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The Best and Not so Great Articles
Original Article: Innovative Strategies for Addressing Substance Use Disorders: The Classic Hallucinogens
By Michael P. Bogenschutz, Psychiatric Times, April 20, 2017,
Dr. Bogenshultz describes this study: Residential psychedelic (LSD) therapy for the narcotic addict. Savage C, McCabe OL. A controlled study. Arch Gen Psychiatry. 1973 Jun;28(6):808-14.
Bogenshultz is taking the value of the results too far without looking at the design of this trial: Unblinded LSD drug given to persons who agree to be in the study. Low N of 39 persons in each comparator group.
He states it was a controlled trial of LSD-assisted treatment of heroin addiction, N=78 with heroin addiction randomized to abstinence based group therapy and urine monitoring vs. 4-5 wks of residential treatment , including a single high-dose LSD session, followed up usual care. Results showed that an “impressive” 25% in the LSD group were continuously abstinent during the 12 months follow up compared to 5% in the control group. 10/39 were abstinent in the LSD arm, and 2/39 abstinent in the control group.
Looking at it the other way, 29 persons (75%) who, in spite of AGREEING to and KNEW they were in the LSD group were not abstinent, and we don’t know how long abstinence lasted after the study ended. The LSD group is clearly not blind and these persons could have some strong placebo effect bias of hope and expectation of being in the active LSD group, and those in the control group knew they did not get LSD, in spite of having some interest in getting it because they knew it was an LSD study when they signed up for it, thus they may have had some disappointment. The researchers were also not-blind-you cant have one time high-dose LSD session and not know what is going on. The non-abstinent rates of 95% of controls and 75% in the active groups do not seem not all that different in the face of an unblinded treatment.
So here, in relatively low numbers studied, we have a fairly large percent of persons NOT maintaining abstinence despite being in an open LSD study. This was a methodologically troubled study: open label for LSD group, persons having an expectation if receiving LSD in both groups with a modest 20% more abstainers in the open LSD group. Open label drug and filtering out of patients who agree to get open label drug is not a controlled study.
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“Psychiatric Times”, March 28, 2017, By Nathaniel Brown, MD
I was surprised that Brown did not cite this article from “JAMA Psychiatry” May, 2014 that could have helped him understand something about half (or more) of servicemen: Thirty-Day Prevalence of DSM-IV Mental Disorders Among Nondeployed Soldiers in the US Army. Results From the Army Study to Assess Risk and Resilience in Service members (Army STARRS)
http://jamanetwork.com/journals/jamapsychiatry/fullarticle/1835338
The study found that almost half of soldiers had some mental disorder when they enlisted. The rates of disorders like attention deficit-hyperactivity disorder and intermittent explosive disorder (IED) in the study were similar in the new recruits as well.
This finding in line with our practice experience in Japan that includes servicing a total population of 100,000 military personnel, dependents, and civilian workers. Most of these persons seemed to us to have similar problems before they entered the service, some got worse in the service.
There is a clear path of employment, training, and for long-termers a pension plan, making the military both a good choice for these persons, and these persons a good choice for the military that recruiting is not likely to give up. However, ADD, ADHD, IED, etc are frequently associated with dysphoric mood states and recurrent brief, persistent, or major depression, in addition to drinking, drug abuse, risk taking behavior, and, along with the stresses of being in a war theater the risk of suicide can increase.
The answer to all of this is that, because so many persons enter the military with mental health problems to begin with, any addition of the horror of war to this baseline will continue to make it very challenging to mitigate morbidity and mortality in this population.
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Psychiatric Times, July 17, 2017 By Rebecca M. Allen, MD, MPH
The open-label GeneSight and unblined Genomind studies are at high-risk for researcher bias and should be suspect to extreme caution. We would never allow anti-depressants to be approved with these kinds of studies (although unblinded/no-blind placebo psychotherapy studies are unreasonably and widely “accepted” as robust data by our profession all the time).
The issue of whether “adverse effects” are related to anxiety are easily investigated with zero-cost means. Patients’ significant others can manage all the medications, crush up the pills, and blind to the patient put them in patients’ morning small glass of orange juice. Do this a few days on and a few days off, keep a record, and see which days corresponded to the patient’s anxiety.
Regardless of a patient being a slow metabolizer, all patients should be started at low doses and can be told to break their starting dose pills in half, crush them, or empty capsules out so that every patient can start low and go slow for a number of days before going up to the low starting dose even. In addition, normal metabolizers may still have adverse effects at usual starting doses due to pharmacodynamics reasons (effects on the receptors etc in the brain) and not pharmacokinetic reasons (ie peripheral metabolism) which is not measured by metabolic genetic testing.
Proper clinical instruction and close follow up (which is necessary regardless of metabolic status) makes the use of these costly tests unnecessary in all but the rare patient with treatment resistance and/or those that have extreme reactions-only when drug is put in their OJ. I strongly suggest we never do a genetic test on any patient having “adverse reactions” on OJ with no drug in it and all the pills accounted for.
No genetic testing company is likely to be happy with what this advice may do to their market.
Doug Berger, MD, PhD
U.S. Board-Certified Psychiatrist
Tokyo, Japan
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Psychiatric Times, April 03, 2017, By Ronald W. Pies, MD
We all know about the slippery slope of giving psychiatric patients to right to request suicide from a medical professional. However, terminally ill medical patients who have terrible pain and suffering and are near death (perhaps on a respirator, have multi organ failure, frequent sepsis, oozing blood from skin and other orifices, repeated seizures, etc), are vastly different from psychiatric patients. Pies and Geppert’s argument does not deny that a physician could not induce a comatose state in these persons, perhaps even a permanent coma until death. Coma (without brain death) is not death medically or legally, although it essentially accomplishes the same thing as death does in removing the patient’s awareness and experience from a living state.
I would have trouble thinking that physician-assisted coma should be illegal or unethical as a form of medical treatment with specific indications just like any other medical treatment (i.e., it would not be indicated for psychiatric illness), and encourage further debate about it. One could argue that these patients can still be aware of things, but the same could be said of patients on morphine. Coma still racks up medical bills, and it may still be painful for a family to see their loved one in this state. Notwithstanding these caveats, we don’t have to argue about physician-assisted dying if we consider coma is good enough.
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THE QUIZ: Headaches
Scientific American, March 30, 2017
http://www.psychiatrictimes.com/psychopharmacology/quiz-headaches/page/0/2
Dr. King, regarding acupuncture, perhaps you can comment on this article:
Research Casts Doubt on the Value of Acupuncture, Scientific studies show that the procedure is full of holes, Scientific American, August 2016
https://www.scientificamerican.com/article/research-casts-doubt-on-the-value-of-acupuncture/
The article makes these statements below, and it seems to me that because of the subjective nature of endpoints used in any clinical trial of pain or migraine treatment, whether acute or prophylactic treatment, that it seems a bit too early to make definitive conclusions about acupuncture worthy of a “True” or “False” in a quiz because there is no way to filter out bias of hope or expectation and/or researcher/treater bias effects on the subject even with masked raters as they only record the report of the patient:
1. effects of acupuncture are the same whether needles are placed along the meridians or at random locations around the body.
2. acupuncture studies are extremely difficult to double-blind—a methodological approach in which neither the researchers nor patients know who is receiving the treatment under investigation and who is receiving the placebo or sham.
3. researchers know which patients receive or do not receive real acupuncture, likely biasing the results.
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The article “Tell it about You Mother ” by Casey Schwartz, June 24, 2015, (http://www.nytimes.com/2015/06/28/magazine/tell-it-about-your-mother.html?_r=1) is a review of a study that suggests there is a link of psychoanalysis with specific brain changes. The article reports the fMRI images of one-patient which is neither a report of results nor analysis, and the one-patient data is a personal contact from the study authors to the NY Times article author, not a publication of the results (“Images from Andrew J. Gerber and Katherine R. Surrence/Columbia University”).
I could not find any results from this fMRI study on a literature search. I asked the authors of the original paper Gerber and Peterson for some data or analysis, and received no reply. One article I did find was a description of the of the study plan but no results are reported: Measuring Transference Phenomena with fMRI, Andrew J. Gerber and Bradley S. Peterson, Am Psychoanal Assoc. 2006; 54(4): 1319–1325 (http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2367227/. This article noted that the study planned only 10 subjects and was not blinded to the therapist nor the subject as to the content of the procedures (so there was no blinded control group). The NY Times article had the term “Preliminary research” under the image, however, In spite of only presenting the data of one unblinded subject, and the data having no publication or analysis, the NYT article says “ goes on to state, “… indicates that brain regions involved in transference include the left and right insula”. The research article itself stated, “It is crucial that the paradigm be designed for optimal reliability and clinical relevance at this stage, before it is applied broadly to questions of development, psychopathology, and psychotherapeutic change.”
Changes in the brain are also seen in other activities. For example, this study, http://www.nature.com/neuro/journal/v12/n11/full/nn.2412.html, Nature Neuroscience 12, 1370 – 1371 (2009); 11 October 2009 | doi:10.1038/nn.2412, found an increase in white matter underlying the intraparietal sulcus following training of a complex visuo-motor skill. This study was not blinded and there was no placebo control group. Mindfulness meditation has also been found to alter regions of the brain associated with memory, awareness of self, and compassion, according to a brain imaging study: Psychiatry Research: Neuroimaging (Jan. 30, 2011). http://www.health.harvard.edu/mind-and-mood/mindfulness-meditation-practice-changes-the-brain. The subjects in this study were not blinded and there was no placebo control group.
The brain is clearly an organ that can modify itself to various stimuli, changes are not necessarily indicative of effects of a specific psychotherapy. There is data on only one subject presented, the study is not blinded, there is no comparison group, no blind placebo group, and no analysis of any cohort of data that can be found in the literature at this time. The NYT should look into whether there is any published data
and analysis of this data, and make an addendum to the Schwartz article of what is or isn’t published, the robustness of any study presented (i.e., number of subjects, blinding, placebo, comparison group, etc.), and revise any suggestions of effects of psychoanalysis on the brain in a new article written by a panel of clinical trial experts or as least by the Editors.
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