Is The Joke On Me?

I recently returned from the American Psychiatric Association (APA) Annual Meeting in Philadelphia.  I had the pleasure of participating on a panel discussing “psychiatrists and the new media” with the bloggers/authors from Shrink Rap, and Bob Hsiung of dr-bob.org.  The panel discussion was a success.  Some other parts of the conference, however, left me with a sense of doubt and unease.  I enjoy being a psychiatrist, but whenever I attend these psychiatric meetings, I sometimes find myself questioning the nature of what I do.  At times I wonder whether everyone else knows something I don’t.  Sometimes I even ask myself:  is the joke on me?

Here’s an example of what I mean.  On Sunday, David Kupfer of the University of Pittsburgh (and task force chair of the forthcoming DSM-5) gave a talk on “Rethinking Bipolar Disorder.”  The room—a cavernous hall at the Pennsylvania Convention Center—was packed.  Every chair was filled, while scores of attendees stood in the back or sat on the floor, listening with rapt attention.  The talk itself was a discussion of “where we need to go” in the management of bipolar disorder in the future.  Dr Kupfer described a new view of bipolar disorder as a chronic, multifactorial disorder involving not just mood lability and extremes of behavior, but also endocrine, inflammatory, neurophysiologic, and metabolic processes that deserve our attention as well.  He emphasized the fact that in between mood episodes, and even before they develop, there are a range of “dysfunctional symptom domains”—involving emotions, cognition, sleep, physical symptoms, and others—that we psychiatrists should be aware of.  He also introduced a potential way to “stage” development of bipolar disorder (similar to the way doctors stage tumors), suggesting that people at early stages might benefit from prophylactic psychiatric intervention.

Basically, the take-home message (for me, at least) was that in the future, psychiatrists will be responsible for treating other manifestations of bipolar disorder than those we currently attend to.  We will also need to look for subthreshold symptoms in people who might have a “prodrome” of bipolar disorder.

A sympathetic observer might say that Kupfer is simply asking us to practice good medicine, caring for the entire person rather than one’s symptoms, and prevent development or recurrence of bipolar illness.  On the other hand, a cynic might look at these pronouncements as a sort of disease-mongering, encouraging us to uncover signs of “disease” where they might not exist.  But both of these conclusions overlook a much more fundamental question that, to me, remains unanswered.  What exactly is bipolar disorder anyway?

I realize that’s an extraordinarily embarrassing question for a psychiatrist to ask.  And in all fairness, I do know what bipolar disorder is (or, at least, what the textbooks and the DSM-IV say it is).  I have seen examples of manic episodes in my own practice, and in my personal life, and have seen how they respond to medications, psychotherapy, or the passage of time.  But those are the minority.  Over the years (although my career is still relatively young), I have also seen dozens, if not hundreds, of people given the diagnosis of “bipolar disorder” without a clear history of a manic episode—the defining feature of bipolar disorder, according to the DSM.

As I looked around the room at everyone concentrating on Dr Kupfer’s every word, I wondered to myself, am I the only one with this dilemma?  Are my patients “special” or “unique”?  Maybe I’m a bad psychiatrist; maybe I don’t ask the right questions.  Or maybe everyone else is playing a joke on me.   That’s unlikely; others do see the same sorts of patients I do (I know this for a fact, from my own discussions with other psychiatrists).  But nobody seems to have the same crisis of confidence that I do.  It makes me wonder whether we have reached a point in psychiatry when psychiatrists can listen to a talk like this one (or see patients each day) and accept diagnostic categories, without paying any attention to the fact that they our nosology says virtually nothing at all about the unique nature of each person’s suffering.  It seems that we accept the words of our authority figures without asking the fundamental question of whether they have any basis in reality.  Or maybe I’m just missing out on the joke.

As far as I’m concerned, no two “bipolar” patients are alike, and no two “bipolar” patients have the same treatment goals.  The same can be said for almost everything else we treat, from “depression” to “borderline personality disorder” to addiction.  In my opinion, lumping all those people together and assuming they’re all alike for the purposes of a talk (or, even worse, for a clinical trial) makes it difficult—and quite foolish—to draw any conclusions about that group of individuals.

What we need to do is to figure out whether what we call “bipolar disorder” is a true disorder in the first place, rather than accept it uncritically and start looking for yet additional symptom domains or biomarkers as new targets of treatment.  To accept the assumption that everyone currently with the “bipolar” label indeed has the same disorder (or any disorder at all) makes a mockery of the diagnostic process and destroys the meaning of the word.  Some would argue this has already happened.

But then again, maybe I’m the only one who sees it this way.  No one at Kupfer’s talk seemed to demonstrate any bewilderment or concern that we might be heading towards a new era of disease management without really knowing what “disease” we’re treating in the first place.  If this is the case, I sure would appreciate it if someone would let me in on the joke.

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49 Responses to Is The Joke On Me?

  1. Altostrata says:

    Sounds like Kupfer is pulling a Biederman — academic empire-building. Bipolar for everybody, all the time!

    Why go to the trouble of taking people off drugs? That often doesn’t go very well. Perpetual medication will take care of those “dysfunctional symptom domains.” Makes it all much easier.

    At least you and David Allen can have a good laugh together.

  2. Hawkeye says:

    “manic episode—the defining feature of bipolar disorder, according to the DSM.”

    I am not a doctor, but here’s one joke, recurrent depression coupled with hypomania can easily respond to mood stabilizers.

    That said, let us hope that the sins of past under recognition are not matched by sins of future, dangerous over treatment. I used to be a bipolar imperialist until I found out that patients are being loaded up with atypicals on suspicion of bipolarity. No!!!!!

    You quote above, “where we need to go in the management of bipolar disorder in the future.” You are right to question this, we don’t know where to go.

    You wanna help people who may be bipolar—take a way their recreational drugs, glutamate rebound is a terrible way to waste a mind. Also make them walk an hour a day, neural regeneration is a fact.

    • Altostrata says:

      “glutamate rebound is a terrible way to waste a mind” — so very true, and a not-too-far-off description of psychiatric drug withdrawal syndrome (disinhibition of the alerting system).

  3. Nathan says:

    Any other interesting parts of the Annual Meeting? I was curious about the discussion Gabbard and Beck had. ;-)

  4. You’re not wrong as you can see the writing on the wall. Soma and Brave New World sort of writing. If the focus were on managing sleep, stress levels, exercise, etc. I wouldn’t be up in arms, but someone show me a long term study of a mood stabilizer (or, God forbid, an antipsychotic) for irritability and the crime of being a teenager…

  5. janis baeuerlen says:

    I think that everyone’s bipolar illness is their own, just as each child I treat diagnosed with ADHD has his/her own difficulties, challenges, strengths, needs, and his/her own parents who have their own challenges as well which interact with the child’s.
    I appreciate your making the effort to think about these dilemmas in psychiatry, and probably all medicine (is everyone’s diabetes or asthma or GI upset the same as everyone else’s?), and to put it on your blog.

  6. Dr. D says:

    Ya know, I’d hate to agree wholeheartedly with Allen Francis, but his editorial today in the NYTimes rang true: The future of mental health should not completely be determined by academic psychiatrists.

  7. Sahana says:

    Dear Steve, you are definitely onto something. It’s a joke that can turn deadly, by changing the landscape of thinking, or way of looking at things, and thus the approaches and responses to life, and life’s problems… As the diagnoses are in question, all intervention methods are researches become questionable too. As to how to turn the joke back on to the people who are behaving so irresponsibly (some of them possibly without intending to) I wish I had better ideas. The fact that people like you are asking the question, that’s a reason for hope! Slowly but surely, we got to turn the tides!!

  8. Peter C. Dwyer says:

    Of course your doubts make sense. If you haven’t read Healy’s new book, Pharmageddon, I strongly recommend it. Much of what he says has been pointed out before, but he’s excellent at putting it in perspective, connecting the dots with devastating clarity about things psychiatry takes for granted but should not.

    Healy: psychiatry (and modern medicine as a whole) cannot be said to be scientific when its algorithms and guidelines are based on trials done by companies WHO DON’T LET ANYONE SEE THEIR RAW DATA. That just isn’t science. As long as that’s how the game’s played, it simply can’t be called science. It’s the man behind the curtain periodically producing more summarized and cooked data that just happens to support PhARMA’s latest marketing goals. Then of course the journal articles are ghost written by PR flacks with PhD’s., all orchestrated by the marketing departments. This presentation you describe reeks of marketing and future drug sales.

    It also isn’t science (at best it’s bad science) when psychiatry is unwilling to subject its unproven assumptions to be verified or refuted by data. Psychiatry assumes mental problems result from diseased brains, and that medical intervention is the best option. Good science subjects its assumptions to rigorous scrutiny; psychiatry’s medical model is an article of faith – a bias – something psychiatry routinely contorts itself to preserve in the face of equivocal or blatantly contradictory evidence.

    When no “mental illness” has an established pathophysiology (much less even a definition), when none has a physical diagnostic test, when so much of the “information” is blatantly false (think Study 329), when clinical trials are stacked by PhARMA in favor of its drugs but still barely show any advantage over placebo (see Kirsch), when hundreds of billions are thrown at psychiatric “research” with at best equivocal results – anyone should be willing to question the foundations of psychiatry’s medical model – DSM, clinical trials, algorithms, assumptions of primary causality resting in genetic and physical defects and physical treatments.

    Some argue that historically lots of scientific theories have lacked support, but with advances in instrumentation and measurement, the blanks were filled in and supporting proof provided. But to go from that observation to the tenacity with which psychiatry adheres to its assumptions requires one to believe that lack of supporting evidence guarantees success – which it does not.

    Psychiatry’s assumptions may ultimately be supported by real proof; but it could also turn out as bogus as alchemy. Given the obvious duplicity and manipulation so far, my bet’s with alchemy. Meanwhile, the profession blindly assumes without seriously considering alternative perspectives – it’s like being in a Borg Cube: erudite people wandering oblivious to possibilities staring them in the face.

    Several years ago I saw a headline claiming some SSRI outperformed St. John’s Wort. I was amazed to find that placebo beat them BOTH handily. That should have been the headline, but of course it wasn’t. Only in psychiatry.

    Or a new favorite: for years psychiatry argued that brain shrinkage showed schizophrenia was a degenerative brain disease. Then Nancy Andreassen produced evidence that the shrinkage was likely caused by neuroleptic exposure. Then some psychiatrists argued, well, maybe shrinking brains is a good thing. The illogic of this obvious contortion speaks to psychiatry’s determination to maintain its medical model regardless of data.

    I’m not at all surprised at your experience. The attendee’s mindset was part of the price of admission to the profession, and you are one of the minority who are asking hard questions.

    • stevebMD says:

      Regarding Healy’s book, yes, I’m reading it now, and it’s an eye-opener. His observations (many of which I share) reassure me that, despite the title of my post, there is no “joke” here. This is very serious stuff and the future of psychiatry– perhaps all of modern medicine– depends on our fixing it.

      The problem is, there are no obvious culprits. It would be easy to point to bad psychiatrists, drug companies, insurance companies, the government, etc, as the source of the problem, but he makes it very clear that we’re all swept along IN the problem. Guideline-based care, evidence-based medicine, redefining “normal,” drug patents, prescription-only medications, direct-to-consumer advertising, pharma-sponsored research…. each of these has been implemented with the best of intentions, but their combination gives rise to the shameful situation we’re now in. Unfortunately, very few people seem to “get it.” What’s even worse is that the leadership of my field MUST get it (they’re not dumb people) but are doing very little to address it.

      • Becky Murphy says:

        While it is true everyone may indeed have been swept along in this, I disagree with your statement “there are no obvious culprits.” C’mon Schaztberg was and now Leiberman is president of the APA—It is the membership that votes this sort of ‘dorktor’ that taints the profession into positions of respect and honor– instead of discrediting or censuring anyone among you for unethical research, biased reporting of the results or and even horrifyingly heinous conduct. (like enrolling children and adults incapable if Informed Consent in Drugs Trials or NOT informing patients or parents of actual risks in clinical trials or clinical practice) KOLs, the elite ‘psycho’ pharmacologists among you harmed not only their own ‘patients/victims; but the patients of every other medical professional’ who erroneously believed the articles were fact based reports of efficacy and safety, not bullshit marketing agendas of the drug companies. The terms ‘peer-reviewed’ and ‘Evidence-Based’ are laughable in respect to psychopharmacology. The latter is a joke because of obvious corruption and fraud (hiding of the data) in collecting, analyzing and reporting results of drug trials—the Evidence Base is CORRUPTED beyond recognition it is not ethically speaking and Evidence Base, it is evidence of criminal fraud though. The term ‘peer-review’ lacks integrity and meaning since obviously flawed and even outright fraudulent unethical research remains within what is theoretically the body of knowledge, supposedly the best information medical science has available about psychotropic drugs. Psychiatry’s ‘peer-reviewed’ ‘evidence base’ for the ‘neurobiological’ paradigm of psychiatry relies on deception, coercion, abuse of power and authority; it subverts science and the Ethical Guidelines of Medicine—it is obvious to me this leaves out even considering what is in the best interest of the patient. Many people have been disabled and have been killed; more will be disabled and killed as a direct result of the unchecked unethical behavior of your colleagues –and the failure of medical ethics committees, and the APA membership at large remaining complicit by remaining silent.

      • Altostrata says:

        I tend to agree with Becky, it’s the clinicians’ responsibility to hold the line on patient safety. if more psychiatrists spoke up and questioned their paradigm and their leadership, the field wouldn’t be in such a pickle. How can the clinicians be blind to adverse effects and iatrogenic deterioration in patients under their care? There’s some serious mental pretzeling going on among the doctors.

  9. pretty soon we’ll see pathology in EVERYONE…. and put psychiatric boosters in our water supply to prevent psychiatric disease. this scares me. whenever i try to describe my questions and concerns with someone else, i feel like chicken little trying to tell people the sky is falling… i’m glad there are professionals out there asking some of the same questions i’m asking… but it sure does sadden me that more money and effort and expertise aren’t dedicated to finding non-pharmaceutical ways to treat debilitating emotional distress of every kind…

  10. Peter C. Dwyer says:

    I agree with Steve, Becky AND Elizabeth.

    Elizabeth – the drugs are already in the water, so many have been flushed.

    Becky – I agree at some point you just have to hold people accountable, regardless of their excuses about how they got involved in a terrible mess that hurts people profoundly.

    Healy provides a basis for holding PhARMA primarily responsible. They have played docs like gullible rubes – surveys show each doctor thinks HE/SHE isn’t swayed by PhARMA’s promotion, but they’re sure their colleagues are. That’s dumb but not criminal.

    But if there’s a role for evil genius, it belongs to PhARMA. Its top people KNOW exactly what they’re doing and why – they’re distorting the culture, committing scientific fraud daily, disregarding the welfare of patients and ruining anyone who seriously threatens them – all, and solely, for MONEY.

    Healy and just about everyone else says “corporations have only one purpose – to make money,” as if that excuses their breathtaking lack of ethics. Gosh – why didn’t I think of this sooner – I’m a lawyer, why don’t I just go a couple miles and help the crack and heroin dealers on the corner to INCORPORATE? Then, whenever hauled into court, they can just brandish their articles of incorporation and walk.

    People on the right bridle against government’s taking away our freedoms. They need to look at certain large corporations. PhARMA is among the elite who virtually own government and impose their profit-making schemes on the rest of us to our profound detriment – including driving up health costs by marking up drugs 3,000% with on-patent pills that are no better than the old ones (see Healy).

    But I also agree with Steve. To quote Pogo from years ago, “We have met the enemy and they are us.” We have all bumbled into this, and it’s too convenient to blame a few demonized enemies for a problem. That lets us off the hook for our part in it and casts us as victims.

    Speaking as an old community organizer, it really is true that others have power only as long as we consent to it. Ultimately every living human represents a basically good and intelligent potential ally, and with enough clear thought, sacrifice, hard work and good will, people can be mobilized to solve any problem. This blog represents an important part of that process.

    • but what can i do? my family gets it. each of us understands- by reading news articles and books and through personal experiences. but i still have friends who seek new prescriptions for themselves and their children. i rarely hear any unbiased news coverage or read unbiased articles in mainstream media outlets. what can i do to help fix the problem? what can i– as a non-provider, former patient- do to help solve this problem?

      • Peter C. Dwyer says:

        Elizabeth,

        that’s a question I’ve struggled with for decades. I’ve talked with people in my personal life and at work (I ran a treatment foster care program for 9 years). I’ve opened some minds some, exposed people to information that may someday click in their minds, and stood up to a lot of people. But it’s very slow.

        I’ve spoken up at meetings of social workers, at grand rounds in one of the country’s most prestigious mental hospitals; I’ve passed out four page summaries of the issues with suggested readings at these meetings and rounds.

        I’ve written to heads of large professional organizations about the issue, with no response at all.

        As director of my program I did have some influence. Staff and foster parents got exposed to presentations by me and videos of some great presenters on the drug issue; I talked them all sick over it, and most of them have a pretty good idea of what the facts are. I instituted a policy that drug treatment was to be used only after psychosocial methods failed, and no starting on or changing of drugs was to occur without consulting our social workers.

        Unfortunately, most people in and out of my program find it easier to go along with the drugging tide. But along the way I’m sure we limited foster care’s scandalous use of drugs in some kids, and occasionally scored a big win by getting a child entirely off drugs, or keeping drugs from being started. It’s hard because the courts, state regs and the Department of Social Services love the drugs. Our state regs mandate than children entering foster care and our program get a psychiatric evaluation – and we know what that means – kids came to us already on 2, 3, 4, 5 drugs, and it’s VERY hard to convince psychiatrists to bake them off.

        But I think it’s better that I’ve done these things than not. You can’t really know what seeds planted will grow. I’m in the process of writing an article I hope to get published in a journal, and I’m kicking around the idea of becoming a presenter for trainings for social workers and other “mental health” professions, directly addressing the drug issue. I’ll see about that after the article’s done.

        Personal support is key, and a network of like minded people can not only support you, but can multiply the efforts of individuals. I belong to ISEPP (The International Society for Ethical Psychiatry and Psychology). Its annual conference (October) is a personal boost and also puts me in touch with great information and contacts. David Oaks of MindFreedom International is great, and his organization is an umbrella group for people who have been in the “mental health system.” They do a lot of advocacy work and provide good support for their members.

        I guess the best advice I can give – from one who has not been nearly as successful as I’d like – is to “be the change you want to see” (Gandhi). Make yourself into the best self you can be and seek close personal relationships with people. In that context, someone might just hear what you’re saying – maybe not the 1st or 10th time, but maybe eventually. Don’t preach, just be someone whose life is a good example for others looking to live well. You never know who you influence and how.

        I wish you all the best.

      • Altostrata says:

        In answer to Elizabeth — Change seems impossible if you look at the enormity of the situation, but you can’t give up. Plant seeds, as Peter says. Write letters. Speak to community groups. Do what you can do in your immediate vicinity. You may convince only one person here and there, but if some of them go out and do the same thing, eventually there’s an impact.

    • Becky Murphy says:

      I did not bumble into this. I was mislead and outright lied to and it wasn’t pharma it was dorktors. The fact of the matter is not a single one of the psychiatrists showed much interest in Informed Consent—WAY too fucking blase about something that theoretically is a FUNDAMENTAL medical principle. A year ago I was told 3 times by a dorktor that the neuroleptics do not cause any brain damage; he then demanded my respect. And ignored valid questions totally, from myself, my brother and my eldest son. Imagine the lack of integrity that must take, to lie to a person’s face and then demand the person’s respect. I know there are good psychiatrists, I just haven’t met any in person…

      It isn’t just that my son has been seriously harmed by all of this, it is these fuckers are doctors who then neglect the medical diseases cause people—what is fucking horrible is these illnesses are also ignored by medical professionals in general, as a matter of course—brain damage–and other physician caused illnesses and impairments coupled outright medical neglect has everything to do with people becoming chronically ill, and dropping dead decades early? Or suddenly? The literature is clear, there is no evidence that suggests using neuroleptic drugs in children is a good idea. There is a strong evidence it is in fact a very bad idea. The APA membership is going along with this massive fraud.

      The announcement made by Army Maj. Gary Wynn of the Walter Reed Army Institute of Research and Col. David Benedik, associate director for the Center for the Study of Traumatic Stress at the Uniformed Services University of the Health Sciences that they are launching a research initiative—utter bullshit–they are going to, “advance the science to catch up with clinical practice,” Wynn said. Let’s be real, clinical practice is supposed to be based on the research, yet treatment protocols are not supported, by the research. It is abundantly clear, there ‘psycho’ pharmacology is not therapeutic it is harming, a great many and it always has used coercion, abuse of power and hiding the data about the efficacy and the adverse effects, events and the fatal outcomes. Awfully convenient that doctors aren’t required to report when their patient experiences an adverse event….

      The plan announced after the latest investigation into the drugging of foster kids with neuroleptic and other psychiatric drugs off-label is to ‘monitor’ not STOP the unethical standard practice of giving neurotoxic drugs to children for no valid medical purpose. Calling it ‘off-label’ prescription does not legitimize Human Experimentation being done in clinical practice. This is not an ethical standard of clinical care. The Practice Parameters and treatment algorithms are based on a so far vain attempt to validate standard practice and fulfill marketing goals. Which is why psychiatric parameters and algorithms for using psychotropic drugs rely on consensus; instead of ethical research data. “Psycho’ pharmacology has substituted opinions for valid empirical data and implemented standards of care that are not based on sound medical judgement. Obviously, these corrupt standards were not developed or implemented in the best interests of patients.

      Any psychiatrist who is not speaking out against this human rights tragedy is complicit; and lacks the ethical integrity a doctor should have.

      • Altostrata says:

        From my own personal sampling of psychiatrists I agree with Becky that personality problems are rampant among them. Arrogance plus ignorance is a particularly repellent combination of traits in a physician.

      • Hawkeye says:

        Becky says: “A year ago I was told 3 times by a dorktor that the neuroleptics do not cause any brain damage; he then demanded my respect.”

        Nancy Andreasen says they do, but she’s backing off a little.

        I can see the building where she works from my building. Want me to wave?

      • Altostrata says:

        Hawkeye, could you go over and ask Andreasen if she’s been under any pressure from outside forces to recant her original observation that it was the neuroleptics causing the shrinkage?

      • Hawkeye says:

        Hello Alto:

        Most academics are driven by ego. How would you like to take yourself very seriously and have your most important work possibly reduced to an artifact?

        It isn’t big Pharma, acadmics are playing for much bigger stakes than that. In fact I speculate the influence of big Pharma in my state is minimal, at least in any environment where research is valued. This is thanks in part to the toughness of my Senator, Chuck Grassley.

        Really, really serious and capable researchers who want to make a lasting contribution are probably not corruptable by money.

        Alto: I expect your usual well considered disagreement.

      • Altostrata says:

        Hawkeye. I’d just like to know why she may be backing away from decades of her own research, see http://www.psychologytoday.com/blog/mad-in-america/201102/andreasen-drops-bombshell-antipsychotics-shrink-the-brain

        I presume, since she’s wired into the psychiatry ol’ boys’ network, she might be under some pressure to conform to the party line. But I could be wrong.

      • Hawkeye says:

        Here is the Pub Med summary:
        http://www.ncbi.nlm.nih.gov/pubmed/21300943.1

        There is an accompanying editorial in the Archives which I am not sure is accessable to non subscribers and I can’t find in any other location.

        It seems to look like a duck and walk like a duck, but nobody can get close enough to hear if quacks like a duck, so for now it is not proved to be a duck.

      • Altostrata says:

        The editorial is available to all at http://archpsyc.jamanetwork.com/article.aspx?doi=10.1001/archgenpsychiatry.2010.187 It suggests reduction in brain volume caused by the magic pills may be a good thing:

        The observation by Ho and colleagues that the amount of antipsychotic treatment predicted the degree of brain volume reduction leaves open the possibility that the patients who benefitted the most continued to receive antipsychotic treatment and subsequently had the greatest brain volume changes. The idea that strategic reductions in brain volume can be functionally beneficial is supported by the improvements in cognitive capacity that accompany cortical gray matter volume reductions during adolescence.

      • Hawkeye says:

        Alto:

        It may in fact be the case that psychotropic drugs are 100% responsible for the brain shrinkage seen in schizophrenic patients, and it may be a price someone, God I guess, will say it is ok to pay. As with your interest in anti depressants however, what happens when the drugs are removed, are the patients in fact worse than they would have been otherwise?

        This may be one of the most interesting informed consent issues ever raised, “We are going to destory part of your brain but it is going to make you happier.” Could be a beer company ad.

        Yeah, I am being far too cool and intellectual. Also may be abusing a privledge by posting too much. Over and out.

      • Altostrata says:

        Hawkeye, the logic is roughly
        antipsychotics = brain shrinkage
        antipsychotics = happiness
        brain shrinkage = happiness

        The last 2 propositions have even less evidence than the first. That antipsychotics = happiness is particularly questionable, given the the frequency of adverse effects and lack of quality of life studies.

        It also seems to me logically inconsistent that researchers claim neurogenesis or expansion in brain regions is beneficial in depression (on questionable evidence) and shrinkage in brain volume is beneficial in schizophrenia (on zero evidence). No one has ever suggested schizophrenia involves an excess of any kind of brain tissue. That depression and schizophrenia have vastly different biologies is unproven.

        My conclusion is the imputation of benefit to brain shrinkage in schizophrenia is yet another contorted psychiatry fantasy to justify the unabated prescription of antipsychotics.

        What happens when people go off antidepressants is often withdrawal syndrome, a form of neurological damage. I am beginning to think that true relapse off antidepressants is the zebra and withdrawal is the horse. Withdrawal symptoms are so poorly recognized that 20 years of research on antidepressant efficacy is hopelessly contaminated by withdrawal mistaken for relapse — if it weren’t already doomed by the placebo effect.

      • Hawkeye says:

        Alto,
        I was trying to be ironic, sorry. I firmly believe that the death of a dear friend was hastened by the decades long administration of neuorleptics.

        This issue is very simple. Is there any really clear evidence that schizophrenia as a stand alone disease, without treatment, causes brain shrinkage?

      • Altostrata says:

        Hawkeye — I’m not an expert on schizophrenia, but I believe Andreasen’s studies are as close as anyone has come to answer that question. (Sorry, I missed your irony! So easy to do on the Internet.)

  11. Hawkeye says:

    Very well said Steve in your post above. I would like to also blame what seems to be a “cult of expertise” in all fields from financial management, to education, to a great deal of medicine to international relations.

    I once asked a psychologist why psychaitrists prescribe so much medicine. The reply: “How would you like to be a doctor who sends 80% of his/her patients away for alternative care?”

  12. annalaw81 says:

    MY ‘takeaway’ from Dr. Balt’s article is what he said below . Yet right after speaking ‘the truth’ about the state of of his profession, he almost seems resigned to it, by admitting that ‘we accept the words of our authority figures without asking the fundamental question…” :

    “It makes me wonder whether we have reached a point in psychiatry when psychiatrists can listen to a talk like this one (or see patients each day) and accept diagnostic categories, without paying any attention to the fact that they our nosology says virtually nothing at all about the unique nature of each person’s suffering. It seems that we accept the words of our authority figures without asking the fundamental question of whether they have any basis in reality.”

    This, for me, a non-scientist and mental health ‘consumer’ / ‘patient,’ depending on who is doing the labeling, is the bottom line. I have been engaged in a game of ‘musical shrinks’ at the clinic I attend, it being seeminly impossible to keep someone there for any length of time. The last one I saw, who informed me upon meeting her that she was only there for 2 months, offered to put me on a new regimen of meds. I declined, telling her I didn’t want to start something new until I was with a doctor who was going to be there to see how it went.

    I liked this doctor, and she was cool enough to step back and leave things as they are, however, the reality is, I’m treading water – waiting for my next label, my next med trial… I haven’t even had a CHANCE to find out if the questions I’m asked have any basis in reality, as by the time I’ve come up with the answers, that doc is gone. This is what it’s like, at least in one psych clinic – they hand off the meds, but don’t have time to really consider the ‘unique nature’ of my suffering. One tried, 3 doctors ago, but since then, it’s just been a crapshoot. How can you even GET to address those questions in a situation like this?

    I know that psychiatrists et al, in related professions, love to discuss ‘the problem’ of being responsive to patients’ needs – but here is what one of us has to say. Whether they fix whatever is wrong with the DSM-V, whether the psychiatrists finally decide to ‘rise up’ as a group, and do more than just ‘accept the words of our authority figures,’ for some of us, particularly lower income patients, it’s a monthly med hand-off, without much more, let alone considering the ‘unique nature’ of our suffering. Vast change is needed, not only in how psychiatrists et al ‘feel’ or think about the shortcomings in their profession, but in the nuts and bolts way it is practiced. Just sayin…

  13. Peter C. Dwyer says:

    Annalaw,

    I’m very sorry to hear that is happening to you. But I am not at all surprised. It’s even worse with kids in foster care. About six years ago, Julie Zito at the University of Maryland published a national study that found kids in foster care were sixteen times more likely to be put on psych drugs than other kids who were also receiving Medical Assistance.

    You could review the records of the kids in my treatment foster care program and find they had received serial diagnoses and serial trials on different drugs: three years ago he had “adhd,” last year he was labeled “depressed,” this year he’s labelled “bipolar,” and probably next year it would be “anxiety disorder.” The biggest howler was “depressive disorder not otherwise specified.” Look up the definition for the perfect example of meaningless circularity.

    The drugs were the same. A kid in care could have started out on ritalin, moved to an sari, then back to ritalin, then to wellbutrin, then to an sari, then ritalin …. One of our social worker realized her kids were seldom seen by the same psychiatrist, or even at the same clinic in his foster care travels; so she went through his record and listed every one of his diagnostic labels and drug changes for the past seven years. The psychiatrist was awed to have that information; he said it was the first time he’d ever seen such a thing. It was like she’d descended from the mountain with the Ten Commandments on the tablets.

    That is really sad. Kids – all people – deserve better care. And it shows how totally seat-of-the-pants day to day psychiatry can be. Especially with kids, who often can’t speak for themselves, or if they do, it is ignored. They are at the mercy of adults.

    This can be particularly horrendous with 15 minute psych. appointments.

    • Becky Murphy says:

      Exactly! Thank you! The neuroleptic drugs have been used for decades for aggression—guess why the drugs are still being trialed for treating aggression?

      I am not impressed by psychiatrists who point out that most prescriptions are being written by GPs and pediatricians at all. These doctors are using protocols and algorithms and parameters and other corrupt reference materials which misinform them due to the abject failure to hold unethical practitioners accountable, or actively work to stop using the marketing agendas like the TMAP type algorithms and learn to conform to ethical treatment standards.

      How many children will be disabled and killed because they are going to continue being used as guinea pigs in a massive real world practice Human Experiment using neuroleptics and other neurotoxic drugs ‘off-label’? http://involuntarytransformation.blogspot.com/2012/05/plan-monitor-dangerous-paradigm-of-care.html

  14. Peter C. Dwyer says:

    Annalaw,

    Sorry to post twice, but my computer went wonky. To finish my last post: The 15 minute appointment goes like this: frustrated foster parent unloads all his/her complaints about the child: he always does this, he never does that, it’s out of control, I don’t know how much longer I can keep him, my social worker is no help, it’s getting worse all the time, he needs something a drug) to fix this. Doctor writes a new rx. Meanwhile kid stares at the floor, answers in monosyllables.

    The real story: foster parent is a good parent, but extremely stressed by 24/7 parenting of a foster child who’s been in twelve homes in two years. THE FOSTER PARENT NEEDS SESSION, and is unloading on the psychiatrist, who mistakes this for actual reporting of facts and unknowingly gives Johnny a drug for the parent’s distress..

    I told my social workers to sit with the parent for a half hour and let the parent’s distress tumble out. Once the parents gets it off their chest, you ask questions: How often did he do X last week? How does that compare with two months ago? What happened to him before he got into a fight at school? (Often it was something awful, like learning he couldn’t return home to his mom).

    It usually turns out Johnny’s doing a lot better now, or his behavior is perfectly understandable given his circumstances; even if not, once the parent’s unloaded, he/she puts it in perspective, remembers he/she loves Johnny, is open to ways to deal with Johnny, and stops demanding more drugs.

    This happens a LOT – not because the foster parent is bad or uncaring. They are often perfectly wonderful, and heroes to boot. But they need to be heard. Psychiatry’s medical orientation and 15 minute “med checks” make this scenario almost unavoidable. And this is on top of my strong conviction that the drugs are the wrong thing to do in the first place.

    Annalaw, you’re already doing something that could help – reading this excellent blog and responses from people who have been in your spot. Also check out MindFreedom International, an advocacy group for people in the system. Try the ISEPP web site, and Robert Whitaker’s Mad In America’s site. Nami can give good support, but they heavily buy into psychiatry’s medical model and you won’t get the perspective you get here (NAMI gets much of its funding directly from drug companies). Information and connection can help counteract psychiatry’s message that you are a permanent victim of your biology and need psychiatrists to “regulate” your chemicals and interpret your life for you. That’s not a good message for most people.

    I wish you all the best.

  15. Stop.Psychiatry says:

    I think that the basic problem is that psychiatry has been demonstrated to be a scam, and a very dangerous one. I want to share my story to let everybody know about the extent of the abuse that pervades the practice of psychiatry. It is important to get the word out because the lives of many people are at stake beyond our American borders.

    First, I want to apologize for telling my story anonymously. As you will see, the whole episode was very humiliating. One of the many unfortunate effects of psychiatric misconduct is the continued stigma that exists in all things related to mental disorders so I am not ready yet to go public with this; maybe someday I’ll find the courage to discuss this openly but I am not there at this time.

    I am an American male, of European origin, in my late thirties. I only hold American citizenship and I only held American citizenship when this thing happened. I am highly educated with a doctoral degree from one of America’s best engineering schools. During most of my adult life I have struggled with a condition that was diagnosed as Obsessive Compulsive Disorder, OCD. The funny thing is that psychiatry dumps into this disorder all kinds of different types of mental distress. In my case it’s an exaggerated fear of contracting HIV through usual contact. Now, I don’t mean to say that this condition is not serious or that it doesn’t cause distress. However, it doesn’t warrant the type of abuse I am about to describe. When this episode happened I was married; my ex-wife was of great help, which probably avoided the ruin of my professional life.

    As the vast majority of people, I had a neutral position on the whole field of psychiatry. I assumed that it was just like any other branch of medicine, tested and confirmed by the scientific method to be 100% accurate both in diagnosis and prediction. All that changed a few years ago when I was involuntarily committed to a psychiatric institution and forcibly drugged in the European country where I was born for treatment of OCD. Unlike the laws of the United States, the laws of this country afford psychiatrists all-encompassing power to commit whomever they wish and to drug people against their will. So any psychiatrist can order to involuntarily commit and drug forcibly any patient in cases in which a psychiatrist determines it to be necessary, regardless of whether a finding that the patient’s life or a third party’s life is in danger exists. I was forcibly detained; tied up for almost one day and then forced to stay in 2 different mental institutions for a total of 12 weeks. The psychiatrists I worked with during that time are amongst the most arrogant people I have met in my entire life, which shows that, if you give anybody such power, they will become inevitably corrupt. The humiliation that I endured will stay with me for the rest of my life. My parents asked the psychiatrist to commit me. Out of respect to them, I did not invoke the protections afforded by international treaties, of which both the European country that detained me and the US are signatories, to citizens detained against their will in a host country. So I was pretty much on my own, with the help of my ex-wife to fight this. I was lucky that the company I was working for at the time here in the US was very patient with me; my ex-wife was able to manage the situation with them, but those psychiatrists who committed me couldn’t care less about my professional situation here in the US or whether I could be laid off for not showing up to work. Needless to say, the relationship with my parents has become strained as a result of the episode. This happened while I was on vacation over there.

    And then there is the forced drugging and the side effects. The American Psychiatric Association, APA, recommended pharmacological regime for OCD treatment involves the prescription of serotonin reuptake inhibitors, either modern SSRIs or older ones such as tricyclic antidepressants -like clomipramine-, at doses that are 2-3 times higher than what is prescribed for normal depression. It is normal practice to supplement the prescription of these antidepressants with antipsychotic medication to “strengthen the effect of the antidepressant drug”, whatever that means. I continued with the medication regime upon coming back to the US. Over the course of 12 months I was prescribed (though at different times) escitalopram, clomipramine, sertraline, risperidone, olanzapine and lorazepam. Even though the APA also says that Cognitive Behavioral Therapy, CBT, alone is more efficient than meds for the treatment of OCD, I was made very clear that unless I agreed to be put on a medication regime, I would not be released from my involuntary commitment. So I had no choice but to agree to be put on meds if I wanted to get out of there.

    Upon my return to the US, I started to be treated by a psychiatrist (meds) and a clinical psychologist (CBT). At the time of my admission to the European hospital, I was given comprehensive blood tests that showed all my biological markers within normal range, those of kidneys and liver in particular. Upon learning of my medication regime, my American psychiatrist ordered new blood tests that showed clear kidney impairment. The creatinine serum level had gone from 1.2 mg/dL to 1.6 mg/dL in 3 months (normal range is <= 1.2 mg/dL). Other markers looked normal. I was sent to a kidney specialist who, after all kinds of tests, couldn't find the cause of kidney malfunction other than the meds I was taking which were "supposed" to be harmless. A few months later, I had new blood tests and this time not only the kidneys didn't show any improvement, but it was the liver markers AST/ALT that were out of range. An ultrasound test showed also that I had began to develop fatty liver. After months that showed no improvement of these two conditions -in addition to the fact that I had been experiencing other side effects associated with antidepressant/antipsychotic sue such as increased cholesterol levels and weight gain-, and against the advice of my American psychiatrist, I made the decision of stopping all medications. One month and a half later, I had a new blood test performed on me and bingo!; the AST/ALT markers were back within range while the creatinine serum level went down to 1.2 mg/dL (in all blood tests I had while I was on meds it had been oscillating from 1.4 to 1.6; my most recent reading before I decided to stop the meds was 1.6). I am not a medical doctor, but I have an excellent doctoral education in the field of signal/statistical processing. The data collected from my case shows very convincingly that in my case these medications were causing significant side effects that risked to cause long term damage to my kidneys and to my liver.

    I learned several things from this ordeal,

    1- Psychiatrists in general love to prescribe drugs. They will use any excuse they can find to do it, even if, as it is widely admitted, the field of psychiatry has yet to find a single biological marker that can be reliably described as the cause of any mental disorder. As to why this is the case, originally I thought it had to do with psychiatrists desire to be considered as equals by doctors who practice other specialties of medicine, a reason that doesn't speak very highly of psychiatrists' inferiority complex but which is understandable. However, after the episode of my involuntary commitment was distant in time, I began to research on the topic and I am appalled at what I found. I was made aware of the work by US senator Chuck Grassley which exposed the undisclosed financial ties to big pharma of "prestigious" psychiatrists such as Joseph Biederman, Charles Nemeroff, Martin Keller or Alan Schatzberg -the latter served as president of the APA even after the extent of his misconduct was publicly known-, the APA, and its front groups such as NAMI; right now I am more of the opinion that it has to do with a more mundane reason: greed. All these people engaged at some point or another in ghost writing, a practice that consists in that somebody hired by a pharmaceutical company writes a book or an article promoting a drug or a given clinical practice. The article/book is then presented as authored by the psychiatrist in question. The end result is that few people question the findings of the work, regardless of its scientific quality, because it is promoted as authored by some "prestigious"
    doctor. Of course, the "prestigious" doctor is duly paid by the pharmaceutical company for the cooperation.

    2- The guides of the APA, such as the DSM, have far reaching effects beyond the American market. The DSM was used to give me the OCD diagnosis in the European country where I was involuntarily committed. If the DSM, as it seems to be the case for DSM5, begins to promote the over use of psychiatric drugs, its effects will be felt not only here in the US but worldwide, which takes me to the third point.

    3- The US is, as it has been in many other instances, a pioneer in the protection of individuals' rights, in this particular case psychiatric patients' rights. A series of opinions by the US supreme court in the seventies, O'Connor v Donaldson and Addington_v._Texas in particular, limited the ability of American psychiatrists to involuntarily commit patients to psychiatric institutions except in those cases where the life of the patient (or the life of a third party) is in imminent danger. Subsequent decisions also limited psychiatrists' ability to drug patients against their will. All this is relevant because I was able to make the decision of stopping all medications without the fear of retaliation only because I am an American living in America. This decision might have meant a trip back to the psychiatric ward in that European country, despite the severe effects I was experiencing. That is not to say that psychiatrists do not abuse their power in the US, there is plenty of evidence to the contrary, however, their ability to abuse patients is severely limited.

    Ideally, we should have the current practice of psychiatry disbanded and the DSM abolished. That is unlikely to happen, at least in the short term, because there are so many special interests (the APA, big pharma, the FDA) interested in maintaining the status quo. However, we can all fight so that their negative effects are attenuated, not only for our fellow Americans but also for the sake of millions of innocent people who live in countries which are less protective of patients' rights and who are likely to be abused by the psychiatric establishment of their countries with an expansive revision of the DSM.

  16. annalaw81 says:

    Thanks, Peter, for your look into how foster care kids are dealt with. I am aware of that to some degree, given what I do. It’s no surprise these kids may be depressed, if they have been in various foster homes or therapeutic settings, and through traumatic family situations, often including domestic violence. I can’t really comment on how psychiatrists handle meds in the foster care setting, although I agree, the parents may need the assistance.

    I’m just an adult, trying to get through the day and do my work. If it is this tough for me, these kids have little chance, without strong advocates who can stand up to psychiatry as usual. Also, the legal system has to address these issues without over medicalizing them, which is what happens a lot. Judges rely on reports from mental health professionals when determining what to do with a child. The good ones step back and consider the whole picture, but some just go with what the ‘forensics’ show. As no one else in the courtroom are mental health folks, it’s very tempting to look to these folks as having ‘the answer.’

  17. Duane Sherry says:

    If each fingerprint on this earth is unique…
    Imagine each brain.
    Each mind.

    Holistic medicine is individualized medicine.
    And that’s why it works.
    And why conventional psychiatry does not.

    Dr. Joseph Mercola says it best… when he compares conventional psychiatric treatment to “trying to kill a mosquito with a cannonball.”

    Duane
    discoverandrecover.wordpress.com

    • Duane Sherry says:

      As pointed out on this blog and other places as well…

      The vast majority of psychiatrists ignore the mind.

      Dr. Hyla Cass says the body is ignored “from the neck-down”.

      IMO, the spirit is ignored “from the toes-up”.

      You folks have a long way to go, Dr. Steve Balt.
      A LONG WAY to go!

      Duane

      • Duane Sherry says:

        “Of all remedies, the physician should choose the least sensational.” – Hippocrates

        (You may remember the name, Hippocrates from an oath you boys and girls took along the way)

        Duane

      • Duane Sherry says:

        re: “boys and girls”…

        when it comes to understanding the complexities of the human brain and mind.. we’re all children.. just a bunch of kids

        all of us,

        duane

      • AA says:

        Duane,

        How is Dr. Cass any better than psychiatrists when she is claiming that a chemical imbalance exists in the brain which is corrected by the supplement she sells? I do realize that supplements aren’t toxic like antipsychotics but they are definitely not side effect free. And she is claiming they help with withdrawal when actually, the last thing that people need who have highly sensitive systems from tapering off of psych meds are more supplements.

        I agree with you that that the body and spirit are ignored by many doctors. I just don’t think that taking many costly supplements is the way to solve the problem.

      • Duane Sherry says:

        Here we go again…
        Comparison of using naturally-occuring nutrients with toxic drugs.

        There simply is no comparison.

        And “costly”?

        A few bucks a bottle for D-3.
        According to Tierraona Low Dog, M.D. with the Center for Integrative Medicine in Arizona, a healthy adult over 50 should be taking 4,000 iu per day – It’s good for both the heart and brain.

        Funny thing about using nutrients – the “side-effects” seem to be on the positive-side… better overall health and wellness!

        Some good research sites for non-drug approaches -

        http://discoverandrecover.wordpress.com/category/research/

        Duane

  18. Hawkeye says:

    “We include here [in manic-depressive illness certain slight and slightest colorings of mood, some of them periodic, some of them continuously morbid, which on the one hand are to be regarded as the rudiment of more severe disorders; on the other hand, pass without sharp boundary into the domain of personal predisposition. In the course of the years I have become more and more convinced that all the above mentioned states only represent manifestations of a single morbid process.”

    –Emil Kraepelin (1921)

    0

  19. yinzer says:

    I had a run-in with a group of psychiatrists affiliated with the University of Pittsburgh who had very dogmatic views on the biological nature of bipolar disorder. They insisted that since I had tolerated Zoloft (although not Prozac) the bipolar II diagnosis given by a different pharmacologist was flat out wrong. They did not even bother to take a complete history or ask me if I had ever experienced any bipolar-type symptoms. Meanwhile, the original psychopharmacologist who diagnosed bipolar II was well aware that I had once been on Zoloft.

    • Hawkeye says:

      I have very dogmatic views on the biological nature of bipolar disorder. I have seen antidepressants cause neurological violence. In the spirit of Steve’s observation that no two bipolar patients are the same, I know of no research result that asserts that anti depressants always make bipolar worse.

      Here is a test for bipolar: Go to Jim Phelps web page and follow his mostly naturalistic recommendations and maybe take a low dose of a mood stabilizer. If you improve, maybe you had bipolar disorder.

      I was having a nice day until I understood the meaning of your post, these folks are probably looking for flagrant mania. A general excitation with spurts of hypomania is every bit as biological as wild conspicuous cycling.

      If you want to treat only absolutely valid diseases, go fix cars. On the other hand have you ever tried to find where that rattle is coming from in your 15 year old whatever?

  20. [...] I sometimes wonder whether I’m practicing psychiatry wrong, or whether my patients are playing a joke on me.  But no, as far as I can tell, I’m doing things right: I prescribe appropriately, I use [...]

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