“manifestly unsuitable for (psychiatric) treatment”

Will Self reviews a recently published book on psychiatry and has some interesting observations on the relationships between addicts, mutual aid groups and psychiatry:

healinghands

Interestingly there is one large sector of the “mentally ill” that Burns believes are manifestly unsuitable for treatment – drug addicts and alcoholics. He points to the ineffectiveness of almost all treatment regimens, possibly because the cosmic solecism of treating those addicted to psychoactive drugs with more psychoactive drugs hits home despite his well-padded professional armour. Elsewhere in Our Necessary Shadow he seems to embrace the idea that self-help groups of one kind or another could help to alleviate a great deal of mental illness, and it struck me as strange that he couldn’t join the dots: after all, the one treatment that does have long-term efficacy for addictive illness is precisely this one.

Psychiatrists are notoriously unwilling to endorse the 12-step programmes, and argue that statistically the results are not convincing. There may be some truth in this – but there’s also the inconvenient fact that there’s no place for psychiatrists, or indeed any of the psy professionals, in autonomously organised self-help groups. Burns agrees with Davies that our reliance on psychiatry, and by extension, psycho-pharmacology, may well be related to our increasingly alienated state of mind in mass societies with weakened family ties, and often non-existent community ones. Surely self-help groups can play a large role in facilitating the rebirth of these nurturing and supportive networks? But Burns seems to feel that just as we will always need a professional to come and mend the septic tank, so we will always need a pro to sweep out the Augean psychic stables. I’m not so sure; psychiatry has been bedevilled over the last two centuries by “treatments” and “cures” that have subsequently been revealed to be significantly harmful. From mesmerism, to lobotomy, to electroconvulsive therapy, to Valium and other benzodiazepines – the list of these nostrums is long and ignoble, and I’ve no doubt that the SSRIs will soon be added to their number.

Sooner or later we will all have to wake up, smell the snake oil, and realise that while medical science may bring incalculable benefit to us, medical pseudo-science remains just as capable of advance. After all, one of the drugs that Irving Kirsch’s meta‑analysis of antidepressant trials revealed as being just as efficacious as the SSRIs was … heroin.

In the doctor’s office

90 day humility by katyhutch
90 day humility by katyhutch

Anna David shares her personal experience with an all-too-common problem. Doctors who don’t understand addiction and do more harm than good:

I continued to see my pinkie-ring psychiatrist for the next year or so, because he told me I had to if he was to keep prescribing me Paxil and Ambien—drugs I was convinced I needed. I thought he was a terrible psychiatrist and a worse person, and found the $250 half-hour sessions a serious financial strain. But he was a professional, and I was desperate and afraid.

Then one day he calmly explained that he couldn’t continue to see me, and I “must know why.” I theorized it had to do with my constantly telling him I’d gone out of town again and—would you believe it—had left my bottle of Ambien in Houston or Vegas (in reality I was barely leaving my apartment and taking roughly 10 times the amount he’d prescribed me). But I was too ashamed to say anything, so I only nodded.

He told me to find a new shrink, and that he wouldn’t give me any more Paxil; then he handed me a prescription for six months’ worth of Ambien. At no point did he mention AA, rehab, or even the words “addict” or “addiction.” I left his office hysterically crying, scrip in hand, feeling like he hoped I would kill myself.

It’s a big enough problem that we decided to add it to our education series.

Following the evidence

Ouch:

Fluoxetine HCl 20mg Capsules (Prozac)
Fluoxetine HCl 20mg Capsules (Prozac) (Photo credit: Wikipedia)

Abstract: This paper raises the question about whether the data on the medications we call antidepressants justify the label of antidepressant. The authors argue that a true antidepressant should be clearly superior to placebo, should offer a risk/benefit balance that exceeds that of alternative treatments, should not increase suicidality, should not increase anxiety and agitation, should not interfere with sexual functioning, and should not increase depression chronicity. Unfortunately, these medications appear to fall short on all of these dimensions. Many of the “side effects” of these medications have larger effect sizes than the antidepressant effect size. To call these medications antidepressants may make sense from a marketing standpoint but may be misleading from a scientific perspective. Consumers deserve a label that more accurately reflects the data on the largest effects and helps them understand the range of effects from these medications. In other words, it may make just as much sense to call these medications antiaphrodisiacs as antidepressants because the negative effects on libido and sexual functioning are so common. It can be argued that a misleading label may interfere with our commitment to informed consent. Therefore, it may be time to stop calling these medications antidepressants.

From the conclusion:

If we do not call these medications antidepressants, what are some alternative labels that may better fit the existing data? The effect sizes for many of the “side effects” are larger than the antidepressant effect sizes. Using labels like antiaphrodisiac medications, agitation enhancers, insomnia inducers, suicidality inducers, mania stimulators, or gas busters obviously would not offer the same marketing appeal. Though tongue in cheek, we consider these possible labels to be more accurate than the commonly used label of “antidepressant.” It could be argued that the outcomes with the largest effect sizes should be offered as the primary label for a medication.

These guys are pretty sarcastic. And, their sarcasm is unlikely to be a conversation starter, but I suspect that there is more of this backlash to come.

It brings to mind a comment from a recent episode of On Being [emphasis mine]:

…individuals are hopelessly biased, they cannot perceive the truth by themselves.

Science is not just an individual activity. We expect our scientists, we exhort them, to be as objective as they can and a good scientist tries to do so very earnestly, but still fails. So therefore, there must be a social process that causes science to work to be a truth-discovering process.

This thing about scientific truth-discovery being a social process  puts it’s finger on something very important. It’s one of the things that so frustrating about hearing people tout evidence-based policies.

Consider the arguments for naloxone distribution. I’ve honestly got no quarrel with it, I just believe that it’s a woefully inadequate response. Of course it’s true that it’s an evidence based policy. I’m sure it saves lives. My problem is that advocates draw a straight line from this truth to universal implementation, AND anyone who balks is anti-science. The problem is that these advocates don’t ask what else we know to be true. For example, treatment also reduces overdose deaths. We fail to discuss what else improves this measure (overdose deaths), we also fail to discuss what other measures are important. If we have that conversation, then we can discuss why it sh0uld or shouldn’t jump to the top of the list without accusing others of being anti-science.

Another example are the evidence-based arguments that opiate substitution medications should be the front-line treatment for opiate addiction. To be sure, these medications reduce opiate misuse. However, there also exists a model, with evidence, that eliminates opiate use in 78% of patients over 5 years. Why not discuss that? Why not allow discussion of whether reduced opiate use is even a good measure? Or, the best measure?

This social aspect of truth-discovery is too often too exclusive. Of course, we can not and should not give equal standing to every goofball with a pet theory, but the points in the antidepressant paper above and the recent GSK scandal demonstrate that the current custodians of evidence are all too capable of leading us into policies based on something other than truth while scolding anyone who questions their evidence.

UPDATE: Just to clarify two things.

First, we’re not anti-medication, but we do believe that their benefits are overstated, the adverse effects are understated, that other methods are just as effective or more effective (And, provide additional benefits.) and that they too often constitutes risk management rather than real treatment.

Second, I see naloxone as first aid. I have no interest in interfering with access to first aid of any kind to anyone with any kind of physical crisis. However, first aid should be FIRST aid (Not last aid or only aid.), and meaningful treatment for the real problem should follow. I tend to bristle because these calls for naloxone programs never seem to include calls for access to treatment of adequate quality, intensity and duration following the overdose.

Coming of Age on Zoloft

An interesting take on anti-depressants from a writer who has benefited from them:

The mainstreaming of medication has bred confusion about what’s normal. In some sectors, we’ve grown so vigilant about the possibility of having a mental disorder that this vigilance becomes counterproductive, a source of anxiety in itself. Every negative emotion becomes a potential sign or symptom. I think people, particularly adults, should use medication if they wish, but I am concerned about the changing goalposts of what’s considered pathological. It’s nice to know that medication is available, but it’s also important not to lose sight of the comfort that can come from talking openly with each other, realizing that not every instance of feeling sad, or overwhelmed, or disappointed, or anxious, is a sign of something medically wrong.

With youth, I feel that a conservative approach to medication is best.

Partly that’s because of the way that getting a mental-health diagnosis can intersect with the adolescent search for self. Being diagnosed and using medication confers an identity, that of someone with a mental disorder. To an adolescent who is preoccupied with constructing an identity anyway, and looking for clues to who she is, that can be a big deal. Some adolescents feel that having a diagnostic label is clarifying and that it helps them. But others wrestle with it. They ruminate about what it means to be sick. They take that identity deep inside, and sometimes magnify it way out of proportion. A diagnosis event can have lasting, rippling consequences, and I think adults should be very cautious and careful before they impose a diagnostic label, or let a young person self-impose such a label, on what may be ordinary developmental struggles.

More thoughts on the use of antidepressants with kids. Here, she’s commenting on a piece in The Atlantic that discussed her book.

I think one thing that piece illustrated nicely is the potential difference between starting antidepressants as an adult and starting them young.

Kelly was saying, ‘Look, antidepressants help people; they helped me; they’re this wonderful thing, and I don’t understand why you people are trying to shoot holes in them.’ Kelly has a story that was similar to that of a lot of adults who start antidepressants: she was in therapy for years; therapy was helpful but notthat helpful; she went into crisis and finally overcame whatever inner resistance she had about trying antidepressants, and they were great — she wished she’d tried them sooner.

I very much respect that story, and many others have one like it. Part of what I’m on about in the book is that for people who start medication as teens, or even younger, the story is different. For them, using medication is often not their choice or not their idea. They don’t have the experience of trying other remedies for years and then reaching a point where they say, ‘You know what, these things aren’t working, this problem isn’t going away, and I’m going to take it seriously now and try something new.’ They haven’t necessarily had a chance to sort out what’s the turmoil of growing up and what might be deeper or longer lasting. Sometimes it’s very obvious that an adolescent is dealing with a real mental problem that goes way outside the realm of teen angst. But in other cases it isn’t always so clear. So for some of the people who start young, the narrative ends up not being one like Maura Kelly’s, of, ‘I had a problem, and then I used my own agency to find a solution, and it was wonderful.’ It’s more like, ‘Someone thought I had a problem, and this thing was given to me, and maybe it helped me or maybe it didn’t, sometimes it’s hard to tell, and if I stayed on it for years then I’ll never be quite sure, either what was the matter in the first place, or how I would have developed if I hadn’t taken this drug.’ It’s a singular experience, but it’s becoming more and more a hallmark of our time. That’s what I was trying to capture in the book.

One trend I find interesting is this. There was a time when anecdotes were used to attack antidepressants. The reaction of researchers and other advocates was that evidence should guide practice. Now, as the evidence has softened, we see many of these advocates using anecdotes to make their case. I’m not one to dismiss experiential knowledge, so this is just an observation.

Racial disparities in antidepressant prescriptions

Fluoxetine (Prozac), an SSRI
Fluoxetine (Prozac), an SSRI (Photo credit: Wikipedia)

A study on racial disparities in antidepressant prescribing:

A research group at the University of Michigan and Indiana University concluded that physicians were 1.52 times more likely to prescribe antidepressants to Caucasians than to Hispanics for the same major depressive disorders.

The researchers also found that whites were more likely to be prescribed newer, more expensive antidepressants, which also happen to be considered the “first line” prescription for the disorders.

It would be interesting to look at differences in the course of their depression.