Tuesday, October 30, 2012

New and Better Ways to Falsely Expand the Definition of Bipolar Disorder

Angst redefines angst!

Blowing Hot Air

The Journal of Affective Disorders, which really should be called the Disordered Journal of Bipolar My A--, is helmed by one Hagop Akiskal, about whom I have previously blogged (A Stupid Study and an Even Stupider Headline, 2/1/2011). On its website, the journal describes itself thus: “The Journal of Affective Disorders publishes papers concerned with affective disorders in the widest sense.” I think they must mean the wildest sense.

In several previous posts, I have described how the authors who regularly contribute to this journal are constantly on the lookout for new and improved ways to re-label patients with depression, anxiety, chronic ongoing interpersonal strife, and, in particular, borderline personality disorder (BPD) as really suffering from some form of mania.  Any form of mania.  Their creativity in spreading this outrageous nonsense is truly impressive.

In a journal article described by my post of 3/6/12, Relabeling Depressive Symptoms as Manic Symptoms, authors suggested that the presence of something that they label as subsyndromal manic symptoms (that is, symptoms that they believe are the same as those that are usually seen in mania episodes, but which are “below the threshold for mania" - whatever that means) are seen in the major depressive episodes (MDE’s) that are also characteristic of bipolar disorder.  

As I stated in that post:

“They discuss how some other authors reported that “the most common manic symptom during bipolar MDEs was irritability (present in 73.1% of the sample), followed by distractibility (37.2%), psychomotor agitation (31.2%), flight of ideas or racing thoughts, (20.6%), and increased speech (11.0%). 

“Now, of course, they do not mention that these very same symptoms are also seen in the major depressive episodes of people who never have had or will have a manic episode. And who respond to antidepressant medication and have no response at all to lithium (which is highly effective in bipolar disorder). Back in ancient history (the 70’s and 80’s) we labeled depressed patients who show such symptoms as having an agitated depression.

In another article described in my blog post of 8/13/2011, More Bipolar Disease Mongering in a Respected Journal, the authors found another way to create the fiction known as “subthreshold” mania – this time in another, major psychiatry journal, the Archives of General Psychiatry.

In this article, they introduced the term bipolarity specifier as if this were an established and valid measure.

As I described in the previous post, here's the definition:

“This bipolarity specifier attributes a diagnosis of bipolar disorder in patients who experienced an episode of elevated mood, an episode of irritable mood, or an episode of increased activity with at least 3 of the symptoms listed under Criterion B of the DSM-IV-TR, associated with at least 1 of the 3 following consequences: (1) unequivocal and observable change in functioning uncharacteristic of the person’s usual behavior, (2) marked impairment in social or occupational functioning observable by others, or (3) requiring hospitalization or outpatient treatment. No minimum duration of symptoms was required and no exclusion criteria were applied.”

That last one, No minimum duration of symptoms was required and no exclusion criteria, is key. It means that any person who has a suddenly angry, agitated, or elated response to an environmental trigger (like a big fight with a family member or winning the lottery) could be labeled bipolar. This would also mean that if they had an episode of emotional dysregulation for the same reason, the reaction would be labeled a bipolar episode. This also makes almost anyone who has borderline personality disorder suddenly bipolar. The “research team” also included in their subthreshold category those patients who had experienced episodes of elevated or irritable mood triggered by antidepressants. Irritibility is a common side effect of drugs like prozac and may have absolutely nothing to do with bipolar disorder.

Some of my colleagues and I tore this study apart in a letter published in the Archives, and were answered with purposely misleading, phony “arguments,” as I described in my post of 6/19/2012,  Disease Mongering in a Respected Journal and Plausible Deniability.

Now comes another doosie of nonsensical research study, recently published online in the Journal of Affective Disorders, called Subthreshold bipolar disorder in a U.S. national representative sample: Prevalence, correlates, and perspectives for Psychiatric nosography by Hoertel, Le Strat, Angst, and Dubertret.  Jules Angst was also one of the authors of the Archives article as well.  I guess one could say that Angst is trying to redefine angst.

Jules Angst, M.D.

In this article they employ yet another brand new way to define “subthreshold” mania.  The criteria they used, in addition to the presence in a patient of an episode of major depression but who have not met the full criteria for an episode of mania or hypomania, is to include for purposes of the study anyone who answers in the affirmative to any one of three screening questions for bipolar disorder.

As I have mentioned many times in this blog, screening questions and questionnaires are purposely designed to cast a wide net, so that a lot of people who do not have the disorder are questioned further to make certain one way or  the other (false positives).  Their purpose is so researchers do not waste a lot of time questioning potential subjects who clearly do not have the disorder (false negatives). In other word, using screening questions to define a clinical entity is completely bogus by definition!

The reader can easily see why this is so by looking at the screening questions used in the paper:  1. In your entire life, have you ever had a time lasting at least one week when you felt so extremely excited, elated or hyper that other people thought you weren't your normal self? or (ii), In your entire life, have you ever had a time lasting at least one week when you felt so extremely excited, elated or hyper that other people were concerned about you? or (iii), In your entire life, have you ever had a time lasting at least one week when you were so irritable or easily annoyed that you would shout at people, throw or break things, or start fights or arguments?

Almost every patient with borderline personality disorder would answer at least one of these three questions in the affirmative.  Especially that third one.

The results of the study showed that people who met this screen for “subthreshold” hypomania (and who therefore had a "disorder" that had been merely defined into existence) were found, compared to depressed patients who did not, to be more likely to have been American born, and never to have been married. They were also less likely to earn more than $70,000 year.  They were more likely to have additional (comorbid) psychiatric disorders, especially personality disorders (other than borderline, interestingly, for which they mention later in the article they did not even bother to assess the subjects!) These included anxiety disorders, substance use disorders and dysthymia.

All of these findings are also true of patients with borderline personality disorder, which may have been what a significant percentage of these “subthreshold” manic patients had all along.

“But this sample of patients all were found to have had episodes of major depressive disorder (MDD),” you might protest. “So are you saying there is a sizable contingent of patients with borderline personality disorder who have co-morbid major depressive disorder?” Well, yes, that is true. But it is even more complicated than that.

The episodes of major depressive disorder seen in patients with borderline personality disorder are often qualitatively different from those in depressed patients who do not have this disorder.  These differences were described beautifully by my friend and colleague Kenneth Silk of the University of Michigan medical school in an article called, The quality of depression in borderline personality disorder and the diagnostic process, in the February 10th 2010 issue of the Journal of Personality Disorders (24:1, pp. 25-37).

Ken Silk, M.D

He describes how MDD in BPD is less likely to be characterized by a full contingent of physical or vegetative symptoms (poor appetite, energy, slowing of thought and behavior, and so on), and less likely to respond to the earliest antidepressant medications (tricyclics).  Their depression was far more likely to be characterized by emptiness, loneliness, and desperation over their interpersonal relationships. Their depressive symptoms tend to be far more changeable (labile) and liable to come on suddenly in response to environmental events than patients with MDD without BPD. 

Patients with BPD are also most likely to be dysthymic, or chronically depressed, when they do not seem to be in the midst of a major depressive episode. In other words, as Dr. Silk says, “…these patients may suffer from chronic dysphoric mood that is being misinterpreted [by psychiatrists] as a [medication] non-responsive major depressive episode.”

The depression of patients with BPD is also much more likely to be characterized by high levels of anxiety. In fact, again according to Dr. Silk, their depression may stem from their exhaustion and demoralization from their unsuccessful battles with their overwhelming anxiety. Patients with an anxious depression are the very ones that will be labeled with subthreshold manic symptoms in articles such as the one under discussion.

By the way, these qualitative differences in the experience of certain patients with depression are not sorted out by the research diagnostic interviews and symptom checklists frequently used in psychiatric studies.  Imagine that.

Tuesday, October 23, 2012

The 12 Steps of Alcoholics Anonymous - a Translation

Getting all of the blame, but none of the credit

One of the central ideas I use in trying to understand the relationships between various theories and treatment models within psychotherapy is that, within all groups of human beings, there is a constant battle (called a dialectic) going on between what Murray Bowen’s protégé Michael Kerr called the "forces of individuality" versus the "forces of togetherness" (collectivism, in politics speak). The dialectic between individual desires and group norms can be seen dramatically within the twelve steps of Alcoholic Anonymous (AA). 

Caveat: while this post may seem critical of some aspects of 12 Step Programs, I want to emphasize that these groups do help a certain percentage of addicts. Being addicted to substances is usually far worse that endorsing any of the problematic aspects of the AA ideology. Until something much better comes along, AA represents the only hope for some individuals. 

The strategy that AA uses to help alcoholics and other addicts is based on techniques used by Protestant religious denominations to convert non-believers. Those, in turn, are based on the techniques that such groups use to enforce group behavioral norms while still allowing a certain degree of individuality, as described by Erich Fromm in his classic book, Escape From Freedom. 

While giving some praise to the individual in a series of clever paradoxes and ambiguities, certain aspects of individuality are ritually denounced - most usually, the "dangers" of unrestricted willfulness. Willfulness, or the desire to follow our own inclinations, is equated with sin, and is seen as leading invariably to de­gredation and despair. 

The alcoholic and the teetotaler really believe much the same thing and need one another desperately. The teetotaler says that self-indulgence leads to ruin, and the behavior of the alcoholic proves the point. Without the example of the latter, the philosophy of the former could not be reasonably maintained. Without the warnings of the non-drinker, the alcoholic would have no one to defy. The success of AA is dependent on a continuing supply of new "sinners." 

The 12 Steps refer to the issue of the individual versus the collective both directly, when the issue of human will is discussed, and indirectly, when they speak of God or a "higher power." To show how often the denigration of individuality arises in Twelve Steps and Twelve Traditions, I am going to list some quotations from the book. 

Admittedly, I am taking these quotes out of context. The reason that I do so is that, as I will show shortly, the context contains large numbers of contradictory statements that are not juxtaposed for comparison, as well as paradoxical statements, which mask the underlying message. Of particular note is that the entire book is written using the collective pronoun we. 

[Page numbers that are referred to are from the following edition: 
Alcoholics Anonymous. Twelve Steps and Twelve Traditions. New York: Alcholics Anonymous World Services, Inc., 1981. (Originally published 1952)]. 

…self confidence was no good whatever; in fact, it was a total liability. (p. 22) 

…the average alcoholic, self-centered in the extreme... (p. 24) 

"How he [the practicing alcoholic] does cherish the thought that man, risen so majestically from a single cell in the primordial ooze, is the spearhead of evolution and therefore the only God that his universe knows!" (p. 25) 

…those filled with self sufficiency who have cut themselves off [from God] (p. 28) 

Now we come to another problem, the intellectually self-sufficient man or woman... far too smart for own good... blow ourselves into prideful balloons... (p. 29) 

cut away the self will... (p. 34) 

The philosophy of self sufficiency is . . . a bone-crushing juggernaut whose final achievement is ruin. (p. 37) 

We want to find exactly how, when, and where our natural desires have warped us. (p. 43) 

It is not by accident that pride heads the procession [of the seven deadly sins]. (p.48) 

It is worth noting that people of very high spiritual development almost always insist on checking with friends or spiritual advisers in the guidance they feel they have received from God. (p. 60) 

It is a spiritual axiom that every time we are disturbed, there is something wrong with us. If someone hurts us and we are sore, we are in the wrong also. (p. 90) 

…any success we may be having [in remaining sober] is more His [God's] success than ours. p. 92) 

…personal ambition has no place in A.A. (p. 183) 

…A.A.'s twelve traditions repeatedly ask us to give up personal desires for the common good... (p. 184) 

Moved by the spirit of Anonymity, we try to give up our natural desires for personal distinction ... p. 187) 

…a loving God as he may express Himself in our group conscience. (p. 

As I mentioned earlier, these types of statements are intermixed with paradoxes and ambiguities. On page 26, we are told that the AA group does not demand any belief or behavior — that all twelve steps are merely suggestions. Of course, on page 174, we are told that any group member that defies the "suggestions" has probably signed his own death warrant. 

We are exhorted to keep an open mind while at the same time to "resign from the debating society" (p. 26). We are told that the best way to get rid of self-will is through our willingness to do so. We are told that dependence upon a higher power is a means of gaining "true independence of the spirit" (p. 36). 

One rather frequent ambiguity in the book is that it sometimes implies that its ideas concerning over-indulgence apply primarily to the issue of alcohol, while at other times it seems to apply its concepts far more generally. Page 36 implies strongly that the twelve steps do not apply just to the issue of alcohol. 

Throughout the entire volume, debatable statements about self-indulgence are mixed up with statements concerning over-indulgence that only a fool would debate. Page 44 sensibly discusses instincts running wild, and, on page 65, we are even told, paradoxically, that God does not expect us to fully eliminate all of our natural drives. 

The book's discussion of pride also presents us with a mix of statements that confuse one type of pride — unwarranted pride — with all types of pride. It is also fascinating that, shortly after discussing the alcoholic's generic pride, the book goes on to discuss the alcoholic's generic feelings of inferiority and inadequacy. Are we to assume that alcoholics are both truly proud and ashamed of themselves simultaneously? 

Allow me to translate the 12 Steps from the collectivism vs. individualism perspective. In step one, addicts admit their powerlessness over their own impulses. The way to stop behaving self-destructively, says step two, is to turn to a power greater than ourselves. Step three defines exactly what it is that we are supposed to do in relation to that power. We are supposed to turn our will over to it. We must not trust our own instincts, but only some power greater than ourselves- the collective, of course. 

In step four, we make a moral inventory, in order to discover our liabilities. The type of "defects" under consideration here are spelled out quite dearly. They are the old familiar seven deadly sins. Notice that the issues of the harm that we have done to others and making amends to others do not come up until steps eight and nine — after this moral inventory. We must deal with our own intrinsic evil before we can address the evil that we have inflicted upon others. 

In step five, we are to admit the exact nature of the wrongs discovered in step four to ourselves, God, and another person. We cannot be honest with only ourselves and God; after all, we may be deluding ourselves about God's will. We must confess our sins to others. We must let them know that we were not in control of our impulses. 

The AA book clearly compares this step with the confession of sins in organized religion. In the group meetings, members announce their names and add, "and I am an alcoholic." They say there is no shame in this, but clearly members are ritualistically humiliating themselves in front of the group. 

They may say that they are doing this in order to overcome the denial characteristic of the alcoholic. However, if alcoholism truly is a manifestation of willfulness, then, when practicing alcoholics insist that they can control their drinking whenever they want to, they are telling the truth. The real denial comes when they "admit" that they were not deliberately choosing to drink all along, but were responding to their "disease." 

Steps six and seven involve asking the higher power to remove our shortcomings; again this is to be done before we even consider the harm that we have done to others. The concept of humility and our own powerlessness over our impulses is stressed. 

If we do well in the future, the credit goes to the higher power who has removed our shortcomings. If we screw up?  Well, that's just our own shortcomings.

After we deal with the harm we have done to others in steps eight and nine, step ten involves continuing the process of self-criticism that had begun in step four. The priority goal of this process is self-restraint and the avoidance of pride. This is accomplished by attributing any sobriety we have achieved not to ourselves, but to God. Kindness and love to others arises from our devotion to God, not from our own selfish instincts or will. 

Step 11 involves the personal relationship to God. We are to meditate. and pray to God "as we understand him." On what this understanding is supposed to be based is never specified exactly. In fact, the book takes a religious stance by adopting the notion that the Lord works in mysterious ways which no mere mortal can understand. 

It is clear that what happens in the world is not supposed to happen according to our own notions of right and wrong or our own will. We are to pray for what God wants, not for what we want; we are to ask only for knowledge about God's will for us and His power to carry it out. 

This knowledge does not involve specific answers to behavioral dilemmas, but only knowledge about how we might best forget ourselves and serve the collective. Only then will love, forgiveness, truth, and harmony come about, and we will be rewarded by a sense of belonging to the group. In the twelfth and final step, we are encouraged to spread the gospel, and to apply it to all of our affairs. 

Why are the anonymous groups so powerful when it comes to stopping compulsive behavior? (At the risk of offending the devout, I am going to discount the possibility of divine intervention.) I submit that the answer to the question lies in the fact mentioned above —that both the practicing and the recovering AA alcoholic prove the point that individual will power is a bad thing: Many of the families of addicts are grappling with problems created by the increasing value placed on the individual by society at large, and how the newer prevailing philosophies conflict with the need for their families to function according to an old set of rules. 

Practicing alcoholics appear to be rebelling against collectivist tendencies by indulging themselves with no concern for the health and safety of loved ones or anyone else. They often lie, put others in double binds, defeat expressions of caring and concern, and drive while intoxicated. 

Many individuals and family members directly involved with the problem of alcoholism argue that this behavior results primarily from the influence of the drug, but the 12 Steps argue more convincingly than I ever could that they really do not believe it. The behavior of the alcoholic is clearly attributed to a self-centered attitude. 

The alcoholic's willfulness, pseudo-selfishness (they are really self-destructive), and lack of concern for others, however, does not work. Alcoholics end up depressed, humiliated, and often physically ill. Their rebellion has failed. Willfulness has failed. The only way to happiness is to return to conformity. When they stop drinking and join AA, their lives improve. 

This proves beyond a doubt that conformity is superior to willfulness. By providing such proof, they help to reinforce the role functioning of other family members who are themselves experiencing internal pressures to express selfish impulses at the expense of old established family rules.

Tuesday, October 16, 2012

Psychotherapy Outcome Research and Treatment for Borderline Personality Disorder, Part II

At the end of Part I of this post of September 12, 2012, I mentioned that doing psychotherapy outcome studies is diabolically difficult, and promised to discuss the reasons why in this post. In fact, because of the literally infinite numbers of uncontrolled variables in studies of human beings both individually and in relationship to other human beings, psychotherapy outcome research can never be the only standard by which the "science" of human behavior-change technology should be measured.  In fact, it's not even the gold standard.  

In order to better understand ourselves and what leads us to change our behavior, we must use ALL available sources of information. We have to look at the widespread clinical experience of psychotherapists who use a variety of techniques and theories with a variety of clinical populations. We have to look for potential biases in both clinical studies and within an individual therapist's anecdotes and the conclusions that we draw from them. In forming conclusions about both anecdotal and controlled-trials data, we have to look at a wide variety of possible explanations, as well as for any information and experiences that would seem to contradict those explanations.

We also have to look at the experience of marketers who have been able to induce a large numbers of people to buy a product or vote for a politician (many of whose very powerful techniques have been discussed in previous posts on this blog). We have to look at the social psychology literature, which shows that people behave very differently when interacting with different groups of people and with different individuals than they might do in a therapist's office. 

We have to look at historical and sociological trends. We have to look at new knowledge from the neurosciences that might account for findings that are difficult to explain or reconcile with other beliefs.  We must look at evolutionary biology. We must examine our own beliefs for logical inconsistencies. We have to be honest about thinking about ourselves what makes us tick personally.

What follows is a list of some of the difficulties psychotherapy outcome researchers encounter, as well as the reasons they may overstate their results.  A fuller discussion of each of them can be found in my book, How Dysfunctional Families Spur Mental Disorders.

1.  The Problem of the “False Self”

People do not act the same way in all social contexts.  They do not act or speak the same way around a boss that they do when they are alone with a lover. A man’s behavior in a strip club is very different than his behavior when he is playing with his children. We have different “faces” or masks which we apply to ourselves in different environments.  Not infrequently, these masks are meant to manipulate others to get them to do what we want them to do. 

I never cease to be amazed at how mental health professionals and researchers seem to believe that they really know what is going on in a patient’s or a research subject’s life based solely on the self report of the patient, or solely on the reports of the patient’s intimates, or even on the reports of people like teachers who observe the behavior of children in only one context that includes thirty other distracting students. If these professionals were asked if they believe that people often act differently in public than they do behind closed doors, they would of course say yes, but they seem to develop amnesia for this fact in discussions and in studies. 

A patient’s family members may be just as motivated to give a distorted view of a patient as is a patient.  Parents, for example, may prefer to believe that their child has some sort of mental defect, so as not to experience as much of their own covert guilt about their parenting skills. Conversely, some may actually prefer to blame the child’s behavior completely on themselves, in order to let their “perfect” child off the hook. Most mental health practitioners do not make home visits to watch patients and family members interact in their natural environment. Even if they did, unless they had a camera operating twenty four hours a day as in the movie The Truman Show, they could still be easily deceived.

2.       Double Blinding

When it comes to psychotherapy treatment outcome studies, we cannot do double blind placebo controlled comparisons of two different types of psychotherapy treatments. This is true because, in a sense, the therapist – or more correctly the relationship between the patient and the therapist – is the treatment. If the study were to meet the criteria for being double blind, that would mean that the therapists who administer the treatment would have to not know what they were doing. 

Of course, they cannot administer psychotherapy without being aware of what techniques they are using. If they could, that would mean that they were incompetent.  Not a fair test of a treatment!  The fact that the therapy relationship is one of the basic aspects of the treatment also makes placebo or “sham” treatments difficult, because any relationship has some effect on an individual. Does this mean we should give up on evaluating psychotherapy treatment scientifically and rely exclusively on clinical anecdotes?  Of course not.  Studies are still important.  We just have to understand their limitations.  

3.       Randomized Clinical Psychotherapy Trials 

One strategy used in therapy studies is to compare the outcomes of two different, presumably active types of psychotherapy treatment techniques with each other, rather than with placebo, on similar groups of patients, without the benefit of double blinding.   These studies are referred to as randomized clinical trials, or RCT’s. 

A large number of different schools of psychotherapy have different approaches to the understanding of and methodology for changing a patient’s repetitive dysfunctional habits.  Most of these therapy schools were designed by charismatic and creative individuals who based their ideas on clinical anecdotes. These innovators are highly invested emotionally in their own personal theories, and want them to look good in comparative psychotherapy outcome studies.

This leads to a so-called allegiance effect in RCT’s. The preferred psychotherapy school of the researcher is likely to be delivered more enthusiastically and with more rigor to subjects in the study than is the competing therapy treatment. One survey study examined 29 RCT outcome studies that compared one type of therapy to another and found a correlation of .85 between researchers’ therapy allegiance and outcome. That is, the researcher’s preferred treatment came out ahead 85% of the time. Just as in sponsored drug studies, this number is too way high to discount the presence of a significant bias in the studies.

When differences are found between two therapies, they are often statistically but not clinically significant. They show that one therapy is slightly more advantageous than the other, but that the actual improvement of the subjects was so minimal as to be inconsequential. 

When both groups of therapists who are providing the treatment in the study are equally committed to the paradigms they are delivering, comparative psychotherapy outcome studies almost always result in a tie. In psychotherapy research circles, it is known as the “dodo bird verdict.”  This refers to a character from Alice in Wonderland, the dodo bird, who in one passage said “Everybody has won, and all must have prizes.”

4.       Treatment as Usual 

Lately, many researchers engaged in psychotherapy RCT’s have employed a control group called treatment as usual (TAU), which really stacks the deck in favor of their pet psychotherapy school. Lining up practitioners of a different school from the researcher’s to act as therapists for a comparison group is often difficult.  Additionally, if the researcher were able to do so, the study might not show his or her therapy to be superior to another type. For these reasons, the use of TAU control groups has become almost epidemic in psychotherapy RCT’s. 

Subjects randomly assigned to the TAU condition, which serves as a comparison group to the group of subjects receiving the researcher’s therapy model, are simply released back into the community to get whatever other treatments are already out there. Some may see practitioners from other therapy schools, some may get medications, some may get both, and many others may get neither.  Both the TAU group and the experimental group are followed up at equal time intervals and given all the same outcome measures.  The psychotherapy methodology that serves as the investigated treatment always seems to beat TAU.

The reader should understand that within any widely-practiced therapy model, both good therapists and bad therapists can be found, just as practicing physicians can be either good or bad psychopharmacologists. For the subjects in the TAU condition who receive treatment, the results of the good clinicians in the community are probably cancelled out by those of the bad ones. TAU subjects may also be seen less frequently. Some, as I mentioned, are getting no treatment at all. Meanwhile, the experimenter’s group is usually getting a lot more individualized attention by therapists who are highly committed to the particular treatment model. These factors may be the real reasons their patients do better than those receiving TAU. 

The experimenter’s therapy is provided by uniformly well-trained and enthusiastic therapists under very well controlled conditions. The psychotherapy that is provided is applied with rigor and consistency, and is scrutinized by other observers through the use of videotapes of the sessions. Therapists who make errors are supervised almost immediately.  On top of this, research therapists often have caseloads that are very much smaller than those of folks out in practice, allowing them to spend more time deciding how to approach the clinical issues they face.  I cannot recall a single instance of a study in which TAU beat another therapy delivered in such a manner. If it did, I would have to wonder how the experimenter could have possibly accomplished such an unlikely feat.

5.       The Choice of Outcome Measures 

Another huge controversy in psychotherapy RCT’s is the question of which outcome measures should be used, because the different psychotherapy schools target different aspects of the patient's problems. What should we measure, exactly?  Symptom relief?  Whether or not the patient continues to meet criteria for a specific DSM disorder?  Whether they stop engaging in chronic repetitive dysfunctional behavior?  Whether they experience fewer conflicted emotions?  Whether they have improved and more satisfying relationships? Whether they can hold a good job?

In their November 1995 issue, Consumer Reports published a large survey on the public’s experience with psychotherapy. In response to the survey, satisfaction with their experience was reported widely by those who had been in therapy. Furthermore, longer term therapy was rated higher than therapy limited in duration by managed care, and satisfaction with psychotherapy was rated about equally by those who had therapy alone and those who were given a combination of therapy and medication.

In surveys of this sort, the question of selection bias arises - whether or not the sample of people polled is representative of the general therapy population. The respondents in this case were almost all middle class and educated, so we have to limit our conclusions to that population rather than the population of the United States as a whole.  Nonetheless, the study was the most extensive study of its type on record. Should opinions expressed by patients evaluating psychotherapy outcomes for themselves count as science?  Many in the field would say no.  

But one must consider, however, that psychotherapy target's a patient’s subjective sense of personal well being. That is, we want to know whether patients feel better mentally about their lives. By this measure, assuming that the survey respondents were being somewhat honest with their answers, we would have to say it should count.  A paradox about the “science” of psychotherapy is that we are attempting to be objective about subjectivity, two concepts which are usually defined as antonyms.

6.       Funding Issues

Another big issue for the field concerns which psychotherapy treatment outcome research studies get funded.  If a scientist cannot get money for a project, it will rarely get off the ground, because these types of studies are very expensive to mount. Most successful psychotherapy RCT’s have employed CBT because of the predominance of this model in professional psychology training programs, and because most CBT treatments aim primarily for symptom reduction, which is relatively easy to measure, rather than personality change, which is not. 

7.       Problems with Generalizability of Study Results

Another big problem with all psychotherapy RCT’s is that most studies require that the subject population be homogeneous, meaning that the subjects in the study must be very similar in the nature of the disorder they exhibit, and in how severe it is. This requirement means that patients who have more than one DSM disorder or psychological problem are often excluded from studies.  In contrast, most patients seen in practice, at least by psychiatrists, have more than one disorder (co-morbidity). This fact alone limits what is termed the generalizability of the study’s finding. We do not know from a study using patients who have only one disorder if the treatment employed in the study would work as well with patients who have multiple problems.

Because studies need subjects who will stick with the treatment until the end of the research project, some subjects who have certain characteristics that are common in clinical practice tend to be excluded. This problem further limits the generalizability of the study.  For instance, most studies of treatments for depression exclude patients who are suicidal!  Another problem with RCT’s is that many subjects drop out of a study or are removed from a study as it proceeds because they do not completely cooperate with the treatment in some way. CBT studies, as do many others, tend to have a fairly high dropout rate. The subjects who end up completing the study are usually the most motivated to change, and would therefore be expected to do better than those who lack this motivation. This all makes the treatment method look much better than it would be if it were employed in a typical clinical practice setting. 

8.       Treatment Manuals

Another big issue in psychotherapy outcome studies is that, in comparing different treatments for different behavioral problems, researchers need to have some way of knowing that all the therapists employed in the study are doing mostly the same things. In early psychotherapy studies, the methods section of a journal report might say that such and such number of patients was “given psychoanalytic therapy,” with no description of what the therapists actually did. This was clearly unacceptable.

The solution to this problem that has been employed most frequently is the use of treatment manuals, as well as manuals that measure the study therapists’ competence in and their adherence to the treatment paradigm.  Treatment and adherence manuals specify exactly what the therapist should be doing under a variety of circumstances. Tapes of psychotherapy sessions of patients in the studies are reviewed to make sure that the therapists are employing the same interventions. A “rater” will count the times the therapist did the right thing and the times the therapist strayed from the procedures specified in the manual. This process assures that all patients are getting approximately the same treatment. 

Unfortunately, a good therapist has to be flexible and employ a variety of different strategies in ways that are tailored to the proclivities and sensitivities of the patient in front of them. Generic interventions may not only fail to work, they may backfire and make matters worse. Verbal interventions must often be phrased differently to different patients in order to reduce the patient’s defensiveness. Treatment and adherence manuals take away a lot of this flexibility, so that the therapy as performed in an RCT is not always similar to the way that clinicians out in the field practice it. Creating treatment manuals can itself be a daunting task. I heard a respected researcher tell a group of other researchers that his team was having trouble designing such a manual because the founder of the treatment they wanted to study was observed to perform psychotherapy completely differently than his own wife, who supposedly was a practitioner of the same model of therapy.

Tuesday, October 9, 2012

“Expert” Doctors Who Shill for Big Pharma Get Greedier

In several posts on my Family Dysfunction and Mental Health Blog (8/7/12, 6/19/12, 3/6/12, 2/21/12,  1/31/12, 10/19/11, 8/31/11), I describe in detail the propaganda and truth-twisting techniques used by the “expert” doctors who shill for Big Pharma (referred to by Pharma as key opinion leaders). They use these techniques in order to sell high-priced, brand-name drugs when cheaper drugs would be just as effective, and, in many cases, psychotherapy would be even more effective. 

In a sense, many of the shills (though certainly not all - some really don’t realize how much they themselves have been influenced) are willing to sell out the well-being of psychiatric patients for money. So the fact that their greed is now being used against Big Pharma in Australia, and most likely everywhere else as well, should not come as much of a surprise.  When it’s done to Pharma instead of for them, the drug companies then squeal like little piggies.

Irony, thy name is Pharma.

Thanks to Ken Harvey, a colleague in Healthy Skepticism, for a heads up on the following story:

Megan Reynolds ( a journalist for the Australian website 6minutes, (a daily pdf newsletter sent to Australian GPs and other healthcare professionals) reported the following on October 2, 2012:

“Demanding doctors with ‘unreasonable’ expectations are driving up the costs of medical educational events, a Pharma industry insider says.

In a submission to the ACCC (Australian Competition and Consumer Commission) the next update to the Medicines Australia's Code of Conduct, an anonymous 'player in the pharmaceutical industry  ‘supports full disclosure of sponsorship payments as he says under the current system of self-regulation, ‘Key Opinion Leader’ doctors are coercing Pharma companies into contravening the Code.

The 'insider' says some doctors demand $1-2k or more for a brief talk based on company-provided slides, in addition to business class airfares of up to $15,000.

Key Opinion Leaders also enjoy holidays as extensions of their conferences, and sometimes never turn up to meetings they are sponsored to attend, as they are 'probably off motoring around Europe somewhere!' he claims.

But companies are reluctant to complain about such demands for fear of alienating doctors of influence, who they claim often pit companies against each other in bidding wars for their services.

‘The Code needs to be stronger to help companies deal with these situations and know that any company that does not do the same thing will be exposed. Until that happens everyone is afraid to be the odd ones out,’ he writes.

He urges the AMA to set industry honorarium fee rates to stop bidding wars, and limiting doctors to just one sponsored event per company. He adds that most doctors as well as the public would be shocked by the amount of ‘paid comment’ to be revealed by transparency.”

Drug companies demanding transparency.  Now there’s a switch!

Tuesday, October 2, 2012

More Astonishing, Cutting-Edge Research in Psychiatry

As we did on my post of November 30, 2011, it’s once again time to look over the highlights from my two favorite medical journals, Duh! and No Sh*t, Sherlock. 

As I pointed out in that post, research dollars are very limited and therefore precious.  Why waste good money trying to study new, cutting edge or controversial ideas that might turn out to be wrong, when we can study things that that are already thought to be true but have yet to be "proven"?  Such an approach increases the success rate of studies almost astronomically.

Psychiatric blogger Nassir Ghaemi agrees: "In some estimates, less than 10% of all NIMH funding is aimed at clinically relevant treatment research on major mental illnesses (i.e., schizophrenia or bipolar disorder). Further, that limited funding is sparingly distributed: the highly conservative, non-risk-taking nature of NIH peer review is well-known."

Here are some of the most interesting new findings reported in these journals.

Side Effects and Therapeutic Effects Are Not The Same Thing

A brilliant new study ( on one anti-depressant concluded: "In the first few months patients either responded to the treatment and improved or didn't and still suffered side effects." Really? People can get side effects from a drug but no benefit? That actually happens?!? I never knew.

The Charleston (WV) State Journal (3/27, Burdette) reports that "a report released last week by Auburn University shows that the high poverty levels and low educational attainment among women have a direct correlation to the region's high number of teen births." The media is so irresponsible! Why haven't they pointed out this correlation more often than the previous 13,000 time?

What?  Combat is more stressful than merely serving in the military??  But it looks like so much fun.

Listening to Loud Music Associated with Substance Abuse

The Los Angeles Times (5/22, Kaplan) "Booster Shots" blog reports that according to a study published online May 21 in the journal Pediatrics, "Teens and young adults who listen to digital music players with ear buds are almost twice as likely as non-listeners to smoke pot.” As a veteran of the San Francisco music scene in 1967, I just never noticed that the people in the audience at the Fillmore auditorium were smoking pot. I always thought that smell came from the incense they were burning, and that those funny cigarettes were just home-rolled tobacco. Additionally, their LSD use was greatly exaggerated. They were not hallucinating. Those light shows were just really amazing.

And on a related note:

Small Study: Medical Marijuana May Impair New Patients' Driving Skills.

Reuters (7/27, Pittman) reported that although it often goes unnoticed during sobriety tests, the use of medical marijuana at the typical doses used by AIDS, cancer and chronic pain patients causes users who have not yet built up a tolerance to cannabinoids to totter from side-to-side when driving, according to a study published online July 12 in the journal Addiction.  Well I’ll be!  Intoxicants impair driving skills?  Who knew?  Legislatures should look into doing something about this, or someone could get killed.

 Review: Negative Interactions with Staff Common Cause of Aggression on Psychiatric Wards

MedWire (5/26, Cowen) reported, "Negative interactions with staff are the most common cause of aggression and violence among inpatients in adult psychiatric settings," according to a review published in the June issue of the journal Acta Psychiatrica Scandinavica. Now come on!! Patients with schizophrenia are just naturally aggressive. It’s in their genes! Don’t let their completely flat affect and their total inability to organize a break out from a locked ward fool you.

Parental Fighting May Lead to Later Depression, Anxiety in Children


HealthDay (6/16, Goodwin) reported that "slamming doors, shouting and stony silences between mom and dad can really scar kids emotionally," according to a study published in the journal Child Development. Investigators found that "Kindergarteners whose parents fought with each other frequently and harshly were more likely to grow into emotionally insecure older children who struggled with depression, anxiety and behavior issues by 7th grade."  Here we go again. This parent bashing has just got to stop. We all know very well that behavior is controlled by genes and that environmental stress has absolutely zero psychological consequences.

And as long as we are on the subject of parent bashing, here’s some more evidence for this horrible trend:

Children's Adherence to Mental-Health Treatment May Depend on Parents' Perceptions


MedPage Today (8/4, Petrochko) reported, "Whether or not a child maintains a treatment for mental health may depend on parents' perceived benefits of that treatment," according to a 573-participant study published in the August issue of the journal Psychiatric Services. How many times can I stress this?  Parenting skills are absolutely irrelevant in determining the behavior of their children.