What's New
Lots happening this month. The long-delayed DSM-5 train finally pulled into the station but most independent commentators seemed to agree that it should have kept going. Alan Frances said that it is about time the whole concept of a diagnostic manual was taken away from the APA and handed to a responsible government agency. That's a bit strange, there's been a government-sponsored diagnostic manual around for a long time, 113 years to be exact. It's called the International Classification of Diseases, issued by WHO, and we're now up to the tenth iteration, ICD-10. In this country and in most others, all hospital admissions are coded using ICD-10, not a privately-owned manual written by drug company shills. I don't use DSM. Some agencies insist on DSM diagnoses but they can be satisfied with two codes, one from ICD and a second from DSM. The quickest way to get rid of DSM-5 is a user's strike.
Two things I mentioned last month, the concept of innate behavioral dispositions and "anything goes" in psychiatry. I'll have to leave innate dispositions for another time. The problem of whether there are limits to psychiatry and where they are has always bothered me. It came up again in our little philosophy group the other week. Somebody asked: "Why are you so concerned with the idea of a science of mind? Why not dump it in the area of metaphysics and leave it at that?"
The answer is one word: Reliability. The whole question of what we should do, what is right, what works, depends on one concept: reliability. If I say to you, "Boys who jump around and talk too much in class have a biological or biochemical disease of the brain and should be put on powerful drugs for life," how reliable is that? Is is sufficiently reliable to put them on drugs? Is it so reliable that we should be held culpable for not giving them stimulants? These aren't trivial questions, as
I'm pleased to say that a paper will be published shortly that throws the question of the reliability of biological psychiatry right into the ring again. "Psychiatry as Ideology" will appear in
Ethical Human Psychology and Psychiatry later this month. It gives the results of a survey of the psychiatric literature I finished last year. I wanted to know the answer to a simple question: When people say that ordinary laboratory investigations will tell us all we need to know about mental disorder, what is their justification? In other words, how reliable is that claim? Because so many very important and influential people keep saying this, it seemed to me that there ought to be a justification somewhere. So, in a fit of madness, I decided to survey the recent psychiatric literature to find it. It started small but kept growing, until I looked at the thirteen most influential English-language psychiatric journals over a period of eleven years, to the end of 2011. There were something like 19,300 separate scientific papers, reviews, editorials, commentaries and surveys, occupying some 150,000 pages (just think of the trees). Every significant psychiatrist from all over the world was included, as well as swarms of the truly insignificant. If the justification exists, it had to be there somewhere.
Now if you're ever feeling a bit masochistic, you try reading all that tosh. By the end of it, I was stupefied, simply scanning the contents lists of the journals, looking for something,
any thing, that would count as a justification but when you see a title like this, which has 19 authors, you know it isn't there: "White Matter Microstructure in Individuals at Clinical High Risk of Psychosis: A Whole-Brain Diffusion Tensor Imaging Study." That's from
Schizophrenia Bulletin. I'm quite sure the editors wouldn't even know how to spell justification, let alone apply it to themselves. Anyway, the outcome is that nowhere, at any stage in the history of psychiatry, anywhere, has anybody in any position of responsibility, or even a complete
galah, given anything that could possibly amount to a justification of the claim "mental disorder is a form of biological disease of the brain." That's all there is to that.
So the statement, "Yes, your son has a biological or biochemical imbalance of the brain but don't worry, these tablets will fix him," has no reliability. In fact, it isn't even a scientific claim, it's ideological, a firmly-held opinion with no empirical justification. Therefore, all the talk about the biology of mental disorder is just a case of people presenting an extremely complex issue (the nature of mental disorder) in over-simplified, biased language to give the impression that the issue has been resolved in their favor when, as a matter of established fact, it hasn't. That is, all claims in biological psychiatry fail to meet the definition of science but, quite remarkably, they do meet the definition of propaganda. Isn't that interesting. Also interesting was the fact that this paper was rejected by five mainstream journals without a reason. Next month, when I've calmed down, I'll tell you about another rejection.
As an aside on the same topic, an article on "Suicide Disorder" in New Scientist didn't do much for my blood pressure. They have an astounding capacity to reduce complex questions to the level where junior high school students have no doubt they've got a grip on them. My response is here.
Anyway, back to our little philosophy group. This week, the speaker was Dr Joyce Arnold, who gave a talk based on her PhD topic, entitled "The Kabbalah in Freudian Psychology." The Kabbalah, as I vaguely knew, is the ancient accumulation of Jewish mythology. I wasn't looking forward to it, thinking it would be some arcane stuff on unproveables, especially as I got over Freud about thirty eight years ago (I was cured by starting to read Fenichel. Never finished). Anyway, to my surprise, her talk was absolutely fascinating. Of course, we're all used to Freudians saying that all of the Master's work was Science and he discovered it himself but guess what? There's not a word of truth in it. Seems that all of his ideas of the unconscious, myths, totems, sexuality and so on came straight from the mythology in which he was born and raised. It wasn't science, and he didn't discover any of it. In the original German, this is apparently quite clear (I can't read Freud in the original, too dense) but somehow, when it was translated into English by Ernest Jones, it was sanitised and whitewashed. Jones, it seems, was a fairly virulent anti-Semite, as were the Stracheys who set up the Hogarth Press to publish Freud's collected works. Freud, of course, was fully Germanised and didn't want anybody to know he was Jewish. By acclamation, Joyce was ordered to keep working on her project; we only hope she can complete the project in one lifetime because it's already grown enormously.
Somebody said something to me about "mood stabilisers" this week but I told him I never prescribe them, and they aren't mood stabilisers anyway, just general non-specific head-whackers (the term "Mood Stabiliser" was not really used before 1995 as it was part of the marketing lingo for Depakote, see Healy The Latest Mania: Selling Bipolar Disorder. PLOS 2006 (FREE FULL TEXT)). Wow, maybe I should learn to control my tongue. He was quite put out, started spluttering about neural membrane stabilisers and so on, so I felt it necessary to ask him if he knew how these drugs got their name? He didn't know. And what's the connection between bits of rat nerve in a Petri dish slowing their action potentials because their voltage-gated Na+ receptors are partially blocked, and a human spending less money? Predictably, he had no answer.
The story of these drugs is enlightening. In about 1966, one of the wealthiest men in the US (and therefore in the world), the financier, Jack Dreyfus, was given a script for phenytoin (Dilantin, one of the first and most toxic of the anticonvulsant drugs). I don't know why he got it, there's no evidence that he was epileptic but he was an odd, difficult and abrasive character so his doctor may have been desperate. Miraculously, this transformed his life. Mr Dreyfus reckoned he was a new man (most people didn't notice, including his wife) so he decided to sell phenytoin to the American medical profession. He set up a foundation to publicise phenytoin as an all-purpose personality restorer and eventually gave it $100mln to play with. One of their projects was to send to every American medical practitioner a copy of Dreyfus' book,
A Remarkable Medicine Has Been Overlooked.
Unfortunately for his pile of loot, it stayed overlooked, partly because the patent was about to expire and the manufacturers weren't much interested, but not least because phenytoin is unpleasant and very toxic. As a highly effective anti-folate agent, there is hardly an enzymic system in the body that it doesn't mess with. Neurologically, it interferes with cognitive and motor function to make people look and feel drunk. It is widely rumored that Dreyfus fed the drug to his friend, Richard Nixon, as he thought it would help his depression. It didn't, of course.
Anyway, by 1974, when I started psychiatry, people were trying carbamazepine in place of phenytoin. About 1968, two Japanese neurologists had found it was effective in calming very aggressive patients (there has always been this vague notion floating around biological circles that aggression is a form of pathological brain discharge), so it wasn't long before it was being given to odd, difficult and abrasive patients in psychiatry (like Dreyfus but without the money). From there, it was a small jump to trying it on psychotic patients. It wasn't a powerful sedative but it seemed to iron out the little ups and downs seen in some people with manic-depressive psychosis, so in no time, it was being sold as a remarkable new advance, to help people who couldn't tolerate lithium (most of them). Nowadays, there is a major industry diagnosing people with the bipolar syndrome and putting them on huge doses of drugs for life. The drugs have been given a new name (mood stabilisers; again see Healy), just as phenothiazines etc. were renamed "antipsychotics" to increase their market.
So we see a carefully-staged process:
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Find a drug that shuts up loud, demanding and/or vexatious people.
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Try it on as many groups as possible, especially groups who annoy psychiatrists. Do not report the failures.
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Give it a name that sounds impressive and plant informercials about the latest medical breakthrough.
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Create a demand for the new class of drugs by secretly subsidising "grassroots mental health groups" (subsidised 'grassroots groups' are better known as 'astroturf groups,' because they are synthetic and the nutrients trickle down, not up). An excellent documentary on the topic at large is (Astro) Turf Wars (Tea Party = Koch Brothers Astroturf). Healy's "Pediatric Bipolar Disorder: An Object Study in the Creation of an Illness" is amongst the best on the topic citing real-life astroturf campaigns.
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Give out research grants to keen young psychiatrists who need to climb the academic slippery pole. Remember, anecdotally I've heard NIH grants generally pay the institution 50-70% off the top (50% Temple University, >70% University of Pennsylvania). Since big-time researchers do meager to no clinical work, no grants = no job.
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Subsidise conferences, buy lots of adverts in psychiatric journals to the point where the editors are scared to upset the advertisers, etc.
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Watch your sales grow and laugh all the way to the bank.
Nifty formula, isn't it. It never fails.
As I said, I never prescribe these drugs. It is no doubt a coincidence that my patients never develop "rapid cycling bipolar disorder."
So much for the good news. The bad news came from our dear friends at the American Psychiatric Association jamboree in May. Somebody from South Carolina feels the need for a new psychiatric subspecialty, to be called "Interventionist Psychiatry." Just as other medical specialties have branched out into what they call "interventionist medicine," so should psychiatry, they feel. With advances in medical technology, specialties like radiology, gastroenterology and neurology have broadened their scope and now perform "interventionist" procedures. This means sticking needles and tubes into people to find out what is happening inside (gastroscopy, colonscopy, hysteroscopy etc) or inserting stents under radiographic control, and so on. Biological psychiatrists, ever anxious to keep up with the Dr Caseys, think we should be allowed to, too. Needles in the brain, that's what you need, my good man. (I can't give a link, it's subscription only but the article was in Medscape,
A New Psychiatric Subspecialty?May 30, 2013).
The authors listed all sorts of ways of spreading joy (not least because procedures make heaps more money than just sitting there listening to people). Their list included:
-Transcranial Magnetic Stimulation (relatively harmless except for the cost). They said: "A recent multisite, naturalistic, observational study of acute treatment outcomes in clinical practice demonstrated greater than 50% efficacy in sicker populations using TMS." Interesting. Placebos usually give about 54% improvement, so it isn't going very far backwards.
-ECT (of course). By the way, after 36yrs of working alone in the most difficult parts of this (admittedly difficult) country, I have to point out that I never use ECT. Never. In both psychiatric hospitals where I was chief psychiatrist, ECT stopped for the duration of my stay, and bed occupancy rates went down. As soon as I left, the ECT was resumed and occupancy rates went back to normal. Nursing unions were greatly relieved as it meant there was no further risk of closing wards. Now that's a shocking (!) thought, isn't it, nurses as advocates for ECT. We won't go down that path today.
-Focal electrically-administered seizure therapy (FEAST). Expensive experimental ECT.
-Vagus nerve stimulation (VNS). As its name sounds, makes your stomach gurgle. However, the authors added glumly: "Unfortunately, VNS was FDA approved prior to any Class 1 evidence of efficacy; thus, insurance companies have been reluctant to reimburse for the implant." Well, what a bunch of killjoys the insurance companies turned into. They want evidence? What next? But how does the FDA approve procedures without evidence? Next question, please.
-Deep brain stimulation (DBS), that's what's next. This involves sticking needles deep into the brain and lightly charring a few nuisance spots. However, they tossed in this aside: "There has also been an explosion in psychiatric side effects of DBS used for neurologic conditions like Parkinson disease." This is not a brilliant start. When DBS is used for Parkinson's Disease, it regularly drives the patients mad. Perhaps this is why they thought it should be used by psychiatrists. But don't worry: "The interventional psychiatrist should be adequately trained to troubleshoot these issues." First we drive you mad then we treat you.
-Finally, Transcranial direct-current stimulation (TDCS). This means wiring a person to get a weak DC current across his head. The good news is that 1mAmp won't kill you, unless you get addled and walk under a bus. Just for reassurance, they noted: "A recent study from Brazil demonstrated that when combined with sertraline, there is a synergistic effect in treating depression." Nobody would know. You could walk around with your patches on and everybody would think you're listening to a samba on your iPod but you're secretly getting your jollies, that's if you can put up with having no sex life because of the sertraline. But don't you love the next bit? "There are limited data currently, but it seems to have great promise and low cost." Of course there are limited data available, that's why they can talk breathlessly about it and suck the grants committees in. As soon as the hard data start to come in, it'll be found to be nothing more than placebo. They always are. You'd think they'd learn, but that's one thing about biological psychiatrists, they never get depressed over no results. Now if we could just distil that from them and market it, we're made. A bit like Groucho Marx: "In business, sincerity is everything. As soon as you can fake that, you've got it made."
Not to be outdone, Psychiatric Times jumped on the bandwagon with an article entitled "Deep Brain Stimulation: Evidence-Based Science or Wishful Thinking?" It was just a rehash of the usual gee-whiz nonsense, the only improvement being that the reporter had the grace to admit she didn't know how to tie her shoelaces. We knew that, but who would put it in a newspaper?
As a corrective to their Brave New World, if you haven't seen the story of Walter Freeman, "The Lobotomist," a documentary on PBS, you should. Ultra-scary. Be warned: Do not watch before bedtime. Talking of billionaires, I see the exquisitely detestable HL Hunt, role model for Dallas and inventor of ultra-conservative (read: fascist) radio and TV disinformation shows (based to some extent on the enviable success of a certain Herr Joseph Goebbels in Germany), had some fifteen children by three wives (all at once). His eldest son, who imbibed a little too deeply of his father's virulent paranoid bile, had the misfortune to became a patient of the good Dr Freeman. Hassie, as he was known, declined to wear clothes ever thereafter but wrapped himself in a sheet, telling people he had to haunt the lake on their estate as the family ghost. Sad but true.
Had a quick trip to Sydney this week to appear on a panel for the Rural Health Education Foundation, which tries to rectify some of the imbalances in opportunities for people who work "out there." It turned out to be a lot of work but everybody seemed to think that, for a bunch of complete amateurs, the five panelists did very well, including Jodey, first time on TV and about 38wks pregnant. We wish her well. I managed to get in my line about antidepressants increasing the risks of suicidal behaviour in the young.
