Debunking Denialism

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Nada Logan Stotland Dethrones Common Myths about Psychiatry

12 Comments Posted by Emil Karlsson on November 7, 2011

Despite the fact that The Huffington Post has become a swamp for all sorts of lunacy, everything from anti-vaccine myths and cancer quackery to creationism and New Age, there are some glimmering diamonds in the seeping cesspool of ignorance. Dr Nada Logan Stotland, who is the Professor of Psychiatry and Obstetrics/Gynecology at Rush Medical College, has written a timely piece entitled Myths About Psychiatry, where she lays out and refutes some of the most common myths and misconceptions about psychiatry. It is a bit dated, but it is worth reading. The myths she dethrones includes the notion that psychiatric illnesses do not exist or are poorly defined and that treatment does not work, but is, in fact, dangerous. Let us look at a few of them, in turn.

Myth #1: Definitions of psychiatric conditions are severely suspect.

A common claim is that psychiatric conditions are labels on healthy human variation, or that is an arbitrary convention. Stotland explains that while

It’s true that some psychiatric conditions exist on a continuum with normal reactions, normal states of being. Differentiating them from normal is no different than deciding what level of blood pressure is ‘hypertension,’ how many pounds add up to ‘obesity,’ or how many hours of labor it should take before a baby is born. A condition rises to the level of disease when it handicaps a person, is associated with bad outcomes, and/or can be treated — in psychiatry just as in the rest of medicine.

In other words, a mental disorder is often a condition with strongly interferes with the day to day life of a person. This fits neatly into the three Ds: distress, dysfunction and deviance as guidelines for deciding if a psychological variation should be labeled as a mental condition: does it cause distress or dysfunction for the person or people around them? Is it just so deviant that it cannot reasonably be counted as healthy human variation? Stotland’s response also fits with how other medical conditions work, such as hypertension and obesity. In other words, mental disorders is a disease of the brain/mind, just like other medical conditions are diseases of the heart, or lungs etc.

Another popular claim is that diagnoses are just voted on and are not supported by evidence. Stotland points out that

This notion assumes that medical diagnoses are handed down on tablets like the Ten Commandments. On the contrary; specialists have to look at the evidence and then make judgments about the criteria for medical diagnoses. The difference between a benign tumor and a cancer is a matter of how many sick cells appear under the microscope. Of course oncologists have to make that decision, and they presumably they have some sort of vote to make it official.

In other words, psychiatrists, as well as other medical doctors, look at the scientific evidence and try to make the best judgment possible about definitions and criteria. This also emphasize the continuity between physical and mental health. Granted, there are limitations to the diagnostic manuals, but the solution is better manuals, not throwing the baby out with the bathwater.

Myth #2: Psychiatrists are diagnosing people to fill practices.

Do psychiatrists just label people with mental disorders just so they will have work to do? As it turns out

There is a shortage of psychiatrists. I don’t know any psychiatrists with time on their hands. Our incomes are at the lower end of the medical totem pole, along with family medicine and pediatrics, which makes it difficult to repay the over $100,000 in student loans we have, on average, but we make a good living.

I find the conspiracy theory that people become doctors just to make money interesting. While I am sure that medical doctors have high wages, it is also true that they work hard, long hours and that they have high debts to pay off.

Myth 3# Psychiatric drugs hurt people more than they help

Next to conspiracies about large pharmaceutical companies, this has to be a very common myth. Stotland asks the rhetorical question

Do psychiatric medications turn people into ‘zombies,’ or change their personalities? Any medication can cause ill effects in some people, especially if they take too large a dose. Are psychiatric medications ‘brain-altering’? A person who recovers from depression, post-traumatic stress disorder, or obsessive-compulsive disorder can seem to have a changed personality — a healthy one. People treated for schizophrenia can use their brains to make contributions to society and have fulfilling lives because their brains are no longer cluttered with hallucinations and delusions.

Ultimately, it is a matter of cost-benefit analysis. The best treatments often combine medications with things like cognitive behavioral therapy. Stotland finishes of by noting that

Prejudice against psychiatry, psychiatric patients, and psychiatrists goes back millennia. It’s hard enough to have a painful and possibly disabling disorder, or to treat one, without suffering from stigma as well. The brain is not only the most complicated organ of the body — it’s one of the most complicated entities in the universe. So psychiatric problems don’t have simple answers. Just like our colleagues in other branches of medicine, no more and no less, there is much more that we don’t know than that we do know. Like our medical colleagues, we’ll keep relieving the suffering of people who are ill, and we’ll keep doing research to understand and treat them ever better.

Dr. Stotland discusses several other myths as well as giving some pretty interesting references. We need more like her, taking on the myths head-on, particularly in enemy territory, like the Huffington Post.

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12 Responses to Nada Logan Stotland Dethrones Common Myths about Psychiatry

Wonderist November 9, 2011 at 02:28
Good summary and analysis, Emil. I’m reposting this link to Facebook.

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Emil Karlsson November 10, 2011 at 18:02
Thanks.

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nickfederale February 22, 2012 at 00:36
‘In other words, a mental disorder is often a condition with strongly interferes with the day to day life of a person.’

Which is why homosexuality was considered a mental disorder until political pressure forced psychiatrists to remove the condition from the DSM in the 1970s. Ask Alan Turing.

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nickfederale February 22, 2012 at 00:41
‘Do psychiatrists just label people with mental disorders just so they will have work to do? As it turns out’ (snip) which makes it difficult to repay the over $100,000 in student loans we have, on average, but we make a good living.’

I think that answers myth # 2.

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nickfederale February 22, 2012 at 00:51
‘Do psychiatric medications turn people into ‘zombies,’ or change their personalities? Any medication can cause ill effects in some people, especially if they take too large a dose.’

So why not use alcohol or heroin? What is the science behind the efficacy of neuroleptics? Tardive dyskinesia and diabetes are not to be taken lightly.

‘Prejudice against psychiatry, (snip) and psychiatrists goes back millennia.’

I would like to see some evidence of this.

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Emil Karlsson February 22, 2012 at 18:11
1. The reason homosexuality was considered a mental disorder stems from the hostility to homosexuals inherent in many world religions.

2. You quote Logan Stotland out of context. She explains that psychiatrists actually do not make a lot of money compared with other medical specialties.

3. The reason psychiatrists do not use alcohol or heroin is that there is no good evidence clinical trials that alcohol or heroin are effective treatments for e. g. clinical depression. In fact, substance abuse tends to make many mental conditions worse.

4. As for prejudice against psychiatry and psychiatrists, it is fairly well-documented that individuals with mental conditions were thought to be punished for their sins or possessed by demons. This of course made the efforts of psychiatrists (or the past equivalent) very difficult.

See e. g.

Fornaro, M., Clementi, N., & Fornaro, P. (2009). Medicine and psychiatry in Western culture: Ancient Greek myths and modern prejudices. Annals of General Psychiatry, 8(1), 21.

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nickfederale March 3, 2012 at 22:55
1. Religion defined homosexuality as a sin. It took psychiatrists to define it as a mental disorder. And due to political pressure it was ‘voted’ out of the DSM.
2. To quote ‘we make a good living’ Is that not enough?
3. Alcohol has been used for thousands of years to cope with depression (clinical or not). It has been shown that SSRIs are little different to placebos. All drugs, including psychotics, can be abused.
4. Prejudice against those deemed to have a mental disorder has always existed. There is little prejudice against psychiatrists (apart from a small minority.)

Are you familiar with ‘anti’ psychiatry works? Robert Whitaker? Thomas Szasz? Richard Bentall? http://www.garygreenbergonline.com/ is an interesting blog. Are you familiar with antpsychiatry.org or Mindfreedom, Critical Psychiatry, the CCHR or Mad Pride? Hundreds of sites growing every day.

Are you aware that in the UK and the US, thousands of professionals including Allen Francis are petitioning against the DSM5? Psychiatry is being found out as the pseudoscience it is.

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Emil Karlsson March 4, 2012 at 02:06
1. Again, you need to understand the religious background in order to understand why homosexuality was considered a mental disorder. In the Bible, sex between two men is punishable by death. Thomas Aquinas considered homosexual sex as “unnatural”. It is in this cultural background that ideas about sexual orientation and identity that homosexuality was a mental disorder arose. Then psychologists reexamined this conclusion, with the three Ds as their guiding principles, and concluded that homosexuality, was in fact, not a mental disorder. The fact that psychiatry has the ability for self-correction shows that it is science-based, not a pseudoscience.

2. No, because the “who profits?” argument is a fallacy know as appeal to motive (alternatively argumentum ad hominem circumstantial). You also deploy it in a self-contradictory fashion, as many leading proponents of anti-psychiatry also makes a ton of money. Finally, it is among the least well-paid specialties.

3a. You are again performing a pretty well-known fallacy, this one called appeal to tradition. The fact that there is a tradition for using alcohol as a treatment for depression does not make it effective. In fact, the long-term effects of alcohol consumption shows that it is not an effective treatment for depression. In fact, alcohol abuse can make depression worse.

3b. It has NOT been shown that SSRIs do no better than placebo. That is the popular media jumping on the bandwagon of the flawed study by Kirsch. As I wrote in Stefan Molyneux’s Unfortunate Spiraling into Anti-Psychiatry:

Kirsch et. al. (2008) closely reproduced the findings of earlier studies such as Turner et. al. (2008). The effect size of all drugs tested where, compared with placebo, positive. None of the calculated confidence intervals overlapped zero, meaning that it is very unlikely that antidepressants tested and placebo are no different in efficacy. However, Kirsch made a radical new interpretation of those findings. Whereas Turner et. al. drew the conclusions that antidepressants where more effective than placebo, Kirsch drew the exact opposite, namely that antidepressants where not better than placebos, using an arbitrary cut-off standard for clinical significance of 0.5 devised by National Institute for Clinical Excellence, a standard which they no longer use. While it is true that a glass that is 1/3 full is not 1/2 full, a 1/3 glass is not empty. If Kirsch’s interpretation was reasonable, we would have to reject psychotherapy as a treatment as well antidepressants, because psychotherapy alone has an even lower effect size than antidepressants alone. This is why a lot of treatments for depression uses both antidepressants and psychotherapy. They work better together than any of them work alone (Hall 2010a, Hall 2010b).

There are many studies looking at the efficacy of antidepressants that show that they are more effective than placebo. I mentioned this in an earlier blog post, but one such example was published in NEJM (Walkup et. al. 2008), that compared the efficacy of sertraline (an SSRI) alone, cognitive behavioral therapy (CBT) alone, placebo, and sertraline and CBT together and the results where: improvement with CBT alone (59.7%), sertraline alone (54.9%) where both better than placebo (23.7%) and a combination of CBT and sertraine (80.7%) was the best option. Side effects where roughly equal in the group recieving the SSRIS treatment and the group receiving placebo. This study is not perfect, but it independently converges with other such studies showing that SSRIs are by and large effective compared with placebo.

4. To be sure, but you and others who subscribe to anti-psychiatry are excellent examples of prejudice against psychiatrists and psychologists.

5. You are performing yet another fallacy, this time appeal to popularity. The popularity of a view does not mean that it is correct. As an example, there are thousands and thousands of websites online peddling young earth creationism, but this does not mean that the earth is just a few thousands years.

6. Regarding the DSM, you are confusing a legitimate scientific discussion on how to best create diagnostic manuals with the pseudoscientific debate of the status of psychiatry overall. DSM has flaws, but let us not throw out the baby with the bathwater.

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nickfederale March 4, 2012 at 12:50
1. Homosexuality was considered a mental disorder by psychiatrists up to the 1970s. Is psychiatry governed by religion or science? The DSM was changed only because of political protests by homosexuals. What was the scientific reasoning used in this case? Ego-dystonic homosexuality was retained in the DSM until 1986 when it again was removed by political pressure. This is pure pseudoscience.

2. ‘We earn a good living’ is self explanatory. Did I say that anti psychiatrists did not make a good living? Where? This is called attacking a straw man.

3a. Alcohol works well for me and many others I know. Do you not drink? As I have stated abuse of all substances (including water to induce hyponatremia) can cause problems. The only drug not mentioned for abuse in the DSM are in fact anti-depressants. Go figure.

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nickfederale March 4, 2012 at 13:33
3b. Of the 74 trials for antidepressants only 38 showed an advantage over placebo. Ignore the fact that active placebos were not generally used. Using the HAM-D depression scale, which in itself is unscientific, the drugs improved scores by 10 points, placebo by 8. As I stated SSRIs showed little difference not, as you claim I said, no difference. Carlos Zarate has demonstrated far better results using ketamine.

The NEJM trial you quote does not make sense. CBT (itself a pseudoscience!) performs better than SSRIs and SSRIs have the same side effects as a placebo?. Something is obviously wrong here. Not least the difficulty of the use of psychotherapy in an RCT. Popper stated that empirical falsifiability as his criterion of what defined a science. One never sees this in psychiatry trials. It is a pseudoscience.

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nickfederale March 4, 2012 at 13:52
4. As I stated, we are a tiny minority at the moment. But growing rapidly.

5. I think that your position is by far more ‘another fallacy, this time appeal to popularity.’

6. Re: Tom Insel, “We don’t talk much about this,” he said, but when it comes to mental illnesses, psychiatrists lag far behind their colleagues in other specialties. “Diagnosis is by observation, detection is late, prediction is poor. Etiology is unknown, prevention is undeveloped. Therapy is by trial-and-error. We have no cures, no vaccines. We’re not even working on vaccines. Prevalence has not decreased. Mortality has not decreased.”

I think it is time we threw out the bathwater to stop the baby from drowning.

7. Are you familiar with the literature I mentioned? Allen Francis maybe?

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Emil Karlsson March 4, 2012 at 15:29
You really have an issue with understanding what other people are telling you. But luckily for you, I have a lot of patience.

1. Psychiatry is one of the youngest medical specialties there are. The reason homosexuality was classed as a mental disorder was because of the cultural background of religion. Then, as more evidence accumulated that homosexuality itself did not cause distress, dysfunction or was deviance, it was removed. This is one of the key features of science: self-correction. Psychiatrists realized that they were incorrect and changed their minds.

2. Again, to say that someone is wrong because they make money is the fallacy of appeal to motive / argumentum ad hominem circumstantial. It is also self-contradictory, as prominent advocates of anti-psychiatry also makes money from e. g. book deals. Do you conclude that they are therefore wrong?

3a. Just because you have the personal belief that “it works for you” does not mean that it is a safe or effective therapy for e. g. depression. That is the fallacy of anecdotal evidence. Real science shows that alcohol has severe negative side effects if used as a treatment. Actually, DSM-IV does not artificially exclude antidepressants from being able to be abused.

3b. Again, the Kirsch study showed an effect size of approximately 0.3. This is not the same as “it is just the placebo effect!!1″

Also, are you really calling one of the most effective psychotherapies that exist “pseudoscience”? Well then, how do you suggest that patients with mental conditions should be treated? Exorcism?

CBT performed slightly better than antidepressants in that particular trial, yes. This is nothing strange. The placebo group had the same amount of side effects because even pharmacologically inert placebos have expectancy side effects. This is called the nocebo effect. I explained how this worked in Why Jerry Coyne is Still Wrong about Antidepressants.

It is not difficult to use psychotherapy in a RCT. You just randomly assign some patients from your patient pool to receive psychotherapy, antidepressants, both, or just a placebo treatment.

The fact that psychiatrists admitted they were wrong shows that claims made by psychiatrists are falsifiable. The same can occur in medical trials of psychiatric medication: all that needs to happen is for there to be no difference between the active treatment and the placebo.

4. Irrelevant. Validity does not depend on the size of the movement.

5. You completely ignored my counterargument! Re-read it: “You are performing yet another fallacy, this time appeal to popularity. The popularity of a view does not mean that it is correct. As an example, there are thousands and thousands of websites online peddling young earth creationism, but this does not mean that the earth is just a few thousands years.”

6. Tom Insel is not only wrong, but pathetically so. Vaccines are for infectious diseases. Mental conditions are not infectious diseases, but caused by an interaction of biological, psychological and social factors. We do not know the exact causes, but we know many factors that influences the probability that a given individual will develop a mental condition. Also, antidepressants have reduced mortality from e. g. suicides. I wrote about this in Stefan Molyneux’s Unfortunate Spiraling into Anti-Psychiatry.

Also, therapy as trial-and-error shows that psychiatrists care about what works for a specific individual and are able to stop using a treatment if it fails, which speaks to the scientific status of psychiatry.

So you are, yet again, contradicting yourself. Well done.

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Debunking Denialism

Nada Logan Stotland Dethrones Common Myths about Psychiatry

12 Responses to Nada Logan Stotland Dethrones Common Myths about Psychiatry

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