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Thanks for the article. As always, very well written.
As always a great article. I thought we had a chance to change the paradigm when Obamacare embraced the model of mental health care being integrated into primary care. In primary care, it might have been possible to skip diagnosis and screen for happiness. Interventions for those deficit in positive moods would consist of yoga, dietary interventions, and support groups. Over at Emory psychiatry, they were even predicting that there would not be much future work for psychiatrists.
I’ve been less than happy with attributing suffering to past trauma. This perspective has resulted in treating everyone as if we were all fragile. Now we announce/warn in our university classes when sensitive topics might be discussed. This has led to criticism from social psychologist, Jonathan Haight.
Anyway, maybe there is hope after the next election for the return of Obamacare and integrating “mental health” into primary care. It’s my hope that we can lose the term “mental health” and all the labels including trauma.
Ketamine is an NMDA antagonist. Data suggest that antagonism of NMDA receptors on Fast spiking GABA interneurons is the basis for psychosis. In animals, ketamine will inhibit the NMDA receptors and also cause death of the fast spiking interneurons. Thus, ketamine trades depression for psychosis.
glad you asked. Stress of various types can induce inflammation. (There are many studies manipulating the variable of stress and then measuring inflammation.) Diet can alter gut microbiota such that leaky gut occurs and systematic inflammation ensues. The good news is that treatments should be directed toward reducing inflammation. For this, diet, exercise, social support, yoga, enhancing vagal tone have also demonstrated efficacy.
I agree that causation cannot be inferred from correlational data. However, causation can be inferred from manipulated variable research. Some people (those with HCV and melanoma) have been treated with IFN-alpha. In response, depression/anxiety occurs in 20-60%. Others have injected LPS, component of bacterial cell wall, into human subjects under the skin (Stone et al., 2007; Eisenberger et al. 2010, 2009; Inagaki et al., 2012). In response people report sadness and anxiety. They are less responsive in the Nucleus Accumbens to reward, and they exhibit more amygdala activity when viewing angry faces. Seems to me the case for inflammation being able to cause depression in some people is pretty good.
I have read Carl Hart. I think he is correct about some people. I have, however, known many well adjusted people, with happy childhoods, who nevertheless were captured by the drug. What convinced me on the dopamine story is that after treatment with dopamine agonists, many persons with Parkinson’s disease get addicted to something (sex, gambling, etc.).
With regard to the disease label, I think its politics. People object because of the denotations of the term. When I discuss this issue in classes I teach, I always ask for a definition of disease. I never get a logical answer.
I have seen many addicts quit using. I think one can get addicted to recovery. It takes work, but that’s what people do. See George Vaillant’s book.
Addictions is one are in which the neuroscientists do have something to say. All drugs that lead to compulsive use to release dopamine from the ventral tegmental area into the Nucleus Accumbens. Kent Berridge and others have clarified the function of dopamine. It’s all about motivation and not about pleasure. Addictive drugs capture the individual’s motivation system such that the behavior is compelled. The affective consequences of consuming the chemical are irrelevant. It’s not about seeking pleasure or seeking relief, its about having no choice. The support for this point of view can be found on the articles I’ve published on this topic which are available through scholarworks or in my book, Neuroscience for Psychologists and Other Mental Health Professionals.
With regard to whether addiction is a disease, I think George Vaillant had it right. We really don’t have a scientific definition of disease. In fact, according to Vaillant, doctors don’t agree on whether hypertension is a disease. Any discussion about whether a phenomenon is a disease or not, is more about politics and not about logical thought. The term disease carries connotations, but again its about politics and not science.
I’m always concerned about mechanisms. A paper by Dominguez-Meijide et al. in Brain, Behavior, and Immunity in May 2017, explores the role of D2 receptors on the angiotensin system in the brain. Turns out that agonists on the D2 receptors on astrocytes decrease the level of angiotensinogen released and increases the anti-inflammatory angiotensin II receptors that counter the angiotensin I receptors. If D2 receptors are blocked (as occurs with all antipsychotics), there will be more brain inflammation. Thus, this might be one mechanism through which antipsychotics shrink the brain.
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A good case can be made for anxiety and depression being linked to systemic inflammation. To treat systemic inflammation, diet and exercise are very important. For diet, on the good list are omega-3s in fish, curcumin as in turmeric, ginger, and probiotics to alter gut microbiota. On the bad diet list are high-fructose corn syrup, saturated fatty acids, and foods (bread and ice cream) containing shelf life extenders. Yoga and mediation are also helpful.
There are rather extensive literatures on each of the above. See my blogs on this website or on my website littrellsneuroscienceofwellbeing.org. A rather technical paper on this topic by me is available at frontiers in psychology website. I also have a book out on this topic, Neuroscience for Psychologists and Other Mental Health Professionals.
Thanks for your very touching story about your son. I’m so happy that the word is getting out on the profound impact of diet on mood and behavior. You might be interested in some other health professionals who are less than enamored with the psychiatric perspective. Steve Francesco has a website and has founded an organization for assisting parents whose children have received psychiatric labels. Steve’s story is tragic. He lost his son to a side effect of an atypical antipsychotic. David Permutter is a neurologist who explores the impact of diet on mood and behavior. He has a website. Bose Ravenel is a pediatrician in North Carolina who genotypes patients for enzymes associated with folate and processing of methionine. He offers an alternative to Ritalin for hyperactivity.
I am a psychologist and I have a masters in immunology. (I also blog occasionally for madinamerica.) I work with the immunologists at Georgia State University where I am employed. My GSU colleague, Andrew Gerwirtz, works on Crohn’s disease and IBD. He has investigated the impact of the preservatives that are put into bread, ice cream, etc. to extend shelf life of products. It’s all bad news. The preservatives induce inflammation. There is an extensive story on inflammation inducing mood and behavior problems. I wrote an article on the connection between inflammation and major depression. The article can be downloaded from Frontiers in Psychology. I also published a book, Neuroscience for Psychologists, which reviews the link between inflammation and psychiatric classifications. The book provides information on life-style changes for decreasing inflammation.
Physicians are trained in the perspective that physiology determines much about mood and behavior. I share this perspective. Rather than relying on drugs, there is a strong case, supported by good science, for treating behavioral problems with life style changes. Since the dietary recommendations to treat behavioral problems are the same as the recommendations for cancer and heart disease, it’s an all-around win. Hopefully, the word will get out.
Hi Sandra-thanks for the post. I tell all my students about your course on antipsychotics. I do think the message will get out eventually. With regard to the pharmaceutical houses capturing medical education, I think this message comes out loud and clear in the video by Andrew Kolodny on the opioid epidemic. (It can be viewed from the pharmedout website under the advocacy tab.) If all the doctors can be convinced by the pharmaceutical companies that opioids aren’t addictive in pain patients, then there is no limit to the gullibility. Perhaps med schools will be embarrassed and change their ways.
The case for inflammation playing a prominent role in depression and anxiety is becoming more greatly accepted. Andy Miller and Chuck Raison have been exponents for this position. Bloggers on this web sit, including Kelly Brogan and myself, have advanced this case. Brain inflammation and activated microglia also may be the cause of psychosis. (See the blog at my website littrellsneuroscienceofwellbeing.org. or my book Neuroscience for Psychologists and Other Mental Health Profesisonals.) At the Biological Psychiatry meeting in May of this year, Tony Grace and Kim Do presented on inflammation and psychosis. The psychiatrists may find a physical basis for symptoms, but the immunologists are the relevant specialty. The treatments will heavily involve diet.
Hi Joanna-It is indeed frustrating to encounter people who don’t want to hear anything new. This May I attended the annual conference on Biological Psychiatry. Kim Do and Tony Grace who both investigate the dopamine system presented. Kim Do’s work is all about Reactive Oxidative Species (brain inflammation), which impair signaling at NMDA receptors, being the culprit in hearing voices. (My book, Neuroscience for Psychologists and Other Mental Health Professionals, covers this story.) Tony Grace, who got an award, also views the fast spiking GABA interneurons, which are controlled by NMDA receptors, as controlling dopamine and therefore is the key for psychosis. An article this month in the Atlantic (One Day in February), is about inflammation and psychosis. The inflammation story seems to be going mainstream. I don’t think psychiatrists are going to quit prescribing antipsychotics until they have an alternative. Perhaps making the case for minocycline, sarcosine, or N-acetylcysteine would give them something to do. These drugs are a much better alternative than dopamine blockers. If they have an alternative they might be more receptive.
Thanks for the post. As you indicated this is a very complicated issue. In the post by Maia Szalzvitz, she indicated that the majority of pain patients use their medications responsibly. There is research to support this assumption. However, it does not follow that the current epidemic is therefore not attributable to the increase in pain medication prescriptions. What preceded the current opioid epidemic was a new emphasis in the medical community on treating the fifth vital sign viz., pain. In the 1980s opiate medications were just not around in household medicine cabinets. Now, with the promotion of treating pain aggressively, there is widespread access to these pills because of the escalation in prescribing. The demographic group with the biggest rise in the use of illicit opiates is middle class, white young people. Most of these young people are introduced to opiates through the family medicine cabinet. Moreover, most teenagers and young adults probably do not regard the ubiquitous OxyContin tablets as risky, because, after all, doctors would not give people these chemicals if they weren’t safe. The problem is that when opiates are readily available and labeled as medicine, then more people will experiment. The treatment of all degrees of pain will ensure that more opiates will be in the family medicine chest, unless the guy with a backache wants to show up every morning at 6 am at the methadone clinic, the only way to ensure that the stuff won’t be in the family medicine cabinet.
Some believe that trauma, PTSD, distress are the major causes of addiction. There is research supporting the higher rate of trauma, PTSD, distress in those with addictions compared to the general population. However, one is making the ecological fallacy when drawing the inference, that trauma, PTSD, and/or distress is the major cause of addiction. Many animal studies prove that exposure to addictive chemicals causes compulsive seeking of drugs. The animals used in the research were not distressed or abused, they just had access to chemicals. Stated alternatively, exposure to high concentration addictive chemicals causes addiction. In fact, this view comports with my experience as a substance abuse treatment provider. Most of the alcoholics and drug addicts I knew were very well adjusted, cheerful people, when they weren’t using. Most had been raised in supportive home-environments. They became addicted because they got exposed. This is also consistent with the conclusions of alcohol researchers, George Valliant and Marc Schuckit.
With regard to more treatment for those who are addicted, many believe that those with addiction should be receive “Medication Assisted Treatment”. This means that the treatment will be the administration of a mu-opiate receptor agonist (methadone or buprenorphine). Presently, there is no clear definition of addiction. Many of the current users of illicit opiates are not physically dependent, although they do seek drugs. If these non-physically addicted people enter treatment with methadone or buprenorphine, which requires that the opiate receptor drugs are constantly in the body, they will become physically addicted. The treatment will thus move them from the category of occasional user to truly dependent. Moreover, there will be another type of opiate drug in the family medicine chest: buprenorphine and perhaps, methadone, if the client has qualified for take-home privileges. More young people will then have another source for experimentation which they are being told is medicine.
Consistent with the point Richard Lewis previously stated, ironically, opiates may not even be a good solution for ameliorating the distress of those in chronic pain. There is a pretty big literature showing that chronic use of opiates enhances pain transmission in the spinal cord. (The explanation has to do with foreign molecules activating the immune system and the white blood cell hormones then enhancing pain transmission. See the review article by Hutchinson, Shavit, Grace, Rice, Maier, & Watkins in Pharmacological Reviews.) Readers of this web site, may recognize a familiar story. As with antidepressants, in the long run, the drug makes the condition the drug was intended to ameliorate even worse. I’m not suggesting that opiates should not be used to ameliorate of the terminally ill cancer patient. I am saying that the pain patient who has reason to believe he/she won’t be dying in the near future, should seek a better solution.
Thanks for your discussion. I think there is a third way beyond psychiatry and anti-psychiatry which you alluded to in your discussion. I, also, think that the NIMH is receptive to it, as evidenced by the fact that the NIMH has embraced the Research Domain Criteria and abandoned the DSM. People in mainstream psychiatry have considered and perhaps even embraced the notion that inflammation can manifest as depressive behaviors. For psychosis, at least at Emory psychiatry, hypofunction of NMDA receptors are viewed as the culprit and inflammation leads to NMDA receptor hypofunction. (My book, Neuroscience for Psychologists and Other Mental Health Professionals, and my website, littrellsneuroscienceofwellbeing.org, cover these stories). There are many studies attesting to the amelioration of inflammation with diet, exercise, yoga, meditation, and social support. Additionally, there are many studies linking psychological stress with inflammation. Thus, one can fully embrace physical explanations for behavioral changes without believing that medications are a good idea. Moreover, with the Affordable Care Act, behavioral health is supposed to be integrated into primary care. In my book, I argue that we should be screening for an absence of happiness in primary care and just skip the self-fulfilling prophecy psychiatric labels. Then behavioral health people can engage individuals in salubrious life-style changes: anti-inflammatory diet, exercise, and support groups. All of these changes are quite consistent with preventing cancer, heart disease, and diabetes. It’s a win all round.
thanks for the post. At a conference at Harvard in June 2015 on opioid prescribing, a study was presented examining factors associated with bup OD. Concurrent prescriptions with SSRIS and antipsychotics were identified. Will bup be an adjunctive med or monotherapy?
Even-thanks for the comment. I spend most of my time working in an immunology lab at GSU. GSU has a center devoted to inflammation. The immune system has multiple arms. The two basic divisions are the innate system and the adaptive immune system. The adaptive system specifically targets particular “foreign” appearing molecules. It does not tear up everything in it’s path. The adaptive system is what is activated with vaccinations. The innate system are the cells which are the first line of defense if you cut your finger. Turns out that a chronically activated innate system will impair the adaptive system. Thus, the ability to fight viruses and cancer cells, the task of the adaptive system, is impaired. A chronically activated innate system is the culprit in cardiovascular disease and cancer. Check out my blog littrellsneuroscienceofwellbeing.org.-the post on Myeloid Derived Suppressor Cells. I agree, you don’t want to break a fever. However, as soon as the infection in a local area is cleared, you want to turn off the innate system cells (mainly, the neutrophils). There are receptors for omega-3s on neutrophils which will help to resolve the immune system activity when the job is accomplished.
Thanks for the comments. There is literature on how interventions such as exercise, yoga, social support decrease inflammation. I have covered this literature in my book. I also have my own blog littrellsneuroscienceofwellbeing.org where I cover this information.
An anti-inflammatory diet consists of omega-3s fatty acids. Charles Serhan who is a chemist who works with fats has examined the direct effect of omega-3s on leukocytes. Omega-3s are anti-inflammatory. Curcumin in tumeric is anti-inflammatory. (Curries use a lot of tumeric.) Yogurt changes gut microbes so they are anti-inflammatory. Stay away from high fructose corn syrup, saturated fats in large quantities, sugars and artificial sweeteners but apples (sugar in fiber) is good. Avoid foods containing preservatives because the preservatives swing gut microbes in the inflammatory direction. All this boils down to a diet with a lot of fish, fresh fruits and vegetables, and olive oil. Use the meat as a garnish rather than a main dish.
thanks for the thoughts on this. What I meant by “basis” is that all behavior begins with physiology somewhere in the brain. Talking is in the left hemisphere. Understanding spoken speech is in the left hemisphere. After an individual suffers a stroke, neurologists watch the person behave and can then pin-point what area of the brain suffered the loss of oxygen. Similarly, hearing voices involves some component in the brain.
The story of fast, spiking interneurons is told in a paper I wrote on “Will the treatment of schizophrenia be changing soon?” which you can download from the scholarworks website at Georgia State. Google my name and scholarworks. Look at the evidence and then make a decision.
The point of this blog is that given one believes the fast, spiking interneurons are the key structure involved in psychosis, antipsychotic drugs are a disaster.
With regard to the money making potential of anti-inflammatories I am pretty much against the antibodies to TNF-alpha which are advertised for the treatment of Rheumatoid arthritis because they can precipitate Multiple Sclerosis. I do think an anti-inflammatory diet and curcumin are worth trying.
Thanks for the post. In my book, Neuroscience for Psychologists and Other Mental Health Professionals, I argue that we should screen for happiness. We could thus avoid the self-fulfilling prophecy with the diagnostic label. As you know under the Affordable Health Care Act, behavioral health is suppose to be integrated into primary care. For those in distress, the behavioral health provider could arrange support groups, yoga sessions, and coaching on an anti-inflammatory diet and more exercise.
thanks Sandy. I agree that for clinicians deciding what to do is a real dilemma. Hearing voices can be scary and very painful for the individual and others around the individual.
To keep the record straight, I think that early relapse after drug discontinuation can be chalked up to drug withdrawal. As you know, I believe in the Wunderink et al. study, those discontinuing medication had more relapses right after discontinuation, but those on meds had more relapses later in the follow-up interval
I’ve been reading American Journal of Psychiatry and JAMA Psychiatry. The last couple of issues are full of the NMDA, fast spiking GABA interneuron story for psychosis. (David Lewis, the guy who did the monkey studies on the anti-dopaminergic drugs, is a big contributor.) I keep wondering, “why no study using drugs that target the fast spiking GABA interneurons without the anti-dopaminergic drugs?” The answer I keep coming up with is that seroquel and abilify are big money makers.
I think we need a campaign to get the money out of medicine.
what about omega-3s for decreasing depression in pregnant women? I believe there is a literature here. If fish are feared because of the mercury, switch to walnuts.
It’s not just psychiatry. As detailed in my prior posts, the current heroin epidemic is attributable to OxyContin prescriptions from physicians. (When the Oxy becomes too expensive, people switch to heroin.) During the drug company campaign to convince doctors that people in pain could not be addicted to opiates, they cited Jink and Porter. No one checked on Jink and Porter which, in fact, was a one paragraph letter to the editor of New England Journal of Medicine. The level of gullibility has no limits.
Sandy-I’m sure you’ve heard the claim that early treatment is better because we can change the long term trajectory. In the discussions on NPR the claim was once again resurrected as a conclusion from this study. To make such a claim, one would have to randomly assign first episodes to immediate treatment or delayed treatment and then follow out 8 years to see if the groups differed on number of episode, severity of episode, etc. What apparently the study did find was that those who had only been symptomatic for a short period of time, exhibited a better response. This generate two competing hypotheses for me: (1) once you start drugging people (you indicated that many had been drugged prior to study entry), nothing will help very much; or (2) the psychotic phenomenon will proceed along some ineluctable path such that people become refractory to treatment. What did I miss?
Hi Sandy-thanks so much for the post. I have not yet read the article, but I did read the material in the New York Times. What caught my interest was that they claimed early treatment makes a difference implying that early treatment could impact the course of the phenomenon. Your post suggests was what they found was that only early on in the course of the phenomena (I won’t use the term disease) does psychological intervention make a difference. This is a very different conclusion. Again, we spin.
I hope you’re going to present at the annual American Psychiatric Association again. With regard to defining the problem according to the view of the individual, there is a whole literature on therapeutic alliance. For major depression and substance abuse (see Project Match), outcomes are better when therapist and client agree on the definition of the problem and the strategy for resolving the problem.
I agree. I put in the quote because even believing everything they say, the case is weak.
e-mail me at [email protected]. I’ll send you the paper
Hi-you might want to check out my paper on schizophrenia available through the Georgia State Library (google “littrell & scholarworks). Alternatively, my book has a chapter on psychosis. There are alternatives to D2 receptor blockers which are much more benign. There’s also an emerging literature on infection and psychosis.
Thank you Norman. Is there any way to influence what is taught in medical schools. I attend grand rounds over at Emory. They never say anything negative about meds. A women presented on pediatric bipolar last week. She made it sound legitimate. There is no questioning about alternatives. There was no questioning of the tricks that Biederman used to make pediatric bipolar sound credible. If physicians continue to be misinformed, is there any hope for the future?
Hi John-I really hope you are right about antibodies to PD-1 and CTLA4 for cancer. I’m hoping for my friend, there will be a doctor around who is willing to use this approach when his cancer returns. (Right now the tumor has shrunk in response to chemo). Let’s be clear though, it was the research scientists at public funded universities that came up with this stuff. I remember listening to Raffe Ahmed over at Emory on PD-1.
With regard to statins. I’m glad people have choices. With regard to no clinical trials on omega-3s, there is epidemiological diet on cardiovascular disease. For clinical trial on omega-3s to be positive, it would require attention to the whole diet. If a person took omega-3s while continuing to consume high fructose corn syrup, then it would not work. It’s all going through the inflammatory loop.
thanks for your comments John. I have a friend with a recent diagnosis of metastatic esophageal cancer. I told him and my brother (CDC physician) about antibodies to PD-1 but no success in finding such treatment. We’re back to slash and burn. With regard to efficacy of the antibodies for solid tumors we aren’t there yet. No strategy for combating Myeloid Derived Suppressor Cells, MAT, and T regs in the tumor.
By the way, a few years back I got curious about why statins are anti-inflammatory. I read a lot of Charles Serhan’s research. (He’s a biochemist who’s into lipids.) He provided the answer. Serhan also has contributed a lot on why omega-3s are anti-inflammatory. Given a choice between statins and fish, I’ll take the salmon.
Stephen-thanks for the comments. I do remember a Frontline where they talked about checking the bacterial status of patients coming into hospitals from nursing homes, where there are high rates of infections. This did not become hospital policy because it was too expensive. And yet our society has money for Abilify for treating foster children.
I think as long as we have “for profit” medicine and “for profit” development of drugs and devices, the truth will never be secure. Some company will always have an incentive to lie. As Marcia Angell points out most drugs are developed/discovered in universities anyway, so I don’t buy the argument that there would be no one willing to do research. Most of the researchers I know are in it for love of discovery and the approval of their peers. I don’t think anyone would lose if we created a system without financial incentives.
I think in a coming blog I’ll talk about the return in some places in medicine to helping the body heal itself. As mentioned elsewhere, I work in an Immunology lab. The hot topic is getting the CD8+ cells to get rid of the tumor. This kind of approach would have far fewer side effects than the current slash and burn approach. Unfortunately as Ghaemi points out modern medicine is an assault on disease rather than an assistance to the body’s natural defenses. I welcome the paradigm shift.
Richard- Thanks for the info. on pain is the fifth vital sign on last blog. With regard to your comments here-there are so many issues. I’m kind of a libertarian so I don’t know if I want to remove options from people even when these options are stupid. However, I think where we would agree is that the medical profession should not be money driven. I’m for nationalizing the drug companies and all medical care generally. Last night Frontline was devoted to antibiotic resistant microbes. This is a crisis and I would move it up in the CDC agenda above everything else, except maybe Ebola. Of course, because there’s no market, no one is paying attention.
I don’t have a problem with anyone choosing to take an opiate for pain or for recreation. I do have a problem with lack of informed consent. I think the government needs to regulate the way those who make money off of drugs portray their products. I think if people knew the consequences of bisphosphonates (bonivia), entanercept (Enbrel), and statins, they would be far less likely to accept these remedies for what are usually minor aliments. When it comes to chemicals, there’s no free lunch.
I wonder whether our society needs to get over the idea that there is a pill for every mild discomfort. I watch the commercials for antibodies to TNF-alpha directed to people with arthritis. One of my students who does not appear to be in pain said she had a hard time resisting her physician’s advice to take antibodies to TNF-alpha for her mild discomfort. Turns out that TNF-alpha antibodies are associated with a failure to myelinate axons. This seems like a major league side effect to experience for some relief from having stiff hands in the morning.
I think that pain patients become drug addicts through their physicians. With regard to opiates before they were made illegal, country doctors making their rounds on horse would leave the vial of opiate with the arthritic persons with directions to use every day. By the time the doctor came back, the patient was addicted meaning he/she would experience withdrawal without the drug. The same thing has happened with regard to prescription OxyContin. Taken according to doctor direction, people were becoming addicted. The same thing occurred with valium. Taken as directed, people do get addicted. When I worked at CIGNA in the Alcohol and Drug Dependency Department, we would regularly ask psychiatrists in the Mental Health Department not to provide prescriptions for valium. The valium detox came out of our department’s budget. We were never successful in changing physician behavior.
Please see the article on the DSM-V written by myself and Jeff Lacasse published in Families in Society. It’s available for download from scholarworks. Google “Littrell and Scholarworks” and it will come right up. I wonder why given that the federal government has abandoned the DSM, schools of social work continue to pay homage. Also, check out my website “littrellsneuroscienceofwellbeing.org”
Hi Sandy-thanks for the post. Carl Tavris has been around for a long time. I think she began her career at Psychology Today. I show my class a video of Carol Tavris interviewing Beth Loftus. Beth is the memory researcher who showed that one can implant whole episodes of false memories. Beth also showed that eye witness testimony is very unreliable and the words the police use right after an event was witnessed can distort what people believe they saw.
Carol Tavris also has written a book on anger. She has questioned whether expressing one’s emotions is always a good idea. The psychoanalytic notion that trauma needs to be processed was also a topic for evaluation for a number of social psychologists including me. (I’ve published three papers on this topic.)
In terms of cognitive dissonance, I think it’s easier to question deeply held convictions if one has a alternative. My mentor, Bob Cialdini, is famous in many circles for his book Influence. What’s useful clinically is the social psychology research on self perception: people behave consistently with the concepts they have of themselves. Using cognitive dissonance, if a clinician gets the client to recall memories of strength, then the client will act consistent with these memories.
The fascination with serotonin continues. In my book, I cover the raphe nucleus where serotonin is produced. Turns out there are at least 7 circuits in the raphe. One of these circuits is a major player in anxiety and learned helplessness. Another circuit, which is induced by warm temperatures, calms the anxiety circuitry. I guess one can say anything about serotonin and be correct.
I don’t spend a lot of time on Tylenol and aspirin, other than the studies which use them to show that targeting inflammation can make a difference in mood. There are better ways to target inflammation with diet rather than pills.
thanks. I’ll check this out.
Load up the diet with anti-inflammatory substances: fish oil and curcumin (turmeric). If you can avoid high fructose corn syrup and eat less processed food. Nuts are great
one controls for other variables with statistics. This is a gross oversimplification but here is an explanation. You calculate the slope between your dependent variable of interest (inflammatory markers) and your independent variable (controlling work schedule). Then you calculate the slope between your dependent variable and the control variable (diet). You subtract the degree of the slope for the control variable from the slope of interest. This is done all the time.
naltrexone is long-acting naloxone. It’s effectively the same thing.
I know in some localities in Europe, they just give people heroin. At the opioid treatment conference in Atlanta, a man who runs a long-acting morphine clinic (which is another form of MAT) presented his data. They might be stricter on pain meds, but they seem to be more liberal on viewing heroin provision as acceptable treatment.
I’m not opposed to MAT. I am opposed to not supporting a person who wants to be sober. I think people should be supported in whatever their decision.
Hi Adam-thanks so much for your post. I hope that you write a letter to the New York Times. You are entitled to equal coverage.
There are alternatives for treatment of dysphoria in pregnancy. The case for distress being linked to inflammation continues to increase. In addition to the information in my article in Frontiers in Psychology and in my recently published book, an article by Setiawan, Wilson, et al. 2015 JAMA Psychiatry I found particularly convincing. In terms of what to do about inflammation, Charles Serhan, a biochemist who works on lipids, studies how omega-3s influence leukocytes. Omega-3s are anti-inflammatory. There’s also a literature on omega-3s and pregnancy (JR Hibbeln). So there are healthy ways to treat distress.
I am also dismayed by this latest report of compromise. However, it is part of a larger backdrop of wanting smaller government and demanding a reduction in taxes. My brother has worked at the CDC for the last 22 years. When he first moved to Atlanta, his desk was under a leaky roof and he placed a waste basket underneath the run off. His report is that the head of Home Depot when touring the place was dismayed by the lack of modern equipment for responding to disasters. Apparently the Home Depot guy passed the hat among his wealthy friends and a new fancy command headquarters was constructed replete with fancy computer screens to respond to world crises. This came in just in time for the Haiti cholera epidemic and the ebola crisis. I think a similar story occurred at the FDA, when they decided to have the drug companies pay for the process of drug approval. Bottom line: you can’t privatize the federal government. If people want something different, they are going to have to pay for it.
Hi Sandy-great news and glad their was a receptive audience. Was there any discussion of other ways to target NMDA receptors-sarcosine, N-acetylcysteine, omega-3s, anti-inflammatories? What about checking for systemic infections? I always wonder why there are no monotherapy studies with these new approaches with first episode patients.
Hi David-my new book, Neuroscience for psychologists and other mental health professionals: promoting well-being and treating mental illness, covers the story on diet, exercise, meditation, and social support. In fact, there is a great deal of support for these interventions to treating distress. The book also covers the lack of support for current psychotropics. Many psychiatrists are stuck on neurotransmitters. In fact, the emerging story in neuroscience is around the immune system as a major culprit in distress and psychosis. Consistent with this idea, Matt Lieberman and Naomi Eisenberg (social psychologists at UCLA) have their subjects play an interactive game from which the subject is then excluded by the others. Predictably the brain’s alarm center lights up. But, if the subject is pre-treated with aspirin, the brain’s alarm center does not light up and no subjective distress. Systemic inflammation responds well to turmeric and omega-3s and exercise. However, the American diet is replete with inflammatory factors-high fructose corn syrup.
I’m delighted that Lieberman chose to talk about you. Lieberman’s comments contribute to the diffusion of information to the public. The group that most needs to be apprised that data exist against current psychiatric practices are the psychiatrists themselves. The more public the controversy, the more likely that doctors will be induced to investigate the issue and find the truth. If med students read the data, it’s pretty clear that psychotropic meds are a bad idea. However, if you are a psychiatrist in training, you just will never hear of any thing negative. Lieberman’s high profile inflammatory remarks may induce his colleagues to start asking questions. Once questions are asked, a negative view of current psychiatric practices will follow.
Any way, you can debate Lieberman on the Canadian broadcast?
I applaud your efforts. I think that a discussion of the history of mental illness is complicated because the definition (inclusion criteria) have been broadened to include the entire human race. In the DSM II, depression referred to the dysphoria of those with psychosis who would now be referred to as Bipolar I. With the publication of the DSM III, those with psychotic depression and neurosis were placed into the mood disorders section. Ghaemi’s account, discussed in my book Neuroscience for psychologists and other mental health professionals, clarifies how those with psychosis were merged with common variety dysphoria. Thus, the DSM III became the book which classifies everyone.
Ironically, in the days of the DSM II, the disorder of Inadequate Personality was represented in the state hospital. It was also discussed in courses on Abnormal Psychology. The disorder is no longer in the DSM. Those with an Inadequate Personality just did not seem to have the drive to take care of themselves. They were perfectly content to be directed by others. I’ve met such individuals. One of my state-hospital patients in the 1960s was labeled “Inadequate Personality Disorder”. Ray was always whistling and happy. He never heard voices. I don’t recall ever seeing him angry. With deinstitutionalization, Ray was kicked out of the hospital. Ray then broke into a building and left a note for the police so that they could pick him up and return him to an institutional setting. Neuroscientists have identified the Ventral Tegmental Area of the brain, an area of high dopamine concentration, as key for motivated behavior. My guess is that Ray suffered from not enough activity in this brain area. He just did not seem to want to do or be anything. He had achieved contentment. I think this is a real big problem for some people, although it the category did get bounced. Perhaps it’s because there is no pharmaceutical to treat it.
Hi Sandy-Thanks for the post. We’re back to the discussion of the ridiculous way in which medicine is practiced in America. I do remember a lecture given by Otis Brawley, who is the medical director for the American Cancer Society, at Georgia State. He talked about occult blood as being a pretty good screening tool for colon cancer. (Relatively cheap.) I guess there is something to be said for colonoscopy and cutting polyps before they undergo epithelial/mesenchymal transitions, but as with breast cancer tumors, my guess is that in the future we’ll know how to predict which ones are “too worry about” and which are innocuous.
I’m currently reading Steven Brill’s America’s Bitter Pill. The first half discusses all the factions that were lined up at the trough when forging the Affordable Health Care Act. The American public was not represented. When I see my doctor, who is a nice guy, I feel like a commodity. Given that the costs of health care are rising faster than even the military budget, can this be sustained?
The discussion of serotonin is somewhat misleading. Serotonin is involved in about 9 different circuits in the brain. (See work by Chris Lowry at U. of Colorado). One cluster of serotonergic neurons creates learned helplessness and anxiety. Another cluster tones down this circuit. Consequently, in order to determine the impact on behavior, one would have to specify where serotonin release is being amplified. If all serotonin release is amplified everywhere then the impact on behavior could not be predicted.
Hi Bonnie-I’m thrilled that the diet story is getting so much attention. Not only is it what you eat, but probably the story on what not to eat deserves attention too. Gretchen Neigh, over at Emory, has studies showing that above a certain level, consumption of fructose makes the mice very anxious. My book, Neuroscience for Psychologists and Other Mental Health Professionals: Promoting Well-Being and Treating Mental Illness published by Springer should be out in April. It covers nutrition (exercise, meditation, yoga) and I cite you folks. Maybe things can change.
Hi Bruce-one of my students conducts interviews for Kerry Ressler’s studies on everyday trauma/PTSD over at the big public hospital in Atlanta. My student, of course, finds that many have experienced traumas-violent deaths of loved ones, crime, etc. She has wondered why they don’t seek treatment. My guess is that those with PTSD are reluctant to self-label. Perhaps, SAMSHA needs to view this as a good thing and start providing services geared toward “community support” or some other positive identity label. If the self-perception literature (Darrel Bem) is to be believed, once a person self-labels, the battle is at least partially lost.
Thanks for the post. I keep wondering when someone will look at the impact of employment on rates of PTSD in returning vets. I’m also remember the recent 60 Minutes segment on the rapid rise in SSDI claimants after the local mill was closed. It’s good for us to remember that the major hammer blows for mental health are lack of fairness and inclusion in society.
Hi Bob-I totally agree with the long-term outcomes of antidepressants being bad. I do wonder, however, whether the rise in SSI and SSDI can be totally accounted for by the use of drugs. I think that bad economies also have something to do with the rise. I remember the 60 minutes segment on the almost the whole town be declared disabled after the local factory was closed. I would chalk the rise in disability to the availability of labels. I used to evaluate people for disability. The label of depression has a pretty low bar. It’s an easy case to make. There was also a major swell in the rates of children getting SSI for ADHD. (I think in recent years, the Social Security System might have tightened up on the criteria for ADHD.) When its hard to earn and the criteria are low, people will find a way.
Richard, as I said, I’m a libertarian. I do wonder whether heroin would be a problem if it weren’t illegal. Addicts die because of the illegality issue. They do have to steal, because its not cheap and readily available. In Europe, in some countries, addicts can get heroin legally through the health clinic. They come in, shoot up their safe dose under observation and then go to work. In this country, opiates were legal prior to 1914. Again, no big problem for the society. Abraham Lincoln used laudanum throughout the Civil War. Personally, I am not for heroin use or addiction. But, I don’t think I need to impose my preferences on others.
Thanks for responding Sandy. I think we are on the same side of most issues. I do think that both you and Moncrieff are correct about selling the disease label and that being terrible.
On the issue of the opiates epidemic largely attributable to prescription oxyContin, I keep wondering whether opiates would be considered to be a problem if they weren’t illegal. ((More propaganda selling the population on another untruth.) Since opiates don’t have such bad long term effects on the body, why not just not worry about it. I don’t think the society will be harmed if we have large numbers addicted to opiates. Opiates do decrease sex drive, but again not a big concern for the society. We’ve come to this position with marijuana in many states. If people get addicted to opiates and they don’t like it, well then there’s AA and the treatment centers. So why should it be an issue of the society. Why should Tom Frieden bemoan the fact that people are getting addicted to Oxycontin, and then turn around and recommend bup or methadone?
With regard to needing to have a disease before a doctor writes a script, this is interesting too. I remember my friend, who was fighting with her ex over an expensive private school for her son, getting a script for Prozac. I said, “but Jay, just one problem, you’re not depressed. ” She replied, “Oh, yea, I know and I’m not going to be.” No worry. The first memory disturbance she experienced and down the toilet the Prozac went. But, Jay’s doctor apparently had not problem with giving a script to someone who obviously was not depressed. My guess is this is not a rare event.
Sandy-I find myself in the uncomfortable position of arguing pro-drug. (I’m against drugs.) However, as a civil libertarian, I think anyone who wants drugs should get them. If I had a prescription pad, and a patient wanted drugs-I would just write the script-following, of course, informed consent. I think if a doctor would write a script for an antidepressant, if requested, he/she should not get squeamish about bup. As you know SAMSA and Nora Volkow love bup. So the government probably won’t have a problem. I don’t think I would worry about the person who just wants to get high. Who cares.
Just doing drug to drug comparisons between Prozac and bup on relevant dimensions, doesn’t look to me that one can argue that Prozac is better than bup. Both drugs are addictive. I would argue that withdrawal from Prozac is worse (dyskinesias, mania, sensory distortion) than heroin, although I have not had much experience with bup withdrawal. You can OD on bup, but I think that the preparation that can be spread on the gums was an attempt to increase safety. As you know there were more drug OD on the old TCAS than there were with opiates. As you know antidepressants, can induce mania and violence. When taken in excess but at lower doses than would cause respiratory depression, heroin addicts just fall asleep. So why isn’t bup preferable to Prozac. At least opiates do have a good track record on altering mood. They’ve got more than placebo to say for themselves.
What’d I miss?
Hi Sandy-thanks for the post. I share with you concerns about long term effects. Moreover, in the literature on fast spiking GABA interneurons-ketamine (which blocks NMDA receptors) will cause these fast spiking inter-neurons to die.
If we must do drugs, I wonder why we don’t use buprenorphine for depression. Jaak Panksepp, a good neuroscientist, argued in a recent issue of an Association for Psychological Science journal, that buprenorphine should be tired. I guess it is in clinical trials in Israel. Heroin addicts did not have negative long term outcomes, although ODs were/are a problem. To my knowledge, heroin does not cause violence and if not used in high quantity, does not impair function.
For ADHD, there are studies using nicotine patches. They are just as efficacious as Ritalin on increasing attention. On a psychological basis, people smoked for years throughout several centuries without devastating psychological effects. Presumably, the nicotine patches don’t cause cancer, although they will raise blood pressure. If I were a parent, I would prefer the nicotine patch to some version of speed.
My preference is no drugs. But, if we’ve got to do drugs, shouldn’t we be weighing the pros and cons of everything.
Ronnie is now HIV+. With his HIV status, he now has housing.
thanks. I’ll check this out for my classes
Doesn’t the author of the Spirit Level argue that inequality-a high level of income disparity in a society-is bad for even the people at the top?
I’m not sure how to respond. Sorry if you are offended.
You caused me to wonder about whether societies with a better safety net have fewer persons with mental health issues in the criminal justice system. I have my students read Russel Shorter’s Going Dutch, a NY Times Magazine article that details the extent of the benefits provided in the Netherlands-for about the same rate of taxation as in the US. I’ll have to check out if those with psychosis fare better in the Netherlands.
I don’t think that living on the street causes mental illness. I make this statement because of a research project I conducted wherein I interviewed about 200 guys. Two-thirds of these individuals were addicted to crack. They weren’t depressed or hearing voices. Most worked everyday through the day labor pool beginning about 5 am. The most frequent adjective that they checked on our mood adjective check-list was “determined”. Many said they did not look for work, because, if they had a job, their cocaine consumption would increase. I think they were right. Moreover, they were using a lot less cocaine on the street than the employed people I met while working in a treatment center.
Hey, I’m a social worker. Could not agree with you more.
If you get rid of the medical model, but you also think that some people should be let off the hook on a murder charge, for supporting themselves, etc., then you have to have some mechanism for determining who should be absolved of responsibility. Got an alternative?
I do think drugs can alter free will. This is the case with antidepressant drug induced psychosis. I also believe that drugs such as alcohol, for some, and cocaine can alter the brain and remove choice in whether one will use. I also think that psychosis can remove free will. I don’t have a problem with the insanity defense. I also think that some people really can’t make a living and support themselves. I think our society should provide for their needs (food, clothing, recreation, a reasonable standard of living, and choice). But, then if we agree to this, there has to be a mechanism for determining who should be absolved of responsibility and who should not. Then, I think, we’re back to the medical model and the Americans with disabilities act.
Clearly, the system is out of control. Your history is a case-in-point. But, Allen Frances does have a real point. There are people who many would regard as “not responsible for their own behavior”. I’m not saying that psychotic people are more likely to be violent than others. I am saying that psychotic people are more likely to be lacking in the capacity for self support and maintaining a job. Given a lack of income, people will steal food, be guilty of public urination, will violate vagrancy laws. Frances question concerns whether such people should be punished or treated. I’m raising the issue of how the society should respond to these people.
What would you do with the people who commit misdemeanors but obviously don’t have the capacity to earn a living in society? My husband and I have been a friend to a homeless guy I met in a research project. (Ronnie tests out with an IQ below 70 and he does not have much impulse control.) I helped Ronnie get Supplemental Security Income which is about $600/month. But Ronnie keeps/kept getting into trouble for minor things (jumping the turn-style at public transportation, prostitution, public urination, hitting an obnoxious roommate over the head with a piece of Tupperware, this and that). He occasionally spent time in jail. Then he was assigned a P.O. When people like Ronnie visit the P.O. they have to pay $50 or so dollars every time. This comes out of the SSI check. The state makes money on the Ronnie’s of this world. If you go to court, you will see judges trying to figure out what to do with the repeat offenders like Ronnie who are brought in for public urination, although they are homeless. It’s really a laughable system.
So was Szasz correct. If a person commits murder when hallucinating because of antidepressants, should this factor be a consideration in sentencing. (There’s a terrific documentary by Ole Hjortdal and Paul-Erik Heilbuth “The Dark Side of a Pill” which interviews people now in prison who committed capital crimes while on Prozac.) We’re back to the same question, can the brain ever cause behavior or does everyone always have free will? That is, physical brain states can never take away free will.
Sorry this post seemed cryptic. My main point is that the criminal justice system and the mental health system in the 1960s were pretty much the same. My second point is that even those psychiatrists who do believe in a physical basis for psychosis should realize that current treatments are barbaric and be demanding better options. Many oncologists I know readily admit that the slash and burn approach needs a replacement. Why aren’t psychiatrists insisting on controlled studies of other treatment options.
Presently, most state commitment laws are time limited. In Georgia, the first commitment duration cannot exceed 6 months. The second commitment is for a year. Commitment in most states requires mental illness + danger to self or others. Some states also have the category of gravely disabled. Some people may be detained for years but this requires multiple legal proceedings. The exception is that if someone has committed a crime, he/she can be kept in the state hospital if mentally ill for the duration of their sentence. (My ex-husband, at the Nebraska state hospital, cared for a ward of pedophiles. They were there for a long time.) Most people only spend 3-4 days in a mental facility following commitment. There is also the option of outpatient commitment. However, if someone refuses treatment as an outpatient, that individual can only be treated if he/she meets criteria for initial commitment (mentally ill and danger to self or others).
My other point in this blog is to ask a question. I’m asking what readers of this blog believe should be done with those who break the law but hear voices. In my opinion, James Holmes and the unibomber are examples. If there is nothing wrong with them, should they get the death penalty or life in prison. These are the options on the table for most people. If there is no such thing as mental illness, then what should be their penalty? By the way, although in capital cases (murder cases) courts do consider mitigating circumstances, according to my friend, Jose Ashford, who evaluates people on death row, he’s never met a person who had been convicted of a capital crime who did not have mitigating circumstances. Given mitigating circumstances, people aren’t sentenced to death but they do get life. Is this the correct outcome for those who hear voices?
Thanks for the post. I’m in total agreement. I believe that taking the money out of medicine might go a long way to correcting things, although certainly it would not correct all misguided behavior on the part of physicians. I’m encouraged because of the occasional story on doctors getting kick backs for prescribing the more expensive pill. On 60 minutes, there was a story on cancer drugs. When a big HMO refused to buy the more expensive pill, the pharmaceutical house gave a kick back to the doctors, but Medicare was continued to be charged the more expensive price. Given that economists keep saying that the cost of medical care will soon exceed, as I recall, 20% of GDP, someone might decide to reign things in. But, they did not do reign in the defense industry, so maybe the standard of living in the US will just continue to deteriorate.
If you go to google scholar and put in Chris Lowrey’s name, many articles will come up. You can download many of them.
Thanks so much for the post. I was curious that the variance/standard deviation increased after Rx relative to before. Michael Thase, an apologist for the industry, always says that the results of drugs are dramatic in some. I always wondered about the variance needing to be larger in the treated group for Thase’s claim to be true. Apparently, the variance is larger. But, does this fact invalidate the use of the statistic? What a mess.
With regard to the serotonin argument, Chris Lowrey finds that the serotonin neurons in the raphe actually entail multiple circuits. One of these circuits, through the caudal dorsal raphe causes learned helplessness and depressive behavior. Even the theory is ridiculous.
Hi Sandy-what about supplementing with dietary anti-inflammatories, N-acetylcysteine, and perhaps something to target NMDA receptors (e.g., sarcosine)? For publishing, numbers are important, but I’ve read “letters to the editor” on case-studies.
Thanks for the post Vivek. I’m also amazed by the absence of awareness in psychiatry that much of the world has moved on. Most psychiatrists appear limited to psychoanalysis along with some information on Pavlovian conditioning (which does somewhat explain anxiety and PTSD). Usually psychiatrists also know about Rogerian reflective listening, although they are more likely to call it “mirroring’ in deference to Kohout. But, the world has much more to offer.
Since the 1970s up until now, I have attended seminars on just about every new treatment being developed. Some of the new ways of proceeding are grounded in Social Psychology, although most often the exponents for these approaches don’t know that they are effectively applying axioms that are well grounded in the empirical, experimental social psychology literature. I’ll explain what psychiatry, and many psychologists, have missed.
My dissertation mentor, Robert Cialdini, is famous in schools of business and throughout the world. When the US Census wants to know how to get people to complete census data, they call Bob. When the British government wants to know how to get people to conserve water, they call Bob. When the US military wants to learn how to influence others, again they call Bob. But, many psychologists, social workers, and psychiatrists don’t know about Bob’s work or even his name.
Cialdini wrote his famous book, Influence, in the late 1970s. His book draws heavily on self-perception theory with a seminal axiom being that what a person believes to be true about himself/herself will determine his/her goals and behavior. One way to change self-concept is to get the person to imagine himself/herself behaving in a new way or, better yet, to highlight a time when the person actually behaved in that way. This principle is highly consistent with Daniel Kahnman and Amos Tversky’s availability heuristic, for which they won a Nobel prize. Basically, according to the availability heuristic, if persons imagine a particular event, they will believe that it is likely. People who are solution-focused therapists make use of these principles all the time. They ask, “tell me about a time when your problematic behavior wasn’t present” (search for exceptions). “What is the first thing you will notice once your problem is no longer there”. “If a miracle happened overnight and your troubles were gone, how would you be different.” “How would others be different toward you?” The late Jay Haley, who studied with hypnotist Milton Erickson, also made use of these principles. A lot of therapists know about Milton Erickson, but psychiatrists don’t.
I was also impressed by Transactional Analysis, which was a big movement in the 1960s and 1970s. Transactional Analysis therapists also view a person’s self-concept as paramount. Given particular self-concepts, people set themselves up for tragic outcomes. This is very consistent with some social psych experiments in which subjects were assigned to one of three future tasks: come in and eat worms; come in and be shocked; come in and work math problems. The next day, when subjects showed up to complete their task they were told that enough people had already performed all the tasks, so the subject could choose which task to perform. The results were that the people who believed they had been assigned to eat worms or receive shock, actually more often volunteered for these tasks when given a choice. The experimenters were interested in those cognitive changes that were correlated with the decision to volunteer to suffer. Some had taken pride in their sacrifice for science. Some had pride in their capacity to tough it out. Some believed that if they suffered voluntarily now, they would not be required to make a future sacrifice. Consistent with the little experiment, TA therapists believe that human beings cut the best deal they can given the limited options available to them as children. Once the deal is cut, human beings find pride in whatever role they have agreed to. The insight here is that in order to change, a person has to acknowledge the positives in the status quo. Whatever the problematic behavior pattern is there is probably some positive aspect for self-concept that is maintaining it.
While the self-perception literature and the choosing to suffer literature are important, the critical social psych literature for any therapist is the literature on emotions. The Freudian notion that expression of emotion will dissipate the strength of the emotion has been contradicted by many experimental findings. If persons are mistreated and they are allowed to vent as opposed to being distracted by, for example, working math problems, they get angrier. Moreover, to some degree, William James has been vindicated. People decide what they feel by observing their behavior and getting peripheral feedback from their muscles or other bodily responses. So maybe sometimes clients, who are very distressed, should not be encouraged to share, and therefore rehearse, their feelings. Let me be clear. While a therapist should be supportive of clients, therapists can focus on client’s triumphs and direct the work to “what’s right with you” rather than “what’s wrong with you” as psychologist Barry Duncan would express it.
There is also a pretty big literature on the relationship between expressing anger and outcome for the individual. One of my students asked the other day, isn’t bad to “stuff emotions”. (This platitude I think derives from Freud.) In terms of experimental findings, the motivation for failing to express emotion matters. Intimidation is not a healthy emotional state. Suppressing emotions is taxing and shifts attention so that salient aspects of social situations are missed. Believing that others are interested in hearing about one’s emotions fosters mental health. However, learning to think about irritations in such a way that one avoids feeling trapped and angry has the most experimental support.
There is also a big literature on misattribution of emotions. People are easily manipulated into believing they are experiencing a particular emotion through manipulation. For example, if I get a person to talk about his/her mother in a group, the individual will transfer the arousal from being the center to attention to the emotional event he/she is talking about. Beware of those who report “I got in touch with my emotion in therapy.” It is highly possible that the therapist created the emotion through some misattribution process.
Beyond the theories and principles, TA, gestalt therapy, psychodrama, and David Burn’s with his externalization of internal voices, have provided a wealth of techniques. I wonder how many psychiatrists know what “two chair work” is. There’s a lot one can do with people, other than talking as one would with a neighbor.
As time moves on, I wonder if people will remember Eric Berne, Fritz Perls, or Milton Erickson. The social psych people are well represented at the Association for Psychological Science. (The Association for Psychological Science was formed by psychologists who were grossed out by the lack of scientific rigor at the American Psychological Association.) But, I’m always amazed about the lack of dissemination of information. What is an “of course” for many is totally unheard of in other circles. It’s a wonder that the culture ever gets transmitted.
Hi Sandy-thanks for the post and the comments at the film festival. Surprisingly, I do think that the body influences mood and behavior, but focusing on the brain and the neurotransmitters misses the big role on how what we eat, exercise and infection influence mood. For psychosis, I’m convinced that antibodies to NMDA receptors and inflammatory factors play a big role. Seems to me that if someone presents with psychosis, the first thing to check should be for NMDA antibodies and/or infection. Next would be for whether the psychosis might have been precipitated by a change in sleeping and eating patterns-since the clock genes keep coming up as associated with bipolar. When will psychiatrists really practice medicine rather than thinking that the brain is not attached to the rest of the body?
Thanks for the post. I agree. Vitriol never helps anything. You probably read the article by Arnold Relman in New York Review of Books. I agree with him. We need to get the money out of medicine. All of medicine has been corrupted. For a profession that views itself as evidenced-based, what do you do when they cheat on the evidence.
I do wonder how psychiatry is going to dig itself out of a hole. I’m pretty convinced by the story that psychosis reflects deficit fast-spiking GABA interneurons and hypo-function of NMDA receptors. The Australians are saying that Bipolar I is also about NMDA receptors. For Kraepelin, the difference between schizophrenia and Bipolar was that one got better and the other did not. My guess is that in the future, the categories will be drastically revamped.
On the issue of NMDA receptors, I just finished Susannah Calahan’s Brain on Fire: My month of Madness. Terrific book. Susannah describes her development of mania, psychosis, and catatonia. Turns out she had developed antibodies to her NMDA receptors subsequent to melanoma. Of course, her pricy neurologists never figured it out. The neurologist who eventually figured it out first did a brain biopsy. Such overkill. Did he not know about sandwich ELISAS?
For the future, I hope we will see more chapters of pharmed out across medical schools in this country. Perhaps when medical students learn they can’t trust their teachers things might improve.
thanks for the article. If you haven’t seen it, Matt Nock’s study on suicide in adolescents is also relevant. Nock and colleagues followed a very large sample over time. Of those kids developing suicidal ideation, the bulk developed their suicidal ideation after entering the mental health system.
I do not think doctors go into medicine to bad things. They just get misinforI don’t think doctors start out wanting to do bad things. They get misinformed by teachers who are often the highly paid (by the pharmaceutical houses) key opinion leaders. I’m delighted that at Pharmed Out at Georgetown Medical School, the med students are protesting. Check it out, their web site is good.
I pretty much agree. I think however, each drug should be considered on its own merits before deciding whether businesses can discriminate. About 20 years ago, the New York Transit Authority fired an African American train operator who was a methadone maintenance patient. The case was argued as a class action basis. Since the majority of heroin addicts in New York were African American it was argued that discriminating against methadone patients was racial discrimination. I think they lost the case, but Enoch Gordis, who had Nora Volkow’s job, wrote an impassioned editorial about discriminating against those with the disease of addiction. If taken in low dose, opiates are not performance impairing-as far as I know.
In the US, we don’t discriminate against people taking meds for epilepsy–which are impairing. Although I don’t know, whether persons with epilepsy can fly for Delta. In terms of confusion on how to regard drugs, a prof from the Philosophy of Neuroscience department at Georgia State gave a symposium advocating that people in high performance jobs (pilots, surgeons, etc.) should be required to take performance enhancing stimulants.
It’s going to take a long time to sort it out. In the meantime, I’m sure we’ll have even more chemical interventions to debate.
Hi Sandy-great post-thanks. I went to a grand rounds where Brian Miller lectured. He found that 35% of those persons with relapsing schizophrenia were positive for UTIs. Treat the infection, the voices go away.
From what I’m hearing mental health will become part of primary care with the masters degree people being the providers. I’m not a big fan of drugs or psychotherapy. But I do believe in support groups, diet, exercise, and yoga. In line with this Tracey Shor, a neuroscientist at Rutgers who looks at the impact of exercise and learning on BDNF levels in the hippocampus, is now working with addicts. Her treatment is teaching them to dance. Works great for preventing relapse and curing depression. Hopefully that is what the new world will look like.
You might want to read my paper on schizophrenia which is posted on digital archives at Georgia State University. Google my name and either digital archives or scholarworks. Fish oil (omega-3s), sarcosine, and N-acetylcysteine (two innocuous drugs) have been used to treat hallucinations. Bonnie Kaplan (blogger here) has successfully treated hallucinations with vitamins and minerals. Antipsychotics create psychosis by sensitizing dopamine receptors-so the wash out from the drugs is pretty hard. Sorry for your plight.
Thanks for the post. With regard to SSRIs inducing suicidal ideation, I’m researching for a book and was surprised to find overt references in the Neuroscience literature on how SSRIs cause suicidal ideation. Chris Lowry at University of Colorado Boulder has investigated the raphe. His investigations identify 9 different tracks for serotonin. One of the tracks is goes to the amygdala. This track is activated in response to uncontrollable shock and participates in creating learned helplessness, the animal model for anxiety/depression.
Another interesting little tid-bit: Andrew Miller has been studying breast cancer patients treated with chemo. These patients exhibit epigenetic changes on the gene for TNF-alpha. Because of the elevated cytokine level, patients experience anhedonia and depression. (Whole big lit on cytokines inducing depression. ) Anyway at Emory, they treat with antibody to TNF-alpha. What was amazing to me was that the neuroscience group at GSU had just heard a lecture from a woman who works on Parkinson’s disease. She said that the patients treated with antibody to TFN-alpha were developing multiple sclerosis symptoms. I checked in out. Yep, TNF-alpha is needed to induce repair/production of myelin sheaths on an axon (Arnett, Mason, Marino, Suzuki et al. Nature Neuroscience, 2001). Hence when you block it with an antibody, MS.
Whatever happened to “First, Do No Harm”?
I’m not surprised by the rejection of the symposium. One can’t expect a profession to commit suicide easily. With clients, therapists know that you can’t expect a client to change behavior without an alternative solution to a problem. I think the same principle goes for professions as well. I am encouraged by the story on the fast-spiking, GABA interneurons and deficient signaling through NMDA receptors as the primary culprit in schizophrenia and probably Bipolar I as well. I was happy to see the NMDA story appear on the front-page attachment of Psychiatric Times (12/13). The treatment for retardation of NMDA receptors include omega-3s (fish oil), N-acetylcysteine, and other chemicals to manipulate the availability of d-serine. All of these interventions are far less damaging. Let’s hope the NIMH funds this stuff and psychiatrists become exponents.
Interesting column. I was glad to hear that Cloe Madanes is alive and doing well. I remember going to her workshops on family therapy when she was married to Jay Haley, whom I was saddened to learn had passed.
I agree with you about people suffering from oppression as the common trigger for mood issues. I also, however, believe that other adjustments are possible. Back 50 years ago, when I was a Sociology major, I remember the lecture on Robert Merton who developed a theory about when the goals and the means to goal attainment are blocked for a group (a form of oppression), some people develop a form of alienation in which they attack themselves-drugs, depression etc. Of course, an alternative adjustment is getting mad and fighting against oppression. I think this adjustment has its own misery: frustration and disappointment. However, with defiance, life is always interesting, although contentment proves elusive.
With regard to psychotherapy and whether the psychotherapist should lecture on positive psychology, I like David Burns’ (The feel good book) approach. He talks about clients who view “living happily ever after” as tantamount to saying that the abuse they suffered was “ok”. Like other therapists who know that therapeutic alliance (agreement between the therapist and client on the goals and the strategies for reaching the goal) is paramount, David Burns listens for the client’s scenario for when and how they can change.
Thanks so much for your efforts on this. Although there are few of us drawing attention to the corruption of medicine, I think we’re having an effect. My school requires completion of training on ethics through the Collaborative Institutional Training Initiative (CITI)for anyone submitting a study to the IRB. The last module of this training now includes material on corruption in drug studies. I’m sure those who aren’t familiar with the “scandal” won’t recognize the significance, but it’s a start.
Hi Sandy-thanks for the post, which is well thought through like your other posts. As I recall, Torrey had is right on another issue. He was enraged when the NIMH shifted focus from the issue of serious mental illness (schizophrenia) to the problems of the worried well (depression, anxiety disorders). This shift, of course, legitimized the expanding market of the pharmaceutical companies, but seriously neglected those with schizophrenia and brought dangerous drugs to the general public.
I think that the only utility in having the labels is to differentiate those to whom the society should give a pass. In the US, everyone works. I think it is helpful to distinguish those who won’t work from those who can’t work. The latter should receive SSI or SSDI. Unlike Szaz, I do want to reserve the death penality for those who were capable of making another choice. If someone commits a crime while laboring under false assumptions, they should be judged by another standard. For purposes of working with people, labels are superfluous. You contract around where they view the problem or need for change. The label adds nothing.
Nicely stated. I think the dramatic counter argument against those who think being homeless is the worst thing that could happen to a person is to see someone who has been on antipsychotics for twenty years. My friend, who had graduated top in her medical school class, now appears to have severe dementia. Through the years, moving toward her end state, she was extremely obese. Her body was twisted because of the high prolactin levels (attributable to the antipsychotics) cause osteoporosis. I never saw her distressed, but she also never laughed. Although she never roamed the streets, in my opinion, she never had a life. For those of us who remember the state hospitals before they were closed, that is what it looked like: a warehouse for zombies.
Hi Sandy-if you have any spare time, would you be available to help me read through and integrate the material on basket and chandelier cells. For schizophrenia, seems to me people are on to something here. I particularly like David A. Lewis’ approach. He’s got a web site at Pitt, where he lays out his inferential process. I trust him more because he also was involved in the Konopaske studies on decrement in glia cells with the antipsychotics. If you buy his argument about fast spiking GABA interneurons being a problem, then the cure will be N-acetyl-cysteine, which as far as I know is pretty benign. (Who doesn’t need more glutathione?) As a faculty member at GSU, I can get any article I want, which is a real advantage. I can send an electronic copy of anything you would like. My e-mail is [email protected]. Home phone is 770-939-7409.
These guys have no shame. I pulled the Nasrallah article. As evidence for a “neuroprotective” effect of atypical he cites Agius and Nandra. In the Agius and Nandra article they cite studies in mice, where they expose animals to atypical and then count the number of newly divided cells. They also looked at mRNA levels of NGF and BDNF. What struck me is the inconsistencies across atypicals and inconsistencies across brain areas. I was also struck by the lack of discussion of whether more dividing cells and/or BDNF is good or bad. I think for actual impact, the new cells need to differentiate and be integrated into new circuits. Moreover, BDNF levels may not have positive impact all over brain. (See Eric Nestler on BDNF in N. Accumbens being associated with more distress.) Further, in the discussion they mention glycogen synthase kinase and Bcl-2 increases, two proteins all over the cancer literature. The articles further did not discuss the articles on impact of atypicals on cortex volume levels or on number of glia where the drugs decrease number of cells(see Konopaske et al.) My take is that Nasrallah is probably collecting a fat compensation from the drug companies.
I don’t think we disagree. You may want to download the paper that Jeff Lacasse and I wrote on antidepressant efficacy. I have published a paper on depression=inflammation. I know that interpersonal interactions can cause depression. I, however, think that turbulent social interactions cause physiological events. (Stress is not just in your thoughts-it’s in your body.) I think you can reverse the physiological impact on the body with diet and exercise and compassionate meditation. (Papers can be downloaded by googling my name and digital archives at GSU.)