Category Archives: Treatment

Yes Virginia, Psychiatric Medication Does Work.

By Marvin Ross

As I’ve said so many times, anecdotes are not proof of anything but I am going to use one to demonstrate the efficacy of anti-depressants. The anti-medication people do nothing but give anecdotes of the dangers of psychiatric medications and the difficulties some have going off them. When research is cited, they usually attack it as being biased and/or funded by big pharma.

Research does show that for most and when prescribed properly, these pharmaceutical agents do help. As an example, I’m the power of attorney for someone with Alzheimer’s Disease. When he was first being assessed by a family doctor, he came out as being depressed on the Beck Depression Inventory. While he was under going evaluation, he was given anti-depressants which he only took rarely.

However, when he had his diagnosis confirmed by the geriatric psychiatrist, it was recommended that he go back on and stay on the anti-depressant to help with both his depression and his anxiety. In order to ensure compliance with that and the Alzheimer’s med, he was given a weekly blister pack. The pharmacist loaded the pills for each day and for the proper time.

He saw the psychiatrist a few months later and was assessed again on the Mini Mental Status Exam (MMSE). The psychiatrist noted that not only did he appear more relaxed and less anxious than at the previous session, but that his dementia score had improved slightly – not because his dementia was better but because he had less anxiety.

Then, a few months later, the home care co-ordinator showed up to do a reassessment. She called me amazed. My friend, she said, was far more relaxed and showed no signs of anxiety or agitation which were evident when she first assessed him. As she said, “he still does not know where he lives or what the date is, but he is very relaxed about everything”.

Yes, this is an anecdote that and not a definitive study but it is an example of the benefit of this class of drugs. For a list of the meta analytic studies done for anti-depressants that do show efficacy, visit this webpage. Check out the home page on that site for other resources. Thanks to Robert Powitzky for pointing me to it.

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.

Conspiracy Theories, Big Pharma and Anti-psychiatry

By Marvin Ross

The world is full of conspiracy theories from President Obama was not born in the US and is a Muslim to vaccines cause autism, cancer could be cured but Big Pharma prevents the cure to make money and Big Pharma drugs people with mental illnesses to also make money.

The only truth in any of that is that Big Pharma’s goal is to make money. And that goal to make money is why they exist as they are private for profit companies in our capitalist society. TV networks, publishers, banks, retail outlets are all designed to make money by providing something that people either want or need.

What’s the big deal?

And if you are opposed to that concept, then join a political movement that advocates for socialism. However, bear in mind that only Big Pharmaceutical companies have the means and motive to invent, study, produce new and better treatments for our ailments. But they need to be monitored, regulated, and whatever research they sponsor that “proves” the safety and value of a new agent needs to be replicated by  independent studies.

Profit companies provide a service or a product that is needed in order to make money for their shareholders or owners. In the case of Big Pharma, it is medications that will help to ameliorate illness – probably not cure but reduce symptoms. They are the ones who do this because governments either can’t or won’t. History has shown that their products have dramatically improved our lives, or at least the levels of health and wealth and comfort that many of us maintain.

The role of governments is to provide a regulatory framework to ensure that these capitalist outfits do not ignore ethics in their pursuit of profits. Restaurants need to abide by rules of cleanliness for example so that their customers do not get ill and there are government inspectors to ensure that. In order to drive a car, you need a license as proof that you are capable.

The banking system requires very stringent regulations to ensure they do not run amok which is what happened to cause the recession in 2008. Many of the banking controls in the US had been removed and we saw what happened. Canada, which has always had a very tightly regulated banking system, was only mildly impacted by the 2008 crash.

And so too Big Pharma. In the US, Teddy Roosevelt brought in legislation creating the FDA in 1906 to regulate food and drug purity. At that time, many medicinal elixers contained opium, heroin and cocaine so regulation was implemented to make these products safer. Today, the FDA regulates drug development via a very stringent process to ensure that when a drug is made available to the public, it has proven to be efficacious for its intended purpose with side effects that do not outweigh its benefits. Absolutely we should not trust them or the doctors who shill their products for big paychecks. But without them there would be no pharmaceutical progress.

In Canada, that role is carried out by Health Canada and in the European Union, it is the European Medicines Agency. Each agency must approve any drug sold in that jurisdiction so that Big Pharma must gain the approval of the FDA, Health Canada and the European Agency to sell their product in those jurisdictions.

And drug development is expensive. It is estimated that for every 5-10,000 agents that begin preclinical testing, only one ends up approved for dispensing. The cost of developing that one prescription item is about $500 million and takes 8-12 years. That is a lot of money and time to get to market. Now I’m not justifying the price of drugs but the company does have to get its money back and show a profit.

The resources required to accomplish all of this are far greater than governments can afford. For those who think that drugs are mostly poisonous and are foisted upon unwitting patients by evil people to make money, this is the process to ensure that the drugs are as safe as possible.

Promising therapeutic agents are identified based on the latest understanding of a particular disease. That agent is then tested in lab animals to determine safety before an application is made to the regulatory body for an investigational new drug license. At this point, the testing involves 3 phases of study. The first involves giving a small amount of the agent to a small group of healthy volunteers to see if there are any adverse effects.

In the second phase, a small group of subjects with that disease are studied to see how effective the agent is. The third phase, if they get that far, can last for years and involve thousands of patients in various locations to test for efficacy compared to a placebo or an already approved drug and side effect profile.

Only then, years later, is the drug submitted for approval to the regulatory agency who then have their own scientists evaluate all the data. A drug approved by one regulatory agency for a particular country as I said earlier will also have to be approved the same way by the regulatory agency in those other countries.

This is a very long and costly process to ensure that the drugs doctors use for their patients are effective and have a side effect profile that is not greater than the benefit they have. And everything has a side effect including something as seemingly benign as water

Of course, it isn’t always possible to predict what will happen when patients begin taking medications in the real world and so regulatory agencies do have adverse event reporting systems in place to track and investigate these occurrences. In many cases, drugs are removed from the market for various reasons that became clear with widespread use over time. Wikipedia has a very long list of these agents, the countries where they were pulled and the reasons.

The system is not perfect but it works for the most part and people are able to have prescription products to help ameliorate their symptoms. To attack Big Pharma for developing these drugs and the doctors who prescribe them for their patients, is absurd. I am not defending Big Pharma or suggesting that they do not sometimes go to excess but simply describing what is and why.

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.

Psychotropic Medication, Addiction, Withdrawal, Discontinuation, Relapse

By Dr David Laing Dawson

I can offer some thoughts on this from many years of observation.

Addiction is addiction. Defined as the development of tolerance (requiring more and more of the drug for the same effect) and physiological withdrawal symptoms upon stopping the drug.

Benzodiazepine drugs are addictive. The “pam” drugs. They are safest prescribed for short periods or for intermittent use. But most of us struggle with this because they offer instant relief and there are few alternatives. (this deserves a longer discussion at another time)

SSRI and NSRI antidepressant medications are not (by definition) addictive. We do not develop tolerance and require higher and higher doses. But when they are stopped abruptly patients often suffer “discontinuation” symptoms. Perhaps this is a euphemism for withdrawal symptoms but usually they are not severe, and some people come off SSRI medication without any such symptoms at all.

Usually these symptoms are unlike a true relapse and are short lived. They are described many ways by people using such words and phrases as “not like myself, foggy headed, pinging, buzzing or electric shocks in my head”.

Some of the SSRI and NSRI medications have worse discontinuation symptoms than others. Perhaps Paxil and Effexor XR are the worst offenders. But again, some patients go on and off these medications without any ill effects. Strategies to ameliorate withdrawal effects include very very slow weaning and switching to an SSRI with a longer half-life.

And it is usually not difficult to distinguish these withdrawal symptoms from a relapse of the original illness being treated with these drugs. The withdrawal symptoms are almost immediate, depending on the half-life of the medication; they are odd feelings rather than the slow return of the depression or anxiety disorder they were treating.

A true relapse of the illness may occur months or even years after discontinuation. And usually the discontinuation symptoms last a few days to a couple of weeks. When these illnesses relapse (depression, anxiety, OCD) the symptoms are usually identical to those of the first episode. This fact is one of the reasons it is reasonable to call Depression, Anxiety, and OCD illnesses.

Anxiety disorders and depressions can be chronic persistent disorders or relapsing and remitting disorders. They can be seasonal or more closely associated with events and transitions in life.

Usually these medications work. And the more severe the illness the more dramatically effective they can be.

Do these drugs actually cause a later vulnerability to depression? I think the short answer is “no”. Impossible to prove of course but I have not seen it. But I have seen much relief from suffering and dramatic improvement in function.

With all that, the SSRI’s are undoubtedly over prescribed for less serious mood problems, unhappiness, and disappointment.

Of course if non-pharmacological means of alleviating mood problems do so for you on their own, then by all means use these instead: exercise, meditation, yoga, SADS lamp, counseling and therapies of any kind, better diet and sleep, better balance in life……

But I must admit that in 40 plus years of prescribing life-balance, exercise, meditation and yoga, my patient compliance rate is running roughly 5 percent. It is very hard to initiate any of these activities if you are house bound with anxiety or morbidly depressed.

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.