Friday, January 29, 2016

Medications, Parrots, and Crazy Virginia Laws

For today's post, I'd like to send you around the web.

First, Pete Earley has a piece up by Robert Whitaker of Mad in America. Whitaker clarifies his position on antipsychotic medications and how their use should be avoided or minimized  in Robert Whitaker Explains his Research after being Pigeon-holed as Anti-Medication.  Let me add my bias: I didn't like Whitaker's book Anatomy of an Epidemic where he concluded that anti-psychotics cause psychiatric disability.  His point was correlational -- as anti-psychotic use went up, so did SSDI (government disability) claims. It's not that easy -- there are other factors that contribute to disability claims including financial & social incentives and the acceptability of being on SSDI.  After you read the post on Pete's blog, I'd like to make two points:

~I don't think that it's controversial that people should be on the lowest possible dose of medications --any medications.  Unfortunately, in psychiatry, we figure out the lowest dose by dropping the medications until someone gets sick.  It's not benign, with each small drop in dose there is some risk that a person will end up psychotic, in the hospital, or unable to function, and recovery can take months or more.  So when someone is doing well, working and involved in meaningful relationships, it's not a low risk issue to drop medications.  If they are having side effects, it's a lot easier to take this risk, because at least you're addressing a problem.  This stuff is not easy when you're talking about real people.

~I remember life before the second generation antipsychotics.  Patients hated taking Haldol and Prolixin and Mellaril and Stelazine.  They were very articulate about how miserable the side effects were, and I don't recall anyone saying that patients wouldn't take Haldol because they had "anosognosia" (ah, we didn't have that word then).  Psychiatrists were well aware that patients didn't take the medications because they made them feel like molasses had been poured into the crevices of their brains, or worse.  Second generation antipsychotics may be no more effective, but they are more acceptable to many patients.

Having said all that, Whitaker may be right that people do better with less medicine, either because those who aren't as sick don't need as much medicine and may be able to completely stop, or because the medications sensitize people and make them worse (I have no answers here.)  When someone is psychotic and suffering, this isn't all that helpful.  I wish we had better answers. Whitaker, and others point to Open Dialogue as a panacea, and it may be a better way with better results -- not much of it is controversial, just expensive and it requires resources for immediate response that we don't seem to have in this country.  There are 5.5 million people in Finland and 321 million people in the US, so the issues are different, and people in Finland get hospitalized and disabled, too. 

While I'm pointing you around, Alex Langford does a nice job of discussing Open Dialogue with all it's pros and cons on his blog Here.  Well worth the read. 

You've heard of Creigh Deeds? He's a Virginia state senator whose very ill and very dangerous son was released from an ER because of a quirk of Virginia state law that said if a bed could not be found within 6 hours, then a patient must be released.  Tragedy ensued -- Gus Deeds repeatedly stabbed his father and then died of suicide.   Over on Clinical Psychiatry News, I explain the idiosyncrasies of Virginia law that could allow such horrors to happen.  See Understanding the Deeds Family Tragedy.


And for the latest news in schizophrenia research, here's a study in Nature that's making headlines everywhere.  If I could understand it, I'd explain it to you.  Maybe Roy could drop by for this one? We haven't seen him for a bit.

Lastly, I'll include a link to an article about PTSD and parrots.  ClinkShrink likes birds, and she loves parrot jokes, so please do share yours.  What Does a Parrot Know About PTSD?



Joel Hassman, MD said...

Yeah, I read Whitaker's post earlier this week, and the thread that followed, and frankly, I think it sad and pathetic that antipsychotic meds are still being sold as the cure all for psychiatric disorders outside psychosis, and moreso, by PCPs these past 7 years.

Doesn't it bother you to get referrals from PCPs and other non psychiatrists who have patients on Abilify/Seroquel/Risperdal/other second gen antipsychotics, sometimes as solo meds, to treat non psychotic illnesses they have diagnosed patients, only to dump it on you to fix?!

Well, I am bothered by it, and find it both lame and on the border of malfeasance to see non psychiatrists playing psychiatrist, and then panicking and expecting us to bail them out! Here's a stat that might interest you: I have no more than 5-7% of patients in private practice on antipsychotics, and about 30% plus in CMHCs I have been working as a temp these past 5 plus years on them.

Is that solely related to environment, or, the questionable choices of my predecessors at these CMHCs? Honestly, there is not a simple answer, as I don't see primary psychotic disorders in my private practice, and, I just don't believe in using antipsychotic meds when I have more say in my prescribing habits in my private practice.

Oh, and per the Virginia point in your post, interesting when a politician is touched by personal consequences of mental health mismanagement, only then do the politicians jump to action.

And yet, when Gabrielle Giffords was shot by that psychotic man, did you see her colleagues in the House of Representatives really band together and offer real, honest, and effective solutions to mental health care interventions?

5 years later, and NO!!!

Perhaps better their short term memories are demented, eh???

Joel Hassman, MD

Dinah said...
This comment has been removed by the author.
Dinah said...

Posting this for Dean MacKinnon, MD, a psychiatrist at Johns Hopkins Hospital:
I haven't read Whitaker before; armchair psychopharmacology skeptics all have one thing in common: they lack awareness of the power of illness. One wonders if any of them have ever spent any time at all with someone in a state of acute mental suffering (or with the family members of a psychotic person). If guys like this have such respect for the illness, they certainly don't show it.

The most telling evidence of naivete? That bit about de-institutionalization being driven by social forces more than thorazine. Puh-leaze. I think it hardly needs to be said that those social forces would have run into a brick wall if unmedicated people in the grip of psychoses started flooding back into the community.

In this text, the real "false narrative" is the one being expounded by Whitaker that "evidence based" medicine is an ideal towards which we should strive as clinicians, when all it really is, I think, is one part--often a small part--of the thinking that goes into the decision to keep someone on a medication. The patient's past experience with treatment, the painfulness of the past symptoms and motivation to avoid recurrence, the impact of illness on family and society are all of course other factors that may trump weak evidence from meta-analyses any day of the week.

Finally, why do these guys always seem to assume that the patient is somehow a passive dupe rather than an active participant in clinical decisionmaking? We psychiatrists are rarely in the position to do more than advise patients to take medications, once they are out of acute danger. Patients who decide the long term costs of meds outweigh the benefits can and do vote with their feet.

PseudoKristen said...

Dr. MacKinnon, as patients we have been duped. Just look at all of the shenanigans with the pharmaceutical companies. (e.g. the withholding of information about zyprexa causing diabetes, the Markingson case, etc). Heck, just read the blog One Boring Old Man if you need some examples of why patients might feel duped. As a patient who takes psychiatric medication it is very hard to trust what I'm being told, because I don't know if the studies these decisions are based upon were done ethically.

I trust my psychiatrist, but it's the lack of ethics with some of the psychiatric clinical trials that concerns me.

I think it's completely understandable why Whitaker has resonated so strongly with people. We need to look at why that's the case and address those concerns.

Unknown said...

If your psychiatrist lives up to your trust by prescribing what are believed to be the best available treatments and, more importantly, follows up with you to be sure that the treatments are working as intended at the minimum possible cost to health, then I would say you are not being duped at all, you are engaged in an open-eyed, risk-benefit-informed therapeutic relationship.

You can't be duped if you don't expect too much. I wouldn't put much stock in what drug companies say for their meds or what psychopharm skeptics say against them. I have seen people who have suffered terrible mental anguish find their way back to health and contentment while using almost every drug out there. And I have seen people have no response at all, or worse, have debilitating side effects on drugs that most people tolerate. By and large, the meds that have survived long enough to get to market are effective for some people, some of the time, so they become part of the toolbox. Personally, I am very slow to prescribe new ones until I have witnessed someone have a positive response to them.

My objection to someone like Whitaker, if I am understanding his message correctly, is not that I think drug companies are ethical players--it's a business just like any other and so the guiding ethic, if you can call it ethical, is to maximize profit while not behaving sleazily enough to ruin the value of the brand--but that he seems to think that doubts about their methods outweigh the evidence of my senses when I treat people who clearly need and respond to treatment. Ultimately, psychiatry is in a primitive state of development relative to the rest of medicine, and we muddle through with the crude tools we have, but by god, I know these things can work for I see it almost every day.

Again, if a reasonably competent psychiatrist does due diligence by gauging, always, that the patient has benefited from treatment and would not benefit more from a different treatment (or withdrawal of treatment), then for an individual patient, such an approach should overcome most misgivings about how the drugs passed the hurdles to get to market.

PseudoKristen said...

I agree with a lot of what you're saying, I just think that instead of people worrying so much about Whitaker there should be more focus on all of the scandals in psychiatric research. Unfortunately, there are some folks out there who are providing Whitaker with a lot of material. That's what needs to be addressed.

When I think of psychiatric research I don't think of words like integrity and ethics, I think of names like Biederman and Nemeroff, and the Markingson case, and Eli Lilly withholding data about Zyprexa, and Johnson and Johnson being in trouble, and scandal, after scandal, after scandal. I worry about how all of these issues in the press affect public perception of psychiatry. So, I guess I just wish there was less focus on Whitaker and more on the need to address the problems with psychiatric research that can affect public trust.