10/14/15

Antipsychotic Big Bang

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.

Harrow 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:

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

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

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

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

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

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a 1987 study, 34 stable outpatients receiving neuroleptic treatment were given an infusion of methylphenidate and then withdrawn from their neuroleptic medication. Three weeks after they were withdrawn from their psych meds, they were given another infusion of methylphenidate.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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

09/30/15

Psychiatry, Diagnose Thyself! Part 1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

08/19/15

A Censored Story of Psychiatry, Part 2

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

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

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

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

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

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

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

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

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

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

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

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

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

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

08/12/15

A Censored Story of Psychiatry, Part 1

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

05/6/15

Parallel Psychiatric Universes

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

12/3/14

To Use or Not Use Antidepressants

Image by Lightsource

I ran across a report from the National Center for Health Statistics when reading Saving Normal by Allen Frances that had some incredible facts about antidepressant use in the United States. The report said that 11% of Americans 12 years and over take antidepressant medication. Women were 2.5 times as likely to take antidepressants as men. Individuals 40 and over are more likely to take antidepressants than those younger than 40. “Twenty-three percent of women aged 40-59 take antidepressants, more than any other age-sex group.”

When the severity of depressive symptoms was considered, use of antidepressant medication rose as the severity of symptoms increases. This seems logical; the worse your depression is, the more likely you are to try medication. But look at the other end of symptom severity—7.6% of those taking antidepressants have NO REPORTED symptoms of depression. The Data Brief pointed out that this group could include people taking antidepressants for reasons other than depression and those who are being “successfully” treated with antidepressants, and just don’t have any symptoms currently. See the table below.

Depressive symptoms	Percent
Total
None	7.6
Mild	19.2
Moderate	28.4
Severe	33.9
Males
None	4.4
Mild	11.5
Moderate	18.6
Severe	21.0
Females
None	10.9
Mild	24.6
Moderate	34.5
Severe	39.9

Allen Frances suggested that part of the problem was that drug companies capitalized on the placebo effect, that is: “people getting better because of positive expectations independent of any specific healing effect of the treatment.” Treating the “worried well” expanded the customer pool and guaranteed a pool of satisfied customers. “Placebo responders often become long-term loyalists to medication use even when the medication is perfectly useless.”

The best way to get great results with a pill is to treat people who don’t really need it—the highest placebo response rates occur in those who would get better naturally and on their own.

What’s at stake? The Statistics Portal indicated that the top ten selling antidepressants in 2011-2012 grossed 8.5 billion dollars. Considering that most of the antidepressants are off patent and not as profitable to the drug companies, this is an incredible haul. Another indication of the pervasiveness of antidepressant use in the U.S. is to look at the number of prescriptions written. The top antidepressant drugs in the U.S. based upon the number of dispensed prescriptions in 2011-2012 are given in the following chart, again from The Statistics Portal.

Antidepressants	Prescriptions
Celexa (citalopram hydrobromide)	39,087,000
Zoloft (sertaline hydrochloride)	37,893,000
Prozac (fluoxetine hydrochloride)	24,961,000
Trazadone (trazadone hydrochloride)	23,449,000
Cymbalta	18,468,000
Lexapro	16,367,000
Paxil (paroxetine hydrochloride)	13,834,000
Effexor (venlafaxine hydrochloride ER)	13,679,000
Wellbutrin (bupropion hydrochloride XL)	13,365,000
Elavil (amitriptyline hydrochloride)	12,880,000

Returning to the NCHS Data Brief, once people start taking antidepressants, they tend to continue taking them. Sixty-one percent of Americans taking an antidepressant have been taking it longer than 2 years; 13.6% have been taking them ten or more years. The problem is that the widespread use of antidepressants and their long-term use may be actually causing depression.

Robert Whitaker commented in Anatomy of an Epidemic that prior to the appearance of antidepressant drugs, depression was seen as a rare problem with typically good outcomes over time. Now the NIMH says that an episode of major depression “can occur only once in a person’s lifetime, but more often, a person has several episodes.” In 2012, an estimated 16 million adults and 2.2 million adolescents had at least one depressive episode in the past year.

Whitaker noted how Italian psychiatrist, Giovanni Fava began in 1994 to look at the changing face of depression. In that article, Fava raised the possibility that “long-term use of antidepressant drugs may also increase the biochemical vulnerability to depression and decrease its likelihood of subsequent response to pharmacological treatment.” In a 2003 article, Fava suggested that antidepressants may, in some cases, actually cause depression. “Whether one treats a depressed patient for 3 months or 3 years, it does not matter when one stops the drugs. A statistical trend suggested that the longer the drug treatment, the higher the likelihood of relapse.”

In a 2014 article, “Rational Use of Antidepressant Drugs,” Fava said that rational use of antidepressant drugs should consider all the potential benefits and harms. They should only be used with the most severe and persistent cases of depression. They should be used for the shortest possible duration. Using antidepressants to treat anxiety disorders should be reduced, unless a major depressive disorder is present or other treatments have been ineffective.

These suggestions may seem to be radically different from current guidelines such as those of the American Psychiatric Association, but they reflect the weighing of risk, responsiveness and vulnerability that should be applied to the use of AD [antidepressant drugs] in each individual case.

To use or not to use antidepressants, that is the question. There is serious potential harm that may occur with their use. And sometimes they can literally save a life. What seems to be clear is that current guidelines for their use can, in the long run, worsen the problem they were originally supposed to “treat.” Along with the above suggestions for the rational use of antidepressants given by Fava, I think there needs to be a change in how we think about psychiatric drugs. The current disease-centered model of drug action needs to be replaced by a drug-centered model of drug action. You can find more on this distinction in the writings of Joanna Moncrieff, such as The Myth of the Chemical Cure and my article, “A Drug is a Drug is a Drug.” Also see two longer articles on antidepressants available in the Counseling Issues section under the “Resources” link of this site.

11/12/14

What a Drag It is Getting Old

lightwise / 123RF Stock Photo

Things are different today. Grandmother needs something to calm down. Although she’s not really ill, they’ll give her a little yellow pill. And it helps her on her way, and gets her through the day. So she goes running for the shelter of a mother’s little helper. Four will help her sleep right through the night; and might even help to minimize her plight.

“Doctor please, some more of these
Outside the door, she took four more
What a drag it is getting old.”

Above and below are the chorus and two paraphrases taken from the lyrics of the Rolling Stones 1966 song, “Mother’s Little Helper.” Following the runaway success of the first modern tranquilizer, Miltown, Hoffman-La Roche brought the newest benzodiazepine—Valium to market in 1963 and then targeted women in its advertising. “From 1968 to 1981, it was the best selling drug in the Western world.”

Recently there has been a good bit of press (Science Daily and Web MD and others) on a study published in the British Medical Journal that indicated benzodiazepine (benzo) use was associated with the risk of developing Alzheimer’s disease. A BBC report about the study quoted some Alzheimer’s experts who minimized the study’s findings by saying that it was hard to know the underlying reason for the link. Other reports, such as that by Paula Span, on her New York Times blog, The New Old Age, noted how the study was designed to reduce the possibility of reverse causation. That is, reverse causation claims the correlation existed because individuals first diagnosed with Alzheimer’s were given benzos afterwards as part of their medical treatment.

Mad in America quoted from the study’s abstract, where the researchers said: “the stronger association [between Alzheimer’s and the use of benzos] observed for long term exposures reinforces the suspicion of a possible association.” The study’s authors further said:

Risk increased with density of exposure and when long acting benzodiazepines were used. Further adjustment on symptoms thought to be potential prodromes [precursors] for dementia—such as depression, anxiety, or sleep disorders—did not meaningfully alter the results.

The results of the study were consistent with five previous studies. It reinforced the suspicion of an increased risk of Alzheimer-like dementia among benzo users, particularly those who are long-term users. Their findings are particularly important when considering the wide spread use of benzos with older people, and the concurrent rise of dementia in developed countries. “Unwarranted long term use of these drugs should be considered as a public health concern.”

A JAMA Internal Medicine article noted that: “The American Board of Internal Medicine Foundation Choosing Wisely Campaign recommends against the use of benzodiazepine drugs for adults 65 years and older.” Paula Span reported in another article that a particular concern with older adults is falls, which are a leading cause of death and disability. The CDC estimated that one out of three older adults over the age of 65 falls each year. “In 2012, 2.4 million falls among older adults were treated in emergency departments and more than 722,000 of these were hospitalized.” Advice for tapering older adults off of benzos and other sleep aids like Ambien is available. See the Paula Span article, “More on Sleeping Pills and Older Adults,” linked in this paragraph.

Not only are benzos problematic when given to older adults long-term, there is a well-documented concern with any long-term use of this class of drugs. Quoting Dr. Stevan Gressitt, Robert Whitaker indicated in Anatomy of an Epidemic that there was no evidence supporting the long-term use of benzos. Additionally, they could aggravate medical and mental health problems like anxiety, depression, cognitive impairment and functional decline.

Whitaker described a 2004 Australian study that looked at the potential deficits in cognitive functioning after long-term benzo use. The duration of benzo use by the patients in the research studies they looked at ranged from 1 to 34 years. The mean was 9.9 years. They found that long-term benzo users were consistently more impaired across all the cognitive categories examined. “The observation that long-term benzodiazepine use leads to a generalised effect on cognition has numerous implications for the informed and responsible prescription of these drugs.”

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, with dozens of studies subsequently confirming the wisdom of that advice, the prescribing of benzodiazepines for continual use goes on. Indeed, a 2005 study of anxious patients in the New England area found that more than half regularly took a benzodiazepine, and many bipolar patients now take a benzodiazepine as part of a drug cocktail. The scientific evidence just doesn’t seem to affect the prescribing habits of many doctors.” (Robert Whitaker, Anatomy of an Epidemic, p. 147)

“Life’s just much too hard today,”
I hear every grandmother say.
The pursuit of happiness just seems a bore
And if you take more of those, you will get an overdose.
No more running for the shelter of a grandmother’s little helper.
They just helped you on your way, towards your busy dying day.

10/29/14

Creating Chemical Imbalances

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

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

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

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

Drug	Prescriptions-2013	Use	Sales-2013
Xanax (alprazolam)	48,465,000	Anxiety
Zoloft (sertraline)	41,416,000	Depression, anxiety, OCD, PTSD, PMDD
Celexa (citalopram)	39,445,000	Depression, anxiety
Prozac (fluoxetine)	28,258,000	Depression, anxiety
Ativan (lorazepam)	27,948,000	Anxiety, panic disorder
Desyrel (trazodone)	26,242,000	Depression, anxiety
Lexapro (escitalopram)	24,920,000	Depression, anxiety
Cymbalta (duloxetine)	18,573,000	Depression, anxiety, fibromyalgia, diabetic neuropathy	5,083,111,000
Wellbutrin XL (bupropion)	16,053,000	Depression
Effexor (venafaxine)	15,796,000	Depression, anxiety, panic disorder
Valium (diazepam)	14,754,000	Anxiety, panic disorder
Paxil (paroxetine)	14,335,000	Depression, anxiety, panic disorder
Seroquel (quetiapine)	14,326,000	Bipolar disorder, depression	1,183,989,000
Amphetamine salts (Adderall)	12,785,000	ADHD	727,892,000
Risperdal (pisperidone)	12,320,000	Bipolar disorder, schizophrenia, iirritability in autism
Vyvanse (lixdexamfetamine)	9,842,000	ADHD	1,689,091,000
Concerta ER (methylphenidate)	8,803,000	ADHD
Abilify (aripiprazole)	8,747,000	Bipolar disorder, schizophrenia, depression	6,293,801,000
Wellbutrin SR-W (bupropion)	8,238,000	Depression
Buspar (buspirone)	8,065,000	Sleep, anxiety
Vistaril (hydroxyzine)	8,052,000	Anxiety
Amphetamine salts ER (Adderall)	7,925,000	ADHD
Zyprexa (olanzapine)	5,101,000	Bipolar disorder, schizophrenia
Concerta/Ritalin (methylphenidate)	5,335,000	ADHD	1,383,814,000
Pristiq (desvenlafaxine)	3,217,000	Depression

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

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

Disturbing, huh?

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

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

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

08/13/14

The Dumbest “Diagnosis” Ever

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Is your child drowsy/sleepy at times? Do you see signs of daydreaming, mental confusion, slowed thinking or behavior, lethargy or apathy? Don’t worry; it may just be the early signs of Sluggish Cognitive Tempo (SCT)! By some estimates, SCT is present in two million children. While still not acknowledged as an official psychiatric disorder, the January 2014 issue of The Journal of Abnormal Child Psychology devoted the entire issue to SCT. Be patient, it will eventually become an official childhood psychiatric disorder, if its advocates have their way. And then you will have a brand new reason to give your son or daughter stimulant medications.

If you think this satire is too off-the-wall, read the April 11, 2014 article in the NYT by Alan Schwartz, “Idea of New Attention Disorder Spurs Research, and Debate.” Schwartz said that “Experts pushing for more research into sluggish cognitive tempo say it is gaining momentum toward recognition as a legitimate disorder—and as such, a candidate for pharmacological treatment.” He added that some of the identified symptoms so far in the research “have helped Eli Lily investigate how its flagship A.D.H.D. drug might treat it.” The psychiatric drug industry has excelled at expanding the market for its drugs, generating tremendous wealth for many.

Becker, Marshall and McBurnett did a search of journal articles (for their own article in January 2014 issue of The Journal of Abnormal Child Psychology) and found that “very few papers explicitly examined or even mentioned SCT between 1985 and 1999.” Since then there has been a steady increase in the articles that either focused on SCT or mentioned it in the body of the paper. They observed that while symptoms of under-arousal and low levels of mental energy were noticed to be part of attention deficit as early as 1798, it wasn’t until the 1970s that inattention was seen as causing even more impairment than hyperactivity. By the mid-1980s, “empirical support for the SCT dimension separate from inattention emerged.”

Russell Barkley, one of the most influential advocates for ADHD, noted in his article for the special issue of The Journal of Abnormal Child Psychology that there was a dearth of studies on SCT. Students now entering the profession could make a successful research career specializing in the research of SCT. He felt there would surely be an increased demand for such empirically-based research in view of the clinical referrals already occurring; and the anticipated increase in the near future as the general public becomes aware of SCT. “The fact that SCT is not is not recognized as yet in any official taxonomy of psychiatric disorders will not alter this circumstance given the growing presence of information on SCT at various widely visited internet sites such as YouTube and Wikipedia, among others.”

Alan Schwartz reported in his NYT article that Barkley has said that SCT “has become the new attention disorder.” Barkley also has financial ties to Eli Lily, receiving $118,000 from 2009 to 2012 for consulting and speaking engagements. He has also published a symptom checklist to identify adults with the condition. The forms are available for $131.75 apiece from Guilford Press. Oh, and Barkley also edits sluggish cognitive tempo’s Wikipedia page. The SCT Wikipedia page carried the following note at the top of the page on June 20th, 2014: “A major contributor to this article appears to have a close connection with its subject. It may require cleanup to comply with Wikipedia’s content policies.”

One of the SCT researchers, David McBurnett, said a scientific consensus on SCT could be many years in the future. “We haven’t even agreed on the symptom list—that’s how early on we are in the process.” And yet, Dr. McBurnett recently conducted a clinical trial funded and overseen by Eli Lilly to see if the proposed SCT diagnosis could be treated with Straterra, the company’s primary ADHD drug. Published in The Journal of Child and Adolescent Psychopharmacology in November of 2013,his study concluded: “This is the first study to report significant effects of any medication on SCT.”

This process with SCT reminded me of what Robert Whitaker depicted in Anatomy of an Epidemic. He showed that in order to sell our society on the benefits of psychiatric drugs, “Psychiatry has had to grossly exaggerate the value of its new drugs, silence its critics, and keep the story of poor long-term outcomes hidden.” This has meant telling a false story to the American public, and then actively hiding research results that reveal the poor long-term outcomes with a drug-centered paradigm of care. Whitaker said it was a conscious, willful process that exacts a horrible toll on our society.

The number of people disabled by mental illness during the past twenty years has soared, and now this epidemic is spreading to our children. Millions of children and adolescents are being groomed to be lifelong users of these drugs. This grooming happens by twisting childhood behaviors like daydreaming, slowed thinking or behavior, and lethargy into symptoms of a new so-called childhood psychiatric disorder.

Allen Frances, chair of the fourth edition of the DSM, said that “’Sluggish Cognitive Tempo’ may possibly be the very dumbest and most dangerous diagnostic idea I have ever encountered . . . .The risk that it could do great harm is real . . . .The last thing our kids need is to be misdiagnosed with ‘Sluggish Cognitive Tempo’ and bathe in even more stimulants.”

Still not convinced? Listen to this pod cast by Peter Breggin where he interviews psychologist Fred Ernst about Sluggish Cognitive Tempo and the “psychiatric assault” on children through psychiatric medication.

Faith Seeking Understanding

Charles Sigler, D.Phil.

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