A Towering Angell Engages Psychopharm by Nathan Szajnberg
A Towering Angell Engages Psychopharm by N. Szajnberg, MD Aug. 5, 2011
A macabre Gorey drawing initiates the NY Review of Books’ intellectual combat between Marcia Angell, former editor of the New England Journal of Medicine, and major figures in American Psychiatry: John Oldham, Richard Friedman, Andrew Nierenberg and Daniel Carlat (“The Epidemic of Mental Illness: Why?” “The Illusions of Psychiatry”; (NYR June 23; NYR July 14; IP/net Aug 3). A boy stretches tiptoed on a stool, reaching unsuccessfully for a squadron of bottles beyond his grasp. We readers are like that boy, trying to get a grasp of what’s at hand here; a battle is engaged and will be formidable; how it will proceed is uncertain. But, we also know that Angell and the New York Review of Books have ignited an important rethinking of using drugs in mental illnesses: no turning back now.
Read the IP post for the details of the arguments. In brief, Oldham, President of the APA, says Angell should have been more balanced. Carlat (whose book Angell reviewed), begins, “Her argument is correct in its essentials.” that psychiatrists over diagnose; are overly fixated on medication, have taken drug industry money. Yet, he states, drugs “on the whole, work.”
Friedman and Nierenberg give no quarter, beginning with “…Angell’s review…contains serious factual and conceptual errors…” and concluding, “she has distorted the potential adverse effects of psychotropic drugs with anecdotes and flawed data…”
Angell’s response is lengthy and detailed and crisp. She starts with “… these letters simply assume that psychoactive drugs are highly beneficial… none .. provides references … (to) substantiate that…” Then, she lists evidence, after evidence. For instance, the U.K. agency overseeing their NHS found that antidepressants provide no clinically significant change in the Ham-D depression index. In general, she restates, while there may be short-term effects for some drugs, there is no evidence for long-term efficacy. She condemns the quality of clinical research in psychiatry; as an expert in judging clinical studies, she is on solid ground.
And what about our kids? Stuart Kaplan’s Newsweek article challenges the stunning rise of bipolar disorder in children and their over medication (http://www.thedailybeast.com/newsweek/2011/06/19/mommy-am-i-really-bipolar.html). Biederman’s life’s work is discredited in part because of his dealings with pharmaceutical companies: when he claims that 1-4% of all U.S. children are bipolar; his credibility suffers further. Kaplan argues that bipolar is a fad diagnosis; that many of the symptoms described in recent popular books, such as Brandon and the Bipolar Bear (imagine Where the Wilds Thing Are revised to sell drugs), portray either the norms of childhood, or (Kaplan argues) more parsimonious diagnoses.
Adolescents often keep us honest or at least not hypocritical: they point out that we tell them (consciously) not to use street drugs, then say that we have just the right drug for you in our cabinet. And colleagues will try to respond to the teen, “You are trying to medicate yourself for your (fill in the diagnosis); I can do it better for you.” But, can we? And why, in many cases, can’t we use the more sophisticated, highly individualized treatment of interacting with the teen (or adult) examining feelings, thoughts, wishes, fears, dreams: that engagement we call psychoanalysis; a treatment that our brain-imaging colleagues may some day show results in pharmacological or neuro-structural changes (If we do our treatment well.).
The New York Review of Books, Angell, Newsweek and Kaplan have provided an important public service, a breach in the wall of big pharma. Psychoanalysts can step into that breach to promote what is in society’s better interest.
Here analysts meet a great challenge. Can we begin to initiate the careful study of adult analytic outcome as Leutzinger-Bohleber and colleagues have done in Germany, or Fonagy and Target’s courageous reexamination of the records in the Anna Freud clinic to find out what works (and doesn’t work as effectively) with children? This kind of research takes a team; takes a discipline willing to support its teams; and takes scientific courage.
Psychoanalysts can show that we are willing to examine our practices and strut our stuff.
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August 5th, 2011 at 7:28 pm
I appreciate Dr. Szajnberg’s succinct summary of the arguments brought to bear on this crucial topic. Some analysts, as he cites, have looked with critical and open minds at analytic work and revised theory and technique accordingly. Another example is the work Jack Novick and I did at the Hampstead Clinic in London in the late 1960′s. We looked at 111 child and adolescent cases, treated in psychoanalysis, who displayed beating fantasies. We found various subgroups, including one group where the outcomes were not good.
Anna Freud was dismayed by our results and pushed us to explicate them with detailed analytic data. We did so, in published work in 1972 and since. Far from covering up our efforts, she then supported our work and encouraged us to explore the reality of development, both normal and pathological, whatever the impact on received psychoanalytic knowledge.
What a contrast to the apologists for wholesale pharmacological treatment with their obfuscations and ad hominem arguments! Let’s take Anna Freud’s example to heart.
August 6th, 2011 at 4:27 pm
I want to commend Nathan Szajnberg on pertinent piece on Angell and the debate on psychopharmacology in “The New York Review of Books.” I think the Angell pieces, specifically her critique of the abuses and mindlessness of contemporary psychiatry, open a vast new potentiality for psychoanalysis and analytic talk therapies. Even Peter Kramer, an apologist for Prosac and other anti-depressants, recommends talk therapy to most if not all of his patients. The so-called psychoanalytic conversatism about medication, which was still in place during my analytic training in the 1980′s, may prove to be clinically sound, as well as scientifically valid. And progressive. I found Angell’s essays convincing about the collusion of contemporary psychiatry with the big drug companies, their tendency to invent often bogus diagnostic categories (requiring new medications), their vast exaggeration of the results of anti-depressants on a wide variety of patients, and not least her unmasking of the scandalous over-medication of children. Psychoanalyts ought to remind the public that we are trained to attend to the full personality, not just to target symptoms; that psychoanalytic therapy has proven efficacy and outcomes; and that patients are eager for therapists who listen carefully, whose focus is understanding and insight, and who offer authentic forms of relationship, affect attunement, and care. Following Nathan Szajnberg, I believe that this is an opportune moment for analyts to be pro-active and aggressive about the good things we have to offer.
August 7th, 2011 at 1:50 pm
A comment on Dr. Szajnberg’s summary.
I do not agree with those who claim that Angell’s critique of the usefulness of drug therapy is an attack on psychiatry, no more than being critical of Israeli politics is an expression of anti-Semitism.
Angell wants to stimulate the professionals to think critically about these drugs, to test so-called evidence based arguments by challenging the evidence based approach itself. The corollary is a cricism of the current drive to convert psychiatry into a kind of neurology coupled with a denial pf psychosocial and psychodynamic factors.
From the time the Enlightenment promulgated the principle that as compared to religion, science is open to the judgment of reason, thus open to debate and asking the hard questions, we may not view Angell’s questions as an attack on psychiatry.
No analyst or psychiatrist with clinical experience will deny the usefulness of drugs in extreme situations, e.g., uncontrollable excitement or destructive fury. At issue is criticizing the indiscriminate use of medications, as a shotgun therapy, with a denial of the usefulness of psychodynamic techniques.
The advocates of drug therapy only as scientific have hijacked to idea of evidence based as applying to drug therapy only. However, psychodynamic psychotherapy has its own evidence base and, as Szahnberg points out, has been validated invarious outcome studies.
A careful longitudinal study of a single case functions as its own built-in contol. Two recent individual stories have appeared in the NY Times: the first by Marsha Linehan, originator of DBT, and the second in today’s paper,
Lives Restored
Learning to Cope With a Mind’s Taunting Voices
By BENEDICT CAREY
Joe Holt spent years trying to determine the cause of his problems in life, before deciding that the question was only a distraction from the real issue he faced: finding a way to live with them.
To my mind both are evidence based and illuminating as important human documents.
The same way Sabbath was made for man and no man for Sabbath, people were made to be first treated as participants in dialogue, communication, contact, commitment, counseling and comforting and not made to prefer pills to psyche but that pills were and should be made to serve real needs, not ad-driven needs.
Zvi Lothane
August 8th, 2011 at 12:38 pm
I would not like to go through a discussion about treatment, because both, pharmacological and psychoanalysis, have advantage and limitations. I would like to propose a change of focus – using metaphoric language – what about trying to see the world by wearing the ordinary people glasses. Reading this article questions have been raised, e.g. why do people accept to be treated by pharmacological treatment so easily? They do trust it. Why is this kind of treatment apparently more efficient for them? I particularly think that currently we live at a time in which quick answers to unknown situations and to uncertainties are always welcome. Also public services must be quick and efficient, thus also looking for certainties. At the end people are looking for what I will call the ideology of ‘magic solutions’ as a way to avoid emotional stress, loss and frustration and simultaneously to not waste time. Hence the pharmacological treatment fits well their search when it gives them some quick relieve (not talking about the cases in which this kind of treatment is really necessary). From my point of view, instead of beginning a discussion about the treatments, perhaps it would be better to ask ourselves how the psychoanalytic knowledge could be used to contain this emergent ideology. After all people are still suffering.
August 15th, 2011 at 10:36 am
Comment from Jim Haushultz:
Dr. Szajnberg’s commentary concerning ‘A Towering Angell Engages Psychopharm’ reveals a wonderful ability to bridge the divide between grand rounds and popular culture. In this case, the patient under review is pharm. Worthy of the NY Times, Harper’s, The Atlantic, etc, perhaps even the WSJ. When our blog is up and running, his piece, in a more condensed form with links, is the sort of community conversation starter I think we should be aiming for. While writing on a topic easy to ‘talk down’ from, he manages to respect his readers. And there is little that is more engaging than respect.