Sunday, August 7, 2022

Comments by Mark Ragins, MD

Showing 22 of 22 comments.

  • Hi,
    You’re right, I’m equivocating a little. After we “rediagnose” the majority of people with attention deficits as being caused, or “secondary” to something else, and then we assess the majority of the rest as “mismatches” along the normal spectrum, are there a few people who actually have a “primary” disorder that should be called ADHD? My sense is that there are, buried under the avalanche of all these other people, a few people, mostly children, who have some kind of neurodevelopmental disorder, perhaps of the timing of myelination, that causes attention problems, often transiently as their brain further develops. I’ve met a handful of adults who I thought had that and hadn’t outgrow it. Child psychiatrists may have a different experience. When I shared this article with my college psychiatrist list serve, they generally agreed with my sentiments, but almost all thought I shouldn’t refuse to ever use stimulants, that there are a few people who should be prescribed them – this same group. Coincidently, or maybe not, last week I met a woman whose older brother was violent to her every day of her life, until at age 18 her parents were pressured into giving him stimulants and his severe hyperactivity, agitation, and violence all disappeared and he went on to college, marriage, having kids and she was able to begin her recovery. Its still hard for me to prescribe stimulants even in that setting, without really knowing what the risks really are, but they’re probably right, I shouldn’t say never.

  • I do worry about this, in my view reasonalby accurate criticism. I don’t have the time to respond to every reply, or even more than a few of them, so I wonder if I should be participating in this community at all, and to be transparent, this isn’t one of the most important communities in my life and I don’t look at it the same way i look at the Village community where I work daily. Some of the time the people who respond to my blogs are either upsetting to me and/or urging me to be more aggressive than is good for me. I’ve corresponded with the organizers of this website community who reassured me that they’d prefer me to be involved somewhat rather than withdrawing altoghter. They also told me that there are 10s of thousands of members who don’t write at all, but read regularly who are welcomed in the community too. They can change their minds and not post my blogs or you (and anyone else) can make an individaul decision and not read them if I seem too presumptuous. I do read the replies to my blogs though usually not the same day they’re written.

  • I looked back over my post to see where I recommnended diagnosing or medicating anyone and couldn’t find it – so while I think there’s alot ot be said about the advantages and disadvantages of diagnoses and medications, I don’t see how it applies here. I’m trying to develop an inclusive strategy that is community wide and not dominated by mental health professionals (or anti-mental health people for that matter) that can hopefully triage people by whatever is engaging to them. My overall point is to begin with relationships instead of with diagnoses or gun control.

    Nonetheless, you bring up an important and, in my opinion, often minimized negative of mental health treatment – the impact of diagnoses, labeling, and being prescribed medications itself – which does have isolating, self stigma, social stigma, hopeless, blaming implications – that can have enormous impacts. We can approach this by 1) trying to decrease these negative reactions and 2) trying to create more positive contexts for helping people and 3) sometimes not doing somehting that might be helpful from an illness centered point of view but damaging from a person centered point of view (for example I once advised someone not to try to push her teenage son to try antidepressants even though I thought it was likley he’d feel better and function better with them because I was concerned that the self stigma, the reaction of his father and frineds and teachers and his resentment of his mother for pushing pills and his giving up on his dreams for the future would all be more damamging than the pills were worth. BTW This is tricky decision making – it appears that the black box warnings on antidepressants for adolescents did lead to decreased prescirptions, but also to higher suicide rates among adolescents – hard to tease out true causality, especially for any individual. Also tricky is that he then “self medicated” with MJ, whihc has far less negative stigma but does have biological negatives too).

    There are certainly biologic negatives of medications as well, though in practice it’s not usually easy to seperate out symptoms and side effects – and many of the posters on this blog have tragic outcomes that they seem to attribute primarily to misinterpreting a side effect as a symptom – and that certainly happens. Using psychatirists interchangeably, in very short time periods, with rare contact and little personal relationships or even busier primary care docotrs to prescribe, as we do in most places, in my opinion, radically increases the chances of not getting the best possible impact from medications (and not avoiding poor impacts) – but no one is doing anything to substantially increase the number of psychiatrists (or other prescribers susbstnatially).

  • I don’t really agree with this simile.

    There are people on this blog who seem to think that the three goal areas I described – reducing violence and aggression, connecting with people, and reducing suffering and increasing ability ot work through suffering by making it less overwhelming are bad goals. NOne of them sound like strangling kittens to me though – maybe “domesticating kittens”?

    There are people on this blog who see medications as ineffective at achieving any of those goals or even counterproductive. Maybe “herding kittens”?

    There are those who think that the benifits are only temporary and not worth the long term inpacts. Maybe “raising kittens”?

    there are those who think that all medications are poisonous for everyone and that any effort to help people that includes medications must be either delusional or lying. That group might like the “strangling kittens” simile.

    I believe that those are good goals in general, that meds if used the way I descirbed in my previous blog about prescibing strategy can be helpful and do substantially more good than harm, though life is uncontrollable. So my simile would be “raising kittens”.

    NOw there are some people, myself included who think that raising kittens is a thankless pursuit more likely to get you scratched than love, but I certainly wouldn’t criticize those people who enjoy raising kittens or try to drain them of all joy drowning them in anger, blame, and suffering.

    Who knows they might swithc specialties and raise puppies instead.

  • I feel my neck and head muscles tightened and get angry and defensive and end up thinking that was the goal of the writer, wheterh it was or not, and that doesn’t help me converse.
    It’s very hard for me to get my head around the balck and white thinking alot of the responses have – soemone says taht everyone who has ever benifited from meds just has a placebo effect, someone else sasy that helping people with medications is like killing kittens, soemone else ataches just a cuckoos nest video. But in this particular post I was reacting to the all that anyone needs to know about Dr Ragins” intro – I can’t define mysefl narrowly in one sentence, so I can’t respond.
    I am aware of the irony that much of what I’m describing is how many of you feel when talking with treating psychaitrists. I don’t think that works either.

  • Your recommendations more or less describe how i do appraoch this man. Isee him several times a week, bothin the Vilalge and in the neighborhood, never in any real clinical / office context. I do sometimes understand what he’s saying or can make a guess – lie he’s reassuring me or like when he talks about bad people over and over i assume someone was mean to him or hurt him. I thkn he likes me a great deal I’ve never locked him up or forcibly medicated him, and our few blocks around here tend to tolerate him, but whenever he leaves here – like looking for family in San Diego, he’s invariably picked up and locked up, almost always in jail, not hospitals – often he’s kept there for a long time until he’s found to be incompetnet to stand trial and then he’s medicated and eventually let out to repeat the whole thing again. I don’t know if RD Laing would’ve tolerated him or not, but he doesn’t meet his responsibilities as a citizen well enough to stay out of jail.

  • In that quote the “we” referred to the system in genral, not to the Village and I was criticizing that approach and offering alternatives.
    Many people at the vilage don’t end up on meds, some of whom I think that’s the right choice and some I don’t and they get full services anyway.
    Many people I lower their meeds and some I help get off, but we weigh both the possible negatives of staying on the meds with the possible negatives of gettign off them – recently a woman i thought should try ot get off chose to and is returnin g to work, but another woman i thought should try to get off didn’t because seh didn’t want to risk her DCFS case taht’s been going on for over a year despite my storng advocacy for her to get her kids back. Another woman i thkn should try to get off her meds, her husband is concerned taht seh might try to smother and kill their 3 year old again and DCFS isn’t letting her back in her own house despite my advocacy either.
    In the same way that many people on this site think that psychiatrists should ask more about what led to symptoms (which i heartily agree with, I never do an initial assessment in under an hour of conversation, and I do know when that started, it was when causes were taken out of DSM 3 when it replaced DSM 2), I think we need to ask alot about the postiive and negative impacts of meds on their feelings and their lives and what’s likely to happen if they taper off meds. Shared decision making to end meds is just as complex as beginning or continuing meds.

  • I was thinking about this issue seriously a few weeks ago. Our present model of having MDs overssee and prescribe lots of medications is falling aprat becuse the demand for meds of many kinds is astronomical and climbing and the supply of MDs ot prescribe them (even if supplemented with Nurse Practitioners and Pshyciian assistants) is more or less static. Though many people on this blog are profoundly anti-medication, the problem our medical system is having is how to satisfy the growing demand for meds of all kinds.
    We presently have three models for taking meds:
    1) self administered – most pills are simply bought in the pharmacy without a prescription or doctor. Many pills that were prescirpition in the past are no longer. This legal market is supplemetned by a large illegal marekt where people buy lots of psychoactive chemicals on their won. Note that insurance companies won’t give patients a blank check because they’d spend too much.
    2) MD prescribed and monitored. Each prescription is explicitly approved by a MD (intial or refill). Many on this blog think that the MDs are doing a poor job of actually overseeing this segment of the psychoactive mendication market – and Fred asks ,perhaps facitiously, if people wouldn’t do better if they took self responsiblity and bougth med s of their own choosing. WE don’t know, but most people have issues with short term rewawrds vs. long term problems, not just psychiatrists.
    3) The model being used in califronia for “medical Marijuana”. I don’t even know if this was intended as a serious model, but it consists of people geting an initial evaluation by a MD sayin g they have a condition that would benifit form Marijuana and then the patient gets a yearly marijuana card taht lets them buy whatever type in whatever amount they think best. There’s an assumptoion that everyone already knows enough about marijuana to use it well.
    it seems to me that we could set up a systme for other meds where there is an initial period of medication collaboration and patient education and building self responsibility followed by gettign a yearly card for our Blood pressure meds, or asthma meds, or seizure meds, or psych meds. DOing something like that would free up the MDs from thousadns of probalby useless “med checks” and allow the saved time to be spent on the front end creating fuller initial listening, mutual understanding, and discovering usefulness, and understanding longer term implications of meds

  • Two points:

    1) I think that most emotioanl healing doesn’t happen within the confines of professional treatment relationships. I try to meet a very high standard of being able to connect to and even love people with serious mental illnesses and keep increasing my self awareness and ailibity over time because I think psychiatrists should be the poeple in our society most able to do this (family have a great caapbility as well coming form anohter direction). MOst of the people who I can’t realte to end up locked up not by me – usually in jail. That side of the “relationship” I have only a very modest impact on. I’ve seen too many people tragically exculded by their families or loved ones because their mental state was intolerable.

    2) I have seen people who could work through things better when thye were on meds – for example they could work on their marriage when they weren’t paranoid or delusionally jealous of their partner, or they could go back to school and rebuild their career when they weren’t paralyzed by depression and negative voices in bed, orthy could work on loss and grief when they didn’t have a panic attack everytime the subject was brought up. These kind of examples aren’t rare – they’re the majority – and I doubt just a placebo or charm effect.

  • You misunderstood my intent. i’m not lamenting the loss of the old days – I’m not old enough to have prcaticed then. I’m wiritng aobut my own develpmental process as i’ve gotten older taht things seem much more complicated and interpersonal and less clear and responsive to my will than they did when I was younger. i’ve expereinced simialr shifts with regard to marriage and childrearing and even going to the movies.

    i do think that i was taught a relatively “developmetnally immature” way of prescribing to simplify it and make it applea to young doctors, but i know mnay psychiatrists who have moved well beyond that approach.

  • I’m not saying not to use psychosocial interventions. My program and myself probably use more of them than hardly any other program.
    I’m saying that our present society won’t pay for, support, or even tolerate good psychosocial interventions. That’s what makes this whole thing a society wide issue.

    One of the huge appeals in my opinion of the “Medications allowed us to empty the psychaitric hospitals” narrative is that it allowed society to reincorporate many people who had been forcibly excluded because we created a new category of people – “People with mental illnesses who are compmliant with their medications”. Most people are far less frightened of that class of people than of mentally ill people in general and more willing to accept them and that has been one of the main foudnations for what limited antistigma and increased tolerance we have achieved – even though it’s a very flawed line of thinking.
    Last night a twenty year old woman hit and ran killed someone while driving 90 miles an hour in Los Angeles. Her father’s defense to the newscasters was “She has a mental illness and I think she’s off her medications.” Presumably he’s hoping that she can get back on her medications, be forgiven, and return to a normal life. This category of “forgiven” mentally ill people becasue they’re now medication compliant include people who get the social rewards of being released from jail, hospitals, conservatorhip, get their children back, get to drive, get to return to work in sensitive jobs, get section 8 housing or SSI. Most people in our society are only wiling to extend these powerful “psychosocial” responses to people who follow their doctor’s orders and take their medications. We’re contiually criticized by visitors for spending so much time and effort and human caring on people who “won’t cooperate and take their medications”. Creating a “counterculture of acceptance” takes a lot of work.

  • Yes, medicine is more individualized trial and error than we would like to think. But psychiatry is ever so much more so for several reasons: 1) When we’re using a medication, like penicillin or Tylenol, tha has a very low toxicity profile, we can safely give dosages larger than most people really need and call that the “normal dose” and nobody notices the individual variance. 2) When we’re dealing with a realitvely simple organism like bone marrow, or kidneys, or a pancreas both the underlying biological mechanisms and the individual variation are likely to be less than when dealing wtih the human brain – the most complex thing in the universe. 3) The brain has an incredible amount of interactive feedback loops and plasticity in it. Keep in mind that Whittaker’s main thesis is not that meds are directly toxic. It is that meds that are intially helpful, but then trigger feedback responses from our brains that are harmful to us over the long run. In effect it’s our brain harming oursleves – and our brain’s responses are highly individual. As an medical analogy, steroids sometimes cause acute toxicity, but they also cause harmful feedback loops within our immune systems that cause damage years down the road. 4) There are high rates of palcebo effects and placebo side effects (much more studied short term than long term) that could be renamed “triggered self healing” and “triggered self harm” that seem to be psychologically mediated and are often even more important than the biological impacts. (That’s one reason why I personally focus so much on treatmetn relationship, trust, personal buy-in, and personal meanings of medications when I prescribe.)

    All of this is not meant to say that it’s a “crap shoot” – doctors should prescribe whatever you want as fast as possible and move on to the next patient. It’s meant to say that effective prescribing requires lots of time and relationship and consideration of lots of different factors like I outlined in the blog posting I started this conversation with.

  • I did mean physically damaging, but I’m not a confident biologist. NAncy Andreason’s long temr study of brain volume published in the last year concluded that both medciation load and psychotic relapses indepndently correlated with loss of brain volume. Note that we tend to move from correlations like that into cuase statements like meds or psychosis cause brain damge that haven’t actually been proven. Aslo note that her conclusions are statistical conclusions, not experimental ones. To my eyes what was stirking aobut this paper was that the graphs of the acutal data looked like scattered dots all over the page. The statistical lines seh drew didn’t really capture the heterogeniety of the data. My main conclusion was that any given person mihgt experience an incredible range of outcomes both with and without meds and with and without brain damage.

  • None of us know what proportion “many” lives would be. It could be a small minority and still be “many” or it could be a sizable majority. Just knowing lots of people in any category – angry survivors, grateful patients, people who think meds have saved their lives, people who believe medications helped them recapture control of their lives from their illnesses so they could be themselves, people who tried to recover without medications and ended up hurting someone, etc – doesn’t make it a predictably common outcome.

    I’m reminded of a friend of mine from Minnesota who was certain in 1972 that McGovern was going to be president becasue everyone he knew was going to vote for him.

    The internet has helped like minded people to organize and expand their voice. Too often the outcome, however, has been to create uncompromosing gridlock rather than diaglogue.

  • Your posting made me wonder something i hadn’t before – many people on this blog believe that the damage done by poor prescribing (or even “good” prescribing) is so much that we should rely entirely on pscyhosocial repsonses to serious mental illnesses.

    Many of the common pscyhosocial responses, especially to “unmedicated” people are strikingly damaging in their own right.

    This week, for example, I worked with people who had been 1) evicted because he broke windows and threatened people, 2) had a restraining order to stay away form her family because she tried to smother her 2 year old, 3) were arrested because he set a fire in an alley to stay warm, 4) pepper sprayed in the face by a stranger they yelled at and they assaulted on the street, 5) were evicted for not having any money to pay rent because they felt too worn down to work anymore but were rejected for SSI, and 6)were pimped out by her boyfriend to get street speed she was addicted to.

    Maybe we should be comparing the toxicity of common “psychosocial interventions” with the toxicity of common medication interventions.

    We don’t live in Gheel Belgium. we don’t even live in a particularly tolerant society. Forgiveness and acceptance and reconciliation (my favorite psychosocial interventions) are pretty rare.

  • I would really favor many more diagnoses instead of the present trend of broadening and boradening a few diagnoses. I think “rape trauma vicitm” would be a reasonable diagnosis – it has a known cause, common problems, and useful treatments (primarily psychotherapeutic and mutual support and political advocacy to make meaning form suffering). My point was that burying this in Bipolar makes it more likely to get various medications instead of specific therapy along with the truamatic impacts of the diagnostic process that you describe.

  • By individual prescribing i mean beginning not with a diagnosis, but with the person’s story , their experiences,and their goals and wokring with them using shared deciions making to see what medicaitons at what dosages improve their lives. Some people feel they’re being experimented on with this tiral and error approach, but the individual variation between people is so great, even within any diagnosis or target symptom, that there’s no way to make more than an educated guess as to how the medicaiton will effect andy give person. Someone will think med A is a lfe svare, while another peorson with similar symptoms will be made worse or have serious side effects. Medicating effectively is a coolaborative, time consuming process of learning together. It’s hard.

  • The usual label is “duration of untreated psychosis”. i’m not aware of studies that try to do what you suggest though it would be helpful – contrasting psychosocial treatment wihtout medications and no treatment and with medications. Even the studies that pruport to tease out the differential effects of illnesses and medications are using statistical methods, not experimental methods.

    i don’t do research, but I have to say that on an everyday basis I spend far more time trying to talk people out of medications and into psychosocial treatments than i do trying to talk them into medications. Many people like the rapid relief of suffering they get with medications.

    I do see people who would like money and housing subsidies and no treatment of any kind – psychosocial or medications – and we do try to acocomodate that, and often it helps alot.

  • Yes I was at that Alternatives conference. I had read both his books. If I hadn’t agreed to show up, Robert wouldn’t have been aloowed to speak.
    However, that experience is part of why I’ve stayed away from this disucssion for the last few years. Even though I learned some important things that day, it’s not an experinece I want to repeat with this blog.


  • I thought it would be better to introduce myself and my program before starting wit specific content. More blogs to follow.

    Short answer – yes almost all of the Transitional Aged Youth had been treated for years with lots of medications. As part of them turning 18 I worked with them to decide what meds they wanted to use and to waht purpose, since they weren’t kids anymore and didn’t just have ot do what they were told. Everyone’s path was different.

    I’ll write more current stuff on meds, but here’s a link to my most complete statement in the past (2009)