Thrilled you made it through. Salt imbalance? Thats a good one. Terrific for putting your name to this. Just down the road from you, my lad hit the skids a couple of years back and was out of school, drugged to the gills for a chemical imbalance before saying there must be a better way. Thankfully there was. If I have one wish it is that no family member of mine falls under a psychiatrist. If I get dementia , just humour me and talk to me but don’t give me whopping antihistamines, which is all seroquel is. All the best to you!
Thrilled you made it through. Salt imbalance? Thats a good one. Terrific for putting your name to this.
Just down the road from you, my lad hit the skids a couple of years back and was out of school, drugged to the gills for a chemical imbalance before saying there must be a better way. Thankfully there was.
If I have one wish it is that no family member of mine falls under a psychiatrist. If I get dementia , just humour me and talk to me but don’t give me whopping antihistamines, which is all seroquel is.
All the best to you!
Of course its possible to have an RCT in FEP, McGorry just did it with small group in Australia. The result was a failure ” group differences were small and clinically trivial”.
Thanks so much, Peter. You were right all long and thankfully my lad got off meds and out of the system when it so very nearly locked him up. We got my son back, 100%.
Great article, so thoughtful and riveting. Shows how family make the difference when things hit the crunch, so pleased you made the decision you did. These drugs are so insidious in their action. They will take time to disappear because Drs will think they are handy to get over a hump but will never have the guts or alternative support to take you off them.
Thanks so much for forensically shining a spotlight on this Robert. My son took himself off antipsychotics (over 8 months) when he realised they weren’t doing anything beneficial. I’m seeing kids strongarmed onto these who aren’t even psychotic and they are just meekly accepting this is their fate, assuming the drugs have been trialled on kids like them. As we all know now, thanks to you, they haven’t. Thank you.
Fascinating. I hope things are heading in the right direction now, you must have felt so alone .
We eventually realised that everything you say to a psychiatrist can be misinterpreted. So you concentrate on what you are trying to achieve and don’t lose sight of the main ball. In our case this was getting out and away from the acute service, and doing more of the things we could see were starting to work.
Great article, great review. Just look at placebo response rate in the efficacy trials. So high the efficacy is negligible. Except fluoxetine, by a mile. What was different with the fluoxetine trial.placebo or the way this placebo arm was managed?
I’m so so pleased for you! We were given the broken brain lecture over my 17 year old son, and went through a ghastly experience like yours. I can’t definitively blame the drugs. My son says they did nothing, I noticed the dark side exacerbated at dose increases. He’s basically recovered now,and like you I feel anger and shock that people who are supposed to help made it worse, as if that were possible. Well played to your lad.
I like the article and agree with a lot of the logic. I have to confess I am sometimes accused by activists here (oldhead!) of being a bit contaminated by middle groundism, so I’ve asked myself why this is and I can think of quite a few reasons:
1. In order to retain the audience whose opinion you want to influence, you need to be reasonable and hold open the possibility that their point of view has some validity, even as you believe it will be dismantled.
2. Its actually easier to prove a middle grounder incorrect. Frances gets stuck on the idea that meds work for some not for others, which researchers from both sides of the argument can disprove. I think some smart bio Psychiatrists see this danger and dig in, because once on middle ground their position is weaker.
3. My personal feeling is that Psychiatry will not collapse but will bend. I am hopeful that in the next 10 years it might move 50% towards an acceptable evidence based position and this is a better result than entrenchment. So middle grounding can be, I’m sad to say, a tactic towards trying to reduce the damage in the here and now rather than pushing the abolition case.
4. I also have to entertain the idea that the flat Earthers might be right about one or two things until I’m sure. There are lives in the balance.
Where you cannot middle ground is on the basic evidence, which is drugs appear to work very slightly in trials, but this plainly so slightly that they are probably simply damage creating.
My problem with middle grounding is that you can forget that you are in the end trying to seek the truth, not a political compromise. So I accept that when I’m putting a case to those in the profession I am mincing words. But I have someone listening.
I feel a right old machiavelli now!
The idea that psychiatrists can decide what is and isn’t scientific – lol.
Totally agree with Rosalee. It must be hard to make sense of it all, but it’s a joy your writing is so coherent, logical and interesting. Everyone including doctors have been subjected to a huge con and it’s hard to come to terms with scale of the disaster. You made it!
And this was pretty obvious during 15 minutes googling I did a year ago.
I put it to the psychiatric doctor that a 2 week taper, which would go from 80% occupancy to zero in one fell swoop, was way too fast. I begrudgingly achieved 3 weeks. Why the rush? Well maybe this “we would like to meet the minute you come off because that is when most people realise that they need to go back on antidepressants”.
Anyway within days they were panicking, doing blood tests, because of unexplained flu symptoms.
This was in the UK – I can honestly say that everything they did, from providing information, obtaining consent, drug choice, dosage and taper was way outside EXISTING pediatric NICE guidelines which require written information and consent, and, on tapering, say “Where antidepressant medication is to be discontinued, the drug should be phased out over a period of 6 to 12 weeks with the exact dose being titrated against the level of discontinuation/withdrawal symptoms. ”
Psychiatrists cannot currently be trusted to prescribe or taper antidepressants to minors in accordance with CURRENT guidelines.
Ghastly and I can totally see how this happens. Whats happening is that butt-covering and psychiatric ideology is trumping your own interests.
In the UK I’ve found that using a private psychologist, although it costs £65 an hour, puts you in charge. Technically they could still break your confidentiality in dire circumstances, but not as badly as an NHS clinical psychologist, who is basically getting intel for the psychiatrist.
I can totally see how this all snowballs out of control and you end up doped up and unable to get back to school. I know because it happened to us. We were told antipsychotics would “get you back into life” (lol) and they would work on helping get back to school. They did no such thing. Instead, when the drugs make you even worse, the psychologist tips off the psychiatrists who threatens sectioning and wants to do higher dose meds. And so a problem in your life becomes life in a coma.
Its so hard because basically its best to keep out of the MH system, but in the early days you don’t know enough and if someone told you how bad the system is, then you wouldn’t believe them.
It sounds like you are back on track again and well done you for that.
I personally think these problems need compassion and commitment from those around you to be there 24/7, not judge, not impinge on your agency, and listen, listen, listen. Then you have to try and do stuff, whatever it is you normally do, maybe supported by someone alongside you. I know thats a bit idealistic but basically the more social hand-holding the better.
Loads of people come through this great, I think thats where we might be heading, but many others fall victims to the system or end up tragically. Crossing everything for you!
If you want to see how the FDA approval process is broken, read this RXrisk article and the accompanying material from FDA reviewers. Be warned, you may feel somewhat out-of-body as you read it, just like the participants in the trials. It will defy all your beliefs:
1. Participants are treatment resistant. Nothing worked – next stop ECT. But they get 16 points out 60 better on the placebo! Some treatment resistance!
2. So the drug, which >50% dissociate on and many others get dizzy, thereby probably unblinding the study, gets 20 points improvement. So, just as Kirsch found ~80% of the antidepressant effect is placebo.
3. They havent got a second proper study, at least 2 other trials simply failed to show anything. Fantastic.
4. So they used a “relapse” study, which showed twice the relapse rate on the placebo. Of course, this would be unblinded. because as soon as you find you aren’t going loopy, you know you have been taken off the drug and the beneficial effect, which was 80% placebo, vanishes. So the placebos relapse straight away and the drug users some months later.
5. But how about this? Over half the placebo group DON’T relapse at all in 18 months or so ! Has 4 weeks of snorting the drug rewired their brain? Have these treatment resistant people for whom nothing worked suddenly got better? Who knows!
6. And finally, this: “There were six deaths in the esketamine for treatment-resistant depression development program as of January 8, 2019, all in esketamine-treated subjects.”
But we have a new drug, in fact a new family of drugs.
Sorry to bore anyone who’s heard my story before, but we got the full BS package from the psychiatrist. Splitting us from our child, telling us “its most important to realize its not teenage angst, its a serious biological blah blah”. Telling the child that antipsychotics will make you feel better, cure your anxiety, get you back into school (no chance). Telling us that antidepressants were out of the question because of suicidality, then telling the child they will lift mood and then prescribing at maximum dose as they didn’t work. Without even knowing the license let alone providing any information.
It stopped when the child said “let’s bring my parents in on this antidepressant decision”, and we said no to the dose increase. Several meetings asking if we had changed our minds. In desperation the psychiatrist tried to split us off again asking for a “private word” in order to continue to hector us about our disregard for our childs serious illness. The child refused.
A second psychiatrist made a unconvincing bid for another off-label antidepressant, a real sedater heavily linked with suicide, we said where’s the evidence.
Eventually many months later came the long process of coming down off meds.
Now back in school and thriving. Wasted 6 months and incurred a few extra scars but survived child psychiatry. I cannot believe this quackery is sanctioned by the state.
You can only prescribe if either there is a clinical benefit in the functioning of the person that outweighs harm.
I think that rules out antidepressants.
For antipsychotics, you have to consider whether sedation and listlessness is a pro or a con.
For either, you must have a clear plan, competence, experience and commitment for tapering off.
You can’t really justify either on the basis of averting suicide, the data just isn’t there except, rather oddly, for clozapine.
You must communicate all potential harms.
Thanks Sam and Alex! I think we are on a similar page? I must admit I don’t look at this at high a spiritual level, I just felt at the time that I had to, then and there, decide in my mind, what the truth was for the incredible difficulties. The bio-broken brain model doesn’t fit the facts on the most logical of levels. A psychological pain, an existential crisies, a psychological injury can account for the troubles. And whatever it is, the route to recovery is psychological and social – we all agree meds are at best just a suppressant. So, I haven’t got time to put this properly, but ask you yourself if are committed, you love and believe – and then communicate that and be there all the time. Sorry that sounds soppy.
“With regard to waist circumference, aripiprazole augmentation and topiramate demonstrated the best impact”
Oh great let’s all have some.
And for those whose dopamine system is already whacked and edging towards parkinsonism, let’s whack it some more because it’s good for the waistline?
Alternatively, just come down off the antipsychotics? Only 1 in 6 benefit anyway.
I get the problem with “psychological injury”. I just needed something to explain how we the family regarded “it” in the face of debilitating, inaccurate and insidious labelling from psychiatry.
Our firmly held belief was “you are not broken, there is nothing wrong with your brain, we all of us believe utterly in you even though what you are going through is seriously crap, and we are begging you to hang on as we throw the kitchen sink in to help you”.
All the bio-crap is defeatist nonsense to make you take the meds.
So I remember thinking “ok it’s bad, but it’s like an injury you can get over, but because there’s nothing wrong with your brain or you as a person, in fact it’s a fantastic and beautiful brain and you are widely loved in the family, it must be psychological or something that is core to life itself, not some neurotransmitter problem”.
But other ways of talking about might work also so I’m interested in what people think.
I get the point about inventing catchy names to describe things that charlatans will jump on.
All I can say is that as we went through the corrupt MH system with all manner of biobabble thrown at us, I came to the idea that “psychological injury” was the best way I could explain to myself what was happening, and that did successfully guide us. probably not the only way I could have looked at it.
To be honest, Cipriani did actually, like he said, “put to bed” the controversy over antidepressants, though not as he would like. They are useless. The effect size of 0.30 was the same as Irving Kirsch’s controversial earlier meta-analysis which most people, including NICE, suggested AD’s weren’t worth it. The Number Needed To Treat was typically around 15 for the average drug.
But its worse. The average effect size was skewed by certain high side effect and second line sedating AD’s that you really wouldn’t want to take, including one, amitryptaline, that the BNF says do not go near, its so toxic. The two most populat antidepressants in the UK, fluoxetine and citalopram , had effect sizes of 0.23-0.24. Hopeless. You can see how bad that is by going here:
And yet still most psychiatrists defend them. Professor David Taylor, lead author of the Maudsley Guidelines, said “much more effective that placebo”. I’m putting that down to a colossal gaff, but still I would steer clear of those guidelines with that level of delusion.
These guys will not stop untl we the people say “No, thats cobblers”. If you do, expect a fight as all manner of BS gets launched at you – but they will rarely provide evidence. If like us, you are cited STAR*D, you can easily debunk it by checking this website which has a balanced analysis.
With 1 in 6 in England on these drugs and the withdrawal problem, still controversial, being openly discussed, there is an almighty mess on their hands since you have to be really careful coming off these things and psychiatrists think you can do it much too quickly.
Lack of efficacy, lack of information, adequate consent, lack of data on long term use and withdrawal, and lack of contrition – its a shambles.
Wonderful analogy Mark, you learn something everyday! I might have to try it on a psychiatrist!
I think what is called for now is choice and rights. I really don’t see the need for any coercive treatment, unless maybe as some emergency sedative, but I’m not even sure about that.
I would also like to be able to state in advance that, whatever happens to me, I do not want to be treated by a psychiatrist, ever.
I think by “organic” they mean basically a faulty brain as opposed to a depressed or a traumatized one. In the UK I was told the “this is not extreme version of normal, it’s ORGANIC, a biochemical babble babble”. They think people who hear a voice are fruit loops and they are simply wrong.
Spot on Steve. I recall being stuck in this conversation about “its most important to realise that this is not an extreme form of normal experience, its different, its a serious illness that sadly blah blah” – all I wanted to do was talk about how we actually do things to get better!
It turned out that, step by incremental step, doing things was the correct approach, and if I could say one thing to that terrified carer in that meeting, I’d say “its all bollocks!”
With great respect to Igor, I don’t think the evidence for gray matter changes in so-called schizofrenia is really there. There are loads of studies with the express of objective of trying to prove this, and some look interesting, but they are often small and I do question how anyone gets a diagnosis of schizofrenia without being given antipsychotics, which is what you need to prove the point.
One thing is clear – antipsychotics reduce gray matter (the monkey study) and that is basically prescribed brain damage.
But I ask myself, what does it matter?
1. The brain changes according to the stresses it is under, so its quite likely that any changes would be like the dopamine theory – a reaction rather than causal. And may be transient.
2. What are you going to do about it anyway? Learn to live with what you have got – thats what. And preferably not shrink it any more!
So whats the point of looking for brain shrinkage? To reinforce the notion that psychosis is not a symptom of a psychological problem, but of a deeper disease, thats why. Psychiatrists would love to be able to prove that the cause has a physical manifestation in the brain because then they can experiment with more chemical cures and keep the psychologists at bay.
Just to clear, oldhead , and I’m sure you will be. You think that studying the long term changes of people already in ect programmes against sham ECT is pointless. That’s a simple yes or no.
Secondly, you think that any study comparing ect and placebo is pointless on theoretical reasons because of what Frank said about placebos not proving anything, although I couldn’t quite grasp his reasoning. Maybe it was about the invalidity of short term apparent results , which I would agree with.
Therefore, is it your contention that the case against ect is based on damage (evidenced) and lack of mechanism of action ( evidenced). Because as much as I want your side of the argument to prevail, I’m not sure that that alone will do it.
The use of antipsychotics in under 18’s is still growing at a rate of a few percent a year. It is clearly the treatment of choice if the patient reports voice hearing.
One of the problems is that misinformation really thrives in under 18 services. They will talk to parents and children separately and there is a big question about who gives consent. In law it is clear, but in practise the minor will be spun a line by the psychiatrist, and if parents ask questions it can be suggested that they are troublemakers and perhaps even to blame for whats happened. Its a ghastly conundrum and the psychiatrist gets his way, initially by claiming a softly-softly approach based on child guidelines and then saying that we really need to look at adult guidelines and max out doses. Does supporting your child mean preventing them from accessing the drug the nice psychiatrist has assured them will “get them back into life”? It’s quite simply horrible and neither child nor parent is sufficiently aware of the evidence when this is thrust upon them.
In the UK, Steve, I hope, perhaps forlornly, that the NICE guidelines put the brakes on antipsychotics in a similar way as they try to put the brakes on antidepressants. Just to buy time so the family can do research and come to terms. But when the patient decision-making is so ambiguous its always going to present opportunities for over-enthusiastic prescribing. I’m pretty sad about it and it takes real balls to push back against the system that I’m not sure I’ve always had.
I’ve read a fair bit about these studies and it’s clear as mud and like all observational studies you make up your mind on something of a hunch. I have concluded that withdrawal hugely affects long term users because the risk of so called relapse goes up and up.
Unless you know the functioning of the group it’s difficult to figure out. I think there is an effect whereby you can be doped up but with less voice hearing and mediocre life quality, versus high functioning but perhaps subject to occasional wobble and certainly likely to wobble when withdrawing.
So, we don’t know for sure but some of us wonder why persistently clobbering your brain with antihistamines was ever a good idea, and if you hadn’t had that mistaken idea that controlling dopamine was the answer, would these drugs even exist.
And let us not forget that, amidst claims in the Hong Kong study that quetiapine halves your relapse risk, joanna Moncrieff has herself highlighted that this drug doesn’t really do what it’s supposed to anyway (because of low effect size). It’s so strange how drugs of questionable efficacy at all, all of a sudden become “relapse preventers”.
To me , the treatment model should be, get you through the crisis – somehow, maybe with drugs- and then ramp up the psychology and psycho social as fast as money can buy, so that you can keep yourself out of trouble , move forward and thrive.
I would say that SSRI’s are NOT antihistamines, because they mostly don’t hit the H receptors. Its the H1 receptor in particular which is associated with allergies. So Fluoxetine, Sertraline, Venlafaxine, Duloxetine and Citalopram I would say are NOT, although I read somewhere that Citalopram might be a mild antihistamine. Mirtazapine on the other hand is rather like the “antipsychotic” quetiapine, and along with olanzapine, these are amongst strongest antihistamines ever developed.
Thanks Auntie, its worth a listen to some this – in a way. An hour of explaining “I haven’t got a clue”!
Which is fine, but no need to subject your audience to such ramblings! The most ludicrous comment from the short section I watched was “Quetiapine is a victim of its own success because its benefits are diffused in a larger group”. Gobbledegook. Its a sedating antihistamine – everything else is blind faith.
He said of Cipriani “antidepressants do work and, for most people, the side-effects are worth it.” You could only say this, if, say 5 out of 10 received meaningfull benefit – as we all know they actually only make a difference compared for placebo for 1 in 10.
And what is the point of that eerie joke about ECT? Beats me!
Frank, you do sham ECT, or just the anaesthetic. What the old sham ECT studies seem to show is a possible short lived improvement but nothing sustainable beyond a few days or weeks. Hence the idea of maintenance ECT. I’m not sure if there exists a maintenance ECT versus maintenance sham ECT trial. So it looks once again like a long term treatment has been derived from a short term one with no evidence whatsoever. So, no successful placebo trial, therefore should not be approved.
With the drugs, Rachel, I’m sure you realise that the approval has been obtained by getting 2 very slightly successful studies out of many failed ones and scraping through the approval process with minimal efficacy. And as time goes on this efficacy appears to get smaller, so Cipriani found citalopram and Fluoxetine had really tiny effect sizes. What then happens is weird – a bunch of professors from London colleges go round saying they “work” whatever that means, and people believe them. So no meaningful clinical efficacy, should not be approved.
So you agree – it is very difficult to carry out a proper placebo study, and therefore ECT should not be approved for use at all. ECT is therefore unjustified and unjustifiable.
Baseline studies are not acceptable, so it should be withdrawn.
I think there has never been a placebo/sham study with proper follow up, certainly not for over 30 years.
With regard to the perfectly good point about running tests about hitting people on the head, I think you have to remember drugs can be just as bad, so you couldn’t do trials on a psychiatric drug either by that logic. To be honest, I agree. I think that if you haven’t got a credible mechanism for any treatment that can cause damage, you cannot ethically do a trial.
I think it needs to disproved evidentially, because it was only criticism of existing studies, leading to a proper blinded trial that did for Insulin Coma Therapy.
What do you mean, oldhead?
I was quite taken by what you said Sam. I agree, you have to see the mindset of the sufferer and not judge it. I think it can be an existential crisis, you know , what are we here for, and, frankly, there are no glib answers because life is a bit pointless. Just hang around, engage with people, things and places, and see if that gives you the reason to go forward and discover fun. Psychosis is a symptom, a living dream, it’s not crazy, but a manifestation of distress or just vivid imagining. The psychiatrist’s view of this is skin deep and reductionist -trying to boil it down to a single chemical, what cobblers. The first step is that the person is not mad, and that you love and believe in them.
ECT cannot be taken seriously until there is something approaching a placebo controlled trial with an adequate length of follow up.
Justifications that avoid this like “what I have observed” and “have to do something” are not valid.
Why no proper trial?
It seems like managed retreat to me. When its obvious to all that we’ve been sold a pup, they start to talking about “possible problems with a subset of patients”, or emerging treatment resistance or rebound that jolly gosh they had never thought of.
This is their cerebral way of describing how you have just realised the treatment was useless to begin with:
“There is a narrow gap between antidepressants and placebo in acute treatment trials, implying that many people who improve while taking antidepressants are placebo responders. In these people, perceived loss of eﬃcacy may be a loss of the placebo eﬀect.”
AD prescribing in under 18s is going full steam ahead in the NHS, with a strong preference for going off label at substantial doses and quick switches when it doesn’t work.
If you ask what the rationale is, the answer comes back that they are safe in kids and star*d justifies switching. Really?
I’m sorry if you find me so annoying oldhead, I really am!
I am quite new to this area, for most of life I didn’t know what on earth mental “illness” was and whether psychiatry even still existed. Well I am in at the deep end now – I’m aghast and up in arms at the biggest medical scam the world has ever seen, and feel nothing but compassion and sorrow for those that over decades have been so damaged, so cynically.
As you have detected, I am for reform, not abolition. If we were starting again, maybe you wouldn’t have psychiatry at all. But I don’t have many decades left and we aren’t going to get rid of psychiatry quickly. We can get choice and informed consent, and enable people to choose for themselves whether they want to go the drug and biobabble route. I think I am just incrementalist, and you are big bang. I am for dismantling the strings holding this illusion up one by one.
I think in the UK we already have some progress. A parliamentary committee is looking at the out of control epidemic of antidepressant prescribing and the statistics are looking more and more ridiculous. The new Mental Health Act is giving new powers to the patient and signalling the beginning of the end for Community Treatment Orders. There is a recognition that patients should be able to have choices in treatment with the right to refuse.
So I’m going to continue prattling on about the total BS and pressure that psychiatrists put on vulnerable people to take these experimental and largely useless drugs. So keep the volume on full, I think people are starting to listen. Did you see that Sir Robin Murray, legendary schizophrenia researcher, as well as having a bit of a volte-face about the causes of psychosis, as he now prefers to call it, also called for psychiatrists to read Mad In America? I don’t think anything like that’s happened before.
@Auntie: Trust old Auntie to tell me off for being inconsistent!
Look, we both agree that large sections of psychiatry are terminally off the rails, and I will never stop telling them that – directly. I will openly tell them that, no you cannot medicate someones thoughts and that no, Mirtazapine is probably not a safe drug for those at risk, that 0.30 is a very small number, and that yes, you can and should be able to recover on psychotherapy alone – especially if that is your wish.
One day biopsychiatry, so sadly deluded, may be replaced by something else. But for now, to help ourselves and others, we work on aiding their retreat. So I’m all for battering away about the grotesque lack of informed consent, breached human rights under MHA, long term damage of antipsychotics, lack of respect, compassion and choice.
He’s got no clothes but he is still the emperor and as is well known, you cannot shake someone out of a delusion overnight.
I will do some digging jancarol that’s a decent suggestion
Show me the link between antipsychotics and suicide oldhead, honestly , I’m not being facetious, I would really like to know. I think it’s there, but I can’t find the proof that’s robust enough to stand up to the propoganda the orthodoxy will throw back.
To try and make care better, more evidence based, honest and less damaging? For others as well as you and your family.
If you aren’t trying to convince mainstream psychiatry to change, what are you actually trying to do?
If – if – your aim is somehow to get psychiatry abolished and replaced by something else, how else would you achieve that without hard evidence?
There is a substantial growing body of what you might call circumstantial evidence around suicide, as well as the whiff of a cover up and possible mechanisms, but I just don’t think it’s yet the smoking gun. What I’ve seen are ever ingenious ways of defending drugs so it’s a battle that constantly requires more and better ammunition.
I think AsgerPM makes a good point. I don’t think this trial points to suicidality in Duloxetine and we have to keep an open mind.
“THEY are MADE to come to terms with what they have done ? ”
Its a good point you make StreetPhoto. I can’t begin to put myself in the mindset of those whose lives have been wrecked by psych drugs. I think I might just have dodged a bullet, but I’m still angry and sad. I do see the evidence of this damage all the time.
For me we first of all have to try to rescue the future. But I totally understand those that want accountability for knowingly damaging patients. I hope none of that comes across the wrong way.
You bother because you are getting your point across, and I’ve got the point believe me, antidepressants will forever scare the cripes out of me based on experience. I also have enough evidence for my own conclusion, based on R Whitaker, P Goetzche and their sources. But, just as one example, Joanna Moncrieff seems unconvinced, and to convince more mainstream psychiatrists of anything it needs to be unequivocal proof battered into the frontal cortex from close range lol.
I am starting to wonder if hardline biospychiatrists are reformable in the slightest. Their gloomy over-labelling and attribution of scientific failure to “treatment resistance” leaves little room for any optimism in the fact that only people get can themselves to a better place.
Thats why I think you have to point out the dishonesty and get comprehensive informed consent and thereby enable people to reject bio psychiatry if they so wish.
Unfortunately, and much as I would like it, they can’t yet find a hard and fast link between antipsychotics and suicide, or even between antidepressants and suicide except at dose changes. Don’t worry, psychiatry hasn’t nobbled me, I look everywhere for the link I think is there, and it was nearly there in carol couplands study, but not quite. I want this link nailed, maybe if the drug companies properly released their trial data it will become obvious.
What we can insist on is honesty, now. So things like “you cannot recover without meds” and “it’s sadly a biochemical imbalance that the drugs correct” (verbatim quotations) stops right now. Next time a psychiatrist says that, anyone who is reading, ask for the evidence in print.
Rasselas: As usual you are thought provoking and it is blindingly obvious that coercive medication that has highly questionable benefits and harms is wrong, and comes in subtle forms. In essence , people are conned by misinformation and an insistence that there is no other way.
Yes I think its going to be difficult to come up with a consent form as well, but something has to be done.
In the UK the bare minimum should be:
1. “is this prescription in accordance with NICE guidelines?” In some cases this actually REQUIRES written consent, but it is not followed.
2. “is it off-label?” Again, this is not always disclosed.
3. “is the person in possession of the patient leaflet and has this been explained to them?” Extraordinary to think that you might not get a patient leaflet isn’t it? But it happens.
I would also LIKE the person to be informed of published efficacy and what it means.
Lots of people are not fans of the NICE guidelines and I understand that you can argue about them, but they at least represent a protocol, even if its too pro-drug.
Interesting perspective from America and signs of a backbone from British psychologists.
I do actually think most British psychologists are silently fuming at drug happy psychiatrists. I can’t believe they want therapy when the person in front of them is clobbered by an antipsychotic.
I just cannot bring myself to trust the clinical psychologist. Everything goes in the notes straight to the psychiatrist who believes that any psychological trait , whether it’s suicide, self harm, misapprehensions (they call them delusions) can be medicated. Yes, they will say this with a straight face, and they will thumb though the drug handbook for something that can do “a little bit of this, a bit of that” in order to “shift” your thoughts. And they won’t think about what it will be like to get you off it because it will always be someone else’s problem.
If you can afford it, a private psychologist is a breath of fresh air, unfettered, honest and confidential. But the NHS will do everything they can (which is not very much actually) to stop this.
The poor psychologist is basically employed by the psychiatrist and is in the invidious position of not being able to speak their mind about drugs, and not being trusted by the person in therapy. They would not subscribe to the “medication first” philosophy in a million years, and they end up going through therapy with a semi zombie in front of them.
“I Truly Wish I Never Went to a Mental Health Service”
Thinking about this. There ARE good things within the NHS. To be honest, almost everything except psychiatry, and thats a terrible state of affairs. Pyschology, care co-ordinators, peer support, nurses, OT, psycho-social interventions, social workers are all good but in short supply.
But the psychiatrist is the weak link. Mono-dimensional, gloomy, medication obsessed, propogandist, they control access to these other services. It feels like everyone is trying to get you better, except the psychiatrist who is simply trying to convince you that your disability is permanent and make you medication dependent. And everyone knows it. I mean, really, are they on your side? I honestly don’t know, and I don’t think they do either.
It has to change, because the psychiatrist is almost becoming laughable if it wasn’t so tragic. Anyone who is in the system now, count the times you hear “chemical imbalance”, “antidepressants are safe and effective in kids”, “antipsychotics correct brain chemistry”, “trial and error will find us the right med for you”, “you can’t recover on psychology alone”, “its no big deal prescribing off-label”, “the side effects wear off”, “all the evidence suggests….”, “we will keep the dose and duration as minimal as possible” – all of which is nonsense.
Sounds a bit like a blind alley but if they can screen people and do an RCT the world could be their oyster. But it sounds pretty improbable.
Pschiatrists really do believe that “the right drug suits the right person” when it looks more like some people are just big placebo responders or perhaps should not have been in the study at all. There is no evidence for the subgroup hypothesis, because if there were, you could test that subgroup.
The big worry with kids is AD induced suicide. Lots of controversy around data, but there is no doubt suicidality spikes on starting and stopping. The whole prescribing of ADs to kids is a scandal when we know they work even less well than in adults, if that were possible.
My anecdotal research suggests informed consent is never followed.
This study doesn’t really suggest fantastic solutions, people should do psychology and psychosocial stuff in any event.
In the UK we need NICE to grow a pair, triple the tapering recommendations, and make smaller tablets available.
To my knowledge , the smallest sertaline tablet in the UK is 50mg, which takes you from 75% inhibition to nothing at a stroke and will tip you into withdrawal for sure.
Thanks for this article, the language of mental health is pretty debilitating.
Linda Quixote – CARE – nice one – I will commit that to memory!
I find myself battling with vocabulary a lot. I DO find I use the word “in recovery” as an alternative to “mentally ill” which the system slugs people with.
I struggle with an alternative to “mental disorder” or “mental illness” and I end just talk about “problems” or “distress”.
People going through the system become very bitter about the language used against them. It seems to me that to get to a better place it is helpful if you genuinely and evidentially believe that you are OK, you are not a freak or an alien – that there is nothing biologically wrong with you, or at the very least nothing you can’t deal with. I do. Psychiatrists are on a mission to persuade you otherwise, and I will have no truck with it. Because, EVEN if it were true that you were “biochemically disordered”, whats the point in going on about it, if you haven’t a clue about what “it” is?
I’m not religious but we all know our bible stories. I wonder, if Jesus, or any other prophet for that matter, had been a psychiatrist (a psychotic one, but lets gloss over that), would he go round slapping labels on people instead of non-judgementally helping them make themselves better people?
Love it Auntie, I like your description of the tactics. Conventional Psychiatry’s use of language is hilarious if it wasn’t so dangerous.
At the risk of a double-decker broadside from the hard-liners here, I would say that I’m pleased that he is speaking out, even though he has books to sell. You have to admit, he makes more sense than a certain Italian psychiatrist from Kings College.
And he gives you specific issues to critique as Phil and you have done. For me, I hook onto that line “medications are absolutely essential for severe depression”, as being something to be specifically examined.
I think that for people critical of psychiatry, his writings are helpful.
CC tacking to port and battening hatches.
It was so liberating to be discharged from acute services here in the UK. No more sleepless nights before being yanked in for massive meetings with the psychiatrist, full of bogus claims and who would never take no for an answer. Lol recall that fantastic quote “we don’t have to agree about everything”. Threats of imprisonment, contentious accusations of disordered thoughts and family problems. Huge CPA meetings about nothing because He had decided what “he was going to do”. Magic day when we left that behind.
I think 2 things that could and should happen are:
1. Stop people being forced onto medication. Even in a voluntary situation, the elephant in the room is always “better do as the psychiatrist says or else”. Take that legal right away in all but the most extreme and temporary circumstances.
2. Stop people bring bullshitted onto medication. Patient leaflets should be mandatory and enforced days PRIOR to going on medication with the clear right of refusal evidenced by written consent for all neuroleptics with extra provisos for off label. For drugs with an effect size less than , say, 0.5, or an NNT over 5, there should be a “Clinical Efficacy Warning”. If possible,there should be a way of giving people a better perspective of the harms in addition to those endless lists.
Fiachra: I’m interested in what you think about this idea that people tend to “relapse” when they stop the meds, and it’s just a question of how many. Do you think for example , the drugs led to “remission” of the problems you had, or did they just suppress a subset of the symptoms for a while, at the same time giving you some more.
It used to really irk me when we were told that the drugs “got you better”, or even more ludicrous “got you back into life” or bizarrely “shifted these ideas” once you got to “therapeutic dose”. It all looks like a load of cods now.
I can’t put my finger on what exactly the drugs do , but I don’t think they get you better , so I’m not sure it’s right to say that people relapse. I know this is an extreme view, basically saying that they are useless and just fool the doctors into thinking the person is “better” when in fact they are just coshed.
I must say I couldn’t really recognise Eleanor either, but who knows, she may have actually been like that. HBC’s Eleanor seemed quite hard to get close to, distant. I think I was expecting someone even more prickly, more tempestuous, more distraught, that we the audience could really feel for.
I hope noone gets cross with me, and please note I do not believe in mental disease, just states of distress. But I expected Eleanor to be far less functional than she actually was. I’m not being patronising, I just think when you are dealing with issues that are depressing your mood and psychosis, plus being physically disabled by a drug thats also addling your brain, it is to be expected that you will act in a way that reflects the turmoil, despair, fatigue and discomfort you are in. At times it seemed that it was Eleanor who was the level headed one and it was the lawyer who was starting to lose it. However I think that was intentional and was meant to demonstrate Eleanors improving health as she reduced her dose.
I hate to say it, but I do wonder if the whole language of relapse is a mistake. It implies a deterioration after a period of improvement, or a return to a previous worse state – as judged by one person with a clear observational bias, the psychiatrist.
The misnamed “anti-psychotics” are really broad spectrum brain suppressants, that, at the very best, suppress psychotic symptoms that may well return at a worse level upon discontinuation. Its worth noting that even this “beneficial” effect is really very weak in most of the drugs. In the process they damage your body, make you dopey and apathetic, and, I would argue, depressed, fatalistic, defeated and psychologically dependent. They therefore put you in an uncomfortable and unsustainable limbo, not a relapsed state of good health.
Relapse implies they got better. They didn’t. The drugs just stuck a lid on things and I think recovery can only begin when you start to come off them.
Yes I think those are good points. The film didn’t move me as much as the trailer did actually. I was probably hoping for too much, but nonetheless I have to give it 2 cheers. A great effort that clearly had very little money. I think Helena Bonham-Carter, despite her controversial “right level of medication” remark, deserves enormous credit for helping this film happen and working so hard on her character. If it raises the issue of psychiatric abuse just a little then thats a step in the right direction.
The technicalities of the law weren’t really made clear. It appears that California already had a law against forced treatment, but that the hospital were essentially breaking it. Their limp defence was, well, if we aren’t medicating to, erhem, help the patient, then we are in breach of the same law. The judgement is worth a read – some of the criticisms of medication are quite good actually, pointing to cognitive disablement and the full raft of life threatening side effects – this is 30 years ago.
It made me think that even a story thats quite straightforward, that doesnt require a big cast or elaborate sets etc, can still be a problem for writers. There were lots of little issues that didnt get fleshed out enough, but I don’t want to be picky about a noble effort to portray a difficult subject.
I was just trying to fathom what this study was trying to say only last week, because its still used as a primary defence for antidepressants, so it was great to see that someone had managed to work it out.
Cherry picking the mood item is a key tactic employed, along side the subset theory (some people have properties that make them benefit a lot – and presumably some people are the opposite and greatly harmed).
Interestingly, the Cipriani review of Feb 2018 had an effect size of just 0.24 for citalopram on the 53 point Hamilton.
Incredibly moving, stopped me in my tracks. I think it should be an essential introduction for all budding mental health professionals. Lest they forget.
Am I right in saying that, in the UK, we basically do not have even the right that Eleanor Riese achieved in California 31 years ago? Specifically, even if you “have capacity”, is it really the case that you cannot refuse treatment if you are sectioned?
I feel an incredible sadness about antipsychotics. Many of them are of marginal efficacy in RCTs, and the disabling effects are all too evident, people tolerating metabolic deterioration believing their abnormal flawed brains are only kept in check by a pill. I went in search of tapering guidelines from NICE, patient leaflets or RCPsych and found none. Please correct me if any exist.
What there is, are studies showing that once you’ve been on them for a while your chances of staying alive or out of hospital are better if you stay on them. I doubt this, because how you fare must depend on how you are tapered and other support you receive, but there does least seem to be a red flag that the longer you are on them the more careful the taper needs to be.
The same Finnish study I’m thinking of also would indicate that since the hospitalisation risk on discontinuation continues to rise on anti psychotics, it’s better to come off earlier rather than leave it too late.
We really don’t know how badly these drugs damage people and cause dependence, whilst all the time stopping people functioning and amazingly actually shrinking their brains.
This paper says that half the people didn’t even ask their doctor before stopping, presumably because they knew the answer – “don’t do it”. It’s a mess.
I hope the UK parliamentary group on prescribed drug dependence has the time to look at antipsychotics as well, because although the numbers are smaller the disablement is huge.
Oldhead: for the record, I have never said the drugs work, psychiatry is in fact currently a health field that claims to make people better, and people that either choose or are forced to receive psychiatric treatment need a name and whilst “patient” isn’t the best i can’t think of a better one at this moment.
Posters on here should really read what others say and stop assuming that everyone apart from them is a baddie. Most of us here are basically on the same side, even people I’ve sometimes disagreed with. There is a difference between critical psychiatry and anti psychiatry to be sure, but it’s a spectrum.
Let’s move on and listen respectfully to the important views and insights everyone has to offer and not simply say “you are confused” – after all, we know that tactic all too well, don’t we?
I don’t see any evidence for a subset in severe, and why on earth that would mean there is a subset in mild as well escapes me. Its another hunch with no coherent mechanism of action.
The bottom line is that we can’t find a clinically significant separation from placebo in anyone. These Star*D results suggest it’s even worse when used in real life. And we still don’t have a credible mechanism of action, do we? I mean, is there a coherent argument left supporting their usage?
So, knowing what we know now, that Fluoxetine and Citalopram have effect sizes some 20% below what NICE at one stage considered clinically significant (0.30), and knowing the increased risk of suicidality, should they ever have been approved in the first place? Shouldn’t they be taken off NICE’s list of approved medications until someone somewhere produces credible evidence to support their use?
At the risk of getting a battering I will say that the talk of political ideology has no place in assessing the efficacy of antidepressants. We need approaches to “it” regardless of where you are on the political spectrum.
I don’t think there is evidence for a subset we can identify for whom antidepressants “work”, so statements like “10 times too many” have no evidential underpinning.
There are approaches that respect and empower the patient, like open dialogue and psycho social and recovery projects, but the current psychiatric profession has either turned away from these or shown luke-warm support and they would need to turn their training on its head to embrace them.
Psychologists need a bigger role because they “get it” and psychiatrists need to lose some of their power because they have abused it. This can start by NHS psychologists undertaking to keep your conversations private and not just act as note-taker for the psychiatrist.
My understanding is that Dr Moncrieff does not point out that a small number benefit from the chemical in the drug, for the simple reason that she cannot find evidence to support this, and nor can the rest of us.
I do not think that, as yet, there is such a thing as an antidepressant, but I am not shaming those who come to a different conclusion and take the drugs. Shame implies that they are doing something I consider morally wrong or stupid, or they have let themselves down and should know better. Far from it. They are told by experts like those whose names appear on the Science Media Centre that the drugs “work” and are “much better than placebo”. Their NHS psychiatrists say unblinkingly that the drugs reverse a chemical balance. I don’t blame them for trying anything that might make them feel better when they are in grave distress, nothing seems to help, and everyone around them tells them it will work. There is no shame in believing what experts tell you. We know where the real shame should lie.
Why is the onus of proof always on those who believe antidepressants don’t work? I thought that you didn’t have a drug until you proved it worked, which the drug companies originally succeeded in doing, but now the results no longer seem to hold up. Where’s the evidence-based argument that they work? There must be some scientific justification, where is it? Do you have any reason to believe they might work? Is it the idea that efficacy must exist because there are some people whose response is on the right hand end of the of the bell curve? Because that applies equally to placebos and just isn’t science.
You are saying we should use them out of a hunch they might work when the data is strongly suggesting the opposite. Thats rather odd, but amidst all the statistics, have we even got a credible drug mechanism or is that guesswork as well?
Dr Moncrieff is highlighting an important paper that is reporting what was intended to be the primary outcome of an expensive study which for some reason was never reported. It is indeed dismal and researchers should be trying to figure why.
Can you tell us why you think there is such a thing as an antidepressant Neil?
Its the process of deduction and honesty that matters to me. No-one can say that biochemical imbalances cause mental problems until evidence proves otherwise. And you can’t say a drug reverses an imbalance if it doesn’t or there isn’t an imbalance.
Psychiatry has to learn to live with uncertainty and be able to hold several theories in mind as possible causes without being definitive.
Jumping to conclusions has got psychiatry in the mess where its drugs are not effective and in a great many cases makes things worse. The lack of scientific rigour in some quarters has become laughable and that is terribly undermining for a profession that I still think we need.
@streetphoto: Well, OK, but please god lets hope psychiatrists don’t start running round with this notion, which is still just a theory.
As a matter of interest, the main drug class that affects gaba is (gasp) benzos, is it not? I think Peter Goetsch said that short term crisis use of benzos has been undervalued. What do you think of that?
With migraine, are you saying that Triptans are not as effective as we are led to believe?
@streetphoto, I hope the bunker is agreeable, I’m thinking of going down to mine when Storm Callum hits.
Don’t you think the GABA theory should be put in perspective? It is a theory where there is some interesting research, stimulated by the increasing doubt over the dopamine theory. It is not yet a cause that has evidence to back it up. It may well go the way of the seratonin theory (always BS) or the dopamine theory (jumped the gun, it might be a pathway but probably not causal). But it might just turn up something, open mind and all that.
So as yet there is no chemical pathology we can find and no brain disease we can identify, and psychiatrists, in the name of their own ethics, should stop telling their patients this until something is found where the weight of evidence is compelling. It does no good whatsoever because the patient feels broken, debilitated and then angry as he/she does their own research – the psychiatrist then loses all credibility and is exposed as a charlatan (strong word but strictly accurate).
Jumping to conclusions is psychiatry’s biggest intellectual failing, ironic since this can be a failing in their patients – I’m sure you agree. I think you could even say that the GABA line of investigation is promising and might yet prove to be part of the puzzle, which is quite something in a research landscape littered with failure, but surely it is no more than that, don’t you think?
A GABA drug supported by 2 flukey unblinded studies is just what we need to muddy the waters. Drugs to down-dopa, up gaba, up sera, up noreph, up adren all based on theories and giving rise to an chronic over-medicated mess. Already the research is massively complicated by universal overprescription of antipyschotics so you can’t work out what’s what.
Off to bunker but have a bit of battery left on the laptop.
Agreed that we do have alot in common, except you have a tin hat.
I’m really pleased you highlighted this paper, and I hope some more academics read and respond to it, because, if it’s right, it’s a bombshell. I say if it’s right because we are all wondering incredulously how the placebo in an RCT can massively outperform the drug in real life. I know it’s apples and oranges, but then we are saying RCTs of psychiatric drugs are so riddled with placebo effects we can’t use them for anything.
We all understand how Irving Kirsch proved the drugs were basically useless as drugs but possibly useful as (rather damaging) placebos. Now it seems that in and of themselves they aren’t even much of a placebo. Even I’m having trouble believing it’s this bad.
Not sure if the bunker has WiFi but when you surface again…..
“How do you know if you are low in the ions necessary to regulate the NMDA? well migraine/anxiety is a sure sign.”
Isn’t that BS of the kind we are all railing against? Sorry if that seems strong, please prove me wrong!
It’s an interesting theory streetphoto, alongside all the other chemical imbalance theories. But where’s the evidence it exists and causes mental “disorders”? Not in those references I don’t think .
@despondent: “extreme mental states are not solely psychological in origin.” That’s a interesting question. Have you any examples? I think that might be right, but I can’t actually think of any at the moment that aren’t psychological in their root cause. I think even enlightened biological psychiatrists are coming round to the idea that it doesn’t start with chemistry, I’m thinking of Sir Robin Murray. We can at least identify highly correlatable psychological factors, but there isn’t any other possible cause that has any evidence at all, is there?
Oh, and Steve: in the UK , I don’t think the driver is money, I think it’s job security and toadying up to your professional leaders. You won’t get fired for doping someone so much they can’t function for years, but if you don’t drug I think that could cost you your job, I thought I saw an example of that .
People have been saying venlafaxine looks as if it is an opioid for a while , it’s good to have credible research into this area, with a firm recommendation to reconsider its use.
Something else about venlafaxine. I trust I didn’t misread her study, but Carol Coupland at the university of Nottingham found in a large observational study that venlafaxine had over double the number of suicides than fluoxetine. There is a possible confounder in that it might be for more depressed patients, but she said it needed looking at.
Lol thanks kindred, sorry, my typo, rush of blood and all that.
Amen to that Steve.
My experience is that the psychiatrist will try to lower your expectations and indoctrinate you with “it’s biological, it’s not curable as such , it’s treatable with chemical but you may never be fixed, it’s psychiatric not psychological, it’s an imbalance that only drugs can reverse”. These are the messages I got from the NHS and it’s shocking. I had to call time once saying we just don’t have time for dogma we have to work on getting better.
When all hopelessness is being heaped on you, just believe in the power of human recovery. Believe in this person , they can and will do it if the people they trust don’t undermine them.
For me, apart from deliberately undermining hope so as to engender dependence, psychiatry’s other biggest sin is to deny the evidence that there is no chemical pathology we can find, no brain disease we can identify, but are there certainly psychological causes for extreme mental distress.
Thanks for an clear summary and your own intelligent views.
“I know people who appear to benefit from these drugs. However, I want to use them in a way that is most helpful and minimizes harm”
I’m finding it hard to sympathise with this position. There is a presumption that they do good, its just a question of how much and at what cost. We don’t know what the drugs are doing (do we? Clozapine, Seroquel?), we would never dream of taking them ourselves, but we do it anyway, trusting what we see and that the orthodoxy must have some basis, and downplaying the lack of efficacy and dropout established in studies.
What you might see is a reduction in voices, which may or may not be helpful. This reduction could be simple time remission in an episodic condition, observation bias, and is most certainly largely placebo effect, as hard as it is to admit that. And it’s not always the main problem is it? The problem might be depression and an unhelpful way of looking at the world, and a broad spectrum brain suppressant might make this worse.
“To put this another way, only 33.1% of those in the studies were in remission.”
They were only able to say this because the short study length meant they had to ignore the 6 month Andreasen time criterion. I think real remission is much lower.
This is interesting because I think these are reputable researchers.
They say “For symptomatic remission, we used the definition proposed by Andreasen without employing the time criterion.” and this is a common assumption and for short 6-12 week trials – there is no other option really. But the time criterion of 6 months where symptom reduction of 50% or is achieved is there for good reason, since psychotic symptoms are episodic. To be honest, to only achieve 33% with that level of improvement over 4-6 weeks is rather dissapointing – you can be sure that the proportion that would stay in good shape for 6 months (true remission) would be much, much less.
The other thing, as you point out, is the mean duration of “illness” of 13.6 years. What are we measuring here? Not people developing psychosis and getting better through antipsychotic drugs. There is no way this cohort would not be on antipsychotics anyway. I think what we are measuring is when they change the antipsychotic to the test drug. So, as you say, you have the efffects of chronic use, possible withdrawal etc. I find it hard to glean anything new here, since the effect sizes of many antipyschotics are rather small anyhow. But it is good that the question is being asked.
It’s OK, if you hang around in one part of the health service long enough you get moved on. I’m not sure you actually get a choice as to whether you have to see your psychiatrist in the NHS anyway.
On the bright side, I don’t know if I’m imagining it, but I’ve found that if you challenge them with evidence, they do seem to give in more and more. But it still feels like that kind of relationship – they want to do something with you and if you don’t like it, you have to resist – and that feels like a real battle. I was in a meeting once with all the MH people and I heard the psych say to himself “ah, now I know what I am going to do”. That sums it up really.
The incredible thing was that I was having to negotiate with them to slow the whole thing down, they were in such a rush. And very insistent to review once off them because thats when you will be feeling so crap you will be needing, well, you’ve guessed it. I was made to feel wierd for just asking for a couple of weeks extra, OK I got one. Its very easy to cut the tablets. I still have no idea why they were in such a hurry. When in the immediate aftermath signs of unspecified ill health did start to emerge, out of the blue they started doing blood tests. My feeling is that they don’t know what they are doing, and I have some evidence for that in the non-guideline things they did.
I don’t think mainstream psychiatrists believe that withdrawal is anything other than a rare event.
Only 6 months ago and in the UK I was involved with a taper from a near maximum dose of an off-label antidepressant in just 3 weeks. It was as much as I could do to negotiate 4. For this particular drug that meant going from 70% reuptake to zero overnight. No talk of withdrawal at all, just the possibility of “your depression coming back”, as if it ever went away.
I don’t disagree with any of that. To be honest, I don’t think we have any idea what blocking seratonin reuptake does, and certainly not a clue about the NRSA’s, NASSA’s, etc. Disabling part of your brain, well, anything can happen.
But I do think its important to expose the very reason these drugs were ever approved: the question of efficacy. They are there, not because of a credible mechanism of action, but because RCT’s showed a statistical, although not meaningful, superiority over placebo. The fact is that the placebo effect and simple remission time have always been the predominant effects observed in the trials. So people did improve compared to baseline ie where they started, but it wasn’t really due to the drug. What we are seeing is that the closer they look at the effect size, the smaller it gets. What this paper shows is that something happens in antidepressant RCT’s to make drugs look better than they really are. In the UK, this finding should surely inform new NICE guidance on antidepressants.
So the placebo in the RCT was something like 80% more effective than the drug in the StarD study. What rubbish performance in the real world, and what a fishy result in the RCT. What’s going on? To me, it looks like it’s all down to placebo effects in different monitoring settings. It’s getting harder to imagine a real drug effect.
Pauline and Kabbal, interesting points. From what I saw of the crisis team it was a box ticking exercise that was slow to react and aimed at protecting themselves, it wasn’t really equipped to deal with a crisis anyway.
I have come to wonder if MH services are really on your side at all. They protect themselves at all costs and aim to eliminate risk by hospitalisation and attempt without much success to eliminate symptoms with “medication”, even if that stops you getting back on your feet.
They would say that dead patients don’t recover, but you could also say drug-wrecked patients, life chances shot, debilitated by a diagnosis of some made-up chronic condition, will become more suicidal. And it is quite possible to commit suicide in hospital anyway. There must be another way.
Looking at strategies is a worthwhile thing to do, certainly we need a bit more than deep breathing and elastic bands. I sometimes think we need a 24 hour psychology service, a kind of “para-psychologist”, who is confidential, non-judgemental and separated from psychiatry, but then I think, thats what a supportive family might sometimes be able to do.
14% of American boys apparently have this “neuropsychiatric disorder “? Really? And this diagnosis seems to depend on subjective assessements of things like forgetfulness, carelessness, impatience and irritability. Seems a bit odd to me.
I know I’ve posted this link to the Guardian article before, but it is quite mind-blowing. Data from a Freedom of Information request shows that a staggering 1 in 6 people in England were prescribed antidepressants in 2017.
The College of GPs and the RCPsych of course try to say how good it is that depression is being diagnosed and treated.
One sixth of the population have clinical depression that requires chemical correction? Bonkers.
Its not as if the drugs actually work anyway, but thats another story.
It looks to me like tranquilizers, or brain suppressants, which is what these drugs really are, can sometimes take the edge off psychotic symptoms. Sometimes. A close look at the RCTs proves they one or two of them, at best, do a little. But its at a huge cost in terms of physical health and overall cognition and dependency. At best they will kick the can down the road, but I think they run the risk of turning a crisis into a permanent disability.
Their use is also accompanied by the unsubstantiated claim that the core problem is an imbalance causing psychosis causing low mood etc. I think it’s the other way around. Life events cause stress, internal conflict and low mood which spills over into psychosis. The difference between these 2 models is that one says , without evidence, that you are broken and all we can do is try and paper over the cracks, whilst the other says you have a psychological and situational challenge on your hands that you need help to overcome.
So the long term studies, such as they are, support this assessment. You may numb people up sufficient to keep them out of hospital, whilst effectively terminating their ability to make their way in the world and reducing their ability to think themselves through their issues. And over time the drugs will sadly derange you even if you try to stop.
The band aid will progessively cripple you – but mental health services have neglected other ways of helping with that stress.
Interesting paper, John. My reading of it is that there must have beeen a 9% reduction of offences on placebo compared to 35% on supplements, hence the 26% difference, over about 20 weeks in a smallish sample of 230. The study seemed to remain blinded. This was in 2002, and we could probably be smarter in the supplements we could use today. Could we have the latest “anti-criminaliser”? I wonder if this was ever acted upon.
However, as I write this, I wonder if I am seducing myself with a chemical imbalance hypothesis!
This is really quite interesting. An honest placebo is as good as “proper” IBS drugs. What’s going on? It has to be the doctor relationship that is driving the healing effect, doesn’t it?
In mental health, the psychiatrist has huge influence with the patient that could in the right context help people improve in and of itself. The shame is that they deal out damaging drugs at the same time, probably in part because they think the drugs placebo effect might help. Indeed it might, but increasingly people are wising up to the harms and the dishonesty, and this probably negates the curative value of this smoke and mirrors. If psychiatrists were more honest and open to suggestion beyond medication, they could achieve alot. But first they have to do no harm.
Sorry – just to correct myself, the RATE of new antidepressant users is falling. The total number of antidepressant users is still rising due to long term usage and the fact that there are still new users, even at a rate that is slowing down. You could say that the juggernaut is slowing down but it has not stopped or reversed yet.
60% of users of antidepressants have in fact been on them a year or more, so it will be a while before we could see falls in the absolute level of antidepressants.
Slightly interesting recent take on this idea in the UK.
The Guardian ran a story recently reporting that the rate of NEW ADULT users of antidepressants has fallen by something like 20-25% over the last 2 years, and suicide has fallen 8%. I don’t claim any association, but I think the reduction in new users indicates that the truth is coming out, and there has been no disastrous explosion in suicide. I wander what the RCPsych and others would say about that.
On the other hand over the last 15 years there is been a 3 to 4 fold INCREASE in young people poisoning themeselves on antidepressants to the point that 10% of poisonings are from this source in England, more than opioids.
I don’t normally think of antidepressants as the go-to suicide method, particularly since amitriptaline is not on the approved list. But from what I have read there are 2 increasingly popular drugs that are much more associated with suicide than the usual SSRIs: Mirtazapine and Venlafaxine. I am cross about this because we had Mirtazapine pushed at us very hard.
So in the UK/England,it seems that antidepressant prescribing is falling overall, with no visible deterioration in suicides. However, in young people, antidepressant poisoning has over time been rising markedly, and I do think they should look at the safety of the individual antidepressants they are prescribing. Apart from the obvious fact that they don’t work at all in young people, there are a couple of them that have an elevated suicide and poisoning risk.
Thanks for keeping the spotlight on this.
Its is incredible the excuses the “experts” give for why, despite the evidence, AD’s work:
(1) “Some people get better on AD’s” Don’t mention that they also do on placebo.
(2) “Clinical Experience”. Yes that gave us insulin coma therapy.
(3) “The RCT’s are flawed”. Well, yes, they did not disclose all the negative stuff that they should have.
(4) “Placebos are getting too good”. For heavens sake. A true placebo would be an active placebo with similar side effects like dry mouth – these studies apparently show AD’s to be even worse.
(5) “all the studies show they prevent suicides”. To my knowledge, there aren’t any convincing studies that show this. Amongst under-18’s, we have rising suicide and rising AD rates.
(6) “they aren’t perfect, but they are getting better”. Top of the league in the Cipriani study (probably due to unblinding and sedation) by a distance was amytriptaline, discovered in 1960 and not reccomended because it is potentially lethal.
(7) “the placebo effect alone is worth having”. But it is not ethical to prescribe a drug which has no therapeutic effect and will quite likely damage you.
The story is out, it really is. I’m just a carer, nothing special, and I know others in my position who know the full story now and will never be fooled.
Ah yes, good point, that is the other possibility – that having “suboptimal” vitamin D (<20) is typical of the population at large. I couldn't find your 75% stat, but I did find a paper that talked of an average of 41% have less than 20 ng/ml on the whole and 73% less than 20 ng/ml in winter (in northern latitudes). This paper talks of 80% less than 20 ng/ml in FEP so, yes, it does look like its elevated. This could be due to the antipsychotic or actually could be due even be partially due to anxiety and isolation.
They don’t seem to say if the FEP people were on antipsychotics. I cannot see how they would not be. So there is the very real possibility that it is the antipsychotic causing vitamin D depletion. They don’t seem to consider this possibility, the way I read it they are basically attributing what they’ve found to the condition.
They say that they have found an association between psychotic symptom severity and vitamin D levels but don’t postulate the mechanism – could it be the antipsychotics?
Either way, vitamin D supplementation would seem to be no bad thing.
It’s a good point, I have wondered about this a lot in relation to my own situation, particularly since extreme independence seems very therapeutic in recovery. I kind of concluded that the problem was not over protection, not directly anyway. It’s a cliche but the social and aesthetic micro inspection that kids suffer from their peers seems to me to be a dominant factor. Bluntly, today’s youth are even more vicious about trivial aspects of the way you look and behave, and there needs to be more emphasis on being decent and supportive (I had to edit my earlier more colourful version).
Rasselas, thanks for that account , really, it makes incredibly interesting reading, and I guess you are saying to that the antis here should reflect on what they wish for.
I would add my admiration for the police, by the way, who react so calmly and non-judgementally, and in doing so gain instant respect which further helps the crisis. If only MH teams had some of that poise and experience.
Some people here have had good experiences with psychiatry. Others markedly different. We had polar opposites in psychiatrists: one did nothing, the other heavily medicated. I felt deceived, threatened and coerced. I’m not fully anti, but psychiatry is running out of time to discover genuine respect and honesty. I don’t agree with labels because they are permanent and disempowing. I think you should get therapy and DBT if you currently display a need. We were told , sorry, youve not got the right label and it means I can treat your thoughts, mood, anxieties, fears and phobias with chemicals that 100% work. I just cannot do anything but condemn that psychiatric approach .
I think a big problem is the power the psychiatrist has: both patients and MH workers are scared of what he/she will “do” next that will not be “informed consent”. I think if you simply take away forced medication (except in extreme emergencies) that would change the way the system works. We were never forced, but the threat affects everything.
It does seem that Soumerai is simply rehashing an argument made in a 2014 BMJ paper:
The 26 responses to this were pretty critical, focussing on the terribly flawed use of psychotropic poisonings as a proxy for suicide rates, when suicide data is available and of course does not support their claims.
Also criticised was the presumption that antidepressant prescribing is a good thing.
So roundly castigated was this study that I for one would welcome any future rehashings by its authors, should they be able to find someone to publish it. It’s desperate really.