Dr. Peter Breggin

[Anuwolf]

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What do you guys think about Dr. Peter Breggin and his views on psych medications?

http://www.breggin.com

 

[PeterG]

I am going to go out on a limb and say that Dr.Breggin is probably not popular around here. 😀

 

[Anuwolf]

PeterG, I can see that LOL.

I had hoped that we could start up a open minded debat about psychiatry.

Dr. Peter Breggin is also a Doctor... with an MD (Just like you guys) .. he also had his private practice with psychiatry.. I do not think hes blowing up smoke without risking his career.

I actually amire this man... I use to believe that every doctor (especially Psychatrists) were the same and only wanted to shove pills down peoples throat (Only experienced i had with psychatrists) for every simple problem that could be solved simply by a serious life change with diet and exercise.

 

[drwatson]

for every simple problem that could be solved simply by a serious life change with diet and exercise.

That pretty much sums up the treatment/cure for most medical problems. I think "serious life change with diet and exercise" is easier said than done. Unless the patient is highly motivated and has a great support system will they be able to do this, and even then how long will it last? I realize there are exceptions to this but the ability to change diet and exercise habits that have lasted decades is just not "simply" done.

 

[Anasazi23]

What do you guys think about Dr. Peter Breggin and his views on psych medications?

http://www.breggin.com

Breggin is a known quack, and has been scientifically discredited on the stand on more than one occasion. His ideas are faulty, and he only popularized Szaz-like notions that "everyone's OK."

Diet, exercise, "free thinking," and witholding the use of medications has proven disastrous in studies during the 70's when this movement was again popular.

 

[whopper]

Breggin was required reading in my undergraduate Psychology curriculum.

I don't agree with all his views but I do think that several of his views need to be addressed to the Psychiatric community. We as a community IMHO now rely too heavily on meds.

Of course, I do think some of his remarks are inflammatory to the point where it hurts his own argument. The debate with the direction of Psychiatry has to be done on an intellectual, open minded and humanitarian level, not on an over emotionalistic & accusatory level.

 

[duneclimber]

Please note that I seem to remember that Peter Breggin never took his psychiatry boards, nor has he practiced medicine, to my knowledge. His books are widely read, but one must question the strength of his knowledge/experience base.

 

[PeterG]

I haven't read a lot by Dr.Breggin but I read his book "Toxic Psychiatry" and I seem to remember he recommended patients just stop their lithium. He didn't recommend anything as a substitute. Not smart in my opinion. I don't know a whole lot about him though.

Anuwolf, what do you think of him?

 

[maranatha]

I haven't read a lot by Dr.Breggin but I read his book "Toxic Psychiatry" and I seem to remember he recommended patients just stop their lithium. He didn't recommend anything as a substitute. Not smart in my opinion. I don't know a whole lot about him though. QUOTE]

Just a med. student, here, but stopping lithium or a mood stabalizer for a bipolar doesn't doesn't like a good idea 😱 !

This Dr. Breggin sounds like a real "Dee Dee Dee!"

 

[Poety]

PeterG, I can see that LOL.

I had hoped that we could start up a open minded debat about psychiatry.

Dr. Peter Breggin is also a Doctor... with an MD (Just like you guys) .. he also had his private practice with psychiatry.. I do not think hes blowing up smoke without risking his career.

I actually amire this man... I use to believe that every doctor (especially Psychatrists) were the same and only wanted to shove pills down peoples throat (Only experienced i had with psychatrists) for every simple problem that could be solved simply by a serious life change with diet and exercise.

Anu, a really good psych actually knows when its INAPPRPROATE to prescirbe meds. Thats the difference btween the good doc that knows you have CAD and start on you on actos for new onset DM and the doc that says "oh you have anxiety, heres xanax" for ya....

Im not saying your prolbems could be reformed with diet and excercise either, i do however think you would benefit greatly from DBT tx.

 

[tennreb]

Dr. Breggin actually came to my undergrad university and met with a class of mine. Then he gave a large lecture on campus. I spoke with him extensively. He made a lot of sense, but I knew nothing about psychiatry then. I think some of his methods, especially in the treatment of ADHD, could be combined with meds to better treat mental illness. In my psych clerkship, I saw lots of suicidal people. Not once did I ever hear a psychiatrist say anything like "don't do it" or "life is worth living" or any kind of reassurance whatsoever. All they did was hand out pills. You say, "I want to die." They say, "Take this pill." That is not any better than what Dr. Breggin is preaching.

 

[Psychintern2006]

This guy is a disgrace, what is APA's stand on him? Bragging about million dollar law suits. Hopefully the jury in future will consist of qualified people when deciding about critical cases. Lawsuit for tardive dyskinesias!!! He should start preaching scientology in Lousiana. He is flat out playing with emotions and cashing out $$$.

http://www.breggin.com/TDverdict.htm

 

[Psychintern2006]

Dr. Breggin actually came to my undergrad university and met with a class of mine. Then he gave a large lecture on campus. I spoke with him extensively. He made a lot of sense, but I knew nothing about psychiatry then. I think some of his methods, especially in the treatment of ADHD, could be combined with meds to better treat mental illness. In my psych clerkship, I saw lots of suicidal people. Not once did I ever hear a psychiatrist say anything like "don't do it" or "life is worth living" or any kind of reassurance whatsoever. All they did was hand out pills. You say, "I want to die." They say, "Take this pill." That is not any better than what Dr. Breggin is preaching.

HOW ABOUT PSYCHOTHERAPY WITH THAT PILL ??? CAN'T BELIEVE YOU ACTUALLY HAD THIS GUY INVITED IN YOUR SCHOOL?

 

[Psychintern2006]

Sazi for your attention please ! this forum is for ''For psychiatry residents and (medical ?)students interested in psychiatry" and not for upset patients ( I just researched on previous posts by some regulars) and other people upset with Psychiatry being a medical speciality().

 

[RustNeverSleeps]

Dr. Breggin actually came to my undergrad university and met with a class of mine. Then he gave a large lecture on campus. I spoke with him extensively. He made a lot of sense, but I knew nothing about psychiatry then. I think some of his methods, especially in the treatment of ADHD, could be combined with meds to better treat mental illness. In my psych clerkship, I saw lots of suicidal people. Not once did I ever hear a psychiatrist say anything like "don't do it" or "life is worth living" or any kind of reassurance whatsoever. All they did was hand out pills. You say, "I want to die." They say, "Take this pill." That is not any better than what Dr. Breggin is preaching.

Doesn't Dr. Breggin claim that ADHD doesn't exist, claiming that the symptoms are often due to lack of attention from parents? Hopefully he will earn his place along the "refrigerator parents as cause of autism" theorists.

Also, if the psychiatrists you worked with really did interact with patients that way, that is sad. However, saying things such as "life is worth living" is arguably not appropriate for all patients. For instance, some people may find it trite. In many cases, medicating a patient with acute psychiatric issues will be much more helpful than saying "Don't kill yourself." Psychotherapy is incredibly important, of course, but generally does not produce instantaneous results.

 

[maranatha]

In my psych clerkship, I saw lots of suicidal people. Not once did I ever hear a psychiatrist say anything like "don't do it" or "life is worth living" or any kind of reassurance whatsoever. All they did was hand out pills. You say, "I want to die." They say, "Take this pill." That is not any better than what Dr. Breggin is preaching.

No offense, but sounds like you've seen some poor examples of psychiatry. Although my experience is limited to my medical school, I've never seen a psychiatrist just give a pill for suicide without trying to address the underlying reason and emotional/psychology motivation. Although not every psychiatrist i've seen did the therapy themselves (some did), they at least always made sure the patient had counseling--always.

 

[tennreb]

No offense, but sounds like you've seen some poor examples of psychiatry. Although my experience is limited to my medical school, I've never seen a psychiatrist just give a pill for suicide without trying to address the underlying reason and emotional/psychology motivation. Although not every psychiatrist i've seen did the therapy themselves (some did), they at least always made sure the patient had counseling--always.

This is at a state hospital in a state with abysmal mental health services. Patients did go to group therapy daily, but that was about it for a lot of them. We readily discharged to homeless shelters. Long-term beds don't exist. The best you can hope for is to find a spot in a care home. They didn't even have the means to enforce mandatory outpatient treatment. It was sad.

 

[Ibid]

I agree with Whopper
I don't agree with all his views but I do think that several of his views need to be addressed to the Psychiatric community. We as a community IMHO now rely too heavily on meds.

Of course, I do think some of his remarks are inflammatory to the point where it hurts his own argument. The debate with the direction of Psychiatry has to be done on an intellectual, open minded and humanitarian level, not on an over emotionalistic & accusatory level.

You can watch can get more than a jist of him here.http://breggin.com/index.php?option=com_content&task=view&id=101&Itemid=95

I don't think he can be dismissed out of hand especially when he takes on some issues that others might sweep under the carpet.

The beauty of psychiatry is that as practitioners, just like patients, no two are quite the same.

 

[michaelrack]

Not once did I ever hear a psychiatrist say anything like "don't do it" or "life is worth living" or any kind of reassurance whatsoever.

Saying something reassuring isn't always helpful. In some circumstances, saying "don't do it" would be appropriate, in other circumstances it would be the wrong thing to say.


Psychotherapy should be part of the treatment of suicidal inpatients. However, psychotherapy is often done by someone other than the psychiatrist.

 

[whopper]

Since my last post on this thread, I've learned more about him. He's gone on the talk show circuit, giving biased presentations that are misleading at best. He's also gone on the right wing shows including the Savage Nation giving a psychiatric assessment on the "liberal" movement that is not based on accepted objective data.

e.g.
http://www.youtube.com/watch?v=u16OFyXSYE4

While he does bring up some good points, a even a broken clock is right twice a day.

A psychiatrist has every right to have extreme and very one sided political viewpoints, even broadcast them with the disclaimer that the views are not medical (unless he could somehow show they are), but to use his profession to support his findings, as if it's medical and scientific goes way way way over the line. There's no excuse from that.

My view of him has gone from a guy on the extreme that I disagreed with on many points, but who may have been sincere, to one where I seriously question WTF is going on with him.

And don't immediately think that his viewpoints are selfless. He's made quite a bit of money being the contrarian.

IMHO, since Breggin has gone too far off the deep end, some of his good points he has brought up should still be brought up in a psychiatry program, but not from him, but from other critics from our own field and others who have not punched below the belt.

No offense, but sounds like you've seen some poor examples of psychiatry. Although my experience is limited to my medical school, I've never seen a psychiatrist just give a pill for suicide without trying to address the underlying reason and emotional/psychology motivation

No offense, but I have, and it was actually quite common. The problem here is not specific to psychiatrists. I've noticed all doctors perform practice that could be balked at, but they have no one to answer to other than a patient who can't tell the practice is poor.

In medical school, and (hopefully) residency, you are in an educational environment, filled with medical doctors who could've likely made much more money doing private practice. Being a professor in a medical curriculum usually doesn't make money, and those that do it either do it for academic/intellectual prestige/entitlement, a sense of self satisfaction in teaching the next generation, love of reseaerch or because it may advance their career in private industry (e.g. drug companies love to hire the high ups in the academic world).

The point being that in academia, you're more likely to get an M.D. who actually has a brain on his head devoted to correct practice, either because he enjoys it, his sense of pride is too high to do poor practice, or he wants to gain from it.

But in the "real" world, you'll more likely have doctors that see patients for just a few minutes and give a pill without explaining what's going on and why.

Academia, Henry Nasrallah, M.D. saw a case that had dozens of doctors stumped. He critically reviewed it and we were all in awe with his findings. A few days later, he's talking to residents on dealing with the emotional trauma of having a patient who commits suicide. He's a doctor at the top of his game--> and he teaches in a medical school and residency.

Real world: I 'm working in a group home where the PCP is giving all the wrong meds out to the patients. It puts me in an awkward position because my insurance company informed me I am not supposed to practice outside the psychiatric. I've gotten some of the patients successfully off of benzos that they were abusing, then the PCP puts them back on it. I call the PCP and he does not answer my calls. After months of informing what was going to the people who ran the group home, they finally got rid of the PCP and replaced him with a new one.

The prior one was there for years and did what he did--the nursing staff hated it. The previous psychiatrists either didn't care or just ignored it.

 

[Ibid]

IMHO, since Breggin has gone too far off the deep end, some of his good points he has brought up should still be brought up in a psychiatry program, but not from him, but from other critics from our own field and others who have not punched below the belt

I agree with this,above, by Whopper as well. Although I might argue about where the belt line is, no matter.

The work of Joanna Moncrieff Consultant Psychiatrist (that means something in the UK for the uninitiated) and lecturer at University College London is straight down the line stuff. By that I mean impeccable and respectable science.

Some of her work here on Pub Med.

http://www.ncbi.nlm.nih.gov/pubmed?term=MONCRIEFF+JOANNA[au]

And here below she responds to critical analysis of her work with out throwing her toys around. Impressive.

http://www.bmj.com/cgi/content/extract/331/7509/155

 

[RedPakotaSea]

^Thank you.

It's comforting to know that I'm not the only skeptic (not counting those that have completely jumped ship and joined the anti-psychiatry movement). I've been fascinated by psychiatry for many years, but the black and white picture that is often painted of "mental illness" and the "pill for every ill" has really turned me off from entering the field.

It seems that a more nuanced approach would result in more personalized and effective care. This includes acknowledging that diagnostic criteria are often somewhat arbitrary, the treatments are far from magic bullets, and the mechanisms of pharmacotherapy, for the most part, remain enigmatic.

One diagnosis I'm particularly skeptical about is ADHD. Can anyone provide solid evidence that there is not essentially a normal (Gaussian) distribution in humans' attention spans and activity levels? Are we not arbitrarily designating a cutoff at the tail end of this distribution and defining it as pathology? Now, to be clear, I'm not saying that those in the mental health field should withhold effective treatment from individuals that struggle with societally-defined deficits, but we need to first acknowledge that this label we are applying to many of today's youth is not as clear cut as many would like to think.

 

[snarfer]

^Thank you.

It's comforting to know that I'm not the only skeptic (not counting those that have completely jumped ship and joined the anti-psychiatry movement). I've been fascinated by psychiatry for many years, but the black and white picture that is often painted of "mental illness" and the "pill for every ill" has really turned me off from entering the field.

It seems that a more nuanced approach would result in more personalized and effective care. This includes acknowledging that diagnostic criteria are often somewhat arbitrary, the treatments are far from magic bullets, and the mechanisms of pharmacotherapy, for the most part, remain enigmatic.

One diagnosis I'm particularly skeptical about is ADHD. Can anyone provide solid evidence that there is not essentially a normal (Gaussian) distribution in humans' attention spans and activity levels? Are we not arbitrarily designating a cutoff at the tail end of this distribution and defining it as pathology? Now, to be clear, I'm not saying that those in the mental health field should withhold effective treatment from individuals that struggle with societally-defined deficits, but we need to first acknowledge that this label we are applying to many of today's youth is not as clear cut as many would like to think.

You start treatment of HTN when BP is at a certain cutoff level x2 in an office setting. Are we applying a label to these individuals too soon? Should we hold treatment until pts come in with malignant HTN and/or blow out their optic disc?

I understand your skeptism as you raised age old concerns for many illness, particularly from individuals who are fortunate enough to have not had any immediate family members affected by the disease. Or just does not see the whole picture. However, we know that the number one cause of kids dropping out of school is due to untreated mental illness. ADHD being one of the major disorders. Should we let these kids flunk out of school, become suicidal or violent, or turn to drugs?

There are tons of solid peer reviewed literature on ADHD at pubmed. Peter Breggin has zero credibility in the scientific community. He has not engaged in any meanigful research or been published in peer reviewed literature. Almost all of his claims and theories are anecdotel and based on 'personal experience'. A judge threw out his 'expert' testimony recently due to this fact.

 

[whopper]

One diagnosis I'm particularly skeptical about is ADHD. Can anyone provide solid evidence that there is not essentially a normal (Gaussian) distribution in humans' attention spans and activity levels? Are we not arbitrarily designating a cutoff at the tail end of this distribution and defining it as pathology? Now, to be clear, I'm not saying that those in the mental health field should withhold effective treatment from individuals that struggle with societally-defined deficits, but we need to first acknowledge that this label we are applying to many of today's youth is not as clear cut as many would like to think.

ADHD is a problematic phenomenon for several reasons. 1-the treatment is often a medication of possible abuse 2-all people have had some ADHD symptoms at some point 3-all people have always wanted to do better in school with less effort. 4-many of the treatments, whether you have ADHD or not, will improve attention.


There is data suggesting ADHD is more of a phenomenon than psychiatrists merely pointing to a problem and giving meds to treat it.

For example, there are EEG readings that can be used as a form of biofeedback to treat ADHD. I hate using Wikipedia as a source of referall, but it's ADHD section is actually quite good.

I will say this, however. No matter how much data we accumulate on ADHD, there's just too many doctors I've seen too willing to give out a stimulant or a dx of ADHD without really testing for it.

Whenever I have someone who may have it, I recommend stimulant medication as a last resort. I also give the person plenty of data showing that ADHD is best treated with multimodal therapy (e.g. healthy diet, removal of white flour from the diet, removal of simple carbohydrates and food dyes, omega 3 fatty acids, etc). If the person still wants medication, I recommend medications first that do not have abuse potential such as Wellbutrin, Strattera, Clonidine, or Effexor (which does have data supporting it in the tx of ADHD despite it not having an FDA approval). If the person does not improve with these meds, only after I've tried a few of them will I consider a stimulant. If the person is open to taking a stimulant, I require that the person 1-go through psychological testing confirming they have ADHD 2-I try to rule out any potential malingering for meds of abuse 3-I demand an EKG, and 4-I try to talk them out of using a stimulant by informing them of the side effects and risks to health stimulants can cause.

 

[snarfer]

ADHD is a problematic phenomenon for several reasons. 1-the treatment is often a medication of possible abuse 2-all people have had some ADHD symptoms at some point 3-all people have always wanted to do better in school with less effort. 4-many of the treatments, whether you have ADHD or not, will improve attention.


. No matter how much data we accumulate on ADHD, there's just too many doctors I've seen too willing to give out a stimulant or a dx of ADHD without really testing for it.

Whenever I have someone who may have it, I recommend stimulant medication as a last resort.

In many of my ADHD cases, the kids come to me after they have either failed out or about to fail out of school (50s and 60s test grades) due to inattention, forgetfulness, impulsivity. They have been seen by their pediatricians multiple times whom have tried other treatment and they have been in therapy for 1-2 years. Their teachers by then had given up on them, daily punishment for 'bad' behavior is routine, and their self esteem is in the dumpster.

ADHD is controversial in adults, as most new diagnosis often is in any medical field, but the adhd kids i see are bouncing off the wall and often times can put themselves in danger due to their impulsivity.

 

[RedPakotaSea]

There is data suggesting ADHD is more of a phenomenon than psychiatrists merely pointing to a problem and giving meds to treat it.

For example, there are EEG readings that can be used as a form of biofeedback to treat ADHD. I hate using Wikipedia as a source of referall, but it's ADHD section is actually quite good.

Thanks. I'll check it out.

You start treatment of HTN when BP is at a certain cutoff level x2 in an office setting. Are we applying a label to these individuals too soon? Should we hold treatment until pts come in with malignant HTN and/or blow out their optic disc?

I understand your skeptism as you raised age old concerns for many illness, particularly from individuals who are fortunate enough to have not had any immediate family members affected by the disease. Or just does not see the whole picture. However, we know that the number one cause of kids dropping out of school is due to untreated mental illness. ADHD being one of the major disorders. Should we let these kids flunk out of school, become suicidal or violent, or turn to drugs?

There are tons of solid peer reviewed literature on ADHD at pubmed.

I understand your argument, but the treatment of blood pressure is a poor analogy. We know that hard outcomes, such as mortality, can be modified by the treatment of hypertension. There are a number of long-term RCTs that consistently demonstrate a benefit to managing BP. We also know that the risk of starting BP medication is low. On the other hand, as far as I am aware, there are no conclusive, unbiased studies showing that stimulant treatment of ADHD results in long-term improvements in performance and well-being. The foundation of evidence for this disorder is particularly flimsy. Peer review is a good model, but it's far from perfect.

Also, I explicitly stated that we should not avoid treating people who may benefit from assistance, but it's important to be fully aware of the ramifications of diagnosis and treatment. In the case of ADHD, jumping straight to stimulant treatments often does more harm than good.

As for personal experience, I have a close friend that was diagnosed with ADHD at age 19. And no, this was not a soft diagnosis. Extensive testing confirmed that he suffered from ADHD. This friend was anything but a malingerer. He had struggled at times throughout his education, but had made it to college. Following the diagnosis and initiation of adderall treatment, he became much more focused, but in the end his stimulant-treated academic performance was essentially unchanged. Toward the end of college he increasingly abused his medication and began to show signs of anxiety and depression. He is now jobless with significant debt, and has suffered from an "isolated psychotic episode" while off stimulant treatment. I have no doubt that he would have been much better off without ever having visited his mental health provider.

 

[stn2006]

you said his concentration got better. Then what's went wrong? Have you other people consider if he has other axis I or II, or III diagnose or other reasons that lead to his decline?

 

[RedPakotaSea]

^Enhanced concentration is not a meaningful endpoint. There was essentially no improvement in his academic performance and the long-term outcome was poor. If I took mixed amphetamine salts, I'm sure my focus and productivity would also improve, in the short-term at least.

Edit (for Whopper): Yes, there were other axis issues that contributed, but they are beside the point.

I'll leave the original post as is, since it is relevant to the discussion, but I understand your concern.

 

[whopper]

Ouch, I'm wondering if we're crossing the line. We're not supposed to give medical advice to people who seek it in the name of treatment. This is not what's going on here, but it's getting very close.

ADHD is controversial in adults, as most new diagnosis often is in any medical field, but the adhd kids i see are bouncing off the wall and often times can put themselves in danger due to their impulsivity.

Fair enough, and I don't do child psychiatry. My comments were only in reference to adult ADHD, and I should've clarified that. (I apologize for not doing so.).

 

[snarfer]

Thanks. I'll check it out.



I understand your argument, but the treatment of blood pressure is a poor analogy. We know that hard outcomes, such as mortality, can be modified by the treatment of hypertension.

We also know that the risk of starting BP medication is low.

On the other hand, as far as I am aware, there are no conclusive, unbiased studies showing that stimulant treatment of ADHD results in long-term improvements in performance and well-being.

As for personal experience, I have a close friend that was diagnosed with ADHD at age 19. And no, this was not a soft diagnosis. Extensive testing confirmed that he suffered from ADHD. . I have no doubt that he would have been much better off without ever having visited his mental health provider.

The point is that most people will develop variants of hypertension at some point during their lives. Mild, lifestyle changes can be effective just as lifestyle changes in mild ADHD. Moderate to severe HTN unresponsive to lifestyle modifications will require antihypertensive, which can have serious side effects including cognitive dulling, sedation, syncope, reflex tachycardia, electrolyte disturbances, etc.. HTN is also chronic and many pts will be eventually be on polypharmacy by age 50 or so due to numerous unknown reasons but maybe due to decreased peripheral vasc or ventricular compliance. It also increases risks of CHF, CAD, aneurysms, renal insufficiency, etc.. despite treatment. However, it may reduce myoicardial ischemic events in the long run. Longitudinally, peer reviewed RCT papers have shown 65-70% of kids treated with stimulants will achieve full remission in ten years.

However many do have residual anxiety or depression which may or may not be related to the consequences of non treatment during the lag time. Many people have comorbid Axis I or II or Axis III diagnosis along with ADHD.

Protecting the child’s development is what we aim for and many child psychiatrists I’ve met do not prescribe any medications to any children without a lot of thoughts. As previously stated, children usually come to us after years of therapy, parents denial, or other treatment by their pediatrician or FP which have failed.

There are no perfect or non biased published papers in any fields. If you look for it, there are flaws or bias in every paper. Some more some less as papers are written and edited by imperfect human beings.

The stimulants as a group are generally safe medications as they have been around since WWII. Adderall has the most abuse potential. The American academy of cardiology published that article regarding small increased risks of sudden cardiac death which has been unsubstantiated. Subsequent studies have not supported their findings and even the american academy of pediatrics do not support the AAC study. The decreased weight and height issues haven’t supported earlier MTA findings with longitudinal, 10 years, RCT study either.

I had many of the same opinions similar to yours while in college and graduate school. However, with further another +decade of training and experiences, it isn’t as black and white. Everyone has an opinion. Often time well intentioned but ill informed. An n of 1 is hardly enough to turn away from psychiatry. The controversy, breggin/cruise/scientology, is what makes psychiatry so difficult yet rewarding.

 

[RedPakotaSea]

You start treatment of HTN when BP is at a certain cutoff level x2 in an office setting. Are we applying a label to these individuals too soon?

You have raised a good point about essential hypertension. It's true that many medical diagnoses are ultimately somewhat arbitrary as well. However, many psychiatric illnesses are presented as specific neurological disorders, despite the lack of cognitive, metabolic, or neurological markers. Simply put, they are presented as something that they are not. Although it may appear black and white to the lay person, the criteria in the DSM-IV do not magically separate the normal from the pathological. The arbitrariness is exemplified by widely varying prevalence rates of ADHD (0.5% to 26%) depending on the epidemiological study.

There are no perfect or non biased published papers in any fields. If you look for it, there are flaws or bias in every paper. Some more some less as papers are written and edited by imperfect human beings.

There are problems with study quality in all fields, but psychiatry has a particularly strong reputation for sloppy science. For example, the National Institute for Health and Clinical Excellence (NICE) guidelines recommended first-line treatment with stimulants for adult ADHD based on three clinical trials. Of these, two, both done at Harvard, were found to have substantial conflicts of interest. Unsurprisingly, these two trials demonstrated much larger effects than others. The third trial was a small crossover study that followed subjects for only three weeks. There is no long term data informing the recommendation.

Longitudinally, peer reviewed RCT papers have shown 65-70% of kids treated with stimulants will achieve full remission in ten years.

Back to childhood ADHD, statistics such as this one are of no help at all. Not only is evidence lacking that stimulants actually treat the underlying disorder (quite the opposite actually), but there is no control group for comparison. Again, my argument is not that struggling kids should not be treated; it's that arguments like this lead to uninformed prescribing habits.

There are tons of solid peer reviewed literature on ADHD at pubmed.

Despite the fact that no specific abnormality has been consistently demonstrated, neuroimaging is often cited as "proof" of a biological basis of ADHD. According to Moncrieff, "after almost 25 years and over 30 studies, researchers have yet to do a simple comparison of unmedicated children diagnosed with ADHD with an age matched control group."

Moncrieff argues that "Popularising the diagnosis of adult ADHD also encourages people to regard longstanding behavioural problems as amenable to a quick fix, thus introducing, undebated, a form of cosmetic psychopharmacology that fits into our increasingly hyperactive lifestyles but at a price of distancing us from our own psychosocial resources and abilities."

To illustrate (not prove) my comment that ADHD is the tail of essentially a normal distribution, I found this blog, which demonstrates my point quite well. Many human traits, such as height, weight, intelligence, etc. follow a normal distribution.

"In our sample, the number of participants reporting high levels of ADHD traits and the number of participants reporting low levels of ADHD traits are approximately the same; with the vast majority of participants reporting average levels of ADHD traits."

To reiterate, my argument is not that patients with significantly impaired functioning should be denied pharmacotherapy or that we should do away with the diagnosis of ADHD. What I am saying is that the desire for a quick fix, coupled with pharmaceutical industry interests, are a set up for ineffective and potentially detrimental mental health care. Psychiatrists need to be more conservative when it comes to endorsing/prescribing new drug treatments. They should be more critical of the available scientific literature, more able to weed out flimsy evidence, and therefore, less inclined to jump at a drug company's next recommendation.

 

[snarfer]

There are problems with study quality in all fields, but psychiatry has a particularly strong reputation for sloppy science.

Back to childhood ADHD, statistics such as this one are of no help at all. Not only is evidence lacking that stimulants actually treat the underlying disorder (quite the opposite actually), but there is no control group for comparison.

According to Moncrieff, “after almost 25 years and over 30 studies, researchers have yet to do a simple comparison of unmedicated children diagnosed with ADHD with an age matched control group.”

Moncrieff argues that “Popularising the diagnosis of adult ADHD also encourages people to regard longstanding behavioural problems as amenable to a quick fix, thus introducing, undebated, a form of cosmetic psychopharmacology that fits into our increasingly hyperactive lifestyles but at a price of distancing us from our own psychosocial resources and abilities.”

Psychiatrists need to be more conservative when it comes to endorsing/prescribing new drug treatments. They should be more critical of the available scientific literature, more able to weed out flimsy evidence, and therefore, less inclined to jump at a drug company’s next recommendation.

There have been no studies between unmedicated ADHD kids vs. medicated ones because we are physicians. To do so would violate the Hippocratic oath. Diagnosing someone and leaving them untreated longitudinally just for scientific curiosity is highly unethical. Citing Moncrieff is fine but she is in the same, biased antipsychiatry camp as peter breggin, thomas sasz, tom cruise, and the other scientologists. Point is these people are not the best to cite as it is akin to supporting serial murder and quoting because J.Dahmer supports it.

You mentioned that psychiatry research is problematic. Is it more that the UK pediatrician who falsely linked MMR vaccine and autism? Countless children have died or severely impaired worldwide because of this study which by the way, the subjects were kids attending a party at his backyard. How about the anesthesiologist who published papers but never did any research? The cardiologists push to use stents, CABG for nonSTEMI? The list goes on and on…..

You are right that ADHD medicine has not shown to change the underlying aberrant neural circuit. Not anymore than oral sulfonurea can fix the islet cells in diabetes. However, the medicine does allow kids to pay more attention, less impulsive and slow them down enough to listen at home and school and keep them from engaging in dangerous behaviors. Once this can happen they can retain information from their teachers/parents, and modulate positive behaviors. They can participate in therapy better because they are not bouncing off the wall. In turns, newly learned behavior can result in positive biological changes in the neural circuitry. So yes, stimulant indirectly does influence the brain neural circuitry.

We also know that therapy is a biological treatment but many times we need medications to allow therapy to work. What’s the saying? How many psychiatrists does it take to change the light bulb? Answer is it depends because the light bulb has to want to change. Kids can’t ‘want’ to change when their brains are racing a thousand times per minute. Medications may or may not have side effects (many kids and adults have no adverse SEs) but there are side effects to non treatment as well.

Not sure where you live but many psychiatric MDs I know and have met do not ‘jump’ to medications readily. We certainly don’t prescribed based on fads or what the pharm reps tell us. There are always the few exceptions to the rule, as often in all of medicine, but not the norm. We know millions and millions of families and patients have been helped by our specialty.

Contructive criticisms are fine and welcomed but not when they are base on the unsubstantiated claims of quacks.

And we certainly don't base on practice on blogs or other popular media outlets.

 

[maranatha]

Despite the fact that no specific abnormality has been consistently demonstrated, neuroimaging is often cited as “proof” of a biological basis of ADHD. According to Moncrieff, “after almost 25 years and over 30 studies, researchers have yet to do a simple comparison of unmedicated children diagnosed with ADHD with an age matched control group.”

Perhaps I'm reading you point incorrectly and I'm mistaken since this is coming from memory, but I thought I have seen at least a few studies that compared ADHD with healthy controls.

Here is one: http://www.ncbi.nlm.nih.gov/pubmed/12365958

 

[Ollie123]

To some extent I agree, though don't entirely understand the focus on ADHD.

I suspect very few disorders have clear diagnostic boundaries. That goes double for Axis II. There is certainly a wealth of evidence supporting a continuous view of depression and a number of other disorders (look up the taxometric method method sometime). Prisciandaro and Roberts have an article in Journal of Abnormal Psychology that came out a few years ago showing this for depression (just an example - that's the only one I remember off the top of my head).

The DSM isn't reflective of reality...I'd hope everyone in this field knows that. To a large extent, it is a practical tool designed to fit within the system of our society. Of course, that is a two way street and it undoubtedly has a role in shaping that same system as well. I don't doubt the same would hold true in other areas of medicine.

The question is, what system would be better? It is very easy to say "Be cautious in medicating" but I suspect much more difficult to come up with a more definitive guideline for doing so than the DSM. Without relying solely on clinical judgment that is...given the wealth of research showing that we, as humans, tend to be pretty universally crappy judges I think there needs to be some sort of semi-objective system in place to avoid complete diagnostic chaos.

 

[Ibid]

Snaffer

Careful who you call a quack.

Dr. Moncrieff is a Consultant and in good standing with the Royal College.

I think you should consider your words and withdraw your slur on her name.

http://www.rcpsych.ac.uk/

 

[billypilgrim37]

My God, I thought the anti's got bored with this debate in like 1995 and moved on to bigger and better things.

 

[maranatha]

To some extent I agree, though don't entirely understand the focus on ADHD.

I suspect very few disorders have clear diagnostic boundaries. That goes double for Axis II. There is certainly a wealth of evidence supporting a continuous view of depression and a number of other disorders (look up the taxometric method method sometime). Prisciandaro and Roberts have an article in Journal of Abnormal Psychology that came out a few years ago showing this for depression (just an example - that's the only one I remember off the top of my head).

The DSM isn't reflective of reality...I'd hope everyone in this field knows that. To a large extent, it is a practical tool designed to fit within the system of our society. Of course, that is a two way street and it undoubtedly has a role in shaping that same system as well. I don't doubt the same would hold true in other areas of medicine.

Tohe question is, what system would be better? It is very easy to say "Be cautious in medicating" but I suspect much more difficult to come up with a more definitive guideline for doing so than the DSM. Without relying solely on clinical judgment that is...given the wealth of research showing that we, as humans, tend to be pretty universally crappy judges I think there needs to be some sort of semi-objective system in place to avoid complete diagnostic choas.

Good points. One of the first things medical students struggle with is trying to memorize the DSM criteria and then getting their panties all bunched up when we're treating patients that do not meet strict criteria for a disorder. That is typically my cue to hoop into a soap box and start explaining that the DSM is just guide and there is nothing magical about the criteria. It is there for communication between clinicians and to help steer us toward treatment...I then go into the importance of how critical it is to look at a patient's level of function and suffering rather then whether or not they fit into the DSM. HOWEVER, the DSM is still very useful for the reasons stated above and I still stress the importance of learning it.

 

[Therapist4Chnge]

The problem with ADHD is that the cluster of symptoms can often masquerade as other things. Compounding the issue is the first line treatment (stimulants) show gains for people with ADHD and also those without. My biggest issue with ADHD is the large grey area between bad parenting and sub-clinical symptoms. Too many people are actually pushing for the Dx, whether it is the school system hoping to decrease problematic behavior, the parent because they want something to blame, the child/young adult so they get 'considerations' in school, etc. I've done research in the area and I've seen some of the worst cases out there, and they were far far different than 98% of the "typical" cases presenting to the pediatrician.

 

[snarfer]

The problem with ADHD is that the cluster of symptoms can often masquerade as other things.

Compounding the issue is the first line treatment (stimulants) show gains for people with ADHD and also those without.

Too many people are actually pushing for the Dx, whether it is the school system hoping to decrease problematic behavior, the parent because they want something to blame, the child/young adult so they get 'considerations' in school, etc. I've done research in the area and I've seen some of the worst cases out there, and they were far far different than 98% of the "typical" cases presenting to the pediatrician.

I agree with your first point. ADHD overlaps with anxiety and even bipolar disorder.

Regarding the second point. Not sure if that means much. You give B-Blocker to NL control, the pulse/BP will decrease. the problem is making the diagnosis. I wish we have pulses/BP to dx. But then it would make our field less complex and interesting.

May be it is the region where i've trained and now practice but I just haven't seen many cases of parents/schools pushing for diagnosis or treatment. Schools definitely don't want parents to request IEPs or 504s with the ADHD diagnosis these days. I've seen many more cases where parents don't want the dx or treatment. I asked my colleagues and they say the same thing. We all have some cases where parents and schools are pushing but these are the exceptions.

In the popular media, however, there seems to be alot of talk about parents/schools pushing for dx and tx. And that pediatricians, FP, and psychiatrists are handing out meds like candy. This just isn't true in many cases.

I think the Judith Warner book 'we've got issues' describes modern psychiatry, particularly child psychiatry, really well.

 

[RedPakotaSea]

Perhaps I'm reading you point incorrectly and I'm mistaken since this is coming from memory, but I thought I have seen at least a few studies that compared ADHD with healthy controls.

Here is one: http://www.ncbi.nlm.nih.gov/pubmed/12365958

I appreciate you bringing the study to my attention; however, this study contains nothing that would validate ADHD as a specific neurobiological disorder. The authors chose a group of kids with ADHD, and then compared them with a group of "normal" volunteers. In separating these two groups, the authors introduced a number of troubling confounders. First of all, in the screening phase for the healthy volunteer group, the authors accepted only 25% of the screened applicants, citing possible undiagnosed psychiatric condition as one of the exclusion criteria. The healthy volunteers scored significantly higher on Wechsler vocabulary standard score, and there were high rates of comorbid psychiatric diagnoses in the ADHD group, neither of which were included in the covariate analyses. It is unsurprising that a group with lower intelligence and significant comorbid behavioral problems has differences in brain volumes when compared with very healthy controls.

There have been no studies between unmedicated ADHD kids vs. medicated ones because we are physicians. To do so would violate the Hippocratic oath. Diagnosing someone and leaving them untreated longitudinally just for scientific curiosity is highly unethical. Citing Moncrieff is fine but she is in the same, biased antipsychiatry camp as peter breggin, thomas sasz, tom cruise, and the other scientologists. Point is these people are not the best to cite as it is akin to supporting serial murder and quoting because J.Dahmer supports it.

You mentioned that psychiatry research is problematic. Is it more that the UK pediatrician who falsely linked MMR vaccine and autism? Countless children have died or severely impaired worldwide because of this study which by the way, the subjects were kids attending a party at his backyard. How about the anesthesiologist who published papers but never did any research? The cardiologists push to use stents, CABG for nonSTEMI? The list goes on and on…..

No need to resort to hyperbole. I think it's quite extreme to simply discount every opinion that runs counter to yours and lump them all together as you have done. Scientology is very different from a thoughtful and informed critique of current psychiatric practice. Also, I acknowledged that all fields have problems with study methodology. I was only stating what I consider a common perception, which is that psychiatric research is a top offender. It not surprising, since there are enormous financial incentives for the development of psychiatric drug therapies and the outcomes in psychiatry research are often more fuzzy and easy to manipulate compared to endpoints like blood pressure or cardiovascular events. That said, corruption certainly is not confined to psychiatry.

That the pharmaceutical industry has a disproportionate and often undesirable influence on psychiatric practice is not a radical argument. Even former APA president, Steven Sharfstein, acknowledges that psychiatry faces a "crisis of credibility."

http://pn.psychiatryonline.org/content/40/16/3.full

You are right that ADHD medicine has not shown to change the underlying aberrant neural circuit. Not anymore than oral sulfonurea can fix the islet cells in diabetes. However, the medicine does allow kids to pay more attention, less impulsive and slow them down enough to listen at home and school and keep them from engaging in dangerous behaviors. Once this can happen they can retain information from their teachers/parents, and modulate positive behaviors. They can participate in therapy better because they are not bouncing off the wall. In turns, newly learned behavior can result in positive biological changes in the neural circuitry. So yes, stimulant indirectly does influence the brain neural circuitry.

Good points, except earlier you seemed to imply that stimulants result in remission of ADHD. Again, I am not completely against the use of drug therapies, and if there is good evidence that such behavioral change is catalyzed by stimulants in conjunction with therapy in children with severe symptoms, I would reconsider. Even then, I think we need more data on the long-term psychological sequelae of stimulant treatment throughout childhood.

We know millions and millions of families and patients have been helped by our specialty.

Again, I'm not attacking child psychiatry. If any of my comments have come across that way, I apologize. I think psychiatrists do a lot of good, and I have a deep respect for the profession as a whole. However, I also think there are a number of things that need to change for the profession to operate most effectively and for it to recover the credibility that has eroded in recent years.