You can’t really erase history, even though we all try. For one thing, it doesn’t go away. It just sits there in the background having an effect even if it has been selectively removed from consciousness. Freud made the analogy of The Mystic Writing Pad [when I was a kid, it was called the Magic Slate]. You wrote on cellophane with a stylus, When you lifted the cellophane, the writing disappeared, but it left traces in the wax below. Freud was using the metaphor to describe memory traces in the Unconscious. 
It was a good analogy. As a psychotherapist, one learns that it’s not like in the movies – some cave full of repressed memories. But rather, the mind just skips over or goes around unpleasant or traumatic previous experience, almost without noticing. While the gain is comfort, the loss is in not learning the important lessons that experience has to teach – so history repeats. And in eliminating chapters from the story, the book-of-you makes much less sense, because we are our stories, our narrative. What else could we be?
Right now, psychiatry seems to be attempting to erase a piece of its own history – a recent piece at that. We’ve had a couple of decades where many academic psychiatrists have been in an unholy alliance with the pharmaceutical industry, one that allowed industry to control our scientific literature, our continuing medical education, and, indeed, the whole direction of our specialty. 
The profits from that alliance have become the stuff of Wall Street legend – blockbusters! The ramifications of those years are everywhere around us – in our diagnostic manual, our relationships with patients and other mental health specialties, our place in the third party payment hierarchy, in the eyes of the public. As those years are finally drawing to a close, they seem to be becoming the elephant in the room that nobody’s talking about.
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Example: Right now, the AllTrials campaign is going great guns. Boehringer Ingelheim, GlaxoSmithKline, Roche, Sanofi, ViiV Healthcare, Pfizer, and now Johnson & Johnson are putting systems in place to allow access to their Clinical Trial data. I’ve been involved with some of the early results of that, and though it’s not a completely easy process, it’s definitely moving in the right direction towards "good enough." But nobody’s saying why they’re doing it. They’re giving us access because they’re good guys. Nobody talks about the stream of ghost written jury-rigged decepticons that flooded our literature for a decade or more, barely disguised drug industry commercials. Nobody talks about the legal settlements that are rapidly escalating to the point where they are going to really start hurting, or the growing clamor for criminal prosecutions. They’re just being generous.
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Example: Right now, Tom Insel is renovating the NIMH. The DSM-anything is out. The RDoC is in, when it gets around to existing. NIMH Clinical Trials have been changed. We’re on a new tack to find new drug targets. The reason the DSM-5 is out? It’s because medications and neuroscience findings don’t map onto the clinical categories. Little is mentioned about the lackey-ing around with drug trials and neuroimaging/genetics/etc. work the NIMH has funded to study and cavort with the industry’s drug output. Nothing is said about the APA/NIMH series of symposia in the lead up to the DSM-5. Not much mentioned that the Research Agenda for the DSM-V essentially laid out the RDoC agenda which came into being as it became apparent that the grand plans for the DSM-5 were going up in smoke. And there’s absolutely no comment about the fact that nothing [not even patients] map well to the DSM because it has been so distorted by outside forces.
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Example: Dr. Lieberman [APA President] and now Dr. Summergrad [APA President Elect] can’t talk enough about something called Collaborative Psychiatry – meaning psychiatrists should work in practices with general physicians. But they don’t mention that psychiatry so bought into the psychiatrists-as-medication-prescribers model and now there are no more new meds to prescribe that they’re trying to find some kind of new identity for psychiatrists to fit into.
We did this already in 1980 – abandoned our history, whether by intent or not. One would’ve thought that the only historical figure that ever mattered was Emil Kraepelin. The psychoanalysts, Adolf Meyers, Harry Stack Sullivan, Karl Jaspers, social psychiatrists, family theorists, psychotherapists [other that CBTers] – the pantheon of psychiatrists who had contributed to our understanding of mental illness were largely forgotten and rarely mentioned in any positive way. And of interest, since the 1980s we haven’t produced any "greats" – only KOLs with a limited shelf-life.
The story of Justina Pelletier, summed up by Philip Hickey, PhD, here:
http://www.madinamerica.com/2014/03/discussion-justina-pelletier-boston-childrens-hospital/
demonstrates that the abuses of psychiatry isn’t going down without a fight and an exponential increase in chutzpah that may as well be an attempt to drive people crazy. I think our Surgeon General and the Attorney General Holder needs to lay down some laws to put some checks on psychiatrists and judges. The relationship between psychiatry, law enforcement, and the courts is way out of balance and needs to be talked about as much as the things you list in this post.
Justina Pelletier had been diagnosed with mitochondrial disease by a specialist. But the the Psychiatry Department at Boston Children’s Hospital refused to let her see a gastrointestinal specialist, because they decided that she was really suffering from somatoform disorder. Then, they turned her parents into child and family services for having her treated by a gastrointestinal specialist and took custody of her.
So, psychiatrists must become medical doctors so that they can ignore medicine? The “it” of psychiatry is not just not scientific, it’s an oppressive institution that has been allowed to spend as little time as possible with their patients, to give disabling labels to people willy-nilly, to drug people to the gills with pharmaceutical cocktails that no one understands, and now they’re on such a high horse they don’t have to pay heed to other medical doctors. I’d love to think that this means that the fever will soon break; but I won’t hope for that until I hear it said everywhere that the “chemical imbalance theory” isn’t even a theory, it’s bunk, and that most of these drugs don’t work at all, many have detrimental effects that are often interpreted as mental illness, and that nobody knows the effects these drugs have in combination. Until someone of substance and important to the field of psychiatry stands up and says in so many word, “My God! What have we done?”, I’m going to assume that they’re still sandbagging and stalling at the top. After a confession, they can start pointing to what seems to be working— no reason to throw the baby out with the bathwater— but they have to be nearly stripped of power in medicine and the courts.
I was at a conference where a psychiatrist enthusiastically described her experience with collaborative care. Every morning, the treatment team would get together (the “huddle”). She gave an example of why this was so helpful. One day, someone mentioned that someone’s PHQ-9 had gone up by a few points (this is a nine item screening for depression). The presenter said something like,”So we agreed to increase the fluoxetine from 20 to 40 mg and we were all set to go!”
This week, we had a report out that the rates of prescribing stimulants had risen dramatically since 2008 especially in women ages 25-34.
http://lab.express-scripts.com/prescription-drug-trends/turning-attention-adhd/
In a NYT article some experts were quoted who saw this as the results of the good effort to reach those afflicted with ADHD.
As we expand to prescribing these drugs to adults, we not only increase the number of people who take them but we vastly expand the potential duration of treatment for each person. The MTA study in children did not paint a rosy picture of long term outcome. As other psychiatric drugs go off patent, many of the ads now in our journals are for shiny new stimulants.
I am not someone of importance (if you saw me, you might say I am of substance but perhaps not what you intended above), but I do wonder, “What have we done and why are we continuing on this path?
Great term, “shiny new stimulants.”
And how about the South?
I can’t find race…
It seems to be a growth industry up north as well. People come in having taken an online assessment or having tried a friend’s pills. In addition to the lack of data on long term outcomes, I am also troubled by the prevailing notion that this is a specific “thing”. If you have the “thing”, you have better focus with the drug. I take the Joanna Moncrieff view that the drugs have effects in everyone and if there is a “thing” that one must have to experience some alerting effect from stimulants, it is a brain. I do not believe these assessments have questions to address false positives.
I would have less of a problem if when they were prescribed the message was,”I understand you are not happy with your current ability to sustain focus or to sit still. This drug may help in the short run. They help most everyone in the short run. It does not mean you have a specific illness because we have no way of knowing that. You may have more trouble than others in these areas of your life. We do not know, however, what the impacts are of taking these drugs for years or decades. We do not know what the impact will be when you decide to stop them. I worry about the accommodating effects on your brain. These are some of my concerns….” But I do not think that is what the message typically is.
I would like to see a chart for rates of stimulants prescriptions to medical students but I guess escripts probably does not track that. That may give us a clue about where this is all heading.
But I am not an expert in this area. I follow it with interest because I am interested in psychosis and I am old enough to have been taught that stimulants were once upon used to create targets for psychosis in animals. I do see people who were prescribed these drugs and became psychotic. In a number of cases, previous doctors told them this “unmasked” another underlying condition. Shame on us.
So if anyone reading this wants to school me or correct me, privately (my e-mail is on my MIA page) or publicly, please do, I come here to learn.
Perhaps anecdotally corroborated by the periodic Cassandra columns, claiming >50% of college students take stimulents.
Those prescribed amphetamine analogs are the perfect drugs for working people.
In the meantime, http://www.biomedcentral.com/1471-244X/14/53
Health-related quality of life among patients treated with lurasidone: results from a switch trial in patients with schizophrenia
George Awad12*, Mariam Hassan3, Antony Loebel4, Jay Hsu4, Andrei Pikalov3 and Krithika Rajagopalan3
* Corresponding author: George Awad gawad@hrrh.on.ca
Author Affiliations
1 Department of Psychiatry, University of Toronto, Toronto, ON, Canada
2 Department of Psychiatry and Mental Health, Humber River Regional Hospital, Toronto, ON, Canada
3 Sunovion Pharmaceuticals, Inc, Marlborough, MA, USA
4 Sunovion Pharmaceuticals, Inc, Fort Lee, NJ, USA
Just legal Meth for urban areas not affected by the illicit versions already.
Adderall is either the speedball component with Rx opiates, or Coke in a capsule/tablet form. I post about this crap weekly of late.
It is trivially easy to talk a doctor into prescribing any kind of psychiatric drug (except the scheduled ones, that takes a little more work).
Let us not forget that the property of “mother’s little helpers” to suppress appetite is very well known. So, an explosion of ADHD among young employed women? Why not??
To Sandra,
I love what you said and think you are so right on about the message. I would not have a problem with drugs as one tool in the toolbox if we were just honest and a little more humble about what we do and don’t know.
You talked about lack of data for long-term outcomes, but in the case of ADHD and stimulants, there is actually a substantial dataset, which has been reviewed multiple times over the last 35 years, starting with Russell Barclay himself back in 1978, and the conclusion has been the same every time: there is no long-term advantage for ADHD-diagnosed stimulant users over those who are never treated or stop stimulants fairly early on. It steams me that we still have so many people talking about how “untreated ADHD leads to increased delinquency and school dropout and, and, and…” when the data shows that stimulants change NONE of those variables in the long term.
Thanks to you and 1BoM for your continued advocacy for sanity in this strange Kafkaesque world of “mental health!”
— Steve
You’re one of the good ones who cares about the patients and thinks critically about your field. I think you are important, especially combined with other professional critics of the current mess that is psychiatry. It’s either going to take some Congressional action, executive orders, or critical mass to overcome the mania of the bio-bio-bio age and it’s greasiness— too much money is being made too fast for too little benefit to too many people. The actual damage can never be assessed, but there is sufficient evidence that there is enough damage being done for someone at the top to engage the brakes and take a look around.
That’s directed at you, Sandra and Mickey. Psychiatry can help a great deal, if it would just lose the millstone round its neck that is the “chemical imbalance” myth of mental illness combined with corruption and payola..
I agree with Sandra that any brain, except a psychotic one, will focus better on a stimulant. I have patients tell me that they tried someone else’s stimulant and focused so much better and that proves they have ADD. That is nonsense, but a lot of people believe it.
When someone who was a straight A student in high school tells me they have ADD because they are getting B’s in college, I tell them they don’t have ADD, otherwise they would not have gotten straight A’s in high school. That is not something they often want to hear because who wouldn’t want a quick fix. But I think they are grateful when I take the time to help them explore other things that might be causing their scholastic difficulty: social stress, missing home, a very different environment, substance abuse, …
There are a number of computerized tests, such as the TOVA, which may not be fully diagnostic, but can at least give more objective data. If I am uncertain I have looked at the relationship between blood levels of the drug and the performance on attentional testing. But that is a lot of work and costs a lot for the patient. Not everyone can afford that.
As far at the eating disorder population, I have seen women who are dying of starvation tell me they need their Adderall because otherwise they can’t focus. Its amazing.
Another part of our history:
http://anp.sagepub.com/content/48/3/224.full
I was in the early part of my career when the conceptualization of depression changed from an episodic to a chronic condition. This was in the early 1990’s. If I remember correctly this work came out of the University of Pittsburgh where David Kupfer was chairman. It was related to studies of antidepressant withdrawal. I am not posing any sort of pharma fueled conspiracy. I think it was just what people thought – and think – based on the observation of high levels of relapse when the drugs were withdrawn. I think in retrospect that there was a failure to consider the effects of drug withdrawal perhaps because the notion of drug withdrawal was more narrowly defined as the type of more dramatic syndrome observed when benzodiazepines, alcohol, or opiates are withdrawn. At least that is how I would reconstruct my own thought processes at the time. The models made sense to me then. I was old enough to think I knew a lot but young enough to have limited perspective on how people did over years.
The implications are profound. Will psychiatry have the will to look behind the curtain and seriously challenge its assumptions of the past decades? In a highly competitive health care market – and let’s face it psychiatry is already an underdog there – I am not optimistic about this.
I am getting on in years; when I was in training in the late 70’s and early 80’s I was taught that for most (but not all) people the natural course of a depressive episode was remission even without treatment with a low rate of recurrence. And for those severely depressed (melancholic?) remission was common. But then things changes. I remember thinking that it happened almost overnight. All of a sudden, psychiatry married Big Pharma and the message changed. “Don’t EVER stop your meds!” “You will have to be on them for life or else you will relapse!” I am not, by nature, a suspicious guy but it is hard to avoid thinking about the role of corrupt KOL’s and Big Pharma in all of this.
As Sandra Steingard says “I think in retrospect that there was a failure to consider the effects of drug withdrawal perhaps because the notion of drug withdrawal was more narrowly defined as the type of more dramatic syndrome observed when benzodiazepines, alcohol, or opiates are withdrawn.”
Withdrawal syndrome misdiagnosed as relapse or emergence of a psychiatric disorder confounds ALL studies of antidepressant efficacy. Not a single one, including STAR*D, contains protocols for identifying withdrawal symptoms. Think about it.
” … if there is a “thing” that one must have to experience some alerting effect from stimulants, it is a brain.”
THANKS for that Sandra! I get so sick of hearing that these drugs are magnificent if prescribed by a doctor, but deadly if taken without a doctor’s advice. Especially when so many people, college kids especially, are getting these prescriptions by simply memorizing a few symptoms of ADHD and reeling them off to a doctor in an eight-minute consult.
It hardly needs saying (but it does) that withdrawing from these drugs can be a protracted agony for many. Just about anyone who takes Adderall for a year, and then stops taking it, will be depressed and dysfunctional. The only variable is, for how long? Mainstream medicine is all too willing to accept the horrors of amphetamine withdrawal when it’s illegal meth. But when it’s legal Adderall or (don’t get me started) Vyvanse, it’s not “withdrawal” — it’s your imbalanced brain calling out for the meds it needs to be “normalized.” Riiiight.
http://www.quittingadderall.com
is a marvelous community founded by some brave young men & women who puzzled this out for themselves, very definitely the hard way. I can’t recommend it enough. Would love to know what psychiatrists think of the stories they see there!
Regarding the withdrawal from antidepressants. When the drug reps (who I didn’t allow in my office) were out passing out samples I would see people who went to their PCP feeling somewhat down. Usually because they had had a couple of bad days. But they were told they were “depressed” and given samples of an SSRI or SNRI. After a couple of weeks the samples ran out and they started having withdrawal symptoms. Of course they were told this was a return of their depression and they needed to continue taking the antidepressants, now of course for a fee.
It reminded me of hearing some of my addict patients telling me how their dealer gave them the drugs for nothing, until they were hooked, and then they had to pay.
Here’s the state of the art understanding of antidepressant efficacy from the Director of the US NIHM, Thomas Insel, in 2011:
“Perhaps the best evidence for efficacy comes from patients who have been treated successfully with antidepressants and are switched in a blinded fashion to placebo. In a meta-analysis of 31 withdrawal studies among more than 4,000 patients, Geddes and colleagues found that 41 percent of patients who were switched to placebo relapsed, compared to 18 percent who remained on an antidepressant. These studies provide compelling evidence that antidepressants are effective for some people.” (Insel 2011)
Sharp thinking, Tom!
How to get an Adderall prescription, in case you or your teenage didn’t already know http://www.wikihow.com/Get-an-Adderall-Prescription