Mr. Whitaker begins his chapter by recounting the discovery of early antibiotics and the realization that medications could be created that had more toxicity some cells and less for others.  He quotes Ehrlich with what I assume will be his definition of a “magic bullet”:

“If we picture an organism as infected by a certain species of bacterium, it will be easy to effect a cure if substances have been discovered which have a specific affinity for these bacteria and act on these alone.  (If) they possess no affinity for the normal constituents of the body, such substances would then be magic bullets.”

Now, what are we to make of this idea?  We need to see if Mr. Whitaker believes that magic bullets exist as described by Ehrlich or if he harbors some doubt.  We may be able to poll people and quote those who are “true believers” in such things, but is there any factual evidence that these exist in any area of human experience?

Mr. Whitaker cites salvarsan as the first “magic bullet.”  How does it stack up?  It is an organic derivative of arsenic that was able to kill the organism causing syphilis.  So far, so good.  But did it really have “no affinity for the normal constituents of the body?”  Not really, salvarsan had significant toxicity that worsened on exposure to air.  The Merck Index simply says, “It is poisonous!”   It is no longer used therapeutically.  It does not seem to be much of a “magic bullet” though it was indeed an advance for its time.  The next “magic bullet” mentioned is sulfanilamide, a member of the class of medications called the sulfonamides, which found it usefulness in treating bacterial infections.  It also worked well to kill bacteria, but the sulfonamides are also known to cause kidney damage, anemias, hypersensitivity reactions, hepatitis, hypothyroidism, arthritis, and various neuropsychiatric disturbances (Goodman and Gilman’s The Pharmacological Basis of Therapeutics).  These are not all common side effects, but they show that this medication does have effects on the “normal constituents of the body.”  The third “magic bullet” mentioned is penicillin.  This comes closest to the idea of a “magic bullet” due to its usefulness in treating infections, but even it is not without potentially harmful effects on the body (most frequently allergic reactions).  Mr. Whitaker points out that as more and more medications were synthesized, society became more optimistic about conquering more and more types of diseases.  The “magic bullet” was about to change psychiatry.

But have we ever found any medication that meets Ehrlich’s definition of a “magic bullet?”  Do any of Mr. Whitaker’s examples suffice?  It is telling that Mr. Whitaker uses examples of antibiotics for his “magic bullets.”  If there were ever to be one discovered, it would be among the medications that target non-animals (even better — noneukaryotes, i.e. bacteria) that affect animals (eukaryotes).  This is Mr. Whitaker’s best chance, but he cannot find a medication without some risk to the host.  How, then, are we to understand the idea of the “magic bullet?”  It is not a real thing — it is an ideal.  We do not criticize a drug for not being a “magic bullet,” but we can assess how close it comes to this ideal.

As Mr. Whitaker tracks drug development into the field of psychiatry, he notes the progress of mental health treatment through the “moral therapy” era and into an era of “physical treatments.”  Contrary to Mr. Whitaker’s statement on page 43, moral therapy was not viewed as a “failed form of care” but became impractical and financially unsupported, leading treaters to seek new forms of care that fit with the cultural forces of the time.  Still, Mr. Whitaker notes several forms of treatment that range from the head-scratchingly bizarre (tooth extraction) to inexplicably successful (electroconvulsive therapy).  He also notes the shortsighted foray into the frontal lobotomy.  His description of the state of some mental hospitals of the time is well-designed to elicit sympathy and horror.  Against this backdrop, Mr. Whitaker quotes various influential people expressing the great need for mental health care and with great hopes for psychiatric treatments.  His last quote is from Dr. Howard Rusk who said, “We must realize that mental problems are just as real as physical disease, and that anxiety and depression require active therapy as much as appendicitis or pneumonia.  They are all medical problems requiring medical care.”  With this, Mr. Whitaker sets up the argument that he intends to knock down.

So, why is this chapter in the book?  What purpose does is serve in Mr. Whitaker’s argument?  It seems to do a few things such as

1.  Set up the idea of the “magic bullet” as a tool with which to criticize psychiatric medications;

2.  Show that historically psychiatrists have provided treatments that over time have been repudiated; and

3.  Blur the lines between opinion and fact.

The first point is rhetorically useful, but intellectually problematic.  If you want to convince people that something is flawed, it is often better to compare your subject to a very high standard.  This makes it stand out more in stark contrast.  A more nuanced and realistic approach may not be nearly as motivating to your audience once they realize that the flaws you are pointing out are not unique.  Such is the case with the “magic bullet.”  No matter where you get your treatment or what kind of treatment you get, there will always be risks of side effects.  There is no treatment that ONLY treats what you aim it at and has no other effects on the person.

The second point is valid and is a sober reminder of the need for responsibility in ALL fields of medicine.  The point is not unique to psychiatry.  The emotional content of the section dealing with this point, however, is apt to be misused to discredit psychiatrists in particular.

The third point may or may not be widely accepted, but here is why I think it plays a role in this chapter.  Almost all of the quotes that Mr. Whitaker uses in the later part of this chapter are OPINIONS.  As opinions, I may choose to agree with them or not, with no harm to logic or meaning.  If I read the last part of this chapter as opinion, then the chapter winds up saying something like, “Infectious disease doctors have cool drugs, and some people hope that psychiatry gets drugs that rival the ideal qualities of antibiotics, though they may not.”  If I read the same section as fact, however, then I wind up believing that “infectious disease doctors have cool medications, and successful psychiatric medications will have the same ideal qualities as the antibiotics.”  It’s not much of a difference, but being disappointed in the opinion reading is less motivating and attention-getting than feeling lied to with regard to the fact reading.

How can we assess the value of a tool independently of the one who uses it?  If I give golf clubs to 100 people, the better golfers will use them better and have better scores.  If I give paintbrushes to 100 people, the better artists will make better paintings.  If I give hammers to 100 people, the better craftsmen will make better structures.  What will happen if I give better medications to 100 doctors?The randomized, controlled trial is designed to determine how efficacious medications are.  By randomizing subjects into the various groups (control, drug 1, drug 2, etc.) all the groups should be identical (or at least similar enough) so that they would respond to a given drug the same way.  This allows us to compare the responses between groups.  The use of a placebo (a treatment with no known efficacy) allows us to see what the effects of the treatment setting would be.  By making the medication the only thing that varies between groups, we can isolate the effect of the medication.  If the study participants and researchers are blind with respect to which patients get which medication, then there is reduced bias in the study, since patients and researchers will not be tempted to exaggerate the effect of the drug being studied.  All of this makes logical sense, so what could be a problem?

Well, there has been a lot written lately about the lack of effectiveness of antidepressants.  This has led some to criticize their continued widespread use.  But the problem with the antidepressant studies is not that people did not get better; it was that too many people were getting better.  The people who were receiving placebos were also improving, so that it was difficult to tell whether the groups receiving medication were showing additional improvement.

The problem of having too large of a placebo response is not uncommon in some types of research but is especially problematic in studies of mental illness.  In an effort to reduce the placebo response, study designers try to standardize the interactions between researchers and study subjects.  They try to make sure that no non-medicine therapeutic interactions are taking place that might obscure the effect of the medication.

This effort to remove the tool user from the evaluation of the tool is akin to giving a golf pro a new set of clubs and telling him “be sure not to use your skill when you try these clubs.”  How much difference would we expect to see between the old (control) clubs and the new (experimental) clubs?  Would this be a valuable test of the quality of the new clubs?

Now, study designers might protest that if we had a groups of golfers of similar skill and they were given the old and new clubs, then we would be able to see the effects of the clubs.  O.K., but who is assessing the skill of the users?  Who indeed ARE the users?  The physicians are one set of users.  So how do we rate a physician’s skill?  The study subjects are also users.  How do we rate a study subject’s skill?  The physician and the study subjects are expected to work together.  How do we measure their joint skill?  Study designers might try to eliminate the skill of the physician by comparing the improvement when a particular physician prescribes a placebo with when the same physician prescribes the study medication.  However, this still leaves the patient skill and physician-patient interaction unmeasured.

The double-blind, randomized, controlled trial also frequently assumes that the clinical change from medication effects and the clinical change from non-medication effects are independent.  This means that change due to one factor does not affect the change attributable to the other.  The problem is that we do not know if this is true.  If the change due to these two factors overlaps each other, then it is possible that a large placebo response might limit the amount of change that is available to be demonstrated by the medication.  If this proves true, it provides further pressure for study designers to limit the placebo response (and thus remove the tool user from the evaluation of the tool).

It seems to me that double-blind, randomized, controlled trials are best designed to detect harmful effects.  If I give 100 people hammers, their skill will determine the quality of their buildings.  However, I can enumerate the amount of destruction the hammers are capable of by simply noting the destructive events.  With this, I can estimate the likely problems encountered when people of similar background use these hammers.

So, if double-blind, randomized, controlled trials have these problems, why are they being relied on for drug approval?  Simply, because we do not have a better tool.  People will continue to want to know whether medications are worth their time, money, and trouble.  This is currently the best (if still flawed) way of giving an answer.

In ritual, we give up our obligation to be “us.”  We play roles that have been passed down with the rituals.  The roles come with duties and the playing of these roles is often associated with a particular attitude or solemnity.  The modern disdain for playing ceremonial roles among some is often excused as a desire to be “genuine,” but I fear it really represents an inability of these individuals to abandon themselves into the transcendental elements of the ritual.  They rob themselves of experience under the guise of “honesty.”  And lest we believe that only the participants have roles, we as witnesses of the events play a ceremonial role as well.

Funerals:  It is good to be reminded from time to time that we will not live forever.  This is the most shocking message delivered at a funeral.  But funerals also allow us a time to see a person’s life — their whole life — in a way that we seldom encounter outside of literature.  In a good funeral (IMHO), we are told who the deceased was, how they lived, and how they died.  In learning about who they were, we stretch our powers of observation and communication to near a breaking point.  Can a person be condensed to mere words?  We try, but we are left with the feeling that no matter the skill of the eulogist, there remains a real loss.  In learning how the deceased lived, we search for the meaning in their life.  We seek the pattern that explains what they did and who they associated with.  And in learning how they died, we learn from the example of those that go where we must.  They send back scouting reports from where we know we will be compelled to go.  In the end, it is a shame that much of what is talked about and learned from a funeral is too late for the deceased, but it can be a profound growth experience for the community.

Weddings:  The meaning of weddings seems to be getting unclear lately.  For those who choose to limit their meaning to “we love each other for now and thought we’d let you know,” I don’t have much to say.  I don’t think that way so I have little I can add.  On the other hand, there are those for whom a wedding is a solemn ceremony in which a man and a woman are bonded together for life, forming a family with the expectation of having children.  This is the wedding ceremony I am familiar with, and the one I will comment on.  If you have another view, you might find my comments don’t apply to your situation.  Back when promises seemed to mean more than they do today, the wedding vows were serious.  The traditional wedding vows were “I _____, take you ______, to be my wedded wife/husband. To have and to hold, from this day forward, for better, for worse, for richer, for poorer, in sickness or in health, to love and to cherish ’till death do us part. And hereto I pledge you my faithfulness.“  Many also included “forsaking all others” and “obedience.”  These are serious vows, and to express these publicly in front of friends and family was a tremendous event.  To witness this level of commitment, recognize the weightiness of these promises, and celebrate the (now practically unheard of) possession of one person by another, was a momentous occasion.   The lady, for the moment, becomes the bride with all the ceremony, respect, and adornment appropriate for her role.  The man becomes the groom (with much less ceremony, respect, and adornment).  Their friends become bridesmaids and groomsmen. Their occasion and location for their vows becomes endued with a sense of sanctity.  The whole setting is full of symbolism (too much for me to describe here).  The wedding moment is magical.  Later, they can be merely husband and wife.  Today they are a bride and groom.  Later, they can go to work, haggle over bills, step on each other’s toes.  Today, they are something more.  Go to weddings and witness this.  If you are married, remember this.  You promised something great — almost superhuman. Regardless of your situation, let’s take marriage seriously.

Graduation:  It seems that in modern times there are graduation ceremonies for everything.  Some may think that this is a good thing.  I wonder if it hasn’t diluted the meaning of these occasions.  Graduations signal the completion of some kind of “rite of passage.”  In our secular society, it is often associated with completing some degree of training.  The ceremony signals a dividing point where the graduate assumes new duties and responsibilities in the larger society, and society (mostly family) is called to witness this.

Other:  There are too many ceremonial opportunities in our society to list.  Some are religious and help define and unite their specific communities.  Some are military and communicate the values and functions of our various services.  Some others are purely secular and address the community as a whole.  Keep your eyes open for ceremony.  Participate in as much as you can.  Open your life to important experiences that have been handed down through the ages.  A life without ceremony is a life diminished.

Last note:  My father was an Air Force pilot.  When he died, the local Air Force base had F-111′s fly a “missing man” formation at the conclusion of his funeral.  This symbolic show of respect still moves me greatly whenever I see or remember it.  There are no words that could express what the symbolism of a military funeral does for me and my family.

Mr. Whitaker starts out this chapter with a story about a visit to the Depression and Bipolar Support Alliance meeting at McLean Hospital in Belmont, Massachusetts.  His description of the event and of his conversations with members of the group provides an apparently fair and respectful picture of the group, its composition, and the unexpected (to Mr. Whitaker) frequency of employment difficulties of the group members.  He then outlines his purpose in relating four anecdotal stories related to him by group members.  He states on page 16, “Still, as we set out to solve this puzzle of a modern-day epidemic of disabling mental illness in the United States, anecdotal accounts can help us identify questions that we will want to see answered in our search of the scientific literature.”

Mr. Whitaker is careful to note that anecdotes have very limited usefulness.  This is true and is due to the fact that while they tell a story about what happened, they cannot tell us a story about what would have happened to other people or what might have happened if things had been done differently.  Still, the first anecdote that he relates is about a woman who had a positive response (by her own admission) to risperidol.  This woman’s history is full of psychological stressors, traumas, possible psychosomatic illnesses, drug use, and eventually behavior that led to an initial diagnosis of bipolar disorder and a later diagnosis of schizoaffective disorder.  She was treated with a variety of medications that apparently allowed to to complete a college degree and form a lasting romantic relationship.  Mr. Whitaker notes that she repeatedly contacted him to say how her medication “saved” her.  She did note that she had some problems with the medication including stiff muscles from haloperidol, “depression” (not defined) from the lithium, possible beginnings of tardive dyskinesia, weight gain, and a subjective sense that she has reduced empathy.  Mr. Whitaker notes that she is not working and feels that the side effects of the medication contribute to her inability to work.

If Mr. Whitaker had stopped here, he could have concluded reasonably that hers was a life improved (but certainly not perfected and certainly accompanied by side effects) by her medications.  Instead, he chooses to ask questions that either are contradicted by his anecdote or cannot even be addressed by it.  He asks, “Is hers a story of a life made better by our drug-based paradigm of care for mental disorders, or a story of a life made worse?”  Well, Mr. Whitaker, she says that she was “saved” by her medication.  She was able to complete her degree and begin a long-term relationship.  Can we not trust her own assessment of her improvement?  He also asks, “How might her life have unfolded if when she suffered her first manic episode in the fall of 1978, she had not been immediately placed on lithium and Haldol, the doctors instead trying other means — rest, psychological therapies, etc. — to restore her sanity?”  This supposes that there are other therapies that have proven successful in treating manic episodes.  Currently, this is not an accepted assumption.  Once someone becomes manic to the point described in this patient’s history, you cannot make them rest or engage in psychotherapy.  He also asks, “Of if, once she had been stabilized on those medications, she had been encouraged to wean herself from the drugs?”  Well, we know from her story that she stopped (not weaned) herself from the drugs on multiple occasions and had relapses.  Would weaning her from the drugs have prevented her multiple relapses?  We can’t tell, but we have evidence that continuing medications reduces frequency of relapse.  He asks several other unanswerable questions before ending with “And if she had been able to fare well without drugs, how much more might she have accomplished in her life?”  As my father-in-law used to say (quoting Don Meridith), “If ‘ifs’ and ‘buts’ were candy and nuts, we’d all have a merry Christmas.”

After posing all of these questions, Whitaker admits, “There is, of course, no way of knowing what a life without medications might have been like for Cathy Levin.  However, later in this book we will see what science has to reveal about the possible course her illness might have taken if, at that fateful moment in 1978, after her initial psychotic episode, she had not been medicated and told that she would have to take drugs for life.”  Finally, Ms. Levin provides Mr. Whitaker with the straw man quote to wrap up this story,  “They don’t have any sense about how these drugs affect you over the long term.  They just try to stabilize you for the moment, and look to manage you from week to week, month to month.  That’s all they ever think about.”  I understand that this is Mr. Levin’s belief and that it might be true in some cases, but this seems to be more of a statement of Ms. Levin’s frustration than an meaningful statement of the mental status of the “psychiatry” golem.

The second anecdote is an inspiring and informative tale of a man who grew up isolated from his peers due to cultural differences, abused by his father, and into amphetamines, marijuana, and cocaine.  He eventually was diagnosed with schizophrenia.  He was medicated with haloperidol (which he did not like) and was suicidal on several occasions.  He continued to have worrisome behaviors (trying to have a gun smuggled into the hospital and helping patients escape the hospital) that resulted in further efforts to control his behavior.  Finally, something changed and he began to improve to the point that he is now a custodial father and an advocate for the mentally ill.  Mr. Whitaker would like us to believe that what changed was his “tonguing” his medications (hiding them in his mouth and spitting them out later).  Certainly, that was a change, but are we really willing to believe that this patient’s psychotic and disruptive behavior was caused by the medication rather than the medication being given in response to his behavior.  Of course, all I can do is guess (since I do not know this man), but I am more likely to believe that this man began controlling his behavior better and needed less medication.  Mr. Whitaker asks, “Given that his recovery began when he stopped taking antipsychotics, is it possible that some people ill with a serious mental disorder, like schizophrenia or bipolar illness, might recover in the absence of medication?”  Of course this begs the question.  How does Mr. Whitaker know that stopping the medication coincided with the start of his recovery?  It is just as likely (or more in my opinion) that his recovery was the cause of him stopping taking medication.

The third anecdote is a touching story about a woman initially diagnosed with major depression but eventually with bipolar disorder.  However, this story has both both good points to make and unfortunate errors.  It starts of with an error.  Mr. Whitaker describes the subject as seeming “like the last person who might have a life of mental illness awaiting her. She came from an accomplished family — her mother was a professor at Wellesley, while her father taught at several Boston-area colleges — and Monica was a child who excelled at whatever she chose to do.”  This is important (with the exception of mental retardation)– mental illness is not an intellectual problem; it is not a moral problem; it is not due to a lack of talent or skill.  To suggest otherwise is to slander the suffering.  Unfortunately, both Mr. Whitaker and the woman in question both revisit this fallacy repeatedly.  Now, on with the touching part of the story…  This woman initially suffered an intense depressive episode for which she was treated with an tricyclic antidepressant (an older type).  As sometimes happens, she began having symptoms characteristic of bipolar disorder.  There is conflicting opinion about whether this constitutes a change in diagnosis or whether such patients are still more characteristic of major depression than bipolar disorder when they are off medications.  Regardless, this started this woman down a long path of medications in an attempt to stabilize her mood.  She was tried on numerous antidepressants but these left her frequently suicidal.  Ultimately, she found more stability off the antidepressants and on lithium.  Though she finds the lithium helpful, she feels that she is not as artistically creative while on lithium.  This anecdote is the most disappointing because the American Psychiatric Association has recognized that antidepressants increase the risk of mood instability and recommends that most antidepressants be used with caution (and never alone).  It is disheartening to hear of patients suffering because of improper use of antidepressants (though it is not clear whether this was generally recognized during the time that this particular patient was being treated with antidepressants).  Still, this should not be continuing to happen!

The last anecdote focuses on a woman who may have been misdiagnosed with bipolar disorder and for whom treatment for bipolar disorder seems to have caused more problems than she would otherwise have gone through.  Mr. Whitaker cites this story as an example of the dangers of sloppy and imprecise diagnosis magnified by the significant side effects of psychiatric medications.  Good story.  You should read it.

The chapter closes with a discussion of Attention Deficit Hyperactivity Disorder (ADHD) and bipolar disorder in children.  Mr. Whitaker relates the stories of two families with young children facing a psychiatric diagnosis.  One family chooses to put their child on medication and one does not.  The stories illustrate well the difficulty that parents face when dealing with mild to moderate problems in behavior.  Mr. Whitaker poses some meaningful and important questions at the end of this section such as:  “Were there studies showing that drug treatment for ADHD or juvenile bipolar illness is beneficial over the long term?”  Good question.  “If you put a young child on a drug cocktail that includes an antipsychotic, how will it affect his or her physical health?”  Another good question.  “Can the child expect to become a healthy teenager, a healthy adult?”  Another very good question.  On the other hand, his first question (unfortunately a leading one) was “‘Did their child really suffer from a chemical imbalance?”  Is this question really important?  Sure, I don’t suggest that people be told that they have a chemical imbalance if we do not know that they have one.  When my patients come to me and say that they have a chemical imbalance, I try to give them a better understanding of what they are dealing with than this tremendously oversimplified statement.  Still, does it matter what the underlying cause is if there is effective treatment?  If the physician and the patient (or patient’s family) are paying attention to the good questions mentioned above, does it matter?

Why does Mr. Whitaker feel the need to include the question “did their child really suffer from a chemical imbalance?”  The pragmatist would say that the answer does not matter.  The fact THAT something works (as indicated by addressing the other questions Mr. Whitaker proposes) is more important than WHY it works.  The scientist might find it important because it is an interesting question and that piece of knowledge would be good to have.  With regard to the parent, however, I would expect that they would be closer to the pragmatist.  If so, then why lead with the above question?  I can think of a few possible arguments (but we must rely on conjecture because Mr. Whitaker did not make it explicit why this is important).

First possible argument:          1) “Psychiatry” believes that mental illness is due to a chemical imbalance.

2)  This book will show that they do not know that mental illness is due to a chemical imbalance.

3)  People who assert things they do not know to be true are deceiving you.

4)  “Psychiatry” is deceiving you.

Second possible argument:     1)  Medications, as chemicals, are only useful if they address chemical imbalances.

2)  Mental illnesses are not due to any known chemical imbalances.

3)  Medications are not useful to treat mental illnesses.

Third argument:                           1)  Medications cause chemical imbalances.

2)  Chemical imbalances cause conditions that look like mental illnesses.

3)  Medication-caused chemical imbalances cause conditions that look like mental illnesses.

There may be many close variations of these arguments one might think of, but I think that these two (or something like them) might be the reason that Mr. Whitaker needs to include the above question.  The first argument is interesting but unfortunately it is a straw man argument.  The second argument is based on a fallacy (the first premise), but this may simply be left unstated in the enthymeme (see part one of this series).  Now I don’t believe that Mr. Whitaker believes the second argument.  He goes out of his way to state that some people may benefit from some medications.  He has also been reported to have been supportive of psychiatric treatment in his previous writings.  Still, I think that some of the emotional impact that his book relies on is based on this unstated argument.  Finally, the third argument is one that he is just introducing in this chapter and one that will be pursued throughout the book.  It is a well-contructed argument whose truth value depends on the truth and generalizability of its premises.  I think it might be true for some particular individuals but not generalizable enough to explain the “epidemic” he wants to address.

Finally, some closing remarks.  In this chapter, Mr. Whitaker continues to wear his medication blinders.  He presents interesting case reports full of numerous potentially helpful facts, then (like the straw man “psychiatry” that he creates) chooses to focus only on the chemical explanation.  Could it not be the abuse his subjects experienced, the chronic stressors they encounter, the illegal drugs they used, or the demands of the society they live in that account for their recurrent illness and disability?  This chapter personalizes the problem of chronic mental illness but only pretends to focus our attention on a solution.

So my questions to any readers who happen by here are as follows:

1.  Is Rodion Rommanovich Raskolnikov mentally ill?  How can we know?

2.  If you somehow knew what was going on, would you have involuntarily hospitalized him?  How would you approach the decision?

3.  In the book, Rodion is found guilty of the murder but was given a reduced sentence because of his mental state.  Was justice done?

I hope that these questions will generate some productive discussion and lead some to enjoy this fascinating book.

Chapter I:  A Modern Plague.  Mr. Whitaker begins his book by outlining the scope of the mental illness problem, especially in America.  Indeed, the facts he marshals are impressive.  Next, sets up the straw man that he intends to destroy.  He introduces the antipsychotics, antidepressants, and antianxiety agents.  He notes that these are based on advances in neuroscience and molecular biology.  And he shows that the excitement about these treatments was promoted by promoted by the media and believed by the psychiatric profession.  Once he has set up this straw man, then it is time to reveal his real point.  He says (on page 5),

“Given this great advance in care, we should expect that the number of disabled mentally ill in the United States, on a per-capita basis, would have declined over the past fifty years.  We should also expect that the number of disabled mentally ill, on a per-capita basis, would have declined since the arrival in 1988 of Prozac and the other second-generation psychiatric drugs.  We should see a two-step drop in disability rates.  Instead, as the psychopharmacology revolution has unfolded, the number of disabled mentally ill has accelerated further since the introduction of Prozac and the other second-generation psychiatric drugs.  Most disturbing of all, this modern-day plague has now spread to the nation’s children.”

Thus, Mr. Whitaker sets out his goal for his book.  Before proceeding with his demonstration, he explicitly lays out the central question — “If we have treatments that effectively address these disorders, why has mental illness become an ever-greater health problem in the United States?”  After presenting some eye-opening statistics about the rate of disability among the mentally ill, he provides the answer his going to focus on.  He asks, “Could our drug-based paradigm of care, in some unforeseen way, be fueling the modern-day plague?”  He proposes that the following information will answer the question,

1.  “A history of science that unfolds over the course of fifty-five years, arises from the very best research, and explains all aspects of our puzzle.”

2.  “The history must reveal why there has been a dramatic increase in the number of disabled mentally ill.”

3.  (The history) “must explain why disabling affective disorders are so much more common now than they were fifty years ago.”

4.  (The history) “must explain why so many children are being laid low by serious mental illness today.”

5.  ‘We should be able to explain why [such a history] has remained hidden and unknown.”

Critique:

In his first chapter, Mr. Whitaker has used rhetorical technique to effectively advance his position.  Still, his technique reveals that his effort is designed to sway opinion and not to prove fact.  This is not to say that he does not cite relevant facts or cites them incorrectly, but is simply to say that his goal is not to prove that his hypotheses are true.

First, let’s address the straw man argument he is making.  He constructs this straw man (and names it “psychiatry”) that is only a caricature of psychiatry as it really exists.  It sprang into existence when medications were discovered and its scope of its interests contains only drugs and biological causes of mental illness.  Lest you think that I am exaggerating, on pages 10 and 11, this straw golem is described as reshaping society, teaching about chemical imbalances, teaching children in the schoolyard that they have something wrong with their brains, and teaching children about the nature of humankind.  And even more amazingly (we will discover), he is doing it all by himself!  I don’t think that Mr. Whitaker is going to have to work too hard to kill this straw man.  It’s a pretty easy one to take shots at.

Second, Mr. Whitaker often uses enthymemes to make weak points stronger.  An enthymeme is an argument in which one part of a syllogism is omitted or implied.  There is nothing technically wrong with this, but they can become so familiar to us that we do not keep our guard up and evaluate the implied premise or conclusion.  For example, a policeman might say, “He has the stolen money, so he must be the robber.”  He thus implies the premise that “only the robber could have the stolen money.”  A good lawyer would make the implied premise explicit and evaluate its truth.

Now, let’s look at some of Mr. Whitaker’s enthymemes quoted above.

“Given this great advance in care, we should expect that the number of disabled mentally ill in the United States, on a per-capita basis, would have declined over the past fifty years.”

We can look at this as an “if-then” statement as follows:  If a great advance in care for the mentally ill in the United States has occurred over the past fifty years, then the number of disabled mentally ill in the United States , on a per-capita basis, will have declined over this same period.  Is this true or false?  How would you know?  Is there anything that logically makes this statement necessarily true or obviously false?

The problem arises because this is not a complete syllogism.  Mr. Whitaker left out either a premise or a conclusion.  If you agree with him, then what are you assuming?  If you disagree with him, what are you assuming?  For example, we could complete a valid syllogism with statement 2 below:

1)  A great advance in care for the mentally ill in the United States has occurred over the past fifty years.

2)  Quality of care is the only factor that determines disability rates for the mentally ill, or all other factors affecting disability rate for the mentally ill are relatively unchanged over the past fifty years.  (I just made this one up, but it seems to be what Mr. Whitaker wants us to imply.)

3)  Therefore, the number of disabled mentally ill in the United States , on a per-capita basis, will have declined over this same period.

What do you think about statement 2?  Did you realize that this (or something very like it) was what was left implied? If Mr. Whitaker had made this statement explicitly, then in order to prove his point he would have to show that statement 2 was true or likely to be true.  I do not believe it.

Now that you have seen an example, try your hand at a few other enthymemes from the first chapter of Anatomy of an Epidemic.

We should also expect that the number of disabled mentally ill, on a per-capita basis, would have declined since the arrival in 1988 of Prozac and the other second-generation psychiatric drugs. 

We should see a two-step drop in disability rates. 

If we have treatments that effectively address these disorders, why has mental illness become an ever-greater health problem in the United States.

Finally (I know — tl;dr), Mr. Whitaker asks for what I believe will be impossible.  As noted above, he listed the data that he required to understand WHY we have such an increase in disability among the mentally ill.  His interest (at least for Anatomy of an Epidemic), however, is narrowly focused on medication.  We have good models describing the contributions of different factors to risk of mental illness.  We know what aspects of mental illness contribute to disability.  There is no reason that these models could not be expanded to include medication exposure.  Still, the only way to prove cause and effect is with an experiment, and I do not see an ethical way to randomly manipulate medication usage independent from all other confounding variables as would be required to test Mr. Whitaker’s hypothesis.

In summary, Mr. Whitaker’s first chapter is compelling writing.  It brings up important issues with regard to the magnitude of the problem of mental illness in our society.  Rhetorical methods are well constructed to sway and influence the reader, but a careful reading reveals the fault lines that will run through the remaining chapters and show this “anatomy” to be a distorted dissection of the body of evidence.

In the movie, Rapunzel was an 18 year old girl who had been stolen from royal parents.  She was stolen because she possessed the power to turn back time and prolong life.  This power had previously been stolen from an old woman who had found it embodied in a magic flower.  It was stolen from her in order to heal Rapunzel’s mother as she was giving birth.  The old woman then stole Rapunzel and regained the power she now embodied.

The creepy thing about the story is that for 18 years, Rapunzel has been kept in a tower by the old woman (who now looks forever young due to Rapunzel’s power).  She has been told that she is incapable of living outside the tower and that she absolutely needs her “mother’s” protection or else she will die.  Rapunzel dreams of getting out of the tower, but she obeys and works for her “mother.”  The song “Mother Knows Best” is one of the creepiest songs in the Disney repertoire (IMHO).

Later in the movie, a young man (a thief) comes to the tower and discovers Rapunzel.  She subdues him and makes him take her from the tower while her “mother” is gone.  He does so in order to recover a crown that he had stolen but Rapunzel had hidden.  The rest of the story is fun but beyond the scope of this post.

I thought of his movie while we were discussing involuntary hospitalization on this blog.  Rapunzel is certainly involuntarily imprisoned in her tower.  Not exactly like involuntary hospitalization, but close enough for this discussion.  I wondered, who is the psychiatrist in this picture?  I thought that many might see the psychiatrist in the “mother,” but in my experience, I think the young man fits the role better.  Here’s why.

It is true that Rapunzel is held against her will, but the “mother” and the young man each treat her very differently.  The mother sees Rapunzel as a treasure to hoard and protect.  Her aim is to hide Rapunzel away so that she cannot be stolen again.  The young man, however, is someone who can walk with her wherever she is.  He enables Rapunzel to leave the tower and try new activities to see how they work.

If you watch the movie, do you ever wonder why Rapunzel didn’t simply just leave?  She had the only access (her hair).  She could have left any time her “mother” was not around.  Before the young man arrived, she was stuck.  She could not make use of the abilities she possessed.  Once she had someone to help her, she was able to grow into a young woman able to make choices for her own benefit and act on them.  Though the movie is not a perfect metaphor, I would urge mental health caregivers to see ourselves in the role of the young man.  All of what Rapunzel accomplished, she did on her own.  What she needed was someone to walk with her and give her the courage to take control of her life.

With regard to the Rapunzel story and trauma, “The Inner World of Trauma” by Donald Kalsched uses the story of Rapunzel as a myth that illustrates the mind’s way of dealing the trauma.  In this view, the “mother” is Rapunzel’s real protector, but she has gotten too powerful and controlling.  Any wish to re-engage with the real world is severely punished.  In this way, the “mother” is the nightmare that warns against resuming contact with society.  The “mother” is the anger that leads to avoidance of living one’s normal life.  “Mother” will keep you safe in your room.  “Mother” is all you need.  On the other hand, the young man represents the urge to engage in life, grow, and be productive.  He tries to rescue the traumatized self from its imprisonment and so represents a threat (seen through the eyes of the “mother”).  These two representatives then fight for the future of the self.  Each on is a bitter enemy of the other but both are acting at least in part in the interest of the self.

Seen in this light, the Rapunzel story is resolved when the young man and Rapunzel overcome the “mother”, who once served a purpose but whose function is no longer needed.  The tower that was once a needed protective device can be left behind.  The world can be re-engaged.  Urges and appetites can be expressed.  Choices can be made.  Joy and suffering can be freely experienced.

Finally, mental health providers need to resist the urge to be the “mothers” in this story.  Like the young man, we can be protective, but we do so as we walk with our patients and as we encourage them to engage the world.

As part of my blog, from time to time I would like to post some ideas that show that biological psychiatry has value.  My goal is NOT to show that it has all the answers or even all the most interesting questions.  My goal is also NOT to defend every assumption or assertion made by every biological psychiatrist.  I would simply like to discuss the ideas underlying the field and how they are used to address the ideas of mental illness and what it means to be human.First, the fields of biological psychiatry and biological psychology, go back to the arguments for and against mind-body duality.  I will not re-hash all of these arguments here, but suffice it to say that there were philosophers who believe that our mind and our bodies were made out of different stuff (the dualists) and others who thought that our mind and body were made of the same stuff (the monists).  Among the monists, there were those that thought that the single stuff was “mind stuff” (the mentalists), that the single stuff was “material stuff” (the materialists), or that mental processes and brain processes were the same thing simply described from different points of view (the identity position).

Over time, the monists seemed to gain the upper hand in this philosophical debate, and the materialists and those holding the identity position became the most influential monists.  The dualism popularized by Descartes, fell into disrepute (by many but not all); and scientists of the mind increasingly became studiers of the brain.  This was not a random choice, however.  Throughout history, people had observed that those with head injuries often had alterations in their mental abilities.  Injuries to the back of the head often resulted in blindness.  Injuries to the front of the brain led to impulsive behaviors.  Strokes in the left hemisphere led to inability to understand or produce speech depending on where the stroke was.  Neuroscience began to reveal specialized areas of the brain and physiological processes capable to storing memories.  The more we knew, the more we became convinced that the mind is a function of the brain.

This explosion of information about the brain and how it produced sensations, movements, memories, physiological control of our bodies, and innumerable complex behaviors, led to immediate improvements in the field of neurology.  Neurologists quickly became adept and localizing lesions within the nervous system and predicting the likely effects of nervous pathology.  But still, there were behavioral problems that did not seem to correspond to any known brain lesion.  What were scientists to make of that?

The answer depended upon your philosophical views.  The scientific materialist saw such behaviors as signs of a malfunctioning brain.  Various metaphors were used to illustrate it such as clocks and computers.  Freud, however, developed theories based on a dynamic unconscious and explained at least some of these behaviors as extreme types of “normal” interactions among conflicting unconscious wishes, desires, beliefs, drives, anxieties, etc.  He developed a method to reveal these dynamics and improve the mind’s ability to manage such conflict.  This led to the development of a variety of “talking cures” for mental illnesses.  This view of mental illness could still be claimed by the scientific materialist since “unconscious wishes, desires, beliefs, drives, anxiety, etc.” are nothing other than functions of the brain.  Thus, even in this case, if these brain functions do not work together to enable a person to live a tolerable life, it can be addressed by fixing the brain.  Easy, huh??

The debate between the relative values of biological and psychological approaches to mental illness (a false dichotomy, IMHO) teetered back and forth for many decades.  Early triumphs of biological approaches include the discovery that General Paresis of the Insane was caused by syphilis and that complex behavioral changes could be caused by deficiencies in vitamin B-12.  The obvious behavioral changes caused by alcohol, opiates, hallucinogens, and stimulants showed that behavior could be pharmacologically manipulated.  More recent discoveries that some cases of obsessive-compulsive disorder are caused by Streptococcus infections and that depressive syndrome can be caused by hypothyroidism, lend further credence to the idea that our mental state rests on a foundation of biological processes.

Thus, it seems that biological approaches to mental health are here to stay.  There is a great deal of controversy over how this information may be used and what price we pay for relying on it.  Some believe that its benefits outweigh the risks.  Some believe that the risks of using this information is too great.  Regardless, the ideas behind biological psychiatry and psychology have grown to be foundational ideas in our society.  Even many of those who think they reject biological approaches to mental health unwittingly endorse it (e.g. “Don’t take those drugs; take my vitamins.”)  These beliefs are so prominent that they have practically become invisible.  I believe that these ideas are also very powerful and are worth careful consideration and serious critique.

When I have follow-up visits with my patients, I prefer them to come to the session with an agenda.  Of course, this does not have to be written out, but I think it is important for the patient to be the driving force behind the work done in the session.  Agenda items might consist of (but are not limited to) the following:

1.  Ongoing or new symptoms,

2.  Ongoing or new stressors,

3.  Medication side effects,

4.  Efforts to engage in normal activities of daily living (accompanied by a report of relative successes or difficulties),

5.  New medical problems and treatments, and

6.  Current goals.

Much of the early part of the session is usually spent talking about the above topics, how to understand them and integrate them into the patient’s life, and how they affect the treatment plan negotiated between myself and the patient.  By the end of this part of the session, my patient and I should have a reasonable agreement concerning what issues need to be addressed and a mutually acceptable way of addressing them.  If not, then a brief period of targeted Motivational Interviewing (too long to describe in this post) is used to try to improve mutual understanding, clarification of the patient’s goals, and identification of obstacles to progress (from the patient’s point of view).

Later in the session, we will take time to discuss the types of new treatments or alterations of ongoing treatments that are available to address the patient’s goals.  We will discuss the likely outcomes and side effects of each of the available choices and how to monitor progress (or lack thereof).  No decision needs to be made during the session if the patient is not ready to choose a treatment.  The patient may ask questions or may simply take additional time to consider how he wants to proceed.  Once the treatment decision is made, or we agree to delay the decision to let the patient make a decision later, the session is usually over.  A return appointment (if necessary) is scheduled by the office staff.

Importantly, if suicidal or homicidal thoughts are reported during the session, these will be addressed.  Every effort will be made to protect the safety of the patient or the object of the homicidal thoughts using the least restrictive means available.  Most such thoughts will not be found to indicate imminent harm to anyone, so no immediate action is necessary.  Some thoughts may indicate some danger, though the patient and I will be able to devise a plan that adequately minimizes the danger.  If so, then outpatient treatment may proceed as planned.  Very rarely, however, the thoughts and behaviors observed will raise the possibility of hospitalization, which will be sought voluntarily unless the patient simply cannot cooperate with this procedure.

]]> http://thealienist.wordpress.com/2011/07/13/follow-up-visits/feed/ 5 thealienist http://thealienist.wordpress.com/2011/07/11/what-to-expect-from-a-first-visit/ http://thealienist.wordpress.com/2011/07/11/what-to-expect-from-a-first-visit/#comments Mon, 11 Jul 2011 18:36:51 +0000 thealienist http://thealienist.wordpress.com/?p=142 ]]> Many of my patients are nervous when they come for their first visit to my clinic.  Many have fantasies about what will happen or concerns about things they will be asked to talk about.  They may worry about what I will think about their problems or if I will coerce them into some situation they fear.  I am writing this post for my patients and for others who might have concerns about what psychiatrists do.  This post addresses only my practice.  Other psychiatrists may do things very differently.

My first visit with a patient is usually scheduled for one hour.  During this time, I have many things I would like to accomplish:

1.  Familiarize my patient with key characteristics of the psychiatric interview,

2.  Get an overall understanding of my patient’s complaint,

3. Get a broad (if superficial) understanding of my patient’s physical and mental development,

4.  Get an overview of my patient’s past experience with mental health providers,

5.  Review my patient’s medical history, and

6.  Review my patient’s social history.

Each one of these goals actually encompasses numerous smaller objectives.  This makes the first visit a very busy session.  If possible, I would also like to establish a diagnosis (if one is applicable), discuss this diagnosis with my patient, and outline the available treatment options.  I find that I can usually accomplish this during the first hour, but sometimes achieving these goals will take longer.

CONFIDENTIALITY

I address the first goal by explaining to my patient that the information I receive from him is confidential within certain limits.  I tell him that while thoughts of harm to himself or others may occur during evaluation and treatment, these are confidential except in cases in which I have cause to believe that an imminent threat to himself or others exists and no other option can be found to address this threat.  In that case, I will be forced to hospitalize, inform the police, or inform Child Protective Services.  These, I tell him, are the options of last resort and should be avoidable under most circumstances.  I also inform him that his records may be released if compelled by a court order.  Finally, I tell him that if I get any information about him from any source other than him, I will tell him what information I received and who I received it from.  This part of the session is usually ended by asking the patient if he has any questions or concerns.

THE CLINICAL INTERVIEW

Goals 2 – 6 are achieved with a clinical interview.  During the early part of the clinical interview, I try to have my patients tell their stories in their own words.  I may occasionally ask questions to make sure I am understanding the story correctly, but mostly, the patients are free to tell it as they like.  Depending on the complexity of the story and the ability of my patients to tell it without excessive digression, this part of the interview may take between 15 and 30 minutes.  Most of the remainder of the session usually consists of questions aimed at eliciting the required information that was not provided in the patient’s story.  If there are important facts that my patient is not comfortable talking about, I will explain to them the need for this information and their right not to discuss it if that is their wish.  Often, they can convey at least a general impression of the needed information.  This additional questioning usually takes between 15 and 20 minutes.

FEEDBACK/DIALOGUE

If time is available, I will give my patients immediate feedback.  I will inform them of the diagnoses I am considering (if any), how I would determine which diagnosis is most appropriate, and what this distinction means in terms of treatment.  I will ask for feedback on the information I have given and ask if they have any thoughts on how they would like to be treated.  Any remaining time is spend considering treatment options, needs for referral, frequency of sessions, and/or medication informed consent.

Throughout the session, I make sure that my patient understands that he is responsible for change and that I am ready to help him to the best of my ability.  He gets to decide what changes are to be attempted in his life, and he gets to decide what measures are used to attempt these changes.  Most of my patients think that this is a satisfactory arrangement.

If all of this seems to be too much to achieve in one hour, it often is.  I must admit that one of my relative weaknesses is adhering to strict time limits for sessions.