Monthly Archives: April 2015

On the Efficacy of Suicide Prevention

David Laing DawsonBy Dr David Laing Dawson

In the past decade, make that two decades, we have witnessed a plethora of mission statements, lectures, programs, public health campaigns, TV ads, crisis services, anonymous telephone answering services, crisis lines, websites, information initiatives, task forces, white papers, all aimed at suicide, reducing the suicide rate in our communities, preventing suicide.

Yet the rate of suicides in Canada, completed suicides, remains statistically unchanged.

All of the above activities make us feel we are doing something about the problem. We are trying. But that is all they do.

The problem with a public campaign to prevent suicides is that it is akin to a public campaign to prevent heart failure. Both are end stages of other processes, but in the case of heart failure we know enough to target smoking, cardiovascular disease, obesity, hypertension, diabetes, rather than “heart failure”. We do not say, “Call this number if your heart is failing.”

We know the demographics of completed suicide. We know the risk factors. We know the specific and usually treatable illnesses that all too frequently lead to suicide. So if we truly want to reduce the actual numbers of people who kill themselves (not threats, small overdoses, passing considerations), then we need to stop wasting resources on “suicide prevention programs” and put them into the detection and treatment of those specific conditions so often responsible for suicide:

  • Some suicides are bona fide existential decisions, a choice to end one’s life of suffering: terminal illness, intractable pain, total incapacity.
  • Some suicides are the result of chronic complex social factors: unemployment, divorce, poverty, loss, alcoholism, addictions, isolation, and chronic illness. We can chip away at these factors with better support and rehabilitation services, improved minimum wage, retraining – but there is nothing we can do quickly and easily.
  • Some youth suicides are the result of impulsivity, intoxication, and an available instrument of death. Impulsivity comes with youth. Parents can keep an eye on intoxication. But we can make sure no instruments of death are available. Guns. Pills. Cars. Get rid of the gun(s) in the house. Lock up the serious drugs. Driving the family car is a privilege, not a right.
  • Some teen suicides today are the result of public shaming, bullying. Watch for this. Chaperone the parties. Monitor Facebook, Snapchat. No cell phones or internet in the child’s bedroom. It bears repeating: NO cell phones or internet in the child’s bedroom.
  • And then we have the specific mental illnesses that all too frequently, especially when undetected or under-treated, lead to suicide. These are Depression, Schizophrenia, Bipolar Disease, Severe Anxiety, PTSD, and OCD. And if we really want to make a dent in that suicide statistic then our programs, our money, our resources, should be directed to detection, comprehensive treatment, and monitoring of these illnesses.
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Are Psychologists Over Educated Bartenders?

Marvin Ross

By Marvin Ross

A rather provocative title but that is the gist of a new book called Psychology Gone Wrong: The Dark Side of Science and Therapy. The book is written by Tomasz Witkowski and Maciej Zatonski, two Polish scientists who argue that psychotherapy is a business and a kind of prostitution rather than an effective evidence-based medical treatment.

Witkowski is a psychologist, science writer, and founder of the Polish Skeptics Club while Zatonski is a surgeon and researcher who debunks unscientific therapies and claims. Their book was reviewed by Dr Harriet Hall on the blog Science Based Medicine.

I’m pleased to hear them call psychotherapy a business as that is a criticism that I’ve lodged against psychology in a couple of my earlier Huffington Post Blogs. In one, I quoted an internal paper I came across from the Canadian Psychology Association. They were concerned that an emphasis by government on treating serious mental illnesses would mean an exclusion of mental and behavioural health which is their domain.

In my second, I suggested that there is a turf war between psychology and psychiatry with psychology trying to gain more clients. If we don’t call psychiatric illnesses an illness but a mental health problem, then it becomes more appropriate for other professionals like psychologists to be the first line of assessment and treatment. Interestingly, psychologists are lobbying to prescribe medications and can do so in three US States. Likely, some of them seem to realize that their own theories may be deficient.

The authors point out that psychotherapy has been unsuccessful. Most of what psychologists do lacks proper evidence. Psychologists are still fixated on childhood trauma as the precursor to personality and as the cause of mental disorders. The only way to treat these mental disorders is with psychotherapy which depends on the reconstruction of childhood experiences. That is the concept underlying a great deal of their theories of problems like schizophrenia.

This concept, they argue, is dangerous and has led to the abuses of the recovered memory movement. In fact, the repressed memories are often the creation of the therapists themselves. Suggesting that schizophrenia is the result of childhood trauma and possible abuse serves no purpose other than to vilify the parents of offspring who are sick through no fault of anyone.

I made reference to bartenders earlier because the common perception that many have is of the wise and friendly bartender providing a sympathetic ear for the problems of his/her patrons and offering sympathy and support. The authors point out that conventional psychotherapy offers no additional benefits to that of a sympathetic friend. That is something we all need and those who are experiencing a serious illness need even more.

My own very special psychologist is Dr Bonnie Kaplan of the University of Calgary. For years, she has been pushing the use of vitamins for mental illness. She now begins her presentations with a warning to her audience with “Don’t Google My Name” as she did twice in this presentation in Syracuse.

Part of the reason she wants no googling is that two of my colleagues and I have been very critical of her vitamin research over the years. She went so far as to file a formal complaint against physician Dr Terry Polevoy with his regulatory body for unprofessional conduct arguing that he had no right to criticize her research. It was thrown out.

And what purpose does telling people not to google them have? We all know that human nature will only result in the opposite happening. Seems that she fails to understand basic human psychology.

Shrinks – The Untold Story of Psychiatry – A Review

Marvin RossBy Marvin Ross

Last week my colleague, Dr David Laing Dawson, provided his own personal history of prescribing psychiatric medications since he became a physician in the late 1960s. David’s experiences fit in with the development of that profession as described by Dr Jeffrey Lieberman in his new book Shrinks, The Untold Story of Psychiatry. Lieberman is a psychiatrist himself, chair of the Department of Psychiatry at Columbia University and the past president of the American Psychiatric Association.

It is highly readable book and what I particularly enjoyed were his anecdotes based on his many connections within the profession. He points out that RD Laing, one of the father’s of the anti-psychiatry movement, had his “convictions ….. put to the test when his daughter developed schizophrenia. After that, he became disillusioned with his own ideas. People who knew Laing told me that he became a guy asking for money by giving lectures on ideas that he no longer believed in.”

Lieberman attributes this information to Dr. E Fuller Torrey. Lieberman also mentions that the other leader of anti-psychiatry, Thomas Szasz, made it clear that schizophrenia did qualify as a true brain disease but that he was never going to say that in public.

Of less intellectual interest is the origin of the term shrink. Headshrinker entered broad use after a 1950 Time Magazine article about Hopalong Cassidy saying that anyone who predicted that he would become a hero of kids would have been led off to a headshrinker – Hollywood jargon for a psychiatrist. Hopy was my hero and I still remember lining up for hours in Toronto wearing my Hopy chaps and vest waiting for a chance to shake his hand.

North American psychiatry was heavily influenced by the psychoanalysts who, Lieberman points out, followed a rigid set of theories that were not grounded in science or scientific proof. In fact, two psychoanalysts from different schools of thought would likely come up with different interpretations for the same patient. As a reaction to this lack of rigour, science and the criticism from anti-psychiatrist, some in the profession began to establish menus of symptoms for each disorder based on data from published research. This was an effort influenced by the Kraeplin approach of the previous century.

And while the psychoanalysts had always emphasized cause based on unconscious conflicts, the development of this new Diagnostic and Statistical Manual (DSM) was to be based on two key concepts. First was that the symptoms must be distressing to the individual or must impair his ability to function. Second was that these symptoms must be enduring. It is interesting that the development of the DSM partly arose from the criticisms of the lack of evidence by anti-psychiatrists. Today, the anti-psychiatrists argue that the DSM is pathologizing everyday life. Lieberman states that the DSM-5 has actually reduced the number of diagnoses to 265 from the 297 in the DSM-4.

In addition to his description of the serendipitous discoveries of effective anti-psychotics, lithium for mania and anti-depressants, Dr Lieberman’s comments about families will please all who have kids with schizophrenia. It is worth quoting in its entirety:

It was not enough that parents had to endure the tragedy of a child’s mental illness; after this onslaught of inane diagnostic formulations, they also had to suffer the indignity of being blamed for the illness because of their own misbehavior. Schizophrenia and bipolar disorder……were now believed to be curable through the right kind of talk therapy. Like a pet cat in a tree, a deranged individual merely had to be coaxed into climbing down to reality.

All in all, a very informative and entertaining read.

Why I’ve Been Prescribing Psychiatric Medication For 47+ Years

David Laing Dawson

By Dr David Laing Dawson

In 1968 the police brought a very tall man to the emergency department of a large urban hospital. I quickly learned the man had two PhD’s, one in literature and one in Library Sciences and he was employed as the chief librarian of an important Canadian Library. He was also manic. He could not sit still; he could not stop talking. What spewed from his mouth was a fascinating, pressured, endless run-on sentence of literary quotations, interpretations, criticisms, philosophical observations, and trivia.

The emergency department was designed as an oval, so it was possible to walk the corridor in a continuous circle of approximately 200 feet. This we did. I kept pace as he strode, talked, ranted, and raved, around and around that oval. I carried with me a glass of water and a pocket of tablets in my little white intern’s jacket. Every second or third circuit when he paused briefly to catch his breath I offered him a tablet and a sip of water. He accepted this, swallowed the tablet and continued his journey. I tried to remember some of what he said. I wish I had had a tape recorder handy. His observations roamed over much of English Literature and the history of western thought, in fragments, non sequiturs, creative associations and rhyming couplets.

The tablets in my pocket each contained 100 mg of Chlorpromazine. At four hundred milligrams he slowed at little. By the time I had given him 600 mg he was able to pause. And finally, at perhaps 800 mg and the passage of the better part of an hour, he could sit. The pressure in his speech diminished. He could now absorb his environment. I could now speak a little and he could now hear me.

In 1970 a dishevelled, tall bearded man was brought to a hospital by his family. They had found him, after months of searching, standing outside the Vancouver library in the rain. He had been sleeping rough; he was malnourished; he was not speaking. He was also a lawyer who had disappeared from his office practice, and his family, after announcing he was running for parliament, emptying his bank account, and then being briefly arrested for causing a disturbance. Now he was homeless, depressed, not communicating.

With clean clothes, a soft bed, good food, friendly nurses, and my anti-depressant medication, he was soon talking, more animated. But then he swung into a manic state: over-talking, grandiose, agitated, irritable, demanding. He wouldn’t sit in my office. He stood, paced, demanded I let him leave, ranted invective at my profession, my interpretations of reality, refused my pills. He stood and paced. I sat and listened. He didn’t leave, though the doors were never locked. His family let him know he needed to stay and accept treatment. The law society told him they would not reinstate him without treatment and a doctor’s note. Eventually he sat. Eventually we talked. He accepted my pills, my mood stabilizing medication, lithium. Eventually he was reunited with his family. Eventually he got his licence back. He became an outpatient. He re-established his practice, stayed on his medication, and asked me if I would like to play squash with him.

In 1978 parents brought a young man to see me. He was mute. He had stopped talking altogether. I had a white board in my office, and pads and pencils. The young man was willing to sit and respond to questions by writing out his answers. I found he dare not speak because if he did some tragic event would occur in the world. People would die. He knew this because it had happened. He had become angry, and had taken the Lord’s name in vain, and an earthquake had killed hundreds of people in the Middle East. He agreed to return to live with his parents, to eat and shower and sleep, and to swallow before bed each night the small tablet of Perphenazine I prescribed, and come to see me weekly. He came each week, and each week for an hour he wrote his answers on my white board, and when he tired of that, on the pad of paper I gave him. On his ninth visit I handed him the pad of paper. He put it aside and said, “We don’t need that anymore.”

On a lovely Sunday morning in June of 2008 my wife and I went for a walk. On the journey back I pondered ways to spend a leisurely afternoon. But then we found a frantic woman waiting for us in our parking lot. “John is psychotic again,” she said. John is her brother. An hour later I was in their father’s house. John was on the back porch smoking and pacing. I joined him there. He was agitated, mumbling half sentences in a semi-coherent fashion, some to himself, some to me. Changeable moods swept across him. His eyes would light up and he would tell himself and me that he was Jesus, and he had a mission to save the world, and that I would be forgiven, and then his mood would quickly darken, and he was evil, perhaps the devil himself, and that he should be punished, that he should destroy himself, and then just as quickly back to Jesus. I offered him a wafer of Zydis, a rapidly dissolving form of Olanzapine. He ignored this. His moods and thoughts continued to shift from Jesus to the devil, from good to evil, from a mission to save the world, to the need to destroy himself. I offered the wafer again, and this time he took it and let it dissolve in his mouth. A half hour later he was able to come into the house, and sit, and to sit quietly, and sip tea, and then to speak more rationally. Over the next few hours he became more coherent, better able to focus on the reality at hand. He would stay this night at his father’s, take another Zydis before bed, and they would come and see me in the morning.

It is now 2015. I am astonished to learn that there are people today, even some mental health professionals, who do not believe in the existence of mental illness, nor of the efficacy of psychiatric medications. I suspect that the closest brush they have had with insanity and pharmaceuticals is reading Jack Kerouac and William Burroughs in college, and the only knowledge they have of mental illness, and of the fate of the mentally ill before these medications were developed, has come from Hollywood, or the episode of Murdoch Mysteries I watched last night.