Psychiatricists Squander Patient Trust

All the controversy over whether or not drug money is corrupting psychiatric practice is helping to break trust between doctors and patient.

Stories of Harvard psychiatrists taking big money from pharmaceutical companies; and then through their institutional influence push antipsychotics on kids based on questionable bipolar diagnoses (Harvard Psychiatrists Flunk Appearance of Propriety) and the lack of drug company payment disclosure by psychiatrists who present themselves in the media as medical experts (Stealth Marketers) destroy the crediblity of the profession.

Tara Parker-Pope explains the dissolution of trust in her NYT article Doctors and Patients: A Rocky Relationship.

• “About one in four patients feel that their physicians sometimes expose them to unnecessary risk, according to data from a Johns Hopkins study published this year in the journal Medicine. And two recent studies show that whether patients trust a doctor strongly influences whether they take their medication.”

Most people are reluctant to get psychiatric treatment in the first place because of the stigma of mental illness. Now a wall has been built between doctor and patient.

Parker Pope offers other reasons for patient distrust:

• Doctors have to spend less time with their clients do to “declining reimbursements and higher costs”.;
• Media reporting of medical errors;
• Direct-to-consumer advertising of medications have encouraged people to research their own aliments.

If there is reform and greater transparency in the psychiatric community and a more equal partnership between between doctor and patient, trust could be restored. However these patient demands are nonnegotiable.

Jon Stewart Interviews Harvard Happiness Professor

As you might imagine Jon Stewart of Comedy Central has a little different take on the academic contributions to the field of happiness. Professor Tal Ben-Shahar’s author of Happier: Learn the Secrets to Daily Joy and Lasting Fullfillment made the unfortunate decision, for Tal, to be interviewed on Jon’s show. See Tal Ben-Shahar interview.

As counterpoint you will find reviews of John Haidt’s The Happiness Hypothesis: Finding Modern Truth in Ancient Wisdom and Tal Ben-Shahar’s book in OhmyNews. an English language Korean publication.

The books are inspired by the discipline of positive psychology which began 10 years ago; and use research data to make their point.

The positive psychology movement has changed the face of mental health. Instead of focusing exclusively on pathology, this new discipline helps people develop and maintain a sense of wellbeing. This is a good thing.

Psychiatrist Says, “Depression not a Disease”

National Public Radio devoted its show Science Friday to a debate between a psychiatrist who maintains that depression is not a disease and one who thinks that depression is a medical illness.

The two principals were:

• Harvard trained Dr James Gordon who founded and directs The Center for Mind-Body Medicine in Washington. Dr Gordon is the author of a new book Unstuck which prescribes a holistic program to deal with depression
• and Dr Peter D. Kramer who teaches at psychiatry at Brown University and practices psychiatry in Rhode Island. Dr Kramer is the author of many books including Listening to Prozac and Against Depression. The latter argues that the term depression has many meanings in our culture but most important is the fact that depression is a medical illness.

What is Depression

To Gordon, depression is a signal that something in one’s life is out of balance and can be a beginning to transformational change where a person can become unstuck and move forward.

On the other hand, Kramer sees depression as a cluster of disease traits and symptoms:

• Level of pain;
• Runs in families;
• Disruptions in normal brain activity;
• Co-morbidity with other illnesses such as diabetes and heart disease;
• And tendency to be recurrent and progressive.

So depression looks, smells and acts like a disease to Kramer.

Causes of Depression

Dr Kramer pressed his point that a depressed person’s brain activity and anatomy is abnormal. The head of the Center for Mind-Body Medicine responded that everything in the human body has biological manifestations.

Dr. Gordon believes that the primary response to depression should be a integrated program which includes meditation, relaxation, nutrition and exercise and help for the patient see the world and himself differently. Dr Kramer doesn’t write off these techniques but stresses that depression interferes with the ability to function which impacts careers and relationships and is dangerously associated with strokes, suicide and heart disease.

Depression and Medication

Gordon pointed out that recent antidepressant studies have shown them to be less effective that previously reported. The reason for this, according to Kramer is that the standards of research study have been raised:

• Studies now are based on larger samples of people;
• People are screened more rigorously before they come into to a study;
• And a closer review is conducted on the people who seemed to improve on the drug.

Dr. Kramer also mentioned that the studies of the effectiveness of psychotherapy has shown lesser results recently because the test bar in research studies has been set higher.

Dr Gordon maintains that usually stress is the primary cause of depression and the patient should first be guided through a multidisciplinary program; and that medication is the treatment of last resort for the very small percentage of people don’t respond to holistic treatment.

Morality and Spirit

During one exchange as Dr Gordon was making the point that a person needed to be guided through his program so that the patient could learn to help himself. Dr Kramer reacted by saying that the use of the word “guide” had a moral and spiritual feel to it that made him uncomfortable. Gordon responded by saying that doctors do help to save souls and they have a moral duty to do so. Kramer acknowledged that religion or spirituality can be very important to the patient.

A lot of what Dr Gordon had to say makes sense. In an ideal world, I would agree with his approach. Medications should be the last resort and not the first.

The profession of psychiatry is in a crisis. Efficacy claims for both psychotherapy and medications have been dropping based on new research studies. To be in the position of saying the reason the two treatments looked good a few years ago is due to bad research practices is devastating.

But there are elements of both our culture and the human equation that neither doctor brought up that explains what’s going on:

• Insurance companies have reduced psychiatrists to pill dispensers because it’s cheaper for a patient to spend 15 minutes talking with a doctor who then writes a prescription and sends them out the door. Of course the psychiatrist will prescribe a med, he’s a human being and wants to help is patient.
• Most people don’t have the time, interest or energy to participate in a multidisciplinary holistic program. Dr Gordon has stories in his book about people who have stretched themselves and been successful but they are very much the exception and not the rule. So the idea of taking a pill is probably the most attractive option for people.

Based on what I heard on Science Friday, I understand why we are in the mess that we are in. A healthy life style falls by the wayside when people don’t have the energy or time because they are figuratively running to stay in place economically; it’s difficult to change old habits; and there is big money to be made and time to be saved with drugs,

Antidepressants: No Diagnosis, No Problem

“Forty-three percent of those who had been prescribed antidepressants, had no psychiatric diagnosis or mental health care beyond the prescription of the drug.”

This comes from The Medicated Americans: Antidepressants Prescriptions on the Rise in the February issue of Scientific American.

The statement is mind-boggling. Most of these prescriptions are written by the family doctor for a drug that can have serious, even fatal side effects.

Reasons

I can see four reasons for this.

• Extensive advertising by pharmaceutical companies create such consumer demand that when many people visit their doctor they ask for an antidepressant and the doctor simply complies.
• The insurance companies steer people towards antidepressants because a pill is cheaper and simpler than paying for therapy or encouraging people to live a healthier life style.
• Many people are under tremendous stress.
• Old habits die hard; most people want a magic bullet. Take a pill, no fuss, no muss.

Results

People are taking antidepressants with no valid medical; others are not getting the thorough medical care they need. This results in some people:

• Becoming even more ill because they are receiving only partial treatment;
• Running to their family physician to take a pill for no medical reason instead of dealing with the root cause of a problem or making simple lifestyle changes.

It also results in a huge waste of money.

The pharmaceutical and insurance companies get richer, lots of money is wasted and people get sicker.

Should Your Child Take Prozac? Ask the Grocer

An article in the The Australian highlights the ambivalence of modern societies towards psychotropic drugs. Particularly the use of those drugs to treat children.

Consider the difference between label warnings in Australia and the US.

• United States – “On the packet of one leading brand, the following warning is displayed in bold type: ‘Anti-depressants increase the risk of suicidal thinking and behaviour (suicidality) in short-term studies in children and adolescents with Major Depressive Disorder (MDD) and other psychiatric disorders.’”
• Australia – “They all say SSRIs are not recommended for use in children and adolescents for depression, but few reveal the increased risk of thoughts of suicide or self-harm in this group.”

The piece exposes a policy contradiction within the governments of both countries.

Although some drug labels in the US warn of suicide in children while Australia uses a “dis-recommendation”, government funded health insurance programs help people buy these drugs.

A quote from the paper attempts to explain the Australian government’s contradiction.

• “The health department said the decision to pay rebates but withhold marketing approval for the use of SSRIs in children for treatment of depression was a “sensible balance” between the risk of inappropriate prescription and the risk of leaving the illness untreated.”

We are talking about children here. Both governments are passing the buck.

As Australia’s Pharmaceutical Benefits Advisory Committee puts it “These treating doctors will, of course, have to carefully consider the options, risks and benefits of prescribing these medicines.”

Here in the US, Food Drug Administration makes its non-decision about the safety of antidepressants based on information provided by the drug companies; and with a child’s life in the balance, lets the psychiatrist roll the dice.

This is like saying “There’s a tomato salmonella outbreak across the country but we’ll let your grocer decide whether or not the tomatoes you buy are safe.”

Our Conversation with Author Sonja Lyubomirsky: On Happiness and Depression

First, I would like to thank Sonja for talking with us. Before we get started, I would like to give our readers some background.

Our guest is Sonja Lyubomirsky a professor of psychology at University of California, Riverside; she’s written a best selling book The How of Happiness A Scientific Approach To Getting The Life You Want. She also has a blog by the same name at “Psychology Today”.

Sonja received her B.A. from Harvard University and her Ph.D. in social psychology from Stanford University. Her research has won her honors such as the 2002 Templeton Positive Psychology Prize and a multiyear grant from the National Institute of Mental Health.

There has a lot of great work being done in the fields of psychology and neuroscience which demonstrate that positive feelings, thoughts and experiences can help with depression and these things can help to bring about positive physiological changes in the brain (See OCD Patients Rewire Their Brains)

The purpose of our talk today is to discuss how the work she’s doing might help people who have problems with depression. So lets get started.

Q: Would you give us an overview of your book The How of Happiness?

Sonja: Yes, the book is basically about the way that people can become happier. All of it is based on scientific research.

My book highlights 12 proven happiness strategies that people can use to improve their sense of wellbeing such as expressing gratitude; avoiding over-thinking and social comparison; and taking care of your body. There are sets of activities you can do to implement each strategy.

One of the unique things about the book is that the reader can take a personality-activity fit test to determine what strategies are right for them so that they can tailor their own program.

Q: Are there strategies that are more effective than others for people with depression?

Sonja: It’s likely that some are more effective but there hasn’t been enough research

For one person, cultivating optimism and gratitude might be good ones and performing acts of kindness may not. It would be difficult for a person to focus on acts of kindness if they are unable to leave the house.

The best strategies for an individual are based on their circumstances, needs and goals.

Q: The How of Happiness talks about the trauma challenge. What does this mean for people struggling with depression?

Sonja: Sometimes when people have a traumatic experience such as sexual abuse or the death of a loved one or some other loss, they become very depressed. Their level of functioning declines and they can’t do the things they used to do.

After such a tragedy happens, there are three paths: surviving; recovering back to where you were; or actually thriving.

Perhaps a person whose has suffered trauma can discover strengths and support they never knew they had or develop some positive interpretation about what happened.

It’s important for me say though, that I don’t want the idea of the trauma challenge to set somebody up for failure. No matter where a person is they shouldn’t think badly about themselves by thinking “It’s been awhile since the trauma and I’m supposed to start thriving. What’s the matter with me?”.

Happiness activities can help move a person along what ever the path they are on.

Q: Is there anything particularly promising on the behavioral research horizon for people with depression.

Sonja: We’ve identified lots of strategies and activities that can make people happier. The research focus now is on trying to really understand how and why they work. This will help us to better tailor programs to each person.

Q: Thanks for talking with us today.

Sonja: Happy to do it. You’re welcome.

How to Avoid a Stroke? Don’t Get Depressed

If you are elderly and depressed, you have a 3 times greater chance of having a stroke.

A Swedish study tracked a group of depressed 85 year-olds including some who had dementia over a 3 year period; and found that the chances of them having their first stroke were triple that of people who weren’t depressed.

The researchers also found an association between high blood pressure and first stroke. However “analysis …of depression revealed that depressed mood was the only predictor of first-time stroke.”

Once again, these results demonstrate how devastating depression can be to your overall health; and the urgency with which this chronic and sometimes progress illness needs to be addressed.

For more see Depression One of the Planet’s Most Devastating Diseases.

The Happiness Curve Allows You to Feel 20 Again

If your a man around 40 or a women about 50 and in the doldrums, cheer up happiness may be right around the corner.

A study of nations around the world has identified that after men and women pass their special age they become happier. Once happiness turns up it keeps on going.

In fact happiness is “U” shaped, you start out in happy and vigorous in your 20’s and then buffeted by experience it starts downhill. Finally the sense of wellbeing or lack of it levels off and then starts back again only to continue through your later years. Two scientists in the article explores some theories about why this phenomena takes place.

Mental Illness: The Courts, Doctor’s Office and Coffee Shop

A June ruling by the Supreme Court is the latest example of our institutions wrestling with the mentally ill’s place in society. Different perceptions about what is right are sometimes based along political and philosophical lines but on the street it’s a different story.

Both the Supreme Court and psychiatric community are struggling with the competence of the severely mentally ill to make their own choices.

The issues at the center of the conflict are the:

• individual rights of the severely mentally ill to make their own choices
• government’s right to protect its citizens
• obligations of health care to serve their patients.

In a split decision, the Supreme ruled that a severely mentally ill person may be competent enough to stand trial with the aid of a lawyer but not competent enough to defend himself.

Majority votes were cast by liberal and moderate judges while dissenting votes were cased by conservative jurists.

This issue is discussed by Dr Peter Kramer on his blog “In Practice”; the title of the post is Degrees of Competence: Do Liberals and Conservative Understand Mental Illness Differently?

The liberal majority indicated that they felt a judge could finely grade the competence of a severely mental ill person; and their ability to participate in their own defense. The underlying assumption is that participating in the trial with the aid of a lawyer is less demanding than defending one’s self.

On the other hand, the dissenting votes of conservative Court members seemed to give the absolute concepts of autonomy, liberty and individual rights greater standing. In the case before him, Judge Scalia also cited the coherence presented by the man who was on trial.

Some people who are psychotic can be artful about how they communicate but yet be suffering from severe delusion. Perhaps Judge Scalia was more worried about the protection of the public at large or the courts being co-opted to send people to the gulag than the nuances of justice for the mentally ill.

The psychiatric community also struggles with the patient’s ability to act in his own self interest.

Does it take less competence on the part of a psychotic patient to accept a doctor’s recommendation than to refuse it. Some ethicists says “yes”. Refusing a doctor’s recommendation is a more complex decision because it would require evaluating other options.

A more specific example of this dilemma is whether or not the government can force a person to take their medications

In some states if the People determine that the person is a danger to himself or others, they entitled to force them to take their meds. As a practical matter states don’t have the resources to monitor compliance.

IMO, judges should exercise the ability to understand the level of competence of a person with severe mental illness so they can participate in their own trial to the maximum extent possible; and states should be able to force a patient to take medication for the protection of the public and patient.

As for the competence of a severely ill person to make his own health decisions, the person has every right to make choices as long as he is not dangerous.

In these extreme circumstances, society’s burden to respect the rights of the mentally ill falls upon the psychiatrist and the judge. As for the every life, affirmation and respect for people with mental illness severe or not, can lift the rest of us whether at work, a sporting event, or the neighborhood coffee shop.

Psychotropic Drugs and Children, Buyer Beware

When Ana Bailey was diagnosed with anxeroia at the age of 12, her psychiatrist prescribed an antipsychotic medication which had weight gain as a side effort. Three years later, Risperdal a drug used to treat schizophrenia, has caused another side effect; dystonia, a painful nerve condition in Ana’s back which requires her to awkwardly twist her neck for relief.

Risperdal is not approved for the treatment of eating disorders.

A doctor can prescribe any drug for any condition. This practice is called using a drug “off-label”. The Federal Drug Administration takes a lassiez faire approach; the regulatory agency neither approves nor promotes “off label” use.

The government requires a pharmaceutical company to get approval for the drug’s initial purpose but after that its buyer beware. Drug companies seldom seek approval of a drug’s new “off label” use because of the time and expense.

So a psychiatrist can prescribe a drug for a child even though it’s only approved for adults.

The post Harvard Professors Flunk Appearance of Propriety documents the pervasive influence of drug company money upon the psychiatric promotion and prescription practices. In the end, corporate marketing influences the type of care a patient receives.

Nevertheless, the profession maintains that it’s independent even though they accept payments from drug companies. When questioned about the appearance of impropriety, psychiatrist Dr Susan Albrecht offered this tone deaf response to the NYT “If someone takes the point of view that your doctor can be bought, why would you go to an E.R. with a sick child and say ‘Can you help me.’”

Because your desperate and there’s no alternative?

Dr. Sharfstein, past president of the American Psychiatric Association, comments in the same article about how patent-protected expensive Lexapro is the top selling antidepressant in the country over the generic Prozac,

“Prozac is just as good if not better, and yet we are migrating to the expensive drugs instead of the generics. I think it’s the marketing.”

Marketing by pharmaceuticals and psychiatrists also seems to have had a huge influence on the increased diagnosis of bipolar disorder in children and the rise of “off-label” prescriptions of antipsychotics and antidepressants to them.

The number of kids diagnosed with bipolar has increased 40 times in a 9 year period and evidence is scarce that the antipsychotics and antidepressants even work.

The story of Ana’s anxeroia, lexapro over prozac and the treatment of children for bipolar are like canaries in a coal mine; all suggest that something is terribly wrong with the drug companies, academics, researchers and psychiatrists that makeup the pharama medical complex.

If Ana’s mother can’t trust her daughter’s doctor for the full story, she is forced to do a lot of homework and make decisions about a complex topic for which she has neither the training nor the experience. There has to be a better way.