Category Archives: Psychiatry

More on Vince Li and Absolute Discharge

By Dr David Laing Dawson

Let me give a little background to my previous blog on Vince Li.

I have had many patients over the years (50 years now, actually) who have done well with treatment, who recover, who have insight, who promise to stay on their medication. They are good people. I like them. We become friends. With some it can involve an ongoing dialogue about needing or not needing to stay on medication.

But at some point most of them stop their medication, at least once. Their lives have changed. They have been well for 20 years. They meet a family doc who doesn’t understand why they are still taking Olanzapine. They fall in love. They move. They get ill in some other way. The pharmacy changes hands. Their doctor moves. They come under the influence of one of any number of cults, including Scientology. They read the bullshit of the anti-psychiatry crowd, or the homeopaths. Someone offers them cocaine.

So at some point most of them stop their medication at least once.

With psychotic illness the illness returns, and it always returns in the same way. With some my relationship is good enough that I can cajole them into going back on their medication. With some I have had to spend hours offering it while my patient tries to decide if I am a friend or the devil. With others it means a complete relapse and re-hospitalization.

And in most cases, the only ones hurt by this relapse are my patient and his or her family. That is no small thing though. The social, emotional, vocational, educational, and sense- of-self cost is huge. Often a year or more of progress is lost.

Lack of insight may be a good predictor of human behaviour, but insight itself is not. An equally poor predictor of future behaviour is remorse, or a display of remorse. “Good behaviour, model patient or prisoner” has also little to do with what will happen in a different context five years from now. I will agree, however, that a good support system is a good predictor, but we need that support system in place for 40 years.

We clinicians are further hampered by our natural empathy, our natural sympathy that flows toward anyone nearby. It is not special; it is just human. At least twice a week during commercials I see on the television screen an emaciated fly-covered child. I get up and refill my glass. But should that child and his mother be in the room with me, my response would be quite different. Hence, as I have seen many times with CCRB cases over the years, the staff actually caring for and treating the patient are very poor at predicting future behaviour.

Now, I have not examined Mr. Li. It is possible he had a psychotic episode that will never reoccur. In my 50 years experience I know this to be only possible if the initial psychosis was caused by a brain injury, a stroke, toxic substances, or withdrawal from toxic substances, or very severe acute trauma within the time-frame of the psychosis. But from what I have read Mr. Li developed a schizophrenic illness with hallucinations and the specific delusion that resulted in a very specific horrendous crime.

So, from my 50 years of experience, I would say the people who know Mr. Li, who have spent time with him, are the last people who should be making predictions of future behaviour. Secondly, insight, remorse, promises, even absolute statements of conviction are not good predictors of distant future behaviour.

We know this man, when well, is a very nice man, and could be a good citizen of any community. We also know when ill he is capable of committing a horrendous crime.

Would it not be reasonable to use the tools we have to keep him well for the next 40 plus years? To protect Mr. Li and any future community in which he resides? They are not overly constrictive or intrusive considering the possible consequences of a relapse.

By allowing even a remote chance of a repeated homicide by Mr. Li you are doing everyone else diagnosed with a psychotic illness a great disservice.

Anti-Psychiatry

By Marvin Ross

I really don’t get it – anti-psychiatry that is. I can understand that if someone has had a bad experience with a psychiatrist, they might be wary and hostile. After all, not all doctors are good and I have no doubt that most of us have run into a bad one over the course of our lives. I certainly have seen my share of rude, arrogant and stupid doctors from family practitioners to cardiologists but I do not condemn them all. I do not devote my energy to attacking emergency medicine because of a bad ER doc I’ve encountered.

A lot of the anti-psychiatrists I’ve encountered fall into this category. They’ve had a bad experience and generalize to all. But a lot of the others aren’t in this group. They are people who have decided that their time should be devoted to attacking psychiatry as their contribution to freedom of the individual or to the good of mankind. And, for the most part, they know very little of neuroscience, medicine or mental illness. If they truly want to make a difference, they should devote their time to advocating for better care and treatment for the seriously mentally ill or to help with the growing problem of refugees, world peace, homelessness, child poverty, and the list goes on.

For the most part, they are mistaken in their views of psychiatry as Mark Roseman pointed out so brilliantly in his review Deconstructing Psychiatry. I highly recommend that people read that. His analysis is far more detailed than mine but I would like to comment on a few of the common myths that he covers in more detail.

The one complaint that is common among the anti-psychiatry mob is that psychiatrists are controlling people who give an instant diagnosis and then force their patients to take toxic drugs.

People do not go to see psychiatrists by calling one up or walking into their offices. They need to be referred by a general practitioner or via a hospital like an emergency room. And they would only be referred to a psychiatrist if they had psychiatric problems that were beyond the expertise of the general practitioner. That referral would only be made after the general practitioner had ruled out non-psychiatric causes of the symptoms and behaviour.

Like all doctors, the psychiatrist will take a detailed history from the patient, consider possible diagnoses and recommend appropriate treatment. The treatment recommended is based on the professional guidelines outlining evidence based strategies. These are the practice guidelines used by the American Psychiatric Association. Similar guidelines are used in different countries. The cornerstones of any medical practice are to do no harm and to relieve suffering.

I often hear comments and criticisms that a psychiatrist put someone on toxic drugs that they were then forced to take for eternity. A comment to my blog on the anti-psychiatry scholarship at the University of Toronto stated “based on the results of a positive diagnosis (from a 15 minute questionnaire score) a patient (including young children) may receive powerful psychoactive drugs for years, the long term effects of which are not yet known.”

As I said above, the diagnosis is not based on a 15 minute questionnaire but on an extensive evaluation. And, regardless of the medical area, drugs are always (or should be) prescribed in the lowest dose for a short period of time and the patient brought back in for evaluation of efficacy and side effects. The goal is to find the lowest dose that is effective with minimal side effects. This is a process called drug titration.

If the drug is not effective or if it causes too many unwanted side effects, it will be changed. No one is forced to take a drug that does them little good in any discipline of medicine. Surely, the patient does have choice to continue with that doctor or not and to take the advice that is offered. People who see psychiatrists are not held captive.

When it comes to children, they are not seen in isolation as the anti-psych criticism I quoted above implied. They are seen with their families who, understandably, do not want their kids on powerful drugs. There are long discussions with the psychiatrist where all less invasive means are explored. When pharmaceuticals are prescribed, the parents are at complete liberty to stop them if they do not work or if they cause troublesome side effects. The children are not held captive by the psychiatrist and force fed pills against the wishes of the parents.

When a child does continue to take the medication it is because it is having a benefit and there are no troublesome side effects. I remember a mother who resisted Ritalin for her hyperactive child for years telling me how well it worked once she decided to give it a try. “I wish I had tried it much earlier”, she told me. “It would have saved so much grief.”

The anti-psychiatry bunch also assert that mental illnesses do not exist and cite the lack of any one definitive test to prove bipolar disorder, schizophrenia or other afflictions. Quite true but the same can be said for many other maladies. How about Parkinson’s as but one example. Doctors cannot measure the amount of dopamine in the brain (which is depleted in Parkinson’s) to definitively say that the person has the condition. They determine the presence of this condition based upon observing the person and his or her movements.

Alzheimer’s is another. Like with schizophrenia, it is diagnosed by eliminating all possible other reasons for the observed dementia and when none can be found, the diagnosis of Alzheimer’s is made. On autopsy, there will be found specific markers but no one ever gets an autopsy to prove that the doctor was correct. And rarely is anyone with schizophrenia autopsied on death but this is a lengthy list of the abnormalities that demonstrate that it is a disorder of the brain.

The anti-psychiatry group should be looked upon with the same disdain that sensible people look upon the anti-vax faction.

Mental Illness and the Political Spectrum

By Marvin Ross

I have always been on the left of the political spectrum – more so in my student days – but I still consider myself left and vote for progressive ideas and progressive candidates. Progressive, of course, is a value laden term but what has baffled me has been the lack of progressive ideas by the left on mental illness.

I’ve just done a Huffington Post piece attacking the establishment of a scholarship in anti-psychiatry at the Ontario Institute for Studies in Education (OISE) at the University of Toronto. After it was penned but before it was published, I was sent a link to an article in Rabble.ca written by the founder of that scholarship, Bonnie Burstow, extolling the supremacy of Toronto academia in anti-psychiatry “scholarship”. She equates this anti attitude for the search for social justice and as diametrically opposed to Toronto’s Centre for Addiction and Mental Health.

Aside from caring for patients, CAMH has a research budget of $38 million a year, is a World Health Organization Collaborating Centre and home to the only brain imaging centre in Canada devoted entirely to the study of mental illness. Among the supporters and activists of anti-psychiatry, Burstow cites David Reville and Cheri DiNovo. Reville was a politician in the disastrous NDP government in Ontario headed by Bob Rae (1990-1995). DiNovo is also an NDP member of the Ontario Legislature.

For non-Canadian readers, the NDP is the Canadian version of a Labour Party.

That disastrous government in Ontario brought in legislation to establish an Advocacy Commission to protect vulnerable people and to promote respect for their rights. That, of course, is laudable but the bill was so flawed and cumbersome that it was immediately repealed by the Conservative government that replaced them in power.

The Ontario Friends of Schizophrenics (now the Schizophrenia Society of Ontario), told the committee that:

Ontario Friends of Schizophrenics has had dialogue with officials because we have been persistent and because we have done our homework in making some solid proposals for improvements in the legislation. We have been unable to meet with a single minister of the three ministries concerned, despite repeated requests and despite the fact that people with schizophrenia are one of the largest groups in the vulnerable population that will be affected by these bills.”

They then pointed out that the bill excluded families; that it gave more power to the commission to enter someone’s home than the police have; that the test of capacity was ability to perform personal care rather than understanding; the low standard of capacity; no provisions for emergency treatment; and too much power to the Consent and Capacity Board.

The Alzheimer’s Society of Metropolitan Toronto was equally critical arguing that the new act penalized the family. Their presenter told the committee that:

“I have serious concerns about the prevailing use of unknown professional advocates with sweeping powers, heavy demands on their time, unclear qualifications and little accountability.”

In Ontario, the only improvement to the Mental Health Act was brought in by the extreme right wing at the time Conservative government under Mike Harris. They have not always been that extreme and the word Progressive precedes Conservative in the name of the party. That improvement to the Mental Health Act was Brian’s Law which enabled those with serious mental illness to be hospitalized if they posed a danger (not imminent as previously) and to be discharged from hospital under a community treatment order. They could live in the community provided that they were treated.

Only 10 members voted against the bill, 6 of whom were members of the NDP. The Health Minister after this was passed was Tony Clement who showed his support for those afflicted with schizophrenia by attending the banquet at the Schizophrenia Society of Canada annual conference when it was held in Toronto. As mentioned above, the schizophrenia group complained that no elected official would meet with them to discuss the flawed bill they were implementing. I have always had respect for Tony while detesting his ultra right policies further honed in the Federal Harper government.

The one member of the legislature who has done the most, in my opinion, to improve services for the mentally ill and the disabled was Conservative Christine Elliott. It was her pressure that resulted in the Liberal Government establishing an all party select committee to look at possible reforms. Despite an excellent report agreed to by members of all three political parties, nothing has been done. Sadly, she left politics after not winning the party leadership but she is the first ever patient ombudsman in Ontario.

And this regressive attitude on mental illness by the left is not unique to Canada. My advocacy friend, DJ Jaffe of the Mental Illness Policy organization in New York often comments that even though he is a Democrat, the most progressive people advocating for improvements in the US are Republicans. He is referring to a bill by Republican Congressman, Dr Tim Murphy called the Helping Families in a Mental Health Crisis Act. I suggested that Canada could use help in mental illness reform from a Republican back in 2013. In 2014 I wrote about how little we could hope for reform in Ontario.

To demonstrate further the left attitude to mental illness, you just have to look at the critical comments that my most recent blog on the anti-psychiatry scholarship garnered. One woman who is doing her PhD in Disability Studies at OISE claimed that I could not criticize because I am a white male member of the bourgeoisie. My proletarian father who worked in a garment factory on piece work and was a member of the Amalgamated Clothing Workers, would cringe in his grave located in the Independent Friendly Workers’ section of the cemetary.

That criticism goes on, quoting Barstow, that all that is needed to cure mental illness is that those with the illness know “we are cared for and that we are in control of our own lives.” Another critic said people “get better because they get free from psychiatry, find peers, get in touch with their inner experience, connect with and rely on others.” That same person also said “Psychiatry was invented by the privileged to dehumanise (sic) women, the neurodiverse, gay and lesbian and transgendered people, the poor, the Indigenous, and never-to-be-heard survivors of child abuse.”

I wonder how the scientists in the Faculty of Medicine or at the Centre For Addiction and Mental Health with their budget of $38 million a year feel about being told they are oppressors?

I haven’t heard such rhetoric since the days of Trotskyites on university campuses in the 1960’s but would love to see these critics spend some time in a psychiatric hospital ward with unmedicated schizophrenics, those experiencing the mania of bipolar disorder, or in a severe depressed state. I’m sure they would find some way to rationalize why their attempts to free them from “dehumanizing” psychiatry did not work.

Anti-Psychiatry Bold and Profane

By Dr David Laing Dawson

Let me make a simple bold and somewhat profane statement about anti-psychiatry. Which I take to mean, really, anti-medical-pharmaceutical-psychiatry.

When I entered medical school and later psychiatry, I would have been content to believe that all these psychiatric illnesses were entirely “psychological” in origin and form. It was the 1960’s so I was even quite ready to believe that all this insanity was really a sane response to an insane world.

Insanity is fascinating. I have spent hours talking with, listening to people who believe the CIA is watching them, their phones are bugged, the television sends them messages, they are emissaries of God, the voices tell them they must kill someone, they are controlled by radar, Xrays, Radio waves, microchips, which in turn are controlled by the police, shadowy evil figures, particular races, the CIA, the Mafia, Martians and Venusians. The devil has figured in many of these conversations. God in many others.

I have talked with people who fear to leave the house, who keep the blinds down lest the watchers watch them, people who can’t cross an open patch of land, people who must count the ceiling tiles, who must pray every time they think a bad thought, people who must have every sequence of action and thought end in an even number.

I have talked with people too depressed to talk, to move, to shit, to piss. I have talked with people too agitated, too distraught, too full of dread to sit. I have talked to people who assumed I came from either God or The Devil or both or either. I have talked to people who could not complete a single sentence without it wandering elsewhere. I have written questions on paper for people who feared to talk at all. I have talked with people who keep their eyes on the door, or on the ground.

I write fiction and plays. Dreaming up historic, family, life event, and even intrauterine causes for mental illness is fascinating. I have entered a patient’s delusions. I have explained to a woman who thought her self to be Queen that I was the Prime Minister and therefore, in our parliamentary democracy, someone she could listen to. I have talked to “the illegitimate son of Adolf Hitler”, to a man who could “whistle up the wind”, and to women who set themselves on fire. I have talked with a man who killed two children and then their mother.

I would actually be content (but for the suffering from depression of my own mother) to have these people in humane mental hospitals, fed and clothed and active and cared for and available for me to talk with, explore, dialogue with, interpret, help to find a psychological cause, a trauma, a series of adverse childhood experiences that might explain their perceptions of reality. In fact I have done all of these. I have sat next to a manic with arm on her chair to comfort without touching, on a mattress on the floor with a man wanting to kill somebody, in parking lots and back porches. I have talked with a “King of Kings.”

It is fascinating. It is human. It is dramatic. It is sometimes comedic. It can provide me with wonderful fodder for my fiction, my plays.

But I am also a doctor. And as much as I romantically like the idea of being an Alienist, living in the manor house of the large Asylum and dining with the “lunatics”, or setting them free to roam a Grecian Isle, I must try my best to relieve their suffering. And, it seems, that from the mid 1960’s, just when I entered this field of psychiatry, we began to develop pharmaceutical agents that actually work, that relieve suffering, that restore functioning, that control these terrible illnesses.

My patients want their suffering relieved. They want their function restored. They want their illnesses controlled.

So, my anti-psychiatry friends, I must continue to prescribe drugs, relieve suffering, help restore functioning, and forgo the psychoanalytic pleasures, the philosophical, poetic explorations, the mad interpretations, just as I must insist on vaccinations for all children, and forgo all the wonderful and fanciful spiritual and moral interpretations of spots, and fevers, and delirium of the early 19th century.

The “Logic” of Anti-Psychiatry

by Marvin Ross

Our last couple of blogs have generated considerable criticism from the anti-psychiatry folks on Facebook. Not unexpected, of course, and I do enjoy (to a point) debating with them. I know that nothing that I or others say will sway them but it is important to expose them. If left unchallenged, they may influence some who are not as well educated in the realities of serious mental illness. And, for far too long, those shrill and hostile voices have made politicians cautious to implement reforms.

My blog on belief systems and anti-psychiatry I modified slightly and redid on Huffington Post. They gave the headline as Anti-Psychiatry Folks Cannot Ignore That Medication Saves Lives A much better head than mine.

One comment this received on Facebook included this:

How many people have you treated, Marvin, that your blogging is somehow more accurate than Robert Whitaker’s journalism? He spoke with psychiatrists and other mental health professionals too, many of which (sic) prescribe medications and are involved in Mad in America.

My reply:

Neither Mr Whitaker nor I have treated anyone as neither of us are doctors. I’m a simple medical journalist like he is but I also have a family member with schizophrenia so I have first hand experience into what the disease is like when it is not treated and the difference that properly prescribed medication makes. I too have talked to many psychiatrists.

The reply

Having a family member who is diagnosed with schizophrenia is not first-hand experience. It is second-hand perception, at best, depending on how much one is trusted. The person with the diagnosis is the only person with first-hand experience…not doctors, not family members.

Now I do agree that those of us who have never experienced a disease do not know exactly what it is like. But that does not mean that medical specialists do not know how best to treat based on the currently available research and the guidelines established by experts in the field. That goes for psychiatric diseases, cancer and all other diseases humans contract. And Robert Whitaker is not in step with mainstream medicine given how many have criticized him.

I don’t know all the people involved in Mad in America but I do know one – Dr Bonnie Kaplan. She is a psychologist at the University of Calgary and the leading “researcher” on The Truehope product called EM Power +. She gives a continuing education course on Mad in America on Nutrition and Mental Health where the value of EM Power + (EMP) is talked about.

To one person who posted in the discussion to her program, Dr Kaplan had this to say:

I do not see why people should not take one of the mineral/vitamin supplements that emanate from the two Alberta companies, but I cannot figure out the context for your question. If you want to discuss offline, my email is kaplan@XXXX. The appropriateness and the dose of these formulas can vary with the individual.

The two companies are Truehope and the offshoot Hardy Nutritional which was formed when the two founding partners – Tony Stephan and David Hardy – dissolved their partnership.

In 2002, Dr Kaplan’s research trial on EMP at the University of Calgary was shut down by Health Canada because it failed to meet the proper standards for a clinical trial.

The blog Neurocritic entitled one of its articles as EMPowered to Kill as one man with schizophrenia went off his meds to take EMP and brutally killed his father in a psychotic state. I have written on this case as well in Huffington Post. Health Canada has declared the product a health hazard on two occasions. I have written critical article about this in various publications and an e-book with Dr Terry Polevoy and a former Health Canada investigator and now private detective in Calgary, Ron Reinold, called Pig Pills.

The vice-president of Truehope is David Stephan who made headlines around the globe when he and his wife were convicted in the death of their toddler from untreated meningitis by a jury in Lethbridge Alberta. Both had worked as well at the Truehope call centre advising customers on their treatment. You can listen to some calls that were made to the call centre here

Dr Kaplan gives lectures where she tells the audience not to google her name (slide 3). She even went so far as to bring professional misconduct charges against Dr Terry Polevoy with the College of Physicians and Surgeons of Ontario because he criticized her work.

She is one of the people involved with Mr Whitaker on Mad in America.

Dr Dawson’s last blog on anti- depressants and benzodiazapines also received a great deal of criticism. A favourite is:

Yeah, I like to get all of my information about psych drugs, withdrawal, discontinuation, and side effects from someone’s hypothetical idea of what it should look like without their having any clue at all what actually happens when people stop or start psych drugs.

And

who wrote this drivel? – It’s not even remotely accurate

I suggested to this last person that they look at the byline to see who wrote it and then look at his bio which is on the blog. I also suggested that they state what specific statement he made that they considered wrong and to provide me with evidence from research to back it up. Nothing. And Dr Dawson has worked in psychiatric hospitals in three Canadian provinces, in the UK, was chief of psychiatry in one and has been treating patients for close to 50 years.

When I suggested to someone that prescription drugs are monitored by regulatory bodies and removed from the market if their are problems, I was met with disbelief that anything is monitored. After I posted the link to the 35 drugs removed from the market by the FDA, there was no comment. Some are psychiatric drugs and two were drugs that I took for arthritis that I had no problem with and were very effective. No comment.

And no one commented when I posted this video of the author of My Schizophrenic Life.

Addendum to Belief Systems, Mad in America and Anti-psychiatry

By Dr David Laing Dawson and Marvin Ross

Reading the comments to this blog and others of ours, there is a lot of a-historic and naive thinking. Recently, someone posted my Huffington Post blog on Open Dialogue in Finland to the Spotlight on Mental Health group set up by the Boston Globe to foster discussion of their series on the sad state of mental illness treatment and care in Massachusetts. One person criticized it claiming that I had no right to comment because I have never been to Finland, and the Finnish psychiatrist I quoted had no right to be critical because he had never been to Lapland. This is part of what that person said:

That paper by Marvin Ross is written around totally wrong information:

1) Marvin Ross has never been to Lapland to check what he wrote; thus he does not know what he speaks about…

2) The psychiatrist whom he telephoned in Helsinki, i.e. some 800 km from Lapland, had never been either…How she knew any of that I do not know.

One person commented on this blog that 10 times as many people diagnosed with schizophrenia die in the first year post diagnosis than 100 years ago and that olanzapine has killed 200,000 people worldwide.

Taking data from a number of public sources, Dr. Dawson put these statistics together:

Some American Statistics

1880

Total population: 50,000,000

A total of 91,959 “insane persons” were identified, of which 41,083 were living at home, 40,942 were in “hospitals and asylums for the insane,” 9,302 were in almshouses, and only 397 were in jails. The total number of prisoners in all jails and prisons was 58,609, so that severely mentally ill inmates constituted only 0.7 percent of the population of jails and prisons.

Average Life expectancy for entire population: low 40’s for whites

Low 30’s for blacks

2016

2016 total population: 324,000,000

Average life expectancy: men 76, women 81 (lower than Canada and most of Europe, lower still for minority groups. Much of this improvement from 1880 by preventing childhood diseases.)

U. S. Prison population : 2,200,000 (2014)

Or 716 per 100,000 American citizens are in prison. (a seven fold increase from 1880)

Mentally ill in prison estimated/measured to be 30% to over 50%

So 700,000 to over one million mentally ill are incarcerated in US prisons.

Incarceration in jail reduces life expectancy by roughly a factor of 10 years for every 5 years incarcerated. (all inmates)

Estimates/measurements of homeless in the USA:  1.5 to 2 million.

Estimates of homeless mentally ill range from 30% to over 50%.

So 500,000 to one million mentally ill are either homeless or living in shelters.

The homeless mentally ill are not receiving consistent psychiatric treatment. The incarcerated mentally ill may be receiving some limited treatment.

Adding this up:

One to two million mentally ill people are either homeless or  incarcerated in prison in the USA.

A high proportion of people with severe mental illness live in poverty.

Severe mental illness without treatment confers higher risks and co-morbidities for several serious diseases, such as cardio vascular disease. People with severe mental illness have a much higher risk of cigarette smoking and poor diet.

Untreated depression, bipolar disorder, and schizophrenia confer a much higher risk of suicide.

Homelessness and incarceration in and of itself reduces life expectancy by a considerable number of years. Neither of these groups is consistently receiving psychiatric treatment.

Psychiatric drugs do have side effects. (as do all pharmaceuticals) In a good outpatient or inpatient facility these can be monitored and treatment adjusted in partnership with patients.

But the real causes of contemporary poor life expectancy of the seriously mentally ill can be found in:

  • The illness itself untreated
  • Reduction and closing of hospitals.
  • Incarceration in jails and prisons
  • Poor or no housing. Homelessness
  • Poverty
  • Poor diet. Illicit drug use. Smoking.
  • Stigma leading to isolation and victimization
  • Poor, inadequate, or limited health care
  • Absence of good consistent psychiatric treatment.

And the overall cost of not providing good early consistent psychiatric treatment in both inpatient and outpatient facilities is calculated in the following article:

http://www.usatoday.com/story/news/nation/2014/05/12/mental-health-system-crisis/7746535/

Belief Systems, Mad in America and Anti-Psychiatry

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.

 

Psychiatry, Eugenics and Mad in America Scare Tactics – Part II

By Dr David Laing Dawson

I am not shocked that we passed through a phase in our evolving civilization when we seriously considered Eugenics. Until we understood a little about genes and inherited traits, every serious abnormality must have been considered an accident or an act of God, perhaps a punishment for some immoral thought or deed. Certainly a stigma and something for a family to hide, if it could. And, at the time, the tribe or village would feel no collective responsibility to look after the impaired child, the disabled adult. This infant and child would be a burden on the family alone until she died, usually very young.

But coinciding with a time our tribes, our villages, our city-states, and then our countries developed a social conscience, a new social contract, and accepted the collective burden to care for these disabled members, we began to learn of their genetic origins. It would be entirely logical to then consider the possibility of prevention.

When medicine discovers a good thing, it always takes it too far, and then pulls back. When men and institutions have power we always, or some of us at least, abuse it, until we put in some safeguards. And there is always at least one psychopathic charismatic leader lurking nearby willing to bend both science and pseudo science to his own purposes.

But we have, here in the western world, passed through those phases (and hope to not repeat them). Now every year we find genetics is more complicated, that there are more factors involved. And every year we pinpoint at least one more detectable genetic arrangement (combinations, additions, deletions, modifiers, absences) that cause specific and serious abnormalities.

But here is where we are now medically and socially in the Western World: We can test the parents’ genetic makeup, we can test the amniotic fluid, if indicated we can test the fetal cells, we can offer parents a choice to abort or not; we can tell them of projected difficulties, available treatment or lack thereof, likely outcome, and possible future improvements in treatment and cure. We have also socially evolved sufficiently (and are rich enough) for the state to assume some, or, if necessary, all of the burden of care.

That is where we are, notwithstanding the difficulties of providing this care, and the antiabortion crowd: Some genetic certainties, some intrauterine tests, some blood tests for carriers, some absolute and some statistical predictions, and parental choice.

Now we come to genetics and mental illness. We have no certainties; we have some statistics; we have no intrauterine tests, no blood tests, and we have parental choice.

For science to not continue to pursue a genetic line of inquiry for serious mental illness would be a travesty.

Nature/Nurture. I think I entered psychiatry at the height of this academic debate. On one hand the psychoanalysts dominated US psychiatry, while biological psychiatry (Kraepelian psychiatry) dominated British psychiatry. (R.D. Laing was an outlier). Meanwhile psychology figured if you could train a dog to salivate at a bell you could train any kid to do anything. At the same time many poets, essayists, and not a few Marxist sociologists were telling us that the insane were not insane. It was the world around them that was insane. From Biological Determinism to parental cause to the Tabula Rasa and back to Social Determinism.

Other psychiatrists worked hard to find a way of including all possible factors: the bio/psycho/social model. (Which I would like to see redefined as the bio/socio/psychological model, for it is clear to me that our behaviors are driven first by our biology, secondly by our social nature, by social imperatives, and thirdly by our actual psychology, our cognitive processes. (Just watch Donald Trump)

How much of our nature is determined genetically, or epigenetically in the womb, and how much by our experiences as infants and children and teens and adults? When it comes to human behavior it is clearly all of the above, to different degrees and proportions.

The studies show that the risk of developing schizophrenia is 50% if your identical twin has schizophrenia, whether raised together or apart. This was often touted to show that 50% of the causative factors for schizophrenia must be environmental. But we now know that identical twins are not really genetically identical. And the interplay of genes, genome, brain development and environment is time sensitive. (Despite her fluent English my wife still stumbles on some English sounds. They were just not the sounds her brain was hearing at age 3.)

On the other hand identical twins reared apart are later found to have developed surprisingly similar traits, speech patterns, skills, and interests. And on every visit with my daughter in Australia she complains about the knees I bequeathed her.

As I mentioned before, genetics gets more complicated the more we are able to study it. Some DNA sequences seem to predict a mental illness in adolescence or adulthood but not the exact one.

Of course that finding may reflect not so much on environmental influences as on the vagaries of our definitions, our current diagnostic system.

An old colleague once remarked that our criteria for the diagnosis of schizophrenia are at the stage of the diagnosis of Dropsy in about 1880. I think he exaggerated. They are closer today to a diagnosis of Pneumonia in 1940. (Note that we can now distinguish a pneumonia that is bacterial caused, from viral, or autoimmune, or inhalational, and which bacteria, but our antibiotics help only one form of pneumonia, and each of these forms of pneumonia may have one of numerous underlying problems (biological and social) causing the vulnerability to developing pneumonia.)

For mental illness the development of drugs (1960’s on) that actually work much of the time threw a monkey wrench into this ongoing debate and inquiry. It tipped the balance to biological thinking for many of us. But it is a logical fallacy to assume a treatment that works reveals the original cause. The treatment is disrupting the chain of pathogenesis at some point but not necessarily at the origin of the chain.

We will continue to argue nature/nurture, and science will continue to investigate. And doctors will continue to treat with the best tools they have available.

If Dr. Berezin is correct (which he is not) and serious mental illnesses like schizophrenia, manic depressive illness, autism, and debilitating depression, OCD, and anxiety are all caused by “trauma”, much hope is lost and we will not find good treatments and cures for centuries. For today, despite what Donald Trump and Fox News tell us, in our childhoods in Europe and North America we experience far less trauma, strife, deprivation and loss than every generation before us. Yet mental illness persists in surprisingly persistent numbers.

Dr. Berezin is taking a leaf from the Donald J Trump book. He is trying to frighten you with images of violence, abuse, regression, lawlessness for his own purposes. He is waving Eugenics and Hitler at you in much the same way Donald conjures images of rapists, criminals, illegals, and terrorists streaming across the American border.

But lets get real:

Serious mental illness (schizophrenia, manic depressive illness, debilitating anxiety and OCD, true medical, clinical depression) are little helped with non-pharmacological treatments alone. The reason we do not see today, mute and stuporous men and women lying in hospital beds refusing to eat and wasting away is because we have the pharmacological means (and ECT) to treat depression. The reason we do not have four Queen Victorias and six Christs residing in every hospital is because we now have drugs that control Psychotic Illness. The reason we don’t see thin elated starving naked men standing on hills screaming at the moon until they die of exhaustion is because we now  have drugs that control mania. The reason we don’t have as many eccentrics living in squalor collecting their own finger nail clippings and urine is because we now have very effective pharmacology to treat serious OCD.

All of these people also need social help and someone in their corner, but without the actual pharmacological treatment it will get us nowhere.

(Though, I must admit, today, you may be able to see untreated catatonia, untreated stuporous and agitated depression, untreated mania and untreated schizophrenia in some of our correctional facilities).

But lets look at the less serious mental problems as well for a minute. A patient tells me she is afraid of flying, and always avoided it. But her father is dying in another province and she needs to fly there to see him one last time. She is terrified of getting on that plane. She imagines having a panic attack and disrupting the flight.

A fear of flying. A phobia of flying. Those of us who have such a phobia can usually manage by avoiding travel by plane.

But my patient. She needs to make this trip. Now perhaps I should send her to a trauma therapist who might uncover the fact a school friend was lost over Lockerbie and have her grieve about this, and still be afraid of flying; or perhaps to a cognitive behavioural therapist who might try to convince her that her fears are unfounded, pointing out how air travel is safer than car travel; or perhaps a desensitization approach in which the counselor uses relaxation techniques and has her imagine being at the airport, boarding the plane, and perhaps accompanying her to the airport on the day of travel; or perhaps I should find out if the fear is based on sitting so close to 300 strangers for 5 hours, or riding in a 20 ton contraption at the speed of sound two miles in the air; or spending 5 hours locked in a cigar shaped coffin with 300 strangers…..

Or I might simply prescribe for her five dollars worth of Lorazepam and offer a few encouraging words to get her through the trip.

Then lets look at something in between, like ADHD, one of the diagnoses mentioned by Dr. Berezin.

It is not a difficult equation for me. The child can’t sit still in class, he is too easily distracted, lacks focus, can’t concentrate, always being reprimanded by the teacher, socially ostracized because he intrudes, he pokes, he speaks out of turn, he angers too easily.

To become a successful adult he needs to succeed in at least one thing, if not more than one thing, in his childhood. If, with accommodation at school, and some parental strategies, some adaptational strategies, such as being allowed to wear earphones and take an exercise break every 20 minutes, have one-on-one instruction, good diet, better sleep – if these work, then he may not need medication.

If they don’t work it means he will fail socially and academically and maybe at home as well. He will be in trouble all the time. He will become surly, or give up, or become more aggressive, or depressed. In his teens he will self-medicate.

If the difference between a child failing or succeeding socially and academically is a single pill taken with breakfast it would be, to use that word again, a travesty to not prescribe that pill. And that is true whether the ultimate or necessary causative factor is inherited or acquired, or some complex combination of biological vulnerability, epigenetics, infantile and toddler experience, parenting styles, pedagogic methods, diet, and video game addiction.

 

 

A Subjective Unscientific Analysis of Anti-Psychiatry Advocates

By Marvin Ross

Many of my Huffington Post Blogs attract some very nasty comments from the various anti-psychiatry adherents. The same applies to the blogs by my colleague Susan Inman and we get some on this blog. The Boston Globe award winning Spotlight Team featured in the film Spotlight, just did a series of articles on the sad state of mental health care in Massachusetts. Wanting to foster dialogue, they set up a Facebook Page for comments. And did they ever get comments!

I’ve been looking at more than my fair share of these comments over the years but decided to try to categorize them. So here goes.

1. I was badly treated, mistreated, misdiagnosed therefore all of psychiatry is evil. In some cases, this alleged mistreatment occurred over 50 years ago. I do believe that this happened in most cases and it should not have happened but it did. Personally, I’ve run into (or family members have) some very incompetent and inept treatment by doctors and/or hospitals. This has occurred in inpatient stays, visits to doctors or in emergency rooms. And some of these misadventures have been serious but I do not spend my time denouncing all hospitals, all doctors or all Emergency Rooms. What I have done is to complain to the appropriate authorities. And most of the time I’m successful.

As my English mom used to say, “don’t throw the baby out with the bathwater”

  2. The other very common cry is that I got help and recovered therefore everyone can recover and if they can’t, it is because the docs are bad or are trying to keep people sick to make money and peddle drugs. I’m sure there is an error term in logic where you extrapolate your particular situation to everyone. That is what these critics are doing. It is like saying I survived prostate cancer which has a 5 year survival of 98.8% so that someone with pancreatic cancer can too. Pancreatic cancer only  has a 4% 5 year survival rate. It is not the same nor is say mild anxiety comparable to treatment resistant schizophrenia. Stop mixing apples and oranges.

3. Involuntary treatment for those who are so sick that they pose a danger to themselves, others, or will deteriorate further without involuntary committal means that the state will lock up, drug and keep everyone indefinitely. None of these fears are true so learn what is entailed and get over it. And when I post a video or an article by someone like Erin Hawkes who went through about a dozen involuntary treatments till a pharmaceutical agent was found that removed her delusions, stop insulting her as some have done by calling her a victim and that she is suffering from Stockholm Syndrome.

How will you learn if you refuse to listen to other opinions?

What I suspect that these involuntary opponents do not understand is that people are not locked up without just cause or forever. There are safeguards in place to ensure regular reviews and appeals. In Ontario a few years ago, a group of so called psychiatric survivors challenged the constitutionality of community treatment orders and supplied the courts with affidavits from people who found them to be bad. This is what I wrote about that in the Huffington Post:

Justice Belobaba only had to look at the affidavit that the plaintiffs filed as part of their attack on CTOs to get an idea of how well they can work. Amy Ness had, prior to being put on a CTO, been involuntarily committed for showing violent behaviour in 2004. In 2007, while hospitalized, Ms. Ness kicked her mother in the back and hit her repeatedly. Then, in 2009, Ms. Ness grabbed a large kitchen knife and marched upstairs toward her mother after discovering a magazine about schizophrenia. In another incident, Ms. Ness kicked and punched the emergency department psychiatrist. By the time she was given a CTO in 2009, she had five hospitalizations.

Since then, while on a CTO, the judge pointed out, she takes her medication and sees her case worker on a regular basis. She has not been hospitalized, she maintains her housing and she works as a volunteer, has a job and takes courses. She does think, however, that the CTO is an attack on her personal dignity.

Herschel Hardin, a civil libertarian once wrote that:

“The opposition to involuntary committal and treatment betrays a profound misunderstanding of the principle of civil liberties. Medication can free victims from their illness – free them from the Bastille of their psychoses – and restore their dignity, their free will and the meaningful exercise of their liberties.”

A psychiatrist I know who is a libertarian (someone who believes that people should be allowed to do and say what they want without any interference from the government) told me that when your brain is immersed in psychoses, you are not capable of doing or saying what you want. Therefore, he was fully supportive of involuntary treatment so that people could get to the position where they had the capacity to do what they want.

4. And then we come to what Dr Joe Schwarcz on his radio show, Dr Joe, calls scientific illiteracy. He used that in his July 10 interview with my colleague, Dr Terry Polevoy, in a discussion on EM Power + and the conviction of the Stephans for failing to provide the necessities of life for their child who died of bacterial meningitis. They refused all conventional medical care, gave him vitamins, herbal products and echinacea till the poor little toddler stopped breathing.

There was a case of scientific illiteracy in that the parents are totally opposed to vaccinations and work for a  company that encourages people with mental illnesses to go off meds in favour of their proprietary vitamins. They had no idea why they were convicted, lashed out at the jury who convicted them and then, at their sentencing hearing, the wife shocked even her own lawyer when she told the court that the Crown had used a phony autopsy report as evidence.

Other examples are that anti-depressants cause violence and suicide. Violence possibly in those under 24 according to a large Swedish study but not in adults. However, the authors state that these findings need validation. There is no definitive proof of this and no evidence of increased violence in adults.

As for anti-depressants causing suicide, a warning that this might be a concern was posted on the labels. Doctors were advised to be cautious when prescribing these for depressed young people.Consequently, this resulted in an increase in suicide attempts.

“Evidence now shows that antidepressant prescription rates dropped precipitously beginning with the public health advisory in March 2004, which preceded the black box warning in October 2004. Since the initial public health advisory, antidepressant prescriptions for children and adolescents decreased, with a consequent increase (14%) in incidence of suicide in these populations.”

On my to-read list is Ordinarily Well The Case for Antidepressants by psychiatrist Peter D Kramer. Kramer is the author of Listening to Prozac and, in this new book, he continues with proof that antidepressants do work and are not simply placebos. Not only do they work, but they are life savers.

In the New York Times review by Scott Stossel, the reviewer points out that when Kramer first began visiting psychiatric wards in the 1970’s, they were filled with people suffering what was then known as “end-state depression”. These were depressed patients in what appeared to be psychotic catatonic states.

Patients like that have not been seen for decades which he attributes to the aggressive use of antidepressants.

And, lest we forget, there is also the common view that the chronicity of psychiatric disorders are caused by the drugs that doctors force on their patients. People love to quote the work of Martin Harrow in Chicago but I suspect that many have not actually read his studies. Some people, he found,  did better after going off anti-psychotics over time than those who continued with their use but that is not surprising. It has always been known that some people improve while others have chronic problems and still others are not able to be helped with anything.

What they do not realize is that in Harrow’s study, 79 per cent and 64 per cent of the patients were on medication at 10- and 15-year follow ups. And that Harrow points out that not all schizophrenia patients are alike and that one treatment fits all is “not consonant with the current data or with clinical experience.” His data suggests that there are unique differences in those who can go off medications compared to those who cannot. And he points out that it is not possible to predict who may be able to go off medication and those who need the long term treatment. Intensified research is needed.

So stop with the reference to Harrow that no one needs meds. And stop also with promoting Open Dialogue when, first, it has never been empirically validated and second, many of their patients are on medication.

5. Regrettably, many of these people lack any civility whatsoever. People are entitled to offer their comments but they should not do so anonymously. And they should show some respect for those who have different views. I’m told that some have been banned from the Spotlight Facebook page and I’ve just banned one anonymous person who posts here for his/her personal attacks. I mentioned above that Erin has been called a willing victim and one who suffers with the Stockholm syndrome for her video and her article. Refute the points she makes but leave the insults aside.

And, one post that I removed from the After Her Brain Broke page on Susan Inman in response to he video What Families Need From the Mental Health System claimed that Susan keeps her daughter locked up and ill and that she likely suffers from Munchausen by proxy.

 

Reforming Mental Illness Services is not Rocket Science

By Marvin Ross

Last week’s blog in Mind You by Dr Dawson on rationally planning services made me realize that creating and implementing services for mental illness is not rocket science. Part of my realization arose from two psychiatric emergencies that my own family had to deal with in the past year. Both had fast and positive outcomes unlike so many others. The reasons, I think, are quite simple.

Starting at the front line of service for serious mental illnesses are the police. Every community needs (as my own community has) a police/psychiatric professional team to respond to emergencies. The city of Hamilton has a Crisis and Outreach Support Team called COAST. Their phone line is 24/7 but they also have a mobile team, consisting of a mental health worker, and a police officer, and will respond to crisis calls between the hours of 8 a.m. and 1 a.m. daily.

To supplement that, a properly trained police force sensitive to the reality of serious mental illness and with compassion is required. Yes there are exceptions that receive a lot of publicity but from what I’ve seen personally and from what people tell me, we mostly have that now. I am continually amazed at the extent that many ordinary patrol officers go, to help in these situations.

What many communities lack is an emergency department reserved for psychiatric patients and staffed by specialists which Hamilton does have. Of course, it has to be well integrated with the regular ER with considerable consultation so that people are not wrongly pigeonholed. As so many of you can testify to, the standard reception in ER is to isolate the psychiatric patient and keep them waiting. Then, they are more often than not discharged over the wishes of their family. If they are admitted, it is only for a brief period of time and they are not allowed to properly stabilize. There are never enough beds in most communities.

Recently, a young suicidal girl in Ottawa spent eight nights in the ER and was discharged because their were no beds. In Guelph, Ontario, the emergency room was brought to a standstill recently because there were so many psychiatric patients there waiting for the too few beds available for them. One mother in Vancouver told me how her son with schizophrenia was “tossed out of” an ER in Toronto as the nurse told the mother via long distance that all he needed was a sandwich.

And that is the other crucial piece – hospital beds. I’m fortunate to live in a community with one of the few stand alone psychiatric hospitals left in Ontario. There are beds and while there may be shortages, people usually get to stay if they need to in order to become stabilized. While not every community can have its own psychiatric hospital, they should have sufficient beds in other hospitals reserved for people with psychiatric problems.

Sadly, they don’t and because of that people often get discharged long before they should as the pressure for more emergency beds increases. Thus, what we get are very sick people hospitalized long enough to take the edge off the worst of their symptoms and then tossed out so more emergencies can be handled. It is the revolving door that we have now. The Vancouver mother I cited above also told me that:

Ten years ago, again in Toronto, my son was turfed out of hospital (St. Mikes) after a couple of weeks, at night, into freezing February winter, with no money, no friends or relatives at hand … nothing. It was a terrifying scramble for us, 3,000 miles away, to try to get him into a hotel so he wouldn’t freeze to death on the streets. Looks like nothing has changed.

What is important for those who do have the fortune to stay long enough to be stabilized is to have a caring competent staff who treat them and their families. Hiding behind fake privacy to exclude families from treatment and discharge decisions saves no one other than incompetents who fear oversight. Finally, the last piece is proper discharge planning. No one should be discharged without a place to stay, follow up with an outpatient clinic or community medical staff, and sufficient supports to help them maintain their improvement.

When governments don’t want to do something but want to give the appearance of doing something, they set up a task force or committee to investigate and bring back a report. It looks good to some but does nothing and that is what so many jurisdictions do. Maybe it is because I live in Ontario but this province is the master when it comes to this. Between 1983 and 2011, there have been 16 reports done by the Ontario government on reforming mental health care and few changes. I haven’t bothered to add in all that has gone on since then but it would add to the numbers.

The solution is easy but getting there is not. We will only get there when we continue to press the politicians and drag them into doing what any civilized community should do and that is to properly care for those who are ill. And by that, I mean all the ill.