Is acute psychosis a brain disorder? Hypothetically yes, but...
August 11, 2016 3:36 PM Subscribe
Over three years, those never treated with antipsychotics had much better outcomes – 8 per cent relapse versus 62 per cent for the drug-treated. I could cite other, more recent studies with similar findings. This is why we may be holding the tail of a tiger. We may be unwittingly turning an acute and generally time-limited condition into a chronic disability.
"It’s not that the lamp is real and the bugs aren’t, it’s that your constructed reality has some things in it right now that my constructed reality does not. It’s not that my version is real and yours isn’t. They’re both real, but both constructed, only out of somewhat different materials.’"
I like this guy.
posted by christopherious at 3:51 PM on August 11, 2016 [11 favorites]
I like this guy.
posted by christopherious at 3:51 PM on August 11, 2016 [11 favorites]
Brain drugs aren't medication, they are just drugs.
Drugs aren't drugs, they're just drugs?
posted by edheil at 4:05 PM on August 11, 2016 [23 favorites]
I have to say I think his particular constructed reality argument is something of an unhappy fudge. When people ask "is it real?" they largely mean something like "is there some mind-independent physical object the existence of which renders my belief 'there is a bug there' true by virtue of correspondence?". Unless you're arguing for a more thoroughgoing antirealism, or at least some sort of ontological relativity (which he isn't, as far as can see, although I am personally inclined to), you're just dodging the question. He still seems to be saying that the symptom is primarily a product of the brain, rather than of mind-independent reality.
Perhaps a more useful answer is that it doesn't matter whether the bugs are real or noy. All that matters is whether it makes you miserable and fucks up your life. It's perfectly possible to construct a relativistic model of the solar system in which the Earth is a fixed point and all other bodies are in motion. It just happens that this is a suboptimal coordinate system for many (although not all) purposes. So it is with potentially suboptimal beliefs about the existence of bugs. Whether it is a useful, harmless or harmful belief is the only really important question.
Without that philosophical leap, it seems to me he's simply returning mechanistic mind/brain supervenience to its roots in the psychotherapeutic tradition, rather than offering a path past the underlying problems that psychotherapy and neuropsychology share.
posted by howfar at 4:15 PM on August 11, 2016 [12 favorites]
Perhaps a more useful answer is that it doesn't matter whether the bugs are real or noy. All that matters is whether it makes you miserable and fucks up your life. It's perfectly possible to construct a relativistic model of the solar system in which the Earth is a fixed point and all other bodies are in motion. It just happens that this is a suboptimal coordinate system for many (although not all) purposes. So it is with potentially suboptimal beliefs about the existence of bugs. Whether it is a useful, harmless or harmful belief is the only really important question.
Without that philosophical leap, it seems to me he's simply returning mechanistic mind/brain supervenience to its roots in the psychotherapeutic tradition, rather than offering a path past the underlying problems that psychotherapy and neuropsychology share.
posted by howfar at 4:15 PM on August 11, 2016 [12 favorites]
The author says he's 70 years old. That means he would have come of age not long after Gregory Bateson came up with the theory that parents give children schizophrenia by giving them mixed messages (the "Double-Bind theory"). Similar theories from Bruno Bettelheim at the time suggested that mothers make children autistic by being insufficiently warm to them (the "Refrigerator Mother" theory).
It's very attractive to believe that diseases are something we can learn to think and feel our way out of, whether through positive thinking or compassionate psychotherapy. Sometimes it's even true. But it's so attractive a belief that I have to admit I'm instinctively suspicious of it. Even when it's presented as a lost bit of wisdom from the good old days of less-medicalized psychiatry.
posted by edheil at 4:23 PM on August 11, 2016 [27 favorites]
It's very attractive to believe that diseases are something we can learn to think and feel our way out of, whether through positive thinking or compassionate psychotherapy. Sometimes it's even true. But it's so attractive a belief that I have to admit I'm instinctively suspicious of it. Even when it's presented as a lost bit of wisdom from the good old days of less-medicalized psychiatry.
posted by edheil at 4:23 PM on August 11, 2016 [27 favorites]
> . But there actually are no demonstrable differences between the brains of psychotic and non-psychotic people. We might be told that there is no physical test that will discriminate these groups. But the words ‘not yet’ are always added, since psychiatry seems to have faith that such a test is around the corner.
Maybe not around the corner, but not beyond imagining, if brain = mind, which is the basic assumption of neuropsych. Probably a *long* way off, farther than some might hope, but not impossible in principle. And if he's claiming it is, we're definitely back to some kind of dualism.
That said, I'm 100% behind more social support, and if psychosis is self limiting absent current medical treatment, neither is understood as well as has been thought. Which isn't to say another type of drug is necessarily the fix. Altogether too much confidence in this corner of medicine, imo.
posted by cotton dress sock at 4:33 PM on August 11, 2016
Maybe not around the corner, but not beyond imagining, if brain = mind, which is the basic assumption of neuropsych. Probably a *long* way off, farther than some might hope, but not impossible in principle. And if he's claiming it is, we're definitely back to some kind of dualism.
That said, I'm 100% behind more social support, and if psychosis is self limiting absent current medical treatment, neither is understood as well as has been thought. Which isn't to say another type of drug is necessarily the fix. Altogether too much confidence in this corner of medicine, imo.
posted by cotton dress sock at 4:33 PM on August 11, 2016
Well, I was full-on psychotic for a stretch, after a bad acid trip during a time when other life factors were contributing stress, too, and with therapy and counseling I recovered. I had acute delusions of reference, serious paranoia that was actually delusional (as opposed to a creative faculty for entertaining paranoid beliefs without adopting them, which is probably a fair way to characterize how my mind works now), occasional auditory hallucinations, and near constant visual hallucinations in my peripheral field of vision. All those symptoms abated over a period of a couple of years with therapy and medication. My psychiatrist told me only time would tell if it was emerging schizophrenia or a more limited term schizoaffective disorder. I said let's go with treating it as a non-morbid condition. Luckily, that decision worked out for me. Remains to be seen whether I'll relapse into schizoaffective disorder again once my current ADD anxiety progresses into full on depression, if I can't stop that from happening, but my sense for it is I know the territory well enough now to keep muddling along in reality.
posted by saulgoodman at 4:42 PM on August 11, 2016 [15 favorites]
posted by saulgoodman at 4:42 PM on August 11, 2016 [15 favorites]
yet again i am commenting before reading due to innate spazziness, but I took a class from a professor who studied the effects of antipsychotic meds across countries and who came to the same conclusion. I have been on them (am on Latuda now which is technically an antipsychotic though it is not marketed as one) and some of them are like a hammer over the head -losing motor control and stuff. Trilafon was gnarly.
Anyway, I think they may be useful in the short term, during an episode to bring you down, but unless you are truly psychotic all the time (and I think that is more rare than we assume) then it seems like massive overkill. But then again, here I am on one. I don't know if it has impaired my cognition but I think antipsychs have done something to me permanently- i have very little short term memory and have found holding a job difficult.
posted by GospelofWesleyWillis at 5:07 PM on August 11, 2016 [4 favorites]
Anyway, I think they may be useful in the short term, during an episode to bring you down, but unless you are truly psychotic all the time (and I think that is more rare than we assume) then it seems like massive overkill. But then again, here I am on one. I don't know if it has impaired my cognition but I think antipsychs have done something to me permanently- i have very little short term memory and have found holding a job difficult.
posted by GospelofWesleyWillis at 5:07 PM on August 11, 2016 [4 favorites]
If we are making people that much worse and failing to look into the matter in depth and hold the medical establishment accountable for such abuses- then we bear liability. The amount of drugs we permit being tested and forced on some of the most vulnerable people strikes me as also an issue of magical thinking rather than evidence based. The fact there are so few long term (as in 20-50 year follow ups and studies that examine lifelong medication use and outcomes etc) strikes me as almost deliberate at this point if I didn't know it's a simply matter of following where the money for research is.
Like cramming the foot in the magic slipper till the foot is torn up and saying "it's perfect. Drugs are the only solution! They are the right solution! Just... jam harder... ignore long term side effects, ignore protests of people who don't want them...blame them as their condition gets worse and worse and use that as a reason to give them more and more drugs they don't want, get their families and friends to shame them if they ever go off them.."
Could be the wrong shoe. How long until we admit it and stop hurting people with the lie that makes us feel more in control? I understand the desire to cling to beliefs that are comforting or that provide jobs and just so explanations-- but when a lot of people are being harmed it might be worth questioning and challenging a little harder.
posted by xarnop at 5:07 PM on August 11, 2016 [8 favorites]
Like cramming the foot in the magic slipper till the foot is torn up and saying "it's perfect. Drugs are the only solution! They are the right solution! Just... jam harder... ignore long term side effects, ignore protests of people who don't want them...blame them as their condition gets worse and worse and use that as a reason to give them more and more drugs they don't want, get their families and friends to shame them if they ever go off them.."
Could be the wrong shoe. How long until we admit it and stop hurting people with the lie that makes us feel more in control? I understand the desire to cling to beliefs that are comforting or that provide jobs and just so explanations-- but when a lot of people are being harmed it might be worth questioning and challenging a little harder.
posted by xarnop at 5:07 PM on August 11, 2016 [8 favorites]
This kind of article always frustrates me, because I think it is important and quite valid to question the extent to which we rely on medications to treat psychiatric disorders. I definitely believe that some people are being overly or incorrectly medicated. I think there are all sorts of issues with how pharmaceutical companies interact with doctors, not to mention the issues of the US healthcare system, which makes it so unnecessarily difficult to get treatment for a psychiatric disorder.
But, I'm also wary any time someone seems to move too far in the other direction. The statistics presented in this article, if true, are compelling. But, the only named source I noticed was Robert Whitaker's Anatomy of an Epidemic. Whitaker is also the author of Mad in America. He is not a doctor or any kind of health professional. He's a journalist. He's certainly spent a lot of time researching and writing about psychiatric treatment, but his writings have received a lot of (to my mind, well deserved) criticism.
I'd like to think we can find a middle ground between where we are currently and the narrative of "drugs are bad, and it's a lie that they actually improve anything, and the whole psychiatric community is either completely ignorant of this fact or purposefully misleading the public."
Although not touched on at all in this article, it's worth noting that there has also been a lot of criticism of talk therapy. The driving force behind more behavioral approaches like CBT and DBT is that a lot of people had come to the conclusion that spending years in psychodynamic therapy wasn't actually helping a lot of people. Without having any data to back this up, I'm willing to hypothesize that one of the reasons people in the mental health field are relying more and more on medication is that at least you can "standardize" medication in a way that is much harder to do with therapy. In fact, a primary care physician can even prescribe psychiatric medication. That's not ideal, but if you are in the midst of a major depressive episode that's sucking the life out of you, and you're stuck waiting two months to get an appointment with the one psychiatrist who will take your insurance, having your PCP hand you a prescription for an SSRI could quite literally be a life saver.
Even if we take it as a given that Carpenter is right about the fact that the right talk therapy is more effective than medication at least for acute psychosis (and that's a very big if), you're still left with the problem that you would have to find someone capable of adequately providing this therapy. You also need to be wealthy enough to pay for this out of pocket, or you need to have health insurance that will actually provide enough coverage for you to engage in long term psychotherapy. That's not the case for a lot of people, at least in the US.
I also think we should be cautious about overly romanticizing the "good old days" where psychiatry didn't rely on medication. After all, the DSM once considered homosexuality to be a disorder. Not to mention the Refrigerator Mother theory of autism.
It also is true that the idea of psychiatric medications correcting a chemical imbalance may not apply to most or even any mental illnesses. We just still don't know enough to draw conclusions about the biological bases of these mental disorders. At the same time, there are plenty of treatments for non-mental illnesses that are used even though they may not "balance out" something that's going wrong in your body. However, I think a lot of people don't really care why something takes away their pain (mental or physical) as long as it actually does.
Again, I don't want to diminish the glaring problems with the current approach to treating mental illness. I think there are so many people who we are doing a terrible disservice to in the way that we approach their care. Drugs with demonstrable and serious side effects are prescribed to some people who would be better served by different or no medication. But I also feel like we have to be careful about going too far in the other direction. This is a such a complicated problem, and I don't think there is a simple answer to this issue.
posted by litera scripta manet at 5:21 PM on August 11, 2016 [27 favorites]
But, I'm also wary any time someone seems to move too far in the other direction. The statistics presented in this article, if true, are compelling. But, the only named source I noticed was Robert Whitaker's Anatomy of an Epidemic. Whitaker is also the author of Mad in America. He is not a doctor or any kind of health professional. He's a journalist. He's certainly spent a lot of time researching and writing about psychiatric treatment, but his writings have received a lot of (to my mind, well deserved) criticism.
I'd like to think we can find a middle ground between where we are currently and the narrative of "drugs are bad, and it's a lie that they actually improve anything, and the whole psychiatric community is either completely ignorant of this fact or purposefully misleading the public."
Although not touched on at all in this article, it's worth noting that there has also been a lot of criticism of talk therapy. The driving force behind more behavioral approaches like CBT and DBT is that a lot of people had come to the conclusion that spending years in psychodynamic therapy wasn't actually helping a lot of people. Without having any data to back this up, I'm willing to hypothesize that one of the reasons people in the mental health field are relying more and more on medication is that at least you can "standardize" medication in a way that is much harder to do with therapy. In fact, a primary care physician can even prescribe psychiatric medication. That's not ideal, but if you are in the midst of a major depressive episode that's sucking the life out of you, and you're stuck waiting two months to get an appointment with the one psychiatrist who will take your insurance, having your PCP hand you a prescription for an SSRI could quite literally be a life saver.
Even if we take it as a given that Carpenter is right about the fact that the right talk therapy is more effective than medication at least for acute psychosis (and that's a very big if), you're still left with the problem that you would have to find someone capable of adequately providing this therapy. You also need to be wealthy enough to pay for this out of pocket, or you need to have health insurance that will actually provide enough coverage for you to engage in long term psychotherapy. That's not the case for a lot of people, at least in the US.
I also think we should be cautious about overly romanticizing the "good old days" where psychiatry didn't rely on medication. After all, the DSM once considered homosexuality to be a disorder. Not to mention the Refrigerator Mother theory of autism.
It also is true that the idea of psychiatric medications correcting a chemical imbalance may not apply to most or even any mental illnesses. We just still don't know enough to draw conclusions about the biological bases of these mental disorders. At the same time, there are plenty of treatments for non-mental illnesses that are used even though they may not "balance out" something that's going wrong in your body. However, I think a lot of people don't really care why something takes away their pain (mental or physical) as long as it actually does.
Again, I don't want to diminish the glaring problems with the current approach to treating mental illness. I think there are so many people who we are doing a terrible disservice to in the way that we approach their care. Drugs with demonstrable and serious side effects are prescribed to some people who would be better served by different or no medication. But I also feel like we have to be careful about going too far in the other direction. This is a such a complicated problem, and I don't think there is a simple answer to this issue.
posted by litera scripta manet at 5:21 PM on August 11, 2016 [27 favorites]
This seems to come so much down to whether the counterintuitive result about long-term outcome and antipsychotics is correct/means what he/Whitaker thinks it means.
So, is it? Does it? Is there actually no longitudinal evidence on the other side?
posted by atoxyl at 5:41 PM on August 11, 2016
So, is it? Does it? Is there actually no longitudinal evidence on the other side?
posted by atoxyl at 5:41 PM on August 11, 2016
E. Fuller Torrey is pretty much the number one anti-anti-psychiatrist (though not necessarily the most uncritical proponent of antipsychotics) so keep that in mind but here's his response.
posted by atoxyl at 5:49 PM on August 11, 2016 [6 favorites]
posted by atoxyl at 5:49 PM on August 11, 2016 [6 favorites]
A rather early study in 1978 set a pattern which, to my knowledge, has never been empirically contradicted.
People haven't.... I mean lots of smart people ... are saying they ... haven't seen it contradicted.
[describes study that is only remembered because it yielded results significantly different than every other study out there]
...Now this study obviously managed to avoid some gaping flaw that each and every other study on the topic fell victim to, so definitely prioritize it.
I could cite other, more recent studies with similar findings.
Oddly all of those papers would have the same authors as the first one but hey, even contrarian scientists gotta make a living, right?
Add in a few people who really really want to believe what you say is true, claim big pharma or big agriculture or big breakfast cereal is trying to cover up the truth and poof: You have a movement.
posted by Tell Me No Lies at 6:04 PM on August 11, 2016 [3 favorites]
People haven't.... I mean lots of smart people ... are saying they ... haven't seen it contradicted.
[describes study that is only remembered because it yielded results significantly different than every other study out there]
...Now this study obviously managed to avoid some gaping flaw that each and every other study on the topic fell victim to, so definitely prioritize it.
I could cite other, more recent studies with similar findings.
Oddly all of those papers would have the same authors as the first one but hey, even contrarian scientists gotta make a living, right?
Add in a few people who really really want to believe what you say is true, claim big pharma or big agriculture or big breakfast cereal is trying to cover up the truth and poof: You have a movement.
posted by Tell Me No Lies at 6:04 PM on August 11, 2016 [3 favorites]
I'm very curious about the author's usage of subjective constructionism, which in the article he uses to explain that the patient's reality-making is influenced by her stress and prior traumatic experiences in childhood and yet also claim that his and her mental realities are "both true", equally valid, etc. At the same time, other studies claim that slightly depressed people tend to be more accurate in assessing/evaluating problems and situations. Not that this latter research necessarily contradicts the author, but there definitely seems to be a tension in how what's valid, what's real, and as the author says a the end, what's shameful gets negotiated within the discipline of psychology as well as between it and its clients, and by extension, how these theories influence the views/attitudes of the society in general.
posted by polymodus at 6:34 PM on August 11, 2016
posted by polymodus at 6:34 PM on August 11, 2016
Acute psychosis, not treated chemically, would often last no more than a year. With kind, safe, custodial care, and good psychotherapy, remission would come more rapidly and be more stable.
A year hospitalized and suffering from psychosis. Author focuses on number of episodes with no consideration of total time spent suffering.
posted by save alive nothing that breatheth at 6:37 PM on August 11, 2016 [8 favorites]
A year hospitalized and suffering from psychosis. Author focuses on number of episodes with no consideration of total time spent suffering.
posted by save alive nothing that breatheth at 6:37 PM on August 11, 2016 [8 favorites]
The fact there are so few long term (as in 20-50 year follow ups and studies that examine lifelong medication use and outcomes etc) strikes me as almost deliberate at this point if I didn't know it's a simply matter of following where the money for research is.
That's because there really aren't that many drugs that have been around for more than maybe 30 years -- not to mention, what are they going to tell you? That people who use the drugs are worse off than those who go off of them? How are you to distinguish that result from the fact that the people who go off of drugs are usually the ones who are doing well enough to afford to do so -- or the people so impoverished that they can't get access to life-saving medication?
I'm not convinced that statements like this aren't just another way of stigmatizing medication: it's a way of telling people that, you poor things, you're just being exploited by the pharmaceutical industry.
posted by steady-state strawberry at 6:49 PM on August 11, 2016 [3 favorites]
That's because there really aren't that many drugs that have been around for more than maybe 30 years -- not to mention, what are they going to tell you? That people who use the drugs are worse off than those who go off of them? How are you to distinguish that result from the fact that the people who go off of drugs are usually the ones who are doing well enough to afford to do so -- or the people so impoverished that they can't get access to life-saving medication?
I'm not convinced that statements like this aren't just another way of stigmatizing medication: it's a way of telling people that, you poor things, you're just being exploited by the pharmaceutical industry.
posted by steady-state strawberry at 6:49 PM on August 11, 2016 [3 favorites]
I'm very curious about the author's usage of subjective constructionism, which in the article he uses to explain that the patient's reality-making is influenced by her stress and prior traumatic experiences in childhood and yet also claim that his and her mental realities are "both true", equally valid, etc.
The main change in my thinking resulting from my own recovery from psychosis was a conscious habit of doing basic reality checks on things I suddenly feel I understand. Epiphany feels glorious but that's not a reason to believe that everything revealed by it is sound.
That recovery, by the way, mostly involved returning home from overseas and spending the next few months in familiar surroundings and getting enough sleep. I'm unconvinced that being drugged and tied to the bed in psych ward was actually a vital part of the process.
That said, I'm quite open to the idea that substantial numbers of people are helped a great deal by anti-psychotic meds. But it would be good if most of the people prescribing them had first spent a bit of time taking them.
posted by flabdablet at 7:03 PM on August 11, 2016 [5 favorites]
She is a very intelligent person and is vexed by people telling her that such things are not real. She cannot doubt her senses, and she sees them. (I say: ‘I agree. I don’t doubt my senses either.’)I think it's really hard for people who have not been psychotic to learn that our senses are not necessarily trustworthy, that they do occasionally feed us information that's unhelpful and misleading, and that an unshakable feeling of certainty is not a reliable indicator that that certainty is justified.
The main change in my thinking resulting from my own recovery from psychosis was a conscious habit of doing basic reality checks on things I suddenly feel I understand. Epiphany feels glorious but that's not a reason to believe that everything revealed by it is sound.
That recovery, by the way, mostly involved returning home from overseas and spending the next few months in familiar surroundings and getting enough sleep. I'm unconvinced that being drugged and tied to the bed in psych ward was actually a vital part of the process.
That said, I'm quite open to the idea that substantial numbers of people are helped a great deal by anti-psychotic meds. But it would be good if most of the people prescribing them had first spent a bit of time taking them.
posted by flabdablet at 7:03 PM on August 11, 2016 [5 favorites]
"That people who use the drugs are worse off than those who go off of them? How are you to distinguish that result from the fact that the people who go off of drugs are usually the ones who are doing well enough to afford to do so -- or the people so impoverished that they can't get access to life-saving medication?"
I guess if we are making people vastly worse, there is just no way to tell. Who is responsible if it turns out the larger portion of people were seriously damaged from this treatment? I respectfully disagree that having concerns about people being made worse and asking questions is "creating stigma". We should be able to ask such questions; and if it's wrong to "create stigma" around meds, is it wrong to "create stigma" about people choosing not to use such meds or to protect their love ones from them? Shouldn't the actual long term outcomes matter and asking for that whether they favor med use in some cases but not others- would seem a humane option.
If we wite off the possibility of long term and lifelong studies helping us find out the effects of this then we ensure we would never know if huge quantities of people are being harmed when they seek or are forced into care. We can do better than that. I just hope that people will agree to do such research without assuming the already know the answer because that is not good science.
posted by xarnop at 7:20 PM on August 11, 2016
I guess if we are making people vastly worse, there is just no way to tell. Who is responsible if it turns out the larger portion of people were seriously damaged from this treatment? I respectfully disagree that having concerns about people being made worse and asking questions is "creating stigma". We should be able to ask such questions; and if it's wrong to "create stigma" around meds, is it wrong to "create stigma" about people choosing not to use such meds or to protect their love ones from them? Shouldn't the actual long term outcomes matter and asking for that whether they favor med use in some cases but not others- would seem a humane option.
If we wite off the possibility of long term and lifelong studies helping us find out the effects of this then we ensure we would never know if huge quantities of people are being harmed when they seek or are forced into care. We can do better than that. I just hope that people will agree to do such research without assuming the already know the answer because that is not good science.
posted by xarnop at 7:20 PM on August 11, 2016
Anecdotal, but a friend has been on what seems like a different anti-psychotic every month for a year now. They all have varying effects, but none of them seem to get the job done. I can anticipate a ten-paragraph response full of hyperlinks that explains why I'm an idiot or an ableist asshole for expecting results, but I don't care: I do expect results.
posted by kittens for breakfast at 7:43 PM on August 11, 2016 [1 favorite]
posted by kittens for breakfast at 7:43 PM on August 11, 2016 [1 favorite]
I feel like some of the responses here have missed the point. Is this author is totally spot on with his citations? No. But neither is he saying drugs are bad or that they can't ever help anyone. He says that he still uses them because it's hard to be in pain. What he's talking about isn't a rejection of drugs, it's a different approach, and even if I don't think he's stumbled on the perfect solution for mental health issues, his approach sounds a whole lot nicer than some of the other options out there.
One of the most painful things about mental illness is being denied respect. You are told that this is a fundamental problem with your brain, and that you will forever be fighting this defect. The way people talk to you about your experience of the world, and the way you look at yourself, can feel like gaslighting.
I have tons of complaints about modern pharmacology and the knowledge-production that drives, and is driven, by it. But I really appreciate this article if only because there's a significant difference for me between saying "this is a disease you will always have" and saying "your recovery may take your whole life." That might sound like a really minor difference, but it isn't as far as I'm concerned. If nothing else, I appreciate someone wanting to more fully consider the patient's perspective as one that isn't just flawed or diseased.
posted by teponaztli at 8:39 PM on August 11, 2016 [6 favorites]
One of the most painful things about mental illness is being denied respect. You are told that this is a fundamental problem with your brain, and that you will forever be fighting this defect. The way people talk to you about your experience of the world, and the way you look at yourself, can feel like gaslighting.
I have tons of complaints about modern pharmacology and the knowledge-production that drives, and is driven, by it. But I really appreciate this article if only because there's a significant difference for me between saying "this is a disease you will always have" and saying "your recovery may take your whole life." That might sound like a really minor difference, but it isn't as far as I'm concerned. If nothing else, I appreciate someone wanting to more fully consider the patient's perspective as one that isn't just flawed or diseased.
posted by teponaztli at 8:39 PM on August 11, 2016 [6 favorites]
Anecdotal, but a friend has been on what seems like a different anti-psychotic every month for a year now. They all have varying effects, but none of them seem to get the job done. I can anticipate a ten-paragraph response full of hyperlinks that explains why I'm an idiot or an ableist asshole for expecting results, but I don't care: I do expect results.
Just in case this is at least in part a response to what I wrote earlier (I really didn't intend to write such a long screed in the first place), I just wanted to say that I 100% agree that we should be asking questions and doing studies, especially long term longitudinal studies, about whether these meds due in fact help more than they hurt.
Even without any data to back it up, I feel comfortable asserting that their are some (probably a lot) of patients who are overmedicated or incorrectly medicated in a way that causes demonstrable harm. Look, take seroquel for example. It's an atypical antipsychotic, but I've personally known multiple people who were prescribed it as a sleep aid. This happened to me, in fact. In these cases, we were all receiving treatment for psychiatric disorders, but none of them were the kind of thing where seroquel would be a first or even a second line treatment. And I hated it. It tanked my blood pressure, knocked me out to the point that I couldn't stay awake if I wanted to, it led to multiple terrifying episodes of sleep paralysis...oh, and then there was the fact that it made me so desperately hungry I couldn't stop myself from devouring whatever food was available. I'm actually pretty picky about not liking junk food or stuff like that, but I would legit eat just about anything. The more carbs the better. It sounds ridiculous now, but even if I hate a full meal immediately before taking Seroquel, within an hour, I'd be standing in front of the fridge, ready for my Second Seroquel Dinner, as I called it. (On the bright side, it was a great way to get rid of extra food we had lying around.)
I was so happy when I finally got off of it, and I wasn't even taking that high a dose (100 mg). And just recently I was getting pissed off about how a psychiatrist was throwing a whole bunch of psych meds at my 95 year old grandmother, even though they couldn't figure out why she was suffering from sudden onset delusions/psychosis.
Another really good example is Borderline Personality Disorder, which in a certain way has been one of the most heavily stigmatized mental illnesses. As in, mental health practitioners basically refusing to treat patients with this disorder. It was widely considered to be something that did not tend to improve over someone's life time. (Hence "personality disorder" and its inclusion on Axis II in previous iterations of the DSM.) Also, lots of people thought it was untreatable.
But guess what, they did some studies, and they found this to be not at all true. For example, from this 10 year longitudinal study:
The rates of BPD remission found here resemble those observed in 10-year follow-up studies that used similar follow-up methods for MDD, bipolar disorder, and panic disorders but far exceed those for social phobia. The rates of BPD relapse found here are dramatically lower than for all of these disorders.
There are a lot of nuances and caveats, and if you're so inclined, you can actually read the entire article through that link. It definitely was a huge contradiction of the previous "wisdom" about the disorder. The creation of evidence based psychotherapy treatments such as DBT also really helped with this. Another great thing about DBT is that it's much more concrete and regimented than more psychodynamic therapies, which helps ensure the quality of therapy offered by DBT therapists (although obviously not a guarantee of quality).
It really is such a difficult issue to sort out. There is so much stigma coming from all directions. Medicalizing mental illness, describing it as something that is treatable but incurable, can feel stigmatizing and demoralizing. At the same time, I still think there are people who avoid even considering taking medications because they are flooded with all the negative narratives about it, and that can lead to lots of people suffering for a very long time when they could get relief from medications. And then again, we circle back to the issue of inaccessibility of mental health care and all of that.
posted by litera scripta manet at 8:58 PM on August 11, 2016 [9 favorites]
Just in case this is at least in part a response to what I wrote earlier (I really didn't intend to write such a long screed in the first place), I just wanted to say that I 100% agree that we should be asking questions and doing studies, especially long term longitudinal studies, about whether these meds due in fact help more than they hurt.
Even without any data to back it up, I feel comfortable asserting that their are some (probably a lot) of patients who are overmedicated or incorrectly medicated in a way that causes demonstrable harm. Look, take seroquel for example. It's an atypical antipsychotic, but I've personally known multiple people who were prescribed it as a sleep aid. This happened to me, in fact. In these cases, we were all receiving treatment for psychiatric disorders, but none of them were the kind of thing where seroquel would be a first or even a second line treatment. And I hated it. It tanked my blood pressure, knocked me out to the point that I couldn't stay awake if I wanted to, it led to multiple terrifying episodes of sleep paralysis...oh, and then there was the fact that it made me so desperately hungry I couldn't stop myself from devouring whatever food was available. I'm actually pretty picky about not liking junk food or stuff like that, but I would legit eat just about anything. The more carbs the better. It sounds ridiculous now, but even if I hate a full meal immediately before taking Seroquel, within an hour, I'd be standing in front of the fridge, ready for my Second Seroquel Dinner, as I called it. (On the bright side, it was a great way to get rid of extra food we had lying around.)
I was so happy when I finally got off of it, and I wasn't even taking that high a dose (100 mg). And just recently I was getting pissed off about how a psychiatrist was throwing a whole bunch of psych meds at my 95 year old grandmother, even though they couldn't figure out why she was suffering from sudden onset delusions/psychosis.
Another really good example is Borderline Personality Disorder, which in a certain way has been one of the most heavily stigmatized mental illnesses. As in, mental health practitioners basically refusing to treat patients with this disorder. It was widely considered to be something that did not tend to improve over someone's life time. (Hence "personality disorder" and its inclusion on Axis II in previous iterations of the DSM.) Also, lots of people thought it was untreatable.
But guess what, they did some studies, and they found this to be not at all true. For example, from this 10 year longitudinal study:
The rates of BPD remission found here resemble those observed in 10-year follow-up studies that used similar follow-up methods for MDD, bipolar disorder, and panic disorders but far exceed those for social phobia. The rates of BPD relapse found here are dramatically lower than for all of these disorders.
There are a lot of nuances and caveats, and if you're so inclined, you can actually read the entire article through that link. It definitely was a huge contradiction of the previous "wisdom" about the disorder. The creation of evidence based psychotherapy treatments such as DBT also really helped with this. Another great thing about DBT is that it's much more concrete and regimented than more psychodynamic therapies, which helps ensure the quality of therapy offered by DBT therapists (although obviously not a guarantee of quality).
It really is such a difficult issue to sort out. There is so much stigma coming from all directions. Medicalizing mental illness, describing it as something that is treatable but incurable, can feel stigmatizing and demoralizing. At the same time, I still think there are people who avoid even considering taking medications because they are flooded with all the negative narratives about it, and that can lead to lots of people suffering for a very long time when they could get relief from medications. And then again, we circle back to the issue of inaccessibility of mental health care and all of that.
posted by litera scripta manet at 8:58 PM on August 11, 2016 [9 favorites]
Sorry for all the commenting, but looking back at the article again, I just wanted to hone in on a couple of things that are leading to my strong reaction to it. For example:
But the words ‘not yet’ are always added, since psychiatry seems to have faith that such a test is around the corner. This faith is robust: in the age of psychopharmacology our humanity is reduced to our brain, and all problems can be salved if not really solved with pills.
I think this is really, really wrong. Yes, that "not yet" is added pretty commonly, and I think it's entirely possible that in the future, we will be able to narrow down more of the biological bases of behavior and not just "abnormal" behavior. But more importantly, someone can believe in the biological bases of behavior without automatically believing that the solution is lots of pills. Some psychiatrists may believe that, but I know that not all psychiatrists subscribe to that theory. In fact, there is a lot of psychiatric literature that says the opposite.
I don't have the studies on hand right this second, but I know I've seen studies about how therapy, like CBT, can in fact cause changes in the wiring of your brain. There's been a lot of very interesting research into neuronal plasticity. There's evidence that negative thought loops (or obsessions/compulsions) become engrained over time, but by "overriding" these automatic thoughts, you can actually change the way your brain responds to things. None of this is static, and a lot of it is changeable, via drugs, behavioral therapy, psychodynamic therapy, all of the above, or maybe even none of the above.
At the same time, I'm not entirely clear on if he's legitimately trying to appeal to some sort of higher level, metaphysical source of psychic pain. I'm a pretty hard core atheist, and my higher power is the scientific method, so yeah, I don't really subscribe this. I believe our thoughts, feelings, and actions are a result of the wirings in our brain. But I also strongly believe that "biology is not destiny." Our environments, our experiences, they can change how your brain works (and how the rest of your body works too). That's why I wouldn't at all be surprised if a lot of instances of acute psychosis are not something that was preordained based on the expression of a particular persons genetic make up.
Which brings me to another point:
What has changed madness is our treatment of it. Our powerful drugs change brains in ways that make them profoundly drug-dependent. Coming off these drugs is a very tricky business. You can quickly become crazier and/or more anxious and/or more depressed than you ever were before starting the meds.
To me, this is a very loaded statement that he makes way too cavalierly. Again, I'm not doubting that some people are medicated when they shouldn't be. I believe that acute psychosis may very well resolve without medication in a number of people. But I am not okay with the way he expresses this. For example, there is absolutely nothing here that supports the idea of "drug dependence" since that is a term used for response to addictive substances. I also would be very interested to see whether there is data to support the idea that in the long term, someone who comes off these meds will be permanently worse off than they were before being put on the drugs. Although again, this is very hard to adequately study, since you then have to try to sort out whether it's the drugs that made them this way, or if this is simply the course of a particular psychiatric illness.
I also have to admit that his description of his therapy session with Martha and his description of her just rubbed me the wrong way. It felt a little bit too much like "here's this female in distress, and here I am, the white knight, perfectly equipped to help her." I don't know, maybe it's just me, but the way he framed this also made me uncomfortable, aside from the more concrete disagreements I have with his thesis.
posted by litera scripta manet at 9:22 PM on August 11, 2016 [7 favorites]
But the words ‘not yet’ are always added, since psychiatry seems to have faith that such a test is around the corner. This faith is robust: in the age of psychopharmacology our humanity is reduced to our brain, and all problems can be salved if not really solved with pills.
I think this is really, really wrong. Yes, that "not yet" is added pretty commonly, and I think it's entirely possible that in the future, we will be able to narrow down more of the biological bases of behavior and not just "abnormal" behavior. But more importantly, someone can believe in the biological bases of behavior without automatically believing that the solution is lots of pills. Some psychiatrists may believe that, but I know that not all psychiatrists subscribe to that theory. In fact, there is a lot of psychiatric literature that says the opposite.
I don't have the studies on hand right this second, but I know I've seen studies about how therapy, like CBT, can in fact cause changes in the wiring of your brain. There's been a lot of very interesting research into neuronal plasticity. There's evidence that negative thought loops (or obsessions/compulsions) become engrained over time, but by "overriding" these automatic thoughts, you can actually change the way your brain responds to things. None of this is static, and a lot of it is changeable, via drugs, behavioral therapy, psychodynamic therapy, all of the above, or maybe even none of the above.
At the same time, I'm not entirely clear on if he's legitimately trying to appeal to some sort of higher level, metaphysical source of psychic pain. I'm a pretty hard core atheist, and my higher power is the scientific method, so yeah, I don't really subscribe this. I believe our thoughts, feelings, and actions are a result of the wirings in our brain. But I also strongly believe that "biology is not destiny." Our environments, our experiences, they can change how your brain works (and how the rest of your body works too). That's why I wouldn't at all be surprised if a lot of instances of acute psychosis are not something that was preordained based on the expression of a particular persons genetic make up.
Which brings me to another point:
What has changed madness is our treatment of it. Our powerful drugs change brains in ways that make them profoundly drug-dependent. Coming off these drugs is a very tricky business. You can quickly become crazier and/or more anxious and/or more depressed than you ever were before starting the meds.
To me, this is a very loaded statement that he makes way too cavalierly. Again, I'm not doubting that some people are medicated when they shouldn't be. I believe that acute psychosis may very well resolve without medication in a number of people. But I am not okay with the way he expresses this. For example, there is absolutely nothing here that supports the idea of "drug dependence" since that is a term used for response to addictive substances. I also would be very interested to see whether there is data to support the idea that in the long term, someone who comes off these meds will be permanently worse off than they were before being put on the drugs. Although again, this is very hard to adequately study, since you then have to try to sort out whether it's the drugs that made them this way, or if this is simply the course of a particular psychiatric illness.
I also have to admit that his description of his therapy session with Martha and his description of her just rubbed me the wrong way. It felt a little bit too much like "here's this female in distress, and here I am, the white knight, perfectly equipped to help her." I don't know, maybe it's just me, but the way he framed this also made me uncomfortable, aside from the more concrete disagreements I have with his thesis.
posted by litera scripta manet at 9:22 PM on August 11, 2016 [7 favorites]
Apologies for dumping all these massive comments in this thread. This is obviously something I've had a lot of personal experience with, as a mental health consumer, as a friend and relative of people receiving mental health treatment, and also as someone who has done a lot of reading about these issues as well as attending a lot of classes and lectures on the subject, hence all of my thoughts and feelings about all of this, but I'm going to step away from the thread so that I don't monopolize the conversation any more than I already have.
posted by litera scripta manet at 9:25 PM on August 11, 2016
posted by litera scripta manet at 9:25 PM on August 11, 2016
Look, take seroquel for example. It's an atypical antipsychotic, but I've personally known multiple people who were prescribed it as a sleep aid.
Direct result of the pharmas pushing for off-label use of these drugs since the original market wasn't enough to sate their greed. Really unconscionable, given the very serious side effects.
But...I live in the big city. I see untreated psychotics on a regular basis. These are not folks who are going to make it to therapy sessions with their kindly seventy-year-old psychotherapist unassisted until they have their spiritual breakthroughs. And the idea that there ever was "kind, safe custodial care" available for more than a handful of the most otherwise-privileged mentally ill...!
posted by praemunire at 9:38 PM on August 11, 2016 [6 favorites]
Direct result of the pharmas pushing for off-label use of these drugs since the original market wasn't enough to sate their greed. Really unconscionable, given the very serious side effects.
But...I live in the big city. I see untreated psychotics on a regular basis. These are not folks who are going to make it to therapy sessions with their kindly seventy-year-old psychotherapist unassisted until they have their spiritual breakthroughs. And the idea that there ever was "kind, safe custodial care" available for more than a handful of the most otherwise-privileged mentally ill...!
posted by praemunire at 9:38 PM on August 11, 2016 [6 favorites]
I also know personally people who are almost certainly on way more drugs (in terms of dosage and in terms of number of drugs) than they need, to their detriment.
But what I was saying in regard to longitudinal studies is - is it actually true that they haven't been done? I would say it's fairly scandalous if they haven't. I would also say it seems fairly unlikely that they haven't - but I don't actually know that.
I notice that both Carpenter and Torrey, on opposing sides of an argument - Torrey is actually responding to Robert Whitaker but Carpenter is drawing heavily from Whitaker - emphasize the that there is a distinction between self-resolving acute psychosis and chronic schizophrenia. The linchpin of the difference between them seems to be Whitaker/Carpenter's belief that there is evidence that antipsychotics can turn an acute psychotic episode into a chronic condition. For me personally, the 8 percent/62 percent study just... kinda sets off my bullshit detector (I'm thinking confounding factors, not fraud or anything.) And likewise the WHO developing country studies seem to bring in a lot of issues of categorization - what a particular illness means and what "recovery" means - though I can believe fairly easily that the mentally ill are treated with more kindness in some societies other than our own. But that's just my gut reaction. I don't know the real, full state of the research.
posted by atoxyl at 9:39 PM on August 11, 2016 [1 favorite]
But what I was saying in regard to longitudinal studies is - is it actually true that they haven't been done? I would say it's fairly scandalous if they haven't. I would also say it seems fairly unlikely that they haven't - but I don't actually know that.
I notice that both Carpenter and Torrey, on opposing sides of an argument - Torrey is actually responding to Robert Whitaker but Carpenter is drawing heavily from Whitaker - emphasize the that there is a distinction between self-resolving acute psychosis and chronic schizophrenia. The linchpin of the difference between them seems to be Whitaker/Carpenter's belief that there is evidence that antipsychotics can turn an acute psychotic episode into a chronic condition. For me personally, the 8 percent/62 percent study just... kinda sets off my bullshit detector (I'm thinking confounding factors, not fraud or anything.) And likewise the WHO developing country studies seem to bring in a lot of issues of categorization - what a particular illness means and what "recovery" means - though I can believe fairly easily that the mentally ill are treated with more kindness in some societies other than our own. But that's just my gut reaction. I don't know the real, full state of the research.
posted by atoxyl at 9:39 PM on August 11, 2016 [1 favorite]
Referenced Harrow paper is weak. n=139. Anything with n below 100 in behavioral science is basically just random noise. n=139 with soft methodology is just as bad, without power to answer this question, especially this one with an initial selection bias, or that fails to account for the psychotogenic effects of antipsychotic discontinuation in vulnerable populations. To take an analogy, if someone had chronic hypertension or arrhythmia, and you control that with medication, but then you abruptly remove the antihypertensive or anti-arrhythmic, you're going to see some risky destabilisation and a temporary elevation in morbidity. After several acute flares (I'm excluding "brief reactive psychosis" without repeats because that seems to be a self-limiting illness where the provoking factors resolve), psychosis is a chronic condition, it needs to be managed like one because the mortality outcomes are appalling. You always try to minimize the drug burden, but you don't say to someone with RA or MS "Hey, why not take a really long drug holiday and then we'll medicate you again when you have an acute flare?"
How about an n of 2230? Or n=58,665. Or an n of 2588? Or an n of 10,934, where duration of untreated psychosis is one of the strongest negative outcome variables? One thing you'll notice is that virtually all of the really first-rank outcome studies for psychiatry are from outside the US, because wihtout a national database or single-payer, the broken and balkanized health care system there both mitigates against good comprehensive treatment for people with psychotic illnesses, and makes it incredibly difficlt for researchers to complete large-scale studies.
This is a much more respectable outcome study than the Harrow one (n=1633)
posted by meehawl at 9:47 PM on August 11, 2016 [9 favorites]
How about an n of 2230? Or n=58,665. Or an n of 2588? Or an n of 10,934, where duration of untreated psychosis is one of the strongest negative outcome variables? One thing you'll notice is that virtually all of the really first-rank outcome studies for psychiatry are from outside the US, because wihtout a national database or single-payer, the broken and balkanized health care system there both mitigates against good comprehensive treatment for people with psychotic illnesses, and makes it incredibly difficlt for researchers to complete large-scale studies.
This is a much more respectable outcome study than the Harrow one (n=1633)
posted by meehawl at 9:47 PM on August 11, 2016 [9 favorites]
Also, this: 11-year follow-up of mortality in patients with schizophrenia (n=66 881).
Long-term cumulative exposure (7–11 years) to any antipsychotic treatment was associated with lower mortality than was no drug use (0·81, 0·77–0·84). In patients with one or more filled prescription for an antipsychotic drug, an inverse relation between mortality and duration of cumulative use was noted (HR for trend per exposure year 0·991; 0·985–0·997)posted by meehawl at 10:08 PM on August 11, 2016 [5 favorites]
I actually think that a focus on the newest drugs is part of the problem. Pharma has been trying to find something more effective than Clozapine for decades, without result. Outside of that basically all antipsychotics released so far are equivalent for efficacy, with varying dropout rates and tolerability.
Yet because of marketing, people can end up spending literally hundreds of times more for one kind of pill than another. Or to take a different example, a generic long-acting depot antipsychotic injection off-patent will cost between $10-$20 per month in the US. But on-patent, such as Abilify or Zyprexa, or the me-too drug Invega (an enantiomer of Risperidone), you're talking thousands a month. Take, say, $3,000, which is middle of the range. Times 12 that's $36,000 a year. Multiply that by a few thousand patients and it quickly adds up. The newer HCV retrovirals are rightly excoriated for being priced at absurd amounts of money - basically just slightly less than a liver transplant. But if they work, that's a definitive cure. Antipsychotics are not. That $36,000 annually? That will just keep on ticking over, year after year. Massive profits. Rent seeking.
These are profits being extracted from the mental health care system (most of the chronically psychotic people depend on Medicaid or Medicare) that, in a more rational world with effective drug bargaining, cost management, outcomes management, etc, could be retained and invested in therapists, occupational trainers, social workers, housing, etc. For many of my patients, I'm confident given the evidence from outcome trials that having more access to skills-based rehab, psychotherapy and supportive housing would improve their lives tremendously more than twiddling doses or switching a drug regimen.
posted by meehawl at 10:35 PM on August 11, 2016 [15 favorites]
Yet because of marketing, people can end up spending literally hundreds of times more for one kind of pill than another. Or to take a different example, a generic long-acting depot antipsychotic injection off-patent will cost between $10-$20 per month in the US. But on-patent, such as Abilify or Zyprexa, or the me-too drug Invega (an enantiomer of Risperidone), you're talking thousands a month. Take, say, $3,000, which is middle of the range. Times 12 that's $36,000 a year. Multiply that by a few thousand patients and it quickly adds up. The newer HCV retrovirals are rightly excoriated for being priced at absurd amounts of money - basically just slightly less than a liver transplant. But if they work, that's a definitive cure. Antipsychotics are not. That $36,000 annually? That will just keep on ticking over, year after year. Massive profits. Rent seeking.
These are profits being extracted from the mental health care system (most of the chronically psychotic people depend on Medicaid or Medicare) that, in a more rational world with effective drug bargaining, cost management, outcomes management, etc, could be retained and invested in therapists, occupational trainers, social workers, housing, etc. For many of my patients, I'm confident given the evidence from outcome trials that having more access to skills-based rehab, psychotherapy and supportive housing would improve their lives tremendously more than twiddling doses or switching a drug regimen.
posted by meehawl at 10:35 PM on August 11, 2016 [15 favorites]
What annoys me about any "No one should take psych meds!" and "Everyone should take psych meds!" arguments is that the argument-maker never seems to distinguish between mild, moderate, and severe symptoms. From what I've read and seen, people with severe psychiatric symptoms benefit enormously from psychiatric medications, and almost not at all from therapy, and arguments about how psych meds are all a conspiracy actively hurt the most vulnerable people with psychiatric disorders. And from what I've read and seen, people with mild psychiatric symptoms benefit enormously from therapy, and almost not at all from psych meds, and arguments about how psych meds (or CBT, or any other "one true way" advice) are the one true thing to fix brain chemistry actively work against people with mild symptoms getting help.
I don't think people with single psychotic episodes should be in a situation where meds are the only positive thing in their lives for the rest of their lives. However, I work with people with severe mental illness who often can function only because they're on medication and they'll need to be on medication for the rest of their lives. If we can, as a society, intervene earlier in order to prevent lifelong psych illness, awesome! But since we're not, as a society, doing that, I think it's particularly perverse that we're also trying to shame adults out of taking medication that helps them function in the society we actually have.
posted by lazuli at 10:47 PM on August 11, 2016 [16 favorites]
I don't think people with single psychotic episodes should be in a situation where meds are the only positive thing in their lives for the rest of their lives. However, I work with people with severe mental illness who often can function only because they're on medication and they'll need to be on medication for the rest of their lives. If we can, as a society, intervene earlier in order to prevent lifelong psych illness, awesome! But since we're not, as a society, doing that, I think it's particularly perverse that we're also trying to shame adults out of taking medication that helps them function in the society we actually have.
posted by lazuli at 10:47 PM on August 11, 2016 [16 favorites]
So this is just definitely and completely untrue. There are literally hundreds of studies that show schizophrenic brains have enlarged ventricles, smaller size with reduced connectivity, white matter abnormalities, abnormal functional connectivity of brain regions etc. etc. Some of those apply to bipolar patients and other psychotic disorders too. Some might be secondary, or due to medication effects, but not the clear genetic component and the documented abnormalities in embryonic/premorbid brain development. Schizophrenia, at least, has a biological basis, even if there's no clinical test and no definite known cause.
Is acute psychosis a brain disorder? Hypothetically yes, but no evidence exists. Of course our brains are involved in all of our experience. This is a trivial truth. But there actually are no demonstrable differences between the brains of psychotic and non-psychotic people.
It's kind of worrying to even hear psychosis referred to as a "disorder"... it's a cluster of symptoms that is part of a number of different illnesses and syndromes, including schizophrenia, depression, bipolar disorder, stimulant abuse etc.
It makes some sense to think that psychiatry as a whole is dismissive of this kind of argument in order to protect itself... but I'm convinced that the psychiatrists I've done research with are personally frustrated simply because it makes it harder for them to help people with the imperfect tools they have (yes medication, but also therapy and community-based treatment).
posted by kleinsteradikaleminderheit at 2:13 AM on August 12, 2016 [6 favorites]
So this is just definitely and completely untrue. There are literally hundreds of studies that show schizophrenic brains
No, you failed at reading comprehension. The author posits a distinction between acute psychosis and chronic psychosis, and he unambiguously implies that schizophrenic brains fall in the latter category. Go back and read it. I suppose one can still find other reasons to critique what he said, but what you said previously simply does not apply to his argument.
Taking a broader picture, I think part of a common mistake in reading this author/article is not grasping that he's posing a kind of very general research problem. He's making a theory-oriented argument, so precisely the wrong response is immediately citing counterexample research, because that tends to project an external standard instead of attending to the conceptual argument that he's constructing. There's some nontrivial reframing and interpretation needed to make sense of what he's really suggesting. He's talking about a change of theory, and thus citing existing evidence without attending to ramifications of differing interpretations is a guaranteed way to not engage with his concerns.
posted by polymodus at 3:21 AM on August 12, 2016 [1 favorite]
No, you failed at reading comprehension. The author posits a distinction between acute psychosis and chronic psychosis, and he unambiguously implies that schizophrenic brains fall in the latter category. Go back and read it. I suppose one can still find other reasons to critique what he said, but what you said previously simply does not apply to his argument.
Taking a broader picture, I think part of a common mistake in reading this author/article is not grasping that he's posing a kind of very general research problem. He's making a theory-oriented argument, so precisely the wrong response is immediately citing counterexample research, because that tends to project an external standard instead of attending to the conceptual argument that he's constructing. There's some nontrivial reframing and interpretation needed to make sense of what he's really suggesting. He's talking about a change of theory, and thus citing existing evidence without attending to ramifications of differing interpretations is a guaranteed way to not engage with his concerns.
posted by polymodus at 3:21 AM on August 12, 2016 [1 favorite]
The main change in my thinking resulting from my own recovery from psychosis was a conscious habit of doing basic reality checks on things I suddenly feel I understand. Epiphany feels glorious but that's not a reason to believe that everything revealed by it is sound.
Yep, this. And that tendency toward self doubt and inaction can come with it's own social and personal costs in the current cultural climate of valuing strong, decisive actors over "weak" and "feminine" self doubt, reflection, and hesitation. It's one of my main beefs with the whole culture of extreme machismo and "strength" that Trump and other self-styled power players embody.
posted by saulgoodman at 5:46 AM on August 12, 2016 [2 favorites]
Yep, this. And that tendency toward self doubt and inaction can come with it's own social and personal costs in the current cultural climate of valuing strong, decisive actors over "weak" and "feminine" self doubt, reflection, and hesitation. It's one of my main beefs with the whole culture of extreme machismo and "strength" that Trump and other self-styled power players embody.
posted by saulgoodman at 5:46 AM on August 12, 2016 [2 favorites]
How can this person even be conducting a serious discussion about the treatment of 'acute psychosis' as if it's one monolithic disease? Psychosis is better conceptualised as a symptom that can present as a part of a range of disorders. It's like saying that we should stop using inhalers to treat cough.
I mean, I get that he's a psychotherapist so he wants to believe that therapy is the answer, and maybe I'm just a doctor who believes drugs are (sometimes) the answer, but this was an amazing mix of simplistic nonsense mixed in with citations! to make it look good. And surely this guy knows there's a difference in management between psychotic depression and schizophrenia even if they're both Acute Psychosis, which just makes his weirdly disingenuous article even stranger.
No, you failed at reading comprehension. The author posits a distinction between acute psychosis and chronic psychosis, and he unambiguously implies that schizophrenic brains fall in the latter category. Go back and read it. I suppose one can still find other reasons to critique what he said, but what you said previously simply does not apply to his argument.
So rude, but given facts are apparently irrelevant to the conceptual argument he is making (weirdly inclusive of many citations) you won't be interested in googling "psychosis MRI" to read all the counterfacts to the argument he is making.
posted by chiquitita at 6:38 AM on August 12, 2016 [6 favorites]
I mean, I get that he's a psychotherapist so he wants to believe that therapy is the answer, and maybe I'm just a doctor who believes drugs are (sometimes) the answer, but this was an amazing mix of simplistic nonsense mixed in with citations! to make it look good. And surely this guy knows there's a difference in management between psychotic depression and schizophrenia even if they're both Acute Psychosis, which just makes his weirdly disingenuous article even stranger.
No, you failed at reading comprehension. The author posits a distinction between acute psychosis and chronic psychosis, and he unambiguously implies that schizophrenic brains fall in the latter category. Go back and read it. I suppose one can still find other reasons to critique what he said, but what you said previously simply does not apply to his argument.
So rude, but given facts are apparently irrelevant to the conceptual argument he is making (weirdly inclusive of many citations) you won't be interested in googling "psychosis MRI" to read all the counterfacts to the argument he is making.
posted by chiquitita at 6:38 AM on August 12, 2016 [6 favorites]
I suppose I mean to say: you can't have it both ways and say that something is a conceptual piece meant to be grappled with on a deeper intellectual plane when it uses citations to published studies to advance that point. If it was a reflection on a patient encounter alone I would accept it, but in putting forth data to support a point, you must be prepared to defend it.
posted by chiquitita at 6:44 AM on August 12, 2016 [3 favorites]
posted by chiquitita at 6:44 AM on August 12, 2016 [3 favorites]
My father was a diagnosed paranoid schizophrenic, and he spent a good chunk of his life in mental hospitals. He didn't bring me up, but typically would visit from time to time, and I took care of him at the end of his life. And I've been convinced by a number of short-term experiences I've had in my own life during extremely stressful periods--coming off of hard drugs when I was much younger, and to a lesser extent later on when quitting tobacco and alcohol--that under certain specific circumstances, I can be crazy too.
I think the author is right. Whatever a drug gives the patient, it takes away in equal measure. If a drug interferes with, say, dopamine, the brain just makes up the difference and the patient is left with a new problem because no drug can be in anyone's system at perfectly uniform levels at all times, therefore a new situation is created where there will be some times when the drugs' effects wane and symptoms are bound to occur.
During what I'm convinced were tough times for him, my dad had a few "nervous breakdowns." (Do they still use that term?) But he never had a chance to develop coping skills that might have gotten him through his crises without drugs, and his brain, that infinitely plastic organ, never got a chance to make the adjustments that might have put him right. Instead they put him on a parade of antipsychotics. When I was a kid it was thorazine, plus some other stuff that was supposed to stop him from thorazine-shaking so much, and i've forgotten the names of most of the others.
I've been convinced for many years that getting diagnosed was the worst thing that ever happened to him.
Our treatment of mental health issues in 2016 mirrors the rests of our culture: we don't value subjective experience, we discount all that which we can't easily quantify. But that is a bit arrogant of us. Humans think too much of their abilities, just as I'm sure they did in the age of leeches as medical treatment. Just because science is the best tool we have for understanding our world doesn't mean that we currently understand everything there is to understand, or that we should behave as though we do.
posted by O. Bender at 9:28 AM on August 12, 2016 [4 favorites]
I think the author is right. Whatever a drug gives the patient, it takes away in equal measure. If a drug interferes with, say, dopamine, the brain just makes up the difference and the patient is left with a new problem because no drug can be in anyone's system at perfectly uniform levels at all times, therefore a new situation is created where there will be some times when the drugs' effects wane and symptoms are bound to occur.
During what I'm convinced were tough times for him, my dad had a few "nervous breakdowns." (Do they still use that term?) But he never had a chance to develop coping skills that might have gotten him through his crises without drugs, and his brain, that infinitely plastic organ, never got a chance to make the adjustments that might have put him right. Instead they put him on a parade of antipsychotics. When I was a kid it was thorazine, plus some other stuff that was supposed to stop him from thorazine-shaking so much, and i've forgotten the names of most of the others.
I've been convinced for many years that getting diagnosed was the worst thing that ever happened to him.
Our treatment of mental health issues in 2016 mirrors the rests of our culture: we don't value subjective experience, we discount all that which we can't easily quantify. But that is a bit arrogant of us. Humans think too much of their abilities, just as I'm sure they did in the age of leeches as medical treatment. Just because science is the best tool we have for understanding our world doesn't mean that we currently understand everything there is to understand, or that we should behave as though we do.
posted by O. Bender at 9:28 AM on August 12, 2016 [4 favorites]
This NYT article is a few years old at this point, but I think it's definitely worth reading if you're interested in these issues. Even though it focuses on SSRIs, I still think it's quite relevant to the arguments made in this FPP.
From the NYT article:
In 2010, researchers revisited Kirsch’s analysis using six of the most rigorously conducted studies on antidepressants. The study vindicated Kirsch’s conclusions but only to a point. In patients with moderate or mild depression, the benefit of an antidepressant was indeed small, even negligible. But for patients with the most severe forms of depression, the benefit of medications over placebo was substantial.
I think the more interesting portion of the article is its examination of studies that look into how exactly SSRIs function to relieve depression, and also what this might tell us about the biological basis of depression. For example:
In 2011, Hen and his colleagues repeated these studies with depressed primates. In monkeys, chronic stress produces a syndrome with symptoms remarkably similar to some forms of human depression. Even more strikingly than mice, stressed monkeys lose interest in pleasure and become lethargic. When Hen measured neuron birth in the hippocampi in depressed monkeys, it was low. When he gave the monkeys antidepressants, the depressed symptoms abated and neuron birth resumed. Blocking the growth of nerve cells made Prozac ineffective.
Also:
Perhaps antidepressants like Prozac and Paxil primarily alter behavioral circuits in the brain — particularly the circuits deep in the hippocampus where memories and learned behaviors are stored and organized — and consequently change mood.
The article doesn't have any definitive answers, and it also brings up a number of very important questions, but I do think it does a good job of looking into ways that psychiatric medications can help patients even if there method of action isn't to literally counteract a "chemical imbalance."
posted by litera scripta manet at 11:01 AM on August 12, 2016 [2 favorites]
From the NYT article:
In 2010, researchers revisited Kirsch’s analysis using six of the most rigorously conducted studies on antidepressants. The study vindicated Kirsch’s conclusions but only to a point. In patients with moderate or mild depression, the benefit of an antidepressant was indeed small, even negligible. But for patients with the most severe forms of depression, the benefit of medications over placebo was substantial.
I think the more interesting portion of the article is its examination of studies that look into how exactly SSRIs function to relieve depression, and also what this might tell us about the biological basis of depression. For example:
In 2011, Hen and his colleagues repeated these studies with depressed primates. In monkeys, chronic stress produces a syndrome with symptoms remarkably similar to some forms of human depression. Even more strikingly than mice, stressed monkeys lose interest in pleasure and become lethargic. When Hen measured neuron birth in the hippocampi in depressed monkeys, it was low. When he gave the monkeys antidepressants, the depressed symptoms abated and neuron birth resumed. Blocking the growth of nerve cells made Prozac ineffective.
Also:
Perhaps antidepressants like Prozac and Paxil primarily alter behavioral circuits in the brain — particularly the circuits deep in the hippocampus where memories and learned behaviors are stored and organized — and consequently change mood.
The article doesn't have any definitive answers, and it also brings up a number of very important questions, but I do think it does a good job of looking into ways that psychiatric medications can help patients even if there method of action isn't to literally counteract a "chemical imbalance."
posted by litera scripta manet at 11:01 AM on August 12, 2016 [2 favorites]
I think antipsychotics have their place in severe incidents and cases, and I hate the term "spiritual emergency", but big pharma is a very real thing. Antipsychotics like Abilify , Seroquel and Latuda are being advertised and prescribed for depression and anxiety without cause and full disclosure, as far as I can tell. The NYT article says it better than I can.
If atypicals are overprescribed for depression and anxiety, I can only imagine how much they are overprescribed for singular incidences of psychosis.
It's also worth noting that not only does trauma affect the brain but behaviors that are related to coping with trauma can also cause breaks- drug use (especially stimulants), workaholism to the point of sleep deprivation and/or malnutrition, and extended insomnia, and severe alcoholism. While the biomedical model has validity, the diagnostic methods of psychiatry can be slipshod and lesser causes of psychiatric illness can be overlooked for years. For me I actually once had a bout of caffeine-induced psychosis. I know that sounds silly but I relied on it to excess to counterbalance my Seroquel which was sedating me. I myself thought it was breakthrough symptoms; I never would've guessed it was my multiple double espressos that was making me super aggro, I just assumed it was mania. Sometimes what looks like a serious symptom can have a simple answer that can be addressed other ways, and even more problematic, if you don't address an underlying cause, you get relapses. It's become a habit to think everything is biologically driven and genetically predetermined.
A friend of mine was diagnosed bipolar just on the basis of depressive episodes once a month or so; she had an abusive history including molestation. That was overlooked and she went down the rabbithole of overmedication. She is now medication-free and functions just fine.
posted by GospelofWesleyWillis at 2:44 PM on August 12, 2016 [3 favorites]
If atypicals are overprescribed for depression and anxiety, I can only imagine how much they are overprescribed for singular incidences of psychosis.
It's also worth noting that not only does trauma affect the brain but behaviors that are related to coping with trauma can also cause breaks- drug use (especially stimulants), workaholism to the point of sleep deprivation and/or malnutrition, and extended insomnia, and severe alcoholism. While the biomedical model has validity, the diagnostic methods of psychiatry can be slipshod and lesser causes of psychiatric illness can be overlooked for years. For me I actually once had a bout of caffeine-induced psychosis. I know that sounds silly but I relied on it to excess to counterbalance my Seroquel which was sedating me. I myself thought it was breakthrough symptoms; I never would've guessed it was my multiple double espressos that was making me super aggro, I just assumed it was mania. Sometimes what looks like a serious symptom can have a simple answer that can be addressed other ways, and even more problematic, if you don't address an underlying cause, you get relapses. It's become a habit to think everything is biologically driven and genetically predetermined.
A friend of mine was diagnosed bipolar just on the basis of depressive episodes once a month or so; she had an abusive history including molestation. That was overlooked and she went down the rabbithole of overmedication. She is now medication-free and functions just fine.
posted by GospelofWesleyWillis at 2:44 PM on August 12, 2016 [3 favorites]
Back in 2011, an alarming and apparently credible study was published suggesting that in the long term, antipsychotics cause brain shrinkage independent of illness severity or substance abuse:
posted by jamjam at 4:12 PM on August 12, 2016 [3 favorites]
In 1991, Nancy Andreasen began a long-running study of first-episode schizophrenia patients, which involved periodically measuring their brain volumes with magnetic resonance scans. In articles published in 2003 and 2005, she reported finding "progressive brain volume reductions" in her patients, and that this shrinkage was associated with a worsening of negative symptoms, functional impairment and cognitive decline. But the implication was that this shrinkage was due to the disease, and that the drugs simply failed to stop it.If this study has been effectively refuted, I haven't seen it.
"The medications currently used cannot modify an injurious process occurring in the brain, which is the underlying basis of symptoms," Andreasen wrote in her 2003 paper.
However, even as she was publishing those findings, other research--in animals and schizophrenia patients--indicated that the drugs might exacerbate this brain shrinkage (or be the primary cause of it.) Then, in a 2008 interview with the New York Times, Andreasen confessed that the "more drugs you have been given, the more brain tissue you lose."
This was something of a bombshell, particularly since it came from Andreasen, who was editor-in-chief of the American Journal of Psychiatry from 1993 to 2005. Now, in the February issue of the Archives of General Psychiatry, she has published those findings, and thus the bombshell has officially landed in the scientific literature.
In this study, Andreasen took periodic MRI scans of 211 schizophrenia patients treated from seven years to 14 years. She found that long-term use of the old standard antipsychotics, the new atypical antipsycotics, and clozapine are all "associated with smaller brain tissue volumes."
Moreover, she found that this shrinkage was dose related. The more drug a person is given, the greater the "association with "smaller grey matter volumes," she reported. Similarly, the "progressive decrement in white matter volume was most evident among patients who received more antipsychotic treatment." Finally, Andreasen reported that this shrinkage "occurs independent of illness severity and substance abuse." Those two factors--illness severity and substance abuse--had "minimal or no effects" on brain volumes. ...
posted by jamjam at 4:12 PM on August 12, 2016 [3 favorites]
"A study published today has confirmed a link between antipsychotic medication and a slight, but measureable, decrease in brain volume in patients with schizophrenia. For the first time, researchers have been able to examine whether this decrease is harmful for patients’ cognitive function and symptoms, and noted that over a nine year follow-up, this decrease did not appear to have any effect."
posted by praemunire at 6:30 PM on August 12, 2016 [2 favorites]
posted by praemunire at 6:30 PM on August 12, 2016 [2 favorites]
No, you failed at reading comprehension. The author posits a distinction between acute psychosis and chronic psychosis, and he unambiguously implies that schizophrenic brains fall in the latter category. Go back and read it. I suppose one can still find other reasons to critique what he said, but what you said previously simply does not apply to his argument.
So rude, but given facts are apparently irrelevant to the conceptual argument he is making (weirdly inclusive of many citations) you won't be interested in googling "psychosis MRI" to read all the counterfacts to the argument he is making.
Actually, I explicitly talked about this problematic in my second paragraph, which you omitted, so where I'm coming from you're conveniently ignoring the contextualization issue in favor of your existing beliefs about a research issue. To me, that is intellectually careless. But my hope is that considering that problematic help you bridge the gap with what the professor is saying.
posted by polymodus at 9:22 PM on August 12, 2016
So rude, but given facts are apparently irrelevant to the conceptual argument he is making (weirdly inclusive of many citations) you won't be interested in googling "psychosis MRI" to read all the counterfacts to the argument he is making.
Actually, I explicitly talked about this problematic in my second paragraph, which you omitted, so where I'm coming from you're conveniently ignoring the contextualization issue in favor of your existing beliefs about a research issue. To me, that is intellectually careless. But my hope is that considering that problematic help you bridge the gap with what the professor is saying.
posted by polymodus at 9:22 PM on August 12, 2016
Sometimes what looks like a serious symptom can have a simple answer that can be addressed other ways, and even more problematic, if you don't address an underlying cause, you get relapses.
Very true. I started having spells of severe agitation and irritability at one point a few years ago that were causing issues in my marriage, and at first I worried I was having some kind of relapse or some new issue, but couldn't shake the feeling this was something more physical and less mental. Not sure why I thought of it, but I started realizing my symptoms were consistent with diabetes. Went to the doctor and told them my hunch, had some blood work done, and sure enough, I was prediabetic, and with treatment, the irritability and other symptoms resolved. If I'd gone to a therapist with the issue instead, who knows where I might have ended up.
posted by saulgoodman at 9:23 PM on August 12, 2016 [1 favorite]
Very true. I started having spells of severe agitation and irritability at one point a few years ago that were causing issues in my marriage, and at first I worried I was having some kind of relapse or some new issue, but couldn't shake the feeling this was something more physical and less mental. Not sure why I thought of it, but I started realizing my symptoms were consistent with diabetes. Went to the doctor and told them my hunch, had some blood work done, and sure enough, I was prediabetic, and with treatment, the irritability and other symptoms resolved. If I'd gone to a therapist with the issue instead, who knows where I might have ended up.
posted by saulgoodman at 9:23 PM on August 12, 2016 [1 favorite]
I suppose I mean to say: you can't have it both ways and say that something is a conceptual piece meant to be grappled with on a deeper intellectual plane when it uses citations to published studies to advance that point. If it was a reflection on a patient encounter alone I would accept it, but in putting forth data to support a point, you must be prepared to defend it.
Theoretical writing does this all the time regarding the use of evidence. Either psychiatrists put some effort in putting themselves in the shoes of a theorist (in both senses of the word), or they don't. What you need to fairly recognize is, why are you "attacking" the data or introducing outside data, without first attending to issues of interpretation, contextualization, and close reading? Either you recognize the divide between psych communities, and do something about that, or do the easy thing and drive the wedge further apart. And basic part of that is learning to read an article showing others a basic comprehension instead of reacting, um, rather rudely, with:
So this is just definitely and completely untrue. There are literally hundreds of studies that show schizophrenic brains .
Demonstrating both careful attention to what the other side actually said, as well as acknowledging that evidence is heavily colored by interpretation and theoretical framework, is what contributes to constructive discourse. Professionals who don't deliberately use these skills end up talking past one another.
posted by polymodus at 9:32 PM on August 12, 2016
Theoretical writing does this all the time regarding the use of evidence. Either psychiatrists put some effort in putting themselves in the shoes of a theorist (in both senses of the word), or they don't. What you need to fairly recognize is, why are you "attacking" the data or introducing outside data, without first attending to issues of interpretation, contextualization, and close reading? Either you recognize the divide between psych communities, and do something about that, or do the easy thing and drive the wedge further apart. And basic part of that is learning to read an article showing others a basic comprehension instead of reacting, um, rather rudely, with:
So this is just definitely and completely untrue. There are literally hundreds of studies that show schizophrenic brains .
Demonstrating both careful attention to what the other side actually said, as well as acknowledging that evidence is heavily colored by interpretation and theoretical framework, is what contributes to constructive discourse. Professionals who don't deliberately use these skills end up talking past one another.
posted by polymodus at 9:32 PM on August 12, 2016
polymodus, don't get me wrong: I do enjoy being lectured on constructive discourse by the person who told me first thing that I failed at reading comprehension :p
Anyway: "Is acute psychosis a brain disorder?" is not a meaningful question. If it has an answer, it's "frequently yes", because schizophrenia is a brain disorder and presents as acute psychosis.
posted by kleinsteradikaleminderheit at 12:14 AM on August 13, 2016 [1 favorite]
Anyway: "Is acute psychosis a brain disorder?" is not a meaningful question. If it has an answer, it's "frequently yes", because schizophrenia is a brain disorder and presents as acute psychosis.
posted by kleinsteradikaleminderheit at 12:14 AM on August 13, 2016 [1 favorite]
Demonstrating both careful attention to what the other side actually said, as well as acknowledging that evidence is heavily colored by interpretation and theoretical framework, is what contributes to constructive discourse. Professionals who don't deliberately use these skills end up talking past one another.
sorry, am I misreading this or are you implying you're a professional in this field then? If so, why not state it explicitly?
posted by some loser at 5:59 AM on August 13, 2016
sorry, am I misreading this or are you implying you're a professional in this field then? If so, why not state it explicitly?
posted by some loser at 5:59 AM on August 13, 2016
I'd like to add that I was obviously a little peeved and hurried when I wrote "Invega (an enantiomer of Risperidone)". It (Paliperidone) is actually the main metabolite of Risperidone. Different thing from enantiomer (that is like the relation of Lexapro/escitalopram to Celexa/citalopram), but still a me-too drug, designed mainly for evergreening.
posted by meehawl at 10:11 PM on August 16, 2016
posted by meehawl at 10:11 PM on August 16, 2016
« Older The Insult | “Twitter is the free speech wing of the free... Newer »
This thread has been archived and is closed to new comments
posted by rebent at 3:45 PM on August 11, 2016 [3 favorites]