Rerun - Thinking Outside the Box: Lessons in Military History, Part II

I'm doing some research based on some talking points Robert Whitaker raised in his book, "Anatomy of an Epidemic" and a recent blog piece of his. In the meantime, another history lesson, published in July last year ...

In Part I, we looked at how thinking outside the box enabled the Romans to defeat rival Carthage at its own game in the First Punic War. Instead of facing the vastly more experienced Carthaginian navy on their own terms, the newbie Romans figured out, in essence, how to stage a land battle at sea.

In Part II, we investigate a mirror opposite, how the American Revolution’s best general (on both sides) took on the British Royal Navy deep in the American wilderness.

The Battle of Valcour Island, 1776

Washington forced the British garrison out of Boston in the spring of 1776, but they returned with a vengeance several months later, with a huge fleet bearing a large army weighing anchor in New York and another armada sailing up the St Lawrence into Quebec.

The British had no problem routing Washington’s army just outside New York City and reducing it to a remnant as it occupied the city and asserted itself in New Jersey. In Canada, they easily swept aside the badly outnumbered Americans there. A British invasion from the north and into New York would bring a swift end to the ill-fated colonial rebellion.

One of the American commanders in Canada, Benedict Arnold, fought a brilliant delaying action, destroying British ships, fortifications, and sawmills as he retreated south.

The British Army followed to the northern shore of Lake Champlain, deep in what was then impenetrable wilderness, while the Americans regrouped on the southern end. This set the stage for one of the strangest campaigns in military history.

The key to transporting the British Army south to New York City was via the waterways, first Lake Champlain, then Lake George, then down the Hudson. But first the British needed to build a fleet, and so did the Americans, if they intended to stop the British.

The Americans had already commandeered a sloop or two, but were at a decided disadvantage, lacking the necessary shipwrights and sailors, as well as supplies and resources.

The British, in the meantime, came well prepared, with 10 prefabricated ships, plus a 180-ton warship that they took apart in Canada, carted overland, and reassembled on Lake Champlain, not to mention the necessary shipwrights to build more boats. By the end of the summer, the British had a fleet of 25 heavily-armed vessels, commanded by a captain of the Royal Navy, together with a full complement of officers and sailors.

More boats were equipped to transport 9,000 British Army regulars.

The Americans, under the leadership of Benedict Arnold, proved extremely resourceful in knocking out their own boats - some little more than wooden platforms - to bring their roster to 15. These were built by mostly carpenter labor, manned in large part by ragged soldiers turned sailors. Arnold was a general who happened to have experience as captain of his own merchant ship.

In mid-October, as the nearby mountains turned white with snow, Arnold headed north with his strange flotilla of 500 “sailors” to meet the British. His intention was to lure the British into the narrow rocky strip of water between Valcour Island and the western shore of Lake Champlain. Here, the British would have difficulty bringing their superior firepower and sailing skills to bear.

The disadvantage was the Americans were backed into a corner, with nowhere to run.

The inferior American fleet held up under a withering British bombardment at extremely close range, managing to inflict serious damage in the process, but as the sun set it was clear the day belonged to the British. Virtually every American boat was ready for salvage. The British, meanwhile, were sitting pretty with ships that had not yet joined battle.

Facing the certainty of total annihilation, Arnold effected a brilliant escape in the dead of night, but with the British in hot pursuit. Under hellish weather conditions, one ship was captured while others had to be scuttled. The remnants of his fleet managed to make it to a refuge, where the boats were torched.

Arnold succeeded in leading the 200 remaining men under his command overland to an American fortification at Crown Point, thence (with the Crown Point garrison) to Ticonderoga, where a large contingent of American irregulars were dug in.

After that, the only thing standing between the British advance down the Hudson (and inevitable victory) was the oncoming winter. It turned out in losing the battle, Arnold had in fact set the scene for winning the war. By forcing the enemy to engage in an arms race way out in the middle of nowhere and then join battle, Arnold had run out the clock, delaying the British offensive by a good three months.

The Brits' only option was to retire to winter quarters in Quebec and try again next spring. This bought the American cause a precious year, time for Washington to rebuild his ragtag remnant of an army into a highly-trained fighting force. Time to assemble a strong regular army on the northern front.

When the British attempted a second invasion a year later, the Americans were ready, with an overwhelming force at Saratoga. The outstanding commander in the field was Benedict Arnold.

Arnold’s extraordinary military achievement is a shining example of thinking outside the box, of reframing issues and coming up with solutions where none seemingly exist. Unfortunately, by shifting his allegiance to the British later in the war and thus betraying his country, Arnold is much better known as a sober object lesson in thinking far too far outside the box.

Thinking Outside the Box: Lessons From History - The Pax Mongolica

I just finished reading Jack Weatherford's "Genghis Khan and the Making of the Modern World." The author, a professor who knows how to write, doesn't exactly present a kinder and gentler Genghis from the one we imagine. But he does make a very strong case that, contrary to popular belief, the net effect of his conquests proved extremely beneficial. Basically, Europe was far too backward to boot up from feudalism to the Renaissance on its own, even with an assist from nearby civilizations.

At the time of his death in 1227, Genghis Khan's holdings extended from the Caspian Sea to the Sea of Japan, embracing virtually all of central Asia, down into China, up into the remote northern steppes. The sheer immensity of his conquests makes Alexander the Great look like a neighborhood bully by way of comparison. Likewise, the Roman Empire and Muslim Caliphate come across as mere subdivisions. Not to be outdone, his successors overran eastern and central Europe, much of the Middle East, and coaxed the rest of China into the fold. In the process, the Empire split into four separate Khanates, but nevertheless kept operating as a fairly cohesive entity.

Historians refer to the 13th and 14th centuries as the "Pax Mongolica." While Europe was contending with war and religious intolerance, Mongolian-ruled Eurasia was enjoying a time of unprecedented peace and prosperity, thanks to the vision of its unlikely founder. Against all odds, young Genghis survived a brutal childhood as part of an outcast family before going on to unite his feuding klansmen into a force to be reckoned with. A brilliant organizer and visionary, he applied the lessons of the remote and inhospitable steppes to managing the world, continuing to learn as he faced new challenges.

The legacy he passed onto his successors included rule of law, secular government, religious toleration, cultural diversity, promotion of learning, free trade, patronage of the arts, the spread of technology, paper currency, appointment by merit, administrative accountability, and much more - one people under one sky.

Suddenly, a seller in China could find a buyer in Europe. Over a now secure Silk Road and new sea routes, goods and ideas flowed in all directions while the standard of living kept improving. The printing press, paper, gunpowder and the compass came west while Arabian science and other advances diffused everywhere. On and on it went, the best of all worlds nurtured by a strange new ruling class unfettered by old conventions.

As Jack Weatherford explains it, "most empires of conquest imposed their own civilizations on the conquered." By contrast, the Mongolians came to the table empty-handed but open-minded. "They did not have to worry about whether their astronomy agreed with the precepts of the Bible, that their standards of writing followed the classical principles taught by the mandarins of China, or that Muslim imams disapproved of their printing and painting."

Likewise, the rulers of the new Mongol Empire had nothing in common with the parasitic aristocracies of the lands they conquered, keepers of the old prejudices. These they killed off wholesale at the slightest pretext.

Of course, nothing lasts forever. Universal ideals were already yielding to the inadequacies of human nature when the largest empire in history was brought down by the humble flea. The bubonic plague broke out in China in the 1330s and spread throughout the rest of the known world on the very trade routes the Mongols had opened up. One-third of China succumbed to the Black Death and anywhere from a quarter to a half of Europe's population met their untimely end.

The plague hit hardest in populated urban centers, literally wiping out the brains of the empire. Commerce and communications ceased. Lands near and far lost touch. The Mongols lost control of their empire and became absorbed into the populations they once ruled. The old order reasserted itself, insular and intolerant, walling the rest of the world out, themselves in.

The Pax Mongolica became a distant memory, but enough after-effects remained to inspire new generations to start thinking outside the box again and shake things up. Ironically, the winds of change blew hardest in backward Europe. History would never be the same ...  

Rerun: Great Moments in Sports History - Game 7 of the 1960 World Series

This from last year, slightly edited ... 

Any enemy of the Yankees is a friend of mine. Nothing personal, just normal blood feud stuff, you know, like the Montagues and Capulets, Bloods and Crips, Mac and PC. Last week, the Rangers eliminated the Yankees, so in this World Series I can freely root for both sides.

I grew up in a Red Sox household in the middle of Connecticut, almost midway between New York and Boston. This meant that every day of my life, I endured the incessant put-downs of those fortunate enough to have been born of Yankee parentage. This was the era of Mickey Mantle and Yogi Berra and Whitey Ford. I think after Ted Williams retired, Eva Gabor was the power hitter for the Red Sox.

The Yankees were perennial pennant winners all during when I grew up. This meant every fall I cheered for whoever they went up against in the World Series - the Milwaukee Braves in '57 and '58. The LA Dodgers (alas, no longer in Brooklyn) in '59 - wait, the Yankees weren't in the World Series that year ...

What you are looking at is the equivalent of my Mount Rushmore, Statue of Liberty, Washington Monument, and tribute to the guy who invented peanut butter combined. On the site of the old Forbes Field in Pittsburgh marks the spot where Bill Mazeroski's winning home run landed in the ninth inning of the seventh and deciding game of the 1960 World Series between the Pirates and Yankees.

Without doubt, until the Red Sox actually won a World Series in 2004, this was the greatest moment in all sports history in the entire existence of the universe, including galaxies far away. (Have I made my point?)

This was the Yankees tenth World Series in twelve years, the Pirates first since getting pummeled by Babe Ruth and the Yankees' infamous Murderers Row in 1927. Again, the underdog Pirates were hopelessly outgunned. After squeaking out an opening victory of 6 to 4, the Yankees unequivocally reminded the Pirates who was boss in the next two games with scores of 16 to 3 and 10 to nothing. Then the Pirates squeaked two in a row - 3 to 2 and 5 to 2 - only to be bombarded by the Yankees in the sixth game by a score of 12 to nothing.

If this were five-day cricket, the Yankees would be leading 46 to 17. Instead, the Series was improbably tied at three each. It all came down to the final game. This time, at home, the Pirates mustered the necessary firepower. Trailing 7 to 4 after seven innings, they banged out five runs in the eighth to take the lead. But the Yankees tied the score in their turn at bat in the ninth with two more runs.

I will never forget the moment. Back in those days, they played games in the afternoon, which meant kids could actually watch. I got off the school bus at my friend Kenny's house and together, as his mom looked on, we sat on the edge of our seats as the last part of the game unfolded. It was the bottom of the ninth. First batter up was second baseman Bill Mazeroski. Definitely not a power hitter. One ball, no strikes. We held our breaths. The wind up and the pitch ...

Smack! The camera swung toward the ivy brick wall in left field. The announcer went crazy. It could only mean ...

Home run! Home run! Home run! The Pirates win the Series!

Forbes Field instantly erupted into what was then the loudest spontaneous human-generated sound in recorded history. Mazeroski headed into second, whipped off his cap and swung it round and round in celebration. As his teammates mobbed him at the plate, the Yankees on the field simply stood in their positions in postures of shock and disbelief.

These were the days before instant replay. I didn't need one. My neurons lovingly recorded every frame. My mind is playing back the great moment right now. What a scene. What a memory ...

Tuning Out The Distractions

This is the eighth in my series based on talking points raised by Robert Whitaker's eye-opening "Anatomy of an Epidemic."

Continuing on from yesterday. As you recall, I began my piece with an American Psychiatry Association annual meeting I attended in San Francisco in 2003. During the meeting, I happened upon a street demonstration of psychiatric survivors brandishing "Psychiatry Kills" and similar signs.

A few months later, six individuals associated with MindFreedom staged a sophistic public display that boiled down to challenging the APA to prove that mental illness existed, with demonstrable biological causes and effects. Robert Whitaker in "Anatomy of an Epidemic" cited the MindFreedom campaign with approval, noting they had "won this battle." In yesterday's piece, I corrected him. In fact, nobody won. Rather, we all lost.

It works this way: When the loudest in our midst are in denial about the reality of mental illness, we simply don't get decent funding for its research and treatment. The funding goes to illnesses whose patient populations have their act together. Thus, for every dollar the NIH spends researching HIV/AIDS per patient, depression and bipolar get one penny. One penny.

In Sept 2006, a friend took me to a function at a drop-in center in Berkeley, CA, organized by antipsychiatry activists. The meeting started with everyone in the circle, myself included, introducing themselves. One guy bragged how he spearheaded a drive to outlaw ECT in Berkeley in the 1980s.

You’re actually proud of that? I wanted to say. 

Another happened to reveal how she organized the very demo I had witnessed outside the 2003 APA in San Francisco. I had to use all my self-control to breathe through my nose. Here is what I was thinking, sitting in my chair, polite smile frozen into place:

If you had actually followed me indoors rather than made noise on the streets, you might have actually learned something.

The speakers inside actually addressed the questions the MindFreedom people had posed, in a nuanced way that totally challenged the thinking of everyone in attendance. So much so that three years later in Berkeley my head was still spinning. At the APA, I heard Daniel Weinberger of the NIMH report on a 2002 study I have mentioned many times in this blog and elsewhere.

The study linked a certain gene variation to the fear response in the amygdala in the brain's limbic system. For possibly the first time, we had a connection between a gene and emotion. This is not the same as saying we have a connection between a gene and a DSM mental illness. Critical distinction.

At about the same time, a study on a birth cohort in New Zealand found that those with this exact same gene variation had a much greater tendency to become depressed when exposed to certain stressful situations such as financial difficulties.

Again, this is hardly the biological causal link that MindFreedom was demanding. The brain is way too complex to yield those kind of pat answers. What these and numerous follow-up studies showed in essence was that bad things tend to happen when a biologically vulnerable brain is exposed to stressful situations. It's an old theory, but now the brain science was beginning to validate it.

No one talks about genes and biology in a vacuum anymore. It's all about the how genes and biology and environment interact.

At another session, I heard Robert Freedman of the University of Colorado tell a demonstrably appreciative crowd that "genes do not encode for psychopathology." In other words, forget about finding a depression gene or a bipolar gene or a schizophrenia gene. Dr Freedman is a pioneer in "endophenotype." He wondered why those with schizophrenia craved cigarettes. He discovered a variation in a nicotinic receptor gene that may account for this, that had to do with "auditory gating" that plays a major role in tuning out distracting noises.

Ah, if we could only tune out the distractions.

Again, hardly a direct biological causal link to a specific mental illness, which was Freedman's very point. The brain is not organized according to the DSM. That's one reason "depression," "bipolar," "schizophrenia," "anxiety," and so on are at best rough guides. Two individuals with bipolar, for instance, may not even have the same symptoms in common. But they are both likely to have messed up sleep. So let's investigate the messed up sleep and see if that will give us insights into why we find ourselves too depressed to get out of bed in the morning.

Then, maybe, we can come up with specific treatments that address our real problems rather than stupid one-size-fits all remedies that fit only a lucky few. Assuming we get some decent research funding, that is.

That's why "chemical imbalance" of the brain doesn't begin to tell us what is going on. Whitaker very elegantly debunked that particular myth in his book, along with the fallacy of treatments to correct this chemical imbalance. An antidepressant to treat depression? It's a stupid idea if we persist in thinking a depression is a depression is a depression. So far so good. But then Whitaker mistakenly assumes that because the chemical imbalance myth is wrong then the whole premise of psychiatry is wrong.

Whitaker not so implicitly takes this further: If psychiatry is wrong, then antipsychiatry has to be right. The problem is there is no nuance to antipsychiatry. Its spokespersons deny that mental illness exists in the first place, along with the possibility of finding treatments, which explains why everyone at the meeting I walked into in Berkeley talked about their experiences in making noise rather than helping people.

What is really going on is that the whole premise of psychiatry is changing to a point where it may not be called psychiatry anymore. The smart thinkers in the field know that the biological psychiatry/disease model of behavior is long past its sell-by date, and that a new science of the mind is taking its place, even if this is not readily apparent at street level. That is what I observed inside the APA annual meeting in San Francisco in 2003. I wish some of the protestors outside could have followed me in. I wish Whitaker could have followed me in.

Previous blog pieces:

Thanks to Stupid Advocacy, Your Life is Worth Just One Penny

The Study Psychiatry Wishes Would Just Go Away - Part II

The Study Psychiatry Wishes Would Just Go Away

Is the Cure Worse Than The Illness?

The Whitaker Controversy: An Irony in Search of Nuance

If Meds Work as Well as Our Psychiatrists Tell Us, Why Do We Have MORE Mental Illness Today Rather Than Less?

RIP: Chemical Imbalance in the Brain

Thanks to Stupid Advocacy, Your Life is Worth One Lousy Penny

This is the seventh in my series based on talking points raised by Robert Whitaker's eye-opening "Anatomy of an Epidemic."

In late April or early May 2003, I was in San Francisco for six days of the American Psychiatric Association's annual meeting. Two or three days into the conference, as I was making my way across the street from the north complex of the Muscone Convention Center to the south, I came upon an organized demonstration of psychiatric survivors brandishing "Psychiatry Kills" and similar signs.

Their personal experience certainly justified their outrage against psychiatry. An earlier generation was subjected to the horrors of captivity in state institutions. A later generation experienced a different type of abuse in the form of the bad practice of medicine, often applied in a not so subtly coercive "take your meds and shut up" environment.

But I was here to find out what was going on inside the Muscone Center, not outside. I waited till the marchers passed, then made my way to my next round of listening to very smart people talk real fast in dark rooms.

I heard more from the psychiatric survivors a few months later in the form of a challenge to the APA, NAMI, and the Surgeon General issued by six individuals associated with MindFreedom, including its founder David Oaks. Robert Whitaker picks up the account in the last chapter of "Anatomy of an Epidemic":

Among other things, the MindFreedom group asked for evidence proving that major mental illnesses are "biologically-based brain diseases" and for any evidence that "any psychiatric drug can correct a chemical imbalance" in the brain.

The six individuals threatened a hunger strike unless one of the organizations served up the evidence. The APA through its medical director wrote back that "the answers to your questions are widely available in the scientific literature, and have been for years," then suggested a textbook and the Surgeon General's 1999 Mental Health report (which ironically stated "the precise [etiology] of mental disorders are not known").

The Six went on their "fast for freedom," which lasted till medical complications broke out. Then they issued a press release stating that the APA, NAMI, and "the rest of the psychiatric community" were indifferent to those "who would deny that serious mental disorders are real medical conditions ..."

According to Whitaker:

It was clear to all observers who had won this battle. The strikers had called the APA's bluff, and the APA had come up empty.

I'm glad Whitaker saved this account for the last chapter rather than the first. Otherwise I would have tossed his book in the trash. Clearly - unless you subscribe to Thomas Szasz - the biology of the brain influences behavior. We think with our meat (thanks, Terry Bisson, for the metaphor). We feel with our meat. We perceive with our meat. And when our meat malfunctions bad things happen. It doesn't matter what you call it, bad things happen.

If psychiatry is stupid, then the antipsychiatry response is equally, if not more spectacularly, stupid. You don't fight stupid with stupid. If gay activists had been in denial about a mysterious phenomenon that was decimating their population back in the eighties, there would have been minimal funding for HIV/AIDS research and treatment. In fact, at the very beginning of the epidemic the gay population was in denial. Then they got smart. They got loud. They literally intimidated the government and medical establishment into action. In 2009, the NIH allocated $3.19 billion for HIV/AIDS research. By contrast, research for depression (including bipolar) was a mere $402 million.

Million, not billion. These are ratios that have held fairly steady over the years. Approximately 1.5 million individuals in the US are affected by HIV or AIDS. About 19 million in the US in any given year deal with depression or bipolar. That translates to the NIH spending $2,013 per patient for HIV/AIDS research vs a paltry $21 per patient for depression and bipolar. Putting it another way, for every dollar the NIH invests in an HIV/AIDS patient, depression and bipolar patients get one penny.

One penny. That's the value the government and medical establishment places on our lives, in large part based on the stupid and in-denial showboating advocacy that Whitaker so enthusiastically endorses. No, Whitaker, no one "won" that battle. We all lost, bigtime. If the loudest in our midst are denying that mental illness exists, then why fund its research and treatment? Obviously the people responsible for funding things have asked themselves that very same question. Don't get me started.

Next: Too late, you got me started ...

Previous blog pieces:

The Study Psychiatry Wishes Would Just Go Away - Part II

The Study Psychiatry Wishes Would Just Go Away

Is the Cure Worse Than The Illness?

The Whitaker Controversy: An Irony in Search of Nuance

If Meds Work as Well as Our Psychiatrists Tell Us, Why Do We Have MORE Mental Illness Today Rather Than Less?

RIP: Chemical Imbalance in the Brain

The Study Psychiatry Wishes Would Just Go Away: Part II

This is the sixth in my series based on talking points raised by Robert Whitaker's eye-opening "Anatomy of an Epidemic."

Yesterday, I reported on a study by Martin Harrow and Thomas Jobe featured in Robert Whitaker's "Anatomy of an Epidemic." The study tracked 64 young patients with schizophrenia from two Chicago hospitals over 15 years. An eye-popping finding was that 40 percent of those not on antipsychotics were in recovery vs just five percent of those taking antipsychotics.

In his book, Whitaker links this study to "a lengthy chain" of research that shows "evidence that long-term recovery rates are higher for nonmedicated patients." Is Whitaker justified in making this inference? The short answer is yes and no. Now to the long answer:

In their study, Harrow and Jobe did not address the efficacy of antipsychotics in the long term. That would have required an entirely different study design. Rather, Harrow and Jobe sought to tease out subgroups of unmedicated patients who "may show adequate functioning or recovery" over time. The authors were coming from a fairly mainstream point of view, namely: Schizophrenia (or any other mental illness) has many different causes and effects and manifestations across broad populations. Consequently, one-size-fits all treatments are likely to fit very few.

Unfortunately, the psychiatry we know is at the one-size-fits all level, which is the best explanation for why so many patients taking meds get worse rather than better. Psychiatry also wrongly assumes that the same meds and dose levels that work in getting us out of crisis are the same ones that will get us into recovery. We hear much about evidence-based medicine, but this is sadly lacking in psychiatry. Long-term drug trials that actually tell us something are very few and far between.

Clearly, it would help if psychiatry could predict on which specific populations meds are likely to work, especially over the long haul, but Pharma has no financial interest in running its clinical trials that way. Likewise, it would help if we knew which patients were likely to do better NOT staying on their meds, which is what Harrow and Jobe looked into. Specifically, they asked: 1) Can patients not on antipsychotics function well? 2) Which particular groups go off their meds and how does this influence outcome and recovery? 3) Are there various developmental, prognosis, and personality factors that enter into consideration?

In other words, is a patient with a prior work history who is not inclined to attribute his or her circumstances to bad luck, who is showing signs of improvement on their antipsychotic, a possible candidate for weaning off their antipsychotic?

Yes, sort of, conclude the authors. In their own words: "The data indicate significantly better functioning for the patients not on antipsychotic medications." This finding literally turns psychiatry on its head, but it hardly tells the whole story, as the authors note. The finding needs to be read with the study's other main finding, namely: Nearly half the patients not on antipsychotics at the end of the study had "favorable prognostic indices" when hospitalized 15 years earlier, in contrast to little better than one in ten patients still on antipsychotics.

Thus, the patients in the study who remained on antipsychotics were a more-ill group of patients to start with. This second finding hardly overrules the first finding, but it does add nuance. Thus, according to the study's authors:
 
Patients who are internally orientated and have better self-esteem are the types of patients who are more likely, if their functioning improves, to urge that they try functioning without medications and/or to choose to try functioning without any treatment at all.

And again:

The current data suggest that for the select subgroup of patients with schizophrenia who are not in clinic settings, who have gone off antipsychotics and did not immediately relapse, and stayed off them for a period of time, a surprising number experienced periods of recovery and continued to function well for a considerable period without antipsychotics.

Which leads to this conclusion:

Clearly, the present longitudinal data suggest that not all patients with schizophrenia need to use antipsychotic medications continuously throughout their lives.

Obviously, a lot more work needs to be done to zero in on this particular group of patients. A 40 percent recovery rate for schizophrenia patients not on meds is clearly an astounding finding, one that offers hope to a good many. But that same figure also indicates a 60 percent failure rate. And until we find out more, going off meds is going to be as risky, it seems, as staying on meds. The bottom line is we're still flying in the dark.

Thus the critical need for follow-up studies, to build on the work of Harrow and Jobe and others. Sadly, this is not likely to happen. Longitudinal studies are extremely difficult to get off the ground and sustain, and the NIMH - just about the only available funding source in the US - is not a bank.

Thus, the Harrow-Jobe study is all we are likely to have for years to come. This means, instead of a progressive train of enquiry yielding a steady stream of answers, we will continue to be asking questions.

Questions, questions ...  

Previous blog pieces:

The Study Psychiatry Wishes Would Just Go Away

Is the Cure Worse Than The Illness?

The Whitaker Controversy: An Irony in Search of Nuance

If Meds Work as Well as Our Psychiatrists Tell Us, Why Do We Have MORE Mental Illness Today Rather Than Less?

RIP: Chemical Imbalance in the Brain

The Study Psychiatry Wishes Would Just Go Away

This is the fifth in my series based on talking points raised by Robert Whitaker's eye-opening "Anatomy of an Epidemic."

A lot of us have heard the story before, but it strongly bears repeating: In 1969, WHO began tracking schizophrenia patients in nine countries. At the end of five years, those in three developing countries - India, Nigeria, and Columbia - had "considerably better course and outcome" than patients in the US and five other developed countries.

Fluke finding? Bad methodology? In 1978 WHO launched a second study tracking mainly first episode schizophrenia patients in ten countries. The results vindicated the first study. After two years, nearly two thirds of those in the developing countries had good outcomes vs those who were chronically ill. This was virtually the exact reverse of how the patients fared in the western world - 37 percent with good outcomes, 59 percent chronically ill.

According to the researchers: "Being in a developed country was a strong predictor of not attaining a complete remission." Follow-up interviews conducted in 1997 with the patients in these two studies found that 53 percent of those in the developing countries were "never psychotic" again, with 73 percent employed.

Could it be that those in the less developed world have the type of supportive families and communities that prove protective against the stresses of daily living? Or, flipping it around, would it be safe to say that modern society literally sets us up to fail? In a crazy world, where we are subjected to crazy demands with no wiggle room, it's only logical that our rates of mental illness will be higher and rates of recovery lower.

But there is also another big wet matzo ball on the table. As Robert Whitaker in "Anatomy of an Epidemic" reports:

Although the WHO investigators didn't identify a reason for the stark disparity in outcomes, they had tracked antipsychotic usage in the second study, having hypothesized that perhaps patients in the poor countries fared better because they more reliably took their medication. However, they found the opposite to be true. Only 16 percent of the patients in the poor countries were regularly maintained on antipsychotics, versus 61 percent of the patients in the rich countries.

This begs the obvious question: Are our meds obstacles to our recovery? In his book, Whitaker places great emphasis on a 2007 study by Martin Harrow and Thomas Jobe of the University of Illinois. Drs Harrow and Jobe tracked 64 young patients with schizophrenia from two Chicago hospitals over 15 years. After two years, those not on antipsychotics were doing slightly better based on a global assessment scale than those on these meds.

Then, at the next checkpoint - 4.5 years - we find a dramatic divergence. Thirty-nine percent of those off their meds were "in recovery" and more than 60 percent were working. Meanwhile, those on antipsychotics had worsened. Only six percent were in recovery and few were working. These findings held steady over the next ten years. At the end of 15 years, 40 percent of those not on antipsychotics were in recovery and more than half working, with 28 percent dealing with psychotic symptoms. In contrast, just five percent of those taking antipsychotics were in recovery, with 64 percent dealing with psychosis.

As Whitaker reports:

Indeed, it wasn't just that there were more recoveries in the unmedicated group. There were also fewer terrible outcomes in this group. There was a shift in the entire spectrum of outcomes. Ten of the 25 patients who stopped taking antipsychotics recovered, 11 had so-so outcomes, and only four (16 percent) had a "uniformly poor outcome." In contrast, only two of the 39 patients who stayed on antipsychotics recovered, 18 had so-so outcomes, and 19 (49 percent) fell into the "uniformly poor" camp.

These are not exactly the type of findings pharm reps cite to the psychiatrists they visit. Indeed, it is fair to say that the psychiatric establishment would like this study to just go away. Indeed, Whitaker points out, the NIMH, which funded the study, never drew attention to it in a press release (which is a valid criticism) nor does NAMI refer to it on its website (which is way out in left field).

Six years ago, I reported on a presentation that Nassir Ghaemi, now at Tufts, made to a symposium at the American Psychiatric Association annual meeting. Part of my account:

The story begins in 1835 when Pierre Louis first applied the art of counting to the most common medical treatment of the day - bleeding, specifically leeching. Fifty percent of pneumonia patients, Louis discovered, died within three days on the treatment. Prior to the study, 33 million leeches were imported into Paris. Two years after the study, only seven thousand.

Don't expect similar turn-arounds in this day and age. Studies that shake our conceptions tend to raise many more questions than answers, so first we need to be asking questions.

Up next: We ask questions ...

Previous blog pieces:

Is the Cure Worse Than The Illness?

The Whitaker Controversy: An Irony in Search of Nuance

If Meds Work as Well as Our Psychiatrists Tell Us, Why Do We Have MORE Mental Illness Today Rather Than Less?

RIP: Chemical Imbalance in the Brain

Is The Cure Worse Than the Illness?

This is the fourth in my series based on talking points raised by Robert Whitaker's eye-opening "Anatomy of an Epidemic."

It turns out Robert Whitaker and I were sitting in the same room, at the same symposium, at the same conference. The venue was the 2008 American Psychiatric Association annual meeting in Washington DC. The session was on "Antidepressants in Bipolar Disorder." Despite the fact that at the time I was writing mainly on my illness, this was only one of two bipolar sessions I recall attending in the five days I was at the conference.

Over the years, I had been expanding the range of my enquiry, which included a lot of research into brain science, as well as illnesses that backed onto and overlapped with bipolar, such as borderline personality disorder, schizophrenia, PTSD, and ADHD. Having experienced a demonstrable improvement in my mental health following a move to rural southern California about 18 months prior, I had also grown interested in the old fashioned "rest cure." So it was that on the first day of the conference, I found myself panning my video camera over a display of postcards of old asylums and spas.

The old institutions had been founded on enlightened principles. They didn't become chambers of horrors till some time later. Whitaker had written quite a bit about this in his 2002 book, "Mad in America." I was moving into Whitaker's world. He was moving into mine.

By two in the afternoon, I was ready to call it a day. My sleep was badly messed up, and this was no time to be a hero. Moreover, I was hardly about to be startled awake by anything new concerning an issue I had been reporting on for years. But the top bipolar experts in the field would be on the panel - two who had written glowing testimonials for my book - and I was not about to miss an opportunity to reconnect, brain dead or not.

Like me, Whitaker was at the conference for other reasons than to listen to bipolar experts. In particular, he was looking forward to a session in which Martin Harrow would talk about long term schizophrenia outcomes. In the meantime, there were two or three hours to kill. As he reports in Anatomy of an Epidemic: "I figured the speakers would simply present trial results that justified, in one way or another, the use of these drugs ..."

Instead, Whitaker found himself furiously scribbling away. I'm glad one of us had the presence of mind to take notes.

First speaker up was Frederick Goodwin, co-author of the definitive "Manic-Depressive Illness," which had come out as a second edition the year before. As Whitaker reports:

"The illness has been altered ... Today we have a lot more rapid cycling than we described in the first edition (which came out in 1990), a lot more mixed states than we described in the first edition, a lot more lithium resistance, and a lot more lithium treatment failure than there was in the first edition. The illness is not what Kraepelin described anymore, and the biggest factor, I think, is that most patients who have the illness get an antidepressant before they ever get exposed to a mood stabilizer."

As I recall, it was not simply a matter of antidepressants making bipolar worse. Dr Goodwin also made a strong case that for many people, clinical depression is bipolar waiting to happen. The rise in the incidence of bipolar, Goodwin noted, coincided with the introduction of SSRI antidepressants. It's not just the bipolar population that is at risk. A lot of those with so-called unipolar depression cycle in and out of depression without ever becoming manic or hypomanic - until you give them an antidepressant. Then they become bipolar.

Other speakers, including Nassir Ghaemi of Tufts and Robert Post, who spent most of his years at the NIMH, backed up Goodwin. Back to Whitaker's account:

Psychiatry, of course, had no "evidence base" for using antidepressants in bipolar disorder, but, Post said, the clinical trials conducted by pharmaceutical companies "are virtually useless for us as clinicians" ... Only a small amount of people, he added, actually "respond to these crummy treatments."

Goodwin further challenged recent pharma studies showing the high rate of relapse once bipolar patients were withdrawn from antipsychotics, noting that the findings were only evidence that "if you suddenly change a brain that has adapted to the drug, you are going to get relapse."

My interest in the whole matter was more than academic. Although it is clear that my bipolar manifested in college, it wasn't till I was 49 that I sought help. I was misdiagnosed with unipolar depression and prescribed an antidepressant which had me bouncing off the walls. Of all things, florid mania proved to be much safer than the suicidal depression I had been in. Ironically, bad psychiatry may have saved my life.

But that same psychiatrist also did something right, for which I am eternally grateful. The second time out, he put me on a low dose mood stabilizer. He didn't overmedicate me or turn me into a zombie. Soon, I was on my way to a new career in mental health journalism. I haven't looked back.

Most patients I have witnessed in more than six years of attending support groups haven't been so lucky. Their mood stabilizer doses were way higher than mine. Plus they were on other high dose meds. These were people in stable condition, but they never got better. Way too often, they got worse.

Whitaker noticed the same thing in the patients he interviewed for his book, but he came to a conclusion I would have never considered: It was the meds that were turning these people into the permanently disabled, he claimed, not the natural course of their illness. There was nothing natural to the course of their illness once the meds structurally altered their brains.

According to Whitaker, back in the old days researchers and clinicians noted that illnesses such as bipolar naturally remitted over a relatively short time. Now something different was going on, and we're not just talking about the side effects most of us know all too well.

As a group, we were more depressed, more manic, more psychotic, more anxious, more stupid, and less able to function than we were before. The medications have changed our brains. And the only answer clinicians have to our meds-induced worsening of symptoms is to respond with - drumroll - yet more meds, in yet higher doses.

How else do you respond to a person in distress? Take him off his meds? Alas, there is no easy answer.

This is a very bleak picture Whitaker paints, but one he is fully justified in painting. I was in the same room as Whitaker more than two years ago. He wasn't making things up. He wasn't taking the speakers out of context. If only we could write him off so easily. But the facts cannot be so easily ignored.

The facts - alas! - the facts.

Much more to come ...

Previous blog pieces:


The Whitaker Controversy: An Irony in Search of Nuance

If Meds Work as Well as Our Psychiatrists Tell Us, Why Do We Have MORE Mental Illness Today Rather Than Less?


RIP: Chemical Imbalance in the Brain

The Whitaker Controversy: An Irony in Search of Nuance

This is a slight detour from my series based on talking points raised by Robert Whitaker's eye-opening "Anatomy of an Epidemic." As many of you know, in July this year the National Empowerment Center, a peer-run organization that takes a dim view of psychiatry and meds, invited Whitaker (pictured here) to deliver the keynote at its Alternatives conference in Anaheim.

There was one catch. The National Empowerment Center is bankrolled by the federal government via SAMHSA. SAMHSA did not like the Center's choice and disinvited Whitaker. Stupid is entirely too mild a term to describe this appalling absence of thinking. The group MindFreedom, with a strong antipsychiatry bent, organized a protest via the internet, and within two days Whitaker was reinvited.

At the conference in early October, it was revealed that Whitaker's restoration had come with strings attached: He was reinstated as a keynoter, but not allowed to present a workshop that had also been scheduled. In addition, an establishment psychiatrist was invited to deliver a second keynote with the stated purpose of discrediting Whitaker, without allowing Whitaker the right of rebuttal.

Stupid-stupid-stupid. The affair, naturally, raised accusations of government censorship, and the blogosphere was rife with outrage. The exception was a piece by JD Jaffe on the Huffington Post, which (after libeling Whitaker) questioned why our tax dollars were financing this sort of conference in the first place. In his own blog on Psychology Today, Whitaker interpreted Jaffe's piece to mean that certain independent-minded groups "risked losing their funding" if they did not fall into line.

The point everybody missed, of course, was that this was neither a censorship issue nor an intimidation issue. When someone else is putting up the money, then that someone gets to call the shots, be it an investor, a donor, or the federal government. There is no exemption for mental health advocacy groups who claim to be the voice of the people.

Pathetically, the National Empowerment Center and such groups as the California Network of Mental Health Clients could not exist for one day without federal or state government largesse, such is the sorry state of mental health advocacy in America.

These advocacy groups are closely aligned with the antipsychiatry movement, whose members nurse a visceral hatred against the most successful of the mental health advocacy groups, NAMI, which Whitaker mischaracterizes in his blog as "powerful." If NAMI were truly powerful, government agencies would be quaking in their boots, mental health services in the US would be a model for the rest of the world, and our jails would not be the largest de facto psychiatric facilities in the country.

Whitaker and others are on more solid ground in pointing out NAMI's heavy reliance on Pharma funding, but if money corrupts, then the National Empowerment Center and the California Network of Mental Health Clients and other groups need to send back their government checks. Then these groups need to do what real advocacy groups do - hustle for members, badger elected representatives, build alliances, offer real services, and dive under the seat cushions for spare change.

Ironically, they would be wise to model themselves on the people who founded NAMI, who did just that. While I'm at it, NAMI would be wise to model itself on the people who founded NAMI.

Three years ago, I requested media credentials to attend the Alternatives conference in St Louis. I was refused. For the record, I have only been refused by one other group - the Society of Biological Psychiatry. NAMI has welcomed me as a journalist, as has DBSA, the American Psychiatric Association, the International Conference on Bipolar Disorder, and numerous other organizations with nothing to hide. 

I could have paid the $300 or whatever Alternatives was extorting from paying customers, but then the conference would have been playing to empty seats. Mental health consumers don't have that kind of money, much less money to get there and stay there. What happens is SAMHSA picks up the tab, provided you're willing to jump through the hoops in applying for a "scholarship."

So: No media. Hand-picked attendees. Don't get me started ...

In the meantime, Robert Whitaker is a journalist who has done his homework. His book represents the strongest challenge to psychiatry by far, based as it is on facts rather than empty rhetoric. He may be championed by the antipsychiatry crowd, but his only agenda is to sell his book. In his own words, he wants an honest discussion. Let's have it ...

Disclosure: I serve on the board of NAMI San Diego, which receives hardly any funding from Pharma. The views expressed here are entirely my own.

If Meds Work As Well As Our Psychiatrists Tell Us, Then Why Do We Have MORE Mental Illness Today Rather Than Less?

Following is the second in an ongoing series based on talking points Robert Whitaker has raised in his recent book, Anatomy of an Epidemic ...

Anyone who has attended a mood disorders support group with any regularity cannot help but notice that a good many there are seemingly “stuck” in their recovery. These are people who are stable and not in crisis, but not well. Or, even if they manage to pass for well, are nevertheless facing major challenges in their relationships and careers.

Another phenomenon involves those who turn up for the first time expressing their profound gratitude for finding the group. These are people who have very recently taken medical leave from work, but are now on an upward trajectory. They religiously attend subsequent groups, make excellent contributions to the discussions, then one day they announce they will be going back to work. You never see them again.

Two streams of people - the stuck and the unstuck. Unfortunately, I have observed way too many of the former. So has author and journalist Robert Whitaker, who sat in on at least one session of a DBSA group meeting at McLean Hospital, just outside Boston. The wrap-up to the gathering, he observed in his book, Anatomy of an Epidemic, could have passed for that of a PTA meeting or a church social. Yet, as far as he could tell, despite the advanced education of most of the attendees and the fact that they were all on meds, only one in their number was currently employed. Most of the others were on disability.

The fate of those with schizophrenia, we know, is far more problematic. If they are not cycling in an out of hospitals and the criminal justice system, we tend to find them in day rooms, staring blankly at TV sets, or living at home with their aging parents. But we also know there are those who do get well, who experience a remission in their illness, who are able to go off their meds, then vanish from the psychiatric radar to lead full and productive lives in the real world.

What is going on? Given the advances in psychiatric care over the the past 50 years, we should be expecting huge drops in the number of mentally ill regarded as disabled. Instead, the numbers have skyrocketed - four times the disability rates for people with psychosis since the introduction of Thorazine in the fifties, according to figures cited by Whitaker.

Shouldn’t it be the other way around? If our meds really worked, shouldn’t the numbers be down, way down? David Healy MD of Cardiff University asked this question some time ago, and in a 2003 article on my website I reported:

“Indeed, he concluded, if SSRIs worked for depression or anxiety the way antibiotics do for GPI (syphilis), we wouldn’t have the illness around anymore.”

Dr Healy has conducted numerous studies pointing out the potential for antidepressants to cause harm in patients, though he himself does prescribe them, presumably with considerable caution.

These days, even psychiatrists not named David Healy are acknowledging that our meds are hardly magic bullets and that there is a major risk of them doing more harm than good. There has been a lot of commentary on this (including on this blog), but Whitaker has gone a lot farther with his provocative and very well documented thesis that our meds may in fact be the CAUSE of a worldwide epidemic in mental illness.

The conversation has just grown a lot more interesting.

Much more to come ...