Are Psychiatrists playing us? Book claims studies show psych meds much less effective than claimed

[Otara]

Hentors point is that anecdotal data being supplied doesnt match up with scholarly data. Rather than being overprescribed, CDC data indicates only 50% of people qualifying for ADHD are actually being treated. This does not mean there might be individual areas where a doctor is overprescribing, but it does mean ‘overprescription as an industry’ isnt supported by that particular example unless other data is supplied.

The books case is interesting but makes some awfully large claims. I hope there are some rebuttals out to it soon so one can weigh the arguments.

We recently had a huge increase in access to low cost psychological counselling in Australia via Medicare, and the outcomes so far seem to be very poor in regards to outcomes regarding improvements in depression or anxiety ratings. There are a variety of reasons for this, but its an example of why I wouldnt put too much hope in that as the magic bullet alternative to pharmacotherapy.

Otara

[astro]

@Otara

We recently had a huge increase in access to low cost psychological counselling in Australia via Medicare, and the outcomes so far seem to be very poor in regards to outcomes regarding improvements in depression or anxiety ratings. There are a variety of reasons for this, but its an example of why I wouldnt put too much hope in that as the magic bullet alternative to pharmacotherapy.

Otara

If studies of drug and non-drug treatment methodologies for moderate mental issues show that non-drug methodologies have a better overall outcomes for individuals over time, the notion that pharmacotherapy should still, somehow, be the preferred default therapy, and non-drug therapy is the “alternative” therapy that has to prove itself is kind of strange. It’s amazing how powerfully ingrained the medicating model for mental illness is in modern American culture. People barely question it. It’s part of the cultural bedrock at this point.

[Hentor_the_Barbarian]

@astro

I think the main concern of the book is that the outcomes over time (to the extent these can be usefully compared across western cultures) for people with mental issues of moderate severity, do not seem to be better for target populations being treated with psycho-active drugs vs those treated with non-drug methodologies.

Again, please provide me with a cite that I can review.

Beyond this, I think there is a valid concern that we do not know enough about the effects of drugs on developing brains to be as insouciant as you appear to be about the effects of these medications on children.

Perhaps I disagree with the position taken by wild-eyed and deceptive “medical journalists” who misrepresent the evidence, and those who want to mindlessly repeat false claims. I don’t think doing so makes me care-free about concerns regarding what we don’t know. Perhaps being familiar with the evidence that we do have about the actual risks and side-effects of stimulant medications, and at the same time being very aware of the severity and breadth of impairing effects of ADHD (diminished academic performance and unnecessary frustrations, social impairments due to noxious interpersonal behaviors, risks for substance use, increased risks for accidents…), makes me concerned that false impressions about pharmacotherapy needlessly results in a portion of kids being prevented from receiving the best therapy. If that seems too cavalier to you, perhaps that’s too bad. I’ve just come to have my fill of bullshit.

That a mental health professional like yourself, who stands as something of a gatekeeper in determining appropriate therapies has this attitude is honestly kind of worrisome for people.

Being in that position, I’m quite pleased to be able to provide parents with information based in reality for them to make their decisions. If I had an attitude that I should reject the empirical evidence in favor of ill-formed internet fear mongering, that would actually be worrisome.

[Hentor_the_Barbarian]

@astro

If studies of drug and non-drug treatment methodologies for moderate mental issues show that non-drug methodologies have a better overall outcomes for individuals over time, the notion that pharmacotherapy should still, somehow, be the preferred default therapy, and non-drug therapy is the “alternative” therapy that has to prove itself is kind of strange.

You keep saying this. Please provide any evidence that I can review regarding this claim.

Please be aware that I am in agreement with the evidence regarding antidepressants.

[Kelby]

@Hentor_the_Barbarian

This one time a friend of a friend told me that none of the kids in her classroom were taking stimulant medications.

Actual data indicates that up to half (depending on the age group) of kids with ADHD were not currently taking stimulant medications. The CDC has a review and a nice bar chart for you: Learn About Attention-Deficit / Hyperactivity Disorder (ADHD) | CDC

Just because a lot of people say something on the internet does not mean that it is true.

I’m sure a large percentage of those children diagnosed with ADHD not taking medication have indeed taken meds in the past but have chosen to discontinue them due to intolerable side effects.

I’ve had a lot of kids tell me that the meds they take do in fact help them focus better in school, but never have had one tell me they like it otherwise or even want to take the medication. Most dislike the “off” feeling it gives them and look for opportunities to discontinue taking the drug.

[astro]

@Hentor_the_Barbarian

Again, please provide me with a cite that I can review.

Per the links in the article disussing the claims of the book regarding theraputic outcomes over time, here are some studies referenced by the book and the article.

Anatomy of an Epidemic" is the first book to investigate the long-term outcomes of patients treated with psychiatric drugs, and Whitaker finds that, overall, the drugs may be doing more harm than good. Adhering to studies published in prominent medical journals, he argues that, over time, patients with schizophrenia do better off medication than on it. Children who take stimulants for ADHD, he writes, are more likely to suffer from mania and bipolar disorder than those who go unmedicated. Intended to challenge the conventional wisdom about psychiatric drugs, “Anatomy” is sure to provoke a hot-tempered response, especially from those inside the psychiatric community.

Factors involved in outcome and recovery in schizophrenia patients not on antipsychotic medications: a 15-year multifollow-up study.

Abstract
This prospective longitudinal 15-year multifollow-up research studied whether unmedicated patients with schizophrenia can function as well as schizophrenia patients on antipsychotic medications. If so, can differences in premorbid characteristics and personality factors account for this? One hundred and forty-five patients, including 64 with schizophrenia, were evaluated on premorbid variables, assessed prospectively at index hospitalization, and then followed up 5 times over 15 years. At each follow-up, patients were compared on symptoms and global outcome. A larger percent of schizophrenia patients not on antipsychotics showed periods of recovery and better global functioning (p < .001). The longitudinal data identify a subgroup of schizophrenia patients who do not immediately relapse while off antipsychotics and experience intervals of recovery. Their more favorable outcome is associated with internal characteristics of the patients, including better premorbid developmental achievements, favorable personality and attitudinal approaches, less vulnerability, greater resilience, and favorable prognostic factors. The current longitudinal data suggest not all schizophrenia patients need to use antipsychotic medications continuously throughout their lives.

Antidepressant Drug Effects and Depression Severity

A Patient-Level Meta-analysis

Jay C. Fournier, MA; Robert J. DeRubeis, PhD; Steven D. Hollon, PhD; Sona Dimidjian, PhD; Jay D. Amsterdam, MD; Richard C. Shelton, MD; Jan Fawcett, MD
JAMA. 2010;303(1):47-53.

Context Antidepressant medications represent the best established treatment for major depressive disorder, but there is little evidence that they have a specific pharmacological effect relative to pill placebo for patients with less severe depression.

Objective To estimate the relative benefit of medication vs placebo across a wide range of initial symptom severity in patients diagnosed with depression.

Data Sources PubMed, PsycINFO, and the Cochrane Library databases were searched from January 1980 through March 2009, along with references from meta-analyses and reviews.

Study Selection Randomized placebo-controlled trials of antidepressants approved by the Food and Drug Administration in the treatment of major or minor depressive disorder were selected. Studies were included if their authors provided the requisite original data, they comprised adult outpatients, they included a medication vs placebo comparison for at least 6 weeks, they did not exclude patients on the basis of a placebo washout period, and they used the Hamilton Depression Rating Scale (HDRS). Data from 6 studies (718 patients) were included.

Data Extraction Individual patient-level data were obtained from study authors.

Results Medication vs placebo differences varied substantially as a function of baseline severity. Among patients with HDRS scores below 23, Cohen d effect sizes for the difference between medication and placebo were estimated to be less than 0.20 (a standard definition of a small effect). Estimates of the magnitude of the superiority of medication over placebo increased with increases in baseline depression severity and crossed the threshold defined by the National Institute for Clinical Excellence for a clinically significant difference at a baseline HDRS score of 25.

Conclusions The magnitude of benefit of antidepressant medication compared with placebo increases with severity of depression symptoms and may be minimal or nonexistent, on average, in patients with mild or moderate symptoms. For patients with very severe depression, the benefit of medications over placebo is substantial.
Author Affiliations: Departments of Psychology (Mr Fournier and Dr DeRubeis) and Psychiatry (Dr Amsterdam), University of Pennsylvania, Philadelphia; Departments of Psychology (Dr Hollon) and Psychiatry (Dr Shelton), Vanderbilt University, Nashville, Tennessee; Department of Psychology, University of Colorado at Boulder (Dr Dimidjian); and Department of Psychiatry, University of New Mexico School of Medicine, Albuquerque (Dr Fawcett).

[Triskadecamus]

I think it is indicative of something that there seems to be a very strong either/or philosophy about psychotropics. I had both types of therapy, and benefited specifically from the synergy of being able to invest in the not drug portions of my therapy precisely because the medications dramatically reduced the symptoms that had left me alone on the side of the road having tactile delusions of cutting myself to pieces.

Using drugs to interrupt destructive behaviors is certainly reasonable. Believing that the absence of the symptoms constitutes relief of the underlying emotional disorder is just plain stupid.

Tris

[Hentor_the_Barbarian]

Thanks for the links, astro. I think that the Harrow and Jobe paper is being misrepresented - I think it’s being described as a study of the outcomes of unmedicated schizophrenic patients. However, all of the people in that study were treated with pharmacotherapy at enrollment, and many of those at the 15 year time point who were not taking medications had taken them at some point between intake and the 15 year assessment point. What the study does find is that at the 15 year follow up, a higher proportion of those patients who were not prescribed medication at that point in time were in a period of recovery than those who were at that point prescribed medications.

It’s not a very impressive study, but if you want to draw interpretations from it, they would be that schizophrenia is episodic and that the severity and course varies across individuals. But think about it. If you follow up 15 years later with any group of patients for any problem whatsoever, which group would you expect to be in the midst of a period of better functioning - those being prescribed medications or those not being prescribed medications? A related question - why are people prescribed medications? Hopefully, and in actuality, people are more likely to be prescribed medications because they are experiencing impairing symptoms. If there’s a group not being prescribed medications at a given time, of course you should expect that more of them would be functioning better at that time than a group that is.

Now, if there are people who think that permanent and enduring pharmacotherapy for schizophrenia is mandatory, this study would provide some corrective feedback.

However, if you think that this study proves that more people with schizophrenia would do better if they were never prescribed medications, it does not come close to saying that. Furthermore, if we were going to draw that conclusion, I would need to see a study with more than 64 participants with schizophrenia, would need to see a comparison to a group that actually never received medications, and would need to see an analysis that examined their relative functioning over time, rather than at one point in time. Show me how symptoms change over time for randomly assigned groups who differ on medication status.

[Hentor_the_Barbarian]

@Triskadecamus

I think it is indicative of something that there seems to be a very strong either/or philosophy about psychotropics. I had both types of therapy, and benefited specifically from the synergy of being able to invest in the not drug portions of my therapy precisely because the medications dramatically reduced the symptoms that had left me alone on the side of the road having tactile delusions of cutting myself to pieces.

This is very much like the description I give to parents about ADHD medications - it only makes sense that if you are having severe problems focusing, concentrating, remembering and so on and so forth, that you are going to have a bit harder time making good use of the other therapy you are getting. This is also very consistent with the evidence from the MTA study, a very large well designed study which convincingly showed that kids with ADHD got the most rapid benefit from a combination of pharmacotherapy and behavioral therapy.
[/QUOTE]

[astro]

@Hentor_the_Barbarian

Now, if there are people who think that permanent and enduring pharmacotherapy for schizophrenia is mandatory, this study would provide some corrective feedback.

However, if you think that this study proves that more people with schizophrenia would do better if they were never prescribed medications, it does not come close to saying that. Furthermore, if we were going to draw that conclusion, I would need to see a study with more than 64 participants with schizophrenia, would need to see a comparison to a group that actually never received medications, and would need to see an analysis that examined their relative functioning over time, rather than at one point in time. Show me how symptoms change over time for randomly assigned groups who differ on medication status.

With respect to schizophernia (and I assume some other mental diseases) this is really the chicken and the egg as you note below.

A related question - why are people prescribed medications? Hopefully, and in actuality, people are more likely to be prescribed medications because they are experiencing impairing symptoms. If there’s a group not being prescribed medications at a given time, of course you should expect that more of them would be functioning better at that time than a group that is.

Now, if there are people who think that permanent and enduring pharmacotherapy for schizophrenia is mandatory, this study would provide some corrective feedback.

The US medical and psychological establishment is very quick to medicate even low level mental issues compared to some other advanced western nations. The outcomes over time don’t seem to indicate this drug centric treatment paradigm is all that much more effective over time for patients with moderate symptoms.

The notion that some patients moderate levels of schizophrenia can get better, or possibly reduce to the level that the symptoms are personally manageable without medication as you age is kind of interesting, and something I have never heard much about. My US based layman’s view of schizophrenia is that it’s a chronic, lifelong disease that may ebb and flow but always needs medical, drug based intervention on some level.

Schizophrenia

Coordinated by the World Health Organization and published in 2001, The International Study of Schizophrenia (ISoS) was a long-term follow-up study of 1633 individuals diagnosed with schizophrenia around the world. Of the 75% who were available for follow-up, half had a favourable outcome, and 16% had a delayed recovery after an early unremitting course. More usually, the course in the first two years predicted the long-term course. Early social intervention was also related to a better outcome. The findings were held as important in moving patients, carers and clinicians away from the prevalent belief of the chronic nature of the condition.[161] A review of major longitudinal studies in North America noted this variation in outcomes, although outcome was on average worse than for other psychotic and psychiatric disorders. A moderate number of patients with schizophrenia were seen to remit and remain well; the review raised the question that some may not require maintenance medication.[162]

A clinical study using strict recovery criteria (concurrent remission of positive and negative symptoms and adequate social and vocational functioning continuously for two years) found a recovery rate of 14% within the first five years.[163] A 5-year community study found that 62% showed overall improvement on a composite measure of clinical and functional outcomes.[164]

World Health Organization studies have noted that individuals diagnosed with schizophrenia have much better long-term outcomes in developing countries (India, Colombia and Nigeria) than in developed countries (United States, United Kingdom, Ireland, Denmark, Czech Republic, Slovakia, Japan, and Russia),[165] despite antipsychotic drugs not being widely available

[seanchai]

It would be illuminating to hear what some of the medical doctors on this board have to say about this topic.

I work in an inpatient psych ward. The majority of our patients are depressed, or bipolar, or schizophrenics. Some come back again and again; some we never see again.

The reasons why this drug or that treatment works or does not work are many and varied. Oh the stories …

Doctors - what say you??

[Otara]

Its not unknown for people to improve over time with psychiatric conditions, in itself this isn’t a controversial concept. In Australia at least, Ive seen many people drop in medication over time, and it for it to be a common part of treatment. Part of what complicates this is more caution about diagnoses that are older - a 60 year old person who was diagnosed with schizophrenia or bipolar at 20 might receive a very different diagnosis now for instance.

Generally the people most strongly encouraged to stay on medication for the longer term are the people who have had repeated and serious relapses in the past, generally including dangerous or being at risk of dangerous behaviour. And of course there are stuff-ups, with people being over and under medicated, misdiagnosed, etc, ‘good’ hospitals’ and ‘bad’ hospitals, like with medicine in general.

Its not unknown for people to deteriorate as well as improve as they age, the tricky bit is predicting who is going to do what. The book claims to have the answer and quotes its favourite institutions. I hope they do have improved methods but would want more evaluations and data about those places from other sources before making a decision.

With this book, single studies in particular directions are being quoted for a particular diagnosis without any other studies being mentioned that might suggest alternatives or complications, which is one reason to be dubious as its pretty rare for areas like this to have single ‘unarguable’ results. Perhaps it does do that more balanced work in the book, because we’re only getting the ‘best’ quotes in the reviews being linked.

One example would be that I looked up the developed vs non developed country schizophrenia study and it said 8% of developed country people were dead at 13 year follow-up vs 11% for less developed, which hopefully also puts into context how serious this condition can be and the risks that non-treatment can involve.

What does this large increase in mortality mean? Is the price for better outcomes more people dying sooner for instance? Or are the outcomes being complicated by the worst cases simply being less likely to survive? The study also found that people in less developed countries did better even when both groups were treated, which suggests its probably not simply a case of worse treatment regimes in the West, but something a bit more complicated.

The study doesn’t argue to know why the outcomes were better and acknowledged that its an area of great debate, rather than making the ‘obvious’ conclusion ‘people are being over-treated in the West’ that the book makes.

Issues like these are known to the people researching these areas, and why people get irritated when books publish these ‘hidden’ studies and these ‘clear findings’ suggesting semi conspiracy arguments rather than outlying the complications that go into evaluating research data and treatment recommendations.

None of this is particularly new really, the debate about ‘overdiagnosis’ and ‘over-treatment’ has been raging since Szasz, and ongoing changes occur as some arguments are supported, and sometimes reversed again as well when new findings come up as the new ‘improved’ regimes are put to the test.

So its a question of what the overall evidence base supports for future research, as opposed to the conclusion of one book which has a clear drum to beat and a great selling angle. I really do hope it does have a few new strong cases to make, and it improves the state of the art, but I wont be holding my breath.

Otara