This week, MIA featured a news item regarding a recent “proof of concept” study conducted at Washington University of St. Louis that investigated whether nitrous oxide, commonly known as laughing gas, was effective in reducing symptoms of depression. In a press release, one of the investigators, notably the anesthesiologist on the team, was quoted as saying,“It’s kind of surprising that no one ever thought about using a drug that makes people laugh as a treatment for patients whose main symptom is that they’re so very sad.”
Surprising indeed. I think one needs to be in the rabbit hole of modern psychiatry to understand why a drug like this would be overlooked as a treatment for depression. I would argue that it is a reflection of what Joanna Moncrieff has called the disease-centered approach to understanding these drugs. We have the conceit that the drugs we prescribe rather than being generic euphoriants or tranquilizers target specific disease states. The narrative of modern psychiatry includes the notion that these states – or disorders – are ones that psychiatrists are adept at identifying. It would have been damaging to the basic premise of modern psychiatry – bolstered by the neo-Kreplinians at Washington University – to admit we were just giving out psychoactive drugs, i.e., substances that would impact most everyone in similar ways. If I were to inhale nitrous oxide, my mood would undoubtedly be elevated. I never tried it during its heyday when I was in college, but I knew many others who did and I did not need a rating scale to know they were – at least for a time – a pretty happy bunch.
There has recently been an interest in the use of ketamine, known as special K, to treat depression. This is another drug that has a dramatic effect on most everyone who uses it. It is used by anesthesiologists and not just for those who are depressed. If you scan the ads in publications aimed towards psychiatry, you will find many ads for stimulants. These drugs, along with the benzodiazepines (Ativan, Valium, etc.), are not disease specific drugs. They may be particularly helpful for those who struggle in certain ways, but they effect us all in similar ways. I do not need to be suffering from any kind of disorder to be sedated by a benzodiazepine.
I remember wondering why we did not give stimulants to depressed patients. As a resident, I was told they were ineffective. It was suggested that they might be helpful for older patients who had low energy but I would have been criticized as a psychiatrist if, thirty years ago, I had prescribed them to a depressed patient. But then the notion was heavily promulgated that children with Attention Deficit Hyperactivity Disorder (ADHD) did not grow out of their problems. We were told that in fact many adults missed out on getting properly diagnosed and were in need of treatment. And the flood gates of stimulant prescribing opened. I see people who have many reasons to be inattentive – on multiple drugs for their other diagnosed conditions, using substances, living in highly stressful environments. I know that it is considered legitimate practice – if they provide the correct history – to diagnoses them with ADHD. As psychiatrists we do not tell patients that there are drugs that – at least in the short run – can increase focus. We say that we have determined that they have an illness and we can give them a drug to treat this. Since ADHD is accepted as a life long problem, when we follow this particular narrative, we create a life long customer for the stimulant industry. I do not think it is a coincidence that this interest in adult ADHD began to arise as most antidepressants were going off patent and their efficacy was being questioned. Although the stimulants have been around for a long time and are available in inexpensive generic forms, what is being promoted now are drugs that resist tampering. These drugs are addictive and often abused. So the market now is for drugs that doctors can prescribe but will be resistant to a problem we know is endemic – misuse, diversion, and abuse. It is interesting that stimulants are now coming back into fashion for the treatment of depression.
While it is not controversial to talk about the general effects of benzodiazepines and stimulants, the group of drugs classified as anti-depressants are thought to be specifically effective for those who are depressed. This idea is worth examining further. Before fluoxetine (Prozac) was marketed, the research focus in psychopharmacology was on determining which individuals would respond to anti-depressants. I was taught in the 1980’s that those individuals who had neuro-vegetative symptoms such as poor sleep with early morning awakening, thoughts of guilt, motoric slowing or agitation, were the ones who should be prescribed anti-depressant drugs. The older antidepressants had many noxious side effects. People – doctors and patients – avoided them. Fluoxetine was considered much safer and better tolerated. So physicians started to prescribe it more broadly, encouraged by the enormous hype surrounding this drug. And what did we find? Many people, not just those who fit the more narrowly defined “melancholic depression” reported improvement. Books were written about their broad effects. But never was the notion widely entertained that these drugs had general effects that most people would experience, the idea was that the drugs worked on people with an ever proliferating set of diagnoses: social phobia, dysthymic disorder, personality disorders, etc.
Why is this a problem? Isn’t it a good thing that these drugs have broader uses? Isn’t it a good thing to reduce suffering among a larger group of people?
Here is the rub. This is what we still do not know about drugs: What are the long term side effects? How hard is it to stop them? How do we deal with the corrupting influence of the profit driven forces so powerful in medicine? Most of these drugs are still studied over weeks and then prescribed for years. With drugs like stimulants, ketamine and nitrous oxide, I have a particular worry because these drugs are known to cause psychosis. Colleagues of mine have told me that they do not see people who become psychotic on stimulants. If they don’t, they are not looking. I am not comfortable assuming when an 18 year old develops psychotic symptoms after several years of treatment with an antidepressant that these two things are not related or that the psychosis was inevitable because the person had a diathesis to Bipolar Disorder. Stimulants are used to create animal models of psychosis because we have known for decades that stimulants can cause a person to become psychotic.
I think these newer drugs have a huge potential for harm. This is due in the short run to the potential for abuse and diversion. But I remain equally worried about long-term consequences. Psychiatry has not begun to reckon with the unanswered questions concerning drugs we have been prescribing for decades. It is reckless to promulgate use of what appear to be even more dangerous drugs before we address these critical questions.
Szasz was an advocate for the legalization of all drugs to (responsible) adults. If this took place it would take the burden of responsibility out of the psychiatrists hands.
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markps2,
Thanks for the comment. While I doubt we can go backward with respect to physicians prescribing privileges, we do have a choice to make about marijuana. It is for this reason that I favor decriminalization or legalization over medical marijuana.
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“One can take virtually any single compound, carry out animal studies with varying doses, and find something that can be used to raise alarm.” http://blogs.nature.com/soapboxscience/2013/05/29/the-presence-of-a-chemical-is-not-the-same-as-presence-of-risk
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Markps2-
This cuts both ways – we can find the compound to be of harm or to be our next miracle cure. The answer is often more complex.
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Hi Sandy-thanks for the post. I share with you concerns about long term effects. Moreover, in the literature on fast spiking GABA interneurons-ketamine (which blocks NMDA receptors) will cause these fast spiking inter-neurons to die.
If we must do drugs, I wonder why we don’t use buprenorphine for depression. Jaak Panksepp, a good neuroscientist, argued in a recent issue of an Association for Psychological Science journal, that buprenorphine should be tired. I guess it is in clinical trials in Israel. Heroin addicts did not have negative long term outcomes, although ODs were/are a problem. To my knowledge, heroin does not cause violence and if not used in high quantity, does not impair function.
For ADHD, there are studies using nicotine patches. They are just as efficacious as Ritalin on increasing attention. On a psychological basis, people smoked for years throughout several centuries without devastating psychological effects. Presumably, the nicotine patches don’t cause cancer, although they will raise blood pressure. If I were a parent, I would prefer the nicotine patch to some version of speed.
My preference is no drugs. But, if we’ve got to do drugs, shouldn’t we be weighing the pros and cons of everything.
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Jill,
I am not sure if you are joking but if you are not, I would have the same concerns about bupe. Although it is safer – with regards to overdose risk – than methadone or heroin – it is nevertheless a highly addictive drug. Determining who wanted bupe to treat depression and who wanted it because it just feels really, really good, would be a challenge to say the least. It was another drug that was hugely hyped and it has not been nearly as easy to prescribe as advertised.
My focus is not on finding better drugs than ketamine or nitrous oxide. I am talking about the failure to learn from our experience the past 60 years. We did not look carefully enough at long term risks, and withdrawal and market distortions.
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Sandy-I find myself in the uncomfortable position of arguing pro-drug. (I’m against drugs.) However, as a civil libertarian, I think anyone who wants drugs should get them. If I had a prescription pad, and a patient wanted drugs-I would just write the script-following, of course, informed consent. I think if a doctor would write a script for an antidepressant, if requested, he/she should not get squeamish about bup. As you know SAMSA and Nora Volkow love bup. So the government probably won’t have a problem. I don’t think I would worry about the person who just wants to get high. Who cares.
Just doing drug to drug comparisons between Prozac and bup on relevant dimensions, doesn’t look to me that one can argue that Prozac is better than bup. Both drugs are addictive. I would argue that withdrawal from Prozac is worse (dyskinesias, mania, sensory distortion) than heroin, although I have not had much experience with bup withdrawal. You can OD on bup, but I think that the preparation that can be spread on the gums was an attempt to increase safety. As you know there were more drug OD on the old TCAS than there were with opiates. As you know antidepressants, can induce mania and violence. When taken in excess but at lower doses than would cause respiratory depression, heroin addicts just fall asleep. So why isn’t bup preferable to Prozac. At least opiates do have a good track record on altering mood. They’ve got more than placebo to say for themselves.
What’d I miss?
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Jill,
I do not know where to begin but I will try to bring this back to what I was trying to say in this post. The interest in drugs like nitrous oxide and ketamine points to the faults in our disease centered approach to drugs. These are not drugs that are specific for particular diseases, they are psychoactive substances with broad effects, some of which might be considered beneficial for some individuals. I am influenced by Joanna Moncrieff. Here is a link to one of her blogs that explains this further. I highly recommend her books:
http://www.madinamerica.com/2014/04/angels-demons-politics-psychoactive-drugs/
What I try to say above, is that currently when these drugs are prescribed, people are not told, here is a mood elevating drug that will improve your mood for a time. We say, you have an illness and you require this drug to treat it. Those are very different messages with different implications. I think that Dr. Moncrieff gets at this point in the blog above.
As to the use of opiates to treat depression, I would suggest you look at how effective their widespread promotion for the treatment of pain has been. It has led to a surge in addiction and now a cottage industry in the treatment of those addictions.
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Thanks for responding Sandy. I think we are on the same side of most issues. I do think that both you and Moncrieff are correct about selling the disease label and that being terrible.
On the issue of the opiates epidemic largely attributable to prescription oxyContin, I keep wondering whether opiates would be considered to be a problem if they weren’t illegal. ((More propaganda selling the population on another untruth.) Since opiates don’t have such bad long term effects on the body, why not just not worry about it. I don’t think the society will be harmed if we have large numbers addicted to opiates. Opiates do decrease sex drive, but again not a big concern for the society. We’ve come to this position with marijuana in many states. If people get addicted to opiates and they don’t like it, well then there’s AA and the treatment centers. So why should it be an issue of the society. Why should Tom Frieden bemoan the fact that people are getting addicted to Oxycontin, and then turn around and recommend bup or methadone?
With regard to needing to have a disease before a doctor writes a script, this is interesting too. I remember my friend, who was fighting with her ex over an expensive private school for her son, getting a script for Prozac. I said, “but Jay, just one problem, you’re not depressed. ” She replied, “Oh, yea, I know and I’m not going to be.” No worry. The first memory disturbance she experienced and down the toilet the Prozac went. But, Jay’s doctor apparently had not problem with giving a script to someone who obviously was not depressed. My guess is this is not a rare event.
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“psychoactive substances with broad effects, some of which might be considered beneficial for some individuals”
Beneficial how? Maybe they do elevate one’s mood but just make a thought experiment and think of a person who is really depressed for whatever reason and is given one or the other drug to manage the “symptoms”. That means this person will use the drug to be able to function, every day. Shortest way to physical dependence and psychological addiction (since coming off the drug will always result in going back to depression, especially when reasons underlying the “depression” remain unresolved/unprocessed). This is the worst idea on the planet.
Studies show that addiction is not linked only to the use of the drug itself but mainly to the reason why the person is using the drug, his/her life circumstances, poverty etc. It’s insanity.
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Jill
You said in the comment below: ” I don’t think the society will be harmed if we have large numbers addicted to opiates.”
I’m having trouble believing you made this comment without a hint of sarcasm or humor; it just oozes with indifference and elitism.
I’ve had some hard core opiate addicts make a similar argument to me about legalization during a counseling session.
For the rich and powerful, they would not care one bit about this segment of the population (just like they don’t care about the poor) if they weren’t committing crimes to support their habit. As tolerance to the drug inevitably grows, so does the amount of money needed on a daily basis to support an addict’s habit.
Tell all that to the families of opiate addicts who suffer while watching the steady decline of their loved ones, while also having to contend with habitual lying and stealing necessary to support an expensive habit.
Tell that to the growing number of families who have had to bury their loved ones in this country’s rapidly rising epidemic of overdose deaths.
Many opiate addicts know how to safely use their (single category) drug of choice, it’s all the other sedative hypnotics (such as benzodiazepines) that they have forgotten are also circulating in their blood stream when they shoot up. We cannot repeat too often the statistic that in over 30% of all deaths from opiate overdoses the deceased person also had benzos in their system; in 2013 there were 94 million benzo prescriptions written in the U.S. Just another crime (among so many) laying at the doorstep of Biological Psychiatry.
Richard
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Regarding “Tell all that to the families of opiate addicts who suffer while watching the steady decline of their loved ones”
The only person that can stop an opiate user, is the user himself.
At the age of 18 or 21 ( depending where you live) we are supposed to be responsible adults, if not ( an adult yet) the legal drinking age should be changed.
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Richard, as I said, I’m a libertarian. I do wonder whether heroin would be a problem if it weren’t illegal. Addicts die because of the illegality issue. They do have to steal, because its not cheap and readily available. In Europe, in some countries, addicts can get heroin legally through the health clinic. They come in, shoot up their safe dose under observation and then go to work. In this country, opiates were legal prior to 1914. Again, no big problem for the society. Abraham Lincoln used laudanum throughout the Civil War. Personally, I am not for heroin use or addiction. But, I don’t think I need to impose my preferences on others.
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Let’s bring back morphine – that worked awesomely the last time around. Psychiatry is a parody of itself (and a tragedy of all the poor “patients” caught in this insanity).
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I’m fine with people using performance enhancing drugs under some circumstances. But calling that medicine and drugs targetted at specific disorders has opened the gates of hell. Not mentioning that these drugs are all addictive and do have side effects, some more, some less serious, especially over the long-term.
If you want to use drugs, that should be your choice but please don’t tell me it’s because of your mental illness.
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I hate to over-use quotation marks, but it’s important to me that I make it clear that I don’t consider extreme states “illnesses” or “disorders.” Also, based on almost 30 years of reading the literature on the effecicacy (or lack thereof) and “side-effects”of a range of psychiatric drugs, I don’t advocate their use – or at least, I advocate that people who consider taking them fully inform thmeselves of the potenital risks and benefits.
But based on personal experience, I feel very differently about the voluntary use of psychoactive substances for the expansion of counsciousness and personal growth. I’ve experienced what others might call “depression” most of my life – although I call it alienation and despair. One of the things that has made a difference in my understanding of myself and my relationship to the universe is nitrous oxide (not done recreationally, but in the dentist’schair). On one such occaission, I experienced the purest joy, the deepest calm, a sense that everything was completely and impeccably understood and that all was perfect as it was. I merged seamlessly with all matter and energy – I WAS all matter and all energy – and no longer a separate entity.
More than any psychiatric treatment or therapy I experienced before then -or in the 40 years since then- this experience with nitrous oxide had a more profound amelioration of my sense of alienation and despair. Theimperfectly recollected feeling of that moment is often the only thing that keeps me in this body. So it’s hard for me to understand why this might be a problem.
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Hi Darby-
Thank you for sharing your experience. All of the drugs – the one you like and the ones you do not – are psychoactive substances. I am not opposed to their use. I am in favor, however, of learning from our past experiences. You took nitrous oxide once. Many others have as well. Has anyone looked systematically at the long term outcomes? What if it gets administered weekly over months or years? If a drug company comes out with a form that is easier to use, will they be transparent about their data? Will they study it for more than six weeks?
Until we reckon with the mistakes that were made in the past, we are likely to repeat them.
But the other point I made was not specific to the pros and cons of nitrous oxide but to the notion that these drugs treat specific illnesses. I think you and I are in agreement that the experience you had with nitrous oxide was not because you suffered from an illness.
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Darby, Thanks for continuing to share your perspective on the meaningful connections for this range of issues. I also wondered if you had ever enjoyed controlled substances where it was as legal as the ground you walk on? We plainly know that expectations and environment can matter as much or more than the intended chemistry. So I doubt that our country has many useful studies of drugs that rankle today’s Carrie Nation’s.
Similarly, I wonder why behavioral healthcare professionals think they can get accurate reports of experiences when the patient’s aren’t enjoying their liberties equally. Then it is back to the random trial data with dubious absence of context all over again.
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Sandra
You make several references to ADHD without using quotation marks or questioning the legitimacy of the diagnosis. I believe there is a great deal of evidence that this has been another manufactured diagnosis created by Big Pharma colluding with the APA for self serving and other nefarious purposes.
I know you are trying to approach these questions from a critical perspective. Where do you stand on this question; are you ready to let go of the ADHD diagnosis?
My experience from critical sources starting with Dr. Peter Breggin many years ago and numerous others in the years since, combined with my own work as a counselor in community mental health tells me the following:
1) that some of the “ADHD” behaviors that lead to labeling By biological Psychiatry certainly do exist, but more fundamentally arise out of a prolonged state of excessive or heightened anxiety.
2) that there are multiple factors in one’s environment that better explain the behaviors (or so-called symptoms) such as a trauma history (either witnessed or directly experienced), oppressive and/or inconsistent confusing, or constantly changing boundaries (for children) maintained by dysfunctional parents, and/or allergic reactions to certain substances or toxins in the environment.
Many drugs (both legal and illegal) have different reactions for different people who have had the above noted experiences. Over the years I have talked with people who are calmed by cocaine and energized by heroin, and some with exactly the opposite reactions. All categories of legal and illegal substances have BOTH short term and long term consequences and the SHORT TERM consequences are NOT always falling on the positive side of the scale.
When you make reference to antidepressants you tend to emphasize or only mention potential dangers of long term consequences (and we are learning more everyday about the long term dangers of perturbing the serotonergic system).
For the short term, what about suicidality, akathisia (extreme anxiety and discomfort), and emotional numbing or a state of “selfish indifference.” The latter description is one that I have noticed in working (for 21 years) with many people on these drugs. I have also seen many people who have been on multiple SSRI’s and never “get better” and seem to get worse or go from one crisis period to another with only short periods of relative stability in between. Sandra, have you not observed the same phenomena among your patients?
We all know (here at MIA) about the past hype of Prozac and other SSRI’s (Prozac Nation etc.). We also know about the significance scientific evidence of the Placebo Effect which clearly explains the explanation of short term positive effects reported by people. A good question to investigate regarding SSRI’s: are there really any significant numbers of people out there who actually claim that SSRI’s work great over a period of many years? Can Biological Psychiatry really prove that there is even a small subset of people who actually benefit from these drugs over the long term? I question if they can do this.
As to more short term negative effects, emotional numbing or “selfish indifference” might have an initial subjective experience that could be described by an individual as “positive.” But even in the short term this effect could be seriously undermining their ability to understand or solve the very problems in their life that are giving rise to the experience of depression.
These drugs can lead people away from seeking out the means and resources to solve their problems, but instead lead them into a state of passive acceptance of the status quo that actually prolongs their experience of depression. This state of passive acceptance can often prevent the development of necessary coping mechanisms and new insights that are essentially to making progress in their life.
So Sandra, my point is that short term effects can also be proven to be quite harmful (in different ways) even prior to the growing evidence of iatrogenic damage done by neurochemical dis-regulation in the long term. I hope you will speak to this as well.
Richard
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Hi Richard,
I agree with Thomas Insel who has called all of the DSM diagnoses “fictive categories”. I have written more about psychiatric diagnosis here:http://www.madinamerica.com/2012/03/what-is-in-a-name-one-psychiatrists-view-of-psychiatric-diagnosis/
My use of the term ADHD was not intended to reify the category or imply it had some essential nature. I was just trying to describe how the stimulants have been promoted in the past decade.
Similarly, my pointing to the lack of knowledge about long term effects was not meant to imply that there are no negative short-term effects. I was trying to point out that most drugs are studied for only brief periods of time before coming to market. They are then often prescribed for much longer durations of time.
I can see from the comments that I did not do as good a job as I thought making my points in this blog!
Thanks for commenting.
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Richard,
I see that I should have written this line:
“But then the notion was heavily promulgated that children with Attention Deficit Hyperactivity Disorder (ADHD) did not grow out of their problems.”
as
“… children labeled with Attention Deficit Hyperactivity Disorder (ADHD)..”.
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Sandra
Thanks for the clarification.
How about the issue of what you are seeing in community mental health for those people on long term use of multiple SSRI’s? Over the years are you seeing chronic levels of dysfunction in those patients?
I know we do not usually see people who are doing well in these clinics (so the sample numbers are skewed) but do you believe Biological Psychiatry could actually prove that there is a subset of people who truly get better from depression over the long term while on these drugs?
Richard
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Richard,
What I do know is this. Since I am fairly outspoken, many people approach me with their stories. A good number report long term benefit from psychiatric drugs including (actually often) SSRI’s. From my clinical experience, as you say, my experience is skewed. First of all, most of the people I see have experienced extreme states (what psychiatrists and some others call psychosis). I do not work primarily with people whose major problem is low mood. I have been skeptical of antidepressant effects for a very long time, so I am not in the habit of starting them (although sometimes I do and sometimes people come to me on them).
For me, this story is rather complex. You tend to put the blame solely on psychiatry (as in your attribution of opiate overdose to biological psychiatry). Although I do not think I am an apologist for the profession (although I know many here consider me that since I have not completely renounced it and walked away), I think the pull to use drugs to treat the pain and suffering of daily life, long precedes the modern era of psychiatry.
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Sandra
For clarification, I do not put all the blame for opiate overdoses at the doorstep of Biological Psychiatry. Certainly the issue of the proliferation of benzo prescriptions is very much related to psychiatry’ prescribing patterns; a high percentage of these drugs do end up in the black market on the street.
Also important to this problem is to critically examine the “Fifth Vital Sign” campaign that took place in the mid to late 1990’s. This involved pressuring all doctors to question patients about pain levels as if it was as important as blood pressure etc., and then coerce them to freely prescribe pain drugs. This was a combined effort of the pharmaceutical industry and certain leaders among pain specialists. This campaign laid the groundwork for the proliferation of pain clinics in this country and was the precursor to the current epidemic of opiate addiction.
From a more macro perspective, I see the material conditions from which major addiction problems arise is directly related to the daily traumas inherent in a capitalist/profit based system that generates and sustains poverty for the underclasses; opiates provide an easily procured form of temporary escape.
Richard
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Does becoming an unbearable as**ole with a macho complex count as a long-term side effect? Reversible upon tapering off the drug (a case of my acquaintance).
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Richard,
Opiate use by country.
US is number 27.
http://www.photius.com/rankings/opiate_drug_consumption_country_ranks.html
The problem is capitalism, again?
Really, Richard?
Duane
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Poverty by country:
http://www.indexmundi.com/g/r.aspx?v=69
Capitalism causes poverty?
Or just opiate use?
Or both?
Psychiatry “blames the brain.”
While many on MIA appear to blame capitalism.
Not sure if blaming either is the real answer.
Call me crazy.
Duane
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Duane
There are no genuine socialist countries in the world today.
Poverty in Third World countries is directly related to the First World countries that control and exploit their cheap labor and natural resources.
Capitalism is a pyramid like structured society with a very narrow peak at the top that represents the tiny minority (often referred to as the one percent) who have all the power and most of the wealth.
If every single adult in this country (including every single minority and poor white person) had a college education along with specific technical training, it would not change (one iota) the actual class structure of our society. Unemployment and specific wage scales are built into the very fabric of capitalism.
This is not “crony” capitalism or “unreformed” capitalism; this is capitalism working just the way it is designed to work.
Richard
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Richard,
There may be no *genuine* (whatever that means) socialist countries in the world.
But there are a few *failed* ones still left.
Cuba comes to mind:
http://business.time.com/2013/02/06/lessons-in-socialism-how-cuba-can-become-relevant-again/
If you want to discuss this further, please take it to the political forum:
http://www.madinamerica.com/forums/forum/things-political-thoughts-paradigm-shift-left-right-center/
Duane
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Cuba is failed? Is it because of the “socialism” or because of the US sanctions? And this “failed” state has better healthcare and literacy than US. Not mentioning that they don’t bomb people or torture them in black sites. I hate this US-centred hypocrisy.
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In keeping with the guidelines of MIA, I’ve left comments for B and Richard in the political forum section (typo in the topic heading):
http://www.madinamerica.com/forums/topic/socialist-states-oppression-poverty-and-failurere/
Sandra,
My apologies for momentarily derailing the blog post topic. I should have created a political topic earlier in the thread.
Duane
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“”that some of the “ADHD” behaviors that lead to labeling By biological Psychiatry certainly do exist, but more fundamentally arise out of a prolonged state of excessive or heightened anxiety.
2) that there are multiple factors in one’s environment that better explain the behaviors (or so-called symptoms) such as a trauma history (either witnessed or directly experienced), oppressive and/or inconsistent confusing, or constantly changing boundaries (for children) maintained by dysfunctional parents, and/or allergic reactions to certain substances or toxins in the environment””
I apologize for temporarily digressing but Richard, as a mental health professional, I strongly urge you to keep sleep apnea in mind when dealing with the possibility of clients being misdiagnosed with ADHD.
http://www.huffingtonpost.com/dr-michael-j-breus/adhd-sleep-disorders_b_3193570.html
Additionally, many people with learning disabilities and central auditory processing disorder are misdiagnosed with ADHD. One thing to watch out for though in getting diagnosed with LD by a psychologist/neuropsychologist is that many of the LDs are in the DSM so of course, they will think that taking a psych med will be very helpful when actually, it would greatly worsen the LDs. Probably better to self diagnose and research compensatory mechanisms if one strongly suspects having LD and doesn’t need an official diagnosis for other reasons.
Speaking of sleep apnea, it has been shown that when the apnea is treated, the depression greatly improves. What a surprise says AA sarcastically.
http://wkzo.com/news/articles/2014/dec/22/treating-sleep-apnea-may-lessen-depression-too/
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AA
Thanks for pointing out these other factors. I was aware of the connection of sleep apnea to so-called “ADHD” but I forgot to include it.
Richard
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“For the short term, what about suicidality, akathisia (extreme anxiety and discomfort), and emotional numbing or a state of “selfish indifference.””
Great points. First, I think it is outrageous that people are prescribed drugs which are known to cause violence and suicides and when these occur they are always blamed on the person not on the drug and the person and not his/her doctor has to face legal consequences. Secondly, the effects of these drugs are highly dependent not only on an individual person but also on momentary circumstances (e.g. alcohol will make a happy person even more joyous but drunk while sad will make one teary or even suicidal – I have both witnessed and experienced it – psych drugs are no different). Also the effects on the person can change in time due to dependence, tolerance etc.
“These drugs can lead people away from seeking out the means and resources to solve their problems, but instead lead them into a state of passive acceptance of the status quo that actually prolongs their experience of depression. ”
I totally agree.
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Heh, while the wondering is going on, why not treat acute psychosis with a general anesthestic ?
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Do people with acute psychosis sleep? I don’t think so. I think YES an anesthetic could help.
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Or just a blow to the head. Maybe a lobotomy or ECT… oh wait that’s already been tried.
Btw, ketamine in higher concentrations is an anesthetic.
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One a related note: I find it curious that it is considered unethical, let alone illegal to aid or even advocate suicide to a depressed person but promoting treatments causing irreversible brain damage (like ECT but also some long-term drug treatments) is totally fine? Moreover if you chose suicide over “treatment” you’re being incarcerated and tortured with the said “treatment” while you’re being prevented from ending your agony.
Is zombie better than dead?
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Dr. Steinberg, I want to mention how readable and fair to drug users you are and point to how much that suggests your attitude toward getting questioned or pressed for further moral explanations tends to be an open one. In fact, almost every psychiatrist I have had to meet has not so much as liked getting consulted, their conceit about knowing their patients’ best interests having drifted all the way over to insisting on docile acceptance.
In other words, my best interest had to be understanding diseases and how dangerous it was to reduce medications, and I saw a lot of this, and almost nothing else. Not just for myself alone, but nearly 100% of requests to continue struggling with personal issues in freedom met with, and I’m sure, still meet with this hypocrisy, no matter that there is no such reason as the doctor will claim to prove dangerous and covert agitation, and that the person has no plan to carry out, no contemplation whatsoever, and no history of actual violence. No, he or she can’t leave because of danger to self or others, since they want to decide for themselves about any little thing.
This is the most outrageous direction for the conceit about drugs-for-diseases to go in. I’m sure that those who get around to planning violence or self-destruction rely on the conceit exactly at the turning point in their careers when they get to live out the reversal of power. I’m also certain that the corresponding effort to sell diseases for the insanity defense hurts the chances for escaping abusive and inappropriate clinical treatments, or just ineffective and misconceived ones, and stands in our way for escaping stigma as much as the glacial pace of reforms in prescribing practices itself.
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Dr Steingard,
as always you have got me thinking deeply about some important issues.
I would just like to say to all mental health professionals that if they ever manage to paint the Mona Lisa on a grain of rice with their rubber ruler (diagnosis of mental illness) and a 4 inch paint brush (drugs) whilst riding on a roller coaster, to give me a call. I don’t mean to discourage them, but after so long one would think they might have examined the task they are trying to achieve and the ineffective tools being employed to achieve it.
Regards
Boans
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Thanks, boans (I think that was a compliment!). I love your metaphor.
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Oh yes, definitely a compliment.
Lots of talk in the literature about the benefits of these drugs, and not enough about the costs. It needs to be spoken about and I appreciate your openness about it.
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“This is what we still do not know about drugs: What are the long term side effects? ”
Uhh… yes, we do. While we may not know every single “side effect” that there may be, we also don’t know every single thing about the universe but yet you don’t hear astronomers and physicists telling the public “but we still don’t know why we’re here or how things work the way they do!”
We know more about psychiatric drugs than ever needed to be known to conclude that they are harmful far beyond any relative degree of “help” they may bring to some. Which reminds me of Phillip Hickeys blog post here about children being afflicted with tardive dyskinesia: what possible benefit could a child possibly receive from a drug that would be worth life-long involuntary movement disorders? A dose of a drug taken years ago, still hurting them today and that will still be hurting them 60 years from now… I think it’s safe to say, we know so much about these drugs, future generations will look back on statements like “we still don’t know how these drugs work in children” and “we still don’t know the long term side effects” as being a shame in the history of medicine. What we do know is far more important than whatever there might be that we don’t know. We know the drugs are just psycoptropic drugs. We know that they don’t really work for any therapeutic purposes and when they’re not being used simply as chemical straight jackets, most people who report improvement would go on to improve with just about any intervention. I think that’s more than enough to conclude that this is a disaster and psych drugs ought to be banned, at least in children.
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Even if we didn’t know – what happened to the cautionary principle? But I do agree with you: for each and every class of psych drugs long-term side effects are at least partially known and they are horrific.
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JeffreyC-
Point well taken. What would have been better would have been to write: What we know about long term effects is far from reassuring and we should pay heed to that before we go looking for new drug cures.
The “we” in this case refers to physicians.
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“The “we” in this case refers to physicians.”
Well if the physicians know less on this matter than the users and some interested members of the general public, then there is a serious problem there which defeats the purpose of even having medical degrees and licenses. I’ve said many of times here before though that I believe there is no way that doctors aren’t totally aware of this. They see the damages caused by those drugs on a daily basis, especially in cases of giving tardive dyskinesia to children. No amount of rationalizations could ever make that seem like a healthy trade-off. They know what they’re doing, they just don’t want to own up to it because prescribing drugs is a quick and easy way to make lots of money.
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New trial : efficacy of gasoline fume inhalation in treating anxiety
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Tickling for depression – at least this one has few side effects. I wonder if psychiatrists realise how ridiculous they sound.
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I don’t have many comments to this topic right now (I could if I had time), but as a kind of a side-note, I think nitrous oxide is an NMDA antagonist, like is ketamine. And I guess our common alcohol is an NMDA antagonist too.
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Perhaps ethanol’s “sedating” GABA actions prevent it leading to more “spiritual” heights, despite the NMDA antagonism? Whatever. Many you affect your NMDA and GABA receptors when enjoying a glass of wine, in a similar manner to laughing gas or ketamine + benzo.
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What if ethanol was only available on doctor’s prescription? If it was a new drug, it would probably be quite easy to make studies that prove it efficacy for anxiety, depression and social phobia.
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Hermes, Alcohol is probably the best drug going for anxiety and social phobia. It works better than psychiatric drugs and a controlled drinker can function and live a reasonable lifespan.
A problem drinker or someone who wants to stop drinking can find hundreds of people in the rooms of 12 Step fellowship that can help them live life sucessfully without the drug, and without psychiatry.
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Fiachra, Another of Dr. Moncrieff’so points has been that the myth of the chemical cure gets sustained along with an equally doctrinaire mindset of prohibitionism. Here for sure we see the likeness between genuinely medical and psychiatric approaches. As well it shows psychologists sitting on their hands rather than bolstering the message when particular individuals advocate for the health benefits of alcohol, or insist on attention to helping chronic pain sufferers get all the relief they need by forcing physicians to make careful discrimination between dependence and risk of dependence versus addiction on the other.
Usually the maverick’s get nowhere with their message and the most protected survivor is the status quo.
So the game of labels and forced treatment for psychiatric survivors themselves, as far as myths and prohibitions and coercion, gets very deadly and cases off-track dangerously, so that errors in favor of the “conceits” assure the anti-self-medication and over-diagnosis outcomes we know are so pervasive and disempowering. Except to the professionals and the apparatchiks of the justice system and media goon squads who like medical model politics just fine for us.
“Conceit” is an especially smart word for pointing out the way to reinforce better attitudes in caregivers one by one, a good little tweak to their mantra that “we must follow the treatment plan.” But from the survivor perspective the main issue with disease talk is getting taken out of the loop in your own right for how your future turns out, and the silliness of getting made to say you understand your illness so that your jailers will turn into doctors again(or what it makes you do). To me, it’s as sanctimonious as it is authoritarian, and the most stupid of things about forced treatment for psychologists to leave unchallenged about their city cousins, the doctors.
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Concerning use of drugs as medicine, I read an interesting book by Ylikangas about the history of drug use in Finland (the book is only available in Finnish). As many know, drugs such as opium, heroin and cocaine were commonly prescribed by doctors and quacks in 19th century and early 20th century in many parts of world. Ylikangas points out that a recurring theme with each new drug was that at first it was promoted as having no side effects or issues at all. It would take longer time to see the actual issues. For instance, heroin was first promoted as similar to opium but without addiction potential.
Heroin, cocaine and opium were widely available. Heroin was used in cough medicine. Finland was actually the biggest consumer of legal heroin during 1930s. After the Second World War, Finland was dealing with poverty and other issues. UN or other such international body demanded an explanation from Finland for the huge use or import of legal heroin. The Finnish president at the time answered that we need lots of heroin because of our climate. It was not commonly said that there’s any problem in public talk. However, restrictions of heroin and other drugs were quite rapidly mandated after some international orders, and the public image of these drugs likewise changed quickly among doctors and general public.
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Regarding “drugs as medicines” . All medicines are drugs, but drugs are not medicines.
Once a doctor prescribes a drug, it magically becomes a medicine.
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Thanks for providing this important piece of history. It shows well that using psychoactive substances to treat societal ills is neither a new idea nor an effective one.
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I found a short English description of this book I referred to: Mikko Ylikangas: Unileipää, kuolonvettä, spiidiä. Huumeet Suomessa 1800–1950 [Opium, death’s tincture, speed. Drugs in Finland 1800–1950]
“This book presents an account of the history of drugs in Finland, as well as changes in legal and illegal drug use. Even in the early 19th century, the authorities were concerned about opium abuse. Medical doctor Elias Lönnrot – best known for collecting the folk poems that make up the Kalevala, the Finnish national epic – coined the name ‘unileipä’, ‘the staff of dreams’, for opium. A period of prohibition of alcohol in the 1920s spurred a huge increase in the sale of cocaine; in the 1930s Finland led the Western world in consumption of heroin as a cough suppressant. In the late 1940s, the United Nations investigated why Finland, with a population of four million, consumed as much heroin in a year as other countries did over an average of 25 years. This was explained by the severity of wartime conditions: drugs were used to maintain battle readiness and to combat anxiety, sleeplessness and tuberculosis. Social problems caused by misuse did not, however, get out of control. This book was awarded a prize for the best science book of the year in Finland in 2009.”
There were issues with addiction and so on, but perhaps even the use of heroin was not entirely bad, at least in those conditions. There were people getting addicted, but there are perhaps many untold stories of people who got through from day to day life with drugs such as heroin, went to work and otherwise led a relatively normal life. The society did not get out of control, even in those severe conditions after the war, even though legal heroin was widely available.
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Sorry, it’s perhaps polite to say where that summary is from. I found it here:
http://www.booksfromfinland.fi/2010/04/mikko-ylikangas-unileipaa-kuolonvetta-spiidia-huumeet-suomessa-1800–1950-opium-death’s-tincture-speed-drugs-in-finland-1800–1950/
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Thanks, Hermes. Oxycontin was widely promoted as similar to other narcotics but less addictive. Richard D. Lewis above talks about the huge push for the “fifth vital sign”. This was all part of a marketing effort by Purdue Pharamceuticals who made oxycontin. This is reviewed in Melody Peterson’s “Our Daily Meds”, an excellent book as well.
I think the push to relabel psychiatric medications as “antipsychotic”, “antianxiety”, and “antidepressant”, was in part an attempt to distinguish them from recreational drugs. This all happened in the 60’s and 70’s when recreational drug use became more mainstream (at least in the US).
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Yes, psychiatry can kill a mosquito with a cannonball.
No more research is needed.
Duane
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I needn’t remind anyone that depression hurts. That the long term effects of nitrous oxide [and ketamine] are unknown doesn’t mean that informed individuals should not be given access. After all, many of us have taken and continue to take SSRIs for depression under long standing representation that each new anti-depressant was more effective. (For readers of MIA, it is no secret that this claim has not survived critical scrutiny where treatment predicated on these medications was supposed to be “evidence based” and representing “best practices.”) Like I said, depression hurts, and given this I trust many individuals will do anything if only to make the pain subside briefly where for so many one, two or three anti-depressants and an antipsychotic adjunctively continues to be treatment in its entirety.
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Joe,
Thanks for sharing your perspective. I would not ever want to minimize the deep despair that some people experience. One challenge here is what we mean by an “informed” individual. One of my points is that our current system has not provided us with the kind of information that we need to make truly informed decisions. this is not only due to study design (one name I have heard for some of them is “experimercials”) to issues of lack of data transparency.
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Dear Sandra
I so much appreciate your posts and that you as a psychiatrist, one of the very few, engage in this extremely important issue and discussion. Sometimes the replies tend to “go far beyond” the original post so I just wish to say how much it means that you share your knowledge and experience.
I would also like to thank Richard for suggesting you to use quote marks around that which is called ADHD. From my perspective I find it to be one of the most important issues at the time being, that we never keep our months shut for the terrible things taking place right now in the western world, and as far I have understood it is also spread to South America – the fact that a lot of Children and Young people are labelled and put on drugs. It is such a shame and it cant be done without protests and by telling the other “truth”. So thanks again Sandra, I so much value your work and word!
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Thanks, Carina. Your words and encouragement mean so much to me.
As I told Richard, in retrospect, I would have worded that sentence differently. I am so used to thinking of all of these labels as (in the words of Thomas Insel, Director of the National Institute of Mental Health) “fictive categories”, that I forget others do not know how I think about these labels.
Rob Wipond has an interesting discussion about how and when to use quotes: http://www.madinamerica.com/comment-history/?id=4177
But hopefully you and other readers gathered from the content of that paragraph on”ADHD” that I share your concerns. It is not just children, it is now many adults as well.
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My first time visiting this site. Great discussion.
Isn’t it interesting how ketamine and laughing gas seem to always need further evaluation before they can be prescribed, yet, doctors are very quick to prescribe very dangerous antipsychotic meds that have only gone through a few 6 week clinical trials?
The recent results for laughing gas showed positive results after only a day of use. Why do you need a study to continue using them? The medicine is cheap. These patients have likely have miserable lives and have been on all kinds of serious psychotic meds for years that have offered little to no relief. Hear they got some relief, and doctors are refusing to continue to prescribe the medicine until further testing is performed.
Both ketamine and N2O have been used for years. The medicines are reported to have well known effects that self regulate on withdrawal of the medicine.
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I personally wish there were more liberations for people who suffer from more severe forms of mental distress and at the same time know what is going on. Ketamine and N2O may be useful for some individuals, used in some proper way. Using them may be better for some individuals compared to what is going on otherwise in psychiatry, with promoting of neuroleptics and SSRIs.
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Pat45,
Welcome to MIA and thanks for commenting!
I did not say much about the quality of the study but it would never be adequate to get FDA approval for this indication. Even though drugs may be on the market, they usually need to go through separate testing to get FDA approval for a new indication. They involve more people than this study did. Also, the effect sizes were surprisingly small. So although they found a difference between the nitrous group and the air group, they are only about 2 points on the rating scale they used. I am not sure that is a clinically meaningful difference. I would have been interested to have another control group – one who did not have depression but got nitrous oxide.
But as I say above, I think we need to understand longer term effects. Although nitrous has been around for awhile, people are not using it – at least in medical settings – repeatedly over weeks or months.
I am also not sure I agree with your last statement about ketamine having known effects that regulate on withdrawal. Again, I am not sure anyone has studied the effects of prolonged and repeated use of ketamine.
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“Again, I am not sure anyone has studied the effects of prolonged and repeated use of ketamine.”
Well, there was at least John Lilly, who extensively studied effects of increasing uses of ketamine on himself. His results were.. different. In any case, he was shooting for some spiritual or extra-terrestrial stuff, he was not on a maintenance dose. I’m also interested in how one larger dose of ketamine (or similar drug) can produce a longer lasting ease from depression.
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It is interesting to follow the discussion here. But again, if we drop the disease centered approach and just examined these drugs from a drug centered perspective, I think we would be in a better position to give people adequate information. The distinction made between psychoactive substances that are good (“medications”) and bad (“drugs”) is artificial.
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I think I’m personally pretty much thinking from the “drug centered” perspective myself, perhaps more so than many other who write here. For instance, when weighted on, I think some NMDA blocking medicine may be much more pleasant and even more effective for many patients than dopamine blocking medicine. And so on. That’s “drug centered” perspective.
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There are drugs and there are drugs. Some drugs calm the person down, some do not. Some drugs, such as NMDA antagonists and benzos, are usually pleasant and conforming to the person. He’ll like to take them. Other drugs, such as dopamine antagonists, often make the patient feel like shit. That’s one reason why psychiatrists have invented concepts such as “patient does not have adherence”, “he does not have insight”, etc. Neuroleptics make you feel like shit. That’s a major reason patients don’t like to eat them. I think there’s some actual reason to look again into laughing gas and ketamine.
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Many doctors seem to have an aversion to prescribing meds that have the potential to make a patient feel good. I expect they have concern that a patient will take the med for the purpose of getting high even when it is not effective at treating the disease. This is a reasonable concern with meds that cause physical addiction or have serious side effect risks. Years of using ketamine and N2O in other applications show them to be non-addictive and to have low risk profiles. So what is the concern with giving them a try? Isn’t there some benefit to providing a few minutes or symptom relief to a person that is suffering with major depression?
Research indicates that 30% of patients with major depressive disorder will not get any benefit from the standard SSRI/antipsychotic med regiment. The standard meds have many risks and side effects.
After years of taking standard medicine and getting no apparant relief of symptoms, doctors told me it is very important that my family member keep taking the medicine. They have warned me that young adults with major depression have a high risk of suicide when they are not taking their meds. Non-compliance seems to be real problem. To me, it does not seem logical to ask a patient to keep taking a med that is not providing benefits especially when the med has high risk of serious, possibly permanent, side effects.
When reporting a lack of response to the medicine, doctors have recommended increasing the dose beyond the FDA approved prescribing guidelines. When asked about possibly prescribing ketamine and N2O, the doctors have refused siting the need for more research and the meds not having FDA approval for that use. To the patient, it appears to be hypocritical to site FDA guidelines as a reason for not using a med and at the same time prescribing another med in a way that exceeds FDA guidelines.
Psychiatrists routinely prescribe meds off-label…when they want to. Now we have Ketamine and N2O that seem to show some promise in treating treatment resistant depression. From the research, patients will know within a matter of days if the meds are working. Therefore, exposure would be limited to a short term if the med is not working. With the SSRIs, you will have the meds in your system for months before you know if they are not working.
Yet, doctors are not willing to prescribe ketamine and N2O for treatment resistant depression that has failed to respond to the current meds.
Suicide is a real risk without EFFECTIVE treatment
I suspect Compliance may be less of an issue with Ket and N2O due to low side effects and they may even like the buzz
Short duration/quick response if it works.
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Ketamine is not a safe drug, by no measure it is.
“Isn’t there some benefit to providing a few minutes or symptom relief to a person that is suffering with major depression? ”
So the answer to “depression” is getting high? Because that is what you’re advocating for essentially. What about heroin then? I bet it can also bring at least temporary relief. I don’t doubt that this is going to make one feel better temporarily but it’s unlikely to help anyone long term unless you want someone to keep getting high in order not to kill oneself. It’s a dead end. These drugs are just as risky as other psychoactive drugs – short term risk include sudden death among others, long-term use is largely a question-mark with some data showing it’s far from innocuous.
If one needs to stay high in order to live what is this life worth anyway?
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Pat45,
While I think you are correct about physicians’ discomfort about prescribing euphoriants, we disagree about the relative safety of these drugs, especially ketamine. Nevertheless, there are now clinics operating where this drug is prescribed.
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Ketamine is dangerous. It can lead to cardiovascular failure and death not mentioning other side effects. I don’t know what is known about the interactions with other drugs but I assume it is not making it safer. Giving people heavy duty drugs with a lot of side effects should be reserved to really dire circumstances (like chemotherapy for cancer). Giving potentially lethal hallucinogens to people to “manage their mood” is criminal.
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“If one needs to stay high in order to live what is this life worth anyway?”
I agree…but my relatives may feel differently.
Though, I’m currently on Suboxone, which doesn’t get me “high,” when I was getting high (or whatever), the reason was so I wouldn’t suicide and ruin my parents’ lives.
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And did it solve anything?
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It has definitely helped.
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Dear Sandra, I read all these comments with mixed interest. However, I myself took one 60 minute PAN- treatment (Psyhotropic analgesic nitrous oxide) session 21 years ago, and I have not had a single drink since, because of the sustained anti-graving state of mind. The treatment transformed my physical and mental life totally in a new balanced direction without side effects.
All in all, PAN treatment has been a part of the South African national healthcare since early 1980’s, and well over 27,000 people have received PAN in Europe with a proven success rate of 98%.
Nitrous oxide treatment for mothers in child labor, in stead of epidural injection has been in use in Europe and Canada since 1947, and from 2011 in the United States. Is it probably because of the known resistance of the pharmaceutical industry toward nitrous oxide that it so unbelievable difficult to admit that the aforesaid treatment could have a significant socioeconomic impact. The U.S. substance withdrawal industry marketplace is saturated with shady treatment spas and crossly negligent 28 day compulsory get sober programs which have nothing to do with scientifically proven methods. AA ‘s 12 step is good, but it is based on faith and the potential will power nothing else.
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