finally read the whitaker book....

[vistaril]

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"Anatomy of an epedemic".......and I was very impressed with him and the book.

I'm sure most of you guys are familar with it as I was before reading it. And I'm sure everyone is familar with the now famous Marcia Angell review and New Yorker series.

I was more impressed after reading his whole book, however. He makes points that are very convincing.....

of course, those are on our side throw all out sorts of reasons for why the data doesn't show what we want it to show, but his point sort of pre-emptively addresses that and says "look, i understand there are potential factors at play that complicate things, but if your drugs were really working you would at least think the results wouldnt be going in the WRONG direction in many cases"......

And as for angell, well......it's hard to challenge her as a medical authority.

Next up is the Kirsch book, which of course I know all about but maybe reading the whole text with it will be informative as well.

 

[IAmAUser]

are you actually a psychiatry resident?
It seems like it would be difficult to function as a resident if you have these kinds of beliefs...

 

[vistaril]

are you actually a psychiatry resident?
It seems like it would be difficult to function as a resident if you have these kinds of beliefs...

of course I am a psychiatry resident.....

And I didn't say I agree with 100% of the whitaker book. Or the angell pieces. But they clearly have a lot of valid points.

As a psychiatry resident, it would be more embaressing to bury my head in the sand and ignore things like this....

 

[nitemagi]

Or you're not a resident. I've seen nothing in your posts to prove it. You have yet to verify yourself as a physician or in a specific program, and are consistently antagonizing (distinct from challenging).

I'm calling your bluff and challenging you to prove that you are the training level you claim to be. This can be done through SDN verification process to verify you are a physician.

 

[vistaril]

Or you're not a resident. I've seen nothing in your posts to prove it. You have yet to verify yourself as a physician or in a specific program, and are consistently antagonizing (distinct from challenging).

and you're misinterpreting challenging as antagonizing......there is nothing remotely antagonizing about my initial post here, for example. I do see that a lot of the posts(not neccessarily on this forum) attack whitaker and the book without basis, and don't provide any real rebuttal except a bunch of hyperbole and ridiculous comparisons.....

 

[BS81]

I'm calling your bluff and challenging you to prove that you are the training level you claim to be. This can be done through SDN verification process to verify you are a physician.

👍

Although I think he is a resident...

Sent from my DROID RAZR using SDN Mobile

 

[nitemagi]

👍

Although I think he is a resident...

Sent from my DROID RAZR using SDN Mobile

He might be. Quite possible. Now he can demonstrate it.

 

[Bartelby]

His central argument seems to be that SSDI payments are increasing and that if mental illness were being treated adequately that those payments should be decreasing, allowing us to see a large-scale proxy for the prevalence and severity of mental illness. I question whether it is a valid measure. A more significant factor could be a transition in the culture both of doctors and patients, seeing SSDI as a more viable long term option and seeking it out more often even if mental illness is not more severe. In other words, might SSDI just be more socially acceptable and easily obtainable?

Also, he argues for pretty benign natural histories for most mental illnesses, including depression, bipolar disorder, and schizophrenia, reporting natural histories that suggest that most of these disorders just kind of clear up on their own shortly. I found his arguments and support for these claims woefully inadequate but would welcome other sources. If they really are this benign, I wonder why we treat them at all? It seems a stay in a hotel that keeps the individual safe for a few months to a year with (maybe) someone to talk with would do the trick for complete and indefinite remission.

I found the Whitaker book to be an interesting read, but it did fly in the face of a lot of the research I have seen. I went to his website (which oddly enough I can't find now) to take a look at some of the studies he describes. He includes a brief summary of the study along with a link to it. Give it a try. I read through a few and found that his interpretation was considerably skewed. His interpretation of STAR*D in particular made some good points but seemed to stretch those points into unmerited conclusions. I did not read through the entire list of studies on the page but I did jump to the ones that seemed most interesting and left disappointed.

Overall I think Whitaker starts with moral assumptions about mental illness and its treatment (namely that medication is not the answer) and seeks out data that can be interpreted to support it without fairly appraising the state of the field as a whole.

This is all from memory having read the book last year, but I wouldn't say he has me convinced.

 

[BobA]

His central argument seems to be that SSDI payments are increasing and that if mental illness were being treated adequately that those payments should be decreasing, allowing us to see a large-scale proxy for the prevalence and severity of mental illness. I question whether it is a valid measure. A more significant factor could be a transition in the culture both of doctors and patients, seeing SSDI as a more viable long term option and seeking it out more often even if mental illness is not more severe. In other words, might SSDI just be more socially acceptable and easily obtainable?

Also, he argues for pretty benign natural histories for most mental illnesses, including depression, bipolar disorder, and schizophrenia, reporting natural histories that suggest that most of these disorders just kind of clear up on their own shortly. I found his arguments and support for these claims woefully inadequate but would welcome other sources. If they really are this benign, I wonder why we treat them at all? It seems a stay in a hotel that keeps the individual safe for a few months to a year with (maybe) someone to talk with would do the trick for complete and indefinite remission.

I found the Whitaker book to be an interesting read, but it did fly in the face of a lot of the research I have seen. I went to his website (which oddly enough I can't find now) to take a look at some of the studies he describes. He includes a brief summary of the study along with a link to it. Give it a try. I read through a few and found that his interpretation was considerably skewed. His interpretation of STAR*D in particular made some good points but seemed to stretch those points into unmerited conclusions. I did not read through the entire list of studies on the page but I did jump to the ones that seemed most interesting and left disappointed.

Overall I think Whitaker starts with moral assumptions about mental illness and its treatment (namely that medication is not the answer) and seeks out data that can be interpreted to support it without fairly appraising the state of the field as a whole.

This is all from memory having read the book last year, but I wouldn't say he has me convinced.

I'm going to ignore the whole the Dr. V argument (used delete key to get rid of snarky comment) for now.

I read the book. I think he does make some valid arguments - but on the whole he failed to subject his own literature review to the same type of analysis he levied at the medical literature. For instance, the idea of using SSDI as a proxy for the effectiveness of drugs is absurd! There are huge con-founders there - like the attorney-government-industrial complex - a huge industry that has developed in order to get people on disability . . . and the largest effect on applications for disability is the unemployment rate, the widening gap between the rich and poor, etc. Moreover, SSDI can actually make people sicker! Work is healthy, and being paid to not-work makes people more ill. Since his main argument is that SSDI for mental illness has increased and therefore drugs are ineffective, I think his book on the whole is deeply flawed. Why not use a more valid measure? Perhaps he wanted to stir controversy?

Several of his other criticisms I think we could all take to heart. We all know the benzo story - that there is strong evidence that they make people worse in the long-term - that CBT is a better treatment for anxiety, that they are addictive and (subtle) benzo withdrawal is often mis-interpreted as anxiety and that thereby benzo's when used chronically perpetuate their own use.


Also, he rightly points out the paucity of research into treating psychosis without medications. There is especially a lack of research into outcomes from lifelong antipsychotic use vs. lifelong placebo. In fact, I've read some expert opinions that rather surprisingly recommend antipsychotics be used in acute psychosis only and then tapered over time due to lack of evidence of effectiveness and clear evidence of harm. Psychosocial treatments (supported employment, case management, cognitive re-training, etc) are probably better long-term treatments although they are largely unavailable because we spend all our mental health dollars are Latuda and Saphris and the like.

Another major flaw in Whitaker's argument is that he fails to recognize the complexity of psychiatric diagnosis and treatment. In particular, he doesn't account for the fact that there is a large heterogeneity of presentation - not all people have the same degree of schizophrenia. Some might almost certainly need life-long medication therapy while others probably have a less severe form of the illness and don't need life-long therapy. But then again, our mental health system hasn't taken this into account either (but reality has - less than half of people with schizophrenia take medication (ie, are out of the mental health system) and some of that half do just fine (while others do suffer).

 

[vistaril]

I'm going to ignore the whole the Dr. V argument (used delete key to get rid of snarky comment) for now.

I read the book. I think he does make some valid arguments - but on the whole he failed to subject his own literature review to the same type of analysis he levied at the medical literature. For instance, the idea of using SSDI as a proxy for the effectiveness of drugs is absurd! There are huge con-founders there - like the attorney-government-industrial complex - a huge industry that has developed in order to get people on disability . . . and the largest effect on applications for disability is the unemployment rate, the widening gap between the rich and poor, etc. Moreover, SSDI can actually make people sicker! Work is healthy, and being paid to not-work makes people more ill. Since his main argument is that SSDI for mental illness has increased and therefore drugs are ineffective, I think his book on the whole is deeply flawed. Why not use a more valid measure? Perhaps he wanted to stir controversy?

Several of his other criticisms I think we could all take to heart. We all know the benzo story - that there is strong evidence that they make people worse in the long-term - that CBT is a better treatment for anxiety, that they are addictive and (subtle) benzo withdrawal is often mis-interpreted as anxiety and that thereby benzo's when used chronically perpetuate their own use.


Also, he rightly points out the paucity of research into treating psychosis without medications. There is especially a lack of research into outcomes from lifelong antipsychotic use vs. lifelong placebo. In fact, I've read some expert opinions that rather surprisingly recommend antipsychotics be used in acute psychosis only and then tapered over time due to lack of evidence of effectiveness and clear evidence of harm. Psychosocial treatments (supported employment, case management, cognitive re-training, etc) are probably better long-term treatments although they are largely unavailable because we spend all our mental health dollars are Latuda and Saphris and the like.

Another major flaw in Whitaker's argument is that he fails to recognize the complexity of psychiatric diagnosis and treatment. In particular, he doesn't account for the fact that there is a large heterogeneity of presentation - not all people have the same degree of schizophrenia. Some might almost certainly need life-long medication therapy while others probably have a less severe form of the illness and don't need life-long therapy. But then again, our mental health system hasn't taken this into account either (but reality has - less than half of people with schizophrenia take medication (ie, are out of the mental health system) and some of that half do just fine (while others do suffer).

paragraph by paragraph:

1) the SSDI argument is just one measure, although the one he does continue to go back to. He also cites study after study *not* based on SSDI. He also mentions all the pharm backed trials thrown out. That said, while your point about SSDI con-founders is correct, let's keep in mind that we are not talking about relatively flat SSDI MH claims, or moderate increase in claims. If this were the case a more reasonable argument could be made that the effectiveness of drugs(which theoretically would push it in the opposite direction) is being offset by the stuff you mention. But we are talking about a MASSIVE INCREASE. That is harder to overlook. As for measures, whether someone can/does work or not is a pretty darn good measure, especially for non psychotic d/os. It measures a *real* outcome.

2) the next two paragraphs you mostly agree with the book

3) your final paragraph(and your only attempted counterpoint besides the weak SSDI argument attempts to do two things, neither of which work. First, you fall back on the "complexity of psychiatry diagnosis and treatment" buzzword, as if whitaker didn't address this very well in his book. Many of the stuff he cites *does* point to work where large numbers of people with various d/os(like schizophrenia) were enrolled and almost certainly had varying degrees of illness. Whitaker clearly understands this. In fact, your last sentence is something Whitaker would likely fully support- one of his main issues is clearly the "one size fits all" approach to psychotic d/o we have in this country....ie someone psychotic comes in, they are started rather shortly on antipsychotics, they then stay in the hospital a week or two and are discharged and told to take their antipsychotics for some amount of time as they go to outpt followup(6 months? 9 months? 1 year?).......Whitaker understands that this one sized fits all approach to psychotic d/o *is* is the problem; something mental health in this country still doesn't get.

 

[IAmAUser]

SSDI as a proxy for the effectiveness of drugs is absurd! There are huge con-founders there - like the attorney-government-industrial complex - a huge industry that has developed in order to get people on disability . . . and the largest effect on applications for disability is the unemployment rate, the widening gap between the rich and poor, etc.

this. I saw a graph somewhere (can't find it now) that showed an inverse correlation with welfare reform / decreased and limited traditional welfare payments corresponding to an increase in SSD. If you can't/won't work and need govt support, this is now the way to get it since the end of traditional welfare.

 

[BobA]

paragraph by paragraph:

1) the SSDI argument is just one measure, although the one he does continue to go back to. He also cites study after study *not* based on SSDI. He also mentions all the pharm backed trials thrown out. That said, while your point about SSDI con-founders is correct, let's keep in mind that we are not talking about relatively flat SSDI MH claims, or moderate increase in claims. If this were the case a more reasonable argument could be made that the effectiveness of drugs(which theoretically would push it in the opposite direction) is being offset by the stuff you mention. But we are talking about a MASSIVE INCREASE. That is harder to overlook. As for measures, whether someone can/does work or not is a pretty darn good measure, especially for non psychotic d/os. It measures a *real* outcome.

2) the next two paragraphs you mostly agree with the book

3) your final paragraph(and your only attempted counterpoint besides the weak SSDI argument attempts to do two things, neither of which work. First, you fall back on the "complexity of psychiatry diagnosis and treatment" buzzword, as if whitaker didn't address this very well in his book. Many of the stuff he cites *does* point to work where large numbers of people with various d/os(like schizophrenia) were enrolled and almost certainly had varying degrees of illness. Whitaker clearly understands this. In fact, your last sentence is something Whitaker would likely fully support- one of his main issues is clearly the "one size fits all" approach to psychotic d/o we have in this country....ie someone psychotic comes in, they are started rather shortly on antipsychotics, they then stay in the hospital a week or two and are discharged and told to take their antipsychotics for some amount of time as they go to outpt followup(6 months? 9 months? 1 year?).......Whitaker understands that this one sized fits all approach to psychotic d/o *is* is the problem; something mental health in this country still doesn't get.

Like I said, I think Whitaker makes some valid arguments and those are the ones I highlighted. While I read the Whitaker book a while ago, my impression was that he would say that NO ONE should be on an anti-psychotic and that's not something I agree with. I think there are differing degrees of illness with different treatments needed.

Drug efficacy doesn't equal decreased disability claims. There are many many things in between the two - including the fact that disability itself makes people sick. When he bases so much of his argument on this illogical, sensational claim it hurts the rest of his book.

 

[vistaril]

Drug efficacy doesn't equal decreased disability claims. .

for some patients no. for some patients it would/may.

If I have a anxiety or depressive d/o pt who is on disability for that, one reasonable measure of treatment would be has this pt's symptoms improved to the point that she can now work.

You are right that other factors(even for anxiety/unipolar dep pts) affect this other than drug efficacy. For example, the pt could have benefited from the drugs and is still endorsing significant symptoms that they claim prevent them from working just because she is lazy and prefers getting a check to being productive. But even in that case, the pt still has to report subjectively that she is not improving on the meds, which since mood symptoms are highly subjective anyways(especially given the time we are with a pt) this does matter.......

He picked disability claims because it was a book intended for people in mental health as well as people outside it, and people can relate to such outcome measures easier than they can obscure(for people outside of mental health) symptom rating scales used in many trials.....but SSDI is hardly the only point he mentioned, and to write off much of the basis of the book because of that is rather silly.

 

[vistaril]

this. I saw a graph somewhere (can't find it now) that showed an inverse correlation with welfare reform / decreased and limited traditional welfare payments corresponding to an increase in SSD. If you can't/won't work and need govt support, this is now the way to get it since the end of traditional welfare.

agreed, but this brings up another concerning point on modern psychiatry......still damning in many ways, even if not 100% related to drug efficacy. That has more to do with out dx approaches and the dsm.....

 

[Ibid]

"Anatomy of an epedemic"....

Next up is the Kirsch book, which of course I know all about but maybe reading the whole text with it will be informative as well.

His website/blog http://www.madinamerica.com/ is all part of the madosphere

A dust up between consumer/survivours and a psychiatrist who had the temerity to use the comment button has led to much wailing and gnashing of teeth

http://www.madinamerica.com/2012/04/guidelines-for-a-thoughtful-discussion/

 

[vistaril]

His website/blog http://www.madinamerica.com/ is all part of the madosphere

A dust up between consumer/survivours and a psychiatrist who had the temerity to use the comment button has led to much wailing and gnashing of teeth

http://www.madinamerica.com/2012/04/guidelines-for-a-thoughtful-discussion/

One thing I've noticed is that a lot of people who don't like what whitaker and others have to say(or except for minor criticisms cant refute it) attempt to lump in whitaker with scientology types......as if just shouting tom cruise does anything.

Whitaker and others in this argument are the ones who are, for the most part, presenting calm and reasonable arguments....

 

[Ibid]

One thing I've noticed is that a lot of people who don't like what whitaker and others have to say(or except for minor criticisms cant refute it) attempt to lump in whitaker with scientology types......as if just shouting tom cruise does anything.

Whitaker and others in this argument are the ones who are, for the most part, presenting calm and reasonable arguments....

The answer to the question "What is the best response to Madness?" will eventually come from "The Mad". It won't arrive in a paper, book or blog but as the result of professional people listening to them (the mad) where ever they find them, on wards, in clinics or on the streets.

All these noisey arguements do is slow down the process as people form opinions and take up practices based on everything except what mad people themselves are saying.

My point is that their is plenty wisdom freely availble if one is interested. Part of the trouble is that no one ever asks the opinion of the person scratching around the ward looking for dog ends of cigarettes because they are not expected to have anything useful to say. In my experience they do but taking the time out to talk to people in this way rather than clinical conversations (which is what people are paid to do afterall) is not part of the culture of mental health services or the people who work in them.

 

[BobA]

for some patients no. for some patients it would/may.

If I have a anxiety or depressive d/o pt who is on disability for that, one reasonable measure of treatment would be has this pt's symptoms improved to the point that she can now work.

You are right that other factors(even for anxiety/unipolar dep pts) affect this other than drug efficacy. For example, the pt could have benefited from the drugs and is still endorsing significant symptoms that they claim prevent them from working just because she is lazy and prefers getting a check to being productive. But even in that case, the pt still has to report subjectively that she is not improving on the meds, which since mood symptoms are highly subjective anyways(especially given the time we are with a pt) this does matter.......

He picked disability claims because it was a book intended for people in mental health as well as people outside it, and people can relate to such outcome measures easier than they can obscure(for people outside of mental health) symptom rating scales used in many trials.....but SSDI is hardly the only point he mentioned, and to write off much of the basis of the book because of that is rather silly.

People who drink coffee are more likely to smoke cigarettes. Does that mean that drinking coffee causes cigarette smoking? That's the form of logic used in Whitaker's argument that drug efficacy = disability claims. It's certainly not something to base one's medical practice on.

 

[vistaril]

People who drink coffee are more likely to smoke cigarettes. Does that mean that drinking coffee causes cigarette smoking? That's the form of logic used in Whitaker's argument that drug efficacy = disability claims. It's certainly not something to base one's medical practice on.

???

These people are on disability FOR mental health illness. That is a pretty damn direct cause and effect relationship. Unlike coffee and cigarettes......

looking at it this way, if someone who smokes stops drinking coffee, they are still smoking. If someone on disabilty stops having a mental illness(or it is effectively treating), they shouldn't(in a decent system) be eligible for disability if they were getting disability because of the mental illness......the two have a cause and effect in such a way(or at least should) that coffee and cigarettes dont.


I get what whitaker is trying to do: measure a real outcome. And measure an outcome that is of a higher quality than something like # of hospital admissions.

regardless, like I said, focusing on that outcome was just a way to more easily relate to non-mental health people. he could have spent more time talking about specific studies, spent more time talking about the incredibly large number of pharm backed trials just tossed out, etc.....

finally, what is a reasonable goal for your non-SMI patients? One practical and valuable one I have is to get them to where there mental illness is causing as little disability as possible. And if their mental illness isn't even treated to the point that their mental illness(not their DM or their CAD) is preventing them from working, well then that is pretty damn concerning......

 

[Bartelby]

???

These people are on disability FOR mental health illness. That is a pretty damn direct cause and effect relationship. Unlike coffee and cigarettes......

IAmAUser put it pretty well above: what about the (strong) possibility that SSDI payments are welfare payments in disguise rather than true indicators of severe mental illness?

Regardless, I remember from another thread that you had an interest in doing med management for a living. If you believe the core message of the book, that psych drugs make people worse in practically all contexts except some short term acute settings, how could that possibly be an ethical career choice? It would be tantamount to ignoring your Hippocratic oath, right? I am not asking this because wanting something to be true makes it true, I am asking because I think it's a major dissonance to reconcile in your own mind and I am interested in how you are dealing with it.

 

[nitemagi]

???

These people are on disability FOR mental health illness. That is a pretty damn direct cause and effect relationship. Unlike coffee and cigarettes......

looking at it this way, if someone who smokes stops drinking coffee, they are still smoking. If someone on disabilty stops having a mental illness(or it is effectively treating), they shouldn't(in a decent system) be eligible for disability if they were getting disability because of the mental illness......the two have a cause and effect in such a way(or at least should) that coffee and cigarettes dont.


I get what whitaker is trying to do: measure a real outcome. And measure an outcome that is of a higher quality than something like # of hospital admissions.

regardless, like I said, focusing on that outcome was just a way to more easily relate to non-mental health people. he could have spent more time talking about specific studies, spent more time talking about the incredibly large number of pharm backed trials just tossed out, etc.....

finally, what is a reasonable goal for your non-SMI patients? One practical and valuable one I have is to get them to where there mental illness is causing as little disability as possible. And if their mental illness isn't even treated to the point that their mental illness(not their DM or their CAD) is preventing them from working, well then that is pretty damn concerning......

Disability doesn't treat mental illness for many people, in fact for some it may perpetuate it, since you can be incentivizing illness.

 

[vistaril]

Disability doesn't treat mental illness for many people, in fact for some it may perpetuate it, since you can be incentivizing illness.

well of course....but that's always been the case. the treatment variable should be psychotropics and/or therapy, not just being on disability.

 

[vistaril]

IAmAUser put it pretty well above: what about the (strong) possibility that SSDI payments are welfare payments in disguise rather than true indicators of severe mental illness?

Regardless, I remember from another thread that you had an interest in doing med management for a living. If you believe the core message of the book, that psych drugs make people worse in practically all contexts except some short term acute settings, how could that possibly be an ethical career choice? It would be tantamount to ignoring your Hippocratic oath, right? I am not asking this because wanting something to be true makes it true, I am asking because I think it's a major dissonance to reconcile in your own mind and I am interested in how you are dealing with it.

well no not really med management. I think when most people refer to "med mgt" they are referring to outpt non-therapy appts. I see myself doing mostly acute inpatient. Yes, that is a lot of medication use of course, but I dont think most people refer to that as med mgt. So the one setting in which there is some need for a more medical model in psychiatry(acute presentations of mania, psychosis) is the one I will mostly work in.

And yes, I most certainly agree that mental health disabilty is "the new welfare". That this is allowed, imo, goes a long way towards problems with psychiatric assessment, dx, and the dsm4. Whitaker touches on more than just the lack of med efficacy in his book, but on psych treatment and assessment in general....and how modern psychiatry is lacking in it with it's medical model.

the most ridiculous thing in psychiatry today is all this nonsense focused on and taught in training programs about what are essentially minor differences in treatment regimens that residents and attendings discuss endlessly and then talk about with patients.....great example: I ocerhead some attending and pgy2 discussing what to do with some ubstable mood d/o pt's meds.....she was on some combination of the usual stuff.....lamictal, effexor....or maybe seroquel and paxil....hell I dunno, but anyways, they were talking about how they could better target this receptor if they increased this med a little and then switched one med to a similar med in it's class that has a little more blah blah activity......you could almost see them making out with stephen stahl as they were discussing this. then no doubt they were going to go in and tell the pt(who has almost certainly become obsessed with meds that arent working anyways) about how this switch will target these new receptors with different affinities through this mechanism which will almost certainly target symptoms x,y,z(maybe throw in some buzzwords like emotional lability)...

there are so many problems with this. but that is the thought process dominating modern psychiatry today, and that is whitaker's main point- this *doesnt work* very well. Now maybe nothing works well with many of these patients. But by golly if it doesn't, nothing can work just as well without the govt spending 4000k a year on seroquel for that patient.

 

[Doctor Bagel]

the most ridiculous thing in psychiatry today is all this nonsense focused on and taught in training programs about what are essentially minor differences in treatment regimens that residents and attendings discuss endlessly and then talk about with patients.....great example: I ocerhead some attending and pgy2 discussing what to do with some ubstable mood d/o pt's meds.....she was on some combination of the usual stuff.....lamictal, effexor....or maybe seroquel and paxil....hell I dunno, but anyways, they were talking about how they could better target this receptor if they increased this med a little and then switched one med to a similar med in it's class that has a little more blah blah activity......you could almost see them making out with stephen stahl as they were discussing this. then no doubt they were going to go in and tell the pt(who has almost certainly become obsessed with meds that arent working anyways) about how this switch will target these new receptors with different affinities through this mechanism which will almost certainly target symptoms x,y,z(maybe throw in some buzzwords like emotional lability)...

You're making me glad that I train where I train because no one here works like that. Is this stuff normal? AFAIK, there's not good data for any of this type of parsing about receptors and whatever efficacy stuff with medications. And I've got to say I also agree with you that our medications aren't that great.

 

[vistaril]

You're making me glad that I train where I train because no one here works like that. Is this stuff normal? AFAIK, there's not good data for any of this type of parsing about receptors and whatever efficacy stuff with medications. And I've got to say I also agree with you that our medications aren't that great.

sure, it's pretty common.

if one were to put together a list of the creme de la creme psychiatrists in america, a disproportionate number of them are either chairs at known programs or "thought leader" type faculty at known programs who either have close ties to pharma or are seen as pharm experts....or both.

We all know the names.....and the key thing to remember is that for every one Nemeroff(ie a giant of giants), there are 40 guys of lesser notoriety just like him. Meaning that instead of being chair at a major program(or former chairs), they are just senior faculty. And instead of making 300k a year on the speaking circuit for bigpharm, they may make 40k.

what's the most common thing we are taught in running through depression protocols when we switch to snri's? We are taught these elegant dose response curves for the snri/ssri ratio of effexor at each dose interval increase. Then we're also taught the same thing for cymbalta, and we're taught how the two compare.

pretty much every pgy2 can state when effexor's "snri action" starts to take over. Probably over half of all pgy2s could state roughlt what the ratio of ssri to snri activity is of Cymbalta at therapeutic doses.

what this has to do with actually helping patients feel better is very questionable.

 

[nitemagi]

You're making me glad that I train where I train because no one here works like that. Is this stuff normal? AFAIK, there's not good data for any of this type of parsing about receptors and whatever efficacy stuff with medications. And I've got to say I also agree with you that our medications aren't that great.

This is the nature of the work we do. We have limited information and limited tools, and we're maximizing what we have. Is it better to ignore the information we Do have, and pretend that pt's feel the same on every SSRI? I don't think so, personally. Nor do I think reductionistic medication only, hit the right receptor and all is well approach fits the bill either. Polypharmacy all too often causes more problems than it helps. Don't swallow propaganda whole. But let's not throw the baby out with the bathwater. We are in the business (as physicians in general) in making complex decisions with limited information. Chew, digest, and spit out what you don't like. Lotta mixed metaphors in there.

Recognize the limitations of the information, and make your best judgment.

 

[vistaril]

This is the nature of the work we do. We have limited information and limited tools, and we're maximizing what we have. Is it better to ignore the information we Do have, and pretend that pt's feel the same on every SSRI?.

is there any evidence this isn't true? What information "do we have"? That information mostly consists of our pts telling us "I couldnt take celexa, but zoloft did great for me........"

Well sure, not every patient "feels the same on every ssri". But I'm not on an ssri period, and I can say I did not "feel the same" in February vs April. If I was a psych patient and I had been switched from prozac to paxil, what is the likelihood I would have attributed that to the switch? Pretty darn high probably

 

[BobA]

???

These people are on disability FOR mental health illness. That is a pretty damn direct cause and effect relationship. Unlike coffee and cigarettes......

looking at it this way, if someone who smokes stops drinking coffee, they are still smoking. If someone on disabilty stops having a mental illness(or it is effectively treating), they shouldn't(in a decent system) be eligible for disability if they were getting disability because of the mental illness......the two have a cause and effect in such a way(or at least should) that coffee and cigarettes dont.


I get what whitaker is trying to do: measure a real outcome. And measure an outcome that is of a higher quality than something like # of hospital admissions.

regardless, like I said, focusing on that outcome was just a way to more easily relate to non-mental health people. he could have spent more time talking about specific studies, spent more time talking about the incredibly large number of pharm backed trials just tossed out, etc.....

finally, what is a reasonable goal for your non-SMI patients? One practical and valuable one I have is to get them to where there mental illness is causing as little disability as possible. And if their mental illness isn't even treated to the point that their mental illness(not their DM or their CAD) is preventing them from working, well then that is pretty damn concerning......

The coffee and cigarettes example was intended to illustrate the fact that two phenomena may appear to have a relationship based on their proximity to one another, but in reality there may be no causation. There are many factors in between coffee and cigarette smoking - just because rates of smoking are increased in coffee drinkers doesn't mean that drinking coffee causes cigarette smoking. Similarly there are too many factors between drug efficacy and SSDI claims to make any kind of determination of causation. Proximity doesn't=causation.

To put it another way, there are many con-founders between med effiacy and disability claims. It is entirely possible that disability claims and med efficacy have nothing to do with each other because there are so many con-founders. Just like drinking coffee and smoking cigarettes have nothing to do with each other.

I think function would be a great way to measure outcomes in patients with any mental illness including SMI. However, the SSDI system is a completely inadequate way to measure drug efficacy because there are so many powerful factors that affect the number of disability claims - the unemployment rate, culture change over 50years, the influence of attorneys, etc- in essence con-founders - that make the data not useful.

Actually, one of the things I found rather annoying about the Whitaker book was that he held the psychiatric literature to a much higher standard than he did his own methodology. He'll criticize the medical literature for having substantial confounds but fail to apply the same standard to his own line of argument.

 

[DOC PENGUIN]

Hey Vistiral, Here is another good book by Whittaker Chambers. It is called Witness, you actually learn something. Also why don't you read blacklisted by history, it shows how McCarthy was 95% right on communism.

 

[aphenomenon]

Agrred with your interpretations and reflections.

I'm going to ignore the whole the Dr. V argument (used delete key to get rid of snarky comment) for now.

I read the book. I think he does make some valid arguments - but on the whole he failed to subject his own literature review to the same type of analysis he levied at the medical literature. For instance, the idea of using SSDI as a proxy for the effectiveness of drugs is absurd! There are huge con-founders there - like the attorney-government-industrial complex - a huge industry that has developed in order to get people on disability . . . and the largest effect on applications for disability is the unemployment rate, the widening gap between the rich and poor, etc. Moreover, SSDI can actually make people sicker! Work is healthy, and being paid to not-work makes people more ill. Since his main argument is that SSDI for mental illness has increased and therefore drugs are ineffective, I think his book on the whole is deeply flawed. Why not use a more valid measure? Perhaps he wanted to stir controversy?

Several of his other criticisms I think we could all take to heart. We all know the benzo story - that there is strong evidence that they make people worse in the long-term - that CBT is a better treatment for anxiety, that they are addictive and (subtle) benzo withdrawal is often mis-interpreted as anxiety and that thereby benzo's when used chronically perpetuate their own use.


Also, he rightly points out the paucity of research into treating psychosis without medications. There is especially a lack of research into outcomes from lifelong antipsychotic use vs. lifelong placebo. In fact, I've read some expert opinions that rather surprisingly recommend antipsychotics be used in acute psychosis only and then tapered over time due to lack of evidence of effectiveness and clear evidence of harm. Psychosocial treatments (supported employment, case management, cognitive re-training, etc) are probably better long-term treatments although they are largely unavailable because we spend all our mental health dollars are Latuda and Saphris and the like.

Another major flaw in Whitaker's argument is that he fails to recognize the complexity of psychiatric diagnosis and treatment. In particular, he doesn't account for the fact that there is a large heterogeneity of presentation - not all people have the same degree of schizophrenia. Some might almost certainly need life-long medication therapy while others probably have a less severe form of the illness and don't need life-long therapy. But then again, our mental health system hasn't taken this into account either (but reality has - less than half of people with schizophrenia take medication (ie, are out of the mental health system) and some of that half do just fine (while others do suffer).