Tag Archives: expansion of psychiatric turf

Mental Health First Aid: Another Psychiatric Expansionist Tool

On December 25, 2016, the Baltimore Sun published an excellent article titled Drug companies prey on children, by Patrick D. Hahn, PhD.  Dr. Hahn is an affiliate professor of biology at Loyola University, Maryland.  Here are some quotes:

“I recently attended Youth Mental Health First Aid Training at a local public school. It was an eye-opening experience.”

“Youth Mental Health First Aid Training, sponsored by the National Council for Behavioral Health, is intended to enable teachers, parents and others in contact with young people to identify potential ‘mental illnesses’ in order to facilitate early detection and treatment by our mental health care system. My fellow attendees were surprisingly open about their own experiences with that system. One mentioned that her son became manic after being diagnosed for ADHD. Another said that both she and her roommate became bipolar after being diagnosed for depression. Neither our facilitators nor anyone else present pointed out that mania and bipolar disorder are toxic effects of medications commonly prescribed for ADHD and depression.”

“Our training manual didn’t say anything about this either, although it did claim that depression is caused by a deficiency of serotonin — a fable that by now has become as discredited as the phlogiston theory of chemistry. It also stated that mental health interventions are ‘evidence-based’ and ‘scientifically tested’ — neglecting to mention that much of that evidence is put forth by drug companies who have a fiduciary duty to do everything they can to maximize sales of their products.”

“So is all this a scheme to push more drugs to more kids? The 2013/2014 annual report for the National Council for Behavioral Health, titled ‘A Legacy of Excellence and Impact,’ gives us a hint. It lists the organization’s supporters as including the Pharmaceutical Research and Manufacturers of America (PhRMA) along with no fewer than 12 different drug companies. Would these folks be ponying up the cash if they weren’t confident this program would increase sales? And do the parents and teachers who attend the council’s training program — no doubt with the best intentions in the world — realize that they are essentially sitting through an eight-hour infomercial bought and paid for by the drugmakers?”

“One out of 13 American children between the ages of 6 and 17 has taken a psychotropic medication within the last six months, according to the Centers for Disease Control. Meanwhile, youth suicide rates are at their peak going back at least as far back as 1999, while the number of children receiving disability benefits for mental illness is at an all-time high.”

Please take a look at Dr. Hahn’s article, and pass it on.  Mental Health First Aid is not a good thing.  Rather, it is just another psychiatric expansionist tool.

MENTAL HEALTH FIRST AID

For readers who are not familiar with the term, Mental Health First Aid, according to its own website, is “…an 8-hour course that teaches you how to identify, understand and respond to signs of mental illnesses and substance use disorders.”

From its FAQ page:

“The evidence behind the program demonstrates that it does build mental health literacy, helping the public identify, understand, and respond to signs of mental illness.”

Incidentally, I Googled the term “mental health literacy” and got 28.8 million results!  There’s also a Wikipedia article on mental health literacy.  Here’s a quote from the opening paragraph:

Mental health literacy has been defined as ‘knowledge and beliefs about mental disorders which aid their recognition, management or prevention. Mental health literacy includes the ability to recognize specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking.1‘”

So mental health literacy doesn’t just mean the acquisition of some information and skills; it also means accepting the psychiatric hoax:  “attitudes that promote recognition and appropriate help-seeking”.  The goal is not just the dissemination of psychiatry-friendly information, but also the active conversion of skeptics to the psychiatric cause.

Reference # 1 in the above quote refers to Jorm et al “Mental health literacy”: a survey of the public’s ability to recognise mental disorders and their beliefs about the effectiveness of treatment, Med J Aust. 1997 Feb 17;166(4):182-6.  The survey in question was conducted in Australia in 1995 and sheds particular light on the present discussion.  Here’s the abstract of the article:

“OBJECTIVES:
To assess the public’s recognition of mental disorders and their beliefs about the effectiveness of various treatments (‘mental health literacy’).

DESIGN:
A cross-sectional survey, in 1995, with structured interviews using vignettes of a person with either depression or schizophrenia.

PARTICIPANTS:
A representative national sample of 2031 individuals aged 18-74 years; 1010 participants were questioned about the depression vignette and 1021 about the schizophrenia vignette.

RESULTS:
Most of the participants recognised the presence of some sort of mental disorder: 72% for the depression vignette (correctly labelled as depression by 39%) and 84% for the schizophrenia vignette (correctly labelled by 27%). When various people were rated as likely to be helpful or harmful for the person described in the vignette for depression, general practitioners (83%) and counsellors (74%) were most often rated as helpful, with psychiatrists (51%) and psychologists (49%) less so. Corresponding data for the schizophrenia vignette were: counsellors (81%), GPs (74%), psychiatrists (71%) and psychologists (62%). Many standard psychiatric treatments (antidepressants, antipsychotics, electroconvulsive therapy, admission to a psychiatric ward) were more often rated as harmful than helpful, and some nonstandard treatments were rated highly (increased physical or social activity, relaxation and stress management, reading about people with similar problems). Vitamins and special diets were more often rated as helpful than were antidepressants and antipsychotics.

CONCLUSION:
If mental disorders are to be recognised early in the community and appropriate intervention sought, the level of mental health literacy needs to be raised. Further, public understanding of psychiatric treatments can be considerably improved.”

So, in 1995, the general public in Australia, as represented by the sample of 2031 individuals in this study, had some interesting views concerning psychiatry.

  1. They rated GP’s and counselors as more helpful than psychiatrists and psychologists for problems of “depression” and “schizophrenia”.
  1. They rated many “standard psychiatric treatments” (antidepressants, neuroleptics, electric shocks, and psychiatric wards) harmful, more often than helpful.
  1. They rated some “nonstandard treatments” (increased physical or social activity, relaxation, stress management, reading about people with similar problems) highly.
  1. They rated vitamins and special diets helpful more often than antidepressant and neuroleptic drugs.

At the risk of stating the obvious, those of us on this side of the issue would consider the general public’s beliefs, as reflected in this survey, to be accurate, and grounded in common sense.  But from the aspect of psychiatry – and particularly psychiatry’s expansionist agenda – these findings are cause for particular concern.  And so, as the authors state:  “…the level of mental health literacy needs to be raised…”

Here’s an interesting quote from the study’s Introduction:

“The lifetime risk of developing a mental disorder is so high (nearly 50%)2 that almost the whole population will at some time have direct experience of such a disorder, either in themselves or in someone close. A high public level of mental health literacy would make early recognition of and appropriate intervention in these disorders more likely.”

Incidentally, the survey was conducted by the Australian Bureau of Statistics, presumably at public expense.

Three years later, Dr. Jorm, the lead author, and his wife Betty Kitchener, founded Mental Health First Aid.  According to his biography on the University of Melbourne site, Dr. Jorm is a highly cited mental health researcher whose work “…focuses on building the community’s capacity for prevention and early intervention with mental disorders.”

The MHFA program spread rapidly in Australia, and by 2015, 350,000 people had received the training.

And Dr. Jorm has been busy promoting mental health literacy in other venues.  In 2000, he published a paper in the British Journal of Psychiatry, the stated aims of which were:

“To introduce the concept of mental health literacy to a wider audience, to bring together diverse research relevant to the topic and to identify gaps in the area.”

And in 2012, he and Nicola Reavley published a paper Public recognition of mental disorders and beliefs about treatment: changes in Australia over 16 years, also in the British Journal of Psychiatry.  The conclusions of this paper were:

“Although beliefs about effective medications and interventions have moved closer to those of health professionals since the previous surveys, there is still potential for mental health literacy gains in the areas of recognition and treatment beliefs for mental disorders. This is particularly the case for schizophrenia.”

THE SCOPE OF THE MENTAL HEALTH FIRST AID PROGRAM

Here’s another quote from MHFA’s FAQ page:

“Mental Health First Aid is intended for all people and organizations that make up the fabric of a community. The course is presented to chambers of commerce, professional associations, hospitals, nursing homes, rotary clubs, parent organizations, social clubs, and other groups. Professionals who regularly interact with a lot of people (such as police officers, human resource directors, and primary care workers), school and college leadership, faith communities, friends and family of individuals with mental illness or addiction, or anyone interested in learning more about mental illness and addiction should get trained.”

And so the tentacles of psychiatric destruction, disempowerment, and, ultimately, despair, are spread to all parts and segments of our society, and people of all ages and all walks of life are shoveled indiscriminately into the insatiable maw of psychiatric dependency and premature death.

Mental Health First Aid (USA) lists on its website 109 organizations across the US (including 45 NAMI chapters) that offer MHFA training.

MHFA AND THE APA

Not surprisingly, the APA has enthusiastically endorsed the program.  Here are some quotes from Mental Health First Aid:  Training for Communities and Families, which you can find on the APA website:

“Mental Health Fist Aid (MHFA) is an eight-hour, in-person training that teaches how to help a person struggling with a mental illness or in a crisis. It provides a basic understanding of mental illness and addiction, signs of addiction and mental illness, the impact of mental and substance use disorders, what helps individuals experiencing these challenges get well and local resources for help.”

Note the emphasis on “mental illness” and “mental disorders”, and the notion that individuals “experiencing these challenges” need to “get well” by accessing “local resources for help”.

“Trainees are taught a five-step action plan and how to apply it in a variety of situations such as helping someone experiencing psychosis, engaging with someone who may be suicidal, or assisting an individual who has overdosed. The training uses role play and demonstrations to convey the information.”

“Five-Step Action Plan – ALGEE

  1. Assess for risk of suicide or harm
  2. Listen nonjudgmentally
  3. Give reassurance and Information
  4. Encourage appropriate professional help
  5. Encourage self-help and other support strategies”

Note:  “encourage appropriate professional help”, conveniently ignoring the reality that the most common form of “professional help” (psychiatric drugging) is causally implicated in the creation of the problems.

“More than 250,000 people have been trained in Mental Health First Aid in the U.S. by 5,200 certified instructors. Twenty-one states have legislation to support Mental Health First Aid, and federal grants support training in some communities.”

So American psychiatry has effectively recruited 250,000 volunteer sales reps, and has managed to get state and federal money to support this enterprise.

“A recent national study of the training concluded that MHFA improves confidence about being able to recognize someone who may be dealing with a mental health problem or crisis and to actively and compassionately listen to someone in distress. Researchers surveyed more than 35,000 people who had completed the training for the study published in the APA journal Psychiatric Services.”

The study mentioned is Crisanti AS, Luo L, McFaul M, et al. Impact of Mental Health First Aid on confidence relation to mental health literacy: a national study with a focus on race-ethnicity. Psychiatric Services in Advance. Published online Nov. 2, 2015.

Here’s the abstract:

“OBJECTIVE:
Low mental health literacy (MHL) is widespread in the general population and even more so among racial and ethnic minority groups. Mental Health First Aid (MHFA) aims to improve MHL. The objective of this study was to determine the impact of MHFA on perceptions of confidence about MHL in a large national sample and by racial and ethnic subgroup.

METHODS:
The self-perceived impact of MHFA on 36,263 people who completed the 12-hour training and a feedback form was examined.

RESULTS:
A multiple regression analysis showed that MHFA resulted in high ratings of confidence in being able to apply various skills and knowledge related to MHL. Perceived impact of MHFA training differed among some racial and ethnic groups, but the differences were small to trivial.

CONCLUSIONS:
Future research on MHFA should examine changes in MHL pre-post training and the extent to which perceived increases in MHL confidence among trainees translate into action.”

In other words, people who take the Mental Health First Aid course expressed confidence that they could apply the skills and knowledge acquired to actual situations.  The implication is that this is important because “Low mental health literacy (MHL) is widespread in the general population and even more so among racial and ethnic minority groups.”

Note that the term “mental health literacy” has now been reified into a desirable commodity, the lack of which can be identified, measured, decried, researched, funded, etc., in the interests of bringing more and more people into psychiatry’s insatiable clutches.  Mental health literacy means the extent to which one has bought the psychiatric hoax.  Those of us who are active in the anti-psychiatry movement are, of course, by implication, mental health illiterates.

There are absolutely no limits to psychiatry’s expansionist agenda.  Despite the well-established destructiveness of their “treatments”, they will never voluntarily curtail their relentless drive for more victims.

And they will not commission, or even call for, a formal, comprehensive study to examine the now blatantly obvious link between psychiatric drugs and the murder-suicides that have become commonplace in our communities.  Psychiatry is intellectually and morally bankrupt.  They have no valid response to their critics, but instead resort to spin and tawdry marketing tactics to shore up their crumbling sand castle.  But just as the tide cleans the foreshore, so the light of logic and truth, and the outspoken protests of its survivors, will one day wash the world of the blight known as psychiatry.

Murphy Bill Being Sneaked Into House Legislation

This morning I received an email from Oldhead, who has been active in opposing the Murphy Bill.  Here are two quotes from the email:

“As succinctly as possible — the main language from MURPHY (including AOT funding) has been consolidated with another bill, the 21ST CENTURY CURES bill, which is being introduced as a House Amendment to the Senate Amendment to H.R. 34, Tsunami Warning, Education and Research Act of 2015.’  In other words, Murphy is being slipped through on another bill’s coattails, if Murphy, Jaffee & Co. have their say.”

“So there we have it, I guess.  We should be calling our congressional representatives TODAY — TUESDAY — to request that they vote AGAINST the 21ST CENTURY CURES bill being amended to H.R. 34 if it is consolidated with HR 4626 (the original Murphy bill).  You could mention that you are specifically opposed to TITLE XIV Section 14002 (AOT) [Assisted Outpatient Treatment].  I know this is a mouthful.  People with the time should focus on Democrats, but first make sure you contact your local representatives. If it’s a Republican, focus on the enormous cost and waste of taxpayer funds. Use our anti-AOT talking points as a general guide. They’re posted in the organizing forum (here) if you don’t already have them.”

On Wednesday (tomorrow), the House is expected to vote on whether to incorporate the Murphy Bill provisions into the 21st Century Cures Bill.

If there was ever a time for political lobbying, it’s now.  If you live in the US, please phone your Congressperson today, and ask him or her to oppose this amendment.  The last thing we need is any more psychiatric drugging, particularly enforced drugging.

If you don’t know how to contact your Congressman, go here.

The Mental Health Reform Act of 2016 (SB 2680) Would Be a Huge Step Backwards

On July 6, HB 2646 (the Tim Murphy Bill) passed the US House and was sent to the Senate.

At the present time, a related bill is working its way through the Senate.  This is SB 2680, The Mental Health Reform Act 2016.  It is sponsored by Lamar Alexander (R-TN), Patty Murray (D-WA), Bill Cassidy (R-LA), Chris Murphy (D-CT), David Vitter (R-LA), and Al Franken (D-MN).  The wording of the bill was finalized in March of this year, and it passed out of committee on March 16.

There is a good measure of bi-partisan support for this bill in the Senate, and if it makes it to the floor it could pass.  If that were to happen, it would likely be reconciled with the Tim Murphy House resolution, and a reconciled version would be enacted.

SB 2680 purports to provide desperately needed help to suffering Americans but is in reality a thinly-disguised tool to expand the scope of psychiatric “care”, with all the drugging, death, damage, and destruction that this entails.

On March 16, 2016, the Committee on Health, Education, Labor, and Pensions issued a press release titled:  The Mental Health Reform Act of 2016 will help Americans suffering from mental health and substance use disorders.  Here are some quotes, interspersed with my comments and observations.

“The Senate health committee today passed legislation to help address the country’s mental health crisis and help ensure Americans suffering from mental illness and substance use disorders receive the care they need.”

Note the term “mental health crisis”.  There is indeed a crisis in the mental health business.  The crisis derives from psychiatry’s spurious and self-serving premise that all significant problems of thinking, feeling, and/or behaving are brain illnesses that are correctable by psychiatric drugs.  This false premise, avidly promoted by pharma, is the cornerstone of the psychiatric-pharmaceutical industry, and is the primary reason that psychiatric drug use in America has reached epidemic proportions.

The fact that these so-called illnesses are so vaguely defined makes it easy for pharma-psychiatry to rope in new recruits.  But the maw of greed can never be satisfied, and pharma-psychiatry continues to lobby for more.  Every undrugged person is money down the drain!

For decades, psychiatry has been inventing new “illnesses” and liberalizing the criteria for others, and it is clear that their objective in all this is to make their so-called mental illnesses as prevalent as the common cold:  everyone gets one from time to time, and psychiatry has “safe and effective treatments”.  There’s no need to suffer – just take a pill or a high-voltage electric shock to the brain.  And keep coming back!

Back to the press release:

“‘One in five adults in this country suffers from a mental illness, and nearly 60 percent aren’t receiving the treatment they need,’ said Senate health committee Chairman Lamar Alexander (R-Tenn.).”

It is a logical and mathematical axiom that one can’t quantify what one can’t define.  But even if we set aside the inanity of these oft-touted statistics, it is clear that vast numbers of Americans who could get a “diagnosis” and a prescription for pills at their local mental health center, choose, wisely, I suggest, not to avail themselves of this “service”.  To Senators Alexander, Murray, Cassidy, Murphy, Vitter, and Franken, however, all of whom, incidentally, have received campaign money from the pharmaceuticals/health products industry, this is a national tragedy – a crisis, no less, that has to be corrected through legislative action.

“‘This bill will help address this crisis by ensuring our federal programs and policies incorporate proven, scientific approaches to improve care for patients.'”

“Proven, scientific approach” means more pharma-funded psychiatric research, with ever more opportunities for over-stated conclusions and even out-and-out fraud.

Senator Murray points out that the bill, if enacted, “…would help expand access to quality care, and make sure that patients receive coordinated mental and physical health care.”

Note again the emphasis on expanding care.  Also note the promotion of co-ordination with physical (i.e. real) medicine; read:  a mental health liaison worker in every GP’s office.  The APA has been pushing this idea for years.  The idea is that one goes to see one’s GP for a bad cough, is “screened” for mental health issues, and comes away with an antibiotic for the cough and an antidepressant for some vague psychosocial concerns.

The press release continues in the same vein.  All the old chestnuts are there, e.g.:

“This bill is an important step in the road to recovery for the 44 million Americans who suffer from a serious mental illness.”

“…our broken mental health care system…”

“…we allow those with mental illness to fall through the cracks.”

“…families struggling to get a loved one the help they need.”

“…prevent suicide…”

“…provide mental health awareness for teachers and others…”

“…evidence-based approaches…”

etc.

DISCUSSION

SB 2680 is littered with platitudes, and for this reason, there is a danger that many of its provisions might be seen as benign, and even desirable.

For instance, the bill calls for the identification of

“…strategic priorities, goals, and measurable objectives for mental and substance use disorder activities and programs operated and supported by the Administration, including priorities to prevent or eliminate the burden of mental illness and substance use disorders;”

and

“…to improve services for individuals with a mental or substance use disorder…”

and

“…ensure that programs provide, as appropriate, access to effective and evidence-based prevention, diagnosis, intervention, treatment, and recovery services…”

etc.

All of these proposals seem positive and helpful, but the bill is solidly rooted in psychiatry’s spurious medical model.  Psychiatric concepts and language permeate the text.  The term “mental illness” is routinely used as if it had the same ontological significance as real illness.

To convey the general tone and thrust of the bill, here’s the full text of Sec 502, which pertains to child psychiatry:

SEC. 502. TELEHEALTH CHILD PSYCHIATRY ACCESS GRANTS.

(a) In General.—The Secretary of Health and Human Services (referred to in this section as the “Secretary”), acting through the Administrator of the Health Resources and Services Administration and in coordination with other relevant Federal agencies, may award grants through existing health programs that promote mental or child health, including programs under section 330I, 330K, or 330L of the Public Health Service Act (42 U.S.C. 254c-14, 254c-16, 254c-18), to States, political subdivisions of States, and Indian tribes and tribal organizations (for purposes of this section, as defined in section 4 of the Indian Self-Determination and Education Assistance Act (25 U.S.C. 450b)) to promote behavioral health integration in pediatric primary care by—”

Translation:  The Federal Government may award grants to promote the embedding of psychiatric concepts and practices into pediatric primary care by:

“(1) supporting the development of statewide or regional child psychiatry access programs; and

 (2) supporting the improvement of existing statewide or regional child psychiatry access programs

(b) Program Requirements.—

(1) IN GENERAL.—To be eligible for funding under subsection (a), a child psychiatry access program shall—

(A) be a statewide or regional network of pediatric mental health teams that provide support to pediatric primary care sites as an integrated team;

(B) support and further develop organized State or regional networks of child and adolescent psychiatrists to provide consultative support to pediatric primary care sites;”

Note:  “networks” of psychiatrists advising and supporting pediatricians!  What kind of advice do you think these networks of psychiatrists will provide?

“(C) conduct an assessment of critical behavioral consultation needs among pediatric providers and such providers’ preferred mechanisms for receiving consultation and training and technical assistance;

(D) develop an online database and communication mechanisms, including telehealth, to facilitate consultation support to pediatric practices;

(E) provide rapid statewide or regional clinical telephone consultations when requested between the pediatric mental health teams and pediatric primary care providers;

(F) conduct training and provide technical assistance to pediatric primary care providers to support the early identification, diagnosis, treatment, and referral of children with behavioral health conditions and co-occurring intellectual and other developmental disabilities;”

What kind of training do you think these access programs will be providing to pediatricians?  Facile “diagnostic” checklists?  Treatment guidelines that recommend neuroleptic drugs for 3-year-olds who display temper tantrums?  The thinly-hidden agenda here is to erode whatever resistance remains among pediatricians to psychiatric orthodoxy, and bring them on board the great psychiatric drugging bonanza.

“(G) inform and assist pediatric providers in accessing child psychiatry consultations and in scheduling and conducting technical assistance;

(H) assist with referrals to specialty care and community and behavioral health resources; and

(I) establish mechanisms for measuring and monitoring increased access to child and adolescent psychiatric services by pediatric primary care providers and expanded capacity of pediatric primary care providers to identify, treat, and refer children with mental health problems.”

In other words, the Feds will be checking to make sure that they’re getting value for their money in the form of more children drugged.

“(2) PEDIATRIC MENTAL HEALTH TEAMS.—In this subsection, the term “pediatric mental health team” means a team of case coordinators, child and adolescent psychiatrists, and a licensed clinical mental health professional, such as a psychologist, social worker, or mental health counselor. Such a team may be regionally based.

(c) Applications.—A State, political subdivision of a State, Indian tribe, or tribal organization that desires a grant under this section shall submit an application to the Secretary at such time, in such manner, and containing such information as the Secretary may require, including a plan for the comprehensive evaluation and the performance and outcome evaluation described in subsection (d).

(d) Evaluation.—A State, political subdivision of a State, Indian tribe, or tribal organization that receives a grant under this section shall prepare and submit an evaluation to the Secretary at such time, in such manner, and containing such information as the Secretary may reasonably require, including a comprehensive evaluation of activities carried out with funds received through such grant and a performance and outcome evaluation of such activities.

(e) Access To Broadband.—In administering grants under this section, the Secretary may coordinate with other agencies to ensure that funding opportunities are available to support access to reliable, high-speed Internet for providers.

(f) Matching Requirement.—The Secretary may not award a grant under this section unless the State, political subdivision of a State, Indian tribe, or tribal organization involved agrees, with respect to the costs to be incurred by the State, political subdivision of a State, Indian tribe, or tribal organization in carrying out the purpose described in this section, to make available non-Federal contributions (in cash or in kind) toward such costs in an amount that is not less than 20 percent of Federal funds provided in the grant.

The meaning and intent of Sec 502 is absolutely clear:  if this legislation passes, Congress is going to pour money and resources into providing more psychiatric care to children.

And how do psychiatrists provide care for children?  They drug them.

THE EMPIRE IS FIGHTING BACK

In the past ten years or so, opposition to psychiatry’s medicalization of virtually every human problem has been growing.  As the venerable and prestigious psychiatric leader Jeffrey Lieberman, MD, has lamented on more than one occasion, psychiatry is the only medical speciality that has its own anti group.  And of course, as we all know, there are very good reasons for this.

We also know that American psychiatry as a whole has been extraordinarily unreceptive to any kind of criticism.  Indeed, their response has been to double down – to assert with increasing vigor that their concepts are sound, their research valid, and their practices helpful and benign.

They have also hired a renowned PR firm and have been lobbying hard in political circles.  SB 2680 and the Tim Murphy House bill are the result of these endeavors.

This is the hidden face of psychiatry, using the legal machinery to push its pernicious concepts and practices deeper and deeper into the lives and institutions of the American people, with increasingly disastrous results.

Incidentally, the sponsors of SB 2680 received the following sums of money from the pharmaceutical/health products industry during the current election cycle (source: OpenSecrets.org):

            Lamar Alexander        $452,548

            Patty Murray               $542,778

            Bill Cassidy                 $234,502

            Chris Murphy              $121,876

            Al Franken                  $131,088

            David Vitter                   $7,850

If you live in the US, please ask your Senators to oppose SB 2680.  Tell them that we don’t need any more psychiatric drugging, particularly of our children!

Integration of Physical and Mental Health

Integration of physical and “mental health” care has been a popular topic in psychiatric circles in recent years.  During his term as President of the APA, the very eminent psychiatrist Jeffrey Lieberman, MD, made frequent references to this matter in his posts on Psychiatric News (the APA’s online newspaper).

For instance, on December 6, 2013, Dr. Lieberman, with co-author Richard Summers, MD, wrote:

“The momentum for patient-centered care, the medical home, and integration of behavioral health with primary care creates a new role for psychiatrists.” [Emphasis added]

Paul Summergrad, MD, continued the theme during his presidential term:

“There is now a critical mass of evidence demonstrating the value of integrating general medical care with psychiatric care, providing higher-quality care to larger numbers of patients, and lowering health care costs. Psychiatry is already undergoing rapid shifts in practice, including new ways of working with our primary care colleagues.” [Emphasis added]  September 26, 2014

“In advocacy, the work group’s recommended strategic plan underscored the importance of integrating psychiatry in the evolving health care delivery system, advocacy for the central role of psychiatry in all care settings, and parity implementation and enforcement.” [Emphasis added]  March 13, 2015

And the present President, Renée Binder, MD, has picked up this particular baton with enthusiasm:

“Telepsychiatry is only one of many avenues that will improve access to care. Integrating mental health care in the primary care setting is another avenue, and telepsychiatry can be part of the integrated care model. For example, through the advent of telepsychiatry, a primary care physician may be able to arrange for a patient (while still in his or her office) to be interviewed by a psychiatrist who is geographically distant.” [Emphasis added] September 24, 2015

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

I’ve never been entirely clear about the nature of this proposed integration of psychiatry with primary care, though from what I’ve gathered, it sounds like there will be a psychiatrist, or other mental health worker, attached to primary care practices, either in the flesh or via computer screens.  What has always been crystal clear, however, is that the proposal would entail a huge expansion of the psychiatric net, a diligent ferreting out, so to speak, of those “mentally ill people” young and old, who are “not being served”, and lots of additional jobs for psychiatrists.  I envisage people who go to their GP’s being “ambushed” and encouraged to take a free screening test for depression, intermittent explosive disorder, or whatever.  They will be given the “dire news” that they have incurable chemical imbalances in their brains.  Then they will be given the “good news” that there are “safe, effective medications”, that if taken for life, can keep these “imbalances” corrected, and keep the dreadful “diseases” in remission.

And lest my fears be considered groundless, here are some quotes from SAMSHA-HRSA’s Guide to Behavioral Health Integration:  Both SAMHSA (Substance Abuse and Mental Health Resources Administration), and HRSA (Health Resources and Services Administration), are branches of the federal Department of Health and Human Services)

“Integrated care begins with screening all patients for other health (including behavioral health) conditions in addition to the presenting problem.  Similar to hypertension, behavioral health conditions can be ‘silent killers’ in that the patient may not lead with this problem, but these conditions can drive and complicate other health concerns.  If not proactively addressed, mental illness can quietly undermine efforts to improve health status.  Routine screening leads to an organized collection of data.”

“Preventative services with an A or B rating from the U.S. Preventive Services Task Force are covered and available at no cost to the individual.  For behavioral health, that includes screening for alcohol misuse and depression by primary care providers.” [Emphasis added]

“Organizations offering integrated care need to be sure that behavioral health is fully embedded into the practice…”

“A common barrier to integrated care is a lack of knowledge and comfort with prescribing psychiatric medications.  Many primary care physicians have gained foundational prescribing competence, yet PCPs are reluctant to proceed without input from a psychiatrist as more people turn to their PCPs for psychiatric medication.”

So, with a little prodding from psychiatrists, these “reluctant” PCPs will be enabled and encouraged to write more prescriptions for psychiatric drugs.

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

I’ve never been aware of any definite timetable for this momentous breakthrough, but a few days ago I received an email from the Colorado Department of Regulatory Agencies on the subject:  SIM Funding Opportunity to Integrate Physical and Behavioral Healthcare.  Here are some quotes:

“We are sending this e-mail to let you know about an exciting funding opportunity for primary care practices interested in providing access to integrated physical and behavioral health care services in coordinated systems. This is a key initiative in Governor Hickenlooper’s efforts to make Colorado the healthiest state.”

and

“Under the State Innovation Model (SIM), Colorado will receive up to $65 million from the federal Center for Medicare and Medicaid Innovation to implement and test its State Health Innovation Plan over a four year period, February 2015 through January 2019.”

I clicked on the SIM link, and here’s what comes up:

SIM Overview

There’s also another document titled What Is SIM?  In this document, which is two pages long, the phrase “integrated primary care and behavioral health services”, or some variation on those words, occurs seven times.  Here are some quotes:

“Our vision is bold. Central to transforming the Colorado health system is the integration of behavioral health and primary care, a necessary step in our accelerated achievement of the Triple Aim. Our integration efforts will be supported by an improved public health infrastructure. In turn, behavioral health integration will improve population health by addressing behavioral factors that often impede the management of chronic health problems, especially obesity, smoking and diabetes. Improving access to behavioral health services and programs for most Coloradans is the cornerstone of the Colorado transformation effort.”

Note the final sentence:  more psychiatric service is the “cornerstone” of the state’s transformation effort.  More spurious “diagnoses”; more disempowerment; and more drugs!

“Our vision is attainable, particularly because we are building on important work that is already underway. And Coloradans know how to work together to accomplish big projects. Today, stakeholders throughout the state and from the full spectrum of the health community are on board to collaborate on our SIM proposal. Key partners include eight leading commercial payers and primary care providers covering the majority of the state population.”

Wow!  All the stakeholders are “on board” in the divvying up of $65M.  What a surprise!

“There is urgency in our work. While we have a strong, collaborative foundation, health costs continue to rise, patients receive fragmented care and key population metrics must be improved. SIM will allow Colorado to strengthen our efforts in primary and behavioral care and broaden our reach to most Coloradans.”

Note the phrase:  “broaden our reach”.  And the irony:  we’ll address rising health costs by pumping another $65M worth of psychiatric services into the system!

“The overarching goal of Colorado SIM is to improve the health of Coloradans by providing access to integrated primary care and behavioral health services in coordinated community systems, with value-based payment structures, for 80 percent of state residents by 2019. There is strong evidence that treating physical health, mental health and substance use disorders together will help us take aim at the ever-increasing burden of chronic disease. Our plan, called The Colorado Framework, creates a system of supports, both clinic-based and through expanded public health efforts, to spur integration.”

Note the truly beautiful obfuscation:  “There is strong evidence that treating physical health, mental health, and substance use disorders together…”  will what?  Lead to better outcomes? improve people’s lives? help people get off the disability rolls?  No.  None of these.  The $65M worth of integration will help the state of Colorado take aim at the increasing “burden of chronic disease”.  With all this money and all this integration, they’re going to be able to take aim at the burden of chronic disease.  And there’s strong evidence for this!

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

DISCUSSION

Although I’ve focused on Colorado in this article,  similar moves are, or soon will be, underway in other states.

If pharma-psychiatry succeeds in expanding its web of destructiveness in this way, it will be a tragedy of enormous proportions.  More and more people will be “diagnosed” with psychiatry’s so-called illnesses; and drugging rates, already high, will soar to heights as yet unimagined.

This is not the practice of medicine.  This is pharma-funded drug-pushing.

Intermittent Explosive Disorder: The ‘Illness’ That Goes On Growing

According to the APA, intermittent explosive disorder is characterized by angry aggressive outbursts that occur in response to relatively minor provocation.

This particular label has an interesting history in successive editions of the DSM.

DSM I  (1952) 

Intermittent explosive disorder does not appear as such in the first edition of DSM, but the general concept is clearly discernible in “passive-aggressive personality, aggressive type”:

“A persistent reaction to frustration with irritability, temper tantrums, and destructive behavior is the dominant manifestation.” (p 37)

Note the term “reaction” in the definition, implying that the temper tantrums are being conceptualized as a reaction to a frustrating experience, rather than an illness, as such.

DSM-II (1968)

By DSM-II, the diagnosis had acquired free-standing status as a “personality disorder”, and was called “explosive personality (Epileptoid personality disorder)”.  Here’s the definition:

“This behavior pattern is characterized by gross outbursts of rage or of verbal or physical aggressiveness. These outbursts are strikingly different from the patient’s usual behavior, and he may be regretful and repentant for them. These patients are generally considered excitable, aggressive and over-responsive to environmental pressures.  It is the intensity of the outbursts and the individual’s inability to control them which distinguishes this group. Cases diagnosed as ‘aggressive personality’ are classified here. If the patient is amnesic for the outbursts, the diagnosis of Hysterical neurosis, Non-psychotic OBS [Organic Brain Syndrome] with epilepsy or Psychosis with epilepsy should be considered.” (p 42-43)

There are three notable features of this definition.

Firstly, the term “reaction” has been eliminated.  With the benefit of hindsight, it is clear that the term “reaction” which was used extensively in DSM-I became an embarrassment for psychiatry.  In 1952, I believe that many psychiatrists would have acknowledged that the problems they encountered in their work were not illnesses in any biological sense of the term.  By 1960, however, the drugs were beginning to come on stream, and the promise was emerging that psychiatrists, if they made some conceptual adjustments, could ride pharma’s bandwagon and become “real” doctors.  And one of the conceptual adjustments that had to be made was the elimination of the word “reaction” and all that it entailed.  So, eliminate it, they did.  They offered no explanation, but there is this charmingly candid little quote on page ix of DSM-II:

“Consider, for example, the mental disorder labeled in this Manual as ‘schizophrenia,’ which, in the first edition, was labeled ‘schizophrenic reaction.’ The change of label has not changed the nature of the disorder, nor will it discourage continuing debate about its nature or causes. Even if it had tried, the Committee could not establish agreement about what this disorder is; it could only agree on what to call it.”

Secondly, the notion that the person is unable to control the aggressive impulses is introduced as a distinguishing feature of the “diagnosis”.  This is a particularly interesting development, in that it is impossible to determine whether a person is, or is not, unable to control his aggression.  All that can be determined is whether a person did or did not control aggressive impulses on any given occasion.

Thirdly, the definition clearly allows the “diagnosis” to be made on the basis of verbal aggressiveness.

Side note on “epileptoid Personality disorder”:  During the first half of the 1900’s, and even as late as the 70’s, there were frequent references in psychiatric writings to epileptic (or sometimes epileptoid) personality disorder.  It was widely believed that people with epilepsy tended to be generally impulsive, explosive, and egocentric.  The notion was given a good deal of credence and attention.  Psychiatric research purported to identify the traits involved, and causative theories were developed and promoted.  Most epilepsy specialists today consider the research to have been questionable, and the supporting observations to have been cases of people “seeing” what they had been taught to expect:   a lesson that psychiatry generally seems unable to assimilate. 

DSM-III (1980) 

In DSM-III, “intermittent explosive disorder” appears as an entry in the category “Disorders of Impulse Control Not Elsewhere Classified.”  Here are the criteria:

“A. Several discrete episodes of loss of control of aggressive impulses resulting in serious assault or destruction of property.

B.  Behavior that is grossly out of proportion to any precipitating psychosocial stressor.

C.  Absence of Signs of generalized impulsivity or aggressiveness between episodes,

D.  Not due to Schizophrenia, Antisocial Personality Disorder, or Conduct Disorder,” (p 297)

Notice that the criteria are fairly simple, and that, even allowing for the vagueness of language, what’s being described is relatively severe and serious:  “…serious assault or destruction of property.”  In other words, DSM-II’s acceptance of verbal aggressiveness as a criterion item has been eliminated: a rare instance of the APA actually tightening their criteria.  The effect of this, however, was probably minimal, as the “diagnosis” was still described under Prevalence as “very rare”.

The diagnostic criteria in DSM-III-R (1987) were essentially similar to those in DSM-III, though the list of exclusions was expanded to:  “…a psychotic disorder, Organic Personality Syndrome, Antisocial or Borderline Personality Disorder, Conduct Disorder, or intoxication with a psychoactive substance.” (p 322)

Prevalence is still shown as “apparently very rare”.

DSM-IV (1994)

DSM-IV made two changes to the criteria.

1.  Item C from DSM-III-R, which had read: “There are no signs of generalized impulsiveness or aggressiveness between the episodes”, was eliminated. Up till DSM-III-R, the “diagnosis of intermittent explosive disorder” was given only to individuals who were generally even-keeled, but who exhibited episodes of explosive anger that were apparently out of character.  DSM-IV offered no explanation for the removal of this item, stating only:  “The DSM-III-R criterion excluding this diagnosis in the presence of generalized impulsiveness or aggressiveness has been deleted.”  Obviously this deletion widens the scope of the “diagnosis”, and allows a great many more people to be given this label than was formerly the case.

2.  As in DSM-III-R, the “diagnosis” is not to be given if the episodes  “…occur during the course of…intoxication with a psychoactive substance”. DSM-IV added the clarification that this included the effects of “medication” – an implied acknowledgement that psychiatric drugs can precipitate outbursts of violence and destructiveness.

DSM-IV also amended the prevalence from “very rare” to “rare”, though in fact, Kessler et al (2006), using DSM-IV’s criteria, reported a lifetime prevalence rate of 7.3%, and a previous 12-month-rate of 3.9%.  A lifetime prevalence rate of 7.3% is approximately one person in fourteen.  This is hardly rare!

DSM-5 (2013)

In DSM-III and IV, a diagnosis of intermittent explosive disorder required several episodes of serious assaults or serious destruction of property.

But DSM-5 changed all that.  Here’s criterion A:

“A.  Recurrent behavioral outbursts representing a failure to control aggressive impulses as manifested by either of the following:

  1. Verbal aggression (e.g., temper tantrums, tirades, verbal arguments or fights) or physical aggression toward property, animals, or other individuals, occurring twice weekly, on average, for a period of 3 months. The physical aggression does not result in damage or destruction of property and does not result in physical injury to animals or other individuals.
  1. Three behavioral outbursts involving damage or destruction of property and/or physical assault involving physical injury against animals or other individuals occurring within a 12-month period.” (p 466)

Note the word “either” in the lead in, and the proliferation of “ors” in 1 and 2.  This makes for labored reading, but one thing is crystal clear:  under DSM-5 rules, a person can be assigned this psychiatric label on the grounds of “verbal aggression” occurring twice weekly, on average, for a period of three months.  A person can also be so labeled on the grounds of physical aggression that does not result in property damage or physical injury.

Essentially what this means is that a person who, say, habitually rants aggressively and obnoxiously at other motorists while driving is actually mentally ill.  Prior to DSM-5, he wasn’t mentally ill; he was just rude and vituperative.  But now, thanks to the endlessly inspired creativity of psychiatry, he is mentally ill, and can be cured of this malady by ingesting a few pills every day for the rest of his (probably shortened) life.

The authors of DSM-5 offer no explanation for this change.

“The primary change in Intermittent explosive disorder is in the type of aggressive outbursts that should be considered:  DSM-IV required physical aggression, whereas in DSM-5 verbal aggression and nondestructive/noninjurious physical aggression also meet criteria.” (p 815) [Emphasis added]

Note also the specification:  “twice weekly, on average, for a period of three months.”  These kinds of frequency statements occur occasionally in DSM-5, and were included, presumably in an attempt to rescue the “diagnosis” in question from the charge of vagueness and unreliability.  What’s not usually recognized, however, is that the frequency criteria are entirely arbitrary.  Why not three times weekly for a period of two months?  Or four times weekly for four months? The answer, of course, is because the APA says so.  There is no evidence, nor can there ever be any evidence, supporting one over the other.

AGE OF ONSET

Age of onset has been an interesting issue across the various editions.

DSM-I and II made no reference to age of onset.

DSM-III:  “The disorder may begin at any state of life, but more commonly begins in the second or third decade” (p 296) [Emphasis added]

DSM-III-R:  The same as DSM-III.

DSM-IV:  “Limited data are available on the age at onset of Intermittent Explosive Disorder, but it appears to be from late adolescence to the third decade of life.” (p 611) [Emphasis added]

DSM-5:  “The onset of recurrent, problematic, impulsive aggressive behavior is most common in late childhood or adolescence and rarely begins for the first time after age 40 years.” (p 467) [Emphasis added].  Also, Criterion E states:  “Chronological age is at least 6 years old.”  [Emphasis added]

So the usual age of onset has progressed from “second or third decade”, to “late adolescence”, to “late childhood”, and as young as 6 years old!

DISCUSSION

What’s particularly noteworthy in all of this is the progressive loosening of the criteria across time, especially the elimination in DSM-5 of the requirement for serious damage or serious assault.  The lowering of the age of onset is also telling, and DSM-5’s criterion that “chronological age is at least 6 years” is chillingly consistent with psychiatry’s present promotion of the need for “early intervention”.  Here’s a quote from Kessler et al 2006:

“Intermittent explosive disorder is a much more common condition than previously recognized.  The early age at onset, significant associations with comorbid mental disorders that have later ages at onset, and low proportion of cases in treatment all make IED a promising target for early detection, outreach, and treatment.” [Emphasis added]

Promising, one is tempted to ask, for whom?

At the risk of stating the obvious, what psychiatrists call “intermittent explosive disorder” is not an illness in any ordinary sense of the term.  There are rare instances where brain damage can precipitate episodes of extreme anger, and these should indeed be considered illnesses.  But in the vast majority of temper tantrums, there is no neural pathology, but rather the simple fact that the individual hasn’t acquired the habit of controlling his/her temper.

To previous generations, the need to train/school children in this regard was considered a self-evident part of normal child-rearing.

But psychiatry needs illnesses to legitimize medical intervention.  And where no illnesses exist, they have no hesitation in inventing them.  And since they invented them in the first place, they have no difficulty in altering them to suit their purposes.  Of course, almost all the alterations are in the direction of lowering the thresholds, and thereby increasing the prevalence.

The idea of medical professionals arbitrarily inventing, and changing, the criteria for the “illnesses” that they treat sounds so preposterous that most people find it hard to believe.  It is widely assumed that psychiatrists have valid, scientifically-based reasons for making these changes.  But in fact, intermittent explosive disorder is nothing more, and nothing less, than what the APA says it is.  And over the years, in successive revisions of the catalog, they have made these changes, culminating in the sea-change of DSM-5.

And remember, DSM-5 was also the birthplace of “disruptive mood dysregulation disorder” – a pathologizing label for children (aged 6 and over) who are persistently bad-tempered.  In intermittent explosive disorder, the psychiatrists also have an “illness” for children (aged 6 and over) who are intermittently bad-tempered.  In psychiatry, as in fishing:  the bigger the net, the bigger the catch.

The great “breakthrough” for psychiatry in this regard was DSM-III’s definition of a mental disorder:

“…a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is typically associated with either a painful symptom (distress) or impairment in one or more important areas of functioning (disability).”  (p 6)

DSM-III-R expanded this to:

“…a clinically significant behavioral or psychological syndrome or pattern that occurs in a person and that is associated with present distress (a painful symptom) or disability (impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” (p xxii)

If you strip away the verbiage, and note the frequent use of the word “or”, what this actually means is:  any significant problem of thinking, feeling, and/or behaving.  This was Robert Spitzer’s “great” achievement:  defining mental disorder/illness in such a way that it could include virtually any and all problems.  It was this simple contrivance that made it possible to expand the psychiatric net more or less indefinitely.  And Dr. Spitzer’s definition has been dutifully retained, with only minor verbal changes, by both DSM-IV and DSM-5.  After all:  “if it ain’t broke, don’t fix it.”  Though it should be noted that DSM-5 did manage to relax Dr. Spitzer’s definition even further by the ingenious use of the word “usually”:  “…usually associated with significant distress…”  “Usually” means not necessarily.

It might be asked:  how can they do this?  How can they just invent illnesses for themselves to treat?  And the answer is simple:  they did it gradually and imperceptibly; and nobody stopped them.  Protesters were marginalized and ridiculed as unscientific blamers and stigmatizers, while the psychiatric juggernaut inched forward year by year, decade by decade, increasing its territory, expanding its scope, selling ever more drugs for pharma and – in the process – destroying people’s brains, and undermining our cultural resilience.

In this regard, here are some interesting quotes:

Intermittent explosive disorder:  Treatment and drugs, at Mayo Clinic:

“Different types of drugs may help in the treatment of intermittent explosive disorder. These medications include:

  • Antidepressants, such as fluoxetine (Prozac) and others
  • Anticonvulsants, such as carbamazepine (Tegretol), oxcarbazepine (Trileptal), phenytoin (Dilantin), topiramate (Topamax) and lamotrigine (Lamictal)
  • Anti-anxiety agents in the benzodiazepine family, such as lorazepam (Ativan) and clonazepam (Klonopin)
  • Mood stabilizers, such as lithium (Lithobid)”

Treating intermittent explosive disorder, from Harvard Medical School:

“A number of medications are known to reduce aggression and prevent rage outbursts, including antidepressants (namely selective serotonin reuptake inhibitors, or SSRIs), mood stabilizers (lithium and anticonvulsants), and antipsychotic drugs.”

Intermittent Explosive Disorder, Child Mind Institute, under the subheading “Treatment”:

“…a variety of medications have been used to help people with IED, including antidepressants and anti-anxiety medications, as well as anticonvulsants and other mood regulators.  After a careful evaluation, a psychiatrist will prescribe the appropriate type of medication for an individual case.”

This is not the practice of medicine; this is drug-pushing in the guise of medicine.  Whatever effectiveness the drugs might have in reducing aggression, is far outweighed by the spurious message to the individual, that he is incapable of controlling his aggression without “meds”, and to parents, that their 6-year-old’s temper tantrums are symptoms of a serious lifelong illness that needs prompt psychiatric attention.

This is not the practice of medicine.  This is a hoax.

Allen Frances Saving Psychiatry From Itself?

On October 12, 2014, the eminent psychiatrist Allen Frances, MD, participated in a panel discussion at the Mad In America film festival in Gothenburg, Sweden.  After the festival, he wrote an article – Finding a Middle Ground Between Psychiatry and Anti-Psychiatry – for the Huffington Post Blog, summarizing the positions he had discussed at the festival. The article was re-published on MIA on October 26, 2014.

The article is ostensibly an attempt to find common ground between psychiatry and its critics, but the piece contains numerous distortions and omissions which I think need to be identified and discussed.

Here are some quotes from the article, interspersed with my comments.

“There will never be any compromise acceptable to the die-hard defenders of psychiatry or to its most fanatic critics.

Some inflexible psychiatrists are blind biological reductionists who assume that genes are destiny and that there is a pill for every problem.

Some inflexible anti-psychiatrists are blind ideologues who see only the limits and harms of mental-health treatment, not its necessity or any of its benefits.

I have spent a good deal of frustrating time trying to open the minds of extremists at both ends — rarely making much headway.”

This is Dr. Frances’s opening passage.  Essentially what he’s saying here is that there are “extremists” on both sides of this issue.  Although he doesn’t say that these individuals are minorities, I think that this is implied.  Certainly those of us in the anti-psychiatry camp are a minority, but the implication that psychiatrists who are  “blind biological reductionists” represent a minority is, I suggest, simply false.  I have been retired now for 13 years, but in the previous twenty-five years, I doubt if I encountered more than three or four psychiatrists who were not “blind biological reductionists”.  The phrases “chemical imbalance” and “illness just like diabetes” were standard fare in psychiatry’s narrative, and the 15-minute “med check” was the standard “treatment” for all problems.

With regards to “inflexible anti-psychiatrists” being “blind ideologues”, I think I can speak from personal experience.  I am indeed inflexibly anti-psychiatry.  My position in this regard is based entirely on the fact that the various problems listed in the DSM (apart from those indicated as due to a general medical condition) are not illnesses, and that conceptualizing these problems as illnesses has done, and continues to do, vastly more harm than good.  I am – to use Dr. Frances’s term – inflexible on this matter in the same way that I am inflexible on the matter that the Earth is round rather than flat.

But, on the other hand, as I’ve stated many times on my website, if psychiatry will adduce convincing evidence that the various items catalogued in their manual really are illnesses, (i.e., stem from an identified biological pathology), then I will accept this evidence, apologize for my errors, and close the website. At the risk of understatement, this evidence is not to hand, and at present, psychiatry’s contentions, explicit and implicit, that the various problems that they “treat” are illnesses are nothing more than destructive, disempowering, self-serving, unsubstantiated assertions.

And lest there be any perception that psychiatry’s love-affair with biological reductionism is a thing of the past, here’s a quote from Jeffrey Lieberman’s June 19, 2012 video Causes of Depression.  Dr. Lieberman is Psychiatrist-in-Chief at New York Presbyterian/Columbia University Medical Center, and at the time of the video was President-elect of the APA.  The video was made by The University Hospital of Columbia and Cornell.

“…the way nerves talk to each other, and communicate, is through the secretion of a chemical called a neurotransmitter, which stimulates the circuit to be activated.  And when this regulation of chemical neurotransmission is disturbed, you have the alterations in the functions that those brain areas are supposed to, to mediate.  So in a condition like depression, or mania, which occurs in bipolar disorder, you have a disturbance in the neurochemistry in the part of the brain that regulates emotion.”

And lest there be any perception that Dr. Frances did not contribute to psychiatry’s ardent embrace of biological reductionism, here’s a quote from the Introduction to DSM-IV, of which Dr. Frances was the Task Force chairman:

“The terms mental disorder  and general medical condition are used throughout this manual.  The term mental disorder is explained above.  The term general medical condition is used merely as a convenient shorthand to refer to conditions and disorders that are listed outside the ‘Mental and Behavioral Disorders’ chapter of ICD.  It should be recognized that these are merely terms of convenience and should not be taken to imply that there is any fundamental distinction between mental disorders and general medical conditions… (p xxv) [Boldface added]

. . . . . . . . . . . . . . . . 

“Fortunately, though, there are many reasonable people in both camps who may differ markedly in their overall assessment of psychiatry but still can agree that it is certainly not all good or all bad. With open-mindedness as a starting point, common ground can usually be found;”

At the risk of appearing cynical, I see this as a rather facile attempt at divide-and-conquer.  Psychiatry is the Goliath here, and the anti-psychiatry movement is a very weak and poorly-provisioned David.  What Dr. Frances is doing is marginalizing the more extreme members of the anti-psychiatry camp, and attempting to gather the more moderate members into psychiatry’s fold, under the pretense that most psychiatrists are reasonable people who will welcome their input with “open-mindedness”.  In reality, apart from a truly tiny number of psychiatrists, there is no receptivity within psychiatry to the anti-psychiatry concerns.  In fact, the dominant feature of the present debate is psychiatry’s increased insistence that the problems they “treat” are indeed real illnesses, and that their “treatments” are safe and effective.

In a recent radio interview with Michael Enright on Canadian Broadcasting Corporation’s The Sunday Edition, Jeffrey Lieberman, MD, one of the most eminent and prestigious psychiatrists in the world, characterized Robert Whitaker as “a menace to society” for daring to suggest otherwise!  And there was scarcely a ripple of protest from psychiatry.

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

“And finding common ground has never been more important. We simply can’t afford a civil war among the various advocates of the mentally ill at a time when strong and united advocacy is so desperately needed.”

Note the term “civil war” with its connotations of brother against brother, families torn apart, etc…  The message here is:  that those of us who are “open-minded” basically want the same thing, so why are we engaged in this struggle?  But note also the phrase “the mentally ill”.  The essential core of the anti-psychiatry movement is that the various problems embraced by psychiatry’s catalog are not illnesses.  But Dr. Frances dismisses this entire issue in the guise of being open-minded and conciliatory.

In addition, the phrase “the mentally ill”, with its connotations of amorphousness, homogeneity, and anonymity, is extraordinarily stigmatizing.  I would concede that person-first language is sometimes promoted to an excessive degree, but the phrase “the mentally ill” is not at all helpful.

Ironically, Dr. Frances uses this phrase in the context of advocacy!  “…various advocates of the mentally ill…”  I respectfully suggest that a good first advocacy step for Dr. Frances would be to stop calling the individuals concerned “the mentally ill”.

Incidentally, the phrase “the mentally ill” occurs in Dr. Frances’s paper three times; the phrase “the severely ill” occurs once.

And why is this “strong and united advocacy…so desperately needed”.  Because:

“Mental-health services in the U.S. are a failed mess: underfunded, disorganized, inaccessible, misallocated, dispirited, and driven by commercial interest. The current nonsystem is a shameful disgrace that won’t change unless the various voices who care about the mentally ill can achieve greater harmony.”

But, and Dr. Frances fails to mention this, it is psychiatry itself that has been running this “shameful disgrace” for the past 150 years or so.  And psychiatry was, and still is, a very willing and devoted partner to pharma, the major commercial interest.

Also note the guilt-trip:  if you’re not joining the great Allen-Frances coordinated unification drive, then you just don’t care about “the mentally ill”, (that phrase again).

 

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

“…those who don’t need psychiatric medicine get far too much: We spend $50 billion a year on often-unnecessary and potentially dangerous pills peddled by Big Pharma drug pushers, prescribed by careless doctors, and sought by patients brainwashed by advertising. There are now more deaths in the U.S. from drug overdoses than from car accidents, and most of these come from prescription pills, not street drugs.”

But Dr. Frances neglects to mention that his own DSM-IV had a clearly expansionist agenda, details of which I’ve discussed in an earlier post.  It is the proliferation of “diagnoses” and the progressive relaxing of the criteria that enables the increases in prescribing.  And Dr. Frances has been a major player in this area.

He also neglects to mention his own interest-conflicted collaborative relationship with Janssen Pharmaceutica in the mid-1990’s in the promotion of Janssen’s drug Risperdal (risperidone).  In that regard, Dr. Frances was quoted in a witness report as stating:

“We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.” [Boldface added]

. . . . . . . . . . . . . . . . 

“The mess is deeply entrenched because 1) there are few and fairly powerless advocates for the most disadvantaged; 2) the commercial interests are rich and powerful, control the airwaves and the politicians, and profit from the status quo; and 3) the mental-health community is riven by a longstanding civil war that distracts from a unified advocacy for the severely ill.

The first two factors won’t change easily. Leverage in this David-vs.-Goliath struggle is possible only if we can find a middle ground for unified advocacy.

I think reasonable people can readily agree on four fairly obvious common goals:

1.  We need to work for the freedom of those who have been inappropriately imprisoned.

2.  We need to provide adequate housing to reduce the risks and indignities of homelessness.

3.  We need to provide medication for those who really need it and avoid medicating those who don’t.

4.  We need to provide adequate and easily accessible psychosocial support and treatment in the community.”

There is indeed a David and Goliath aspect to this issue.  Pharma-psychiatry is Goliath; and the struggling anti-psychiatry movement is David.  But note how Dr. Frances has reconfigured this. Goliath is now “the commercial interests” (presumably pharma), and David is psychiatry (without, of course, the few “blind biological reductionists”) plus those “reasonable” members of the anti-psychiatry movement who genuinely care for “the mentally ill”.  Casting pharma and psychiatry as being on opposite sides of this issue, and portraying psychiatry as the powerless, innocent victim, are extraordinary feats of mental gymnastics.

. . . . . . . . . . . . . . . . 

“Eighty percent of all psychiatric medicine is prescribed by primary-care doctors after very brief visits that are primed for overprescribing by misleading drug-company advertising.”

But not a single one of those prescriptions could have been written if psychiatrists had not invented, and avidly promoted, the “illnesses” for which they are prescribed.

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

 “Many psychiatrists also tend to err by being too quick to write prescriptions.”

But isn’t this an integral part of the medical model:  diagnose the illness, prescribe the treatment; follow-up.  This isn’t some kind of unforeseeable aberration.  Rather, this is psychiatry as psychiatrists – leaders as well as rank and file – have consciously and deliberately sculpted it over the past 50 years.  This spurious and destructive travesty is the inevitable culmination of psychiatry’s efforts to establish itself as a bona fide medical specialty.  The fact that it is such a colossal failure is not a reflection on the efforts of the participants, or the pharma money that fuelled those efforts.  Rather, it reflects the obvious fact that the medical model is not a useful way to conceptualize or approach non-medical problems of thinking, feeling, and/or behaving.   

. . . . . . . . . . . . . . . . 

“I think reasonable people can agree that we need to reeducate doctors and the public that medications have harms, not just benefits…”

Doctors need to be re-educated to the fact that medications have harms, not just benefits!  Don’t they read the PDR?   And note the use of the generic term “doctors” rather than psychiatrists, even though it was psychiatrists who routinely proclaimed the safety and efficacy of the drugs they pushed, and downplayed adverse reactions, when they mentioned them at all.  And it was the pharma-funded psychiatric research mill that churned out, and continues to churn out, the spurious studies that “established” the safety and efficacy of these products.

. . . . . . . . . . . . . . . . . 

“…it is equally ludicrous that anyone should be sent to jail for symptoms that would have responded to medication if the waiting time for an appointment had been one day, not two months.”

First, note the implication that the criminal behavior is a “symptom” that “would have responded to medication.”  But what of the increasing number of very serious criminal acts committed by people who are actually taking psychiatric drugs, particularly SSRI’s?

. . . . . . . . . . . . . . . . 

“When, more than 50 years ago, Tom Szasz began to fight for patient empowerment, freedom, and dignity, the main threat to these was a snake-pit state hospital system that warehoused more than 600,000 patients, usually involuntarily and often inappropriately. That system no longer exists. There are now only about 65,000 psychiatric beds in the entire country, and the problem is finding a way into the hospital, not finding a way out.”

This is not entirely accurate.  The late Thomas Szasz, MD, was indeed concerned about coercive psychiatry, but he was even more concerned about psychiatry’s spurious medicalization of non-medical problems: what Dr. Szasz called the myth of mental illness.  And this latter concern is one that Dr. Frances consistently fails to address, or even acknowledge.  To abuse the late Dr. Szasz’s legacy in this way strikes me as dishonorable.  And to suggest that the concerns so forcefully expressed by Dr. Szasz are now a thing of the past is simply false.

. . . . . . . . . . . . . . . . 

“Anti-psychiatrists are fighting the last war. Psychiatric coercion has become largely a paper tiger: rare, short-term, and usually a well-meaning attempt to help the person avoid the real modern-day coercive threat of imprisonment.”

So psychiatric coercion is rare, short-lived, and is essentially an act of kindness to keep people out of prison.  But on August 28, 2014, Dr. Frances wrote an article on the Huffington Post Blog in which he lionizes D.J. Jaffe, whom he describes as “one of a small group of stalwart defenders of the 5 percent” (people with “severe mental illness”).  Dr. Frances provides an extensive quote from D J. Jaffe in which Mr. Jaffe clearly supports the infamous Tim Murphy bill, which, if implemented, would increase vastly the amount of coerced psychiatric “treatment” in the US.

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

Depression is not an illness.  Childhood inattention is not an illness.  Painful and distressing memories are not illnesses.  Habitual criminality is not an illness.  Psychiatry’s routine medicalization of these and other non-medical problems is a disaster of monumental proportions, and Dr. Frances has been a major contributor to this process.

At the present time, psychiatry is being exposed as the self-serving, disempowering, and destructive charlatanism that it is.  The anti-psychiatry movement, though still the David, is gaining ground and adherents daily.  Psychiatry has no defense, and can see the edifice, so carefully and deceptively constructed over decades, crumbling by the day.

What Dr. Frances is trying to do is co-opt the anti-psychiatry movement, by marginalizing its more extreme members, while gathering the rest under a dubious banner of reasonableness and compromise.  But beneath the thin veneer of amenability, there are still the spurious, self-serving concepts and the destructive, disempowering practices of a system that is intellectually and morally bankrupt, and has no legitimate claim to being a medical specialty.

The Use of Neuroleptic Drugs As Chemical Restraints in Nursing Homes

There’s an interesting article in the July-August 2014 issue of the AARP Bulletin.  It’s called Drug Abuse: Antipsychotics in Nursing Homes, and was written by Jan Goodwin.  AARP is the American Association of Retired Persons.   Jan Goodwin is an investigative journalist whose career, according to Wikipedia, “…has been committed to focusing attention on social justice and human rights…”

The article is essentially a condemnation of the widespread and long-standing practice of using neuroleptic drugs to suppress “difficult” behavior in nursing home residents.

Here are some quotes:

“According to Charlene Harrington, professor of nursing and sociology at the University of California, San Francisco, as many as 1 in 5 patients in the nation’s 15,500 nursing homes are given antipsychotic drugs that are not only unnecessary, but also extremely dangerous for older patients.”

“‘The misuse of antipsychotic drugs as chemical restraints is one of the most common and long-standing, but preventable, practices causing serious harm to nursing home residents today,’ says Toby Edelman, an attorney at the Center for Medicare Advocacy in Washington, D.C.”

“If one drug caused sleeplessness and anxiety, she was given a different medication to counteract those side effects. If yet another drug induced agitation or the urge to constantly move, she was medicated again for that.”

“Antipsychotic drugs are intended for people with severe mental illness, such as patients with schizophrenia or bipolar disorder. As such, they carry the FDA’s black-box warning that they are not intended for frail older people or patients with Alzheimer’s or dementia. In those populations, these drugs can trigger agitation, anxiety, confusion, disorientation and even death. ‘They can dull a patient’s memory, sap their personalities and crush their spirits,’ according to a report from the California Advocates for Nursing Home Reform.”

There’s an implication in this quote that neuroleptic drugs have these adverse effects only on frail older people.  In fact, they have these effects on almost everybody who takes them.

Back to the AARP article:

“And pharmaceutical companies have been aggressively marketing their products as an easy and effective way to control these issues.”

Gwen Olsen’s book Confessions of a Rx Drug Pusher (2009) provides some very compelling insights into this kind of pharma marketing, e.g.:

“It was the end of the third quarter, and I was behind in my sales quota for Haldol…So, I determined the best way to build my Haldol business would be to campaign for the institutionalized patient. These patients were not only encouraged to take the medication; they were actually given the drug. This completely eliminated the compliance issue.”

“I set about scheduling training in-services in the local nursing homes and mental health and mental retardation (MHMR) facilities. I increased my call frequency on physicians whom I knew to have nursing home relationships and directorship responsibilities.” (p 48) [Emphasis added]

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

It is particularly heartening to see an article like Jan Goodwin’s in an established magazine such as AARP Bulletin (readership 37 million +).  It represents a huge advance over the take-your-psychiatric-medication-as-the-doctor-ordered drivel that passes for journalism in most mainstream media outlets.  I commend Jan Goodwin, and hope that we see more material of this sort in the future.

At the same time, however, I was disappointed in that the role of psychiatry in the promotion of these neurotoxic chemicals was not even mentioned.  Responsibility for the problem was laid at the feet of pharma, whose aggressive, irresponsible marketing was unequivocally condemned.

But pharma doesn’t write prescriptions.  And pharma didn’t invent the “illnesses” that legitimize these prescriptions.

For the past sixty years, psychiatry’s primary objective has been to promote the spurious and destructive notion that virtually every human problem is an illness.  Their efforts have been extremely successful, and this false notion today permeates our culture, our language, our political and social institutions, and even our nursing homes.

Using dangerous, toxic chemicals to drug a frail, elderly person into submission is possible because psychiatry has invented and sold the fiction that his agitation, anxiety, and aggression are illnesses, and that the toxic chemicals are medications.  Pharma certainly funded the fraud, but it was psychiatry that conducted the “validating research.”  It was psychiatry that codified and formalized the spurious diagnoses into a manual.  And it is psychiatry that lobbies unremittingly for the acceptance of these “diagnoses” by government entities and by other professions.

And this was not an innocent error.  Psychiatrists invented and promoted their fictitious illnesses and their destructive “treatments” to promote their own aspirations to be seen as a legitimate medical specialty, and to expand their business, their influence, and their prestige.

In this process, they have created a monster that feeds on human life, but they continue to insist, against rapidly mounting evidence, that their “diagnoses” are valid and their “treatments” effective, and have engaged the services of an international PR firm to marginalize their opponents and to sell this travesty to the public, the media, and the political establishment.  Psychiatry is not something that is basically OK, that just needs some minor corrections.  Rather, psychiatry is something fundamentally flawed and rotten: a wrong turning in human history; a blot on humanity’s collective conscience.

Let us hope that we see more articles like this in the mainstream media, and that more investigative journalists like Jan Goodwin will find the motivation and the courage to speak out against this disempowering and destructive edifice whose shadow has for too long been allowed to darken the hopes and aspirations of people of all ages.

 

Blame the Clients?

On June 6, I wrote a post titled Psychiatry DID Promote the Chemical Imbalance Theory.  The article was published on Mad in America, and generated a number of comments on that site, five of which were from TherapyFirst, who in his first comment identified himself as Joel Hassman, MD, a practicing psychiatrist. 

Dr. Hassman did not argue with the general notion that psychiatric practice today consists almost exclusively of the prescription of drugs.  Indeed, in one of his own blog posts on June 16, 2013, he wrote in an open letter to newly qualified psychiatrists:

“…you are now agreeing to basically just prescribe medication and give limited, selective diagnoses that serve insurer and/or bureaucratic agendas first and foremost.”

 and

“…your interest will be narrowly directed to prescribing more likely multiple medications from moment one of meeting the patient…”

And this general position – that psychiatry consists essentially of prescribing drugs – continues to be evident in his comments on the MIA post.

But then he introduces a twist that I haven’t encountered before – he blames the clients for what he aptly calls the “chemicalization” of mental health.  Here are some quotes:

“Everyone rails about psychiatrists and other prescribers just dumbing down mental health care complaints to writing scripts, but, in the last 10 years or so, people come into treatment venues just wanting drugs, and dismiss any other intervention for care, irregardless of how appropriate and indicated as a standard of care such a treatment is warranted.”

“Seems to me it fits the antipsychiatry narrative at the end of the day. It is easier to crucify the doctors, harder to attack the general public who are reinforcing ‘better living through chemistry’, eh?”

 “Sorry, but if there is going to be a valid and honest discussion/debate about who is at fault in the ‘chemicalization’ of mental health, don’t just pick on the doctors. Patients are pervasively demanding drugs, often ones of abuse potential of late, and have little to no interest in problem solving nor wanting to implement real and effective change for the better.”

 “…where are the muzzle prints on these ‘victims’ foreheads that demand they take medication?”

 “…you as a patient come to someone with an expertise and then have the gall to argue and demand interventions that do not fit as treatment A for the problem in front of the clinician, and I am to refer to him/her as ‘victim’?? Get real!”

As I noted earlier, this is an unusual and complicated  perspective.  On the one hand, there’s an element of truth in Dr. Hassman’s position.  A great many people do indeed go to psychiatrists for the specific purpose of obtaining a prescription.  And I think we can believe Dr. Hassman’s assertion that some of these individuals may become impatient and dismissive, and perhaps even demanding, when invited to explore other options.

But on the other hand, drug prescriptions are psychiatry’s stock in trade.  It’s what the vast majority of psychiatrists offer, and what their customers have, reasonably and legitimately, come to expect.  I have even heard numerous reports from clients that they were pressured by psychiatrists into taking pills.

I’m old enough to remember a time when outpatient psychiatry was almost entirely a talking and listening profession.  Depression was considered a fairly ordinary and understandable phenomenon – part of the human lot, so to speak – and remediation was conceptualized as being largely a matter of seeking support and solace from friends and loved ones, and of making positive changes in one’s circumstances and lifestyle.  In extreme cases, people did consult psychiatrists, but the purpose of these visits was to discuss issues and problems – not to obtain drugs.

I imagine that psychiatrists in those days felt that their years of medical training were somewhat wasted.  The problems that they were helping people address were not considered medical in nature, except perhaps in very extreme cases, and there was nothing particularly medical about the “treatments.”  And, of course, there were fewer psychiatrists.

Obviously things are very different today, and I think the fundamental questions here are:  how did these changes come about? and, who’s to blame?

There is an obvious parallel between the growth of psychiatric prescribing and the growth of the illegal drug trade over the past fifty or sixty years.  It is also obvious, and generally accepted, that the illegal trade is driven by demand, and would collapse overnight if that demand were to dry up.

So the question arises:  is what Dr. Hassman calls the chemicalization of psychiatry essentially a product of consumer demand for drugs?  And, of course, the answer, at least to some extent, is yes.  If people stopped going to psychiatrists for prescriptions, then psychiatrists would have to either disband as a profession or find something else to do.

But there is another side to this coin.  People who deal in illegal drugs make no pretense that their products are medications.  For psychiatrists, however, this is their primary marketing tool.  For decades, they and their pharmaceutical allies have promoted this fiction using every means at their disposal.  Very few psychiatrists have distanced themselves to a significant degree from this position.

They have spread the seductive deception that virtually all significant problems of thinking, feeling, and/or behaving are caused by neurochemical imbalances which can be corrected only by ingesting their products.  They have issued, and continue to issue, dire warnings as to the consequences of not taking these pills.  They have persuaded parents that their children’s brains are impaired, and that even toddlers need to take the pills.  And so on.  The whole sordid tale has been exposed many times, but psychiatry, without a hint of shame or compunction, continues to spread this self-serving and destructive deception.  In fact, at the present time, psychiatry, as represented by the World Psychiatric Association and the American Psychiatric Association, is actively working to improve its tarnished image with a view to expanding its market even further.

So, Dr. Hassman is probably correct when he writes that some clients do come to psychiatrists to obtain drugs, and are resistant to alternative suggestions.  But I think there’s a bigger issue:

A steady stream of individuals, of all ages and from all walks of life, coming to psychiatrists for drugs is precisely the objective towards which the psychiatric leadership and vast majority of the rank and file have worked diligently for the past fifty years. 

It wasn’t the customers who invented and disseminated the term “a chemical imbalance, just like diabetes.”  And, it wasn’t the customers who wrote and expanded the DSM to provide an impression of legitimacy for the drug-pushing activity.  That was psychiatry!

* * * * * * * * * * * * * * * * * * * *

This article has also be posted at the Mad in America site.

 

 

Childhood Social Functioning Predicts Adult Schizophrenia Spectrum Disorder. Or Does It?

In November 2013, the journal Schizophrenia Research published a paper by Tsuji, T. et al. titled Premorbid teacher-rated social functioning predicts adult schizophrenia-spectrum disorder: A high-risk prospective investigation.  Here’s the abstract:

“Social functioning deficits are a core component of schizophrenia spectrum disorders, and may emerge years prior to the onset of diagnosable illness. The current study prospectively examines the relation between teacher-rated childhood social dysfunction and later mental illness among participants who were at genetic high-risk for schizophrenia and controls (n=244). The teacher-rated social functioning scale significantly predicted psychiatric outcomes (schizophrenia-spectrum vs. other psychiatric disorder vs. no mental illness). Poor premorbid social functioning appears to constitute a marker of illness vulnerability and may also function as a chronic stressor potentially exacerbating risk for illness.”

The study was done in Denmark by a Danish-American team, as part of a large scale longitudinal developmental study.  Studies of this sort are often done in Denmark, incidentally, because the Danes have a central mental health register and other data bases that facilitate the gathering of follow-up information.

The social functioning measure consisted of five items, each of which was rated on a five point scale.  The total score was obtained by adding the five individual item scores.  Lowest possible score was 5; highest possible score was 25.  The items were:

1. The child does not seem to take part when the rest of the class is having fun.
2. The child has no friends.
3. The child is often teased.
4. The child does not actively seek friends.
5. The child seems to avoid contact with other children.

Here are some more quotes, interspersed with my comments:

“Results suggest that, even though many psychiatric difficulties are associated with deteriorations in social functioning, teacher-rated social deficits among school-age children appear to represent a marker of vulnerability specific to disorders within the ‘family’ of schizophrenia spectrum illnesses. These findings highlight the value of teachers in identifying key markers of risk such as social deficits.”

In the abstract quoted earlier, the authors acknowledge that “social functioning deficits are a core component of schizophrenia spectrum disorders.” [Emphasis added]  With this in mind, it seems to me that the best and most parsimonious way to conceptualize the research finding is that children who have poor social skills will, in many cases, grow up to be adults with poor social skills.  In particular, there seems to me no justification (other than psychiatric dogmatism) to conceptualize the matter in medical terms, and to impose a medical framework – “a marker of vulnerability” – on the data.

“Thus, social functioning has emerged as an important area for researchers interested in the core features of emerging psychotic illness…”

Here again, note the assumption of an “emerging…illness.”

“…results from this 48-year longitudinal record suggest that children on a trajectory toward schizophrenia-spectrum disorders demonstrate interpersonal deficits early in life, and that teachers provide valuable information regarding children’s social functioning.”

Again, note the medical language:  children with poor social skills are “on a trajectory toward schizophrenia spectrum disorders.”  The term “on a trajectory” also entails an element of inevitability, implying that children with poor social skills become psychotic in the same way that people who inherit the Tay-Sachs gene get the disease.  Note also the identification of teachers as sources of “valuable information.”

A follow-up period of 48 years (1959-2007) is impressive in a longitudinal study, and it is likely that the findings will be afforded a high measure of credibility and status within the psychiatric community.  A Google search on May 14 for the title got 7,770 hits.  So the study is attracting attention.

In recent years, organized psychiatry has been actively promoting the notion of early intervention in schools and other settings for people who are considered “at risk” for acquiring a diagnosis of schizophrenia (e.g. here and here).  The DSM-5 workgroup promoted the “diagnosis” of attenuated psychosis syndrome, as a means of identifying teens considered to be “at risk,”  and this “diagnosis” is included in the manual as a specific example in the category:  “Other Specified Schizophrenia Spectrum and Other Psychotic Disorder 298.8” (p 122).

In this general context, a simple (5-item) teacher-completed social skills rating scale is likely to have considerable appeal.  For these reasons, it seems important to subject the study to some scrutiny.

SOCIAL SKILLS AND “SCHIZOPHRENIA”

Perhaps the study’s most significant shortcoming is the one already mentioned:  that poor social skills are in fact the primary defining feature of DSM-5’s “schizophrenia spectrum and other psychotic disorders.”  The defining features of these psychiatric “diagnoses” are set out on pages 87 and 88 of the manual, and include the following, all of which fall, I suggest, under the heading of social skills deficits:

    • reduction in the expression of emotions in the face
    • showing little interest in…social activities
    • diminished speech output
    • lack of interest in social interactions
    • childlike silliness
    • lack of verbal…responses
    • staring
    • grimacing
    • mutism
    • echoing of speech
    • switching topics

Even delusions and hallucinations, the cornerstones of these “diagnoses,” are closely connected to social skills. A child who grows up with poor social skills is often victimized and bullied, and quickly learns that the “real” world is not usually a source of joy or reward.  The subsequent retreat into a private realm is not only understandable, but in many cases adaptive.

So when Tsuji et al. discovered, through their research, that children who are rated by their teachers as socially unskilled, have a better than average chance of attracting a “diagnosis” of a schizophrenia spectrum disorder in adulthood, all that they have found is that some individuals, who are socially unskilled as children, are socially unskilled in adulthood.  Poor social skills is an inherent component of the definition of “schizophrenia.”  The notion that this needs to be discovered as a “marker of vulnerability” is specious and misleading.

FALSE POSITIVES

The study write-up is sparse in both description and data, so it’s not possible to subject the numbers to serious scrutiny.  But it is clear that many of the participants who were rated poor on social skills during childhood grew up to have “no mental illness” in later life.  The authors do tell us that the “…[s]ocial functioning scores ranged from 6 to 25 with an overall sample mean of 20.83 (SD = 3.78).”  They also provide means and standard deviations for the three outcome groups.

chart 1 May 14

 

 

 

 

 

It should be noted that the above table does not appear in the text, but was created by me from data presented as run-on text in three separate sections of the paper.  (Higher scores mean better social functioning)

What’s immediately clear from this table is that there is considerable overlap in the social skills scores from the three outcome groups.  We can get an estimate of the range of the three groups from the standard deviations.  Most of the participants’ scores will lie in the range from two SD’s below the mean to two SD’s above the mean.  So we can calculate tentative score ranges as follows:  (The range for all scores was 6-25, so 25 is always the upper limit.)

Chart 2 May 14

 

 

 

 

 

 

It is reasonably certain that many of the low scorers in the NMI group scored below the mean of the schizophrenia spectrum group, and yet these individuals had never been assigned a mental illness “diagnosis” of any kind.  It’s not possible to say, based on the published data, what the absolute numbers were, but given that the NMI group is four times larger (133 vs. 33) than the spectrum group, it is entirely feasible that there were as many, or even more, individuals in the NMI group scoring below the “spectrum” mean (17.55) as there were in the spectrum group.  Using the spectrum mean (17.55) as a prognostic cutoff would have created the prediction that these individuals were on the so-called trajectory to a schizophrenia spectrum disorder.  But in fact they acquired no mental health “diagnoses” at all.  So using this social skills scale, or indeed any similar scale, is likely to “identify,” and target for psychiatric treatment, large numbers of individuals who in fact were “on a trajectory” to “no mental illness.”

And there’s another problem.  Of the 33 individuals who received a diagnosis of a schizophrenia spectrum disorder in adulthood, only 18 of these had been assigned a diagnosis of schizophrenia.  The remaining “diagnoses” were:

Psychosis NOS or delusional disorder                                    8

Schizotypal, paranoid, and schizoid personality disorder      7

The authors state that their decision to group these categories together was “…guided by familial research suggesting genetic links between the disorders…”  However, it is entirely possible that the grouping was done to increase the size of the high “pathology” group in order to make the association seem more robust.  It is also possible that the data was pre-examined and it was noticed that a large proportion of the poor-social-skills group had been assigned these other diagnoses in adulthood.

I have no way of knowing if any data massaging of this sort happened.  But the decision to group the diagnoses in this way, coupled with the sparseness of data in the write up, raises questions.  At the very least, it increases the chances of a predictive “hit” by the simple expedient of widening the target.

Another troubling aspect of the “diagnosis” grouping is that the authors are not using the term “schizophrenia spectrum disorders” in the same sense as DSM-5.  In particular, the authors have included the conditions known as paranoid and schizoid personality disorders, neither of which is included in the DSM-5 grouping.  This, I suggest, is important for two reasons.  Firstly, most readers on coming across this term in the title and in the abstract, would have assumed that it referred to the DSM-5 category.  At the very least, the authors should have stated explicitly that this is not the case – that in fact, they were using the term differently.  Secondly, and more importantly, the behaviors entailed in the paranoid personality and schizoid personality labels are entirely a function of social skills.  It is likely that individuals who meet these general descriptors would score very low on a social skills scale at age 11-13, and this may have been a major factor in depressing the overall score of the spectrum group.

Many credible accusations of data massage have been leveled at psychiatric researchers in recent years, and in this regard it would have been helpful if Tsuji et al. had published some more numerical data. Even the means and standard deviations of the “paranoid” and “schizoid” personality groups would have been useful.

PREDICTIVE VALUE OF THE RESULTS

As mentioned earlier, the title of the article is Premorbid teacher-rated social functioning predicts adult schizophrenia-spectrum disorder: A high-risk prospective investigation.

This, I suggest, is misleading.  The social functioning risk ratio for no mental illness vs. spectrum disorders was only 1.31 (with a 95% confidence interval of 1.17 to 1.46).  This does not indicate high predictive potential.  To illustrate this, imagine 100 envelopes spread out on a large table; 50 red and 50 blue.  A person is informed (truthfully) that half of the blue envelopes contain a $100 bill and the other half contain a go-to-jail-now card.  With the red envelopes, the odds are better – 19 jail cards and 31 $100 bills.  The person is invited to choose one envelope and open it.  If it is a jail card, he will be incarcerated.  If it contains a $100 bill, he gets to keep it.  Obviously, other things being equal, he should choose a red envelope, but he still runs a 38% chance of going to jail, versus a 50% with the blue envelopes.  The risk ratio for blue to red is about 1.31.  So, yes, the color red does predict dollars over jail – but the potential for error (i.e., jail) is still high.  Similarly, if a person were to use the five item social skills scale described in this study to predict a “schizophrenia spectrum disorder” in adulthood (odds ratio also 1.31), his prediction would be false a great deal of the time.  The word “significantly” in the abstract refers only to statistical significance, and indicates that the result is unlikely to have occurred by chance.  It has no bearing on the magnitude of the effect.

A more accurate title for the paper would be:

“Teacher-rated social functioning at age 10-13 (as measured by a five-item scale) is correlated modestly with acquiring a diagnosis of schizophrenia, or psychosis not otherwise specified or delusional disorder or schizotypal personality disorder or paranoid personality disorder or schizoid personality disorder, in adulthood.”

SOCIAL SKILLS

The great tragedy in this area is that poor social skills is an eminently remediable condition.  Social skills can be taught as easily, and as readily, as counting, spelling, and playing simple games.  Children, for instance, who are excessively boastful, which in later life will attract the label “grandiosity,” can be coached successfully to downplay their self-promotion and to pay compliments to others.  Ordinary conversational skills such as making eye contact, admitting to mistakes, smiling, allowing others an opportunity to speak,  etc., can all be coached without difficulty.  Conscientious parents have been doing this since the dawn of civilization, and probably even earlier.

Unfortunately, however, in the present time this kind of teaching often doesn’t take place.  While children who can’t count or read attract lots of remedial attention, the lack of social skills is somehow seen as an inherent defect that doesn’t lend itself to coaching.  Social skills are often conceptualized, even by teachers, as an integral part of “the child’s personality,” or as indicators of “deeper” problems, rather than skills that can be acquired, practiced, and cultivated in the normal way.  Children with deficits in this area are often sent to the mental health center, where they acquire various “diagnoses,” and are given the false and disempowering message that they are sick.  The Tsuji et al. study will lend unwarranted credence and support to this practice, in that it will be used to promote the notion that these individuals are “on a trajectory” to a “schizophrenia spectrum disorder,” and that this “trajectory” can be altered only by timely psychiatric intervention.

It is also the case that some people, children and adults, don’t want to socialize.  They prefer their own company, and often excel in various non-social areas.  The present drive towards “early intervention” will pathologize these individuals, and will draw them into psychiatry’s disempowering and destructive net – for their own good, of course.

AUTHORSHIP

Although Thomas Tsuji (a sixth-year grad student in the UBMC Department of Psychology) is shown as first author, it is clear the Jason Schiffman, PhD, is the principal investigator.  Under the heading “contributors,” the article states:  “Dr. Schiffman formulated, conducted, and/or oversaw the study design, data analysis, data interpretation and manuscript preparation.”  Dr. Schiffman is also listed as the “corresponding author,” with an address at the University of Maryland, Baltimore County (UMBC).  You can see his UMBC bio here.  His listed research interests are:  “Early identification and treatment of youth at risk for psychosis.  Reduction of stigma against people with serious mental health concerns.”

Some of Dr. Schiffman’s recent research publications are also listed.  Here are two quotes from these studies:

“Brief self-report questionnaires that assess attenuated psychotic symptoms have the potential to screen many people who may benefit from clinical monitoring, further evaluation, or early intervention.” (here)

“The validation of attenuated symptoms screening tools is an important step toward enabling early, wide-reaching identification of individuals on a course toward psychotic illness.” (here)

Dr. Schiffman is also on the staff of the Center for Excellence on Early Intervention for Serious Mental Illness.  This agency was created last year by a $1.2 M grant from the State of Maryland as part of the state’s response to the problem of mass shootings in schools and other locations.  The center is headed by Robert Buchanan, MD, a professor of psychiatry at University of Maryland.  Dollars for Docs indicates that Dr. Buchanan received $34,520 from pharma in the period 2009-2012.  Information on the Center’s activities to date is sparse, but I did find two Baltimore Sun articles about the Center.  The first article, titled New Maryland mental health initiative focuses on identifying and treating psychosis by Jonathan Pitts, was published on October 21, 2013.  Here are two quotes:

“Research has shown those who eventually develop psychosis have often exhibited early warning signs, clues that give family members, teachers, health-care providers and others a chance to intervene early, if only they know what to look for.”

“The Clinical High-Risk program will be contacting schools, houses of worship, law enforcement and other communities that come into contact with youth to promote public awareness about such signs, Schiffman said, and clinicians will be available to provide testing and offer treatment options.”

 The second article, written by Jean Marbella, was published on March 21, 2014.  It’s titled UMBC study among efforts to increase awareness of mental illness.  Here are some quotes:

 “‘Many of the folks who need help get lost somehow,’ said Jason Schiffman, an associate professor of psychology at the University of Maryland, Baltimore County who is heading the study. ‘There are so many kids and young adults who slip through the cracks.'”

 “Schiffman has long been interested in early intervention and de-stigmatization programs for those suffering mental health problems, but more recently, his work is benefiting from a new focus on the role such illnesses may have played in some shootings.”

 And perhaps most telling of all:

“‘As a society, if we normalize the seeking of help,” he said, “people are more likely to seek that help.'”

There is it:  psychiatry for all.  A “diagnosis” for every problem and a pill for every “diagnosis.”

SUMMARY

And so it goes.  Psychiatry, reeling under an ever-increasing barrage of criticism, has taken nothing on board with regards to its spurious concepts and its destructive treatments.  Instead, it has hired a PR firm to polish up its image, and is actively cultivating the media and the politicians, with a view to embedding its concepts and practices more deeply into the legal and social fabric of our society.  It is also exploiting shamelessly the public concern about the mass murders to promote its own expansionist agenda, indifferent to the stigmatizing effect that this will have on millions of innocent, socially isolated teenagers..

A great deal of their present effort is directed at two main themes:  integration of psychiatry with primary care (a mental health worker in every GP’s office), and early intervention.  Watch out for media infomercials on these topics in your local newspapers, and for bills on these topics in your statehouses.  And please speak out.  Early intervention is just a catch-phrase to sell more drugs to children and to destroy more lives.

. . . . . . . . . . . . . . . 

DISCLAIMER

In critiquing a paper like Tsuji et al., it is difficult to avoid using psychiatry’s terminology.  My use of the terms “schizophrenia,” “schizoid personality disorder”, “schizophrenia spectrum disorders,” etc. should not be taken to imply any endorsement on my part of the validity of these concepts.  On the contrary, the central theme of this website is that these terms have no ontological or explanatory significance, and are nothing more than loosely defined labels which psychiatry uses and promotes to legitimize the prescription of psychiatric drugs.

Social Services and Psychiatry

The controversy surrounding Justina Pelletier and her family has expanded its scope in recent months, and has now become a general public scrutiny of Massachusetts’s Department of Children and Families.

On April 29, State Governor Deval Patrick gave a press conference in which he announced the resignation of DCF Commissioner Olga Roche.

I think there’s a very real risk of confusing some issues here.  The sad fact is that, despite the enormous strides we have made as a society, there are still a great many children who are abused and neglected.  Every state in the US has a social services department, one of whose statutory responsibilities is to investigate reports of abuse and/or neglect.  The case workers who conduct the investigations are required to follow set procedures.  Often they find that the allegation is unfounded, and the investigation is terminated.  When they do find probable cause, they are required by law to present their findings to a judge, who scrutinizes the evidence in accordance with the normal judicial procedures.  The social services department, the parents, and the child are usually represented by attorneys.

A wide range of options is available to the court, from outright termination of parental rights to outright dismissal of the case. Both of these extremes are rare.  The usual outcome is some kind of remediation program, whereby the parents are encouraged and coached in childcare matters.  Sometimes the children are placed in foster homes pending resolution of issues in the home.   If the home issues aren’t resolved, the foster care placement can be lengthy.

The system isn’t perfect.  Mistakes get made, and sometimes the mistakes are serious. I have no way of knowing if the Massachusetts Department of Children and Families was more error-prone than social service departments in other states. Obviously the commissioner Olga Roche has to take responsibility.  But whether she was personally derelict in her duties or was just the designated fall-gal, I don’t know.

But this I do know: the spotlight has been taken off psychiatry.

The central issue in Justina’s case was, and is, the “diagnosis” of somatic symptom disorder and the allegation of medical child abuse.  And there’s a danger of losing sight of that when a departmental commissioner gets tossed to the wolves and the state governor says

“DCF has one of the toughest assignments imaginable. Every single day they’re called upon to intervene and make difficult decisions…And most of the time, DCF gets it right.”  (Quoted from a Metro article by Morgan Rousseau).

Most of the time, DCF does get it right.  Most of the time they’re dealing with allegations of blatant abuse and neglect; children being raised in unsanitary and unsafe conditions; children being sexually abused and even prostituted; etc… Social services case workers investigate these complaints on behalf of society.  They are bound by strict procedures, and when they go to court they are subject to cross-examination, and their findings are subject to official and legal scrutiny.

The issues are never simple, but the critical questions are usually clear and understandable.  If a child has a broken bone, X-ray reports are introduced into evidence, and the radiologist is subject to cross-examination.  If there are allegations of an unsafe home environment, photographs are produced.  If there are live electric wires protruding from wall sockets, everybody in the courtroom can see the pictures, and everybody knows the potential danger if there are toddlers in the home.  And so on.

But all of this changes in a case of “somatic symptom disorder” and alleged medical child abuse.  In these cases the issues, the “realities,” consist entirely of psychiatric opinion.  When a psychiatrist states on the witness stand that the child “has somatic symptom disorder,” the impression is conveyed that this is a real illness with the same kind of verifiable reality as asthma or diabetes or kidney failure.  So there’s a very strong tendency for the lawyers, and even the judge, to afford the same kind of respect to a psychiatrist’s statement as they would to a report from a radiologist or other genuine medical specialist.

What’s not routinely recognized is that the psychiatric “diagnosis” is nothing more than the psychiatrist’s opinion.  In the case of Justina, the “diagnosis” was somatic symptom disorder, which simply means that Justina in the opinion of a psychiatrist, was inordinately preoccupied with her medical condition.

I have worked with a great many sick people over the years, and have struggled with chronic medical problems myself, and frankly, I can’t even imagine how one could assess whether a person’s concerns in these areas were excessive or inordinate.  And this is especially the case in that, since DMS-5, the “diagnosis” of somatic symptom disorder can be assigned even in cases where the person actually has a real illness!

And the allegation of medical child abuse simply means that, again in the opinion of a psychiatrist, Justina’s parents had been foisting on her the notion that she was sick, and had pressured various surgeons and other specialists  to subject their child to extreme and invasive medical procedures.

Here we have no photographs of exposed electric wires; no reports of young children being left home alone; no evidence of malnutrition or emaciation; no medical evidence of young children having been sexually abused; no X-ray reports of broken bones; etc… Only the opinions and the invented “diagnoses” of psychiatrists!

When Governor Patrick stated that DCF usually get things right, he made no distinction between the kinds of abuse/neglect that social services departments traditionally investigate and the inherently vague psychiatric “abuse” of which Justina’s parents stand accused.

It was perhaps inevitable that media coverage of Justina’s case would expand into a general criticism of DCF and the commissioner.  Criticism of that sort is healthy, and is one of the cornerstones of democracy.  But what’s noteworthy at present is that we’re seeing very little coverage of psychiatry or of the role that the psychiatric “diagnosis” played in this matter.  This is critical, because without the “diagnosis” of somatic symptom disorder and the subsequent allegation of medical child abuse, none of what’s happened to Justina and her parents could even have gotten off the ground.

Psychiatry captured Justina with one of their spurious labels, confident, presumably, that the parents would cave and play along.  But the parents rebelled, and the psychiatric sham was exposed for what it is.  Psychiatry, as usual, had no rational defense, so instead they side-stepped the issues, and the spotlight has moved elsewhere.

And let’s not forget that psychiatry’s leaders are being schooled by Porter Novelli, a major PR firm, in how to interact with the media.