Welcome to my blog, a place to explore and learn about the experience of running a psychiatric practice. I post about things that I find useful to know or think about. So, enjoy, and let me know what you think.

Thursday, May 28, 2015

I Don't Know What to Think

A friend forwarded me this piece:

Leading American Psychiatrist Conducted Disturbing Experiments -- and Now He's Smearing Journo Who Uncovered It. (Bruce Levine/Alternet)

It's about experiments conducted by Jeffrey Lieberman. Here are the abstracts:

Arch Gen Psychiatry. 1987 Jul;44(7):597-603.
Prediction of relapse in schizophrenia.
Lieberman JA, Kane JM, Sarantakos S, Gadaleta D, Woerner M, Alvir J, Ramos-Lorenzi J.

Despite the proven efficacy of neuroleptic drugs in the acute and maintenance pharmacotherapy of schizophrenia, practical methods for identifying patients who require neuroleptic treatment to prevent relapse are lacking. This study evaluated the use of a methylphenidate challenge test to predict the outcome in 34 stable outpatients with schizophrenia receiving neuroleptic treatment. Patients received two infusions, one of methylphenidate and one of placebo, in randomized order one week apart while receiving neuroleptic treatment and again three weeks after drug withdrawal. Behavioral, cardiovascular, and neurologic responses were evaluated before and after infusion under double-blind conditions. Patients were then followed up without medication for 52 weeks or until symptom recurrence. The results indicate that specific measures, including behavioral response to methylphenidate, presence of tardive dyskinesia, and, under specific pharmacologic conditions, tardive dyskinesia, blink-rate, and pulse-rate responses to methylphenidate, are associated with time and propensity to relapse following neuroleptic withdrawal. These measures may be potentially useful in the identification of candidates for neuroleptic withdrawal and/or dosage-reduction treatment strategies.
PMID: 2886110 [PubMed - indexed for MEDLINE]

Psychopharmacol Bull. 1990;26(2):224-30.
Behavioral response to methylphenidate and treatment outcome in first episode schizophrenia.
Jody D1, Lieberman JA, Geisler S, Szymanski S, Alvir JM.
Sandoz Pharmaceuticals, Sandoz Research Institute, East Hanover, NJ 07936-1951.

In order to examine the relationship of behavioral response to psychostimulants and acute treatment response, we administered methylphenidate (0.5 mg/kg i.v.), an indirect dopamine (DA) agonist, to 38 patients who met Research Diagnostic Criteria (RDC) for definite or probable schizophrenia or schizoaffective disorder, were experiencing their first acute episode of psychosis, and had received less than 12 weeks or no prior lifetime neuroleptic exposure. Following baseline methylphenidate infusions, patients received a standardized regimen of acute neuroleptic treatment. Methylphenidate produced an increase in psychopathology reflected by a worsening of both positive and negative symptoms. Using a priori criteria, 61 percent of patients exhibited psychotic symptom activation, and 39 percent showed no change. Activation during methylphenidate infusion during the initial acute phase of illness was not correlated with time to achieve antipsychotic treatment response but was associated with side-effect vulnerability.
PMID: 2236460 [PubMed - indexed for MEDLINE]

In the 1987 study, they were trying to figure out which patients with schizophrenia require maintenance treatment with neuroleptics to prevent relapse. So they took 34 stable outpatients who were on meds and gave them IV ritalin, so they might get psychotic. Then they kept them off meds for a year or until they got psychotic. They learned that certain responses to ritalin are associated with a tendency to relapse. I don't have access to the full article, so I don't know which responses.

How did using the ritalin help answer their question? They could have just taken them off their meds and followed them. Sure, that would have been uncontrolled. But how does trying to make stable patients unstable tell you which stable patients will relapse off meds? It only tells you which stable patients given ritalin will relapse off meds.

In the 1990 study, they took 38 first break patients and gave them IV ritalin, which made 61% of them sicker. Then they looked at how these patients responded to antipsychotics. 

Also back in 1987, Lieberman wrote a review of 36 studies that established the pscyhotogenic potency of ritalin. So the authors of the two studies above were aware that ritalin would likely make the patients psychotic.

According to the Levine piece,

On April 26, 2015, Jeffrey Lieberman, former president of the American Psychiatric Association, stirred up controversy by calling investigative journalist Robert Whitaker a “menace to society” on CBC radio because Whitaker, in his book Anatomy of an Epidemic, had challenged the long-term effectiveness of psychiatric medication...

In Whitaker’s Globe 1998 series in the segment “Testing Takes Human Toll,” he interviewed Lieberman about his and other psychotic symptom exacerbation and provocation experiments. Lieberman asserted, “To say that increasing a particular symptom—like hearing voices for a couple of hours in somebody who has been hearing voices for 10 years—is causing [suffering] rather seems like a stretch.”

I don't know what to think. I don't truly believe Lieberman is a monster. A jerk, maybe, but not a monster. But first break patients haven't been hearing voices for 10 years.

Maybe the idea was that they could learn a lot about who did and didn't need meds by causing a little bit of extra suffering, and that ultimately, that knowledge would help a lot of people. The same way it hurts to be vaccinated, but it's helpful. 

Maybe it was easy to get stuff like this by an IRB in the late 80's and early 90's.

Maybe the patients were able to give consent, and understood what was being done to them. To me, that, "Rather seems like a stretch." You're hearing voices that are frightening you? We'll just give you something to make those voices worse, and by doing so, we'll know exactly how to treat you. 

Maybe it's the same kind of logic that comes up in Shrinks. We'll do a scan of your brain, and then we'll know exactly what's causing your mental illness.

Levine wants to blame the APA. He states, "Why would the American Psychiatric Association elect Lieberman president in 2012? Because psychiatry sees nothing wrong with these psychotic symptom exacerbation and provocation experiments."

Obviously, I don't agree with that opinion. And I also don't equate the APA with psychiatry.

There just seems to be so much stuff that comes up around this one guy.

I just don't know.


  1. Not agreeing with the rhetoric is a good starting point. The only mistake Lieberman in this case was daring to speak out against Whitaker. In this case the author uses legitimate peer reviewed research from 25 years ago to attempt to make him look bad and then make the APA and all psychiatrists look bad. As you point out they are not connected in any way. President of the APA is basically an anointed position usually given to researchers and/or academics with with little political savvy. A minority os psychiatrists vote for the President. Lieberman's wrongdoing in this case was to not specifically criticize Whitaker. I think the message is clear about what will happen to anyone who does.

    1. I think Lieberman's biggest ethical problem is that he is just fine with the idea of treating patients one does not actually see or talk to in a collaborative model. This is because he is an enthusiastic fellow traveller in the proACA crowd, and he'll say anything to support it while ignoring professionalism. Is that overly harsh? Consider what would have happened to a resident on C&L twenty years ago who didn't bother to interview a patient whom he treated in the hospital. Completely unacceptable and unprofessional. I stand by my position that he is suspect regardless of whether or not his research critics have gone too far. And by the way, he was kind of asking for it when he came out with the "neuroprotective" schtick. Good researchers should be a little more nuanced and less promotional about drugs that cause TD.

      The APA and its membership can't get off the hook by dismissing APA presidency as ceremonial although I agree with you that it is. The fact is that he was elected as the face of the profession and it is the fault of the membership for not electing someone more savvy and more nuanced. Remember one year they did elect Harold Eist so it can be done.