Attitude

It matters

This post is not about ECT. It is about something much bigger and more important: attitude.

Last week, I quoted Prof. Colleen Loo, of Sydney, who mentioned a paper from Singapore from 2020 which seemed to be supportive of ECT. I say ‘seemed’ because the follow-up period after the last ECT treatment was not years or even months, but 1-2 days. To my surprise, she sent me the link (public access) which confirms that yes, on that flimsy evidence-base, they decided ECT for involuntary patients was a good thing:

… the majority of patients lacking capacity and receiving ECT have overall satisfaction with ECT and were unlikely to sue practitioners for providing ECT … there are significant and increasing legal barriers for patients lacking capacity to access ECT, often requiring a judge to approve ECT treatment with resulting delays in access to care. In some jurisdictions, ECT may be illegal for patients lacking capacity (p151-2).

The paper confirms that ECT usage in the US is declining steadily: “…at least 20 years of decreasing inpatient use of ECT in the United States resulting in only 1 in 10 US hospitals offering ECT and only 1.5% of severely depressed inpatients receiving ECT …” (p153). As they note, it is now largely restricted to the stereotype of what has been called “mildly-troubled, middle-aged, middle class white women with private insurance being treated in private hospitals” [1; this has all the relevant figures] It is also true that in the UK, ECT has declined by some 90% since 1980, to the point where, on per capita basis, Queensland now uses ECT 1,000% more than England. But it’s not just English-speaking countries. If we had to pick a country where we think ECT is most likely to be used, Poland would probably be close to the top. However, Australia uses ECT 4,400% more than Poland. Obviously, their gloomy weather doesn’t produce a gloomy national disposition, or they have less shocking ways of dealing with the glums.

After showing that the patient’s legal status (legally capable vs incapable) didn’t make much difference to the outcome of ECT, the authors concluded:

In the US, ECT was far more likely to be performed for consenting white individuals in private health facilities with private insurance coverage than on poor, destitute and incarcerated patients from minority races with severe mental illnesses and lacking capacity (p155) … These results support the provision of a framework for substitute decision making, enabling ECT treatment in the patients’ best interests for those patients unable to provide their own consent (p156).

The reader is left with the impression that ECT is very important in psychiatry and should not be restricted to those who can pay but should be spread around to all the unfortunates stuck in prisons or mental hospitals who can’t afford it and don’t want it, but without all the palaver of applying for legal authority and such like as that only causes unnecessary delays, implying, as they didn’t say, worse outcomes. I agree: ECT is indeed “very important in psychiatry,” but for all the wrong reasons, and this paper shows them clearly, not by what it says but by what it leaves unsaid or carefully skirts around. We will come back to them after a brief foray into concerns about Mr Kennedy’s effect on psychiatry.

Two articles in this week’s Psychiatric Times provide figures for the changes being forced on medical research in the US. Facts Over Fiction: The Current State of Psychiatry, lists the effects of up to 40% budgetary cuts on a range of major institutions. Huge numbers of research programs have been abruptly halted and the staff “let go,” with unpredictable results still to come. The article is a handy summary of the chaos that follows handing untrained and undisciplined ideologues the power to make major decisions on matters of which they know nothing. When Mao’s Red Guards did this during the Cultural Revolution, the West affected to be appalled. The second article asks the very relevant question Make America Healthy Again—What About Psychiatry? However, it immediately launches into yet another attack on their mortal enemy, antipsychiatry. This is defined as “the belief that psychiatric practice is unscientific, toxic, and oppressive” put about by “the usual antipsychiatry list of grandees, including Thomas Szasz and Robert Whitaker.” I’m sure Mr Whitaker will be honoured to read that, especially as his very detailed work over the past 25 or so years has shown that psychiatry is all of those things and more [2, 3].

According to the writer, the well-known polemicist, Dr Daniel Morehead, “antipsychiatry” has been moribund for years: “Fortunately, the vast majority of the American public now fully supports mental health diagnosis and treatment … the view of mental illness as medically treatable and real was going to achieve the status of common sense…” However, mortal danger threatens: “… the antipsychiatry movement seems to have lurched off its deathbed and staggered into the streets. Unlike the zombies featured in most apocalypse movies, this one is armed to the teeth…” That is, it has friends in high places, specifically the new Secretary of Health and Human Services, the widely loathed but immensely powerful RFK Jr.

During his confirmation hearings, Mr Kennedy indicated he would be looking into the “epidemics” of ADHD and ASD in the US, as well as the deleterious effects of common psychiatric drugs including SSRIs and stimulants. He expected to sort out ASD by September (he didn’t say which year), meaning they would no longer need all those highly-paid researchers. Needless to say, all this has thrown mainstream psychiatry and their henchmen, the drug companies, into a panic. Having spent decades implementing their carefully-laid plans to convince the world that all mental disorder is due to bad genes, along comes their nemesis, a totally-unqualified and skeptical outsider with absolute power over their budgets and staffing who thinks it’s all due to bad chemicals in the environment and diet. OMG, disaster looms. So what does mainstream psychiatry do? Well, they do what they always do, blame the international antipsychiatry conspiracy.

The only problem with blaming this conspiracy is that nobody actually knows where it is or who their leaders are. Having met Bob Whitaker a number of times, I can assure readers that his second name isn’t Adolph. He doesn’t lead anything like a vast subterranean cabal of Luddite berserkers, or even a latter-day Boston tea party (he lives in Boston). Instead, he likes to sit in libraries poring over old medical journals. Aha, that’s it then, he's a latter-day Marx, who wrote his explosive doctrine in the British Museum. Not at all. The fact is, there is no “antipsychiatry” movement or conspiracy of flesh-eating zombie critics. If psychiatry wants to be seen as a valid science, any and all criticism of mainstream psychiatry isn’t just allowed, but is ordained by the fundamental principles of science. Criticism of the status quo is so much part of the scientific ethos that people (like Dr Morehead) who rail against critics are, in fact, breaching those principles. If there’s no criticism, there’s no science. Full stop. Psychiatrists who are angered by criticism, and that’s most of them, shouldn’t be in the job. They can go and join a cult because only cults are immune to criticism.

Before we leave him, what bothered Morehead so? Criticism of benzodiazepines, specifically alprazolam (Xanax):

The article (in Wall St Journal) contains no indication of the countless individuals with life-threatening and treatment-resistant anxiety who have been helped by benzodiazepines. Nor does it compare negative reactions to benzodiazepines with horror stories that some individuals taking nonpsychiatric drugs such as statins or various antibiotics could tell us. Finally, it fails to explain how almost all doctors work very carefully with patients to avoid overuse.

This is pure propaganda. First, humans survived “life-threatening” anxiety for millennia before benzos were invented, and many of them actually had a lot to be worried about. Second, “treatment-resistant anxiety” appears to be increasing, hand-in-hand with the explosive increase in prescriptions of psychoactive drugs such as SSRIs, antipsychotics and, of course, benzos. Is there anything to suggest these drugs are responsible? Yes, plenty [2] but nothing I’ve seen that proves it definitively. Perhaps this should have been studied in the 1970s when they were first released? Next, please don’t try to distract us with “horror stories” of other drugs. We’re talking about benzos, not other drugs; a lot of highly qualified people are looking into other drugs (e.g. Peter Gotzsche, of Copenhagen, who also has plenty to say about psychiatric drugs). Next, the claim that “almost all doctors work very carefully to avoid overuse” is unmitigated bullshit. They don’t. Over half a million Americans were killed by American doctors dishing out extremely toxic opioid drugs willy-nilly (more figures in Wikipedia here). Finally, he says: “These stories … are the kind of thing that keeps us psychiatrists up late into the night.” That’s crap. Psychiatrists who believe mental disorder is all biological don’t worry about their patients at night, only psychotherapists do that.

OK, armed with our newly-issued licence to criticise anybody and everything in psychiatry, let’s turn back to the energetic Dr Loo and her ECT machine. The comments I made last week are valid: 1-2 days follow-up is absurd; she could get ethical permission to study ECT in involuntary patients if she applied for it; and ECT is routinely used as first choice, not something to be used only “where nothing else has worked." Let’s look at some of their claims:

• 1. … the majority of patients lacking capacity and receiving ECT have overall satisfaction with ECT and were unlikely to sue practitioners for providing ECT.

The naïveté is breathtaking. Psychiatric patients know that the chances of successfully suing a psychiatrist are close to zero. Unless it’s something outstandingly awful, nothing happens: look at the bizarre case of Selwyn Leeks in New Zealand. Gross sexual, physical and emotional abuse of children and teenagers went on for years and what did the authorities do? Fcuk all. The reason nothing happens is because the people deciding on the complaint are ideologically-aligned with and mostly friends of the offender. They’re not going to convict one of their own. Second, patients who complain can expect to be punished in one of the myriad underhand ways available to the keepers of the nuthouse, starting with being kept in longer to get more ECT (“He says we’re damaging him, he’s clearly suffering a paranoid state”).

• 2. Judicial delays in approving ECT.

In Norway, ECT can only be administered in government hospitals, and there is usually an eight week delay in getting an appointment.

• 3. In some jurisdictions, ECT may be illegal for patients lacking capacity.

Er, doesn’t that indicate it’s an option and not “indispensable, essential, life-saving”?

• 4. Rich white women in private hospitals get most of the ECT …

Why isn’t that seen as money-grubbing misogyny? Regardless of what anybody says, it isn’t science.

• 5. …while “… poor, destitute and incarcerated patients from minority races with severe mental illnesses and lacking capacity” miss out on this life-saving gift.

Somehow, they survive. What this says is that the allocation of an allegedly life-saving form of treatment has nothing to do with “clinical indications” and everything to do with how fat their wallets are.

• 6. “These results support the provision of a framework for substitute decision making, enabling ECT treatment in the patients’ best interests for those patients unable to provide their own consent.”

Here, we come to the core of this little study: trying to justify giving involuntary patients more ECT rather than less. Now we see that if they’re unable/unwilling to consent, it’s in their “best interests” to get it anyway. Armed with this little study, psychiatrists can feel they’ve got the science on their side when they apply to give ECT to everybody who says “I don’t want it.” What we know of mental health tribunals is that they are greatly impressed by this sort of thing.

We can now revisit what I said is more important than ECT, the attitude of the psychiatrists who want to give it to everybody. Their attitude, their belief system, their ideology [4] is that mental disorder is biological and only biological-type treatments can work. What they don’t tell anybody, what they carefully omit so that nobody suspects it, is the hard, factual evidence that says ECT is not necessary. All psychiatrists can practice without it – IF they have a model of mental disorder that tells them what to do, IF they have the requisite skills and, above all, IF they want to.

The brilliant economist, John Maynard Keynes, criticised Friedrich Hayek's book Prices and Production from 1931 as “...one of the most frightful muddles I have ever read … an extraordinary example of how, starting with a mistake, a remorseless logician can end in Bedlam.” Starting with a fixed belief on ECT, psychiatrists carefully sift through the evidence and find their opinions confirmed.

Moreover, their attitude that they alone know anything about mental disorder and that all critics are malicious and “antipsychiatry” has nothing to do with science and everything to do with cults. If psychiatry decided to register as a cult, it meets most of the criteria already.

References:

1. McLaren N (2017). Electroconvulsive Therapy: A Critical Perspective. Ethical Human Psychology and Psychiatry 19: 91-104. DOI: 10.1891/1559-4343.19.2.91

2. Whitaker R (2009). Anatomy of an Epidemic: Magic Bullets, Psychiatric Drugs and the Astonishing Rise of Mental Illness in America. New York: Random House.

3. Whitaker R, Cosgrove L (2015). Psychiatry Under the Influence: Institutional Corruption, Social Injury, and Prescriptions for Reform. New York: Palgrave MacMillan.

4. McLaren N (2013). Psychiatry as Ideology. Ethical Human Psychology and Psychiatry 15: 7-18. 10.1891/1559-4343.15.1.7