Tuesday, February 17, 2009

Where Dumb Psychiatry Meets Dumb Antipsychiatry


In my last blog, I urged that we consider issues in terms of "smart vs dumb" rather than "pro vs anti." In the final analysis, dumb psychiatry and dumb antipsychiatry serve the same master. Let me give you an example:

For at least three decades, it has been widely accepted that prescribing an antidepressant (with no mood stabilizer) to someone with bipolar runs a strong risk of flipping a patient into mania or speeding up the cycle or both. The American Psychiatric Association in it's 2002 Practice Guideline for treating bipolar issues a blanket warning against this practice.

The catch is that it is often difficult to distinguish unipolar depression from bipolar depression. The result is that too many of us with bipolar are misdiagnosed with unipolar depression and prescribed meds that make us worse.

There is an additional twist to this catch: Many people experience "recurrent" and "highly recurrent" depressions that come and go in a pattern very similar to bipolar cycling. The pioneering diagnostician Emil Kraepelin observed this phenomenon way back in the early twentieth century.

When Kraepelin coined the term, manic-depression, he wasn't merely referring to bipolar. He also included those with recurrent depression. This was the widely accepted view until the DSM-III in 1980 separated out bipolar and lumped recurrent depression with "chronic" depression.

The result is that doctors tend to treat all depressions alike - with predictably disastrous results. This is an example of "dumb" psychiatry, the indiscriminate prescribing of antidepressants to anyone who happens to say they're depressed.

Reformers in the profession, such as former head of the NIMH Frederick Goodwin MD and Nassir Ghaemi MD of Tufts, have long urged that psychiatrists think twice before prescribing antidepressants. The best way to turn certain unipolars into bipolar, they would argue, is to prescribe an antidepressant.

Dr Goodwin and a good many others have campaigned for years to realign the next DSM so that it is more closely in tune with Kraepelin's original conception of manic-depression. This would get doctors to rethink their prescribing practices.

We don't know if change will happen. But no doubt the task force charged with issuing an updated DSM is considering the matter. Indeed, the possibility of a new "bipolar III" diagnosis was the basis of a blog post last week from Furious Seasons, fairly typical of antipsychiatry sentiment:

"I think it's been a boon to doctors - who get a patient for life - and Big Pharma - which gets a long-term customer - but I have my doubts about how useful the depression-is-bipolar thing is for patients who wind up on an atypical and an anti-seizure drug when they are dealing with something that's not even in the ballpark of mania."

To respond in brief:

Yes, big pharma would love a customer for life, but to make a case for a drug industry conspiracy one would have to bend time a hundred years. Kraepelin wrote his classic text, "Manic-Depressive Insanity and Paranoia," decades before drug manufactures came up with the first psychiatric meds, and psychiatrists have been arguing ever since where best to carve nature at its joints.

Moving on, bipolar is more accurately a cycling illness, not a polar illness. So is recurrent depression. Thus "something that's not even in the ballpark of mania" is irrelevant. The purpose of treatment is to manage the cycle, bring it under control, not necessarily treat symptoms at one pole or the other.

An antidepressant may work in some patients with recurrent depression. But a logical first option is to consider using a mood stabilizer such as lithium or Depakote or Lamictal.

Once the cycle is under control, it may be possible to consider low-meds or no-meds options in conjunction with cultivating cognitive skills such as mindfulness.

Admittedly, Lamictal had a lot to do with drawing attention to "soft bipolar" several years back, and GSK profited handsomely. But these days the drug has gone generic, along with lithium and Depakote. Thus GSK and others have no financial stake in pushing for an expanded bipolar diagnosis.

If anything, an expanded diagnosis would significantly reduce antidepressant sales. This is why you don't see drug companies sponsoring clinical trials to prove Drs Goodwin and Ghaemi right.

No doubt, some manufacturer will try to jump on the bandwagon with some implausible claim trumpeting the virtues of their house antipsychotic, only to be laughed out of town. But this would be an example of opportunism, not hatching a conspiracy.

As for psychiatrists wanting a patient for life: The best indication is that psychiatrists are driving away their patients. Only a small minority of patients adhere to their meds over the long term. Matching the right meds to the right diagnosis might change this.

So now we return to the issue of smart vs dumb. Dumb psychiatry treats all depressions as the same. So does dumb antipsychiatry. Dumb psychiatry favors preserving psychiatry's status quo. So does dumb antipsychiatry. Ironic, isn't it?

10 comments:

Bill Lichtenstein said...

John:

Your article would be a little more transparent if instead of referring to Fred Goodwin as a "reformer," you noted a more critical aspect of his relationship to this matter; that being his pocketing of an undisclosed $1.2 million in marketing fees from GlaxoSmithKline to speak to doctors about Lamicatal at dinners held at steak houses and resorts across the country from 2000 to 2007 (see November 22, 2008 New York Times). While, as you noted, Lamictal is generic now, it wasn't then, and GSK "profited handsomely," as you said, with more than one million dollars of that profit going to Goodwin.

Furthermore, you might also want to mention that your site gets advertising dollars from pharmaceutical companies (such as the current ad campaign for Concerta that targets kids). This is not unrestricted educational funding, which is highly regulated with regard to conflicts of interest, but pharmaceutical advertising dollars. It's not a question or "smart" or "dumb"; there's just nothing to be said against transparency.

-- Bill Lichtenstein

John McManamy said...

Hi, Bill. To respond point by point:

1. You and Dr Goodwin enjoyed an excellent relationship for a number of years through "The Infinite Mind." The series achieved high critical acclaim and helped untold people. In is a partnership that you should be proud of. The fact that the two of you had a bitter falling out should not detract from the high achievements of your partnership.

2. Dr Goodwin is a reformer, simple. He has the track record to prove it. The fact that you have an axe to grind with him is only relevant to your contractual relationship with him, not to his numerous accomplishments.

2. The NY Times piece you refer to was a hatchet job on Dr Goodwin. The piece raised the innuendo that he was on the payroll of GSK to put a positive spin on Paxil suicide data, which was definitely not the case and was a clear libel. As a journalist yourself, you should know this.

3. The Times piece was circulated uncritically throughout the blogosphere, including antipsychiatrists and clinician bloggers who should know better. The clinician bloggers unprofessionally added their own nasty gossip. The antipsychiatrists and clinician bloggers took perverse delight in this group character assassination.

4. I listened to "The Infinite Mind" show in question. It was an excellent show. Its major weakness was that there was no dissenting voice on the panel. In hindsight, I'm sure you wish you had lined up someone like David Healy MD. Had that happened, no one would be making a fuss.

5. Re Lamictal fees: Dr Goodwin's relationship with drug companies was well-known and would have been known to you. I heard Dr Goodwin speak at an APA symposium sponsored by GSK. They would have been disappointed. He may take their money, but he clearly hasn't been bought.

6. I published three blogs on HealthCentral's BipolarConnect re Dr Goodwin and The Infinite Mind. As a disclosure, I reported that Dr Goodwin authored a front cover blurb to my book. I received a lot of negative feedback, but none of it based on facts or even fair comment. The best anyone could do was attack me on the basis that I have drug company advertising on my website (as does John Grohol who attacked me for defending Dr Goodwin).

7.I regard the Dr Goodwin-Infinite Mind issue as closed. I gave it full airing in my old blog. This blog piece raises important issues that need to be aired. Dr Goodwin is not one of them. Please feel free to comment - pro or con - on the issues.

8. Speaking of advertising dollars, I don't need to mention that my site gets advertising dollars. People already see the ads. They are free to make up their own minds if I'm a pawn of the industry or not. I publish a full disclosure on my website, and will on this blog should I decide to accept pharm ads here.

9. Re disclosure, here is the statement on my website:

"McMan's Depression and Bipolar Web is a wholly independent website, funded by John McManamy and voluntary donations from individuals, plus Amazon affiliate links, plus paid and non-paid advertising.

"Any ads appearing on this site and satellite blog sites are the result of third-party transactions via Google and Amazon and HealthCentral. This website neither solicits ads for specific products, nor endorses specific products that appear via Google and Amazon and HealthCentral.

"The move to paid advertising on this site is a recent one, mid-2007, well after the site’s reputation for independence and fairness and integrity had long been established. Editorial content is not influenced by advertising. Equally important: Editorial opinion is not influenced by currying favor with my readership. One one hand, you the reader come first. On the other, I will not hesitate at publishing an article that may displease you. As a journalist, my prime obligation is to deal honestly with the facts."

Cristina Romero-Sierra said...

Hi John. What a most excellent rebuttal to the tiresome and petty Goodwin bashing, as well as to the supposed big pharma and psychiatry conspiracies. It certainly smacks like a bit of paranoia to me. With my bipolar-1, one of my predominant symptoms when unwell is paranoia. On a small scale, paranoia manifests as hypersensitivity or increased suspicion. It’s incredible how the conspiracies by psychiatrists, pharmaceutical companies, institutions, governments and other people in the world virtually dissolve when my bipolar is under control. It’s not that I’m necessarily accusing others of being paranoid; I’m just sharing my experience. When I start seeing conspiracies around me, I check in to see if there are other signs of bipolar crisis.

John McManamy said...

Hi, Cristina. Many thanks for your comments. I'll leave Mr Lichtenstein out of this, so nothing I say next can be interpreted as applying to him.

Re the supposed big pharma conspiracies: I've experienced just about the full gamut of irrationality from the anti-science, anti-intellectual crowd. Foaming-at-the-mouth disease would be my diagnosis, with co-morbid aversion to the facts.

Back in the old days, these people would have lived very lonely lives, but now they do very well as talk radio hosts. :)

Cristina Romero-Sierra said...

John, I'd give you (and me) the foaming-at-the-mouth-disease diagnosis, but not a comorbid condition of aversion to the facts. You know your facts well and put them in plain sight. Conspiracies are based on speculation, not facts, or twisting of facts, which are then in fact not really facts.

Paranoia aside, black-and-white thinking is also something I can get into when not well. Good examples of that are Big, Bad Pharma, or Big, Bad Psychiatry. The gray area, which is *supposed* to be an area of intellectual stimulation and interesting debate, instead becomes pure black or white too.

John McManamy said...

Hey, Cristina. Facts are the first casualty of black and white thinking. The easy stuff has all been figured out long ago, so we're left navigating our way through murky shades of gray. In the world of black and white, there are no surprises. Everything is certain. If you're certain, you better damned well be enlightened. :) Otherwise, welcome to my gray world.

John McManamy said...

To readers:

Just so we're clear on the ground rules of posting comments here.

This particular blog post raises important (and controversial) issues. Many people are bound to see things a lot differently than I do, and I welcome these comments. This is how we all learn.

In my blog post, I was critical of the points raised by another blogger, but I restricted my criticism to a discussion of the issues, based on extensive research. I did not personally attack the blogger.

So far, I have had to reject two comments. Neither addressed the issues raised in this blog post. One gratuitously attacked a prominent psychiatrist mentioned in my blog post, plus personally attacked me (not a way to win friends and influence people).

Another made this libelous comment: "You feel comfortable defending drug pushers, especially those pushing on children, whose main interest is in the color green?"

To clarify:

This is not a forum where whoever shouts the loudest in the most irrational way wins the argument.

This is a place where thoughtful individuals can express their views and learn from one another in a safe environment, without fear of personal attack, or of the conversation being hijacked.

Ninety-nine percent of you don't need to be told this. So please interpret my remarks as reassurance that I will keep "Knowledge is Necessity" safe for you.

Anonymous said...

Cristina I'm sorry you suffer from paranoia and black and white thinking when you're sick, that's really too bad. However, are you implying that those who raise criticisms about psychiatry or pharmaceutical company practices are also merely suffering from delusions?

John McManamy said...

Hey, Anonymous. Let me first say I appreciate your comments and that your question to Cristina is totally appropriate.

I'm jumping in here only because this is a new blog and because your question can act as a template for addressing other people who post. So - please - interpret what I say below in a good light.

Re your question to Cristina: "Are you implying that those who raise criticisms about psychiatry or pharmaceutical company practices are also merely suffering from delusions?"

If her answer is yes, then call us all delusional. Nearly all of us (myself included) have a lot not to like about psychiatry and the drug industry. You only have to scan these pages to see that some of the strongest criticism of psychiatry and industry practice comes from me.

I also appreciate that others take a stronger (but equally valid position) on the topic, and I learn a lot from them.

But we have to make a distinction between valid critics and the irrational nihilists and conspiracy buffs, who respond to facts and fair comment with wild accusations and bullying personal insults.

Way too much of this is going on, and a lot of us are fed up with screamers who purport to speak on our behalf.

Believe me, Cristina and others are perfectly justified in calling them out and in questioning their motivations and behavior.

I know Christina can speak for herself, but I feel I need to register my support for her. Had Cristina posted her comments on almost any other mental health blog, she would have been mercilessly attacked by no end of perpetually angry people.

So forgive me if I seem to be going out of my way to make "Knowledge is Necessity" a safe place for thoughtful people to speak out, without fear of being abused.

Again, please interpret this in a good light. Your question is a model of how to approach another commenter in a skeptical way, and I'm looking forward to others following your example.

Trust me, once we all settle in here, you will hear a lot less from me. So please forgive me for rambling on for so long.

calvin said...

Anti-psychiatry usually refers to a configuration of groups and theories that emerged in the 1960s hostile to most of the fundamental assumptions and practices of psychiatry. Its igniting influences were Michel Foucault, R. D. Laing, Thomas Szasz and, in Italy, Franco Basaglia. The term was first used by the psychiatrist David Cooper in 1967.[1] Some now prefer the term critical psychiatry to avoid connotations that may appear oppositional merely, although the two concepts are distinct.
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Two central contentions of the anti-psychiatry movement are that:
The specific definitions of, or criteria for, hundreds of current psychiatric diagnoses or disorders are vague and arbitrary, leaving too much room for opinions and interpretations to meet basic scientific standards.
Prevailing psychiatric treatments are ultimately far more damaging than helpful to patients