Monthly Archives: August 2020

A Psychiatrist Critiques Open Dialogue

This is number four and appeared August 10, 2015

By Dr David Laing Dawson

We humans are a strange and contradictory species. While most of us are willing to take any number of potions and pills to limit the effect of the common cold, to boost our energy levels, to ward off aging, sore joints, and failing libidos, and a great many of us are willing to consume dangerous liquids, pills, and injectables to ameliorate the anxiety of knowing we are vulnerable, mortal and inconsequential life forms, and some of us decide to undergo toxic chemotherapy for a ten percent better chance of survival, there are others of us (perhaps not different people) who would deny (proven effective) antipsychotic drugs to someone suffering the devastating and dangerous symptoms of psychosis, of schizophrenia.

Even if some form of two year intensive counseling/therapy/group therapy worked as well as four weeks of Olanzapine, what on earth would be the justification for withholding the Olanzapine?

To be fair we have been here before. We have all, including psychiatrists, wanted to see, to understand, mental illness, both in mild form and severe form, as adaptations and temporary aberrations of the workings of the mind. And, by extension, amenable to persuasion, love, kindness, respect, and a healthy life style. In the Moral Treatment era of the mid to late 1800’s that healthy life style was based in Christian principals of routine, work, duty, etiquette, and prayer in a pastoral setting. For someone with a psychotic illness this undoubtedly would be preferable to the imprisonment that came before, to the massive overcrowded mental hospitals that grew and grew after the industrial revolution, and even, for many, preferable to the mental health systems of 2015. But it did not treat or cure psychosis.

Through the 40’s, 50’s and 60’s many notable psychoanalysts tried treating schizophrenia with their own particular form of “open dialogue”. I read many of their books and case histories. And while they are fascinating explorations of the human condition and equally interesting attempts to find meaning within madness, it did not work, at least not as a treatment to alleviate suffering and disability.

And then in the sixties and early seventies we experimented with therapeutic communities. When I listen to the staff of Open Dialogue in Finland talking about their program I can imagine my colleagues and I saying the same things about our experience in Therapeutic Communities of the 1960’s. It was humbling, as close to a level playing field as possible, a marvelous learning experience for staff, a laboratory of interpersonal and group dynamics, an open, respectful environment for patients, but it was not an effective treatment for psychotic illness, at least not without the addition of anti psychotic medication.

Harry Stack Sullivan, a psychiatrist working before the introduction of chlorpromazine wrote that “schizophrenics are not schizophrenic with me.” And what he meant, I think, was that, with a little skill, plus respect, patience, a non-judgmental attitude, knowing when to talk and when to listen, knowing what to avoid and what to ignore, one can have an enlightening and pleasant conversation (dialogue) with someone suffering from Schizophrenia. But that conversation is not a lasting treatment or cure.

It is also notable, I think, that the psychiatrist and director of Open Dialogue in Finland, in interview, acknowledged that she prescribes neuroleptic medication for “about 30 percent” of their patients. Now, from what I know of human nature and our tendency to round our figures up or down depending on the social moment, maybe that is 35 to 40%. And given the way they work as a 24 hour on call mobile immediate response team, with no filters for severity or urgency, even if only 30% receive neuroleptic medication, it sounds about right. In truth then, Open Dialogue in Finland is NOT not using neuroleptic medication to treat people with severe psychotic illness.

I have no doubt that they have created relationships and a social environment for their patients in which less medication is necessary to help them survive and function. I think it is the same thing our ancestors did in the moral treatment era, and again, what we did in some therapeutic communities of the 1960’s.

Open Dialogue also reminded me of some other experiments with around-the-clock, immediate response teams preventing hospitalization and achieving better results than hospitalization. When I explored some of these in the 1970’s and 1980’s wondering if they could be reproduced outside of their funded clinical trials I found young idealistic doctors and nurses quite willing at that time in their lives to be on call 24/7 without extra pay, with limited personal life during the course of the experiment. We could approximate these programs in real life but we could not replicate them.

We have ample reason to not trust big pharma and their incessant push to expand their customer base, but let us also be aware of both history, and the realities that surround us, of the many people with psychotic illness now back on the streets, in the hostels and jails, of the need for better mental health care systems, and the need for better cost effective treatment, and of the many people for whom our current medications have been both sanity and life-saving.

The Corrosion of American Institutions

By Dr David Laing Dawson

Lies, Damn Lies, and Statistics

I understand why career politicians obfuscate, avoid, and lie at times to protect their careers, their standing, their livelihood, especially those who do not have a lucrative or solid “private life” to fall back on.

But I can think of no excuse for Dr. Stephen Hahn of the FDA.

Physicians understand the nuances, the outcomes, the statistical findings, a study design’s characteristics and reliability, to varying degree. But Dr. Hahn, as head of the FDA, must understand them as well as anyone. He should be an expert in this field. It is his job.

So his presentation of treatment with antibody plasma as bringing about a 35% reduction in mortality was obviously a bold faced lie, not something that could have been phrased better, not a small semantic variation. He would know the data ( from a single very imperfect study) did not show that. Not at all. At best one could say this one study indicated the possibility of a 2% reduction in mortality from COVID. (which might or might not be duplicated in further studies, which might or might not be better than placebo, which might or might not be caused by chance alone, and might or might not exceed negative effects)

So Dr. Hahn caved to political pressure coming directly or indirectly from Donald Trump.

Which also seems to indicate, for me, that America is now at a point in the erosion of democracy where none of their institutions is immune from the corrupting influence of one Donald J. Trump and the cult he has fostered. And that includes now the CDC which  has tonight been reported to have slowed testing, decreased testing for COVID 19, on orders from the White House.

Belief Systems, Mad in America and Anti-Psychiatry

This first appeared on August 15, 2016 and is ranked at number 3.

By Marvin Ross

I keep reading comments from people wondering how anyone could possibly support Donald J Trump. Fact checking his statements demonstrates how wrong he is on much of what he says. And then there are the numerous comparisons of statements that he makes that contradict each other.

Not so surprising, sadly enough, when we look at the people who believe what Robert Whitaker and the anti-psychiatry movement believe.

Put simply, Whitaker and the Mad in America anti-psychiatry folks are adamant that anti-psychotic medication for schizophrenia makes people sick and shortens their lives. Research fails to support these contentions but they persist and the data is ignored. The two latest studies provide overwhelming evidence that anti-psychotics help – but more on that in a moment.

The late Dr William M. Glazer of Yale writing in Psychiatric Times four years ago had this to say of Whitaker:

Should we accept the analysis of a journalist who (1) to my knowledge, has not treated a patient or implemented a study and (2) reaches conclusions that run counter to well-established practice guidelines? Whitaker’s ideological viewpoint, which is implied throughout the book, is that our guidelines are inaccurate and driven by industry and our own need for income—that we are dishonest brokers. Beauty is in the eye of the beholder.

Criticisms of Whitaker have been done by many eminent psychiatrists but my favourite is by blogger Natasha Tracy in Healthyplace.com. Natasha explained why she refused to even read his book with these words:

Sure, he cites studies, he just contraindicates what the study actually proves. And nothing ticks me off more than this because people believe him just because there is a linked study – no one ever bothers to check that the study says whatever Whitaker says it does.

Except, of course, the people who do – the doctors. You know, the people who went to medical school for over a decade. You know, the people actually qualified to understand what all the fancy numbers mean. You know, those people.

And I, for one, rely a lot on what doctors make of medical data and they are the ones most able to refute Whitaker’s claims.

As for the contention by Whitaker and his minions that anti-psychotics make people sick, let’s look at two recent studies.

In 2013, the highly respected British Medical Journal, The Lancet, published a German meta-analysis on the efficacy and side effect profile of all anti-psychotics. The results are summarized simply in a blog by Dr Gerhard Gründer with a link to the original study.

The meta-analysis combined 212 studies with a total of 43,049 patients. All of the anti-psychotics produced improvements that were statistically better than placebo. The best agent was clozapine.

The most recent study was conducted in the Province of Quebec and published in July and was based on real world evaluations of all people prescribed with anti-psychotics for schizophrenia between January 1998 and December 2005. The cohort consisted of 18 869 patients. Outcome measures consisted of mental health event (suicide, hospitalization or emergency visit for mental disorders) and physical health event (death other than suicide, hospitalization or emergency visit for physical disorders).

The researchers pointed out that data from randomized control trials are often limited in terms of generalizability thus real world studies like this one are much more realistic. What they found was that taking anti-psychotics reduced the risk of having either a mental or a physical problem compared to those who discontinued taking them. The only anti-psychotic that performed poorly was quetiapine (seroquel) while clozapine had the best results.

The other criticism from the anti-psychiatry bunch is that taking anti-psychotics results in premature death for people with schizophrenia. Studies have shown that people with schizophrenia do die years earlier than others but the reasons are not well understood.  One hypothesis that I mention in my book Schizophrenia Medicine’s Mystery Society’s Shame is discrimination by health care practitioners. Studies show that people with schizophrenia often do not get adequate basic medical care and treatment.

Researchers in Sweden conducted a real world analysis of 21,492 patients with schizophrenia. Subjects were followed up from 2006 through 2010. Data on drug use and outcomes was obtained from national registers.

What was found was that Antipsychotics and antidepressants were associated with a significant reduction in mortality compared with no use. The opposite of what the anti-psychiatry crowd claim. However, there was a clear dose-response curve for benzodiazepine exposure and mortality. More benzos, greater mortality. Note that benzodiazepine drugs are not anti-psychotic medications. They provide short term relief from anxiety, but they are addictive when used over a long period. Which means with long term use people develop tolerance and then crave more. And if they stop them they experience serious withdrawal symptoms. They are never prescribed alone to treat psychosis.

Psychotropic medications prescribed properly to those who need it, are beneficial despite what you may hear from some journalists and a vocal minority.

 

Donald Trump’s Mental and Emotional Age?

For the next five weeks, we will be posting articles that have appeared before based on the top five blogs in popularity since we began in 2015. This is the 2nd most viewed blog and first appeared on October 17, 2016. We will be back in early September.

By Dr David Laing Dawson

trumppumpkinThe recent revelations about Donald Trump, especially his barging into the dressing room of pageant contestants, left me wondering about emotional and mental age; specifically, at what age in a boy’s development would we find some of Trump’s behaviour, if still not laudable, at least common?

1. Peeking in the dressing room to get a glimpse of girls in partial dress: age 13 to 15

2. Complaining that the moderators are unfair and gave Hillary more time: 6 to 12 (preteen sibling rivalry)

3. Name calling repeatedly: age 6 to 12 (the school yard taunt)

4. Use of single word hyperbole to describe something: Age 14 to 16 (“It was like horrible, horrible.”)

5. Lying even when it is not necessary: 14 to 17 (Some teens get so used to shading their responses to questioning by parents that they lie even when the truth would get them kudos). Donald could have said, truthfully, that he decided, within a year or so of its onset, that the invasion of Iraq was a mistake, and he would have sounded thoughtful and mature.

6. Never taking responsibility; it is always the fault of someone else: age 10 to 15. (“The teacher hates me, I wasn’t doing nothing when…”.)

7. Boasting about sexual prowess: 16-18 (Actually at that age males usually boast about sexual prowess to an audience of peers who know the story is fiction. It’s more of an in-joke than a real boast. We all understand the deep level of insecurity that lies behind a real boast.)

8. Groping or kissing women without consent. Perhaps 15 to 25 but only if the young man is brain damaged, severely inebriated, or mentally handicapped.

9. Denying the obvious truth. Perhaps 13 to 16. (“The marijuana you found in my sock drawer – it’s not mine. I have no idea how it got there.”)

10. Broadly lashing out at unfairness when challenged. Perhaps age 3 to 10, and beyond that into teens when the boy has Fetal Alcohol Syndrome (FASD) or Autism Spectrum Disorder.

11. Just a few days ago, Mr. Trump said something I haven’t heard since I was privy to post football game teenage drunken banter:  “Look at her.” he said, implying clearly that he would only consider assaulting a more attractive woman.

12. And he keeps giving us fodder to think about. The latest: “I think she’s actually getting pumped up, you want to know the truth.” Now beside the bizarre accusation (he’s referring to Hillary) he uses one of his favourite phrases, “you want to know the truth.” There are many variants to this: “To tell the truth.” “I have to be honest.” “If you want to know the truth.” “Gotta be honest with you folks.” Now these kinds of qualifiers are not limited to adolescents, but they are precisely the phrases boys between the age of 14 and 19 use just before they lie. And addicts of all ages.

Fortunately Donald Trump’s candidacy is foundering on his behaviour and attitude toward women. The threat of having him in the White House is diminishing. But really, by my calculations, if Donald Trump were to be elected, we would be giving an immense amount of power to someone with the judgment and emotional age of a 7 to 15 year old boy, and not a sober, stable, empathic, conscientious 7 to 15 year old at that.

The Decline of Mental Illness Treatment from the 1980s On – Repeat

For the next five weeks, we will be posting articles that have appeared before based on the top five blogs in popularity since we began in 2015. This is the most viewed blog and first appeared on December 27, 2017. We will be back in early September.

By Dr David Laing Dawson

Through the 1970’s into the 1980’s I ran what we called Community Psychiatry Services. They were General Hospital based and consisted of teams of psychiatrists, nurses, social workers and psychologists. We used what we called an “Active Intake” process that ensured that the severely ill received appointments very quickly and the worried well were rerouted to other agencies. The “active” part of the intake process was a pre-appointment engagement of the patient, the family, the other caregivers. Doing this required that the clinic not become specialized, and that it did not have exclusionary criteria.

The second component necessary for this is a true team, with each member involved, the care plan decided by the team led by a psychiatrist, and that the nurses and social workers be willing to function as case managers. It also required that each member of the team be prepared to help with medication compliance and monitoring, medical care, budgeting, finding bus passes, talking to families, giving shopping lessons, helping with all activities of daily living and also counseling.

Doing this work requires a high tolerance for chaos, uncertainty, anxiety, and insanity.

What happened?

Several things I think, though it is difficult to see the forces of change while living within them.

1. The length of stay in hospitals for the mentally ill became shorter and shorter, driven at least in part by spurious management and budget ideals.

2. The mental hospitals continued to downsize, in some part as a naive ideal, but mostly as a means of shifting cost (and responsibility) from Province and State to Community and Federal Governments. (Note the stats of the Chicago area show an exact mirror image between the declining numbers in hospitals, and the inclining numbers in jails and prisons from 1970 to 2010)

3. The general Community Psychiatry Service is not a good academic career choice. Academics need to specialize for teaching and research opportunities. Hence the development of Anxiety Disorder and Bipolar Clinics. This doesn’t work for the severely mentally ill because to satisfy all the research and protocol needs the waiting list is long, the assessment phase onerous.

4. Again, based on naive idealism, many community services shifted location from the hospital to the community. But once a clinic is moved away from the hospital (geographically and managerially) several things happen:

a. They can no longer risk taking disorganized, chaotic and potentially dangerous patients and

b. Non-medical and non-psychiatric philosophies start to dominate, and the severely ill are excluded. And

c. (at least in my experience) away from the stable budget and managerial practices of a hospital, strange things happen, all the way from pop psychology to fraud.

5. I suppose it was inevitable that each discipline develop more of a sense of autonomy and independence. Social workers and other mental health professionals are no longer case managers working with psychiatrists. They are independent counselors. The development of simplistic models of counseling (CBT and DBT) which can be applied once per week for ten weeks helped this along. This has also contributed to something of an anti-pharmaceutical attitude. (By the way, there is no evidence that CBT is any more helpful than any other professional counseling relationship, but being a rigid simplistic set of responses it is easier to study)

6. I am also convinced that by putting addictions and mental health (illness) under the same umbrella, we diluted what sympathy and empathy the community was developing for the seriously mentally ill.

7. This was compounded by the so-called recovery model, which at its heart, really means (and this may be appropriate for addicts) that if you really try hard enough and think only good thoughts (CBT), and are sufficiently “supported”, you can get well and recover fully.

8. The corollary of this being that if a person with a psychotic illness is not recovering it just means he is not trying hard enough.

9. De-stigmatization. I just happened to watch “Big” the other night and noticed that the actor who played a walk through part, non speaking, looking homeless and mumbling to himself in downtown New York, was listed in the credits as playing “Schizo”. The real way to de-stigmatize any illness is not by feel good infomercials, but by providing adequate and successful treatment. Think Leprosy, AIDS, cancer.

10. Without a team to work with, to case manage, to field crisis calls, to make home visits, to check on progress more frequently, a lone psychiatrist will find it difficult to treat the severely ill.

11. The tightening of the mental health acts and processes in each state and province,  the protection of individual rights and the provision of due process (as defined by lawyers), again based on a sort of naive idealism, resulted in four unintended consequences: thousands of people suffering from untreated psychotic illnesses in the streets and shelters, a burgeoning population of mentally ill in the prisons, the dramatic growth of locked Forensic Psychiatry Units, and a sad return to locked doors for the rest of the hospital now dominated by the Forensic units.

Between 1900 and 1960 the severely mentally ill were mostly institutionalized, treated in mental hospitals for long lengths of stay, by doctors who were often imported and/or had limited licenses. Then as now, the Academic and North American trained psychiatrists worked in private offices treating a small number of patients over many years. These patients could be counted on to be articulate, educated, and at least middle class.

Between about 1960 and 1990, with new effective medications and the move to de-institutionalize, community clinics like the ones I worked in developed in many parts of North America; the General Hospitals developed psychiatric programs, and for at least two decades, perhaps three, we seemed to be moving in the right direction. In parts of Canada incentives were developed to keep psychiatrists working in hospitals with the severely ill or as they were called then, the seriously and persistently ill. And the University Departments of Psychiatry finally took an interest in the medical treatment of the severely mentally ill.

We were going in the right direction.

And now it seems we must re-invent the wheel.

For more information on schizophrenia, check out the documentary Schizophrenia in Focus

 

Now Live – My Name is Walter James Cross and I Have Schizophrenia

By Marvin Ross

Well I did say that the current production would have to be spectacular to be better than the original film and it is. This is what one person who saw it on stage had to say:

I recommend this play to every person who is sensitive and caring about other human beings. I saw it in March 2020, and I will see it again. The play is very emotional, insightful and uncovers the mind and soul of people who we usually neglect. Performance deepened my level of empathy in a very subtle way.

Here it is in its entirety