Over-Medicating America
There is an important study in this month’s issue of the Annals of Family Medicine It concerns something that most health care professional in the United States have been worried about for some time: it is direct-to-consumer advertising of prescription medicines. I rarely watch much television, but out of interest I had one channel on for an hour this morning and saw six advertisements for medicines. It is not widely known that this practice is illegal in most of the rest of the world, with the exception of New Zealand.
The research suggests that this direct-to-consumer television advertising of prescription drugs may be influencing Americans to believe that they are sicker than they really are. This may in turn lead to taking more medication than they actually need.
The study was funded by the National Cancer Institute’s Centers of Excellence in Cancer Communication Research and the Robert Wood Johnson Foundation, and was led by Dominick Frosch from the David Geffen School of Medicine at the University of California, Los Angeles.
The researchers evaluated the educational value of 38 direct-to-consumer television advertisements for prescription drugs and analyzed how they tried to influence viewers. The drugs in question were for treating illnesses ranging insomnia and depression to high cholesterol and high blood pressure.
Their findings suggest that the advertisements had virtually no educational value. Furthermore they failed to describe who is most at risk for which illnesses, what their symptoms might be, and whether non-medicinal alternatives such as lifestyle changes might also be viable options.
According to the figures cited, Americans watch up to 16 hours of television advertising about prescription drugs per week. The scientists watched the advertisements shown during the evening news and prime time periods. They used a coding system that takes into account a number of attributes of each ad. The attributes included the factual claims made about the illness the drug is aimed at, the method used to attract the consumer, and also what is revealed about the behavior and lifestyle of the people in the advertisement.
Although they found that over 80% of the advertisements did make some factual claims and put forward rational arguments for use of the drugs, only 25-26 per cent of them described symptoms and causes of illnesses, the associated risk factors and how common or rare they are.
The scientists also found some common strategies: many of the advertisements portrayed the drugs in terms of people losing control over their lives (58%) and then regaining it (85%) once they took the medication. 78% of the ads also portrayed the medication as engendering social approval, while 58% of them implied that the drug was a medical breakthrough.
The findings also show that nearly all advertisements (95%) used emotional appeal to influence viewers and none of them showed lifestyle and behavior change as viable alternatives, except for 19% of them that showed this as an adjunct to taking the drug. 18% of the advertisements suggested that changes to lifestyle would not be enough to deal with the illness.
The conclusion of the study is that despite the claims that television advertisements play an educational role, they contain limited information about causes and symptoms of their target illnesses, their prevalence and risk factors. They also show people that have “lost control over their social, emotional or physical lives without the medication; and they minimize the value of health promotion through lifestyle changes. The ads have limited educational value and may oversell the benefits of drugs in ways that might conflict with promoting population health.”
Dr Frosch said that “We’re seeing a dramatization of
health problems that many people used to manage without prescription
drugs,” and that the “ads send the message that you need drugs to
manage these problems and that without medication your life will be
less enjoyable, more painful and maybe even out of control.” He said
that the US should consider banning direct to consumer television
advertising of prescription drugs too. Something that was echoed in the
accompanying editorials.
I have spent a great deal of time weighing the pros and cons of direct-to-patient advertising with health care professionals and people in the pharmaceutical industry in Europe, the United States and Australia and New Zealand. Despite all of our work to empower people, I remain unconvinced that they are ultimately in peoples’ best interests.
Toxoplasmosis and Behavior
Last August I wrote an article about some extraordinary new evidence implicating Toxoplasma gondii in some psychological and psychiatric illnesses. Latent infection with
Toxoplasma gondii is amongst the most prevalent of human infections and it
had been generally assumed that it is asymptomatic unless there is
congenital transmission or reactivation because a person has an immune system that has become depressed or compromised. That assumption is being completely re-evaluated.
The article generated some extremely interesting correspondence and some spirited discussions.
Here is a very insightful letter from a physician:
Dear Dr. Petty,
I thought about the concept of psychological illness caused by a virus or other organism. I was wondering what would be the mode of dispersion of such a virus. Upper respiratory tract infections, skin and gastrointestinal infections spread by cough, by touch and hand to mouth respectively. How would such a brain virus or protozoal organism promote itself? Of course it could be by the above methods but it seems that there should some way that the specific disease process is connected to a behavior that helps it to spread itself.
Then I got to thinking; diseases have learned physical ways to disseminate themselves, I wonder if a disease could change behavior to promote it’s own dissemination and survival? I imagine that if that were true, people with the flu would be sociable, people with infectious diarrhea would be sociable and hungry, people with AIDS would have increased libido. I haven’t yet seen any data for this. Although I’ve always felt that there was one disease that did alter behavior in a way that is conducive to disseminating itself, and that is rabies. The host goes from being docile, to seeing all others as the enemy. He then attacks them, bites them and thus passes on the organism. A true mind altering virus, although it’s psychology works better with animals than with people. Do you think that there are other diseases that spread purely by behavior, that cause the host to seek out the next host and not just pass the disease from one to another just due to proximity?
This was my response:
What great questions!
And believe it or not, there’s quite a lot of empirical research on these very topics.
There is a whole textbook on the behavioral effects of parasites edited by Janice Moore entitled Parasites and the Behavior of Animals. Here’s an interesting one: rats and mice are hard wired to avoid cats. Millions of years of programming have ensured that Tom’s very presence would send Jerry packing. Cats carry Toxoplasma gondii and if mice or rats become infected with it, usually by eating cat poop, they lose their fear of felines. So now Tom can have lunch at his leisure.
I’ve also talked about the way in which people with creativity and schizotypal personality disorder (i.e. carriers of genetic risk) tend to be promiscuous, while people with schizophrenia have fewer children. Both groups tend to get more sexually transmitted diseases than the general population. It would be tempting to think that toxoplasmosis can be spread that way, however there’s a 32-year old study in German that showed that Toxoplasma was not transmitted by intercourse. However, cytomegalovirus, a common partner to Toxoplasma may be. And both modulate dopamine activity in the regions of the brain involved in salience.
I have done a very detailed literature search encompassing papers written in all the languages that I can read, and have not been able to find any clear evidence of behavior change induced by HIV, influenza or infectious diarrhea: what interesting and important questions to research.
We do have some more data confirming the effects of Toxoplasma infections on the behavior of rats: they become less anxious and therefore do not respond to environmental threats as quickly as uninfected rodents. An antipsychotic medication (haloperidol), a mood stabilizer (valproic acid) and two chemotherapeutic agents – pyrimethamine or Dapsone – have all been shown to prevent the development of Toxoplasma-induced behavioral change.
Another recent study from the Departments of Parasitology, Microbiology and Zoology, Charles University, the Centre of Reproductive Medicine and GynCentrum, in the Czech Republic also speaks to the significance of latent Toxoplasma infections: the presence of the parasite in the blood of pregnant women increases their chance of giving birth to boys. The increased survival of male embryos in infected women may be explained by Toxoplasmosis infections modulating and suppressing the immune system.
If Toxoplasma plays a part in the development of some psychiatric illnesses, yet a high proportion of the population carries it without any problems, one obvious question is what activates it? Environmental stress might, perhaps, cause the Toxoplasma to become reactivated and play a part in the development of specific psychiatric symptoms.
This story is continuing to develop and I am going to watch it closely. If it is confirmed, it could open up some brand new avenues for helping treat and perhaps even prevent some types of psychiatric illness.
Mystical Experience
I recently wrote a little bit about mystical experiences and mentioned the most widely used “definition,” the Stace Criteria:
- Deeply positive mood
- Experience of Union
- Ineffable sense
- Enhanced sense of meaning, authenticity and reality
- Altered space and time perception/transcendence
- Acceptance of normally contradictory propositions
There are many ways of inducing the mystical state: –
- Meditation
- Prayer
- Control of breathing: e.g. Pranayama
- Chanting: e.g. Zoroastrian priests
- Dance and movement: for example the whirling Dervishes or Morihei Ueshiba who reportedly achieved a state of mystical union after performing kata
- Light, as happened with the mystic Jacob Boehme
- Biofeedback
- Mantra
- Drugs
Although many people deliberately seek mystical experiences, some come out of a clear blue sky: the French writer, philosopher and Marxist materialist, Simone Weil, reported how reciting a devotional-metaphysical poem by the English religious poet George Herbert (1593-1633) while highly concentrated and emotional, turned her from an agnostic into a mystic. She was not looking for it to happen: it was unsought as it was unexpected. What was interesting was that after that first time, particularly in the last year of her life, she had mystical insights several times a week. Despite – or perhaps because – she was suffering from tuberculosis and was first in a hospital and then in a sanatorium during most of that time.
Some children have had a mystical glimpse before the age of ten, more during adolescence and still more during their thirties or forties. Richard Maurice Bucke in his classic book, Cosmic Consciousness, thought that the peak time was in the early thirties, but it can still happen in people in their seventies.
Many people need a dramatic shock – some form of enforced awakening – that subjugates the ego. Only then do they come alive spiritually. This enforced awakening is effective only if it breaks down old habits, trends, and beliefs. It may come about through working with or reading a teacher like Krishnamurti or Gurdjieff, or through major life events like a life threatening illness or unexpected bereavement. There is also little doubt that people become more interested in spiritual matters and more receptive to them at key points in their lives. Sometimes the experiences may occur as part of the process of individuation described by Carl Jung.
Some years ago I wrote a speculative piece suggesting that some mystical experiences may be triggered by a neurological mechanism involving the reticular activating system of the brain. The popular idea that mysticism is somehow related to the right hemisphere of the brain is probably not accurate. With the passage of time, it begins to look as if those speculations were accurate. Though one of the points that I made at the time, is that although we might be able to find a neurological substrate for mystical experiences that provide the form of the experience, that still left us with the problem of the content of the experience and therefore of its meaning for the individual.
At the beginning, the content of the mystical experience is culture bound and tends to be a product of a person’s belief system, which is why some mystics contradict each other. The Indian spiritual teacher Swami Ramdas (1884-1963) said that joy was both evidence of spiritual fulfillment and an ingredient of spiritual practice, while Simone Weil took an exactly opposite view and substituted unhappiness and suffering for joy: each proposed that a personal experience reflected a broadly universal truth. This is has been a common error for many spiritual teachers and their followers.
Saint Teresa of Ávila, a.k.a. St. Teresa de Jesus, the Spanish nun, mystic and author (1515-1582) was brought up in the Roman Catholic Church, and her mystical revelations fit into classical Catholic dogma. In contrast a modern Christian mystic – Holden Edward Sampson – who was brought up in the Protestant Evangelical Church, thought that his personal experiences proved that Saint Teresa’s writings were false.
These differences of opinion, even amongst the most advanced mystics, are striking but not often discussed. As an example, it amused me to see Ramana Maharshi make gentle fun of Sri Aurobindo’s doctrine of spiritual planes. I love and rever the workds of both of these sages. Simone Weil staunchly promoted the spirituality of Greek culture while the French-born writer René Guénon a.k.a. Sheikh ‘Abd al-Wahid Yahya thought that there was nothing much
to it. As people progress, there is usually more of a confluence:
mystics tend to report similar experiences, but they are often still
colored by their past lives.
Many people have mystical and spiritual experiences without knowing what is happening to them: they have never studied or been taught anything about them. I have seen quite a number of people who were supposed to be suffering from a psychotic episode, but who were actually having a profound spiritual experience. I have seen many thousands of psychotic people in almost fifty countries, and it is normally not that difficult to differentiate a breakdown from a breakthrough. Though even the most experienced of people sometimes find it difficult to be 100% certain what is going on.
It is essential for health care providers and for anyone who comes into contact with an individual who is having strange experiences, not simple to label them as mentally ill, but to remain alert to the possibility that there may be something yet more profound and meaningful going on in their lives.
Though for some people medicines, psychotherapy and the rest may be very helpful, others need spiritual support and guidance as they grow through a process of spiritual growth.
Hearing Voices
In 1973, there occurred a notorious episode in the history of psychiatry. A psychologist named David Rosenhan did an infamous experiment in which he had a group of eight people present themselves to twelve hospital emergency rooms claiming that they were hearing the words, “Empty, “Dull” or “Thud.”
Most were admitted and given psychiatric diagnoses. The second part of the experiment consisted of asking staff at a psychiatric hospital to detect non-existent ‘fake’ patients. They did rather badly. A paper about this was published in the journal Science, with the title, “On Being Sane in Insane Places.”
In its day, this paper was considered a damning critique of psychiatry and a plank in the ant-psychiatry movement that was in full swing at the time. In truth, it tells us only that if you lie to doctors and nurses you may deceive them. And second it is only a criticism of bad psychiatry. The idea of diagnosing schizophrenia or any other mental illness on the basis of hearing a single word is absurd. At least 40% of the population will at some time hear their name being called, particularly in times of stress or after bereavement. And very many people in the general population will occasionally hear a word being spoken. It is diagnostic of nothing.
I sincerely hope that none of the people that I’ve taught in 45 countries around the globe would EVER diagnose schizophrenia or any other mental illness simply on the basis of hearing voices, a.k.a. auditory hallucinations. As I’ve stressed time and again, the only purpose in making a diagnosis is to guide treatment and prognosis. Simply hearing voices can guide neither.
This topic came up during one of the things that I was doing to advocate for patients, because September 14th 2006 was World Hearing Voices Day, and I received some very interesting information from a UK based organization, the Hearing Voices Network. (There’s also a nice article here as well.)
There is some excellent research on people who hear voices yet are not mentally ill. Many of these people do not feel the need for any treatment and not only peacefully coexist with them, but regard them as a blessing. Most of the research has been done by Professor Marius Romme and Sondra Escher from Maastricht University in the Netherlands, Richard Bentall from the University of Manchester, and Gordon Claridge at Oxford.
About 4% of the general population hears voices, and most of them are not mentally ill. It is essential for us to understand the notion of dimensional rather than categorical diagnoses. I’m mentioning it again, because it prevents us falling into the error of labeling people for no readily apparent reason. For some people their voices are supportive and comforting.
One of several studies has shown that the form and content of auditory hallucinations is much the same whether someone has been labeled with a mental illness or not. Trauma and abuse can reactivate voices, or make them threatening.
The key to the hearing voices is whether or not they are causing distress to the individual or to those around them. There are four major coping strategies typically used by people who hear voices: distraction, ignoring the voices, selective listening to them, and setting limits on their influence.
The biggest danger for people who are hearing voices and are suffering from cognitive impairment or a mental illness, is that the voices may form the basis for delusions. As people are trying to make sense of their experiences, they may develop highly creative explanations.
I once worked with someone who was not hearing voices, but feeling odd sensations coursing along her limbs. She got a textbook of Chinese medicine, and became convinced that she was feeling the flow of Qi in her body. But because she also felt the sensations in places that were nowhere near the channels and meridians, she became convinced that it was her mission to redefine not just the courses of the channels, but to re-write the whole of Chinese medicine according to the sensations in her body.
Her attempt to make sense of her experiences made her grandiose and delusional. She became unable to care for herself, eventually became very distressed and was grateful to have some treatment which eradicated the sensations, which in turn caused the delusions to evaporate.
So treat each person as an individual and forget the unhelpful and stigmatizing labels.
Psychiatric Diagnosis
Several months ago I wrote about the advantages of seeing psychiatric problems on a spectrum rather than independent categories. And that it is also essential to look at the whole person: there is currently a terrible tendency in medicine and in psychiatry to reduce people to the neurotransmitters in their brains, which is not just a very limiting way of seeing an individual, it’s just plain rude.
One of the reasons why it is essential to look at the whole person is that the agenda of a physician and of a person asking – or being sent – for help may be entirely different. A doctor may want the voices to go away, and for the person to stop being fearful about the things that the TV is saying to them. The person may want help with making sense of their experiences. If someone believes that they are feeling this way because they’ve been abandoned by God, you can pour medications into them until you are blue in the face: they will not help the core problem. Yes, of course you can re-balance their dopamine, serotonin, GABA and acetylcholine receptors. But if their core belief has to do with abandonment, your efforts are unlikely to be crowned with success.
These issues came up again when I had the privilege of speaking to a meeting of the National Alliance of the Mentally Ill in Natchez, Mississippi last week.
There were all the usual questions about advances in mental health, and on the chances for recovery. My answer to that one is always the same: the chances for recovery from any mental illness – including schizophrenia and bipolar disorder – are better than they have ever been. The largest single barrier is expectation. If doctors, psychologists and therapists assume that nothing can be done apart from controlling symptoms, then it is unlikely that people will get better. We all know what will happen if we start the day assuming that’s it’s going to be terrible.
I’d like to highlight two blogs – here and here – that were started by the same person after she had recovered from a psychotic episode. She contacted me after my earlier posts. She has an excellent website which she started after an exchange with two psychiatrists who said essentially the same thing:
“If the person can be cured, then it is NOT schizophrenia. Schizophrenia is a chronic mental illness that has no cure.”
This is not true: but rather than being an indictment of psychiatry, it’s an indictment of bad psychiatry. We have a great deal of evidence that the brain is a highly plastic organ, and that many of the typical changes seen even in unmedicated people with the illness can return toward a normal pattern. This shouldn’t be a surprise: it has been known for many years that at least a third of people who carried a diagnosis of schizophrenia recover completely. To say that the recovery indicates that the original diagnosis was wrong is an extraordinary piece of circular reasoning.
The statement also implies that the writer doesn’t see a difference between healing, treatment and cure, which for me are three different interactions.
There is also another point that I made in Natchez: psychiatric diagnoses are still descriptive and are therefore largely at the level of the rest of the medicine of 100 years ago, when a person might be diagnosed with “dropsy,” “anasarca” or “icterus.” Terms now rarely used because we understand the underlying pathology. In the same way terms like schizophrenia will eventually give way to descriptions based on the biological, psychological, social and spiritual issues going on in a person.
Because the diagnoses are descriptive, getting too worried about the precise one is unlikely to be helpful. I once had a family become very angry with me. Their son had seen many specialists, who had all offered different diagnoses. After many day’s observation and exhaustive investigations, the one that I came up with did not please them. Because I wanted to treat their son as a human being with a problem that had responded to an antipsychotic and therapy, but they wanted him to have a less intimidating diagnosis. I tried in vain to explain that these were all just descriptors, and the important thing was that he was getting better with our treatment.
The reason for making a diagnosis at all is so that we can communicate, that it may guide treatment and allow us to offer some advice about prognosis. If someone has a heart attack, it is usually not too difficult to diagnose it. The reason for the diagnosis is not so that we can write it on a form or so that we can label someone, but because it can help guide us.
I certainly don’t agree with every one of points made in the articles that he’s posted, but that’s just fine. Active debate is always better than ignoring each other. Or as Winston Churchill once said, “Jaw, jaw, is better than war, war.”
On the main points in these blogs, I think that we are in complete agreement:
- Even without drugs it is possible to induce mania and psychosis in just about anyone: sleep deprivation, arousal and sensory overload will usually do it in a few days. If someone has a family history of psychiatric problems it will likely take half as long. If they have a personal history it might take a quarter as long.
- Recovery should be the aim for anyone with a psychiatric problem.
- Recovery is not necessarily the same as cure.
- Not all people diagnosed with “psychiatric problems” have them: some are having genuine spiritual experiences: I’ve seen many people going through kundalini and other types of spiritual awakening who had been given psychiatric diagnoses. I used to get some raised eyebrows when I had a string of referrals from clergy and spiritual teachers that usually read something like, “I don’t know if this person is psychotic or possessed. Please could you see them and advise me.”
- The quest for meaning and purpose is essential to our humanity. I have seen some of the most damaged of people with large traumatic holes in their brain trying to extract meaning and purpose from what had happened to them. Psychotic, manic, depressed and cognitively impaired, but still trying to work out the meaning for them personally.
The major psychiatric illnesses can be very hard to help: I regularly see everyone else’s problems when I travel: 45 countries and 47 states at last count. But it’s very unusual to find someone for whom we can do nothing.
But I never let clinicians give up: the people who come to us for help deserve better than that.
And for people who got through the process on their own, I congratulate you. But I beg you, please don’t suggest to everyone that they can do the same thing. Many need outside help that addresses all five dimensions of their being.
Toxoplasmosis, Behavior and Mental Illness
This title may seem odd, but this item may actually turn out to have enormous implications for all of us.
A couple of years ago I read a fascinating book: Parasites and the Behavior of Animals, in which the author – Janice Moore from Colorado State University – cataloged some of the extraordinary ways in which parasites can impact the behaviors of a vast array of animals. As difficult as it is to interpret studies of parasites in humans, I kept coming back to some odd observations about an illness with which I’ve been involved for more than 30 years: schizophrenia. I kept wondering if some of the odd observations made over the years could be explained by the parasites?
What kind of odd observations?
- Reports of mental illness have been found throughout history, yet this strange illness that we now call schizophrenia seems to have been very rare until about 1750, when it increased dramatically throughout Western Europe. I have had the privilege of working at the Bethlem Royal Hospital from which got the word “bedlam.” I know of the incredible records kept there. Something began to change in some of the types of patients being admitted at that time. I have also had the opportunity to look at some of the records at the Philip’s Hospital in Southern Germany, which has been in existence since 1533. Again the records show the sudden appearance of many cases of something that had been quite rare until then. 1750 marked the early years of the industrial revolution in Europe and the mass migration of people from the countryside to the new and very crowded cities
- There has been recent evidence that being born and raised in a city increases your chance of developing schizophrenia.
- There is increasing evidence that acute episodes of psychosis, mania and depression are associated with increases in circulating inflammatory mediators. There is also intriguing new data that both psychosis and depression can be improved by giving people COX2 inhibitors.
- There has also been the strange observation that bipolar disorder may have been becoming more common in recent years, over and above our greater ability to recognize the illness.
Several years ago the well-known psychiatrist E. Fuller Torrey first suggested that a small protozoal parasite called Toxoplasma gondii might be responsible for all of these observations. Cats can carry it, which is why pregnant mothers are advised not to pet their cats during pregnancy.
The idea that such a complex disease as schizophrenia might sometimes be caused by a parasite caught the media’s attention, but in recent years the story – but not the ongoing research – died down a bit.
There was an excellent and provocative blog item by Carl Zimmer about this almost three weeks ago, but I wanted to check everything out before responding. He gave a brief review of a new paper published in the Proceedings of the Royal Society, by Kevin Lafferty from the University of California in Santa Barbara. Lafferty has attempted to correlate the varying rates of Toxoplasma in different countries with predominant personality traits and therefore – since our societies are aggregates of all our personalities, cultural characteristics.
That may all sound far-fetched, but I don’t think that it is. And I don’t think that the Proceedings would have taken a completely half-baked proposition.
I have also found a report published in the journal the Proceedings of the Biological Society. Four eminent authors, including Torrey, revisited the while issue of Toxoplasmosis and mental illness. When the parasite gets into the nervous system it can alter behavior: Rats are normally programmed to avoid cats, but once infected they are attracted to cats. Over the last few days I’ve been plowing the world literature, and I’ve learned some very interesting things that support the idea that Toxoplasma may be playing a role in several different types of psychiatric illness.
There is strong evidence that schizophrenia, bipolar disorder and major depressive disorder lie on a spectrum. The illnesses are not the same, but people often switch from one type of clinical presentation to another. The precise type if illness would be determined by the interaction of genes, physical and Intrapsychic environment. Nobody would be sufficiently naïve to try and reduce the whole of psychiatric illness to a single bug. Mental illness is a great deal more than just a physical problem, and apart from anything else, the rates of Toxoplasma infections show remarkable variations around the globe, while the rates of major mental illness are much the same everywhere.
So what have I learned?
- There are a remarkable numbers of studies showing that many people with schizophrenia have antibodies to Toxoplasma, including people having their first attack of the illness
- Blood donors infected with Toxoplasma have decreased levels of novelty-seeking
- In women who become infected, there are some marked changes in personality.
- Toxoplasma affects the dopamine systems of the brain that we know are intimately involved in mood, cognition, movement and motivation.
- Some drugs used to treat psychosis (haloperidol) and mood disorder (valproic acid) inhibit the replication of Toxoplasma gondii. The valproic acid already does it at concentrations lower than we normally aim for when treating humans.
- There is some intriguing work going on into the use of antibiotics to kill Toxoplasma and reverse its behavioral effects.
In the last few years, so many illnesses have turned out to have infectious origins, from peptic ulcers to arteriosclerosis and some cancers. Perhaps some mental illnesses will be next.
Last year Barry Marshall and Robin Warren were awarded the Nobel Prize in Physiology or Medicine for their pioneering work on Helicobacter. I have a strong sense that there are more prizes to come on the interaction between infectious agents, inflammation, genes, the psyche and the environment.
Perhaps the reason that some antipsychotics and mood stablizers can reverse some of the neurological damage associated with schizophrenia and bipolar disorder is becuase they are killing off the causative agents and allowing the brain to repair itself.
I shall keep you posted!
