On May 5, 2017, Donald Goff, MD and seven other psychiatrists, including the very eminent Jeffery Lieberman, MD, published an article in the American Journal of Psychiatry. The title is: “The Long-Term Effects of Antipsychotic Medication on Clinical Course in Schizophrenia.” Here’s the abstract:
“Concerns have been raised that treatment with antipsychotic medication might adversely affect long-term outcomes for people with schizophrenia. The evidence cited for these concerns includes the association of antipsychotic treatment with brain volume reduction and with dopamine receptor sensitization, which might make patients vulnerable to relapse and illness progression. An international group of experts was convened to examine findings from clinical and basic research relevant to these concerns. Little evidence was found to support a negative long-term effect of initial or maintenance antipsychotic treatment on outcomes, compared with withholding treatment. Randomized controlled trials strongly support the efficacy of antipsychotics for the acute treatment of psychosis and prevention of relapse; correlational evidence suggests that early intervention and reduced duration of untreated psychosis might improve longer-term outcomes. Strategies for treatment discontinuation or alternative nonpharmacologic treatment approaches may benefit a subgroup of patients but may be associated with incremental risk of relapse and require further study, including the development of biomarkers that will enable a precision medicine approach to individualized treatment.”
Note the concession:
“Strategies for treatment discontinuation or alternative nonpharmacologic treatment approaches may benefit a subgroup of patients…”
But, such strategies
“…may be associated with incremental risk of relapse…”
This is standard psychiatric scare-mongering, though the word “may” suggests less certainty in this regard than psychiatry has formerly expressed.
“…and require further study, including the development of biomarkers that will enable a precision medicine approach to individualized treatment.”
So these eminent psychiatric experts need biomarkers to identify those individuals to whom they should not give neurotoxic chemicals, but they don’t need biomarkers to maintain the practice of giving these neuroleptic drugs (forcibly if necessary) to everyone whom they label as schizophrenic.
. . . . . . . . . . . . . . . .
Here are the article’s conclusions (p 6-7):
“Results from many randomized clinical trials strongly support the beneﬁt of antipsychotic drugs for the initial treatment of psychosis and for the prevention of relapse. While naturalistic studies suggest that a small number of patients may recover from a ﬁrst episode of psychosis without pharmacologic treatment or may discontinue medication and remain stable for extended periods of time, we do not have clinical measures or biomarkers that allow us to identify them prospectively. Because relapses and delays in the treatment of psychosis have been associated with poorer outcomes, there may be risk associated with withholding or discontinuing medication. Evidence from preclinical animal models is mixed regarding whether antipsychotics have ‘neuroprotective’ compared with ‘neurodegenerative’ effects, and it is not possible to conclude from available clinical imaging studies whether the brain volume loss observed during the course of illness is attributable to antipsychotics or to the underlying illness. More research is needed to clarify long-term effects of antipsychotics on brain volume and their consequences. Existing clinical evidence for a negative long-term effect of initial or maintenance antipsychotic treatment is not compelling. Patients and their families should be made aware of the strong evidence supporting antipsychotic efficacy and of the side effects that vary between drugs. Additional research is needed to help quantify the risk-beneﬁt ratio associated with continuation compared with discontinuation of antipsychotic treatment and to identify predictive biomarkers in order to facilitate shared decision making and a personalized medicine approach.”
In other words, despite the caveats, all is well in the realm of psychiatry. Its drugs, in this case neuroleptics, are safe and effective, which has always been their contention, and concerns that have been expressed in this regard, particularly on the long-term effects of these drugs are “not compelling.”
CONFLICTS OF INTEREST
Five of the eight authors disclose extensive conflicts of interest. The other three authors, Peter Falkai, MD, Jingping Zhao, MD, and Jeffrey Lieberman, MD “report no financial relationships with commercial interests.” However, on May 12, 2017, a week after the publication of Goff et al, Dr. Lieberman reported the following disclosures on Medscape:
“Jeffrey A. Lieberman, MD, has disclosed the following relevant financial relationships:
Served as a director, officer, partner, employee, advisor, consultant, or trustee for: Clintara; Intracellular Therapies
Received research grant from: Alkermes; Biomarin; EnVivo/Forum; Genentech; Novartis/Novation; Sunovion
Alkermes, Novartis, and Sunovion are manufacturers of neuroleptic drugs (Risperdal, Clozaril, and Latuda, respectively). As the Goff et al paper is essentially a defense of neuroleptics, it is difficult to reconcile Dr. Lieberman’s denial of a conflict with the above information that he posted on Medscape a week later.
PRESS RELEASE AND OTHER PUBLICITY
On May 12, 2017, Columbia University Psychiatry Department issued a press release publicizing the paper. Here’s the opening paragraph:
“An international group of experts has concluded that, for patients with schizophrenia and related psychotic disorders, antipsychotic medications do not have negative long-term effects on patients’ outcomes or the brain. In addition, the benefits of these medications are much greater than their potential side effects.”
Note the contrast between the above assertion that “antipsychotic medications do not have negative long-term effects on patients’ outcomes or the brain,” and the much more cautious wording in the Goff et al conclusions:
“Evidence from preclinical animal models is mixed regarding whether antipsychotics have ‘neuroprotective’ compared with ‘neurodegenerative’ effects, and it is not possible to conclude from available clinical imaging studies whether the brain volume loss observed during the course of illness is attributable to antipsychotics or to the underlying illness.” [Emphases added]
The issue here is brain shrinkage, but the press release denies any negative effects on the brain. In fact, it has been known since 1954 that neuroleptic drugs cause permanent brain damage (e.g., tardive dyskinesia), and warnings to this effect have been included in product information for all neuroleptics for decades. For the Columbia Psychiatry Department to state publicly that these drugs “…do not have negative long-term effects on . . . the brain” is a new low for a profession that is already steeped in deception and other ethical lapses. Incidentally, the very eminent Dr. Lieberman is the chairperson of Columbia’s Psychiatry Department.
In addition, on May 12, 2017, the illustrious Dr. Lieberman posted a Medscape video of himself, dressed in an immaculate white coat, announcing two pieces of “good news.”
The first piece of “good news” is the formation of a steering committee which would update the DSM on a continual basis (as opposed to every ten or fifteen years). Dr. Lieberman expresses “some degree of pride” with regard to the formation of this committee because in the period leading up to its last update, the DSM was “the target of vicious criticism” led by “antipsychiatry critics.” Dr. Lieberman describes these critics as:
“Individuals who were traditional nonbelievers in mental illness or the efficacy and scientific competence of psychiatry, like Scientologists or just rabid ideologues, to individuals that were anti-medical model, antiscience.” [transcribed from video]
Dr. Lieberman’s second piece of good news was, of course, the publication of the Goff et al paper affirming the safety and efficacy of neuroleptic drugs in the “treatment” of people labeled schizophrenic.
“The second thing which I’m very happy to say is a positive development, and the beacon of the good and the fidelity to what really underpins the medical profession and all of like sciences: a commitment to research and the discovery of knowledge and truth based on evidence…” [transcribed from video]
Dr. Lieberman’s elocutory skills are not stellar, and coherence in the spoken word is not his strong suit, but I think what he’s trying to say here is that the Goff et al paper is really great; like a beacon… or something?
Dr. Lieberman tells us that he had the “privilege” of participating in the article which was occasioned by:
“…the fact that over the years despite the triumph of psychopharmacology reflected in mood disorders, anxiety disorders, psychotic disorders, attentional and cognitive disturbances, there are continual critics, again, coming largely from various constituencies in the antipsychiatry movement, who have assailed the efficacy of these treatments…” [transcribed from video]
These critics, Dr. Lieberman continues,
“…who really gave rise to this notion, that antipsychotic treatment was adversely affecting long-term outcome, were sowing seeds of untruth, misleading ideas, and were ignoring entirely, in their pursuit of some ideological goal or need for self-serving acclamations, the harm that they were causing many people who would unwittingly accept these as credible statements and follow their guidance.” [transcribed from video]
Poor, poor Dr. Lieberman, striving valiantly to do the right thing, but beleaguered on all sides by cads, bounders, rabid ideologues, and self-promoting acclamation-seekers. Oh my!
Dr. Lieberman concludes by praising the composition, scholarship, and rigor of the review, which he asserts
“…comes to a very clear and definitive conclusion, that we all should take note of, apply in our clinical practices, and use where needed in the education of patients, and the refutation of individuals who are really trying to create mischief for their own nefarious purposes.” [transcribed from video]
As we’ve seen earlier, the study did not come to “a very clear and definite conclusion.” The abstract was deceptively optimistic concerning the continued use of neuroleptic drugs, but the actual conclusions section contained several caveats:
“…there may be risk associated with withholding or discontinuing medication.”
“…it is not possible to conclude from available clinical imaging studies whether the brain volume loss observed during the course of illness is attributable to antipsychotics or to the underlying illness.”
“More research is needed to clarify long-term effects of antipsychotics on brain volume and their consequences.”
“Additional research is needed to help quantify the risk-beneﬁt ratio…” etc. [Emphases added]
But, as is well known in medical circles, a great many (probably most) physicians read only the abstracts.
MY FAILURE TO WRITE A REBUTTAL
As I studied Goff et al, I was struck by the fact that the paper contained several serious flaws and omissions, and I decided that I should write a rebuttal. However, as happens increasingly with my advancing years, the willingness of the spirit was eclipsed by the weakness of the flesh. The days passed in the inexorable way that they do, and nothing was getting written.
And then on May 21, Robert Whitaker, founder and director of Mad in America, posted a superbly comprehensive critique of the Goff et al article. Robert’s post is titled “Psychiatry Defends Its Antipsychotics: A Case Study of Institutional Corruption,” and it is truly a brilliant piece of work.
The “evidence” and interpretations presented by Goff et al in support of their positions are meticulously analyzed, and shown to be distortive of the facts and selective of data. Mr. Whitaker presents his conclusions in a section headed “All is Well in the Land of Psychiatry”:
“What can be seen here, in this deconstruction of the review by Lieberman and colleagues, is that they presented information, time and time again, in a way that protects guild interests and their current protocols for prescribing antipsychotics.
- They never provide data from the studies showing that 60% or so of first-episode patients may recover without the use of antipsychotics.
- They always dismiss the better outcomes for unmedicated patients in cited studies, arguing that it is an artifact of an unequal comparison for some reason or another (Schooler, Rappaport, Harrow, and Moilanen).
- They report no data from modern longitudinal studies that tell of much better long-term outcomes for the unmedicated patients.
- In their discussions of drug-induced brain shrinkage and dopamine supersensitivity, they fail to discuss information from the larger body of scientific literature essential to assessing whether these drug effects could explain the poor long-term outcomes seen in the longitudinal studies.
Having reviewed the literature in that guild-protective manner, Lieberman and colleagues then drew these conclusions:
- There is ‘little evidence’ that initial use of antipsychotics or maintenance treatment with the drugs have a ‘negative long-term effect.’
- There are just a ‘small number’ of patients that may ‘recover from a first episode of psychosis without pharmacologic treatment or may discontinue medication and remain stable for extended periods of time.’
- Randomized clinical trials (Leucht) and drug-withdrawal studies ‘strongly support the efficacy of antipsychotics for the acute treatment of psychosis and prevention of relapse.’
They were an ‘international group of experts,’ and they had come to a comforting conclusion for the guild: The drug-use protocols the profession has been using for decades are just fine.”
Under the heading “The Harm Done,” Robert writes:
“In his video, Lieberman talks about critics ‘sowing seeds of untruth’ and how such ‘untruths’ can cause harm, and I have to agree that sowing seeds of untruth can cause harm. We can see it so clearly in this case of institutional corruption.
The studies that tell of 60% of unmedicated first-episode patients recovering, and of better long-term outcomes for unmedicated patients, speak of an opportunity for psychiatry to grasp: they could change their protocols and give a chance to people who suffer a psychotic episode to recover and get on with lives unburdened by the many adverse effects of antipsychotics. There is an ‘evidence base’ that tells of new possibilities for people so diagnosed.
But Lieberman and colleagues did not present that possibility in this review. Rather they hid it from view. That is an action that does harm to millions of ‘patients’ and their families, and thus to all society. We will continue to live in a society organizing its care—and its laws regarding psychotic patients—around a false narrative, one told to serve guild interests, rather than the best interests of patients.” [Emphasis added]
And under the heading “The Challenge for Our Society”:
“In a study of institutional corruption, the ultimate goal is to present ideas for solving the corruption. Lisa Cosgrove and I admittedly struggled with this section of our book [Psychiatry Under the Influence, 2015]. While problems in psychiatry have become well known to our society, societal focus has been on curbing pharma’s influence over psychiatry. But how can the influence of its guild interests be curbed?
I really don’t know. The problem is that the power lies with the guild and its academic psychiatrists, who pen articles such as this one. They have the standing in society as experts; their papers are published in ‘medical journals’; and they have access to the press. Mad in America is meant to serve as a forum for critiquing that conventional narrative, but I am pretty sure that psychiatrists in Iceland will not soon be talking about the ‘untruths’ sowed by Lieberman’s article in the American Journal of Psychiatry.”
“But I do have one wish. I wish that all psychiatric residents would familiarize themselves with this controversy, and read the research articles that have been cited, and then ask themselves: Is this published report, the ensuing press release, and Lieberman’s video the work of a medical profession they are proud to join? Or are they the work of a medical profession that needs to be thoroughly remade, with this remaking to be their gift to the mental health of people everywhere? That could be quite a legacy for a new generation of psychiatrists.”
BUT… IS PSYCHIATRY REFORMABLE?
In his final paragraph above, Mr. Whitaker expresses the hope that psychiatry will reform itself.
Calling for reform, and inviting the profession’s new recruits to spearhead such endeavors, seem like eminently sensible and appropriate initiatives. But they ignore a fundamental reality: that psychiatry is inherently unreformable because its primary thesis is false. The central assertion underlying all psychiatric activity, and embodied unambiguously in DSM-III, IV, and 5, is that all significant problems of thinking, feeling and behaving are illnesses — real illnesses just like diabetes — which need to be addressed by medically qualified specialists, using medical-type diagnoses, and medical-type treatments. And this central assertion is simply false.
Psychiatry could certainly pursue some reforms. They could sever their corrupt ties to pharma. They could stop publishing spurious, self-serving research. They could start getting honest about the adverse effects of their so-called treatments. The illustrious, white-coated Dr. Lieberman might even manage to gain an age-appropriate measure of control over the intemperate rants that he routinely directs towards psychiatry’s critics. But psychiatry can’t turn non-illnesses into illnesses. Once psychiatrists begin to acknowledge the illness falsehood — which is the underpinning of their entire structure — then their very reason for existing evaporates. As the mental illness hoax becomes increasingly exposed, it becomes commensurately clear that the psychiatric “treatment” of these non-illnesses is nothing more than drug-pushing, differing in no essential respect from the street corner variety. What psychiatrists provide is a temporary, chemically-induced feeling of comfort, control, docility, etc., at the expense of long-term damage. No psychiatric drug corrects any biological/neurological malfunction. In fact, the reverse is the case: all these drugs produce their effects by distorting, and in many cases, permanently damaging, normal functions.
And this is emphatically not an academic issue. Physicians are trained in the medical disease-centered model. This approach, which is extraordinarily effective in the treatment of real illness, is proportionately harmful when applied to problems of thinking, feeling, and behaving. The critical difference here is that real illnesses have a very large degree of homogeneity with regards to their origins, etiology, course, outcome, and appropriate treatment. By contrast, the kinds of life problems that psychiatry purports to address do not have this homogeneous core. Pneumonia is caused by germs in the lungs and the treatment consists essentially of eliminating those germs. The causes of depression and other forms of “psychiatric” distress, however, are as varied as the individuals who experience them. The notion that one can develop guidelines for the “treatment” of human distress analogous to those for real illnesses is a fundamental error. Shoe-horning the vast complexity of human problems into psychiatry’s invalid and unreliable “diagnoses,” and using these labels to justify widespread drugging and electric shocks, is arguably the most destructive hoax in human history. And as long as the illness thesis is retained, there is no possibility of reform. But if the central thesis is abandoned, then psychiatry loses the reason for its existence, and psychiatrists will have to find honest work. And that is the critical issue: for psychiatry this a death-struggle.
Through the persistent efforts of the antipsychiatry movement, psychiatrists have already lost the chemical imbalance theory of depression, one of the main supports of their house of cards, and they recognize that the writing is on the wall with regards to their other so-called neurological illnesses. When the neuroleptics-are-necessary-to-treat-schizophrenia myth falls, psychiatry is finished. And that is why Goff et al was produced: a desperate attempt to maintain its position by a profession that is truly on the ropes.
The way forward is to continue to expose the hoax, and to discredit psychiatry to the point where it can no longer attract new customers or new recruits. They have vast resources and lobbying power which they are using to fight back, but like a sand-castle, they have no substance, and the tide is coming in.
Psychiatry, self-servingly wedded as it is to the medical model, is not only unnecessary in this area, it is an effective barrier to genuine help. It is simply not reformable. Psychiatrists, as human beings, could, of course, become genuine helpers, but only if they abandon their spurious diagnoses and their destructive “treatments.” At which point, they would cease to be psychiatrists. And the venerable Dr. Lieberman would even have to surrender his white coat!
My disagreement with Robert Whitaker on the reformability, or otherwise, of psychiatry should not be interpreted as a criticism of his deconstruction of the Goff et al paper. His deconstruction of this document is simply superb, and I encourage readers to read Robert’s paper in full, and to disseminate it as widely as possible. Send links and/or paper copies to local politicians, mental health centers, GP’s offices, local newspapers, etc. Goff et al is out there right now in cyberspace and in print, spreading its self-serving and destructive message. Please do what you can to offset this deception with some genuine facts and analysis.
Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.