Chemical Imbalance Theory – Again and Again

 

I had this letter published today with my co-author Ron Pies, MD. It is basically a rebuttal to a more elaborate article (linked at the top of the letter) on chemical imbalance theory. I encourage any interested reader to look at that argument and then read our brief essay on why none of it supports a chemical imbalance theory.  Both Dr. Pies and I have written about this in the past – me on this blog and Dr. Pies in other literature (5-8). Several other authors have also discussed related issues (1-4, 9).  I think the refutation is fairly straightforward so this blog will be about the process. Why does this along with many other inaccurate portrayals of psychiatry continue to come up in the literature?  What follows is a few very clear answers but I fully realize that theses and explanations are rarely adequate to counter rhetoric.

1:  Repeating inaccurate claims is a standard strategy these days – it actually has been for decades.  The clearest modern example if the Big Lie of the last Presidential election.  Even a comprehensive presentation of the real evidence by the January 6^th Congressional Panel is not enough to shake the belief of election deniers.  In fact – election denial has become the latest cottage industry delivering hundreds of local lectures across the country.  Chemical imbalance theory has a similar life of its own and a group of proselytizers.  If the political comparison is too harsh – consider the advertising approaches. Any number of products that make health claims are sold every day based on repeating the same messages.  For years alcohol carried the message that it was a heart healthy product that increased HDL cholesterol and reduced the risk of heart attacks. Now we know that those studies were biased because they included alcohol users in recovery in the control group.  Dietary supplements are a $62 billion dollar industry despite questionable value and some concerns about toxicity in healthy populations with no clear nutritional deficiencies. All of these examples illustrate the power of repetitive messaging.

2:  It appeals to anecdotal experience – a common response is “well I heard somebody say it”, “I saw it posted on a web site”, or “my psychiatrist said it to me.”  Anecdotal experiences exist and obviously we cannot examine the intent of every statement. The reality for psychiatrists is that in psychopharmacology and biological psychiatry lectures, in textbooks, and in the published literature there is no reference to “chemical imbalance theory”.   In fact after reviewing the literature I concluded that comprehensive theories really don’t exist in psychiatry. On the other hand, over the past 40 years there have been over a hundred hypotheses about the causes of depression.

3:  There are clear biases against psychiatry as a field – when reading authors whether in professional journals, periodical, or books it is always useful to consider what else they have written. Is the book or paper a one-sided harsh criticism?  Does their previous work seem to make similar statements about the field?  It is already known that psychiatry gets much more than the expected levels of criticism in the press.  Is that criticism warranted? In many areas of this blog, I have pointed out that it is not warranted and, in many cases - it is grossly inaccurate.

4:  There have been no accurate histories of the intellectual development of the field.  To be sure there are specialized biographies of prominent historical figures and some of their influences but no clear timeline of how developments build on previous thought. I recently read that now that one of these historical figures has “scholars” rather than clinicians describing his work – we could expect much more, but I am not seeing it. To me – people who train and teach in the field are still the primary keepers of the working intellectual development of the field and everything that is relevant.

 Given all of these factors what can readers of our published letter do with that information?  If you are a psychiatrist or a physician – think carefully about your use of terms.  If you have used the term “chemical imbalance theory” or just “chemical imbalance” as a metaphor or something else – please reconsider. I think it is more useful to patients to let them know that depression or other clinical entities cannot be reduced to a single chemical event and I would invite you to use a statement from Nicholas Giarman – a noted neuropharmacologist:

“…nosologically it might be fair to compare the depressive syndrome with the anemias. Certainly, no self-respecting hematologist would subscribe to a unitary biochemical explanation for all of the anemias.”

 Nicholas J Giarman (1920-1968)  – The Biochemical Basis of Neuropharmacology – Fourth Edition 1982. p. 212

 

An explanation of heterogeneity and brain function would be ideal, but given time constraints and variable expectations of patients – an illustration of biological complexity is superior to a hopelessly inadequate metaphor. The same is true for literature that is handed out to patients. In that case, quoting the typical disclaimers in FDA approved package inserts as well as a brief summary of the research evidence for specific patients is a more optimal approach.

That is the real take home message.  

 

George Dawson, MD, DFAPA   

 

Supplementary 1:  What about advice to patients?  If you are considering taking an antidepressant or any other medication as a patient that usually means you are having a significant problem that you expect help with. The literature critical of psychiatry often suggests that this decision is casually made but that is not my experience either as a patient or a prescribing physician. Consider what is written about the mechanism of action of antidepressants. Chemical Imbalance Theory often implies that there has been dishonesty in presenting how a medication works and by extrapolation that psychiatrists don’t know much about anything. In fact, there are probably very few medications that you take where the mechanism of action is known with any high degree of certainty.  Aspirin was used for 70 years before its mechanism of action was determined (10).   Acetaminophen was first used clinically in 1887 and a preliminary report suggesting several potential mechanisms of action became available in 2009 (11).   Most decisions to take medications are not made based on knowing a mechanism of action. The overemphasis on mechanism of action of antidepressants is most likely based on pharmaceutical company advertising in the 1980s and 1990s.  At that time, the manufacturers of newer antidepressants emphasized that they were novel agents that probably worked through different mechanisms than the older medications and had a more favorable side effect profile.

As a patient you are entitled to as much detail on mechanism of action as you want and I hope that you will be able to get it directly from your physician or from other sources. I have treated basic scientists for depression and bipolar disorder and was able to give them adequate information – so it is definitely out there. But at a practical level – every person with a significant problem wants relief from that problem and no additional problems. The clinical discussion needs to be focused on whether the medication is working and the side effects are either non-existent or tolerable.  Further – informed consent means that you should have adequate information to make a decision about taking a medication.  That includes the likelihood of severe adverse drug events as well as more common side effects. Another common discussion in the media these days is withdrawal from antidepressant medications. A prescribing physician should be able to discuss that side effects in detail as well as rare events and a plan to address them.

 Credits:

1:  My co-author Ron Pies, MD read this post and made valuable suggestions for modifications.  It is difficult to indicate but he is a co-author of this post.

2:  Eduardo A. Colon, MD took the photograph used at the top of this post.

References:

1:  Morehead D. It’s Time for Us To Stop Waffling About Psychiatry. Psychiatric Times.  Dec 2, 2021  https://www.psychiatrictimes.com/view/its-time-for-us-to-stop-waffling-about-psychiatry

2:  Morehead D.  It’s Time for Us to Realize We Are All on the Same Side.  Psychiatric Times. Jan 18, 2022  https://www.psychiatrictimes.com/view/its-time-for-us-to-realize-we-are-all-on-the-same-side

3:  Morehead D.  The History of Psychiatry—A History of Failure? Psychiatric Times. April 19, 2022  https://www.psychiatrictimes.com/view/the-history-of-psychiatry-a-history-of-failure

4:  Morehead D.  Is There a Cure for Ignorance? The Shocking Truth About Psychiatric Treatment.  Psychiatric Times. June 27, 2022  https://www.psychiatrictimes.com/view/is-there-a-cure-for-ignorance-the-shocking-truth-about-psychiatric-treatment

5:  Pies RW.  Debunking the Two Chemical Imbalance Myths, Again.  Psychiatric Times. August 1, 2019  https://www.psychiatrictimes.com/view/debunking-two-chemical-imbalance-myths-again

6:  Pies RW. Nuances, narratives, and the “chemical imbalance” debate. Psychiatric Times. April 1, 2014.  https://www.psychiatrictimes.com/view/nuances-narratives-and-chemical-imbalance-debate

7:  Pies RW.   Psychiatry’s New Brain-Mind and the Legend of the “Chemical Imbalance”.  Psychiatric Times.  July 11, 2011 https://www.psychiatrictimes.com/view/psychiatrys-new-brain-mind-and-legend-chemical-imbalance

8:  Pies RW.  Doctor, Is My Mood Disorder Due to a Chemical Imbalance? Psychiatric Times.  August 12, 2011  https://www.psychiatrictimes.com/view/doctor-my-mood-disorder-due-chemical-imbalance

9:  Ruffalo, M. L., & Pies, R. W. (2018, August 19). The reality of mental illness: Responding to the criticisms of antipsychiatry. Psychology Today. https://psychologytoday.com/us/blog/freud-fluoxetine/201808/the-reality-mental-illness…

10:  Montinari MR, Minelli S, De Caterina R. The first 3500 years of aspirin history from its roots - A concise summary. Vascul Pharmacol. 2019 Feb;113:1-8. doi: 10.1016/j.vph.2018.10.008. Epub 2018 Nov 2. PMID: 30391545.

11:  Smith HS. Potential analgesic mechanisms of acetaminophen. Pain Physician. 2009 Jan-Feb;12(1):269-80. PMID: 19165309.

 

 

 

 

News Flash From Channel 5: "There is a shortage of psychiatrists"

This was an actual headline from a local news channel.  Of course the first question is where have they been for the last 30 years?  That was about the last time Anoka Metro Regional Treatment Center (AMRTC) was adequately staffed by psychiatrists.  In fact, at that point some of the psychiatrists working there considered it to be a high point in the education of medical students from the University of Minnesota.  One of them told me that their clinical rotation was the highest rated of any in the department.  The gist of this story is that the shortage of psychiatrists has led to inconsistent staffing for patients who need consistency.  The reporter emphasis was on Minnesota Department of Human Services hiring three psychiatrists with disciplinary actions on record with the Board of Medical Practice.  They also make the point that many of their psychiatrists are flown in for a few weeks at a time to see patients and this disrupts continuity of care.  The mother of a patient and a State Ombudsman comment about the importance of continuity of care.  If you watch the entire clip, the end is rather anticlimactic as the reporter points out that Minnesota is really no different than other states.  They are all suffering from the shortage of psychiatrists.

All in all a very dramatic presentation of a problem that nobody wants to solve.  After all, I just pointed out that in the late 1980s and early 1990s staffing at this same hospital was excellent.  The psychiatric staff there was first rate and one of the best hospital staffs that could be found anywhere.  So what happened?   In a word that I have used frequently on this blog mismanagement.  At some point professional managers decided to ignore the once popular theories of Peter Drucker and manage professional workers like production workers.  They saw psychiatry as a production job and eliminated the systems aspects critical for a team approach to psychiatric treatment.  That team approach is also critical to the practice environment and the practice environment and patient care also suffers when governments and insurance companies start telling physicians what to do and what to prescribe.  The outcome is as predictable as the current failed state hospital system.

None of those basics are in this sensational piece from Channel 5 News.  The only narrative I can detect in this story is that there are long distance psychiatrists and problematic psychiatrists practicing problematic psychiatry at the state hospital - at least until the main reporter starts with a focus on the shortage of psychiatrists.  Psychiatrists in this story function only as scapegoats.  That is easy to do when you limit the practice and hire people who are willing to work in a compromised treatment environment.  It is also easy to do when you eliminate psychiatrists and experienced psychiatric nursing staff from the management and planning aspects of the system.   Just last week I pointed out that there were no psychiatrists on a Governor's Task Force on Mental Health.  There are no psychiatric experts discussing hospital care or what it will take to repair the system in the news piece.  It is as if we are in a parallel universe, pretending that politicians and bureaucrats can do the job of psychiatrists without any training.  They can turn around and ration access to psychiatrists and then blame psychiatrists for all of the problems they have created.    Luckily,  I have been writing about this curious set of circumstances here for a few years.  You can follow my commentary in the links below and see how it compares to the skewed news version.

The additional question any reader should ask is why psychiatrists are never consulted and why attorneys and bureaucrats with no psychiatric training are in charge of these facilities?  This the cultural trend that started 30 years ago.  Throw out the doctors and run the healthcare system with politicians and bureaucrats that tell the doctors what to do.  Make is seem like doctors in state hospitals can operate in a vacuum rather than on teams and have the bureaucrats tell them how to manage clinical problems.  For a good portion of that 30 year period the word on the street was that the State of Minnesota was shutting down state hospitals and they were going to shut down AMRTC.  Those rumors do not inspire the confidence or commitment from medical or nursing professionals that you need to build a first rate state hospital system.  Who wants to go through credentialing and all that professional applications involve to apply to a hospital that is rumored to be closing soon?

The problem in Minnesota is not about trusting psychiatrists, no matter how bad a media article attempts to portray them.  This article is about trusting the politicians and bureaucrats that run this system.  In 30 years those politicians and bureaucrats have done nothing to merit anyone's trust in managing the public system of mental health care.  The failed state mental health system in Minnesota is an excellent example of what happens when you leave the management of a profession up to amateurs.


George Dawson, MD, DFAPA



Previous posts on the management deficiencies in the Minnesota state mental health system (click on the last word in each line for the post):


Executive Order: No Psychiatrists On Governor's Task Force On Mental Health [ 5/4/2016 ]

Minnesota's Mental Health Crisis - The Logical Conclusion of 30 years of Rationing [11/2/2015 ]

Minnesota State Hospitals Need To Be Managed To Minimize Aggression [1/6/2016 ]

Minnesota Psychiatrist Workforce Shortage [12/2/2015 ]

The CMS Investigation Of Anoka Metro Regional Treatment Center [1/19/2016 ]

Minnesota Finally Rejects Managed Care [5/29/2015]

More On Violence And Aggression In Minnesota Hospitals [12/11/2014 ]

Minnesota Continues A Flawed Approach To Serious Mental Illness And Aggression [12/9/2014 ]

The Shadow State Hospital System [ 11/6/2014 ]

Use Of "Medical Model" As A Pejorative Term

Hearing “medical model” being used used pejoratively is quite tiresome.  I have heard it used that way for the past thirty years, usually to take a shot at psychiatrists.  I thought I would illustrate how this goes and what I disagree with by responding to a recent article authored by the British Psychological Society on how the system of care for psychotic disorders should be changed.  My interest is not in provoking an argument since I think that these errors are obvious.  The target audience is also relevant here and it is described as “service users, their friends and families, journalists, policymakers, mental health workers and the public.”  As such this is really a political document very similar in nature to the documents generated in the US by SAMHSA or treatment guidelines generated by other special interest groups like managed care companies.  That being the case, I will not spend any time on the technical aspects of psychosis alluded to in this paper.  As a political document it requires active refutation or the suggestions might be adapted as wholesale measures.  I don’t know if British psychiatry is any more successful in doing that than the American counterparts, but judging from what I have read in editorials – I doubt it.  Let me start out with a couple of the authors’ statements about the “medical model”.

"At least in the UK, most mental health services are currently based on the ‘medical model’ – the assumption that experiences such as hearing voices indicate illness and result from some sort of problem with the brain. (p. 103). This idea is also enshrined in mental health law and is the basis for compulsion. In the past many professionals have also believed that people experiencing distressing voices or paranoia are unlikely to recover without treatment (usually medication). This belief has led to a perceived ‘duty of care’ to provide treatment, and a tendency to view someone who does not want the treatment being offered as lacking in insight. As this report has shown, both of these assumptions are unfounded." (p. 103 from Reference 2)

And:

"In the past services have been based on what might be called a ‘paternalistic’ approach – the idea that professionals know best and that their job is to give advice. The ‘patient’s’ role is to obey the advice (‘compliance’). This now needs to change. Rather than giving advice, those of us who work in services should think of ourselves as collaborators with the people we are trying to help." (p. 104 from Reference 2) 

The authors definition of a “medical model” looks at three dimensions.  The first is the assumption that psychotic experiences are due to a brain problem.  That is partially true.  They limit themselves to what they describe as “idiopathic” causes of psychosis and ignore specific psychotic states and etiological factors.  They also exclude medical illnesses that are clearly associated with psychotic symptoms.  That happens to be the area that psychiatrists are trained to recognize and treat.  Trivializing psychiatric diagnosis as a list of symptoms that most clinicians do not refer to anyway is certainly consistent with the authors’ main points of contention, but fortunately that is not reality.  Finally, the diagnostic manual that they criticize has numerous categories that have been researched strictly as psychotic disorders (and anxiety and mood disorders) caused by social etiologies rather than brain problems per se.  Early in my career, I reviewed the predominately Scandinavian literature on brief psychoses or brief reactive psychoses so that I could provide necessary prognostic information to patients and their families.  More clear evidence that significant psychotic symptoms can spontaneously remit without any medical intervention.  That information is a critical part of any medical approach to a spontaneously remitting illness.

Secondly, they go on to say that this also means that “professionals” believe that people are unable to recover without treatment.  I don’t know about other professionals but psychiatrists since the time of Kraepelin have known that people recover without treatment, although in Kraepelin’s day they considered asylum care alone to be treatment.  Like many illnesses people can recover without treatment and the literature on brief psychosis is further evidence.  Psychiatrists have also known that specific types of psychosis (catatonia for example) have very grim prognoses without treatment. Some of the earliest studies showed that malignant catatonia had an 80% mortality rate at the turn of the 19th century.  By the turn of the 20th century the mortality rate approaches 1% or less with modern treatment. So the second part of the definition is clearly wrong.

Finally, the authors use “paternalism” to characterize the role of physicians.  This is a charge that frequently accompanies the so-called medical model often amidst the associated charge of authoritarianism.  It is also incorrect.  Medicine is based on the informed consent model of care.  Any psychiatrist is more aware of this than most other physicians.  Informed consent is based on the idea that the patient is provided with adequate information to make a risk-benefit decision and the patient and physician collaborate on the patient’s decision.  I have these conversations every day and many times a day.   Doing nothing, being referred somewhere else, and being denied the agreed upon care by a managed care company are all additional possibilities.  These conversations can occur with patients who are actively bleeding out on the floor and refuse to allow a trauma surgeon to intervene due to impaired judgment from psychosis.  In that particular situation surgeons are likely to remind anyone involved in the care that they would be assaulting the patient if they intervened and did not have informed consent.  Similar situations occur with people who have various forms of treatable but life threatening illnesses (operable cancer, impending paralysis, uncontrolled diabetes mellitus, etc) who were unable to make decisions in their best interest due to the effects of psychosis.

So - the authors’ definition of a medical model is wrong in 2 ½ of 3 dimensions. That is not a good starting point for a proposal to go beyond the “outmoded medical model”.  It is always good to know what the model really is before declaring it outmoded.  I think a lack of scholarship and experience in these matters in a common characteristic of people who criticize the “medical model” in psychiatry.  Of course it is generally not a scholarly endeavor.  For anyone interested in educating themselves in what a real medical model might look like I would suggest reading Systematic Psychiatric Evaluation (Reference 1) or any other guide to psychiatric evaluation.   Take a look at Appendix A and B for the quick story.   The fact that models like this one are widely emulated by nonphysicians may speak to their utility in understanding and treating psychosis and other mental disorders.

How do the authors do on their characterization of psychosis?   They seem to touch on the high spots. Mention of hallucinations, delusions, and formal thought disorder are all there.  They are obviously heavy on phenomena that would not typically come to the attention of psychiatrists, people who experience hallucinations and delusions or some grey zone phenomena that are not quite psychotic symptoms.  But what about the central feature of psychosis that generally comes to the attention of psychiatrists (the ones within the “medical model”)?  It turns out the authors have little to say about judgment or insight.  They have nothing to say about the conscious state of the individual.  These are the distressing and often life threatening aspects of the illness.  This is the aspect of psychotic illness that causes friends and family to state that they no longer recognize the person due to the disruption of their personality characteristics.  Are we really to believe that psychiatrists are having casual conversations with people intellectually curious and not bothered by hallucinations and delusions? Are we really to believe the affected person may not have experienced a profound change in their conscious state that makes them unrecognizable to their friends and family and unable to work or perform their basic life activities? Are we really to believe that change in conscious state may not possibly represent an acute danger to the person affected or their loved ones? Only people who have not been seriously affected by psychotic states and people who are not responsible for assessing and treating those states can make those statements.  Those people generally do not need to see psychiatrists.

The authors claim that a “lack of insight” can result in a person being detained for mental illness. That does not happen where I practice. I have to document “behavioral evidence” rather than a lack of insight and treatment refusal can also not be used as a basis for detaining someone.  In the USA, there is a strong financial incentive to discharge people from hospitals as soon as possible.  The businesses and governments who manage these facilities welcome treatment refusals.  The patient can be discharged immediately with no follow up demands.  From a business perspective that is "cost-effective care".  If any paternalism exists, it is at a societal level.  Society is the proper arbiter of how its most vulnerable citizens should be treated.  Should they be forced into treatment or allowed to die with their rights on?  Psychiatrists have no choice but to follow society's lead.  If psychiatrists have no vested interest in forced treatment, one of the critical questions is why it exists in the first place?  The obvious answer is that it is a far from perfect approach to help families get their loved ones treated and even then families are routinely disappointed.  Hospitals and courts can still have their own interpretations of these laws that will save them money but not provide necessary treatment.  In the end there is still no medical paternalism.

There are two other sections in this paper that merit commentary – dangerousness and etiologies of psychosis.  After their selective and inaccurate characterization of psychiatric assessment the authors drop this bomb:

"Some psychologists are reaching the conclusion that psychosis is often no more and no less than a natural reaction to traumatic events. For example one recent paper suggested that ‘there is growing evidence that the experiences service users report … are, in many cases, a natural reaction to the abuses they have been subjected to. There is abuse and there are the effects of abuse. There is no additional ‘psychosis’ that needs explaining’." (p 42 from Reference 2)


That is a very interesting observation to psychiatrists who screen all of their new evaluations for trauma history and post-traumatic stress disorder (PTSD).  Instead of a “recent paper” what if I am a psychiatrist seeing 500 new cases per year and I screen everybody I see for psychosis, PTSD, childhood adversity and other forms of psychological trauma.  What if over the space of 4 years and 2,000 new evaluations I observe that about 30% of my patients have significant childhood adversity or psychological trauma, about 5-10% have PTSD related to that trauma and about 5% have psychotic symptoms totally unrelated to previous trauma.  I pose that hypothetical because it would be the common experience of most psychiatrists.  The issue of trauma being a cause for symptoms should also lead to the examinations of previous errors postulating trauma as an etiology for symptoms most notably the Multiple Personality Disorder (MPD) fiasco and the associated phenomenon of Satanic Ritualistic Abuse (SRA).  I would recommend against even using highly qualified statements about this as a possible etiology for psychosis without ample evidence.  Although research bias is a frequent accusation in the area of psychopharmacology research, there is no reason to suspect that favorite theories in psychosocial research are less bias producing.

The authors fall back on the statement about mental illnesses not implying dangerousness.  In the vast majority of cases that is true.  It is also true that the population with the most significant illnesses need to be evaluated for suicidal and aggressive behavior.  Tragedies that occur as a result of impaired judgment and altered conscious states from psychotic disorders are commonplace.  People with these problems can be successfully treated and violence and suicide can be prevented.  It is not enough to suggest that people with mental illnesses may be stigmatized by any connection with violence.  People with psychotic disorders and aggression are among the most stigmatized people in our society.  The solution is not to deny that this problem exists but to identify this as a treatable problem and develop an appropriate public health response.  There is also a very strong bias in the American legal system to punish rather than treat anyone with a psychosis who commits a crime.  Escaping punishment as a result of the not guilty by reason of insanity defense (NGRI) is one of the most consistent urban legends in America.  This defense is hardly ever a success and even then it is likely that the patient involved will spend more time in a forensic prison/hospital than they would have if they were criminally sentenced without the NGRI defense.

The authors are certainly wrong about any “medical model” of psychosis or mental disorders that I am used to seeing.  My medical model is the model of Engel and Chisholm and Lyketsos informed by Kandel and others.  There are very few places it can be practiced in the United States because business interests run the field of psychiatry and medicine.  American managed care companies and governments can certainly reduce psychiatric assessment to a series of checkmarks in the electronic health record and documentation that may be unreadable.

A business model of rationing is not a medical model by any stretch of the imagination.  That business model is also not one that will prove to be receptive to any enlightened model of community care.  The best evidence of that is that the ACT (Assertive Community Treatment) Model invented by Stein, Test and others in 1974.  This model consists of active outreach, crisis intervention and housing, medical and psychiatric care, vocational rehabilitation, and peer counseling with a focus on helping individuals maintain stable housing in the community.  There is no insurance company that I know of that supports this level of care.  The ACT Model is cost shifted to state governments and they strictly ration who gets that level of care.  With regard to Cognitive Behavioral Therapy there is no insurance company that I know of that consistently supports research recommended course of therapy for the conditions that have long standing indications – the anxiety and depressive disorders.  What is the likelihood that it will be supported for the treatment of psychotic disorders and grey zone conditions?

I will hold my remaining remarks on the treatment implications of this paper.  This blog contains extensive commentary on that issue and the real limitations on comprehensive assessment and treatment.

None of those limitations are due to a “medical model.”

George Dawson, MD, DFAPA


References:

1. Margaret S. Chisholm, Constantine G. Lyketsos. Systematic Psychiatric Evaluation. A Step-by Step Guide to Applying The Perspectives of Psychiatry. 2012 The Johns Hopkins University Press. 243 pp.

2. The British Psychological Society. Understanding Psychosis and Schizophrenia. Edited by Anne Cook. Available on the web site of the British Psychological Society.

Turning the United States Into Radioactive Dust

I don't know if you noticed, but it appears that the post cold war era is over.  The Putin appointed head of a Russian news agency Dmitry Kiselyov went on Russian television this morning and stated that Russia is "the only country in the world capable of turning the USA into radioactive dust."  In case anyone wanted to dismiss that as being short of a threat, he went on to say the President Obama's hair was turning gray because he was worried about Russia's nuclear arsenal.  We have not heard that kind of serious rhetoric since the actual Cold War.  As a survivor of the Cold War, I went back and looked at what time period it ran for and although it is apparently controversial the dates 1947 to 1991 are commonly cited.  I can remember writing a paper in middle school on the doctrine of mutually assured destruction as the driving force behind the Cold War.  In the time I have thought about it since, some of the cool heads that prevented nuclear war were in the military and in many if not most cases Russian.  We probably need to hope that they are still out there rather than an irresponsible broadcaster who may not realize that if the US is dust, irrespective of what happens to Russia as a result of weapons, the planet will be unlivable.

I am by nature a survivalist of sorts.  And when I detect the Cold War heating up again I start to plan for the worst.  The survivalist credo is that we are all 9 meals away from total chaos.  So I start to think about how much food, water, and medicines I will have to stockpile.  What king of power generation system will I need?  What about heating, ventilation and air filtration?  And what about access?  There are currently condominiums being sold in old hardened missile silos, but what are the odds that you will be able to travel hundreds of miles after a nuclear attack?  If you are close to the explosion there will be fallout and the EMP burst will probably knock out the ignition of your vehicle unless you have the foresight and resources to store it inside a Faraday cage every night.  There is also the question of what happens to the psychology of your fellow survivors.  In the post apocalyptic book The Road - a man and his son are surviving in the bleakest of circumstances on the road.  We learn through a series of flashbacks that their wife and mother could not adapt to the survivalist atmosphere and ended her life.  In one scene, they meet an old man on the road and the man gets into the following exchange with him after the old man says he knew the apocalyptic event was coming.  It captures the paradox of being a survivalist (pp 168-169):

Man:  "Did you try to get ready for it?"
Old Man:  "No.  What would you do?"
Man:  "I don't know"
Old Man:  "People always getting ready for tomorrow.  I didn't believe in that.  Tomorrow wasn't getting ready for them.  It didn't even know they were there."
Man:  "I guess not."
Old Man:  "Even if you knew what to do you wouldn't know what to do.  You wouldn't know if you wanted to do it or not.  Suppose your were the last one left?  Suppose you did that to yourself?"

By my own informal polling there are very few people who want to unconditionally survive - either a man-made or natural disaster.  Many have told me that they could not stand to be in their basement for more than a few hours, much less days or months or years.

For the purpose of this post, I want to hone in on the rhetoric or more specifically the threats.  I have had previous posts on this blog that look at how this rhetoric flows from the history of warfare and dates back to a typical situation with primitive man.  In those days, the goal of warfare was the annihilation of your neighbors.  In many cases, the precipitants were trivial like the theft of a small number of livestock or liaisons between men and women of opposing tribes.  In tribes of small numbers of people, even when there were survivors if enough were killed it could mean the extinction of a certain people.  Primitive man seemed to think: "My adversaries are gone and the problem is solved."

Over time, the fighting was given to professional soldiers and it seemed more formalized.  There were still millions of civilian casualties.  I think at least part of the extreme rhetoric of Kielyov is rooted in that dynamic.  Many will say that is is propaganda or statements being made for political advantage and in this case there are the possible factors of nationalism  or just anger at the US for some primitive rhetoric of its own.  But I do not think that a statement like this can be dismissed without merit.  There were for example two incidents where Russian military officers exercised a degree of restraint that in all probability prevented a nuclear war.  In one of those cases the officer was penalized for exercising restraint even though he probably avoided a full scale nuclear war.  In both cases the officers looked into the abyss and realized that they did not want to be responsible for the end of civilization as we know it.

I don't think extreme rhetoric is limited to international politics.  It certainly happens with every form of intolerance at one point or another if that intolerance is rooted in race, religions or sexual preference.  That is especially true if there are physical threats and physical aggression.  Intolerant rhetoric can also occur at a more symbolic level.  We have seen extreme rhetoric on psychiatry blogs recently.  Rather than the annihilation of the United States, the posters would prefer the annihilation of psychiatry.  I would say it is a symbolic annihilation but it is clear that many of them want more than that.  It still flows from the sense of loyalty to tribe, the need to annihilate the opponents, the necessary rigid intolerance and the resulting distortion of rational thought.  Certainly self serving bias exists to some extent in everyone, and it may not be that apparent to the biased person.  It took Ioannidis to open everyone's eyes to that fact in the more rational scientific world.  It can serve a purpose in science where the active process often requires a vigorous dialogue and debate.  Sometimes people mistake science for the truth when science is a process.  In order for that dialogue and debate to occur in an academic field there has to be a basic level of scholarship in the area being debated.  Without it there is a digression to tribal annihilation dynamics and complete intolerance.  That is counterproductive and negates any legitimate points that the proponents might otherwise have.

In science, the risks are lower.  At the minimum it adds nothing to the scientific debate.  An irrational bias with no basis in reality is the most primitive level of analysis.  In the 21st century, nobody needs to be annihilated in reality or at the symbolic level.

George Dawson, MD, DFAPA

Cormac McCarthy.  The Road.  Vintage Books.  New York, 2006.

An Obvious Response to "Psychiatry Gone Astray"

David Healy has what I consider to be inconsistent viewpoints.  I have previously critiqued his viewpoint on the "addictive" qualities of antidepressants (they clearly are not) and whole heartedly endorsed his position that pills don't treat depression - psychiatrists do.   He recently posted what I would refer to as a screed written by a Danish internist on (what else?) all of the problems with psychiatry.  The obvious lack of symmetry here is striking.  You won't find a psychiatrist anywhere posting a similar piece about internal medicine, even though it could be easily done and would probably be more evidence based.  In that regard this physician has slightly more credibility that the typical layperson screed against psychiatry - but not much more.  What follows is my point by point refutation of the "myths".  They are mythical in that they are from the mind of the author - I know of no psychiatrist who thinks this way.

Myth 1: Your disease is caused by a chemical imbalance in the brain -

This is a red herring that is frequently marched out in the media and often connected with a conspiracy theory that psychiatrists are tools of pharmaceutical companies who probably originated this idea.  What are the facts?  Psychiatry has at least a century old tradition of researching all possible etiologies for mental health problems.  Psychiatrists were among the first people to look at the effects of social deprivation in orphanages, the effects of acute grief and loss, the effects of psychological trauma, the effects of a full gamut of psychotherapies, and the effects of family and environment.  The biopsychosocial formulation of Engel in 1977 was an advance detailed in Science magazine.  Any comprehensive psychiatric formulation covers all possible etiologies (as an obvious example see Systematic Psychiatric Evaluation by Chisolm and Lyketsos).  In addition there are many clinical methods where the diagnostic formulation is essential for the treatment plan for psychotherapy based treatment.  By definition that formulation would have few biological references.  So the alleged myth fails at the clinical level.

It fails even worse at the neurobiological level.  Chemical imbalance rhetoric always seems to ignore one huge fact and that is Eric Kandel's classic article on plasticity in 1979 in the New England Journal of Medicine.  Certainly any psychiatrist who saw that article has never bought into a "chemical imbalance" idea and I can recall mocking the idea when pharmaceutical companies presented it to my colleagues and I in medical school.  So why don't we hear: "Your disease is caused by plasticity?"  Probably because they gave Eric Kandel the Nobel Prize for it.

Myth 2: It’s no problem to stop treatment with antidepressants - 

Another red herring.  I have trained psychiatrists, internists, family physicians and medical students and taught them psychopharmacology.  A general principle of psychopharmacology is no abrupt changes in therapy and most drug prescribing information suggests that.  I routinely address this issue as part of informed consent and advise people that there may be difficulty discontinuing antidepressants and describe the potential symptoms.  This criticism from an internist has a certain degree of asymmetry to it.  Certainly there are medications prescribed by internists that cause both acute withdrawal and discontinuation symptoms.  My impression is that many adults who see internists are basically going along with life long therapy in many cases for conditions that could be treated by psychosocial measures.  It is quite easy to criticize if you are never faced with the prospect of discontinuing therapy.

Myth 3: Psychotropic Drugs for Mental Illness are like Insulin for Diabetes -

The author here conflates the certainty of insulin deficiency with pathophysiological certainty in medicine and how that correlates with prescribed treatment.  Certainly that is not the case in diabetes mellitus Type II or the recent example I provided with an asthma exacerbation.  In fact the pathophysiology in those heterogenous groups are about as accurate as endophenotypes in psychiatry.  Am I getting prednisone for my asthma because I am deficient in prednisone?  Am I getting it because of some specific pathophysiological mechanism rather than a shotgun approach to shut down all of my inflammatory signalling?  Was predisone prescribed only based on the purported pathophysiological mechanisms?  The answer to all three questions is - of course not.  If the author is really concerned about medication side effects, I can't think of any psychiatric medication that is the equal of prednisone but I am certainly not going to suggest that it should not be prescribed.

Myth 4: Psychotropic drugs reduce the number of chronically ill patients - 

I don't know of anyone who has actually suggested this and from an internal medicine perspective does it make sense?  Here are a few additional comparison statistics on asthma and hypertension for example.  There is a 10% prevalence of asthma in the developed world.  Only 1 in 7 has their symptoms in good control.  People continue to die of asthma possible as many as 1/250 deaths world wide.  In the case of hypertension, 31% of Americans have it and another 30% have prehypertension.  Only 47% have adequate blood pressure control.  There is really not much evidence that medications prescribed by internists are much more effective than what he refers to as "psychotropic drugs" and that is borne out in a previous analysis and my own recent experience with the health care system.

I find this argument also demeaning to anyone with a severe psychiatric disorder who is interested in staying out of hospitals and being able to function or trying to avoid a suicide attempt.  Being able to adhere to that kind of plan depends on multiple variables including taking medications.  It is reckless to suggest otherwise and any psychiatrist knows about severe adverse outcomes that have occurred as a result of stopping a medication.  The author conveniently plugs his book at this point.

Myth 5: Happy pills do not cause suicide in children and adolescents -

The author reveals his antipathy to medication used by psychiatrists here by referring to antidepressants as "happy pills."  I know of no psychiatrist who I have ever met who calls antidepressants "happy pills" and in fact most of us are engaged in trying to find an effective medication with minimal side effects.  David Healy himself describes this as one of the primary functions of psychiatrists.  On the actual suicide issue, psychiatrists goal is preventing suicide.  Suicide is a possible outcome of all clinical encounters and psychiatrists follow this symptom closely.

Saying that happy pills are a cause of suicide is the equivalent of saying that "sugar medicine" (insulin) is a cause of hypoglycemia that harms children and therefore it should not be prescribed.

Myth 6: Happy pills have no side effects -

The author has one legitimate point in that depression screening is not a good idea but in his zeal to criticize everything psychiatric he has to whip that into "happy pills have no side effects".  Of course they do and I have elaborated my clinical method on how to approach that in detail.  He goes on to make an anecdotal argument about single study results versus "what the company says."  In fact, companies have to rigorously record side effects in clinical trials and all of that is recorded in the FDA prescribing information.  Looking at standard FDA reported data for sexual side effects (his example) the number for all SSRI antidepressants is   9-37% and not the 5% figure suggested by the author.  (see page 1684 of Drugs Facts and Comparisons 2013).

Myth 7: Happy pills are not addictive -

This is interesting because of David Healy's confusion on this subject.  It indicates a serious lack of knowledge about addiction because there are no behavioral features of antidepressant medications or animal models that describe these drugs as addictive.  They have no street value and they will not make you high.  The authors comparison to amphetamine is completely off the mark and consistent with his general lack of knowledge of addiction.

Myth 8: The prevalence of depression has increased a lot -

He has to attach epidemiological data on depression in order to attack the argument that increasing antidepressant use is not a problem because of the increasing prevalence.  He offers a sarcastic comment as evidence and misses both the issue of why antidepressant prescriptions are increasing and the real data on the prevalence of depression.  Even if his argument is correct, since 80% of antidepressants are prescribed by primary care physicians wouldn't this be "Primary care gone astray?"

On the epidemiology issue I would encourage a quick look at an actual text on the issue like Textbook of Psychiatric Epidemiology, 3rd Edition.(p 292)  The authors look at 30 national and international studies and do not conclude that there is an increasing prevalence of depression, but that variation is likely due to methodological differences and sociocultural factors. 

Myth 9: The main problem is not overtreatment, but undertreatment -

More sarcasm as evidence here.  I debunked the arithmetic used in this argument in an earlier Washington Post piece.  This is also a huge disservice to people with severe mental illness and addictions in this country who have been thrown out of treatment, received useless hospital treatments, and restricted from medications by managed care.  The primary prescribers of antidepressants (by far) are primary care physicians and it is certainly possible that they are prescribing too many antidepressants.  But don't blame psychiatrists for that.

Myth 10: Antipsychotics prevent brain damage -

More rhetoric.  In this case he is using a research hypothesis and suggesting that this has something to do with clinical psychiatry.  Despite significant obstacles, psychiatric research at the neurobiological level continues and studies on imaging are a large part of that process.  One of the major areas has to do with brain volumes and their implications.  The author presumes he knows what the outcome of that research will be.  He also talks about antipsychotic medication with the arrogance of a person who does not have to treat acutely psychotic people and incredibly talks about these drugs killing people.  In fact, the number one killer of people with severe mental illnesses is tobacco smoke and there is ample evidence that they get suboptimal primary care.

At the end of this refutation what have we learned?  I am more skeptical than ever of David Healy and his web site.  I thought he did good work with his investigation of SSRIs and his analysis of the role of psychiatrists as opposed to medications was accurate.  But I can't ignore the fact that he places this screed on his web site.  He also lists  himself as a "scientist" and this screed contains surprisingly little science.  It is essentially all rhetoric and politics.

It is one thing to ridicule psychiatrists but the obvious concern here is that it stigmatizes people who need treatment especially treatment with medication who are actively denied treatment in the U.S. on an ongoing basis.  The author here uses a familiar dynamic that I have described in the past. He suggests that internists (like the author here) have clearly superior methods or pathophysiological mechanisms than psychiatrists but they don't.  In terms of the accusation of overprescribing, it is well know in the US that the 20 year CDC initiative to control antibiotic overprescribing is a failure.  Some authors believe that this heralds a new "post antibiotic era" where untreatable infections will become the rule.

It seems to me that internists have enough to focus on in their own specialty before criticizing an area that they obviously know so little about.  It also seems that if you claim your web site is scientific, you should probably put a little science on it.  The author here also states that he is affiliated with the Nordic Cochrane Center and I think that anyone who considers the output of that Institute should consider what he has written here and the relevant conflict of interest issues.

George Dawson, MD, DFAPA

Supplementary 1: About a month after this post was completed Ronald Pies, MD came out with an article in the Psychiatric Times entitled Nuances, Narratives, and the “Chemical Imbalance” Debate.  He presents very similar arguments to the ones presented here and concludes that it is time for the critics using this false argument to give it up.  I also like his characterization of "a recent online polemic posing as investigative journalism" and how the "chemical imbalance hypothesis" is used to mischaracterize psychiatry.  He also provides a link to a 2011 article that he wrote that contain the following quote:

"I am not one who easily loses his temper, but I confess to experiencing markedly increased limbic activity whenever I hear someone proclaim, “Psychiatrists think all mental disorders are due to a chemical imbalance!” In the past 30 years, I don’t believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. "

Readers of this blog have heard seen me say this many times before.  It is good to see these opinions being offered in the more mainstream media.  It is also good to see Dr. Pies taking calling a critic on what is rhetoric rather than reality.  Well done.

Supplementary 2:  I have an updated post on the issue of how medical syndromes and psychiatric syndromes are far more similar than different and how there is a complete lack of criticism relative to psychiatry. (added on September 3, 2015).

Quebec beer-drinker's cardiomyopathy revisited

In the 1960's a condition called Quebec beer drinker's cardiomyopathy was described in the medical literature.  Between August 1965 and April 1966 46 men and 2 women were admitted to 8 hospitals in Quebec with acute cardiomyopathy and congestive heart failure.  Twenty of them died.  During the epidemiological analysis it was determined that they were all heavy beer drinkers.  An extensive analysis of the this phenomena is available in full text at the initial link on this page.  For those of us trained through the end of the 20th century the clinical methods in the 1960s were not that far removed.  The mystery was solved then by a combination of epidemiology and pathology:

"Suspicion of cobalt as the toxic agent was aroused after examination of the thyroid glands removed at autopsy showed changes similar to those found in cobalt intoxication. Had cobalt been added to the beer? Yes"

Similar patterns had been observed in Minneapolis, Omaha, and Louvain (Belgium).  Why am I suddenly interested?   The New England Journal of Medicine Clinical Problem-Solving case of the week entitled "Missing Elements of the History."  In this case a 59-year old women who was previously in good health develops acute congestive heart failure and a cardiomyopathy is diagnosed.  She has a complicated course with an initial pericardial effusion.  After acute treatment no etiology of the cardiomyopathy was determined and she was assessed for heart transplantation.  Her heart failure worsened and she developed cardiogenic shock and needed a left ventricular assist device.  Three months later she received a heart transplantation and was discharged home in 20 days.

Was the patient in question a drinker of cobalt laced beer?  No - but she did have cobalt in her body.  She had bilateral DuPuy ASR metal-on-metal hip prostheses that had been placed 5 years and 4 years prior to the heart transplant.  She had learned about one year prior to transplantation that the prostheses were being recalled due to a higher than expected failure rate and a protocol for follow up was sent to her.  She was advised to get repeat hip imaging and serum cobalt levels done.  Pelvic MRI showed reactive areas with fluid collection and the cobalt level was elevated at 287.6 mcg/liter with a reference value of less than 1.0 mcg/liter.  The prostheses were removed 11 and 13 months post heart transplantation.  She had a complicated course but apparently recovered.  Serial cobalt levels were done and 16 months after transplantation remained at 11.8 mcg/liter a significant drop.  She also had a chromium level determined at 248.9 mcg/liter about 8 months after transplantation.

The NEJM article points out that about 1 million people had these prostheses implanted between 2003 and 2010.  The authors here strike me as being overly modest in saying that they cannot absolutely confirm that this is a case of cobalt induced cardiomyopathy, but there is just too much evidence to hedge around.  Read their timeline of events in Table 1. and see what you think.  It would certainly seem to have implications for regulatory bodies like the FDA.  The parallel regulatory body in the UK states that any patient there needs lifetime annual follow up including imaging and blood cobalt and chromium levels.   The FDA recommendations are much more nonspecific and they appear to be placing the monitoring burden on primary care physicians and  other specialists.

What does the New York Times report about this story?  They have a story in November 2013 about $2.5 - 3 billion being award to a group of about 8,000 patients in the US.  They have another story that the manufacturer seemed to know earlier about the high than expected failure rate and need for replacement.  In that same story they quote the total number of recipients as "93,000 people, about one-third of them in the United States" as opposed to the NEJM estimate of 1 million people world wide.  Most of the stories I could find (15 of 26) were in the business section.  There is an interesting quote near the end of the article about how taking it off the American market was strictly a business decision.  In other articles there is a hint of a cover up and a hint of doctors not speaking up to warn other doctors, but the story has been out there since March 2010.  Where is the outrage?

We have just gone through a several year period of bashing psychiatrists for daring to rewrite a diagnostic manual that they use by themselves.  Further that manual explicitly says that you really can't just read the manual.  You need to be trained in medicine and psychiatry first.  There was plenty of outrage then.  Critics of all types in the New York media writing an endless stream of negatives about psychiatry and the DSM-5.  Accusations of conflict of interest (more appropriately the appearance of conflict of interest).  Outrage over various parties not being to have enough input into the book (when in fact the web site designed for that purpose took in thousands of comments that were debated by the work groups).  Outrage over whether the manual was written to appease the pharmaceutical industry that ignored the basic facts.  I could certainly go on, but what is the point?  Everyone has heard these stories.  They are commonplace.

The DSM-5 came out and nothing happened.  Clinical psychiatrists did not blink an eye or make any major changes.  Nobody ended up with elevated cobalt or chromium levels.  Nobody ended up with needing  more surgery or congestive heart failure from cardiomyopathy.   I certainly do not want to minimize what all of these hip implant patients are going through but it seems that the press and the FDA are doing just that.  I think the lesson is certainly there when you look at how the media overreacts to psychiatry they end up appearing to be very tolerant of significant problems in other fields of medicine.

My suggestion for the psychiatry critical press is that it might actually be worthwhile to critique other branches of medicine where there are significant problems.  Hold them up to the standard that you apply to psychiatry and see what happens.

If you can't there is clearly something wrong.  At the minimum I propose that outrage should be proportional to a real problem rather than the appearance of a problem.  Or better yet - it could just disappear and be replaced by a more rational analysis.

George Dawson, MD, DFAPA

Allen LA, Ambradekar AV, Devaraj KM, Maleszewski JJ, Wolfel EE.  Missing elements of the history.  N Engl J Med 2014: 320(6): 559-566.

Siegel E, Lautenbach AF.  Determination of cobalt in beer. Siebel Institute of Technology and World Brewing Academy.  Interesting historical document on why cobalt may be added to beer including the fact that the FDA apparently approved this application in 1963.

Clinical Note 1: I added this for the clinical psychiatrists out there who I know see a large number of people with hip implants.  Be on the lookout for pain, lack of follow up with their surgeon or signs and symptoms of congestive heart failure.  The FDA warning also suggests depression and cognitive changes.  MedlinePlus also has patient handouts.  It probably is also a good idea to remember that some people may be taking cobalt and/or chromium ionic forms as a supplement.  As an example poor quality information that can be seen on the Internet, there is some information on the that cobalt boosts erythropoetin (EPO) and athletic performance that is based on animal studies from the 1950s.  Trying that would obviously be an extremely bad idea.  A history of use of supplements is important for these reasons.

The Lancet's Illogical Digression

The latest editorial in the Lancet has an illogical digression.  The brief note starts out by stating that there will soon be a revolution in psychiatry based on a genomics study published in the Lancet.  It concludes with a digression to a discussion of about the provision of mental health services across the lifespan with a pejorative connotation:

"The child with ADHD at 7 years could be seen by a child psychiatrist, but at the age of 18 often loses access to mental health services altogether, until he presents with a so-called adult mental health problem. Substance misuse and personality disorders may complicate the picture."

It seems to me that practically all adult psychiatrists would not have any difficulty at all in getting a history of an earlier diagnosis of ADHD and deciding how that would be treated.  I wonder if the Lancet's editors would make the same commentary on childhood asthma presenting to an Internal Medicine clinic.  Would that be "so-called adult asthma"?  The asthma example is instructive because it turns out that what physicians have been calling asthma for decades is more complicated than that.  Recent research has adopted the endophenotype/endotype methodology that has been used to study schizophrenia.  The reason why adults are seen by adult psychiatrists rather than child psychiatrists is the same reason why people stop seeing their pediatricians as adults.  Treating cormorbid substance misuse and personality disorders is just a part of that reason.

As far as the idea that the future of psychiatry is set to change any more than the future of the rest of medicine consider the statement:

"The future of psychiatry looks set to change from the current model, in which ADHD, bipolar disorder, or schizophrenia are considered as totally different illnesses, to a model in which the underlying cause of a spectrum of symptoms determines the treatment."

If that were true, psychiatry would have suddenly catapulted into the most scientifically advanced medical specialty because currently there is no other medical specialty that treats illness based on an underlying genetic cause.   The Lancet's attached paragraph on access to services across the lifespan is accurate, but it really has nothing to do with the possible genetic revolution in psychiatric diagnosis.  If the services are anywhere near as bad in the UK as they are in the United States (Is public health rationing as bad as rationing done by corporations?) there is a widespread lack of services and disproportionate rationing relative to the rest of medicine.

Until psychiatrists, psychiatric services, and mental illness are destigmatized there is no reason to think that a genetic revolution will mean more access to services.

George Dawson, MD, DFAPA

The Lancet.  A revolution in psychiatry.  The Lancet - 1 June 2013 ( Vol. 381, Issue 9881, Page 1878 ) DOI: 10.1016/S0140-6736(13)61143-5.

Cross-Disorder Group of the Psychiatric Genomics Consortium.  Identification of risk loci with shared effects on five major psychiatric disorders: a genome-wide analysis.  The Lancet - 20 April 2013 ( Vol. 381, Issue 9875, Pages 1371-1379 ) DOI: 10.1016/S0140-6736(12)62129-1

Hamshere ML, Stergiakouli E, Langley K, Martin J, Holmans P, Kent L, Owen MJ, Gill M, Thapar A, O'Donovan M, Craddock N. A shared polygenic contribution between childhood ADHD and adult schizophrenia. Br J Psychiatry. 2013 May 23.  [Epub ahead of print] PubMed PMID: 23703318.

Larsson H, Rydén E, Boman M, Långström N, Lichtenstein P, Landén M. Risk of bipolar disorder and schizophrenia in relatives of people with attention-deficit hyperactivity disorder.  Br J Psychiatry. 2013 May 23. [Epub ahead of print] PubMed PMID: 23703314.

The Latest Proclamation by Allen Frances

Just when you think that Allen Frances has run out of editorial venues for his anti DSM5 critiques another one pops up.  This time it is in the Annals of Internal Medicine.  This is a note about that process before I get into addressing his repetitive critiques.  The Annals is a respected medical journal.  For a number of years I was an ACP member and subscribed to it myself.  Why would the Annals go along with publishing an editorial piece that is basically a rehash of what has been published in the New York Times and the Huffington blog and who knows where else?  There is really precious little science involved.  I think the only logical explanation is that the staff of the Annals has jumped on the popular bias against psychiatry that has been widely noted in the press by Claire Bithell and her group that studies these issues.  I am not a current subscriber to the Annals but the question is whether there was equal time for rebuttal.  If not is this professional bias against psychiatry?

Probably the best way to address this rehash of old criticisms is to link up to previous blog posts here where that occurs.  Beginning in paragraph one Dr. Frances cites a famous study about pseudopatients as though it has some applicability to the issue of “unreliable and inaccurate” psychiatric diagnosis.  He cites this study as if it is somehow relevant to the problem.  All of the considerable scholarship refuting this study as meaningful by various authors including Spitzer and Kety is ignored.   Using this as a premise for a scholarly article on the validity of psychiatric diagnosis should raise an eyebrow or two, but on the other hand I doubt that there is anyone on the editorial board at this Internal Medicine journal who is familiar with this literature.

The issue of diagnostic inflation is a frequent critique used by Frances and others to suggest that this invalidates the DSM5.  Most people are very surprised to learn that compared to previous editions and the ICD-10 this is really not an issue.  The previous blog post illustrates that compared to the ICD-10, the possible increase in diagnostic categories in the DSM is trivial.  The increase in the number of codes for a knee fracture alone approximates the total codes in the DSM!  Contrary to his description of “holding the line” with DSM-IV diagnoses – the data presented in that post shows that the DSM-IV added twice as many diagnoses as the DSM5 will.

Dr. Frances uses the “no bright line” approach to say that there is no way to separate the worried well from people with disorders.  There certainly is no written “bright line” in the DSM.  Every DSM has a section with qualifying statements about its use and that fact that diagnostic criteria alone are not sufficient.  A psychiatric diagnosis, especially a diagnosis made by psychiatrists in the same group with the same focus is very consistent and it is a reliable marker of illness severity.  Professional judgment is required.  The “no bright line” issue is not a problem that is unique to psychiatry.  It is omnipresent in general medicine with regard to chronic pain diagnoses, chronic pain treatment, and in the overprescription of pain medications and antibiotics.  The overprescription of antibiotics has been identified as a problem by the Centers for Disease Control (CDC) for 20 years and recent authors suggest that minimal progress has been made.  It seems that other specialties are subject to the “fallible subjective judgments” suggested in this article.

Another implicit myth used by Dr. Frances and other critics of psychiatry is that there is some magical diagnostic process that occurs in medicine and surgery that makes them better than psychiatric diagnoses.  What happens when we test that theory by looking at the reliability of general medical diagnoses?  Looking at that data, it is clear that the published reliability data from medicine and surgery is no better than the frequently criticized data from psychiatry even when objective medical tests are used.  Practically everyone I know has a favorite story about a misdiagnosis and/or ineffective treatment of a medical or surgical problem.  That evidence does not support the contention that psychiatry is somehow less accurate or effective than the rest of medicine.  Some medical specialties used similar descriptive techniques even when they have numerous biological markers of the illness.  The other elephant in the room on this diagnosis issue is medically unexplained symptoms.  The studies of all patients coming in to a clinic setting suggest that 30%  do not get a diagnosis to explain their symptoms.  These patients often get multiple tests looking for a cause for their problem.  This is by far the most significant problem that I hear from relatives, acquaintances, and the public in general.  If nonpsychiatric medical diagnoses are supposed to be highly accurate based on biological tests – a substantial number of people never actually experience that.

On the fuzzy diagnosis in psychiatry critique, a common theme here is to go after the bereavement exclusion and suggest that normal bereavement will be treated like depression.  I have an extensive response to this when it was posted in a newspaper article and invite any interested reader to look at the previous blog post and the fact that this approach to grieving patients who come to the attention of psychiatrists has been written about for over 30 years (see last 5 paragraphs at link).  Practically every point in this section of the editorial can be disputed but the point of the article is not a scientific review, it is basically a selection of comments to support a specific viewpoint.

To Dr. Frances credit he references an excellent meta-analysis by Leucht, et al on how the results of psychiatric treatment are as good or better than the results of other medical specialties.  He is silent on how that occurs if psychiatric diagnosis is so unreliable and inaccurate.  How is it possible to get results that good compared with other specialties?  Maybe it is because as I have just suggested, the “special problems” in psychiatric diagnosis are really general problems that are shared by all medical specialists?

The criticism is less focused in the final paragraphs with some commentary on style points about the DSM political process, the issue of conflict of interest focused on publishing profits, and the idea that the APA should submit the DSM to oversight by a broad coalition of “50 mental health associations”.  Let me take the last point first.  There are a number of other diagnostic approaches and manuals that have been completed by coalitions of several other mental health organizations.  With the number of different approaches, I would encourage any organization to publish their own approach to the diagnosis of mental disorders.  Contrary to the rhetoric suggesting that there is a DSM monopoly, nothing could be further from the truth.  The entire text of the World Health Organization’s (WHO) ICD-10 is available free online.  The Mental and Behavioral Disorders section of the ICD-10 gives detailed descriptions of each disorder.  The detailed research criteria for ICD-10 can be purchased for about ¼ the cost of a DSM5.  It seems to me that there is a marketplace of ideas and plenty of competition.  If I was not a psychiatrist with an interest in reading about developments in my field, I would not be compelled to purchase a DSM5.  I would probably take a few courses in the changes to DSM-IV and stick with that for a while.

On the issue of submitting the DSM5 to outside groups there are several compelling reasons why that would not be a good idea for most psychiatrists.  Some critiques have suggested that psychiatry should be open to forced collaboration by others based on previous relationships.  Over the span of my career, I have noted that there is often an adversarial approach by other organizations rather than an affiliative one.  And why wouldn’t there be?  This is the United States and everyone here is familiar with the competitive and politicized atmosphere.  It seems like that has been left out of the equation when charges of “conflict of interest” are leveled at the APA in the area of publishing a DSM.  A recent critique of the DSM5 also suggested broader collaboration with social scientists and I critique that article here.  The political slant of all of these articles is that the APA needs the input of others to improve descriptive psychiatry.  Including that in an article that has a basic thesis that: “We will be stuck with descriptive psychiatry for the forseeable future.” (line 27-28) being a negative is inconsistent.  If anything Dr. Frances seems to be suggesting that we should be moving more to the biomedical side and  distancing ourselves from the social scientists.  The bottom line here is that the DSM5 is a diagnostic guideline for psychiatrists to use in clinical practice.  It is not synonymous with a psychiatric diagnosis and it is used at some level by psychiatrists to understand mental disorders.  It is not designed for anyone to read and act like a psychiatrist and it has nothing to do with people who do not have psychiatric problems.  It is not a “Bible” like the New York Times suggests.  It is a tool for psychiatrists and if you are not a psychiatrist there may be no reason for you to buy it or even think that it is relevant to you.

On the issue of Dr. Frances serial DSM5 critiques - this seems like a war of attrition to me.  Dr. Frances has an infinite number of venues that are quite willing to publish his very finite and repetitive criticisms of the DSM5 and the associated process.  Outside of myself – there appears to be nobody else including the American Psychiatric Association who is willing to offer the obvious counterpoints.  He has more time on his hands and many more connections than I do.  So in terms of sheer volume I guess this is a Pyrrhic victory of sorts.  I will have to be content with expressing the opinion of a psychiatrist who practices real psychiatry,  making diagnoses and helping people every day and knowing that my results are on par with anybody else in medicine and that there is nothing random about it.

George Dawson, MD, DFAPA