could have been caused by the psychiatric drugs their patients have taken for years” Yet this has been shown repeatedly in many reliable studies, especially for neuroleptic drugs.

Peter Gøtzsche said the prevailing paradigm in psychiatry, that its drugs have specific effects against specific disorders, is unsustainable when the research in support of it is critically appraised. He said psychiatry needed a revolution; reforms were not enough. “We need to focus on psychotherapy and to hardly use any psychiatric drugs at all.” Dr. Gøtzsche is a medical researcher and the Director of the Nordic Cochrane Center. Along with 80 others, he helped start the Cochrane Collaboration in 1993, which is “a global independent network of researchers, professionals, patients, carers, and people interested in health.” The work of the Cochrane Collaboration is recognized as an international gold standard for high quality, trusted information.

04/7/17

Souless Psychiatry

A psychiatric resident at Stanford University School of Medicine wrote an essay on the crisis with psychiatry that appeared in a Scientific American blog. The author said the field was in decline as fewer medical students sought to specialize in psychiatry. He stated psychiatry was looked down upon by nearly every segment of society; and patients avoided treatment because of the stigma related to the field. His solution was to change the name of the field—call it something else.

The crisis, in his view, stems largely from a misunderstanding of what psychiatry is. He said it was “the medical field where doctors incorporate neuroscience and medical research to treat patients with diagnosable mental disorders.” But his friends seem to think he interprets dreams and administers Rorschach tests. Administering Rorschach tests and interpreting dreams are activities associated with psychoanalytic practice that dominated psychiatry up until the 1970s. While “mental health” has made great strides raising awareness (i.e., May is now National Mental Health Awareness Month), “psychiatry has been left behind as its anachronistic forebear.” So he asked, “Would renaming the field help?”

The word psychiatry evokes thoughts of dated medical practices, like Freudian analysis and ice-pick lobotomies. Its sordid history turns away patients, providers, and the public from the progress of mental health care today.

He acknowledged where relabeling could be seen as a Band-Aid. A mere name change ignores the root causes of the problem, which from his perspective is the stigma attached to psychiatry and mental illness. However, citing studies of name changes within the U.S. and other countries, he suggested these language shifts helped psychiatry sound more reputable. He imagined most people would rather have a mental health disorder than a psychiatric disorder, “even if it were the same thing.”

“Mental Health Care” would be a simpler name for the field instead of psychiatry. Psychiatrists would then become “mental health physicians.” Medical centers could create departments of mental health, combining specialties such as internal medicine, psychiatry, psychology and social work. “By uniting these fractured disciplines under one roof, clinicians could provide more comprehensive care to patients without the stigma associated with aging terminology.” Mental health units were said by the author to be far less frightening than psychiatric wards.

In conclusion, he noted how the term psychiatry meant: “healing of the psyche,” drawn from the Greek goddess of the soul—Psyche. “It’s a romantic notion, but we don’t treat patients’ souls. We treat diagnosable diseases of the brain. Perhaps it’s time to rename the field.”

In reading this essay, I was reminded of what psychiatrist Jeffrey Lieberman wrote in his book, Shrinks about psychiatry. He commented that in the 1970s, “the majority of psychiatric institutions were clouded by ideology and dubious science,” mired in a pseudomedical Freudian landscape. But now in the twenty-first century, psychiatry offered scientific, humane and effective treatments. “Psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” You can read about the fallacies of “Freudian analysis and ice pick lobotomies” in Shrinks, but you won’t hear the complete and unvarnished truth about psychiatry.

Robert Whitaker astutely commented that Shrinks is more of a story of how psychiatry sees itself as an institution, than it is an accurate history of psychiatry. And I see the same approach here. I wonder if the Stanford psychiatric resident who wrote “Maybe We Should Call Psychiatry Something Else” is simply rehashing the received view of psychiatric history.

If you want a truly unvarnished look at psychiatry, read Whitaker: Mad in America, Anatomy of an Epidemic, and Psychiatry Under the Influence. You can read more about Lieberman and Shrinks on this website. Do a search for “Lieberman.”

The term “psychiatry” was originally coined by Johann Reil—a German physician—in 1808. And it does literally mean the medical treatment of the soul. Another German physician, Johann Heinroth was the first person to hold a chair of psychiatry. He also staked out working with the mentally ill as medical territory. Since there was little or no knowledge within the medical tradition to equip doctors to deal with mental disturbances, he proposed the creation of a new branch of medicine—psychiatry.

In his 1818 Textbook of Mental Disturbances, Heinroth said: “Since we are speaking of medical art and science, we should think that nobody but a doctor should have a right to make mental disturbance the object of his studies and treatment.” In The Myth of Psychotherapy, Thomas Szasz said of this time:

The birth of psychiatry occurs when the study of the human soul is transferred from religion to medicine, when the “cure of souls” becomes the “treatment of mental diseases,” and, most importantly, when the repression of the heretic-madman ceases to be within the jurisdiction of the priest and becomes the province of the psychiatrist.

There have been some radical shifts in how psychiatrists function since the early 1800s. Initially they were administrators of large institutions for the insane. Under Freud’s influence, psychiatrists began to consult with individuals living in society rather than working solely with those within institutions. Then in 1909, Freud was invited to give a series of lectures on psychoanalysis by Stanley Hall, the president of Clark University.

The cover photo for “Maybe We Should Call Psychiatry Something Else” shows seven men from the time of that conference, but only identified Sigmund Freud and Carl Jung. At the time, Jung was still friendly with Freud. The photo credit said the others were “pioneers in psychiatry,” but that is not entirely accurate. The photo shows Sigmund Freud and Carl Jung on either side of Stanley Hall in the front row. In the back row from left to right are Abraham Brill, Ernest Jones and Sandor Ferenczi.

Stanley Hall was a well-known American psychologist in addition to the then president of Clark University. He had an interest in Freud’s psychoanalytic theories and invited him to be part of a “galaxy of intellectual talent” to celebrate the twentieth anniversary of the founding of Clark University. Jung and Ferenczi were invited as the leading European disciples of Freud. Ernest Jones, another protégé of Freud, was then in Toronto Canada, building a private psychoanalytic practice and teaching at the University of Toronto. Jones would later become a biographer of Freud. Brill was the first psychoanalyst to practice in the U.S. and the first translator of Freud into English. In 1911 he founded the New York Psychoanalytic Society.

So these individuals are better seen as pioneers of Freudian psychoanalytic practice —the approach dismissed by the author of “Maybe We Should Call Psychiatry Something Else” as a dated medical practice, which he placed alongside ice pick lobotomies.

By the 1940s, psychoanalytic theory had not only taken over American psychiatry, it had become part of our cultural psyche. Alfred Hitchcock’s 1945 film, Spellbound is an example of how influential psychoanalytic thinking was. The opening credits of the film announce that it wanted to highlight the virtues of psychoanalysis in banishing mental illness and restoring reason. Look for the Freud look-a-like character as Ingrid Bergman’s psychoanalyst and mentor.

Psychoanalytic thought dominated the field until the 1970s when the birth of biological psychiatry was ushered in by Robert Spitzer and his reformulation of psychiatric diagnosis. After Spitzer was appointed to do the revisions for the 3^rd edition of the DSM in 1974, he was able to appoint whomever he wanted to the committees. He made himself the chair of all 25 committees and appointed individuals who he referred to as the “young mavericks” psychiatry. In other words, they weren’t interested in Freudian analysis. Spitzer said: “The feeling was that the same techniques that were useful in medicine, which is you describe something, you do laboratory studies; that those same kind of studies were appropriate for psychiatry.” Except it didn’t happen because in the 1970s, there just wasn’t a lot of psychiatric research. So the decisions of the committees were based on the expertise of the committee members.

David Chaffer was part of the process back then. He said committee members would gather together into a small room. Spitzer would sit with a mid 1970s “portable” computer and raise a provocative question. “And people would shout out their opinions from all sides of the room. And whoever shouted loudest tended to be heard. My own impression was … it was more like a tobacco auction than a sort of conference.” So much for using the same techniques as those used in medicine. Listen to the NPR story, “The Man Behind Psychiatry’s Diagnostic Manual” for the above information on Spitzer and the DSM.

But the real driving force behind the revisions made by Spitzer and others was because a “psychopharmacological revolution” couldn’t begin with the diagnostic process that existed before Spitzer and the DSM-III. Allen Frances, the chair of the next revision, the DSM-IV, acknowledged as much in his comments before the American College of Neuropsychopharmacology in 2000. Frances said the DSM-III was an innovative system that focused on descriptive diagnosis and provided explicit diagnostic criteria. “In many ways this aided, and was aided by, the knowledge derived from psychopharmacology. . . . The diagnostic system and psychopharmacology will continue to mature with one another.”

The psychopharmacological revolution required that there be a method of more systematic and reliable psychiatric diagnosis. This provided the major impetus for the development of the structured assessments and the research diagnostic criteria that were the immediate forerunners of DSM-III. In turn, the availability of well-defined psychiatric diagnoses stimulated the development of specific treatments and increasingly sophisticated psychopharmacological studies.

In the Foreword to his book, The Anatomy of an Epidemic, Robert Whitaker explained how he first wandered into the “minefield” of psychiatry by writing in the mid 1990s about research practices such as rapidly tapering schizophrenic patients off of their antipsychotic medications and then giving them a drug to exacerbate their symptoms. This “research” was done in the name of studying the biology of psychosis. Jeffery Lieberman took part in some of those studies, using methylphenidate (Ritalin, Concerta) to deliberately provoke psychotic symptoms in schizophrenic patients. Read “Psychiatry, Diagnose Thyself! Part 2” for more information on Whitaker’s articles and Lieberman. Incidentally, the series of articles Whitaker co-wrote for the Boston Globe was a finalist for the Pulitzer Prize for Public Service. Whitaker said in the Foreword to Anatomy of an Epidemic:

I began this long intellectual journey as a believer in the conventional wisdom. I believed that psychiatric researchers were discovering drugs that helped “balance” brain chemistry. These medications were like “insulin for diabetes.” I believed that to be true because that is what I had been told by psychiatrists while writing for newspapers. But then I tumbled upon the Harvard study and the WHO findings, and that set me off on an intellectual quest that ultimately grew into this book, The Anatomy of an Epidemic.

Maybe there is a stigma against psychiatry for more than just the past use of ice pick lobotomies or insulin comas or ice baths or the electroshock treatment shown in One Flew Over the Cuckoo’s Nest. But simply changing the name of what we now call psychiatry will not change the opposition against a medical specialty that no longer treats patients’ souls. And perhaps that is really why the field is in decline.

03/7/17

Between a Rock and a Hard Place

Terry Lynch is an Irish physician and psychotherapist who challenged the commonly held view that psychiatric disorders are legitimate brain disorders. He did so in a brief video that had an interesting take on the issue. He showed where two of the organizations affiliated with the U.S. National Institute of Health (NIH) apparently have different opinions about whether several psychiatric disorders should be considered to be brain disorders.

In his video, “It’s official: Psychiatric diagnoses are NOT known brain disorders,” Lynch gave a screen capture from the “Brain Basics” educational resources page of the National Institute of Mental Health (NIMH). He highlighted the opening statement there, which says: “Welcome. Brain Basics provides information on how the brain works, how mental illnesses are disorders of the brain, and ongoing research that helps us better understand and treat disorders.” Further down the page is the following: “Through research, we know that mental disorders are brain disorders.” These disorders were said to include depression, anxiety disorders, bipolar disorder, attention deficit hyperactivity disorder (ADHD) and many others.

He also called attention to a second NIH Institute, the National Institute of Neurological Disorders and Stroke (NINDS). The official mission statement of NINDS is “to seek fundamental knowledge about the brain and nervous system and to use that knowledge to reduce the burden of neurological disease.” On the NINDS homepage is search engine where you can search by disorder. Lynch proceeded to show that depression, bipolar and schizophrenia were not listed in the NINDS database as neurological disorders. ADHD does appear in the NINDS, database but was not mentioned by Lynch in his video. You can replicate what I’ve said here be searching the “Brain Basics” page on NIMH and the NINDS database here.

One response to the differences Lynch found would be to say that NINDS attends to neurological disease, while NIMH addresses a different kind of brain dysfunction, namely mental or psychiatric disorders. But that response doesn’t resolve the dilemma. Because the next question becomes what is the difference between neurological disease and mental/psychiatric disorder? Attempting to articulate the difference may have placed psychiatry in a sort of catch-22 situation.

Lynch addressed this dilemma in an essay he wrote, “Psychiatry: Between a Rock and a Hard Place.” His opening statement there was that contrary to their repeated claims of doing so, “psychiatrists do not treat known organic illnesses.” They do not treat known organic brain disorders, which are under the care of neurology and neurosurgery. He said emotional and psychological distress typically comes under the care of counseling or psychology. So where, then, does psychiatry fit in?

Psychiatry is caught between a rock and a hard place—somewhere between the medical specialties treating known brain diseases (neurology and neurosurgery) and the talk therapies of counseling and psychology. Psychiatrists, according to Lynch, invented terms such as “mental illness” or “mental disorder,” and made themselves the experts who would diagnose and treat said illness/disorder. “They have fed the public with unsubstantiated ideas about neurotransmitters, chemical imbalances and brain disorders, ideas which the public have generally believed wholeheartedly.”

The challenge for psychiatry has been to carve out its own distinct identity. Claims that depression and other psychiatric diagnoses are biological illnesses are crucial to psychiatry’s identity and its unmerited position at the top of the mental health pyramid. These assertions separate psychiatry from the talk therapies and ensure that psychiatry has first claim to these “diseases” and the people they diagnose as having them.

He said psychiatry wants to be more closely aligned with the respected medical standing of neurology than to psychology or counseling. But it has to be seen as distinct from neurology to maintain a separate identity. “Specializing in ‘mental illnesses’ and ‘mental disorders’ provides the needed distinction.” Towards that end, Lynch said psychiatry has convinced the general public (and perhaps themselves) that psychiatric disorders are biological illnesses. In the process, they have side stepped “the fact that there is no reliable corroborative scientific evidence for this.”

For over a century, psychiatry has reassured the public that both the necessary understanding and more effective solutions lie just around the corner. “Bear with us, we are almost there,” psychiatry’s catchphrase for the past 100 years and more, buys them more time, every time.

Lynch thought psychiatry would confront a nightmare of their own making if it ever connected brain abnormalities to psychiatric diagnoses. If structural or functional brain abnormalities were ever found to be associated with psychiatric diagnoses, care of those individuals would likely be transferred away from psychiatry to neurology—“a specialty that deals with known brain abnormalities.” He said precedent within medicine would dictate that responsibility for those patients would be transferred to neurology or some other relevant specialty.

Given this, Lynch thinks the best position for psychiatry is to stay exactly where it is. As long as there are no reliable biological abnormalities identified, there is no threat to their position. By claiming that mental disorders are rooted in biology, psychiatry has set itself apart from talk therapies. “As long as no biological abnormalities are reliably identified, there is no threat that their bread and butter will be removed from them to other medical specialties.” Maintaining the myth that biological solutions are imminent, satisfies the public and preserves it’s position.

“If biology isn’t seen as central to the experiences and behaviours that have become repackaged as so-called “mental illnesses,” what special expertise can mainstream psychiatrists claim to possess?” So when psychiatrists defend their pronouncements on depression or any other psychiatric label, they are not just defending a diagnosis. “They are defending themselves, their ideology, their modus operandi and ultimately, their status and role in society as the perceived prime experts in mental health.”

Lynch is not alone in his views of psychiatry and diagnosis. There are clear echoes of the thought of Thomas Szasz in what he says. Peter Breggin, Joanna Moncrieff, Robert Whitaker, Peter Gøtzsche, David Healey, Sami Timimi and others would agree with parts, if not all, of what he asserts. Here, for example, is a blog article by Chuck Ruby for the International Society for Ethical Psychology & Psychiatry (ISEPP), “Blue Illness.” Reflecting on an article that affirmed depression was a mental illness, Ruby noted that for decades, attempts have been made to demonstrate the brain-pathology basis of depression.

Despite the billions of public dollars invested in this research, no such evidence of brain pathology has been discovered. The only thing this research has shown is that our experiences and behaviors are mirrored by changes in the brain. This is something we already knew. Yet, instead of giving up the search and redirecting those monies to more worthy research of real diseases, the mental health industry repeats the worn out pronouncement that discovery is just around the corner! Ironically, if such a discovery came, wouldn’t depression then fall within the medical specialty of neurology, the real medical specialty that studies real brain illnesses?

In the concluding paragraphs of their book, Psychiatry Under the Influence, Robert Whitaker and Lisa Cosgrove wrote that from a scientific standpoint, psychiatry is facing a legitimacy crisis. “The chemical imbalance theory is collapsing now in the public domain.” The former director of the NIMH, Thomas Insel, has written of how second generation psychiatric drug are no better than the first, “which belies any claim that psychiatry is progressing in its somatic treatment of psychiatric disease.”

The disease model paradigm embraced by psychiatry in 1980 has clearly failed, which presents society with a challenge: what should we do next?

Terry Lynch is right. Psychiatry is between a rock and a hard place. But save your sympathy for the patients who are there with it.

01/24/17

Herding Pharma “Cats”

The Chinese government released a report in September of 2016 by the State Food and Drug Administration (SFDA) that found fraudulent clinical trial practices on a massive scale. The SFDA concluded that over 80% of clinical trial data was fabricated. The scandal was the result of a “breach of duty by supervision departments and malpractice by pharmaceutical companies, intermediary agents and medical staff.” More than 80% of the applications for the mass production of new medications have been cancelled, with warnings by the SFDA that further evidence of malpractice might still emerge.

Radio Free Asia also reported the SFDA indicated much of the clinical trail data was incomplete at best. But it also failed to meet basic analysis requirements or was untraceable. “Some companies were suspected of deliberately hiding or deleting records of adverse effects, and tampering with data that did not meet expectations.” Apparently, this came as no surprise to industry insiders. “Clinical data fabrication was an open secret even before the inspection.”

Many of the new drugs were combinations of existing ones. Clinical trial outcomes were written beforehand, and their data presented so it agreed with the fabricated outcomes. A doctor at a top Chinese hospital said the problem lay with the failure to implement regulations governing clinical trial data. “Guangdong-based rights activist Mai Ke said there is an all-pervasive culture of fakery across all products made in the country.” Reporting for Pharmafile, Ben Hargreaves said:

The root of the issue is then not regulation, with regulation for clinical trials running on similar lines to Western practises, but in the lack of adherence to them. China’s generic drug industry has struggled with quality problems and therefore there is a temptation for companies to manipulate data to meet standards. The report found that many of the new drugs were found to be a combination of existing drugs, with clinical trials outcomes written beforehand and the data tweaked to fit in with the desire outcomes.

Sadly, clinical trial problems are not unique to China. An editorial published in the British journal The Lancet Psychiatry described multiple issues beginning with how subjects are recruited, moving on to determining what the control group should be, and ultimately defining meaningful outcome measures. Sometimes, trial recruits receive “care” they didn’t agree to. “Researchers and ethics review boards need to examine the ethical arguments and practical procedures from other areas of medicine where consent is problematic.” If such trials are done, regular and rigorous monitoring is essential. Patient safety and autonomy needs to be a priority.

In his discussion of the editorial, Justin Carter elaborated on one of the problems with recruiting subjects. An individual was recruited into a study on three antipsychotics while under a forced commitment order from a judge. “The psychiatrist who recruited him was in charge of the study and was his treatment provider and was also empowered to report on the patient’s progress to the judge.” The individual died by suicide during the drug trial.

The work of Irving Kirsch and others has shown the problem with inert placebos (sugar pills). The side effects from medication make it easy for participants to guess which study group they are in.

And when the trial is over and the data in, do the outcome measures really provide something meaningful for people’s lives? If the ultimate goal is for people to fell better and resume their prior level of functioning, should outcome measures by primarily patient self-reports, clinical assessment, or differences shown by imaging or the as-yet-to-be-clearly-identified biomarkers?

Given the problems running and interpreting psychiatry trials, it is essential to learn how even the most successfully tested interventions work in real clinics with the broad patient population. Implementation, uptake, and effectiveness in real-life settings must be analysed, and delivery of new innovations modified accordingly. Future research should be thought of not as a plain linear process from innovation to trial to implementation, but as a virtuous circle where research feeds into the clinic and vice versa.

Another issue pointed to by Carter was the validity and reliability of the diagnosis or classification system used to determine who to include and who to exclude from the trials. The DSM system, now in its fifth edition (DSM-5), is the current “bible” for assessing and diagnosing problems the psychiatric medications in clinical trials are supposed to “treat” in the U.S. Yet there have been questions about the reliability and validity of the DSM dating from an argument raised by Robert Spitzer and others in the 1970s that ushered in changes still embedded in the DSM-5. Rachel Cooper gave a brief history of the reliability questions with the DSM in “How Reliable is the DSM-5?” You can also refer to “Psychiatry Has No Clothes,” “Where There’s Smoke …”, and “The Quest for Psychiatric Dragons,” Parts 1 and 2.

A few weeks before the release of the DSM-5, Thomas Insel, then the NIMH Director, announced the NIMH would be “reorienting” its research away from DSM categories. The agency’s new approach is called the Research Domain Criteria (RDoC) project. For now, RDoC is a research framework and not a clinical tool. But NIMH has high hopes for it: “RDoC is nothing less than a plan to transform clinical practice by bringing a new generation of research to inform how we diagnose and treat mental disorders.” While Tom Insel has moved on to work for Alphabet (Google), RDoC is alive and well within NIMH. You can keep up with news about RDoC on the “Science News About RDoC.”

The Science Update for February 16, 2016 noted the March 2016 issue of the journal Psychophysiology would be devoted to the RDoC initiative. Dr. Bruce Cuthbert said the special issue was a unique opportunity for researchers to engage with one another and reflect on work being done in various laboratories throughout the country. He thought it was encouraging to see many investigators already engaged in the kind of work RDoC advocates. “What this shows is that while the RDoC acronym may be new, the principles behind RDoC are certainly not new to psychiatric research.”

If the principles behind RDoC are not new to psychiatric research, how can it bring “a new generation of research to inform how we diagnose and treat mental disorders” in order to transform clinical practice? It sounds a lot like using the same deck of cards to just play a new card game. RDoC may not be the transformative framework it’s touted to become.

Added to these issues is the failure of pharmaceutical companies to publically report the results of clinical trials, as they are required by law to do. New reporting rules will take effect on January 18, 2017. But advocates for transparency in clinical research have cautioned the success of the new rules will depend upon the willingness and vigor of government enforcement of those rules. The failure to enforce the existing rules, which went into effect in 2008, led to widespread noncompliance with reporting requirements. If the FDA had fined the violators, they could have collected an estimated $25 billion.

Reporting for STAT News, Charles Piller said studies have indicated only a small fraction of trials will comply with the law. Yet there are no current plans to increase enforcement staffing at the FDA and NIH. That’s a big problem, according to Ben Goldacre, an advocate for full disclosure in clinical research. Francis Collins, the NIH director said they are serious about this and will withhold funds, if needed. “It’s hard to herd cats, but you can move their food, or take their food away.”

The legislation that created ClinicalTrials.gov emerged from numerous cases of drug manufacturers withholding negative trial results, making drugs look more effective and less harmful. Efforts to market the antidepressant Paxil for teenagers more than a decade ago stimulated the push for better reporting. A recent analysis in the journal BMJ found that GlaxoSmithKline, Paxil’s manufacturer, failed to disclose 2001 data showing the drug to be no more effective than a placebo, and was linked to increased suicide attempts by teens.

Writing for Time, Alexandra Sifferlin reported on a new study that suggested many of the medical reviewers for the FDA go to work for the drug companies they oversaw while working for the government. One of the study’s authors said: “I don’t think there is overt collusion going on, but if you know in the back of your mind that a major career opportunity after the FDA is going to work on the other side of the table, I worry it can make you less likely to put your foot down.”

Returning to the Francis Collins metaphor, it seems that the willingness to try and herd Pharma cats is dependent on whether or not you are afraid they will scratch you in the attempt.

10/28/15

Positively NOT Psychiatry

Positive psychiatry is a growing phenomenon within the profession of psychiatry. And Dr. Dilip Jeste, a former APA President, seems to be the primary “evangelist” for the positive psychiatry movement. The theme for his year as APA President in 2012 was: “Pursuing Wellness Across the Lifespan.” He said positive psychiatry was the future of psychiatry. In a Psychiatric News article for June of 2012, Jeste said: “I believe that, as the medical field begins to appreciate the value of positive psychosocial factors in the prevention and management of pathology, positive psychiatry will increasingly take a central stage within medicine and health care.”

David Rettew, a child psychiatrist, wrote of his invitation by Dr. Jeste, to speak at a symposium on Positive Psychiatry at the 2015 annual conference of the American Psychiatric Association (APA) held in Toronto. He was excited by the opportunity and sees positive psychiatry as an opportunity for his profession to become “physician experts in mental health,” as opposed to their current emphasis on mental illness. Dr. Rettew noted that for too long, psychiatry has had two primary interventions: psychotherapy and medications. “Expanding our efforts into domains of wellness gives us so many more avenues to help children and families thrive.”

Jeste is also one of the editors of Positive Psychiatry: A Clinical Handbook, which was just released in June of 2015. Dr. Rettew is one of the contributing authors to that work. Jeste, Barton Palmer (co-editor of Positive Psychiatry), Rettnew, and Samantha Boardman (contributor to Positive Psychiatry) coauthored an article in the June 2015 issue of the Journal of Clinical Psychiatry, “Positive Psychiatry: Its Time Has Come.” They noted how psychiatry has traditionally focused on the diagnosis and treatment of mental illnesses. However, trying to find what causes mental illness and developing “safe and effective treatments” has not been enough to fulfill “the enormous potential of psychiatry to promote human welfare.”

The time has come to integrate positive mental health into psychiatric practice, training, and research and to expand psychiatric expertise to encompass the full spectrum of mental functioning.

Instead of an emphasis on managing mental disorders, Jeste et al. said positive psychiatry is a science and clinical practice that seeks to promote well-being through “assessment and interventions aimed at enhancing behavioral and mental wellness.” As a branch of medicine, positive psychiatry is rooted in biology and seeks to decipher the biological underpinnings of positive psychosocial characteristics (PPCs). “And eventually promote health and well-being through psychosocial/behavioral and biological interventions.“

Positive psychiatry traces its immediate influence to the positive psychology movement that was pioneered by Milton Seligman in the later 1990s. In his presidential address to the American Psychological Association in 1998, he called for “a reoriented science that emphasizes the understanding and building of the most positive qualities of an individual.” These qualities include: optimism, courage, work ethic, future-mindedness, interpersonal skills, the capacity for pleasure and insight, and social responsibility. Similarly, Jeste et al. pointed to how a growing body of research shows that higher levels of PPCs, such as resilience, optimism, and social engagement are associated with objectively measured better health outcomes. You can watch a TED talk given by Seligman, “The New Era of Positive Psychology,” where he describes positive psychology.

Possible biomarkers for positive mental health were noted by Jeste et al. They were: allostatic load, telomere length, oxidative stress, neuroinflammation and immune function. The authors then ran through the “association” of several positive psychological characteristics (PPCs) with biological factors. Jeste et al. believed that by strengthening the development of positive traits through psychotherapeutic, behavioral, social and biological interventions, “positive psychiatry has the potential to improve health outcomes and reduce morbidity as well as mortality.”

Instead of being narrowly defined as a medical subspecialty restricted to the management of mental illnesses, psychiatry of the future will develop into a core component of the overall health care system. Psychiatrists will thereby more explicitly reclaim their role as physicians in addition to their roles as mental health professionals. Clearly, much more work is needed to make positive psychiatry a norm in psychiatric practice, but it is time to start that process.

I’m troubled by the rhetoric of the so-called “positive psychiatry” movement. On the one hand, it is encouraging to hear an eminent psychiatrist like Dr. Jeste call for attention and research into positive psychological traits. Psychiatry has concentrated on the prevention and management of pathology, while it largely ignored positive psychological traits like resilience, optimism and self-efficacy and how important they are in preventing and managing pathology. This next quote, taken from the Jeste et al. article, succinctly captures both what encourages me and sends chills up my spine: “The time has come to integrate positive mental health into psychiatric practice, training, and research and to expand psychiatric expertise to encompass the full spectrum of mental functioning.”

The time has come to consider positive mental health in psychiatry. However, the expansion of psychiatric “expertise” and the authority that will accompany such expertise in modern society is not a positive outcome for society. It has disturbing social and political dimensions that were foreseen and noted by psychiatrist Thomas Szasz over fifty years ago. In his 1977 work, The Theology of Medicine, he said:

In the scientific-technological concept of the state, therapy is only a means, not an end: the goal of the therapeutic state is universal health, or a least unfailing relief from suffering. The untroubled condition of man and society is a quintessential feature the medical-therapeutic perspective on politics: conflict among individuals, and especially the individual and the state, is invariably seen as a symptom of illness or psychopathology; and the primary function of the state is accordingly the removal of such conflict through appropriate therapy—imposed by force if necessary. (Thomas Szasz, The Theology of Medicine, p. 128)

If we value personal freedom and dignity, we should, in confronting the moral dilemmas of biology, genetics, and medicine, insist that the expert’s allegiance to the agents and values he serves be made explicit and that power inherent in his specialized knowledge and skill not be accepted as justification for his exercising specific controls over those lacking such knowledge and skill. (Thomas Szasz, The Theology of Medicine, p. 17)

It seems that within “positive psychiatry,” psychiatrists are seeking to not only maintain their hegemony over preventing and managing pathology, but expand it to “encompass the full spectrum of mental functioning.” There has been a growing concern with the failed promises of psychiatry, such as the identification of biological or genetic cause in the “mental illness.” Critiques of DSM diagnosis have come from within psychiatry from individuals such as Allen Frances and Thomas Insel. Frances was the chair for the DSM-IV. Insel is the Director of the National Institute of Mental Health (NIMH). In Saving Normal, Frances’s critique of the DSM-5 and the medicalization of everyday life, he said: “Unfortunately, the DSM approach has been far too influential—dominating the field in a way we never intended.” Insel announced before the publication of the DSM-5 that the NIMH would be “reorienting its research away from DSM categories” (see “Psychiatry Has No Clothes”).

It was encouraging to hear Dr. Rettew acknowledge how psychiatry has been having an identity crisis. He alluded to the dominance psychiatry had as “skilled therapists” when it was ruled by psychoanalytic thought. But there is another way to see the consequences of the “explosion of neuroscience” and the “promise of medications.” Just as the reliability and validity of psychiatric diagnosis was effectively questioned, and from within and outside psychiatry, and psychiatrists faced losing their social status and power, they reframed diagnosis along purely biological guidelines and aligned themselves with the pharmaceutical industry.

As Rettew said: “Recent research has revealed that many of the risks of medications may have been under appreciated while the benefits somewhat overblown.” He noted how neuroscience research has been impressive, but lacking immediate clinical applications. Despite the promise that these results may eventually help improve early identification and facilitate effective treatment with a variety of disorders, “in reality there remains a large number of dots to connect before that actually happens.”

Positive psychiatry seems to be about maintaining hegemony in the face of another serious challenge to its authority. It is not humbly admitting the limitations of a purely biochemical explanation for human behavior, it’s just “kicking the can” of research further down the road. The reductionism of the medical model is still at the heart of how positive psychiatry views psychopathology. Biology is still the “root” of positive psychiatry. Jeste et al. said:

As a branch of medicine, positive psychiatry is rooted in biology and seeks to decipher biological underpinnings of PPCs [positive psychosocial characteristics] and eventually promote health and well-being through psychosocial/behavioral and biological interventions.

Jeffery Liebeman, the president of the APA immediately after Dr. Jeste, has published a book, Shrinks, that purports to tell the story of how psychiatry overcame its dubious past. Lieberman seems more willing to acknowledge the still dominant medical model in psychiatric diagnosis and treatment. With regard to the field of psychiatry, he said: “Ever since the very earliest psychiatrists began conceiving of disturbed behaviors as illnesses (and even long before), they held out hope that direct manipulation of a patient’s brain might one day prove therapeutic” (Shrinks: The Untold Story of Psychiatry, p. 160). With regard to diagnosis, he said: “The DSM-III turned psychiatry away from the task of curing social ills and refocused it on the medical treatment of severe mental illnesses.” (Shrinks, p. 147)

Research into the impact of positive psychological characteristics on mental functioning and psychopathology is certainly a good thing, but it is positively NOT psychiatry that should have a controlling, leading role in that research. Its seemingly positive and hopeful view of the future is based upon seeing humanity as biological machines. While I don’t think this would lead to the dystopian future, like that portrayed in the Terminator movies, the rise of the biological machine would be just as apocalyptic. For an alternative way of doing psychiatry, see “Psychiatry Is Not Neurology.”

10/7/15

Psychiatry, Diagnose Thyself! Part 2

Similar to what happened to Robert Spitzer, just as Jeffrey Lieberman released his “untold story of psychiatry” in Shrinks and began his book tour, the very themes he presented as the uncensored truth about psychiatry were being challenged by others. Whose story about psychiatry and its history would the public believe? Although Lieberman did acknowledge in his CBC interview that he was “unfortunately” familiar with Robert Whitaker, he didn’t elaborate on how far back their acquaintance goes.

Like his description of David Rosenhan in Shrinks, Lieberman attempted to discredit what Whitaker and T. M. Luhrmann had to say by his ad hominem assessment of them (see “Psychiatry, Diagnose Thyself! Part 1”). Luhrmann’s work on psychiatry, Of Two Minds, received several awards, including the Victor Turner Prize for Ethnographic Writing and the Boyer Prize for Psychological Anthropology. Anatomy of an Epidemic by Whitaker won the 2010 Investigative Reporters and Editors book award for best investigative journalism. And in 1998, he co-wrote a series on psychiatric research for the Boston Globe that was a finalist for the Pulitzer Prize for Public Service. It was while writing this series of articles that Lieberman and Whitaker first became acquainted with each other.

The first installment of the series, “Testing Takes Human Toll” was published on November 15, 1998. In this article, Whitaker and others described how beginning in 1972, psychiatric researchers used a variety of agents such as methylphenidate (Ritalin, Concerta), ketamine, and tetrahydrocannabinol (THC) “to deliberately provoke psychotic symptoms in more than 1,200 schizophrenic patients.” In some cases, the level of psychosis experienced by these patients was called “severe.” Jeffrey Lieberman was one of those researchers. He conducted methylphenidate challenge tests for more than a decade.

Here is a sampling of three articles where Lieberman was a co-author of studies where methylphenidate was given to schizophrenic patients in order to activate psychotic symptoms.

In a 1987 study, 34 stable outpatients receiving neuroleptic treatment were given an infusion of methylphenidate and then withdrawn from their neuroleptic medication. Three weeks after they were withdrawn from their psych meds, they were given another infusion of methylphenidate. Then the unmedicated patients were followed up for 52 weeks—or until they relapsed; in other words their symptoms returned.

A 1994 study had a similar methodology, 41 stable patients receiving neuroleptic treatment were given an infusion of methylphenidate. They were also withdrawn from their neuroleptic meds and followed for 52 weeks, or until relapse.

In a 1990 study, 38 patients who met the criteria for schizophrenia or schizoaffective disorder were given an infusion of methylphenidate, followed by a regimen of standard acute neuroleptic treatment. This time the patients were individuals who were experiencing their first acute episode of psychosis. The methylphenidate produced an increase in psychopathology reflected by a worsening of their symptoms.

Another 1987 article with Lieberman as a co-author was a meta-analysis of 36 studies that used psychostimulants (PS) in schizophrenia. The authors noted that non-amphetamine drugs like methylphenidate appeared to have a greater “psychotogenic potency.” In other words, they elicited a greater psychotic reaction than amphetamine drugs. “Approximately 40% evidence a psychotogenic response to PS administration in doses that are subpsychotogenic in normal’s.” Don’t miss the fact that Lieberman knowingly used a psychostimulant in his own studies that he knew would elicit a greater, more intense psychotic reaction than amphetamine drugs.

Psychologist Bruce Levine gave a scathing response to Lieberman’s “menace to society” remark concerning Whitaker. He unpacked the pre-1994 studies and questioned the claim that the subject and family members were willing and able to sign informed consent. Levine said: “Who in their right mind would give consent for themselves or for a family member for a procedure that was hypothesized to make a patient worse?”

When Whitaker interviewed Lieberman for the first article in the Boston Globe series, “Testing takes human toll,” Lieberman admitted that the induced symptoms were sometimes “scary and unpleasant.” He even acknowledged that some patients get worse. “But in my experience, the symptoms never exceeded the range of severity that occurred in the course of their illness previously.” Ironically, Lieberman was entirely silent on the topic of schizophrenic challenge studies in Shrinks. They weren’t even discussed as one of the positive examples of how modern psychiatry “now practices an enlightened and effective medicine of mental health.”

Dr. Davis Shore, who was doing ketamine challenge studies for the NIMH, minimized the harm done to patients in challenge studies. He argued that the increase in symptoms was very short-lived in patients who had experienced them over years. ‘”To say that increasing a particular symptom – like hearing voices for a couple of hours in somebody who has been hearing voices for 10 years – is causing [suffering] rather seems like a stretch.” Here is a 1987 account of one such “stretch” Whitaker saw reported in the scientific literature. The individual was a patient with bipolar disorder who was injected with methylphenidate.

Within a few minutes after the infusion, Mr. A experienced nausea and motor agitation. Soon thereafter he began thrashing about uncontrollably and appeared to be very angry, displaying facial grimacing, grunting and shouting … 15 minutes after the infusion, he shouted, ‘It’s coming at me again, like getting out of control. It’s stronger than I am.’ He slammed his fists into the bed and table and implored us not to touch him, warning that he might become assaultive. Gradually over the next half hour, Mr. A calmed down and began to talk about his experience.

Whitaker’s 1998 series for the Boston Globe is still a worthwhile read. Part 2, written by Deborah Kong, gives more details on “Debatable forms of consent.” She noted how researchers have conceded in court documents that they did not tell mentally ill patients the whole truth for fear of scaring them away from enrolling in the experiments. Part 3 by Robert Whitaker, Lures of riches fuels testing, looks at the influence of the pharmaceutical industry on drug research. In Part 4, “Still no solution in the struggle on safeguards,” Dolores Kong wrote about how the psychiatric community has argued that challenge and washout studies are important avenues to understanding the underlying biology of mental illness. “To this day, some psychiatric specialists are conducting medical experiments in which research subjects are allowed to grow sicker.”

On May 6, 2015, Robert Huber received a letter of apology from the University of Minnesota saying that the university was sorry that his “rights and welfare were compromised.” In July of 2007, Huber was admitted to the University of Minnesota Medical Center with symptoms of schizophrenia, where he was for two weeks. During that time, he was recruited daily to volunteer for a drug trial for an experimental drug called bifeprunox. He was repeatedly told the drug was safe, even though determining safety was one of the goals of the study. In the process of his recruitment for the study, he was also shown “the cost of his hospital care if he didn’t sign up and have the study pick up the tab.”

But there were problems. He experienced severe abdominal pains, which required two ER visits. His records indicated that the doctor in charge of the study thought it unlikely that they were due to the medication. At one point, he contemplated suicide because of the pain. In August of 2007, the FDA decided to not approve bifeprunox, but Huber was not informed of that decision and remained in the study until he withdrew in October of 2007. The university also acknowledged that he was not informed in his consent form of the risks of a medication washout that was necessary before starting the new medication, bifeprunox.

There are several concerns with these kinds of psychiatric research methods. The giving and withholding of medication may create unique risks for the subject. Individuals diagnosed with schizophrenia are at a greater risk of suicide during relapses. Adverse events of all types are more likely to occur as medications are increased or decreased in dosage. George Annas, chair of Health Law Department at Boston University School of Public Health said: “We let researchers do things to people with mental illness that we would never let them do to people with physical illness.”

There are three basic research designs with medications in psychiatry: placebo, washout (where medication is tapered and withdrawn), and challenge (symptoms are provoked in some way). In “Ethics in Psychiatric Research: Study Design Issues,” Gordon DuVal gave a helpful summary of these three research designs. His conclusion was:

Despite a history that has included serious abuses, psychiatric research is important—not least to those who suffer from mental illness. Clinical psychiatric research creates challenging ethical dilemmas. The choice of research design can have significant implications for subject safety and must be carefully considered. While these issues are not necessarily unique to this context, the particular vulnerabilities attending psychiatric illness merit close attention in the design of research involving persons with psychiatric disorders.

DuVal singled out challenge studies as particularly risky, despite the potential research benefits. The risk is that someone who is already sick or vulnerable to a negative response to the challenge “may have harmful symptoms provoked or exacerbated or may suffer a relapse.” He said it was unclear whether the balance of risks and potential benefits can ever justify people in studies where “potentially harmful responses are intentionally induced.” But this is exactly what schizophrenic challenge studies done by Lieberman and others were designed to do. They often have a washout element, which heightens the ethical concerns. “Finally, for practical reasons, challenge studies often require that subjects be deceived, or at best partially informed, about the details of the study.”

A search in Google Scholar found 1,030 entries for “challenge studies”, psychiatry since 2011. This suggests that some psychiatric specialists are still conducting medical experiments in which individuals with various mental illnesses are allowed to grow sicker, and even triggered to so do, in the name of science. This technique is seen as a valuable and necessary element in psychopharmacological research. D. C. D’Souza and J. H. Krystal said in 2001 that: “Psychopharmacological challenge studies have made significant contributions to understanding the neurobiological basis of psychiatric disorders.” They may continue to provide an important method of testing pathophysiologic mechanisms and studying potential pharmacotherapies.

So here’s what I’m thinking. Dr. Jeffery Lieberman writes a book that is supposed to be the untold story of psychiatry for the general public. But he is totally silent in Shrinks about research where psychiatric symptoms are triggered in patients by challenge agents. It’s not given as an example of the scientific standing of the field or the revolutionary process in psychiatry over the past fifty years. His past use of the methods, coupled with his silence, also suggests he still believes that it has a place in psychiatric research. And it certainly is not given as an example of psychiatry’s “long sojourn in the scientific wilderness” in Shrinks along with lobotomies, coma therapy, and fever cures.

Could he have decided to not mention challenge studies, because he thought the public would not accept them or would misunderstand their importance? Worse still, similar to the Rosenhan study, would they be seen as an example of the bankruptcy of psychiatry? Robert Whitaker could connect the dots for the general public between Lieberman and his past challenge studies, so did he become a particular target for marginalization and discrediting by Lieberman? Another possibility is that discussing challenge studies complicates the story of progress and heroism Lieberman wanted to tell in Shrinks. His goal does seem to have been a retelling of the same old rhetoric put forth by the APA since 1980. As Whitaker observed in his review of Shrinks, this mantra was:

The disorders in the DSM are real diseases of the brain; the drugs prescribed for them are quite safe and highly effective; and psychiatric researchers are making great advances in discovering the biology of mental disorders. Therapeutic and research progress are to be found at every turn.

It will be interesting to see what the future holds for psychiatry. Does the given rhetoric of the APA hold sway, or will the growing questions about psychiatry and diagnosis lead to another revolutionary change. Will the public continue to believe Lieberman’s version of the untold story of psychiatry; or will they begin to see it in light of what Whitaker has written? Stay tuned.

09/30/15

Psychiatry, Diagnose Thyself! Part 1

Wow. I can hardly believe he said the things he did. Dr. Jeffery Lieberman, a former president of the American Psychiatric Association and the Chairman of the Department of Psychiatry at the Columbia University College of Physicians and Surgeons, took umbrage at an op-ed article written in The New York Times on January 17, 2015 by Stanford anthropologist T.M. Luhrmann, “Redefining Mental Illness.” Luhrmann referred in her article to a report by the British Psychological Society, “Understanding Psychosis and Schizophrenia,” that suggested interpreting paranoid feelings and hearing voices as symptoms of mental illness was only one way of thinking about them. She indicated the report said antipsychotic medications were sometimes helpful, but “there is no evidence that it corrects an underlying biological abnormality.” It went on to warn about the risks of taking these medications over the long term.

In a Medscape video “What Does The New York Times Have Against Psychiatry?” Lieberman referred to the NYT publication of her article as “journalistic opportunism.” He chided the editors for thinking that “providing a platform for this would be useful.” With regard to Luhrmann, he cited the title of her books, whose subject areas dealt with religion and God, witches, and psychiatry. Yes, they were eclectic topics, but how does that then lead him to this comment:

The equating of psychiatry with these other topics suggests that she thinks of psychiatry not as a hard science but as something that is either a philosophical or religious discipline, has a supernatural or religious dimension, or is in the realm of the supernatural.

I’ve read two of her books, Of Two Minds and When God Talks Back, and for the life of me I cannot follow how he can make that connection. There was not association of psychiatry with witchcraft or religion on Luhrmann’s part in her NYT article; I can only conclude the association was somehow in Lieberman’s mind, not Luhrmann’s article.

But she did comment how there was plenty of scientific evidence for the report’s claims. She then had the audacity to mention that the National Institute of Mental Health (NIMH) announced in 2013 that it would no longer pursue diagnosis-driven research. Under a program called Research Domain Criteria (RDoC), all research would begin from a matrix of “functional dimensions, grouped into broad domains such as cognition and reward-related systems.” One example she gave from the RDoC site was how psychiatric researchers would no longer study people with anxiety. Rather they would study fear circuitry.

Lieberman went on to name some additional publications by Lurhmann, and said: “This hearkens back to the days when psychiatry had only fanciful theories about the mind and what caused mental illness in people.” Thankfully, he said we are well past that. Articles like Luhrmann’s, according to Lieberman, are a throwback to the days of ignorance and fear; and they spread stigma.

Why would The New York Times do this? It is very disturbing that we still live in an age when the stigma of mental illness and the lack of interest in trying to present medical science as it deserves and needs to be for an informed public, is still preyed upon by this kind of journalistic opportunism.

Then Lieberman was interviewed on CBC radio podcast, “The Sunday Edition” on April 26, 2015. He was there to promote his new book, Shrinks, a history of psychiatry for the general public. After playing an excerpt of an interview he did over a year ago with Robert Whitaker, the host asked Lieberman to comment on what Whitaker had said in the excerpt. Lieberman said: “What he says is preposterous. He’s a menace to society because he’s basically fomenting misinformation and misunderstanding about mental illness and the nature of treatment.”

But he wasn’t finished. Lieberman went on to say how Whitaker “ostensibly considers himself to have been a journalist.” Whitaker has won awards for his journalism and was even a finalist for a Pulitzer in Public Service. But Lieberman lamented: “God help the publication that employed him.” Lieberman also thought Whitaker’s comments that some unmedicated patients did better than medicated ones were absolutely wrong. If you did a randomized, controlled study of any of the various psychiatric illnesses, using whatever is state of the art in psychiatry, including medication, Lieberman said: “the outcomes will be extraordinarily superior in the treated group.”

This led to “A Challenge to Dr. Lieberman” by Whitaker on his website for Lieberman to provide a list of randomized studies that show how medicated patients have a much better long-term outcome than unmedicated patients. He noted how he had posted the abstracts of the studies he cited in his book, Anatomy of an Epidemic on his website, madinamerica.com. “So here is you chance to point to the studies I left out.”

1 Boring Old Man commented on this outburst by Dr. Lieberman and Whitaker’s reply, observing how Lieberman sees himself as the spokesman and champion for “Psychiatry.” His article also described the Lieberman rant against Lurhmann and also cited several articles written by Lieberman over the past few years with the same theme. I’d just finished reading Lieberman’s book and was struck in reading 1 Boring Old Man’s article by how it seemed Lieberman was casting himself in a role similar to the one he gave Robert Spitzer in Shrinks. Spitzer was portrayed there as an unlikely hero and a psychiatric revolutionary who, in effect, saved psychiatry from imploding during the 1970s. Psychiatry today seems to be in similar situation, with questions being raised about the current validity and reliability of DSM diagnosis, and the credibility of psychiatry itself.

So if Lieberman sees himself as a modern psychiatric hero, then Robert Whitaker would be a natural pick by Lieberman as an antipsychiatry foil, replacing David Rosenhan, who was a “foe” of psychiatry in the 1970s. In Shrinks, Lieberman discussed the controversies over the DSM-5, saying the APA hadn’t experienced that kind of public pressure since the early 1970s, “when the Rosenhan study, the homosexual controversy, and the antipsychiatry movement compelled the APA to move away from psychoanalysis and endorse a radically new paradigm for psychiatric diagnosis. See “A Censored Story of Psychiatry, Part 1, Part 2” and “The Quest for Psychiatric Dragons, Part 1, Part 2” for more on Spitzer, Rosenhan and these issues.

In his role as a “foe of psychiatry,” Whitaker has published three well-received books by both the general public and individuals within the mental health profession that are critical of the current state of psychiatry and mental healthcare. His most recent book, Psychiatry Under the Influence, was just released on April 23, 2015.

So we have these successive actions: Lurhmann’s article published in the NYT on January 17th. Three days later Lieberman recorded his Medscape response, which was published online on February 18, 2015. The release date for Lieberman’s book, Shrinks, was on March 10, 2015. Whitaker’s review of Shrinks appeared on his website, Mad in America on March 19th. The release date for Whitaker’s book, Psychiatry Under the Influence, was on April 23rd. Lieberman’s CBC interview was on April 26, 2015. Whitaker’s invitation to Lieberman was on April 26th as well.

I don’t think he’ll take Whitaker up on his challenge. He can’t. The science doesn’t support his position. Go to madinamerica.com and read through the abstracts mentioned above by Whitaker to confirm this. But why would one of the top psychiatrists of our time write and say such obvious drivel?

It’s all PR. In his review of Shrinks, Whitaker noted how Shrinks doesn’t tell a previously unknown tale. Rather, it “relates a story that the American Psychiatric Association has been telling the American public ever since it published DSM III in 1980.” Whitaker and Cosgrove noted in Psychiatry Under the Influence that by adopting a disease model and insisting psychiatric disorders were discrete illnesses in the 1970s, the APA simultaneously responded to its antipsychiatry critics and addressed its image problem by presenting itself to the public as a medical specialty. “Metaphorically speaking, psychiatry had donned a white coat.” Whitaker pointed out in his review how Lieberman wore a doctor’s white coat for a promotional video he did on YouTube, where he discusses his book. I noticed that he did the same thing for his Medscape video critique of Lurhmann and the NYT.

Whitaker said Shrinks provided a revealing self-portrait of psychiatry as an institution. Lieberman repeats the same story the APA has been telling the public since the publication of the DSM-III. “And it is this narrative, quite unmoored from science and history, that drives our societal understanding of mental disorders and how best to treat them.” He observed that Lieberman diagnosed the Freudians as extravagant, grandiose and having irrational faith in its world-changing powers. The same symptoms seemed to be present in Shrinks.

09/23/15

Psychiatry Is Not Neurology

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Psychiatry is not neurology; it is not a medicine of the brain. Although mental health problems undoubtedly have a biological dimension, in their very nature they reach beyond the brain to involve social, cultural and psychological dimensions. These cannot always be grasped through the epistemology of biomedicine. The mental life of humans is discursive in nature.

Wow. I want to get in contact with a psychiatrist in the Pittsburgh area who believes and practices their profession consistent with this position. The article from which I took the opening quote, “Psychiatry beyond the current paradigm,” is reminiscent of Thomas Szasz, who presented his argument that mental illness was a myth in his seminal book, The Myth of Mental Illness. His original article of the same title, “The Myth of Mental Illness,” is available on the website, Classics in the History of Psychology.

Szasz said that the notion of mental illness assumed that there was some neurological defect, “perhaps a very subtle one,” behind all disorders of thinking and behavior. “The crux of the matter is that a disease of the brain, analogous to a disease of the skin or bone, is a neurological defect, and not a problem in living.” Pat Bracken et al., who wrote “Psychiatry beyond the current paradigm” for The British Journal of Psychiatry, were more nuanced. They acknowledged the undoubted biological dimension in mental health problems, but also admitted the reality of other dimensions beyond the grasp of “the epistemology of biomedicine.” They believe the biomedical dimension should be a secondary—not the primary—consideration in psychiatry.

A “biomedical idiom” has guided psychiatry’s understanding of mental health problems. Problems with feelings, thoughts, and behaviors were thought to be capable of exploration and understanding just like our livers and lungs. The scientific tools and methods used to investigate problems with biological life would help unlock the secrets of mental life. In recent decades, even models of cognitive psychology have been developed to work within this “technological paradigm.” Its main assumptions made are:

The problem to be addressed is that of a faulty mechanism in the individual.
The mechanism or process can be modeled in causal terms; it can be described in a universal way that works regardless of the context.
Technological interventions are instrumental.

In the technological paradigm, mental health problems can be mapped and categorized with the same causal logic used in the rest of medicine, and our interventions can be understood as a series of discrete treatments targeted at specific syndromes or symptoms. Relationships, meanings, values, cultural beliefs and practices are not ignored but become secondary in importance. This order of priorities is reflected in our understanding of the training needs of future psychiatrists, what gets published in journals, what topics are selected for analysis at conferences, [and] the types of research that are promoted.

Bracken et al. said the overall evidence did not support the idea that mental health problems were best understood through this technical paradigm. While medical knowledge was relevant, “the problems we grapple with cry out for a more nuanced form of medical understanding and practice.” Psychiatrists need to develop an approach to mental health problems that is genuinely sensitive to the interplay of forces (biological, psychological, social and cultural) that underlie them.

Pat Bracken said in a lecture he gave at the University of Copenhagen in 2012, that: “The realm of mental health is one area of human life that cannot be grasped in a purely technical way.” He argued that psychiatry is very much a product of the cultural shift brought on by the Enlightenment. Without the Enlightenment, Bracken believes we would not have the discipline of psychiatry as it exists today. The attention to unreason, came as a byproduct of the Enlightenment emphasis on rationality or reason. It also gave rise to the isolation and confinement of the “mentally ill.”

As a result, they became the subject matter for the new discipline to study, theorize and treat. There could now be a “science” of madness and distress, with its own experts and authorities. The new medical specialty sought to frame all its problems within a modernist, scientific and technical idiom. This grew to become the technological paradigm of psychiatry. Now it’s the dominant paradigm of psychiatry and mental health. “It underscores not just the medical model in psychiatry, but many of the alternatives being argued for at present.”

This technological approach is the foundation of the medical model of psychiatric “disease,” some of the psychological approaches to mental health, and positivist forms of social science. The only questions asked by this approach are: does it work; is it efficient; and is it cost effective. The technological paradigm shapes the classification systems of mental health problems (the DSM-5 and the ICD-10), the research into mental health problems, and the delivery system of clinical care. This is particularly true in the concept of “evidence-based medicine,” which has become the standard for many aspects of clinical care. Looking for a specific technical “fix” for a condition pushes the less technical issues to the periphery. They are still acknowledged, but are seen as secondary issues or causes.

In an article published in the journal World Psychiatry, Bracken detailed how psychiatry is currently going through a crisis of confidence. He argued the need for a hermeneutical shift in psychiatry. And if it is to be truly “evidence-based,” psychiatry needs to radically rethink its guiding epistemology, namely that of the technological paradigm. “We need a radical rethinking of our guiding epistemology: a move from reductionism to hermeneutics.” He rejected the heralded Research Domain Criteria (RDoC) project (see “Psychiatry Has No Clothes;” or “Psychiatry’s Mythical Phoenix;” or “The Quest for the Holy Grail of Psychiatry”) as a “quintessentially technological view of the future” that conceptualizes mental illnesses as brain disorders. He believes such an approach is simply inadequate.

Good psychiatry, he contends, involves a “primary focus on meanings, values and relationships,” both in terms of how patients are helped and where their problems come from. When the word “mental” is put in front of the word “illness,” it demarks “a territory of human suffering that has issues of meaning at its core. This simply demands an interpretive [hermeneutical] response.”

I do not believe that we will ever be able to explain the meaningful world of human thought, emotion and behaviour reductively, using the “tools of clinical neuroscience”. This world is simply not located inside the brain. Neuroscience offers us powerful insights, but it will never be able to GROUND a psychiatry that is focused on interpretation and meaning. Indeed, it is clear that there is a major hermeneutic dimension to neuroscience itself. A mature psychiatry will embrace neuroscience but it will also accept that “the neurobiological project in psychiatry finds its limit in the simple and often repeated fact: mental disorders are problems of persons, not of brains. Mental disorders are not problems of brains in labs, but of human beings in time, space, culture, and history.”

Pat Bracken has an intriguing background. Not only is he a clinical psychiatrist, he also has a Ph.D. in philosophy. His thoughts can be found in various places online. Here is a link for “Bracken” on Mad in America. He helped found the UK division of the International Critical Psychiatry Network (ICPN). He’s co-written Postpsychiatry: A New Direction for Mental Health. Currently he is the Clinical Director of the Mental Health Service in West Cork, Ireland. Sadly he lives too far away to consult on cases in the Pittsburgh area.

08/19/15

A Censored Story of Psychiatry, Part 2

I was taken aback by Lieberman’s tone in describing Rosenhan as scornfully observing that no staff raised an issue of the apparent sanity of the pseudopatients in his famous study: “Being Sane in Insane Places.” Lieberman then said Rosenhan “saw another opportunity to inflict damage on psychiatry’s crumbling credibility.” Actually, a research and teaching hospital had been vocally saying that they doubted that such an error could occur in their hospital. So Rosenhan approached them and proposed that over a three month time period (not a year, as Lieberman claimed in what he indicated was a direct quote), “one or more pseudopatients would attempt to be admitted into the psychiatric hospital.” Here is what Lieberman wrote concerning what Rosenhan did:

He approached a large prestigious teaching hospital that had been especially vocal in contesting Rosenhan’s finding with a new challenge: “Over the coming year, I will send in another round of imposters to your hospital. You try to detect them, knowing full well that they will be coming, and at the end of the year we will see how many you catch.”

Rosenhan reported that the hospital staff members rated each patient on the likelihood of being a pseudopatient. Judgments were obtained on 193 patients admitted for psychiatric treatment. All staff members that had contact with the patients were asked to make judgments. Forty-one admissions were judged with high confidence to be pseudopatients. “Twenty-three were considered suspect by at least one psychiatrist. Nineteen were suspected by one psychiatrist and one other staff member.” Rosenhan then said: “Actually, no genuine pseudopatient (at least from my group) presented himself during this period.” Rosenhan encapsulated the question raised by his study in the provocative opening sentence of his article: “If sanity and insanity exist, how shall we know them?”

Psychiatry was at a crucial time of its history in 1973. Rosenhan’s article was published in January of 1973. Lieberman reported that the Board of Trustees for the American Psychiatric Association (APA) called an emergency conference in February of 1973 “to consider how to address the crisis and counter the rampant criticism.” He said that the Board realized that the best way to counter the “tidal wave of reproof” was to produce a fundamental change in how mental illness was “conceptualized and diagnosed.” They authorized the creation of a third edition of the Diagnostic and Statistical Manual, the DSM.

The APA eventually appointed Robert Spitzer to chair the revision process of the DSM-III, which was a radical change in how psychiatric diagnosis was done and how mental illness was conceptualized. As Robert Whitaker and Lisa Cosgrove reported in Psychiatry Under the Influence, the DSM-III was an instant success. “In the first six months following its publication, the APA sold more copies of its new manual than it had previously sold of its two prior DSM editions combined.” The DSM was adopted by insurance companies, the courts, governmental agencies, colleges and universities. It structured discussion in psychology textbooks. It was required to do research in the U.S. and eventually abroad as well. “DSM III became psychiatry’s new ‘Bible’ throughout much of the world.” Lieberman claimed:

The DSM-III turned psychiatry away from the task of curing social ills and refocused it on the medical treatment of severe mental illnesses. Spitzer’s diagnostic criteria could be used with impressive reliability by any psychiatrist from Wichita to Walla Walla.

What’s missing from this triumphal rhetoric is the battle waged by Spitzer against Rosenhan’s study and its implications as he and others worked to revise psychiatric diagnosis—and its reliability problems. In the 1980 issue of the Journal of the American Academy of Child [& Adolescent] Psychiatry, Michael Rutter and David Shaffer, both academic psychiatrists, were critical of the published reports of reliability studies done of the DSM-III field trials. Referring to two 1979 published reports by Spitzer, they commented that while the studies were useful, “as pieces of research they leave much to be desired.”

Both reports concern the reliability study which involved clinicians “from Maine to Hawaii.” Unfortunately this impression of spread is largely spurious in that the reliability concerned agreements only between close colleagues (each clinician chose his own partner in the study). . . . Of course, we are acutely aware of the difficulties involved in such field studies and it may well be that this was the best that could be done within the time and resources available. However, the findings do little to provide a scientific basis for DSM-III.

Note how Rutter and Shaffer’s comments about: “clinicians from Maine to Hawaii” applies equally to Lieberman’s rhetoric on: “any psychiatrist from Wichita to Walla Walla.” Both Psychiatry Under the Influence and The Selling of DSM have more comprehensive critiques of the claimed success in conquering reliability and validity problems with psychiatric diagnosis. But Lieberman’s “uncensored history” of psychiatry in Shrinks is completely silent on this well documented dispute. Ironically, in the same issue of the Journal of the American Academy of Child Psychiatry, Spitzer and Cantwell described how the DSM-III was “considerably more inclusive and more comprehensive,” than its predecessor, the DSM-II.

In a disclaimer paragraph on the page before the Shrinks Table of Contents, Lieberman said that bucking the convention in academics of using ellipses or brackets in quotations, he avoided them. “So as to not interrupt the narrative flow of the story.” But he assured us that he made sure that any extra or missing words did not change the original meaning of the speaker or the writer. So he did not use an author-date reference system that included endnotes with references and page numbers for the quotes he cited. But he did say the sources of the quotes are all listed in the Sources and Additional Reading section. And if you wanted to see the original versions of the quotations, they were available at: www.jeffreyliebermanmd.com. When I checked the website at the end of July 2015, they were not available for download or viewing on any page.

As I think I’ve demonstrated, Dr. Lieberman made some very specific claims about David Rosenhan’s professional background and expertise that were false. His presentation of the famous Rosenhan study appeared to be distinctly biased and inaccurate in places. He presented as a quote of David Rosenhan something that he did not say in “Being Sane in Insane Places.” Was it a quote from another source, perhaps someone else claiming the quoted material as what Rosenhan said? We don’t know and cannot know because Lieberman didn’t use conventional citations in presenting his storyline for Shrinks. He was tellingly silent on issues such as questions about the reliability of DSM-III diagnoses from the time of its publication.

Because of these and other problems with his version of psychiatric history, I did not find that Shrinks was “the uncensored story of how we [psychiatry] overcame our dubious past.” If anything, its dubiousness seems to be continuing into the present. But you won’t hear about those issues in Shrinks.

If you are interested in alternative views of psychiatric history, ones with endnotes and footnotes, I suggest you read Mad in America or Anatomy of an Epidemic by Robert Whitaker; Psychiatry Under the Influence, by Robert Whitaker and Lisa Cosgrove; or The Mad Among Us by Gerald Grob. Chapter two of Psychiatry Under the Influence, “Psychiatry Adopts a Disease Model,” gives a significantly more nuanced survey of psychiatric diagnostic history than Shrinks. Whitaker and Cosgrove’s use of the idea of guild interests of psychiatry was very helpful to me in putting Shrinks into perspective.

Be forewarned that Whitaker is not one of Lieberman’s favorite people. In a radio interview promoting his new book Shrinks, Dr Lieberman said that Whitaker was a “menace to society because he’s basically fomenting misinformation and misunderstanding about mental illness and the nature of treatment.” Here is a link to where this was reported on Whitaker’s website, Mad in America. There is also a link there to the original radio interview. Look around at the other material on the site, including further responses by Whitaker and others on Dr. Lieberman’s remarks.

08/12/15

A Censored Story of Psychiatry, Part 1

Doctor Jeffrey Lieberman, the Chair of Psychiatry at the Columbia University College of Physicians and Surgeons and a former president of the American Psychiatric Association (APA), recently wrote a book, Shrinks. It purports to tell the true story of how psychiatry grew from a pseudoscience into “a science-driven profession that saves lives.” But for me, it reads more like a piece of APA propaganda. What follows is an illustration of why I believe Shrinks is not a credible historical account of the history of psychiatry.

In his Introduction, Dr. Lieberman wrote: “As I write this, psychiatry is finally taking its rightful place in the medical community after a long sojourn in the scientific wilderness.” He added that psychiatry has earned much of its “pervasive stigma.”

There’s good reason that so many people will do everything they can to avoid seeing a psychiatrist. I believe that the only way psychiatrists can demonstrate just how far we have hoisted ourselves from the murk is to first own up to our long history of missteps and share the uncensored story of how we overcame our dubious past.

He said that modern psychiatrist now possesses the tools (medications?) to lead anyone “out of a maze of mental chaos into a place of clarity, care and recovery.” He said he is fortunate to be living through the time in history when psychiatry matured from “a psychoanalytic cult of shrinks into a scientific medicine of the brain.” But in concluding his book, he said he was under no illusion that “the specters of psychiatry’s past have vanished,” or that psychiatry has “freed itself from suspicion and scorn.” Notice the implication that any current suspicion or scorn of psychiatry is illegitimate, as its missteps are in the past.

Lieberman is aware that others disagree with his sense how psychiatry has become “a scientific medicine of the brain.” Again in his Introduction, he said: “The profession to which I have dedicated my life remains the most distrusted, feared, and denigrated of all medical specialties.” He then quoted from some of the rude and abusive emails he’s received. His comment was that such skeptics don’t look to psychiatry to help solve mental health problems. Rather, they see psychiatry itself as a mental health problem. While not explicitly using the term at this point, Lieberman does seem to be referring to what he calls the “antipsychiatry” movement.

This is a term that has been applied to individuals critical of some aspect psychiatry, or even psychiatry as an institution, since the 1960s. And Lieberman touched on and dismissed many of the historically big names tied to “antipsychiatry”: Thomas Szasz, R.D. Laing, and David Rosenhan. Here, I want to look at Lieberman’s portrayal of Rosenhan and give you an alternate perspective to his to illustrate why I see Shrinks as APA propaganda.

In an aside, Lieberman seems to have neglected to mention Dr. E. F. Torrey’s 1974 contribution to the antipsychiatry movement, The Death of Psychiatry. Torrey maintained that most of the so-called mentally ill are suffering from problems in social adaptation, not from diseases of the mind. He would later become affiliated with The Stanley Medical Research Institute (SMRI), where he is now an Associate Director. SMRI has spent over $550 million researching “brain diseases” like schizophrenia and bipolar disorder since it began in 1989. It seems Torrey changed his tune. Perhaps that’s why his antipsychiatry work wasn’t mentioned. Lieberman also cited Torrey as providing anecdotal evidence (no references or footnotes) that both Laing and Szasz eventually believed that schizophrenia was a brain disease, but would not sat so publically.

In chapter three of Shrinks, Lieberman described the impact of the classic 1973 study done by David Rosenhan, “Being Sane in Insane Places.” Another copy of the article is available here on a link from Harvard University. Lieberman gave an inaccurate and unfair gloss of Rosenhan as “a little-known Stanford-trained lawyer who had recently obtained a psychology degree but lacked any clinical experience.” As a matter of fact, David Rosenhan had a BA in mathematics from Yeshiva College (1951), an MA in economics (1953) and a PhD in psychology (1958), from Columbia University—the same academic institution to which Lieberman would become affiliated in his own professional career.

In addition, Rosenhan was a psychologist for the Counseling Center at the Stevens Institute of technology from 1954 to 1956; a lecturer at Hunter College and the director of research in the Department of Psychiatry at City Hospital at Elmhurst from 1958 to 1960. He was an assistant professor for the Departments of Psychology and Sociology at Haverford College from 1960 to 1962; a lecturer for the Department of Psychology and Psychiatry at the University of Pennsylvania from 1961 to 1964; a lecturer for the Department of Psychology at Princeton University from 1964 to 1968; a professor in the Department of Psychology and Education at Swarthmore College from 1968 to 1970; and a visiting professor in the Department of Psychology at Stanford University from 1970-1971. He was a professor of law and psychiatry at Stanford from 1971. The above biographical information on David Rosenhan was taken from a February 16, 2012 article from the Stanford Law School News announcing his death at 82 years old.

This information was readily available to anyone interested enough in David Rosenhan to do a simple online search. It certainly doesn’t agree with Lieberman’s dismissal of Rosenhan’s credibility. Here’s what David Rosenhan did in his study. He had eight “pseudopatients” (individuals with no history of serious psychiatric disorders) seek admission to 12 different psychiatric hospitals. They complained of hearing voices say “empty,” “hollow,” and “thump.” They were all admitted to the various hospitals. The eight pseudopatients consisted of a psychology graduate student in his 20s, three psychologists, a pediatrician, a psychiatrist, a painter and a housewife. Rosenhan was one of the three psychologists. Three pseudopatients were women and five were men.

Once admitted to the hospital, they stopped simulating any symptoms of abnormality and waited to see how long it took before they were released. Their length of stay at the hospitals ranged from 7 to 52 days, with an average of 19 days. None of the pseudopatients were indentified as such by hospital staff members. However, it was quite common for the patients to uncover the pseudopatients. Other patients in the hospitals were reported as saying things such as: “You’re not crazy. You’re a journalist, or a professor [referring to the continual notetaking]. You’re checking up on the hospital.” Rosenhan commented: “The fact that the patients often recognized normality when staff did not raises important questions.”

Lieberman said that claim was debatable, “since many nurses did record that the pseudopatients were behaving normally.” Actually, Lieberman’s comment is itself debateable. If nursing staff recognized the pseudopatients as normal, why was the average length of stay 19 days? If nursing staff recorded impressions that particular pseudopatients were behaving normally, it seems their observations were ignored or failed to result in speedy identification and release. Seven of the eight were admitted with diagnoses of schizophrenia and their discharge diagnoses were schizophrenia “in remission.”

What Rosenhan actually said was that the pseudopatients were to secure their own release from the hospital by convincing staff that they were sane. The psychological stressors associated with hospitalization were considerable and as a result, the pseudopatients were motivated to be discharged “almost immediately after being admitted.”

They were, therefore, motivated not only to behave sanely, but to be paragons of cooperation. That their behavior was in no way disruptive is confirmed by nursing reports, which have been obtained on most of the patients. These reports uniformly indicate that the patients were “friendly,” “cooperative,” and “exhibited no abnormal indications.”

Rosenhan’s study and its opening question, “If sanity and insanity exist, how shall we know them?” remains today a powerful question of the legitimacy of psychiatric diagnosis. He noted how most mental health professionals would insist they are sympathetic toward the mentally ill. But it is more likely that “an exquisite ambivalence” characterizes their relationships with psychiatric patients. The mentally ill, said Rosenhan, are society’s current lepers. Negative attitudes are the natural offspring of the labels patients wear.

A psychiatric label has a life and influence of its own. Once the impression has been formed that the patient is schizophrenic, the expectation is that he will continue to be szhizophrenic. When a sufficient amount of time has passed, during which the patient has done nothing bizarre, he is considered to be in remission and available for discharge. But the label endures beyond discharge. . . . Such labels, conferred by mental health professionals, are as influential on the patients as they are on his relatives and friends, and it should not surprise anyone that the diagnosis acts on all of them as a self-fulfilling prophecy.

Psychiatry had a guild interest at the time for revising psychiatric diagnosis. Citing an article by M. Wilson in their book, Psychiatry Under the Influence, Whitaker and Cosgrove noted where APA leaders felt psychiatry was under siege and worried that it could be headed for extinction.

Psychiatry in the 1970s faced a crisis of legitimacy and Rosenhan was one of its opponents who intensified the crisis. Although the publication of the DSM-III would become an answer to that crisis, Rosenhan’s study threatened to discredit psychiatry before that makeover could be accomplished—to recast psychiatry as “a science-driven profession that saves lives.” The censored history of psychiatry presented by Lieberman attempts to present “an extreme makeover” of a profession that may still be more “pseudo” than science. Whitaker and Cosgrove’s comment seems to hit the mark:

Remaking psychiatric diagnoses could be part of a larger effort by psychiatry to put forth a new image, which metaphorically speaking, would emphasize that psychiatrists were doctors, and that they treat real ‘diseases.’

Faith Seeking Understanding

Charles Sigler, D.Phil.

Tag Archives: psychiatry