South West Psychiatry

The Art of Psychiatry

Qrd — Sat, 09 Jul 2011 10:26:13 +0000

http://www.artofpsychiatry.co.uk/

The Art of Psychiatry society has been formed to explore the shared elements between the arts and psychiatry.

Many psychiatrists have a strong interest in the creative arts and this informs their practice. Both psychiatrists and creative artists are concerned with exploring human behaviour and motivation, and come to the subject of the mental disorder from different viewpoints and with different narratives. For instance the language creative artists and psychiatrists use to record or express psychopathology is totally different but equally valid.

The society will hold bimonthly meetings. If you have a suggestion for one of our meetings please contact us.

Filed under: Fun Tagged: art

Antidepressant-Induced Chronic Depression Has a Name: Tardive Dysphoria

Qrd — Sun, 03 Jul 2011 12:28:12 +0000

http://www.psychologytoday.com/print/68229

Now Antidepressant-Induced Chronic Depression Has a Name: Tardive Dysphoria

By Robert Whitaker

Created Jun 30 2011 – 9:35am

Three recently published papers, along with a report by a Minnesota group on health outcomes in that state, provide new reason to mull over this question: Do antidepressants worsen the long-term course of depression? As I wrote in Anatomy of an Epidemic, I believe there is convincing evidence that the drugs do just that. These latest papers add to that evidence base.

Although this concern first surfaced in the late 1960s and early 1970s, when a handful of psychiatrists expressed concern that antidepressants were causing a “chronification” of the disorder, it was in 1994 that Italian psychiatrist Giovanni Fava, editor of Psychotherapy and Psychosomatics, urged the field to directly confront this possibility. He wrote: “Within the field of psychopharmacology, practitioners have been cautious, if not fearful, of opening a debate on whether the treatment is more damaging [than helpful] . . . I wonder if the time has come for debating and initiating research into the likelihood that psychotropic drugs actually worsen, at least in some cases, the progression of the illness which they are supposed to treat.”

In subsequent papers, Fava set forth a biological explanation for why this may be so. Psychiatric drugs perturb neurotransmitter pathways in the brain, and in response to that perturbation, the brain undergoes a series of compensatory adaptations in an effort to maintain normal functioning of those systems. In scientific terms, the brain is trying restore its “homeostatic equilibrium.” Fava has dubbed this compensatory response to a psychiatric drug “oppositional tolerance.”

For instance, a selective serotonin reuptake inhibitor (SSRI) blocks the normal reuptake of serotonin from the synaptic cleft, which is the tiny gap between neurons. Serotonin now stays in the cleft longer than normal, and feedback mechanisms immediately kick into gear. The presynaptic neurons begin putting out less serotonin than usual, while the postsynaptic neurons—the neurons receiving the message—decrease the density of their receptors for serotonin. The drug is acting as an accelerator of serotonergic activity; the brain responds by putting down the brake.

When Fava first raised this issue in the 1990s, several American researchers wrote that this was a valid concern, which needed to be investigated. One who did so was Rif El-Mallakh at the University of Louisville School of Medicine. He has periodically revisited this issue, and in a paper published in the June issue of Medical Hypotheses, he provides an overview of “emerging evidence that, in some individuals, persistent use of antidepressants may be pro-depressant.”

El-Mallakh’s Overview

In the early 1990s, El-Mallakh notes, only about 10% to 15% of patients with major depressive illness had treatment-resistant depression (and thus were chronically ill.) In 2006, researchers reported that nearly 40% of patients were now treatment-resistant. In a period when use of SSRI antidepressants exploded, refractory depression went on the march.

This condition, El-Mallakh writes, often develops in people who had a good initial response to an antidepressant, and then continue taking the drug. However, up to 80% of patients maintained on an antidepressant suffer a recurrence of symptoms, and once that “initial treatment response is lost,” continued efforts to treat the relapsed patient with antidepressants frequently results in “poor response and the rise of treatment-resistant depression.” Ultimately, this process—the continual prescribing of antidepressants to someone who has become treatment resistant—may “make the chronic depression permanent.”

In his discussion, El-Mallakh notes that people without any history of depression who are prescribed an antidepressant for other reasons—anxiety, panic disorder, or because they are serving as “normal controls” in a study—may become depressed, with that depression at times persisting for a fairly long period of time after the antidepressant is withdrawn. The reason that antidepressants may have a “prodepressant effect,” El-Mallakh writes, is that “continued drug treatment may induce processes that are the opposite of what the medication originally produced.” This is the “oppositional tolerance” that Fava has written about, and this process may “cause a worsening of the illness, continue for a period of time after discontinuation of the medication, and may not be reversible.”

This same basic mechanism—oppositional tolerance to a psychiatric drug—has been proposed to be a cause of tardive dyskinesia (TD), which develops with some frequency in long-term users of antipsychotic medications. TD is characterized by repetitive, purposeless movements, such as a constant licking of the lips, which is evidence that the basal ganglia has been damaged by the drugs. Although various explanations for TD have been put forth, one thought is that it is caused by drug-induced dopamine supersensitivity. Antipsychotics block dopamine receptors (and in particular, a subtype known as the D2 receptor), and in compensatory response, the brain’s neurons increase the density of their D2 receptors, and thus become “supersensitive” to this neurotransmitter. That may lead to the constant firing of neurons controlling motor movement (such as tongue movement), and even when the offending antipsychotic is withdrawn, TD symptoms often remain, which suggests that the brain is unable to renormalize its dopaminergic pathways.

With antidepressants, the problem may be that patients, because of the “oppositional tolerance” process, end up with a depleted serotonergic system. The postsynaptic neurons end up with a reduced density of receptors for serotonin; in rat studies, long-term treatment with an SSRI led to markedly reduced levels of serotonin in “nine areas of the brain.” El-Mallakh, in his paper, details several other ways that exposure to an SSRI may deplete serotonergic function, and notes that in experiments with young animals, such impairments are “associated with increased depressive and anxious behaviors.”

In conclusion, El-Mallakh writes that “a chronic and treatment-resistant depressive state is proposed to occur in individuals who are exposed to potent antagonists of serotonin reuptake pumps [i.e. SSRIs] for prolonged periods. Due to the delay in the onset of this chronic depressive state, it is labeled tardive dysphoria. Tardive dysphoria manifests as a chronic dysphoric state that is initially transiently relieved by — but ultimately becomes unresponsive — to antidepressant medication. Serotonergic antidepressants may be of particular importance in the development of tardive dysphoria.”

Another Side of Oppositional Tolerance

El-Mallakh detailed how tardive dysphoria may develop in patients who initially respond to an antidepressant and then stay on antidepressants long term. But what if patients respond well to an antidepressant and then stop taking the drug? Their brains have been modified by exposure to the antidepressant (i.e. oppositional tolerance has developed), and thus, upon withdrawal of the drug, are they more likely to relapse than if they hadn’t been exposed to an antidepressant in the first place?

This is the question investigated by Paul Andrews and his collaborators at Virginia Commonwealth University in a report that was published online this week inFrontiers in Evolutionary Psychiatry. In the study, Andrews compared relapse rate for patients who remitted while on placebo during the initial phase of a study and then remained off-drug during a follow-up period (placebo-placebo group) with the relapse rates for patients who remitted while on an antidepressant during the initial phase of a study and who were then withdrawn from the drug during the follow-up period (drug-placebo group.) He hypothesized that the drug-exposed patients, because of oppositional tolerance, would have a higher rate of relapse, and he found that to be true. In a meta-analysis of 46 studies, he determined that the relapse rate for the placebo-placebo group was 24.7%, compared to 44.6% for the drug-placebo patients.

Next, Andrews teased apart the relapse rates by antidepressant type. His hypothesis was that the relapse rate upon drug withdrawal would increase according to the drug’s potency. For instance, SSRIs increase serotonin levels much more than tricyclics do (and thus are more potent in that regard), and Andrews reasoned that the strength of the brain’s “oppositional tolerance” response to an SSRI would be greater than it was to a tricyclic. Then, when the antidepressant is withdrawn, the “oppositional forces” that have arisen in response to the drug operate unopposed, and thus the greater the oppositional forces, the greater the risk of relapse.

Andrews uses this metaphor to explain this process: “As one pulls a spring from its equilibrium position, the spring exerts an oppositional force that attempts to bring the spring back to equilibrium; the more one displaces the spring from its equilibrium position, the greater the oppositional force that the spring produces. Similarly, antidepressants with greater perturbational effects should trigger stronger oppositional forces that attempt to bring [neurotransmitter] levels back to equilibrium. The buildup of oppositional tolerance under antidepressant treatment could then cause the system to overshoot its equilibrium upon discontinuation, and the degree of overshoot should be proportional to the perturbational effect of the antidepressant.”

In his meta-analysis, Andrews found that the risk of relapse does indeed vary according to the potency of the antidepressant. The greater the potency, the greater the risk of relapse. This finding, he concludes, is consistent with the idea that the drugs induce an “oppositional tolerance,” and that this change puts patients at increased risk of relapse upon drug discontinuation.

Length of Initial Exposure to Antidepressant May Affect Relapse Rates

The next question raised by this “oppositional tolerance” model is this: Does it, in any way, become more pronounced over time, such that the risk of relapse upon drug withdrawal increases? The findings from a French study of more than 35,000 patients, which were published in Pharmacopsychiatry, suggest that it may. The French investigators studied patients treated with an antidepressant for an “index” episode of depression who then subsequently stopped taking the medication for at least two months. The researchers then looked at whether those patients—after that two-month period had lapsed—subsequently started taking an antidepressant again, as this was seen as a marker for relapse.

The French scientists found that those who initially took an antidepressant for less than one month before withdrawing were less likely to relapse than those who took an antidepressant for two to five months. Those who were exposed to an antidepressant for longer than six months had more than twice the risk of relapse compared to those exposed for less than one month (as measured by a subsequent return to the use of antidepressants.)

The French investigators didn’t consider whether this higher risk of relapse could be due to a biological change triggered by the antidepressants. Indeed, it could be that those who took an antidepressant longer the first time around were more severely ill. But another possible explanation is that “oppositional tolerance” changes induced by an antidepressant become more pronounced over time, which would then increase the risk of relapse upon drug withdrawal.

Clinical Ramifications

As is now well-documented, in the clinical trials of SSRIs, the drugs did not provide a significant clinical benefit compared to placebo for patients with mild-to-moderate depression. Given this absence of benefit, the review by El-Mallakh and the findings by Andrews and the French scientists provide a compelling rationale for not prescribing an antidepressant to first-episode patients with this severity of depression.

According to El-Mallakh’s review of the literature, if patients respond well to the antidepressant and then stay on the drug indefinitely, they are at high risk of eventually suffering a recurrence of symptoms (even while on the drug.) Once that happens, the patient is at significant risk of becoming chronically depressed. Yet, if patients respond well to an antidepressant and then withdraw from the medication, Andrews’ study shows they are at a higher risk of relapse than if they had gotten better on placebo. In addition, the French study suggests that this risk of relapse may increase with time on the drug before withdrawal. But if a patient does indeed relapse and then goes back on an antidepressant, that person may now be on a path that leads to chronic illness.

In other words, initial exposure to an antidepressant—because of this drug-induced “oppositional tolerance”—can often lead to a poor long-term outcome. In contrast, people who remit on placebo have not undergone “oppositional tolerance” brain changes, and thus may have a much better long-term prognosis.

Minnesota’s Glum Report on Depression Outcomes

The STAR*D trial, which was funded by the NIMH, provides evidence of how, in our modern SSRI era, depression runs a very chronic course. Once Ed Pigott and otherscarefully parsed the STAR*D data, it became known that only 108 of the 4041 patients who entered the trial remitted, and then stayed well and in the trial during the yearlong follow-up. All of the other patients either failed to remit, relapsed, or dropped out.

Now comes a report from MN Community Measures, a non-profit organization in Minnesota, which gathers data health outcomes in that state. In 2010, they reported that only 5.8% of the 23,887 patients treated for depression were in remission at the end of six months, and that only 4.5% were in remission at the end of twelve months. In other words, 95% of the patients in Minnesota with major depression now appear to be chronically ill.

What Next?

The historical context for these dispiriting results is this: In the 1960s, at the start of the antidepressant era, experts in this disorder regularly wrote that depression was an episodic disorder, which could be expected to clear up with time. As Dean Schuyler, head of the depression section at the NIMH explained in a 1974 book, most depressive episodes “will run their course and terminate with virtually complete recovery without specific intervention.” In 1969, George Winokur, a psychiatrist at Washington University, made the same point: “Assurance can be given to a patient and to his family that subsequent episodes of illness after a first mania or even a first depression will not tend toward a more chronic course.”

But now here we are 40 years later, with perhaps ten percent of American adults taking an antidepressant, and researchers are writing about “oppositional tolerance,” and drug-induced “tardive dysphoria.” That is surely a health outcomes story that needs to investigated, and if we want to put this into an even sharper moral context, we need only consider this: Many teenagers are now being prescribed an antidepressant, and when they take the drug, their brains will develop “oppositional tolerance” to it. What percentage of these youth will end up with drug-induced tardive dysphoria, and thus suffer a lifetime of chronic depression?

Filed under: Articles Tagged: depression, medication

Prescription Drugs Associated with Reports of Violence Towards Others

Qrd — Wed, 22 Jun 2011 10:04:46 +0000

PLoS ONE: Prescription Drugs Associated with Reports of Violence Towards Others.

Prescription Drugs Associated with Reports of Violence Towards Others

Thomas J. Moore¹^*, Joseph Glenmullen², Curt D. Furberg³

1 Institute for Safe Medication Practices, Alexandria, Virginia, United States of America, 2 Department of Psychiatry-Cambridge Hospital, Harvard Medical School, Cambridge, Massachusetts, United States of America, 3 Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, United States of America

Abstract

Context

Violence towards others is a seldom-studied adverse drug event and an atypical one because the risk of injury extends to others.

Objective

To identify the primary suspects in adverse drug event reports describing thoughts or acts of violence towards others, and assess the strength of the association.

Methodology

From the Food and Drug Administration (FDA) Adverse Event Reporting System (AERS) data, we extracted all serious adverse event reports for drugs with 200 or more cases received from 2004 through September 2009. We identified any case report indicating homicide, homicidal ideation, physical assault, physical abuse or violence related symptoms.

Main Outcome Measures

Disproportionality in reporting was defined as a) 5 or more violence case reports, b) at least twice the number of reports expected given the volume of overall reports for that drug, c) a χ2 statistic indicating the violence cases were unlikely to have occurred by chance (p<0.01).

Results

We identified 1527 cases of violence disproportionally reported for 31 drugs. Primary suspect drugs included varenicline (an aid to smoking cessation), 11 antidepressants, 6 sedative/hypnotics and 3 drugs for attention deficit hyperactivity disorder. The evidence of an association was weaker and mixed for antipsychotic drugs and absent for all but 1 anticonvulsant/mood stabilizer. Two or fewer violence cases were reported for 435/484 (84.7%) of all evaluable drugs suggesting that an association with this adverse event is unlikely for these drugs.

Conclusions

Acts of violence towards others are a genuine and serious adverse drug event associated with a relatively small group of drugs. Varenicline, which increases the availability of dopamine, and antidepressants with serotonergic effects were the most strongly and consistently implicated drugs. Prospective studies to evaluate systematically this side effect are needed to establish the incidence, confirm differences among drugs and identify additional common features.

Filed under: Articles Tagged: minimum medication, news, psychiatry

Audio Q&A – Robert Whitaker – “Anatomy of an Epidemic”

Qrd — Wed, 22 Jun 2011 09:52:11 +0000

Audio Q&A – Robert Whitaker – “Anatomy of an Epidemic” | Need to Know.

Manufacturing mental illness

By Alexandra Nikolchev

June 29, 2010

Are the drugs used to treat mental illness working? Research shows that the number of people on government disability due to a mental illness has gone up dramatically, rising from 1.5 to over 4 million in the past 20 years. Need to Know asks Robert Whitaker, author of the recent book, “Anatomy of An Epidemic,” about his analyses of scientific studies and what they mean for the future of mental healthcare in this country.

Filed under: Articles Tagged: news, psychiatry

Anatomy of an Epidemic – Wikipedia, the free encyclopedia

Qrd — Wed, 22 Jun 2011 09:48:06 +0000

Anatomy of an Epidemic – Wikipedia, the free encyclopedia.

From Wikipedia, the free encyclopedia



Author(s)	Robert Whitaker
Original title	Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America
Publisher	Crown Publishing Group
Publication date	2010
ISBN	978-0-307-45241-2
Dewey Decimal	616.89

Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs, and the Astonishing Rise of Mental Illness in America is book by Robert Whitaker published in 2010 by Crown.^[1]^[2]^[3] Whitaker asks why the number of Americans who receive government disability for mental illness approximately doubled since 1987.^[4] He tries to answer that question and examines the long-term outcomes for the mentally ill in the U.S. In April 2011 IRE announced that the book had won its award as the best investigative journalism book of 2010 stating, “this book provides an in-depth exploration of medical studies and science and intersperses compelling anecdotal examples. In the end, Whitaker punches holes in the conventional wisdom of treatment of mental illness with drugs.” ^[5]

Synopsis

Magic bullets

Number of Americans who received SSDI and SSI for mental disability in 1987 (blue) when Eli Lilly and Company introduced the antidepressive drug Prozac, compared to 2003 (red).

Whitaker begins by showing that the antipsychotics, benzodiazepines and antidepressants were discovered as side effects during research for antihistamines (specifically promethazine), gram negative antibiotics (specifically mephenesin) and the anti-tuberculosis agents isoniazid and iproniazid respectively. The psychiatric mechanisms of action of these drugs were not known at the time and these were initially called major tranquilizers (now typical antipsychotics) due to their induction of “euphoric quietiude,” minor tranquilizers (now benzodiazepines) and psychic energizers (now antidepressants) due to patients “dancing in the wards.”^[6] These compounds were developed during a period of growth for the pharmaceutical industry bolstered by the 1951 Durham-Humphrey Amendment giving physicians monopolistic prescribing rights and followed the industry’s development of “magic bullets” that treat people with, for example, diabetes. It was not until many years later, after the mechanisms of these drugs were determined that the serotonergic hypothesis of depression and dopaminergic hypothesis of schizophrenia were developed to fall in line with the drug’s mechanisms. According to Whitaker’s analysis of the primary literature lower levels of serotonin and higher levels of dopmine have proved to be true in patients WITH prior exposure to antidepressants or antipsychotics but NOT in patients without prior exposure.^[7]^[8]^[9]^[10]^[11]^[12]^[13]^[14]^[15]^[16]^[17]^[18]^[19]^[20]^[21]^[22]^[23]

So far there is no clear and convincing evidence that monoamine deficiency accounts for depression; that is, there is no ‘real’ monoamine deficit.

– Stephen Stahl, Essential Psychopharmacology^[24]

Psychiatric drugs

While Whitaker is pro-drug, he believes that medication must be used in a “selective, cautious manner. It should be understood that they’re not fixing any chemical imbalances. And honestly, they should be used on a short-term basis.”^[25] He finds the idea that the “invention of [the antipsychotic] Thorazine” emptied asylums to be a myth.^[26] He traces the effects of what looks like an iatrogenic epidemic^[27]—unfortunately, the drugs that patients receive can perturb their normal brain function.^[28]

Whitaker suggests that the “wonder drug” glow around the second generation psychotropics has long since disappeared. He views the “hyping” of the top-selling atypical antipsychotics as “one of the more embarrassing episodes in psychiatry’s history, as one government study after another failed to find that they were any better than the first-generation anti-psychotics”.^[29]

Whitaker can only offer as a “solution” the style of care documented by professor Jaakko Seikkula at Keropudas Hospital in Tornio in Lapland where drugs are given to patients only on a limited basis—with good outcomes. According to Whitaker, the district has the lowest per capita spending on mental health of all health districts in Finland.^[30]

Children

Whitaker sees that children are vulnerable to being prescribed a lifetime of drugs. As the author says, a psychiatrist and parents may give a child a “cocktail” to force him or her to behave. Then when this child grows up to eighteen, Whitaker says he or she becomes a disabled adult.^[31]

Review of data and statistics

Over the year and a half he spent researching this book,^[28] Whitaker thoroughly reviewed U.S. government statistics and evidence in the scientific literature.^[32] He maintains a website where the scientific studies are linked.^[33]

Reception and media coverage

Whitaker, who was a finalist for the 1998 Pulitzer Prize for Public Service and is an award-winning^[34] author and a former director of publications for the Harvard Medical School, did interviews with Salon and The Boston Globe during the release of this book.^[25]^[35] He also did a book tour, and he spoke for an hour and a half on C-SPAN where there is an archived video.^[36] Still, in his book he explains that this story was never told in mainstream newspapers.^[37] For example, Whitaker says a study of long-term outcomes for people with schizophrenia done by Martin Harrow in 2007 (which Whitaker thinks is the best work ever done on the subject in the U.S.) was never in a National Institute of Mental Health press release and thus never reached reporters at U.S. newspapers.^[38]

As of October 2010, the only negative review of the book, written by sleep researcher Dennis Rosen for The Boston Globe, asks for a review of data, and devotes a paragraph to Thabo Mbeki and AIDS denialism.^[39] Other reviews were in New Scientist,^[2] The Record,^[3] Time magazine,^[1] and Salon.^[25]

Controversy

Whitaker, who had been an invited keynote speaker, was “uninvited” from the Alternatives 2010 conference. The event has been funded since 1985 by the Substance Abuse & Mental Health Services Administration of the United States Department of Health and Human Services. MindFreedom International started an online campaign and many people wrote to President Obama. Whitaker was reinvited and delivered his address.^[40] However a psychiatrist, Dr. Mark Ragins, was added to the program to rebut Whitaker.^[41]

Filed under: Articles Tagged: medication, psychiatry

Report Documents Psychiatrists’ Corrupt Practices

Qrd — Wed, 22 Jun 2011 09:39:17 +0000

Alliance for Human Research Protection – Confidential Expert Witness Report Documents Psychiatrists’ Corrupt Practices.

Confidential Expert Witness Report Documents Psychiatrists’ Corrupt Practices

Wednesday, 15 June 2011

“From the start, the [Tri-University Schizophrenia Practice Guidelines] project subverted scientific integrity, appearing to be a purely scientific venture when it was at its core, a marketing venture for Risperdal.”

The case filed against Johnson & Johnson by Allen Jones and the State of Texas was recently postponed until November. But some of the documents from the case are now publicly available at the Travis County, Texas courthouse.

The confidential Expert Witness Report by Dr. David Rothman of Columbia University (March 22, 2011), is the most damning document that we’ve seen in which not only is J & J’s “detestable” conduct–as described by Judge Couch who presided over the court decision against J & J in South Carolina–laid bare, but Rothman’s report also describes the shameless active collaboration by prominent academic psychiatrists–including the Chairman of the DSM-IV.

The prominent academic psychiatrists who were paid by Johnson & Johnson to formulate the Tri-University Guidelines are: Dr. Allen Frances, Chairman of the Dept. of Psychiatry, Duke University; Dr. John P. Docherty, Professor and Vice Chairman of Psychiatry, Cornell University; and David A Kahn, Associate Clinical Professor of Psychiatry, Columbia University; who took the lead in designing and developing the Tri-University Guidelines as a marketing strategy designed to elevate their then new so-called, Atypical Antipsychotic, Risperdal, to first-line treatment.

The report describes how these prominent psychiatrists developed commercially driven prescribing algorithms that they helped masquerade as legitimate, science-based medication prescribing guidelines.

“Not only were Frances, Docherty, and Kahn ready to violate standards of conflicts of interest in mixing guideline preparation with marketing for J&J, but also in publicizing the guidelines in coordination with J&J. The three men established Expert Knowledge Systems [EKS]. The purpose of this organization was to use J&J money to market the guidelines and bring financial benefits to Frances, Docherty, and Kahn.

Dr. Rothman’s report states that the 1995 Tri-University Schizophrenia Practice Guidelines was the first of subsequent psychotropic drug prescribing guidelines formulated by prominent academic psychiatrists at the behest of Johnson & Johnson. The best known of these Guidelines was the Texas Medication Algorithm Project (TMAP), which adopted the Tri-University Guidelines en masse.

Excerpt describing the inception of the Tri-University Guidelines, page 14: [link]

“As one of its first activities, and in disregard of professional medical ethics of principles of conflict of interest, in 1995 J&J funded a project led by three psychiatrists at three medical centers [Duke, Cornell, and Columbia] to formulate Schizophrenia Practice Guidlines. From the start, the project subverted scientific integrity, appearing to be a purely scientific venture when it was at its core, a marketing venture for Risperdal. In fact, the guidelines produced by this project would become the basis for the TMAP algorithms, giving a market edge to the J&J products in Texas.

Three psychiatrists, Dr. Allen Frances, Chairman of the Department of Psychiatry, Duke University, Dr. John P. Docherty, Professor and Vice Chairman of Psychiatry, Cornell University and David A Kahn, Associate Clinical Professor of Psychiatry, Columbia University, took the lead in designing and developing the Tri-University Guidelines. The project would employ three questionnaires to establish the guidelines: one went to academic experts, one to clinicians, and one to policy experts. Including the third group was in all likelihood J&J’s idea as witness to the fact that Frances wrote J&J: “This is new to us and requires additional discussion. The panel members would include mental health commissioners, community mental health directors, NAMI representatives, experts in pharmacoeconomics, and so forth.”

These were precisely the constituencies that J&J was eager to influence. J&J was the exclusive supporter of the project, dividing an “unrestricted” grant of $450,000 among the three schools. It further agreed to a $65,000 bonus incentive payment if the team was timely with its product. The team met the requirement, requested the additional payment, and received it.

The guideline team promised wide distribution of its product, including publication in a journal supplement. The team was prepared to have J&J participate in its work, not keeping the company even at arms length. With a disregard for conflict of interest and scientific integrity, the group shared its drafts with J&J. On June 21, 1996, Frances wrote Lloyd: “We are moving into the back stretch and thought you would be interested in seeing the latest draft of the guideline project… Please make comments and suggestions.” So too, the group was eager to cooperate with J&J in marketing activities. Frances wrote without embarrassment or equivocation: “We also need to get more specific on the size and composition of the target audience and how to integrate the publication and conferences with other marketing efforts.”

Indeed from the start J&J had made it apparent to the team that this was a marketing venture. In a letter to Frances, Lloyd set forth what he called an “aggressive time line” for the project, and added: “There are a number of other Treatment and Practice Guidelines for schizophrenia being developed or published during this same period that may well serve our marketing and implementation needs at a substantial lesser cost.”

“Not only were Frances, Docherty, and Kahn ready to violate standards of conflicts of interest in mixing guideline preparation with marketing for J&J, but also in publicizing the guidelines in coordination with J&J. The three men established Expert Knowledge Systems [EKS]. The purpose of this organization was to use J&J money to market the guidelines and bring financial benefits to Frances, Docherty, and Kahn.

EKS wrote to Janssen on July 3, 1996 that it was pleased to respond to its request to “develop an information solution that will facilitate implementation of expert guidelines.” It assured the company: “We are also committed to helping Janssen succeed in its effort to increase its market share and visibility in the payor, provider, and consumer communities.” Now that the “first phase” was completed, with guidelines created, “EKS is now ready to move forward in a strategic partnership with Janssen.” The strategy will allow Janssen to influence state governments and providers… Build brand loyalty and commitment with large groups of key providers around the country.”

EKS also promised “rapid implementation,” with particular attention to having an impact on Texas decision making. “It is our intent to work with the State of Texas immediately in implementing this product in a select number of CMHC’s with the assistance of A. John Rush, MD.” Again, EKS emphasized: “It is essential for Janssen to distinguish Risperidone from other competitors in a timely and creditable way.” In its Summary of the document, EKS wrote: “Your investment in the development of state of the art practice guidelines for schizophrenia is already beginning to pay off in terms of positive exposure in the Texas implementation project.”

The costs for these various activities included: $250,000 for “educational conferences;” and dissemination of publication at $177,659. J&J agreed to them. So all told, J&J paid at least $942,659 on the production and marketing of the Tri-University guidelines.

The report is posted at: http://boringoldman.com: pp.1-20; pp. 21-42; pp.43-65 ; pp. 66-86

Filed under: Articles Tagged: medication, news, psychiatry

Mental health services in crisis | The Guardian

Qrd — Mon, 20 Jun 2011 21:13:40 +0000

Mental health services in crisis over staff shortages | Society | The Guardian.

Mental health services in crisis over staff shortages

Exclusive: Royal College of Psychiatrists warns society will be overwhelmed if ministers fail to fill gap

Dinesh Bhugra, the outgoing president of the Royal College of Psychiatrists, says British doctors are not training as psychiatrists and those from abroad cannot fill the gap.

Professor Dinesh Bhugra, the outgoing president of the Royal College of Psychiatrists, told the Guardian that widespread failures in inpatient care for mentally ill people meant many hospital wards did not meet acceptable standards and discharged back into society sick people who remained a risk to themselves and others.

Bhugra blamed the problem partly on a “dangerous vacuum” created because British doctors are not training as psychiatrists, while visa restrictions mean doctors from abroad can no longer fill the gap.

“Society will be overwhelmed by the demand of those in need if government doesn’t act now,” he said in an interview.

A survey by the royal college found that 544 consultants’ posts in the UK – 14% of the total – are either unfilled or filled by a locum. In addition, 209 consultants intend to retire or resign soon, a situation exacerbated by the government’s cap on immigration from outside the EU.

“This is a huge, a massive problem,” said Bhugra. “We will be left with a dangerous vacuum of help for people with mental health disorders or will be forced to get special dispensation from the government to recruit heavily from countries who can ill afford to lose their mental health professionals.”

His warnings are supported by a study to be published next week in which the royal college describes how about half of patients – mostly women – report feeling unsafe in many of worst-performing hospital trusts. The report also says:

• Average bed occupancy rates in English inpatient units are much higher than the 85% standard, with some wards running at 120% occupancy.

• Access to psychological therapies falls far short of acceptable standards recommended by the National Institute for Health and Clinical Excellence and other health bodies.

• Daily one-to-one contact with nursing staff is less than that accepted as being conducive to recovery.

• Outreach links into the community are insufficient in two-thirds of the wards inspected by the royal college’s centre for quality improvement.

Bhugra said the failure of wards on the 85% bed occupancy rate was particularly troubling. The report reveals that more than half of all adult general wards run at more than 100% occupancy, with 16% meeting the required target. Just 21% of acute wards meet the 85% target.

“Very high bed occupancy militates against quality and safety of inpatient care,” Bhugra said. “It is a main driver of inpatient care standards. [High bed occupancy] can result in patients becoming more distressed and unwell, and likely to need more longterm care.

“Given the continued reduction in bed numbers and increased community care over the past decade, inpatient units have become places for crisis stabilisation and are likely to admit only those individuals who are the most disturbed, distressed or unwell. For such people especially, as they are unable to make the choice to leave, the ward is their home.”

The report also reveals that wards are failing to provide separate sleeping and toilet facilities for men and women, despite gender-segregated accommodation having been government policy for a decade. Just 85% of wards have segregated sleeping accommodation and less than 60% have separate lounges. “This remains an intractable problem,” said Bhugra.

Several dozen psychiatric patients take their own lives while in NHS care every year. Mental health charities such as Rethink claim this shows that care needs to be improved and staffing levels boosted.

Rethink spokeswoman Rachel Whitehead said: “Psychiatric wards are not a therapeutic environment. Many people tell us they don’t feel safe there and they are not getting access to the support and therapy they need. Supervision is also a problem, largely due to overstretched staff and wards which are over their occupancy levels.”

Another research paper by the college, to be published next month, shows that the number of medical graduates who accepted an offer of psychiatry training posts in England and Wales fell from 184 in 2009 to 158 in 2010. Bhugra said “dangerously few” doctors train as psychiatrists because the specialism suffers from a poor reputation compared with other medical disciplines. “It is wrongly seen as less scientific,” he said.

Professor Peter Jones, head of the neuroscience department at Cambridge University, admitted the lack of psychiatry applications was a “terrible state of affairs”. He said the formation of specialist mental health trusts had made psychiatry “seem more remote from mainstream medicine”. He also said stigma “is a huge problem for people with mental health disorders and trickles into professional lives.”

Wards are also failing to provide structured therapeutic activities, the royal college report finds, with 35% of patients complaining of too little to do during weekdays, rising to 54% in the evenings and at weekends.

Bhugra said: “The value [of this] cannot be overestimated. A lack of regular activities can lead to boredom, frustration and inactivity, which not only impede recovery but also can instigate unsafe, violent and erratic behaviour. Inpatients may be experiencing paranoia, be easily over-stimulated and sometimes frightened and disorientated.”

Bhugra criticised wards for falling short in standards of security, risk management, violence prevention and management, medicines and confidentiality.

The report highlights evidence revealing that in the worst-performing 20% of trusts, only 50-60% of patients said they felt safe. Overall, less than 45% said they “always” felt safe.

“The Care Quality Commission has found that unnecessary and excessive restrictions, and security measures are sometimes imposed on detained patients,” said Bhugra. “Undue restrictions on a patient’s autonomy compromise their personal dignity and rights as an individual. Such excessive restrictions are upsetting for the patient and can delay recovery.

“Safety and risk policies are in place to aid patient recovery. Unnecessary bureaucracy and rules can not only hamper a patient’s recovery but possibly exacerbate their mental illness. Whether a person is detained or voluntarily admitted to hospital, general ethical standards that are adhered to in the community should, wherever possible, apply on the ward.”

The report found just 52% of patients claimed to have “supportive”, one-to-one meetings with staff for at least 15 minutes every day. In 20% of the worst-performing trusts, as few as 50% of patients felt they were given enough time with a psychiatrist and even fewer said they were given enough time with a nurse. Bhugra said every patient should have a one-to-one session with a relevant staff member once a day.

Bhugra also admitted deep worries about the drop in British medical graduates going on to train as psychiatrists. He said that government’s cap on immigration from outside the European Union will make the problem much worse.

The Royal College’s survey reported that 544 consultants posts in the UK are either unfilled or filled by a locum: 14% of all posts. In addtion, there are 209 consultants who intend to retire or resign in a short time.

“This is a huge, a massive problem,” he said. “We will be left with a dangerous vacuum of help for people with mental health disorders or will be forced to get special dispensation from the government to recruit heavily from countries who can ill-affod to lose their mental health professionals.”

A Department of Health spokesperson said: “Mental health is a cross-government priority. We published No Health Without Mental Health, our cross-government mental health outcomes strategy, to drive up standards in services and improve the nation’s mental health. The strategy makes clear that mental health services should be just as important as physical health services such as those for cancer and heart disease.

“We have supported the Royal Colleges of GPs and Psychiatrists to develop advice and support for commissioning consortia to commission effective mental health services. The strategy emphasises the importance of improving quality and productivity across the system, while making efficiency savings that can be reinvested in the service to deliver quality improvements.

“In addition, we will invest around £400m over four years in psychological therapies for those who need them in all parts of England, expanding provision for the entire population.”

Overcrowded and understaffed psychiatric wards are leaving patients fearful for their safety and unable to make proper recoveries, according to a damning assessment of Britain’s mental health service by its lead professional body.

Filed under: Articles Tagged: news, psychiatry

Five Big Developments in Neuroscience to Watch – David DiSalvo

Qrd — Sun, 19 Jun 2011 09:23:56 +0000

Five Big Developments in Neuroscience to Watch – David DiSalvo – Neuropsyched – Forbes.

Neuropsyched

David DiSalvo

Jun. 17 2011

Image via Wikipedia

Neuroscience is in many ways a discipline still in its infancy, making it ripe for claims that veer closer to science fiction than science. In this post I’ve taken a cut at describing five real-deal developments in neuroscience that are going to heat up in the years to come, along with implications pro and con.

1. Boosting Thought Control with Real-time Brain Feedback

Research conducted this year shows that people control their thoughts more effectively when they can see how their brain reacts. While in an fMRI machine, study participants were told to complete a set of mental tasks that either raised or lowered introspective thought (introspection requires higher-order, abstract thinking; non-introspection focuses on bodily sensations). They were simultaneously shown a real-time scan of their brains and could clearly see how part of their prefrontal cortex reacted when they worked on a task.

Participants with access to the brain scan significantly improved their brain regulation to successfully perform the tasks. A control group without access to the scan showed no improvement.

This is a development with a lot of upside. It’s plausible that we’ll eventually have a brain feedback app that clues us in when we’re losing focus or need to change mental direction. We’re obviously a long way from there, but the first step has been taken.

2. Changing Behavior with Non-invasive Brain Stimulation

Researchers in Taiwan recently found that applying a weak electrical current over the front of study participants’ scalps for just ten minutes significantly improved their ability to control their behavior. The current is thought to “jump start” impulse control in a section of the prefrontal cortex called the pre-supplementary motor area.

The research also showed that the opposite effect can be induced by using the electrical current to suppress impulse control. Brain stimulation is not new (deep brain stimulation has been around a long time), but non-invasive stimulation or suppression of behavior that actually works is cutting edge.

On the positive side, this could be the beginning of new therapies to treat ADHD and a buffet of impulsivity disorders without medications and their side effects. The fear is it could also be the beginning of non-invasive mind control techniques; plenty of paranoia fodder here to work with.

3. Erasing Targeted Memories

We’ve heard about memory manipulation for ages, but in the last couple of years it has made the transition from theory to practice. A handful of credible studies have shown that memory can indeed be erased using procedures that involve removal or manipulation of specific proteins in the brain. Down the road, it’s possible that we’ll be able to target specific memories for erasure.

In very recent research, Israeli scientists showed that they can erase memories linked to drug addiction, thereby removing one of the most confounding factors in addiction treatment. That study speaks to the upside of memory erasure, along with the benefits of erasing traumatic memories. But targeted memory erasure begs a slew of ethical questions, not the least of which is whether we’re ready to accept the consequences of neutralizing part of what makes us human.

4. Altering Moral Judgments with Magnetism

Research of the last couple decades has shown that injuries to a part of the brain called the right temporoparietal junction (RTPJ), located at the brain’s surface above and behind the right ear, can change a patient’s moral judgments. When these patients are asked to answer morally challenging questions that weigh the life of one person against others, they consistently make utilitarian decisions without feeling the least bit uneasy. Their moral judgments about life and death, so vexing to most of us, become clinical and routine.

Researchers have recently found that they can induce a similar effect using magnetism (transcranial magnetic stimulation, or TMS) to disrupt RTPJ activity. When participants were exposed to magnetic “bursts” from a TMS device, their judgments about what is morally permissible significantly changed. For example, they were more likely to say that intending to harm another was morally permissible if the other person luckily avoided becoming a victim; they considered the intention of the first person to be irrelevant. The effect was only temporary, but the implications are massive. Most of us consider moral judgment a higher order thought process, but this research shows that it can be tweaked by a weak magnetic field in a matter of minutes.

This development stirs multiple fears, but one that immediately comes to mind is the possibility of tuning down moral apprehension even lower and creating synthetic psychopaths. On the other hand, perhaps there’s a good case to be made that some of us could use a little tuning down.

5. Controlling microRNA to Make Brain Cells Death-resistant

Like tiny toggle switches, microRNA are powerful molecules that silence the activity of as many as two-thirds of all human genes. In recent years they have emerged as key players in neurobiological development and disease. This year, researchers at the University of North Carolina, Chapel Hill, made the remarkable discovery that microRNA may also be able to make brain cells resistant to programmed death, or “apoptosis.”

A huge amount of the human brain’s neurons die as we undergo normal growth and development. A portion, however, do not die, and they live on for the long haul. No one has been sure why those neurons survive the destructive “pruning” phase that eliminates droves of other neurons. The current research indicates that microRNA are at the heart of neuron survival, acting to essentially turn off the apoptosis mechanism that leads to cell death.

The upside is that if microRNA can be controlled in the brains of patients with neurological diseases such as Alzheimer’s, ALS and Parkinson’s, then we may be able to halt the cell destruction those diseases cause and effectively stop the disease before the damage is done. It’s important to note that this research was conducted using mice, but it’s also the first to make this discovery in any mammalian brain and a promising initial step.

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Filed under: Articles Tagged: neuroscience, news

changing the subject – a poem by carole satyamurti

Qrd — Sun, 12 Jun 2011 14:32:04 +0000

2 – outpatients

women stripped to the waste,

wrapped in blue,

we are a uniform edition

waiting to be read.

these plain covers suit us:

we’re inexplicit,

it’s not our style to advertise

our fearful narratives.

my turn. he reads my breasts

like braille, finding the lump

i knew was there. this is

the episode i could see coming

although he’s reassuring,

doesn’t think it’s sinister

but just to be quite clear …

he’s taking over,

he’ll be the writer now,

the plot-master

and i must wait

to read my next installment.

3- diagnosis

he was good at telling,

gentle, but direct;

he stayed with me

while i recovered breath,

started to collect

stumbling questions. he said

cancer with a small c

– the raw stuff of routine –

yet his manner showed

he knew it couldn’t be ordinary for me.

walking down the road

i shivered like a gong

that’s been struck

– mutilation … what have i done …

my child … how long

and noticed how

the vast possible array

of individual speech

is whittled by bad news

to what all frightened people say

that night, the freak storm.

i listened to trees fall,

stout fences crack,

felt the house shudder as the wind

howled the truest cliche of them all.

7 – how are you?

when he asked me that

what if i’d said,

rather than “very well”,

“dreadful — full of dread”?

since i have known this,

language has cracked,

meanings have re-arranged;

dream, risk and fact

changed places. tenses tip,

word-roots are suddenly

important, some grip

on the slippery.

we’re on thin linguistic ice

lifelong, but i see through;

i read the sentence

we are all subject to

in the stopped mouthes of those

who once were “i”,

full fleshed, confident

using the verb “to die”

of plants and pets and parents

until the immense

contingency of things

deleted sense.

they are his future

as well as mine,

but i won’t make him look.

i say, “i’m fine”.

Filed under: Articles Tagged: poetry

A Biological Decalogue for the Millennium

Qrd — Sun, 12 Jun 2011 08:08:59 +0000

An Extract from: Steven Rose – The Biology of the Future and the Future of Biology – Perspectives in Biology and Medicine 44:4

A Biological Decalogue for the Millennium

If we are to transcend biology’s reductionist view of nature for the new millennium, and to create what I would regard as an understanding of living processes more in accord with the material reality of the world than our present, rather one-eyed view, we need some principles with which to work.These principles will of course not reject the explanatory power of reductionism, but will recognize its limitations.They should accept too, Goodwin’s call for the return to a science of qualities, to complement reductionist quantitation. Such a science will rejoice in complexity, in dynamics, and in an emphasis as much on process as on objects. In my recent book Life Beyond the Gene, I enumerate a set of such principles; by chance rather than design, there are 10 in all.To exemplify all its principles would extend this essay beyond reasonable length, but enough has I trust been said to give a feel for the conceptual approach I am arguing for. In brief, here is my decalogue:

1. Scientific knowledge is not absolute, but provisional, being socially, culturally, technologically, and historically constrained.

2. We live in a world that is ontologically unitary, but our knowledge of it is epistemologically diverse.There are multiple legitimate ways of describing and explaining any living process.

3. Different sciences deal with different levels of organization of matter of increasing complexity.Terms and concepts applicable at one level are not necessarily applicable at others. Thus genes cannot be selfish; it is people, not neurons nor yet brains or mind, who think, remember, and show emotion.

4. Causes are multiple, and phenomena richly interconnected. Adequate explanation demands finding the determining level.To take an example, the high levels of murder in the United States by comparison with, say, Europe or Japan are best explained not by some special feature of the U.S. genotype, abnormal genes, or biochemistry which predispose to violence (despite a major research program dedicated to identifying such biological predispositions), but by the high number of personal handguns in society, and a culture and history of their use.

5. Living organisms exist in four dimensions, three of space and one of time, a developmental trajectory or lifeline, always autopoietic, both being and becoming. Lifelines are stabilized through dynamic processes. The traditional biological concept of homeostasis as a regulatory mechanism needs transforming by that of homeodynamics, to emphasize that for any living organism stasis indeed means death.

6. Organism and environment interpenetrate: environments select organisms (the process of natural selection), but organisms choose and transform environments. Organisms are thus active players in their own destiny.

7. Living organisms are open systems far from thermodynamic equilibrium; continuity is maintained by a constant flow of energy and information. All is flux; stability emerges through process, not structure.

8. Evolutionary change occurs at the intersection of lifeline trajectories with changing environments.

9. Organisms cannot predict patterns of change, and selection therefore always tracks environmental change. Nothing in biology makes sense except in the context of history.

10. Thus the future, for humans and other living organisms, is radically unpredictable; we make our own history, though in circumstances not of our own choosing

Email: s.p.r.rose@open.ac.uk.

This article is extracted from the valedictory lecture given at The Open University, 16 September 1999. An abbreviated version of this paper has been published as “A New Biology” (Prospect, Feb. 2000, pp. 27-31). The ideas presented here are developed more fully, with references, in Rose, S., Life Beyond the Gene (New York: Oxford Univ. Press, 2001), and Rose, H., and Rose, S., eds. Alas, Poor Darwin:Arguments Against Evolutionary Psychology (New York: Harmony Books, 2000).

Filed under: Articles Tagged: biology, evolution

Australia’s Reckless Experiment In Early Intervention | Psychology Today

Qrd — Sun, 12 Jun 2011 06:31:30 +0000

Australia’s Reckless Experiment In Early Intervention | Psychology Today.

Blogs

DSM5 in Distress

The DSM’s impact on mental health practice and research.

by Allen Frances, M.D. (was chair of the DSM-IV Task Force and of the department of psychiatry at Duke University School of Medicine, Durham, NC. He is currently professor emeritus at Duke.)

Australia’s Reckless Experiment In Early Intervention

Prevention that will do more harm than good

Published on May 31, 2011 by Allen J. Frances, M.D. in DSM5 in Distress

Patrick McGorry is a charismatic psychiatrist who has recently gained heroic status. First he was chosen to be Australia’s Man Of The Year. Now, he has convinced the Australian government to spend more than $400 million over five years to fund his plan for a nationwide system of Early Psychosis Prevention and Intervention Centres. McGorry is the visionary prophet and pied piper of preventive psychiatry. His goal is to diagnose mental disorders early and treat them expectantly- before they can do their worst damage.

McGorry’s goal is certainly great. But its current achievement is simply impossible and Australia’s plans are patently premature. Early intervention to prevent psychosis requires first that there be an accurate tool to identify who will later become psychotic and who will not. Unfortunately, no such accurate tool exists. The false positive rate in selecting prepsychosis is at least about 60-70% in the very best of hands and may be as high as 90% in general practice. That’s right, folks, nine misidentified non patients for one accurately identified truly prepsychotic patient. Those are totally unacceptable odds.

What are the costs? McGorry does not recommend antipsychotic medications as a routine part of his prevention regimen. But experience teaches us that they will be overused despite having no proven efficacy and posing the risk of massive weight gain (and its consequent array of serious complications). The false positives will also suffer unnecessary stigma and worry and will undergo unnecessary and misdirected treatment. And surely there are many more productive ways to spend $400 million doing a better job of managing the mental health needs of those who have real and treatable psychiatric disorders.

Unfortunately, Mcgorry is a false prophet who’s visions are offered at least a few decades before their time. Australia, led astray by his impractical hopes, is about to embark on a vast and untried public health experiment that will almost surely cause more harm to its children than it prevents. Before embarking on this headlong and reckless rush, the following research steps need to be accomplished:

1)Developing a proven and reliable definition of “Psychosis Risk”

2)Learning how to use it in a way that reduces current outrageously high false positive rates to levels that are tolerable.

3)Demonstrating that the interventions chosen are indeed effective in preventing psychosis.

4)Determining the likely rate of antipsychotic use and how this influences the overall risk/benefit balance sheet of early intervention.

5)Studying the beneficial and harmful impacts of early diagnosis on stigma and self perception.

6)Comparing the marginal utility of a dollar spent trying to prevent an alleged future disorder vs a dollar spent treating an already clearly established one.

This is a research enterprise that will take many groups around the world many decades to complete. But it is an absolutely necessary precondition before spending $400 million on what is likely to be a failure. The Australian experiment will be flying blind on an airplane that is not at all ready to leave the ground. Doing prevention prematurely and poorly will give a good idea an unnecessary bad name.

McGorry’s intentions are clearly noble, but so were Don Quixote’s. The kindly knight’s delusional good intentions and misguided interventions wreaked havoc and confusion at every turn. Sad to say, Australia’s well intended impulse to protect its children will paradoxically put them at greater risk. Let’s applaud McGorry’s vision but not blindly follow him down an unknown path fraught with dangers.

Filed under: Articles Tagged: dsm, early intervention, psychiatry

Psychotherapy versus second-generation antidepress… [J Nerv Ment Dis. 2011]

Qrd — Sat, 11 Jun 2011 11:17:39 +0000

Psychotherapy versus second-generation antidepress… [J Nerv Ment Dis. 2011] – PubMed result.

Abstract

Most meta-analyses have concluded that psychotherapy and pharmacotherapy yield roughly similar efficacy in the short-term treatment of depression, with psychotherapy showing some advantage at long-term follow-up. However, a recent meta-analysis found that selective serotonin reuptake inhibitors medications were superior to psychotherapy in the short-term treatment of depression. To incorporate results of several recent trials into the meta-analytic literature, we conducted a meta-analysis of trials which directly compared psychotherapy to second-generation antidepressants (SGAs). Variables potentially moderating the quality of psychotherapy or medication delivery were also examined, to allow the highest quality comparison of both types of intervention. Bona fide psychotherapies showed equivalent efficacy in the short-term and slightly better efficacy on depression rating scales at follow-up relative to SGA. Non-bona fide therapies had significantly worse short-term outcomes than medication (d = 0.58). No significant differences emerged between treatments in terms of response or remission rates, but non-bona fide therapies had significantly lower rates of study completion than medication (odds ratio = 0.55). Bona fide psychotherapy appears as effective as SGAs in the short-term treatment of depression, and likely somewhat more effective than SGAs in the longer-term management of depressive symptoms.

Filed under: Articles Tagged: minimum medication, psychotherapy

Systematic Review of the Efficacy and Clinical Effectiveness of Group Analysis and Analytic/Dynamic Group Psychotherapy

Qrd — Mon, 30 May 2011 17:59:51 +0000

IGA_GAS_FINAL_REPORT_UPDATED.pdf (application/pdf Object).

This can be found here.

Executive summary:
Aims of the review
The main aim of the review is to assess the evidence for the efficacy and effectiveness
of Group Analysis (GA) and Analytic/Dynamic (A/D) Group Psychotherapy. Factors
that influence the outcome of group therapy are also reviewed. Information is
presented on the types of clients using GA and A/D groups, the size of groups, and
duration of therapy.
Methods
After initial scoping searches of the PsycINFO database, the review team conducted a
sensitive search of seven electronic databases including Medline, EMBASE, CINAHL,
the Cochrane Database of Systematic Reviews (CDSR), the Central Register of
Controlled Trials, Health Technology Assessments (HTA) Database and the Database
of Abstracts of Reviews of Effects (DARE), using key terms approved by a specialist
advisory group (‘Expert Panel’) appointed by the Institute of Group Analysis, London
(IGA) and the Group Analytic Society (GAS). The key terms included ‘group analysis’,
‘group dynamic psychotherapy’ and ‘psychoanalytic groups’. Studies were selected if
their results were published in English between 2001 and 2008 where an evaluation
of GA or A/D group psychotherapy was described that included a control or
comparison group. The criteria adopted meant that randomised controlled trials,
cohort studies, ‘before and after’ studies, qualitative studies and systematic reviews
were included; studies with other designs were not. Findings from studies before
2001 were captured by synthesizing evidence from systematic reviews of primary
research which included them. Reference lists from included studies were followed
up and contact was made with key authors in the field. As the studies identified were
heterogeneous, findings from both primary and secondary studies were combined in
narrative syntheses.
Findings
Number of studies
We identified 37 primary studies and 23 reviews which met the inclusion criteria.
Of the 37 primary studies, data were not extracted from three papers17,24,27 which
focussed on moderating, secondary variables (such as group climate, self-efficacy or
treatment duration.) One of these was a preliminary brief report with incomplete
data reporting. These three studies were included in our review of the impact of
moderating variables (see 3.7).
Of the 34 remaining primary studies, 5 (15%) were randomised controlled trials
(RCT), a further 2 (6%) were randomised controlled trials where group therapy was
only one element in a complex treatment (RCT-partial), 5 (15%) employed case
controls mainly using a ‘matched’ or ‘wait-list’ comparison group (CaCo), 21 (62%)
were observational studies (Obs), and 1 (3%) was qualitative (Qual).
Of the 23 reviews, two were excluded because they only covered papers already
included in our systematic review, one was excluded because it included just one
group-based intervention, and one was excluded because it was not a review per se
but was, instead, a specialist re-analysis of a previous meta-analysis. Nineteen
relevant reviews which included studies published before 2001 were identified and
summarised in a ‘review of reviews’.
Efficacy and Clinical effectiveness
Randomised controlled trials:
Five randomised controlled trials gave the following results:
• Piper et al., 2001 found patients with complicated grief improved in both
psychodynamic and supportive group treatment; there was no significant
difference between therapy types.
• Blay et al., 20024 found brief psychodynamic group treatment gave clinically and
statistically significantly greater benefit than usual clinical care for a mixed
diagnosis group at the end of 8 weeks treatment, but at follow up (9-30 weeks
post randomisation) there was no significant difference.
• Lanza et al., 200213 compared psychodynamic group therapy with group cognitive
behaviour therapy for reducing aggression and violence in male veterans with a
history of assault. With a small sample size (n=10) the degree of improvement was
not statistically significant for either therapy and there was no significant
difference in outcome between the psychodynamic group and the CBT control,
although the rate of improvement was better in the psychodynamic group.
• Tasca et al., 200630 found binge-eating patients gained similar benefit from
psychodynamic interpersonal therapy and group cognitive behaviour therapy, both
being superior to no-treatment controls at the end of therapy: follow up data on
the no-treatment control group were not available;
• Lau et al., 200714 compared modified group analysis with systemic group therapy
and found the latter somewhat more effective, although both groups showed a
treatment response.
These results provide evidence for the efficacy and clinical effectiveness of group
therapy approaches in a range of clinical problems, but not for specific benefits of any
particular theoretical approach.
Other controlled studies:
The other controlled studies gave support for the use of group psychotherapy in a
variety of conditions.
Analysis of the ‘outcome predictors, mediators and moderators’ identified by
included studies suggests that there may be important effects of age, sex, self efficacy,
duration and psychological mindedness on outcomes and that attachment
style and interpersonal distress influence group attendance. These effects have been
reported for specific client groups and may not generalise to others; they may also be
mediated by group climate and individual factors. The quality of object relations- the
lifelong pattern of interpersonal relationships – seems to be an important moderator
of the impact of treatment type on outcome. Those with high quality of object
relations had better outcomes from interpretive group therapy than from supportive
group therapy whereas those with poorer quality of object relations were helped
more by supportive group therapy. Predictors of outcome for long term analytic
group therapy are likely to be different from those for short-term groups.
Observational studies
The observational studies also showed consistently promising results across a variety
of settings, conditions and measures.
Benefits identified by these studies tend to derive from treatments of longer duration
than is typically the case in RCTs, which tend to use shorter, manualised treatments.
Furthermore, observational studies may employ different measures of change or
assess qualitative changes and these may not be identified in more formal designs
because researchers are not investigating them. It should be noted that the results of
observational studies are based on pre-post outcomes and may be misleading as
there are no controls or randomisation. There is no way of attributing the changes
found to the effects of the group intervention rather than to confounding factors
such as ‘spontaneous’ improvement, selection bias, reporting bias etc .
Review of reviews
A review of reviews was undertaken which confirmed that group therapies in general
are more effective than wait list or standard care controls. Where a specific
comparison was made between group therapy and individual therapy, there was
typically no advantage to group therapy, although there are exceptions to this finding.
Most of these comparisons are examined through meta-analysis rather than through
‘head-to-head’ trials with adequate statistical power and cost-effectiveness analysis.
In general, the type of group therapy does not predict outcome.
Conclusions
The studies examined, including earlier reviews, consistently support the use of
Group Psychotherapy as an effective approach, across diverse conditions, participant
groups and settings. In addition, there may be important effects of age, sex, selfefficacy,
psychological mindedness and the quality of object relations on outcomes;
attachment style and interpersonal distress have an important bearing on group
attendance. However, the number of empirical studies, in particular of high quality
RCTs, into the effectiveness of Group Analysis and Analytic/Dynamic Group
Psychotherapy is small.
The methodological quality of the studies identified was variable. Unpublished
outcome measures with unknown psychometric properties were too often used, and
the variety of outcome measures made it impossible to conduct meta-analysis. In
respect of reporting, the terminology used to describe the therapeutic interventions
was often ill-defined. Key words were omitted from titles and abstracts thus making
it difficult to capture these studies via electronic searches. These problems
presented significant methodological challenges to the review.
The relatively low numbers of currently available studies on GA and A/D group
Psychotherapy presents both a challenge and an opportunity to the therapeutic
community to undertake research into these group approaches in order to
consolidate these conclusions.
Recommendations for further research
To increase the amount and the quality of the evidence base for GA and A/D group
psychotherapy there is an urgent need for more high-quality studies, employing both
qualitative and quantitative methods.
Areas where evidence is currently lacking include:
• the types of patients for whom GA and A/D group therapies are most effective;
• the different indications for group versus individual psychotherapy and the
comparative cost-effectiveness of the two treatment modes;
• the aspects of heterogeneity versus homogeneity of group membership that
impact on outcome;
• equivalence or non-inferiority trials of GA and A/D group therapies compared with
CBT group therapies;
• a study of group members’ experience or a review of service users’ personal
testimony.
If possible, further research should be undertaken to address these areas. To
increase the awareness and use of research, and to facilitate systematic reviews, the
reporting of research in GA and A/D group psychotherapy requires improvement.
Specifically, we recommend the use of structured abstracts, clear definitions of
different types of group intervention and agreed keywords for use in titles and
abstracts and consistent use of a set of outcome measures. The research committees
of the IGA and GAS, after consultation with other relevant bodies, could develop
these recommendations further by producing good practice guidelines for the
conduct and publication of research examining GA and A/D group psychotherapy.

Filed under: Articles Tagged: group therapy, psychoanalysis

Clinical relevance of findings in trials of antipsychotics: systematic review

Qrd — Mon, 23 May 2011 08:42:27 +0000

Review article

Clinical relevance of findings in trials of antipsychotics: systematic review

Peter Lepping, MD MRCPsych MSc

Betsi Cadwaladr University Health Board, North Wales and Wrexham Academic Unit, Department of Psychiatry, Glyndr University, Wrexham

Rajvinder Singh Sambhi, MD MRCPsych

Department of Psychiatry, Betsi Cadwaladr University Health Board, North Wales

Richard Whittington, BA, PhD, CPsychol, AFBPsS, PGCert

Department of Health Services Research, University of Liverpool

Steven Lane, PhD MSc BSc(HON)

Centre for Medical Statistics and Health Evaluation, Liverpool

Rob Poole, MB BS FRCPsych

Department of Psychiatry, Glyndr University, Wrexham, Wales, UK

Correspondence: Peter Lepping, MD, MRCPsych, MSc, Wrexham Academic Unit, Technology Park, Croesnewydd Road, Wrexham LL13 7YP. Email: peter.lepping@wales.nhs.uk

Declaration of interest

P.L. has accepted speakers’ honoraria for talks on medicalethics and capacity legislation from AstraZeneca and Ely Lilly.R.P. has accepted speakers’ honoraria from Lundbeck,Janssen, Ely Lilly, AstraZeneca and Pfizer.

Background

There is concern over the methods used to evaluate antipsychoticdrugs.

Aims

To assess the clinical relevance of findings in the literature.

Method

A systematic review identified studies of antipsychotics thatused the Brief Psychiatric Rating Scale (BPRS) and Positiveand Negative Syndrome Scale (PANSS). A published method oftranslating these into Clinical Global Impression – Changescale (CGI–C) scores was used to measure clinical relevance.

Results

In total 98 data-sets were included in the BPRS analysis and202 data-sets in the PANSS analysis. When aggregated scoreswere translated into notional CGI–C scores, most drugsreached ‘minimal improvement’ on the BPRS, butfew reached that level for PANSS. This was true of both first-and second-generation drugs, including clozapine. Amisulprideand olanzapine had better than average CGI–C scores.

Conclusions

Our findings show improvements of limited clinical relevance.The CGI–C scores were better for the BPRS than for thePANSS.

Main findings

The published trial literature consistently reports improvementin participants with schizophrenia and other psychotic illnesseswhen they are given antipsychotic drugs. However, our studysuggests that on average the clinical significance of the reportedfindings is disappointingly limited. There is little differencein this regard between first- and second-generation drugs ascategories, although there are differences between individualdrugs.

Broadly speaking, our findings are similar to other recent studies,both with regard to the similarities between first- and second-generationantipsychotics as categories, for example, CutLASS,⁶ and with regard to differences between the different second-generationantipsychotics, for example CATIE⁵ and two recent meta-analyses.^4,10 In the reported studies, amisulpride and olanzapine appear,by and large, to lead to a greater overall clinical improvementthan other drugs. Ziprasidone, quetiapine, sertindole, aripiprazoleand chlorpromazine appear to perform relatively poorly. However,only the most effective drugs produce a moderate improvementon CGI–C when PANSS and BPRS changes are translated into notional CGI–C scores. No drug achieved this on boththe PANSS and BPRS score. Interestingly, even clozapine doesnot perform well in our analysis. This stands in contrast toother studies, despite including the CATIE results in our sample.However, in most, if not all other studies clozapine was used for individuals with defined therapy-resistance. Thereforeit is not surprising that the clinical effects observed wereonly moderate.

Comparison of first- and second-generation antipsychotics ascategories shows neither class of drug achieving a mean CGI–Cscore of great clinical significance. Clinical Global Impression– Change scores derived from PANSS and BPRS scores showa similar pattern between drugs, but BPRS scores translateinto greater clinical improvement than PANSS scores. This maybe a result of the greater prominence of negative symptoms inthe PANSS scale.

Drug trials are conducted using groups of participants thatdiffer considerably from clinical populations with acute illnesses.Naturalistic studies of individuals under treatment for acuteschizophrenia-spectrum disorder may show greater improvementsin PANSS scores than those seen in drug trials. For example,Jäger et al¹¹ conducted a naturalistic study of 280 in-patientswith schizophrenia. There was a mean reduction in PANSS scoresof 47% (equivalent to a CGI–C score of –1.75) betweenadmission and discharge. The PANSS reduction was 25% (equivalentto a CGI–C of –0.8) in the subsample of individuals with a history of multiple admissions, a result much more akinto our findings. The PANSS reduction for the total sample wasunusually large compared with the drug trial literature. Theauthors suggested that this was the result of the individualsbeing treated holistically in a naturalistic study, togetherwith the inclusion of a larger proportion of individuals with first-episode psychosis than would be possible in a drug trial.This underlines the value of naturalistic studies, where conditionsand, it seems, findings correspond more closely to clinicalexperience.

Other explanations for our findings include the possibilitythat the clinical relevance of antipsychotics is in fact limited.Alternatively, symptomatology may only be a small aspect inindividuals’ overall assessment of their quality of life.¹² In addition, our method of aggregating and averaging resultsmay hide the larger improvements that certain individuals gainfrom antipsychotics. With regard to first- and second-generationantipsychotics as categories, poorly performing drugs may havemasked the admittedly limited effects of better performing drugs.Other reasons or combinations of reasons may also apply.

Filed under: Articles Tagged: antipsychotics, schizophrenia

Kapur questions dopamine dysregulation in schizophrenia

Qrd — Mon, 23 May 2011 08:38:38 +0000

DOPAMINERGIC FUNCTION IN TREATMENT

RESISTANT SCHIZOPHRENIA

Arsime Demjaha1,2, Robin Murray1, S. Kapur1, and Oliver. D.

Howes1,2

1Psychosis Studies, Institute of psychiatry, London, UK;

2Medical Research Council Clinical Sciences Centre, Imperial College London,

London, UK

Background: Molecular imaging studies have consistently reported presynaptic

striatal dopaminergic elevation in schizophrenia, but no such studies

have investigated the dopaminergic function in treatment resistant patients,

and it remains unknown whether the neurobiology of treatment resistance

is linked to dopamine dysregulation. We thus examined the dopaminergic

function in a cohort of treatment resistant patients with schizophrenia by

means of [18 F] -DOPA uptake and a high sensitivity 3 dimensional positron

emission tomography. Methods: Eight patients with treatment resistant

schizophrenia (mean age 45 years) and 8 healthy volunteers matched

for gender, age, weight and cigarette smoking underwent [18 F] DOPA PET

scanning (ECAT EXACT 3D). Striatal dopamine uptake influx rate constants

(Ki values) were measured for the whole striatal region of interest

(ROI) and for the functional subdivisions relative to uptake in the reference

region. Independent t test statistics was used to compare ROI based Ki values

between patients and healthy volunteers. Results: No between-group

differences were observed for age, gender, weight or cigarette smoking.

We observed no significant differences between groups for [18 F]

-DOPA uptake Ki values for the whole striatum (P = .99) or for its sensorimotor

(P = .58), limbic (P = .99) or associative (P = .93) sub divisions

Conclusion: Our preliminary findings suggest that the dopaminergic dysregulation

may not be the primary neurochemical abnormality in treatment

resistance. This may indicate that treatment resistant schizophrenia constitutes

a distinct subtype of psychotic illness.

Filed under: Articles Tagged: dopamine, psychosis, schizophrenia