Monday, February 4, 2013

Did Psychiatry Kill Richard Fee?

According to the NewYork Times, it can be a toxic mix.

Begin with a culture that uses medication to solve all manner of emotional problems.

Add  the belief that the drug world is divided between the good drugs given by physicians and the bad drugs given by street-corner pushers.

Add college students and young adults who are trying to squeeze the last drop of gusto out of their lives.

Add psychiatrists who are better compensated for writing prescriptions than for talking to their patients.

Add psychiatrists who trust the answers patients give on questionnaires.

Put it all together and you get an overuse and a likely abuse of amphetamine-based drugs like Adderall.

Some people will get addicted to the drugs, and some, like Richard Fee will commit suicide.

It is not a new story. One recalls Elizabeth Wurtzel’s harrowing account of her own addiction to Ritalin in More, Now, Again.

The psychiatrist who was writing Wurtzel’s prescriptions did not see her patient very often. Happily, Wurtzel survived, thanks to weeks of hospitalization.

Under today’s medical regime, one wonders whether a patient could have received long-term inpatient treatment?

Some people have criticized the Times for exaggerating the problem. They have criticized it for using the case of a single individual to indict the psychiatric-pharmaceutical complex.

And yet, how many people were aware of the addictive power of Valium before Barbara Gordon wrote: I’m Dancing as Fast as I Can.

Before Gordon’s book, everyone had assumed that since Valium was being prescribed by credentialed professionals, it was safe.

Keep in mind, the Times is a newspaper. It tells stories. It put the story of Richard Fee on the front page of the Sunday paper, above the fold, to provoke discussion and debate. The case offers a less than flattering look at the way psychiatry is practiced in America today.

Author Alan Schwarz summarizes the problem clearly:

Medications like Adderall can markedly improve the lives of children and others with the disorder. But the tunnel-like focus the medicines provide has led growing numbers of teenagers and young adults to fake symptoms to obtain steady prescriptions for highly addictive medications that carry serious psychological dangers. These efforts are facilitated by a segment of doctors who skip established diagnostic procedures, renew prescriptions reflexively and spend too little time with patients to accurately monitor side effects.

Richard Fee’s experience included it all. Conversations with friends and family members and a review of detailed medical records depict an intelligent and articulate young man lying to doctor after doctor, physicians issuing hasty diagnoses, and psychiatrists continuing to prescribe medication — even increasing dosages — despite evidence of his growing addiction and psychiatric breakdown.

Very few people who misuse stimulants devolve into psychotic or suicidal addicts. But even one of Richard’s own physicians, Dr. Charles Parker, characterized his case as a virtual textbook for ways that A.D.H.D. practices can fail patients, particularly young adults. “We have a significant travesty being done in this country with how the diagnosis is being made and the meds are being administered,” said Dr. Parker, a psychiatrist in Virginia Beach. “I think it’s an abnegation of trust. The public needs to say this is totally unacceptable and walk out.”

Young adults are by far the fastest-growing segment of people taking A.D.H.D medications. Nearly 14 million monthly prescriptions for the condition were written for Americans ages 20 to 39 in 2011, two and a half times the 5.6 million just four years before, according to the data company I.M.S. Health. While this rise is generally attributed to the maturing of adolescents who have A.D.H.D. into young adults — combined with a greater recognition of adult A.D.H.D. in general — many experts caution that savvy college graduates, freed of parental oversight, can legally and easily obtain stimulant prescriptions from obliging doctors. …

Some doctors worry that A.D.H.D. questionnaires, designed to assist and standardize the gathering of a patient’s symptoms, are being used as a shortcut to diagnosis. C. Keith Conners, a longtime child psychologist who developed a popular scale similar to the one used with Richard, said in an interview that scales like his “have reinforced this tendency for quick and dirty practice.”

The Times is not saying that everyone who uses these drugs becomes an addict or commits suicide. But, it makes sense to say that if the number of prescriptions being written every month for adults ages 20 to 39 has risen from 5.6 million in 2007 to 14 million in 2011, then  clearly there is a problem. Otherwise you have to believe that there’s an epidemic of A.D.H.D.

Since this spike in prescriptions corresponds to the Great Recession, it seems reasonable to believe that demoralized young people are medicating their depression, not just with Prozac, but with stimulants.

Most of those who are taking the drugs do not become addicted. How many of those who use the drugs do? According to the Times, a significant number do:

2006 study in the journal Drug and Alcohol Dependence claimed that about 10 percent of adolescents and young adults who misused A.D.H.D. stimulants became addicted to them. Even proper, doctor-supervised use of the medications can trigger psychotic behavior or suicidal thoughts in about 1 in 400 patients, according to a 2006 study in The American Journal of Psychiatry. So while a vast majority of stimulant users will not experience psychosis — and a doctor may never encounter it in decades of careful practice — the sheer volume of prescriptions leads to thousands of cases every year, experts acknowledged.

Is the Times right to sound an alarm? Of course, it is.

Knowing that Ritalin and Adderall have helped large numbers of children does not mean that they have not been overprescribed or that they have very likely been abused.

Amphetamines are dangerous medications. Prescribing them is very big business indeed. Experts will assert their expertise to defend their business. They insist that the case of Richard Fee is an anomaly and that any medication can yield bad results.

Yet, we are talking about a stimulant that is prescribed 14,000,000 times a month.

The Times reports:

Almost every one of more than 40 A.D.H.D. experts interviewed for this article said that worst-case scenarios like Richard Fee’s can occur with any medication — and that people who do have A.D.H.D., or parents of children with the disorder, should not be dissuaded from considering the proven benefits of stimulant medication when supervised by a responsible physician.

By all accounts Richard Fee’s medication was “supervised by a responsible physician.” In fact, it was supervised by several responsible physicians.

But, as you read through the Times story, you see that the only people who really understood what was happening to Richard Fee were his parents.

The story of Richard Fee tells how two parents tried to save their son from the system. They knew their son better than anyone else. They cared about their son more than anyone else. But they were not experts. The system won and their son died.


JP said...

This is classic Americana.

Standard-issue stimulant craze, which eventually ends when the culture waks up and says..."hey, abusing these addictive stimulants is a really bad idea!"

I suspect this is one of the first steps down that road.

Stuart Schneiderman said...

Exactly... classical Americana!

DeNihilist said...

My youngest son was diagnosed with ADHD. Thank God we had a brilliant child psychiatrist. For 2 years we worked with him and our boy without using drugs. trying behavior modifications. It was a very limited success. As he approached grade 8, we finally made the decision to use Ritilan. Our Psychiatrist had a strict regime, 1 dose only, in the morning before school, no doses on weekends, and no doses during holidays. The drug was only to help him at school.

At the start of grade nine, I was driving my son to his first early morning band class, when I asked him if he had taken his Ritilian. He said no, that he did not want too anymore, that it made him feel weird. We came to an agreement, if he could keep his marks up, stay social, cause no disruptions and do his home work, no Ritilian.

He is now in second year music at university, has a great girlfriend and is very focused (of course! LOL). We still have that bottle of left over Ritilian,and I thank God for Dr.Rhaman, a very gentle and loving man!

Anonymous said...

"But, as you read through the Times story, you see that the only people who really understood what was happening to Richard Fee were his parents."

I find it fascinating that you have such issues with therapy AND drug treatment, yet when it comes to gun control, you want the psychiatric establishment to come riding in like the calvary to save the day.

Lanza's mother should have turned her son over to the Marine psycho dctors. "Maybe they could have found out what was wrong with him."

Your solution to gun violence (the same as Hannity, Fox, the NRA), is to just lock up all the crazies, which presupposes a psychistric establishment you believe in and have faith in, one supposes. Unless maybe you think the solution is to just lock them up in chains like the 19th century and throw aqqway the key.

After all, if you really and truly think "committing" all possibly dangerous people is the solution, you are going to have an influx of millions of people into the psychiatric system. That's putting a lot of responsibilty on psychiatry (ironic, coming from a blog named Had Enough when it comes to guns).

Maybe once all the crazies get into these institution, you basically tell them "get over it" and send them on their way. Or put them all in Skinner Boxes?

I hope you figure out a solution, because it's the only one you've offered for the problem of guns and violence.

Stuart Schneiderman said...

It's helpful to try to think clearly. To think clearly one must draw a few relevant distinctions.

First, the problem with people like Lanza and Holmes and Loughner is psychiatric. They were all dangerous schizophrenics and needed to be locked up.

Second, the problem with gun violence in this country is certainly not limited to these few cases. The problem involves gang and drug violence through many of America's inner cities. I have not offered solutions to that problem, though it looks like Rahm Emanuel's approach has not been very successful.

Third, the emphasis on these few psychotics has drawn attention from the real causes of inner city gun violence.

Fourth, Richard Fee was not a psychotic. His worst problems were drug induced. Such is not the case with schizophrenics. He would certainly have done better if he had been allowed a longer stay in a psychiatric institution.

Fifth, there is a radical difference between treating a relatively small number of schizophrenics in an in-patient facility and handing out amphetamines fairly indiscriminately to tens of millions of people.

Is that clear enough?