Tag Archives: depression

Cures For Brain Disorders

On January 18, Thomas Insel, MD, published an article on The World Economic Forum Blog.  The article is titled 4 things leaders need to know about mental healthDr. Insel is the Director of the National Institute of Mental Health.  The World Economic Forum “is an International Institution committed to improving the state of the world through public-private cooperation.”

Dr. Insel’s paper makes a number of assertions, some of which are misleading.  Here are some quotes, interspersed with my comments.

“Too many people dismiss mental illnesses as problems of character or lack of will, rather than recognizing these disorders as serious, often fatal, medical  disorders.”

This is a fairly standard psychiatric assertion.  Note particularly how Dr. Insel has couched the issue as a choice between two alternatives:  “mental illnesses” are either:

problems of character or lack of will
or
serious, often fatal, medical disorders

In reality, the many problems of thinking, feeling, and/or behaving that psychiatrists list as mental illnesses can be conceptualized in a great many other ways.  It is inconceivable that a person of Dr. Insel’s stature and prestige isn’t aware of this, and so the question needs to be asked:  why would he present such an important and controversial question in such a misleadingly simplistic way?

. . . . . . . . . . . . . . . .

“For anyone who has not experienced depression, the most common mental illness, it is important to distinguish the disorder of depression from the sadness, disappointment, or frustration we all experience in our lives.”

This is another piece of standard psychiatric orthodoxy:  depression (the “mental illness”) is not at all the same kind of entity as depression (the “sadness, disappointment, or frustration we all experience in our lives”).  And although this is repeated frequently by psychiatric practitioners and leaders alike, no one, to my knowledge, has ever provided proof of this assertion.  Indeed, the APA itself provides fairly convincing indications to the contrary.  The first item in their list of criteria for major depressive disorder is:

“Depressed mood most of the day, nearly every day, as indicated by either subjective report (e.g., feels sad, empty, hopeless) or observation made by others (e.g., appears tearful).  (Note: In children and adolescents can be irritable mood.)” (DSM-5, p 160)

I suggest that feeling “sad, empty, hopeless” or appearing “tearful” to others, or irritability are pretty much the hallmark of depression (the “sadness, disappointment, or frustration” that we all experience from time to time).  The remaining DSM criterion items reflect the severity or depth of the depression, but there is nothing in the list to suggest that depression (the “mental-illness”) is something that needs to be distinguished in any dichotomous sense from less severe depression.  Nor, it needs to be stressed, does Dr. Insel provide us any evidence to support this assertion.

. . . . . . . . . . . . . . . .

“In extreme forms, depression can be so disabling that the thought of getting out of bed or making a phone call becomes overwhelming.”

The word “disabling” is ambiguous.  It can mean that a person is literally incapable of performing the act in question (for instance, a paraplegic’s inability to walk), or it can mean that a person finds the act difficult.  An example of the latter would be a person who had the flu, describing his plight as “disabling” – in the sense that it made it difficult to go about his ordinary activities.  The term “overwhelming” has similar ambiguity.

But Dr. Insel’s statement occurs in the section of his paper titled “When you can’t get up or make a call” [Emphasis added].  So I think it’s clear that he’s using the term “disabling” in the former sense.  In other words, he’s asserting that a severely depressed individual might be as incapable of getting out of bed or making a phone call or presumably engaging in other ordinary activities, as a paraplegic is of walking around the block.

There are two observations that need to be made.  Firstly, there is no way that psychiatrists – or anyone else, for that matter – can know what a depressed person is not capable of doing.  We can know what a person is capable of doing by observing what he/she actually does.  If an individual does something, then clearly he can perform this act.  But the fact that a person does not engage in a certain activity provides no logical grounds for assuming that he can’t  This is not particularly abstruse.  It is Logic 101.  Secondly, to tell depressed people that they are incapable of getting out of bed or engaging in other normal activities is a fundamentally disempowering act, and is a grave disservice to the individuals in question.  It also, incidentally, serves to trivialize and devalue the plight of people who really can’t do these things.

. . . . . . . . . . . . . . . .

“In the United States, approximately 7% of people suffer an episode of depression and about one in five people experience some form of mental illness each year. With prevalence rates so high, the human and economic case for leaders to take mental health more seriously is clearly compelling. What do they need to know?”

Psychiatry’s so-called prevalence figures have to be seen against a context in which they can inflate the numbers at will, by the simple expedient of widening the criteria items or by inventing new “illnesses”. Examples of this in DSM-5 are:  the removal of the bereavement exclusion in major depression; the removal of the inexplicability requirement in somatization disorder; the invention of disruptive mood dysregulation disorder, and attenuated psychosis disorder; etc., etc….  The paradigm example from DSM-IV was the removal of the need for a manic episode for a “diagnosis” of bipolar disorder.

. . . . . . . . . . . . . . . .

But setting all that aside, let’s take a look at the five items that Dr. Insel believes leaders “need to know”.

“First, mental disorders are brain disorders. The brain is a bodily organ just like any other. We should no more blame ourselves or others for a malfunctioning brain than for a malfunctioning pancreas, liver, or heart.  People with brain disorders deserve exactly the same level and quality of medical care as they expect for disorders of any other part of the body.”

The reality is that apart from those “mental disorders” clearly identified as being “due to a general medical condition”, or to “the effects of a substance”, there is no published evidence to support the notion that the various problems of thinking, feeling, and/or behaving catalogued in DSM-5 are brain disorders.  Dr. Insel must be aware that his assertions in this regard are controversial, and if he has evidence to support his contentions, there is, I suggest, an onus on him to cite it.

Note also how Dr. Insel has injected the same spurious dichotomy mentioned earlier into this first item that leaders “need to know”.  The suggestion is that one must either accept his contention that “mental disorders” are brain disorders, or one is blaming the individuals concerned.  In reality, there are multiple other perspectives.

. . . . . . . . . . . . . . . .

“Second, mental illnesses are tied inextricably to physical illness beyond the brain. Brain disorders like depression and schizophrenia greatly increase the risk of developing chronic diseases such as cardiovascular and respiratory diseases. People with mental illnesses and substance abuse are at increased risk of certain infectious diseases such as HIV/AIDS.”

In real medicine it is widely recognized that some illnesses are frequently associated causally with other illnesses.  Chronic hypertension, for instance, is a leading cause of kidney failure, as is diabetes.  Head colds sometimes progress to pneumonia, etc…  In most of these situations, the causal sequence is well understood.  High blood pressure, for instance, can damage the vessels in the kidney, and in extreme cases can cause kidney failure.

There is in Dr. Insel’s second item a suggestion that something similar is at work with regards to “mental illnesses.”  The assertion that “…brain disorders like depression and schizophrenia greatly increase the risk of developing chronic diseases such as cardio-vascular and respiratory disease” implies a causal link.  But the implication is spurious.  Psychiatry defines major depression by the presence of five or more problems of thinking, feeling, and/or behaving from a checklist of nine.  One of these items is weight gain of more than 5% of body weight.  Another item is diminished interest in activities.  It is known that weight gain leads to cardiovascular problems.  So the notion that major depression causes cardiovascular illness is simply an artifact of the APA’s definition.

Similarly with regards to inactivity, the World Heart Federation writes:

“…if you do not keep active, the risk to your cardiovascular health is similar to that from hypertension, abnormal blood lipids and obesity.”

So by making reduced activity a criterion for major depression, psychiatrists are in effect selecting into this diagnostic category people at increased risk for cardiovascular disease.  Then, like Dr. Insel, they announce that depression “increases the risk” of cardiovascular disease.  What a surprise! 

. . . . . . . . . . . . . . . . 

“Third, mental illnesses can be as fatal as physical ones. Suicide causes more deaths than homicide.”

Here again, we have the implication that the psychiatric “illness” called major depression is causing people to kill themselves, when in fact suicidal thoughts/activity are one of the defining features of this condition.  What Dr. Insel is saying, in effect, is that people who think a lot about suicide, and/or make suicide attempts, have a high incidence of suicide.  This is not very profound.

. . . . . . . . . . . . . . . . 

“Fourth, effective treatment can be low-cost and low-intensity. Not everybody with a mental illness needs expensive drugs, hospital care, or even direct access to highly trained psychiatrists. In low resource environments, locals or family members can be trained to provide brief, effective psychotherapies that treat moderate forms of depression or anxiety. Even phone- or internet-based therapy can be used to help recovery. While we don’t have the equivalent of a vaccine for measles or the bed net for malaria, there are low-cost, highly effective interventions for most people either at risk for, or already suffering from, a mental illness.”

The general concept expressed here is non-contentious, but the vast majority of psychiatrists routinely prescribe drugs (some of which are very expensive indeed) to virtually everyone who comes through the door.

. . . . . . . . . . . . . . . .

“Finally, this is an area where policy makers need to do more than ‘build it and they will come.’  It is not enough simply to make treatment available. People with psychotic disorders may deny they are ill and those with depression may be too consumed by self-loathing to feel worthy of help. Even in the developed world, it is estimated that only about half of all people with depression are diagnosed and treated. In the developing world, WHO estimates that 85% of people with a mental illness are untreated. We need sensitive ways to identify those at risk and to help those who are most disabled receive treatment.”

So only half the people “with depression” in the developed world are “diagnosed and treated”.  This is another standard psychiatric assertion.  The much more interesting statistic, of course, would be:  which of these groups does better – those who receive psychiatric treatment or those who don’t.  Psychiatry’s widespread promotions of their treatments, including Dr. Insel’s article, imply that those who receive psychiatric treatment do better, but here are three references and quotes that suggest otherwise:

Do nations’ mental health policies, programs and legislation influence their suicide rates? An ecological study of 100 countries. 

“Contrary to the hypothesized relationship, the study found that after introducing mental health initiatives (with the exception of substance abuse policies), countries’ suicide rates rose.”

The relationship between general population suicide rates and mental health funding, service provision and national policy: a cross-national study

“The main findings were: (i) there was no relationship between suicide rates in both genders and different measures of mental health policy, except they were increased in countries with mental health legislation; (ii) there was a significant positive correlation between suicide rates in both genders and the percentage of the total health budget spent on mental health; and (iii) suicide rates in both genders were higher in countries with greater provision of mental health services, including the number of psychiatric beds, psychiatrists and psychiatric nurses, and the availability of training in mental health for primary care professionals.”

National suicide rates and mental health system indicators: an ecological study of 191 countries.

“Significant positive correlations between suicide rates and mental health system indicators (p<0.001) were documented. After adjusting for the effects of major macroeconomic indices using multivariate analyses, numbers of psychiatrists (p=0.006) and mental health beds (p<0.001) were significantly positively associated with population suicide rates.”

. . . . . . . . . . . . . . . .

The notion of people denying that they “are ill”, or feeling that they are not “worthy of help”, as well as the asserted need to find “sensitive ways” to help those who are “most disabled” reads very much like coerced “treatment”.

There is certainly a great push at present among many psychiatrists and their supporters to persuade political leaders that coercive “treatment” needs to be expanded and made more accessible.  It appears that Dr. Insel is supporting this drive, but his words aren’t entirely clear, and I may be misinterpreting.

. . . . . . . . . . . . . . . .

Then Dr. Insel appears to reverse his general stance.

“…it should be acknowledged that treatments for mental illness remain far from infallible. Of those who get treated, only about half get the right treatment, and only about half of those remit.”

So – of the people that do get drawn into psychiatry’s web, only half get the “right treatment”, and only half of those “remit”.  Which leaves me wondering:  what happened to the half who got the wrong treatment?  And, is wrong treatment the same as malpractice?  And if so, then what is organized psychiatry doing about this?  If half the people who receive psychiatric treatment are getting the “wrong treatment”, shouldn’t this be a cause for major concern within the APA?  Shouldn’t the APA be holding press conferences to alert the public to such a scandalous state of affairs?  Shouldn’t  there be Congressional inquiries?  Shouldn’t we be seeing full-page cautionary ads in newspapers and online?

. . . . . . . . . . . . . . . .

” But for many people, today’s treatments are not good enough.”

And who could argue with that?

Tragically, Dr. Insel’s recipe for remediation is to go on with more of the same:

“Biomedical research gives us hope for cures, for brain disorders as much as any other part of the body. With better policies for providing existing evidence-based treatments in the near-term and research for developing better treatments in the long-term, we can aspire eventually to consign mental illness to the history books.” [Emphasis added]

So we’ll all have our brains corrected.  No more depression; no more defiant or inattentive children; no more crazy people disturbing the peace; no more delinquency; no more anxiety; no more temper tantrums; no more obsessiveness; no more substance abuse;  . . . .  There will be a drug to cure every human problem of thinking, feeling, and/or behaving.

Oh Happy Day!

Depression/ ADHD

This post was submitted by a reader.I was searching Google for effects of propaganda on the human psych, and stumbled upon this site. After reading a few stories, I felt I had to share my own. 

When I was in high school I was depressed. To the point where I was a walking text book definition. Failing grades, poor hygiene, isolation. All the signs were obvious.

I had to go to rehab for drinking too much cough syrup.

When I went to the doctor he diagnosed me with ADHD. I have never been a hyper person. always rather slow and calm.

Than he tells me that he is going to just experiment with multiple drugs to see what works, and than diagnose me with whatever that drug treats.

First drug was Vyvanse (lisdexamfetamine dimesylate)

Its a new “abuse-free” amphetamine. Due to a coating of protein, the chemical can only dissolve in your stomach acid. Injecting, Smoking, or Snorting would not activate it.

However the prescribed dose taken once a day was enough to make me a full effect of amphetamines, and I began losing alot of sleep. After having multiple panic attacks on this medication, I demanded the doctor take me off of it.

He than gave me Focalin (Dexmethylphenidate Hydrochloride)

Another new “abuse-free” drug. During my younger years I experimented with MDMA, and I would compare the feeling of Focalin with that of Extacy.

When I got into college my doctor pulled me off of it saying that college kids are more likely to sell it, and that he must change my prescription.

Next drug was Strattera (atomoxetine). I threw up every time I took it. It gave me intense piriods of happiness followed by extreme bursts of anger for no reason at all.

I stopped going to the doctor, I stopped taking medications. I no longer trust the medical system, the pharm companies, or even the government. I’d rather suffer the depression untreated than go through what I went through in high school.

On a side note, The experience made me drop out of school, and get my GED. That year, my school experienced a higher drop out rate than ever before.

 

Anonymous

 

More Bogus Conclusions From More Bogus Research

Robert Findling, MD, is a pediatrician and a psychiatrist.  He is the Director of Child and Adolescent Psychiatry at Johns Hopkins Children’s Center, and Vice President of Psychiatric Services and Research at the Kennedy Krieger Institute.

On July 31, Dr. Findling published a brief video (and article) on Medscape:  Adverse Events Caused by a Drug Warning?

Dr. Findling’s article is essentially a commentary on a study by Christine Lu et al, which was published by the BMJ on June 18.  Here is the conclusion paragraph from the Lu et al report:

“Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting.”

The Lu et al study was fundamentally flawed from various perspectives, and was widely criticized.  I did a critique of the paper here.  In that critique, I expressed the belief that the Lu et al study was never meant to be about science.  Rather:

“It was about spin and PR.  Its purpose was to attack and embarrass the media in order to keep them in line.  The fundamental message in the study, and in the NIH press release, is:  If you reporters print bad things about antidepressants, this will lead to reduced usage of these products, which in turn will lead to more suicides, and you will have blood on your hands!  Psychiatry is intellectually and morally bankrupt.  It has no valid response to its critics and is increasingly resorting to this kind of spin and PR.”

In fact, to their credit, the mainstream media did not pick up the Lu et al study to any marked degree, though the NIH, who funded the study, did issue a very misleading, and at times blatantly false press release.

But, back to Dr. Findling’s article.  Dr. Findling confined his observations to the adolescents (10-17) in the study.  Here are some quotes from his article interspersed with my comments.

“What did the study find? First, there was a 31% reduction in the rate of antidepressant prescriptions. Second, there was an increase of 21% in the rate of psychotropic drug poisonings in adolescents.”

This statement is false.  Here’s the passage from Lu et al:

“We estimated a relative reduction of 31.0% in antidepressant use in the second year after the warnings…At the same time as the substantial reduction in antidepressant use, we observed a sharp increase in psychotropic drug poisonings (fig 1). We estimated a significant relative increase of 21.7% in psychotropic drug poisonings in the second year after the warnings…”

The key word in this last quote is “estimated,” which appears twice.

Lu et al did not, as Dr. Findling asserts, find a 31% reduction in the rate of antidepressant prescriptions, nor did they find a 21% increase in the rate of psychotropic drug poisonings.  Rather, Lu et al estimated these numbers.

They graphed antidepressant use and psychotropic drug poisonings for 1.1 million adolescents who were enrolled in a consortium of group insurance plans.  The data was graphed from 2001 (q.1) to 2010 (q 4).  The black box warnings were mandated by the FDA in October 2004.

From the 2001 (q 1) to 2003 (q 3) data, Lu et al calculated trend lines for antidepressant use and for drug poisonings.  They excluded from this trend analysis the period 2003 (q 4) to 2004 (q 4) on the grounds that this was a phase-in period for the warnings.

They extended these trend lines for the second half of the study period, as shown in the diagram below.  The orange dotted lines are the trend line extensions.

Fig 1 Lu et al

 

 

 

Adolescents (10-17)

 

 

 

 

 

 

 

 

 

They chose the last quarter of 2006 (i.e. two years after the mandated black box warnings) as a reference point and calculated that at that point, antidepressant use was down 31.0%.  But these changes were not calculated against the actual data at the time of the warnings.  They were calculated against Lu et al’s trend line estimates of what would have been the case in 2006 (q 4) had the data continued to trend in the same direction, and at the same rate.  Here’s Lu et al’s statement on the matter:

“…we also provided absolute and relative differences (with 95% confidence intervals)…in the second year after the warnings (that is, in the last quarter of 2006), which were estimated by comparing the overall changes in outcome attributable to the warnings with counterfactual estimates of what would have happened without the warnings.” [Emphasis added]

In reality these kinds of short-term trend lines are notoriously unreliable, and the notion of assessing a percentage change against what might have been the case is fraught with potential for error.  And incidentally, I’m not familiar with the term “counterfactual,” but Merriam-Webster’s Collegiate Dictionary (2009) gives “contrary to fact” as the definition.  So perhaps Lu et al were trying to tell us something!

What the data, for this particular group of adolescents, actually shows is that antidepressant use did decrease beginning about a year before the black box warnings.  It is likely, but not certain, that this decrease was related to the publicized suicidality concerns, the FDA advisories, and the FDA warnings.  But psychotropic drug poisonings remained relatively flat (with some fluctuations) from the beginning of the study until about the beginning of 2008.  At that point the graph starts to climb.

A critical point here is that one can manipulate trend lines readily by choosing the start and finish points for one’s study period.  There is nothing  in the Lu et al data to support an association (much less a causal link) between the reduction in antidepressant use that started in 2003 (q 4) and the increase in drug poisonings that started about the beginning of 2008.  And even if these two variables were perfectly correlated, in the absence of additional evidence, there would be no reason to believe that the adolescents who didn’t take the antidepressants were the same individuals who were hospitalized for drug poisoning.

. . . . . . . . 

Back to Dr. Findling:

“The purpose of the current study was to examine 3 key variables during the second year after the FDA warnings were issued:

• Rate of antidepressant prescriptions;

• Rate of psychotropic drug poisonings (which can serve as an indicator of suicide attempt rate); and

• Rate of completed suicides.”

Despite the cautious wording in the second item, there is a clear implication that psychotropic drug poisonings (ICD-9 code 969) can be used as a substitute, or proxy, measure of suicide attempts.  In my earlier post, I drew attention to the fact that drug poisoning is only one method of committing suicide, and in many cases is not a suicide attempt, but rather an accidental overdose.  I also pointed out that ICD-9 code 969 includes poisonings by caffeine, marijuana, amphetamines, and Ecstasy, overdoses of which are not, to my knowledge, often used as methods of suicide.

Here’s what Lu et al say on this matter:

“…instead of deliberate self harm E-codes, we used poisoning by psychotropic agents (international classification of diseases, ninth revision, clinical modification (ICD-9 code 969), a more reliable proxy for population level suicide attempts.33 34

Reference 34 is to an earlier Lu et al study, on the completeness of deliberate self-harm (E-codes) in commercial insurance plan databases.  So the only reference cited in support of using drug poisonings as a proxy measure for suicide attempts is reference 33.  This is a 2010 paper by Patrick et al.  On July 14, less than a month after the publication of Lu et al, the BMJ published a letter from Catherine Barber, Matthew Miller (two of the authors in Patrick et al) and Deborah Azrael, all of Harvard School of Public Health.  Here’s a quote from their letter.

“Lu et al used poisonings by psychotropics (ICD-9 code 969) as a proxy for suicide attempts in claims data from 11 health plans, in spite of the fact that the code covers both intentional and unintentional poisonings. Our paper, which is the sole reference to their claim that code 969 is a ‘validated’ proxy for suicide attempts, in fact shows that in the U.S. National Inpatient Sample the code has a sensitivity of just 40% (i.e., it misses 60% of discharges coded to intentional self-harm) and a positive predictive value of 67% (i.e., a third of the discharges it captures are not intentional self-harm).”

And, in reference to other studies cited in Barber et al’s letter:

“On balance, the evidence shows no increase in suicidal behavior among young people following the drop in antidepressant prescribing. It is important that we get this right because the safety of young people is at stake. Lu et al’s paper sounding the alarm that [suicide] attempts increased was extensively covered in the media. Their advice that the media should be more circumspect when covering dire warnings about antidepressant prescribing applies as well to their own paper.” [Emphasis added]

So, the very people that Lu et al were citing to support their use of drug poisonings as a proxy measure of suicide attempts, have not only repudiated this methodological decision, but have also cited evidence contradicting Lu et al’s primary finding.

. . . . . . . . 

Back to Dr. Findling:

“An accompanying editorial [in the BMJ]…commented that the net effect was that the FDA warning led to more harm.”

This is an accurate reflection of the content of the editorial in question, which was written by John Geddes, Professor of Psychiatry at Oxford University; Andrea Cipriani, Senior Clinical Researcher, also at Oxford Department of Psychiatry; and Rob Horne, Professor of Behavioral Medicine, University College London.  Here’s what they wrote:

“The net effect of the warning was probably counterproductive and led to more harm.”

In fact, for the reasons given above, there is nothing in the Lu et al data to even suggest that the warnings “led to more harm.”

But Geddes et al went on to distort the facts further:

“Completed suicide is such a rare event that even this large observational study lacked the power to investigate this outcome.”

There is a subtle implication here that the warnings did lead to an increase in completed suicides, but that the Lu et al study lacked the power to detect this.  In fact, the Lu et al study did have the power to detect fluctuations in the suicide rate, and did investigate this specific outcome.  Lu et al stated very clearly:

“Our study was the first to examine the effects of the warnings on completed suicides over a long period. In contrast with the increases in suicide attempts, even with large sample sizes we observed no changes in suicides after the warnings. Completed suicides are rare; only one tenth as common as suicide attempts. Nevertheless, our data are consistent with the Centers for Disease Control and Prevention report that showed gradual increases in completed suicides between 1999 and 2010, without sudden discontinuities around the time of the FDA warnings and media reports, among people aged 10-34 years…”

And

“Completed suicides did not change for any age group.”

The Geddes et al editorial, copied dutifully by Dr. Findling, is a scandalously deceitful piece of psychiatric propaganda.

. . . . . . . . 

And finally, from Dr. Findling:

“The data from this study suggest that adverse events not only can occur from medicines but also as a result of warnings. This leads to the unanswered question: How do we communicate treatment-related outcomes and treatment-related concerns effectively and openly to ensure improved patient outcomes without unwanted consequences?”

In reality, the only significant consequence of the warnings emerging from the Lu et al study pertaining to adolescents (10-17) is a reduction in the use of antidepressant drugs in this particular group.  There is no evidence of an increase in psychotropic drug poisonings, suicide attempts, or completed suicides.

The essential dynamic in all of this is that the FDA’s warnings, which incidentally were long overdue, had a negative impact on pharma-psychiatry’s image, and on their business, but had no negative impact on client welfare.  Nevertheless, psychiatry continues to resist the reality that their sacred drugs do in fact cause harm, and that the FDA warnings were needed.  For psychiatry, business and professional status routinely trump client welfare.

Psychiatry is morally and intellectually bankrupt.  They have never had any intelligent or logical response to the criticisms that are being leveled against them, including the well-established fact that their so-called antidepressant drugs induce suicidal feelings and actions in some people, particularly children and young adults.  They refuse to accept this because it contradicts their dogma.  Instead, they use spin, propaganda, and fear-mongering to promote their drugs.

AND INCIDENTALLY

Dr. Findling, according to his Johns Hopkins bio,

“…has been honored with numerous awards and has received both national and international recognition as a clinical investigator.”

And  yet, he apparently couldn’t see the flaws in the Lu et al study, even though these flaws have been widely publicized.  This is indeed puzzling, but becomes clearer as one continues with his bio:

“Findling is currently the principal investigator on an NICHD contract that is comprehensively examining lithium in the treatment of pediatric mania. In addition, he is the principal investigator of an NIMH study that is assessing the longitudinal course of children with manic symptoms. He is also the site principal investigator of an NIMH-supported clinical trial that is examining the treatment of children with severe aggression. His research is also supported in part by the Stanley Medical Research Institute and the pharmaceutical industry.”

Antidepressants and Overall Wellbeing

There was an interesting article published on April 12, 2014 in Psychotherapy and Psychosomatics.  It’s called The Efficacy of Antidepressants on Overall Well-Being and Self-Reported Depression Symptom Severity in Youth: A Meta-Analysis, by Gary Spielmans and Katherine Gerwig, both of the Psychology Department, Metropolitan State University, St. Paul, Minnesota.

The authors conducted a word-search in Medline, PsychINFO, and the Cochrane Central Register, and identified 8 studies that met their criteria.  They combined the data from these studies and concluded:

“Though limited by a small number of trials, our analyses suggest that antidepressants offer little to no benefit in improving overall well-being among depressed children and adolescents.”

In the Discussion section of the paper, they stated:

“We found no evidence that antidepressants offer any sort of clinically meaningful benefit for youth on self-report measures of depression, quality of life, global mental health, or parent reports of autonomy.”

The authors acknowledge that their study has limitations,  “…the most obvious being the small sample of included trials.”

“A larger sample of relevant trials may lead to differing conclusions.  However, even the strongest signal of efficacy in our results (a pooled statistically nonsignificant effect of g = 0.16 across measures of autonomous functioning, self-esteem, global mental health, and quality of life among adolescents) provides little reason to suspect any robust treatment effects.”

The article goes on to discuss the relative merits of self-report vs. practitioner ratings as measures of efficacy in antidepressant trials:

“Given the high emphasis on clinician-rated depression measures in the reporting of clinical trial outcomes and subsequent reviews…it seems that even the modest efficacy found in prior antidepressant meta-analyses is inflated.  Perhaps this is best illustrated by fluoxetine [Prozac].  The discord between small to moderate effect sizes on clinician-rated measures in three trials (0.52, 0.60, and 0.40)…and negligible to quite modest effects on self-reports (-0.07, 0.22, and 0.15) is notable.  Further, the only fluoxetine trial to report quality of life and global mental health outcomes found no treatment benefit.”

and

“It is unclear exactly how different outcome measures should be weighed, but our findings suggest that the overall benefits of antidepressants in youth have been overstated and that their overall benefit over placebo may be vanishingly small.”

And more disturbingly:

“…a recent systematic review found a much elevated risk of excessive arousal/agitation among youth taking antidepressants versus placebo…Data from a Food and Drug Administration systematic review also found that antidepressants were linked to a statistically significantly higher rate of hostility or agitation relative to placebo…Clearly, a more expansive examination of the risk-benefit ratio of antidepressants in youth, extending beyond clinician-rated depression measures and suicidality, is needed.”

. . . . . . . . 

The first review mentioned in the above quote is Offidani E. et al, 2013.  Here’s their conclusion:

“Risks of excessive mood elevation during antidepressant treatment, including mania-hypomania, were much greater than with placebo, and similar in juvenile anxiety and depressive disorders. Excessive arousal-activation in children or adolescents treated with antidepressants for anxiety as well as depressive disorders calls for particular caution and monitoring for potential risk of future bipolar disorder.”

The FDA review mentioned is the 131 page review by Tarak Hammad, MD, PhD on the link between suicidal behavior and antidepressants’ in youth.  On the link to hostility/agitation, Dr. Hammad stated:

“Although none of the individual trials had a statistically significant result, the overall RR [risk ratio] for Paxil and the overall RRs for all drugs and for all SSRIs were statistically significant showing an increase in the risk of developing these symptoms in the drug group as compared to the placebo group.”

. . . . . . . . 

Perhaps it’s time to stop calling these drugs antidepressants.

AND INCIDENTALLY

I found no links to the Spielmans, Gerwig article in the mainstream media.  In fact, I found only two outlets that picked it up:  MinnPost, where I found it, and MDLinx.  MinnPost is  “…a non-profit, nonpartisan enterprise whose mission is to provide high-quality journalism for news-intense people who care about Minnesota.”  MDLinx is an online newsletter that  “…aggregates medical articles and research from more than 1,200 peer-reviewed journals and leading news media on a daily basis.”

Simon Says:  Happiness Won’t Cure Mental Illness

Professor Simon Wessely, who was recently installed as President of Britain’s Royal College of Psychiatrists, has just written his second post in that capacity.  It’s called Happiness: The greatest gift that I possess?

The background to Dr. Wessely’s article is the recent launching of the UK’s Centre Forum’s Mental Health Commission’s report:  The pursuit of happiness:  a new ambition for our mental health.  This is a very interesting report, the gist of which can perhaps be gained from these quotes:

“The pursuit of happiness should be a goal of government.”

“Mental health problems are the biggest contributor to poor wellbeing.”

“The national curriculum should include the requirement to teach children and young people how to look after their mental health and build emotional resilience through approaches such as mindfulness.”

“A dedicated mental health minister in the Department of Health should be created with responsibility for mental health services and a Cabinet level Minister for Wellbeing reporting to the Prime Minister should be appointed.”

“Every Health and Wellbeing Board (HWB) should appoint a Wellbeing Champion to advocate parity of esteem between mental and physical health and promote wellbeing.”

“Good mental health and wellbeing policy is simply good health policy, and investment in this new ambition would do more to reduce the human and financial costs of misery and mental health problems. Investment in this ambition could work towards the following achievements:

  • Reduce poverty and social disadvantage;
  • Promote human rights and inclusion;
  • Reduce the human impact of mental health problems;
  • Prevent premature death;
  • Reduce the economic costs to society;
  • Put knowledge of cost-effective treatments into practice.”

The report is interesting in that it appears to be trying to walk a line between psychiatry’s standard cry for more treatment for “mentally ill” individuals on the one hand, and the development of more general strategies for alleviating inequality, promoting competence etc., on the other.  The term “mental illness” occurs 19 times; while the term “mental health problem” occurs 91 times.  I may be over-reading this, but I did get the impression that the Commission is endorsing the illness doctrine with regards to the conditions labeled schizophrenia, bipolar disorder, and major depression, but rejecting, or at least not endorsing, the doctrine with regards to the other psychiatric “diagnoses.”

In any event, they are recommending that efforts to alleviate mental health problems be expanded to include methods other than psychiatric drugs, electric shock, etc….

Dr. Wessely’s reaction to all of this was interesting.

“At the same time public mental health is also being included in a wider social issue – the current debate loosely around what we might call the ‘wellbeing agenda’.  Few people, and probably no members of this College, can, or will, deny the importance of strong communities, families and relationships, to name but three, to our general sense of well being.   But in my opinion we need to be a little more cautious about mixing public mental health with this ‘dash for happiness’ – and its various facets such as positive psychology, well being and optimism.”

But his enthusiasm is not total.

“But as an academic psychiatrist with a major interest in population approaches, I am not yet convinced that this will do something significant about reducing the burden of morbidity that we deal with – for example disorders ranging from major depression, phobic disorders, OCD, autism, schizophrenia and so on and so forth.  The evidence for this is slender…”

In other words, public promotion of happiness and wellbeing won’t alleviate psychiatric illness.  Only psychiatrists can do that.

“Ideally we could do both.  Support what we traditionally do, and what our patients expect from us, whilst at the same time also lending our support to the broader agendas that are now being looked at by all three political parties.  Unfortunately as we all know ‘there is no more money’.   And my worry is that the money for the experimental interventions, which is what they are, will come from our own budgets.  I have noticed that is often the case – something that is new, buzzy, smart and promises much tends to be more attractive precisely because it is innovative, and will take resources from what is seen as ‘conventional’.”

On the one hand, Dr. Wessely points out that there is little evidence for the efficacy of the happiness/wellbeing agenda, but ignores the fact that the evidence for the efficacy of psychiatric treatment is based almost entirely on short-term, interest-conflicted, pharma-funded trials.  He also seems to have forgotten that it isn’t all that long ago that psychiatric drug treatment was “new, buzzy, smart,” and promised much, and incidentally, hasn’t lived up to its promises.

“…you can come at this from the other direction i.e. that by treating their mental illness, patients will inevitably become happier as their suffering is alleviated. And I certainly can’t argue with that.”

The word “inevitably” strikes me as grandiose.  What of the people who have been so damaged by SSRI’s that they are virtually incapable of feeling normal joy?  What of those people whose lives have been destroyed by neuroleptic-induced tardive dyskinesia and akathisia?  What of the people whose lives have been ruined by benzodiazepine withdrawals?  What of the victims of electric shock treatment who can’t remember that they went to college and got a degree?  The notion that “psychiatric treatment of mental illness” will inevitably make people happier is the very height of psychiatric arrogance.  In my experience, the only inevitable outcome from long-term psychiatric treatment is significant to profound organic damage, coupled with disempowerment and stigmatization.

“So if we have to make choices, we should remain on the side of patients, carers and the evidence.  It’s a difficult balancing act, one that confronts all the three main political parties as they prepare their health manifestos. In the meantime, let’s pursue happiness, but equally let’s not expect that happiness alone will deal with the problem of mental disorder.”

There it is again:  this happiness stuff is peripheral; our “patients” are sick, and they need us psychiatrists to “treat” them.  It’s the same old song.

. . . . . . . . . . . . . . . .

Early in the article, Dr. Wessely stresses the magnitude of the “mental disorder” problem.

“Mental health is an important public health issue…since mental disorder is responsible for an astonishing 23.6% of the years lost to disability in the UK – the second largest cause behind musculoskeletal disorders…. Such a large burden of mental disorder is due to a combination of high prevalence, early onset in the life course, and broad range of impacts including in public health related areas. These impacts result in an annual cost to the English economy alone of £105 billion…and, looking further afield, annual global costs of US$2.5 trillion…and €532.2 billion in the European Union…. Vastly more importantly, this represents a wealth of human suffering.”

Psychiatrists and psychiatric associations have been quoting these kinds of statistics increasingly in recent years, and tragically they are being picked up and promoted unquestioningly by politicians and by the media.  But let’s take a closer look:

“…mental disorder is responsible for an astonishing 23.6% of the years lost to disability in the UK…”

In this context, depression is often cited as one of the “illnesses” that contributes to occupational absenteeism.  And depression, of course, is a fact of life. We all have our ups and downs.  But psychiatrists insist that what they mean by major depression, dysthymia, etc., is not the ordinary ups and downs – but depression-the-illness, which they contend is something radically different.

So the question naturally rises, how do we distinguish between ordinary feeling down, on the one hand, and depression-the-illness on the other.  Psychiatry’s answer is that depression-the-illness causes  “…clinically significant distress or impairment in social, occupational, or other important areas of functioning.”

This phrase occurs as a criterion feature in almost all psychiatric “diagnoses,” and is embodied in the DSM definition of a mental disorder, but is unsatisfactory from a number of aspects.  Firstly, the term “clinically” has no meaning, other than a thinly-veiled attempt to lend a medical flavor to the phrase.  Secondly, the term “significant” is not defined, and inevitably rests on the subjective opinion of a psychiatrist, who, in many cases, has a vested interest in “finding” a “diagnosis.”  Thirdly, the term “impairment” suggests an inability of the individual to engage in the activity in question, when in fact, the only information that is usually to hand is that the individual hasn’t actually engaged in the activity.  Fourthly, the phrase asserts that the causal sequence runs from the “disorder” to the activity (the depression, for instance, causes the person to miss work), when in fact the opposite sequence is just as plausible (missing work causes depression).

But with regards to Dr. Wessely’s statement, there’s an even more serious problem. At any given time, a certain percentage of the population will be experiencing some measure of depression.  (Even this isn’t quite accurate, in that depression-joy is a continuum with no sharp cut-offs; but let’s set that consideration aside.)  Let’s say that the proportion of people experiencing depression is 10%.

According to psychiatry, a sub-group of these individuals have depression-the-illness.  The criterion by which a person gets from the first group to the second group is the clinically-significant-distress-or-impairment standard cited above.  One way – and I suggest the major way – of meeting this standard is absence from work.  So, a person who is depressed, according to psychiatry, is not necessarily mentally ill, but if he’s depressed and missing work, then he crosses the threshold, and is mentally ill.

So, psychiatry posits absence from work as one of the major criteria for mental illness, and then “discovers” the astonishing fact that mental illness causes (“is responsible for”) a great deal of work absenteeism!

But Dr. Wessely takes the nonsense further.  Not only is he blind to his own circular reasoning, he actually goes on to tell us why mental disorders impose such a burden of economic loss and human suffering.

“Such a large burden of mental disorder is due to a combination of high prevalence, early onset in the life course, and broad range of impacts including in public health related areas.” [Emphasis added]

It is not because of high prevalence, early onset, and broad range of impacts that the so-called mental disorders constitute such an economic burden.  Rather, it is because of the way psychiatry defines them.  When psychiatrists assert that depression-the-illness causes a great deal of missed work, the essential meaning of this statement is that workplace absenteeism is caused by people missing work.  This is not quantum physics.  It is logic 101.

Yet psychiatry remains routinely and resolutely blind to its specious assertions in these areas, and continues to disseminate these “burden-of-disease” figures as a justification for their continued existence.  This is emphatically not because psychiatrists are inherently stupid.  Rather, it is because the primary agenda of psychiatry is the promotion of psychiatry, and Dr. Wessely is staying firmly in this role in his new position.

AND INCIDENTALLY

It occurs to me that the title of Dr. Wessely’s article may be lost on some – particularly younger – readers.  In 1963, Bill Anderson, an American country singer, wrote and recorded a song called “Happiness,” the first line of which is the title of Dr. Wessely’s article.  It’s a pleasant song with a catchy tune, but it didn’t do particularly well.  But in 1964, the British singer/comedian Ken Dodd recorded it, and it took off. The theme of the song is that the best things in life are free.  Here’s a quote:

“Happiness to me is a field of grain
Lifting its face in the falling rain
I see it in the sunshine, I breathe it in the air
Happiness, happiness everywhere”

Which strikes me as being a far cry from psychiatry’s notion that virtually all negative feelings can be banished with pills.  Ken Dodd is 86, still touring, and apparently still enjoying the simple pleasures.  You can see a much younger Ken singing “Happiness” here, with the late Freddie Mercury singing along (kind of).  But I must warn you:  if you’re the sort of person who gets tunes stuck in your head, don’t open this link!

. . . . . . . . . . . . . . . .

Disclosure:

I have no financial ties to Ken Dodd.

 

 

What If You Should Be Depressed?

This post was submitted by a reader.i have been very depressed three or four times. always it was the same cause. i’ve never had the experience of being depressed for no reason. i’ve never gone to bed feeling fine and woke up feeling depressed.

i think i’ve acquired enough sophistication to say:

i can’t imagine anyone under the same circumstances not becoming very depressed, crying constantly, hating himself, thinking of killing himself.

i also think the circumstances are new to human experience. that is, in the past my guess is such circumstances were very uncommon.

what were they every single time: 

a beautiful girl or woman who was unavailable. but not because i was ugly or boring or whatever.

because of my family background.

i live in the us. despite college entrance exams above the mean for admits to all of america’s best universities. despite the same for its graduate school entrance exams, i never had a chance of getting in. my parents divorced. my dad hit me, fornicated, was a loser.

and so am i. social reproduction is reason enough to top yourself.

the pills didn’t work. the psychiatrists and therapists were idiots.

my solution has been alcohol.

i’m in the following study believe it or not https://www.cog-genomics.org/.

but i have no prospects and never will.

anyway, blah, blah, blah…

it is a fundamental tenet of the american ideology, so to say, that the locus of pathology is the individual, never his society and never the two together.

i know that many americans would simply dismiss me as a weak whining “pussy”. all i produce is excuses.  i understand this. i’d even say the same of some people.
my only response can be, “it isn’t as simple as that.”

 

A Reader

 

Suicidal Behavior After FDA Warnings

On June 18, the British Medical Journal published an article by Christine Lu et al, titled Changes in antidepressant use by young people and suicidal behavior after FDA warnings and media coverage: quasi-experimental study

Here’s the conclusion paragraph from the abstract:

“Safety warnings about antidepressants and widespread media coverage decreased antidepressant use, and there were simultaneous increases in suicide attempts among young people. It is essential to monitor and reduce possible unintended consequences of FDA warnings and media reporting.”

Note the slightly rebuking tone directed against the FDA and the media.

SOURCE OF DATA

The researchers interrogated the claims databases (2000-2010) of eleven medical insurance groups who collectively cover about 10 million people in 12 geographically scattered US locations.  All groups were members of the Mental Health Research Network (MHRN).

The general concept behind this sort of research network is that computerized insurance claims data represent an enormous repository of potentially very useful information, which researchers can readily tap for answers to questions that are difficult to resolve with smaller-scale data.  MHRN’s website, under the tab “Funding“, states:

“Initial funding for the MHRN is through a 3-year cooperative agreement with the National Institute of Mental Health (U19 MH092201 “Mental Health Research Network: A Population-Based Approach to Transform Research”) and through a supplement from NIMH to the existing Cancer Research Network funded by the National Cancer Institute.

During the initial funding cycle, the MHRN developed core infrastructure for collaborative research and conducted four developmental research projects to test and leverage that infrastructure in specific clinical areas.”

The Lu et al study is one of these four projects.

MHRN’s “virtual data warehouse” contains information on inpatient and outpatient treatment, and outpatient pharmacy data.  It also contains, for deceased members, the date and cause of death.

The present study included all adolescents (10-17), young adults (18-24), and adults (20-64) in the eleven insurance groups.

VARIABLES STUDIED

From the pharmacy data, the authors calculated the quarterly percentages of individuals who were dispensed an antidepressant.

The frequency of suicide attempts was measured by the quarterly incidence of “poisoning by psychotropic agents,” (ICD-9 code 969), that resulted in inpatient or ER treatment.

The frequency of completed suicides per 100,000 members was also calculated quarterly.  Although the other data elements are presented for each quarter up to the end of 2010, the completed suicide data stops at the end of 2008.  The authors explain:  “There is generally a lag time of 12-24 months for both reporting of deaths and availability of data; therefore we analyzed data on deaths up to and including 2008.”

TIME FRAME

The study’s time frame was from the first quarter of 2000 to the last quarter of 2010.  The researchers divided this time frame into three segments:

1.  The pre-warning phase (2000, q1 – 2003, q3)
2.  The phase-in period (2003, q4 – 2004, q4)
3.  The post-warning period (2005, q1 – 2010, q4)

The FDA black box warnings were mandated in October 2004.

The authors justify the use of a phase-in period as follows:

“To deal with the possibility of an anticipatory response to the warnings, we considered the last quarter of 2003 to the last quarter of 2004 as a ‘phase-in’ period that spanned the entire period of FDA advisories, the boxed warning, and intense media coverage, and excluded these five data points from the regression models.”

Regression, in this context, basically means finding a line-of-best-fit through a series of points which represent data on a graph.

RESULTS

The study included approximately the following numbers of individuals:

Adolescents (10-17)                1.1 million
Young adults (18-29)              1.4 million
Adults (30-64)                            5    million

The results for the three age groups are set out in graph form and are designated Figures 1, 2, and 3.

Let’s start with the adolescent graphs (Fig 1)

Fig. 1 Rates of antidepressant use, psychotropic drug poisonings, and completed suicides per quarter before and after the warnings among adolescents enrolled in 11 health plans in nationwide Mental Health Research Network

Fig 1 Lu et al

 

 

Adolescents (10-17)

 

 

 

 

 

 

 

 

 

 

 

The graph is divided into three parts.  The upper part shows antidepressant use, quarter by quarter, for the period of the study (2000, q1 – 2010, q4).  Each dot represents the percentage of the 1.1 million adolescents that were taking antidepressants in that particular quarter.  So in the first quarter of 2000, a little over 1.5%  were taking the drugs, and so on.

The middle part of the figure shows the percentage of adolescents who were treated for psychotropic drug poisoning in each quarter.

And the lower part shows the number of completed suicides (per 100,000) in the group, plotted quarterly, and graphed as a continuous line (the dark green line) rather than as dots.  The lighter lines represent the 95% confidence interval.  In other words, the chances are 95% that the true suicide rate for the population lies between these lines.

The slightly darker vertical band that goes up through the middle of all three graphs is the phase-in period (2003, q 4 – 2004, q4).  The solid lines in the upper and middle sections are the regression lines for the pre and post warnings data.  The post lines are curves because the authors report that this fitted the data better.  The orange dotted lines in the post area are simply the projection of the pre-warning regression lines; i.e. a projection of what purportedly would have happened if the warnings had not been issued.  Completed suicide data for the last two years of the study was not available.

. . . . . . . . . . . . . . . .

The data for the young adults (Fig 2) is presented similarly.

Fig 2 Rates of antidepressant use, psychotropic drug poisonings, and completed suicides per quarter before and after the warnings among young adults enrolled in 11 health plans in nationwide Mental Health Research Network

Fig 2 Lu et al

 

Young Adults (18-29)

 

 

 

 

 

 

 

 

 

 

 

The data for older adults is shown in Fig. 3

 

Fig 3 Rates of antidepressant use, psychotropic drug poisonings, and completed suicides per quarter before and after the warnings among adults enrolled in 11 health plans in nationwide Mental Health Research Network 

Fig 3 Lu et al

 

Older Adults (30-64)

 

 

 

 

 

 

 

 

 

 

 

 

The FDA warnings were not aimed at adults.  The authors state that the adults were included in the study  “…as a ‘control’ group.”

From all of this data, the authors draw the following results/conclusions:

1.  The FDA safety warnings, plus the media coverage, “decreased antidepressant use.”

2.  There were simultaneous increases in suicide attempts by young people.

3.  It is essential to monitor “unintended consequences” of black box warnings and media reporting.

4.  Completed suicides did not change for any group.

The main thrust of the article is expressed in the final paragraph:

“Undertreated mood disorders can have severe negative consequences. Thus, it is disturbing that after the health advisories, warnings, and media reports about the relation between antidepressant use and suicidality in young people, we found substantial reductions in antidepressant treatment and simultaneous, small but meaningful increases in suicide attempts. It is essential to monitor and reduce possible unintended effects of FDA warnings and media reporting.”

Again, we see the rebuking tone aimed at the FDA and the media.

NIH PRESS RELEASE

As mentioned earlier, the study was funded by the National Institute of Mental Health (NIMH), which is a division of the US National Institutes of Health (NIH).  The study was published on June 18.  On June 19, NIH issued a two-page press release via its own website, Medline Plus.

Here are some quotes from the press release, interspersed with my comments and observations.

“Teen suicide attempts rose nearly 22 percent after the U.S. Food and Drug Administration (FDA) warned about dangers of antidepressants, a new study finds.”

This statement is false.  What the study found was that within the HMO Research Network’s insurance plans in ten states, psychotropic drug poisonings (including, incidentally, according to the press release, poisonings by marijuana, amphetamines, and Ecstasy), that required medical treatment, rose by the stated amount.  This is only one method of attempting suicide, and in many cases might not be attempted suicide at all.  The study provided no information on the incidence of confirmed suicide attempts measured as such.  Incidentally, ICD-9 code 969, which Lu et al used as a proxy measurement for suicide attempts, also includes “poisoning by caffeine”!

The statement is also misleading, in that the changes in the rates of psychotropic poisonings were measured not against the previous rate of poisoning as is implied in the above quote, but against the projected rate, based on the 2000 – 2003 regression line.  This is critical because regression lines can be extraordinarily poor predictors, as any stock market analyst can attest.

Regression lines are also easy to manipulate by the simple expedient of delineating the time boundaries to show a desired trend.  In the present study, for instance, the exclusion of the phase-in data from the pre-warning regression analysis definitely had the effect of lowering the poisoning trend projection in the young adult group (Fig 2), and probably had this effect in the adolescent group (Fig 1).  Excluding the phase-in data from the regression analysis was an arbitrary decision.  The researchers might just as readily have used a simple pre-post cutoff based on the quarter in which the warnings were mandated.

It is also noteworthy that the percentage changes in antidepressant prescriptions and psychotropic poisonings were assessed solely on the 4th quarter of 2006.  The authors’ statement on this matter is interesting:

“In addition, we also provided absolute and relative differences (with 95% confidence intervals)…in the second year after the warnings (that is, in the last quarter of 2006), which were estimated by comparing the overall changes in outcome attributable to the warnings with counterfactual estimates of what would have happened without the warnings.”

Note the unwarranted causal implication (“attributable”), and the assumption that the authors knew what would have happened had the warnings not been issued.  “Counterfactual” according to my Webster’s means “contrary to fact”.  I’m not sure what the authors had in mind in describing their projections this way.

There is also, I think, a suggestion in the above quote that the result applies to the general population.  This, however, would only be the case if in fact the group of individuals studied had been selected at random from the US population.  This is emphatically not the case.  The study group comprised all the individuals between ages 10 and 65 who were enrolled in the eleven MHRN insurance groups in the 12 states..  This group, for instance, is certainly not representative of uninsured people, nor of people in other locations.

. . . . . . . . . . . . . . . .

“Following the warnings, antidepressant prescriptions for young people fell by more than a fifth. At the same time, suicide attempts rose, possibly because depression was being undertreated, according to background information in the study.”

This statement is false.  What the study found was that antidepressant prescriptions for adolescents (10-17) declined from a peak of about 1.9% in 2003, q3 to a low of about 1.3% in 2008, q2, and then climbed to about 1.7% in 2010, q 3 (Fig 1).  But the figures for young adults (18-24), who are presumably included in the term “young people” as used above, remained remarkably constant at about 4% from 2004, q1 to 2010, q4.  The only “fall” for this group is a notional fall from the trend line. (Fig. 2)

Again in this quote, we see the implied causal link to suicide attempts, and even a suggested explanation:  “possibly because depression was being undertreated.”  The study provides no information on general nationwide trends in the frequency of suicide attempts, and even if suicide attempts were trending upwards during the period in question, there are many other possible explanations.  Also in this quote we see the invalid substitution of the term “suicide attempts” for psychotropic drug poisonings.

. . . . . . . . . . . . . . . .

“‘We found a substantial reduction in use of antidepressants in youth, and also in adults — who were not targeted by the warning,’ said lead author Christine Lu, an instructor in population medicine at the Harvard Pilgrim Health Care Institute in Boston.”

Here again, this statement is false.  The antidepressant use data for young (Fig 2) and older (Fig 3) adults remained almost perfectly flat in the post-warning period.  As noted earlier, the only falls were from the projected trend lines.

. . . . . . . . . . . . . . . .

“Lu attributes the drop in prescriptions to the FDA’s warning and resulting media coverage. ‘To a certain extent, the FDA’s black box warning was legitimate, but the media emphasis was really on suicide without noting the potential risk of undertreatment of depression. Because of that, there has been an overreaction, and that overreaction has sent alarming messages to parents and young people,’ she said.”

Note the skilful tightrope walking.  Dr. Lu and the NIH want to bash the media for publicizing the link between antidepressants and suicidal activity, but at the same time not overly antagonize the FDA.  The media ignored the “potential risk of undertreatment”; the media overreacted; the media caused alarm.  Big bad journalists need to get into line!

. . . . . . . . . . . . . . . .

Then we have a truly magnificent piece of psychiatric spin:

“Although the initial studies showing an increased risk of suicide in teens taking antidepressants prompted the black box warnings, researchers never proved that the medications were the cause of the increased risk of suicide, only that there was a link.

Likewise, though the current research finds a strong association between the uptick in suicides and the drop in antidepressant use, Lu and her colleagues weren’t able to definitively show that a decrease in antidepressant prescriptions was directly responsible for the recent increase in suicide attempts.”

The deliberations and the data on which the FDA black box warnings were based were comprehensive, and showed a clear link between antidepressant use in young people and suicidal activity.  And the evidence was sufficient to convince the FDA to take action.

The findings in the Lu et al study do not come even close to this standard.  But by counterposing them in this way, the NIH is trying to convey the impression that the findings of the present study are comparable in quality to the earlier work.

Note also the blatant falsehood:  “…the current research finds a strong association between the uptick in suicides and the drop in antidepressant use…”  [Emphasis added] In fact, the Lu et al study found no increase in completed suicides.  They stated clearly in their abstract:  “Completed suicides did not change for any group.”

. . . . . . . . . . . . . . . .

“Coverage of the warning may have had unintended consequences, Lu said. Doctors may have been less willing to prescribe antidepressants and parents may have been fearful of letting their children take them, she said.

The lesson, Lu said, is that the media and the FDA should strive for the right balance so potential overreactions don’t occur.”

Again, big bad media needs to get in line and print only what psychiatrists tell them to print (“the right balance”).

. . . . . . . . . . . . . . . .

“Undertreating depression is worse than the slight increase in suicidal thoughts antidepressants may cause, Lu said. ‘It’s also a reminder for doctors to weigh the risk of a drug with the risk of not treating or undertreating the condition,’ she said.”

This is extremely misleading.  Note how the concerns on which the boxed warnings were based are dismissed:  “…the slight increase in suicidal thoughts antidepressants may cause.”

The pediatric meta-analysis data on which the FDA deliberated in 2003-2004 are written up in detail (131 pages) here.  Tarak Hammad et al published the formal journal report in 2006.  It is clear that great pains were taken to include in the primary outcome measure only adverse events that had clear suicidal potential.  The primary outcome, which was labeled “suicidal behavior or ideation”, contained three elements:

  • Suicide attempts, and/or
  • Preparatory actions towards imminent suicidal behavior, and/or
  • Suicidal ideation

The overall risk ratio (drug vs. placebo) for the three elements combined was found to be 1.95 (95% CI, 1.28 – 2.98).  The risk ratio for suicidal behavior (first two items) was 1.90 (95% VCI, 1.00 – 3.63).  In other words, the individuals in the studies who took the drug were about twice as likely to have made a suicide attempt, and/or made preparations for imminent suicide, and/or had been actively thinking about suicide than those who took the placebo.  This is emphatically not something to be dismissed as “a slight increase in suicidal thoughts…”

Hammad et al acknowledged the limitations of their study, but went on to state:

“Despite the limitations, the observed signal of risk for suicidality represents a consistent finding across trials, with many showing RRs [risk ratios] of 2 or more. Moreover, the finding of no completed suicides among the approximately 4600 patients in the 24 trials evaluated does not provide much reassurance regarding a small increase in the risk of suicide because this sample is not large enough to detect such an effect.”

They also provide the following interpretation of their findings:

“…when considering 100 treated patients, we might expect 1 to 3 patients to have an increase in suicidality beyond the risk that occurs with depression itself owing to short-term treatment with an antidepressant.” [Emphasis added]

In addition, since the issuing of the black box warnings in 2004, there have been two studies confirming the link between suicidal activity and antidepressants.

Olfson et al 2006 found:

“…in children and adolescents (aged 6-18 years), antidepressant drug treatment was significantly associated with suicide attempts (OR [odds ration], 1.52; 95% CI, 1.12-2.07 [263 cases and 1241 controls]) and suicide deaths (OR, 15.62; 95% CI, 1.65-infinity [8 cases and 39 controls]).”

And Olfson et al 2008 found:

“Among children, antidepressant treatment was associated with a significant increase in suicide attempts (odds ratio [OR] = 2.08, 95% confidence interval [CI] = 1.06 to 4.10; cases, N = 51; controls, N = 239; p = .03).”

PRESS COVERAGE

The Lu et al article, and the authors’ conclusions, received wide coverage in the general media. Most of the mainstream media simply regurgitated the gist of the study plus the press release with additional quotes from two of the authors, Christine Lu, PhD, and Steven Soumerai, ScD, both from Harvard’s Department of Population Medicine.

Both the Washington Post and The Boston Globe delivered the authors’ message pretty much without reservation.  Here’s a quote form the Washington Post:

“…Wednesday’s study wrote that while the government’s actions in 2003 and 2004 were legitimate and thorough, ‘FDA advisories and boxed warnings can be crude and inadequate ways to communicate new and sometimes frightening scientific information to the public.’ Likewise, researchers argue that while media attention can create much-needed awareness…sometimes ‘the information may be oversimplified and distorted when communicated in the media.'”

And from The Boston Globe:

“The study’s authors say that patients and doctors, frightened by news coverage that exaggerated the risk of antidepressants, shunned treatment that might have prevented the suicide attempts.”

In fact, there is no information in the report as to whether the victims of the poisonings had taken antidepressants or not.

And amazingly,

“Steven B. Soumerai, a coauthor and a Harvard professor of population medicine, said black box warnings typically have little effect on physician behavior, unless they are accompanied by news reports.”

In his attempt to castigate the press for publicizing the black box warnings, has Dr. Soumerai inadvertently shot psychiatry in the foot?  Do psychiatrists actually pay more attention to news reports than to FDA warnings?

Bloomberg also ran the standard story:

“A widely publicized warning by U.S. regulators a decade ago about risks for teenagers taking antidepressants led to plummeting prescriptions and increased suicide attempts, Harvard University researchers said.”

Note the clearly implied causality (“led to”), the exaggeration (“plummeting”) and the mischaracterization of psychotropic poisonings as “suicide attempts.”

“‘After the widely publicized warnings we saw a substantial reduction in antidepressant use in all age groups,’ said Lu, an instructor in population medicine at Harvard Pilgrim Health Care Institute, in a telephone interview. ‘Warnings, especially widely publicized warnings, may have unintended consequences.'”

“Lu said the focus by the media on the risk of suicide, even though the review of data found no increase in completed suicides, frightened patients and parents.”

Again, the big bad media frightening patients and parents.

But Bloomberg also obtained some rebuttal quotes from Marc Stone, MD, a senior medical reviewer at the FDA:

“‘It’s a stretch to say that the people that are committing suicide or the increase in suicide attempts has to do with the prescription of antidepressants,’ Stone said in a telephone interview. ‘There’s absolutely nothing in the study to say that these are the people who would have been prescribed the antidepressants if it weren’t for the warnings.'”

“There are other issues that could be influencing the drop in antidepressant prescription and rise in poisonings, Stone said. The data presented in the study shows a steady increase before the warnings in antidepressant prescription rates for adolescents while drug poisonings remained relatively steady. The rise in poisonings after the warnings when prescriptions declined slightly in that group doesn’t show a link between the two events, he said.

‘They’re describing a very strange phenomenon in society that’s supposedly being held back by antidepressant use,’ Stone said. ‘It doesn’t stand up to what we know about the mental health situation in the United States.'”

I could find nothing in the New York Times, the Wall Street Journal, or the LA Times about the study or the press release.

Medscape, a web resource for physicians and other health professionals, toed the party line:

“The safety warnings were covered widely in the media and led to a decrease in antidepressant use by young people, but at the same time, there was an increase in suicide attempts, Christine Y. Lu, PhD, of the Department of Population Medicine, Harvard Medical School in Boston, Massachusetts, and colleagues found.”

Again, note the inaccurate characterization of drug poisonings as “suicide attempts”.

“The researchers say that it is possible that the warnings and extensive media attention led to ‘unexpected and unintended population level reductions in treatment for depression and subsequent increases in suicide attempts among young people.'”

And the focus on the “extensive media attention”.

The APA drew attention to the Lu et al study in a Psychiatric News Alert, but the tone of the piece was appropriately and, I must say, surprisingly, skeptical.  The only quote was from Mark Olfson:

“Mark Olfson, M.D., M.P.H., a professor of psychiatry at Columbia University Medical Center and an expert in mood disorders, told Psychiatric News that ‘the new findings shed little light on the complex associations between anxiety and depressive disorders, antidepressant treatment, and the risk of self-harm and suicide. The measure of suicide attempts used in this study, psychotropic poisonings (ICD-9 code 969), is only loosely related to suicide attempts. Most suicide attempts in young people do not involve poisoning by psychotropic drugs and most intoxications do not represent suicide attempts.’

Because of the recent substantial increase in unintentional poisonings from stimulants, Olfson stated that the increase in psychotropic overdose could be a result of an underlying substance use disorder rather than suicide. ‘This trend [of psychotropic overuse by youth], which may be driven by complex societal factors, deserves study and clinical attention,’ Olfson concluded.”

. . . . . . . . . . . . . . . .

Finally, the most reasonable interpretation of the Lu et al data is that following the black box warnings, the long-standing increase in the use of antidepressant drugs was halted, but suicide rates remained about the same (N = 7.5 million).

SOME HISTORY

This is not the first attempt to discredit/undermine the black box warnings for these drugs.  In September 2007, Robert Gibbons, PhD et al published Early evidence on the effects of regulators’ suicidality warnings on SSRI prescriptions and suicide in children and adolescents in the American Journal of Psychiatry.  The paper was based on a study of US and Dutch SSRI prescription rates to children and adolescents from 2003 to 2005, and was funded by NIMH grant.  The authors reported the following results:

“SSRI prescriptions for youths decreased by approximately 22% in both the United States and the Netherlands after the warnings were issued. In the Netherlands, the youth suicide rate increased by 49% between 2003 and 2005 and shows a significant inverse association with SSRI prescriptions. In the United States, youth suicide rates increased by 14% between 2003 and 2004, which is the largest year-to-year change in suicide rates in this population since the Centers for Disease Control and Prevention began systematically collecting suicide data in 1979.”

And drew the following conclusions:

“In both the United States and the Netherlands, SSRI prescriptions for children and adolescents decreased after U.S. and European regulatory agencies issued warnings about a possible suicide risk with antidepressant use in pediatric patients, and these decreases were associated with increases in suicide rates in children and adolescents.”

The report contains a graph showing a sharp increase in suicide rates for children and adolescents (5 – 19) between 2003 and 2004.

Gibbons Fig 2

The data for this graph was extracted from the CDC WONDER Compressed Mortality Database (up to 2002) and from the CDC WISQARS Injury Mortality Report Database (2003 – 2004).  On the face of it, this graph does seem to show a dramatic increase in completed suicides for this age group between 2003 and 2004.  But when we look at the bigger picture, this trend is not so obvious.

On July 1, I extracted completed suicide rate and population data from the CDC website for the period 1979 to 2010.  The Gibbons et al graph is for ages 5 – 19.  I was unable to obtain that graph from the CDC site, but I was able to collate the raw data and draw the graph using Excel software.  Here’s the graph:

Suicides per 100,000, 1979-2010

As can be readily seen, the increase in the suicide rates for this age group from 2003 to 2004 does not appear as marked or as noteworthy when viewed against the wider background.  Drawing conclusions from short-term trends is fraught with potential for error.  Dr. Gibbons et al were obviously aware of these issues, and provided a lengthy discussion/argument in support of the relevance of the associated trends.  Nevertheless, here’s their closing paragraph:

“In December 2006, the FDA’s Psychopharmacologic Drugs Advisory Committee recommended that the black box warning be extended to cover young adults, and in May 2007, the FDA asked drug manufacturers to revise their labels accordingly. If the intent of the pediatric black box warning was to save lives, the warning failed, and in fact it may have had the opposite effect; more children and adolescents have committed suicide since it was introduced. If as a result of extending the black box warning to adults there is a 20% decrease in SSRI prescriptions in the general population, we predict that it will result in 3,040 more suicides (a 10% increase) in 1 year (17). If the FDA’s goal is to ensure that children and adults treated with antidepressants receive adequate follow-up care to better detect and treat emergent suicidal thoughts, the current black box warning is not a useful approach; what should be considered instead is better education and training of physicians.”

The Washington Post ran an article on the Gibbons et al study, Youth Suicides Increased As Antidepressant Use Fell, September 6, 2007.  The article included the following quotes:

“Thomas Insel, director of the National Institute of Mental Health, said, ‘We may have inadvertently created a problem by putting a ‘black box’ warning on medications that were useful.’ He added, ‘If the drugs were doing more harm than good, then the reduction in prescription rates should mean the risk of suicide should go way down, and it hasn’t gone down at all — it has gone up.'”

“The trend lines do not prove that suicides rose because of the drop in prescriptions, but Gibbons, Insel and other experts said the international evidence leaves few other plausible explanations.” 

Given the behavior of the trend line since 2004, these quotes suggest, at the very least, an over-reaction from the authors and from the NIMH.  And the fact that the NIMH funded both studies suggests that they may have an agenda:  to promote antidepressant drugs as safe, and to downplay any indications to the contrary.

If the NIMH genuinely wants to explore the sources/causes of suicide, they need to recognize three facts:

1.  Suicide is a complex, psychosocial phenomenon, and its roots/causes vary enormously from individual to individual, and from community to community.  Psychiatry routinely asserts that the root, or major cause, of suicide is depression, but this assertion is meaningless because suicidal activity/rumination is one of psychiatry’s defining features of depression.  A genuine understanding of human actions involves so much more than assigning labels.

2.  The facts surrounding any completed suicide are always, by the nature of the matter, at least partially hidden.

3.  Any attempt to understand suicide must involve a detailed, open-minded exploration of individual cases.  Variables that appear associated with suicide trend lines provide, at best, suggestions that might inform these explorations, but can also be very misleading.

ANECDOTAL INFORMATION

At the present time, there is a great deal of anecdotal information, on the Internet and elsewhere, to the effect that individuals who were not previously suicidal, became so, shortly after starting SSRI’s.  The psychiatrist Joseph Glenmullen drew attention to this graphically and convincingly in Prozac Backlash (2000).  Here’s a quote:

“…the key elements in these stories appeared to be the ‘dramatic change’ observed in these people after starting Prozac, how ‘out of character’ their behavior was on the drug, and the often extraordinary degree of violence not only toward themselves but toward others.”

Elsewhere in the book, Dr. Glenmullen makes it clear that his comments apply, not only to Prozac, but to all drugs in the SSRI category.  Psychiatrist Peter Breggin has made similar points.  AntiDepAware has accumulated an enormous amount of anecdotal information on this matter.

Psychiatry tends to dismiss these kinds of concerns as “anecdotal”.  In this context, “anecdotal” usually means:  based on casual or incidental information rather than on systematic observations and evaluations.  In particular, the term suggests a subjective, rather than an objective approach.

But in fact, the raw data for virtually all psychiatric research is anecdotal in this sense.  If a person reports suicidal ruminations after taking an SSRI, this is anecdotal.  But if a study participant reports that he’s feeling better after taking an SSRI, this is also anecdotal.  And if 20 people make essentially similar statements, that’s 20 anecdotal statements.  And if they make these statements by answering 17 questions on the Hamilton Rating Scale for Depression, then we have 340 anecdotal statements.  The fact that the HDRS-17 is widely used, and yields numerical data which can be collated into rows and columns and analyzed with sophisticated computer programs doesn’t alter the fact that the raw data is anecdotal.

No one on this side of the issue is suggesting that a large proportion of people taking antidepressant drugs kill themselves.  If that were the case, then the drugs would have been removed from the market long ago.  What is being contended, however, is that these drugs are inducing strong suicidal urges in a relatively small proportion of individuals who had not previously had thoughts of this kind, and that some of these people are succumbing to these urges, and are taking their own lives.  That is indeed anecdotal information.  But it’s also very important, and it warrants investigation even if it involves only a fraction of one percent of the people taking the drugs.  To dismiss these widespread and credible contentions on the basis of the dogmatic insistence that the drugs are wholesome, or that the individuals were probably suicidal to begin with, is simply unconscionable.  This is particularly the case in that firstly, the proof of the wholesomeness of these products is also, ultimately, based on anecdotal information, and secondly, there is no way to reliably identify the individuals concerned prior to prescribing the drugs.

Prescribing these psychoactive drugs is like playing Russian roulette with someone else’s life.  The notion that this information should be suppressed because it might scare people from taking the products is cruel, callous, and irresponsible.  Psychiatry’s persistent and self-serving efforts to suppress this information is a national, and indeed, worldwide, scandal.

The Lu et al study, and the NIH press release, reminds me of a statement made by Patrick B. Kwanashie, Assistant Attorney General in Connecticut, after the Adam Lanza murders/suicide:

“Even if you can conclusively establish that Adam Lanza’s murderous actions were caused by antidepressants, you can’t logically from that conclude that others would commit the same actions as a result of taking antidepressants.  So it’s simply not legitimate, and not only is it not the use to which they are proposing to put the information not legitimate, it is harmful, because you can cause a lot of people to stop taking their medications, stop cooperating with their treating physicians just because of the heinousness of what Adam Lanza did.”

PSYCHIATRY’S SUPPRESSION OF INFORMATION

The Lu et al study has been subjected to a great deal of criticism.  These criticisms have been cogent and valid, but there is also a bigger picture.  The Lu et al study was never meant to be about science.  It was about spin and PR.  Its purpose was to attack and embarrass the media in order to keep them in line.  The fundamental message in the study, and in the NIH press release, is:  If you reporters print bad things about antidepressants, this will lead to reduced usage of these products, which in turn will lead to more suicides, and you will have blood on your hands!  Psychiatry is intellectually and morally bankrupt.  It has no valid response to its critics and is increasingly resorting to this kind of spin and PR.

Organized psychiatry realizes that it has lost the present debate on its logical/scientific merits.  They realize that their only hope for survival as a profession hinges on their ability to control the media.  In the pursuit of this objective, there truly are no depths to which they will not sink.

Over the past two decades, I have become convinced of two things:

1.  SSRI’s, and possibly other psychiatric drugs, are inducing strong suicidal and violent urges in some people.
2.  This information is being systematically suppressed by psychiatry and by the NIMH.  To the extent that they acknowledge it at all, they pretend that this suppression is in the public interest.

If there was ever a time when we need courageous and well-informed reporting, it is now.  Let us hope that the press has sufficient integrity and courage to resist psychiatry’s tawdry blackmail, to follow the evidence, and to print the truth.   In this context, it is very encouraging that neither the New York Times, nor the LA Times, nor the Wall Street Journal took the Lu et al bait.

It is time to end the charade.  The link between psychiatric drugs and suicide/violence needs urgent study by independent, adequately funded investigators who are given access to all the information.

The Propaganda Is Everywhere

I recently came across the May 2014 issue of The Costco Connection, which is published by Costco Wholesale.  This is the first time I’ve seen a copy of this magazine, and I would describe it as a catalog/lifestyle periodical. There are lots of ads for Costco’s own products, and the articles are wide ranging, topical, and easy to read.

This particular issue was drawn to my attention because on page 57, there’s an article titled Blues Clues.  The subtitle is:  “Physical pain is one of the unexpected signs of depression.”   The author is Jodi Helmer, a freelance journalist.

Here’s the opening paragraph:

“Debilitating back pain led Kristin Bower to make an appointment with her doctor.  She assumed he would prescribe pain meds, and send her home to rest.  Instead, Bower left the office with a diagnosis of depression.”

The author goes on to cite the NIMH estimate of 15 million American adults who “suffer from depression”.  She also draws attention to an unnamed study that reportedly found that “…up to 76 percent of those with depression experienced physical and emotional symptoms.”.

We then have a quote from Ken Duckworth, MD, Medical Director of NAMI:

“The biology of the brain impacts the biology of the body.”

which is fairly non-contentious, and:

“There is a biological connection between pain and mood.  The neurotransmitters serotonin and norepinephrine regulate both, which, according to Duckworth, is the reason ‘it’s common to experience depression as a psychological and physical illness.'”

This sounds awfully like the old chemical imbalance theory of depression, which the eminent psychiatrist Ronald Pies, MD, assures us was never promoted by any well-informed psychiatrist.

The author discusses the link between depression (the “illness”) and pain, and is clearly promoting the notion that the latter is often a manifestation, or symptom, of the former.  This contention is supported by another quote from Dr. Duckworth, in which he reportedly noted that pain can be “…a somatic expression of distress”.

The general theme is further reinforced by Jonathan W. Stewart, MD, Professor of Psychiatry at Columbia University, who is quoted as saying:

“The brain is terrific at rationalizing the pain…A mental health clinician can help decipher whether there is a connection.”

Then the article gets to the point:

“If pain and depression are linked, a class of antidepressants called selective serotonin reuptake inhibitors, or SSRIs, can be an effective form of treatment.  The drugs help increase the production of serotonin and norepinephrine, easing both depression and pain.”

This passage, which is also an endorsement of the chemical imbalance theory, is not attributed to Dr. Stewart, but is sandwiched between two of his quotes, and the impression is given that it is his message.

The article concludes by harking back to Kristin Bower, the lady with the back pain.

“For Bower, a combination of antidepressant medication and regular appointments with her doctor help keep her depression and pain in check.  When she starts to notice twinges in her back or an uptick in migraine headaches, she recognizes that her depression is about to flare, too.”

I think it’s fairly obvious that what’s going on here is old-fashioned psychiatric “disease-mongering.”  For decades, psychiatrists have been spreading their message that people who are depressed have chemical imbalances in their brains that can be treated with psychiatric drugs.  The “symptoms” of this so-called illness are feelings of depression, loss of interest in activities, insomnia (or, amazingly, hypersomnia), feelings of guilt, etc…  And now, through a cozy little article in the Costco Connection, they’re adding physical pain to the “symptom” list.  In a sidebar to the article, there is a list of the “top somatic complaints associated with depression”:

  • Headaches
  • Muscle aches and joint pain
  • Back pain
  • Upset stomach, diarrhea
  • Acid reflux
  • Heartburn
  • Dizziness
  • Chest pain

It doesn’t take too much imagination to see how this might increase the numbers of people asking their GP’s to screen them for depression.

. . . . . . . . . . . . . . . .

AND INCIDENTALLY

Kristin Bower, who is introduced to the reader simply as a 44-year-old corporate recruiter who went to her doctor with back pain and came away – surprise, surprise – with a “diagnosis” of depression, is also, according to her Twitter page, a “… mental health advocate/speaker/blogger…”  She is also, according to sidebar information on her blog Adventures of a Survivor! A Community Correspondent for Partners For Mental Health, and a volunteer for the Canadian Mental Health Association.  It is also clear from her blogs that she has carried a “diagnosis” of depression for quite some time.  On her blog posts she describes depression as an illness and as “…a disability for which there is no cure.”

Partners for Mental Health, according to its own website, is a Canadian charitable organization that is “…supercharging a ground-breaking social movement that will transform the way we think about, act towards and support mental health in Canada.”  One of their stated goals is:  “More funding for programs and services,” and they strive for a “new norm” where there is “acknowledgement and understanding that there is no health without mental health.”  Lundbeck, the maker of Celexa and other psychiatric products, is one of their two founding sponsors.

As mentioned earlier, Ken Duckworth, MD, is the Medical Direct of NAMI, teaches at Harvard Medical School and the Boston University School of Public Health., and is an Assistant Professor of Psychiatry at Harvard Medical School.

Jonathan Stewart, MD, is a Professor of Psychiatry at Columbia University.  He has received research support from Pfizer, Alkermes, Forest Pharmaceuticals, and Shire Pharmaceuticals.

Jodi Helmer, the author of the article, is a freelance writer.  Her work has appeared in a wide range of magazine and periodicals, and she has written articles for NAMI (e.g. here and here.)

. . . . . . . . . . . . . . . .

So, what appears on the surface to be a nice, personalized healthcare advice article, turns out, with a little research, to be another part of the widespread and well-orchestrated media blitz that psychiatry has launched to drown its opposition, promote its products, and continue the expansion of its turf.

Psychiatry is morally and intellectually bankrupt.  It has no logical or scientifically-founded response to its critics.  So instead, with the help of its loyal supporting organizations and pharma money, and a major PR/marketing firm, it has launched this tawdry, deceptive PR campaign.  They are flooding the media with their false and destructive message, and then they wonder why they are not given the respect afforded to real doctors.  I can’t even imagine a real medical specialty engaging in something so shabby.

A Client’s Perspective on “Mental Illness”

A very important and compelling article was posted on Mad in America on June 18.  It’s by Andrew L. Yoder, and is called An Open Letter to Persons Self-Identifying as Mentally Ill.  Here are some quotes:

“My physician was not so cautious.  He was a very pleasant man that always seemed to take his time with me and did not talk down to me.  Yet as I described some of the emotional distress I was experiencing, and the ways it was affecting my life, he told me with great certainty that mine was a totally common experience.  He told me that I had a biological condition in my brain, one in which certain chemicals were ‘imbalanced.’  He told me that there should be no stigma about asking for assistance from him.  Specifically he told me, ‘Trying to not be depressed is like telling a diabetic to just make more insulin.’  He prescribed an antidepressant medication, saying that this was no different than taking medication to regulate blood pressure or manage cholesterol.  I was told of the likelihood that I would need to remain on some form of medication for an indefinite future.”

“I believe that anyone, given the right context and circumstances, can experience even the most extreme forms of cognitive and emotional distress.”

“However, I believe that treating the term ‘mental illness’ as a literal truth does more to harm that hope of recovery than it does to help it.  You see, along with the popular claim that mental illness is a literal organic brain disease ‘just like diabetes’ is a set of other dogmas unproven and unsupported by evidence.  These include, being regularly told that not only do you have a disease but that this disease also has no cure and that you will struggle with it for your entire life.  I have trouble imagining anything more hopeless than that.

It also includes being told that you must take psychiatric medications, and often many different psychiatric medications for the rest of your life, and you should never ever consider stopping them.”

“Looking back now, I wish the physician who prescribed me anti-depressants would not have told me stories of ‘chemical imbalance’ that are simply not based in science.  In truth, most psychiatric medications alter normal brain activity, and there’s no evidence of an identifiable chemical imbalance of any sort at the root of emotional suffering.  Research suggests that there are some risks associated with long-term use of antidepressants, including the possibility of decreasing benefits from the drug and something referred to as ‘treatment resistant depression.'”

“Those of us challenging the evidence-absent medical model and the objective ‘mental illness’ label that goes with it are not trying to take away something hopeful and healing from you.  Instead, we wish to counter the false-hopelessness of a system that sees you as second-class people who will never be ‘normal.'”

“We know that mental and emotional suffering is a real experience that many, many people face.  We also know that nothing good comes from convincing people that they have a biological disease when no evidence supports that.  Questioning the legitimacy of ‘mental illness’ doesn’t make the reality of the pain any different.  But it does help people avoid the pitfalls of misinformation and powerlessness in their own recovery and wellness.”

“I am not saying that you are not hurting.  I am saying that you are not broken.”

Andrew has managed to express, in candid yet empathic terms, so many of the issues that are central to this debate.  Please read and pass along.

Do We Underestimate the Benefits of Antidepressants?

On April 19, 2014, The Lancet published an article titled Do we underestimate the benefits of antidepressants by German psychiatrists Mazda Adli and Ulrich Hegerl.

The Lancet, founded in 1823, is a weekly, general medical journal which since 1991 has been owned by Elsevier, a private, Amsterdam-based, publishing house with offices in the UK, USA, and other countries.

The gist of the article can be gathered from the opening paragraph:

“In the past 5 years, doubts have been raised about the therapeutic effectiveness of antidepressants in patients with depressive disorders, because of the small differences in symptom improvement between antidepressants and placebo recorded in randomised controlled trials (RCTs). With the recent debates about lowering of disease thresholds in the Diagnostic and Statistical Manual of Mental Disorders, fifth edition, and the medicalisation of normal bereavement, this scepticism has increased. For the large group of patients with mild depression, the differences between antidepressants and placebo are not thought to be large enough to be clinically significant—ie, at least three points on the Hamilton Depression Rating Scale, HAMD-17.1 Therefore, several guidelines…no longer recommend antidepressants as first-line treatment for patients with mild and moderate depression, and instead generally favour psychotherapy. We are concerned that scepticism about the benefits of antidepressants goes too far, and risks depriving many patients with depression of effective treatment.”

The authors argue that randomized controlled trials (RCT’s), as currently conducted, systematically underestimate the benefits of antidepressants and overestimate the benefits of psychotherapy.  They present six main arguments.

1. (a)  Trial participants who are actually taking the drug (as opposed to the placebo) have less hope/expectation of benefit, because they know that they might just be taking the placebo.

(b)  Participants who are actually taking the placebo have more hope of benefit, because they know that they might be taking the drug.

2.  One of the problems with RCT’s is that participants drop out for various reasons.  Most RCT’s deal with non-completers by assuming that their outcome status at the point of drop-out remains the same for the pre-determined period of the study.  This is known as the last observation carried forward (LOCF) technique, and can sometimes underestimate treatment efficacy, because the non-completers dilute the statistical impact of those participants who took the drug and, presumably, steadily improved for the entire period of the trial.

3.  Study participants may not mirror real-life patients.  The authors point out that the prospects of free treatment coupled with financial incentives could result in more “inappropriate and uncompliant” individuals being enrolled in studies than one would find in a typical psychiatric practice setting.

4.  In routine care, practitioners can change the drug and the dosage to meet the emerging needs of the individual, whereas this kind of creative modulation of treatment is often not permitted in RCT’s.

5.  Effect sizes in psychiatric RCT’s are comparable to many effect sizes in general medicine.

6.  The evidence base for psychotherapy is less solid than that for antidepressants.

All of these issues are interesting and debatable.  Any research that involves human activity, thoughts, or feelings is fraught with problems of definition, quantification, and procedures.  Questions can be difficult to formulate, and answers are seldom simple and clear.  Each of the authors’ contentions have been debated at length in the literature, and it is easy to offer counter-arguments.  For instance, with regards to the LOCF issue, it is true that in situations in which treatment is linearly correlated with improvement, LOCF does indeed underestimate treatment efficacy; but in a context in which treatment can also cause deterioration or adverse effects, LOCF can lead to overestimates of efficacy and underreporting of harm.

Similarly with regards to argument number 1 above, it is also widely recognized that a great many trial participants can tell whether they are taking the drug or the placebo – thereby increasing the placebo effect for those taking the drug.

Argument number 3 neglects to point out that the randomization process ensures that there are as many “inappropriate and uncompliant” participants in the placebo group as there are in the drug group.  That’s the purpose of randomization!  And so on.

. . . . . . . . . . . . . . . .

But what’s interesting is that in all the years that pharma-psychiatry was churning out its fraudulent, spurious and self-serving “findings,” I never heard of a single complaint from psychiatry about these kinds of methodological issues.  Now that their drug “treatments” are being exposed as not quite the panacea that they had claimed, they cry “foul!”

It’s also interesting that the article focuses solely on the relative merits of antidepressants vs. psychotherapy, but makes no reference to the much more serious problem – that long-term ingestion of antidepressants is the primary cause of what psychiatry in characteristically self-exculpatory fashion calls treatment resistant depression.

This article is not about science.  It is not, as it purports to be, a discussion of scientific methodology.  A genuine discussion of the six points listed above would have presented both sides of the coin, and many such genuine discussions have been published in the past 50 years, not only in mental health, but in general medicine and other fields.  The Adli and Hegerl article is PR and marketing, and this becomes clear in the final paragraph:

“In summary, the present approach to estimation of the benefits of antidepressant treatments is likely to underestimate the clinical significance of antidepressants and overestimate that of psychotherapy. At the same time, we are experiencing an increasing tendency to medicalise individuals who have emotional reactions to difficult life circumstances but without any clinical signs of depression, and to offer them antidepressants or psychotherapy which might not be appropriate to their needs.…We should be careful not to offer our treatments to the wrong patients, but to provide them consistently to the right patients.”

Note particularly the second sentence:  “… to medicalise individuals who have emotional reactions to difficult life circumstances but without any clinical signs of depression…”

This is just a rewording of the old psychiatric chestnut:  that depression-the-illness is fundamentally different in kind from depression-the-ordinary-feeling-that-we-all-get-when-we-experience-a-loss-or when-life-isn’t-going-too-well.  This is one of the great psychiatric falsehoods because, in practice and in theory, the fact that a person’s depression might be an “emotional reaction to difficult life circumstances” has no bearing whatsoever on whether the individual is assigned a diagnosis, and is prescribed an antidepressant.  The widely-used term “clinical depression” crystallizes this falsehood by creating the impression that such an entity exists (after all, it has a name!), and is fundamentally different from ordinary, everyday depression.  The implication in the authors’ apparently benign and sensible injunction is that psychiatrists should drug clients who have clinical depression, but not those whose depression is merely an emotional reaction to “difficult life circumstances.”

But it’s a meaningless recommendation, because there is no “diagnosis” in the DSM-5 chapter on Depressive Disorders that contains an exclusion clause based on the fact that the depression is a reaction to difficult life circumstances.  Indeed, the whole thrust of DSM and psychiatry for the past fifty years has been that if a person is significantly depressed – for any reason – this is diagnosable as a psychiatric “illness” and should be “treated” with drugs.    Even the tenuous two-month bereavement exclusion of DSM-III and IV has now been eliminated, as the authors themselves noted.

And in fact, DSM-5 specifically cautions practitioners not to rule out the possibility of a major depressive disorder in cases in which people are having understandable reactions to difficult life circumstances.  Here’s a quote from the Diagnostic Criteria section for Major Depressive Disorder (p. 161):

“Note:  Responses to a significant loss (e.g., bereavement, financial ruin, losses from a natural disaster, a serious medical illness or disability) may include the feelings of intense sadness, rumination about the loss, insomnia, poor appetite, and weight loss noted in Criterion A, which may resemble a depressive episode.  Although such symptoms may be understandable or considered appropriate to the loss, the presence of a major depressive episode in addition to the normal response to a significant loss should also be carefully considered.  This decision inevitably requires the exercise of clinical judgment based on the individual’s history and the cultural norms for the expression of distress in the context of loss.”

All that’s needed for a diagnosis to be made is a psychiatrist’s “clinical” and, incidentally subjective, judgment that the vague “diagnostic” criteria are met.

In addition, Axis IV (Psychosocial and Environmental Problems), which had provided practitioners an opportunity to at least identify relevant life circumstances, has also been eliminated.  Psychiatry’s old distinction of endogenous vs. exogenous depression didn’t die a natural death.  Rather it was systematically eliminated by the APA on the ground that it was irrelevant.

The authors’ final cautionary note – not to offer the pills to the wrong “patients,” but to provide them consistently to the right “patients” – is also a meaningless platitude, because within psychiatry’s diagnostic framework, there is no way of distinguishing these two groups on any dimension other than severity, and there is no reliable way of accomplishing even that.  In practice, the assessment of severity, and hence the status of the “diagnosis” is always a function of a practitioner’s subjective opinion, and, also in practice, the pills are given to virtually anyone who can be shoe-horned into a depression “diagnosis,” regardless of precipitating circumstances, which is precisely the state of affairs towards which pharma and organized psychiatry have striven for the past fifty years.

INCIDENTALLY

The article concludes with the following disclosure statement:

“MA [Mazda Aldi] has received grants or research support from Aristo, Servier, and Bristol-Myers Squibb; honoraria for speaking from Deutsche Bank, the Johanniter Order, East German Savings Banks Association, Pusch Wahl Legal Lawyers, HRM Forum, Helios Media, Lundbeck, Bristol-Myers Squibb, Boehringer Ingelheim, Servier, Aristo, Viiv, and Gilead; travel grants from the Alfred Herrhausen Society, Lundbeck, and Servier; and has been a consultant to Deutsche Bank, Bristol-Myers Squibb, Aristo, Merz, and Lundbeck. UH [Ulrich Hegerl] has received funding from health insurance companies (Barmer BEK, Central Versicherung); is or has been a member of advisory boards for Lilly Deutschland, Lundbeck, Otsuka, and Takeda, and has received honoraria for speaking from Bristol-Myers Squibb, Medice Arzneimittel, and Roche Pharma.”