Thursday, January 17, 2019

Comments by Craig Wagner

Showing 38 of 38 comments.

  • Rachel, congrats on finding your way out of the woods. Many haven’t. The whole message that “this is a lifetime problem that is only managed by drugs” is incredibly disempowering.

    Yes, my approach to get the message across is lower key. What I’ve found is that there are many people within mental health that see the poor outcomes they’re producing and want to find a better way. They feel constrained – not wanting to step too far outside of psychiatric orthodoxy lest they get ostracized from their career choice. A lower-keyed approach has allowed me bring the message to NAMI, the Psychiatric Rehabilitation Association and others, considered fairly mainstream psychiatry.

    I think we need a combination of approaches to advance a new mental health paradigm: the frontal assault of MIA and others, a lower key “expand the options of recovery” approach, a heavily research-based approach, a strongly emotional approach, and more. Different people respond to different approaches. The more we can push with a variety of approaches, with a variety of audiences, the better.

  • Rachel, good observation. Yes, there might well have been placebo effect with the woman I mentioned, or perhaps even withdrawal effects masquerading as relapsing symptoms. For me the biggest trump card is self-determination and trusting an individual to interpret and direct their own experience. For that reason, I didn’t hammer on drugs any further in that conversation. I left our dialogue with a bit of optimism – she had a very strong sense of self-determination and hope which are among the most powerful tools of recovery. She apparently had come a very long way clawing back from a difficult experience. That human capacity can help her potentially revisit her use of antipsychotics in the future.

  • Steve, good point. And further, since nearly all classes of psychiatric drugs can be given for almost any diagnosis, the meaningfulness of an accurate diagnosis is diminished. We give antipsychotics for bipolar depression, major depression, and PTSD even when the individual doesn’t have psychotic symptoms. Benzodiazepines are prescribed across all diagnoses. In the presence of all this uncertainty, and drug solutions that provide attributable benefit to only a small percentage of people, experimenting with options that have a lot fewer downsides than psychiatric drugs seems like the prudent path…

  • Gerard, you see the problem clearly. Over the last few months, I’ve looked at over 100 bipolar studies in a fair amount of detail. There is a lot of messiness in all of them. Large drop-out rates. A lot of information isn’t tracked. The tools used to measure symptoms vary. Some studies aren’t placebo controlled. There is acknowledged bias going on – to the extent that meta-analyses attempt to assess the degree of bias… The saving grace is that if the studies are large enough and placebo controlled, at least we hope the things we can’t account for will be somewhat evenly distributed between the placebo group and the treatment group.

    Then the biggest confounding factor is this: although the studies can give us odds, at one level it doesn’t really matter too much what happened to 500 people in Timbuktu who took the drug 5 years ago, we never know the results until we try something. With that said, the odds are really important since they tell us that 4 out of 5 people won’t get substantial improvement from the drugs they take…

    That one reality is the only thing I would need as incentive to vigorously investigate reasonable nondrug approaches…

  • CatNight, Thanks for the the kind words. We each can add something to the equation here. I’m a detailed guy who can figure out all the nuance and present in an understandable form. We have many on this site who are passionate about their lived experience and courageously proclaim it. We have others who fearlessly take on established psychiatric wisdom with a full-throated howl… It takes a village. Your comments are part of that symphony.

  • Sylvain, thanks for the feedback. Good stiuff. My effort here is to advocate informed choice about drugs and to try to provide information to support that choice. I attempted to show, by highlighting a lot of negative information on drugs, that the cost/benefit equation is much worse than most people realize.

    But you touch on a meaty topic that I’ve struggled with, and you have obviously thought about it. We agree on the overwhelming abundance of pro-drug information. To someone who does their homework, pro-drug arguments are weak and lob-sided. But the question is, how do we respond to that biased view? Are we best served countering a lob-sided view by building a lob-sided argument of our own? I think the stronger argument is one that embraces full transparency. The evidence is on our side. Just as we can rip down a pro-drug biased argument with ample negative data, if we play the same game and refuse to acknowledge any benefit in drugs, I think we weaken our own argument. We’re too easy to dismiss.

    And the reason I acknowledge value in drugs is an important conversation I had a year ago that really stuck with me. I presented similar material to a group of peer support specialists and emphasized the many downsides of drugs. At the break a woman came up to me and told me, “Craig, you can give me all the negative research in the world on antipsychotics, but that doesn’t matter to me. The only reason I am able to do my job is because of the antipsychotics I take. Be sure you never take your argument to the degree of saying drugs are bad in every situation, because I’m living proof that they’re not”.

    I think two perspectives are needed. The “only the critic should be put forward” can win the hearts of many. There is much negative data to stoke that fire. It can help shake the foundation of things to promote change.

    But that argument doesn’t work well with the rationalist who wants a full picture. They need an argument that appeals to their head, not their heart. There are many people who see pro-psychiatry as biased and anti-psychiatry as biased. They want some reasonably transparent portrayal of the facts in all their muddled gray. That’s one perspective that I have attempted to offer. And I think we have a strong argument. We will win by capturing both the head and the heart and offering both perspectives.

    Dr. Joanna Moncrieff does a good job of explaining why the evidence on lithium and suicide is weak. That’s one reason I used the word “suggest” in that context. Although RCTs to clearly test it may never be run, there is considerable circumstantial evidence that supports the word “suggestive” (but not “conclusive”).

    Thanks for the stimulating thoughts.

  • Cat, thanks for mentioning the fitness angle. Although there is a concern for it encouraging mania, it’s clearly beneficial for depression and one way to combat the weight gain and diabetes risk accelerated by psychiatric drugs – especially if olanzapine is used. Walking outdoors in nature is a particularly good way to slow down the mind while getting the heart pumping – but whatever works for someone. I think you’re right on target with getting insurance coverage for preventive/restorative approaches like fitness and yoga, which not only can promote sustainable wellness, but decrease total cost in the long run… Good luck, Cat.

  • Hi Cat, Thanks for the kind words. I find that there is so much complex detail in mental health research that we need some way to distill it to things that are a lot easier to understand – something to separate the wheat from the chaff. People need that clarity. I would love to see this kind of information in every dialog about care options. Unfortunately, the downsides are rarely discussed in detail, and there is little appreciation for the reality that the lion’s share of benefit from every psychiatric drug is our body’s natural healing ability (placebo effect).

  • Miranda, thanks for mentioning Functional Medicine! Yes, Functional Medicine practitioners leverage the pioneering work and concepts of Abram Hoffer and Carl Pfeiffer – a very common sense approach of running straightforward lab tests that might detect potential influencing factors to mental health. Dr. James Greenblatt is one of the leading practitioners that continues in that vein today.

  • Anthony. Thanks for the kind words. It is a little confusing, but there are actually 4 sets of references: each of the first three infographics has their own references (note at the very end of the article there are separate links for each of these infographics, pointing to their associated references – these links take you back to pages on my site, http://www.OnwardMentalHealth.com) and the text of the post has its own set of references which are included at the “show 6 footnotes” links above. Also thanks for your references, I’ll look them up. Also note that I have an updated version of this post on my site at https://www.onwardmentalhealth.com/blog-1/8-years-of-mental-health-research-distilled-to-4-infographics that has benefited from the wisdom of some who posted comments above, resulting in changes to both the benzodiazepine and antipsychotic infographics.

  • Rasselas.Redux. On review, I agree that the Gray study throws in a new data point to what had been fairly consistent evidence showing a tie between benzos and cognitive decline. I’ve highlighted the mixed results and softened the wording in an updated infographic that can be found at https://www.onwardmentalhealth.com/blog-1/8-years-of-mental-health-research-distilled-to-4-infographics. I’ll retain the previous version intact in this thread to support the dialog. Thanks again for the reference.

  • Frank. You make a good point that doesn’t get discussed: people are not getting a complete picture of the downsides of these drugs from prescribers. Most often, the dialog is, “there are a variety of side effects (insert list here), but severe ones occur seldomly, and let’s stay close to monitor your specific reaction”. These graphics can put more substance to the side-effects dialog. However, I can see where it is difficult for a prescriber to say, “Although meta-analyses show that antidepressants are only slightly better than placebo, I’m prescribing them anyway.” They don’t want to undercut their prescribed care. The issue of conformance comes into play as well, and I understand how prescribers don’t want to scare people away from what are (rightfully or wrongfully) front-line therapies. Given all that, I think it is important to make this information available in an easy-to-consume form for lay people. And you are absolutely right: at the high level, there is only one purpose to all three of the drug infographics – they are an attempt to have people understand that drugs by themselves rarely are satisfactory, and they therefore must look beyond them…

  • Hi Survived, and I’m glad you did! Thanks for the comments. I think Szasz is right that every discipline has a belief system, including psychiatry. My dear friend Stephanie is a great example of belief systems at work. She was diagnosed with bipolar disorder as a young adult. She was in and out of psychiatric hospitals for many years. She tried an endless variety of therapies: psychotropics, electroconvulsive therapy, transcranial magnetic stimulation, ketamine treatments, acupuncture and herbs, meditation and yoga, and more. The game changer was when she changed her belief system and fired her psychiatry team at a leading university after four years of countless treatments that made her worse, not better. She went into a different hospital and luckily had an inpatient integrative psychiatrist. With that care, instead of daily suicidality she enjoys being alive. She ended her drug-centric belief system and was open to any alternative. Luckily she found one that worked for her. The important thing for me here is that we don’t need to wait for the old belief system to wither away – any individual in an instant can change their belief system. That’s what Stephanie did. I find that one of the best ways to encourage a dysfunctional belief system to wither away is to walk away from it and put our energies into a new one – and communicate compellingly about it. It takes a long time, but it is demise by neglect. We each must decide. If the drug-centric belief system is flawed, what is a better one? After 8 years of searching I’ve found nothing better than the non-drug approaches of integrative mental health. But, if there are better things, I’m all ears!

  • DragonSlayer… You touch on an interesting subject. I like MIA’s “rethinking psychiatry” mission because it leads to the follow-on step of re-doing. If we were to put the circle-backslash through today’s psychiatry creating a clean slate, what would we build on that clean slate tomorrow? Wouldn’t we include some of the non-drug options that integrative mental health promotes today (e.g. good diet, sound sleep, mindfulness, nutrient balance, helping people work through past trauma, freedom from abuse, etc.)? I think a lot of what integrative mental health people are thinking is “I’ll let others worry about what to do with conventional psychiatry, I’ll predominantly leave it alone and create a wellness oriented approach on a clean slate in my own practice”…

  • Congrats on the great progress. Sounds like you’ve figured out key things to help (thyroid and gut)… Gut/diet issues, including gut permeability are hugely important. Here is a post I wrote recently on the gut-brain connection that you might find interesting (https://www.onwardmentalhealth.com/blog-1/the-gut-brain-connection-research-meets-clinical-care-in-integrative-mental-health). Good luck.

  • It’s easy to feel discouraged, and in a lot of ways it is a natural response. A couple of things to consider. Thousands of people have recovered, and when I get down (as a care provider), I like to talk to peer support specialists. Not to get anything specific, but I find that their courage seems to rub off on me as I see that they have come back from dark places and have made the noble commitment to help others. We all need those kind of people in our life. Second, there are 5 broad stages of recovery… 1) Distress, 2) Awareness, 3) Preparation, 4) Rebuilding, and 5) Maintenance. A tipping point (and a potential stalling point), a fundamentally human challenge, comes at the beginning of stage #2. It is where we look ourselves in the eye and viscerally feel: a) I want to get better, b) I can get better (others have), c) I’m going to push ahead (and stumble along the way) until I do get better… It is finding some way to set the discouragement aside for periods. Just like anything, it is a developed skill. Mindfulness can help with that.

  • Sa, Absolutely. You want to find a biomedical practitioner trained in the Walsh Institute protocols, Orthomolecular protocols, or similar. Look here for a directory: https://www.walshinstitute.org/clinical-resources.html for Walsh trained docs. Note that if you don’t find someone in your area, they have telemedicine providers (you get a blood test run locally and work over phone/Skype with practitioners). For the most complete list of biomedical providers and how they differ, go to https://www.onwardmentalhealth.com/resources. Look at two documents: 1) Biomedical IMH Practitioner Finder, and 2) Biomedical Test Panels. The former helps you find a practitioner, the latter gives you a list of the biomedical tests they should be running. Second document also lists a couple of labs that can do the analysis. Every practitioner favors a little different testing protocol, so I suggest using the second document to arrive at an agreed plan with your chosen provider, perhaps testing in waves. Important: just going to a GP and saying “please run these tests” won’t work. You need someone trained in what all the results mean from a mental health perspective and what specific interventions should be given based on the lab results. At the same time you are working the biomedical angle, I would find a good psychologist/therapist to investigate the psychosocial side. Client/therapist rapport is key. Cognitive Behavioral Therapy helps virtually every diagnosis and there is a variant customized for nearly every diagnosis. Therapists can evaluate the need and recommend specific therapies. If the biomedical and psychosocial efforts don’t predominantly address the issues, you can consider drugs to address residual symptoms (but really study the above infographics first). If you do, start with low dosages, assess impact plus and minus. Not to hawk my book, but it goes through all of the evidence on what seems to work. Steep discounts of book for those in financial need.

  • Glad to see a note from our brethren to the north. You have the good fortune of having many more Orthomolecular practitioners in Canada than we have in the U.S. Abram Hoffer did the great ground work that formed the basis of today’s nutrient therapy. He handed his work to Carl Pfeiffer who in turn put it in the capable hands of William Walsh. From the Michigan area, I and others have gone to Toronto for assistance. The good news is that we are seeing practitioners trained in nutrient therapy sprouting up in the U.S. The Walsh Institute (www.WalshInstitute.org) also has a directory of telemedicine providers.

  • Sam, I admire your foresight in looking for more holistic solutions with your wife. It is difficult to swim upstream against the fast rushing flow of psychiatric drugs, but it seems like you did it. Integrative Mental Health offers a much more sensible answer in my mind. Their approach: 1) Start with wellness fundamentals (diet, exercise, mindfulness, safe home, etc.) since we know those dramatically impact mental health, 2) Do testing/evaluation to find all the factors that are out of whack and address those found (there are a number of biomedical factors that are easy to check for but rarely are – see the Resources page at http://www.OnwardMentalHealth.com for a list of those tests), 3) Doing the first two should reduce symptoms, so if they are still not manageable, drugs can be considered for RESIDUAL symptoms. Conventional psychiatry does it in the opposite order: start with drugs (and often end with drugs). I too am a caregiver, and I hear you on the frustration angle. I have to remind myself that when I get frustrated, that is something I can and should control. Mindfulness and present-momentness is what works for me to be able to cast aside frustration. I especially like to read Eckhart Tolle when I get wound up.

  • TinyTortoise, good catch. Taking a psychological view of distress is so often overlooked – especially in situations of the many forms of anxiety. We are such tightly integrated mind-body-spirit beings that the distinction between causes and effects becomes blurry. That’s why I think it more helpful to think of a dynamic web of causation where factors can be both causes and effects. Ron Unger in his CBT-for psychosis class (https://www.udemy.com/cbt-for-psychosis/?couponCode=ISPS-US%20Regular%20price) points out that social isolation can cause psychosis to worsen – AND – Psychosis can cause us to become more socially isolated. The problem gets big when that feedback loop starts to spiral out of control…

  • Hi Frank, Thanks for your thoughts. You make an interesting point about trying to fix one form of impairment (i.e. mental distress) with another (drug use). Indeed, the impairment created by antipsychotics is well documented, especially in the long-term studies. Many of the non-drug approaches for psychosis (including CBT for psychosis, Open Dialogue, and Hearing Voices Network) don’t try to medicalize psychosis, but seek to meet the experience, understand it, and find ways to work through the issues it may present.

  • Don, thanks for the welcome and frankness over your reservations.

    Yes, I value peer support too. The “been there” credibility is irreplaceable and can be a remarkable gateway to recovery. The risk I take in an article limited by space like this is giving a partial list in each category of care, always leaving important things out.

    I can understand your perspective about my associations with NAMI and APA. Many on this site testify to being harmed by these organizations. What I can tell you is that although both organizations are heavily drug-oriented, there are people within them that are diligently working to expand the adoption of non-drug treatments. It isn’t happening at a rate anywhere near what we want, but it is moving. I think my net impact on both organizations is to push them ever so slightly toward non-drug treatments, and in my mind, that is good.

    I’m glad you mention Codex Alternus, I was a contributing editor to Dion Zessin’s impressive work and I pulled some interesting therapies from the book that I include in my work.

  • Hi Sally, thanks for the comments. Like you, I don’t want to recommend anything that doesn’t have evidence. To do so would be fairly irresponsible. In the short space I had in this article, I couldn’t get in to all of the detailed evidence that exists for these non-drug therapies. Some have great evidence (e.g. Omega-3, Vitamin D, CBT, etc.). Others are weak. For instance, although many people swear by it, the evidence for the effectiveness of homeopathy is fairly weak, so I don’t recommend that as a starting place for recovery.

    To try to get to the root of this variable degree of evidence, I propose non-drug solutions in three tiers: Tier-1 is well-proven with good meta-analyses, Tier-2 has a number of good studies, and Tier-3 is more suggestive. If you are interested in what that looks like, consider checking out the prioritized non-drug treatments for depression, anxiety, schizophrenia and bipolar (https://goo.gl/XwsgkZ).

  • Randall, thanks for the comments and warm welcome. Yes, there is a paradigm shift underway toward integrative health as people begin to see the tremendous value of non-drug solutions. That is really good to see. Unfortunately, its not nearly as fast as any of us would like. But, as individuals, and as psychiatric survivors, we can seek out these alternative treatments even if conventional psychiatry does not.

    You mention zinc… Zinc/Copper balance is really important for mental health and is one of the fundamental tests done in the Walsh nutrient protocol (see footnote #7 in this post if you are interested in his book). Yes, Omega-3s are important and so is gut health with probiotics.

    Good luck on your odyssey. The good news is that you are grabbing the self-determination to make your own therapy choices. Hopefully you can find good practitioners who can help.

  • PhoenixRising, Congrats on your three years! None of this is cookie cutter. We each have to find our way by experimenting with approaches that match our bio-individuality, history and preferences – most often guided by practitioners we trust. It sounds like you found the right combo that works for you. Hearing your story is a jolt of juice for me. It helps me retain my enthusiasm to continue doing this.

  • Steve, thanks for the comments. I think we are a lot closer in thought than it seems.

    Yes, these are far from benign forces. They are powerful forces that resist change in many dimensions. There are forces in drug companies seeking profit, forces in insurance companies seeking to reduce cost, forces to keep the DSM symptom-based, forces in medical schools that resist providing meaningful training of non-drug training, professional forces that impact practitioner reputation if they step too far outside of the envelope of conventional care, financial forces that make it more lucrative to prescribe drugs than deliver psychotherapy, malpractice forces that keep practitioners fearful of doing things outside the guidelines of the DSM. And more.

    I think the challenge here may be my use of the word “inertia” which may seem to be similar to “benign”. My use of the word “inertia” here was an effort to underscore the strong resistance to change in many major institutions. I would never call these forces benign (i.e. unharmful). I think we all see the combined harm they do.

    In a comment down below, I speak a little to my belief that we need to change our collective consciousness and embrace non-drug solutions and flood the practices of practitioners who share this consciousness. At an individual level we can choose to simply walk away from the drug model. Yes, that is hard for a number of reasons, especially financial. But, is it easier to counter all of these huge forces, or simply start starving them of oxygen? I think the latter, though that too is a long and difficult road.

  • Phoenixrising, I’m not a doctor, so I can’t give you individual medical advice. What I can offer is a perspective from a number of researchers on antidepressants.

    1) There are many studies that show antidepressants are only a little bit better than placebo in relieving symptoms with a difference so small, that most people won’t even notice it. MIA education has a great video on that (https://goo.gl/qYBa0S). Especially given that many people have significant side effects, in general, I personally believe that attempting to get off of antidepressants is a good idea.

    2) Getting off of antidepressants isn’t easy. The latest numbers I’ve seen are that 55-63% of people will have withdrawal symptoms, for some individual antidepressants, I’ve seen higher numbers. So, if you work to get off of antidepressants, understand that you may well have withdrawal symptoms and that is a common occurrence. Be prepared for that.

    3) Although there is little literature on how to withdraw from psychiatric drugs, those who do it successfully, seem to do it through a very slow taper. The worst results seem to come when people cut cold turkey. Since your doctor is telling you that you can’t get off of antidepressants, I would suggest you consider getting a second opinion from a practitioner who respects the downsides of antidepressants. To find such a practitioner, consider the list of directories found in this document (https://goo.gl/MvYj8s) on non-drug approaches to depression.

    4) The recovery statistics from using the Walsh-protocol nutrient therapy is fairly stunning for depression. 70% of people are able to get symptom free and off of antidepressants. Nearly all of the rest can get symptom free with a significant reduction in antidepressant dosages. You may want to consider a Walsh-trained doctor as your second opinion (Walsh-trained doctors can be found from a directory mentioned above).

    5) Changing drug dosages should be done under the care of a practitioner that understands it and that you trust. Personally, in looking for a second opinion, I would ask the prospective doctor the number of patients they have helped get off of antidepressants and what their experience was. There is also information on the web, but I’ve not looked at it closely so can’t really weigh in on it.

    6) Self-determination and making your own decision on your personal health is important. It can aid recovery. At the end of the day your practitioners are your guides, not your boss. This is your choice to make. I wish you well with your choice. With a handle like PhoenixRising, I’d guess that you believe in your gut that you can bring the change you need. That is a good thing.