Sunday, March 29, 2015

The psychogenic legacy of Adolf Meyer

Useful paper by Jordan Devylder on Adolf Meyer's psychogenic model of schizophrenia (dementia praecox), relevant to a previous post, summarises what I have been trying to say about Meyer. The article describes the development of Meyer's psychogenic theory in the context of related work in the period from Kraepelin to Bleuler. It reminds us that Kraepelin provided a "provisional and very indefinite" hypothesis that the biological cause of dementia praecox was intoxication from the sex glands causing a poisoning of the brain during puberty. As Meyer said, this was a theory that was "so vague as to demand consideration only if actual facts can be adduced and other facts should fail".

The article argues that we are beginning to see a revival of Meyerian psychiatry. I'm not convinced by Devylder's attempt to link this with the stress-vulnerability model, which is essentially still biomedical. However, as he says, "Meyer's legacy ... is the psychogenic perspective" (see my chapter The biopsychological approach in psychiatry: The Meyerian legacy in my edited book Critical psychiatry: The limits of madness).

The importance of antidepressant discontinuation problems

Giovanni Fava (who I have mentioned in a previous post) et al (2015) have produced what seems to be the first systematic review of clinical aspects of the discontinuation of serotonin specific reuptake inhibitor (SSRI) antidepressants. As they point out, the limited attention to this topic is surprising, considering its importance as SSRIs are widely used in practice.

Discontinuation symptoms may occur with any type of SSRI but seem to be more frequent with paroxetine. Gradual tapering does not eliminate the risk. The syndrome typically occurs within a few days and lasts a few weeks but many variations are possible, including late onset and/or longer persistence. A wide range of psychological and physical symptoms may occur. As I mentioned in a previous post, a survey has confirmed that the primary symptom is anxiety. In my book chapterWhy were doctors so slow to recognise antidepressant discontinuation problems?, I made reference to the paper by Schatzberg et al (1997), which described the core psychological symptoms as anxiety/agitation, crying spells and irritability. That paper also divided the physical symptoms into five clusters: disequilibrium, gastrointestinal, flu-like, sensory and sleep disturbances. There are many similarities with the withdrawal symptoms from benzodiazepines and other antidepressants. Discontinuation symptoms may easily be misidentified as signs of impending relapse.

As Fava et al point out, the use of the term 'discontinuation syndrome', rather than 'withdrawal syndrome' was heavily supported by the pharmaceutical industry to emphasise that SSRIs do not cause addiction or dependence. I have always emphasised the psychological dependence caused by SSRIs since my letter to the BMJ and my Antidepressant discontinuation reactions website. This vulnerability should not be minimised.

Friday, March 20, 2015

The miracle of psychiatry

Like Robert Whitaker (see previous post), I bought Shrinks: The Untold Story of Psychiatry by Jeffrey Lieberman (see eg. another previous post) because I intended to blog on it, but after reading it I initially thought I wouldn't bother (see Robert's blog post).  Lieberman makes claims about brain abnormalities associated with mental illness, which need challenging. However, it's difficult to do so, because there are no references in the book, although there is a list of sources and additional reading at the end. I'm also not sure what has been untold about his story of psychiatry, because there doesn't seem to be much new in the book. Perhaps he thinks that what he calls anti-psychiatry has the dominant narrative in the history of psychiatry and he needs to replace it with his own.

Like Robert, what grated on me was the messianic nature of the book. Lieberman needs to be more circumspect about his claims for psychiatric treatment effectiveness. His tale of psychiatry, as he himself says, is of the "dramatic transformation from profession of shrinks to profession of pill-pushers". Although he is "under no illusion that the specters of psychiatry's past have vanished, or that my profession has freed itself from suspicion and scorn", he believes in the "mind-boggling effectiveness of medication". Steady on! He describes what he calls the "accidental discoveries of miracle medications". The introduction of psychiatric medications may well have been serendipitous but was it miraculous? When chlorpromazine was first introduced in state-funded mental institutions in America, as far as he is concerned, "the results were breathtaking". His enthusiasm for psychiatric medication extends to ECT. This is because he's seen "patients nearly comatose with depression joyfully bound off their cot within minutes of completing their ECT". As Robert Whitaker says, this is "a modern-day story of Jesus, curing the lame, who could now throw away their crutches and walk".

At the beginning of the book, Lieberman gives the history of a psychotic patient he calls Elena Conway, the daughter of a well-known celebrity. Three weeks treatment with risperidone, "a very effective antipsychotic medication", as far as he is concerned, and care in hospital led to a "dramatic improvement". The trouble is that he doesn't say what happened to Elena long-term, apart from suggesting that if she had carried on with aftercare treatment she would have had a "good recovery". Shouldn't we be told if she had a poor long-term outcome?

The combination of psychiatrists' belief in their treatments and patients' faith in psychiatrists may produce a powerful placebo remedy. Psychiatrists, like Lieberman, may be deluded into believing that their prescribing is having specific effects. Lieberman suggests that "instead of Daniel Amen's unproven claims for SPECT-based diagnosis of mental illness [see previous post], we will have scientifically proven methods of diagnosis [in the future] using brain-imaging procedures". But such simplistic and biologically reductionist accounts of mental illness are no different from those of Amen or some of the historical treatment excesses Lieberman describes in the book. Such faith and self-deception still sustains modern pharmacotherapy. The wish-fulling claims of modern psychiatry need to be shrunk to more realistic proportions.

Saturday, March 07, 2015

"There are serious critics of psychiatric diagnosis and ... treatment ..."

Allen Frances, who I have mentioned in a previous post, has been attacked by Paula Caplan (see her article) for being very well paid by Johnson and Johnson (J&J) for producing guidelines which promoted the use of its drug, risperidone, as "first choice" in schizophrenia. Frances, in reply, argues that this is what he believed at the time, but admits it was unwise to have done this with drug industry funding. It suited both doctors and patients to believe that the atypical antipsychotics, like risperidone, were an advance in treatment (see my OpenMind column).

There has also been illegal over-marketing of risperidone. J&J pleaded guilty to a misdemeanor criminal charge of improperly marketing risperidone as a treatment for elderly dementia patients (see NYT article). It has also settled in cases where it has been accused of other "off-label" marketing, particularly in children, and of overstating the safety and effectiveness of the medication (eg. see report on Texas case).

Even some of the most biomedical of psychiatrists have expressed concern about unethical practice in psychiatry (eg. see my book review). The corruption of modern psychiatry does influence the academic debate about diagnosis and treatment (eg. see previous post).