“Psychiatric Medications Have Led to Dramatic Improvements in Mental Health Outcomes” (Big Lie No. 2)

In continuing my discussion of Robert Whitaker's Anatomy of an Epidemic from my last post, I begin with the results of a study on the use of anti-psychotic medication for treating schizophrenia; it is one of many such studies discussed by Whitaker which report very similar outcomes.  This study was funded by the National Institute of Mental Health (NIMH) and conducted at NIMH's clinical research facility in Bethesda, Maryland.  According to Whitaker:

"[T]hose treated without drugs were discharged sooner that the drug-treated patients, and only 35 percent of the non-medicated group relapsed within a year after discharge, compared to 45 percent of the medicated group.  The off-drug patients also suffered less from depression, blunted emotions, and retarded movements."  The investigators reported that, over the long term, the medicated patients were "less able to cope with subsequent life stresses."

Study after study shows that, in the short term, anti-psychotics do reduce unrealistic thinking, anxiety, suspiciousness and auditory hallucinations, but in the long-term, they make those continuing on medication much more prone to relapse and re-hospitalization than non-medicated patients or patients given a placebo.   "Schizophrenic patients discharged on medications were returning to psychiatric emergency rooms in such droves that hospital staff dubbed it the 'revolving door syndrome.'  Even when patients reliably took their medications, relapse was common, and researchers observed that 'relapse is greater in severity during drug administration than when no drugs were given.'"

In other words, schizophrenic patients who received no medication had much better long-term results than those treated with anti-psychotic drugs.  This jibes with both (1) a historical comparison between long-term outcomes for schizophrenic patients prior and subsequent to the introduction of anti-psychotics; and (2) a comparison between long-term outcomes for schizophrenics treated with anti-psychotics in the developed world versus those in poor countries treated without them (much better).  Study after study bears this out.

In short-term usage, psychiatric medications for psychotic disorders have value in stabilizing patients and reducing the severity of their symptoms, but long-term usage makes those people more prone to relapse and "may prolong the social dependency of many discharged patients."   And here is the tricky part:  If patients are withdrawn from their medications, they do poorly, then do better once they have been put back on those drugs.  For this reason, it appears to be proof that the drugs "work"; but do they only "work" in the sense that they ameliorate a problem created by placing the patient on those very drugs in the first place?  In study after study, it is patients given no medication whatsoever who have the best outcomes.

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“You Have a Chemical Imbalance in Your Brain” (Big Lie No. 1)

 

My colleague Jeff Kaye PhD recommended that I read Robert Whitaker's The Making of an Epidemic (pictured above) for insight into the scientific evidence concerning the effects of psychiatric medication. I read the entire book in one day and feel it is the most important work I've read in years. This and the following two posts will summarize Whitaker's most important findings but I recommend that you read this book if you're at all interested in or concerned about these drugs and what they actually do.  Although some sections of the book discuss neurological processes and there's a fair amount of statistical data to support his arguments, you don't need to be a psychologist or a physician to understand the material. For me, the experience was like reading a well-written legal thriller: I found it riveting.   As a clinician, I've always doubted the effectiveness claims associated with Prozac and the other so-called "anti-depressants", viewing them as propaganda that drives profits for Big Pharma, as I've discussed elsewhere.  The full truth is far more disturbing.

Whitaker began as a newspaper reporter, then co-founded his own publishing company that reported on the business aspects of clinical testing for new drugs; his readers worked at pharmaceutical companies, medical schools and private medical practices, so he did not come to his subject area with an ax to grind.  He began his research for Anatomy when he discovered that as a whole, schizophrenic patients in poor countries, only 16 percent of whom were regularly given antipsychotic medication, had much better long-term outcomes than patients in developed countries who received such drugs. He set out to understand this puzzle, not to launch a crusade.  Before writing his book, he "believed that psychiatric researchers were discovering the biological causes of mental illness and that this knowledge had led to the development of a new generation of psychiatric drugs that helped 'balance' brain chemistry." Many of you may believe the very same thing -- not surprising, since it's the story that has been given to us by the medical profession and regularly repeated in the media.

After painstaking research, Whitaker found that there is absolutely no scientific evidence to support the theory that mental illness is a result of an imbalance in brain chemistry. Let me repeat that: there is absolutely no scientific evidence to support the theory that mental illness is a result of an imbalance in brain chemistry.  As an example, let's take the best known theory, that depression is caused by low serotonin levels in the neural synapses.  An entire class of drugs -- the "selective serotonin reuptake inhibitors" (SSRIs) inhibits the removal of serotonin from those synapses and thus ( in theory) restores normal serotonin levels.  So, if this theory is true, depressed people should have below-normal levels of 5-HIAA (serotonin is matabolized into 5-HIAA) in their cerebrospinal fluid.

Study after study has failed to find any significant difference in the 5-HIAA levels of depressed and non-depressed patients.   No correlation has been found between 5-HIAA levels and severity of depressive symptoms.  Whitaker is thorough and devastating on this particular point, exposing flawed research designs and statistical analysis in the very few studies that purport to show even a very small link between serotonin levels and depressive symptoms.  Furthermore, no correlation has been found between levels of 5-HIAA in cerebrospinal fluid and degree of response to anti-depressants.  This widely accepted theory has absolutely no basis in fact:

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Lessons from Amy Chua, the Tiger Mother

I recently read Amy Chua's controversial book, Battle Hymn of the Tiger Mother, and it fell right in with a train of thought I've been following in two recent posts, one questioning whether we always try to do our best, and the other about elements of truth to be heard from that savage inner voice.  While I believe many of Ms. Chua's methods are abusive (I can't see any value in calling your child "garbage"), there's a lot to be said for upholding high standards for our children, and a great deal of truth in her criticism of permissive Western parenting.

Upholding those high standards (for ourselves as well as our children) without resorting to a perfectionistic cruelty is the challenge, and one at which Ms. Chua fails.  She recounts many instances where she treats her children with a contemptuous perfectionism that shows little regard for their feelings, those of her husband or of anyone else in her environment.  She badgers and threatens and withholds until she gets the results that she wants.  She brooks no opposition, always insisting that her demands be met.  And she gets amazing results.  How many families have two young daughters play Carnegie Hall?

From the anecdotes Chua tells, it's clear that without her relentless demands, her daughters would not have reached such a high level of academic and musical excellence.  In one case where her younger daughter was struggling to master a piece of music where each hand played a radically different rhythmic pattern, the daughter kept insisting she couldn't do it; Chua forced her to continue practicing, against her will, for hours and hours, until at last, she mastered it.  Without the mother's drive and demanding nature, the daughter would not have mastered that skill, would  not have done her very best.  Let's put aside for a moment the question of whether such an achievement was worthwhile and at what emotional cost; the story illustrates how we often do not do our very best because it takes such an enormous effort.

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Charlie Sheen’s Rant and the Power of Destructive Narcissism

Charlie Sheen's recent rant on The Alex Jones Show offers a perfect illustration of my earlier post about defenses against shame, as well as many features of narcissistic personality disorder.   Although I wouldn't classify Mr. Sheen as NPD per se, he exhibits a great many features of pathological narcissism.  If you haven't seen or heard the full radio interview, you might want to watch this YouTube video.  It's astonishing, deeply upsetting and sad.

From the beginning of the interview, Mr. Sheen makes clear we're dealing in the territory of shame.  "Dude, I'm 0-for-three with marriage and nary an excuse.  Like in baseball, the scoreboard doesn't lie."  At first, this quote makes it seem as if he's putting himself in the "losers" camp (to use his own terminology); but he rejects any sense of shame in the next sentence while discussing the current women (the "goddesses") in his life:  "What we all have is a marriage of the heart ... of the hearts.  To sully or contaminate or radically disrespect this union with a shameful contract is something I will leave to the losers and the Bible-grippers."

This is what I hear Sheen saying:  "I'm not a shame-ridden loser in marriage because marriage itself is the loser.  People who get married are the losers.  Rather than contaminate myself, I've engaged in a superior polyamorous form of relationship, where we exist on the level of gods and goddesses, peering down with contempt upon you pathetic mortals."  As I've discussed, this kind of contempt is a classic defense against unbearable shame; poor Mr. Sheen must be drowning in it.  Brittle and defensive, he next reports that one of the women in his menage-a-quatre has decamped; he wishes her luck in her new life because "she will need it."  Unable to bear the pain of rejection, he treats his former goddess with the contempt he feels for everyone outside his "family".

In Charlie Sheen's quotes, he continually exhibits a kind of grandiose narcissism, another primary defense against shame. "I'm so tired of pretending that my life isn't perfect and bitchen and winning every second and I'm not perfect and just delivering the goods at every second."  That's a verbatim quote, difficult to decode exactly, but he clearly wants to convince everyone, especially himself, that he has a close-to-perfect existence that's the envy of the contemptible losers around him.  "Look what I'm dealing with, man -- I'm dealing with fools and trolls.  ... I don't have time for these clowns, I don't have time for their judgment and their stupidity.  They lie down with their ugly wives in front of their ugly children and just look at their loser lives and they look at me and they say, 'I can't process it!'  Well no, and you never will.  Stop trying.  Just sit back and enjoy the show."  From Sheen's heavily defended viewpoint, he's a godlike spectacle the world should simply watch and admire.  Beneath that surface, he has to feel confused, out of control and shamed of what he's done with his life.

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The Fallacies of Psychological Diagnosis

As you may have heard, the American Psychiatric Association is in the midst of a revision to its Diagnostic and Statistical Manual of Mental Disorders, used to identify different mental illnesses and assign diagnostic labels to patients.  This newest edition, the DSM-V, will be published some time in 2013.   Among the more controversial changes is the elimination of five of the 10 personality disorders currently listed, the best known of which is Narcissistic Personality Disorder (NPD).

This revision seeks to move diagnosis toward a greater emphasis on descriptive traits, based on the undeniable fact that individuals diagnosed with one personality disorder often demonstrate traits associated with another.  As many clinicians have pointed out, the personality disorders exist along a spectrum.  I suppose this refinement in the DSM is a step in the right direction as it appears to treat people a bit more like individuals than categories, but I have a more fundamental problem with the idea of assigning diagnostic labels in the first place.

The fundamental assumption behind the DSM is that its categories of mental illness, with their official code numbers, actually correspond to a discrete syndrome exhibited by real people; in this sense, it is meant to be the psychological counterpart of the International Classification of Diseases 9 (ICD-9) used by physicians to diagnose and label physical illness.  In theory, applying the DSM-IV label Narcissistic Personality Disorder should carry the same weight and have as much scientific validity as an ICD-9 code for, say, diabetes.  The impending elimination of NPD from the DSM-V proves that such an analogy is fallacious.   Can you imagine if the American Medical Association suddenly announced it intended to eliminate diabetes from the ICD-9?
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