Thursday, June 30, 2011

Guest Blogger SG on How the Pharmaceutical Companies Have Damaged Psychiatry

SG put a comment on our last post on The Chapter I Wish We'd Written on Bad Psychiatrists.  With permission, I'm making part of those comments their own post.  I gotta tell you, SG, we shrinks aren't so happy about these issues either.

Per SG:

I don't think the issue is so much a few bad shrinks but bad psychiatry. What I object to most is the pervasive compromising of science by pharmaceutical companies and all-out advertising.

This toxic influence is so pervasive that one comes to the forlorn conclusion that evidence-based medicine as it is currently practiced is really just a way for pharmaceutical companies to generate new revenue streams. The companies are so savvy they realized if they own the evidence through biased studies and suppressed trial data (failed studies, nasty side effects), they would have physicians eating out of their hands and prescribing their pills for whatever they wanted. I really think this dynamic is similar to state ownership of the media by totalitarian regimes.

Of course this is endemic in all of medicine, but psychiatry is uniquely vulnerable to this phenomenon because it has become so rigorously based on medical therapy (read: pills) since the DSM III ushered in the new "biologically based" model of mental health.

I refer the posters on this thread to the 1boring old man website in which a retired psychiatrist has been relentlessly examining internal emails between pharma execs, presentations by prominent psychiatrists like Madhukar Trivedi, seriously compromised studies like STAR-D, and various political infighting between powerful psychiatrists.

It's all very vertiginous and one comes away with the conclusion that the last 30 years of psychiatric "breakthroughs" are largely built on sand.
 

I think it is imperative that psychiatry look at ALL the evidence in evidence-based medicine, even if it provokes cognitive dissonance.

We must remember this about evidence-based medicine: it works on paper, but when you factor in human bias, fear, greed, and stubborn attitudes, you could have the most air-tight science (or evidence) in the world, but if it doesn't tell us what we want to hear, then the medical community automatically thinks it's flawed. How is that true evidence-based medicine?

It's time for psychiatry to come to some harsh truths and own up to them so ALL psychiatrists, even the good ones (and yes there are some good ones!) can practice at a higher standard. Even if a psychiatrist does everything right these days, I know they could do far better if they had a more honest and transparent evidence base to draw on.

46 comments:

Discover and Recover said...

Charles Whitfield, M.D. goes as far as to call psychiatric drugs 'Agents of Trauma' -

http://nhne-pulse.org/wp-content/uploads/2010/12/Psychiatric_Drugs_As_Agents_of_Trauma_JRS508.pdf

He's not alone in his concern... He's joined by other voices of dissent, to include, Peter Breggin, M.D., Marcia Angell, M.D., Grace Jackson, M.D., Joanna Moncrieff, M.D., Karen Effrem, M.D., Gary Kohls, M.D., Mary Ann Block, D.O., David Healy, M.D.

I think the days of conventional psychiatry are numbered... In fact, in many ways, I think psychiatry (as practiced today) is dead.

I see no way that your profession will ever regain a decent reputation until their is reconcilliation, and a committment to change directions... a paradigm shift unlike any known in the history of medicine... Short of that, it's over for you folks.

I'm tired of the spitting matches.
As far as comments back to readers (a few of whom 'hate' me)...
I choose to sit on my hands.

Duane Sherry, M.S.
discoverandrecover.wordpress.com

Shrink2B said...

Do you think funnel plots are helpful? I know they are supposed to show whether studies have been unpublished and the likely bias in evidence, but I've never seen a study examining the accuracy of funnel plots. I have seen many medication studies put into funnel plots only to discover there are likely many studies missing.

Anonymous said...

I feel absolutely betrayed especially after I found out my doc got over $100,000 from drug companies while prescribing me the meds that were destroying my life thru behavioral problems and (probably) akathisia, for years. I am absolutely unwilling to ever try psychiatric medication again, except maybe lithium should I get severe mania again. It is interesting my depressions became chronic during treatment, wheras before I was normal much of the time. Did the meds do that too? No way to know, but I think there is a good chance. I went thru all that hell with med side effects for NOTHING. Most of these drugs were not effective in bipolar, but rather, drug company scams. Not to mention the thousands of dollars I shelled out for garbage pills. And then I see these Abilify and Seroquel ads targeted towards people who don't have severe mental illness. Thank God I didn't get diagnosed as a child.

SG said...

First off, thank you Dinah for this opportunity to talk about widespread pharmaceutical company corruption and its implications for psychiatry. I hope this is the start of a diplomatic dialogue between everyone on all sides of psychiatry.

To wit: I'd like to begin by mentioning Martin Luther King's "I have a dream" speech which I think has startling resonance for the current situation in psychiatry.

Many forget King wasn't just speaking to embattled blacks. He was speaking to ALL Americans. He was savvy enough to realize America thrives on a uniquely rich mix of cultures and viewpoints. I think this is true for psychiatry as well: the solution will thrive on the realization that everyone on the psychiatric spectrum has something important to say.

He begins his speech by positioning himself as the spiritual offspring of Abraham Lincoln, as he seeks to complete the great President's work of emancipating the slaves (he does this explicitly by riffing off the Emancipation Proclamation's famous opening line). Full equality for blacks was King's goal, but he was insightful enough to realize that white America had something to offer too and his idea of equality for all was entirely in keeping with the forefathers' intentions. I similarly believe that mainstream psychiatry DOES have items of value for patients, but just as in the White America of King's time, it could be doing a hell of a lot better job and could be much more honest in its intentions.

More and more I feel the push for ethical medical treatment and objective science in medicine is the civil rights issue of our times. I fully believe it's no exaggeration that patients who must bear the devastating stamp of tardive dyskinesia simply because they couldn't taper off their antipsychotics (or weren't warned of the possibility of TD) or those tragic young men and women who may have permanently lost their sexual functioning and emotional response because they weren't told of this risk when going on SSRIs have similarly been, in King's words, "seared in the flames of withering injustice."

I do not call upon King's words in illusions of grandiosity, but simply to prove that horrendous human injustice and crimes against humanity are as alive and well now as they were in any other era. The longer medicine ignores this, the longer the suffering will continue.

Similarly, I consider the drugging of children (from infancy to young adulthood) with poorly understood drugs manufactured from an unholy birth of corruption and bottomless greed to be nothing less than my generation's Vietnam. Our nation's children's lives -- and their very quality of life -- are being lost to something more mundane but no less tragic than a shelled battlefield: a medical paradigm rotting from the inside from greed and, most dangerously, the cowardice and ignorance to stop it.

If this paradigm of "care" continues, children will come of age unable to feel the giddy rush of first love or the life-affirming radiance of sexual and emotional intimacy, or indeed any deep emotions at all. Are we cutting children's spirits off at the legs before they even learn to walk?

To be continued...

SG said...

...and now, the second part of my post:

It's an almost unfathomably horrifying prospect, but it's on the horizon. In fact, I'll include in my next post links to two youtube videos of what the future could look like if this medical paradigm continues. One is of a young man who has permanently lost his sexual functioning after withdrawing from an SSRI and must resort to injecting his penis every time he wants to be sexually active. Another video is of a young man wracked with myoclonic jerks after having an adverse reaction to a psychiatric medication. Videos such as these go a long way in supporting Whitfield's article that psychiatric meds can indeed be agents of trauma in some cases. Seemingly permanent loss of sexual functioning and akathisia and myoclonic jerks such as those seen in the video aren't side effects. It's trauma in the raw.

But I also think a child's inability to feel despair is equally devastating. I am of the school of thought that depression -- even its most oily-black cousin, suicidal depression -- can be useful or else it wouldn't have stubbornly endured for so long in humanity's history. It takes style and courage -- two things we have lost a taste for in this society -- to see it as a hidden blessing and warning that something is very wrong in one's life.

If anything, this overmedicated society has dammed (damned?) one of humanity's most lustrous wellsprings: uncertainty. A poly-drugged existence is one bereft of life's sweet surprises and, yes, tragedies that are later seen as blessings and sources of growth. In my advancing years I've come to the conclusion that one's tolerance of uncertainty is a far truer measure of a person's worth than IQ or capacity for happiness. Uncertainty and an understanding of life's pointless, chaotic nature allows for limitless ways to grow, a sharp contrast from the easy solution of a "pill for every ill."

Easy solutions are killing us and are putting our souls to sleep. But here's the point: being anti-psychiatry is an easy solution too. And so is being pro-psychiatry. The hard work begins when we realize this and try to put aside our razor-toothed biases and try to meet in the middle while still giving the mainstream model of care (and big pharma) hell.

I think this realization helps answer the question we all need to ask these days: what makes us UNIQUELY human? Is it to follow the status quo like any pack animal, or to face our cognitive dissonance head on and dissolve our once-cherished values and rebuild them anew to solve our current problems?

What initially made America great was this controlled chaos of a historically unprecedented mix of disparate cultures and values which forced people (especially in densely populated cities like NYC) to challenge their beliefs and to forge unique solutions to problems. Unfortunately what has recently catapulted America to superpower status is not this exhilarating, chaotic flux of cultures, but instead something to not be proud about in the least: the triumph of a single narrative of corruption and sleazy salesmanship on a global scale.

To be continued...

SG said...

...the third part of my post:

And of course, for this reason (and our insatiable lust for easy answers to complex problems), the bio-medical model of psychiatry couldn't have arrived -- and flourished -- at a better time or place. We were ripe for easy answers and the pursuit of pleasure and relief at all costs, even if it meant losing what it meant to be human. And that is precisely what's happening to the nation's youth in increasing numbers. College psych clinics are overwhelmed with record numbers of students on meds, and I'd bet that at least 10% of college students are losing their relationships to medication side effects in what is supposed to be the "the best four years of their lives" (see the PSSD video below for what is no doubt happening to some college-age men).

We've been enraptured by technology and science steadily since the Enlightenment, and now it's become decadent. Many academic scientists have become all-too-willing to become, in Nietzsche's words, "scholarly oxen", slavishly serving the illusion of "limitless progress" of science such as looking for genetic precursors for depression and chemical explanations for mental illness with all the sophistication of a six-year-old on an easter egg hunt. I'm not saying science is the boogeyman or that scientific progress isn't important. It is. What I object to is the childish monomania which quickly (and inevitably) leads to corruption and bottomless greed. I also object to the current implicit assumption in science and medicine that life as it is isn't good enough, and that even the slightest discomfort is downright evil and must be banished. This belief in particular, I believe, which appeals to our most reprehensible instincts of fear, laziness, and selfishness, is what has fueled the widespread acceptance of psychiatry in the last 30 years, and I think when the dust settles and we take a long, hard, unbiased look at the aggregate outcomes we'll realize how much trouble we've created for ourselves with such poisonous, inhuman beliefs.

To sum up: sometimes the most heroic and life-affirming thing to do is make do with the present moment, no matter how painful. After all, the present moment is all we have. Remarkable how easily such common sense flies out the window in light of the Svengali-like grip of technology and "progress."

To be continued...

LINKS:

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

Akathisia Youtube video: http://www.youtube.com/watch?v=svoDpICEnsg

Anonymous said...

Dinah,

I wanted to thank you for this blog entry. I know it is tough to post about the negatives in your profession. Personally, I would have a hard time doing that.

However, this is a discussion we need to have as painful as it is.

SG, you said,

""Easy solutions are killing us and are putting our souls to sleep. But here's the point: being anti-psychiatry is an easy solution too. And so is being pro-psychiatry. The hard work begins when we realize this and try to put aside our razor-toothed biases and try to meet in the middle while still giving the mainstream model of care (and big pharma) hell.""

You have made many outstanding points but I think the above exert wins the award on this blog for the best comment.

I hope when things get heated on this blog, that we all can remember this particular point

AA

SG said...

the fourth and final part of my post:

I urge the posters here to watch, of all things, the music video for Ice Cube's (!) song "wicked," which was Cube's incendiary call to arms after the Rodney King riots.

I request this for a couple reasons. One is that the amazingly palpable sense of anger, frustration and betrayal rings very true with how a lot of psych patients feel about their "treatment" (I certainly feel this way at times) and how their voices haven't been heard, much like the black cries about the corruption of the LAPD and the old saying that "it's not a problem until it's a problem for middle white America." Its righteous outrage is eternally instructive, like all great art, and its savvy reversal of culturally-loaded imagery (such as the cop getting firehosed and beaten by an anonymous attacker in a Reagan mask, which is an explosive comment on the firehosing of blacks in the civil rights era) packs one hell of a punch. I must tell you I've fantasized about turning the hose on that psychiatrist who dosed me at age 14, and I'm sure many other psych patients feel the same way. And we have every right to feel that way. I often ask myself how far away a "Rodney King" moment is for psychiatry, where the boiling discontent reaches a flash-point. There is currently a Swiss study (http://www.ncbi.nlm.nih.gov/pubmed/20018455) that hypothesizes that the use of SSRIs in pregnant women may at least partially account for the explosive rise in autistic spectrum disorders in children. IF (and of course that's a big IF) this turns out to be true, it could be the Rodney King moment for psychiatry.

The other reason I mention this video is I wouldn't have even begun listening to hardcore rap like this if it weren't for my newfound appreciation for the struggles of African-Americans who are no strangers to the tremendous pain and sense of betrayal that I now feel, courtesy of psychiatry. I should also mention that even though I have been to some very dark places thinking about the future of my sex/love life and if I'll get a full return of my emotions, that very despair has helped me grow and come to appreciate another culture's suffering (that is, the suffering of African Americans) and has enriched me. I hope this is proof that it is indeed possible to turn searing emotional pain into something enriching and that such emotions are far from useless and not always in need of drugging.

In conclusion, I have this to say to psychiatry: you have the permission to be wrong as everybody does, but NOT to continue practicing knowing you're wrong and the literature is tainted. That is a clear violation of "do no harm" and this toxic tomfoolery has been going on for far too long. If you don’t look at the corruption and seek to end it and heal the innocent lives that have been devastated by it, you will be no better than the jury who acquit the cops who brutally beat Rodney King all while being video taped. I think as long as we realize the cultural failings I have outlined and the scientific failings Whitaker has outlined in Anatomy of an Epidemic, we may just have a shot at a better medical paradigm of care for everyone. Medicine has a long climb to regain its credibility, but the journey of 1000 steps begins with one step. This is not empty rhetoric ticked off a teleprompter, but comes with the full backing of successful revolutions that are as old as humans.

Once again, thanks to Dinah for this opportunity for me to express my opinions!

Ice Cube "Wicked" Video: http://www.youtube.com/watch?v=4HmvRqJArxY

Sideways Shrink said...

Part 1
I have only been doing for 10 years now and half that time was with the severely mentally ill. But my response to SG and to this post is: what the hell are shrinks prescribing to their patients? I joke with my patients that "I push for full symptom remission" but that is predicated on the premise that the side effects of medication are relatively minimal.
I never practiced in the era of haldol, prolixen, tri-cyclics, MAO-Is, low dose speed in the morning for treatment resistant depression. Then there was twice daily valium for anxiety. Or, better yet, I have heard and seen on a geripsych unit, xanax 4 times a day for panic. As I understand it, haldol and prolixen and that class caused gob stopping tardive dyskinesia. (In training I was taught they initially thought TD was a schizophrenic acting out so they would up the dose to make the TD go away. Think of a field of medicine without some ugly, ugly stories. I almost became a nurse.) Long before I met her my best friend's mother committed suicide in 1988 with a month's supply of a tri-cyclic given to her after a month's stay in a psychiatric hospital. The speed for depression speaks for itself. Benzos for anxiety are a recipe for either chronic addiction and/or the constant rebounding that is the hell of qid xanax use. I think those were the bad old days of psychiatry. Those techniques/medications are not used now.
I am not defending the corporate whores in Big Pharma. Whoever, SG is, I am guessing he or she is old enough to remember when those drugs were the only options--unless SG is not a prescriber but simply has a love for the work of Dr. King that might bespeak that age.
The only reason patients made it out of that alive was that the middle class patients who got treatment also got therapy and were closely monitored.

Sideways Shrink said...

Part 2
My patients simply do not suffer (for very long) like the descriptions I read about because I tell them every possible side effect that could happen and what to do and how to reach me if it does. I also do not give out drugs if I can not predict the likely side effects at any given dose. I have mitigation strategies for side effects that patients will be sent home with for PRN usage depending on the likelihood of the side effect and the risk/benefit WITH FULL PATIENT KNOWLEDGE.
"Conventional psychiatry" is dead in the hands of a generation trying to maintain a $200,000.00 a year salary. Current reimbursement structures invite those psychiatrists sell their ethics practice out. But the real death of "conventional psychiatry" (whatever that means) will come with the retirement of that generation, when the demographics show that there are few shrinks coming up behind them in all English speaking countries to replace them.
(Also I really think that besides the abysmal reimbursement, etc. the way to ensure that the best and brightest young medical minds pursue this new, more rigorous evidence based medicine is to join the chorus of what lame asses shrinks all are....)
I believe the real civil rights issue at hand is systemic: it was Reagan's defunding of the community mental health system which was created to provide treatment, housing, job training for those de-institutionalized in the 70's. These people had nowhere to go and with the returning Vietnam Veterans became those who were called the "homeless" in the 80's. That is the real civil rights issue at hand. In this bigger picture, there is a platform in which to defend the rights of children and the chronically mentally ill. One by one, each patient gets lost in an anecdotal tirade blaming shrinks for being greedy or incompetent or gullible or numbing people with pills versus torturing them with the side effects of terrible pills.
I honestly appreciate your post, SG. I do not like the ethics of psychiatry as currently practiced and despise the Pharma system, but we need to look for solutions we can control. I do not have much hope for changing the practice of entrenched psychiatrists rounding the last lap toward retirement. We need to work on legislation at the state level, working within our local and state professional organizations, forming nonprofits to provide care to patients and education to providers. Therein lies the future of change.

rob lindeman said...

SG should be congratulated for a thoughtful post.

When we arrive at places such as where we are now with psychiatric drugs, it's useful to re-examine our premises. In other words, before we evaluate benefits and harms of drugs we prescribe, we ought to ask first, what are we treating? and do we need a drug to treat it?

Until we get a fix on the pathophysiology of mental illnesses, we attempt to treat them with drugs at our peril.

wv = shrai. Three, in Sanskrit

Dinah said...

There was nothing difficult about posting this. It condemns unethical practices by the drug companies and by select psychiatrists who chose to participate with such practices.

The Shrink Rappers have no ties to pharmaceutical company, though I still enjoy serving my friends coffee in a Prozac mug and I sometimes use the old sticky pads.

ClinkShrink said...

The only pharmaceutical reps I see are the ones who get caught.

Sideways Shrink said...

Rob
I am so happy for you that it appears that you never suffered from severe mental illness or had a family member who has. You are fortunate. No one comes to me because they have nothing else to do, because they are bored, or even because it rains or is utterly sunless 320 days a year here in Seattle. Stigma aside, no one wants to go to a shrink of any kind and say they don't understand their feelings or they feel out of control. I avoid going for physicals! No one wants to go to the doctor. So, if you weren't in serious pain, why would you return again and again to a shrink? Think it out. Really, I ask you to pause over this suggestion that somehow we shrinks lure or trick people into treatment they don't need. That fits in with your "no involuntary commitment at any cost" philosophy because those people are, according to your many posts being unnecessarily treated.
Why would such a variety of people: a lawyer, several computer programers, a judge, 2 fellow physicians, several artists, several disabled people due to mental illness, some academics at the U, some stay at home parents, several retail clerks all come to see me if they did not need to? They are not bored, stupid, weak, deluded. They have weathered many difficulties in life. They are not therapy lifers, per se.
I think maybe you should form a blog and post on KevinMD as a specialist/educator on the dangers of psychiatry. Why would I go to a site for pediatricians and argue against routine vaccinations because "they cause autism" over and over again? Would that help or persuade the pediatricians at that site?
It convolutes the discussion of everyone here, especially the people with the most skin in the game: the "patients" who post here who are concerned about their treatment experiences or their need for treatment. In my training I "had to" undergo psychoanalysis--so I am one of the patients of whom I speak. The last thing a person in the middle of a personal process needs to hear is someone grinding a seemingly purely intellectual ax about psychiatry when they have never disclosed anything about their own personal reasons for what drives their opposition to psychiatry.
Who said it? Was it actually Bob Marley? That means it's Friday. "You can fool some people sometimes, but you can't fool all the people all the time." If you ere more forthcoming about your own personal feelings or experiences with psychiatry others who are in this funny, cool community would probbaly be more receptive to what you have to say.

SG said...

Everyone -

It brings me a lot of (tentative) hope to hear what's being said here, especially among the shrinks. After reading these posts I had a daydream of everyone on the psychiatric spectrum -- psychiatrists of all ages, patients of all ages, journalists like Robert Whitaker, mental health bloggers, and others -- coming together in a symposium for a reasoned yet passionate discussion where everyone had a say and knee-jerk reactions and shouting matches were set aside in lieu of a discussion about maximizing patient outcomes and righting the wrongs of a paradigm of care contaminated by profit-driven incentives.

I can see this happening because it IS happening. Such discussions have already begun at The Foundation for Excellence in Mental Health Care, a nonprofit founded for the purpose to do what psychiatry (and a lot of medicine in general) should have been doing all along: discussing patient care paradigms that are based on good, unbiased science and constructing a standard of care that's based on positive patient outcomes, not profit. I've included a link below to its mission statement and a summary of its activity to date.

But for such a project to succeed, a seismic re-conceptualizing of psychiatry must occur. I agree with Sideways that the real death of status quo psychiatry will be with the retirement of the boomer psychiatrists. I see this as a good thing because it means the end of psychiatry as we know it.

CAREFUL! I used the words "as we know it" carefully, to mean that psychiatry can be reconfigured into something even better, something more effective, with even better patient outcomes, not the total end of psychiatry as a profession. It's common sociological knowledge that many deep-seated cultural and professional mores churn over with generational replacement. As a new generation of psychiatrists come of age in the next decade, we as a society are at the cusp of something very exciting, where new, younger minds can inject psychiatry with much-needed revolutionary views. They could do this by starting more non-profits, starting psychiatric medication withdrawal clinics (there will be no shortage of patients there!), or devising ways to fight big pharma.

I was disappointed, though, with Sideways' dismissal of Rob's views. I think Rob cares just as much about patients as Sideways, and his questions ("before we evaluate benefits and harms of drugs we prescribe, we ought to ask first, what are we treating? and do we need a drug to treat it?) are fair, aren't they? And his statement, "Until we get a fix on the pathophysiology of mental illnesses, we attempt to treat them with drugs at our peril" gets to the crux of the issue, does it not? I don't even think psychiatry would deny the pathophys of mental illnesses is still largely a mystery, and it's only common sense that to drug patients for a symptomology we can't explain (WITH a drug whose mechanism we can't explain and was "safety tested" by corrupt pharmaceutical companies) is far from ideal, and can open up a lot of potentially harmful possibilities for the patient. These are the very questions and issues central to the Foundation for Excellence in Mental Health Care's cause.

But I'm not disappointed in Sideways as a PERSON. When I become aware of my own bias and look closer, I see a young medical professional who truly does care about the suffering of his patients. He also makes excellent points about painful lessons learned about past abuses of meds like Haldol, Prolixen and Xanax. I'd like to conjecture, however, that such changes of practice did not come easily, but with much gnashing of teeth between patients and professionals, such as what is occurring on this blog.

My responses continue in next post...

SG said...

My response, part II:

Speaking of Xanax, the nightmare of addiction and rebound anxiety upon withdrawal COULD have been avoided entirely if the undue influence of big pharma and their nefarious rigging of drug trials wasn't so well-entrenched and unchallenged by the medical community. To read the horrifying truth of the flagrant human rights violations inherent in the original Xanax trials by Upjohn, see Whitaker's Anatomy of an Epidemic, 295-299.

I cite Xanax for the simple fact that IF we hadn't allowed drug companies to get away with this in the first place, so much suffering of patients could have been prevented, and it's likely we wouldn't have had to learn the hard way about benzos and perhaps other drugs like Haldol, MAOIs, etc.

Part of the problem with the "bad old days" argument that Sideways mentions is the implicit assumption that things have changed dramatically for the better in psychiatry and that the source of rot -- corruption -- has withered. Considering the devastating side effects of the atypicals (diabetes, TD, brain shrinkage upwards of 1% a year), the reckless drugging of children for bipolar disorder largely based on Biederman's cult of personality (and might I mention the man is compensated to the hilt by drug companies), and emerging literature on persistent sexual dysfunction and emotional anhedonia from the SSRIs, I can't accept that argument completely. The source of rot (corruption) is still very much alive and well, and one would have to be a complete fool to think that we'll get different results this time around by doing the same thing (that is, not exposing corruption and pushing for a culture of unbiased, transparent science in medicine).

We need to do that most painful thing, which is to admit to ourselves that the bad old days have, at least in some cases, become the bad new days. Only the problems (juvenile diabetes caused by the explosion of childhood bipolar and its medication, persistent SSRI sexual dysfunction, antipsychotic-induced brain shrinkage upwards of 1% a year) look different, but the SOURCE of the problems (industry corruption) is all the same.

And yet, something potentially wonderful is happening. The pharma companies are now engaging in a mass exodus from psychiatry. Now let's not BS ourselves here. They're not leaving psychiatry because they're swell folks. They're leaving because they won. They achieved their goal of saturating the psych market and decided it wasn't in their profit margin to spend real money on R&D to develop a truly novel class of drugs. They realized they couldn't roll out any more me-too patent extending drugs like Pristiq because, after all, molecules can only be tweaked so much. They won and psychiatry (and its patients) lost, left out in the cold like some ripped-off chumps.

I say this is potentially wonderful because it opens the possibility for psychiatry to reclaim its full therapeutic potential and explore new avenues of care such as the Open Dialog therapy of Finland that has had some very promising results for schizophrenic patients. What's most amazing about the therapy is its TASTEFUL use of medication in close conjunction with talk therapy. It's obviously more complex than my quick synopsis, and I encourage everyone to read the full overview of it in Whitaker's Anatomy of an Epidemic, pp 336-344. And a possible spoiler: the open dialog therapists don't completely dispense of psychiatry! Gasp!

So in the coming years, as big pharma recedes from psychiatry, it will be up to psychiatry to either continue to fervently embrace medication or to adopt a more open-minded and holistic approach to mental wellness, backed by unbiased science. I think the only precedent for this situation was back when the DSM III was about to come out, and we all know the can of worms that opened. Let's not blow it this time around, people.

SG said...

Huh. Seems the posting mechanism is getting goofy again. It didn't post the first part of my response, but it posted my second one!

Here's the first part. Read this first!

Everyone -

It brings me a lot of (tentative) hope to hear what's being said here, especially among the shrinks. After reading these posts I had a daydream of everyone on the psychiatric spectrum -- psychiatrists of all ages, patients of all ages, journalists like Robert Whitaker, mental health bloggers, and others -- coming together in a symposium for a reasoned yet passionate discussion where everyone had a say and knee-jerk reactions and shouting matches were set aside in lieu of a discussion about maximizing patient outcomes and righting the wrongs of a paradigm of care contaminated by profit-driven incentives.

I can see this happening because it IS happening. Such discussions have already begun at The Foundation for Excellence in Mental Health Care, a nonprofit founded for the purpose to do what psychiatry (and a lot of medicine in general) should have been doing all along: discussing patient care paradigms that are based on good, unbiased science and constructing a standard of care that's based on positive patient outcomes, not profit. I've included a link below to its mission statement and a summary of its activity to date.

But for such a project to succeed, a seismic re-conceptualizing of psychiatry must occur. I agree with Sideways that the real death of status quo psychiatry will be with the retirement of the boomer psychiatrists. I see this as a good thing because it means the end of psychiatry as we know it.

CAREFUL! I used the words "as we know it" carefully, to mean that psychiatry can be reconfigured into something even better, something more effective, with even better patient outcomes, not the total end of psychiatry as a profession. It's common sociological knowledge that many deep-seated cultural and professional mores churn over with generational replacement. As a new generation of psychiatrists come of age in the next decade, we as a society are at the cusp of something very exciting, where new, younger minds can inject psychiatry with much-needed revolutionary views. They could do this by starting more non-profits, starting psychiatric medication withdrawal clinics (there will be no shortage of patients there!), or devising ways to fight big pharma.

I was disappointed, though, with Sideways' dismissal of Rob's views. I think Rob cares just as much about patients as Sideways, and his questions ("before we evaluate benefits and harms of drugs we prescribe, we ought to ask first, what are we treating? and do we need a drug to treat it?) are fair, aren't they? And his statement, "Until we get a fix on the pathophysiology of mental illnesses, we attempt to treat them with drugs at our peril" gets to the crux of the issue, does it not? I don't even think psychiatry would deny the pathophys of mental illnesses is still largely a mystery, and it's only common sense that to drug patients for a symptomology we can't explain (WITH a drug whose mechanism we can't explain and was "safety tested" by corrupt pharmaceutical companies) is far from ideal, and can open up a lot of potentially harmful possibilities for the patient. These are the very questions and issues central to the Foundation for Excellence in Mental Health Care's cause.

But I'm not disappointed in Sideways as a PERSON. When I become aware of my own bias and look closer, I see a young medical professional who truly does care about the suffering of his patients. He also makes excellent points about painful lessons learned about past abuses of meds like Haldol, Prolixen and Xanax. I'd like to conjecture, however, that such changes of practice did not come easily, but with much gnashing of teeth between patients and professionals, such as what is occurring on this blog.

My responses continue in next post...

Anonymous said...

Robert Whitaker put up a good post yesterday on his blog concerning some of the long term problems resulting from use of SSRI's, as well as about how Pharma cooked the trials.

http://www.madinamerica.com

Sideways Shrink said...

SG
Do you agree with the idea that a fundamental problem for the mentally ill in the US is not just bad medications, but a lack of wrap around services: case management, housing, sheltered workplaces, private insurance that pays for couples and family therapy as well as individual therapy that pays sustainable rates?
To hold the position that "the problem" is bad medications is to be, ironically, pro-psychiatry of some biological variety that may never come to fruition. This biological notion of psychiatry, one could argue has not been able to be achieved due to profit motives of Pharma etc. But, look at neurology: many neurological conditions can not be treated without horrific side effects. Pharma certainly influences medical neurology but we can not think that better medications alone will necessarily prove magical for our patients.
I agree that Pharma is slowly retrenching from psychiatry--particularly in this down economy. Their patents are expiring, they are firing their drug reps and they are departing. New research will continue to be done by universities (as most of it has been all along) who might actually keep their own patents on the drugs their research develops. Or am I really a pie-eyed optimist? It is Friday!! Happy Independance Day!

SG said...

Sideways,

You bring up some excellent points.

Yes, I heartily agree with you that the lack of insurance coverage for wrap-around services is a big deal for patients AND doctors. As one doctor told me recently, "We do what we can with what little we have." Many patients don't understand just how strapped many doctors are by pitiful reimbursement rates that give them an incentive to jam as many patients into their day as possible to not just maximize their take-home $, but also to get out from under student loans (you know, like to the tune of $300k!). The rise of HMOs and "managed care" has spread the misery around far and wide, and not just among patients. I truly feel for you guys, as you're in one hell of a bind. As one doctor said to me, "If I'd known what I know now about medicine, I wouldn't have gone to med school."

However, I was focusing on medications on this thread because the thread topic is explicitly about pharma companies and their corruption of psychiatry. The topic of insurance, reimbursement, etc is a worthy topic, however, and I think it plays a large role in the abuse of psych meds by good psychiatrists who feel boxed in by plummeting reimbursement rates, and bad psychiatrists who realize they can game the system by jamming in as many patients as possible in an hour with 15-minute med checks (see the NYT article, "Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy").

BUT, even with all this being said, the fact remains that the meds being used today in psychiatry were developed under far less-than-perfect circumstances where corruption ran wild. Even if insurance was overhauled and more people were supported with talk therapy instead of drugs or drugs were used more responsibly, it is still the ethical duty of medicine to learn the TRUTH about what these drugs truly do to the brain and what the long-term effects are.

I also must respectfully disagree with your belief that pharma may, at least in part, be retrenching from psychiatry because of a down economy. I can tell you I've read a lot about the economic downturn and one finding that is remarkably consistent is that corporations are doing just fine. They are still raking in the dough. They just don't invest that money in their workers like they used to.

Pharma is pulling out of psychiatry because they realized they've come to the end of the road in this field of medicine and no new revenue streams can be created because the public is starting to get wise to their pseudoscience (chemical imbalances, "broken brains," depression as a disease, etc) and all-out lies and the only way to still make money in psychiatry is to develop drugs that truly work and are based on real science. Their actions speak louder than words -- they're leaving. Whitaker explores this issue here: (http://madinamerica.com/madinamerica.com/Whitaker.html) - scroll down, the post is titled, "Drug Companies Just Say 'No' To Psych Drugs"

To be continued...

SG said...

Sideways,

You bring up some excellent points.

Yes, I heartily agree with you that the lack of insurance coverage for wrap-around services is a big deal for patients AND doctors. As one doctor told me recently, "We do what we can with what little we have." Many patients don't understand just how strapped many doctors are by pitiful reimbursement rates that give them an incentive to jam as many patients into their day as possible to not just maximize their take-home $, but also to get out from under student loans (you know, like to the tune of $300k!). The rise of HMOs and "managed care" has spread the misery around far and wide, and not just among patients. I truly feel for you guys, as you're in one hell of a bind. As one doctor said to me, "If I'd known what I know now about medicine, I wouldn't have gone to med school."

However, I was focusing on medications on this thread because the thread topic is explicitly about pharma companies and their corruption of psychiatry. The topic of insurance, reimbursement, etc is a worthy topic, however, and I think it plays a large role in the abuse of psych meds by good psychiatrists who feel boxed in by plummeting reimbursement rates, and bad psychiatrists who realize they can game the system by jamming in as many patients as possible in an hour with 15-minute med checks (see the NYT article, "Talk Doesn't Pay, So Psychiatry Turns Instead to Drug Therapy").

BUT, even with all this being said, the fact remains that the meds being used today in psychiatry were developed under far less-than-perfect circumstances where corruption ran wild. Even if insurance was overhauled and more people were supported with talk therapy instead of drugs or drugs were used more responsibly, it is still the ethical duty of medicine to learn the TRUTH about what these drugs truly do to the brain and what the long-term effects are.

I also must respectfully disagree with your belief that pharma may, at least in part, be retrenching from psychiatry because of a down economy. I can tell you I've read a lot about the economic downturn and one finding that is remarkably consistent is that corporations are doing just fine. They are still raking in the dough. They just don't invest that money in their workers like they used to.

Pharma is pulling out of psychiatry because they realized they've come to the end of the road in this field of medicine and no new revenue streams can be created because the public is starting to get wise to their pseudoscience (chemical imbalances, "broken brains," depression as a disease, etc) and all-out lies and the only way to still make money in psychiatry is to develop drugs that truly work and are based on real science. Their actions speak louder than words -- they're leaving. Whitaker explores this issue here: (http://madinamerica.com/madinamerica.com/Whitaker.html) - scroll down, the post is titled, "Drug Companies Just Say 'No' To Psych Drugs"

To be continued...

Anonymous said...

Do you folks really think it is getting better re: meds? I don't think so. Only last year I had explained to a doctor that I couldn't handle the anticholinergic side effects of antipsychotics, and wondered if there was some new strategy we could try, and she chirped out "Try Saphris!" She didn't hear anything I said. I gave up on meds, which has been a blessing, and a few months later, read Whitaker's book, which I wish he had written it years ago. I really don't think psychiatrists in my area have changed. they get paid not to think.

SG said...

...continued:

I also don't think the profit motives of big pharma can be viewed in a vacuum. Their profit motives alone did not block "some biological variety [of psychiatry]" from coming to fruition. It was BOTH the profit motives of big pharma AND the inability of psychiatry to stand up to big pharma that ultimately made psychiatry shoot itself in the foot and fumble the ball on realizing the full potential of a biological model of psychiatry. Psychiatry chose (and still does choose, to varying extents) to believe in corrupted human citation factories like Joseph Biederman, Charles Nemeroff, Alan Schatzberg, Trivedi, etc and look the other way at outrageous pharmaceutical company tactics like ghostwritten articles. It's easy to look the other way when there's so much money in it, after all: many psychiatrists (even outstanding ones like Dan Carlat) chose to cash in by being KOLs for drug companies (see "Dr Drug Rep" NYT article: http://www.nytimes.com/2007/11/25/magazine/25memoir-t.html).

And even no less than NIMH president Tom Insel is embroiled in controversy: he's all over the Nemeroff firing/re-hiring controversy. In fact, take a look at this link (http://1boringoldman.com/index.php/2010/06/15/who-is-not-telling-the-truth-yes/), which charts the whole sad saga of Insel and Nemeroff. You'll come away realizing that pharmaceutical corruption has trickled down mightily to academia as well. Ask yourself this: are these the kind of clowns you want representing your profession? I think it's time for the good psychiatrists (and they are out there, and on this board!) to get angry and take action, like voting to throw Insel out. That would be a start.

If psychiatry, rather than journalists like Whitaker, had challenged pharma's rigged studies and insisted on real scientific evidence when these pills first came out, it's likely pharma would have done what they are doing now (that is, pulling out of psychiatry), or psychiatry would have at least looked very different. But the fact is psychiatry has enabled big pharma to achieve its financial goals beyond its wildest dreams and even exhaust them, as it has now. And as with all power grabs, it's the guys lowest on the totem pole (here, it's patients and good psychiatrists) who are the losers.

I'm not saying that even in the best circumstances perfect pills would be invented, but that at least harm would be greatly reduced and the doctrine of informed consent would truly be honored if such corruption were to stop.

Speaking of Whitaker, I'd like to thank anonymous for posting the link to his latest post in which Whitaker mentions emerging literature on "tardive dysphoria" caused by long-term SSRI use. My only caveat with the post is it is my theory, along with many in the SSRI withdrawal community, that a lot of the literature about relapse and "tardive dysphoria" has been confused with WITHDRAWAL, which may be prolonged and mistaken for a return of original symptoms. One can recover from withdrawal, even if it takes years. Irving Kirsch, author of THE EMPEROR'S NEW DRUGS, is now aware of this fact and its implications on the statistics and studies.

Anonymous said...

I just want to say that I have had a good experience with psychiatry and with the meds.

Sideways Shrink said...

I continue to direct the conversation back to neurology. There are very few "slam dunks" in the treatment of any neurological conditions--ineffective, horrible side effects, looming specter of hellish depression to treat your MS, which many people might find in and of itself a looming specter.
I know I sound like an apologist for the pharmaceutical industry, but it is really that I do not feel (even having had my own experience as a patient) that I harm my patient as seems to be the theme THAT WON'T STOP ON SHRINK RAP lately. My patients are not debilitated. They are not so struck by transference that they can't see straight. They would vote with their feet if the medication. All this is just to say that even if my perceptions were self serving or deluded (I have met those colleagues), the body count in my therapy practice can't be that off.
Dinah, Clink and Roy, I respect that you are letting the hostile opposition have its say on your blog. It shows a lot of "Je ne ce quoi". I don't speak French. But it makes me feel a lot of ennui. There are other doc blogs where psychiatry is slammed all the time: either we don't know pharmacology at all or we are just pill pushers. Whatever. I didn't go into psychiatry to be admired among my peers. I wasn't a cheer leader either. But the point here is to discuss, say, in detail, the latest finding on a certain psychiatric medication or psychotherapeutic technique or, I loved the discussion on what to do when patients won't pay!
Hell, next I propose we discuss exit strategies out of psychiatry--like all the internists are doing. (NOTE THE SARCASM) But with all the excoriation, perhaps all psychiatry is dead and we would serve the public better if we huddled and discussed what other medical fields we should go into to spare people from psychiatry. OK, never mind. Bob Marley would not like that attitude. It is not mellow.

Sunny CA said...

I think that psychiatrists are not capable of solving the influence-peddling of pharmaceutical companies. We need federal laws that prohibit prescribing doctors from accepting payments from drug companies and we need federal legislation that requires the public release of data from all studies done on all pharmaceuticals (not just psychiatric medications). I believe all doctors, including psychiatrists, do their best to determine which medications work and what the possible side-effects are, but they are hampered by the drug company desire to deceive. The government must step in. Doctors can't stop it.

There is an interesting 2-part-article in New York Review of Books which discusses books that probe this issue:

http://www.nybooks.com/articles/archives/2011/jun/23/epidemic-mental-illness-why/

http://www.nybooks.com/articles/archives/2011/jul/14/illusions-of-psychiatry/

Even if we can stop payments to physicians and the hiding of research studies by pharmaceutical companies , consider this:

"In addition to the money spent on the psychiatric profession directly, drug companies heavily support many related patient advocacy groups and educational organizations. Whitaker writes that in the first quarter of 2009 alone,

Eli Lilly gave $551,000 to NAMI [National Alliance on Mental Illness] and its local chapters, $465,000 to the National Mental Health Association, $130,000 to CHADD (an ADHD [attention deficit/hyperactivity disorder] patient-advocacy group), and $69,250 to the American Foundation for Suicide Prevention.

And that’s just one company in three months; one can imagine what the yearly total would be from all companies that make psychoactive drugs. These groups ostensibly exist to raise public awareness of psychiatric disorders, but they also have the effect of promoting the use of psychoactive drugs and influencing insurers to cover them."

Anonymous said...

I am so tired of hearing about Peter Breggin and Whitaker and the rest on this blog. For those of you who feel like I do, why don't you join me in playing sock puppet over at their blogs?

Yup, I'm going start at Breggin's blogging community. I'll be touting psychiatry over and over and over and over .... and then over and over some more. Doesn't that sound like fun!

And then at Whitaker's blog, promos for the Shrink Rap book would be a good pay-back for all the free publicity he's gotten over here.

Alison Cummins said...

Anonymous,

I too have greatly benefitted from the support of psychiatrists and psychiatry. I tried therapy alone for several years and suffered harm. My psychiatrist (now retired) offered me twenty minutes of psychotherapy however often I needed it: as often as every two weeks or as infrequently as twice a year. It was beneficial.

As I have mentioned several times on this blog over the years, meds have a HUGE advantage over psychotherapy in that if you don't like them you just stop taking them. Doctors are cool with this. If they have prescribed you something that makes you worse, they will stop prescribing it. If you don't like psychotherapy, that's simply proof that your judgement is warped and you need to continue with psychotherapy. If therapy is making you worse, psychotherapists will congratulate you on the great work you're doing and will do even more of whatever they have been doing to harm you.

I have a psychotherapist I see when things are tough, and she helps. But if I ever had to choose between my psychotherapist and my doctor, I'd go with my doctor every time.

My doctor just wants me to be well. My psychotherapist also wants me to justify her philosophy.

jesse said...
This comment has been removed by the author.
jesse said...

Sideways: Having been in this field quite a long time I do find that 1) the majority of psychiatrists are good physicians who care about helping their patients, 2) medications are used judiciously for the most part and the psychiatrists are watchful about side effects, 3) while there are certainly people on medications who might be better off of them, the psychiatrists weigh the pros and cons of their use and are properly concerned about preventing relapse, 4) we know the difference between relapse and withdrawal. 5) if anything serious in terms of mental health ever occurs to a person I know, I would recommend that he start off by seeing a good psychiatrist.

Of course there are problems in psychiatry, but as to the medications most every psychiatrist I know uses his own experience vastly more than what any pharmaceutical company says. We are in the trenches. I have seen disastrous results of patients deciding to come off their medications, thinking that they did not need them, doing OK for a while, then having a relapse even worse than their earlier episodes.

So I truly respect the comments and experiences expressed here, but in the last analysis it is much easier to make global generalizations when you don't take responsibility for the outcome.

Sideways Shrink said...

Jesse,
Thank you for that post. Despite my sarcasm, I hope you could see through my posts that I agree with you write almost completely. I think it is possibly that we may differ along generational lines: psychiatry used to be a proper "specialty" and was reimbursed to docs with no student loans as such. The playing field is different now and I see far too many psychiatrists in my area going to cash only practices once they hit 50 years old. To me this looks like avarice as they did not pay on the front end and now are willing to contribute to the lack of psychiatric provider access so they can cash in on the back end. Oh, and they don't take Medicare which they are about to cash in on....

SG and ROB

I cry foul on your shared assertion that

"before we evaluate benefits and harms of drugs we prescribe, we ought to ask first, what are we treating? and do we need a drug to treat it?) are fair, aren't they? And his statement, "Until we get a fix on the pathophysiology of mental illnesses, we attempt to treat them with drugs at our peril"

Au contraire. A lot of medical treatment is based on controlling symptomatology to preserve the body as a whole. The example of penicilin springs to mind. Before giving it to patients, research physicians new it was effective against gram positive bacteria. To this day anti-biotics are presribed for conditions to save lives though they carry serious risks of fatal medication reactions like Steven-Johnson and medication allergies without knowing exactly what bacteria is at work or why that bacteria struck that otherwise healthy person in a devastating way. Even given the serious risks and the accidental pregnancies due to poor communication between providers/pharmacists and patients, the anti-biotics are still prescribed. Despite the specter of uncertainty about pathophysiology of the illnes, the medications are prescribed and they save lives.
I am all for more government funding of non-Pharma driven research into the pathology of mental illness. But, we are not going to get it and my patients (not a one) has had a permanent side effect, died, or committed suicide or homicide under my care so I guess I will just stumble on being effective leaving the super theoretical questions to those who don't actually treat psychiatric patients. (Yeah, what Jesse said! only cruder....)

rob lindeman said...

Penicillin differs from chlopromazine in one important respect. The pathology and pathophysiology of Gram-positive bacterial infections is well understood. Koch's postulates are all satisfied and penicillin demonstrates in vitro and in vivo activity against the pathogen.

With schizophrenia we know neither the lesion we presume to treat nor the pathophysiology of the lesion. What are we treating? We don't know, though we're pretty sure it is NOT dopamine excess in dopaminergic axis.

As for harms, I'm well aware of harms in antibiotic use. That's why I use them rarely, and only when in my judgment benefits outweigh harms. At least I know I have a scientific basis for my treatment.

Wv- reintset. Yet another error message appearing immediately prior to system crash

Anonymous said...

Sideways Shrink,

First of all, I greatly appreciate your posts and how carefully you monitor side effects.

What is the average time a patient is in your care?

As an FYI, I have tinnitus which a PCP said may be permanent. It is from being on Wellbutrin XL.

I hope everyone has a good 4th.

AA

Sideways Shrink said...

ROB,
How long did it take the multiple researchers who came up with penicillin to figure those things out? Fifty plus years. Yes, the dysfunction of the dopamine receptor in schizophrenia is not the primary driver of the illness. We all know that. But the ethics of the question really come down to letting an adult patient be tortured, say, by internal voices they hear outside their heads telling him or her that they are an awful person worthy of death everyday of their lives or give them a medication that will stop the dopamine from hitting the auditory nerve and relieving that and other truly painful, unbearable symptoms? Apparently you aren't cut out for symptom remission in the face of etiologic ambiguity. That is fine fine. It is best that this is not your field. But I do suggest you start fundraising for homeless shelters, halfway houses and group homes if you really want to enact your goal of medication only in the face of complete pathophysiolgic certainty for schizophrenics.

Anonymous said...

I have a mixed opinion on the contention that psychiatrist are not forcing their patients to come to them and take their medications.

(I am not going to address forced treatment here, and I have bipolar and that's all I know about)

The trouble is that patients are told that the ONLY WAY they can be responsible people who aren't ruining the lives of all their loved ones is to take medication. We are told there is NO OTHER WAY.

Well, I love my husband and the rest of my family! I don't want to put them through hell. Therefore, NAMI and all the books about bipolar are morally compelling me to take medication, or I will be harming those whom I love and love me.

Also, patients are told that there is no other way to be well, that if you just keep trying, you WILL find a medication that helps you, etc. etc. They give this chirpy advice and then if you don't get good results, you wonder "what the hell is the matter with me?"

Then psychiatrists on various blogs (maybe not this one, not sure) state that if meds didn't work for a person, they MUST be borderline, and they were misdiagnosed. Yeah right, I have CLASSIC bipolar, and yes, lithium works on mania, but nothing works on the depression.

OK, so psychiatrists didn't MAKE me go get treatment with all those horrible pills and ECT, but it was made clear to me thru the books, groups like NAMI that I must be some kind of horrible person if I would not do this for my family because bipolar treatments are supposedly so good that most people can live a normal life.

Even if you, the doctor, have not compelled patients to come in for treatment, you are not practicing in a vacuum. I don't blame my physicians for this, it is the messages from books about bipolar and NAMI and drug companies etc.

This message that you MUST MUST MUST take meds for bipolar is EVERYWHERE. That would be great if the damned pills worked for everyone!!

Anonymous said...

Sideways Shrink writes, "But I do suggest you start fundraising for homeless shelters, halfway houses and group homes if you really want to enact your goal of medication only in the face of complete pathophysiolgic certainty for schizophrenics."

How many people with schizophrenia who are medicated don't still require halfway houses and group homes? I've been surrounded by this for years with a relative with schizophrenia. I never saw the miraculous recovery with meds, nor did I see it with any of her "peers" as they like to call them. She would be homeless, medicated or not, if my grandparents had not created a trust that ensures her rent is paid each month.

aek said...

What would happen if a treatment paradigm was introduced which flipped medications from a default first line therapy to a non-pharm primary approach in non life threatening cases? For example, using strategies to promote protective mechanisms such as intensive sleep hygiene (education &/CBT), nutrition therapy (introduction of a mildly ketotic diet and gluten free trial), introduction to yoga, tai chi and other forms of gentle exercise and mindful meditation, case management around social and work support, etc.

One theme that runs throughout patients' experiences is a lack of autonomy and control over self management. Another is lumping all people with symptoms of mental distress and disability together.

While the science is demonstrating ever more robust associations between symptoms of depression and inflammation, as has been discussed, the mechanisms underlying the signs and symptoms of the defined disorders are for the most part, unknown. This is not comforting for sufferers, let alone physicians. None of us tolerates ambiguity all that well if invested in compassionate treatment and recovery.

Which brings me to my last point: the absence of comfort, reassurance and touch in mental healthcare. The boundaries issues of yore just don't hack it here. Hospice, gerontologic, pediatric, oncologic, etc. nurses and docs use touch because it is such a basic human need. Yet it is intentionally withheld in psychiatry. It's a cruelty imposed on people already feeling apart and distressed.

Simply listening without comforting, validating and reassuring does not meet the standard of care and practice in any other field outside of psychiatry. Why is it still present?

I get the impression that often assessment is conflated with treatment and care. I can't say that I perceive that there is truly care in the clinical sense as practiced in current psychiatry. Treatment, for sure.

rob lindeman said...

Aek: well-said

jesse said...

eak: I can comment only on how I look at what you describe, I'm sure others see it differently. I never just think "medication is a first line therapy," but rather try to understand the situation and diagnosis sufficiently to come up with the best way to proceed. That might be by further history, psychotherapy, family consultations, medical consults, psychological interventions, and yes, medication, but it all depends on a multitude of parameters. Certainly there are situations in which I know within minutes that medications is indicated, others in which I suggested medication after many months of other approaches, and a great many in which no medication at all is used. There is no substitute for knowledge and experience in most things.

As to comfort - I agree completely in theory, but with major modifiers in practice. Good psychiatric treatment of any type is not cold and unfeeling. It is warm and connected. However, for successful treatment to occur patients need to feel safe. One learns to be warm and professional without physical contact except perhaps for shaking hands (for geriatric patients some different considerations apply).

For a patient, being understood is extremely important - one does not need a hug in order to feel understood, and in very many situations any physical contact at all could be anxiety provoking for the patient and inappropriate.

SG said...

Has anyone heard of Joseph Biederman getting "disciplined" by MGH? He and two of his fellow psychiatrists have been punished for not adequately reporting their pharmaceutical payouts, which total in the millions. Link to the story here: http://www.bizjournals.com/boston/news/2011/07/01/mass-general-punishes-three.html

I honestly think they got off too easily. I think the time has come for real repercussions for such brazen misconduct: I'm talking firings and, in particularly egregious cases, stripping of medical licenses. Otherwise these guys will just play nice for a few years until the heat's off and then just resume business as usual (corruptly, that is).

This is all too familiar, sadly. It's very similar to what Charles Nemeroff did at Emory, which ultimately got him fired (although he was rather promptly hired as chair of psychiatry at the University of Miami! Many suspect a corrupt quid-pro-quo alliance between Nemeroff and NIMH president Thomas Insel was what got Charlie such an appointment so quickly. See this link for more: http://1boringoldman.com/index.php/2010/06/15/who-is-not-telling-the-truth-yes).

In fact the situation is uncannily similar: both Biederman and Nemeroff failed to disclose their financial ties to pharma companies and when they did, they played the "I wasn't aware of the rules" card. They were also outed by Senator Grassley.

All of this tells me that very little -- if anything -- has changed regarding corruption in psychiatry.

Since Biederman has been the biggest champion of childhood bipolar and his influence is all throughout the literature, this recent disciplinary action casts a lot of doubt on a large swath of childhood bipolar research and the very legitimacy of it. And, of course, many innocent children's lives are at risk because of this. See this link (http://1boringoldman.com/index.php/2011/07/03/bipolar-kids-biedermania-and-super-angrygrouchycranky-irritability/) for a quick rundown for the damage done to the childhood bipolar field by Biederman's corrupted influence.

What does everyone think of all this and what it means for psychiatry? How can we stop it from happening over and over again?

rob lindeman said...

Bad for psychiatry? Hell, it's bad for all of us, pediatricians included. The question is, once the truth comes out, is it possible to get the toothpaste back in the tube?

wv = trove (no kidding). What Biederman et al locked up courtesy of Pharma

SG said...

Rob, I couldn't agree with you more. This widespread corruption is an inner rot that threatens all of medicine. I feel particularly bad for you pediatricians as more and more kids are dosed based on corrupt "science." It's almost like you're flying blind. If a doctor can't rely on honest studies, what CAN they rely on? Word on the street? That shoe-shiner in the rough part of town that seems to know everything?

Here's yet another article 1boringoldman just put up about Biederman. It looks like the boringoldman found another ghost-written study to add to the bonanza. As Mickey (the boring old man himself) said, "Detestable."

http://1boringoldman.com/index.php/2011/07/03/bipolar-kids-postscript-detestable/

aek said...

aek said...

I am much more skeptical about any sanctions placed on the three psychiatrists. Harvard has many affiliated teaching hospitals. Massachusetts General is part of a larger hospital network called Partners. The head of Partners, Gary Gottlieb, is a Harvard faculty member and psychiatrist. His wife, Derri Shtasel, is a Harvard faculty member and psychiatrist directing the Mass General community psychiatry program. Psychiatry at Mass General is a cash cow for Harvard and Partners in that the research $$ and industry funded $$ are tremendous drivers.

I would advocate for website based financial disclosures for every Harvard Medical School, Harvard faculty member, and affiliated hospital researcher/clinician/faculty member so that patients and providers can get a full sense of where actual and potential conflicts of interest might lie.

Harvard is also being investigated for the research that produced harm and patient deaths while deliberately failing to disclose this to subjects in a nursing home based investigation of padded underwear related to hip fractures (Boston Globe July 2, 2011 edition). This isn't a problem confined to psychiatry.

aek said...

Jesse:

Thank you for your thoughtful response. It leads me to this: where are the studies providing evidence about what is perceived and received as comforting (as a clinical concept) to patients receiving psychiatric care? As far as I can determine, there are only a few very small studies in non-psych patient populations looking at this (Kathy Kolcaba's comfort theory). I am interested in learning about how touch is perceived and received by patients who are being initially evaluated (psych virgins), who are in crisis, and who are managing chronicity.

In your (and perhaps Dinah's) practice, you see patients for broader therapy. But in the "psychopharm" only visits, there isn't anything beyond the meds, so you response doesn't seem to fit there.

And to stir the pot a bit: I'm not convinced that psychiatrists are really pharmacologists. Pharmacologists have a different rigorous education, and they are the go-to experts about medications. In this regard, I do think that psychiatrists are cutting themselves into an ever shrinking (grin) corner if they continue to practice in this manner.

Thanks again for providing such a thoughtful perspective.

(I like the decor and company in this living room.)

jesse said...

aek: again, very thoughtful questions, deserving a blog article of their own. About touching and comfort: I don't know of any studies. A physician learns to behave in a manner that is thoroughly professional, in which patients feel comfortable disrobing and allowing access to themselves that they would never do otherwise. Even so, physical examinations of a male physician with a female patient occur with a female assistant present.

For psychiatrists, we want our patients to be able to discuss the most intimate and embarrassing feelings and acts if they believe it is warranted to do so. This is vastly more difficult to achieve than for a physical examination. Very small things might make a patient feel uncomfortable when thinking of discussing something so that it never is spoken. This could be a significant loss to the treatment.

Hugging or physical contact (adult psychiatry, not geriatric) would entail a totally different treatment model from the one I use. I cannot say that it is wrong, only that there would be trade-offs that would compromise treatment much more than add to it. And this does not even begin to touch on the numerous examples of male psychiatrists who got into inappropriate relationships with female patients, causing huge harm to them.

Even if a patient comes to me only for medication, which is rare, I still practice the same way, and feel that the same reasons apply.

On pharmacology, that is a good point and I'd like to hear others address it.

aek said...

Jesse:

You referred to hugs a couple of times, and I guess that I wasn't thinking about "full body contact" so much as reassurance types of touching, such as pats on the arm, the shoulder or even hand holding. In a chronic institutional setting, such as a nursing home, long term hospital or home setting, the relationships might be different, and hugs might very well be a part of the touch package, as it were. So setting, in my view, would be a factor.

And asking about touch and preferences in the patient interview would be most appropriate, just as sensory interventions are assessed. What, if not touch, is more sensory oriented?

I think that most clinicians in and out of psychiatry are pretty savvy about not invading personal space and not crossing boundaries when patients are in crises of all types. But it seems cruel to completely forego and withhold touch based on outdated and unsupported notions, especially given that it's a powerful and immediately available source of comfort and connection.