Furious Seasons

Comments: Charles Nemeroff Writes Self To Pay Self

I've read Dr. Goodwin's statement, and it sounds pretty reasonable to me. I wonder what other people's thoughts are who have read it?

Posted by dguller at December 18, 2008 12:58 PM

I agree, dguller. It's perfectly reasonable and shows the anti-psychiatry crowd for what they are.

Phil, you look like an idiot. Why on earth would Goodwin waste his time with you when a respected and unbiased journalist like Liz Spikol is willing to listen to reasoned discussion.

Posted by A Believer at December 18, 2008 01:23 PM

dguller, I agree - sounds reasonable to me too.

Posted by CHCH at December 18, 2008 02:23 PM

no i don't look like an idiot. you look like a fool defending a corrupt old man who couldn't reveal his pharma payoffs when he was legally (and morally) obligated to. and since you've attacked me personally, i'm going to warn you once that if you do that again, i'll ban you from comenting on this site.

and if i look like an idiot, then what does sen. grassley look like? come on, believer, i really really want to hear this one.

Posted by Philip Dawdy at December 18, 2008 02:31 PM

Dear Lisa,

If shrinks can write letters to themselves, then why not? Effexor causes all kinds of fun withdrawal problems, don't you wish you had been warned about it before you took it? Don't you wish you could have all those co-pays refunded?

Sincerely,
Lisa

Posted by Lisa at December 18, 2008 03:06 PM

Phil--keep going.

These revelations are a total disgrace to the profession.

How can people who cannot even apply a simple moral argument to themselves claim to be "doctors of the mind"?

It is pathetic.

Posted by Bob at December 18, 2008 04:16 PM

Philip,

Liz was on Goodwin's radio show. You never were. Maybe he just sent it to former guests. I wouldn't stress about it, it was probably an oversite.

From what I could glean, Liz was the only one one got it. Or at least published it. I didn't get one.

Posted by susan at December 18, 2008 05:43 PM

Ban away. It just proves my point.

Posted by A Believer at December 18, 2008 11:31 PM

Bob:

You are arguing that if a person cannot apply a moral argument to themselves, then they are unfit to be a "doctor of the mind", correct?

I assume that you, being a human being and all, have engaged in some immoral actions that you convinced yourself were necessary through various cognitive and emotional contortions. I only assume this, because we have all done this.

There's a great book on the subject called "Mistakes Were Made (But Not By Me)" by Carol Tavris and Elliot Aronson, which goes into the cognitive and psychologist evidence for how we delude ourselves into accepting things that are untrue.

So, given your argument -- unless you are a saint, and then I apologize -- you are also unfit to make recommendations about the mental health of others, including Dr. Goodwin, and thus that includes determining which mental states make someone an authority on a subject or not. It also includes offering opinions about what are the appropriate treatments for mental health issues, because that would assume that you are also an expert of the mind, which you cannot possibly be, given your likely ethical lapses.

Therefore, your argument is invalid.

Or, maybe we can agree that ethical lapses can cast doubt upon someone's beliefs and expertise, which would prompt a close examination of their work for errors? If that examination finds that their studies are false, then they are refuted. However, their character will never falsify their work, because that is an ad hominem fallacy.

Take care.

Posted by dguller at December 19, 2008 04:20 AM

You should like this, though. From the UK's Times:

December 19, 2008
AstraZeneca row as corruption claims engulf Nobel prize

David Charter

The integrity of the Nobel prize was called into question last night after it emerged that a member of the jury also sat on the board of a pharmaceuticals giant that benefited from the award of this year’s prize for medicine.

Prosecutors were studying whether AstraZeneca, the London-based multi-national pharmaceutical company, could have exerted undue influence on the award.

The joint winner of this year’s Nobel Prize for Medicine, Harald zur Hausen, was recognised for his work on the human papilloma virus (HPV), which can lead to cervical cancer. AstraZeneca has a stake in two lucrative vaccines against the virus.

Two senior figures in the process that chose Mr zur Hausen have strong links with the pharmaceutical company, which has also recently begun sponsoring the Nobel website and pro-motional subsidiary. The company strongly denies any wrongdoing.

It is not the only question mark hanging over the probity of the Stockholm-based foundation. The Swedish prosecutor yesterday opened a parallel investigation into bribery allegations after several members of Nobel committees admitted enjoying expenses-paid trips to China to tell officials how candidates are selected for prizes.

Other members of the Nobel Foundation are said to be gravely concerned that the reputation of an organisation that honours the highest achievements in human endeavour is under threat from companies and nations hungry for Nobel glory.

Questions began to be asked about AstraZeneca’s role after it agreed to sponsor Nobel Media and Nobel Web. Neither the company nor the foundation will say how much the contracts are worth, although they are estimated to run into hundreds of thousands of dollars over the next three years.

Further concerns were raised by Swedish radio, which revealed that Bertil Fredholm, the chairman of the five-strong committee that assesses Nobel candidates, was a paid consultant for AstraZeneca in 2006. Bo Angelin, a member of the 50-strong committee that votes for the winner, also sits on the board.

Last year, AstraZeneca acquired a company that developed a key component licensed for the production of two HPV vaccines made by other companies.

Christer van der Kwast, the director of the Swedish police anticorruption unit, ordered a preliminary investigation. His actions have been dismissed by Michael Sohlman, executive director of the Nobel Foundation, who told Scientific American magazine: “How should I put this? He often appears in the media.”

Mr van der Kwast told The Times last night: “My initiative was to look into this to see if there were grounds for investigation. I have ordered the prosecutor-in-charge to look into this.”

A spokesman for AstraZeneca rejected any suggestion that its influence over the Nobel Foundation was improper. He said: “We have no influence over the prizewinners nor would we ever seek to.AstraZeneca as a company is not involved in the process of Nobel prize selection. Bo Angelin’s involvement on the Nobel committee is completely independent of his role on AstraZeneca’s board. Bertil Fredholm is a well-respected expert. He did some work for us in 2006, as we work with many people who are experts in their field. The relationship was . . . no more than that.”

Juicy, what?

Posted by A Believer at December 19, 2008 05:08 AM

A Believer--sorry, it does not prove your point at all. That's just another thoughtless tag-line.

Posted by Bob at December 19, 2008 05:33 AM

"I agree, dguller. It's perfectly reasonable and shows the anti-psychiatry crowd for what they are"

You say "anti-psychiatry" as if it were a dirty word...

Psychiatry is a dangerous cult and twisted ideological regime. It feeds on the exploitation of the human condition..

As a human being with compassion and empathy for my fellow man..

I am proud to be "anti-psychiatry"...

Posted by truthman30 at December 19, 2008 06:56 AM

This issue would be hilarious, if not so tragic!
"Dear Me."
Maybe Nemeroff was following the "multiple personality disorder" treatment strategy of building communication between his various personalities!

Posted by MedsVsTherapy at December 19, 2008 10:21 AM

Goodwin's letter is very defensive. Imagine spending paragraphs defending things that he thinks Gardiner "implied" but didn't actually say. He must really be highly sensitive; as far as I'm concerned he had an agenda for that show and he knows it. I still say that show was packed with, as Philip puts it, "howlers," misrepresentations, idiotic arguments, gross assertions and all the things that he and his cohorts were accusing the media of. I just listened to it again -- it was painful. The problem is he and his buddies believe their rubbish and can't even see the flaws in their own arguments. What was bad about the show was not so much literally what they said although some of it was almost juvenile and full of assertions, but the tone and the patronizing, arrogant attitude they had both to the media and to victims. They seemed insulted that anyone would even dare to bring up that a school shooter was on an antidepressant as if somehow this was an affront to their profession. As for the scores of victims and survivors who testified at FDA hearings in 1991, 2004 and 2006, when one of the guests was asked about it, he actually never directly replied about what it was like to hear those stories. They seemed to think that if someone was troubled then ergo the medication could not in any way be implicated in the violent act which is a non sequitur. Also they seemed to be at pains to treat suicidal ideation and suicide as two distinct and almost opposing phenomena which is just ridiculous. It's not credible. Finally they latched on to prescriptions going down and suicides up as if this were some holy grail of proof that antidepressants prevent suicide when countless other factors could be at play. It's not even clear that those trends move in synch over time anyway. Even if they did it's no proof of anything. To say that warnings should not be in place because they frighten people away from treatment when we already have 25-30 million people taking antidepressants is just absurd. We have a serious overtreatment problem, not an undertreatment problem. Finally their assertions of efficacy were just that assertions. I agree with Philip's comment about the show -- that there was no science in it whatsoever and that it reflected religion more than anything else, biological psychiatric religion. These guys were out to protect their territory, not provide any new insights into the relationship between antidepressants, suicide and violence.

Posted by Sara at December 19, 2008 10:44 AM

dguller: You make a very general argument to avoid a very obvious particular moral lapse--that of a scientist ( a doctor of the mind) who either cannot or will not follow the most basic rules of science.

My comment was made more in disgust than as a general principal of moral behavior and our capacity to judge the same.

What I find disturbing about these conflicts of interest is that basic ethics, and the basic ethics of science, should be central to the work of doctors of the mind. If even doctors of the mind cannot follow such universally understood ethical rules as these, maybe we should look even deeper into the failings of psychiatry/psychology. Maybe its fundamental premises are wrong, especially as so many luminaries in the field were guilty of ethical lapses, and then of denying them once they were found out.

Many very ordinary people and many OTHER kinds of scientists are able to stay within basic ethical guidelines concerning their professions and other areas of their lives.

We are all shocked and angered when Catholic priests are caught abusing children.

It is arguable that some of these recent drug cases are actually worse since many thousands of children (even toddlers!) are being given strong medications without proper research but only on the word of "doctors" who have serious conflicts of interest.

Is that science? Why are you defending such behavior?

Posted by Bob at December 19, 2008 12:23 PM

Bob:

You raise many interesting points, and I will only reply to a few.

First, you are correct that the conflict of interest scandals of a few of the luminaries in psychiatry are concerning, and they should certainly be reprimanded accordingly. I never defended their unethical behaviour, but just felt that their punishment should fit the crime.

In other words, they should feel the shame of being caught breaking the rules and should have their research examined with greater scrunity, because their ethical lapses in one area could have also spilled over into others. If their work is found to be false and fraudulent, then their opinions should be disregarded, because they are invalid.

My point is that an ethical lapse does not automatically disqualify a person's work. A close examination of it for fraud and falsity is the only thing that can accomplish that end, and that has not happened yet.

If you would like to scrutinize the research papers and studies of Dr. Goodwin, Dr. Nemeroff, and Dr. Biederman, then by all means, fire away. However, do not assume that their work is fraudulent a priori on the basis of their ethical lapses.

Is this science? Absolutely. The inquiry of science involves a great deal of skepticism about the work of peers, which requires great scrutiny. The idea is that ethical lapses are to be expected, which is why the evidence is so closely examined. That is the reason why positions are to be taken on teh basis of the strength of the evidence, and not on individual authority, because people are flawed. That is built into the very fabric of science, unfortunately or fortunately, depending on how you look at it.

I think that is fairly straightforward, but it can easily be missed when hatred and disgust are already in play, which sees people through a much harsher lens that actually can distort things in an illogical fashion. I just want us to be reasonable about our outrage, and not to throw the baby out with the bathwater.

Take care.

Posted by dguller at December 19, 2008 01:45 PM

dguller:

The core ethics of science include selfless rationality, appropriate and sufficient research, letting the facts speak for themselves. The core ethics of medicine include do no harm, rational diagnoses, and prescriptions and treatments based on sound science.

There is no good science behind giving psychoactive medications to children, let alone toddlers. There is no clear biological basis for administering a chemical correction for poorly diagnosed behavioral signs. There is no clear understanding of long term effects. There is no medical justification that outweighs safety for the patient in giving psychoactive medications to toddlers.

The harm is obvious, and if not then surely the risk of harm must be. When psychiatrists and psychologists take money in an unethical fashion and then go out an actively promote the products of the companies from whom they have taken money, they are committing a serious offense to their patients, their colleagues, and the general public.

I am going to refrain from commenting on their work, except to say that at the very least it all has to be redone if anyone wants to use any of it as a basis for medicating anyone.

Posted by Bob at December 19, 2008 05:42 PM

Bob:

Again, you are assuming that an entire body of work is automatically false if any of the authors have committed ethical lapses. I would love to hear your argument for this position, which will not result in the rejection of all human knowledge.

Posted by dguller at December 19, 2008 09:12 PM

Nemeroff, the most conflicted of all KOL's, this leaves me speechless, but what left me most speechless, were the you tube videos he created.

Senate investigations just don't happen every day to leading researchers funded by pharmaceutical companies for no reason.

Anyone with a gripe send it to Grassley! or think about why it's happening! Gene Combs, a psychiatrist calls all of this an embarrassment to his profession and he is not the only one!

Posted by Stephany at December 19, 2008 11:23 PM

dguller,

You write:

"If you would like to scrutinize the research papers and studies of Dr. Goodwin, Dr. Nemeroff, and Dr. Biederman, then by all means, fire away. However, do not assume that their work is fraudulent a priori on the basis of their ethical lapses."

Again, your pulling that bogus idea that if you're not a doctor you have to believe whatever the doctors say. You hit on the very point. The average person can't replicate a study to determine if a drug is safe in the comfort of their own home prior to taking the drug, hence we have controls in place so that we can trust the data of those qualified to gather it. When the controls are violated, the entire study is invalidated. Whether their work is fraudulent or not it is unreliable and of no value, a waste of time and money, and worse a false assurance based on facts that don't exist.

Posted by Sally at December 20, 2008 12:51 AM

dguller:

I hope you realize that your defense is based entirely on generalities. You probably know the old saw for lawyers--"When the facts are on your side argue the case. When they are not, argue the law."

So in a very general sense, yes, I agree with your interpretation of the law--individual moral lapses do not necessarily invalidate someone's research.

The problem with these cases are the facts--the kinds of moral lapses in question. Money to prominent psychiatrists from companies whose products are being promoted by those same psychiatrists. And since these psychiatrists were so prominent, they were taken more or less on their word. It was their word that led to the drugging of millions of children.

As mentioned, the very premises of their kind of "science"--even if it were conducted ethically--is highly dubious. There is no science behind the assumption that children who exhibit certain behaviors have "chemical imbalances" in their brains; furthermore, there is no science behind the assumption that giving them untested psychoactive chemicals will fix those unproved "chemical imbalances"; furthermore, there is almost never anything even resembling a biological diagnosis in individual cases; furthermore, it is well-known that "doctors" prescribe these "medications" on little more than a parent or teacher's word.

Moreover, using such dubious "treatments" on such dubious conditions without having diligently checked the safety of these drugs is terrible medical practice.

So add it up. We have bad science, bad medical practice, conflicts of interest, and weak studies bolstered only by the reputations of these "doctors." And all of this leads to the harming (or at least the profound risk of harming) millions of children.

So, I agree with your general position, but believe it is not apposite for these cases. In these cases, it is the kind of ethical lapse, made by a certain kind of person, based on unethical science that has led to the harming of (or the risking of harm) of millions of children. Personally, I think it is more than clear that these drugs cause significant harm in most cases and MAY be justified in no more than a handful of cases based on what we actually KNOW now, not what some high-status "doctor" says.

If a celibate monk is caught discreetly masturbating, no one will mind. When he is caught fondling children, we all mind a great deal. Similarly, if these doctors have ethical lapses in their personal lives, no one will mind. But when their ethical lapses are so huge and have such great impact on so many trusting lives, we all should mind a great deal.

Posted by Bob at December 20, 2008 04:54 AM

Sally:

You appear to endorse the principle that if the author of a study has been found to have engaged in unethical behaviour, then their entire body of work should be rejected as suspect. I happen to disagree, because much of science would have to be cast aside on the basis of your strict criteria. There are several examples of influential figures who have engaged in unethical behaviour:

(1) Robert Oppenheimer attempted to poison his tutor in university.
(2) Jean-Jacques Rousseau abandoned all his children.
(3) Carl Jung slept with his patients.
(4) Albert Einstein was verbally and physically abusive towards his family, and he failed to credit the work of Mileva Maric, his first wife.
(5) Martin Heidegger supported the Nazis.

I can go on, if you like. I think it is unreasonable to reject someone’s work on the basis of ethical lapses, and we must judge the work on its own, independent of the life of the author. Certainly, the life of the author would impact the scrutiny with which we would examine their work, but it can never refute it.

Now, if you could specifically cite the studies by Biederman, Nemeroff and Goodwin that you are now rejecting, then that would be helpful, because we can see if the results have been replicated by less ethically challenged researchers. We can also look at the studies themselves to see if the data was skewed or fudged in any way. However, what we would be engaging in is good scientific practice of looking at the evidence itself and not the author of it.

Oh, and you do not have to believe what the doctor’s say. You have the right to reject medical advice.

Finally, what controls have been violated that nullifies the three aforementioned authors’ entire bodies of work? They have all disclosed their ties to the drug industry in their publications. The problems are that the first two did not disclose the extent of financial renumeration to various agencies, and the third one did not disclose them at all on a radio show, but did do so in all his publications. So, how do we go from those situations to a rejection of all their work?

Take care.

Posted by dguller at December 20, 2008 07:22 AM

Bob:

You made several excellent points to which I would like to reply.

1. “There is no science behind the assumption that children who exhibit certain behaviors have "chemical imbalances" in their brains”.

I assume that you are referring to the controversial diagnoses of childhood bipolar disorder and ADHD. You are correct that there is no science behind the theory that there is a chemical imbalance. That theory went out of style in the 1980’s, but popular culture hasn’t caught up with the science, unfortunately, and that has ramifications for clinical practice. However, there was a kernel of truth in the sense that neurotransmitters do likely play an important role in the generation of subjective experience, and depending on which neurotransmitter in which part of the brain, various different forms of mental states can be activated.

I’d like to focus on ADHD, because it has the best literature, and childhood bipolar disorder is still quite new and the science is in its infancy. With ADHD, there is a large body of evidence that dopamine deficits in the PFC, in particular, play an important role in the illness. You can find a good review at Neuropsychological Review (2007; 17(1):39-59) on this subject.

Have a look and tell me what you think, but it is disingenuous to say that “there is no science” behind the dopamine deficit hypothesis of ADHD, because there is quite a bit.

2. “furthermore, there is no science behind the assumption that giving them untested psychoactive chemicals will fix those unproved "chemical imbalances"”.

Focusing on ADHD once more, the fact that psychostimulants are so effective at improving attention and hyperactivity in controlled trials must be partially explained by the fact that they significantly inhibit dopamine transporter function, thus increasing dopamine levels in the synapse. They consistently display large effect sizes compared to placebo, and thus their efficacy is not doubted. Their safety is another matter altogether. The efficacy, mechanisms and safety of stimulant medications in ADHD is reviewed in the same issue of Neuropsychological Review (2007; 17(1):61-72).

Again, there is “science behind the assumption” that you mentioned. Is it conclusive and rock solid? Of course not. Nothing in science ever is, but there is enough evidence that it would be highly unlikely that the true causes of ADHD symptoms in the brain have nothing at all to do with dopamine in the PFC. There are likely other factors, as well, but dopamine plays an important role.

3. “furthermore, there is almost never anything even resembling a biological diagnosis in individual cases”.

I assume that you are referring to some kind of laboratory test or radiological imaging that is diagnostic of ADHD, for example. And you are absolutely correct that psychiatric diagnoses at this time lack such testing. However, it is a far cry from the absence of such tests and the implication that the illness itself is unreal. Many illnesses in the past had to wait many decades before technology allowed a pathological diagnosis to be made, and thus we must make due with the tools we have until then. In addition, if you are saying that any cluster of symptoms that lacks a clear biological basis does not count as a legitimate illness, then perhaps you can explain whether dementia, delirium and autism are true illnesses, and if they are not, then what are they and would should we do about them (if anything)?

4. “furthermore, it is well-known that "doctors" prescribe these "medications" on little more than a parent or teacher's word.”

That is completely inappropriate. When I completed my child psychiatry rotation, we would never prescribe psychostimulants without a thorough examination of their clinical record, school record, parental interviews, clinical examination of the child, and neuropsychological testing. That is the standard of care.

5. “Moreover, using such dubious "treatments" on such dubious conditions without having diligently checked the safety of these drugs is terrible medical practice.”

How do you recommend that the safety of medications is tested? The current system has its problems, but I was wondering what you would propose in its stead.

Take care.

Posted by dguller at December 20, 2008 11:55 AM

dguller:

You are defending medicating children and toddlers based largely on the unethical propagandizing of some of America's leading psychiatrists.

I realize that science is messy. In trying to keep my statements brief, I am sure I have overstated some of my points, which I will probably do again now. But here are what seem to me to be some of the core issues. I will try to aim at your latest comments and not repeat too much of what I said before.

1) There is no good science for giving these meds to children and toddlers. (I personally believe there is only bad science for giving them to most adults, but leave that aside for now.)

2) Little is known of the long-term effects of these meds on children and toddlers.

3) They are not prescribed responsibly in most, if not nearly all, cases. We can know this by the enormous number of children on ADD and ADHD meds, but also from smaller bits of information such as the frequency of prescriptions double in children from divorced homes. You may yourself prescribe reasonably (which for me would be rarely if ever), but most of these meds are dispensed by family doctors without many questions being asked. This is hard to deny as there are many studies supporting this conclusion.

4) A major reason so many young people are being medicated in these ways is the influence of the doctors being discussed in this string.

5) There are many alternatives to giving powerful untested meds to children--better diet, natural supplements, omega 3, vitamin D, exercise, good counseling, etc.

You ask how to check the safety of medications. In the cases we are discussing (strong meds for kids) DO NOT DO IT. DO NOT give them to children and toddlers whose brains are developing before we know they are safe and effective for adults, which we do not.

dguller--I really suggest you step back from this subject and do a far-reaching reality check with the better traditions of history and science and with reasonable people outside of your profession. There are many reasonable people in this country who are simply appalled at the bad ethics and weird science behind medicating children (and so many of them!).

For me, some of this reads like the medical "science" that justified lobotomies or the "work" of Ian Cameron or Sidney Gottlieb, among others.

I do understand that science can and should be bold and that theories sometimes must be developed without adequate proof. I favor that approach in many cases. But I cannot favor it when it endangers children, even one child let alone some many millions of them.

Posted by Bob at December 20, 2008 01:31 PM

dguller,

None of the situations you mention are analagous to the conflict of interest that Biederman, Nemeroff and Goodwin are involved in because none of the ethical lapses are relevant to the reliability of the data. I'll relist your examples and address each one by one.

You write:

"1) Robert Oppenheimer attempted to poison his tutor in university.
(2) Jean-Jacques Rousseau abandoned all his children.
(3) Carl Jung slept with his patients.
(4) Albert Einstein was verbally and physically abusive towards his family, and he failed to credit the work of Mileva Maric, his first wife.
(5) Martin Heidegger supported the Nazis."

If Robert Oppenheimer had been a spokesperson for the idea that tutor's were better off dead funded by the poison manufacturer, yep, we could reject his work based on his ethical lapse.

If Jean-Jacques Rosseau were applying to be an adoptive parent or a child psychologist, his behavior as a parent would become relevant.

I'm still waiting for my Carl Jung sex toy catalog to come in the mail;0

I don't believe Einstein sought to become a marriage and family counselor.

Heidegger was a philosopher. He didn't hide his support of the Nazis.

Our guys are hiding large sums of money specifically paid by pharma cos to sell diseases that you can't prove exist and falsify data regarding drugs made by these companies hence their ethical lapses are relevant.

Posted by Sally at December 20, 2008 02:24 PM

Bob:

First, what counts as "good science" to you?

Second, by your criteria we should not be giving children ANYTHING until we have determined its long-term safety. However, how can we determine this without giving them to some children? Also, you mentioned all kinds of alternatives to psychotropic medications. What are the long-term studies that prove that they are safe at the doses and daily frequency recommended by you?

Thanks.

Posted by dguller at December 20, 2008 07:08 PM

Sally:

Fair points about the examples I cited.

However, I would like to focus on Rousseau for a moment. He actually was one of the first authors to write about early childhood development as a key process of personality development in general, about paying attention to the subjective emotional experience of children, and about educational approaches that are akin to the Montessori schools today (i.e. meeting children at their level, and working with their interests). He mostly wrote about this in his novel, Emile.

Now, I would agree with almost everything that he wrote about the importance of early childhood development and understanding their experiences at their level, and I think that you would agree, as well. So, how do you square that with his abandoning all his children at birth? This was a topic that he was exquisitely sensitive to, and felt like a total hypocrite, which he was. According to your criteria, we have to reject in total all his writings on children, because of the rank unethical conduct he had towards his own children.

Of course we would not reject his works, because we judge them on the basis of their content, and not his character. As I mentioned before, a thief is telling the truth when he tells you not to steal, even though he is being a total hypocrite.

Judge the content, not the character. If the character is suspect, then judge the content even more rigorously, because the standards of proof are raised to account for the possibility of fraud. However, there is no valid argument going from a suspect character to fraudulent results, and I challenge you to offer one. Even in the legal system, just because someone has a prior criminal history does not automatically convict him of a current alleged crime. Rather, the prosecution must build a case that will certainly include prior offences, but will mainly rest on the current crime and how tightly the accused can be tied to the crime.

I submit that a similar procedure must be utilized when judging clinical research. And until someone here can look at the studies that the three condemned authors produced and find fault in their methodology, statistics and results, then you are equivalent to those who accuse a murder suspect, “Well, he killed someone before, he must have killed this person now!” – without any further ado.

Take care.

Posted by dguller at December 20, 2008 07:19 PM

The problem with the conflicts of interest in psychiatry, as Sally suggests, is that they are shaping a whole belief system that influences how the science is conducted and reported. It is far more fundamental than the lapses dguller is citing. This is why, in my mind, Goodwin's conflict of interest is only part of the story; much more relevant from my point of view is the whole flawed belief system he and his cohorts brought to the radio show that made them present their case in a biased, assertive, arrogant, patronizing and flawed fashion.

Posted by Sara at December 20, 2008 08:35 PM

dguller said, "However, there is no valid argument going from a suspect character to fraudulent results, and I challenge you to offer one."

This kind of thinking is scary to me.

Posted by Lisa at December 21, 2008 11:19 AM

dguller:

I said there is no good science for giving the meds under discussion to children and toddlers. I am sure I have made myself clear on this point--the theory behind these meds is dubious and has not been substantiated; the value of the meds has not been clearly established in adults, let alone children and toddlers; the diagnostic techniques employed for the relevant conditions are not sound, not based on much biology; in practice diagnostic techniques are actually even worse; the safety of these drugs for children has never been studied; we have no idea of their long-term effects.

Basically, our understanding of the brain is not good enough to support using a chemical method to "cure" a "mental condition" whose biological basis (if indeed there is any) has not been clearly established.

You say: "...by your criteria we should not be giving children ANYTHING until we have determined its long-term safety." But that is not what I said. I said "In the cases we are discussing (strong meds for kids) DO NOT DO IT." Why? Because the science is not good. It's not safe for the kids.

You ask: "...how can we determine this without giving them to some children?" First, establish that the medications are safe for adults and that they are prescribed appropriately. Then the ages may be slowly and prudently decreased. Even the first step of this has not been done.

In regards to natural supplements you ask: "What are the long-term studies that prove that they are safe at the doses and daily frequency recommended by you?" Generally, these substances (omega 3, vitamin D3, etc.) have been established as essential for good health. Since many people do not get them in their diets, supplementing these (and other) substances up to established safe levels (yes, they have been established) may correct behavioral problems caused by their absence. As mentioned, diet, exercise, and counseling should be included in this regimen.

Please step back and look anew at this subject. There are many papers on the brain, and we do understand it better than we did twenty years ago. But the truth is we still do not have a good grasp of how it works, let alone how to fix it. Strong meds for kids, in my view, constitutes terrible science for the reasons given.

Psychiatry, it must be admitted, has a considerable history of insularity, close-mindedness, arrogance, and being wrong. Yes, it's true, so do most sciences. The problem with psychiatry is that when psychiatrists are wrong and treat patients with biological interventions, enormous harm can be and is done to many people.

With a recent history that includes the Freeman-Watts lobotomy procedure (known then as the "precision method"), the "psychic driving" concept of Ewen Cameron (sorry, I wrote "Ian" in a post above), and the "mind control" "work" of Sidney Gottlieb, I believe it is time for "doctors of the mind" to slow down and re-examine some of their basic premises, especially those concerning patient safety and ethics.

I urge you and other readers to look up the names mentioned just above and consider whether their stories are not relevant to our current discussion. Is history repeating itself yet again? I fear that it is.

Posted by Bob at December 21, 2008 12:07 PM

Exactly Sara. I posted a link on the Chemical Imbalance Site in which the website owners refuted point by point what Goodwin had said. DGuller seemed to concede at the time that they had some points. Here is the link to remind him and everyone what the real issues are:

http://chemicalimbalance.org/?p=113

Posted by AA at December 21, 2008 12:13 PM

Thanks, AA. I missed that analysis first time around. Very good. I posted a comment covering some of those points on Dr. Carlat's blog under the Goodwin/disclosure post he made a few days ago and also hopefully a comment of mine will show up on Trouble with Spikol under Goodwin's letter.

Posted by Sara at December 21, 2008 02:32 PM

Lisa:

An assertion, no matter how heartfelt and passionate, is still not an argument. Provide an argument for your position that if a person has shown unethical conduct in their area of expertise that their entire body of work is false, please.

Posted by dguller at December 21, 2008 04:51 PM

Bob:

First, I cited two review articles in a reputable scientific journal that went over the evidence for a dopamine deficit in the prefrontal cortex being present in ADHD, and which presented the evidence for the mechanisms, efficacy and safety of psychostimulants in ADHD. In response, you cited no evidence, no studies, no review articles, and no scientific authority. You simply declared that there is science behind the use of these medications in children for ADHD. Perhaps a declaration is sufficient replace arguments and evidence? Or perhaps not.

Second, could you please provide me with the names of medications given to children that have met your strict criteria of first being shown to be effective and safe in adults, and then prescribed to adolescents, and then to children?

Third, I am still waiting for you to cite the studies that demonstrate that all the treatments that you recommended for children have long-term safety proven. Again, it is nice to simply assert something – “I am a millionaire!” Sadly, it does not make it so.

Take care.

Posted by dguller at December 21, 2008 05:05 PM

Dguller,

You write of Rousseau:

"Now, I would agree with almost everything that he wrote about the importance of early childhood development and understanding their experiences at their level, and I think that you would agree, as well.So, how do you square that with his abandoning all his children at birth?"

I would ask, how do you square maintaining your position the face of my responses to your other four examples? And then go on to point out that there was no conflict of interest, that I know of, in Rousseau abandoning his children and previously, concurrently or later writing down his theories of child rearing. Furthermore, to my knowledge he didn't market his book as "the real truth about children or what I learned as a stay at home dad." He was just explaining his views and thoughts.

Our dudes are different, their character problems directly relating to their "medical" research and practice and ministering to the public. Objectivity is a central idea in research as you don't want external events to skew data. If their were no problems with the biopsych model, these dudes wouldn't be scrutinized, it's just that anecdotal reports are so drastically different from their mainstream rap as to make it appear someone is lying or that the research is flawed in crucial ways. And when it turns out the researchers were paid big bucks that they hid, well, help me to understand why you don't get how fishy that looks.

Posted by Sally at December 21, 2008 07:23 PM

Hi Sara,

I did see your comments on Carlat's blog and they were excellent. It was good too see you over there:)

Posted by AA at December 22, 2008 12:54 AM

Sally:

You claim that there was no conflict of interest between Rousseau abandoning all his children at their births and his writings books on childhood development and superior parenting and educational techniques. By the way, he did write those books as describing the truth about the aforementioned issues. Rousseau was not humble enough to offer his ideas as theories, but rather as facts. However, the point was that he never openly disclosed his abandonment of his children in the works I mentioned. According to your position, that is an unforgivable ethical lapse of failing to disclose a vital piece of information, and thus automatically falsifies his entire body of work. Help me to understand how this is not the case.

Posted by dguller at December 22, 2008 04:04 AM

dguller:

I believe I have made my points clearly enough for a forum of this type.

To sum up, I do not believe that you have effectively defended the use of powerful drugs on children and toddlers. Nor do I believe that you have effectively addressed the seriousness of the ethical questions surrounding the doctors who propagandized those drugs while taking money from the companies who manufacture them.

I think that your arguments are defensive, somewhat evasive, overly generalized, and often beside the point. I fear this is due to an American medical culture that is often blind to its own failings. The doctors in question have provoked strong feelings in people because they are emblematic of the bad side of their profession and because they seem to be oblivious to their own ethical failings.

I do agree with you in general about how all of us have ethical failings, and I do understand how it may have happened that the doctors got themselves into the positions they are now in. On a personal level, I sympathize with them. On a public level, I do not believe their behavior should be condoned.

I appreciate your statements and do believe that you are being honest in your replies, for which I thank you. As mentioned, though, I also fear that you may be trapped in a culture that is too often blind to its own failings.

One last time--the problem with the drugs for toddlers "science" is it is not based on good biology; we do not know enough about the brain; it is not safe for patients; millions have been affected.

I may write more in this string if something new comes up. But for now, this is as far as I want to go in this forum. Thanks to all who have read this far.

Posted by Bob at December 22, 2008 05:39 AM

Bob:

Happy holidays, and take care. :)

Posted by dguller at December 22, 2008 08:44 AM

Dguller,

You write: "Rousseau was not humble enough to offer his ideas as theories, but rather as facts. However, the point was that he never openly disclosed his abandonment of his children in the works I mentioned. According to your position, that is an unforgivable ethical lapse of failing to disclose a vital piece of information, and thus automatically falsifies his entire body of work. Help me to understand how this is not the case."

Man, you're troubled and you either don't understand my position or you're deliberately misstating it. And you as a pshrink have the power to subjectively label someone as "severely mentally ill." Troubling.

Can't you see that the only way you can think of to defend your pshrinks is by bringing up Rousseau's personal life. Abandoning a child in his day also signifies abandoning a repressive society which is consistent with Rousseau's beliefs, still it's sad that you are attempting to change the subject. I'm not an expert on Rousseau and have always been a bit leary of his ideas because of the sexism in his personal life but you're on a false analogy trail again implying that I can't question psychiatry because I don't know enough about Rousseau!!!

I don't get why abandoning children precludes one from having opinions about child rearing. Godwin, Nemeroff, and Biderman, et al pretended that they were objective scientists when really they were getting pay offs to have a certain opinion. Can you understand why if a food critic names a certain restaurant the best and it turns out that restuarant paid him a huge amount of money, the review is not reliable? What about if a dog wins best in show at Westminister and it turns out the winner's owner bribed the judges (objective note - this is the case any time any dog other than the Basset Hound wins as they are always the superior dog in any setting;)? Where is the objective data in which these guys are shilling?

Posted by Sally at December 22, 2008 08:57 AM

Sally:

Just as you stated about the psychiatrists in question, the problem was their FAILURE TO DISCLOSE important information. With regard to Rousseau, he was offering his advice to parents without telling them upfront that he abandoned all five of his children at birth. According to you, we must reject his entire body of work, because of his failure to disclose that important information that would compromise his credibility. If not, then what is the difference between him and those you mentioned?

Take care.

Posted by dguller at December 22, 2008 02:02 PM

dguller,

What are the similarities? You avoid the obvious question which is what is the value of an opinion you are paid to give, particularly when you lie about the payment?

This guys were failing to disclose the fact that they were hired by a client to provide a scientific defense of their product. What part of this don't you get? Again, do you really not understand why a food critic names a certain restaurant the best and it turns out that restaurant paid him a huge amount of money, the review is not reliable, especially if the critic publicly stated numerous times that the restaurant had not compensated him in any way?

Posted by Sally at December 22, 2008 04:31 PM

The mental health "sciences" behave much more like totalitarian ideologies than sciences. They aggressively seek to be judge, jury, and enforcer of standards determined only by themselves. They seek to dominate society's definition of what is human, what is "normal," what is "pathological," what is "right" and what "wrong."

They exploit the respect accorded science while using harmful methods based on poor reasoning. They rely on people's tendencies to respect authority while avoiding concomitant responsibilities.

This whole affair of conflict of interest is a good example of how wrong they are. Unethical behavior and showmanship at the root of the very weak evidence they claim supports a theory that cannot be proved (or falsified) with today's technology. And that has not been tested for safety.

And this they claim the right to feed toddlers. This is a mental health industry that is completely crazy.

Posted by Bob at December 22, 2008 05:36 PM

Sally:

The similarities are that both Rousseau and the psychiatrists that you mentioned did not disclose important pieces of information that would compromise their authority. The former did not disclose the abandonment of all his children while promoting himself as an authority of proper parenting and children’s education. The latter did not disclose the degree of drug company money that was given them while offering their opinions of psychiatric medications. In both cases, if that information was known to the public, then their views would be looked upon with more scepticism, because they are conflicts of interest.

I hope that I have established the similarities between the cases to your satisfaction. Now the onus is upon you to demonstrate why we should conclude that the psychiatrists’ work is entirely false and to be rejected, but Rousseau’s work remains truthful and trustworthy.

Perhaps you will reply that the difference between them is that the psychiatrists received money for the sole purpose of distorting the evidence in order to cover the drug companies’ products with a veil of legitimacy, whereas Rousseau simply hid his disgraceful past actions in order to avoid public censure and rejection. This is a difference that should make a difference, but it doesn’t. That is because you would have to prove that the psychiatrists falsified evidence in exchange for money. Do you have such proof of the psychiatrists in question explicitly stating in documentation that they would distort their findings in exchange for drug company money? Or is it mainly that the fact that they accepted drug company money at all that automatically falsifies their work? Is that the ethical lapse, i.e. receiving drug company money, irrespective of whether they disclosed this fact at all? Is that the difference that is supposed to make a difference?

I do not think so. As I said earlier, engaging in suspicious behaviour is not the same as being found guilty of a crime. That requires proof, as it does in the criminal justice system. Even past criminal behaviour is not a proof of current criminal behaviour. Where is the evidence supporting your contention that they falsified their research for the sake of monetary gain? I surely hope you have more than innuendo and insinuation.

Take care.

Posted by dguller at December 22, 2008 07:24 PM

Bob:

First, you keep using words like "science", "evidence", "proof", "reasoning". Rather than citing those words, why not actually use them by providing evidence, arguments and proofs? All you have brought thus far are many inflammatory accusations and assertions, and when I cite reputable peer-reviewed articles in support of my position, as well as various arguments, you respond with an idle wave of your hand, declaring it all to be unscientific and unreliable. Again, declaring that X is false is not the same as proving X to be false.

Second, here are the outstanding questions that I have asked you during this discussion that you have not answered:

1. What do you consider “good science”?

2. Could you please provide me with the names of medications given to children that have met your strict criteria of first being shown to be effective and safe in adults, and then prescribed to adolescents, and then children?

3. What are the studies that support the long-term efficacy and safety of the various treatments that you recommended over the course of our discussion?

I look forward to your answers to these questions.

Take care.

Posted by dguller at December 22, 2008 07:35 PM

dguller,

You write:

"Now the onus is upon you to demonstrate why we should conclude that the psychiatrists’ work is entirely false and to be rejected, but Rousseau’s work remains truthful and trustworthy."

Nope, the point is that since the psychiatrists didn't just receive money but lied about it, their research is not necessarily false, it's just meaningless, i.e. neither true nor false. Their research will have to be repeated by people who weren't biased by under the table cash, by violating the rules they themselves set in place, to determine what the research will show.

You write:

"Where is the evidence supporting your contention that they falsified their research for the sake of monetary gain? I surely hope you have more than innuendo and insinuation."

I haven't contended this. I've contended that since they violated the controls necessary to make their studies objective any findings are invalid. I believe the reason for precluding researchers from taking large amounts of under the table cash is to prevent bias. I suspect they falsified studies but this has not yet been proven.

I think we're getting a bit redundant here. The scientists made assurances that they wouldn't take drug money. I don't know that Rousseau signed some kind of an oath saying he would not abandon his children. I don't know that the fact that he abandoned his children, assuming he did, I'm taking your word for it, compromises his authority.

Posted by Sally at December 23, 2008 01:54 AM

dguller:

You say: "All you have brought thus far are many inflammatory accusations and assertions, and when I cite reputable peer-reviewed articles in support of my position..." I have made myself very clear on where I stand and why. My accusations may seem "inflammatory" but I maintain that is because the treatments you are defending are indefensible, to say nothing of the ethical conflicts of those propagandizing those treatments. Your "reputable peer review articles" are based on assumptions (mentioned in posts above) that while interesting have not been proved (we don't know enough about the brain) and are not safe (for reasons given more than once above).

You say: "...declaring that X is false is not the same as proving X to be false." It is well-known that it is hard (impossible) to prove a negative. You keep trying to stay on the initiative by asking all of the questions (as if this were a chess game rather than a discussion in search of some sort of reasonable view). Now let me ask you:

What is the theoretical foundation for giving strong meds to toddlers and children?

Where is the proof for the soundness of this approach? For the safety of this approach?

The burden of proof is on you, not me. I and others have pointed out numerous flaws in the science, evidence, reasoning, diagnostics, treatment, and methodologies of psychiatrists who give strong drugs to children (to say nothing of their ethical conflicts). You have not answered any of our objections or questions except in general ways or by citing some study that presupposes the correctness of drug interventions and the theories behind it. (As mentioned, I favor bold science that may be weak on evidence and theory, but NOT when children are endangered by it.)

You ask: "1. What do you consider “good science”?" I have answered in the positive (see just above) and in the negative--what I consider to be bad science (mainly endangering children and others based on unsound theories, diagnoses, practices, and evidence). It is perfectly valid to define something by saying what it is not. For a definition of "good science" I would need to see the context. Good science can be very bold--for example the Australian scientist who proved his cure for ulcers by giving HIMSELF ulcers (not OTHER people or SMALL CHILDREN). He took the risk HIMSELF and I admire him for it.

You ask (question 2): Why do I need to waste my time answering that and derailing our discussion? When are YOU going to explain in brief clear language how it can be justified to give strong meds to toddlers? Do you support Freeman and his "scientific" "reasoning" on lobotomies? Do you support the "theoretical basis" behind the "psychic driving" of Ewen Cameron? Again, please, YOU answer briefly and clearly how you justify giving strong meds to toddlers.

You ask (question 3): I have already answered that.

I said that the mental health "sciences" behave more like totalitarian ideologies than sciences because they do. For years, no one controlled Freeman and his "precision method" lobotomies. For years, no one controlled Ewen Cameron and his "psychic driving"; indeed, he received government funding. And now no one is controlling ethically and intellectually challenged "doctors" who are drugging our children in a vast, ill-founded experiment that is based on extremely weak theories and virtually no good evidence.

If you want credibility in this discussion you are the one who needs to be answering these core questions. Please be brief and clear and stay on topic.

By the way, I do admire you for hanging in there. I also hope you will at some point step outside of the "professional psychologist's" world-view and see it for what it is--a narrow little world filled with sloppy thinking, weak evidence, and terrible, frightening techniques that keep being used on helpless "patients." I am quite confident the day will come when we will look back on this period of the history of psychology with the same sense of horror that we now feel when we look back on the "work" of Freeman, Cameron, and others.

Posted by Bob at December 23, 2008 05:55 AM

Sally:

Thank you for your reply.

So, your contention is that since those researchers were not fully open about the money they received from the drug companies, then their research is not necessarily false, but to await replication from others whose work has controlled somewhat for the impact of drug company bias. I actually agree with this, and have said so all along. I said that those who have engaged in unethical behavior should not have their work automatically rejected as false and fraudulent, but rather to be looked upon with greater scrutiny, which includes replication of results with better controls in place. In the end, we are in agreement after all. :)

So, let us continue on this path together.

Can you tell me which studies that they performed are compromised? Can you please offer some citations so that I can search the literature to see if the studies were performed by others? Maybe we can salvage some of their work?

Oh, and if someone was offering you advice on how to be a better parent, and they didn’t tell you that they abandoned all their children at birth, because their presence in his life was an interference, then can you honestly tell me that you would take him seriously? Regardless, since we agree in principle that unethical behavior does not falsify a body of work, we can drop this point. :)

Take care.

Posted by dguller at December 23, 2008 10:51 AM

Bob:

First, you are correct that our understanding of the brain is limited, and likely will never be complete, especially since it is an extraordinarily complex organ. However, we do know quite a bit, including the fact that dopamine in the prefrontal cortex is essential to the maintenance of concentration and attention. There have been multiple studies that have demonstrated this fact, and thus this is not simply an “assumption” on my part, but has been empirically shown to be true. Again, I refer you to the review article that I cited for the multiple references on this subject.

Second, you claim that you have already demonstrated that psychostimulants are unsafe for children. I looked at the thread above, and could not find any demonstrations, but only more accusations and assertions. Can you please cite some evidence in support of your position?

Third, I am not asking you to prove a negative. You assert that psychostimulants are ineffective and unsafe in children. I am just asking you to support this assertion with evidence. I have already provided my own for the opposite position, which consisted of actual studies that compared children who received psychostimulants to those receiving placebo and there was a large effect size between them. They have been demonstrated to be effective. If you cannot accept scientific experiments and research, then I am afraid I have nothing to discuss with you.

Fourth, you make valid comments about needing to know the context in which something can be declared good or bad science.

Fifth, I do not support Dr. Freeman’s use of lobotomies in the 1930’s, and I do not even know what “psychic driving” is. Sorry.

Sixth, regarding my second question, you have set a criterion that guides the permissibility of giving medications to children: first demonstrate safety and efficacy in adults, then adolescents, and then children. I assume that this criterion applies to all forms of medications given to children. Has Tylenol met this standard? Has Aspirin? Has Sudafed? Has anything? I mean, you can’t just pull a criterion out of the air without any empirical support, or can you?

Seventh, regarding my third question, you have not cited the studies that support long-term use of your strategies. Can you please at least cite your comment in this thread where you believe you did, because I cannot find it.

Take care.

Posted by dguller at December 23, 2008 11:31 AM

Dguller,

We don't agree.

You write:

"So, let us continue on this path together."

No, you're troubled and giving me the creeps. I won't respond to another of your comments on this thread.

You give me this order:

"Can you tell me which studies that they performed are compromised? Can you please offer some citations so that I can search the literature to see if the studies were performed by others? Maybe we can salvage some of their work?"

No, find your own citations. Argue that their work is salvageable, but then, if you could do that I guess you wouldn't be arguing Rousseau against my poor hypothetical little children.

Posted by Sally at December 23, 2008 01:14 PM

The bottom line for me is that if a researcher cannot follow the rules, then perhaps they should find other work. Patients who agree to be part of a clinical trial do so with the expectation that the rules are being followed. That means those running the study don't get to do whatever whatever they damn well please & ignore the rules they find irritating. I guess character doesn't matter to some, but I would imagine character matters quite a lot to the patients who participated in Nemeroff's (and others) clinical trials.

Posted by Lisa at December 23, 2008 02:15 PM

dguller said, "Provide an argument for your position that if a person has shown unethical conduct in their area of expertise that their entire body of work is false, please."

The problem, dguller, is that when researchers get caught lying, then it leads people to wonder if they fudged the answers on other questions in the study as well. If they cannot even answer a very simple question about income in an honest manner, then what makes you think they are going to be honest when it comes to reporting adverse effects? After all, reporting adverse effects is probably a real pain in the ass. It involves a lot of paper work, might piss off the sponsor who is paying them big bucks, etc. A question I have is, why would they lie about their income? Are they afraid the IRB wouldn't approve the study?

Posted by Lisa at December 23, 2008 02:41 PM

Actually, the FDA has shown more concern re: children and OTC cold medicines than the safety and efficacy and long term effects of antipsychotics in children.

http://bipolarsoupkitchen-stephany.blogspot.com/2007/03/fda-reviewing-safety-of-childrens-over.html

If a psychiatrist or health care professional asks for proof for something in their field, they are bound to be the bearer for evidence to prove what they believe, teach and practice on patients is indeed valid, etc.

Ultimately, the patient should not have to bear the burden of knowing as much as savvy consumers do re: medications and psychiatry, and pharma.

Nemeroff is the most conflicted of KOL's and in the USA it is not every day one or more psych researcher has a Senate investigation pulled out on them.

I wonder why Nemeroff resigned from EMORY? I wonder why he has boatloads of pharma cash, and the patent to Lithium patch? oh so many questions for conflicted corrupt crooks.

Posted by Stephany at December 23, 2008 09:09 PM

Lisa,

AE reporting is one of those things that is closely monitored in clinical trials. The critical issue (from the sponsor's perspective) is whether the AE is attributed to the drug under study or not. The paperwork isn't really the issue - it's an institutional denial and lack of insight (I realise the irony is rather thick here).

This problem could be readily resolved with objective diagnostic tests. Unfortunately, these do not exist and so we are left with the clinician's guesswork and institutional bias. We see this same issue in other therapeutic areas, but psychiatry seems especially susceptible to falsely ascribing AEs to disease rather than drug effects.

I firmly believe we will never be able to conduct a valid clinical trial for a psychotropic until some sort of robust diagnostic can be validated.

Posted by Paul at December 23, 2008 09:40 PM

dguller, your ignorance of psychic driving astonishes me. Cameron is a former (disgraced)president of the World Psychiatry Association and founder of psychic driving, in which he maintained the cure for mental illness was in breaking down the personality via techniques now recognized as torture, and reforming the individual with brainwashing techniques. He was quite successful in achieving the former with his captive patients, and not at all successful in rebuilding what resulted in a severely regressed, infantile, paranoid, incoherent and incontinent, psychologically shattered walking dead patient population.

Of course he was hired by the CIA.

http://www.spartacus.schoolnet.co.uk/JFKcameronDE.htm

Posted by flawedplan at December 23, 2008 10:58 PM

flawedplan:

I certainly apologize for my ignorance of "psychic driving". I was aware of Dr. Cameron's work of using mind-altering techniques to shock patients into a regressed state in which they were a clean slate ready to be brainwashed. I just didn't know it was called "psychic driving".

Naomi Klein's book, "The Shock Doctrine", discussed Dr. Cameron's work as the earliest example of using shock to cause regression that made people easier to manipulate. You are correct that his work was sponsored by the CIA and that they used it in their field manual on how to interrogate prisoners.

Take care.

Posted by dguller at December 24, 2008 05:15 AM

Ewen Cameron was also president of the American Psychiatric Association.

Sidney Gottlieb is another psychiatrist whose career you might want to check out.

Psychologists who helped torture prisoners at Gitmo are another angle on the ethics of this profession.

Lobotomies are still given today. The procedure was common into the 1950s, less in the sixties, and trailed off almost completely only during the early 1970s. It was banned in the Soviet Union in 1950 because it was "contrary to the principles of humanity", and because it turned "an insane person into an idiot".

There are many indications that the drugging of "difficult" children today is based on theories, diagnoses, and treatments that have as much basis in fact as those backing lobotomies.

Freeman, among others, was infamous for giving lobotomies for practically any reason at all. Sound familiar? Got a "problem child" in your class? Call the doctor! Got a one-year old who cries too much? Get some meds, this one must be bi-polar!

It was said that some people really did "get better" after having had a lobotomy. Sound familiar? What about all those who got worse? Oh well, they would have been even worse if they had not had the procedure! Anyway, it's a symptom of their "disease" and only proves why they needed treatment in the first place!

There was no reasonable theory behind the procedure. No consistent diagnosis. Just a few "behavioral" problems that anyone could assess any way they wanted. Sound familiar?

It just seemed to work on some people. Sound familiar?

Freeman had his license pulled after personally having given thousands of lobotomies but only because one of his "patients" finally died from his "precision method." How many have died due to misuse of drugs in children (and adults)? How many suicides? How many murders have been committed by people on those meds? Check it out for yourself: the list is very long and includes practically every school shooting you can think of--Columbine, Virginia Tech, Kip Kinkel, and many more.

There is an old saying--"'Tis better to err on the side of caution." Might be a good motto for this profession. "First, do no harm" just doesn't seem to get through.

Posted by Bob at December 24, 2008 09:08 AM

This website is a collection of 2700+ news stories with the full media article available, mainly criminal in nature, that have appeared in the media (newspapers, TV, scientific journals) or that were part of FDA testimony in either 1991, 2004 or 2006, in which antidepressants are mentioned.

http://www.ssristories.com/index.html

Posted by Bob at December 24, 2008 10:30 AM

Bob:

First, you are correct that psychiatry has been involved in horrendous practices in the past. You will get no argument from me here.

Second, you are correct that Dr. Cameron, a past president of the APA, was involved in developing techniques that became used to interrogate and torture prisoners, and that some psychologists and psychiatrists continue to participate in such practices. However, you failed to mention that the APA has recently condemned torture and participating in “enhanced interrogation techniques” in May 2006.

Third, I think it is highly unreasonable to take a single case of a psychiatrist who was engaged in horribly unethical behaviour that led to lasting damage to his patients and conclude that all of psychiatry is engaging in analogous practices. That is the problem with arguments from analogy. They exclusively focus on what two subjects have in common, and they fail to mention all the things they do not have in common. For example, Dr. Freeman did not have any controlled studies to support his lobotomies; did not utilize any reliable rating scales to assess the outcome of the procedure; and largely based his extensive practice on anecdotal evidence. That is unlike contemporary psychiatric practice that does have large, controlled trials in support of its practices, which have been found to be effective, albeit in varying degrees.

Fourth, the website www.ssristories.com is an important collection of anecdotal evidence that certainly supports the idea that SSRI’s can have paradoxical and violent effects in a minority of vulnerable individuals. That is why we always include the possibility of personality changes, mixed state induction, akathasia, and other adverse effects that could lead to a patient harming themselves or others while on the medication.

Fifth, I eagerly await your responses to the points I raised in my previous post.

Happy holidays.

Posted by dguller at December 24, 2008 05:58 PM

Paul, thanks for the response. Very good points.

Posted by Lisa at December 24, 2008 11:53 PM

dguller:

Happy Holidays to you and yours.

I drew the analogy with Freeman and his lobotomies because it is illustrative. I continue to maintain that there is no decent evidence for the theory behind psych meds for kids (and adults, but they should have more leeway if they want it), no evidence for the broad diagnoses for which people are treated with these meds, no evidence or objective test for individual diagnoses, no evidence that the meds work as claimed (or at all on balance with their numerous deleterious "side" effects), no evidence the meds are safe, but a good deal of evidence that they are not.

You say: "...the website www.ssristories.com is an important collection of anecdotal evidence that certainly supports the idea that SSRI’s can have paradoxical and violent effects in a minority of vulnerable individuals." When there are that many stories, it is not anecdotal. It's good evidence. "Minority of vulnerable individuals"? Many credible researchers put the number of these "vulnerable individuals" in the tens of thousands.

Honestly, I am not sure which questions of yours I have failed to answer. If you mean the studies showing something about brain chemistry, I would maintain they are interesting but in no way support the broad use of the meds in question for reasons given above and elsewhere.

I really do believe that we will one day look back on this period of time with the same sense of horror we now feel toward lobotomies.

Here is an excellent film I recommend you and others take the time to view. I will link the first part, but be sure to watch all ten parts. It's a bit long, but very much worth the time.

Making A Killing: http://www.youtube.com/watch?v=_sYhTdeLRM8

I had to hunt a bit to find part two, but it is there. Please watch the whole thing and let me know what you think.

Posted by Bob at December 25, 2008 04:38 AM

To all:

If you take the position that all psychiatrists are to be universally condemned, because they endorse practices that lack supporting evidence, and which actually lead to significant harm to people, then why not look more closely at Senator Grassley?

Grassley has been on the record as being for criminalizing the use of marijuana. He actually equated marijuana use with murder, rape, child abuse and genocide in a letter dated October 5, 2007. He has consistently voted for harsh penalties for drug possession.

In 2007, about 770,000 Americans were arrested for marijuana possession. A disproportionate amount of these arrests were of minority groups. In his state of Iowa, the penalty for being convicted of possession of any amount is up to 6 months in prison for the first offence, up to one year for the second offence, and up to two years for any subsequent offence. Iowa authorities have arrested about 6,000 Iowans per year since 1997.

We are talking about millions of Americans who have acquired criminal records, and possibly prison time, which has likely impacted their ability to be accepted into schools, employed for work, and other important life activities. How many of them have been so frustrated by these limitations that they have become recurrent offenders? Perhaps that might be justifiable, if there was evidence that these life-ruining policies actually have led to a reduction in marijuana use and have led to the betterment of society in general. There is no evidence of such an effect, and thus the impact of such policies is universally negative.

Now, for those of you who declare psychiatry to be rejected in total, because its practices allegedly have no evidence and lead to significant harm, behold Senator Grassley and his support of the destruction of millions of Americans’ lives without any supporting evidence that shows that marijuana is more harmful than alcohol and cigarette smoking.

So, you have two options:

(a) Be consistent and reject all of Senator Grassley’s work as false and fraudulent as you have rejected psychiatry in total without anything possibly helpful in it, which means that you also have to reject his Senate investigation.

(b) Be inconsistent and accept all of his work as valid despite his endorsing activities that harm millions of Americans without any evidence of benefit, and thus lose one of your primary arguments against psychiatry.

Or, you can do the reasonable thing, and agree that flaws in a part of someone’s work do not automatically discredit the entire body of work, that such flaws indicate the increased probability of falsehood, and thus merit a closer scrutiny of the related body of work. And if you accept this, then we can agree that although much work by Goodwin, Biederman and Nemeroff are now under a cloud of suspicion, that some psychiatric practices in the past have led to significant harm of patients, that we still have to take the evidence on a case by case basis and not jump to any conclusions on the basis of emotional reactions?

Take care.

Posted by dguller at December 25, 2008 06:43 AM

Mr Guller (I presume this is your surname here?),

My understanding is that many people have grave concerns with the validity of Psychiatry as an institution. Yes, certain notable individual psychiatrists can be held as illustrative examples of the problem, but I haven't heard anyone claim that ALL psychiatrists are so corrupted - I agree this is clearly not the case.

The Nazi Party analogy works here as not all members of the German Nazi Party held and practiced its core values. This in no way minimizes the evilness of that institution, nor do critical, well-intentioned psychiatrists absolve Psychiatry of its unsupportable premises and questionable practices.

Psychiatry's historical ties to Nazism and other oppressive political entities make such comparisons unavoidable, but I do appreciate why these analogies make psychiatrists unhappy. It is important to know the roots of one's discipline and knowledge so as to practice with some humility and reverence, however.

I don't think Psychiatry is being unfairly treated here. Its history and CURRENT beliefs and practices more than amply justify a most jaundiced view of its credibility. Here is what needs to happen to correct this, in my opinion:

1. Psychiatry must be stripped of legal/quasi-legal power to force otherwise law abiding persons to undergo procedures and medications against their will. This is barbarism full stop, though I rather prefer to liken it to rape. Psychiatry MUST lead and secure this effort.

2. Existing psychotropic drugs should be reclassified as Schedule II/III substances to severely curtail and restrict their prescription to the most dire circumstances where side effects and withdrawal are of little concern.

3. Correspondingly, off-label use of psychotropics should be disallowed.

4. Psychotropics should be unapprovable [sic] without validated diagnostics to indicate the disease and treatment course parameters.

5. If Psychiatry wishes to be considered a medical art, then it most hold itself to the same conventions and practices in a most transparent fashion.

6. Psychiatry must disentangle itself from commercial monies and interests - psychiatrists are, of course, free to do what they want.

This is not mean to be an inclusive list, but I believe these are necessary as Psychiatry has been unable to police itself nor admit and correct its most basic errors. The institution needs to be reigned in severely until such time it has proven itself worthy of the power and privileges that wider Medicine enjoys.

Also, your example of Senator Grassley is a bit obtuse so I won't bother to comment on it.

Thanks, and a very Merry Chistmas to you and everyone!
Paul

Posted by Paul at December 25, 2008 06:34 PM

Bob:

First, I think it is highly disingenuous for you to say that there is “no evidence” for something when there are hundreds and hundreds of placebo-controlled studies that show a significant amount of evidence for psychiatric treatment. How do you explain away all that data?

Second, a well-known remark by researchers is that “the plural of anecdotes is not data”. In other words, an anecdotal incident is only useful for the formulation of a hypothesis, which can then lead to the design and implementation of a randomized controlled trial to answer the hypothesis. There are so many confounding factors in anecdotes that they are basically useless. The website that you cited has thousands of anecdotes, but cannot determine which of the SSRI-related adverse events were due to underlying physical or mental illness, substance abuse, other medications, and/or the antidepressants themselves. It is certainly likely that a good number of them were exclusively due to the antidepressants, but the format of the information makes it impossible to know how many of them were.

Third, you state the studies that I cited that demonstrate a dopamine deficit in the prefrontal cortex of children with ADHD are “interesting” but do not support the use of psychostimulants in the treatment of ADHD. That is puzzling to me, because if psychostimulants significantly improve attention and hyperactivity in ADHD children, and are known to boost dopamine in the PFC, then it appears that there is a plausible scientific justification for their use. Help me understand why this isn’t so.

Fourth, the questions that I am awaiting your answer to are the following from December 23, 2008 at 11:31 am:

“Sixth, regarding my second question, you have set a criterion that guides the permissibility of giving medications to children: first demonstrate safety and efficacy in adults, then adolescents, and then children. I assume that this criterion applies to all forms of medications given to children. Has Tylenol met this standard? Has Aspirin? Has Sudafed? Has anything? I mean, you can’t just pull a criterion out of the air without any empirical support, or can you?

"Seventh, regarding my third question, you have not cited the studies that support long-term use of your strategies. Can you please at least cite your comment in this thread where you believe you did, because I cannot find it.”

Take care.

Posted by dguller at December 25, 2008 07:06 PM

dguller:

You say: "...for those of you who declare psychiatry to be rejected in total, because its practices allegedly have no evidence and lead to significant harm..."

No one is saying that. We are saying that the "science" behind the drugging of children (and adults, depending) is not based on evidence, but on hype by a bunch of ethically-challenged frauds.

The rest of your argument is nothing but pseudo-logic in defense of pseudo-science.

Did you watch the movie? (Making A Killing: http://www.youtube.com/watch?v=_sYhTdeLRM8 Be sure to view all ten parts.)

Best regards...

Posted by Bob at December 26, 2008 06:14 AM

Bob:

You are correct that psychiatry has no scientific basis if you exclude -- a priori -- all the controlled trials and scientific literature. How that is a legitimate strategy in a discussion is beyond me.

Take care.

Posted by dguller at December 26, 2008 01:23 PM

I believe the correct quote is "The plural of anecdote is data," said by Nelson Polsby.

Posted by Sara at December 26, 2008 03:08 PM

Paul:

First, if you have read some of the comments on this blog, then you will see that many regular posters do, in fact, view all psychiatrists as evil incarnate. The posts that you were responding to were in reaction to their views. I am glad, however, that you do not share their views.

Second, if we are going to discuss the roots of current organizations and use those historical antecedents as valid current criticisms, then we can look to the following people and institutions who supported Nazi Germany: Ford, GM, Chrysler, IBM, Exxon-Mobil, GE, and others. I am not too sure what the implications are with regards to the personal computer, American automobiles, oil production, appliance manufacturing, and so on, but I doubt that they should be cast in a sinister light in the present for their past behavior.

Third, you state that psychiatry should be prohibited from forcing people to do anything against their will. I agree that we must tread very lightly here, because it appalls me to take anyone’s rights away. However, I think I’ll need some clarification from you here. Does that include people who come to a physician and state that they will kill themselves? Should we just let them go and complete their intent? Or is involuntary admission and treatment sometimes permissible, i.e. when someone’s life is in danger?

Fourth, I agree with you that psychotropic medications should only be used in an evidence-based fashion.

Fifth, you recommend that until there are “validated diagnostics” and “treatment course parameters”, there should be no approval for the use of psychiatric treatment. I think there are fairly good “treatment course parameters” in the sense of multiple reliable rating scales that are routinely used to assess treatment efficacy and side effects. I am not too sure what you mean by “validated diagnostics”. Could you provide a bit more information, please?

Sixth, I agree with you that psychiatry should minimize or eliminate its reliance upon drug company funding, and should engage in its practices in an open and transparent fashion. No disagreement here. :)

Take care.

Posted by dguller at December 26, 2008 05:33 PM

Paul:

Oh, and about my comments regarding Senator Grassley. I am trying to make a point to those on this blog who believe in the following:

“If a person or institution has been found to engage in a practice that consists of deception, lacks any evidence and results in significant harm to others, then their entire body of work should be rejected”.

That is the underlying principle behind the wholesale rejection of psychiatry by some visitors to this website. I just wanted to extend the implications of that principle beyond the realm of psychiatry, and happened to come across Senator Grassley’s support for criminalizing marijuana, which actually consists of deception, the absence of evidence, and has resulted in significant harm to millions of Americans. Therefore, if people are going to reject psychiatry in total based on the above principle, then they must also reject Senator Grassley’s work, including his Senate investigation.

This is actually a form of reductio ad absurdum in the sense that since no reasonable person will reject the Senator’ work in its entirety on the basis of his stance on marijuana, it follows that the principle that I cited above must be rejected as false. Without that principle, there is no grounds to reject all psychiatry, but rather we must be cautious and look at the evidence in an objective fashion on a case by case basis, which will likely result in the rejection of some psychiatric treatments (e.g. atypical antipsychotics as monotherapy for depression), and the acceptance of others (e.g. atypical antipsychotics as short-term augmenting agents for depression), depending on the quality of the evidence.

In short, there is no reason to reject psychiatry in total, but rather we should criticize its practices where defective with the intention of improving its ability to help people.

I do not believe this is obtuse in any way.

Take care.

Posted by dguller at December 26, 2008 05:45 PM

Sara:

It is unclear who was the originator of the phrase, "The plural of anecdote is not data". Check out the following website for one person's attempt to track down the source: http://bearcastle.com/blog/?m=20050808

But for balance, a good response to "the plural of anecdote is not data" would be "the plural of data is not proof". :)

Take care.

Posted by dguller at December 26, 2008 07:17 PM

Sara:

Oh, and one more thing. Nelson Polsby did not originate the quote that you mentioned. He cited it in a 1984 article where he quoted Raymond Wolfinger saying it in a 1969/70 graduate seminar at Stanford.

Take care.

Posted by dguller at December 26, 2008 07:26 PM

M. Guller,

You are comparing apples and oranges. Sen Grassley is in no way way comparable to Psychiatry's KOLs nor is the American political system with Psychiatry.

These two institutions are not on equal footing logically. This is a basic Type 1 error. The comparison you attempt to make is fatally flawed imo.

Paul

Posted by Paul at December 26, 2008 08:57 PM

M. Guller,

A couple quick responses.

Psychiatry is a very different beast from Ford, Chrysler, BMW. The comparison you make misses the entire point that coercion and force are at the heart of problems with Psychiatry.

Involuntary commitment must err on the side of personal liberty imo. I admit that this might result in some degree of suicide completion, but it's not simple to assess how many are driven to suicide from due to in-patient commitment or lack thereof - so many cultural and social issues that confound this.

However, the issue is what happens to people held against their will: forcibly treated with drugs and other procedures such as ECT and psychosurgery. It is one thing to temporarily hold someone for 72 hours, but I would consider any forced treatment as an assault.

I think the the existing process cedes too much power to psychiatrists. If you are trusting of Psychiatry and psychiatrists perhaps this is not a problem, but I think there are far too many examples of abuse, historically and presently, to be so easily convinced.

I'm not entirely happy with an evidence based approach. I think this has failed psychiatric patients. EBM serves the group not the person and I think this is the one area where Psychiatry should differentiate itself by focusing on individuals and not groups.

lastly, current assessment tools are wholly inadequate and every CNS clinician in pharma bemoans this. We want validated biomarkers and lab tests to specify disease, onset, progression, differentiation, and so on. These bloody questionnaires are next to worthless.

Thanks again,
Paul

Posted by Paul at December 26, 2008 09:34 PM

Yes I believe Raymond Wolfinger is the correct originator of the phrase, one I heartily support, and that the phrase you quoted that the plural of anecdote is NOT data, dguller, is a perversion of the original saying by academic researchers who objected to it -- funny that -- what a coincidence. I found the correct original quote in a book by David Dobbs just given to me. It was in a list of quotes that preceded the text of his book and he attributes it there to Nelson Polsby. I had just noted that specific quote right before you posted your comment. Whether data is proof or not depends on how it comes together to demonstrate a thesis. I think data often provides proof.

Posted by Sara at December 26, 2008 10:11 PM

Some good comment/s Paul. I vote Gulligan off the Island though.

Posted by Stephany at December 26, 2008 10:50 PM

Paul:

First, how does the principle that I mentioned apply to psychiatry, but not to Senator Grassley?

Second, do you honestly feel that the conflicts of interest that exist within psychiatry due to the large amounts of money involved have no parallel to the American political system?

Third, it appears that your main point in mentioning the involvement of some psychiatrists with Nazi Germany was that the shared a notion of coercion, and that was the focus of your criticism. In that sense, my inclusion of American corporations was misplaced.

Regarding coercion, you state that we should err on the side of personal liberty and thus you would tolerate a certain percentage of completed suicides as permissible. So, the issue is not harm per se, because you obviously are not averse to people harming themselves, but rather people not being able to make decisions based on appropriate information, which results in harm. This is a fair point, but the issue is a bit more complicated. For example, for someone to voluntarily agree to a treatment, they should be able to understand and appreciate the consequences of the treatment, which presumes a certain degree of cognitive function and insight. How can someone voluntarily agree to something when they are simply unable to comprehend what they are being asked to agree to due to overwhelming emotion, distorted perception, cognitive impairment, and so on?

In Canada, we are not allowed to involuntarily treat someone when they are certified for up to 72 hours. At that point, the patient is allowed to refuse treatment, but if their certification period is extended, then they have a right to a review board hearing to make their case for refusing treatment. The review board is made up of several community members and physicians, as well as one psychiatrist. They make the ultimate decision. So, in Canada, we do attempt to safeguard a person’s liberty by providing them with multiple opportunities to express their disagreement. It is only once they are deemed incapable to consent to treatment and a review board has agreed with this conclusion that they may require involuntary treatment, but it is almost always in a context in which either their lives or the lives of others are threatened.

Fourth, your points about EBM are well taken and largely true. EBM does focus on the statistical properties of treatments on groups of people, which does not translate well into individual treatment, because of a variety of factors. However, EBM is extremely important to discover whether a treatment is genuinely effective or if someone got better as a result of the natural course of their illness, spontaneous remission, the Hawthorne effect, regression to the mean, and/or the placebo effect. Without EBM, we would still be in the times of quackery where all we had were uncontrolled studies and anecdotal stories, which are not especially useful from an objective standpoint.

That said, just because a well-designed study shows that a particular treatment is more effective than placebo, it does not follow that it will work in a specific patient, because they will have characteristics that are likely not represented in the study, and thus inhibit a study’s applicability to them. It is a fact that we never know for certain why someone improved while taking a treatment, because it could have been due to a variety of factors. However, with EBM we can say that a treatment had some impact in addition to the other factors mentioned above. But you are right that this has not always led to improvement in the lives of patients.

Fifth, you are correct that current rating scales are imperfect, and until we do have the biomarkers and other diagnostic tools, they will have to do. However, I disagree with you that without such biomarkers we cannot study an illness and possible treatments. What biomarkers exist for dementia, delirium and autism? Are these not legitimate illnesses that require some form of treatment? Perhaps in the course of research, some biological diagnostic markers can be discovered that can account for why some individuals respond to some treatment and others do not. Perhaps we are in a similar situation today as physicians were in the 19th century with “dropsy”. That was a vague diagnosis involving swollen limbs that was thought to be a single illness, but was actually secondary to renal, cardiac, respiratory and other causes that each were distinct entities. Only time will tell, though.

Take care, and thank you for your well thought out remarks.

Posted by dguller at December 27, 2008 07:55 AM

Paul said, "Involuntary commitment must err on the side of personal liberty imo. I admit that this might result in some degree of suicide completion, but it's not simple to assess how many are driven to suicide from due to in-patient commitment or lack thereof - so many cultural and social issues that confound this."

I agree with this. How many patients leave psych hospitals more damaged & more depressed than they went in (raising my hand)? I have to live with the memories of seeing adults taken down to the floor screaming, and so many more horrible images that I cannot get rid of. That doesn't exactly lead to feelings of well being. Traumatizing people does not save them from suicide.

Also, dguller please do not assume everyone who disagrees with your views see psychiatrists as "evil incarnate" or wishes to abolish all of psychiatry because it's not true.

Posted by Lisa at December 27, 2008 09:25 AM

Yes, I would also like to add that I have seen involuntary treatment as well as threatening someone with renewed involuntary treatment if they are not compliant with recommended psychopharmacology lead to a serious decline in mental health and de novo suicidal ideation as a result of what is witnessed in the hospital and clinical outpatient settings. And in psychiatry, because we are dealing here with the narratives of people's lives, I will always require so called "anecdotes" to support any statistical or compiled data to prove a thesis and I do not think EBM proves very much at all in psychiatry because it is so often done with obfuscation and predetermined agendas.

Posted by Sara at December 27, 2008 11:46 AM

Lisa:

I did not assume that everyone who disagrees with my views see psychiatrists in that way. That is why I said "some visitors to this website". I certainly never meant to include everyone. I happen to have had the most extensive discussions here with those who feel that psychiatry has been a satanic influence in the world and wish it to be abolished in its entirety. It is to those people that I referenced my comments, not others who have a more moderate approach.

Take care.

Posted by dguller at December 27, 2008 01:15 PM

dguller, okay good.

Posted by Lisa at December 27, 2008 02:37 PM

M. Guller,

Grassley vs. Psychiatry is an apples and oranges comparison. I am tempted to outline a lengthy logical diatribe, but it would be a distraction and it's not all that important. If you think they're equivalent - fine, but you're still wrong ;)

The conflict of interest is different. Psychiatry NEEDS the money to legitimise itself whereas in politics it is the currency of speech and power. The parallel is limited and not central.

Psychiatry's connection to Nazism goes beyond individuals - it's ideological and woven into the basic substrate. Little has been done to openly acknowledge and purge these aspects from the institution. And yes, if modern corporations still held and practiced sympathetic views I should expect they would be exposed and roundly condemned as well. I should also expect their boards and chief executives to be summarily fired and replaced. But enough about Nazis.

Your Canadian system is interesting and seems a bit more balanced. There are state to state variations in the US. Most often this decision is made in probate court by a judge who may or may not actually be a jurist. Forced treatment is not uncommon in the US, especially in compromised populations. The hospital almost always prevails. It's curious though that if a patient can survive 72 hours without drugs what changes that now requires society to forcibly administer an agent. I guess the issue is that the hospital cannot legally hold a person for more than 72 without declaring them incompetent which then leads to the forced treatment. I've seen this happen on many occasions. I'm still amazed that a patient is considered competent to sign a treatment plan, but incompetent if they refuse. Courts in the US accept this reasoning carte blanche.

There are but few instances when a person needs to be involuntarily treated. These almost always emergency life threatening scenarios - e.g: treat now or someone dies right now. Physicians already have the power to treat emergencies, so I fail to see a justification to involuntarily treat someone after 72 hours unless it to extend an emergency treatment. This almost never the case in psychiatric commitments as few true emergencies last for days on end. Overwhelming emotion, distorted perception, cognitive impairment will improve over time (presuming there is no pathological reason it shouldn't) sufficiently for a person to make their decision. We may not like it, think it's reasonable, or even rational - that's free will and we should respect and honor it. Forced treatment is unjustifiably too common.

I don't think Psychiatry can properly inform people about their pharmaceutical/ECT-type treatments because few would accept the high risks and low probability of actually curing the malady. The reality is that people broadly rely on their physicians to vet the safety and efficacy of drugs who in turn are influenced by KOLs, journal articles, colleagues, and their own anecdotes. You don't seem entirely happy relying on anecdotes, but KOLs and journals aren't the bastions of credibility either - at least in Psychiatry. Psychiatric patients aren't being properly consented imo. I admit it's hard to do when so little is known about mechanisms of action and conditions being treated. I also think it's more useful to think of pharmaceutical intervention as high risk experimental treatment. It's a bit more honest and comes closer to a proper consent than what is done presently.

I'm not suggesting that EBM is useless. It has been very useful where the signal is distinct and strong, the theoretical underpinnings provable and falsifiable, and possible to know and control confounders. In Psychiatry this has not been the case. Find me one statin study with even a 20% placebo response rate. Don't bother, you won't - not for an approved, marketed statin at least which should tell us something... The high rates of placebo response should scream at you that there is something inherently wrong with the hypothesis, the study protocol, the drug, or your markers of efficacy. This is a pandemic problem in CNS trials. We know the drugs do what they do (sort of), we just don't know how or why that should translate into a particular thought or mood. We know how to design a good RCT, but this always presumes we do it and must also believe we can control confounders (institutional bias wreaks havoc here). Lastly, markers of efficacy plain SUCK. If CNS were held to similar criteria as CV/Metab they'd all be sacked were it not for Psychiatry being the partner in hand. EBM in Psychiatry could be considered a form of quackery.

Biomarkers and objective diagnostic tools are NECESSARY for developing drugs intended to treat mental illness. They are NOT NECESSARY to treat a patient, but they sure would reduce the vague experimental aspect in the prescription of psychotropics. Pharma has been working very hard on this because using questionnaires or relying on personal observations to measure efficacy has proven farcical in RCTs. Biomarkers and objective diagnostics would give credibility

We shouldn't settle to use crude tools because they are all we have. If there was more transparency and honesty then I'd reconsider this position. Sometimes it's best to do nothing at all until we have the right tools - perhaps we can learn from art restoration?

The larger problem is that we shouldn't be fucking around with neurotransmitters in humans when we don't know what we're doing. We shouldn't be telling people that they have chemical imbalances when we know they don't. We shouldn't be experimenting on humans without irb/iec oversight, an approved protocol, published results, and properly consenting the patient. If this retards advances in psychiatry then so be it. I think Psychiatry will be the better for it and psychiatrists would be viewed and held with similar esteem as the rest of Medicine enjoys. It would do so legitimately. They would probably be indistinguishable from neurologists...

Thanks,
Paul

Posted by Paul at December 28, 2008 12:55 PM

Paul,

First, what precisely are the connections between psychiatry and Nazism that you are referring to? How does psychiatry believe in the inherent superiority in a particular race of people, which justifies the enslavement and ultimate destruction of all other races for the sake of the superior race? Or perhaps is your analogy inadequate?

Second, corporations act in ways that maximize short-term profit even at the expense of long-term outcomes for millions of poorer individuals in the Third World. If psychiatry should be condemned for latent Nazism of whatever variety, then multinational corporations should be even more roundly condemned for the negative impact that they have had on the global environment and stomping on the rights and livelihoods of entire nations. Feel free to read any of Noam Chomsky’s works on the subject, and for a recent treatment that will get your blood boiling, please read Naomi Klein’s “Shock Doctrine”.

Third, you claim that there is no justification for involuntarily treating a patient after the 72 hour observation period has expired. What if the person refuses to eat food, because the CIA is poisoning it? Would you happily release them to the streets as they starve to death, or would you recommend involuntary treatment with antipsychotics, because there is a decent chance that their delusions will be attenuated to the point that they will be able to eat food again?

Fourth, you are correct that mental status must be repeatedly re-evaluated, and once it improves to the point that someone is capable to consent or refuse treatment, then their wishes must be taken into consideration. In other words, just because someone has been declared incapable does not imply that they are forever incapable. In Canada, they are free to challenge their incapacity.

Fifth, I disagree with you that psychiatrists cannot acquire proper consent, because there is little understanding of the conditions and the treatments and that there is a low likelihood of success and a high likelihood of negative outcome. You would have to specify what conditions you are referring to, what medications you are considering, and so on, before I could comment further, but the idea that antidepressants are little better then placebo, especially for severe forms of depression, is simply untrue. They have a small to moderate effect size, which is certainly not spectacular, but you cannot simply disregard it entirely. We can inform patients that studies have shown that such medications are superior to placebo in patients who meet DSM-IV criteria for major depression, and that they come with risks of various side effects. I am unsure what else you require for adequate consent to occur. Also, I am unaware of any psychiatrist telling their patients that medications would “cure” them. If the high likelihood of a cure would be required for adequate consent to occur, then insulin would also be disqualified, because it does not cure diabetes, but only treats the symptoms.

Sixth, you are correct that the significant placebo response rate in antidepressants, in particular, tells us that their efficacy is quite limited (hence the small to moderate effect size). Most of the benefit that patients experience is due to a combination of natural course of illness, spontaneous remission, Hawthorne effect and the placebo effect (due to the psychosocial context of the trial itself, i.e. regular visits, receiving medications, expecting improvement, etc.). That is why I never tell my patients that medications will solve all their problems, but rather that they can improve their mood and neurovegetative symptoms to some extent that will allow them to do the real work of addressing the biopsychosocial context that activated their psychological distress. That said, there is decent evidence both for improvement of symptoms, as well as reduction in relapse rate, that cannot simply be explained as antidepressants being simply placebo. They are more than that, but you are correct that their story is far more than improving mood symptoms through neurotransmitters in exclusion to a variety of other factors.

Seventh, I agree that in a perfect world, objective biomarkers would be necessary, but sadly, there are multiple illnesses that have none. These include dementia, delirium and autism, to name a few. Should we discontinue all treatment, because there are no objective markers? What about treating various pain syndromes? Should we stop treating them, because pain is subjective? I agree with you that telling patients that medications are guaranteed to solve patients’ emotional problems is unacceptable, but telling them that there is good evidence that someone’s depression will improve with medications without any guarantee of efficacy in the case at hand, how is that inappropriate?

Take care.

Posted by dguller at December 28, 2008 06:08 PM

M. Guller,

This is probably my final comment to you as you don't seem to read my comments all that carefully - either that or you deliberately misstate or misconstrue what I wrote.

I'm done talking about Nazis and their historical connection with psychiatry. It's all there for you to read. It's not my analogy, it's history.

Let's look at your non-eating, CIA delusional character. It's a real example that you represent in such a foolish manner. I presume you've somehow determined he is a risk to himself and/or others, cannot manage his adls, and lacks insight into his disease? Good, so now you can have him declared incompetent and treat him as you see fit. How long do you plan to hold this person to make sure they continue to take drugs you forced upon him or her? Perhaps, some variety of out-patient commitment with bolus injections? I don't think I would treat this person in this way, but this approach is standard psychiatric care, no? Regardless, I did not say there is never any justification. I qualified this to emergency use, but you chose to selectively quote me. You seem to do this fairly regularly with other commenters as well.

I will find it difficult to extend you any further professional courtesies as it seems deliberate.

Regards,
Paul

Posted by Paul at December 28, 2008 09:24 PM

DGuller, you said, "That said, there is decent evidence both for improvement of symptoms, as well as reduction in relapse rate, that cannot simply be explained as antidepressants being simply placebo."

Where? The Star-D study, sponsored by NIMH, and not scientologists, showed a 33% remission rate. That isn't even decent for crying out loud with all the side effects.

Where are the studies that show that ADS work long term and prevent relapses? Interestingly, when I started tapering off of meds, the relapses that I was suppose to have according to your bleeping statistics that sentenced me to life on meds didn't happen. This was in spite of dealing with my mother's death, job instability and severe insomnia from Remeron withdrawal which you all deny exists.


Oh wait, there are studies. But of course, they blame it on the depression worsening instead of the meds. It always the patient's fault and never the fault of the med.

Interestingly, you depend on studies like the Star-D to justify your use of antidepressants but even though there are plenty of studies for example show the effectiveness of fish oil capsules in helping depression, you say the evidence isn't clear cut. Even if it isn't, which I disagree with, doesn't the fact that fish oil capsules have less side effects and at least has an equal chance of working as well as ADS, shouldn't they be tried first? Your logic totally escapes me.


If you don't like fish oil capsules, how about testing patient's vitamin D level which is known to affect depression? What about inisotol, which has elevated my mood in spite of the insomnia continuing?

Unfortunately, it is all about drugs with psychiatry come heck or high water. There is no curiosity or willing to think outside the box. If the drug industry collapsed (nice fantasy isn't it for most FS readers), psychiatry would collapse because you would have no clue as to what tools to use. You are as addicted to using meds as an alcoholic or a heroin addict needs his/her fix.

DGuller, with all due respect, your arguments are getting old. You say you have learned from us but what? What are you going to do differently with your patients?

Posted by aa at December 29, 2008 03:40 AM

AA, "Interestingly, when I started tapering off of meds, the relapses that I was suppose to have according to your bleeping statistics that sentenced me to life on meds didn't happen."

My severe chronic mental illness cleared up once I got off my cocktail. I have not relapsed either. I have never gone back to the psych hospital since leaving AMA in 2002. But, they don't study those that leave the mental health care system & really they should.

In fact, once my drug induced fog cleared I went back to school, obtained a 3rd degree & graduated magna cum laude. Had I remained compliant I would be sitting in the day program for adults w/ severe mental illness that was prescribed for me, swallowing handfuls of meds, and likely still cycling in & out of the psych hospital. That's no kind of life.

Posted by Lisa at December 29, 2008 04:09 PM

Paul said, "We shouldn't be experimenting on humans without irb/iec oversight, an approved protocol, published results, and properly consenting the patient."

Yes! Yes! Yes! I assumed, incorrectly, that when my shrink put me on Lamictal + Effexor + Wellbutrin & then threw in Prozac to be sure I went completely over the edge that there was some kind of data to support this. I have not been able to find the Lamictal + Effexor + Wellbutrin + Prozac study anywhere. Maybe he was doing his own little study?

Posted by Lisa at December 29, 2008 04:13 PM

Paul:

Regarding the example that I cited of someone refusing to eat their food due to its being poisoned by the CIA, I did not mention it because it was “foolish”. I have participated in the care of many such people, and thus it is not an academic issue to me. I missed the part of your post when you agreed with the necessity of involuntary treatment when emergency conditions prevail, which I understand to be when someone’s safety is at issue. I apologize for my confusion.

Getting back to the case, they would certainly be declared incapable and put on antipsychotics, and their mental status would be reassessed regularly. Once their insight and judgment have returned and they recognize their delusions as being psychotic symptoms, then they can be given the choice to continue with their treatment or to discontinue it. If they choose to discontinue their medications after an appropriate titration, and they are able to function without their or others’ safety being an issue, then they continue to be monitored, but there is no need for them to take medications. Mandatory treatment only becomes a consideration if they have shown improvement on medications and deterioration when their medications are discontinued to the point that safety becomes an issue.

You state that you would not treat this person in this way. What is your preferred approach to the case that I mentioned?

I truly hope that we can continue this discussion in as professional a manner as we can.

Take care.

Posted by dguller at December 29, 2008 05:44 PM

aa:

First, the STAR-D study found that by the end of the study, 67% of its subjects had attained remission. During the first phase, 33% of subjects on Celexa attained remission. Personally, I think that this study is interesting, but highly inconclusive since there was never any control groups included, and thus we have no idea about the true efficacy of any of the treatments utilized during the study. That is the most damning, but not the only, problem with the study. For a thorough criticism, please see Evidence-Based Mental Health 2008; 11:97-99. It’s available online for free. :)

Second, a meta-analysis that demonstrated a 70% reduction in relapse rates of subjects on antidepressants versus placebo from 6 to 36 months can be found at Lancet 2003; 361:653-61.

Third, no-one is guaranteed to have a relapse if they go off their antidepressants. I am happy that you did not have one after going off antidepressants.

Fourth, find me one study that unambiguously states that if a patient worsens while on an antidepressant, then it is absolutely due to the illness and not the medication. Just one. Please.

Fifth, I never said that omega-3 fatty acids were not beneficial in the treatment of depression. There is a great meta-analysis at the Journal of Clinical Psychiatry (2007; 68:1056-61). I actually routinely recommend it.

Sixth, could you please read my posts in response to Sally at the threat at “Scientific American Interview”, especially near the end. I certainly do not believe that medications are the only answer to mental illness, but I do feel that they can be useful in some severe situations. I would like to read your comments about my posts to Sally. :)

Seventh, if my arguments are getting old, then please answer them.

Take care.

Posted by dguller at December 29, 2008 07:21 PM

I'd like to see some studies on psychiatrists and fish oil. Back in the 90s I saw two totally mainstream psychiatrists who got me on them; the one at the public clinic even handed me a flyer during my intake explaining their benefits, and recommended dosage. I was actually skeptical about mixing alternative medicine with pharmaceuticals but since going off psych drugs I still take 2000 fish oil a day notice a diff when I neglect to take them.

Posted by flawedplan at December 29, 2008 10:25 PM

dguller: that 67 percent figure you cite from star-d is at the end of four phases of treatment over like 18 months and we don't even know how long the alleged remission was for. you're engaging in additive probability there as well, which is a big no-no in stats. the most successful med was celexa at about 30 percent remission. that's as good as it gets in star-d and none of it is a ringing endorsement of standard depression treatments.

Posted by Jones at December 29, 2008 10:27 PM

Jones:

First, it is true to say that about 2/3 of subjects who stayed in the trial achieved remission by the end of the study, and 1/2 of them by the end of the second phase. Those figures aren't too bad, but there are multiple problems with the trial that make generalizability very difficult and actually make its conclusions quite inconclusive.

Second, additive probability is appropriate in this case, because the subject sample was the same group of people from start to finish of the trial. You are correct that additive probability is inappropriate if, for example, I was adding the probabilities from two different studies, because the samples are different. However, here it is perfectly okay. :)

Take care.

Posted by dguller at December 30, 2008 06:27 AM

M. Guller,

At least you are consistent. I did not say the example was foolish, but rather that you represented it in a foolish manner. This also means I didn't say YOU are foolish.

You are just playing silly mental games, thought experiments, with people here. I have better things to do.

Goodbye,
Paul

Posted by Paul at December 30, 2008 07:55 AM

Paul:

First, I wrote:

"What if the person refuses to eat food, because the CIA is poisoning it? Would you happily release them to the streets as they starve to death, or would you recommend involuntary treatment with antipsychotics, because there is a decent chance that their delusions will be attenuated to the point that they will be able to eat food again?"

How is this case presented in a foolish manner? Was it foolish in the sense that it was inappropriate, given the fact that you had agreed that involuntary treatment was necessary in some situations? If that is the case, then yes, it is foolish, because I was incorrectly making a point that was irrelevant to our discussion.

Second, if your complaint against me is that I misread and misinterpreted your post, then I can make the same claim against you. After all, you state that "I didn't say YOU are foolish". I never implied this anywhere. If you are of the opinion that anyone who misreads someone in such a way that presents them as unreasonable should be ignored and rejected, then I will happily apply that criteria to you, as well. :)

Third, I object to your characterization of the person too paranoid to eat their food, and being at risk of starving to death, as "silly mental games, thought experiments". I will be sure to tell the next patient I see in the emergency room who hasn't eaten in a week due to paranoia that they are "silly mental games, thought experiments" rather than real, struggling people.

Funny how easy it is to nitpick someone's posts and make them appear to be utterly foolish, eh? I would have preferred that we discuss the content of our ideas rather than the form in which they were presented, but so be it.

Goodbye.

Posted by dguller at December 30, 2008 05:53 PM

I started writing my blog to give myself an outlet when I was flooding this site with comments.

Posted by Stephany at December 30, 2008 07:29 PM

I wonder why the only two alternatives when someone refuses food are to release them to the streets to starve to death or submit them to involuntary treatment with antipsychotics. Those are two pretty extreme alternatives. I would imagine there might be other options. I am sure this is a case you have encountered, dguller, and it would be interesting to know what this person's history was -- both their personal history and their treatment history -- to get them to that point.

Posted by Sara at December 30, 2008 08:09 PM

M. Guller, surely, you must be daft or is English not your native language?

You do realise you misquoted me yet again trying to "... nitpick someone's posts and make them appear to be utterly foolish..." - incredibly funny.

Since you seem to have such difficulty, I will help you.

I said:

"At least you are consistent. I did not say the example was foolish, but rather that you represented it in a foolish manner. This also means I didn't say YOU are foolish."

You quoting me:

'After all, you state that "I didn't say YOU are foolish". I never implied this anywhere.'

I never said you implied anything - you just made that up out of whole cloth. You misquoted me and added a complete fabrication of your own.

The last sentence unambiguously clarifies that I was NOT in any way referring to you as foolish, just your representation. I felt this sentence necessary due to your tendency to misquote and misstate comments. Prescience sometimes has its unforeseeable curses.

I also did not characterise the man in your example as a silly mind game. I was referring to your conduct. You should be able to separate comments about you from comments about what you say.

You said:

'...I object to your characterization of the person too paranoid to eat their food, and being at risk of starving to death, as "silly mental games, thought experiments"'

What I actually said in entirety:

"M. Guller,

At least you are consistent. I did not say the example was foolish, but rather that you represented it in a foolish manner. This also means I didn't say YOU are foolish.

You are just playing silly mental games, thought experiments, with people here. I have better things to do.

Goodbye,
Paul"

There is no characterization of our CIA man here. You invented this. Object all you want.

Here is what I have said about the man:

'Let's look at your non-eating, CIA delusional character. It's a real example that you represent in such a foolish manner. I presume you've somehow determined he is a risk to himself and/or others, cannot manage his adls, and lacks insight into his disease? Good, so now you can have him declared incompetent and treat him as you see fit. How long do you plan to hold this person to make sure they continue to take drugs you forced upon him or her? Perhaps, some variety of out-patient commitment with bolus injections? I don't think I would treat this person in this way, but this approach is standard psychiatric care, no?'

You presented this hypothetical situation, limited in scope and information, and offered two choices. I said this representation was foolish - the context being discussion of forced treatments. I was very clear that I was speaking about the representation having repeated and corrected you several times on this very point.

You seem to do this with others here, too. Your MO is to misquote, apologise, and then continue to misquote. It seems more time is spent correcting your misstatements than actually discussing the issue at hand. This is a classic debate technique to control the discussion and to keep your opponent always on the defensive to gain the debate advantage.

I know what your on about. I won't play and I hope too many others won't either. Sorry.

Back to CIA guy (or why I'm glad I'm his physician):
I decided that I had other choices other than what you offered: throwing him to the streets or forcing neuroleptics on him. I ran some routine labs and an endocrine panel on your guy: TSH through the roof, low T3, low cortisol. He agreed to the lab tests because I spent a fair amount of time talking with him to gain a modicum of trust. His energy level also seemed to pick up a bit in mid AM and again after lunch (which I didn't force him to eat btw). The next day, I drew diurnal labs, an AM cosyntropin stim test, and noted some abdominal tenderness. A head and abdomen MRI revealed a pituitary adenoma and lesions on both adrenals. He didn't get your neuroleptics. He got surgery and later joined the CIA where he eats lunch every day. He takes his levoxyl and hydrocortisone as directed. I get a Christmas card every year. My guy is also real - except for the joining CIA part.

You cherry-picked a scenario where forced use of an anti-psychotic agent would necessarily be the conventional psychiatric treatment. It's foolish to offer up a rhetorical question as evidence of proof. Forced treatment is far too serious and complex a matter to be treated this way. You seem more interested in playing games and toying with people.

Paul

Posted by Paul at December 30, 2008 11:34 PM

Phillip,

I think this thread has probably devolved far enough and long enough. One would hardly know it was about Chucky's self-addressed stamped envelope anymore.

Paul

Posted by Paul at December 30, 2008 11:37 PM

Here's a nice synopsis of exactly what Nemeroff did:

http://clinpsyc.blogspot.com/2007/08/when-to-say-sorry.html

Dguller writes:

"What if the person refuses to eat food, because the CIA is poisoning it? Would you happily release them to the streets as they starve to death, or would you recommend involuntary treatment with antipsychotics, because there is a decent chance that their delusions will be attenuated to the point that they will be able to eat food again?"

Is that reference to the "mental ill" person as an it perhaps a Freudian typo?

Of course if someone is so malnourished from not eating that they are in any danger, they will be in a medical ward getting fed iv (or egads treated with the dignity the increased status of just being "sick" and not mentally ill allows people who refuse food in a medical context, a protocol).

I wonder, when someone refuses food, what the definition of refusing food is. Forcing food when someone is so weak from not eating that it's hard to get an iv into their body is not I suspect what dguller is talking about. I suspect he's exaggerating and that folks he encounters refusing food in a psych hospital are people who began to refuse food as protest for being forcibly imprisoned a psych hospital, an understandable hunger strike that could be cured by release from the hospital. Perhaps many prisoners in prisons have a similar reluctance to eat at first. I wonder how many folks this guy has actually seen who really refuse food when in medical danger of expiring from not eating and how many just refuse lunch one day and thus make the pshrink angry because of his control issues.

Or is this a cry to involuntarily treat people who are so poor on the outside that they can't afford food, otherwise known as the starving. The idea that there's no real poverty on earth but that the poor are "mentally ill" whose brain chemistry makes them poor is a popular one with psychiatry.

Perhaps malnourishment brought on by the poverty that goes hand in hand with the result of having a psych label can be falsely attributed to a delusion, but the question, why does someone think the CIA is poisoning their food, would be a good one. Forcing drugs like zyprexa that stimulate appetite, not such a good solution as zyprexa really is poison and forcing someone to be poisoned as a remedy to a hunger strike is similar to the murder them so they won't commit suicide strategy of psychiatry. It achieves it's end but who is really "helped?"

In other words, if you think the government is out to get you and so to "treat" you, the government locks you in a prison when you've committed no crime, what sort of healing is going on? If the ward wasn't locked and the food was freely available wonder what would happen.

Posted by Sally at December 31, 2008 06:08 AM

Sara:

First, what are the "other options" that you "would imagine"?

Second, I have encountered probably a half dozen cases of people too paranoid to eat or drink, and they were mostly people living alone, abandoned by their families and supported by a disability pension. They were all tragic cases that improved on antipsychotics, and began eating again within a few days of treatment. You are correct that using mind-altering drugs with the possibility of significant long-term adverse effects is "pretty extreme", but they do work at improving many psychotic symptoms. Sadly, they do not help much with others, e.g. negative and cognitive symptoms.

Third, I have considered starting a blog, but I don't have enough ideas to post! :) It takes a particular talent to be able to write fresh ideas regularly, and I am mainly good at responding to the ideas of others. :)

Take care.

Posted by dguller at December 31, 2008 07:01 AM

I just wonder if these people had treatment histories and whether the trajectory of their illnesses was actually made worse by those treatments. Also were those people eating because the antipsychotics were messing up their appetite control mechanisms rather than really soothing their psychoses in a significant way? It could well be that many of these individuals do need an institutional setting of some sort but not the kind that is readily available to most of them currently unfortunately.

And yes, although I wasn't the one who made the point about starting your own blog I recommend it because you are picking on commenters here with a ferocity and determination that, to me, belies any real intent to learn. It's more like you want to teach everyone here a lesson and spite them. That's the way it comes across.

Posted by Sara at December 31, 2008 09:45 AM

Sally,

You make some excellent points. Here's the pattern I see:

1. The police and/or a social worker end up bringing in people who seem to be behaving erratically.

2. These people typically are homeless or without permanent shelter, often alcoholic, and almost always malnourished.

Most, especially vets, want to be left the fuck alone - their words, but it depends how cold it is outside.

Some been living this way for years.

3. A quick interview establishes with person as mentally ill: paranoia, delusional, psychosis, schizophrenic, etc..

4. The hospital quickly moves to forced treatments because this group tends to be belligerent, loud, obnoxious, uncooperative - none of which are illegal or dangerous.

The hospital is always worried about liability and just can't release them until they are stable - which means neuroleptics in almost every case.

Seroquel is dispensed here for almost everything you can imagine. Maybe it's related to the AZ clock on the wall?

5. If a patient were truly in danger of dying, they would be receiving iv support, not neuroleptics and sent on their merry way.

The mistake psychiatrists make is that they think they can predict what a person will do and then force treatment on them accordingly. This is akin to to sending released felons back to prison because they are very, very likely to commit further crimes upon release. We don't do this with criminals, only those diagnosed with a psychiatric issue.

I've seen many instances of hunger strikes for precisely the reasons you state. I find this a reasonable reaction to an intolerable situation. The hospital views this as a lack of insight and self harm - leads to commitment procedures and more seroquel scripts.

Posted by Paul at December 31, 2008 10:11 AM

Well, my daughter was so paranoid she wasn't eating or drinking, all water was contaminated in her mind, as cups and single serving bottles. She had severe psychotic event and it turned into a medical emergency.

The medical hospital would not treat her, though she arrived via ambulance with an IV in her arm placed by an ER doctor for care in a medical ward, when they found out she was a psych patient they treated her inhumanely to say the least.

Why did she become paranoid? Why didn't the last 6 antipsychotics prevent that? why didn't Clozaril prevent that?

Because there is no cure, not one drug to guarantee psychosis being lifted.

How would I have liked my daughter to be treated?

WITH DIGNITY, without forced treatment (that she got when she was shipped to the psych ward and injected against her will with a B-52. which is Haldol and other goodies that terrified her, caused her to drool and cry on my shoulder until she slumped over on me).

The professionals here can squabble all they want to, and I have been silent watching this "professional debate" take a nose dive with pleasure and entertainment actually.

Guller you say you wouldn't have much to write about on a blog? make that you wouldn't have anyone to talk down to or take notes on for your residency, IMHO.

Paul, you left a refreshing set of comments, and I agree with you walking away from this thread.

Charles Nemeroff is one of the most influential KOL's that depicts psychiatry for what it is in the USA. It is highly influenced by pharma companies, the date is cooked or buried, and I am not antipsychiatry or anti-med.

I am pro-truth and the truth hurts sometimes doesn't it?

Posted by Stephany at December 31, 2008 10:13 AM

Paul:

You are absolutely correct that a medical work-up is essential in the work-up of the paranoid individual that I mentioned. We routinely include a physical examination, bloodwork, urinalysis and brain imaging as part of any admission of a psychotic patient. It is extremely rare that any of it shows anything significant. Naturally, if there are organic causes, then they must be addressed. That is standard in any guidelines of the work-up of a psychosis, and thus your approach was perfect with regards to that patient, and congratulations on diagnosing a treatable medical cause of that patient’s paranoia. I wouldn’t have done anything differently, and neither would anyone I work with. Recently, I diagnosed a gentleman who presented with mania and dementia with neurosyphilis, and after treatment with penicillin, he dramatically improved.

Now I assume that your approach to your patient would have been different had your medical work-up been negative, as happens very often. It was this type of patient that I was referring to with my example, but I should have specified that my approach is not to immediately start using antipsychotics until a medical work-up has been completed. However, once it is negative, then my approach is to offer them antipsychotics to help relieve their paranoia, and if they refuse, then to declare them incapable (if their justification is rooted in their delusions), and if a review board agrees with me, then to start them on their medications. As you rightfully stated, they would receive IV nutrition in the meanwhile until they are ready to initiate PO intake of food and drink.

I truly hope that we can agree that this approach is appropriate in the scenario that I described, as I can agree that your approach is appropriate when a medical cause is identified. However, I think that this topic is moot, because we both agree with involuntary treatment when appropriate. We simply got sidetracked, because I read your posts too casually and misquoted you too often. Sorry, that’s what happens when I’m visiting family and checking the computer with limited time and angry glares from family members. :)

I promise you that I am usually far more careful with my quotations. :)

Take care, and Happy New Year.

Posted by dguller at December 31, 2008 11:46 AM

Sally:

Actually, the example that I mentioned, which I have treated on a about half a dozen occasions, are not those with refuse to eat food out in the form of a hunger strike in order to protest their imprisonment, which I would actually feel is appropriate in many cases. As long as they are able to understand and appreciate the consequences of their actions, then they are free to do what they like, and I would not involuntarily treat them.

I recently participated in the care of a patient who was arrested and suspected of having cocaine packets in his colon, and was at risk of having them rupture and cause an overdose. He refused to allow an ER physician to do a rectal examination, and the ERP wanted psychiatry to do a capacity assessment. I assessed him and found that he was capable to refuse treatment, and so they sent him back to jail. We did not call him psychotic and force treatment upon him. He was able to understand and appreciate the consequences of his actions, and thus it was his right to refuse treatment, even if it leads to his demise.

The situation is different with someone who has stopped eating for a few days before coming to hospital secondary to paranoid delusions about the CIA poisoning their food. After a medical work-up is negative, and they continue to refuse to eat, then I feel that treatment with antipsychotics is appropriate. There is no guarantee that their paranoia will resolve, but in my experience, it usually does, and they begin to eat again. I do not think it is appropriate to simply give them IV fluids, and then send them out while they state that they will still refuse to eat due to their delusions. If treatment with antipsychotics has brought no improvement, then that may be what has to be done, but I think it would be negligent not to at least attempt to treat their psychosis in the hopes that they will eat of their own accord. I view this as a life and death issue that requires intervention.

Take care.

P.S. Oh, and when I referred to “poisoning it”, the “it” was the food, not the person. I guess we all mistakenly misquote each other from time to time. :)

Posted by dguller at December 31, 2008 12:00 PM

Stephany and Sara:

Please point to one instance where I was condescending or rude to anyone here. I am just posting my opinions, just like the rest of you. I am sorry if I am rubbing some of you the wrong way, but I assure you that I am trying to be as polite and professional as I can, even in the face of being called horrific insults.

Just look at the thread above, and see how many times I have agreed with commenters here. Whenever someone here agrees with me, it always comes with some measure of insult.

You asked how I have changed. I have reduced my prescriptions of psychotropic medications in my practice as a result of visiting this website, and have spent more time speaking with my patients and getting a better sense of their identities as whole persons with unique histories and lives.

For that, I thank you all.

Happy New Year.

Posted by dguller at December 31, 2008 12:07 PM

If more shrinks thought like Paul & if psych hospitals treated people respectfully imagine the difference it would make.

During one of my inpatient visits there was an elderly woman there who wouldn't eat. I sat at the same table in the cafeteria. She mentioned her fear of the food being posioned (and considering it was all unhealthy, high fat, enriched flour, junk food that was served she was pretty darn close).

The patients at the table told her the staff were too dumb to think up something like that. She smiled. The interesting thing was that with some support from fellow patients she did begin to eat a little bit.

During my stay I never saw a single staff member came over to encourage her to eat. Not once. So, this woman who hasn't eaten in who knows how long is just beginning to eat but meal time is up. It's time to go to the neverending, mindnumbing activity known as "group." Myself & those at the table approached the staff & asked if they could wait a few more minutes because the patient was finally eating. Nope, time to go to group. So much for her meal. They didn't give a rip.

Posted by Lisa at December 31, 2008 02:00 PM

dguller said, "You asked how I have changed. I have reduced my prescriptions of psychotropic medications in my practice as a result of visiting this website, and have spent more time speaking with my patients and getting a better sense of their identities as whole persons with unique histories and lives."

I'm glad. I think your patients will benefit. Never underestimate the ability of patients to get well even those who have been labelled treatment resistant, chronic, etc.

Posted by Lisa at December 31, 2008 03:05 PM

dguller, I'm very glad to hear it and thank you for letting us know.

Posted by Sara at December 31, 2008 03:40 PM

Lisa:

That is terrible, and I am very sorry for anyone who has been treated as subhuman in any capacity, but especially while under the care of anyone in my profession.

Take care.

Posted by dguller at December 31, 2008 05:15 PM

I'm happy I came here to wish dguller a happy new year.
It's good to know you're listening to your patients.
After being on so many psych-drugs because side effects were being diagnosed as diseases, loosing 15 years of my life coping with side effects and withdrawal symptoms, now being hocked to 150 mg Effexor, 200 mg Seroquel and 2 mg Klonopin I hope that nobody, nobody experience the same I did.
After reading what people are suffering going from one drug to another without success it hurts me the hell.
I'm thinking about Susan right now who is coping with side effects...
Gianna who has been withdrawing for four years and has been on 37 psych-drugs...
Stephany who was prescribed Seroquel as a sleeping pill and other drugs... her daughter being prescribed a drug
So many people...
I've been reading since 2005 the withdrawal hell specially of SSRIs...
I've spent 19 months tapering Effexor and after three months off it I had to take it again because of severe withdrawal symptoms that made living impossible.
Now I'm feeling terrible side effects.
I have read many times: "I don't know who I am anymore" "This drug destroys lives."
If I were a psychiatrist I was going to dedicate my life helping people withdraw.
After withdrawing Paxil, Seroquel, Topomax, Lamictal, Klonopin and Neurontin I wish I could help.
We are here daily, obsessively trying to tell what we have suffered and witnessed what other people suffered and are suffering.
Philip and others are dedicating their lives to do what the media don't. He is paying for his beliefs. He has been there, it doesn't show, but he has.
It's a hard job.
Dear Lord!
Since April, when I found Furious Seasons and found out that there was so many people blogging I'm doing what I can.

I started writing my blog to give myself an outlet when I was flooding this site with comments.

Just like Stephany I had to start a blog after three months flooding this site with comments.
I confess I'm exhausted.
I have cried and cried and cried. I've been angry, angry and angry...

But how can it be that patients have a knowledge of their own that are not heard by those who are supposed to take care of them?

I've also been on Ziprexa, Donaren, Rohypnol I don't even remember how many drugs I've tried.
One of them made me sleep-walking.
The doctor said "It will go away." Another night I woke up in the middle of the living room making another speech.
And the hallucinations caused by Halcion?
"It will go away. You'll forget."

I don't forget. There's no therapy for that.
What psychiatry caused me is part of who I am.
I've finished my therapy. Twenty years of therapy.
As the first psychiatrist told me: "You need therapy."
He's already dead. He was one of the most important and is recognized.
But he prescribed me clonazepam.
I took it for 5 years randomly.
But one day I spend three days without it and all of a sudden I've found myself sat on the floor without being able to move calling a friend of mine who brought me the drug.
I've searched a psychiatrist to help me withdraw.
He prescribed diazepam and... Tofranil.
I can't even describe what I felt.
Anxiety seems too little.
Was taken to another psychiatrist.
He prescribed me:
amitriptyline, Parnate, Stelazine, Xanax and Fernegan. Sometimes he added something new.
Went to another psychiatrist...

I guess that being here telling you all this is a way of trying to heal myself.
Nobody understand what has happened to me.
I know you understand.
All I needed was not be put on drugs: I needed get out of drugs.

Happy new year!

I just hope I made myself clear. If I read it again I'll not have the courage to click on Post.

Posted by Ana at December 31, 2008 08:05 PM

Guller, address me directly, not grouped together with Sara and mixed with other comments.

You're a bore.

Posted by Stephany at January 1, 2009 12:45 AM

Guller said, "I have reduced my prescriptions of psychotropic medications in my practice as a result of visiting this website"

It's quite obvious you are using the commenters here for information about a group of people you clearly do not understand or have personally observed.

You've flooded this comment section with demands for evidence, and constantly asking anyone what the definition of dementia is; when a patient walks into a psychiatrist's office with information from the 'Net they are met with distain.

I can clearly see how the grand rounds lecture was most likely influenced by our stories, and made it appear you know us.

You don't.

Posted by Stephany at January 1, 2009 12:53 AM

Yes, to all the psychiatrists who visit this site either occasionally or sporadically, I hope they will read other blogs besides this one -- Beyond Meds, for one, and the recent posts on Tilting at Windmills. And Ana's and Stephany's and on and on. These are narratives that need to be paid close attention to; there are thousands of them out there. And every time you pull out your script pad you need to ask yourself whether you are starting another life altering narrative for someone else. There are many who don't live to tell the tale of how that script changed their life, like my daughter. I am left to do it for her.

Posted by Sara at January 1, 2009 10:03 AM

Sara said:

"These are narratives that need to be paid close attention to; there are thousands of them out there. And every time you pull out your script pad you need to ask yourself whether you are starting another life altering narrative for someone else. There are many who don't live to tell the tale of how that script changed their life, like my daughter. I am left to do it for her."

I've just been reading through the archives and happened across your story again Sara. It brings me much sadness to hear words I have said myself:
"I am left to do it for her". Though my daughter is alive; which gives me courage somehow to keep speaking out.

Thank you for speaking out for your daughter, and I am truly sorry she is gone.

Posted by Stephany at January 1, 2009 11:34 AM

Stephany:

First, you are correct that I am participating in this website to better understand a class of patients that I have little understanding of. I would have thought that you would be pleased with me attempting to correct my ignorance of patients who feel neglected by the psychiatric community, and to implement my lessons here with my patients. Would you rather I ignore your experiences and continue practicing as before? I mean, what exactly do you want psychiatrists to take your experiences into account or don’t you?

Second, if you are referring to my grand rounds lecture on the philosophical foundations of scientific knowledge, then you are incorrect that it was based on my experiences here. I gave that presentation in March 2007, and gave it in response to another grand rounds in which a visiting professor argued that there was no such thing as objectivity and rationality in the sciences, and that it was all simply a matter of power and propaganda, i.e. the typical postmodernist position. It really had nothing to do with this website, which I began visiting several months later.

Third, I am posting here in the hopes of finding middle ground between those who believe that psychiatry brings bliss on earth versus hell on earth, has excellent scientific evidence versus zero scientific evidence, has no need for reformation at all versus must be abolished from the face of the earth. I believe in neither the former nor the latter, and rather feel that psychiatry exists in the middle, independent of either extreme position. I try only to post when someone makes an extreme position of either the former or latter. That’s all.

Take care.

Posted by dguller at January 1, 2009 11:58 AM

And so the story goes! Someone comes to a comment section as an apologist for the likes of Nemeroff, Biederman, Goodwin, Darrel A. Regier, and a host of other unsavory characters claiming to be renowned psychiatric doctors. Why I must ask? The answer rings something like this; because you are cut from the exact same mold as the above mentioned embarrassments to what many in professional medical circles call pseudo-medicine or the subpar medicine of psychiatry. The Guller’s of this world speak the same language, and believe in the same worn out doctrines. They have their professional life and personal ego vested in it!
They tout how they are here to learn and debate; but in truth they are just spewing the same old crap that most here have heard from hundreds of different psychiatrist in a futile journey within that inhuman profession (I’m not saying there are no good psychiatrist, but the number are so few in scope and practice that it is having little effect on how this off shoot of real medicine runs their treatment modality and how it has short changed and abused the patient continuously for decades). There is nothing new or novel about your approach or philosophy Guller. It has been used over and over again; unfortunately it is still used today in a continued losing and failed effort for patients.
You don’t have to sit there typing away thinking you know better! Yet it shows quite clearly in your doctrine and opinions expressed here. If you had to come here for patient feedback and to learn from those so called nah Sayers; I would have to strongly question how much validity you have actually placed to in the actual patients charged in your treating hands in all reality.
Paul appears to be a sound professional with some practical experience you would be wise take heed of. But Unfortunately I don’t see much of that happening with you either. You are locked in your small safe dismal world, and when that world is questioned or threatened you use every trick in the book to win at all cost. But who’s winning? Do you really think because you believe having won some aggrandized philosophical argument, your patients somehow win also? You are sadly mistaken in this line of thinking and conjecture if you have this ingrained belief system working for you. Interesting that of all medical professions; Psychiatrist were the least to have faith or belief in a higher power (you can research that one on your own); one would have to wonder then what they really believe in? Maybe they are taught to be their own Gods? Interesting data to ponder anywise!
I’m sure you will respond as you always do with question upon question trying continuously in your futile effort to sway minds and win converts. I seriously doubt you have won anyone over here. I can almost hear those words echoing now; How about dementia, hysteria, and such diagnosis as you try in earnest to deflect what you cannot defend with your failed approaches and pseudoscience.
Please show me a single person you have cured with your kind of medicine? Do you have even a single case you can show me or any of those here with absolutely no relapse or adverse long term effects and diminished capacity of life; that you can directly attribute to your treatment modality? Show us your evidence in real life terms. I challenge you to bring that to our attention! Or will just continue your blabbering quotes of studies and data that we all know are suspect at best, inconclusive in all reality and complete rubbish at worst.
Quote from Dguller: “Please point to one instance where I was condescending or rude to anyone here. I am just posting my opinions, just like the rest of you. I am sorry if I am rubbing some of you the wrong way, but I assure you that I am trying to be as polite and professional as I can, even in the face of being called horrific insults.
Just look at the thread above, and see how many times I have agreed with commenter’s here. Whenever someone here agrees with me, it always comes with some measure of insult.
You asked how I have changed. I have reduced my prescriptions of psychotropic medications in my practice as a result of visiting this website, and have spent more time speaking with my patients and getting a better sense of their identities as whole persons with unique histories and lives.”
You just don’t get it, do you? You’re not sorry or concerned at all! So don’t pull that “I’m the victim” out your garbage heap here. You don’t agree with commenter’s, you only concede a point to make another self serving point in your little mind game; as commenter Paul so wisely and justly pointed out to all here.
Inquiries have been made and letters written to those in high standing; so they are aware of your little gamesmanship here. I believe you have over stepped your bounds as a practicing resident doctor here. Since you know clearly and without any reservation that the vast majority of commenter’s have been or are ongoing patients in the process of treatment. I would have to say you have put your ego ahead of your Hippocratic Oath without much doubt. I welcome you to go back through the literally hundreds of post you have made here in the span of less than a month and still say you have not been condescending in anyway. If that is true, then your also right about your hero’s and mentor’s the afore mentioned psychiatric doctor criminals listed about.

You would think you would not have had to come here to a blog to learn about how medications don’t work? Have you been walking around on your rounds with your eyes closed for the past several years? You read like a text book and college debate team member; not a person that has taken an oath to do no harm. Take a long hard look around this blog you pompous apologist. It’s your medicine that has caused this harm; that is what you’re standing up for and protecting. I would call that arrogance and ignorance in its most hideous form.
You can write a response to this post until hell freezes over; and yet there will be nothing but silence and blank pages in return.
Automatic

Posted by Automatic at January 1, 2009 12:40 PM

Sara,
Thank you very much for listening.
Yesterday I told my story once again but in the back of my mind I was thinking: does it matter? No.
I'm not scientific data.
I will hear what many have heard:
"I'm very sorry you had this terrible experience. However you have to admit that... these drugs help... chemical imbalanced... now scientists are discovering that .. according to DSM.... what if a patient..."
I remember reading many times back in 2005: "What about us? It seems we don't exist." at Socialaudit discussion board where people were reporting SSRIs withdrawal hell getting help over the Internet.
We still don't exist.
Sara Carlin, Traci Johnson, Candance Downing and many others are not scientific data.
Side effects, withdrawal and iatrogenic condition are not scientific data.
People changing from drug to drug without success... not scientific data.
What is scientific?
I have to stop smoking because it causes many diseases.
I'll just go to the drugstore buy Chantix.
Unfortunately I'll have to wait till next week because it's too expensive.
Scientific is what happens when we have a family member in a mental institution without knowing how is he being treated.
They are being treated scientifically.

Posted by Ana at January 1, 2009 01:14 PM

I'll shut up now and let science keep on taking good care of us all.

Posted by Ana at January 1, 2009 01:18 PM

"Would you rather I ignore your experiences and continue practicing as before?"

I'm not here to advise you on your career choice or validate it.

Posted by Stephany at January 1, 2009 03:08 PM

Sara,
I'm sorry. I didn't read the part you talk about your daughter.
I'm feeling suffocated here and I've noticed that it's not just me.
I'll talk to you when Furious Seasons comes back to normality.
And I hope with all my heart that it happens as soon as possible because I hate seeing people I like being mistreated this way once again.
If psychiatrists don't learn in their real practice, and it seems to me that some of them don't listen to their patients because they have to be in blogs, I don't know where ar... blah blah blah.... blah blah... blah...

Stephany,
It's too much.
Please take care. Notice that it's me who is telling you to take care. This is what we say to each of our blog friends in times of trouble.

Take good care my friend. Take care

Posted by Ana at January 1, 2009 03:26 PM

...The problems I've discussed are not limited to psychiatry, although they reach their most florid form there. Similar conflicts of interest and biases exist in virtually every field of medicine, particularly those that rely heavily on drugs or devices. It is simply no longer possible to believe much of the clinical research that is published, or to rely on the judgment of trusted physicians or authoritative medical guidelines. I take no pleasure in this conclusion, which I reached slowly and reluctantly over my two decades as an editor of The New England Journal of Medicine.

from: "Drug Companies & Doctors: A Story of Corruption"

http://www.nybooks.com/articles/22237

Posted by Bob at January 2, 2009 07:04 AM

Dguller,

You write:

"You asked how I have changed. I have reduced my prescriptions of psychotropic medications in my practice as a result of visiting this website, and have spent more time speaking with my patients and getting a better sense of their identities as whole persons with unique histories and lives.”

One would have to wonder if you've sent the letters out to people you "treated" before this "change" admitting that you over prescribed drugs and didn't spend enough time with them, confessing to "medical" malpractice?

Posted by Sally at January 2, 2009 10:57 AM

Sally:

Nope, I haven't done that, but since they are no longer my patients, it would be inappropriate of me to interfere with their current care. I do not believe that I did anyone any harm in my brief time as their treating physician, but by prescribing medications more frequently than I currently do, I certainly increased the possibility of an adverse event due to side effects.

Posted by dguller at January 2, 2009 03:46 PM

I'm glad to see the comment removed that was over the top, off topic,condescending and rude to another commenter. Thanks.

Philip Dawdy notes: actually it was the commenter who asked me to edit it.

Posted by Stephany at January 2, 2009 07:14 PM

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