International Society for Ethical Psychology and Psychiatry Position Paper By Dr. Jacqueline Sparks, Project Leader, Heart and Soul of Change Project

The American Academy of Pediatrics (AAP) recently updated their guidelines for the diagnosis and treatment of attention-deficit/hyperactivity disorder (ADHD) to include preschool children (www.pediatrics.org/cgi/doi/10.1542/peds.2011-2654 ). The lowered age limit for treatment in the new AAP guidelines inevitably will increase the use of stimulant medications for this vulnerable age group. The use of these drugs and diagnoses of ADHD continue to rise (http://psychiatryonline.org/cgi/content/abstract/appi.ajp.2011.1103038). The numbers are sure to swell as pediatricians are given the green light to prescribe psychostimulants for very young patients.

Treatment related evidence for the AAP clinical ADHD practice guidelines relied on a recent review prepared by the Agency for Healthcare Research and Quality (AHRQ) (Charach, 2011). This review examined 15 reports representing 11 investigations of the use of psychostimulants by preschoolers and claimed that studies found the drugs to be safe and efficacious. However, the review acknowledges that “the evidence comes primarily from short-term trials lasting days to weeks with small samples” (p. Es-8). When comparing methylphenidate with parent behavior training (PBT), the review concludes that the strength of evidence for use of PBT was high due to number of studies and consistency of results but low for methylphenidate because of only one good-quality study (The Preschool ADHD Treatment Study, PATS). While PATS found modest differences on endpoint measures between the drug and placebo, only 21% of best-dose methylphenidate achieved defined criterion for remission set for school-age children diagnosed with ADHD. Moreover, 30% of parents spontaneously reported moderate to severe adverse events in all phases of the study, including irritability, repetitive behaviors, tics, and emotional outbursts (Wigal et al., 2006). For those children who remained on medication, annual growth rates were 20.3% less than expected for height and 55.2% for weight (Swanson et al., 2006).

In 2006, the Drug Safety and Risk Management Advisory Committee of the FDA urged stronger warnings on ADHD drugs, citing reports of serious cardiac risks, psychosis or mania, and suicidality for children taking them. A review of past studies on the effect of ADHD drugs on children’s growth found that the drugs suppress both height and weight for the duration of the trials that were studied (Drappatz et al., 2006). Height and weight effects were noted by the AHRQ review. Moreover, the AHRQ review cites that “Evidence that psychostimulant use in childhood improves long-term outcomes was inconclusive” (p. vii). . . [and] the majority of studies examining the long-term safety and efficacy of ADHD drugs are industry-funded and may result in “enhanced representations of efficacy and safety” (p. ES-9). The report concludes: “The increasing use of off-label prescriptions [of ADHD drugs] for very young children is concerning . . . “There is one primary implication from the review . . . the first line intervention for young children [at risk of ADHD] is evidence-based PBT” (p. 171).

Based on their own investigation, opening the floodgates for ADHD medications for children under the age of 6 is not justified. In light of current evidence, the International Society for Ethical Psychology and Psychiatry (ISEPP) strongly opposes the new AAP Guidelines and urges the AAP to reconsider the implications for lowering the age for which ADHD drugs may be recommended. The ISEPP further urges the AAP to retract their new guidelines until such evidence surfaces that ADHD drugs provide an acceptable risk relative to their benefit for children under the age of 6.

For references, see full position paper at: http://heartandsoulofchange.com/resources/psychiatric-drugs/

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Survey Finds Behavioral Health Professionals Earn Less Than Fast Food Workers

Washington DC (April 11, 2011)—According to the 2011 Behavioral Health Salary Survey just released by the National Council for Community Behavioral Healthcare (National Council), the nation’s mental health and addictions treatment professionals are paid far less than their counterparts in other healthcare sectors.

“Just as people with mental illnesses and substance-use disorders are routinely stigmatized, it appears those working in the behavioral health sector are also treated differently—even within the healthcare community,” says Linda Rosenberg, National Council president and CEO.

The survey of more than 850 mental health and addictions treatment organizations finds:
• A direct care worker in a 24-hour residential treatment center earns a lower median salary ($23,000 a year) than an assistant manager at Burger King ($25,589).
• The annual salary range for a chief medical officer at a behavioral health organization is $101,000–$150,000, compared to the national average of $183,947–$292,395 for the same position in any other type of healthcare organization.
• A social worker with a master’s degree in a mental health-addictions treatment organization earns less ($45,344) than a social worker in a general healthcare agency ($50,470).
• A registered nurse working in a behavioral health organization earns $52,987 compared to the national average for nurses of $66,530.
• “The survey underscores the need to end the second class status of employees working in mental health and addictions organizations,” says Rosenberg, who cites the recent economic crisis and state budget cuts for contributing to the problem.

“Until we achieve equity with the rest of the public healthcare safety net, we will continue to struggle to recruit and retain the number and caliber of professionals needed for more efficient and effective mental health and addictions services.”

The survey, conducted in partnership with the National Association of Addiction Treatment Professionals, includes salary data for executives, administrators, clinicians, direct care and support staff in public and private behavioral healthcare organizations. Completed in November 2010, survey findings are based on salaries reported by 860 respondents from 46 states, Puerto Rico and the District of Columbia. Annual salary data are based on the time period between July 1, 2009 and June 30, 2010.

The full report is available for purchase at www.TheNationalCouncil.org. For more information, contact Meena Dayak at MeenaD@thenationalcouncil.org

But of course, we don’t do this work because we thought we would attain the lifestyles of the rich and famous, and we knew that what we do is not particularly valued by our culture at large given funding cuts, etc over the years. So why do we do it? If you have read my recent book, you know the answer according to the largest study of therapists ever done, a massive 20-year multinational study of 11,000 therapists conducted by researchers David Orlinsky of the University of Chicago and Michael Helge Rønnestad of the University of Oslo (both contributors to the venerable Handbook of Psychotherapy and Behavior Change)–we do for the intrinsic reward of the work, attaining what these authors call “healing involvement” with our clients. But there’s no free lunch here–we have to work on our development to have these kind of quality experiences with our clients. My upcoming May article in the Psychotherapy Neworker addresses what you have to do make them happen. As soon as it is available, I’ll post it to the blog.

On the lighter side, are you looking for that silver bullet cure or magic pill, that perfect intervention for all the situations that clients bring us?

Here is the silver bullet cure. Pay attention to how the therapist carefully considers the client’s feedback:

And the magic pill:

Don’t forget Bob Bohanske’s webinar this Friday. Become a CDOI Member!

I am back from Rome and it was quite an inspiring experience on many levels. Rome is an enchanting and spiritual city. As many of you know who have read the preface to Heroic Client, I have been following the kid and psychiatric drug issue for the duration of my career. And as much as the data doesn’t support the prescription of psychiatric drugs to children, the practice has skyrocketed. It has at times been a very disheartening experience when the concerns are so quickly discounted, not only by psychiatrists but also by almost everyone else. I can’t tell you how many times people just dismiss it out of hand and have thought I was a fruitcake (or anti drug or anti psychiatry or even anti science) for even bringing it up. Keep in mind that this attitude persists despite the fact the data clearly show that drugs should never be a first line treatment, especially for kids. This doesn’t mean that they are never helpful.

But most did not dismiss us in Rome, esppecially the people that can make a difference. The presentation was very well received and got some very good publicity (http://www.catholicreview.org/subpages/storyworldnew-new.aspx?action=9117) Furthermore, we received strong support from various Vatican officials and there is hope for doing an international, multi-religion conference in Rome about this. The implications here are quite exciting.

Here is the text of presentation:

Here are the slides from my presentation. 

And I also made three short videos from around Rome about my presentation which will be up in a couple of days.

A final note about Rome. This would have never happened without the persistence and dedication of Marcia Barbacki. She has selflessly worked on this project for several years and doesn’t know how to take no for an answer. Long after I held little hope for getting the Vatican involved in this issue, Marcia continued to lobby until she succeeded in getting me on this recent program which led to many opportunities for further meetings.

On another note, the next free webinar is scheduled on December 29th 6:00 to 7:30 Central (and the previous one for Chapter Five is posted): On Becoming a Better Therapist: Chapter Six Discussion. This chapter keeps the focus on you, encouraging you to envision your identity as a helper and further contemplate this unpredictable and complexly human enterprise called therapy. It takes a whimsical look at therapist identity using the classic fable, The Wizard of Oz, to illustrate three different therapist personas. Concomitant to reflection about your identity is your personal description of what therapy means to you. This chapter encourages you to define and continually edit your personal rendition of what you do as a therapist. Psychotherapy is presented as a discovery-oriented process, a non-cookie cutter search for what works for each unique client. Feedback provides a comforting compass, a way to manage the uncertainty that is just as characteristic of therapy as it is of life.

Register now at: https://www2.gotomeeting.com/register/537803827

I have a presentation coming up soon at the Vatican at a conference about equitable health care. I am presenting about social justice, kids, and psychiatric drugs so I have been researching, with my colleague Jacqueline Spark’s help, the latest information. I found some pretty disturbing stuff regarding the differential prescription rates of poor kids. A study of 11,700 children under age 18 covered by Medicaid found that the number of children newly treated with antipsychotics increased from 1,482 in 2001 to 3,110 in 2005 (Mathak, West, Martin, Helm, & Henderson, 2010). In other words, a staggering 26% of kids in this sample were taking antipsychotics. Another study found that children covered by Medicaid were prescribed antipsychotics at a rate four times higher than children with private insurance, and were more likely to receive antipsychotics for unapproved uses (Crystal, Olfson, Huang, & Gerard, 2010), or in other words, for reasons of control, not treatment. A study of foster care children found that 57% received three or more drugs (Zito et al., 2008), six times the national average in spite of the fact that no research supports more than one drug for kids. Finally, the use of antipsychotics with privately insured children, aged 2 through 5, has doubled between 1999 and 2007 (Ofson, Crystal, Huang, & Gerhard, 2010). About 1.5% of all privately insured children between the ages of 2 and 5, or one in 70, received some type of psychiatric drug in 2007 despite the fact that there is little to no evidence in this age group.

When you consider the research of antipsychotics with kids (the TEOSS study found that only 12% of kids benefited from antipsychotics and that serious adverse events were all but guaranteed), this is quite a distressing situation. My presentation and the resulting paper will call for a higher standard of prescriptive care. Where children are concerned, the stakes are higher. They are, essentially, involuntary patients—most do not have a voice to say no to treatments or devise their own, and depend on adults to safeguard their wellbeing (Sparks & Duncan, 2008). Moreover, poor children often have fewer adults watching over them and are vulnerable to dangerous drugs used as interventions of control rather than therapy, and therefore require more care to ensure equitable treatment. The evidence demands that the trend of rising prescriptions and lower psychosocial intervention be stopped and a higher standard of care implemented: 1) psychosocial intervention should be considered first–families and youth should have a voice in decisions about their care, especially the disenfranchised; 2) no off label prescribing; 3) no polypharmacy; 4) immediate separation of the pharmaceutical company influence from science and practice; and 5) monitoring treatment response with consumer rated measures. My presentation will call for a higher standard of care for our most vulnerable and precious commodity, our children, that invites unity among all concerned health professionals. It is time to no longer accept prescriptive practices that do not follow the evidence and increasingly put clients at perilous risk for serious health consequences, dependence, and disability. Read more about psychiatric drugs here and watch a video here.

On another note, we have applied for evidence based treatment status with SAMHSA thanks to the Norway Feedback Trial (congrats to Morten Anker on his Ph.D., just conferred this week) and the two RCTs by Jeff Reese. I’ll keep you posted.

Finally, don’t forget the free webinar this month about my book, On Becoming a Better Therapist: November 23rd at 6:00 PM Central. Register now!

Some of you may remember that I (along with Jackie and the support of many others from the Heroicagencies List) took issue with a Newsweek article about a study published in the July, 2008 issue of American Journal of Psychiatry. (For the full story, visit http://chemicalimbalance.org) The study looked at two variables: SSRI prescription rates and suicide rates and compared these in various age groups. The authors suggested that a drop-off in prescribing caused by the Black Box warning led to increased suicide rates.

Newsweek was one of the media outlets that enthusiastically supported the study’s claims. Their article, “Trouble in a Black Box” was written by Tony Dokoupil.

We sent an email to the author and the editor of Newsweek pointing out the problems with the article. The problem was that an examination of the study revealed that the “parallel” development was not parallel at all. A graph in the study clearly demonstrated that the precipitous drop in prescriptions occurred after the increase in suicides. As you read this exchange, keep in mind that everything we pointed out was eventually acknowledged by both the New York Times and The Boston Globe – but not Newsweek.

Dear Editor:
Please find below our letter in response to the article, “Trouble in a Black Box.” Our examination of the study forming the basis for the article revealed a glaring inaccuracy–the study’s results do not match the findings reported in the Newsweek article. Given that very few individuals read or understand research, we believe it important for Newsweek readers to be aware of this discrepancy to evaluate the necessity of the Black Box warning:

Tony Dokoupil’s Trouble in a ‘Black Box’ (July 16) importantly addresses the risks and benefits of prescribing antidepressants to children. However, the referenced study is far from “compelling” evidence for removing the FDA Black Box warning and such an interpretation of its findings is misleading. An inspection of this industry funded study reveals that the precipitous drop in SSRI prescriptions did not occur, as reported, from 2003 to 2005 but rather from February to October of 2005 (over 85% of the drop in the last 6 months of the reported time). The so-called “parallel development” of increased suicides occurred between 2003 and 2004—and therefore had no relationship to the drop in prescription rates reported in this study. Given that the decrease in prescription rates and increase in suicides occurred in different time periods, it begs the question of how such unsubstantiated statements could be made by the experts cited in the article.

Only 3 of 15 clinical trials have shown antidepressants to be superior to a sugar pill on primary measures. Children and parents in those 15 studies reported no advantage of antidepressants over a sugar pill. Data from the FDA and its British counterpart demonstrate that children and adolescents taking antidepressants are twice as likely to experience suicide-related events. Given the meager results and increased risk for suicide-related events (as well as other serious adverse events), antidepressants are not a good first choice for youth struggling with depression—a conclusion reached after an extensive risk/benefit analysis conducted by the American Psychological Association’s Work Group on Psychotropic Medication

Dear Dr. Duncan:
Thank you for responding to my recent story, “Trouble in a Black Box.” In answer to your concerns, I writing to let you that the important “parallel development” we had in mind was that child and adolescent use of antidepressants dropped (for the first time since coming on the market) while suicides rose significantly for the first time since the late 1970s. The fact that antidepressant use dropped most steeply in 2005, the year for which suicide data is still forthcoming, may merely foreshadow trouble–which is why the FDA is concerned. “The evidence is very compelling,” they say.
Tony Dokoupil

Dear Mr. Dokoupil:
Thanks for your note. I understand the proposed relationship between the increase in suicides and decrease in prescriptions that your article and the cited experts were asserting. But the evidence for such a relationship is far from “compelling” when the two developments occurred over different time periods. Your article and the cited experts gave the impression that the “parallel development,” as the word “parallel” suggests, occurred during the same period and therefore were related to one another. This was quite misleading given that an inspection of the study and its graphs revealed something quite different. Had you only commented that it could be a foreshadowing, and offered other explanations, then the article would have not so misrepresented the data. I would appreciate your clarification for Newsweek readers or that my letter be published.

Dear Ms. Lichtschein and Mr. Dokoupil:
I would greatly appreciate knowing your decision regarding our letter. It is of course your perrogative to print or not print any letter you receive. In this case, however, we believe it is critically important for you to get the facts straight because of the unfortunate misrepresentation of the data reported in your article. It is particularly troubling given the bold and even outrageous comments made by the cited experts which, at times, bordered on hysteria and fear mongering, far removed from an objective interpretation of the facts. Perhaps an interesting story would address how the drug company affiliated researchers responded to the findings as a “parallel development” while understanding full well that the precipitous drop in their study occurred after the increase in suicides.

Dear Dr. Duncan,
We appreciate your concerns, but don’t have plans to run your letter. We feel that the story adequately expresses the available data, which concerns the simultaneous snapping of two 15 year trends. The fact that the sharpest drop in antidepressant use occurs in the year for which suicide data is still forthcoming is significant, but more significant in this context is the reversal of a steep, longstanding trend toward increased SSRI use. We also sought comment from experts with interests on all sides of the issue.
Tony Dokoupil

Dear Mr. Dokoupil:
Thank you for your response. Just for the record, you are stating that you will not print our letter because “the story accurately expresses the available data.” We have, in fact, shown that, based on data from the cited study, it does not. The “simultaneous snapping” of the two trends is clearly neither simultaneous nor “parallel” as your story and letter depict. Nor is there enough available evidence to make any definitive statement about youth suicide trends for the time frame mentioned. Perhaps you “sought” consultation from experts on both sides. However, you did not publish both sides. Nowhere in the story are there opposing points of view or other possible interpretations for any trends the existing data might foreshadow. We must assume that, based on your refusal to publish a valid and important counterpoint, it is your intention to keep counter voices from your readers. Not only does this do a disservice to your readers, it walks a perilous line. It reflects how a major media source can, through biased reporting, create unjustified fear and potentially influence the repeal of a warning label implemented, after extensive scientific debate, to protect children. It is our belief that any observer of this process may likely view it as we do—representative of neither balanced nor ethical journalism, especially as it involves a life-and-death issue impacting our nation’s youth.

Thus, while The New York Times and The Boston Globe addressed the problems Newsweek never did. Strike one.

Particularly egregious were the comments in the Newsweek article by Robert Vuluck: “You may induce two suicides by treatment, but by stopping treatment you’re going to lose dozens to hundreds of kids. You’re losing more than you’re saving. That’s the calculus,’ says Dr. Robert Valuck, of the University of Colorado Health Sciences Center.”

While sloppy journalism and lack of fact checking is expected from the media, the bold and even outrageous comments that Valuck made went well beyond just an unfortunate misrepresentation of the data. His comments bordered on hysteria and fear mongering, far removed from an objective interpretation of the facts and offered a conclusion from the data that he must have known, as a study co-author, to be false. This is a serious ethical violation because it created unjustified fear and could potentially influence the repeal of a warning label implemented, after extensive scientific debate, to protect children. This was neither balanced nor ethical science especially as it involves a life-and-death issue impacting our nation’s youth.

Researchers, especially those funded by corporate interests have to be held accountable. We tried to hold him accountable but the University of Colorado Committee on Research Ethics (CRE), specifically, John E. Repine, M.D. who informed us that the CRE did not find sufficient evidence to warrant an inquiry. Strike two.

That’s the past. But these things happen all the time. Case in point. Consider an article just out in the New Yorker:

http://www.newyorker.com/arts/critics/atlarge/2010/03/01/100301crat_atlarge_menand  

It is a review of two new books about antidepressants. It has many redeeming qualities in that it acknowledges the problems with diagnosis and the research suggesting that antidepressants are no more effective than placebo. But it’s all downhill after that, and begins making a not so hidden argument for antidepressants. It purports to do a pro/con analysis of the drugs and psychotherapy but makes two incredulous omissions. One is that it doesn’t discuss, at all, the adverse effects of antidepressants; and two, it fails to mention long term comparisons between psychotherapy and medication. Finally the article cites (and significantly misrepresents) the STAR*D study to support antidepressants, and to refute the claim that SSRIs are no better than placebo.

After I read it, there was no turning back. I had to respond. Do any of you know a cure for that? I included Jackie and my analysis of the STAR*D study from the new Heart and Soul of Change. Given it calls into question their fact checking, I doubt it will be published. Strike three, Barry, yer out!

Here it is:
In the entertaining review, “Head Case,” Menand effectively covered the controversy surrounding psychiatric drugs. Two important issues, however, relevant to assessing the risks and benefits of psychiatric medication were omitted: the significant side effect profile of antidepressants and the poor performance of antidepressants in the long haul (especially as compared with psychotherapy). The STAR*D study illustrates. In the STAR*D, the average remission rate based on the primary outcome measure was 28% and 25% on the first two levels, and 14% and 13% on the last two. At Level 1, 28% experienced moderate to intolerable side effects. At Level 2 (participants augmented or switched), 51% experienced side effects ranging from moderate to intolerable. For all levels, 24% exited due to drug intolerability. Data from the 12-month follow-up of those who either remitted or responded indicated a relapse rate of 58%. Menand’s review omits the significant number of STAR*D drop-outs and claims that a 67% effectiveness rate after all levels. This figure was apparently derived by cumulatively adding percentage rates across levels, a practice statistically meaningless and certainly misleading. Since the rates of effectiveness are calculated from the numbers of participants in each level, average, not cumulative percentages correctly reflect overall improvement. For example, in the first two levels, out of a total of 4,168 participants, 1114 achieved remission, a 27% effectiveness rate, not the 56% rate reported by Menand. When drug studies are reported, original sources must be examined to insure that risks and long term follow up are considered.

Hope to see you soon in New Orleans!

Sometimes, people don’t believe me when I talk about the evidence regarding psychotropic drugs. It does sound far-fetched some times because the evidence is so much different than what you hear in everyday conversation.  The difference between what you hear or read in the media and the clinical trial data is striking, so much so that reporting the real evidence often leads to raised eyebrows. But you know, I couldn’t make it up near as well or as damning as the actual clinical trial evidence. For example consider the latest about antipsychotics and kids.

Prescriptions for antipsychotics for children continue to skyrocket, despite underwhelming evidence. Here is how we wrote about the NIMH funded Treatment of Early Onset Schizophrenia Spectrum Disorders (TEOSS) (Sikich et al., 2008) in our recent chapter in the Heart and Soul of Change, 2nd Edition (Sparks, Duncan, Cohen, & Antonuccio, 2010):

“Described as a landmark trial (McClellan et al., 2007), TEOSS sought to examine the efficacy, tolerability, and safety of two second generation antipsychotics (SGAs; Risperdal and Zyprexa) for youths diagnosed with early-onset schizophrenia spectrum disorder and to compare these to a first generation antipsychotic FGA (molindone or Moban). Fewer than 50% of subjects completed 8 weeks of treatment and response rates were low and not significantly different for all three groups (Sikich et al.). Participants in the study were allowed concomitant use of antidepressants, anticonvulsants, and benzodiazepines, compromising even these disappointing findings. A 17-year old boy committed suicide and an unspecified number of participants were hospitalized due to suicidality or worsening psychosis. These events are particularly disturbing in light of the fact that youths considered at risk for suicide were excluded from the study. Weight gain was deemed serious enough to warrant suspension of the Zyprexa arm (McClellan et al.).”

It gets better or should I say worse? Follow up, available on line and soon to be published in the June issue of Journal of the American Academy of Child & Adolescent Psychiatry (see the abstract at http://www.jaacap.com/article/S0890-8567(10)00294-7/abstract, revealed that only14 of the 116 youth (12%) responded to the medication and stayed on it for one year. That’s right, you read it correctly–12%! Recall that in the famous adult trial of antipsychotics (the CATIE trial) that 74% dropped out. So it is even worse in youth—88% failed to benefit.

So let’s break this down. First, TEOSS was not placebo-controlled. The 116 youth enrolled into the trial were randomized either to a first generation antipsychotic (Moban) or to an atypical antipsychotic or so called second generation antipsychotic (Risperdal and Zyprexa). At the end of eight weeks, the response rate was 50% for those treated with Moban, 46% for Risperdal, and 34% for Zyprexa. Adverse events were “frequent” in all three groups.

Only those youth who “responded” during the initial eight weeks — 54 of the 116 — were entered into the 44-week maintenance study. Forty of the 54 youth dropped out during this period because of “adverse effects” or “inadequate response.” Thus, only 14 of the 116 youth who entered the study responded to the medication and stayed on it for as long as one year—only 12%.

Pharmacotherapy helps some children and adolescents, although apparently not very many. However, the preponderance of empirical research indicates that the risk may not be worth it. While pharmacotherapy involves considerable risk for young people, psychosocial interventions have a strong track record with virtually no adverse associated medical events. APA’s Working Group on Kids and Psychotropics (2006) concluded:

For most of the disorders reviewed herein, there are psychosocial treatments that are solidly grounded in empirical support as stand-alone treatments. Moreover, the preponderance of available evidence indicates that psychosocial treatments are safer than psychoactive medications. Thus, it is our recommendation that in most cases, psychosocial interventions be considered first. (p. 16. Italics added)

As the evidence regarding TEOSS suggests, the automatic prescription of antipsychotics for sure, but with any psychotropic, is unwarranted. Where children are concerned, the stakes are higher. They are, essentially, mandated clients—most do not have a voice to say no to treatments or devise their own, and depend on adults to safeguard their wellbeing (Sparks & Duncan, 2008). If you are seeing kids taking antipsychotics, you are on very firm ground to raise concerns and ensure the treatment is fitting client preferences.

Read more about psychiatric drugs and the evidence at http://heartandsoulofchange.com/resources/psychiatric-drugs/

Many of you have asked me for a Vatican Update. Sorry it has been so long but this has been and will likely continue to be a long term process that requires a sustained effort to reach success. As you know, Jacqueline Sparks and I continue our efforts (see our chapter in the new Heart and Soul) to encourage folks to consider the risk/benefits of psychiatric drugs and our conclusion that the data do not support drugs as a first line intervention or rising prescription rates. This of course does not mean that we are anti drug or anti psychiatry but rather that we challenge automatic prescription, and believe that clients should have access to information, informed consent, and a range of alternatives that honor their preferences—and have the ability to monitor the results.

And many of you know that I did a radio show on Voice America about this same issue with Marcia Barbacki and David Cohen (many episodes available at http://heartandsoulofchange.com/resources/audio-presentations/ ). Marcia is the most persistent and selfless person I know. She works tirelessly at her own expense to bring this controversial topic to mainstream awareness and her efforts over the past three years have focused on enlisting the Catholic Church to help stem the tide of rising prescriptions, especially to kids given they have little voice in such decisions. I was intrigued and inspired by the idea that the Church and her vessels could counter the forces of corporate power and greed. Few institutions or even governmental entities seem to be able to stand up to economic tsunami of the pharmaceuticals…over 40 billion in sales last year and more spent on marketing than on research and development; and there is a pharmaceutical lobbyist assigned to every member of congress. Remember that good marketing, and unlimited lobbying, can overcome bad data every single day of week. Knowing that, I couldn’t help but be smitten by the idea that if the Church could be persuaded that the evidence does not support the prescription rates especially with children, considering the risks, then, through all the channels available—religious communities, churches, and schools—they might promote a cautionary, no first line use stance , and call for each professional to look at the evidence him or herself as well as a more defined separation between the pharmaceutical industry and research/education. For a great article about the negative effects of blurring this distinction as well as recommendations to fix the influence of drug companies on research and education, see Marcia Angell’s excellent article at: http://bostonreview.net/BR35.3/angell.php. This is not a wide eyed anti drug zealot but rather a former editor of the New England Journal of Medicine. I hope that this article might convince you that we are not just conspiracy theorists!

Marcia Barbacki and I recently did a presentation in Lourdes, France—a place that is inspiring on many levels—to an international group of Catholic physicians, nurses, pharmacists, and other health care professionals. Check out this presentation available in PowerPoint for your free download as well as the narrative summary at a new page of articles about psychotropics: http://heartandsoulofchange.com/resources/psychiatric-drugs/. The video from the presentation will be available soon. It will at the least be entertaining because I am wearing a suit and look like a fish out of water or perhaps like Gomer Pyle in his Sunday best. Golly! Marcia’s efforts and the presentation paid off. I am presenting at the Vatican’s annual conference in November. This could lead to an international conference on this important topic. Keep your fingers crossed.

And speaking of kids and drugs, Jacqueline just sent me this music video on ADHD:

And now for something completely different: I also wanted to remind you about the CDOI Directory. The benefits of listing will only increase over time as it becomes more known. Traffic to the site is increasing and will continue as other things develop including upcoming press releases about the alliance article as well as Networker and Psychotherapy in Australia articles. Besides allowing others to find you and know that you aspire to CDOI ideas and practices, it will allow you to network with folks holding similar values about practice, perhaps allowing you to find a local community. It can also provide additional exposure of your practice and let potential funders, interns, volunteers, etc, know of you and your interests. Over time, I hope to let funders know of our list and the benefits that members can offer because of their attention to client benefit and the alliance. And Rebecca just added another feature. You can download the CDOI Registered Provider icon from your listing and place it on your website to inform your visitors of your membership in the directory and what it means.

I am hoping for 100 members by the time of the Heart and Soul of Change Conference so I can show it to folks. I would appreciate your consideration. And while you are considering that, consider coming to the conference!

Two recent articles highlight the amazing fact that good marketing overcomes bad data every single day of the week. As Jacqueline Sparks (Project Leader) and I and our colleagues say in the new Heart and Soul of Change:

The fact that a for-profit industry plays a role in fashioning what counts as evidence may no longer surprise many. The former editor of the New England Journal of Medicine called attention to the problem of “ubiquitous and manifold . . . financial associations” authors of drug trials had to the companies whose drugs were being studied (Angell, 2000, p. 1516). The result is a direct correlation between who funds the study and its outcome. For example, Heres et al. (2006) looked at published comparisons of five antipsychotic medications. In 9 out of 10 studies, the drug made by the company that sponsored the study was found to be superior…Antonuccio, Danton, and McClanahan, (2003) detail the vast reach of the pharmaceutical industry—from Internet, print, and broadcast media, direct-to consumer-advertising, “grassroots” consumer-advocacy organizations, and professional guilds to medical schools, prescribing physicians, and research—even into the board rooms of the FDA. They conclude, “It is difficult to think of any arena involving information about medications that does not have significant industry financial or marketing influences” (p. 1030). Given the infiltration of industry influence, reliance on press reports, web pages, and even the academic literature as a basis for sound decision-making is unwise. Discerning good science from good marketing requires a willingness to engage primary source material.

Think this is overkill? Think twice. Check out the embedded article “From Evidence-based Medicine to Marketing-based Medicine: Evidence from Internal Industry Documents” written by Glen Spielmans & Peter Parry. Here is the abstract:

While much excitement has been generated surrounding evidence-based medicine, internal documents from the pharmaceutical industry suggest that the publicly available evidence base may not accurately represent the underlying data regarding its products. The industry and its associated medical communication firms state that publications in the medical literature primarily serve marketing interests. Suppression and spinning of negative data and ghostwriting have emerged as tools to help manage medical journal publications to best suit product sales, while disease mongering and market segmentation of physicians are also used to efficiently maximize profits. We propose that while evidence-based medicine is a noble ideal, marketing-based medicine is the current reality.

Here is the article:

And, as a case in point, consider this is true nowhere more than with antidepressants. The slightly better than placebo efficacy of antidepressants has been know for many years. Roger Greenberg and Seymour Fisher exposed antidepressants in their classic 1997 book, From Placebo to Panacea and we reviewed the subsequent literature and reported it (along with several others) as far back as 2000 and 2004 in The Heroic Client as well as the 2000 article, “Exposing the Mythmakers,” which received the All Time Top Ten Award for one of the most influential articles in the Psychotherapy Networker’s history. But yet millions are still prescribed and millions still take them as a first line of defense (nothing against folks who do and surely some benefit). Irving Kirsch, the person who meta-analyzed FDA trials and reported that the antidepressant emperor wore no clothes, has a new book. Check out this article in Newsweek about it: http://www.newsweek.com/id/232781  

Here is a brief summary of Kirsch’s research that we (Sparks, Duncan, Cohen, & Antonuccio) summarize in the new Heart and Soul of Change:

Kirsch and Sapirstein (1998), in a meta-analytic review of nineteen studies involving 2,318 people, showed that 75 percent of the response to antidepressants was duplicated by placebo. They speculated that the remaining 25 percent of the positive antidepressant effect may be attributable to the un-blinding power of side effects. Adding to the critique, Kirsch, Moore, Scoboria, and Nichols (2002) analyzed the efficacy data submitted to the US Food and Drug Administration (FDA) for the six most widely prescribed antidepressants approved between 1987 and 1999. Approximately 82% of the response to medication was duplicated by placebo control groups—57% of the studies failed to show a drug-placebo difference. When a difference was found, the drug/placebo difference was only, on average, 1.8 points on the clinician-rated Hamilton Depression Rating Scale (HDRS). FDA memoranda intimated that the clinical significance of such a small difference was questionable (Laughren, 1998).

In a review of antidepressant trials involving 12,564 persons (Turner, Matthews, Eftihia Linardatos, Tell, & Rosenthal, 2008), 94% of published trials had favorable results whereas the percentage of positive results for published and unpublished trials together drops to 51%. The authors warn that publication bias of this magnitude dramatically distorts reported effect sizes and has serious implications for researchers, health care professionals, and clients. Kirsch et al. (2008) provide further evidence that the belief in antidepressant efficacy is scientifically unfounded. Meta-analytically examining all trials submitted to the FDA for the licensing of four popular SSRIs, the authors found no clinically significant differences between placebo and the drugs, with the exception of the most distressed in the severely depressed group. Even this negligible difference was found to be due not to the drug, but to a decreased response to placebo.

Regarding taking a critical stance about psychiatric drugs, check out the new webiste of the International Critical Psychiatry Network: http://www.criticalpsychiatry.net/  The Heart and Soul Project’s own Certifed Trainer and psychiatrist, Sami Timimi, is a key member. 

On another note, a new webinar by our own John Murphy has been scheduled for February 17:
Respect, Resources, and Recovery: Putting the 3 Rs into Action with Children, Adolescents, and Schools
Wednesday, February 17, 2010, 1:30 to 2:30 Central
Based on the persistent belief that young people and their caregivers are capable of remarkable changes when invited to actively participate in services and to apply their “natural resources” toward solutions, this webinar describes practical ways to put the principles of CDOI and recovery into action in schools, counseling agencies, and other child/youth settings. Real-world examples are used to illustrate the power of partnership and the benefits of client-driven/strength-based practice.

John Murphy, Ph.D., professor of psychology at the University of Central Arkansas, has extensive experience implementing collaborative approaches with young people and school problems (www.drjohnmurphy.com). He recently authored (with Barry Duncan) the book, Brief Intervention for School Problems (2nd ed.) (Guilford, 2007) and Solution-Focused Counseling in Schools (2nd ed.) (2008, American Counseling Association.

John is also a Project Leader of the Heart and Soul of Change Project and a featured speaker at the Heart and Soul of Change Conference in New Orleans. Join John and Barry for this timely discussion of kids and school at: http://www.cdoimembers.com/Default.aspx?pageId=199866