McMan's First Annual (Or Whenever) Psychiatric Exasperater Awards

One of the things I love about my job is the challenge of chasing a moving target. There are no certainties. Every idea is on the table. In place of what we now call psychiatry, a whole new science of the mind is beginning to emerge. A quick scroll through my blog pieces over the last year reveals just a small sample of highly dedicated scientists who are are changing the way we think:

Jill Bolte Taylor, Nora Volkow, Husseini Manji, Hagop Akiskal, Marsha Linehan, Fred Gage, David Braff, Nancy Andreasen ...

Likewise, hats off to the authors and commentators and film-makers who connect the dots and challenge us to connect our own: Robert Whitaker, Pete Earley, John Gartner, Jonah Lehrer, Katie Cadigan ...

Not to mention some of my favorite bloggers: Therese Borchard, Willa Goodfellow, Gina Pera ...

Plus no end of the unsung, those in the trenches, responding to the call, refusing to take no for an answer, rolling up their sleeves and doing - doing, doing ...

But scroll through my recent blog pieces and you will also encounter a number of individuals I have felt duty-bound to call out for their flagrant violation of the facts. Spirited and even heated discussion has a way of moving the conversation forward, but only when the facts are honored. In some strange and ineffable way, we move closer to an ever-elusive truth. Humanity is served.

The individuals I have singled only seem to serve themselves. Coincidentally, these individuals happen to be psychiatrists. So, without further ado, my first annual (or whenever) Psychiatric Exasperater Awards ...

Andrew Nierenberg

Earlier this year, Andrew Nierenberg, professor of psychiatry at Harvard and a prominent researcher into mood disorders, purported to “repudiate” and “refute” compelling evidence raised against indiscriminate use of antidepressants and antipsychotics by Robert Whitaker, author of “Anatomy of an Epidemic.”

Had Dr Nierenberg accomplished but one one-hundredth of his stated mission, I would have thanked him for profusely for adding his learned voice to a badly needed dialogue. Instead, Nierenberg - obviously without having even read Whitaker’s book - resorted to ad hominem attacks (comparing Whitaker, whom he referred to as “ignorant,” to Sarah Palin), faulty marshaling of facts (such as misrepresenting one key study as “retrospective” when it was in fact prospective), and a very sick attempt at humor (such as showing a slide with a fake insulting black box warning appended to Whitaker’s book).

In the end, the only thing that Nierenberg proved was his own intellectual bankruptcy. As for Whitaker, we are still awaiting a credible response from someone with an MD.

(See Whitaker vs Quack Psychiatry - Part II.)

Peter Kramer

Earlier this month, Peter Kramer, clinical professor of psychiatry and human behavior at Brown University, published an article in the NY Times, entitled “In Defense of Antidepressants.” Dr Kramer is author of the 1993 “Listening to Prozac,” the product of a far more credulous age when researchers and clinicians and patients alike believed in miracle treatments for illnesses we actually still know next to nothing about.

In his article, Dr Kramer presumed to respond to an uncontradicted scientific study with his own speculation. Just that - speculation, no facts, no science. Moreover, Dr Kramer willfully ignored both the leading real-world clinical trial that cast considerable doubt on treating depressed patients like guinea pigs, as well as very strong evidence of the very harmful effects of prescribing antidepressants to substantial portions of the population.

We would all benefit enormously from an intelligent discourse on when and when not to use antidepressants. On that vital point, Dr Kramer had nothing to contribute. Instead, in defiance of both reality and “first do no harm,” Dr Kramer would have the general public believe it is still 1993.

(See Peter Kramer and Antidepressants - Oy!)

Stuart Kaplan

The June 19 Newsweek contained an article by Stuart Kaplan, clinical professor of psychiatry at Penn State. The article - “Mommy, Am I Really Bipolar?” - is adapted from his new book, “Your Child Does Not Have Bipolar Disorder.” Asserted Kaplan: “There is no scientific evidence to support the belief that bipolar disorder surfaces in childhood.”

Except, of course, for a whole bunch of kids who cycle in and out of depression and mania.

Well, no, says Kaplan. These kids are really ADHD or oppositionally defiant. Or have something called “temper dysregulation disorder.” Anything but bipolar. The following flat-out misstatement screams for the return of the Star Chamber: “The description of childhood bipolar disorder by its advocates is dramatically different [from adult bipolar].”

No it’s not.

Had Dr Kaplan stuck to the facts, he could have assisted us in our understanding of how best to improve the lives of kids in obvious distress, not to mention their families. Instead, by dogmatically clinging to an absolutist position, Dr Kaplan came across as the head cheer-leader in an academic food fight. Unfortunately, this food fight involves the well-being of our children.

(See The Child Bipolar Diagnosis is Under Attack - Yet Again.)

Allen Frances

Reading Allen Frances on Psychology Today and the Psychiatric Times is as painful as viewing a painting by Thomas Kinkade. Dr Francis, professor emeritus at Duke University, headed up the DSM-IV of 1994. With the unveiling of the draft DSM-5 in Feb 2010, Dr Frances returned to the spotlight as its loudest and most inept critic.

Essentially, there are two Dr Frances - the one who fell in love with his 1994 opus and will brook no changes, and the one who feels he has sinned against humanity for his 1994 opus and likewise will brook no changes. In either case, his arguments come across as disordered and bizarre.

In citing numerous experts critical of DSM-5 changes, Dr Frances overlooks the obvious, namely that most of the problems faced by those working on the DSM-5 are the direct result of the Frances-led failures in bringing the DSM-IV into some kind of alignment with clinical reality back in 1994. The critics of the DSM-IV are justifiably legion. Not a peep from Dr Frances on this.

Dr Frances, by virtue of his elder statesman status, was in the enviable position of setting the tone for the debate, and thus informing us all on the challenges of taking diagnostic psychiatry into a new era. As it happened, intelligent expert commentary never materialized. Present and future generations of those seeking professional help will end up paying dearly.

(See The Dimensional Side to Personality.)

Final Word

With a major paradigm shift underway, we are living in an age of both inspiration and exasperation. The “inspirators,” though clearly the wave of the future, are by no means infallible - hence the need for spirited conversations. The “exasperaters” see themselves as guardians of the old paradigm and are often right a lot of the time, hence - again - the need for spirited conversations.

Unfortunately the exasperaters cited here add nothing to the conversation. To the contrary, they come across as authoritarian, anti-intellectual, and as maladaptive reactors to their changing environments. Hysterical reactionism is always a response to progress, which is good news. The bad news is that as the paradigm further shifts, we are likely to witness much more of this type of behavior.

Stay tuned for my next crop of annual awardees. I guarantee you won’t have to wait a year.

Peter Kramer and Antidepressants - Oy!

I was going to have a relaxing evening tonight, recovering from my trip to Chicago and a very busy four days at the NAMI national convention, plus two days in airports. I was saving tomorrow for gradually settling back into my blog with some of cool stuff I came across in Chicago. Then I encountered a piece in the July 9 NY Times by Peter Kramer, entitled, “In Defense of Antidepressants.”

Okay, before we start, here’s an extract from my lead mcmanweb article on antidepressants:

The strongest scientific evidence we have is not how well antidepressants work, but how badly they perform and how harmful they may be to certain individuals. Here's the low-down:

Two meta-analyses of the FDA clinical trials conducted by Irving Kirsch of the University of Connecticut in the late 1990s-early 2000s of Pharma-sponsored clinical trials - including ones not published - in the FDA database found that antidepressants worked only marginally better against depression than placebos. There have been a number of expert rebuttals to these findings, but no actual study to contradict Kirsch.

The article reports on the most authoritative real-world study on antidepressants, the NIMH-underwritten STAR*D from the mid-2000s. We continue from my article:

Commenting on STAR*D, in a 2009 blog, Nassir Ghaemi MD of Tufts University noted that:

“Even if antidepressants worked in the short term (2 months, which is also what the meta-analysis assessed), one-half of patients who stayed on them relapsed into depression within one year. At the one year outcome, only about 25% of patients actually had remained well on and tolerated an antidepressant, much below the levels most clinicians seem to feel occurs in their clinical experience.”

One in four! According to the best data we have, just one in four individuals treated with an antidepressant get well and stay well. And this was in the best possible care setting. Is your clinician aware of this? Probably not.

Neither is Peter Kramer of Brown University. Dr Kramer is the author of the 1993 “Listening to Prozac,” which is largely a product of the time, back when we all trusted Pharma a lot more than we do now. We have learned a lot since then, including the fact that these drugs can be highly destabilizing to individuals with bipolar and with depressions that cycle like bipolar.

But Dr Kramer in his NY Times article mentions neither STAR*D nor the obvious risks of taking an antidepressant. Huh?

Dr Kramer’s defense of antidepressants is specious and drearily unoriginal, one based on a speculative nitpicking of Kirsh. Back in a newsletter piece I did nine years ago, I referred to this as the “Van Meegeren Defense.”

Prior to World War II, Han Van Meegeren earned a nice living for himself selling bad forgeries of Vermeers. When World War II came along, one of Van Meegeren’s customers turned out to Reichsmarshall Hermann Goring. After the War, Van Meegeren was arrested for collaborating with the Nazis and charged with treason.

Here’s the part of the story I love: Van Meegeren’s defense to selling cultural treasures to the Nazis was that they were not real Vermeers, but his own forgeries. In other words, he had to convince the court that he had cheated.

Okay, now that you “get” the Van Meegeren Defense, here is what Dr Kramer has to say in his NY Times article:

Consequently, companies rushing to get medications to market have had an incentive to run quick, sloppy trials.

In other words, to cheat. What Dr Kramer is saying is that clinical antidepressants trials sponsored by drug companies might have yielded better results had they stuck to protocol and included only patients most likely to respond to antidepressants, namely those with severe depression. In effect, the drug companies, in their haste to recruit patients, probably included a substantial number of likely non-responders, namely those with milder forms of depression or those who plain lied to get into a trial. Thus, according to Kramer:

Often subjects who don’t really have depression are included — and (no surprise) weeks down the road they are not depressed. People may exaggerate their symptoms to get free care or incentive payments offered in trials. Other, perfectly honest subjects participate when they are at their worst and then spontaneously return to their usual, lower, level of depression.

As I stated earlier, this is not a new explanation. I first came across it soon after Kirsch’s second meta-analysis was published in 2002. Basically, academic critics acknowledged that Kirsch had made a bullet-proof case based on the evidence. So, then, how to explain the evidence?

Ah, the Van Meegeren Defense. In other words, if the drug companies had not cheated to begin with, maybe, just maybe, the results might - just might - have come out more in their favor.

It’s all speculation, of course. The only real way to counter Kirsh’s bullet-proof evidence is with bullet-proof evidence of one’s own. And while we're at it, to come up with an authoritative real-world study to counter the STAR*D real-world study.

There are many nuances to the antidepressant debate, and in all likelihood these meds work for a certain subpopulation of depressed patients (if we only knew who they were), but - again - this is speculation, not science.

The bottom line is the most convincing evidence we have on the (non)efficacy of antidepressants comes from Kirsch and STAR*D. The only counter-evidence is recycled speculation, Kramer-style.

***
Robert Whitaker on his Mad in America blog picks Kramer apart in far greater detail, concluding with:

On Sunday, in this essay "In Defense of Antidepressants," the American public has been treated to yet another dose of misinformation. 

Rerun: Depressed or Thinking Deep - My Take

From Nov, last year. Enjoy ...

Therese Borchard of Beyond Blue always has a way of making me feel that on a planet of six billion strangers I have at least one person I can talk to. Last week, she opened a blog piece this way:

I spent my adolescence and teenage years obsessing about this question: Am I depressed or just deep?

When I was nine, I figured that I was a young Christian mystic because I related much more to the saints who lived centuries ago than to other nine-year-old girls who had crushes on boys. I couldn't understand how my sisters could waste quarters on a stupid video game when there were starving kids in Cambodia. Hello? Give them to UNICEF!

Now I look back with tenderness to the hurting girl I was and wished somebody had been able to recognize that I was very depressed.

See what I mean? I just know that had we been in the same class at grade school, while the other kids played ball during recess, Therese and I would have found a quiet spot to sit under a shade tree, sharing cookies our moms packed and discussing how Augustine of Hippo must have felt after Alaric the Visigoth sacked Rome in 410 AD.

So, what was it? Were Therese and I two sensitive souls waxing philosophical, or two depressives acting strange? Therese cites both Paula Bloom PsyD (from a blog on PBS) and Peter Kramer MD, author of "Against Depression" (from a NY Times piece) in support of the proposition that depression and thinking deep are clearly distinct. Says Dr Kramer:

"We idealize depression, associating it with perceptiveness, interpersonal sensitivity and other virtues. Like tuberculosis in its day, depression is a form of vulnerability that even contains a measure of erotic appeal." First the ancient Greeks, then Renaissance thinkers, and later the Romantic movement assigned spiritual and artistic and even heroic virtues to melancholy. Nonsense, Dr Kramer responds. "Depression is not a perspective. It is a disease."

If I interpret Therese correctly in her blog piece, she found comfort in this. It came as a great relief to her to realize that her capacity to think deep, even at a young age, although unusual, was not pathological.

I, on the other hand, have an entirely different reaction. "Wait!" I want to scream at Dr Kramer. "You mean my depressions have all been for nothing?" My lost hours, lost days, entire lost years, a lost life practically, served no useful purpose whatsoever?

Screw you, Kramer! I want to keep screaming for no logical reason, whatsoever. Something that took so much from me, so much out of my life, I demand some kind of return - Jedi powers, a mystical third eye, roll-over phone minutes, whatever.

Yes, Dr Kramer is right, but so is everyone else. When it comes to the enduring question - Who the hell am I? - we are all struggling to find the truth. Here's what I'm looking at right now:

Proposition One: Any depression that is not part of my temperament sucks - whether mild or severe. Take my depression - please. They throw me off my game, ruin my day, wreck my life. Whether it's a depression that is the equivalent of a mild cold or one that is psychic double pneumonia I seriously don't want to be inside my brain on this planet when my neurons have gone on strike. If this is the disease that Peter Kramer is talking about, I'm behind him one hundred percent.

Proposition Two: At the same time, mild to moderate depression is part of my temperament, my personality (as is hypomania). As opposed to my disease depressions, I'm very comfortable in this state. It is a part of who I am. My energy is down, my thoughts tend to be very dark, but - here's the key difference - I thrive in this state. My neurons are working with me, or perhaps me with my neurons. It's as if I'm calmly sifting through the ideas I rounded up in my hypomanic frenzies, whether I'm lying in bed, at my desk, or taking a walk. If this is Dr Kramer's version of just thinking deep, I would have to respectfully disagree.

What we are talking about is the classic distinction between "state" and "trait." Trait is who we are. State is invasion of the brain snatchers. But no distinctions are ever as clear-cut as they seem.

We tend to get hung up on DSM-IV check lists while ignoring a key DSM injunction - namely that we are only in a state of mental illness when the symptoms interfere with our ability to function (as in work or relationships). So - from my personal perspective - if I am comfortable and not struggling while depressed, then I hardly have an illness that needs treatment.

Now let's flip it. I also get hypomanic, and I've written a lot about this. Here's the test: For Marilyn Monroe to act like Marilyn Monroe (at least when she's up) - that's normal, for Marilyn, anyway. For someone else to act like Marilyn Monroe, on the other hand - that's probably a sign that very bad things are about to happen.

So, back to depression. For me to act like me (when I am down), under most situations that is normal for me. I can handle it, it is healthy. For someone else to act like me, trust me, that is cause to get one's personal affairs in order.

Here's where it gets complicated. When does my productive depression start becoming a nuisance and when does this nuisance seriously start messing me up? Similarly, when does my upbeat hypomania cross over into social embarrassment and in turn morph into something that causes me to make very bad decisions?

It's as if we're turning up the heat. When, in effect, instead of a nice warm soak in the tub, do we find ourselves in hot water? Everyone has different tolerance thresholds, and you can make a good case that we can expand the range of these thresholds to lead healthier lives. Of course, every time I congratulate myself on doing this, God just laughs and throws a psychic lightning bolt in my direction.

So - my normal would probably cause most people to stay in bed for six months, or (in the other direction) have neighbors dialing 911.

One more twist. In her blog, Dr Bloom reported on this confused reaction from a patient: "When I reflected to her that she sounded depressed she said 'I don’t think so, that is just my personality.' So many people confuse depression with just being a lazy, unmotivated person."

So our depressed state tends to give us a wrong read on our baseline traits. Who the hell are we? It's a question I'm still trying to figure out.

***
Therese is my fellow terminal deep thinker and favorite blogger. Please check her out at Beyond Blue.

Depressed or Thinking Deep - My Take

Therese Borchard of Beyond Blue always has a way of making me feel that on a planet of six billion strangers I have at least one person I can talk to. Last week, she opened a blog piece this way:

I spent my adolescence and teenage years obsessing about this question: Am I depressed or just deep?

When I was nine, I figured that I was a young Christian mystic because I related much more to the saints who lived centuries ago than to other nine-year-old girls who had crushes on boys. I couldn't understand how my sisters could waste quarters on a stupid video game when there were starving kids in Cambodia. Hello? Give them to UNICEF!

Now I look back with tenderness to the hurting girl I was and wished somebody had been able to recognize that I was very depressed.

See what I mean? I just know that had we been in the same class at grade school, while the other kids played ball during recess, Therese and I would have found a quiet spot to sit under a shade tree, sharing cookies our moms packed and discussing how Augustine of Hippo must have felt after Alaric the Visigoth sacked Rome in 410 AD.

So, what was it? Were Therese and I two sensitive souls waxing philosophical, or two depressives acting strange? Therese cites both Paula Bloom PsyD (from a blog on PBS) and Peter Kramer MD, author of "Against Depression" (from a NY Times piece) in support of the proposition that depression and thinking deep are clearly distinct. Says Dr Kramer:

"We idealize depression, associating it with perceptiveness, interpersonal sensitivity and other virtues. Like tuberculosis in its day, depression is a form of vulnerability that even contains a measure of erotic appeal." First the ancient Greeks, then Renaissance thinkers, and later the Romantic movement assigned spiritual and artistic and even heroic virtues to melancholy. Nonsense, Dr Kramer responds. "Depression is not a perspective. It is a disease."

If I interpret Therese correctly in her blog piece, she found comfort in this. It came as a great relief to her to realize that her capacity to think deep, even at a young age, although unusual, was not pathological.

I, on the other hand, have an entirely different reaction. "Wait!" I want to scream at Dr Kramer. "You mean my depressions have all been for nothing?" My lost hours, lost days, entire lost years, a lost life practically, served no useful purpose whatsoever?

Screw you, Kramer! I want to keep screaming for no logical reason, whatsoever. Something that took so much from me, so much out of my life, I demand some kind of return - Jedi powers, a mystical third eye, roll-over phone minutes, whatever.

Yes, Dr Kramer is right, but so is everyone else. When it comes to the enduring question - Who the hell am I? - we are all struggling to find the truth. Here's what I'm looking at right now:

Proposition One: Any depression that is not part of my temperament sucks - whether mild or severe. Take my depression - please. They throw me off my game, ruin my day, wreck my life. Whether it's a depression that is the equivalent of a mild cold or one that is psychic double pneumonia I seriously don't want to be inside my brain on this planet when my neurons have gone on strike. If this is the disease that Peter Kramer is talking about, I'm behind him one hundred percent.

Proposition Two: At the same time, mild to moderate depression is part of my temperament, my personality (as is hypomania). As opposed to my disease depressions, I'm very comfortable in this state. It is a part of who I am. My energy is down, my thoughts tend to be very dark, but - here's the key difference - I thrive in this state. My neurons are working with me, or perhaps me with my neurons. It's as if I'm calmly sifting through the ideas I rounded up in my hypomanic frenzies, whether I'm lying in bed, at my desk, or taking a walk. If this is Dr Kramer's version of just thinking deep, I would have to respectfully disagree.

What we are talking about is the classic distinction between "state" and "trait." Trait is who we are. State is invasion of the brain snatchers. But no distinctions are ever as clear-cut as they seem.

We tend to get hung up on DSM-IV check lists while ignoring a key DSM injunction - namely that we are only in a state of mental illness when the symptoms interfere with our ability to function (as in work or relationships). So - from my personal perspective - if I am comfortable and not struggling while depressed, then I hardly have an illness that needs treatment.

Now let's flip it. I also get hypomanic, and I've written a lot about this. Here's the test: For Marilyn Monroe to act like Marilyn Monroe (at least when she's up) - that's normal, for Marilyn, anyway. For someone else to act like Marilyn Monroe, on the other hand - that's probably a sign that very bad things are about to happen.

So, back to depression. For me to act like me (when I am down), under most situations that is normal for me. I can handle it, it is healthy. For someone else to act like me, trust me, that is cause to get one's personal affairs in order.

Here's where it gets complicated. When does my productive depression start becoming a nuisance and when does this nuisance seriously start messing me up? Similarly, when does my upbeat hypomania cross over into social embarrassment and in turn morph into something that causes me to make very bad decisions?

It's as if we're turning up the heat. When, in effect, instead of a nice warm soak in the tub, do we find ourselves in hot water? Everyone has different tolerance thresholds, and you can make a good case that we can expand the range of these thresholds to lead healthier lives. Of course, every time I congratulate myself on doing this, God just laughs and throws a psychic lightning bolt in my direction.

So - my normal would probably cause most people to stay in bed for six months, or (in the other direction) have neighbors dialing 911.

One more twist. In her blog, Dr Bloom reported on this confused reaction from a patient: "When I reflected to her that she sounded depressed she said 'I don’t think so, that is just my personality.' So many people confuse depression with just being a lazy, unmotivated person."

So our depressed state tends to give us a wrong read on our baseline traits. Who the hell are we? It's a question I'm still trying to figure out.

***
Therese is my fellow terminal deep thinker and favorite blogger. Please check her out at Beyond Blue.