Showing posts with label OMGThat'sWhatTheySaid. Show all posts
Showing posts with label OMGThat'sWhatTheySaid. Show all posts

Suicide Immoral? WTF?

Guilty pleasure: Eavesdropping on psychiatrists talking with each other about us loonies. Like many guilty pleasures, it is not always good for my well-being. But I am endlessly curious. And it has yielded a number of blogposts in the OMGThat'sWhatTheySaid thread.

My go-to source for blog material is Psychiatric Times. It reports the latest news and research in Loony Land. It reflects on the practice of psychiatry. Sometimes it turns to mud wrestling. Oh, the good ol' DSM days!

A couple months ago, one of the editors, Ron Pies wrote a brave (foolhardy?) editorial inspired by Jennifer Michael Hecht's book, Stay: A History of Suicide and the Philosophies Against It. Intending to provoke, he titled it, Is Suicide Immoral?  Let the rumble begin.

Introducing Allen Frances

Allen Frances was the editor of the DSM-IV, first published in 1990.  He is now the fiercest critic of its next major revision, the DSM-5.  For over three years, he has been blogging weekly to this end at Psychology Today.  This week I will summarize his steady drumbeat.  I hope soon to publish an open letter to him.

Frances' complaint in a nutshell is that the DSM-5 creates fad diagnoses and changes criteria of older diagnoses to medicalize a whole range of normal behavior and miseries.  The link lists these problem diagnoses and a number of the following points, in an article published all over town last December.

These issues have been discussed widely, in public and private circles.  I am not qualified to address each point, though I did give a series over to one of them, the bereavement exclusion.  The best of the batch, if I do say so myself, is Grief/Depression III - Telling the Difference, which got quoted in correspondence among the big boys.

The Therapeutic Alliance - Or Not

My therapist asked, Does writing your blog help you overcome your trust issues with psychiatry?

Hah!  So she doesn't read my blog.

Not that I think she should.  Of all the many things about which I have strong opinions, whether care providers should google their patients is not one of them.  They can have that discussion among themselves.

Trust My Psychiatrist?

But her question started me thinking.  I trust my own psychiatrist.  How did that happen?  I tucked that question away for a future blog.

Then last September David Mintz wrote about Psychodynamic Psychopharmacology.  Psychodynamic psychopharmacology explicitly acknowledges and addresses the central role of meaning and interpersonal factors in pharmacological treatment.

One particular paragraph brought my therapist's question and my tucked away post back to mind:

The Prescriber and the Placebo Effect

An analysis of the data from a large, NIMH-funded, multicenter, placebo-controlled trial of the treatment of depression found a provocative treater x medication effect. While the most effective prescribers who provided active drug (antidepressant) had the best results, it was also true that the most effective one-third of prescribers had better outcomes with placebos than the least effective one-third of prescribers had with active drug. This suggests that how the doctor prescribes is actually more important than what the doctor prescribes!

Turned to the patient's perspective, if your meds don't work, maybe you don't need different meds.  Maybe you need a different doctor. 

That is not where David Mintz, MD went with this finding.  He cites research indicating that a strong therapeutic alliance is one of the most potent ingredients of treatment.  Well, an alliance has two partners.  But his article focused on just one side of the alliance, on patients, how our personal psychodynamics might interfere with treatment, (with a passing reference to countertransference in relation to overprescribing).  He pretty much ignored, as in, totally ignored the nature of the alliance.

Today I ask the question the way the patient would ask the question:

What helps me trust my doctor?

I didn't trust my first two psychiatrists.  I had very specific reasons.  When I told one of them that a particular behavior on her part had decreased my trust in her and damaged our relationship, she said, I don't do relationships.  I use pharmacology to treat psychological disease.

Well, I knew where I stood.

But I do trust my current psychiatrist.

I walked into her office predisposed not to trust.  Yes, I did.  I had so little expectation of being heard that I had laryngitis, literally.  Some of that distrust came from my own long-term issues, the psychodynamics of a trauma history.  I will own that.

Part of it came from my work on this blog, reading research articles, discovering the shoddy nature of some research design and unethical practices in publication, coming across the language that generated my OMGThat'sWhatTheySaid feature, disrespectful language, and reading case after case after case of unethical sales practices in the pharmaceutical industry, resulting in lawsuits and fines (not to mention neglectful prescribing practices and consequent harm to patients).

Part of it came from my experiences with those other two psychiatrists.

Mintz would put all this under the category negative transference.  Me, I would put some of it under the category of psychiatrists' behavior.

I can identify specific behaviors on the part of my current psychiatrist that helped me overcome this distrust.

Doctors Apologize?

The very first thing -- she apologized.  It was an institutional screw-up, not hers, that had me sitting in the waiting room for thirty minutes before our first appointment, not filling out paper work, not answering questions, just sitting, no explanation, silence.  But on behalf of the institution, she apologized.

Wow.  Like it mattered, the anxieties I went through during that half hour.  Like I had the right to be treated better.  Like I could expect that in this relationship, and there would be a relationship this time, I would be respected.

Ellen Frank wrote in Treating Bipolar Disorder, ...perhaps because many patients with bipolar disorder have had the great personal or familial success that often accompanies the energy and enthusiasms of bipolar disorder, a subset of patients with bipolar I disorder present with an entitled stance that is rarely seen in other outpatient populations [such as self-effacing unipolar] ... your IPSRT patients will sometimes expect that... you are never late for an appointment, that you never change or cancel...  sometimes there is nothing that can be done other than to apologize for this "affront."

That "affront," in quotes, confused me.  The notion that expectations about being on time come from a sense of entitlement confused me.  Oops -- that the doctor would be on time.  Me, when I am late or I cancel, I apologize, because I respect the doctor.  My new psychiatrist canceled once, is late occasionally.  Each time she apologizes.  I don't think she thinks I have a sense of entitlement.  I think she respects me.

Maybe Frank ought rather to be concerned about her self-effacing unipolar patients.  Maybe part of their depression is the habit of internalizing the disrespect of authority figures.

Respect As The Ground For A Therapeutic Relationship

Last October, John McManamy published a Mental Health Patients' Bill of Rights.  They included:

  • The Right to a psychiatrist who listens
  • The Right to a psychiatrist who values us as human beings
  • The Right to a psychiatrist who values our uniqueness as human beings
  • The Right to a psychiatrist who is committed to getting us well, not just stable.

I think "The Right to a psychiatrist who respects us" is the overarching category.  John's list includes actions and attitudes that proceed from respect.

If my doctor respects me, I can expect certain things to follow.  I can expect that the doctor has my interests at heart when handing me a prescription.  I can expect that the doctor will listen to, care about and remember my concerns, my values, my life outside the office, and the effect of treatment on that life.  I can expect that the doctor pays attention to the results of a particular treatment on me, specifically me.

These issues are important, because the treatments are powerful.  Whether or not they help, they sure can harm.  If my doctor respects me, I can believe that she will pay attention to the harm.

Then I can feel safe(r).  Then we can have a therapeutic alliance.

Next week -- more specific behaviors that demonstrate respect and build a therapeutic alliance.

flair from Facebook

OMGThat'sWhatTheySaid: 2010 in Review

Best Of... Worst Of...  The turning of the year is time for evaluation and new direction.  So here is a long ago promised review and ***competition*** for 2010's Readers' Choice Best/Worst/Whatever OMG Award.

The OMGThat'sWhatTheySaid Award was invented when I began reading what scientists say about those of us who have a mental illness.  It expanded to include media contributions to idiocy, offensiveness and outrage exhibited in language about mental illnesses and the people who have them.  The OMG Award allows me to reframe idiocy, offensiveness and outrage into irony -- granting an award for what ought to receive lashes across the backside.

I intended this to be a monthly award.  But, whatever.  I keep going on a tear with some series and lose track. -- I think this blog is charting my major hypomanic cycles?  Many months go by awardless.  So here are not twelve, but just four contenders.  The titles are links to the entire original posts.

September 12, 2010: OMGThat'sWhatTheySaid -- Noncompliance

The doctor tells you to weigh your costs and benefits before you take a medication, because it is your body, your decision.  The prescribing sheet says the doctor already weighed them for you.  If you decide differently than the doctor, then you are noncompliant, you uncooperative mental case, you.

July 23, 2010: OMG!!!That'sWhatTheySaid -- Failed Method/Successful Attempt

If we hang ourselves, or take pills, or jump off a bridge and yet we survive, then we have failed.  If we die, then we were successful.  Feel the love.

March 13, 2010: OMGThat'sWhatTheySaid! -- They

This one is more global.  I gave it to myself, and to any of us who are closeted mental cases, who think, quite accurately as a matter of fact, that if we acknowledge our mental illness, we will lose authority to talk about it.

December 26, 2009: OMGThat'sWhatTheySaid! -- Stigma

I know, this one reaches back to the previous year.  But it is still tragically timely and I am still flummoxed by the good doctor, Paul Steinberg, who thinks that the President should not send letters of condolence to the families of soldiers who commit suicide in a war zone.  (Staff Sgt. David Senft is the most recently reported example.)  Steinberg's reasoning? -- It might take away the stigma of suicide.  And with less stigma, more soldiers with mental illnesses might kill themselves.

So those are the contenders for the 2010 OMG Award.  Vote in the comments.  Feel free to lobby your friends to pad the count.

If you are curious about earlier monthly awards, they include:

November 15, 2009: OMGThat'sWhatTheySaid! -- Language

What they call us and what they call themselves determines the relationship.  The fact that they name the relationship means they have the power, regardless of the words they choose.  Provider/consumer is the new PC relationship, supposedly being more mutual than doctor/patient.  But I disagree.  It does not level the playing field.  It makes one active and the other passive.  What if we called ourselves customers?

September 4, 2009: OMG!!! That's What They Said! Significant

In common usage people think significant difference means a big difference.  Researchers think significant difference means large enough that the difference was not by chance.  (If it was a big difference, they would call it robust.)  Pharmaceutical companies sell a lot of drugs because you don't know the difference.

July 23, 2009: OMG!!! That's What They Said! Relapse

This one was about a research study designed to find out if they could cause relapse in women whose depressive symptoms were in remission.  Again, feel the love.

June 13, 2009: OMG!!! That's What They Said!

Here is the post that inspired the OMG feature, in which I discover a textbook that describes suicide as one of the unfortunate complications of major depressive disorder.

And In Conclusion...

I am always delighted to receive suggestions for new awards.  Let's say it together:

Thanks for reading Prozac Monologues.  Here's hoping I can keep it up in 2011.  You, too.

photo of trophy by Sebcaen and used under the GNU Free Documentation License.
image of whipping girl from La Grande Amie, in  public domain
flair from Facebook

OMGThat'sWhatTheySaid -- Noncompliance

Before I move to the costs side of Weighing the Costs and Benefits, I pause to consider the concept of noncompliance.

Noncompliance is not one of the best candidates for the OMG! Award, because I cannot point to specific usage -- it is ubiquitous.  On the other hand, it is precisely what this award is about, going to the heart of how language frames thought.  In this case, the word simultaneously names and creates a relationship between consumer and provider.

I don't particularly care for the terms consumer and provider when it comes to health care.  But I use them here, where they distinguish those who consume, literally put pills inside our mouths, from those who fill out those little slips of paper that provide the pills.  Providers replaces pushers, a term I used in a fit of pique last week.  This week, I have resolved to be more polite.

Consumers are told to weigh our costs and benefits.  When we comply with these instructions and, having done so, decide that the costs exceed the benefits, and therefore decide not to consume, then providers call us noncompliant.  What exactly is communicated here?

What is noncompliance, anyway?

I went to the dictionaries.

According to Webster's New World College Dictionary, noncompliant means failure to comply; refusal to yield, agree, etc. puts it this way: Noncompliance: The failure or refusal to comply: the failure or refusal to conform and adapt one's actions to a rule or to necessity.

Don't you hate it when one word is defined by another word that still needs to be defined?  I went back to Webster's, and got these alternatives. 

1: a -- the act or process of complying to a desire, demand, proposal or regimen, or to coercion; b -- conformity in fulfilling official requirements;
2 : a disposition to yield to others;
3 : the ability of an object to yield elastically when a force is applied.

So.  One has a desire, demand, proposal, regimen or official requirements, and may have access to force or coercion.  The other fails, refuses, or does not yield.  I wonder which is which? 

Scientists Study Noncompliance

Providers are disconcerted when consumers fail to consume, and spend a lot of time trying to figure out why.  By the way, this link goes to a review of literature by Alex J. Mitchell, a consultant and senior lecturer in liaison psychiatry at the Leicester Royal Infirmary in the United Kingdom, who receives no compensation from pharmaceutical companies.  I often link to reviews of literature.  Their authors read a jillion studies, including ones to which I do not have access.  Then they summarize the highlights of whatever consensus may have come from these studies.  Reviews of literature put a lot of information in one place.  Mitchell has 59 footnotes (okay, not a jillion -- I exaggerated), in case you want to look up the research behind a particular point.

So scientists speculate, do research, write articles, hold conferences and  train residents, all in efforts to increase compliance.  Their hypotheses about the causes of this behavior include inaccurate beliefs about medication, lack of insight into ones illness, lack of education in general, cognitive impairment, weight gain, sexual dysfunction, and poor patient/doctor relationship.

Mitchell even developed a flow chart to categorize the behaviors of patients: full, partial and excess adherence, intentional and unintentional non-adherence, for external or internal reasons, and various combinations of these.  Not telling your doctor that you have stopped taking your medication is called covert discontinuation, and in other places, covert noncompliance -- that word again, this time with the naughtiness of covert.

A friend noticed that Mitchell missed a category on his flow chart, the consumer who is compliant with other medications, but consistently, though inadvertently, forgets one particular medication that she thinks is the source of uncomfortable side effects.  That could be covert internal unintentional partial non-adherence.  Or would it be covert internal intentional partial non-adherence, covert here meaning that her intention is undisclosed to herself?  The flow chart matters, because having divided noncompliant consumers into subgroups, then they test different strategies to bring different subgroups back into compliance.

Some notice the non-PC nature of the word noncompliance.  While most articles I found use the term, occasionally, as in Mitchell, I come across non-adherenceNon-adherence is supposed to imply a mutual agreement between two parties about what the treatment regimen will be.  Other articles use the terms interchangeably, recognizing a fig leaf for a fig leaf.  After all, presumably the consumer and the provider have agreed together about the regimen to which the consumer will adhere.  Only notice, if the consumer does not adhere, then he/she has violated an agreement, or broken a promise.  Still naughty.

Matthew Keene, who serves as an adviser or consultant to GlaxoSmithKline, Cephalon and Pfizer, might have merited the OMG Award on his own, for Confusion and Complaints: The True Cost of Noncompliance in Antidepressant Therapy.  But why pick on just him, because, like I said, this language and weltangshauung (as they say in philosophy -- it means world view) permeates the literature?

Why Don't Consumers Consume Their Antidepressants? -- What the Providers Say

Mitchell cites a study indicating that 10% of those prescribed antidepressants never show up at the pharmacy at all.  Keene's figures are that 28% quit within the first month, 50% within 60 days, and only 28% are still in compliance at six months.  Keene asks, Why do patients prematurely discontinue antidepressants, medications that may improve and perhaps even save their lives?  His answer -- one of the 3 C's of noncompliance: confusion, costs, and complaints. 

Confusion, costs and complaints.  Notice that each of these is patient-centered.  He didn't say incoherent, financially foolish and picky.  But they are implied in the rest of the article.  Notice also that he did not describe the phenomenon from the patients' perspective.  He could have said inadequate communication, ineffective or intolerable medications and inaccessible health care and still preserved his clever alliteration.

Why Don't Consumers Consume Their Antidepressants? -- What the Consumers Say

What if patients wrote these articles, or were even consulted?  Actually, they have been consulted.

44% consumers who discontinue medication before their providers would like (the research calls it prematurely) say they did so because it made them sick, most commonly nausea, headache, drowsiness, and increased anxiety.  Well, duh.

I don't know.  Has it occurred to anybody besides me that we could solve this puzzle and put all that research time and money to better use if we gave the scientists a turn as the lab rats?

Another 44% consumers report that they discontinue because the medication is not effective.

That leaves 16% unexplained.  I will get back to them when I discuss costs more thoroughly.

I sorted through lots of these studies before it finally occurred to me to compare rates and reasons.  Noncompliance at six months is 72%.  Back to NIMH's STAR*D study, when trial subjects received compensation, free medical care, extensive information and regular support, antidepressants were ineffective for 50% of those who took them and intolerable for 16%, a total of 66%. -- That was the first trial.  By the third trial, medications were ineffective for 83% and intolerable for 26%, more even than the total.

What I want to know is just how many people take antidepressants when they make them sick and/or don't work anyway?  I personally know three.  Consistent with research findings, that better educated consumers are more compliant, these three have among them a BA, a Masters and a PhD.

Is there something going on here that is not about good medicine?

Rethinking Consumer Noncompliance

Psychiatrist Allan Showalter, Rethinking Patient Noncompliance, challenges the premises behind repeated and repeated research on noncompliance, a behavior which found across other diagnoses, not to mention life issues ranging from flossing to portfolio diversification, as well.  Here is the video of an Iowa Hawkeye football player on a motorcycle, one week before the game with our biggest rival.  A football player.  No helmet.  Despite repeated pleas of Kirk Ferentz, the Hawkeye coach.

I do recommend that you follow Showater's link for the novelty of his thinking.  One example: Nothing in [the definition of noncompliance] implies a moral obligation on the part of the patient to follow those recommendations or to the clinician who makes those recommendations to enforce them.


Yuval Melamed and Henri Szor, The Therapist and the Patient: Coping With Noncompliance, focus on the relationship between the patient and therapist as the source of noncompliance, rather than taking patients at their word.  On the other hand, they use a word that I did not find in any other article.

Countertransference.  Okay, ignoring the definition that includes the word transference, [again -- so irritating when dictionaries do that], Webster's defines countertransference as the complex feelings of the psychotherapist toward the patient.

Melamed and Szor think that noncompliance arouses reactions in therapists who feel that this behavior exemplifies a lack of trust in them and in the corpus of knowledge they represent.  I think that takes us part way there.

It is the therapist's job to manage the dynamics of countertransference in what is an unequal power relationship. That management would include not allowing the therapist's feelings toward the patient to misinterpret the patient's experience as hostility and thus misdirect the intervention.

I have not found evidence that providers of medication ever explore the impact of their own feelings on their treatment of consumers, at least in the arena of noncompliance.  Countertransference is a regular part of psychotherapists' training.  If it is ever mentioned in medical school, none of the literature gives evidence that the lesson sticks.

Weighing the Costs and Benefits -- Progress Report

Sorry about all the numbers in this post.  I have not found in the research any effort to measure the costs side of you have to weigh the costs and benefits that is not filtered through the concept of noncompliance.  So the algorithm will suffer from research that is compromised by its initial assumptions.  Thta is why we had to start with the OMG Award.

Next week, the Muppets will give us a break, while my brain does a bunch of number crunching.

drawing of dictionary in public domain
Adam and Eve by Albrecht Durer, in public domain
photo of Warren G. Harding in public domain
photo of woman pointing taken by David Shankbone,
used by permission under the Creative Commons 
remainder flair from facebook

OMG!!!That'sWhatTheySaid -- Failed Method/Successful Attempt

OMG!  it has been four months since I last gave an OMG! Award.  It's not that I don't keep finding excellent candidates.  It's just that I have been covering other major topics.  Plus, life just...

I am amazed and disappointed to give this month's award to for their July 22nd news release, Failed Suicide Method May Predict Likelihood of Successful Attempt.

First, let me introduce  From their website:

Health Central's mission is to empower millions of people to improve and take control of their health and well-being.
  • Our 35+ sites provide clinical resources and real-life support to those with life-changing conditions.
  • Our wellness resources and tools help people to live healthier, more fulfilled lives.
  • We are honored to serve over 12 million visitors each month.

Health Central addresses lots of different health issues, including mental health.  Often their information is excellent.  This time they missed the boat with this OMG Award-winning title to one of their featured articles.  They don't get points for originality.  They have repeated a much too popular -- what shall I call it?

Let me put it this way:

A twenty-seven year old woman is diagnosed with breast cancer.  Young women with breast cancer generally have a poor prognosis.  So she receives the most aggressive treatment available, including procedures that damage her body in ways that can be mended and other ways that cannot.  She undergoes intense pharmacological treatment using harsh chemicals that leave her sick, debilitated and at risk for other health complications.  Willing to try anything, she joins a support group, does mindfulness and visualization and changes her diet.

These measures eventually do work.  Her cancer goes into remission.  Her health is monitored carefully for a long time.  Just when she and her family begin to breathe again, she relapses.  Again, she opts for aggressive treatment, tries new drugs prescribed in off-label use, and again is left too weak to care for her children or leave the house.

This time, everybody's best efforts do not work.  She dies.

Does her doctor call that a success?  Does the preacher say she fought a long hard battle and finally succeeded?

Let me put it another way.

A middle-aged man has heart disease.  He gets regular medical attention, takes all his meds, monitors everything he is supposed to monitor, changes his lifestyle, even his job to reduce stress.

Nevertheless, he has a heart attack, in fact, several heart attacks.  Each time he is rushed to the hospital, where emergency personnel work their butts off to save him.  He is transferred to ICU, then to a regular bed, then to rehab.  His family posts frequent status reports on facebook, and his church prays for him every week.

Does anybody say he failed?  That he wasn't serious about these heart attacks of his?  When he returns to church or the golf course, do they turn their faces, afraid they might say the wrong thing and provoke another attack?  One that might be successful?

Mental illness is physical illness.  It has a mortality rate, just like cancer and heart disease.  We struggle desperately for years and undergo every treatment we can find and tolerate, trying to survive our illnesses.  Death by mental illness is not a success.  It is a tragedy.  Survival is not a failure.  When somebody has to be rushed to the hospital and manages to fight his or her way back to life, it is a hard won victory celebrated in heaven.  It ought to be celebrated on earth.  This person deserves a party.  With balloons.  And a cake.

Now let me pause to discuss the content of the article with this outrageous title, because the article does give important information.

The article reports research into the prognosis of suicidal individuals according to the method of self-harm they originally use.  The numbers are astounding.

Those whose initial act of self-harm takes the form of hanging, suffocation or strangulation have the poorest prognosis.  Of those who survive, 85% of them die at their own hand within a year.  They do not get it out of their system.  They die.  Within the year.  85% of them.

Those who jump, or use a firearm or drowning are at a moderately lower risk of subsequent death (69-78%, as reported in the original research.)  Those who use poisoning, overdose or cutting have the lowest risk of completed suicide with in year (25-36%.)

These figures hold true when controlling for diagnosis and for sociological factors.

That said, the single greatest risk factor for death by suicide is a previously survived episode.  Nobody gets it out of their system.

These findings have implications for aftercare.  Just as the most aggressive treatment is warranted for younger women with breast cancer and out of shape persons with heart disease, those whose original method of self-harm is hanging, strangulation or suffocation need the most intensive follow-up, monitoring and treatment.

Again that said, one potentially harmful consequence of this report is that those who use less lethal means, such as cutting or poison, may be dismissed as not serious, as engaging in attention-seeking behavior.

Yes, cutting and overdose are attention-seeking behaviors.  They are the serious attempts of seriously ill people to get serious attention for their serious condition.

Cutting and overdose have serious health consequences.  They are the methods used most often by Latina and African-American girls, who have less access to health care and mental health care anyway.  The consequences of not receiving the attention that these girls plead for are first, brain and liver damage, and then further deterioration of their lives, including dropping out of school, substance abuse, being continued victims of violence at their own hand or that of family and acquaintances, continued poor health choices and early death on account of all of the above.

If you turn your face from anybody who commits a potentially fatal act of self-harm by any means, you become the Scribe who turned his face from the man who was mugged, beaten and left for dead on the road to Jericho, because you count your agenda more important than that person's life.

As I said, this would be an unintended consequence of this article, and one that the author seek to avoid: However, "although use of more lethal methods of self-harm is an important index of suicide risk, it should not obscure the fact that self-harm in general is a key indicator of an increased risk of suicide," Hawton wrote.

Back to the OMG! Award.  I am on a Mission from God.  It is my mission, in whatever years I have remaining of my own life, permanently to eradicate the use of the word successful in the same sentence as the word suicide, and to eliminate the scandalous naming of survival as failure.

So I plead for your help.  I plead, when you hear a grieving friend or family member say that their loved one who died of mental illness was successful in the attempt, I plead that you tell that person, kindly and gently, Suicide is not a choice; it happens when pain exceeds resources for coping with pain.  I am so sorry for your loss, and so sorry that your loved one has lost the battle.

I plead that you, whenever you hear health care professionals refer to a failed attempt, that you feel and that you express your shock and horror at the words.  I plead that you confront them, and urge then to examine the hostility toward their patients and clients that lie beneath their words.

I don't usually inform people that they are winners of the OMG!!That'sWhatTheySaid Award.  Following what I have urged you to do, I will inform Health Central of their award.  Right now. 

OMGThat'sWhatTheySaid! -- They

"We are more alike than we are different."  That was the first thing they wrote on the whiteboard at my Peer to Peer class.  And that was the first thing I wrote in my new notebook.  I had a sense that a revolution was coming.  But I didn't know yet what it was.

The next week we introduced ourselves by how we are different, our differential diagnoses.  We were Mary Obsessive Compulsive Disorder, Frank Bipolar, Sarah Borderline Personality Disorder, Peter Bipolar Antisocial Schizoaffective Disorder ("But I'm not so sure the schizoaffective part is right"), James Schizophrenia, Anna Major Depressive Disorder, Henry Bipolar Alcoholic, Willa Major Depressive Disorder ("But I wonder about Bipolar II").  Of course, I have changed the names.

The power of naming -- the third week we sorted out our seating arrangements.  That wasn't part of the class.  It just happened, when we entered the room and chose our seats.  The OCDs sat with the OCDs.  The Mood Disorders sat with the Mood Disorders. Interestingly enough, those with Schizophrenia did not sit together.  They dispersed themselves among us Mood Disorders.

OMGThat'sWhatTheySaid! -- Stigma

On November 26th, the New York Times published an article about the presidential policy not to write letters of condolence to the families of service men and women who commit suicide in a war zone.  These letters of condolence have gone out since Abraham Lincoln started writing them during the Civil War.  Given the upswing of suicides in the Armed Services lately and the attendant publicity, this policy of silence, which began in the Clinton era, is coming under scrutiny and challenge.
In response to this article, psychiatrist Dr. Paul Steinberg wrote an Op-Ed commentary titled "Obama's Condolence Problem," winning him this month's OMG Award for -- oh, it's hard to choose.  There are so many prize-worthy lines.  But let's call it for: Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts. I will deconstruct this sentence after putting it in context.

Dr. Steinberg is concerned that any recognition of suicide, even the reporting of it, glorifies it and makes the taking of one’s life a more viable option. If suicide appears to be a more reasonable way of handling life’s stresses than seeking help, then suicide rates increase.

Dr. Steinberg is clearly in the voluntarist camp, believing that people make a conscious, reasoned choice to kill themselves.  Suicide, in his view, is an option, a way of handling life's stresses.  He is in, if not good, then plentiful company, who believe that even while the thought processes of those who commit suicide are impaired, their will is not. They remain responsible for their choice.

Regular Prozac Monologues readers know that I am not in the same company.  Dr. David L. Conroy gave me the words.  From Out of the Nightmare: Recovery from Depression and Suicidal Pain, "Suicide is not chosen; it happens when pain exceeds resources for coping with pain."

Conroy describes the many ways that people who are suicidal attempt to reduce their pain and save their own lives.  Those who are suicidal sometimes use the language of choice and reason.  Conroy, who speaks from personal experience, says it is terrifying to have such little control over our own emotional state that it can shove us headlong over the abyss.  This lack of control is part of, and adds to suicidal pain.  To claim that we have considered the options and are making a reasoned decision is a grasping for the image of control; it is an effort to relieve pain.

Steinberg asserts that choosing suicide over treatment is deserving of shame.  Now that first-rate treatments for depression and post-traumatic stress have evolved and are readily available, and people with emotional problems do not have to suffer quietly, are we taking away the shame of suicide?  When he decribes depression treatments as first-rate, he parts company with the National Institute of Mental Health and many doing research in the field, who acknowledge the true state of treatment.  At least a third of those who seek treatment are not able to find a medication that is effective and tolerable.  Meanwhile, certain side effects of these first-rate treatments themselves increase the risk of suicide, doubling it in the case of insomnia, a frequent side effect of SSRI's and SNRI's.  Akathesia (called "inner restlessness" on prescribing information sheets) is one of the most under-reported side effects, due to euphemisms, and among the five top risk factors for suicide among hospitalized patients.  [Side note: when you read "inner restlessness" on your prescribing sheet, did you realize that "inner restlessness" could significantly raise your risk of suicide?]

Steinberg believes that letters of condolence to family members could be an inadvertent incentive to suicide.  In light of the condolence-letter controversy, the administration is appropriately reviewing the policy that has been in place for at least 17 years — and may indeed want to consider leaving it as it is. But as a country, let’s focus our energies on doing everything we can to diminish inadvertent incentives that might increase self-inflicted deaths.  And elsewhere: We need to find the right balance between concern for the spouses, children and parents left behind, and any efforts to prevent subsequent suicides in the military.

I feel downright silly answering this argument.  But here it is:

First, the shaming of suicide is indeed one of the resources that we possess against it.  But it is an even more significant reason why people do not acknowledge and seek help for thoughts of doing it.  Shame interferes with willingness to report symptoms.  And failure to report symptoms is a significant factor in failure to recover.  To think that we can shame suicide and prevent it at the same time is fanciful. There is no balance to be found here.

Second, it is well known that surviving family members are themselves at greater risk of suicide.  Shame increases their pain, including their suicidal pain.  It is a barrier that prevents them from seeking support and prevents friends from offering it.  A letter from the President could go some distance in reducing the shame of family members and providing comfort in the midst of their pain.  If prevention of suicide is the goal, here is the most direct intervention the President could make.

Now back to the beginning.  Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts.  Putting to one side the impossibility of de-stigmatizing the second while stigmatizing the first, let's take a closer look at what Dr. Steinberg wants to de-stigmatize -- the help soldiers need.  What help would that be?  Psychiatry, leading the mental health professionals.

Steinberg wants to stigmatize suicide and de-stigmatize himself.  That's natural enough.  Nobody likes to be the object of stigma.  People who experience suicidal pain can identify with him in his desire. But I took a fanciful direction upon reading this op-ed piece.  I imagined Dr. Steinberg as a chaplain taking a course in Clinical Pastoral Education.  Are my clergy readers following me here?  Think back to your CPE experience.  Imagine the conversation in group after Dr. Steinberg says Indeed, there is nothing wrong with stigmatizing suicide while doing everything possible to de-stigmatize the help soldiers need in dealing with post-traumatic stress and suicidal thoughts.  Somebody from my CPE group would surely have asked, "How does it feel to be the object of stigma?"  And if he returned the question with a quizzical look, "How do you feel to know that people would rather commit suicide than come to you for help?  What does that mean to you personally?"

To my psychiatrist readers (do I have any?), do you have any training like CPE, where you are asked to examine your personal feelings and consider how they affect your judgments and your treatment of patients?  Does it include your judgments about suicide?  How do you feel about yourself when one of your patients commits suicide?   How do you feel about that patient, and the next patient with suicidal ideation?  Can you acknowledge those feelings?  Is shame part of your own experience?  Where have you put your shame?  Your feelings are just that, feelings.  Can you use them to inform your understanding of your patients?

I posted a facebook status last week with a link to Dr. Steinberg's article, asking, "Do patients with any other disease face such disrespect from their doctors?"  I am going out on a limb here.  But I wonder if many psychiatrists have not yet dealt with their feelings about their patients' dying.  When oncologists did, the treatment of cancer patients changed.  Now, who even remembers that cancer once was shamed?

OMGThat'sWhatTheySaid! -- Language

The following post contains material that could be considered uppity, outlaw, provocative, offensive and paranoid. 

This month's OMGThat'sWhatTheySaid Award considers the nature of the vocabulary that we all use for mental illness, in particular, the language that norms the relationship between those who receive a diagnosis and those who make it.

Once upon a time, I wrote a senior thesis for Reed College on this topic.  I was a religion major, and it was 1975, when the Episcopal Church was considering the ordination of women.  My topic was what priests are called.  My thesis was that the language we use establishes the normative relationship between priest and parishioner.  I am discouraged thirty-four years later, that new, freshly graduated priests in Iowa still permit and even encourage little old ladies to call these twenty-somethings "Father."  Oh well.

In the mental health field, this kind of paternalism is out of favor, perhaps the influence of so many women in the field.  But the language has not escaped from reinforcing the power relationship, one up and one down.

Weighing the Risks and Benefits - Will My Life Be Better?

"You have to weigh the risks and benefits."  That is what the doctor says.  It's your body, your decision, your responsibility.

But how do you weigh them?  There is that list of side effects.  They sound pretty scary, but the doctor assures you they are usually manageable.  Then there is the potential benefit of feeling better.  Well, that would be the gold ring, now wouldn't it?  Being able to get back to your family, your job, your life?

It's not a hard sell.  Reach out your hand and the pharmaceutical company will place in it that most precious of all commodities, hope.

Perverse little smarty pants that I am, after my hopes had been dashed six times, I started to read.  For four years I read journal articles about clinical studies.  The basic format begins with a measurement of depressive symptoms, usually the Hamilton Rating Scale for Depression, HAMD, depressed mood, suicidal ideation, sleeplessness, loss of appetite, etc.  You get points for severity.  Unlike your junior high math exam, the higher the score, the worse off you are.  In fact, if you ace this test, they will administer electric shocks to your brain (yes, I know, you will be unconscious at the time and won't feel a thing) until you forget how bad you feel and get a lower score.

So there are two groups, as alike as possible, Group A averages a HAMD score of 21.6, Group B's average is 22.1.  That's the mid range for moderately depressed, and the typical test subject score.  They don't include you in medical trials if you keep getting a high score, because now it's the medication that is being tested, and they want an audience that is easier to please.  Group A gets the medication being tried, Group B gets the placebo.  After 8 weeks, Group A's HAMD score is 8.2, Group B's score is 10.9, both in the mildly depressed range, but the difference is "statistically significant."  [That would depend on how big the sample is, and I am not doing the math.]  More people in Group A than Group B reached remission, a HAMD score of 6 or less.  A certain number dropped out because of side effects, so they don't count.  And there we have it.  The medication improves depressive symptoms by a statistically significant amount and is well tolerated, and you should get yours today.

But you know what?  That study with all its statistics did not answer your question.  Will you feel better?  Will you get your life back?  It told you what the odds are that your depressive symptoms would be reduced.  But that is not the same thing.  Not at all.

For example,the truck driver who is sad, not sleeping well, has no appetite, worries a lot and feels guilty is given Zoloft by his family practitioner.  Now he's eating better and is learning to put past sins behind him.  But he is too dizzy to drive, gets in fights with his friends and can no longer satisfy his wife, or even himself in bed.  So he decides to quit his meds.  The doctor is focused on his HAMD score and is very concerned, convinces him to try another med, then another.  But each time he gets the same side effects, and meanwhile has lost his job.

The truck driver has weighed the risks and benefits, asking is my life better? No, it isn't.  Let's hope his doctor knows that Cognitive Behavioral Therapy is often as effective as antidepressants for mild and moderately depressed people.  Ditto aerobic exercise, which could help his lose those extra pounds, improve how he feels about himself, and change the nature of what happens when they turn out the lights.

It turns out there are lots of psychological tests.  Many try to do what the HAMD does, and their inventors think that their tests do it better -- measure depressive symptoms.  But there is also a test that asks the real question: Are the lives of the people who take this medication better?  The Sheehan Disability Scale is a three question test, answered by the patient.  On a scale of 1-10, how much have the symptoms disrupted your work/school, your social life, your family/home responsibilities this past week?  It's simple.  It's easy.  It's what the people who are taking the meds want to know, will my life be better.  The people doing the research are focused on symptoms, not on the patient's life.  So that is how I read journal articles for four years and had never heard of the Sheehan Disability Scale (SDS).

For some reason, the clinical trials for Abilify decided to ask the patient's question, using the SDS.  Actually, they used seven different tests.  When the journal articles came out, they reported only one, the Montgomery-Asberg Depression Rating Scale (MADRS), a substitute for HAMD.  My September 4 post, OMG!! That's What They Said! Significant, reported its not particularly impressive, but FDA passable,  "statistically significant reduction in depressive symptoms."  The other test results disappeared.

But somebody noticed, and called them on it.  That is when I learned that the SDS even existed.  Why would they go to all the trouble of doing seven different tests, and then publish the results of only one?  Turns out that while says that "Clinical studies of adults with depression showed that adding ABILIFY to an antidepressant helped to significantly improve depressive symptoms compared to adults treated with an antidepressant alone," as far as the people who actually swallowed the stuff were concerned, it was a wash.  When you weigh symptoms and side effects, they reported that there was no improvement in their work/school life, a little improvement in family life.  But overall, it was a wash.

What was the author's response?  "Robert Berman from Bristol-Myers Squibb wrote... "this may be due to the lower sensitivity" of the measure."  I got that from "Abilify, Depression and the Memory Hole" at  Robert Berman, chief author of the research report, is not only an employee of Bristol-Myers Squibb, his compensation also includes stock options -- a little side note on how medical research is conducted in a for-profit health care system.

Okay, so the Sheehan Disability Scale is not sensitive enough to pick up what were pretty small decreases in depressive symptoms anyway.  That isn't its purpose.  What it will do is weigh your risks and benefits. Will Abilify improve my life, at work, at home, at play?  Nope.  Not if you are taking it for depression.  It won't.

What Prozac Monologues wants to know is what the Sheehan Disability Scale would tell me about Lamictal, the medication I have just added to my antidepressant instead of Abilify.  But as far as I know, nobody asked.

photo by Hans Anderson, This file is licensed under the Creative Commons Attribution ShareAlike 3.0

OMG!!! That's What They Said! Significant

"Clinical studies of adults with depression showed that adding ABILIFY to an antidepressant helped to significantly improve depressive symptoms compared to adults treated with an antidepressant alone."

Okay, first let me say that this is not "Pick on Abilify Month."  I usually wander the web, (not quite so intentional as surfing), for interesting little tidbits to share with my readers.  But at my last appointment, my doctor gave me a list and told me to do my research and pick one.  So for the last month, I have had a focus.

Abilify has long since been eliminated as the winner of this assignment.  But it is such a good example of so many of my interests, including the use of language (as in this monthly OMG!! feature), marketing and clinical trials, that I can't let it go.  In fact, it gets another post later this month.  Not because I am picking on it, but because, well, stay tuned.

I found the winning quote for the month's OMG contest, "...helped to significantly improve depressive symptoms..." at  It's the word "significant" that wins the award.  They really should share this award with many contestants, because that's what they all say, "significant."

The passage is found on the page intended for consumers.  So you would think they are speaking in the language that consumers speak.  This is not the case.  "Significant" in this sentence does not mean "significant" in the language that you and I speak.  The authors are referring to clinical trials, where the word "significant" is as significant as "toast," as in, "We are having toast for breakfast."  It is not significant enough to include as a facebook status update.  It is more like a twitter.  Though in FDA Land, it is the magic word, like "Open, Sesame", Sesame meaning big bucks.  So that is significant in the language that you and I do speak.  But I don't have a button for OMG Sesame!

At a University of Berkeley site, you can find the following definition:
Significance, Significance level, Statistical significance:  The significance level of an hypothesis test is the chance that the test erroneously rejects the null hypothesis when the null hypothesis is true.
And they wonder why we turn to Wikipedia? -- where it says:
In statistics, a result is called statistically significant if it is unlikely to have occurred by chance.

So here is the deal. is talking about their clinical trials, where people who were not responding to an SSRI or SNRI, one of the current crop of antidepressants, tried adding Abilify or placebo.  There are many interesting features about how Wyeth conducted these trials, and you will hear about them later.  The point is that they had to demonstrate to the FDA that those who took Abilify along with their antidepressant got better results than those who took the placebo.  If they could demonstrate that, the "effectiveness test," then they are part way toward approval for on-label usage, and a vast expansion of their market share, because there are a lot of us around who don't get better on the current crop of antidepressants, and more of us every day.  They also have to pass the "safety test" -- an issue for another day.

So how much better?  A "significant" amount.  And as I said, that does not mean what most people think it means, as in "I feel significantly better since I added Abilify to my treatment strategy."  Did you think that it did, when they said that "adding ABILIFY to an antidepressant helped to significantly improve depressive symptoms"?  It does not mean that at all.

So what does it mean?  There are several tests that researchers use to measure levels of depression.  One is the Montgomery Asberg Depression Rating Scale (MADRS).  This is a ten item scale that lets an evaluator rank your symptoms on a scale of 0 to 6, 0 meaning no symptoms, 6 meaning whale shit on the bottom of the ocean, to quote crazymeds.  Items include feelings of sadness, appearance of sadness, appetite, sleep, suicidal thoughts, etc.  Theoretically, you could get a total of 60 points, but that would put you out of the reach of clinical trials.  They don't let people that sick into clinical trials. They want to pass their clinical trials. So they go for a crowd that is easier to impress.

There were three clinical trials done for Abilify.  The results were consistent from one to the other.  So I will use just one as an example, the third, published in April, 2009.  172 people took a placebo along with their antidepressant.  They had a range of MADRS scores, and the middle score (the "mean") was 27.1, which is moderately depressed.  177 took Abilify with their antidepressant.  They also had a range of MADRS scores, with the middle score of 26.6, also moderately depressed.  There are a variety of small differences between these two groups.  In each case, those receiving the placebo were a lttle bit sicker, but as far as I know, not "significantly" sicker.  After six weeks, both groups had lower MADRS scores, meaning that both had reduced their depressive symptoms.  That is good news for both groups, from the patient's perspective.

Since the placebo group improved as well as the Abilify group, you could infer that some of the improvement came from the experience of being in a clinical trial itself, or maybe just from the passage of time, because people with depression do get better.  But the $64,000 question for Wyeth is whether there was a "significant" difference between the two.  And the answer -- ding,ding,ding -- is yes.  The placebo group reduced its score by 6.4 points, and the Abilify group by 10.1.  So the difference between the two was 3.7.  In the language of statistics, the probability that this difference of 3.7 points was due to chance is .1% -- one in a thousand.  If you get that score for two clinical trials, that's good enough for the FDA.  And they got it for three.

So isn't that significant?  Yes, if you are a statistician.  If you are a patient, if you are weighing the risks and benefits, then maybe yes, maybe not so much.  In a test with a possible score of 60, the difference between the two groups was less than four, or two questions that were answered just a little differently.  3.7 points on the MADRS scale means going from "looks miserable all of the time" to "appears sad and unhappy most of the time," and from "slightly reduced appetite" to "normal appetite."  Do you consider those two differences to be significant?  Is that what you expected when you read, "adding ABILIFY to an antidepressant helped to significantly improve depressive symptoms"?

I have to thank for helping me find the original research report.  In the next stage of the Abilify story, I will explore why these results, significant or not, did NOT impress the people who actually took the medication. 

OMG!!! That's What They Said! Relapse

"The goal of treatment was to maximize the number of patients achieving clinical remission because this would then render them eligible for the mood challenge." [italics added]

The winners of this month's Omgodthat'swhattheysaid Award are
Segal, Kennedy, Gemar, Hood, Pedersen, and Buis in "Cognitive Reactivity to Sad Mood Provocation and the Prediction of Depressive Relapse," Archives of General Psychiatry 63:7 July 2006.

They wanted to answer a question I asked in my last post, why does depression come back? Cognitive Behavioral Therapy (CBT) says that automatic negative thoughts cause depression. CBT is designed to make people aware of these thoughts, to interrupt and reframe
them. It is often as effective as antidepressants in treating mild and moderate depression, and better in terms of relapse rate. Nevertheless, people treated with CBT do relapse. One explanation is that CBT addresses the cognitive processes that dominate during a depressive episode, but there are underlying and ingrained thought processes that persist even in remission. Give people a list of adjectives, ask them which apply to them, and those who have been depressed but are in remission will nonetheless pick out more negative words than those who have never been depressed.

OMG!!! That's What They Said!

First, how did I ever start reading so much about depression, medication and the brain, the topics of Prozac Monologues?  Well, it was after I took two antidepressants that made me crazy and one that made me sad.  Then I was back in a psychiatrist's office, and she said, You have to weigh the costs and benefits.  And I took her seriously. 

But the information she gave me and that I found on the prescription information sheet wasn't very much information at all, not the kind that would have helped me when I was taking the antidepressants that made me crazy.  I knew this because I had read them, and they didn't help me.  I will write more about this some other time. 

The Language Of Doctors And Scientists 

Popular Posts