Wednesday, 3 September 2014

Propaganda: A battle for our hearts and minds?

World War 1  Propaganda and the public mind

As you will be aware, it is now 100 years since Britain entered World War 1. It was a war, as period propaganda claimed, “To end all wars”; we now know how false that claim was. It was also portrayed as a war to protect freedom and to safeguard democracy.

History tells us that propaganda had an enormous impact on the events and outcomes of WW1. Noam Chomsky suggests that one legacy of the ‘Great War’ is that it brought into focus just how effectively the “public mind” could be manipulated by propaganda; thus undermining a basic principle of democracy: the “consent of the governed”. [1]

In the modern world where we live immersed in a sea of information, misinformation and downright deception – vying for our attention and compliance – I wonder if we run the risk of being so acclimatised to its presence that we fail to see its impact on shaping: how we think; the opinions and values we hold; what we do; our ability to make free and reasoned choices and even on how we see and understand ourselves. In one sense we are of course inseparable from the society in which we live, but this still raises the question: how free are we in a 'free society'? And what are the impacts on our health?

A battle for our minds  can we simply walk away?

I think you will agree that our minds are open to suggestion and deception at many levels and from all sides – through TV, newspapers, social networking sites, advergames, through our letter boxes, adverts on bill boards or popping up everywhere on the internet – even within respectable medical journals. This constant stream or torrent of propaganda, persuasion, exploitation and deception – sometimes in our faces, at other times more covert – all in an effort to manipulate what we think, do, and how we spend our money: we are perpetually being told how we should look, what foods to eat, where to shop, what to wear, the fashion to follow, products to buy, the best holiday deals, the pills to perk us up, the perfect cream to prevent wrinkles…

But of course it goes deeper than that.

A society hungry for at least the-appearance-of-science

Perhaps some of the most subtle (and perhaps powerful) influences on our thinking are the oft repeated everyday discourses that have infiltrated our lives and assumed an air of authority way beyond their truth value – I’m thinking of dominant discourses that have set an established or acceptable way of viewing things and govern attitudes and public opinion on health, mental health, democracy, gender, ethnicity, body image, education and the like – that are often reinforced by the repeated, uncritical and careless acceptance of the media and any with vested interests. These attitudes and beliefs then become a fertile ground for manipulation by those with political and/or financial interests. 

More specifically, in the arena of mental health, dominant discourses are fed by a broad diet, including: ‘pop psychology’ and also its overlap with the self-help industry; the deceptive use of medical and/or scientific terminology; the creation and perpetuation of unsubstantiated claims as if they are fact by mental health agencies and professional bodies – often using misleading metaphors that carry popular appeal; direct marketing and misinformation (sometimes downright deceit) by drug companies; and increasingly the misleading use of pseudo-neuroscience lingo, imaging and claims (what Prof Raymond Tallis refers to as “neuromythology” and “neurotrash”) – all in all, a diet that seems to feed and possibly mislead a society hungry for at least the-appearance-of-science to explain and address life’s uncertainties, pain and mysteries.

Media savvy, clever branding, celebrity endorsements and pretty charts

At one time it was the large corporations, the media, and governments that had the greater means to shape and manipulate our thinking; yet today, in the social media age, everyone has the means to promote their ideas. But sincerity and truth can become clouded in a world where news is infused with advertising and the boundaries between good will and the manipulation of others becomes blurred. It worries me when I see groups (including charities) fire out tweets supposedly showing concern for others, but who seem motivated by a need to meet targets; where web chats hosted by "experts" can have the ulterior purpose of drawing in customers (this happens in mental health); and where misleading (out of date and subjective) statistics are frequently circulated to drum up support for particular causes (I see this a lot with children's mental health): this is self-serving, sensationalism and scaremongering. I sometimes wonder if media savvy, clever branding, celebrity endorsements and pretty charts have superseded wisdom and integrity.

The appearance of freedom  consent without consent

This potential for deception and exploitation in the modern world leads me to wonder how free we really are in a so-called free society and to what extent this battle for our minds shapes how we understand ourselves, impacts upon our ‘mental’ health and well-being, and on how we see our place or purpose in society: essentially, who I am and why I am here.

We have perhaps merely the appearance of freedom where our personal decision-making can be little more than “consent without consent”[2] – a term originally used by sociologist Franklin Giddings in the 20th century – whereby we are erroneously led to believe that we are freely making choices [3].

But for a moment, let’s return to the First World War, as in one sense, the seeds of the widespread propaganda and manipulation of our minds today were propagated through those fields of death and decay – the very battles fought to protect our freedom and to safeguard democracy. What I mean by this will soon be clear.

Lured to war – the power of propaganda

Though World War 1 was well well before my time, I did come close to this war for just a moment some years back: I had been asked to help sort through an old suitcase packed full of correspondence; as I sifted through these letters and post cards I realised they had been written by a soldier fighting on the front lines in France during the ‘Great War’. Time seemed to fade as I read them and as I held a small yellow wild flower, still almost as bright as the day it was picked, that he had taken from the Somme – placed carefully in a folded letter – and then posted home to his wife here in England. I now know that there were large patches of Wild Mustard (Yellow Charlock) at the Somme.[4]

There are many amazing things about WW1; not least, that so many young men volunteered to go to the killing fields to be mown down by artillery or gassed to their death – with, for example, nearly 20,000 British deaths (and many more wounded and maimed) on just day one of the Battle of the Somme.

But the soldier I mentioned did survive the Battle of the Somme; in fact, he survived the war and lived to old age. His wife, though, held on to those memories with his letters and flower as she outlived him. A few years after his death, now bedridden, she was helped from her bedroom; noticeably, her husband’s clothes were still across the bottom of their bed as if he had never gone.

Behind the scenes: a battle for minds & hearts – not just a conspiracy theory

News of the loss of husbands, brothers, colleagues and friends did not derail the war recruitment campaign which drew nearly 2½ million volunteers to the theatre of war (what a misleading euphemism that is) prior to conscription in 1916: that propaganda ‘machine’ – driven in part by the covertly set up War Propaganda Bureau here in the UK – churned out many thousands of posters and leaflets to drum up support and sway public opinion. 

This war was not just a battle of tactics, brute force and barbarism on the battlefields but also a battle for peoples’ hearts and minds. Misinformation proved to be a powerful force; indeed, the amazing power to manipulate the minds of people and nations to such a great effect got one man, among others, thinking. If propaganda could change the course of war among nations, it could surely manipulate a nation in peace time too: meet Eddie Bernays – the “father of spin”.

Edward Bernays (1891-1995 yes, that’s correct, he lived to 103), nephew to Sigmund Freud, was familiar with the power of spin as he was a member of the US Creel Commission that was instrumental, through its propaganda campaign, in swaying US public opinion to support their entry into WW1. He had also noted how effective propaganda was for the British during the war.

Puppets on a string

I mention Bernays as his 1928 public relations manual – Propaganda: the Public Mind in the Making – seems to describe so clearly the manipulation and deception that is now so typical of aspects of business and politics in our democracy, where a minority hold most of the wealth and decision-making power. Ironically, his manual reads more like a blue print for a more totalitarian society rather than for the democratic society we would hope for. You can read the full text – over 150 pages – here.

But here the cat is out the bag: we can see the makings of an unequal and divided society that is modelled on a top-down rather than genuine participatory democracy – with a cocktail of capitalist-consumerist thinking blended in; and ‘the public’, that's you and me, viewed as mere puppets on a string. You can get a taste from some quotes in the graphic below.

Shaping what we eat and our thinking around food

The food and drinks industry is a clear example of Bernays' model in practice. Over the past 50 years the industry's advertising has lured countless millions, from cradle to grave (literally), into eating poor quality, processed, and adulterated food; meanwhile, a few major companies have become fat on the profits and wield enormous power and influence (see image below) – and let's not forget the McDonalds-type fast food chains and the targeting of children through games, gifts, gimmicks, advergames and the like – appearing to offer choice whilst manipulating the minds and habits of our children too. This is, to coin a phrase in the tradition of Big Pharma: 'Big Foodma'. I'm no scaremonger, but this battle by Big Foodma can of course lead to all manner of health problems, including heart disease, diabetes (potentially causing blindness and other severe disabilities) and early death.

It is perhaps easy to forget, amid the constant barrage of food advertising, especially on TV, that the building blocks for the neurotransmitters in our brains – the nerve pathways that the drug companies tell us need modifying through 'mood stabilisers' and 'antidepressants' and the like – are formed and maintained through a nutritious diet. So for our brains to produce serotonin, for example, we need the amino acids L-tryptophan and 5-HTP in our diet. In addition, a nutritious diet provides us with the necessary vitamins and other micro-nutrients essential for mental and physiological health, including hormonal balance.

That's not of course to say that all answers to life's woes come in the form of food (or drink!). And let's not assume that natural automatically means healthy or that the health food and supplement industries are not there for mega bucks either.

A sad casualty of the propaganda model of the food & drinks industry is that many of us fail to realise the extent that foods have on our thinking, moods, behaviour, and mental stability – as well as on our physical health. If this were a book, the impact of diet on our mental well-being would be a chapter.

A propaganda model of health  where our health is the casualty

The fact that boundaries between health and sickness are often really quite arbitrary leaves the door open for exploitation; thus, many aspects of our everyday lives are misleadingly being portrayed as ill-health. This may be good for the drug industry but it may not be good for our health. We get this with, for example, childhood behaviour problems, bereavement, and the ageing process. Simply tweaking a threshold, as was done with osteoporosis (the thinning of bones) led to an 85% increase in patients overnight [5]. The problem is, there is a strong cultural expectation that healthcare decisions are usually in our best interests, when this is not necessarily true. As Dr Iona Heath says, it is “in the interests of pharmaceutical companies to extend the range of the abnormal so that the market for treatments is proportionately enlarged.”[6]

We get a similar pattern in mental health.  As Dr Allen Frances writes: “There's been a rapid diagnostic inflation over the course of the last 35 years, turning problems of everyday life into mental disorders resulting in excessive treatment with medication. Pretty soon everyone's going to have a mental disorder or two or three, and it's time we reconsider how we want to define this and whether the definitions should be in the hands of the drug companies, which is very much what's happened in recent years.”

And if you think I exaggerate, please look to the drug company business plans – here, for example, one company’s projection is that “The Attention-Deficit Hyperactivity Disorder (ADHD) therapeutics market value will rise from $6.9 billion in 2013 to $9.9 billion by 2020, with broadening diagnostic criteria a key driver of growth”. That’s hot off the press, August 2014, and here’s their more in depth “reasons to buy”. And let’s not forget, this is about making money out of the attention and behavioural struggles of growing children. I write about ‘ADHD’ here, and comment on the medications here.

We have, says Prof Leemon McHenry, “a propaganda model of medical research” in which “drug promotion masquerades as scientific research” and one in which “Pharmaceutical companies have become the patrons of medicine” [4].

So devious is the drug industry track record that medical researcher Prof Peter Gøtzsche of the Cochrane Collaboration goes as far as to say: “Remind yourself constantly that we cannot believe a word of what drug companies tell us, neither in their research nor in their marketing or information to patients.”[7] What is beyond dispute is the wake of multibillion dollar legal fines following misconduct and illegal practices by the drug companies across the globe. Here are some of the big ones; I’ll leave you to do the maths.

“Yes, we are big, racking up $300 million in sales every day” says Pharma CEO

We really do need to be on our toes as the drug companies seek to infiltrate and manipulate so many aspects of our lives through: behind the scenes lobbying of government ministers here in the UK, creating front groups, funding patient groups (for say, ‘Bipolar Disorder’, ‘ADHD’) that the public expect to be unbiased, having their say surreptitiously in parenting web sites, getting people to complete online questionnaires that then indicate a particular disorder and treatment, influencing the scripts in TV soaps, having vested interests in many health web sites – the very places that are becoming the first place to look for health information. This is the "engineering of consent" (Bernays, 1947).

Pharma is much smarter and further ahead of the game than most people realise. What’s more, they have the profit power to do this. As one Pharma CEO boasts, their revenues for last year were $78 billion, and “yes, we are big, racking up $300 million in sales every day”. It's not that drugs are necessarily bad, but that our freedom to make informed choices is dependent on the honest and free availability of industry-independent analysis of the data – and it is this open access and transparency that drug companies so often resist.

The sinking of NHS Illustrious

It is also alarming that private health care firms with close ties to Tory donors (more details here) are being awarded vast sums under ‘health care reforms’ as the NHS – the envy of many a nation – is being dismantled and disabled by back-door creeping privatisation through misguided (and misleading) government policies and agendas. Yet again, this is not about the publics’ interests, but the profits of the privileged few.

The illusion of freedom in a free society – winners and losers

In Britain the gap between the rich and poor seems to be widening; in addition, a relatively small group of people still hold disproportionately high levels of wealth, power and influence. We also know that social deprivation, social inequality and income inequality are a significant predictor of mental and emotional problems in a person’s life. This isn't the hard won democracy (lit people + rule), the rule of the people that many have given their lives for. Sadly, something really isn't working is it? But this is not simply about propaganda or even misinformation, but like any battle, it is also about power, and power struggles too.

Inevitably a class-divided society becomes increasing volatile as deceit and manipulation lead to oppression. There are winners and losers, and in a society where the increase between those who have and those who have little continues to rise, we can expect not only a rise in social unrest and civil disorder, but also widespread mental, emotional and social problems. The idea that so-called ‘mental illness’ happens (and/or can be treated) outside of a social and interpersonal context is a misleading one. 

More and more I am realising that conventional responses to personal concerns are not sufficient and leave people still looking for answers or feeling lost and abandoned. We have to get way beyond thinking in terms of anxiety, depression, mood disorders and the like as if they were specific entities or diseases that match predetermined treatments. The personal problems encountered are so often rooted in peoples' experiences of a society with contradictory messages and values – and these are destructive.

In a highly competitive power-seeking society, bombarded as we are from all sides – with unlimited information, propaganda, suggestion and deception – it's not easy to form authentic opinions or even a clear enough sense of who we are and a personal sense of meaningfulness or purpose. This needs much careful consideration in the stillness, if we can find it, aside from the competing 'voices' all around us that are fighting for our attention and obedience.

I am finding that people often experience liberation through being able to see more clearly – on a personal, interpersonal, and societal level. I believe a crude reductionist and simplistic category-defined approach to personal concerns is a ‘convenient’ product of our times that can hinder our insight. To a significant degree we are being shaped and miss-shaped by a society that is ripe with contradictions and tensions: purporting to advocate freedom while ensnaring the majority, and where essential values of human decency can so often be suppressed by the drive and rule of profit-power serving motives at large.

“But, by my love and hope I entreat you: do not reject your love and hope!"
– Friedrich Nietzsche, Thus Spake Zarathustra

© Mick Bramham 2014


[1] Chomsky, N. (2001) Propaganda and the Public Mind. Pluto Press, London; Chomsky, N. (2003) Understanding Power. Vintage Press, London; Chomsky, N. & Herman, D. (1994) Manufacturing Consent. Vintage Press, London.
[2] Chomsky, N. (1998) Profit over People. Seven Stories Press. New York.
[3] Democracy and Empire by Franklin Giggings. Review by Evander Bradley McGilvary. Duke University Press. See here.
[4] Hill, A. W. (1917) The Flora of the Somme Battlefield. Kew Bull. Misc. Information, Nos. 9 and 10, pp. 297-300.
[5] Welch, H.G. (2011) Over-diagnosed: Making people sick in the pursuit of health. Massachussets: Beacon Press.
[6] Heath, I. Combating disease mongering: Daunting but nonetheless essential. PLoS Medicine April 2006 Vol 3 Issue 4
[7] Gøtzsche, P. (2013). Deadly Medicines and Organised Crime: How Big Pharma Has Corrupted Healthcare. Radcliffe Publishing. London/New York

Answer to earlier question: Spoof!

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.
He has a particular interest in ethical issues and also in how our lives are shaped by the society, circumstances and culture in which we live.
Mick was Executive Director of a crisis response and mental health charity for over 20 years - working in partnership with social care and health - in support of socially marginalised (including those homeless) people.
He has an ongoing interest in the theory, practice, and policy-making in regard to what is generally referred to as 'mental health'.
You can read more about his work and find his contact details here.
Follow Mick on Twitter @MickBramham

Friday, 11 July 2014

Sex and SSRIs

There was a time when combat trauma was dismissed as personal weakness, failure, and even cowardice. We’ve all seen images of shell-shocked youths emotionally scarred through World War 1 trench warfare. And tragically, the only recognition that some of them got was a brief medical examination and trial before facing a firing squad as they were shot as deserters. In fact, that same merciless attitude lingered on after WW1 - we see this in a British Government report of 1922 that made clear: “No soldier should be allowed to think that loss of nervous or mental control provides an honourable avenue of escape from the battlefield.” [1]

Over time, trauma, including combat trauma and stress, has become recognised as potentially debilitating and not as a sign of weakness or cowardice. Official recognition seems to have been spurred by the countless US Vietnam war veterans needing help. And I have no doubt that the DSM III creation of the diagnostic category of Post Traumatic Stress Disorder (PTSD) in 1980 - in the wake of the end of the Vietnam War - was in some way connected to the need for referencing insurance claims.

Post-SSRI Sexual Dysfunction (PSSD)

There is however another trauma that some people are experiencing. It is not the result of war but rather from a battle with depression. These people are also victims and there are those who are not keen for it to be recognised for what it really is. Alas, their suffering continues. It is the damage caused by the SSRI antidepressants: I am specifically thinking of Post-SSRI Sexual Dysfunction (PSSD). PSSD has been referred to as a “stress syndrome” (details here) - such is the impact on the body’s physiology.

Put simply, this is drug-induced damage to a person’s sex life leading to a possible long-term condition known as Post Treatment Enduring Sexual Dysfunction (PTESD). Not what you might expect from taking such commonly used and every day drugs – antidepressants.

There are two aspects here: sexual dysfunctions that people experience after stopping the drugs (PSSD) and sexual problems as adverse effects while still taking them.

Although drug-induced sexual dysfunctions have been played down by drug companies, some suggest they occur in over 50% of people taking antidepressants [2]. We know that a range of sexual dysfunctions are common with people taking SSRIs, as with their close relative the SNRIs. For example, this study on Iranian patients showed:
"A total of 75% of patients reported sexual dysfunction: 66.7% of men and 79.7% of women. A total of 74.1% of patients on fluvoxamine, 100% on fluoxetine, 75% on sertraline, 71.4% on citalopram and 100% on paroxetine reported sexual dysfunction. The most frequent sexual dysfunction was difficulty with orgasm, which affected 41.17% of women and 33.33% of men."[3] (These figures refer to adverse effects while actually on these drugs)
Attributing these sexual problems to a person’s depression - the blame the patient game - fails to hear those people who are clear that sexual problems/dysfunctions were not present in spite of their depression prior to taking SSRIs. And there are of course others who take SSRIs for reasons other than depression, but still end up with sexual dysfunctions.

But the issue here is not simply the occurrence of these terrible problems during treatment with these antidepressants; rather, it’s the reality that these problems could persist or occur after stopping the drugs [4]. In fact, some people will only become aware of this treatment-induced disorder after stopping these antidepressants.

PSSD is not spoken about a lot. Some people with vested interests may tell you it doesn’t exist. For those harmed by these drugs, it is of course a very private and personal matter. Silent suffering may mean the extent of this problem is considerably more widespread than so far recognised. And yet, I have not heard of anyone being warned when put on SSRIs that for some people - taking them could mean an end to their sex life for some years, maybe longer.

According to Prof David Healy, we are not necessarily talking about high doses over many years; notably, “PTESD can happen after very brief exposure to an SSRI or related drug (3 days)” - see here. Yes, you read that correctly, after just a few days use.

And as you can also read in that paper, SSRIs are not the only drugs that can cause PTESD (drugs such as quetiapine, lithium and haloperidol seem to be implicated too). You will see in Table 6 of that paper that there is a range of sex-related problems that can occur through taking SSRIs, including: loss of libido, genital anaesthesia, orgasm difficulty, ejaculation problems, and erectile dysfunction.

Like much of modern life, commercial interests seem to govern what we know or don’t know. But, as Audrey Bahrick writes here, the fact that “the short acting SSRI dapoxetine (Prilogy) is currently marketed in over 50 countries to treat premature ejaculation” gives us just a hint about what drug companies really know about the effects of these antidepressants. According to RxISK “The U.S. package insert for Prozac is the only place that says that ‘symptoms of sexual dysfunction may persist after treatment has stopped.’”

As with combat stress, people with PSSD need to know they are not making this up, they need to be believed, and they need to know the truth. Remember how millions of people were coaxed into volunteering to the WW1 trenches: through poster advertising campaigns, door-to-door visits and even popular music hall artistes wooing them to war. Most had little idea of the horrors that really awaited them.

Over the past 25 years antidepressants have been heavily marketed through a carefully crafted campaign. But a closer look at the testing trials of these drugs shows deceit and cover up by drug companies – leading to benefits being exaggerated and risks played down. And yet, over 50 million antidepressant prescriptions are issued in England each year (based on 2012 figures) - I understand that’s approx 100 every minute. How many people do you think were warned of the possibility of PSSD?

From my experience from working with adults, families and young people I feel sure that antidepressants are way over-promoted and over-prescribed without people being made aware of the risks. I mention some of the other risks here. And I agree with Dr Mickey Nardo, that “antidepressants are used too often, too long, too casually, and stopped too abruptly.”[5]
"It is important that patients are informed about the high probability of sexual side effects while on SSRI medications... Patients should also be told that there are indications that in an unknown number of cases, the side effects may not resolve with cessation of the medication, and could be potentially irreversible." Csoka et al [6]
Now that raises an important question. Is PSSD treatable? This is a question others are asking and discussing at RxISK here.

It took far too long for the trauma and stress of war to be taken seriously. Indeed, there are those who would say that even today the plight of those wounded in this way is not taken seriously enough. Dodging the grave issue of PSSD won’t give sufferers any hope or relief – or prevent others taking these drugs unaware of the risks. Ultimately our GPs need the facts to inform their patients. Inevitably this takes us to the need for genuine transparency when it comes to drug testing, marketing and prescribing so that at the very least, people can make informed decisions for their mental, emotional and physical welfare.

See below for references. 

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.
He has a particular interest in ethical issues and also how our lives are shaped by the society, circumstances and culture in which we live.
He trained at Regent's College London, and is a member of the Society for Existential Analysis.
Although he has serious concerns about the inappropriate and excessive use of mental health medications, he supports the freedom to choose (to take or not to take these drugs) and the right to be fairly informed of their limits and the risks. He offers support for people who are considering reducing or coming off psychiatric drugs.
He has a long-standing interest in non-clinical (and non-coercive) responses to mental and emotional distress.
You can read more about his work and find his contact details here. Follow Mick on Twitter @MickBramham

 Ted Bogacz. War Neurosis and Cultural Change in England, 1914-22: The Work of the War Office Committee of Enquiry into 'Shell-Shock'. Journal of Contemporary History, Vol. 24, No. 2, Studies on War, (Apr., 1989) Available here.
[2] Healy, D. et al 2012 Data Based Medicine Position Paper: Antidepressants for Takers (RxISK). Available here.
[3] Safa et al. Study of Effects of Selective Serotonin Reuptake Inhibitors On Stages Of Sexual Function In Iranian Patients With Major Depressive Disorder. Therapeutic Advances in Psychopharmacology Dec 2013. Available here.
[4] Bahrick, A. Persistence of Sexual Dysfunction Side Effects after Discontinuation of Antidepressant Medications: Emerging Evidence. The Open Psychology Journal, 2008, 1, 42-50. PDF available here.
[6] Csoka et al. Persistent Sexual Dysfunction After Discontinuation of Selective Serotonin Reuptake Inhibitors. J Sex Med. 2008 Jan;5(1):227-33. Abstract here

Further info
Wikipedia editor inserts foot in mouth (RxISK), blog post here.
PSSD – One Hundred and Twenty Cases (RxISK) blog post here.
Recovering from PSSD (RxISK) blog post here.

Friday, 27 June 2014

Umm. Do I smell a lab rat?!

I see there is a new study out (Funded by the Agency for Healthcare Research and Quality, and the National Institutes of Health) that suggests that there is "no substantial increase in the risk of cardiac malformations attributable to antidepressant use during the first trimester" of pregnancy.

As this conclusion appears to go against the grain of what I have already heard about the risks of SSRI anti-depressants, I am left wondering if I have previously been misinformed - or whether I am now being misinformed. So often it is more about what is not being said, rather than what is presented in a study report, that governs the conclusions we might come to.

When I see the potential for conflicts of interest in studies I do wonder about research bias. Of course this is not necessarily so, but I ask myself: "Do I smell a rat?!"

I look forward to reading comments on the New England Journal of Medicine website in due course (hoping they will publish readers' responses) that might enlighten me.

But should a rat eat just one grain of truth - are we left with truth?

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.

He has a particular interest in ethical issues and also how our lives are shaped by the society, circumstances and culture in which we live.
He trained at Regent's College London, and is a member of the Society for Existential Analysis.
Although he has serious concerns about the inappropriate and excessive use of mental health medications, he supports the freedom to choose (to take or not to take these drugs) and the right to be fairly informed of their limits and the risks. He offers support for people who are considering reducing or coming off psychiatric drugs.
He has a long-standing interest in non-clinical (and non-coercive) responses to mental and emotional distress.
You can read more about his work and find his contact details here. Follow Mick on Twitter @MickBramham

Monday, 2 June 2014

Caught in the crossfire: antidepressants are good, no they are bad

Are antidepressants a good or a bad idea? Based on recent articles from the popular and academic press - these drugs are seriously harmful, or they are as safe as houses. It just depends on who you believe. Confused? You should be.

Now any sensible thinking person will immediately say: “it’s not that simple, it’s not a clear-cut case of good or bad, or either-or.” And of course, you are right.

As I have suggested, recently there seems to have been a spate of articles on antidepressants and other mental health drugs. But repeatedly releasing articles (with minor variations) doesn’t really work for me: I feel storm-battered and, in fact, I simply stop listening. It’s the same when someone loudly raises their voice in discussion – I begin to suspect their argument might be flawed.  I don’t want this to get unnecessarily personal, so for once I won’t include links and citations; suffice to say, in the main, I’m referring to medical doctors and academics writing for or against these drugs.

But as you have also noticed, there is more going on here. It’s not just about whether antidepressants (or other mental health drugs) are good or bad for us. There’s more at stake.

It’s far too easy to get locked into a defensive position, isn’t it? Ideas can become ideals, and before long our personal sense of identity can become bound to an ideological position. Our reasoning becomes unreasonable and soon we can end up quite simply stuck in the mud of cherished beliefs. Sadly, it can feel a safe place to be.

I know about dogma and ideology. I grew up being told what ‘the truth’ was. This ‘truth’ told me who I was and why I existed. This ‘truth’ had ‘answers’ (so I thought) for much of life and stifled out comparative views or discourse. As a young person I formulated an idea about who I was in terms of what I was not; that is, not like one of those who didn’t see life through this narrow and life-constricting lens. Though that’s not how I would then have seen it.

With the passing of time and unforeseen grievous experiences along the way, the pillars of my truth-existence were shaken to their foundations. I slowly began to see that truth is not as fixed or absolute as I had been led to believe.  I recognised that truth is no ‘it’ but rather what emerges when there is openness rather than dogmatism.

And yet, with regards to mental health I see and read the same old arguments going back and forth as they have done for decades. The camps are clearly defined and their advocates seem to know just where they are positioned.

Strange really that I should mention this, for when it comes to antidepressants I too have strong views. When I read critical analyses of drug company misrepresentations of RCTs I know I have been systematically lied to by the drug companies. And something is terribly wrong when harms are being trivialised by so-called key opinion leaders even though the evidence is there and countless people are witness to devastating harms - including the loss of loved ones.

It can be discouraging when opposing parties will not listen – not just to one another, but to their own consciences. How deaf we can be to what could be a co-evolving and emerging sense of truth and rightness – or, to use an old English and now obsolete word, “rightwiseness” where wisdom and truth can merge for the benefit of all.

I respect the frustration of those who believe that their sense of what is true is not being heard. I respect the desire to protect others from unnecessary harms. But doing this in such a way that people don’t stop listening and remain open to dialogue is not always that straightforward.  I so like the concept of ‘discourse’, our English word derived as it is from the Latin discursus “running to and fro”. As I see it, discourse invites us to run to and fro as it were, back and forth, this way and that, as we seek to level out that which is not worthy of truth or justice. But it is not a running away from difficult counter-challenges or hiding behind personal or ad hominem attacks.

Finding the balance between having an opinion and not imposing it upon another isn’t always that easy. And there can be casualties caught in the crossfire of “these drugs are good for you” and “no they are not…”. What about the person who has tried time and again to come off the drugs - but for one reason or another, this has not worked out for them? Are they unintentionally being set up for more discouragement and a greater sense of failure? Perhaps these people could be borne in mind when articles are written.

What about those who genuinely find antidepressants and other mental health drugs helpful? Are their experiences to be denied? Equally, insisting these drugs are virtually harm free, as I have recently read, denies the reality of the experiences of those seriously and permanently harmed by them. Furthermore, talk of reducing or stopping can be most intimidating for the individual who believes the drugs to be a life-line; as perhaps their only hope. It calls for sensitivity. It calls for wisdom.

But considering another person’s feelings and possible reactions does not mean compromising one’s values. I guess it’s not just what is said, but how.

“We each begin probably with a little bias and upon that bias build every circumstance in favour of it.”
- Jane Austen, Persuasion

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.
He has a particular interest in ethical issues and also how our lives are shaped by the society, circumstances and culture in which we live.
Although he has serious concerns about the inappropriate and excessive use of mental health medications, he supports the freedom to choose (to take or not to take these drugs) and the right to be fairly informed of their limits and the risks. He offers support for people who are considering reducing or coming off psychiatric drugs.
He has a long-standing interest in non-clinical (and non-coercive) responses to mental and emotional distress. You can read more about his work and find his contact details here.

Friday, 7 February 2014

Mental illness or injury?

“It was all I knew” said one person to me recently who suffered sexual abuse, violence and total neglect from when just 4 or 5 years old. “I may have been even younger when it all started, I just don’t know”, the person added.

Given the right opportunity, it is no surprise that those who have been treated so unjustly (words fail me) begin to ask all manner of questions as they try to somehow make some sense of the senselessness. “To what extent has this made me the person I am today?” “The extreme moods, the feeling depressed, the difficulty sleeping at night…is this a mental illness?” And without even a hint of self-pity: “Why me?”

A year or two ago I had an email discussion with someone who contacted me but who wished to remain anonymous. She began with a question: isn’t it sometimes more appropriate to speak of injury rather than mental illness when referring to those who have been abused? (That’s mental, emotional, violent and/or sexual abuse).

She felt that “labelling survivors of abuse as having an ‘illness’ only serves to assist those who have a vested interest in that situation remaining unidentified and uncorrected” – those were her exact words. It was as if she was being made out to be the sick one – instead of being recognised as the injured party and the victim of injustice. One could of course argue that viewing her plight as an ‘illness’ does not necessarily mean that it was not also an ‘injury’. She too recognised that, as that which injures us (including trauma) can make us sick in one way or another.

In our discussion she pointed out that an injury is “damage or harm done to or suffered by a person”. Interestingly, our word ‘injury’ is derived from the Latin ‘iniūria’, which has a range of meanings: a wrong, injury, abuse, sexual assault, damage, hurt, offence, injustice, outrage.

Our discussion broadened as we considered the experiences of those people who have found psychiatric practices to be overly coercive and injurious.  And what about the harms (sometimes irreversible debilitating long-term damage) from taking mental ‘health’ drugs – isn’t this also injury? Sadly, people still get told that it is their (mental) ‘illness’ when adverse drug reactions such as anxiety, depression or psychotic experiences occur.

There is of course an old Szaszian debate about whether or not so-called ‘mental illness’ is rightly deemed ‘mental’ (the impact affects the whole of our lives) or is really an ‘illness’ as such (medically speaking); just now, that’s a distraction and I have no intentions of going there. But there is no doubt that there are countless people diagnosed as suffering with anxiety, depression, fears, and the like, who have been oppressed by others and are the victims of repeated and horrendous injustice. It may be that some of these people (like the anonymous person who so thoughtfully wrote to me) may find it helpful to think of the impact of their life experiences more in terms of ‘injury’ (what others have done to them) than as an ‘illness’ (that they happen to have).

“A person may cause evil to others not only by his actions but by his inaction, and in either case he is justly accountable to them for the injury.”
― John Stuart Mill, On Liberty

Wednesday, 31 July 2013

ECT: This is shocking

A recent BBC Newsnight feature asked: “Why are we still using electroconvulsive therapy?” It’s an important question. While crude psychiatric ‘treatments’ from the early-mid 20th century like surgical lobotomies and insulin coma therapy have been recognised for what they really are (dangerous and barbaric) and have been withdrawn from use, electroconvulsive therapy (ECT) has managed to survive.

I first came across ECT back in 1975 when I saw it portrayed in the film One Flew Over the Cuckoo’s Nest. I was at that time working in a small psychiatric unit where the psychiatrist-in-charge was making radical changes - including the removal of bars from the windows and developing a more home-like milieu. His contextual understanding of mental and emotional troubles had a profound influence on my life.

Then, within a few years of seeing One Flew Over the Cuckoo’s Nest, ECT came nearer home as I had the unpleasant experience of accompanying one of my parents to a London hospital for repeated ECT treatments. The whole process was depressing (for both of us) and erased important memories from my parent without any hint of lifting the depression. Since then I have known many people who have endured multiple ECT ‘treatments’.

ECT ‘works’ by inducing a grand mal seizure. This is shocking; there’s no getting away from that. Prof Steven Rose describes it like this: “ECT puts a blast of electricity across the brain, temporarily disrupting communication, killing some cells, erasing recent memory and generally inserting a large clumsy spanner into the brain’s machinery…for any neuroscientist, the thought of such a massive, if brief, intervention into the delicate workings of the brain must be a cause of concern, however well intentioned the therapeutic goals might be”.[1]

This ‘treatment’ inevitably raises ethical issues; not least, when used against a person’s wishes, as still happens here in the UK. But there is another ethical issue: what if a psychiatrist would rather not subject a patient to ECT?  This matter was raised by the Critical Psychiatry Network in a letter to the Royal College of Psychiatry (RCPsych). The request (signed by Dr Joanna Moncrieff and Dr Rhodri Huws) asks “that the College consider dropping the obligation for trainees to conduct ECT during their training.” Now that’s an interesting request.

It is understandable that some psychiatrists would want to take an ethical position against having to administer ECT; rather like doctors are able to opt out of conducting abortions. What is striking is the immediate displeasure by the President of the RCPsych and the strength of the refusal by the follow-up letter ten months later on by the Dean.

I have never thought about it quite like this before, but insisting that all trainee psychiatrists perform ECT must surely act like a filtering system – potentially screening out some very able and conscientious people who are loyal to the “Do no harm” principle underpinning medical ethics; perhaps the very people able to compassionately respond to those suffering with mental and emotional pain.

A willingness to reflect on what we are doing (or asked to do) and why we are doing it is of course essential for progress. This reminds me of R.D. Laing’s experience: “As a young psychiatrist in general hospitals and psychiatric hospitals, I administered locked wards and ordered drugs, injections, padded cells and straightjackets, electric shocks [ECT], deep insulin comas [drug-induced comas] and the rest… I went around in a white coat, with stethoscope, tendon hammer and ophthalmoscope sticking out of my pockets, like any other doctor.  Like them, I examined patients clinically…It looked the same as the rest of medicine, but it was different.  I was puzzled, and uneasy.  Hardly any of my psychiatrist colleagues seemed puzzled or uneasy.  This made me even more puzzled and uneasy.” (Wisdom, Madness & Folly 1985)

In the US, ECT machines are Class III medical devices (Class III includes devices “which present a potential, unreasonable risk of illness or injury”). Any Class III device does of course have to be approved by the FDA for safety and efficacy – though this has been side-stepped by the makers of shock-machines. This is because “Electroshock machines were ‘grandfathered’ into the system when the FDA assumed jurisdiction over medical devices in 1976 (source)”. At long last the FDA is currently requesting this data, but no deadline has been set. This means that the device makers are in fact relying on the clinical literature to infer safety and efficacy. That’s amazing, and alarming. Since Congress ordered the FDA to have shock machines tested back in 1990, the makers and others with vested interests have been dragging their feet to avoid the necessary safety tests (source). In fact, they have even tried to have the Class III status revoked so as to be exempt from Class III conditions.

Early in 2010 Prof David Cohen made clear and definitive recommendations to the FDA concerning the evaluation of ECT devices. Please see his letter to the FDA here, which is made available with his permission. As for any evidence that full and adequate testing is being carried out – still waiting, and waiting.

And yet, in spite of this, shock-machine makers make some very bold claims for success, such as “providing up to an 80% response rate”.  Another maker boasts a similar treatment success: “ECT is an exceptionally effective medical treatment, helping 90% of patients who take it”. And not surprisingly, they promote their devices as safe with assertions like: “the safety of these devices is unparalleled, and as such these devices are an advance that will impact the safety and effectiveness of the ECT treatment.” It is surely time they were made to provide robust data to defend such claims.

But what about brain damage from the use of RCT? The maker, Somatics, make another bold claim in answer to this question: “The available evidence speaks strongly against this possibility.” There are, however, those who would strongly contest this. Traumatising the brain, even with the best of intentions, has got to be hazardous. I also understand that “In rare cases, ECT can cause heart rhythm problems” too. (source)

We know that a single general anaesthetic carries serious risks (hence the patient signs a disclaimer). And even if the estimate of “about five deaths for every million anaesthetics given in the UK” is an accurate one, this is still a risk, especially as some people have 20 or more ECT treatments – each under general anaesthetic.

I wonder if there are any long-term follow up studies showing any possible links to ECT use and later onset dementia, especially bearing in mind the recent research (see The Guardian report here) that raises the possibility that general anaesthetics (especially in older people) may significantly increase the risk for dementia.

Although there are claims of short-term benefit from ECT, this does not prove that ECT is curative. Interestingly, “there is an intriguingly high sham [placebo] ECT response rate in some of the studies” (Rasmussen KG, 2009). Also, I surmise that some people will likely misconstrue the iatrogenic “postictal bliss” - sometimes reported by people following a seizure - with a diminishing or lifting of depression.

What surprises me is that there aren’t more law suits against the makers of these devices – though attorney Kendrick Moxon reports a number of cases. There is another account of litigation here.

Should ECT be banned? I guess you have already made up your own mind on this.  According to attorney Kendrick Moxon,“ECT remains at best, an experimental or theoretical ‘therapy’.” I concur with him that the manufacturers should be made to “prove the safety and efficacy of any ECT devices before more patients are subjected to this damaging treatment.” Otherwise, this long-standing human experiment should be drawn to a rapid close. But “what about individual choice?” you may say. Maybe there’s always a counter argument.

Since electro-convulsive therapy (ECT) was first used 75 years ago there have always been both supporters and critics. ECT continues to have the power to divide as most people seem to either strongly defend its use or to vehemently oppose it. And when it comes to choice: here in the UK trainee psychiatrists have no choice to opt out of administering ECT; some patients are still forced to undergo ECT for their ‘good’; but the makers of shock-machines seem to be a law unto themselves and have chosen, so far, to avoid adequately demonstrating that their machines are safe and effective. Shocking.

Mick Bramham is an Existential Psychotherapist based in Dorset, UK.
He has a particular interest in ethical issues and also how our lives are shaped by the society, circumstances and culture in which we live.
He trained at Regent's College London, and is a member of the Society for Existential analysis. 
Although he has serious concerns about the inappropriate and excessive use of mental health medications, he supports the freedom to choose (to take or not to take these drugs) and the right to be fairly informed of their limits and the risks. He offers support for people who are considering reducing or coming off psychiatric drugs.
He has a long-standing interest in non-clinical (and non-coercive) responses to mental and emotional distress.
You can read more about his work and find his contact details here. You can follow Mick on Twitter @MickBramham

[1] Rose, S. (2006) The 21st Century Brain. UK: Vintage Books

Monday, 15 July 2013

Deep brain stimulation: Treating or tampering with our brains?

A history of trial and error

Tampering with the brain is inevitably fraught with risks. Everything seemed fine when Henry Molaison awoke from the operation to treat his epilepsy. But all wasn’t well: his ability to form new memories was severely impaired. In the words of Benedict Carey: “For the next 55 years, each time he met a friend, each time he ate a meal, each time he walked in the woods, it was as if for the first time”.

When it comes to mental health, there is a history of trial and error with the development and use of brain treatments. The surgical lobotomy (pre-frontal leucotomy) which was widely practiced in the 1950s is one such example, where the aim was to modify the brain to change moods, thinking, and behaviour. Most people will agree, that despite early optimistic reports on its use, it was a crude and disastrous failure that left many people “debilitated by serious brain damage” (Nuffield report p. 3).

Over the years many mental health drugs have been marketed under the pretext that they might correct imbalances in brain function or structure. They do, however, create all manner of unwanted ill-effects and carry serious risks too. What’s more, there is a view that they create rather than correct chemical imbalances in the brain[1]. To those with an entrepreneurial spirit - this apparent failure to consistently, successfully and safely modify the brain to address psychiatric concerns - may seem like a beckoning gap in the market place.

Novel neurotechnologies such as Deep brain stimulation

New procedures (“novel neurotechnologies” as they are often called) are currently being developed to try and adjust how the brain functions. These are already attracting considerable interest and investment. One such novel neurotechnology is Deep brain stimulation (DBS), in which electrodes are implanted deep within the brain and are then connected to a battery that is implanted in the chest. Then an electric current (modulated by a remote control device) is delivered to a specific location within the brain. It is sometimes compared to a heart pacemaker. Well, that’s the theory. [...]

Tuesday, 7 May 2013

From DSM-5 to RDoC - From bad to worse?

A personal crisis can remind us of our frailty and increase the wish for a sense of order and meaning; consequently, it can be reassuring when a doctor frames our difficult-to-define experiences in a clear and organised way by using familiar diagnostic criteria - usually beginning with "You are suffering from ..."

Though we may welcome some semblance of order during mental or emotional distress, it is not reassuring to know that the producers of DSM-5 have failed to come up with the scientific evidence to support the diagnostic categories that form the basis of this code book. In truth, these are simply just one way of trying to understand our personal struggles and crises (I write more about this here). Furthermore, the limits and risks of the DSM-5 have been loudly trumpeted by many people, including Dr Allen Frances, such as here in the New Scientist.

With the precise timing akin to an experienced actor entering the stage, Dr Insel (Director of the National Institute of Mental Health – NIMI) has announced that they (NIMI) have the answer. They are developing another new classification system (the Research Domain Criteria, RDoC) that will, he asserts, be far superior and have a more robust scientific basis. And with reference to DSM-5, Dr Insel concludes: “The weakness is its lack of validity”.

When I read Dr Insel’s report, some things didn’t ring true. I mention just one: he explains that the research for this new classification system “began with several assumptions”, including the one that “mental disorders are biological disorders involving brain circuits”.

It’s elementary, isn’t it - if science is an open and unbiased (as far as possible) quest for knowledge (and truth) - research cannot be based on narrow and rigidly predetermined assumptions without prejudicing the outcome. Dr Insel is in effect saying “we have decided mental disorders are biological disorders involving brain circuits, and on this basis we will introduce a new diagnostic approach and treatments to match.” It’s certainly wilful, but I don’t see this as science. As Dr Insel says of DSM-5, here again with RDoC the same applies: “the weakness is its lack of validity”. [...]

Tuesday, 30 April 2013

A time to grieve, a time to console, and a time to profit?

Eli Lilly and Co. are not slow to seize a business opportunity. As the American Psychiatric Association has opened up the way for the excessive diagnosing and treating of grief (through DSM-5), Eli Lilly has, it seems, a drug ready and waiting in the wings - Cymbalta.

In reality grief is not a sickness waiting for a cure; rather, it is a natural response to the loss that is an unavoidable part of life. And sadly, the older we get the more likely we are to experience the loss of family and friends.

With this in mind there are those who think that medication is an answer to the experience of grief in the elderly. In fact, the antidepressant Cymbalta (duloxetine) has been trialled as a “treatment on grief” - assuming that grief could really be treated. Dr John Shuster was the principal investigator in this drug trial of Cymbalta - sponsored by Eli Lilly. And as with most trials, it was a mere 8 weeks – not long enough to accurately assess the side-effects. In passing, it is worth mentioning that out of 44 patients referred and screened for this trial, 26 were enrolled and only 18 actually completed (3 dropped out because of the drug side-effects).  [You can read the trial specifications here.]

It seems that Eli Lilly are ahead of the game in testing Cymbalta for “bereavement-related depression” - now that DSM-5 has changed the diagnostic guidelines so that many more people are likely to be medicated for feeling down following a bereavement. As you may realise, the previous guidelines (DSM-IV) had a 2 month “bereavement exclusion” built in - to delay the experience of grief from being hastily diagnosed and medicated as depression.  But the whole notion of trying to put a time-scale on grieving seems to me quite absurd. I touch on this in my blog on grief here, “No stranger to Grief”. [...]