Thursday, May 23, 2019

Comments by MT

Showing 16 of 16 comments.

  • You are quite right that informed consent with severely ill persons is a major issue. The medical community and the legal system agree, which is why the laws on this are very clear. If a person is unable to appropriately weigh the risks and benefits of a medical decision, they are considered to lack decisional capacity, and having them sign an informed consent is illegal. In that case, care can be given only on an emergency basis (ECT doesn’t qualify) or with the informed consent of their legal decision maker, often whoever is their medical power of attorney. Even with the consent of the POA, at least in my state, ECT cannot be given against the wishes of the patient without going through a separate and very extensive legal process regarding guardianship. Usually a patient will agree to treatment because they trust their loved one to make the right decision.

    It is absolutely appropriate to question the ethics of this whole situation. However, in practical terms, what is the alternative? Severe depression is life-threatening, and medications will take several weeks, at best, to take effect. It is basically impossible to do meaningful psychotherapy with most severely depressed individuals. In many cases ECT is the only treatment that will take effect quickly enough.

  • Hi John — thanks for your thoughts. Dr Read is an outspoken opponent of biological psychiatry and would surely support the protests this article describes. I don’t know why his findings with literature reviews are consistently different from those of others. His is indeed the most recent review on the topic, though I will also add that research on ECT is unfortunately very rare nowadays, simply as a matter of funding. The best I can say is that the studies should be compared side by side to try to figure out why their findings are so disparate.

  • Hi John,

    Dr Read’s review indeed shows minimal benefit to ECT. I’ll point out that Dr Read has long been an opponent to biomedical models of mental illness and was seeking evidence to discredit ECT from the start. This might be why his review has quite different findings from several others:

    http://www.ncbi.nlm.nih.gov/pubmed/15087991
    http://www.ncbi.nlm.nih.gov/pubmed/12642045
    http://www.ncbi.nlm.nih.gov/pubmed/3882006

    Dr Read’s study is worth reading and raises reasonable concerns. You should absolutely present it to your hospital. If they know what they are doing, they ought to have literature to address your concerns. If not, they shouldn’t be administering it in the first place.

  • Julie, I’m sorry to hear that, and it’s clear that you feel very strongly about this. If I believed what you say to be the case, that psychiatry is imprisonment, slavery and genocide, I wouldn’t be willing to work in the field and would not respect anyone who did. There are depths of suffering among psychiatric patients that cannot be fathomed by those who have never cared for them. Treatments like ECT are only used when practitioners believe that they are the only way to pull a person out of suicidal depression or profound catatonia, both of which are acutely life-threatening. I’m sorry that you had such a wretched experience with psychiatrists, because it sounds like you were indeed severely mistreated. I hope that the people who did that to you are brought to justice. I do not believe that they are representative of psychiatry in general, which in my experience is populated largely by well-meaning people trying to alleviate suffering.

  • I have no problem agreeing with Ms. Andre. By the sound of it she was severely misled about the effects of ECT, which is malpractice, tantamount to assault. Her proposed ECT consent is, for the most part, quite reasonable. Our understanding of risks and benefits has increased substantially since she wrote this in 1991, and I believe she downplays the therapeutic benefits, but I am in absolute agreement about fully informed consent before treatment.

  • The open classroom model is great, and I hope that there are not mental health experts arguing against its use. The challenge is bringing it into wider use. Part of working in mental health is (or ought to be) advocacy for patients, so I quite agree with you and would do what I can to support these. I am not convinced that open classrooms work for ALL children with ADHD, and as you know the diagnosis requires that the child is having problematic symptoms at home as well. The use of medications can indeed be minimized but not, in my opinion, ruled out entirely.

    The problem of comorbidity with ADHD is a real one. DSM criteria are atheoretical, that is to say, they do not speculate (in the criteria) on the origins of ANY psychiatric disorders. A competent provider ought not make a diagnosis exclusively on DSM criteria, but rather should be taking a thorough personal and psychiatric history, which hopefully would bring a history of trauma to light. Admittedly this does not always (or often) happen outside of academic medical centers; but if the root cause of a child’s symptoms are trauma-related it would be substandard treatment to only provide them with stimulants.

    I hope it did not seem that I was arguing for a purely biological model of ADHD. I wouldn’t argue for a purely biological model of ANYTHING in mental health that does not have a very clearly established brain pathology (e.g. Huntington’s). I’m sure that many different factors contribute to a child’s developing ADHD, and treatment has to address all of these. I would hazard a guess that higher rates of ADHD among foster children is not just a diagnostic artifact; it could also be that certain experiences, exposures &c raise their risk for the illness later in life, much as repeated early childhood trauma raises risk for borderline personality, or early childhood bereavement raises risk for major depression. Treatment for ADHD ought to be multimodal; but again, in at least some cases this will not succeed without medications.

  • Apologies, here are direct links to the studies:
    http://www.ncbi.nlm.nih.gov/pubmed/21699268
    http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4235029/
    I think I was myself speaking out of a misunderstanding. I had apparently understood that long-term evidence exists where there is none. I’ve been looking but still cannot find any studies going beyond two years. Evidently I overstated the case for long-term benefits, for which I apologize.

    The bottom line regarding the article in question, for me, is that it is not designed to assess long-term efficacy of continuous medications; and aside from comments in the discussion (which, I think, argue that long-term medication did not provide benefit, yet on the same page admit that the study could not have detected benefits anyway), they did not include this in their data — for example, how many children in each group were on medication by the end, or comparing all of the children who were on medication at the end point with all the children who were not. As far as I can tell, the paper’s most important finding is that self-limited behavioral or medication interventions did not have persistent benefit at 6 to 8 years; medication aside, this also seems to show that behavioral therapy, which is usually regarded as having long-term benefits even after completing treatment, unfortunately did not do so in this case.

  • If there is a viable alternative to medications and physical interventions like ECT in the treatment of the severely mentally ill, I would love to hear about it. Paralysis is induced in order to prevent the person being treated from breaking bones or teeth while having a seizure, not for the comfort of providers. By its very nature, this type of induced paralysis is completely unrelated to seizure threshhold, so higher voltages are not needed or used. If you speak to a neurologist you will find that they understand ECT almost as well as psychiatrists do, since it has also been an occasional treatment in their own field; and they will tell you that self-limited seizures, like those induced in ECT, are not in themselves dangerous to the brain. And above all, the bulk of the evidence clearly supports the use of ECT in the treatment of severe depression and catatonia. Neglecting the evidence and NOT offering ECT when it is clinically indicated would actually be considered malpractice.

    http://www.ncbi.nlm.nih.gov/pubmed/15087991
    http://www.ncbi.nlm.nih.gov/pubmed/12642045
    http://www.ncbi.nlm.nih.gov/pubmed/3882006

    The argument that ECT should be banned because it is ineffective is not going to gain traction because it is not based in reality. Arguments that its risks outweigh its benefits or that it is being misused are much more likely to prevail.

  • I have indeed seen many people who have received ECT and found it to be a life-saving treatment. Some have returned to work, including intellectually demanding work, without any apparent loss in function. I would welcome your detailed response if it includes any sort of evidence, but at this point, the scientific data (as I understand it) overwhelmingly demonstrates that ECT is an effective short-term treatment for severe depression.

    Finally, psychiatrists are not seen as Gods and have not been since the days of Freud. In the 21st century, we are far more accustomed to criticism and personal attack from people essentially ignorant of the nature of our work. No one enters psychiatry in order to practice sadism and tyranny on vulnerable patients. We enter the field because we appreciate the profound suffering of the mentally ill and want to help people who have been misunderstood, exploited and abandoned by society at large.

  • I’m sorry to hear about your grandmother, that is indeed a tragedy. I wonder if there is more to the story, because what you’ve said gives no indication that she had any sort of illness that would have been treated with ECT. Depression in later life can be severe to the point of disability, and indeed untreated depression often leaves people blank, absent, inattentive, &c.

    Incidentally, you cannot administer ECT with a baseball bat, because the purpose of the electrical stimulus (the “shock”) is to produce a seizure. Though this indeed has significant risks and side effects, it is much safer than producing seizures with injection of medications or boluses of insulin, as used to be done in the 40s and 50s. I am very surprised to hear that you have an acquaintance receiving involuntary ECT twice a week, because in order for this to be true he would have to be involuntarily committed to a psychiatric hospital, and THAT would require proving in a civil hearing that he is at serious danger of harming himself or someone else due to a treatable mental illness. Involuntary ECT is actually very uncommon these days.

    Finally, psychiatry is in no danger of going extinct, until some other profession proves itself capable of caring for the seriously mentally ill.

  • Keep in mind that the Berkeley ban was voided within a year of passage, essentially because it was regarded as interfering with a patient’s right to choose appropriate treatments. Voluntary ECT is unlikely to be criminalized, as long as there is evidence that it works (and there is), and as long as patients are being informed about its risks (memory loss, cognitive damage, &c). If someone is not reasonably informed of these risks, their physician deserves to be sued for malpractice. Banning involuntary administration of ECT, which is what most of the protesters above are lobbying against, is a separate question and is much more likely to succeed. Involuntary hospitalization and treatment in general should be the initial battleground in these debates. Treatment in children is also an enormous question in itself, and if indeed children are receiving ECT against their parents’ advice, this is an injustice and should be stopped. As above, however, there are clinical situations where ECT (with consent from parent and child) is still known to be the best available treatment.

    Dr Chabinski, I am deeply saddened by what happened to you in your childhood. You were absolutely mistreated by physicians who were supposed to be helping you, and no one can reasonably dispute that. I will just say that ECT today bears no resemblance to what you received and is nothing akin to torture; it is administered under general anesthesia and paralysis, so that the person experiences and remembers nothing, and the seizure is restricted only to the brain (without any bodily manifestations). It is used in the treatment of severe depression, catatonia, agitation or psychosis. Deviating from these is nothing short of malpractice, and using ECT as punishment would be a repulsive violation of professional standards and indeed of basic human rights. However, until it can be shown that ECT is ineffective in treating these illnesses, or that its side effects clearly outweigh its benefits, or a superior treatment is available (TMS and tDCS are encouraging but not home runs), it will remain within the psychiatrist’s therapeutic armamentarium.

  • Hi Jonathan — you are right, I missed that line in the study. I will say that this study also notes that “Inferences about potential advantages that might have occurred with continued long-term study-provided treatment are speculation” (p. 496) simply because of the nature of the study. Treatments were indeed terminated at 18 mo.; some of the patients continued medication, while many of those in other study groups started them in the subsequent years, such that by 6 and 8 years, “group differences in medication use were no longer significant” (p.488) — which is to say, about 50% of the kids, regardless of their initial treatment, were taking stimulants. Altogether this study is just not equipped to judge long-term benefits, and does not claim to do so. There is actually a huge deficit in research into long-term benefits beyond 2 years, but there are many studies following for 1 – 2 years with positive results, e.g.:
    http://www-ncbi-nlm-nih-gov.ezproxy.welch.jhmi.edu/pubmed/21699268
    http://www-ncbi-nlm-nih-gov.ezproxy.welch.jhmi.edu/pubmed/24305033

    To “blah” — not “old guard,” just a young practitioner in the field with a commitment to evidence-based treatment. Child psychiatry as a field is in no serious danger of being phased out, at least until some other field can prove themselves competent in caring for seriously mentally ill children; and stimulants will remain the treatment of choice for ADHD until we find something better. Atomoxetine, venlafaxine, bupropion and clonidine all have their place but none have been as effective as stimulants. Making changes to the school environment is great and very effective for mild to moderate ADHD, but (1) they are not available to most American children, and (2) they are not adequate for the treatment of children with severe ADHD, who, without medications, will severely disrupt their own education regardless of environment. It would be wonderful if stimulants could be phased out by superior treatment — it would also be wonderful if antidepressants, antipsychotics, antihypertensives, cholesterol lowering drugs, and opioid pain medications could be phased out as well. We’re just not there yet.

  • Okay… as is often the case on this blog, I agree with the general sentiment but there is an unfortunate tendency to cherrypick and misrepresent data.

    Regarding #1, there are MANY studies on long-term use of stimulants. There are not many regarding Vyvanse because it is a new medication, but keep in mind that Vyvanse is lisdexamfetamine, a prodrug of dextroamphetamine, a medication that has been in use since 1935. Focalin is a long-acting formulation of dexmethylphenidate, the D-enantiomer of methylphenidate, which has been in use since 1954. Both have extensive long-term safety data. However, it is absolutely true that medications need only be shown to be non-inferior to existing treatments to be considered efficacious by the FDA. This is a problem not just in psychiatry but in medicine as a whole, and is simply and transparently a strategy by pharm companies to have a steady supply of on-patent products.

    Regarding #2, it is well known that stimulants are addictive. That’s why they are schedule #2, why they require a paper script from a doctor (not electronic or phone), and why they should be the responsibility of parents, not kids. Doses are increased because children get bigger and require more medication for the same blood level. Stimulants will indeed get you high if you snort or inject them, somewhat like cocaine, but not if you take them as prescribed; and there are several formulations of stimulants (e.g. the Daytrana patch) specifically designed to prevent this type of diversion and abuse. Stimulants do NOT cause OCD in 50% of the children who take them; rather, if you read the article Dr Corrigan refers to, 50% of these children had increased compulsive behaviors, described as “subtle and transient,” and which did not come remotely close to meeting OCD criteria. Obsessions and compulsions are actually remarkably common even among normal children, such that subsyndromally they are not even regarded as pathologic. Regarding the reductions in blood flow to the brain, the linked article is a three-page essay by a nonprofessional, citing outdated research, on a website, “Neurosoup,” that is apparently devoted to psychotropic drugs and sharing “trips” with other users. And regarding fatalities, the linked article describes an intelligent young man exploiting incompetent physicians and becoming addicted to prescription stimulants. It brings into question one practice’s prescribing patterns and the too-common diagnosis of adult ADHD, but it is not otherwise a reflection on the medications themselves.

    Regarding #3, please look at the study for yourself. Basically it is saying that receiving 14 months of treatment with stimulants, and then STOPPING, did not significantly improve outcomes 8 years later. Neither did intensive, multicomponent behavioral therapy, by the way. What this article shows us is that stimulants do not permanently cure ADHD, particularly if you’re not taking them — surely this is not surprising. However, when you look at studies of children with ADHD who have been maintained on stimulants during childhood and adolescence, you find that their behaviors and academic performance are remarkably better. Medication only works if you’re taking it.

    Finally, I wish that we could stop accusing parents and physicians of “drugging” their children. It is needlessly inflammatory and basically shows that we have already made up our minds about this and are not interested in any arguments to the contrary. It might be helpful if we talk about problems in prescribing trends, the structure of mental health treatment, &c, rather than accusing parents and physicians who are, for the most part, trying to do what’s right for the children in their care.

  • An article about approaching the research with caution… must itself be approached with caution. Follow the Vox piece to the study in question (Epilepsy Behav. 2013 Sep;28[3]:522-9) and you will find that it is not nearly so simple. The method of determining a paper’s value is rather arbitrary and definitely favors recently published research, since it defines value almost entirely by the number of citations. It only considers citations in 2011, citations between 2001 and 2011, and citations in a “standard” epilepsy text — plus another few points at the PI’s discretion. A major breakthrough in 1981 that was later supplanted by a more effective or safer treatment will be judged as having no enduring value. By that same standard we would also say that Charcot, Janet or Babinski did not produce anything of enduring value either.

    It is definitely true that there is a lot of research and clinical literature out there that is essentially useless before the ink even dries. Every field has its “throw-away” journals, which generally have lower standards for peer review and rather obvious links to pharma. This study just isn’t the best way to show that. And keep in mind that there are also journals that are much more reliable and more likely to publish data of lasting importance — e.g. JAMA, NEJM, or Lancet.