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Friday, December 16, 2011

An Update of Some Earlier Blog Posts


There have been some new developments recently concerning some of the issues and stories I have discussed previously on this blog, so I thought I would write a new post that updates some of my previous ones.

First, apropos my post of May 25, Pro-death Florida Legislators Run Amok, about a recently-enacted Florida law prohibiting health care practitioners from even discussing health care concerns about gun ownership with their patents: it was temporarily blocked by Federal U.S. District Court Judge Marcia Cooke. The state plans to appeal the injunction blocking enforcement of the law.

Second, concerning the debate about SSRI antidepressants and whether they are better than placebos:  A Commentary in the December 2011 edition of the American Journal of Psychiatry pointed out that placebo response rates to antidepressants in studies have increased as much as 7% per decade since 1980. 

Not coincidentally, this bizarre inflation of placebo response rates correlates very well with the timing of the rise of the so-called contract research organization, or CRO (http://opp.morningstar.com/PDFs/MOI-EvoCRO.pdf).  These organizations are usually doctors in private practice who are hired by drug companies to do their randomized controlled studies of medications.  These doctors get paid - quite handsomely - for each subject that they successfully recruit for the study. 

The subjects are, in turn, recruited through offers to pay them for their participation. ABC News recently did a story about stay-at-home moms who turn themselves into guinea pigs to earn extra cash. The use of paid subjects has led to the phenomenon of the "professional research subject" who participates in multiple drug trials.

Under these circumstances, both the doctors and the patients are being given cash incentives for exaggerating their symptoms in the initial evaluation so they can qualify for the study!  Once they are picked, no one then has a financial incentive to exaggerate symptoms on follow-up exams.

No wonder placebo response rates have skyrocketed.

CRO Newspaper ad clues in potential research subjects who wish to get paid as to what symptoms to complain about


Last, there are two developments concerning schizophrenia and its treatment with antipsychotic drugs. 

First, as the states have been cutting back on funding for community mental health centers due to the economic downturn, we are seeing a lot of what is described in the following news article:

http://www.freep.com/article/20111127/OPINION02/111270434/After-closing-psychiatric-hospitals-Michigan-incarcerates-mentally-ill-?odyssey=tab%7Ctopnews%7Ctext%7COpinion

After closing psychiatric hospitals, Michigan incarcerates mentally ill

"Wayne County Sheriff Benny Napoleon spoke for most sheriffs when he said, during a community meeting earlier this year, that his jail had become his county's largest mental health care institution.
Over the last two decades, changes in state policy and big cuts in funding for community mental health care have pushed hundreds of thousands of mentally ill people into county jails and state prisons...

"'We closed too many (hospitals), too quickly,' Mark Reinstein, president of the Mental Health Association in Michigan, told me this month. "It wasn't done in a planned, rational way."
Community mental health agencies -- which were supposed to take up the slack but never received the resources to do so -- face continuing budget cuts. The state has resumed warehousing its mentally ill -- this time behind bars...

 "In 1999, a Department of Community Health study -- conducted by Wayne State University -- of jails in Wayne, Kent and Clinton Counties found that more than half their populations were mentally ill and one-third were seriously afflicted, suffering from schizophrenia, bipolar and other psychotic disorders... Since 2008, the state has slashed $50 million from community mental health agencies, with Wayne County absorbing more than half of the cuts.

"Treating one client in a community program costs about $10,000 a year, compared with $35,000 a year to house one prisoner.  Statewide, more than 200,000 people a year use community mental health services, but experts say at least twice that many need them."

To really understand what happens when funding to community mental health centers is cut significantly, one has to realize that fewer patients with schizophrenia will get treated with anti-psychotic medication. Such medication is all the treatment that community mental health centers are providing nowadays.  In addition, those patient with schizophrenia who are seen will be seen much less frequently.  We know from multiple sources that lack of close follow-up highly exacerbates the issue of people not taking prescribed medications (non-compliance).

Off their meds, psychotic patients still end up being incarcerated, but as this story indicates, in jail, not in a hospital. Paradoxically, psychotic inmates are usually then prescribed anti-psychotic medications in prison - at a much higher cost.

One wonders how author Robert Whitaker (Anatomy of an Epidemic), who believes that antipsychotic medications make psychotic people worse, explains away how people with schizophrenia somehow become far more likely to end up in jail when they do not take antipsychotic medication.  Or perhaps he thinks that this development is the result of a malicious government plot .

The question of whether schizophrenia is in fact a real brain disease, and why it has been so hard to pin down the actual pathology, was recently addressed in a newspaper column by neuroscientist  par excellence John J. Medina. 

John J. Medina
An excerpt:

"... a biological explanation for the disease seems heartbreakingly just out of reach. Schizophrenia has a powerful genetic component (heritability percentage is in the low 80s), something I’ve known for years, something that could make it low-hanging research fruit. There is also a large clinical base on which to do studies: schizophrenia afflicts millions of people (the estimated prevalence rate is about 1% of the global population). Despite these seeming advantages, a molecular mechanism capable of describing all aspects of schizophrenia has almost completely eluded researchers.
"There’s a simple reason for this. A deep understanding of schizophrenia at such an intimate level has been hampered by a single technical bottleneck: the lack of a robust in vitro [in the lab as opposed to in the body] disease model.

"That may all be about to change. The results from a study that used cells derived from a deceased patient’s skin tissue has recently been published. Findings from the study may provide just such a model. It is not yet full-fledged schizophrenia-in-a-dish, but the findings portend a powerful future for the field."

Medina then goes on to explain a new technology - a way to produce something called Pluripotent stem cells (iPSC's) which I will not go into here.  Basically, they are re-programmed stem cells.  He then goes on to say:

"With these technologies in mind, I now have the tools needed to understand how to create a dish-bound model of schizophrenia. It involves answering some simple questions: What if you took the skin cells from patients who had schizophrenia and turned them into neurons? Would they exhibit behaviors of typical, healthy cells? Or would they exhibit behaviors reminiscent of previously determined properties of neurons in patients with schizophrenia? If the latter were observed, would you have a robust cellular model of schizophrenia, the missing link in this line of work? A consortium of researchers decided to to find out."

Skin cells from diseased patients made iPSCs that were similar to cells that were obtained from unaffected people.

"The most interesting result came from what happened next. Even though the reprogrammed cells were clearly neural tissue, they did not behave like typically functioning neurons. Several observed differences were eerily similar to previous findings other researchers had seen in tissue samples from patients with schizophrenia."

Despite what you may hear from mental illness deniers, neurons (brain cells) derived from patients with previously diagnosed schizophrenia "exhibit specific, aberrant properties."  I do not wish to get into highly technical neuroscience on this blog, but anyone interested might want to look up definitions for the following terms, and learn about how brain cells from people with schizophrenia differ from those who do not show symptoms of the disorder:

Dendritic arborization,  neuregulin expression, and Global gene expression changes.

After pointing out that this technology does have some problematic aspects to be resolved, Medina concludes: "Having a dish filled with cells that carry many characteristics of a human disease is a lot like having a flashlight in a dark cave. The greatest utility is in the ability to illuminate molecular mechanisms that might go undetected without such a model. It can go a long way toward relieving the frustration often associated with this line of work. Give it enough time and it might even—someday—illuminate a cure."

Undoubtedly, mental illness deniers will find something wrong with any evidence that schizophrenia is a brain disease.  It's in their nature.

12 comments:

  1. I find your remarks about so-called mental illness deniers, extremely irritating!

    I am one of many folks currently diagnosed with schizophrenia, and I do not feel it is a brain disease.

    I am quite sure I am not alone in my very experienced opinion. I feel the disease is multivariable. Everyone seems to hold schizophrenia as a special disorder, when there has been a steady diagnosis-creep for many so-called schizophrenics. Many, it turns out, can be seen as schizoaffective... or bipolar. Suddenly, with those diagnoses, the good docs, like yourself, are willing to see us in a more familial light.

    I am very aware that ANYONE can be diagnosed as schizophrenia, under the right (or wrong) conditions. You do not need a brain disease to be delusional. Lack of sleep, plays into many a psychotic experience.

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  2. The other issue, often overlooked, is that patients "off their meds" often do not wean gradually off medications, which would make it less likely that they would have a relapse.

    I have a friend who when she runs out of anti-depressant, immediately starts crying and getting a lot more irritated about little things in her life.


    After a few days, she finds this effect lessens. My friend only uses the lowest dosage of anti-depressant.

    I've explained to her that her brain reacts to sudden changes in medication status. In effect, the reaction is a "withdrawal response."

    For psychosis, I believe the drugs are significantly stronger. So the rebound response could be worse? I postulate that sometimes a psychotic response from withdrawal, instead of being one that is evidence of disease, may simply be a rebound effect, from removing the obstacle to normal brain chemistry that is imposed by any medication.

    In response to suppressing activity of dopamine receptors, does not the brain produce more dopamine? If so, then when the antipsychotic is removed, the floodgate is open to receiving the overabundant dopamine.

    Not unlike the stomach's response to produce more acid once a person suddenly "comes off" a proton pump inhibitor. I've experienced that directly, so it is my best comparison.

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  3. I'm happy to share again, my frustration with your depiction of Whitaker? You are most unfair. I am not a mental illness denier, either. Can't put me in that group.

    I can't help wondering if you have really read his work cover to cover.

    Would love for you to discuss things more reasonably once you have.

    I too have my points of disagreement with him, for I know there are medical reasons for the illnesses he discusses at length. I don't agree that all psychosis is about personal transformation.

    However, there is a great deal more to the book. The reasonability of it, and the way it decloaks the myths around so-called mental illnesses, opens the way for a more whole-body approach to mental health.

    After all, last I heard, the head was attached to the body. And now we know there is a strong relationship between the gut and brain. And my Lord, we now know the brain is plastic and resilient!

    We are going to deny schizophrenics any hope outside of medications with health-destroying side-effects? For shame!

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  4. Smitty,

    You are correct that people who get labeled with schizophrenia are a heterogeneous group, some of whom are completely misdiagnosed. There are also mild cases that may not require antipsychotic medication. I agree that patients with the disorder deserve more intensive rehabilitative treatment in addition to meds. And heaven knows I wish we had antipsychotic medications that are less toxic than the ones we have now.

    However, there are also many clear-cut cases of schizophrenia, particularly among the so-called SPMI's - severely and persistently mentally ill. The current meds are the best we have, and way better than warehousing them in prisons and hospitals. Psychosocial interventions are next to worthless if they are actively delusional and hallucinating.

    As to Whitaker, he asks the right questions but consistently comes up with the wrong answers. I turned to random pages in this book, and on every page was either a half-truth or a cherry-picked reference - sometimes authored by the very types of psychiatrists he criticizes. Sorry, but that being the case, I do not need to read every page - I've better things to do with my time.

    Also, while antidepressants clearly do have withdrawal effects, I seldom see anything of the sort with antipsychotics. After an accutely psychotic patient stops them, the symptoms they get are absolutely identical in every way to the ones they had before they were ever medicated in the first place. They are neither worse nor different. And they go away again when the patient starts back on the meds.

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  5. Have you hugged someone todayDecember 20, 2011 at 10:58 AM

    Whitaker doesn't argue that mental illnesses aren't real, and also does not argue that antipsychotics should never be used. His statements are much more nuanced than you are aware of. It's summaries of his positions and one hour radio shows that distort (due to time restrictions) what he actually says.

    The trouble is, if someone does poorly on meds, many psychiatrists just say that person has borderline and it can't be that the pills are no good for some people. It's almost always blame the patient. And drugs were oversold as a cure-all for everything (which I know you do not advocate that) and side effects (particularly of antipsychotics) not disclosed to patients, and so a major correction of the record was going to happen sometime. In all my years of taking antipsychotics, no doctor ever told me to be sure I don't get pregnant or checked to see if I was gaining 30+ pounds. They just watched it happen while I drooled away. Also, "advocacy" groups like NAMI never recognize that you can have milder psychosis and not need antipsychotics for (your now shortened) life.

    Irving Kirsch used original data from drug companies to look at antidepressants and placebo effect, not recent data, as you discuss. I don't see how any decent research is going to happen when it's all profit motive and no unbiased academics involved anymore.

    I guess what I know is that when I took all these pills, I could barely function, and now that I've been off them a couple years, I am still a mess of depression, but I can get more stuff done. And my relationships are so much better. Medications turned me into a complete dysfunctional jerk. There are many anecdotal stories like mine. Perhaps there is a subgroup of people for whom these meds are pure poison, and another group for whom they are a miracle, and it can't be determined from the data. Patients for whom medications are poison - they drop out of treatment, and the psychiatrists are then unaware of them. Kirsch himself mentioned that his data could mean that very thing - that some are improving on antidepressants, and others are getting worse. I personally wonder if sexual side effects are damaging relationships, and that is part of what is going on.

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  6. Have you hugged someone todayDecember 20, 2011 at 11:10 AM

    I forgot to say, our area counties have supported peer recovery programs, and that has had a big payoff. People who are sick enough that they have to live in group homes - they are not well enough to participate, unfortunately. But most people in the programs, if not all, have severe and persistent mental illness, and the group activities has reduced their isolation, and at little cost compared to traditional interventions. Some professionals push hard to add traditional programming though, and wreck the whole thing. People with serious mental illness (but not too sick) get group up to their eyeballs and do not need MORE time to talk about how awful their lives are. Playing Monopoly with friends is MUCH better. I don't know why mental health providers think a patient should spend all their time talking about their problems - that's just ruminating, and the situation becomes ever worse. I think they have to keep documenting so they can provide services, is my cynical view.

    I think the budget cutting is horrible. The most vulnerable people rarely vote, so they don't matter to a lot of politicians.

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  7. Hi Hugged,

    You may find that if you read the rest of my blog or my book, that I agree with almost all of what you say.

    Unfortunately, many of my peers are doing a bad job of monitoring patient responses and side effects to meds. But that does take more time and a lot of patients are simply not willing or cannot afford to pay for that time. Insurance companies sure don't. Purchasers of insurance need to complain more about crappy coverage.

    I know Whitaker takes a more nuanced stance than the psychiatry bashers, and like I said he asks good questions, but unfortunately it's some of his totally-off-the-mark conjectures that get quoted in the media.

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  8. Hugging others and baking cookies todayDecember 24, 2011 at 4:58 PM

    I also think that there are more 15 min med check doctors than psychiatrists who see people for longer periods of time, and a 15 min med checker is going to see 4x more patients in a day, too. I think the vast majority of people with serious and persistent mental illness are being seen by the 15 min med checkers, and the people who have much milder problems are far more likely to see the docs who take time with them, because they have not fallen into poverty due to severe mental illness.

    I do read your blog, but sometimes I forget what you wrote before, since I've read it for months. What I like is that you really emphasize family problems.

    My new doc sees me for an hour, and Medicare does pay for that - how did I get stuck with 15 min med checkers all that time? I didn't know there was anything else.

    Great job working in that plug for your book! I do plan to get it soon. LOL! I won't even get it at the library. (I still laugh over some authors I like who were "outraged" that they got a nasty review of their novel from someone who got it at the library).

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  9. Oh Lord, I wish I could find a private psychiatrist who took my insurance, and took his/her time to really know my story! I find that the doctors who take insurance either have so many patients to serve that they cannot give any of us an hour. Or else, perhaps they wish a higher hourly wage, and get better reimbursed by insurance for the classic 15-minute medication appointment?

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    Replies
    1. Hi Smitty,

      The fact that many psychiatrists do not take at least 45 minutes to get to evaluate a new patient is a scandal. It's all about the cash - and having a very limited world view called "biological reductionism."

      I set aside an hour for a new patient, but I cover some family dynamic issues that other docs don't even know about. And I have developed ways to keep the interview moving without badgering the patient.

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  10. By the way, any chance you could remove the word verification step on blog comments? If you haven't commented on anyone else's blog lately, you might want to see how troublesome it is to even read the cryptic letters.

    After all, you do moderate comments. That is a good enough screen don't you think?

    One of my "words" this time was "mervally", and it was a bit hard to decipher
    Thanks!

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    Replies
    1. Hi Smitty,

      Unfortunately, Google controls that and I don't get a say. I sometimes do have the same trouble when I post on other blogs. Usually there is a button that allows you to keep getting new and different combinations of letters until you finally get one you can read.

      Delete