Anti-psychotics, damn lies and statistics

Today, I was asked to clarify some information surrounding an earlier post about Carrie Fisher and the role that anti-psychotic medications may or may not have played in her death from a heart attack.  I appreciated the question which was about whether I’d seen the statistics put up by the Mad In America (MIA) blogger who wrote about Carrie Fisher (the blog which, incidentally, Dr Leaf had then uncritically decided to slyly try to regift it in the form of her newsletter article).

In the opening of her post, the MIA blogger said, “There’s an important question here. Is she one of the cases in point to explain why our community has a 25 year lower life expectancy?” and then threw in a table plucked out of context from a journal article.  At least, unlike Dr Leaf, the MIA blogger was intellectually honest enough to attach the source of the table, which was an article published in the European Heart Journal in 2012.

While the MIA blogger is certainly entitled to her opinion, I thought it was worth discussing the statistics in a bit more detail, if for nothing else than to give some context to the whole “anti-psychotics kill you” trope that keeps getting around.

First, there needs to be the proper context.  No one is denying that there’s a higher mortality rate amongst people with schizophrenia and other forms of psychosis, though I don’t see exactly where she got her “25 year lower life expectancy” line from. To me, that seems excessive.

Then to the study itself.  The paper that the table is extracted from is Honkola et al [1]. The study specifically examines the association between the use of different classes of psychiatric medications with the rate of sudden cardiac death during a coronary event (a heart attack, or angina).

In her post, the MIA blogger throws around a lot of numbers but she was loathe to put her numbers in the right context.  For example, she claimed that “smoking is four times safer than the older types of antipsychotics. And it’s twice as safe to smoke as it is to take any antipsychotic, including the newer ones”.  Except, her comparison is a fallacy of conflation – she’s comparing the all cause mortality of smoking (which is more like three-fold rather than two-fold, just FYI [2]) with the highly specific ‘sudden cardiac death during a heart attack’ mortality of the study she’s referencing.  It’s apples and oranges – the groups aren’t directly comparable.

Besides, even if her numbers were directly applicable, the positively immoral sounding four-fold increase in the rate of death sounds is just an association, not a cause.  There is a dictum in science, “Correlation is not the same as causation.”  Just because two things occur together does not mean that one causes the other.  There may be other explanations beside the medication that might explain that number, including but not limited to, statistical anomalies and lifestyle factors, and other factors not considered in the analysis.

There are other problems with relevance too.  Most of the numbers in the table were small and not statistically significant (that is, could have been related to chance alone).  The only strong numbers were for old anti-psychotics, phenothiazines, tricyclic antidepressants and butyrophenones, none of which are first line medications for psychosis or depression anymore.  Newer anti-depressants and the newer atypical anti-psychotics did not have a statistically significant association.

And, like I said before, this study is looking at the association between sudden cardiac death in people having a heart attack, which is a very specific form of mortality.  It’s not particularly applicable to everyone on the medications, so even if the 4- or 8-fold increase is rock solid, you can’t translate that statistic to everyone on anti-psychotic medications or anti-depressants, or Carrie Fisher for that matter since no one really knows how she died other than she had a heart attack.  The rest is just disrespectful speculation.

For me, rather than trying to take a table full of weak and inapplicable statistics and beat a conclusion out of them, a more useful thing would be to know the benefit or harm of anti-psychotics on all causes of death.  If anti-psychotics were really as poisonous as Dr Leaf and the MIA blogger portrayed, then all-cause mortality would be much higher in those exposed to the drugs versus those who were never exposed to the drug, which is why this study by Torniainen and colleagues [3] is particularly interesting, and in particular, this graph – https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4393693/figure/F1/

In this study, the chance of dying from any cause was significantly higher in those people with schizophrenia who were never treated with anti-psychotics compared to those who were treated.

Does this answer the question why there is a lower rate of mortality? Not really, because in fairness, this study also showed just an association between no anti-psychotics and a higher death rate.  It doesn’t specifically prove causation one way or another.

Does it show that we should throw anti-psychotics around like lollies, or that they are wonder drugs without any associated harm? No, they are medicines and need to be used responsibly.

It does show there’s a general benefit to anti-psychotics for people with schizophrenia so they’re not the toxic killers Dr Leaf and the MIA blogger try and make them out to be.

Anyone can cherry-pick weak statistics and bend them to suit their self-interested propaganda.  The remedy to damn lies and statistics is to look more broadly and consider the strength of the numbers and their context.  When we do that with the studies on anti-psychotic medications we see that they aren’t the evil killers that some people would like to make them out to be.

References
[1]        Honkola J, Hookana E, Malinen S, et al. Psychotropic medications and the risk of sudden cardiac death during an acute coronary event. Eur Heart J 2012 Mar;33(6):745-51
[2]        Jha P, Ramasundarahettige C, Landsman V, et al. 21st-century hazards of smoking and benefits of cessation in the United States. The New England journal of medicine 2013 Jan 24;368(4):341-50
[3]        Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63

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Caroline Leaf – Carrie Fisher killed by bipolar meds

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No longer content with just wilful ignorance, Dr Caroline Leaf has stooped even further by using the death of a beloved actress as a sick segue against psychiatric medications.

Dr Caroline Leaf is a communication pathologist and self-titled cognitive neuroscientist.  She markets herself as an expert in neuroscience and mental health despite not knowing how genes work (https://cedwardpitt.com/2014/09/27/dr-caroline-leaf-and-the-genetic-fluctuations-falsehood/ and https://cedwardpitt.com/2017/01/07/dr-caroline-leaf-the-christian-churchs-anti-vaxxer/).

In her latest “Mental Health News – January 2017” e-mail newsletter, Dr Leaf makes some astounding and outlandish statements about mental health.

She starts by claiming that Carrie Fisher’s death was ultimately caused by the psychiatric medications she was taking.

“Few people, however, are talking about the possible link between her heart attack and her psychiatric medication. As mental health activist Corinna West shows, ‘new antipsychotics cause weight gain, diabetes, and a bunch of other risk factors associated with heart disease.’ We have to take these risk factors seriously. We are not merely talking about statistics—we are talking about real people, people like Carrie Fisher.”

Dr Leaf, no one’s talking about the possible link between her heart attack and her psychiatric medication because we respect the Carrie Fisher too much and would rather celebrate her life and achievements, not perform a hypothetical post-mortem motivated by prejudiced speculation.

No one’s talking about the possible link between her heart attack and her psychiatric medication because no one really knows what caused Carrie Fisher’s heart attack.  No one knows if she had any other risk factors for heart attacks, or what medications she was on.  There could be a dozen other reasons why she had a heart attack.  No one else is asking because it’s none of our business.

No one’s talking about the possible link between her heart attack and her psychiatric medication because we know that psychiatric medications do much more good than harm.

No one is talking about the possible link between her heart attack and her psychiatric medication because it’s highly disrespectful to use someone’s death to promote your political or ideological position.  Using Carrie Fisher’s death as a segue to your soapbox about psychiatric medications is like someone using Princess Diana’s death as an opportunity to talk about the dangers of speeding in tunnels.  It’s ungracious, unbecoming, and in poor taste.

What’s even more dishonouring to Carrie Fisher is that Dr Leaf’s claims about psychiatric medications are not accurate.

“Sadly, individuals suffering from mental health issues ‘die, on average, 25 years earlier that the general population.’ These medications are incredibly dangerous, and we have to start asking ourselves, as the investigative journalist and mental health campaigner Robert Whitaker notes, if the benefits of these drugs truly outweigh the risks.”

Notice the giant hole in her argument?  She assumes that the increased risk of death in those with mental illness is the medications they’re on, just like she’s assumed that Carrie Fisher died because she was taking psychiatric medications.

That’s confirmation bias, not science.

Real mental health experts – the ones with training, clinical experience and research acumen – directly contradict Dr Leaf.  Experts like Correll, who say that, “Although antipsychotics have the greatest potential to adversely affect physical health, it is important to note that several large, nationwide studies providing generalizable data have suggested that all-cause mortality is higher in patients with schizophrenia not receiving antipsychotics.” [1]

In other words, the life expectancy of people with schizophrenia is shorter than the rest of the population, but it’s much shorter in schizophrenics not on meds.  Psychiatric medications help people with schizophrenia live longer.

In fact, the use of any anti-psychotic medication for a patient with schizophrenia decreased their risk of dying by nearly 20% [2] whereas the risk of dying for schizophrenics who didn’t take anti-psychotics was nearly ten times that of the healthy population [3].

This is the same for other psychiatric medications as well, “clozapine, antidepressants, and lithium, as well as anti-epileptics, are associated with reduced mortality from suicide.” [1]

Psychiatric drugs aren’t “incredibly dangerous”.  Like any tool, when used in the right way, they can bring radical transformation.  What IS incredibly dangerous is the disingenuous and ill-informed making libellous and inaccurate statements about medications they don’t understand.

Not content to just insult Carrie Fisher’s memory, Dr Leaf went on to claim that psychiatric labels are also as harmful as psychiatric drugs.  “These risks are not limited to taking medication. Psychiatric labels can also harm the individual involved. Child psychiatrist Sami Timimi recently discussed the adverse effect the autism label can have on children and adults alike. Labels can lock people in, taking away their hope for recovery, affecting their ability to perform everyday tasks and crippling their determination to live above their circumstances. Words can harm people as much as “sticks and stones” do, as psychologist Paula Caplan notes in her talk on psychiatric survivors and diagnoses.”

It’s witless to suggest that labels harm people or that they somehow lock people in and take away their hope.  The right label, which doctors call a diagnosis, doesn’t lock people in at all, it does the exact opposite:
* The right diagnosis gives hope – hope that comes from receiving the right treatment and not wasting time, money and energy pursuing the wrong treatment.
* The right diagnosis gives power – it empowers people by giving them the ability to make accurate decisions about what’s best for themselves and their loved ones.
* The right diagnosis gives certainty – in many situations, knowing what the diagnosis is reduces unnecessary anxiety and fear.

Imagine that you had a freckle on your arm, and it started growing suddenly.  You go to the doctor, and the doctor says that the freckle is actually a skin cancer.  Does that label lock you in and take away your hope?  Of course not.  It gives you the certainty of knowing that treatment is needed, and the power to decide if you want that treatment.  And it gives you hope that with the right treatment, you can continue to live a healthy life.

In the same way, a psychiatric diagnosis doesn’t lock people in and remove their hope.  A child who understands that they have autism can stop beating themselves up for being ‘odd’ and instead, they can understand that their different wiring gives them special powers that other kids don’t have.

Psychiatric labels do not harm an individual, it’s the backwards opinions of so-called mental health experts that harm individuals with psychiatric illness.  The stigma of a diagnosis is related to the way in which society treats individuals with that diagnosis, not the diagnosis itself.  Perpetuating the myth that that ‘depression and autism aren’t really diseases’ reduces the acceptance of society for those who suffer from those conditions.  That’s what causes harm.

Dr Leaf should apologise to her followers for showing such disrespect for Carrie Fisher, and to all those who take psychiatric medications.  Carrie Fisher spent her life supporting people with mental illness, trying to break down the stigma of psychiatric illness and treatment.  Her life’s work should be celebrated, not defaced by Dr Leaf and her unscientific opinion.

References

[1]        Correll CU, Detraux J, De Lepeleire J, De Hert M. Effects of antipsychotics, antidepressants and mood stabilizers on risk for physical diseases in people with schizophrenia, depression and bipolar disorder. World psychiatry : official journal of the World Psychiatric Association 2015 Jun;14(2):119-36.
[2]        Tiihonen J, Lonnqvist J, Wahlbeck K, et al. 11-year follow-up of mortality in patients with schizophrenia: a population-based cohort study (FIN11 study). Lancet 2009 Aug 22;374(9690):620-7.
[3]        Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63.

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