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.

Carlat's Response to Whitaker - A Discussion at Last

We left off with a self-proclaimed “refutation” and “repudiation” by Andrew Nierenberg of Harvard that neither refuted nor repudiated “Anatomy of an Epidemic” by Robert Whitaker. In a response to a grand rounds delivered by Whitaker at Mass Gen on Jan 13, Dr Nierenberg accused Whitaker of “misinformation, simplistic interpretations of statistics, faulty reasoning, and wrong conclusions,” but when the dust cleared the perpetrator of these crimes turned out to be Dr Nierenberg himself.

Throw in his gratuitous personal attacks on Whitaker and we have clear evidence of a psychiatrist gone wild. Of all things, Whitaker came out totally unscathed.

I’m sure we can fashion an ancient Chinese proverb from Dr Nierenberg’s oppositionally defiant behavior, but the clear lesson is that virtually all refutations are doomed to fail (even against such palpably absurd beliefs as “creation science”). Refuting the refuter, needless to say, is like shooting fish in a barrel.

So would a more reasoned approach, say one that actually acknowledged the validity of Whitaker’s arguments, have been far more effective? Funny you should ask.

Daniel Carlat produces The Carlat Report and is the author of “Unhinged,” which is highly critical of Pharma marketing dressed up as science. In late Jan, in the first of a two-part review on his blog, Carlat noted:

My overall take is that Whitaker has his basic facts right, and that he communicates them in a compelling style that I envy. But I disagree with his interpretation of the facts.

Now we’re getting somewhere.

Dr Carlat restates Whitaker’s thesis that the steep rise in psychiatric disabilities over recent years has coincided with a similar rise in psychiatric meds prescriptions. Yes, this is true, Dr Carlat agrees, but “correlation does not imply causation.” To say that med use has actually caused the disability, as Whitaker claims, is a stretch. There are other factors involved, Dr Carlat says, including:

There are more psychiatric disorders to diagnose - 297 in the current DSM, about the same as the DSM-III-R from 1987 (at 292), a bit more than the DSM-III of 1980 (at 265), a lot more than the DSM-II of 1968 (at 182), and a whole lot more than the DSM-I of 1952 (at 106). Dr Carlat contends that “the rise in diagnosis has been largely driven by changes in disease classification and subsequent training - not by toxic medications.”

Dr Carlat also notes that because there are more treatments available, doctors have more of an incentive to make a diagnosis. In other words, doctors are not inclined to make a diagnosis for something they cannot treat.

Then Dr Carlat mentions the obvious: That a major reason for the rise in psychiatric disabilities probably has to do with the changed status of psychiatric disabilities. Eligibility has been expanded, thresholds lowered.

To expand on Dr Carlat, a whole disability industry has grown up to facilitate a normally arduous application process. Clinicians and social workers routinely advise even good prognosis patients that they may qualify for disability. A fairly new specialty of disability lawyers is there to assist. Both political parties are more than happy to play along, as those on disability are not counted as being unemployed.

To tie this into a bow: Dr Carlat offers his views by way of “interpretation” rather than “repudiation.” Whitaker may not have shown cause and effect, but neither did he. Instead, Dr Carlat is presenting credible alternatives, supported by his own set of facts. This is the way to make a case.

Let’s forget for the time being whose arguments are more credible. One thing we can all agree on is at last we have a discussion going, something Whitaker wanted all along. Finally, a discussion, not a Nierenberg hissy fit.

More to come ... 

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.