Sunday, April 21, 2013

Bipartisan Push for Better Mental Health Care Won’t Be Helpful

In the aftermath of the shootings at Sandy Hook Elementary School, with memories of the Aurora movie theater shooting, the Gabby Giffords shooting, and the Virginia Tech shootings still in mind, people demanded that the U.S. Congress do something. These shootings, along with many others, were perpetrated by mentally ill individuals. Liberals wanted more gun control. Conservatives wanted more armed guards and armed civilians to take down the shooters. The divided congress was unable to pass a gun control measure. But apparently liberals and conservatives were able to agree on one thing, according to a recent New York Times article: better care for the mentally ill. According to the article, “[t]he emerging legislation would, among other things, finance the construction of more community mental health centers, provide grants to train teachers to spot early signs of mental illness and make more Medicaid dollars available for mental health care.” There would also be support for children who faced trauma, and suicide prevention initiatives. Approximately 1.5 million additional people with mental illness would be treated each year.

This is a good, thing, right? What’s there to complain about more mental health treatment? There’s nothing to complain about, if one believes in the current drug-based model of care. Treatment in this context will be primarily psychoactive drugs. The community mental health center will recruit and encourage people to see a doctor and get a prescription for a psychotropic medication. Teachers will spot early signs of ADHD, depression, and bipolar disorder in children, and put the children on the road to chronic stimulant, antidepressant, and antipsychotic drug treatment. Medicaid is notorious for drugging up the children who rely on it for health care. Suicide will be prevented by prescribing antidepressant drugs. The vast majority of the 1.5 million additional treated people will be prescribed drugs.

After reading Anatomy of an Epidemic (which I review here), I stopped believing that psychotropic drugs are an effective long-term solution for most mental disorders. The evidence is just not there. Some drugs, such as antipsychotics and benzodiazepines, are effective short-term solutions to psychotic or anxious symptoms. The problem is that they don’t help the patient function better over the long term. While the evidence isn’t clear that drugs caused the explosion of debilitating mental illness in recent years, they certainly haven’t helped prevent it. Drugging of children in particular (for ADHD or bipolar disorder) has likely led to poor long-term outcomes, including mental (psychotic disorders, increased suicide rate, rapidly-cycling bipolar) and physical (extreme weight gain and type 2 diabetes for children taking atypical antipsychotics).

I would have preferred to see congress pass a gun control measure. The mentally ill and guns go together like North Korea and nuclear weapons. People with mental illness should not be allowed to purchase firearms. They should not have access to them in their homes. Adam Lanza’s mother was tragically irresponsible for having guns in her home. Her son used these guns to kill her in her home, then 26 people at Sandy Hook Elementary, including 20 children.

I have lived with serious mental illness for some 30 years. Mine has been under better control than many people. I have never been hospitalized for mental illness. I have never had to quit or leave a job due to mental illness. But I would never trust myself with owning or having possession of a gun. The reason is that there are times when my emotions become extreme or difficult to control. In those times, I don’t want access to a gun. It only takes one mistake for a personal or public tragedy to occur.

Gun sales and ownership should be banned for anyone who has been treated for a psychiatric disorder—I mean anyone treated at any time in their life. This would be a major change from current American law, and would require confidential records being unsealed, but it is for the greater good. Anyone living with someone who has been treated for mental illness should be required, if they own a gun, to keep it locked and inaccessible. The NRA will be furious and scream that we are becoming Nazi Germany, but tough. The NRA’s refusal to consider any type of gun control legislation, and their control of most Republican legislators, have allowed these preventable tragedies to happen.

If the government wants to spend money, what should it spend it on, if not treating mental illness? What about research? The problem with research is that the biochemical / drug paradigm still dominates psychiatric research, decades after it’s been clear that the chemical imbalances that drugs supposedly treat don’t exist. The drugs themselves cause chemical imbalances, but after millions of dollars and decades of research, no one has been able to show that any psychiatric disorder is caused by a chemical imbalance. Any government research money will be wasted on new drugs, new brain imaging, new tests, and other things that won’t do anything to improve the lives of the mentally ill. Research on alternative treatments would be more promising, but only a tiny fraction of any allocated funds would go into this type of research.

I’d like to see the government spend its money on providing a solution to the homeless problem. Current policy is to leave the homeless to their own resources. If they want to live on the street, or in a public park, fine. Short-term treatment with medication is useless, since they go off the medication as soon as they leave the hospital or treatment center. Many homeless are afflicted with mental illness and substance abuse. The fact that they are living on the streets is an indictment of the entire drug-based psychiatric paradigm. Deinstitutionalization began in the 1960’s, a half-century ago. Drugs were supposed to provide the severely mentally ill the stability and mental resources to live outside the hospital. But, as I've said above, drugs are not an effective long-term solution for most mental disorders. Thus many deinstitutionalized patients were not able to control their problems, and live independently on their own. Those without financial or family resources to fall back on ended up on the streets. They are the government’s responsibility, and the fact that they are still on the streets decades after deinstitutionalization began is a sign of abject public policy failure.

I have a recent personal experience with the homeless problem in Salt Lake City. On a rainy night, I stopped in at the city library. The Salt Lake City Library is an architectural masterpiece. Here are some pictures of it:

The city library may be a masterpiece of modern architecture, but it’s a leaky masterpiece. There were many containers filled with leaking water that rainy night. This indicates that beautiful and practical architecture are not equivalent. More relevant for the current discussion is that on every floor of this spectacular library there were homeless people. They were sitting on the chairs, using the Internet, and using the bathrooms. One of the homeless guys camped out in the handicapped stall, prompting a man in a wheelchair to complain. The city library is basically a homeless shelter. This is an insult to the taxpayers who support it, to the patrons who want to enjoy its resources, and to the homeless themselves. They should have a permanent home, and the government should provide it.

During most of my lifetime, American homelessness was largely a problem of mentally ill and substance abusing people. Recent years has seen more short-term economic homelessness. What we need to do is to separate out those who are capable of being employed, and those who aren't. Programs for the short-term economic homeless should focus on getting them a temporary residence, and preparing them to get a job. Even better, prevent them from being homeless in the first place by having available state-supported short-term housing for them if they become evicted from their homes. The long-term homeless, those who are too physically or mentally disabled to work, should have permanent state-subsidized housing. This housing must provide care for their disabilities. They should not have the option to be homeless. If they don’t like the state-subsidized housing, let them show that they can independently live in regular housing, or can live with friends or relatives.

Commitment laws need to be changed. This doesn't mean that mentally ill people should be committed to short-term hospitalization, to undergo forced drugging. It means that homeless mentally ill people should be committed to long-term housing. In some cases, those who are most impaired, this will mean state hospitalization.

This change to our homeless policy will be expensive. It can be paid for with reduced entitlement spending (Medicare and Social Security), reduced defense spending, and increased taxes. The benefits will be enormous—we can reclaim our public spaces, our libraries, parks, and streets, and the homeless will no longer be homeless. It would be a much better use of state funds than expanding mental health drug treatment.

Antipsychotics the New Weapon of Choice for American Soldiers

Prescriptions for antipsychotic drugs to American active-duty soldiers increased 1,083% from 2005 to 2011, according to a recent New York Times article. For the statistics-impaired, this is an almost 12-times increase. This increase occurred despite a steady reduction in combat troop levels since 2008. As a comparison, prescriptions for antipsychotic drugs to civilians increased 22% during this time period. The military attempts to screen out recruits with psychiatric disorders, so what’s the reason for this massive increase in antipsychotic drug prescriptions?

The article’s author speculates that antipsychotics are being prescribed off-label for use as sedatives. Prescriptions for other sedating drugs, such as benzodiazepines and anticonvulsants, also showed a large increase in this time period. There is weak evidence that antipsychotics are effective for PTSD. The evidence is stronger for SSRI antidepressants being effective for PTSD, but antidepressant prescriptions declined by almost 50% between 2006 and 2009. The author speculates that the military favors the quick-acting drugs versus the longer-acting antidepressants.

Have soldiers become more psychologically disturbed in recent years, which would explain the massive increase in prescriptions for sedating medications? It’s difficult to understand why. Iraq and Afghanistan have a unique set of challenges for soldiers’ mental health. Unlike past wars, where there was a dangerous front line and relatively safe zones everywhere else, the front line in Iraq and Afghanistan is everywhere. There is always the danger of encountering an IED, or being ambushed. But this was the case in 2005, so why did it increase so much between 2005 and 2011?

Along with the fear of death and injury, soldiers serving overseas experience additional stresses of being separated long distances from family and friends, and being in an unfamiliar and hostile environment. Those who are geomagnetically sensitive also suffer from being in a vastly different geomagnetic environment from which they grew up. But this was a problem in other foreign wars, when soldiers weren't as drugged as much as they are now.

The main purpose of using psychoactive drugs is for soldiers to escape from reality. This is the case for the legal prescribed drugs along with the illegal drugs. The different classes of drugs allow for soldiers to escape from reality in different ways. For example, psychedelic drugs like LSD or PCP create hallucinatory experiences. Opiates like morphine and heroin relieve physical and psychological pain. Benzodiazepenes like Valium and Xanax relieve anxiety. Alcohol has been used for thousands of years as a means for soldiers to escape reality. These drugs also impair soldiers in different ways, and some of them are highly addictive, so it’s important for the military leadership to keep drug use under control.

Based on the 12-fold increase in antipsychotic prescriptions to soldiers, the military leadership has apparently decided that these drugs are a safe and effective way for the soldiers to escape the horrors of their situation. Antipsychotics allow the user to escape from reality by blunting emotions and desires (antidepressants have a similar psychological effect, but are less effective than antipsychotics, and have less dangerous side effects). An irony is that although antipsychotics were designed to combat the delusions of schizophrenics, it’s a mass delusion among psychiatrists and other doctors who prescribe them that they are safe and effective in the long term. Antipsychotics have some of the worst side-effect profiles of any psychoactive drug (nicotine and alcohol are worse). One side effect of the older antipsychotic drugs (and to a lesser extent the newer ones) is a debilitating permanent condition known as “tardive dyskinesia”, i.e. involuntary body movements such as lip smacking, grimacing, and upper or lower limb movements. The newer ones are associated with serious metabolic disorders, including weight gain and type-2 diabetes. Their long-term effectiveness in treating schizophrenia, the condition they were originally designed and approved to treat, is questionable. Their long-term effectiveness in treating PTSD and other conditions afflicting soldiers is even more questionable. The fact that they cause a major reduction in emotion and motivation is not helpful for a soldier’s performance at his job.

One reason military doctors are gung ho about prescribing antipsychotics is that they are not addictive. But not addictive is not the same thing as safe or effective. They aren’t addictive because most people find the absence of emotions or desires unpleasant. This is the reason that people go off these drugs so frequently. This is the reason why they aren’t a viable long-term solution to psychotic disorders. Prescribing them off-label to soldiers as a sedative is bad medicine, and should be banned.

19% of American High School Boys Diagnosed with ADHD

A recent New York Times article reported the disturbing fact that 19% of American high school boys have received an ADHD diagnosis. 11% of school-age children overall have received the diagnosis. There has been a 16% increase in children between ages 4 and 17 being diagnosed with ADHD since 2007, and a 41% increase in the last decade. The increased diagnosis correlates with increased prescriptions to stimulant medications like Ritalin and Adderall. These medications, while offering short-term increased concentration abilities in children with true ADHD, also have risks of side-effects, including addiction, anxiety, and occasional psychosis. Evidence that stimulants improve long-term outcomes in children with ADHD is lacking.

These numbers are making some academic psychiatrists concerned. James Swanson is a professor of psychiatry at Florida International University, and one of the primary ADHD researchers in the last 20 years. According to Swanson, “There’s no way that one in five high-school boys has A.D.H.D. If we start treating children who do not have the disorder with stimulants, a certain percentage are going to have problems that are predictable — some of them are going to end up with abuse and dependence. And with all those pills around, how much of that actually goes to friends? Some studies have said it’s about 30 percent.”

Think about this—30% of stimulant medication is going to children who don’t have any disorder. They are using it to focus, to stay awake, and to improve their grades. Parents, doctors, and pharmacists are essentially giving normal children access to speed. Maybe these children will do better at school in the short term. But they are risking a life of drug abuse and dependence. Sure, grades are important, but are they really that important?

Dr. Ned Hallowell, a child psychiatrist and author of best-selling books on the disorder, is another psychiatrist who has changed his viewpoint on ADHD. For years Dr. Hallowell would reassure skeptical parents by telling them that Adderall and other stimulants were “safer than aspirin.” He now says, “I regret the analogy” and “won’t be saying that again.” Halloway still thinks that many children with ADHD continue to go unrecognized and untreated, but wants more rigorous diagnostic procedures. “I think now’s the time to call attention to the dangers that can be associated with making the diagnosis in a slipshod fashion,” he said. “That we have kids out there getting these drugs to use them as mental steroids — that’s dangerous, and I hate to think I have a hand in creating that problem.”

Regarding rigorous diagnostic procedures: proposed changes to the DSM, to be released soon in the DSM-V, allow for more adolescents and adults to qualify for the disorder. Some of the proposed changes include increasing the age of first symptoms from 7 to 12; examples, such as repeatedly losing one’s cell phone, that are applicable to teenagers; and a change in the requirement that symptoms cause “impairment” to symptoms simply “impacting” daily activities.

Pharmaceutical companies predictably use their marketing power to persuade parents and doctors to get more children an ADHD diagnosis and prescription for stimulant medication. An example of this is a pamphlet for Vyvanse from its manufacturer, Shire. In the pamphlet, a parent looks at her son and says, “I want to do all I can to help him succeed.”

The stimulant drugging of our youth is a national crisis that needs to be addressed. It is unlikely that psychiatrists and pharmaceutical companies will reform themselves without outside pressure. Left alone, the corrupt pharmaceutical-psychiatric establishment will diagnose and drug more children, as evidenced by the numbers mentioned above, and proposed changes in the DSM-V. The government needs to be involved in the solution. Some needed changes include the outlawing of off-label prescribing to children, tightening the diagnostic standards of ADHD, restricting the prescribing of stimulant medications to children, encouragement of using non-drug alternative solutions to ADHD, encouraging  research in alternative treatments for ADHD, outlawing drug company advertising to the public, outlawing drug companies’ bribes to doctors, and expelling from school any children found with stimulant medication that is not prescribed to them, or any children sharing their medication with other children. There also need to be more long-term studies done of the effects of stimulant medications on children with or without ADHD.