Disease-modifying or something else?

 

A paper written by S. Nassir Ghaemi, MD was posted this week and in it he discussed the concept of diseases modifying medications and whether any medication used for psychiatric purposes might be included in that category.  Dr. Ghaemi is a distinguished psychiatrist who has written on diverse topics.  He is a prominent psychiatric theorist and also has complied many of his ideas about psychiatry and psychopharmacology in the book Clinical Psychopharmacology (1).   

In the book he presents a brief discussion of disease modifying medications and how few there seem to be in psychiatry as well as what he considers to be obstacles to the discovery of these agents.  He does suggest in the book that lithium, clozapine, and possibly a few anticonvulsants may be considered disease-modifying rather than symptomatically effective or palliating medications. This recent paper presents his latest ideas on the subject.

In his paper he is much more specific.  His premise is that there are disease-modifying drugs and drugs that only treat symptoms and that nearly all psychiatric drugs fall into the latter category. He reviews his rationale for these classifications and emphasizes the lack of understanding of pathophysiology of mental illnesses as a main reason for this deficiency. His talking points are ideal newspaper headlines and will probably are easily assimilated by many who don’t know much about psychiatry or medicine.  This blog post is an elaboration of this story.

In order to build those arguments, let me start with a brief introduction to rheumatology.  My personal introduction to that field occurred in medical school when I had my first acute gout attack and had a medicine attending who was a rheumatologist and two senior medicine residents who aspired to and eventually became rheumatologists. I happened to be at the medical school with one of the top experts in the field Daniel J. McCarty. MD.   Rheumatology in general looks at inflammation in the narrowest sense in joints but more broadly in the body and in multiple organ systems. Rheumatologists are experts in all forms of arthritis but also systemic illnesses with joint manifestations like systemic lupus erythematosus (SLE) and rheumatoid arthritis (RA).  The American College of Rheumatology lists the diagnostic criteria for 20 major groups of illnesses on their web site with additional criteria for subclassification.

Why should psychiatrists have an interest in rheumatology?  My initial interest was in the diseases themselves as well as the classification system. Like psychiatric categorial diagnoses, the rheumatology classification system is criterion based, based on expert consensus and ongoing scientific review, and the sensitivity of the criteria are adjusted according to what is clinically indicated. For example, a category could be adjusted to be more inclusive with more false positives – if it was important to identify early disease stages and prevent progression in the future.  The disease categories are important to psychiatrists because their overlap with psychiatric diagnoses.  For example, neuropsychiatric SLE (NPSLE) is defined as the usual symptoms of SLE with a central nervous system manifestation like seizures, psychosis, or cognitive problems.  It is in the differential diagnosis of patients with psychosis. In addition, there are currently active hypotheses about the role of inflammation in the pathophysiology of depression, psychosis, and neurocognitive disorders at a level that is far below the threshold for overt rheumatological disease.

The similar classification system brings up similar concerns in rheumatology relative to psychiatry. The issue of classification versus diagnosis for example. In a recent review of that issue the problem described in rheumatology by a group of experts is basically the same problem encountered in psychiatry:

“Rheumatologists face unique challenges in discriminating between rheumatologic and non-rheumatologic disorders with similar manifestations, and in discriminating among rheumatologic disorders with shared features.  The majority of rheumatic diseases are multisystem disorders with poorly understood etiology; they tend to be heterogeneous in their presentation, course, and outcome, and do not have a single clinical, laboratory,pathological, or radiological feature that could serve as a “gold standard” in support of diagnosis and/or classification.” (3)

 Psychiatry or the equivalent term could be substituted for rheumatology, rheumatologic, or rheumatic in the above paragraph without skipping a beat. Before the current pandemic many rheumatology clinics were treating patients with symptoms that could not be clearly attributed to rheumatic disease.  In some cases, about 1/3 of patients were in that category (4).  The issue is complicated by the fact that non-rheumatic origins of some of these symptoms need to be recognized and addressed (5).  The difficulties associated with rheumatic diseases have led to “spectrum” descriptions of illness but as far I can tell no push for dimensional rather than categorical diagnoses. There has also been a concern about recognition in primary care settings with delayed referral to rheumatologists (6).

Disease complexity is difficult to address and rheumatologists like psychiatrists see a number of conditions that do not remit, are progressive and can be fatal and/or very disabling, and for which there are few good treatments. It is common in psychiatry to see patients with rheumatoid arthritis who are treated on a chronic basis with low dose prednisone – where the dose is adjusted according to disease activity and degrees of complications from the medication. In other words, the focus of treatment is symptomatic rather than curing or modifying the course of the disease.   

Unlike psychiatry, rheumatology had an early focus on disease modification and using the term “disease modifying” drugs.  The earliest reference to “disease-modifying” in PubMed that I could find was 1976 (7). 

 

 

But the connections to subsequent papers from that original paper seemed to stop in the 1980s.  That suggests to me that there was an evolution of the terms and the medications used as DMARDS.  Searching through modern medicine texts like UpToDate shows that most of the references to disease-modifying medications is focused on rheumatology diseases, multiple sclerosis and some other neurological illnesses, and a few rare conditions.  In some cases, the focus is on a complication is a single organ system or an intermediate phenotype of the main disease.

In a paper specifically written about the term in rheumatology, Buer (8) describes the concept of disease modifying anti-rheumatic drugs or DMARDS beginning in the 1970s with the goal of preventing bone erosion from rheumatoid arthritis. Use of the term increased over the next two decades outlasting several competing terms.  The early purpose was to distinguish between medications that could slow or modify the progression of disease and those that provided symptomatic relief. 

Another potential reason that the disease-modifying was developed in areas of medicine where inflammation and immunological mechanisms where thought to play a part in disease pathology was the longstanding and widespread use of glucocorticoids (GC).  GC drugs like prednisone have been used for 60 years, are used by a substantial portion of the population and that use is growing (15).  The purported mechanisms of action have been clarified over time and are currently characterized as genomic and non-genomic (cytosolic GC receptor mediated and specific/nonspecific effects).  The effect occurs at the level of cytokines, cell membranes, and immune cells. The disease modifying effects of GC were first described in 1995 and are thought to be limited to bone loss in the early stages of rheumatoid arthritis.

Considering the characteristics of an ideal medicine that is curative or preventive and the definitions of a disease modifying drug there is a lot of room for interpretation.  Endocrinopathies come to mind – specifically deficiency states where replacement therapy of thyroxine, corticosteroids, growth hormone, or gonadal hormones corrects the deficiency state that is some cases is life-threatening.  Diabetes mellitus is another example.  Correcting insulin deficiency culminating in human insulins designed to provide more even coverage of glucose levels has resulted in a significantly altered life span for juvenile onset diabetes and for adults. There are also examples in cardiology both from the standpoint of longevity and secondary prevention of heart attacks, strokes, and renal failure. But most of the literature on disease modifying medications is focused on rheumatology and multiple sclerosis (US).

Using MS as an example, I compiled a table of all current FDA approved MS treatments, the year of approval, and what is known about the mechanism of action (MOA).  The MOA in each case is taken directly from the FDA approved package insert.  In the case of natalizumab, there were several paragraphs describing the purported mechanism of action so I included a link to the package insert. The important observation from this table is that in the case of all 18 FDA approved medications – the mechanism of action is unknown. That statement is made in various ways. For example, there may be a suggested hypothetical MOA but it is just that. In the case of MS disease-modifying drugs are based on an unproven hypothesis, rather than a known mechanism of action or theory. I have not constructed a table for rheumatology disease modifying drugs but I expect the same results based on the quotation from reference 3 above. Disease-modifying drugs do not appear to be specifically designed to address and underlying MOA – but are empirically determined based on hypotheses like every other drug.

 

FDA approved drugs for MS and Mechanism of Action

Drug	Type	MOA
Glatiramer (Copaxone) Approved 1996	SC Injection	“The mechanism(s) by which glatiramer acetate exerts its effects in patients with MS are not fully understood. However, glatiramer acetate is thought to act by modifying immune processes that are believed to be responsible for the pathogenesis of MS.”
Interferon beta 1a (Avonex) Approved 1996	IM injection	“The mechanism of action by which AVONEX exerts its effects in patients with multiple sclerosis is unknown.”
Interferon beta 1b (Betaseron) Approved 1993	SC injection	“The mechanism of action of BETASERON (interferon beta-1b) in patients with multiple sclerosis is unknown”
Peginterferon beta 1a (Plegridy) Approved 2014	SC injection	“The mechanism by which PLEGRIDY exerts its effects in patients with multiple sclerosis is unknown”
Dimethyl fumarate (Tecfidera) Approved 2013	Oral tab	“The mechanism by which dimethyl fumarate (DMF) exerts its therapeutic effect in multiple sclerosis is unknown. DMF and the metabolite, monomethyl fumarate (MMF), have been shown to activate the Nuclear factor (erythroid-derived 2)-like 2 (Nrf2) pathway in vitro and in vivo in animals and humans. The Nrf2 pathway is involved in the cellular response to oxidative stress. MMF has been identified as a nicotinic acid receptor agonist in vitro.”
Fingolimod (Gilenya) Approved 2010	Oral cap	“Fingolimod is metabolized by sphingosine kinase to the active metabolite, fingolimod-phosphate. Fingolimod-phosphate is a sphingosine 1-phosphate receptor modulator, and binds with high affinity to sphingosine 1-phosphate receptors 1, 3, 4, and 5. Fingolimod-phosphate blocks the capacity of lymphocytes to egress from lymph nodes, reducing the number of lymphocytes in peripheral blood. The mechanism by which fingolimod exerts therapeutic effects in multiple sclerosis is unknown, but may involve reduction of lymphocyte migration into the central nervous system.”
Teriflunomide (Aubagio) Approved 2012	Oral tab	“Teriflunomide, an immunomodulatory agent with anti-inflammatory properties, inhibits dihydroorotate dehydrogenase, a mitochondrial enzyme involved in de novo pyrimidine synthesis. The exact mechanism by which teriflunomide exerts its therapeutic effect in multiple sclerosis is unknown but may involve a reduction in the number of activated lymphocytes in CNS.”
Alemtuzumab (Lemtrada) Approved 2001	IV infusion	“The precise mechanism by which alemtuzumab exerts its therapeutic effects in multiple sclerosis is unknown but is presumed to involve binding to CD52, a cell surface antigen present on T and B lymphocytes, and on natural killer cells, monocytes, and macrophages. Following cell surface binding to T and B lymphocytes, alemtuzumab results in antibody-dependent cellular cytolysis and complement-mediated lysis.”
Mitoxantrone (Novantrone)   Approved 2000	IV Infusion	“Mitoxantrone, a DNA-reactive agent that intercalates into deoxyribonucleic acid (DNA) through hydrogen bonding, causes crosslinks and strand breaks. Mitoxantrone also interferes with ribonucleic acid (RNA) and is a potent inhibitor of topoisomerase II, an enzyme responsible for uncoiling and repairing damaged DNA. It has a cytocidal effect Reference ID: 3105100 on both proliferating and nonproliferating cultured human cells, suggesting lack of cell cycle phase specificity. NOVANTRONEâ has been shown in vitro to inhibit B cell, T cell, and macrophage proliferation and impair antigen presentation, as well as the secretion of interferon gamma, TNFα, and IL-2”
Natalizumab (Tysabri) Approved 2004	IV infusion	“The specific mechanism(s) by which TYSABRI exerts its effects in multiple sclerosis and Crohn’s disease have not been fully defined”  additional
Dalfampridine (Ampyra) Approved 2010	Extended-release tab	“The mechanism by which dalfampridine exerts its therapeutic effect has not been fully elucidated. Dalfampridine is a broad spectrum potassium channel blocker. In animal studies, dalfampridine has been shown to increase conduction of action potentials in demyelinated axons through inhibition of potassium channels.”
Ofatumubab (Kesimpta) Approved 2009	SC injection	“The precise mechanism by which ofatumumab exerts its therapeutic effects in multiple sclerosis is unknown, but is presumed to involve binding to CD20, a cell surface antigen present on pre-B and mature B lymphocytes. Following cell surface binding to B lymphocytes, ofatumumab results in antibody-dependent cellular cytolysis and complement-mediated lysis.”
Cladribine (Mavenclad) Approved 1993	Oral tab	“The mechanism by which cladribine exerts its therapeutic effects in patients with multiple sclerosis has not been fully elucidated but is thought to involve cytotoxic effects on B and T lymphocytes through impairment of DNA synthesis, resulting in depletion of lymphocytes.”
Siponimob (Mayzent) Approved 2019	Oral tab	“Siponimod is a sphingosine-1-phosphate (S1P) receptor modulator. Siponimod binds with high affinity to S1P receptors 1 and 5. Siponimod blocks the capacity of lymphocytes to egress from lymph nodes, reducing the number of lymphocytes in Reference ID: 4409346 12 peripheral blood. The mechanism by which siponimod exerts therapeutic effects in multiple sclerosis is unknown, but may involve reduction of lymphocyte migration into the central nervous system.”
Ocrelizumab (Ocrevus) Approved 2017	IV infusion	“The precise mechanism by which ocrelizumab exerts its therapeutic effects in multiple sclerosis is unknown, but is presumed to involve binding to CD20, a cell surface antigen present on pre-B and mature B lymphocytes. Following cell surface binding to B lymphocytes, ocrelizumab results in antibody-dependent cellular cytolysis and complement-mediated lysis.”
Ponesimod (Ponvory) Approved 2021	Oral tab	“Ponesimod is a sphingosine 1-phosphate (S1P) receptor 1 modulator that binds with high affinity to S1P receptor 1. Ponesimod blocks the capacity of lymphocytes to egress from lymph nodes, reducing the number of lymphocytes in peripheral blood. The mechanism by which ponesimod exerts therapeutic effects in multiple sclerosis is unknown, but may involve reduction of lymphocyte migration into the central nervous system.”
Diroximel fumarate (Vumerity) Approved 2013	Oral delayed release capsule	“The mechanism by which diroximel fumarate exerts its therapeutic effect in multiple sclerosis is unknown. MMF, the active metabolite of diroximel fumarate, has been shown to activate the nuclear factor (erythroid-derived 2)-like 2 (Nrf2) pathway in vitro and in vivo in animals and humans. The Nrf2 pathway is involved in the cellular response to oxidative stress. MMF has been identified as a nicotinic acid receptor agonist in vitro.”
Ozanimod (Zeposia) Approved 2020	Oral capsules	“Ozanimod is a sphingosine 1-phosphate (S1P) receptor modulator that binds with high affinity to S1P receptors 1 and 5. Ozanimod blocks the capacity of lymphocytes to egress from lymph nodes, reducing the number of lymphocytes in peripheral blood. The mechanism by which ozanimod exerts therapeutic effects in multiple sclerosis is unknown but may involve the reduction of lymphocyte migration into the central nervous system.”

 

Effect sizes for the above medications can be calculated from the package inserts.  The typical active drug/placebo comparisons include relapse frequency (per time interval), percentage of relapse-free patients, reduction in relapse rates, time to first or second relapse, progression free days, and numbers of new Gadolinium enhancing lesions on MRI scan. This data is also plotted on survival curves. The calculations will be made at some point and compared to similar data for lithium and selected DMARDs.

With that backdrop consider the main points in Dr. Ghaemi’s paper – that do go beyond the disease-modifying concept:                                                                                                                                                

     1.  Symptomatic versus disease modification:

As I hoped to capture in the preceding paragraphs – the issue of disease modification is a laudable goal but a complex one. Even chemotherapy treatments that are curative vary in effectiveness and can leave patients with complications from treatment that are disabling or even fatal. There can also be at higher risk for future cancers unrelated to the original treated cancer. Many symptomatic medications used on a maintenance basis decrease mortality risk and disability (hard outcomes) even though they are not disease-modifying. Anticonvulsant medications are a good example.  Where seizure risk in generalized tonic-clonic seizures can be decreased it significantly reduces the risk of sudden unexpected death in epilepsy (SUDEP) (9).

      2.     Effect size:

The paper cites effect size as being problematic at two levels.  The first is the actual calculated effect size and the second in the end point – clinical metrics versus hard outcomes measures. The first issue has been explored in the literature at an exhaustive level. The unfortunate approach by many including a prominent epidemiologist who suggested antidepressants had no effect and then later was a coauthor of a paper showing an effect is a dichotomous one rather than an exploration of reality. The issue is the same with all polygenic heterogenous diseases.  There will be a group of responders, a group of partial responders, and a group of non-responders.  There is an associated overlay of placebo and nocebo responders. And depending on the trial there are varying levels of severity, heterogenous recruitment levels, and varying levels of support for research subjects confounding the trials.

The classification of effect sizes has also been problematic. Benchmarking of mild, moderate, and robust effects sizes have been suggested but are generally considered a weak approach.  The actual effects sizes can be calculated and discussed along with moderating factors. It is possible to include different effect size calculations in the same table by specifying the method used and the relevant parameters of the trial.   Effect sizes that are considered low can become significant over large populations.

      3.     Disease modification specific to psychiatry:

Lithium, clozapine, and some anticonvulsants are known to be disease-modifying drugs in psychiatry largely measured with the hard outcomes of time to relapse or number of relapses in a set period of time. These medications address some purported mechanisms at the hypothetical level since there is no widely accepted theory about how they work and there are many hypothetical mechanisms.  Considering the entire course of illnesses in psychiatry medications that are not technically disease-modifying can make a significant difference in hard outcomes. The best example that I can think of and Luther Bell (10) described a mortality rate of 75% in a cohort of 40 patients admitted to McClean Hospital in 1849. Today with the advents of advances in both medical treatment and electroconvulsive therapy the mortality in this group of patients is essentially zero. Does preventing death qualify a medication approach as disease-modifying?  If so, the modern medical treatment of catatonia (benzodiazepines, antipsychotics, mood stabilizers) qualify. Another example is the use of long acting injectable (LAI) antipsychotic medications.  These medications clearly reduce the rate of relapse in both schizophrenia and bipolar disorder.  Does that qualify them for disease modifying status even though the specific mechanism of action is unknown?  Clinical psychiatry has clearly made progress in terms of hard outcomes irrespective of where you draw the line on disease modification.

      4.     The DSM is biologically invalid:

Somewhat of a straw man – I don’t think there was ever a claim that it was. That said there has been rumored validity markers of psychiatric disorders that have apparently never been released by the DSM study groups and the most obvious marker of robust medication effect has never been used.  Further study of the RDoC and other proposed alternate systems of classification do not seem any more biologically valid at this point. At the minimum biological phenotyping may be useful and it currently exists to a limited degree (catatonia).  A lot of mileage has been made out of the fact that a focus on the biological aspects of psychiatric illness has not yielded any pertinent clinical information and that this somehow justifies increased psychosocial research. That minimizes the issue of complex heterogenous diseases and what it takes to understand them. Psychiatry compared with rheumatology is a good example – but on the other hand psychiatric disorders are more intimately linked to conscious states and those states can affect every level of interpretation of a drug response.  

      5.     Clinical trial design deficiencies

 There are many and I have already listed a few.  An additional deficiency is the general regulatory scheme that seems to focus on getting a minimal efficacy signal.  Pharmaceutical companies are incentivized to complete these trials as soon as possible.  Anyone who has worked as an investigator in a clinical trial knows that this is a frustrating process largely due to the inclusion and exclusion criteria. There are pressures to recruit the necessary patients as soon as possible.  Randomization is a hurdle.  What does it say when the number of people declining participation in the study greatly outnumbers the people who have been recruited?  Many of them decline because of randomization to possible placebo or an inability to be notified after the study about whether they received placebo or not. At the design level, the recruiting problem also can affect choices of comparator drugs and the doses of those drugs. More long-term studies require more funding and retaining patients in the study becomes an important task for researchers.  Intent-to-treat analysis based on considering all of the patients entering the protocol as the denominator in the study is another limitation in that it does not resemble clinical practice where getting to responder status as soon as possible independent of any particular drug is a priority.  

 The discontinuation design in maintenance studies of antidepressants were described as a problem in terms of falsifiability.  Most of them show an active drug effect and apparently psychiatric medications are the only class of drugs that the FDA allows to use this discontinuation paradigm. The practical issue in terms of clinical treatment is what happens when antidepressants are stopped.  Some early work in the pattern analysis of antidepressant response suggested that the placebo effect faded over time but the active drug effect did not.  Psychiatrists need to know what the treatment scenarios are with drug discontinuation.

 There has not be enough discussion of registry and observational studies. The advantages are that they use large data bases and can look at hard outcomes like relapse, hospitalization, suicide, and other types of mortality.  It fits the current FDA regulatory category of Real World Evidence (RWE) and Real World Data (RWD).  The main advantage is the population studied in the registry is not screened by inclusion and exclusion criteria or by a participatory agreement and therefore more accurately approximates a true clinical population (14).  The time interval for RCTs is typically limited by funding for a duration of years. Registry studies based on a database can be much longer in duration and the data is a standard administrative feature. Safeguards have been developed to reduce bias in registry studies and some groups consider them to be a good indication of how a medication works in real clinical settings. Although I have not seen it done, registry studies could potentially confirm some of the effect sizes when applied to much larger populations.

      6   Academics versus Industry versus Clinical Practice:

Closer collaboration between the pharmaceutical industry and may be useful, but there will always be significant conflict of interest issues.  The pharmaceutical industry is clearly looking for an efficacy signal they can use to get FDA approval and market a drug. The trade-off is that these are typically small studies with stringent inclusion criteria that can result in later drug withdrawal due to complications noted only with greater exposure in post-marketing surveillance. It is not clear to how this system will ever produce medications that are disease-modifying versus those that are used to treat symptoms.

 An even larger problem is that clinicians are typically an afterthought by the academics and pharmaceutical industry.  The job of every psychiatrist is to see people who are acutely symptomatic and diagnose and treat those people. Psychiatrists are currently under more constraints than they have ever been.  Managed care companies demand that people are discharged from hospitals barely treated while psychiatrists are concerned about adequate treatment of the symptoms that led to hospitalization.  There are very few – if any clinical trials that apply to this scenario.  In 22 years of acute inpatient care – my estimate would be that about 5% of the people I treated would not be excluded from a standard clinical trial.  That experience was reinforced by my experience as an investigator in clinical trials of antidepressants, anxiolytics, antipsychotics, and Alzheimer’s disease. From a clinician’s perspective, the main failure of drug development is continuing to ignore real-world patients for an idealized clinical trials process.

 Concluding this post – I hope that I have communicated alternate viewpoints that capture the broader clinical landscape. It is not intended as a refutation of Dr. Ghaemi’s viewpoint and I don't consider anything in his paper to be controversial.  What I am suggesting is that psychiatrists need to know all of the viewpoints on these topics and why they exist in order succeed in clinical settings. For example, they need to know how to use both symptom-modifying and disease-modifying medications and the limitations of that distinction. They need to know the limitations of any medication prescribed and how to rapidly determine when a medication needs to be discontinued and a new medication or mode of therapy initiated. They need to know about placebo and nocebo effects as well as the entire range of side effects, effects on comorbid medical illnesses, and drug interactions. And they need to know the relative merits of randomized clinical trials using intent-to-treat analysis and real-world observational and registry studies.  All of those knowledge is necessary to treat complex polygenic illnesses that probably have many underlying biological processes and that consideration is not limited to psychiatry.

That is the true state-of-the art in the field.  There is no royal road to the truth and the current road is never easy.  Many people go into psychiatry for that reason, they get to know this body of knowledge and the associated decision-making and they are very good at helping people with significant problems.

George Dawson, MD, DFAPA

 

 References:

1:  Ghaemi SN.  Clinical Psychopharmacology: Principles and Practice.  New York, Oxford University Press 2019.

2:  Ghaemi SN. Symptomatic versus disease-modifying effects of psychiatric drugs. Acta Psychiatr Scand. 2022 Jun 2. doi: 10.1111/acps.13459. Epub ahead of print. PMID: 35653111.

3:  Aggarwal R, Ringold S, Khanna D, Neogi T, Johnson SR, Miller A, Brunner HI, Ogawa R, Felson D, Ogdie A, Aletaha D, Feldman BM. Distinctions between diagnostic and classification criteria? Arthritis Care Res (Hoboken). 2015 Jul;67(7):891-7. doi: 10.1002/acr.22583. PMID: 25776731; PMCID: PMC4482786.

4:  N. L. Maiden, N. P. Hurst, A. Lochhead, A. J. Carson, M. Sharpe, Medically unexplained symptoms in patients referred to a specialist rheumatology service: prevalence and associations, Rheumatology, Volume 42, Issue 1, January 2003, Pages 108–112, https://doi.org/10.1093/rheumatology/keg043

5:  Smythe HA. Explaining medically unexplained symptoms: widespread pain. The Journal of Rheumatology. 2009 Apr 1;36(4):679-83.

6:  Gran JT, Nordvåg BY. Referrals from general practice to an outpatient rheumatology clinic: disease spectrum and analysis of referral letters. Clinical rheumatology. 2000 Nov;19(6):450-4.

7:  Gumpel JM. Cyclophosphamide, gold and penicillamine--disease-modifying drugs in rheumatoid arthritis--tailored dosage and ultimate success. Rheumatol Rehabil. 1976 Aug;15(3):217-20. doi: 10.1093/rheumatology/15.3.217. PMID: 968355

8:  Buer JK. A history of the term "DMARD". Inflammopharmacology. 2015 Aug;23(4):163-71. doi: 10.1007/s10787-015-0232-5. Epub 2015 May 23. PMID: 26002695; PMCID: PMC4508364

9:  Pensel MC, Nass RD, Taubøll E, Aurlien D, Surges R. Prevention of sudden unexpected death in epilepsy: current status and future perspectives. Expert Rev Neurother. 2020 May;20(5):497-508. doi: 10.1080/14737175.2020.1754195. Epub 2020 Apr 26. PMID: 32270723.

10:  Leucht S, Helfer B, Gartlehner G, Davis JM. How effective are common medications: a perspective based on meta-analyses of major drugs. BMC Med. 2015 Oct 2;13:253. doi: 10.1186/s12916-015-0494-1. PMID: 26431961; PMCID: PMC4592565.

11:  Bell, L. 1849. On a form of disease resembling some advanced stage of mania and fever. Am. J. Insanity 6, 97–127.  

12:  Fava M.  Rational use of antidepressants. Psychother Psychosom 2014;83:197–204. doi: 10.1159/000362803

13:  Cosci F, Fava GA. Prescribing Pharmacotherapy for Major Depressive Disorder: How Does a Clinician Decide?. Biomedicine hub. 2021;6(3):118-21.

14:  Taipale H, Tiihonen J. Registry-based studies: What they can tell us, and what they cannot. Eur Neuropsychopharmacol. 2021 Apr;45:35-37. doi: 10.1016/j.euroneuro.2021.03.005. Epub 2021 Mar 25. PMID: 33774390.

15: Frew AJ.  Glucocorticoids. In:  Clinical immunology: principles and practice, 5^th edition. Rich RR, Shearer WT, Schroeder HW, Frew AJ, Weyland CM, editors. Amsterdam: Elsevier; 2019. p 1165-1175

Supplementary:  This post is another work in progress. I hope to calculate effects sizes of the above medications for MS, another table for rheumatic conditions (RA or SLE) and compare them to effect sizes for lithium, clozapine, valproate, and carbamazepine.  I am interested in the longest RCTS and registry studies that examine these problems.  If you have favorite studies please post the references here or email them to me. 

Image credit:  My wife took this photo of the Bong Bridge between Duluth, MN and Superior, WI. It is an expansive structure and hope I communicated that concept in the above writing.

Normal People

 

Connell and Marianne are two high school students in Ireland. They fall in love in high school and this series follows them into Trinity College and several path crossings over the next several years. That is the basic plot of Normal People a 12-episode series on Hulu television.  When it first came out it was accompanied by a lot of hype about the intensity of their relationship.  I decided to give it a while and consider it at a later date.  But then I realized I was watching one of the costars Daisy Edgar-Jones in two different series – War of the Worlds and Under the Banner of Heaven.  At that point I decided to start Normal People.  Connell is played by Paul Mescal.

I hope to give my impressions of why this is such a good story without getting into a play-by-play of the plot, but I am sure there will be inevitable spoilers. A summary of each episode is available on Wikipedia.  I also don’t plan to belabor any points about psychiatric diagnosis or treatment because unless a film is explicitly about psychiatry that kind of analysis does not strike me as being very realistic.

The series begins introducing us to the lives of Marianne and Connell in high school and their home lives. We learn that Marianne’s family is fairly wealthy and that Connell’s mother works for them as a housekeeper.  Marianne’s mother is a barrister.  Her older brother Alan also lives at home. There is tension due to a distant relation with her mother and an openly hostile relationship with her brother who is overtly abusive. In two scenes Alan physically assaults Marianne.  At school, Marianne is irritable and sarcastic. She argues with teachers and criticizes them in front the class to the point that she is disciplined. When her peers react with criticism, she is critical of them and does not hesitate to point out that none of them are equal to her academically.  She is very bright, and is aware of the fact that Connell is her only real academic competition.  She isolated without an obvious peer group.  

Connell is successful athletically as well as academically.  He has a peer group that is supportive of his athletics, but intrusive and critical of his private life.  As he and Marianne have some initial awkward exchanges it becomes obvious that they are attracted to one another. Marianne initiates the sexual aspect of their relationship – even though she has no prior experience. She agrees to tell nobody about their relationship at Connell’s request, because of his concern that it would be awkward with his peer group. Throughout this period of time, Marianne observes his activity at school where he is popular but gives no indication that they have a relationship.  The first break in their relationship occurs when Connell fails to ask her to a large social event and asks a girl who is more acceptable to his peer group.

One of the key early points in the film that distinguished this drama from a more typical young adult love story was Connell’s mother confronting him about the way he was treating Marianne. She expressed extreme disappointment that he was having a sexual relationship with her and hiding their general relationship from his peers at school. He protested and asked her if she should not take his side and her reply was not one that I have seen in any previous movies – there were some things in life that you should feel badly about and this was one of them. Eventually – the discord in the relationship amplified by his peer group – some speculate that they are having a relationship.   After their first break up, they will have 2, 3, 4 and even 5 more times to makes things right.  During some of those times, they date other people and we see them trying to relate to those new partners and realize that it is not close to what they had with one another.  That often led to conflicts with the new partners when they directly observed Marianne and Connell interacting in social settings and their continued attraction and concern for one another was obvious.

Marianne and Connell’s personalities are similar in many ways.  Both seem to be prone to anxiety and depression and Connell seems to be more aware of this. He openly talks with her about having severe panic attacks just walking down the street in Dublin and how that might affect his decision to travel to New York for an MFA program in creative writing. After the death of one of his friends from suicide he has an episode of severe depression and is supported by Marianne via telecommunication while she is studying in Sweden.  There are many situations where the couple’s tendency toward self-criticism and self-loathing is clear. For Marianne that includes either acquiescing or explicit requests to be treated badly by her partners. In one critical scene she requests that Connell do the same and we learn it is something that he cannot do.

This series highlights the importance of emotion and does a good job of portraying high levels of emotional intensity early in the relationship with some moderation over time. There are scenes where the emotion is overwhelming and the causes are not explicit.  Throughout many of their breakups – an emotional event occurred but the specific cause was never addressed or addressed in a much later episode.  These emotional events also occurred with other people and the viewer gets potential explanatory bits of information along the way.  As an example, over time we learn that Marianne’s father who is deceased had a history of being abusive toward his family. We see how she is treated by an emotionally distant mother and her abusive resentful brother. Over a Christmas holiday an open rift with her family occurs and she moves in with Connell’s family. She is with them when she encounters her mother walking toward them in town. Her mother glares at her but walks by without speaking.  As they drive away Marianne asks Connell’s mother about what the people in town think of her mother and the reply is ”she is a bit odd.”  More than enough information there to speculate about how Marianne might have been impacted by the family environment.

One of the dimensions that comes up in a film like this is the intersubjective state with the audience that is created by the actors.  The themes in this film are so realistic and compelling that it would be a rare person who does not experience associations to what has happened in their life.  How can you find an ideal partner at many levels and never seem to develop a lasting relationship?  How do you recognize aspects of your own experience and personality that consistently get in the way? How do you give yourself enough credit in life and realize that you will make it?  Can you realistically assess what happened in your family of origin and how it might affect you in the present day? And at an even more basic level – have I had relationships like this in my life? Do I wish things had gone differently? Would my life have been different if that relationship had succeeded?  That is just a short list of questions that could occur while watching this series.  

I imagine that any review of this series discusses the nudity and implied sexual activity.  Viewers should expect much more nudity than is seen on typical American network television or in most movies. It is one of the warnings. I have seen the series referred to as “pornographic” in some social media sites. That really diminishes the importance of this drama.  It is easy to lose the importance of a complicated relationship in the context of sexual activity and this story is definitely about much more than sex.  The sexual activity is critical in developing the story of these individuals and their relationship as a couple.

These are just a few areas that came up in Normal People and also explain the title. Both Marianne and Connell consider themselves to be defective in several ways. They also realize that their love for one another has allowed them to accomplish more through mutual support than they might have accomplished on their own. Despite many scenes of tension, anxiety, depression, and anger most observers will realize that they are just a couple of normal people with real life problems and a lot of those problems come down to how they negotiate this relationship that on one hand is passionate. loving, and supportive and on the other is complicated by life circumstances and frequent misunderstandings. I was pulling for them for all 12 episodes. I won’t tell you how it ends – but I was pleased with the ending. I know there is a lot of fan support for a season 2 – but I have also read that the author and screenwriter said that the original intent was to just produce one season.

The best single sentence characterization about this series is that it is about a young couple who function much better together than they do apart – but they have not figured out how to stay together.  This was a compelling story – and I looked forward to every episode.  

 

George Dawson, MD, DFAPA

    

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.

 

 

 

 

Gun Extremism Not Mental Illness

With the most recent school shooting in Uvalde, Texas the familiar repetition persists. There is public outcry to do something.  Many commentators make the comparison to the Sandy Hook Elementary School shooting a decade ago that produced public outcry but no effective response.  In fact, since Sandy Hook there have been 266 additional incidents of school shootings. Member of the pro-gun party have already spoken out and it is clear that their position of supporting gun ownership at all costs is essentially unchanged. That includes access to military grade weapons and high capacity weapons, with minimum and in many cases no regulations.  We keep hearing about all of the polls of “responsible gun owners” who support more reasonable regulation of firearms and more reasonable firearms – but they are generally drowned out by the aggressive tactics of the gun extremism faction.

Before going any further, I will provide my assessment of gun extremism. It is based on my personal observation about how guns have essentially been radicalized over the past 50 years.  When I was in middle school in the early 1960s living in a small town in northern Wisconsin, gun ownership by adults was common.  That gun ownership was focused on hunting seasons – primarily water fowl and deer hunting.  Middle schoolers took the NRA Hunter safety course in order to be able to handle firearms and hunt. Gun safety was taught primarily with the use of lectures and pamphlets. I can still recall some of the passages in the pamphlet with captions like “alcohol and gunpowder don’t mix” and a page with suggestions about what a safe target was. There was no explanation about why a crow is a safe target. The practical side of the training was with BB guns and then a .22 caliber rifle. Even though the common deer hunting rifles at the time were larger calibers like 30.06 there was no training with those guns. There was a competition series based on accuracy and most people in the class were eventually awarded Distinguished Marksman if they practiced and submitted enough targets. Memberships in the NRA was required and for $18.00/year – you got the National Rifleman magazine sent to your home every month.  The centerfold of that magazine was an array of inexpensive rifles, often “sporterized” surplus rifles from WWII.  They typically held 5 cartridges and could be used for hunting.

But like most kids taking the course. I never went hunting or acquired any additional firearms. My family was not a family of hunters and we did not have a typical cabin in the woods where everybody gathered during hunting season. The course was taught by an instructor who had been doing it for years. His overriding message was that guns had to be taken very seriously. In fact, one of the prerequisites for taking the course was that students had to vow never to “play” at guns again. That involved never pointing a gun at a person, even accidentally on the gun range. He described a number of incidents where people were accidentally shot by relatives to emphasize that point.  We all took it very seriously and there were no close calls in the class. There was no emphasis on “gun rights”, the need for self-protection, or the Second Amendment.  Handguns were not discussed because they were not used for hunting and you had to be 21 years of age to own one.  Gun rights was not an issue in any political campaign.

I don’t want to create the impression that the firearm situation was idyllic during my childhood.  Two classmates died by firearm suicide and one was killed in a hunting accident. I knew all three of them.

That is the backdrop against which gun extremism has evolved and it contains several elements.  First of all, politics. There are obvious contradictions when politicians say it is not a time for politics in the wake of the next mass shooting after they have passed laws that allow people to avoid background checks, carry military grade weapons with high capacity magazines, allow large purchased of ammunition, carry guns without permits, carry guns openly, and not have to “stand down” in confrontations – even when their opponent is not armed. That is all politics and if you are trying to deal with the aftermath pf a shooting – you are dealing with the aftermath of that politics especially if your politics facilitated that.

At a broader political level what has to be considered is how most polls show that Americans favor “common sense” gun laws – but the gun extremists continue to have their way.  In the decade following the Sandy Hook Elementary School Shooting, nothing has been done at the federal level.  Even the most basic fix of eliminating loopholes in the background checks laws has been avoided. Even when a law has been passed in the House (HR8) that makes a few changes – to the background check law there is practically no chance that it will pass in the Senate, even though the Republicans in the Senate represent 44 million fewer people. This situation has been referred to as the tyranny of the minority or a highly motivated smaller group of people dictating in this case the laws of the nation. That tyranny is even more complicated by Republican appointed Supreme Court making decisions on both gun laws and probably abortion consistent with what the minority party wants. Demographically that comes down to white, rural, less college educated voters making the laws that in the case of guns carry out an extremist agenda.

What do I mean about gun extremism?  Basically, all of the interventions over the past two generations that have allowed lax background checks and registration, lowered minimum age to purchase handguns and high-capacity military grade weapons, the increased carrying of weapons (both concealed and open) in many cases without permits, and stand your ground laws that say there is no obligation to retreat in a confrontation – even in the case where one of the parties is unarmed. There is an associated lack of gun safety and that has clearly been a factor in accidental death of adolescents and teenagers, suicides, carrying firearms into schools, and even arming mass shooters. That lack of basic gun safety is a likely contributing factor to firearm deaths being the leading cause of death in children and adolescents (1). And finally, there is a constant stream of pro-gun rhetoric that routinely distorts those facts about gun availability and usefulness.   There is good evidence that this gun extremism began in the 1970 and 1980s and has been unabated since then. 

Since the school shooting in Uvalde, gun extremists jumped to the defense of permissive to non-existent gun laws.  They offered alternate explanations for the school shooting. Governor Abbot of Texas suggested the shooter had a “mental health challenge” since anyone who shoots someone does.  That is clearly not true.  Recent evidence from high profile media cases where a homicide occurred during a fight over a firearm are cases in point. The vast majority of homicides by firearms does not involve mental illness of any kind.  In carefully selected samples – probably biased because they are selected based on forensic criteria – only 10-25% of the sample is described as having a mental illness diagnosis (2,3).

If mental illness is not an explanation for a mass shooter or mass school shooter behavior what is more likely? Given the fact that this behavior has been going on for at least 2-3 generations at this point it likely represents a subcultural phenomenon.  Subcultures are cultural groups within a larger culture that hold beliefs at variance with the larger culture.  American culture in general is steeped in violence and crime largely through entertainment and news media outlets. There are well known violent subcultures in the United States including organized crime, gangs, domestic terrorists, and various hate groups that perpetrate violence against specific people.  These other crimes are frequently seen in the news. It is easy to ascribe some of the behaviors of these groups to individual psychopathology. You can see these efforts in many true crime television shows. Crime dramas are likely to emphasize profiling as a way that the crimes are solved. Practically all of these cases lack features that are typically seen with individual psychopathology. Instead, we hear about a profile of social factors and circumstances that are cited as motivations for the violence and aggression. Those factors are also not uniform explanations for all of the violence and aggression seen across all categories and typically are collected long after the commission of the crime and by people who seemingly have unlimited time to do that task.  A good example was a forensic psychiatrist giving a profile of the Uvalde, Texas shooter describing him as a marginalized loner who had been bullied in the past and pointing out that many shooters have this profile but only a small number of people with the profile ever engage in firearm violence.

I think it is highly likely that the mass shooter and mass school shooter have become a meme that is passed in this subculture of primarily men or boys who feel that they have been victimized and they begin to see this as acceptable payback for their perceived victimization.  It is subculturally acceptable even though it produces outrage and is completely unacceptable in the larger culture and that is why the questions about “motivation” always go unanswered. Firearms and secrecy are obviously a big part of this meme and the way it is typically enacted. Gun extremism makes it much easier to enact.  In analyzing these situations, the usual starting point is where the individual perpetrator has gone wrong.  From the perspective of an alienated subculture these people and those who identify with them consider what they are doing to be correct for various reasons and more importantly widely accepted in that subculture (7). There are many reports that these subcultures are reinforced and more accessible through social media sites where manifestos, threats, time lines, and in some cases photos and recordings of the violence are posted.

In addition to the subcultural effects, important developmental effects are seldom considered.  In the past 20 years development and brain maturation has been the object of increasing neuroscience scrutiny and in addition to structural brain changes – correlations with culture, socioeconomic class, and social network/peer environment have also been investigated. In an excellent review of this topic Foulkes and Blakemore (3) point out that averaging of large samples has been used so far to get to statistical significance – but they discuss the benefits of looking beyond the averages at the total variation of normal brain development. They illustrate significant variation in the brain volume of subcortical grey matter structures over the course of ages 7 to 23.3.  I think it is generally accepted that brain maturation by these indices is not complete until mid-20s for most people, but the graphs also suggest that there may be quite a lot of variation even at that point. Beyond that they discuss several aspects of cognition and social cognition that develop in the transition from adolescence to adulthood including reasoning, risk perception, risk taking, the varied effects of social exclusion, and the use of others’ perceptions in decision making. They demonstrate what appear to be specific cultural, socioeconomic and peer effects and discuss the neuroscience correlates where they are known.  An analysis of mass shooters at this level of detail may provide better answers in terms of prevention.

What can be done to interrupt this cycle of school and mass shooter violence? Plenty can be done.  A basic time-tested public health intervention is to remove the means for perpetrating the violence and injury. This has worked in the case of suicide prevention by specific methods as well as preventing gun violence.  In a previous post, I pointed out that Tombstone had an ordinance in 1881 forbidding the carrying of deadly weapons within the city. This was a time commonly referred to as the Wild West (1865-1895).  This period is typically idealized by movies like Gunfight at the OK Corral. That was a 30 second gunfight between three Earp brothers and Doc Holiday and 5 cowboys that occurred in 1881.  One of the precipitants of that gunfight was violation of the city ordinance about carrying deadly weapons. Contrary to most accounts – both Wyatt Earp and Doc Holliday were arrested and charged with murder.  They were released after a three-day probable cause hearing. Even during America’s Wild West days, people knew that removing deadly weapons would lead to less violence.

In many ways American streets are less protected from gun violence than they were in Tombstone in 1881.  All 50 states allow people to carry handguns.  Twenty-four states require no permit to carry a firearm.  Federal law requires a handgun holder to be 18 years of age and 21 years of age to purchase a handgun. There are currently 21 million concealed carry permit holders in the US.   There is no minimum age for possessing a rifle or a shotgun.  There was a ten-year ban on assault rifles at the federal level from 1994-2004.  The ban grandfathered in all assault weapons before 1994 and there were also many other qualifications that decreased the overall impact of the bill.  Despite these limitations the ban may have decreased the frequency of mass shootings when it was in effect. (6).  Considering that there are 258.3 million Americans over the age of 18, the manufacture and importation of firearms is brisk to say the least as well as the concentration of handguns. (Click to expand the graphic)

Concluding this post, the most clearcut path to reducing gun violence of all kinds is to improve gun regulation.  The evidence is clearly there in terms of reductions in suicides, homicides and accidental deaths. The idea that gun regulation has no effect on gun deaths or that the Second Amendment is a sacred clause that mandates gun extremism is pure misinformation.  Even as I typed this post today, the Prime Minister of Canada announced stricter handgun regulations in the interest of safety.  There is absolutely no reason that high-capacity military grade weapons are necessary in society and there are many groups of responsible gun owners who openly acknowledge that fact.

Gun extremists’ additional rhetoric about how mental illness is the real problem rather than gun access is also incorrect.  Mental illness is not defined by homicide, but by constellations of findings and associated disability. There are general developmental, socioeconomic, cultural and subcultural trends associated with violence and aggression – but none are precise enough to allow for predictions of who will likely perpetrate mass homicide.  It will take continued large longitudinal studies to examine all of these factors close enough to produce an effective population wide intervention. One of my suggestions since I started writing this blog is explicit homicide prevention.  You won’t be able to find that is a book or research paper – it is based on my experience in acute care psychiatry. In that context, I encountered many people with acute homicidal thinking who ended up on my inpatient unit.  Irrespective of any psychiatric diagnosis, we were able to help them resolve that crisis.  Before the rationed mental health system takes on another significant task, it has to be adequately funded.  And beyond the mental health system – social services are required to address many of the factors associated with violence and aggression.

George Dawson, MD, DFAPA

 

 

References:

 

1:  Goldstick JE, Cunningham RM, Carter PM. Current Causes of Death in Children and Adolescents in the United States. N Engl J Med. 2022 May 19;386(20):1955-1956. doi: 10.1056/NEJMc2201761. Epub 2022 Apr 20. PMID: 35443104.

2:  Stone MH. Mass murder, mental illness, and men. Violence and Gender. 2015 Mar 1;2(1): 51-86.

3:  Hall RCW, Friedman SH, Sorrentino R, Lapchenko M, Marcus A, Ellis R. The myth of school shooters and psychotropic medications. Behav Sci Law. 2019 Sep;37(5):540-558. doi: 10.1002/bsl.2429. Epub 2019 Sep 12. PMID: 31513302.

4:  Firearms Commerce Report in the United States: Accessed 05.29.2022:  https://www.atf.gov/firearms/docs/report/2021-firearms-commerce-report/download

5:  Foulkes L, Blakemore SJ. Studying individual differences in human adolescent brain development. Nature Neuroscience. 2018 Mar;21(3):315-23.

6:   DiMaggio C, Avraham J, Berry C, Bukur M, Feldman J, Klein M, Shah N, Tandon M, Frangos S. Changes in US mass shooting deaths associated with the 1994-2004 federal assault weapons ban: Analysis of open-source data. J Trauma Acute Care Surg. 2019 Jan;86(1):11-19. doi: 10.1097/TA.0000000000002060. PMID: 30188421.

7: Simon Cottee (2021) Incel (E)motives: Resentment, Shame and Revenge, Studies in Conflict & Terrorism, 44:2, 93-114, DOI: 10.1080/1057610X.2020.1822589

8: Rostron A. The Dickey Amendment on Federal Funding for Research on Gun Violence: A Legal Dissection. Am J Public Health. 2018 Jul;108(7):865-867. doi: 10.2105/AJPH.2018.304450. PMID: 29874513; PMCID: PMC5993413

9:  Loftin C, McDowall D, Wiersema B, Cottey TJ. Effects of restrictive licensing of handguns on homicide and suicide in the District of Columbia. N Engl J Med. 1991 Dec 5;325(23):1615-20. doi: 10.1056/NEJM199112053252305. PMID: 1669841.

Graphics Credit:

Photo by Ed Colon, MD

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Racism and gun violence both exist in an overtly gun extremist society: They cannot be explained away by mental illness.

I suppose I should have not been very shocked that a Wall Street Journal editorial this morning (1) chose to double down on both gun rights and the myth that racism is not a problem and had nothing to do with the recent mass shooting – while scapegoating both mental illness and the rationed system of mental health care that we have in this country.  For good measure he added another conservative agenda item - that there was also blame for the public health officials like Dr. Fauci for mismanaging the pandemic.  This post is to straighten all of that out.

Let me preface these remarks by saying that I have no information about the most recent mass shooting other than what is reported in the media.  The author of the editorial does not seem to either. What I do have is 22 years of experience in acute care psychiatry and involuntary care. That’s right – for 22 years I was one of the guys you would have to see if you were admitted to my hospital on a legal hold for behavior that involved threatening or harming other people or yourself.  That included all kinds of violence - homicide, suicide attempts and severe self injury, and violent confrontations/shoot outs with the police.  I had to evaluate the situation with the considerable assistance from my colleagues and decide if that person could be released or needed to be held for further assessment and treatment. People (including psychiatrists) like to summarize that situation by saying: “Nobody can predict future dangerousness” and that is certainly true. But we do pretty well in the short term (hours to days).  We also do well coming up with a plan to prevent future violence.

The details about the most recent mass shooting are still being reported at this time, but so far include interviews with the families of the victims, police reports, videos, and excerpts from a manifesto written by the perpetrator.  According to reports that manifesto discussed Replacement Theory as a potential motive for the mass shooting.  Replacement Theory is a white nationalist, far right ideology that claims non-whites are a threat to the white majority in several countries including the US. A corollary is that the Democrats are trying to get aligned with more non-white voters to develop more political power. This is the rationale currently given in the media for the actions of the mass shooter who scouted neighborhoods and said very explicitly in documents that his intent was to murder as many black people as possible. He had no difficulty obtaining firearms legally – even though he was detained and sent for an emergency evaluation a little less than a year earlier for stating “murder-suicide” in response to an online question about what he planned to do upon retirement.  Those details and his response talking about how he got out of it and continued to plan to kill people are at this link.  

As a psychiatrist and member of the American Psychiatric Association, I can’t speculate on the diagnosis of anyone who I have not personally assessed and if I did do an assessment – I would need a release from the person to discuss any details.  The editorialist is under no constraints speculating that “signals were missed” and that “psychotic young males whose outlet is killing” is not the object of his column.  Instead, he makes the claim that he is really concerned about the post pandemic mental illness and addiction trends in this country. He is apparently not consulting the correct sources about what has happened in this country in terms of mental health care before the pandemic.

I will start with his anchor point in the 1970s.  At about that time Len Stein, MD and coworkers invented Assertive Community Treatment and a number of additional innovative approaches that were focused on keeping people with severe mental illnesses in their own homes.  Dr. Stein was one of my mentors and in seminars he would show what Wisconsin state hospital wards used to look like. About a hundred patients in one large room with their cots edge-to-edge and all wearing hospital pajamas. By the time I was working with him in the 1980s, those folks were living independently supported by case management teams and psychiatrists. Dr. Stein and his colleagues also ran a community mental health center that included crisis intervention services and outreach. That model of community mental health and crisis intervention is still practiced and has been covered in the New England Journal of Medicine.  Psychiatric residents are still trained in community mental health settings and many prefer to practice there.  Counties are not as enthusiastic and have shut down many if not most community mental health centers.

Community psychiatry is an obvious 50-year-old solution but it has to be funded. The same is true of affordable housing.  In some cases that housing needs to be supervised and also a sober environment. Both community psychiatry and affordable housing are casualties of business rationing that can only occur with the full cooperation of both state and federal governments. The current system costs about a trillion dollars in overhead that is directed to Wall Street profits and unnecessary meddling by middle managers. The only people who “sweep mental health under the rug” are large healthcare organizations and state bureaucrats who disproportionately ration it.  The "science of mental health" is not difficult at all.  Being forced to do it for free is difficult.

The 1980s were a critical time in establishing the managed care industry and taking all healthcare out of the purview of physicians.  While rationing psychiatric resources was being ramped up, services to treat alcoholism and addiction were essentially demolished. Suddenly you could not longer get detoxification services at most hospitals.  People were sent to social detox units run by counties where there was no medical coverage.  The thinking was that if a person developed medical complications like seizures or delirium tremens they could always be sent back to the hospital. The biggest risk was continued substance use and immediate relapse. Residential and outpatient treatment facilities never materialized.  Inadequate funding was a significant problem.  The managed care industry played a role in that case as well with absurd expectations and limits on treatment.  It is no accident that treatment for substance use disorders basically became non-existent.  None of the disproportionate rationing of mental health or substance abuse treatment is new.  It has been like this for 30 years because it is the government endorsed model of care.  

Overall, this editorial is a smokescreen over the proximate issues of guns and racism.  The author trivializes this as political rhetoric when in fact the rhetoric has all been pro-guns and pro-white supremacy.  It is the only rational explanation for turning the United States into an armed camp that has progressively increased the likelihood of gun violence. We are not talking about a pandemic precipitated phenomenon.  The gun violence has been multi-year and the pro-gun party has “doubled down” on it to make it more likely.  As far as politics go – now that we know how a partisan Supreme Court works – the Heller decision and the resulting liberalization of gun ownership should not come as a surprise.  On the issue of hate crimes, I can’t really think of anything more relevant in a case based on the public disclosures.  This was a specific crime directed at black Americans intentionally perpetrated in a neighborhood that was scouted ahead of time for that ethnicity. Brushing that aside to claim that this is a response to an embarrassing record on mental illness, when there is no evidence that is a factor is disingenuous.

American history including other recent mass shootings tells us that racism can be a causative factor.  What is never addressed is the omnipresent gun culture in the USA.  People with an apparent need for military weapons and handguns and politicians willing to give them unlimited access to carrying them in public, carrying them without permits, and stand your ground laws - encouraging violent confrontations with firearms.  All fueled by one party and their affiliated special interests.

Disingenuous discourse and misinformation is what we typically see these days. If you want the facts about what needs to be there in terms of a functional mental health system (and I know there are absolutely no business people and very few politicians that do) – ask a psychiatrist. If you want to know about what gun control needs to be in effect rather than claiming that psychiatrists are not preventing gun violence from people with no mental illness – you can also ask me.

I could put all of those details on a 4” x 6” card and it would work. 

But there is certainly nobody on the right or at the WSJ who wants to know that either.

 

George Dawson, MD, DFAPA

 

References:

1:  Daniel Henninger. The Next Pandemic: Mental Illness.  Wall Street Journal. May 18, 2022.

Graphics Credit:  Eduardo Colon, MD