Dear Peter Symons, could you please do a quick search for disclosures/conflicts of interests of the editorial writers Michael Hill and Sean Dukelow and post here? Many thanks.
“We argue that a multi-dimensional, multi-level extended evolutionary meta-model (EEMM) provides consilience and a common language for process-based diagnosis. The EEMM applies the evolutionary concepts of context-appropriate variation, selection, and retention to key biopsychosocial dimensions and levels related to human suffering, problems, and positive functioning. The EEMM is a meta-model of diagnostic and intervention approaches that can accommodate any set of evidence-based change processes, regardless of the specific therapy orientation. In a preliminary way, it offers an idiographic, functional analytic, and clinically useful alternative to contemporary psychiatric nosological systems.”
Steven C. Hayes, Stefan G. Hofmann, Joseph Ciarrochi,
A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model, Clinical Psychology Review, 2020 https://www.sciencedirect.com/science/article/abs/pii/S0272735820300969
Dear fellow disillusioned psychiatrist Dr E Baden please connect also with me rob at brisbaneactcentre dot com dot au â i believe i could also help, in various ways. See also http://www.brisbaneactcentre.com.au and perhaps also http://actinpsychiatry.com/
Dear fellow disillusioned psychiatrist đ Dr E Baden please connect also with me rob at brisbaneactcentre dot com dot au – i believe i could also help, in various ways. See also http://www.brisbaneactcentre.com.au and perhaps also http://actinpsychiatry.com/
From the linked study, full free access, worth the read: “Although the important limitations of the evidence base, esketamine was labelled as a breakthrough therapy for TRD. The strategy to approve it as REMS could help addressing some safety issues, but this will require a long time and exposure of many persons with depression to this new agent. Considering the explanatory nature of existing studies, large pragmatic trials are urgently needed to better define the place in therapy of esketamine, aiming to clarify if there is more than just smoke and mirrors.
Finally, we argue that the EMA should take into due account all these critical issues when assessing the marketing authorisation of esketamine for Europe, and, more broadly, we call for a radical change of current regulatory rules for psychotropic drug approval.”
Dear Gavin Crowell-Williamson
The link to the study is incorrect, thanks for fixing up, when you get the chance. Rob Purssey
Great interview – notably long term studies have been done – MTA – and medicated kids did worse at 3 and 6 years, but this wasn’t the PR on it – Whitakers slides on it from May 2016 “Medicating ADHD: If Long-term Outcomes Are Considered, Is This An Evidence-Based Practice?” https://www.madinamerica.com/wp-content/uploads/2017/01/Medicating-ADHD.pdf
The actual paper has NO data on whether the women were on medication – incredibly NOTHING WHATSOEVER. Unless excluded, we have to assume many would have been. Mindblowing that this was published at all, and the commentary equally astonishing – and tragic misinformation.
“An investigative report uncovers little recognized and unpoliced potential conflicts of interest among those who serve on FDA advisory panels that review drugs. Some members of such panels are later receiving significant payments from either the makers of drugs they previously reviewed, or from competitors. … those asked to weigh in stand to gain tremendously in their further professional careers. “It’s in their best interest to play nice with the companies.” FDA may also have missed or judged insignificant financial ties physicians had before their service on the drug approval advisory panels.” http://science.sciencemag.org/content/361/6397/16
Edward Bullmore’s disclosures – âI work half-time for GSK, leading a small group focused on immunological mechanisms and therapeutics for mood disorders.â â enough said. Straight to the bin. https://www.neuroscience.cam.ac.uk/directory/profile.php?etb23 This “radical theory” appears primarily intended to link depression to profits. I strongly recommend against giving this pharmaceutical company employee any further airtime.
Dear Niall and Brett, thanks for your work in correcting misinformation from my College. In August last year I took the trouble to post a direct message to the president of the College Dr Kym Jenkins on a college forum thread which she had commenced, about “college strategic plan” which included the following “values”: âOur Values ⢠Integrity ⢠Respect ⢠Compassion ⢠Collaboration ⢠Quality ⢠Innovation ⢠Sustainabilityâ.
In regard to “integrity” â my post follows: Robert Purssey – 31/08/2017 7:06:09 PM
RE:The RANZCP Strategic Plan
Dear Kym
Re: “Integrity”
on “Your Health In Mind” (RANZCP college website for the general public) – i note – “How do medications treat mental illness – Medications work by rebalancing the chemicals in the brain” – a statement very clearly implying a pre-existing chemical imbalance. Dr Ronald Pies (along with many others) has recently proclaimed “I am not one who easily loses his temper, but I confess to experiencing markedly increased limbic activity whenever I hear someone proclaim, “Psychiatrists think all mental disorders are due to a chemical imbalance!â In the past 30 years, I donât believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. On the other hand, the âchemical imbalanceâ trope has been tossed around a great deal by opponents of psychiatry, who mendaciously attribute the phrase to psychiatrists themselves.2 And, yesâthe âchemical imbalanceâ image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patientsâ understanding.3 In truth, the âchemical imbalanceâ notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists.”
Please note also “Linking Molecules to Mood – New Insight Into the Biology of Depression. Krishnan and Nestler, AJP Oct 2010” – “Since monoamine enhancers improve depressive symptoms, it was suggested historically that depression is caused by deficits in monoaminergic transmission (âmonoamine hypothesisâ), which continues to be a prominent preoccupation of the field. However, after more than a decade of PET studies (positioned aptly to quantitatively measure receptor and transporter numbers and occupancy) (31), monoamine depletion studies (which transiently and experimentally reduce brain monoamine levels) (32) as well as genetic association analyses examining polymorphisms in monoaminergic genes (27, 33, 34), there is little evidence to implicate true deficits in serotonergic, noradrenergic, or dopaminergic neurotransmission in the pathophysiology of depression.” – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031089/
And furthermore, re IATROGENESIS of this “urban legend” – https://static1.squarespace.com/static/51cb73eee4b07cb3e8507d7e/t/56b8f015e707eba737d9d09e/1454960662195/beh+therapist.pdf
Please explain how this “information” on College websites comports with “Integrity”.
This comment, while undoubtedly true, is a devastating critique on modern psychiatry practice, which ought be to be acutely sensitive to harms of any and all of our interventions: “…due to institutional corruption within academic psychiatry it is quite difficult to successfully pass the review process with such papers. Most psychiatric experts reviewing for the leading scientific journals refuse peremptorily any report calling into question the merits of psychiatric drugs.”
FIRST DO NO HARM – and such exemplary work as Michael Hengartner and crew are doing should be front and centre of the leading journals. Thanks for the excellent and ongoing work!
Humans do struggle, and help is sometimes useful. Over the years our wisdom traditions have provided this, along with families, friends – and nowadays it’s (sometimes) professionals. Science can be part of this. This article is FAR from unbiased: “FL, AA, MH, PL, CS research, teach, and practice psychodynamic therapy (PDT) and have published books or book chapters dealing with PDT” PDT = psychodynamic therapy, Freud and all that followed thereafter. Lead author has many such articles eg “Leichsenring F, Leweke F, Klein S, Steinert C. The empirical status of psychodynamic psychotherapy – an update: Bambi’s alive and kicking. Psychother Psychosomat. (2015)” His everyday JOB is psychoanalytical psychotherapy, “Falk Leichsenring, Dipl.-Psych, Psychoanalyst” and similar for co-authors. There was back and forth in BMJ about this a few years ago. Here’s a very interesting blog on where “CBT” (whatever that phrase means) appears to be going in 2018 – http://drericmorris.com/2018/02/05/post-cbt/
Another excellent brand new ACT self-help resource, postnatal orientation but still relevant “Postpartum Depression and Anxiety â The Definitive Survival and Recovery Approach” â “is a unique, user-friendly self-help approach to support and guide mild, moderate and severe sufferers to a place called recovery and beyond.” From New Zealand, and a great newspaper article about it here â http://www.stuff.co.nz/life-style/parenting/101541339/christchurch-postnatal-depression-survivor-and-psychologist-team-up-to-write-book – hope both of these may be helpful to some.
“Becoming Mum” is a superb Acceptance and Commitment Therapy (ACT) self-help book extremely useful in overcoming perinatal and postnatal depression â drawing upon strategies within ACT, mindfulness-based Cognitive Behavioural Therapy and Behavioural Activation â all of which have an evidence-base in the treatment and prevention of depression. Becoming Mum would be a useful companion to any woman seeking to prevent or overcome both perinatal and postnatal depression. Highly recommended, and relevant sites: https://becomingmum.com.au/ and the authors site here http://www.koawhittingham.com â check out both! Btw research shows ACT and similar modern psychotherapy self-help books to work better with the help of a skills coach a.k.a. therapist.
(Request as sent to Jeff Baker at ‘[email protected]’ on 26/03/2018â no response as yet, so reposting here) As a psychiatrist acutely aware of the pervasiveness and harmfulness of chemical imbalance myth I was very interested in seeing this YouTube. It very nicely goes through the evidence against this falsehood, and usefully quotes the most mainstream of psychiatrists in summarising decades of evidence.
I would like to be able to link this YouTube lecture to emailed information I send my patients, and link on my practice site, however I can find nothing whatsoever online about “Advancing Mental Health.org” or about Jeff Baker in any detail. I am not disputing his good intentions, nor that of the organisation/brand which has the YouTube channel â but I cannot professionally/personally feel comfortable in linking such materials without knowing a bit about the background of individuals and groups providing them.
I’m sure all readers of MIA are aware enough of the problems within our field to understand why!
I would be grateful for MIA editors, or Jeff Baker, or ANYONE for providing some background information about Mr Baker and advancingmentalhealth.org
Great article, thanks! And “At the same time, I do think that once-popular metaphors such as the âbroken brainâ and a âchemical balanceâ have been debunked quite effectivelyâyou donât hear much of them these days, even in pharma ads, which are the last to change.” – see the Royal Australian and New Zealand College of Psychiatry’s website for the general public “Your Health in Mind” information on medication, which very clearly continues perpetrating these falsehoods â “How do medications treat mental illness? Medications work by rebalancing the chemicals in the brain. Different types of medication act on different chemical pathways.” I have directly emailed the president of RANZCP about this factual error and iatrogenesis of the falsehood (and shown them Lacasse and Leo 2015 paper – Antidepressants and the Chemical Imbalance Theory of Depression: A Reflection and Update on the Discourse.) But of course no response. So it continues… https://www.yourhealthinmind.org/treatments-medication/medication
“…psychoanalysis is emotionally demanding, time-consuming and often expensive” – ON THE OTHER HAND – modern evidence based psychotherapies can help with burnout MUCH faster and cost-effectively, including using supported self help materials eg “Burnout: Break the Vicious Cycle with Acceptance and Mindfulness; Waadt & Acker, 2013a” – Conclusions: Our study provides empirical support for decreasing stress and promoting well-being through ACT (acceptance and commitment therapy) and emphasizes the potential of PF (psychological flexibility) in promoting well-being (in a 6 week supported self help program). see full study at https://www.sciencedirect.com/science/article/pii/S1697260017300650
and # 11 – Michael B First, author of beneath, works for Lundbeck and others, and advises Pharma on how to craft studies / approach FDA and EMA to fulfill DSM / ICD disorder criteria (I have read this disclosure elsewhere) – “Harmonisation of ICDâ11 and DSMâV: opportunities and challenges” Michael B. First – The British Journal of Psychiatry Oct 2009 – full article here http://bjp.rcpsych.org/content/195/5/382#skip-link
Just posting in case of interest (no time to discuss further i’m afraid) “Freud Was a Fraud: A Triumph of Pseudoscience” – Frederick Crews has written a reassessment of Freud based on newly available correspondence and re-evaluation of previously available materials. He shows that Freud was a fraud who deceived himself and succumbed to pseudoscience. https://sciencebasedmedicine.org/freud-was-a-fraud-a-triumph-of-pseudoscience/
My comments (re the Australian context) If only the RANZCP (Australian psychiatry training college) would accept this – the ONLY way to do “advanced training in psychotherapy” is psychodynamic, i.e. modern Freudian – AND the Faculty of Psychotherapy continues utterly so biased. Their conferences etc – modern behaviorism / contextual behavioral science https://contextualscience.org doesn’t get a mention and cannot be taught – sheesh.
âFreud: The Making of an Illusion [is] a . . . stake driven into its subjectâs cold, cold heart. . . . Crews is an attractively uncluttered stylist, and he has an amazing story to tell.ââLouis Menand, The New Yorker
âA powerful and thorough takedown of Sigmund Freud.ââVulture
âCrews [is] going in for the kill. A damning portrait.ââEsquire
âDiligently documented . . . neither sensationalized nor ranting . . . a scorching summation.ââThe Chronicle of Higher Education
âAn elegant and relentless exposĂŠ . . . Impressively well-researched, powerfully written, and definitively damning. Crews wields his razor-sharp scalpel on Freudâs slavish followers, in particular, who did not want to see or who willfully redacted the sloppiness of Freudâs research methods in order to âidealize him.â ââKirkus Reviews (Starred Review)
âCrews relentlessly shreds the deceptions that Freudians even now try to maintain. . . . This thorough dismantling of one of modernityâs founding figures is sure to be met with controversy.ââBooklist (Starred Review)
âA stunning indictment . . . this fascinating biographical study paints a portrait of Freud as a man who cared more about himself than his patients and more about success than science.ââPublishers Weekly
âFor those who worship Freud, and even those millions who have simply admired his ideas, Crewsâs rigorous and captivating detective work will be a bracing challenge.ââElizabeth Loftus, co-author of The Myth of Repressed Memory
Thanks for the Wikipedia link – we need to add to / work on this: “Most cases of discontinuation syndrome last between one and four weeks, are relatively mild, and resolve on their own; in rare cases symptoms can be severe or extended” – clearly not the case (i.e. NOT RARE to have MUCH more WD issues), AND this community, and the RxISK etc community need to get onto that Wiki page…
Dear Eve, thank you for this powerful blog article – I have shed and strongly encouraged my doctor colleagues, esp psychiatrists to please read. The very critical comments in the thread above of course have a great deal of justification – many of those within the MIA community have been lied to by organised psychiatry and much more seriously personally harmed, losing their family members et cetera, than ourselves in the profession.
However, I would encourage all to please understand how HARD it is to make such a leap that Eve describes – which can cost one’s entire livelihood, rendering decades of training futile/worthless, AND irreparably separate a person from one’s peers, and friends. And consider how depressing are these paragraphs…
“Todayâs senior residents in psychiatry get an average of 100 job offers to do medication management. And there are no other options out there. Many graduating residents have huge medical school loans to pay back, and may not even have much knowledge of the risks inherent in the prevailing models…” This is undoubtedly true, and devastating.
Thank you for your brave blog post â (brave even from my perspective – a psychiatrist who became aware of the problems from the late 90s onward.)
Excellent BBC documentary which graphically highlights the big issues in mental health especially. DSM, pharma-psychiatry links, Pfizer’s GHQ9 (and its purpose), the ADHD false epidemic, Joseph Biederman saga, how AD’s “prescribed for poverty”, and more. Psych stuff in first half largely – very very good. Allen Frances, Chairperson of DSM 4 the blueprint of modern psychiatry. “We were trying to protect people from excess medicine. We failed.” – Youtube link for worldwide access here https://www.youtube.com/watch?v=HGhAePaZeSU
All psychiatric guidelines I’m aware of would score woefully by these excellent measures – this tool deserves a blog / educational highlight on MIA – Cosgrove? Lexcin? Whitaker? – it ought be highlighted on the site: the measures which are used:
Relevance threats
1. The patient populations and conditions are relevant to my clinical setting.
2. The recommendations are clear and actionable.
3. The recommendations focus on improving patient-oriented outcomes, explicitly comparing benefits versus harms to support clinical decision making.
Evidence threats
â4. The guidelines are based on a systematic review of the research data.
â5. The recommendation statements important to you are based on graded evidence and include a description of the quality (e,g, strong, weak) of the evidence.
â6. The guideline development includes a research analyst, such as a statistician or epidemiologist.
Interpretation threats
â7. The Chair of the guideline development committee and a majority of the rest of the committee are free of declared financial conflicts of interest, and the guideline development group did not receive industry funding for developing the guideline.
â8. The guideline development includes members from the most relevant specialties and includes other key stakeholders, such as patients, payer organizations, and public health entities, when applicable.
With gratitude for the authors and the Delphi panellists – Rob Purssey
Chapter 8 of the essential “Psychiatry Under the Influence” by Whitaker and Cosgrove is “The End Product: Clinical Practice Guidelines” – so i was skeptical about this new tool, G-TRUST – until i’ve just read “said last author Lisa Cosgrove, Ph.D.” – with 6 other fabulous authors we all ought respect! The article is FREE FULL ACCESS – presently anyway – IF A HEALTHCARE PROVIDER – PLEASE CHECK IT OUT, AND DISSEMINATE – http://www.annfammed.org/content/15/5/413
Thanks for this GREAT blog post Brett, and for all that you do. For those unfamiliar with the excellent work Brett has put in to this area, i strongly recommend you check in this previous MIA post https://www.madinamerica.com/2015/10/psychologists-critique-the-biomedical-model-of-psychological-problems , and in particular thoroughly read the superb special edition of The Behaviour Therapist which Brett, edited focusing on “critical analysis of the biomedical paradigm. The purpose of this special issue of the Behavior Therapist is to contribute to this analysis. This special issue features 11 articles that present critical analyses of different aspects of the biomedical model. Contributors to this special issue include award-winning scientists and journalists, three ABCT presidents, the president-elect of the British Psychological Society, and individuals from clinical psychology, counseling psychology, journalism, neuroscience, psychiatry, and social work. These authors share a commitment to scholarly rigor and scientific evidence as the foundation for critical analysis of the biomedical approach. The exceptional articles featured in this special issue deserve a careful reading, and their provocative conclusions warrant serious consideration and ongoing professional dialogue.” Full edition is here https://www.madinamerica.com/wp-content/uploads/2015/11/Behavior-Therapist-Oct-2015.pdf
Great article about “The Happiness Trap”. Some foundational insights from Acceptance and Commitment Therapy in here. Worth the read!
Shorter half life = quick onset, quick OFFSET and rebound anxiety = need more. Alprazolam is thus the “crack cocaine of the benzo world” – only surpassed by Triazolam (Halcion – see above). Plus it is extraordinarily high potency (see Ashton manual) Also the shorter half life ones “feel nicer” which is itself naturally a higher risk. None of this means that diazepam (longer half-life, comes in much lower dosages, feels relatively unpleasant) is without significant risk, because of course it is, but overall diazepam IF used very cautiously and very sparingly is a significantly safer drug than alprazolam. Nevertheless overall this article is very well written and accurately highlights a very problematic area.
“Why on earth is this given space on MIA?” – Know thine enemy. It is very useful to see, so clearly, what is driving the expansion of drugging, and the simple financial rationale behind it.
May be of interest to some re this post:
An Acceptance and Commitment Therapy (ACT) intervention for Chronic Fatigue Syndrome (CFS): A case series approach
Highlights
⢠Acceptance and Commitment Therapy can improve wellbeing in chronic health conditions.
⢠Chronic Fatigue Syndrome is a debilitating and challenging chronic syndrome.
⢠We examine guided ACT self-help in a case-series of individuals with CFS.
⢠ACT was linked with increased physical activity and valued behavior.
⢠Across cases, evidence for effects on psychological flexibility was mixed.
Abstract
Objective
Acceptance and Commitment Therapy (ACT) has been shown to improve the psychological well-being of individuals suffering from a range of chronic health conditions, and aims to increase psychological flexibility in order to foster greater engagement in personally meaningful behavior. We aimed to assess whether the approach (delivered via guided bibliotherapy) may have utility for individuals experiencing the debilitating effects of Chronic Fatigue Syndrome (CFS).
Methods
We used a mixed-methods multiple single-case design to explore the effects of a six week self-help ACT intervention for six participants diagnosed with CFS.
Results
Significant increases in ratings of valued living were replicated and maintained in four participants, with qualitative data further highlighting the importance of the values component of the intervention. Acceptance scores improved in four participants but were not maintained at follow-up, whereas improvements in psychological flexibility were observed and maintained for three participants. All participants wearing an activity monitor evinced increased physical activity postintervention, which was maintained at follow up in half of the participants.
Conclusion
The ACT self-help intervention appeared to benefit most participants on at least one assessed metric, particularly in terms of the promotion and pursuit of individual values, and increased physical activity. However, the results suggest these benefits may be difficult to maintain longer term without further input.
Unfortunately “This content is available exclusively to Chronicle subscribers” – can you find another link? Thanks!
Thanks (also for this one) to Brett Deacon for responding appropriately to this post / link – your time, wisdom and academic rigor is greatly appreciated. Rob Purssey (ACT therapist and psychiatrist)
Thanks to Brett Deacon for responding appropriately to this unfortunate post / link – your time, wisdom and academic rigor is greatly appreciated. Warmly Rob Purssey (ACT therapist and psychiatrist)
valbenazine – must be close to tetrabenazine, used for decades for TD (and not terribly effective and many s/e’s of course) – interested in comments on this, thanks
“Full” disclosures from article (inverted commas as it appears bizarre that none are noted for Leiberman)
From the Nathan Kline Institute for Psychiatric Research and New York University Langone Medical Center, New York University School of Medicine, New York; the Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany; the Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry, Medical University Innsbruck, Innsbruck, Austria; the New York State Psychiatric Institute and New York Presbyterian Hospital-Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York; the Department of Psychiatry, Brain Center Rudolf Magnus, UMC Utrecht, Utrecht, The Netherlands; the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; and the Department of Psychiatry, Chinese National Clinical Research Center for Mental Disorders, Mental Health Institute, The Second Xiangya Hospital of Central South University, Changsha, Hunan, P.R. China.
Address correspondence to Dr. Goff ([email protected]).
Dr. Goff has received research support from Avanir Pharmaceuticals, NIMH, and the Stanley Medical Research Institute. Dr. Fleischhacker has received research support from Boehringer-Ingelheim, Janssen, Lundbeck, and Otsuka; he has received honoraria for serving as a consultant to and/or on advisory boards for Allergan, Dainippon Sumitomo, Gedeon Richter, Janssen, Lundbeck, Otsuka, Takeda, and Teva; and he has received speakerâs fees and travel support from AOP Orphan, Dainippon Sumitomo, Gedeon Richter, Janssen, Lundbeck, Pfizer, Otsuka, and Teva. Dr. Girgis receives research support from Allergan, BioAdvantex, Genentech, and Otsuka. Dr. Kahn has received consulting fees from Alkermes, Forrest, Forum, Gedeon-Richter, Janssen-Cilag, Minerva Neurosciences, and Sunovion and speakerâs fees from Janssen-Cilag and Lilly. Dr. Uchida has received grants from Astellas Pharmaceutical, Dainippon-Sumitomo Pharma, Eisai, Eli Lilly, Meiji-Seika Pharmaceutical, Mochida Pharmaceutical, Novartis, Otsuka Pharmaceutical, and Shionogi; speakerâs honoraria from Dainippon-Sumitomo Pharma, Eli Lilly, Janssen Pharmaceutical, Meiji-Seika Pharma, MSD, Otsuka Pharmaceutical, Pfizer, Shionogi, and Yoshitomi Yakuhin; and advisory panel payments from Dainippon-Sumitomo Pharma. All other authors report no financial relationships with commercial interests.
The authors thank Dr. Shitij Kapur, for his important contributions to the initial formulation of this project, and Dr. Lisa Dixon, for the invaluable perspective she provided as a consultant to the process.
“An international group of experts was convened…” – where? when? who funded this ‘convening of experts’? No information whatsoever. Traditionally such convening of psychiatric experts on a drug topic has been funded by drug manufacturers, under a ‘university cover’. The full article disclosures are below. I wonder if Dr Donald Goff [email protected] might answer the questions above regarding funding of this ‘expert consensus’ project. Others might enquire, i don’t have the time and energies.
Your latest interview / podcast with Robert Whitaker is perhaps the best interview with him that Iâve heard (and Iâve heard MANY) so ⌠VERY well done, simply superb.
I cannot recommend this podcast highly enough.
Rob
Dr Robert Purssey, MBBS FRANZCP, Psychiatrist and ACT Therapist, Director – Brisbane ACT Centre – http://www.brisbaneactcentre.com.au
Stephen – the trouble is this review is saying the pharma funded studies are indeed not valid, and the NIMH studies “show” on the other hand that SSRIs help kids. It is thus especially sneaky, and will hook folks into thinking it’s “on the side of good” whilst advocating MORE use of drugs proven to be unhelpful and proven also of course to be significantly harmful.
This is an incredibly concerning publication. âIt is the premise of this review that meta-analyses that include the large number of industry-sponsored antidepressant trials distort the picture of antidepressant efficacy for teen depression.â It is clearly intended to reverse the increasing reluctance of doctors to prescribe SSRI/SNRIs to children and adolescents, thanks to excellent and solid studies such as Cipriani et alâs Lancet 2016 (no benefit), and Sharma et alâs BMJ 2016 (double the risk of suicidality and aggression). The author was part of the TADS study, which has been noted on this site to have been grossly misreported â https://www.madinamerica.com/2012/02/the-real-suicide-data-from-the-tads-study-comes-to-light/ and this should be weighed when considering his opinion that these clearly ineffective dangerous drugs have âa broad and important role for antidepressant medications in pediatric internalizing conditions.”
This âreviewâ was, I suppose, inevitable, and will naturally be hugely reprinted and broadly distributed to GPs and psychiatrists by every pharmaceutical company with SSRI/SNRIs selling in the child/adolescent population. That is their marketing role (and sadly of this publication). The âaccompanying editorialâ serves the same purpose â from Medscape âDaniel Pine, MD, of the NIMH Intramural Research Program, and Robert Freedman, MD, of the University of Colorado School of Medicine in Aurora, note that some clinicians working with children and adolescents might have hesitated before recommending an SSRI, because of continued questioning in the media of the evidence for their effectiveness. This review “helps to generate a more balanced perspective, which promises to reduce the burden facing these clinicians,” they write. How fortunate for those clinicians do no longer face such a âburdenâ in prescribing drugs without an evidence-based of efficacy, but clear and well published evidence-base of harm to children/adolescents.
I do not have the time to dissect either paper, or editorial, nor chase down the 3 authors declared disclosures, and industry ties including funding of their research programs, but it is very important for those psychiatrists and other concerned doctors who might have time and inclination to investigate, publish and broadly publicise a thorough evidence and science-based rebuke to these flimsy opinion based promotions of the prescription of SSRI/SNRIs to children/adolescents.
Dear Ron
My apologies â I should have been more respectful, and written a “modern form of CBT”. I just read your prior post, and commented â which of course won’t actually be read but there it is! The idea that we should not seek to understand and use the content of our thoughts and feelings is not actually integral within ACT, sometimes doing so can be extraordinarily helpful, and sometimes doing so can have us spinning in wheels which are not so terribly helpful â it is the workability in helping us live a life more fully and richly which matters of course. It is quite true that ACT takes good deal from “traditional CBT”, and also true that it differs in significant and fundamental ways from “traditional CBT”, particularly the strategy/philosophy of science underpinnings clearly articulated – functional contextualism â and the reticulated strategy from basic to applied and across fields. In any case thank you so much for your valuable work.
Warm wishes, robpurssey
Very late comment but “it tends to suggest there is no way of reconciling with the angry, scary, noisy parts of the psyche which may be objecting to those actions. For a different point of view, consider the perspective of Eleanor Longden”⌠Is a common misunderstanding of ACT. Your suggestion of “a wise âbus driverâ would alternate between at times being firm and taking some actions despite âpassengersâ yelling and complaining, but also at times being flexible and seeking to understand strongly expressed complaints and to come up with reasonable solutions that resolve difficulties and make peace with the passengers” sounds exceedingly workable, very important potentially in a certain individual and certain circumstances, and certainly something that would be embraced by a psychological flexibility point of view. ACT in no way dismisses personal experience, as ACT practitioners do not dismiss our evolutionary history, and we simply seek to notice when entanglement with figuring out not moving us to where we want to go â and sometimes it can be exceedingly helpful in understanding the nature of our difficulties â see Steve Hayes recent TED talk in which he talks about his early life experiences contributions to his difficulties (I’m aware this came out after your posting)https://www.youtube.com/watch?v=o79_gmO5ppg
Simply a realistic observation: “Participants were informed of an online survey via widespread media advertising. The criteria for participation included having been prescribed antidepressants in the last five years, living in New Zealand and being 18 years of age or over. The survey was available online from March 2012 until January 2013.”
If I was working in marketing for a pharmaceutical company in New Zealand selling antidepressants from March 2012 until January 2013, it would be an essential responsibility of my JOB to have as many of my representatives and their relatives and friends as possible to have been responding to this survey in a very positive fashion. (But not enough to look suspicious.)
To NOT respond by doing this would mean NOT doing my job properly – i.e. marketing my products.
We’ll NEVER know how much of this occurred, I expect, and the authors would be very unlikely to comment one way or the other (it would – should, again, doing the job – invite “outrage” among such “users” as being invalidated) but it MAY help to account for “In this study, 84 % of participants in this study answered in the affirmative to a question about whether they felt antidepressants had reduced their depression, a number well above that suggested by efficacy studies [5, 26]. This suggests that the findings of this study might over-represent positive responses to antidepressants.”
I expect for David, as for me (another psychiatrist exceedingly cautious regarding medication excess and deeply interested in the state of the “evidence” and how drugs actually work) – the answer is something along the lines of being an old-fashioned doctor, more concerned with the patients i’m helping than with my wallet, and taking informed consent and ‘first do no harm’ seriously. David’s generally too busy to respond to post threads, but would consider himself scientifically and medically conservative- and the present state of the field anything but. Warm wishes, rob purssey http://www.mindfulpsychiatry.com.au
Mickey was the most inspiring doctor I have known, doing all he possibly could, very practically and tirelessly, to right our sorry state of medical data, especially psychiatric of course. With his passing we have lost a giant. A practical matter – must one be a US citizen to sign that petition? thanks for clarifying.
Re grey zone includes “antidepressants for adolescents”. Such a pity, this is clearly false and harmful. The exact article quote: “However, the majority of tests and treatments fall into a more ambiguous grey zone, 23 24 which includes: services that offer little benefit to most patients (eg, glucosamine for osteoarthritis of the knee); those for which the balance between benefits and harms varies substantially among patients (eg, opioids for chronic pain, antidepressant medications for adolescents)” The harms of AD for adolescents = double risk self harm and suicide, agitation, mood instability, sexual s/e, dependence, numbing preventing normal emotional learning CLEARLY outweigh whatever marginal benefit ADs have in this population. This might be said for older adults, but NOT for younger people.
I appreciate this phrase isn’t the MIA editors one, but it ought be commented upon perhaps. Thanks nevertheless for highlighting an important series of articles.
Rob Purssey – Psychiatrist and ACT therapist http://www.brisbaneactcentre.com.au
Dear Duncan
Please see also this excellent website http://missd.co . By the way, chatting with a psychiatrist colleague just now, who like me often sees this adverse effect with SSRI / SNRI’s, we think that we doctors are just narrowly taught to think “akathisia = dopaminergic S/E” hence calling it “nervousness and tremor”, or agitation, or whatever. Feeling very very uncomfortable and restless (without necessarily putting on a nice pacing “sign” for the doctor) is reasonably termed akathisia – and those who’ve taken the MANY drugs which can cause it WELL know it’s one of the key experiences leading to harming self or others. If the patient / client / person experiences it, they’re experiencing it, and for doctors, validating, caring, and minimising potential contributors are our key responsibilities.
Best wishes,
Very good, useful study. Re: “The HR (people at high risk) mental state has much in common with depression and anxiety; very few people transitioned to full psychosis over 2 years, in line with other recent evidence.” What would have occurred if these HR folks had been pre-emptively been given AP’s as has been the push for over a decade – few transition = AP’s work – in contrast, few transition because FEW TRANSITION. The next sentence of this study is great “This new understanding will help people at HR receive appropriate services focused on their current mental state.” i.e. help them with the problems they have, NOT what you think they might “get”.
Sorry Kermit, but this is a TERRIBLE article with many awful nonsense messages which “buy into” chemical imbalance myths in the worst way eg “Thereâs long been an association made between serotonin and depression. Itâs still unknown what comes first; low serotonin or depression. Does depression cause lower serotonin or does lower serotonin cause depression? Scientists arenât sure yet… According to Science Daily, low serotonin has also been linked to other important disorders like attention-deficit hyperactivity disorder (ADHD), bipolar disorder, schizophrenia and sleep disorders.” “A serotonin deficiency can cause us to seek out other ways to balance out the chemicals in our brain.”
All utter BS, and interspersed with terrible pseudoscientific guff – looks like a pharma DTCA job, except from a “lifestyle channel”. And the other “academic” article which states “For the last 4 decades, the question of how to manipulate the serotonergic system with drugs has been an important area of research in biological psychiatry, and this research has led to advances in the treatment of depression.” also complete nonsense – it’s advertising with pseudoscientific sheen.
Please consider highlighting how THE CHEMICAL IMBALANCE / WONKY SEROTONIN MYTH IS PERVASIVE. including in “lifestyle / natural health” circles.
Exercise because it’s good for you, connect with others because love matters, be kind on yourself – and DON’T buy into “my sadness / anxiety means i’m chemically faulty”.
With thanks for the great stuff you usually post, and kind caution regarding posting dodgy stuff!
These clearly misreported data would, i suspect have tipped the balance clearly against SSRI/SNRI medications (overall simply very poor classes of chemicals the data consistently states) including fluoxetine.
Further, if adverse effects properly considered: eg âAdverse emotional and interpersonal effects reported by 1829 New Zealanders while taking antidepressantsâ http://www.psy-journal.com/article/S0165-1781(14)00083-3/abstract eg âSexual Difficulties (62%) and Feeling Emotionally Numb (60%). Percentages for other effects included: Feeling Not Like Myself â 52%, Reduction In Positive Feelings â 42%, Caring Less About Others â 39%, Suicidality â 39% and Withdrawal Effects â 55%â â weighed against minimal, if ANY short term gain â is this an intervention we ought seriously be considering?
Jureidini critically emphasises this is NOT in any way saying âdonât treatâ â simply donât treat ineffectively (i.e. with these medications), with unacceptable risks, and intolerable adverse effects short, medium and longer term. Please show us the solid, verifiable, openly accessible patient level data, not âexpert opinionâ, which shows otherwise.
“Dr Chung has disclosed that he serves on an advisory board for Pfizer.” – took 30secs to find this – http://pedsinreview.aappublications.org/content/36/7/299 – someone please add comment with this to WSJ thread, i cannot from Australia it seems.
Important article, useful New York Times commentary, but when the newspaper note this
Other experts cautioned that the study tracked behavior but not other abilities that medication can quickly improve, like attention and academic performance, and said that drugs remained the first-line treatment for those core issues.
âI think this is a very important study, and the take-home is that low-cost behavioral treatment is very effective,â said Mark Stein, a professor of psychiatry and pediatrics at the University of Washington, âbut the irony is that that option is seldom available to parents.â
They didn’t also note this about Mark Stein (which took me two minutes in web search) â Disclosure: Grant/Research Support: Cephalon, Eli Lilly & Company, McNeil Pediatrics, Novartis; Speakers’ Bureau: McNeil Pediatrics, Novartis, Shire Pharmaceuticals, Inc. http://www.medscape.org/viewarticle/571123
It is lazy, inadequate, and irresponsible of journalists to not directly note easily accessible disclosures regarding conflicts of interest. Seen all the time, and quite unacceptable nowadays.
a scientific alternative: “Problems in psychological functioning can be thought
of as narrow or rigid repertoires of behavior, linked to
inappropriate selection criteria, at the wrong level or
dimension, with insufficient retention of successful
variants that may occur given the current context.”
See “Modern psychotherapy as a multidimensional multilevel evolutionary process” https://www.researchgate.net/publication/272396184_Modern_psychotherapy_as_a_multidimensional_multilevel_evolutionary_process
I’m a psychiatrist seeing new patients / clients daily in Australia. Over 90% believe the chemical imbalance myth, i reckon 95%. Similar if not higher for GPs. Sadly similar for psychiatrists. I think Philip’s view that “the chemical imbalance hoax is the most destructive and far-reaching hoax ever perpetrated against the human race.” is quite possibly correct. Although “global warming ain’t so” must be up there!
Warm wishes and thanks for your ongoing excellent work. The lamotrigine examination was very helpful. Cheers, rob purssey
“The Biomedical Model of Psychological Problems” – the problems, and a paradigm shift – see the October 2015 edition of the Behavior Therapist here http://www.abct.org/docs/PastIssue/38n7.pdf
Great article, and important topic. I dearly hope, as the situation is increasingly apparent from the information you’ve outlined, that the Am Psychol Assoc’n is moving toward dropping this terribly misguided guild interest push. Good on you for the hard work, James!
“Treatment Advocacy Center” was new to me in Australia, so i checked – “Educating policymakers and judges about the true nature of severe brain disorders, advanced treatments available for those illnesses, and the necessity of court-ordered treatment in some cases” Wow, what disinformation, E Fuller Torrey”s personal bandwagon, and Biopsychiatry zealots i see – makes the post from Dennis Embry, and this one, make more sense. For US folks suffering behavioral struggles – please advocate science, not non-science such as this – thanks for all efforts!
Similarly from J Aff Dis:
âDepression is who I amâ: Mental illness identity, stigma and wellbeing.
Highlights
⢠Identification with a group, even a stigmatized group, is protective for wellbeing.
⢠These relationships have not been tested in the context of mental illness identity.
⢠We surveyed 250 people with depression from 23 countries.
⢠Identifying as depressed predicted lower wellbeing.
⢠Identifying as depressed predicted conforming to the norms of depressed people.
Abstract
Background
Previous research has found that in the face of discrimination, people tend to identify more strongly with stigmatized groups. Social identification can, in turn, buffer wellbeing against the negative consequences of discrimination. However, this rejection identification model has never been tested in the context of mental illness identity.
Methods
A survey was conducted with 250 people with diagnosed depression or current symptoms of at least moderate clinical severity.
Results
Experiencing mental illness stigma was associated with poorer wellbeing. Furthermore, people who had experienced such stigma were more likely to identify as a depressed person. Social identification as depressed magnified, rather than buffered, the relationship between stigma and reduced wellbeing. This relationship was moderated by perceived social norms of the depressed group for engaging in depressive thoughts and behaviors.
Conclusions
These findings suggest that mental illness stigma is a double-edged sword: as well as the direct harms for wellbeing, by increasing identification with other mental illness sufferers, stigma might expose sufferers to harmful social influence processes.
Here are the relevant Medical Board of Australia carefully written “informed consent” guidelines. It would seem very worthwhile to present, point by point, American and other “informed consent” guidelines for physicians, and see to what degree mainstream psychiatric practice is regularly breaching these carefully outlined statutory guidelines regarding legal obligations to disclose information to patients. It seems to me that they are breached on many points in Australia.
Medical Board of Australia
GOOD MEDICAL PRACTICE: A CODE OF CONDUCT FOR DOCTORS IN AUSTRALIA – March 2014
3.5 Informed consent
Informed consent is a personâs voluntary decision about medical care that is made with knowledge and understanding of the benefits and risks involved. The information that doctors need to give to patients is detailed in guidelines issued by the National Health and Medical Research Council (NHMRC).8
THE GUIDELINES ISSUED BY THE NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL (NHMRC) STATE, ON PAGE 11: D GENERAL GUIDELINES ON INFORMATION – INFORMATION TO BE GIVEN
Doctors should normally discuss the following information with their patients:5
⢠the possible or likely nature of the illness or disease;
⢠the proposed approach to investigation, diagnosis and treatment:
â what the proposed approach entails
â the expected benefits
â common side effects and material risks of any intervention6
â whether the intervention is conventional or experimental
â who will undertake the intervention
⢠other options for investigation, diagnosis and treatment;
⢠the degree of uncertainty of any diagnosis arrived at;
⢠the degree of uncertainty about the therapeutic outcome;
⢠the likely consequences of not choosing the proposed diagnostic procedure
or treatment, or of not having any procedure or treatment at all;
⢠any significant long term physical, emotional, mental, social, sexual, or other
outcome which may be associated with a proposed intervention;
⢠the time involved; and
⢠the costs involved, including out of pocket costs.
1 INFORMING PATIENTS OF RISKS
Doctors should give information about the risks of any intervention, especially those that are likely to influence the patientâs decisions. Known risks should be disclosed when an adverse outcome is common even though the detriment is slight, or when an adverse outcome is severe even though its occurrence is rare. A doctorâs judgement about how to convey risks will be influenced by:
⢠the seriousness of the patientâs condition; for example, the manner of giving information might need to be modified if the patient were too ill or badly injured to digest a detailed explanation;
⢠the nature of the intervention; for example, whether it is complex or straightforward, or whether it is necessary or purely discretionary. Complex interventions require more information, as do interventions where the patient has no illness;7
⢠the likelihood of harm and the degree of possible harm more information is required the greater the risk of harm and the more serious it is likely to be the questions the patient asks; when giving information, doctors should encourage the patient to ask questions and should answer them as fully as possible. Such questions will help the doctor to find out what is important to the patient;
⢠the patientâs temperament, attitude and level of understanding; every patient is entitled to information, but these characteristics may provide guidance to the form it takes; and
⢠current accepted medical practice.8
2 PRESENTING INFORMATION
The way the doctor gives information should help a patient understand the illness, management options, and the reasons for any intervention. It may sometimes be helpful to convey information in more than one session. The doctor should:
⢠communicate information and opinions in a form the patient should be able to understand;
⢠allow the patient sufficient time to make a decision. The patient should be encouraged to reflect on opinions, ask more questions, consult with the family, a friend or advisor. The patient should be assisted in seeking other medical opinion where this is requested;
⢠repeat key information to help the patient understand and remember it;
⢠give written information or use diagrams, where appropriate, in addition to talking to the patient;
⢠pay careful attention to the patientâs responses to help identify what has or has not been understood; and
⢠use a competent interpreter when the patient is not fluent in English.9
3 WITHHOLDING INFORMATION
Information should be withheld in very limited circumstances only:
⢠if the doctor judges on reasonable grounds that the patientâs physical or mental health might be seriously harmed by the information;10 or
⢠if the patient expressly directs the doctor to make the decisions, and does not want the offered information. Even in this case, the doctor should give the patient basic information about the illness and the proposed intervention.11
4 EMERGENCIES
In an emergency, when immediate intervention is necessary to preserve life or Prevent serious harm, it may not be possible to provide information.
Sorry, typo, that was meant to say “ironic” â and not “I write” to see it coming out of HarvardâŚ.
This appears to be absolutely predictable. If we look medications functionally, rather than regarding “diagnosis” we would have picked it up earlier I expect. Of course psychiatry has given people at risk, or experiencing psychosis, stimulants in a way abrogating their informed consent and human rights has been made clear upon the site. So, to be expected.
I write to see it coming out of Harvard University/Maclean Hospital, the home of Dr Joseph Biederman, who has done more than any other professional to escalate the usage of stimulants in young people.
“And what has been the resulting social injury? It has led to the pathologizing of millions of children”… Just released, “The Australian Child and Adolescent Survey of Mental Health and Wellbeing” Almost one in seven (13.9%) 4-17 year-olds were assessed as having mental disorders in the previous 12 months. This is equivalent to 560,000 Australian children and adolescents. ADHD was the most common mental disorder in children and adolescents (7.4%), followed by anxiety disorders (6.9%), major depressive disorder (2.8%) and conduct disorder (2.1%). Based on these prevalence rates it is estimated that in the previous 12 months 298,000 Australian children and
adolescents aged 4-17 years would have had ADHD, 278,000 had anxiety disorders, 112,000 had major depressive disorder and 83,600 had conduct disorder. http://youngmindsmatter.org.au/http://health.gov.au/internet/main/publishing.nsf/Content/9DA8CA21306FE6EDCA257E2700016945/$File/child2.pdf
Sadly our predominant model in Australia is also KOL psychiatrist led, with GPs doing most prescribing, including to kids, encouraged by KOLs. And as in the USA, “our healthcare system is structured deincentivizes prescribing providers from taking a more contextual approach. If you talk to clinicians on the ground, that is what they want to do, but they are incentivized to prescribe.”
There is a science of intentional behavioural change, at individual, family, community and societal level which has been incrementally developed over the last 40=-50 years, and which is wonderfully encapsulated in a simply superb new book “The Nuture Effect” – see http://www.nurtureeffect.com/
We have the tools to help our families and schools to be more nurturing. Rather than addressing each psychological, behavioral, or health problem as though it is unrelated to every other problem, we need to get all of the organizations working on human wellbeing to band together to help make all of our families and schools more nurturing.
No matter the context or the problem at hand, following these universal principles of a nurturing environment creates the best chances at success. Nurturing environments do four things:
Minimize toxic social and biological conditions.
Teach, promote, and richly reinforce prosocial behavior.
Limit influences and opportunities for problem behavior.
Promote psychological flexibility, which is a mindful approach to pursuing oneâs values even in the face of emotional, cognitive, and real-world challenges.
I am not saying the problem is that you’re outlining do not exist, they most certainly do, and Robert’s excellent book, and your book “Her Lost Year” I hope many people disentangle from psychopharmacological pseudoscience, and engage in much more helpful behaviours toward rich and meaningful lives.
And Tony Biglan’s review of the science of positive intentional behaviour change at all levels over the last 40 years will I hope be of great interest to both of you.
Dear Rob
From a practising psychiatrist, THANK YOU from the bottom of my heart for scanning the literature and highlighting key / relevant studies regarding what should be every prescribers’ FIRST duty – to be very aware of the potential/actual harms of the poisons we have the responsibility of prescribing, which are sometimes useful and called “medications”.
With deep gratitude, rob purssey
Hi Sandra
I’m also going to butt in. I have some clients/patients with “old fashioned manic depression” (not DSM bipolar) who are on NO regular medications, and use ACT psychological flexibility strategies daily (mindfulness skills, orientation to valued actions, acceptance skills, exercise, sleep diet etc) AND occasionally with stress / seasons have manic episodes. We step back stressors IF possible, increase health strategies, AND use short term LOW dose diazepam/temazepam and chlorpromazine (more flexible, lower dose than quetiapine also less appetite/weight issues but functionally very similar) short term – and they’ve settled and OFF medication in about a month, max 6 weeks. Nothing ongoing. One developed hepatotoxicity on chlorpromazine so (to his great dismay) across to short term quetiapine. Will be only a few weeks max then off. All carefully negotiated. All with email support. With ongoing focus minimal meds, maximal health strategies, minimal labelling and issues that all brings. Hope helpful, Rob Purssey
Last listed, but corresponding and apparently senior author: “Correspondence: Professor E Eriksson, Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, POB 432, Gothenburg SE 405 30, Sweden. E-mail: [email protected]” AND, guess what? “Conflict of interest… Elias Eriksson has been on advisory boards and/or received speaker’s honoraria from Eli Lilly and H Lundbeck.”
Dear Sandra,
Before taper, learning evidence-based psychological flexibility skills to better handle the broader range of emotions and possible difficult thoughts and other experiences which may arise as major tranquilizers are decreased, they also be extremely helpful in assisting patients to wean. Please see the following articles which increasingly demonstrate efficacy of ACT in this process.
Please email me if requiring full PDF of any of the above,
Warm wishes, Rob Purssey
I discussed this with a concerned journalist colleague, who recommended that I and other psychiatrists who have some expertise in this area nominate ourselves upon the Science Media Centres in our respective countries so as to provide a more measured, scientifically grounded, perspective upon stories such as these.
There is a Science Media Centre of the United States, website here http://www.sciencemediacenter.org/usa/ , which has links to the Science Media Centres of Australia, Canada, New Zealand, Japan and United Kingdom.
If you are a psychiatrist or pharmacologist reading this list post please consider nominating yourself as an expert to the Science Media Centre in your relevant country so as to provide a more grounded, measured, scientifically focused perspective upon stories such as these. Otherwise those academics strongly influenced by industry will continue to shape the public debate.
I discussed this with a concerned journalist colleague, who recommended that I and other psychiatrists who have some expertise in this area nominate ourselves upon the Science Media Centres in our respective countries so as to provide a more measured, scientifically grounded, perspective upon stories such as these.
There is a Science Media Centre of the United States, website here http://www.sciencemediacenter.org/usa/ , which has links to the Science Media Centres of Australia, Canada, New Zealand, Japan and United Kingdom.
If you are a psychiatrist or pharmacologist reading this list post please consider nominating yourself as an expert to the Science Media Centre in your relevant country so as to provide a more grounded, measured, scientifically focused perspective upon stories such as these.
This paper “Linking Molecules to Mood: New Insight Into the Biology of Depression” best summarises the evidence of NO chemical imbalance. Written by lead NIMH “academic neuroscientist psychiatists” Vaishnav Krishnan and Eric J. Nestler
Full access here http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031089/ and
The key paragraph is here: “Since monoamine enhancers improve depressive symptoms, it was suggested historically that depression is caused by deficits in monoaminergic transmission (âmonoamine hypothesisâ), which continues to be a prominent preoccupation of the field. However, after more than a decade of PET studies (positioned aptly to quantitatively measure receptor and transporter numbers and occupancy) (31), monoamine depletion studies (which transiently and experimentally reduce brain monoamine levels) (32) as well as genetic association analyses examining polymorphisms in monoaminergic genes (27, 33, 34), there is little (FOR WHICH READ “NO”) evidence to implicate true deficits in serotonergic, noradrenergic, or dopaminergic neurotransmission in the pathophysiology of depression.”
The material preceding and following this is largely biobabble, and it might seem curious that with the massive lack of progress from SO much research it’s still being pushed – the key to why is in this final sentence: “We should look well beyond monoamines, cortisol, BDNF and the hippocampus to determine tomorrowâs novel medical and surgical therapeutic avenues for depression.” – i.e. thinking that “psychiatry’s” sole purpose is in finding “novel medical and surgical therapeutic avenues” – good medicine involves contextual, environmental, relationship, ALL modalities of easing suffering, but alas, not for the NIMH.
Reading this: “Dr. John H. Krystal, chairman of psychiatry at Yale and a pioneer in the study of ketamine for depression” – so Googled his name plus “…patent ketamine” and … guess what? http://patents.justia.com/inventor/john-h-krystal Note he also is editor of Biological Psychiatry where the experimercial is published http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671489/ – enough said, it’s a marketing push, is the reason for it all. The names on the patents very revealing.
Sadly, this article looked like nothing more than an advert for agomelatine, and a quick glance confirms this: “The authors declare that over the past 3âyears, Brian Harvey has participated in speakers/advisory boards and received honoraria from Servier” – who sell agomelatine. Such profound insights as “We propose that either hyperserotonergia or hyposerotonergia may underlie the syndrome.” Okay, it’s either too much, or too little 5HT… wow! “What this review has attempted to consolidate is that ADS may be exclusively a problem of acute 5-HT release evoked by antidepressants such as SRIs, SNRIs, TCAs and some atypical compounds leading to changes in 5-HT homeostasis. By using agomelatine as a counterpoint to this argument, it is now evident that an effective antidepressant need not engender a risk for ADS.” i.e. BUY OUR STUFF INSTEAD! and “The unique pharmacodynamic and pharmacokinetic profile of agomelatine may hold the key …” so PAY ME FOR MORE “RESEARCH” ON IT… only actually it’s a dud – see http://1boringoldman.com/index.php/2013/09/04/a-breath-of-fresh-air-3/ IN SHORT – don’t bother reading this neurobabble pretending to seriously examine a VERY serious issue, but in fact simply pushing “chemical imbalance” aetiologies and selling a non-SSRI competitor.
Great article, and your NZMJ likewise. I hope this Trojan horse can be stopped. Pharma and more will be doing a GREAT deal behind the scenes to make it happen, so all public resistance is critical.
From the Patient Health Questionnaire-9 study: Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann 2002;32:509â21 comes this disclosure re the lead author: “Dr. Kroenkeâs research is supported by Pfizer Inc. and Eli Lilly. He is also
a member of Eli Lillyâs advisory board.” Enough said. Herding patients to the pharmacy.
Dear Joanna
Great post – I am ardently hoping you’re working on this for a journal article. Warm wishes, and power to your pen. Rob Purssey
“…from our international friends, is off-label prescribing legal in your countries?”
In Australia, the sad answer is DEFINITELY YES (in fact most psychotropic prescribing is “off label”) And Pharma Reps do NOT have the legal limitations on pushing these as in the US. KOL’s are recruited to “push the envelope” as there. In Australia the Gov’t reimbursement scheme (Authority) specifies “diagnoses” AND doctors routinely defraud this in “prescribing off label” while noting certain non-existent diagnoses. AND rubberiness of DSM (even more as we’re seeing in DSM V) allows pretty much everyone to fit most remunerative (pharma wise) diagnoses anyway. Never challenged legally. I’ve not seen a single case for falsely using Authority diagnoses. Sorry, long way of saying yes. I expect this is true for all Anglo countries.
“Depression is a disorder of the brain” “Bipolar disorder … usually lasts a lifetime” “Researchers think brain circuits may not work properly in people who have OCD” “Schizophrenia is a severe, lifelong brain disorder” – not the greatest site, IMHO.
Best to all on this site, rob purssey
Superb post, thank you so much for the hard and careful work. Will disseminate as widely as possible. Hats off to Adam Urato!
These are not really “older adults” but all over 40. In press about this study, Jeste is “damage controlling” – stating in dementia and off label we ought worry â but this is âaged > 40 years, having psychosis associated with schizophrenia, mood disordersâ â i.e. the majority of the market. Keep that quiet. The real implication ought be shouted from the rooftops, all blogs etc. Best wishes to all on this forum, Rob Purssey
While the study may seem related to personal experiences, it’s worth noting that a) it’s in a “rat neurodevelopmental model of schizophrenia” – i.e. animal models which in this area so far haven’t proven helpful, as “schizophrenia” (like depression) is a thoroughly verbal (images, words etc) problem, and rats don’t display verbal behavior. Also that b) it’s an Eli Lilly study, essentially, so for the purpose of developing pharmacotherapy at heart, and c) it’s full of “maybe’s” eg “potentially as a consequence of …” and “may be associated with …”
I daresay that personal accounts of sleep problems and psychotic / psychosis like experiences, and how individuals handle these more effectively, may be more fruitful for helping those suffering such interactions.
Best wishes, rob purssey
See “A Beautiful Mind” for a film representation of this functionally workable psychological move. As Steven Hayes recently posted in ACT for the Public email listserve:
A lot of folks think voices are so unusual they work differently but
a) they are not that unusual, and
b) they seem to work the same as other experiences (e.g., panic; depressive thoughts).
Back up, notice them, don’t take them literally (neither comply nor argue back/fight),
learn what experience shows is useful to learn from them (e.g., notice when they occur etc),
shift attention to what you care most about, link behavior to values
– Steven C. Hayes, Foundation Professor, Department of Psychology, University of Nevada
Dear Peter Symons, could you please do a quick search for disclosures/conflicts of interests of the editorial writers Michael Hill and Sean Dukelow and post here? Many thanks.
“We argue that a multi-dimensional, multi-level extended evolutionary meta-model (EEMM) provides consilience and a common language for process-based diagnosis. The EEMM applies the evolutionary concepts of context-appropriate variation, selection, and retention to key biopsychosocial dimensions and levels related to human suffering, problems, and positive functioning. The EEMM is a meta-model of diagnostic and intervention approaches that can accommodate any set of evidence-based change processes, regardless of the specific therapy orientation. In a preliminary way, it offers an idiographic, functional analytic, and clinically useful alternative to contemporary psychiatric nosological systems.”
Steven C. Hayes, Stefan G. Hofmann, Joseph Ciarrochi,
A process-based approach to psychological diagnosis and treatment:The conceptual and treatment utility of an extended evolutionary meta model, Clinical Psychology Review, 2020
https://www.sciencedirect.com/science/article/abs/pii/S0272735820300969
Dear fellow disillusioned psychiatrist Dr E Baden please connect also with me rob at brisbaneactcentre dot com dot au â i believe i could also help, in various ways. See also http://www.brisbaneactcentre.com.au and perhaps also http://actinpsychiatry.com/
Dear fellow disillusioned psychiatrist đ Dr E Baden please connect also with me rob at brisbaneactcentre dot com dot au – i believe i could also help, in various ways. See also http://www.brisbaneactcentre.com.au and perhaps also http://actinpsychiatry.com/
From the linked study, full free access, worth the read: “Although the important limitations of the evidence base, esketamine was labelled as a breakthrough therapy for TRD. The strategy to approve it as REMS could help addressing some safety issues, but this will require a long time and exposure of many persons with depression to this new agent. Considering the explanatory nature of existing studies, large pragmatic trials are urgently needed to better define the place in therapy of esketamine, aiming to clarify if there is more than just smoke and mirrors.
Finally, we argue that the EMA should take into due account all these critical issues when assessing the marketing authorisation of esketamine for Europe, and, more broadly, we call for a radical change of current regulatory rules for psychotropic drug approval.”
https://www.cambridge.org/core/journals/epidemiology-and-psychiatric-sciences/article/esketamine-for-treatment-resistant-depression-a-trick-of-smoke-and-mirrors/F8BB2D5C3F290FE671639CBB0F31C7E9/core-reader
Dear Gavin Crowell-Williamson
The link to the study is incorrect, thanks for fixing up, when you get the chance. Rob Purssey
Great interview – notably long term studies have been done – MTA – and medicated kids did worse at 3 and 6 years, but this wasn’t the PR on it – Whitakers slides on it from May 2016 “Medicating ADHD: If Long-term Outcomes Are Considered, Is This An Evidence-Based Practice?” https://www.madinamerica.com/wp-content/uploads/2017/01/Medicating-ADHD.pdf
The actual paper has NO data on whether the women were on medication – incredibly NOTHING WHATSOEVER. Unless excluded, we have to assume many would have been. Mindblowing that this was published at all, and the commentary equally astonishing – and tragic misinformation.
“An investigative report uncovers little recognized and unpoliced potential conflicts of interest among those who serve on FDA advisory panels that review drugs. Some members of such panels are later receiving significant payments from either the makers of drugs they previously reviewed, or from competitors. … those asked to weigh in stand to gain tremendously in their further professional careers. “It’s in their best interest to play nice with the companies.” FDA may also have missed or judged insignificant financial ties physicians had before their service on the drug approval advisory panels.” http://science.sciencemag.org/content/361/6397/16
Edward Bullmore’s disclosures – âI work half-time for GSK, leading a small group focused on immunological mechanisms and therapeutics for mood disorders.â â enough said. Straight to the bin. https://www.neuroscience.cam.ac.uk/directory/profile.php?etb23 This “radical theory” appears primarily intended to link depression to profits. I strongly recommend against giving this pharmaceutical company employee any further airtime.
Dear Niall and Brett, thanks for your work in correcting misinformation from my College. In August last year I took the trouble to post a direct message to the president of the College Dr Kym Jenkins on a college forum thread which she had commenced, about “college strategic plan” which included the following “values”: âOur Values ⢠Integrity ⢠Respect ⢠Compassion ⢠Collaboration ⢠Quality ⢠Innovation ⢠Sustainabilityâ.
In regard to “integrity” â my post follows: Robert Purssey – 31/08/2017 7:06:09 PM
RE:The RANZCP Strategic Plan
Dear Kym
Re: “Integrity”
on “Your Health In Mind” (RANZCP college website for the general public) – i note – “How do medications treat mental illness – Medications work by rebalancing the chemicals in the brain” – a statement very clearly implying a pre-existing chemical imbalance. Dr Ronald Pies (along with many others) has recently proclaimed “I am not one who easily loses his temper, but I confess to experiencing markedly increased limbic activity whenever I hear someone proclaim, “Psychiatrists think all mental disorders are due to a chemical imbalance!â In the past 30 years, I donât believe I have ever heard a knowledgeable, well-trained psychiatrist make such a preposterous claim, except perhaps to mock it. On the other hand, the âchemical imbalanceâ trope has been tossed around a great deal by opponents of psychiatry, who mendaciously attribute the phrase to psychiatrists themselves.2 And, yesâthe âchemical imbalanceâ image has been vigorously promoted by some pharmaceutical companies, often to the detriment of our patientsâ understanding.3 In truth, the âchemical imbalanceâ notion was always a kind of urban legend- – never a theory seriously propounded by well-informed psychiatrists.”
Please note also “Linking Molecules to Mood – New Insight Into the Biology of Depression. Krishnan and Nestler, AJP Oct 2010” – “Since monoamine enhancers improve depressive symptoms, it was suggested historically that depression is caused by deficits in monoaminergic transmission (âmonoamine hypothesisâ), which continues to be a prominent preoccupation of the field. However, after more than a decade of PET studies (positioned aptly to quantitatively measure receptor and transporter numbers and occupancy) (31), monoamine depletion studies (which transiently and experimentally reduce brain monoamine levels) (32) as well as genetic association analyses examining polymorphisms in monoaminergic genes (27, 33, 34), there is little evidence to implicate true deficits in serotonergic, noradrenergic, or dopaminergic neurotransmission in the pathophysiology of depression.” – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031089/
And furthermore, re IATROGENESIS of this “urban legend” – https://static1.squarespace.com/static/51cb73eee4b07cb3e8507d7e/t/56b8f015e707eba737d9d09e/1454960662195/beh+therapist.pdf
Please explain how this “information” on College websites comports with “Integrity”.
Kind regards,
Dr Robert Purssey
MBBS FRANZCP
ps notably such misinformation (among other on the site) clearly breaches our National Health and Medical Research Council guidelines for medical practitioners on Informed Consent https://www.nhmrc.gov.au/guidelines-publications/e57
pps note also Dr Patrick McGorry’s recent quote above in relation to this matter – and the relevant weblink https://www.yourhealthinmind.org/treatments-medication/medication
This comment, while undoubtedly true, is a devastating critique on modern psychiatry practice, which ought be to be acutely sensitive to harms of any and all of our interventions: “…due to institutional corruption within academic psychiatry it is quite difficult to successfully pass the review process with such papers. Most psychiatric experts reviewing for the leading scientific journals refuse peremptorily any report calling into question the merits of psychiatric drugs.”
FIRST DO NO HARM – and such exemplary work as Michael Hengartner and crew are doing should be front and centre of the leading journals. Thanks for the excellent and ongoing work!
Humans do struggle, and help is sometimes useful. Over the years our wisdom traditions have provided this, along with families, friends – and nowadays it’s (sometimes) professionals. Science can be part of this. This article is FAR from unbiased: “FL, AA, MH, PL, CS research, teach, and practice psychodynamic therapy (PDT) and have published books or book chapters dealing with PDT” PDT = psychodynamic therapy, Freud and all that followed thereafter. Lead author has many such articles eg “Leichsenring F, Leweke F, Klein S, Steinert C. The empirical status of psychodynamic psychotherapy – an update: Bambi’s alive and kicking. Psychother Psychosomat. (2015)” His everyday JOB is psychoanalytical psychotherapy, “Falk Leichsenring, Dipl.-Psych, Psychoanalyst” and similar for co-authors. There was back and forth in BMJ about this a few years ago. Here’s a very interesting blog on where “CBT” (whatever that phrase means) appears to be going in 2018 – http://drericmorris.com/2018/02/05/post-cbt/
Another excellent brand new ACT self-help resource, postnatal orientation but still relevant “Postpartum Depression and Anxiety â The Definitive Survival and Recovery Approach” â “is a unique, user-friendly self-help approach to support and guide mild, moderate and severe sufferers to a place called recovery and beyond.” From New Zealand, and a great newspaper article about it here â http://www.stuff.co.nz/life-style/parenting/101541339/christchurch-postnatal-depression-survivor-and-psychologist-team-up-to-write-book – hope both of these may be helpful to some.
“Becoming Mum” is a superb Acceptance and Commitment Therapy (ACT) self-help book extremely useful in overcoming perinatal and postnatal depression â drawing upon strategies within ACT, mindfulness-based Cognitive Behavioural Therapy and Behavioural Activation â all of which have an evidence-base in the treatment and prevention of depression. Becoming Mum would be a useful companion to any woman seeking to prevent or overcome both perinatal and postnatal depression. Highly recommended, and relevant sites: https://becomingmum.com.au/ and the authors site here http://www.koawhittingham.com â check out both! Btw research shows ACT and similar modern psychotherapy self-help books to work better with the help of a skills coach a.k.a. therapist.
(Request as sent to Jeff Baker at ‘[email protected]’ on 26/03/2018â no response as yet, so reposting here) As a psychiatrist acutely aware of the pervasiveness and harmfulness of chemical imbalance myth I was very interested in seeing this YouTube. It very nicely goes through the evidence against this falsehood, and usefully quotes the most mainstream of psychiatrists in summarising decades of evidence.
I would like to be able to link this YouTube lecture to emailed information I send my patients, and link on my practice site, however I can find nothing whatsoever online about “Advancing Mental Health.org” or about Jeff Baker in any detail. I am not disputing his good intentions, nor that of the organisation/brand which has the YouTube channel â but I cannot professionally/personally feel comfortable in linking such materials without knowing a bit about the background of individuals and groups providing them.
I’m sure all readers of MIA are aware enough of the problems within our field to understand why!
I would be grateful for MIA editors, or Jeff Baker, or ANYONE for providing some background information about Mr Baker and advancingmentalhealth.org
Great article, thanks! And “At the same time, I do think that once-popular metaphors such as the âbroken brainâ and a âchemical balanceâ have been debunked quite effectivelyâyou donât hear much of them these days, even in pharma ads, which are the last to change.” – see the Royal Australian and New Zealand College of Psychiatry’s website for the general public “Your Health in Mind” information on medication, which very clearly continues perpetrating these falsehoods â “How do medications treat mental illness? Medications work by rebalancing the chemicals in the brain. Different types of medication act on different chemical pathways.” I have directly emailed the president of RANZCP about this factual error and iatrogenesis of the falsehood (and shown them Lacasse and Leo 2015 paper – Antidepressants and the Chemical Imbalance Theory of Depression: A Reflection and Update on the Discourse.) But of course no response. So it continues… https://www.yourhealthinmind.org/treatments-medication/medication
And just out – The Predictive and Moderating role of Psychological Flexibility in the Development of Job Burnout
December 2017Universitas Psychologica 16(4):1-8 https://www.researchgate.net/publication/314664391_The_Predictive_and_Moderating_role_of_Psychological_Flexibility_in_the_Development_of_Job_Burnout
Also see https://www.researchgate.net/publication/51070991_Acceptance_and_commitment_therapy_for_the_treatment_of_stress_among_social_workers_A_randomized_controlled_trial
http://www.emeraldinsight.com/doi/abs/10.1108/AMHID-09-2015-0046
http://www.tandfonline.com/doi/abs/10.1080/10615806.2015.1025765
https://www.brisbaneactcentre.com.au/reduce-stress-burnout/
and many more studies available on ACT / mindfulness alleviating burnout at a quick Google
“…psychoanalysis is emotionally demanding, time-consuming and often expensive” – ON THE OTHER HAND – modern evidence based psychotherapies can help with burnout MUCH faster and cost-effectively, including using supported self help materials eg “Burnout: Break the Vicious Cycle with Acceptance and Mindfulness; Waadt & Acker, 2013a” – Conclusions: Our study provides empirical support for decreasing stress and promoting well-being through ACT (acceptance and commitment therapy) and emphasizes the potential of PF (psychological flexibility) in promoting well-being (in a 6 week supported self help program). see full study at https://www.sciencedirect.com/science/article/pii/S1697260017300650
and # 11 – Michael B First, author of beneath, works for Lundbeck and others, and advises Pharma on how to craft studies / approach FDA and EMA to fulfill DSM / ICD disorder criteria (I have read this disclosure elsewhere) – “Harmonisation of ICDâ11 and DSMâV: opportunities and challenges” Michael B. First – The British Journal of Psychiatry Oct 2009 – full article here http://bjp.rcpsych.org/content/195/5/382#skip-link
Just posting in case of interest (no time to discuss further i’m afraid) “Freud Was a Fraud: A Triumph of Pseudoscience” – Frederick Crews has written a reassessment of Freud based on newly available correspondence and re-evaluation of previously available materials. He shows that Freud was a fraud who deceived himself and succumbed to pseudoscience. https://sciencebasedmedicine.org/freud-was-a-fraud-a-triumph-of-pseudoscience/
My comments (re the Australian context) If only the RANZCP (Australian psychiatry training college) would accept this – the ONLY way to do “advanced training in psychotherapy” is psychodynamic, i.e. modern Freudian – AND the Faculty of Psychotherapy continues utterly so biased. Their conferences etc – modern behaviorism / contextual behavioral science https://contextualscience.org doesn’t get a mention and cannot be taught – sheesh.
âFreud: The Making of an Illusion [is] a . . . stake driven into its subjectâs cold, cold heart. . . . Crews is an attractively uncluttered stylist, and he has an amazing story to tell.ââLouis Menand, The New Yorker
âA powerful and thorough takedown of Sigmund Freud.ââVulture
âCrews [is] going in for the kill. A damning portrait.ââEsquire
âDiligently documented . . . neither sensationalized nor ranting . . . a scorching summation.ââThe Chronicle of Higher Education
âAn elegant and relentless exposĂŠ . . . Impressively well-researched, powerfully written, and definitively damning. Crews wields his razor-sharp scalpel on Freudâs slavish followers, in particular, who did not want to see or who willfully redacted the sloppiness of Freudâs research methods in order to âidealize him.â ââKirkus Reviews (Starred Review)
âCrews relentlessly shreds the deceptions that Freudians even now try to maintain. . . . This thorough dismantling of one of modernityâs founding figures is sure to be met with controversy.ââBooklist (Starred Review)
âA stunning indictment . . . this fascinating biographical study paints a portrait of Freud as a man who cared more about himself than his patients and more about success than science.ââPublishers Weekly
âFor those who worship Freud, and even those millions who have simply admired his ideas, Crewsâs rigorous and captivating detective work will be a bracing challenge.ââElizabeth Loftus, co-author of The Myth of Repressed Memory
Thanks for the Wikipedia link – we need to add to / work on this: “Most cases of discontinuation syndrome last between one and four weeks, are relatively mild, and resolve on their own; in rare cases symptoms can be severe or extended” – clearly not the case (i.e. NOT RARE to have MUCH more WD issues), AND this community, and the RxISK etc community need to get onto that Wiki page…
Dear Eve, thank you for this powerful blog article – I have shed and strongly encouraged my doctor colleagues, esp psychiatrists to please read. The very critical comments in the thread above of course have a great deal of justification – many of those within the MIA community have been lied to by organised psychiatry and much more seriously personally harmed, losing their family members et cetera, than ourselves in the profession.
However, I would encourage all to please understand how HARD it is to make such a leap that Eve describes – which can cost one’s entire livelihood, rendering decades of training futile/worthless, AND irreparably separate a person from one’s peers, and friends. And consider how depressing are these paragraphs…
“Todayâs senior residents in psychiatry get an average of 100 job offers to do medication management. And there are no other options out there. Many graduating residents have huge medical school loans to pay back, and may not even have much knowledge of the risks inherent in the prevailing models…” This is undoubtedly true, and devastating.
Thank you for your brave blog post â (brave even from my perspective – a psychiatrist who became aware of the problems from the late 90s onward.)
BBC Panorama “A prescription for murder?” youtube link here (and search around if it changes) https://www.youtube.com/watch?v=tPykg6pa3dA&t=29s
Excellent BBC documentary which graphically highlights the big issues in mental health especially. DSM, pharma-psychiatry links, Pfizer’s GHQ9 (and its purpose), the ADHD false epidemic, Joseph Biederman saga, how AD’s “prescribed for poverty”, and more. Psych stuff in first half largely – very very good. Allen Frances, Chairperson of DSM 4 the blueprint of modern psychiatry. “We were trying to protect people from excess medicine. We failed.” – Youtube link for worldwide access here https://www.youtube.com/watch?v=HGhAePaZeSU
All psychiatric guidelines I’m aware of would score woefully by these excellent measures – this tool deserves a blog / educational highlight on MIA – Cosgrove? Lexcin? Whitaker? – it ought be highlighted on the site: the measures which are used:
Relevance threats
1. The patient populations and conditions are relevant to my clinical setting.
2. The recommendations are clear and actionable.
3. The recommendations focus on improving patient-oriented outcomes, explicitly comparing benefits versus harms to support clinical decision making.
Evidence threats
â4. The guidelines are based on a systematic review of the research data.
â5. The recommendation statements important to you are based on graded evidence and include a description of the quality (e,g, strong, weak) of the evidence.
â6. The guideline development includes a research analyst, such as a statistician or epidemiologist.
Interpretation threats
â7. The Chair of the guideline development committee and a majority of the rest of the committee are free of declared financial conflicts of interest, and the guideline development group did not receive industry funding for developing the guideline.
â8. The guideline development includes members from the most relevant specialties and includes other key stakeholders, such as patients, payer organizations, and public health entities, when applicable.
With gratitude for the authors and the Delphi panellists – Rob Purssey
Chapter 8 of the essential “Psychiatry Under the Influence” by Whitaker and Cosgrove is “The End Product: Clinical Practice Guidelines” – so i was skeptical about this new tool, G-TRUST – until i’ve just read “said last author Lisa Cosgrove, Ph.D.” – with 6 other fabulous authors we all ought respect! The article is FREE FULL ACCESS – presently anyway – IF A HEALTHCARE PROVIDER – PLEASE CHECK IT OUT, AND DISSEMINATE – http://www.annfammed.org/content/15/5/413
Thanks for this GREAT blog post Brett, and for all that you do. For those unfamiliar with the excellent work Brett has put in to this area, i strongly recommend you check in this previous MIA post https://www.madinamerica.com/2015/10/psychologists-critique-the-biomedical-model-of-psychological-problems , and in particular thoroughly read the superb special edition of The Behaviour Therapist which Brett, edited focusing on “critical analysis of the biomedical paradigm. The purpose of this special issue of the Behavior Therapist is to contribute to this analysis. This special issue features 11 articles that present critical analyses of different aspects of the biomedical model. Contributors to this special issue include award-winning scientists and journalists, three ABCT presidents, the president-elect of the British Psychological Society, and individuals from clinical psychology, counseling psychology, journalism, neuroscience, psychiatry, and social work. These authors share a commitment to scholarly rigor and scientific evidence as the foundation for critical analysis of the biomedical approach. The exceptional articles featured in this special issue deserve a careful reading, and their provocative conclusions warrant serious consideration and ongoing professional dialogue.” Full edition is here https://www.madinamerica.com/wp-content/uploads/2015/11/Behavior-Therapist-Oct-2015.pdf
Great article about “The Happiness Trap”. Some foundational insights from Acceptance and Commitment Therapy in here. Worth the read!
Shorter half life = quick onset, quick OFFSET and rebound anxiety = need more. Alprazolam is thus the “crack cocaine of the benzo world” – only surpassed by Triazolam (Halcion – see above). Plus it is extraordinarily high potency (see Ashton manual) Also the shorter half life ones “feel nicer” which is itself naturally a higher risk. None of this means that diazepam (longer half-life, comes in much lower dosages, feels relatively unpleasant) is without significant risk, because of course it is, but overall diazepam IF used very cautiously and very sparingly is a significantly safer drug than alprazolam. Nevertheless overall this article is very well written and accurately highlights a very problematic area.
“Why on earth is this given space on MIA?” – Know thine enemy. It is very useful to see, so clearly, what is driving the expansion of drugging, and the simple financial rationale behind it.
May be of interest to some re this post:
An Acceptance and Commitment Therapy (ACT) intervention for Chronic Fatigue Syndrome (CFS): A case series approach
http://www.sciencedirect.com/science/article/pii/S2212144717300315
Highlights
⢠Acceptance and Commitment Therapy can improve wellbeing in chronic health conditions.
⢠Chronic Fatigue Syndrome is a debilitating and challenging chronic syndrome.
⢠We examine guided ACT self-help in a case-series of individuals with CFS.
⢠ACT was linked with increased physical activity and valued behavior.
⢠Across cases, evidence for effects on psychological flexibility was mixed.
Abstract
Objective
Acceptance and Commitment Therapy (ACT) has been shown to improve the psychological well-being of individuals suffering from a range of chronic health conditions, and aims to increase psychological flexibility in order to foster greater engagement in personally meaningful behavior. We aimed to assess whether the approach (delivered via guided bibliotherapy) may have utility for individuals experiencing the debilitating effects of Chronic Fatigue Syndrome (CFS).
Methods
We used a mixed-methods multiple single-case design to explore the effects of a six week self-help ACT intervention for six participants diagnosed with CFS.
Results
Significant increases in ratings of valued living were replicated and maintained in four participants, with qualitative data further highlighting the importance of the values component of the intervention. Acceptance scores improved in four participants but were not maintained at follow-up, whereas improvements in psychological flexibility were observed and maintained for three participants. All participants wearing an activity monitor evinced increased physical activity postintervention, which was maintained at follow up in half of the participants.
Conclusion
The ACT self-help intervention appeared to benefit most participants on at least one assessed metric, particularly in terms of the promotion and pursuit of individual values, and increased physical activity. However, the results suggest these benefits may be difficult to maintain longer term without further input.
Unfortunately “This content is available exclusively to Chronicle subscribers” – can you find another link? Thanks!
Thanks (also for this one) to Brett Deacon for responding appropriately to this post / link – your time, wisdom and academic rigor is greatly appreciated. Rob Purssey (ACT therapist and psychiatrist)
Thanks to Brett Deacon for responding appropriately to this unfortunate post / link – your time, wisdom and academic rigor is greatly appreciated. Warmly Rob Purssey (ACT therapist and psychiatrist)
valbenazine – must be close to tetrabenazine, used for decades for TD (and not terribly effective and many s/e’s of course) – interested in comments on this, thanks
“Full” disclosures from article (inverted commas as it appears bizarre that none are noted for Leiberman)
From the Nathan Kline Institute for Psychiatric Research and New York University Langone Medical Center, New York University School of Medicine, New York; the Department of Psychiatry and Psychotherapy, Ludwig-Maximilians-University Munich, Munich, Germany; the Department of Psychiatry, Psychotherapy and Psychosomatics, Division of Psychiatry, Medical University Innsbruck, Innsbruck, Austria; the New York State Psychiatric Institute and New York Presbyterian Hospital-Columbia University Medical Center, Columbia University College of Physicians and Surgeons, New York; the Department of Psychiatry, Brain Center Rudolf Magnus, UMC Utrecht, Utrecht, The Netherlands; the Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan; and the Department of Psychiatry, Chinese National Clinical Research Center for Mental Disorders, Mental Health Institute, The Second Xiangya Hospital of Central South University, Changsha, Hunan, P.R. China.
Address correspondence to Dr. Goff ([email protected]).
Dr. Goff has received research support from Avanir Pharmaceuticals, NIMH, and the Stanley Medical Research Institute. Dr. Fleischhacker has received research support from Boehringer-Ingelheim, Janssen, Lundbeck, and Otsuka; he has received honoraria for serving as a consultant to and/or on advisory boards for Allergan, Dainippon Sumitomo, Gedeon Richter, Janssen, Lundbeck, Otsuka, Takeda, and Teva; and he has received speakerâs fees and travel support from AOP Orphan, Dainippon Sumitomo, Gedeon Richter, Janssen, Lundbeck, Pfizer, Otsuka, and Teva. Dr. Girgis receives research support from Allergan, BioAdvantex, Genentech, and Otsuka. Dr. Kahn has received consulting fees from Alkermes, Forrest, Forum, Gedeon-Richter, Janssen-Cilag, Minerva Neurosciences, and Sunovion and speakerâs fees from Janssen-Cilag and Lilly. Dr. Uchida has received grants from Astellas Pharmaceutical, Dainippon-Sumitomo Pharma, Eisai, Eli Lilly, Meiji-Seika Pharmaceutical, Mochida Pharmaceutical, Novartis, Otsuka Pharmaceutical, and Shionogi; speakerâs honoraria from Dainippon-Sumitomo Pharma, Eli Lilly, Janssen Pharmaceutical, Meiji-Seika Pharma, MSD, Otsuka Pharmaceutical, Pfizer, Shionogi, and Yoshitomi Yakuhin; and advisory panel payments from Dainippon-Sumitomo Pharma. All other authors report no financial relationships with commercial interests.
The authors thank Dr. Shitij Kapur, for his important contributions to the initial formulation of this project, and Dr. Lisa Dixon, for the invaluable perspective she provided as a consultant to the process.
“An international group of experts was convened…” – where? when? who funded this ‘convening of experts’? No information whatsoever. Traditionally such convening of psychiatric experts on a drug topic has been funded by drug manufacturers, under a ‘university cover’. The full article disclosures are below. I wonder if Dr Donald Goff [email protected] might answer the questions above regarding funding of this ‘expert consensus’ project. Others might enquire, i don’t have the time and energies.
Your latest interview / podcast with Robert Whitaker is perhaps the best interview with him that Iâve heard (and Iâve heard MANY) so ⌠VERY well done, simply superb.
I cannot recommend this podcast highly enough.
Rob
Dr Robert Purssey, MBBS FRANZCP, Psychiatrist and ACT Therapist, Director – Brisbane ACT Centre – http://www.brisbaneactcentre.com.au
Re TADS and suicidality, please also read this post and related papers in detail https://www.madinamerica.com/2012/02/the-real-suicide-data-from-the-tads-study-comes-to-light/
Stephen – the trouble is this review is saying the pharma funded studies are indeed not valid, and the NIMH studies “show” on the other hand that SSRIs help kids. It is thus especially sneaky, and will hook folks into thinking it’s “on the side of good” whilst advocating MORE use of drugs proven to be unhelpful and proven also of course to be significantly harmful.
This is an incredibly concerning publication. âIt is the premise of this review that meta-analyses that include the large number of industry-sponsored antidepressant trials distort the picture of antidepressant efficacy for teen depression.â It is clearly intended to reverse the increasing reluctance of doctors to prescribe SSRI/SNRIs to children and adolescents, thanks to excellent and solid studies such as Cipriani et alâs Lancet 2016 (no benefit), and Sharma et alâs BMJ 2016 (double the risk of suicidality and aggression). The author was part of the TADS study, which has been noted on this site to have been grossly misreported â https://www.madinamerica.com/2012/02/the-real-suicide-data-from-the-tads-study-comes-to-light/ and this should be weighed when considering his opinion that these clearly ineffective dangerous drugs have âa broad and important role for antidepressant medications in pediatric internalizing conditions.”
This âreviewâ was, I suppose, inevitable, and will naturally be hugely reprinted and broadly distributed to GPs and psychiatrists by every pharmaceutical company with SSRI/SNRIs selling in the child/adolescent population. That is their marketing role (and sadly of this publication). The âaccompanying editorialâ serves the same purpose â from Medscape âDaniel Pine, MD, of the NIMH Intramural Research Program, and Robert Freedman, MD, of the University of Colorado School of Medicine in Aurora, note that some clinicians working with children and adolescents might have hesitated before recommending an SSRI, because of continued questioning in the media of the evidence for their effectiveness. This review “helps to generate a more balanced perspective, which promises to reduce the burden facing these clinicians,” they write. How fortunate for those clinicians do no longer face such a âburdenâ in prescribing drugs without an evidence-based of efficacy, but clear and well published evidence-base of harm to children/adolescents.
I do not have the time to dissect either paper, or editorial, nor chase down the 3 authors declared disclosures, and industry ties including funding of their research programs, but it is very important for those psychiatrists and other concerned doctors who might have time and inclination to investigate, publish and broadly publicise a thorough evidence and science-based rebuke to these flimsy opinion based promotions of the prescription of SSRI/SNRIs to children/adolescents.
Dear Ron
My apologies â I should have been more respectful, and written a “modern form of CBT”. I just read your prior post, and commented â which of course won’t actually be read but there it is! The idea that we should not seek to understand and use the content of our thoughts and feelings is not actually integral within ACT, sometimes doing so can be extraordinarily helpful, and sometimes doing so can have us spinning in wheels which are not so terribly helpful â it is the workability in helping us live a life more fully and richly which matters of course. It is quite true that ACT takes good deal from “traditional CBT”, and also true that it differs in significant and fundamental ways from “traditional CBT”, particularly the strategy/philosophy of science underpinnings clearly articulated – functional contextualism â and the reticulated strategy from basic to applied and across fields. In any case thank you so much for your valuable work.
Warm wishes, robpurssey
https://www.youtube.com/watch?v=o79_gmO5ppg that link is active
Dear Ron
Very late comment but “it tends to suggest there is no way of reconciling with the angry, scary, noisy parts of the psyche which may be objecting to those actions. For a different point of view, consider the perspective of Eleanor Longden”⌠Is a common misunderstanding of ACT. Your suggestion of “a wise âbus driverâ would alternate between at times being firm and taking some actions despite âpassengersâ yelling and complaining, but also at times being flexible and seeking to understand strongly expressed complaints and to come up with reasonable solutions that resolve difficulties and make peace with the passengers” sounds exceedingly workable, very important potentially in a certain individual and certain circumstances, and certainly something that would be embraced by a psychological flexibility point of view. ACT in no way dismisses personal experience, as ACT practitioners do not dismiss our evolutionary history, and we simply seek to notice when entanglement with figuring out not moving us to where we want to go â and sometimes it can be exceedingly helpful in understanding the nature of our difficulties â see Steve Hayes recent TED talk in which he talks about his early life experiences contributions to his difficulties (I’m aware this came out after your posting)https://www.youtube.com/watch?v=o79_gmO5ppg
Hi Ron
I expect you’re also well aware of “Acceptance and Commitment Therapy (aka modern CBT) and Mindfulness for Psychosis” – text here http://au.wiley.com/WileyCDA/WileyTitle/productCd-1119950791.html and another recent text “Incorporating Acceptance and Mindfulness into the Treatment of Psychosis – Current Trends and Future Directions” https://global.oup.com/academic/product/incorporating-acceptance-and-mindfulness-into-the-treatment-of-psychosis-9780199997213?cc=au&lang=en&
Warm wishes, Rob Purssey, psychiatrist and ACT therapist, Brisbane Australia
Simply a realistic observation: “Participants were informed of an online survey via widespread media advertising. The criteria for participation included having been prescribed antidepressants in the last five years, living in New Zealand and being 18 years of age or over. The survey was available online from March 2012 until January 2013.”
If I was working in marketing for a pharmaceutical company in New Zealand selling antidepressants from March 2012 until January 2013, it would be an essential responsibility of my JOB to have as many of my representatives and their relatives and friends as possible to have been responding to this survey in a very positive fashion. (But not enough to look suspicious.)
To NOT respond by doing this would mean NOT doing my job properly – i.e. marketing my products.
We’ll NEVER know how much of this occurred, I expect, and the authors would be very unlikely to comment one way or the other (it would – should, again, doing the job – invite “outrage” among such “users” as being invalidated) but it MAY help to account for “In this study, 84 % of participants in this study answered in the affirmative to a question about whether they felt antidepressants had reduced their depression, a number well above that suggested by efficacy studies [5, 26]. This suggests that the findings of this study might over-represent positive responses to antidepressants.”
I expect for David, as for me (another psychiatrist exceedingly cautious regarding medication excess and deeply interested in the state of the “evidence” and how drugs actually work) – the answer is something along the lines of being an old-fashioned doctor, more concerned with the patients i’m helping than with my wallet, and taking informed consent and ‘first do no harm’ seriously. David’s generally too busy to respond to post threads, but would consider himself scientifically and medically conservative- and the present state of the field anything but. Warm wishes, rob purssey http://www.mindfulpsychiatry.com.au
Mickey was the most inspiring doctor I have known, doing all he possibly could, very practically and tirelessly, to right our sorry state of medical data, especially psychiatric of course. With his passing we have lost a giant. A practical matter – must one be a US citizen to sign that petition? thanks for clarifying.
Re grey zone includes “antidepressants for adolescents”. Such a pity, this is clearly false and harmful. The exact article quote: “However, the majority of tests and treatments fall into a more ambiguous grey zone, 23 24 which includes: services that offer little benefit to most patients (eg, glucosamine for osteoarthritis of the knee); those for which the balance between benefits and harms varies substantially among patients (eg, opioids for chronic pain, antidepressant medications for adolescents)” The harms of AD for adolescents = double risk self harm and suicide, agitation, mood instability, sexual s/e, dependence, numbing preventing normal emotional learning CLEARLY outweigh whatever marginal benefit ADs have in this population. This might be said for older adults, but NOT for younger people.
I appreciate this phrase isn’t the MIA editors one, but it ought be commented upon perhaps. Thanks nevertheless for highlighting an important series of articles.
Rob Purssey – Psychiatrist and ACT therapist http://www.brisbaneactcentre.com.au
Dear Duncan
Please see also this excellent website http://missd.co . By the way, chatting with a psychiatrist colleague just now, who like me often sees this adverse effect with SSRI / SNRI’s, we think that we doctors are just narrowly taught to think “akathisia = dopaminergic S/E” hence calling it “nervousness and tremor”, or agitation, or whatever. Feeling very very uncomfortable and restless (without necessarily putting on a nice pacing “sign” for the doctor) is reasonably termed akathisia – and those who’ve taken the MANY drugs which can cause it WELL know it’s one of the key experiences leading to harming self or others. If the patient / client / person experiences it, they’re experiencing it, and for doctors, validating, caring, and minimising potential contributors are our key responsibilities.
Best wishes,
Rob
Dr Robert Purssey
MBBS FRANZCP
Psychiatrist and ACT Therapist
Director – Brisbane ACT Centre
7 Marie Street, Milton Q 4064
[email protected]
http://www.brisbaneactcentre.com.au
Very good, useful study. Re: “The HR (people at high risk) mental state has much in common with depression and anxiety; very few people transitioned to full psychosis over 2 years, in line with other recent evidence.” What would have occurred if these HR folks had been pre-emptively been given AP’s as has been the push for over a decade – few transition = AP’s work – in contrast, few transition because FEW TRANSITION. The next sentence of this study is great “This new understanding will help people at HR receive appropriate services focused on their current mental state.” i.e. help them with the problems they have, NOT what you think they might “get”.
Sorry Kermit, but this is a TERRIBLE article with many awful nonsense messages which “buy into” chemical imbalance myths in the worst way eg “Thereâs long been an association made between serotonin and depression. Itâs still unknown what comes first; low serotonin or depression. Does depression cause lower serotonin or does lower serotonin cause depression? Scientists arenât sure yet… According to Science Daily, low serotonin has also been linked to other important disorders like attention-deficit hyperactivity disorder (ADHD), bipolar disorder, schizophrenia and sleep disorders.” “A serotonin deficiency can cause us to seek out other ways to balance out the chemicals in our brain.”
All utter BS, and interspersed with terrible pseudoscientific guff – looks like a pharma DTCA job, except from a “lifestyle channel”. And the other “academic” article which states “For the last 4 decades, the question of how to manipulate the serotonergic system with drugs has been an important area of research in biological psychiatry, and this research has led to advances in the treatment of depression.” also complete nonsense – it’s advertising with pseudoscientific sheen.
Please consider highlighting how THE CHEMICAL IMBALANCE / WONKY SEROTONIN MYTH IS PERVASIVE. including in “lifestyle / natural health” circles.
Exercise because it’s good for you, connect with others because love matters, be kind on yourself – and DON’T buy into “my sadness / anxiety means i’m chemically faulty”.
With thanks for the great stuff you usually post, and kind caution regarding posting dodgy stuff!
Rob Purssey
How might Cipriani et al have reported this if also closely considering âSuicidality and aggression during antidepressant treatment: systematic review and meta-analyses based on clinical study reportsâ BMJ 2016 Sharma et al http://www.bmj.com/content/352/bmj.i65 , and âSuicidal risk from TADS study was higher than it first appearedâ HĂśgberg et al, 2015 â http://content.iospress.com/articles/international-journal-of-risk-and-safety-in-medicine/jrs0645 both appearing after their data cut-off point.
These clearly misreported data would, i suspect have tipped the balance clearly against SSRI/SNRI medications (overall simply very poor classes of chemicals the data consistently states) including fluoxetine.
Further, if adverse effects properly considered: eg âAdverse emotional and interpersonal effects reported by 1829 New Zealanders while taking antidepressantsâ http://www.psy-journal.com/article/S0165-1781(14)00083-3/abstract eg âSexual Difficulties (62%) and Feeling Emotionally Numb (60%). Percentages for other effects included: Feeling Not Like Myself â 52%, Reduction In Positive Feelings â 42%, Caring Less About Others â 39%, Suicidality â 39% and Withdrawal Effects â 55%â â weighed against minimal, if ANY short term gain â is this an intervention we ought seriously be considering?
Jureidini critically emphasises this is NOT in any way saying âdonât treatâ â simply donât treat ineffectively (i.e. with these medications), with unacceptable risks, and intolerable adverse effects short, medium and longer term. Please show us the solid, verifiable, openly accessible patient level data, not âexpert opinionâ, which shows otherwise.
“Dr Chung has disclosed that he serves on an advisory board for Pfizer.” – took 30secs to find this – http://pedsinreview.aappublications.org/content/36/7/299 – someone please add comment with this to WSJ thread, i cannot from Australia it seems.
Important article, useful New York Times commentary, but when the newspaper note this
Other experts cautioned that the study tracked behavior but not other abilities that medication can quickly improve, like attention and academic performance, and said that drugs remained the first-line treatment for those core issues.
âI think this is a very important study, and the take-home is that low-cost behavioral treatment is very effective,â said Mark Stein, a professor of psychiatry and pediatrics at the University of Washington, âbut the irony is that that option is seldom available to parents.â
They didn’t also note this about Mark Stein (which took me two minutes in web search) â Disclosure: Grant/Research Support: Cephalon, Eli Lilly & Company, McNeil Pediatrics, Novartis; Speakers’ Bureau: McNeil Pediatrics, Novartis, Shire Pharmaceuticals, Inc. http://www.medscape.org/viewarticle/571123
It is lazy, inadequate, and irresponsible of journalists to not directly note easily accessible disclosures regarding conflicts of interest. Seen all the time, and quite unacceptable nowadays.
a scientific alternative: “Problems in psychological functioning can be thought
of as narrow or rigid repertoires of behavior, linked to
inappropriate selection criteria, at the wrong level or
dimension, with insufficient retention of successful
variants that may occur given the current context.”
See “Modern psychotherapy as a multidimensional multilevel evolutionary process”
https://www.researchgate.net/publication/272396184_Modern_psychotherapy_as_a_multidimensional_multilevel_evolutionary_process
I’m a psychiatrist seeing new patients / clients daily in Australia. Over 90% believe the chemical imbalance myth, i reckon 95%. Similar if not higher for GPs. Sadly similar for psychiatrists. I think Philip’s view that “the chemical imbalance hoax is the most destructive and far-reaching hoax ever perpetrated against the human race.” is quite possibly correct. Although “global warming ain’t so” must be up there!
Warm wishes and thanks for your ongoing excellent work. The lamotrigine examination was very helpful. Cheers, rob purssey
“The Biomedical Model of Psychological Problems” – the problems, and a paradigm shift – see the October 2015 edition of the Behavior Therapist here http://www.abct.org/docs/PastIssue/38n7.pdf
Btw, Robert Whitaker invited speaker to ABCT conference, just held, see here http://www.abct.org/conv2015/?mn=14&fn=Invited_Speakers#speak_1
Cause for optimism!
Great article, and important topic. I dearly hope, as the situation is increasingly apparent from the information you’ve outlined, that the Am Psychol Assoc’n is moving toward dropping this terribly misguided guild interest push. Good on you for the hard work, James!
“Treatment Advocacy Center” was new to me in Australia, so i checked – “Educating policymakers and judges about the true nature of severe brain disorders, advanced treatments available for those illnesses, and the necessity of court-ordered treatment in some cases” Wow, what disinformation, E Fuller Torrey”s personal bandwagon, and Biopsychiatry zealots i see – makes the post from Dennis Embry, and this one, make more sense. For US folks suffering behavioral struggles – please advocate science, not non-science such as this – thanks for all efforts!
Similarly from J Aff Dis:
âDepression is who I amâ: Mental illness identity, stigma and wellbeing.
Highlights
⢠Identification with a group, even a stigmatized group, is protective for wellbeing.
⢠These relationships have not been tested in the context of mental illness identity.
⢠We surveyed 250 people with depression from 23 countries.
⢠Identifying as depressed predicted lower wellbeing.
⢠Identifying as depressed predicted conforming to the norms of depressed people.
Abstract
Background
Previous research has found that in the face of discrimination, people tend to identify more strongly with stigmatized groups. Social identification can, in turn, buffer wellbeing against the negative consequences of discrimination. However, this rejection identification model has never been tested in the context of mental illness identity.
Methods
A survey was conducted with 250 people with diagnosed depression or current symptoms of at least moderate clinical severity.
Results
Experiencing mental illness stigma was associated with poorer wellbeing. Furthermore, people who had experienced such stigma were more likely to identify as a depressed person. Social identification as depressed magnified, rather than buffered, the relationship between stigma and reduced wellbeing. This relationship was moderated by perceived social norms of the depressed group for engaging in depressive thoughts and behaviors.
Conclusions
These findings suggest that mental illness stigma is a double-edged sword: as well as the direct harms for wellbeing, by increasing identification with other mental illness sufferers, stigma might expose sufferers to harmful social influence processes.
Here are the relevant Medical Board of Australia carefully written “informed consent” guidelines. It would seem very worthwhile to present, point by point, American and other “informed consent” guidelines for physicians, and see to what degree mainstream psychiatric practice is regularly breaching these carefully outlined statutory guidelines regarding legal obligations to disclose information to patients. It seems to me that they are breached on many points in Australia.
Medical Board of Australia
GOOD MEDICAL PRACTICE: A CODE OF CONDUCT FOR DOCTORS IN AUSTRALIA – March 2014
3.5 Informed consent
Informed consent is a personâs voluntary decision about medical care that is made with knowledge and understanding of the benefits and risks involved. The information that doctors need to give to patients is detailed in guidelines issued by the National Health and Medical Research Council (NHMRC).8
THE GUIDELINES ISSUED BY THE NATIONAL HEALTH AND MEDICAL RESEARCH COUNCIL (NHMRC) STATE, ON PAGE 11: D GENERAL GUIDELINES ON INFORMATION – INFORMATION TO BE GIVEN
Doctors should normally discuss the following information with their patients:5
⢠the possible or likely nature of the illness or disease;
⢠the proposed approach to investigation, diagnosis and treatment:
â what the proposed approach entails
â the expected benefits
â common side effects and material risks of any intervention6
â whether the intervention is conventional or experimental
â who will undertake the intervention
⢠other options for investigation, diagnosis and treatment;
⢠the degree of uncertainty of any diagnosis arrived at;
⢠the degree of uncertainty about the therapeutic outcome;
⢠the likely consequences of not choosing the proposed diagnostic procedure
or treatment, or of not having any procedure or treatment at all;
⢠any significant long term physical, emotional, mental, social, sexual, or other
outcome which may be associated with a proposed intervention;
⢠the time involved; and
⢠the costs involved, including out of pocket costs.
1 INFORMING PATIENTS OF RISKS
Doctors should give information about the risks of any intervention, especially those that are likely to influence the patientâs decisions. Known risks should be disclosed when an adverse outcome is common even though the detriment is slight, or when an adverse outcome is severe even though its occurrence is rare. A doctorâs judgement about how to convey risks will be influenced by:
⢠the seriousness of the patientâs condition; for example, the manner of giving information might need to be modified if the patient were too ill or badly injured to digest a detailed explanation;
⢠the nature of the intervention; for example, whether it is complex or straightforward, or whether it is necessary or purely discretionary. Complex interventions require more information, as do interventions where the patient has no illness;7
⢠the likelihood of harm and the degree of possible harm more information is required the greater the risk of harm and the more serious it is likely to be the questions the patient asks; when giving information, doctors should encourage the patient to ask questions and should answer them as fully as possible. Such questions will help the doctor to find out what is important to the patient;
⢠the patientâs temperament, attitude and level of understanding; every patient is entitled to information, but these characteristics may provide guidance to the form it takes; and
⢠current accepted medical practice.8
2 PRESENTING INFORMATION
The way the doctor gives information should help a patient understand the illness, management options, and the reasons for any intervention. It may sometimes be helpful to convey information in more than one session. The doctor should:
⢠communicate information and opinions in a form the patient should be able to understand;
⢠allow the patient sufficient time to make a decision. The patient should be encouraged to reflect on opinions, ask more questions, consult with the family, a friend or advisor. The patient should be assisted in seeking other medical opinion where this is requested;
⢠repeat key information to help the patient understand and remember it;
⢠give written information or use diagrams, where appropriate, in addition to talking to the patient;
⢠pay careful attention to the patientâs responses to help identify what has or has not been understood; and
⢠use a competent interpreter when the patient is not fluent in English.9
3 WITHHOLDING INFORMATION
Information should be withheld in very limited circumstances only:
⢠if the doctor judges on reasonable grounds that the patientâs physical or mental health might be seriously harmed by the information;10 or
⢠if the patient expressly directs the doctor to make the decisions, and does not want the offered information. Even in this case, the doctor should give the patient basic information about the illness and the proposed intervention.11
4 EMERGENCIES
In an emergency, when immediate intervention is necessary to preserve life or Prevent serious harm, it may not be possible to provide information.
Sorry, typo, that was meant to say “ironic” â and not “I write” to see it coming out of HarvardâŚ.
This appears to be absolutely predictable. If we look medications functionally, rather than regarding “diagnosis” we would have picked it up earlier I expect. Of course psychiatry has given people at risk, or experiencing psychosis, stimulants in a way abrogating their informed consent and human rights has been made clear upon the site. So, to be expected.
I write to see it coming out of Harvard University/Maclean Hospital, the home of Dr Joseph Biederman, who has done more than any other professional to escalate the usage of stimulants in young people.
“And what has been the resulting social injury? It has led to the pathologizing of millions of children”… Just released, “The Australian Child and Adolescent Survey of Mental Health and Wellbeing” Almost one in seven (13.9%) 4-17 year-olds were assessed as having mental disorders in the previous 12 months. This is equivalent to 560,000 Australian children and adolescents. ADHD was the most common mental disorder in children and adolescents (7.4%), followed by anxiety disorders (6.9%), major depressive disorder (2.8%) and conduct disorder (2.1%). Based on these prevalence rates it is estimated that in the previous 12 months 298,000 Australian children and
adolescents aged 4-17 years would have had ADHD, 278,000 had anxiety disorders, 112,000 had major depressive disorder and 83,600 had conduct disorder. http://youngmindsmatter.org.au/ http://health.gov.au/internet/main/publishing.nsf/Content/9DA8CA21306FE6EDCA257E2700016945/$File/child2.pdf
Sadly our predominant model in Australia is also KOL psychiatrist led, with GPs doing most prescribing, including to kids, encouraged by KOLs. And as in the USA, “our healthcare system is structured deincentivizes prescribing providers from taking a more contextual approach. If you talk to clinicians on the ground, that is what they want to do, but they are incentivized to prescribe.”
I was surprised and informed to read this: Big pharma gets a lot of the heat that should be placed on âBig journalâ: http://www.washingtonpost.com/news/morning-mix/wp/2015/03/27/fabricated-peer-reviews-prompt-scientific-journal-to-retract-43-papers-systematic-scheme-may-affect-other-journals/
and even more so about journals’ profits: http://svpow.com/2012/01/13/the-obscene-profits-of-commercial-scholarly-publishers/ – as i commented in the blog post where these came up: â that is important and VERY relevant information, and I had absolutely NO idea!!! I doubt many others do, but it puts the purposes of the NEJM and CMA editorials into clear perspective for me. That gravy train needs to keep rolling along, and the experimercials are the coal feeding the furnace. (to mangle metaphors!)
here’s the blog post: http://1boringoldman.com/index.php/2015/07/20/a-snails-pace/#comments
Dear Norman and Tabitha,
There is a science of intentional behavioural change, at individual, family, community and societal level which has been incrementally developed over the last 40=-50 years, and which is wonderfully encapsulated in a simply superb new book “The Nuture Effect” – see http://www.nurtureeffect.com/
We have the tools to help our families and schools to be more nurturing. Rather than addressing each psychological, behavioral, or health problem as though it is unrelated to every other problem, we need to get all of the organizations working on human wellbeing to band together to help make all of our families and schools more nurturing.
No matter the context or the problem at hand, following these universal principles of a nurturing environment creates the best chances at success. Nurturing environments do four things:
Minimize toxic social and biological conditions.
Teach, promote, and richly reinforce prosocial behavior.
Limit influences and opportunities for problem behavior.
Promote psychological flexibility, which is a mindful approach to pursuing oneâs values even in the face of emotional, cognitive, and real-world challenges.
I am not saying the problem is that you’re outlining do not exist, they most certainly do, and Robert’s excellent book, and your book “Her Lost Year” I hope many people disentangle from psychopharmacological pseudoscience, and engage in much more helpful behaviours toward rich and meaningful lives.
And Tony Biglan’s review of the science of positive intentional behaviour change at all levels over the last 40 years will I hope be of great interest to both of you.
Warm wishes, Rob Purssey
http://www.brisbaneactcentre.com.au
Dear Rob
From a practising psychiatrist, THANK YOU from the bottom of my heart for scanning the literature and highlighting key / relevant studies regarding what should be every prescribers’ FIRST duty – to be very aware of the potential/actual harms of the poisons we have the responsibility of prescribing, which are sometimes useful and called “medications”.
With deep gratitude, rob purssey
Hi Sandra
I’m also going to butt in. I have some clients/patients with “old fashioned manic depression” (not DSM bipolar) who are on NO regular medications, and use ACT psychological flexibility strategies daily (mindfulness skills, orientation to valued actions, acceptance skills, exercise, sleep diet etc) AND occasionally with stress / seasons have manic episodes. We step back stressors IF possible, increase health strategies, AND use short term LOW dose diazepam/temazepam and chlorpromazine (more flexible, lower dose than quetiapine also less appetite/weight issues but functionally very similar) short term – and they’ve settled and OFF medication in about a month, max 6 weeks. Nothing ongoing. One developed hepatotoxicity on chlorpromazine so (to his great dismay) across to short term quetiapine. Will be only a few weeks max then off. All carefully negotiated. All with email support. With ongoing focus minimal meds, maximal health strategies, minimal labelling and issues that all brings. Hope helpful, Rob Purssey
Last listed, but corresponding and apparently senior author: “Correspondence: Professor E Eriksson, Department of Pharmacology, Sahlgrenska Academy, University of Gothenburg, POB 432, Gothenburg SE 405 30, Sweden. E-mail: [email protected]” AND, guess what? “Conflict of interest… Elias Eriksson has been on advisory boards and/or received speaker’s honoraria from Eli Lilly and H Lundbeck.”
Dear Sandra,
Before taper, learning evidence-based psychological flexibility skills to better handle the broader range of emotions and possible difficult thoughts and other experiences which may arise as major tranquilizers are decreased, they also be extremely helpful in assisting patients to wean. Please see the following articles which increasingly demonstrate efficacy of ACT in this process.
http://www.actmindfully.com.au/upimages/bach%26hayes-_act_schizophrenia.pdf
http://actskills.com/wp-content/uploads/Long-Term-Effects-of-Brief-Acceptance-and-Commitment-Therapy-for-Psychosis.pdf â A LONG-TERM FOLLOW-UP OF THE INITIAL STUDY
http://www.scattergoodfoundation.org/sites/default/files/innovation-submissions/Gaudiano-BRAT.pdf
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3673289/ – A MEDIATION STUDY
http://www.tandfonline.com/doi/abs/10.1080/17522439.2012.671349 – A MORE SOPHISTICATED MEDIATION STUDY
http://www.amazon.co.uk/Acceptance-Commitment-Therapy-Mindfulness-Psychosis/dp/1119950791/ref=sr_1_1?s=books&ie=UTF8&qid=1432638636&sr=1-1&keywords=Acceptance+and+Mindfulness+psychosis – A BOOK LENGTH REVIEW OF THIS AREA
http://www.amazon.co.uk/Incorporating-Acceptance-Mindfulness-Treatment-Psychosis/dp/0199997217/ref=sr_1_1?s=books&ie=UTF8&qid=1432638624&sr=1-1&keywords=Incorporating+Acceptance+and+Mindfulness+Into+the – ANOTHER BOOK LENGTH REVIEW OF THIS AREA
Please email me if requiring full PDF of any of the above,
Warm wishes, Rob Purssey
I discussed this with a concerned journalist colleague, who recommended that I and other psychiatrists who have some expertise in this area nominate ourselves upon the Science Media Centres in our respective countries so as to provide a more measured, scientifically grounded, perspective upon stories such as these.
There is a Science Media Centre of the United States, website here http://www.sciencemediacenter.org/usa/ , which has links to the Science Media Centres of Australia, Canada, New Zealand, Japan and United Kingdom.
If you are a psychiatrist or pharmacologist reading this list post please consider nominating yourself as an expert to the Science Media Centre in your relevant country so as to provide a more grounded, measured, scientifically focused perspective upon stories such as these. Otherwise those academics strongly influenced by industry will continue to shape the public debate.
I discussed this with a concerned journalist colleague, who recommended that I and other psychiatrists who have some expertise in this area nominate ourselves upon the Science Media Centres in our respective countries so as to provide a more measured, scientifically grounded, perspective upon stories such as these.
There is a Science Media Centre of the United States, website here http://www.sciencemediacenter.org/usa/ , which has links to the Science Media Centres of Australia, Canada, New Zealand, Japan and United Kingdom.
If you are a psychiatrist or pharmacologist reading this list post please consider nominating yourself as an expert to the Science Media Centre in your relevant country so as to provide a more grounded, measured, scientifically focused perspective upon stories such as these.
This paper “Linking Molecules to Mood: New Insight Into the Biology of Depression” best summarises the evidence of NO chemical imbalance. Written by lead NIMH “academic neuroscientist psychiatists” Vaishnav Krishnan and Eric J. Nestler
Full access here http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3031089/ and
The key paragraph is here: “Since monoamine enhancers improve depressive symptoms, it was suggested historically that depression is caused by deficits in monoaminergic transmission (âmonoamine hypothesisâ), which continues to be a prominent preoccupation of the field. However, after more than a decade of PET studies (positioned aptly to quantitatively measure receptor and transporter numbers and occupancy) (31), monoamine depletion studies (which transiently and experimentally reduce brain monoamine levels) (32) as well as genetic association analyses examining polymorphisms in monoaminergic genes (27, 33, 34), there is little (FOR WHICH READ “NO”) evidence to implicate true deficits in serotonergic, noradrenergic, or dopaminergic neurotransmission in the pathophysiology of depression.”
The material preceding and following this is largely biobabble, and it might seem curious that with the massive lack of progress from SO much research it’s still being pushed – the key to why is in this final sentence: “We should look well beyond monoamines, cortisol, BDNF and the hippocampus to determine tomorrowâs novel medical and surgical therapeutic avenues for depression.” – i.e. thinking that “psychiatry’s” sole purpose is in finding “novel medical and surgical therapeutic avenues” – good medicine involves contextual, environmental, relationship, ALL modalities of easing suffering, but alas, not for the NIMH.
Reading this: “Dr. John H. Krystal, chairman of psychiatry at Yale and a pioneer in the study of ketamine for depression” – so Googled his name plus “…patent ketamine” and … guess what? http://patents.justia.com/inventor/john-h-krystal Note he also is editor of Biological Psychiatry where the experimercial is published http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3671489/ – enough said, it’s a marketing push, is the reason for it all. The names on the patents very revealing.
Btw re Depression, this is invaluable: The Depths: The Evolutionary Origins of the Depression Epidemic – http://www.amazon.com/The-Depths-Evolutionary-Depression-Epidemic/dp/0465022219
best wishes to all, rob purssey
Sadly, this article looked like nothing more than an advert for agomelatine, and a quick glance confirms this: “The authors declare that over the past 3âyears, Brian Harvey has participated in speakers/advisory boards and received honoraria from Servier” – who sell agomelatine. Such profound insights as “We propose that either hyperserotonergia or hyposerotonergia may underlie the syndrome.” Okay, it’s either too much, or too little 5HT… wow! “What this review has attempted to consolidate is that ADS may be exclusively a problem of acute 5-HT release evoked by antidepressants such as SRIs, SNRIs, TCAs and some atypical compounds leading to changes in 5-HT homeostasis. By using agomelatine as a counterpoint to this argument, it is now evident that an effective antidepressant need not engender a risk for ADS.” i.e. BUY OUR STUFF INSTEAD! and “The unique pharmacodynamic and pharmacokinetic profile of agomelatine may hold the key …” so PAY ME FOR MORE “RESEARCH” ON IT… only actually it’s a dud – see http://1boringoldman.com/index.php/2013/09/04/a-breath-of-fresh-air-3/ IN SHORT – don’t bother reading this neurobabble pretending to seriously examine a VERY serious issue, but in fact simply pushing “chemical imbalance” aetiologies and selling a non-SSRI competitor.
Great article, and your NZMJ likewise. I hope this Trojan horse can be stopped. Pharma and more will be doing a GREAT deal behind the scenes to make it happen, so all public resistance is critical.
From the Patient Health Questionnaire-9 study: Kroenke K, Spitzer RL. The PHQ-9: a new depression diagnostic and severity measure. Psychiatr Ann 2002;32:509â21 comes this disclosure re the lead author: “Dr. Kroenkeâs research is supported by Pfizer Inc. and Eli Lilly. He is also
a member of Eli Lillyâs advisory board.” Enough said. Herding patients to the pharmacy.
Dear Mark
you will love this recent book:
http://au.wiley.com/WileyCDA/WileyTitle/productCd-1119950791.html
http://www.amazon.com/Acceptance-Commitment-Therapy-Mindfulness-Psychosis/dp/1119950791
warm wishes, rob purssey
Dear Joanna
Great post – I am ardently hoping you’re working on this for a journal article. Warm wishes, and power to your pen. Rob Purssey
“…from our international friends, is off-label prescribing legal in your countries?”
In Australia, the sad answer is DEFINITELY YES (in fact most psychotropic prescribing is “off label”) And Pharma Reps do NOT have the legal limitations on pushing these as in the US. KOL’s are recruited to “push the envelope” as there. In Australia the Gov’t reimbursement scheme (Authority) specifies “diagnoses” AND doctors routinely defraud this in “prescribing off label” while noting certain non-existent diagnoses. AND rubberiness of DSM (even more as we’re seeing in DSM V) allows pretty much everyone to fit most remunerative (pharma wise) diagnoses anyway. Never challenged legally. I’ve not seen a single case for falsely using Authority diagnoses. Sorry, long way of saying yes. I expect this is true for all Anglo countries.
“Depression is a disorder of the brain” “Bipolar disorder … usually lasts a lifetime” “Researchers think brain circuits may not work properly in people who have OCD” “Schizophrenia is a severe, lifelong brain disorder” – not the greatest site, IMHO.
Best to all on this site, rob purssey
Superb post, thank you so much for the hard and careful work. Will disseminate as widely as possible. Hats off to Adam Urato!
These are not really “older adults” but all over 40. In press about this study, Jeste is “damage controlling” – stating in dementia and off label we ought worry â but this is âaged > 40 years, having psychosis associated with schizophrenia, mood disordersâ â i.e. the majority of the market. Keep that quiet. The real implication ought be shouted from the rooftops, all blogs etc. Best wishes to all on this forum, Rob Purssey
While the study may seem related to personal experiences, it’s worth noting that a) it’s in a “rat neurodevelopmental model of schizophrenia” – i.e. animal models which in this area so far haven’t proven helpful, as “schizophrenia” (like depression) is a thoroughly verbal (images, words etc) problem, and rats don’t display verbal behavior. Also that b) it’s an Eli Lilly study, essentially, so for the purpose of developing pharmacotherapy at heart, and c) it’s full of “maybe’s” eg “potentially as a consequence of …” and “may be associated with …”
I daresay that personal accounts of sleep problems and psychotic / psychosis like experiences, and how individuals handle these more effectively, may be more fruitful for helping those suffering such interactions.
Best wishes, rob purssey
See “A Beautiful Mind” for a film representation of this functionally workable psychological move. As Steven Hayes recently posted in ACT for the Public email listserve:
A lot of folks think voices are so unusual they work differently but
a) they are not that unusual, and
b) they seem to work the same as other experiences (e.g., panic; depressive thoughts).
Back up, notice them, don’t take them literally (neither comply nor argue back/fight),
learn what experience shows is useful to learn from them (e.g., notice when they occur etc),
shift attention to what you care most about, link behavior to values
– Steven C. Hayes, Foundation Professor, Department of Psychology, University of Nevada
Best to all, rob purssey
Pity they don’t recommend Acceptance and Commitment Therapy for Psychosis, which has an increasing evidence base – see http://www.div12.org/acceptance-and-commitment-therapy-for-psychosis/ also http://contextualpsychology.org/search/node/psychosis