We Can All Get Along - Can't We?

Last week, I killed off the term, “antipsychiatry.” These days, we only hear the word used as an insult, too often in the context of attempting to discredit even mild critics of psychiatry. 

I may know what I mean when I use the A-word, but others hear it in a different way. They hear it as a weapon to silence skeptical enquiry, to discredit the recovery movement, and - worst of all - to devalue the personal experiences of those who have stories to tell.

So - good riddance to the term. Yes, there is a fringe element out there, but we’re going to have to find a new way to describe them. In the meantime, it is useful to focus on what we all appear to agree on. Forgive me if this all seems obvious, but that is the very point of this little exercise ...

We all believe in recovery.

Not only that, we’re in general agreement on the things we need to be doing to achieve recovery. These may vary widely from individual to individual, but there is a very broad consensus that meds are only a small part of the equation. The real work - which tends to involve accepting brutal realities, making tough decisions, and implementing serious lifestyle changes - is up to us.

It goes without saying that settling for badly compromised existences in the name of stability is wholly unacceptable, but I’ll say it anyway.

We all believe in mental illness.

When we happen to describe the hells we’ve had to endure and the unbearable pain we’ve been through, we’re not just making this up. This is not psychiatry labeling us or pathologizing our behavior. By the time we come to the attention of the psychiatric profession, we have already performed a spectacularly successful job of wrecking our lives beyond recognition. We want the pain to stop - at any cost - and sadly too many of us wind up choosing what we think is the only way out.

We can argue all we want about what to call it and how to define it - much less how to treat it - but when all is said and done, we tend to be fairly relieved when we discover that someone has a name for it. Call it “Fred,” for all I care. 

We all want to know what the hell is really going on.

Brain science is yielding spectacular new insights on the interactions between our genetic makeup and the environments inside and outside of us. This in turn is forcing us to rethink human behavior from every conceivable angle. The one thing we know for sure is that we don’t know very much, which means literally every idea is on the table. No one has an easy answer, which means rigid belief systems no longer cut it with us.

But - oh! - the thrill of discovery. A new piece of evidence, a new insight, a new revelation. We connect our own dots. We draw our own conclusions. We make our own decisions.

We all realize the paradigm is changing.

Psychiatry and its over-reliance on medications is experiencing a current self-inflicted lack of respect. This is occurring at the same time as Big Pharma is pulling out of the business of new psychiatric meds development. A new generation of psychiatrists pushing the same old meds serving up the same old explanations simply defies credibility. 

Thankfully, a new science of the mind is emerging, along with a consumer-driven recovery movement. Psychiatry can choose to be part of both, but when the dust settles it is highly unlikely that as an institution it will be leading either.

We all respect each other.

There may be a general consensus on the same issues, but our own diverse experiences and ways of looking at the facts guarantee that no two people are going to agree with each other on all issues all the time. Thank heaven for that.     

R.I.P. "Antipsychiatry," the Term

Following is a piece of a comment posted yesterday by KA on mcmanweb:

... No one is saying "anti-psychiatry is right" because anti-psychiatry isn't a belief system. It can't be right. It's an open-ended criticism. Skepticism is not a position; it's a process.

In my article, Stupid Advocacy Kills, based on blog pieces here, I attacked antipsychiatry for its obstinate denial, in complete defiance of the facts, that “mental illness exists in the first place, along with the possibility of finding treatments ...”

Trust me, notwithstanding KA, I view antipsychiatry as a rigid belief system that has nothing to do with open-ended enquiry, but if I have to explain myself every time I use the term, well, perhaps I should be looking around something better.

This came through loud and clear when Corinna West - a recovery advocate I hold in high regard - posted this two months earlier in response to a piece here on Knowledge is Necessity:

... I do ask, please, that you correctly identify those of us that are psychiatric survivors and leaders of our mental health recovery civil rights movement. Antipsychiatrists are completely different people with different agendas. Folks like to use the antipsychiatry insult to denigrate our work, and lumping us together is just about as inaccurate as trying to rebut Whitaker.

Ms West was referring to my attack on Robert Whitaker’s “mindlessly unqualified endorsements of the antipsychiatry movement and his ill-informed cheap shots against advocacy groups that actually get off their asses and help people ...”

The piece, Rebutting Whitaker: Not Such a Good Idea, was actually very supportive of Whitaker and highly critical of psychiatry’s response (and nonresponse) to his book, Anatomy of an Epidemic.

Do you see a problem here? Practically every person with a brain or someone who knows someone with a brain - myself included - has massive reservations concerning both the practice of psychiatry and what passes for its scientific underpinnings. But we hardly define ourselves according to our negative orientations, nor do we want to be mistaken for those who do. We ARE the 99 percent - the rigorously enquiring pro-recovery majority.

Yes, there is an anti-intellectual, anti-science nihilist fringe out there, but is there a better term for describing them than antipsychiatry? Yes there is - let’s call them the anti-intellectual, anti-science nihilist fringe.

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

Rerun - Where Dumb Psychiatry Meets Dumb Antipsychiatry

Yesterday, in Part V of Spitzer and the DSM, I discussed at length how a major error in the DSM-III of 1980 has gone uncorrected for 29 years. This concerned separating out "recurrent depression" from bipolar, to which it is a close cousin, and lumping it with "chronic depression." As a result, many in the bipolar spectrum are misdiagnosed and spend years leading miserable lives on one failed antidepressant after the other. In light of two reader comments to yesterday's piece and the importance of the issue, I thought it appropriate to republish this from February:

In my last blog, I urged that we consider issues in terms of "smart vs dumb" rather than "pro vs anti." In the final analysis, dumb psychiatry and dumb antipsychiatry serve the same master. Let me give you an example:

For at least three decades, it has been widely accepted that prescribing an antidepressant (with no mood stabilizer) to someone with bipolar runs a strong risk of flipping a patient into mania or speeding up the cycle or both. The American Psychiatric Association in it's 2002 Practice Guideline for treating bipolar issues a blanket warning against this practice.

The catch is that it is often difficult to distinguish unipolar depression from bipolar depression. The result is that too many of us with bipolar are misdiagnosed with unipolar depression and prescribed meds that make us worse.

There is an additional twist to this catch: Many people experience "recurrent" and "highly recurrent" depressions that come and go in a pattern very similar to bipolar cycling. The pioneering diagnostician Emil Kraepelin observed this phenomenon way back in the early twentieth century.

When Kraepelin coined the term, manic-depression, he wasn't merely referring to bipolar. He also included those with recurrent depression. This was the widely accepted view until the DSM-III in 1980 separated out bipolar and lumped recurrent depression with "chronic" depression.

The result is that doctors tend to treat all depressions alike - with predictably disastrous results. This is an example of "dumb" psychiatry, the indiscriminate prescribing of antidepressants to anyone who happens to say they're depressed.

Reformers in the profession, such as former head of the NIMH Frederick Goodwin MD and Nassir Ghaemi MD of Tufts, have long urged that psychiatrists think twice before prescribing antidepressants. The best way to turn certain unipolars into bipolar, they would argue, is to prescribe an antidepressant.

Dr Goodwin and a good many others have campaigned for years to realign the next DSM so that it is more closely in tune with Kraepelin's original conception of manic-depression. This would get doctors to rethink their prescribing practices.

We don't know if change will happen. But no doubt the task force charged with issuing an updated DSM is considering the matter. Indeed, the possibility of a new "bipolar III" diagnosis was the basis of a blog post last week from Furious Seasons, fairly typical of antipsychiatry sentiment:

I think it's been a boon to doctors - who get a patient for life - and Big Pharma - which gets a long-term customer - but I have my doubts about how useful the depression-is-bipolar thing is for patients who wind up on an atypical and an anti-seizure drug when they are dealing with something that's not even in the ballpark of mania.

To respond in brief:

Yes, big pharma would love a customer for life, but to make a case for a drug industry conspiracy one would have to bend time a hundred years. Kraepelin wrote his classic text, "Manic-Depressive Insanity and Paranoia," decades before drug manufactures came up with the first psychiatric meds, and psychiatrists have been arguing ever since where best to carve nature at its joints.

Moving on, bipolar is more accurately a cycling illness, not a polar illness. So is recurrent depression. Thus "something that's not even in the ballpark of mania" is irrelevant. The purpose of treatment is to manage the cycle, bring it under control, not necessarily treat symptoms at one pole or the other.

An antidepressant may work in some patients with recurrent depression. But a logical first option is to consider using a mood stabilizer such as lithium or Depakote or Lamictal.

Once the cycle is under control, it may be possible to consider low-meds or no-meds options in conjunction with cultivating cognitive skills such as mindfulness.

Admittedly, Lamictal had a lot to do with drawing attention to "soft bipolar" several years back, and GSK profited handsomely. But these days the drug has gone generic, along with lithium and Depakote. Thus GSK and others have no financial stake in pushing for an expanded bipolar diagnosis.

If anything, an expanded diagnosis would significantly reduce antidepressant sales. This is why you don't see drug companies sponsoring clinical trials to prove Drs Goodwin and Ghaemi right.

No doubt, some manufacturer will try to jump on the bandwagon with some implausible claim trumpeting the virtues of their house antipsychotic, only to be laughed out of town. But this would be an example of opportunism, not hatching a conspiracy.

As for psychiatrists wanting a patient for life: The best indication is that psychiatrists are driving away their patients. Only a small minority of patients adhere to their meds over the long term. Matching the right meds to the right diagnosis might change this.

So now we return to the issue of smart vs dumb. Dumb psychiatry treats all depressions as the same. So does dumb antipsychiatry. Dumb psychiatry favors preserving psychiatry's status quo. So does dumb antipsychiatry. Ironic, isn't it?

Postscript

For how I abandoned my ex-wife that I mooched off of for years and other high-crimes and misdemeanors while the crusading Philip Dawdy was busy saving the world, check out this entertaining piece of fiction from Furious Seasons.

I'm a Tool of Scientology!

This is too funny for words.

Above is a screenshot from the Recovery page on my website McMan's Depression and Bipolar Web taken just a few minutes ago.

No, you are not seeing things. In the lower right hand corner, you are viewing an advertisement for the Church of Scientology. Like nearly everyone who operates a website or a blog these days, I employ Google Ads to help pay the rent. I do not - nor have I ever - solicited advertising. Rather, Google automatically loads advertisements that its various algorithms decide is a good fit for the page.

Apparently, the Google algorithm determined that I am a friend of Scientology.

In a similar fashion, HealthCentral loads ads into the top banner portion of my mcmanweb pages. At the time of this writing, for this particular page, an ad for Ensure is on display. Across another page right now is an ad for Prisiq, which looks like this:







Various antipsychiatry bloggers such as Philip Dawdy of Furious Seasons periodically (and tediously) attempt to discredit my writing based on the fact that I happen to carry these ads on my site.

Apparently I am a tool of Big Pharma.

But no, the conspiracy is even more evil and far-reaching. I'm also a tool of Scientology!

Okay, okay. I confess. It was me you saw on the Grassy Knoll one day in late November. Whew! It's a relief to get that out of my system. In the meantime, don't forget to support my sponsors ...

OCD - Why Science Has Rendered Antipsychiatry Irrelevant

Antipsychiatry dogma contends that because science has failed to show any link between underlying brain dysfunction and psychiatric symptoms that mental illness is a myth and psychiatry is a fraud.

Antipsychiatrists have been getting away with this for years. Mental illness, after all, is highly complex, which doesn't lend itself to gift-wrapped causes and effects the way a simpler brain illness - say Huntington's - does.

Wait - I take that back. Last night, at my local NAMI here in San Diego, I heard Neal Swerdlow MD, PhD of UCSD talk about obsessive-compulsive disorder (OCD).

OCD is a failure in the brain to screen out certain thoughts. People with OCD, for instance, may drive themselves (and others) crazy obsessing over whether one's pet poodle has succeeded in picking three sets of door locks and is now being carved up for lab experiments.

The thought is ridiculous, but the consequence is deadly serious. Literally, the victim cannot stop the thought. The thought takes over to the point where the victim may feel compelled to leave work and drive home. Should that happen enough times, the victim becomes both unemployable and a social leper.

Dr Swerdlow opened with a short clip of a Huntington's patient. Individuals with Huntington's experience uncontrollable movement. The brain, literally, fails to screen out certain movement impulses. The area of the brain responsible, the cingulate, is the same area of the brain most implicated in OCD.

With Huntington's, of course, the symptoms are obvious (uncontrollable movements). Of course something mechanical in the brain has to be wrong. Uncontrollable thoughts and inner torment, on the other hand, are invisible. Of course psychiatry is at fault for creating a mythical illness out of thin air in order that Big Pharma can sell more drugs.

Forget about the victim.

The problem with OCD, Dr Swerdlow explained, lies in "gating." I have discussed gating on this blog numerous times in relation to schizophrenia. The victim is overwhelmed - too much sensory input, too much thought, too much emotion. The brain can't filter out the irrelevant stuff, cannot focus, cannot function, cannot cope.

In a normal brain, on a cellular level, the neuron essentially makes a "yes-no"decision in response to a neurotransmitter message from another neuron. Air conditioner noise? "No." Not relevant. Tune it out. Instructions from your doctor? "Yes." Very relevant. Pay attention.

On a systems level, the thinking and reacting areas of the brain - and areas in between - are organized around processing and prioritizing all the "incoming." These circuits are referred to as "cortico-striatal-thalamic-cortical loops" and similar-sounding names. Self-correcting feedback is both top-down and bottom up and exists in interdependent relationships with parallel loops.

Neurons that specialize in gating tend to exist in the mid-brain regions, such as the cingulate. In a famous set of experiments performed two decades or so ago, OCD subjects (ones obsessed with cleanliness) shared a brain scan machine with a "dirty" sweat sock. Their respective brain loops lit up like a Christmas tree (much like the image on the right). When exposed to a "clean" sock, their brains quieted down (much like the image on the left).

We know that with Huntington's the neurons in the cingulate die off. There is no gating function to regulate excess dopamine signaling related to movement, and the brain fails to compensate by recruiting gating neurons from other areas of the brain.

Similarly, with OCD, we know that the cingulate is operating below capacity, with about 15 percent less neurons. In some cases, serotonin antidepressants may enhance cingulate function. Or the brain may be successful in recruiting gating neurons from other areas of the brain. This is why CBT and other talking therapies can work so well for OCD and other mental illnesses - often, we can literally train our brains to lay down new roadwork.

Because of our knowledge of cause and effect and our ability to pinpoint an exact location, brain surgery to treat OCD is not only feasible, it is being performed, albeit very rarely and only as a last resort for severe cases on treatment-refractory individuals. Capsulotomies and cingulotomies essentially compensate for lack of gating by surgically turning off the flow of certain brain circuits.

In February this year, the FDA approved deep brain stimulation (DBS) for OCD. DBS has a history of use in Parkinson's and is showing promise for depression. A lead is inserted near the affected brain area. Electrical pulses travel up wiring from a pacemaker device implanted below the brain. For OCD, the signaling from the lead has the effect of interrupting the thoughts that the cingulate is supposed to be screening out.

Brain surgery for psychiatric illness, of course, raises a whole host of ethical and other issues, and you can expect antipsychiatry to add its unmodulated voice to this conversation. But in the context of this blog piece, think of surgery for OCD as the icing on the cake.

Mental illness is indeed, unequivocally real. We can point to the brain systems. We can link breakdowns in these systems to behavior. We have treatments based on this knowledge.

In the face of such overwhelming evidence, why would antipsychiatry think otherwise? Hmm ... defective thought gating?

Darwin Award to Leading Antipsychiatrist

The Darwin Awards Committee has announced that its top prize for 2009 goes to prominent antipsychiatry spokesperson, Clovis Bullright.

The Darwin Awards honor people who "do a service to Humanity by removing themselves from the gene pool."

The 55-year-old Mr Bullright has specialized in taking himself out of the gene pool his entire adult life through behavior seemingly designed to repel the opposite sex. A new psychiatric diagnosis in his honor is scheduled to appear in the next edition of the DSM in 2012.

Nevertheless, Mr Bullright refuses to acknowledge anything out of the ordinary about his Guinness World Record list of symptoms, much less take medications or enter therapy. "People who value individuality," he once wrote from jail, "don't complain when you leave a turd on the table."

Mr Bullright found his niche in the antipsychiatry movement, where thinking is not a requirement. Over the years, he has built up a following of people who subscribe to his beliefs that Big Pharma is responsible for the future assassination of JFK.

"It's simple," he explained. "Lee Harvey Oswald spelled backwards is Zyprexa."

His book, "You Can All Gargle Razor Blades," is regarded as an antipsychiatry classic.

Unfortunately for Mr Bullright - but fortunately for the genetic future of humankind - his success as an antipsychiatrist does not translate well in the real world. "What part of 'nice boob job' don't women understand?" he once said from the back of a police car.

Nevertheless, the year started out on a promising note when Mr Bullright entered an email relationship with a woman also not on meds. "You would almost look passable if you stuck your face in a wind turbine," he is reported as saying by way of introduction.

His correspondent interpreted this as a declaration of love, and in no time the two agreed to meet up in a secluded section of the local park.

At the appointed hour, the woman rode up on a bicycle, jumped off, removed her clothes, and invited him to "take anything you want."

Mr Bullright took the bicycle and rode off, thereby permanently removing himself from the gene pool.

Rush Limbaugh, Nihilism, and Antipsychiatry - Where is the Off-Button?

Only in America:

Yesterday, right-wing radio blabbermouth Rush Limbaugh challenged President Obama to a debate. From the transcript of his March 4 show:

"Why doesn't President Obama come on my show? We will do a one-on-one debate of ideas and policies. ... I am offering President Obama to come on this program - without staffers, without a teleprompter, without note cards - to debate me on the issues. Let's talk about free markets versus government control. Let's talk about nationalizing health care and raising taxes on small business."

Do the words grandiose and delusional come to mind?

And didn't Limbaugh earlier say he hopes the President will fail?

How about nihilist to describe the guy?

Funny thing - call it my own internal Rorschach test - when I think nihilist I think antipsychiatrist. In his blog on Psychology Today, Nassir Ghaemi MD of Tufts University writes:

"I suggested that many critics of academic psychiatry, especially those who attack links to the pharmaceutical industry, suffer from postmodern nihilism. They do not believe in any truths; thus they see the manipulative interests of private enterprise and the greedy search for wealth behind everything."

Wait, here's the kicker: "Scientologists cannot be accused of that motivation. If anything, they are true believers ..." Say whatever you want about Scientologists, at least they stand for something.

So, is it possible to be in sync with antipsychiatry and not be an antipsychiatrist? Yes, as long as you don't let "anti" define you. Let me give you an example:

Back in 2003, I attended a two-day Non-Pharmaceutical Approaches to Mental Disorders conference in Pasadena, sponsored by Safe Harbor, which is the best source of non-meds info on the web. Founder Dan Stradford has connections with Scientology, which I'm only bringing up before someone else does in a negative guilt-by-association way. When you hear Dan speak you can't help but be moved by his story about his late father.

At the conference, I heard Lewis Mehl-Madrona, MD, PhD discus integrative psychiatry and Native American healing, Julie Ross on natural supplements, William Walsh PhD on methylation and metal poisoning, Doris Rapp MD on toxins, Kathleen Crowley on procovery, and much much more

I love Ms Crowley's advice, by the way: "Just start anywhere."

Intriguingly, a panel of parents of bipolar kids testified on the progress of their kids on natural regimens. Mind you, we didn't hear any failure stories, but in strong contrast to the antipsychiatry party line we did hear explicit recognition that bipolar in kids is horrific and real.

Naturally, I was interested in what the people who paid to attend thought of the proceedings. It's fair to say they were not exactly bullish on psychiatry, but neither did they identify themselves by what they were against. Instead, they were hopeful that people could live better lives, and to a person they wanted to be part of that process. One group of very pleasant women was interested in forming a "NAMI Natural" branch to their local NAMI.

Clearly, these people weren't antipsychiatrists. Far from it. And because they actually had something to say, not to mention showing an interest in where I was coming from, I was all ears. With antipsychiatrists, take my word for it, you wish you had a button to turn the audio off. Ah - so that's why they remind me of Rush Limbaugh.

Antipsychiatry: Dumb and Dumber

A few weeks ago, I came across a comment from an antipsychiatry blog referring to Kay Jamison as "lithium-addled." Yesterday, I stumbled on a blog post from someone named Stan, entitled, Kay Jamison, The Unquiet Fraud.

What gives?

First Stan comments on Vincent Van Gogh:

"If he lived today he would be locked away painting blank canvasses to no one ... blinded by antipsychotics ... "

Actually, Stan, for all we know, he might have picked up an Oscar the other night and thanked Pfizer for making it possible. What we do know is that Van Gogh aimed a pistol at his chest and pulled the trigger. He was 37.

But Stan contends, "it was never a life in vain."

Let's defer to Van Gogh, himself, on this: "What am I in the eyes of most people - a nonentity, an eccentric, or an unpleasant person - somebody who has no position in society and will never have; in short, the lowest of the low."

Who knows what choices Van Gogh would make today? Maybe he would choose not to lead a tortured life. Maybe he would choose to stay on meds. Maybe he would choose not to paint. That's the point, he could choose. He would have choices.

I really don't want to pick on Stan, and I would really rather be writing about other things, but this sort of thing is all too typical of the commentary on the blogosphere. The only reason I found this piece was because it came up near the top under a Google Blog search that day.

This is the new democracy of web 2.0. Anyone who takes five minutes to set up a Blogger account can get the same attention as Kay Jamison.

Speaking of Kay Jamison: In the same blog post, Stan takes Dr Jamison to task for ascribing Van Gogh's "precious madness" to the false label of bipolar. Not only that:

"Kay Jamison has been running around for many years publishing one book after another telling us all how wonderful her drugs are in controlling her 'Bipolar Label.'"

Hmm, excuse me if I'm wrong, but ...

Off her lithium, Dr Jamison attempted suicide. On her lithium, she is a professor at Johns Hopkins, co-author of the definitive text on bipolar, best-selling author, recipient of a McArthur genius grant and numerous other awards, plus was in a successful marriage (cut short by the death of her husband).

In short, Dr Jamison exercised a choice that was, sadly, unavailable to Van Gogh.

***

From mcmanweb:

Vincent and Me

There was that little bit of sky pressing down on the fields, as if of a heavier substance than earth, and there were the fields trying to crowd the sky out of the canvas, as if vaster than the heavens. And there were the crows, hedging their bets, represented by stark black flicks. ...

Madly Creative

Says Dr Jamison, in her introduction:

"The fiery aspects of thought and feeling that initially compel the artistic voyage - fierce energy, high mood, and quick intelligence, a sense of the visionary and the grand, a restless and feverish temperament - commonly carry with them the capacity for vastly darker moods, grimmer energies, and, occasionally, bouts of 'madness.'"

Where Dumb Psychiatry Meets Dumb Antipsychiatry

In my last blog, I urged that we consider issues in terms of "smart vs dumb" rather than "pro vs anti." In the final analysis, dumb psychiatry and dumb antipsychiatry serve the same master. Let me give you an example:

For at least three decades, it has been widely accepted that prescribing an antidepressant (with no mood stabilizer) to someone with bipolar runs a strong risk of flipping a patient into mania or speeding up the cycle or both. The American Psychiatric Association in it's 2002 Practice Guideline for treating bipolar issues a blanket warning against this practice.

The catch is that it is often difficult to distinguish unipolar depression from bipolar depression. The result is that too many of us with bipolar are misdiagnosed with unipolar depression and prescribed meds that make us worse.

There is an additional twist to this catch: Many people experience "recurrent" and "highly recurrent" depressions that come and go in a pattern very similar to bipolar cycling. The pioneering diagnostician Emil Kraepelin observed this phenomenon way back in the early twentieth century.

When Kraepelin coined the term, manic-depression, he wasn't merely referring to bipolar. He also included those with recurrent depression. This was the widely accepted view until the DSM-III in 1980 separated out bipolar and lumped recurrent depression with "chronic" depression.

The result is that doctors tend to treat all depressions alike - with predictably disastrous results. This is an example of "dumb" psychiatry, the indiscriminate prescribing of antidepressants to anyone who happens to say they're depressed.

Reformers in the profession, such as former head of the NIMH Frederick Goodwin MD and Nassir Ghaemi MD of Tufts, have long urged that psychiatrists think twice before prescribing antidepressants. The best way to turn certain unipolars into bipolar, they would argue, is to prescribe an antidepressant.

Dr Goodwin and a good many others have campaigned for years to realign the next DSM so that it is more closely in tune with Kraepelin's original conception of manic-depression. This would get doctors to rethink their prescribing practices.

We don't know if change will happen. But no doubt the task force charged with issuing an updated DSM is considering the matter. Indeed, the possibility of a new "bipolar III" diagnosis was the basis of a blog post last week from Furious Seasons, fairly typical of antipsychiatry sentiment:

"I think it's been a boon to doctors - who get a patient for life - and Big Pharma - which gets a long-term customer - but I have my doubts about how useful the depression-is-bipolar thing is for patients who wind up on an atypical and an anti-seizure drug when they are dealing with something that's not even in the ballpark of mania."

To respond in brief:

Yes, big pharma would love a customer for life, but to make a case for a drug industry conspiracy one would have to bend time a hundred years. Kraepelin wrote his classic text, "Manic-Depressive Insanity and Paranoia," decades before drug manufactures came up with the first psychiatric meds, and psychiatrists have been arguing ever since where best to carve nature at its joints.

Moving on, bipolar is more accurately a cycling illness, not a polar illness. So is recurrent depression. Thus "something that's not even in the ballpark of mania" is irrelevant. The purpose of treatment is to manage the cycle, bring it under control, not necessarily treat symptoms at one pole or the other.

An antidepressant may work in some patients with recurrent depression. But a logical first option is to consider using a mood stabilizer such as lithium or Depakote or Lamictal.

Once the cycle is under control, it may be possible to consider low-meds or no-meds options in conjunction with cultivating cognitive skills such as mindfulness.

Admittedly, Lamictal had a lot to do with drawing attention to "soft bipolar" several years back, and GSK profited handsomely. But these days the drug has gone generic, along with lithium and Depakote. Thus GSK and others have no financial stake in pushing for an expanded bipolar diagnosis.

If anything, an expanded diagnosis would significantly reduce antidepressant sales. This is why you don't see drug companies sponsoring clinical trials to prove Drs Goodwin and Ghaemi right.

No doubt, some manufacturer will try to jump on the bandwagon with some implausible claim trumpeting the virtues of their house antipsychotic, only to be laughed out of town. But this would be an example of opportunism, not hatching a conspiracy.

As for psychiatrists wanting a patient for life: The best indication is that psychiatrists are driving away their patients. Only a small minority of patients adhere to their meds over the long term. Matching the right meds to the right diagnosis might change this.

So now we return to the issue of smart vs dumb. Dumb psychiatry treats all depressions as the same. So does dumb antipsychiatry. Dumb psychiatry favors preserving psychiatry's status quo. So does dumb antipsychiatry. Ironic, isn't it?

Of Psychiatry and Antipsychiatry

In January, I asked readers this question: "What best describes your condition over the past 30 days?" Only 14 percent replied they were "back to where they want to be" or "better than they ever could have imagined."

This month, I'm asking: "How do you rate your meds in managing your illness?" So far, 82 percent rate their meds as either "most important," or as important as other tools. Only 12 percent ascribe little or no importance to their meds.

Do you perceive a discordance between the two poll results here? Granted, this is not a scientific survey. Nevertheless, the results beg the following question: Why do we place such great emphasis on meds, when obviously they are not living up to our expectations?

Or: Are our expectations so low to begin with that we have given up on ourselves?

Hold those thoughts for a second, then surf around to various patient/consumer/survivor/whatever blogs. You will note the vast majority have a decided antipsychiatry slant to them. Many of these blogs set out to expose the lies of the drug industry, which - believe me - are in abundant supply. Others have a much greater emphasis on helping their readers achieve recovery through non-pharma interventions.

Even blogs that find value in meds and psychiatry (such as this one) do so in the context of sharply critical enquiry.

It's as if we're all saying in unison to psychiatrists: We trusted you. We placed our faith in you (and apparently still do). But we're the ones who have to live with the results, and - let's put it this way - we're not exactly happy.

Simply put: If meds worked the way the drug industry and psychiatrists would have us believe, compliance rates would be nearer to 100 percent (instead of more like 30 or 40 percent over the long term), we would enjoy similar employment rates and stable relationships as the rest of the population, and mental illness would be in sharp decline rather than (apparently) on the rise.

Thus, there is a rational basis to antipsychiatry.

But life is never that simple. If we have to be binary in our beliefs, it's much more useful to think in terms of "smart vs dumb" than "pro vs anti." Far too many of us have been victims of dumb psychiatry. Similarly, dumb antipsychiatry (and there is an awful lot of it going around) can lead to disastrous personal decisions.

The antidote to both is "smart."

More on this in future blogs ...