Tag Archives: over-medicalization of everyday life

Is Psychology Going the Way of Psychiatry?

On January 7, Maria Bradshaw, co-founder of CASPER, published an interesting article on Mad in America.  It’s called Prescribing Rights for Psychologists, and it suggests that psychology as a profession may be falling into some of the same errors that enmire psychiatry.

Maria makes some very compelling points, and focuses particularly on the fact that psychologists have won prescribing rights in a number of jurisdictions, and are engaged in an ongoing effort to expand this aspect of their work.

The article points out that the DSM-5 Task Force comprised “nearly 100 psychiatrists and 47 psychologists,” and also expresses concern that as psychologists become more heavily involved in the prescribing of drugs, they will inevitably become targets for pharma corruption.

Maria explores the possibility that psychologists may be moving closer to psychiatry’s medical model of human problems, a model that formerly they viewed as erroneous and dangerous.

This article is timely.  At present, I would guess that most psychologists are still on this side of the debate, particularly in the UK, where the medical model has always been viewed with a good measure of skepticism, and where recently the clinical division of the BPS took a major step away from this model.  But there are deep-seated and disturbing trends, especially here in America.  And these trends have been long in the making.  For decades a significant proportion of the questions on the psychologist’s licensing exam in the US have been based on the DSM.  For example, a scenario would be sketched and the examinee had to identify the “correct diagnosis” from a list of four or five.  The choice: “This is an inane question” was never listed.  The examining body is currently engaged in the process of integrating DSM-5 into the exam content.  This is logically equivalent to asking chemistry graduates to identify the correct methods for transmuting base metals to gold.

In the May 1993 issue of the Behavior Therapist I wrote:

“Today it is not unusual to find practitioners who describe themselves as behaviorists discussing these disorders [DSM “diagnoses”] as if they had the same ontological status as diabetes or pneumonia, which of course, they don’t.”

That was 20 years ago, and I don’t think the trend has slowed.

The prescribing rights movement is, in my view, a giant step in the wrong direction, but shows no signs of losing momentum.  When psychiatry’s ship finally founders in the storm of scrutiny and survivor protest, psychology, as a profession, may also be swept away, especially if it is perceived as a sister profession.

Psychology is the discipline that studies human thoughts, feelings, and behaviors, and applies its findings to helping people resolve problems and find a more fulfilling and empowered lifestyle.  Psychiatry is the non-science that treats non-illnesses.  Strictly speaking they should have very little in common, similarity in name notwithstanding.  The urgent need for psychology today is to re-find its roots, and generate distance between itself and psychiatry.  Otherwise it will inevitably be tarred with the same brush.

 

Understanding Human Behavior

A couple of months ago I wrote an article concerning ECT which generated some controversy.  One of the issues that came up was the relationship between biological explanations of human activity and more global explanations, which, for want of a better term, I’ll call person-centered explanations.

Any human activity can be viewed from different levels of abstraction.  Suppose, for instance, that I am sitting in my living room reading a book.  Then I put the book down, stand up, and go outside.  If the question were to be asked:  why did he put the book down and go outside? A wide range of perspectives and answers are possible.  One could, for instance, focus on the fact that I am a biological organism, and one could develop a detailed and comprehensive flow sheet of every muscle movement, every heartbeat, every sensory input, neural impulse etc., that had occurred from the moment that I put the book down until I was standing outside.  Such an account might be more or less detailed.  There would, of course, be physical limitations on the amount of information of this sort that is attainable, but from a theoretical point of view, one could compile a detailed, complete, and accurate biological account of the actions in question.  And such an account would be a valid response to the question:  why did he put the book down and go outside.

But there are other perspectives.  One could, for instance, ask me why I had behaved in this way.  This would be a person-centered approach.  And suppose I reply:  I had been sitting inside for too long; I wanted some fresh air.  Assuming that I’m truthfully describing my motives and feelings, this is also a valid and accurate explanation.

Of particular note is that although the two explanations appear very different, they are entirely compatible.  In fact, if the biological account is thorough and complete, one would be able to identify the neural activities that corresponded to my feelings of restlessness, my decision to move, my muscular movements, and my relief on getting outdoors.  Again, I stress that I doubt if that level of precision is, or ever will be, possible in practice, but the concept is valid.  Every element of the person-centered explanation will have a corresponding element in the biological flow-sheets.

For this reason it makes no sense to argue about which explanation is correct.  They are both correct.  I – the subject of the person-centered perspective – am also the subject of the biological perspective.

The act of stepping outside for fresh air is trivial and unremarkable, but the same plurality of perspectives can be applied to all our actions, including dysfunctional or counterproductive behavior.  The activity can be viewed as biological and can be probed and catalogued by neurologists, physiologists, etc…  Or it can be seen from a person-centered perspective and explored and formulated from that point of view.  There are also other perspectives, e.g. economic, political, social, familial, occupational, etc…  From the economic perspective, for instance, I would be considered a consumer, and my restlessness and my desire for fresh air might identify me as a marketing target for outdoor wear, wilderness vacations, bird-watching magazines, etc…  From a familial perspective, I am a husband, father, father-in-law, and brother within a fairly extended network of supportive relationships.  From a political perspective, I am a voter.  And so on.  I can be observed and studied from all of these perspectives, and although the observations will look very different, they are entirely compatible provided they are accurate.

For every thought, feeling, and behavior there is a corresponding neural event.  Some people contend that the thought/feeling causes the neural event; others say that the neural event causes the thought/feeling.  Still others contend that the cognitive/emotional activity and the neural activity are the same thing, but viewed form different perspectives.  The relative merits of these contentions have been debated by philosophers for hundreds of years, but for our present purposes, it doesn’t matter which is correct.  The point here is that there are neural events and there are thoughts/feelings/actions, and there is a correspondence between the two.  A super-neurologist with super-equipment could probe my brain and identify and catalog various patterns and clusters of neural and chemical activity.  But I experience these neural activities as thoughts and feelings.  Each perspective is valid, and each has its proper place.

A neurosurgeon, for instance, would be primarily concerned with the biological perspective, while most of our day-to-day interactions with other people are approached from a person-centered perspective.  A person asking me, for instance, why I had stepped outside is not enquiring about neural activity, inside my skull.  He’s asking about my thoughts/feelings/actions.

It is often tacitly assumed in psychiatric circles that because every thought, feeling, and/or behavior has a corresponding neural underpinning, therefore counterproductive thoughts, feelings, and/or behaviors must be the result of faulty or malfunctioning neural equipment.  But this is an unwarranted assumption.

Let’s take the example of childhood temper tantrums – and let’s look at these from a person-centered perspective.

If a child throws a tantrum in a grocery store, demanding candy or a toy or whatever, and if the parent gives in to his demands, then other things being equal, the probability of a tantrum in future store visits is increased.  This is one of the ways that we learn:  if an action brings about a favorable result, we try it again.  This is an adaptive mechanism.  It is not an instance of something going wrong in the child’s brain.  Rather it is an instance of something going right.  The child’s learning “machinery” has worked perfectly.  And from a person-centered perspective, it is an instance of the child learning to navigate his way in social relationships.

In the example above, I’ve described the scenario and outcome in very simplistic terms and have included the qualifier “other things being equal.”  But in practice other things are never equal, and the precise outcome on any given occasion is impossible to predict.  But whenever we interact with our children, we are teaching them something, and they are teaching us something.  In the above example, the child has learned:  if I want candy, I throw a tantrum.  The parent has learned:  if I want to stop his tantrum, I give him candy.  Unless something significant changes, it is likely that two things will happen.  The child will start to throw tantrums in other situations besides grocery stores, and any attempt on the part of the parent to regain control of the situation will be met initially with escalation of the tantrums.  This is not an instance of something going wrong within the child.  Instead, and apparently paradoxically, it is something going right.  The child is expanding his behavioral repertoire in accordance with the normal principles of behavior acquisition.  What has gone wrong is that the parent is teaching a response that ultimately will be problematic and counterproductive.

From a person-centered perspective, even frequent and severe temper tantrums can be understood as normal responses to suboptimal situations.  Obviously, in this context, I do not mean statistically normal.  Severe and frequent temper tantrums are not normal in the statistical sense of the term, but in the circumstances outlined above, they are normal in that they can be understood if viewed from a person-centered perspective.  There is no a priori need to invoke explanations based on neural malfunctions or pathology in the absence of compelling indications that such factors are present and causally significant.

Obviously each tantrum has a specific neural underpinning, but it is fallacious to assume neural  pathology based purely on the presence of negative or counterproductive behaviors.  Neuronal circuits and neurotransmitters that are functioning perfectly can underpin and drive destructive behavior as readily as constructive behavior.

The distinction between a person-centered perspective and a bio-neurological perspective applies to almost every facet of human existence.  We are biological organisms, but we are also thinking, feeling and self-directed persons.  For instance, I carry within me memories of the home in which I grew up and of my family of origin.  These memories are complex and intertwined, but I can bring them to the forefront of consciousness more or less at will.  Now let’s say that my super-neurologist with his super-equipment can probe around inside my skull and locate the neurons in which all these memoires are stored.  And let’s make him (or her) even more super, and imagine that he can “read” these various neuronal engrams.  There is still a fundamental qualitative difference between his readings and my memories of my childhood.  A good analogy would be that he can read the book, but I’m living the part.  Another analogy:  a person could, in theory at least, analyze a movie on a DVD and identify every pixel and sound unit.  But this is not the same as watching the movie.  A chemist can analyze every molecule of paint and canvas in the Mona Lisa, and still know absolutely nothing about the picture as a work of art or the motivation of the artist.

Our super-neurologist could analyze and catalog perfectly every sensory input and neuronal impulse in the actions of a tennis player making a spectacular backhand return.  But this is not the same kind of experience as that of the tennis player or even of the exulting fans.  And so on.

It’s tempting in this context to say that psychiatry has lost sight of the forest for the trees.  But it’s worse than that.  They’ve lost sight of the tree for the minute fibers and biological processes that sustain the tree’s growth.

There’s a quality to human experience that transcends neurons.  One can know everything that there is to be known about neurons and neurochemicals and know nothing of human life.  People are living, sentient, motivated beings, and we each have our own perspective and point of view.  We can be studied at various levels of abstraction:  atomic, molecular, bio-molecular, physiological, neuromuscular, skeletal, psychological, social, economic, political, occupational, etc… But we can also be approached and understood simply as individual people, with our individual histories, contexts, hang-ups, and aspirations.  No one perspective has any legitimate claim to being the preferred point of view.  One’s perspective has to be chosen in the light of the context.  If a person is sick (with a real sickness), then a biological perspective is probably preferable.  If he is sad or anxious, then a person-centered perspective seems the most apt.  If he is lonely and isolated, a social perspective might be most fruitful.  And so on.

In my experience virtually all the problems listed in the various editions of the DSM can be best approached, understood, and ameliorated from a person-centered perspective.  If you want to know why someone is depressed, take the time to get to know him, and then ask him.  Most people can tell you why they’re depressed or worried or nervous or scared or whatever.  But if it’s clear that your only interest is a 15-minute med check, they will tell you nothing.

If there is neural pathology then this, of course, should be addressed and alleviated to the extent possible.  But tampering crudely with the brain in the absence of confirmed pathology is dangerous and destructive.  Drugs do create altered states of consciousness, but the notion that we can provide effective help to people with problems of thinking, feeling, and/or behaving by tweaking their neurons betrays a fundamentally flawed and condescending view of humanity.

 

 

 

The Sandcastle Continues to Crumble: ADHD Does Not Exist

BOOK PREVIEW

Richard C. Saul, MD
ADHD Does Not Exist:  The Truth About Attention Deficit and Hyperactivity Disorder
Publication date:  February 18, 2014

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

Those of us on this side of the psychiatry debate have been saying for decades that the condition known as ADHD is not an illness, but is rather an arbitrarily delineated cluster of vaguely defined problems that children have acquired in various ways.  We have also pointed out that psychiatry’s labeling of this condition as an illness is simply another instance of their inexorable turf expansion, and that their widespread drugging of the individuals so labeled is destructive and disempowering.

And, also for decades, psychiatry has been marginalizing us as unscientific mental illness deniers, who seek to put the clock back and deprive people suffering from this “illness” of the vital “treatment” that they so desperately need.

In recent years, we have seen some fracturing in psychiatry’s defenses.   Individual psychiatrists have been dissenting – sometimes very forcibly – against psychiatry’s philosophy that every problem is an illness and for every illness there’s a pill.

And now their voices are joined by Richard C. Saul, MD, an experienced and highly regarded neurologist who practices in the Chicago area.  He has written a book, ADHD Does Not Exist:  The Truth About Attention Deficit and Hyperactivity Disorder, which is due out next month.  The book is sure to present a formidable challenge to the orthodoxy and practices of organized psychiatry, with regards to this particular “diagnosis,” that has seen an almost four-fold increase in prevalence from 1987 to the present day.

Kyle Smith, a journalist who writes for the New York Post, has written a promotional article on the book for the Post (January 4).  Here are some quotes from the article:

“After a long career treating patients complaining of such problems as short attention spans and an inability to focus, Saul is convinced that ADHD is a collection of symptoms…”

“Treating ADHD as a disease is a huge mistake, according to Saul. Imagine walking into a doctor’s office with severe abdominal pains and simply being prescribed painkillers. Then you walk away, pain-free. Later you die of appendicitis.”

“Adderall and Ritalin are stimulants, though, and the more you take them the more you develop a tolerance for them, which can lead to a dangerous addiction spiral.”

“The explosion in ADHD diagnoses and related prescriptions of stimulants is not without substantial costs. Potentially addictive drugs are not to be given out like Skittles.”

“‘I know of far too many colleagues,’ Saul writes, ‘who are willing to write a prescription for a stimulant with only a cursory examination of the patient, such as the ‘two-minute checklist,’ for ADHD.'”

“Two minutes to jot down a prescription may lead to years of consequences: short-term side effects of stimulants include loss of sleep, increased anxiety, irritability and mood problems. Over the long term, use of these drugs can lead to unhealthy weight loss, poor concentration and memory, even reduced life expectancy or self-destructive behaviors not excluding suicide.”

Dr. Saul’s debunking of ADHD as a disease entity should come as no surprise.  There was never a shred of evidence or valid reason for considering it an illness in the first place.  It became an illness the same way other psychiatric conditions became illnesses – by APA fiat:  Let there be illness, said the APA, and illness appeared everywhere.

It will be interesting to see how the APA leadership spin this.  I imagine that today they’re just reaching for the acetaminophen, but we can be sure that their ever-resourceful Office of Communications and Public Affairs will be all over it soon, and that our esteemed Dr. Lieberman’s fluent pen will be generating persuasive prose to reassure us that psychiatric diagnoses reflect real illnesses, and that there are vast unmet needs in this area.

The DSM’s so-called nosology is like a sandcastle on the foreshore.  The tide of scrutiny, particularly from survivors, is rising, and as the APA’s cherished edifice crumbles, organized psychiatry’s hold on reality becomes increasingly tenuous.

Training the Psychiatrists of the Future (According to Dr. Lieberman): More Cheerleading

Jeffrey Lieberman, MD, President of the APA and Chair of Psychiatry at Columbia University, published a post on November 26 on Psychiatric News.  The article is called Training the Psychiatrists of the Future, and is co-authored by Richard Summers, MD.  Dr. Summers is a Professor of Psychiatry at the University of Pennsylvania.

Drs. Lieberman and Summers open by telling us that psychiatrists’ roles “…are changing and will continue to change.”  That sounds great, but don’t expect too much.  There will still, they tell us, be a need for:

“…continued commitment to the essential skills and attitudes we all hold dear while developing new learning objectives, venues, and experiences to prepare our trainees for the times ahead.”

I’ve known a good many psychiatrists in recent decades, and the only essential skill that I’ve noticed with any measure of regularity and consistency is in the activity known as the “med check.”  This consists of a 10-15 minute interview exploring the effects of drugs previously prescribed.  It’s difficult to know what Drs. Lieberman and Summers mean by “attitudes” in this context.  Perhaps it’s:  doctor knows best; or there, there, these pills are very safe; or everything goes better with pills; or it’s an illness just like diabetes, etc…

But whatever the attitudes are, Drs. Lieberman and Summers assure us that we all hold them dear.  Could this be the same “we” as in the condescending “How are we doing today, Mr. Jones?”

But let’s not get hung up on the preamble.  The good doctors tell us that there are five areas of psychiatric training that will need particular attention in the future.

1.  DOCTOR-PATIENT RELATIONSHIP

In this regard, the authors stress the importance of the doctor-patient relationship and the need for trainee psychiatrists to develop their rapport-building, history-taking, and collaboration skills.  They also stress the need to develop an effective therapeutic alliance.

This sounds great.  Psychiatrists are finally going to start getting to know their clients and taking the time to relate to them as people rather than as clusters of druggable symptoms.

But alas, read on:

“The psychiatrist of the future will likely have less regular face-to-face contact with patients…” [emphasis added]

Less than 10-15 minute “med checks” every three months?  How can a reduction in face-to-face time promote improved rapport or a more effective therapeutic alliance?

I can imagine my readers’ skepticism.  It can’t be done, you might say.  One can’t improve rapport while reducing face-to-face time!  But wait – this is psychiatry we’re dealing with.  Ordinary Aristotelian logic doesn’t apply.  Drs. Lieberman and Summers tell us that they’re going to accomplish this therapeutic miracle using the following techniques:

  • telepsychiatry (webcam?)
  • other forms of telephonic contact (the phone?)
  • Internet contact (emails?)
  • team-based care (tell the social workers to establish rapport?)
  • Assertive Community Treatment (big topic – future post)

And (and this I can’t even begin to fathom)

  • “…communicating with patients while accessing electronic medical records…”

I think this means that they’re planning to “develop their rapport-building” and improve the “therapeutic alliance” by teaching trainee psychiatrists how to talk to clients, while at the same time reading the client’s file on their tablets or notebooks or desk computers.  The mind truly boggles!

2.  DIVERSITY, BROAD RANGE OF TREATMENTS, BROAD RANGE OF ROLES

Psychiatry, they tell us:

“…encompasses a broad range of illnesses and a particularly broad range of treatments.”

They don’t mention that the problems that they “treat” are not illnesses in any conventional sense of the term.  Nor do they point out that the broadness of this spectrum is entirely a function of 60 years of APA voting and fiat, and not a product of the kind of scientific discovery that characterizes real medicine.

The authors also tell us that there will be a need for “behavioral health specialists” (read: psychiatric assistants) who are “…integrated with primary care.”

This “integration with primary care” has been a constant theme in Dr. Lieberman’s writings in recent months.  The idea is to have a psychiatrist, or a tame psychiatric assistant, in every GP’s office!

3.  INTEGRATED BEHAVIORAL HEALTH CARE

This next paragraph, I have to quote in full:

“The momentum for patient-centered care, the medical home, and integration of behavioral health with primary care creates a new role for psychiatrists. Many are doing this now, but the roles are evolving as the systems are changing. We do know that this role, which will expand in the coming years, involves increased knowledge and comfort with primary care medicine, understanding of chronic illness and how people adapt, a population-based approach, as well as strong skills in interpersonal communication and collaboration and knowledge about systems of care.”

Although I greatly appreciate everything that Dr. Lieberman has done, and continues to do, for the anti-psychiatry movement, I have to acknowledge that he is not always entirely clear in his writings.  I find myself struggling particularly with the above paragraph, but here’s my best shot:

The medical home according to Wikipedia is a team-based healthcare delivery model.  Its purpose is to provide comprehensive primary care for all patients, and there would be recognition, including financial reimbursement, for co-ordination activities, and not just for face-to-face physician-patient contact.  It is, in fact, the model which, in theory at least, underlies almost every mental health center in the US.  It is an elaborated version of the interdisciplinary team which, whatever its merits in former decades, has frequently degenerated in recent times under psychiatric leadership to little more than a committee-to-pressure-clients-to-take-their-drugs.

What the good doctors are saying in this paragraph (or at least what I think they’re saying) is that there is momentum to introduce this kind of interdisciplinary approach in general practice, and that psychiatrists need to get on this bandwagon and establish themselves as a necessary and integral component of every primary practice in the country.

In short, it’s just another instance of psychiatry latching onto an opportunity to expand its turf and find new outlets for its drugs.  Their ideal is clearly that every visit to a GP will involve a mental health screening.  This almost inevitably will “uncover” a hitherto unrecognized mental illness and a prescription for a psychotropic drug.

What the authors mean by “…a population-based approach” I can’t even imagine.  (Quetiapine in the drinking water?)

4.  NEUROSCIENCE EDUCATION

“There is clearly an appetite for learning about neuroscience and an increasing requirement for providing it. This will become increasingly important as the gap between neuroscience knowledge and psychiatric practice closes.”

In other words, the great neuroscientific breakthrough is just around the corner, and we need to start training new psychiatrists in these practices.  Now where have we heard that before?

“A nationally developed, shared, and disseminated set of resources to support improved neuroscience education would help to meet these goals. The American Association of Directors of Psychiatric Residency Training’s Neuroscience Education Initiative is taking on this challenge and is supported by our APA Council on Medical Education and Lifelong Learning. Grant funding may be required to achieve this goal.”

In other words: give us more money.  Now where have we heard that before?  Pharma-funded “education” is waning under the spotlight of legislative scrutiny.  So new sources of money will be needed – presumably tax dollars.

5.  SYSTEMS OF CARE AND QUALITY IMPROVEMENT

“The increased awareness that errors reside in systems and that outcomes are determined by processes as much as individuals provides an extraordinary opportunity to improve care. But this will only occur if we learn how to effectively and efficiently study our systems and change them appropriately.”

These are wise words.  Sometimes we can become so entrenched in our practices and perceptions that we are doing more harm than good.  And there are certainly many errors residing in psychiatry’s systems.

The primary error, I would suggest, is the systematic and spurious medicalization of all significant problems of thinking, feeling, and/or behaving.  What a difference it would make if psychiatry were to “…learn how to effectively and efficiently study…” that particular system.  Or the systematic prescription of dangerous chemicals for virtually all human problems.  Surely that warrants some effective and efficient study.  Or the systematic rejection of negative client feedback as symptoms of their putative illnesses.

Alas, no.  Drs. Lieberman and Summers are not thinking of anything so far-reaching.  Traditional quality assurance is what they’ve got in mind with some improved “…metrics and measures of care quality…”  (e.g. medication compliance measurements?)

CONCLUSION

The authors conclude their article with this startling pronouncement:

“The psychiatrists of the future will certainly need to know how to connect with and relate to others…”

implying, I suggest, that psychiatrists of the present don’t know how to do this.  Doesn’t the truth have a way of slipping out?  Goldarnit!

Psychiatry’s new recruits will also, we are told:

“…need training in integration with primary care practice…”

There it is again – a psychiatrist in every GP’s office.

DISCUSSION

On October 14, 2013, I wrote a post titled Health Care Reform and Psychiatry.  In this article I criticized psychiatry’s persistent failure to address, or even acknowledge, its problems, and I also drew attention to the APA’s Council on Communications’ mission:

  • Connecting the public emotionally to psychiatrists
  • Creating excitement about psychiatrists’ ability to prevent and treat mental illness, and
  • Branding psychiatrists as the mental health and physician specialists with the most knowledge, training, and experience in the field

My point then was, and now still is, that this is nothing more than a tawdry PR job, when what’s needed is a massive house-cleaning.

What’s interesting in the present context is that Dr. Lieberman has clearly taken the Council on Communications agenda to heart.  All of his posts lately have been more like cheerleading scripts than what one might legitimately expect from the President of a specialty medical association.  He plugs away endlessly at the same few self-serving themes, e.g.: we’re real doctors – really; we need a psychiatrist in every GP’s office; we need to expand services; we need more mental health screening; we need parity with general medicine; the great neuroscientific breakthrough is just around the corner, etc…

But no sign of an apology for the damage they have done, no critical re-appraisal of their spurious concepts, and no retreat from the expansionist philosophy that has driven psychiatry for the past 50 years.  Just the same old spurious, self-serving propaganda.

 

 

Neuroleptics for Children: Harvard’s Shame

In December 2012, Mark Olfson, MD, et al, published an article in the Archives of General Psychiatry.  The title is National Trends in the Office-Based Treatment of Children, Adolescents, and Adults with AntipsychoticsThe authors collected data from the National Ambulatory Medical Care Surveys for the period 1993-2009, and looked for trends in antipsychotic prescribing for children, adolescents, and adults in outpatient visits.  Here are the results:

Age Increase in no. of antipsychotic prescriptions per 100 population (1993-2009)
0-13 0.24-1.83 (almost 8-fold)
14-20 0.78-3.76 (almost 5-fold)
21+ 3.25-6.18 (almost 2-fold)

 

The authors provide a breakdown of the diagnoses assigned to the children and adolescents during the antipsychotic visits.

Diagnosis Visits %
Children
(0-13)
Adolescents
(14-20)
Schrizophrenia 6.0 8.1
Bipolar 12.2 28.8
Depression 11.2 20.9
Anxiety 15.9 14.4
Dev Disorders 13.1 5.0
Disruptive Behavior Disorders 63.0 33.7
Other Dx’s 18.0 16.8

 

Percentages do not total 100, because some individuals were assigned more than one diagnosis.

It is clear that disruptive behavior disorders are the most common diagnoses used in antipsychotic visits for both children and adolescents.

Thirty years ago, the prescription of neuroleptic drugs to children under 14 years of age was almost unheard of.  It was rare in adolescents, and even in adults was largely confined to individuals who had been given the label schizophrenic or bipolar.

By 1993, the first year of the Olfson et al study, about a quarter of 1% of the national childhood population were receiving antipsychotic prescriptions during office visits.  The percentage for adolescents was about three quarters of 1%.  By 2009, these figures had increased to 1.83% and 3.76% respectively.

The devastating effects of these neurotoxic drugs are well known, and it is natural to wonder what forces might be driving this trend.  The authors suggest that:

“Increasing clinical acceptance of antipsychotics for problematic aggression in disruptive behavior disorders may have increased the number of children and adolescents (especially male youths and ethnic/racial minorities) being prescribed antipsychotics.  The increase in the number of clinical diagnoses of bipolar disorder and autistic spectrum disorders among children and adolescents may have further increased antipsychotic use by youths, particularly by boys.”

They also note that:

“The trend in the prescribing of antipsychotics to youths occurred within the context of a dramatic increase in the clinical diagnoses of bipolar disorder among young people.”

The notion that the increase in the prescription of neuroleptics for children is driven by increased use of the bipolar diagnosis is supported by another study:  Most Frequent Conditions in U.S. Hospitals, 2010,  by Plunter et al, January 2013, published by the Agency for Healthcare Research and Quality (a division of the US Department of Health and Human Services).  This study, which analyzed hospital admission data from 1997 to 2010, found that mood disorder, which in 1997 had been in the fourth place (behind asthma, pneumonia, and appendicitis) was by 2010 the most common diagnosis for children aged 1-17.  In the 13-year period admissions for mood disorders had increased 80%, while admissions for asthma and pneumonia had decreased by 30% and 16% respectively.

Most of the increase in mood disorder frequency was for bipolar disorder.  In the period studied, admissions for children for depression rose 12%, but admissions for bipolar disorder rose 434% (from 1.5 per 100,000 population to 8.2).  For children in the age group 5-9, the increase was 696%! – a seven-fold increase.

So, over the last decade or two, we’ve seen a huge increase in the number of children being hospitalized for bipolar disorder and in the number of children being prescribed neuroleptics in office visits.

HOW DID THIS HAPPEN?

Neuroleptics are probably the most damaging drugs used in psychiatry.  The adverse effects, including permanent and extensive brain damage, are devastating, and occur in virtually all of cases where use is prolonged (Breggin, 2011, p 197).  In former decades, their use was confined mainly to adults who had been labeled schizophrenic or bipolar.  It was routinely claimed by psychiatrists that their benefits outweighed the risks, though this contention is not standing up to the increasing scrutiny that has occurred in the past decade or so.

The increase in the prescription of neuroleptic drugs for children is a direct consequence of the increased use of the bipolar label in that population.  And most of the responsibility for that increase can, in my view, be laid at the door of one person:  Joseph Biederman, MD, of Harvard Medical School and Massachusetts General Hospital.  Dr. Biederman will go down in history as the inventor of pediatric bipolar disorder.

DSM-III-R was published in 1987.  It makes no reference to the existence of childhood bipolar disorder.  The total entry under Prevalence is:

“It is estimated that 0.4% to 1.2% of the adult population have had bipolar disorder.” [emphasis added]

DSM-IV, published in 1994, greatly expanded the concept of bipolar disorder, essentially by removing the requirement of a manic episode or a mixed (manic-depressive) episode.  References to age are vague – e.g.:

“Approximately 10%-15% of adolescents with recurrent Major Depressive Episodes will go on to develop Bipolar I disorder.”

It is not clear whether this “development” might occur in late adolescence or in adulthood. There is no suggestion that bipolar disorder can occur in a pre-adolescent child.

By 1996, however, Dr. Biederman and his colleagues at Harvard were promoting childhood bipolar disorder as an accepted psychiatric diagnosis that needed to be treated with pharmaceutical products, including neuroleptics.  This was accomplished primarily by selling the notion that childhood temper tantrums could legitimately be regarded as symptoms of mania.  This blatant distortion of the traditional concept of mania was facilitated by the “not otherwise specified” (NOS) qualifier which has been a component of almost all diagnostic categories since DSM-III.  The purpose of the NOS diagnoses is to enable psychiatrists to assign the diagnosis in question to an individual even though he doesn’t actually meet the criteria.  The fact that this renders the criteria somewhat pointless is generally lost on psychiatrists, but that’s a different story.

What the Bipolar Disorder NOS diagnosis enabled Dr. Biederman and his colleagues to say was essentially this:

We know that temper tantrums aren’t really an integral component of bipolar disorder as it is traditionally conceived.  But we believe that that’s how bipolar disorder presents itself in young children, and so that’s what we’re going to call it.

This is on a par with dermatologists deciding that pattern baldness is a symptom of psoriasis!  In real medicine, this isn’t how it’s done, but in psychiatry it’s the norm.  The “diagnoses” are fictitious.  They can be created, modified, and eliminated with strokes of a pen.  This is what Dr. Biederman and his Harvard colleagues did, and American psychiatry followed.  The neuroleptics-for-children spigot was opened, and is running freely to this day.

The creation and promotion of pediatric bipolar disorder has been described and critiqued by several writers.  Joanna Moncrieff, a British psychiatrist, provides an excellent account in her book The Bitterest Pills (2013 , p 200-205).  Here are some quotes:

“Although it is the adult market that accounts for the bulk of sales of atypical antipsychotics, it is the use of these drugs in children alongside the emergence of the diagnosis of paediatric bipolar disorder that best illustrated the way in which a severe mental disorder can be morphed into a label for common or garden difficulties, as well as the role that money plays in this process.”

“Moreover, by locating the problem in the brain of the child, it seemingly detaches it from the situation within the family.”

“Academic psychiatry fuelled this craze, with added financial incentive from the pharmaceutical industry…”

“In the 1990s, a group led by child psychiatrist Joseph Biederman, who was based at Massachusetts General Hospital and the prestigious Harvard Medical School, started to suggest that children could manifest ‘mania’ or bipolar disorder, but that it was frequently missed because it was often co-existent with other childhood problems like ADHD and ‘antisocial’ behaviour…  In a paper published in 1996 the group suggested that 21% of children attending their clinics with ADHD also exhibited ‘mania’, which was diagnosed on the basis of symptoms such as over-activity, irritability and sleep difficulties…  A year later the group were referring to bipolar disorder in children as if it were a regular, undisputed condition, and emphasized the need for ‘an aggressive medication regime’ for children with the diagnosis…”

“Neither Harvard nor Massachusetts General Hospital nor any other psychiatric or medical institution has commented on the fact that prominent academics were found to be enriching themselves to the tune of millions of dollars through researching and promoting the use of dangerous and unlicensed drugs in children and young people.  Although some individual psychiatrists have expressed misgivings…academic papers continue to discuss the diagnosis, treatment and outcome of bipolar disorder in children as if no controversy existed, with more than 100 papers on the subject published in Medline-listed journals between 2010 and 2012.  Notwithstanding…the disgrace of Joseph Biederman, the practice of diagnosing children with bipolar disorder and treating them with antipsychotics remains alive and kicking.”

The spurious creation of childhood bipolar disorder has been critiqued also by Mickey Nardo, MD, a retired psychiatrist who blogs under the name 1 Boring Old Man (which, incidentally, he isn’t).  On July 2, 2011, he published a post called bipolar kids: an all too familiar lingo…  Here are some quotes:

“What happened in that second half of the 1990s is that they created a new diagnosis – Pediatric Bipolar Disorder. Looking at these articles…or at the COBY Study [started right around this time], Bipolar Disorder in children was becoming a common diagnostic term, but the diagnostic criteria bore little resemblance to the familiar symptom complexes from the Manic Depressive Illness of old. It was something new masquerading as something old [or vice versa]. These kids weren’t euphoric, they were irritable.”

“…the Biederman-led movement to broaden the category to call all kinds of difficult and disruptive children Bipolar had little to no scientific basis. It felt like a rationalization to use the new atypical antipsychotics to control difficult behavior-disordered kids – a trick.”

“And even without knowing what we know today about what happened, at the turn of the last century there was plenty of reason to smell a rat [named pharma]. The articles had all the tell-tale phrases – “urgent public health problem” “emerging new treatments” “need for more research” – an all too familiar lingo that pointed down a well-traveled yellow brick road. And this time it didn’t lead to Oz, it lead to Harvard University. And the guy behind the curtain was Joseph Biederman …”

Ultimately Dr. Biederman was disgraced – not for the spurious expansion of a diagnostic category.  Diagnostic expansion has been psychiatry’s primary agenda for the past 60 years.  A small minority of psychiatrists might have had reservations concerning Dr. Biederman’s work, but the mainstream psychiatry-pharma alliance embraced the new development with their customary zeal and self-serving enthusiasm.

Nor was Dr. Biederman disgraced because he had deliberately encouraged the exposure of thousands of children to neurotoxic chemicals.  Again, that’s just business as usual.  And in fact, he received awards and accolades for drawing attention to the plight of these tragically “underserved” children.  Here are some of the awards and honors he has received since his ground-breaking work on childhood bipolar disorder:

  • NAMI Exemplary Psychiatrist Award
  • NARSAD Senior Investigator Award
  • ADHD Chair of World Psychiatric Association
  • Outstanding Psychiatrist Award, Massachusetts Psychiatric Society
  • Excellence in Research Award, New England Council of Child and Adolescent Psychiatry
  • Mentorship Award, Psychiatry Department, Massachusetts General Hospital
  • William A. Schonfeld Award for outstanding achievement and dedication
  • Distinguished Service Award, MGH/McLean Child and Adolescent Psychiatry Residency

He was disgraced for under-reporting to his employers at MGH and Harvard the amount of money he was receiving from the pharmaceutical industry for conducting research that was used to promote their products.  Here again, there was nothing particularly unusual in this.  The so-called Key Opinion Leaders (KOL’s) in psychiatry have been awash in pharma money for decades.  But Dr. Biederman’s take ($1.6 million) was on the high side, and came to light at a time when the corrupt psychiatry-pharma alliance was being exposed nationally, largely through the efforts of Iowa Senator Charles Grassley.

Dr. Biederman was also criticized for promising Johnson & Johnson a positive result for their neuroleptic drug risperidone in pre-school children before he had actually conducted the research.  Obviously this makes a mockery of the research, but psychiatric research was hijacked by pharma marketing decades ago.  It has long since ceased to be a source of genuine scientific information, and much of it instead is little more than marketing material bought and paid for by the pharmaceutical industry.  Dr. Biederman’s error in this area was that he committed his promises to writing (in the form of slides that he presented to Johnson & Johnson executives), and these slides and other correspondence came to light during lawsuits against Johnson & Johnson for fraudulent marketing of their products.  These are the same lawsuits that Johnson & Johnson recently settled for $2.2 billion.

The great irony with regard to Dr. Biederman’s premature promise of a positive result for Johnson & Johnson is that he was absolutely correct!  If you give a neuroleptic drug to a misbehaved child, the incidence of misbehavior will indeed decrease.  If you give him enough, he’ll go to sleep and won’t misbehave at all!  That’s why these drugs used to be called major tranquilizers.  Dr. Biederman could accurately predict this result in advance because that’s what major tranquilizers do.  If you conduct a study to see if alcohol will make people drunk you’ll get a positive result.  If you conduct a study to see if major tranquilizers subdue childhood temper tantrums, you’ll get a positive result.  Dr. Biederman couldn’t use this defense, however, because he, like psychiatrists in general, has to play along with the big fiction:  that childhood temper tantrums are a symptom of an illness, and that the drugs are medicines targeting specific faults in neural circuitry or chemical imbalances or whatever.  Dr. Biederman’s proposed study would have produced a positive results for Risperdal in the same way that most industry-sponsored studies obtain positive results:  by limiting outcome criteria to the known effects of the drug, by keeping follow-up times short, and by ignoring adverse effects.

Dr. Biederman’s ethical lapses were thoroughly investigated (for three years) by his bosses at MGH and Harvard, and in 2011 they gave him and two of his colleagues (Thomas Spencer – total take:  $1.0 M, and Timothy Wilens – total take:  $1.6 M) very, very severe slaps on the wrists.  The Boston Globe covered this story.  Here’s a quote:

“The three psychiatrists apologized in their letter for the ‘unfavorable attention that this matter has brought to these two institutions.’  They called their mistakes ‘honest ones’ but said they ‘now recognize that we should have devoted more time and attention to the detailed requirements of these policies and to their underlying objectives.’

They said the institutions imposed remedial actions, requiring them to refrain from all paid industry-sponsored outside activities for one year, with an additional two-year monitoring period during which they must obtain approval before engaging in paid activities. They were also required to undergo unspecified additional training and suffer ‘a delay of consideration for promotion or advancement.'”

The notion that the ethical lapses of these three psychiatrists were “honest mistakes” is a little hard to credit, given that the total dollar amount was more than $4 M!

Today Dr. Biederman is fully rehabilitated and is back in business. He’s receiving research funding from ElMindA, Janssen, McNeil, and Shire, and is once again churning out research papers on topics such as ADHD and, guess what? – pediatric bipolar disorder.

THE BIG QUESTIONS

The two big questions in all of this are:

1.  Why do Harvard and Massachusetts General Hospital stand for this kind of blatant corruption and deception in the upper echelons of their psychiatry department?

2.  Why does the APA not take a stand against the medicalization and drugging of childhood temper tantrums – a problem that parents of previous generations simply took in their stride as an integral part of normal childrearing?

With regards to the APA, it’s really not much of a question.  Their agenda has always been: more psychiatric drugs for more people, and the neuroleptics-for-children development is really just business as usual.  They have dulled their ethical sensibilities through decades of prescribing benzodiazepines, SSRI’s, methylphenidate, and various other neurotoxins for an ever-widening range of human problems, and prescribing a neuroleptic to a 1½ year old for temper tantrums is a short step.

The APA, however, did express some mild concern about the spurious extension of the bipolar label to children.  In DSM 5 (p 132) they state:

“In individuals with severe irritability, particularly children and adolescents, care must be taken to apply the diagnosis of bipolar disorder only to those who have had a clear episode of mania or hypomania – that is, a distinct time period, of the required duration, during which the irritability was clearly different from the individual’s baseline and was accompanied by the onset of Criterion B symptoms.”

But rather than risk losing the pediatric business, hard-won by Harvard’s psychiatrists, they created a new diagnosis:

“When a child’s irritability is persistent and particularly severe, the diagnosis of disruptive mood dysregulation disorder would be more appropriate.”

The effect of all this is that psychiatrists can go on prescribing drugs for childhood temper tantrums, but instead of calling them bipolar disorder, they should use the new label:  disruptive mood dysregulation disorder – but they can continue to use the bipolar diagnosis also, with a few caveats, couched in the APA’s characteristically vague language.

Harvard’s stance on the scandals is a little harder to fathom.  After all, Harvard is hallowed ground – America’s Oxbridge.  It has acquired an image as a center of learning where educational and research standards eclipse all other considerations.

And in fact, there are legal and medical ethicists at Harvard who clearly recognize the implications of the psychiatric scandals.

Earlier this year, the Journal of Law, Medicine & Ethics (Vol 41, Issue 3) published a symposium of 17 papers written by members of Harvard’s Edmond J. Safra Center for Ethics.  Here are some of the titles:

Here are some quotes:

“The pharmaceutical industry has corrupted the practice of medicine through its influence over what drugs are developed, how they are tested, and how medical knowledge is created.” (Light et al)

“In this article, we analyze how drug firms influence psychiatric taxonomy and treatment guidelines such that these resources may serve commercial rather than public health interests.” (Cosgrove and Wheeler)

“Pharmaceutical and medical device companies apply social psychology to influence physicians’ prescribing behavior and decision-making.” (Sah and Fugh-Berman)

Clearly these papers are addressing important and relevant topics.  But what’s particularly noteworthy, from the present perspective, is that they originated in Harvard – the same institution in which senior psychiatry faculty members were hand-in-glove with pharma in the production of fraudulent research and advertizing.  How are we to understand this contradiction?  How are we to understand the minimal response from Harvard’s management, and incidentally from the other academic departments, given that such a wealth of ethical resources was there on their own campus, presumably available and willing to be consulted on these kinds of matters.

BUSINESS ETHICS VS UNIVERSITY ETHICS

In America, it is becoming increasingly recognized, and even accepted, that big businesses are frequently amoral.  Considerations of right and wrong are routinely subordinated to bottom line accounting.  Many big pharmaceutical companies are perceived in this light.  Indeed, the recent $2.2 B  penalty levied against Johnson & Johnson was discussed in some media outlets quite simply as a “cost of doing business.”  The question of whether it is a good thing to promote the use of neuroleptics for children doesn’t even come on the radar.  The perverse calculus is reduced to the difference between the projected profits from the drugs sales, and the fines and lawsuit settlements that might ensue.

Has Harvard’s Psychiatry Department, in concert with their pharmaceutical allies, crossed this line?  Have they now, implicitly or explicitly, adopted the ethical standards of the business world?  Have they subordinated their sense of decency and shame to considerations of prestige and revenue?

And what of the MGH/Harvard leadership?  Do they actually believe that the sanctions imposed on Dr. Biederman and his colleagues are adequate?  Or do they reckon that the years of past and future pharma revenue are worth the cost?  Have they crossed the line into the shady realm of business ethics?

And as we ponder these thorny questions, let’s not forget that the Johnson & Johnson lawsuit listed psychiatric researchers at other renowned universities, including Johns Hopkins, Stanford, UCLA, University of Illinois at Chicago, University of Texas at Austin, Georgia Regents, University of Toronto, and Dalhousie University.

Meanwhile the destructive prescribing continues, and Dr. Biederman is still at MGH, where he is Chief of the Clinical and Research Programs in Pediatric Psychopharmacology and Adult ADHD, and at Harvard, where he is a full Professor of Psychiatry, a position, which, by his own account, ranks just below God!

Psychiatry’s primary agenda for the past 60 years has been the expansion of their diagnostic net to embrace an increasing range of ordinary human problems, and the unscrupulous prescribing of more and more psycho-pharmaceutical products to more and more people.  In the final analysis, Dr. Biederman’s problem was that he was particularly good at this job.  He was, in effect, a Model Psychiatrist – the perfect embodiment of everything that the APA stands for.

CLARIFICATION OF TERMINOLOGY

My frequent use of the term bipolar disorder in this article should not be interpreted as an endorsement on my part of the ontological validity of this expression, much less its status as an illness or disease.  I use the term bipolar disorder (and the various other so-called diagnoses) for the sake of readability and linguistic convenience.  What I mean by “bipolar disorder” is:  the vaguely defined and loosely clustered behaviors, thoughts, and feelings that psychiatrists call bipolar disorder.

Causes of High Mortality in People Labeled ‘Mentally Ill’

ANOTHER VIDEO FROM DR. LIEBERMAN

On October 28, Jeffrey Lieberman, MD, President of the APA, made another video.  This one is titled An Important Look at Mortality in Mental Illness: A Decade of Data on Psychotropic Drugs, and was made for Medscape.  You can see the transcript at the same site.  Medscape is a web resource for medical practitioners.

The video is Dr. Lieberman’s commentary on an article that appeared in JAMA Psychiatry online on August 28:  Comparative Mortality Risk in Adult Patients With Schizophrenia, Depression, Bipolar Disorder, Anxiety Disorders, and Attention-Deficit/Hyperactivity Disorder Participating in Psychopharmacology Clinical Trials, by Arif Khan, MD, et al.

Dr. Lieberman tells us that:

“The bottom line from this very good and important study, which was carried out with a large amount of data obtained from the administrative database of the FDA, is that psychotropic drugs are in the aggregate very beneficial — not just in suppressing patients’ symptoms, but in extending their overall survival and reducing mortality. In the ongoing debate in the literature as well as in the media about whether psychotropic drugs are overprescribed or are potentially detrimental to health, as physicians we must always be aware that medications should be used only when indicated and very judiciously in all people, particularly in children and the elderly — but we should never withhold them when they are needed, because they are very beneficial in terms of therapeutic effects. They should not be avoided, and their benefits are not substantially mitigated by concerns about adverse effects and shortened life spans.”

and

“They found, as has been previously reported many times, that individuals who have psychiatric disorders, and particularly schizophrenia, bipolar disorder, and depression, have lower overall survival (increased mortality). Of interest, being on a psychotropic medication (antipsychotic, mood stabilizer, bipolar medication or a combination of drugs) was associated with increased survival and lower mortality in patients with schizophrenia or bipolar disorder.”

WHAT THE ARTICLE ACTUALLY SAYS

The JAMA Psychiatry article by Arif Khan et al searched the FDA data bases for Summary Basis of Approval (SBA) reports of new and supplemental drug applications for 28 drugs approved between 1990 and 2011.

The researchers extracted mortality and drug exposure information from these SBA reports and collated the results.  The combined analysis included data on 92,542 clients.

The authors drew the following conclusions.

“These data suggest that increased mortality rates reported in population studies are detectable among adult patients with psychiatric illnesses participating in psychopharmacological trials. Furthermore, 3- to 4-month exposure to modern psychotropic agents, such as atypical antipsychotic agents, selective serotonin reuptake inhibitors, and selective serotonin-norepinephrine reuptake inhibitors does not worsen this risk. Given the inherent limitations of the FDA SBA reports, further research is needed to support firm conclusions.”

 So as you can see, there’s a huge discrepancy between the conclusions drawn by the authors and the “conclusions” promoted by Dr. Lieberman on his Medscape video.  Dr. Lieberman stated that:

“…psychotropic drugs are in the aggregate very beneficial — not just in suppressing patients’ symptoms, but in extending their overall survival and reducing mortality.” [Emphasis added]

The researchers point out that these studies entailed only 3-4 month exposure to the drugs – clearly not enough time to make any kind of definitive statement about reductions in mortality rates.  This is especially true in that psychiatrists routinely tell their clients that they need to take the drugs for extended periods – sometimes for life.

The researchers also point out that the FDA’s SBA reports have some “inherent limitations” with regards to the present study.  They discuss some of these limitations:

“Because of the abbreviated and variable form of FDA SBA reports, we could not assess premorbid history, age and sex of the clinical participant, family history, course of  illness, or details of any autopsy reports. Furthermore, deaths occurring among clinical trial participants exposed to placebo or active comparators were infrequent and difficult to interpret.”

and

“In addition, we could not fully evaluate all the clinical trial data for a variety of reasons. First, the data included in the FDA SBA reports in general consist of data from the registration or “pivotal” trials. These are only a fraction of studies conducted, and unfortunately data from the others cannot be accessed via the FOIA as interpreted by the FDA.” [Emphasis added]

And again, they stress the need for caution in interpreting their findings:

“Our results suggest that further detailed analysis of the clinical trial data by the FDA or the pharmaceutical companies is required before any firm conclusions can be drawn.

Furthermore, it is desirable to acquire much longer-term data, such as a decade in duration, regarding potential mortality risk when exposed to psychotropic agents based on the findings from the population studies. To obtain definitive results, prospectively designed studies are required.” [Emphases added]

DISCUSSION

It is clear that Dr. Lieberman has significantly misrepresented the results of the Khan et al study.  So there are two possibilities:  either he was genuinely confused, or he is consciously attempting to deceive medical practitioners who rely on Medscape.

The notion that he is genuinely confused is hard to sustain because in the first half of his video, he makes it clear that he is aware of the debate concerning the mortality-drugs link.  He says:

“This is important, because it has previously been suggested (and this fact has been used by critics of psychotropic medications) that psychotropic drugs, particularly the second-generation antipsychotic medications or mood-stabilizing drugs, contribute to side effects and medical comorbid conditions that shorten survival and increase mortality. These findings suggest that the opposite is true. Being on the medication in no way increased mortality; in fact, it actually reduced mortality, despite the fact that the studies that were obtained and analyzed were largely acute treatment studies of short duration, not the long duration that patients take these medications.”

Dr. Lieberman is obviously aware of the widely-expressed concerns that neuroleptics and SSRI’s are contributing to the increased mortality of people who take these drugs.  He is also aware that the toxic effects of these products are cumulative, and that most of the mortality effects become apparent in the long-term, rather than in the first 3-4 months.

He should also be aware of the following studies:

Bralet M C, et al, Cause of mortality in schizophrenic patients: prospective study of years of a cohort of 150 chronic schizophrenic patients, Encephale. 2000 Nov-Dec;26(6): 32-41. [original article in French].

“Concerning the comparisons between the deceased subjects and the survivors, there were five significant differences: gender, age, duration of the illness, neuroleptic dosage, negative symptoms (BPRS negative subscale). The deceased subjects were older, there was more men, the duration of the illness and the neuroleptic dosage were higher and the BPRS negative subscale was lower. These five variables were introduced in the discriminant analysis to explore notably their respecting weight. The corresponding power of the five variables were in decreasing order: neuroleptic dosage, negative symptoms, age, gender, duration of the illness.” [Emphasis added]

Honkola J, et al, Psychotropic medications and the risk of sudden cardiac death during an acute coronary event, Eur Heart J. 2012 Mar: 33(6): 745-751.

“The use of psychotropic drugs, especially combined use of antipsychotic and antidepressant drugs, is strongly associated with an increased risk of SCD [sudden cardiac death] at the time of an acute coronary event.”

Osborn DP, et al, Relative risk of cardiovascular and cancer mortality in people with severe mental illness from the United Kingdom’s General Practice eRsearch Database, Arch Gen Psychiatry. 2007 Feb; 64(2): 242-9.

“…a higher prescribed dose of antipsychotics predicted greater risk of mortality from CHD [coronary heart disease] and stroke.”

Berg K, et al, Pre-Admission Use Of Selective Serotonin Reuptake Inhibitors Is Associated With ICU Mortality, presentation American Thoracic Society 2012 International Conference, San Francisco.

“After adjusting for age, gender, ICD-9 diagnosis, disease severity and co-morbidities, the researchers found that patients on SSRI/SNRI’s prior to admission to the ICU were 73 percent more likely to die in the hospital (p<0.001), and that the increase in risk persisted at one year.”

Newcomer JW, Antipsychotic medications: metabolic and cardiovascular risk, J Clin Psychiatry. 2007; 68 Suppl 4:8-13.

“…psychotropic agents, including some antipsychotic medications, are associated with substantial weight gain, as well as with adiposity-dependent and possibly adiposity-independent changes in insulin sensitivity and lipid metabolism, which increase the risk of diabetes and cardiovascular disease.”

Sernyak MJ et al, Association of diabetes mellitus with use of atypical neuroleptics in the treatment of schizophrenia, Am J Psychiatry. 2002 Apr; 159(4):561-6.

“In this large group of patients with schizophrenia, receipt of a prescription for atypical neuroleptics was significantly associated with diabetes mellitus.”

American Diabetes Association Professional Tool #1: Screening and Monitoring in a High-Risk Population: Antipsychotic Medications and the Risk of Diabetes and Cardiovascular Disease

“A 2004 American Diabetes Association (ADA) Consensus Development Conference concluded that certain SGAs [second generation antipsychotics] are associated with the potential for rapid weight gain, deterioration in lipoprotein profile and increased risk of type 2 diabetes. Although the mechanisms underlying these effects remain incompletely understood, these potential side effects are of significant concern because of the association between these adverse cardiometabolic events and risk for diabetes and premature cardiovascular mortality.”

Weinmann S et al, Influence of antipsychotics on mortality in schizophrenia: Systematic review, Schizophr Res. 2009 Aug; 113(1):1-11

“There is some evidence that long-term exposure to antipsychotics increases mortality in schizophrenia. More rigorously designed, prospective studies are urgently needed.” [Emphasis added]

On the basis of all this, it is difficult to avoid the conclusion that  Dr. Lieberman made and published this video with the express purpose of deceiving medical practitioners who rely on Medscape for up-to-date information.  He never once drew attention to the authors’ own cautionary statements.  Even his presentation’s title (as shown on the transcript) is misleading: An Important Look at Mortality in Mental Illness: A Decade of Data on Psychotropic Drugs.  Combining the words “mortality” and “decade” in a title gives the impression that mortality figures were tracked for a ten-year period.  This was emphatically not the case.  What was analyzed was a decade’s worth of data, all of which involved a 3-4 month follow-up period.

His statement towards the end of the video is unambiguous:

“They [psychotropic drugs] should not be avoided, and their benefits are not substantially mitigated by concerns about adverse effects and shortened life spans.”

When we remember the truly horrendous adverse effects of neuroleptics, SSRI’s, and benzodiazepines, it is an extraordinarily sweeping – even reckless – statement.

By way of contrast with Dr. Lieberman’s sweeping statement, here’s what Michael Birnbaum, MD, a psychiatrist at Zucker Hillside Hospital in New York said when asked by Medpage for a comment:

“The majority of the studies included in this paper were of 3 to 4 months’ duration, and so what we really need to do now is appreciate the long-term effects of these medications on the brain and the body…Our psychiatric patients are often on these medications for months if not years, so it would be important for us to recognize the potential impact of these medications on mortality long term.”

Of course Dr. Birnbaum is not an eminent thought leader like Dr. Lieberman.

Psychiatry is under attack on a wide range of fronts.  The attacks are founded, and psychiatry has no rational, coherent response.  All they can do is repeat their spurious mantra that all significant problems of thinking, feeling, and/or behaving are brain illnesses that need to be treated with drugs.  They are blind and indifferent to the damage and disempowerment that they leave in their wake, and they grasp at any straw to support and promote their position.  They appear to be incapable of critical self-appraisal.

INCIDENTALLY

Dr. Khan, psychiatrist, the principal author of the JAMA study, received $1,518,215 from pharmaceutical companies in the period 2010-2012 [Dollars for Docs].  At the present time he serves as Medical Director for two pharmaceutical companies:   Columbia Northwest Pharmaceuticals LLC, and Rhine Pharmaceuticals LLC, of Bellevue, Washington (from his curriculum vitae).

Dr. Khan owns and operates Northwest Clinical Research Center in Bellevue, Washington.  NWCRC is a prolific producer of psychiatric research.  They publish papers in journals, and on posters which are displayed at various medical association conferences.  I looked at two of their articles published in 2011:  Weisler RH, Khan A, et al, and Khan A, Cutler AJ, et al.  Both of these studies found favorable results for their sponsors’ products (Bristol-Myers Squibb and Forest Labs respectively).

MORTALITY AND PSYCHIATRIC “DIAGNOSES”

It is indeed the case that people who are assigned psychiatric “diagnoses” have generally higher mortality rates than the general population.  This fact is frequently presented as proof that the conditions in question are real illnesses.

The logic, however, is fallacious.  Mountain-climbers have higher than average mortality, but nobody would suggest that mountain climbing is an illness.  The same could be said of people who routinely ride bicycles in heavy traffic, engage in unprotected sex, work in dangerous occupations, etc…

The excess mortality associated with psychiatric “diagnoses” derives from two main sources:

Firstly, the DSM criteria that define these so-called illnesses contain many items that are, I suggest, intrinsically linked to higher mortality.  These include:  disorganized behavior; poor nutrition; lack of goal-directed activity; risk-taking; distractibility; disrupted sleep pattern; agitation; attempted suicides; feelings of guilt; social isolation; animosity towards others; outbursts of anger; neglect of health; etc… Psychiatry uses items like these to define “mental illnesses,” and then “discovers” that the people with these “illnesses”  have a high mortality rate.  In fact, the high mortality rate is built into their very definitions of these conditions.

Secondly, the drugs that psychiatry uses to “treat mental illnesses” all have toxic effects, which over time create medical problems and lower life expectancy.

So, instead of helping these individuals overcome these problems and lead fruitful and longer lives, psychiatry drugs them, often involuntarily, and thereby shortens their lives even further.

Psychiatry is not something good that needs some minor corrections.  It is something flawed and rotten that needs to be criticized, exposed, and ostracized.

Care For Your Mind (CFYM): A New Advocacy Group

On September 27, Psychiatric Services, a journal of the APA, published an article called Blog Brings Doctors, Patients Together to Address MH Issues.  It was written by Vabren Watts, a Psychiatric News Journalist.

The article is a booster piece for the recently-formed CFYM (Care For Your Mind):

“…an online forum for people with mood disorders—along with their families and psychiatrists—to discuss the mental health care system and changes that may affect them under health care reform.”

The article tells us that CFYM is a

 “…joint venture by the Depression and Bipolar Support Alliance (DBSA) and Families for Depression Awareness (FFDA).”

The author trots out the usual statistics:

“According to the National Institute of Mental Health, mood disorders affect 21 million people in the United States annually, are linked to 90 percent of the nation’s suicides, and cost $23 billion a year in lost workdays. Despite the prevalence of these illnesses and the serious sequelae, only about half who need care receive adequate treatment.”

Susan Weinstein, JD, director of programming and marketing at FFDA is quoted as saying:

“We are looking at the Affordable Care Act to open a lot of doors for people to get mental health care access.”

Cheryl Magrini, Ph.D., vice president of the DBSA Board of Directors is quoted:

“The ACA can be so confusing….I’m finally learning about what it means for people to get access to insurance and what actions to take that will lead us down the quickest road to access it,”

CFYM has a “Welcome” page and an “About” page.  The content of these is what you’d expect, e.g.:

“Our hope is that, by learning about current mental health care issues and engaging in the Care for Your Mind community, we will all come together to help increase everyone’s access to, and improve the quality of, mental health care in America.”

 and

“By learning about the issues and engaging in this dialogue, you will help increase everyone’s access to, and improve the quality of, mental health care in America.”

At the end of the “About” page, however, you’ll find this:

“The Takeda Lundbeck Alliance’s involvement in Care for Your Mind (CFYM) is solely as a financial supporter. The Takeda-Lundbeck Alliance was not, and is not, involved in the organizing of CFYM, creation of the content on CareForYourMind.org, or content or development of enduring materials created for or related to CFYM.”

I had never heard of the Takeda Lundbeck Alliance, but I discovered on the Internet that it was formed in 2007:

“…to Develop and Commercialize a Portfolio of Novel Compounds in the US and Japan for the Treatment of Mood and Anxiety Disorders”

And CFYM is trying to give us the impression that this alliance’s funding comes with no strings attached.  Let them highlight a few hard-hitting survivor articles and see how quickly the funding evaporates.

And speaking of funding, DBSA, one of the creators of CFYM, receives a great deal of pharma money.  According to their annual report for 2011, the latest year I could find, Lilly, Forest, Janssen, and Pfizer all made contributions above $25,000; Merck contributed in the $10,000-24,999 range; and Alexza in the $2,500-4,999 range.  In the  2010 report, AstraZeneca’s contributions were in the $150,000-499,999 bracket, and in the 2009 report, both AstraZeneca and Wyeth were in the $150,000-499,999 bracket!

I was unable to find an annual report for FFDA.  However, according to Dollars for Docs, Scott Aaronson, MD, one of FFDA’s Advisory Board members, received more than $300,000 of pharma money between 2009 and 2012.

CFYM’s inaugural post Access to Care was written by Ron Manderscheid, PhD.  He’s the Executive Director of the National Association of County Behavioral Health and Development Disability Directors (NACBHDD).

In the inaugural article, Dr. Manderscheid trots out the standard statistics: e.g.

“Mental disorders affect 1 in 4 US adults (45.6 million) and children/youth (15.6 million)”

He also sings the standard lament that only 40% of these ever get mental health services.  Here are some quotes:

“Without diagnosis and treatment, people get sicker faster.”

“Access to evaluation and diagnosis can help prevent or delay the onset of these conditions. Access to early intervention can move people with diagnosed mood disorders and other mental health conditions toward health and recovery.”

Since their inauguration on May 1 of this year, CFYM has been busy.  They have put up 67 posts in six months.  Their general themes are:

  • promotion of the medicalization of human problems
  • need for increased access to treatment
  • treatment consists primarily of drugs – especially modern drugs
  • the need for mental health preventive programs and screening  in schools
  • need for mental health preventive programs and screening in the workplace
  • expansion of mental health coverage
  • working to bring about parity for mental health coverage

PHARMA FUNDING

Intuitively we know why pharma funds these advocacy groups.  But there’s an interesting article in PharmExec October 2004, that clarifies the issues neatly and succinctly.  It’s called Public Relations: Why Advocacy Beats DTC, and was written by Josh Weinstein, a pharmaceutical executive.

Josh criticizes the in-your-face direct-to-consumer marketing of pharma products.

“…exercises of this type do little to dissuade consumers from the belief that pharma companies have more money than they know what to do with—and those ads are not good for brands, or the industry, in the long run.”

Then the author lays out what he calls the “responsible alternative”:

“On the other hand, working with advocacy groups is one of the most accomplished means of raising disease awareness and enhancing the industry’s image as deliverer of new and tangible value to patients. Often this advocacy work is unbranded, stimulating consumers to ask doctors about their symptoms. Then, companies can compete by promoting their brands to physicians.” [Emphasis added]

CFYM and its sponsors DBSA and FFDA are just cogs in the huge pharma-psychiatric machine in which people’s lives are sacrificed for the sake of corporate profits.

The Allen Frances – Lucy Johnstone Debate

On October 28, Allen Frances, MD, Chairperson of the DSM-IV task force, published an article on Psychology Today.  It is titled Does It Make Sense To Scrap Psychiatric Diagnosis? and is essentially a response to the British Psychological Society’s Division of Clinical Psychology’s (DCP) call to abandon the medical model in situations where it is not appropriate, and to embrace a psychosocial approach.  You can see a copy of the DCP’s May 13, 2013, statement here.

Dr. Frances identifies Dr. Lucy Johnstone, PhD as the “most articulate and energetic supporter” of the DCP position, and most of his article is directed towards material Dr. Johnstone has recently written on these matters.  For ease of reference, Dr. Frances reproduces Dr. Johnstone’s material in his own article.

Dr. Frances sets the tone in the first sentence:

“I am always sceptical of suggested new ‘paradigm shifts’ and worry that ambitiously striving for them will wind up causing more harm than good.”

Dr. Frances lists three examples of proposed paradigm shifts that, in his view, have caused, or will likely cause, more harm than good.

Firstly:

“DSM 5 failed so badly precisely because it promised a ‘paradigm shift’ in psychiatric diagnosis.”

In support of this position, he suggests that the revised manual:

“…may mislabel as mentally ill millions of normal enough people who would do better left alone.”

This, of course, is an interesting perspective, though in my view DSM-5 is failing, not particularly because it sought a paradigm shift or because it continued the APA’s long-standing expansionist agenda, but because psychiatric concepts and practices generally are being exposed as spurious and destructive.  The publicity surrounding the release of DSM-5 gave impetus to this movement, but the general anti-psychiatry sentiment was already well established when the manual was printed.  It is also arguable that DSM-IV, of which Dr. Frances was the architect, widened the diagnostic net at least as much as DSM-5 is likely to do.

Secondly:

“The National Institute of Mental Health has neglected the current needs of the mentally ill because of its preoccupation with producing a ‘paradigm shift’ in understanding the neural networks that cause psychiatric problems.”

And:

“Dreams of the future potential of a neuroscience ‘paradigm shift’ have blinded NIMH to the crying needs of patients in the present.”

I could quibble with some of Dr. Frances’s terminology here, but at a more substantive level, I think it is inaccurate to describe the NIMH’s RDoC program as a paradigm shift.  It’s actually just an extension of what psychiatry has been promoting for decades:  that human problems are best conceptualized as brain illnesses and are best treated with drugs, ECT, and lately, other biological interventions.  Dr. Insel and the NIMH may like to think of RDoC as a paradigm shift, but it isn’t.

Thirdly:

“… the Division of Clinical Psychology (a sub-section of the British Psychological Society) has issued a statement announcing its own opposite brand of radical ‘paradigm shift.’ While paying superficial lip service to the role of brain in generating mind, the DCP suggests abandoning altogether what it regards as an overly restrictive biomedical model- it would eliminate any role for psychiatric diagnosis and instead focus on the role of external stressors in generating symptoms.”

Somewhat by way of an aside, there is a confusion here that needs to be clarified.  Under the present psychiatric system, the primary objective of the initial interview is the assignment of a “diagnosis.”  This “diagnosis” then becomes the basis of “treatment.”  If the “diagnosis” is, say, depression, then the “treatment” will be an antidepressant; if schizophrenia, the treatment will be a neuroleptic, and so on.  Then as treatment progresses, the drugs are changed, doses adjusted, etc., in response to client feedback.  The presenting problem(s) are conceptualized (spuriously) as caused by the diagnosis, and little or no attention is paid to other matters such as personal history, social supports, lifestyle, economic issues, etc…  This is what’s meant by the medical model.  What’s particularly noteworthy about this model is that in medical matters, it is very effective.  If a person has complete kidney failure, for instance, his likely diagnosis will be end-stage renal disease (ESRD), and this diagnosis gives the nephrologist a great deal of the information he needs to provide excellent care.  The nephrologist will, of course, gather additional data in order to tailor make the treatment to the patient, but an accurate diagnosis constitutes the bulk of what he needs to know in order to design good and effective treatment.

But, and this is a crucial point, problems of thinking, feeling, and/or behaving that are not biologically caused, are so varied and individualized as to their source and presentation, that they simply are not amenable to this kind of approach.  A DSM diagnosis, which is nothing more than a notoriously unreliable label, provides very little of the information that a helping professional needs in order to provide good and effective help, and often presents no useful information at all.  In fact, it is frequently a hindrance.

So when Dr. Frances characterizes the DCP’s position as calling for the elimination of “…any role for psychiatric diagnosis and instead focus on the role of external stressors in generating symptoms…,” he is simplifying the DCP’s position to the point of caricature, as even a cursory reading of the DCP’s paper will attest.

The charge of “paying lip-service to the role of brain in generating mind” reflects a misunderstanding of the DCP paper.  The paper clearly acknowledges the role of the brain in the production of thoughts, feelings, and behaviors, and specifically recognizes the value of the DSM’s system in “conditions with an identified biological aetiology.” [emphasis added]  What the DCP paper challenges is the assignment of “an unevidenced role for biology as a primary cause” [again, emphasis added]  in mental problems generally.

But to get back to the main thread, essentially what Dr. Frances is saying is that what’s needed is a middle way.  Those who see mental problems as purely biological, he tells us, are in error, as are those who see these problems as purely psychosocial.  He advocates a biopsychosocial approach, and he develops this theme for the rest of the article.

Dr. Frances begins this discussion by listing the areas in which he is in agreement with Dr. Johnstone and the DCP.

  • Biomedical reductionism is simplistic and misleading.
  • Mental distress must be understood in its context.
  • There are many ways of dealing with emotional difficulties, and excessive professional competition is unhelpful.
  • Limitations in current knowledge of the brain and behavior call for humility.

Then he turns to areas of disagreement.

“But then there are our areas of continuing disagreement. I fear that you [Dr. Johnstone] would replace biological reductionism with a psychosocial reductionism that is equally incomplete, and potentially harmful to patients. Human nature encompasses the complex interaction of biological, psychological, and social factors and understanding and treating psychiatric symptoms requires adequate recognition of each. The biological model has been greatly oversold and medication has been greatly overused- but both remain essential if kept in their proper place.”

It should be noted that psychosocial reductionism is a kind of contradiction in terms – at least as the term is being used here.  This has already been pointed out by Duncan Double in a recent post.  But I think it is reasonably clear that Dr. Frances means focusing on psychosocial factors to the exclusion of biological factors.

“Human nature encompasses the complex interaction of biological, psychological, and social factors…”

This part of the sentence is true, but doesn’t say very much.  All it says is that we humans are made up of biological tissue; and that we can think, feel, learn, etc.; and that we interact a good deal with one another.  But Dr. Frances uses this obvious truism as a springboard for the second part of the sentence:

“… and understanding and treating psychiatric symptoms requires adequate recognition of each.”

This assertion is the central issue of the entire debate, but Dr. Frances has just tucked it in under the biopsychosocial platitude as if it followed logically therefrom, which it does not.

Let’s consider the analogy of Mr. Jones, a businessman, who is in financial difficulty.  He goes to his banker to negotiate an extension to his line of credit.  Imagine if the banker said something like this:

“Mr. Jones, you are a biopsychosocial organism, and for that reason, I need to factor all of these perspectives into your loan application.  So let’s start with your childhood illnesses.”

Or take the case of a person who consults a lawyer to sue his employer for false dismissal.  Would it be reasonable for the lawyer to begin the interview by reviewing the individual’s medical and social history, purely on the grounds that the client is a biopsychosocial organism?

Or if a person went to see a surgeon to have a hernia repaired, how appropriate would it seem for the surgeon to perform a detailed survey of the person’s psychosocial history, again on the grounds that the patient is a biopsychosocial organism.

One can readily think of hundreds of similar examples.  The central point is:  yes, we humans are indeed a complex composite of biological, psychological, and social factors.  We can also be conceptualized from political, economic, historical, evolutionary, artistic, ethnic, linguistic, etc., perspectives.  But this doesn’t mean that all of these factors have to be addressed every time a person seeks help.  To the surgeon, I am primarily a biological entity; to the lawyer, I am primarily a citizen with certain statutorily-defined responsibilities and rights; to Wal-Mart, I’m a consumer with money in my wallet; to a teacher, I’m someone seeking knowledge; etc…

The essential point here is that each practitioner focuses on those aspects of my human nature that are appropriate to the situation.  Of course a certain amount of spillover is warranted in certain cases.  For instance, a surgeon working with a frail, elderly person might want to ensure that the person will have adequate post-surgical care at home, but these kinds of matters, though often important, are usually incidental rather than central.

From this perspective, let’s take another look at “…understanding and treating psychiatric symptoms requires adequate recognition of each.”

My position is simple:  if a problem of thinking, feeling, and/or behaving stems from a biological illness or malfunction, then it should be treated biologically.  Some “spillover” into the psychosocial area might be warranted, but it would be incidental and secondary.  The problem is a genuine medical matter, and a medical model is appropriate.

On the other hand, if the problem is a function of psychosocial factors, which, I contend, the vast majority of these problems are, then it is along those lines that the problem should be conceptualized and addressed.  Here again, spillover will occur.  For instance, if a person has been neglecting his health because of a psychosocially-induced problem, then some medical care might be needed.  But the problem itself is not medical in nature.  The medical model is not an appropriate conceptual framework, and medical interventions are not called for.

At the present time (with the exception of the due-to-a-general-medical-condition category and some of the substance abuse categories), no DSM “diagnosis” has been definitively linked to an identifiable biological illness or malfunction.  No psychiatric drug in current use fixes or resolves any biological malfunction, and there is growing evidence that the drugs are doing a great deal of harm.

Dr. Frances mentions other areas of disagreement and discusses them briefly.  He cautions against over-reliance on psychiatric diagnosis, but warns also against abandoning it altogether.  He agrees that psychiatric drugs are over-used, but stresses that sometimes they are needed.

He concludes his piece with a very reasonable-sounding summary:

“The integrated bio/psycho/social model has a long tradition and remains the best guide to clinical practice. It has always been threatened by reductionisms that would privilege one component over the others- but this interacting tripod of bio/psycho/social approaches is unstable and incomplete without the firm support of all three of its legs. In my view, it is equally mistaken to call for a premature ‘paradigm shift’ tilting toward biology (as was suggested by DSM and NIMH) or a ‘paradigm shift’ tilting toward the psychosocial (as was suggested by the DCP). An integrated bio/psycho/social model is essential to understanding each patient and also to unite the mental health professions.

And we certainly need to be united. Mental health care is terribly disorganized and grossly underfunded, especially (but not exclusively) in the US. I think we should find a unified voice to advocate for better care, not be distracted by debates about paradigm supremacy—especially since all three paradigms are absolutely necessary.”

All of this sounds very reasonable, but let’s take a look at the details.  Firstly, the “integrated bio/psycho/social model” does not have a long tradition – at least not here in the US.  In this regard, the only mental health tradition that I am aware of is the inexorable expansion of the diagnostic net through successive revisions of DSM, and the corresponding medicalization of an increasing array of human problems.  Lip service is paid to psychosocial factors, but in practice they are trivialized or ignored.

“An integrated bio/psycho/social model is essential to understanding each patient and also to unite the mental health professions.”

Here again, this sounds very good, but I suggest that it simply isn’t true.  If a person is going “crazy” because of late-stage syphilis, then, I suggest, psychosocial factors have little or no relevance.  On the other hand, if a person is depressed because his wife has left him, his daughter is in jail, and he hates his job, then, I suggest, biological factors are largely irrelevant.  There might, of course, be “spillover” in each case as discussed earlier, but this is incidental to the general position.

“…to unite the mental health professions.”

This is a complex issue, but I don’t think there will be any significant easing of tension between psychiatry and the other mental health professions until psychiatry abandons what has clearly been its mission for the past 50 years:  the medicalization and commandeering of an ever-increasing range of human problems.  Some problems of thinking, feeling, and/or behaving are indeed medical matters.  Others (probably most) are not.  At the present time, psychiatry is giving no indication that they appreciate this distinction.  In fact, I would argue that the very act of putting a problem in the DSM medicalizes the matter.

Dr. Frances himself acknowledges that “…the biological model has been greatly oversold and medication has been greatly over-used…,” but he doesn’t seem to take on board just how damaging and destructive these developments have been and continue to be, both to individuals and to society in general.  Against this background, his notion that an “integrated bio-psycho-social model” will unite the mental health professions strikes me as fanciful, if for no other reason than the fact that psychiatry appears to be moving further and further from such a model with each passing year.  On September 29, Jeffrey Lieberman, MD, President of the APA, was interviewed on 60 Minutes.  The reporter asked him:

“This [schizophrenia] is really a disease of the brain.  Not a disease of the mind?”

To which Dr. Lieberman replied:

“Absolutely.”

Dr. Frances suggests that we find “…a unified voice to advocate for better care, not be distracted by debates about paradigm supremacy…”

Here again, in my view, he’s missing the point.  This is not some kind of turf war, where we all need to just stop squabbling and sit down and work together.  It is precisely because we “advocate for better care” that we challenge the psychiatric orthodoxy, and call for a paradigm shift.  Decades ago, psychiatry formed a destructive and corrupting relationship with pharma, the results of which persist to this day.  The expansion of the “diagnostic” net was not an accident – it was policy.  The prescribing of drugs for an ever-increasing range of human problems (even to the point of giving neuroleptics to 2-year-olds!) was also policy.  The rift between psychiatry and the other mental health professions is of psychiatry’s making, and it emphatically is not a matter of perceptions, professional rivalry, or turf wars.  It is a real rift.  There is a fundamental incompatibility between the bio-reductionist approach that psychiatry has so avidly embraced, (and shows no sign of relinquishing),  and the approach of most other helping professions.  Most of the non-psychiatric professionals I encountered during my career saw the DSM diagnosis as an inane procedure mandated by psychiatry, for its own self-aggrandizing purposes, to which all must conform if they wish to have a seat at the table.

It is obvious (or at least obvious to me) that the medical paradigm is supreme in medical matters, and the psychosocial paradigm is supreme in psychosocial matters.  The only professional group that disagrees with this position are the psychiatrists, who insist that the medical paradigm is supreme in all matters.

What has changed in recent years is simply this:  psychiatry has pushed its spurious and destructive practices so far that survivors and non-psychiatric mental health workers are no longer willing to just go along.

Sometimes a paradigm shift – meaning a sea-change in concepts and practices – is what’s needed.  When the oxygen theory of combustion supplanted the old phlogiston theory, there was no question of a compromise.  There was no possibility of the two sides sitting down, recognizing the value of each other’s contribution, and agreeing to respect each other’s position.  There was no oxy-phlogistonic approach, nor should there have been.  The simple fact is that some explanatory concepts are better than others.  And psychosocial concepts provide a better framework for understanding and responding to psychosocial matters than do medical concepts.

Psychiatry’s medicalization agenda should have died a natural death (from lack of evidence) decades ago, but has been kept alive through pharma money and psychiatric lobbying and hegemony.  It is truly time for a paradigm shift, and the DCP’s paper is a very good starting point.  Dr. Frances makes the point that the DCP’s approach is untried and unproven, and for that reason should be treated with caution.  I suggest that he talk to social workers, counselors, psychologists, case managers, job coaches, and other non-psychiatric professionals working in the mental health field.  I believe he will find that few if any of them rely on psychiatry’s medical model as a conceptual basis for their work.  They pay lip service to it, of course, because in the end of the day, they need their jobs.  But the concepts and practices that drive their day-to-day interactions with their clients are emphatically psychosocial.  And if Dr. Frances will listen very carefully, I think he will find that these concepts and practices are very similar, though perhaps not as formally stated, as the DCP proposals.

Far from being untried and unproven, the DCP’s paradigm is the unspoken philosophy of the non-psychiatric mental health workers.  These are the dedicated backbone of the mental health system, who for decades have watched with consternation as increasing numbers of their clients have been sucked into the insatiable maw of pharma-psychiatry.

I don’t doubt Dr. Frances’s sincerity.  He appears to believe that the widening rift between psychiatry and the other helping professions can be resolved through dialogue and mutual respect.  Perhaps, in this regard, he sees himself in a mediator role.  But no amount of discussion, however amiable or well-intentioned, will alter the fact that problems that are psychosocial in their origin and in their nature are not amenable to medical intervention.  In fact, medical intervention has proven disastrous for many of psychiatry’s clients, and psychiatric survivors are speaking out with increasing frequency and vigor against the stigmatizing and destructive treatment that they received at the hands of psychiatrists.  To the best of my knowledge, psychiatry is the only medical profession that has a survivor movement.

But again, Dr. Frances doesn’t seem to get it.  In his October 21, 2013, dialogue with Patrick Bracken, an Irish psychiatrist and a founding member of the Critical Psychiatry Network, Dr. Frances expressed the belief:

“Psychiatry is still by far the most human and humane of the medical specialities.”

In response to which I can only shake my  head in disbelief.

 

A Psychiatric Case Study. A Sad Story

One of the criticisms that I routinely make of psychiatry is that its primary agenda during initial evaluations is the assignment of a “diagnosis,” and that ongoing “treatment” consists of 15-minute “med checks,” during which drug regimens are changed and adjusted.  The essence of my criticism is that this kind of approach inevitably oversimplifies human problems, and in practice does more harm than good.

My contentions in this regard have from time to time been challenged.  It has been said that my portrayal of psychiatry is a kind of misleading caricature, and that in reality, psychiatrists do, in fact, concern themselves with human issues over and above “diagnosis” and drugs.  This debate will, of course, continue, but I recently read an article on Psychiatric Times that has some bearing on the matter.  [Thanks to Nick Stuart for the link.]  The title is Conduct Disorder, ADHD – or Something Else Altogether?  The author is Steven Dilsaver, MD, and the piece is dated October 11, 2013.  The article is a case study of the psychiatric “treatment” of an eight-year-old boy (John).

John was brought to an outpatient clinic because of “…highly aggressive destructive behavior and sleeping problems.”

It was noted that his “…parents had been killed in a car accident when he was 5 years old, and just a year later, he had witnessed the violent death of his uncle.”  John was being cared for by his aunt, who became ill during his “treatment” and could no longer care for him.  At this point, he was placed in a facility for homeless children, where he remained for about 10 weeks.  Then he went to live with his grandmother.

JOHN’S TREATMENT

Here’s a summary of John’s psychiatric treatment as described in the case study.

On the basis of the initial interview, John was assigned “diagnoses” of ADHD, PTSD (with hallucinations), and mixed episode.

Day 1.             Rx: 2 mg of prazosin (Vasoflex); 750 mg divalproex (Depakote); 10 mg of aripiprazole (Abilify)
Day 2.             follow-up phone call
Day 8.             no changes
Day 15.           Rx: aripiprazole increased to 15mg

John was “lost to follow-up,” with no treatment, while in the facility for homeless children.

Day 111.         Rx: prazosin 2mg; divalproex 750mg; aripiprazole 15mg
Day 129.         Lisdexamfetamine (Vyvanse), 30mg at 7p.m. added to treatment regimen.
Day 139.         Lisdexamfetamine discontinued following reports of aggression.
Day 143.         no changes
Day 158.         dexmethylphenidate (Focalin) 5mg added to drug regimen
Day 173.         dexmethylphenidate increased to 10mg
Day 185.         dexmethylphenidate increased to 15mg
Day 205.         last visit.  “John had been doing well for 3 weeks.”

The above is a summary.  The text of the article makes reference to reports from caregivers, blood work, and other details.  But it is clear that the “treatment” is conceptualized as the administration of drugs, and there is no reference to any other kinds of intervention.

Final Rx:         2mg prazosin; 750mg divalproex; 15 mg aripiprazole at 6p.m., and 15mg of dexmethylphenidate (7 pm).

Final diagnoses:  PTSD; bipolar I disorder (mixed episode in remission); and ADHD-combined type.

The final paragraph of the article is interesting.

“John presented a complex clinical picture. His behaviors might have led one to suppose he had ADHD-combined or primarily hyperactive type and conduct disorder. However, there was a strong history of trauma and an affective disturbance that included not only irritable but also depressed and euphoric mood along with grandiosity, and the results of the structured interview indicated that he formally met the criteria for both PTSD and mixed episode at presentation. If not for the use of a structured interview format, the features defining these disorders might have been missed and the child treated only for ADHD. His final diagnoses were PTSD, bipolar I disorder, mixed episode in remission, and ADHD-combined type.”

I think most of us on this side of the debate would agree that “John presented a complex clinical picture.”  But what is clear from the article, and especially the final paragraph, is that what the author meant by that was that John “had” more than one “diagnosis.”  It is also clear that “treatment” consisted of prescribing drugs and tweaking dosages.

The truly sad part of all this is that Dr. Dilsaver appears to believe that this “treatment” is what John, with his extraordinarily troubled history, needs.  We’ll probably never know what happens to John.  But we can be reasonably certain that these stigmatizing and disempowering “diagnoses” will follow and define him for years – perhaps for life.  We know that he will be identified by various official and semi-official figures as someone who needs to be “on meds.”  We know that attempts on his part to discontinue these dugs will be met with resistance.

We can’t predict the future, but, I suggest, the odds for John are not great.  At age 8, with his world shattered in an unbelievably horrific manner, he has been shunted into the marginalized siding of psychiatric chemical restraint, from which he may never escape.  If he hasn’t already, he will probably soon be given a disability “award” with all the implications of damage and reduced expectations.

This post is not just a criticism of Dr. Dilsaver.  After all, he’s a psychiatrist, and this is what psychiatrists do.  In fact, because psychiatry has been so successful in marketing and promoting its so-called illnesses, Dr. Dilsaver would have been open to censure and lawsuits if he had not taken these kinds of actions.  Until these professional, legal, and cultural pressures are changed, we will see more and more children “treated” in this way.

Part of the irony in this matter is that it is clear from the article that Dr. Dilsaver believes he has done good work, and seems proud of the fact that he didn’t miss the PTSD and bipolar “diagnoses,” and that he “treated” these “illnesses” successfully.

Incidentally, according to GoodRx, a month’s supply of John’s final drug regimen costs $779.  (prazosin $8; divalproex $17, aripiprazole $712, and dexmethylphenidate $42).

The Stigma Attached to ‘Mental Illness’

On Monday, October 7, 2013, The Sun, a British tabloid newspaper ran the following headline:  1,200 Killed By Mental Patients.  Shock 10-year toll exposes care crisis.  It took up almost all of the front page.

The headline precipitated a great deal of protest from politicians, advocacy groups, mental health professionals, and others.  The general points in most of these protests were that the headline was sensationalistic, misleading, and would serve to increase the stigma associated with “mental illness.”

Other British newspapers,  including the Guardian, the Independent, and the New Statesman, ran articles criticizing the Sun’s piece.

The Guardian pointed out that people with a history of “mental” problems are already considerably stigmatized, and cited interesting figures from an NHS survey.  The Guardian also challenged the accuracy of the 1200 figure, and stated that 738 was the true total for the decade.

The Independent reported on the various individuals and agencies that protested the headline.  The Independent also pointed out that people with mental illness are ten times more likely to be victims of crime than the average person.

The New Statesman attacked the Sun’s headline as misleading, and expressed the opinion that:

“…part of the reason the government is able to impoverish and stigmatise those receiving care in the community with relative ease, is that there has been a relentless campaign against mentally ill benefit claimants, a campaign led by right-wing tabloids like the Sun.”

The New Statesman also states that:

“In Britain and across the global north, one in four people will experience significant mental health problems in their lifetimes.”

Apparently the Sun has responded to these criticisms by claiming that they were not trying to stigmatize the mentally ill, but rather to draw attention to the fact that these people have been let down by inadequate mental health services over the past decade.

So what should we make of all this?

Firstly, I need to say that I have not read the Sun’s article because it’s behind a paywall, but I have seen a copy of the front page in question.  It’s embedded in some of the other papers, including The Huffington Post UK, and it is clearly sensationalistic, stigmatizing, and irresponsible.  But it probably sold copy, and that, I imagine was the idea.

Secondly, there are no mental illnesses.  Mental illness is the name, or label, that psychiatry gives to an ever-increasing range of human problems of thinking, feeling, and/or behaving, in order to promote psychiatric turf and to legitimize the sale of psycho-pharma products.  Psychiatrists have taken this notion a step further by actively promoting the unfounded notion that these “mental illnesses” are really brain illnesses, and that the drugs they prescribe are necessary to correct and “treat” these neurological malfunctions.

Thirdly, although psychiatry routinely claims that their relentless process of medicalizing human problems reduces stigma, the opposite is actually the case.  The promotion of biogenetic models of human problems actually increases stigma.  Angermeyer et al (2011) systematically reviewed 39 population studies  that had addressed the stigma question, and concluded that:

“…biogenetic causal beliefs or interventions are negatively associated with expectations of recovery and good prognosis.”

and

“…there seems to be a danger that biogenetic illness concepts increase rather than decrease public stigma of mental illness.”

So, reprehensible as the Sun’s headline was, it seems to me that its actual stigmatizing impact pales in comparison with that inflicted by bio-psychiatry over the last 50 years.

And in the same context, let’s not lose sight of American psychiatry’s present attempt to capitalize on the mass killings by promoting the notion that the “mentally ill” are inherently dangerous and will likely become more so unless mental health services are expanded.  This, despite the growing indications that psychiatric drugs are a significant causative factor in these incidents.

It’s one thing for a yellow press tabloid to engage in scaremongering sensationalism.  We expect no better.  But for a helping profession to engage in this sort of thing is, in my view, very questionable.  Here are a few examples:

Perhaps the truth is that psychiatry is not really a helping profession.