Tag Archives: Mad in America

Psychiatry in Scandinavia

By Marvin Ross

There must be something in the water in Scandinavian countries that produces some strange treatment modalities for serious mental illnesses. The latest is drug free units within psychiatric hospitals in Norway. Previously, we had (and still do) the open dialogue program in Northern Finland which claims to cure almost all of schizophrenia drug free.

This program has been touted for years by the anti-medication/anti-psychiatry proponents of the US journalist Robert Whitaker and his adherents in Mad in America. I wrote about this program in Huffington Post back in 2013 and pointed out that there is almost no research showing it to be effective. A Finnish psychiatrist confirmed that “most mental health professionals in Finland would agree with your view that Open Dialogue has not been proven to be better than standard treatment for schizophrenia. However, it is also a widespread view that the programme is attractive due to its client-centredness and empowerment of the service user, and that good studies are urgently needed to establish the effectiveness of the programme. Before it has been established to be effective, it should be seen as an experimental treatment that should not (yet?) be clinical practise.”

At the time, some of my critics on social media attacked me for actually asking a Finnish psychiatrist what mainstream shrinks in Finland thought of the program. Just recently, I received a message from someone on Linkedin asking me if I was still negative about Open Dialogue as there is now new research showing how good it is. I replied that I was negative but would love to seen the research. I never heard from her again.

More recently (in 2015), Dr Dawson also wrote about Open Dialogue in this blog. He commented that “Even if some form of two year intensive counseling/therapy/group therapy worked as well as four weeks of Olanzapine, what on earth would be the justification for withholding the Olanzapine?” And he pointed out that “the psychiatrist and director of Open Dialogue in Finland, in interview, acknowledged that she prescribes neuroleptic medication for “about 30 percent” of their patients.”

Now, Norway has added to this anti-drug position and “By 2017 all health regions in Norway have established medication-free treatment services in mental health care, following a direct requirement from the Ministry of Health and Care Services.” (from correspondence from the Norwegian health ministry).

What is being offered is that “All the drug-free units emphasize creating recovery processes based on patients’ own experiences and wishes. Most services create treatment plans in collaboration with patients. The treatment in Vestre Viken HF in the South-Eastern Regional Health Authority and Vegsund DPS in the Central Norway Regional Health Authority have fixed schedules. Common treatment approaches of the drug-free units are psychotherapy; both individual therapy and group therapy, environmental therapy, art therapy, Illness Management and Recovery (IMR),psychoeducation, physical and social activity, exposure therapy, and networking; both in regards to relatives and work/education.”

Even though this program was first introduced starting in 2015 at the insistence of “user organizations” (and what they are is not defined), no evaluations have been done comparing those who do not get medication to those who do. That research is just recruiting patients and is not expected to have results until 2023.

The issue to me is should this drug free experiment have ever been begun in the first place and the answer is no. The evidence based consensus guidelines for the treatment of schizophrenia all recommend that anti-psychotics should be used in the acute phase and that they should be used in order to prevent relapses once the patient is stable. Not using accepted treatment for serious mental illnesses is as stupid, in my opinion, of oncology centres forgoing standard cancer treatment and allowing patients to try the type of quack remedies you find in alternative medicine.

The one survey that has been done is of psychiatrists and their view of this experiment. The research conducted by a Norwegian hospital was reported on by Mad in America who said “The research, which was funded by a grant from the Stavanger University Hospital, found that psychiatrists carried negative opinions of this initiative. They understood the programs to be unscientific and rooted in the perspectives of dissatisfied service-users within a patient group that “lacks insight” into their problems. These recent findings were published in the Journal of Psychopharmacology.”

Needless to say that Mad in America disagrees with the criticisms and argue that :

here exists substantial debate in the clinical and research literature over the long-term effects of antipsychotic drug treatment for psychosis and whether the significant safety risks outweigh any benefits. Also, critics have pointed to the impact of guild interests and institutional corruption on current guidelines recommending this treatment.”

Please not that the references they cite to demonstrate their points are all from Mad in America – a highly reputable source of all things scientific.

This entire situation is forcing me to go have a few pints of homeopathic lager!

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Further Reflections on the Misguided Concept of Recovery

By Marvin Ross

Last year, I wrote about what I called the unintended consequences of focusing on recovery in schizophrenia. I’ve also published an e-report called The Emergence of the Recovery Movement by Lembi Buchanan that explores the anti-psychiatry and anti-medication underpinnings of this movement.

In October, the New England Journal of Medicine published three articles by cardiologist Lisa Rosenbaum. The first is called Liberty versus Need — Our Struggle to Care for People with Serious Mental Illness which contains a section on recovery. The other two articles are listed and linked on the right hand side of that page. Toronto psychiatrist, Dr David Gratzer, brought them to my attention and then I discovered that my friends at Mad In America (MIA) detested the articles so, from both sources, I knew they would be good.

Comments by MIA on the article include:

“This is paternalistic rubbish”

“It is no wonder that people are turning against such white, wealthy elites, as exemplified by recent events such as Brexit and Trump’s election, when so many experts such as this (white, wealthy) psychiatrist think they can impose their view about who is right on common people and their families.”

“The arrogance is a notch higher than you might have realized. The author is a cardiologist.”

Dr Rosenbaum mentions that the Recovery movement began partly to combat stigma by pointing out that US policy makers wanted to show that people could get better. She quotes a 2003 report that said “because recovery will be the common, recognized outcome of mental health services, the stigma surrounding mental illnesses will be reduced, reinforcing the hope of recovery for every individual with a mental illness”

She then quotes psychiatrist/historian, Joel Braslow, stating that “What unifies the (recovery) movement is its self-perception as a radical departure from the past.” Consequently the problem with recovery, she says, is that it becomes antagonistic to and a subtle rebuke of psychiatry. Thus, psychiatrists are seen as having created dependency so that their patients will need them forever. To this she says that “psychiatrists are no more responsible for the chronic needs often associated with schizophrenia, for instance, than medical doctors are for those associated with HIV.”

The needs are there because of the disease and not because of the efforts of those treating the sufferers.

If you defer to the patients’ choice, a positive outcome is guaranteed because success is self-determination. Whatever the patient decides is in his or her best interests is a positive outcome even if objectively, it is not. And she cites recovery maven, Patricia Deegan, who wrote “Although the phenomenon (recovery) will not fit neatly into natural scientific paradigms, those of us who have been disabled know that recovery is real because we have lived it” That reasoning, says Rosenbaum, stifles dissent because who can argue with lived experience.

And she cites Oliver Freudenreich, a German-born psychiatrist who now practices at Massachusetts General Hospital. He pointed out to the author that “It’s a very American idea: if you try hard enough, pull yourself up by the bootstraps, you can do it.”

It is that last statement that bothers me the most because many people cannot recover to the point where they have no deficits and need no medications. Anyone who can’t (and they are in the majority to varying degrees) are made to feel like it is there own fault that they are not better.

Most people are familiar with the concepts put forth years ago by people like Dr Bernie Siegal (Love Medicine and Miracles) and Norman Cousins (Anatomy of an Illness) who talk about curing your diseases with imagery, positive thinking, laughter and relaxation.

These ideas were studied in the case of metastatic breast cancer and there was no improved survival at 5 years. The latest Cochrane metaanalysis concluded that “there is a relative lack of data in this field, and the included trials had reporting or methodological weaknesses and were heterogeneous in terms of interventions and outcome measures.”

A number of years ago, I had the opportunity to meet with a number of women who were involved in one such trial on survival. The most difficult article I’ve ever done because I sat with about 10 women all of whom were terminal and about to die. All of the women told me how desperately they wanted to live and how they hated Bernie Siegal and Norman Cousins. Their philosophy, they said, suggests that if we die from cancer, it will be our fault – that we did not work hard enough to think positive thoughts and to will our cancer away. That is not the case at all. Their will to live was not able to stave off the consequences of advanced metastatic cancer.

Nor is it the case with people with schizophrenia or any other serious mental illness who are not able to throw out their pills and return to good health. Many (or most) will continue to need them and will continue to need support to varying degrees. If they cannot achieve what has been arbitrarily defined as recovery, it will have been their fault. It is not! They should be supported in whatever it takes to keep them as well as they can become.

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.

 

 

Psychiatry, Eugenics and Mad In America Scare Tactics – Part I

By Marvin Ross

Much of what I read on the Robert Whitaker website, Mad in America, stretches logic but this newest blog has to be one of the biggest stretches I’ve seen. Dr Robert Berezin, a US psychiatrist, warns that psychiatry is moving closer and closer to eugenics.

As defined by dictionary.com “eugenics is a word that made everyone at the event uncomfortable. … The very subject evokes dark visions of forced sterilization and the eugenics horrors of the early 20th century. … The study of hereditary improvement of the human race by controlled selective breeding.”

The most famous proponent of eugenics was Adolph Hitler who wanted a pure Aryan race but the subject has been advocated by many in recent history in an attempt to eradicate debilitating diseases. In fact, one could say that the reason for amniocentesis is to do just that. Sampling of the amniotic fluid of pregnant women can predict such things as Down’s Syndrome. And some parents will opt for abortion if Down’s is found but many do not.

Amniocentesis can also predict such genetic conditions as Tay Sachs Disease where the infant usually only lasts to about age 4. But, nowhere in the article by Dr Berezin does he actually show that modern psychiatry is planning to eliminate anyone who suffers from schizophrenia or any other psychiatric disorder.

What he talks about is the fact that genetics is being employed to try to understand these conditions better. He states that:

The accepted (and dangerous) belief is that psychiatry deals with brain diseases – inherited brain diseases. We are back to absolute genetic determinism. Today’s extremely bad science is employed to validate not only the idea that schizophrenia and manic-depression are genetic brain diseases, but that depression, anxiety, phobias, psychopathy, and alcoholism are caused by bad genes

I have no idea why he considers the genetic research to be bad science other than he does not agree with it. So what if he doesn’t. He does state that “The temperamental digestion of trauma into our personalities is the source of psychiatric conditions.” But, as Dr David Laing Dawson has written on this blog:

Childhood deprivation and childhood trauma, severe and real trauma, can lead to a lifetime of struggle, failure, depression, dysthymia, emotional pain, addictions, alcoholism, fear, emotional dysregulation, failed relationships, an increase in suicide risk, and sometimes a purpose, a mission in life to help others. But not a persistent psychotic illness. On the other hand teenagers developing schizophrenia apart from a protective family are vulnerable, vulnerable to predators and bullies. So we often find a small association between schizophrenia and trauma, but not a causative relationship.

Dr Berezin’s concern does not come from anything that anyone has said about aborting fetuses that genetic testing proves will be born with schizophrenia or bipolar disorder or any serious psychiatric condition. And the reason for that is that genetics and the understanding of the causes of these diseases is nowhere near a point that this can be demonstrated with 100% accuracy. Science is a long way from getting to that point if it ever is able to.

Suggesting that these research avenues will lead to abortion, eugenics or something similar is absurd and nothing but scare tactics perpetrated by someone who does not agree with the causation theories being investigated. If these avenues lead nowhere and it is discovered that science has been on the wrong path, then science will self correct. Attempting to generate unfounded fear is counterproductive.

Next Part II by Dr David Laing Dawson

The Best Treatment for Psychotic Illness is no Secret.

By Dr David Laing Dawson

Nor does it require argument and more research comparing one component to another. This is it:

  • Early intervention, thorough assessment.
  • Treatment with medication by a knowledgeable physician/psychiatrist.
  • A good working relationship between psychiatrist and patient and his or her family.
  • Adequate housing with support.
  • A supportive family.
  • Ongoing education for patient and family about illness and treatment.
  • A wise, grounded counselor/therapist/support worker.
  • Easy access and rapid response support team for crises and emergencies.
  • Healthy diet and exercise.
  • Good general medical care.
  • Membership, belonging to a group or organization of some kind.
  • Daily routine.
  • An activity that provides some sense of worth and value.

When the support systems are in place, and a good working relationship has developed between the psychiatrist and patient and family, pharmacological treatment can be (safely) titrated down (or up) to the lowest effective maintenance dosages. Occasionally, with close monitoring over a long period of time, this can mean trials of no medication.

In the real world there are dozens of reasons this ideal is not often achieved, or only partially achieved. And some of those reasons include the interminable nonsense spouted by the Mad in America Group, inter-professional rivalries for prestige and money, illness deniers, would-be gurus, and politicians and planners listening to this nonsense.

A Comment on “Me, My Mind and Baked Beans” & “The Holocaust Intrudes…”

stone of madness     By Dr David Laing Dawson

There is no doubt we need to be careful and cautious with labels. And comparing The Holocaust (as Peter Kinderman did) to anything other than another systematic and extensive act of genocide trivializes the former and reduces whatever criticism was intended of the target to a nasty school yard epithet. It is just plain thoughtless, stupid, and insensitive – as James Coyne pointed out.

But the concept of disease is just that, a concept. The word itself is a conjunction of “dis” and “ease”. The modern concept of disease has a two or three hundred-year history. And it is, after all, the very concept that allowed us to eradicate – well, almost eradicate – measles, mumps, polio, diphtheria, cholera, to treat some cancers, heart disease, pneumonia, and to improve the lives of those suffering from the conditions of bipolar disorder, depression, and schizophrenia.

We have philosophical and scientific approaches to the concept of disease, and folk definitions. These may invoke evolution, constructivism, objectivism, adaptation, and concepts of “abnormal” and “normal”. And “normal” itself, can entail ideas of function, value, ideals, averages, and adaptation, as well as bell curves, actuarial tables, standard deviations.

The concept of disease does also imply a biological insult, difference, or malfunction of some sort, from its history of scientifically seeking cause and effect and the linkages between them, of leaving older explanatory concepts of magic, karma, miasma, destiny, god, evil, the devil and possession behind, to say nothing of the wholly unfounded notion that a “refrigerator mother” can cause autism or psychosis in her child.

We do have a recent history of overusing the disease concept in our modern world, of allowing flawed ideals and values (and commerce) to inform some of our definitions. But, in truth, it was not the overreaching concept of disease that caused damage, but the laws of the time that allowed abuse to follow. And the abuse, as is usually the case, was of power, not of semantics.

Today, on one side of the coin, we have the advocates for addictions and alcoholism petitioning for those afflictions to be called diseases, and on the other side, certain U.K. psychologists  asking that all mental disorders be removed from under the rubric of disease. The former, I’m sure, because the concept of disease does absolve one of some moral responsibility for his or her behaviour, and the latter, I’m sure, because the concept of disease requires a physician to head the team of professional helpers.

But let us bring this down to basics:

We perceive someone to be “badly off.” He may or may not perceive himself to be badly off. We then ask ourselves if the disease concept will be of benefit in this situation. Does the idea of “illness” fit? Is he suffering? Is he causing others to suffer? Folk definitions may be applied at this point: “Call the cops.” “He needs a doctor.” “He seems to be okay, he’s not bothering anybody.” “He needs his medications adjusted.” “He’s just a little eccentric.” “That’s just Joe being Joe.” Or even that contradictory but common conclusion, “What a sick bastard.”

This person is brought to or finds his way to a medical professional. The medical professional asks herself similar questions: “Is he badly off?” “Does he perceive himself to be badly off?” “Is he suffering?” “Is he causing others to suffer?” And, then, “Does the concept of disease offer any help in this situation?”

And there is absolutely no doubt (how could there be any doubt today?), that for those behaviours and experiences, those symptoms and signs and suffering that constitute severe mental and emotional disorders, that fulfill the definitions of schizophrenia, bipolar disorder, severe anxiety disorder, severe depression, the answer is YES, ABSOLUTELY.

And that ‘yes’ encompasses treatment today, and research tomorrow.