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    Some people say that our province’s strong mental health laws save lives. A constitutional court challenge says they lead to discrimination, abuse, fear and the flight of psychiatric refugees.

     

    THE PSYCHIATRIC NURSE held out a paper cup with pills. Sarah clasped a handwritten note. Having learned not to protest loudly, the 24-year-old gave the nurse her note that read, “I have a right to my mind and my body.” Then, she reluctantly put the pills in her mouth.

     
    Sarah knew that she had to execute her escape out of British Columbia quickly, before the drugs seized control of her mind again.

     
    Sarah (she requested her name be withheld) is sharing her story to show support for a constitutional court challenge recently launched by Community Legal Assistance Society (CLAS). The Vancouver non-profit is arguing that a key part of British Columbia’s Mental Health Act, called “deemed consent,” violates the Canadian Charter of Rights and Freedoms.

     
    “At CLAS, we’re routinely told that people are either considering leaving BC to avoid our deemed consent laws, or that they’ve done so in the past,” says Laura Johnston, one of the lawyers representing three plaintiffs in the case.


    CLAS has many concerns about BC’s Mental Health Act, explains Johnston. However, this case is focused on how the “deemed consent” provision violates rights to security of the person and equality before the law. “This case isn’t arguing that forced treatment can never be constitutional,” says Johnston, “But it does say that forced treatment which is imposed unilaterally by a doctor with no checks or balances and no recourse to anybody else is unconstitutional.”


    Every Canadian has the right to allow or refuse medical treatments, even if our choice could cause injury or death—such as choosing whether to undergo risky surgery. We can write advance directives about what we will and won’t accept if we lapse into a coma or otherwise become mentally incompetent, and appoint a “substitute” to make decisions for us. However, in BC, the moment we become an involuntary psychiatric patient, those rights are eviscerated. Mentally competent or not, and regardless of what’s in our advance directive or what our substitute says, we are “deemed” to consent to any treatments a psychiatrist recommends.


    “I was shocked when I came across these sections of [BC’s] Mental Health Act. I thought I was misunderstanding things,” says Melanie Benard, a lawyer with the Council of Canadians with Disabilities (CCD) which is one of the plaintiffs in the case. “There’s a blatant violation of the equality and liberty rights of people with disabilities,” she says.

     

     

    Escape from British Columbia.jpg

    Benard says psychiatric patients’ rights were clarified in constitutional law 25 years ago and implemented in every province—except BC. For example, in other provinces, after being involuntarily committed, a person still cannot be involuntarily treated until a competency test is conducted. “You look at things like, does the patient understand their diagnosis? Do they understand the treatment that’s proposed, the risks and benefits of undergoing the treatment?” says Benard.


    “It’s really discriminatory to assume that everyone with a mental health problem is mentally incapable of making their own treatment decisions,” says Johnston. She says it’s also important to understand how “wide-sweeping” involuntary treatment has become. “A lot of people believe that you have to be a danger to yourself or others to be involuntary, and that’s just not true.” In BC, anyone can be committed if a physician believes that the person has a mental disorder and that committal could provide “protection” or prevent the person’s “mental or physical deterioration.” 
    “It gives a lot of discretion to the doctor,” comments Johnston.

     
    According to government statistics, BC psychiatrists have been involuntarily committing people at unprecedented rates: 13,641 people last year—a doubling since 2002, or 73 percent increase per 100,000 people.

     
    Though statistics weren’t available, it’s widely believed that the use of “Extended Leave” has increased even more dramatically. This occurs when someone is considered well enough to be released from hospital and live at home, but is still being forcibly treated. And there seem to be more people like Sarah who voluntarily seek help, only to get committed if they disagree with recommended treatments.


    Jonny Morris, the Canadian Mental Health Association’s (CMHA) provincial policy director, says involuntary treatment has been “a long-standing issue” of polarized contention among patients, family members, service providers and community groups. Morris hopes that this constitutional challenge will “raise public awareness about an often hidden part of the system” and promote “respectful” dialogue about how things could be managed differently.

     
    The initial court submission from Community Legal Assistance Society provides a glimpse into this hidden world.

     

     

    The dangers of psychiatric treatments 
    Plaintiff Louise MacLaren is a 66-year-old retired nurse from Victoria. She’s been frequently treated against her will in hospital and at home over the decades. According to the submission, MacLaren experiences “extreme anxiety” when forced to undergo electroconvulsive therapy (ECT), which causes her “confusion and disorientation” for weeks afterwards, and permanent memory losses. While a typical ECT treatment involves 12 rounds of shocks over three weeks, MacLaren has received 300 rounds. “In 2010, staff administering ECT forgot to place a mouth guard in Ms. MacLaren’s mouth during the treatment,” says the submission. “Ms. MacLaren shattered her teeth due to the convulsions in her jaw[.]”


    The other plaintiff is a 24-year-old Vancouver man with a Master’s degree in music and piano. Since 2015, he’s been forced to take antipsychotic medications at home that cause “involuntary movements, muscle stiffness, muscle pain, and loss of dexterity, all of which impede his ability to play the piano.” These side effects, the submission states, cause him deep suffering “because playing piano is such a fundamental aspect of his life.”

     
    Apart from Council of Canadians with Disabilities, the plaintiffs aren’t speaking to media. Other people, though, paint an equally grim picture of involuntary treatment.


    After what she calls a “bad event” in her life, Sarah went to a Lower Mainland psychiatric hospital seeking help. She asked for a sleep medication, but didn’t want anything more. “I wanted to be able to manage what was going on for me, especially relating to the emotions that I was feeling, and the negative feelings, without medication…That was very important to me.”


    However, she was also given an antipsychotic. “It was an ugly, ugly feeling,” says Sarah, describing how the antipsychotic dulled her thinking and emotions. “If a family member came to visit me, I wouldn’t feel that happiness that they were there. Which was terrifying.”


    Sarah asked to stop the antipsychotic. Instead she was made an involuntary patient and told that if she didn’t take it, then security would inject her. So she continued to take the drug orally, which was almost equally repugnant to her. “The fact that I had to do this to myself…It’s you actually taking the pill and putting it in your mouth.”


    For many, involuntary treatment is often violent.

     
    Irit Shimrat is the Vancouver-based author of Call Me Crazy: Stories from the Mad Movement, and editor of a magazine published by the recently shuttered West Coast Mental Health Network—BC’s only charitable non-profit service organization run by and for people who’ve experienced psychiatric treatment. (WCMHN had its $100,000 in annual funding axed by the BC government without explanation, while hundreds of millions in new funding has gone to conventional services run by mental health professionals.) Shimrat has twice gone for over a decade without any psychiatric involvement, but in between those periods has been forcibly treated over a dozen times. The last time that she “went crazy,” says Shimrat, was after both her closest friend and her mother died. “I was shattered emotionally, and I was behaving in ways that were very disturbing to my neighbours.” When in acute distress, Shimrat’s been apprehended after throwing her belongings out the window, and after running around naked yelling “Emergency!”

     

     

    Shimrat says many people like her experiencing intense mental turmoil become afraid and “loud and feisty and angry and irrational” when threatened with forced treatment. In response, staff can become “mean,” she says. During one admission, Shimrat says she fought as she was stripped in front of male police and orderlies, tied to a gurney in four-point restraints, injected with an antipsychotic, and locked in isolation. “The experience of being locked up is brutal,” comments Shimrat. “But the experience of being locked up and then debilitated with antipsychotics is much worse.”


    Antipsychotics are tranquilizing medications that are the most commonly used drugs in situations regarded as short-term “psychiatric emergencies” or long-term “psychosis.” While some people can find a tolerable dosage that quells their mind but leaves them still functional, for others—especially when they’re not allowed to participate in treatment decisions—antipsychotics can be debilitating.

     
    “The whole time that I was ever on antipsychotics I sort of fluctuated between wanting to die and thinking that I had died and gone to hell,” says Shimrat. “All colour was drained from the world, like everything was grey, and I couldn’t remember where I was from moment to moment or why I was standing where I was standing, what I had been planning to do. There was just a sort of sense of grinding, endless tedium and pain, physical pain as well as the pain of not being able to think.”


    Shimrat says she has also experienced akathisia, a restlessness and agitation that 30 percent of antipsychotic users sometimes experience and that can, in extreme cases, cause suicidal feelings and violent rages. “It’s horrible,” she says.


    “I’ll never recover completely from the trauma of it,” says Shimrat. Her experiences of being involuntarily treated, she says, have been “infinitely worse than even the worst moments of my so-called mental illness.” Shimrat believes that many psychiatric patients are becoming worse and not better because “they’re having their brains tampered with” in these frightening and damaging ways.


    For her part, Francesca Simpson says she’s “feeling pretty good” on medications because they “bring me down and take the edge off.” However, she wants more control over the types and amounts. She’s currently being administered a long-acting antipsychotic injection, plus two antipsychotics and a mood stabilizer daily, which she finds excessive. Since 2010 she’s been almost continuously involuntarily treated in her home by an Assertive Community Treatment (ACT) team. Simpson describes it as “intrusive,” “humiliating” and “demeaning.” She must be at home at certain times every day to have her meds “witnessed.” For the injections, she must pull her pants down. ACT staff change constantly; she prefers women but can’t refuse the “strange men” entering her home. Staff probe her personal life while looking for signs of any emerging need to re-hospitalize her. “Everything that I do is pathologized,” says Simpson.

     

     

     The whole experience “used to just make me furious,” says Simpson, “but I’ve given up on that.”


    Many people raise concerns that, over the long term, treating people against their wills dissuades even those who want help from seeking it, because it undermines trusting relationships with mental health practitioners. “It’s dangerous to ask for psychiatric help,” Simpson concurs. “Certainly when I get through this, if I’m ever in trouble again, I will go nowhere near that system.”

     

     

    Trust and distrust of psychiatry
    Several health authorities declined to provide interviews about involuntary treatment. The BC government issued a written statement saying that some patients “may not understand or realize that they need psychiatric care.” That’s also the concern for Deborah Conner, provincial director of the British Columbia Schizophrenia Society, who says BCSS could intervene in the CLAS case.

     
    Conner bristles to hear words like “outdated” linked to BC law. “The reality is our Mental Health Act is actually leading the charge in doing the least harm.” Conner says the “safeguard” that BC law provides is that people don’t “languish” in hospital but get treatment quickly and continually, which she claims prevents brain matter loss. “That’s been proven,” she says. “When you have early intervention which includes medication, those treatments actually prevent ongoing brain damage.”

     
    “There are very many people in this world of psychosis who have no way—they don’t share the same reality—they have no way of stepping outside their illness and having insight into what’s happening to them,” says Conner. “We have lots of people who said, ‘Thank God you treated me forcibly, because if you didn’t, I would be dead.’”

     
    I mention that others describe forced treatment as traumatizing.


    “Unfortunately, in some cases that’s the only way to save that person so that they can get treated and get on a path to recovery,” says Conner. “Just painting [with a broad] brush, saying in all these cases it should be treated this way and nobody should be traumatized, that’s like seeing with rose-coloured glasses.”


    BCSS shares a little common ground with CLAS. “We’ve always supported family or caregiver involvement in any situation,” says Conner. The BCSS wants policies allowing people to have psychiatric advance directives and to appoint family members or others to participate in admissions and discharge planning. But BCSS stops short of wanting anything legally binding. Conner says psychiatrists must retain powers to exclude appointees who aren’t “appropriate” and to bypass advance directives.


    What about people seeking help at hospitals just for depression or anxiety at levels that might not unduly interfere with their competency to make treatment decisions? Conner points out that long-term involuntary treatment requires two psychiatrists to agree. “If people are involuntarily committed, it seems to us that there’s a reason why that happened.”


    I suggest that it sounds like Conner is putting a lot of trust in psychiatrists. “When you have two psychiatrists who’ve done a thorough review and assessment and where they have family input, that’s the trust,” responds Conner. She concedes that such assessments can be difficult, but believes that medically-trained psychiatrists are best qualified to make them.


    In contrast to Conner, Shimrat argues that involuntary psychiatric treatment is primarily a means for policing very upset and/or very socially disruptive but otherwise law-abiding people, that has become culturally acceptable because it is masked as science-based health care. “Psychiatry is seen as a branch of medicine and distress is seen as a form of illness,” says Shimrat. “And so with the mindset that they’re saving lives and improving things for people, the practitioners feel that they’re morally in the right.”


    Certainly, pharmaceutical industry money and influence have had profound impacts on psychiatry and our cultural beliefs. Governments, families and patients alike are often swayed by psychiatrists’ assertions of “proven” and “evidence-based,” where more accurate would be “some studies seem to suggest…” Barely a day goes by, for example, that we don’t hear about blood tests for depression, brain scans for anxiety disorders, the genetics of schizophrenia, brain damage caused by psychosis, and unequivocally “safe and effective” psychotropic pharmaceuticals. If any one of these “discoveries” were ever truly validated, though, it would be Nobel Prize-worthy. However, the last time psychiatry garnered a Nobel was for lobotomies—since then, Nobel committees have apparently more rigorously vetted psychiatric claims.

     
    Instead, the widely promoted “chemical imbalance” theory of mental disorders has been so resoundingly debunked that prominent psychiatrists like Ronald Pies have taken to insisting that it was only an “urban legend” which no “well-informed psychiatrists” ever believed. The American Psychiatric Association recently clarified that no mental disorders can be detected through any biological tests. “Anti-anxiety” drugs are just addictive sedatives. “Antidepressants,” “antipsychotics” and “mood stabilizers” are marketing names for drugs with clinical pharmacology descriptions stating that their “therapeutic mechanism of action is unknown”—while their known harmful side effects are legion, including sometimes brain damage. And there’s a growing body of research suggesting that, over long-term use, most psychiatric medications are doing most people more harm than good, while being extremely difficult to withdraw from.


    The ultimate recourse for involuntary treatment proponents is to argue that disordered people “lack insight” while, as BCSS board member John Gray has written, “[C]ompulsory treatment will usually restore someone’s freedom of thought from a mind-controlling illness…”

     
    Though superficially compelling, these are philosophical—not medical—assertions that provoke many questions. How often and for how long do we keep aggressively “freeing” someone’s mind, exactly, before the person becomes free enough to refuse our interventions? Who among us has the rightful authority to determine who has “proper” insight into reality? Is it crazy to be driven mad by an insane and destructive society, or is it a sign of sensitivity that should be nurtured and supported rather than drugged away? Meanwhile, if we simply claim that the answers are “obvious” to anyone “sane,” then we cut off an important human legacy and potentiality—our ability to deeply question ourselves and our culture.

     

     

    Stigma, stereotypes…sanism
    If final judgments to psychiatrically treat people against their wills are not truly being driven by indisputable medical science, then what is driving them?

     
    A person in BC can appeal a committal to a three-person tribunal. Hearings are not open to the public, not bound by rules of court process, and notoriously erratic. Patients are often forcibly drugged during hearings. Though every patient has a right to a legal aid lawyer, hundreds annually cannot get one because government hasn’t provided sufficient funding. Less than one-fifth of patients win.

     
    In August, a patient sued to push the BC government to fund enough legal advocates. “It’s very troubling that despite numerous calls on the government to increase funding to ensure that everyone who is entitled to legal aid gets it, that they’ve pretty much ignored the problem,” says Kate Feeney of the BC Public Interest Advocacy Centre, co-counsel in that case. (Government began negotiating, so the case adjourned until December.) Many argue that this whole farce is but one example of how prejudiced society is against psychiatric patients—pointing to how even the BCSS and CMHA have done little over the years to raise alarm about this legal representation crisis.

     
    Lawyer Benard believes stigma, stereotypes and sensational news stories about rare cases of violence drive much of society’s support for involuntary treatment. “We feel like we need to be protecting these people at all costs and that we know what is best for them better than they can themselves.” Benard notes that organizations run by people with disabilities or with experience as psychiatric patients, like Council of Canadians with Disabilities, often take different positions from most mental health organizations, which are typically run by mental health professionals and family members of patients. “Sometimes there is a conflict between protecting the rights of a person in crisis and the desires and wishes of those around them,” says Benard.


    Because of these ubiquitous prejudices, Shimrat says that she’s “really happy” about the constitutional challenge but also skeptical. “Whatever is going to be on paper is unlikely to change what happens on the ground.” Indeed, Ontario’s rate of involuntary treatment seems to be only slightly lower than BC’s.


    A former BC tribunal chair says she saw appeal panels frequently exhibit a “deference to” and “over-reliance on” psychiatrists’ perspectives. Michael Perlin, an expert on US mental health law, blames it on “sanism.” Perlin’s books show, in encyclopaedic detail, that a near all-permeating deference to psychiatrists exists within judicial processes, coupled with an “irrational prejudice of the same quality and character of other irrational prejudices” towards people diagnosed with mental disorders.

     

     

    Sarah splits BC
    Sarah requested an appeal. Her psychiatrist didn’t have to, but chose to stop forcibly medicating her. Faculties back intact, Sarah researched and discovered that Alberta’s laws were different. She began preparing an escape plan, just in case.


    The review panel for Sarah’s appeal reached a 2-1 split decision—leaving Sarah incarcerated. She began a silent protest, giving staff handwritten objections when they handed her drugs. For two days, her tight-lipped protest also provided a cover for tonguing and not ingesting the pills. But her psychiatrist soon proposed an antipsychotic injection that would keep Sarah drugged for weeks. Sarah worried that her thinking would become so foggy she’d never be able to execute her plan. “I knew I had to leave,” she says.

     
    Into a small satchel bag she stuffed a change of clothes. Cash she’d been withdrawing to avoid using a trackable credit card. Her iPad. She acted like she was going for a smoke break, walked to where she could get a taxi, and got out where she could disappear into a crowd. She changed her clothes in a public bathroom and threw out the ones she’d been wearing at the hospital. She cut off her hair. Then she bought a ticket for a red-eye bus to Alberta.


    “It was the most nerve-wracking bus ride of my life,” says Sarah. “I had a feeling every time we stopped that there would be RCMP waiting for me.”


    The driver announced when the bus had crossed into Alberta and begun the descent from the mountains. “I actually got very emotional as I crossed the border,” says Sarah. “I’d spent the entire night in the dark…It was really beautiful, early in the morning, the sun was coming up…I was crying, and there was somebody sitting a couple seats from me, said ‘Are you okay?’ And I was like, ‘Yeah, I’m fine.’”


    But as the bus sped into Calgary, she saw her picture appear on the RCMP website as a “missing person,” along with a warrant for her arrest.

     

     

    There are other ways
    Media coverage of the CLAS constitutional challenge has been sympathetic, and there seems to be mounting support for possible mental health law changes in BC to remove “deemed consent” and allow people to have competency tests, advance directives, and substitutes.

     
    The CMHA’s Morris says there should be general equality between the way people experience both physical and mental health care. “What would it take to ensure that people with mental illness are afforded all of the similar rights and protections [as everyone else]?” Morris also notes that forced treatment is often related to a late-stage crisis that might have been prevented with more voluntary supports in our communities, and improvements in other “social determinants of health” like housing, income, employment, and education.

     
    Similarly, Chris Summerville of the Schizophrenia Society of Canada says that his organization is recognizing advances in understanding of how people can recover through self-empowerment and assistance in meeting their biological, psychological, social, spiritual and communal needs. In contrast to the BC Schizophrenia Society position, Summerville feels BC law could be updated to have “a little more care and caution” built into it.


    Francesca Simpson and Irit Shimrat suggest that if we at least made our psychiatric hospitals warm, respectful places that provided plenty of options and supports for people to voluntarily explore enhancing their own wellness, we wouldn’t have to worry much about people not wanting to go for help, or “languishing” in them. Offering robust counselling and psychotherapy services in our hospitals would seem to be a logical start—rather than relying almost totally on drugs and ECT, as is now the case.


    Shimrat points to alternative approaches such as exercise, arts, mind-body practices, and non-drug emergency response methods like peer respite homes and Open Dialogue family interventions. “There are other ways,” says Shimrat. “But that knowledge is suppressed and disrespected because of the strength of the status quo.”


    Johnston says she’s “under no illusion” that the constitutional challenge will cure the mental health system or society. But she hopes that at least the BC government will “engage with stakeholders and many different people and organizations to craft a new, fair legal framework for treatment for involuntary patients.”

     

     

    “Not detainable”—in Alberta
    Sarah turned herself in to Calgary police. She overheard the officer explain to her psychiatrist in BC that, under Alberta mental health law, Sarah didn’t appear detainable. “It was a good feeling,” she says. “But I knew it was a very scary next chapter of my life, starting it completely from the ground up.”


    Sarah is now in Ontario, where she has supportive family, and is studying natural ways of improving well-being. “I’ve been very fortunate in certain respects,” says Sarah. “What am I missing? My friends. My family… I was seeing somebody, that was a positive thing in my life, and that’s gone now.”


    She finds the term “psychiatric refugee” strong, but also feels it’s in some ways apt. “I would love to come back,” says Sarah. “If the laws change, I probably would.”


    Rob Wipond has been reporting on the lack of civil rights in the BC mental health system since 1998. He is the recipient of a number of journalism awards for his writing in Focus.

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    As a psychiatrist in the U.S., I am not in a position to comment on the legal and ethical issues raised in this piece, vis-a-vis practices in British Columbia. However, having been cited in the piece in connection with the so-called "chemical imbalance theory" (which was never a bona fide theory in the scientific sense of that term**), I do feel compelled to address several inaccuracies in the discussion of psychiatric medications.

    The piece makes many claims about the alleged ineffectiveness or harmful side effects of psychiatric medications, without providing substantial evidence or references; e.g.,

    " “Anti-anxiety” drugs are just addictive sedatives. “Antidepressants,” “antipsychotics” and “mood stabilizers” are marketing names for drugs with clinical pharmacology descriptions stating that their “therapeutic mechanism of action is unknown”—while their known harmful side effects are legion, including sometimes brain damage. And there’s a growing body of research suggesting that, over long-term use, most psychiatric medications are doing most people more harm than good, while being extremely difficult to withdraw from."

    These claims are, at best, gross oversimplifications, and, at worst, misleading and unsupported canards. To be sure: psychiatric medications, like all medications, can have substantial side effects, which must be carefully balanced against their benefits. This is true in every medical specialty, from oncology to neurology. But overall, medications used in psychiatry are, on average, as effective as those used in general medicine [1], and their side effects are usually manageable with dosage reduction or substitution. There is also good evidence that some psychiatric medications--such as lithium (used in bipolar disorder) and antipsychotics--can reduce suicide rates in appropriately diagnosed patients. [2,3]. Quality of life is also enhanced for many patients taking antipsychotics or antidepressants [4,5,6].

    Of course, psychiatric medications can be inappropriately prescribed or overused--just as antibiotics can be over-prescribed by GPs--but when carefully prescribed and monitored, they may literally be life-saving for many desperately ill and suffering patients.

    Ronald Pies MD

    Professor of Psychiatry

    SUNY Upstate Medical U.

    and Tufts USM

    [Dr. Pies discloses no financial conflicts of interest or associations with any pharmaceutical companies]

    1. Leucht S. et al: Br J Psychiatry. 2012;200:97-106. http://bjp.rcpsych.org/content/200/2/97.long. Accessed September 22, 2016.

    2. Bernard V et al:

    Encephale. 2016 Jun;42(3):234-41. doi: 10.1016/j.encep.2016.02.006. Epub 2016 Mar 19.

    3. Haukka J et al:

    Pharmacoepidemiol Drug Saf. 2008 Jul;17(7):686-96. doi: 10.1002/pds.1579.

    4. Pies RW, Pierre JM:

    http://pro.psychcentral.com/quality-of-life-and-the-case-for-antipsychotics/0015547.html

    5. Reed C et al, J Affect Disord. 2009 Mar;113(3):296-302. doi: 10.1016/j.jad.2008.05.021. Epub 2008 Jul 7.

    6. Skevington SM, Wright A: The British Journal of Psychiatry Mar 2001, 178 (3) 261-267;

    **See, e.g., Pies R: http://www.mentalhealthexcellence.org/nuances-narratives-chemical-imbalance-debate-psychiatry

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    A magazine does not follow the same protocols as a medical journal in terms of providing citations. But if asked, I am happy to provide references. However, I cannot discern what exactly Ronald Pies is suggesting are the “inaccuracies” in my article; consequently, I feel compelled to provide evidence for everything he quotes from my article, and to review his own citations as well, because it concerns me that he seems to be trying to imply to readers that everything in the quote is inaccurate.

    First, it seems we are in agreement that the “chemical imbalance theory” of mental disorders has never been truly a theory by any reasonable scientific standards. I myself would call it more of a promotional gimmick masquerading as a scientific theory that has had extraordinary popular success.

    Benzodiazepine drugs are the most common drugs used as anti-anxiety medications, prescribed to over 5% of U.S. adults in 2008.(1)  According to the official FDA drug label for every benzodiazepine, these are “sedating” drugs and Schedule IV controlled substances under the Controlled Substance Act by the U.S. Drug Enforcement Administration because they “can be abused or lead to dependence.” (2)

    I sincerely hope that Dr. Pies understands that the terms “antidepressant”, “antipsychotic” and “mood stabilizer” are indeed marketing names and not actually scientific, chemical names for drugs. But if he does not know that and needs a reference to begin his research, he might find this article on the history of the term “mood stabilizer” a good place to start.(3)

    If Dr. Pies reads the official FDA-approved drug information labels for psychiatric medications – and I would hope that he at least occasionally does, as a psychiatrist with prescribing powers and legal authority to forcibly treat people – then he should know that in the “Clinical Pharmacology” section of the FDA long-form drug label for literally every single psychiatric drug that is approved for use in the United States appears the phrase or an analogue for the phrase “The precise mechanism by which (drug X) exerts its (psychiatric) effects is unknown.” (3)

    Dr. Pies does indicate awareness that psychiatric drugs do have adverse effects, so that seems to be covered. I certainly agree that some of these adverse effects can be managed by many people, if by managed we mean survived on a daily basis.
    It’s difficult to imagine that Dr. Pies is unaware that there is a growing body of evidence that psychiatric drugs might be doing many people more harm than good over the long term, since the longest-ever formal studies into both ADHD stimulants and antipsychotic drugs, for example, returned virtually no evidence of overall benefits, and clear suggestions of harm. (4-9)

    As for drug withdrawal effects and the necessity for careful tapering, these facts are described in the FDA drug labels for antidepressants, ADHD stimulants, benzodiazepine anti-anxiety drugs, and anticonvulsant mood stabilizers.(10) In terms of major psychiatric drug classes, that leaves only antipsychotics – though antipsychotic discontinuation syndrome has long been recognized in the scientific literature. (11)

    That covers all of my statements. As for Dr. Pies own statements and citations, let’s run through some of the key ones:

    “[O]verall, medications used in psychiatry are, on average, as effective as those used in general medicine”. One might assume from this characterization that the effectiveness comparison would include some of the reasonably effective medications from general medicine like, say, antibiotics, insulin, or oral contraceptives. Instead, the authors of the cited study chose to compare psychiatric medications to cholesterol-lowering drugs, anti-hypertensives, pre-diabetes treatments, antacids, and blood pressure medications – basically, a veritable hit parade of the most intensely marketed, dubiously effective, and immensely controversial “lifestyle” drugs of the past two decades. The issue we’re seeing here, I would suggest, isn’t that the standards of psychiatry are rising to the level of modern medicine; rather the standards of modern profit-driven, direct-to-consumer-advertising-driven medicine are increasingly falling to the levels of psychiatry.

    The alleged “good evidence” that lithium reduces suicide rates comes from some observational studies that are prone to all manner of confounders and biases. Conversely, all of the randomized, placebo-controlled trials were explored in a 2004 systematic review published in the American Journal of Psychiatry, which found that, “Data from these randomized trials were insufficient to estimate the possible suicide prevention effect of lithium[.]” (12) And notably, from what I can see, the particular study that Dr. Pies cites states only that lithium appeared to be less suicidogenic “in comparison to antidepressants or other mood-stabilisers”.

    In response to Dr. Pies statement of absolute certainty that “Quality of life is also enhanced for many patients taking antipsychotics”, I’ll quote what the authors of one of Pies’ cited articles actually wrote: “There are certainly large gaps in our knowledge of how antipsychotic medication affects “quality of life” as compared with placebo or no medication treatment. In particular, most studies are not randomized or placebo-controlled and of those that are, most are short-term (< 1 year). Our conclusions, therefore, must be considered provisional.” Of note, casual readers may wish to be informed that one of the authors of the above quote – which I think most readers would say sounds distinctly uncertain about the alleged quality of life benefits of antipsychotics – is actually Ronald Pies. And of further relevance on that topic are again my citations (4) and (5) which I expect Dr. Pies knows are the only major studies of the long-term impacts of antipsychotics, and which his cited article co-written by himself curiously avoids even mentioning.

    Finally, of course, lots of things “may” be life-saving for some people in some circumstances. But science is supposed to be about evidence and, on that point of his, scientific references are notably absent. If Dr. Pies can provide any actual solid scientific evidence from double- or triple-blinded, placebo-controlled trials that any psychiatric drug has ever been proven to be “life-saving”, the Nobel medical committee is waiting to hear from him. Until then, as a journalist who has researched this topic extensively over the years, I can say very confidently that this kind of misleading, drug-promotion rhetoric is having very unfortunate impacts on far too many people.

    Rob Wipond

    (1) Olfson, Mark, Marissa King, and Michael Schoenbaum. “Benzodiazepine Use in the United States.” JAMA Psychiatry 72, no. 2 (February 2015): 136–42. doi:10.1001/jamapsychiatry.2014.1763.

    http://jamanetwork.com/journals/jamapsychiatry/fullarticle/2019955

    (2) U.S. FDA. Klonopin (clonazepam) Drug Label. (March 25, 2016)

    http://www.accessdata.fda.gov/drugsatfda_docs/label/2016/017533s055lbl.pdf

     

    (3) Harris, Margaret, Summit Chandran, Nabonita Chakraborty, and David Healy. “Mood-Stabilizers: The Archeology of the Concept.” Bipolar Disorders 5, no. 6 (December 1, 2003): 446–52. doi:10.1046/j.1399-5618.2003.00069.x.

    http://onlinelibrary.wiley.com/doi/10.1046/j.1399-5618.2003.00069.x/abstract

     

    (4) Harrow, M., T. H. Jobe, and R. N. Faull. “Do All Schizophrenia Patients Need Antipsychotic Treatment Continuously throughout Their Lifetime? A 20-Year Longitudinal Study.” Psychological Medicine 42, no. 10 (October 2012): 2145–55. doi:10.1017/S0033291712000220.

    https://www.scribd.com/document/154255449/Do-all-schizophrenia-patients-need-antipsychotic-treatment-continuously-throughout-their-lifetime-A-20-year-longitudinal-study

     

    (5) Wunderink L, Nieboer RM, Wiersma D, Sytema S, and Nienhuis FJ. “Recovery in Remitted First-Episode Psychosis at 7 Years of Follow-up of an Early Dose Reduction/Discontinuation or Maintenance Treatment Strategy: Long-Term Follow-up of a 2-Year Randomized Clinical Trial.” JAMA Psychiatry 70, no. 9 (September 1, 2013): 913–20. doi:10.1001/jamapsychiatry.2013.19.

    http://archpsyc.jamanetwork.com/article.aspx?articleid=1707650

     

    (6) Richters, J. E., L. E. Arnold, P. S. Jensen, H. Abikoff, C. K. Conners, L. L. Greenhill, L. Hechtman, S. P. Hinshaw, W. E. Pelham, and J. M. Swanson. “NIMH Collaborative Multisite Multimodal Treatment Study of Children with ADHD: I. Background and Rationale.” Journal of the American Academy of Child and Adolescent Psychiatry 34, no. 8 (August 1995): 987–1000. doi:10.1097/00004583-199508000-00008.

    https://www.ncbi.nlm.nih.gov/pubmed/7665456

     

    (7) Jensen, Peter S., L. Eugene Arnold, James M. Swanson, Benedetto Vitiello, Howard B. Abikoff, Laurence L. Greenhill, Lily Hechtman, et al. “3-Year Follow-up of the NIMH MTA Study.” Journal of the American Academy of Child and Adolescent Psychiatry 46, no. 8 (August 2007): 989–1002. doi:10.1097/CHI.0b013e3180686d48.

    https://www.ncbi.nlm.nih.gov/pubmed/17667478

      (8) Molina, Brooke S. G., Stephen P. Hinshaw, James M. Swanson, L. Eugene Arnold, Benedetto Vitiello, Peter S. Jensen, Jeffery N. Epstein, et al. “The MTA at 8 Years: Prospective Follow-up of Children Treated for Combined-Type ADHD in a Multisite Study.” Journal of the American Academy of Child and Adolescent Psychiatry 48, no. 5 (May 2009): 484–500. doi:10.1097/CHI.0b013e31819c23d0.

    https://www.ncbi.nlm.nih.gov/pubmed/19318991

     

    (9) Stratton, Allegra. "Ritalin of no long-term benefit, study finds." The Guardian. (November 12 , 2007.) http://www.guardian.co.uk/news/2007/nov/12/uknews.health

     

    (10) See FDA Drug Label Information Database at http://www.accessdata.fda.gov/scripts/cder/daf/index.cfm

     

    (11) “Tips to Manage and Prevent Discontinuation Syndromes.” Accessed December 8, 2016.

    http://www.mdedge.com/currentpsychiatry/article/60403/depression/tips-manage-and-prevent-discontinuation-syndromes.

     (12) Geddes, John R., Sally Burgess, Keith Hawton, Kay Jamison, and Guy M. Goodwin. “Long-Term Lithium Therapy for Bipolar Disorder: Systematic Review and Meta-Analysis of Randomized Controlled Trials.” American Journal of Psychiatry 161, no. 2 (February 1, 2004): 217–22. doi:10.1176/appi.ajp.161.2.217.


    http://ajp.psychiatryonline.org/doi/full/10.1176/appi.ajp.161.2.217

    Edited by Rob Wipond

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    I appreciate Mr. Wipond’s taking the time to reply in detail to my earlier comments. Despite our disagreements, I suspect that—from widely differing experience and perspectives—we are both seeking the safest, most effective, most humane and most ethical ways of caring for patients with serious psychiatric illnesses.  

    That said, I stand behind my characterization of his piece as containing “gross oversimplifications…misleading and unsupported canards [and] several inaccuracies in the discussion of psychiatric medications.”  To explain why this is so in detail would require a 15-20 page, referenced essay, which I do not propose to offer in a non-professional venue. Instead, I refer Mr. Wipond and readers of Focus to the textbooks, links and references cited below. Since my specialty is in adult psychopharmacology, I am not addressing medications used primarily in children and adolescents, such as stimulants for ADHD.

    Suffice it to say that responsible journalism requires objectivity, balance, and carefully nuanced claims. Sadly, Mr. Wipond’s tendentious article falls far short of that standard. Specifically, I count at least ten derogatory or negative descriptions of psychiatric medication effects (e.g., “drugs seized control of her mind”, “antipsychotic dulled her thinking and emotions”, “debilitated with antipsychotics” “akathisia” etc.), and only three somewhat positive statements (e.g., “While some people can find a tolerable dosage that quells their mind but leaves them still functional…”), including one from Deborah Connor.

     Like some non-clinician journalists here in the U.S., Mr. Wipond does not seem to understand that a full and fair assessment of psychiatric medications requires extensive clinical experience with these agents, and a first-hand appreciation of the immense suffering that psychiatric illness imposes on patients and their families. These requirements cannot be fulfilled via armchair literature reviews or interviews with a handful of patients.

     In nearly 35 years in psychiatry (I am now retired), and having treated hundreds of severely ill patients, I have no doubt that, on balance, the suffering endured as a consequence of psychiatric illness far exceeds the negative side effects of medication. And, contrary to Mr. Wipond’s criticism, we do not need to know the precise mechanism of action of a drug to know that it is safe and effective, when properly prescribed and monitored. For example, many drugs used in cancer chemotherapy have as yet unidentified (or speculative) mechanisms of action, yet they clearly benefit patients—despite having some potentially serious side effects. (Only in recent years have we learned the mechanism of action for aspirin!). Nor does it matter whether we call clozapine an “antipsychotic” or a 5HT2/D2 receptor antagonist—it is still effective for refractory schizophrenia and has the U.S. FDA’s approval as a medication that reduces risk of suicide in schizophrenia.

    As for Mr. Wipond’s assertions that “there is a growing body of evidence that psychiatric drugs might be doing many people more harm than good over the long term”; or that, “over long-term use, most psychiatric medications are doing most people more harm than good”, I would very much like to examine this “growing body of evidence”, as I have seen no credible scientific data to back these claims. Perhaps Mr. Wipond could provide the references for his claims, and answer the following questions re: this “body of evidence”: 1. Which psychiatric drug classes have been shown to do “more harm than good” in the long term; for what conditions, and at what doses? 2. How are the terms “harm” and “good” defined in these supposed studies? 3. How was the ratio of harm-to-good computed? 4. Were “harms” and “goods” determined on a case-by-case, patient-level basis, or using aggregate measures? 5. Is the evidence based on the “double- or triple-blinded, placebo-controlled trials” that Mr. Wipond wants to invoke in criticizing my assertion that psychiatric medication can be “life-saving”?  

    If Mr. Wipond can back up his claims with such high-level evidence, I would encourage him to submit a paper to a peer-reviewed, medical journal—and let us see what the reviewers have to say. Absent such documentation, Mr. Wipond’s “more harm than good” claim amounts to nothing more than scary, rhetorical posturing. Of course, if Mr. Wipond is merely asserting that some psychiatric medications can sometimes do more harm than good for some patients in the long run, then we have no disagreement; indeed, every third-year medical student would assent to such a trivially obvious claim.

    To be sure: psychiatric medications should always be used conservatively, at the lowest effective dose, and for the minimum time necessary to treat acute symptoms and/or prevent relapse and recurrence of the illness. Informed consent is always essential, with detailed discussion of both risks and benefits, and frequent monitoring for side effects. Whenever possible, treatment should be voluntary and done with great respect for the patient’s preferences and concerns.

    To understand the immense suffering and self-harm psychiatric illness can inflict on patients, I refer Mr. Wipond and Focus readers to this description by Mr. Pete Earley, re: his son,  in his foreword to the important new book, Committed (D. Miller & A. Hanson, 2016):

                “Imagine your child, a loving and brilliant young art student in college. One morning, his friends deposit him on your doorstep and tell you that he is crazy. He is argumentative, refuses to eat or sleep, and is convinced that he needs to go immediately to the White House because God has given him a message for the president. Imagine watching him pace back and forth in front of the television with tin foil wrapped around his head to keep the Central Intelligence Agency from reading his thoughts. Imagine him being arrested because he has broken into a stranger’s house to take a bubble bath. Imagine listening to someone you love scream at you, call you the enemy, tell you that he hates you. Imagine watching your son hit his own head to clear the voices inside his mind, which are screaming at him, telling him that he will die if he steps out of a car, taunting him to hurt himself...Picture that and remember that this is your son. What would you do?” [12]

                I know what I would do, having evaluated and successfully treated scores of patients like Mr. Earley’s son. I would do everything in my power to see that this tormented individual received appropriate antipsychotic medication, as well as humane treatment, counseling, and social-vocational support. It is unfortunate that Mr. Wipond’s biased and ill-informed comments on medication may discourage many such suffering persons from seeking appropriate psychiatric treatment.

     

     

    Ronald Pies MD

    Professor of Psychiatry and Lecturer on Bioethics & Humanities,

    SUNY Upstate Medical University;

    Clinical Professor of Psychiatry, Tufts University School of Medicine

    Editor-in-Chief Emeritus, Psychiatric Times

     

     

    P.S. Mr. Wipond is mistaken in his snide allusion to “lobotomy.” The 1949 Nobel Prize was awarded not to a psychiatrist (or to “psychiatry”), but to the Portuguese neurologist, Egas Moniz, for his development of the procedure called prefrontal leucotomy. This, of course, was well before antipsychotic medication for schizophrenia was available, and before the terrible side effects of this procedure were fully recognized. In 2000, psychiatrist Eric R. Kandel, a professor at Columbia University in New York, was awarded the 2000 Nobel Prize in Medicine or Physiology for his work on the neuronal basis of memory.

     

     

    References: [note: some links may need to be manually copied and pasted into your browser]

    Pies, R. Handbook of Essential Psychopharmacology. Washington: American Psychiatric Press.  
    Second edition, 2005.

    Jacobson S, Katz I, Pies R: Clinical Manual of Geriatric Psychopharmacology. American Psychiatric Press, Inc.,Washington DC, 2007

    Pies R. Are Antidepressants Effective in the Acute and Long-term Treatment of Depression? Sic et Non.
    Innovations in Clinical Neuroscience. 2012;9(5-6):31-40.

    Pies RW. Antidepressants: Conundrums and Complexities of Efficacy Studies. J Clin Psychopharmacol.
    2016 Feb;36(1):1-4.

    Leucht S, Tardy M, Komossa K, et al. Maintenance treatment with antipsychotic drugs for schizophrenia.
    Cochrane Database Syst Rev. 2012 May 16;5:CD008016. http://www.ncbi.nlm.nih.gov/pubmed/22592725.

    Ran MS, Weng X, Chan CL, et al. Different outcomes of never-treated and treated patients with schizophrenia: 14-year follow-up study in rural China. Br J Psychiatry. 2015;207:495–500.
    http://www.ncbi.nlm.nih.gov/pubmed/26382951.

    Pies R: Long-term Antipsychotic Treatment: Effective and Often Necessary, with Caveats
    http://pro.psychcentral.com/long-term-antipsychotic-treatment-effective-and-often-necessary-with-caveats/0012596.html

    Pierre J: Psychosis Sucks! Antipsychiatry and the romanticization of mental illness
    Psychology Today. Posted Mar 05, 2015
    https://www.psychologytoday.com/blog/psych-unseen/201503/psychosis-sucks

    Meltzer HY, Alphs L, Green AI, et al. International Suicide Prevention Trial Study Group.
    Clozapine treatment for suicidality in schizophrenia: International Suicide Prevention
    Trial (InterSePT) [published correction appears in Arch Gen Psychiatry. 2003;60:735].
    Arch Gen Psychiatry. 2003;60:82-91.

    Herings RM, Erkens JA. Increased suicide attempt rate among patients interrupting use of atypical antipsychotics. Pharmacoepidemiol Drug Saf. 2003;12:423-424.

    Pies R: How Antipsychotic Medication May Save Lives. Psychiatric Times
    http://www.psychiatrictimes.com/blogs/how-antipsychotic-medication-may-save-lives
     [Also available at:

    http://pro.psychcentral.com/how-antipsychotic-medication-may-save-lives/0013724.html

    Pies R: The Astonishing Non-Epidemic of Mental Illness: An Update on Data in U.S. Adults,
    2000-2015.
    http://pro.psychcentral.com/the-astonishing-non-epidemic-of-mental-illness-an-update-on-data-in-u-s-adults-2000-2015/0016052.html

    Pies R: Trivializing the Suffering of Psychosis: How the British Psychological Society’s Report Fails Our
    Sickest Patients. http://pro.psychcentral.com/trivializing-the-suffering-of-psychosis-how-the-british-
    psychological-societys-report-fails-our-sickest-patients/006850.html

    Tondo L, Baldessarini RJ. Long-term lithium treatment in the prevention of suicidal behavior in
    bipolar disorder patients. Epidemiol Psichiatr Soc. 2009 Jul-Sep;18(3):179-83.

    Guzzetta F, Tondo L, Centorrino F, Baldessarini RJ.Lithium treatment reduces suicide risk in recurrent
    major depressive disorder. J Clin Psychiatry. 2007 Mar;68(3):380-3.

    Lauterbach E1, Felber W, Müller-Oerlinghausen B, et al Adjunctive lithium treatment in the prevention
    of suicidal behaviour in depressive disorders: a randomised, placebo-controlled, 1-year trial. Acta
    Psychiatr Scand. 2008 Dec;118(6):469-79. doi: 10.1111/j.1600-0447.2008.01266.x. Epub 2008 Sep 18.

     

     

     

     

     

     

     

     

     

     

     

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    Dr. Pies seems to not understand that there are differences between the author's own opinion and the author presenting his interviewees' experiences and opinions. In any case, I notice that in his very lengthy response Dr. Pies continues to simply ignore the very body of evidence that I accused him of ignoring, and then spends a great deal of his letter in rather dramatic and flamboyant flourishes pleading for me to provide this very peer-reviewed evidence that I in fact already provided in part, with links. And of course, Dr. Pies I expect knows as well as anyone but does not openly say that the pharmaceutical industry that funds the majority of drug studies has noticeably declined to fund virtually any of these kinds of large-scale studies of the long-term effects and harms of any psychiatric drugs beyond 5 years, which is why he can feel confident that there is a limit to how many such studies I can cite. And it's also why he can comfortably assert that his own anecdotal experiences with psychiatric drugs over long-term use are what really count, and not anyone else's anecdotal reports.

    That seems to about sums things up.

    Rob Wipond

     

    Edited by Rob Wipond

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    In this exchange between Rob Wipond and Dr. Pies, in my opinion, Rob Wipond emerges as the clear winner.  Dr. Pies disparages Wipond's position as lacking balance and critiques him for using "negative words", suggesting that in doing so Wipond is not being "objective". However this begs the question, for if on balance the psychiatric drugs do far more violence than good, then the "objectivity" requires that this be said. Correspondingly, Pies states that in his own personal experience he sees the drugs as doing far more good than harm.  What makes Pies think that a psychiatrist trained to see "dulling" as a good outcome is in any position to objectively evaluate?  Is not the fact that evaluations are overwhelming done by care prpfessionals  with a demonstrable bias exactly what has always made the "treatments" look good?

    Objective? Hardly! Thank you, Rob Wipond, for exhibiting far greater "objectivity"!

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