The Conflation of Chronic Sadness With Major Depression

When I bring up with many other professionals the idea that major depression is now over-diagnosed by relabeling what used to be called dysthymia as "mild' major depression, a lot of them seem to disagree. Or they just tune out. “That’s just your opinion,” I might hear. Well, luckily the DSM-V now provides evidence that I am on the right track. In the DSM-V, the term “dysthymia” has been replaced! It is now called Persistent Depressive Disorder. 

As I have discussed in many previous posts, my opinion about major depressive disorder is that it is more of a brain disorder than mere unhappiness. The word depression itself is a symptom, not a disorder. It is in the interest of drug companies to conflate chronic psychological unhappiness with major depression so they can sell more antidepressant drugs to people who will not actually benefit from them.  Now,  it is also possible to have both, which is called double depression.

While many of the criteria are the same for the new diagnosis as the previous criteria for dysthymia, there are subtle differences that obscure the difference between that disorder and major depressive disorder. In a percentage of people with the latter disorder, it may become chronic. This is seen in the new definition of the disorder, which reads “This disorder represents a consolidation of DSM-IV-defined chronic major depressive disorder and dysthymic disorder. These disorders should not be consolidated.

There is one additional change which is telling. The only specific criteria for the disorder that has been changed has gone from “The disturbance is not better accounted for by MDD or MDD in partial remission” to “Criteria for Major Depressive Disorder (MDD) may be continuously present for 2 years, in which case patients should be given comorbid diagnoses of persistent depressive disorder and MDD."  Double depression has nothing to do with the length of the major depressive episode.

Drug companies have enlisted academic psychiatrists to become “key opinion leaders” in order to push this idea, and have even advocated the use self report surveys designed to screen for major depression (therefore having a lot of people test positive who don’t really have the disorder  – false positives) as diagnostic instruments.

This has led to a host of articles in the popular press that seem to indicate that antidepressants are nothing more than placebos. Nothing could be further from the truth, but a lot of psychiatry critics like Robert Whitaker have seized on “research” articles (which do a crappy job of making the correct diagnosis) that seem to show this to be the case.  After all, since most anti-depressants are generic,  it's better for drug companies' bottom line if instead of those drugs, expensive new anti-psychotic drugs can be recommended instead.

The critics also use the fact that we don’t know exactly what causes major depression to dismiss the whole diagnosis. The incorrect hypothesis that the condition is due to a “chemical imbalance,” which is sometimes advanced by clinicians, must mean that it is not a real disease. Dumb. Clinicians have often used this oversimplified idea to convince resistant patients to take the medications. Researchers rarely if ever actually said that a chemical imbalance was the cause of the disorder.

Of course, it’s not always easy for clinicians to tell the difference between dysthymia and major depression in a given patient, but in most cases it’s fairly straightforward.  There is nothing that stops anyone from being chronically unhappy when they are not having an episode(the euthymic state) of major depression. And major depression is episodic with normal-for-them baseline mood periods in between episodes.

A good clinician will define a response to antidepressants as good if the patient returns to their baseline. They don’t have to be in a good mood to have had a good response, but may just need psychotherapy like any other dysthymic patient. Nonetheless, many of these patients who have double depression are mislabeled in the literature as “treatment resistant,” which means that docs are encouraged to add still more drugs to antidepressants to “augment” them. There are of course patients who actually are treatment resistant and need this augmentation, but in my 45 years of practice this was a relatively small contingent.

Briefly and in an oversimplified manner, distinguishing the two disorders has to do with the “three P’s” – persistence, pervasiveness, and pathological. (You can tell if a study employs the correct definitions by seeing how the diagnosis was made with their subjects. The P’s are emphasized in an excellent diagnostic interview called the SCID). Persistent: this is the duration criteria. An episode has to last at least two weeks. Admittedly, the two-week criteria is arbitrary, but is put in so clinicians don’t make the diagnosis after too short a period.  The “everything is bipolar” crowd routinely poo poo's the duration criteria.

Pervasive: the symptoms have to be present nearly all day every day no matter what goes on in a patient’s life. This means that if a patient were to win the lottery, it wouldn’t cheer him up all that much.  Pathological: this means that the ways that the patient reacts to any stress is different from the way they might react if they were not in an episode. See the lottery statement. Also, if a lover were to, say, break their heart, this would not always make a whole lot of difference in how bad they feel.

These issues are not seen with good doctors, who not only know how to take a complete bio-psycho-social history but actually still do them.

Ultra Rapid Cycling Bipolar Disorder

OMG! Watch out for flying pigs!  DUCK!

Pigs in Spaaace

Something I have been harping about for years was finally correctly set straight in - of all places - a throwaway, drug-company supported, pharmaceutical-advertisement infested psychiatry journal - Current Psychiatry. Frozen hell!

In an article by Joseph F. Goldberg M.D., a clinical associate professor of psychiatry at the Mount Sinai School of Medicine in New York, the following summary was highlighted as a "bottom line: "Ultra rapid cycling [bipolar disorder] has not been validated as a distinct clinical entitiy, and frequent mood swings should not be used as a criterion for diagnosing bipolar disorder."

In the diagnostic Bible, the DSM, a rapid cycling bipolar disorder is defined as an individual who has four episodes of depression or mania per year, not per hour.  Yet the "bipolar disorder is everywhere" crowd has insisted for decades that there was such a beast as an "ultra-rapid cycler."  Thus anyone who was moody, had a sudden mood change no matter how brief, or had  the unstable emotions characteristic of individuals with borderline personality disorder, was suddenly "bipolar" and in need of medication for his "bipolar spectrum disorder." 

"Psychotherapy? What's that?" they seem to say.

The supposed existence of rapid cycling was advanced as an argument against using anti-depressant medication in bipolar patients having a depressive episode, because the drugs allegedly induced it.  This argument was even picked up by Robert Whitaker, author of Anatomy of an Epidemic, as a possible reason to be cautious about using antidepressants in general.  An argument based on a phenomenon invented by some psychiatrists that does not even exist!

Funny how after having practiced for 35 years in two states, with a wide variety of clinical populations, and specializing in the treatment of borderline personality disorder, I have never seen rapid cycling, with the possible exception of one case in which sudden episodes of psychosis (not mood changes) would come and go without warning.  Maybe I've just been lucky.  Or rapid cycling could be so rare as to be nearly non-existant.

When I first saw the cover of Current Psychiatry under discussion, I must admit was prepared for the worst.  "Oh no, not again,"  I thought. At least, I figured, I would have more material for a new post with another scathing attack on the whole bipolar spectrum craze.

Then I read the article.  What a pleasant surprise.

Meanwhile, in other myths-about-bipolar-disorder news, a new small study seems to contradict a bit of current conventional wisdom about the disorder: A study published in the January issue of the Journal of Affective Disorders (Baldessarini et. al.,136, 2012 pp. 149–154) reported: "Patients with bipolar I disorder show disease progression that is random or even 'chaotic.'"

After following 128 patients with bipolar I disorder for about six years to assess "inter-episode intervals (cycle length)," researchers found that "most current bipolar I disorder patients are unlikely to show progressive shortening of recurrence cycles."

In the past, the impression that bipolar patients had episodes more frequently as they got older, the authors believed, was a statistical artifact caused by a minority of patients with frequent recurrences!

As most of these subjects were being treated with medications, and were probably going on and off of them every so often as patients are wont to do, this is evidence that the treatments do not make bipolar disorder worse over time.

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.

The Increase in Psychiatric Disability in the USA

As an academic psychiatrist, I supervise residents in an outpatient psychiatric clinic whose patients are predominantly on Medicaid (called Tenncare in Tennessee).  Many of these patients were able to qualify for Tenncare because they are on Social Security disability (SSI), and the majority of these had been placed on disability for psychiatric reasons based on the recommendations of previous psychiatrists.

In this clinic we see patient after patient with obvious personality problems who seems to be able to take care of almost any task that "normal" people can all do except hold a job. They have been labeled by psychiatrists with phony or inappropriate misdiagnoses such as bipolar II, adult ADHD, and even Asperger's syndrome. They had been put on disability with their psychiatrist's blessing.

Their families gladly go along with the psychiatrist's assessment because they do not want to take responsibility for having helped to create the patient's psychological problems in the first place.

My sources tell me that the same thing is happening all over the country.

Patients who really do have bipolar disorder should almost never be on disability anyway because, in the vast majority of cases, it is a highly treatable illness, and people are completely normal if they take their medications, are not in a manic or depressive episode, and do not have any co-occuring psychological issues.

ABC News recently reported that applications for SSI have gone up considerably since the start of the recession.  The obvious implication is that people who are just plain unemployed are attempting to support themselves by claiming to be disabled.

Then there is the outright disability fraud known in some circles as crazy checks, as I described in my post of October 10, 2010, in which parents coach their kids to act out of control for a psychiatric disability evaluation.  As I have said, apparently fooling psychiatrists into making serious diagnoses on kids who are acting out – or just plain acting – is as easy as pie.

The states have gone along with this charade because it transfers a lot of their welfare costs to the Feds. What a difference this is from the 1980's, when the Reagan administration was kicking people off of the disability roles who really were disabled (e.g., patients with chronic schizophrenia). The courts finally had to step in to stop this. I used to do SSI evaluations in California back then and saw this first hand. My evaluations were often completely ignored.

We've gone from one extreme to the other.

I do not bring up this issue merely to infuriate taxpayers.  The whole disability process has another, far more destructive and insidious effect.  It can be extremely damaging to the mental health of the involved individuals.

Consider this: if your entire family, along with professionals who are supposed to be experts, believe that you are impaired, who are you to argue? People in this situation are not only being paid to think of themselves of disabled, but really do start to believe that they are damaged goods. 

Their self-esteem, already in trouble because of their having been scapegoated by their families, goes down the toilet.  They truly and deeply believe that they are both brain damaged and big losers to boot.  They are validated in this belief by the most powerful people in their environment.

Read this description of a patient from a fellow psychiatric blogger (Thought Broadcast): 

"When I first saw her, she appeared overweight but otherwise in no distress.  An interview revealed no obvious thought disorder, no evidence of hallucinations or delusions, nor did she complain of significant mood symptoms.  During the interview, she told me, 'I just got my SSDI so I’m retired now.'  I asked her to elaborate.  'I’m retired now,' she said.  'I get my check every month, I just have to keep seeing a doctor.'

When I asked why she’s on disability, she replied, 'I don’t know, whatever they wrote, bipolar, mood swings, panic attacks, stuff like that.'  She had been off medications for over two months (with no apparent symptoms); she said she really 'didn’t notice' any effect of the drugs, except the Valium 20 mg per day, which 'helped me settle down and relax.'

Keisha is a generally healthy 27 year-old.  She graduated high school (something rare in this community, actually) and took some nursing-assistant classes at a local vocational school.  She dropped out, however, because 'I got stressed out.'” 

Retired? 

Getting someone like this off of disability is nearly impossible. Even if they start to believe in themselves and begin to succeed, they would then lose their Medicaid and would not be able to pay for the treatment that might help them to maintain their employment and make further gains. They are literally trapped by the disability system into feeling themselves to be nothings and nobodies.

And a lot of psychiatrists are doing this to their patients. 

Please keep in mind, however, that there also are a plenty of psychiatrists who are as appalled by this trend as I am.  

R. Scott Benson, M.D., the speaker-elect of the General Assembly of the American Psychiatric Association (APA), confirmed in yet another way this whole picture in a personal communication with me.  He said, “The APA has a Business collaborative. There are articles by HR [Human Resources] managers lamenting the fact that psychiatrists in general do not seem to believe that people should work.

I have been doing reviews for Disability Insurance companies and people with what appear to be mild symptoms are kept off work with no change in their treatment plan. Then they are depressed that they do not have money, lose their house and car, etc. Yes the SSI disability racket is a strange beast. The money never seems to be spent on any kind of treatment."

MentalHealthWorks, an APA publication, actually had to spell out the following recommendations to psychiatrists concerning disability:

Principle #1. Inability to work is a psychiatric crisis.

Principle #2. Return to work is a fundamental goal of treatment.

Principle #3. Occupational disability is a complex biopsychosocial phenomenon. 

Principle #4. Symptoms are not impairments; impairments are not disability. A decline in function is often temporary and does not need to meet the threshold of total incapacity. Disability often includes interpersonal issues at work, physical complaints, other medical conditions, and psychological issues.

Like, Duh! You mean these things are not obvious to someone smart enough to get into and get through medical school? Really?!?

And check out this personal communication from Randy Bock, a family practitioner who specializes in addiction treatment:

“I had a woman today who wants to go on naltrexone [a treatment for opioid addiction]. She had been doing heroin and just finished a detox.

Recently she was at [a halfway house].  They 'made' her apply for Social Security/disability (‘which they do for everyone’); so as to get their own bills paid regularly … including multiple drug tests/week. Additionally once she got her 'disability check' they were taking 'half her income' - some $400…

The halfway house sent her to a psychiatrist who diagnosed her promptly with 'PTSD, bipolar, anxiety, depression,' and gave her a disability finding.

She says they wanted her to ‘leave her past’ (which in this case meant also her job) and ‘only look forward’, and that involved her not working (at all) for the subsequent 14 months in the halfway house.”

Author Robert Whitaker (Anatomy of an Epidemic) has made a lot of noise about the large increase in psychiatric disability recently, but completely misidentifies the cause.  His thesis is that the appropriate use of psychiatric medication has been making people worse, and he seems to think that if a patient gets worse, it must be due to the medications.  This is circular reasoning.

A psychiatrist who does a complete evaluation of ALL possible biological, psychological, and social factors affecting a given patient is in a much better position to make the call as to exactly which factors have led to a patient’s deterioration (and yes, Alto, not infrequently it is from debilitating side effects from medication that are ignored by the doctor).

Then again, as another fellow blogger Moviedoc cracked, that is a moot point because problem psychiatrists are not taking much of a history nowadays anyway.

Practice of Doping up Children to Treat Parental Anxiety Continues to Grow

I have already written several posts about the inappropriate "diagnosing" of bipolar disorder in children and the even more inappropriate use of antipsychotic medications in children.  My main point has been that, rather than having a psychiatric disorder, the vast majority of these children are just acting out.  (For those readers who have difficulty making distinctions - especially those who automatically assume that things that look vaguely alike must be identical - this opinion does NOT apply to those uncommon children who are actually psychotic or to older adolescents who are clearly and obviously manic).



So what proof can I offer?  Well, at the American Psychiatric Association Annual Meeting, John Goethe, MD (director of the Burlingame Center for Psychiatric Research and Education at Hartford Hospital’s Institute of Living), presented the results of a decade-long study of antipsychotic prescribing for children and adolescents in psychiatric hospitals.

The results? Forty-five percent of patients with such behavioral disorders as ADHD or conduct disorder were given antipsychotics and 44% of patients with post-traumatic stress disorder (PTSD) received them. The percentage for other anxiety disorders was 31%!

Forgetting for the moment that an ADHD diagnosis may just be yet another case of acting out, antipsychotic medication is not indicated for ADHD.  In adults, antipsychotic medications are not indicated nor FDA-approved for any anxiety disorder or PTSD.  Not only that, but there is not the slightest evidence from any neurobiological study that the purported mechanism of action of antipsychotic medication has anything to do with anxiety disorders or ADHD. 

And conduct disorder?  This "disorder" was formerly called juvenille delinquincy.  Acting out by any other name. Don't even get me started.

One of the predominant side effects of these medications, is however, sedation.  So one might conclude that the reason the meds seem to both the parents and incompetent doctors to "work" is that the kids quiet down because they are being doped up. (This prescribing practice does not just apply to some psychiatrists but also to many other primary care doctors as well -as to pediatricians, read Claudia Gold's blogpost, Pediatricians Prescribing Psychiatric Medication: A Dose of Reality),

But who's anxiety is really being treated here? 

I submit that it is the anxiety of the parents. Parents who have out-of-control, acting-out children are the real objects of these "treatments."  These parents covertly feel guilty when they are unable to control their children due to inconsistent, neglectful, or abusive parenting practices.  Yet they have great difficulty changing these practices for a variety of reasons - sometimes very understandable reasons.  (One of which is that their doctors make no effort to understand what is really going on in their homes, and take advantage of their insecurities). 

Nonetheless, when the kids are doped up and are therefore less trouble, the parents feel better. And they have the doctors stamp of approval that the problem resides entirely within the child, not with them.

An unsolicited plug


The use of these drugs in kids diagnosed with PTSD is particularly instructive.  Unless you are treating victims of such disasters as the recent outbreak of tornadoes in the South and Midwest, or working with victims of crime like Jaycee Dugard, the most common trauma leading to PTSD in children is child abuse.

Of course, this whole process of sedating acting-out children usually does not end with the first prescription.  For most drugs that have sedation as a side effect, the sedation gradually subsides after  a few weeks on the medication.  Then, of course, the kid starts doing what kids always do - start reverting back to their previous behavior.

The parents then drag him or her back to the incompetent doctor, who starts to take one of the following steps and then another, in no particular order:

1. Increase the dose of the medication.
2. Change to a different medication which also is not indicated for anxiety and conduct disorders.
3. Add a prescription for a second one of those medications, and then perhaps a third or a fourth.
4. Change the diagnosis to something else other than acting out, and begin the whole process all over again.

Since the kid still is not controlled after the sedative side effect subsides, another step the parents can take is to apply for social security disability for the child.  This gives the child the message that the parents think he or she is both sick and incompetent.

Readers of the blog know what I believe happens next.  The child develops a false self that only seems to be sick and incompetent.  Such children hide their abilities as they grow into adults, continue to act in ways that preclude employment, and continue on social security disability. 

When you take the time to actually get to know them, however, it seems that the only thing they can not seem to do that most people can is maintain employment.

And then Robert Whitaker thinks that the medications were the cause of the disability, just like the less-than-thorough doctors thought that the medications caused the initial improvement of the child's "mental illness" when it was just a side effect that temporarily muted acting out behavior. 

It always amazes me how much people who seem to be on opposite sides of a debate think alike.  Basing their conclusions on totally incomplete information seems to be a favorite blind spot of theirs.

SSRI Tales

In 23 years of clinical experience prescribing them since they first made the scene, I have found that the type of antidepressant medications called Selective Serotonin Inhibitors (SSRI’s) are, for the majority of patients (with some important exceptions described in the next paragraph), relatively side effect free. Especially when combined with a long acting benzodiazepine tranquilizer such as Clonazepam, they are also highly effective for many patients who have major depression, panic attacks, obsessive compulsive disorder, PTSD, or the extreme emotional hyper-reactivity characteristic of borderline personality disorder.

Just so I don’t have to keep answering the same question, YES, some people do indeed have nasty side effects from them. YES, the drugs can increase suicidal ideation for some patients under some circumstances. YES, they often wreck havoc on sexual functioning. YES, they can have nasty withdrawal symptoms if stopped cold turkey, especially Paxil. YES, they do not work for everyone. But NO, there is not a shred of clinical or experimental evidence to back up Robert Whitaker’s assertion that patients who get better with the meds in the short run are made worse by them in the long run

In my new book I talk about how first benzodiazepines and now antidepressants are being demonized by the drug companies ever since most of the drugs in each class became available (or were about to) as cheaper generic medications. The only antidepressant that is really different that is not available as a generic is Cymbalta, which is technically not an SSRI. (Lexapro and Prestiq are just old drugs in new packages, as per my blog post of June 14).

Cymbalta has been trying to position itself as the drug best for people with chronic pain – but the old antidepressants like Elavil work just as well for that – and for the wastebasket diagnosis of fibromyalgia. (Another disclaimer: just because fibromyalgia is a made-up disease does NOT mean that “neurogenic” pain is not very very real and significant, so please, no nasty missives on that subject).

Back in January, the headline "Antidepressants May Only Be Effective in Treatment of the Severest Depression" was seen in newspapers around the country and even made the network newscasts. It was based on a meta-analysis, which means that the results of several different individual studies were combined.

The headline was sort of true in some ways but was extremely misleading. It is true that a milder type of depression called dysthymia is less likely to respond to drugs than a more severe variety of depression called major depression. Dysthymia tends to involve the thinking parts of the brain more and is usually more amenable to psychotherapy; major depression tends to involve a more primitive part of the brain called the limbic system more and tends to respond better to drugs. Of course there is considerable overlap between the two syndromes because all parts of the brain are highly interconnected, so diagnosis can at times be an issue.

The news stories did not mention psychotherapy at all and left the vague impression that current drugs should not be used much. Maybe doctors should be adding Abilify, just as the commercials say. NOT!

Only six studies were used in this meta-analysis. All of them did a poor job of distinguishing major depression from dysthymia. All six studies compared anti-depressants to placebo (sugar pill) and only tested one drug. Clinically, that is not the way the drugs are used by psychiatrists. Patients who do not respond to one of the antidepressants often will respond to another. Sometimes we have to try three or four before meeting success. There are diminishing returns with each switch, but the total response rate to antidepressants is the sum of the response rate to drug one plus the response rate to drug two, and so on. The type of study I am criticizing makes the drugs look way less effective than they actually are.

Not only that, but in at least one of the studies, the antidepressant was severely under-dosed! Do you think the authors were trying to make it look bad or something?

In my book, I also tear apart an article in the usually well-respected New England Journal of Medicine that purported to show that antidepressants do not work in depressive episodes seen in bipolar disorder. That paper was dishonest as the day is long.

Now comes a brand new attack on  something called the STAR*D study.  The STAR*D study attempted to study antidepressants in the way that clinicians actually use them, rather than the way they are used in studies. It did indeed show that if one antidepressant does not work after the required amount of time, then another should be tried and so on, and if this is done then the total response rate to antidepressants is actually fairly high in properly diagnosed patients with major depression.

The authors of the attack (Psychother Psychosom. 2010;79:267-279) pointed out that “the effectiveness of antidepressant therapies was probably even lower than the modest one reported…with an apparent progressively increasing dropout rate across each study phase."

“We found that out of the 4041 patients initially started on the SSRI [selective serotonin reuptake inhibitor] citalopram in the STAR*D study, and after 4 trials, only 108 patients had a remission and did not either have a relapse and/or dropped out by the end of 12 months of continuing care,” lead study author Ed Pigott, PhD, a psychologist with NeuroAdvantage LLC in Clarksville, Maryland, told Medscape Medical News.

In truth, if a study has a lot of dropouts, then it can just as easily underestimate as overestimate drug effectiveness. This is especially true for antidepressants because they must be continued for a few months after remission is achieved, and patients will often quit taking them prematurely precisely because they feel better. They then relapse. It is disingenuous to the utmost to count drop outs as non-responders!

I agree that the Star-D study was poorly designed to determine sustained efficacy, because that was not its main purpose. The initial good results on the patients who did not drop out are pretty much identical to what is seen clinically.

It is important to follow depressed patients very closely and have a therapeutic relationship with them to emphasize the need to stay on the medication for a while. Some patients have also significant psychosocial stressors that they do not tell the doctor about either because no one asked, or because of shame. A doctor has no hope of sorting out antidepressant response from other variables - often difficult under the best of circumstances - if he or she does not know about the psychosocial context in which symptoms are seen. The type of relationship in which such information becomes readily available to the doctor just does not happen in studies.

In general, drop outs in almost all studies are not tracked, so we have no way of knowing how many might relapse.

Two of the authors of the attack paper, H. Edmund Pigott, PhD, and Gregory S. Alter, PhD., are founders of NeuroAdvantage, LLC, a for-profit "neurotherapy" company. This is a company that has products that one can reasonably assume are competition for antidepressants. The company “offers a number of light & sound neurotherapy (LSN) programs designed to decrease symptoms of depression and anxiety as part of an overall treatment plan. Numerous clinical researchers have found that LSN is a robust treatment effective in facilitating profound relaxation and meditative states.” (From their website).

The first SSRI that was FDA approved was Prozac. As mentioned earlier, that was 23 years ago in 1987. Paxil, Zoloft, and Luvox followed soon thereafter. Isn’t it amazing, after all that time, that a whole bunch negative “new “information about SSRI’s is coming out just as they are all going generic?

Of course, I cannot prove that Big Pharma or alternative medicine is behind this.

Certainly, Big Pharma does want as many depressed patients as possible to be put atypical antipsychotics like Abilify while they still have the patents. More frightening potential evidence is that the drug company giant GlaxoSmithKline sat on data that showed that Paxil caused a huge number of birth defects in pregnant rats (teratogenesis) that they had known about since the drug first came out. Now, after twenty years and like magic, this data suddenly has seen the light of day!

Coincidence? You be the judge.

Psychiatric Drugs

Some people who read my blog may get the wrong idea about where I stand on the issue of the use of psychiatric medications, so I want to make something perfectly clear: I am an advocate of the proper use of psychiatric medications, and I think that when used correctly, they are highly effective. I prescribe them to almost all of the patients I treat, including my psychotherapy patients. If fact, my patients who exhibit signs and symptoms of borderline personality disorder would not be able to engage in the type of therapy I do if their high emotional reactivity were not partially controlled on meds.

I even prescribe atypical antipsychotics, even though they can have toxic side effects. I monitor my psychotic patients' for the emergence of metabolic syndrome by checking their blood sugar, cholesterol, and triglycerides (fat). I watch them closely for the emergence of tardive dyskinesia, a neurological side effect that may emerge after long-term treatment with antipsychotic medications. (If you saw the movie "The Dark Knight," Heath Ledger's Joker character's mouth movements look a lot like this syndrome).

Without antipsychotics, many more patients would be living out on the street in cardboard boxes. Additionally, sometimes the atypicals are the only medications that stop certain patients with borderline personality disorder from severely mutilating themselves. They are not my first choice for that, but they are sometimes necessary.

On the basis of my obvious disgust with pharmaceutical companies' disease mongering and the sloppy use of diagnostic terms by many psychiatrists, I hope no one lumps me together in the same camp as Peter Breggin or Robert Whitaker, who grossly exaggerate the dangers of psychiatric medication and distort the studies in a fashion precisely opposite to the way the drug companies do. Nor I am a fan of Tom Ssazz or R.D. Liang, who think that there is no such thing as a psychiatric disease.

BTW, Dan Carlat posted on his blog an excellent description of PhARMA disease mongering by Adriane Fugh-Berman, available at http://bostonreview.net/BR35.3/fugh-berman.php.

One of the drug company strategies that is not described in this article is to label their critics as members of Scientology. Just so you know for certain, I think the idea that mental illness is caused by a volcano god (Xenu) and space aliens (body thetans) is just a wee bit ludicrous, and that Scientology is a dangerous cult. I remember when I was a resident receiving a mailing from them asking me to come and confess my sins. Clever.

I find that doctors who buy into disease mongering are usually well-meaning but incompetent. Some, however, are predators. On an earlier post, I mentioned something called sensory integration dysfunction. I said it was a "mysterious illness" which might have caused confusion to some readers. This "dysfunction" is not recognized as a disorder by the DSM or the International Classification of Diseases, and its descriptions in the literature are highly dubious. There are no adults who are diagnosed with it. Even if it does exist as a syndrome, it is could easily be something that is due to other factors like anxiety. Yet there are doctors who prescribe expensive "treatments" for it to the children of unsuspecting and naive parents. This is shameful.