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