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Leave the Schizophrenia Diagnosis to the Experts, Please!

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What is it about psychiatry that generates so much animosity from the lay public? Psychiatric treatment strategies and the science upon which they are based do not differ from that of gastroenterology or cardiology. We do not see the antipathy towards medications for atrial fibrilation or gastroesophegeal reflux disease (GERD) that we see for schizophrenia treatment. And some gastroenterologists, cardiologists and other "ologists" also act as consultants for big pharma like some shrinks do. Medical writers who focus in these other specialties do not pick up the same following as Robert Whitaker, the popular (in some circles) critic of psychiatry.

As an example, one of his fans when I debated Whitaker on his facebook page responded to my comment that ad hominem arguments were not appropriate with "Oh, and Marvin, I am not engaging in ad hominem 'arguments' here on Mr. Whitaker's site. I am flat-out atacking (sic) you because you and your hateful lies disgust me. I'll leave the 'arguments' to other capable contributors here."

And then, this same person, Suzanne Beachy, responded to a comment on Susan Inman's Huffington Post article that made reference to Dr E Fuller Torrey, a highly respected research psychiatrist, with: "No, I argue that Torrey's critique is invalid because it is full of lies, which are clearly exposed here.

It is rare, if not unheard of, for a medical writer to gain such fame and following as does Robert Whitaker in his critiquing of psychiatry and treatment for schizophrenia. In February, he gave a presentation to lawyers in Boston entitled "The Scientific Case Against Forced Drug Treatment." I don't have enough space to fully critique this, but will just highlight problems with some of his assertions.

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Whitaker cites the World Health Organization (WHO) long term studies in the above presentation and states that among other things "being in a developed country was a strong predictor of not attaining a complete remission." In developing countries that did not use antipsychotics, those with schizophrenia do better. However, a WHO undated publication states that "A substantial body of evidence shows a more benign course and better outcome in developing countries." (P 15). Schizophrenia may be less severe in those countries.

Two of the authors of the WHO studies wrote in 2008 that:

"The outcome of patients in the developing countries was not uniformly better, as compared to the outcome in developed countries. While high rates of complete clinical remission were significantly more common in developing country areas (37 per cent) than in developed countries (15.5 per cent), the proportions of continuous unremitting illness (11.1 per cent and 17.4 per cent) did not differ significantly across the 2 types of setting. Patients in developing countries experienced significantly longer periods of unimpaired functioning in the community, although only 16 per cent of them were on continuous antipsychotic medication (compared with 61 per cent in the developed countries)"

A study published in the British Journal of Psychiatry in 2007 found that there was a very high death rate for people with schizophrenia in outcome studies in India and that this had not been taken into account. They state:

"In schizophrenia outcome studies spanning 15-25 years, the proportion of patients who died or were lost to follow-up ranged from 23 per cent in Chennai to over 50 per cent in Chandigarh and Agra." And, they added "The mean age at death was 34.2 years, which is well below the national average life span of 60.5 years."

So, maybe those who did not die had less severe forms of schizophrenia. Dying during followup is a very bad outcome.

Whatever the answer, these studies are not definitive but do suggest, as many of the authors have said, that other factors are at play such as cultural differences in how families, friends, and society deal with those who are ill.

Whitaker also cites the work of Martin Harrow in Chicago to demonstrate that people not taking antipsychotic medication do better than those who do. Harrow followed a group of people diagnosed with schizophrenia for 15 years and assessed them at 5-year intervals. Whitaker talks about the comparison for those who were on antipsychotics at each time point with those who were not on and that those not taking medications did better.

Quite true, but what he fails to explain is that 79 per cent and 64 per cent of the patients were on medication at 10- and 15-year follow ups. Those who were not on medication, did better on the outcome measures than those who were on but would that not be expected? Why they stopped the medication or were removed from it by their doctors was not explained, but we can presume that it was because they did not need the medication. In fact, Harrow states that not all schizophrenia patients are alike and that one treatment fits all is "not consonant with the current data or with clinical experience." His data suggests that there are unique differences in those who can go off medications compared to those who cannot. In a paper Harrow just published in March, he points out that it is not possible to predict who may be able to go off medication and those who need the long term treatment. Intensified research is needed.

Whitaker also talks about people becoming sensitized to antipsychotic medication and not being able to stop its use without becoming worse from the medication itself. Harrow touches on this in his latest paper and points out that this is not uncommon for many drugs and not just antipsychotics. Insulin resistance is not uncommon for diabetics, there is resistance over time to asthma medication and tamoxifen for breast cancer as well as others. What he does not say but I will is that we do not stop treatment for diabetes or asthma or cancer because the medications as all medications, have problems.

Neuroscience, medicine and pharmacology are complex and evolve as more is learned. And scientists never make, from my experience, definitive statements like Whitaker does. Dr. Harriet Hall, a physician writing as skep doc, pointed out that "A scientist knows that if you search hard enough you can find studies to support almost any belief. Scientists strive for an unbiased evaluation of all the scientific evidence to determine "if" something is true." Treatments for schizophrenia are far from perfect and, as I have written before, doctors do not always follow their own treatment protocols as they should but the medications have benefited many.

In another evaluation on science based medicine by Dr Hall, she quotes her psychiatric expert on schizophrenia that:

"No credible neuroscientist doubts that the schizophrenic syndrome arises from genetically influenced brain abnormalities present at birth that interact with subsequent brain development and environmental contributors in a manner that increases the risk of undergoing a psychotic transition sometime in adolescence or early adulthood." As for Mr Whitaker, she says "His arguments are not convincingly supported by evidence, but they do suggest directions for research."

I have to wonder if Mr Whitaker has any personal experience with a family member with schizophrenia. Those of us who have lived with the horrors of untreated psychosis in a loved one, seen the transformation that takes place when the medication kicks in and the return to the horror of psychosis if it is stopped, can attest to the efficacy. It's not perfect, but it is better. Mr Whitaker should walk in the shoes of any parent with a son or daughter with schizophrenia to learn what that reality is. Or, as a psychiatrist suggested, he should spend a few months in Cook County Jail or Rikers Island with unmedicated psychotics.