yesterday’s piece, I reviewed earlier posts here on Robert Whitaker’s 2010 “Anatomy of an Epidemic,” which presents a well-reasoned argument in support of the proposition that over the long term psychiatric meds may worsen - not improve - the course of mental illness. On January 13, Whitaker delivered a grand rounds to Mass General, using chapter six of his book, “A Paradox Revealed,” to make his case.
Chapter six features a 15-year study by Martin Harrow of the University of Illinois. The study was meant to identify good prognosis schizophrenia patients likely to benefit from from being weaned off their antipsychotics, but Whitaker interpreted the hard data to support his own conclusion that the patients not on antipsychotics in the study fared way better over the long haul than those on antipsychotics in all subgroups, even the bad prognosis patients.
According to Whitaker’s account of his ground rounds, prominent researcher Andrew Nierenberg of Harvard would then “share his perspective” (in the words of the grand rounds invitation) following Whitaker’s presentation.
Dr Nierenberg was one of the principal investigators of the NIMH-underwritten STEP-BD bipolar trials of the mid-2000’s and was also involved in its sister STAR*D depression trials. STEP-BD found that only one in three patients got well and stayed well on their meds over two years while STAR*D found that only one in four achieved a similar result over one year on their antidepressants.
I have heard Dr Nierenberg deliver very insightful talks at various American Psychiatric Association annual meetings, one in which he challenged the doctors in the audience to actually measure if their patients’ symptoms improved, noting they were likely to be in much worse shape than imagined.
I had occasion to talk with Dr Nierenberg in early 2007, at an NIMH-sponsored one-day conference on child bipolar in Maryland, just outside Washington DC. I was seated in an outside foyer, sipping coffee, reviewing my conference materials prior to the first session, when Dr Nierenberg took a seat next to me and graciously introduced himself. He had recently taken over as Director of the NIMH follow-up to STEP-BD, The Bipolar Trials Network.
I recall mentioning to Dr Nierenberg that it would be great if we could follow the STEP-BD patients over the next 20 years to see what happened, sort of equivalent to a Framingham study. Dr Nierenberg enthusiastically agreed. Alas, funding-funding ...
Naturally, I was looking forward to Dr Nierenberg’s response to Whitaker. On his Mad in America site, Whitaker had his own account of the response, plus downloads to Nierenberg’s slide presentation. I skimmed Whitaker’s account very briefly, then went straight to the slides.
What I saw was extremely disconcerting. From the first slide, Dr Nierenberg - or, rather his evil twin - signaled that he was not there to “share his perspective.” Rather, his presentation read, “A Refutation of The [sic] Anatomy of an Epidemic.”
Then came a Merriam Webster definition of refute, “to prove wrong” or “show to be false or erroneous.”
Stupid-stupid-stupid. Two slides in and Dr Nierenberg was already acting oppositionally defiant, with no intention of engaging in a learned and constructive dialogue. Then came a slide with a definition of repudiate. Then a pic of Sarah Palin with the caption, “repudiate.”
Was Dr Nierenberg actually comparing Whitaker to Sarah Palin? Then a Krugman quote with the word “ignorant." Was Dr Nierenberg referring to Whitaker as ignorant? Other slides portray Whitaker as being stuck in a dark ages Cartesian dualist mindset.
Ad hominem attacks of this nature are in extremely bad taste. They are also extremely unprofessional. They also feed into the stereotype of the arrogant and bullying psychiatrist who prefers lashing out to listening.
It gets worse. Further on in the slide presentation, Dr Nierenberg refers to the Harrow study as “retrospective.” Wrong - dead wrong. The study is “prospective,” which is a much higher standard than retrospective. The first sentence to the study abstract explicitly states it is a prospective study.
If Dr Nierenberg can’t even read a study abstract correctly, then, obviously, he cannot be entrusted to read the labeling to the meds he prescribes to patients. In all likelihood, Dr Nierenberg did not take the time from his very busy schedule to carefully read Whitaker’s book, much less think about it, choosing instead to hand off the assignment, together with his rebuttal, to a graduate assistant.
This type of thing goes on all the time in academia.
There are various ways of interpreting the Harrow study, and Dr Nierenberg - or his ghost writer - offers the predictable one of the patients in the study going off their meds as likely to be more well in the first place than those who stay on their meds. But this is neither a refutation nor a repudiation. Moreover, the actual data in the study most unequivocally supports Whitaker’s interpretation.
If Dr Nierenberg or any other expert is able to come up with an argument discrediting the Harrow study, we need to hear it. We really do. And it needs to be done in a thoughtful way that doesn't insult our intelligence.
(An excellent review of the Harrow study is presented by an anonymous patient blogger on Ruminations on Madness.)
Almost out of desperation, Dr Nierenberg came up with a study of a Chinese population that was not even on the point. It gets even more bizarre. Although Whitaker did not bring up antidepressants in his talk, Dr Nierenberg decided to refute and repudiate chapter eight of his book dealing with long-term antidepressant treatment. But the study Dr Nierenberg cited was not a long-term study. Yes, it tracked patients over 25 years, but the actual trial merely tested for dose efficacy over the short term.
It was as if Dr Nierenberg told his assistant, Dig up a study - any study.
What is totally weird is that the best long term trial data on antidepressants - one that shows a dismal result that supports Whitaker - comes from the very STAR*D trial that Dr Nierenberg himself was involved in.
Early in his “refutation,” Dr Nierenberg served up population statistics to rebut Whitaker’s claim of an epidemic in psychiatric disabilities, coinciding with steep rises in psychiatric prescriptions. I’m sure a crack epidemiologist could challenge Whitaker on this, and I would love to hear from one. I will compassionately spare you from Dr Nierenberg’s embarrassing presentation.
This is Dr Nierenberg’s final slide.