Noel Hunter, Doctoral Student

A recent article in the Washington Post, entitled “Her brain tormented her, and doctors could not understand why.” was a heart-wrenching story of a troubled young woman who suffered greatly in her final years before dying at the young age of 23 due to a reaction to a prescription drug. This story is a haunting example of the all-too-common tragic outcomes of people who suffer from extreme states of human distress. Unfortunately, the Post’s rhetorical tale, which is based on misinformation, extreme reductionism, and a distortion of research, only adds to the tragedy of Ms. Pam Tusiani.

The Post’s first error is in taking as fact the idea that extreme emotions, suicidal thoughts, and seemingly strange ideas and behaviors are “symptoms” of a medical, biological disease. The problem is exemplified in the statement: “What was once thought to be the result of child abuse or a manifestation of post-traumatic stress is now its own complex personality disorder. And it’s deadly”. This statement is somewhat incomprehensible considering that “personality disorder” is simply a label and nothing more. It doesn’t describe a “disease”; it describes a problem. 

At no point does the author express how or why a post-traumatic reaction suddenly was re-conceptualized as a “deadly” disease according to his resources (assuming he has any). In fact, research does continue to show that up to 92% of individuals labeled with borderline personality disorder (BPD) have experienced some kind of childhood abuse¹. In addition, they are more likely to have experienced sexual abuse, specifically, and they have a greater number of perpetrators than people labeled with other kinds of psychiatric diagnoses. Dismissing off-hand the post-traumatic nature of the problem called BPD is an egregious error and not based on the scientific research. Further, the biological evidence the author cites as proof of “disease” (i.e., problems in the amygdala and “fight or flight” reactions) are precisely those that occur in individuals who have experienced extreme, chronic stress and/or trauma such as child abuse. But it must be emphasized that these biological consequences do not cause BPD. They are natural human reactions to intense and chronic stress of any kind. Presenting them as evidence of disease is like saying concussions are evidence that playing football is a disease.

With this in mind, then, one must first wonder what “cure” all the medical doctors are looking for? Have they read the work of Bessel van der Kolk, M.D. or Marsha Linehan, Ph.D.? Have they read any of the extensive studies showing the effectiveness of trauma-focused therapy, dialectical behavior therapy, yoga, meditation, somatic therapies, and others? What is this biological cure so many are seeking? Perhaps they may start by increasing efforts to prevent and ameliorate child abuse.

Second, giving the benefit of the doubt that DSM-defined categories are true diseases that exist in nature separate from the subjectivity of the person making said diagnosis (which is a dubious assumption), the author discusses the case of a young woman diagnosed with BPD, yet goes on to state: “We barely understand a healthy brain, so how are we to understand one haunted by psychosis?” This statement is a glaring error in even the most rudimentary understanding of psychiatric problems, for one would be hard pressed to find a clinician who deemed BPD to be a characterized by psychosis. However, the author may be saved by the fact that DSM-diagnostic categories lack validity and reliability anyways (the Director of the National Institute of Mental Health said so in 2013) and there are, in fact, no distinct lines that can define any one person’s experience completely.

Another error in research reporting is the author’s claim that “The suicide rate is higher for people with BPD than for those with major depression and schizophrenia; about 4 to 9 percent kill themselves”. In fact, the commonly cited estimate for suicide in persons diagnosed with schizophrenia is 10% to 13%, with approximately two to five times that rate attempting suicide^{3, 4}. Additionally, approximately two thirds of all cases of suicide include the occurrence of “depression” ^{5, 6}. The overall message should be that people who suffer, and suffer deeply, are more likely to commit suicide. Why make erroneous comparisons that are not even backed up by resources?

Perhaps the greatest error within this article is the complete disregard for the long-standing iatrogenic effects her so-called “treatment” may have had.  The author’s own statement should have raised huge, waving red flags: “She was on a laundry list of medication”. Many of these that are listed, including Paxil, Prozac, and Zoloft, are known to create an increased risk of suicide, violence, and agitation, especially in young adults and adolescents. Even more importantly, a recent study showed that pharmacotherapy for BPD “is not supported by the current literature” and that “polypharmacy should be avoided whenever possible”, recommending psychotherapy is the first-line treatment for BPD⁷. Another disregarded potential exacerbating factor is the internalized stigma, shame, and helplessness that comes from being told one has a “brain disease” instead of having the source of her pain recognized and addressed. She was in and out of hospitals, an experience that has been shown to directly create post-traumatic phenomena in those with the most severe problems, such as psychosis⁸. Lastly, many of the drugs that Ms. Tusiani was on are also shown to create psychotic experiences. Yet, not once does the author acknowledge or explore these clearly evident possibilities. Even the fact that the young woman died as a direct result of taking the antidepressant Parnate does not lead to an investigation of how this “laundry list” of drugs might have affected her. Instead, the subject is put to rest by blaming it on the fact that the drug was prescribed in a treatment center that was providing unlicensed medical care. Would the outcome have been any better if the center had that license? 

The story of Ms. Tusiani and her fatal experiences with inner turmoil and ineffective treatments is one that should be heard by an audience much larger than that served by the Washington Post. However, her story also deserves to be told with the integrity and fortuitousness of a critical journalist unafraid to ask the important questions. The family of Ms. Tusiani is understandably angered and determined to ensure that others do not have to endure the misfortunes that became their daughter. Such prevention begins by looking at the evidence that stares us directly in the eyes.

References:

1. 1. Zanarini, M. C., Williams, A. A., Lewis, R. E., Reich, R. B., et al. (1997). Reported pathological childhood experiences associated with the development of borderline personality disorder. The American Journal of Psychiatry, 154, 1101-1106.
2. 2. Ogata, S. N., Silk, K. R., Goodrich, S., Lohr, N. E., Westen, D., & Hill, E. M. (1990). Childhood sexual and physical abuse in adult patients with borderline personality disorder. The American Journal of Psychiatry, 147(8), 1008-1012.
3. 3. Siris, S. (2001). Suicide and schizophrenia. Journal of Psychopharmacology, 15, 127-135.
4. 4. Caldwell, C. B., & Gottesman, I. I. (1990). Schizophrenics kill themselves too: A review of risk factors for suicide. Schizophrenia Bulletin, 16, 571-589.
5. 5. Conwell, Y., Duberstein, P. R., Cox, C., Herrmann, J. H., Forbes, N. T., & Caine, E. D. (1996). Relationships of age and axis I diagnoses in victims of completed suicide: A psychological autopsy study. American Journal of Psychiatry, 153, 1001-1008.
6. 6. Henriksson, M., Aro, H., Marttunen, M., Heikkinen, M., Isometsa, E., Kuoppasalmi, L., & Lonnqvist, J. (1993). Mental disorders and comorbidity in suicide. American Journal of Psychiatry, 150, 935-940.
7. 7. Francois, D., Roth, S. D., & Klingman, D. (2015). The efficacy of pharmacotherapy for borderline personality disorder: A review of the available randomized controlled trials. Psychiatric Annals, 45, 431-437.
8. 8. Berry, K., Ford, S., Jellicoe-Jones, L., & Haddock, G. (2013). PTSD symptoms associated with the experience of psychosis and hospitalization: A review of the literature. Clinical Psychology Review, 33, 526-538.

Chuck Ruby, Ph.D.

Dr. Thomas Insel, the head of the National Institute of Mental Health (NIMH), has announced he is stepping down after serving in the position for the past 13 years (see http://www.nytimes.com/2015/09/16/health/tom-insel-national-institute-of-mental-health-resign.html). Dr. Insel’s main impact was to reorient the focus of NIMH toward a biological approach to the understanding of mental disorders, especially the serious ones. During his tenure, NIMH’s budget has been about $1.5 billion annually, with the great majority of those dollars going to research on the biology of mental disorders.

Dr. Insel’s appointment to the NIMH, along with his shift in focus, came on the heels of George H. W. Bush’s Decade of the Brain in the 1990’s, that was promised to unlock the mysteries of psychiatric problems by uncovering the biology and genetics of disordered brain functioning. President Obama more recently boosted this focus in his Brain Initiative in 2013, although perhaps too late for Dr. Insel. Nevertheless, this shift in focus was touted as a more scientific approach to diagnosing and understanding brain disorder, bringing psychiatry in line with the other medical sciences like neurology and cardiology.

It was under Dr. Insel’s tutelage that NIMH initiated the Research Domain Criteria (RDoC) program, which is intended to replace the current psychiatric diagnostic system of the DSM series, by building a bottom up system of diagnoses based on brain scan and genetic technology showing dysfunctioning brain biology for each disorder. Dr. Insel launched this program after publicly announcing in 2013 that the prevailing DSM diagnostic scheme was seriously flawed (DSM continues to be used today!).

Despite all the billions and all the rhetoric about how we are almost to the point of unlocking the biological secrets of mental disorder, we still have no reliable or valid biological marker. All we have are pretty brain scan pictures and genetic data showing what we already knew: biology changes, depending on how the body is used. This is true for mental disorders as it is for any human activity, including thinking, imagining, running, singing, and crying. But even with all this research, not one biological marker has been discovered that would enable diagnostic decisions. One would wonder if this is the reason for Dr. Insel’s departure. Have the failed research attempts convinced him to throw in the towel?

Regardless of Dr. Insel’s motivation for leaving, NIMH is left with a problem. It has been assumed the reason they haven’t found the “Rosetta stone” of biological psychiatry is that their research is either underfunded, inadequate, or they just aren’t looking in the right direction. Frequent chants of “we’re almost there!” echo from their halls, but this claim is unjustified. No other scientific research endeavor would continue along such a long line of failed attempts, hoping for the tide to turn “soon”. Other areas of research would have long since abandoned such theories that are not supported by the evidence.

NIMH has overlooked the real reason for not finding the stone: mental disorders (even the “serious” ones) are not brain diseases. In all the decades of scientific research, there has been no reliable evidence that supports the theory of mental disorders as caused by bodily pathology. Therefore, there is neither a disease to diagnose, nor biological marker to find. So-called “mental disorders” or “mental illness” or “mental disease”, whatever interchangeable term is used, are natural human reactions to the vicissitudes of life. Trying to jam these square pegs into the round holes of medicine does nothing but harm people, strip them of their dignity and humanity, and funnel them into a psychiatric pipeline of disability and despair.

The billions poured into brain scan research has acted as a subterfuge. It is like a house built upon a very weak foundation. The house may look impressive, and sell at a high rate. But if its occupants insist on living in it without checking the condition of the foundation, it will soon crumble under its own weight and trap all inside.

Our own David Rose, a Vietnam War veteran, put together this song about his experiences with war trauma. Check it out here.

David says, "I have received over 300 hours of post war PTSD therapy from the VA. As I was leaving my therapist's office following a session, on the way out the door she said, 'David, just don't sit and think about your PTSD so much.' I went home and wrote this two line piece. 'I don't sit and think about my PTSD, my PTSD thinks about me and I sit.'"

One of the alternative therapies David has been involved with is songwriting with OperationSong.org. He used these lines as a foundation for his song and built the rest of the song around it by sharing some of his other PTSD thoughts and experiences. The PTSD warrior on the couch in the video is David.

Al Galves, Ph.D.

A recent edition of U.S. News and World Report highlights the provisions of two bills in Congress that claim to enhance the mental health system in our country. See here for the report.

But a more critical examination of these bills shows us they are both dangerous.

God knows we need to improve our mental health system, especially our ability to help people who are diagnosed with serious mental illnesses¹. One piece of evidence is the following underreported fact: The great majority of people who have shot up schools, workplaces, movie theaters, churches and families have been patients in the mental health system and the system has failed them.

The Federal government is a major source of funding for mental health services, spending about $72,000,000,000 in 2014². Thus, the Federal government has an opportunity to improve the mental health system. These two bills in Congress are designed to improve the system. By far the more important one is HR 2646, the Helping Families in Mental Health Crisis Act. It was introduced by Representative Tim Murphy (R-PA).

If enacted in its present form, HR 2646 will make our mental health system more punitive, oppressive and medicalized. By defunding and downgrading programs that help people recover from the states of being that are associated with diagnoses of serious mental illnesses, the bill goes in exactly the wrong direction. Here is what HR 2646 does:

It increases the scope and breadth of court-ordered (involuntary) outpatient psychiatric treatment by providing funds to states for spreading it and requiring states to adopt such laws by conditioning receipt of Federal funds for community mental health centers on such adoption;

It emasculates the recovery-oriented, consumer-involved initiatives of the Substance Abuse and Mental Health Systems Administration (SAMHSA) by placing SAMHSA under a newly-created Assistant Secretary for Mental Health and Substance Abuse and preventing SAMHSA from establishing any program or project not explicitly authorized or required by Congressional statute.  This puts in jeopardy the efforts to train recovered peers and establish peer specialists as an integral part of the community mental health system, the annual Alternatives conference and the spreading of Emotional CPR;

It terminates funding for the National Empowerment Center and the National Coalition for Mental Health Recovery, both organizations which develop and promote recovery-oriented approaches and the incorporation of recovered peers into the mental health system;

It increases funding for biopsychiatric treatment and research by giving control over the $400,000,000 annual appropriation for community mental health centers to the Assistant Secretary and giving increased funds for brain research to the National Institutes for Mental Health. The bill stipulates that these funds can be used only for "evidence-based practices". This can be used to abandon recovery-oriented approaches which are clearly effective but have not been subjected to rigorous research; and,

It weakens the ability of the protection and advocacy agencies to protect the human rights of persons diagnosed with mental disorders by prohibiting them from "counseling an individual with serious mental illness who lacks insight into their condition on refusing medical treatment or acting against the wishes of the individual's caregiver."

Here are some other problems with the bill:

It downgrades and weakens the federal agency most supportive of recovery, peer support and community integration;

It places much more emphasis on medical treatment rather than on supporting the empowerment and recovery of persons through their active participation in their recovery and community;

It promotes a narrow, professionally-focused system of care in stark contrast to current thinking in healthcare which is moving rapidly to implement patient-centered care, shared decision-making and self-management of chronic conditions;

It ignores the significant role of toxic stress and trauma and precludes interventions which have been proven to be effective in helping people who suffer from those experiences;

It will keep people in clinical revolving doors rather than moving forward with their lives; and,

It expands the use of forced treatment which harms rather than helps people.

The Murphy bill, as it is called, reinforces and expands the mainstream standard of care. That standard of care has led to a dramatic increase in the number of Americans who receive Social Security Disability due to a mental illness³. The Murphy bill enfranchises a system of care which uses drugs as the primary modality of "treatment", an approach which harms rather than helps people. The fact that most of the billions of dollars spent by the Federal government on mental healthcare harms rather than helps people is tragic. This bill would make that tragedy even more widespread and entrenched than it is today.

What would a good mental health bill look like? It would close the gap that has been created by the $4,000,000,000 reduction in state funding for community mental health over the past 5 years. It would promote and expand alternatives to the mainstream standard of care such as Soteria-type sanctuary houses, open dialogue approaches, the Hearing Voices Network of support groups, peer-run crisis respite programs, peer bridgers, supportive employment, housing first and peer-directed training such as WRAP, Emotional CPR and Intentional Peer Support.

¹The term "mental illness" is being used in this article in order to facilitate a discussion between people with extremely varied conceptions of what "mental illness" is. There are big problems with the term "mental illness". Although many “mental illnesses” are illnesses in the sense that they impair the ability of people to function well, to live full and satisfying lives, the states of being that are diagnosed as “mental illnesses” are much more than illnesses. They are also wake-up calls, opportunities for learning and growth, numinous experiences of connection with the divine and moves towards reconstitution of selves which have been discounted, abused and traumatized. To see them just as illnesses and disorders is a damaging distortion.

²Substance Abuse and Mental Health Services Administration. (2008). Projections of National Expenditures for Mental Health Services and Substance Abuse Treatment, 2004-2014, Garfield, R.L. (2011). Mental Health Financing in the United States: A Primer. Kaiser Commission on Medicaid and the Uninsured.

³Whitaker, R. (2010). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Crown Publishers.

The ISEPP Chairman of the Board of Directors, Chuck Ruby, Ph.D., was interviewed by Ohio's WLJA Radio program called Bedlam in America. It is set to air on Tuesday, August 18th, from 10:00 to 11:30am. After that it will be available via stream at the program's website at https://www.wljaradio.net/bedlam-in-america.html.

Dr. Ruby discussed several issues of importance, to include the recent American Psychological Association's resolution banning psychologists from participating in national security investigations, violence, the problems with psychiatric drugs, the weak foundation of the medical model of mental illness, the invalidity of the DSM diagnostic system, and the NIMH's RDoC program to create a new diagnostic system, but that will be just as flawed as the DSM.

Thanks to WLJA for helping ISEPP get the word out!

Mary Vieten, Ph.D., ABPP

A recent study claiming that brain scans can help predict a person's response to SSRI drug treatment for PTSD is flawed from the start.

Brain scans to diagnose or determine the treatment of poorly defined constructs with very little inter-rater reliability and as little validity (e.g., all mental illness diagnoses) is yet another example of scientists who are forging ahead with sophisticated research that is based on the assumption that “mental illnesses” are in fact real illnesses and that they are discrete, scientifically identifiable diagnoses.

The fact is, anyone who was placed in the PTSD positive group in this study was put into that group in the exact same way every “mental illness” patient gets categorized, labeled, branded: some combination of interview (or symptom checklist) and self report.  Nothing objective, scientific, or medical is involved.  Hundreds of ways in which this could go wrong.  Every participant could have ended up in another diagnostic category, or no category at all.

Science isn’t supposed to work this way.  Variables should be clearly, independently identifiable.  The streptococci bacteria, the cancer cell, the fracture, death: no issues with reliability or validity here.  The problem is that we are pathologizing undesirable aspects of the  normal range of human experience, and pretending we have identified real illness that we can see on a brain scan.  An intelligent observer should be torn between the scandal of resources being used in this way, and the serious lack of critical thinking skills among our research scientists.

William Schultz, Doctoral student, Minnesota School of Professional Psychology

A recent piece by CNN health presented the “truth” about eight depression myths. The author of the piece, Dr. Iliades, pointed out some facts. It is true that depression may sometimes be difficult to treat. It is also true that depression does not always present as sadness. However, Dr. Iliades presented more fiction than fact. See the full article here.

First, he characterized depression as a “real disease” which implies a biological, bottom-up pathology, such as cancer. A common public understanding is that depression is a “brain disease” caused by a “chemical imbalance”. This is misleading. Many medical diseases, like cancer or diabetes, can be identified with bio-markers and clinical tests. But in mental health, “we don’t have rigorously tested, reproducible, clinically actionably biomarkers for any psychiatric disorder (Insel, 2014, p. 395) and there is little scientific evidence that depression is caused by a chemical imbalance (Schultz, 2015). Psychological disorders are different than typical biological diseases. This distinction is important. Thinking of psychological disorders as biological diseases can have negative effects on how well clients believe they will do in treatment and this, in turn, can have negative effects on client’s clinical outcomes (Lebowitz, 2014).

Second, Dr. Iliades argued that it’s a myth antidepressants don’t work. This depends on what he means by “work”. Well established evidence shows that antidepressants do not treat depression better than placebos in a clinically significant way (Moncrieff & Kirsch, 2015).

Third, Dr. Iliades asserted that shock therapy (ECT) may sound scary but it isn’t. In fact, he claimed it’s “86% effective.” That’s not right. The available evidence suggests only 10 – 35% of patients will experience enduring positive outcomes from ECT treatment (Fosse & Read, 2013). Even this percentage range is highly dubious because it’s based on studies that do not have a placebo group. When ECT is compared to simulated ECT, there’s no significant difference in enduring treatment effects (Fosse & Read, 2013). And ECT is scary. Researchers don’t know how it works to produce its purported therapeutic effects (McCall, Andrade, & Sienaert, 2014) and it has a variety of significant negative effects on the brain (van Daalen‐Smith, Adam, Breggin, & LeFrançois, 2014).

Fourth. Dr. Iliades claimed that antidepressants are safe. Safe is a relative term. Antidepressants have a large variety of negative side-effects, from negative effects on the heart to sexual dysfunction. Some researchers have argued that these side-effects outweigh the benefits (Andrews, Thomson, Amstadter, & Neale, 2012).

Fifth, Dr. Iliades argued that antidepressants combined with psychotherapy is probably the best treatment for individuals with depression. But research has shown that psychotherapy alone performs as well as psychotherapy plus medication (Khan, Faucett, Lichtenberg, Kirsch, & Brown, 2012). As Kirsch (2014) put it, “When different treatments are equally effective, choice should be based on risk and harm, and of all of these treatments, antidepressant drugs are the riskiest and most harmful” (p. 132).

Finally, Dr. Iliades breezed through a section on the difference between depression and bereavement. The distinction he mentioned was vigorously debated by experts during the creation of the DSM-V (Wakefield & First, 2012). Needless to say, it is impossible for Dr. Iliades to give justice to the debate, much less to pronounce what feelings and experiences are and are not acceptable after the death of a loved one.

The truth about depression is our culture is far too quick to reach for a pill and far too slow to consider the social and psychological challenges underlying psychological disorders.

References

Andrews, P. W., Thomson Jr, J. A., Amstadter, A., & Neale, M. C. (2012). Primum Non Nocere: An Evolutionary Analysis of Whether Antidepressants Do More Harm than Good. Frontiers in Psychology, 3, 117, 1-19.

Fosse, R., & Read, J. (2013). Electroconvulsive treatment: hypotheses about mechanisms of action. Frontiers in Psychiatry, 4, 94, 1-10.

Insel, T. R. (2014). The NIMH research domain criteria (RDoC) project: precision medicine for psychiatry. American Journal of Psychiatry, 171(4), 395-397.

Khan, A., Faucett, J., Lichtenberg, P., Kirsch, I., & Brown, W. A. (2012). A systematic review of comparative efficacy of treatments and controls for depression. PLoS One, 7(7), e41778.

Kirsch, I. (2014). Antidepressants and the placebo effect. Zeitschrift für Psychologie, 222(3), 128-134.

Lebowitz, M. S. (2014). Biological conceptualizations of mental disorders among affected individuals: A review of correlates and consequences. Clinical Psychology: Science and Practice, 21(1), 67-83.

McCall, W. V., Andrade, C., & Sienaert, P. (2014). Searching for the Mechanism (s) of ECT’s Therapeutic Effect. The Journal of ECT, 30(2), 87-89.

Moncrieff, J., & Kirsch, I. (2015). Empirically derived criteria cast doubt on the clinical significance of antidepressant-placebo differences. Contemporary Clinical Trials, 43, 60-62.

Schultz, W. (2015). The chemical imbalance hypothesis: an evaluation of the evidence. Ethical Human Psychology and Psychiatry, 17(1).

van Daalen‐Smith, C., Adam, S., Breggin, P., & LeFrançois, B. A. (2014). The Utmost Discretion: How Presumed Prudence Leaves Children Susceptible to Electroshock. Children & Society, 28(3), 205-217.

Wakefield, J. C., & First, M. B. (2012). Validity of the bereavement exclusion to major depression: does the empirical evidence support the proposal to eliminate the exclusion in DSM‐5?. World Psychiatry, 11(1), 3-10.

See CNN's coverage of Dr. Mary Vieten's Operation TOHIDU here.

See an expanded video of ISEPP member Mary Vieten, Ph.D. and the staff of Operation TOHIDU here.

Operation Speak Up just launched an online petition here. We ask that you sign it and share it widely.