Ronald Pies MD

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  1. 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. 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. Pies R: Long-term Antipsychotic Treatment: Effective and Often Necessary, with Caveats Pierre J: Psychosis Sucks! Antipsychiatry and the romanticization of mental illness Psychology Today. Posted Mar 05, 2015 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 [Also available at: Pies R: The Astonishing Non-Epidemic of Mental Illness: An Update on Data in U.S. Adults, 2000-2015. Pies R: Trivializing the Suffering of Psychosis: How the British Psychological Society’s Report Fails Our Sickest Patients. 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.
  2. 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. 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: 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: