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

Dr Caroline Leaf – Not a mental health expert

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Dr Caroline Leaf is a communication pathologist and self-titled cognitive neuroscientist.  She wrote a PhD on a learning program developed for an educational setting.  She is not a medical doctor.  She is not a psychologist.  She has no experience or training in the diagnosis and management of mental illness.  She is no more qualified to give advice on mental illness than my hairdresser is.

And it shows in her latest social media post: “Lets really start loving as a church- true unconditional non judgmental love – pushing people away and locking them up and drugging them against their will is not the solution to the the problems of life.”

Her statements is a nonsense, nothing more than a scarecrow fallacy.  Yes, pushing people away and locking them up and drugging them against their will is not the solution to the problems of life, that’s why no one does it.  If people were locked up or drugged against their will because of “the problems of life” then we’d all be locked up and drugged.

The only people that are forcibly treated are those with the most serious of mental illnesses whose condition has deprived them of the insight they need to make the decision for themselves.  Even then, the consent for treatment is given by the next of kin, and if no next of kin can provide consent, then the consent is usually made by a independent statutory body so there’s no conflict of interest.

That Dr Leaf continues to make such inane statements about mental illness confirms that she is not fit to give the church, or anyone else for that matter, any advice on mental health.  She may have a PhD in communication pathology but that is a highly specialised field that doesn’t even begin to cross over to clinical knowledge of mental illness.

Dr Leaf has chosen to fill her vacuum of mental health experience with the opinions of Mad In America, a group that’s irrationally biased against modern mental health care.  She regurgitates their creed almost verbatim – mental illness is over diagnosed, psychiatric medications are useless and dangerous, and Dr Leaf also claims that psychiatric medications are only prescribed to bring the cabal of the American Psychiatric Association and the pharmaceutical companies more power and money.

Psychiatric medications are more helpful than harmful (Leucht et al, 2012, Torniainen et al, 2015).  I’ve discussed this in blog posts in the past.  Yes, they’re not without their side effects, and they’re not for every patient, but they have their place in psychiatric care.  That Dr Leaf can’t or won’t review this evidence is just another indictment against her ministry.  That she actively promotes the idea that pharmaceutical companies and the APA are actively attempting to harm people for their own power and riches is scandalous.

If Dr Leaf was serious about promoting good mental health through the church, she should stop promoting baseless anti-psychiatric propaganda, and start encouraging Christians with mental illness to seek the best treatment available, whether that be medications or counselling or both.  She should also start teaching the church the truth about mental illness … That mental illness isn’t caused by poor choices or toxic thoughts, but because of genetic abnormalities that make the affected persons brain more vulnerable to external stress.

Because to stop turning pain and trauma into shame, anger, fear and then hate, people need correct information to allow them to offer real loving understanding and nonjudgmental support to move through the pain.  At the moment, Dr Leaf isn’t offering the church anything even close to that.

References

Leucht S, Tardy M, Komossa K, et al. Antipsychotic drugs versus placebo for relapse prevention in schizophrenia: a systematic review and meta-analysis. Lancet 2012 Jun 2;379(9831):2063-71.
Torniainen M, Mittendorfer-Rutz E, Tanskanen A, et al. Antipsychotic treatment and mortality in schizophrenia. Schizophrenia bulletin 2015 May;41(3):656-63.

Dr Caroline Leaf – Increasing the stigma of mental illness again

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Let me tell you a story.

A couple of years ago, one of my patients was an elderly gentleman in his late seventies.  He was living in a nursing home at the time, but because of his history of psychosis, he remained on a treatment order – a requirement by law that if he was to remain outside of a mental facility, he had to have regular anti-psychotic medication every few weeks.

This man was on a treatment order because his disease caused him to have delusions.  He misinterpreted what was going on around him, and would not consider that he could be wrong.  In his particular case, he was convinced that his next-door neighbour was a paedophile, and he was planning to ambush his neighbour and castrate him.  Luckily the police had taken my patient into custody before he got the opportunity.  With treatment, my patient had clear thoughts, although needed close supervision.  Without his medication, he became confused and violent.

According to a post on the blog Mad in America and promoted by Dr Caroline Leaf, my patient’s diagnosis was spurious, and he was denied his basic human rights by being forced to take medications.

Dr Caroline Leaf is a communication pathologist and self-titled cognitive neuroscientist.  She is also a self-declared expert in mental health, despite not having any professional training in medicine, psychiatry, psychology or even cognitive neuroscience for that matter.

Indeed, if she had any experience or expertise in mental health, she would have recognised the basic factual errors and logical fallacies that riddled the post she quoted from.

Take the quote that Dr Leaf posted on social media.  The full quote from the Mad in America post is:

“Despite the fact that no one in history, not even the omnipotent American Psychiatric Association – which produces and profits mightily from the ‘Bible’ of mental disorders — has come up with a halfway good definition of “mental illness,” and despite the fact that the process of creating and applying the labels of mental illness is unscientific, any of those labels can be used to deprive the person so labeled of their human rights. This is terrifying. It ought to terrify those who are so labeled and those who are not, because deprivation of human rights on totally arbitrary grounds is inhumane and immoral.”

This is the same tired, emotionally laden and misleading rhetoric that’s so often barked in fervent paroxysms through the foaming lips of those opposed to modern psychiatric practice:

  1. There is no good definition of ‘mental illness’
  2. The American Psychiatric Association is just a profit-driven cabal
  3. The DSM5 (which the author alludes to as the ‘Bible’ of mental disorders) is unscientific
  4. Psychiatric diagnoses are unscientific
  5. Any psychiatric diagnosis can be used as a trigger to force people into unwanted treatments or incarceration
  6. Therefore psychiatric diagnosis and treatment is against basic humans rights and is inhumane and immoral.

Inhumane and immoral hey?  Tell that to my patients neighbour who almost became a eunuch except for that “inhumane and immoral treatment” of my former patient.

Caplan claims just don’t stand up to any rational scrutiny.

  1. There are lots of good definitions of mental illness … modern psychiatry critics just don’t like them. But take the definition used by the CDC, “Mental illness is defined as … ‘health conditions that are characterized by alterations in thinking, mood, or behavior (or some combination thereof) associated with distress and/or impaired functioning.’” There’s nothing wrong with this definition. It describes mental illness and helps differentiate mental illness from variations of mood, thought and behaviour that are part of the everyday human experience.
  1. The American Psychiatric Association isn’t the only group to have created a classification of psychiatric illnesses. The World Health Organisation publishes the International Classification of Diseases, or the ICD, which is also used for psychiatric diagnosis. Is the WHO an evil profit-driven junta too?
  1. The DSM, the ICD, and any other system of diagnosis, are simply different classification systems. Over the last century, clinicians have noted clusters of symptoms and have tried to classify them into common groups. How is that unscientific?  It’s no different to scientists looking at the different characteristics of various animals and creating a taxonomy, to provide a common system and language for clinicians and researchers across disciplines and across countries.The DSM system isn’t perfect, but what system ever is?  As knowledge of neuroscience grows, the classifications are reviewed and tightened in an ongoing process of improvement.  If those who oppose the DSM want to come up with something better, they’re welcome to put something forward.
  1. The old saying goes that medicine is an art and a science. Human beings, as nuanced as we are, often don’t fit into diagnostic criteria as easily as we would like. That doesn’t invalidate the diagnostic criteria or make the process unscientific as critics of modern psychiatry would have us believe, just like an unusual and hard-to-classify form of cancer doesn’t invalidate the other cancer classifications that are well defined.  Psychiatry, by it’s nature, relies on verbal report from patients rather than a clean-cut blood test or piece of tissue under a microscope, so at this stage in history, it seems imprecise.  That doesn’t make it any less scientific.
  1. The allegation that any psychiatric diagnosis can any be used to deprive the person so labeled of their human rights is utter nonsense. It’s a giant scarecrow – it seems really scary, but on closer inspection, it’s just a tarted-up mound of straw.People are never forced into treatments unless they really are “dangerous to themselves and/or others”.  This rule can’t be invoked willy-nilly.  There are multiple checks and balances, and a whole school of civil rights lawyers expectantly circling, ready for the whiff of blood in the water (http://www.mhrt.qld.gov.au/?page_id=2 is an example of the process in my home state, but each jurisdiction has their own version).

Caplan rightly pointed out that those with mental illness were less likely to be the perpetrators of violence and more likely to be the victims, but that doesn’t negate the need for protection of the community from those with mental illness who have shown violent intent and no capacity to control their behaviour.

If you want to find a group that really are suffering from inhumane and immoral deprivations of their human rights, then that would be Christians.  Around the globe, millions of Christians are oppressed, imprisoned, tortured, raped, and murdered every year.

Time and space preclude a full analysis of Caplan’s post, but what’s really important is that both the American Psychiatric Association and the U.S. Department of Health and Human Services’s Office of Civil Rights, an independent ombudsman, dismissed formal appeals by Caplan relating to her hysterical claims of inhumane forced psychiatric treatment.  Dr Leaf conveniently left that out of her social media post.

Instead, Dr Leaf chose to publish one of the most alarming quotes from an article heavy on scaremongering, from a disaffected author on an extremist blog.  If Dr Leaf was a real expert on mental health instead of being a self-declared one, she would have easily seen how nonsensical Caplan’s post was.

By posting this quote on social media today, it’s highly likely that Dr Leaf has caused harm to thousands of vulnerable Christians by unnecessarily increasing the stigma and fear of a mental health diagnosis.  This, in turn, is likely to lead to these same vulnerable Christians missing out on (drug and non-drug) treatment which would help them rise to their true potential in God and in life, leaving them trapped and suffering in their mental destitution.

Dr Leaf has a track record of misinformation when it comes to mental health.  Christians suffering mental illness need more support, not more stigma.  It’s time Dr Leaf stepped aside, and stopped making things worse.