Iatrogenesis

This, by my standards, is a rather long post.

Iatrogenesis, for me, is a new word. I had never heard of it before. Apparently it from the Greek for "brought forth by the healer" and refers to (quote), “any effect on a person, resulting from any activity of one or more persons acting as healthcare professionals or promoting products or services as beneficial to health, that does not support a goal of the person affected”.

This is a rather long-winded way of saying that a medical professional, instead of doing “no harm”, is actually causing harm.

The fact that word “Iatrogenesis” even exists gives cause for concern and gets me on my “high horse”, again! This is particularly so in relation to mental health.

NOTE - In case you were unaware:-
Common adverse effects of antidepressant medications include headache, nausea, agitation, sedation, sexual dysfunction, cognitive changes, weight gain, and metabolic abnormalities.

Rarer, more serious adverse events include cardiac, neurologic, and hepatic effects. Possible increased risk of suicidality is also an issue in certain patient populations.

In this regard there is quite surprising information in the 2012 report of the Australian National Mental Health Commission. According to this report:

“…. there is little or no accountability as to what improvements we are getting for such a significant investment, whether it improves the health and wellbeing of people with a

mental illness and provides them with the services they need.

Most Australians may not know that treatments with prescribed psychiatric drugs may lead to worse physical health. There are increased risks for some specific treatments such as antipsychotics and for those with underlying vulnerabilities such as diabetes. This can mean that the antipsychotic medications that are prescribed to manage severe mental illnesses such as schizophrenia, contribute to the risk of having severe physical illnesses.”

Interesting. I wonder why this information is not widely disseminated?

If, as many mental health professionals assert, mental disorders are genetic in origin it is interesting to note the curiously plaintive comment made by David Kupfer, MD, Chair of Diagnostic and Statistical Manual, version 5 (DSM 5) Task Force, in the American Psychological Association (APA) press release No. 13-33, dated 3^rd May 2013 wherein he stated:

“The promise of the science of mental disorders is great. In the future, we hope to be able to identify disorders using biological and genetic markers that provide precise diagnoses that can be delivered with complete reliability and validity. Yet this promise, which we have anticipated since the 1970s, remains disappointingly distant. We’ve been telling patients for several decades that we are waiting for biomarkers. We’re still waiting.”

In all this the human brain remains a 1.4 kilogram (3 pound) lump of grey matter, alive but without any sense of touch (it has no pain receptors).

Now I fully appreciate that, often, with mental health, “the facts are uncertain, values are in dispute, stakes are high and decisions are urgent”. In such circumstances it is difficult to resist the temptation to cherry pick data to suit whatever popular theory is being promoted at the time.

Mental health, however, cannot ever be “cured” by drugs alone – in fact antipsychotic and antidepressant drugs are not as effective as “big Pharma” would like us to believe.  I read somewhere (source unknown) that one can hardly prescribe drugs without knowing what is wrong with the patient - and that requires the delivery of a diagnosis – but diagnosing problems in mental health is fraught. There is currently no way – repeat no way – to accurately diagnose a mental health “problem” – apart from Alzheimer’s disease.

The reasons for relying on drugs is an important question that is more often than not ducked by “Health Professionals” and left unanswered. There is, however, a great deal of information available, that is both alarming and illuminating, if one is prepared to dig around.

My point is IF (and it is a big if) these drugs - which have been around in one form or another for over fifty years - are so effective, and if the percentage of people with mental health issues has remained constant for years, at (so we are told) about 1 person in 5, why then is the use of these drugs increasing – not just in Australia, but worldwide?

The medicines, the pharmaceutical drugs that have been developed for use in situations when a person’s mind is deemed to be unhinged or they are behaving in a manner considered to be “abnormal”, work up to a point, to maybe calm the patient. But no one (psychiatrists, psychologists, neuroscientists, pharmacologists et al) knows WHY or HOW they work.

Using the same methods over and over again expecting different results each time is not very clever – in fact I believe this is an indication of some mental problem! Following the same course of action – prescribing medications that cause problems that further application of more powerful medications cannot alleviate is, also, not very clever. And yet this is the current approach to mental health!!!

So there!!!

It has been admirably stated by others that, “If you talk to God you are praying. If God talks to you, you are schizophrenic.”

Consider Moses (Exodus 3.2) - he heard the voice of the Lord coming from a burning bush but no one thinks that’s odd. Now if I presented myself to a medical professional and said that I heard the voice of the Lord coming from a burning bush I know that I would be diagnosed as schizophrenic and immediately medicated!!

A “mental illness” may affect a person’s behaviour - something that they DO.  How can anyone, except the person concerned, determine if such behaviour is “wrong” or “abnormal”? To my knowledge there is no universally accepted definition of “normal” – what is “normal” for me may not necessarily be “normal” for you.  Is it not conceivable that certain behaviours  may be considered eccentric? Surely there are enough “odd-ball” and eccentric people in the broader community to allow for the odd extremes without hospitalising and forcing pharmaceutical drugs on them against their will.

Fixed name diseases – a patient “is” psychotic; or “is” schizophrenic. Whereas another patient may “be a” diabetic; or may “have” breast cancer. Note the difference – the patient is not “breast cancer”. At least with cancers and diabetes there is a physiological condition – something that may be confirmed with a biopsy, a blood test or by other medical means.

What chemical, hormonal or neurological predisposition is there for psychosis, schizophrenia or depression? There are none. That people do suffer from mental problems is indisputable – but what is the cause? And what is the “best” remedy? Is there a “remedy”? If so, why and how would the remedy “work”?

Is it not possible that any and all “mental problems” are the result of the sufferer’s retreat from a perceived threat; a shutting down of “normal” reactions and defence mechanisms; an overwhelmed emotional system; the result of some “unconscious” fear?

More drugs are not the answer!

Can or should grief be medicated?

It is with dismay, bewilderment and some disbelief I read that grief has now been medicalised and been classified as a “pathological” condition. Grief is the most natural emotion or feeling experienced when someone they love dies. I mean even swans grieve (or at least show signs of loss) when their mate dies and will remain near the body of their mate.

Humans have suffered grief and have mourned since they first walked the earth – some 1.5 million years ago so why is it only now in the last few years that it is considered in the same category as a “mental illness”?

Now (as “defined” by the American Psychiatric Association – APA, in their Diagnostic and Statistical Manual version 5, DSM 5) there are Major Depressive Disorders (MDD); bereavement-related major depressions (BRMD); Later Bereavement Disorders (LBD); also - possibly - an Adjustment Disorders (AD) – adjusting to the now changed circumstances. Then there is also apparently research into the validation of intense lengthy grief to determine if this is a “pathology”, (in other words a biological “illness”) - a pathology called “prolonged” or “complicated” grief (PG or CG). Validation, I understand, rests on the risk of “future harm” – thus confusing the (possible) risk of a “illness” with an actual “illness” – if you get what I mean! Or even (gasp!) that grief has been “derailed” and become “frozen” or an “interminable” grief!   

Furthermore, apparently, those who determine these things have decided that grief should only last for two weeks. Any longer and it then becomes depression. Once it becomes depression antidepressants may then prescribed.

One is left to wonder if these “experts” have ever grieved or mourned.

It has been written that: “Grief is an automatic reaction, presumably guided by brain circuitry activated in response to a world suddenly, profoundly, and irrevocably altered by a loved one's death.”

There is one HUGE assumption in that statement; the presumption that grief is the result of brain function. But is this really the case?

In my case it was my “heart” that felt the pain of loss – a gut loss - like a wrenching, a tearing of something. My reasoning – my head – tells me that my wife is dead but it is my heart that feels it, that feels the emotion of the loss. Her love; her companionship; her emotional support; her intelligence; her sense of humour are all now absent.

And I still feel the loss – eighteen months after the “event”. But do I need to be medicated; am I depressed; am I suffering from a “frozen” or “interminable” grief?

Apparently, and totally unconsciously, I have adopted an ancient method of coping – writing and reading about grief and grieving. I certainly find this helps me.

But I know that I will always miss her.

PTSD and those who suffer.

That people suffer the after effects of traumatic events is indisputable and very unfortunate for those experiencing the emotional and mental upheaval – whether or not they have had it diagnosed as Post Traumatic Stress Disorder (PTSD). Yet this condition – PTSD - was “created” by the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM) only in their1980 third revision – DSM III. Prior to this date – while people certainly suffered – it was not categorized as Post Traumatic Stress Disorder.

Traumatic and highly stressful experiences rob us of our belief that we can keep ourselves safe in the world and we wait anxiously for the next traumatic event and react nervously to every unexpected sound –compounding our fearful expectations. Whatever our traumatic experience it is important to remember that such events, though terrible, evoke responses that are ordinary human responses to extraordinary circumstances. Everyone going through such an “out of normal” and fearful experience needs comfort and support, just as we all need comfort and support when, for instance, we are injured, lose a close friend or someone we love. But to categorize our ordinary reactions to this fear or grief as a “mental disorder” both diminishes and demeans our experience. We have had this experience, which is outside our normal expectations, and we react by trying to master our memory of the event and the emotions that are evoked. The mind will often attempt to ‘retreat’ from unpleasant life circumstances. It will do so in the only way it can, by going to a place of refuge and shutting off the ‘hurt’. This can manifest in many ways – as ‘depression’, as apparently delusional thoughts or neurotic behaviour. Such reactions far from being an “illness” are but a desperate attempt to preserve our concept of self, our identity, which is in danger of being overwhelmed.

Since humans first evolved millions of people would have experienced highly stressful or traumatic events. People in antiquity, as far as I understand history, would have suffered the after effects of the trauma experienced in battles and ever present likelihood of being captured and taken into slavery. Similarly in their daily experiences with the natural world of their times – wild animal, floods, earthquakes, droughts, starvation and such like would have tested the resilience of the strongest characters.  

With the winding down of the military activities in Afghanistan many military personnel are arriving home with emotional and psychological scars which need to be healed. Assistance is available for those who wish to take advantage of what is offered.

What happens, however, to those Iraqis, Afghans or Sri Lankans who were caught in the middle – between government military and the Taliban, supporters of Al-Qaeda or militants fighting for their cause? Those people who lost their livelihood, family members or were themselves severely injured by Improvised Explosive Devices (IEDs) or who suffered revenge attacks because they happen to support the “wrong” side – what support do they get? Do they cry? Do they dull the pain with opium? Do they get drunk?

As in most wars it is women and children who bear the brunt of trauma; in all countries it is women and children who endure the effects of violence and abuse of any kind. What support do they get from anyone – anyone at all? What is of great concern about any traumatic event is the long term health effects, even generational health effects it may have on people – possibly even those not yet born.  

Drugs, except in the very short term, generally don’t help and are not a “cure” for PTSD. In any event the side effects of antidepressants and antipsychotics are quite severe. Furthermore to suggest chemicals can address the distressing flash-backs, the recurring memories and recollections, the guilt, the “what if …” or the “if only…” is plain wrong. All chemicals do is to help dull the pain and put a brake on the expression of any emotional response – they have the effect of “dumbing down” the sufferer. This may be good – in the very short term – to give a person time to gain strength but let it be known that there is no known test for a “chemical imbalance” in the brain. Let it be known, also, that no one knows how to measure the “chemical balance” for any person’s brain or to determine what such a “balance” should be.

What is needed is counselling and as much love and emotional support that the PTSD sufferer can get – and time, and sleep, that “knits the ravelled sleeve of care” (Shakespeare – Macbeth).

If antidepressants drugs are so effective ….

If antidepressant and antipsychotic drugs are so effective why are they being prescribed in ever increasing numbers? Something is out of kilter here.

The percentage of the population with some sort of mental issue remains fairly constant at about one person in five (in developed countries that is). But the number of prescriptions issued for antidepressants and antipsychotics are increasing year by year – according to the New York Times “In 2011 alone, they and other antipsychotic drugs were prescribed to 3.1 million Americans at a cost of $18.2 billion, a 13 percent increase over the previous year, according to the market research firm IMS Health.” Again, according to the American Psychological Association (APA) “The use of psychotropic drugs by adult Americans increased 22 percent from 2001 to 2010, with one in five adults now taking at least one psychotropic medication, according to industry data.”  

In Australia the rate of increase in such medications is similar with the rate per 1,000 population of community-dispensed prescriptions for mental health-related medications increased from 2005–06 to 2009–10 by an annual average increase of 2% - roughly 10% in five years or (extrapolating the figures) roughly 20% in ten years (Australian Medicare records).

In the same ten year period the population of the US increased by (again roughly) 10% and that of Australia by roughly 12%.

In summary then – populations of both the USA and Australia have increased by about 10%-12% in the years2001 – 2010 but mental health medication has increased at roughly 20% - 22% in the period.

It may not be a widely known fact but documented research constantly shows that antidepressants and antipsychotics are only marginally more effective than a placebo (a sugar pill). Yet the pharmaceutical companies – they are huge money making organizations – keep telling us otherwise.

My point is IF (and it is a big if) these drugs - which have been around in one form or another for about fifty years - are so effective, and if the percentage of people with mental health issues has remained constant at about  1 in 5 for years, why then is the use of these drugs increasing?

As I said at the beginning of this post – something is out of kilter!!