Opportunity Knocks

After last week’s post on involuntary treatment, my colleague asked:

“Do you think that some psychotic individuals may require involuntary restraint. Questions about who should do the restraining and further considerations are another matter.”

Answer: Yes, as I said, we act with caution. There are cases for which brief detention with or without involuntary treatment is appropriate. Acutely psychotic people, acting under delusional beliefs or hallucinated experiences, may put themselves or others at serious risk, and common humanity demands some form of restraint. Similarly, severely distressed people quite often act in an uncharacteristic manner for which, even a few minutes later, they may be intensely regretful, so restraint is again appropriate.

As a society, we need to find a path between the extremes of what is called “libertarianism” and the heavy-handed paternalism in force in most western countries today. I am not convinced by Thomas Szasz, among others, who proclaim that individual liberty is the supreme and universal good that must never be restricted in any way. This includes freely allowing people to kill themselves, such as placing the means of suicide in prisoners’ cells, and leaving people deemed psychotic free to roam the streets in any condition and engage in any behaviour so long as they obey the law. He also insisted there should be no restrictions on drug use. When the Szaszian position is analysed closely, it becomes self-contradictory, which is true of all ultra-libertarian positions, so I don’t think we need take it seriously [1].

However, psychiatry’s biological paternalism is a different matter: people are forced to take drugs with a huge range of side effects ranging from unpleasant to dangerous and, overwhelmingly, are treated like lumps of meat. Rates of detention vary enormously from one jurisdiction to another. In New South Wales, 54% of hospitalisations are involuntary but in West Australia, it is only 10%. In the Northern Territory, it is an implausible 86% but it was about 20% when I was there. The psychiatrists involved will all swear that what they’re doing is justified as scientific. Once caught up in the system, it is very hard for people to get out of it, while anybody who passes through the doors of the forensic branch can abandon all hope.

As for who should do the job, the answer is surely: “People who know what they’re doing.” Does that include modern psychiatrists? I don’t think it does. For a start, they can’t even agree on what scientific model they should use: should it be a model that recognises the causal reality of the mind (i.e. a “biopsychosocial” model) or one that says it’s all biological (a “biomedical” model)? A good start would be to subject themselves to the discipline of actually writing their models so we can see just what they mean, because that’s never been done.

However, a sudden, bracing dose of discipline is on its way, from a completely unexpected quarter: Mr DJ Trump. Actually, it’s not coming from Mr Trump, it’s coming from his newly appointed Secretary of Health, Robert F Kennedy, Jr. One of Trump’s torrent of executive orders establishes a commission to Make American Healthy Again. I’m not sure if it ever was healthy but it sounds impressive. In case anybody doesn’t know, RFK Jr, son of RFK Snr, who was assassinated during the 1968 presidential campaign (which he would almost certainly have won) is not a chip off the old block. His cousin, Caroline, daughter of JFK, called him a predator and drug abuser who is completely unsuitable for the position. His anti-vaxxer views should have sunk him but he got the job and had a lot to do with organising the people who wrote the program in the executive order (which Trump didn’t read). The best that could be said for him is that he’s a loose cannon.

The order itself isn’t long and has some interesting stats to show how, despite $4.5trillion annual expenditure, far and away the highest per capita in the world, American health outcomes are poor and declining. It’s not clear how anybody could be surprised by this: if in a privatised system, 25million poor people don’t have any health insurance and tens of millions more can’t afford treatment, they’re going to be sicker and die younger than people in sensible countries (see the situation in Virginia a few years ago, described by Joe Bageant [2]; despite Obamacare, it’s hardly improved). In particular, it points out how health standards among children, teenagers and young adults are poor and getting worse. Thus, a major focus for the new commission will be to formulate a Make Our Children Healthy Again Strategy, which will:

(i) identify and describe childhood chronic disease in America compared to other countries;

(ii) assess the threat that potential over-utilization of medication, certain food ingredients, certain chemicals, and certain other exposures pose to children with respect to chronic inflammation or other established mechanisms of disease, using rigorous and transparent data, including international comparisons;

(iii) assess the prevalence of and threat posed by the prescription of selective serotonin reuptake inhibitors, antipsychotics, mood stabilizers, stimulants, and weight-loss drugs;

(iv) identify and report on best practices for preventing childhood health issues, including through proper nutrition and the promotion of healthy lifestyles;

(v) evaluate the effectiveness of existing educational programs with regard to nutrition, physical activity, and mental health for children;

(vi) identify and evaluate existing Federal programs and funding intended to prevent and treat childhood health issues for their scope and effectiveness;

(vii) ensure transparency of all current data and unpublished analyses related to the childhood chronic disease crisis, consistent with applicable law;

(viii) evaluate the effectiveness of current Federal Government childhood health data and metrics, including those from the Federal Interagency Forum on Child and Family Statistics and the National Survey of Children’s Health;

(ix) restore the integrity of science, including by eliminating undue industry influence, releasing findings and underlying data to the maximum extent permitted under applicable law, and increasing methodological rigor; and

(x) establish a framework for transparency and ethics review in industry-funded projects.

That sounds great, can we have one of them too? Each of these points is critically important and has the potential to blow the lid off various rackets, but it won’t be smooth sailing, especially the noble and long-overdue Pt (iii), on over-prescription of drugs. The new Commission has only 100 days to provide an initial program, during which the drug companies and their tame academic psychiatrists, and the country’s voracious private health insurance industry, will be frantically working to sabotage it. Compounding the matter, Bro. Musk’s Salvation Show has already led to thousands of the people qualified to implement these programs being sacked. They’re proposing a massive realignment of policy but with no staff to do it. Not a great start.

As with everything significant in the US, it’s important to understand the political background because if this order fails, and there’s every chance of failure, it will be because of the money-soaked free-for-all that passes for politics in that strange country, not the science. Take just one small but politically significant example: corn syrup. The US produces vast quantities of corn, far more than it can reasonably consume, but it’s expensive. At the same time, three southern Republican states, Florida, Louisiana and Texas, grow about 4 million tons of cane sugar per year. However, Brazil can land cane sugar in the US for about half the cost of American sugar. As a result, their exports are blocked by heavy tariffs and import restrictions so tens of thousands of Republican-voting farmers aren’t put out of business. Tariffs, of course, are a disguised tax which transfer money from ordinary people to rich, inefficient producers so they can get richer.

Because the price of sugar is artificially inflated, it becomes worthwhile to use the excess corn for industrial purposes. One, pushed by GW Bush, was to make ethanol but it actually consumes more energy than it produces, and drivers hate it, so that hasn’t gone very far. The other use is to manufacture lakes of corn syrup, a sickly sweet goo that’s put in absolutely everything. This is a major factor in the “epidemic” of obesity in the US (and Mexico, because a lot of it goes there). Parents can either buy nutritious food or get something cheap that provides heaps of calories and keeps the little monsters quiet while they watch the idiot box. In poor areas, of course, there generally isn’t much fresh food available so they just reach for the snacks and sweets.

Any move to improve the generally poor nutrition of American children, especially poor, rural, minority, single- or working-parent families, will need to restrict sales of corn syrup, which will outrage the Mid-West farmers who grow it, leading to more arguments with the southern farmers on their heavily-protected sugar farms. In a genuinely free market, none of this would happen but, because of the vested interests, it is deeply woven into the political fabric. And, as Mr Kennedy will surely find out, meddling with it is a death-trap. This is especially true since Mr Musk cancelled the US Agency for International Development (USAID), which bought heaps of excess farm produce and exported it as emergency aid. With the stroke of Trump’s ideological pen, that’s all stopped and large numbers of farmers in swing states who voted for Mr Trump are suddenly facing bankruptcy. Needless to say, they’re not happy. Losing their subsidised corn syrup industry would wipe out most of the remainder so it seems very unlikely that there will be much change. They could feed it to pigs who quite like the stuff but they end up making more fat than meat. Is there a message in that for humans?

When it comes to mental health, everything is far more complex. The US pharmaceutical industry, known as Big Pharma, has a huge and immensely effective lobbying industry, spending about $250million a year on the 600 or so members of Congress (that’s what they declare, it’s probably much more in total). The entire industry business plan for Big Pharma comes down to one principle: Get more people taking more drugs for longer. This is why drugs in the US cost about ten times as much as the rest of the world, and drugs are more favoured by insurance companies over non-chemical treatments. Thus, the Sackler family, owners of Purdue Pharmaceuticals, decided to market oxycodone, a highly addictive synthetic opioid, as the ideal “non-addictive” drug for chronic pain. This triggered the current “opioid epidemic,” which has resulted in at least a million deaths, although hardly any convictions. Similarly, the wave of corn-syrup induced obesity in the US, with all its complications, opens a vast market for the new weight suppressant drugs which are sold in the US at up to 10 times the prices charged elsewhere. Needless to say, we won’t know their side effects for many years.

For psychiatry, the drug company plan was two-fold: convince psychiatrists to dump all psychological theories of mental disorder in favour of biological, and make sure nobody mentions the word ‘addictive’ in the same sentence as ‘psychiatric treatment.’ This has been a brilliant and self-reinforcing success: the more drugs they sold, the more money they were able to spray over the psychiatric profession to convince them drugs solve all problems. Partly, this was in direct payments to prominent psychiatrists (“key opinion leaders”) for speakers’ and advisory fees ranging up to six figures a year, and partly by financing research projects designed to prove drugs are the only way to go. It’s not widely known that when an academic psychiatrist receives a research grant, the university takes up to 60% of it as a “facilities fee.” So the late Joseph Biederman, of Harvard, who invented childhood bipolar disorder and extended ADHD to practically everybody, took in over $15million from NIMH, plus unknown amounts from industry, from which the university creamed off about 50%. That’s probably why they didn’t sack him when he was exposed for trousering millions himself (his Wikipedia page has been neatly sanitised).

There’s no end to the subterfuges used by the drug industry to sell their version of “biological mental health science.” Money flows to academics, to universities, to politicians, and to the various charities and “grassroots” organisations, many of which are almost entirely supported by drug money. Research projects are designed to give the results the drug company wants, while negative results are actively suppressed (see Pt (vii) above). Research papers and even influential text books may be “ghost-written” by company employees, while relentless advertising programs hammer home the message: “Feeling a little queer today? See your doctor (who will give you our drugs).” When drug companies are shown to be cheating the system in one of their many ways, they simply cough up the fines and write them off as a business expense. Since 2000, they paid a collective $123billion, mostly relating to psychiatric drugs, although hardly any of the plotters were locked up.

We can therefore wish Mr Kennedy the best of luck in his crusade but I don’t think he knows what he’s up against. Can he compel psychiatry to admit that it doesn’t have a scientific grasp of mental disorder, that the whole thing is ideology alone? I’m sure he thinks it’s just a matter of kicking a few heads but self-righteous convictions aren’t enough when dealing with the infinite cunning and patience of the drug industry. He has at most two years to push changes through Congress before the usual mid-term wipeout shifts the balance of power. In particular, if he decides to clamp down on the relentless spread of stimulant prescriptions for “ADHD,” he can expect to be tarred and feathered. The ADHD industry is immensely powerful and can instantly mobilise millions of voters to flood their representatives with angry emails and phone calls.

All this rolls along under the pretence that psychiatry has full scientific justification. If Kennedy and his eager team manage to expose this charade, they will do society a great service. I wonder if we could convince them to investigate involuntary treatment while they’re at it? We ordinary mortals can only wait and see what emerges.

References:

1. McLaren N (2012). Critical review of Thomas Szasz. Chapters 14-16 in The Mind-Body Problem Explained: The Biocognitive Model for Psychiatry. Ann Arbor, MI: Future Psychiatry Press.

2. Bageant J (2007). Deer Hunting with Jesus: dispatches from America’s class war. Random House/ Three Rivers Press: New York.

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