Monday, August 19, 2019

Comments by MedLawPsych

Showing 47 of 47 comments.

  • Fair point perhaps, it’s a style of speaking, some would say gentle, or avoidant. But yes, ice pick lobotomies, despite their Nobel Prize affiliation, were horrific barbarism. It seems inconceivable they were used at all, just like, to me at least, unmodified ECT. 10% of the population taking “antidepressants”, the rise in rates of Bipolar and ADHD diagnoses all seem horrendous to me.
    ECT remains a live debate in our societies and I believe blogs like this one are crucial in that debate. I haven’t come to the absolute position that ECT is always and forever wrong although I believe it is overused esp. in some contexts.

  • I don’t know that it’s really known how ECT leads to the range of effects it is associated with, including those that result in it being judged as “working” or providing “relief”.

    I would be relatively confident that the ways in which it diminishes capacity are underexplored.

    I don’t know whether the “relief” involves the same mechanisms as the reduction in capacity (esp memory)

    The “diagnostic label by committee” depression, appears to be very different to the “psychotic depression” for which ECT is commonly used.

    It undoubtedly requires further study, preferably without animal experimentation.

  • Hi Samruck2,
    Thank you for your post and sharing your experience of being with a person with dissociative identity disorder, or DID.
    You describe, in my view, a respectful and compassionate, way of being, and responding to a person in great distress, who sounds like they are becoming less coherent, “together” at times, overwhelmed, I suspect, by traumatic thoughts, memories & feelings commensurate with those experiences.

    In providing a compassionate, containing approach one enables over time a great deal of healing.

    While you mention a personal, rather than clinical approach, I believe/suspect there are a great many similarities between how you are obviously responding and a therapist skilled in a modern psychodynamic approach.

    It would be rare for an individual with DID to escape a great deal of psychopharmacology – just as people with “Bordeline Personality Disorder” often end up on an “antidepressant”, “antipsychotic” and a “mood stabiliser”. Interestingly, medications have been shown, in general, not to help that condition.

    I wonder the phenomenology of the “voices”, “delusions” etc, in DID are likely different to the classic mood congruent symptoms of what is often called psychotic depression.

    Even so, your approach sounds like an inherently supportive and compassionate on that emphasises “being with” a suffering person. I believe there needs to be more of that in the day to day interactions with those who suffer (i.e. patients)

  • Recovered, thank you for your post. I suspect you may have made some implicit assumptions which were inherent in your post re others appreciation & assessment of the placebo effect. Also I’m not clear whether you were referring to medications or ECT. I’ll start with medications. In general, I don’t believe antidepressants really work. The fact that an individual or prescriber believes they do is of limited use. It’s easy to (mal) design a study showing a 10% benefit over placebo, esp in three short term. I write chapters each year on antidepressants, focussing mainly on adverse effects, but still requiring a close examination of the efficacy literature. I’ll let you in on a secret – in general, they don’t work that well, and any benefit is mostly placebo. I could conduct a study to show seaweed was an effective antidepressant and it would pass FDA approval. That would largely rely on the placebo effect (but also a lot of non-specific effects despite supposed blinding of the RCT.

    You comment re being unable to make an assessment if not appreciating the gravity of the risks is somewhat problematic in my respectful opinion. It is not always possible to be 100% sure of what is meant in a short post. If there is a risk of death with a treatment I suspect one could make an assessment regardless of whether death was viewed as grave or not. I think there may be a risk of conflating one’s opinion and judgment about a risk (eg memory loss in ECT), including the gravity of it, and the risk benefit analysis of whether or not to give it.
    I relation to your last sentence about assessing and accurate measurement I’m having trouble with the logic of this, like so many statements I suspect it’s a bit seductive in that it seems sensible but may be more complex. What is the parameter to which you are referring requires accurate measurement? Akathisia? Memory impairment in ECT.

    I would add in closing that I am not for a moment denying the lived experience and suffering associated with psychiatric treatment and inflicted by psychiatric treatment. Despite being a psychiatrist I don’t feel a blanket need to defend the profession again critics, many of whom have in my view (and I am circumspect about my own view) good reason.

    I am a persistent critic of psychiatry – for no personal reason, despite being subjected to involuntary treatment, referral for ECT, TMS and much poisoning. I bring a number of perspectives to my evaluation of psychiatry (as my handle suggests) including that of a patient.

    The most important question a clinician should routinely consider is – how would you be / feel in the patients position.

    Best wishes for your continued recovery.

  • Hello Kindredspirit, in my own defence, I find myself frequently arguing against the use of ECT and disparaging its use in the majority of cases where I’m involved. For example, in a young woman (often women’s) with a history of CSA, anorexia and deliberate self harm – there’s little chance ECT will help and a high likelihood it will cause persistent problems. I don’t take an absolute position on it, but in terms of the spectrum of views are about as far to the “nay” as is possible to be without being a genuine expert on the subject. I wouldn’t want it because I fear the 1% memory impairment figure is a dimensional rather than categorical figure, in other words 1% have a clearly identifiable sever and persistent deficit, but many more have problems that don’t achieve definition. I would view the risk benefit calculation as akin to amputation. You don’t want to lose the arm but may have to. I suspect many will dislike that metaphor, but I would emphasise it involves and explicit recognition of actual harm – which many (most?) would not accept at all, seeing it instead as a rare and uncommon side effect (a view I don’t share)

  • The authorities, or those with the legal power to intervene, will not, except in the most egregious cases, find the so called experts guilty of anything, because to do so would implicate them.

    I frequently see drug induced psychosis morph into so called schizophrenia with CTOs and depot injections used. It’s heartbreaking.

    The current laws are clear regarding clearly explaining side effects and documenting them. Using these laws would be a good place to start.

    Within the profession, unless you are a Breggin, you run the risk of being instantly labelled and not listened to if you go about it the wrong way. The ultimate goal has to be moving the profession towards a more rational, less drug based approach.

    I think one reason why psychiatrists prescribe too much is that they are uncomfortable with their skills – they have perhaps been de skilled in favour of biological “treatments” which pay much better. Who but the rich can afford $10,000 a year for talking therapy?

  • I wasn’t aware (or remembered) that RW in his excellent book spoke of a deliberate conflation of antipschiatry with CCHR. It would make sense as a strategy as it enables one to use a “straw man” approach – e.g. “oh, you don’t like Psychiatry, but you believe in Xenu, aliens and Hawaiian volcanoes etc etc” – ridiculing the opponent while not really engaging on the crucial issue.

    I don’t think there’s a central group that plots psychiatry’s rise and retention of power, per se, but suspect that something works systemically, to effectively maintain incomes, and generate (obscene) profits.

    The chemical imbalance lie is merely a convenient sham where psychiatry attempts to achieve a conventional medical legitimacy, which, in many instances, it is not entitled to. Treating “depression” is not like managing blood sugar or PKU.

  • I half agree. Exercise is vastly more effective than any pill but is rarely sufficiently recommended. I wonder though self interest at least would tend to result in TMS being pushed much harder if it were truly effective. Part of the problem is that Psychiatry is not awash with effective treatments (at least ones that are quick, simple and easy). People dont seem to want to spend the time, as time is not as well remunerated and many don’t have the confidence to provide effective talk based assistance.

  • Ouch! I’m not a FF. I prefer not to use drugs and talk to people. Even though talking doesn’t pay as well as drugging. It’s the easiest thing to “diagnose” MDD and write a script but largely useless. Much more involved to spend tome and work towards an understanding.

    And if you don’t have a basic kindness/compassion for the person sitting in front of you there’s little point.

    Many of my patients thus treated do recover (arguably some or many would have recovered anyway – but a lot feel supported and cared for while they do). Having said that, I’m not particularly “defensive” regarding psychiatry – it needs to be rigorously held to account – especially as it sucks a huge amount of public resources.

    “Lost Connections” by Johan Hari is probably the best thing on depression I’ve ever read (and, dare I say, I’ve read a lot).

  • Wow, what an horrific journey.
    Psychiatric drugs are quite scary.

    Psychiatrists are taught the figure of 0.5-1 % enduring memory impairment.

    I suspect how a practitioner uses that figure is important. Conceptualising it in a categorical way (as an ADR that happens to a small number of people) would have a different effect (on practice) than seeing it in a dimensional way.

    If, given “best practice” (?), an effect on memory happens to many more than 0.5-1.0, with a percentage having severe effects, the warnings (which are sometimes glossed over) should be much stronger.

    Having survived what was clearly a dreadful ordeal, it would be helpful to receive your observations on what you feel would have been a better approach to assisting you.

    Would it be “simply” a matter of a more compassionate, patient, engaged approach. Sometimes achieving a shared understanding, and truly “being with” a suffering person does make more difference than throwing pills (and labels) at them.

    If you feel inclined, and don’t mind revisiting your journey for a few moments, I would appreciate whatever comments you could make.

  • I would offer a perspective on your observation. When I got into Psychiatry 29 years ago it was the Cinderella of Medicine. Then came SSRI’s and “The Decade of the Brain” – Psychiatry went from being a backwater to more mainstream. Industry got so huge and powerful that even several hundred billion dollar fines, for their misdeeds, didn’t stop them. I suspect they refined their understanding of decision making processes in doctors especially using psychiatry. Those same approaches are used across medicine. The average practitioner doesn’t have the time to review available evidence in detail. It has to be in detail otherwise you don’t tweak to the myriad tricks and issues used to promote a drug. I have absolutely no doubt I could conduct a RCT to show, oh I don’t know, anything, certainly any pill, was 10% “better” than placebo.
    Anyway, I suspect what’s happened in Psychiatry has influence the rest of medicine, and probably not in a good way. I don’t think it’s that psychiatry in the black hat has corrupted the rest of medicine in the (previously) white hats – but it seems more indirect (to me at least).

  • Excellent point, why are schizophrenia outcomes apparently better in the developing world with fewer resources and vastly fewer drugs. I think they were WHO studies. I haven’t looked at them for a while, but they are a very interesting finding. There is too much pressure to prescribe and BigPharma is always gonna generate “research” to do so and buy a few mouthpieces. Dollars for Docs is a good site.

  • I’m being very bad here, by pulling in other topics.

    However your post reminds me of the Tibetan Buddhist Monks, grossly tortured by the Chinese, who strove earnestly to retain compassion for their tormentors.

    I believe oppression sometimes has to be confronted. The trick of the clever oppressor is to gain power while concealing it. It calls for an ongoing careful response.

    Which is why, I’m not a fan of much of the CCHR but still feel they’re essential

  • JanCarol, thanks for your comments and observations. Also for your recommendation – Peter C. Gøtzsche is, in my opinion, a wonderful example of how the rest of the profession should approach the evidence. The money trail is key, as is burying negative studies, buying Key Opinion Leaders and the whole range of dreadful manipulations that occur. Doctors are supposed to smart people but as a profession we’ve swallowed BigPharma’s lies again and again. Happily, for me, I’m not in the US Health system. I forget who said “It is difficult to get a man to understand something, when his salary depends upon his not understanding it”..

    I can appreciate your saying “psychiatry apples . . . the worst of the bunch” as I understand it’s relationships with BigPharma have been amongst the most venal.

  • Arguably the problem with our society is a lack of love, although I would probably prefer compassion as a term. It would be nice to see more compassion in medicine generally and psychiatry specifically. I suspect that requires a respect for, and capacity to really, see, the other person. Doing that, or at least trying to, would result in a very different approach in many cases. (I suspect I have the same general feeling about Republicans and Conservative politicians as most here have about psychiatry)

  • Gosh, people shouldn’t be “allowed” to see or not see anything. What you or I believe is not, fundamentally, up to anyone else.

    That’s really scary speech.

    If people in general saw it as a failed branch, I believe we’d be off what you call a Hamster wheel.

    Psychiatry in the main, is not generally seen as a failed branch of medicine at all, but an indispensible aspect of medical care. The evidence for this is its funding, remuneration and place in medical school curricula.

    I think though there are far far greater means of repression than psychiatry, such as the law & our politics and the use of war and conflict as a tool of power.

    That statement will doubtless result in howls of anger and all sorts, which is perhaps understandable, but still questionable.

    Because, making the observation, is of course not the same as my being completely happy with the practice of psychiatry.

  • R777 thank you. I hear been a hard road. I too came from a family that was very unlike the mainstream which made the loss of someone close to me hit me hard and derailed me with the result of ending up in SSRI’s for 10 years – dreadful and promoted akathisia and others have blamed it for my substance use which took some years to finally beat. Naturally along the way, referred for ECT (declined – lucky to have the option), TMS (had it but useless) but was given a bunch of wrong diagnoses – (akathisia and suicidal thoughts and behaviour being misdiagnosed as depression and bipolar – psychiatry not being very imaginative or understanding at times.

    Income inequality, the fact that all the productivity gains of the last 25 years have gone to the 1%, rampant obesity (made worse by psych drugs and BigFood), the medicalisation of the resultant human distress, it being a profit making opportunity for drug companies all have a lot to answer for.

    You’ve clearly won though some life threatening times and I applaud and celebrate your survival and success (in all seriousness in spite of psychiatry, not because of it) Well dome you.

  • One of the things I try to do not to conflate opinion with fact. Another is to be patient with hostility and rudeness, and to try to listen to the point behind what people are saying. Because, people matter and should be respected, not just the “nice” ones. Whether or not they’ve examined everything they talk about or not (most don’t and just mouth off on the basis of their prejudices, including doctors at times).

    You may regard psychiatry as a greater evil than all other issues, but I wonder I they’re related.

    Sure, I’ve attached electrodes, taught others to do the same, and/but very frequently argued vehemently against ECT. Whether you (or/I) laud a person’s insight or disagree is irrelevant and of no consequence, what matters, is what works and what doesn’t work, the risk benefit analysis. It seems for you and some others ECT is wrong under all circumstances, a view I don’t share but am very interested in)

    Icepick lobotomies I suspect are wrong under all circumstances, I’m not so sure about some surgery for the worst intractable cases chronic OCD, I haven’t reviewed the evidence.

    It’s gotta come back to evidence the end.

  • You – we must bother. Both from inside and out.
    Bipolar diagnoses are going through the roof, as are Autism Spectrum Disorder, and 10% on Antidepressants. Don’t get me started on the Opiate of the Masses. It all seems to involve the medicalisation of human distress and that distress created by increasing injustice and income inequality. Medicine and Psychiatrists are not the answer to these problems. Antidepressants can be useful, but usually aren’t. I don’t believe Antipsychotics are protective of the brain (!??). Brains aren’t made to have foreign chemicals put in them (forgive the logical and philosophical assumptions in such a remark). Enough Meth will give most people a psychosis, which will likely lessen with Antipsychotics, but that doesn’t mean such a person should be wrongly branded schizophrenic and put on CTO’s. Anyways, one has to bother. In the spirit of Voltaire, I may not like the antipsychiatry movement or the CCCH that much, but they are essential. There has to be checks and balances on power (and psychiatry has fearsome power sometime), especially when profit and social control is involved. Not all checks work for the common good, eg 2nd amendment rights don’t seem to reduce suffering (but even there I’m not sure – perhaps gun ownership saves hundreds of lives a day that we don’t hear of). In my experience a good way to stop a practice is with rigorous fearless science. That’s difficult and expensive, it needs public funding.

  • Thank you. Most of the time I’m deprescribing and reducing and ceasing meds. I started in Psychiatry in 1989 and have seen the false start of the “decade of the brain” and the profession move closer and closer to the drug companies and a ridiculous 10% of people take antidepressants which even BigPharma grudgingly acknowledge increase the risk of suicide.

    I’m terms of my own (or any practitioner’s responsibility) I see that as making strenuous efforts to get the best possible information (and that generally means not ghost written papers funded by BigPharma or sponsored by their (IMHO) poodles like Charles Nemeroff or Henry Nasrallah – Dollars for Docs is a good site)

    For me, despite the understable vitriol of those who have suffered as patients at the hands of psychiatrists (as have I), having visited this site I’m prompted to have a close look at some of the references provided by others on the alleged damage caused by ECT.

    Anyways, thank you for your response

  • Interesting comment, wonder what the evidence is.
    Certainly the medical profession generally and psychiatrists in particular did support the regime.
    But eugenics was not discredited as it has been since, Churchill and many elements of the US were sympathetic to those sort of views.
    However tempting it may be for some to ascribe all evil, including Hitler’s to Psychiatry, I doubt it’s a view that really stands scrutiny.

    That’s not to say of course that Psychiatry has a shameful history but I suspect one should careful not to confuse a hatred of psychiatry with all evils.

    We used to use leeches and believe in the 4 humours

  • I’m sorry you have had such a difficult path & would like to understand better how supportive measures may have been a batter approach. I think there is not enough feedback from those with your lives experience. It behooves the profession to understand as best it can what you mention.

    It’s terrible that your experience of psychiatry has been of barbarism – it would seem an indictment of the attention you recieved.

    Unfortunately there is not enough listening and too much prescribing.

    If there isn’t an appropriate and helpful trusting relationship not much can happen.

  • Not quite. Simply pointing out a possible consequence of not doing it in a clear situation. You have actually twisted my words somewhat. It’s not at all matter of shock to save ones behind, it’s a matter of defending the position of not giving it when it is indicated and a patient suiciding as their depression was unrelieved. With my medical litigation hat, I know how that would be dealt with.

    Doesn’t mean that possibility affects every decision.

    As for baseball bats, that’s a bit of a straw man argument. Although far too many barbaric “treatments” have admittedly been used in psychiatry which doesn’t have a glorious history!

  • I’m sorry you have had such a difficult path & would like to understand better how supportive measures may have been a batter approach. I think there is not enough feedback from those with your lives experience. It behooves the profession to understand as best it can what you mention.

    It’s terrible that your experience of psychiatry has been of barbarism – it would seem an indictment of the attention you recieved.

    Unfortunately there is not enough listening and too much prescribing.

    If there isn’t an appropriate and helpful trusting relationship not much can happen.

  • Many interesting points.
    I teach medical students to not be duped by psychiatric nosology and classification – a psychiatric diagnosis is not like say, a diagnosis, of staphylococcal pneumonia which is objective.

    You have a point about symptoms of depression (with psychotic features) but using the same rationale you could and I suspect (though I may be wrong then have a totally nihilistic absence of any theory of mind.

    NDE’s are often but not always transformative, it seems just silly to propose actually risking someone’s life for the possible benefits.

    In terms of how one could possible know if a person had a psychotic depression, I guess history, examination, consideration of alternative possibilities – the usual.

    Seizure control (of random seizures)is a little different to inducing one in a controlled context. Yes, status epilepticus can kill, but that I’m itself doesn’t mean one way or another that induced seizures are good or bad.

    I agree it seems a bit barbaric and mediaeval to use electro-shock, esp as we don’t have a comprehensive biochemical theory of depression, which as you rightly point out is a fuzzy “diagnosis” (I was very impressed by Johan Hari’s book on depression “Lost Connections” was

  • Thank you, I will have a look at them and also Peter Breggin’s work.

    You’re right that it has been used as an agent of control. I’ve also seen it used inappropriately for conditions (or perhaps more accurately situations) where it really wouldn’t be expected to do anything (and didn’t), such as eating disorders and “borderline personality”.

    However there have been occasions where I suspect it may have been life saving. True melancholic & psychotic depression.

    Whatever the case I’m personally committed to examine dissent and the evidence.

    A figure I carry is at least 1 in 200 have a permanent memory deficit plus the anaesthetic risk. That figure, which may be an underestimate is quite scary.

    Anyway thanks for your reply and I will have a look at what you kindly referred me to.

  • Your angry, and I don’t doubt you have good reason to be. I certainly have from both sides of the desk. There is much to be cynical about in heath care delivery, including who it really serves. Doctors don’t start out to screw patients over, but little by little they get socialised and moved towards big corporate agendas and profit, almost imperceptibly.

    Go to your work and tell your boss he’s an unprincipled money grabbing selfish idiot. See how long you last.

    Having said that, the dominant paradigm must be questioned and undone.

    It’s tough and forums like these are where it starts.

  • Since when was ECT indicated for Lyme disease? Should your medical doctor – psychiatrists have had a wider differential diagnosis for the cause of your symptoms? If so that in itself doesn’t mean ECT is good or bad of the issue is misdiagnosis. I suspect Lyme disease and other parasitic conditions are often overlooked. Does t mean antibiotics, or ECT, or whatever wrong treatment are necessarily bad and so t have a place. Having said that, sure psychiatry fails a lot of people and hope you have found what helps you.

  • No, victims of trauma might be better served by other approaches but it is not correct IMHO that being a trauma victim makes you immune from other conditions. Sure, you will likely benefit from trauma informed care and a developmental approach (as opposed to strict medical reductionist bullshit) but you MAY developers a clear psychotic depression which MAY respond to ECT better than drugs CBT and other therapies.

  • Can’t agree completely but yes there is much quackery. When you’ve got an actively suicidal elderly man who feels his guts are rotting, the devil is after him and hears the voices of demons, what would YOU do? Bearing in mind if he does from suicide next week and you haven’t given him ECT for his psychotic depression you WILL be easy meat for the families lawyers who will have a preponderance of medical experts lining up to call you negligent?

  • If you’re gonna proceed with treatment that has the possibility of “damaging young brains” or causing persistent memory impairment you’d better be sure that the risk-benefit equation truly favours this prospect IN THE JUDGEMWNT OF PATIENT AND OR FAMILY.

    It gets tricky where you (as a practitioner) are potentially liable for suicide for NOT giving it.

    Ideally it’s the patients (or their family/ advocates decision)

  • Interesting comment.
    My lived experience as a practitioner is seeing suicidally depressed suicidal people recover amazingly quickly with ECT, as well as many for whom it was useless (and I suspected would be useless)
    Further my lived experience as a patient is being referred for dubious value ECT and TMS that was useless.
    My experience as an academic is noting that ECT appears to be of some value in a select population.
    We don’t know why it works when it does, but there are reliable indicators when it might.
    Unfortunately there is evidence that it can cause persistent memory deficit in 0.5% (I suspect the real number is higher and tell my patients this)

  • While I agree with much of the scepticism, caution and general dissatisfaction with the often appalling practices of the mental health industry expressed in the article, I have some reservations about completely dismissing ECT as a treatment.

    Corporate malfeasance is practically enshrined in our legal system with the best interests of companies often being totally at odds with the welfare of patients. I’m not surprised ECT companies have behaved badly as of course drug companies have time and time again.

    Despite practicing as a psychiatrist, I suspect the author may be more familiar with most of the literature on ECT than I.

    Having said that, I continue to believe that despite undoubted instances where ECT is misused or is I appropriate, there are also instances where the risk benefit equation favours its use. Psychotic Depression in the suicidal elderly is often (but not always) situation where it can be helpful.