Psychiatry Now Admits It's Been Wrong in Big Ways - But Can It Change?

Wednesday, 05 March 2014 10:05 By Bruce E Levine, Truthout | 


When I interviewed investigative reporter Robert Whitaker in 2010 after the publication of his book Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America, he was not exactly a beloved figure within the psychiatry establishment. Whitaker had documented evidence that standard drug treatments were making many patients worse over the long term, and he detailed the lack of science behind these treatments.

Whitaker's sincerity about seeking better treatment options, his command of the facts, and his lack of anti-drug dogma compelled all but the most dogmatic psychiatrists to take him seriously.

For Anatomy of an Epidemic, Whitaker won the 2010 Investigative Reporters and Editors Book Award for best investigative journalism. This and other acclaim made it difficult for establishment psychiatry to ignore him, so he was invited to speak at many of their bastions, including a Harvard Medical School Grand Rounds at Massachusetts General Hospital, where he faced hostile audiences. However, Whitaker's sincerity about seeking better treatment options, his command of the facts and his lack of anti-drug dogma compelled all but the most dogmatic psychiatrists to take him seriously.

In the past four years, the psychiatry establishment has pivoted from first ignoring Whitaker to then debating him and attempting to discredit him to currently agreeing with many of his conclusions. But will Whitaker's success in changing minds result in a change for the better in treatment practices?

I was curious about Whitaker's take on the recent U-turns by major figures in the psychiatry establishment with respect to antipsychotic drug treatment, the validity of the "chemical imbalance" theory of mental illness and the validity of the DSM, psychiatry's diagnostic bible. And I was curious about Whitaker's sense of psychiatry's future direction.

Bruce Levine: In 2013, the director of the National Institute of Mental Health (NIMH), Thomas Insel, announced - without mentioning you -  that he agreed with your conclusion that psychiatry's standard treatment for people diagnosed with schizophrenia and other psychoses needs to change so as to better reflect the diversity in this population. Citing long-term treatment studies that you had previously documented, Insel came to the same conclusion that you had: In the long-term, not all, but many individuals who have been diagnosed with psychosis actually do better without antipsychotic medication. Was it gratifying for you to see the US government's highest-ranking mental health official agreeing with you? 

Robert Whitaker: Shortly before Thomas Insel wrote that blog, I had posted my own on madinamerica.com, related to a recent study by Lex Wunderink from the Netherlands. Wunderink had followed patients diagnosed with a psychotic disorder for seven years, and he reported that those randomized, at an early date, to a treatment protocol that involved tapering down to a very low dose or withdrawing from the medication altogether had much higher recovery rates than those maintained on a regular dose of an antipsychotic.

I wrote that in the wake of Wunderink's randomized study, if psychiatry wanted to maintain its claim that its treatments were evidence-based, and thus maintain any sort of moral authority over this medical domain, then it needed to amend its treatment protocols for antipsychotics. I don't know if Dr. Insel read my blog, but his post did nevertheless serve as a reply, and as you write, he did basically come to the same conclusion that I had been writing about for some time.

I suppose I took some measure of personal gratification from his blog, for it did provide a sense of a public acknowledgment that I had indeed been "right." But more important, I felt a new sense of optimism, hopeful that maybe psychiatry would now really address this issue, which is so important to the lives of so many people. A short while ago, The New York Times published a feature story on Dr. Insel, noting that he had recently raised a question about the long-term use of antipsychotics, which had caused a stir in psychiatry because it contradicted conventional wisdom. That is a sign that perhaps a new discussion is really opening up.

In Anatomy of an Epidemic, you also discussed the pseudoscience behind the "chemical imbalance" theories of mental illness - theories that made it easy to sell psychiatric drugs. In the last few years, I've noticed establishment psychiatry figures doing some major backpedaling on these chemical imbalance theories. For example, Ronald Pies, editor-in-chief emeritus of the Psychiatric Times stated in 2011, "In truth, the ‘chemical imbalance' notion was always a kind of urban legend - never a theory seriously propounded by well-informed psychiatrists." What's your take on this?

 

The "disease model," as a basis for making psychiatric diagnoses, has failed.

This is quite interesting and revealing, I would say. In a sense, Ronald Pies is right.Those psychiatrists who were "well informed" about investigations into the chemical imbalance theory of mental disorders knew it hadn't really panned out, with such findings dating back to the late 1970s and early 1980s. But why, then, did we as a society come to believe that mental disorders were due to chemical imbalances, which were then fixed by the drugs?

Dr. Pies puts the blame on the drug companies. But if you track the rise of this belief, it is easy to see that the American Psychiatric Association promoted it in some of their promotional materials to the public and that "well informed" psychiatrists often spoke of this metaphor in their interviews with the media. So what you find in this statement by Dr. Pies is a remarkable confession: Psychiatry, all along, knew that the evidence wasn't really there to support the chemical imbalance notion, that it was a hypothesis that hadn't panned out, and yet psychiatry failed to inform the public of that crucial fact.

The low-serotonin theory of depression has been so completely discredited by leading researchers that maintaining the story with the public has just become untenable.

By doing so, psychiatry allowed a "little white lie" to take hold in the public mind, which helped sell drugs and, of course, made it seem that psychiatry had magic bullets for psychiatric disorders. That is an astonishing betrayal of the trust that the public puts in a medical discipline; we don't expect to be misled in such a basic way.

But why now? Why are we hearing these admissions from Dr. Pies and others now? I am not sure, but I think there are two reasons.

One, the low-serotonin theory of depression has been so completely discredited by leading researchers that maintaining the story with the public has just become untenable. It is too easy for critics and the public to point to the scientific findings that contradict it.

Second, a number of pharmaceutical companies have shut down their research into psychiatric drugs [see Science, 2010], and they are doing so because, as they note, there is a lack of science providing good molecular targets for drug development. Even the drug companies are moving away from the chemical-imbalance story, and thus, what we are seeing now is the public collapse of a fabrication, which can no longer be maintained. In the statement by Dr. Pies, you see an effort by psychiatry to distance itself from that fabrication, putting the blame instead on the drug companies.

Challenging the validity of DSM is, in many ways, potentially much more of a paradigm-changer than are the scientific reports that detail how the medications may be causing long-term harm.

And recently, establishment psychiatrists have even been challenging the validity of psychiatry's diagnostic bible, the DSM. Last year, NIMH director Insel, citing the DSM's lack of scientific validity, stated that the "NIMH will be re-orienting its research away from DSM categories." And psychiatrist Allen Frances, the former chair of the DSM-4 task force, has been talking about how the DSM is a money machine for drug companies ("Last Plea To DSM-5: Save Grief From the Drug Companies"), and Frances thoroughly trashed the DSM-5 in his 2013 book Saving Normal.

I think this challenging of the validity of DSM is, in many ways, potentially much more of a paradigm-changer than are the scientific reports that detail how the medications may be causing long-term harm. Our current drug-based paradigm of care, which presents drugs as treatments for the symptoms of a "disease," stems from DSM III. The APA [American Psychiatric Association] and its leaders boasted that when DSM III was published in 1980, that the field had now adopted a "medical model," and thus its manual was now "scientific" in kind.

In fact, the APA had adopted a "disease model," and if you carefully read the DSM III manual, you saw that the authors acknowledged that very few of the diagnoses had been "validated." The APA's hope and expectation was that future research would validate the disorders, but that hasn't happened. Researchers haven't identified a characteristic pathology for the major mental disorders; no specific genes for the disorders have been found; and there isn't evidence that neatly separates one disorder from the next. The "disease model," as a basis for making psychiatric diagnoses, has failed.

We are now witnessing, in Insel's statements and those by Allen Frances, an acknowledgment of this failure. And here is why this is potentially such a paradigm-changer: The foundation of any medical specialty begins with its diagnostic manual, which should be both reliable and valid. If the disorders listed in a manual haven't been validated, then you can't conclude they are "real," in the sense of the disorders being unique illnesses, and the diagnoses being useful for prescribing an appropriate treatment.

Thus, when Insel states that the disorders haven't been validated, he is stating that the entire edifice that modern psychiatry is built upon is flawed, and unsupported by science. This is like the King of Psychiatry saying that the discipline has no clothes. If the public loses faith in the DSM and comes to see it as unscientific, then psychiatry has a real credibility problem on its hands, and that could prove to be fertile ground for real change.

So do you feel you have accomplished your mission? And can dissident mental health professionals - who have for years been talking about invalid diagnoses, pseudoscientific theories of mental illness, and drug treatments that cause moderate and acute problems to become severe and chronic ones - now have reasons to be optimistic about their profession? Or are you pessimistic that the recent admissions of establishment psychiatry will result in substantive changes in treatment? 

My "mission" would be to see that our society would actually build a system of care that was truly "science" based, particularly in its use of psychiatric drugs.

This is a good question, and I vacillate in my personal response between guarded optimism and complete pessimism. From an intellectual, scientific standpoint, I think psychiatry is facing a deep crisis. There is an understanding, within psychiatric research circles, that the DSM diagnoses haven't, in fact, been validated. And, at the very least, there is a recognition that psychiatry's drug treatments are inadequate. In 2009, Insel wrote an article stating: "For too many people, antipsychotics and antidepressants are not effective, and even when they are helpful, they reduce symptoms without eliciting recovery." And I do think that my book Anatomy of an Epidemic has contributed to an awareness of the limitations of the drugs, and at least a discussion, in some psychiatric circles, that the drugs may be worsening long-term outcomes.

But in terms of accomplishing my mission, well, I guess my "mission" would be to see that our society would actually build a system of care that was truly science-based, particularly in its use of psychiatric drugs. I think this is such an important story for our society and one of extraordinary moral importance when it comes to medicating children and adolescents, none of whom could be said to have really "consented" to such treatment. I turned madinamerica.com into a webzine with the hope that by providing a forum for a community of writers interested in "rethinking psychiatry" and combining their voices with reports of research that provide a foundation for such rethinking, it could become a real force for change. We'll see if that happens, but our readership is steadily increasing.

I should note, as you say, that dissident mental health professionals have been plugging away at promoting such change for a long time. I hope that madinamerica.com is providing that community a forum for voicing their criticisms and making them known to a larger audience.

And now for why I can be so pessimistic. Even as the intellectual foundation for our drug-based paradigm of care is collapsing, starting with the diagnostics, our society's use of these medications is increasing; the percentage of children and youth being medicated is increasing; and states are expanding their authority to forcibly treat people in outpatient settings with antipsychotics drugs. Disability numbers due to mental illness go up and up, and we don't see that as reason to change either. History does show that paradigms of psychiatric care can change, but, in a big-picture sense, I don't know how much is really changing here in the United States.

I think dissident mental health professionals also have to confront this question. Can they be hopeful that their professions will change their ways, and their teachings? I think so, but there is so much that needs to be done.

Any medical specialty has guild interests, meaning that it needs to protect the market value of its treatments.

Is it really possible for psychiatry to reform in any meaningful way given their complete embrace of the "medical model of mental illness," their idea that emotional and behavioral problems are caused by a bio-chemical defect of some type? Can they really reform when their profession as a financial enterprise rests on drug prescribing, electroshock and other bio-chemical-electrical treatments? Can psychiatry do anything but pay lip service to a more holistic/integrative view that includes psychological, spiritual, social, cultural and political realities?

I think we have to appreciate this fact: any medical specialty has guild interests, meaning that it needs to protect the market value of its treatments. If it is going to abandon one form of treatment, it needs to be able to replace it with another. It can't change if there is no replacement in the offing.

When the APA published DSM III, it basically ceded talk therapy to psychologists, counselors, social workers and so forth. Psychiatry's three domains, in the marketplace, were diagnostics, research and the prescribing of drugs. Now, 34 years later, we see that its diagnostics are being dismissed as invalid; its research has failed to identify the biology of mental disorders to validate its diagnostics; and its drug treatments are increasingly being seen as not very effective or even harmful. That is the story of a profession that has reason to feel insecure about its place in the marketplace.

Yet, as you suggest, this is why it is going to be so hard for psychiatry to reform. Diagnosis and the prescribing of drugs constitute the main function of psychiatrists today in our society. From a guild perspective, the profession needs to maintain the public's belief in the value of that function. So I don't believe it will be possible for psychiatry to change unless it identifies a new function that would be marketable, so to speak. Psychiatry needs to identify a change that would be consistent with its interests as a guild.
The one faint possibility I see - and this may seem counterintuitive - is for psychiatry to become the profession that provides a critical view of psychiatric drugs. Family doctors do most of the prescribing of psychiatric drugs today, without any real sense of their risks and benefits, and so psychiatrists could stake out a role as being the experts who know how to use the drugs in a very selective, cautious manner, and the experts who know how to incorporate such drug treatment into a holistic, integrated form of care. If the public sees the drugs as quite problematic, as medications that can serve a purpose - but only if prescribed in a very nuanced way - then it will want to turn to physicians who understand well the problems with the drugs and their limitations.

That is what I think must happen for psychiatry to change. Psychiatry must see a financial benefit from a proposed change, one consistent with guild interests.  

The Truth About "Erectile Dysfunction"

For many men, medical treatments for erectile dysfunction are ineffective because ED is often a psychological problem.
By Maneet Bhati and Chris MacKinnon, The Good Men Project
June 8, 2011


One of the most common sexual complaints men present to their primary care physicians is trouble “getting hard” and “keeping it up.” For the last 20 years the treatment for erectile dysfunction (ED) has improved tremendously with the advent of medications such as Viagra, Cialis, and Levitra. Over 75 percent of men taking these medications are able to restore erections. However, for the remaining 25 percent of men, medical treatments are largely ineffective. In addition, a high percentage of men stop taking their medication. This can be explained in part by the fact that ED is both a physical and psychological problem.

Identifying and Changing Beliefs About Sexual Performance

For starters, a lot of men carry the belief that sexual performance and having a firm erection is one of the most defining and important characteristics of every sexual experience. As men try to make sense of their ED, many traditional (and implicit) male values about sexuality are triggered. For example, the inability to maintain erection often leads to feelings of shame because many men believe that “real” men should be able to satisfy their partner. And the only—or best—way to satisfy their partner requires an erection. Some partners will hold similar expectations of the need for the satisfying partner that can serve to worsen the situation.

ED is often strongly linked to performance anxiety. Performance anxiety is a widespread psychological phenomenon that affects many aspects of life, not just sex. It occurs when men become fearful of failure or embarrassed that they cannot achieve or maintain erections. Common thoughts that run through the man’s mind are, “Do I have an erection yet?” or “Am I going to have an orgasm this time?” A vicious circle of anxiety can develop where the anticipated fear of not having an erection results in recurring difficulties actually having one.

Here’s how the cycle starts: Men may hold some imagined fantasy of good sex, which leads to pressure to perform. When men do not achieve the result they were hoping for (i.e., a firm erection), this leads to troublesome feelings—sadness, disappointment, guilt and shame—and a return to negative thoughts that are now compounded by performance anxiety in the company of self-criticism.

The cycle can go on for a long time. For men to break the cycle, they first need to recognize that it exists. Only then can men start to change maladaptive ideas about sexuality that are not entirely helpful. First, men need to appreciate that setting the bar too high is a recipe for failure. Men need to reassure themselves that they do not have to be hard enough to drive nails every time they are intimate. Research has shown that many men with ED actually underrate their erectile response during sexual activity.

Secondly, men need to know that occasional sexual difficulties are normal and thus so are they. Research shows that most healthy men occasionally experience erectile dysfunction or failure. It does not mean you are necessarily impotent or that there is something inherently wrong with you. This can happen to anyone, and usually does at least occasionally.

Third, in western society we see a trend towards “instant gratification.” We want everything right away and instantaneously. This trend influences our relationships and sexual performance by creating a pressure to have an erection instantly and to be outstanding sexual performers. This trend of instant gratification does not take into account the fact that sexual performance is a learning process that takes time. Achieving mastery in sexual performance is no different than achieving mastery in sports or other activities: it takes practice. Sexual performance is a life-long learning process.

Reframing sexual performance as an evolving process that changes over time can lower the pressure that may be causing ED. For example, in the beginning of his career Michael Jordan was a prolific dunker who dominated games with his athletic ability. But as he got older, he relied more prominently on jump shots. The results were the same: He was still able to score—he just did it differently.

♦◊♦

Changing the Ways Couples Think About Sexuality

In too many cases, a man’s inability to reach a firm and enduring erection leads to the end of all sexual activity. Here’s a provocative idea for couples: Good sex does not have to involve sexual intercourse. Couples can learn many different non-intercourse forms of sexual stimulation. For example, oral sex, cuddling, sensual touching, sexual massage, role-play, introducing sexual videos, or even food creates new and interesting ways to achieve sexual intimacy and orgasm.

Couples can collaboratively identify novel ways of being sexual together. It is not always easy to start these conversations, but once the subject is introduced and a rule is established about refraining from judgments, people can begin to risk sharing something new they may want to try.

One way to open up a supportive and non-judgmental dialog is by having each person write privately something the couple used to do sexually but rarely does anymore, then share these together. Partners can share their beliefs around what constitutes sexual intimacy. They can voice their frustrations about what is not satisfying them, validate and reinforce the activities that they enjoy, and make suggestions for different types of sexual activity they want to engage in.

It is also important for men to discuss the anxieties, pressures, and negative feelings (shame, guilt, etc.) they face when it comes to sexual performance. Vocalizing these fears can help increase empathy, understanding, and awareness. It also gives both partners an opportunity to examine how each of them may contribute to the ideas that exacerbate ED.

If there are negative relationship patterns that are not helping one’s sex life or relationship, there are ways to change them. A great starting point is for the couple to make the commitment to read together John Gottman’s The Seven Principles for Making Marriage Work. Reflect together on the chapters as they pertain to your relationship and complete the exercises contained inside. These exercises can help strengthen the relationship and lay a firm foundation for increasing sexual intimacy.

♦◊♦

Getting Help for Your Erectile Dysfunction

We always recommend contacting your primary care physician first for a thorough assessment in determining the extent to which a man’s ED is physical or psychological. Many of the psychological difficulties that maintain ED are self-induced. This means that men have the ability not only to exacerbate sexual problems; they also have the power to overcome them. The old adage that you must always have a firm erection quickly followed by sexual intercourse to qualify for having good sex is unrealistic and simply inaccurate. Challenging these unrealistic beliefs, tempering unreasonable expectations, embracing sexuality as a life-long process, and being open to different forms of sexual activity can help men achieve diverse kinds of intimate moments with their partners.

The Marketing of Madness: Are We All Insane?

The Marketing of Madness: Are We All Insane? (2009)

Psychotropic drugging - it's business. This is the story of the high-income partnership between psychiatry and drug companies that has created an $80 billion psychotropic drug profit center, and millions of patients addicted to these drugs or developing worse health problems due to the use of these drugs.

This movie will break your heart.

vidlink (if video doesn't show)

New research restores psychedelics’ medical respectability

By Eric W. Dolan Tuesday, September 7th, 2010

Recently published studies suggest that 'magic mushrooms' and 'ecstasy' may have medical value.

Before the enactment of the Controlled Substances Act in the late 60's, psychiatrists had been eagerly investigating the use of psychedelic drugs as an aid to psychological therapy.

Unfortunately, as the government sought to eliminate the recreational use of these drugs, it consequentially eliminated nearly all research into their effects.

Although there was almost no research on psychedelic drugs from the early 70's to late 90's, within the last decade studies have reaffirmed that 'magic mushrooms' and ecstasy (MDMA) can be valuable tools for mental health professionals.

A study published in the Archives of General Psychiatry found psilocybin, the active substance in 'magic mushrooms,' can safely improve the moods of patients with advanced-stage cancer and anxiety.

The study was headed by Dr. Charles S. Grob, a professor of psychiatry at the Los Angeles Biomedical Research Institute at Harbor-UCLA Medical Center.

In Dr. Grob's study, twelve volunteers, ages 36 to 58, with advanced-stage cancer and anxiety were given a moderate dose of psilocybin and, on a separate occasion, a placebo. The study employed a double-blind procedure, meaning neither the volunteers nor the researchers monitoring them knew whether they'd been given a placebo or psilocybin.

After receiving a dose of psilocybin or a placebo, volunteers were monitored for six hours. They were encouraged to lie in bed, wear eye shades and listen to soft music during the first few hours after ingesting the medication or the placebo. The volunteers were then interviewed after the six-hour session and over the next six months to assess the consequences of the treatment.

The study found a significant improvement of mood and a reduction in symptoms of anxiety up to six months after receiving psilocybin-assisted therapy.

"We are working with a patient population that often does not respond well to conventional treatments," said Dr. Grob. "Following their treatments with psilocybin, the patients and their families reported benefit from the use of this hallucinogen in reducing their anxiety. This study shows psilocybin can be administered safely, and that further investigation of hallucinogens should be pursued to determine their potential benefits."

Although some may be concerned that a relatively unstudied and illegal substance such as psilocybin may pose health risks, a study published in the peer-reviewed journal Psychopharmacology in 2004 found there is "no cause for concern that [psilocybin] is hazardous with respect to somatic health" in healthy adults.

The only physiological side-effects the study found was a brief increase in blood pressure and a small increase in levels of thyroid-stimulating-hormone (TSH), prolactin, cortisol, and adrenocorticotropic hormone. None of these side-effects were considered dangerous to healthy adults.

"Typically, the experiences after [medium and high doses of psilocybin] were rated positive, with retrospective statements ranging from ‘pleasurable’ to ‘ineffably beautiful,’ " according to the study. One volunteer had a fearful experience after being given a high dose of psilocybin, but his anxiety was resolved without the need for pharmacological intervention.

Recently published research has also found Methylene-dioxy-methamphetamine (MDMA), better known as the club drug esctasy, to be a viable treatment for Post-Traumatic Stress Disorder (PTSD).

The study was headed by Michael C. Mithoefer and published in the peer-reviewed Journal of Psychopharmacology.

For their study, Mithoefer and his colleagues recruited twenty people who suffered from chronic PTSD. The majority of the participants in this study were women and had been diagnosed with PTSD for an average of 19 years.

Of these twenty participants, twelve were randomly assigned to receive MDMA-assisted therapy while the remaining eight were assigned to receive the same psychotherapy, but with a placebo pill instead of ecstasy.

The psychotherapy consisted of two, eight hour sessions at an outpatient office.

The method of psychotherapy used followed principles similar to those developed by Dr. Humphry Osmond, Dr. Stansilav Grof, and others in the 50's and 60's for LSD psychotherapy.

There was a significant difference between the group of participants who received ecstasy-assisted therapy and those who received psychotherapy without ecstasy.
Volunteers treated with a combination of MDMA and psychotherapy saw clinically and statistically significant improvements in their PTSD – over 80% of the trial group no longer met the diagnostic criteria for PTSD, stipulated in the Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV-TR) following the trial, compared to only 25% of the placebo group.

In addition, all three volunteers who reported being unable to work due to PTSD were able to return to work following treatment with MDMA.

Mithoefer and his colleagues believe that the use of ecstasy during psychotherapy may be effective because it allows the patient to emotionally engage traumatic memories without becoming overwhelmed by fear or anxiety.

"The goal of using MDMA is to temporarily reduce fear and increase trust without inhibiting emotions, especially painful emotions, allowing these patients a window where psychotherapy for their PTSD is effective."

Due to the preliminary nature of the study, these findings are limited, but Mithoefer and his colleagues are enthusiastic that long-term research will show similarly positive results.