Saturday, March 25, 2023

Comments by Les Ruthven

Showing 22 of 22 comments.

  • You would think Dr. Gotzsche’s excellent meta-analysis of the ineffectiveness of antidepressants in treating depression would put the nail in the coffin on the sales of the drug treatment of depression; however, history tells us there will be no turn around in drug treatment of depression. When research of drug treatment of depression looked bad psychiatry/pharma invented a disease called Treatment Resistant-Depression (TRD) and added an add-on antipsychotic drug when antidepressants fail, which only increases the drug revenues for this “disease”. I knew it was just a matter of time but have you seen the latest research on Treatment Resistant Schizophrenia (TRS)? Since TRD worked for depression why not TRS for schizophrenia? I predict you will soon see hallucinogenic antipsychotic drugs for both TRD and TRS.

    In my 2005 book (“Antidepressant: Science, Magic or Marketing?” I accused psychiatry of having substantially lower efficacy standards than many medical treatment but after turning to review medical research I found I had been wrong. Psychiatry still wins the first place award for bogus treatments but after reviewing “medical” treatment I found it runs a close second to psychiatry/pharma.

  • In 22 years my BH management firm (Preferred Mental Health Management, Inc.) for private self-insured employer health plans, 65,000,000 callers to our staff psychologists complained of either depression or an anxiety disorders. Anecdotally just about 100 % of the callers were aware of the source or sources of their current life difficulties and unlike the BH industry at the time our psychologists never authorized psychiatric drugs to address these patient’s life difficulties. After our psychologists’ assessment we referred these callers to Ph.D. licensed psychologists or licensed clinical social workers for solution focused psychotherapy which averaged just under six sessions. After discussing their problems with a PMNM psychologist about 15% of the callers refused a referral saying they felt they could now handle the presenting problems. If a caller asked about their need for medication our policy was to start therapy and if medication were found to be needed the patient should call back and a referral to a psychiatrist for medication would be implemented. As far as I know not one patient called back for drug treatment. A satisfaction survey was sent to each caller referred for psychotherapy (there was a 28% return) and over 90% of those returning the surveys were very satisfied with their therapy. Psychotherapy for BH problems is very cost effective when provided by well trained psychotherapists.

  • Early in my career as a clinical psychologist treating acute hospitalized schizophrenics I was an advocate of Thorazine, an early antipsychotic medication, which seemed to stabilize patients and reduce hallucinations and delusional ideation. We psychologists at the time referred to the drug as ego glue in stabilizing the psychotic patient. Before we knew it, however, these drugs without any intervening evidence came to be considered mandatory for the patient’s lifetime! In my reading of the pertinent drug literature on both antidepressant and antipsychotic drugs the longer patients are on these drugs the worse the outcome. Some psychiatrists might tell us this holds for only those patients with the most severe disorders but I prefer another explanation. I know both classes of drugs are said to restore and normalize brain functions but I believe a better case can be made that these drugs significantly impair brain functions, which makes it difficult for the patient to focus on distressing personal and on adverse life situation factors that gave rise to the adverse symptoms and behaviors.
    I have a possible solution to find the answer to whether or not these drugs compare the brain. I am the inventor of the Ruthven Impairment Assessment (RIA), which is a brief, online, computer performance measure of normal or impaired cognition. Once there is a diagnosis of hospitalized patients with depression or acute schizophrenia give the patient a few days of humane treatment and respite care and then test the patients cognitively before the patient is prescribed medication. We have, then, a cognitive baseline before medication but these patients would only show the cognitive brain impairing effects of their mental disorders or diseases as psychiatrists prefer. Re-test these patients cognitively with the RIA throughout the patient’s drug treatment. One asset of the RIA is that there is little or no practice effects with serial testing. Since the RIA came out in 2017 in Applied Neuropsychology I have taken the RIA about 20 or more times and fortunately I have been fairly cognitively stable. If psychiatrists are right these two groups of drug treated patients should show substantially improved cognition and if I am right both groups would show significant cognitive decline. My reading of the literature and some clinical research use with the RIA I would say some psychiatric drugs initially in the early stages show reversible brain impairment (when the drug is tapered) but I suspect with long term use structural brain damage is the unfortunate outcome. In the above “experiment” each patient becomes his or her own control.

  • Dr. Kriegman’s “reduced emotional reactivity” to explain the marginal benefit of the drug over placebo is one possible explanation but my reading of the pertinent literatures suggests another. In the early stages of antidepressant drug use the drug causes brain impairment, which makes it difficult for the patient to focus on distressing thoughts and distressing life situation difficulties. At this stage the brain impairment is reversible with drug tapering. However, with long term antidepressant use the literature suggests actual structural brain damage from antidepressants (and antipsychotic drugs as well). Some psychiatric researchers have accepted the bad news on the long term use of these drugs on the brain but a few have taken the same data and re-defined both depression and schizophrenia as neurodegenerative disorders!

  • Peter, correct me if I am wrong here. I take it 15% of the drug treated had a greater reduction of depressive symptoms than those who were on placebo. However, did the investigators compare the top 15% of the antidepressant group (who experienced greater reduction of symptoms than the bottom 85% of the same group) with the top 15% of the placebo group who had greater symptom reduction than their placebo peers? It would also be good to know the distribution of symptom reduction in the antidepressant and placebo groups.

  • Robert, excellent description of the non-efficacy in the treatment of clinical depression with drugs, which is consistent with my review of the research literature on the subject. The only thing I would add is that the longer the depressed patient is on antidepressant drugs the worse the outcomes, which incidentally is also true with antipsychotic drugs in treating chronic schizophrenia. Psychiatrists retort to this published research by saying only the most serious cases do not respond but 80 to 90% get and stay better! To this I would add (1) both drug classes are addicting and (2) both drug classes impair the brain, which undermines the patient’s ability to learn and thereby solve distressing maladaptive life situations.

  • In this large, meta-analytic study of medication and therapy I think we have a good understanding of the medication side (e.g., antidepressants, antipsychotics, etc.) but what was the variable “therapy”? For example, is a Ph.D. psychologist with a CBT orientation to treatment the same or equivalent to a nurse doing CBT (after attending two workshops on CBT) or a counselor with two years of graduate education doing CBT? I don’t think so. In my 5 year doctoral program in clinical as well as other branches of psychology the first two years consist exclusively in the study of normal human behavior, which I think is necessary for those who want to go on to diagnosing and treating the full range of the mental disorders. I would like to see some sound efficacy research on medication vs. well trained psychotherapists.

  • Katel, akathesia is a very severe adverse side effect which is clear evidence of severe brain impairment, which may or not be reversible. Actually we don’t know because drug companies do not test drugs for impairment of the brain. They should.

    You are right that a cognitive test (such as the Ruthven Impairment Assessment) should be taken before and after ECT. It has been known for many years that ECT causes memory problems but we do not know if the memory (or other brain impairment) is reversible or not. Is is time to get the answer.

  • When psychiatrists turned to the concept of mental health conditions as brain diseases that was a recipe for poly pharmacy and for non-psychiatric physicians to become the largest group of mental health professionals in the country, the latter having had a 6-week rotation in psychiatry during the internship. MIA published another article of mine partially on data I obtained on psychiatric drug prescribing (80% by non-psychiatric physicians); many patients were one two and sometime three classes of psychiatric drugs and one patient was on 5 different antidepressant drugs. Rather than looking at the patient’s behavior (psychiatrists and psychologists used to do that in the 1960s) psychiatrists now seem to be most concerned with various neurotransmitters and manipulating them. Forgive me but I don’t think this approach is working, which Robert Whitaker discovered years ago.

  • Steve you are right. There is no present health entity or organization that sees any need for such an authority. Health Insurance Companies, health providers, Managed Care, the FDA all like the status quo (increasing healthcare costs while thinking we have the best healthcare in the world) and see no need for such an authority. However, in my recent book I believe those who pay the healtcare bill (e.g., employers) is the only entity with the power to improve the quality and cost of healthcare but they need to be educated on how best to overhaul the present systm. Payment must be restricted to only scientifically proven treatments and not the current “just a little bit better than the placebo benefit”.

  • Rebel, yours is a sad but unfortunately not a unique story of poly pharmacy and some of the harm this causes. Actually any efficacy these drugs have is due to the brain impairing effects of these drugs. Without brain impairing effects there is no “improvement”. It is BS that these drugs are treating the neurotransmitters (e,g, seratonin and dopamine) as the cause of these brain diseases. The remaining $64.00 question is whether or not the brain impairment is reversible (with drug tapering) or irreversible if the drug is taken a longer period of time. In my recent book I describe a brief, computer delivered cognitive test called the Ruthven Impairment Assessment (RIA) or another cognitive test can be take prior to and following administration of a psychiatric drug to determine cognitive health prior to and during drug treatment. In this situation does cognitive status remain the same, get better or get worse after drug initiation? A self report of cognitive status after drug use or following drug tapering should be considered but objective measures of cognitive status are stronger evidence.

  • Dear Ed. If a person complains of mental impairment and believes it may be due to a specific drug before tapering take a cognitive test such as my Ruthven Impairment Assessment (RIA) and repeat testing during and completely after the tapering. If there is no improvement in Ci after the tapering, and there was evidence of Ci before the tapering, the brain impairment is due to another source other than the drug in question.
    Even though a person feels “fully” recovered after drug tapering I believe objective cognitive testing would still be in order. We can be perceived by our perception of improvement, particularly when there is substantial improvement. Les

  • Rebel, thank you for your comments. In addition I think that physicians are most comfortable with treatments that are consistent with their training, which is basically in the biological and physical sciences. Psychiatry in the 19th and early 20th centuries was completely outside traditional medicine (psychoanalysis) and psychiatrists were seen by medicine as less than “real” doctors. However, when psychiatry turned to drugs and began treating brain diseases involving dopamine, serotonin and other neurotransmitters of the brain psychiatry was welcomed back into the traditional field of medicine! Psychiatry was happy with their new found acceptance from their physician colleagues and general physicians were also happier because, like psychiatry, they now had the tools to also treat the full range of mental disorders, that is, a copy of the DSM and psychiatric drugs. However, their “gain” translated to a greater loss in the quality, appropriateness and safety of a great deal of healthcare today. For one, many of the major diseases are preventable and arise from our self-injurious behavior. For another, most visits to our doctor (whether we have a disease or not) arise from stress and adverse, non-organic and troubling, distressing life situations. What’s worse is that now for these non-organic health problems we are prescribed Prozac or a Xanax and told to come back in 30 days!

  • I agree with you and none of the present health entities will do it. However, I make the case that the only entity that has the potential to provide the necessary reform of current healthcare is the payer of healthcare, the government and the self-insured employer sponsored employee health plans. The government payers can’t do it because of politics; the large employers can do it but this group needs to be educated about authorizing payment only for scientifically proven treatments, not a payment system that is not based more on clinical opinion and provider experience.

  • Ed, if you go to my book you will find the research references and discussion. The research concerns not only antipsychotics but antidepressants as well. These studies were done by psychiatric researchers. However, several other psychiatrists accepted the bad news but re-defined both disorders as neurodegenerative disorders to accound for the brain damage in both groups. Short term antidepressant use causes brain impairment that is reversible, which comes from a professional woman who came to me with complaints of memory problems. I gave her the Ruthven Impairment Assessment (RIA) a brief, online, computer delivered performance cognitive tests. She was impaired on speed of mental processing, most impaired on attention/memory but on complex problem solving she scored above college student norms. I believe her impairment was due to 50 mg of Celexa daily; on my recommendation her physician tapered the Celexa and there was no more memory problems. I am not certain but I suspect that if she had remained on the drug long enough the impairment would have been irriversible. Further research is needed. Both drug classes can cause Tardive Dyskinesia (TD), a brain disease that is said to only involve the motor system! I think we need to cognitively test TD patients to assess their higher order brain functions as well as schizophrenics who have been on neuroleptics for varying number of years.

  • Mella, you are quite right. I believe harm in psychotherapy includes most of depth therapy and of course therapist exploitation of the patient. This includes keeping the patient in therapy for a life time. I have always felt that good psychotherapy and behavioral treatment should add to the patient’s life and not become the patient’s life. I would say, however, despite the above inappropriate drugs such as antidepressants and antipsychotic drugs do greater harm then bad therapy.

  • We are on the same page, including shameless marketing by the pharmaceutical industry. An egregious example on TV are ads for drugs for treating type 2 diabetes. All of the “patients” are over weight (the “silent message is you can be over weight and my drug will get your A1c under 7), the patient is seen as happy, enjoying life, enjoying good food with family and friends, very active, etc. Pharma knows as well as we do that the most efficacious treatment is weight loss, appropriate exercise, good nutrition and as a psychologist I would add managing your stress. Type 2 diabetes shortens one’s life by 10 years and I would bet that without substantial life style changes a drug induced A1C just under 7 will not give you a normal life span.
    I was diagnosed with Type 2 diabetes 20 years ago and my physician wanted to prescribe Metformin. I refused. I was 230 pounds at 6 feet even and 20 years later I am 171 pounds, exercise 3 times a week in a health club and a recent A1c is 5.3 (the normal range is 4.1-5.6) at 86 years of age.

  • Yes, Marie, you are right. Patients want and should get help from their doctor but real help in these high NNT health treatments does not help and harms the patient. How about giving the patient knowledge of his or her health problem and what the patient can do to improve their health such as lose weight, get more exercise, etc. In these cases the doctor should refer the patient to another health professional who is expert in assisting patients to change their behavior

  • Dear Someone Else:
    Thanks for your nice comment on my article. Since your were interested in the topic you might be interested in my health blog ( which has 80 plus article from my review of research on the effectiveness and safety of many popular psychiatric and non-psychiatric therapies. You might also take a look at my new book, a link to which is in my NNT article.