06/9/17

Worse Results with Psych Meds

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Psych meds are popular. One in six U.S. adults (16.7% of 242 million) reported filing at least one prescription for a psychiatric medication in 2013. That increased with adults between the ages of 60 and 85, where one in four (25.1%) reported using psych meds. Only 9% of adults between the ages of 18 and 39 reported using one or more psych drugs. Most psychiatric drug use was long-term, meaning patients reported taking these meds for two years or more; 82.9% reported filling 3 or more prescriptions in 2013. “Moreover, use may have been underestimated because prescriptions were self-reported, and our estimates of long-term use were limited to a single year.”

The above findings were reported in a research letter written by Thomas Moore and Donald Mattison in JAMA Internal Medicine. Their findings got a fair amount of media attention, including articles in Live Science (here), The New York Times (here), Mad in America (here), Psychology Today (here) and even Medscape (here).

Moore said the biggest surprise was that 84.3% of all adults using psychiatric medication (34.1 million) reported using these meds long-term, meaning over two years. He said the high rates of long-term use of psych meds raises the need for closer monitoring and a greater awareness of the potential risks.

Both patients and physicians need to periodically reevaluate the continued need for psychiatric drugs. . . This is a safety concern, because 8 of the 10 most widely used drugs have warnings about withdrawal/rebound symptoms, are DEA Schedule IV, or both.

The ten most commonly used psychiatric drugs in ranked order were:

  1. Sertraline (Zoloft, an SSRI antidepressant)
  2. Citalopram (Celexa, an SSRI antidepressant)
  3. Alprazolam (Xanax, a benzodiazepine for anxiety)
  4. Zolpidem tartrate (Ambien, a hypnotic prescribed for sleep)
  5. Fluoxetine (Prozac, an SSRI antidepressant)
  6. Trazodone (an antidepressant often prescribed for sleep)
  7. Clonazepam (Klonopin, a benzodiazepine for anxiety)
  8. Lorazepam (Ativan, a benzodiazepine for anxiety)
  9. Escitalopram (Lexapro, an SSRI antidepressant)
  10. Duloxetine (Cymbalta, an SNRI antidepressant)

Drawing on data from a different source in “Drugs on the Mind” for Psychology Today, Hara Estroff Marano said the Institute for Healthcare Informatics (IMS) reported there were 4.4 billion prescriptions dispensed in 2015, with total spending on medicines reaching $310 billion. “Over a million of the prescriptions written for a psychiatric drug were to children 5 years of age or younger.” There were 78.7 million people in the U.S. using psychiatric meds. Within this group, 41.2 million were prescribed one or more antidepressants; 36.6 million were given anti-anxiety medications; and 6.8 million were given antipsychotics.

These figures were different than the percentages reported above from the Moore and Mattison study. Moore and Mattison found that 12% (29 million) reported using antidepressants; 8.3% (20 million) reported using anxiolytics and 1.6% (3.9 million) reported using antipsychotics. Their 1 in 6 (16.7%) figure would then be 40.4 million people using at least one psychiatric medication. Regardless of which data source you use, there are millions of U.S. citizens taking at least one psychiatric drug and therefore at risk of experiencing the adverse effects associated with these drug classes.

Anatomy of an Epidemic by Robert Whitaker described how psychiatric drugs seem to be contributing to the rise of disabling mental illness rather than treating those who suffer from it. What follows is a sampling of comments from Anatomy that he made about benzodiazepines (anxiolytics), which are widely used to treat anxiety and insomnia. Whitaker said long-term benzodiazepine use can worsen the very symptoms they are supposed to treat. He cited a French study where 75 percent of long-term benzodiazepine users  “. . . had significant symptomatology, in particular major depressive episodes and generalized anxiety disorder, often with marked severity and disability.”

In addition to causing emotional distress, long-term benzodiazepines usage also leads to cognitive impairment (137). Although it was thirty years ago that governmental review panels in the United States and the United Kingdom concluded that the benzodiazepines shouldn’t be prescribed long-term … the prescribing of benzodiazepines for continual use goes on (147).

In her article for Medscape, Nancy Melville pointed out the CDC found zolpidem (a so-called “Z” drug) was the number one psychiatric linked to emergency department visits. As many as 68% of patients used it long-term, while the drug is only recommended for short-term use. Up to 22% of zolpidem users were also sustained users of opioids.

Among the concerns with antidepressants are that they are not more effective than placebos (see discussions of the research of Irving Kirsch, starting here: “Do No Harm with Antidepressants”). In some cases they contribute to suicidality and violence (see “Psych Drugs and Violence” and “Iatrogenic Gun Violence”) and they have a risk of withdrawal symptoms upon discontinuation.

In a systematic review of the literature, Fava et al. concluded that withdrawal symptoms might occur with any SSRI. The duration of treatment could be as short as 2 months. The prevalence of withdrawal was varied; and there was a wide range of symptoms, encompassing both physical and psychological symptoms. The table below, taken from the Fava et al. article, noted various signs and symptoms of SSRI withdrawal.

The withdrawal syndrome will typically appears within a few days of drug discontinuation and last for a few weeks. Yet persistence disturbances as long as a year after discontinuation have been reported. “Such disturbances appear to be quite common on patients’ websites but await adequate exploration in clinical studies.”

Clinicians are familiar with the withdrawal phenomena that may occur from alcohol, benzodiazepines, barbiturates, opioids, and stimulants. The results of this review indicate that they need to add SSRI to the list of drugs potentially inducing withdrawal phenomena. The term ‘discontinuation syndrome’ minimizes the vulnerabilities induced by SSRI and should be replaced by ‘withdrawal syndrome’.

Updating his critique of the long-term use of antipsychotics in Anatomy of an Epidemic, Robert Whitaker made his finding available in a paper, “The Case Against Antipsychotics.” There are links to both a slide presentation and a video presentation of the information included in his paper. The breadth of material covered was difficult to summarize or select out some of the more important findings. Instead, we will look at what Whitaker said was the best long-term prospective study of schizophrenia and other psychotic disorders done in the U.S. The Harrow study assessed how well an original group of 200 patients were doing at various time intervals from 2 years up until 20 years after their initial hospitalization for schizophrenia. In his paper, Whitaker reviewed the outcome for these patients after 15 and 20 years of follow up.

Harrow discovered that patients not taking medication regularly recovered from their psychotic symptoms over time. Once this occured, “they had very low relapse rates.” Concurrently, patients who remained on medication, regularly remained psychotic—even those who did recover relapsed often. “Harrow’s results provide a clear picture of how antipsychotics worsen psychotic symptoms over the long term.” Medicated patients did worse on every domain that was measured. They were more likely to be anxious; they had worse cognitive functioning; they were less likely to be working; and they had worse global outcomes.

There is one other comparison that can be made. Throughout the study, there were, in essence, four major groups in Harrow’s study: schizophrenia on and off meds, and those with milder psychotic disorders on and off meds. Here is how their outcomes stacked up:

As Whitaker himself noted, his findings have been criticized from several individuals. However, he answered those critiques and demonstrated how they don’t really hold up. Read his paper for more information. But his conclusions about the use of antipsychotic medications are not unique. In the article abstract, for “Should Psychiatrists be More Cautious About the Long-Term Prophylactic Use of Antipsychotics?” Murray et al. said:

Patients who recover from an acute episode of psychosis are frequently prescribed prophylactic antipsychotics for many years, especially if they are diagnosed as having schizophrenia. However, there is a dearth of evidence concerning the long-term effectiveness of this practice, and growing concern over the cumulative effects of antipsychotics on physical health and brain structure. Although controversy remains concerning some of the data, the wise psychiatrist should regularly review the benefit to each patient of continuing prophylactic antipsychotics against the risk of side-effects and loss of effectiveness through the development of supersensitivity of the dopamine D2 receptor. Psychiatrists should work with their patients to slowly reduce the antipsychotic to the lowest dose that prevents the return of distressing symptoms. Up to 40% of those whose psychosis remits after a first episode should be able to achieve a good outcome in the long term either with no antipsychotic medication or with a very low dose.

All three classes of psychiatric medications reviewed here have serious adverse effects that occur with long-term use. In many cases, they lead to a worsening of the very symptoms they were supposed to “treat.” Increasingly, it is being shown that the psychiatric drug treatments are often worse than the “mental illness” they allegedly treat.

04/28/17

Psychiatric Huffing and Puffing

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

04/7/17

Souless Psychiatry

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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 3rd 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.

07/12/16

Common Sense with Lithium

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© Suljo | stockfresh.com

Lithium carbonate (not the element lithium) is used as a psychiatric medication primarily with bipolar disorder. It can be used with other psychiatric disorders such as major depression and schizophrenia, when first line medications are not effective. There are several advantages to lithium, particularly when it comes to cost. Available as a generic medication, a typical daily dose costs between 90 cents and $1.20. Major downsides are that therapeutic doses are just lower than toxic doses and there is the potential of direct damage to the kidneys and thyroid.

The website drugs.com said that since the toxic levels for lithium are so close to the therapeutic levels, patients and their families should watch for early symptoms, then discontinue the drug and inform the physician should they occur. Indications of lithium toxicity may include: diarrhea, vomiting, drowsiness, muscular weakness and lack of coordination. There are a host of other potential side effects that include: confusion, dry mouth, muscle twitching or trembling, vertigo, increased urination, memory problems and weight gain. These are only a few of the side effects found in 10% or more of the persons using lithium. See drugs.com or the Wikipedia listing for a more detailed discussion of lithium side effects.

In the late 1800s lithium was a popular ingredient in elixirs and tonics. It was even added to beer and other beverages. The theory was that it dissolved uric acid, so it could break up kidney stones and the uric acid crystals associated with gout. It was found to have no such effects. Lithium was eventually banned by the FDA in 1949 when it was found to cause cardiovascular problems.

Coincidentally, that same year an Australian physician named John Cade published a paper describing his treatment of 10 patients with mania with lithium. Cade had noticed that lithium made guinea pigs docile, so he thought it could have a therapeutic effect in manic patients. He announced dramatic effects in his paper and claimed they were specific to mania. What he failed to mention was that one patient died, two others had to discontinue lithium because of severe toxicity and one patient refused to take it. None of this was reported in his paper. Side effects were noted 41 times in the clinical records, but only 1 time in the published article. See The Myth of the Chemical Cure by Joanna Moncrieff for a more detailed description of lithium as a psychiatric treatment.

In Anatomy of an Epidemic, Robert Whitaker noted that psychiatrists in the U.S. had little interest in lithium until manic-depression was distinguished into unipolar and bipolar forms. Only a few placebo-controlled trials of lithium had ever been done up to that point. In 1985 UK researchers could only identify four with any merit. But within those studies, lithium was said to have a good response rate in 75% of the patients. This was much higher than the response rate in the placebo group.

A 1994 meta-analysis of nineteen studies by J.P. Baker of patients who were on lithium and had their lithium withdrawn showed that 53.7% of the patients relapsed, versus 37.5% of the lithium-maintained patients. This was seen as clear evidence that lithium prevented relapse. However, only 29% of patients who were gradually withdrawn from lithium relapsed. Note how this rate was better than those in the drug-maintained group.

Whitaker said this wasn’t very robust evidence of lithium’s benefit to patients, especially when you considered the additional studies raising concerns about lithium’s long-term effects. There was also a high rate of patients who stopped taking lithium—over 50%—because of how the drug dulled their minds and slowed their physical movements. In 1999 Baldessarini et al. found that almost half of all patients relapsed within five months of quitting lithium, while individuals who did not use lithium took nearly three years to reach that percentage of relapse. “The time between episodes following lithium withdrawal was seven times shorter than it was naturally.” Whitaker noted:

Although lithium is still in use today, it lost its place as a first-line therapy once “mood stabilizers” were brought to market in the late 1990s.

Now there has been a growing body of evidence that suggests lithium prevents suicide. In 2003 Baldessarini and others found that long-term lithium maintenance patients had lower suicide rates than individuals who did not. Cipriani et al. found lithium was an effective treatment for reducing the risk of suicide in people with mood disorders as well as bipolar disorder. Lewitzka et al. did a comprehensive review of more than 20 years of studies investigating the anti-suicide effect of lithium in patients with affective disorders. They also concluded lithium to be “an effective treatment for reducing the risk of suicide and suicide attempts in patients with affective disorders over the long-term course.”

Joanna Moncrieff reviewed several meta-analyses indicating the anti-suicide effects of lithium in The Myth of the Chemical Cure and said the studies included in these analyses had conflicting results. An article on her website, “Lithium and Suicide: What Does the Evidence Show?” said the proposed effect of decreased mortality rates was inexplicable since lithium was a toxic drug that made most people feel rather depressed. She wondered if the sedating effect of the lithium sapped people of the will to act. “A closer look at the evidence, however, suggests the idea [lithium reducing suicidality] is simply not justified.”

The first issue was that the evidence supporting this idea consisted of follow-up studies with individuals on long-term lithium, as with Copper et al. Moncrieff commented how these people are a particularly compliant group with medication. “People who follow their lithium regime religiously are, in general, not likely to be the people who are chaotic, impulsive, desperate and most likely to commit suicide.” One study, by Gonzalez-Pinto et al., showed that people who were highly compliant with their lithium were five times less likely than those who were ‘poorly compliant’ to commit suicide. A second issue was that given small margin of error between therapeutic and toxic doses of lithium, people with suicidality tendencies are less likely to be given lithium.

Another confounding issue is that people with medical conditions are less likely to be given lithium. Not only can lithium cause kidney and thyroid problems, but it interacts with many commonly prescribed drugs like diuretics, ACE inhibitors and NSAIDS like aspirin and ibuprofen. This can result in dangerously high lithium levels. So caution is used when starting lithium with someone who is physically sick or taking other medication. Moncrieff said better randomized controlled trials are needed.

She thought it curious that a meta-analysis by Cipriani et al. in 2013 did not include a single placebo-controlled trial where the suicide rate was zero, so she looked more closely at its methology. Moncrieff discovered that the authors excluded any trial whose treatment arm was uninformative, namely those whose suicide rates were zero. “This decision is totally unsound, however, as it reduces the denominator (the total number of participants) and thereby makes the events included appear more common than they actually were.” She speculated this was why some well-known studies were not included in the analysis of suicides. When the studies with no suicides were included, “the number of participants would have been much larger and the proportion of suicides in the placebo group much smaller.”

 So there is the evidence on lithium and suicide. The meta-analysis that has been accepted as demonstrating that lithium prevents suicide spuriously inflated the suicide rate on placebo by excluding studies in which no suicides occurred. The only double blind, prospective study designed to test whether lithium reduces suicide in people at high risk, ended up unblinding many of its participants, and in any case suicidal events were low in both groups.

The fact that studies of suicide prevention have been so difficult to recruit to, suggests patients may have more sense than researchers in this field!

05/31/16

To Be or Not to Be Bipolar

53409894_sOn The Oprah Winfrey Show in October 2007, Sinéad O’Connor disclosed that she had been diagnosed with bipolar disorder in 2003. The website, “Famous Bipolar People,” said Sinéad had suffered from depression and had thoughts of suicide since the age of 23. She also experienced voices urging her to harm herself. The voices got so loud, she said, she took herself to hospital. She was put on antidepressants, which helped. “These all confirmed that she had bipolar disorder.” Then a few years ago, she went public with an announcement that she had been misdiagnosed with bipolar disorder for eight years.

During her interview with Oprah, she said she didn’t think she was born with bipolar disorder. She thought her illness was caused by a number of outside pressures. “I believe it was created as a result of the violence I experienced.” She was scared to take the medication at first. But she realized that she had nothing to lose, so she tried them. “It was brilliant because I felt this huge hole. And when I took the meds, within half an hour, it was literally like I felt concrete coming in to fill the hole.” She said she thought she had died and then was ‘born again’ as a result of taking the meds.

But after spending eight years on the medications, she realized her depression was still there. Additionally, “some of the same problems she’d had before being medicated were persisting.” And she received complaints about her weight from people in the music business. By the way, weight gain is one of the side effects from antipsychotic medication. When she mentioned her weight problem to her doctors, they suggested taking her off of the bipolar meds as a remedy.

Writing for About Health, Angel Rouse said O’Connor was alarmed with the casualness of the suggestion and aware that simply stopping meds could be dangerous. So she sought outside opinions, eventually getting three additional ones. Their conclusion was that she was not bipolar. Rather, she actually suffered from PTSD. She revealed that when she cancelled her tour in 2012, she had tried to stop taking her medication cold turkey. Ironically, as a result of that attempt, she struggled with bipolar problems of mania and depression for nearly a year. Interviewed for the Irish Mirror, she said:

The illness was in fact what happens when you don’t go about coming off these meds properly. I’m delighted to be able to say that after ten years of poisoning myself with these drugs and having to live with the extremely difficult side-effects of them I can shortly begin the very, very slow indeed, process of getting them out of my system and my life and getting my life back.

Sinéad O’Connor is not a unique case. The NAMI (National Alliance on Mental Illness) website claims that 2.6% or 6.1 million American adults have a bipolar disorder. NAMI referenced this “mental health fact” on data they took from the National Institute of Mental Health (NIMH), which in turn cited this article by Kessler et al. from JAMA Psychiatry on the prevalence, severity and comorbidity of DSM-IV disorders. See Table 1 in the article for the reported percentage. But if Sinéad O’Connor could be misdiagnosed as having a bipolar disorder and mistakenly placed on potentially harmful medications that are seen as necessary to stabilize and control the bipolar ‘illness,’ how many others are similarly misdiagnosed? Regarding the medications she was on, O’Connor told the Irish Mirror:

They are extremely debilitating drugs. Tiring to the extreme. Ironically, extremely depressing. They can cause suicidal or self-harm type thinking. They can mess up your menstrual cycle very badly and cause you to be incapacitated for a week before. . . . [They] f**k up your liver, your kidneys, your eyes, your appetite, your entire way of thinking and generally your entire life.

Within his seminal book, Anatomy of an Epidemic, Robert Whitaker described “The Bipolar Boom” in chapter nine. He related a talk given by Fredrick Goodwin at the 2008 annual meeting of the American Psychiatric Association (APA). Goodwin said the illness has been altered since 1990. There was more rapid cycling; more mixed states; more lithium treatment failures than when he’d coauthored Manic-Depressive Illness. “The illness is not what Kraepelin described anymore, and the biggest factor, I think, is that most patients who have the illness get an antidepressant before they ever get exposed to a mood stabilizer.” Whitaker said not everyone speaking agreed that antidepressants had been disastrous for bipolar patients, but no one questioned Goodwin’s assessment that bipolar outcomes had noticeably worsened since 1990.

On his website, Whitaker noted that before 1955, bipolar illness had been a rare disorder. Only 12,750 people were hospitalized with the disorder that year. There were only about 2,400 “first admissions” that year in the country’s mental hospitals. Outcomes were fairly optimistic. Seventy-five percent of these first-admissions were projected to recover within 12 months. And only 15% of first-time admissions were expected to become chronically ill. And at least 70% were projected to return to work and have active social lives.

Today, bipolar illness is said to affect one in every 40 adults in the United States. A rare disorder has become a very common diagnosis. There are several reasons for this. First, many drugs–both illicit and legal–can stir manic episodes, and thus usage of those drugs leads many to a bipolar diagnosis. Second, the diagnostic boundaries of bipolar illness have been greatly broadened.

Allen Frances is a psychiatrist and the author of Saving Normal. He was also the chair for the DSM-IV, which expanded the criteria in diagnosing bipolar diagnosis by adding the bipolar II category. In Saving Normal, he described a dilemma when the APA was revising bipolar diagnosis for the fourth edition of the DSM. Patients with “hypomania,” less-than-full-manic episodes, didn’t fit neatly into the unipolar or bipolar depression categories. The bipolar II category was seen as a compromise that would lessen the dangers of classifying them as having unipolar depression and treating them with antidepressant medication that could trigger a manic episode.

We knew that bipolar II would expand the bipolar category somewhat into unipolar territory, but we did not think that it would double. Undoubtedly, our decision resulted in more accurate diagnosis and safer treatment for many previously missed truly bipolar patients. But like all fads, it overshot and had led to unnecessary medication for many unipolar patients who have been misdiagnosed as bipolar on very flimsy grounds and are now receiving unnecessary mood stabilizing drugs.

Whether you agree with Frances’ assessment that adding bipolar II resulted in more accurate diagnosis and safer treatment for many, don’t miss that he also said it led to misdiagnosis and unnecessary medication.  If you follow this link, also given above, to Robert Whitaker’s website, Mad in America, you will find a series of journal articles describing how substance abuse can be related to developing bipolar disorder; the effects of antidepressant use on bipolar disorder and how these drugs can worsen long-term bipolar outcomes; and the deterioration of bipolar outcomes in the modern era.

For a postscript, I want to return to note one last piece of information on Sinéad O’Connor. While she has cast off her diagnosis of bipolar disorder, it isn’t finished with her. Many websites, like that of “Famous Bipolar People” mentioned above, still list her as one of their own. There was a concluding note in the “About Health” article on Sinéad O’Connor that said: “In spite of her having stated clearly on several occasions that she does not have bipolar disorder, O’Connor continues to be included at many sites that compile lists of famous bipolar people.”

Famous Bipolar People, if Sinéad had said it’s over between the two of you, accept it and move on. There are plenty of more fish in the sea. You still have Kay Redfield Jamison. She’s written two books that touch on bipolar disorder, An Unquiet Mind and Touched with Fire. And both have been made into movies. The movie, Touched with Fire, is a fictional love story about two people with bipolar disorder who meet in a psychiatric hospital and fall in love. The trailer has a slight Romeo and Juliet feel to it; two young lovers who family and friends try to keep apart. So there will be plenty of new discussions about who is and who isn’t bipolar related to the movie. Just let go of Sinéad; let her go and move on.

02/16/16

Nearsighted Drug Development

© Antonio Gravante | Dreamstime.com

© Antonio Gravante | Dreamstime.com

I was encouraged to hear that ALKS 5461 failed in two late-stage clinical trial studies. This isn’t because I have something against Alkermes, the pharmaceutical company developing the drug. I don’t own stock in a competing company trying to bring their new fast-acting antidepressant drug to market ahead of Alkermes. I do think antidepressants are overprescribed and have potentially harmful side effects for some people, but that’s not why I was happy to hear that ALKS 5461 is in trouble. I just don’t think that putting an antidepressant drug on the market that uses a potentially addictive opioid as its active ingredient is a good idea.

Reporting for Reuters, Amrutha Penumudi said that when news of the failed clinical trails for ALKS 5461 were made public by Alkermes, the company saw its shares fall in value by 42.8%, a $3.88 billion loss for the company. ALKS 5461 is the company’s main product, so the bad news about the clinical trials was a major financial blow. William Tanner, an analyst for Guggenheim Partners was widely quoted by Reuters and others as saying that “We believe trial failures present a major setback in the evolution of the company.” Even if ALKS 5461 succeeds in a third as-yet not completed clinical trial, more studies may be required, according to Ken Cacciatore.

ALKS 5461 is a new molecular entity (NME) that has been fast tracked by the FDA for approval as a treatment of Major Depressive Disorder (MDD) with patients who didn’t respond to standard antidepressant therapies. It is a combination of buprenorphine, a Schedule IV Controlled Substance and samidorphan, a naloxone-like substance. Suboxone, which is a combination of buprenorphine and naloxone, is commonly used as an opioid substitution medication for heroin and prescription opioid addicts. The major difference between ALKS 5461 and Suboxone as far as buprenorphine is concerned is that ALKS 5461 is currently being tested in 2 mg and .5 mg doses, where standard protocols for Suboxone as an opioid substitution drug could reach 16 mg or higher. You will find more information on ALKS 5461 and my concerns about its use to treat depression in: “The Coming Depression Apocalypse,” an article I published here a few months ago.

But it doesn’t seem Alkermes is going to give up the fight. In their press release, Richard Pops, the CEO of Alkermes said:

We are steadfast in our commitment to developing new medicines for serious CNS conditions where there is a clear and compelling need for new treatment options for patients and their families. . . . Major depressive disorder is one of these conditions. We are building a large body of evidence supporting our belief in the clinical utility and the novel mechanism of action of ALKS 5461. We await the results of FORWARD-5 and will determine our next steps along the regulatory path with those results in hand.

In one of the failed trials, Alkermes did post-hoc analyses (reanalysis of the data after the fact) that indicated the 2 mg dose was more effective than a placebo. Given the results of the two failed studies, Alkermes said they plan to increase the number of patients in the ongoing trial and “update” the planned statistical analysis for FORWARD-5, the third efficacy study in the FORWARD program. The updated analysis sounds like it means they plan to use the same analysis process applied to the 2mg dose group for FORWARD-4 after the fact. This is bit like cheating if the researchers went p-hacking or data-dredging in their post-hoc analysis. See “How to Lie About Research” for more information on p-hacking.

Another factor regarding Alkermes and ALKS 5461 that concerns me is how the company describes the drug. In their above-linked press release, Alkermes said that ALKS 5461 acted “as a balanced neuromodulator in the brain;” and was “designed to rebalance brain function that is dysregulated in the state of depression.” This sounds eerily similar to the chemical imbalance theory of depression that even psychiatrists such as Ronald Pies have said was always a kind of urban legend. In an article in Psychiatric Times, he said: “To my knowledge, no professional psychiatric organization has ever publicly promoted a ‘chemical imbalance theory’ of mental illness in general.” Look at Robert Whitaker’s response to that article by Pies and the reams of additional evidence to show how Pies’ claim was clearly wrong.

But there is now another concern with the use of opioids to treat depression. A study by Scherrer et al., published in the Annals of Family Medicine, found that people who used prescription opioids for longer than a month may have an increased risk of developing depression. Scherrer was quoted by Agata Blaszczak-Boxe for Live Science as saying the researchers rigorously controlled for pain, “and we feel strongly that these results are independent of the known contribution of pain to depression.” The longer individuals were taking opioids, the greater was their risk of depression.

Citing a 2014 study by Howe and Sullivan in General Hospital Psychiatry, Scherrer et al. said that research on the efficacy of opioids in treating depression was limited by small sample sizes, short follow-up time and lack of control groups. So they do not support opioids as effective long-term treatments for depression. “This evidence, combined with the finding from the present study, supports the conclusion that opioids may cause short-term improvement in mood, but long-term use is associated with risk of new-onset depression.”

Buprenorphine was not one of the opioids studied, but the findings of the Scherrer et al. study does give me increased concern with the fast-track status the FDA has given ALKS 5461. Recent findings do suggest the risk of new onset of depression increases with a longer duration of opioid use. A replication attempt of Scherrer’s study with buprenorphine seems needed before approving ALKS 5461. The short-term projected improvements could lead to long-term problems with depression.  “Patients and practitioners should be aware that opioid analgesic use of longer than 30 days imposes risk of new-onset depression.”

Hopefully the FDA will have the foresight to weigh all the potential adverse effects with ALKS 5461 before approving it. There is a very real potential for physical dependency to develop with ALKS 5461 given that its active ingredient is a Schedule IV controlled substance. Heroin addicts have told me buprenorphine was more difficult for them to come off of than heroin or methadone. And to top it all off, there seems to be evidence that using opioids longer than 30 days carries a risk of new-onset depression. This is not a very promising profile for a future treatment for depression.

Additionally, the initial statistical analysis done on the first two clinical trials failed to demonstrate that it was more effective than a placebo. Only after a post hoc analysis was there evidence of any statistically significant results. And then it was only with the higher, 2mg, dose. Will that lead to even higher doses of buprenorphine to increase its effectiveness? Read more on the concerns with outcome switching in clinical trials here.

Revising the statistical analysis (outcome switching) of the remaining clinical trial may produce statistically significant results, and if it does, it seems Alkermes intends to argue with the FDA to approve ALKS 5461. On the one hand, I can see where Alkermes would attempt to salvage their “lead product.” But I’m hoping their nearsighted focus on profits and the company’s market value will not blind the FDA to the long-term consequences of using opioids like buprenorphine to treat depression.

10/14/15

Antipsychotic Big Bang

© sakkmesterke | 123rf.com

© sakkmesterke | 123rf.com

Duff Wilson wrote in “Side Effects May Include Lawsuits” that antipsychotics were a niche product for decades. Yet they have recently generated sales that have surpassed that of “blockbusters like heart-protective statins.” In the 1990s, pharmaceutical companies began marketing them for much broader uses than the original FDA approved uses for more serious mental illnesses, like schizophrenia and bipolar disorder. A Scientific American article reported that pediatric prescriptions for atypical antipsychotics rose 65%—from 2.9 million to 4.8 million—between 2002 and 2009. And a New York Times article noted that federal investigators have found widespread overuse of psychiatric drugs by older Americans with Alzheimer’s disease.

There are two more facts to introduce you to about neuroleptics or atypical antipsychotics. First, in 2008, antipsychotics sales reached $14.6 billion, making them the biggest selling therapeutic class of drugs in the U.S. Second, each of the following pharmaceutical companies that marketed antipsychotics has been investigated for misleading marketing under the False claims Act. All their neuroleptics—Risperdal (risperidone; Johnson & Johnson), Zyprexa (olanzapine; Eli Lilly), Seroquel (quetiapine; AstraZeneca), Geodon (ziprasidone; Pfizer), and Abilify (aripiprazole; Bristol-Myers Squibb and Otsuka)—are now off patent.

The primary use off-label use of neuroleptics for the elderly and with children has been for behavioral control. A recent study commissioned by the Pennsylvania Department of Human Services found that children between the ages of 6 and 18 who were in foster care was four times higher than other youth in Medicaid. More than half of these youth had a diagnosis of ADHD. “This is concerning, as the majority of these youth did not have another diagnosis that clinically indicated the use of antipsychotics.” Risperidone was the most frequently prescribed antipsychotic medication among the youth. However, Abilify and Seroquel grew to exceed risperodone over the course of the study. Zyprexa was the least commonly used antipsychotic among all youth.

A trade group for nursing homes, The American Health Care Association, indicated that while antipsychotics helped some dementia patients who have hallucinations or delusions, “They also increase the risk of death, falls with fractures, hospitalizations and other complications.” The American Psychiatric Association, among others pointed to a JAMA Psychiatry study that showed mortality risks increased in patients given antipsychotics to reduce their symptoms of dementia. Another study published in Health Policy said the benefits and harms of using antipsychotic medications in nursing homes should be reviewed.

Antipsychotic medication use in nursing home residents was found to have variable efficacy when used off-label with an increased risk of many adverse events, including mortality, hip fractures, thrombotic events, cardiovascular events and hospitalizations.

Another “add on” area for neuroleptic use is when it is used with an antidepressant for “treatment resistant” depression. On BuzzFeed, Cat Ferguson reported how the sale of antipsychotics such as Abilify, and Zyprexa “skyrocketed” as they were approved to treat depression as an add-on medication. Seroquel is not FDA approved to treat major depression, but along with Abilify and Zyprexa is approved to treat bipolar depression in adults. Zyprexa and Seroquel are approved for some indications of bipolar disorder in adolsecents, but Abilify is only used off label with bipolar children, having “low or very low evidence of efficacy.” See the Psychopharmacology Institute for more information on these drugs and their approved and off-label uses.

Ferguson quoted a few psychiatrists expressing concern about the antipsychotic boom, and there are some surprises given other stands they’ve taken. Allen Frances, the former chair for the DSM-IV, agreed there has been heavy marketing of antipsychotics. He thought they are prescribed too quickly for depression and without clear indication of their efficacy. He added there seemed to be pressure from the pharmaceutical companies. He said: “These drugs should have a narrow indication, and instead they’ve become the highest revenue-producing drugs in America.”

Over the past few years Allen Frances has become an outspoken critic of some psychiatric practices, including the overuse of antipsychotics and antidepressants. He’s also been critical of the DSM-5. He’s even written Saving Normal to address his concerns with psychiatry and psychiatric practice. Search for his name here to find several articles where he is mentioned.

I was surprised and encouraged to see Jeffrey Lieberman, the chair of psychiatry at the Columbia University College of Physicians and Surgeons express concern with the over prescribing of antipsychotics. Lieberman has positioned himself as defender of psychiatry and psychiatric practice, recently publishing Shrinks. You can also search his name here to see other articles interacting with his book and position on psychiatry. Lieberman said that antipsychotic medication should be used sparingly in treating nonpsychotic disorder, including depression. He said: “I think there’s the possibility that antipsychotics are overprescribed, not just for depression, but in other areas.”

My point is that when two prominent psychiatrists with opposing views on many areas of psychiatry and psychiatric practice agree that antipsychotics are overused, pay attention. Both Frances and Lieberman have pointed out elsewhere how pharmaceutical marketing strategies contribute to this problem, but some pharma companies and representatives put the blame back on doctors. An Eli Lilly spokesperson said pharmaceutical companies aren’t responsible for how their drugs are used by doctors. “Physicians make prescribing decisions, not pharmaceutical companies. . . . While certainly we inform doctors of the benefits and risks of our medicine, it’s really up to physicians to prescribe the right medicine.”

But this attempt to deflect responsibility onto physicians is a cop out when you consider the marketing done by pharmaceutical companies for their products. In this YouTube advertisement for Abilify as an antidepressant add-on, you see how Bristol-Myers Squibb actively encouraged individuals to “ask your doctor if Abilify is right for you.” Pay attention to the fact that the first thirty seconds verbally describes how Abilify can help, while the rest of the 90-second commercial has the woman and her family going on a picnic while the adverse side effects are described.

Another problem is that all clinical trials for drug approval are done over short periods of time—six or eight weeks—antipsychotics included. But what are the long-term consequences of antipsychotics? As Dan Iosifescu, the director of the Mood and Anxiety Disorders Program at Ichan School of Medicine at Mount Sinai Hospital said, “It’s just a fallacy to take short-term data and extrapolate it for long term.” His bottom line is that antipsychotics tend to be helpful in the short term, but can have major consequences in the long term.

Thomas Glasen, writing in Schizophrenic Bulletin, weighed the pros and cons of medication treatment for psychosis. In the case for medication, he noted that the benefits of medication were profound. The therapeutic power of antipsychotic medication had been validated in countless studies and was now the primary treatment of schizophrenia. “In today’s climate, treating schizophrenia without medication mobilizes high anxiety among treaters for the safety of their patients from irrationality and for the safety of themselves from litigation.” However, in the case against medication, Glasen said:

Antipsychotics obscure the pathophysiology of psychosis by altering the neurobiology of the brain and the natural history of [the] disorder. . . . Medication can be lifesaving in a crisis, but it may render the patient more psychosis-prone should it be stopped and more deficit-ridden should it be maintained.

So how do individuals on long-term antipsychotics do? In Anatomy of an Epidemic, Robert Whitaker described Martin Harrow’s presentation of a long-term study funded by NIMH on sixty-four individuals diagnosed as schizophrenic between 1975 and 1983. Whitaker had just reviewed a series of studies questioning whether there was a long-term benefit to the use of antidepressants before discussing the Harrow study. He then said: “If the conventional wisdom is to be believed, then those who stayed on antipsychotics should have had better outcomes.” Harrow found that after two years, there was evidence that the off-med group was doing slightly better than the group on drugs.

Then, over the next thirty months, the collective fates of the two groups began to dramatically diverge. The off-med group began to improve significantly, and by the end of 4.5 years, 39 percent were “in recovery” and more than 60 percent working.

The outcomes for the medication group worsened and this divergence continued. At the fifteen-year follow up, 40 percent of those off drugs were in recovery and more than half were working; only 28 percent suffered from psychotic symptoms. “In contrast, only 5 percent of those taking antipsychotics were in recovery, and 64 percent were actively psychotic.” The 2007 Harrow study can be found here. Harrow said that not only was there a significant difference in global functioning between the two groups, 19 of the 23 (83%) schizophrenic patients with uniformly poor outcome after fifteen years were on antipsychotics.

symptomsHarrow et al. (2014) continued his study and reported data in Psychological Medicine at the twenty-year stage of his follow-up schedule. Here he investigated whether multi-year treatment with antipsychotics reduced or eliminated psychosis; and whether the results were superior to individuals in the non-medicated group. The data showed that the pattern noted above by Whitaker in Harrow’s 2007 report continued: “A surprisingly high percentage of SZ prescribed antipsychotic medications experienced either mild or more severe psychotic activity.”  The figure to the left, originally from the 2014 Harrow et al. report, shows that 68% of the medication group experienced psychotic activity, while only 8% of the off-med group experienced any psychotic activity. The source of the figure was a slide reproducing the Harrow data in a presentation by Robert Whitaker at the “More Harm than Good” conference sponsored by the Council for Evidence-Based Psychiatry (CEP). The slides and videos of the presentation can be found here.

Harrow et al. thought the high percentage of the medication group experiencing psychotic activity was influenced by two factors. One was the high vulnerability to psychosis of many schizophrenic patients, leading to a high risk of psychosis. But that begs the question of how the medication group in the study had such a high number of patients “at risk of psychosis.” Given the above data, their second factor seems to have been the more important factor: prolonged use of antipsychotics (or partial dopamine blockers) may produce a medication-generated build-up of supersensitive dopamine receptors or excess dopamine receptors.

The production of excess or supersensitive dopamine receptors would then be an iatrogenic, drug induced effect from the long-term use of antipsychotics. The brain increases or sensitizes the receptors, thus compensating for the blockade of original receptors in the postsynaptic neuron. Again, drawing from Whitaker’s presentation slides at the CEP conference, it would look like this:

dopamine

The above presentation of Harrow’s data and the discussion from Whitaker’s CEP presentation seem to affirm Glasen’s thesis that antipsychotics could alter the neurobiology of the brain. Antipsychotics reduce the activity of dopamine systems, stimulating the increase of receptors. When the antipsychotic is tapered or withdrawn, this would not immediately diminish the number of additional dopamine receptors produced by the brain to compensate for the dopamine blocking action of the antidepressant. With decreased antipsychotic levels, the result would be increased activation of the postsynaptic neurons because of the greater number receptors to absorb dopamine.

The person’s symptoms could intensify through the increased absorption of dopamine because of this disregulation of the dopamine system. In other words, tapering off of antipsychotics could activate symptoms like mania, paranoia and hallucinations because of the chemical imbalance produced by the medication. The experience of mania from a too sudden withdrawal of an antipsychotic is in this view, likely a withdrawal or discontinuation symptom instead of proof that the person needs to remain on an antipsychotic because they have a chemical imbalance. Robert Whitaker’s conclusion in Anatomy of an Epidemic was:

What the scientific literature reveals is that once a person is on an antipsychotic, it can be very difficult and risky to withdraw from the medication, and that many people suffer severe relapses. But the literature also reveals that there are people who can successfully withdraw from the medications and that it is this group that fares best in the long term.

10/7/15

Psychiatry, Diagnose Thyself! Part 2

© lightwise | 123rf.com

© lightwise | 123rf.com

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

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© lightwise | 123rf.com

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.

08/19/15

A Censored Story of Psychiatry, Part 2

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© alexskopje | 123rf.com

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.