5.05.2010

The Problem with Sophistry AND Psychiatry, All at Once

Salon recently published another article undermining -- and honestly, Wishydig, at some point these articles add up to something -- the foundations of contemporary American psychiatry. Read the original, but here are a few interesting excerpts:
Salon: And yet many studies have shown that antidepressants can treat depression, especially in severe cases.

Robert Whitaker: In severe cases, you do see that people benefit from antidepressants, and that shows up consistently. But you still have to raise the question, even in that severe group: What happens to those medicated patients in the long term, compared to what happened in previous times? One thing that surprised me, looking at the epidemiological literature from the pre-antidepressant era, is that even severely depressed, hospitalized patients could with time expect to get well, and most did. Today, however, there’s a high incidence of patients on long-term drug therapy that become chronically ill.
And later...
Salon: Are you suggesting that psychiatrists are beholden to pharmaceutical companies?

Robert Whitaker: Not exactly, although most of the leading academic psychiatrists act as consultants, advisors and speakers for them. The problem is that psychiatry, starting in 1980 with the publication of the DSM-III, decided to tell the public that psychiatric disorders were biological ailments, and that its drugs were safe and effective treatments for those ailments. If it suddenly announces to the public that a long-term NIMH-funded study found that the 15-year recovery rate for schizophrenia patients was 40 percent for those off meds and 5 percent for those on meds, then that story begins to fall apart. By not reporting the results, psychiatry maintains the image of its drugs in the public mind, and the value of psychiatrists in today’s therapy marketplace.
So, psychiatrists are worried about losing their place in the therapy marketplace... so they spin some sophistic defenses to keep themselves relevant. But I'm sure my sophistic friends will tell me I should've titled this post, "The Problem with Psychiatry and ineffective Sophistry." Yeah, maybe.

Or somebody could just tell the unvarnished truth once in a while, to everyone's benefit: "Ladies and Gentlemen, your mental and emotional problems are real, and perennial, and difficult. With patience and discipline, you have a good chance at significant recovery. Good luck. These pills don't help much. And they might turn you into a chronic head-case, whereas staying off them gives you a chance at recovery."

21 comments:

Insignificant Wrangler said...

How isn't your "authentic" response sophistic? Cause I'm pretty sure sophistry is grounded in highlighting that which isn't said (seeking a third, etc., etc., etc.).

pure_sophist_monster said...

Arguments you like are still arguments, Casey. And changing the prescription doesn't make it not a prescription.

pure_sophist_monster said...

Which is also to say, "Thanks for sharing." I am completely comfortable with the idea that "cures" have to compete rhetorically with other "cures." And so that psychologists might have to find new ways to peddle their wares, which, it seems, they still believe are valuable.

Wishydig said...

c'mon monster: "psychologists"? where's that attention to detail that got you this far?

ok casey. you have to decide what reasons you have to believe whitaker. because the interview doesn't give me any.

he likes to throw in a lot of claims about how things are worse for some and how the good ol' days might have actually been good. and his claims about pyschiatry's motivation are lovely for a character in fiction -- but it's pure conjecture on his part about the structure of system he's pretty heavily invested in seeing proved. some points:

using disability statistics as a reflection of the current state of mental health is shoddy logic. disability claims and payouts are part of a system that's about a lot more than psychiatrists and mental health.

the study of antipsychotics is a nuanced one about some schizophrenics who showed little or not relapse going off drugs and who showed a better prognosis without them. there were other factors in the differing prognoses. and it did suggest that antipsychotics are not necessary for all schizophrenics. that's nothing new. psychiatrists already know that. the question is then, are there ways of predicting/recognizing which patients will respond without them.

why did so few of the patients on drugs get better? let's use a crass example: why do so few people shot in the head recover even with surgery, while people shot in the arm often survive even with simple stitches? because there was an important variable other than the treatment at play. according to your fellow here, surgery would be a bad idea for treatment of gunshot wounds.

the study wasn't a cross-section of all schizophrenics with drugs/no-drugs as the variable being studied. it was a look at patients who had been given different prognoses and were undergoing a variety of treatments based on their therapists decisions regarding their needs. many of those were were off meds were off them because they and their therapist directed their treatment that way.

what did the study find? that the psychiatrists and patients were sometimes correct in choosing that option. and the goal of the study was to define that subgroup. how could psychiatrists and their patients make that correct determination more regularly?

and why would the NIMH "hide" this study? obviously because they're an evil empire that's trying to save itself right? i'd suggest it's because the study needed follow-up and didn't actually change knowledge in an important way. it didn't say anything other than 'psychiatrists who look for predictors of success without drugs can sometimes find them.'

did you read the study?

another important and related thing to note: so much of the raw data out there concerning drugs and mental health makes a claim about the limits of psychiatry as a specialization. this study is actually a good piece of evidence to the contrary. when you have specialists who know how to read and treat mental health issues, you end up with less reliance on drugs and a more interactive and responsive treatment. the psychiatrist knows how to work with the individual needs. so who screws this up?

other physicians who have the power to prescribe geodon and xanax and celexa and risperdal and prozac and wellbutrin and lexapro but have no idea what else to do. general practitioners can very easily deal with a patient who says "i'm feeling scared of people" with a simple scrip. and the family doctor can be a hero for a mother whose son is acting crazy in school. and those prescriptions are too big a segment of mental health "treatment." psychiatry is the solution to that problem, not the cause of it.

Casey said...

1: Wrangler, that's why I threw in that caveat about "bad sophistry." I understand that you can always say that what I'm calling "the truth" is just more effective than the unconvincing rhetoric delivered in the interview. Yeah, maybe.

2: PSM -- what I'm angling for is an admission that certain arguments are a zero-sum game, and where we're talking about a service like psychiatry, we ought to be able to at least hope that the focus is on the consumer's side. So, IF (I know, big if) it's true that psychiatrists would be out of business if anyone caught onto their scheme, and they persisted in scheming just for fear of being unemployed, and not because they actually believed they were helping their clients, that would be bullshit. And if you can't tell the difference between that argument and the argument that seeks to reinforce the existing order despite mounting evidence that undermines psychiatry's authority, then... well, you get -5 in the credibility column with me.

3: This would be where to look if we all believed and agreed that we believed that it's all a big con... because then it would just be about how to best "peddle your wares," regardless of whether they help or not. Snake oil, right? Just relabel it "antidepressant" and you're good. Unless we want to talk about this stuff actually working. And then that's not okay.

4: Wishydig, as honestly as I can say: part of the reason I tend to believe the writer is that he reinforces some of my skepticisms, and I've always been aware of that kind of stuff. When I was 19 and starting to doubt my childhood religion, I found voices of those who were doing the same more persuasive--is that purely rational? I guess not. But we do tend to notice what we're looking for, right? It seems to me like everyone's having a baby right now, but probably only because I'm having one.

But further: it strikes me as the same reasoning here that leads people to question the motives of bank CEOs. Let's try a neutral territory: Dentistry. I bet you'll agree that I should be able to trust that my dentist won't perform unnecessary surgery on my teeth, but I think you'd also admit that certain dentists might be tempted to perform such superfluities if, say, their livelihood were contingent on such action. Why wouldn't psychiatrists be subject to the same kinds of temptations? Whitaker's point about how the field of psychiatry has "reframed" anxiety for a new generation as "depression" seems borderline unethical to me, though I suppose you could argue that the name of the symptom hardly matters--but only if you thought public perception and culture (etc.) didn't count for anything. I didn't read the NIMH study because it just sounds so typical now. This article cited the one that spurred the Newsweek article a while ago... I posted on that a while ago, and we concluded with you saying, "I'll send the first round of what I've found--":

http://tr-th.blogspot.com/2010/02/antidepressants-work-but-dont-ask-how.html

Now, I'm not saying you "buried" the story or anything, but I wasn't surprised when you didn't tell me that you read the study and found it to be altogether unconvincing.

As for the part about schizophrenia and recovery off-meds: I believe that because it feels right, in my experience. ;)

[P.S. -- thanks for the responses, gang. I just drank a huge think of Diet Coke, and now I'm grumpy and crashing, and need to go change a diaper. So, I'm guessing this'll all sound a little sharper than my usual moderate/welcoming tone. Ha.]

Wishydig said...

"Why wouldn't psychiatrists be subject to the same kinds of temptations?"

simple answer: they are. but that's not the argument whitaker is making. he's saying they're lying about the research and efficacy of drugs. and not just distorting or inflating it, but reversing the information. that's a lie.

"Whitaker's point about how the field of psychiatry has 'reframed' anxiety for a new generation…"

that's not a lie, but a distortion. the new 'frame' is based on a new understanding of the comorbidity of anxiety and depression, as well as a common overlap of symptoms. they're still distinct diagnoses and psychiatrists are well aware of that. but now the role of pharmaceutical advertising comes into play, and i agree that advertising pharmaceuticals is troublesome and in many ways harmful to the work of mental health treatment.

"I didn't read the NIMH study because it just sounds so typical now."

really not a good admission when you're trying to defend your understanding of the study. you've in essence, said that you've decided on the findings and implications of the study, and altho i give you a counter analysis based on reading it, you stick with your view. my advice: say that you just believe something and you don't need any studies to support your view.

"Now, I'm not saying you "buried" the story or anything…"

i did. you're lucky you've gotten this much out of me. i've got deadlines boy!

Casey said...

Okay, you go read Kirsch (from the Newsweek article) and figure out if he's distorting, lying, or the messiah. And I'll read the NIMH study. We'll meet back here at sunset on Thursday.

pure_sophist_monster said...

Casey, when you write "mounting evidence" you are making my point. Evidence is marshaled to make arguments persuasive. We are, in essence, having an argument about what cures to privilege. As you have made clear (and as Wishy's thorough analysis - hehe - of you makes clearer), you and your allies are lined up against PSYCHIATRY and find much evidence that suggests they are snake oil salesmen. That's fine.

All I was arguing is that in the FREE MARKET (you like, yes), they ought to have an opportunity to make their case.

I was likewise arguing that you are somewhat disingenuous when you make your complaint about their rhetoric, when the REAL complaint you have is simply that you disagree with their prescriptions. That is, quit making RHETORIC the whipping boy here. It's a SHORT CUT around engaging real differences of opinion.

pure_sophist_monster said...

Also, making up your mind ahead of time and then employing the dialectic is classic Philosophy - not Sophistry.

P.S. We are out of Diet Coke and I am thus grouchy. Pax Papa!

Casey said...

Monster, you make an interesting point about the market -- I concluded a while ago that free markets only really work when you'v got a culture of self-restraint and ethics in place before turning the market loose. I say "really" because if nobody drills that deep, I don't like to think about that--

I certainly DO disagree with the prescriptions, and maybe I shouldn't make rhetoric the whipping boy. But it seems, well: when was the last time you saw an advertisement for an orthopedic surgeon who said, "I can heal your broken bones." The answer is, like, never, because they don't have to advertise. Because their shit works.

So do I hate the snake oil, or hate the game? All of it.

Making up my mind ahead of time... it stings to be outed so explicitly here. But the alternative has seemed to me to be an endless regression: "Okay, let's check the research. Okay, let's check to see if the research is unbiased and objective. Okay, let's double-back on our theory of objectivity just to be sure. Okay, let's inquire into the nature of 'Mind' in the first place..."

I guess I think Wishydig made up his mind ahead of time too? I mean, his dad's a psychiatrist! That's why I pick on him. And you, Monster... aren't you in the direct lineage all the way back to Gorgias?

Gorgias begat Isocrates, Isocrates begat Pixamander, Pixamander begat mumbles, and so on...

Wishydig said...

ohhhh, find your direction and run. by all means. as i have. and if you want to investigate it en route, do so.

so then, if you claim to be able to defend your direction, you should be ready when asked to defend it.

Casey said...

So, Wishydig, you said:

"did you read the study?"

And: "the study needed follow-up and didn't actually change knowledge in an important way. it didn't say anything other than 'psychiatrists who look for predictors of success without drugs can sometimes find them.' "

So I tried to read the study, because I am interested in following through. Unfortunately, the link from Salon only led me to a page where I could read the Abstract (any suggestions?). But even the abstract seemed to say more than you're suggesting above. This is from the abstract:

"A larger percent of schizophrenia patients not on antipsychotics showed periods of recovery and better global functioning (p < .001)."

So, are you saying that doesn't change anything? That sounds really close to "the drugs are worse than nothing" to me.

Wishydig said...

"A larger percent of schizophrenia patients not on antipsychotics showed periods of recovery and better global functioning (p < .001)."

do you remember the point i made about surgery and gunshots? this isn't saying that the only variable was meds/no-meds. the study looked at 64 schizophrenics, (and 81 non-schizophrenics as controls). and yes, when they split the groups into medicated/non-medicated they found favorable #s for the non-med group. BUT-- and this is vital to the point of the study -- they also took care to determine what other variables were at play. here i'll include some cleaned-up discussion from the paper:

"The results from Figure 4 indicate significantly more favorable prognostic scores…at index hospitalization for schizophrenia patients later not on medications (versus those on antipsychotics) at both the 4.5-year follow-ups…and the 15-year follow-ups…. The results from Figure 5 indicate more favorable premorbid developmental achieve- ments for schizophrenia patients not on medications (versus those on antipsychotics) at the 4.5-year follow-ups…and the 15-year follow-ups…."

so basically, WHY were they not on medication? because they and their doctors had evidence that they could go off the meds and possibly do well. the psychiatrists had done prognosis assessments, had seen that they had the skills and support systems to do well, and SO decided to try going off meds. and the doctor's assessments looked to be decently supported.

as i said earlier, the study was looking for a subgroup of patients that show promise for going off meds. there is that subgroup. can doctors learn how to better identify its members? that's what the study was looking for. it did not do a controlled study of medications as the independent variable.

Casey said...

Wishy,

Is it possible to quantify schizophrenics? I mean, isn't each one a kind of "unit" unto him or herself? So, I see what you're saying about other variables and selecting those who look like they have potential--but how else could it go? Is there a better way to design a study comparing on-meds and off-meds?

Wishydig said...

of course everyone is an individual. mr rogers told me so!

yes there would be a way of studying the variables. and there are ways of using meds as the independent variable. this study wasn't trying to do that of course.

but if a study did try, it might do something like a longitudinal study and track many patients, in many cities, being treated by many physicians and therapeutic approaches. it would keep track of the prognostic scores, genetics, comorbid disorders, how the patient presents the disorder in question (schizophrenia), age of onset, and all other variables that would make this a naturalistic and representative group.

when all has been accounted for, they would look at the data over several years and divide the cases into groups as many ways as possible. and they would look for any indication, that when all other things are equal, meds have some sort of effect on recovery that persists thru the categories set by other variables.

so patients with an early prognostic score of "N" would be split into med/non-med assessments…

patients with schizophrenic parents would be split into med/non-med…

patients who had post-adolescent onset would be split into med/non-med…

patients who were were schizophrenic AND epileptic would be split into med/non-med…

right? then the study would look at all subgroups and determine what difference meds are making to treatment.

and that's how the research on meds has gone so far. right now the research is showing that there is no measurable placebo effect for schizophrenia. and patients who relapse when they go off the meds have few options otherwise.

this study we're talking about has gone an important step forward, not in finding the limitations of meds, but in finding other tools for psychiatrists to use, and determining which forms of assessment have been reliable.

Casey said...

See I'm not going to continue blathering about this, because I can see that I haven't read enough. But, for me, this sentence tells a BIG story:

"[There is] no measurable placebo effect for schizophrenia."

Doesn't that maybe tell us something about the nature of the "problem?" Schizophrenics are unpersuaded by commitments that the rest of us hold with confidence. I bet Aspirin works worse on schizophrenics too.

Wishydig said...

kinda like those cancer patients are unpersuaded by commitments, right? that's why placebos don't work on them.

Casey said...

Really? -- there's no placebo effect in cancer patients? That sort of surprises me.

Casey said...

...and, when did they ever give placebos to cancer patients to test that? Ethics alert?

Insignificant Wrangler said...

Well, Plato did dismiss sophistry as a kind of drug. Which is funny, because Gorgias praised it for the same reason.

Casey said...

Makes me reconsider the old line from Marx about "religion is the opiate of the people."