How Psychiatry Lost its Way | Interview with Robert Whitaker

okay hi I'm Dr Yosef with during and today I'm joined by award-winning journalist Robert Whittaker probably most well known for um anatomy in an epidemic a great book that came out in 2010 but he's also written a lot of other great books uh Psychiatry Under the Influence being another one which we're going to be talking about he's joining us today to cover a couple of topics one is you know what is wrong with the way Psychiatry is practiced today in the US and maybe also globally and then what I think is actually more more interesting and something that I think about a lot is why there are so many problems and why they haven't been fixed so I hope you enjoy this so I'm going to turn it over to you Bob and just um you know say welcome and ask you describe what the problems are with the way Psychiatry is practiced in the US today sure well thanks first of all for having me it's a pleasure to be here you know in a big picture where I think you can simply you can state it quite simply and that is ever since dsm3 was published in 1983 1980 excuse me when dsm3 was published in 1980 you know the American Psychiatric association says it adopted a medical model it's really it was a disease model and one of the ideas was that these hypotheses actually was that these were discrete illnesses and of course one of the hypotheses was they were caused by chemical imbalances in the brain and then pretty soon we and prescribers began hearing about that we had drugs that fixed those chemical imbalances which is a A Narrative of great progress and so we we as a society first the United States but then this model was exported organized ourselves around that narrative which was a narrative of great progress I mean think about how complex the human brain is and we were being told that they had identified researchers had identified the molecule that causes Madness the molecule that causes depression and if that were true I'd say that's one of the greatest discoveries of medical discussions of all time given the complexity of human brain but it wasn't true in other words it was a hypothesis dsm-3 was basically created it to say we we're going to hypothesize these are diseases in the brain and then we'll hope we'll find evidence for it to be so but the hypothesis wasn't promoted to the public and pretty soon Psychiatry itself convinced itself of this great progress it was making if you look at the annual statements presented by the the presence of the APA starting it's all well we're making these great understandings how the human brain works but that's the problem ultimately is that we organized our thinking around a narrative that told of great progress of discovering the causes of diseases and effective treatments for for those diseases and if you look in the science that wasn't the story in the science you know the chemical balance story was falling apart as far as the the drugs you know they didn't fix any known pathology uh the the benefits were you know exaggerated the risks were minimized and then you know there was this influence or this capture of American Psychiatry and academic Psychiatry for a period by the pharmaceutical company so we had both of those groups telling this story we had the money from the pharmaceutical companies and their advertisements telling it but we had the APA running educational campaigns as well oftentimes in concert with the NIMH let me ask you this so so there's these two events you know one we have the DSM the dsm-3 comes along and you know previously to this you know when you have anxiety and depression you know there used to be all this language you know reaction you know and and it was more the way psychiatrists would describe this you know officially in the earlier version of versions of the DSM is in ways where it could be more linked to contextual stresses and things happening in their life but that gets thrown out the door and then you just get you know major depressive disorder five out of nine symptoms for two weeks it kind of just you know kind of puts it neatly into this box of symptoms where you lose all of that you know as a due to trauma or is it due to contextual stresses you know it's just that and so it becomes this you know this this disease model and then there's this other part of it you know this like you say the the story of progress when you know the antidepressants and the antipsychotics come onto the market and oh you know there seems to be some therapeutic effect so let's now say that anything that fits in this major depressive to sort of box you know is this illness and we have this pill for it and I want to ask you so those I totally agree that those are the ideas how do you see them how did you see that trickling down into the clinics and the family practice settings and the places where people were receiving care what do you think changed there at that level well you know I think this is really important also going back to dsm1 and dsm2 what a huge shift it was because with those descriptions of reactions you're talking about human beings that are responsive to their environment environment matters right and what and also that the the the you know there are many different Pathways to feeling depressed or anxious and also for example that anxiety was quite normal depression happens that sort of thing so there was a conception there of human beings being responsive to their environment and that if you could change environments these things could be episodic and all that and that is so much more in in sync with like what we know from in any sort of historical sense of conceptions and also what you see in novels lays religious tracks Etc we lose all that that holistic that complex sophisticated sort of sense and now all of a sudden we say oh it's just inside the brain of the individual it's a molecular problem well that's actually a reconception of who humans are and how they move throughout the world and it's such an impoverished philosophical perception or conception of human beings it's just it's a historical and impoverished now you asked how does that filter down the problem is that impoverished idea conception filtered into the clinics and it also shut off communication as you know your doctor one of the most important things of being having a a good having a good outcome is an effective relationship with your doctor a doctor who will listen to the patients you know the doctor should be listening but I can tell you how often I heard people say they don't their psychiatrist would no longer listen they just said you have this problem take the pill if you're experiencing problems it's the disease not the pill so it shut off this communication as well and then the other problem that happened is when people got worse under on which happens to some people of course it was never seen as the drug it was always like oh that's your conditioning worsening so what happened with this shift at the clinical level is so often the prescribers retreated into this very narrow mindset where they stopped listening they thought the people weren't even good witnesses to their own lives they attributed all the problems to the disease and not the drug so you you ended up at a clinical level with this sort of uh impoverished reaction between the two and also the ignoring of the the patient's experience and their life experience their trauma what was going on are they in poverty are they you know are they grieving over something or what you know what's their life situation like so at a clinical level it led to just an interaction between prescribers and patients that was ultimately harmful the reaction the interaction itself was harmful yeah and and I think that's probably how a lot of people feel now when they see their psychiatrist it's like you know this person doesn't doesn't really care about me you know they don't really care about what's going on in my life you know you know it's more like you know uh you're having some depression any anxiety any insomnia and then um okay yep yeah it's been gone how long has this been going on for done you know and and that's and that's kind of the level of understanding they're going for and we could talk about you know there's other things there's this thing such as the rise of I guess managed care insurance and the fact that there's pressures to see people in you know 15-minute visits now where it's it's I mean that model almost serves that kind of visit because you end up having a production line kind of Psychiatry where you just you know okay you've got this condition and and now we've got a treatment for it and and so there's there's that part of it which I think also lead you know is why this was so useful and kind of churning people through the clinics and making it easier for clinicians and I guess the people that are um you know uh invested in having higher flow through the clinic because of the you know the money that it brings in but then the other thing that's interesting with the DSM is that you know they use things like it causes clinically significant distress you know if you have five out of nine symptoms that cause clinically significant distress and it's like what the heck is that you know and and so I mean you've got some people who who could have you know mild mild symptoms that might clear up in a couple of weeks you know a young man going to a university starting out afresh there and it and it's it's stressful um maybe he doesn't want to go to you know classes that one week is that is that clinically significant to stress that there's and there's no guidance in there for what it is they leave it completely up to people to just um kind of go for it and then and then the other thing that's interesting about the DSM and I guess most of the depression scales is you know when you have like a list of you know nine symptoms and you can pick five of them I mean they change you can have two depressants that look completely different and no one really cares about that either um and so like you said there's this impoverished reduced view where it's just like okay but why does this person look different from that one who cares you know it's um it's it's not like you know this is coming from some contextual stressor or maybe maybe you have an inflammatory disorder or something like that and the autoimmune condition that's causing some depression in all of these cases where you could kind of go after a root cause it's this Paradigm of like we're not you know we're only interested in the symptoms we're not interested in the cause that just I I guess yeah it drives the kind of production line Psychiatry that you see now yeah you know this is really interesting you can tell me if I'm wrong here but my understanding there was a time before dsm3 one of the first things that psychiatrists tried to do was or even the medical community is rule out physical causes for these things because we do know that you know illnesses can cause depression they can cause psychosis it's inflammation in the brain that sort of thing but never but once we move to just a symptom thing the symptoms of course were mistaken for it but the signs of an illness okay and they in other words have a known illness somehow and just going forward here is after dsm-3 American Psychiatry said oh we're going to be psychopharmacologists we're going to leave the counseling to those other people basically what happened that's why you got the 15-minute visits by the way I can't imagine going to medical school in order to just prescribe drugs to four people an hour I mean it seems why would you want to do that but that's what happened and then what I think happened within psychiatrists they had allegiance to the story to the narrative because and somehows it made them feel like as we know you know doctors treating real illnesses and it did give them more prestige in society and the newspapers would always be talking they were sort of telling the story as well and so what happened was not only did they stop listening but they stopped seeing their patients in the way you're talking about physical problems this sort of context and all I can say is the feeling was that their allegiance was to their own story their own narrative and maintaining it for themselves their own belief in that story so sometimes we say oh Managed Care is the problem because they only pay for 15 minutes well that sort of came in response to the psychiatrist saying we don't need more than 15 minutes we're just going to check the symptoms and then if and then if they're changing we'll give them some other drugs or whatever and you get into the polif pharmacy so in my opinion everything went awry in 1980 when American Psychiatry decided to Recon reconceive itself as basically a treater of illnesses of the brain without any scientific Discovery behind that reconception and then you have all these problems problem problems you're talking about lack of context not listening a historical and the irony for me is if you really wanted to be a medical doctor if that's the way you wanted to present yourself then the first thing you should be is really good at identifying physical illnesses that may be causing these secondary symptoms right and you know we know all this is to it we'll go back to in-stage syphilis Parkinson's disease can cause psychotic symptoms inflammation of the brain causes it toxins can cause it there's all sorts of biological Pathways to these different you know poor diets no exercise Etc but all that gets lost with this impoverished non-scientific it's really was a you know as as American Psychological Association said when dsm3 was published this is more of a marketing document than a scientific documents and that has had you know such profound consequences for our society because as it was promoted to the public the public started seeing themselves this way oh I'm not having a bad time because it is I have depression or I have bipolar illness or I have ADHD it's not that the schools stink and they're boring and you're given to any of that stuff it's this is inside me it's a change to how we think about ourselves changed how we raised our kids changed how parents think about their kids yeah and I mean it's interesting that you say it it it's it's marketing because from my experience in drug companies you know the the DSM in that whole conceptualization of mental illness is the greatest thing ever when it comes to um you know marketing it because I mean you you know drug companies they don't just Market the drugs they they Market the illness and they can do this in a lot of different ways and it it may it may be something as simple as getting behind um seemingly Grassroots patient organizations who want to promote uh depression and bipolar and talk about how difficult the conditions are in the stigma and in and of itself you know that's that's not a bad thing but if the message is coming out of these organizations are very aligned with you know the idea that these are biological conditions you know and and that's kind of what they're putting out there all the time than that I mean it just it essentially it floods the media with that story you know and and this is kind of in the same way that the media is flooded with those stories when you have drug companies running clinical trials which are talking about depression in this way it floods the medical literature in that way because they're the only groups that have the resources and the staff to consistently pump out these articles with these you know authorship lines to die for you know the people that are leading the field and so it has this influence and you know I say this in my day-to-day a lot I was talking to a chap yesterday who developed pssd and for his whole 20s I mean he was on different antidepressants having adverse reactions to them he was irritable he was short with friends he had sexual problems and um his whole conceptualization of that the entire time was there is something wrong with me this is my depression and eventually I mean the story has a sad end because he ends up with pssd and he's uncertain if it's going to recover but he looks back at this time and how he was sucked into that Narrative of you know this is just me and my mental illness and and a lot of the mood instability have now gone away and he's and and he was just oblivious to it the entire time and just wreaked havoc on his life that that one idea in there of depression is a biological problem um so you know two things it's one it's it's it is a an uh conception that says these things are chronic and not episodic right that that there's a law within you which is a very pessimistic thing to adopt you know after I published anatomy of an epidemic in 2010 a magazine said what do you want to write about on this and I said pssd it hasn't gone into the business in 2010. and I but I said I've looked at your magazine you are have a lot of ads by drug companies and I don't think you'll run this and the editor says oh no no we have this wall between advertising and editorial so I interviewed a number of people at that time for pssd which really it was starting to be a germ within you know the social media there were you know different groups starting to form saying hey what's going on and there it was Audrey bayrick and University of Iowa I think she was where she had sort of brought some attention so I interviewed maybe 20 people and they were devastated and what they said it's not just sexual dysfunction they just felt they couldn't amount sort of real extreme you know they say oh I see a rainbow and I don't care I hear a great song I don't care and they were just feeling that so much the loss was devastating now do you think no no and the editor actually quit because he said yeah I guess we don't have a wall yeah and and I don't in a way I don't blame the magazine in a sense I should have never done it because who who really has one major Advertiser in all the magazines of course it's and this was a men's magazine okay so you know they had all sorts of ads from from pharmaceutical companies I think this is I mean this is a nice time to segue into uh I want to get your impression on another issue so anatomy of an epidemic if you haven't read it one of the major themes in there is that we don't know enough about what these drugs do long term and in fact they may actually worsen um worsen the underlying condition or put you in a state of uh chronicity whether it's with psychosis or depression that was in 2010 um and I mean that made a lot of sense to me back then I've seen it with with patients that I treat you know taking them off the medication and watching them flourish but it hasn't I mean it hasn't I wouldn't say it's influenced mainstream Psychiatry at all you know in terms of how you know you know most psychiatrists practice tell me about that what what happened I mean why do you think this is not caught on at all or why why it's you know why has this been been shut down why hasn't there been more I guess studies and interest and people asking questions about that I'd love to hear your thoughts on that oh this is a great question because you know when I did publish this in 2010 I tried to gather the evidence that did sort of provide insight into how the medications were shaping long-term outcomes and now the one interesting thing is there were there were some responses to it that they didn't make it into the major media but uh people came forward and they founded something called the foundation for excellence in mental health care I actually helped found that and I actually raised the first million dollars for it and then I got out of it because I didn't want and then what the first mission was to fund further research of this sort more research and actually they did give money to Martin Harrell and Tom Jobe to continue their analyzes that was one of the things they did so there was that you do see some other studies now that have come up and been published related to antipsychotics related to antidepressants related to uh long-term effects of stimulants for ADHD in kids so actually the information you can find or the evidence basically confine in the scientific literature is much stronger today than it was in 2010. and what was interesting for me there were some attempts to prove me wrong in the literature okay so for example Jeffrey Lieberman and his group at Columbia there were two different groups that looked at this question of long-term effects of antipsychotics the first group interested in Lieberman wasn't not part of that and they just said there's not enough information on it we don't know 60 years after using this we don't know how these drugs impact long-term outcomes okay that and but they excited me basically we're going to see if Whitaker is wrong and they just weren't willing to say that well that hero is worthwhile or any of the other data is worthwhile well you know wondering it's not it's not like they said oh my God you know there's nothing out there and this should be a priority you know yeah interesting Lieberman and Donald uh what's his name I transferred from MGH but anyway a group they also did the same thing and they said well you know we know they reduce relapse they owe relapse studies but they they did admit that we really don't have evidence that antipsychotics improve long-term outcomes so that's a shift from where I'm just talking within the research literature because you're absolutely right on in terms of once we get into the public um and then there's been like uh I think there's heroin their last thing cited seven different studies from different countries that all came to the conclusion that that you see higher recovery rates for people diagnosed with psychotic disorders among those who get off now I don't think that translates into a No Use model I think it does translate into a selective use model but that's what they show there's no study they could find that shows medicated people do better than unmedicated groups in The Psychotic disorders and I think antidepressants of course we've had um uh other studies come up that also concluded that look at the medicated people are doing worse and you know refill Malik does that name ring a bell to you refill Malik it used to be a mood disorders expert at Eli Lilly and then he noticed he wrote a paper saying is this the tachyphlaxis guy is that uh he's got the part of this foreign guy I thought of this for yeah I have read his article yep yeah so now here's the guy from play Lily's saying we're getting this increase in tar in treatment resistant patience antidepressant could this be due to tardive dysphoria and then they came up with this idea of oppositional tolerances as the sort of mechanism for this worsening so within the research literature and in research Community there has been a shift now no one wants to admit that drugs do harm that's too much that's that's a step too far to go well I mean that's in essence what El Malik is saying but mostly it's like well we don't have evidence of long-term benefits now did you see what nasogami wrote uh was it a year last summer he wrote he's at Tufts I know and then he went to the pharmaceutical industry and I think he left there but I I don't think I read his editorial or maybe I didn't just figure out but please yeah what did he say listen there's no evidence that these these drugs are they're just they're not Curative they're just affecting symptoms we have no evidence that they improve long-term outcomes they should be used only short term and as low doses as possible that's a break with this sort of almond narrative but that's in these little research quarters and where the men in America is the only one that's trying to make this research known to the public for some reason I'm actually interested in your thoughts on this of course prescribers once they start doing things it's hard for them to change and once they have a narrative and I think within the the larger Mental Health Community First of all they don't know this research they're afraid of This research it it the cognitive dissonance has spread it's spread to journalists because journalists don't really want to write about this either it spread it spread to psychologists it spread to Mental Health Counselors it spreads throughout the society that did glom on to this narrative they organized their life around this narrative prescribers counselors families and it it it's really hard to say wow this could have all been a big mistake and maybe we're harming people that's the only thing I can make of it but you're absolutely right is more people are getting medicated more people are ending up on multiple drugs what is it like 25 of the kids that come to college now have a diagnosis and now you have Tick Tock where they're all saying I'm bipolar I'm ADHD give me my drugs it's mind-blowing yeah I could share some thoughts on that and I'd like your Reflections on it so why is this happening um that that people aren't able to to realize that one one reason I think is um is it is one one of the best ways to shut something down is just to ignore it you know just just because Nasir gave me publishes something in the medical literature that says hey I think we should really be cautious about chronic long-term use on these things I mean who who even reads that I mean you know maybe it's I mean most boots on the ground psychiatrist they may not have the time to do it maybe you stumble across and go oh that's interesting and move on um and and then when you get to let's say the more authoritative guidelines things like the APA guidelines and stuff like that they're completely silent on the topic and that might be a document that someone goes to so one way to shut it down is to just not mention it and then you have to say you know what might be the reasons why you know authoritative groups universities educators of mental health practitioners and therapists why wouldn't they want to talk about this and something that at least I felt while I was going through training and uh is that there is this I mean there's almost an intimidation that comes out there when there's when you're constantly being bombarded with things that say don't stigmatize depression don't stigmatize bipolar disorder and and you know people will say these things to you when you when you're talking about the risks of these medications they will try and cast you in a light like you are some kind of part of some organization that just has a bone to pick where with medication you you know that you're just of the impression that people just shouldn't be on meds they pull themselves up there like that by their bootstraps because that's the way I did it and I'm just going to force my perspective on everyone else so they write you off they say that you've got some kind of agenda and then they accuse you of stigmatizing mental illness and so so that's the I I don't know where this came from maybe you could share it but it's palpable it is palpable going through training that you know you don't don't knock the sacred cow of medication because if you do you're stigmatizing mental illness and you're gonna and people are gonna come off their meds and they're going to commit suicide and it's going to be on you so I think this is combination of intimidation and also just silence on the matter and and I guess that that comes from what what people want to fund you know they want to fund certain narratives and certain perspectives and then that just the the global pressure comes in yeah what do you think about that well you know this is this is so true I mean if you go back um one of the reasons that they are they ostrich and sort of discredit that person it's because in fact they don't have the evidence base to argue from so you know they really can't go and say wait a minute look how good our trials are look at how effective these drugs are safe and long-term outcomes they really don't have that so because they can't even though they're saying they're evidence-based that's part of their self-image they really can't argue on the science because it's out of sync with their own thinking actually and then of course and now what you're talking about is psychiatrists well we can talk about all these things but Psychiatry sort of became a tribe because of these vulnerabilities and right from what you say like within the the training programs they make it clear like you're going to join this tribe and and and and we know and part of it is the people who criticize this are biased right it's always The Outsiders the bias Etc they and and they're not they're not thoughtful you know they're not caring for people because of the stigma thing so that is part of the training of mental health professionals and it's not just in Psychiatry it's done to psychologists counselors today as well don't break with the tribe and because there's also thought is where are you going to work right because most of these systems have a narrative for how they operate and you've got to be part of that narrative so I think what you have here and then I'll talk about the historical precedent for this is it's it's like a a vulnerable tribe called a guild but it operates as a tribe and the way they kept going was to ostracize push out people who who started criticizing that story look what happened to Healing you can look you can see it over and over again that the people who said wait a minute they got pushed out and once you know Peter yeah yeah no he he got kicked out of the Cochran collaboration now he's he's a radical guy in the way he just like the way he speaks and all he didn't you know it's like a wrecking ball you know I love it yeah well he doesn't mince his words at all but it wasn't until he criticized Psychiatry that he started being pushed out so and I think it's because they couldn't respond now before you jump in there I wanted to just tack on something to this point because you know I want to talk about you know it's it's it's not just psychiatrists you know and you know since my training in residency you know I've I've worked in corporations I've obviously I've worked at the FDA and I've worked in pharmaceutical companies so I know how organizations think and work and and this is something that I think everyone in the audience would probably relate to you know if you've been in kind of these situations it doesn't serve you to go against the grain you in fact will make your life more complicated you know if I'm working you know and this happened to me as a resident if I'm saying you know hey attending physician this guy you know you just put on more antipsychotic it actually has akathasia from from the antipsychotic medication that they're they're already on that's not going to go down well you know that's that's going to end up um you know you might you might come across someone who's like oh tell me more Joseph but by and large people are busy they're trying to get through their day they have their kind of agenda and they need to knock out 10 patients in the morning and they're just going to say who are you to question me so you know it's it's it's it's this kind of broad um I think it applies to anyone when you kind of work in these organizations that are kind of hierarchical that you it's you either get in line or you get out you know that's kind of what happens yeah listen I mean if this is the story of whistleblowers right whistleblowers always end up getting killed I mean not not literally but metaphorically they end up getting killed because and it doesn't even matter if they're right it doesn't matter when the corruption surfaces if you want a team player and the sort of collective needs team players and they need team players even more when they're doing some things that aren't really up to Snuff that's when they yeah I mean that's one of the things this institutional corruption is is that as institutions stray from what is expected to be their public service or their you know their moral Behavior people who start saying that if once the institution starts to shift they're going to push those people out the whistleblowers get killed I mean so yeah I mean this is one of the problems is that and it's not just Psychiatry and it's not just of course medicine but medicine we we have this cherished idea that they're open they can change their minds you know they can but you know all of medicine I think training so much today is training smart people to accept whatever is seen as the dogma of the day and feel good about like oh we're the ones with knowledge but you they you take these very I was at Harvard Medical School uh director of Publications for a couple years I think it's really bright curious people sometimes and you turn them into automatons sort of like the people who can regurgitate whatever the common wisdom is and so often it's not just Psychiatry you don't see the whole patient last time I went to a doctor I I don't generally go to doctors the last time I went he was so busy he didn't know I had no idea was he got down there he got on his computer to see who I was talked to me never looked up from his computer I told him what was going on and then he said okay someone will come in and then he hurried off he never looked at me yeah never saw me in the face and I'm like this is like medicine 101 but anyway I I'm wandering here I just want to say it this way of thinking of social behavior is the problem is it leads to bad medicine it really was because it's the human beings are so complex and so idiosyncratic but it is a problem that is pervasive in American medicine today you know how guidelines are Set uh how we say what's an illness what is not an illness that whole thing I want to go back one thing you said about yes how they treated critics as the other as threats you really see this going on in 1992 because and and this is one of the sort of most unfortunate things about this whole story so you know project comes to Market and there is some worry that these drugs Prozac can stir akathesia or homicidal impulses suicidal impulses and then there was Jonathan Cole at M uh you know if he does his healthy volunteer study and he says yeah we have I think six people who had stirred homicidal or suicidal impulses and who were Ordinary People so this presented a challenge to Prozac and if you look at the FDA documents that were sent back to Eli lilies they said oh this can kill Prozac if this gets out of hand this sort of thing and then we'll be hearing so what does what does Eli do it calls in its thought leaders including um uh why am I draw a blank on this thing wrote from MGH Rosen Rosenbaum I don't know something like that he's the part of the department but he was also Mr Prozac and they had a meeting that you can see and they said ah we'll say this complaint is coming from the Scientologist because the scientologists were gathering uh you know these uh adverse event reports sent to sent to the medwatch program so what they know is with that thing they had a strategy for linking criticism to this crazy cult so the fact that Scientology got involved with this was so damaging because it gave such a a knee-jerk way to dismiss dismiss this and say people that make criticisms oh they're like scientologists or they are scientologists so and that became the thought within the larger commute Society became within um you know mainstream media and all the critics were scientologists and that really shut things down and they played that card for like 20 years the Scientology yeah and if you mentioned anything about antidepressants making people suicidal you're putting people at risk because you were scaring them off the medication and you know exposing them to the danger of their underlying condition where if you look you know and this is just epidemiology you know just published in the FDA labels I mean I mean this is something that's interesting I don't I don't even know like how we can prescribe these medications to children without some you know without having done absolutely everything else first because when you look at the data you know on a population level you have more suicide attempts uh in the in the groups that are treated and it's you know okay sure you know it decreases your depression you know as measured by on a scale but when you look at the real outcome there you'd probably want less suicide attempts um I mean so there's this this there's something in there that's just really really bizarre especially when it comes to the populations under age 25 um but yeah yeah I mean it's a it you know this whole you know this whole idea this whole suicide thing you know like you said in 1992 it took until 2006 until there was a boxed warning until then they shut it down and anyone who had a drug-induced kind of akathasia and became suicidal they probably had their dose doubled you know and because they were like you know this this doesn't happen it can't increase suicide and it you could imagine how many families that ruined by by of course one of the big uh one of the sort of poster you know poster for um corruption was what is it study three three twenty three I think that's it 329 David here sorry yeah yeah yeah you know they had suicidal events in the in the drug treated group and they hid that they spun it and they tried to make a placebo and and you know that helps form this idea that oh they they're not causing increasing the risk of suicide in in kids and there was also the same thing with some fudging with the Prozac data on the Tad study if you look at the have you ever looked at the Tad study yeah yeah I have okay what did they say they said there was no evidence of an increase in Risk on on Prozac correct that's in the abstract do you know actually what happened because there's a graphic in there that tells you whether people were on Prozac when they attempted suicide or not now what happened was so 18 of 19 attempted suicides were on Prozac so how did they say it was the same the way it was designed was you had people coming in randomized to Placebo or to cognitive behavior therapy without drug and then after six weeks they were then put on drug now if they attempted suicide after they were put on drug they it still charted up as a placebo group suicide attempt so that's how they came up with a tads thing saying oh there's no extra signal of suicide with Prozac when in fact it was like 18 of 19 suicide attempts where people on drug and and on Placebo I don't think there was a single suicide when while they're on Placebo I think there was one on CBT now after that study was published I know a woman whose son broke up with a 17 year old son broke up with her his girlfriend first love and all that became depressed she took him to a psychiatrist psychiatrist said we're going to give him Prozac she said wait a minute isn't that a problem he said no we have this Tad study there's no increased risk he hung himself like two weeks later and then when we published the real tax data on Madden America she was unbelievably devastated is the only way to say it yeah oh I'm understandably you know the one thing I wanted to add on the antidepressant suicide research was how you know the narrative was fun that this was something that you could only figure out with statistical significance at a population level and what I mean by that is you know 100 people on one arm 100 people on another arm you know which group had more suicides um or suicide attempts you know you'd have to look at um those two numbers and compare them and see if the magnitude of difference was large enough David Healy was the first person to start talking about you could just look at the person you know you could say all right the way they're changing after being on the medication is so out of character to their normal condition you know that that this must be drug-induced and you know there's a reason you know all drugs can have paradoxical effects and there may be a certain group of people who are not suited to this and Etc um and you know oh and by the way when I took them off the medication or when others had taken off the medication it's gone away and when they've been re-exposed they've gone into this dysphoric agitation which could logic you know which could precipitate someone into suicide to this day that's still the best way to understand this and and what was promoted was like oh we need more meta analyzes we need more pooling of studies and the and the thing is that's how most people think of it to this day but it actually doesn't make sense because let's say you know antidepressants they can have a therapeutic effect at least in the short term by mood constriction so it's very possible that the drug actually decreases suicide attempts in in a large section of that population and maybe in just a handful of them it causes it if you're going to look at things at a population level I mean you could get you know 10 suicides on a placebo arm with like a hundred people and you know and you might even have just two suicides on the antidepressant treatment arm but one of those people still could have been drug induced you know because you have this this differential effect I mean so it's ridiculous I mean that but that was the way that Eli Lilly dismissed it for so long you know we can't see the difference at the population level and it was just it was the wrong analysis and and they were so successful in promoting that idea and getting people to publish about it in that way and say it's still uncertain we need more data we need more this and that but it um I don't know to me it's a good example about how you can just grab a hold of it and just say this is what you need to look for and and Healy was right about it the whole time from the from the beginning yeah you know I think what you're saying here is so important and how do you practice medicine right yeah it's not like everybody responds the same to medicines right and especially psychiatric medicine there's a spectrum of outcomes by the way you see that spectrum of outcomes of course in the in the in the data right some good responders some non-responders some worsening of people so if you really wanted clinical trials and especially if trials were done in real world patients to be a guide to good clinical practice the message wouldn't be these are effective for everyone right we'll treat all people the same you still need to be cognizant is it helping your patient and if you're getting the sort of thing that you're talking about you've got someone who's worsening in response to it so you need to be alert to that but you're right now I think what happened is this was this was done not by accident of course by pharmaceutical companies they wanted their drugs to be seen as at a sort of base level as decreasing suicide or not Constitution so they they hide behind that sort of statistical population level data or you know these meta-analyzes These are the final word as if mental analyzes deliver a a a clinical protocol a clinical practice for everyone they don't this is part of I think the real problem with medicine is and it's it's not just Psychiatry but in psychiatrists particularly so because there is no you know unifying pathology right and and and for whatever reasons people have such different responses to these drugs and the message should be just as you say figure out who benefits who doesn't and who worsens and that means you've got to be paying attention and the suicide is such a great example because you're right maybe it saves some people from suicide in other words you know they get yeah fantastic but then if you have three out of 100 who are now becoming suicidal you got to protect those people I mean on the drug this is example of a moral failure you've highlighted that this is this is a story of how medicine needs to change and how Psychiatry needs to change you know another thing that that comes to my mind which which I I want to bring up is I guess the public probably has an impression that the doctors understand the type of data you know the clinical trial design and then the kind of data analysis that go along with it these things are incredibly difficult to understand I mean these are graduate level courses that you would do for a couple of years to understand the kind of meta-analyzes and epidemiology and clinical trial design to do these so most of what doctors would hear is this drug is safe and effective for the treatment of major depressive disorder and pediatric populations and they go that's fine and and they go with it they don't say well actually what was your primary outcome okay so you used a ham D depression scale is there anything about you know whether they do better in their relationships or do better in their jobs or have more satisfaction about life is there anything in there about how they do it year three you know and if they ask these questions the answer is no you know it's it's they know how they do up to you know six weeks if you're lucky it's up to maybe like six months if it's a particularly long study but that's incredibly rare and so you know all they hear is safe and effective and then they look at the authorship line and go oh you know the chairman of the Department of Psychiatry where I used to go is is one of the authors here um you know and so I'm just gonna go with it you know and and that makes sense and you know if there's a paper out there you know bashing you know David Healey or others who are talking about some of the risks and it's again got this kind of authorship line there you go well I guess I'm just going to believe these people because who am I to go against the chairman of Psychiatry at my institution or some other place it's like you know the and and this kind of trickles into clinical practice and I want to you know the the God you know you write a really nice chapter in uh Psychiatry under the influence on the antidepressant guidelines and and you know how they just how they just leave things out which I think is great but people like you could have a patient that that comes in and they're suicidal and you know if the guideline in the US says you know first line treatment is an antidepressant you know medication maybe maybe they're already on an antidepressant there is so much literature and support out there saying you know maybe put them on an antipsychotic because that's what you do for treatment resistant depression but there is next to no authoritative guidelines with authorship lines of chairmans of Psychiatry which will tell you how to effectively treat someone who's having a drug-induced akathisia or suicide you know you are on your own so so you're tasked with making this decision well maybe it's a drug problem or maybe it's treatment resistant depression well you know as we mentioned before you know with the diagnosis and Psychiatry it could be whatever you want it to be technically you know as long as it's one of those things I actually also think because of the amount the imbalance in the research saying treat treat treat treat treat treat more people just go that way because it feels supported it feels like you know if if I get hauled into court one day I could say well they had these symptoms and you know all of these people said I should put them on you know Abilify now and I'm just acting Within These guidelines and you know there's there's nothing that says the other part of it and so I mean that that's another pervasive problem I see with just the imbalance and the amount of research on efficacy and there's just like nothing on risk that people could hang their hat on and feel confident following yeah I mean I think this is what you know the research that has churned out and what the money flow is is meant to do and you know if you're an academic researcher money flows to you it doesn't flow to you for a highlighting risks it flows to you for highlighting you know benefits and then you can go on these talks and all that sort of thing and you get the you know you have The Prestige of writing guidelines and that sort of thing yeah this is this is such a problem in that in that there are there's a machinery for turning out um turning out stories of treat treat or guy you know these are this is what you need to do and there's no machinery for saying wait a minute are you causing harm there's just nothing in into sort of in any sort of large-scale way that really addresses that concern and the other thing is if I'm a prescriber and and I do what is I'm told to do I have no vulnerability right like suicide that's fine I mean I'm just saying that's that becomes I did what I was supposed to do and all the problems and uh go to the patient and stuff but you know the case that was in um that was it Chestnut Hill case you know in the 1990s where someone did not they did not give a depressed person uh and antidepressants yeah yeah yeah yeah you know I heard about that one well this was really key because I think it's Chestnut Lodge is what it was um we've had a long history with psychoanalysis and that sort of thing at this old way of doing things and they had this person why I can't remember his name come in he didn't get better under the Psychotherapy and then he complained that I would have gotten better on the antidepressant now what happened was the APA at this time loved this lawsuit because they sought as a way to kill psychotherapy and really consolidate around just doing giving the drugs that this would be what we cycle pharmacologists do but that was a real message to people like not treating with drug exposes you to vulnerabilities into lawsuits whereas you treat your your home free and I there's a you know I wrote about a while back there's this initiative in Norway where [Music] um the health Minister ordered every there's four Health districts in in Norway to set aside some beds within the hospital for people who wanted medication-free treatment okay and there was an idea that there should be agency among the patients and if they want medication free we should still provide it anyway there was this guy at a couple psychiatric nurses they set up a private Hospital and they began getting ref basically the people who would get referred to them were people who just failed within the regular system they would be on like 30 drugs 20 drugs they'd come through anyway I went there uh that they were getting people off and as you know when you have someone on 10 drugs you start tapering them down they often come alive right they treated 660 patients okay of chronic people people have been hospitalized for years they had one suicide in six years well then there was a big stink about the suicide because basically Norwegian psychiatrists said aha we can like now nail him on this suicide and a paper ran a newspaper ran like oh you know they had us they had a person die when they were tapering him down well how many suicides are happening within the regular hospital system they happen all the time so you know just to add something here we do exist within a capitalistic Society right yeah and a lot of money flow for treatment and there's you know that whole thing you know what is it what do we spend on Health Care in this country like 20 of our GDP now or something like that crazy well that's all about treat treat treat treat and then if you look at it from that point of view doctors prescribers are just calls in that Machinery that big sort of capitalistic machinery and talking about risks and harms and treating people less boy there's just no Financial reward for that there's Financial vulnerability and there's provincial professional vulnerability and you know how human beings behave it's hard then to get them to do something that goes against their self-interest at some point yeah yeah totally um yeah yeah it's that that that's so true um can I ask you a question real quick sure yep you help people get off beds with diazepines right yeah and do you help people get off antidepressants yes and how vulnerable do you feel for doing that you know here's the interesting thing about me and it's it's probably why I why I do this work you know because I've you know because I've gone to places like the FDA where I you know I was doing safety there you know I was writing drug labels I know the literature inside and out about these risks and um I I also you know I've been on my drug safety specialist in a pharmaceutical company I guess I to me I came to peace with the fact that if I was to get called into court I would probably know more than the opposing expert there I mean they could probably find someone there but you know the way the way I see things you know if they're you know it's I think I could defend myself you know just because I have you know I'm a professional uh adverse reaction you know kind of detector that's that's that's my day trade you know doing doing that so there's there's certainly risk but then the other thing is you know probably the riskiest cases of folks that are on antipsychotic medications you know who want to come off those because they're of course more problems than than the other group and really when it comes to it I think it's it's about documentation and getting the family on board I like to think about it you know what would I need if if something went awry and you know I'd usually need someone's spouse to say yeah you know I'm totally supportive of them doing this you know you know the the patience she doesn't want to be on the medication anymore it's causing terrible weight gains doesn't really feel like it's helping her and we no longer consent today you know to to Everyday treatment in fact we would like her to be offered and to use it as needed and you know if I could put together something like that and and they're on board for that kind of treatment plan I feel like it's fairly defensible um you know say hey for this individual patient daily use wasn't working and we just decided that we would you know treat the Outburst so so that's that side of it and honestly I also you know when it comes to the people who have antidepressants most of them already have you know severe withdrawal symptoms and just a debilitated and they just want to come off and it but it's the same protocol we try and get get family involvement in there we do the traditional things that every psychiatrist would do you know limit access to lethal means and you know frequent visits if they're you know in high risk but I actually feel it's okay and I hope other people feel feel it's more okay to do this kind of work in the future well no you know we hear we I get emails all the time from people saying who can I go see and sometimes trouble finding a a prescriber you know a psychiatrist who will support them with through withdrawal I mean we hear all the time how hard it is to find people who will support them in this way well I'm pleased to say I'm licensed and probably like 14 States now so I'll give you a list of those um uh after this so you can send people my way if you'd like oh I would like to that'd be great yeah yeah um but the other thing I was going to say um my thought came back to me which I lost earlier on you were talking about there's no there's no Machinery to get information out there about risks and this is just so true and I I think it's interesting for people to realize that within pharmaceutical companies there's a group called medical Affairs you know they're closely linked to Commercial and their job is to anticipate the concerns that providers are going to have about the drugs so if they're concerned about us you know a side effect you know they or or maybe there's a new population that's not kind of on label but they need to kind of you know maybe the drug has been effective in some case reports that group will get that information out there and so its whole agenda is to spin things in a positive light and diminish concern but that you know if they're not going to publish a manuscript on a side effect because you know I've been in companies and when this has come up you know they go oh we don't want to blow this out of proportion you know we don't want to make this a bigger deal than that that it is you know and and you would think that there would be a check and balance that someone at the FDA or you know heads of journals would say hey for every efficacy paper you put out you need to publish one on the risks there's no checking balance and so there's just a deluge of Articles generated from within pharmaceutical companies with authorship lines of you know the people they used in their clinical trials who are already you know very on board with the drug you know spinning you know positive stories about the drug diminishing negative ones and this you know no investment in in those stories and so again that's like that's just another way that you just get this heavy skewing of uh you know that the drugs don't have any Harms yeah you know you see every once in a while I think there's a journal of international risk and safety or something called that sometimes looks at this and then there's Thomas Moore's group what is it what does he put out quarter watch or something like that I forget what it was but other than that there's not even you know there's not much mining in the midwatch you know Adverse Events database and it just doesn't it you know it what's so funny to me is of course the advertisements they have to waste like five minutes of advertisements but we're so attuned to saying oh those are just rare risk or something like that and we just tune it out so yeah I mean this is part of a big societal problem is that you know I I don't know are there any medications that don't have any adverse effects or possible side effects I don't know yeah but it's just we still sort of have a Magic Bullet conception of things that like um the drugs work drugs work and their side effects or whatever and and you know at a public health level where is the advance in public health with the increase in spending you don't see you don't certainly don't see in advance of Public Health outcomes for psychiatric disorders but it's also you know like longevity diabetes um so many problems we don't see an improvement in public health as we use more and more drugs no no it's the fact this you know this this opportunity cost at the individual level for being on a drug because you just think it's going to solve your problem rather than I don't know making the changes that you need you know it you know for the chat I talked about earlier on you know who thought he was depressed for you know his 20s I mean it just it completely demoralizing uh you know conceptualization of what's going on with the eye you have a mental illness rather than hey let's have a look at some of the things that aren't working maybe I need to you know stop this bad habit or stop seeing these people but it's yeah no there's no so you know yeah it all goes back to the story of what narrative do we you know in our society do we organize ourselves around and you have a narrative that exaggerates safety and efficacy in what drugs do and a narrative that doesn't look at the wrist doesn't bring that information forward gosh the amount of but you know in my line of work you know when I because because people come to me when they've had injuries that that's that's my typical patient it's not someone who's just like oh I just want to come off you know safely you know they beat a path to my door when something has gone terribly wrong and the amount of betrayal that they feel um from you know from their doctors you know sometimes it's young people who have been almost coerced into taking medication during their adolescence by their parents who thought that they were really helping them and now they've developed you know severe problems from the antidepressants I mean it's just I mean it's it's the saddest stories ever you know lives lives just destroyed by this narrative yeah yeah I mean uh we have we we see this all the time at Latin American of course we publish personal stories and it is it is a story of lives destroyed and people feeling betrayed because of what they were told so we've we've we're about we're out I mean we've kind of blown through the hour a little bit but I hope you don't mind me asking you just one more question um so so you know after after you did Psychiatry Under the Influence um it's been a bit since then what are you doing with your time now you know where are your efforts going these days yeah you know so um I did start mad in America this websites and we have daily science reports and we have personal stories and all and uh I sometimes write reports for them that look into like what you know update reports the long-term effects or I did a story about uh suicide in the age of Prozac looking at some of these questions so I I still do have my hand in that and then I'll give you another example of one thing I did is you know the story was that antipsychotics lengthen life right this is why you should give them even though like in any cohorts that they diminish you know they increase mortality but somehow this became the thing oh we should prescribe antipsychotics to psychotic people because it it reduces mortality anyway I get a piece on that it's in uh is an example where I try to keep my hand in like what is the evidence space but what has happened really is Madden America really took off and so we now have Affiliates in 11 countries and we're going to be Affiliates in four more countries so 15 Affiliates and and the shared mission is really you know societies around organize themselves around a false narrative and we try to provide information that you know gives a more honest narrative and includes patient voices in it and but we have uh you know we have podcasts now and we have for a long while we had a continuing education arm so and of course I have to raise the money to keep this going so that's the problem I mean what I'm really doing now is I mean I say it's a problem because I would love to go back to writing books I love writing books okay not just about Psychiatry it's writing a book sometimes is like uh it's like such a learning experience such a a way to indulge your curiosity it's like the best thing imaginable and I I miss that but unfortunately you know unfortunate unfortunately and fortunately unfortunately in the sense of my writing career it took me but fortunately in the sense that I do think what we're doing is important that you know in even sort of a societal level of trying to give people a different narrative to to know about I mean you asked for example you know maybe finding someone that help you could fish out all this information about say drug risks and what was Finding but we try to do that five times a week and you know you can go around and really find it so that's what I'm doing and and just to finish this up is you were talking about how many lives have really been destroyed and harmed and diminished because of this narrative and the way we're raising our kids is just the idea you would have 20 to 25 of your kids on psychiatric drugs is just astonishing and and there's no evidence you're helping these kids grow up there's all plenty of evidence you're helping them you've screwing them up physically emotionally socially stunting their growth yeah and there's even this thing that two-year-olds need to be on stimulus which just shows that like the the the narrative is just insane um so it's it's meaningful work to sort of try to correct this narrative and and help provide other information so that's what I'm doing I mean something was really interesting again the chap I was talking to about PSS estate legitimately had questions about his sexual identity because he struggled so much to maintain sexual arousal when he was with women that he thought he was attracted to I mean it could you I mean I mean this is just one story but could you imagine you know you know kids 12 13 years old who haven't really reached sexual maturity who have been maintained on these medications I think you know having to go through everything that's already so confusing about adolescence but with you know with with that thrown in there as well I mean it's it's it's it's you know the more the more I think about it the more depressed I get about it just how how nasty it is yeah it's throwing up you know what I the way I like to describe it is we were sort of born with it and I'm not a religious person but I'm going to use this with a god-given right to try to make something out of ourselves that's we grow up and that and that includes trying to become somewhat comfortable with our minds because they're often you know strange places you know you experience your own mind in a strange way but that's sort of the existential path in life and that's sort of the great Voyage we're on when you medicate people and that means like you know dealing with sexuality and having all those sort of tumult around sexuality that's part of the way of course you the process of moving from a pre-teen to an adult is so much about that and we're robbing kids of that we're robbing them with the chance to decide who they're going to be and and and and to go through difficulties and see themselves as human beings that struggle and and and and have all these ups and downs with sexuality into and and you know powerful versions urges passions jealousies that's all part of being human and we're robbing our kids at that and I know nothing that is it it's hard to say the level of harm that is or the level of sort of existential harm that is being done to kids who get pathologized in this way yeah no it's it's it's it's a nightmare um well I want to say thank you so much uh for coming on you know it's my first time talking to you an absolute pleasure to meet you and uh Pleasures are mine but now you're gonna return you're going to return it we're going to have you on Madden America yeah I'd love that and uh yeah so so definitely uh stay in touch and um I look forward to talking with you more yeah me too I look forward to continuing the conversation if you let me know when this runs right um probably in like three or four days it's usually the 101 times America okay all right okay great thank you take care really nice to meet you

Channel: Dr. Josef

Views: 19,048

Keywords:

Id: eFWeCvlaOP4

Length: 68min 17sec (4097 seconds)

Published: Sun May 07 2023