Tuesday, February 8, 2011

Whitaker vs Quack Psychiatry - Part II

In 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.

Really, this is sick - very sick.


Tony the cretin said...

I would direct you to Daniel Carlat's blog. He has some thoughtful critiques of Whitaker's book that are interesting and not as antagonistic as Nierenberg's.

John McManamy said...

Hey, Tony. Many thanks for the heads up. I went to Carlat's blog an found very intelligent criticism of Whitaker. Carlat makes serious dents in Whitaker's thesis using valid arguments and without personal attacks or cheap shots. He also does it in the spirit of enlightening readers. I'll do a quick report tonight or tomorrow on Carlat's main points. Again, many thanks.

Readers: Please let me know of any other critiques of Whitaker.

Smitty said...

I appreciate Carlat, but still hold Whitaker in the highest regard. I've been a skeptic about medications since my first experience using medications...in 1991. I suppose that makes me mistrust any doctors who have not taken the time to really appreciate a patient's point of view.

Carlat, alas, is still a doctor, and so retains a bias in my mind. Once the man has the pen and the script... I tend to mistrust. I hope one day to meet a doctor who gives me the benefit of the doubt without having to fight for it. When I meet that doctor, I will trust him or her and their caveats about Whitaker's work.

All this criticism of him not reading the science right just pisses me off.

John McManamy said...

Hey, Smitty. I hear you. Nierenberg's refutation was an outrage, and we should be outraged by it. Of all things, HE was the one who read the one who didn't read the science right - glaringly so.

Carlat is a stranger character who seems to have a man-crush on various antipsychiatry bloggers, who can do no wrong in his estimation. Who then fires off hysterical pot shots at doctors he doesn't happen to like (a lot of hidden agenda stuff he fails to disclose).

But for some reason, this time, he seems to have dialed in his critique just right.

As for trust/mistrust, you really got me thinking. Okay, here's the test: Any psychiatrist who is not afraid to get up in front of his peers and patients and loved ones and say, "We have to change the way we practice medicine," - that's a psychiatrist I trust.

Anonymous said...

Dr. Carlat also has a newly published book. It offers an interesting perspective, particularly about his thoughts on working as a hired gun for the pharmaceutical industry, and then deciding that it was not ethical.

Tony Previte said...

Yes, it is sick... and you know what? It's not just psychiatry, it's society. Psychiatry just happens to be the front line player, the offensive line to use a football analogy... The quarterback is the crusty old throwback named society needing to retire. Retire so that a new generation society QB can take over and better manage the team and re-write the play-book!

As someone who has lived with my various labels and done well off of medications exactly 94% of the time in the past 24 years, Robert Whitaker has confirmed for me what I've known all along. Psychiatry as it's largely practiced, is a highly subjective, non-scientific specialty of the mind.

Unfortunately they have taken the position over the past few decades of masquerading medications as magic bullets that if used in the right combination can make a person whole. They've abandoned the psychoanalytic principles of therapy and taken psychology completely out of the game.

But... is it their fault? Is psychiatry itself the boogie-man?

Surprisingly, I say NO!

Psychiatry has been the unwitting participant in molding itself to what society has wanted to see. Psychiatry is the mirror of a profoundly sick society that refuses to acknowledge a fundamental truth. That fundamental truth is that the mind is something that isn't connected to the brain in a one-to-one relationship. To bring in hard science to the equation let us consider that we know without dispute that the brain is neuroplastic. That means that the brain will essentially re-wire and re-map itself when something happens to it. That applies to not only physical damage, but non-physical damage as well. So with that simple FACT, how is it that Psychiatry has purported a belief that science backs up their assertions that these medications are beneficial in the long-term? How is that possible when that simple FACT tells us that our brains will compensate for the things we throw at it? It IS that simple!

John McManamy said...

Hey, Tony P. Yep - we are to blame. You hear MDs across all disciplines complaining about patients who are just looking for a pill as a substitute for refusing to put in the work. So - yes - we created the current practice of psychiatry.

As to your QB analogy, exactly. We need to take over and run a new game plan. We bring up a lot of these issues here, thanks to you and others.

As for "highly subjective non-specialty of the mind," Nobel Laureate Eric Kandel talks of the new "science of the mind," one that incorporates both brain science AND the old psychoanalytic principles.

As you can see, I love these discussions. :)

Tony Previte said...

Absolutely!! Now we just have to bring it forth with action... and it's happening, but alas it's quite SLOW. If you haven't taken a gander at this, you might want to have a look at Richard Brodie's Virus of the Mind and the emerging Science of Memetics. http://bit.ly/dJIRQ5

Devon said...

I read Whiatker's book, then well, started to decline, or deteriorate cognitively, from 9 shocks, and the failure of my psychiatry to factor in my HYPOXIC brain injury into the equation.

Whitaker makes great sense over all, I believe that our receptors to get sensitized to the drugs, and I believe that it causes chronicicty of the disease and so on, in many cases, but MOST crucial is it damn well damages the brain.

We know that antipsychotics, same recipe, same forumula first and second generation, are the same kind of damage to the brain, as was shown in numerous studies.

and we know ECT is instant "closed head injury damage" from the Sackeim 07 study, and of course all of the brain dead, survivors who sleep their days away not remembering their lives...I am one of them, yes I'm pretty sure cause equals correlation, in this case.

But will psychiatry ever pay for their crimes? Will there ever be an apology, heh, no most get away with mentally and often physically "murdering" their patients, their spirits, their intellect, and their vital organs, and when we complain, it's the f'ing illness.

I loved it when I went to my neuro told him of mhy ECT's my birth injury, and all the insults that a 7 year old would immediately see, but these guys are better lawyers than doctors, he said you seem hypomanic, well no kidding, good dr. I have no brain, am wired up on adrenal supplements just to get out of bed,

and yes thanks for wasting my time, and giving me more psyche meds that I won't take.