The Increase in Psychiatric Disability in the USA

As an academic psychiatrist, I supervise residents in an outpatient psychiatric clinic whose patients are predominantly on Medicaid (called Tenncare in Tennessee).  Many of these patients were able to qualify for Tenncare because they are on Social Security disability (SSI), and the majority of these had been placed on disability for psychiatric reasons based on the recommendations of previous psychiatrists.

In this clinic we see patient after patient with obvious personality problems who seems to be able to take care of almost any task that "normal" people can all do except hold a job. They have been labeled by psychiatrists with phony or inappropriate misdiagnoses such as bipolar II, adult ADHD, and even Asperger's syndrome. They had been put on disability with their psychiatrist's blessing.

Their families gladly go along with the psychiatrist's assessment because they do not want to take responsibility for having helped to create the patient's psychological problems in the first place.

My sources tell me that the same thing is happening all over the country.

Patients who really do have bipolar disorder should almost never be on disability anyway because, in the vast majority of cases, it is a highly treatable illness, and people are completely normal if they take their medications, are not in a manic or depressive episode, and do not have any co-occuring psychological issues.

ABC News recently reported that applications for SSI have gone up considerably since the start of the recession.  The obvious implication is that people who are just plain unemployed are attempting to support themselves by claiming to be disabled.

Then there is the outright disability fraud known in some circles as crazy checks, as I described in my post of October 10, 2010, in which parents coach their kids to act out of control for a psychiatric disability evaluation.  As I have said, apparently fooling psychiatrists into making serious diagnoses on kids who are acting out – or just plain acting – is as easy as pie.

The states have gone along with this charade because it transfers a lot of their welfare costs to the Feds. What a difference this is from the 1980's, when the Reagan administration was kicking people off of the disability roles who really were disabled (e.g., patients with chronic schizophrenia). The courts finally had to step in to stop this. I used to do SSI evaluations in California back then and saw this first hand. My evaluations were often completely ignored.

We've gone from one extreme to the other.

I do not bring up this issue merely to infuriate taxpayers.  The whole disability process has another, far more destructive and insidious effect.  It can be extremely damaging to the mental health of the involved individuals.

Consider this: if your entire family, along with professionals who are supposed to be experts, believe that you are impaired, who are you to argue? People in this situation are not only being paid to think of themselves of disabled, but really do start to believe that they are damaged goods. 

Their self-esteem, already in trouble because of their having been scapegoated by their families, goes down the toilet.  They truly and deeply believe that they are both brain damaged and big losers to boot.  They are validated in this belief by the most powerful people in their environment.

Read this description of a patient from a fellow psychiatric blogger (Thought Broadcast): 

"When I first saw her, she appeared overweight but otherwise in no distress.  An interview revealed no obvious thought disorder, no evidence of hallucinations or delusions, nor did she complain of significant mood symptoms.  During the interview, she told me, 'I just got my SSDI so I’m retired now.'  I asked her to elaborate.  'I’m retired now,' she said.  'I get my check every month, I just have to keep seeing a doctor.'

When I asked why she’s on disability, she replied, 'I don’t know, whatever they wrote, bipolar, mood swings, panic attacks, stuff like that.'  She had been off medications for over two months (with no apparent symptoms); she said she really 'didn’t notice' any effect of the drugs, except the Valium 20 mg per day, which 'helped me settle down and relax.'

Keisha is a generally healthy 27 year-old.  She graduated high school (something rare in this community, actually) and took some nursing-assistant classes at a local vocational school.  She dropped out, however, because 'I got stressed out.'” 

Retired? 

Getting someone like this off of disability is nearly impossible. Even if they start to believe in themselves and begin to succeed, they would then lose their Medicaid and would not be able to pay for the treatment that might help them to maintain their employment and make further gains. They are literally trapped by the disability system into feeling themselves to be nothings and nobodies.

And a lot of psychiatrists are doing this to their patients. 

Please keep in mind, however, that there also are a plenty of psychiatrists who are as appalled by this trend as I am.  

R. Scott Benson, M.D., the speaker-elect of the General Assembly of the American Psychiatric Association (APA), confirmed in yet another way this whole picture in a personal communication with me.  He said, “The APA has a Business collaborative. There are articles by HR [Human Resources] managers lamenting the fact that psychiatrists in general do not seem to believe that people should work.

I have been doing reviews for Disability Insurance companies and people with what appear to be mild symptoms are kept off work with no change in their treatment plan. Then they are depressed that they do not have money, lose their house and car, etc. Yes the SSI disability racket is a strange beast. The money never seems to be spent on any kind of treatment."

MentalHealthWorks, an APA publication, actually had to spell out the following recommendations to psychiatrists concerning disability:

Principle #1. Inability to work is a psychiatric crisis.

Principle #2. Return to work is a fundamental goal of treatment.

Principle #3. Occupational disability is a complex biopsychosocial phenomenon. 

Principle #4. Symptoms are not impairments; impairments are not disability. A decline in function is often temporary and does not need to meet the threshold of total incapacity. Disability often includes interpersonal issues at work, physical complaints, other medical conditions, and psychological issues.

Like, Duh! You mean these things are not obvious to someone smart enough to get into and get through medical school? Really?!?

And check out this personal communication from Randy Bock, a family practitioner who specializes in addiction treatment:

“I had a woman today who wants to go on naltrexone [a treatment for opioid addiction]. She had been doing heroin and just finished a detox.

Recently she was at [a halfway house].  They 'made' her apply for Social Security/disability (‘which they do for everyone’); so as to get their own bills paid regularly … including multiple drug tests/week. Additionally once she got her 'disability check' they were taking 'half her income' - some $400…

The halfway house sent her to a psychiatrist who diagnosed her promptly with 'PTSD, bipolar, anxiety, depression,' and gave her a disability finding.

She says they wanted her to ‘leave her past’ (which in this case meant also her job) and ‘only look forward’, and that involved her not working (at all) for the subsequent 14 months in the halfway house.”

Author Robert Whitaker (Anatomy of an Epidemic) has made a lot of noise about the large increase in psychiatric disability recently, but completely misidentifies the cause.  His thesis is that the appropriate use of psychiatric medication has been making people worse, and he seems to think that if a patient gets worse, it must be due to the medications.  This is circular reasoning.

A psychiatrist who does a complete evaluation of ALL possible biological, psychological, and social factors affecting a given patient is in a much better position to make the call as to exactly which factors have led to a patient’s deterioration (and yes, Alto, not infrequently it is from debilitating side effects from medication that are ignored by the doctor).

Then again, as another fellow blogger Moviedoc cracked, that is a moot point because problem psychiatrists are not taking much of a history nowadays anyway.

The Deterioration in Quality and Usefulness of the Notes Written by Psychiatric Nurses

The hospital notes of psychiatric nurses are starting to be as unrevealing of the patient's true condition as the notes by psychiatrists. Both types of notes are relying more and more on useless symptom checklists. As my friend James Woods observed, using a symptom checklist to make a diagnosis is only slightly more accurate than throwing darts at a dartboard - blindfolded.

Whenever a psychiatrist sees a new patient who had been treated by another clinician in the past, it is usually standard operating procedure for the doctor to obtain any prior medical or hospital records that pertain to that patient’s case. However, an ethical psychiatrist does not rely completely on another doctor’s diagnosis or treatment, but does his or her own evaluation to form an opinion. 

The previous doctor might have had things completely wrong. The former chairman of the academic department in which I was the residency training director, Dr. Neil Edwards, used to tell residents in training that the evaluation of each patient new to a clinician should take into account two different possibilities: first, that any prior clinician was competent, thorough and correct. Second, that the prior clinician was none of these things. 

In order to judge the diagnosis made by a mental health professional from the medical records, there has to be more than just a diagnosis on the chart or a quick “mental status” exam from one or two points in time. There has to be a narrative description of the patient. Particularly in a psychiatric hospital setting, there should also be a description somewhere in the chart of the patient’s ongoing behavior on the ward, particularly when the patient is not aware that he or she is being observed, and any major consistent changes in that behavior over time as treatment progresses.

To understand why this is important, let me relay some personal experience. I worked for a time in the main psychiatric emergency room in Memphis, from which many patients were referred for psychiatric hospitalization. After having evaluated a patient in the ER, I would later see the same patient in the hospital on weekends, when I was covering a service for the doctors who were in charge of the patient in the new setting. I would review the patient’s chart for the events and subsequent evaluations that had occurred since admission. One thing I witnessed time and time again – and not just with trainees but with the attending faculty as well – was quite striking. 

In the ER, some patients looked very depressed and showed all the signs (observed characteristics) and complained of all of the symptoms of clinical major depressive disorder. Their movements and speech were slow (psychomotor retardation), and they complained of chronic and persistent changes in appetite, sleep, pleasure, energy, and concentration. Since the patient seemed to meet all of the necessary DSM criteria, the diagnosis of major depressive disorder was therefore made by my resident, and I concurred.

However, in many cases in which I saw the patient in the hospital the very next day, or heard a description of the patient’s behavior on the ward by the nurses on the day following admission, an entirely different picture emerged. The patient was observed to be actively socializing with other patients, friendly and talkative on approach, speaking with normal rate and volume, sleeping on hourly bed checks (although they often had been given a sedative), and eating 100% of served meals!

One major characteristic that distinguishes true major depressive disorder from other types of depression is that its symptoms do not evaporate overnight, nor do they disappear merely because of a change of venue for the patient. They persist and are present in all environmental contexts. They can get to the point where a patient could win the lottery but not crack a smile. If symptoms change radically with a change in venue, then the primary problem for the patient resides in the venue, not in his or her mental disorder.

Clearly, everyone’s initial diagnostic impression of these patients – including my own – was incorrect. 

Yet surprisingly, the patients’ diagnosis was almost never changed during the entire course of their hospitalization. Their admission and discharge diagnoses were identical. Furthermore, they had been given treatments that patients who actually had major depression would be given.

Were my observations of this phenomenon biased in some way? Perhaps not changing a diagnosis in the light of new and conflicting information was something peculiar to doctors practicing in academic settings or only those practicing in Memphis, the city in which I was located. Possible, but not likely. How do I know?  Well, in over 30 years of practice, I have had the opportunity to review medical records of patients who had been psychiatrically hospitalized all over the United States. 

Nowadays, I often do not even bother to even send for hospital records, for they have become next to worthless for understanding a patient's condition. In the doctor’s initial evaluation, there would be no information about the time course, pervasiveness, or persistence of any symptom the patient was alleged to have had. There might be a "description" of symptoms that would consist of meaningless terms such as  “paranoid” or “suicidal” without any explanation of what the term meant as applied to the particular patient, or the context in which it occurred. Did “paranoid” mean delusional, or merely distrustful? No information.

With electronic medical records, I often have access to the notes and evaluations of several previous clinicians. Often no “target symptoms “ are described when a patient is put on a medication, and there is no information later on about what, if any, symptoms, had gone away in response to treatment. No way to know if the patient should have stayed on the medication. Sometimes the meds would be changed, but no reasons would be given for doing so. Did it not work? Or were there intolerable side effects? Or what?

With hospital records, I used to overcome the problem of physicians’ notes lacking any indication of how the patient was behaving on the ward by looking at the nurses’ notes. They used to actually describe such things. The patient might be noted the day after admission to eat, say, 100% of meals, be up and about socializing on the ward, sleeping on one hour bed checks, and pleasant and appropriate on approach.  If such a patient had been diagnosed as major depression or manic by the doctor the day before, I would know that this diagnosis was incorrect.

Imagine my reaction when I recently learned that the major local psychiatric hospital in my area, which is a haven for manufacturing bipolar disorder diagnoses where none exist, was instructing its nursing staff on what and what not to include in its nursing notes. I thought I’d better take a look at them to see what was being included and what was not.

It was far worse than I thought. There were very few narrative nurses notes at all! The main part of the nurses' notes consist of  a checklist which basically completely omitted the type of information I was looking for.

I asked a patient about it. She told me that the nurses would line up all the patients on their ward at certain times of day, take their blood pressures and other vital signs, and ask them if they were suicidal or not. The patient told me that the nurses spent almost zero time observing them on the wards!

I really had to look at even the checklists very carefully to glean anything about how the patient was behaving. Another patient was diagnosed as bipolar, but even on the checklist, the patient's energy was marked normal, affect was marked appropriate, and mood was checked "euthymic" (normal). Bipolar, my ass.

There was also a separate sheet with observations allegedly made every 15 minutes, which of course was inconsistent with what my other patient told me about how often they were closely observed. The patient's behavior on the sheet was again not a narrative description but a number with each digit defined so generally as to be diagnostically meaningless.  Even then, this patient was noted to be sleeping throughout the entire night.

To be fair, there were some narrative notes scribbled on the back of these checklists, often written by a psychiatric technician and not a nurse. Many were illegible, and they contained fairly minimal information. Even so, an allegedly bipolar patient was described as "isolating to room frequently."  [How frequently? Why? In this case the patient later told me that there was a specific reason for going to her room that had nothing to do with a mood disorder], "Pleasant mood, appetite good," and "no distress noted." [Bipolar? Really??]

What is the hospital trying to hide? You can bet that somehow limiting the validity of the information on the patients' charts helps them to maximize their reimbursements from insurance companies - perhaps hiding the fact that they want their doctors to diagnose patients with something serious rather than something the insurance companies might question. Patient welfare be damned. 

Recent Psychiatric New Headlines of Relevance to This Blog

All the News That’s S**t  to Print

Keeping up with all of the new developments in psychiatry from multiple journals, as well as all of related recent sociopolitical events, has been made much more simple of late thanks to medical daily e-mail news services from Medscape (from WebMD), the American Psychiatric Association, and various other psychiatric publications. 

Often the headlines are more telling than the actual stories. Some of the headlines seem to blindly accept misleading conclusions of the type about which I blog frequently – although the publications do use the word “may” a lot so as not to imply that any conclusion is actually proven. Other stories clearly contradict these same very conclusions.

Here are some of the recent stories that touch on issues discussed and debated in this blog, organized by topic.  My comments are in italics.

Bipolar Disorder, My A**.

10/2/12.  Study: Screening For BD May Reveal Undiagnosed Anxiety Disorder. MedWire (10/2, Grasmo) reports, "Patients who receive a false-positive diagnosis during screening tests for bipolar disorder [BD] are likely to have an undiagnosed anxiety disorder," according to a study published in Dec. 1 issue of the Journal of Affective Disorders. For the study, "1534 patients attending the Black Dog Institute Depression Clinic completed the Mood Swings Questionnaire (MSQ)-46 and 852 also completed the Mood Disorders Questionnaire (MDQ)." Notably, "46% of MSQ-assigned false positives and 63% of MDQ-assigned false positives in the unipolar non-melancholic group had comorbid anxiety conditions."

Patients with obvious anxiety disorders who have been misdiagnosed as having bipolar disorder are beginning to show up in my office with alarming frequency, often having been placed on a whole stew of inappropriate medication. Also, the MDQ is one of those totally invalid symptom checklists.

2/15/2013.  Mania Symptoms Appear Similar For Kids, Teens. Medwire (2/15, Piper) reports, "The nature of mania symptoms appears to be similar in young people with bipolar disorder, irrespective of whether they occur in childhood or adolescence," according to a study published in the March issue of the Journal of Affective Disorders. The study authors did find, however, that "the only exception was the emergence of psychotic symptoms, including hallucinations and delusions, in adolescents with adolescent-onset of symptoms, but not in children with child-onset symptoms." The study also found that "mania symptomatology that was similar across 163 children with child-onset of symptoms (before 12 years of age), 94 adolescents with child-onset of symptoms, and 90 adolescents with adolescent-onset of symptoms (after 12 years of age) was characterized by 'activated/pleasure seeking' and 'labile and disorganized' behaviors."

Question: Isn't it a surprising coincidence that the one symptom that actually might establish a link between some active children and bipolar disorder – psychosis – is almost never found in children, while on the other hand, symptoms suggestive of acting out are prominent.  Answer:  No. 

Shoddy Psychiatric Care Practices 

12/13/12.  Older Americans Concerned About Mental Health Care They Receive, Survey Finds.  A survey released today of Americans aged 65 and older finds troubling gaps in the care these individuals receive for mental illnesses. Among the key findings are that 46% of seniors who are in treatment for a mental health problem said their provider did not follow up with them within a few weeks of their beginning treatment to see how they were doing and that 38% said that their provider had not discussed the possible side effects of prescribed medications. The findings are from a survey of more than 1,300 older adults conducted in November and published in a report by the John A. Hartford Foundation, which describes itself as "a committed champion of health care training, research, and service-system innovations that will ensure the well-being and vitality of older adults."  In addition, 33% of respondents said their provider failed to discuss treatment options, 40% said there was no discussion of how long treatment might last, and 34% said they were not told what steps to take if their condition seemed to worsen. The survey also asked survey participants about their knowledge of depression. Judging from the responses, considerably more education is needed, particularly regarding the links between depression and overall health. For example, only 34% were aware that depression is associated with a substantial risk of heart disease, a link that has been described in multiple studies and reported extensively.

The findings highlighted in red are indeed disturbing.  If your psychiatrist fails to do some or all of them, please run away as fast as you can, and find another psychiatrist immediately.

Cuts in Mental Health Services

 It’s amazing how some people keep wondering why there are so many more mentally ill people homeless on the street, and/or why they are crowding our jails.

12/26/12.  Studies: Number Of US Inpatient Psychiatric Beds Shrinking. The Denver Post (12/23, O'Connor) reported that a report published last February in the journal Emergency Physicians Monthly found a 60% decrease in the number of psychiatric beds available for inpatients in the US between the years 1970 and 2002. Bed counts at hospitals run by counties and states plummeted by 90%, the article said. A 2008 study [pdf] conducted by the American College of Emergency Physicians revealed that Colorado has only 11.8 inpatient psychiatric beds per 100,000 persons, which appears to be one of the worst rates in the US.

12/27/12.  Report: $4.35B Cut From State Mental Health Services Since 2009. The Huffington Post (12/27, Horowitz) reports, "In the past three years, $4.35 billion for services has been cut from state budgets across the country, according to a report by the National Association of State Mental Health Program Directors Research Institute." At the same time that "states are slashing funding for treatment, private care is getting harder to obtain. Mental health advocates say that the number of [practitioners] nationwide has decreased in recent years."

1/23/13. More Psychiatric Patients Forced To Wait In EDs Due To Cutbacks In Inpatient Beds. The Washington Post (1/23, Khazan) reports on an "increasingly common" problem for psychiatric patients nationwide, where mental health patients are "boarded" in hospital emergency departments "in part because of cutbacks in inpatient hospital beds." The Post explains, "As states trimmed their budgets in the economic downturn, resources for mental health patients were among the casualties." The piece notes, "For many patients suffering from psychiatric crises, this translates to longer waits in emergency departments, where they receive no treatment for days - and sometimes weeks - while social workers try to chase down open spots in psychiatric wards, doctors said."

ADHD

Here’s a bunch of evidence for the "safety" of amphetamine use - if they are legal, that is.  If they are illegal, they are very dangerous. Interesting, since they all do exactly the same thing.

1/10/12.   Psychotic Symptoms More Likely Among Meth Addicts. MedPage Today (1/10, Phend) reports, "Methamphetamine use makes hallucinations and other psychotic symptoms substantially more likely among addicts, particularly for those abusing other substances," according to a 278-patient study published online Jan. 9 in JAMA Psychiatry. "The odds of psychotic symptoms were 5.3-fold higher during periods of meth use (P<0.001)," researchers reported. "That risk was dose-dependent and further doubled by frequent marijuana or alcohol use," the study found.

2/4/13.  Addictive Potential Of AD/HD Medicines Examined. On its front page, the New York Times (2/3, A1, Schwarz, Subscription Publication) reported that medications like Adderall (amphetamine, dextroamphetamine mixed salts) "can markedly improve the lives of children and others with" attention-deficit/hyperactivity "disorder [AD/HD]. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers." Some doctors "skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects." While "very few people who misuse stimulants devolve into psychotic or suicidal addicts...AD/HD practices can fail patients, particularly young adults."

1/10/13.  Among Meth Addicts, MedPage Today (1/10, Phend) reports, "Methamphetamine use makes hallucinations and other psychotic symptoms substantially more likely among addicts, particularly for those abusing other substances," according to a 278-patient study published online Jan. 9 in JAMA Psychiatry. "The odds of psychotic symptoms were 5.3-fold higher during periods of meth use (P<0.001)," researchers reported. "That risk was dose-dependent and further doubled by frequent marijuana or alcohol use," the study found.

1/11/13.  Dose-Dependent Relationship Found Between Meth Use and Psychosis Symptoms.  There appears to be a large dose-dependent increase in the occurrence of psychotic symptoms during periods of methamphetamine use, according to a study published online in JAMA Psychiatry. Australian researchers found a 5-fold increase in the likelihood of psychotic symptoms during periods of methamphetamine use compared with periods of no use. The increase was strongly dose-dependent: individuals who had used methamphetamine 16 or more days in the prior month were significantly more likely to experience psychotic symptoms than those who had used the drug 15 days or less.  The researchers looked at 278 participants aged 16 or older who met DSM-IV criteria for methamphetamine dependence but did not meet DSM-IV criteria for lifetime schizophrenia or mania. The main outcome measures were clinically significant psychotic symptoms in the prior month, defined as a score of 4 or more on any of the brief psychiatric rating scale items of suspiciousness, hallucinations, or unusual thought content.  “Although psychotic symptoms appeared to be largely circumscribed to periods of methamphetamine use, the long-term effect of methamphetamine use on a person’s vulnerability to psychosis needs to be better understood,” the researchers said.  For more information about the mental health effects of methamphetamine see Psychiatric News here.

1/28/13. Report: AD/HD Medication-Related Emergency Room Visits Up Sharply. The Los Angeles Times (1/25, Healy) reported in its "Booster Shots" health blog that a study found that between 2005 and 2010, "ADHD medication-related emergency room visits have more than doubled - from 13,379 in 2005 to 31,244 in 2010," with the increase being "particularly pronounced in those over 18." The data was "reported Thursday in an issue of the DAWN (Drug Abuse Warning Network) Report, published by the Substance Abuse and Mental Health Services Administration, an office of the National Institutes of Health." About half of the "stimulant-related emergency department visits --15,585 in 2010 - were for 'non-medical' use of ADHD medication: They were to treat stimulant-related effects in patients who either had not been diagnosed with ADHD and prescribed the drugs or in patients who were not taking the medication as prescribed."  HealthDay (1/26, Preidt) adds SAMHSA administrator Pamela Hyde said in an agency news release, "ADHD medications, when properly prescribed and used, can be of enormous benefit to those suffering from ADHD, but like any other medication they can pose serious risks - particularly when they are misused." Cases for adults "rose from about 2,100 to 8,100 among those aged 18 to 25, from about 1,750 to 6,100 among those aged 26 to 34 and from roughly 2,500 to nearly 8,000 among those over 35, during the time period." The study found that the gap between males and females in the number of ER visits related to nonmedical use of ADHD drugs was narrowing. "In 2005, the numbers were about 3,800 for males and about 1,400 for females. In 2011, numbers reached 8,650 for males and about 6,900 for females." Medscape (1/26, Brauser) also covered the story.

2/8/13.  Maternal Depression, Domestic Violence May Raise Kids' Risk For AD/HD. HealthDay (2/8, Mann) reports, "Preschoolers whose parents report depression and intimate partner violence may be more likely to develop attention-deficit/hyperactivity disorder (AD/HD) by the age of six." Furthermore, "young children with depressed moms may be more likely to receive prescription drugs to treat behavioral and mental health issues down the road," according to a study published online Feb. 4 in the journal JAMA Pediatrics. The study "included more than 2,400 children who were three years old" and their parents who answered questionnaires regarding domestic violence and personal depression history.

So you mean some of the kids who are diagnosed with ADHD are in reality just reacting to chaotic families and not to video games? And they are not diseased?

2/12/13.  Violent Video Game Proliferation Has Not Coincided With Spikes In Youth Violent Crime. On the front of its Science Times section, the New York Times (2/12, D1, Carey, Subscription Publication) reports, "In surveys about 80 percent of high school-age boys say they play video games, most of which are thought to be violent, and perhaps a third to a half of those players have had a habit of 10 hours a week or more." The Times notes, however, that "the proliferation of violent video games has not coincided with spikes in youth violent crime." In fact, "the number of violent youth offenders fell by more than half between 1994 and 2010, to 224 per 100,000 population, according to government statistics, while video game sales have more than doubled since 1996." The article describes contradictory research into how media violence and video games may affect behavior.

1/31/12.  Non-Drug Treatments May Not Reduce Key Symptoms Of AD/HD. MedPage Today (1/31, Bankhead) reports that "nondrug treatments for attention deficit/hyperactivity disorder have limited evidence of efficacy and their use for core symptoms is not supported, a European guideline committee concluded." While "uncontrolled clinical evaluations produced positive results for a variety of dietary and psychological interventions," these "significant benefits disappeared in 'probably blinded' assessments, except for free fatty acid (FFA) supplementation and avoidance of artificial food color, according to" an article from the European ADHD Guideline Group published online January 30 in the American Journal of Psychiatry. MedPage Today adds, "Meta-analyses and systematic reviews have supported the efficacy of nonpharmacologic interventions in ADHD, but inclusion of nonrandomized trials and non-ADHD patients and outcome measures has complicated attempts to evaluate the interventions' effects on ADHD core symptoms, the committee members wrote."  HealthDay (1/31, Gray) reports that the "multinational team of experts" involved in the study "identified no positive effects from psychological treatments including mind exercises (cognitive training), neurofeedback and behavioral training (positive reinforcement). And the researchers discovered only small benefits associated with dietary treatments: supplementation with omega-3 and omega-6 free fatty acids, and elimination of artificial food coloring." HealthDay notes that "according to the American Psychiatric Association, between 3 percent and 7 percent of U.S. children have" ADHD. Medscape (1/31, Cassels) also covers the story.

Notice how exactly no non-drug treatments that  involve intervention with dysfunctional families, or even talk therapies, were included in this study. The psychological treatments they do mention are of course totally inadequate and off the mark, yet the authors broadly conclude that no non-drug treatments are likely to be effective. 

This is what we refer to in logic circles as a Straw Man Argument. It is probably also true that if the authors did  a similar studies on drug therapy, and the drug used was penicillin, that "drugs" would be shown to be ineffective as well.

***
And finally, of course as we all know there is no evidence of a push by big Pharma to increase the number of ADHD diagnoses dramatically.

1/22/13.  ADHD Diagnoses in California Health Plan Jump 24 Percent in 10 Years. Rates of diagnosis of ADHD among children in a large California health plan jumped 24 percent from 2001 to 2010, according to a report this week in JAMA-Pediatrics. In the study, researchers at Kaiser Permanente Southern California (KPSC) examined medical records for all children who received care at KPSC from January 2, 2001, through December 31, 2010. Records for 842,830 children were studied. The main outcome measure was incidence of physician-diagnosed ADHD in children aged 5 to 11.  The researchers found that rates of ADHD diagnosis were 2.5% in 2001 and 3.1% in 2010. They also found that the rate increased most among whites, followed by blacks and Hispanics, and that children living in high-income households were at increased risk of diagnosis compared with peers in lower-income households. The increase in ADHD diagnosis among blacks was largely driven by an increase in diagnoses among girls.  “The findings of this study suggest increasing trends in the clinical diagnosis of ADHD among children in the health plan,” the researchers said. “We also observed disproportionately high ADHD diagnosis rates among white children and notable increases in rates among black girls over time.”

Schizophrenia

Readers of this blog know that it can be extremely difficult determining which neuroscientific findings represent evidence of brain pathology and which do no. However, in the case of schizophrenia, the evidence of a miswired brain keeps on piling up. To me, this evidence is especially convincing since many findings - like oddly abnormal eye movements -  involve brain areas that have nothing to do with hallucinations, delusions, or other symptoms of the disorder, and therefore would not be better accounted for by normal environmental conditioning of brain pathways through neural plasticity. And many of these phenomena are found in patients who have never taken an antipsychotic medication. (As if it weren’t already blatantly obvious that schizophrenia is a real disease to anyone who has spent significant time working with patients over time in a state mental hospital). 

9/10/12.  Can a new eye test detect schizophrenia? A mathematical model that assesses eye movements known to be abnormal in individuals with schizophrenia appears to discriminate schizophrenia cases from controls with near-perfect accuracy. The lead scientist was philip benson, ph.d., of the university of aberdeen in scotland, and study findings were published in biological psychiatry. "this is a very interesting study," l. Elliot hong, m.d., a professor of psychiatry at the university of maryland and a schizophrenia expert, commented to psychiatric news. "[however] the important next steps are [determining] whether these measures are specific only to schizophrenia or whether they can also separate different psychiatric diagnoses...." benson agreed. "we already know that the model can distinguish cases diagnosed with bipolar disorder [from those diagnosed with schizophrenia] with around 95 percent accuracy. We have preliminary data suggesting that major depressive disorder can also be distinguished [from schizophrenia], which is a tremendously exciting finding."

10/12/12.  Meta-Analysis: Brain Volume Reduced In Patients With Schizophrenia. Medwire (10/12, Cowen) reports, "Medicated and antipsychotic-naïve [meaning that the patients have never taken these drugs] patients with schizophrenia show significant reductions in brain volume," according to a study published online Oct. 5 in the Schizophrenia Bulletin. "In a meta-analysis of data from 317 published studies," researchers "found that intracranial and total brain volumes were significantly reduced in schizophrenia patients compared with controls, after accounting for age, gender, duration of illness, and other variables."

12/13/12.  Small Study: Relatives Of Patients With Schizophrenia May Show Cortical Thinning. Medwire (12/13, Cowen) reports, "Patients with schizophrenia and their unaffected relatives show significant cortical thinning compared with mentally healthy individuals without such a family history," according to a study published in the journal Cerebral Cortex. Researchers arrived at that conclusion after having "used magnetic resonance imaging to assess cortical thickness in 25 patients with schizophrenia, 29 of their first-degree relatives, and 37 age-, gender-, and parental education-matched mentally healthy controls without a family history of schizophrenia."

Research Models

2/12/13.  Researchers: Mice May Be Poor Models For Studying Some Human Ailments. The New York Times (2/12, A19, Kolata, Subscription Publication) reports, "For decades, mice have been the species of choice in the study of human diseases." However, in a study published in the Proceedings of the National Academy of Sciences, "researchers report evidence that the mouse model has been totally misleading for at least three major killers - sepsis, burns and trauma." The study's "authors said" the findings "raise troubling questions about diseases like the ones in the study that involve the immune system, including cancer and heart disease."  Bloomberg News (2/12, Lopatto) reports that some "explanations for the discrepancy may be that the model mice are too inbred to be useful, or that the modeling doesn't reflect the illnesses experienced by trauma patients." Moreover, "the difference in recovery time between mice and people may play a role, and clinical care, such as drugs, surgery and life support, may further attenuate similarities."

Or it could be that rats do not have much capacity for reasoning. Rats who are turned into alcohol addicts, after all, never hide the bottles.

How Dysfunctional Families Spur Mental Disorders

2/14/13.  "Helicopter" Parents May Make Their College-Aged Kids Depressed. Reuters (2/14, Goldsmith) reports that according to a study published in Springer's Journal of Child and Family Studies, helicopter parents who overcontrol aspects of their university student children's lives may be causing the young people to become depressed. Researchers arrived at this conclusion after analyzing survey results taken from 297 undergraduates from US institutes of higher education.

What a shock!!