Why We Need Psychoactive Meds by Harold Koplewicz

[compsports]

Before I post the article, I just wanted to say that I think Koplewicz is just as bad as Biederman.

 

To refresh your memory about this guy, several years ago, he proposed a ransom notes advertisement campaigns regarding autism that gave rise to the worst stereotypes about the disorder. It was because of the efforts of Ari Neuman, an autism activist that his efforts were brought to a halt.

 

He was also coauthor of the fraudulent Paxil 329 study.

 

Anyway, here is the article. I will make some comments at the end.

 

http://tinyurl.com/3er6r5l

 

Among the balloons that exploded during this super-heated summer was the intensifying debate over the worth of psychotropic medications.

 

Marcia Angell, the distinguished ex-editor of the New England Journal of Medicine, kicked things off with a ferocious two-part attack in The New York Review of Books on antidepressants, antipsychotics and, in general, medications to treat psychiatric disorders. Her argument distills charges often made much more sloppily: that psychiatrists dispense unnecessary and potentially harmful drugs. She impugns both the medications and the motives of the psychiatric profession. Both deserve clarifying responses.

 

Angell reviews several recent books claiming that careful analyses of studies of psychotropic drugs, done to win FDA approval, reveals that many are no more effective than placebos. Then why are they in such wide use? Angell sees a conspiracy of psychiatrists and drug companies for their mutual benefit, with patient benefit only a distant concern.

 

In her telling, it started in the late '50s, when psychoactive drugs began to appear. Psychiatrists, competing for patient income with a surging number of psychologists, pushed what Angell calls the "medicalization" of mental illness -- the idea that mental illness is a product of brain chemistry -- so that only they (and not their non-medical doctor brethren) could prescribe the necessary medication. Then, her theory goes, these psychiatrists invented diagnostic criteria -- in the form of the American Psychiatric Association-approved Diagnostic and Statistical Manual (DSM III) -- to match illnesses to available medications. The DSM writers, she charges, were deep in the pocket of the drug companies, who paid them personally and financed their professional organizations.

 

Like most conspiracy theories, it's breathtaking in its audacity. And, like other conspiracy theories, it becomes difficult to dissect the real from the imaginary.

 

First, it's preposterous to describe decades of scientific work linking emotional states and disorders to brain chemicals as basically a psychiatric plot to capture more of the mental health market. She writes (as do others) as if psychiatrists were bored by less remunerative talk therapy and wanted to hype their income by quickly dispensing pills. In fact, the drive for medication was fueled by the surprising observation that they were better treatments for mental illness than talk therapy or earlier sedative drugs. With apologies to Angell, more effective and less toxic medications for devastating illnesses such as schizophrenia, major depression, bipolar depression, OCD and panic disorder are as significant, in terms of public health, as finding new cancer medications.

 

Second, Angell's assertion that the DSM was a thinly-veiled ploy to justify medications ignores its real value, which is promoting reliable clinical communication. Before DSM, diagnosis was basically a labeling free-for-all. A particular diagnosis meant very different things to different people. The drive to make diagnosis less subjective was not an effort to create a market for medications, but to make psychiatric communication effective. Nothing in the DSM, notes my colleague Dr. Donald Klein, former director of research at Columbia's New York State Psychiatric Institute and member of the original DSM III task force, "pushes" medication -- or any other form of treatment.

 

That some psychiatrists and professional organizations take money from pharmaceutical companies is a fact. It may be true that some allow such money to influence their treatment decisions. This problem plagues all branches of medicine, but psychiatry is particularly affected, as it still lacks diagnostically sufficient laboratory methods. In recognition of the public's current distrust of pharmaceutical companies, the Child Mind Institute does not accept their funding. But we are staunch advocates for more research into mental illness, and the pharmaceutical industry is one of the biggest funders of basic and treatment science. This is simply a fact. A researcher's work cannot be dismissed simply because funding came from a drug company. There's a desperate shortage of funding for research, and not developing new treatments, or not pushing the science forward, in order to avoid the appearance of corporate ties is a far more troubling eventuality.

 

Which brings us to the issue of the studies Angell says show that antidepressants and other psychoactive medications aren't appreciably better than placebos. Peter Kramer, the author of "Listening to Prozac," responded to this charge in a piece in The New York Times, in which he argued that the studies Angell highlighted were undermined by the biased process by which patients were recruited. Many recruits were not, in fact, clinically depressed, so most get better over time, whether on placebos or real medications. There is a further claim that even the patients who do get psychoactive medications get better because of a sort of "extra strength" placebo effect: The side effects of the medication let them know they're getting the real thing, which undermines double blind precautions and makes them inclined to feel improved. This ridiculous notion must surprise the companies whose side-effect-rich medications never make it through the FDA review for efficacy.

 

Dr. Klein also explains that there is a real challenge to getting good, clinically useful data out of studies performed after a company gets a patent, in the process of seeking FDA approval for marketing. Because the clock starts ticking as soon as a new medication is patented, a drug company's goal is to move through the testing process as rapidly as possible. So in the first phase of human studies, doses are picked that will not cause FDA rejection because of side effects. The goal is often to use the lowest dose likely to produce statistically significant benefit, however marginal, over the placebo alternative. The result is that the studies' dose is often too small to regularly be clinically useful.

 

What's the takeaway of all this?

 

Good studies for psychiatric treatments are desperately needed. In the meantime, we have patients, in our case children and adolescents, who desperately need help. These children may be out of control, overwhelmed by anxiety, dangerously aggressive, disorganized in their communication, floundering in school. We need to help them. Medications, often along with behavioral therapy, can have a transformative effect. If they don't help, we are not forced to continue using them. We would like to see objective research catch up with the clinical realities but can't wait until that happens. Furthermore, falling back on pure non-pharmacological treatment is not the better alternative, since these treatments have rarely undergone objective evaluation.

 

As to the issue of psychoactive drugs actually harming patients by altering their brain chemistry over the long term, which Angell posits, here too data is lacking. It makes no sense to forego present benefit because of undemonstrated future harms. We try to weigh the risks of psychoactive drug treatment against the risks of forgoing treatment. That risk often includes academic failure, dropping out of school, substance abuse and even suicide. Unfortunately, the risks of avoiding demonstrated useful treatments are not something critics, like Angell, consider.

 

My comments - Interesting how he says drugs are ok even though he admits they haven't been tested long term. It is not true that long term non pharmacological treatments have not been tested.

 

And once again, more fear mongering.

 

He has some nerve impugning Marcia Angel as someone who contributed to a fraudulent study.

[cinephile]

Just posted a comment. Or, as it turns out, multiple comments. Hopefully they'll post all of them.

 

PLEASE, if anybody can help out posting the truth about these articles that are cropping up now, please do. Me and Alto can't do this alone. We REALLY need some serious team work here people!

 

Before I proceed with my post, I'd like to mention that Dr. Koplewicz was one of the authors of the Paxil 329 study, which was a pharmaceutical-company sponsored drug trial on the safety of Paxil on adolescents. Actually, the article was ghostwritten by the infamous Sally Laden, who was also hired by GlaxoSmithKline (the makers of Paxil) to ghost-write an entire textbook singing Paxil's virtues to the general practitioner community so as to grow the brand outside of psychiatry (link on this: http://carlatpsychiatry.blogspot.com/2010/12/nemeroff-and-schatzbergs-textbook.html). That is to say, the authors didn't really author the study at all. They just signed off on the drafts and made some token revisions. The study also hid negative evidence (largely stating Paxil was no better than placebo, a fact which Koplewicz so strongly decries here, and that teens were at a greater risk for suicide who used Paxil) and cherry-picked the favorable evidence. And the conclusion of this article? "[Paxil] is generally well tolerated and effective for major depression in adolescents." An in-depth account of this fraud can be found at these two links:

http://1boringoldman.com/index.php/2011/05/07/retract-study-329/

http://psychcentral.com/blog/archives/2008/04/30/more-on-infamous-paxil-study-329/

 

Now, a few things about this article:

 

"In her telling, it started in the late '50s, when psychoactive drugs began to appear. Psychiatrists, competing for patient income with a surging number of psychologists, pushed what Angell calls the "medicalization" of mental illness -- the idea that mental illness is a product of brain chemistry -- so that only they (and not their non-medical doctor brethren) could prescribe the necessary medication."

-This is largely true. Robert Whitaker, in his book ANATOMY OF AN EPIDEMIC, outlines all this and more, particularly in the "The Rise of an Ideology" chapter. Here is a relevant passage from the book:

"New Jersey psychiatrist Arthur Platt was at a professional meeting in the late 1970s when a keynote speaker laid it out for them: 'What is going to save us is that we're physicians.' [Psychiatrists] could write prescriptions and the psychologists and social workers couldn't, and that was an economic landscape that presented the field with an obvious solution...Threatened by [psychiatrist Thomas Szasz's] criticism that psychiatrists did not really function as 'doctors,' the APA argued that psychiatrists needed to more explicitly embrace this role. 'A vigorous effort to remedicalize psychiatry should be strongly supported," said the APA's [Melvin] Sabshin in 1977."

 

"Then, her theory goes, these psychiatrists invented diagnostic criteria -- in the form of the American Psychiatric Association-approved Diagnostic and Statistical Manual (DSM III) -- to match illnesses to available medications."

 

-Well, not all the diagnoses in the DSM are bogus, but some certainly are, and that means a boon for the pharmaceutical companies. One example is Premenstrual Dysphoric Disorder (PMDD), which was nothing more than Eli Lilly's attempt to rebrand their antidepressant (Prozac) with a new "indication" so that it could stay on patent and Lilly could keep raking in the profits. Read more about it here: http://www.msmagazine.com/Summer2008/pathologizingyourperiod.asp

 

-"Second, Angell's assertion that the DSM was a thinly-veiled ploy to justify medications ignores its real value, which is promoting reliable clinical communication. Before DSM, diagnosis was basically a labeling free-for-all. A particular diagnosis meant very different things to different people. The drive to make diagnosis less subjective was not an effort to create a market for medications, but to make psychiatric communication effective."

-You don't have to be a psychiatry critic to believe the DSM is a "thinly-veiled ploy to justify medications." In fact, you could be Allen Frances, none other than the lead editor of the DSM IV! In a Wired article (http://www.wired.com/magazine/2010/12/ff_dsmv/all/1) Frances bemoans the upcoming DSM V's danger of pathologizing normal human behavior with all kinds of bogus disorders so as to line drug company's pockets. Among his admissions, Frances said, "there is no definition of a mental disorder. It's bullsh**. I mean, you just can't define it." He also said that the way the DSM changed psychiatric diagnosis actually opened the floodgates for misdiagnosis and overdiagnosis because it introduced the descriptive diagnosis system (essentially a checklist) where patients' disorders were considered clusters of symptoms. As an example, a patient would have major depressive disorder if they only had 5 of the 9 diagnostic criteria, regardless of their life situation or what they thought about their problems. This "checklist" system enabled many psychiatrists to dehumanize patients and to get sloppy in their diagnoses and throw pills at patients.

[compsports]

""PLEASE, if anybody can help out posting the truth about these articles that are cropping up now, please do. Me and Alto can't do this alone. We REALLY need some serious team work here people!""

 

Cine,

 

Thank you for your responses on the Huffington Post. They are great.

 

Actually, I have done alot of posting on various sites, particularly, when people say they have trouble getting off of ADS. I also have posted on many psychiatry blogs to refute various points.

 

CS

[Altostrata]

Great comment, cine.

 

And thanks also for your tireless work, cs!

[Altostrata]

More about Koplewicz http://bipolarsoupkitchen-stephany.blogspot.com/2010/06/drharold-koplewicz-used-nytimes-to-name.html

[cinephile]

I was happily surprised that all of the responses to the article were critical of Koplewicz (including one from a psychiatrist!) until the inevitable psychiatric party-pooper came on board ("sobrien1359"). He/she has used all the old tactics (emotional arguments, ad hominem attacks, straw man attacks, anecdotal evidence) to discredit the critics. I couldn't help but post a response to him/her. Here it is:

 

This is a typical response to people who are critical of psychiatry. It's an emotional response complete with ad hominem attacks on critics of psychiatry to fashion them into monsters ("How dare anyone try and deny the benefits of these medications and the countless lives they have saved?") and offers no evidence for their claims beyond anecdotal examples ("I have seen patients come in addicted, hallucinating...and after on medication they do a complete 180").

 

I personally would never want to take medications away from patients. I know they work for some people (sometimes fabulously) and I've seen this in person. BUT it is our moral duty to practice good science and develop a risk/benefit profile so as to honor the "do no harm" doctrine and truly provide informed consent. Only then will we truly maximize the therapeutic value of meds and other non-med interventions.

 

As it currently stands, so much of psychiatric "science" isn't science or even pseudoscience: it's advertising. And everybody, from patients to psychiatrists, loses. And it's still happening. Look at the analysis of the research behind the new atypical antipsychotic Latuda here: http://1boringoldman.com/index.php/2011/09/27/ought-to-know-by-now/ Very little has changed over the decades because the winning formula of biased drug research still works very well.

 

Secondly, sobrien is using the Nirvana fallacy of logic when he/she asks, "Are [the meds] perfect?" Of course they're not -- I doubt most people want perfection in a drug. This is a rhetorical tactic to uphold the status quo because only perfection is an acceptable alternative to the status quo and of course perfection doesn’t exist, so the status quo remains and no steps toward improvement are taken. Sad.

 

If you really drill down most dissatisfi­ed psych patients, they say they are angry because they felt lied to or coerced by psychiatri­sts to take meds that are poorly understood­, products of corrupt FDA trials that hid side-effec­ts (sometimes very serious - see the Paxil 329 study for this, and this link for an analysis of that dangerousl­y fraudulent study: http://cli­npsyc.blog­spot.com/2­008/04/pax­il-lies-an­d-lying-re­searchers-­who.html), have no longitudin­al studies of long-term symptoms, or were told they have a "chemical imbalance" even though no such thing has been proven for any mental illness, and yet psychiatri­sts such as Daniel Carlat still admit to using the theory to get reluctant patients to take their meds (see pgs 74-75 of his 2010 book UNHINGED for this). And now long-term, wholly unexpected consequenc­es of long-term SSRI use are coming out, such as PERMANENT sexual dysfunctio­n that persists for a decade or more even after SSRI use is stopped. It's called PSSD (Post-SSRI­-Sexual-Dy­sfunction) and it's already in the literature (Bolton, J., Sareen, J., & Reiss, J. (2006). Genital anaesthesi­a persisting six years after sertraline discontinu­ation. Journal of Sex & Marital Therapy, 32(4), 327-330; Csoka, A., Bahrick, A., & Mehtonen, O. (2008). Persistent sexual dysfunctio­n after discontinu­ation of selective serotonin reuptake inhibitors­. Journal of Sexual Medicine, 5(1), 227-233.).

[Altostrata]

Cool!

 

The answer I'd give to the "all meds have side effects" hooey (which enrages me, too) is: All meds have side effects, but conscientious doctors balance risk against benefit before prescribing. The risks for psychiatric medications have been hidden, much to the disgrace of the pharmaceutical industry and psychiatric profession, making reasonable risk-benefit assessments impossible.