Posts Tagged ‘ Psychopharmacology ’

New Issue – Viertelsjahrhefte für Zeitgeschichte

758035a810The latest issue of Viertelsjahrhefte für Zeitgeschichte contains at least one article that interests the readers of h-madness.

“Wendung nach Innen. Sozialpsychiatrie, Gesundheitspolitik und Psychopharmaka in der Deutschen Demokratischen Republik, 1960-1989” von Viola Balz und Ulrike Klöppel

Der Beitrag beschäftigt sich mit den Reformbemühungen in der DDR bezüglich der Psychiatrie zwischen 1960 und 1989. Aufgrund von bisher unausgewerteten Archivunterlagen des Gesundheitsministeriums sowie psychiatrischer Publikationen haben wir rekonstruiert, wie sich der Staat und die Psychiater bemühten, die psychiatrische Fürsorge zu verändern. Während der 1960er wurde einigen reformorientierten Krankenhausärzten ein gewisser Einfluss auf die Planung der psychiatrischen Fürsorge eingeräumt, der ab den 1970ern zugunsten einer Handvoll parteitreuer Psychiater eingeschränkt wurde. Um die Psychiatrie in Richtung rehabilitativer Formen der Fürsorge weiterzuentwickeln, förderten die Reformer psychotrope Medikamente, um die Patienten zu mobilisieren. Tatsächlich stellte sich heraus, dass diese hauptsächlich zu sedativen Zwecken eingesetzt wurden. Eine andere Maßnahme, um die psychiatrischen Anstalten zu leeren, war die Gesundheitserziehung. Damit wurde das Risiko, eine psychische Störung zu entwickeln oder dass sich eine Störung verfestigte, an die Eigenverantwortung der Staatsbürger delegiert.

Psychiatry’s Identity Crisis

American psychiatry is facing an identity crisis, writes Cornell psychiatrist Richard A. Friedman in a New York Times opinion piece published this week:

AMERICAN psychiatry is facing a quandary: Despite a vast investment in basic neuroscience research and its rich intellectual promise, we have little to show for it on the treatment front.

With few exceptions, every major class of current psychotropic drugs — antidepressants, antipsychotics, anti-anxiety medications — basically targets the same receptors and neurotransmitters in the brain as did their precursors, which were developed in the 1950s and 1960s.

Sure, the newer drugs are generally safer and more tolerable than the older ones, but they are no more effective.

To read the rest of this article, click here.

New Issue – Culture, Medicine, and Psychiatry

A new issue of Culture, Medicine, and Psychiatry is now available. Readers will find no “historical” articles but I think that the general topic The Anthropology of Psychopharmaceuticals will interest a lot of subscribers of this blog. To read the abstracts of this special issue, click here.

On the same topic, Somatosphere ran two months ago several excellent posts on Risperdal on trial by Kalman Applbaum.

Hans Pols: “Treating Mental Illness Before It Strikes”

As we have mentioned before, H-Madness publishes an essay every month for the online magazine Psychiatric Times.  We know, however, that many H-Madness readers do not subscribe to the magazine (although, it is free).  In order to be sure that you don’t miss any of the pieces there, we will be making a point of posting those essays and reviews here on H-Madness as well.  What follows is a commentary posted last month at Psychiatric Times, written by co-editor of H-Madness, Hans Pols.

Treating Mental Illness Before it Strikes

by Hans Pols

Hans Pols is senior lecturer at the Unit for History and Philosophy of Science at the University of Sydney. He is interested in the history of psychiatry and the mental hygiene movement in North America and Europe, psychiatric war syndromes, and colonial psychiatry, in particular in the Dutch East Indies.

Psychotic episodes are devastating for the individuals who have them, their friends, and families. Wouldn’t it be wonderful if individuals could receive treatment before the first psychotic episode strikes, so that it could be avoided altogether? After all, an ounce of prevention is better than a pound of cure. Unfortunately, in psychiatry, we are a long way from achieving primary prevention—there is no vaccine for psychosis, nor have clear genetic markers for severe and persistent forms of mental illness been identified. Throughout the twentieth century, psychiatrists have therefore focused their attention on the early detection of signs and symptoms of mental ill health, assuming that early treatment will stop conditions from becoming worse. However, the ideal of secondary prevention can only be realized if these early signs and symptoms, or a “pre-psychotic syndrome” can be identified successfully. During the twentieth century, psychiatrists have defined many of these “pre-mental illness syndromes”; unfortunately, it has not always been demonstrated that they indeed constitute the early phases of severe and persistent forms of mental illness.

In June 2011, a number of Australian newspapers reported that a high-profile medical trial targeting psychosis in young adults would not go ahead. It was to be conducted by Prof. Patrick McGorry, who had been Australian of the year (an honorary and mostly symbolic title bestowed by the Australian government on an unusually deserving citizen advocating worthy causes). In the proposed trial, youths as young as 15 would receive Seroquel when they were first diagnosed, not with psychosis but with attenuated psychosis syndrome (previously called psychosis risk syndrome). Treating young adults with this syndrome would nip the danger in the bud—their potential psychosis would be treated before it even arose. The trial was to have been sponsored by the drug’s manufacturer, AstraZenaca, which, like many pharmaceutical companies, was probably eager to test its medication on a younger age group to expand the market for its medications. What could be wrong with such a commendable initiative?

Attenuated psychosis syndrome is proposed for inclusion in DSM-V and has attracted an unusual amount of discussion (and dissent). In particular, its relation to psychosis is unclear. Emeritus professor Allan Frances, who chaired the task force which produced DSM-IV, is a fierce critic of the concept. According to him, there is hardly any evidence that attenuated psychosis syndrome, if left untreated, will ultimately develop into a full-blown psychosis (current estimates state that this will happen in merely 10 to 20% of cases). The number of “false positives” is therefore staggering. According to him, treating a group of individuals of whom 90% would never become psychotic appears to be a waste of resources and a rather risky proposition.

McGorry’s proposed trial was widely criticized by psychiatrists world-wide, raising a number of significant ethical problems. First, there is the high number of false positives who would receive medication for a condition they would never develop if left untreated. The trial would not target incipient psychosis but probably address more or less unrelated conditions. This leads to the second ethical problem: a great number of young people would therefore be put on a medication they do not need. This would not matter so much if only aspirin or vitamin tablets were tested. Unfortunately, Seroquel has many highly undesirable side-effects including extreme weight gain and diabetes. One should only prescribe it when it is absolutely necessary.

Last April, AstraZeneca settled a lawsuit by the U.S. government after allegations it paid kickbacks to doctors while promoting the drug for unapproved uses by children, the elderly, veterans and prisoners for $525 million (New York Times, July 28, 2011). It has also settled, for $647 million, product liability cases for misleading patients about the risks of diabetes and weight gain associated with the use of the drug. Total expenses in legal fees associated with Seroquel are now $1.9 billion, which constitutes less than five months of Seroquel sales. Not a great medication to prescribe to individuals who do not need it.

McGorry’s proposed research has attracted (unfavorable) media attention (in Australia); I highlight it here not because it is exceptional or unusual in any way, but instead because it illustrates ways of thinking that have been part and parcel of twentieth century psychiatry. The most important of these is the ideal of secondary prevention in psychiatry: it is imperative to treat psychiatric conditions when they first appear and when they are not as serious as they could become if left untreated. This prevents them from becoming worse and less responsive to treatment. This strategy is of course commendable when there is a proven link between these less serious conditions and more serious ones. In most cases, it has been assumed that such a link exists; it has hardly ever been demonstrated.

The emphasis on prevention is not unique to psychiatry but characterizes developments in several (if not all) medical specialties. In days long since gone, one would see a dentist when one’s toothache became unbearable—today, dentists fill cavities and polish our teeth so that we will never end up in this situation. They also whiten and straighten our teeth although this prevents neither toothaches nor tooth decay. Today, the demands we make of physicians (and dentists) far exceed those of average patients a hundred years ago. Today, physicians do a lot more than treating serious illness—and we expect them to do that.

Most historians of psychiatry have discerned two themes in the history of twentieth century psychiatry. First, there has been a broadening of the definition of what constitutes mental ill-health. A wide range of conditions in between mental health and severe and persistent forms of mental illness have been identified and investigated. The formerly almost absolute distinction between mental health and mental illness has been replaced by a wide spectrum of conditions, which has led to the blurring of the distinction between the normal and the abnormal. Second, conditions on this spectrum have increasingly become the target of psychiatric intervention; psychiatrists now treat a variety conditions less serious than severe and persistent forms of mental illness but definitely in need of treatment. During the twentieth century, prevention has been the most important argument to hold both themes together: treating less serious psychiatric conditions prevents these from becoming worse—because it has been assumed these conditions will inevitably become more serious over time. It was well into the twentieth century before any effective medical treatments for severe and persistent forms of mental illness were developed. Mental hospitals were severely overcrowded while little could be done for their inmates. Therapeutic nihilism reigned. Any type of intervention that promised to prevent mental illness from developing or becoming worse was therefore worth considering.

The blurring of the distinction between normal and abnormal is generally associated with Sigmund Freud: according to psychoanalysis, nobody is entirely normal, although some individuals are better in keeping their unconscious desires in check than others, thereby maintaining an appearance of mental health and normality. Despite differences in appearance, we are all to a certain extent mad. Views like these open up unexpected vistas for psychiatric attention: behind the everyday veils of normality, happiness, and adjustment hides psychopathology, lust, and perversion. Nevertheless, the blurring of the distinctions between the normal and the abnormal is not unique to psychoanalysis. The historian of psychiatry Elizabeth Lunbeck has analyzed (in The Psychiatric Persuasion, 1994) how, in the 1910s, American psychiatrists proposed psychopathy as a category to designate forms of psychopathology that had previously been unrecognized because they had been able to pass as normal. No longer would mental illness, as insanity, be limited to insane asylums, where it could be contained successfully. On the contrary, the widespread presence of psychopaths everywhere, hiding under the veil of normality, threatened the social fabric of American society. These views made psychiatric intervention even more compelling: not only would it remove sick individuals from public life, it could also protect the social order.

In my own work on the history of the mental hygiene movement, similar themes appear. In the 1920s, mental hygienists launched a major project on the treatment of juvenile delinquency to prevent children from developing life-long criminal careers. The concept of adjustment as an essential marker of mental health, central to the philosophy of mental hygiene, brought a great range of human behavior under the purview of psychiatry. Instead of treating maladjustment in adults (for example, adults with mental illness), mental hygienists argued that treating maladjustment in children (for example, children with enuresis or temper tantrums) would prevent serious forms of mental illness arising later in life. By labeling all forms of undesirable behavior as maladjustment, it became self-evident to expect relatively innocent forms of maladjustment to become serious forms of maladjustment later on. Rather than punishing delinquency, the therapeutic treatment of children with “pre-delinquent syndrome” could be expected to bear fruit. Unfortunately, the central assumptions of this approach were never put to the test, and would most certainly not hold up when investigated properly. Led by their convictions, psychiatrists and mental hygienists were not bothered by this. They focused on lesser complaints, while neglecting the plight of the mentally ill in increasingly overcrowded mental hospitals (leaving them to somatic psychiatrists who experimented with insulin therapy, metrazol shock therapy, ECT, and lobotomy).

The mistaken impression could arise that the two themes in the history of psychiatry identified thus far (blurring the distinction between normal and abnormal, and targeting less serious states for psychiatric intervention) were a characteristic of psychoanalysis or other psychiatric approaches focusing on mental and behavioral factors. It would be too easy to dismiss them because, with psychiatry becoming increasingly biological and scientific, such trends have been reversed today. Nothing could be farther from the truth, however. During the last twenty years or so, we see these trends developed in an unprecedented way in psychopharmacological psychiatry. In the 1950s, only individuals with severe and persistent forms of mental illness received medication such as Thorazine. Today, fidgety and distracted kids as well as shy adults are portrayed as individuals who could benefit from psychopharmacology. Increasingly, a wider range of psychiatric medications are prescribed to young children, with the idea that early intervention will prevent problems from getting worse. It is this mind-set, now more than a century old, that made McGorry’s research project appear innovative and cutting edge.

McGorry has introduced a slight modification to his study, which will now go ahead. Instead of Seroquel, he will now test the efficacy of fish oil.

Book Review – Robert Whitaker, Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America (Crown 2010)

By Michael Oldani

By an odd coincidence I was able recently to watch the end of One Flew Over the Cuckoo’s Nest on television, while I was reading the end of the script for Next to Normal – the winner of the 2010 Pulitzer Prize for drama.  This proved to be an interesting and disturbing juxtaposition that allowed me to ruminate on the state of modern psychiatry and mental health treatment.  In Cuckoo’s Nest we have a fictional representation of the ‘beginning of the end’: the end of the mental health institution as we knew it (coming out of its 1950s high/low points), and the beginning of the deinstitutionalization movement in the United States.  The lasting final image embodies this moment, that of “Chief” breaking out of the institution and wandering back into the unknown, on his own, and reclaiming his life outside the institution.

Next to Normal, which I recommend reading (or seeing), captures the current moment forty years after Cuckoo’s Nest was published.  The musical centers on Diana, a bi-polar mother, who struggles with medication, family relationships, and the meaning of her life. If Diana had been cast in Cuckoo’s Nest she easily would have been a permanent resident in the women’s ward of that institution, perhaps even suffering the lobotomized fate of Randle McMurphy (Jack Nicholas’s character in the movie).  Instead, Diana lives with her family on and off medication for over a decade, trapped between pharmaceutical cocktails, eager-to-prescribe psychiatrists, and unspeakable grief (the loss of an infant child).  So much for psychiatric progress.

Similar to Chief at the end of Next to Normal, Diana breaks free and goes off on her own, walking away from her family (at least for the time being).  For me interesting parallels emerged between Chief and Diana and the representation of mental health (care) in America.  In particular, neither individual perceives their “self” as mentally ill.  Chief is a victim of institutional racism and clearly is sane.  For Diana the question is less clear-cut, her symptoms and moods allow for functional and less functional days.  Nonetheless, these characters and the fictional worlds they inhabit direct our attention towards pathologies that have changed little over the last forty years.  They point us away from the inner pathology of the mentally ill person and towards outer pathologies; the sickness of society, institutions, experts, caregivers, and even psychotropic medication itself – the pharmakon of efficacy/toxicity.

What has happened to psychiatry over the last forty years? Why have deinstitutionalization, the DSM-revolution, the modern pharmacopoeia of psychiatric medication, and the emergence of bio-psychiatry as the dominant form of expertise not converged to significantly improve the lives of the mentally ill, or reduce “psychiatric disease” – as mental illness is increasingly referred to by bio-psychiatrists and neurologists?  Here is where I think Robert Whitaker’s Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America becomes a very useful explanatory text.  Whitaker uses his considerable skill as an investigative journalist (e.g., in-depth interviews; archival work; media/press analysis; and exegesis of the psychiatric literature) to help tell an important story about psychiatry, roughly covering the last sixty years.

One thing to keep in mind is that most mainstream psychiatrists would find this book too radical. They might lump it together with Thomas Szasz and Scientology, thus dismissing this critique as conspiratorial or as operating on the fringe. Whitaker astutely anticipates these types of dismissals of his research by showing how most critics of psychiatry in the 1960s and 1970s were indeed marginalized as part of Szasz’s anti-psychiatry movement and/or “the cult” of scientology – many clinician’s careers were irrevocably altered.

So what is so radical about Whittaker’s claim? His work is part of a growing body of literature that questions the pharmaceutical-first model of psychiatric disease management (see Marcia Angell for a two-part published review of these newer works, including Whitaker’s  Whitaker’s real success is to show readers how a psychiatric narrative of care has been constructed over time.  There are powerful stories being told about mental illness or psychiatric disease that have deep political and ideological roots. To put it another way, psychiatric science remains important if it fits with the dominant psychiatric story of our times.  And this powerful narrative is quite simple: psychiatric disease is caused by neuro-chemical imbalances in the brain with biological/genetic roots, which can be treated by psychiatric medication. He astutely shows through case studies how, for example, depression became a “chronic disease” (chapter 8), bipolar (II) became an “epidemic” (chapter 9 and 10), and in particular how children have become the new markets for psychiatric medication (chapter 11).

In my opinion Part Four of this text, “Explication of a Delusion,” is the most powerful and most damning.  Here Whitaker provides us with a cultural history of psychiatry’s conversion to the biological model (at any cost – including marginalizing the careers of psychiatrists that encouraged social psychiatry models or non-drug-first models).  Of particular interest to readers may be the role granting agencies, such as the NIMH, played in funding biologically/pharmaceutically oriented studies.

Whitaker does for mental healthcare history what Greene (2007) accomplished for the diabetes-lipid-hypertension triad in Prescribing by Numbers. We cannot just blame Big Pharma’s marketing machine. Instead, it takes real detailed historical investigations to unearth how public (mental) health research dovetailed with ideological transformations within psychiatry to provide fertile ground for a sea change in how we view and treat the mentally ill individual.

Yes, researchers in the early half of the 20th century “discovered” drugs that altered “mental states” in all kinds of patients.  These became psychiatry’s “magic bullets” (see Part Two: The Science of Psychiatric Drugs). However, after reading Whitaker, it becomes clear that the real magic happened afterwards when psychiatry, and a range of institutions, staked everything on the pharmaceutical model.

The challenge after reading Whitaker’s important contribution will be how to use it to make real changes in psychiatric care.  A recent exchange between Thomas Szasz and Edward Shorter in the journal “The Psychiatrist” exemplifies the ongoing divide and the challenges ahead. Both, in my opinion, have made important contributions to the history and critique of psychiatry.  Yet, Szasz remains too radical for Shorter, who dismisses most of Szasz’s essay.  In fact, Shorter, whose Before Prozac is a recent contribution to psychiatric critique, advocates for using the term “psychiatric disease” to stress biological causation of mental distress.  Szasz, like Whitaker, continues to push us to see the ideological, the political, and the cultural components to the current psychiatric narrative. And this narrative has real human effects – Whitaker takes pains in his opening chapter to point out the consequences of 1,100 people a day (a quarter of them children) being diagnosed as mentally disabled in the United States.  How can this be described as psychiatric progress?

Michael J. Oldani, Phd, MS is Associate Professor of Medical Anthropology at the University of Wisconsin-Whitewater. He also holds an adjunct faculty appointment in the Medical Humanities and Bioethics Program at Northwestern University School of Medicine.  He previously worked in the pharmaceutical industry during the 1990s.  His work focuses on the intersection of pharmaceuticals sales and marketing, medical care, and culture.  He is currently working on an ethnographic manuscript (Duke Press) entitled Tales from the Script: An Ethnography of Pharmaceutical Prescribing – 1989 to 2010.


Have American Psychiatrists Given Up on Psychotherapy?

Psychiatric Times recently featured two responses to a 5 March 2011 piece in The New York Times that outlined what it called “the switch from talk therapy to medications” among practicing psychiatrists in the United States.  The New York Times article cites a 2005 government purportedly finding “that just 11 percent of psychiatrists provided talk therapy to all patients, a share that had been falling for years and has most likely fallen more since. Psychiatric hospitals that once offered patients months of talk therapy now discharge them within days with only pills.”

Two psychiatrists and contributing writers to Psychiatric Times, however, expand upon and take issue with at least some of the portrait painted by the news story.   Ronald Pies (editor in chief emeritus of Psychiatric Times and professor in the psychiatry departments of SUNY Upstate Medical University and Tufts University School of Medicine) agrees that “the declining use of psychotherapy in psychiatric practice is unquestionably worrisome,” noting that the shift away from psychotherapy between 1996 and 2005 has coincided with changes in reimbursement, managed care, and medication prescriptions.  What The New York Times article neglected to mention, he argues, however, was that evidence shows that most psychiatrists provide psychotherapy to at least some of their patients.  Moreover, the 2005 study defined “psychotherapy” in such a narrow fashion as to leave out forms of “very brief psychotherapy” (J. Gustafson) as well as other forms of patient contact.

James Knoll IV (editor-in-chief of Psychiatric Times, and director of forensic psychiatry at SUNY Upstate Medical University), in his response, rejects what he refers to as “the implications that psychiatrists must now ‘play the game,’ and resign themselves to a bleak future of harried pill dispensing.” Instead, he encourages colleagues and students to consider taking up the historical mission of caring for those in institutional settings, albeit under the changed circumstances of today:

Many of our patients have been relocated. Jails now house more persons with serious mental illness than do psychiatric hospitals. Perhaps we might consider a return to the original ideals of our path–the care and well being of persons suffering with serious mental illness, and especially the many who are now in our ‘new asylums.’ The fact is that such jobs are plentiful, lucrative and rewarding. One can practice without any false partitions. Medical concerns, medications, psychotherapy-– all may be attended to by the psychiatrist. The patients are grateful for competent care, and time constraints are far less of an issue. Here is a noble calling and return to psychiatry’s roots. There is great honor in following this path that was originally traveled by names such as Rush, Ray, Pinel, and Menninger, among many others.

Keep in mind, you must register to read articles in Psychiatric Times, but registration is free.

Advertisements for Psychotropic Drugs in East Germany

"Papachin – for old age vertigo"

Going through some old boxes of notes, I came across the following:  a number of East German advertisements for stimulants, sleeping pills, and anti-anxiety medications.  The ads are all from the psychiatric journal Psychiatrie, Neurologie und medizinische Psychologie.  Unfortunately, I did not keep notes on the exact dates of the ads, but a few, at least, appear to be from around 1963.

For those interested, Director Volker Hess, Viola Balz, and Ulrike Klöppel at the Institute for History of Medicine in Berlin are presently conducting research on a project examining the manufacture, distribution and uses of psychotropic drugs in East Germany –“Psychochemicals Crossing the Wall: Die Einführung der Psychopharmaka in der DDR, 1952-1989.”

"Medication for sleeping and getting back to sleep – Dormutil"

"Fast acting – deep and peaceful sleep – waking without depression: Dormutil"

An ad for the stimulant "Aponeuron," comparing its effectiveness to caffeine

"Neuroton – for treatment of anxiety, tension, depressions"

– Eghigian

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