Another Spurious Correlation? – ADHD

10/30/2017        In the News 0 Comments

Another Spurious Correlation? - ADHD

by Chuck Ruby, Ph.D.

Are we seeing yet another spurious correlation peddled to the public as medical research? A study published at JAMA Pediatrics suggests that acetaminophen use during pregnancy causes ADHD. This study harkens back to the thalidomide controversy of the early 1960's, but instead of birth defects, the fear is that  a common over-the-counter drug may disrupt fetal brain development leading to ADHD. It has been reported to the general public here and here, among other outlets, not only causing fear among parents but also continuing to perpetuate the myth that ADHD is a real disease.

For now, let's set aside the fact that little evidence supports the neurobiological defect model of ADHD, the debunking of the Diagnostic and Statistical Manual of Mental Disorders (DSM), in which ADHD is listed as a disorder and is thus also invalid, and that ADHD makes no sense from a logical perspective. Let's instead get into the weeds of this study and consider a simpler explanation for the data showing a correlation between acetaminophen use during pregnancy and later ADHD.

This study was an analysis of over 64,000 mothers and their children  from the Danish National Birth Cohort from 1996 to 2002. The researchers gathered data regarding the mothers' acetaminophen use during pregnancy and the later incidence among these mothers' offspring of problems associated with hyperactivity. The study found that the offspring of mothers who took acetaminophen during pregnancy had higher rates of these problems.

However, the difference between offspring of mothers who used acetaminophen and those who didn't was quite small. Overall, the offspring of the mothers who took acetaminophen had a 13% increased risk of scoring moderately on the Strengths and Difficulties Questionnaire. A more detailed breakdown showed the offspring of the acetaminophen mothers had: 1) a 17% increased risk of hyperactivity; 2) a 14% increased risk of conduct problems; 3) a 5% increased risk of emotional problems; and 4) a 1% increased risk of peer problems. Interestingly, there was no difference in the scores of the childrens' prosocial behaviors (this is odd since one would expect someone diagnosed with a real neurological defect to lack prosocial behaviors too).

But these are relative risk statistics. If one looks at the absolute risk, the difference becomes even more meaningless. For example, using the largest risk ratio (# 1 above - hyperactive risk), the difference in risk was a matter of 5.7% vs. 4.3%. In other words, an offspring of a mother who took acetaminophen during pregnancy had a 5.7% risk of scoring greater than a 7 on the Strengths and Difficulties Questionnaire Hyperactivity Scale, in contrast to a 4.3% risk of scoring greater than 7 by the offspring of mothers who did not take the pain reliever.

This minimal difference in risk is even more diluted when looking at the confidence intervals for the risk ratios. For two out of the four risk ratios above (emotional problems and peer problems), the 95% confidence intervals included a risk ratio of 1, which would mean there is no difference in risk between the groups of offsprings. The other two risk ratios' confidence intervals came very close to including 1.

These forgoing measures were of "ADHD-like behaviors". Well, let's see what the risk of actually being diagnosed with ADHD (actually the researchers looked at those diagnosed with hyperkinetic disorder). For the offspring of mothers who took acetaminophen, there was  a 37% increased risk of being diagnosed. But again, a look at the absolute figures dilutes the practical significance of this risk ratio. The absolute risk difference in being diagnosed was around 1.5% for those mothers who took acetaminophen vs. 1% for the mothers who didn't. Hardly a matter of alarm or evidence of disease.

If there is any evidence that a drug causes fetal birth defects or neurological damage it should be taken seriously, regardless of the absolute risk. In the case of thalidomide, there was ample evidence that the toxic nature of the drug caused real defects. And, if acetaminophen is shown to cause real fetal defects, it should be treated similarly and prescribers and parents warned. But the resulting defect would not be called "ADHD" or "hyperkinetic disorder". The resulting defect would be more appropriately called a neurological disease, as would any other toxic chemical exposure, and fall under the bailiwick of the real field of medicine called neurology. The defect wouldn't be treated as ADHD and we certainly would not want to use toxic stimulant drugs to treat a real defect that was caused by another drug's toxic properties.

But this study was not looking at brain damage or defect. It was looking at the association between the incidence of acetaminophen use during pregnancy and the subsequent categorization of the offsprings' social problems using a set of checklists, not as having a neurological defect (no such defect has ever been demonstrated).

What would be a more simple interpretation of the results of this particular study? It is quite probable that parents who are more likely to resort to a pain reliever such as acetaminophen are also more keenly aware of bodily ailments, and more inclined to use chemicals to soothe those conditions instead of merely tolerating them. As these parents have children, they are also likely to transfer that concern and awareness to their children's ailments. 

Therefore, when these parents wonder about their children's hyperactive behavior and other social problems that are subsumed within the diagnostic criteria of ADHD, they would be more likely to see these issues as problematic and indicative of something going wrong rather than as within the normal range of childhood behavior. They would also be more likely to consider seeking out a pediatrician or child mental health professional. Due to the pressures to diagnose in order for health insurance to reimburse a professional's time, these children would then be more likely to receive ADHD (and other) diagnoses, in addition to being the target of symptom checklists such as the Strengths and Difficulties Questionnaire. This alone could easily account for the small correlation between acetaminophen use during pregnancy and the later identification of these problems in the offspring.

The biggest problem with this study is it perpetuates the misunderstanding of ADHD as a real neurological defect, in this case one that is caused by the hormonal disruption of acetaminophen.

Alternative History of the Native American Mental Health System

10/27/2017        ISEPP In Action 0 Comments

Watch ISEPP's David Walker speak about how the mental health industry has privileged "white" America and disenfranchised the native people who preceded the European invasion.

A New Treatment for Depression – Really?

9/24/2017        In the News 0 Comments

A New Treatment for Depression - Really?

Chuck Ruby, Ph.D.

Pay attention to language! Here is a typical example of how language is used in mental health research in order to give the impression of medicine and disease, when in fact there is nothing medical or pathological about it. Yet, it is a linguistic smoke screen that obscures the real results.

JAMA Psychiatry recently published the results of a study that claims “whole-body hyperthermia” outperformed placebo in reducing the symptoms of depression. It sounds very clinical, medical, and based on an understanding of neuroscience. The study's lead paragraphs especially set the tone and give the impression of neuroscience at work. The researchers' conclude that hyperthermia "holds promise as a safe, rapid-acting, antidepressant modality with a prolonged therapeutic benefit." Isn't there a more direct way to say this?

If you take the time to dig into the weeds and see what this study is actually saying, it is quite commonplace. It is merely proposing that increased warmth can make people feel better. Didn’t we already know this? All the talk about brain structures and pathways activated during the process of warming is irrelevant, yet it is used to make depression sound like a matter of brain pathology and "whole-body hyperthermia" as medical treatment.

Beyond the critique of language, an examination of the data further question the value of this study.

To start off, the overall difference in depression between the "whole-body hyperthermia" group and the placebo group was minimal. At 6 weeks after treatment (the longest post-treatment assessment made), the hyperthermia group’s average score on the Hamilton Depression Rating Scale was about 12 and the placebo group’s average score was about 17. A Hamilton score of 12 is within the “mild” range and 17 is within the “moderate” range. The cutoff between mild and moderate ranges is 13-14. (For now let's ignore the issue of the 86% sensitivity and 92% specificity ratings of the Hamilton).

Added to the questionable meaning of these Hamilton score differences is the fact that the confidence intervals were quite large. For example, the 6 week difference in scores was 4.27. But the 95% confidence interval for this difference was 7.94 to .61. This means there is a 95% chance that the true difference between the groups’ scores was between 7.94 and .61, and a 5% chance the difference score was outside that range. Given that the cut off score between “mild” and “moderate” depression of the Hamilton is 13-14, claiming any practically significant difference between the hyperthermia group and placebo group is dubious.

Further, it must be remembered that the above Hamilton scores are group averages and they do not sufficiently account for the individuals’ scores. The two groups' score distributions overlap such that some in the placebo group did better than those in the hyperthermia group. At 6 weeks, the Cohen's d effect size between the groups was 1.66. At this value, about 40% of the two groups overlap. And remember, this is using the 4.27 Hamilton score difference, which is questionable given the large confidence intervals.

Finally, the placebo effect was greater for the hyperthermia group than placebo group. After the study, 94% of the hyperthermia group guessed correctly that they were in the experimental group, whereas only 71% of the placebo group thought they were receiving the experimental treatment. This would have artificially reduced the hyperthermia group's scores on the Hamilton based on the placebo effect alone.

Linguistic gymnastics are used in this and many other studies to give a medical model impression. More over, the very statistics reported ostensibly to justify a claim of superior treatment demonstrate the unconvincing nature of the results. Trivial effects, excessive confidence intervals, nomothetic washing away of individuality, and the placebo effect make this study of questionable use, other than to demonstrate that warmth can help some people feel better. How surprising is this?

Breggin Fails in Court

Breggin Fails in Court

Remember folks, Peter Breggin is on our (ISEPP’S) side; so, when Peter fails, we fail. Or do we? How did we/he fail this time?

Commonwealth of Massachusetts vs Michelle Carter. Guilty of manslaughter

Michelle was found guilty of encouraging, coaxing, pushing her despondent boyfriend, Conrad Roy, to kill himself. Peter noted that in June of 2014, Michelle was actually encouraging Conrad to get psychological help, not kill himself. In fact she volunteered to go with him to work on her own problem, an eating disorder. She was then started on Celexa by her doc (she had been taking Prozac for years). By July 2014, a month into her new antidepressant treatment, Peter noted she had become -- transformed if you will -- apathetic, prone to bouts of mania, nightmares in which the devil told her to kill herself. In addition, according to the “Psychiatric Times,” September 2017, p. 13, Peter also testified:

[Carter] was enmeshed in a delusional system…really…a delusion where she’s thinking that it’s a good thing to help him die…[She] was unable to form intent because she was so grandiose that what she was doing was not to harm -- even though she was encouraging his suicide, her absolute intent was to help Conrad.

Well, the judge would have none of it. (Michelle chose not to have a jury trial.) When Michelle encouraged him to poison himself with carbon monoxide, there was no indication of an attempt to “help.”

This case bothers me. Although I am in Peter’s corner, railing against toxic substances poisoning the minds of vulnerable kids, I probably would have made the same judgment as Judge Lawrence Moniz. “The drug made me (her, him) do it!” is a slippery slope, particularly if you are of an existential bent as am I. We existentialists believe in personal responsibility. Note: Of all the drugs on the market, the drug causing the most violence is, you guessed it, alcohol. And alcoholic intoxication is not a defense in a court of law. 

So many culprits in this case

Yes, I know alcohol intoxication is quite different from taking a drug prescribed by an “expert.” When we drink alcohol, it is on our own recognizance.

But, isn’t it peculiar that pregnant women are warned that alcohol might be injurious to the health of the fetus but there is no black box warning indicating that alcohol might impair judgment, remove social inhibitions, lead to violent actions towards others or oneself?

What interests me is: WAS MICHELE EVER WARNED that Celexa could impair her moral judgment? How did the prescriber counsel her? Was she told that apathy was a possible effect? Most of all, the question is still open – where does personal responsibility end and professional responsibility begin? It is here that I am sympathetic to Judge Moniz’s decision. He is called upon to pass judgment on the person, not the system. There are so many culprits in this case: the careless prescribing physician; the corrupt pharmaceutical industry; distortions promulgated by the profession of psychiatry; the negligent families of each of these kids; society, with its futile dependence on pseudo-technical solutions to psychologic/spiritual problems. Michelle and Conrad were the end point of myriad influences. Conrad is dead. Michelle will do some jail time. Maybe she’s wiser. Are we?

Let’s clarify something. It is a mistake to think that patients always follow doctor’s orders. There are very persuasive accounts in the literature that the opposite is true, particularly when it comes to antidepressants.

Some examples:

  1. From Sawada, N et al. Persistence and compliance to antidepressant treatment in patients with depression: A chart review. BMC Psychiatry 2009:38. “In this retrospective chart review, 6-month adherence to antidepressants was examined in 367 outpatients with a major depressive disorder (ICD-10)… Only 161 patients (44.3%) [!] continued antidepressant treatment for 6 months.”
  2. From Warden D et al. Identifying risk for attrition during treatment for depression. Psychother Psychosom 2009:78:372-379. “The attrition rates in the first 12 weeks of treatment can be as high as 65% [!] in naturalistic setting (2,3,4) and 36% in clinical trials [5] and as many as 15% of the patients never begin a prescribed antidepressant [6].”
  3. From SansoneR.A. et al. in “Innovations in Clinical Neuroscience,” 2012. P41-46, “…approximately 50% of psychiatric patents and 50% of primary care patients prematurely discontinue antidepressant therapy…”

My sympathy goes out to Michelle and to Conrad’s family. I can’t explain why Michelle did not toss the drug down the drain, not wanting the effects that may have contributed to Conrad’s death. Often one’s desire to escape psychological pain has dire consequences. Is that what happened to Michelle Carter? “Die Conrad, I don’t want to feel your pain any more.”

It’s All Settled Now! Antidepressants Work. Or Do They?

9/5/2017        In the News 5 Comments

It's All Settled Now! Antidepressants Work. Or Do They?

by Chuck Ruby, Ph.D.

A recent Medscape Psychiatry article announced the results of a "mega-analysis" study of the effectiveness of antidepressants vs. placebo. The lead researcher boldly claims "I think, once and for all, we've answered the SSRI question." There are many follow on assertions just as brazen, but just as misleading. Here are a few:

"...SSRIs work. They may not work for every patient, but they work for most patients. And it's a pity if their use is discouraged because of newspaper reports."

"The finding that both paroxetine and citalopram are clearly superior to placebo...when not producing adverse events, as well as the lack of association between adverse event severity and response, argue against the theory that antidepressants outperform placebo solely or largely because of their side effects...."

"...our results indirectly support the notion that the two drugs under study do display genuine antidepressant effects caused by their pharmacodynamics properties."

"And we did have an impressive, robust difference between active drug and placebo...."

These statements sound impressive. But the effect sizes between the SSRI and placebo groups in the study demonstrate that the difference between the groups is nearly meaningless. The reported effect sizes ranged from .31 to .49. See the graphic representation below which shows an effect size of .5:

The dark blue group would represent the people who took the SSRIs. The light blue represents the placebo group. One can see that the average level of depression for the SSRI group is less than that of the placebo group.

But look at how much the two groups overlap. Given the range of effect sizes in the study, 80-88% of the two groups would overlap. This means many people in the placebo group did better than people in the SSRI group, and many people in the SSRI group did worse than the people in the placebo group! With this in mind, how could the above claims of SSRI superiority be justified? They can't.

This bold sounding announcement that the question has been finally settled about SSRIs' superior effectiveness is typical of those who continue to support the medical model of human suffering. They use statistics to obscure practical and clinical significance. Looks good in medical journals and unless one understands the basics of statistical analyses (in most cases, the effect size is the telling number), it sounds good in media reports too.

The article mentions Irving Kirsch, Ph.D., who has critiqued the use of SSRIs (as have many others). Dr. Kirsch rightly points out another little known issue with studies like these. Not only is a placebo effect likely just because someone knows they are taking a substance (and they think it is the SSRI), but also because those taking the real SSRI will notice the psychoactive effects of the real chemical, and this will enhance the placebo effect. So, one would expect a small effect size difference between the SSRI and placebo group based on this alone. This is exactly what the study shows. Dr. Kirsch cautions that we should weigh this small, meaningless, effect with the potentially harmful side effects of taking these and other drugs to quell human emotional struggles, typically in combinations with other psychoactive drugs.

These above issues make this announcement weak. The study is far from demonstrating that SSRIs, or any other psychoactive drug, is an effective way to address the meaning-laden and personal struggle we call depression.

VA Damage Control: The VA Has Been Infiltrated!

This is an actual letter I mailed recently to help raise money for my veteran patient . Identifying information including the dog’s name, has been changed.



September 1, 2017

To Whom It May Concern:

Re: Skip Sullivan, Honorably Discharged Veteran
DOB: Too Young

VA’s Failure

Skip was referred to me by Sally H, Visiting Nurse for Veterans, Camp X, the South. He flew here to the Washington, DC area because he was informed by Colonel Sharon Z. founder of HELPFOR VETSUSA that I could help him.

Two deployments to Iraq, the deaths of a dozen comrades by enemy fire and by suicide, two suicide attempts himself, as well as musculoskeletal damage due to an enemy IED. You would think that would all be enough for him to deal with: psychological trauma, moral injury, the gut of war. No! His principle dilemma now is iatrogenic. Skip lost count after 40 different drugs had been prescribed for him over the last 7 years. When he arrived at my office on August 17, 2017, he was on high doses of nine different drugs all of which have had profound adverse reaction impact. Before arriving at the VA for medical care in 2010, his vision was perfect, now impaired. Before arriving at the VA he had normal GI functioning, now impaired. Before arriving at the VA, he had normal sexual functioning, now impaired. Before arriving at the VA, although in psychological turmoil, he had excellent cognitive function and could emotionally feel authentically, now, “I fake feeling. I know I’m supposed to feel but I can’t.” And he nods off in the middle of substantive discussion.

Skip flew 1500 miles from the MidWest because he could find no doctor with the will or the knowhow within the VA system to wean him. Be clear. Although I am an “expert,” I made it clear to Skip the complexity of dozens of psychotropic drugs interacting is BEYOND KNOWABLE. Without any guarantees, Skip and I have entered into a struggle, requiring daily monitoring and extraordinary help from his fellow vets, a different vet showing up each day to bring him along with Charlie, his companion dog, to my office since it would be dangerously foolhardy for him to drive himself.

What’s the big deal? Just stop the drugs! Well, stopping these drugs cold turkey would be inviting mortal danger. The body and all its systems, neurological, gastrointestinal, cardiovascular, adapt to the onslaught of these potent substances with a myriad of potential adverse reactions. Abrupt withdrawal would be like blowing up a dam, psychologically flooding – overwhelming the organism. It must be done slowly. Unfortunately, it is also painful. It takes courage, “I’m willing to put up with the pain if I can just be normal again.”

Why all the drugs? Thousands upon thousands of veterans are going through this. I believe the difficult answer to this question is that the VA has been infiltrated with self-defeating, and what I consider odious ideas about what it means to have suffered the damage of war battle. Pathologizing these returning warriors rather than accepting, hearing, understanding, and supporting their terror-filled experiences drives them further into misery, e.g., as soon as the idea of “suicide” is mentioned almost invariably the VA physician reaches for the prescription pad. And as the veteran experiences the first adverse reaction, the second drug is added, then the third, the fourth, etc. In time there is utter confusion about what is “real” and what is drug-induced. The chance then of finding a remedy becomes less and less.

So I will work with Skip this next year, seeing him frequently, daily when necessary, doing the necessary testing (e.g., he is probably Mg depleted as his GERD caused by one of his many drugs is being treated with yet another drug, a proton pump inhibitor (PPI), which potentially depletes this essential element. Note, he has been on this drug for more than six years while the recommended length of time to use PPIs is about three months!) and, most importantly working psychotherapeutically, existentially, spiritually as he comes to grips with war trauma. Ultimately, his goal is to help other vets. I believe he’ll do it.

Finally, Nurse Sally is paying for his treatment out of her own pocket. I am giving her some discount. This is a travesty! The government agency that has so poorly treated this veteran does not now take the responsibility of paying for the treatment that he had to seek out on his own. As an American, I feel shame and I am disheartened.


Joseph Tarantolo, MD

Board Certified Psychiatrist



Book on Suicide Prevention

8/16/2017        ISEPP In Action 0 Comments

ISEPP's Hank McGovern has come out with a book on suicide prevention. Check it out at Amazon. Hank speaks from personal and professional experience. Take a look at his recent interview below with Michele Paiva, ISEPP's marketing guru.

The book has received 5 stars out of 47 reviews so far. From one review: "The author artfully uses the dramatic frame of a suicide note and a tumultuous, well-drawn childhood to take readers through his quest for meaning, peace, and balance...His encapsulations of various therapies, particularly rational emotive behavior therapy, are soulful and illuminating, and emphasize the power of practical, positive action and  behavior...Overall, this is an evocative, intriguing, self-exploration...sometimes overwhelming, yet compelling..."

ISEPP Demands Ethical Guidance on the DSM

8/15/2017        ISEPP In Action 0 Comments

ISEPP was joined by allied sister agencies in demanding ethical guidance from five leading professional mental health member organizations regarding serious problems with the Diagnostic and Statistical Manual for Mental Disorders (DSM). Ever since its publication in 2013, mental health experts and international organizations have decried the DSM's lack of validity. Applying an invalid diagnostic system to people is unethical and harmful. Still, it continues to reign as the official diagnostic system and there has been no attempt to rectify this problem.

In an Open Letter sent Tuesday, August 15, 2017, ISEPP spelled out how this places mental health practitioners in an ethical double bind. They must knowingly use an invalid and potentially harmful manual to help people in need, as health insurance companies require a DSM diagnosis for services to be reimbursed. But if they abide by their ethical standards and refuse to use the invalid manual, people in need will not be able use insurance benefits to afford services and they will go without help. Either choice will place the practitioner squarely in conflict with their prime ethical mandate of "do no harm."

The following agencies joined with ISEPP in this Open Letter:

International Society for Psychological and Social Approaches to Psychosis, United States Chapter

Center for Loss and Trauma

National Coalition for Mental Health Recovery

MindFreedom International

Hearing Voices Network USA

MISS Foundation

Volunteers in Psychotherapy

Warfighter Advance


Religion – Is It All In The Brain?

8/9/2017        In the News 2 Comments

by Chuck Ruby, Ph.D.

A recent study in Neuropsychologica about veterans and brain trauma is a prime example of how medical model thinking and nomothetic research design and analysis wrongly imply: (1) that meaningful human experiences can be best understood by looking at the brain; and (2) that differences between research groups as identified by statistical tests, mean that the class of people in one group share a common characteristic different from the class of people in the other group(s). Unfortunately for the authors of the study, this is not true.

First, the follow quotes from the study reveal how meaningful human experiences are falsely reduced to brain structures:

“…religious beliefs are critically represented in the anterior frontal lobe.”
“…fundamentalist religious beliefs arise from the integrated processing and computations in a distributed brain network….”
“…a vmPFC lesion induces increased fundamentalism.”
“…religious beliefs are partially dependent on correct functioning of the PFC.”

None of these statements are accurate. We’ll never find religious beliefs inside the skull and brain activity does not give rise to religious belief, even though religious belief cannot happen without brain activity. Religious belief, in addition to a plethora of other kinds of meaningful human experiences, can only be understood by understanding the individual person, and even that changes over time. Further, given that they are individuals, people are inescapably nuanced, complex, and unique in terms of the factors that interact and lead up to any one particular characteristic, such as religiosity.

It is true that damage to an area of the brain necessary for a person to have a certain opinion, belief, conviction, or feeling can change the person’s experience of those things. However, especially in the case of highly meaningful things, like religiosity, such changes occur more often not because of damage to those areas but because of experiential changes in living. This study never takes this into account: that veterans who have suffered TBI had more severe and meaningful experiences (both during the trauma and post-trauma) than those who hadn’t suffered TBI. How did those experiences, and not brain damage, affect their turn toward religious fundamentalism?

Regarding the second issue, there was a statistically significant difference in fundamentalism scores between the group of veterans who suffered damage to the ventromedial prefrontal cortex and the group with damage to the prefrontal cortex but outside the ventromedial and dorsolateral regions. Yet, the Cohen’s D was only .71. This means the two group distributions of fundamentalism scores overlapped around 73%.

Given this amount of overlap of groups, it does not justify the researchers’ claim that, “…participants with vmPFC lesions reported greater fundamentalism.” or “[p]atients with vmPFC lesions scored higher in fundamentalism than patients without PFC lesions….” Neither of these claims represents the data. In fact, a large number of people in the ventromedial group had lower fundamentalism scores than the other group, and vice versa, contrary to the claim. If damage to that region increases religious fundamentalism, it should apply to all of them.

Moreover, the amount of variance in the data explained by the ventromedial lesions was only 1%. That means 99% of the observed variance in fundamentalism data among the participants was due to something other than the lesions. In fact, this study found that openness (9.7%) and cognitive flexibility (4.6%) explained far more variance in the data than did the lesions. This suggests a person’s subjective understandings of the world, separate from brain injury, are more important in understanding religiosity. And note that even with all of the studied variables included, only about 18% of the variance was explained; 82% was unexplained. This is the important statistic. Much of what people do can't be explained by using medical model, nomothetic approaches. It is important to understand one person at a time.

Despite the above, the “moral of the story” according to the authors is how damage to brain structures affects one’s religious fundamental beliefs. This perpetuates a medical model of humanity that reduces meaningful experiences to sterile brain activity, and it stereotypes people without even a minimal amount of justifying evidence.

“I Want To Die”

"I Want To Die"

If you are a psychotherapist, counselor, psychoanalyst, and especially if you are a psychiatrist, you have heard variations of this refrain many times, which has soullessly come to be called "suicidal ideation". “I don’t want to live anymore… I want to kill myself… I wish it were all over…," etc. What to do with these laments?

Before I address the question, a personal note. I am 74 years old and I’ve been depressed many times. I have never had ETC or pharmacological intervention. I worked on the “depressions” the old-fashioned way. Reflection. Talk. Analysis. Struggle. My bias is that I don’t trust colleagues who claim they have never been depressed. Really? Never depressed? I don’t prescribe ECT either. I’ve witnessed only one ECT administered and that was during my training. OK, I got that off my chest.

Back to suicide talk. In Tom Szasz’s last book, Suicide Prohibition: The Shame of Medicine, (see my book review in Ethical Human Psychology and Psychiatry, Vol. 14, #1, 2012, pg. 74) he makes a powerful case that by locking up patients who speak about self harm we not only infringe on their civil liberties, but also drive that speech underground.

Think of it, if someone tells me they are suicidal I am duty bound to call the cops! An exaggeration, but not much of one. Hospitals and doctors are frequently sued by surviving families. “You should have been more attentive, careful, protective. Had you not been derelict my son/daughter/wife, etc., would still be alive.” So hospitals and clinics and counselors always have on their checklist a rating for self-harm. That checklist surely is for legal purposes. Or perhaps it is there for reassurance for the institution.

You would not be surprised, I suspect, that some in conventional psychiatry would promote, then, their various somatic treatments as suicide preventative. Allow me if you will to focus only on ECT. This blog is not going to be a diatribe against ECT. If you are hankering for an “I-hate-ECT" thesis, read Linda Andre’s Doctors of Deception: What They Don’t Want You To Know About Shock Treatment (2009, Rutgers University Press). She claims that ECT “impaired my intellect” (pg. 131) and did irreparable harm to retrieving her early life memories. She rakes the ECT profession over the coals.

If you are in a particularly angry mood you’ll like Andre’s book. She bashes Peter Breggin as well calling him a “costly disaster “(pg. 118). Evidently the Marilyn Rice case way back in 1977, the first case to adjudicate a malpractice suit against an ECT Doc for memory loss, did not go well for the plaintiff. Breggin was Rice’s expert witness. I’ve never discussed the case with Peter. I assume it is no easy task to prove that ECT treatment in one particular case is the cause of the memory loss. Do your own research. I’ll comment later.

Oh, but you may feel kindly about ECT. Then by all means read Edward Shorter’s and David Healy’s Shock Therapy, A History of Electro Convulsive Treatment in Mental Illness (2007, also Rutgers University Press) which they dedicate to a “small band of European emigres [who]… saw the merits in ECT… [they are] heroes in [the] 20th century of psychiatry…” (dedication page)

Shorter is a prominent medical historian and Healy was a presenter at the 2015 ISEPP Conference. Healy is the beloved psychopharmacologist of our organization because of his litigative efforts that helped lead to the black box warning for SSRIs. In his book Let Them Eat Prozac (2004, New York University Press) he takes on the fraudulence in the psychopharmaceutical industry that hid the danger of SSRI therapy. In his book he also shares some of the best work I know of in testing the impact of these drugs on “normals.” On the other hand he is anti-beloved by many in our organization because of his high regard for ECT. Nobody’s perfect. 

In Shock Therapy, Shorter and Healy toss a lot of statistics at us (see page 97) supporting their thesis that ECT prevents suicide. Maybe. “[There is]…no doubt that ECT was effective in the prevention of suicide. This was confirmed in 2005 in a large multi-center study led by Charles Kellner at University of Medicine and Dentistry of New Jersey.” The second of 16 authors this study was Max Fink, the father of American ECT. The authors hold out this study as particularly worthy to their cause. The conclusion of this very ambitious study is that it was “irresponsible" not to prescribe ECT sooner clinically, not as a “last resort” after the failure of chemical treatments. I had to read this study. After all, I don’t want to be “irresponsible.” But first, some statistics.

If you go to the American Foundation for Suicide Prevention website you are quickly smacked with the statistic: “An American dies every 12.3 minutes by suicide.” That is 42,773 in 2016. Wow, a lot of suicide. And, oh, BTW, 90% of them had diagnosable disorders. Thank God for the DSM to clarify difficult issues!

Hold on. Let’s put aside the hysteria. Just how many people did die in 2016? According to the National Center for Health Statistics that would be 2,626,418. That is, one American died every 12 seconds in 2016. I did the math. What did they die of? The usual suspects:

-Heart Disease: 614,348

-Cancer: 591,699

-Stroke: 133,103

-Alzheimer’s 93,541

-Diabetes: 76,488

-Flu and Pneumonia: 55, 227

-Nephritis: 48,116

-Suicide: 42,777

In other words, only 1.5% of those who died in 2016 were those who chose to die sooner rather than later. When talking about death in America, suicide is not common. Yes, of course it is often tragic, like a kid suffering bullying who can’t stand it any more. Tragic does not mean common.

Back to Kellner and Fink’s large multi-center (there were 5 hospital centers throughout the country) work. They “studied “ 444 depressed ECT patients, 131 of whom reported suicidalness according to the Hamilton Depression Scale. Results: after one ECT treatment, 15% dropped their Hamiltonian suicidalness to 0; after 3 ECT treatments 38% dropped their Hamiltonian suicidalness; 61% after 6, and 76.3% after 9 ECT sessions. And 87.3% dropped their Hamiltonian suicidalness after completing the treatment course. Wow, pretty impressive. No? Well I’m not convinced either. Remember the statistic – suicide is really not that common. Thinking about ending an unhappy life is very common. So let’s go to the fine print.

There were 2 patients in the study who died of suicide, 2 white men aged 76 and 80. One had expressed “no suicidal intent” before or after the treatment and the other scored a “1” before and a ‘0’ after the treatment. Thus this study only corroborates that ECT has a dramatic impact on stopping thinking about suicide. It tells us nothing about the actual action.

And this is why I don’t prescribe ECT. It interferes with thinking and remembering. For me it is more a philosophical stance than a medical-statistical position. I value thinking and remembering. Thinking about suicide is so common, so important, but actual suicide is so rare, it is my impression that suicidal thinking and dialogue in therapy is much more about life than it is about death. What I mean is that many unhappy people just don’t have the language to examine their unhappiness. The best they can do is, “I want to die, end it.” The therapeutic relationship helps give voice and create expressive language. Scrutinizing why someone is suicidal is important, ok. But really, we know why people want to die: despair, rage, hopelessness, pain, profound shame, abject loss. That needs to be validated of course. But as important, perhaps more important is what keeps us alive. So for me it is more important to ask, “What stops you? Why haven’t you done it?” And then I begin to hear about their life. That’s where the therapeutic action is.

I’ve had one completed suicide in my practice, that is, one who killed himself while in therapy. He never once talked of ending his life. Not once. I wish he had. If he had, he might still be alive today.