Tuesday, June 26, 2012

Peter Breggin Goes Off the Deep End

Peter Breggin

Peter Breggan is a psychiatrist who is often highly critical of the use of any and all psychiatric medication, which makes him the favorite psychiatrist of the rabid anti-psychiatry movement along with Tom Ssazz. 

For some of these zealots, it is very understandable why they hate psychiatrists so much.  As anyone who reads my blog knows, incompetent psychiatrists or those docs who have been brainwashed by big Pharma often do a lot of damage to patients through misdiagnosing them, using inappropriate medications, and/or not monitoring their patients for side effects.

I cannot blame such victims for having a highly emotionally charged negative attitude towards my entire profession. 

Still, that does not make everything they think correct.  In fact, it often kind of impairs their ability to be objective about psychoactive substances.

Personally, I always felt that Breggin has used half truths to justify some of his opinions.  But now I think he has gone completely off the deep end. 

After reading what follows, I have this to say to anyone who still thinks he has a shred of credibility: You should look into joining the Flat Earth Society. You’d fit right in.

A news article by Phil Willon of the Los Angeles Times appeared on June 12, 2012, with a follow up story the very next day and again on June 21.  I quote parts of the three stories:

“A San Bernardino County prosecutor Tuesday urged a jury not to be swayed by testimony that the antidepressant Zoloft put a former Westminster police detective in a fog that made him not responsible for kidnapping and raping a waitress in 2010. Deputy Dist. Atty. Debbie Ploghaus called the so-called Zoloft defense, backed by a psychiatrist's testimony, "a bunch of baloney" and a desperate attempt by Anthony Nicholas Orban to sidestep overwhelming evidence against him.

Orban was identified by the victim, was implicated by his best friend, was captured on security video footage at the scene of the attack and left his police service weapon, with his name on it, in the victim's car. Ploghaus told the jury that while bar-hopping in Ontario before the kidnapping, Orban groped a woman's chest, grabbed a man's crotch and repeatedly texted a former girlfriend hoping for an afternoon tryst. "He was a highly trained officer who wanted to have sex. He had sex on the mind. Don't forget that," Ploghaus told jurors in her closing argument.

The Westminster detective is accused of abducting the waitress, then 25, as she walked to her car after a Saturday shift at the Ontario Mills mall. His police service weapon drawn, Orban forced the victim to drive to a self-storage lot in Fontana, according to authorities. The victim told the jury that Orban sexually brutalized her in the parked car, hidden behind tinted windows, as people walked a few feet away.

At one point, Orban snapped pictures with his cellphone, telling her to "smile for the camera." He chambered a round in his semiautomatic pistol, shoving the barrel deep into her mouth as tears rolled down her cheeks, she said. "He said if I cried, he would kill me," the victim told jurors. "Then he pulled the gun out and said, 'I think we'll continue this in the desert.'"

Orban had shared eight margaritas and two pitchers of beer with a friend, and was seeking sexual encounters before he kidnapped the victim at gunpoint and made her drive to a Fontana storage facility, where he raped her, Ploghaus told jurors.

Orban's attorney, James Blatt of Los Angeles, said the assault ran counter to a life spent protecting community and country as a police detective and a Marine veteran of the Iraq war. The only plausible explanation for the defendant's behavior, Blatt argued, was the potent effects of Zoloft, which sent Orban spiraling into an "unconscious" delirium.

"At the time he was not aware, not aware of the torturous things he had done,'' Blatt told the jury…The victim sat in the front row of the Rancho Cucamonga courtroom, clutching a friend's hand, as the prosecutor recounted her testimony that Orban rubbed his weapon against her face during the attack.

Now here’s the relevant part:

The defense relied on Dr. Peter Breggin, a New York psychiatrist and critic of psychotropic drugs who has testified in other cases across North America. Breggin said he believed Orban suffered a psychotic break from reality shortly before the kidnapping and was in an unconscious state of delirium, void of control or memory, during the attack. "I don't even think he knows he's tormenting her," Breggin testified. "He would not under any circumstances behave like this if he was not driven over the edge by the drugs." Orban had temporarily quit taking Zoloft, prescribed by his psychiatrist, then resumed it at full dosage five days before the attack, which Breggin said sent him into a state of manic psychosis.

Breggin testified that Orban had stopped taking the prescribed antidepressant, then resumed it at full dose, provoking a psychotic break during which he was "delirious" and not fully aware of his actions.

The prosecutor criticized Breggin as "intentionally misleading" and told jurors that the scientific community rejects his medical theories. Ploghaus' medical expert, Dr. Douglas Jacobs, an associate clinical professor at Harvard, testified that Zoloft has been prescribed to millions of people and proved to be safe. There has been no evidence that Zoloft causes delirium or unconsciousness, he said.

While antidepressants can definitely cause someone who actually has bipolar disorder to become manic (more on that near the end of the post), and even though Breggin used the word "manic" in his testimony, symptoms of mania were not what Breggin and the defendant testified to.  

They said he was in an unconscious state of delirium.  That is not and has never been alleged to be a symptom of mania at all.  And the degree of the planning and execution of the series of events involved in the rapes is entirely inconsistent with delirium, which is defined as a disturbance of consciousness - reduced clarity of awareness of the environment with reduced ability to focus, sustain or shift attention - and is usually caused by metabolic abnormalities due to a medical condition or to an overdose of certain drugs, Zoloft not being one of those drugs.  

The actions of the defendant seemed  pretty focused to me! In fact, it sounded as if he were mentally quite sharp even though he had mixed the Zoloft with a lot of alcohol. (Being drunk is not at all the same as being delirious).

And then there was this from the defendant:

Within days, he said, he was overwhelmed, hearing voices at night, contemplating suicide and fantasizing about killing his wife and dog.

Sounds more like depression to me, not mania.  Perhaps a “mixed state,” but those are fairly rare.

And the kicker: the prosecutor questioned the defendant about parallels between his testimony and similar accounts in a magazine and book by a well-known critic of psychotropic drugs.  Orban acknowledged reading both works, but denied they had influenced his testimony.  Oh, and the critic who authored the book?  Breggin!

And now to the issue of antidepressant-induced mania. Apparently no one else testified that the detective had any history of having the disorder.  If he were bipolar and Zoloft was going to make him switch into mania, it would have most likely already happened when he was first taking the drug – not when he resumed it after a short break.  Resuming a “full dose” may lead to other side effects, but not that one.  As far as I know, the ability of antidepressants to kick someone into a manic state is not dose-related.

Besides, very few patients in a manic state become violent rapists. 

And patients in a manic state still can still tell right from wrong unless they are out-of-their-mind psychotic.  There was apparently no evidence he was delusional.  (If there is, then I might have to take back some of what I am saying about this case, and, if it turns out that the detective had a grandiose delusion that raping the woman would somehow save the world from an alien invasion, owe Dr. Breggin an apology).

As to the rape being "counter to a life spent protecting community and country?"  As we all know, soldiers in Iraq and police are never guilty of violent behavior.  Before he died, you could have asked Rodney King.  And I suppose we know for a fact that this was not just the first time he got caught.

What this is, barring further revelations about the defendant’s history of mental illness, is a variation of “The devil made me do it.”  Or perhaps a version of assassin Dan White’s defense in the case of his murder of two San Francisco politicians, “He did it because he was depressed, as evidenced by the fact that he was pigging out on a lot of Twinkies.”

Dan White assassinated  San Francisco Mayor George Moscone and  Supervisor (and gay hero) Harvey Milk on November 27, 1978, and was sentenced to only seven years
Apparently, the jurors also thought it was a stupid defense:

A jury of eight women and four men deliberated less than a day before dismissing that defense and finding Orban guilty of kidnapping, two counts of rape, two counts of forced oral copulation, two counts of sexual penetration with a foreign object and one count of making a criminal threat.

Orban is now facing a sanity hearing to determine whether he knew the difference between right and wrong at the time of the attack. He almost certainly faces a life prison sentence if the jury determines he was sane. If declared insane, he would be sent to a state mental institution for treatment, and later could be released. The same jurors have been impaneled for the sanity proceeding.

"What it comes down to is whether, at the time of this incident, he understood the difference between right and wrong," Orban's attorney, James Blatt of Los Angeles, said outside the courtroom. "I believe [the jury] will keep an open mind in reference to the sanity phase."

Addendum (6/27/12): The jury rejected the insanity defense, although some prosecutors apparently did blame the alcohol (rather than the Zolfot) for his "mental fog."  That's nonsense, too, considering the intricacies of his actions during the attack.  Looks like he had a lot of tolerance to the booze.

Tuesday, June 19, 2012

Disease Mongering in a Respected Journal and Plausible Deniability

In my post of August 31, 2011, Plausible Deniability, I illustrated how doctors under the sway of pharmaceutical companies widely distribute a completely invalid “take home message” to readers of journal articles and those who listen to academic-sounding presentations, while simultaneously providing themselves with an “out” so that they can deny doing just that.  Some of these strategies have been created from information gathered from the drug company marketing departments' intensive research into physicians and the way they think (see post: Physicians As Unwitting Research Subjects, 1/3/12). 

Apparently, these strategies are widely disseminated to physicians and researchers working with Pharma.  They are just too common.  A great example occurred in a rebuttal to a letter to the editor that I and several of my partners in crime (Peter I. Parry, Robert Purssey, Glen I. Spielmans, Jon Jureidini, Nicholas Z. Rosenlicht, David Healy, and Irwin Feinberg) managed to get published in the June 2012 issue of the Archives of General Psychiatry.  The Archives is considered one of the two top journals in psychiatry.

The letter was highly critical of a study that was published in a previous issue.  The article was one I blogged about in a previous post (More Disease Mongering in a Respected Journal, 8/13/11).  The gist of our published letter was described in that post, and I will not repeat it here.

However, let me use the rebuttal to our letter, printed in the same issue of the Archives, to illustrate how the authors avoid actually addressing the criticisms in the letter and deny that they meant to conclude from their "study" that which was highly implied by their journal article.  The latter issue is what I previously referred to as plausible deniability

Please keep in mind that when journals publish letters to the editor that are critical of one of their published studies, they allow the authors of the original study to respond to the criticisms, but that is where it ends.  They do not give letter writers the chance to respond in the journal to the rebuttal.  (It is a situation similar to that of reporters at a presidential press conference who are not allowed to ask follow-up questions).  So I’m doing it here.  Next to what they wrote in said rebuttal, I will provide my own commentary.

We are pleased to respond to the points raised by Allen et al, some of which take material out of context and quote news media articles beyond our control. For example, the letter states that “The message is that almost half the patients with a major depressive episode have undiagnosed bipolar disorder and are ‘not receiving necessary mood stabilizer treatment.’” The authors are well aware of exactly how the news media were going to interpret their study.  Ditto doctors who read the article.  The drug companies have apparently taught these authors that readers will routinely ignore the disclaimers that they list next in their rebuttal – a case of plausible deniability.  The article is designed to give a very specific “take home message.”  The success of this strategy is illustrated by those very news stories over which they are now saying they have no control.  Of course they don’t need to have direct control to achieve this goal.

Our actual statements are: "Based on these studies and the major differences in treatment guidelines for MDD [major depressive disorder] and bipolar disorder, we recommend that, among patients with MDEs [major depressive episodes], the presence of bipolar features, including all those with significant predictive value reported in this study, should be investigated carefully before a decision is made to prescribe antidepressants. If patients exhibit bipolar symptoms that impair everyday functioning, treatment with a mood stabilizer or an atypical antipsychotic may be useful." The take home message from what they “actually said:” exactly what we said it was.  This paragraph subtly equates "bipolar features" with agitation seen in major depressive disorder - a fact nowhere in evidence.  

This conflation is even more pronounced in the abstract of the article (the short summary at the beginning of the article which is usually the only thing that most busy physicians actually read). The introduction states "Many patients with major depressive episodes who have an underlying but unrecognized bipolar disorder receive pharmacologic treatment with ineffective regimens that do not include mood stabilizers."  This sounds like the article is going to demonstrate unrecognized signs of bipolar disorder and will "orient" anyone who reads the whole thing to think along those lines.

They assert that “The study’s findings are based on a ‘bipolar specifier’ requiring ‘no minimum duration of symptoms’ and ‘no exclusion criteria,’ ” and that “Any subject who came to psychiatric attention with an angry, agitated, or elated response to environmental triggers or psychoactive substances might have met criteria for ‘bipolarity.’ ”  

The criteria, stated in the “Methods” section of our article,1(p793) were (1) an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with (2) at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR …The minimum duration of symptoms required for a hypomanic episode was 1 day. Here the authors are flat out contradicting themselves! I quote from the original article itself: “No minimum duration of symptoms was required and no exclusion criteria were applied.” (page 793).  And exclusion criteria in the article do not exclude active drug abusers, which we brought up and the authors just ignore in their rebuttal.

 We assessed the duration reported for hypomanic episodes in 5 groups. Among subjects with major depressive episode with hypomanic episodes, 7.8% reported episodes of 1 day’s duration; 2 to 3 days’ duration was more frequent than 4 to 6 days.  Even if they did have a minimum duration criteria, the DSM criteria for even a hypomanic episode is four days.  Really, one day? In patients who met criteria for major depressive disorder?  Riiiight.

…associated with (3) at least 1 of the 3 following consequences: unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, marked impairment in social or occupational functioning observable by others, or requiring hospitalization or outpatient treatment.  Neither the article nor the rebuttal tells us how the study doctors made the determination that there was an unequivocal  “change in functioning uncharacteristic of the person’s usual behavior. “  Especially since under their rules you only have to agitated for a day, and if you took cocaine or had a big fight with your mother, you might have an unequivocal change in your “usual” functioning. What the phrase is supposed to mean is that the patient’s functioning has unequivocally changed under any and all environmental contingencies.  They would have to be more reactive than they usually are to all unpleasant situations to a similar degree. 

So how do would the study doctors know this?  Did they take the patient’s or a family member’s word for it?  I can tell you beyond a shadow of a doubt that patients rarely really understand what psychiatrists mean by this phrase.  The only way a doctor can know this is the case is to observe the patients several times over several weeks, both during and outside of the specified time period.  

Even a close approximation would require taking an extensive psychosocial history including evaluating current environmental stresses as well as an exploration of the nature, past history of, and current status of the subjects relationships with spouses, lovers, parents, and children.  Maybe they did that, but I doubt it, because doctors like these tend to denigrate the importance of such factors in favor of “disease” explanations.  And it would take a LOT of time.

No exclusion criteria for manic/hypomanic episodes associated with antidepressant or other drug use were applied. So people who got agitated from a side effect of an antidepressants were not excluded by their own admission.  Someone gets a side effect from a drug, and that proves they are manic? 

Importantly, the initial eligibility criterion was that patients have presented to clinical settings for evaluation and treatment of a major depressive episode per DSM-IV-TR criteria. These sequential criteria, applied by senior psychiatrists in each country, are entirely inconsistent with the assertion that the psychiatrists conducting the assessments enrolled “any subject who came to psychiatric attention with an angry, agitated, or elated response to environmental triggers.” 

The statement that 23.2% of subjects experienced elevated or irritable mood triggered by antidepressants did not “define the subjects as having ‘bipolar disorder.’” Rather,it addresses the DSM A criteria, which are essential, but not sufficient, for diagnosis of bipolar disorder. As Figure 1 in our article shows, mood lability while taking antidepressants occurred in 55.8% of bipolar specifier–positive vs 23.0% of bipolar specifier–negative subjects (odds ratio, 1.7;95% CI, 1.4-2.0) and mania/hypomania while taking antidepressants occurred in 37.2% of bipolar specifier–positive vs 3.4% of bipolar specifier–negative subjects (odds ratio, 5.7; 95% CI, 4.4-7.5).  Sorry, but with this paragraph the authors are still implying that their subjects MAY be bipolar, and assumes precisely what the article is supposed to show – that a patient who is agitated when depressed could have a manic symptom.  So if patients with an agitated depression are more likely to become more agitated on an antidepressant than depressed patients without agitation, that is supposed to show that they might be bipolar?  Only by circular reasoning.

Allen et al view their position as part of a “debate” about the “ever-widening bipolar spectrum.” We consider data, not debates, as central to the progress in the scientific understanding of mood disorders.  Ha!  This is a brazenly outrageous statement. The “debate” is specifically ABOUT "data" like theirs – both its validity and what it means.

They make several references to borderline personality disorder. The BRIDGE study assessed for comorbid diagnoses in all subjects. Five hundred thirty-two patients (9.3%)met DSM-IV-TR criteria for borderline personality disorder. This large sample provides an opportunity to analyze patients who met borderline criteria vs those who did not. We are completing a manuscript that will provide useful evidence on this subject. Maybe they should have said this in the original article.  But we know from the work of Zimmerman and others (My Psychology Today blogpost 12/11/11) that many patients who have borderline personality disorder are misdiagnosed.

Allen et al cast unseemly aspersions that the BRIDGE study was a vehicle to promote sales of an antipsychotic drug sold by sanofi-aventis. sanofi-aventis has no antipsychotic with an indication for bipolar disorder.  Here the study authors are being complete weasels.  The misleading point is contained in the phrase “with an indication for bipolar disorder.”  What they say is literally true - in the United States. Unfortunately, Sanofi does have an antipsychotic drug called amisulpiride (brand name, Solian). In fact, in the United States, it is not FDA-approved for any indication, let alone for bipolar disorder.   

However, Solian is approved and widely marketed in Europe and Australia, and at least according to Wikipedia, used for bipolar disorder.  (This may be why the study was conducted overseas). In addition, Sanofi also sells a preparation of depakote, which while an anticonvulsant and not an antipsychotic, is widely used in both actual and misdiagnosed bipolar disorder. 

Besides, as I described in my post of 6/12/12, marketing for off-label uses of drugs for bipolar disorder is unequivocally rampant.  Maybe the authors didn’t know this?  NOT.

We know of no evidence that this was the case at any stage of development and execution of the BRIDGE study. Sanofiaventis ceased financial support for analyses of the study in 2010. All work subsequently conducted has been achieved by our local funds. The drug company got out of the game just in time for the authors to claim they were not biased due to the funding source. Actually, the original article says “The sponsor of this study (sanofi aventis) was involved in the study design, conduct, monitoring, data analysis, and preparation of the report.” 

In addition, all of the clinicians recruited for the study received fees, on a per patient basis, from Sanofi-Aventis in recognition of their participation in the study. The key lead authors, all with significant Pharma connections, did not disclose their other pharmaceutical company ties.  These authors: Allan H. Young, MD, Jules Angst, MD, Jean-Michel Azorin, MD, Eduard Vieta, MD, Guilio Perugi, MD, Alex Gamma, PhD, Charles L. Bowden, MD.  

They should be ashamed of themselves.

Tuesday, June 12, 2012

Epidemic of Mania, Pharmaceutical Company Type Claims Yet Another Victim

It seems like just when I get finish with a post about yet another drug company getting in trouble for off-labeling marketing of a drug that is used in bipolar disorder, another company adds itself to the list.  This time, it is Abbott Laboratories, maker of the second-line drug for mania prophylaxis, Depakote.  Depakote is effective for mania prophylaxis, although probably not as effective as lithium.  Still, drug companies just refuse to satisfy themselves with honest marketing of an effective drug.

ABC World News (5/7) reported, "Tonight one of the largest drug companies, Abbott Laboratories has agreed to a staggering settlement" with the US Justice Department. "Today $1.6 billion in criminal and civil fines for improperly marketing the anti-seizure drug Depakote in nursing homes. The company convinced the nursing homes to use the drug to treat aggression in dementia patients, despite the lack of credible evidence that the drug was effective for that use." 

This fine included $700 million in criminal penalties.   

The AP (5/8) reported, "At a news conference at the Justice Department, US Attorney Timothy Heaphy said that the top levels of Abbott carried out a strategy of systematically marketing the drug for purposes other than what federal regulators had allowed. The illegal conduct was not the product of 'some rogue sales representatives,' said Heaphy, the US attorney for the western district of Virginia. He said the company engaged in the strategy from 1998 to at least 2006." 

Other off label (non FDA-approved) indications for which the drug was marketed included schizophrenia and autism.  

For a while, it seemed to me that every time I saw a hospital report about a patient diagnosed with schizophrenia, they had been treated with Depakote along with the usual anti-psychotic medication.  As far as I could tell, it added nothing to the treatment of delusions and hallucinations other than some extra sedation.  I never understood the rationale for this practice. Now it's clear.

Abbott's off-label marketing efforts were directed at nursing-home directors, geriatric doctors, and other long-term care providers in addition to psychiatrists.  The company also gave doctors illegal kickbacks to talk up off-label uses so that sales of depakote would increase.

Tuesday, June 5, 2012

GUEST POST: When Conflict Brings You Together… And Then Drives You Apart

You initially bonded over a drink as you both shared similar tales about upbringings that could have mirrored one another’s. The abusive relationship with alcohol and drugs, the physical bruises that left far deeper emotional ones, the lack of communication within the family… these were things you both experienced and they bonded you together. You became inseparable because no one else could possibly understand what you had gone through. Until one day it all fell apart. The very glue that held you two together in the first place became a repellant, something you want nothing more than to leave behind forever, but their presence is a constant reminder…

This situation happens more often than you probably realize. Two people with common conflicts in their backgrounds meet and fall madly in love with one another, bonded by their mutual past troubles. This was true for one of my acquaintance and his wife. They both shared rough upbringings and came from broken families, and this shared past made them inseparable… for a while. 

This scenario is all too common for people coming from broken pasts. The troubles they face bind them in a way that true love, shared passions, and positive upbringings binds others, until one day the past troubles become a rock in your shoe. It’s annoying, but not entirely detrimental.

However that rock slowly morphs into a wedge that creates more conflict, and before you know it a full-blown wall between you and your professed lover. Such was true for my acquaintance. He and his wife followed a tumultuous course; one that almost exceeded his own troubled past, until they finally couldn’t stand to be around each other anymore. But why does this happen? How does something so binding become something so revolting?

One reason is that the constant reminder becomes unbearable. While you were initially able to share and empathize with one another over similar circumstances, when that becomes the defining point in your relationship the reminder of your past can become the only thing you’re able to see when you look at your partner. And that constant reminder can become unbearable to the point that it ruins the relationship. For my acquaintance, this meant turning to alcohol and drugs in an effort to blur reality and forget. It meant turning into himself and all the dark demons that had been following him.

Then there’s the point of needing to actually deal with the source of the problems. Being able to talk about something and share experiences with one another is not synonymous with actually confronting demons in your past and dealing with them. Sure you can talk through some of the basics of problems that are rooted in your past with someone who has been through a similar upbringing; however the basics are just that – they’re a superficial way of “dealing” with all of the negative emotions. 

What you really need is to talk to someone who is trained in helping individuals move past life events that have had a negative impact. At that point one or both of you should consider seeking professional help.

When you’re commiserating with someone over conflicted experiences you likely are only able to add your own two cents about a similar event. This rallying of negative emotions only adds fuel to the fire, and instead of diminishing the negativity it helps it flourish. For my acquaintance this meant that they went through harsh benders on drugs and alcohol together, pooling their shared miseries and fighting as they regained soberness. It was a never-ending cycle of bad happening upon worse, until they finally came up for air and found the strength to separate from one another. 

Neither is perfect now, but both are at least pursuing a future that doesn’t include rebounding negativity off of one another.

Dating someone who has a similar conflicted upbringing as you can be a breath of fresh air at first. However if left untreated, it can become stale, or worse, drive the two of you farther into a pit of despair, leaving your relationship stagnant instead of thriving.

Elizabeth’s Bio:
Liz just a simple lady tries to convey some of what it is like to date online through dating websites. For any further information on online dating you can email her at: liznelson17 “@ “