What Do Psychiatrists Say When They Talk to Each Other?

Jill Littrell, PhD
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Last week I attended a lecture presented at the Department of Psychiatry Grand Rounds at a major Southeastern University.  The presenter, a psychiatrist employed in a student counseling center at the same university, discussed the historical evolution of the orientation of university counseling centers.   Her audience was largely comprised of other psychiatrists both practicing and in-training.  “Grand rounds” is considered an educational event.  Doctors can receive continuing education credits for the attendance.

The presenter explained that historically, counseling centers viewed most of the students presenting for services as experiencing adjustment problems in transitioning to adult roles.  Assuming adult responsibilities, moving away from home, pressures to achieve high grades in a competitive atmosphere were viewed as adjustments that understandably could create some temporary angst.  In contrast to the previous perspective, now more counseling centers are run by psychiatrists trained in identifying major mental disorders.

What the presenter failed to address is whether the shift in orientation has resulted in better outcomes.  More young people are being labeled and medicated; that’s a fact.  According to the presenter, prescriptions for antidepressants exceed prescriptions for antibiotics at the presenter’s university.  Since the presenter did not even address the issue of whether the change in orientation represents a good thing, I decided to do some investigating.

Suicide prevalence seemed an obvious index that might offer a barometer for assessing whether the shift in thinking is associated with better outcomes.  The CDC report informs us that suicide rates have tripled since 1950s for all persons 15 to 24 years of age.  The American Association of Suicidology reports that suicide rates for this age group remained stably high between the late 1970s and mid-1990s, but have declined by 28.5% since 1994, while still exceeding rates in earlier periods.  In contrast to rates of suicide for young people generally, suicide rates on college campuses have declined since 1960 which is accounted for by more females (who have far lower suicide rates than males) being included in later samples (Schwartz, 2006).  Others have specifically examined how antidepressant treatment availability relates to rates of suicide.  Kessler et al. (2005) contrasted rates of suicidal behavior for all ages during 1990-1992 with 2001-2003 and rates of psychiatric treatment in the two epochs.  Kessler et al. concluded, “Despite a dramatic increase in treatment, no significant decrease occurred in suicidal thoughts, plans, gestures, or attempts in the United States during the 1990s.”   Thus, there is little evidence that the dramatic shift in orientation from a developmental perspective to a pathology orientation has improved outcomes.

During the presentation, conspicuous by its absence was the lack of discussion of the black box warning from the FDA.   The FDA advisory states “Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders.”  The finding of more thoughts about suicide in antidepressant treated compared to placebo treated was replicated in the “Treatment of Adolescents with Depression Study”, a large multisite study examining antidepressant efficacy in youth.  During the presentation there was no discussion of whether the counseling center takes any extra precautions in monitoring the students who are placed on antidepressants.  Given, that Grand Rounds are part of the training for new psychiatrists, the topic of how to discuss these issues with patients and how to properly monitor might have been appropriate.

In some states, there are informed consent laws.  Doctors are required to discuss both the benefits and potential harm of recommended treatments.  Many people remain on antidepressants for over two years.  The problem for a young person opting to take antidepressants is getting off of them.  Possible withdrawal symptoms include mania, motor problems in the jaw, depression and anxiety, and nausea (Ceccherini-Nelli et al. ,1993; Haddad, 1997; Lejoyeux & Adés, 1997; Stoukides & Stoukides, 1991).  For young people beginning careers, opting to take an antidepressant during college means that they may need time off from work later to detox from prescription drugs.  The imperative of discontinuing antidepressants is high for women.  For young women, continuing on antidepressants during pregnancy carries severe consequences.  Antidepressants are associated with increased risk of autism in the baby (Croen, Grether, Yoshida, Odouli, & Hendrick, 2011).  Antidepressants consumed during gestation are associated with heart malformations in the baby and problems in establishing proper lung function after birth (Chambers et al., 2006; Gentile, 2011; Udechuku, Nguyen, Hill, & Szego, 2010).  During the presentation, there was no indication that a cost-benefit analysis is routinely addressed prior to providing prescriptions.

Later in the week, I attended the graduate Biology seminar at another university.  The presenter discussed the efficacy of curcumin (found in turmeric) in preventing breast cancers and other cancers.  She presented her data, which were pretty convincing.  I asked the presenter about curcumin as an antidepressant, which I knew had been shown to be effective in animal work, and she told me that curcumin is being tested in clinical trials as an antidepressant.  As I sat there, I wondered why student counseling centers are not recommending interventions with fewer side effects.  There is a literature on omega-3s preventing and ameliorating depression and anxiety.  Recently, Glaser and Kiecolt-Glaser published a study showing that omega-3s are effective in reducing anxiety in medical students during examinations.  There is a literature on the antidepressant effects of exercise.  Are psychiatrists totally ignorant of these other interventions which have been proven to impact biological causes of behavioral depression?   To their credit, counseling centers do still offer counseling along with drugs.  However, there was little indication that psychiatrists give time for the psychotherapy to work prior to providing medications.  What could be the rationale for prescribing medications with black box warnings and severe withdrawal symptoms when efficacious and less harmful treatments are available?  Of course, there was also no mention of Irving Kirsch’s work on the lack of efficacy of antidepressants, anyway.  I guess the psychiatrists will have to watch Leslie Stahl’s “60 Minutes” broadcast this Sunday to learn about this.

Chambers, C. D., Hernandez-Diaz, S., Van Marter, L.J., Werier, M. M., Louik, C., Jones, K.L., Mitchell, A. A. (2006).  Selective serotonin-reuptake inhibitors and risk of persistent pulmonary hypertension of the newborn.  New England Journal of Medicine, 354(6), 579-587.

Croen, L. A., Grether, J.K., Yoshida, C. K., Odouli, R., & Hendrick, V.  (2011).  Antidepressant use during pregnancy and childhood autism spectrum disorders.  Archives of General Psychiatry, 68 (11), 1104-1112.

Kessler, R. C., Berglund, P., Borges, G., Nock, M., Wang, P. S.  (2005).  Trends in suicide ideation, plans, gestures, and attempts in the United States, 1990-1992 to 2001-2003.  JAMA, 283, 20, 2487-2495.

Kiecolt-Glaser, J.K., Belury, M. A., Andridge, R., Malarkey, W.B., & Glaser, R.  (2011).  Omega-3 supplementation lowers inflammation and anxiety in medical students:  A randomized controlled trial.  Brain, Behavior, and Immunity, 25 (8), 1725-1734.

Schwartz, A.J.  (2006).  Four eras of study of college student suicide in the United States:  1920-2004.  Journal of the American College Health, 54 (6), 353-366.

Schwartz, A. J.  (2006).  College student suicide in the United States:  1990-1991 through 2003-2004.  Journal of the American College Health, 54 (6), 341-352.

TADS (2007).  The Treatment for Adolescents with Depression Study.  Archives of General Psychiatry, 64(10), 1132-1144.

 

15 COMMENTS

  1. I totally agree. I dont imagine that there was any discussion regarding normal brain levels of serotonin, and abnormal levels, how they might routinely measured, and the level of precision of antidepressants in correcting supposed serotonin abnormalities? See below an interview I did Tues 14th Feb 2012 on the ‘science’ of psychiatry in the Irish Times http://www.irishtimes.com/newspaper/health/2012/0214/1224311742403.html#.TzrGUftdfQk.facebook

  2. There is no reasonable rationale to give kids SSRI’s. But what i can say is, from my conversations with psychiatrists, is that they are delusional and are suffering from a serious case of cognitive dissonance. And i do not say this lightly. On the one hand they are “doctors” who believe in evidence and are supposed to be helping people, but in reality they are prescribing largely ineffective pills that are causing massive amounts of brain damage. When you confront them with the evidence that shows SSRI’s don’t work and cause serious damage, as i have, they do not believe it and/or downplay it. It is really something else. Better yet, you can tell your regular doctor this and they will have a hard time believing it. I guess what it comes down to is doctors do not like the idea they were conned and have wittingly or unwittingly taken part in one the biggest frauds in medical history.

    • This whole issue is larger than psychiatry. As Marcia Angell has told us, the pharmaceuticals and purveyors of devices have taken over the medical schools. It’s a disaster for the sovereign debt and devastating to the health of Americans. I keep wondering when someone over at the CDC is going to catch on to this very real public health issue.

      • That is what i am saying, they live in their own little psychiatric bubble impervious to facts. It is truly disturbing. They really are delusional and/or enjoy hurting people. Furthermore, the US government knows exactly what is going on and either do not care, or they cannot do anything about it because of the clout of PHRMA. Every couple of years they bring Peter Breggin before a House sub-committee and he breaks down the debacle that is US psychiatry. After he states all of the horrors, nobody does anything. This has been going on for many years if not decades. PHRMA runs the show in Washington. Just follow the money.

        • I could not agree more with all that you have said. They are still totally convinced that we have brain based diseases and that they have these wonderful pills that can cure them all. How they believe it is beyond me. I was taught to critically analyse research and to never take anything at face value, while doing a simply arts degree. How can these people become doctors and not critically analyse anything. If I attempted to hand in 99% of what they classify as research for any piece of collage/university assessment I would be failed. Yet they worship it and will not question any of it?? There is NO research anywhere at all for the long term benefits, no research anywhere at all about what these disorders really are, etc, and yet they continue to go on about them being proven medical facts. While I acknowledge they do not want to admit they were conned, common sense has to ask why they are not able to do so. Why are they so convinced of something that has never had any real research to back it up. Why have they stopped asking for real research, etc.

          No one could develop antibiotics without first being able to put bacteria into a test tube. One had to be able to kill bacteria before they decided they had a treatment for it. Yet here someone comes along with a drug to treat something and yet we have no idea at all of what it is and they are 110% convinced of the effectiveness of the drug, even when there patients are saying it doesn’t work they still say it does. Even when they watch patients die of side effects, have them report terrible side effects they still say the side effects are minor. Depression is feeling sad, psychosis is hearing voices. One cannot put feeling sad or hearing voices in a test tube. The fact that the most educated people in the world cannot work that out is beyond me!!

  3. Jill, thank you for sharing your observations. That university counseling centers may be dispensing more antidepressants than antibiotics is truly cause for concern. Remembering my own days as a student in two major Southeastern universities, I recall followup care being nonexistent for health issues, not surprising given the student population they served ranged from 20,000 – 30,000+ students.

    Were mandatory followup visits part of the prescribing protocol?

    Another concern is the prevalence of binge drinking and substance misuse on college campuses. Add to the FDA blackbox warnings the dangers of mixing alcohol and prescription drugs and “cause for concern” becomes cause for alarm…

    I wonder what trends might appear if we looked not just at college suicide statistics but also accidental alcohol-related deaths and overdoses? Or if we looked at first-time disability rates in this population?

    How might we make families and students aware of these risks?

  4. How do they justify continuing prescribing antidepressants? John Grohol, editor-in-chief of PsychCentral.com, explains it here http://psychcentral.com/blog/archives/2012/02/20/i-walked-away-really-confused-says-cbss-lesley-stahl-on-antidepressants-placebos/

    – Irving Kirsch must be wrong.
    – Short-term studies, such as those submitted to the FDA, are not like clinical practice, where people are maintained on antidepressants longer.
    – Long-term studies (which don’t exist), which are more like clinical practice, would reveal higher efficacy for antidepressants.
    – Despite “confirmatory bias,” patients and doctors are convinced antidepressants work well.

    • Hi-
      I just wrote a response to the 60 Minutes show for International Society for Ethical Psychiatry and Psychology which will appear on their blog. There are plenty of long term analyses (although no studies where antidepressants tested directly against drugs). One can make a strong case that relapses are fewer for those not on drugs. Tom Insel, Director of the NIMH on his blog, will point to studies where people who have recovered on drug are taken off anti-depressant drug and then relapse in droves. What he fails to recognize/admit is that several publications (my 1994 publication included) have argued the high relapse rates reflect drug withdrawal.

      In America, first we have the failure to acknowledge the housing bubble and now the failure to recognize the obvious with these drugs. Is this entire culture about making money?

      • The entire culture, or rather the culture promoted by government and big business, is indeed about making money, preferably for big corporations.

        The same problems are found in banking, big pharma and climate change where the basic facts, and the basic science in the case of psychiatric drugs and climate change, are denied by industry funded PR and minimised by regulators and government. Billions of pounds of profit buys a lot of publicity and a lot of lunch for regulators, politicians and practitioners.

        This is why I see Occupy Wall Street and other movements that seek to limit corporate power are linked to limiting the abuses of psychiatry.

  5. Great article.

    The argument for the use of antidepressants is always the same… they “save lives”.

    Really?
    Where are the numbers for all these “saved lives”?

    The numbers are certainly not there for a decrease in suicide rates… So, if the expression refers to a better quality of life (figurative use of the term, “saved lives”), show me the improvement in the quality of life.

    Those numbers are not there either.

    Duane

  6. I think the best treatment for suicidal people is to accept it. Help them to take the appropriate and responsible steps, leading up to their desired death. Have them complete the legal establishment of their Last Will and Testament: http://en.wikipedia.org/wiki/Will_%28law%29

    Help and support these people to face death, because that’s what they’re asking. Help and support them in the Will process (MANDATORY “treatment” for suiciders).

    Help them to know their Will in death, and also help them to be VERY clear for their Will in life. Maybe you’ll discover that that is exactly the problem: some people do not know their Will in life.

    What is your will in life and in death?

    Suicide is a way to face death and to “know” death. Rephrase the condition to something that ISN’T a problem or a wrong. Death is a natural part of life – we KNOW death exists! Death actually happens in us automatically when we learn about it or if someone we know dies. Death happens inside of us when we become parents. Rephrase suicidality into a study of death. You could offer it as a class in curriculum at exactly the age where suicidality presents MOST OFTEN.

    Feeling suicidal or having suicidal thoughts isn’t bad or wrong. It’s normal. What’s not normal is having no idea how to support, educate and navigate.