Tag Archives: over-medicalization of everyday life

Are ‘Psychiatric Disorders’ Brain Diseases?

Steven Reidbord MD is a board-certified psychiatrist who practices in San Francisco.  He writes a blog called Reidbord’s Reflections.  On December 12, 2015, he posted an article titled Are psychiatric disorders brain diseases?  It’s an interesting and thought-provoking piece, with many twists and turns.

Here are some quotes, interspersed with my comments and reflections.

“Of the conditions deemed inherently psychiatric, some seem rooted in biological brain dysfunction.  Schizophrenia, autism, bipolar disorder, and severe forms of obsessive compulsive disorder and melancholic depression are often cited.  It’s important to note that their apparently biological nature derives from natural history and clinical presentation, not from diagnostic tests, and not because we know their root causes.  Schizophrenia, for example, runs in families, usually appears at a characteristic age, severely affects a diverse array of mental functions, looks very similar across cultures, and brings with it reliable if non-specific neuroanatomical changes.  Even though schizophrenia cannot be diagnosed under the microscope or on brain imaging, it is plausible that a biological mechanism eventually will be found.  (The same type of reasoning applied to AIDS before the discovery of HIV, and to many other medical diseases.)  A similar argument can be made for other putatively biological psychiatric disorders.”

This is a complex paragraph.  Dr. Reidbord names five psychiatric “diagnoses” and expresses the belief that they seem “rooted in biological brain dysfunction”.  He stresses that their apparently biological nature derives from their appearance (natural history and clinical presentation), and not from diagnostic tests or a knowledge of any pathology involved.

As an example of this, he states that “schizophrenia”

  • runs in families
  • usually appears at a characteristic age
  • severely affects a diverse array of mental functions
  • looks very similar across cultures, and
  • is associated with reliable, though non-specific, neuroanatomical changes

And, it has to be acknowledged, that, at first look, these five factors, if present, might constitute grounds to suspect brain dysfunction. But let’s take a closer look.

RUNS IN FAMILIES

A “diagnosis of schizophrenia” is based on the presence of two or more of the following:

  1. delusions
  2. hallucinations
  3. disorganized speech
  4. disorganized behavior
  5. apathy or avolition

It seems obvious to me that each of these behaviors (or lack of behaviors, in number 5) can be passed on from generation to generation through normal social learning, without any assumption of a genetically-mediated pathology.  If I, for instance, believe that airplane contrails contain toxic substances that are being spread by the government as part of a sinister plan to render the citizens docile and debilitated, and if I had communicated these concerns to my children during their formative years, there is a good chance that one or more of them would have accepted these assertions at face value, and might even pass them along to their children in turn.

Similarly if my growing children had witnessed me responding to stimuli that were clearly internal rather than external, or speaking in a markedly disorganized way, there would be, I think a reasonable expectation that one or more of them might also acquire these habits through social learning.

And so on for the other three “symptoms”.  There is no need to assume genetic transmission in these behaviors.  Indeed, an assumption of genetic transmission of any behavior is always doubtful.  Genes transmit biological structure.  Structure has an impact on behavior, obviously, but there are always multiple intervening factors.

APPEARS AT A CHARACTERISTIC AGE

I have addressed this issue at some length in earlier posts (here, here, and here).  But for the present purposes, it is perhaps sufficient to note that the “characteristic age” for the “onset of schizophrenia” is during the transition from late adolescence to adulthood (i.e. about 17 to 25).  For a majority of the population, this is probably the most difficult period of life, especially because it comes at a time when we are particularly inexperienced in dealing with complex challenges.   It is a period during which many people experience a good deal of failure, disappointment, embarrassment, and discouragement.  All of which can push an individual towards a negative perspective, and in severe cases to a state of belief that would qualify as “delusional”, without any assumption of a “biological brain dysfunction”.

DIVERSE ARRAY OF MENTAL FUNCTIONS

These are not so diverse really.  The APA criteria essentially identify:  false/mistaken beliefs; responding to internal stimuli; lack of organization in speech and behavior; and apathy/joylessness.  But only two of these need to be present in any given individual.

LOOKS SIMILAR ACROSS CULTURES

This issue has become almost impossible to address in any methodical way, because western influences (including the influence of the DSM) have reached virtually every corner of the globe.  The DSM has become the distorting lens through which all problematic behavior is viewed and assessed, and there are enormous formal and informal incentives for psychiatrists everywhere to find “diagnoses”.

But in 1963, these influences were considerably weaker and less widespread.  In that year, Henry Murphy, MD, et al sent questionnaires about “schizophrenia symptoms” to psychiatric centers in various parts of the world, and received responses from 27 countries.  Here’s how they summarized their results:

“The main significance of our findings at this stage is that doubt has been thrown on the picture which Euro-American psychiatry has built up of the schizophrenic process.  For instance, considering the high percentages of the simplex and catatonic sub-types of schizophrenia reported for certain Asian samples (in some instances our respondents kindly sent actual figures) and the low percentages of the paranoid sub-type, it might be questioned whether the delusional systems which are the most familiar feature of chronic schizophrenia in Euro-American hospitals are an essential part of the disease process.  Might they not be culturally conditioned attempts by the personality to ‘make sense’ of that process, attempts which Eastern cultures inspire to a much lesser degree?” (pp. 248-249 Murphy HBM et al, A cross-cultural survey of schizophrenic symptomatology, International Journal of Social Psychiatry, 1963, 9: 237-249)

Dr. Murphy et al are obviously committed to the disease concept, but their finding of such cultural diversity casts doubt on the universality of “schizophrenia”.

And in 1973, E. Fuller Torrey, MD, prior to his conversion to biological reductionism, reviewed the evidence on the universality of schizophrenia, and summarized the matter:

“In fact, however, there is no evidence upon which to base a belief in the universality of schizophrenia.  The studies which have been used to support this belief are found, on careful examination, not necessarily to point in this direction at all.  If anything, they may lead to the opposite conclusions:  Schizophrenia may not be a universal disorder.” (p. 53 Is schizophrenia universal? An open question, Schizophrenia Bulletin, 1973, 7: 53-59)

and

“‘Once an idea becomes part of a textbook, it develops a life of its own and is seldom questioned.  This is what has occurred with the idea that schizophrenia is universal.'” (ibid, p 56)

and

“Finally, within the past few years some preliminary data on schizophrenia in New Guinea have become available. Burton-Bradley, a psychiatrist who has been there for a decade and a half, reported 343 cases of schizophrenia among the first 1,000 cases of mental disease which he examined. Virtually every one of the cases, however, occurred among individuals who had been living in the larger towns (‘the person of limited cultural contact, the so-called bush individual, very rarely presents with the symptoms of schizophrenia [Burton-Bradley 1969]’) or who had just migrated from rural areas to the towns (‘Not uncommon is the acute schizophrenia of sudden onset coming on usually within three months of  the patient’s leaving the village and working for the first time in a large town. Such patients readily recover and are returned to their village, at which level they can function without disturbance [Burton-Bradley 1963]’)” (ibid p 57.  The Burton-Bradley reference is:  Burton-Bradley, B.G. Culture and mental disorder.  Medical Journal of Australia, 15:539-540, 1963)

So, the fact that “schizophrenia” looks similar across cultures is more likely to reflect an artifact of cultural colonialism than any intrinsic property of the so-called illness.  And this is not merely a matter of psychiatrists seeing what they expect to see.  Once the “diagnosis” has been made, psychiatrists and other mental health workers actually begin a process that consists essentially of training the individual in how to “be schizophrenic”.  This process entails “educating” the client on the “symptoms and course of the illness”, and encouraging him to self-identify with the label.

NEUROANATOMICAL CHANGES

Dr. Reidbord doesn’t specify which changes he has in mind.  The main change of this nature that comes to my mind is brain shrinkage, but I think that there is broad consensus at present that this is more a function of extended use of neuroleptic drugs than any putative underlying disease process.

. . . . . . . . . . . . . . . . 

ANALOGY TO AIDS AND HIV

The analogy to AIDS prior to the discovery of HIV is unconvincing.  All the “symptoms” of the various psychiatric disorders that Dr. Reidbord mentions are behaviors, feelings, or thoughts.  And for each, there are plausible and eminently credible explanations from psychology, sociology, and indeed from ordinary experience and common sense.  But the symptoms of AIDS are clearly indicative of biological dysfunction. These symptoms include:

  • Fever
  • Chills
  • Rash
  • Night sweats
  • Muscle aches
  • Sore throat
  • Fatigue
  • Swollen lymph nodes
  • Mouth ulcers

It would be quite a stretch to conceptualize this cluster of symptoms as anything other than a biological malfunction.  But it is entirely plausible to think of “schizophrenia” in this way.  And indeed, Dr. Reidbord himself is restrained in his conclusion:

“Even though schizophrenia cannot be diagnosed under the microscope or on brain imaging, it is plausible that a biological mechanism eventually will be found.  ” [Emphasis added]

In my view, it is considerably more plausible that such a biological mechanism will not be found. This is particularly the case in that more than a hundred years of highly-motivated and generously funded searching for this “holy grail” of psychiatry has to date found nothing.

. . . . . . . . . . . . . . . . 

But all of this, important as it is, is not the main point of Dr. Reidbord’s paper.  Let’s go on.

“Lately, however, some big names in psychiatry have taken a more ideological stance, declaring that psychiatric disorders in general are brain diseases — right now, no further proof needed.  Dr. Charles Nemeroff, widely published professor and chairman of psychiatry at the University of Miami Miller School of Medicine, writes:

In the past two decades, we have learned much about the causes of depression. We now know from brain imaging studies that depression, like Parkinson’s disease and stroke, is a brain disease.

Dr. Thomas Insel, recent director of the National Institute of Mental Health (NIMH) wrote:

Mental disorders are biological disorders involving brain circuits…

Psychiatrist and Nobel laureate Dr. Eric Kandel says:

All mental processes are brain processes, and therefore all disorders of mental functioning are biological diseases.

These claims by prominent psychiatrists agitate critics.  No biomarker for any psychiatric disorder has yet been identified. Genetic vulnerabilities have been discovered, but nothing resembling a smoking gun.  Functional brain imaging reveals biological correlates of mental impairment, not etiology, and no such imaging can diagnose a specific psychiatric condition.  Our best account for most mental disorders remains a complex interaction of innate vulnerability and environmental stress, the ‘diathesis-stress model’.  These psychiatric leaders know the research as well as anyone. How can they call psychiatric disorders brain diseases without scientific proof?”

At this point, readers might be thinking that, despite his earlier comments on biological brain dysfunction, Dr. Reidbord is arguing on our side of the debate.  But wait!  The argument progresses.

“The brain mediates all mental activity, normal or not.  Consequently, any psychiatric intervention — or influential life experience — acts upon the brain.  This is not a new discovery.”

 “It is a philosophical position, monism as opposed to Cartesian dualism, not a scientific finding.”

 “Psychiatric ‘brain disease’ is neither an exaggeration nor a lie.  It does not require scientific proof — and brain imaging has neither strengthened nor weakened the case.  For as long as one is not a philosophical dualist, it is surely true.  In theory, all psychology can be reduced to electrochemical events in brain cells. All psychopathology can be reduced to aberrant electrochemical events, i.e., brain disease.”

Dr. Reidbord is entirely correct in stating that the brain mediates all mental activity.  It also mediates all physical activity.  I cannot lift a finger, shed a tear, recall my mother’s face, hum a tune, feel sad, or even absent-mindedly scratch my ear, without the corresponding neural activity occurring within my brain, and eliciting the thought, feeling, or action in question.

Dr. Reidbord is also correct in stating that, in theory, all psychology can be reduced to electrochemical events within and between brain cells.  In theory, a super-neurologist could identify exactly what happens in a child’s brain when the child learns that two plus two is four; or what happens in a person’s brain when he/she becomes depressed or happy or plays the piano, etc… But the key phrase here is: “in theory”.  This is because, firstly, the complexity and miniaturization of the brain’s circuitry probably precludes the possibility that this kind of detailed super-analysis will ever be feasible. Secondly, and more importantly, a detailed micro-analysis of an event can never capture the kind of qualitative factors that emerge from a macro-analysis.

Take, for instance, the action of a five-year-old boy kicking his teacher in the shin.  Let us pose the question:  Why did he do that?

Our super-neurologist – in theory – could give us a complete account of the entire neurochemical sequence, from the activation of the first sensory neuron to the activation of the last muscle fiber.  In theory, this account, which would run to millions (perhaps billions) of words, would, if accurate, constitute a complete and accurate answer to the question posed above.

A psychological assessment of the incident, however, might conclude that the boy had been raised in a violent home, had never been trained in effective anger control, routinely reacted violently when confronted or given instructions, and that the teacher had told him to stop running around the classroom and to sit down. So he had kicked her.

A sociological perspective might note that the frequency of such attacks in classrooms was increasing generally, and might note associations between this kind of violence and parental conflict, unemployment, cultural background, etc.

The critical point here is that although each account is describing the same incident, there are qualitative differences between them that are critically important.  The neurological account, no matter how complete and thorough it is, could never capture the uniquely human dimensions of the interaction, any more than the psychological account could capture the extraordinary complexity of human biology.  The issue here is not which account is correct, but rather which account is more suited for a given purpose.  If the purpose is to understand human biology, then the neurological account is more helpful.  But if the purpose is to understand the child’s actions and develop corrective measures, then the psychological account is clearly the preferred approach.

And this, of course, takes us straight to the heart of the psychiatric hoax:  that all significant problems of thinking, feeling, and/or behaving constitute brain diseases and are best ameliorated by modulating neurological activity.

Which in turn takes us to Dr. Reidbord’s conclusion in the above quote:

“All psychopathology can be reduced to aberrant electrochemical events, i.e., brain disease.”

And unlike his earlier premises, this conclusion is false.

The best way to illustrate this fallacy is with some examples, but first let’s clarify the language.  “Psychopathology” is a complex term, subject to diverse interpretation.  So rather than try to define this term, let’s use the APA’s Diagnostic and Statistical Manual as a starting point, and accept, for discussion’s sake, that any “diagnosis” or “symptom” listed in the manual constitutes “psychopathology”.

Childhood temper tantrums, for instance, are listed in the DSM as “symptoms” of oppositional defiant disorder, disruptive mood dysregulation disorder, and intermittent explosive disorder.  Therefore, according to Dr. Reidbord, temper tantrums of the severity and frequency specified for these “diagnoses”, “can be reduced” to aberrant electrochemical events.  The phrase “can be reduced to” in this context clearly means “can be conceptualized as”, or “are caused by”.  And the phrase:  “Aberrant electrochemical events, i.e. brain disease”, clearly means:  a malfunction in neurological equipment.

But in fact, a child can acquire the habit of throwing temper tantrums without any neurological malfunction.  Generally speaking, there are two principal ways in which a child can acquire this, and other, habits: learning from results; and learning from imitation/coaching.

LEARNING FROM RESULTS

If a child throws a temper tantrum, and the tantrum produces a positive result (e.g. a parent yielding to his demands), then, other things being equal, there is an increased probability that temper tantrums will become habitual, especially if they continue to produce the same kind of outcome.  This is not a function of aberrant electrochemical events in the brain cells.  In fact, it is exactly the opposite:  a perfect example of the normal human learning apparatus operating flawlessly.  It is not an example of something going wrong in the brain, rather it is an example of something going right.  We humans learn from the results of our actions, an obvious fact that has been verified experimentally countless times, and in addition accords perfectly with common sense and general observation.  And we acquire functional, productive habits in exactly the same way and by means of the same cognitive apparatus as counter-productive and problematic habits.  Acquiring the temper tantrum habit is particularly easy, in that babies are born with an anger apparatus which needs little encouragement to express itself in rage and aggression.  In fact, the opposite is the case:  teaching anger control is the challenge.

LEARNING BY IMITATION/COACHING

Imitation is another major component of our normal learning apparatus.  The child acquires skills and habits through imitating, at first his parents and siblings, and later individuals outside the home.

It is self-evident that through imitation and coaching a child can acquire habits that are useful and helpful; but it is equally obvious that he can also acquire habits that are destructive and counter-productive.  Through imitation a child can, for instance, learn to fear objects that are dangerous, but through precisely the same mechanism, he can learn to fear harmless objects such as spiders, closed-in spaces, open spaces, cats, hypodermic needles, air travel, dogs, heights, elevators, social gatherings, etc… All of these fears are “psychopathological” in the sense specified above, but all can be acquired, through imitation, by a person with a perfectly normal-functioning brain, provided the fear in question is being modeled by a significant person in the child’s life.  It is fallacious to assume brain pathology based solely on the fact that the acquired behaviors/feelings are counter-productive or distressful.

Similar observations can be made with regards to every “symptom” listed in the DSM.  Habits of paranoid speech, incessant speech, over-eating, self-deprecating speech, grandiose speech, rule-breaking, cruelty, violence, stealing, suicidal threats, suicidal gestures, apathy, etc., can all be acquired by a person with a normally-functioning learning apparatus, either through learning from results or learning by imitation, or both.  In the absence of specifically identified and credibly causative brain pathology, this is the most reasonable and parsimonious way to conceptualize the acquisition of these kinds of habits.

In his ground-breaking monograph, “The Jack-Roller” (1930), Clifford Shaw provides graphic, first person accounts of how a child can acquire the habit of stealing in this way.  For example:

“On the trips with William, I found him to be a rather chummy companion.  I regarded him, not as a brother, but rather as a boy friend from another home.  He was five years my senior.  He sort of showed it in his obvious superiority.  But I didn’t seem to notice that fault.  He was a ‘mamma’s boy’ at home, but oh, Lord, how he changed on our trips!  He taught me how to be mischievous; how to cheat the rag peddler when he weighed up our rags.  He would distract the peddler’s attention while I would steal a bag of rags off the wagon.  We would sell the rags back to the victimized peddler.  He also took me to the five and ten cent store on Forty-seventh Street, and would direct me to steal from the counter while he waited at the door.  I usually was successful, as I was little and inconspicuous.  How I loved to do these things!  They thrilled me.  I learned to smile and to laugh again.  It was an honor, I thought, to do such things with William. Was he not the leader and I his brother?  Did I not look up to him?  I was ready to do anything William said, not because of fear, but because he was my companion.  We were always together, and between us sprang up a natural understanding, so to speak.

One day my stepmother told William to take me to the railroad yard to break into box-cars.  William always led the way and made the plans.  He would open the cars, and I would crawl in and hand out the merchandise.  In the cars were foodstuffs, exactly the things my stepmother wanted.  We filled our cart, which we had made for this purpose, and proceeded toward home.  After we arrived home with our ill-gotten goods, my stepmother would meet us and pat me on the back and say that I was a good boy and that I would be rewarded”

And stealing is psychopathology:  a “symptom” of “conduct disorder”, “kleptomania”, and “antisocial personality disorder”, but I suggest it is clear that there is nothing wrong with the narrator’s neuro-cognitive apparatus.  He isn’t learning the behaviors approved by the dominant culture.  But he is learning the rules of the smaller group to which he belongs and feels connected.

The habits of thinking, feeling, and behaving mentioned above make perfect sense when viewed from the individual’s perspective, but appear counter-productive and dysfunctional from the perspective of so-called “normality”.  But within the context of psychiatry’s intractable commitment to the medical model, the search for a “diagnosis” precludes any search for meaning or sense in the “patient’s symptoms”.  For psychiatry, the “patient” is “sick”.  His brain is assumed, without evidence, to be broken.  There is no meaning or sense to his “symptoms”.  And in this way, psychiatry has locked itself in a cocoon of comforting but destructive and condescending certainty, which they show no inclination to leave.

. . . . . . . . . . . . . . . . 

At this point, Dr. Reidbord’s paper takes another interesting twist:

“Without elucidating the causative mechanisms, however, this reductionism amounts to little more than political rhetoric.  Calling psychiatric disorders brain diseases serves no clinical or research purpose, it only serves political ends: bringing psychiatry into the fold as a ‘real’ medical specialty, impressing Congress and other funding sources, perhaps allaying stigma.  As a tactic it smacks of insecurity and self-aggrandizement, wholly unbefitting a serious medical specialty.”

To which I would certainly agree, adding only that the reductionism also constitutes an invalid inference, as outlined above.

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

“Freud’s psychoanalysis acts on brain cells, and ultimately alters chemical bonds in those brain cells.  We could rename psychoanalysis and psychotherapy ‘verbal neuromodulation.’  But to what end?  A reductionistic account of this sort, festooned with pseudoscientific verbiage, has no practical significance.

Brain research is a young field.  It should be vigorously pursued for what will surely be learned.  If history is any guide, many conditions currently considered psychiatric will eventually be explained biologically — and ironically, they will no longer be psychiatric conditions, as was the case with Huntington’s disease, brain tumors, lead poisoning, and many other diseases that now belong to other medical specialties.

Stumping for psychiatry as clinical neurobiology will be justified when basic research in this area affects clinical practice. Until then, ‘brain disease’ is only a philosophical technicality, a spin, to give our clinical work and the institution of psychiatry an air of scientific credibility.  Particularly in light of how diseases leave psychiatry once they are well understood, the field should embrace uncertainty, not preempt it with the premature use of brain disease language.”

So what we’ve got here is an interesting and curious mix of very commendable honesty and professional self-interest coupled with the oft-heard psychiatric assertion that sometime in the future the brain pathologies will be discovered.  In the meantime, Dr. Reidbord contends that promoting clinical neurobiology is not justified, and will not be justified until basic research affects clinical practice.

But, in my view, Dr. Reidbord misses the essential point:  that the “real-illness-just-like-diabetes” assertion has been, and continues to be, widely and avidly promoted by psychiatry, and that clinical practice is already based almost entirely on the false contention that all problems of thinking, feeling, and/or behaving are best conceptualized as neurological illnesses.  It is extremely rare to encounter, or even hear about, a psychiatrist who offers any kind of “treatment” other than drugs or high voltage electric shocks to the brain.  On his website, Dr. Reidbord tells us that his clinical practice “skews towards dynamic psychotherapy” and that he has “a healthy skepticism of commercial influences on medical practice.”  Again, this is commendable but rare.

Dr. Reidbord downplays the practical significance of the “aberrant electrochemical events” falsehood by calling it a philosophical position rather than a scientific finding.  But from either perspective, it is problematic.  From the former it is fallacious (as shown earlier); from the latter it is non-existent (such research does not exist).  Nevertheless, it is widely promoted within psychiatric circles, and is routinely used to medicalize non-medical problems, and to legitimize the use of dangerous drugs to “treat” an ever-increasing range of human problems.

. . . . . . . . . . . . . . . . 

And, incidentally, in another interesting twist in the paper, Dr. Reidbord actually seems to be saying something very similar to this:

“Freud could then have made it a point to declare, as Drs. Insel and Kandel do now, that all mental disorders are biological diseases.  No additional science was required even a century ago.

He didn’t because there was nothing to gain.  The best treatments at the time were psychological, not biological.  There was no grant money at stake, no research agenda to support.  The status and livelihood of early psychoanalysts did not depend on their treatment being biological.”

In other words, if I’m understanding Dr. Reidbord correctly, psychiatry is positing the brain disease concept today because it is good for business.  And in this, of course, he is absolutely correct.  But, ironically, by asserting the falsehood that “all psychopathology can be reduced to aberrant electrochemical events, i.e. brain disease” Dr. Reidbord is himself contributing to, and legitimizing, the hoax.

 

Antidepressants:  Drugs, Not Medication

On April 7, John Read, PhD, a psychologist at Swinburne University of Technology in Melbourne, published a short article on Mad in America.  The title is:  Largest Survey of Antidepressants Finds High Rates of Adverse Emotional and Interpersonal Effects.  The article presents the results of a survey conducted in New Zealand and published online in February, 2014 in Psychiatry Research.  The survey involved 1,827 individuals who were taking antidepressants.  Dr. Read is widely published.  

Here are some quotes from the MIA article:

“Eight of the 20 adverse effects studied were reported by over half the participants; most frequently Sexual Difficulties (62%) and Feeling Emotionally Numb (60%).”

Note that more than half (60%) of respondents reported feeling “emotionally numb” as a result of taking antidepressants.  In a clinical trial, these people would probably be counted as treatment successes!

“Percentages for other effects included: Feeling Not Like Myself – 52%, Agitation 47%, Reduction In Positive Feelings – 42%, Caring Less About Others – 39%, Suicidality – 39%, and Feeling Aggressive – 28%.   If one had to imagine a combination of feelings most likely to increase the chances of a tragedy involving the loss of multiple lives it would be hard to do better than emotional numbing, agitation, aggression, suicidality and caring less about others.”

“It is worth mentioning that even a group of people who had accepted a biological treatment for their difficulties and had (mostly) found it helpful, did not unquestioningly swallow the ‘chemical imbalance’ theory of depression (and everything else) espoused by biological psychiatry and the drug industry.  The most strongly endorsed causes were:  Family stress (90.8% ‘agreed’ or ‘strongly agreed’), Relationship problems (89.9%), Loss of loved one (87.5%), Financial problems (86.9%), Isolation (86.3%),  and Abuse or neglect in childhood (85.4%), with Chemical imbalance (84.8%) coming in 7th, Heredity 12th, and Disorder of the brain 13th.”

“Finally, we gave participants ten possible reasons that prescription rates of antidepressants are so high (in 2013 the number of prescriptions in England – 53 million – surpassed the total population – 52.6 million). Among the more commonly endorsed  explanations were:  ‘Drug companies have successfully marketed their drugs’ (61%), ‘Drug companies have successfully promoted a medical illness view of depression’ (57%),  ‘GPs don’t have enough time to talk with patients’ (59%), and ‘Other types of treatments are not funded or are too expensive’ (56%). The least endorsed explanation for high prescribing rates was ‘Anti-depressants are the best treatment‘ (20%).”

 . . . . . . . . . . . . . . . .

The reality is that depression is not an illness, and antidepressants are not medication.  They are drugs that provide a transient feeling of well-being, or at least a feeling of numbness or “something different”.  They in no way address the root causes of depression, which are what they always have been:  the sad things that happen to us in our lives and/or a joyless, unfulfilling, treadmill-type of existence.

And it has long been my contention that in their “hearts”, both the psychiatrists and the recipients of these drugs know this.  The psychiatrists know that they are drug pushers, and the “patients” know that what they are getting is “a fix.”  And so the dance goes on.  The psychiatrists continue the pretense that they are real doctors; the “patients” settle for the fix; the APA invents the diagnoses; the psychopharma business booms; and the damage accumulates.

Psychiatry is not something good that needs some minor corrections.  Rather, it is something so fundamentally flawed and rotten as to be beyond redemption or compromise.  The blatant falsehood, that depression is an illness, has not only destroyed individuals, but eats at our personal and cultural resilience like a cancer.  It is time to put this lie to rest.  Please, if you’re not already doing so, speak out against this insult to human integrity and decency.

Polarization or Compromise

On February 2, Robert Whitaker published an article on Mad in America.  The title is Disability and Mood Disorders in the Age of Prozac.  The article echoes and updates one of the themes of his 2010 book “Anatomy of an Epidemic”:  that the steady increase in the numbers of people receiving disability benefits for depression and mania is driven largely by the corresponding increase in the use of antidepressant drugs.

Robert provides some up-to-date statistics from the US Department of Social Security, and his paper is cogent and compelling.  He ends on a sad but realistic note:

“And so the disability numbers march on.”

This general issue has received a good deal of attention in the literature, but for those not familiar with the matter, there are two essential factors.  Firstly, there is the well-established fact that some people who take antidepressants become floridly manic, which in many cases leads to a diagnosis of bipolar disorder, and a subsequent disability award.  Secondly, a great many people who take antidepressants for an extended period develop a kind of drug-induced anhedonia, and a correspondingly increased rate of being adjudged disabled.

Robert’s post generated about 120 comments, the majority of which were positive, but a few days later (February 14), Timothy Kelly put up a post, also on Mad in America, challenging the validity and/or appropriateness of Robert’s article.  Tim’s paper is titled Robert Whitaker Missed the Mark on Drugs and Disability: A Call for a Focus on Structural Violence.

Here are some quotes from Tim’s article, intermingled with my thoughts and comments:

“There’s no doubt that his writing has opened up important discussions about psychiatric medications. At the same time, my own lived experience — and reading of the literature — have led me to different conclusions on core aspects of these issues, including the putatively causal role of medication in increasing disability.
In what follows, I chart an alternative perspective on psychosocial disability that calls for the decentering of psychiatric drugs in both public discourse and advocacy. Concretely, I suggest refocusing reform efforts along two axes:
1.  The identification of areas where interests and perspectives align among advocacy groups that may otherwise strongly disagree about the role of psychiatric treatment in recovery.
2.  The intersections of psychosocial disability and poverty, the criminal justice system, and broader socioeconomic and health disparities, particularly among marginalized racial/ethnic/indigenous and/or sociopolitical minority communities.”

So essentially, what Tim is saying is that we should spend less time and energy on contentious issues like the “role of psychiatric treatment in recovery”, and focus instead on areas where we can find agreement, and on the role of poverty and injustice in the genesis of counterproductive thoughts, feelings, and/or behavior.

On the face of it, this seems a reasonable stance – put aside our differences, and pool our resources – but as is often the case, there are problems in the details.  Tim encourages us to refocus our “reform efforts” through collaboration, but what will these reform efforts look like, if the parties concerned are fundamentally divided on the validity/usefulness of psychiatric care.

The kind of compromise and accommodation that Tim advocates can only succeed if in fact there is more agreement than disagreement between the various parties, or if the areas of contention are a relatively minor part of the whole.  Neither of these conditions is true in the present context.  Psychiatry, with its spurious diseases and toxic treatments, is the proverbial elephant in the living room of the present debate.  Those who support psychiatry and those who oppose it might be able to agree on what to order for lunch, but not, I suggest, on much else.  The pretense that we can find common ground and “work with” psychiatrists has been the great error of the past fifty years, during which psychiatry, with the help of its pharma allies, has consolidated its turf, and successfully marginalized and ridiculed all opposing viewpoints.

Psychiatry’s fundamental tenet, embodied unambiguously in all editions of the DSM since DSM-III, is that every significant problem of thinking, feeling, and/or behaving is an illness, that can only be addressed successfully through medical intervention – specifically drugs and electric shocks to the brain.

Psychiatry has expended, and continues to expend, enormous sums of, mostly pharma, money in their attempts to establish the validity of this spurious tenet.  So far, all of these efforts have been in vain, and it is extremely unlikely that the core tenet will ever be validated.  Nevertheless, psychiatrists, at both leadership and rank and file levels, continue to promote this self-serving and deceptive notion with undiminished ardor and enthusiasm.

Nor is the matter academic.  Psychiatry’s application of its core tenet is damaging and destructive.  Firstly, and perhaps most profoundly, persuading people that they have a disabling illness, when in fact they don’t, is inherently disempowering, and encourages people to think of themselves as incapable of living a normal life.  Secondly, all psychiatric treatment disrupts normal brain functioning, and in many cases this disruption, especially when used for extended periods, causes permanent impairment.

The fact that psychiatric drugs produce a transient desired effect is irrelevant to the medicalization issue.  Crack cocaine produces a transient desired effect, but nobody is suggesting that street corner dealers are performing a medical function.  In fact, apart from the legality of their respective activities, there is no essential distinction between psychiatrists and street corner drug dealers.

. . . . . . . . . . . . . . . . . 

“In this discussion of disability I intentionally leave aside questions of whether the experiences classified in the DSM5 are most usefully characterized as medical problems, even if they have a biological basis. In my view, the ‘body’ and the ‘mind’ are mutually entangled, and so of course there are physiological processes involved in all human experiences, as well as considerable variability among bodies. The extent to which a biomedical approach is useful or resonant for any given person is contingent on the particularity of that person within their sociocultural surround.  How persons negotiate the meaning(s) of their (our) own experience in relation to different explanatory models is highly contextually specific.  For instance, using medication does not necessarily imply agreement with a biomedical model, just as the efficacy of yoga or mindfulness may be characterized in more biological, rather than spiritual terms depending on context. I’d like to see us shift our attention from debates about medications, loosening up polarizations that hamper our ability to work effectively on these issues, towards careful thinking and contextual grounding in fields such as mad studies, survivor research, medical anthropology, the medical humanities, and social and cultural psychiatry.”

This passage is not entirely clear, but in general what Tim seems to be saying is a variation of the old 60’s phrase:  “different strokes for different folks”.  Some people find it “useful or resonant” to conceptualize their problems as “illnesses” that call for “medication”; others don’t.  Either way it’s not that important, so let’s move on to other issues on which we can agree.

This kind of conceptual relativism is fine as far as it goes.  We have freedom of speech, so we certainly have freedom of thought.  But it is still the case that some conceptual frameworks are more valid and more accurate than others.  In the long run, comfort, or “resonance” bought at the expense of truth usually proves a bad bargain.

. . . . . . . . . . . . . . . . 

“That psychiatric diagnoses do not index discreet disease processes with clearly identified etiologies has also been acknowledged by leading proponents of otherwise mainstream psychiatric treatment like Thomas Insel (Director of the National Institute of Mental Health). This is also clearly inscribed in the DSM5 which acknowledges that current psychiatric categories do not map onto discrete disease processes with homogenous ‘biomarkers,’ that knowledge is therefore provisional, and the state of the science still limited.  In this post, I have therefore opted to sidestep issues that are already relatively well-accepted across academic and activist contexts (such as the scientific and philosophical limitations of psychiatry).”

Thomas Insel, MD, has indeed stated unambiguously that the various DSM entities (which, incidentally, Dr. Insel calls “labels“) do not correspond in any systematic fashion with specific neural pathologies.  With regards to DSM-5, Tim does not provide a page number, but I’m not aware of an acknowledgement in that text that “current psychiatric categories do not map onto discrete disease processes with homogenous ‘biomarkers’.”  But in any event, the matter is moot, because the contrary notion is still very much alive and well in psychiatric circles.  Most psychiatrists are still telling their clients that they have “chemical imbalances”, though some are moving with the times and substituting the equally nebulous and equally unproven “neural circuitry anomalies”, and are promoting the impression that the various DSM labels are indeed discrete disease entities with scientifically proven etiologies.  A great many psychiatric clients actually believe, erroneously, that a brain scan would show this pathology clearly and unambiguously.

So, Tim’s statement that he decided to sidestep these controversial topics because they’re “already relatively well-accepted” is, I suggest, premature.  He is, of course, free to sidestep them if he wishes, but, in so doing, he is working with a very limited canvas.  He is focusing on some, admittedly interesting, and important, trees at the edge of the woods, but has turned his back on the dark and forbidding forest.  And in particular, he has missed the fact that the forest is literally shading and starving those trees on which he pins so much hope.

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

Then Tim takes us into really deep waters:

“On the other hand, I am deeply concerned about the degree to which the dogmatic anti-psychiatry positions of some are being leveraged at the federal level in favor of The Helping Families in Mental Health Crisis Act. So, even while advocating an emphasis on structurally and socioculturaly informed perspectives and psychosocial approaches, I also feel a duty to make the following statement explicit:
My decades of experience living with ‘severe mental illness’ and disability myself, alongside a family member with even more intense disability, my years of formal academic study and research, critically reading the literature and engaging with a wide range of other persons with lived experiences all tell me there is no question that these experiences are both real and heterogeneous, and that medication is helpful for many people. The question is: for whom, for how long, and how best to weigh the benefits against the risks. My larger point in this post, however, is that there would be a lot more space to develop psychosocial approaches and address broader systemic issues if we decentered medication in these discussions, while also challenging those who would presume to speak for ‘us’ by characterizing our experiences as not real.”

My Merriam-Webster dictionary (2000) gives the following definition of the word “dogma”:

1  a.   something held as an established opinion; esp: a definite authoritative tenet
b.  a code of such tenets
c.  a point of view or tenet put forth as authoritative without adequate grounds
2. a doctrine or body of doctrines concerning faith or morals formally stated and authoritatively proclaimed by a church

Now I am very proud to describe myself as antipsychiatry.  I am unambiguously opposed to psychiatry because it is based on false and spurious premises, and is destructive, disempowering, and stigmatizing in its practices.  But I am emphatically not dogmatic.  In fact, one of my arguments against psychiatry is that its core principles are ultimately statements of belief, vigorously and authoritatively promoted, without any kind of supportive evidence.  And I have written on many occasions that all psychiatry has to do to silence me is produce evidence in support of their tenets, at which point I will fold my tent and enjoy my retirement.

In addition, I can’t think of a single antipsychiatry advocate whose pronouncements could even remotely be described as dogma, in any ordinary sense of the term.

But Tim is taking this rhetoric even further.  He tells us that the expression of these “dogmatic anti-psychiatry positions” is actually being used “at the federal level” to promote the infamous Tim Murphy (Helping Families in Mental Health Crisis) Bill.  I’m certainly not aware of any such dynamic.  In fact, my reading of recent events is that the Tim Murphy bill has been derailed largely because of the protests from the antipsychiatry faction.

With regards to his manifesto, obviously I respect Tim’s personal convictions, but there are some matters that, in my view, warrant clarification.  Firstly, I have never encountered or read any critic of psychiatry who adopted the position that clients’ experiences or distress weren’t real.  The issue for most of us is that the various labels catalogued in the DSM are not illnesses.  In this regard, those of us on this side of the debate recognize the reality of these problems far more clearly than psychiatrists who bundle them neatly into spurious “diagnostic categories” without ever taking the time to understand or appreciate their very real human significance.

The notion that we in the anti-psychiatry camp dismiss clients’ problems as “not real” is a common ploy that adherents of psychiatry often use to discredit us, and for this reason it is particularly disappointing that Tim would come at us with this particularly facile and groundless attack.

Secondly, Tim asserts that “…medication is helpful for many people.  The question is: for whom, for how long, and how best to weigh the benefits against the risks.”  This is also a fairly standard psychiatric formula, though in practice, the pills are dished out a good deal more liberally than the formula would suggest.  But the question that comes to my mind is:  how does Tim know that “medication” is helpful for many people?  What standards are being used to assess helpfulness, and where are the randomized controlled studies that provide the evidence?  The point of Robert’s original article was that the drugs are actually doing a great deal of harm in the long run, a contention that is receiving a good deal of support from research studies in recent years.

Tim tells us that he reached the conclusion quoted above from:

  • his own personal experience;
  • the experience of others;
  • years of formal academic research

Lived experience, obviously, is the bedrock of all our knowledge and skills, and our personal assessments and reactions are generally excellent guides with regards to the costs and benefits of various activities and substances.  But there are certain substances which, through their action on brain chemistry, routinely deceive us in this regard.  Alcohol, nicotine, heroin, cocaine, etc., all have in common that, through direct action on the brain, they induce a false sense of well-being, which often blinds the ingestor to their long-term toxic effects.  It is this accident of biology that underlies and drives the phenomenon that we call chemical addiction.

Most users of nicotine find the experience pleasant and rewarding.  Many also report that this substance improves their ability to study and concentrate.  Alcohol induces a sense of well-being and relaxation.  And so on.

Pharmaceutical antidepressants are specifically designed through their action on brain chemistry, to induce a transient and false sense of well-being.  And this sense of well-being also has the effect of blinding the user to their long-term toxicity and adverse effects.

The point here is that lived experience, valuable as it is in most matters, is generally a poor guide when it comes to evaluating the efficacy or helpfulness of brain-altering chemicals.

There are also problems with regards to “formal academic study and research.”  Most of this has been conducted by pharma-psychiatry, focuses on short-term outcomes, suppresses negative results, and is an unreliable guide to long-term effects.

Tim mentions the need “to weigh the benefits against the risks”, and this advice is attached to virtually every psychiatric drug in the PDR.  But in reality, it’s a hollow formula.  How can one weigh the benefits of a transient and false sense of well-being against the longer term risk of chronic, and more or less permanent, damage?  There is not, and never can be, any kind of calculus for making such comparisons.  And the issue is compounded by the fact that the risks vs. benefits question is usually presented as if the drug were the only option.  In fact, there are a great many ways to resolve feelings of depression that entail no particular risks at all – principally:  by dealing with the problems that precipitated the depression in the first place.

. . . . . . . . . . . . . . . . 

Tim tells us that “…there would be a lot more space to develop psychosocial approaches and address broader systemic issues if we decentered medication in these discussions…”.  To which I can only disagree.  Prior to about the year 2000, the antipsychiatry movement was virtually non-existent.  Those few of us who did speak out were ridiculed, marginalized, and at times vilified.  There was virtually no discussion on the downside of what Tim euphemistically calls “medication”.  By Tim’s argument, there should therefore have been lots of “space” to develop psychosocial approaches, and address broader systemic issues.  But in fact these things didn’t happen.  The spurious illness philosophy, and the ubiquitous drugs, held the field.  Other concepts and practices were effectively suppressed, and truly millions of lives were destroyed.

Today, when the antipsychiatry movement is growing in leaps and bounds, we are actually seeing a great deal more discussion of psychosocial approaches and broader issues than at any time in the past fifty years.

Today, the antipsychiatry issues are being heard, and progress is evident on all fronts.  But psychiatry, unconvinced and unrepentant, continues to resist.  There is some receptiveness, on the part of a very few psychiatrists, to alternative perspectives.  But for the most part, the leadership and the rank and file are redoubling their efforts to promote their medicalization agenda.  The APA has even engaged the services of a PR firm to improve their image and sell their philosophy.

But the facts have not changed.  Depression is not an illness.  Outbursts of temper are not an illness.  Academic inattentiveness is not an illness.  Painful memories are not an illness.  Bereavement is not an illness. 

But in the looking-glass world of psychiatry, these age-old human problems – and hundred more besides – are all illnesses that need to be “treated” with psychiatry’s so-called medication.

So for all of these reasons, I, for one, will continue to critique psychiatry and its destructive “treatments” with all the vigor at my disposal.  And I will do this because psychiatry is not something good that just needs to be expanded to embrace psychosocial and other broader issues.  Rather it is something fundamentally spurious and destructive; a wrong turning in human history.  It not only destroys individuals, but saps our cultural resilience with its self-serving insistence that virtually every significant human problem is an illness which needs a pill.  Psychiatry is not a healing force in the world.  Rather, it is a disabling force, and the pills are the most visible facet of its destructiveness.

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.

 

 

Driving Under the Influence of Stimulants

On April 22, I published a post on this general topic.  In that article I pointed out that the notion of stimulant prescription drugs improving the driving of people who “have ADHD” was gaining traction.

Since than I have come across two articles on this subject from Australia.  (Thanks to Nanu Grewal for the links.)  Both articles appeared in the Sunshine Coast Daily, and you can see them here and here.

Apparently in 2009, four people, including five-year-old twin girls, died in a two-car accident.  The driver of one of the cars had been prescribed dexamphetamine for the treatment of ADHD by a local psychiatrist, and was found to have had six times the prescribed dosage of dexamphetamine in his system at the time of the crash.

In the first article, dated October 2011, two years after the accident, it was noted that the psychiatrist’s prescribing practices were under investigation.  But the general manager of the psychiatric hospital where the psychiatrist practiced is quoted as saying that none of the allegations had been substantiated.

“Not one shred of evidence against anyone has been unearthed.”

The article also quotes Michael Cleary, Queensland acting chief health officer, as saying

“An analysis of available medical evidence has found that under-medicating is potentially more dangerous than prescribing higher doses, particularly when expert physicians consider a higher dose is appropriate”

So if an “expert physician” (presumably a psychiatrist) says that it’s OK to drive stoked to the gills on speed, then it’s OK!

The second article is dated July 2013, four years after the fatal accident.  Here it is reported that the prescribing psychiatrist whose practices had

“…been the subject of complaints by colleagues and nurses for many years, has had severe restrictions placed on his right to practice.”

 It is also reported that two nurses who were fired after

“…repeatedly raising concerns” about the psychiatrist were planning to sue for reinstatement.

What’s noteworthy about all of this is that, firstly, it took four year and persistent pressure from the dead girls’ father before some kind of action was taken against this psychiatrist.  Secondly, there had evidently been multiple complaints about this psychiatrist, but they were ignored by the hospital

. . . . . . . . . 

The idea of prescribing stimulant drugs to people who drive motor vehicles has always seemed problematic to me.  I worked for five years in the chemical dependency treatment area, and I have heard more horror stories about driving under the influence of stimulants than I care to remember.  Today the notion is gaining credence that stimulant drugs improve driving performance in people who “have ADHD.”  All of the research that supports this notion was industry sponsored , and most was conducted in simulators and under artificial conditions.

In real-life driving, it has to be recognized that stimulants are addictive drugs.  School children sell them to their classmates for recreational use.  Adults buy them illegally on the street.  People who receive them on prescription sometimes save them up for a weekend binge.  How many traffic accidents today are stimulant-induced?  How much of the frenetic, aggressive driving that we see on our highways stems from the use of these products?

There is a movement in most western countries today to combat drunk driving, and this is having considerable success.  In this context, psychiatry’s contention that people who “have ADHD” drive better under the influence of stimulants has to be seen as a major step backwards.

Is there truly no limit to what psychiatry will do to sell drugs and enhance their own perceived importance?

Sluggish Cognitive Tempo – A New Diagnosis?

On April 11, 2014, journalist Alan Schwarz (brief bio here) published an article in the New York Times on this topic, titled Idea of New attention Disorder Spurs Research, and Debate.  Alan has written extensively on the rising rates of the condition known as ADHD, and on the abuse of the drugs that are used to “treat” this condition. He has drawn a good deal of criticism from psychiatry’s believers.

In the NY Times article Alan draws attention to the fact that sluggish cognitive tempo (SCT) is being promoted as a new disorder  “… characterized by lethargy, daydreaming and slow mental processing.”  He makes the obviously valid point, that the formalization of such an entity  “… could vastly expand the ranks of young people treated for attention problems.”

The NY Times article was prompted by the fact that the Journal of Abnormal Psychology featured this emerging “diagnosis” in its January 2014 issue.  The issue contained eleven articles on the topic.  These articles addressed questions like:

  • Is SCT a sub-domain of ADHD?
  • Is SCT a disorder in its own right?
  • What are the symptoms of SCT?
  • What are SCT’s co-morbidities?
  • In what ways does SCT differ from ADHD, inattention type?
  • How does SCT differ from depression and anxiety, etc.?

It is a central theme of this website that mental illnesses/disorders, including ADHD and SCT, have no ontological or explanatory significance, are not a helpful way to conceptualize human existence, and in fact are intrinsically disempowering and stigmatizing.  The fact that these so-called illnesses are adduced by their psychiatric inventors to legitimize toxic treatments adds to their destructiveness.  The details of these critiques need not be repeated here.

HISTORY OF SCT

Sluggish cognitive tempo is not a new concept.  ADHD has long been criticized, even by psychiatrists, as embracing two very different kinds of presentations:  inattentiveness, on the one hand, and hyperactivity/impulsivity on the other.  DSM-III-R (1987) acknowledged this problem and created the new “diagnosis” 314.00 Undifferentiated Attention-Deficit Disorder (p 95).  The manual describes this condition as follows:

“This is a residual category for disturbances in which the predominant feature is the persistence of developmentally inappropriate and marked inattention that is not a symptom of another disorder, such as Mental Retardation or Attention-deficit Hyperactivity Disorder, or of a disorganized and chaotic environment.” [Emphasis added]

DSM-IV (1994) also acknowledged this issue, and split ADHD into three distinct “diagnoses.”

  • ADHD Combined type
  • ADHD Predominantly inattentive type
  • ADHD Predominantly hyperactive-impulsive type

DSM-IV-TR (2000) created the “diagnosis” 314.9  Attention –Deficit/Hyperactivity Disorder Not Otherwise Specified

“This category is for disorders with prominent symptoms of inattention or hyperactivity-impulsivity that do not meet criteria for Attention-Deficit/Hyperactivity Disorder.  Examples include:

1.  Individuals whose symptoms and impairment meet the criteria for Attention-Deficit/Hyperactivity Disorder, Predominantly Inattentive Type but whose age at onset is 7 years or after.

2. Individuals with clinically significant impairment who present with inattention and whose symptom pattern does not meet the full criteria of the disorder but have a behavioral pattern marked by sluggishness, daydreaming, and hypoactivity.” [Emphasis added]

DSM-5 has two residual categories in this area:

  • Other Specified ADHD (314.01)
  • Unspecified ADHD (314.01)

These “diagnoses” do not mention sluggishness, daydreaming and hypoactivity specifically, but these attributes are clearly embraced by the definitions.  This is particularly the case in that practitioners working with DSM-IV-TR would have become accustomed to conceptualizing this particular presentation as a “sub-diagnosis” of ADHD and, in addition, DSM-5 did not repudiate the SCT example given in DSM-IV-TR.  DSM-5 offers no examples of the residual diagnoses, the most reasonable interpretation of which is that the older examples are still to be considered valid as well as any others that individual practitioners encounter/invent as they go about their work.

It is noteworthy also that the DSM-5 main entry on ADHD contains the phrases: “mind seems elsewhere” and “may include unrelated thoughts.”  These phrases did not occur in the DSM-IV-TR main entry, and are clearly intended to embrace the notion of daydreaming.

So it is clear that the APA’s notion of ADHD (predominantly inattentive type) has long embraced daydreaming and lethargy, and it was probably inevitable that psychiatry, with its ever-expanding agenda, would eventually begin to conceptualize this as a distinct “illness.”  So today we have sluggish cognitive tempo emerging as a “diagnosis” in its own right, and attracting comment and attention.

CURRENT STATUS OF SCT

Earlier this year, Catherine Saxbe MD, a psychiatrist, and Russell Barkley PhD, a psychologist, wrote a paper reviewing the history of research on sluggish cognitive tempo.  The paper, The second attention disorder? Sluggish cognitive tempo vs. attention-deficit/hyperactivity disorder: update for clinicians, was published in the Journal of Psychiatric Practice.  Here’s a quote:

“Sluggish cognitive tempo (SCT) refers to an impairment of attention in hypoactive-appearing individuals that first presents in childhood. At this time, it exists only as a research entity that has yet to debut in official diagnostic taxonomies. However, it seems likely that a constellation of characteristic features of SCT may form the criteria for a newly defined childhood disorder in the foreseeable future, provided limitations in the extant findings can be addressed by future research.”

The authors expressed the belief that sluggish cognitive tempo is an unfortunate name for the disorder  “…since the term sluggish is associated with connotations of being retarded, slow-witted or just plain lazy.”  They remind us that

“More than semantics is at stake here.  The nosology reflects the way we conceptualize a disorder, view our patients, and how they understand themselves.”

They suggest that “concentration deficit disorder” or “developmental concentration disorder” or “focused attention disorder” would be better names for the problem, and appear to be entirely blind to the fact that the negative effects of referring to a child as “sluggish” pale to nothing compared with the stigma and disempowerment inherent in the notion that he is a “patient” with a “mental illness” (regardless of the name given to this illness).  In addition to which, of course, must be reckoned the destructive effects of the “treatments.”

Here are some more quotes from the Saxbe and Barkley article:

“No large-scale medication trials have examined response to stimulants specifically in SCT, but one recent investigation shows promise for the potential use of atomoxetine.”

and

“This is an exciting finding and warrants further investigation as it is the first published report to show improvement in SCT with any medication.”

and

“Given the overlap of SCT with anxiety and depression, perhaps selective serotonin reuptake inhibitors (SSRIs) might be [another] possible treatment.”

The study in question is Wietecha L. et al., titled Atomoxetine improved attention in children and adolescents with attention-deficit/hyperactivity disorder and dyslexia in a 16 week, acute, randomized, double-blind trial.  This appeared in the November 2013 issue of Journal of Child and Adolescent Psychopharmacology.  The paper is a study of the efficacy of atomoxetine in the “treatment” of various attention problems including SCT.  Atomoxetine is a selective norepinephrine reuptake inhibitor (NRI) marketed as Strattera by Eli Lilly.  The study (Wietecha et al.) found that:

“The atomoxetine-treated ADHD-only subjects significantly improved from baseline to Week 32 on…all K-SCT [Kiddie-Sluggish Cognitive Tempo Interview] subscales…”

and

“This is the first study to report significant effects of any medication on SCT.”

All of this is particularly interesting because:

  1. Ritalin, which is now off patent, and other stimulants, are reportedly ineffective in the “treatment” of SCT “symptoms.” (Saxbe and Barkley, 2014, p. 47)
  2. Atomoxetine, which is still on-patent, is now “proven” effective in this area.
  3. Linda Wietecha works as a Clinical Research Scientist for Lilly USA, LLC
  4. According to Dollars for Docs, the following co-authors on the study have also received money from Eli Lilly in the period 2009-2012: Bennett Shaywitz, MD, $963,003; Stephen Hooper, PhD, $16,540; David Dunn, MD, $56,886; and Keith McBurnett, PhD, $5,000.
  5. Russell Barkley, PhD, co-author of the article cited earlier, received $120,283 from Eli Lilly for consulting, speaking, and travel between 2009 and 2012 (Dollars for Docs), and as recently as February of this year gave a lecture tour in Japan sponsored by Eli Lilly.

All of which raises the interesting question:  is SCT disorder being promoted at the present time by Eli Lilly’s paid hacks as a way of increasing sales of atomoxetine (Strattera) while it is still on patent?

PSYCHIATRIC CREDIBILITY

Interestingly, and sadly, most of the research and promotion of SCT has been done by psychologists rather than psychiatrists.  This fact prompted Jeffrey Lieberman, MD, President of the APA, and very eminent psychiatrist to  tweet on April 11 “no credible psychiatrist takes this [SCT] seriously” in response to Alan Schwartz’s article in the New York Times.  Dr. Lieberman seems to be unaware that in DSM-IV-TR (2000), the APA created a specific “diagnosis” for the sluggishness/daydreaming/hypoactivity presentation (using those exact words), and that this “diagnosis” has been clearly retained in DSM-5 (though without those specific words).  I’ve never been aware of any great outcry from organized psychiatry, or from individual practitioners, on this matter.  So, if we are to take Dr. Lieberman at his word (and why would we not do that?), there must be an enormous dearth of “credible psychiatrists” within the APA’s ranks.

In this context, it is also noteworthy that the Wietecha et al. article was published in the Journal of Child and Adolescent Psychopharmacology, which suggests – at least to me – that the journal takes SCT seriously.  The editor-in-chief is Harold Koplewicz, MD, psychiatrist, founding member and President of the Child Mind Institute.  Dr. Koplewicz has held many prestigious positions, and has received numerous awards, including the 2009 American Psychiatric Association McGavin Award for lifetime contributions to child psychiatry.  But alas, he must now be considered a psychiatrist with no credibility.

And

The Saxbe and Barkley article was published by the Journal of Psychiatric Practice, the editor of which is John Oldham, MD, Senior VP and Chief of Staff at the Menninger Clinic, and a psychiatry professor at Baylor College of Medicine.  Dr. Oldham is a past President of the APA (2010-2011), and of the American College of Psychiatrists (2010-2011).  He has also been President of the International Society for the Study of Personality Disorders, and was a member of the DSM-5 Personality Disorders workgroup.  But, here again, no credibility!

The general point here is that psychiatry has embraced the concept of medicalizing daydreaming. Dr. Lieberman either doesn’t realize this, or is trying to conceal the fact.

DISCUSSION

It would be easy to get distracted by this recent attempt to promote childhood daydreaming as a mental illness.  As mentioned earlier, daydreaming, or to use psychiatric terminology, “the persistence of developmentally inappropriate and marked inattention,” has been a specific “mental illness” since DSM-III-R, 1987, (p 95).

The fact is that any human presentation can be considered a mental illness.  All that is needed is the APA’s say so.  And the APA made their position absolutely clear in the foreword to DSM-II (1968).  In the paragraph where they discuss what “diagnoses” should be included in the manual, they state:

“The Committee has attempted to put down what it judges to be generally agreed upon by well-informed psychiatrists today.” (p viii)

In other words:  if we say it’s a mental illness, then it’s a mental illness!

In subsequent editions of the manual, they offer a definition of a mental disorder, which when stripped of verbiage boils down to:  any significant problem of thinking, feeling, and/or behaving.  And who decides something is a problem?  A psychiatrist, of course.

Sluggish Cognitive Tempo (or concentration deficit disorder, as Drs. Barkley and Saxbe would prefer to call it) is more psychiatric nonsense.  But that’s all it is – more of the same; another inevitable result of psychiatry’s fundamentally flawed, spurious, and destructive medicalization of human existence.  Psychiatry continues to expand its net of entrapment into all aspects of life and into every corner of the globe.

By all means let’s speak out against this latest encroachment, but let us not lose sight of the corrupt and spurious engine that has been driving this endeavor since the 1950’s, or of the trail of human suffering and destruction that it has left, and continues to leave, in its wake.

Nor let use lose sight of the fact that many of the greatest writers, scientists, and artists were chronic daydreamers.  We can only imagine how much better the world would be today if these individuals had received the benefits of modern psychiatric treatment. We can also look forward to a better future – a future where daydreaming will be routinely recognized as the illness that it is, it’s victims will be “treated” appropriately with psychiatric drugs, and this plague, that has beset humanity since pre-historic times, will finally be eradicated.

* * * * * * * * *

There is absolutely no facet of human existence that psychiatry will not pathologize in the pursuit of its own self-serving agenda.

Antidepressants Make Things Worse in the Long Term

In June 2011, Rif El-Mallakh, MD, et al. published an article, Tardive dysphoria: The role of long term antidepressant use in inducing chronic depression, in Medical Hypotheses.  The article is a thorough and wide-ranging study review.

Here are some quotes from the abstract:

“Treatment-resistant and chronic depression appear to be increasing.”

“Depressed patients who ultimately become treatment resistant frequently have had a positive initial response to antidepressants and invariably have received these agents for prolonged time periods at high doses.” [Emphasis added]

The authors propose the term “tardive dysphoria” to describe this condition.  Tardive means delayed; dysphoria means unhappy or depressed.  The idea is that just as prolonged ingestion of neuroleptics causes tardive dyskinesia, so the prolonged ingestion of antidepressants causes tardive dysphoria.  It’s a nice idea, but the name hasn’t caught on – at least not yet.

The paper by Dr. El-Mallakh et al. is very detailed, and cites 85 references.  The arguments are well-marshaled and compelling.  Here’s a brief summary.

Depression affects about 5% of the world’s population.  Risk of recurrence is high (about 50-80%).  Maintenance antidepressant therapy may reduce the risk of relapse in the first year after an episode.  The APA recommends maintenance therapy for recurrent major depression.  But recurrence of depression is common even among individuals on maintenance therapy.  Recurrences of this sort are called treatment-resistant depression (TRD), the prevalence of which among depressed individuals may be as high as 30-50%.  This prevalence has increased from about 10-15% in the early 1990’s to about 40% in 2006.  Various reasons have been suggested for this increase, but, there “…are reasons to believe that antidepressant treatment itself may contribute to a chronic depressive syndrome.”

The authors provide a great deal of evidence in support of this conclusion.

“Up to 80% of patients diagnosed with major depressive disorder will experience a recurrence of depressive episode despite constant maintenance dose of an antidepressant.”

“Attempts to treat these individuals frequently result in poor response and the rise of TRD.”

“…there have been several reports of the loss of antidepressant efficacy.”

And perhaps most telling:

“A long-term placebo-controlled, blinded maintenance study of fluoxetine [Prozac] in major depression, found no difference after 62 weeks in subjects who were still euthymic [i.e. not depressed] on fluoxetine (11%) or placebo (16%).”

Dr. El-Mallakh et al. point out that individuals who were not initially depressed, but were given antidepressants for other problems (e.g. anxiety), often became significantly depressed.

“In a recent study 27% of patients without any history of a mood disorder who had received antidepressants for an average of 29 months for panic disorders, developed a cyclothymic illness that persisted for 1 year after antidepressant discontinuation.” [Emphasis added]

Also, and perhaps most alarmingly, it is stated:

“In…patients who have developed TDp [tardive dysphoria], ongoing attempts to treat the depression with antidepressants perpetuate the TRD, and may ultimately make the chronic depression permanent.”

The article was published in 2011, and the authors conclude their paper by calling for

“…blinded, randomized antidepressant discontinuation/continuation trials in TRD patients, over at least 1 year.”

They also suggest that

“…clinical trials of antidepressant taper and discontinuation for 6-12 months in patients who have failed most other options appear reasonable.”

Despite this call, I have not been able to find any follow-up research on this matter.

The notion that long-term ingestion of antidepressants leads to chronic, severe depression is not new. The present authors attribute the introduction of the concept to Giovanni Fava, MD, in his editorial Do antidepressant and antianxiety drugs increase chronicity in affective disorders?, Psychotherapy and Psychosomatics, 1994.

They also mention a paper by Verinder Sharma, MD, Treatment resistance in unipolar depression: Is it an iatrogenic phenomenon caused by antidepressant treatment of patients with a bipolar diathesis? Medical Hypotheses, 2006.

Dr. El-Mallakh himself and two other authors, Courtney Waltrip and Christopher Peters, wrote:  Can Long-Term Antidepressant Use Be Depressogenic? as a letter to the editor in the Journal of Clinical Psychiatry in 1999. 

In Anatomy of an Epidemic (2010), Robert Whitaker also addresses this issue (Chapter 8 – An Episodic Illness Turns Chronic).  Robert’s summary on this matter is clear and straightforward:

“We can now see how the antidepressant story all fits together, and why the widespread use of these drugs would contribute to a rise in the number of disabled mentally ill in the United States.  Over the short term, those who take an antidepressant will likely see their symptoms lessen.  They will see this as proof that the drugs work, as will their doctors.  However, this short-term amelioration of symptoms is not markedly greater than what is seen in patients treated with a placebo, and this initial use also puts them onto a problematic long-term course.  If they stop taking the medications, they are at high risk of relapsing.  But if they stay on the drugs, they will also likely suffer recurrent episodes of depression, and this chronicity increases the risk that they will become disabled.  The SSRIs, to a certain extent, act like a trap in the same way that neuroleptics do.” (p 169-170)

So, since at least 1994 – twenty years ago – researchers and commentators have been adducing evidence and arguments that antidepressants, even though they may have been initially successful in altering feelings of depression, when taken for extended periods may actually lead to persistent, treatment-resistant depression.  Discontinuation of the drug sometimes produces a slow and gradual lightening of the mood, but in some cases this does not occur, and the chronic depression can become more or less permanent.

Amazingly, or perhaps I should say predictably, organized psychiatry has not launched a major investigation into this matter, and I can find no indication that any such investigation is in the works.

In fact, the current (2010) APA treatment guidelines for major depressive disorder state:

“During the maintenance phase, an antidepressant medication that produced symptom remission during the acute phase and maintained remission during the continuation phase should be continued at a full therapeutic dose.” [Emphasis added]

Of course, the APA’s guideline will generate more drug sales.  But surely that wouldn’t be a consideration.  Would it?

Benzodiazepines: Disempowering and Dangerous

I recently read an article by Fredric Neuman, MD, Director of the Anxiety and Phobia Center at White Plains Hospital, NY.  The article is titled The Use of the Minor Tranquilizers: Xanax, Ativan, Klonopin, and Valium, and was published in June 2012 by Psychology Today.  Thanks to Medicalskeptic for the link.

Dr. Neuman opens by telling us that benzodiazepines are “…very commonly prescribed for any sort of discomfort.”

“They are called anxiolytics, and they are prescribed for any level of anxiety and more or less to anyone who asks for them.”

Dr. Neuman has been working at the Anxiety and Phobia Center for 41 years, first as Associate Director and then as Director.  So when he says that benzos are routinely given to “anyone who asks for them,” it’s probably safe to say that he’s being accurate.

He tells us that the benzos have a “modest tranquilizing effect” in the doses at which they are “usually prescribed.”  But –

“…I see patients all the time who feel they cannot manage ordinary situations in life without taking one of these pills.”

and

“…I think these individuals suffer a loss of self-confidence. Their ability to rely on themselves has been undermined by their reliance on these drugs.”

Dr. Neuman asserts that benzos

“…are the most commonly prescribed drugs in the world. They are for the most part safe, but even safe drugs can sometimes cause problems.”

He provides a list of those adverse effects that concern him most.

  1. They are addicting.
  2. They effect coordination, particularly in the elderly.
  3. They compound the effect of other drugs and alcohol.
  4. They interfere to some extent with memory. 

And to this list he adds the dangers of abrupt discontinuation and

“…the fact that I think something is lost, as I indicated above, when someone relies on something make-believe to get through the day.”

Dr. Neuman concludes:

“…these drugs are sometimes helpful a little, and in some ways hurtful a little.  But I don’t wish to give the impression that they are really bad. If a patient demands them, I will usually acquiesce, assuming the dose is small. I always encourage patients to take less as time goes on.  If they won’t, I don’t usually argue with them.”

and

“I know most doctors give these drugs much more readily than I do.”

 DISCUSSION

In the article Dr. Neuman comes across as a reasonable and helpful person.  He prescribes benzos, but he recognizes and articulates the disempowering aspect of relying on drugs, and I think it is reasonable to assume that in his practice he encourages people to pursue genuine resolution of fears and anxieties rather than chemical masking.  But what struck me most forcibly in the article was the sentence:

“If a patient demands them, I will usually acquiesce, assuming the dose is small.”

Dr. Neuman is to be commended for his honesty, but it is a truly amazing admission – particularly his use of the word “demand.”  It has long been my contention that there is very little essential difference between psychiatric “prescribing” of psychoactive drugs and the illegal selling of drugs on the street.  Dr. Neuman’s use of the word “demand,” his admission that he usually acquiesces, and his credible assertion that most doctors prescribe these drugs more readily than he does, lends support to this contention, at least as far as benzos are concerned.  It is difficult to reconcile his statements with the notion that these drugs, when used in a psychiatric context, are medications being prescribed to treat illnesses.

MORTALITY HAZARD

The same day that I read Dr. Neuman’s piece, I also read an article in the BMJ:  Effect of anxiolytic and hypnotic drug prescriptions on mortality hazards: retrospective cohort study, by Weich et al.  Here are the conclusions:

“In this large cohort of patients [34,727 participants and 69,418 matched controls]  attending UK primary care, anxiolytic and hypnotic drugs were associated with significantly increased risk of mortality [hazard ratio: 3.3] over a seven year period, after adjusting for a range of potential confounders. As with all observational findings, however, these results are prone to bias arising from unmeasured and residual confounding.”

The increased risk for those participants who had taken only benzodiazepines was slightly higher at 3.68.  Risk ratios were adjusted for age, gender, and the following health problems:  “arthritis, asthma, cancer, ischaemic heart disease, stroke, chronic obstructive pulmonary disease, diabetes, epilepsy, gastrointestinal disorders, hypertension, musculoskeletal disorders, anxiety disorders, sleep disorders, other (non-anxiety), psychiatric disorders, and prescriptions for non-study drugs.”  The association followed a dose-response pattern.  Participants who had taken benzos at the highest doses had a hazard ratio of 5.1.

Even allowing for the standard disclaimer, the study raises serious doubts as to the oft-claimed safety of these products, especially as other studies have produced similar findings.  It should also prompt us to question Dr. Neuman’s somewhat cavalier approach to these products – an approach which in my experience is widespread in psychiatry.  A three-fold increase in mortality rate over seven years is not a trivial matter.

Benzodiazepines: Dangerous Drugs

On February 25, Kristina Fiore published an article on MedPage today.  It’s titled Killing Pain: Xanax Tops Charts

The article is based on a study conducted by Jann M et al, and published in the February 2014 issue of the Journal of Pharmacy Practice.  The study is titled Benzodiazepines: a major component in unintentional prescription drug overdoses with opioid analgesics.  Here’s a quote:

“During 2003 to 2009, the 2 prescriptions drugs with the highest increase in death rates were oxycodone 264.6% and alprazolam 233.8%. Therefore, benzodiazepines have a significant impact on prescription drug unintentional overdoses second only to the opioid analgesics. The combination prescribing of benzodiazepines and opioid analgesics commonly takes place. The pharmacokinetic drug interactions between benzodiazepines and opioid analgesics are complex. The pharmacodynamic actions of these agents differ as their combined effects produce significant respiratory depression.”

Alprazolam is a benzodiazepine.  It was marketed as Xanax in 1981, and has been available in generic form since 1993.  It is used by psychiatrists as an anti-anxiety agent.

When the benzodiazepines were first introduced, it was widely claimed, both by psychiatrists and by pharma, that they were non-addictive.  This claim was subsequently abandoned in the face of overwhelming evidence to the contrary, and the addictive potential of these products is now recognized and generally accepted.  Incidentally, you can find some interesting history on the promotion of tranquilizers, including benzos, on a Medpage timeline published last month.  The timeline presents ads gathered from the New England Journal of Medicine and from the Journal of the American Medical Association.  It’s tawdry stuff.  Thanks to Laura Delano for the link.

Back to Ms. Fiore’s article.

“When a patient comes in with complaints about anxiety, it’s easy to write a prescription for Xanax, Jann said.  Like other benzodiazepines, it’s cheap and it’s perceived to be safe.”

She also quotes Daniel Carlat, MD, professor of psychiatry at Tufts:

“Xanax really is a tried and true medication…When patients take it, they feel its effect quickly.”

 And

 “It also goes to work fast, which may be a reason why patients show a preference for it…”

 Miss Fiore has also interviewed Allen Frances, MD, former psychiatric chair at Duke and architect of DSM-IV:

“And the drug is an easy solution for primary care doctors who are pressed for time, said Allen Frances, MD, a professor emeritus and former chair of psychiatry at Duke University.

Indeed, the majority of benzodiazepine prescriptions in 2013 were written by family practice or internal medicine doctors, totaling some 44 million prescriptions. That’s vastly more than the 13 million written by psychiatrists.

Frances said that if the FDA were to conduct a thorough review of Xanax, it might not be so widely prescribed.

‘The effects of Xanax are much more subtle and dangerous,’ he said. ‘In combination it can be deadly, and for many people it creates an addiction problem that’s worse than the original condition.’

‘I think if there was a careful review of its risks and benefits, it would be taken off the market,’ he added, ‘or it would at least have much more restricted use.'”

Dr. Frances has reinvented himself in recent years as an outspoken critic of DSM-5 and of psychiatric excesses generally.  His points are usually cogent and well made, but he remains unreceptive to the fact that his own brainchild, DSM-IV, was an integral step in psychiatry’s spurious and self-serving medicalization of non-medical problems.

The fact is that anxiety is not an illness, and drugs that dissipate anxiety are not medications – they are drugs.

Benzodiazepines have a legitimate use in general medicine, and in that context are indeed medicines in the proper sense of the term.  But when prescribed for anxiety on a routine, daily basis, they are drugs.  They fall into the class of drugs that addictionologists call sedative-hypnotics, and are similar in their general effects to alcohol and opiates.  I worked in the chemical dependency field in the late 80’s – early 90’s, and even then we were admitting large numbers of people addicted to benzos.  It was, and is, an extremely difficult addiction to overcome.  Withdrawals are typically difficult, protracted, and sometimes dangerous.  Monica’s Cassani’s website Beyond Meds goes into this in great detail.

Dr. Frances makes the point – undoubtedly true – that general practitioners prescribe more benzodiazepines than psychiatrists.  This is a common cry from psychiatry when confronted with the damage that their products are causing.  But the argument is specious, because no practitioners could prescribe these drugs as a daily “treatment” for anxiety if psychiatry had not, in the first place, promoted the false message that anxiety is an illness.  No doctor could prescribe these products for these purposes if psychiatry had not invented, packaged, and sold their various anxiety “diagnoses.”  When psychiatry embarked on its great mission to medicalize every conceivable human problem, they basically drove the bus off the cliff .  Mental health today is still in a state of uncontrolled free fall.  And every time we hit an outcropping, or the bus turns end over end, psychiatry says: “Oh dear!  How did that happen?”  Well it happened because organized psychiatry put money and prestige above intellectual and moral integrity.  The damage this has done, and continues to do, is beyond reckoning. 

Psychiatry has damaged and killed human beings who came to them for help.  They have routinely disempowered people, and have spuriously equated all human distress to their confidently-touted, but fictitious, chemical imbalances, and, more recently to the twitching of aberrant neural circuits.  They have arrogantly promoted themselves as the arbiters of normalcy and the healers of emotional pain.  They have systematically undermined the notion of self-improvement through effort, and through natural social support networks.  They have enslaved millions to their toxic psychotropic chemicals.  And we haven’t hit bottom yet.

Anxiety is not an illness.  It is a normal human response to ambiguous or potentially challenging or dangerous situations.  I’ve written more on this in my post Anxiety Disorders.  Modern life is fraught with anxiety-arousing situations.    If psychiatry had had the slightest interest in truly helping people, it would have focused on this reality, and developed genuinely helpful concepts and practices in this area.  But there isn’t much money in that.

So instead, intoxicated by its customary delusion of infallibility, it did what it always does:  issued the self-serving decree that anxiety is an illness best treated by “medications.”

Dr. Frances is correct:  benzodiazepines should be taken off the market – not only because they are dangerous, but also because the notion of washing away people’s anxieties and concerns in a drug-induced haze of semi-euphoria is fundamentally disempowering, and makes a mockery of the practice of medicine.  The only possible honest response from a physician who is asked to treat anxiety, is to point out that anxiety is not a medical matter.

People who take these drugs as a routine measure to insulate themselves from life’s multi-variate challenges and vicissitudes are not medicated.  They are stoned.

And the great irony here is that everybody knows this.  The individuals know it; their family members know it; their friends and co-workers know it; the psychiatrists themselves know it.  And the street pushers who obtain benzos illegally know it.

But the great fiction has to be maintained.  Here’s a quote from Benzodiazepines:  A versatile clinical tool, by Bostwick et al in Current Psychiatry, April 2012

“Since the discovery of chlordiazepoxide [Librium] in the 1950s, benzodiazepines have revolutionized the treatment of anxiety and insomnia, largely because of their improved safety profile compared with barbiturates, formerly the preferred sedative-hypnotic.”

And psychiatry and pharma go on making a killing.  According to the Kristina Fiore article mentioned earlier, there were 94 million prescriptions for benzos written in the US in 2013.  Psychiatry is out of control.