Among the balloons that exploded during this super-heated summer was the intensifying debate over the worth of psychotropic medications.
Marcia Angell, the distinguished ex-editor of the New England Journal of Medicine, kicked things off with a ferocious two-part attack in The New York Review of Books on antidepressants, antipsychotics and, in general, medications to treat psychiatric disorders. Her argument distills charges often made much more sloppily: that psychiatrists dispense unnecessary and potentially harmful drugs. She impugns both the medications and the motives of the psychiatric profession. Both deserve clarifying responses.
Angell reviews several recent books claiming that careful analyses of studies of psychotropic drugs, done to win FDA approval, reveals that many are no more effective than placebos. Then why are they in such wide use? Angell sees a conspiracy of psychiatrists and drug companies for their mutual benefit, with patient benefit only a distant concern.
In her telling, it started in the late '50s, when psychoactive drugs began to appear. Psychiatrists, competing for patient income with a surging number of psychologists, pushed what Angell calls the "medicalization" of mental illness -- the idea that mental illness is a product of brain chemistry -- so that only they (and not their non-medical doctor brethren) could prescribe the necessary medication. Then, her theory goes, these psychiatrists invented diagnostic criteria -- in the form of the American Psychiatric Association-approved Diagnostic and Statistical Manual (DSM III) -- to match illnesses to available medications. The DSM writers, she charges, were deep in the pocket of the drug companies, who paid them personally and financed their professional organizations.
Like most conspiracy theories, it's breathtaking in its audacity. And, like other conspiracy theories, it becomes difficult to dissect the real from the imaginary.
First, it's preposterous to describe decades of scientific work linking emotional states and disorders to brain chemicals as basically a psychiatric plot to capture more of the mental health market. She writes (as do others) as if psychiatrists were bored by less remunerative talk therapy and wanted to hype their income by quickly dispensing pills. In fact, the drive for medication was fueled by the surprising observation that they were better treatments for mental illness than talk therapy or earlier sedative drugs. With apologies to Angell, more effective and less toxic medications for devastating illnesses such as schizophrenia, major depression, bipolar depression, OCD and panic disorder are as significant, in terms of public health, as finding new cancer medications.
Second, Angell's assertion that the DSM was a thinly-veiled ploy to justify medications ignores its real value, which is promoting reliable clinical communication. Before DSM, diagnosis was basically a labeling free-for-all. A particular diagnosis meant very different things to different people. The drive to make diagnosis less subjective was not an effort to create a market for medications, but to make psychiatric communication effective. Nothing in the DSM, notes my colleague Dr. Donald Klein, former director of research at Columbia's New York State Psychiatric Institute and member of the original DSM III task force, "pushes" medication -- or any other form of treatment.
That some psychiatrists and professional organizations take money from pharmaceutical companies is a fact. It may be true that some allow such money to influence their treatment decisions. This problem plagues all branches of medicine, but psychiatry is particularly affected, as it still lacks diagnostically sufficient laboratory methods. In recognition of the public's current distrust of pharmaceutical companies, the Child Mind Institute does not accept their funding. But we are staunch advocates for more research into mental illness, and the pharmaceutical industry is one of the biggest funders of basic and treatment science. This is simply a fact. A researcher's work cannot be dismissed simply because funding came from a drug company. There's a desperate shortage of funding for research, and not developing new treatments, or not pushing the science forward, in order to avoid the appearance of corporate ties is a far more troubling eventuality.
Which brings us to the issue of the studies Angell says show that antidepressants and other psychoactive medications aren't appreciably better than placebos. Peter Kramer, the author of "Listening to Prozac," responded to this charge in a piece in The New York Times, in which he argued that the studies Angell highlighted were undermined by the biased process by which patients were recruited. Many recruits were not, in fact, clinically depressed, so most get better over time, whether on placebos or real medications. There is a further claim that even the patients who do get psychoactive medications get better because of a sort of "extra strength" placebo effect: The side effects of the medication let them know they're getting the real thing, which undermines double blind precautions and makes them inclined to feel improved. This ridiculous notion must surprise the companies whose side-effect-rich medications never make it through the FDA review for efficacy.
Dr. Klein also explains that there is a real challenge to getting good, clinically useful data out of studies performed after a company gets a patent, in the process of seeking FDA approval for marketing. Because the clock starts ticking as soon as a new medication is patented, a drug company's goal is to move through the testing process as rapidly as possible. So in the first phase of human studies, doses are picked that will not cause FDA rejection because of side effects. The goal is often to use the lowest dose likely to produce statistically significant benefit, however marginal, over the placebo alternative. The result is that the studies' dose is often too small to regularly be clinically useful.
What's the takeaway of all this?
Good studies for psychiatric treatments are desperately needed. In the meantime, we have patients, in our case children and adolescents, who desperately need help. These children may be out of control, overwhelmed by anxiety, dangerously aggressive, disorganized in their communication, floundering in school. We need to help them. Medications, often along with behavioral therapy, can have a transformative effect. If they don't help, we are not forced to continue using them. We would like to see objective research catch up with the clinical realities but can't wait until that happens. Furthermore, falling back on pure non-pharmacological treatment is not the better alternative, since these treatments have rarely undergone objective evaluation.
As to the issue of psychoactive drugs actually harming patients by altering their brain chemistry over the long term, which Angell posits, here too data is lacking. It makes no sense to forego present benefit because of undemonstrated future harms. We try to weigh the risks of psychoactive drug treatment against the risks of forgoing treatment. That risk often includes academic failure, dropping out of school, substance abuse and even suicide. Unfortunately, the risks of avoiding demonstrated useful treatments are not something critics, like Angell, consider.
Harold S. Koplewicz, M.D. is a leading child and adolescent psychiatrist and the president of the Child Mind Institute. For more about Dr. Koplewicz, go to childmind.org, which also offers a wealth of information on childhood psychiatric and learning disorders.
Follow Dr. Harold Koplewicz on Twitter: www.twitter.com/DrKoplewicz
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This logic also allows psychiatry to make one of its favorite claims: the risks of not treating a depressed patient far outweigh treating them with meds. If the patient is untreated, they could commit suicide, psychiatry claims. This flies in the face of the fact that most bouts of depression spontaneously resolve with time and support, not meds. Only the most severe cases of depression need meds (a small minority of people), but the drug companies don't want you to know that or they'd lose their profit.
Finally, part of the problem with evaluating risk with psych meds is so much of the negative data and side effects were hidden by the drug companies for decades. And no long-term safety studies have been conducted. Taken together, it's nearly impossible to come up with a risk/benefit ratio and provide informed consent to psychiatric patients about the meds when the side effects and long-term risks have been repressed or not studied at all.
I personally would never want to take medications away from patients. I know they work for some people (sometimes fabulously) and I've seen this in person. BUT it is our moral duty to practice good science and develop a risk/benefit profile so as to honor the "do no harm" doctrine and truly provide informed consent. Only then will we truly maximize the therapeutic value of meds and other non-med interventions.
As it currently stands, so much of psychiatric "science" isn't science or even pseudoscience: it's advertising. And everybody, from patients to psychiatrists, loses. And it's still happening. Look at the analysis of the research behind the new atypical antipsychotic Latuda here: http://1boringoldman.com/index.php/2011/09/27/ought-to-know-by-now/ Very little has changed over the decades because the winning formula of biased drug research still works very well.
Continued...
Secondly, sobrien is using the Nirvana fallacy of logic when he/she asks, "Are [the meds] perfect?" Of course they're not -- I doubt most people want perfection in a drug. This is a rhetorical tactic to uphold the status quo because only perfection is an acceptable alternative to the status quo and of course perfection doesn’t exist, so the status quo remains and no steps toward improvement are taken. Sad.
'Marcia Angell...has enormous integrity and credibility, in my opinion. I was therefore deeply disappointed in Dr. Oldham's defensive reply to her review... I wish he had instead written something like the following':
"Thank you for shedding light so cogently on a deeply disturbing problem in the psychiatric profession. We are ashamed of prominent members who have taken obscene amounts of money from the pharmaceutical industry, then attempted to conceal that fact. Studies have shown that the more money a physician receives from drug companies, the bigger their blind spot for how that influences their prescribing habits. This is what we call rationalization. Our organization is working to prevent our members from being manipulated by industry...I have directed our Ethics Committee to develop effective guidelines to halt the corrupting influence of drug company money in psychiatry. You agree that psychotropic drugs are effective, when used judiciously. Your review also makes the important point that clinical trials sponsored by drug companies are marred by obvious commercial conflicts of interest. Examples are revealed in the media on a regular basis. We know this problem is not limited to psychiatry, but affects every medical speciality. Nevertheless, we intend to set an example for other specialties in fighting to protect our professional integrity. Our patients deserve no less."
Richard M. Waugaman, M.D., Professor of Psychiatry, Georgetown University
You are no healer, but a capitalist/ opportunist convincing himself of his own abilities to cure while lining
his own pockets.
He also said that the way the DSM changed psychiatric diagnosis actually opened the floodgates for misdiagnosis and overdiagnosis because it introduced the descriptive diagnosis system (essentially a checklist) where patients' disorders were considered clusters of symptoms. As an example, a patient would have major depressive disorder if they only had 5 of the 9 diagnostic criteria, regardless of their life situation or what they thought about their problems. This "checklist" system enabled many psychiatrists to get sloppy in their diagnoses and throw pills at patients.
-"Second, Angell's assertion that the DSM was a thinly-veiled ploy to justify medications ignores its real value, which is promoting reliable clinical communication. Before DSM, diagnosis was basically a labeling free-for-all. A particular diagnosis meant very different things to different people. The drive to make diagnosis less subjective was not an effort to create a market for medications, but to make psychiatric communication effective."
-You don't have to be a psychiatry critic to believe the DSM is a "thinly-veiled ploy to justify medications." In fact, you could be Allen Frances, none other than the lead editor of the DSM IV! In a Wired article (http://www.wired.com/magazine/2010/12/ff_dsmv/all/1) Frances bemoans the upcoming DSM V's danger of pathologizing normal human behavior with all kinds of bogus disorders so as to line drug company's pockets. Among his admissions, Frances said, "there is no definition of a mental disorder. It's bullsh**. I mean, you just can't define it."
"Then, her theory goes, these psychiatrists invented diagnostic criteria -- in the form of the American Psychiatric Association-approved Diagnostic and Statistical Manual (DSM III) -- to match illnesses to available medications."
-Well, not all the diagnoses in the DSM are bogus, but some certainly are, and that means a boon for the pharmaceutical companies. One example is Premenstrual Dysphoric Disorder (PMDD), which was nothing more than Eli Lilly's attempt to rebrand their antidepressant (Prozac) with a new "indication" so that it could stay on patent and Lilly could keep raking in the profits. Read more about it here: http://www.msmagazine.com/Summer2008/pathologizingyourperiod.asp
Now, a few things about this article:
"In her telling, it started in the late '50s, when psychoactive drugs began to appear. Psychiatrists, competing for patient income with a surging number of psychologists, pushed what Angell calls the "medicalization" of mental illness -- the idea that mental illness is a product of brain chemistry -- so that only they (and not their non-medical doctor brethren) could prescribe the necessary medication."
-This is largely true. Robert Whitaker, in his book ANATOMY OF AN EPIDEMIC, outlines all this and more, particularly in the "The Rise of an Ideology" chapter. Here is a relevant passage from the book:
"New Jersey psychiatrist Arthur Platt was at a professional meeting in the late 1970s when a keynote speaker laid it out for them: 'What is going to save us is that we're physicians.' [Psychiatrists] could write prescriptions and the psychologists and social workers couldn't, and that was an economic landscape that presented the field with an obvious solution...Threatened by [psychiatrist Thomas Szasz's] criticism that psychiatrists did not really function as 'doctors,' the APA argued that psychiatrists needed to more explicitly embrace this role. 'A vigorous effort to remedicalize psychiatry should be strongly supported," said the APA's [Melvin] Sabshin in 1977."
To be continued...
http://1boringoldman.com/index.php/2011/05/07/retract-study-329/
http://psychcentral.com/blog/archives/2008/04/30/more-on-infamous-paxil-study-329/
In my next post(s) I'll address some of Koplewicz's claims.
You write "With apologies to Angell" - do you mean this or is this sarcasm? Because people I know find the attitudes of some psychiatrists as damaging as some of the drugs. You speak of "devastating illnesses such as schizophrenia, major depression, bipolar depression, OCD and panic disorder". I find that curious. I have not seen any studies that prove conclusively they are illnesses. Out of the 100s of people I have worked with who have been diagnosed as such, as I really get to know them over time - the troubled lives they have lived and the thoughts and behaviours they struggle with are not incongruent. What I am saying is, there seems enough that we do know to support their responses (extreme responses to extreme experiences, though of course I over-simplify here as this is not the place for a thesis!) without the need to impose the unproven idea (and possibly stigma too) that they are illnesses.
Those of us who are "against" psychotropic drugs(and I use that loosely) are not necessarily against the drugs themselves. I have witnessed plenty of cases where psych drugs have enabled people to live full lives, but I have also seen people abuse them(popping SSRIs only when feeling anxious instead of taking them properly). I am against prescribing them to anyone and everyone for little to no reason without proper monitoring and education to the patient.
The backlash against psychotropic drugs comes partly because it is difficult to believe that the answer to every problem is a pill.
We depend on doctors to honestly and ethically figure out whether or not we really need drugs based on our symptoms and/or what we tell you is going on inside. Unfortunately it seems like too many doctors are not making the responsible choices, so it is up to many of us to second guess a prescription that was handed to us after 3 minutes of conversation.
I am someone who was diagnosed as schizophrenic, forcibly injected with horrible drugs like Prolixin and Thorazine, and without trial locked up in a Cuckoo's Nest State Hospital in Connecticut. I have learned to consider everything uttered by psychiatry to be mystifying nonsense.
It is trauma, learned dysfunction, that is causing the millions of us to become unable to function, and until we are encouraged to learn what happened to us, to have safe places to go to and safe people to talk to, the problem will only get worse. Read Bob Whitaker's book, Anatomy of an Epidemic, if you want the truth, and if you truly want to help suffering people. The lies in this article are multiple, including the one that there are no studies that reveal the dangers of long term use of anti-psycotics. I would no more believe the nonsense from this man than I would from the jerk down the street peddling Meth. Both enrich a few by destroying the minds of many. Hugh Massengill