Avandia and Heart Attacks: Hold Your Horses
The report in today’s New England Journal of Medicine about an apparent association between Avandia (rosiglitazone) and heart attacks made the front page of USA Today.
While it is an important study, it is important that we don’t go overboard until we have a little more information.
There is a key principle that we have looked at before: one study is rarely enough to prove that a thing is so. The scientific method is based on the principle of falsifiability: now that this data has been published it is up to scientists and investigators to try and disprove the finding.
The analysis in the New England Journal suggests that the risk of a heart attack increases by 43% for patients taking rosiglitazone compared to control groups, and the risk of death by heart attack by 64%. This data comes from the so-called “A Diabetes Outcome Prevention Trial” (ADOPT). This is one of three studies on the topic. The Diabetes Reduction Assessment with Ramipiril and Rosiglitazone Medication (DREAM) study that involved over 5,000 patients was published in the Lancet last September. This study showed small increases in cardiovascular events compared to controls, which were not statistically significant. The other key finding of the DREAM study was that it reduced the risk of progression of pre-diabetes to type 2 diabetes by 62%. That is important because it may mean that we need much longer studies: diabetes increases the risk of heart disease year after year. ADOPT involved more than 4000 patients, with the only significant relevant finding an excess of congestive heart failure episodes for rosiglitazone-treated patients compared with people who received the older diabetic medicine, glyburide (22 compared with nine events).
So there may be a signal there, but before stopping the medicine, we need to remember that the numbers of patients who developed problems is small. Obviously big enough if you are one of them, but the risk is still not that high given the high rates of heart diseases in people with diabetes.
There is another study on the horizon: The Rosiglitazone Evaluated for Cardiac Outcomes and Regulation of Glycemia in Diabetes (RECORD) trial, which is a phase III trial specifically designed to analyze cardiovascular events connected to use of rosiglitazone. The study that hit the front page is a meta-analysis, and even the authors admitted that there were some weaknesses in it. Though it is a personal choice that people have to make with their clinicians, many experts think that we can wait for the results of the third study so that we can make some sensible decisions.
And for the record, I have no connections with the manufacturer of Avandia, GlaxoSmithKline.
An Important Change in the Warning on Antidepressant Medicines
If we could, we would only use natural medicines to treat depression.
Sadly it is not always possible to do that, and it doesn’t help when people with a demonstrable biochemical disturbance are told that their depression is all about internalized anger or an unwillingness to face some issue in their lives.
The trouble with those theories is that they often don’t take into account a tragic fact: depression can be fatal.
Not only because of the risk of suicide and other kinds of self-injury, but because depression is associated with many physical problems including chronic inflammation and carbohydrate intolerance.
Today the United States Food and Drug Administration (FDA) asked makers of all antidepressant drugs to change the existing "black box" labels on their products to warn about increased risk of suicidality (suicidal thinking and behavior) among young adults aged 18 to 24 in the first few weeks of treatment.
The FDA has also asked the pharmaceutical companies to revise the existing warning to show that there is no evidence that this risk exists for adults over 24, and furthermore, for those aged 65 and older the scientific data suggests the suicidality risk is decreased.
The American Psychiatric Association (APA) said this:
"The FDA’s new labeling acknowledges, for the first time, that untreated depression puts people at risk for suicide."
They said that studies showed that the old label issued in 2004 was associated with a steep drop in use of antidepressants and was followed by an increase in the rate of suicide "reversing a decade-long decline in suicide deaths in the United States".
The FDA said the emphasis on the new labels should be that depression and other serious psychiatric illnesses are themselves the most important causes of suicide.
Director of FDA’s Center for Drug Evaluation and Research, Dr Steven Galson said that:
"Today’s actions represent FDA’s commitment to a high level of post-marketing evaluation of drug products."
"Depression and other psychiatric disorders can have significant consequences if not appropriately treated. Antidepressant medications benefit many patients, but it is important that doctors and patients are aware of the risks."
The FDA recommends that people who are currently taking antidepressants should not stop taking them as a result of hearing this news.
The warning revision applies to all antidepressants and comes in the wake of controlled trials that showed a reasonably consistent risk of suicidality across most of the antidepressant drug categories. The FDA said that the evidence does not support excluding any antidepressant medication from this update request.
This update request follows the labeling changes made in 2005 to warn of increased suicidality in children and adolescents taking antidepressants.
Since then, the FDA undertook a comprehensive review of 295 drug trials examining the risk of suicidality among adults taking antidepressants.
The trials included over 77,000 adult patients with major depressive disorder (MDD) and other psychiatric conditions.
The results was that in December last year, the FDA’s Psychopharmacologic Drugs Advisory Committee said labels should be changed to tell doctors about the increased risk of suicidality among younger adults taking antidepressants.
The Committee also said the labels should remind doctors that the disorders themselves present the greater risk, and that among older adults the antidepressants do not carry the suicidality risk and have an apparent beneficial effect.
The FDA is preparing drafts of patient guides and wording for the labels. The manufacturers have 30 days to submit their own versions for FDA review.
The drugs affected include:
— Anafranil (clomipramine)
— Asendin (amoxapine)
— Aventyl (nortriptyline)
— Celexa (citalopram hydrobromide)
— Cymbalta (duloxetine)
— Desyrel (trazodone hydrochloride)
— Elavil (amitriptyline)
— Effexor (venlafaxine hydrochloride)
— Emsam (selegiline)
— Etrafon (perphenazine/amitriptyline)
— Lexapro (escitalopram hydrobromide)
— Limbitrol (chlordiazepoxide/amitriptyline)
— Ludiomil (maprotiline)
— Luvox (fluvoxamine maleate)
— Marplan (isocarboxazid)
— Nardil (phenelzine sulfate)
— Norpramin (desipramine hydrochloride)
— Pamelor (nortriptyline)
— Parnate (tranylcypromine sulfate)
— Paxil (paroxetine hydrochloride)
— Pexeva (paroxetine mesylate)
— Prozac (fluoxetine hydrochloride)
— Remeron (mirtazapine)
— Sarafem (fluoxetine hydrochloride)
— Seroquel (quetiapine)
— Sinequan (doxepin)
— Surmontil (trimipramine)
— Symbyax (olanzapine/fluoxetine)
— Tofranil (imipramine)
— Tofranil-PM (imipramine pamoate)
— Triavil (perphenazine/amitriptyline)
— Vivactil (protriptyline)
— Wellbutrin (bupropion hydrochloride)
— Zoloft (sertraline hydrochloride)
— Zyban (bupropion hydrochloride)
The APA said:
&
quot;We believe the new label, which still contains important warning information, reminds physicians and patients that antidepressants save lives. Physicians and patients need all the facts in order to make appropriate, informed decisions about any proposed course of treatment."
This change is not in any way an indictment of the medicines, it just acknowledges the reality that depression is dangerous.
Why is the risk apparently greater in younger people? It is thought that it has to do with the fact that the frontal lobes of the brain, that are involved in the control of emotions, have not yet fully formed.
House Supporting NAMI
Regular readers will know two things about me:
- I am a huge advocate for the mentally ill
- Last year I had to publish two denials after some mendacious individual posted the preposterous suggestion that the character of Gregory House in the wonderful TV show, was in some way based on me. To this day I don’t know where that idea came from, other than the fact that I have specialized in trying to crack diagnostic conundrums.
Take the two together, and I’d like to give credit where it’s due.
I was delighted to see that the entire cast and crew got together to support the National Alliance of the Mentally Ill (NAMI).
House has a well known expression, "Everyone lies." The the show’s producers and cast members, along with the slogan, will benefit the organization and its work in education, support, and advocacy for individuals and families affected by mental illness.
For a limited time, T-shirts from the show, emblazoned with the phrase "Everybody Lies," are being sold on-line.
The executive producer of house is Katie Jacobs, and she had this to say:
"Mental illness is stigmatized and misunderstood in our society, and we’re trying to do something about that. We’re very fortunate to be celebrating an extremely successful third season for HOUSE, and we’d like to give something back to a cause we feel is both worthy and overlooked."
The TV show, in the course of showing Dr. House attempting to diagnose illnesses with hallucinatory or psychotic symptoms, has helped educate the public about the medical nature of many psychiatric symptoms including mood and personality changes. These diagnoses have included herpes encephalitis, syphilis, hypercortisolism (Cushing’s), Wilson’s disease, hemochromatosis, and Korsakoff’s syndrome (vitamin B1 deficiency).
"Everybody Lies" conveys a message about stigma, false perceptions and misinformation about mental illness. In the TV show, the phrase represents that people who are being diagnosed with ANY illness often withhold information. In a time when it seems that Hollywood has been indifferent to, or even has propagated, stigma about mental illness, it is refreshing that the producers and cast of a TV show are helping to combat that.
NAMI executive director Mike Fitzpatrick says,
"On behalf of every individual and family who live with major depression, bipolar disorder, schizophrenia and other mental illnesses, NAMI thanks the show and cast. They are making a difference in people’s lives."
In addition to the sale of the T-shirts, an on-line auction is running for seven days (1 May 2007 through 7 May 2007) to sell five special autographed items. All proceeds go to NAMI.
Honey Bees, Blue Tits and Canaries
“If the bee disappeared off the surface of the globe, then man would only have four years of life left.”
–Albert Einstein (German-born American Physicist and, in 1921, Winner of the Nobel Prize in Physics, 1879-1955)
Anyone interested in Integrated Medicine should also be interested in trends that may have a major impact on our health and our potential to grow.
Over the last year the sparrow population of England has been declining, and now there is something new. In recent weeks there have been reports from bird watchers in Southern England that some species of birds have suddenly started become obese. The birds most affected seem to be blue tits. There is no suggestion about why it is happening, or what they are eating. Or whether something else in the environment is changing and causing the problem.
Second, British Government inspectors are investigating reports of unusually high numbers of honeybee deaths. Beekeepers all over Southern England are reporting that their hives have been decimated. This is a serious matter. Not just to the bees, but because bees pollinate fruit trees and other crops, the consequences for British farmers of a collapse in honey bee numbers could be devastating. The total contribution of bees to the British economy has been estimated at somewhere around 2 billion dollars.
No one yet understands the cause of these widespread honey bee colony deaths, and it is not just in the England: unexplained, severe colony losses with bees failing to return from their searches for pollen and nectar in Poland, Greece, Italy, Spain and Portugal.
But here in the United States the situation is even worse: Beekeepers in 25 US states have lost 50 to 90 per cent of their colonies to a mystery condition being called Colony Collapse Disorder (CCD) – in which bees suddenly abandon their hives and disappear to die. It is having a major effect on the mobile apiaries (Bee farms) that are transported across the US to
pollinate large-scale crops, such as oranges in Florida or almonds in
California. Some have lost up to 90 per cent of their bees.
The cause of CCD is unknown, but some of the suspects include pesticides, malnutrition, antibiotics, mites and increased solar radiation due to ozone thinning. There has also been a theory that it might have something to do with all those towers that support the cell phone network, or the introduction of genetically modified crops.
In the 1990s, honeybee populations were badly affected by the varroa mite – a parasite that makes colonies more vulnerable to viruses. Some experts believe the recent deaths could be caused by the parasite becoming resistant to drugs used against it.
Like most things in nature, animal populations go through regular cycles: there is a sophisticated mathematics that can be used to describe fluctuations in populations. But when we see several odd things at once, that don’t fit the mathematical models, it is time to ask the question whether the obese blue tits and the disappearance of sparrows and bees are a harbinger of further changes in our environment.
Are the bees and blue tits the “Canaries in the Coal Mine”?
Earth Day
Today is Earth Day. I am sure that everyone living on the planet is eager to keep it a decent place to live, and the recent flurry of gloomy reports has energized people in a way that I have not seen in decades.
Yes, there are plenty of nay sayers who point to the ice core date and say that there’s not a problem, but that band is shrinking as quickly as the Arctic Ice. Information from the Lake Vostok ice core analysis has provided data going back 420,000 years, during which there have been four temperature peaks before the current one, all comparable to today’s temperature levels. The causes for those peaks are poorly understood, but I am more and more persuaded that something profound is going on with the planet’s weather, and we really have only three choices:
- Prevent, which may be too late
- Adapt
- Mitigate
On April sixth, scientists and officials from more than 100 governments met in Brussels and agreed that Climate change is already under way and the Earth faces water shortages and famines in the poorest countries, plus huge floods and species extinctions if no action is taken to slow it down.
There was an unprecedented consensus on the mounting threat
posed by global warming, and the final report was unanimously approved, even by the United
States, China and Saudi Arabia. The officials from these countries had spent four days and
two nights challenging the more dire predictions line by line.
The
report by the Intergovernmental Panel on Climate Change (IPCC) warns that
global warming will hit hardest in the Arctic, sub-Saharan Africa, on
small islands and highly populated river deltas in Asia.
For example it predicts that 600 million more people could suffer from
droughts in Africa and billions will face risks from coastal flooding
by the end of this century.
And if that seems to far away to be of immediate concern, the report also makes a number of remarkably precise near-term predictions. The 21-page
“policymakers summary” of a full report to be published later this year,
charts the impact of temperature rise over the past 30 years and
calculates the implications of the rise of about 3 degrees Celsius by the end of this
century forecast by another IPCC panel in January.
Rajendra
Pachauri, the chairman of the panel, said: “It’s the poorest of the
poor in the world, and this includes poor people even in prosperous
societies, who are going to be the worst hit. This does become a global
responsibility in my view.”
Professor Martin Parry, who was co-chair of the panel’s working group on climate change
impacts, said evidence of changes already taking place that could be
attributable to human influence had been found in 29,000 sets of data.
He said, “For the first time we are not just arm-waving with models.”
Professor
Parry said actions to adapt to climate change, such as sea defences and
new forms of agriculture, should take priority over efforts to reduce
greenhouse gases, which would take years to have any impact. He went on to say,
“In the near term, adaptation is vital. The sooner we get on with that
the better.” Dr Pachauri revealed that the process had been a “complex
exercise”.
Many scientists objected to what they saw as an unprecedented level of
interference from government officials in arriving at what is meant to
be a scientific summary.
Professor Parry added that: “I don’t think it is the right thing to say the message was watered down.” Though he conceded that the scientific team made some compromises in their final report. As an example he revealed that a graph showing that billions would be at risk of coastal flooding by 2080 was changed to read “millions”.
Joseph
Alcamo, who is an American-born professor of environmental science and
engineering at the University of Kassel in Germany, said: “I question why
it needs to be such a difficult fight to get the science out there.
Scientists have to play a role we are not really trained for. It is a
dilemma for us.” Professor Alcamo chaired the working group studying changes
in Europe. He reproted that he had appeared on the podium to confront
skeptical governmental delegations at 2am, after some objected to his use of the term “unprecedented” to describe the heatwave in Europe in 2003 which claimed up to 35,000 lives.
For the first time, the scientists broke down their
predictions into regions, and forecast that climate change will affect
billions of people.
Africa will be hardest hit. By 2020, up to 250 million people are likely to be exposed to water shortages.
According to the report, in some countries, food production could fall by half.
North
America will experience more severe storms with human and economic
loss, and cultural and social disruptions. It can expect more
hurricanes, floods, droughts, heatwaves and wildfires, it said.
Northern Europe will at first experience some benefits, such as a
reduced demand for heating, but southern Europe will face more
heatwaves and drought, with a reduction in crop productivity.
Parts
of Asia are threatened with widespread flooding and avalanches from
melting Himalayan glaciers. Europe also will see its Alpine glaciers
disappear.
These were the Key Points from the report:
- There is clear evidence that from all continents that climate change is happening now
- The key “tipping points” are in the Arctic, small islands, sub-Saharan Africa and Asian “mega-deltas.”
- Coastal flooding threatens “bilions” of people in low-lying delta regions with high population growth
- In Asia, climate change could put close to 50 million people at risk of hunger by 2020, with that number rising to 132 million by 2050 and to 266 million by 2080
- By 2080, between 1.1 billion and 3.2 billion people
will face water shortages, and between 200 million and 600 million will
face extreme hunger. - Up to 30 per cent of animal species face displacement or extinction with average warming of 2 degrees C.
- If temperatures rise more than 3C, sea level rise threatens a third of coastal wetlands.
- Cereal productivity will drop globally with a rise of between 1 degree C and 2 degrees C – which could happen by 2050.
- Some impacts are already unavoidable due to past emissions
There remain some disagreements:
- The United States, China, Russia and Saudi Arabia objected to the
statement that there is “very high confidence” that climate change is
impacting on “many natural systems, on all continents and in some
oceans”. - The United States objected to the statement that North America could suffer “severe economic damage” from warming.
- The United States
led objections to the statement that European heatwave of 2003, which
killed more than 20,000, was “unprecedented” but was routed by
scientists. - Billions affected by sea level rise changed in some places to millions.
- One
illustration full of specific numbers – that up to 600 million more
people in Africa were having difficulty finding water, and that 5,000
more heat-related deaths in Australia followed a 2 degree C temperature rise –
was dropped after skeptical governments, including the United States, objected.
The publication of this report coincided with another published in the journal Current Biology
showing that more than half of the tropical coral reefs in the world are being degraded beyond repair. And 30 million people depend entirely on coral reefs for their income and for their food
This report also address the effects of climate change on disease and the threat that it will provoke wars over scarce resources. Those may be dealt with in more detail later in the year.
You may be interested to look at a projected timeline for some of these likely changes.
Despite these gloomy predictions, there is some cause for optimism: even if some were dragged in kicking and screaming, this is the first time that so many countries have agreed about ANYTHING. And secondly, the imminence of these changes hsould stimulate not just conservation and technological innovation, but a greater understanding that we cannot continue to live as we have done in the past: the planet is a great deal more fragile than our economies.
Sage Words about Violence and Mental Illness
One of the blogs that I highlight down of the left-hand side of this one is attached to schizophrenia.com.
They have a particularly good entry for April 20th, that discusses not just the tragedy in Virginia and its possible relationship to mental illness, but also some broader social questions. Having been born and raised in the UK, and then worked there and in the United States in both medicine and psychiatry I can really relate to many of the points made in the article. It really should be disseminated as widely as possible, so I am going to do something that I usually do not, and quote the article in full:
The Loss of Life in Virginia, and How it Could Have Been Prevented
Read more… Schizophrenia, Poverty & CrimeWhenever a tragedy happens such as the recent shootings in Virginia,
the question inevitably turns to why did it happen, and how could it
have been prevented.While some reports (such as here, here and here)
have suggested the shooter in this tragedy – Cho Seung Hui – might have
suffered from psychotic depression, schizophrenia or bipolar disorder –
its impossible to know with the limited amount of evidence available,
and even after all the evidence is reviewed it will never be known for
sure.From what has been reported it does, however, seem obvious that he
was seriously depressed and socially withdrawn, and had some
significant delusions of persecution and paranoia. Whether these
symptoms add up to a serious mental illness or some type of sociopathic
disorder is unknown. Some factors don’t seem to point towards
schizophrenia – as Cho Seung Hui did not seem to suffer from the lack
of motivation (called avolition) that is so common with schizophrenia.
He was able to attend college and, from the sounds of things, was
attending classes regularly and finishing his assignments. Typically
when a person develops schizophrenia schoolwork and personal hygiene
the first thing that suffers, and an inability to complete schoolwork
is common.With regard to the question of why did it happen – it is of course
impossible to know for sure. But at the same time research into mental
illness and brain disorders does point to some possible answers.The path towards mental illness (any mental illness) is a complex
one with many different factors – from genetic predisposition and
pregnancy factors, to early life stresses and environmental factors, to
social stresses. We have more information on this in our “Preventing Schizophrenia”
– but fundamentally the factors that nudge people towards mental
illness are many and varied. The factors that have been conveyed about
the life of Cho Seung Hui suggest that early life experiences could
have been factors. Here are some of the relevant points that have been
discussed in the news:1. A Difficult Early Life – news on the family has suggested that
they had a difficult (low-income) family life in Korea which prompted
the move to the US when the parents had a young family. A low income
life that motivates a young family to leave a country – is likely to be
a high stress environment – a factor that could contribute to mental illness.2. Social stresses of immigration to the US (many studies out of the
UK have indicated that immigrants frequently face extremely difficult
social challenges in new countries due to a lack of understanding of
social norms (as well as racism) – which causes a great deal of social stress and significantly higher rates of mental illness.3. Cho Seung Hui’s Father worked in a Dry Cleaning company – and the family may have been exposed to higher levels of dry cleaning chemicals – which are linked to neurological damage.
Additionally, on a related topic, Dr. Michael Merzenich, the Neuroscientist at UCSF – comments in his blog
on the important issues related to the general social environment that
is also a factor in the extremely high levels of gun violence and
deaths in America – typically 300% to 600% higher than in other
developed countries:“Our jurisprudence is based on
the principle of “blame” for behaviors that should by hypothetically
controlled by our “free will”. Alas, human observers and psychologists
(and with increasing clarity, we brain scientists) have understood from
the beginning of time that your or my “will” is not entirely “free”.
The boundaries of “good judgment” are defined by a combination of the
inherited factors governing our brain function, by our physical brain
status (2 million head injuries/annum in the US alone!), and the
brain’s own plasticity-embedded experiences. For most of us, our
genetics combined with fortuitously not busting our skull in the wrong
place and with our particular plastic, experientially-driven brain
‘history’ adequately protects us from serious transgression. At the
same time, in our (and other) contemporary society(ies), we tolerate
conditions that result in millions of young men and women being reared
with an experiential history that is NOT adequate to keep THEM safe
from offending. THIS IS THE PART OF THE EQUATION THAT IS UNDER OUR
(SOCIETY’S) CONTROL. We’re doing a bad job with it. In fact:
1) We live in a violent society chock full of models of behavior (a
violence & fear-obsessed media, violent films, gangsta rap, et
alia) that are well outside any rational societal norms. The mass
murder of children on school campuses is one our MANY rather
spectacular modern American-violence inventions with little historical
precedent.2) We tolerate the hardening of young brains to
otherwise-not-tolerable bloody, shoot-em-/slash-em-up violence as an
acceptable source of intensive training “fun” in the heavily-rewarded
game-play of millions of our children. All that intensive training is
somehow supposed to be just fine for the child and their brain?! Those
tens or hundreds of thousands of violent repetitions in rewarded
behaviors just don’t matter a whit? Stuff and utter nonsense.3) We continue, collectively, to find innumerable ways to shame
children in their young lives as “failures”, “weaklings”, “misfits” or
“oddballs” in school and in life.4) We send juveniles and young adults off to crime school (prison) at an extraordinarily high (and growing) rate.
Sometimes I think that we could hardly be doing a better job of
training young people to misbehave. When they do, we hold them to a
universal high standard of acceptable behavior that they may actually
have had little experience with, in their own path through life, in our
very own society.”Lastly – there is the issue of easy access to guns in the US – which
when combined with all the above factors makes for an extremely toxic
mixture. Easy access to guns results in high death rates in shootings;
death rates that are typically 500% to 1,000% higher in the US than in
other civilized countries, as can be seen in the diagram below.National Comparisons for Selected Countries Homicide Rates Per 100,000 Population
Source: Corrections Service CanadaAs New Scientist Magazine notes
“Scientific studies have demonstrated over and over that owning a gun
makes it significantly more likely that you will be shot. The US has
the highest rate of firearms-related homicide in the industrialized
world – Americans are literally sacrificing hundreds of innocent
citizens each year upon the altar of the Second Amendment.”Are any of these factors preventable? Yes – of course they are – but
the actions are costly and complex. To prevent these types of tragedies
takes:1. Better education of the public about how to achieve mental health for their children,
2. Early and easy treatment for mental disorders with early testing and screening in schools,
3. Good insurance coverage
so that people can actually get their mental health problems addressed.
The US is the only developed country in the world that severely limits
coverage of mental health problems. Better and easier access to high
quality mental health treatments is a great need in the US.
4. Laws that make it possible for mentally ill people to get treatment, even though they may not understand the need.
5. A reduction in the culture of violence in the US (a movement to reduce violence in movies, on TV, and in video games). Read: In denial about on-screen violence for more information.
6. Strict gun controls
that take the millions of hand guns off US streets, and that will make
it more difficult for the people who become mentally ill or who have
psychiatric disorders – to obtain guns. Approximately 29,000 US
citizens are killed by their fellow citizens each year, by hand guns.
(see Statistics, Gun Control Issues, and Safety for more information)The answers are relatively clear – but whether we actually do anything about it is up to you.
Related Reading:
Mental Health, the Law and Predicting Violence (NPR)
America’s tragedy – Its politicians are still running away from a debate about guns (The Economist)
Mayors urge Bush to tighten gun control laws
Stricter gun control after shootings at U.S. university – not going anywhere fast
Relationship of US gun culture to violence ill-understood
Violence may be a ‘socially infectious disease’
Schizophrenia, Psychosis and Psychopathy
Ever since the tragedy in Virginia earlier this week, everyone has been trying to second guess what happened. As I said, to the trained eye there is a lot to suggest that he had a psychotic condition, but whether it was schizophrenia, bipolar disorder or psychotic depression is guess work.
One of the things that has been worrying in all the media coverage has not only been the sensationalism that we have seen in some quarters, but the mistakes that reporters – and even some of the "experts" – have made in talking about mental illness. I have heard people constantly mixing up schizophrenia and psychopathy, which is more accurately called antisocial personality disorder. I have even heard an old mistake that I had thought died years ago: that schizophrenia is a "split personality." I think that mistake probably goes back to a misunderstanding of the roots of the term "schizophrenia," and it was perpetuated by Alfred Hitchcock’s movie Psycho in 1960.
Let me just repeat: schizophrenia is NOT a split personality. Neither is it multiple personality disorder. There is even a lot of discussion whether multiple personality disorder, now known as "Dissociative identity disorder" really exists: a discussion for another day.
Because there has been so much confusion, I thought that it would be good to clarify what each of these disorders is.
You can get some of the information from Wikipedia. What has worried me a bit is that some websites have slightly questionable infrmation. Many people know that I do a great deal of advocacy work for the mentally ill, so these notes are from my own lectures.
For reliable back up information, I recommend using Healia.com to search, and you can check out at Wikipedia, Schizophrenia.com, the National Institute of Mental Health website, Medline Plus and the National Alliance for the Mentally Ill.
Psychosis
Psychosis is simply a generic term for a mental illness in which people have a "loss of contact with reality." There are often other symptoms, such as hallucinations, delusional beliefs, disorganized thinking and a lack of insight into the unusual or bizarre nature of his or her behavior. Almost anything that stresses the nervous system enough may lead to psychosis. I have often told students that it is possible to induce psychosis in just about anyone. It is a symptom and not a disease. We sometimes call it the "fever of the nervous system."
Schizophrenia
This is a group of illnesses that describe a mental disorder characterized by impairments in people’s perception or expression of reality
and by significant social or occupational dysfunction. The point is that other people don’t share their view of reality and it is causing suffering. There is always some smart Alec student who says, "But isn’t religion a delusion?" The answer is no, of course it isn’t. Millions of people share the same beliefs. The second piece is also important: is it causing suffering, distress or disability? Many people have ideas that are "different." That does not mean that they are mentally ill. Professionals should not get involved unless the beliefs are causing a problem.
A person
experiencing schizophrenia typically has disorganized thinking, and may experience delusions or hallucinations. In Western cultures these are most commonly auditory hallucinations. Simply having hallucinations does NOT mean that someone is mentally ill. I seem to be one of the few psychiatrists that supports the aims of the Hearing Voices Network. The Network tries to help people who are experiencing hallucinations and to educate the public and professionals that there are many possible reasons for hearing voices and many have nothing to do with mental illness.
One of the most disabling things about the schizophrenic group of illnesses is that they primarily affect cognition, and that is one of the things that can lead to chronic problems with behavior and emotion. For a long time there was a worry that the cognitive problems were a result of being on some of the older medications. But these cognitive problems were identified decades before the introduction of these medicines. Hence the old name of schizophreia: dementia praecox.
The diagnosis is based on self-report and observation. We do not have a laboratory test for these illnesses, but we are finding reproducible changes in the brain and in many genes. The main evidence for the illnesses is still based on their response to treatment.
There has been a lot of discussion about whether we should abandon the term "schizophrenias," since the current diagnostic approach is flawed: many people have psychotic experiences without becoming dsitressed or disabled. Neither can they – or should they – be diagnosed. This gets back to the categorical and dimensional argument that I have talked about before. The second point is that the label "schizophrenia" can be so stigmatizing.
Antisocial Personality Disorder
Antisocial personaity disorder is also referred to as psychopathy, sociopathy or dyssocial personality disorder. It is a condition characterized by lack of empathy or conscience, and poor impulse control or manipulative behaviors. The term originally came from the Greek psyche (meaning soul, breath or mind) and pathos (to suffer). At one time the term was used to describe all mental illness, and that is why there is confusion. It is quite different from psychosis. Psychosis is a chronic or intermittent symptom that comes on at some time in life. Antisocial personality disorder should have been present all the time, even though we cannot formally diagnose it until the age of eighteen. The term "psychopath" is not a good one: it has no precise equivalent in either the DSM-IV-TR or the ICD-10.
Only a minority of diagnosable psychopaths are violent offenders . There has been a lot of discussion about whether the manipulative skills of some of the non-violent psychopaths are valuable in corporate America, the military and academia, because they may bold and often charismatic leaders. The has even been a suggestion that becoming a "psychopath" may be an adaptation to working in a highly competitive
environment: it gets results for both the individual and for their
corporations or countries.
There is a recent book – Snakes in Suits – that does a good job of exploring these ideas.
In summary:
Psychosis = A symptom
Schizophrenia = A group of acute or chronic illnesses in which psychosis is a central feature
Antisocial Personality Disorder = a.k.a. "Psychopathy:" life long personality trait
The Tech Tragedy and the Mind
I have had a great many questions about the psychiatric aspects of the terrible tragedy at Virginia Tech.
Many friends and colleagues have swung into action to help with the oceans of grief and the inevitable post-traumatic stress disorder that will follow for many people.
The other questions have all been about the alleged gunman. Perhaps we can now stop saying "alleged."
I mentioned yesterday that the videos and "manifesto" might help us make some sense of the senseless.
What they show is incredible anger that had been building up and, until Monday, had no outlet. That kind of internalized anger can be very dangerous and is sometimes hard to pick up. Experts will often do some very careful "button pushing" to reveal what is going on inside. If a person is challenged, then the anger, disorganization and psychosis can all erupt. But it is a difficult technique unless you are a real expert.
A lot of what he says is disjointed and at times difficult to hear because he whispers and then becomes more and more angry. As expected there is some clear evidence of what we call "thought disorder" or "communication disorder."
You do not need to be a psychiatrist to see that the videos and the "manifesto" were the products of a very sick young person, and that the sickness lead to the tragedy.
Many commentators have asked questions along the lines of, "If he was so angry against the rich, why didn’t he attack the rich?" That would be a good question except for one thing: psychotic delusions are usually "Un-understandable."
This clumsy term was introduced by the German psychiatrist and philosopher Karl Jaspers, since he believed that they were not produced by any kind of coherent thinking. Though not everyone agrees with this idea, it captures something important: it can sometimes be exceedingly difficult to understand the thought processes of the person in the depths of a delusion. We still try to understand their thinking, but it can be tough: some of the normal rules of logic do not apply. And one of the keys to delusions is that people hold them even when presented with evidence that their beliefs are wrong. It is totally different from people who hold odd or eccentric beliefs, but are happy to modify them as more evidence some along.
I am about to give a lecture to a large group of young doctors, and I have been told to expect a lot of questions about what they should do if they ever come across someone like this young man.
Answer: with hindsight the diagnosis seems clear; nobody can diagnose everyone every time. But trust you instincts, get another professional to have a look at the person and above all a it safe.
The Accelerating Open Access Revolution
It is only a couple of days since I last wrote something on the revolution in open access to information, but here are two new things that I need to share with you.
First, today saw the launch of the journal Open Medicine.
These are a couple of extracts from James Maskalyk’s editorial in the inaugural issue:
…To attain their true worth, medical journals need to place the knowledge on their pages into as many capable hands as possible. In the past, this opportunity was limited mainly to those with a university library close by. Now, because of the Internet, one simply needs to be near a telephone line. The capacity of medical journals to disseminate knowledge has never been greater…
Unfortunately, physicians attempting to answer a clinical question are faced with two unappealing options: to navigate a sea of unedited pages of varying quality, or to pay for access to more carefully reviewed scholarly information. It seems an anathema to the spirit of medical research that, largely for economic reasons, the information it produces remains hidden from many potential users. Access is limited not only for health professionals in poorer countries, but also for health care providers in wealthy countries (most of whom do not have "free" access to information unless they work in universities), and for patients, who deserve the opportunity to become informed about research that affects their lives. The transformation of research findings and discussion of the results — the application of knowledge — is curtailed. Just as importantly, the debate over its merit is stifled before it can properly begin….
Medical knowledge should be public and free from undeclared influence. When possible, it should be free for those who apply it. Since people’s lives depend on it, that knowledge must be filtered several times before it is ready to use. Studies need to be peer reviewed, to have their statistics analyzed, their content edited, then copy edited, then published quickly for as wide an audience as possible. The prospect of having a high-quality source of information that held true to these principles but was also free and globally accessible was impossible to imagine 20 years ago….
The second thing is something very helpful on Peter Suber’s excellent blog:
OA podcasts from non-OA journals
Charles W. Bailey Jr. has collected some links for journals offering OA podcasts.
In
a recent SSP-L message, Mark Johnson, Journal Manager of HighWire
Press, identified three journals that offer podcasts or digital audio
files:Here are a few others:
Reconstructing a Troubled Mind After Virginia Tech
There’s going to be a lot of discussion and speculation about the tragic events at Virginia Tech.
Ten years ago I became very involved with the media after a tragic shooting at the Capitol building by a man suffering from mental illness, and so I know the questions and the second guessing that will go on.
I have, of course, not examined the alleged perpetrator of the events on Monday, but I have received a great many questions about what I think may have been wrong with him.
I did not want to answer until I had put together as much material as I could.
From the reports that I have received we can begin to construct a very plausible scenario.
The first thing to say is that it is very unusual for people with mental illness to commit major violent crimes.
Second is that many of the most horrendous serial killers have not had a psychiatric disorder at all. That may sound odd: how could someone do something awful and not be sick? Some people do bad thing because they are bad. Not because they are suffering from an illness.
Third, it is always easy to be wise after the event. Sometimes when people are mentally ill the illness itself stops them from communicating, especially to health care providers. Many people have admitted to me that they were hearing voices telling them to say nothing to me or to deny their existence. That is why we always watch to see if people may be attending to auditory hallucinations, or if they are preoccupied by internal stimuli.
Many years ago I knew a man who was obviously ill but would reveal nothing. Without tangible evidence of mental illness the courts told him to go on his way. The experience and gut instinct of one of the world’s top psychiatrists counted for little in the eyes of the court: they wanted evidence.
So the man left and immediately threw himself under a train. It was only later that his family found his writings and drawings about his fear that a demon was pursuing him. The poor man had been hallucinating and delusional all along. There are many ways of telling the difference between someone having evil experiences and someone with a mental illness: there are many people who specialize in such things.
I have been looking at the reports in the media that agree on certain points, and I am going to pick out the ones that really jump out at me as a professional.
- “He sat right beside the door, and as soon as class was over, he left."
- “On the first day, when the instructor asked students to write their names on a sheet of paper and hand it up, Cho wrote a question mark.”
- “Always wore a hat and sunglasses.”
- "He never looked up.”
- “He never looked anyone in the eye. If you even say hi, he’d keep walking straight past you."
- “He often spoke in a whisper, if at all.”
- "He would keep his headphones on a lot."
- "It was like he was carrying on a conversation with himself."
- “Nobody knows him really, he’s always quiet. When I talk to him, there’s no response."
- “The teacher had addressed a question to him and he really just stared off into space. He didn’t even recall acknowledging that she was talking to him.”
- “He disappeared from class.”
- “Taking secret pictures of his classmates.”
- “A loner.”
- “Angry, menacing, disturbed and so depressed that he seemed near tears.”
- “Rambling multi-page "manifesto" directed against the rich, the spoiled and the world in general.”
- On the day of the tragedy, “Cho’s face was blank and expressionless. There was always just one look on his face.”
- And in 2005 he was declared mentally ill and said to “present an imminent danger to himself as a result of mental illness."
We do not yet know what diagnosis and treatment were offered, but he does not seem to have followed up. As with the man who jumped in front of a train, people with persecutory delusions can be very good at concealing them.
If we look back over these items, it is likely that he sat by the door so that he could escape from some perceived threat; he probably had real questions about who he was; the hat and sunglasses are commonly worn for “protection” and the avoidance of eye contact is usually because people are preoccupied by things going on inside their heads, or because they fear that you can see through their eyes. Many people who are experiencing auditory hallucinations use portable music systems to drown out the voices: I have known more than one person who has had hearing damage from cranking up the volume. He probably was carrying on a conversation with the voices in his head. The avoidance and staring into space are usually signs of being preoccupied with internal experiences. The pictures would have been used to fuel his paranoia. The blank, expressionless face is a classic feature of one of the schizophrenic illnesses as is the social isolation. We would have to see the “rambling manifesto” to be sure, but the “rambling” could be a sign of what is known as “thought disorder” or “communication disorder.”
Several previous killers have been found to have different forms of brain disease. Taken together these clinical features are most likely the signs of a major psychiatric illness rather than something like a brain tumor.
The other thing of importance is that at least one person said that he seemed to be “mean,” so there may have been more than just a psychiatric or neurological illness going on.
Time will tell, and this is so far all informed guesswork. But at this point it makes some sense of this tragedy.
There will inevitably be a lot of speculation about what could or should have been done. But there is an extra factor that needs to be considered: the law is designed to allow people’s freedom. I have been in mental health courts on countless occasions and it is rare for a person to be committed for involuntary treatment unless there is really compelling evidence of a person being a danger to themselves or someone else.
Many people will feel that they should have noticed the signs of mental illness. Well hindsight is always 20/20 and I can tell you that the greatest experts have sometimes been fooled. If I, or one of my colleagues had, by some strange chance, run into this young man, would we have been able to diagnose him? As with my patient all those years ago, I would have been pretty sure, but I couldn’t prove it. And without that proof it is very hard to take any action.
Let me finish by saying again that the vast majority of people struggling with mental illness are not dangerous. The job of professionals is to find the ones who are, and to this day we have no reliable way of doing it.
