Psychiatry and 1984

This is probably my last post in this blog, unless something truly important comes up. First of all, I am no longer formally authorized to write about psychiatry, because I don't do it anymore; I withdrew from my residency program and thus relieved myself of any and all responsibility.

Secondly, and most importantly, I realized that psychiatry is not an evil in itself, but only a symptom of the malady that the whole Western society seems to be suffering from. To criticize psychiatry without regard to our society's economy, politics, history or ecology is like treating depression without regard to a person's lifestyle, income, diet or love. Such treatment, and such critique, generates a lot of visible 'action' but is in fact pointless and doesn't help.

Besides, there are people who've said everything long ago and with such clarity that I can never hope to achieve. When's the last time you read Orwell's 1984? This book doesn't even mention psychiatry, but it contains everything that there is to understand about it. If you've read and understood this book, I really have nothing else to say to you; and if you haven't understood it, then no amount of my blogging is going to help you anyway.

And remember: Freedom is when you can say that two by two equals four, even if your Party (or your Doctor) claims otherwise. That's all there is to it, really.

Will the gene of schizophrenia help you?

So why am I not being too enthusiastic about psychiatric genetics? Why am I not excited by the prospect of uncovering the genetic basis of mental disorders, despite the proponents' claims that it should make diagnosis more reliable and eventually provide avenues for effective treatment?

Because these promises do not sound realistic to me. I have to admit that the question of psychiatric genetics is very interesting academically, and it is also readily funded by both drug companies seeking profit and the government seeking some kind of solution to the overwhelming quantities of mentally disturbed citizens. Still, I find it difficult to buy that genetic advances will benefit the real-world patients, and here is why.

First of all, the genetics of mental disorders is subtle and multifactorial. Therefore, even if some genetic predisposition could be statistically proven, in any concrete individual the environment plays a dominant role in determining whether the disorder will appear. In other words, regardless of whether a particular person possesses the wrong genes or not, his being sick or normal will largely depend on his life situation (which is exactly what we've known for a hundred years).

Let's take an example from oncology. There is a gene called BRCA1 that, if mutant, has been recognized as carrying much higher risk of breast cancer development. Now, in oncology the diagnosis can be made much more accurately than in psychiatry; the genetic association with BRCA1 gene is also simple and straightforward. Nonetheless, oncologists do not usually make predictions about any particular patient; even though the risk may be significantly increased, we still cannot say to the carrier or the mutant gene: "You will have breast cancer", or to the carrier of the normal gene: "You're cool, go home."

Whatever gene associations are found in mental disorders, they will not be enough to make predictions, because the environment plays a major role in the fate of any organism. Hence, we can only afford hunting for genes after we've done everything possible to fix the environment. Talking genetics when there are major problems in people's psychological well-being (look around!) is like cleaning the carburetor when the car's wheels are missing. It could help, but it's not the biggest concern right now.

The second reason why genetics is unlikely to benefit the patients is that psychiatry has a tendency of rushing things into practice as soon as they are discovered (if it can be profitable, of course). It is theoretically possible that genetic discoveries will lead to the creation of the effective treatment for psychiatric disorders, but most likely this simply won't have time to happen. What will happen much sooner is that some type of genetic analysis will be implemented, and people who are at risk will be recommended to take the medications preventively.

This will be catastrophic, because the drugs can make a healthy person sick; so there will be no way of disproving that they were really needed. This will reinforce the sense of scientific correctness, and promote further treatment and propaganda efforts, supported by the drug manufacturers. The tradition of giving drugs to healthy people, mandatory genetic testing of children and adults, and the arising legal battles will change the whole landscape of psychiatry into something entirely different from what we know today.

In the resulting confusion the original goal of the genetic research (to develop treatment) will be postponed, as scientists of the day will concentrate on getting out of the current crisis. And everything will repeat again - only the counter of the innocent victims of psychiatric help will advance by a few tens of millions... but who counts them?

Drug Therapy: Does The Easiest Mean The Best?

From a conversation with a psychiatrist one typically gets the impression that the medications are the most powerful tool for treating mental disorders. Yes, you can try therapy, or lifestyle modifications, but if you are dealing with anything serious, the drug treatment is the only thing that has the real power to help.

At least partly, this conviction is based on the practical difficulty to use alternative treatments. For example, good psychotherapy exists but is hard to find and expensive; life style is possible to modify, but it requires significant time and energy invested into patient education and follow-up. Some patients cannot use these treatments even if they want to, because their mental disturbances result in the inability to understand and follow complex directions. The lifestyle modifications may be unattainable for economic or social reasons: someone whose entire family of nine lives in a one-bedroom apartment might want to modify his lifestyle, but be unable to do so.

A pill is certainly the easiest means of treatment, whether or not the most helpful. It can be used in any circumstances and by people of any economic, educational or social background. It is therefore true that medication therapy may be usable in cases when other types of treatment may not; however, any further implications about efficacy are much harder to prove.

Taking Medication Is Voluntary

Taking a psychiatric medication is a voluntary act. Unless you are brought to a psychiatric hospital by ambulance, or suspected of being a possible danger to yourself or others, or not obeying the directions of hospital personnel, or hallucinating, or not agreeing to take the drugs voluntarily for too long when the doctor deems it necessary, you cannot be given a medication against your will.

Don’t Talk About It! Do It!

(re-posted from my old blog, skpsycho.wordpress.com)

In response to the critique of the psychiatric medications, many people try to discredit the effectiveness of psychotherapy. In math this is called ex adverso, or proof by contradiction; when one is unable to prove his rightness, he tries instead to prove that his opponent is wrong. But in math this approach is used very carefully, and only with two mutually exclusive hypotheses. In psychiatry, as in politics, the presumed mutual exclusiveness of the poles is only an illusion, a classic “choice without choice”. If you’re asked to choose between a coffee from McDonalds and from Dunkin Donuts, then you’re screwed if what you really wanted was a good coffee, or a tea, or if, for that matter, you were not thirsty at all.

Notwithstanding the bias behind the statement, if someone says to me that psychotherapy doesn’t work, I will probably agree. Because the person saying so is most likely referring to the classic American understanding of psychotherapy: “talk therapy.” It is just what it says: two people talk about the problems of one of them. I carry no illusions about such therapy, in part for reasons that I have discussed elsewhere. In my opinion, the majority of people who benefit from talk therapy belong to one of the two categories: those whose problems are so insignificant that they can be helped by a sincere conversation with any intelligent being (and they should really go talk to their friends instead), and those who don’t want to change anything in their life and prefer to use the therapist as a kind of garbage can for their perpetually accumulating waste.

Fundamentally, all that the stereotypical talk therapy can do is generate new words. It allows the client to verbalize his feelings, give coherent definitions to his problems, and re-formulate his “wrong” principles in a different way. If the therapy is successful, the client can gain insight (which is learn to describe his internal happenings in words), reach new understanding (which is improve the wordings of his personal law-book of life) and, hopefully, achieve the improvement (which is also a word).

The whole system is based on a presumption that if you say the right words, the right doings will follow. But the universe doesn’t quite work this way. The acknowledgment of your sins by itself doesn’t cure those who suffer from them, nor does it teach you to live your life differently. To define and describe yourself as kind and balanced a person is not quite the same as to become one in reality; no more so then proclaiming yourself a violinist teaches you to play.

In fact, it works in exactly the opposite way. The more you talk, the less you’re able to do. Moreover, filling your head with the nicely-formulated verbal solutions to your problems discourages you from seeking the real, nonverbal solutions. Planning the future prevents you from perceiving the present. Conceptualizing your experiences spoils all the fun. Producing the more and more elaborate descriptions of your life leaves you no time to actually live it.

Good therapy, therefore, should be more like teaching, or coaching; the art being taught, the art of living. A good coach, does not talk much with his students; his role is to motivate them and gently correct their mistakes while they practise, practise, and practise. There’s no point in having conversations about the art of swimming; one simply needs to get into the water, and swim until he does it well. It may help to have a responsible adult nearby at first to save you if you lose control; but once you’re resuscitated, there’s no need to discuss it for too long - simply jump into the water and try again. The danger of talking about it too much is that eventually you may become completely convinced that you are capable of swimming. With this conviction under your belt you will proudly drown in the first real river on your way.

Don’t talk about it! Do it. Don’t verbalize your feelings; feel them. Don’t acknowledge that you’re bad; become good. Don’t apologize; start behaving differently. Don’t thank; accept. Don’t seek the correct definitions; definition is just a word.

If you don’t have a Zen master nearby as you’re reading this, take something heavy from your desk and, without saying what it is, hit yourself on your head.

Nine Reasons Why Psychiatrists Believe In Drugs

It is very tempting sometimes to blame the evil psychiatrists for everything, as if they were in some kind of conspiracy against the rest of us. It is obvious, however, that such a large and diverse group of people cannot maintain any conspiracy for long. Besides, many psychiatrists I've seen are very nice people.

Of course there are financial "incentives," but they would not mean much if the doctors did not really believe that their drugs work.

I've been trying to think of the reasons why they believe it. It looks like the practice of a typical psychiatrist is organized in such a way that the more medications he prescribes, the more convinced he becomes in their helpfulness - sometimes in spite of his own logic and common sense. It is a classic self-reinforcing loop, and drug prescription almost becomes a bad habit.

Once you start prescribing drugs, you are practically doomed to continue, unless something causes you to strongly suspect that something is not right, and make a forceful effort to break out of the vicious circle. (Incidentally, this is probably the moment when the financial incentives play a major role, as the sudden exacerbations of suspiciousness in a psychiatrist are soothed by the large doses of cash.)

So far I have though of nine mechanisms of the erroneous self-reinforcement that the psychiatrists fall prey to.

1. Placebo response.
2. Lack of control group.
3. "Could be worse" logic.
4. Selective memory.
5. Selective interpretation.
6. Short-term efficacy of drugs.
7. Long-term dependence on drugs.
8. Lying to psychiatrists.
9. Attributing success to drugs instead of doctors.

I will discuss each one in more detail in the following posts.

Psychiatry Critique and Antipsychiatry

I would like to make myself clear: I am not an antipsychiatrist.

The easiest way to change your point of view is by changing its sign to create the opposite. In this manner, religion is converted into atheism, love into hatred, promiscuity into puritanism, and psychiatry into antipsychiatry. Although the result is as far from the origin as possible, the similarity between the two points of view is still apparent.

An atheist spends as much time and effort as a preacher thinking about God, only trying to prove His non-existence instead of existence. An antipsychiatrist still limits his thinking to the arguments of psychiatry, only trying to prove them wrong. And all of these people remain rigidly faithful to their points of view.

I don't know if psychiatry - in general - is good or bad. I think that psychiatry could be used to help people. I think it could be one of the most humane and rewarding professions. This is why I had become a psychiatrist (I wouldn't like to practice in the United States today, but that's another story). I am fascinated by the works of Jung, Assagioli, Laing and others who took the art of psychiatry one step further, from simply "fixing" people to fit the social average, to helping them achieve self-realization and spiritual growth.

This said, I can't help noticing that today psychiatry in America is practiced in a very strange fashion. It is no longer art, but science. It is not uncommon to meet a psychiatrist who knows a lot about biology and chemistry but has no idea how to talk to people. (You wouldn't go to a concert where the musicians know all about the physics of sound and theory of composition, but cannot actually play, would you? What if they had shown you their certificates?)

People are being lied to or confused on every step of the way. Every first-time patient that I saw at the hospital was convinced that since he had signed in voluntarily, he may leave at any moment - which was of course not the case. People are distracted from solving their real-life problems by the unnecessary talks of genetics and chemical imbalance. People are told that the prognosis of schizophrenia is better with drug treatment, but it is not proven. People are told that what matters is the symptoms, and not the cause of their depression, but it is ridiculous. They are told that modern drugs are safer than the older ones, but it is a lie. They are told that the drugs are scientifically proven to work, but it is a mystification.

At the same time, most of the doctors are very nice people, and they really believe that what they do is good. I don't know how that happens, but I see that for some reason many professionals have adopted rather simplistic and superficial views of human nature, reducing it to mere behavior, and refusing to understand its depths. I have seen psychiatrists making a diagnosis of schizophrenia and prescribing a drug to the patients complaining of hearing voices, without even so much as asking what those voices were saying. They are simply not interested - and with good reason: the drug that they prescribe will still be the same.

I am not even going to mention here the enormous financial pressures that psychiatry now has to endure. It is a subject for a long discussion.

To sum it all up: psychiatry in general is not good or bad per se, but at this point of its development in America it seems to be hurting more people than it helps, while proclaiming the opposite. Thus, although psychiatry may be helpful to some people, in dealing with it a healthy degree of skepticism and common sense needs to be maintained.

Software Problems

When your text processor displays the wrong font size, you don't typically reach for a screwdriver to look for a problem in the hardware of your computer. The software is not directly caused by the hardware, although there is certainly a relationship between them. This relationship, however, is of a remote, abstract, and dynamic nature.

Psychiatrists deal with even less clear objects than computer scientists do. Yet they usually disregard the abstractness of the connection between the brain and the mind, and treat it in a straightforward fashion.

Take the neurotransmitters idea as an example. Saying that a mental disease is caused by too much neurotransmitter is like saying that your incorrect font size is caused by too much electricity. While true in some sense, it has little practical significance. Neurotransmitters are too simple molecules to be anything more than local electrochemical signals. And it is not the amount of signals that is the problem, but their dynamic distribution patterns. Simply modifying the level of a neurotransmitter in the brain makes as much sense as plugging a computer to 220 volts outlet instead of 110 and hoping for the best.

An Excellent Piece Of Writing

I have found this as a comment to this article on the alternet.org portal. There was no link to the comment itself, and it was buried under the pile of other comments, so I decided to re-post it here in its entirety. It is really an excellent piece of writing.

Quote:

Human progress is not a given consequence of new technology.

Posted by: Coleman on Jun 18, 2008 8:29 AM

Fifty years ago social scientists were writing utopian pamphlets wondering what ordinary folks were going to do with all their free time. The buzzword of the day was "automation." With modern machines, it took fewer and fewer people to reproduce the conditions necessary for the current standard of living. For example only a very small percentage of the population is engaged in agriculture, yet industrialized nations consistently yield food surpluses.

However, as we all know, the surpluses in agriculture, like every other commodity, are scandalously squandered while many go hungry. At every point in our system there is waste, from the excess restaurant food scraped off plates into the trash, to the most high-tech industrial processes which are - again, scandalously - devoted to producing the latest electronic trifles. This very act of wasting may be inherent in our notion of the "good life". And even if you don't agree with that, it's certainly central to the functioning of capitalism.

People who don't like work, or school, or cops, or the job options of their ghetto, people who are bored, people who don't identify with chauvinistic sexuality, people who are bad at performing their correct social roles are, by definition, a problem. They're a contradiction. They know, deep down, that nearly everything our society celebrates and champions - cutthroat competition, narrow and artificial standards of beauty, "efficiency" (the most Orwellian of popular terms) - are bankrupt notions emptied of their meaning.

However, as the aspiring social worker pointed out above, even with the best intentions (like becoming a social worker!), it is increasingly difficult to escape. The age-old social injunction to "get with the program," has always been delivered by parents, schools, judicial authorities, etc. Now, all of these entities have the option to medicate their subjects and abort the self-reflection and growth that comes with the individual negotiating her place in the world. It proves to be far cheaper, but like most cost-cutting, it might be fatally short-sighted.

The great irony is that a largely drugged populace may prove to be devoid of the dynamism and struggle that enabled the progressive aspects of capitalism in the first place. The bourgeoisie myth of the free, rebellious, maverick individual who flees his home and makes his own way seems is not only a relic of another time, but in the advanced capitalist nations is physically impossible. There is nowhere unthreatened by the great Sameness of our dumbed-down discourse, of our distracted and alienated corporate culture. There is nowhere to flee where you won't be trespassing.

Which is not to say that we shouldn't have anti-psychotic drugs or automation. Clearly we want these things, to some extent. And it is also not the case that we shouldn't have universal symbols for "get food here" or "get computers here", which is the benevolent aspect of easily recognized brands. The question is, as always, who is in control? Is their claim to rule legitimate? And why do they need to put so many people in jail? And why do they need to put so many people on drugs? And why are our schools like prisons, too? And why, if my job is unnecessary to life on earth, indeed, if my job is wasteful and thus detrimental to life on earth, why, then, do I work so hard?

Prozac As Good As Placebo

In a PLoS Medicine article, a British professor Irving Kirsch and his colleagues have reported that the antidepressant drugs like Prozac are not more efficient then placebo in the treatment of depression.

The authors have gained access to, and analyzed the data from the unpublished trials of these medications.

Even before that, according to the most optimistic data from the published studies, the drug and placebo response rates were around 50% and 40% respectively. Now when the unpublished studies are taken into account, it turns out (perhaps not surprisingly) that the drug-placebo difference is almost non-existent.

A Guardian article comments on this more extensively, and describes some drug producers's reaction to these findings.

To Become Or Not To Become

Martin says I must become a psychiatrist precisely because I understand so much about how the enterprise really works - so I could help many people. This makes a lot of sense, but to me it's still not very convincing. It is a bit like recommending someone who understands everything about politics to go ahead and become a politician. A layman has the luxury to be optimistic; when you know the organization well enough, you may also know that it cannot be changed.

No Test Required

Another interesting point that Mr. Jeff Griffin makes in the interview I mentioned yesterday is that psychiatrists do not have to use any objective medical tests in order to make a diagnosis or prescribe a medication.

Some tests have been developed, and are even used in clinic and in research. All these tests consist of questions and answers. They are not, strictly speaking, objective. What they provide is a quantative scale. The result of such a test is usually a number, that the researchers can compare with other numbers received from other research. Yet, this number still depends on the subject's ability to understand the question, willingness to answer it truthfully, as well as the interviewer's manner of gathering the information.

So, these tests are subjective, if convenient for comparative measuring. Yet, even they are not required in clinical practice. A subjective judgment of a psychiatrist alone is still enough to detain someone in a psychiatric hospital, label him with a diagnosis and give him medications agains his will. Strange as it is, this is the law.

Financial Side of Children's Bipolar Disorder

In a New York Times article it is reported that several world-famous Harvard psychiatrists have failed to disclose the bigger part of their income received from pharmaceutical companies for the last 7 years.

The research activity of these psychiatrists during this time has influenced the public and professional opinion on the problem of bipolar disorder in children and adolescents, as well as the patterns of drug prescription to the younger patients. Largely as a result of their studies it is now an accepted norm to prescribe atypical antipsychotic medications to children, for the treatment of bipolar disorder. It turns out that those studies were de facto funded by the pharmaceutical companies that produce the drugs in question.

The concept of pediatric bipolar disorder is controversial in itself, because a lot of symptoms that allow for this diagnosis (mood swings, rebellious behavior, sadness, appetite loss, problems in communication with peers, et cetera) may just as well be regarded as normal stages of child or teenager's development.

The credibility of the Harvard psychiatrists's research is questioned, but it is too late: the idea that children can be diagnosed with bipolar disorder and given antipsychotics has spread around the world. It will take years, and many thousands of children, to revert this trend.