Wednesday, November 11, 2009

The Three Stooges of the Mind

If you sit still and try to clear your mind, as in meditation, one of the first things you’ll notice is how quickly you start judging your experience and yourself. This is boring. My back hurts. I must not be doing this right. Meditation isn’t for me. This is the voice of your judging mind, your Inner Critic. All of us have one. The voice is a product of stress, of the need we feel to classify our experiences quickly into simple categories without experiencing them too deeply—so we can quickly move on to the next thing stressing us. When we’re scared or anxious, that Critic is most active, putting down your friends and loved ones, your accomplishments, and yourself. It’s the voice that gives you a disproportionate share of the blame when things go wrong. It’s the voice that makes mountains out of molehills. What’s wrong with you? There’s nothing to be scared of, don’t be such a baby! Why haven’t you started exercising yet? You can’t stick to anything! Sound familiar? It’s something most of us hear whenever we’re feeling stressed. Automatic judging like this your frontal lobe, the “higher” mental center, trying desperately to hold on to control, while you’re trying to clear your mind. Most of us, when we’re unhappy, are caught between that Inner Critic and another part of the self that is busy defending ourselves. I call it the Timid Defender. It wants to silence the Critic, but it can’t, because it uses the usual habits of the mind—denial, rationalization, dissociation. Alcohol and drugs. Shopping and overeating. It has us trying to escape or forget about the Critic, but that only works for a little while, because while we’re escaping or forgetting, we’re giving the Critic more ammunition. You idiot, pretending to be something you're not. Trying to drown your sorrows. You can’t get rid of me that easily! The critic and the defender are both sealed up together in the same little tuna fish can, and they’re not even trying to get out, they’re so preoccupied with each other. When we’re bouncing around between the Inner Critic and the Timid Defender, who’s at the controls? Who’s running our lives, making our decisions? It’s like we have the Three Stooges up in our heads. Moe the brutal sadist, torturing us while the ineffectual Larry whines pathetic excuses. Curly, the id in this metaphor, full of appetites and drives, causes all the trouble in the first place. Nobody’s in charge of our lives, and the plane is yawing and swooping all over the sky, never getting anywhere and always in danger of crashing. And this is how unhappiness persists. We blame ourselves far too much, and make ourselves more miserable. Then we defend ourselves ineffectively, and perpetuate a vicious circle. We have to try something radically different. That’s what therapy does. I don’t turn off the Inner Critic and I don’t strengthen that Defender for my patients; instead, I help people detach from this struggle. That’s what mindfulness does too. A good friend of mine uses the phrase compassionate curiosity to describe the ideal therapist’s attitude toward the patient. We begin therapy with a much more compassionate, kind, understanding stance toward the patient and his problems than the patient has himself. And we are curious, in a calm, unafraid way—we want to understand how things got to be so bad, and we assume that by fearlessly facing reality we will help the patient find relief from his distress. Compassionate curiosity is the attitude most of us, depressed or not, need to apply to ourselves as well. What a change that would be for almost everyone I know! That battle between the Inner Critic and the Timid Defender is much like the way inconsistent parents treat their children. When the Defender is in charge we indulge and spoil ourselves; we let ourselves off the moral hook, we make promises to ourselves we know we won't keep. But that Inner Critic is still there, waiting for our defenses to slip—as they always do—ready to condemn us, always finding that we don't measure up. We vacillate between spoiling ourselves and punishing ourselves. And, as with children who are raised that way, we end up frightened and traumatized, with no self-esteem and a lot of self-hate. Compassion replaces all that with patience, gentleness, love, grace, mercy, concern. It suggests giving up judging and replacing it with empathy, a willingness to face the truth and all your feelings about it, without fear but with confident strength. Curiosity suggests a little cool detachment from the emotional heat, a desire to understand objectively why we feel what we feel, why we do what we do—especially when it’s troublesome or self-defeating. Why did I get angry just then? What’s making me so blue today? We look at ourselves, not to torture ourselves, not to give ammunition to the Critic, not with desperation for a quick fix, but with compassion, sincere interest, and the belief that there are answers that make sense. No matter how nonsensical our behavior, no matter how odd our feelings, there are always reasons—and knowing the truth will help set us free. We look a little deeper than usual, with more objectivity, and we don’t just slap ourselves on the wrist and make an empty promise to do better next time. Why? What’s bothering me? Why am I afraid to look? We understand that our feelings are just human; they won’t destroy us or drive us crazy. Most likely, they are tapping on our shoulder, trying to tell us something important.

Sunday, November 1, 2009

Mental Health and Healthcare Reform

Now that it looks like some form of health care reform will be passed this year—barring a catastrophe like Joe Lieberman—we have some idea of how the eventual act will affect mental health services. All of the plans now under consideration will mean some real improvements for mental health consumers, and there doesn’t seem much likelihood of these improvements being cut out before passage. However, it appears that individuals and employers will still have to purchase their insurance from private insurance companies, without competition from a strong public option like Medicare available for everyone. Nevertheless, the “reform” aspect of the bill would require private insurers to make some real changes in how they treat mental health issues. Here are the key benefits:

· “Parity” for mental health and substance abuse services. As it is now, when you see a mental health provider, your insurance company will probably pay him or her less for your visit than they would pay your GP or specialist for a similar service. They might require a higher copay from you for a mental health service than a GP visit. They might limit your total annual or lifetime benefits for mental health services. For instance, I have many chronic depression clients who need year-round supportive therapy, but their annual benefits run out in August or September. Most patients have to pay me a $30 or $40 copay from their own pockets, rather than the $10 or $15 that their GP charges. With a reform bill, private insurers would have to end these practices. That will make it much more possible for patients to receive the care they need without added expense. It will also make it possible for patients who need medication to see a specialist, and not have to rely on the family doctor to prescribe medications he’s not really expert at. Eventually, it may lead to more practitioners entering mental health, a real benefit because credentialed providers are in short supply.

· No discrimination based on pre-existing conditions. The fact that insurers currently can, and do, refuse to insure you for pre-existing conditions is one of the major factors that keeps consumers tied to their jobs. It also forces them to contort themselves anxiously through COBRA plans and sensitive negotiations with their employers to stay on their old plan. And of course the old plan is currently still free to let you go, cap your benefits, or charge you a higher rate for those pre-existing conditions. This doesn’t hurt only mental health consumers, of course, but also those with cancer, heart disease, diabetes, or any other chronic/recurring illness. The current policy thus causes a great deal of stress for many, many consumers, which hopefully will be greatly eased by the new legislation.

· No rate changes based on health status. With reform, insurers will no longer be able to raise your rates because you develop a chronic or expensive condition. All subscribers in the same age group will pay the same rate.

· Greater availability of insurance, at lower cost. Though the details haven’t been worked out yet, all the bills have as a major goal greater availability of insurance plans to individuals and to people who can’t afford healthcare now. Many people with mental health disorders like long-term depression are not able to sustain themselves in challenging or stressful jobs, resulting in poverty or underemployment. The current economic collapse and the fact that insurance rates keep rising more than twice as much as the general cost of living has put health insurance out of reach for many. Reform is meant to make insurance much more available.

· Expansion of Medicaid. Medicaid is the government-run healthcare plan available to the poor. It’s a program that works well, and though there are some problems they are nothing like the problems with private insurance. The bill would basically expand the definition of the poor to include more working-class, low-income families. The fact that so many households have parents working two or three part-time jobs, none of them providing private insurance, means that Medicaid expansion and the greater availability of low-cost private plans will take a tremendous worry off of working people’s backs.

These are all great steps forward, especially for everyone who sees a therapist or takes an antidepressant or other psychiatric medication—or needs to. However, the devil is always in the details. Here are some potential pitfalls I haven’t seen addressed in the reform plans.

· “Managed” care. Over the last twenty years, private insurers have added huge expenses to the cost of care by employing thousands of people whose sole job is to restrict benefits. For instance, many plans will only pay for a few counseling sessions before requiring the provider to file a form justifying continued treatment. This is sometimes referred to as “Mother may I” care. The insurer is free to make arbitrary decisions to change the treatment plan or limit the kind of care available to the patient. The army of bureaucrats employed to run managed care programs has provided a way for insurers to vastly add to the cost of care, in the name of controlling the cost. Obviously some form of management is necessary to prohibit greedy practitioners from overcharging and overprescribing, but I haven’t seen anything in the bills that would control or regulate this practice. This may lead to the point where some practitioners will not accept some plans because they require unnecessary hassle to pay legitimate claims. This is the case now in my geographic area, and doctors accept some plans and not others because of this. Consumers have no means of knowing about this practice, so they often choose a plan that none of their providers will accept. If there were some form of standardizing these practices, most providers would then accept all, making comprehensive health care much more accessible, and reducing insurance company’s overhead.

· No reform of drug industry practices. The pharmaceutical industry is no longer honest or reliable when their drugs are reviewed in academic journals. The FDA has been fooled regularly by tainted research. In work on depression, some highly respected researchers have taken drug industry payments under the table—as much as $500,000—to distort their findings in favor of a particular drug, or to support drug use in general. Your home-town psychiatrist can receive payments of $5- or $10,000 for adding their name to ghost-written research, and their prescribing habits can be monitored by drug companies, giving them a powerful incentive to prescribe a particular drug. I’m sure the same practices apply to drugs for other diseases. These developments are not addressed at all in this round of reform, and they should have been. They add tremendously to the cost of care, and they often result in patients not getting the best medication available.

· No real guarantees of reduced cost. There’s a long time between when a bill is passed and the actual practical guidelines are worked out. Given the influence of insurance and drug industry lobbying, there’s a lot of opportunity to find ways for costs to be passed on to consumers. I fear that whatever final bill is passed, it will lack the teeth to enforce some of the benefits we’ve described.

· No emphasis on preventive care. Relatively simple screening tools for depression, anxiety disorders, and other conditions are available and effective. If they were implemented routinely, a lot of pain and suffering would be alleviated and the overall cost of health care would decrease. Public attitudes about mental health issues need to change. The biggest obstacles to treatment remain the patient’s own self-blame and fear about what mental health services are like. Though there is some promise in some of the bills for services to address these needs, this is a soft area that remains vulnerable to misguided cost-cutting.

· Lack of a real public option. If there were some form of universal, government-administered plan like Medicare available to everyone, private insurers would need to compete with it—and Medicare is much more cost-effective than private insurance. Every other developed country in the world offers a government plan of some sort. All of them have their good points and bad points, which we could learn from. But Americans pay twice as much for health care as the next most expensive country (Belgium) and receive second-rate care. By most measures of public health, we rank well below the top ten of all countries. A good public option would change all this; our total healthcare expenses would drastically decline, resulting in a vastly improved economy. Employers would be spared the expense and administrative costs of providing care (we’re also the only country in the world that ties health insurance to employment).

I work with several Medicare patients. They don’t abuse services, but they take advantage of what’s available to them. Without Medicare, their depression would leave them withdrawn, isolated, unable to make the best decisions, and panicked about their future. And that’s exactly the state many depressed people are in right now—all those who lack insurance or have restricted care. I think we as a society are better than that.

SO—like most of life, it’s good news and bad news. The planned reforms should make health insurance cheaper and more available to everyone. Those who need mental health services will no longer be made to feel like second-class citizens because the care they need is more expensive and more restricted. Mental health consumers out-of-pocket expenses for their care should decline. People won’t have to worry so much about losing their insurance if they require expensive care or change jobs. People who don’t have insurance now will be able to get it more easily. But as it is now, reform leaves a lot to be desired. Private insurers will still play a central role, and their incentive is always to make a profit rather than provide the best care. You will have no guarantee that the doctor or therapist you want will accept your insurance plan. The drug industry will continue to drive up the cost and reduce the quality of care. Without a strong public option, there’s no real guarantee that our individual health care expenses will be greatly reduced. Still, we will probably see big steps in the right direction, which may gather enough support that the further reform we need will take place without such great resistance.

Friday, August 28, 2009

Adjusting the Happiness Thermostat

My last book, Happy at Last, borrowed from psychology, economics, brain science, and social research to identify how we can be happier. It turns out that each of us has our own set point for happiness, like on a thermostat. Some of us are constitutionally bubbly, others seem to be natural grumps. When good things happen to us, those who are on the grumpy side can feel good for a while, but they usually return to their previous set point. If we want to stay happier, we have to put in focused attention and practice. The good news is that it really works. Both brain research and the social sciences have shown that we can make a permanent adjustment in our happiness quotient by making a few changes in how we think and what we pay attention to.

With that in mind, here are some suggestions that will add both joy and satisfaction to your life:

1. Happiness is a skill. It’s not an innate gift. It requires that we pay close attention to our experience and see objectively what makes us happy. Our minds and our culture tell us a lot of lies about what might make us happy (getting rich, beating out the competition, acquiring a lot of things). We have to get past those assumptions and systematically learn what makes us happy.

2. Practice mindfulness meditation at least four days a week for a half hour. Just sit, clear your head, focus on your breath, and listen to the noise your brain makes while you're trying to disengage from it. Your brain really doesn’t want to give up control. But as you practice this, you will become healthier, calmer, less stressed, more aware of hidden meanings and patterns in your life, and less subject to anxiety running away with you. By some measures, experienced meditators are the happiest people in the world.

3. Practice mindful thinking and observation. Because we’re under so much stress, we feel we have to quickly categorize our experience into simple, black and white categories. This makes us miss out on the rich details of life. If you practice noticing how you judge, slowly you’ll begin to stop. View yourself and the world with compassionate curiosity, the desire to understand and the belief in your own worth. Learn to be noncategorical, detached, willing to let go, willing to think independently, willing to take responsibility. Cultivating mindfulness will make you more aware of opportunities for joy, help you make better decisions so you’ll reduce unnecessary misery and experience greater satisfaction and meaning.

4. Exercise aerobically for a half hour, three to four times a week. There’s an enormous body of research out there to prove a very simple point: the more you exercise, the better you feel.

5. Don’t fall for the belief that you’ll be happy when you get what you want. Inevitably, when you get what you want, you’ll quickly get used to it and start wanting something else. And while you’ve been waiting, you’ve missed out on a lot of opportunities for joy.

6. Work on wanting what you have. Look around you and try to appreciate your possessions and possibilities as if you were Ben Franklin popped into the 21st century. Central heating, air conditioning, indoor plumbing, a stove and refrigerator. A vehicle that will take you 600 miles in a day, in comfort, on paved roads. An orchestra you can carry in your pocket. If Franklin doesn’t do it for you, simply look carefully at your surroundings. Your furniture, books, possessions. There’s beauty and memories there. Savor them.

7. Contemporary living conditions are not what our bodies and minds were designed for. We’re designed to live in small cooperative groups; to work no more than four hours a day; and to spend the rest of the time communing with each other, making music, making art. So don’t assume there’s something wrong with you if you’re not happy. Being happy in today’s world takes effort.

8. Most unhappy people have an Inner Critic in their brains. The Inner Critic is the voice that blames you whenever things go wrong and is never satisfied no matter how well you do. It’s your brain looking for someone to blame for your stress and disappointment, and settling on the most convenient suspect—you. You can’t argue with this Inner Critic, because it doesn’t play by the rules of logic. It’s a result of crossed wires in your nervous system. Imagine that you have a volume control for it. When you hear the voice of your Inner Critic, turn the volume down a little and distract yourself with other things. The more you practice this, the easier it will get to ignore the Inner Critic.

9. Happiness is smaller than you think. Cultivate small pleasures. Learn to cook. Eat well. Cook for friends. Expose yourself to awe and beauty; get out in nature, and pay attention. Watch less television. Play more. Get a dog. Join a laughter club. Get more touching into your life.

10. At bedtime, let yourself go to sleep thinking about three things to be grateful for, things that made you happy, or simply the best memories of the day. As you do this, pay attention to the feelings in your body: the smiling reflex, a warmness in your heart, the flow of tension out of your neck and shoulders. Whenever you feel good, let your body express it. Just doing this exercise every night has been proven to raise your happiness quotient as long as you keep it up.

Tuesday, August 18, 2009

In the garden

One of my great joys of middle age has been perennial gardening. In addition to other benefits, it has proven to be a great stress reducer. I freely acknowledge having no conception whatever of garden design. I buy one of any plant I like and stick it in where I have room, with just a little thought to color combinations and space. As a result my garden from afar looks like a crazy quilt.

But I like to look at it from up close, to see the growth of individual plants that interest me, how their leaves and stems spring up from the earth, how they blossom and flourish in the summer heat. There is something about the rebirth of the world in spring, the cycle through summer and even into the fall, when I can see the plants preparing themselves for the winter to come, that I find deeply satisfying and calming. It seems to me to have to do with the cycle of death and rebirth, something about how I experience my own body aging but my children coming into full maturity, that gives me a sense of continuity and some degree of acceptance of my own mortality. And it's more than just a state of mind. I get up early in the morning and go out to see what I see new in the garden. I come home from work and can't wait to go weeding or transplanting. I feel energy throughout my body.

But the Zen-like peace that I find in the garden only lasts through the waning days of fall. By February I'm bored, grouchy, sorry for myself, withdrawn, a bear who can't get to sleep. The intensity of the change certainly feels to me as if it comes from something more than being deprived of my favorite leisure activity. It feels qualitatively different. There are plenty of other things I can do besides gardening, but I don't want to do them; and I have trouble enjoying the other things I normally enjoy. I can usually force myself out of this mood, but it requires a deliberate act of will.

My little meltdown in winter is a microcosm, I think, for the situation far too many of us face today. We're deprived of the opportunity to be in touch with nature, and that is a very real stress, and stress hurts us in ways science is just beginning to understand. Humans were designed to live in harmony with the cycles of the day and night and seasons. We were surrounded with reminders to be humble—that earth and the universe were much bigger than us, that birth and death were all around us, that hunger was always just around the corner. We had a lot of quiet time when we could let our minds shift into a contemplative state—watching the sun rise, waiting for the fish to bite, hauling water, tending the garden.

It turns out that contemplative state is necessary for our mental health. When we have the opportunity to lean on the hoe and just be, we're letting our left brains—the creative, impressionistic, coherent side—take over and giving the right brain time to rest. The right brain is terribly overworked by all the decisions we face every day, the busy schedules we keep, the overstimulation of traffic and television. When we can use the left brain, we can see ourselves in our own mind's eye—consider the self as a whole person, connected with the real world—and get our priorities back on track. Scientists who have been studying the effects of regular meditation have found it has wonderful effects on the mind and body: it helps us with major depression, chronic pain, anxiety and panic; it makes our mood more positive and our immune systems stronger. I think it won't be long before science proves that activities like walking in the sunshine, petting the dog, and planting, watering, weeding and just viewing the garden, have the same kind of healthful benefits. They make us slow down, be patient, pay attention; stop striving so hard all the time and get in harmony with the world.

Tuesday, August 11, 2009

Getting Organized

There is a simple tool that can be used for organizing our lives so that more time is available for the things we like to do. It also helps us focus on our own goals, and planning how to achieve them. We can classify all tasks and activities on two dimensions, importance and urgency.

1. urgent

but unimportant

2. urgent

and important

3. not urgent

and not important

4. not urgent

but important

When people do this, they generally find that they are spending most of their time in cells 1 and 2, activities that seem urgent but may or may not be important. If we fall behind the pace of contemporary life, we have to spend far too much time in Cell 1, “Urgent but Unimportant”—paying the bills just before they come due, rushing a deposit to the bank to cover them. On a broader scale, if you neglect your child’s emotional needs now, you may have to spend a lot of time later in family therapy or family court.

It’s especially dismaying to recognize how little of our time is spent in cell 4, on activities that may be very important but carry little urgency. Most people realize that, if they were able to address the important but nonurgent items, many of the urgent but unimportant things would take care of themselves. Cell 4 is preventive maintenance: getting the car in for oil changes, having our teeth cleaned, setting up an automatic deduction to pay the mortgage so you don't have to scramble at the end of the month to get the payment in on time, and paying attention to your relationships.

Monday, July 27, 2009

Take Two Cadillacs Every Night

I'm sure a great deal of research, money, and worry goes into the topic of naming new drugs, especially those that work on our minds. Sonata, for instance, is a great name for a sleeping pill. It sounds soothing and comfortable but not overpowering. You can go too far with names by promising too much. Is it any wonder that sedatives Halcion and Placidyl became so sought after?—the drugs were abused and turned out to be dangerous for many.

The newest antidepressants sound remarkably like cars, and maybe that's no accident. I'm going for a ride in my Celexa. Have you seen the new 2010 Remeron? Cymbalta sounds powerful, like an Escalade. All these names seem to suggest precision engineering, a quiet, smooth ride, a certain elegance in helping us to get over life's obstacles. By contrast, who'd want to ride in a Prozac? It sounds like a Yugoslavian import. Zoloft is a big German clunker. You can tell these drugs have had their day.

Since there are lots more new antidepressants in the pipeline, I have a suggestion for the pharmaceutical companies: take the car theme even further. Sierra is a nice name for a drug, as well as a car. Makes you feel rugged and powerful. Aspen, clean and bracing. Infiniti—talk about being above it all. Even cars whose names don't mean anything have such recognition that they would pack powerful placebo effects in pill form. I'm really beat; I think I'll take a BMW. Feeling depressed and anxious? Ask your doctor about Lexus. I'll bet the auto makers would be open to licensing the names, maybe even some tie-in marketing.

Since men buy most cars, though, maybe the drug manufacturers are neglecting the woman's market; after all, women are three times more likely than men to get diagnosed with depression. How about a Prada line of antidepressants? Maybe Donna Karan would be interested. I don't think I'd want my wife to take a Martha Stewart, though…I might not live up to her new standards.

But when you think about the psychological boost we get when we treat ourselves well and look good, maybe we could just eliminate the middleman…you know, the drug industry? We could get our health insurance to buy us a new wardrobe or a new car every couple of year instead of expensive anti-depressants.

Don't get me wrong. Depression is a serious disease. I treat patients for it and I have suffered from it myself. But this is an age of cosmetic psychiatry. Antidepressants are now half of the six top selling prescription drugs. For some people who really need them, they're a godsend; but for lots of other people, some sort of magic is being marketed in pill form. Wouldn’t we all be better off if we could figure out a way to separate some of those wishes from dependency on drugs?

Sunday, July 26, 2009

The Dark Side of Antidepressants

Undoing Depression, my book from 1997, will be coming out in a completely revised edition in 2010. There have been a great many developments in the field and in my thinking about depression that have begged for an update. But some things had to be left out of the book, both because of space and because I occasionally strayed from the narrow focus of the book.

Here’s a section I had to omit, reluctantly; but I had to agree with my editor that it wasn’t really necessary for a self-help book on depression. If you read on, though, I think that you’ll agree it’s really important news both about depression and the whole field of pharmaceutical research.

Antidepressant medication is of great help to many people; I want my severely depressed people to be taking something, because it can often relieve their distress and mobilize them to start to take action against their depression. But the drug industry, which underwrites most studies, has drastically and dishonestly manipulated formal academic research to the extent that we really can’t trust anything much of what respected journals say about antidepressants—especially SSRIs like Prozac, Zoloft, Celexa, and Lexapro, and the SNRIs like Effexor and Cymbalta. In some cases, they have simply bribed researchers, some of them the most respected in the field.

Here’s one example: the original research that got FDA approval and set off the craze for these drugs had very low standards, which were not revealed to the public. They were generally two- or three-month trials, very short over the lifetime course of depression, and the definition of cure was simply no longer meeting all the criteria for major depression. You might still be feeling suicidal and wracked with guilt, but if your sleeping had improved, as far as the FDA was concerned, the drug had demonstrated its effectiveness. Then there was the fact that in all these trials the drugs proved only slightly better than placebo—in most cases, about 40 percent of people got better with a sugar pill, and about 50-60 percent improved with an SSRI.[i] Added to that is the fact that many of these studies stacked the deck by excluding people who were most responsive to placebo.[ii]

Subsequent studies, with larger groups over longer periods of time, have shown about the same disappointing results. The STAR*D study, with a large sample of real-world patients, without excluding placebo responders, found that about 50 percent of patients had a significant response to medication, but only about 30 percent met the researchers’ definition of remission.[iii] During follow-up, a significant number of patients relapsed. Overall, the recovery rate was only slightly better than chance alone. STAR*D was sponsored by the National Institute of Mental Health and should be considered relatively free of drug company influence.

Tainted research

More and more news keeps coming out about hidden payments from drug companies to the supposedly objective researchers investigating their drugs—especially antidepressants. Frequently, these researchers have national reputations and carry great respect; they’ve published articles on other subjects that are objectively excellent, some of which I’ve cited in my books. But their greed has resulted in their downfall. In one case, it was Dr. Charles Nemeroff of Emory University, the drug company was GlaxoSmithKline, and the drug was Paxil. According to Senator Charles Grassley’s Finance Committee, Nemeroff received a total of $2.8 million from Glaxo and other Big Pharma companies, all of which he sought to hide from his employers and the publishers of his articles. Senator Grassley has found a tree with some very low-hanging fruit, because this pattern seems to be increasingly the rule, not the exception, among leading academic researchers. Another, even more shocking, case is that of Dr. Frederick K. Goodwin, the retired director of the National Institutes of Mental Health, who hosted public radio’s series “The Infinite Mind” for many years, during which time he earned at least $1.3 million from drug companies, which he did not disclose to NPR. Many of the programs covered subjects relating to the same drug companies. For instance, in one broadcast Dr. Goodwin stated that children with bipolar disorder who are left untreated could suffer brain damage, which is not a common opinion. He then went on to recommend mood stabilizers as both safe and effective. According to the New York Times, on the very same day as the broadcast Dr. Goodwin earned $2500 from GlaxoSmithKline for giving a lecture touting the benefits of Lamictal, a drug considered less effective than other mood stabilizers.

On May 15, 2008, Newsweek’s cover feature was “The Bipolar Child,” the culmination of the exponential growth in the diagnosis of pediatric bipolar disorder over the last few years—a forty-fold increase from 1994 to 2003. Much of this growth can be attributed to the work of Dr. Joseph Biederman, a Harvard child psychiatrist who has published multiple articles pointing with alarm to his own discoveries of the high incidence of pediatric bipolar disorder and the need for treatment with strong antipsychotic drugs. Three weeks after the Newsweek feature, Sen. Grassley revealed that Dr. Biederman had received $1.6 million in consulting fees from drug makers, income which he had gone to great lengths to hide from his employer and from the journals that published his articles. Essentially, Dr. Biederman both created an epidemic and found a cure for it—by turning a generation of children into guinea pigs—though it must be said that his “cure” was often worse than the disease, creating a lot of drug-dependent, fat, unhealthy kids completely unable to control themselves. In this case, Dr. Biederman and his colleagues, Dr. Timothy Willens and Dr. Thomas Spencer, were employed by Harvard and Mass General; the drug company was Janssen, and the drug was Risperdal, a powerful antipsychotic; though the trio also received funds from many other drug companies.

Senator Grassley also ran across Dr. Melissa DelBello of the University of Cincinnati. She touted Seroquel, a powerful antipsychotic drug, as effective for treating depression in children. Let me just quote from the Times:

Dr. DelBello’s studies of Seroquel in children have helped to fuel the widespread pediatric use of antipsychotic medicines. Those studies were inconclusive, but she has described them as demonstrating that Seroquel is effective in some children.

Asked in a past newspaper interview how much she was paid by AstraZeneca [the manufacturer] to help market Seroquel, she had said, “Trust me, I don’t make much.” Mr. Grassley said this week that her disclosure forms at the University of Cincinnati show she received $100,000 from AstraZeneca in 2003 and $80,000 in 2004. Dr. DelBello consults for seven other drug makers as well.[iv]

The hospitals, universities, and publishers who work with these researchers all have clear conflict-of-interest policies, which were all violated in every case. The researchers usually went to great lengths to cover up their outside income, which certainly suggests they all had the guilty knowledge that they were doing something unethical.

Some of these people may have their wrists slapped by their employers, but they don’t have to worry about money. They also don’t have to worry unduly about their professional reputations, because the professional community tends to ignore these things. An earlier, similar scandal makes that point: In 1999 the Boston Globe revealed that Dr. Martin Keller of Brown University had received $550,000 in unreported consulting fees from the makers of antidepressants that had been touted in his published research.[v] In 2009 you could do a computer search of all psychiatric literature since 1999, looking for an editorial or letter that mentions Dr. Keller, and you would find nothing. That means that all his published research is still accepted at face value, unless you happen to have read the Globe. That will most likely also be the fate of all this new tainted research.

But it’s not just the big names who are involved in this. It’s quite likely that your psychiatrist has been invited to speak at conferences which can earn him or her $10,000 a year or more for reading a speech written by a drug manufacturer. He may be given the opportunity to add his name to a published research study they have ghost-written. At the very least he will be invited to attend “educational conferences” at resorts and vacation spas, all expenses paid. One such conference took place at Yankee Stadium during a game. Big Pharma wouldn’t be doing things like this if they didn’t have evidence that such payments will influence what drugs your doctor prescribes. Dr. Stephen Sharfstein, past president of the American Psychiatric Association, questions why Celexa is currently the most-prescribed SSRI, when Prozac, equally effective, has gone generic.[vi]

This is all the result of hubris, of course, except for some cases that may just be greed at work. The big-name researchers and the psychiatrist in your neighborhood probably believe that their research and prescribing habits are objective and not swayed by the money they take; they are so vain they think they’re immune to influence. They need to look at decades of social psychology research showing how easily influenced we are: finding a dime on the sidewalk influences our mood, reading about older people makes us walk slower, and monetary rewards affect our decisions.

Objective studies of antidepressants, funded by governments with larger groups over longer periods of time, have shown disappointing results. The STAR*D study, with a large sample of real-world patients, without a placebo washout phase, found that about 50 percent of patients had a significant response, but only about 30 percent met the researchers’ definition of remission.[vii] During follow-up, a significant number of patients relapsed. Overall, the recovery rate was only slightly better than chance alone. STAR*D was sponsored by the National Institute of Mental Health and should be considered relatively free of drug company influence.

Withdrawal problems

The effects of stopping SSRIs have also been minimized. There can be significant withdrawal problems when you stop taking SSRIs—“SSRI Withdrawal Syndrome”—including extreme anxiety, skin crawling, confusion, GI distress, insomnia, and agitation. For some individuals these symptoms are excruciating. I had a patient who went through pure hell—fever, nausea, chills, extreme depression, and the certainty she was losing her mind—going off a pill I had encouraged her to take. The best advice is to discontinue any of these medications by tapering off slowly and under a physician's care.

Personality changes

Last but not least, there are worries that antidepressants interfere with emotional vitality. One study of non-depressed volunteers found that taking an SSRI for only a week interfered with their ability to read facial expressions, especially of anger and fear.[viii] Another study of normal volunteers found that four weeks of Paxil significantly reduced their ability to feel sad or angry when appropriate.[ix] A group of patients who were experiencing sexual side effects also developed significantly less ability to cry or care about others’ feelings. They also lost erotic dreaming, surprise, creativity, anger, and ability to express their feelings.[x]

Therapists who take SSRIs themselves were very disturbed by these findings, wondering if it meant they were losing their ability to be empathic; many of us have stopped medications as a result. I know a musician who tried Lexapro for his social anxiety and asthma. He noticed that he stopped getting chills and goose bumps when he was really moved by music. When he stopped Lexapro, he was able to get goose bumps again. Another male patient, who was prone to picking up girls for one-night stands, reported that with Paxil he stopped feeling guilty. At least he recognized this was a problem.

It seems quite possible that SSRIs (and other antidepressants, for all I know) get some of their effect from an overall emotional blunting, especially of negative feelings. Their use may make us temporarily a little shallow or insensitive. That’s a good thing if you’re seriously depressed, but a problem otherwise. As far back as Listening to Prozac (1993),[xi] Peter Kramer was advancing the theory that people with depression may be especially sensitive to signs of rejection, and that SSRIs helped them cope better. This is one of the reasons why I’m so against the use of antidepressants by people without severe depression who simply want to feel better. They may worry less, but it can damage their relationships, reduce their enthusiasm, make them more shallow and unrealistically complacent. This may be why, in this age of stress, so many people are using antidepressants—the drugs can help people put up with things they should not put up with.

Bottom line on SSRIs? Depression is a serious illness, and these are serious medications. No one should ever take them lightly. They definitely can do harm, but the harm depression can do can be much worse. If you have a severe depression, you owe it to yourself to give medication a genuine try. But it needs to be part of a balanced plan that includes good psychotherapy and a lot of self-care. One thing medication can do is let you have the energy or hope to follow through.

[i] Irving Kirsch, Thomas J. Moore, Alan Scoboria, and Sarah S. Nicholls, “The Emperor's New Drugs: An Analysis of Antidepressant Medication Data Submitted to the U.S. Food and Drug Administration,” Prevention and Treatment 5 (article 23) 2002.

[ii] W. A. Brown, “Placebo as a Treatment for Depression,” Neuropsychopharmacology 10:4, 265–288 (1994).

[iii] Madhukar H. Trivedi, A. John Rush, Stephen R. Wisniewski, et al., “Evaluation of Outcomes With Citalopram for Depression Using Measurement-Based Care in STAR*D: Implications for Clinical Practice,” American Journal of Psychiatry 163, 28-40 (2006).

[iv] Gardiner Harris, Benedict Carey, and Janet Roberts, “Psychiatrists, Children and Drug Industry’s Role.”,” New York Times, May 10, 2007.

[v] Alison Bass, “Drug Companies Enrich Brown Professor.”,” Boston Globe, p. A1 (Oct. 14, 1999).

[vi] Harris, Carey, and Roberts, New York Times, May 10, 2007.

[vii] Madhukar H. Trivedi, A. John Rush, Stephen R. Wisniewski, et al., “Evaluation of Outcomes With Citalopram for Depression Using Measurement-Based Care in STAR*D: Implications for Clinical Practice.”,” American Journal of Psychiatry 163, 28-40 (2006).

[viii] Catherine J. Harmer, Nicholas C. Shelley, Philip J. Cowen, and Guy M. Goodwin. “Increased positive Versus negative Perception and Memory in Healthy Volunteers Following Selective Serotonin and Norepinephrine Reuptake Inhibition,” American Journal of Psychiatry 161, 1256–1263 (2004).

[ix] Brian Knutson, Owen M. Wolkowitz, Steve W. Cole, Theresa Chan, et al., “Selective Alteration of Personality and Social Behavior by Serotonergic Intervention,” American Journal of Psychiatry 155, 373–379 (1998).

[x] Adam Opbroek, Pedro L. Delgado, Cindi Laukes, et al., “Emotional Blunting Associated with SSRI-Induced Sexual Dysfunction. Do SSRIs Inhibit Emotional Responses?” International Journal of Neuropsychopharmacology 5, 147–151 (2002).

[xi] Peter Kramer, Listening to Prozac. (New York: Penguin, 1993).

Saturday, July 25, 2009

Weasels I Have Known

I'm at work on a new book, tentatively titled How to Be a Man, not a Weasel: Written by a Guy Who's Heard it All. Most of my clients are women, and every day I hear stories about how their husbands, fathers, sons, bosses make complete asses of themselves, totally obliviously. I wince inside.

For instance, there's the guy who calls his wife to tell her he'll be home at 8:30. When he arrives at 9:15, the first words out of his mouth are, "I hope you're not going to spoil the evening just because I'm a little late."

Or the couple where his drinking has become a real problem. On one occasion he's caught in a total lie; he's been drinking and denied it up and down, but there's proof. Within 24 hours he's turned things around so that he thinks he deserves credit for being honest.

Not unlike Mark Sanford, caught dead to rights at the Atlanta Airport by a reporter, whom he tries to con. He gets on the plane to Charleston, has some time to think it over, and decides he'd better fess up. Then his supporters claim he's a great guy for coming clean.

It seems to me that men are much better at massaging reality to make themselves look good than women are. I don't know why this is but I hope to find out in doing my research for this book. The awful thing is that women generally know when we're doing this, and they go along with it to protect our fragile egos.

Men feel they have to prove themselves to be a man; whereas women are just women. Guys turn weasel because they don't know exactly how a real man would act in a certain situation, so they try to have it both ways. I invite you to share with me your own stories on these themes. Maybe you (anonymously) will get into my book.

Introducing myself

This blog will contain features from my books, Undoing Depression and Happy at Last, as well as commentary about mental health and society. I'm a firm believer that mental illness is not simply a brain disease (though the brain is definitely affected)--rather it arises from childhood experiences, quality of parenting, trauma, and relationships, including how the individual is treated by society.
I've been a therapist for 30-plus years now, a rich experience that has definitely made me a little wiser about how I conduct my life. I've also been a depression sufferer. That doesn't mean I haven't enjoyed my life; but if you have depression finding joy and satisfaction requires more work--difficult, sustained work--than it does for other people.
Many people tell me they have benefited enormously from my books and lectures. Blogging is something new for me, but I hope it will help others, and give me the opportunity to muse on subjects that don't fit into a book.
I hope you'll become a regular reader of this new endeavor.