Monday, January 24, 2011

Anatomy of an Epidemic: The Carlat Take, Part 2

In my last post, I critiqued one aspect of Robert Whitaker's endlessly fascinating book, Anatomy of an Epidemic. Now I'll do yet some more critiquing.

To recap, his book consists of two general arguments:

1. Rates of psychiatric disability have soared during the period when many new psychiatric medications have been introduced--contrary to what you would assume should happen if the drugs worked so well.
2. Long-term studies actually comparing patients on meds vs. those off meds have yielded an apparently paradoxical result: patients not taking meds end up doing better over the years than those taking meds.

Last time, I rebutted the disability argument, pointing out that the skyrocketing rates of psychiatric disability have to do with increasing enthusiasm for diagnosing psychiatric illness and for increasing government financial incentives that encourage people to seek a psychiatric diagnosis.

In this post I'll consider his second argument. Whitaker argues that essentially all classes of psychiatric drugs are harmful in the long-term--including antidepressants, anti-anxiety drugs, and ADHD drugs--but I'll focus on antipsychotics, because this seems to be his main focus.

Before beginning, as anybody who has followed my blog knows, I readily acknowledge that psychiatrists over-rely on drug treatment of mental illness and should be doing more therapy. In order to maximize profits, drug companies consistently downplay the side effects of their medications. It's not that I believe drug treatment worsens conditions--rather, that our obsession with psychopharmacology has deprived many patients of integrative treatment, which combines the judicious use of medications (when needed) with the right kind psychotherapy (also, when needed). Thus, while both Whitaker and I end up with a similar conclusion--that psych meds are inappropriately used in the U.S--we arrive at that conclusion in very different ways and we mean different things by "inappropriate use."

On his website, Whitaker has posted a useful page in which he provides links to the studies he mentions in his book. He lists 34 studies, including links and brief summaries. Don't worry, I won't go through all 34, I'll just make two general observations.

1. The studies cited by Whitaker are old, and the patients who were diagnosed with "schizophrenia"often did not have that illness. 


Most of the long-term outcome studies in the literature were published in the 60s, 70s, 80s, and early 90s. But they are actually even older than that, because these studies often describe people who were diagnosed with "schizophrenia" 10 to 20 years before the date of the publication. For example, the Vermont longitudinal study was published in 1987, while is already pretty old, but the study describes patients who were originally diagnosed with schizophrenia in the late 1950s and early 1960s.

Why does this matter? Because before DSM-III was published in 1980, American psychiatrists had a bad habit of vastly over-diagnosing "schizophrenia." Patients who would now be labeled with bipolar disorder, borderline personality disorder, depression, and various other problems, were, in the 60s and 70s, likely to be diagnosed "schizophrenic."


The classic study to demonstrate American psychiatry's historic infatuation with the schizophrenia diagnosis was published in 1971.  The researchers showed videotapes of 8 patient interviews to a few hundred psychiatrists in both Britain and the U.S. After viewing the videotapes, the doctors were asked to make a diagnosis. The disagreements were glaring--and were somewhat embarrassing for the Americans. For example, in one case, "Patient F," the patient was a man from Brooklyn who had hysterical paralysis of one arm and a history of mood fluctuations associated with alcohol abuse. The diagnosis? According to 69% of American psychiatrists, the man had schizophrenia, whereas only 2% of the British psychiatrists favored that diagnosis. Most of the British psychiatrists diagnosed the patient with "hysterical personality disorder."

The point is that most of the long term outcome data Whitaker cites is based on unreliable and very broad conceptions of schizophrenia. While he accurately describes studies showing that schizophrenic patients who were not on medications often did very well, I'll bet you a dime to a dollar that many of these high functioning schizophrenics never had schizophrenia in the first place, at least not according to current DSM-IV criteria. They did perfectly well off antipsychotics for the same reason somebody without diabetes would do well off insulin--they didn't actually have the disease.


2. Most of the studies Whitaker cites are observational studies--which are suggestive, but not definitive. 

The best way to figure out if a medication is helpful or harmful for schizophrenia is to conduct a placebo-controlled study. You randomly assign patients to two treatments: an antipsychotic or a sugar pill placebo. A recent meta-analysis of 38 such randomized studies of second generation antipsychotics, which pulled together data from 7323 patients, found that antipsychotics outperform placebo with a response rate of 41% vs. placebo's 24%. These were mainly short term studies, lasting a couple of months or so. Thus, we know that antipsychotics are moderately effective in the short term, although they can have some nasty side effects. 

In order to convincingly show that antipsychotics improve (or worsen) schizophrenia over the long term, you would have to do a placebo controlled trial lasting many years. That has not been done--not through some conspiracy of the pharmaceutical industry, but because it would be extremely hard to conduct such a trial. Imagine if you were schizophrenic and a researcher asked you to be in a 10 year long study in which you might get an active medication or a sugar pill. Schizophrenia is a serious, like threatening condition.  Would you roll the dice with your life, taking the chance that you would be on a sugar pill for 10 years? Probably not. Furthermore, even if you agreed, chances are good that you would drop out of the study before the 10 year mark--for any number of reasons, such as moving away, worsening mental or physical illness, side effects etc.... 

Because these gold-standard long term studies do not exist, we are forced to fall back on much less convincing evidence--observational studies. This is where researchers enroll, say, 200 patients with schizophrenia and ask them to agree to periodic evaluations. The patients can get their care wherever they want, they can continue to see their doctors, take or not take medications, seek enlightenment in the Himalayas, or go to Lourdes. It's all up to them. Every few years, the researchers contact them and ask them how they are doing. Are they taking meds? Are they having psychotic symptoms? Do they have a job? And so on.

You can immediately see why such observational (also termed "naturalistic") studies are suboptimal. If, 10 years after the study starts, the patients who are not taking meds anymore are doing better than the patients who are taking meds, how do you interpret this? You could conclude that antipsychotics worsen schizophrenia. Or, you could conclude that the patients who are not on meds after 10 years simply were blessed with a milder version of schizophrenia, such that they recovered after a few years and didn't need meds anymore.

This inherent weakness of observational studies is why the Harrow study is so hard to interpret. Whitaker and Andrew Nierenberg debated this study on Radio Boston recently.  In this study, Harrow and colleagues identified 64 patients with schizophrenia and reinterviewed them five times over the next 15 years. At the final 15 year follow up, 64% of the patients who were taking antipsychotics still had psychotic symptoms, whereas only 28% of those not taking antipsychotics had such symptoms. What does this mean? Whitaker sees this as evidence that antipsychotics worsen mental illness. I see it differently. I suspect that the patients still taking antipsychotics after 15 years had more severe cases of schizophrenia to begin with, and therefore required more prolonged treatment with medications. The medication didn't cause the psychosis--the psychosis caused patients to still need the medications. 


Over the last few days, I've spent many hours thinking and writing about Anatomy of an Epidemic. Mostly, I've chipped away at its central thesis, and yet the fact that this powerful book has riveted my attention for so long means something. It's fascinating. It's enthralling. And it is the work of a highly intelligent and inquiring mind--a person who is struggling to understand the nature of psychiatric treatment.  Put it on your reading list, and join the debate.

76 comments:

Anonymous said...

But you ignore Dr. Nancy Andreasen's work showing that long term anti-psychotic medication use basically destroys the basal ganglia and leads to a shrinkage of the frontal lobes. And that can't be good for executive functions!

Anonymous said...

Of course the results of the Harrow study are open to interpretation and Dr. Harrow sees the data much as you do -- some schizophrenic patients have premorbid strengths that allow them to go off medications. That's fine. But what is ignored is the mere fact that there is a significant subgroup of schizophrenics who can pull this off. This goes against official American Psychiatry dogma, Big Pharma, and their surrogates like NAMI who maintain that everyone has to stay on meds for life or else they will relapse. It just ain't so.

David Behar, MD, EJD said...

Most psychotic people are either normal or personality disorder people who drink and use drugs a lot. A real schizophrenic is very difficult to find. Any study with hundreds of people likely contains mostly drug induced psychosis.

In many cases, brain damage results, especially from alcohol. In those not damaged, it takes years to recover fully.

As a matter of policy, I would prefer to pay such an impaired person a disability payment than to have that person in a position of responsibility and dangerousness at a job.

The psychiatrist does not control relapse of drug addicts, and relapse makes medications ineffective.

Lots of addicts decide to cut back on alcohol and illegal drugs. They will improve without medication. None of the studies had blood levels of neuroleptics to at least show ingestion. None had illegal and alcohol drug screens.

This is a rookie mistake made by anyone who has not spent an hour or two in an outpatient clinic. To anyone who has, the problem of illegal drug use is self-evident as a confounding factor.

Anonymous said...

Dr. Carlat, it doesn't seem to me that you've "chipped away" at Robert Whitaker's central thesis so much as refined the argument. Thank you for your take on it; it's much appreciated.

Dr John said...

Anon 2 is exactly correct and this insight as he notes is completely at odds with psychiatric dogma. Dr Carlat implies that newer studies are better at diagnosing Schizophrenia and therefore remission rates in older studies are do to over diagnosing.This implies that psychiatry has improved in its diagnostic accuracy over time. I know of no data to support this. I don't think it is even possible to produce it.

More importantly Dr Carlat falls into the language trap without clearly realizing it and the fallacy of identifying ideas of mental illness(a construct schizophrenia) as the same thing as identifying corporeal pathology.Again he says that people who got better in the Vermont study really "did not have Schizophrenia". How does he know? If you get better do you no longer have it? Did you ever? How do you know if it's gone or taking a holiday? What is Schizophrenia exactly and how does one "know" if one has it or not? Go up to your average psychiatrist and ask him these questions.His/her eyes will glaze over.

Psychiatry relies on purely operational definitions(no known objective pathologic markers) which have questionable construct validity.As long as that is the case you will have debates about the accuracy of 30 y/o studies. That is why Bipolar disorder used to be .1% of the population and now is 5%. Does that mean that old studies on Li are not valid? Not according to his newsletter.

These are the same new psychiatrists who we are supposed to be trusting to make accurate dx of Schizophrenia? Dr Carlat has already pointed out they are responsible for the explosion in disability rates and not to be trusted. Why are we to assume this new crop of clinicians are only good at diagnosing psychotic people? The answer is you can not!

It is also why you can never ever really trust a psychiatric DX and why there is almost nothing as scary or dangerous as a psychiatrist who is sure of himself.

gewisn said...

"David Behar, MD, EJD said...
Most psychotic people are either normal or personality disorder people who drink and use drugs a lot. A real schizophrenic is very difficult to find. Any study with hundreds of people likely contains mostly drug induced psychosis."

Um, try reading the study...
"The sample of 145 DSM-III diagnosed patients included 64 schizophrenia patients and a control sample of 81 nonschizophrenia patients who were psychotic at index hospitalization.... The 81 nonschizophrenia patients who were psychotic at index included 31 bipolar manic patients, 28 psychotic unipolar depressives, 6 psychotic bipolar depressives, 5 paranoid disorders, and 11 patients with other psychotic disorders."

And why would you decide that none of these Hospitalized patients had a drug screen performed?

"David Behar, MD, EJD said...
As a matter of policy, I would prefer to pay such an impaired person a disability payment than to have that person in a position of responsibility and dangerousness at a job. "

There's a plan. Let's try that.
In fact, I'm sure my judgment is impaired in comparison to yours. When you send me the first personal check for $800/month, I'll know you're serious.

Sara said...

Great comment, Dr. John.

This idea that a person who gets well never really had the disease is one that psychiatry falls back on a lot. Personally I think that is a chicken's way out given the overall precision of psychiatric diagnoses. And it's one you can never prove.

I want to recommend two excellent books by highly intelligent writers that seem relevant to this debate. The first is Schizophrenia: A Scientific Delusion? by Mary Boyle and the second is Of Two Minds by T. Luhrmann. I don't agree with Luhrmann's stand on the wonders of the "new" generation of drugs -- she was writing her book about ten years ago in the heyday of their launch -- but she's brilliant on trends that compromised the practice of psychiatry in the last twenty plus years. You practicing clinicians need to read more books like these and less APA Journal articles. You'd learn a lot more. Try Joanna Moncrieff's book The Myth of the Chemical Cure too.

Sara said...

http://www.theatlantic.com/magazine/archive/2010/11/lies-damned-lies-and-medical-science/8269/

http://www.newyorker.com/reporting/2010/12/13/101213fa_fact_lehrer

And two really excellent articles about why randomized placebo controlled clinical trials may not be all they are cracked up to be and certainly not the "gold standard" that everyone seems to assume they are.

moviedoc said...

Agree with Dr John: Schizophrenia may turn out to be 7 different illnesses that just happen to look the same on the surface. Even if they all have the same illness, it may turn out, as in the case of some other illnesses, that because of genetic differences some respond to antipyshotics better than others, and some are injured by antipsychotics more than others. We are so in the dark here. But we still have to do the best we can with what we've got and what we know.

Joel Hassman, MD said...

I honestly do not know what is worse, this antipsychiatry diatribe going around the internet at sites like this, or, equally the pervasiveness of sizeable portions of colleagues who are basically treating first and asking real diagnostic impressions later.

All of you with any invested interest into the affairs of mental health, if not psychiatry in general, should be watching the developments per the litigating of the Tucson tragedy very closely, and you will see hypocrisy and scapegoating become textbook.

Why I offer this? Because you will read and hear people who will say out of one side of their mouths how this man was "insane" and should have had his issues brought to the attention of authorities and providers sooner, then say out of the other side how there is no mental health defense to be offered and he should be put to death immediately, and then, incredulously out of the center of these mouths will come "Psychiatry does not do enough to impact on aiding the community and we do not need them anymore."

Yes, these comments would make any head spin who was somewhat grounded in reality as we know it in America. And yet, we are exposed to it now as much have heard it for years prior. There are too many people who want everything, and yet will do fairly much nothing to work/earn for it, and then try to find the scapegoat who denies them these alleged needs and entitlements.

And psychiatry overall has foolishly and inattentively allowed to be pigeonholed into this trap. But, now it is time to step back and appraise the situation for what it is. I really do think it parallels the story of the 10 commandments, and not that we are Moses as a field, but, the people we try to educate and aid just rebel and detract from realistic limit setting and boundaries while waiting for the truth to be presented.

Even some psychiatrists are guilty of this too. But, not the field as a whole. Hey folks, call it whatever you want that is a term others can understand, but schizophrenia is an illness throughout cultures and time. You'll see this word used a lot with the Tucson incident for the next couple of years, and in the end, if it fits, all of you concerned with what happened need to decide what to learn from it that prevents history from repeating itself as best possible.

You can let the Whitakers set this course, or, perhaps have some trust and faith in those of us who deal with this illness with regularity?

Just pay attention to the deeds and not just the words of who you will trust!

Anonymous said...

Dr. Carlat said: "psychiatrists had a bad habit of vastly over-diagnosing "schizophrenia."// Funny how they used to "vastly over-diagnose schizophrenia" and now they vastly over-diagnose bipolar disorder. What will be the next fad? And who will be harmed by the label assigned to them in the process? I would have more faith in the specialty if it weren't so prone to fads. It's like watching the fashion business morph each year - only the consequences are much more serious.

Dr. John said: "there is almost nothing as scary or dangerous as a psychiatrist who is sure of himself."// I am so glad you said this. While thinking this weekend about why I seem increasingly to dislike my psychiatrist (this dislike grows stronger every time I see him), it occurred to me that I do not like his absolute confidence in the robustness and legitimacy of his specialty and its supporting evidence. It's a farce (e.g., DSM process, pharma-sponsored drug studies, pharma-created "disorders") and if he were actually engaging his brain, he would know this. Or perhaps he does know it and he is simply trying to pull one over on his patients so they'll do what he tells them to do. Either way, I'm uncomfortable with his seeming comfort.

Sarah said: "And two really excellent articles about why randomized placebo controlled clinical trials may not be all they are cracked up to be and certainly not the "gold standard" that everyone seems to assume they are.// Thank you for posting your links. Physicians have it beaten into their heads that the only decent study is a placebo-controlled, randomly-assigned trial. Hogwash. And then when it's convenient for them, they're completely OK with relying on anecdotal data from their own small group of patients (relative to the universe of patient). Funny that.

Sara said...

If you really find Whitaker's book fascinating and worthwhile, then I hope you will follow up and read Mad in America, a book that left me numb and dumb-founded when I finished it, one of my early reads on this journey of discovery.

Mike T said...

Dr. Carlat- Surely you will agree there has been an extreme increase in diagnoses among children that 'require' treatment with dopamine antagonists. We don't know the long term affect on these children wrt learning in general and also atrophy of mid-brain 'mammalian' structures, behaviors and granular (non- reptillian)affects and emotions. The little research there is on these subjects indicates the outcomes for these children will not be good in terms of learning, at least.
Unlike adults who have choices wrt compliance, these children are forced to be medication -compliant by at least one parent, whoever 'buys in' to the 'Bipolar Child' speil

This is now 10% of the US population coming along. The Islamic, African and Asian countries who are not drugging 10-15% of their children will provide us with a 'macro laboratory' soon enough. Who will have a saner and more productive population in 10 years, us or them ?

Despite these last few posts - you remain one of my heroes, for your work to reform CME. Keep up the good work !
-Mike T. father of a 'Bipolar Child'

Anonymous said...

I am a psychiatrist who works in the area of disability. I have reviewed thousands of charts of people claiming disability and have examined thousands of patients for disability examinations over the last 25 years.

In recent years I have seen more people who are disabled from their drugs. Patients given atypicals who are disabled by either akathisia or oversedation are often mislabeled as bipolar mixed.

Whitaker did not write that side effects from drugs combined with poor care are disabling, but that is what I have been seeing.

In chart reviews, I often see the patient doing OK until referred to psychiatry and being taken off of two drugs and placed on 3 new drugs all at once. One can argue that they were given the drugs because they were getting worse. The counter argument is that it was the drugs that made them worse. Still, if they were getting worse, shouldn't the drugs make the patients more healthy than they were before the referral?

Jeff Johns said...

The American Psychiatric Association does not mandate indefinite antipsychotic treatment for all patients with schizophrenia, but it does recommend it "for patients who have had multiple prior episodes or two episodes within 5 years." In clinical practice, most psychiatrists maintain that indefinite treatment is required. However, as Dr. Carlat points out, we lack evidence of long-term efficacy and safety. The APA treatment guideline cites very few studies to justify its conclusions.

While conducting trials to prove the long-term utility/safety of psychotropic drugs is difficult, the question has not been sufficiently debated within psychiatry. Just bringing up the question is often considered heresy. I am grateful for Dr. Carlat for addressing this issue here.

Several, albeit imperfect, studies suggest cause for concern. If we are to be a scientifically-sound profession, then we should maintain a healthy dose of skepticism for our own treatments. We should welcome criticism and inform our patients of the limits of our knowledge.

Anonymous said...

Carlat makes an assertion that schizophrenia was "overdiagnosed" several decades ago. I don't remember seeing any epidemiological data to suggest that prevalence rates have changed since the first DSM was published. Hardly a scientific conclusion.

Whitaker's book may be fascinating to some readers, but if one is to accept his conclusions what solutions are offered? Do we stop all pharmacologic treatments of this disorder based on his risk-benefit analysis? I'd be very interested in the results of that 15-year prospective outcome study. Unless we want to go back to a mental asylum system or to allow our prisons to become even more overcrowded de facto state hospitals for the severely mentally ill I'd be open to some rational alternatives from Mr. Whitaker.

And Sara, I would posit that the reason you dislike your psychiatrist is an important part of your treatment. It's called transference. Look it up. It has nothing to do with psychopharmacology.

Anonymous said...

To add Whitaker's voice to this debate, I've copied below his post on Carey Goldberg's blog: Special Report: Do Psych Drugs Do More Long-Term Harm Than Good? It is broken up into 3 posts since there is a 4,096 character limitation on posts to Dr. Carlat’s blog.

Here it is:

This is the beginning of a much-needed discussion. As such, I think it is worthwhile to provide more information about the disability data and studies alluded to here.

1. The disability data

The number of people receiving SSI or SSDI due to mental illness rose from 1.25 million in 1987 to 4 million in 2007. That is a hard number, and it tells of the number of adults 18 to 65 years old who receive government support because they are “disabled” due to mental illness.

Dr. Nierenberg stated, during his presentation, that there had been no rise in disability, over this time, and to support this claim, he cited surveys that looked at the number of people with disabilities of all types—physical, mental, etc.—and said this percentage hadn’t risen. But this was data that included people with physical handicaps, neurological ailments (Alzheimer’s disease, etc.) This is not data that isolates the number of people with “disabilities” due to mental illness. Equally important, this is data that tells of people with disabilities, and not of people who are receiving government support because they are, in government terms, “disabled.”

So, our society needs to ask: Why the extraordinary rise in the number of people on SSI and SSDI due to mental illness?

2. The rise in treatment and the rise in disability numbers from 1990 to 2003.

You quote Dr. Nierenberg stating that disability rates have remained the same even as far more people sought treatment. But, in fact, as the SSI/SSDI data shows, the number of people on disability due to mental illness actually soared during the past 20 years. And after I got home from the Grand Rounds, I realized that Dr. Nierenberg had unwittingly presented data that showed a direct correlation with increased treatment and increased disability.

If you were to look at his slides, you would find that he reported that 29.4% of the American adult population had a psychiatric disorder from 1990-1992, and that 30.5% did in 2001-2003. The prevalence of psychiatric disorders remained the same. What changed was that in 1990-1992 only 20.3% of those with a psychiatric disorder were treated, whereas in 2001-2003, 32.7% were treated. Now if you look up census data for the number of adults in 1990 and 2003, and do the relevant math, you find that the number of people treated rose from 11.16 million adults in 1990 to 21.77 million in 2003.

And what happened to the number of adults receiving SSI or SSDI due to mental illness during that period of increased treatment? It rose from 1.47 million people in 1990 to 3.25 million in 2003.

Anonymous said...

3. The Harrow Study

I would encourage anyone interested in this topic to really look at the data in this study, and to go beyond the spin that has been put on it. This is the most important long-term outcomes study for schizophrenia that has ever been done, and it is the only study that charts long-term outcomes for medicated and unmedicated patients. As a society, we really need to look at this NIMH-funded study closely.

Martin Harrow is a psychologist at the University of Illinois College of Medicine. From 1975 to 1983, he enrolled 64 adults diagnosed with schizophrenia into the study, recruiting them from two Chicago hospitals, one public and one private. This was a young cohort of patients (median age 22.9 years), and for two-thirds, this was either their first or second hospitalization. In addition, he enrolled 81 others with milder psychotic disorders into his study.

Now, for the next 15 years, Harrow followed the patients and charted their outcomes. He assessed how they were doing at regular intervals (2 years, 4.5 years, 7.5 years, 10 years, and 15 years), and whether they were taking antipsychotic medications. If you dig into the data he reported, in his various tables, and read the study closely, you find that here were the outcomes:

• At end of 15 years, 40% of the schizophrenic patients off antipsychotics (25 of the 64 patients) were in recovery, versus 5% of those on medication. This stark divergence in outcomes appeared by the 4.5 year followup, and remained throughout the study.

• At the 10-year and 15-year follow-ups, only 28% of those off meds suffered from psychotic symptoms, while around 70% of those on drugs remained actively symptomatic.

• At the outset, Harrow also divided his schizophrenia patients into those with a “good prognosis,” based on their internal sense of self, and those with a “bad prognosis.” Starting with the 4.5-year followup and continuing through the 15-year followup, the good prognosis schizophrenia patients off medication had better global outcomes than good prognosis schizophrenia patients on medication, and the bad prognosis schizophrenia patients off medication had better global outcomes than bad prognosis schizophrenia patients on medication.

• Among those with milder psychotic disorders, those off medication—close to half of the cohort of 81 patients-- did much better long-term.

• In terms of all patients, the global outcomes for the patients lined up like this, from best to worst: milder disorders off medication, schizophrenia off medication, milder disorders on medication, schizophrenia on medication.

So what do you see in this data? You see that no matter how you group the patients, those off medication did much better over the long-term. And most startling of all, you see that schizophrenia patients off meds did better longer term than those with milder disorders on meds.

Now, the way that this data has been spun—and frankly, the published articles contains this spin—is that a number of good prognosis patients, having stabilized well on the medication, then were able to get off. That’s the official explanation: the better outcomes reflect a better prognosis, and Dr. Nierenberg, in his quote above, was saying that I had it “backward” to suggest otherwise.

But what I did at the Grand Rounds was report the data, not the spin. And everywhere you look in this study, it was the unmedicated patients who did better. And those with a much more severe diagnosis at the start—the schizophrenia patients—who then got off antipsychotics had a better long-term outcome than those with a milder psychotic disorder who stayed on psychiatric medications. And that is data that needs to be known and its implications discussed.

Anonymous said...

4. The Chinese Study

As a rebuttal to the many NIMH-funded studies I presented at the Grand Rounds, all of which contradicted the conventional wisdom that people diagnosed with schizophrenia need to be on antipsychotics all their lives, Dr. Nierenberg cited a 1994 study, which looked at patients in a Chinese community with schizophrenia symptoms who had never been treated. (Ran, Br. J of Psychiatry 2001, 178:154-58.)

Here was the design of that study. The researchers went into the community, and identified 510 people with psychotic symptoms. Now 156 of that group had never been treated for their symptoms. This never-treated group had a median age of 48 years, and had been ill for 13 years. And here’s the first important point: This study identified people who had never been treated and who had remained ill. People who had suffered psychotic symptoms in the past and then recovered (without treatment) would not likely have been included in this study.

Now, at that moment of identification, the researchers found that there were 30 people who were on antipsychotic medications and had been taking the drugs regularly. This cohort was younger (35.9 years), and had been ill for a shorter time (7.8 years.) The researchers assessed how these two cohorts were doing at that one snapshot in time, and concluded that those on medications were doing better, on the whole, than the never treated group. They were less likely to have active symptoms, etc.

The researchers then followed the untreated group for two years. They didn’t follow the treated group, and so there is no time comparison at all. And sure enough, this untreated group that had been psychotic for a long time tended to stay psychotic.

You can see the difference between the Harrow study and this study. In the Harrow study, Harrow began following a large sample of patients from early in the course of their illness, and charted their medication use and outcomes. The Chinese study simply reports that a group of chronic, elderly patients who had never been treated stayed chronic. And one final note: 77.6 percent of the chronic patients in the Chinese study were able to do part-time or full-time work. That work rate is far, far above what we see here in the United States.

5. The NIMH’s Long-term Study of Depression

In the article above, Dr. Nierenberg is quoted as stating that in a longitudinal study of depression, those who got treatment virtually doubled their odds of getting better. The study he is referring to is known as the National Institute of Mental Health Collaborative Depression Study, which began in 1998, and it showed no such thing.

In his talk at Grand Rounds, Dr. Nierenberg cited one of the many spin-off studies that have been published form this long-running study of depression. This particular study looked at people who had been treated for an initial episode of depression and then relapsed. The researchers then found that those who were treated for this recurrent episode with a high dose of an antidepressant were more likely to recover from that episode than those treated with a low dose or no drug at all. As much as anything, it was a study designed to assess dosage of antidepressant to be used when people suffer a recurrent episode of depression. (Leon, Am J Psychiatry, 2003, 160:727-33.)

But the key spin-off study from that larger long-running study, which I cite in Anatomy of an Epidemic, is one that looked at the six-year outcomes for depressed patients who were either treated for the disorder, and those who weren’t treated at all. And in that study, 32.3% of those who got treated suffered a “cessation of role function” and 8.6% “became incapacitated,” while only 9.8% of those who didn’t get treated suffered a “cessation of role function,” and only 1.3% became incapacitated. (Coryell, Am J Psychiatry, 1995, 152:1124-29.)

Anonymous said...

A Need for Discussion

I have posted this long comment because I do truly hope it can be a beginning for a larger societal discussion we need to have. Psychiatric medications can often help over the short-term, and there are people who stabilize well on them for the long term. But in terms of how their long-term use affects long-term outcomes in the aggregate, well, that is a different story indeed. And the soaring SSI and SSDI numbers tell us that we need to look at this “epidemic”, and think what might be done differently.

--Robert Whitaker

David Behar, MD, EJD said...

This one is over 100 years old. When you offer money for disability, its rate increases. When there is economic dislocation, such as outsourcing, unemployables (due to obsolete skills) increase the rolls of disability.

There is an ascertainment bias in the data of Robert Whitaker, making it propaganda. People with growths of any kind do worse if they receive chemotherapy. Who receives chemotherapy? People with bad tumors, not benign growths, especially in poor areas of China.

Also, the diagnoses used in those studies may be 19th Century superstitions, or broad final common pathways, as broad as the terms, fever, cancer, or mental retardation, covering 100's of underlying conditions, half of which require future discovery. The terms may be meaningless except to justify payment.

Patients on any treatment have high rates of non-adherence. They do single case, on-off experiments repeatedly. Those still on medication have had their treatment validated by the consequences of being off medication many times. Nothing had better clinical validity for individual management decisions.

Lastly, for Robert Whitaker. VTech. That is the consequence of irresponsible obstruction to treatment, including involuntary, forced depot medications of paranoid schizophrenics. Off meds for 2 years. Multiple complaints unaddressed due to irresponsible, left wing obstructionist regulation.

Dr John said...

Anon asks appropriately in reference to Whitaker's book "Do we stop all pharmacologic treatments of this disorder based on his risk-benefit analysis?" Maybe not but it certainly should give us great cause to completely re-evaluate our model which means giving lower doses for shorter periods and maybe even for some with milder symptoms no meds at all and just psycho-social TX.

And by the way your rather smug response to Sara "I would posit that the reason you dislike your psychiatrist is an important part of your treatment. It's called transference. Look it up." is why people dislike psychiatrists to begin with. I don't ever remember reading any studies that linked positive outcome to disliking your psychiatrist. You have no idea what so ever if this is a transference issue. It certainly is presumptive of you to just assume this.I would not go so far as to say this relic of psychoanalytic thought is without importance to us Drs but it certainly is meaningless to pts. We don't always need antiquated Freudian myth to explain why pts don't like their psychiatrists. We just need to listen a little closer to their complaints. Maybe her psychiatrist is just an asshole.

Becky Murphy said...

The fact of the matter is Dr. Carlat we all would have better data with which to do a risk benefit analysis if the APA and it's members or partners wanted it more readily available. Instead, the American people have been bombarded by a massive media campaign.

the data of course could be had if you and your buds were required by Law to report ADVERSE events. I personally, given what psychiatry did to my son, think failure to disclose known effects, should be a felony crime when harm results, and a gross misdemeanor at least, if it does not. I know the APA does not want this being done.

Sara said...

I was not the commenter who said I disliked my psychiatrist. I think if someone wants to insult another commenter they should be more careful to whom they address their remarks.

jon leo said...

Dr. Carlat, I hate to point this out but if we need to disregard a 1987 study of schizophrenia because the patients probably didn’t even have schizophrenia then by the same reasoning we need to disregard the most famous studies in all of psychiatry – the famous Kety schizophrenia adoption studies. These studies are almost universally cited as showing that schizophrenia is genetic. If these patients didn’t really have schizophrenia then what genes were they passing down? Or what were the researchers studying? There are several critics who have pointed this out but they are given little credence amongst psychiatrists. In fact, I would venture to bet that every medical student in the world, for their introductory lecture on schizophrenia saw a slide of the Kety studies unequivocally showing that schizophrenia is genetic. The same goes for Irv Gottesman’s figure showing that the relatives of a patient diagnosed with schizophrenia have a better chance of being diagnosed with schizophrenia the more closely they are related (Figure 10 from his book). His figure is almost a mainstay of every med school textbook chapter written on schizophrenia. The idea that schizophrenia is genetic is a central pillar for the entire foundation of the psychiatry profession. If the studies that all this is based cannot be relied on then there are bigger problems for the profession than Bob Whitaker’s book.
Ref:
Leo, J.L. and Joseph, J,. Schizophrenia: Medical Students are taught its all in the genes but are they hearing the whole Story? http://www.ingentaconnect.com/content/springer/ehss/2002/00000004/00000001/art00002

Anonymous said...

As a social worker in the frontlines of dealing with patients suffering from mental illness for over 25 years I believe that our patients are the evidence that the medications we have been depending on are not getting the job done. Most psychiatrists spend 10 or 15 minutes max with there patients and whip out the script pad. I believe that if you follow the money you will get to the truth of our current situation. MDs have a serious financial bias in maintaining the status quo in terms of how treatment is delivered. If you look at the work being done in Finland using Open Dialogue Treatment to manage psychotic patients you will see that in the USA we are not open to looking at any alternative treatments other then meds. The nonmed approaches were railroaded out when Loren Mosher and his Soteria were work were buried at NIMH in the 1980s. The APA and big pharm have zero interest in looking at anything else other then more meds. For that matter they would propose giving antipsychotics to an increasing number of behavior disordered childen rather then dealing effecitively with the behavioral issues. It is all about making money and a quick easy if ineffective fix.

Anonymous said...

I agree with Dr. Leo's comments. It is sort of like the contretemps over antidepressants: Those who respond to placebo are "really" not depressed. Schizophrenics who maintain functioning off medication are "really" not schizophrenic. And on and on. It's funny: I had some marked OCD symptoms in medical school and was cured with psychoanalysis, not meds. I guess I "really" didn't have OCD! The logic of biological psychiatry is breathtakingly twisted.

Daniel Carlat, M.D. said...

Hi Jon,

It's true--one has to be suspect of any older articles that are not very clear about the diagnostic criteria used. I tend to trust DSM-III and after, but even before DSM-III many researchers were using the Research Diagnostic Criteria upon which DSM-III was based. As long as the methodology is clearly described I tend to trust those articles.

I haven't looked closely at the Kety articles, so I don't know how trustworthy the diagnoses are.

Daniel Carlat, M.D. said...

An overall comment--disagreeing with large portions of Whitaker's argument is not equivalent to endorsing all of modern psychiatric practice!

Yes, we over-prescribe, we have minimized the importance of side effects, we have been bought out by pharma--all this is now so widely known that even many of the former pharma KOLs are willing to admit it.

My main problem with his book is that I think he overstates his case and paints all psych meds with the same broad brush of toxicity.

David Behar, MD, EJD said...

"It is all about making money and a quick easy if ineffective fix."

When parents forget to give the medication, the symptoms are all back as a reminder. They give them late, and a couple of hours later, things are better. Patients and families decide the benefits each time they ingest a medication.

The anti-medication movement is really a movement against patient choice. They do not want poor, dark skinned people getting the same expensive medication they expect for themselves.

The "compromise" in this argument will likely be greater regulatory restrictions and barriers to care.

pj1280 said...

--- "The anti-medication movement is really a movement against patient choice. They do not want poor, dark skinned people getting the same expensive medication they expect for themselves."

Having worked in community mental health for the last 3 years, and being somewhat "anti-medication" myself, I would amend this statement slightly. I do not want people who don't need medication (yes, most of whom are poor and dark-skinned) getting the same expensive medication that others who do need it cannot afford.

It's a vicious cycle. The poor and indigent are easily labeled mentally ill (due to their very real but nonpathological complaints of "stress" or "anxiety") and have free access (thru Medicaid or other programs) to potent, expensive meds.... meds which are effective in the right patients, but in those with no underlying mental illness, they just create the disability that we are trying to prevent.

No one wins.

David Behar, MD, EJD said...

Dr. PJ1280: I have worked in similar places. The problem you describe is rare, less than 1 in 100 patients are just stressed out. None would get medication, anyway. For example, a child has lost the entire family in a fire. No meds unless a collateral condition is found on screening. Teacher complain of pre-existing ADHD symptoms, those might be treated but unrelated to the referral complaint.

The opposite is far more prevalent. Undertreatment leading to catastrophic injuries and harsh outcomes.

Vtech, Mr. Whitaker. Address VTech.

Sara said...

David Behar,

Just what is your point about Virginia Tech? What is it that you are so confident about in your assessment of Cho that makes you think his case would put holes in Whitaker's argument? Are you aware that Cho was on Paxil for over a year sometime in the few years before the shooting? Did you know that his roommate saw him taking prescription medication the morning of the shooting and that initial reports said that medications for psychological problems were found in his personal effects? Yet the name (or names) of these meds were never released. Do you know that his health records mysteriously disappeared from the college health center? Do you know his toxicology report was never released even though this would certainly be something of public interest? Just what are you trying to say -- that he was "untreated" and needed forcible treatment? You don't have any idea what his real history with respect to medication may have been nor how it may have been exacerbating his anti-social and psychotic tendencies. A year on Paxil and an abrupt withdrawal could wreak all sorts of permanent damage on someone with a vulnerable psyche.

And what exactly is your point about missing or stopping medication? Are you suggesting that someone's "illness" comes roaring back when they stop a med or miss a dose? Is that what you would say if someone was addicted to heroin or cocaine and they got sick when they missed a day? Are you not even aware of the chemical dependency and symptoms of discontinuation and rebound that can easily occur even between doses on some of these meds? Sure a medication has a "benefit" if someone is addicted to it or dependent on it, but that is hardly a health benefit that we want to encourage. It's unfortunate that the very symptoms these meds produce in withdrawal are ones that are similar to the symptoms of the initially presenting disorder but in most cases the withdrawal symptoms are far worse. For years the myth has been perpetrated that this is the "disease" coming back and poor patients as well as naive doctors believe it.

And to Dr. Carlat, there really is no evidence at all, except for the wishful thinking of treating psychiatrists, that the brush of toxicity these meds produce is not very broad indeed.

pj1280 said...

Dr Behar,

Perhaps we work in two very different places. In my setting, undertreatment is not more prevalent.

While there certainly are exceptions, if I even suggest to a patient that he/she doesn't need meds (much less disability benefits) the outcry from the patient-- and, increasingly, from my medical director and from county mental health administrators-- is swift and harsh.

Soteria? Open Dialogue Treatment? Ha! Those take time! Patients might resist!!

No wonder the 15-minute med-check and Rx is the standard of care. It's a hell of a lot easier than providing real treatment. And to top it all off, we all (patients, doctors, clinics, pharma companies) get nice checks at the end of the month.

John M. Nardo MD said...

Well, your post really brought out the comments. I've enjoyed them as they've accumulated and can identify with the position taken by most responders - having felt the same way over the years as the different aspects of the problem gain ascendency in a given case. I'm now kind of old, and only see patients as a volunteer in a couple of charity clinics, one of which serves children and adolescents. Every time I see a new case of clear Schizophrenia brought in by a baffled family, I still feel the cringe of all the points made here, including Whitaker's. I start the medicines, hoping to get away with the lowest dose of the softest antipsychotic, rarely succeeding at that. When things improve, I drop the dose as soon as possible. I occassionally get away with that. I try stopping the medications. I almost get away with that. And I worry.

I'd worry if I didn't use the medications. I worry if I do. I guess I feel the weight of the history of those of us who have tried to deal with this very big illness since there were people like us. And I wish I could land on a way to look at this that carried a conviction. My own resolution of the dilemma is to stay worried when I see these cases. I try to be sure that what I'm treating really is what we agree constitutes Schizophrenia, and not something else. After that, I guess I see worry, confusion, and indecision as being as much a part of treating these patients as it is a part of having the disease itself.

Dr John said...

Thank you Dr Nardo for your post. It very much hits home. I share your sense of uncertainty and concern for our pts. I think if clinicians as a whole and more importantly researchers and psychiatric leadership expressed the kind of sentiment and uncertainty you have, many including some of the folks who post on this blog would be far less contemptuous of psychiatry.

David Behar, MD, EJD said...

I invite Mr. Whitaker and Sara to volunteer for one shift as client care workers in a locked psychiatric ward. It's just 8 hours. Show us how to improve care, and not cause brain damage anymore.

The condition is that for that day, no psychiatric medication can be dispensed.

I am sure one can find a medical director to agree to this experiment.

Anonymous said...

Dr. Behar, I must confess I find your comments completely and absolutely ridiculous, and I mean that in the most polite way. The "anti-meds" people (and I am one) don't want them for dark-skinned, poor people????? You're kidding, right??? And you want Mr. Whitaker to volunteer for an 8 hour shift with patients withdrawing from meds? My goodness. BUT I am finding much of the other give and take on this subject to be fascinating and I appreciate it.

altostrata said...

Dr. Carlat, we can stipulate this: "In order to maximize profits, drug companies consistently downplay the side effects of their medications."

Yes, and research psychiatry and psychiatry's own leadership collaborate in this, as you yourself have written many, many times.

Only too willing to swallow the field's propaganda, the clinician is misled into believing the drugs are much, much safer than they are and over-prescribes them.

Due to indoctrination and self-interest, if adverse reactions occur, the clinician will fail to identify them, misdiagnoses, and treats them with inappropriate polypharmacy, as Anonymous described in his or her Jan 24 post.

As Robert Whitaker describes in great detail in Anatomy of an Epidemic, overmedication and prolonged exposure to adverse drug effects lead to disability.

The actual diagnosis is not relevant. The disability resulting from incompetent treatment is.

Dr. Carlat, how could you miss this very central point in Whitaker's book?

By the way, Dr. Hassman, the reason psychiatry is so widely mistrusted is because so many people have been exposed to bad medicine as practiced by psychiatrists. More than 10% of the US population over the age of 6 is taking psychiatric medication. That kind of saturation leads to a lot of dissatisfied customers.

This may make you uncomfortable, but injured patients will continue to speak out instead of letting the "experts" continue their business as usual.

Joseph P Arpaia, MD said...

Dr. Behar,

I'm seriously questioning the veracity of your claim to experience working with indigent clients.

You claim that most are not "stressed"??? What poor people do you work with? I do volunteer work at a clinic which serves the poor. All of my patients there are stressed because poverty is stressful.

David Behar, MD, EJD said...

Dr. A: Most patients are not referred for stress induced conditions. Stress is common, as a factor, but not the chief complaint.

Most are referred for solid, major psychiatric disorders. Only the rare patient, such as a massive mental trauma patient, will get referred, and not get medication automatically. As most clinicians will do, we send those currently using drugs and alcohol to excess to addiction evaluation and treatment programs. So the use of psychiatric medication is quite conservative and not discretionary in most patients remaining in local clinic.

I like the way Dr. Carlat allows personal remarks by irresponsible left wing deniers, and censors replies by those not sharing his Boston views. But half of my replies to personal attacks have not made it through. Personal attacks are all that remain, since the facts abandoned the left 100 years ago.

Again, where is Mr. Whitaker on VTech? Where is Mr. Whitaker on working a shift in a psychiatric unit where all the medication has been stopped for 24 hours? One good beat down by an agitated paranoid schizophrenic is worth 3 hours of arguing. Of course, the other staff will not be allowed to grab anybody, since the left wing denier has also forced providers to go restraint free. Hopefully, the paranoid choking and pounding Mr. Whitaker will respond to deescalation techniques and quiet counseling, such as that provided in his model treatment programs. Those programs have not been used enough by the mainstream.

John M. Nardo MD said...

"anti-medication movement"
"left wing deniers"
"irresponsible, left wing obstructionist regulation"

Lions, and Tigers, and Bears! Oh my!

altostrata said...

Dr. Carlat, on Jan 25 you say "Yes, we over-prescribe, we have minimized the importance of side effects, we have been bought out by pharma..."

Okay, so where is your conclusion on harm to patients? This is what Whitaker is driving at -- showing where patient harm might appear. Psychiatry has displayed no interest whatsoever in this direction of research, preferring instead to investigate ever-expanding uses for its drugs.

I look forward to your next book detailing the serious harm to patients done by psychiatry's sellout.

As for Whitaker painting with too broad a brush -- do you not agree that, long-term, ALL psychiatric drugs, far from "balancing" the brain, cause a possibly dysfunctional compensation throughout the nervous and hormonal systems?

This is another central point in Whitaker's book you have failed to address. By the way, psychiatric diagnosis is probably no more accurate today than it was 40 years ago, and study populations no more carefully vetted.

The quality of psychiatric research is another area where psychiatry has long failed the most basic standards of good medicine.

Dr. Behar, regarding your Jan 30 post, Whitaker states psychiatric medication can be effective in the short term for acute episodes. He points out the damage occurs with long-term dosing and polypharmacy. You might find his book interesting.

Also, I'd like to point out, although pharma promotions threaten widespread drugging with antipsychotics (profit from antidepressants having run its course) around 90% of the 30 million-plus Americans on psych drugs are on antidepressants (Olfson & Marcus, 2009). It's curious to me this conversation has wandered into a relatively rarefied argument about schizophrenia.

Long-term dosing with SSRIs and SNRIs has done its part turning a large number of productive citizens with occasional depression into the disability cases that show up in Whitaker's recent statistics.

Do all of these people really need to be medicated with risky drugs? Where are the protocols for gradual withdrawal?

Joel Hassman, MD said...

I just love the overgeneralizations made by people in their attempts to bash a field or profession:

"By the way, Dr. Hassman, the reason psychiatry is so widely mistrusted is because so many people have been exposed to bad medicine as practiced by psychiatrists. More than 10% of the US population over the age of 6 is taking psychiatric medication. That kind of saturation leads to a lot of dissatisfied customers."

Just so readers remember, over 70% of antidepressants are written by non-psychiatrists, and with the push by pharma to get second generation antipsychotics indications for any illness that involves the brain, even migraines per Lilly's attempt 8 years ago with Zyprexa, with reps calling on PCPs and Family MDs, don't pin this statistic on psychiatry alone, altostrata!

At the end of the day, if you are striving for honesty, integrity, and fair balanced reporting, you won't have an anchor of the agenda or unspoken alliances with organizations that benefit from publications or profit motivated products/services.

What could be in Whitaker's closet, eh?

moviedoc said...

Altostrata, I think you're all talk. If you really mean what you say, do something about it. Promote use of electroshock, VSN and TMS over drugs. Stand outside those doc's offices and tell prospective victims of "antidepressant toxicity" not to take their drugs. But since I suspect NON-psychiatrists prescribe many more doses of SSRI's and SNRI's than psychiatrists, you may want to choose a primary care office. I suspect most of them just keep renewing the prescriptions without those horrid 15' "med checks" and psychotherapy? Fuggetaboutit.

Anonymous said...

Rather than insulting and attacking those who express anger, mistrust or other negative feelings toward psychiatry, perhaps the psychiatrists reading those comments could look inward and try to determine what it is about psychiatry and the way psychiatrist practice their trade that leads to the commenters' emotions. Perhaps those comments can be a learning opportunity rather than an opportunity to get defensive and retaliate by leaving insulting, sarcastic comments in return. Just a thought. Perhaps part of healing the profession should be learning from those who have a problem with it...and communicating with them on a mature, adult level... which requires mature responses, self-reflection, etc.

Dr John said...

I certainly would agree with Dr Hassman in that most of the psychotropics are being written for by GP's so casting dispersions only at psychiatry is unfair. However, it is psychiatry that generates the "science" and the "thought leaders" that drive pharma promotion in part and hence GP prescribing. Without the blessings of the psychiatric elite such prescribing would never take place. So in this instance both blame and shit flow up hill.

Anonymous said...

I found every sentence of Whitaker's book alternately fascinating and frightening. I read the book while on vacation and literally could not put it down.
On my first day back on the job, (I'm a psychiatric nurse practitioner) I saw a patient, who had stopped taking Risperdal 2 weeks earlier. He was sobbing uncontrollably-terrified he would be murdered by his neighbors, whose voices tormented him day and night.
He refused to take Risperdal or to be hospitalized, but consented, reluctantly, to try another antipsychotic.
What's the alternative? This is human suffering on a grand scale. My best guess is that, if he takes this medication, he will be much better within a week.
These medications do have great value. It is their overuse and abuse along with the inflated claims of psychiatry that, I think, Whitaker expertly illuminates. Abilify for sad soccer moms and dads? Statements that medications are safe and well tolerated? (Weight gain, cognitive and emotional blunting, impotence, tremor, potential for TD, etc. How long would you take a medication like that?)
It is, of course, not a simple, black and white issue. Medications have value, but, they are extremely imperfect, and poorly understood. Risk, as pointed out numerous times in this blog, is often down-played, minimized and outright dismissed, while benefits are, often grossly exaggerated.
Treatment with psychiatric medications seems to be a kind of Faustian bargain. I thank Robert Whitaker for his fascinating and insightful book.

SG said...

A few observations and comments:
-Where’s the outrage? I’ve noticed that a lot of laypeople and health care professionals agree there is massive corruption in the pharmaceutical industry, and yet we’re more reliant than ever on pills. And yet I detect a sense of resignation to it, as if pharmaceutical companies are too big, too monolithic, to fight and bring into line. We sure have some strange priorities in this country. Everyone is obsessed about going green and researching the most eco-friendly lightbulbs and such, and yet WHERE IS THE OUTRAGE for the massive corruption of the pharmaceutical companies which has a major direct impact on our and our children’s lives? Will psychiatrists and the rest of the medical community join together and fight hard in Washington to end this insanity? Or will they just continue to work around the decaying system and make do with scraps? That is, the unbiased studies that trickle through the overwhelming flood of drug-sponsored biased ones? What medical professional could stand for that in any good conscience? Is it really impossible to conduct an unbiased long-term (at least five years) study on psychiatric medication side effects and what remodeling effects it has on the brain? Is psychiatry really that scared of what might be revealed?
-What I’m mostly seeing here is a back-and-forth argument that only stirs the mush of RCTs and science around. Can’t anyone see that the RCTs and studies (and the religious devotion to them) is the common denominator here, on both sides of the issue? I openly challenge any psychiatrist on this blog to visit a site like paxilprogress.org and READ a good amount of the stories and join the forum and field questions from the message board. But will they do that? Will they put aside their unswerving belief in endless studies and get in the trenches with those 1000s of patients who’ve been wronged by these medications? I’m doubtful.
-And it’s also not surprising nobody has talked about the anecdotal stories in Whitaker’s book, only the studies. What about Jasmine’s story? And what about the mixed bag of ups and downs in Cathy’s story? What do the psychiatrists have to say about those stories?
-And what about people suffering with PSSD? I’d like all the psychiatrists on this blog to watch the youtube video below, in which a young British man tells his story where after coming off antidepressants, he was rendered impotent. Eleven years later, he is still impotent and must inject his penis every time he wants to have an erection. And please don’t pass him off as statistically insignificant. HOW WOULD YOU FEEL if you were labeled statistically insignificant with this disorder? I really hope at least one psychiatrist on this blog doesn’t have an extra brain where their heart should be.
-And yet I think this is the only way for us to personalize psychiatry and do the complex conditions of depression, anxiety, bipolar, etc any justice. In fact, I think taking a hard look at anecdotal evidence is cutting edge because it is HUMAN. It acknowledges the patients as humans, not points on a graph or statistics in a study. Are the millions of patient voices not valid because they weren’t part of a study? COME ON. If psychiatry continues to ignore patients like me and millions of others, then we will have no other choice but to go to the internet for answers. Even then, sometimes we have no other choice but to wait on the balls of our ass and hope that we can withdraw from our medication safely and recover from our side effects.

Youtube PSSD video: http://www.youtube.com/watch?v=9-6pmsVOe3g

SG said...

@ moviedoc: Click on the links below and read Altostrata’s posts. Altostrata has tirelessly collected much important research and has also run an SSRI support group in the Bay Area, perhaps the first of its kind. She has also collected many anecdotal stories of protracted withdrawal from SSRI medication (some lasting YEARS) for fellow sufferers to bring to their doctors so they believe them. These stories are also being used by researchers. I think that’s damn close to your request for her to “Stand outside those doc's offices and tell prospective victims of "antidepressant toxicity" not to take their drugs.” But WILL you read these links? Doubtful. Thanks, though, for the pleasure to call your bluff.

To conclude my thoughts on this issue, I believe psychiatry must do three equally important things to restore the public's faith:

1) Begin conducting unbiased long-term studies on psychiatric medication safety that last for AT LEAST five years,
2) Shift the psychiatric model from one in which powerful psych meds are offered as a first line of defense to one where meds are offered as a last resort, and,
3) Begin research into why some people develop devastating, persistent side effects like PSSD and anhedonia (that may not resolve even AFTER they get off the meds) and how these symptoms can be reversed, either naturally (preferably), or with careful pharmaceutical intervention.

LINKS:

-Altostrata's personal 5-year struggle with protracted SSRI withdrawal: http://www.paxilprogress.org/forums/showthread.php?t=15807
-Altostrata's thread for those suffering with protracted SSRI withdrawal: http://www.paxilprogress.org/forums/showthread.php?t=20079

pj1280 said...

Just browsing Robert Whitaker's website tonight and found the following letter written by a family practice doc about our unabashed tendency to pathologize and medicate:

http://bit.ly/epTOE2

Not much more needs to be said, IMO.

moviedoc said...

SG: I'm sorry for Altostrata's posters. I hope someday we can determine whether any of their problems are related to their use of SSRI's. "Psychiatry" should start that research right away. Just please send "psychiatry" a check for $100,000,000 or so. Let me get you my address. While you're at I bet "oncology" could use one too, not to mention "hematology" and "neurology." There is no single "psychiatric model." Medication as a last resort? "Let's try electroshock first, then psychotherapy and witchcraft. If those don't work, we'll try meds." OK, but don't you think the patient should get to choose? Do I wish we had better data, free from Pharma influence? You bet. Are you gonna pay for it? I didn't think so. If Altostrata's efforts bear fruit, I will welcome it.

pj1280: I read Mark's letter, too. Nothing new there. I guess he'll be sending all those patients who really shouldn't have come to a doctor in the first place to their pastor's. I wish them luck.

Anonymous said...

Dr. John, great points as always.

To expand on what you said, it also isn't primary care physicians who are responsible for the terror this woman is experiencing as the result of being forced to undergo involuntary outpatient ECT.

http://www.mindfreedom.org/shield/ellis-ect/support-elizabeth

Sadly, this is not an isolated incident.

AA

SG said...

Moviedoc: Actually, I am paying for pharmaceutical studies. I've been paying for their studies ever since I went on Paxil at age 14. That was 13 years ago, and I'd have loved to have withdrawn from it at least ten years ago but couldn't, because no psychiatrist could taper me off effectively. And no amount of sarcasm on your part is going to negate my experiences and side effects over those 13 years.

And, whether you care to admit it or not, Altostrata's efforts have borne fruit. For one, she and others at Paxil Progress have expressed how important a 10% taper every 3-6 weeks is to minimize withdrawal symptoms, and there are success stories based on that taper. Did I learn that from any psychiatrist? Nope. Is this method helping me realize a decade-plus dream of getting off a med I shouldn't have been on in the first place? You bet.

And if it wasn't for Altostrata, I would still be using benzodiazepines such as Xanax for my panic episodes. But thanks to her I now use magnesium citrate and it treats the panic as well as Xanax, without any danger of horrific withdrawals. Did any medical professional, including psychiatrists, mention magnesium to me as an alternative? Nope.

And why are so many psychiatrists threatened by this line of thinking and this evidence? I'm not, as you state, against a patient's decision to choose what treatment they receive. All I'm for is more tools in the toolbox, and an approach that minimizes harm and maximizes benefit. Don't you think a patient has a right to as wide an array of treatment options as possible, starting with the least risky (such as meditation, nutrition, exercise, supplements, light box therapy, acupuncture, massage, etc) first and then, if all else fails, medication? And, of course, a patient can choose medication as a first option but ONLY after they have been warned of the hefty side effects they may experience. I wasn't allowed that luxury, and I've been paying the price for 13 years.

But people believe what they want to believe, and only some are able to take a courageous step back and look at their beliefs and question them.

I will conclude this post by saying Dr. John IS one of those people and his nuanced and sensitive posts are a model for other psychiatrists to follow. And I'm not just saying that because his opinions are similar to mine -- he considers all sides of the issue, and I don't necessarily agree with everything he says. What I admire is his peerless insight, well-controlled ego, and three-dimensional thinking. Bravo Dr John!

Anonymous said...

I was prescribed numerous psychiatric drug cocktails by my psychiatrist for pain and insomnia due to a car accident. He gave me every psychiatric pill in the PDR till I was a morbidly obese zombie. I had trusted him as a physician to help me and found out the opposite.

I have been completely psyche drug free for 8 years. My life is a 1,000% better and I have mental clarity the drugs had taken away when on them.I was told by other medical professional I was never "mentally ill" and should not had been on those drugs at all.
Go figure....

Dr John said...

SG. thank you for your very kind words. They mean a great deal. I will check things out at Paxilprogress. Hope I do not get stoned by the angry mob.

Anonymous said...

Dr. John, the Paxil Progress folks use other means besides stoning:)

All jokes aside, it would be great if you and psychiatrists and other medical professionals would visit the board, http://www.paxilprogress.org to check it out. For those of you not familiar with the board, ti is a support board for people who want to taper off of antidepressants. Many folks also visit who want to get off of other psych meds such as benzos.

Like SG, I credit this board's slow tapering advice (10% of current dose every 3 to 6 weeks) for being able successfully get off of a psych med cocktail after being on them for 15 years. I am convinced that if I followed the fast tapering schedule set by my former psychiatrist, I would not have succeeded.

Of course, everybody's mileage will vary but it is quite obvious as mentioned in Whitaker's book, that the issue of tapering has not been satisfactorily addressed.

I am sure the administrator, Laurie Yorke, an RN, would be happy to answer any questions that people had. As an FYI, no commercial links are allowed on the site and it is not affiliated with Scientology.

AA

Philip Hickey, PhD said...

Dr. Carlat,

“…struggling to understand the nature of psychiatric treatment.”

Apart from the insultingly patronizing tone, what you are doing is playing the old mental health elitism card: We understand things that nobody else can understand. But good ol’ Robert – he’s “struggling” to catch up (or to see the emperor’s new clothes?)


Philip Hickey, PhD
http://behaviorismandmentalhealth.com/

Anonymous said...

To Anonymous ["AA"]:

Your site is plenty helpful. I've never prescribed Paxil, having been alerted to the withdrawal by a friend early on, but I've certainly prescribed SSRIs. The advice for slow withdrawal [very slow] seems true for them all. Low doses, dropping doses after a response, very slow withdrawal - all helpful advice. But the best advice of all is to stop the medicine if it doesn't work instead of pushing it or piling on. Many of the people I've seen that have trouble stopping are people who never really responded in the first place...

Anonymous said...

Well well well.. Archives of General Psychiatry, February 2011; Anti psychotics essentially fry your brain? Wanna comment on this article from Andreasen's group at Iowa??? Seems that Whitaker may have been right all along!

Anonymous said...

The author has completely missed the point of his own introductory comment. Rates of psychiatric "disability" have soared since 1990 because (a) psychiatrists make the subjective decision to classify someone as disabled or not; (b) rates of malingering have soared and psychiatrists do not use existing methods to detect malingering; (c) Psychiatrists, like most physicians, are reckless in granting disability status to anyone who asks, knowing that they are handing over their problem to a disability insurance company and that they will never be held financially repsnsible for the resultant waste of money. Finally (d) psychiatrists who know that a patient is malingering will, in 99%of cases or more, not identify the malingerer. There is an epidemic of malingering which is being facilitated and fuelled by psychiatrists abnegating their responsibility to diagnose malingering when present.

Anonymous said...

I would challenge Carlat Blog readers to read the following book: "We've Got Issues: Children and Parents in the Age of Medication" by Judith Warner, New York, Riverhead Books, 2010, 336 pp. You can purchase this outstanding book for under $10 at:

http://www.amazon.com/Weve-Got-Issues-Children-Medication/dp/159448497X/ref=sr_1_1?ie=UTF8&qid=1297450032&sr=8-1

I am a psychiatrist who has no affiliation with or conflict of interest related to this book or its author.

This book is so well researched and fair balanced on the subject of psychopharmacology in children and misconceptions about the pharmaceutical industry. An important antidote to the biases of the anti-pharma zealots, including Whitaker, and the inaccuracies embedded in Carlat's most recent book.

moviedoc said...

It's more complicated than malingering and recklessness, Anon. If I certify a patient as disabled, she may be better able to afford to pay me. If I say I believe she can work, she may dump me for someone more accommodating. Psychiatrists who do this collude with their patients to get them money. This role conflict leads me to refuse to assess disability in my own patients. Forensic psychiatrists can assess disability without contaminating the treatment.

Nathen said...

Dr. Carlat,
On one hand, I appreciate your thoughtful critique here, and especially your hosting this conversation on your blog. It's nice to see so much thinking and debate around what most would consider such a fringe topic.

On the other hand, the opinions of psychiatrists and other prescribers on this matter are subject to such intense pressures from cognitive dissonance, confirmation bias, and conformity heuristics, that I find myself very skeptical of your take, and that of many of your commentators. Unfortunately for this conversation at large, there are very few people weighing in who understand statistics and research methods, are familiar with the specific studies in question, and whose academic and professional careers have not been spent studying and prescribing psychopharmaceuticals. I'd love to have non-clinical, experimental psychologists weighing in, for example, or even sociology or business faculty types.

Joel Hassman, MD said...

Everyone has a slant or agenda until proven otherwise, per Nathen"s above comment, so why should this thread be open to the persuasian of "non-clinical, experimental psychologists weighing in, for example, or even sociology or business faculty types" as the alleged unbiased, objective opinion on this topic?

As a board certified psychiatrist practicing for over 17 years now, having "been around the block" working in community mental health, private practice, addiction services, and brief periods in inpatient and correctional services in the past 10 years, I have, what I believe, is a well rounded experience in my field. And what do I conclude? Everyone has an agenda, a need, a purpose that is not always solely the altruistic, well intended needs of care and providing care.

As I have commented here in the past, disability is a true double edged sword in psychiatry especially. Once you are on it, the label sticks whether intended or not! So, the question I ask my colleagues who come here is this: what are your expectations in independency versus dependency? Because isn't one of the treatment goals for the majority of those we treat to restore or solidify independent, autonomous functions?

I have seen some colleagues' eyes somewhat glaze over when I ask this question. And haven't we seen psychopharmacology oppose these intentions? "I need a pill, doc, whatcha got?"

Which is what concerns me about the profession these days.

Anonymous said...

Folks might want to read this latest blog entry on Robert Whitaker's blog titled A Long-term Path To Disability by a PhD writer/artist. She became incapacitated from being on up to 7 meds.

It seems because of symptoms like serotonin syndrome, she was forced to either taper most of the meds quickly or cold turkey them which definitely didn't help matters.

Anyway, the next time you think people are gaming the disability system, you might want to refer back to this article. Personally, I think these people are whom Whitaker had in mind when he came up with these statistics.

Of course, it is easy to ignore the problem with meds causing disability and blame the cheaters.

http://tinyurl.com/4flouqw

AA

orwegian Psychlogist Kjetil Mellingen said...

I am a clinical psychologist, and it is interesting how therapy for depression and Psychosis is missing from this discussion. With cognitive therapy techniques I am a able to remove anxiety sometimes in minutes, sometimes it takes a few weeks, depression often lifts within 6 weeks, and the results are usually permanent. With these techniques I was able to remove hallucinations in a patient who was taking 5 different anti psychotics at the same time with no effect. The choice is not between drugs and trying to make it on your own. All patients who try to go off medications should have good therapy as the alternative. Some of the techniques may even be used to fight the abstinence. Most doctors are well meaning professionals, and many are enthusiastic at the prospect of being able to help patients with quite simple CBT techniques. So to those of you who feel a bit uneasy prescribing after reading a blog like this: learn some CBT. It is not difficult, and you sleep better at night when you know you have been using a treatment without adverse effects.

P Dwyer said...

Re Dr. Carlat's reference to the meta-analysis of 38 RCT with 7323 patients, showing neuroleptics outperform placebo by 41% to 24%:

A) These were short term studies. Whitaker acknowledges some short term benefit, so these studies don't contradict his thesis that neuroleptics do damage over years and decades.

B) Data in psychiatry is at best unreliable and at worst falsified. In his book, Mania, David Healy concludes that accurate information is virtually unavailable in psychiatry because of the pervasive influence of Pharma money in RCT's and in publication. Publication bias alone would filter out most studies showing placebo equal to or better than neuroleptics. Not to mention the usual ways RCT's are manipulated: preliminary placebo washouts put subjects already on neuroleptics into withdrawal - when the drug group resumes with a neuroleptic, their withdrawal is halted, while those randomized to placebo continue in withdrawal, and of course they don't do well; the use of non-active placebos, so patients and doctors know they're getting placebo; post hoc comparisons; use of last observations carried forward.

There are so many ways for researchers who are Pharma sponsored (or just true believers) to have their thumbs on the scale; the only way to get reliable data is to have truly disinterested researchers, or, as Whitaker has done, look at the studies VERY carefully.

C) Re Dr. Carlat's valid point that longitudinal placebo controlled studies are difficult with schizophrenia: we do have something close to that in the two WHO studies, which approach placebo controls by including countries where only about 15% of subjects received neuroleptics. The second WHO study took pains to assure subjects received competent DSMIII diagnoses of schizophrenia, addressing Dr. Carlat's point about old studies' inclusion of "overdiagnosed" subjects. And the WHO wasn't "anti-psychiatry," so we should take seriously the implications of their finding that subjects in the non-industrial nations, generally not on neuroleptics, fared about twice as well as subjects in the developed nations.

And what of Loren Mosher's Soteria studies showing non-drug intervention with equal or better outcomes compared to standard drug treatment? Mosher's research was heavily scrutinized by his pro-drug NIMH colleagues, yet his data remains unchallenged today.

Finally, Whitaker cites the Lapland Open Dialogue program. Using minimal drugs, it has turned an area with terrible outcomes into one with outstanding outcomes. Similar programs are also documented in Scandanavia.

I would love to see commenters address the Lapland project. If its subjects are carefully diagnosed as schizophrenic under DSM-IV, and they have the 80%positive long term outcomes Whitaker claims, that's a powerful argument in Whitaker's favor.

D) An unbiased observer would have to say there is at least reasonable ground for wondering who's right here. This doesn't bode well for biopsychiatry; the available information is the most advantageous Pharma's money could buy. One would think Pharma's $60 billion promotion budget, $40 billion research budget (funding 80% of all RCT's) and paying 33% of peer reviewed journal budgets would be able to spin a more imposing picture.

This level of controversy doesn't exist over antibiotics, or diabetes medication (to which biopsychiatry loves to analogize). That's because these deal with known diseases, with known pathophysiologies, with physical diagnostic tests - none of which is true of psychiatry's "disorders."


It is so easy to overlook how stacked the deck is here. If psychiatry aspires to be scientific and evidence based, the burden must be on biopsychiatry to establish long term efficacy and safety, by clear and convincing evidence. The present state of the evidence does not meet that burden.

Anonymous said...

Psychiatry seems to be one tragically bad joke. Anyone with an interest in the welfare of people diagnosed with what ostensibly are financially motivated, contrived mental disorders, ought to applaud Whitaker, nothing else. There is so little out there challenging the current paradigm. Whitaker has brought his challenge to the attention of much of the public with Anatomy of an Epidemic, and personally, I thank him for doing so. This book addresses misconceptions that psychiatry and Big Pharma have been exploiting and cashing in on for years. It also illustrates the crappy outcomes associated with psycho-pharms that you'd never hear about from a psychiatrist, pharmaceutical company, or the freakin' media, who has ultimately failed here, leaving the public to be pharmacologically exploited, to the detriment of our health, as well as the thickness of our wallets.

Anonymous said...

Psychiatry seems to be one tragically bad joke. Anyone with an interest in the welfare of people diagnosed with what ostensibly are financially motivated, contrived mental disorders, ought to applaud Whitaker, nothing else. There is so little out there challenging the current paradigm. Whitaker has brought his challenge to the attention of much of the public with Anatomy of an Epidemic, and personally, I thank him for doing so. This book addresses misconceptions that psychiatry and Big Pharma have been exploiting and cashing in on for years. It also illustrates the crappy outcomes associated with psycho-pharms that you'd never hear about from a psychiatrist, pharmaceutical company, or the freakin' media, who has ultimately failed here, leaving the public to be pharmacologically exploited, to the detriment of our health, as well as the thickness of our wallets.

"And it is the work of a highly intelligent and inquiring mind--a person who is struggling to understand the nature of psychiatric treatment."

Hmmm... I don't think he's struggling to understand the nature of psychiatric treatment at all; I think he's figured it out quite well actually. Remember the part of his book listing the prominent psychiatrists' financial ties to pharmaceutical companies? I do: it's money!! The nature of psychiatric treatment, that is. Money. Money for psychiatrists and money for the pharmaceutical companies.

Alex M said...

I just wanted to point out something that you said in your post:

"They did perfectly well off antipsychotics for the same reason somebody without diabetes would do well off insulin--they didn't actually have the disease."

I think the last sentence is very important. In his book, Robert Whitaker talks about the fact that many people are being prescribed medication for disorders that they don't really have, or can be treated with cognitive-behavioral therapy. One of the examples I remember is of a guy going to college at Harvard who went to his general practitioner complaining of anxiety related to an upcoming trip.

To any of us, it's obvious that he was worried about his trip and needed help dealing with his worries. Instead, his doctor not only diagnosed him with some kind of anxiety disorder, but told him that unless he started taking antidepressants to treat it, the disorder will get progressively worse.

After a year or so on the medication, he tried to withdraw, because like most people, he was told that it was not addictive. During withdrawal, he ended up in such a cloud that he stole a fellow student's backpack without realizing it and almost got himself kicked out of Harvard.

Your point about how studies and diagnoses were done in the past compared to how they are done today may be valid, but it actually strengthens Mr. Whitaker's argument about how the drug companies, along with the APA, are helping to diagnose people with disorders they don't really have, so that they can be put on medications they don't need for the rest of their lives.

Anonymous said...

"I saw a patient, who had stopped taking Risperdal 2 weeks earlier. He was sobbing uncontrollably-terrified he would be murdered by his neighbors,"

Take a normal person off the street, get
them hooked on Risperdal and then take
them off it cold turkey. I bet many would
have exactly the same reaction.

Sean said...

You're telling me that a placebo is just 17% less effective than the actual meds?!?

Give me the placebo any day of the week!

(you were trying to make the opposite point... but apparently that is missed on you)

Anonymous said...

The brain imaging work cannot be so easily refuted. It demonstrates that shrinkage of the brain can be best explained by the amount of medication the person took.

Whether the person was a drug addict or not is irrelevant. Some people taking a lot of medication may be addicts and some take little medication may be addicts. Ultimately is irrelevant because there is no evidence the the more medication a person take the more likely he/she is to be a drug addict.

The point is that brain shrinkage cannot be explained by severity of the illness which is what you would expect if the illness were causing the shrinkage. It can be best explained purely by the amount of medication. Also all of these results have been replicated in animals.

Surely the animals aren't smuggling drugs into their cages and becoming drug addicts!

The brain shrinkage evidence is strong. And its been replicated by more than one researcher.

Duane Sherry, M.S. said...

Conventional psychiatry is missing-in-action...

The key is finding the underlying physical or emotional cause -

http://discoverandrecover.wordpress.com/2011/09/15/root-causes-of-mental-illness-and-non-drug-solutions/

Duane

Anonymous said...

And while you all debate, which is healthy, I am on anti-psychotics for manic depression and afraid for my life and the future. So far at least 75% of my episodes happened while I was on meds; I have been consistenly over-medicated despite my pleas about being over-sensitive to drugs and I have had many adverse reactions to a number of them. I take my meds because I don't know what else to do, but I can see that the pill-pushing pschiatrists are definitely a problem and that these illnesses are little understood because of the emphasis on drugs. I hate being in this position and wish there was more enlightened search for deeper causes, such as underlying trauma, which I have discovered to be contributors in my case.