Friday, January 21, 2011

Robert Whitaker's Anatomy of an Epidemic: The Carlat Take

I haven't reviewed Anatomy of an Epidemic until now, partly because I once shared a meal with the author, Robert Whitaker. It's hard to be objective reviewing the work of someone you know, whether you like him or dislike him.

As it happens, I quite like Robert Whitaker. We had dinner at a Chinese Restaurant in Harvard Square last June just before I gave a book talk for my book Unhinged. Over wonton soup and kung pao chicken, we chatted pleasantly about our work. He's an extremely intelligent and devoted journalist who really cares about the treatment of the mentally ill.

I had read parts of his book before we met, and told him that I disagreed with various aspects of it. He understood my points, saw their merits, but cordially held fast to his own convictions. I haven't spoken with Bob since then. I continue to respect him and I'm sure our paths will cross again.

Generally, I don't think it's great practice to review books when you know the author, and most mainstream publications prohibit it. But hey, this is a blog and I think we can be a bit less "ruley" in this context.

My overall take is that Whitaker has his basic facts right, and that he communicates them in a compelling style that I envy. But I disagree with his interpretation of the facts.

My argument is not all that different from the MGH/Andy Nierenberg rebuttal that was beautifully covered by Carey Goldberg in the CommonHealth Blog. You gotta check her post out--it includes video clips of Whitaker's brave grand rounds talk at MGH and captures the atmospherics of the ether dome, where I often went to grand rounds when I was a psych resident there.

Before I offer my rebuttal, here is Whitaker's overall argument:
1. Over the past couple of decades, many new and supposedly more effective psychiatric drugs have been introduced.
2. If these drugs were so effective, you'd think rates of psychiatric disability would have declined over this period, but in fact, rates of psychiatric diagnosis and disability have skyrocketed.
3. There are some poorly publicized studies suggesting that patients with serious mental illness actually do better when they do not take drugs.
4. Therefore, it's reasonable to conclude that psychiatric drugs are actually bad for many people, at least when taken for more than a short period of time.

This is obviously a simplified version of a long book that makes several other points as well, but this is pretty much the arc of his argument.

Here is my basic rebuttal: Correlation does not imply causation. In other words, yes, many more people take psych drugs, and yes, many more people are psychiatrically disabled. But the med use has not caused the disability. Instead, the skyrocketing disability rates are caused by several other factors, having almost nothing to do with any putative toxic effects of long-term medication use.

In my opinion, the apparent rise in psychiatric disability has three major causes.

Cause #1: There are more disorders to diagnose. 

The number of official DSM diagnoses has grown from about 100 in 1952 to about 300 today--see the table below.


Version
Year Published
Number of Pages
Number of Diagnoses
DSM-I
1952
130
106
DSM-II
1968
134
182
DSM-III
1980
494
265
DSM-III-R
1987
567
292
DSM-IV
1994
886
297
DSM-IV-TR
2000
886
297

Each time a new version of the DSM is published, clinicians get trained in how to recognize the new categories of disorders. There's plenty of room for debate about whether all these "new" disorders are truly new or valid, but my point here is that, valid or not, the rise in diagnosis has been largely driven by changes in disease classification and subsequent training--not by toxic medications.

Cause #2: There are more treatments available, so clinicians have a greater incentive to look for diseases.

Unless there is a treatment for a disease, doctors have little incentive to take the extra time required to diagnose it. Not only has there been an explosion of new psychiatric drugs, but there are many more types of targeted psychotherapies as well. New drugs and therapies have motivated psychiatrists, psychologists, and social workers to ask more questions to discover newly treatable disorders.

Again, one can argue that drug companies have practiced "disease mongering" and have unethically persuaded doctors to recognize questionable disorders simply in order to make money. This has certainly happened at times, as I document in Unhinged. Sure, drug companies have revved up the diagnosis of disorders, but their drugs haven't actually caused the disorders.

In addition, it's certainly true that psych drugs have many side effects, and that side effects can cause certain disabilities. But this is true for all drugs in all fields of medicine. Antipsychotics are effective at reducing delusions and hallucinations, but they can also cause weight gain, diabetes, tremor, etc.... It's up to the doctor and the patient to decide together whether the side effects are so disabling as to overwhelm the benefits. But this does not mean that psych drugs cause worsening psychiatric disabilty, any more than blood pressure drugs cause worsening blood pressure.

Cause # 3: Changes in federal law have encouraged more people to seek disability status.

To understand the ins and outs of Supplemental Security Income (SSI), you must read an outstanding recent series in the Boston Globe, called The Other Welfare: A Legacy of Unintended Side Effects.The short version of these articles is that SSI is a well-intentioned program to provide income and insurance for disabled citizens. But over the years, it has expanded to include various psychiatric disorders that are difficult to diagnose and that can be easily faked, such as ADHD and PTSD. Indigent people have realized that it's not too hard to get a psychiatric diagnosis and a medication, and once you have these you can apply for SSI benefits. The application is an arduous process, with no guarantee of success, but the numbers cited in the Globe tell the story (the Globe article focuses on children). In 1990, only 24,000 children qualified as psychiatrically disabled under SSI; by 2009, 640,000 children had qualified, a 26-fold increase.

Okay--I'm running out of steam and this post is already too long. Bottom line: Whitaker does a great job documenting an astonishing rise in psychiatric disability, but he erroneously blames the drugs, when the actual causes are more nuanced and multifactorial.

Next time I'll get into some of the studies he cites in support of the idea that psychiatric drugs can worsen mental illness. I believe he is on shaky ground here as well.

71 comments:

pj1280 said...

"Unless there is a treatment for a disease, doctors have little incentive to take the extra time required to diagnose it."

That's like saying I didn't realize I needed an iPad until Apple introduced it and I bought one.

But we're not talking about gee-whiz technology here, we're talking about disability. I think the disability discussion should always start with the question "Is this person disabled?" and, if so, determine whether his/her mental disorder is to blame.

It sounds like you're suggesting that because we have so many new disorders (and so many new treatments for them), we naturally look for them, and because we've now labeled more people as "ill," they must also be disabled.

The diagnosis shouldn't determine eligibility for disability benefits, the disability should. To suggest otherwise means that our labels are more important than a person's experience and inner resources (or lack thereof), and that's extremely disempowering.

Eric Whalen said...

Do you really believe it has nothing to do with how toxic and damaging the drugs are? Could it have anything to do with the profound impairment people taking the drugs report?

Robert Whitaker mentions a paper by Lars Martensson, titled, Should Neuroleptic Drugs be Banned? Could the fact that the so-called atypical neuroleptic drugs are just as brain damaging a trap have anything to do with rising disability rates?

David M. Allen M.D. said...

I agree with your analysis. Whitaker takes some facts and then draws conclusions as if they, too, were facts - when there are other, better explanations for the original facts. I haven't read the whole book but I saw an hour-long tape of one of his lectures.

As "evidence" for antipsychotics worsening the course of psychosis, he talks about the "revolving door" into state hospitals. If he spent one day in a psychiatric emergency room, he would know that it is the people who go off the meds (or who are substance abusers) who are in the revolving door.

His whole talk was steeped in such breathtaking inferential leaps. He compares the number of people who were in state hospitals before deinstitutionalization with the numbers on disability today. That is nonsense due to all the factors you cited in your post.

Of course, he neglects the fact that deinstitutionaliation was only possible in the first place because of antipsychotic meds.

His idea that psych meds might cause a tardive depression in the way that antipsychotics cause tardive dyskinesia is an interesting hypothesis, but there is very little data to suggest that that is true.

He talks about how some (industry-corrupted) psychiatrists claim that stopping lithium or using antidepressants can cause rapid cycling in bipolars.

In 35 years I've never seen that happen in my patients or those of anyone else I know, but hey, maybe my patient population is atypical. Most of those "rapid cyclers" are in reality misdiagnosed borderlines in my extensive experience.

moviedoc said...

Your psychiatric disorder count misleads the uninitiated. Those added disorders include entities like Creutzfeldt-Jakob Disease (an infectious disease), Narcolepsy (a sleep disorder), Tourette's (neurological?), not to mention splitting out all the substance related disorders by drug and symptom. Honestly, if you counted the FDA "approved indications" would you really see a marked increase? All I can think of is maybe social phobia added to the traditional psychoses, mood disorders and anxiety disorders. Are you really worried that Lilly will try to get moxachlorazanilapine approved for treating Transvestic Fetishism?

In any event an increase in the number of diagnoses doesn't mean more disability.

In my opinion case management's negative impact on psychotherapy practices led to invention of new diagnoses, most of which seem to be "addictions", most notably internet addiction. You just claim to be an expert at treating it and patients flock to your door.

David M. Allen M.D. said...

Eric -

Atypicals are in fact toxic to SOME (a minority) of patients - but it's not psychiatric toxicity but endocrine, cardiovascular and neurological toxicity.

So in anwer to your question, the drugs have nothing to do with the increase in psychiatric "disability," which is due to a vast increase in people who are not disabled at all being labeled with bogus bipolar, ADHD, or even Aspergers diagnoses, not to mention the fakers scamming the system for "crazy checks."

You can ask Gabrielle Giffords how toxic UNTREATED schizophrenia can be. Or go down to skid row or your local jail and see how they get to live.

Risk vs benefit. It applies to all medical treatments. (I agree the risk of atypicals is such that they should only be used when there are no better alternatives. They are WAY over-prescribed).

Anonymous said...

Dr. Allen: When did you assess and diagnose the shooter of Giffords?

Anonymous said...

CARLAT SAYS: Next time I'll get into some of the studies he cites in support of the idea that psychiatric drugs can worsen mental illness. I believe he is on shaky ground here as well.


GOOD LUCK. MOST OF THESE STUDIES WERE PUBLISHED IN THE AMERICAN JOURNAL OF PSYCHIATRY!

Dr John said...

Fascinating debate. How brave of Mr. Whitaker to present his work in such a venue. It's like Farrakhan preaching at a KKK rally. I would have to agree more with Dr Carlat however that the explosion in disability rates is a byproduct of the disease model in psychiatry and the explosion of those being diagnosed along with the pt/lawyer/Dr disability industry rather than meds causing the disability.

Regardless Mr Whitaker's overall indictment of contemporary biological psychiatry has merit. I cannot see how anyone could look at the contradictory data such as the WHO outcomes on psychotic disorders or the 15 yr Harrow study and not seriously doubt the current paradigm.(Those who get psychotic should always be given anti-psychotics and mostly should always be left on them)

Why would anyone believe that? The drugs are a shotgun which may in fact blunt some symptoms but they certainly do not treat or reverse an understood neuro-pathologic process. I see just as many relapses on meds as off yet we always assume relapses are mostly secondary to people coming off their meds. Maybe for some they help and others they may worsen the course but we have no ability to predict what they are going to do for any pt we see in the long term. In the short term their benefits are not exactly impressive for most.

I am not so sure deinstitutionalization can be credited to meds. That was a complex social and economic process. State hospitals and community in-pt psychiatric beds are evaporating. Are we to assume this is simply do to improvements in meds? There certainly is no evidence for this.

After investing all that time in training I would love to say Robert Whitaker is mostly wrong in his general hypothesis about the failure of biological psychiatry and its potential to create iatrogenic pathology. Watching people get pscyhiatric TX for 15 years and seeing most of them either not get any better long term or even be made worse by it convinces me he is mostly right.

David Behar, MD, EJD said...

The majority of serious mental problems are caused by drugs, indeed, namely alcohol, illegal drugs, and caffeine.

Almost no suicider has a prescribed medication in him. Half are legally drunk, as are half the murderers, and half the murder victims. Today, the majority of psychotic symptoms stem from the irresponsible, uninterrupted, and all out partying of patients.

When a tract falsely scapegoats a set of products and a profession, that has a name, hate speech.

moviedoc said...

If you have a better paradigm, Dr. John, do share it with us. We do not have to predict who will benefit. The patient ultimately decides whether the benefits outweigh the risks based on his own trial of the drug. And the patient chooses whether to face the consequences of refusing treatment.

Joseph P. Arpaia, MD said...

Most of the anxious and depressed patients I work with are dealing with job stress or relationship stress, and if those resolve a lot of their anxiety and depressive symptoms magically disappear.

I think a lot of the increased anxiety and depression is associated with a breakdown in social cohesion, i.e. higher divorce rates, reduced parental time at home, breakup of communities, ...

I've got several patients who work in one department of a local employer whom I could cure of anxiety and depression by having someone put thorazine in the bosses morning coffee.

Anonymous said...

Whitaker's book is much more encompassing than a review of disability trends in psychiatry! He raises good and compelling questions that need to be answered empirically. But psychiatry's knee jerk reaction is to label him some lunatic Scientologist, which he is not. And Martin Harrow's work is beyond reproach. He is the dean of schizophrenic outcome research, perhaps in the world. Oh and as to drugs being responsible for deinstitutionalization? Come on! That never happened. All the patents just went to nursing homes!

Anonymous said...

I find Dr. Allen's critique fascinating since he hasn't read the 400 page book but listened to a one hour talk; Whitaker himself states how difficult it is to get his points across in any interview or debate because of the time limitation. Much less his "knowledge" of the shooter's difficulties or medication history.I agree with Dr. John.

SteveM said...

Danny, because a psychiatric model is now heavily weighted toward psychopharmacology, the explosion of DSM diagnoses is a red herring. Psychopharmacology is actually reductionist. It reduces the psychiatric diagnostic set to the indications that map to psychotropic drugs. The diagnostic granularity that extends beyond a pharmaceutical PI is irrelevant in this context.

Re: "Not only has there been an explosion of new psychiatric drugs..."

Is sort of misleading, because the explosion has been mostly "me-too" drugs of a limited number of classes which often turn out to have marginally better clinical utility and adverse effect profiles. In fact, it can be argued that some newer pharmaceuticals like Zyprexa and Cymbalta are inferior in several dimensions versus generic alternatives:

http://clinpsyc.blogspot.com/2010/10/cymbalta-and-effexor-hype-over-science.html

Non-psychiatrists like Whitaker have to make those apparently factual observations, since the psychiatric community refuses to do so.

Another major issue with all pharmaceuticals, especially psychotropics is a lack of access to the results of clinical trials sponsored by the Pharma developer. For example, according to clinicaltrials.gov, Eli Lilly has completed 84 clinical studies of Duloxetine (Cymbalta.) Of those 84, only 20 have reported results. So there are 64 studies unavailable to the public that may contain data suggesting marginal clinical value and/or substantial adverse events for Cymbalta. Meanwhile thousands of Cymbalta induced iatrogenic car wrecks pile up at anecdotal websites. It beats me again why the APA and leading psychiatrists do not beat on FDA for access to those study results.

And Re: "It's up to the doctor and the patient to decide together whether the side effects are so disabling as to overwhelm the benefits."

Given the importance of planting a placebo seed when a psychiatrist writes a script, how many actually frankly discuss the side effect implications that may induce a nocebo effect? Does any clinical motive trump "fully informed"? Another topic generally avoided inside of psychiatry.

It's not that Whitaker is right or wrong, it's that he has to pose safety and efficacy questions as an outsider because the insiders of psychiatry do not. In the end, what Whitaker is primarily doing is pointing out psychiatry's disturbing sins of omission.

David M. Allen M.D. said...

Like Whitaker, I can't raise all the relevant points in a short blog post, but just a few reactions to some of the comments.

1. Were the anonymous commentators around and involved in the system when de-institutionalization was taking place? I was. Of course there were other factors besides the drugs, but I see an awful lot of patients who would be in state hospitals today if it were not for the drugs, and are now living stable and independent lives on medication.

2. No one is claiming that the drugs cure schizophrenia or reverse the disease in any way, so that is a straw man argument.

3. I absolutely agree that Whitaker is NOT a lunatic scientologist, and that he raises important questions that should be researched. But that's the issue, isn't it? There is very limited research to justify his conclusions. And everyone can cherry pick studies to support whatever claim they want to.

One has to look at the preponderance of the evidence. How many of you do literature searches and read several studies (and not just the abstracts?)

4. I suppose all of the many people interviewed in various media outlets could be misinformed when they described Gifford's shooter's refusing treatment, his loose associations and bizarre delusions, etc. And of course I do not know for certain about his diagnosis since I've only heard his voice on the videos he made that were shown on TV. However, next time you think someone around you has either a cold or hay fever, how often are you incorrect?

5. There are indeed some bad studies in the American Journal of Psychiatry and also many excellent, non drug-company sponsered articles.

I wonder how many of the anonymous comentators really know how to evaluate study designs, the statistics used, potential weaknesses of the studies etc.

I suspect some are reading critiques of the studies by interest groups, and they themselves have limited such knowledge. And they often do not read the critiques by the interest groups on the opposite side of such debates.

6. If a drug is not working for a given patient, of course they should not be taking them, and the doctors who continue to prescribe drugs that are not working are the ones who are in need of rehabilitation.

Asslete said...

This debate is far too nuanced to have a victor. But I believe that Whitaker’s premise is a misplaced indictment of the medication instead of the social/medical mores that have morphed Psychiatry into a 15-minute culture of victimhood med-check.

I think we’d all agree that if the refrigerator constantly tells you that Jesus doesn’t love you…then you probably need meds. But it takes time, commitment and subtlety to explain to Mr./Mrs. Joe Sixpack that little Johnny is acting out because Mom and Dad are distant and self-absorbed with inconsistent parenting skills. It’s far easier just to label Johnny “bipolar” and blast down his “temperament” with Abilify.

“Look how calm little Johnny is now…umm Johnny, you’ve got a little drool on your chin…Oh nevermind. Just enjoy your X-box.

Of course, now Johnny doesn’t have to learn better coping skills, because it’s not his fault he’s this way…it’s the disease! Poor Johnny. Where can he sign up for some free Government cheese?

Until we as a specialty can objectively assess both the biological underpinnings of our very subjective emotions/pain, and until we as a society can move beyond our moral hazard that make walking away from personal responsibility “OK,” I expect our disability rates to continue to rise and our meds to be the straw man that facilitates the process.

But what do I know. According to the DSM V, I have Temper Dysregulation Disorder with Dysphoria. So if you don’t like my opinion, well, it’s really no my fault. It’s my illness. Free cheese anyone?

Dr John said...

moviedoc, in no way do I imply that I have a better paradigm. My entire point is that most of what psychiatry is attempting to deal with is not well understood within a paradigm. A medical paradigm is in my opinion often the worst as it reinforces illness behavior in many hence the increase in disability rates. That is what is so problematic about psychiatry. There is not sufficient knowledge to support any paradigm so we pick and choose as we please or like me you become hopeless because you must confront the truth of not really knowing shit.

I could not disagree with you more that pts "choose" meds and ultimately decide in the end after weighting the risks and benefits. I almost NEVER come across a pt on meds who has had a legitimate discussion with any doctor on this issue. Most have no idea what so ever as to any risks or what limited evidence supports long term benefit. When I tell them these things they are horrified. Some choose to remain on them but most ask me how they can come off or just quit them altogether.

I agree with asslete. There is no victor in this debate but it is a debate we should indeed have because organized psychiatry is little more than the handmaiden of big pharma and it believes in its TX's in a way that cannot possibly be supported by credible scientific information but rather out of the conjoined self-interest of its pharma masters.

Sara said...

It appears that neither Dr. Allen nor Dr. Carlat have actually been able to get through Whitaker’s entire book before taking potshots at it. I’m not surprised that psychiatrists have a hard time sticking with it. It’s a pretty powerful indictment of the paradigms they’re using on a daily basis.

Maybe Bob does rely more heavily on rates of disability as evidence for problematic paradigms than on equally damning evidence of toxic iatrogenic effects of the drugs themselves, but he certainly touches on these too in his book. And there is more than one reason why disability rates have skyrocketed. He doesn’t deny that. But since when did a diagnosis alone become grounds for disability eligibility? And what does that say about diagnoses in psychiatry? Just what I always thought – that they are labels for life – damning sentences of incurability and hopelessness regarding our emotional ills. The best one can hope for is “controlling symptoms,” but to be free of the diagnosis – no sir, that isn’t in the cards. No wonder people are seeking disability for mental illnesses. Is this a way to practice medicine – remove the possibility of “cure” or “recovery?”

Bob doesn’t want to dwell on the iatrogenic effects of the drugs because he wants a wide audience. He wants to be heard by those taking and prescribing the meds so he’s focusing on the wider picture that there is no outcome measure out there indicating current paradigms are doing anything good for our society as a whole. The issue of iatrogenesis is explosive and highly variable by individual – and it’s compounded by the fact the drugs often act paradoxically, creating the illusion of miraculous change for the better first before the hammer falls and the debilitating effects set in. Nothing comes without a price. Still that issue of potential harm is secondary to the fact no one is actually getting better and shedding their diagnosis.

Regarding the Tucson shooter, I don’t think anyone should rush to the conclusion that this fellow was “untreated” just because he had never been in the public health system. It is as likely as not that his psychosis was substance – or drug induced. There have been lots of rumors and hearsay that he was on drugs, medications or both. This is not necessarily a case of "classic untreated schizophrenia" as everyone seems to want to believe.

The Harvard psychiatrists refuting Bob were truly laughable. They seem to think that all it takes for them to be convincing is to say “I don’t agree” and issue a few ad hominem attacks. There was not one substantive argument that the way they practice medicine is actually doing good. And then for Dr. Rosenbloom to take pride in the fact that their department was actually one of the first to acknowledge “discontinuation” and "rebound" twenty or more years after the drugs were introduced just added insult to injury as far as I was concerned. This is what is so frightening about psychiatry – there is some gross disconnect between the doctors and their patients. What the doctors “see” and the patients describe is completely at odds. Until that comes into alignment we are in for some serious trouble and the trends Whitaker describes will only get worse.

moviedoc said...

OK, Dr John, but what do you consider a "legitimate" discussion, you know these discussion were not legitimate how? You witnessed them? I doubt it. My experience is that I can tell a patient they might die from a rash from lamotrigine, and they still take the drug if I tell them it might prevent a mood episode. And a substantial number of them forget our discussion by the next visit. (Not to mention the PI the pharmacist gives them, which they don't bother to read, and which they can find on the Web.) Patients have ample access to information about drugs. Don't blame the psychiatrists.

I propose a solution: Dr John, post a video on YouTube of you doing what you consider a legitimate review of risks and benefits. Our patients can watch at their leisure to supplement -- not replace -- discussion with their own clinician.

Finally I would like to thank Dr John, Dr Behar, Dr Carlat (especially) and any other psychiatrists who participate in these discussions which are good for our profession and our patients.

David M. Allen M.D. said...

I totally agree with Asslete (check out my blog), but I also agree with a lot of what was said in the last posts by Dr. John and Sara.

There are a lot of iatrogenic problems, although we may not always agree about which ones they are. Also, I come across lots of patients who have been put on antipsychotics and know nothing about metabolic syndrome or tardive dyskinesia.

I do think Dr. John is overstating our lack of effective paradigms a bit. A lot of the problem IMO is that many psychiatrists are not using the effective paradigms but are throwing drugs at patients willy nilly and making bullsh*t diagnoses. In addition, some psychotherapists use a one-size-fits-all or a myopic paradigm, so not surprisingly many of their patients do not get better.

Dr. John, I hear you just got elected to the rock and roll hall of fame! Just kidding.

Dr John said...

moviedoc. You are correct in that I have no idea what has been told to pts. Sometimes they are told things and do not hear them or they are selective in the information they provide. I can never really know. I can only come to these conclusions when I ask people if they know Seroquel can induce symptoms of DM or Haldol can cause TD and they start cursing that the person who put them on it never told them this. In addition as most psych drugs are given by very busy family Drs who are in my opinion less attuned to these issues than the folks reading this blog, pts are far less likely to be told they may not need Seroquel to sleep or there are risks.

The issue is systemic. Pts are sold these meds on TV. They are laid out for folks like they are buying kitchen items or a new car even if they do have some guying reading off the side effects at the end.

The brand spanking new APA guidelines on TX of MDD recommend meds as a first line TX for mild-mod depression. The best science we have says these meds are no better than placebo in that group yet are own leaders tell us we are essentially committing malpractice if we do not give them.
How do you expect pts to make informed decisions when the APA cannot even do it.

The youtube video is a great idea but I am not pretty enough to do it. I would try to get George Cloony maybe. Without that no one would watch it.

I admit I always play devils advocate in these discussions not because I believe we are incapable of helping people but because the vast majority in this profession are far too comfortable with passing out meds like PEZ without a shred of care or humility.

I echo Dr Allen in thanking everyone for their respectful and thoughtful comments even if there is disagreement.

Joel Hassman, MD said...

Maybe not completely related to this post, but I include the below link how shenanigans of several mental health programs here in maryland have sullied the efforts of honest and responsible providers here who try to care for patients, so now the state is going to increase scrutiny of programs, more likely just terrorize those who are trying and just encouraging better cloaking devices of those who just want to cheat the system.

http://www.baltimoresun.com/health/bs-md-house-hearing-on-bbh-20110120,0,5072733.story

I see it relate because it just gives ammunition to the Whitakers. And that is why we have to shine the spotlight on our "colleagues" who only have that title in name only. It is time to try to bring psychiatry back to the place it belongs, and that is the biopsychosocial model. I mean, wasn't that the purpose of the Axis model of diagnosis, pay attention to personality, medical, social factors in the presentation?

Perhaps time to take off the blinders?

Anonymous said...

If a small percentage of this book is valid, it is cause for concern. Something is, of course, amiss with psychiatry, as anyone who reads this blog is aware. We’ll dismiss this book with an eloquent essay or two, but the idea that something is wrong with psychiatry will remain. Psychiatry’s response to criticism is to feel attacked, defend the camp, and further polarize the issue.

David M. Allen M.D. said...

What's amiss with psychiatry is exactly the same thing that's amiss with America. We want our problems solved immediately, we want them solved fast, and we want them solved cheap.

You get what you pay for.

Jeff said...

We psychiatrists should be embarrassed that we don't have good data to show that our meds help people over the long-term (i.e., years and decades). If we did, then refuting Whitaker's arguments would be easy.

Anonymous said...

Dr. Carlat,

I never thought in a million years that you would post a review of Anatomy of an Epidemic on your blog. Thank you for proving me wrong:)

By the way, I heard Mr. Whitaker speak on my birthday. It was a great birthday present:)

I wanted to respond to Dr. Allen's comments about people analyzing studies. Warning - my comments may seem off topic but I think this discussion is important as I get the feeling that he and people with similar views think that all people like me do is read views from people that rubber stamp what we believe.

Dr. Allen, to answer your questions, I used to be able to analyze studies although it took a great deal of effort. Since I have tapered off of psych meds, that ability has been lost. I know causation doesn't equal correlation but I thought the irony was interesting.

Hmm, you have got me thinking though. Perhaps I should really make an attempt to regain this ability. It would be a good brain exercise.

Personally, I compensate by simply being skeptical of all claims. When Mr. Whitaker wrote an article that suggested that the Star D study had a 3% remittance rate, I wondered if that could be accurate even though the cynical part of me thought it might be. But as the daughter of a scientist, I have to fight my biases and look at the facts.

So I posted on a board asking for help. Someone who was very knowledgeable agreed the study was very faulty and that the claim of 70% effectiveness rate was extremely questionable. I can't remember if he agreed with the 3% remittance but he felt alot of the statistics didn't add up.

By the way, this all happened before the report came out by those 4 researchers which included one person with financial conflicts who found fault with the study.

I also try to find sites that will not always agree with me. For example, this site, http://chekhovsgun.blogspot.com/2010/04/do-antidepressants-enhance-stroke.html blasted Mr. Whitaker's book but agrees with my skepticism regarding antidepressants enhancing stroke recovery.

I doubted from personal experience (I feel psych meds worsened my LD issues over time) that this could be accurate. Of course, personal experience does not make a study. So it was nice that a professional like this neuropsych confirmed this even though it was for different reasons.

By the way, I take the same approach when I see studies that tout the effectiveness of supplements. At the same time, I am also skeptical when mainstream medical organizations seen to keep bashing supplements for no reason.

Also, one reason why I purchased Dr. Carlat's book, was that I really did want to hear his arguments for why he felt meds were effective. To be honest, I read nothing in his book that made the case and I did read it very carefully and slowly.

If I remember correctly, he quoted the Star D study but as I have previously mentioned, I feel that has major problems.

Dr. Carlat will obviously disagree with me but I think this is a perfect example that I try to read a variety of opinions. I think many people who feel the same way as I do about psych meds do the same.

If we just spout what seems like propaganda, our arguments lose credibility.

Finally, I agree that this discussion has been mostly civil. However, this exert by Dr. Behar, "When a tract falsely scapegoats a set of products and a profession, that has a name, hate speech" should not be tolerated on this blog.

Mr. Whitaker has done nothing to deserve this type of comment.

AA

David Behar, MD, EJD said...

AA: I welcome your speech, however offensive and wrongheaded.

Briefly. Studies with any exclusion criterion. Studies using parametric statistics (based on the bell shaped curve, reflecting large population rates, not individual response, better described by the binomial statistic). Studies shorter than a year.

Garbage science. It is almost unethical to base clinical decisions about individual patients on such. They may serve as screening tools, indicating a positive benefit or lack of one.

Many prominent scientist may have skipped Day One of 11th grade statistics or they would know all that.

Substitute the word, Jew or Black for psychiatrist, and it is easier to see what is going on. Here is where this is coming from. The government elite is on a witch hunt against psychiatrists. They do not want them using expensive brand name medications on government funded care of dark skinned people. They want generics used that they would refuse for their dogs. Left wing ideologues are taking their cues and permission for hate speech from these racially biased lawyer elites.

moviedoc said...

Dr John: No need to be pretty. Here, ultimately for public consumption, is some of what I would like to think I tell all my patients before prescribing gabapentin: http://www.youtube.com/watch?v=_DtnULV9rlk

me said...

If there's so much controversy about whether or not long term use of psychiatric medications worsen the course of disease, cause deleterious neural remodeling and neurological damage, and cause deterioration in patients' ability to function and their quality of life:

how about some current, scientifically valid studies examining these specific concerns? And not sponsored, paid for, and edited and censored by the corporations who stand to profit or lose financially from what the studies reveal.

Because I can't believe the thousands of people searching for help every day, who claim to be suffering terrible, disabling ill effects due to the use of psychotropic drugs, should be ignored.

We may not all be psychiatrists, but we come from all walks of life and the full range of IQ. Many of us are, or once were, scientists ourselves. Not one of us ever signed up to be a lab rat. We're people, and we're suffering, and we used to be healthy.

And you can argue and debate, but the scientific questions have not been answered by currently available studies. Until we produce some valid, neutral data, it's all words.

Which is Whitaker's point. He doesn't set out to prove that psychiatric drugs are dangerous; his book is simply stating that we need to stop assuming they are NOT, until we can definitively prove otherwise, because there is suspicious evidence that needs to be looked at.

Including an immense amount of suffering being reported every day by actual human beings, who were initially put on psychiatric drugs not for severe mental illness but for such everyday experiences as normal grief, stress, PTSD due to assault, feeling anxious at parties, bedwetting, and even hot flashes.

"First, do no harm." Do you truly believe these medications are harmless?

Prove it.

Joel Hassman, MD said...

Wow, after reading David Behar's reply above, I am both bewildered and annoyed that the last defense of the scoundrel has been introduced. Racism? Really? I would concur there is always the concern of bias and discrimination of the general psychiatric patient, which I believe is apparent in politics at least, with mental health services the quickest to be axed in budget cuts, primarily as psychiatric patients are not a strong voting block so least threatening to politicians.

But to focus the issue on "dark skinned people" does not accomplish anything to aid a debate. Come on folks, with the Tucson shooting putting a spotlight, albeit a brief light, on mental health concerns, we as providers need to keep the focus of the beam on what can be positively affected for the best of the population.

Dividing the concerns of invested parties and allowing those who are not interested in treating psychiatric patients to thus conquer is not benefiting anyone in the end. Psychiatrists have made mistakes here in treatment interventions, no doubt, but, who here is pure and without error?

Certainly not detractors to psychiatric care. Just like the debate about health care reform, if you do not like the intiatives offered, what are the alternatives? And going back to the status quo is NOT an alternative. Things are not going to be better as is, nor will they be better with the flaws of legislation by politicians who did not entertain any real dialogue from those at the front lines of this struggle.

By the way, the disability argument in my opinion does not really aid Whitaker's position of strong worth, but note this fact, at least of Maryland psychiatric based disability patients: over 95% retain their disability status for more than 7 years after initial determination,, and yet not even 20% of them are primarily psychotic diagnoses. Are you telling me that people who are diagnosed with other disorders like mood/anxiety/substance abuse cannot resume a level of function to get off disability rolls within 7 years?

That is a fact that disturbs me as much as the use of antipsychotics more indiscriminately. This fact means that something is failing our abilities to see people get better.

A free ride. But, it really isn't free, is it? As long as it doesn't come from your wallet, hey, no pain, tres gain, eh?

Anonymous said...

David M Allen MD wrote"

"If he spent one day in a psychiatric emergency room, he would know that it is the people who go off the meds (or who are substance abusers) who are in the revolving door."

I think this statement actually supports Whitaker's viewpoints. He points out that many psychoactive medications alter the brain chemistry so that when patients go off the meds, they have serious symptoms. This creates a cycle that ultimately serves to increase the profits of the pharmaceutical industry and the psychiatry profession.

lsyorke said...

“Almost no suicider has a prescribed medication in him”

Really?....that is an amazing stat, false, but amazing.

“One has to look at the preponderance of the evidence. How many of you do literature searches and read several studies (and not just the abstracts?)”
“I wonder how many of the anonymous commentators really know how to evaluate study designs, the statistics used, potential weaknesses of the studies etc.”


I believe you’d be shocked at how many “lay people” have taken the time to learn, read and evaluate clinical trials and studies to determine what is going on with family members. That said, when those studies only reflect what is going on in that specific well controlled environment; it’s far from the whole story. It is common knowledge that the true risk/benefit of a drug isn’t realized until it is in use the general population. The problem is that once in the general population the documentation of adverse effects becomes voluntary, grossly under reported and if reported, dismissed as “anecdotal”.
“If a drug is not working for a given patient, of course they should not be taking them, and the doctors who continue to prescribe drugs that are not working are the ones who are in need of rehabilitation. “

Couldn’t agree more, yet this is not the response that a lot of patients will get. The “it’s your disease, not the drug” is more likely going to be the answer. That response only solidifies the patient’s belief that they are permanently damaged and only drugs will help their situation.
“Of course, now Johnny doesn’t have to learn better coping skills, because it’s not his fault he’s this way…it’s the disease! Poor Johnny. Where can he sign up for some free Government cheese?”

Whitakers point! We’ve taken bad or developmental behavior and made it a biological disease. A perfect example is how temper tantrums are now “temper dysregulation with dysphoria, giving those parents the excuse to not change behavior, but just give a pill…because it’s a disease. Johnny has now entered the world with a lifelong label and most likely a lifetime of trying to find the perfect drug, for something that was easily treated with some therapy.
“Most have no idea what so ever as to any risks or what limited evidence supports long term benefit. When I tell them these things they are horrified. Some choose to remain on them but most ask me how they can come off or just quit them altogether.”

Another key point. Historically patients have relied on their doctor to give them the information about the drug that is being prescribed. The “my doctor just told me to take it” is something I hear in my practice every single day. No one told patients that the rules have changed, and now they are responsible for doing the research and if they do quite a few psychiatrists will tell them to stop going to the internet(even if these are medical studies). So on one hand psychiatry subscribes to the “just listen to me I know best” way of practicing, and when things fall apart they change to the “the patient should have known to read about the drug before taking it”. One can’t have it both ways. I talk to psychiatric drug users everyday and the first sentence uttered is usually “I had no idea this drug could do this to me”.
I don’t not deny the fact that there are some seriously mentally ill people, believe me, I’ve seen my share. What I have a real problem with is the lack of response by psychiatry(or medicine in general) to a patients reports of problems with a drug. Sadly, those reports are, for the most part, dismissed as the rantings of a mentally ill person, regardless of the initial diagnosis.
Until reports are collected that include at least a majority of complaints, we truly don't have the data that is needed to make a definitive claim, either for or against.
Until that is done, Whitakers claims are just as valid as those who deny them, maybe more so since there is at least some data to support what he is saying.

Sara said...

For the most part this is a valuable and civil debate and I would just like to say I appreciate being able to participate in a forum with doctors, psychiatrists, therapists and patients and actually feel like I can speak without being automatically dismissed. I learn a lot from all of you "on both sides of the examining table" and appreciate that none of this is easy. Thanks to Dr. Carlat for making this possible.

Mary said...

The problem with medication is not so much the fact that it is used on patients, as with the prevailing medical model that assumes that the patient presents with a condition best controlled with drugs, or with institutionalization plus drugs.

Research since the days of Loren Mosher and Soteria, for example, has indicated the florid symptoms of schizophrenia usually subside within about six weeks, whether drugs are used or not. A more recent example is Open Dialogue treatment in Finland, which relies on medication quite sparingly and results in impressive long-term recovery rates. It might be objected that in the "real world" psychiatrists have few options but to give medication, but that's different from evidence that medications are, in general, required.

I think we need to keep in mind that it is our systems of care that lack options, and not that medications are definitely "necessary." They may be at times the only option people can see because our systems of care are defective. Why else have ex-patients and consumers formed protest groups demanding legal rights and alternative methods of treatment? The formation of these groups is beyond strange. It may help put this in perspective to ask whether there are similar groups demanding legal rights and better methods of treatment for cancer patients, or diabetics, or patients with heart disease. I think not.

SG said...

I'd just like to chime in as a long-term patient of SSRIs and what I have experienced first-hand on these meds:

In a brief summary: I was put on Paxil at age 14 for anxiety over my father's cancer (I'm glad to say he recovered). My psychiatrist swiftly prescribed this medication (along with Lithium, for some reason) without any warning whatsoever of its side effects. It really was as if I was being given Pez. Sorry, it's true.

He also never told me how painful it would be to withdraw from it. He initially suggested a week-long taper off the Paxil. It was a disaster. I woke up on the third day off of the Paxil with my brain feeling like it was in a frying pan. I was bedridden for days, and finally went screaming back to my psychiatrist for an answer on what was going on. He had no answer, and I went back on the Paxil, feeling like a slave to a potentially damaging drug I didn't even need to be on in the first place.

For the next 13 years, up to the present day, I was on either Paxil or Lexapro (I'm still on Lexapro to this day).

In the last four years, my symptoms have truly taken off. My short-term memory simply isn't what it used to be: I'll forget why I went into a room or why I got on the computer. Sometimes it's so bad I'll be disoriented and forget where I am. And, most heartbreakingly, my libido and motivation isn't what it used to be. I cannot tell you how utterly shattering it was for me, at age 24, to finally realize a decade-long dream of being in my first relationship and not be able to perform sexually with my girlfriend because of the sexual side-effects of this drug. Still hurts. Do you know that pain? Do you feel the dreadful weight of a secret shame that you must carry everyday within you? The secret shame that you have been chemically neutered by a med that is murder to withdraw from? To this day I still have erectile difficulties and genital anaesthesia.

My blunted motivation and emotions are also a constant hindrance for me, as at this point in my life I should be excited and motivated to build a career. Too bad I have to reach down deep and expend a tremendous amount of energy to find a scrap of motivation so I can fool myself into thinking I'm excited about forging a career. It's exhausting. And, by the way, it's NOT depression. I know the difference, and so do the psychologists who've treated me.

So what do the psychiatrists on this board have to say about these long-term symptoms and my chances of ever recovering from them? I sincerely hope they don't default to saying I'm "statistically insignificant" (sorry, such dehumanizing statements don't cut the mustard) or merely "anecdotal." Sorry, I'm not anecdotal, I'm a human being. A human being that hurts.

PS: I'm currently tapering off Lexapro in 10% dosage drops every month. I learned about this technique NOT from any doctor or psychiatrist, but from an online message board. I ask you: isn't there something profoundly wrong with psychiatry if 1000s of patients like me have to resort to the internet for advice and support, and not their doctors? What's going on here? What happens to patients like us who want our lives back but are terrified of permanent side effects like PSSD? Don't know what PSSD is? It's permanent sexual dysfunction caused by antidepressants that lasts even after discontinuing antidepressants. It's real and it exists, and only now the medical community is realizing what us poor patients have known for decades.

I ask you: WHO in psychiatry will boldly step forward, put their ego aside, and admit massive wrongdoing on behalf of their profession? Who will lead research on how to heal us long-term users' brains so we can reclaim our lives? Unfortunately, experience tells me not to hold my breath...

David Behar, MD, EJD said...

4 of 66 young suiciders had an antidepressant in their bodies, here:

http://www.ncbi.nlm.nih.gov/pubmed/15291679

Alcohol and illegal drugs are a much greater factor in suicide, murder, and murder victimization.

Rhiannon Griffith (aka "me") said...

In response to Joel Hassman:

"over 95% retain their disability status for more than 7 years after initial determination,, and yet not even 20% of them are primarily psychotic diagnoses. Are you telling me that people who are diagnosed with other disorders like mood/anxiety/substance abuse cannot resume a level of function to get off disability rolls within 7 years?"

Yes.

People who were initially diagnosed with something as simple as mood or anxiety disorders are, after using common psychiatric drugs such as SSRIs and benzodiazepines, experiencing levels of chronicity and disability so unrelenting that they are not able to get off the disability rolls. That is what is happening.

Most of them were functional, successful and normal before the medications. Often they were medicated for simple, transient grief or stress reactions, or even for nonpsychiatric conditions. Their stories are beyond tragic. Perhaps we should be listening.

"A free ride. But, it really isn't free, is it? As long as it doesn't come from your wallet, hey, no pain, tres gain, eh?"

Well, it's a digression, but since you bring it up: Do you have any idea how much money people on disability are awarded? $1000 a month is on the generous side. Try living on $12,000 this year. Do you really consider that a "free ride?"

Forgive me, but I have very little patience with people who live on substantial incomes and complain about Social Security "freeloaders" whom they've never even bothered to meet or talk to. I've never met anyone on disability who wouldn't FAR prefer to be able to work. The majority of people on disability would give anything to be able to work hard and live normal lives again. And be able to afford to buy a new pair of shoes from time to time.

Mary said...

SG,

It looks like between the two of us, we have managed to shut down all discussion of Whitaker's book and its charges against psychiatry.

Don't take it personally. I've noticed before that the surest way to put a stop to a discussion like this is to inject a little reality into all the professional self-deception. But for the sake of future patients, keep it up. Whistle blowers like you are our best hope.

Anonymous said...

RE:
David Behar, MD, EJD said...
"4 of 66 young suiciders had an antidepressant in their bodies, here:
http://www.ncbi.nlm.nih.gov/pubmed/15291679"

You need to read that a little more carefully Doctor. Then look for some newer and/or larger studies. There have been several within the last few years.

Joel Hassman, MD said...

Ah, Ms Griffith:

blaming medication that keeps people on disability has little traction as an argument, but, I would agree that people, in their desperation to avoid losing their disability determination, do turn at times to medications that have no functional intervention, and yes, some are dependency causing like benzos.

Regrading your rebuttal about money, a sizeable percentage of patients I have treated in the past see $1000 a month much better than zero, and they find ways to make money "under the table" to add to the disability check, so they have money to keep them afloat. How to you respond to these people who complain that their checks are not enough for them a month, coming in with tobacco habits, cell phones, noting their recent purchase of a flat screen TV or Wi device?

I agree $1000 a month is a bare income, but, why aren't these patients following through in my recs to seek out Voc Rehab services and see if they can get trained to learn or relearn a trade or skill?

And, here is the argument I find just repulsive to hear as a defense: "why do I only get $800 a month when my neighbor gets $1600, oh, but yeah, the neighbor worked for 10 years and had a skill, but I have been just sitting around since high school living off my parents and making no effort to seek out supports and growth." That is the population inside the disability group that ruins it for those who genuinely need disability support services. There is no blank check for every "hard luck" story that walks into an office.

So, I disagree, from my YEARS of experience working with this subgroup of people who are freeloaders. Sorry you haven't met them, because they would displease you after hearing such lame tales!

And, what defines a substantial income per your terms? Compared to my average colleagues, I am in the lower end of yearly income of my profession, so that generalization is not applicable until you define your terms and apply them realistically to those who you charge as, what, overpaid?

Anonymous said...

I am struck by how weak the rebuttals of Robert Whitaker's book are. I have seen some legitimate addition of nuance to his argument, but the fundamental thrust is only strengthened by the thin gruel available as rebuttal material.

Dr John said...

I am sorry Ms Griffith I must agree with Dr Hassman when it comes to your conclusions about many on disability. The majority I see are those that are gaming the system. Just to say you want to work and don't want to be in that position does not mean you are willing to do what it takes to progress beyond it. Often I see people getting disability checks no longer on any psychotropic drugs or in any TX. Many spend a good portion on drugs and Etoh. I don't think in 15 years I have seen one making an active attempt to get off disability.Yes life sucks but for many it is better than working minimum wage and self reliance. You do not need to be BF Skinner to see the results of giving checks out.

I blame their psychiatrists more than I blame the pts. If I were on SSI I would be setting aside a few bucks a month for gold or silver because the system is going to collapse in on itself along with the dollar as a reserve currency and SSI as we know it will no longer exist. Dr Hassman and I make a good income but that is not the point. We know SSI is a Ponzi scheme and it cannot survive as it currently exists. Our frustration is driven by that.We want it to exist for those who really need it.(Drs are not often better judges of disability than a layperson) It is the psychiatrists who promote disease and dysfunction along with disability who are to blame. I guess in the end you and I are mad at the same people but for different reasons.

SG said...

Mary, I totally hear you. I agree patients will help cut through the noise of endless ingrown professional back-and-forth about studies, statistics, trends, etc. I honestly believe stories like mine speak loudly because they are HUMAN, not statistics in a medical journal.

I agree with anonymous's posting that Whitaker brings up some provocative questions that absolutely MUST be empirically tested. And in the long-term, since many patients (including myself) are on these meds long term.

I believe randomized controlled trials can be subtly dehumanizing because they unnaturally sterilize the astonishingly complex human body/mind into black and white binaries of "successful/unsuccessful." I absolutely think studies have their place in health care. Absolutely. But let's not underestimate the chilling effect they have on listening to actual patients and seeing them as human beings with valid observations. Too much science and data subconsciously wires a lot of doctors to discredit their patients' stories because their patients weren't part of some randomized trial or some other study. A pity. And dangerous.

And can't we see the big picture here, that the current studies aren't enough to truly see the entire spectrum of efficacy and long-term side effects of these meds?

I admit the possibility that Whitaker's assertions may be proven wrong once tested in unbiased long-term studies, but isn't it reasonable to ask psychiatrists to do the same and admit the possibility that they may be wrong if at least some of Whitaker's assertions are proven TRUE in these studies?

I think the best thing Whitaker's book has done is ask the deadly -- yet paradoxically life-affirming -- question "What IF?" to psychiatry. "What IF" psychiatry has fundamentally misunderstood these drugs? What does that mean for the current psychiatric model?

It would mean big changes, and, one hopes, big changes for the better. I'm sure I'm not the only patient who believes psychiatry is in spectacular need of a major overhaul.

What I find curiously lacking in all this discussion is a compassion for patients who are caught up in the psych jungle. It was heroically included in Whitaker's book, but largely isn't here. Let me be the first to offer my condolences:

Dear patient: I know how scary it is to realize the med you were put on for situational depression or anxiety has flattened your emotions and made you a stranger to yourself. I understand how terrifying it was to contend with an impersonal medical architecture that didn't believe your symptoms when you withdrew from you medication. All of a sudden, you realized that the health professionals that could routinely make you well throughout your life now have no answers for you. I know the terror of realizing the only suggestions the doctors have for you is more psych meds.

But please, don't despair. There is hope. It is within you, and you need to learn how to heal yourself and believe in yourself again. Remember that the current medical culture vastly underestimates the body and mind's ability to heal itself. You were once a healthy and productive professional woman before a bout of situational depression, and you will be that woman again. 1000s regain their old selves everyday outside of the medical system, and you can too. It won't be easy, but I'm sure you won't mind too much. In the process of healing you will learn more about yourself and the world than you ever did when you were on meds. Now let's get to work and get your life back.

Anonymous said...

I appreciate your review and rebuttal of Whitaker's points, in particular your point that "correlation does not imply causation." However, you then proceed to imply causation from correlation yourself by enumerating three "causes." With your third point, you say "Sure, drug companies have revved up the diagnosis of disorders, but their drugs haven't actually caused the disorders." Whitaker is trying to look afresh at existing studies to determine whether this is so. If the studies aren't rigorous enough to support his position, they are also not rigorous enough to support your conclusion.

Anonymous said...

Dr. Carlat said: "But the med use has not caused the disability. Instead, the skyrocketing disability rates are caused by several other factors, having almost nothing to do with any putative toxic effects of long-term medication use ... He erroneously blames the drugs."// Are you sure of this? If so, HOW are you sure? You say this as though it were fact, yet you do not provide support for your statement. It is implied that we should take what you say as fact simply because you are a psychiatrist, so of course none of the drugs you prescribe could have effects or consequences you don't know about. You call others out for doing this. Why are you doing it? Job security? Sorry for the crankiness, but this is just the kind of over-confidence that is so worrisome coming from psychiatrists. And you're the last person I would hope to see it from.

Anonymous said...

David M. Allen said: "using antidepressants can cause rapid cycling in bipolars ... Most of those "rapid cyclers" are in reality misdiagnosed borderlines."//

Oh, nice use of language. Way to turn a person into a disorder. Might you consider acknowledging their personhood by referring to these patients as people with bipolar disorder or people with borderline personality disorder, instead of "bipolars" or "borderlines." Just a thought.

Your use of language shapes how you view the world and view others. I am not encouraged by how you view your patients. You depersonify them. This happens too often in medicine. And it should not happen AT ALL in psychiatry, where practitioners are supposed to acknowledge the importance of the person. But, I guess this should not be surprising given the direction of the specialty.

Anonymous said...

Dr. John said:
"I could not disagree with you more that pts "choose" meds and ultimately decide in the end after weighting the risks and benefits. I almost NEVER come across a pt on meds who has had a legitimate discussion with any doctor on this issue. Most have no idea what so ever as to any risks or what limited evidence supports long term benefit. When I tell them these things they are horrified."

I agree. Psychiatry isn't exactly into shared decision-making. It speaks out of both sides of its mouth. Psychiatrists can't really get into shared decision-making if they want anyone to do what they *tell* them to do - the evidence for their advice is equivocal. They'd go out of business if they actually fully informed patients as a rule rather than an exception.

Anonymous said...

I wanted to respond to Dr. Hassman's comments.

Regarding his recommendations that his clients see voc rehab services:

Many years ago, a major psychiatric organization (sorry I forgot which one) wanted authorization to provide their own voc rehab services to clients because they felt the most state voc rehab agencies were not helpful.

As someone with a dual disability (not psych), my experiences with voc rehab have also not been that great in the past. I am slightly optimistic that my current experience will be better. Only time will tell.

Personally, I don't know too many people in the disability community who have had great experiences with state voc rehab agencies. And this seems to not be limited to one disability group as everyone is extremely dissatisfied.

The problem is that voc rehab counselors are judged on on how many cases they close and not how long a client stays in a job. As a result, they will generally push you into jobs that are not suitable.

So if your clients aren't following your recommendations to seek voc rehab services, there could be darned good reasons why.

Unfortunately, there aren't any alternatives as everything seems to be funneled through state voc rehab agencies.

Regarding the people you describe who have all those luxuries. how do you know they weren't given as gifts? Just saying.

As far as your money comments, the issue isn't that you don't deserve your salary as a psychiatrist. The issue is would you switch places with those folks that you think are freeloading if you feel they have it so good?

Finally, if you think medication shouldn't keep people on disability, I challenge you to try something like Seroquel for a few days. I would be curious to know how effective you felt after taking a pill or two.

By the way, a psychologist did exactly what I am suggesting you do:

http://tinyurl.com/4e9jskz

One more thing - Even if people want to get off disability, they risk losing all their benefits, particularly health insurance. At least this was true in the past. I am not sure how Obama Care has effected this.

AA

moviedoc said...

Anon: I don't know how Dr Hassman or I would respond to quetiapine (Seroquel), but do you really think we psychiatrists don't treat dozens if not hundreds of patients who work every day, some as highly skilled professionals, with that drug or others like it? and would be very angry if we refused to prescribe it for them because they suffer so much without it?

Joel Hassman, MD said...

I hope I may have the opportunity to rebut AA's comment, and then I will end my involvement in this thread.

First, your comments about state Voc Rehab programs has some merit, but, I have worked with pts who just dismiss my general recommmendations to seek out programs like Voc Rehab or other options to regain or just plain learn or access skills/training, as they have no interest to try to better their situation. And, I am not talking about treatment resistant cases involving psychosis or pervasive mood disorders. No, a sizeable percentage of these dismissive patients have at least coexisting substance abuse/dependence issues and/or personality disorder features, and being "the victim" or "permanently disabled" is a label too costly to lose. Hey, maybe other colleagues will agree or not with my perspective, but, learned helplessness as a concept is out there, I truly believe it.

And your last comment of patients losing their insurance should they lose their disability status is true, but if the effort to end it is done responsibly, the risk of going uncovered is minimal, and I know that from good experiences with patients who want to be involved and invested in the community.

Finally, this rhetoric of telling people to take psychiatric meds without true mental health need is just an empty argument. It really is equivalent to telling people arguing with addicts "to use cocaine or heroin and then you will know where I am at." Of course if anyone who is not dysfunctional with mental health issues takes psychotropics, they will be negatively affected by them. I cannot speak for any one else, but I have never asked a patient to take a psychotropic unless I feel such individual seems to reveal symptoms and struggles that meet a criteria for a possible illness that deserves consideration for the medication. I also believe in the adage "start low and go slow" to avoid intense reactions as best possible, so that seems to have minimized negative side effects in my travels.

I will end with this: the majority of people I have met who are on or pursuing disability meet the need for it at the onset of my involvement. The problem with time has been a sizeable portion seem to have the potential to get off it, and benefit being off disability. Irregardless of whether they stay on meds or not if they are at a point to get off disability, you can't realize how empowering it is to see a person regain independence and productivity, to feel like they are appreciated and valued as an employee/contributing member of the community.

You just have to experience this to appreciate it! Good thread here, Dr C, a nice rebound after the hiatus this past few weeks!

David M. Allen M.D. said...

Anonymous,

I agree that calling people by their diagnosis can be problematic if the person doing that thinks in a certain way (I don't).

On the other hand, did you ever call a "person with diabetes" a diabetic? How about an epileptic? A cancer survivor? If you say no, I guess I'd have to believe you.

In my book I went out of the way to use the "long form," but writing a quick blog note? Give me a break!

In regards to the revolving door, another anonymous wrote "...psychoactive medications alter the brain chemistry so that when patients go off the meds, they have serious symptoms." So, after a patient stops a medication after a few days, and develops the same symptoms he/she had before being placed on them, it was the meds that caused the symptoms the second time?

What great logic!

Like Dr. Hassman, I will end my involvement in this thread with this post.

SG said...

I would also like to thank Dr. Carlat for making this discussion possible. It is indeed tragically unusual for such a free exchange of ideas between patients, laypeople, and psychiatrists to occur, and I thank him for the opportunity.

Anonymous said...

Dr. Hassman, I know you said you have ended your discussion but I am still going to respond to a point you made because I think this is important. You said,

"Finally, this rhetoric of telling people to take psychiatric meds without true mental health need is just an empty argument. It really is equivalent to telling people arguing with addicts "to use cocaine or heroin and then you will know where I am at. Of course if anyone who is not dysfunctional with mental health issues takes psychotropics, they will be negatively affected by them."

Let me clarify. As readers remember, I made the suggestion that perhaps if psychiatrists took psych meds, they might understand with developing side effects, that getting off disability isn't as easy as it seems in reality."

My point is even if it wasn't your intention, you were coming across as awfully judgmental as someone who has never been on disability. Perhaps if you experienced psych meds personally, you wouldn't be that way.

I wish I could find the link to this article as this demonstrates my point perfectly. It was about a woman who taught students with learning disabilities. Unfortunately, this woman developed a hearing loss.

Interestingly, as she found she had to work so much harder to grasp conversations due to her hearing loss, she realized that she never gave her students credit for having to work so hard to overcome their disability. She realized she had made assumptions about them that weren't fair as the result of developing a hearing loss.

Anyway, the themes I heard in that article are the same I am hearing about people who are on disability.

Of course, there are always going to be people who game the system. But to stereotype a whole group of people as cheaters based on your experience is simply not fair.

If I decided that based on my experience, psychiatrists were a bunch of frauds, you would jump on me for being a crazy anti psychiatry zealot. But yet when it suits you, you seem to have no problems stating your experiences as fact.

Finally, I hate to break it to you but people with mental health issues can be negatively effected by psych meds. Of course, the issue is do the benefits outweigh the negatives but to act like someone is immune from side effects just because they have mental health issues is simply faulty reasoning.

Anonymous said...

I found the article that I had referred to in my previous post.

http://tinyurl.com/4fum8mb

FOURTH SCHOOL
At my fourth and last special education school, my hearing deteriorated in the other ear, and it wasn’t fixable due to some very unusual nerve damage. After many years of being a teacher, I was a student again, learning more difficult, painful lessons. One of them was realizing how really courageous many of my students were and how much harder they worked then I had often given them credit for.

WHAT I LEARNED ABOUT MY STUDENTS-- Some Parallels Between Hearing Loss & Learning Differences

They say you have to walk in another’s shoes to truly understand. All the years I had been working with my learning disabled students, I had understood the issues intellectually and with empathy, I like to think. But the real thing is really different. Something about that Frog trying to walk on little cat feet...

Anyway, for those of you who wonder how this relates to the topic, Mr. Whitaker talks about people on disability. The themes that have come up are that people are freeloaders and gaming the system.

I am trying to point out that unless you walk in someone else's shoes, it is easy to be judgmental. This article is a perfect example of that.

AA

altostrata said...

Dr. Carlat, do you really think the DSM is an accurate reflection of the state of mental health? Not only is it a highly abstract (and currently controversial) construct, appropriateness in diagnosis depends on the skill of clinicians, which is variable, to put it politely.

In other words, a count of DSM diagnoses or even clinician opinion is irrelevant.

As Whitaker points out, what is relevant is outcomes. No matter what you call these conditions, 30 years of psychopharmacology has done NOTHING to lessen the incidence of severe mental illness leading to disability.

Psychopharmacology hasn't even made a dent in depression. Even with more than 10% of the US population over the age of 6 on psychiatric medication, psychiatry's own estimates of the rate of depression keep on rising. (Or is the specialty merely trying to generate more business for itself? Critics of the DSM-V think so.)

As for all drugs having side effects and risks, when is psychiatry going to own that? You continually decry the corruption of judgment by too cozy a relationship with pharmaceutical companies, yet you haven't moved to the next logical conclusion: It's not just ungentlemanly behavior. Such corruption, which deliberately underplays drug risks in order to sell them, causes patient harm.

Where would you expect to see the outcome of psychiatry's conflicts of interest? What do you think happens when a clinician is poorly informed about medication risks?

As Whitaker describes, the very common practice of clinicians misidentifying side effects and employing polypharmacy to treat them is certainly a contributor to iatrogenic mental disability.

Whitaker has done a brilliant job of stripping away all the mumbo-jumbo around diagnosis and come right down the the nub of the thing: Statistics show overall, people are not getting better from treatment with psychiatric medications.

Dr. Carlat, you still have not come to grips with your own cognitive dissonance. Your criticisms of psychiatry are highly praiseworthy, yet you cannot face the issue of patient harm from psychopharmacology. How can you admit so much of the pharmacological advice you've published over the years has been based on propaganda?

At least Robert Whitaker has stood up and told the story straight.

altostrata said...

Dr. Allen:

In your Jan 21 post: "Atypicals are in fact toxic to SOME (a minority) of patients - but it's not psychiatric toxicity but endocrine, cardiovascular and neurological toxicity."

That is such a bizarre defense of the drugs and, in my opinion, reveals something very, very wrong in psychiatric thinking. This is the way psychiatrists absolve psychiatric drugs of any sin.

How can you possibly draw a distinction between "psychiatric toxicity" and damage to endocrine, cardiovascular, and neurological systems?

Certainly the endocrine, cardiovascular, and neurological systems are linked to the "psychiatric" system. (Where the heck is that??) One might even say psychiatric health is dependent on healthy functioning of all these parts, and more.

If disability results from psychiatric drug damage of ANY system, it is iatrogenic damage and an adverse effect of the medication.

In your Jan 22 post: "If a drug is not working for a given patient, of course they should not be taking them, and the doctors who continue to prescribe drugs that are not working are the ones who are in need of rehabilitation."

Where are the mechanisms to identify and "rehabilitate" these doctors? You see in these comments patient complaints, and you see Whitaker's exhaustively documented critique, and you dismiss all of them. How would you know if a patient's treatment was working without listening to the patient?

Psychiatry doesn't police itself. In fact, psychiatry supplies apologists to cover up treatment failures.

Their tactics are predictable, such as suggesting non-specialists cannot read and assess scientific papers. Could this be another way of dismissing even informed patient complaints and going on with business as usual?

Anonymous said...

Dr. Allen said,

"In regards to the revolving door, another anonymous wrote "...psychoactive medications alter the brain chemistry so that when patients go off the meds, they have serious symptoms." So, after a patient stops a medication after a few days, and develops the same symptoms he/she had before being placed on them, it was the meds that caused the symptoms the second time?"

Why the condescension?

You're totally misinterpreting anonymous's point. As I am sure you know as a physician, cold turkeying or discontinuing a med too quickly can cause rebound symptoms that look like a return of the illness but aren't.

Joseph Glenmullen, who is not anti meds states this in his book, the antidepressant solution. He mentions that psych med withdrawal issues appear quickly while relapse issues take time to develop.

AA

Anonymous said...

Dr. Allen,

In fact, no, I have never referred to patients as "diabetic" or "epilectic". I *have* diabetes and I tend to think of people as people, not as diseases. If you read the diabetes blogs, you will find "PWD" written frequently. That's "people with diabetes." Imagine that. People with biomedical illness don't like to be called by their disease names, either. This should not come as a surprise.

And, no, I will not give you a break. Blog comment, or not, you should not be calling people diseases. You are a doctor, I assume. And you are one who is supposed to acknowledge the importance of people's psychological dimensions - a psychiatrist, I assume. When you call human beings a disease, you are focusing on the biomedical and failing to acknowledge that they are people - failing to acknowledge their emotional side.

Do you also refer to patients who have cancer as "cancer"? No? Why not? How is that different from calling psych patients by their "disorders"?

Do you think calling someone "that cancer" would be considered offensive? I do, too. Think about that and think about why you have a double standard. And if you don't have a double standard and you don't think that calling someone a "cancer" would be considered offensive, then you really are out of touch with how people react and respond to language.

If you were diagnosed with bipolar disorder or borderline personality disorder, how would it make you feel to hear someone call you a "borderline" or a "bipolar"? Be honest with yourself. And if it wouldn't affect you, fine. But just know that it does affect other people. You are supposed to do no harm. Calling people diseases/disorders is hurtful. In psychiatry, causing psychic hurt is considered harmful. That you are fighting this says much about the way you think about patients, in general.

Jenn said...

Robert sticks to the studies. Many of which were done by NIMH and other government funded agences that did not find the drugs to be effective but did find harmful effects. So with all hypothosis asside on whether the medications are causing the disabilities, he does make a clear argument that they do not cure anything, and in the long term have found to make symptoms worse and create side effects that have to be controlled by more meds. The rate of disability, from what I have seen, as a practitioner, advocate, Intensive Case Manager, working at community based as well as group home settings, is the self fulfilling prophesy drives the disability. If one limits themself by virtue of a diagnosis (that has no medical proof besides behavioral "symptoms") then they will in turn be limited. It is a sick cycle; a child behaves in a manner that seems out of control (once upon a time called a temper tantrum) then we become alarmed and wonder if this child is bipolar or ODD or some other diagnosable condition. The doctors (many who are taught from texts and Universities with wings and grants from big Pharma) that these diseases exist and can only be treated effectively with meds. The doctors tell the parents this and then dose the kid up. So there is no responsibility or industry afforded to the parent or the child. The child is ill, the parent nor the child has control over this, and then we expect nothing more. So nothing more happens. I see it daily. It is also pervasive in the schools with these "Learning Disabled" diagnosis. We have children graduating from high schools with IEP's and who cannot read because the teachers, children and parents were exonerated by the disability diagnosis. Learned helplessness then hopelessness, and that is diagnosable too.

Anonymous said...

I have no idea why I'm even reading all of these comments, perhaps I'm just bored. I would like to comment on something that was said in this discussion.

"Regrading your rebuttal about money, a sizeable percentage of patients I have treated in the past see $1000 a month much better than zero, and they find ways to make money "under the table" to add to the disability check, so they have money to keep them afloat. How to you respond to these people who complain that their checks are not enough for them a month, coming in with tobacco habits, cell phones, noting their recent purchase of a flat screen TV or Wi device?"

That is baffling. I'm on SSI for so-called bipolar disorder and I've been trying to get off of it for years. I get $674 (or very near that, it's direct deposit and I rarely check it) a month. The DHS sometimes kicks in a living assistance check of an extra $45 and I get a bridge card with $84 on it. I live in a $400 a month Flint MI ghetto motel that somehow amazingly has wifi (or maybe I'm leeching it off someone near here) and can not even begin to understand how those people you see get all of that stuff. Do you ever question the possibility that they were never disabled and may even just be drug dealers looking for a front for their suspicious behaviors? I've talked to and been around a lot of people in the SMI category of mental illness, most live in group homes, with family or in cheap motels like me. Never heard of one with a big screen T.V., I wouldn't even have a laptop had I not of stole it. I think the patients you come across as you describe are cheating the system.

Robert Kybird said...

Back to basics
Question 1
What does a normally functioning serotonin system achieve in the brain.
Question 2
What goes wrong in depression?
Question 3
What effect do reuptake inhibitors have on long term normal functioning?

My own view.. Serotonin system is for succesful object avoidance (including social obstacles).
In depression the obstacles become too large, or the system is overactive, or there is a tryptophan shortage. Cognitive pathways (succesful learned avoidance) are over-ridden by Amygdalic pathways.

So what do the reuptake inhibitors achieve?

Anonymous said...

Jenn,

I wanted to respond to your post since you mentioned that many people diagnosed with a learning disability are on these psych meds.

I am not saying you are doing it but I am concerned that people in reading your message will wrongly assume that LD is not a legitimate diagnosis. It definitely is as long as it is not diagnosed based on a drug reaction.

Assuming it is legitimate, the problem is that many people with LD develop anxiety and depression due to not knowing how to cope with their disability. So instead of being referred to professionals such as educational therapists or psychologists who could provide that assistance, they are usually poly drugged.

By the way, I can't remember where I saw this but Mr. Whitaker says that long term, psych meds will definitely cause LD issues.

Anyway, it sounds like from what you are saying, that parents sadly didn't do the hard work of making sure their kids were being taught appropriately, particularly in reading.

As one who has a legitimate diagnosis of LD who has reading issues, that breaks my heart.

Anonymous said...

I have read many of the comments on this blog as well as the original review of the book, Anatomy of an Epidemic. For me, although I am somewhat skeptical about some of Whitaker's assessments, I was incredibly pleased to find that somebody had written a book about the over-prescription of psychotropic medications in this country. Regardless of why there is such an astonishing rise of documented mental health disorders, I believe that we are doing many people a huge disservice by prescribing psychotropic medication and neglecting to see that there are other ways in which people can heal. I was personally exposed to the mental health system as a young adult and was on numerous medications for over ten years. The whole time I was quite weary of this treatment and despite numerous attempts to fight this incredibly powerful system of care, I continued to take medication that made me gain weight, made my thyroid go hypo, fuzzed my brain, and caused other disconcerting symptoms. Four years ago, I finally had enough but could not find any psychiatrist to help me safely come down on the medications. In my mid-twenties I had been manic, psychotic, depressed, etc. and no doctor felt like it was wise for me to go off lithium. So, I found a Chinese doctor (who is an acupuncturist/herbalist) in this country who helped me. He gave me a combination of herbs and slowly helped me decrease my medication. The end result: I've been off every psychotropic for about four years and I am symptom free. I am not saying that everybody is the same or that everybody can do something like this and fare as well. However, we need (especially psychiatry) to think more about what people really need to feel/get better. I believe they need to feel like they can trust somebody, to feel supported, to feel loved, to talk about things, to believe that they can, in fact, recover. I do think that medications can often make things worse and can cause other symptoms, like when Prozac made me at least hypomanic. I hope you post this and that you consider that there are really not more "disorders." We are living in a medicalized society where so many people are unfortunately pathologized. I believe we need to swing this pendulum the other way and that it is disgraceful that we are treating people in such disempowering and damaging ways.

P Dwyer said...

Dr Carlat starts with correlation not equalling causation. Psychiatry constantly cofuses these two; this is a field that has not a single "disorder" with a known pathophysiology or a single physical diagnostic test, yet acts like the general fact of mental problems' physical causation is already established, and all that remains is to "tease out" the specifics.

The lack of physical evidence is a major reason for the proliferation of new "disorders." Human experience can be slice and diced in an infinite number of ways. So Pharma and biopsychiatry can re-define as medical conditions everything from crushing emotional pain to minor problems of living.

In a field that's used to not having physical diagnoses for its "diseases," there is no reality check for the proliferation of new "disorders," or, for scientific evaluation of the pills used to treat newly conjured "disorders."

Psychiatry has a history of dismissing countervailing information to protect its theoretical framework. Moniz's lobotomy work wins the 1948 Nobel, and lobotomy persists well into the '50's; neuroleptics are touted next with psychiatry taking 20 years to acknowledge the threat of tardive dyskenesia; the evidence was there from the start about SSRI's - but not 'til 2004 was the danger of suicidality acknowledged, and warnings required in England and the US for kids and young adults. Not 'til Irving Kirsch's meta-analyses did the truly marginal effectiveness of SSRI's get real acknowledgement.

I don't believe everything Robert Whitaker says about skyrocketing disability; but his broad point makes sense when you look at the two WHO longitudinal studies, or the Lapland Open Dialogue model with first-time psychosis, or the Soteria experience. Even if you cut Whitaker's disability figures by 80%, there still is little to support biopsychiatry's claims of "breakthroughs." Take each piece of the puzzle - RCT's paid for and controlled by Pharma, the ghost writing and publication bias, the FDA approval process based on the same RCT's, Pharma's $60 billion/year promotial budget and academic psychiatry's dependence on Pharma's $40 billion for "research." Whitaker has it substantially right.

John said...

I will briefly outline my experience in New Zealand and India. - I am a software developer and developed some paranoid thoughts and so stayed away from work for 3 years. So my family took me to a psych hospital where I was incarcerated for 3 months on a staple of Zolpidem,haldol,resperdal and a variety of other drugs.
Back in NZ I found myself so week I could barely walk 400 meters.After the zolpidem I could hardly sleep for months.The psychiatrists in NZ instead of helping me put me on Risperdal which made me hyper salivate and generally feel sick.Life became so intolerable I tried to take my life.
Following this I came under compulsory treatment and was given an overdose of olanzapine which I did not need.Currently even though I am long cured of my paranoia , the psychiatrists would have none of it and keeps drugging be by force(20mg olanzapine and 10 mg abilify).
I am in a truly helpless situation because the judges always accept the psychiatrists point of view.Honestly all the psychiatrists I have come across seem to be dogmatic,inflexible and highly subjective in their diagnosis. They believe that I need to be drugged forever even though I am long cured of any paranoia- I have shown no other symptoms of schizophrenia.
Psychiatry is more than disappointing- it is dangerous.

John said...

I will briefly outline my experience in New Zealand and India. - I am a software developer and developed some paranoid thoughts and so stayed away from work for 3 years. So my family took me to a psych hospital where I was incarcerated for 3 months on a staple of Zolpidem,haldol,resperdal and a variety of other drugs.
Back in NZ I found myself so week I could barely walk 400 meters.After the zolpidem I could hardly sleep for months.The psychiatrists in NZ instead of helping me put me on Risperdal which made me hyper salivate and generally feel sick.Life became so intolerable I tried to take my life.
Following this I came under compulsory treatment and was given an overdose of olanzapine which I did not need.Currently even though I am long cured of my paranoia , the psychiatrists would have none of it and keeps drugging be by force(20mg olanzapine and 10 mg abilify).
I am in a truly helpless situation because the judges always accept the psychiatrists point of view.Honestly all the psychiatrists I have come across seem to be dogmatic,inflexible and highly subjective in their diagnosis. They believe that I need to be drugged forever even though I am long cured of any paranoia- I have shown no other symptoms of schizophrenia.
Psychiatry is more than disappointing- it is dangerous.

Anonymous said...

You sound arrogant.

Plus, I'm not much interested in reading a review of someone who didn't give a careful study of the book but only read parts of it.

Anonymous said...

Such a long winded but interesting debate. When I read Whitakers books my main concern was that he would often assert that a subgroup of patients on psychiatric medications would have worse outcomes whilst a similar group on no medications would not. However I couldn't help wondering whether he was making the mistake that the patients that were on the medications were on these because they had a more severe form of the illness. For example, it would be like stating a patient with very occluded coronary arteries on anti-coagulant medication still having a heart attack means that the patient was made worse by the treatment whereas the patient with only minor occlusions not on medications is an indicator that not being treated is better for you. I don't think he addressed this issue enough.

However, it is clear that as a society western liberal democracies have more and more access to mental health services, extending to the medication of our children, yet we are getting more mentally unwell!!! I don't think that can be ignored.

We now pathologise every human emotion and have managed to convince people that they cannot deal with the viccisitudes of life without the help of professionals and a grab bag of potent and dangerous medications. We are weakened by this reliance as individuals and as communities.

Whitaker's book is most important in this regard and the sooner we are able to realise that psychiatrists form the minority opinion in mental health the better we all may be.

Mark p.s.2 said...

"But the med use has not caused the disability."
So tell me who is going to take responsibility?
Can a person think on psychiatric drugs? No. Volunteers took medicine.
Then you, the drug dealer and judge say it was no ones fault. Nice way to absolve yourself.

Maggie Maguire said...

I am really interested if anyone else noticed the contradictions between the figures proving the "epidemic".

On page 6 in the chapter titled A Modern Plague he notes that in 1955 there were 566,000 people in state and county mental hospitals in the USA.

“However only 355,000 had a psychiatric diagnosis”. He goes on to say that in 1987 this number had grown and there were 1.25 million people in the USA receiving a disability payment because of mental illness.

He calculates this as an increase from 1 in every 468 Americans hospitalized by mental illness in 1955 to 1 in every 184 Americans on disability payments for mental health problems n 1987. Indeed if these figures are correct then there really is an epidemic.

However a bare 45 pages later he notes :
“During the war, (World War 11) psychiatrists had been charged with screening draftees for psychiatric problems and they had deemed 1.75 million American men mentally unfit for service. While many of the rejected draftees may have been feigning illness in order to avoid conscription, the numbers still told of a societal problem.”

There is only slightly more than a decade between the war years and 1955 when Whitaker notes there were only half a million people in state and county mental hospitals in the USA. If there were 1.75 million men rejected from military service during the war because of mental health problems isn’t it more likely that in 1955 there was a huge number of people, both men and women, who didn’t fess up to mental problems similar to those who are now on disability payments?

As far as the disability payments go the increasing numbers on disability after 1990 is related to the baby boomers getting older. Age is associated with increasing disability.

As the biggest proportion of those on disability are people with mental health problems naturally the mentally ill will figure in this growth.

This is certainly the case in Australia. However as far as kids on disability payments go, Whitaker is on the money in my view.

Mark Brody, MD said...

Psychiatrists have been consistently admonished about the risks drug use, particularly regular drug use to the development of mental illness. Whether it is hallucinogens causing psychosis, narcotics causing antisocial behavior, alcoholism causing liver or brain damage, marijuana causing abnormal spermatogenesis or abulia, or cocaine or amphetamines causing psychosis or mania, there is little doubt that these drugs are regarded as dangerous. As a psychiatrist myself, I have seen cases of mental illness subsequent to drug use or abuse.

However, in response to Whitaker's conclusions and those of the authors who formed the evidence base for his book, there is a tendency to object to the theory that prescription drugs can cause mental illness, too.

It is true, psychotropic drugs are not necessarily equivalent to many of the other drugs of abuse, but there is an increasing breakdown in the distinction
between drugs of abuse and psychotropic drugs, as drugs such as stimulants, benzodiazepines and prescription narcotics are increasingly being abuse.
Also, psychotropic drugs are quite distinct from each other, by group, and sometimes within groups. Benzodiazepines have little in common pharmacologically with buspirone, for example.

So it is hard not to see the defense of psychopharmaceutical agents as being a bit hypocritical, or at least inconsistent with the generally cautions attitude towards drugs, when they are not prescribed by a physician. We see the same
skepticism arise when antidepressants are prescribed by primary care physicians or psychologists seek to expand their prescribing priveleges.

Psychiatrists generally protest that all these apparently self-serving views are actually protecting patients by promoting best practices. The fact that they protect psychiatrists interests is held to be purely coincidental, and we are supposed to believe that the benefits that accrue to psychiatrists are completely irrelevant to their professional views. We have heard the same refrain about psychiatrists not being influenced by gifts, awards and other drug-company handouts.

Forgive me for being a little skeptical. Whitaker may not have got every point right, but his main point, that there is a problem that warrants attention, which is connected to the rise in psychiatric disability alongside of an every growing arsenal of supposedly ever-improving psychiatric treatments still is not refuted.