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  #81  
Old 08-07-2011, 01:15 PM
ledocs ledocs is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

My hypothesis about this dv is that Horgan first read the two-part article by Marcia Angell in "The New York Review of Books," then he read the book by Whitaker. He probably could have confined himself to the Angell articles in his discussion with Johnson. Angell "reviewed" four books in the two articles, one by a psychologist, one by a journalist (Whitaker), one by a psychiatrist (Daniel Carlat), who I believe has probably been interviewed by Terry Gross on "Fresh Air," I have heard her interview a dissident psychiatrist who uses psychopharmacology almost exclusively but who would prefer to use more talk therapy. Then the new psychiatric manual is discussed a bit. Marcia Angell used to be editor-in-chief of "The New England Journal of Medicine" but has also written a muckraking book about drug companies. One might be able to read the Angell articles online. They are in the two most recent editions of the magazine.

I don't have time just now to discuss the Angell articles at length, but the general thrust is to raise a lot of doubts about the biological model of contemporary psychiatry (psychiatric disorders are brain disorders to be treated by psychopharmacology) and to suggest that this revolution in psychiatry is largely explained by the collusion of psychiatry with drug companies which benefit from the sale of psychotropic and psychoactive drugs. The revolution also happens to coincide with changes in the economics of psychiatry. There is not a lot of good scientific evidence, according to Angell, to support the biological model of mental illness.

This whole discussion dovetails remarkably with the discussion I introduced in response to the prior Formerly Science Saturday. People who do not have time to read the Whitaker book may have time to read the NYRB pieces.
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  #82  
Old 08-07-2011, 02:08 PM
Ocean Ocean is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Originally Posted by ledocs View Post
My hypothesis about this dv is that Horgan first read the two-part article by Marcia Angell in "The New York Review of Books," then he read the book by Whitaker. He probably could have confined himself to the Angell articles in his discussion with Johnson. Angell "reviewed" four books in the two articles, one by a psychologist, one by a journalist (Whitaker), one by a psychiatrist (Daniel Carlat), who I believe has probably been interviewed by Terry Gross on "Fresh Air," I have heard her interview a dissident psychiatrist who uses psychopharmacology almost exclusively but who would prefer to use more talk therapy. Then the new psychiatric manual is discussed a bit. Marcia Angell used to be editor-in-chief of "The New England Journal of Medicine" but has also written a muckraking book about drug companies. One might be able to read the Angell articles online. They are in the two most recent editions of the magazine.

I don't have time just now to discuss the Angell articles at length, but the general thrust is to raise a lot of doubts about the biological model of contemporary psychiatry (psychiatric disorders are brain disorders to be treated by psychopharmacology) and to suggest that this revolution in psychiatry is largely explained by the collusion of psychiatry with drug companies which benefit from the sale of psychotropic and psychoactive drugs. The revolution also happens to coincide with changes in the economics of psychiatry. There is not a lot of good scientific evidence, according to Angell, to support the biological model of mental illness.

This whole discussion dovetails remarkably with the discussion I introduced in response to the prior Formerly Science Saturday. People who do not have time to read the Whitaker book may have time to read the NYRB pieces.
I agree with your overall interpretation of the issue and its players.

From my perspective, this is the problem with books like Whitaker's and with Angell's article. He may have an overall good idea or valid point, , but, if in their effort to collect data to support their claim they end up publishing a lot of inaccurate data or misinterpreting the conclusions that can be made, their whole argument becomes weaker instead of stronger. Except in the eyes of the lay person who can't discern between solid data and anecdotal narratives.

But let's go to Angell's overall point. I tend to agree with a number of concerns that she raises. The effect of pharmaceutical companies on prescribing patterns, misguiding the public and creating the idea that medications are the new path to happiness are extremely troublesome. The direction towards biological psychiatry to the exclusion of other treatment interventions is also very problematic.

The problems with BigPharma go beyond psychiatry and enter the entire field of medicine. It has to do more with what the government in this country allows these companies to do than with the actual practice of medicine. It has to do with free markets, regulations (or lack of), lobbying and kick backs. It's as corrupt a business as any for profit enterprise that has expensive products with high volume of sales exercising power on the government. The same power that the SC gave to all corporations.

The problem of biological psychiatry has to be interpreted in a historical context. Before the turn towards biological psychiatry about 30 years ago, psychiatry was dominated by the view that all psychiatrists could offer was psychoanalysis for the milder problems or your regular neurotics, and horrible drugs for the psychotic. As neuroscience and psychopharmacology developed due to the availability of better instruments to study the brain, psychiatry made a turn in that direction. It was the end of an era and the surge of a new one. This is the turn that's being criticized.

So, let's recap. Before the era of biological psychiatry, psychotherapy/psychoanalysis were criticized. It was too woo for the rest of medicine and science. When psychiatry joined the rest of medicine with its biological findings, it became better respected by the rest of medicine. But now it's being criticized for abandoning the psychosocial dimensions. I'm not pointing this out to arouse pity, but rather because it is a typical pattern of change. The pendulum goes to one end and then the other.

Interestingly, it is now when we are finally starting to have instruments that can open windows on how the brain and mind (to use a familiar dyad) can be put together in a coherent body of knowledge. So in a way, Angell's concerns are well taken but not timely. Ten or fifteen years ago would have been a better time, when managed care was pushing psychiatry towards psychopharmacology. And Whitaker's argument isn't much of an argument unless he's willing to clean up his book from all the useless data and then use what's left to claim something of value. His primary claims don't seem to be supported. He may have some valid points, like anyone who looks at the state of a field and raises questions. But, again, not much data to support it.
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  #83  
Old 08-07-2011, 02:44 PM
badhatharry badhatharry is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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I have a lot of admiration and appreciation for folks like you who do this work.
I'd like to take this opportunity to thank you.
I wanted to do this yesterday but got distracted. Me, too.
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  #84  
Old 08-07-2011, 02:58 PM
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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I wanted to do this yesterday but got distracted. Me, too.
Me three.
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  #85  
Old 08-07-2011, 05:57 PM
willmybasilgrow willmybasilgrow is offline
 
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Default Re: John has gone off the deep end

What a shame this thread has gotten hijacked. It's really boring, guys!
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  #86  
Old 08-07-2011, 06:10 PM
AemJeff AemJeff is offline
 
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Default Re: Jeff has gone off the deep end

Sorry Basil, but I doubt this is going to end any time soon.
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  #87  
Old 08-07-2011, 06:20 PM
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Default Re: Jeff has gone off the deep end

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If I have a problem (and I do!) it has to do with unwillingness to let things go and stop defending what I've said until long after it's become clear that there's neither good faith nor good will to be had from some of my interlocutors.
More double-talk.
Quote:
Simply pointing to a conversation and applying an adjective isn't an argument. In fact, have you ever offered a detailed argument, as opposed to catty insinuations and muddled retorts that ignore whichever parts of your interlocutors' arguments you either don't understand or don't find convenient?
Muddled and catty...man, I suck.
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  #88  
Old 08-07-2011, 06:24 PM
AemJeff AemJeff is offline
 
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Default Re: Jeff has gone off the deep end

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More double-talk.Muddled and catty...man, I suck.
I'm not sure you quite understand what "double-talk" means; but "muddled and catty" - I think we're onto something there!
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  #89  
Old 08-07-2011, 06:31 PM
sugarkang sugarkang is offline
 
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Default Re: Jeff has gone off the deep end

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As far as your Nazi comparison, I understand your point: Liberals here tend to think they're doing God's Work by attacking conservatives with insults and name-calling. Also, they seem to think that Godwin's Rule is a scientific principle, or something.
I really wasn't trying to call the Gang of 12 a bunch of Nazis. And I really didn't. But apparently it's an affront to all senses. Call Republicans racists and xenophobes everyday. That's no problem. Yay! Casually slander a person. I never knew it could be this much fun!

And if anyone wants to take an honest look at the conversation between Jeff and Harry, I left it all out in the open and made it as easy to read and honest as possible. Whatever Ocean's criticism was, it was completely irrelevant as to the conversation between Jeff and Harry. I stand by my characterization of events.

Now, how can liberals plead for the mercy of Palestinians, or the poor in America, or the unfortunate anywhere, when they unthinkingly insult anyone and everyone with whom they disagree on an internet message board? I've almost never seen an earnest effort by the Gang of 12 to empathize with differing opinions. Not that they're under any obligation. But if you can't be civil on a message board, how is it that you think you're qualified to create peace for Israel/Palestine? The really big stuff is somehow going to be easier than the small stuff?
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  #90  
Old 08-07-2011, 06:43 PM
Ocean Ocean is offline
 
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Default Re: John has gone off the deep end

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What a shame this thread has gotten hijacked. It's really boring, guys!
I actually agree with you. There's a lot of drama to be had at the drop of a hat. No pun intended.
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  #91  
Old 08-07-2011, 06:45 PM
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Default Re: Jeff is deep

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I really wasn't trying to call the Gang of 12 a bunch of Nazis. I didn't even call them Nazis, but it's an affront to all sense. Call Republicans racists and xenophobes everyday. That's no problem. Yay! Casually slander a person. I never knew it could be so fun!

And if anyone wants to take an honest look at the conversation between Jeff and Harry, I left it all out in the open and made it as easy to read and honest as possible. Whatever Ocean's criticism was, it was completely irrelevant as to the conversation between Jeff and Harry. I stand by my characterization of events.
I know you weren't calling them Nazis. By Godwin's Rule I meant the way they overreact at a the mention of Nazis, as if it were an actual disqualifying action.

Quote:
Now, how can liberals plead for the mercy of Palestinians, or the poor in America, or the unfortunate anywhere, when they unthinkingly insult anyone and everyone with whom they disagree on an internet message board. I've almost never seen an earnest effort by the Gang of 12 to empathize with differing opinions. Not that they're under any obligation. But if you can't be civil on a message board, how is it that you think you're qualified to create peace for Israel/Palestine peace? The really big stuff is somehow going to be easier than the small stuff?
Many of them suffer from low emotional IQ. They have the need to express anger or superiority or whatever, and a message board is a convenient conduit. Dispensing with civilized discourse is considered a noble act sanctioned by Alinsky
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  #92  
Old 08-07-2011, 09:41 PM
eeeeeeeli eeeeeeeli is offline
 
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Default Re: John has gone off the deep end

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I actually agree with you. There's a lot of drama to be had at the drop of a hat. No pun intended.
Yes, very silly.

Hey, kudos on the shout out, Ocean. I too, find you one of the more reasonable people around here. Helps keep us honest!
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  #93  
Old 08-07-2011, 09:51 PM
Ocean Ocean is offline
 
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Default Re: John has gone off the deep end

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Yes, very silly.

Hey, kudos on the shout out, Ocean. I too, find you one of the more reasonable people around here. Helps keep us honest!
Thanks!
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  #94  
Old 08-07-2011, 10:07 PM
eeeeeeeli eeeeeeeli is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Then there's this bit about people with Schizophrenia doing better without treatment than with treatment. Another amazing claim. Where's the evidence? John says it's anecdotal and non conclusive. So, perhaps we should also toss out claims based on anecdotal and inconclusive evidence.
In my time working with schizophrenics, a phrase you would often hear is "he went off his meds", or he's doing well now that he "back on his meds". Clearly, there are are serious side effects, and it all depends on the chemistry of the individual, etc. And there are certainly cases where limiting certain medications, under certain circumstances, is appropriate, as the illness can fluctuate.

But the most tragic thing I saw was improperly managed care. This could have been because the individual was determined not to medicate - many of them seemed to kind of ebb and flow - or because of little social support. A reoccurring theme was an absence of family. I don't know the field so well, but I imagine that families of the mentally ill experience illness at much higher levels, and when dysfunction, poverty, etc. is involved it is that much more difficult.

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Patient with severe mental illness, including schizophrenia, ended up their days in state hospitals, or asylums. Some, the ones that had families and not serious behavioral problems, may have been kept in their homes, taken care of by family members. That's what happens in much of the world with intact extended families, especially if there's significant stigma associated with mental illness. People suffering from those problems are hidden from the rest of society because they're a shame to the family.

In the US, after desinstitutionalization, thanks to the availability of antipsychotic meds, patients were supposed to be reintegrated to the community through programs that would provide the necessary support. At the beginning the idea is that with the money saved from long term hospitalization those programs can be funded. Of course, those are the programs that get cut every time we get governments that decide that cutting spending is more important than the health or wellbeing of the most vulnerable populations.

So, many of those patients dropped out of treatment. Some are in the streets, in the shelter systems. They are many of the homeless that you can see living under bridges. Others are in prison. Others end up in state hospitals, in and out.
I encourage everyone who hasn't to see the piece on Frontline about mental health getting pushed into the prison system.

You know, for so many years I've worked with and around vulnerable populations whose lives literally hang in the balance of state and federal funding. That is, without it might mean the difference between recovering form a traumatic brain injury, receiving a hot meal in hospice, getting drug treatment, staying on meds and safe indoors, or a chance to thrive in school.

Yet the "starve the beast" mentality goes directly at, as you say, these populations. Loury mentioned this in his recent discussion with McArdle: these people don't have as much of a political voice (I would argue this is one area that teachers' unions do stick up for spending on poor kids - had to throw that in there!). But anyway, this stuff is so vital, and yet it gets played with as if it were a luxury. So when someone says they don't want to be a government "serf", or that taxation is "slavery", or that "they know how to spend their money better than the government", I get kind of sick to my stomach. I think of all the people who I've worked with over the years whose lives have been made so much better, and yet are still getting a raw deal out of life, when so many have so much.

Charities are wonderful - bless them. But they are not able to do near all the work that needs to be done. There but for the grace of government response go so many individuals who are true heroes - those facing hardships that most of us can only dream of. They are truly the least among us and pretending that we "can't afford" to help them, while people in this world are driving around in Bentleys, getting nose jobs, furnishing their mansions, or buying billion dollar yachts is enough to turn one's stomach.
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  #95  
Old 08-07-2011, 10:18 PM
Ocean Ocean is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

Good observations.

And that yacht! Yuck! It's incredibly ugly. A joke perhaps?
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  #96  
Old 08-07-2011, 11:09 PM
sugarkang sugarkang is offline
 
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Default Re: Jeff is deep

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Originally Posted by look View Post
I know you weren't calling them Nazis. By Godwin's Rule I meant the way they overreact at a the mention of Nazis, as if it were an actual disqualifying action.
Oh, I know. I didn't mean to sound defensive, but I guess it's a reaction against the mob.

Quote:
Many of them suffer from low emotional IQ. They have the need to express anger or superiority or whatever, and a message board is a convenient conduit. Dispensing with civilized discourse is considered a noble act sanctioned by Alinsky
Well, I didn't even bother to point out, in clearer terms, that the primary objection Jeff seemed to have in that pointless spat had much more to do with vicariously protecting the honor of Ocean's social standing as a psychiatrist (versus the lowly psychotherapist) when all Harry seemed to care about was the actual job description. Jeff's assigning blame outward rather than inward is telling, I think. And I think if you weren't actually in the Gang of 12 and compared the actual text versus my interpretation of them, I think at least half of the disinterested readers would see my version as accurate. That's obviously my own bias. You'd have to get over the "N" word and I guess that's a hard thing to do.
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  #97  
Old 08-07-2011, 11:27 PM
willmybasilgrow willmybasilgrow is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

Logic, reason in the house.

More of my selective copying from the Carlat piece. I just couldn't not. This is the best representation of this point of view I could ever hope to read or dream up myself.

Cogent. Invaluable.

Ah logic. Ah reason. Thank you Mary.

Mary said...

The problem with medication is not so much the fact that it is used on patients, as with the prevailing medical model that assumes that the patient presents with a condition best controlled with drugs, or with institutionalization plus drugs.

Research since the days of Loren Mosher and Soteria, for example, has indicated the florid symptoms of schizophrenia usually subside within about six weeks, whether drugs are used or not. A more recent example is Open Dialogue treatment in Finland, which relies on medication quite sparingly and results in impressive long-term recovery rates. It might be objected that in the "real world" psychiatrists have few options but to give medication, but that's different from evidence that medications are, in general, required.

I think we need to keep in mind that it is our systems of care that lack options, and not that medications are definitely "necessary." They may be at times the only option people can see because our systems of care are defective. Why else have ex-patients and consumers formed protest groups demanding legal rights and alternative methods of treatment? The formation of these groups is beyond strange. It may help put this in perspective to ask whether there are similar groups demanding legal rights and better methods of treatment for cancer patients, or diabetics, or patients with heart disease. I think not.
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  #98  
Old 08-07-2011, 11:47 PM
AemJeff AemJeff is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Originally Posted by willmybasilgrow View Post
Logic, reason in the house.

More of my selective copying from the Carlat piece. I just couldn't not. This is the best representation of this point of view I could ever hope to read or dream up myself.

Cogent. Invaluable.

Ah logic. Ah reason. Thank you Mary.

Mary said...

The problem with medication is not so much the fact that it is used on patients, as with the prevailing medical model that assumes that the patient presents with a condition best controlled with drugs, or with institutionalization plus drugs.

Research since the days of Loren Mosher and Soteria, for example, has indicated the florid symptoms of schizophrenia usually subside within about six weeks, whether drugs are used or not. A more recent example is Open Dialogue treatment in Finland, which relies on medication quite sparingly and results in impressive long-term recovery rates. It might be objected that in the "real world" psychiatrists have few options but to give medication, but that's different from evidence that medications are, in general, required.

I think we need to keep in mind that it is our systems of care that lack options, and not that medications are definitely "necessary." They may be at times the only option people can see because our systems of care are defective. Why else have ex-patients and consumers formed protest groups demanding legal rights and alternative methods of treatment? The formation of these groups is beyond strange. It may help put this in perspective to ask whether there are similar groups demanding legal rights and better methods of treatment for cancer patients, or diabetics, or patients with heart disease. I think not.
I think the reason that "cancer patients," "diabetics," and "patients with heart disease" (and I fit two of three categories) don't form groups like that is because it's generally obvious that modern medicine can be extremely effective at giving us something that's very much like a normal life. I can state objectively that my life is vastly better than it would be without medical intervention, and it would be suicidal for me to trade that for any "alternative treatment."

Mental health issues present a different class of challenges altogether, I think. I lost a schizophrenic friend to suicide. He started refusing his meds because he found the side-effects to be intolerable. His choices were between two terrible options, and the one he chose, it's fair to argue, led to his death.

This was a long time ago and Thorazine was probably the state of the art anti-psychotic at the time. Modern drugs are apparently quite a bit more likely to be tolerable to most people. I understand there's a difference between anecdotes and data; but it seems to me that organizations like NIMH have access to a lot of data. I doubt that the choices faced by contemporary patients with terrible mental health conditions are nearly as clear-cut as mine have been; but I'm pretty certain they''re quite a bit better than those that confronted my friend.
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Last edited by AemJeff; 08-07-2011 at 11:50 PM.. Reason: fix typo
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  #99  
Old 08-08-2011, 07:42 AM
Ocean Ocean is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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I think the reason that "cancer patients," "diabetics," and "patients with heart disease" (and I fit two of three categories) don't form groups like that is because it's generally obvious that modern medicine can be extremely effective at giving us something that's very much like a normal life. I can state objectively that my life is vastly better than it would be without medical intervention, and it would be suicidal for me to trade that for any "alternative treatment."

Mental health issues present a different class of challenges altogether, I think. I lost a schizophrenic friend to suicide. He started refusing his meds because he found the side-effects to be intolerable. His choices were between two terrible options, and the one he chose, it's fair to argue, led to his death.

This was a long time ago and Thorazine was probably the state of the art anti-psychotic at the time. Modern drugs are apparently quite a bit more likely to be tolerable to most people. I understand there's a difference between anecdotes and data; but it seems to me that organizations like NIMH have access to a lot of data. I doubt that the choices faced by contemporary patients with terrible mental health conditions are nearly as clear-cut as mine have been; but I'm pretty certain they''re quite a bit better than those that confronted my friend.
Jeff,

The reality is that anybody that has worked with people with severe mental illness know the difference between medications and no medications.

When I hear people here being so vocal about anecdotes posted in the internet I can only compare it to comments denying climate change because there was a particularly cold or pleasant day where they live. It's meaningless and it tries to deny a reality that can only be evaluated with aggregate data.

In the old times we used to say in regards to schizophrenia (and note that there are two other disorders which are briefer: acute psychosis - 1 month- and schizophreniform disorder - 6 months) that the natural course was 1/3 of people got better (not well, but better), 1/3 would remain the same (psychotic, impaired), and 1/3 gets worse (more psychotic, and more impaired/dangerous).

There's plenty to be said about changing the way the treatment for these conditions is implemented. Currently it is far from perfect and often rather upsetting for a variety of reasons. Some of the newer medications are outrageously expensive. Too often patients are being treated with doses that are too high or with polypharmacy. There aren't enough outpatient supports/ program that would lead to rehabilitation.

But having said all that, this nonsense about conspiracies, and making people worse with medications rather than without, is missing the boat altogether. It is a disservice to this population.
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  #100  
Old 08-08-2011, 09:26 AM
ledocs ledocs is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

I think that "conspiracy" is a complete misnomer for what is being alleged, and we just had the same discussion with respect to the federal government's reluctance to fund research into medical marijuana. Bad economic incentives were put in place for the practice of psychiatry, and drug companies probably had a lot to do with this. It would be a mistake to pretend that doctors or psychiatrists are exempt from economic incentives and pressures. And it's not as though the federal government and its agencies are somehow independent arbiters in all this, they are not, not even close.

Here is a link to the interview with Carlat from "Fresh Air" to which I referred. Carlat is a kind of whistle-blower about the marketing of psychotropic drugs to doctors, he tells his story from an insider's point of view. I had forgotten this whole aspect of his story, because I was concentrating on what he had to say about what is known about the mechanism of the serotonin uptake inhibitors and about the aetiology of mental illness generally. Carlat is clearly not some sort of wild-eyed radical. He's just somebody with a little self-respect and a conscience. He was trained at Harvard, he's on the medical faculty at Tufts. And his voice is exactly like that of my former GP in San Francisco, who was also trained at Harvard.

http://www.npr.org/templates/story/s...ryId=128107547

In this interview, one learns that a high percentage of articles about Zoloft published in the most prestigious medical research journals were ghost-written by publicists for drug companies during some period of time. Psychiatrists, acting as shills, were simply appended as authors and paid. Carlat suspected (interview in 2010) that some not insignificant percentage of articles in medical research journals continue to be ghost-written, and no one was ever severely punished because of this practice.

No group of people got together in a room and planned how to cause the financial meltdown and how to profit from that meltdown. Nevertheless, there was a meltdown, and some people profited handsomely from it. This story is perhaps different, but not that different. Doctors are certainly much less close to being purely economic actors than investment bankers, I grant that.

For example, shitty mortgage-backed securities were sold to supposedly highly sophisticated investors who relied, at least to some extent, on rating agencies. Similarly, highly trained physicians can be sold a bill of goods about a drug. Behind the mortgage-backed securities and the rating agencies were highly trained "quandts," assuring people that securities were much safer than they were. Time and again, the most sophisticated mathematical models have failed when applied to the behavior of financial markets (see Yves Smith, "Econned"). So one has to ask, how sound is the neurological science behind the aetiology of various mental illnesses, how sound are the initial diagnoses, how sound is the knowledge of the mechanisms for the workings of the various drugs, and so on. Carlat says, in effect, "not too sound at all" in reply to all of these questions. With regard to the drug regimens in place when he was interviewed, he says that some drugs seem to work very well for some patients, but there is no scientific explanation of why they work. The psychologist, Kirsch, whose book is reviewed by Angell, hypothesizes a "super-placebo effect" for the anti-depressants. Drugs which produce side-effects are recognized by patients as having effects, therefore they could also be having positive effects in addition to the undesired side-effects, therefore they are having positive effects, and the patients then report feeling better (see Angell, NYRB, June 23, 2011, p. 23). "Neurotransmitter function seems to be normal in people with mental illness before treatment" (ibid.). "Carlat refers to the chemical imbalance theory as a `myth' (which he calls `convenient') because it destigmatizes mental illness), and Kirsch, whose book focuses on depression, sums up this way: `It now seems beyond question that the traditional account of depression as a chemical imbalance in the brain is simply wrong (ibid).'"

My interest in all this is that we see here perhaps the best possible example of how the mind = brain hypothesis could lead people astray. I think that scientism has infected the entire species now in a potentially very dangerous and undesirable way. When I have a medical problem, I typically go to a Western doctor. I do have one medical problem that is not terribly troublesome that has completely eluded both diagnosis and treatment, in my opinion. But generally speaking, I am an admirer of Western medicine, I have two artificial hips, they have kept me free from pain for 13 years and out of a wheelchair. I would also have died in infancy had it not been for modern medicine, because I swallowed some Drano while in my grandmother's care.

I, too, have been close to people with serious mental illness, and if someone close to me were suffering from serious depression or were diagnosed with schizophrenia, I would not be opposed to treating her with drugs. But, on the other hand, I would regard it as a trial-and-error process, if it seemed to be beneficial on balance, fine, if not, I would not hesitate to question the doctor's authority about the treatment and try to insist that the drug regimen be changed or simply halted. The problem as I understand it, and this comes out in the Carlat "Fresh Air" interview, is that psychiatry has attempted to put itself on a par with other recognized medical specialties, such as orthopedics (cardiology is the example in the interview), but orthopedics or cardiology have to do largely with mechanics, the mind or the brain do not.
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  #101  
Old 08-08-2011, 09:55 AM
badhatharry badhatharry is offline
 
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Logic, reason in the house.


The problem with medication is not so much the fact that it is used on patients, as with the prevailing medical model that assumes that the patient presents with a condition best controlled with drugs, or with institutionalization plus drugs.
Are you familiar with John Nash?

Quote:
Was Nash's recovery unusual or remarkable, much less miraculous, when compared to the course the illness takes with other people with schizophrenia? Apparently not. "We know as a general rule, with exceptions, that as people with schizophrenia age, they have fewer symptoms, such as delusions and hallucinations," says E. Fuller Torrey, M.D., author of the best-selling book, Surviving Schizophrenia. "So that when Nash hits his late forties and fifties, and his life gets better, it's not shocking at all. Anyone who follows the literature would never characterize it as a miracle."
I wonder if the age relatedness would give some clues as to how to cure the disease or lessen symptoms.
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  #102  
Old 08-08-2011, 10:25 AM
cragger cragger is offline
 
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I haven't read the source article so the advocacy groups referred to may be about something else entirely, but there is a basic difference between mental health patients and medical patients like diabetics or people with heart problems beyond perceived efficacy of treatment. So far as I know, there is no legal regime that the latter are subject to that can force them to take insulin, or to perhaps stop smoking, lose weight, etc. as well as take particular drugs to mitigate heart problems. The patient is free to accept a suggested therapy or reject it, and may seek out doctors whose favored treatment aligns better with the patient's wishes, be they informed or not. There is a stark difference in the mental case in which someone who is concerned or annoyed regarding the behavior of another can refer to state authorities who can then turn those individuals over to practicioners who can use whatever force is required to treat them with whatever drugs or other modalities the practicioner thinks best or which those running an institution find convenient for the operation. The patient has no choice under those instances, which is a possible reason for ogranized objection.
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Old 08-08-2011, 10:44 AM
eeeeeeeli eeeeeeeli is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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I think that "conspiracy" is a complete misnomer for what is being alleged, and we just had the same discussion with respect to the federal government's reluctance to fund research into medical marijuana. Bad economic incentives were put in place for the practice of psychiatry, and drug companies probably had a lot to do with this. It would be a mistake to pretend that doctors or psychiatrists are exempt from economic incentives and pressures. And it's not as though the federal government and its agencies are somehow independent arbiters in all this, they are not, not even close.

Here is a link to the interview with Carlat from "Fresh Air" to which I referred. Carlat is a kind of whistle-blower about the marketing of psychotropic drugs to doctors, he tells his story from an insider's point of view. I had forgotten this whole aspect of his story, because I was concentrating on what he had to say about what is known about the mechanism of the serotonin uptake inhibitors and about the aetiology of mental illness generally. Carlat is clearly not some sort of wild-eyed radical. He's just somebody with a little self-respect and a conscience. He was trained at Harvard, he's on the medical faculty at Tufts. And his voice is exactly like that of my former GP in San Francisco, who was also trained at Harvard.

http://www.npr.org/templates/story/s...ryId=128107547

In this interview, one learns that a high percentage of articles about Zoloft published in the most prestigious medical research journals were ghost-written by publicists for drug companies during some period of time. Psychiatrists, acting as shills, were simply appended as authors and paid. Carlat suspected (interview in 2010) that some not insignificant percentage of articles in medical research journals continue to be ghost-written, and no one was ever severely punished because of this practice.

No group of people got together in a room and planned how to cause the financial meltdown and how to profit from that meltdown. Nevertheless, there was a meltdown, and some people profited handsomely from it. This story is perhaps different, but not that different. Doctors are certainly much less close to being purely economic actors than investment bankers, I grant that.

For example, shitty mortgage-backed securities were sold to supposedly highly sophisticated investors who relied, at least to some extent, on rating agencies. Similarly, highly trained physicians can be sold a bill of goods about a drug. Behind the mortgage-backed securities and the rating agencies were highly trained "quandts," assuring people that securities were much safer than they were. Time and again, the most sophisticated mathematical models have failed when applied to the behavior of financial markets (see Yves Smith, "Econned"). So one has to ask, how sound is the neurological science behind the aetiology of various mental illnesses, how sound are the initial diagnoses, how sound is the knowledge of the mechanisms for the workings of the various drugs, and so on. Carlat says, in effect, "not too sound at all" in reply to all of these questions. With regard to the drug regimens in place when he was interviewed, he says that some drugs seem to work very well for some patients, but there is no scientific explanation of why they work. The psychologist, Kirsch, whose book is reviewed by Angell, hypothesizes a "super-placebo effect" for the anti-depressants. Drugs which produce side-effects are recognized by patients as having effects, therefore they could also be having positive effects in addition to the undesired side-effects, therefore they are having positive effects, and the patients then report feeling better (see Angell, NYRB, June 23, 2011, p. 23). "Neurotransmitter function seems to be normal in people with mental illness before treatment" (ibid.). "Carlat refers to the chemical imbalance theory as a `myth' (which he calls `convenient') because it destigmatizes mental illness), and Kirsch, whose book focuses on depression, sums up this way: `It now seems beyond question that the traditional account of depression as a chemical imbalance in the brain is simply wrong.'"

My interest in all this is that we see here perhaps the best possible example of how the mind = brain hypothesis could lead people astray. I think that scientism has infected the entire species now in a potentially very dangerous and undesirable way. When I have a medical problem, I typically go to a Western doctor. I do have one medical problem that is not terribly troublesome that has completely eluded both diagnosis and treatment, in my opinion. But generally speaking, I am an admirer of Western medicine, I have two artificial hips, they have kept me free from pain for 13 years and out of a wheelchair. I would also have died in infancy had it not been for modern medicine, because I swallowed some Drano while in my grandmother's care.

I, too, have been close to people with serious mental illness, and if someone close to me were suffering from serious depression or were diagnosed with schizophrenia, I would not be opposed to treating her with drugs. But, on the other hand, I would regard it as a trial-and-error process, if it seemed to be beneficial on balance, fine, if not, I would not hesitate to question the doctor's authority about the treatment and try to insist that the drug regimen be changed or simply halted. The problem as I understand it, and this comes out in the Carlat "Fresh Air" interview, is that psychiatry has attempted to put itself on a par with other recognized medical specialties, such as orthopedics (cardiology is the example in the interview), but orthopedics or cardiology have to do largely with mechanics, the mind or the brain do not.
Isn't the bottom line efficacy though? I've been taking anti-depressants for years (pain/depression) and I'm not convinced it couldn't just be a placebo. But I'm actually doing better now than I ever have. It seems there is legitimate controversy regarding the efficacy of ssri's. As George said, while drug-makers aren't totally clear as to what is going on, they are working with real science, and it can be reasonably argued that they do indeed work (albeit with caveats).

But with more serious mental illness, the stakes are obviously a lot higher, and while the science is still very tricky, as Ocean has mentioned, many of us have clearly seen them work, and there seems much less controversy as to their efficacy.

I don't know whether the claim that psychiatry has attempted to put itself on par with other, more effective areas of medicine. I think any psychiatrist will admit to their being a lot of unknowns, and that different drugs are going to be more or less effective on different patients. Put simply, mental illness is really hard to understand, especially as it comes in so many - often time overlapping - forms, and there is a sense of trial and error with medications.

But on the other hand, there is a lot of science that gives us clues as where to go, even as much more research is needed. I would in this sense liken it to oncology, where outcomes are more more vague and finding causal mechanisms is very hard.
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  #104  
Old 08-08-2011, 10:54 AM
miceelf miceelf is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Originally Posted by badhatharry View Post
Are you familiar with John Nash?

...

I wonder if the age relatedness would give some clues as to how to cure the disease or lessen symptoms.
This may not directly apply to John Nash, but two additional possible explanations for the lessening of symptoms as people age:

1. The people with the most severe symptoms are most likely to die young. Suicide rates are very high, and the poorer functioning schizophrenics are also very likely to be homeless, use drugs, and have all of the risks attendant to living on the street as a drug user: overdose, violent death of various kinds, untreated chronic physical health problems, exposure, etc. It's possible that the schizophrenics who survive into later life were always the ones who had less evere symptoms and/or a better support system in place. So, as the least healthy schizophrenics get censored out due to death, the population is going to look healthier and healthier.

2. I wonder what the diagnostic situation was like 30 years ago when these schizophrenics were diagnosed. Perhaps someone with a less severe mental illness was diagnosed. I recently lost a family member who had been diagnosed with schizophrenia in thelate 60s; roughly 40 years later, when there were health problems that were necessitating a full workup, it turned out that said family member in all likelihood had bipolar disorder, not schizophrenia. oh, and PS, sorry about all of those high voltage shock treatments.
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  #105  
Old 08-08-2011, 10:55 AM
badhatharry badhatharry is offline
 
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There is a stark difference in the mental case in which someone who is concerned or annoyed regarding the behavior of another can refer to state authorities who can then turn those individuals over to practicioners who can use whatever force is required to treat them with whatever drugs or other modalities the practicioner thinks best or which those running an institution find convenient for the operation. The patient has no choice under those instances, which is a possible reason for ogranized objection.
Geez, I hate to open up this hornet's nest again (really, I do) and I may be maligned for it, but this is another piece of evidence that shows it isn't at all accurate to say that if a patient is being treated he is probably satisfied.

Just sayin'

and this is not to say that the mental health professions are not valuable.
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  #106  
Old 08-08-2011, 12:05 PM
cragger cragger is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

Not necessarily. This is a different category than your hypothesized group of patients who are finding psychoanalysis unrewarding but who are chosing to continue in response to being told that their lack of perceived progress is due to psychological resistance that needs to be overcome. Not much if any overlap between the two hypotheses.
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Old 08-08-2011, 01:52 PM
Wonderment Wonderment is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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There is a stark difference in the mental case in which someone who is concerned or annoyed regarding the behavior of another can refer to state authorities who can then turn those individuals over to practicioners who can use whatever force is required to treat them with whatever drugs or other modalities the practicioner thinks best or which those running an institution find convenient for the operation. The patient has no choice under those instances, which is a possible reason for ogranized objection.
That is not true in the USA. Patients can refuse medication. The law was reformed in 1975 and refers to both involuntary hospitalization and medications. There are some limitations involving temporary treatment for those who are a threat to the themselves or others (sedating a violent person in order to restrain him/her), and some guardians for people with advanced dementia and similar disorders may oversee the administration of psychotropics, but generally what you suggest is illegal.
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  #108  
Old 08-08-2011, 02:08 PM
Wonderment Wonderment is offline
 
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So one has to ask, how sound is the neurological science behind the aetiology of various mental illnesses, how sound are the initial diagnoses, how sound is the knowledge of the mechanisms for the workings of the various drugs, and so on. Carlat says, in effect, "not too sound at all" in reply to all of these questions.
Nobody disputes how shameless, misleading and manipulative the pharmaceutical companies are. This is apparent to anyone who has turned on a television in the past 20 years. In addition, all you attribute to Carlat above is not inconsistent with the medications being effective.

Part of the problem in analyzing the data is that pharma and brainwashed consumers have persuaded (or bribed or conned) physicians into over-prescribing meds. Again, that doesn't mean nothing works, and the data certainly supports that many psychiatric medications DO work, even if we don't understand to any degree of certainty how they work, which is what you state in the following:

Quote:
With regard to the drug regimens in place when he was interviewed, he says that some drugs seem to work very well for some patients, but there is no scientific explanation of why they work.
The "super-placebo effect" seems, however, like quite a stretch as an explanation for the vast majority of successful treatment for serious mental illnesses.
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  #109  
Old 08-08-2011, 03:11 PM
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Originally Posted by badhatharry View Post
I wonder if the age relatedness would give some clues as to how to cure the disease or lessen symptoms.
Definitely not! If the treatment included telling patients to take no aspirins and don't call me in the morning, 'cause you'll be better in a few years anyway. Well ... where would the profit be?
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  #110  
Old 08-08-2011, 03:15 PM
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Are you familiar with John Nash?
I am. He helped me to see more clearly.
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Old 08-08-2011, 05:15 PM
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It's possible you are correct, but a bit of searching seems to indicate that things are more complicated and that the law might vary state to state. See for example this Mass. SC ruling from '83:

"The Supreme Judicial Court of Massachusetts stated its appreciation for "the helpful analysis of the issues in amicus curiae briefs by . . . the American Psychological Association", among others, and ruled that involuntarily committed patients may be competent to make treatment decisions unless the patient's incompetence is determined by a judge. If so determined, the judge must make a substituted judgement decision deciding whether the patient would have consented to the medication if competent. A patient may also be treated with antipsychotic medication against his will without prior court approval to prevent the "immediate, substantial and irreversible deterioration of a serious mental illness" but a court must make a substituted judgement determination at the earliest possible opportunity."

from http://www.apa.org/about/offices/ogc/amicus/mills.aspx

There was some other language about allowing forced medication when the patient was deemed to have the potential for violent behavior. In practice, once having declared a patient incompetent I suspect that the medical staff is generally granted considerable latitude in its judgement about the patients condition.

Incidentally, Cuckoo's Nest came out in '75, so maybe patients have Kesey to thank for any improvement in their legal status.

Tangentially, I once worked in a hospital and was sometimes assigned to the mental health unit. The patients there who had ever been in the state institution had an absolute horror of being sent back there.
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Old 08-08-2011, 06:34 PM
SkepticDoc SkepticDoc is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

This reference was in my in-box today:

Quote:
Abstract

Over the past two decades, the use of antidepressant medications has grown to the point that they are now the third most commonly prescribed class of medications in the United States. Much of this growth has been driven by a substantial increase in antidepressant prescriptions by nonpsychiatrist providers without an accompanying psychiatric diagnosis. Our analysis found that between 1996 and 2007, the proportion of visits at which antidepressants were prescribed but no psychiatric diagnoses were noted increased from 59.5 percent to 72.7 percent. These results do not clearly indicate a rise in inappropriate antidepressant use, but they highlight the need to gain a deeper understanding of the factors driving this national trend and to develop effective policy responses. To the extent that antidepressants are being prescribed for uses not supported by clinical evidence, there may be a need to improve providers’ prescribing practices, revamp drug formularies, or vigorously pursue implementation of broad reforms of the health care system that will increase communication between primary care providers and mental health specialists.
http://content.healthaffairs.org/con.../1434.abstract
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  #113  
Old 08-08-2011, 07:06 PM
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Wonderment said:

Quote:
The "super-placebo effect" seems, however, like quite a stretch as an explanation for the vast majority of successful treatment for serious mental illnesses.
Kirsch's book, which profers this explanation, is almost entirely about depression and anti-depressants, per the NYRB articles. The book was convincing enough not to evince incredulity from the reviewer, who I presume to have some scientific competence, and Kirsch looked at all the available published evidence, as well as other unpublished and previously unavailable evidence that he got from the FDA using the FIA.
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  #114  
Old 08-08-2011, 09:21 PM
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I agree with some points and disagree with many. I think I have more or less expressed my opinion in my previous comments on most or all the points you bring up. If you're interested in what I think, I would suggest you read my comments again. And if not, well, you'll save some time.

I'll just clarify a couple of things. The "chemical imbalance" argument is idiotic unless it's presented in a well defined context. Why? Because almost anything that goes wrong in the brain is either caused, mediated or ends in a chemical imbalance. Neurons communicate with each other through their synapses and the language of communication is chemical (neurotransmitters), so unless someone says that there's nothing wrong with the brain, there will be at some point some effect in those communications between neurons. The sentence that you cite about Carlat seems to point at a different angle which is the framework shift towards chemical imbalance as a medical/biological illness. This angle was beneficial to patients because historically the stigma was that psychiatric problems were a character flaw, a weakness that could be overcome if only people got over it. That stigma has been incredibly detrimental to people with psychiatric disorders and their families. Explaining to them, in a simple way that there was a chemical imbalance allowed them to understand that it was an illness and that treatment was available. Again it is a completely separate issue from the main topic about whether psychiatric medications work or not.

Lastly, just a request for caution. You seem to come into the topic with an interest in finding a dichotomy between brain and mind:

Quote:
My interest in all this is that we see here perhaps the best possible example of how the mind = brain hypothesis could lead people astray. I think that scientism has infected the entire species now in a potentially very dangerous and undesirable way.
And you may be reading into this topic aspects that don't exist. We are talking about hallucinations, delusions, mania or clinical depression among the main serious mental disorders.

I wish I had more time to discuss and explore the topic here with all those who seem to be so interested in the topic. The reality is, I worked 11 hours in the clinic today and I'm on call by phone until the morning. Tomorrow I'll have to work for another 10+ hours again. No time to get into much discussion now.
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  #115  
Old 08-08-2011, 09:34 PM
Ocean Ocean is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Originally Posted by ledocs View Post
Wonderment said:



Kirsch's book, which profers this explanation, is almost entirely about depression and anti-depressants, per the NYRB articles. The book was convincing enough not to evince incredulity from the reviewer, who I presume to have some scientific competence, and Kirsch looked at all the available published evidence, as well as other unpublished and previously unavailable evidence that he got from the FDA using the FIA.
ledocs, I agree with Wonderment. There has been a lot of discussion about how pharmaceutical companies conduct their studies and there's a lot of skepticism about some of the claims that had been accepted without much challenge before. So all those arguments are well taken. Still trying to argue that the whole thing is some kind of collective delusions is, well, rather exaggerated if not delusional itself.

I suspect that this topic resonates with you and some doubts and preconceived ideas. My experience is that when that happens the best is that you work it out with your own research. In that way you'll look for those sources that seem authoritative to you, instead of us here in an internet forum.

I have done book reviews for scientific journals. I don't know whether you have done the same in other fields and what the language used in other disciplines is. In psychiatry, you have to look at the fine print to get the real review. I'm just saying that for perspective when you read the reviews you've been referring to.
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  #116  
Old 08-08-2011, 09:47 PM
Ocean Ocean is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Originally Posted by cragger View Post
It's possible you are correct, but a bit of searching seems to indicate that things are more complicated and that the law might vary state to state. See for example this Mass. SC ruling from '83:

"The Supreme Judicial Court of Massachusetts stated its appreciation for "the helpful analysis of the issues in amicus curiae briefs by . . . the American Psychological Association", among others, and ruled that involuntarily committed patients may be competent to make treatment decisions unless the patient's incompetence is determined by a judge. If so determined, the judge must make a substituted judgement decision deciding whether the patient would have consented to the medication if competent. A patient may also be treated with antipsychotic medication against his will without prior court approval to prevent the "immediate, substantial and irreversible deterioration of a serious mental illness" but a court must make a substituted judgement determination at the earliest possible opportunity."

from http://www.apa.org/about/offices/ogc/amicus/mills.aspx

There was some other language about allowing forced medication when the patient was deemed to have the potential for violent behavior. In practice, once having declared a patient incompetent I suspect that the medical staff is generally granted considerable latitude in its judgement about the patients condition.

Incidentally, Cuckoo's Nest came out in '75, so maybe patients have Kesey to thank for any improvement in their legal status.

Tangentially, I once worked in a hospital and was sometimes assigned to the mental health unit. The patients there who had ever been in the state institution had an absolute horror of being sent back there.
There are some general rules that apply across the board for involuntary commitments and some that are specific to each state.

Generally speaking, involuntary commitment to a hospital doesn't automatically imply that forced medication is allowed. There are exceptions where medications can be given against the patient's will for safety reasons: patient getting aggressive, violent, self injurious, or in certain extreme states that pose a risk to the patient's health (severe catatonia). Other than that, a judge has to authorize involuntary use of medications. Two psychiatrists can sign temporary documents that allow involuntary medications for three days (in NJ) until a judge can review the application and make a determination.

All this is for inpatient care of psychiatric patients.

For outpatient care, the different states also have very different rules. Some have what's called outpatient involuntary commitment, which is a mandate for treatment. NJ didn't have those procedures, until recently when under some circumstances there's a mandate for treatment. This applies only to people who are considered to be dangerous to self or others in the absence of treatment.

In case someone is wondering, I practice outpatient psychiatry. None of my patients are under the "involuntary treatment" procedures I mentioned before (rare in NJ). All my patients are voluntary. Of course, there may be people whose families or case workers urge them to continue treatment, but no one is forced to come in.
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  #117  
Old 08-09-2011, 10:00 AM
badhatharry badhatharry is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Not necessarily. This is a different category than your hypothesized group of patients who are finding psychoanalysis unrewarding but who are chosing to continue in response to being told that their lack of perceived progress is due to psychological resistance that needs to be overcome. Not much if any overlap between the two hypotheses.
Right, but I didn't say that there was overlap except in the sense that it is not (or may not be) true that just because a person is continuing to be treated, they are satisfied with the treatment. The mental health professions are unique in this way. There is no objective way to know how the treatment is going besides the anecdotal experience of the patient. A patient might be getting better but doesn't feel that they are and vice versa. Obviously the character and insight of the mental health practitioner is an important component in all of this.
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  #118  
Old 08-09-2011, 01:08 PM
willmybasilgrow willmybasilgrow is offline
 
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Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

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Are you familiar with John Nash?



I wonder if the age relatedness would give some clues as to how to cure the disease or lessen symptoms.
Just checking back in, and will respond here first. Lord, E. Torrey Fuller - I know it'll make some on here cringe, but you might as well have been quoting Nurse Wratched. I mean, come on. And what a self-serving quotation.

Yes, I am familiar with John Nash.

There are a LARGE NUMBER of people who get through a diagnosis of schizophrenia without long term use of drugs and their bad effects. It's not at all apparent to me that many participating in this forum are even slightly familiar with these trends and movements beyond just labeling them "anti psychiatry" which of course many are. Seriously, guys, there are lots of people out there cobbling together treatments of their own, with help from friends and family members and the occasional professional. I know such a scenario must conjure up images of shotguns and violent psychotics to many of you, but that just ain't the reality.

Branch out.
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  #119  
Old 08-09-2011, 01:18 PM
willmybasilgrow willmybasilgrow is offline
 
Join Date: May 2008
Posts: 142
Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

Not only that Cragger. But there is a test for diabetes. That whole comparison is a sham.
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  #120  
Old 08-09-2011, 01:21 PM
graz graz is offline
 
Join Date: Mar 2007
Posts: 3,162
Default Re: Science Saturday: The Mental Illness Epidemic (John Horgan & George Johnson)

Quote:
Originally Posted by badhatharry View Post
Right, but I didn't say that there was overlap except in the sense that it is not (or may not be) true that just because a person is continuing to be treated, they are satisfied with the treatment. The mental health professions are unique in this way. There is no objective way to know how the treatment is going besides the anecdotal experience of the patient. A patient might be getting better but doesn't feel that they are and vice versa. Obviously the character and insight of the mental health practitioner is an important component in all of this.
Keep f*&%'n that chicken.
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