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!

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!