Category Archives: Psychiatry

Reinventing the Wheel – More on Health Standards Organization

By Marvin Ross

Back in November, I wrote a very critical blog about the Health Standards Organizations and their attempt to find a psychiatrist to finish a draft standard on mental health services in Canada. Their efforts had previously been criticized by Susan Inman in the Huffington Post. She then wrote in the Tyee that with these new standards, those with severe mental illness will wind up getting even worse care than they do now.

The president of the Canadian Psychiatric Association (CPA) also complained to them as did another psychiatrist in a blog on the CPA site. All the criticisms are linked in my blog.

That blog did get a number of comments that were also critical of them. One reader in the US stated:

“I got a headache trying to understand what the HSO was, what is it’s authority, and what is it’s driving source of funding and philosophy. Standards of care and accreditation should be a governmental or professional organizational function. The HSO is an enigma.”

Another Canadian reader stated:

Unfortunately, Accreditation Canada https://accreditation.ca/ appears to have SUBCONTRACTED the development of new standards to HSO — which appears to be part of some larger, multinational organization of mysterious origins. In any case, their shoddy work and obvious ignorance is astounding. (When I completed HSO feedback form on draft mental health standards, it asked for my zip code)

 

There was also a reply from Health Standards which can also be seen at the end of that original blog. I did not think it made much sense so I attempted to find their media person but got caught in their voice mail hell and hung up when I could find no human operator. I still have no idea who that person is but I did send an e-mail to them November 17. They responded via twitter on November 19 that they had my e-mail and were preparing answers. On December 12, I reminded them that they had not responded This is what I asked below in bold marked with a Q, their responses sent to me on December 17 marked with an R. My editorial comments to their answers are in italics starting with My comment. Despite my correspondence with them, no one has ever given me their name. The e-mail was not signed and came from “communications”. A robot? A secretary? The person who delivers coffee? I have no idea.

Q. What are the requirements for your committees?

R. The Mental Health and Addiction Technical Committee is made up of 16 voting members and three advisors and will soon include a psychiatrist as a voting member.

Worth highlighting are the two co-chairs of the committee:

Rita Notarandrea, MHSc, CHE, is currently the CEO of the Canadian Centre on Substance Abuse and Addiction and has held several roles during the 21 years she worked at the Royal Ottawa Hospital (Mental Health Care & Research), including 13 years as the COO.

Ed Mantler, Registered Psychiatric Nurse, MSC, is the Vice President of Programs and Priorities at the Mental Health Commission of Canada.

You can see the rest of the committee members on page II of the draft standard at http://healthstandards.org/files/Mental-Health-EN-PR-2018.pdf.

My Comment: Ms Notarandrea has been with substance abuse for many years and when she was with the Royal Ottawa Hospital (a psychiatric facility) she was the chief operating officer and left in 2005. Not, in my opinion, sterling qualities for this role as it does not appear that she has clinical experience.

Mr Mantler is with the Mental Health Commission of Canada which is an organization that I have severely criticized for years. His main focus, it seems, is on reducing stigma and promoting mental health first aid. Again, efforts that I have written critically about for a number of years. Prior to that, he was CEO of physician recruitment in Saskatchewan and senior operating officer at the University of Alberta Hospital. Physician recruitment and operations of a hospital are not clinical roles in mental health.

Both of those agencies were part of an extensive re-evaluation on the usefulness of their role by Health Canada and both were deemed to be expendable. The Globe and Mail reported that “it is also clear that, in all the scenarios, three organizations come out big losers: the Mental Health Commission of Canada, the Canadian Partnership Against Cancer and the Canadian Centre on Substance Abuse and Addiction.”

Q Who are the general interest members and what committee criteria do they posses.

R You can find information on HSO Technical Committees here: https://healthstandards.org/standards/technical-committees/. There is an infographic about halfway down the page that explains the composition and defines each group. If you haven’t already, you can also learn more about the standards development process on this page: https://healthstandards.org/standards/development-process/.

Technical Committee Requirements

Technical Committee members apply on our website at www.healthstandards.org. They find out about us through social media, our partners, existing relationships, conferences, and targeted outreach that we conduct.

We take the following into account when selecting Technical Committee members:

1.Professional/clinical experience as it relates to the scope of the standard

2 Acceptance of agreement with of the role of the patient as a partner in care and a member of the care team

3.Knowledge of standards and familiarity with accreditation

4.Relevant committee/extracurricular participation

5.Unique experience/perspective or contribution that relates to the standard’s topic

6.Commitment and anticipated level of engagement in the technical committee

7.A balance of positions within the health system (for example national versus provincial, acute care, and primary/community-based services)

  1. Balanced representation from a geographic perspective (remote, rural, and urban)

Q Who are the policy makers, how big is the committee and how were they solicited and/or accepted?

My comment:  This does not seem to have been answered unless it is part of the answer to the previous question

Q What is a product user?

My comment: This also does not seem to be answered

Q. You statedUnlike clinical practice guidelines, our standards follow the patient journey through the system by including elements of population health to plan services and identify health inequities, chronic disease prevention and management”

What does this mean? How do you prevent chronic diseases like schizophrenia or bipolar disorder?

My comment  Not answered

Q. You are a not for profit so could you send me your last financial statement?

R Our financial information is made available to the public on Canada Revenue Agency’s website: https://apps.cra-arc.gc.ca/ebci/haip/srch/t3010form23-eng.action?b=852490200RR0001&fpe=2017-12-31.

Unlike many other non-profits, HSO do not receive funds from public entities outside of fees for services performed.

My Comment The stated aim of HSO from their financial reporting is the promotion and protection of health. I am not sure what that means other than maybe they are protecting our health and promoting it. How do they do that?

Their main activity is to provide the international health sector community with leading edge accreditation, education and advisory services to improve health care and patient safety. I am not sure how that translates into programs

To accomplish all this, HSO has 10 full time employees all earning over $120,000 a year and one earning over $350,000. There are also 13 part time employees earning a total of about $142,000. Total salaries comes to a little over $2 million. Total revenue is $4.8 million with Total non tax-receipted revenue from all sources outside Canada (government and non-government) of $1.4 million. Total revenue from sale of goods and services (except to any level of government in Canada) is $3.4 million. Total expenditures are $5.6 million with $1.3 million going to professional and consulting fees.

Q Why do you charge $100 for standards?

R Except in the rare case when another organization works with us to sponsor a standard, we cover 100% of the cost of developing our standards. This cost is recuperated through the sale and licensing of our standards. This model is used by many other Canadian and International Standards Development Organizations, including the CSA Group and ISO.

Q Health Quality Ontario just brought out guidelines/standards for the treatment of schizophrenia and they list all members of the committee. Many of them I know either personally or by reputation and it is a very competent group. Why are your standards needed?

R Clinical practice guidelines focus on a specific illness – for example, schizophrenia – and recommend things like assessment tools, medications, and treatment options. HQO standards provide clinical practice guidelines, specific to Ontario.

HSO quality and safety standards can be applied across Canada and, in many cases, internationally. They focus on providing the best possible patient journey rather than focusing on how to treat a specific illness. This includes topics such as: accessibility and safety of services; health promotion and disease prevention; awareness and early detection of illnesses, including initiation of treatment and continuity of care during transitions in service; and engaging clients and families in service design. HSO standards are based on the HSO Quality Framework, which consists of eight quality dimensions that all play a part in providing safe, high quality care. For more information on the HSO Quality Framework, see page XII of the draft standard.

Both types of documents have a place in the health system. HSO quality and safety standards are intended to be used along with clinical practice guidelines and health care providers’ professional and regulatory requirements; they do not replace or duplicate them.

My Comment I do have to say that in my opinion their rationale for what they are doing is gibberish. When you suffer from an illness, you want the best possible treatment developed using appropriate evidence and recommended by those who actually treat. Those are what clinical practice guidelines are whether we are talking about schizophrenia, hypertension, stroke or whatever. Those are guidelines that apply to everyone everywhere.

The Health Quality Ontario guidelines which they dismiss as being relevant only for Ontario is an absurd contention. Clinical practice guidelines do not know geographic or political boundaries and should not.

Health Standards focuses on “best possible patient journey”. Well, if you or a loved one face a health problem, the best patient journey is to receive timely diagnosis and timely treatment using the best modalities that we have. What else is there or am I missing something?

As always they mention disease prevention and would that not be wonderful if we could prevent many of the illnesses that plague us – cancer, mental illness, whatever. But the truth of the matter is that we cannot prevent unless we know what the cause is. That is certainly the case with most serious mental illnesses. How will their efforts prevent someone from developing schizophrenia or bipolar disorder?

As my US colleague, DJ Jaffe, wrote recently, Serious mental illness is about biology and it CAN NOT be prevented.

If Health Standards is serious about improving the patient experience then all the money they have for staff would be well used in providing more psychiatric hospital beds for those in acute phases, more community programs for those stabilized and more affordable supported housing for those trying to survive in the community. Neither the streets nor jail are suitable therapeutic venues.

 

 

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Coming in January: Mind You The Realities of Mental Illness A Compilation of Articles from the Blog Mind You

We have decided to publish a book on the best of our mental illness blogs over the past 4 and a bit years. The book will be available in print and e-book formats everywhere in early 2019.

Below is the introduction:

We began this blog in October 2014 in order to provide commentary on the state of mental illness and its treatment for the lay public. What we provide is a viewpoint from that of a psychiatrist with many years of experience (David Laing Dawson) and a family member of someone who does have schizophrenia (Marvin Ross). Aside from his personal experience (or lived experience as it is commonly referred to), he is also a medical writer, advocate and publisher of books that take a unique look at mental illness.

To date, we have had close to 75,000 views and have been read in 151 different countries since 2014.

We also write on other topics but these are the ones on mental illness covering topics like recovery, treatments, suicide, addictions, and alternative treatments (or pseudo science).

When we began, we had this to say of our purpose:

 Welcome to the launch of Mind You. While we intend to post on mental illness,mental health and life, we decided on the name Mind You to reflect that not everything is black and white. There are ideas and opinions but then mind you, on the other hand, one can say…….

And that is what we would like to reflect. Ideas about mental illness,health and life that can be debated and discussed so that we can come to a higher understanding of the issues. And, we have separated out mental illness from mental health because, despite their often interchangeability, they are distinct.

The National Alliance on Mental Illness defines mental illness as a medical condition that disrupts a person’s thinking, feeling, mood, ability to relate to others and daily functioning. Just as diabetes is a disorder of the pancreas, mental illnesses are medical conditions that often result in a  diminished capacity for coping with the ordinary demands of life. Serious mental illnesses include major depression, schizophrenia, bipolar disorder, obsessive compulsive disorder (OCD), panic disorder, post traumatic stress disorder (PTSD) and borderline personality disorder.

On the other hand, the World Health Organization defines mental health as a state of well-being in which every individual realizes his or her own potential, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to her or his community. That is quite different from mental illness.

Unfortunately there is a tendency to confuse these and organizations like the Mental Health Commission of Canada have a tendency to talk about mental health issues and problems which are not the same as mental illnesses.

 Both Dr David Laing Dawson and I (Marvin Ross) will be posting on a regular basis on a variety of topics.

The posts we have selected for this volume are the most widely read over the past 4 years.

Mind You, ISBN 978-1-927637-31-9, 193 pages distributed by Ingram

 

Reinventing the Wheel -The Health Standards Organization

By Marvin Ross

In mid October, Bridgeross author Susan Inman (After Her Brain Broke), did a piece in Huffington Post about standards for mental health services in Canada being developed by an organization in Ottawa called Health Services Organization (HSO). Susan pointed out that “HSO minimizes the impact of severe illnesses and then fails to suggest needed services. It’s important to note that the committee creating these standards did not include any psychiatrists

In the Tyee, Susan pointed out that with these new standards, those with severe mental illness will wind up getting even worse care than they do now. I agree with Susan on the absolute stupidity of developing guidelines on an illness while not consulting doctors who treat people with those illnesses. That’s like developing standards of care for those who have heart attacks and neglecting to include cardiologists in the development.

Their draft standards were open for consultation till the end of October and I gather they are still considering the comments that they received.

My blogging partner, Dr David Laing Dawson, summed up the gist of their standards into one sentence:

“We should all treat each other nicely and kindly and use as many euphemisms as possible.”

One of my readers complained to them as well about the lack of psychiatric input and was asked if she could recommend a shrink. My only reaction to that is to quote Little Richard and “good golly miss molly”. This is an organization “formed in February 2017, to unleash the power and potential of people around the world who share our passion for achieving quality health services for all. We are a registered non-profit headquartered in Ottawa, Canada.”

Are they not capable of finding psychiatrists?

The Canadian Psychiatric Association (CPA and also in Ottawa) is only 4 miles away from them in the same city. A short cab ride (Uber if you prefer) or they could meet in the middle. But then, when the CPA found out about what they were doing, they sent them a letter. On October 26, the president of the CPA told them that “I am writing today to express the CPA’s concerns about the proposed standard, and in particular, about the composition of the advisory committee, which did not include any psychiatrists.” You can read the full letter here.

On November 3, psychiatrist Nachiketa Sinha wrote a blog on the CPA site suggesting that the disregard for experts in mental health is a symptom of the stigma that mental illness faces. Dr Sinha added “How can I possibly trust that the care I am receiving is appropriate for my illness if the policy and programs have been created by laypeople, administrators, and NO EXPERTS on my mental illness and the care I need?”

And while I used the example of heart disease standards needing cardiologists to develop them, Dr Sinha wondered if anyone would trust a bridge built by people with no engineers involved.

On twitter, HSO commented to Dr Sinha that they are “trying identify a psychiatrist to join this committee.” Again, “good golly” how hard can it be to find experts to work on this? And I should point out that the CPA along with similar organizations in other countries, does produce clinical practice guidelines that detail how various diseases should be best treated based on all of the current evidence. CPA has guidelines on the treatment of anxiety disorders, depressive disorders and schizophrenia. And, of course, so does the American Psychiatric Association. And we should not forget all of the reports (over the course of 11 years) developed by the Mental Health Commission of Canada.

Do we really need someone else to reinvent the wheel at considerable cost? The money wasted could be well spent on funding more beds which are desperately needed.

The Art of Psychiatry

By Dr David Laing Dawson

The Eyes, ahh, the Eyes.

Some years ago a psychiatrist asked me to see one of his patients on the ward of the mental hospital. She had been admitted in a state of psychosis; he had prescribed appropriate medication, and then later increased that medication, and now she sat alone all day, communicating with no one. Was the dose too high? Had he made her toxic? Should he stop the medication?

In her room the woman sat fully clothed on the side of her bed staring straight ahead. I introduced myself and talked with her. I sat beside her on the bed and talked to her. I received no answer, verbal or non-verbal. I looked closely at her eyes.

I left her room and talked with her doctor. Increase her medication I told him. He raised his eyebrows. No, I said, I’m sure.

He did so and the patient recovered, first in small ways, acknowledging the presence of others, and then talking, engaging, and plans for discharge were made.

Her eyes told me she was in a state of high arousal, not drugged at all, but rather in turmoil, flooded by fears and anxieties to the point of immobility. Her eyes were alive but focused internally.

It is easier to be a poet than a scientist when it comes to eyes. A nurse might say to me about a patient, “The lights are on but nobody’s home.” It is an apt phrase, so accurately describing a state of dementia. In early dementia the right image, phrase or music might bring that person back home for a while, but then she will leave home again, and, eventually, not return.

And then there is the stare of the true believer, aroused and focused, all knowing, all seeing. They are the same eyes one sees in delusional states. Perhaps they are daring one to challenge them. They send no signal of welcome, no invitation for discourse, no flicker of doubt. They are the easiest to imitate.

Boys on the ASD spectrum avoid eye contact, and when they are coaxed into making such “contact”, the eyes quickly touch and then slip away, as we do when we glance at the sun.

The girls, the ASD girls sometimes stare fixedly, unblinking. They make “good” eye contact we notice, but the dance is wrong, the movement static, the intent unreadable; my smile goes unanswered by her eyes.

The eyes of the man with schizophrenia are similar, but often flit from certainty to perplexity and back again, as if they are trying to decipher a very difficult passage in an ancient text.

Depression is always present in the eyes. The light is dimmed, the person home, but slow to answer the door. Sometimes they are hooded and dull, but other times, in agitated depression, fearful and searching.

And then mania. If it is an angry mania I sit low in my chair and make only fleeting eye contact, for fear of adding fuel to the blazing fire within my patient’s eyes. If it is a grandiose mania, I watch the eyes of delusion and true belief and wait for a moment of doubt, a shadow to cross those eyes, before I offer a comforting smile and some medication.

Drugs and Violence

By Dr David Laing Dawson

In medicine, when we find something that works we overuse it. That is as true of antibiotics, anti-inflammatories, and blood pressure drugs as it is for psychiatric drugs.

And this means that some people who really didn’t need the drug in the first place may be suffering unnecessary side-effects. Over time medicine usually corrects with broad studies and new guidelines.

(Although it is as difficult for doctors to convince a patient that he needs to exercise rather than take Prozac, as it is to convince a mother that her child’s cold and earache will run its course with or without antibiotics.)

But to blame psychiatric drugs for violence and murder is patently ridiculous.

In fact, if one extrapolates from the murder rate trends around the world, or just within large Canadian cities, one could make a case for the wide prescription of anti-depressant and anti-psychotic medication being the source of less violence in our societies.

Murder rates in the middle ages were shockingly high by all estimates. Similarly throughout the 1800’s.

In Toronto and Montreal the murder rates climbed from 1900 into the 1960’s, peaking in the mid 70’s and then declining ever since.

The powerful psychiatric drugs were introduced in the 60’s but mostly used within hospitals and outpatient clinics of hospitals. Wider use developed in line with the reduction of psychiatric hospital beds and the introduction of newer drugs in the 1970’s and 1980’s: the so-called atypical anti-psychotics (Risperdal, Seroquel eg) and the SSRI’s for anxiety and depression (Prozac onward).

The increasing use of these drugs within the community and less ill population, when charted, is a reverse image of the declining murder/homicide rates.

Many other factors are at play as well, of course, so I cannot make a case for these drugs specifically being responsible for the declining rate of homicides, but I can from this data be confident that wide-spread use of these medications is NOT increasing the homicide rate.

new-1

The first group of antidepressants were introduced in the 1950’s, again primarily in hospitals, outpatient clinics and for severe depression. (Imipramine, Amitriptyline)

Prozac, the first SSRI antidepressant was introduced in 1989. Currently 86 people per 1000 in Canada take an antidepressant, usually an SSRI or NSRI medication.

(note both the highest suicide rate and the lowest consumption of antidepressants falls to South Korea)

Similarly the first antipsychotics (Chlorpromazine etc.) were introduced in the late 1950’s/early 60’s and were used primarily within the mental hospital population. The second generation only became available in the 1980’s. Currently a little over 1% of the American population takes anti-psychotic medication.

If one considers the percentage of the population that suffers from severe mood disorders it is reasonable to say that the antidepressants are being somewhat over prescribed.

On the other hand if one considers the percentage of the population suffering from a psychotic disorder (schizophrenia, bipolar disorder, psychotic depression, autism with psychosis) the anti-psychotic medications are being underutilized.

But, either way, to blame these medications for violence or homicide in 2018 is ridiculous, as the data clearly demonstrate.

 

The Danforth Shooting – Violence and Mental Illness

By Dr David Laing Dawson

In the wake of the Danforth shooting a couple of my colleagues have been quick to point out that the association between mental illness and violence is small, that most people suffering from mental illness are more likely to be victims of violence than perpetrators of violence. They are worried about the stigma of violence attaching itself to mental illness. And of course they are right. Though one of them goes on to use those horrible euphemisms of “mental health issues” and “mental health challenges”.

Language is important as are the questions we ask.

If we expand the problem to “mental health issues” then I am sure I can rightly say that all acts of physical violence by one human against another are the products of “mental health issues”. Otherwise we will have to expand our concepts of normal and healthy to include physical violence.

And the use of such ill defined euphemisms plus our worry about stigma cause us to ask the wrong questions. Did he suffer from “mental health challenges” and “issues”? Of course he did. Is a circle round?

These are the better questions to be asked:

1. Did treatable mental illness play a role in the Danforth shooting?

(I have just read that the man in question “repeatedly cut into his face with a pencil sharpener blade” and talked of hearing voices – both symptoms of a treatable mental illness, a psychosis, probably schizophrenia)

2. If he did have such an illness why was it not being adequately treated?

(Not “supported”, “counselled”, “accommodated”, but treated)

And finally, because question 2 will always lead to imperfect answers, 3. How did he get a gun?

I have to add that while many people suffering from delusions never act on those delusions, especially if they are being treated, a very specific sign that a psychotic and delusional person will act upon a delusion (that is, attack his imagined torturers) is self injury to face or genitals.

How Science Tries to Understand Mental Processes

By Dr David Laing Dawson

When science tries to understand human behaviour it can develop methodologies to look at multiple levels of our organization. These levels could range from subatomic particles to the behaviour of tribes, nations, the population of the entire world.

Within the medical sciences we are interested in the behaviour of cells, of neurochemistry, and, at the other end of this chain, the experiences and behaviour of individual humans.

Behaviour can be observed, and observed within different contexts, and under specified situations. Internal experiences require self reporting within a social context, and self reporting is notoriously unreliable. (Imagine asking Donald Trump what he is thinking and feeling, and why he is having these thoughts and feelings, and whether he has written many books.)

Until quite recently the behaviour of brain cells, of neurochemistry, could only be studied by measuring the rise and fall of various metabolites in blood and urine.

And between these extremes (human behaviour and the rise and fall of metabolites in blood and urine) there existed an enormous black box containing the interaction of chemistry, cells, neurons, organs within the brain, systems of arousal and perception, systems of neural organization, complex biochemical and electrical feedback systems….

With EEGs, CT Scans, MRI’s, Pet scans, molecular biology, genome mapping, our new ability to at least see which parts of the brain are active (metabolizing, using glucose and oxygen) and which are dormant when we talk, listen to music and/or hallucinate, that Black Box has shrunk. But it is still there.

Behaviour is a visible product of a long complex chain of events from cell activity, neurohormone production, arousal and filtering systems, inhibiting and stimulating feedback loops.

Ritalin is a stimulant. Yet when given to a boy with ADHD it usually slows him down. So my best guess here is that with ADHD our stimulant is stimulating an inhibitory mechanism.

Like many medications, the power of Chlorpromazine (Largactil) to quell psychosis was discovered by accident. This time in France. Heinz Lehmann brought it to Canada to use in a trial at The Douglas Hospital. It worked dramatically, but why and how it worked is another question. Following the methodologies mentioned above it was first determined that chlorpromazine and drugs developed within the same family affected the neurochemical, neurotransmitter, dopamine. From this arose the dopamine hypothesis of schizophrenia.

But we have since learned that each mental illness is the product of long, complicated pathways from neuron to dendrite to neuron to behaviour (sometimes through long chains and multiple pathways), and that different medications can affect the final behavioural outcome by affecting different parts of that chain, sometimes by stimulating production of a neurohormone, sometimes by emulating a neurohormone, sometimes by inhibiting a neurohormone, sometimes by blocking the transmission of a neurohormone, and sometimes by inhibiting the degradation of a neurohormone (hence the SSRI’s – Selective Serotonin Reuptake Inhibitors)

With the modern technologies we can describe with accuracy what exactly each drug does at a neuronal, biochemical level. But there remains a black box between that level and the actual observed behaviour. Though it is getting smaller and smaller and easily bridged with hypotheses.

But psychosis is not simply too much dopamine, nor depression inadequate serotonin. Although medically altering those two neurochemicals (neurotransmitters) does affect (usually) the chain of electrical/molecular events that leads to psychosis and depression.

RIP Dr Fred Frese

By Marvin Ross

The world just lost another advocate for serious mental illness. Dr Fred Frese was a psychologist with schizophrenia and an active promoter of better care for the seriously mentally ill. He had been a board member of the National Alliance on Mental Illness and one of the founders (along with Dr E Fuller Torrey) of the Treatment Advocacy Center.

I met Fred, and his wife Penny, when they gave a talk at the Hamilton Program for Schizophrenia in the late 1990s and did a profile of them for one of the medical papers that I wrote for. Both of them were incredible speakers. Fred first got sick when he was an officer in the US Marine Corps guarding the largest repository of nuclear weapons in the US.

He became quite paranoid and was eventually transferred to Walter Reed Hospital in Washington where, he said, may of his fellow psychiatric inmates were high ranking officers. While a patient there and elsewhere, he pursued his education and obtained a PhD in psychology. He joked that he went from being an involuntary patient in one hospital in Ohio to becoming its chief psychologist years later.

He commented that he continued to study because people with mental illness simply cannot find work. His sense of humour was evident when he talked about dating his wife. They had gone for a long walk in the woods and it was then that he decided to tell her that he had paranoid schizophrenia. Not the best place to do that, he commented. She did not run off screaming, they married and had four children.

Dr Frese has always been a strong supporter of involuntary treatment when it is necessary (as it often is) and for the fair treatment of those who are ill.

He explains his position in this presentation below:

As he said in the video clip below, he refuses to be ashamed of his illness and that he is not recovered (despite all his credentials) but is in recovery.

I should also mention that Fred was very generous with his time and was an active supporter of the late Dr Carolyn Dobbins (another psychologist with schizophrenia) and was gracious enough to write a very good blurb for Katherine Flannery Dering’s book, Shot in the Head.

Those of us who advocate for improved services for the mentally ill will have to step up our efforts to make up for Fred’s loss.

Blue Dreams – the Story of Psychiatric Drugs

By Marvin Ross

I’ve just finished reading Blue Dreams The Science and the Story of the Drugs That Changed Our Minds and it is the most balanced accounting of psychiatric meds that I’ve ever read. Lauren Slater is a psychologist and someone who has taken psychotropic medication for bipolar depression for most of her life. She has been in and out of hospitals many times so she speaks from both experience and academic awareness.

She starts out with a very detailed account of how chlorpromazine, the first anti-psychotic, came to be and gradually made inroads against the psychoanalysis that was prevalent at the time. What surprised me was that there were psychoanalytic neurologists who considered Parkinson’s to be the result of psychology and not brain chemistry. She then moves on to give the history of the first anti-depressant, imipramine.

As a political aside, both of those drugs were first used in North America by Dr Heinz Lehmann in Quebec. He came to Canada as a refugee fleeing Hitler. His colleagues arranged a ski vacation for him to Quebec as a ruse so he left Germany with his skis and all his luggage. A lesson for the Donald on the value of refugees.

Her discussion of lithium is quite interesting as its use goes back many years for all manner of ailments but it was slow to be accepted by medicine for psychiatry because there cannot be a patent on a naturally occurring substance. No money can be made and so, to this day, no one has ever bothered to try to find out what it does to the brain or how it works. A sad condemnation of science and of the profit motive in drug development.

Ms Slater began suffering depression at quite a young age and was eventually sent to see a psychiatrist in her early teens. She saw the doctor three times per week. After about 6 years of no progress, her doctor put her on imipramine which had recently become available but it did not help and gave her terrible side effects. When Prozac became available, she was switched to that and she spent 17 years taking it.

This is what she had to say:

“Both before and while I was on imipramine, my emotions were wild and I was whipped between states of utter despair, whirling anxiety and unstable ecstacy that allowed me to pull all-nighters writing lengthy tomes that later, in the sober light of another day, lacked what I felt at the time of composition had been a poetic essence. I was also a revolving-door mental patient in and out of the hospital admitted and discharged five times between the ages of thirteen and twenty-four, with not much hope for a full future……”

“Prozac turned my life around and did it fast, one two.”

“On SSRIs, however, I have been able to stay out of mental hospitals, to write nine books, to bear two babies who are now adolescents with their own keen interests and proclivities to manage with their own interests, to manage a marriage and then a divorce, and, just as important, to nurture a circle of friends.”

Unfortunately, over the years she has had to increase the dose until Prozac became ineffective and she had to switch to other medications. And, the drugs had a severe impact on her health causing her to gain weight and to develop diabetes. But, she said, that was the price she had to pay for sanity.

While she has been helped by pharmaceuticals as have many people, she is very critical of psychiatry and its theories which are quite simplistic. I was surprised to learn that despite the dopamine theory of schizophrenia, it turns out that those with this disease can have a wide range of dopamine levels and the levels are not related to the presence of the disease or its severity. The same applies to serotonin in the case of those with depression. Prescribing is a guessing game and there are doctors who prefer certain drugs and that is what they prescribe based simply on their preferences and not the science of why a certain drug works. However, drugs that dampen or increase levels of these neurotansmitters do help with the symptoms but psychiatry still has no clue about etiology.

This ideological adherence to certain drugs is one that I encountered a number of years ago. I pitched a story to a psychiatry/neurology newspaper on research done comparing the side effect profile of the older anti-psychotics with the new atypicals. The pitch was accepted and I submitted the story which showed that the newer drugs had just as many side effects as the older ones. The editor called and told me the research was preposterous and should never have been accepted as a presentation at a psychiatry conference. They refused to run the story but paid me anyway because they had accepted my pitch (in error I was told).

Of course, we all now know that the research was correct.

One interesting fact she mentions is that even with drugs like Prozac, the rates of depression are increasing. The reported incidences of depression have increased a thousandfold since the introduction of anti-depressants. She suggests that this might be the result of an American society that emphasizes individualism and has very few safety nets like universal health care. Sociological studies have shown that depression increases with isolative societies.

It would be interesting to compare rates of depression over time between the US and other western countries that are less individualistic like Canada and Western Europe.

I was pleased to see that while she references my old opponent, Robert Whitaker, she discounts his views. Yes, anti-depressants do cause changes in the brain as he points out but then, untreated depression (and schizophrenia) cause changes in the brain and the patient when untreated, is not able to manage.

Psychiatry and our knowledge of the brain is still in its infancy and we can only hope that greater progress is coming.